Ijpot july sept 2011

Indian Journal of Physiotherapy and Occupational Therapy

An International Journal

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

Volume 5 Number 3 July - September 2011

website: www.ijpot.com

INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPY

EditorDr. Archna Sharma (PT)

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

Executive EditorDr. R.K. Sharma

Dean, Saraswathi Institute of Medical Sciences, Ghaziabad (UP)Formerly at All-India Institute of Medical Sciences, New Delhi

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

International Editorial Advisory BoardDr. Amita Salwan, USA

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

Heidrun Becker, GermanyRosi Haarer Becker, Germany,

Prof. Dra. Maria de Fatima Guerreiro Godoy, BrazilDr. Venetha J. Mailoo, U.K.

Dr. Tahera Shafee, Saudi ArabiaDr. Emad Tawfik Ahmed, Saudi Arabia

Dr. Yannis Dionyssiotis, GreeceDr. T.K. Hamzat, Nigeria

Prof. Kusum Kapila, KuwaitProf. B.K. Bhootra, South Africa

Dr. S.J. Winser, MalaysiaDr. M.T. Ahmed, Egypt

Prof. Z.W. Sliwinski, PolandDr. G. Winter, Austria

Dr. M. Nellutla, RwandaProf. GoAh Cheng, Japan

Dr. Sema Oglak, TurkeyDr. M. Naveed Babur, Pakistan

Print-ISSN: 0973-5666 Electronic - ISSN: 0973-5674, Frequency: Quarterly (4 issues per volume).“Indian journal of physiotherapy and occupational therapy” An essential indexed double blind peer reviewed journal for all Physiotherapists & Occupational therapists provides professionals with a forum to discuss today’s challenges - identifying the philosophical and conceptual foundations of the practics; sharing innovative evaluation and tretment techniques; learning about and assimilating new methodologies developing in related professions; and communicating information about new practic settings. The journal serves as a valuable tool for helping therapists deal effectively with the challenges of the field. It emphasizes articles and reports that are directly relevant to practice. The journal is now covered by INDEX COPERNICUS, POLAND. The journal is indexed with many international databases, like PEDro (Australia), EMBASE (Scopus) & EBSCO (USA) database. The journal is registered with Registrar on Newspapers for India vide registration DELENG/2007/20988. The Journal is part of UGC, DST and CSIR consortia.

Website : www.ijpot.com

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

EditorDr. Archna Sharma

Aster-06/603, Supertech Emerald CourtSector – 93 A, Expressway

NOIDA 201 304, Uttar PradeshPrinted, published and owned by

Dr. Archna SharmaPrinted at

Process & SpotC-112/3, Naraina Industrial Area, Phase-I

New Delhi-110 028Published at

Aster-06/603, Supertech Emerald Court, Sector – 93 A, Expressway, NOIDA 201 304, Uttar Pradesh

Contentswww.ijpot.com

July - September 2011Volume 5, Number 3

Indian Journal of Physiotherapy and Occupational Therapy. July - September. 2011, Vol. 5, No. 3

1 Effect of Balance Training on Foam Platform in Geriatric Population: A randomized controlled trialRenu Chauhan

6 Botulinum Toxin as Treatment Modality for Spastic Diplegic Cerebral Palsy Child: Our experience in 21patientsRitesh Runu, Vaibhav Agrawal, Arunim Swaroop, Devendra Dave

10 Is Knee Range of Movement on Discharge Important After Total Knee Replacement - A prospectiveaudit based studyRoss Darch, Jonathan Swan, Tom Wainwright, Robert Middleton

14 The Effect of Transcutaneous Electrical Nerve Stimulation in the Treatment of Chronic Pelvic PainSyndrome: An evidence based electromyographic studiesAhmed F Samhan, Nermeen M Abd-Elhalim, Emam H Elnegmy, Mohamed M Roiah

18 Cardio –Vascular and Respiratory Responses to Valsalva Maneuver, Isometric Hand Grip Exercise andHarvard Step Test and Recovery in Healthy IndividualsSanjiv Kumar, Shivappa B Anurshetru, Prabhker Kore

23 Effect of FAME Program on Chronic Stroke Patients in Indian PopulationShanta Pandian, Kamal Narayan Arya, Archana Kaushik

28 A Comparitive Study on the Efficacy of End Range Mobilization Techniques in Treatment of AdhesiveCapsulitis of ShoulderK S Sharad

32 Role of Physiotherapist in the Management of On-field Sport Injuries – A case study of field hockeySuraj Kumar, Vijai P Sharma, Rakesh Shukla, Ravi Dev, Anoop Aggarwal

36 Comparison of Task Oriented Approach and Bobath Approach in Improving Balance and ReducingFear of Falling in Adults with StrokeJayachandran V, Gayathri Ethiraj

40 A Cost-effective Patient Designed Hand Splint for Rehabilitation After Two-stage Flexor TendonReconstructionMuhammad Adil Abbas Khan, Mark Gorman, Arvind Mohan, Zain A Sobani, Alastair Platt

42 Altered Current Perception Ratio: A tool to identify small fiber neuropathy in high risk Diabetic footUnnati Pandit, Hutoxi Witer, Bharati Bellare

46 Relationship between Depression and Cardiopulmonary Fitness in Post Cardiac Surgery IndividualsK Charan, K Asha Jyothi, P Tabitha, K Madhavi

50 Effectiveness of Physiotherapy Provision within An Occupational Health SettingLaran Chetty

54 To Assess the Relation Between Walking Capacity and Cardio-respiratory Function in Post Polio ResidualParalysisAshish V Gupta, Lata Parmar

58 Comparing the Effectiveness of Positional Release Therapy Technique & Passive Stretching on HamstringMuscle Through Sit to Reach Test in Normal Female SubjectsManivannan M Kaandeepan, E S Cheraladhan, M Premkumar, Shikha K Shah

62 Comparative Study Between Efficacy of PNF Movement Patterns Versus Conventional Free Exerciseson Functional Activities Among Patients with Chronic Peri-Arthritis of ShoulderManobhiram Nellutla, Pramod Giri

68 Intervention Based on Dynamics of Postural Control in Children with Cerebral Palsy- An integralapproachMeenakshi Batra, Vijai Prakash Sharma, Gyanendra Kumar Malik, Vijay Batra, Girdhar Gopal Agarwal

74 An Evaluation of Exercise Tolerance in COPD Patients Using Six Minute Walk Test- A prospective StudyT S Muthu Kumar, T Mohan Kumar

79 Pattern of Orthopaedicians Referral for Physiotherapy in a Tertiary Care Hospital: A preliminary reportKavitha Vishal, Narasimman Swaminathan, Benjamin Varghese, Sudeep MJ Pais

83 Short Term Effect of Body Positions on Dynamic Lung Compliance in Mechanically Ventilated Patientswith Lung Pathology- A randomised cross over studySwagata De, Narasimman Swaminathan

Indian Journal of Physiotherapy and Occupational Therapy. July - September 2011, Vol. 5, No. 3

89 Corelation Between Knee Extensor Strength and Endurance in Dependent and Independent ElderlyNidhi Sharma, Anish Raj, Ruchika Chugh, Sumit Kalra

96 Effectiveness of Bladder Rehabilitation Program in the Management of Urge Urinary Incontinence in Older WomenNirupma Singh, Kamal Narayan Arya

100 EInfluence of Stair Climbing on the Self Efficacy in Post Cardiac Surgery PatientsUchil P, Khan I, Kamath N

103 S-D Curve an Effective Diagnostic Test for Physiotherapists: A case reportPankaj Gupta , M Satish K Paul

105 Effectiveness of Strength Training Program on Bone Mineral Density in Postmenopausal WomenParamjot K Dhillon, Sonia Singh

110 Effectiveness of Coccygeal Manipulation in Coccydynia: A randomized control trialSubhash M Khatri, Peeyoosha Nitsure, Ravi S Jatti

113 Effect of Warm-up and Cool-down on Delayed-onset Muscle Soreness in University StudentsBhatia P, Arun

117 Comparison of Jacobson’s Progressive Muscle Relaxation and Diaphragmatic Breathing on Cardio-Respiratory Parameters in Healthy Adults – A Randomized cross over trialPrem V, Bhamini Krishna Rao, Arun Maiya Gundmi

122 A Comparison Study of 3 Stretching Protocols on Hamstrings LengthPriya Kannan, Stanley John Winser

126 Effect of Long Term Physical Exercise Training on Auditory and Visual Reaction TimeShashi kant Verma, Anand Mishra, Ajit Singh

130 Effect of Hamstring Static Stretch Training on Knee Flexion Concentric TorqueAmr Almaz Abdel-aziem, Osama Ragaa Abdelraouf

134 Sports Injuries: A new perspective on causationArunachalam Kumar

135 Effects of Different Elbow Positions on Latency and Amplitude of Motor Nerve Conduction Study of Ulnar NerveKakkad Ashish

139 Effectiveness of ‘Multidirectional Reach Test’ to Analyze Centre of Pressure Excursion in Healthy GeriatricPopulationAsmita Karajgi, Sujata Yardi

144 The Effect of Proprioceptive Exercises and Strengthening Exercises in Knee OsteoarthritisAastha Maggo, Shobhit Saxena, Shalini Grover

149 Predicting Neuromotor Outcome in Very Low Birth Weight Infants at One Year of Corrected Age UsingMovement Assessment of Infants ScaleDeepa Metgud, V D Patil, S M Dhaded

153 Comparison Among Different Head Neck Positions for the Effects on Wrist Flexor Torque ProductionDheeraj Lamba, Sapna Kharayat, Jaya Mehta, Ajay Joshi, Manish Kandpal

157 Effect of Saddle Heights on Craniovertebral Angle During Ergonomic CyclingDheeraj Lamba, Satish Pant, Girish Chandra

161 A Comparative Study of Cardiovascular Fitness in Normal Versus Obese ChildrenGaurang D Baxi, Tushar J Palekar, M Vijayakumar, Varoon C Jaiswal

167 Test Retest Reliability and Validity of Hindi Version of Neck Disability Index in Patients with Neck PainHalima Shakil, Sohrab A Khan, Puja C Thakur

170 Effect of Ankle Foot Orthosis on Plantar-flexor Tone and Gross Motor Functional Abilities in Children withHemiplegic Cerebral PalsyMeenakshi Batra, Vijai Prakash Sharma, Vijay Batra, Gyanendra Kumar Malik, Girdhar Gopal Agarwal

175 Normative Data of Evaluation Tool of Children Handwriting –manuscript (ETCH-M)Ganapathy Sankar U, R Riya

179 Effect of Passive Straight Leg Raise Sciatic Nerve Mobilization on Low Back Pain of Neurogenic OriginGurpreet Kaur, Shallu Sharma

185 Fatigue and its Correlation with Functional Outcome in Patients with StrokeHamdani N, Dhawan L, Maurya M

191 Effect of Exercise Rehabilitation Programme on Clinical Health Status of Osteoarthritis Knee PatientsJagmohan Singh, Paramvir Singh, M S Sohal

199 Effect of Supervised Versus Home Based Cardiac Rehabilitation on Heart Rate Recovery in Patients withCoronary Artery Bypass GraftingS Shagufta, Jamal Ali Moiz, Rajeev Aggarwal

1Renu Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Effect of Balance Training on Foam Platform in GeriatricPopulation: A randomized controlled trialRenu ChauhanM.P.T., Neurology, Department of Physiotherapy, College of Applied Education and Health Sciences, CAEHS, Meerut

Abstract

Background of Study

Fall prevention program is an important health strategy forelderly population. Thus, there is a need to develop effectivebalance training programs that improve balance in elderly.

Purpose of Study

To compare the effect of balance training on foam platformand on floor for the improvement of balance scores in the geriatricpopulation.

Procedure

The study is a randomized controlled trial. 30 Elderlysubjects, with age ranging from 60 – 75 yrs, were taken fromOutpatient Department of CAEHS, Meerut. Subjects weredivided into two groups: experimental and control. Experimentalgroup (n=15) were given balance training on Foam Platformand Control group (n=15) were given balance training on floor.All the subjects received balance training for 5 days a week for30 minutes for 4 weeks. Balance scores of all the subjects weretaken in the beginning and at the end of 4 weeks using BergBalance Scale (BBS) and Functional Reach Test (FRT). Datawas analyzed using student’s t-test.

Results

The mean & standard deviation values of experimentalgroup for FRT on day ‘30’ were 10.2 + 1.52 and BBS on day ‘30’55.26 + .96. The mean & standard deviation of control group forFRT on day ‘30’ was 9.0 + 1.25and BBS on day ‘30’ was 52.26+ 2.91. The p values obtained were significant i.e. p value wasless than 0.05.

Conclusions

Balance training on foam platform was found to be moreeffective than balance training on floor.

Introduction

WHO (World Health Organization) defines those “aged 60-74 years as geriatric and those older as aged”. The elderly arethe fastest growing segment of our population. In the comingyears, it will become essential for more health care professionalsto develop clinical expertise in evaluating and treating the uniquehealth concerns of this group.1

Geriatric people show a decline in ability to maintain balancewhen faced with the perturbations imposed by functionalrequirements such as dividing attention between task as isneeded to keep balance when walking in a crowd2. Falling hasbeen associated with an increase in morbidity and mortality ratein elderly population3.

A person who falls or almost falls could become fearful oranxious about subsequent falls and serious injury and associated

potential consequences. It results in loss of confidence,restriction of activities, social isolation and increaseddependence on others4.

Efforts to reduce the risk and incidence of falls in olderadults are plentiful as evidenced by intervention studies whichhave appeared in the literature with in the last 2 decades detailingvarious exercise interventions intended to reduce falls5-7.Exercise is effective in lowering falling risk in among elderly8-9.

These interventions have emphasized a variety of exercisemodes including resistance training, flexibility exercises10 manyof this interventions have focused too heavily on simplemaneuvers that are easier to quantify but that may not addressadequately the varied needs of different individuals.

However, because many different types of were studied, itwas impossible to determine which type was most effective.Keeping this in mind this study was designed with the purposeof improving balance in geriatric population while using foamplatform.

Methods

Design of Study

Experimental Study. Pre test and Post test match subjectdesign.

Population

Geriatric subjects from old age home and outpatientdepartment of College of Applied Education and HealthSciences, Meerut.

Sampling Technique

Convenient sampling

Inclusion Criteria

• Age 60- 75 years

Exclusion Criteria

• Any Neurological disease - stroke, hemiplegia,parkinson.

• Any acute Musculoskeletal injury• Acute Congestive heart failure• Severe visual deficit.• Any cognitive impairment• Sensory impairment

Instrumentation

• Foam pad - 16"x 9" x2"• Berg balance scale• Functional reach test• Standard measuring tape• Chair of 46 cm. of seating height

• Ball

Procedure

The subjects were invited to participate in the study. Adetailed explanation of the procedure was given after which thesubjects on informed consent. The subjects were assessed onthe two balance scales. The Berg Balance Scale (BBS) and thefunctional reach test (FRT).

Berg Balance Scale

Berg Balance Scale is an objective measure of static anddynamic balance abilities. The scale consists of 14 items thatare scored from 0 to 4, where 0 indicates an inability to perform

the task and 4 indicates the tasks were performed correctly andindependently. The maximum score of the test is 56. The itemsrange from sitting to standing, standing unsupported, sitting withback unsupported on the floor or on the stool, transfers, standingunsupported eyes closed, standing unsupported with feettogether, reaching forward with outstretched arm while standing,picking up an object from the floor in standing position, turningto look behind over the left and right shoulders while standing,turning 360º, placing alternate foot on step or stool while standingunsupported with one foot in front and standing on one leg.Scores obtained during the assessment were used in dataanalysis.

Functional Reach Test

Reach Test was measured by attaching a leveled yardstickto a wall with tape at the height of the right acromion process.The subject was asked to stand in a relaxed stance with theirshoulders perpendicular to the yardistick, and was instructednot to touch the wall but to extend the elbow with the shoulderat 90º flexion and hold the position for 3 sec. The hand is fisted.The placement of third metacarpal was recorded (position 1).The subject was then asked to reach as far forward as withoutlosing their balance or taking a step and hold for 3 sec. A repeatmeasurement is made in the forward reach position. Functionalreach was measured as the difference between positions 1 & 2and used for data analysis.

Renu Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Fig. 1: Illustrate the subject is performing one of the 14 itemsof Berg Balance Scale

Fig. 3: Illustrate the subject is performing Functional ReachTest

Fig. 4: Illustrate the subject is practicing to semi tandem position.

Fig. 2: Illustrate the subject is performing one of the 14 items ofBerg Balance Scale

Subjects of groups A received the balance training on foamplatform, which consists of

Flexibility exercise (3 to 5 repetitions 30 sec. hold)• Hamstring stretch• Calves stretch• Quadriceps stretch

The Balance exercises start with placing the feet in a seriesof positions that gradually reduce the base of support, holdingthe stance for 10-30 seconds.

• Semi tandem - Stand on foam with one foot in front ofthe other in semi tandem position.

• Full tandem - Stand on foam with heel of one footdirectly in front of the toes of the other foot.

Table 1: Comparison of Mean and SD of age, sex, height andweight of Group A and Group B

Age (mean No. of male Height Weight + SD ) / female

Group 68.6 + 3.92 Male - 7 159.0 + 7.9 63.8 + 10.1A Female - 8

Group 70.5 + 4.17 Male - 6 159.3 + 7.0 63.4 + 6.9 B Female - 9

Table 2: Comparison of Mean and SD of group A and group Bfor FRT

FRT 0 FRT 30 T0 test(Mean + SD, (Mean + SD,

N= 15) N= 30) t P

Group A 6.9 + 1.2 10.2 + 1.5 15.8 .000

Group B 7.13 + .99 9.0 + 1.3 5.5 .000

Table 3: Comparison of Mean and SD of group A and group Bfor Berg Balance Scale

BBS 0 BBS 30 T0 test(Mean + SD, (Mean + SD,

N= 15) N= 30) t P

Group A 49.9 + 3.9 55.2 + 1.0 6.6 .000

Group B 48.4 + 2.6 52.2 + 2.9 6.6 .000


Fig. 5: Illustrate the subject is practicing stepping in differentdirection

Fig. 6: Illustrate the subject is picking up an object from thefloor

Graph 1: Illustrates Mean and S.D. of F.R.T.

Graph 2: Illustrates Mean and S.D. of B.B.S

Graph 3: Illustrates Mean and S.D. of F.R.T. & B.B.S.

• Standing up on toes on the foam pad.• Standing on one foot on foam pad.Gradually, additional exercise that to the following are

introduced.Add dynamic movements to perturb the center of gravity,

such as:- Leaning or stepping in different direction on foam pad.- Reaching- Picking up on object on from the floor on standing on

foam pad.

4

Table 4: Comparison of Mean and SD of group A and group Bfor FRT and BBS.

Group A Group B T0 test(Mean + SD, (Mean + SD,

N= 15) N= 15) t P

FRT 0 6.93 + 1.16 7.13 + .99 .50 .61

FRT 30 10.2 + 1.52 9.0 + 1.25 2.3 .02

BBS 0 49.9 + 3.91 48.4 + 2.64 1.25 .21

BBS 30 55.26 + .96 52.26 + 2.91 3.78 .001

- Five minutes of cool down and relaxation activities.Breathing exercises for relaxation.

Subjects of group B received the same balance training onfloor.

Data was analyzed by using SPSS software. A student’s t-test was used to analyze the difference in the balanceimprovements in group 1 and group 2. Intra-group analysisbetween pre-intervention and post - intervention scores was alsodone for both the groups. A significance level of p < .05 wasfixed.

Results

A student’s t-test was used to compare the performance ofsubjects of group A and B on Functional Reach Test (FRT) andBerg Balance Scale (BBS) prior to the intervention programme

Discussion

We found significant improvement in both the groups butthe subjects who participated in the balance training on foamplatform showed better improvement in balance as comparedto those subjects who participated in the balance training onfloor.

The obvious importance of being able to improve balancehas resulted in a number of balance intervention studies. Whichinitially focused on task specific exercises and every day activitiessuch as getting in an out of a chair, or stepping up and from onelevel to another (Harada et al, 1995, Judge, 2003; Lord et al,2003, Nelson et al, 2004, Nitz and Choy, 2004, Steadman et al,2003), demonstrated that balance could be improved greatly,especially in rehabilitation and nursing home environments.

James, W. Bellew has shown significant effect of balancetraining (Medial - lateral and anterior posterior movement andbilateral partial squats) while standing on semi compressiblefoam roller devices in older women.11

Based on the findings of the FICSIT study and others, thespecific inclusion of balance activities is warranted in exerciseinterventions with goals of improving balance.12 However, manyprograms reported in the literature are of significantly greaterduration and frequent and require more specialized equipment,staff and facilities than the program reported in this study13.

This balance training program is short term, could beperformed independently and requires no expensive equipment.This program provides a simple effective and enjoyableopportunity for elderly to participate in exercises that arepromising in terms of preventing falls and keeping elderly moreactive for a longer period of time.

Limitations of the study

A small sample size was one of the major limitationsof the study. Also, most of the participants belonged to the samecommunity and were leading an active lifestyle. Thus, results

obtained cannot be generalized for all population types.

Clinical implications

These data suggest that the balance training on foamplatform is more effective in improving balance in geriatricpopulation as compared to the balance training on floor. Thishelps us to choose a better balance training program in geriatricpopulation above 60 years in order to improve balancesignificantly even in a short time duration.

The ultimate effect of this study is to improve balance withthe aim of reducing injurious falls in elderly population.

Future Research

Future research involving a longer time period andcomparing the effects of the two intervention programs ispossible. Also the research can be oriented towards finding outthe reduction in falls following balance training in either groupby maintaining a follow up for few months to years. The relevanceof this study can be increased by taking a larger sample ofsubjects.

Conclusion

This study concludes that although both balance trainingon floor and balance training on foam platform show significantimprovement on balance outcome scales, the subjects whoparticipated in the balance training on foam platform showedbetter improvement in balance as compared to those subjectswho participated in the balance training on floor. .

References

1. Falls and the elderly: Judith Mc Elhinney, R.N. GNP.Kenneth, J. Kovl. MD and Joseph O. Zuckerman, MD Vol.2, No. 1 winter. 1998.

2. Bloem BR, Valkenburg VV, Slabbekoom M, Willemsen, MD.The multiple tasks test development and normal strategies.Gait Posture 2 vol., 14 : 191-202.

3. Biomechanical assessment and Stress Test of dynamicPostural sway to preduct falls in healthy elderly. (John DLioyd, CPE, lifford M Gross.

4. Psychosocial effects on an exercise program in olderpersons who fall. Kevin m means, M.D., Patricia S. ‘O’sullivan).

5. Judge Jo, Lindsey C, Underwood M, Winsemius ‘D’ balanceimprovement in older women. Effects of exercise training.Phys Ther. 1993-73 : 254-265.

6. Hinman MR comparison of two short term balance trainingprograms for community dwelling older adults J Geriatricphysiotherapy 2002, 25 (3) : 10-15.

7. Bellew JW, Yates JW, Gater DR the initial effects of lowvolume strength training on balance in untrained older menand women J. strength cond res. 2003 :17 : 121-28.

8. Province MA, Hadley EC, Horn brook MC, Lipsitz, L.A, NillerJP, Mulrow CD, ory MG, et al. The effects of execise onfalls in elderly patients. A preplanned metaanalysis of theFICSIT trials. J Am Med Assoc. 1998, 273 :1341-47.

9. Gardner MM, Robertson MC Campbell AJ, exercise inpreventing falls and fall related injuries in older people : areview of randomised controlled trials. Br J Sports Med2000, 34 : 7-17.

10. Kromogata S, Netwton R. The effectiveness of Tai Chai onimproving balance in older adults : an evidence basedreview. J Geriatricf phy. Ther. 2003; 26(2): 9-16.

11. Province MA, Hadley EC, Hornbrook MC, LIksitz, LA, Miller


5Renu Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

JP, Mulrow CP. ory MG, sattin RW, Tinetti ME, Wolf SL.The effects of exercise on falls in elderly patients. J. Am.Med Assoc. 1995, 273 : 1341-1347.

12. Tinetti M, Baker D,Garrett P,Gotts chalk M, Koch M, Horwitz

R. Yale FICSIT: risk factor abatement strategy for fallprevention. J Am Geriatr Soc.1993; 41:315-320

13. Wolfson L, Whipple R,Judge j , Amerman P, Derby C, KingM. Training balance and strength in the elderly to improvefunction. J Am Geriatr Soc .1993; 41:341-343.

6

Botulinum Toxin as Treatment Modality for Spastic DiplegicCerebral Palsy Child: Our experience in 21 patientsRitesh Runu*, Vaibhav Agrawal**, Arunim Swaroop*, Devendra Dave****Assistant Professor, Orthopaedics, **Assistant Professor, Physiotherapy, ***Associate Professor, Department of Orthopaedicsand Department of Physiotherapy, Subharti Medical College and Hospital, Meerut, Uttar Pradesh

Abstract

Spasticity in cerebral palsy is one of its most important andcommon clinical presentation.It produces contractures,deformities and also hampers physiotherapy if not treated. Fortreatment of spasticity there are various modalities like stretchingexercises, casts, muscle relaxants, phenol injections, intraspinalbaclofen pump and dorsal selective rhizotomy. Botulinum toxinA, neuromuscular blocker, is a newer addition in this list. Wehave done a prospective uncontrolled study in 21 patients withdiplegic spastic cerebral palsy. The toxin was injected in lowerlimbs for spastic hamstrings and gastrosoleus. The average ageof patients was 6.1yrs. Average number of injection given wasone. The patients were followed up for 6 months after injection.We conclude that Botulinum toxin A is a good muscle relaxant,easy to administer and has negligible side effects. It improvestolerance to cast application and physiotherapy which makesthe rehabilitation of patient easy. Except the cost of therapy andits “window period” it is best modality of treatment for the spasticdiplegic cerebral palsy patients.

Key Words

Botulinum toxin A (BTX - A), Cerebral palsy (CP), ModifiedAshworth scale, Spasticity, Tardieu Scale.

Introduction

Cerebral palsy (CP) is a neuromuscular disordercharacterized by aberrant control of movement and posture dueto injury to the developing brain. It is non progressive disorderand the symptoms appear early in life. Apart from motor deficitsthe patients of CP may have sensory deficits (hearing or visual),mental retardation, epilepsy, equilibrium problems, learningdisabilities, and emotional problem.1.

In spastic CP one limb (monoplegic), two limbs (diplegic),four limbs (quadriplegic) or one half of body (hemiplegic) mayget affected. Due to spasticity the child is unable to attain normalposture which causes dynamic and fixed contractures, bonytorsional deformities, truncal imbalance and delayeddevelopment of motor skills.2. It also hampers physiotherapy dueto pain and reflex spasm of the muscles.2. Thus the rehabilitationof the patient is delayed. For proper and adequate physiotherapya patient should have calm environment, relaxed mind andmuscles.3. Muscle relaxation is usually attained by medicines(oral) and local intramuscular agents. They are usually shortacting or produce generalized muscle weakness. For adequatemuscle relaxation, the dose of medicine required is too high.This makes a child floppy and any physiotherapy becomesdifficult.4.

Any agent producing localized muscle relaxation withoutaffecting brain and is reversible in nature is an ideal relaxant for

these patients. Botulinum Toxin A (BTX – A) is such agent whichproduces localized muscle relaxation and is reversible in nature.It produces the chemical denervation, thereby relaxes the muscleand helps in physiotherapy.5.

There have been few studies done in Indian subcontinenton use of botulinum toxin A in cerebral palsy.6. Being differentpopulation characteristics and poor socio economic condition,we conducted a prospective study over the effect of BTX - A inspastic diplegic CP in Indian subcontinent.

Material and Methods

This was a prospective trial on 21 randomly selected spasticdiplegic CP patients. The duration of study was from July 2008to December 2009.

Inclusion criteria were: 1 age 2–9 years,2 spastic diplegia,3

community or indoor ambulator,4 No fixed musculoskeletaldeformities,5 ongoing physical therapy (PT) of a minimum of60-minute session per week. All participants received directphysical therapy for a minimum of 1 hour per week during thestudy period. The therapy regimen was left to the discretion ofthe treating physical therapist.

The patients having fixed contractures, associatedneurological disorders, mental retardation and operated caseswere excluded from the study.

The patients were selected in OPD after careful clinicalexamination. Before admission the patients were clinicallyevaluated twice at interval of one month. They were put onphysiotherapy at least for one hour per week. After pre anestheticexamination and consent the patient was taken for BTX - Ainjection under general anaethesia. Before injection the patientwas reevaluated. Then the target muscle area was cleaned andneedle was inserted. The dose of toxin is 3-6units per kg ofbody weight for large muscles and 1-2 units per kg of body weightfor small muscle. The reconstituted toxin was given immediately.No second dose was given. Before injection the location ofneedle was confirmed by movement of the part. In hamstringsthe needle moved on flexion and extension of knee joint and ingastrosoleus it moved on plantar flexion and dorsiflexion of theankle. Once needle position was confirmed, injection was givenat 2 points in hamstrings and at four points in gastrosoleus.After injection below or above knee cast was applied. It supportedthe joint at time of greatest muscular weakness and preventsthe recurrence of contracture. After two weeks the casts wereremoved and the patients were put on structured vigorousphysiotherapy. For hip adductors abduction pillow was given.For hip flexors prone lying was suggested.

Tools for patient assessment were clinical examination,modified Ashworth grading for spasticity and Tardieu scale. Thelevel of significance was measured using paired t test.

Modified Ashworth scale7.: It is to determine the tonicity of themuscle.

0- Normal,1- Increased tone felt as catch in the range of motion

(ROM) at the end,1+ - increased tone felt as catch with minimal resistance in

less than 50 % of ROM,2 – Increased tone felt as catch with mild resistance in

Address for correspondence:Dr. Ritesh RunuAssistant Professor, OrthopaedicsSubharti Medical CollegeMeerut, UP- 250002

Ritesh Renu / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

7

more than 50% of ROM, 3 – Marked increase in tone with passive ROM difficult, 4 – Limb fixed in flexion or extension.

Tardieu scale 8.: It is to know the dynamic muscle length.When the limb is moved across the joint fastly, the position wherecatch appears is R1. Similarly appearance of catch in slow modei.e. range of motion is R2. The difference (R2 – R1) shows thedynamic muscle length and amount of spasticity. The patientswith more spasticity and R2 nearer to the end of ROM benefitmost from the BTA injection. Those with less value have moreof fixed deformity and they require surgery.

Observations and Results

All 21 patients were randomly selected and evaluated inOPD. These patients were again evaluated before injection andthen at 6 weeks and 6 months after injection. The tools forevaluation were modified Ashworth grade and Tardieu scale.The results were classified as good, fair and poor. Good werehaving significant reduction of spasticity (2 point reduction inAshworth grade) and better postural control( unsupportedstanding for more than 30 seconds), fair were having moderatereduction in spasticity(1 point reduction in Ashworth grade) andbetter postural control and poor were having slight or noreduction in spasticity and poor postural control..

The average age of patients was 6.1yrs (2yrs – 9 yrs). 15were male and 6 were female patients. The commonly injectedmuscles in lower limb were gastrosoleus and hamstrings. TheAshworth grading was assessed pre injection and then at everyvisit (6wks, 12 wks and 24 wks) post injection for each musclegroup. The change in ashworth grading was measured. Themaximum change in grade was seen at 6 weeks which waslower than the pre injection state. At end of 6 months the changein ashworth grading for Gastrosoleus (n= 26) was 1.80. This isapprox 2 point improvement in the muscle spasticity. Similarlythe improvement in the spasticity of hamstrings (n=32) was 1.59.The overall improvement in spasticity was noted in both themuscles. At 6 months the spasticity recurred in 32% patients(including both gastrosoleus and hamstrings). The gradeincreased but the level was still lower than the pre injection status.The significance of this change was measured using paired ttest. Comparing the pre injection data with the post injectiondata, we found significant (p value < 0.05%) change in ashworthgrade.

The change in spasticity was clinically correlated with theincrease in range of motion that is, change in Tardieu scale. Itwas measured in every patient for each muscle group. Forgastrosoleus the maximum dorsiflexion possible with suddenjerk (R1) and maximum dorsiflexion with sustained force (R2)was recorded. Similarly for hamstrings the R1 and R2 forpopliteal angle was noted. For gastrosoleus (TA) and hamstrings(HAMS), post BTX-A injection the change in range of motionwas noted. The ROM increased in 2 patients (Right TA), 1 patient(Left TA), 3 patients (Right hams) and 3 patients (Left hams).No change occurred in 4(right TA), 5(left TA), 2(right hams) and2 patients (left Hams). The ROM reduced in remaining patients.We found consistently no change or marginal change in the R2.We compared the pre injection ROM with the post injection ROMby paired t-test. It showed insignificant change in the ROM (pvalue < 0.05%).

Out of 21 patients 9 were community ambulators and 12were home ambulators. All ambulators required orthosis andphysical support for walking. The ambulation was started at 2weeks after removal of casts. Then it was observed at everyvisit. All 9 community ambulators who were able to walk beforeinjection, deteriorated at 2 weeks after injection. At 12 weeks allpatients required orthotic support for walking and at 6 months 5patients were able to walk without physical support.

In the home ambulator group, 7 patients were able tobecome community ambulator. They were able to walk withorthotic support.

Parental assessment is a crude method of assessment.The parental assessment was found to be different comparedto clinical parameters. It was due to slight improvements, highexpectation, unrealistic approach and illiterate parents.

Out of 21, six had good, thirteen had fair and two had poorresults at the end of 6 months.

Discussion

Cerebral palsy, a common chronic disabling condition,occurs in 1.5 to 3/1000 live births with similar prevalence rate inadolescence and adulthood.9. Among various types, spasticcerebral palsy is the commonest seen in 70 – 80% cases.10.

Topographically it is classified into hemiplegic, diplegic andtetraplegic types according to the involvement of body part.

Diplegic CP is a condition where lower limbs are affectedmore than upper limbs with fair to good trunk and head controland little or no bulbar involvement. It is the most common formof spastic CP.11. Due to spasticity the muscles do not relax fully,producing abnormal pull over the soft bones of children. Thisleads to bony deformity.

The main goal of treatment in these patients is to maximizethe function, minimize the contractures and deformity, delay theneed of surgery, develop good posture control and balance sothat they can equally participate in activities with peers, candevelop good cognitive skills, social skills, and can haveemotional control and vocational potential. These goals can beattained only by reduction of spasticity, physiotherapy trainingand avoidance of secondary insults to brain.12. In younger agegroup, the spasticity is more while fixed deformity is less. Henceearly intervention has better results.

After first therapeutic use of Botulinum Toxin- A for treatmentof strabismus in 1980 several studies have been conductedregarding its use in spastic cerebral palsy.13,14. The effect anduse of BTX-A in CP is only for reduction of spasticity. Thisreduction in spasticity is dose dependent.15. Hence the doseshould be measured and planned. Usually the dose has beendefined for each muscle by the members of the Spasticity StudyGroup. This dose is again changed according to patient weight,duration of therapy, muscle bulk, number of muscles injected atone sitting, Ashworth score and muscle weakness.1

Apart from CP the indications have been extended in adultorthopaedic problems. For example; multiple sclerosis 16 stroke17

head injury18 lateral epicondylitis.19

The mode of action of BTX-A is focal chemodenervation ofthe spastic muscles20,21,22. With time, through diffusion, the toxinproduces chemodenervation and muscular relaxation. Thischemodenervation due to BTX-A is not permanent. Within fourweeks, restoration of the SNARE protein complex allowsexocytosis of Acetylcholine to resume. This reestablishes thenerve conduction, initially by new axonal sprouting andelongation of the end plates and eventually by retraction of thenew axonal sprouts.15. Thus a spastic muscle is temporarilychemodenervated and relaxed for 12 to 16 weeks. This “windowperiod” is clinically used for physiotherapy. This period is usuallyof 8 weeks.15. The return of spasticity may take longer time. 24.

There have been several studies showing beneficial effectsof BTX – A in CP patients with lower limb spasticity.25,26,27. Mostof the studies have been done on lower limb spasticity speciallyequinus deformity.2 Koman et al and other authors have shownreduction in spasticity and improvement in gait and balancefollowing BTX-A for dynamic foot and ankle deformities.2,28,29.

Studies shows that children with more of spastic deformities,show most dramatic and long lasting effect of BTX-A.2

Due to spasticity, cerebral palsy patients develop a dynamicdeformity which causes pain with orthosis. Judy Leach claimthat the use of BTX injection allows the patient to use the orthosis


8

which was previously impractical to use.30.

The effect of BTX-A on spasticity is not consistent. Thespasticity recurs with time due to nerve sprouting. There aredifferent observations which show spasticity returns either tothe previous level or less. Ozlem et al found significant reductionin spasticity (modified Ashworth Scale) following BTX-A injection.This reduction in spasticity gradually decreased with time, butthe spasticity was still less than the base line findings. 26,28,29,31,32.

Contrary to these reports there are studies showing no orlimited benefit of using BTX-A in CP patients15,28,31,32. Studiesalso show that spasticity returns to pre injection level.28

An important limitation of using spasticity as a clinicalendpoint is that it cannot be correlated with functional change.This has been shown that Tardieu score is more reliable andsensitive than Ashworth scale.33,34. Higher dose of BTA producesgreater reduction of spasticity but substantial functional declineoccurs simultaneously. Hence reduction of ashworth scorecannot be correlated with improvement.

In our study, we found significant change in Ashworth gradein patients. The patients were able to do physiotherapy and wereable to use the orthosis. But the Pre injection and post injectionchange in Tardieu score was insignificant. This was becausethe change in R2 was less. The ROM for the joint improved butthe end point did not change much. Comparing with Ashworthscale, due to BTX- A the initial spasticity subsided but the totallength of the muscle did not increase. Hence Ashworth gradingimproved but the Tardieu grade changed little. More importantlythere was significant improvement in ambulatory status.

Limitation of our study was small sample size and the shortduration of study. The non inclusion of Gross Motor FunctionControl Scale and gait analysis reduced the objectivity of thestudy. Cost of medicine was the biggest hurdle in our study.Due to low socioeconomic status and no insurance coveragefor this disease, it was very difficult to persuade the parents forthis injection. Other difficulty was lack of physiotherapist andlow motivation level in parents to take their child tophysiotherapist. Lack of awareness among primary physicianwas also found to be a hurdle regarding this treatment modality.

In assessing the net outcome in CP patients it is essentialto know and document the baseline functional capabilities ofthe patient. All the patient cannot achieve the same level of motorskills after 6 months. Hence individual counseling is must. Theoutcome also depends on the age of intervention, previousphysiotherapy given or not, parents dedication, amount ofspasticity at the age of first intervention, and economic status ofthe patient.

Our field of work was western Uttar Pradesh in India wheremaximum population is rural based and level of literacy is low.This study is significant because no similar study has been donein this region of Asia.

Conclusion

A CP child develops their own skill as per the deficit. Theyachieve the milestones which is new for them contrary toneurologically compromised adult who had already experiencedall the abilities for some time. BTX - A injection can be used forpatients with dynamic contractures in less than 3 muscle groupshindering the rehabilitation of the patient. Cost is the prohibitivefactor for its use. But considering the disability and social burdenof cerebral palsy the use of this drug is very much cost effective.

References

1. Barry S. Russman, Ann Tilton, Mark E. Gormley. Cerebralpalsy: A rational approach to a treatment protocol and therole of botulinum toxin in treatment. Muscle and nervesupplement 1997; 20 (suppl 6): S 181 – 193.

2. Roslyn B, Graham HK. Botulinum toxin A in themanagement of children with cerebral palsy: indications

and outcome. European J Neurol 1997; Vol 4 (supple 2):S15 - 22.

3. Tardieu C, Tabary JC, Tabary C, Huet de la Tour E.Comparision of the sarcomere number of young and adultanimals. J Physiol 1977; 73: 1045-55.

4. Verrotti A, Greco R, Spalice A, Chiarelli F, Iannetti P.Pharmacotherapy of spasticity in children with cerebralpalsy. Paediatr Neurol 2006; 34: 1-6.

5. Koman LA, Mooney JFIII, Smith B, Goodman A, MulvaneyT. Management of cerebral palsy with botulinum A toxin :preliminary investigation. J Paediatr Orthop 1993; 13: 489-495.

6. Chitnis A, Johari A, Doshi L, Agrawal T. Botulinum toxininjection for cerebral palsy in second decade of life.Physiotherapy 2002;vol 1,Issue 1: 5 – 10.

7. Ashworth B: Priliminary trial of carisoprodal in multiplesclerosis. Practitioner 1964; 192: 540.

8. Tardieu G, Shentoub S, Delarue R. A la recherché d’unetechnique de mesure de la spasticite. Rev Neurol 1954;91: 143-144.

9. Morton RE, Hankinson J, Nicholson J. Botulinum toxin forcerebral palsy; where are we now? Arch Dis Child.2004;89:1133– 1137.

10. Ozlen P, Can K, Leyla L, Ozgur B, Haluk B. J child neurology2006; no12: 1009-1012.

11. Blair E,Stanley FJ. Issues in the classification andepidemiology of cerebral palsy. Ment Retard Dev DisabilRes Rev. 1997;3: 184-193.

12. Russman Barry S, Tilton Ann, Gormley Mark E. Cerebralpalsy: A Rational Approach to a Treatment Protocol; andthe Role of Botulinum Toxin in treatment. Muscle andNerve, Suppl 6; 1997: S 181- 192.

13. Scott AB. Botulinum toxin injection of eye muscles to correctstrabismus. Trans Am Opthalmol Soc 1981; 79: 734- 770.

14. Bjornson K, Hays R, Graubert C, Price R, Won F,McLaughlin JF, et al. Botulinum Toxin for Spasticity inchildren with cerebral palsy: A comprehensive evaluation.Paediatrics 2007; 120(1): 49 – 58.

15. Eames NW, Baker R, Hill N, Graham K, Taylor T, CosgroveA. The effect of botulinum toxin A on gastrocnemius length:magnitude and duration of response. Dev Med Child Neurol.1999; 41: 226 – 32.

16. Hyman N, Barnes M, Bhakta B, et al. Botulinum Toxin(Dysport) treatment of hip adductor spasticity in multiplesclerosis: a prospective, randomized, double blind, placebocontrolled, dose ranging study. J Neurol NeurosurgPsychiatry 2000; 68: 707- 12.

17. Miscio G, Delconte C, Pianca D, et al. Botulinum Toxin inpost stroke patients: stiffness modification and clinicalimplications. J Neurol 2004; 251:189-196.

18. FockJ, Galea MP, Stillman BC, Rawicki B, Clarke M.Functional outcome following Botulinum Toxin A injectionto reduce spastic equinus in adults with traumatic braininjury. Brain Inj 2004; 18: 57-63.

19. Morre HH, Keizer SB, Van os JJ. Treatment of chronic tenniselbow with Botulinum toxin. Lancet 1997; 349: 1746.

20. Arnon SS, Schechter R, Inglesby TV, et al. Botulinum Toxinas a biological weapon: medical and public healthmanagement. JAMA 2001; 285: 1059- 70.

21. Koman LA, Smith BP, Shilt JS. Cerebral palsy. Lancet 2004;363: 1619- 23.

22. Blasi J, Chapman E, Link E, et al. Botulinum neurotoxin Aselectively cleaves the synaptic protein SNAP – 25. Nature1993; 365: 160-3.

23. De Paina A, Meunier FA, Molgo J, Aoki KR, Dolly JO.Functional repair of motor end plates after BotulinumNeurotoxin Type A poisoning: biphasic switch of synapticactivity between nerve sprouts and their parent terminals.Proc natl Acad Sci USA 1999; 96: 3200-5.

24. To EW, Ahuja AT, Ho WS, King WW, Wong WK, Pang PC,


9

Hui AC. A prosapective study of the effect of botulinum toxinA on masseteric muscle hypertrophy with ultrasonographicand electromyographic measurement. Br J Plast Surg 2001;54: 197 – 200.

25. Baker R, Jasinski M, Maciag- Tymecka I, et al. Botulinumtoxin treatment of spasticity in diplegic cerebral palsy: arandomized ,double blind, placebo controlled, dose rangingstudy. Dev Med Child Neurol 2002; 44: 666-75.

26. Koman LA, Mooney JF 3rd, Smith BP, Walker F, Leon JM.Botulinum Toxin Type A neuromuscular blockade in thetreatment of lower extremity spasticity in cerebral palsy: arandomized, double blind, placebo controlled trial: BOTOXstudy group.J Paediatr Orthop 2000; 20: 108-15.

27. Sutherland DH, Kaufman KR, Wyatt MP, Chambers HG,Mubarak SJ. Double blind study of botulinum A toxininjections into the gastrocnemius muscle in patients withcerebral palsy. Gait Posture 1999; 10: 1 – 9.

28. Reddihough DS, King JA, Coleman GJ, Fosang A, McCoyAT, Thomason P, et al. Functional outcome of botulinumtoxin A injections to the lower limbs in cerebral palsy. DevMed Child Neurol 2002; 44: 820 – 27.

29. Cosgrove AP, Graham HK. Botulinum Toxin A in themanagement of spasticity in cerebral palsy. Br J Surg 1992;74-B: 135-136.

30. Judy Leach. Children undergoing treatment with botulinumtoxin: The role of the physical therapist. Muscle and nerve1997; suppl 6: 194 – 206.

31. Ubhi T, Bhakta BB, Ives HL, Allgar V, Roussounis SH.Randomised Double blind placebo controlled trial of theeffect of botulinum toxin on walking in cerebral palsy. ArchDis Child 2000; 83: 481- 487.

32. Ade Hall RA, Moore AP. Botulinum toxin type A in thetreatment of lower limb spasticity in cerebral palsy.Cochrane Database Syst Rev 2000; CD 001408.

33. Boyd RN, Graham HK: Objective measurement of clinicalfindings in the use of botulinum toxin type A for themanagement of children with cerebral palsy. Eur J Neurol1999; (Suppl 4): S23-S35.

34. Fosang AL, Galea MP, McCoy AT, Reddihough DS, Story I:Measures of muscle and joint performance in the lowerlimb of children with cerebral palsy. Dev Med Child Neurol2003; 45: 664-670.


10

Is Knee Range of Movement on Discharge Important After TotalKnee Replacement - A prospective audit based studyRoss Darch*, Jonathan Swan**, Tom Wainwright***, Robert Middleton*****Orthopaedic Physiotherapist, **Orthopaedic Therapy Team Leader/ Extended Scope Practitioner Physiotherapist, ***ClinicalResearcher in Orthopaedics, ****Consultant Orthopaedic Surgeon, The Royal Bournemouth and Christchurch Hospitals NHSTrust, England, The Royal Bournemouth Hospital Visiting Associate, CoPMRE, Bournemouth University, U.K.

Abstract

Questions

Is knee range of movement on discharge important aftertotal knee replacement? Is there a difference in flexion over 6weeks post TKR between sub-groups based on varying flexionscores on discharge?

Design

A prospective audit utilising a repeated measures designwas adopted, using a 6-week follow-up period to allow for initialpost-op tissue healing and a physiotherapy treatmentintervention to commence.

Participants

A convenience sample of 24 patients undergoing TKR wasmeasured prior to discharge and then at their routine 6-weekfollow-up.

Intervention and Outcome Measures

A standard hand-held goniometer was used to measuresubjects’ knee flexion and extension on discharge and at a six-week follow-up in both sitting on the edge of a plinth andsupported long sitting respectively using 5º measurementintervals.

Results

During the first six-weeks post TKR, all patients significantlyincreased their knee flexion (CI 95%, P<0.0001). It is alsoapparent that knee excursion also significantly increased overthe same time period regardless the patient’s movement atdischarge. There was a statistically significant change in kneeextension scores in all patients post TKR (CI 95%, P<0.004).This showed a reduced ability to extend the knee after a TKR.There was no significant difference in flexion scores betweengroups over the six weeks (CI 95%, P<0.5).

Conclusion

This study supports the notion that range of movement atdischarge is not essential as all patients improved their kneeflexion and total movement over a six-week follow-up anddifferences between groups were not significant. Furtherresearch is needed to support the outcome of reduced kneeextension post TKR and the implications it has on rehabilitationpost TKR.

Introduction

There is supportive evidence to suggest that total kneereplacement (TKR) is an effective treatment intervention forosteoarthritis and that it not only relieves pain but also greatlyimproves mobility in 90% of patients.1 Arthritis can limit activerange of movement (AROM) at one or both extremes of range.2

The goal of TKR is to provide the best possible outcome for thepatient by relieving pain and substantially improving patients’mobility and quality of life (QOL).2

Knee range of movement is a major component of mostjoint-specific scoring outcome measures3,4 as it is widely useddue to its simplicity to understand and as it directly measuresthe joints’ condition 4, 5. It is therefore important to evaluate theeffectiveness of objective outcome measures such as activerange of movement. From this an evaluation of surgical successand its impact on a patients’ QOL can be made. Clinically, athreshold of 95° has been documented as the minimum amountof knee flexion required to perform activities of daily living. 3, 4,although another study indicated that a range of activities fourmonth post TKR required between 54°-69° flexion to completecompetently6. This study suggests figures would suggest aflexion angle of much less than ninety would be sufficient tocontinue with normal daily activities.

Contrastingly, Rowe et al.,2 state that more than 90° isneeded to complete some daily activities. This study also reportsthat patients who require more than 90° flexion may not achievethis with a TKR and may therefore affect their QOL. It concludedthat the most common outcome for TKR is likely to be a loss ofAROM from pre-operation and therefore a reduced ability toperform functional activities, with the primary benefit of TKRbeing reduced pain.

There is sparse research into the relationship betweenAROM and QOL. There is also conflicting evidence to supportthe net gains in AROM from TKR. There is limited grade Ia andIb levels of evidence to clarify the flexion gains post TKR. Thepurpose of this study is to determine if there is a differencebetween patients in knee movement at six weeks depending ontheir movement at discharge. The experimental hypothesis isthat there will be a significant difference in flexion scores at sixweeks post TKR between groups of varying flexion scores atdischarge.

Methods

Design

This study used a quantitative approach, employing arepeated measures design. This increased the generalisabilityof the data collected and allowed for more objective andmeasurable outcomes when establishing a relationship betweenAROM on discharge and at a 6-week follow-up. The datacollector at the 6-week follow up was blinded to the results ondischarge from hospital.

Participants

Twenty-four subjects were enrolled to the study using a

Ross Darch / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Address for correspondence:Mr Ross DarchBSc (Hons) MCSPOrthopaedic Physiotherapist, The Royal Bournemouth andChristchurch Hospitals NHS Trust, [email protected]

11

convenience sampling method. Patients were included who hadundergone a TKR at the Derwent Unit (Royal Bournemouth andChristchurch Hospitals NHS Trust, RBCH). There were nowithdrawals and no subjects refused to be re-measured at thesecond data collection. The participants were aged 58-72 witha mean age of 65.

Intervention

All participants underwent a TKR procedure with astandardised rehabilitation process as an in-patient. All subjectshad their maximal knee flexion and extension scores measuredprior to discharge. Flexion and extension were measured insitting and supported sitting respectively. Following the recordingof base-line measurements at discharge, all participantsunderwent a physiotherapy programme at their nearest hospital.All participants were given a standard series of knee range ofmovement and quadriceps strengthening exercises and wereinstructed to complete these three times a day. 7 All patientswere given advice on PRICE principles to help limit thecomplication of swelling and pain, which could potentially havelimited improvements in knee range of movement at the 6-weekfollow-up. All patients were re-measured at a routine 6-weekfollow up appointment. Flexion and extension scores were re-measured in the same positions.

Outcome Measures

Table 1: Allocation of subjects

Flexion onGroup D/C No. Male Female

1 75>79 9 4 5

2 80>84 6 2 4

3 85>89 6 3 3

4 90> 3 2 1

Measures were taken by the use of a standard one-degreeinterval goniometer, using bony landmarks previously tested byLenssen et al.8 Measurements were recorded at five-degreeintervals as supported by Holm et al.,9 who states that measuringlower limb range of movement using 5-degree intervals has ahigh reliability between researchers.

Data Analysis

A sample size calculation of 18 subjects using a powerfrequency of 0.8 was taken. The study used an actual samplesize of 24 to allow for withdrawals.

Descriptive statistical methods were used to analyse theextension and flexion movements of all subject groups both on

Table 2: Knee movement results

Extension on Flexion on Extension Flexion at discharge discharge at 6-weeks 6-weeks

Mean (SD) Range Mean (SD) Range Mean (SD) Range Mean (SD) Range

Group 1 4.44 (3.01) 0-10 75 (0) 0 6.67 (5) 0-15 88.33 (8.29) 75-100

Group 2 2.5 (2.74) 0-5 80 (0) 0 5 (7.75) 0-15 93.33 (8.75) 85-110

Group 3 3.33 (2.58) 0-5 85 (0) 0 5 (3.16) 0-10 95.83 (4.92) 90-100

Group 4 1.67 (2.89) 0-5 91.67 (2.89) 90-95 5 (5) 0-10 101.67 (7.64) 95-110


Comparison of knee flexion between sub-groups

Graph 1: Comparison of knee flexion

12

discharge and at a routine 6-week follow-up.Normality of all data was tested, using the Shapiro-Wilk

test and was found not to be significantly different from normal(P= 0.241 to 0.36), therefore the data was analysed using

parametric statistical analysis. An independent ANOVA was usedto detect any significant differences over time. A repeatedmeasures ANOVA was used to detect a between-group changein the movement excursion post TKR. All data was analysed ata level of statistical significance of 0.05 and a power of 0.95.

Results

Flow of Participants Through the Study

A total of 24 patients participated in this study. At baseline,patients were sub categorised based on their flexion theyachieved on discharge scores (Table 1). There were noparticipant withdrawals, 9 (37.5%) achieving 75-79° flexion, 6(25%) 80-84°, 6 (25%) 85-89° and 3 (12.5%) 90° and over ondischarge. Table 2 shows the characteristics of the sub groups’range of movement at baseline and at 6 weeks follow-up.

Graph 1 shows that all subject groups increased kneeflexion from baseline measurements at discharge to the six-week follow-up. Patients who achieved greater flexion ondischarge also achieved a greater amount of flexion at 6-weeks.

Although all patient groups experience improvements inflexion (Graph 1), it appears that active knee extension worsensin the first six weeks after discharge following a TKR procedure.Graph 2 highlights those that had the least amount of flexion ondischarge (Group1) had the biggest losses in knee extension.This means that those who struggled to flex their knee ondischarge lost the ability to extend their knee more than otherpatients six weeks post TKR.

These results show that knee flexion increases but

extension is lost over the first six weeks following discharge,irrespective of knee flexion on discharge.

Graph 3 shows that knee flexion scores over a six-weekperiod increase more in groups of patients who have less kneeflexion at discharge (Groups 1 and 2). In summary, those whohave poor knee flexion on discharge gain more knee flexion inthe first six-weeks post operation but still have less flexion thatthose who were discharged with 90° knee flexion. Those patientswho have the most knee flexion on discharge still improve theirknee flexion during the first six-weeks post TKR but at a slowerrate.

Knee flexion for all subject groups showed a significantincrease (CI 95%, P<0.0001) over a six-week follow up period.The patients’ ability to extend their knees showed a significantdecrease (CI 95%, P<0.004) over a six-week follow up period.Total knee excursion for all subjects showed a significantincrease (CI 95%, P<0.0001) over a six-week follow-up period.There was no significant difference for between group changesfor end knee flexion, extension and excursion over a six-weekperiod.

Discussion

Importance of Knee Flexion

When analysing the descriptive data, significant increasesin knee flexion scores were demonstrated in all TKR patients intheir first 6 weeks. However there was no statistical differencein flexion at 6 weeks between patients grouped by flexion ROMat discharge. It can therefore be interpreted that despite adifference in ROM on discharge, patients continue to improveknee flexion no matter how much flexion they achieved ondischarge.

When extrapolating the results of the study clinically, thisstudy could be used to challenge the theory that 90° flexionrange of movement is required at discharge 2, as all patientsimproved their knee flexion at six-week follow-up regardless oftheir range on discharge. A minimum flexion range of 75° couldhave positive implications for patient length of stay and paincontrol. Chiu et al.3 reported that increases in pain levels arelikely to increase length of stay. By lowering the threshold of 75°this may allow patients to be better pain controlled and reducelength of stay.

Although all patients improved their flexion at 6 weeks,descriptive data indicates that the group with 75° on dischargedid not achieve, on average, 90° or over at 6 week follow up.Rowe et al. 2 found that 50% of TKR patients could not flex theirknee beyond 90° at a one-year follow-up. Rowe et al. 2 supportsover 90° as a threshold by stating that more than 90° is neededto competently complete some activities of daily living. In thecurrent study, 79% of patients were able to achieve this rangeat a 6-week follow –up. Other research indicates that a thresholdof 95° is the minimum knee flexion required to be able to risefrom a chair, climb stairs and walk normally.3,4 In the currentstudy, 46% of patients reached this threshold recommendationof knee flexion at 6 weeks.

In contrast to other studies, Myles et al6 recommended thatpatients require only 69° to complete most activities of daily living.All flexion scores of the current study surpass therecommendations of Myles et al.6 and further support the notionthat patients could be discharged from hospital post TKR withless than 75°. If patients continue to make significant gainsover the first 6 weeks after being discharged with 75° flexion (asin the current study) then a strong case for challenging thedischarge criteria for knee replacements can be made. This isfurther supported by evidence indicating that mobilisation underanaesthetic (MUA) is most commonly performed on patientswith flexion of less than 80° 1 year post TKR10,11. The currentstudy demonstrates flexion greater than 80° at a 6-week follow-


Comparison of knee extension between sub-groups

Graph 2: Comparison of knee extension

Comparison of total knee movement between sub-groups

Graph 3: Knee movement changes over 6-weeks

13

up for all patients, which is superior to that reported in the MUAstudies.10, 11

It seems reasonable to suggest that further follow-upintervals at 3, 6 and 12 months, would be beneficial to helpidentify if the improved range at 6 weeks is continued at longerterm follow up. This would also enable further analysis of thetrend of reducing flexion in the 75° group demonstrated in thedescriptive data. From this a change to the discharge criteriafor flexion post operatively could be suggested, which could havebenefits for both the patient and resources, without any long-term limitations to function. In addition to longer term follow up,a larger sample size would benefit future studies. Althoughgreater than the number needed from a sample powercalculation, a larger sample size would improve the study.

Importance of AROM as a Discharge Criteria

It is important to note that knee flexion is just one aspect ofbeing able to competently complete a functional task and thatthere are many other factors including hip movement, lower limbstrength and knee extension. This further highlights theimportance to assess a surgical outcome such as TKR with afunctional measure that incorporates more than just knee flexion.

When analysing the descriptive data it was also found thatall TKR subjects demonstrated a loss in active knee extensionover the first post-operative 6 weeks. This was found to bestatistically significant. This could be due to a lack of compliancewith PRICE principles leading to poor management of post-opswelling. This could also be due to physiological tightening ofthe joint capsule and hamstrings or the varying rehabilitationthat patients received post TKR. There is no research to theauthor’s knowledge reporting loss of knee extension post TKR.

In conclusion, this study could be used to support the notionthat high flexion range of movement at discharge is not essentialas all patients improved their knee over a six-week follow-up. Italso reports that not all patients reach the common surgeonbased goal of 90° flexion at their six-week follow-up. Evaluationof the literature suggests that high AROM is not necessarily animportant discharge criteria or outcome measure post TKR;however, further research is required to evaluate minimum flexionrequired to give a good functional outcome.

References

1. Woolhead G, Donovan J, Dieppe P. Outcomes of total kneereplacement: a qualitative study. Rheumatology.2005;44:1032–103.

2. Rowe P, Myles C, Nutton R. The effect of total kneearthroplasty on joint movement during functional activitiesand joint range of motion with particular regard to higherflexion users. Journal of Orthopaedic Surgery.2005;13(2):131-138.

3. Chiu K, Ng T, Tang W, Yau W. Review article: Knee flexionafter total knee arthroplasty. Journal of Orthopaedic Surgery.2000;10(2):194–202.

4. Miner A, Lingard E, Wright E, Sledge C, Katz J. Knee rangeof motion after total knee arthroplasty. How important isthis as an outcome measure? The Journal of Arthroplasty.2003;18(3):286-294.

5. Murray R, Fitzpatrick K, Rogers H, Pandit D, Beard J, CarrJ, Dawson J. The use of the Oxford hip and knee scores.Bone Joint Surgery. 2007;89(B):1010-14.

6. Myles C, Rowe P, Walker C, Nutton R. Knee joint functionalrange of movement prior to and following total kneearthroplasty measured using flexible electrogoniometry. Gaitand Posture. 2002;16:46-54.

7. Beaupre L, Lier D, Davies D, Johnston B. The effect of apreoperative exercise and education program on functionalrecovery, health related quality of life, and health serviceutilization following primary total knee arthroplasty. TheJournal of Rheumatology. 2004;31(6):1166-1172.

8. Lenssen A, Van Dam E, Crijns Y, Verhey M, Geesink R,Van den Brandt P, De Bie R. Reproducibility of goniometricmeasurement of the knee in the in-hospital phase followingtotal knee arthroplasty. BMC Musculoskeletal Disorders.2007;8:83.

9. Holm I, Bolstad B, Lutken T, Ervik A, Rokkum M, Steen H.Reliability of goniometric measurements and visualestimates of hip ROM in patients with osteoarthritis.Physiotherapy Research International. 2000;5(4): 241-248.

10. Esler C, Lock K, Harper W, Gregg P. Manipulation of totalknee replacements. Is the flexion gained retained? Thejournal of bone & joint surgery. 1999;81(1):27-29.

11. Namba R, Inacio M. Early and late manipulation improveflexion after total knee arthroplasty. The Journal ofArthroplasty. 2007;22(6):58-61.


14

The Effect of Transcutaneous Electrical Nerve Stimulation in theTreatment of Chronic Pelvic Pain Syndrome: An evidence basedelectromyographic studiesAhmed F Samhan1, Nermeen M Abd-Elhalim1, Emam H Elnegmy2, Mohamed M Roiah3

1Physical Therapy Department, New Kasr El-Aini Teaching Hospital, Faculty of Medicine, Cairo University, 2Physical TherapyDepartment for Growth and Developmental Disorders in Children and Its Surgery, Faculty of Physical Therapy, Cairo University,3Andrology and STDs Department, Faculty of Medicine, Cairo University, Egypt

Abstract

Background and Objective

Chronic Pelvic Pain Syndrome type III or chronic non-bacterial prostatitis (CP/CPPS) is characterized by Lower UrinaryTract Symptoms, discomfort or pain in the pelvic region for atleast 3 months of duration and sexual dysfunction. The purposeof the study was to evaluate the efficacy of TENS in the treatmentof CPPS.

Subjects and Methods

Forty male volunteer patients, suffering from non-bacterialCPPS, participated in the study their age was ranging from 35to 55 years. Patients were randomly assigned into 2 groups ofequal number study (group 1) and control (group 2). Patients ingroup 1 received TENS plus traditional medical treatment inthe form of antibiotics (ofloxacin 300 mg t.d.s.), and analgesics(ibuprofen 400 mg b.d.). Patient in group 2 received placeboTENS plus the traditional medical treatment as in group 1. Theparameters investigated including EMG activity at rest, and NIH-CPSI pain domain questionnaire scores.

Results

The results revealed no significant difference between thetwo groups in all parameters (EMG activities at rest and NIH-CPSI pain, domain questionnaire) before treatment while afterthe treatment, significant improvement was recorded in allparameters in group 1 and non-significant was recorded in group2.

Conclusion

It could be concluded that TENS is an effective means ofnon-invasive symptomatic treatment of CPPS and the resultsof this study was based on the changes of electrical activity ofpelvic floor muscles by EMG.

Key Words

Transcutaneous Electrical Nerve Stimulation (TENS),Chronic Pelvic Pain Syndrome (CPPS), Electromyography(EMG).

Introduction

Prostatitis is defined as painful inflammation of the prostatethat is often associated with lower urinary tract symptoms(LUTS), such as urinary burning, hesitancy, and frequency, aswell as with sexual dysfunction or discomfort, including erectiledysfunction, painful ejaculation, and postcoital pelvicdiscomfort; adverse sexual effects are reported inapproximately half of men with prostatitis1 .The InternationalProstatitis Collaborative Network and the National Institutesof Health (NIH) have established a classification system forprostatitis. The system’s four categories, describe acute andchronic infectious forms (NIH categories I and II) as well as

the more prevalent forms that have not been correlated withinfectious etiologies (NIH categories III and IV) 2.

Chronic Pelvic Pain Syndrome type III or chronic non-bacterial prostatitis (CP/CPPS) is characterized by LUTS,discomfort or pain in the pelvic region for at least 3 months ofduration and sexual dysfunction. Over the last decade this benignentity has attracted much attention due to the high prevalence,socio-economic impact and severe impact on the quality of lifeof a CP/CPPS patient. However, knowledge about the etiology,the pathophysiology and proper therapy for CP/CPPS is stilllacking 3.

The use of antibiotics in NIH category III is based on theuncertain etiology and the possibil-ity that a potential pathogenor a cryptic non-cultur-able organism may be causative.Combination of analgesics, alpha-blockers, antibiotics, andmuscle relaxants coupled with prostatic massage and supportivetherapy (perineal support, pelvic floor physiotherapy, biofeedbackand relaxation therapy) has been reported to yield higher curerate and relief of pain and voiding symptoms compared toantibiotics alone and is the treatment option favored by mosturologists 4.

TENS was introduced as an alternatively therapy topharmacological treatments for chronic pain. TENS currently isone of the most commonly used forms of electro analgesia5.

The use of EMG studies shows that CPPS sufferers ascompared to normal are manifest preliminary resting baselineinstability. Initial resting baseline hypertonicity, instability, anddecreased endurance contractile capacity statisticallysignificantly categorize men as more likely to suffer from CPPS.These findings indicate that pelvic floor muscle (PFM) statuslikely plays a role in at least some subset of CPPS sufferers andthat PFM evaluation with EMG can help identify this populationas those who may benefit PFM rehabilitation 6.

The needs for the treatment of pain in CP/CPPS with anon-invasive, non phar-macological, non-addictive techniquesuch as TENS clearly exist. Instability in the PFM in patientspresenting with type III CP/CPPS has been reported by EMG.The purpose of the present study was therefore to determinethe efficacy of TENS in the treatment of CP/CPPS.


Subjects Selection

Forty male CP/CPPS type III non-bacterial prostatitispatients participated in this study. They were selected from KasrEl-Aini Hospital and Department of Andrology and STDs at CairoUniversity Hospitals. The inclusion criteria were randomlyselected men age between 35-55 years, previously diagnosedas category III CP/CPPS. Exclusion criteria were prostate andother urogenital cancer and infec-tion, loss of skin sensation atand around painful area, previous exposure to TENS and otherelectro analgesia. The forty patients were randomly assignedinto two groups of equal number.

Outcome Measures

Measurement of Myogenic Activity (EMG activities) of PFM:Using Toennies NeuroScreen Plus system EMG biofeedback

Ahmed F Samhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

15

unit to examine the patient’s muscle activity at rest (Amplitudeper turn A/T in mV for right and left side of PFM). The surfaceelectrodes were placed 3 cm from the anal sphincter on bothsides. Surface EMG/biofeedback evaluation was done as partof the overall physical therapy evaluation6.

Assessment of NIH-CPSI pain, domain questionnaire: TheNIH-CPSI is a commonly used 13-item questionnaire for theassessment of symptom severity in men with CP/CPPS. NIHchronic prostatitis symptom index questionnaire, the paindo-main (1a, 1b, 1c, 1d, 2a, 2b, 3, and 4) describing the location,frequency and severity of pain was presented to each patientand instruction was given to indicate the pain characteristicslevel 7. The total score of pain domain questionnaire is rangingfrom 0 to 21. Evaluation was conducted twice before the firstsession of treatment (Pre-treatment) and after 4 weeks oftreatment (Post-treatment).

Treatment Procedures

The TENS plus Medical Treatment Group (Group 1):Twenty patients were used TENS application, patients werecomfort-ably positioned based on the painful area (to cover theperineal-suprapubic region) for electrode place-ment. It wasascertained that sensitivity of the area was intact, and that therewas no resistance, this allowed for effective stimulation. TENSgel was applied on the surface of the electrodes to aid maximumtransmission of cur-rent. Electrodes were placed on the skinoverlying the painful area and held firmly in position. The machinewas switched on; a suitable and comfortable frequency and pulsewidth were selected on the stimulator by turning the appropriateknobs. Patients were stimulated with TENS daily for an averageof 20 minutes, mean frequency, pulse width and intensity of100Hz, 100ìs and 25mA respectively for a mean duration daily,5 times per week for 4 consecutive weeks. The medical treatmentwas in the form of antibiotics (ofloxacin 300 mg t.d.s.), andanalgesics (ibuprofen 400 mg b.d.).

The placebo TENS plus Medical Treatment Group(Group2): Twenty patients were used TENS application withthe machine off, as a placebo treatment, patients werecomfort-ably positioned with the electrodes placement over thepainful area for a mean duration of 20 minutes daily, 5 timesper week for 4 consecutive weeks. Patients were receivedtraditional medical treatment as in group 1.

Data Analysis

Collected data were fed into computer for the statisticalanalysis; parametric test for determination of EMG activities ofPFM at rest (A/T in mV for right and left side of the pelvic-floormuscles) and the NIH-CPSI pain, domain questionnaire. Acomparison was made by student t-test to compare betweentwo independent means.

Results

There was non-significant difference between patientcharacteristics before treatment in study group and control group,thus the patients’ selection was homogenous.

In the present study, the effect of TENS in the treatment ofCP/CPPS was investigated. As shown in table 1, the meanvalues of A/T in mV on right side at rest pre-treatment was0.2090± 0.02315 mV and 0.2065±0.01725 mV in group 1 andgroup 2, respectively. P-value was 0.701, which means a non-significant difference. After 4 weeks of the treatment, meanvalues of A/T at rest was 0.0965± 0.0722 mV and 0.1925± 0.0522mV in group 1 and group 2, respectively. P-value was 0.002,which means a significant difference in favor of group 1. As shownin table 2, the mean values of A/T in mV on left side at rest pre-treatment was 0.2085± 0.02315 mV and 0.2115± 0. mV in group1 and group 2, respectively. P-value was 0.612, which means a

Table 1: The statistical analysis of differences (t-test) of (A/T)on right side:

A/T on Group Mean Standard P-value right side deviation ±

Pre-treatment Group 1 0.2090 0.02315 0.701Group 2 0.2065 0.01725

Post-treatment Group 1 0.0965 0.0722 0.002Group 2 0.1925 0.0522

non-significant difference. After 4 weeks of the treatment, meanvalues of A/T at rest was 0.0970± 0.07349 mV and 0.1955±0.05246 mV in group 1 and group 2, respectively. P-value was0.002, which means a significant difference in favor of group 1.Figure 1 demonstrates the mean values difference of A/T onboth sides pre-treatment and post-treatment between group 1and group 2.

As presented in table 3, the mean values of NIH-CPSI pain,domain questionnaire scores pre-treatment was 0.2090±0.02315 and 17.40±2.23371 in group 1 and group 2, respectively.P-value was 0.612, which means a non-significant difference.After 4 weeks of the treatment, mean values of pains scoreswas 2.20± 5.19717 and 17.45± 2.13923 in group 1 and group 2,respectively. P-value was 0.000*, which means a highlysignificant difference in favor of group 1. Figure 2 demonstratesthe mean values difference of NIH-CPSI pain, domainquestionnaire scores before pre-treatment and post-treatmentbetween group 1 and group 2.

Discussion

CPPS is a common urologic occurrence in men less than50 and accounts for a large number of urologist visits each year8.

Table 2: The statistical analysis of differences (t-test) of (A/T)on left side:



Post-treatment Group 1 0.0970 0.07349 0.002Group 2 0.1955 0.05246

Table 3: The statistical analysis of differences (t-test) of NIH-CPSI pain, domain questionnaire scores



Post-treatment Group 1 2.20 5.19717 0.000*Group 2 17.45 2.13923


Fig. 1: The mean difference values of (A/T) on both sides.

16

CPPS negatively affects quality of life and sexual function inmen of all ages 9. The treatment of men with CP/CPPS is difficultbecause the pathogenesis is unclear. Several treatmentmodalities such as antimicrobial agents, analgesics, anti-inflammatory agents, muscle relaxants, alphablockers, 5-alpha-reductase inhibitors, heat therapy, surgery, and biofeedbackphysical therapy have been proposed and investigated 10. Pelvicfloor tension myalgia may contribute to the symptoms of CPPS.Therefore, measures that diminish PFM spasm may improvethese symptoms 11.

A study by Hetrick et al., 2006 6 proved that, CPPS patientsmanifest PFM instability compared to normals. Pre-baselineresting hypertonicity and instability along with endurancecontraction weakness reliably predicts subject membership inthe CPPS vs. normal group. EMG activity of PFM may be avaluable screening tool to identify patients with CPPS who maybenefit from therapies aimed at correcting PFM dysfunction.Another similar study was conducted by Martinez and Diaz, 200812 suggested that EMG with cutaneous patches can be ofdiagnostic use in CP/CPPS patients, and open the possibility ofusing alternative PFM therapies such as biofeedback,neuromodulation and Botulinic toxin use.

The result of the present study was in agreement with asimilar non invasive complementary and alternative medicine(CAM), reported by Capidice et al., 2007 13; they investigatedthe ef-fect of acupuncture in 10 men diagnosed as CP/CPPS(category IIIA or IIIB). Acupuncture was applied for 30 minutes,twice weekly for 6 weeks. They reported significant decrease inNIH-CPSI for pain and LUTS and quality of life. Another studywas conducted by Sikiru et al., 2008; 24 patients diagnosedwith CP/CPPS were referred for physiotherapy from the Urologydepartment. The pain level was assessed using the NIH-CP(pain domain) index. The TENS group received TENS treatmentand all subjects were placed on antibiotics throughout thetreatment period. The findings of the study revealed significanteffect of TENS on CP/CPPS pain at p < 0.05.

TENS may be indicated in the management of chronicpros-tatitis pain; a similar visceral organ as labor pain. With anysymptomatic therapy, however, ef-ficacy must be weighed withthe risks involved. TENS might be preferable to large amount ofanalgesics and their side effects. Also, TENS is readily availableto both patients and therapists, cheaper and easy to applycompared to other non invasive, non pharmacologicalcomplementary and alternative medicine therapies14.

A study by El-Nashaar et al., 200615 consisted of 80consecutive male patients affected by CPPS and 80 healthycontrols who were asked to complete the Arabic version of theNIH-CPSI. The translation was performed by a group consistingof an andrologist and professional translators. The results ofthe 160 subjects enrolled, 82 (50 patients and 32 controls)completed the study. The total Arabic NIH-CPSI scores and thescores of each subscale differed significantly between the two

groups with good discriminant validity. The questionnaire hadalso a high internal consistency and the authors concluded that,the Arabic version of the NIH-CPSI and recognize it as a validand reliable tool in the assessment of local patients with CPPS.

In the present study, more than one method of evaluationwas used to find definite reasons about the efficacy of TENS inthe treatment of CP/CPPS evidence based EMG studies as it isthe 1st time to use TENS and measuring the EMG activity whichin turn demonstrated the tone the PFM. Using placebo TENSwith the traditional medical treatment in the form of antibioticsand analgesics in the control group (group 2) was non-significant,but use of TENS with the medical treatment gave a highlysignificant improvement (group 1). The results of this randomizedcontrolled crossover parallel arm trial contribute to the existingbody of knowledge. Evidence has shown that EMG studies A/Tin mV on both right and left side of PFM gave a significantdifference in favor of group 1. The traditional medical treatmentin the treatment of CPPS is not sufficient treatment as pain isstill present after treatment in group 2. Physiotherapists couldbe one of the medical staff in treating CPPS with TENS andother physical therapy modalities (biofeedback and heatmodalities) in conjunction with oral medication or other treatmentchronic pelvic pain syndrome.

Conclusion

In this study, we used TENS in treatment of patientssuffering from CPPS. After application of TENS plus medicaltreatment in the form of antibiotics (ofloxacin 300 mg t.d.s.),and analgesics (ibuprofen 400 mg b.d.) in group 1, pain wasrelieved and electrical activity of PFM was returned to normality.It can be satisfactory concluded that TENS is an effective meansof non-invasive symptomatic physiotherapeutic management ofCPPS and the results of this study was based on the changesof electrical activity of PFM by EMG.

References

1. Potts J and Payne RE: Prostatitis: Infection, neuromuscularDisorder, or Pain Syndrome? Proper Patient Classificationis Key. Cleveland Clinic Journal of Medicine 2007; 74(3):S63-S71.

2. Krieger JN, Nyberg LJ, and Nickel JC: NIH ConsensusDefinition and Classification of Prostatitis [Letter]. JAMA1999; 281: 236-237.

3. Cornel EB, Van Haarst EP, et al: The Effect of BiofeedbackPhysical Therapy in Men with Chronic Pelvic PainSyndrome Type III. European Urology 2005; 47: 607-611.

4. Barbalias GA, Nikiforidis G and Liatsikos EN: Alpha-Blockers for the Treatment of Chronic Prostatitis withAntibiotics. J Urol. 1998; 159: 883-887.

5. Sikiru L, Shmaila H, and Muhammed SA: TranscutaneousElectrical Nerve Stimulation (TENS) in the SymptomaticManagement of Chronic Prostatitis/Chronic Pelvic PainSyndrome: A Placebo-Control Randomized Trial.International Braz J Urol. 2008; 34(6): 708-714.

6. Hetrick DC, Glazer H, Liu Y-W, Turner JA, Frest M andBerger RE: Pelvic Floor Electromyography in Men withChronic Pelvic Pain Syndrome: A Case-Control Study.Neurology and Urodynamics 2006; 25: 46-49.

7. Clemens JQ, Calhoun EA, Litwin MS, et al: Rescoring theNIH Chronic Prostatitis Symptom Index: Nothing New.Prostate Cancer and Prostatic Diseases 2009; 12: 285-278.

8. Rossi PJ and Dickey JL: Chronic Pelvic Pain Syndrome.The AAO Journal 2004: 23-25.

9. Van Alstyne LS, Harrington KL, and Haskvitz EM: PhysicalTherapy Management Chronic Proatatitis/ Choronoc PelvicPain Syndrome. Phys Ther. 2010; 90: 1795-1806.


Fig. 2: The comparison between group 1 and group 2 the meanvalues of NIH-CPSI pain, domain questionnaire scores.

17

10. Cornel EB, Van Haarst EP, Browning RW Schaarsberg Band Geels J: The Effect of Biofeedback Physical Therapyin Men with Chronic Pelvic Pain Syndrome Type III.European Urology 2005; 47: 607-611.

11. Zhang-Qun YE, Dan CAI, Guang-Hui DU, et al: BiofeedbackTherapy for Chronic Pelvic Pain Syndrome. Asian J Androl.2003; 5: 155-158.

12. Martinez CP and Vargas Aiaz IB: Case-Control Study ofPelvic Floor Electromyography in Patients with ChronicPelvic Pain. Rev Mex Urol. 2008; 68(4): 225-228.

13. Capodice JL, Jin Z, Bemis DL, Samadi D, Stone BA, Kapan

S, and Katz AE: A Pilot Study on Acupuncture for LowerUrinary Tract Symptoms Related to Chronic Prostatitis/Chronic Pelvic Pain. Chin Med. 2007; 2: 1.

14. American College of Obstetrician and GynecologistsCommittee on Practice Bulletins — Gynecology. ACOGPractice Bulletin No. 51 “Chronic pelvic pain”. ObstetGynecol. 2004; 103: 589-605.

15. El-Nashaar A, Fathy A, Zeedan A, Al-Ahwany A, ShamloulR: Validity and Reliability of the Arabic Version of theNational Institutes of Health Chronic Prostatitis SymptomIndex. Urol Int. 2006; 77: 227-231.


18

Cardio–Vascular and Respiratory Responses to ValsalvaManeuver, Isometric Hand Grip Exercise and Harvard Step Testand Recovery in Healthy IndividualsSanjiv Kumar*, Shivappa B Anurshetru**, Prabhker Kore*Principal & Professor, KLES Institute of Physiotherapy, Belgaum, **Consulting Cardio-Thoracic Surgeon and Associate Professor,KLESH & MRC, Nehru Nagar, Belgaum

Abstract

Objective

To assess the responses of Cardiovascular and respiratorysystem to Valsalva maneuver, Isometric handgrip exercise, andisotonic Harvard step test in healthy individuals.

Design

Randomized design used in this study to find out the effectof 3 different physical stressors on healthy individual.

Setting

OPD of KLES College of Physiotherapy Hubli.

Sample

300 Healthy individuals randomly allotted into 3group (A,B, C) with homogeneous gender distribution and of age group16 year to 30 years.

Method

Group A underwent Valsalva maneuvers, Group B wasexposed to Isometric exercise sustained handgrip, and GroupC performed Isotonic exercise Harvard step test.

Result

Inter and Intra group analysis for significance was donetaking pre and post Exercise value and ANOVA and found thefollowing. Intra group within A (A1, A2, A3) none of the valuefound significant, also the values of B group does not show anysignificance with present data. In-group C Systolic Bloodpressure(BP), Rate pressure product(RPP) and Double product(DoP) shown great significance may be attributed to age andstress level. Stress level may be more appropriate as it effectingSystolic BP and in turn RPP and DoP. Inter group analysisthrough ANOVA shows other then Pulse rate of A1, B1, C1nothing found significant.

Conclusion

The greater stress levels have significant changes inparameter even in normal young individual. Few individual haveshown poor cardio-vascular responses during exercise and atrecovery period. Hence risk for sub clinical heart aliment cannotbe overruled just by looking the baseline parameter at rest.Sedentary individual were slow to recover then active individual.

Key Words

Valsalva maneuvers, sustained handgrip exercise, Harvardstep test, Healthy individuals, and Outcome measures.

Introduction

Cardio-Vascular – respiratory System is a most vital systemin the body and responds to any alteration in physical, mentaland social changes. On application of physical stress the cardiovascular system responds by increasing cardiac output up tomaximum of 8 folds of the normal. Exercise facilitates themuscular activities, which in turns demands more oxygen andnutrition to full fill the demand, local vasodilatation and increasesympathetic stimulation takes place. This facilitation of circulationremoves metabolites, waste products and facilitates kidneyfunctions. In this study the cardio vascular system is exposedto physical strain of three different activities. The study wasdesigned to compare the responses of cardio vascular systemto these activities. The activities include Valsalva maneuver,1

isometric sustained handgrip2 and isotonic Harvard step test.These stressors are used, to understand the functional capacityof heart and lung and help to diagnose the heart related problem,and introduced to individuals who have no symptoms to assessthe capacity of heart and lung.

The study is planned after it becomes known to medicalfield that the heart conditions are no more old age problems.Many young individuals are now developing cardiac diseaseslike M.I or even cardiac arrest though they were clinically normalin prior examination. This study was targeted towards the normalhealthy individual with intention to identify the risk individualsand sub clinical problems among them. This study intended tofind out the cardio vascular responses in healthy individuals andcompare the effect of physical stressors between the groupsand responses in the genders.

Aims and Objectives of Study

To assess the responses of Cardiovascular and respiratorysystem to Valsalva maneuver, Isometric handgrip exercise, andisotonic Harvard step test in healthy individuals. And To comparethe responses of all three physical stress factors in healthyindividuals, inter group and intra group.


Study design for this study was randomized design to findout the effect of 3 different physical stressors on healthyindividual. The subjects participated in this study were fromdifferent educational institution of Hubli. Medical ethicalcommittee of KLE University’s Research ethical board approvedthe procedure of physical stressors before commencement ofthe study. The healthy individuals of age group 16-30 years wereincluded in the study and a informed consent was taken fromthem. Simple random sampling method was followed. HealthyIndividuals were allotted into groups by simple lottery methodthrough chits. And the size of the sample was 300 Healthyindividuals. Inclusion Criteria: In this study only healthyindividuals were included. No major illness in last three monthsand must be physically sound to perform the exercise. ExclusionCriteria: Any individual who does not satisfy the above criteriawere excluded from the study. Instruments used in this studywas Digital BP machine, Disposable syringe, handDynamometer, stopwatch, and metronome, Step of 20" height,GSR Equipment, Height scale, Weight scale.

Sanjiv Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

19

Procedure

The subjects were randomly allotted into 3 groups withhomogeneous gender distribution and age group 16 year to 30years each group was further sub divided in sub group 1,2,3.

Group A consist’s of 100 healthy individuals who wereexposed to valsalva maneuver. In this the individual were askedto blow through the disposable syringe end to thesphygmomanometer and sustain it for 15 sec such that the

mercury column shows a reading of 40mmHg in sitting position.This is followed by assessment of cardiovascular responses bythe investigator. Group B participants were asked to performsustained handgrip exercise using manual dynamometer. Thegrip should be 30% of maximal contraction for 5 minute wasused. Group C participants were asked to performed isotonicexercise in the form of Harvard steps test as sub maximalexercise. In this the participants performed stepping up and downon 20" tall step at the speed 30 repetitions per minute for five

Table 2: Showing Mean Weight with SD of individual in various group

A1 A2 A3 B1 B2 B3 C1 C2 C3

Mean 54.3 54.6 58.2 52.3 54.07 55.6 57.4 55.1 56.3

Sd 9.7 12.2 9.2 7.1 9.03 7.4 9.9 9.05 7.45

Table 3: Showing Mean BMI with SD of individual in various group

A1 A2 A3 B1 B2 B3 C1 C2 C3

Mean 20.79 21.2 22.4 20.4 20.9 21.7 21.3 20.65 21.9

Sd 3.41 4.12 2.13 2.86 2.14 2.4 3.25 2.69 1.77

minute. Outcome measures before and after exercise - Pulserate, Systolic BP, Diastolic BP, RPP (Rate pressure product)=(HR X SP) / 100, DoP(Double product)= HR X MP, RespiratoryRate, GSR Actual, GSR Basal.

Results

The analysis revealed some significant finding. Mean heightand SD was calculated and it was found that minimum heightwas recorded in C3 1.59Mt with 0.075SD (Table-1). Maximumheight was noted in Group B3 1.7 Mt with SD 0.075.The meanweight of B1 was 52.3 KG with SD 7.1 and was minimum amonggroups and mean Maximum weight recorded was of A3 group58.2KG with SD 9.2 (Table-2). BMI of B1 was 20.4 with SD 2.86which was least among groups and 22.4 with SD 2.13 of GroupA3 was maximum. (Table-3)

In analysis pre and post exercise data of Pulse rate wasanalyzed and it was found that Mean pulse rate of A1 wasmaximum 80.3 with SD 14.35 and B3 was minimum recordedwith 70.03 and SD 5.7(Table and Figure – 4) in pre exercisecondition

Mean of Post exercise pulse rate was maximum in C3,152.2 with SD 12.4 and minimum was noted in 72.8 A3 withSD5.7 (Table-4 and Figure – 1)

Before exercise mean value of Systolic BP maximum wasnoted is 121.4 with SD 11.4 in A2 and minimum was reported in


Table 1: Showing Mean height with SD of individual in various group

A1 A2 A3 B1 B2 B3 C1 C2 C3

Mean 1.62 1.59 1.607 1.610 1.6 1.7 1.63 1.62 1.59

Sd 0.093 0.090 0.083 0.089 0.084 0.075 0.65 0.88 0.075

Fig. 1: Pulse rate

Fig. 2: Systolic Blood Pressure

Fig. 3: Diastolic Blood Pressure

20

Table 4: Showing Mean Pulse Rate with SD of individual in various group

A1 A2 A3 B1 B2 B3 C1 C2 C3

Pre. Mean 80.37 74.8 71.44 77.5 76.21 70.03 78.33 76.12 71.9

Sd 14.35 10.54 5.647 10.651 10.25 5.7 11.5 11.9 6.2

Post Mean 83.91 77.54 72.8 80.3 79.6 74.4 135.3 149.5 152.2

Sd 16.08 12.1 5.7 9.3 8.47 5.9 22.1 19.2 12.4

Table 5: Showing Mean Systolic BP with SD of individual in various group

A1 A2 A3 B1 B2 B3 C1 C2 C3

Pre. Mean 117.8 121.4 115.10 118.58 118.2 115.07 117.25 118.5 117.1

Sd 9.35 11.4 8.4 8.4 10.9 7.45 10.5 10.6 7.2

Post Mean 121.6 125.8 119.9 122.6 123.03 122.5 156.91 163.7 163.3

Sd 10.2 11.6 11.9 8.35 11.97 8.84 15.1 10.8 8.41

115.1 with SD 8.4 in A3. After exercise the maximum value wasrecorded in 163.7 with SD 8.41 in C2 and 119.9 with SD 11.9 inA3 group (Table-5 and Figure – 2)

Mean Diastolic BP of B3 was maximum 78.81 with SD 12.4and C1 was minimum recorded with 71.9 and SD 8.04) in preexercise condition.

Mean of Post exercise Diastolic BP was maximum in C387.3 with SD 8.04 and minimum was noted in B1 72 with SD9.54 (Table - 6 and Figure – 3)

Significant changes in respiratory rate developed in GroupA and C found though the GSR outcome were inconsistenceand none significant.Inter and Intra group analysis for

Table 6: Showing Mean Diastolic BP with SD of individual in various group

A1 A2 A3 B1 B2 B3 C1 C2 C3

Pre. Mean 72.2 74.3 75.03 73.9 73.37 78.81 71.9 76.1 76.6

Sd 7.5 8.19 6.63 6.47 7.20 12.4 8.04 7.17 6.09

Post Mean 73.3 75.08 76.79 72. 74.46 79.6 81.1 85.3 87.3

Sd 7.2 7.7 6.49 9.54 9.02 6.68 11.9 9.01 8.04

Table 7: Intra group – ANOVA P-Value

Pulse SBP DBP RPP DoP GSR Actual GSR Basal

A (A1, A2,A3) 0.456 0.788 0.65 0.50 0.45 0.29 0.45

B (B1, B2, B3) 0.479 0.0161 0.31 0.134 0.16 0.39 0.27

C (C1, C2, C3) 1.48 0.0097 0.71 0.0001 0.003 0.62 0.37

Table 8: Inter group – ANOVA P-Value

Pulse SBP DBP RPP DoP GSR Actual GSR Basal

A1, B1, C1 0.0000 1.46 1.31 5.7 2.3 0.48 0.45

A2, B2, C2 7.7 7.43 5.82 1.2 4.8 0.67 0.4

A3, B3, C3 1.15 2.24 1.68 7.73 3.4 0.45 0.39

significance was done for pre and post Exercise value usingANOVA and found the following (Table 7 &8). Intra group withinA (A1, A2, A3) none of the value found significant, also the valuesof B group was also does not show any significance with presentdata. In-group C Systolic BP, RPP and DoP shown greatsignificance may be attributed to age and stress level. Stresslevel may be more appropriate as it effecting Systolic BP and inturn RPP and DoP. Inter group analysis through ANOVA showsother then Pulse rate of A1, B1, C1 nothing found significant.

Discussion

Valsalva maneuver produces initial rise in systolic anddiastolic pressure followed by fall in blood pressure and pulsepressure with increased heart rate then sudden transient fall inblood pressure at the termination of expiration. Response ofthis stressor has effect on the neurovascular system. Valsalvain diabetes mellitus alters the autonomic function responses ofthe cardio vascular system.3. The study was performed on normal


21

healthy individual hence it has no effect on such system andcan be proved by consistence in outcomes. Outcome of BMIalso suggests consistence in the participant features.

The heart rate outcome was significant and toward higheronly in C group and can be contributed to the stress level of theexercise or deconditioned attitude of individual. The higher heartrate in exercise where arm was used above the level of heartwas the expression of larger static and postural component4.The change in pulse rate was least in the group in which thestress level was least. It is likely that smaller muscle mass andvasculature of arms offers greater resistance to blood flow thenthe larger muscle mass and vasculature of the legs blood flowto the arms during exercise. This would therefore require muchlarger systolic blood pressure. Clearly this form of exerciserepresents greater cardiovascular strain because the work ofthe heart is increased considerably. For individuals who havecardiovascular dysfunction these observations support the useof exercise that requires large muscle group such as walking,bicycling, and running, in contrast to unregulated exercise thatengages a rather limited muscle mass such as shovelingoverhead hammering or even arm ergometery.5 In our studystep test could produce maximum change in blood pressurethen other as the large musculature were exposed for strenuousactivity then other two. Autonomic function assessment was donein diabetic patients using valsalva and sustained handgrip.Significant rise in pulse rate and blood pressure were noted inthe participants.6 there were changes noted in vlasalva and handgrip exercise even in our study but were not significantasDiastolic blood pressure increase in participants of step testin this study.

Hand grip stress also shown changes in base line readingbut was very insignificant compare to step test Sustained handgrip exercise at 30% of maximum voluntary force used on normalhealthy individual and has shown increased diastolic bloodpressure 7Sustained Isometric handgrip exercise was found tobe producing significant increase in systolic and diastolic bloodpressure & heart rate. 8 Isometric exercise at 50% of maximalvoluntary contraction was applied for 60 seconds and it wasfound that there is significant rise in arterial pressure.9Exerciseresponses during the wall pulley exercise verses bicycleergometer work, the heart rate response was greater for armexercise than for leg exercise. The systolic blood pressureresponse was greater for arm exercise than bicycle ergometer10.

Effect of exercise speed on heart rate, systolic bloodpressure and rate pressure product during upper extremityergometry was done and significant difference in immediate postexercise heart rate pressure product across the exercise speedwas found. No significant difference was found in immediatepost exercise systolic blood pressure. A moderate speedexercises produced least cardiovascular stress.11

Effect of tread mill exercise in normal individual wasassessed and compared with sustained handgrip. It was foundthat isotonic tread mill exercises resulted in enhanced diastolicfilling with increased heart rate and blood pressure compare toisometric hand grip exercise.12

Effect of leg exercise and arm exercise in sitting andstanding body position on energy out put and on same cardiorespiratory parameters was studied. Significant higher heart rateand blood pressure was found in arm cranking in cycling at sub-maximal workload. Only postural difference in arm work was13% higher workload achieved at maximal effort when standingthan compared to sitting.13

Yoga training of six weeks duration modulates sweatingresponse to dynamic exercise and improves respiratorypressure, Handgrip strength and handgrip endurance and foundthat attenuation of the sweating response to step test by yogatraining. Yoga training for a short period of six weeks can producesignificant improvements in respiratory muscle strength and

endurance.4Exercise lasting longer than a minute or two acardiac output and heart rate linearly increased with peripheraloxygen uptake. The mean systemic arterial pressure increasesand vascular resistance in active muscles falls, leading to largeincrease in blood Flow to the muscle. Blood is pumped back tothe heart by muscular contraction, and the cardiac output isdetermined by venous return. Cardiac output and heart raterecorded at maximal exercise have been viewed at maximallimiting values, but both increased when exercise by arms isadded to maximal leg exercise. Thus increasing energy demandsdominate increase in cardiovascular responses. This studysupports our present data as same trend of cardiac responsenoted in them.14

The outcomes of hand grip exercise have minimal effecton cardio vascular system and insignificant changes inrespiratory system. However significant increase in tidal volume,respiratory rate, minute ventilation, O2 consumption CO2production occurred during unsupported low intensity upper limbexercise in normal subjects.6 which actually not in tandem withour result and may be attributed to intensity of exercise. We donot made any attempt to assess the body temperature after orbefore exercise though it was evident from the response ofIsometric handgrip exercise and dynamic two leg bicycleexercise increases in skin temperature and blood circulation.15

The step test provided greater intensity and stress and showngreater CVTS responses. C V responses to moderate intensitiesof static contraction can be produced primarily by motorcommand, but that both motor command and muscle chemo-reflexes contribute to CV responses at higher intensities of staticexercise.16

The sustained hand grip a form of isometric exercise alsoshown in terms of increased heart rate and blood pressure andchanges in DoP and RPP, however none of the value wasstatically significant. Upper extremity exercise tended to evokegreater demand on the CVS like that of isometric componentexercise.17

The variability of homodynamic and cardiovascularparameters obtained during upper body exercise found that theRPP varied with duration and intensity of exercise.18 Effects ofdynamic and static handgrip exercises on hand and wrist volumefound that After dynamic and static handgrip exercises, handand wrist volume increased significantly, the elevation of handand wrist volume after dynamic exercise was significantly higherthan that after static exercise. 23 Ventilatory responses to statichandgrip exercise found that progressive increases in mean tidalvolume inspiratory ventilation, heart rate and arterial BP nosignificant changes in respiratory frequency .19Isometric handgripexercise does not increases base line sympathetic activity fromresting levels it significantly diminished increase of sympatheticactivity during neck suction.20 C V responses to moderateintensities of static contraction can be produced primarily bymotor command, but that both motor command and musclechemo-reflexes contribute to CV responses at higher intensitiesof static exercise.16

The study was conducted for relating various stress leveland its responses in normal individual and could correlate thesame. However many individual could not completed theexercise which it self signify the status of their CVS. And thestudy also could locate that approximately 5% of individual couldnot recover their CVS parameter on time which puts them inrisk group. The individuals failed to complete also makessusceptible group of CVS risk and conditioning recommended.The study does not provided any significant outcome, howeverit also does not overrules the sub clinical risk in individual. Thestudy has limitation inform of small sample size as forgeneralization of the result a larger sample size at multiplecenters need have to be assessed. It is the need of the hour toaddress the most rapidly spreading life style illness which istaking toll of health and cost related to it.


22

Conclusion

The greater stress levels shows significant changes inparameter even in normal young individual. Few individual haveshown poor cardio-vascular responses during exercise and atrecovery period. Hence risk for sub clinical heart aliment cannotbe overruled just by looking the baseline parameter at rest.Sedentary individual were slow to recover then active individual

References

1. Bhatia S.G., sainani G.S., Nayak N. J. and Diwate P.G.Valsalva maneuver as atest of autonomic neuropathy inDiabetes Mellitus. Jr. Asso. Phys. Ind. Vol.24 Feb1976, 89-93

2. Kamiya Atsunori, Kichikami daisaku et.al. Static handgripexercise modifies arterial baroreflex control of vascularsympathetic outflow in humans. J Appl Physiol 94:2212-2216, 2003.

3. Mikes D S Cardiovascular responses to upper bodyexercise in normal and cardiac patients. Med. Sci. SportsExercise 21:5126,1989

4. Madanmohan, Sivasubramniyank. et.al. Effect of six weeksyoga training on weight loss following step test, respiratorypressure, handgrip strength and handgrip endurance inyoung healthy subject. Department of physiotherapy,JIPMER.

5. Ikeda, Elizabeth R et.al. The valsalva maneuver revisited:the influence of voluntary breathing on isometric musclestrength. The journal of strength and conditioning research,2008.

6. Petta A C, Jenkins S.C and Allison G Ventilator andcardiovascular responses to unsupported low intensityupper limb exercise in normal subject, Australian journal ofphysiotherapy Vol. 44 No. 2 1998; 123-129

7. Helfant Richard H., Devilla Maria A., Meister Steven G.Effect of sustained isometric handgrip exercise on leftventricular performance. Pub Med 1971

8. Haskell W L, Savin WM, Schroeder J S Alderman E A InglesN B et. al. Cardiovascular responses to hand grip isometricexercise in patients following cardiac transplantation.Circ.Res. 1981 Jun;48 (6Pt2):1156-61.

9. . Amundsen L R , Takashi M, Carter C L, Exercise responseduring wall pully versus bicycle ergometer work, Phy. Ther.1981 Feb 60 (2) 173-178

10. Mac master V. Harned and Pamela P W. Effect of exercisespeed on heart rate, Systolic blood pressur, and ratepressure product during upper extremity ergometery. Phy.Ther. Vol-67 No-7 July 1987: 1085-1088

11. Mizushige K, Mastsuo H, Nozaki S, Kwan O l, DeMariaAN. Differential responses in left ventricular diastolic fillingdynamics with isometric handgrip versus isotonic treadmillexertion. Am. Heart J. 1996 Jan; 131 (1) : 131-7

12. Voka s Z Bell H et. al Oxygen uptake , heart rate relationshipin leg and arm exercise in sitting and standing J. Appl.Physiol. 1975July 39(1):54-59

13. Tandon R. Bajpait H.S., Agarwal J K. A comprehensive studyof autonomic nervous system dysfunction in diabetesmellitus. JAPI 1985, Vol. 33, No-4

14. Marino Nino, DePasquale Eugene et al: Physiology insports, text principles of sports medicine editor W normannScott, William and wilkins 1993.

15. Taylor W F, Johnson J M, Kosiba W A, and Kwan,Cutaneous vascular responses to isometric handgripexercise. Journal of applied physiology, Vol 66, Issue 4,1989, 1586-1592.

16. Gandevia S C and Hobbs S F Cardiovascular responsesto static exercise in man, Journal of Physiology Vol 430,1990, pp 105-117

17. Greer M, Weber T et al: Physiological responses to lowintensity cardiac rehabilitation exercise. Physical therapy1980: sept;60(9): 1146-1151

18. Craig P.J., Otto R.M. et al: The variability of homodynamicand cardiovascular parameters obtained during upper bodyexercise. American college of sports medicine 45th Annualmeeting June 3-6, 1998; Orange county convention centerOrlando, Florida.

19. Muza S R , Lee L Y , Wiley R L , S McDonald, F W ZechmanVentilatory responses to static handgrip exercise Journalof applied physiology: respiratory, environmental andexercise, physiology.01/07/1983;54(6):1457-62.ISSN:0161-7567

20. Eckberg D L and Wallin B G, Isometric exercise modifiesautonomic baroreflex responses in humans, Journal ofApplied Physiology, Vol 63, Issue 6, 1987, 2325-2330.


23

Effect of FAME Program on Chronic Stroke Patients in IndianPopulationShanta Pandian*, Kamal Narayan Arya**, Archana Kaushik****Superintendent OT, OPD, **Sr Occupational Therapist, ***Occupational Therapist, PDU Institute for the Physically Handicapped,University of Delhi, Ministry of Social Justice & Empowerment, Govt. of India. New Delhi

Abstract

Background

Stroke is a leading cause of disability among adultsworldwide. Many stroke survivors have chronic deficits that limitphysical activity and cause subsequent physical deconditioning,which propagates disability and worsens cardiovascular diseaserisk. Evidence suggests that exercise following stroke has apositive impact on functional outcomes even after years. Fitnessand Mobility exercise (FAME) is evidence based group exerciseprogram developed in Canada for people with chronic stroke. Itincludes task specific activities and exercises that promotefitness and mobility and help prevent further strokes, heartattacks or falls that can cause significant functional declines.

Aims & Objectives

To examine its effectiveness on fitness, balance, mobilityand overall impact of stroke.

Methodology

Design – Pretest Post test Single groupSample size –10 (both male & female)Outcome Measures – The performance- oriented mobility

assessment, StrokeImpact scale, Functional Reach Test, Time Up and Go test

& 6 Minute Walk TestProcedure – The program was administered for 6 weeks,

twice a week (12 sessions).

Results

There was significant difference between pre and postassessments.

Conclusion

The FAME program is beneficial for improving some ofthe functional deficits resulting from chronic stroke.

Introduction

Stroke is a leading cause of long-term disability, and 90percent of people living with stroke have some functionallimitations, including muscle weakness, pain, spasticity, cognitivedysfunction, poor balance, and frequent falls. These impairmentscan lead to reduced activity and sedentary lifestyles, with furtherdeclines in function and disability status. Rate of recovery of allimpairments maximizes with in first 2 weeks of stroke and slowsdown after 2-3 months and probably stops after 6-12 months.Many stroke survivors have chronic deficits that limit physicalactivity and cause subsequent physical deconditioning, whichpropagates disability and worsens cardiovascular disease risk.Exercise can improve ambulatory function and fitness even yearsafter stroke.

Usually rehabilitation focuses more on improving motorcontrol and use adaptive methods for such clients; ill effects of

sedentary life style and reduction in over all fitness are missed.Fitness and Mobility Exercise Program (FAME) is an

evidence based group exercise program developed in Canadafor people with chronic stroke. It includes task specific activitiesand exercises that promote fitness and mobility and help preventfurther strokes, heart attacks or falls that can cause significantfunctional declines. The FAME Program addresses multipledomains, including balance, muscle strength, bone health,mobility, cardiovascular fitness and depression. It has beentested in three trials with people with chronic stroke in Canadaby Janice Eng, Andrew Dawson Daniel Marigold and MarcoPang. The trials have shown improvements in balance function,balance confidence, walking speed, leg muscle strength, andquality of life.

Marco Y. C. Pang et al (2005) examined the effects of acommunity-based group exercise program for older individualswith chronic stroke. The intervention was community-based. TheFAME program was feasible and beneficial for improving someof the secondary complications resulting from physical inactivityin older adults living with stroke. It may serve as a good modelof a community-based fitness program for preventing secondarydiseases in older adults living with chronic conditions.

Similarly, Alain Leroux (2005) concluded that an exerciseprogram offered by a community organization can lead toimprovement in motor performance of individuals with chronicstroke. To prevent decline in motor performance, community-based exercise programs should thus be made available forstroke patients discharged from rehabilitation services.

Further, Kathleen M. Michal et al (2006) discussed therelationship of “Fatigue after stroke” with mobility, fitness,ambulatory activity, social support and fall efficacy. They studied53 community dwelling stroke patients and found that fatiguewas common and persistent in common stroke survivors. Yet, itwas not known how mobility deficits, fitness and other factorssuch seen as social support, relate to fatigue severity of fatiguewas examined and relationship among fatigue and other factorswas identified.

Also, Richard F. Macko, et al (2008) investigated the effectsof an adaptive physical activity (APA) program on mobilityfunction and quality of life (QOL) in 20 chronic stroke patients.APA has the potential to improve gait, balance, and basic butnot instrumental activities of daily living profiles in individualswith chronic stroke. Also, in improving stroke related quality oflife.

Mary Stuart, Sarah Chard, Suzanna Roettger, (2008)emphasized on growing evidence on the efficacy of exercisemodels for improving multiple domains of physiological healthand fitness in people with chronic stroke. The use of a structure-process-outcome framework is suggested to facilitate exchangebetween international research teams regarding developmentof evolving stroke exercise models.

In addition, Richard F. Macko, Joseph Hidler, (2008) focusedon exercise models which can be targeted to affect multiplephysiological systems that determine long-term health andfunctional outcomes in both stroke and Spinal Cord Injury (SCI).Findings support a rationale for regular exercise to reduce insulinresistance and improve cardiovascular health and fitness forindividuals with SCI and stroke-related disabilities.

More recently, Rose Galvin et al (2008) conducted arandomized controlled trial to evaluate the impact of additional

Shanta Pandian / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

24

family assisted exercise therapy in people with acute stroke. Itwas a prospective multi-centre single blind randomizedcontrolled trial. Forty patients with acute stroke were randomizedinto either an experimental or control group. The experimentalgroup received routine therapy and additional lower limb exercisetherapy in the form of family assisted exercises. The controlgroup received routine therapy with no additional formal inputfrom their family members. Participants were assessed atbaseline, post intervention and followed up at three months usinga series of standardized outcome measures.

Furthermore, Janice J. Eng, Marco Y. C. Pang Maureen C.Ashe (2008) recommended the role of exercise in reducing therisk of fragility fractures, which would be a relatively newapplication in stroke rehabilitation. The promising treatment alsohas potential to reduce incidence of falls as well as maintain orimprove bone health. Given the many health benefits associatedwith exercise, it should be considered an important modality forthe management of falls and maintenance of bone healthfollowing stroke.

Literature review shows that there are very few studies doneon determining the effect of exercises in chronic stroke patients.There are hardly any such studies in Indian context. The presentstudy focuses the need.

Aims & Objectives

• To implement FAME program on chronic strokepatients.

• To examine its effectiveness on fitness, balance,mobility and overall impact of stroke.

Methodology

Design – Pretest Post test Single groupSample size –10 (8 male & 2 female)Place of Work – Department of Occupational Therapy, Pt.

DDU Institute for the Physically Handicapped, New DelhiInclusion Criteria:People with stroke with mobility problems ranging from very

slow walking speeds of 0.3 m/s to fairly normal walking speedof 1.0 m/s walk short distances (e.g., 3 meters) with minimalsupervision).

May do the exercise program with support of chair or walker.Should have “near-normal” cognitionExclusion Criteria: Those who cannot perform standing

exercises while holding onto a support.

Outcome Measures

The performance- oriented mobility assessment (POMA):The performance- oriented mobility assessment

developed by Tinetti provides a brief and reliable measure ofboth static and dynamic balance. Items are organized into twosubtests of balance and gait. POMA I has a total possible scoreof 28.

Timed Get Up and Go Test (TUG):Timed Get Up and Go Test developed by Podsialdo and

Richardson is a quick measure of dynamic balance and mobility.Research indicates that most adults can complete the test inless than 10 seconds. Scores between 11 to 20 seconds areconsidered within normal limits for frail elderly or individualswith a disability; scores over 30 seconds are indicative ofimpaired functional mobility.

Functional Reach Test (FRT):Developed by Duncan et al provide a quick screen of

balance problems in older adults. It is a performance-basedtest to assess postural responses to voluntary movementperformed during a daily activity. It is a measurement of themaximal distance one can reach forward beyond arm’s length

(in the horizontal plane) while maintaining a fix base in thestanding position.

Six meter walk test (6MWT): developed by RJA Butland,is important for examination of postural control and functionalmobility. It is a performance base test distance walked in 6minutes is measured and reported in meters or feet. A greaterdistance indicates a better performance.

Stroke Impact Scale(SIS): (developed by PW Duncan &colleagues) SIS (Version 3.0) is a disease specific evaluativeinstrument that measure impact of stroke in multiple domains,including physical, emotional, memory/thinking, communicationand social participation. The purpose of stroke impact scale isto evaluate how stroke has impacted patient’s health and life. Itfurther asses patient’s perception of stroke – “how stroke hasaffected you & your quality of life?”

Procedure

The program was administered for 6 weeks, twice a week(12 sessions).

Participants were screened for the general healthconditions.

Pre-Assessments were done using the outcome measuresbefore the initiation of the program.

Duration of Program

Each session lasts 1 hour. The program has been testedwith a frequency of 3X/week and has been successfully testedwith durations of 8-19 weeks. Ideally, a 3-4 month program isrecommended to achieve sustainable benefits. We recommenda minimum of 8 weeks if undertaken 3X/week and a longerduration (12 weeks) if only 2X/week. In addition, we recommendan additional home exercise day if the group program is only2X/week. If appropriate screening (e.g., stress test) and acardiovascular component is used (e.g., training. Exercises werestopped if participant faces any adverse effects eg. Pain orfatigue, dizziness, chest pain and breathlessness is seen.

Maximizing adherence and having fun: Adhering toregular exercise is difficult for everybody. There is no doubt thata charismatic instructor can make a huge difference in motivatingparticipants. However, a number of initiatives can be done tomaximize adherence. Encourage socialization! Encourage fun!

Re-assessing

The Participants were re-examined on the outcomemeasures to analyze progress.

Data Analysis & Results

Data was taken from excel spread sheet and was analyzedby SPSS version 11 for alpha value < 0.05 as significant.

Results are summarized in table no. 1 to 8 & Figure 1 to 10SIS (total score) pre mean was 108+23.8, post mean276.1+25.72, found to be significant (p value < 0.025).SIS (recovery) on a scale of 0 to 100 as perceived by patientswas found to be significant (p< 0.025) pre mean 59+16.46postmean77.5+13.3.Subcategories of SIS- Physical problems, mood & emotions,communication and community mobility were found to besignificant (refer tables)While subcategories of SIS- Memory & thinking, Activities oftypical day, Hand ability and Participation in life were not foundsignificant.POMA pre mean 20.3 + 4.42 post mean 26.7 +1.76 was notfound to be significant.TUG pre mean 17.29+ 4.20 seconds post mean 14.9+ 3.7seconds, was found to be highly significant (p < 0.0005)6MWT pre mean 105.3+28.15 meters post mean 128.1+22.9


25

Table 1: Difference Pre Post S I S

Pre PostMean + SD 184 + 276 +

23.8 25.72

t value - 2.272

p value < 0.025(significant)

Table 2: Difference Pre Post SIS %

Pre PostMean + SD 59 + 77.5+

16.46 13.3

t value - 2.68


Table 3: Difference Pre Post FRT

Pre PostMean + SD 10.24 14.27+

+2.89 2.59

t value - 1.8


Table 6: Difference Pre Post SIS 3

Pre PostMean + SD 26.6+3.4 47.4+3.34

t value - 1.92


Table 5: Difference Pre Post SIS 1

Pre PostMean + SD 7.3+1.82 14.8+2.44

t value - 2.8


Table 4: Difference Pre Post TUGPre Post

Mean + SD 17.29+4.20 14.95+3.7

t value 4.816


Table 7: Difference Pre Post SIS4

Pre PostMean + SD 26.6+2.16 37.4+3.56

t value - 1.88

p value 0.05(significant)

Table 8: Difference Pre Post SIS6

Pre PostMean + SD 26.6+2.16 37.4+3.56

t value - 1.88

p value 0.05(significant)


Fig.1:

Fig.2:

meters was not found significant.FRT pre mean 10.24+2.89 inches post mean+2.59 inches foundto be significant (p value <0.05)Fall frequency was reduces in most of the subject. It was

Fig.3:

26

assessed by 3 point scale – never -1, occasionally-2 & frequently-3.Pre FAME there was two, three & five subjects respectively innever, occasionally & frequently group. Post FAME there wasfive, five & zero subjects respectively.

Discussion

Major achievement of this study is that quality of life of thesubjects was significantly improved. Richard F. Macko, et al(2008) also found similar results. The total SIS scale was foundto statistically significant though some of the individualcomponents of the scale were not found statistically significantbut clinically improvement was observed on those components.Most of the conventional therapy programs consider therapyrestricted to individualized body parts but do not emphasize onclients perception and needs while FAME recommendssocialization, mood & emotion, interaction with similar type of


Fig.4:

Fig.5:

Fig.6:

Fig.7:

Fig.8:

Fig.9:

Fig.10:

27

persons etc. during therapy. Depression is always a challenging problem in different

stages of stroke. Depression is not measured particularly butmood and emotions were much better clinically as well as foundstatistically significant. That was the main motive of group therapyprogram, where patients could interact with each other andtherapists during therapy session. – Improved Mood & emotionwould further prevent fatigue as discussed and conclude byKathllen Michal et al (2006).

Balance was improved both clinically and statistically asmeasured by FRT. This achievement could be attributed tocomponents of FAME based on balance and coordinationactivities. Marco Y. C. Pang et al (2005) studied effect of FAMEprogram on chronic stroke patient; significant improvement inbalance, mobility and cardio respiratory fitness was founded. Inthe present study balance was improve which further preventsecondary complication like fall risks, fracture in chronic strokeand improve bone health in such patients, same was alsosupported by Marco Y. C. Pang et al (2005), Alain Leroux (2005)& Janice J Eng. Et al (2008).

Since the program was given in group in which every subjecthad opportunity to lead the session and to encouragesocialization as recommended in FAME program. Usuallywhenever stroke patients take therapy or managementeverybody talks about the related impairment and dysfunction.This program emphasized on the normal socialization even withany extent of impairment which explains the significantimprovement in SIS-4 (Communication & conversation).

Components of FAME such as one leg standing, tandemstanding & tandem walking, quick wait shifts, slow & fastmarching were individually practiced in every therapy session,this could explain the significant improvement in mobility at homeand community(SIS-6)

Physical endurance in some cases also improved clinicallybut statistically it was not found significant which could attributeto small sample size and could also be due to measurementstaken in meters. Though as per the guidelines of 6MWT readingscan also be taken in feet.

Though the result of TUG was statistically highly significantwith mean decrease of 2.5 seconds in performance of the test,functionally this amount of difference does not show muchachievement.

POMA has subpart of different components of gait whileFAME does not emphasize in individual physical componentswhich could explain the non significant statistical results. Furtherthere was not much difference between pre and post mean dueto small sample size and gait components of POMA.

Limitation of the Study

1. Sample size was small2. Large group could not be taken due to space problem.3. Natural environment like garden could not be used during

therapy4. Music as recommended by FAME could not be used during

therapy session.5. Due to transportation problem in metropolitan cities like

Delhi some patients were either irregular or were not ableto come as per our schedule.

Recommendation for Future Research

1. Long term study by using measure like bone densitometry,force / pressure sensors, motion analyzer can be done.

2. Effect of home program based on FAME could be studied.3. Cardiopulmonary endurance testing should be considered.4. Prevention of second stroke should be studied.

Conclusion

The FAME program is beneficial for improving some of thefunctional deficits resulting from chronic stroke.

FAME program is beneficial for chronic stroke patients inimproving quality of life and balance. Mobility and fitness alsoimproves up to certain extent.

Acknowledgement

1. Dr. Dharmendra Kumar, Director, PDUIPH.2. HOD (OT) and all our Seniors & Juniors of Dept. of OT.3. All our Patients and their family members

References

1. Alain Leroux, Exercise training to improve motorperformance in chronic stroke: effects of a community-based exercise program, International Journal ofRehabilitation Research 2005;(28) 1.

2. Galvin R, Cusack T, Stokes E. A randomized controlledtrial evaluating family mediated exercise (FAME) therapyfollowing stroke, BMC Neurol 2008; (8) 22.

3. Gresham GE, Fitzpatrick TE, Wolf PA, McNamara PM,Kannel WB, Dawber TR. Residual disability in survivors ofstroke—The Framingham study. N Engl J Med. 1975;(293)19.

4. Janice J. Eng, Marco Y. C. Pang Maureen C. Ashe VBalance, falls, and bone health: Role of exercise in reducingfracture risk after stroke. JRDD;2008(2).

5. Kathleen M. Michal et.al. Fatigue after Stroke, RehabNursing, 2006, (31).

6. Lamb SE, Ferrucci L, Volapto S, Fried LP, Guralnik JM;Women’s Health and Aging Study. Risk factors for falling inhome-dwelling older women with stroke: The Women’sHealth and Aging Study. Stroke. 2003;34(2).

7. Marco Y. C. Pang et al A Community-Based Fitness andMobility Exercise Program for Older Adults with ChronicStroke: A Randomized, Controlled Trial, Journal of theAmerican Geriatrics Society;2005,(53)10.

8. Mary Stuart, Sarah Chard, Suzanna Roettger, Exercise forchronic stroke survivors: A policy perspective JRRD; (45), 2.

9. Richard F. Macko et al, Adaptive physical activity improvesfunction and quality of life in chronic hemiparesis. JRRD,2008, (2).

10. Richard F. Macko, et al, Adaptive physical activity improvesmobility function and quality of life in chronic hemiparesisJRRD; 2008. (45).

11. Richard F. Macko, Joseph Hidler, Exercise after stroke andspinal cord injury: Common biological mechanisms andphysiological targets of training, JRRD, 2008; (45), 2. (Guesteditorial).


28

A Comparitive Study on the Efficacy of End Range MobilizationTechniques in Treatment of Adhesive Capsulitis of ShoulderK S SharadAsst. Professor, Department of Physiotherapy, National Institute for the Orthopaedically Handicapped, Kolkata-700 090

Abstract

Exercises and ultrasound therapy is the widely usedtreatment for chronic adhesive capsulitis and has ample researchliterature support while the same is not true regarding the claimspertaining to the applicability of Manual Mobilization Techniquesin resolution of clinical complaints associated with adhesivecapsulitis. This randomised control trail was conducted to assessthe effectiveness of End Range Mobilization Techniques in thetreatment of chronic adhesive capsulitis. A matched subject sizeof 22 patients with frozen shoulder was divided into two groupsof 11 subjects each and named Experimental (Age Range – 41to 55 years, Mean age – 46.5 Years S.D 4.44) and Control group(Age Range – 40 to 56 years, Mean age – 47.45 years S.D5.49).

Both groups were treated for 3 weeks with Exercises andUltrasound and the experimental group was given the EndRange Mobilization Techniques also. The outcome measurestaken were variation in Active and Passive ROM (ManualGoniometric measurement) and pain (Visual analog scale).

The data obtained was statistically analysed using Student’st test and ANACOVA (F ratio).Analysis showed that there wasno difference between the groups in the amount of pain reductionobtained ( p< 0.05), but the Experimental group was considerablybetter ( p< 0.05), than control group in terms of gaining activeand passive ranges of motion among the subjects.

Introduction

Shoulder joint is one of the most common joint to be treatedin a physiotherapy department among which the diagnosis ofadhesive capsulitis also known as frozen shoulder is very oftenseen. Adhesive capsulitits is a condition characterised by aninsidious, painful and progressive loss of active and passivemobility of glenohumeral joint1, 2 due to capsular contracture andpresents a typical pattern in range of motion restriction withcapsular end feel in later stages3, 4.

The condition has been observed to be clinically divisibleinto three stages known as freezing, frozen and thawing stages.In Acute stage pain and discomfort in function are the chiefcomplaints while in chronic stage the chief complaint is the lossof mobility of the Glenohumeral joint4.

Review of literature shows that various authorities on thebasis of their studies have incriminated different structures asbeing the culprit. It was first described by Dupley in 1972 asscapulohumeral periarthritis, Neviaser2 in 1945 suggested thename Adhesive capsulitits based on his surgical explorations.In1934 Codman used the term frozen shoulder for the first timebut did so in association with tendonitis of the rotator cuff andstated that even the most severe cases recover with or withouttreatment in 2 years.

Omari and Bunker6 confirmed that fibroblast proliferationconsistently altered both the rotator cuff interval and thecoracohumeral ligament by depositing a dense matrix of type IIIcollagen.. Suzuki and colleagues7 suggested that pathologicalterations in the shoulder capsule are important contributors tothe symptoms in Adhesive capsulitis.

One common observation was that the capsule becomescontracted and adherent to itself and the humeral head andwith the progression of the condition rotator cuff, Bicipital tendon

its sheath, fascial covering, all become involved at variousstages.

Literature shows lack of agreement over the best methodof preventing and treating it. However there is agreement overtreatment goals these are, pain relief and restoration ofmovements. The presently used interventions areTranscutaneous Electrical Nerve Stimulation (T.E.N.S),Ultrasound, Cryotherapy and Heat in the form of Diathermy,along with Exercises and Passive movements. The Exercisesare performed actively with or without mechanical aids andPassive Movement are applied in the form of general stretchingor in the specialised form of Manual Mobilization Techniques.1,4,8

Zancan.A Gialanella.B. et al9 carried out instrumentalevaluation of ultrasound therapy in patients with periarthritis ofthe shoulder, to find the real effectiveness of anti inflammatoryaction of ultrasound. The results demonstrated a real influenceof ultrasound therapy on periarthritis of shoulder, in favour ofapplication of Ultra sound.

Cyriax recommends that the exercises should be prescribedaccording to the stage of the disease, the end feel and painresistance sequence3. Although the use of exercises in acutestage is not advisable, in chronic stage active and passiveexercises are recommended to be performed vigorously.

Active exercises allow more patient control than domechanical exercise such as done using shoulder wheels,pulleys and wands. Muscle re-education may be needed torestore normal physiological balance to the entire shouldercomplex and spine. Strengthening exercises are not advisableuntil near normal range of motion is achieved.1, 12

Thus the use of ultrasound and active exercises has beenwell supported in the literature and the research studies, but thesame is not true for the use of mobilization techniques.

It is believed that exercises done only in cardinal planes donot deal with the laws of Joint play and therefore often provokepain and do little to increase shoulder joint Range of Motion.Authorities such as Maitland and cyriax have recommendedpassive stretching in all functional planes by means of GradedManual Mobilization Techniques to regain normal extensibilityof the shoulder joint capsule but data to support the use of thesetechniques is lacking. Mobilization grades recommended for thechronic stage of adhesive capsulitits are grades III and IV sinceonly these grades touch the movement barrier hence are alsoknown as End of the Range Mobilization techniques (ERMT).3,

12

Few studies which did explore the use of mobilization14,15

did so using widely variable parameters and hence presentedmixed results and some associated their use with lesssatisfactory outcomes. Bulgan, Binder et al 1984 in their studyon 42 patients with frozen shoulder compared Intra articularsteroids, Mobilization, Ice therapy and no treatment andconcluded that there is little long term advantage in any of thetreatment regimens but steroid injections may benefit pain andROM in early stage of the condition.

H.M.Vermeulen Obermann W.R et al 200013 in their studyof 7 subjects with frozen shoulder found no adverse effects onthe recovery of the patients when treated with end rangemobilization techniques and found significant increase in jointcapacity and humeral mobility after 3 months of treatment. Theyrecommended a case control study so as to verify theeffectiveness of Mobilization techniques.

K S Sharad / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

29

This study is thus aimed at assessing the effectiveness ofend range manual mobilization techniques, as an adjunct to thestandard treatment by ultrasound therapy and exercise for thetreatment of chronic adhesive capsulitits of shoulder joint.

Material and Methodology

Study Design

A prospective experimental study design of matchedsubjects was used consisting of a sample size of 22 subjectswith adhesive capsulitis. The study was conducted in thePhysiotherapy department of the Indore Institute of MedicalSciences, M.P. from July 2007 to December 2007.

The subjects were patient aged between 40 to 60 years,who were selected if they had insidious onset of the conditionwith duration of symptoms more than three months and apresentation of movement restrictions in all planes by at least25 percent.

Subjects with early onset of pain in the Range PainResistance Ratio assessment, history of Diabetes or any otherconcurrent disorder which may interfere with the treatment wereexcluded from the study. Written informed consent was obtainedfrom each subject and they were randomly ascribed to eitherControl or Experimental group.

Procedures

Control Group

On the first day following the basic assessments the patientin control group were treated with

1. Ultrasound Therapy

Patient supine, Ultrasound at 2 Watt/cm2 for 10 minutes tothe glenohumeral joint anteriorly, posterior and inferiorly witharm abducted. A machine with 1MHz frequency and an outputof 0 to 3.5 Watt/cm2 with Head size 2.5cm2 was used.

2. Active Glenohumeral Exercises

These were self stretching exercises preceded by warmup exercises and ending with a cool down phase, done undertherapist’s supervision and guidance. No mechanical exerciseswere given.

3. Home Exercises

Simple stretching exercises were chosen to be done athome once daily.

The exercises were progressed and modified as per thepatient response.

The treatment was given five days per week for three weeks.

Experimental Group

The experimental group patients were treated with the sametreatment as for the control group, in addition they were given acourse of End Range Mobilization Techniques which were carriedout immediately following the application of ultrasound. Initiallya few minutes of warming up was given using mid rangemobilization with the patient positioned supine. Following whichintensive end rage mobilisation techniques, Grades 3 and 4 asdescribed by Maitland12,13 in all the movement planes were given,interspersed with accessory movements (glides). Effort in eachdirection had ten to fifteen repetitions. The rhythm speed andduration were varied in accordance with patient presentationand tolerance.

Outcome Measurment

The outcome measures used were variations in ShoulderMobility using a half circle six inch Goniometer and the variationin perceived level of Shoulder pain as assessed using a VisualAnalog Scale. External Rotation in Horizontal plane, Abductionin scapular plane and Flexion in sagital plane were used formeasurement of outcome.

A Visual Analog Score (VAS) was used to measure pain ordiscomfort at and around the shoulder joint. All outcomemeasures were taken on day one before the treatment and werethen measured a day after the last treatment. All measurementswere taken by the researcher himself, each measure was takenthrice and the mean used for calculations.

Statistical Analysis

Demographic Data

Study sample characteristicsExperimental group– n= 11

Age: range – 41 to 55 years, Mean age – 46.5 years withstandard deviation of 4.44. Duration of disease: Range 3 to 7months Mean duration 4.9 Months with standard deviation of1.17 Sex: 46 % subjects were male and 54% subjects werefemales.

Control group – n = 11Age: range – 40 to 56 years, Mean age – 47.45 years withstandard deviation of 5.49. Duration of disease: Range 3 to 6months Mean duration 4.63 Months with S.D of 1.05Sex: 37 % subjects were male and 63% subjects were females.

Outcome Measurements

The Outcome measure data collected from the study wasstatistically analysed using

1. Student’s paired and unpaired t test 2. Analysis of covariance (ANACOVA)

1. Alteration In Shoulder Pain

2. Alteration In Shoulder ROM

Table 1: Showing mean visual analog scale (VAS) values

VAS Mean Pre Mean Posttreatment value treatment value

Experimental 3.60 0.9Group

Control Group 3.72 1.09


Fig.1: Comparing the mean VAS values between the two groups

30

Visual Pre t/t VAS Independent Post t/t Independent DependentAnalog Score mean t test value VAS mean t test value t test value

Control group 3.72 0.147 1.09 0.44 9.31 p< 0.05P > .05 p > 0.05

Experimental group 3.6 0.9 7.86 p< 0.05

Table 2: Results of statistical analysis of change in pain

Analysis: There is significant difference between the pre and post treatment value within both the groups (p > 0.05), but there wasinsignificant difference between the two group’s pre treatment values and also between the two group’s post treatment values (p >0.05) which means that, the difference in amount of pain reduction between the two groups was not statistically significant.

Analysis: Each of the 6 pairs of ROM measures were analysed by the method of Analysis of Covariance (ANACOVA).The adjustedpopulation variance were compared with the use of F test. The critical value of F at 5% level of significance if 4.38, all the calculatedF values for Active and Passive ROM were greater than this critical value.

Discussion

This randomized control trial yielded results which showthat the gain in ROM was more in the group which receivedmobilization however the reduction in pain was similar in boththe groups.

This could have been so because there was localization ofstretch at the glenohumeral joint capsule by mobilization. Itenables resolution of adhesions in the restricted portions of thecapsule. Mobilization also enables restoration of accessorymovements and joint play by emphasizing the gliding componentof joint motion hence restoring the normal mechanics at the

glenohumeral joint.Exercises done following mobilization are proposed to have

greater effectiveness in gaining mobility due to availability ofaccessory movements improved by the preceding mobilizationtechniques and hence the possibility that the exercises werecarried out with better joint mechanics would have contributedto the gain in ranges of motion.

The raise in temperature of the tissues by application ofultrasound prior to mobilization allows a greater amount ofdeformation of the tissues using the low deformation force.

The use of mobilization also brings in normal mechanismof function at the shoulder complex reducing the amount of

Table 5: Results of statistical analysis of gain in ROM using ANACOVA

Active ROM Passive ROM

ROM Adjusted variance between F ratio Adjusted variance between F ratiosamples / within samples samples / within samples

External Rotation 178.21/28.43 6.26 505.13/28.92 17.46

Abduction 2123/265.38 8.03 3058.24/214.57 14.25

Flexion 1175.218/134.43 8.73 1189.62/149.82 7.94


Fig.2: Comparison of gain in mean Active ROMs in experimentaland control group

Table 3: Showing gain in Mean Active ROMs

Gain in Experimental Group Control Group

Mean External 16.18 9.3Rotation

Mean abduction 40.26 22.00

Mean flexion 36.82 21.18

Table 4: Comparison of gain in Mean Passive ROMs

Gain in Experimental Group Control Group

Mean External 19.64 12.37Rotation

Mean abduction 44.73 22.45

Mean flexion 50.27 21.73

Fig. 3: Comparison of gain in mean Passive ROMs inexperimental and control group

31

abnormal potentially pain producing stresses on the related softtissues. All these factors must have interacted in the outcomeof this particular treatment method.

Thought the reduction in pain was not more in theexperimental group it did as well as the control group and inaddition showed greater gain in mobility than the control groupand hence ERMT can be considered successful in providinggreater relief to the patients.

The reason for absence of difference in the amount of painreduction between groups may be that ERMT requires forcefulentry in to the restriction barrier and hence breakage ofadhesions formed by the contracted joint capsule which by itselfis noxious.

The findings of this study are in accordance with the multiplesubject case report by H.M.Vermeulen et al. (2000), howeverthey had no control group in their study. These results do notagree to those found in the study by Bulgan and Binder et al.(1984) who found that use of manual mobilisation was associatedwith less satisfactory out comes in the treatment of frozenshoulder.

The time required for treatment session by inclusion of thesetechniques was increased but amount of gain for the patient interms of amount of resolution of the condition is considerable.There is also definite benefit of greater satisfaction on patient’sside due to hands on caring by the therapist thus it is rationalenough to consider these techniques as essential part in thetreatment protocol for the stage II of chronic idiopathic adhesivecapsulitis.

There were certain limitations in the study such as smallsample size and limited measures of outcome were used. Nofollow ups were carried, and no blinding was done this couldhave biased the results. Hence the generalisability of the resultsis limited and should be cautiously done.

Conclusion

It can be concluded that this study provides evidence thatEnd Range Mobilisation Techniques, when used as an adjunctto application of Ultrasound and Exercises, provide better resultsin terms of gain in shoulder ranges of motion and reduction ofshoulder pain in patients with chronic adhesive capsulitis andhence should be a part of the treatment regimen for the same.

References

1. Donatelli RA Physical Therapy of the shoulder 2nd EditionChurchill Livingstone New York 1997

2. Julias.S. Neviaser. Adhesive capsulitis of shoulder: A studyof the pathological findings in periarthritis of shoulder.Journal of Bone and Joint Surgery Am, 1945; 27: 211-222

3. Cyriax J. Text book of orthopaedic medicine 7th Edition Vol.1Balliere Tindall London 1978

4. Calliet R Shoulder Pain 2nd Edition F.A Davis Philadelphia1981

5. Neviaser JS. Adhesive capsulitis and the stiff painfulshoulder. Orthop Clin North Am 1980; 11(2):327-331.

6. Omari A, Bunker TD. Open surgical release for frozenshoulder: surgical findings and results of the release. JShoulder Elbow Surg 2001;10(4):353-357.

7. Suzuki K, Attia ET, Hannafin JA, et al. The effect of cytokineson the migration of fibroblasts derived from different regionsof the canine shoulder capsule. J Shoulder Elbow Surg2001;10(1):62-67.

8. John Low and Ann Reed. Electrotherapy Explained, 3rded. Publisher-Butterworth Heinemann. 2000.

9. Zancan.A, Gialanella.B, Luisa.A, Casale.R, et alcomparative clinical assessment of the treatment ofshoulder periarthritis using ultra sound. Med Lav 1993 Jan– July 15 (1-4) 55-8

10. Roger J. Allen. Physical agents use in the management ofchronic pain by physical therapists. Physical Medicine andRehabilitation Clinic N Am, 17 (2006) 315-345

11. Therapeutic Exercise: Foundations And Techniques Book:Therapeutic Exercise: FoundationsAnd TechniquesCarolyn Kisner, Lynn Allen Colby F. A. Davis Company.2007

12. Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, RozingPM and van den Ende CH (2000): End-range mobilizationtechniques in adhesive capsulitis of the shoulder joint

13. Elly Hengeveld, Kevin Banks. Maitland’s PeripheralManipulation. 4th Edition.Elsevier.2007

14. Bulgen A.I, Binder D.Y et al F.S: a long term prospectivestudy.Ann of Rheum. Dis. 1984 Jun 43(3):353-60.

15. Bulgen A.I, Binder D.Y et al F.S: Prospective clinical studywith an evaluation of three

treatment regimens. Ann. of Rheum. Dis. 1984 43(3):353.


32

Role of Physiotherapist in the Management of On-field SportInjuries – A case study of field hockeySuraj Kumar1, Vijai P Sharma2, Rakesh Shukla3, Ravi Dev4, Anoop Aggarwal5

1Master in Physiotherapy, Senior Research Fellow, 2Professor and Head, Department of PMR, 3Professor, Department of Neurology,4Professor, Department of Neurosurgery, Chatrapati Sahuji Maharaj Medical University, Lucknow- 226018, India, 5Physiotherapist,Pt DDU Institute for Physically Handicapped, New Delhi

Abstract

Study Design

Prospective cohort study of Indian women field hockeyplayers.

Background

On ground sports injuries have become a challenging taskfor physiotherapists around the world and lack of literature datamakes it more difficult. In India it is still in growing phase. Thisis the first case study which provides the basic base line dataregarding potential areas of injury, their types, treatments andoutcome of the treatment on subjects and on game results.

Case Description

This study belongs to 16 Indian women field hockey playersparticipated in 15th Asian games held at Doha from 1st Dec to 15Dec, 2006 where they played total 7 matches, each of 70minutes.

Outcomes

Throughout the tournament, 39.3% of total players gotinjured. Three body parts affected by 7 different types of injuriesand rehabilitated according to symptoms by using physicaltherapy which is cost effective. Occurrence of muscle relatedinjury was the highest (35%) and cut injury at head and eyewere the least (2%). Forwards were at highest risk (43%) whilegoal keeper the least (0%). The effect of treatment was 100%and recovery time ranged from 5 min to 35 min. Out of 22 totalscored, forward scored the maximum (19 goals-86%) followedby midfielder (2 goals-9%) and defender (1 goal-5%). Afterrehabilitation, injured player scored significantly (p<0.01) moregoals (68%) than the not injured (32%) shows physiotherapyenhanced the game performance.

Discussion

Muscular related injuries which were found most may bedue to running or less flexibility in the muscles. Forwards affectedmost may be due to their quick responses and chasing the ballat both the end goals.

Key Words

Field hockey, sports injury, physiotherapy, rehabilitation

Address for correspondence:Suraj Kumar (Ph.D. Scholar)Senior Research Fellow (ICMR)C/o Sanjay KumarRZF – 587/1, Raj Nagar – II,Palam Colony, New Delhi – 77E.Mail :- [email protected] no.:+ 91-98890-92835

Background

Physiotherapy has become an integral part of many sportsaround the world. Management of on ground injuries is achallenging task for physiotherapists and lack of literature &documented data make it more difficult. In India, it is still ingrowing phase.

Sports physiotherapy is a well recognized profession whichdemonstrates advanced competencies in the promotion of safephysical activity participation, provision of advice and adaptationof rehabilitation and training intervention, for the purposes ofpreventing injury, restoring optimal function, and contributing tothe enhancement of sports performance, in athletes of all agesand abilities, while ensuring a high standard of professional andethical practice.1 Sports physiotherapy is a combination ofmanual techniques and other therapies including manipulationand mobilization, massage, hydrotherapy, exercise programmes,electrotherapy (ultrasound and interferential therapy).Physiotherapists not only treat the problem but also help toprevent the recurrence of problem. The purpose of physiotherapyis to decrease body dysfunctions, reduce pain caused either bytrauma, inflammation, degeneration and surgery.

Sports medicine, sports physiotherapy and nutrition are thenewer fields, and yet to be utilized to their potential. During recentpast, sports have now become very competitive and much ofscientific research and support towards sports teams found tobe rewarding. The team doctors, team sports physio serviceshave become very essential for most of the teams, health, SPA(sports physiotherapy for all) and health gymnasiums.

Hockey is an ancient sport thought to be the forerunner ofall ‘stick and ball’ games, played in most of the countries aroundthe world. It is a game of strength, speed and skill. It is amongthe most difficult to master, the costliest to equip, the fastest towatch and the most dangerous to play. It requires a combinationof power, endurance and flexibility. It is game of control and lackof control, both of emotions and flying objects.

Epidemiological studies have consistently shown thatinjuries in hockey are numerous and can be serious. Most seriousinjuries result from being struck by the stick or the ball. Overuseinjuries to the ankles and lower back are also occurredfrequently.4,5 Most injuries presenting to hospitals are to the upperlimb (mostly injuries to the hand and forearm), face (mostly struckby stick or ball) and lower limb (mostly ankle, foot and kneeinjuries). Injuries to the eyes are infrequent, although tend to besevere.14

In literature, most of the studies describes single case reportwith specific injury and its treatment and did not show muchabout group injuries (team) especially on ground injuries duringgame.15,16,17 For the first time, this case study was aimed whichexplore on ground injuries related to hockey and out come oftreatments. Beside this the effect of treatments on game resultwas also observed. Basic data of this case study may be helpfulfor other physiotherapist.

Case Description

This case study belongs to 16 Indian women hockey playersparticipated in 15th Asian games13 held at Doha from 1st Dec to15 Dec, 2006. The player’s characteristics are presented in Table1. As this case study is about on ground injuries during the game,

Suraj Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

33

the details of injury occurred; their treatments and outcome ofthe treatments were summarized in Table 2 and date wiseindividual injury and game result in Table 3. Player’s age, heightand weight ranged from 15-18 yrs, 1.53-1.68 m and 46-61 kgrespectively with an average 22.44 yrs, 1.60 m and 54.13 kg

respectively. Similarly, no of match played (international) andgoal scored in this tournament ranged from 7-162 and 0-8respectively with an average 55.19 and 1.31 respectively. Outof 16, 2 were goal keepers, 3 mid fielders, 7 forwards and 5defenders and among these 5 were reserved (interchangeable)

Table 1: Player’s characteristics who participated in 15th Asian games held at Doha, 2006Player no/ Age Height Weight Position of International Match Tournament goalJersey no (yrs) (m) (kg) play played (no) scored (no)

1 26 1.57 60 goal keeper 71 0 3 25 1.65 59 defender 62 0 4 27 1.66 57 mid fielder 38 0 5 21 1.64 58 mid fielder 36 1 8 16 1.58 61 forward 7 0 9 24 1.54 49 forward 94 8 10 25 1.60 48 forward 86 2 12 23 1.64 57 goal keeper 13 0 13 18 1.68 59 defender 13 0 14 15 1.56 50 forward 8 0 18 19 1.64 58 forward 52 1 20 28 1.53 46 forward 172 5 23 25 1.57 52 defender 78 0 24 21 1.57 50 forward 51 3 25 26 1.56 51 defender 36 1 30 20 1.55 51 mid fielder 66 1

Table 2: Date wise on ground injuries, their types, treatments and outcome of the treatments

Date Number Type Treatment Outcome

03 6 Knee pain (1) Taping, Ultrasound Improved, Fit to playAnkle pain (1) Ice, Crape bandage Improved, Fit to playMuscle pain (3) Taping Improved, Fit to playLow back pain (1) Taping, DMST, TENS Improved, Fit to play

05 6 Knee pain (1) Taping, Ultrasound Improved, Fit to playAnkle pain (1) Ice, Crape bandage Improved, Fit to playThigh muscle pain (2) Taping, Improved, Fit to playCut injury at eye (1) Stitching, antibiotics,

analgesicLow back pain (1) Taping, DMST, TENS, Improved, Fit to play

06 7 Knee pain (1) Taping, Ultrasound Improved, Fit to playAnkle pain (1) Ice, Crape bandage Improved, Fit to playThigh muscle pain (3) Taping Improved, Fit to playLow back pain (1) + Taping, DMST, TENS, Improved, Fit to playCut injury at head (1) Antibiotics, analgesic

08 7 Knee pain (1) Taping, Ultrasound Improved, Fit to playAnkle pain (1) Ice, Crape bandage Improved, Fit to playThigh muscle pain (3) Taping Improved, Fit to playLow back pain (1) Taping, DMST, TENS Improved, Fit to playWrist injury (1) Taping Improved, Fit to play





34

players (P4, P8, P12, P13 and P14).Physiotherapist joined 15 days before the tournament in

India. In his first screening 5 players (P5, P9, P13, P20 and P3)had chronic injuries (low back pain, knee pain, ankle injury andthumb injury) even though they were fit in their daily activitiesincluding play. According to symptoms, they were rehabilitatedbefore the tournament. These players also joined generalphysiotherapy rehabilitation programme with others while theirstay in India. None of the participants had had a systematicintensive course of physiotherapy before. During game at Doha,individual’s injury and type of injury was recorded by thephysiotherapist. Individual who suffered multiple injuries of samekind was counted as 1. The injured player rehabilitated on theground and off the ground. This study did not require any patientsconsent.

0- not injured/loss, 1-injured/win

Table 3: Player wise each day injuries and game results

Date P1 P3 P4 P5 P8 P9 P10 P12 P13 P14 P18 P20 P23 P24 P25 P30 Result

3 0 0 0 1 0 1 1 0 1 0 0 1 0 0 0 1 1 5 0 0 0 1 0 1 1 0 1 0 0 1 0 0 0 1 0 6 0 0 0 1 0 1 1 0 1 0 0 1 0 0 0 1 1 8 0 0 0 1 0 1 1 0 1 0 0 1 1 0 0 1 1 9 0 0 0 1 0 1 0 0 1 0 1 1 1 0 0 1 011 0 0 0 1 0 1 0 0 1 0 0 1 1 0 0 1 013 0 0 0 1 0 1 0 0 1 0 0 1 1 0 0 1 1

ball; head and eye injuries, when penalty was called.Except hit injuries, the rehabilitation of other injury was done

by physiotherapist. According to symptoms, treatments weregiven as taping, mobilization, manipulation, dynamic muscularstabilization technique (DMST), cold therapy, ultrasound, TENS,stretching exercises and relaxation exercises, crape bandageand strengthening exercises. Except ultrasound, TENS andrelaxation exercises other treatments were given on the groundduring the game. In all the intervention, rate of recovery was100% and the time of recovery was from 5 min to 35 min.

Area wise distribution of injuries (Fig. 1) shows that theoccurrence of muscle (thigh and calf) related injury was thehighest (35.6%) and hit and cut injury at head and eye were theleast (2.2%). Ankle injury was the second highest (20.0%)


Fig. 1: Area wise distribution of injuries (%).

Fig. 2: Position wise distribution of injuries (%) during the game.

followed by low back pain and knee injury (15.6%) and wristinjury (8.9%). Similarly, position wise distribution of injury (Fig.2) shows that forwards were the highest at risk (31.8%) whilegoal keeper the least (0%). Midfielders were second highest atrisk (31.8%) followed by defenders (25%).

Out of 22 total scored goals, forward scored the maximum(19 goals-86.4%) followed by midfielder (2 goals-9.1%) anddefender (1 goal-4.5%) (Fig. 3). Comparing goal scored betweennot injured and injured players, the ratio of goal scored by injuredplayers (17) was significantly high (p<0.01) than the not injured(5). Interestingly, out of 22 total scored goals, 5 players (31.3%)who were injured before the tournament and their injury remainsthroughout the tournament, scored 15 goals (68.2%) showsphysiotherapy not only rehabilitate their injury and improve theirplaying skill and power but also enhanced mental, physicalstrength and game performance.

Discussion

Case research plays an important role in gathering evidencefor more efficient practice, especially in relation to physiotherapy,where it is common to find interventions that are context-dependent and multifaceted.2 Exercise therapy is generallyprescribed to be a specialist clinical skill and the most complexand difficult part of physiotherapy7. This case report hasdescribed the rapid recovery of an athlete in case of groundinjury and her achievement and satisfaction with the outcomeafter physiotherapy intervention. It has been suggested thatphysiotherapist should, at the initial examination, identify the

Outcomes

During their stay at Doha, players played 7 matches, eachof 70 minutes. In 7 matches, India scored total 22 goals, won infour along with bronze medal. Out of 112 (16 players X 7 games),total 44 players (39.3%) get injured. During the tournament, total7 types of injuries occurred which were low back injury (pain),ankle injury, knee injury, wrist injury, muscle injury, and hit andcut injury at head and corner of eye. Eight players did not getinjured throughout the tournament. Only one player (P20) hadmultiple injuries (low back pain and cut injury at head) during 3rd

match of the tournament. Most of the injuries occurred whenthe player was near the goal or within the 25-yd line and werecaused by contact with stick or ball or with players, chasing the

Fig. 3: Position wise distribution of goal scored.

35

patient’s goals and objectives in order to maximize outcomes ofphysiotherapy intervention. Core aspects of physiotherapymanagement in ground injuries are to reduction in painimprovement in function and prevention to further deterioration.

All the physiotherapeutic intervention (taping, mobilization,manipulation, dynamic muscular stabilization technique (DMST),cold therapy, ultrasound, TENS, stretching exercises andrelaxation exercises, crape bandage and strengtheningexercises) provided during the tournament are welldocumented6,8,9,10,11 and practitioners uses these in their dailytreatments. These treatments may blocks pain pathways,mobiles bound neurological structures or enhance themusculoskeletal efficiency.12

In this case study, 39.3% total players get injured. Threebody parts affected by 7 different types of injuries andrehabilitated according to symptoms. Occurrence of musclerelated injury was the highest (35%) and cut injury at head andeye were the least (2%). Forwards were at highest risk (43%)while goal keeper the least (0%). The effect of treatment was100% and recovery time ranged from 5 min to 35 min. Afterrehabilitation, injured player scored significantly (p<0.01) moregoals (68%) than the not injured (32%) which showsphysiotherapy enhance the game performance. Muscular relatedinjuries which were found most may be due to running or lessflexibility in the muscles. Forwards affected most may be due totheir quick responses and chasing the ball at both the end goals.

This case study strongly recommends that all hockeyplayers should undergo at least a pre-season fitness screeningfor general strength, flexibility and endurance. Coaches shouldbe trained to screen players and to refer them on to appropriateprofessionals if problems are evident. Equipment (requiringhelmets and padded gloved) and rule changes (to decreasefield congestion near the goal) as well as evidence-based injuryprevention interventions (prophylactic ankle taping/bracing,neuromuscular balance exercise programs) may be viableprevention initiatives for reducing injury rates in women’s aswell as men’s field hockey players.18

The objective of physiotherapist while rehabilitating the onground injured sports person is “to make player fit for play withinthe shortest possible time”. In this study it varied from 5 min to35 min. The other possible physiotherapeutic interventions withoptimal time may be highly imperative. The basic baseline dataof this case study may be beneficial in future to otherphysiotherapist.

Acknowledgement

First author of this study was as a physiotherapist of Indianwomen field hockey team who participated in 15th Asian gamesheld at Doha from 1st Dec to 15 Dec, 2006, wants to thankcoaches (Mr. M.K. Kausik, A.B. Subbaiah and Anurita Saini),team manager (Mrs. Rajbeer Rai) and all the players. Authoralso want to thank Director, Sport Authority of India, Lucknow,Women Hockey Federation of India and Government of Indiafor honoring as a physiotherapist.


References

1. Bulley C, Donaghy M. Sports Physiotherapy competencies:the first step towards a common platform for specialistprofessional recognition. Physical therapy in sport. 2005;6: 103-108.

2. Sousa JP, Cabri J, Donaghy M. Case research in sportsPhysiotherapy: A review of studies. Physical therapy insport. 2005; 8: 197-206.

3. Derscheid GL, Feiring DC. A statistical analysis tocategorize treatment adherence of the 18 most commondiagnosis seen at a sports medicine clinic, J Orthop SportsPhysi Ther 1997; 9: 40-46.

4. Refshauge KM, Maher CG. Low back pain investigationsand prognosis: a review. Br J Sports Med 2006; 40: 111-115.

5. Goldby LJ, Moore AP, Doust J et al. A randomized controlledtrial investigating the efficiency of musculoskeletalphysiotherapy on chronic low back disorder. Spine 2006;31: 1083-1093.

6. Warden SJ, McMeeken JM. Ultrasound usage and dosagein Sports Physiotherapy. World federation for Ultrasoundin medicine and biology 2002; 28: 1075-1080.

7. Lynn DB. Physiotherapy management of accelerated spinalrehabilitation in an elite level athlete following L4-S1instrumented spinal fusion. Physical therapy in Sports.2003; 4: 40-45.

8. Richardson CA, Jull CA. Muscle Control-Pain Control. Whatexercises would you prescribe? Man Ther 1995; 1: 2-10.

9. Fall M. Electrical pelvic floor stimulation for the control ofdetrusor instability. Neurourology and Urodynamics. 2005;4: 329-335.

10. Shields N, Gormlay J, O’Hare N. Short-wave diathermy:current clinical and safety practices. PhysiotherapyResearch International. 2006; 7: 191-202.

11. Holmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB,Bjerg AM, Krogsgaard K. Effectivness of active physicaltraining as treatment for long standing adductor-relatedgroin pain in athletes: randomized trail. The Lancet. 1999;353: 439-443.

12. http://www.london-osteopath.com/Physiotherapists.html.Physiotherapy- For Treatment and Rehabilitation.

13. http://www.doha-2006.com. Doha Asian Games.14. http://www.monash.edu.au/muarc/reports/muarc143.html.

A Review of Field Hockey Injuries and Countermeasuresfor Prevention.

15. Bolhuis JH, Leurs JM, Flogel GE. Dental and facial injuriesin international field hockey. Br J Sports Med. 1987; 21:174-177.

16. McIntosh AS, McCrory P. Preventing head and neck injury.Br J Sports Med. 2005; 39; 314-318.

17. Boden BP, Prior C. Catastrophic spine injuries in sports.Curr Sports Med Rep. 2005; 4: 45-49.

18. Dick R, Hootman JM, Agel, J, Vela L, Marshall SW, MessinaR. Descriptive Epidemiology of Collegiate Women’s FieldHockey Injuries: National Collegiate Athletic associationInjury Surveillance System, 1998-1989 Through 2002-2003.Journal of Athletic Training. 2007; 42: 211-220.

36

Comparison of Task Oriented Approach and Bobath approach inImproving balance and Reducing Fear of Falling in adults withStrokeJayachandran V,* Gayathri Ethiraj***Lecturer, **Assistant Professor, University of Technology Mara (UiTM), SRM University, Malaysia, India

Abstract

Objective

To find out the effectiveness of Task Oriented Approachand Bobath approach in improving balance and reducing fearof falling in adults with Stroke.

Methods

Quantitative research design was employed across 20subjects, each 10 in both control (bobath) group andexperimental (Task Oriented Approach) group. Treatment wasgiven, one hour per day on alternate days for 30 days indepartment of Occupational Therapy, Vijaya hospital & S.R.M.hospital, Chennai. Dependent variables were balance and thesubject’s confidence level about their fear of falling during dailyactivities. Berg Balance Scale (BBS) and Falls Efficacy Scale(FES) were used as outcome measures. Data analysis was doneby using Mann-Whitney ‘U’ test and Wilcoxon‘t’ test.

Results

Shows that significant improvement in balance, in bothcontrol (p=0.007) and experimental (p=0.005) group. Similarly,there was significant reduction in the fear of falling in both control(p=0.005) and experimental group (p=0.005). However, theimprovement in experimental group [BBS (m) =49.30; FES (m)=88.50%] is more marked, when compared to the control group[BBS (m) =24.90; FES (m) =31.70%]

Discussion

The more marked improvement in experimental group wasattributed to the generalizing effects of Task Oriented Approachwhen compared to the bobath approaches. Task OrientedApproach gives emphasis on practicing the whole task ratherpracticing the task progression from part by part. Previousresearches also stated that random practice is always betterthan the blocked practice. Hence, there was markedimprovement in experimental group than the control group.

Conclusion

Task Oriented Approach may be more effective than theBobath approach. Occupational therapists are encouraged touse task specific activities and changing the task requirementaccording to the environmental contexts to enhance functionalperformance.

Key Word

Task oriented approach, Bobath approach, Stroke, Fearof falling and Balance

Introduction

Stroke is the leading causes of activity limitations in adults.

It is a common clinical problem with significant on its survivorand on the society. It often present as a disabling illness involvingmany aspects of patients life, especially, on the ability to performactivities of daily living and ambulation.

Stroke is the third leading cause of death in the UnitedStates and is the most common causes of chronic disabilityamong adults. Incidence of stroke is age related beinguncommon under age 50 but doubling each decade after theage of 55 years. Incidence of stroke in India is 1-2 per thousandswith a prevalence of 5 per thousand and recurrence rate of 20%- 30%. Some common impairment after stroke is impaired motorfunction sensory perceptual deficits, impaired balance cognitivelimitation, aphasia and depression1. But disability in balance isvery common after stroke. It has also been postulated in researchthat balance cannot be separated from action of which it is anintegral component1. Therefore balance is considered as“Foundation for all voluntary motor skill”.

Since controlling the body’s position in space is an essentialpart of functional skills restoration of balance is a critical part ofthe recovery of ability after stroke2. The exact demands on thebalance control system are determined both by the task itselfand by the environment, in which it is performed and differenttasks and environment alter the biomechanical and informationprocessing required for balance control3.

Fear of falling is more in stroke patients4. Incidence of fallin stroke rehabilitation unit and their frequency are increasedand it leads to decreases functional outcomes and impairments.Fear of falling may thus lead to a debilitating spiral, marked byloss of confidence and reduced activity ultimately resulting inloss of independence. So, the identification and prevention ofpatient’s risk of fall may be the first step towards the rehabilitationprogram5.

A patient with central nerve system (CNS) dysfunctionevaluation primarily focus on the sensorimotor and cognitivecomponents of muscle tone reflexes and abnormal movementpatterns, postural control, sensation, perception, memory andjudgment psychological components and environmental contextwould rarely be evaluated. Treatment using a traditionalapproach focuses on remediating whatever components wereidentified as impaired on evaluation. Common treatmenttechniques include the use of various sensory stimuli to inhibitspasticity, abnormal reflex and abnormal movement patternsand to facilitate normal, muscle tone, equilibrium response andmovements patterns6.

It emerges from the system model of motor control andinfluenced by contemporary developmental and motor learningand skill acquisition theories7. It is based on the assumptionthat the CNS is heterarchically organized. Occupational therapistwould collaborate with clients in determining which tasks wereproblematic and important to evaluate given clients role inenvironmental context. The therapist would observe clientsperforming selected functional task in varied context8, this wouldprovide information about the role of environmental context onperformance as well as clues about the interaction of systemand subsystem that were contributing to functional deficits.Treatment using a contemporary approach focuses on helpingthe clients find the optimal strategy for achieving functional goals.However, studies, which talk about the remediation of balancecontrol following Stroke by using Task Oriented Approach, arelimited.

Jayachandran V / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

37

Research is needed to determine whether Task OrientedApproach is better than bobath approaches. Hence this studyhas been undertaken to compare the effectiveness of TaskOriented Approach and traditional approaches in improvingbalance and thereby reducing fear of falling in adult with Stroke

Methodology

Study Design

It was a Quantitative research design. The participants wereselected by using a convenience sample from occupationaltherapy department of SRM and Vijaya Hospital. 20 Patientswith stroke were selected from occupational therapy department(S.R.M. Hospital and Vijaya Hospital, Chennai) out of 20 patients17 were males and 3 were females and the age group rangingbetween 30-70 years in that 10 were right hemiplegia and 10were left hemiplegia, duration of illness range from 0-2 year.

Inclusion Criteria

1. Subjects diagnosed as stroke as per CT/MRI Scan.2. Right and Left hemiplegia and having the first onset of

stroke.3. Both genders.4. Subjects scoring 19 and above in mini mental status

examination.5. Subjects scoring 6 - 15 in National Institute of health stroke

scale.6. Subject with expressive aphasia.

Exclusion Criteria

1. Subjects with the previous history of any other neurologicalproblems like Head injury, Parkinson, Multiple sclerosis etc.

2. Subjects with the history of any other cardiac and respiratoryproblem.

3. Subjects with bilateral stroke.4. Subjects with severe internal capsule bleed as mentioned

in the CT scan and MRI Report.

Test used

All the patients were assessed using a Falls Efficacy Scale(FES Tinetti, 1990) and Berg Balance Scale (BBS Kathy Berg,1992) validity and reliability of scale were studied in variousstudies early. The FES consists of Visual analog ratio scale.Having 10 ADL activities and the scale extended from 1 to 10points which measure the level of confidences of the subjectson falls. The BBS consist of 14 items rated from 0 to 4. Therewere 14 items deals about various level of balance from sittingto standing balance zero means patients had difficultly in doingparticular item, four means highly independent in doing particularitem total score is 56.

Procedure

Consent forms were obtained prior to the study from all 20subjects. After they concord, pretest was done by using Bergbalance scale and falls efficacy scale. Ten subjects in controlgroups were under went traditional occupational therapytreatment and 10 subjects in experimental group were undergone Task oriented approach.

Task oriented approach was given for the period of 30 days.Fourteen activities were selected based on the Task orientedapproach. Activities were graded from simple to complex.Specific activities were chosen for each subject according to

their ability. The activities are,1. In sitting, forward reach and takes peg and keep it back.2. In sitting, transferring pegs to opposite side.3. In sitting, sideward reach and takes pegs and keep it back.4. Ball throwing and catching in the back supported chair and

then to back unsupported stool.5. Transfer the pegs from sitting position to standing position

with various level of stool.6. Ball throwing and catching in standing unsupported.7. Simulating the soaping activity to face.8. Catching and throwing ball with feet together.9. In standing, pickup object in front with forward reach.10. In standing, pickup the shoe placed in front of feet.11. Transfer pegs from back to back.12. Kicking ball in standing position in forward backward and

sideward direction.13. Lower half dressing in standing position.14. Climbing up and down stair with alternate steps.

The intervention period is carried over for 30 days, onehour per day on alternate days. After the intervention periodsubjects were underwent post therapy evaluation.

Results


Statistical analysis was done by the SPSS version 16.Statistical measure such as Mann Whitney u test and Wilcoxonsing rank test were used to analyze the data. The results wereconcluded to statistically significant with p < 0.05.

The Wilcoxon sing rank tests were used to compare thedifference of pre and post test of each group. Mann Whitney utests were used to compare differences between the two groups,(bobath and task oriented group).

Balance

All the pre and post test scores of Berg Balance Scale inboth control and experimental group were compared. Beforethe intervention patients balance mean score were 20.50 and13.40 in control and experimental group respectively. But afterintervention the balance mean score was 24.90 and 49.30 incontrol and experimental group respectively. When comparingpost test scores of control and experimental group, task orientedactivities are improve balance more markly than the bobathtechniques.

Falls Efficacy Scale

All the patients were assessed using a structuredquestionnaire instrument of falls efficacy scale to find aconfidences level of patients in day to day activities. Whencomparing pre and post test scores in control and experimentalgroup confidences level of patient is improved in both casesbut more markedly in experimental group. Correlation betweenbalance and confidence level in ADL without fall. The post testscores of Berg Balance Scale and fall efficacy shows that thereis positive correlation. When balance increases confidence levelof the patients are also increased.

Table 1 shows the comparison of control and experimentalgroup in pre and post tests scores of Berg Balance Scale.Wilcoxon Singned rank test was used to compute the results. Itshows that there is stastically significant difference betweenpost test scores of control and experimental group at 0.05 levels.Hence, the experimental group has the marked improvementin balance. When compared to the control group.


38

Table 1: Pre and Post test scores of BBS in control andexperimental group

S. No. Groups in BBS N Mean S.D

1. Control group Pretest 10 20.50 6.43 Post test 10 24.90 5.65

2. Experimental Pretest 10 13.40 9.94group

Post test 10 49.30 4.95

Table 2: Pre and Post test scores of FES in control andexperimental group

S. No. Groups in BBS N Mean S.D

1. Control group Pretest 10 18.40 6.54Post test 10 31.70 8.59

2. Experimental Pretest 10 18.00 7.38group

Post test 10 88.50 13.60

Table 2 shows the comparison of control and experimental groupin pre and post tests scores of falls efficacy Scale. WilcoxonSingned rank test was used to compute the result. It shows thatthere is stastically significant difference between post test scoresof control and experimental group at 0.05 levels. Hence theexperimental group has the marked improvement in theirconfidence level. When compared to the control group.

Table 3: Correlation between the Berg Balance Scale and FallsEfficacy Scale

S. Post Test N Spearman’s Correlation(rs)No. Level of Significance

1. Berg Balance 10Scale

0.739 0.0152. Falls Efficacy 10

Scale

Discussion

The purpose of this study was to compare the effectivenessof task oriented approach and traditional approaches inimproving balance and there by reducing fear of falling in patientswith stroke. Results of pre and post test scores in control groupshowed improvement in balance by using traditional approach.According to Gordon, etal (1987) improvement was seen intraditional treatment but that does not necessarily carry over toimprovement in functional performances. Like wise subjects inthe control group showed improvement but it doesn’t show anyeffect on the functional performances. This has been proved byfalls efficacy score of subjects in control group. Their confidenceslevel in doing the ADL is very low (FES=31.70%) Schmidt, et al1988, indicated that blocked practice was better than randompractice and progression from part of the whole tasks wasdesirable for motor learning. Hence the blocked practice oftraditional activities may have contributed to the improvementin balance in the control group. Results of pre and post testscores of experimental group showed improvement in balanceby using task oriented approach. According to shea etal, 1979,random practice is better than blocked practice practicing thewhole task is effective than practicing the task progression frompart by part. Contemporary task oriented approach focuses onhelping the clients find out the optimal strategy for achievingfunctional goals. Hence, in this study those subjects involved intask oriented activities have showed increased confidence level(FES=88.50%) in their daily activities when compared to thecontrol group. This was supported by Salbach, etal (2004),proved that task oriented intervention is enhancing walkingdistances and speed in the first year post stroke for the peoplewith moderate walking deficits. When comparing the results ofcontrol and experimental group significant differences in balancewere found. The improvement in balance in experimental group(m=49.30) is more marked when compared to the control group(m=24.90). Hence, the task oriented approach is more effectivein improving balance than the traditional approach. Krutulyte,etal, 2003, stated that task oriented physical activities will bemore effective than the facilitation and inhibition strategies suchas the bobath programme in the rehabilitation of stroke.Mathiowetz, etal, 1994, stated that in task oriented approach,the generalization will be more for the patients, i.e. they will adaptto the functional activity easily. Burton, etal 1992 suggested thattherapist may alter task requirements or the environment contextto enhance performances. Hence specific and the taskrequirements were also changed according to the environmentalcontext. There fore in this study the subjects who haveparticipated in the experimental group have performed morefunctional oriented tasks in different environmental contexts,which may contribute to the improvement in balance. Thesubjects in the experimental group had more confidence leveland less fear of falling during daily activities when compared tothe control group after intervention.

Few limitations of this study included small number samplessize. Convenience sampling was used for the selection of theparticipants. 60 subjects were not selected according to thegeographical location, race, ethnicity and other factors so thisresult cannot be generalized.


Table 3 shows the correlation between the Berg Balance Scaleand Falls Efficacy Scale spearman’s correlation test was usedto compute the result. It shows that there is positive correlationbetween the post test scores of berg balance scale and fallsefficacy scale is experimental group (r = 0.739, P<0.015) at 0.05level.

39

Hence it is recommended that future research can be donewith large number of samples. Randomized control trail studiescan be used to find the effectiveness of Task Oriented Approachto get an accurate result. We also recommended to Task orientedapproach can also be used to identify the effectiveness of otherfactors like, co-ordination, gait and hand function.

Conclusion

This study concluded that there is statistically significantdifference in balance and reducing fear of falling by using bobathand task oriented approach. However, improvement inexperimental group is more marked than the improvement incontrol group. Hence, task oriented approaches may be moreeffective than bobath approaches further researcher arerecommended to find the effectiveness of task oriented approachby using randomized control trail model and sufficient numberof samples from various geographical location

References

1. Carry JH, Shepherd RB. Neurological rehabilitation:optimizing motor performance oxford butterworth -Heinemann Ltd. 1998; 154-181.

2. Shumway Cook A, Woollawt MH. Abnormal postural control.Motor control: theory and practical applications - LippincottWilliams & Wilkens. 2001; 163-191.

3. Huxham FE, Goldie PA, Patla AE. Theoretical considerationin balance assessment. Austr. J. Physiother. 2001; 47:89-100.

4. Hellstrom K., Lindmark B. Fear of falling in patients withStroke: A reliability study. Clinical Rehabilitation.1999;13:509-517.

5. Tinetti ME, SpeechleyM, GinterSF. Risk factors for fallamong elderly person living in the community. N Engl JMed. 1988; 319:1701-1707.

6. Mathiowetz V. Role of physical performance componentevaluations in Occupational Therapy functionalassessment. AJOT. 1993; 47: 225-230.

7. Horak FB. Assumptions underlying motor control forneurological rehabilitation; contemporary management ofmotor control problems. Proceedings.1991

8. Burton AW, Davis WE. Optimizing the involvement andperformance of children with physical impairments inmovement activities. Pediatric exercise science.1992;4:236-248

9. Garland SJ, Willems DA. Recovery of standing balanceand functional mobility after stroke. APMR 2003: 84; 1753-1759.

10. Krutulyte G, Kimtys A. The effectiveness of physical therapymethods (Bobath and motor relearning program) inrehabilitation of stroke patient’s of medicine (Kaunas). 2003;39-9: 889-895.


40

A Cost-effective Patient Designed Hand Splint for RehabilitationAfter Two-stage Flexor Tendon ReconstructionMuhammad Adil Abbas Khan*, Mark Gorman*, Arvind Mohan*, Zain A Sobani**, Alastair Platt****Plastic Surgery Trainee, **Medical Student, ***Plastic Surgery Consultant, University Hospital of North Staffordshire NHS Trust,Stoke-on-Trust, United Kingdom, Castle Hill Hospital, Hull, United Kingdom

Abstract

Background

A number of splints have been described to aid in therehabilitation after two-stage flexor tendon reconstruction. Wepresent an innovative splint design by a motivated patient toassist in his own functional recovery in a cost-effective manner.

Case

A 45 year old male engineer underwent a traumatic motorbike injury to the volar aspect of his left middle finger at the levelof the distal interphalangeal (DIP) joint. He was found to have asegmental loss of the distal segment of the flexor digitorumprofundus (FDP) that prevented a primary repair. He wasplanned for a two stage repair with physiotherapy. After consultingwith the therapist, the patient designed a device to aid himselfwith the flexion of the DIP, PIP and MCP joints of his affecteddigit which he used during this period. His post operative recoverywas remarkable with excellent functional recovery scoring 95%of normal movement on the Strickland’s Adjusted system.

Conclusion

In combination with a hand therapy regime, we recommendthis innovative patient designed splint as a simple andinexpensive alternative to existing splints for rehabilitation fortwo-stage flexor tendon reconstructions.

Key Words

Ocupational therapy; flexor tendon reconstruction; splint;FDP (flexor digitorum profundus); FDS (flexor digitorumsuperficialis); PIP (proximal interphalangeal) joint; DIP (distalinterphalangeal).

Introduction

A number of splints have been described to aid in therehabilitation after two-stage flexor tendon reconstruction. Wepresent an innovative splint design by a motivated patient. Thenovel aspect is that in this case the well informed patient cameup with the idea which was recognized by the clinical team andhand therapist who allowed the patient to assist in his ownfunctional recovery in a cost-effective manner.

Address for correspondence:Muhammad Adil Abbas KhanPlastic Surgical Trainee10 Harvey LodgeAdmiral WalkLondon W9 3THUnited KingdomPhone: 0044 786 333 2517Email: [email protected], [email protected]

Case Report

A 45 year old male engineer underwent a traumatic motorbike injury to the volar aspect of his left middle finger at the levelof the distal interphalangeal (DIP) joint and underwent a primarydebridement of a surgically contaminated wound. He was foundto have a segmental loss of the distal segment of the flexordigitorum profundus (FDP) that prevented a primary repair. Afterconsulting with the therapist, the patient designed a device toaid himself with the flexion of the DIP, PIP and MCP joints of hisaffected digit. He also underwent a standard protocol of digitalexercises supervised by hand therapists in the three monthsleading to his first stage flexor reconstruction with a siliconerod. Postoperatively he remained compliant with physiotherapyand continued wearing his splint. Three months later at the timeof his second stage reconstruction, he was observed to have90 degrees of flexion at the DIPJ and PIPJ of the affected digit.

After the second stage reconstruction he was againassessed by the hand therapist and a week later started wearinghis designed splint again for another four weeks. His postoperative recovery was remarkable with excellent functionalrecovery scoring 95% of normal movement on the Strickland’sAdjusted system [(PIP + DIP) flexion extension deficit x 100/175 degrees].

The Splint - Design and Application

The splint designed by the patient consisted of a Velcrohood constructed by stitching together two Velcro straps (wiresecuring Velcro bought from an electrical store). This hoodcovered the tip of the digit and was secured to the wrist withelastic bands that passed as adjustable straps through a slit oneach side of the hood. The elastic straps were secured distallywith knots allowing the elastic band length to be adjusted (if itbecame loose secondary to overstretching) by simply pullingthe band distally through the slits and securing the newly adjustedlength with a new knot. The distal segment of the band couldthen be cut off enabling this design to be used successfully indigits of all lengths with easy adjustment.

The elastic straps chosen by the patient were soft and thesplint design allowed the fulcrum to rest of the dorsum of thehand (just distal to the wrist joint) (Figure 1) enabling passiveassisted flexion of the digit at both the DIPJ and PIPJ after eachactive extension (Figure 2). Despite allowing full extension ofthe finger against the elastic, there was still enough tensionremaining to provide sufficient traction when flexed. There wasno restriction imposed on the the volar surface of the hand bythe device. The elastic straps despite not having a base did notdig into the wrist or the finger webs and hence did not pose arisk for neuropraxia or pressure. The splint was worn fulltime bythe patient prior to first stage reconstruction and in the interimperiod between the first and second stages (when it kept thePIP, DIP and MCP joints in flexion), and also after a few days ofthe second stage of reconstruction (when it allowed both passiveflexion as well as extension against some resistance).

It could also be easily removed and washed for hygienepurposes and the total cost price of the Velcro and elastic bandswas described by the patient to be 0.40 pounds sterling(approximately US $ 0.65).

Muhammad Adil Abbas Khan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

41

Discussion

Prior to a two stage flexor reconstruction, it is wise to startthe patient on a range-of motion and scar softening therapyprogram to attain maximum preoperative passive range ofmotion.1-3 After stage one of flexor reconstruction, passive motionexercises are started 2 – 3 days after surgery.4 In thepostoperative therapy after stage two of flexor reconstruction,there has been a steady trend toward early active mobilization.1,

5, 6

There are several splint designs and splinting protocolsincluding the Duran and the Kleinart rubber traction, the Brooke

Army palmer-bar modification, the Mayo clinic synergistic wristsplint, Evan’s short arc motion, and the Strickland hinged wristsplint and active tenodesis. The splints can vary in design fromsimple elastic straps around PIP and DIP joints, elastic strapsof various designs around the palm and distal phalanx, flexiongloves with elastic traction or with an extra strap around thedistal phalanx and palm. Other alternatives include palm baseddynamic finger flexion splints or sticking hook-Velcro to the nailplate and attaching a loop or elastic from the palm to the wrist.

Most of these alternatives are complex in design and haveto be custom made by occupational therapists and can have asubstantial cost and time factor involved in the manufacturingprocess. Full details of the treatment protocol, the rationale forwhy splints are used and how the different existing designsaddress specific treatment objectives such as early protectedmobilization are beyond the scope of this manuscript.

The patient designed splint acted as a flexion strap whichallowed him to regain flexion at the DIP and PIP joints. The factthat the patient had an excellent outcome may not be enoughevidence that this splint is generally effective, but the splintdesigned by the patient proved to be innovative, simple,inexpensive and fulfilled the requirements of therapy. The designhas since been used to help other patients with good outcome.

Conclusion

In combination with a hand therapy regime, we recommendthis innovative patient designed splint as a simple andinexpensive alternative to existing splints for rehabilitation fortwo-stage flexor tendon reconstructions.

Acknowledgements

The patient has given consent to them being presented asa case and we would like accredit

Mr. Ian Tomkins for the splint he has designed.

Authors Statement

All authors have contributed to the conception and draftingof the above mentioned article. All the authors have seen andagreed to the submitted version of the paper, and bearresponsibility for it.

All who have been acknowledged as contributors or asproviders of personal communications have agreed to theirinclusion, the material is original and has been neither publishedelsewhere nor submitted for publication simultaneously.

None of the authors have any conflicts of interests or anyfinancial disclosures to make. No funding was required for thismanuscript.

References

1. Mackin EJ, editor. Physical therapy and the staged tendongraft: Preoperative and postoperative management. AAOSSymposium on Tendon Surgery in the Hand; 1975; St.Louis, CV: Mosby.

2. Mackin EJ. Therapist’s management of staged flexortendon reconstruction. . In: Hunter JM SL, Mackin EJ,,editor. Rehabilitation of the Hand. 2nd ed. St. Louis, CV:Mosby; 1984.

3. Mackin EJ, Maiorano L. Postoperative therapy followingstaged flexor tendon reconstruction. In: Hunter JM SL,Mackin EJ,, editor. Rehabilitation of the Hand. St. Louis,CV: Mosby; 1978.

4. Cannon NM, Strickland JW. Therapy following flexortendon surgery. Hand Clin. 1985 Feb;1(1):147-65.

5. Hunter JM, Blackmore S, Callahan AD. Flexor tendonsalvage using the Hunter tendon implant. J Hand Ther1989;2:107-13.

6. Stanley BG. Flexor tendon injuries: late solution. Therapist’smanagement. Hand Clin. 1986 Feb;2(1):139-47.

Muhammad Adil Abbas Khan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Fig. 1: Dorsal view of the worn splint.

Fig. 2: Lateral view of splint with flexed PIP, DIP and MCPjoints.

42

Altered Current Perception Ratio: A tool to identify small fiberneuropathy in high risk Diabetic footUnnati Pandit*, Hutoxi Witer**, Bharati Bellare****Associate Prof., Dept. of Physiotherapy Pad. Dr DY Patil University, Nerul, Navi Mumbai, **Prof & HOD, School of Physiotherapy,TN Medical College, Mumbai, ***Hon. Prof. M.G.M. School of Physiotherapy, Kamothe, Navi Mumbai

Abstract

Background

Diabetics neuropathy & associated vascular affection isknown to cause high risk of foot ulceration. This comparativepilot study was therefore aimed to explore whether the ratios ofdistal to proximal sensory threshold [RST] & pain threshold [RPT]respectively can serve as diagnostic tools to identify small fiberdiabetic neuropathy & indicators of risk of foot ulceration.

Methodology

25 subjects [15males & 10 females] within the age of 45 to60 years were studied as per selection criteria. 25 age & sexmatched healthy subjects volunteered as Controls. Plain faradiccurrent stimulus was used to pick up sensory & pain thresholdsof sural nerve at ankle [distal]& lateral cutaneous nerve of calf[proximal ] & distal to proximal RST & RPT were determined.In addition ABI was also assessed. SPSS-16 soft ware was usedto compare RST & RPT & ABI between controls & study groupusing independent t test.

Result

SPT, RPT & ABI showed significant affection [reversal] instudy group [ t = 3.97 , 8.25 & 9.16 respectively & p<0.000 in allthree].

Conclusion

RST & RPT serve as effective tools to identify small fiberdiabetic neuropathy & the same with ABI can serve as effectiveindicators of risk for foot ulceration in diabetic subjects.

Introduction

Diabetes mellitus has reached epidemic proportionsworldwide as we have entered the new millennium. The WorldHealth Organization (WHO) has commented that there is anapparent epidemic of diabetes which is strongly related to lifestyleand economic status. The prevalence of diabetes for all age-groups worldwide was estimated to be 2.8% in the year 2000and predicted to be 4.4% in the year 2030. 1

G Said et al [2007]2 reported that diabetic neuropathy whichis the most common neuropathy in industrialized countries, isassociated with a wide range of clinical manifestations.NidalA.Yunus et al [1999] 3 report that Neuropathy is the major etiologiccomponent of most diabetic ulcerations; involving more than80% diabetics. Loss of protective sensation[LOPS] is the primaryfactor in foot ulceration in diabetics3,4,5 As per R Gary Sibbard etal [2009]5 LOPS in those with diabetic neuropathy, throughcombination of high planter pressure & repetitive stress duringdaily activity, may wear a hole in their foot just as one wouldwear a hole in stocking.

As per Arendt-Nielsen L [2009]6 Quantitative sensory testing[QST] provides psychophysical methods that systematicallydocument alterations & recognition in peripheral nervous system

functions & in particular, the nociceptive system. Concept ofCurrent perception threshold [CPT] is already established asone of the assessment methods of QST 7,8,9 having its reliability& reproducibility already established [1989] 8

Affection of distal to proximal gradients of variousparameters related to peripheral neuropathies are reported inliterature, . J P Conomy-[1979] 10 reported alteration in the Distalto proximal cutaneous sensation in diabetes mellitus-; whereas Gary L. Pittenger et al [2004] 11 observed that intra-epidermalnerve fiber density (IENF) progressively decreases (P < 0.001]from proximal to distal sites in patients with diabetic neuropathy.Similar findings in various parameters specifically related todiabetic neuropathy are also reported11,12,13,14,15,16 Maria Nebuchennykh et al [2009]17, further recommend that the reversalof gradients to be considered as strict criteria for the diagnosisof small fiber neuropathy; which is seconded by Bashar Katirji18

Sensory & Pain thresholds can serve as parameters of CPT,hence assessment of Distal to proximal ratios of sensorythreshold [RST] & Pain threshold [RPT] respectively can behypothesized as synonymous tools to assess distal to proximalgradients in cutaneous perception

Vascular disease can independently pose as a risk factorfor ulcers. More over it is frequently associated with distaldiabetic neuropathy.2,3,4,5,19,20,21,22,23. Atherosclerosis is acceleratedin diabetic patients compared to nondiabetics. It commonlyinvolves the tibial and peroneal arteries20,21,22,23. The concomitantpresence of neuropathy and ischemia predisposes the foot tominor trauma, which is often the precipitating factor forulceration4.

Eearly detection of diabetic neuropathy with associatedvascular insufficiency if any forms an essential tool inprevention of ulceration in diabetic foot. Therefore this pilotstudy was aimed with a hypothesis that distal to proximal ratiosof sensory & pain threshold [RST & RPT] respectively studiedin lower limbs along with ABI can serve as effective diagnostictools to detect small fiber diabetic neuropathy & high risk offoot ulceration respectively.

Methodology

It was an exploratory cross sectional pilot study .For thestudy group, 62 Diabetic subjects from In & Out-patient depts.at BYL Nair hospital were screened & 25 subjects [15Males +10 females] between the age group of 40-65years-[mean value52 + 3.98 years] were selected as per the following inclusion /exclusion criteria

Inclusion Criteria

Medically monitored -H/O diabetes for more than 10 yearswith at least 4 out of following 7 components evident on the skinof the foot indicating trophic changes 1) absent sweating 2) dryscaly skin, 3) distended dorsal veins, 4)- thin and shiny skin, 5)scars and calluses, 6) inter-digitation, 7)- fungal nails – Thosewith unilateral foot ulcer were also included.

Exclusion Criteria

Subjects who were irregular in taking medication, evidenceof Diabetic ulcers [healed /unhealed] on both the feet or a known

Unnati Pandit / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

43

History of smoking,-Alcoholism, open injury/ ulceration on eitherfoot due to trauma or any other pathology having potential forperipheral vascular disease or neuropathy.

The Control group included age & sex matched 25 healthyindividuals from the staff of BYL Nair hospital & relativesaccompanying the patients who volunteered to participate inthe study. Informed consent was obtained from each subject.Detailed evaluation was conducted & status of ulcer if any, trophicchanges, fresh Blood sugar values were noted. for each subjectfrom Study group, including the details of pain in the feet if any.

Assessment of Sensory & Pain Threshold

Concept of Current perception threshold [CPT]waspopularized by Katim JJ et al as promising tool for initialscreening of patients with sensory neuropathies .[1987] 7, theyestablished the reliability & reproducibility of this tool [1989] 8

RST & RPT are the two parameters of CPT. Literature reportsabout a specific type of current for CPT. A constant current typeof electrical stimulator is recommended with a provision of sinewave current with facility to select three frequencies –i.e- 2000Hz for large myelinated fiber function, 250Hz for small myelinatedfibers & 5Hz for non-myelinated fibre function respectively.24,25,26,27,28,29,30The clinical policy bulletin on Sensory testingmethods [1999], declared Neurometer which is patented as“Neurotron”; as reliable, valid & approved tool for the CPTassessment & sustained this policy after its review again in 2009.29

Though use of Electrical currents forms a major therapeutic& diagnostic [Strength duration curves] component inPhysiotherapy practice, perhaps due to lack of awareness aboutCPT amongst Physiotherapy practitioners in this country, thereis no demand for Neurometer , hence it is neither manufacturedindigenously, nor imported. A traditional diagnostic stimulatoravailable here is a constant voltage type which does not providerecommended frequencies for CPT .Therefore in this study therewas no option left but to use any safe current available in thetraditional diagnostic electrical stimulator. Since normativevalues of sensory & pain thresholds using specific traditionalelectrical current are not available ; in order to eliminate thebiases if any in this study, the ratios were used for comparisonof distal to proximal gradients in sensory & pain perception ,instead of actual values of Sensory & Pain threshold

In this study a well calibrated digital stimulator [model :Microstim-Genius manufactured by M/s Electrocare systems &services PVT LTD, Chennai ] was used . For CPT, plain Faradictype of current –i.e- monophasic rectangular pulse of 1milliseconds width & 50Hz frequency was used & intensityrequired for the sensory threshold [ST] & pain threshold[PT]was noted in millivolts. A pair of silver disc electrodes routinelyused for the nerve conduction studies were used. The areaselected for the respective nerve stimulation was fist rubbedwell with solvent ether to minimize the resistance. The electrodeswas cleaned with ether & then placed on the selected area usingEKG gel to overcome the resistance, & fastened with Velcrostrap maintaining distance of 5 mm between each electrode.For Distal CPT -Cutaneous distribution of sural nerve was used& the active electrode was fixed postero-inferior to Lateralmalliolus. Where as for the proximal CPT, lateral cutaneous nerveof calf was selected & the active electrode was fixed at thejunction of upper 1/3rd & lower 2/3rd of postero-lateral aspect ofthe leg. The electrical stimulus was then applied by increasingthe intensity slowly & the subject was instructed to report at thefollowing –

1. The moment he/she felt the current –This intensity wasnoted as sensory threshold(ST).

2. The moment current sensation turned painful-which wasnoted as pain threshold(PT)Ratios of Distal to Proximal Sensory Threshold [RST] &

Pain threshold RPT] respectively were then calculated for boththe groups.

Assessment of Ankle Brachial Index[ABI]

Beth D Weatherley et al [ 2006]31 established the reliabilityfor the ABI based on single ankle and arm. In their study, SBPswas 0.61 (95% CI: 0.50, 0.70) and the reliability of the ABIcomputed as the ratio of the average of two ankle Systolic Bloodpressure [SBPs] to two arm SBPs was estimated from simulateddata as 0.70. The literature widely supports on use of ABI asone of the investigation tools in Diabetes related vascular lesions20,21,22,23

For the assessment of ABI., the subject was asked to restin supine position on a plinth. Systolic blood pressure of posteriorTibial artery at Rt ankle & Brachial artery at Right Arm was notedfor each subject with the Hg manometer at ankle and armrespectively. The ratio of Systolic pressure of Post tibial arteryvs Brachial artery was calculated as Ankle –Brachial Index[ABI].

Statistical analysis of the data collected was done usingindependent sample t test on SPSS-16. The values of distal toproximal RST, RPT, & ABI were compared between the control& study group.

Result

The age of Control group [ 51 + 5.6 years] matched wellwith the Study group 52 + 7.8 years]. In the study group Historyof Diabetes was 14.41+ 3.36 years ; Fasting & PP Blood glucoselevels were 160.3 + 75.99 & 263.3 + 97.58.respectively.

21 out of 25 diabetic subjects had established symptomsof pain /burning sensations in feet, where as 6 subjects hadhealing ulcer on the opposite foot . Average skin score of entirestudy group was 4.3 + 0.03. The statistical analysis of RST,RPT & ABI was as follows-

In the Control group, RST & RPT were 0.91 + 0.21 & 0.72+ 0.19 respectively, where as in the study group they were 1.47+ 0.67 & 2.9 + 1.31 respectively. ABI in the controls & Studygroup was 1.36 + 0.29 & 0.81+ 0.06 respectively. Comparisonof the values between Controls & Study group showed highsignificant reversal of ratios [ RST : t= -3.86 p =0.000 / RPT:t = -8.051; p=0.000 / ABI : t = 9.17;p = 0.000] which confirmedthe distal to proximal pattern of affection.

DiscussionTable 1: Comparison of Distal to Proximal RST, RPT & ABI

Controls Study groupn=25 n=25 t value p value

RST 0.91 + 0.21 1.47 + 0.67 - 3. 86 **0.001

RPT 0.72 + 0.19 2.9 + 1.31 - 8.051 ** 0.000

ABI 1.36 + 0.29 0.81 + 0.06 9.17 **0.000

** highly significant

As per .Marc M. Treihaft et al [2002]32, Peripheralneuropathies involve different populations of nerve fibers.Majority of patients with peripheral neuropathy exhibit evidenceof large fiber or IA fibre involvement. who subserve motorfunction, position, and vibration sensation , hence. associatewith reduced vibratory and position senses & complain ofnumbness, tingling, and muscle weakness. Where as small FiberNeuropathy[SBN] ,which mainly affects thinly myelinated Adelta and unmyelinated C fiber ,hence shows clinicalmanifestation of burning pain but diminished thermal andpain perception

G Said et al [2007]2 reported diabetic neuropathy as the


44

most common neuropathy in industrialized countries whichexhibits a wide range of clinical manifestations. More than 80%diabetics have distal symmetrical form of neuropathy whichremains highly pronounced in feet-indicating longest nerve fibersbeing more vulnerable. This is a small fiber type of axonopathythat progresses in a fiber-length-dependent pattern[Lengthdependent diabetic polyneuropathy [LDDP], with sensory andautonomic manifestations predominating as pain & trophicchanges in the feet This pattern of involvement ,because of smallfibers being heavily affected & large ones are spared, projects“Psudo- syringomyelic type of diabetic neuropathy 2

As such for the diagnostic studies of peripheral nerveaffection, EMG & Nerve conduction studies are considered tobe ideal . However , as per Menkes D. L. et al [2000]30, theyare suitable only for the demyelinating polyneuropathies whichtend to affect larger myelinated fibers ; where as for axonalpolyneuropathies which tend to affect smaller fibers before largerfibers, in a distal to proximal gradient , NC studies have a lot oflimitation. Findings of Menkes et al are supported strongly inthe literature15,32,33,34 In fact in such cases CPT is recommendedto distinguish demyelinating from axonal polyneuropathies30,

Our study group manifested typical symptoms of smallfiber LDDP, in the form of burning pain in feet & high skin score,justifying use of RST & RPT as appropriate assessment tools

Even though intra-epidermal nerve fiber density (IENF), isestablished as an authentic tool in identifying small fiberneuropathy,11,15 it is an invasive mode & may not be easilyavailable or would be costly if available for routine assessmentto detect risk factors of diabetic ulcers. RST & RPT are simplenoninvasive & easily available methods to assess small fibertype of peripheral nerve affection, specially the LDDP type. Highlysignificant reversal of RST & RPT found in our study groupproved this method to be an effective mode for diagnosis.However, this study needs to be extended by correlating thevalues of RST & RPT [after establishing the same on largerpopulation] with other authentic parameters though as per GraziaDevigili et al[2008]15, no gold standard is defined yet for clinicalpractice or research in identification of small fiber neuropathy.

Diabetes is known to be an important risk factor for severeperipheral arterial disease which predominantly involves distalvessels & in combination with diabetic neuropathy contributesto the higher rates of limb loss35,36 Our study also showedassociated arterial insufficiency , confirming that RST,RPT alongwith ABI can serve as effective detector tools to identify risk ofulceration in diabetic foot..

Conclusion

Distal to proximal RST & RPT confirmed to be effectivetools for identification of Small fiber type of diabetic neuropathy.& these parameters along with ABI proved to be the effectiveindicators of high risk of ulceration in the diabetic foot consideredfor assessment. Physiotherapy professionals expertise inutilizing Bioelectrical agents for therapeutics & diagnostics.However the diagnostic expertise is not expanded enoughbeyond motor studies [Strength Duration.curves]. This pilot studyis therefore expected to give incentive to the Physiotherapyresearchers to explore & establish norms with various therapeuticcurrents which can not only serve as diagnostic tools but canalso serve as objective assessment tools during clinical trialsfor evidence based practice.

References

1. Sarah Wild, MB Bchir, Gojka Roglic,Andres Green,et alGlobal Prevalence of Diabetes: Estimates for the year 2000and projections for 2030, [2004]Diabetes Care 27:1047–1053,

2. Gérard Said, Diabetic Neuropathy—A Review: ClinicalAspects of Diabetic Neuropathy,Nat Clin Pract

Neurol. 2007;3(6):331-3403. Nidal A. Younes, Abla M. Albsoul; and Hamzeh Awad, A

prospective study of risk factors for diabetic foot ulcer. TheSeattle Diabetic Foot Study. Diabetes Care.1999;22(7):1036-1042 7.

4. James A. Birke, Andrew Novick, MA, Elizabeth S. Hawkins,Charles Patout Jr., A Review of Causes of Foot Ulcerationin Patients with Diabetes Mellitus Publications-JPO.1992,vol 4,number 1 pp-13-22

5. R. Gary Sibbald ; David G. Armstrong, and Heather L.Orsted, ; Pain in Diabetic Foot Ulcers Ostomy E Wound,management:October 4, 2009

6. Arendt-Nielsen L,Yarnisky D, Experimental & clinicalapplications of quantitative sensory testing applied to skin,mucosa & viscera[2009];J pain Jun,10[6]:552-72

7. Katims JJ, Naviasky EH, Rendell MS, Ng LKY, Bleeker ML:Constant current sine wave transcutaneous nervestimulation for the evaluation of peripheral neuropathy. ArchPhys Med Rehabil 1987; 68:210-213

8. Katims JJ, Rouvelas P, Sadler BT, Weseley SA: Currentperception threshold. Reproducibility and comparison withnerve conduction in evaluation of carpal tunnel syndrome.ASAIO Transactions 1989; 35:280-284.

9. Katims JJ, Taylor DN, Wallace JI, Bekesi JG, Masdeu JC:Current perception threshold in HIV-positive patients, inProceedings of the Neurological and NeuropsychologicalComplications of HIV Infection, Satellite Conference of the5th International Conference on AIDS. 1989, p 39.

10. J P Conomy, K L Barnes, J M Conomy , Cutaneous sensoryfunction in diabetes mellitus.[ [1979 ]J Neurol NeurosurgPsychiatry;42:656-661-

11. Gary L. Pittenger, Madhumita Ray, Niculina I. Burcus, ,etal Intraepidermal nerve fiber density (IENF may prove auseful end point in therapeutic trials for neuropathy DiabetesCare August 2004 vol. 27 no. 8 :1974-1979

12. Ka Meh & Miro Deni- Subclinical neuropathy in type-Idiabetic children;[Jun1998] ,Clinical Neurophysiology /Electromyography & motor control,vol109,issue3:274-80

13. Aaron I. Vinik, Diabetic Neuropathy: A Small-Fiber Disease;07/24/2001 Medscape CME- : processing....Small-FiberDysfunction

14. Kristine Orstavik, Barbara Namer, Roland Schmidt et al,Abnormal function of C fibers in patients with DiabeticNeuropathy ;[2006] J Neuroscience, 26[44]:11287-94

15. Grazia Devigili1, Valeria Tugnoli2, Paola Penza3, Thediagnostic criteria for small fibre neuropathy: from symptomsto neuropathology ,Brain 2008 131(7):1912-1925

16. Amanda Peltier, MD 1, A. Gordon Smith, MD 2 3, James W.Russell, MD, MS et al ,Reliability of quantitative sudomotoraxon reflex testing and quantitative sensory testing inneuropathy of impaired glucose regulation,[3Mar2009]Muscle & Nerve, vol 39, issue 4, Pages 529 – 535

17. Maria Nebuchennykh, Sissel Løseth, Sigurd Lindal andSvein Ivar Mellgren et al; The value of skin biopsy withrecording of intraepidermal nerve fiber density andquantitative sensory testing in the assessment of small fiberinvolvement in patients with different causes ofpolyneuropathy, Journal of Neurology[2009] Volume 256,Number 7 / July,

18. Bashar Katirji, Diabetic neuropathies Last reviewed July27, 2009, Medlink, Neurology: Clinical summery-Pre-view

19. Richard M Stillman, Diabetic ulcers, [2009]emedicine-medscap updated: Oct 28.

20. Matthew A. Allison, William R. Hiatt, Alan T. Hirsch, A HighAnkle-Brachial Index Is Associated With IncreasedCardiovascular Disease Morbidity and Lower Quality of Life,J Am Coll Cardiol, 2008; 51:1292-1298,

21. Vincente Lahoz C, Taboada M, Laguna F et al Ankle –Brachial Indexin patients with diabetes mellitus : Prevalence& risk factors, Rev Clin Esp [2006]May,206[5] :225-9-


45

22. Yoshimura T, Suzuki E, Sakaguchi M, : Impaired peripheralcirculation in lower-leg arteries caused by higher arterialstiffness and greater vascular resistance associates withnephropathy in type 2 diabetic patients with normal ankle-brachial indices.[ 2008] Diabetes Res Clin Pract 80: 416–423

23. Louis Potier, Marine Halbron, Florence Bouilloud, et al,Ankle-to-Brachial Ratio Index Underestimates thePrevalence of Peripheral Occlusive Disease in DiabeticPatients at High Risk for Arterial Disease, Diabetes CareApril 2009 vol. 32 no. 4 e 44

24. Julia Finkle Charls Young, Jesica Yarvitz et al,Neuroselective sensory Electrodiagnostic evaluation with4% Lidocaine, [ 2002] Anaesthesia & Analgesia, May vol194,no 5 : 1259-1262

25. E. A. Masson1, A. Veves1, D. Fernando1 and A. J. M.Boulton1 Current perception thresholds: a new, quick, andreproducible method for the assessment of peripheralneuropathy in diabetes mellitus 1989. Diabetologia; Volume32, Number 10 / October, 1989

26. Kempler P, Keresztes K, Marton A, Váradi A, Hermanyi ZS,Márczy V, Kádár É, Vargha P: Evaluation of currentperception threshold (CPT) by the Neurometer®: Adiagnostic tool to detect early abnormalities of peripheralsensory nerve function in non-insulin-dependent diabetesmellitus, in Varro V, de Chatel R (eds): Proceedings of the22nd Congress of the International Society of InternalMedicine. Bologna, Italy, Monduzzi Editore, SpA, 1994, pp765-768.

27. Herbert N. Chado , Neurodiagnostic Evaluation of the PainPatient : Pain Digest 1995; 5:127-134.

28. Regene-Oregon & Otah-Medical policy-QuantitativeSensory Testing-policy no 9-[2001]

29. Clinical Policy Bulletin: Quantitative Sensory TestingMethods [effective 11-11-1999/last review 6-30-2009]AETNA- Number: 0357

30. MENKES D. L. ; SWENSON M. R. ; SANDER H. W. ,

Current perception threshold : an adjunctive test fordetection of acquired demyelinating polyneuropathies,Electromyography and clinicalneurophysiology 2000, vol. 40, no 4. 205-210

31. Beth D Weatherley1 , Lloyd E Chambless2 Gerardo Heiss3

Diane J Catellier2 and Curtis R Ellison4 The reliability ofthe ankle-brachial index in the Atherosclerosis Risk inCommunities (ARIC) study and the NHLBI Family HeartStudy (FHS)[ 2006]BMC Cardiovascular Disorders, 6:7

32. Marc M. Treihaft, MD, FAAN; Painful Feet: The Small FiberNeuropathies, CNI Medical Review Journal , Fall2002;Volume 13, Number 2

33. Ezekiel Fink, and Anne Louise Oaklander, Small-FiberNeuropathy: Answering the Burning Questions, Sci. AgingKnowl. Environ., 8 March 2006, Vol. 2006, Issue 6, p. pe7

34. G Said; Diabetic Neuropathy—A Review: Clinical Aspectsof Diabetic Neuropathy, NatClin Pract Neurol. 2007;3(6):331-340

35. Jamie D, Santilli, Steven M Santilli; Chronic Critical LimbIschemia: Diagnosis, Treatment and Prognosis, April 1 1999;American Family Physician

36. Fatma Al-Maskari & Mohammed El-Sadig, Prevalence of riskfactors for diabetic foot complications, BMC Family Practice2007, 8:59


46

Relationship Between Depression and Cardiopulmonary Fitnessin Post Cardiac Surgery IndividualsK Charan*, K Asha Jyothi*, P Tabitha*, K Madhavi***MPT II Year, **Principal (i/c), College of Physiotherapy, SVIMS University, Tirupathi

Abstract

Objective

To know the relationship between depression andcardiovascular fitness in post cardiac surgery patients afterphase 1of cardiac rehabilitation.

Methodology

Observational study was done on 30 samples. The patientswho underwent cardiac surgery were taken up for the study.After phase 1 of cardiac rehabilitation, samples were screenedfor depressive symptoms using CES-D scale and the 6 minutewalk test to predict peak oxygen consumption (VO2peak).

Results

Correlation analysis was done between CES-D and VO2peak.The negative correlation coefficient of -0.951, with significanceat p<0.000 was obtained.

Conclusion

There exists a negative relationship between depressionand cardiopulmonary fitness.

Introduction

Depression is the term which describes a spectrum of mooddisturbance ranging from mild to severe and from transient topersistent. Depressive symptoms are continuously distributedin any population but are judged to be of clinical significancewhen they interfere with normal activities and persist for at leasttwo weeks, in which case a diagnosis of a depressive illness ordisorder may be made..1 Significant depressive symptomatologyare found 43% preoperatively and 23% postoperatively in cardiacpatients.2

It is noted that 50% of the patients who were depressedbefore surgery were also depressed 1 month after surgery 3,and about one in six patients who has a myocardial infarctiondeveloped major depression. The occurrence of depression hasbeen found to be independently associated with poor outcome,including poor quality of life, increased heart disease, andprobably increased mortality. There is some evidence that thosewho have a severe heart disease are at greatest risk of anadverse outcome attributable to depression. Depression is animportant independent contributor to medical and psychosocialmorbidity up to 6 months after CABG.4

The causes of development of depression in cardiacdisease can be attributed to the stress after surgery anddevelopment of depression in reaction to the illness 5. Stresshas been shown to be one of the most potent triggers or inducersof depression6. With stress, the hypothalamicpituitary-adrenocortical (HPA) axis and the sympatheticadrenomedullary(SA) system are activated, which leads to release ofCatecholamines (epinephrine and norepinephrine).Catecholamines increase alertness. Especially epinephrine

usually evokes more anxiety and fear.7 With resolution of stress,these 2 systems should return to their basal states. Geneticpredisposition, such as specific serotonin transporter genepolymorphisms, coupled with gene– environment interaction mayexplain why some individuals recover from life stressors andothers develop depression.8

Another possibility is that depression is a secondarydevelopment in cardiac patients, whereby patients with moresevere cardiac disease or a heavier burden of comorbidconditions may become depressed in reaction to their illnesses.In this case, adverse outcome is the result of the greater diseaseburden but not of depression itself.9

Many of the studies have done on depression in myocardialinfarction (MI) and chronic diseases. It is revealed from variousstudies that depression is associated with 50% of mortality andmorbidity. But neither physician nor patient recognize theimportance of management of depression.10Considering theabove facts, depressed individuals will have decreased physicalactivity level and decreased exercise capacity. Depression alsoaffects cardiopulmonary fitness. Depression is an independentprognostic factor for mortality, readmission, and cardiac eventsafter CABG.11

Since a primary focus of cardiac rehabilitation (CR) is toimprove cardiopulmonary fitness, VO2 max is a reliable indicatorof cardiopulmonary fitness it can be taken as an outcomemeasure for cardiopulmonary fitness.12

Need of the Study

Many previous studies have examined the relationshipbetween depression and cardiopulmonary fitness after secondphase of cardiac rehabilitation few studies are available whichstudied the relationship at the time of discharge. Studying therelationship between cardiopulmonary fitness and depressionat the time of discharge will help us to understand the complexinteraction among various factors within the hospital influencingthe outcomes after phase 1 of cardiac rehabilitation. This will inturn help us to plan the first phase of CR more effectively toimprove the exercise capacity.

Aim

To analyze the relationship between cardiopulmonaryfitness and depressive symptoms in post surgical cardiac surgeryindividuals.

Objectives

To study the depressive symptoms in relation to thecardiopulmonary fitness, age, sex, BMI and length of hospitalstay.

To compare mildly the depressed (group 1) and thesignificantly depressed (group 2) in relation to cardiopulmonaryfitness, age, sex, BMI and length of hospital stay in post surgicalcardiac surgery individuals.

Methodology

This observational study was conducted in thecardiothoracic ward in a tertiary care center Sri Venkateswara

K Charan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

47

institute of medical sciences university in Tirupathi city of AndhraPradesh in Republic of India. The study was conducted for sixmonths. The Sample size taken was 30. Individuals agedbetween 20 – 60 years of age, who have completed phase 1 ofcardiac rehabilitation after an open heart surgery, CES-D scoreof greater than 16 and showing their willingness to participate inthe study were included. Patients were excluded if they wereunable to fill CES-D scale i.e. if more than 5 questions were leftunanswered or if they were unable to complete six minute walktest (6MWT) or if they were suffering from any severeneurological diseases which may limit subject’s ability tocomplete 6MWT.

Procedure

Written informed consent was taken from successivepatients between the age 20-60yr entering cardiac rehabilitationafter open heart surgery, they were assessed at the end of phase1 of cardiac rehabilitation for the following outcome measures.Depressive symptoms are measured as score using a translatedTelugu version of The Center for Epidemiologic StudiesDepression Scale (CES-D), cardiopulmonary fitness is measuredas VO2peak in ml/kg/minute using a 6MWT and VO2peak wasestimated using the regression equation. VO2peak = [0.03 X6MWD (meters)] + 3.98; where 6MWD - Six Minute WalkDistance and length of hospital stay were noted from hospitalrecords.

The Center for Epidemiologic Studies Depression Scale(CES-D) is a 20-item, self-report depression scale developedto identify depression. It was designed to cover the majorsymptoms of depression identiûed in the literature, with anemphasis on affective components: depressed mood, feelingsof guilt and worthlessness, feelings of helplessness andhopelessness, psychomotor retardation, loss of appetite, andsleep disorders. CES-D were selected from existing scales,including Beck’s Depression Inventory (BDI), Zung’s Self-ratingDepression Scale (SDS), Raskin’s Depression Scale, and theMinnesota Multiphasic Personality Inventory.13

The CES-D is normally self-administered but may be usedin an interview. Items of this questionnaire refer to the frequencyof symptoms experienced by the patient during the past week.Each question uses a 0 to 3 response scale; except for the fourpositive questions, a higher score indicates greater depression.Questions 4, 8, 12, and 16 were worded positively, in part todiscourage a response set, and their scores are reversed bysubtracting the score from 3. Question scores are then summedto provide an overall score ranging from 0 to 60. 14

Radloff had reported alpha coefficients of 0.85 for generalpopulation samples and of 0.90 for a patient sample; Similarresults were obtained by Himmelfarb and Murrell. The concurrentvalidity, construct validity and reliability of the CES-D have alsobeen established in community samples. Okun et al. reportedon the content validity of the CES-D, which covers seven of thenine DSMIV symptoms of major depressive episode. Thesensitivity and specificity of the CES-D have been frequentlyreported and generally appear to be very good.( Weissman etal., Shinar et al., and Parikh et al.).15

Results


Diagnosis: ASD-07, VSD- 02, ICR- 01, AVR- 05, MVR- 06,DVR- 03 and CABG-06.

After collecting the data, the data was processed usingSPSS 17.0 statistics package. Microsoft 2007 spread sheet wasused to tabulate the date and to plot graphs.

A total of 87 patients were screened for depression usingCES-D scale of which 30 patients were found to fit into the

Table 1: Patient Characteristics

Parameter Min. Max. Mean SD

GenderMale 17Female 13Total = 30

Age 26 54 38.14286 ± 10.23904CES-D score 18 38 25.66667 ± 6.127008VO2peak 13.18 19.4 16.1475 ± 1.635242BMI 14.2 20.89 17.475 ± 2.430732No. of days of 09 19 12.43333 ± 2.775302hospital stay

inclusive criteria. Correlation analysis was done to find thecorrelation between CES-D scores and other parameters. Theresults are shown in the table 2.Table 2: correlation between CES-D score and VO2peak, age,BMI, Length of stay in hospital.

VO2peak AGE BMI LENGTH OF STAY

CES Pearson -0.951** 0.951** 0.943** 0.625**

-D Correlation

Sig. (2-tailed) .000 .000 .000 .000

N 30 30 30 30

*indicates that values are statistically significant at 0.001 level.

All the parameters showed a significant correlation withCES-D.Further analysis was performed to test the significancedifference of the CES D-Score. the patients(n= 30) were dividedinto two groups based on the CES-D scores. Patients with ascore of <22 (n= 14) were included in mildly depressed group(group 1) and patients with e”22 (n= 16) were included insignificantly depressed group (group 2). The impact of CES D-score was observed in various parameters such as BMI, VO2Peak, Duration and Age. For this the suitable statistical tool usedis independent samples t – test and descriptive measures werealso reported for each parameter.

In table below, a comparison is made to observe the impactof CES- D score in all the parameters. Results showed that inall the parameters there exists statistical significance betweenthe groups 1 and 2. Mean and standard error values are reportedalong with t-statistic and p-value. If we observe the statisticalmeasure, the mean response of subjects in group 2 have highermean than that of subjects in group 1. For visualization of thestatistical measures, line diagram representation is made withwhiskers. The graphs are displayed below the table 3.Table 3: Comparison between group 1 and group 2 for impactof CES-D score on all the parameters.


Parameter Status N Mean Std. t Sig.(2CES-D Error -tailed)

MeanAge < 22 14 26.71 0.997 -7.001 0.000*

e” 22 16 42.81 1.963

VO2 Peak < 22 14 17.55 0.215 -6.302 0.000*e” 22 16 14.95 0.288

BMI < 22 14 15.47 0.271 -6.719 0.000*e” 22 16 19.23 0.467

Duration < 22 14 11.14 0.678 -2.610 0.014*e” 22 16 13.56 0.632

48

comparatively higher than that of males. So it can be concluded Table 3: Comparison of depression scores between male andfemale

Sex N Mean Std.Error t-statistic andMean sig. (2 tailed)

CES- D Male 17 23.47 1.033 -2.427score

Female 13 28.54 1.976 (0.022*)

*indicates that values are statistically significant at 0.001 level.that depression score will be higher in females than that of males.

Discussion

All parameters showed a high correlation with CES-D score.The negative correlation between CES- D score and VO2peak (-0.951) suggests that with the increase of depression there willbe more reduction in the VO2peak. There are two mechanismspreviously proposed to explain the relationship between thedevelopment of depression and stress, one is related to problemwith the regulation of hypothalamic – adrenaocortical axis (HPA)activation and the other with development of secondarydepression owing to co morbidities in cardiac disease. Thisreduction in the VO2peak can be attributed to the disease itself.The greater the severity of disease greater will be the stress onthe individual and subsequently resulting in depression.

When we compared the two groups in relation to the age,sex,BMI, VO2peak and length of hospital stay, The significantlydepressed group had a higher mean value except for VO2peak.Results of this study are in concurrence with previous studiesby Walter Swardfager (2008).11 Low physical activity level relatedto depressive symptoms may be the cause for a decreasedVO2peak and an increased BMI in these individuals. Low valuesof VO2peak in group 2 may also be due to the patient’s level ofinterest and motivation, which may be significantly influencedby the depression.

A mean BMI of 15.47 and 19.23 was seen in group 1 and 2respectively. On comparison between the two groups, group 2is found to be having an increased BMI. This was in concurrencewith the report by Elizabeth Johnson (2004). Relation betweendepression and obesity will depend not only on the measuresused to assess the obesity for e.g. Robert et.al. found that usinga BMI > 85th percentile as a cutoff point for obesity result in asignificant relationship between depression and obesity. Whereas using BMI > 30 did not. We did not use any cut off point forobesity. Instead we have seen the variation of BMI score betweengroup 1 and group 2.

We also studied the relationship between depression andlength of hospital stay. We found that people who were in thesignificant depression group had a longer stay in the hospitalwhen compared with people with mild depression. This may bedue to high symptom burden in the significantly depressedindividuals. SM Saravay (1990) in his study on general medicaland surgical patients and Verbosky LA (1993) in hip fracturepatients.

We also studied the sex difference in the development ofdepression and found that women are more likely to developdepression than men. This may be due to lack of emotionalsupport from the close relatives like siblings, parents and spouse.Women were found to be more sensitive regarding thedevelopment of depression if they did not get emotional supportfrom the family which is limited at the hospital. As HPAdysregulation is the most consistant neuroendocrine abnormalityin depression, depressive disorder occurs twice as commonlyin women than in men.16 It was also noted that women havingmajor depression show a greater HPA axis dysrgulation andthan depressed men.

Significant correlation between depression and other factors(VO2peak, BMI, age, length of stay) may not be generalized to thewhole cardiac surgery population due to a relatively small sample


Graph 1: Comparison of CES-D score between group 1 andgroup 2

Graph 2: Comparison of VO2 peak between group 1 and group 2

Graph 3: Comparison of BMI between group 1 and group 2

Graph 4: Comparison of Length of hospital stay between group1 and group 2

*indicates that values are statistically significant at 0.001 level.Female gender has high depression score when compared

to male. There exists significant impact of depression score infemales rather than in males. The mean response of females is

49

size 17. But it is warranting a further research with a large samplesize covering a wide range of cardiac surgeries. Depressivepeople are less likely to complete cardiac rehabilitation.18

Irrespective of mechanism, several arguments can be madethat depression should be detected and treated in cardiacpatients:• Depression is prevalent as a co morbid illness in cardiac

patients and itself is characterized by tremendous morbidity(eg, hopelessness, poor quality of life), as well as increasedmortality risk through suicide.

• Depression is unhappily under recognized and undertreatedin medical populations overall and certainly withincardiovascular populations.

• If depression is linked to cardiovascular disease throughphysiological mechanisms, then recognition and treatmentmay lead to improved patient outcomes throughmodification of the adverse physiological changes thataccompany depression.

• If depression is linked to cardiovascular disease throughbehavioral mechanisms, then appropriate recognition andtreatment may help remove the “depression barrier” andimprove adherence to medications, lifestyle changes, selfmanagement, and receipt of appropriate testing and follow-up.By treating depression, we can improve the quality of life

of our patients and we may improve adherence to cardiac carerecommendations.5

Conclusion

There exists a significant negative relationship betweendepression and cardiopulmonary fitness. So patients should bescreened for depression before and during the cardiacrehabilitation. Stress management should be incorporated in tothe phase 1 cardiac rehabilitation.

Study Limitations

This study has several possible limitations. The first one isits sample size. With a small sample size we can not generalizethe results to the whole population. We did not have a clinicaldiagnosis of depression but rather assessed severity ofdepressive symptoms using the CES-D scale. Study resultscould be affected by response bias because willingness toparticipate was an inclusion criterion. It is also possible thatpatients with depressive symptoms were more likely to reportmore physical limitations as a consequence of their depressedmood rather than actual worse health status.

References

1. Harrison’s principles of internal medicine SeventeenthEdition page 2552 – 2558.

2. Paul A. Pirraglia et al Depressive symptomatology in

coronary artery bypasses surgery patients. Int J GeriatrPsychiatry. 1999; 14:668–680.

3. McKhann GM, Borowicz LM, Goldsborough MA, Enger C,Selnes OA: Depression and cognitive decline after coronaryartery bypass grafting. Lancet 1997; 349:1282–1284

4. Matthew m. burg, M.Cristina Benedetto, RobertaRosenberg and Robert Soufer. Psychosomatic Medicine65:111–118 (2003) Presurgical Depression Predicts MedicalMorbidity 6 Months After Coronary Artery Bypass GraftSurgery

5. John S. Rumsfeld and P. Michael Ho Depression andCardiovascular Disease: A Call For Recognition Circulation2005;111;250-253

6. Kendler KS, Karkowski LM, Prescott CA. Causalrelationship between stressful life events and the onset ofmajor depression. Am J Psychiatry. 1999;156:837– 841.

7. Review of Medical Physiology twenty-first edition WilliamF. Ganong.

8. Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW,Harrington H,\ McClay J, Mill J, Martin J, Braithwaite A,Poulton R. Influence of life stress on depression: moderationby a polymorphism in the 5-HTT gene. Science.2003;301:386 –389.

9. Depression and Cardiovascular Disease: A Call ForRecognition John S. Rumsfeld and P. Michael HoCirculation 2005;111;250-253

10. Harrisons Principles of Internal Medicine 16th Edition. Page-2552

11. Walter Swardfager, Nathan Herrmann, Yekta Dowlati, PaulOh, Alex Kiss,and Krista L. Lanctôt. Relationship betweendepression and cardiopulmonary fitness and depressivesymptoms in cardiac rehabilitation patients with coronaryartery disease. J Rehabil Med 2008; 40: 213–21814.(Dalal,H.M., Evans, H. (2003) Achieving national serviceframework standards for cardiac rehabilitation and secondaryprevention. British Medical Journal, 326, 481–4.).

12. Milani RV, Lavie CJ, Mehra MR, Ventura HO. Understandingthe basics of cardiopulmonary exercise testing. Mayo ClinProc (2006; 81: 1603–1611).

13. Radloff LS. The CES-D Scale: a self-report depressionscale for research in the general population. Appl PsycholMeasurement 1977;1:385–401.).

14. Sayetta R, Johnson D. Basic data on depressivesymptomatology, United States, 1974–75. Washington, DCDHEW (PHS)80-1666: United States Government PrintingOfûce, Public Health Services, 1980., p31.

15. Ian McDowell MEASURING HEALTH A Guide to RatingScales and Questionnaires THIRD EDITION, p355

16. Elizabeth A. Young; Roger F. Haskett; Virginia Murphy-Weinberg; Stanley J. Watson; Huda Akil. Loss ofGlucocorticoid Fast Feedback in Depression. Arch GenPsychiatry, Aug 1991; 48: 693 - 699.

17. Lenoir H et.al. Relationship between blood pressure anddepression in the elderly. The Three-City Study. JHypertens. 2008 Sep;26(9):1765-72.

18. Turner SC, Bethell HJ, Evans JA, Goddard JR, Mullee MA.Patient characteristics and outcomes of cardiacrehabilitation. J Cardiopulm Rehabil 2002; 22: 253–260.


50

Effectiveness of Physiotherapy Provision within an OccupationalHealth SettingLaran ChettySenior Physiotherapist, Royal Free Hospital, Health and Work Centre, National Health Service, United Kingdom

Abstract

Background

An occupational health physiotherapy service was set upin May 2008 for staff at an occupational health centre based atan acute London NHS hospital. This service was set up followinga service review in 2006-7.

Aim

To evaluate the effectiveness of physiotherapy provisionwithin an occupational health setting as part of a qualityimprovement exercise.

Methods

A 1-year retrospective study was performed to evaluateoutcomes following discharge from physiotherapy. All data werecaptured on the computerised cohort database system andanalysed descriptively.

Results

The mean number of physiotherapy consultations beforedischarge was 3.9 sessions. There was a high attendance rateof 72.9%. The average waiting time for a physiotherapy initialassessment was 6.56 days. Spinal injuries contributed to thehighest proportion of musculoskeletal injuries (57%). The largeststaff group seen was staff nurses (24%). Injuries made worseby work contributed to the highest number of cases (46%). 76%were advised to remain at work after discharge fromphysiotherapy. A financial analysis showed significant cost savingwhen benchmarked against other physiotherapy providers.

Conclusions

The physiotherapy service has demonstrated productivity,value of money and positive outcomes. The improved outcomesare attributed to an innovative, rapid access service togetherwith multidisciplinary input.

Key Words

Physiotherapy, Effectiveness, Occupational Health.

Introduction

Musculoskeletal disorders (msds) account for 49 percentof sickness absence from work, the biggest health problem facingcontemporary workforces.1-2 In terms of occupational

Address for correspondence:Laran ChettySenior PhysiotherapistRoyal Free Hospital, Health and Work Centre, National HealthService, United KingdomE-mail: [email protected]

musculoskeletal injury, the bone and joint decade asserts thatthe whole population should be considered at risk.3 The drive totackle musculoskeletal sickness absence is not only to reducepressure on public funding, but also to improve people’s health,wellbeing and quality of life, and to tackle poverty and socialexclusion.4 There is a growing recognition that musculoskeletalsickness absence is best managed by occupational healthservices that are proactive in early intervention.5 It is in thiscontext that the focus of musculoskeletal disorders on work isrequiring increased attention from all stakeholders, includingclinicians and policymakers.6

Background

In May 2008, an occupational health (OH) physiotherapyservice was set up for staff at an acute London National HealthService (NHS) hospital. This service was set up following aservice review in 2006-7. This service was implemented inresponse to the high number of musculoskeletal cases referredto the OH department and the associated high levels of sicknessabsence and workplace restrictions. In the past, staff that soughtphysiotherapy services had to endure long waiting times fortreatment and most often referred via their General Practitioner.

It was envisaged that a physiotherapy service dedicated tostaff would improve waiting times for musculoskeletal cases inorder to enable the employee to return-to-work earlier or toreduce the possibility of chronic conditions developing and topositively impact on sickness absence and litigation claims. Inaddition, the service would contribute to the development ofmultidisciplinary working practices, resulting in theimplementation of appropriate return-to-work rehabilitationpackages. This service is supported by the recommendationsof several national guidelines targeting early physiotherapyintervention to reduce the impact of disability frommusculoskeletal injury, the reduction in sickness absence andthe overall health promotion of staff.4-5, 7

The OH physiotherapy service provides care forapproximately 5000 staff at the hospital. The physiotherapyservice is well advertised and is accessible to all staff. Thephysiotherapy service runs for 37.5 hours per week from Mondayto Friday. One full-time physiotherapist, employed by the OHcentre manages the service. The service broadly consists oftwo clinic days dedicated to initial physiotherapy assessmentsand three clinic days for follow-up appointments per week. Staffmay be referred to the service via management or self-referral.The OH centre also offers specialist medical consultancy, nursingadvisory and clinical psychology services and receivesadministrative support.

Purpose

The purpose of this study was to evaluate the effectivenessof physiotherapy provision within an OH setting as part of aquality improvement exercise.

Methodology

A retrospective study design was used, in which injury dataover a 1-year period was reviewed. All employees that attendedtheir OH physiotherapy appointment during the review period

Laran Chetty / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

51

were included in the analysis. Data was extracted using acomputerised Cohort database system from 2009, 01 April to2010, 31 March and analysed using Microsoft Excel. Thedatabase was used to extract information pertaining to age,gender, body part affected, type and stage of injury, mode ofreferral, staff user groups, attendance rate, waiting times andreturn to work (RTW) outcomes at the time of discharge.

RTW outcomes were further defined by therecommendations given on discharge i.e. remain at work, return

to work, unfit to work, go off sick. A financial analysis wasperformed to estimate the direct cost saved related tophysiotherapy treatment compared against the nationalbenchmark and corporate sector. The comparative savings perindividual staff member was also calculated. The cost of eachphysiotherapy session was standardised at £90 per session.

The data was reduced to percentages and presenteddescriptively. In order to ensure reliability and accuracy of thedata extracted, all information was validated by a second

Table 1 depicts the different staff groups seen and the total number of physiotherapy treatment sessions. The highest staff groupsseen were staff nurses (n=56, 24%), domestic assistants (n=28, 12%) and healthcare assistants (n=20, 9%). The highest number ofphysiotherapy sessions were received by staff nurses (n=208, 24%), with domestic assistants and administration both receiving 100physiotherapy sessions in total.

Total number Total number of PT!

Staff Groups of staff % sessions %

Administration 16 6% 100 11%Adviser 4 2% 10 1%Assistant Manager 2 1% 10 1%Biochemist 2 1% 8 1%Biochemist Scientist 10 4% 56 6%Clinical Nurse Specialist 2 1% 8 1%Deputy Director 2 1% 18 2%Dietician 4 2% 18 2%Domestic Assistant 28 11% 100 11%Healthcare Assistant 20 8% 54 6%Maintenance 8 4% 36 4%Manager 4 2% 6 1%Midwife 2 1% 8 1%MTO 2 1% 4 0.5%Nurse Specialist 4 2% 8 1%Occupational Therapist 8 4% 36 4%ODP 2 1% 4 0.5%Palliative Care Nurse 2 1% 8 1%Pharmacist 8 4% 46 4%Physiologist 2 1% 18 1%Physiotherapist 4 2% 4 0.5%Porter 4 2% 10 2%Practice Development Nurse 2 1% 6 1%Radiographer 8 4% 38 4%Research Technician 2 1% 2 1%Senior Nurse Manager 2 1% 2 1%Sister/Charge Nurse 4 1% 12 1%Specialist Nurse 6 3% 20 3%Specialist Registrar 2 1% 16 1%Staff Nurse 56 23% 208 23%Student Nurse 4 2% 14 2%Supervisor 2 1% 4 0.5%Technician 2 1% 6 1%Trainee Clinical Scientist 2 1% 4 0.5%Ward Clerk 2 1% 6 1%Total Individuals Seen 234 Total Appointments 908

reviewer.

Results

Demographic Data

A total of 1246 physiotherapy sessions were booked duringthe review period, of which 908 were attended and 338 werecancelled. The mean age for this group was 43.5 years and therange was 20 to 78 years. Self-referrals made up 87% of referralsand the remaining 13% were referred by management. Withregards to gender, the majority of the caseload was female (73%)

with the remaining 27% being males. All cancelled sessionswere excluded from the analysis. This indicates a 72.9%attendance rate.

Service Provision

The average waiting time for an OH initial physiotherapyassessment was 6.56 days. A total of 234 physiotherapy initialassessments and 614 follow-up sessions were attended. Theaverage number of physiotherapy consultations before dischargewas 3.9 sessions. Spinal injuries contributed to the highestproportion of musculoskeletal injuries (57%), followed by lowerlimb injuries (23%) and upper limbs injuries (20%). Work-related

! Physiotherapy


52

injuries were recorded in 24% of cases, injuries made worse bywork in 46% of cases and non work-related injuries in 30%.58% of injuries were in the acute stage, while 42% presented inthe chronic stages. Only eight staff members (3%) were re-referred back to physiotherapy after discharge.

Projected Savings

A financial analysis was performed to estimate the potentialfor direct treatment cost savings for the employer of staff treatedat the OH centre. The formulas based on the TriHealth BusinessModel were used to determine this cost saving.8 On average,clients seen at the OH physiotherapy clinic were discharged 2.9sessions and 1.24 sessions sooner than the national benchmarkand corporate sector respectively. This amounts to a reductionof £61074 and £26114, yielding a saving of £252 and £112 perinjured staff treated respectively.

Discussion

Physiotherapy is an integral part of occupationalrehabilitation, contributing to areas such as musculoskeletaltreatment, injury prevention advice, health promotion, functionalcapacity evaluations, restorative exercises, work hardening andconditioning, pre-work screening, ergonomics and casemanagement.9 Since the introduction of the OH physiotherapyservice the waiting times for referrals that would have traditionallygone to physiotherapy outpatients, orthopaedic clinics,rheumatology clinics or directly into secondary care has beenlowered significantly. The majority of staff are seen within 6 days.This compares favourably against national waiting times forphysiotherapy which was 5 months in 2008 and 6 months in2009.10-11

The high attendance rate indicates that the OHphysiotherapy service is valued by its users who are gainingsome benefit from attending. The OH physiotherapy servicefollows the bio-psychosocial model of care, offering injuryprevention advice, to providing therapy and rehabilitation andempowering employees to maintain their own health throughhealth promotion campaigns, while communicating withemployers and the larger multidisciplinary team. The low re-referral rate has shown that staff members are appropriatelydischarged and the advice and resources given was adequateto encourage self manage in the event of an injury recurrenceor exacerbation of symptoms.

Spinal injuries contributed to the highest proportion ofmusculoskeletal injuries and so legitimately the service needsto promote the management of these injuries through healthpromotion initiatives, such as spinal fitness pamphlets or back

care seminars. The recent NICE (2009) guidelines for themanagement of non-specific low back pain, with acupuncture,mobilisations/manipulation and tailor exercises being endorsed,must also be considered in the context of service delivery.12

This service review has highlighted key areas for futuredevelopment including targeting poor work practices inproblematic areas for the identified staff groups. The assumptionthat a service design can simply roll forward from one year toanother with few marginal changes is becoming increasingextinct. The OH physiotherapy service is continuouslyprogressive and has demonstrated real service impact and hasdone so by addressing the national framework of priorities,including meeting rising service expectations and accesstogether with financial gain.

The improved RTW outcomes are due to an innovativeand rapid access approach. The decisions regardingphysiotherapy interventions and the need for subsequent follow-up appointments are made by the OH physiotherapist at eachsession. This differs from the tradition physiotherapeutic modelwhich is normally heavily prescriptive in frequency and duration.The added benefit of OH physiotherapy is assessing thefunctional capabilities of the employee in relation to their jobtasks and the ability to communicate the advice directly with theline manager and other members of the multidisciplinary team,which is perhaps the key driver in achieving these successfulRTW outcomes.

Considering the multi-factorial nature of work-relatedmusculoskeletal disorders, it is advantageous for occupationalhealth services to have physiotherapists, because of the healthsynergies they promote. Even greater outcomes could beachieved by increasing the involvement of the physiotherapistin the decision making process within this occupational healthsetting. The integration of the physiotherapist’s unique skills set,together with the knowledge and ability of the rest of themultidisciplinary team would only enhance the effectiveness ofa truly bio-psychosocial approach to the management andprevention of musculoskeletal disorders. Furthermore, thecommitment of line managers is essential in the prevention ofmusculoskeletal disorders, and their implementation of OHrecommendations should be seen as an investment rather thana cost as this promotes a healthier and more motivatedworkforce.13

A new physiotherapy role and a new way of working hasemerged, and at the same time historical and traditionalphysiotherapy care models are being challenged and changed.The OH physiotherapy service, with its solution-focused, person-centered approach, is ideally placed to play a major role inoccupational health service delivery.

Limitations

This study is limited in that the author was unable toestablish form the computerised Cohort database, the exact datefor return to work in order to determine the actual reduction indays off work. Therefore the additional savings reflected in thereductions of lost working days could not be determined. Afurther study addressing this limitation is warranted. In addition,the treatment of many staff involved the simultaneous use ofphysiotherapy with other interventions provided by differentservices offered by the OH department, and therefore it is notpossible to determine which intervention contributed more tothe improvement in outcomes.

Conclusion

The OH physiotherapy service is committed to the provisionof a high quality, dedicated and professional services for staffwith musculoskeletal conditions, centered on clinicalassessment, treatment and adequate case management plans.This service evaluation has highlighted the need for


Fig. 1: depicts the outcomes from OH physiotherapy afterdischarge. The recommendations given on discharge were asfollows: 76% to remain at work, 1% to return to work, 19% wereunfit to work and 4% to go off sick.

Occupational health physiotherapy outcomes.

53

physiotherapy provision within an occupational health settingand has clarified the unique contribution of the profession. Thedata collated in this study demonstrates clearly the benefitsphysiotherapy can bring to an organisation and the completepackage of care to staff. The OH physiotherapy service hasdemonstrated productivity, value of money and positiveoutcomes. In the current changing political climate in the UK,and the radical shift in healthcare provision, a positive approachis essential. It would seem appropriate to begin developing keyrelationships with relevant stakeholders to show what OHphysiotherapy can offer. This paper lays the foundation for abusiness plan by showing both clinical and financialeffectiveness.

Conflict of Interest

None declared.

References

1. Fit for Work? Musculoskeletal disorders in the Europeanworkforce (2009). The Work Foundation.

2. Reilly T, editor (2002). Musculoskeletal disorders in health-related occupations. Amsterdam: IOS Press

3. Bone and Joint Decade website: www.boneand-jointdecade.org. (Accessed 28/04/10).

4. Dame Carol Black’s review of the health of Britain’s workingage population (2008). Working for a healthier tomorrow

5. The Boorman’s review of NHS workforce health andwellbeing (2009). The final report

6. Department for Work and Pensions (2006). Security inretirement: towards a new pensions system

7. Professor the Lord Darzi of Denham KBE (2008). Highquality care for all: NHS Next Stage Review final report

8. Douglas H et al (2002) Effectiveness of occupationalmedicine centre-based physical therapy. Journal ofOccupational and Environmental Medicine 44(1): 48-53

9. Isernhagen SJ (1991) Physical therapy and occupationalrehabilitation. Journal of Occupational Rehabilitation 1(1):71-82

10. Hunt L (2008) Minister spells out plans to cut waits forphysiotherapy. Physiotherapy frontline 14(19): 6-7

11. Hart (2009) The Bevan Legacy. Physiotherapy frontline15(9): 17-19

12. National Institute for Health and Clinical Excellence (2009)Early management of persistent non-specific low back pain

13. Foster NE, Dziedzic KS, van der Windt DA, Fritz JM, HayEM (2009) Research priorities for non-pharmacologicaltherapies for common musculoskeletal problems: nationallyand internationally agreed recommendations.BMCMusculoskeletal Disorders 10:3 PMID: 19134184.


54

To Assess the Relation Between Walking Capacity and Cardio-respiratory Function in Post Polio Residual ParalysisAshish V Gupta*, Lata Parmar***Lecturer, **Principal, K.M. Patel Institute of Physiotherapy, Shree Krishna Hospital, Gokal Nagar, Karamsad 388 325, Gujarat, India

Abstract

Background

Poliomyelitis is on edge of eradication, but more than 50lakhs residual polio survival are reported in India, moreover, inview of reported PPS, it is necessary that PPRP patients shouldbe followed up with regards to their functional status.

Objectives

To identify and determine the relation between walkingcapacity and cardiorespiratory function in PPRP, and to comparethe same with normals.

Method

30 participants of PPRP and 30 healthy, age matchedparticipants were recruited. A baseline evaluation inclusive ofMMT was done for the study group. In both the groups, walkingcapacity was assessed by 12 MWT and cardiorespiratoryfunction were assessed by measuring the vitals viz. PR, RR,BP, RPP, PR Recovery Time and RPP.

Results

The distance covered by study group participants wassignificantly less (p=0.00). No significant change was seenregards to change in PR, RR, BP, RPP and PR recovery time,however post test RPE was significantly high in study group(p=0.003).The study group showed negative correlation betweenchange in RPE and12MWD (p=0.014), at the same time changein RPE positively correlated with change in PR (p=0.006) andchange in RPP(r=0.522, p=0.003). Further sum of paretic limbmuscle strength did not show any significant correlation.

Conclusion

Walking capacity is severely compromised in the PPRP.The cardio respiratory parameter did not show any significantdifference, RPE however was significantly higher in PPRP.

Key Words

Polio, cardiorespiratory fitness, submaximal exercisetesting.

Introduction

Poliomyelitis although not typically a life threateningcondition, it has potency to cause significant deformity anddisability1. There are number of Studies which have correlated6 minute walk test (6MWT) distance and lower extremitiesmuscle strength2 in polio, and energy cost of walking is shownto be strongly related to the extent of muscle weakness in thelower extremities3,4. Poliomyelitis is on edge of eradication, butmore than 50 lakhs residual polio survivors are reported in India5,moreover, in view of reported post polio syndrome (PPS), it is

necessary that post polio residual paralysis (PPRP) patientsshould be followed up with regards to their functional status.This study therefore aimed to assess the walking capacity andcardiorespiratory function and relation between two withhypothesis that cardiorespiratory parameters are not theresponsible factors for limited walking capacity of PPRP patients.


The study proposal was approved by the “Human ResearchEthic Committee, of the institute. The study design was anobservational case control study. 30 participants of PPRP wererecruited arbitrarily, based on their satisfying inclusion andexclusion criteria and, 30 healthy (self declared, not on anymedication) age matched participants were recruited from vicinityof the study center.

Inclusion Criteria

1) Known case of PPRP predominantly affecting one lowerlimb.2) Participants independently ambulatory with or without awalking aid/ orthosis .3) All age group – both males & femaleswith minimum of 2 years after the onset of poliomyelitis.4) Abilityto understand and follow the commands and capable to provideinformed consent.

Exclusion Criteria

1) Acute poliomyelitis. 2) Neurological, musculoskeletal andcardiovascular-respiratory conditions other than PPRP.3) Morethan one lower limb involved, unable to walk.

Informed consent was obtained from every participant; theparticipants who were willing to participate were interviewed fortheir medical history and demographic data. All the participantsclaimed no known cardiorespiratory, musculoskeletal andneurological (other than polio) pathology affecting their walkingcapacity and were able to walk independently with or withoutorthosis/walking aids.

For PPRP participants, Muscle strength was measured bymanual muscle testing (MMT), according to the medical researchcouncil Scale. Muscle group tested by MMT were hip flexors,hip extensors, hip abductors, hip adductors, knee extensors,knee flexors, dorsi flexors and planter flexors. To achieve scorethat indicates the functional values of muscle strength, MMTvalues 3 and below 3 was set at 0. MMT value 4 was set as 1and MMT value 5 was set as 2. Thus resulting in values foreach muscle group in the range from 0 to 2. By adding the scoresof all 8 muscles group of tested one affected leg (strength sum)was obtained in the way similar to Nollet 19991.

For both the groups, walking capacity was measured by 12minute walk test (12MWT). The test procedure was exactly thesame as recommended by Mcgevin6. PR, RR and BP weremeasured using standard methods. Rate of perceived exertion(RPE) was assessed by 16 points Borg scale7, while Ratepressure product (RPP)8 was measured by a product of PR ×Systolic BP. Participants were advised to wear comfortablecloths, shoe, orthosis/walking aids and then instructed to walkas far as possible with their comfortable speed around a 30meter long corridor. Post test immediately the said parameterswere measured. Recovery time for PR was measured at the

Ashish V Gupta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

55

end of 3 minutes, 5 minutes and 7 minutes. These values wererecorded under two groups i.e. d”5mins and >5mins.

For statistical analysis, SPSS software was used. Statisticalmethod used in the analysis were Unpaired’t’ test, Chi-squareand Pearson’s correlation. The statistical significance level foreach comparison was considered at 5% Level (P < 0.05).

Results

The descriptive statistics are as shown in table 1a. Themean BMI for both groups is seen to fall within normal limits.

Characteristics of study group are as given in table 1 b.Age ranges for study group was between 10 to 60 years.

Seven participants of study group used walking aids in the formof cane and crutch while only one participant used Knee AnkleFoot orthosis.

The range of sum of muscle strength of affected limb forstudy group was 0/16 - 10/16.Table 1a: Characteristics of the study population

Characteristics of Normal PPRP Total participants

Number of 30 30 60participants

Sex (M/F) 26/4 26/4 52/8

Mean age ± SE 30.63 ± 2.34 29.2 ± 2.21 -

Mean BMI ± SE 20.58 ± 0.6531 19.9107 -± 0.6191

Table 1b:Characteristics of post polio residual population

SR AGE SEX BMI ORTHOSIS SUM OFNo MMT

(AffectedLeg)

1 10 F 13.73 - Right 3/162 14 M 16.45 Stick Right6/163 15 M 14.22 Crutch Right 3/164 16 M 15.15 Stick Left 6/165 16 M 15.35 - Right 4/166 16 M 14.4 Stick Right 0/167 17 M 15.14 - Right 3/168 17 M 17.74 Stick Right 2/169 18 M 18.01 KAFO Right 5/1610 18 F 20.7 - Left 7/1611 22 M 18.75 - Left 10/1612 26 M 22.22 Stick Left 3/1613 26 F 22.22 - Left 3/1614 28 F 20.93 - Left 2/1615 29 M 21.33 - Right 1/1616 30 M 21.33 - Left 3/1617 31 M 22.14 - Right 8/1618 32 M 23.43 - Right 1/1619 33 M 20 - Left 5/1620 33 M 21.63 - Left 0/1621 34 M 19.45 - Left 3/1622 36 M 22.5 - Left 2/1623 39 M 25.39 - Right 5/1624 40 M 23.87 - Left 1/1625 41 M 25.71 - Right 6/1626 42 M 20.76 - Right 0/1627 42 M 20.82 - Right 5/1628 49 M 24 Stick Left 1/1629 50 M 18.67 - Left 8/1630 56 M 21.28 - Left 4/16

*P < 0.05

Table 2: Comparison of 12 minute walk test between two groups

Subjects Distance (meter) t-value P value

Normal 1043.83±16.07 10.022 0.000*

PPRP 685.64±31.92

12 minute Walk Test

As shown in table 2, PPRP participants covered significantlyless distance during 12 MWT compared to control group (p =0.00).

Table 3a & 3b show that although the changes inhemodynamic parameters were higher in PPRP participantscompared to normal on observation, the change in PR, RR,RPP, BP and recovery time for PR was not statistically significantbetween two groups.

With regards to RPE, as shown in table 3c, the significantdifference in resting RPE and post test RPE was seen betweenstudy and control groups (p<0.05). However change in RPEbetween the two group was not statically significant (p=0.052).

Change in RPP and the change in RPE level was negativelycorrelated (p= 0.028), (p= 0.014) resp. with 12 minute walkdistance (12MWD) in PPRP participants as seen in Table 4a,4b.

Table 3a: Comparison of different hemodynamic variablesbetween two groups

Change inhemodynamic Normal PPRP t- value p-parameter value

Change in PR 17.44 ± 2.31 21.4 ± 2.60 1.14 0.259

Change in RR 6.17 ±0.56 7.24 ± 0.78 1.11 0.271

Change in SBP 10.53 ± 1.00 14.3 ± 2.12 1.620 0.111

Change in DBP 3.33 ± 0.75 4.00 ± 1.04 0.521 0.605

Change in RPP 30.04 ± 3.58 40.44 ± 5.15 1.65 0.103

Change in RPE 3.97 ± 0.39 5.20 ± 0.48 1.98 0.052

*P < 0.05

Change in RPP and change in PR however was positivelycorrelated with change in RPE (p= 0.003), (p =0.006) resp. Onlyin the study group (table 5a, 5b).

In the present study there was no statistically significantrelation seen between the sum of paralytic limb muscle strengthto distance walked and / or with RPE (table 6 & 7).

With regards to RPE, as shown in table 3c, the significantdifference in resting RPE and post test RPE was seen betweenstudy and control groups (p<0.05). However change in RPEbetween the two group was not statically significant (p=0.052).

Change in RPP and the change in RPE level was negativelycorrelated (p= 0.028), (p= 0.014) resp. with 12 minute walkdistance (12MWD) in PPRP participants as seen in Table 4a,4b.

Change in RPP and change in PR however was positivelycorrelated with change in RPE (p= 0.003), (p =0.006) resp. Onlyin the study group (table 5a, 5b).

In the present study there was no statistically significantrelation seen between the sum of paralytic limb muscle strengthto distance walked and / or with RPE (table 6 & 7).


56

Table 3b:

Duration Normal PPRP Total Pearson Chi-Square P value

Recovery < 5min 25(83.3%) 23(76.7%) 48(80%)time (PR) 0.417 0.519

> 5min 5(16.7%) 7(23.3%) 12(20%)

Table 3c: Comparison of RPE between two groups

MeanRPE Normal PPRP t-value P value

Resting RPE 6 ± 0 6.83 ± 0.23 3.54 0.001*

Post test RPE 9.96 ± 0.39 12.03 ± 0.53 3.10 0.003*

Change in RPE 3.97 ± 0.39 5.20 ± 0.48 1.98 0.052

Table 4a: Correlation of various change in parameters with 12 minute walk distance

Participants Change in RPP Distance (Mean±SE) Correlation value P value(Mean±SE)

Normal 30.04 + 3.58 1043 + 16.07 0.386 0.035*

PPRP 40.44 + 5.15 685 + 31.92 -0.402 0.028*

*P < 0.05Table 4b:

*P < 0.05


Normal 3.97 + 0.39 1043 + 16.07 0.212 0.260

PPRP 5.20 + 0.48 685 + 31.92 -0.445 0.014*

Table 5a: Correlation of various change in parameters with change in RPE level

*P < 0.05


Normal 17.44 + 2.31 3.97 ± 0.39 0.129 0.496

PPRP 21.4 + 2.60 5.20 ± 0.48 0.489 0.006*

Table 5b:

*P < 0.05


Normal 30.04 + 3.58 3.97 ± 0.39 0.036 0.851

PPRP 40.44 + 5.15 5.20 ± 0.48 0.522 0.003*

Table 6: Correlation of Sum of paretic limb muscle strength with 12 minute walk distance

Participants Sum of paretic Distance (Mean±SE) Correlation value P valuelimb muscle

PPRP 3.66 + 0.47 685 + 31.92 -0.024 0.9

Table 7: Correlatio of sum of paretic limb muscle strength with change in RPE level

Participants Sum of paretic Distance (Mean±SE) Correlation value P valuelimb muscle

PPRP 3.66 + 0.47 5.20 ± 0.48 0.086 0.650


57

Discussion

The PPRP participants covered 34.27% less distance thancontrol group. According to Dean & Ross9 the performance insubmaximal exercise test depends on two factors: 1) movementeconomy, 2) cardiorespiratoty fitness. These both factors reflectdifferent physiological entities in physically disabled group;excessive oxygen cost at submaximal work rates is a hallmarkof reduced movement economy. While for cardiorespiratoryfitness a suboptimal relationship between HR and VO2 duringexercise is required. An excessive HR for a given VO2 is ahallmark of cardiorespiratory deconditioning.

In present study the cardiorespiratory fitness was assessedduring 12MWT, although post test hemodynamic variables suchas change in PR RR, RPP and recovery time for PR were higherin PPRP participants, statistically no significant change wasfound suggesting that cardiorespiratory response to 12MWT wassimilar in both the groups. However, it is noteworthy that thecardiorespiratory responses were similar in both groups despitea drastic difference between the distances walked. Also reviewof literature suggest that on submaximal level the polioparticipants show cardiorespiratory changes mainly inassociation with reduce muscle capacity, which is most likely afactor that predisposes polio participants to premature fatiguein sustained activity3,10 thus it is assumed that the higher valuesof hemodynamic variables after 12MWT seen in PPRP groupmay have resulted due to reduced muscle capacity/movementeconomy.

With regards to RPE, PPRP participants had more RPEafter 12MWT (P=0.003), also the change in RPE was negativelycorrelated with distance walked in 12MWT (p=0.014). There wasno such correlation seen in control group suggesting that highRPE level in study group can be a cause of limited distancecovered in 12MWT. Again, it has been reported that impairedcardiorespiratory function and impaired movement economyhighly influences the RPE11, because of its heterogeneous origin,subjective in nature and influenced by psychological factors,none of these factors have been formally tested in controlledtrials but possible argument for increasing RPE are stated tobe probably due to limited number of motor neurons, change infiber type of polio with increasing in type1cross sectional areawith low capillary density12 and decrease in oxidative andglycolytic enzyme13, low anaerobic threshold14, increasing energycost of walking because of neuromuscular and musculoskeletalimpairment4. Since the study group did not show significantdifference in cardiorespiratory parameters, increase in RPE levelcannot be attributed to poor cardiorespiratory fitness.

The present study is in agreement with the March of dimesbirth defect foundation15 that RPE could be used as valid tool ofself measure by the polio population to limit/pace the activitiesof daily living, as change in RPE was seen to be correlatedwith change in PR & RPP in PPRP group.

The distance walked by the PPRP participants was 34.27%less compared to control group, the similar result were found innumber of studies2,16 who used 6MWT, they found thatneuromuscular and musculoskeletal impairment in people withchronic poliomyelitis is a primary cause of limitation to thedistance walk in 6MWT as they got no relation between thephysiological measure and 6 minute walk test distance. Thepresent study didn’t find any association between sum of pareticlimb muscle strength and distance covered. A number of studiestried to find out relation between walking speed and musclestrength and have found significant correlation10,17. The presentstudy however have studied walking capacity at comfortablespeed only.

In the PPRP group all participants could successfullycomplete the 12MWT, except 4 individuals who completed the

test with few minutes of rest in between. These individuals alsotraversed less distance with high RPE score, this was seendespite the sum of paretic limb muscle strength similar to othersin the group. The cause may be difficult to establish as numberof factors viz BMI, severe deformities, sedentary life orprogression toward PPS could have influenced the above results,future studies are necessary to establish association.

Conclusion

Walking capacity was significantly compromised in polioparticipants while cardiorespiratory response to 12 minute walktest was almost same in both the groups, except RPE whichwas found to be significantly high in polio subjects.

References

1. Nollet F et al. Disability and functional assessment in formerpatients with and without post polio syndrome. Arch PhysMed Rehabil.1999; 80:136-43.

2. Sif Gylfadottir et al.The relation between walking capacityand clinical correlates in survivors of chronic spinalpoliomyelitis. Arch Phys Med Rehabil.2006; 87:944-52.

3. Nollet F et al. Submaximal exercise capacity and maximalpower output in polio subjects. Arch Phys MedRehabil.2001; 82:1678-85.

4. Merel-Anne Brehm et al. Energy demands of walking inpersons with post-poliomyelitis syndrome: Relationship withMuscle Strength and Reproducibility. Arch Phys MedRehabil.2006; 87:136-40.

5. Punarbhava- National interactive portal on disability. censusdata on disability. http://www.punarbhava.in/index.php?option=com_content&task=view&id=229&Itemid=537.

6. McGavin CR et al. Dyspnoea, disability and distancewalked: A comparison of estimates of exercise performancein respiratory disease. Br Med J. 1978; 2: 241-43.

7. Borg GV, Psycho physical basis of perceived exertion. MedSci Sports Exer,1982;14: 377-81.

8. Richard R, Nelson et al. Hemodynamic predictors ofmyocardial O2 consumption during static and dynamicexercise. Circulation. 1974; 50: 1179-89.

9. Dean E & J Ross. Movement energetic of individual with ahistory of poliomyelitis. Arch Phys Med Rehabil, 1993; 74:478-83.

10. Davies CT et al. Effect of training on physiologicalresponses to one and two leg work. J Appl Physiol. 1957;38: 377-85.

11. McGavin et al. A higher PRE has been to be related toshorter 12 minute distance. Br Med J. 1976; 822-23.

12. Borg K, Borg J. Motorneurone firing and isomyosin type ofmuscle fibers in prior polio. J Neurol Neurosurg Psychiatry.1989; 52: 1141-48.

13. Borg k et al. Prior poliomyelitis- reduce capillary supply andmetabolic enzyme content in hypertrophic slow twitch musclefibers. J Neurol Neurosurg Psychiatry. 1991;54:236-40.

14. Willen C et al. Physical performance in individual with lateeffect of polio. Scand J Rehabil Med.1999; 31: 244-49.

15. March of Dimes International Conference on post poliosyndrome.2000 may19-20.

16. Vanessa K, Noonan et al. The relationship between selfreported and objective measures of disability in patientswith late sequelae of poliomyelitis: a validation study. ArchPhys Med Rehabil. 2000;81: 422- 27.

17. Carin Willen et al. How is walking speed related to musclestrength? A study of healthy person and person with lateeffects of polio. Arch Phys Med Rehabil. 2004; 85: 1923-28.


58

Comparing the Effectiveness of Positional Release TherapyTechnique & Passive Stretching on Hamstring Muscle ThroughSit to Reach Test in Normal Female SubjectsManivannan M Kaandeepan*, E S Cheraladhan*, M Premkumar*, Shikha K Shah*Assisstant Professor, KJ Pandya College of Physiotherapy, Sumandeep Vidyapeetth , Pipariya, Waghodia Taluk, Vadodara- Gujarat391760, India

Abstract

Aim

To find out the effectiveness of Positional Release Therapyand Passive Stretching Techniques on lumbar flexion musclerange of motion flexibility outcome measurement in normalfemale subjects.

Methods

A total of 40 asymptomatic subjects among studentcommunity within 18 to 25 years of age were selected fromvadodara city and from the department of physiotherapy,Sumandeep Vidyapeeth University, sampling method throughconvenient sampling. The subjects were randomly divided intwo groups i.e. Group-1 given positional release therapytechnique and Group-2 given passive stretching technique onhamstrings muscle respectively. Active lumbar flexion range wasmeasured by Sit to Reach Test before and after the intervention.The data were collected and analyzed by Paired’ and unpaired‘t’test method.

Results

The‘t’ showed a significant (p=0.000) post testmeasurement values for both the groups.

Conclusion

When comparing the results of both group post values, itshows p-value [0.933]. No statistically significant differenceswere found in between two groups post test values in bringinglumbar flexion movement flexibility more beneficial. Bothtechniques are equally effective in bringing lumbar flexion rangeof motion flexibility.

Key Words

Flexibility, Stretching, Positional Release Therapy, Sit toreach test.

Introduction

Flexibility is the ability to move a single joint or series ofjoints smoothly and easily through an unrestricted, pain-freerange of motion. Flexibility is related to the extensibility ofmusculo-tendinous units that cross a joint based on their abilityto relax or deform and yield to a stretch force. 1 It is importantboth inflexibility and hyper-flexibility can result in higher risks ofinjury. In addition, an imbalance in flexibility could predisposethe individual to an increased risk of injury. 2 Mobility ismaintained in most individuals by routine, daily use of their limbsand joints in normal daily activities. However, adaptive shorteningcan occur in those who spend long periods in single posture[e.g. sitting most of the day] and mobility can be lost. Normalmobility includes adequate joint range of motion and muscle

range of motion. Progressive adaptive shortening of the softtissue occurs as the body responds to decreased loading. Thisshortening limits mobility and function, reducing the patient’sability to carry out normal activities of daily living, work or leisureactivities. The patient accommodates these limitations bysubstituting other joints or limbs to achieve functional goals, thereby contributing to the disuse.3 Forward bending is a coupledmovement combining lumbar flexion and pelvic rotation, the so-called lumbar–pelvic rhythm. It results from coordinated activitybetween the back extensor muscles (erector spinae) and thehip extensor muscles (gluteus and hamstrings).4 The hamstringsare example of muscle groups that have a tendency to shorten5.Stiffness in the hamstrings is often compensated by lumbar spinemotion, placing more load on the spine. Lengthening thehamstrings minimizes the stress placed on the spine and is thebasis for hamstring stretching, an approach used by somepersons to remedy back pain.3 Muscle tightness can be presentwithout a joint contracture. Multi joint muscles are particularlyvulnerable to developing tightness, especially in those individualswho do not regularly perform stretching exercises.6 Duringforward bending, stiff hamstrings can restrict pelvic forwardrotation, resulting in flexion stress on the lumbar spine.7 Whenlimitation of joint motion is because of soft tissue shortening,stretching have been found to be effective6 and PositionalRelease Therapy is also a highly effective technique that helpsreduce pain and restore function to muscles, bones, and joints8.

Numerous researchers have compared various stretchingtechniques to determine which technique is most effective forincreasing joint range of motion (ROM). Static stretching is acommonly used method of stretching in which soft tissue areelongated just past the point of tissue resistance and then heldin the lengthened position with a sustained stretch force over aperiod of time. Static stretching is an effective form of stretchingto increase flexibility and a safer form.9 Positional release therapyis method of total body evaluation and treatment using tenderpoints and a position of comfort (POC) to resolve the associateddysfunction. Positional Release Therapy is an indirect (the bodypart moves away from the resistance barrier, i.e. the direction ofgreatest ease) and passive (the therapist performs all themovements without help from the patient) method of treatment.As a result of treatment using PRT, there is a decrease in muscletension, facial tension, and joint hypo-mobility. These changesin turn result in a significant increase in functional range of motionand decrease in pain. [10] It is a hands-on treatment that alleviatesmuscle and connective tissue tightness by the use of veryspecific treatment positions held for 90-120 seconds. [8] Manyauthors have studied different approaches of muscle stretchingand the duration of application of such procedures but no studieswere there in comparing the significant effect in relation to ourtopic.

Methodology

A total of 40 young female subjects among studentcommunity within 18 to 25 years of age were selected. Thisstudy was comparative study using convenient sampling.Orthopedics problem around hip, knee and spine, subjects withhamstring strain or contusion, Obesity, any congenital conditionsor diseases in lower extremity are excluded. Subjects werevolunteers and signed an approved informed consent statement.

Manivannan M Kaandeepan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

59

Two groups were divided each into 20 and Group-1: were givenpositional release therapy technique, Group-2: were givenpassive stretching. First to check hamstring flexibility, the subjectsdid Sit to Reach Test and measurement were taken. Second,for group-1, positional release therapy technique was given inhamstring muscles and for group-2 passive stretching given.Again subjects did sit to reach test and measurement arerecorded. Sit to reach test procedure is a test involves sitting onthe floor with legs stretched out straight ahead. Shoes shouldbe removed. The soles of the feet are placed flat against thebox. Both knees should be locked and pressed flat to the floor -the tester may assist by holding them down. With the palmsfacing downwards, and the hands on top of each other or sideby side, the subject reaches forward along the measuring lineas far as possible. Ensure that the hands remain at the samelevel, not one reaching further forward than the other. After somepractice reaches, the subject reaches out and holds that positionfor at one-two seconds while the distance is recorded.11 InPositional release technique procedure, the subject lies supinewith thigh extended and abducted off the edge of the plinthslightly, and then the knee was flexed passively to 40 degreesand adds slight adduction (varus force) and marked internal

rotation of the tibia. These positions were held for exactly 90second and measured using a standard watch time and thenlimb were returned to the resting position. 12 In Passive stretchingprocedure, therapist kneels on plinth. With the subjects kneefully extended, supporting the subjects lower leg on therapistarm or shoulder. Stabilize the opposite extremity along theanterior aspect of the thigh with one hand. With the knee atzero degree extension, and the hip in neutral rotation, flex thehip as far as possible. These positions were held for exactly 60seconds and were measured using a standard watch time andthen limb was returned to the resting position. 13, 15

Data Analysis

Descriptive statistics including numbers, proportions, meanand standard deviations were used to present data. Student t-test (paired and unpaired) were used to compare data withingroup and in-between the two groups. A probability level ofp<0.05 will be accepted as statistically significant. SPSS version16 will be used to analyze the data.

Table 1: Comparison of pre and post values for group-1 using paired t-test

BEFORE Positional Release AFTER Positional Release t-valueTechnique Technique

MEAN Standrad Standrad MEAN Standrad Standrad -10.384Deviation Error Deviation Error

24.1000 7.50018 1.67709 27.5500 7.13387 1.59518

Table 2: Comparison of pre and post values for group-2 using paired t-test

BEFORE Positional Release AFTER Positional Release t-valueTechnique Technique

MEAN Standrad Standrad MEAN Standrad Standrad -6.909Deviation Error Deviation Error

23.6500 9.50083 2.12445 27.7750 9.56622 2.13907

Table 3: Comparison of both group-1 and group-2 post test values using unpaired t-test

AFTER Positional Release AFTER PASSIVE t-value Sig 2(tailed)Technique STRECTHING

MEAN Standard Standard MEAN Standard Standard -.084 .933Deviation Error Deviation Error

24.1000 7.50018 1.67709 27.7750 9.56622 2.13907

Results

The data were collected and analyzed with Paired t-testand unpaired t-test methods. In group-1the results shows thatthere were statistically difference in bringing hamstring flexibility(p=0.000). In group-2 the results.

Findings

Flexibility is an important physiological component ofphysical fitness, and reduced flexibility can cause inefficiency inthe workplace and is also a risk factor for low back pain.Increasing hamstring flexibility was reported to be an effectivemethod for increasing hamstring muscle performance onselective isokinetic conditions(Worrell et al, 1994).[14]

In our study, Subjects were not involved in any exerciseactivity at the start of the study and agreed to avoid lower-extremity exercises and activities other than those advised.


Group 1: Pre-test and Post-test values for Positional ReleaseTechnique in hamstrings muscle in Group-1

60

Muscle tightness is one of the limiting factors for restricted rangeof motion and reduced flexibility of joint. Especially hamstringmuscles are more prone for tightness in sedentary life becauseof prolonged sitting posture and cause reduction in flexibility oflumbar movement in future days. The technique of relievinghamstring tightness used in this study was to passively andstatically stretch the hamstring muscles. The outcome of thisstudy revealed that both applications of static stretching as wellas positional release technique procedures resulted in significantimprovement in hamstrings muscle flexibility in the interventiongroups. We selected this topic because many studies showedregarding static stretching beneficial effects and only few studiesare there regarding positional release therapy. Both thetechniques are easier for application. But when comparing thetime and application methodology, static stretching was bestthen positional release therapy. Static stretching can be appliedinstantly but positional release therapy needed couch and moretime because of positioning. Other side when viewing positionalrelease therapy we can apply this technique to old age patientsbecause the application method was easier, smooth mannerand not forceful. The implication of this finding was thatindividuals with hamstrings tightness would benefit the sameeffect. The similarities between the post values of both groupstudies could be a result of the difference in the frequency andthe duration for which the static stretching and positional releasetherapy were carried out, the procedure were carried out oncein each subjects in our study and not continued for next day orweeks by several authors who did the same techniques onhamstring muscle. Our study was limited to the effects ofstretching the hamstring muscles on lumbar flexion range ofmotion. Although 60-second, three times, single time bout ofstatic stretching the hamstring muscles was found to be aseffective, similarly positional release therapy was found to beas effective, studies are needed to evaluate the effects of variousdurations and of frequencies in stretching the hamstring muscleand on other muscles like back extensor muscles etc., We onlyexamined static stretching of up to 60 seconds in duration andthe positional release technique given for 90 seconds .Additionalresearch is needed to evaluate whether durations of secondsor frequency of applications for few days will provide moreflexibility. Because, the sample we taken for this study wasrelatively young, with a mean age of 26 years. Future researchis needed on subjects in different age groups, sports injuriesrelated conditions, OA knee patients, back pain patients etc.,

Conclusion

There were no difference in effects between static stretchingand positional release therapy with post test values. Both thetechniques are equally effective in bringing lumbar flexion range

of motion flexibility. The results from this study will be helpful forindividuals who desire to increase the flexibility in an attempt toincrease lumbar flexion motion.

Acknowledgement

The authors are thankful to Sumandeep VidyapeethUniversity, Vadodara, K J Pandya College of physiotherapyDepartment, for providing facility to do this research work. Theauthors are very thankful for the subjects who participated inthis study for completing this research work in limited time.

References

1. Carolyn kisner, Lynn Allen Colby., Therapeutic Exercise 5th

Edition. Stretching for impaired mobility.Page no:66, chapter-4.

2. Lan jeffregs, Essentials of strength Training andconditioning. Warm up and stretching. Page no: 297,chapter-13.

3. Lan jeffregs, Essentials of strength Training andconditioning. Warm up and stretching. Page no: 114,

chapter-7.4. C.M. Norris, M. Matthews ‘Correlation Between Hamstring

Muscle Length And Pelvic Tilt Range During ForwardBending In Healthy Individuals’: An Initial Evaluation.Journal of Bodywork and Movement Therapies (2006) 10,122–126. Page-2.

5. Turner D, Gossman R. M., Nicholosn C.G, ‘Comparison OfCyclic And Sustained Passive Stretching’ Phys Ther69(3):314-320.

6. Frances E. Huber, Chris L. wells. Therapeutic Exercise.Treatment planning for progression. Page-73, chapter-3.

7. Carrie M.Hall, Lori Thein Brody. Therapeutic Exercise.Moving Towards Function 2nd edition. Page-363, chapter-18.

8. BarryKrost, Positional Release Is Effective Therapy.Article:Http://Ezinearticles.Com/Expert=Barry_ Krost.

9. Carolyn kisner, Lynn Allen Colby., Therapeutic Exercise 5th

Edition. Stretching for impaired mobility. Page no:79, chapter-4.10. Prasant N.P; “ Comparison Of Muscle Energy Technique

And Positional Release Technique In Acute Low Back Pain-RCT” Indian Journal Of Physiotherapy And OccupationalTherapy Year:2010,Volume:4,Issue:2.

11. Brain Mackenzie - Book author ‘101 PerformanceEvaluation tests’.

12. Trevor B. Birmingham, Julie Kramer, jim Lumsden, KathyD. Obright, john F.Kramer. ‘Effect of a positional releasetherapy technique on hamstring flexibility’. Canada


Group 2: Pre-test and Post-test values for Static StretchingTechnique in hamstrings muscle in Group-2

Group 3: Post-test values of Positional Release TechniqueGroup-1 and Static Stretching technique Group-2 in hamstringsmuscle.

61Manivannan M Kaandeepan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

physiotherapy, volume 56, number 3, page no ; 168.13. Carolyn kisner, Lynn Allen Colby., Therapeutic Exercise 5th

Edition. Stretching for impaired mobility. Page no:99, chapter-4.14. Worrell, T. W., Smith, T. L. and Winegardner, J. W. (1994).

‘Effect of hamstring stretching on hamstring muscleperformance’. J. Orthop. Sports Phys. Ther. 20: 154-159.

15. William D Bandy, Jean M Irion, and Michelle Briggler, ‘TheEffect of Time and Frequency of Static Stretching onFlexibility of the Hamstring Muscles’ Physical TherapyOctober 1997 77:1090-1096.

62

Comparative Study between Efficacy of PNF Movement PatternsVersus Conventional Free Exercises on Functional ActivitiesAmong Patients with Chronic Peri-Arthritis of ShoulderManobhiram Nellutla*, Pramod Giri***Lecturer, Physiotherapy Department Kigali Health Institute, Faculty of Allied Health Sciences, P.O. Box 3286, Kigali, Rwanda,**Former Principal and Guide, Laxmi Memorial College of Physiotherapy, AJ Towers, Balmatta, Mangalore, Karnataka, India

Abstract

Objective

To investigate the efficacy of Proprioceptive NeuromuscularFacilitation (PNF) movement patterns in improving functionalindependence in patients with Chronic Peri-Arthritis (PA) of theshoulder.

Subjects

40 Patients diagnosed with PA of the shoulder wererandomly and equally allocated (n=20) into a control (receivingconventional free exercises) and an experimental group(receiving PNF movement patterns).

Methods

Assessment was done to check functional independenceboth prior to and after the treatment programme. Descriptivestatistics were used to enumerate the positive responses foreach question on functional activities on the Simple ShoulderTest (SST) for each patient. Neer’s Criteria was used to classifythe patients into different groups based on their Constant’sShoulder Functional Score (CSFS).

Results

There was improvement in the functional independence ofparticipants in both groups based on t test results for both withinthe group and between groups. Though there was no significantchange in both the groups post treatment scores, there weremore participants from the experimental group who showedchange in both Neer’s criteria of CSFS and “Yes” responses toSST.

Conclusion

PNF movement patterns when included in the routinetreatment of chronic PA of the shoulder may be as efficacious inincreasing the function of the involved shoulder when comparedwith the treatment by conventional free exercises.

Key Words

Peri-Arthritis Shoulder, Functional Activities, ProprioceptiveNeuromuscular Facilitation (PNF), Conventional Free Exercises,Simple Shoulder Test, Constant Shoulder Functional Score.

Address for correspondence:Manobhiram NellutlaP.O. Box 5532Kigali. RwandaMobile: [email protected]

Introduction

Grubbs defined frozen shoulder as “a soft tissue capsularlesion accompanied by painful and restricted active and passivemotion at the glenohumeral joint”1. Neviaser2 in 1946 surgicallyexplored Peri-Arthritis (PA) shoulder cases, finding an absenceof the glenohumeral synovial fluid, a redundant axillary fold ofthe capsule, as well as thickening and contraction of the capsule,which had become adherent to the humeral head, hence heused the term “Adhesive Capsulitis”.

Cyriax3 clarified that arthritis exhibits limitation of passivemotion in characteristic proportions, which he called the capsularpattern. The capsular pattern of PA of the shoulder is most limitedin external rotation, followed by abduction, and by internalrotation. Abduction is limited by the loss of the inferior redundantfold and limited external rotation.

Periarthritis of the shoulder has three classical stages4.Thefirst stage is the “freezing “phase, characterized by the onset ofan aching pain in the shoulder. The second stage is theprogressive stiffness or “frozen” phase. Pain at rest usuallydiminishes during this stage, leaving the patient with a shoulderthat has restricted motion in all planes. The final stage is theresolution or “thawing” phase. This stage is characterized by aslow recovery of motion. The duration of the condition is variableand dependent on multiple factors, such as age, underlinedmedical conditions like diabetes mellitus, and on timing ofintervention before resolution.

PA shoulder most commonly occurs in patients above 40years of age, with a higher incidence in females. The idiopathicform in uncommon. It is estimated that in a one-year incidencein patients in general, it ranges from 2:1,000 to 2:100. Theprevalence in the elderly population has been shown to be lessthan 1/100. The secondary form may be more common. Themost significant association is with insulin-dependent diabetes.Bilateral disease occurs in approximately 10% of patients, butcan be as high as 40% in patients with a history of insulin-dependent diabetes4.

Although there is little agreement on PA shoulder’streatment when it occurs, there is agreement on the treatmentgoals; pain relief and restoration of normal shoulder movement.The normal procedures of treatment for chronic PA of theshoulder include giving emphasis on increasing Range of Motion(ROM) of the shoulder5. Most of the treatment modalities toachieve this include mobilizations, active exercises and reducingthe inflammatory process through the use of ultrasound.

Proprioceptive Neuromuscular Facilitation (PNF) helps inactivating the agonist muscles and at the same time stretchingthe antagonist muscles so that they activate a strongercontraction and hence stronger movement6. PNF facilitatesmass movement patterns against resistance in a spiral ordiagonal motion during flexion and extension. This technique isthought to alter the responses of muscle spindles to increasethe maximum range of motion, although it may also do so bystimulating an increase in the force produced by each muscle7.It also stretches the capsule while the movement is done in adiagonal pattern thereby increasing joint ROM 6,8. Simliar spiraland diagonal movement patterns are later used for functionalactivities and walking9. Joshi and Kotwal5 advocated graduatedrelaxed sustained stretching based on PNF principles, whichmay increase the ROM of the shoulder joint and hence functional

Manobhiram Nellutla / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

63

independence.The purpose of this study was therefore to determine the

efficacy of PNF movement patterns in improving function amongpatients with chronic Peri-Arthritis of the shoulder.

Methods

The study was conducted in the physiotherapy clinic of theLaxmi Memorial College of Physiotherapy, the outpatientphysiotherapy department of the A.J. Hospital and ResearchCenter as well as the outpatient physiotherapy department ofthe Government Wenlock District Hospital. All three researchsites are located in Mangalore, India.

Participants

Study participants were selected from patients who weretreated between January 2003 and December 2003. Both menand women aged between 40 and 70 years were selected. Double Blinded Random sampling was used to select patientsdiagnosed with chronic frozen shoulder with restricted joint ROMand limitations in activities of daily living (ADL). Patients were

referred by an orthopaedic surgeon. Only patients who had mildor no pain on the constant shoulder functional score (CSFS) i.e.score of 10 or 15 were included in the study, (pain is not a clinicalfeature of chronic PA and only patients with chronic stage of PAwere selected).

Instrumentation

1. An assessment chart was used to record the patient’shistory, subjective and objective physical examination,differential diagnosis, and treatment plan and outcomemeasures.

2. An x-ray of the involved shoulder was taken and analyzedto rule out some of the exclusion criteria e.g. biceps tendonrupture.

3. The Simple Shoulder Test (SST)10 was executed. Becauseof the critical importance of systematic documentation ofshoulder function, a series of 12 questions were asked ofpatients about the function of the involved shoulder. “YES”or “NO” responses to these questions provided astandardized way of recording the function of a shoulderbefore and after treatment.(Table I)

4. Constant Shoulder Functional Score11. This scale consists

Table 1: Simple Shoulder Test

Twelve questions of the SST are:

1) Is your shoulder comfortable with your arm at rest by your side?2) Does your shoulder allow you to sleep comfortably?3) Can you reach the small of your back to tuck in your shirt with your hand?4) Can you place your hand behind your head with the elbow straight out to the side?5) Can you place a coin on a shelf at the level of your shoulder without bending your elbow?6) Can you lift one pound ( a full pint container) to the level of your shoulder without bending your elbow?7) Can you lift eight pounds ( a full gallon container) to the level of the top of your head without bending your elbow?8) Can you carry 20 pounds at your side with the effected extremity?9) Do you think you can toss a softball underhand 10 yards with the affected extremity?10) Do you think you can throw a softball overhand 20 yards with the affected extremity?11) Can you wash the back of your opposite shoulder with the affected extremity?12) Would your shoulder allow you to work full-time at your usual job?

of pain, ADL, ROM, and Shoulder Power. Each item has arespective score, adding to a total of 100 points for thescale. (Table II)

• Pain score (15 points) measured subjectively. Severe Pain(0 points), moderate pain (5 points), mild pain (10 points)or no pain (15 points)

• Activities of Daily Living. The patient is asked what activitiesthey can do and each is scored to total 20 points. Some ofthe activities included are ability to perform full work withthe involved shoulder (4 Points), full recreation or sports (4points) whether sleep is unaffected (2 points) and questionsregarding the quantity of hand movement - up to waist (2points), up to xiphoid process (4 points), up to the top ofthe head (8points), or above the head (10 points).

• Range of Motion in the CSFS is calculated after thegoniometric readings by using an Universal Goniometer12.A total of 40 points is assigned to ROM abduction, flexion,external rotation and internal rotation, each movementhaving 10 points. Points for abduction and flexion are givensuch that 180 = one point, for external rotation 90 = onepoint; for internal rotation 80 = 1 point. These points weregiven according to the normal ROM occurring at theshoulder for each movement divided by 10 points. In thisway the ROM points are calculated for each movementbased on the amount of movement the patient makes.

• The CSFS has 25 points for shoulder power. This wascalculated by asking the patient to lift a 4lb dumbbell for 10repetitions. For each lift the patient was awarded 2.5 points.

Procedure

Ethical clearance was obtained from the Ethical Committeeof the Laxmi Memorial College of Physiotherapy. Permissionwas sought and granted by the health facilities used as studysites. Written informed consent was obtained from participants.The patients were then randomly allocated into two groups, onecontrol group and one experimental group.

The number of “YES” or “NO” responses for the 12questions in the SST and the total number of points obtained onthe CSFS were recorded and noted on Neer’s Criteria for all thepatients on the first day (at recruitment) and after three weeksof treatment.

Treatment Intervention

Participants in both groups received the following treatmentprocedures:1. Ultrasound: A dosage of 0.8 watts/square cm, with a pulse

ratio of 1:2 for 8 minutes was administered for each sessionthat is 6days a week for 3 weeks.

2. Maitland Mobilizations: Grade 3 for a) the Glenohumeraljoint – caudal glide (to improve abduction), posterior glide(to improve flexion and internal rotation), anterior glide (toimprove external rotation) were given. For theAcromioclavicular joint anterior glide (to increase jointmobility) was given.b) the sternoclavicular joint - posteriorglide to (increase retraction), anterior glide (to increaseprotraction), inferior glide (to increase elevation) and


64

superior glide (to increase depression) were given. c)though the scapula-thoracic articulation is not a true joint,the scapula was lifted and moved in the desired directionto obtain normal shoulder girdle mobility13. Regularoscillations at 2 or 3 per second for 1-2 minutes were givenfollowed by rest. 5 repetitions were performed in eachsession.

Table 2: Constant Shoulder Functional Score

Item Score

PAIN 15None 15Mild 10Moderate 5Severe 0

ACTIVITIES OF DAILY LIVING 20Full Work 20Full recreation/Sports 4Unaffected Sleep 4Hand Position Up to waist 2

Up to xiphoid 4 Up to top of head 8 Above head 10

RANGE OF MOTION 40 Abduction 10 Forward Elevation 10 Internal Rotation 10 External Rotation 10

SHOULDER POWER 25 Pounds to Resist

TOTAL 100

NEER’S CRITERIA FOR SHOULDER:Excellent = 89-100Good = 71-88Poor = 51-69

Treatment for Participants in the ControlGroup

In addition to the ultra sound therapy and mobilization, thecontrol group also received conventional free exercises whichincluded finger ladder exercises, Codman’s exercises, andoverhead shoulder pulley and shoulder wheel.14,15

Codman’s exercises or pendulum exercises wereperformed by the patient with gravity assisting, the patient wasbent at the waist with the upper extremity dangling, the weightof the extremity producing joint traction. The patient was givena 4lb dumbbell to hold in the hand for additional traction. Thenthe patient was advised to move the shoulder forwards andbackwards, medial to lateral and circular motions made with theentire extremity. Ten repetitions were performed in each set ofmovements. A total of 2 sets for each movement8,13,16 wereperformed.

The patients were then asked to sit under the shoulderpulley and first had to place the hand sideways and then lift thearms into abduction by pulling the other side of the rope. Thishelps in stretching and increasing abduction. The patient wasthen asked to move the arms and place them forward and pullthe ropes thus aiding flexion movement at the shoulder joint.This was also done for 10 repetitions in all the sets of movementsand with a total of 2 sets for each session.

Patients were taken to the shoulder wheel and were told to

rotate the wheel both anteriorly and posteriorly whilst standingsideways with the shoulder level with the axis of the wheel. Tenrepetitions were performed for each movement. They werecautioned not to exert as this could cause further pain ordiscomfort.

Abduction and flexion on the finger ladder were the nextexercises. These were done with the patient standing sidewaysfacing the ladder. Each movement was repeated 10 times.

Finally, home exercises were taught to the patient whichincluded simple Codman’s exercises with an iron box in handand finger wall exercises and all the active movements aroundthe shoulder joint. They were told to repeat each movement 10times. They were advised to perform these home exercises twicedaily – once in the early morning before coming for the treatmentand once in the evening as this would aid recovery.

Treatment for Participants in the ExperimentalGroup

In addition to ultra sound therapy and mobilization, theexperimental group also received PNF6 movement patterns asexercise as follows: The patients were first made to lie down onthe bed in supine and taken into D1 and D2 patterns for theupper limb by the therapist. This was done so that the patientcould understand the amount of stretch required at the end rangeand the components of the whole exercise movement.

o Shoulder Flexion, Abduction and External Rotation thatwas started at Shoulder Extension, Adduction and InternalRotation.

o Shoulder Flexion, Adduction and External Rotation thatwas started at Shoulder Extension, Abduction and InternalRotation.

This was performed till the patient understood how heshould be performing the patterns within the available range.The patients were made to perform in front of a mirror forfeedback and to demonstrate the movement to the therapist.The patient was advised to perform these patterns 10 repetitions,thrice daily in each set and 2 sets for each session, and advisednot to overstretch or fatigue the muscles.

Participants in both groups underwent treatment for threeweeks.

Data Analysis

Microsoft Excel was used to enter data. CSFS scores wereanalyzed by paired ‘t’ test for within group of both control andexperimental at 1st day and after 3 weeks of treatment. Bothgroups post treatment date were analyzed by a unpaired ‘t’ test.Scores from the SST and Neer’s Criteria of CSFS were analyzeddescriptively.

Results

Forty patients (20 in each group) with chronic PA of theshoulder participated in the study. The mean age of participantswas 56.15± 8.71 with 24 male participants and 16 femaleparticipants.

Results of paired ‘t test for CSFS scores ofControl Group

t= 14.8 degrees of freedom = 19

The probability of this result,assuming the null hypothesis, is 0.00


65

Table 3: CSFS Scores (out of 100) of Control Group treatedwith Conventional Free Exercises. No. of Control Group

Patients1st Day 3rd Week

1. 65 86

2. 59 84

3. 58 90

4. 62 83

5. 62 80

6. 58 86

7. 62 88

8. 67 91

9. 60 80

10. 71 86

11. 59 86

12. 52 87

13. 64 89

14. 50 73

15. 60 82

16. 65 82

17. 72 85

18. 57 89

19. 54 83

20. 68 94

Results from Table III show a significant increase in the CSFSscores after 3 weeks of treatment in the Control Group.

No. of Control GroupPatients

1st Day 3rd Week

1. 51 79

2. 48 75

3. 73 88

4. 77 89

5. 67 79

6. 53 82

7. 58 75

8. 53 84

9. 61 85

10. 74 87

11. 69 85

12. 52 80

13. 72 91

14. 60 82

15. 68 88

16. 57 82

17. 60 82

18. 56 86

19. 61 92

20. 69 85

Table 4: CSFS scores (out of 100) of Experimental Group treatedwith PNF movement Patterns.

Results of paired ‘t test for CSFS scores ofExperimental Group

t= 18.5

degrees of freedom = 19The probability of this result, assuming the nullhypothesis, is 0.000

Results from the post treatment scores of CSFS from boththe groups were then analyzed using an unpaired ‘t’ test andthe results showed that there was no significant differencebetween the two groups. Hence stating that both the treatmentmethods were significant and that PNF movement patterns whenincluded in the exercise are as effective as the ConventionalFree

Exercises

Table V shows that prior to treatment none of the patientsin either group could be classified as ‘excellent’ according toNeer’s criteria of CSFS. After treatment no patients wereclassified as ‘poor’ according to Neer’s criteria. However therewere two more participants classified as ‘excellent’ aftertreatment in the experimental group compared to the controlgroup.

The following graph shows the frequencies of “Yes”responses Simple Shoulder Test – SST) by participants fromboth groups regarding shoulder function, prior to and aftertreatment.

For all 12 questions there were more participantsresponding positively to functional ability of the shoulder on theSST (Table IV). It was also observed that there were twice asmany patients in the experimental group able to; ‘place theirhand behind the head with the elbow straight out to the side’.

Discussion

The improvement in the functional activities of allmovements in both groups may be attributed to the increase in


66

Table 5: Neer’s Criteria of Constant Shoulder Functional Score (CSFS)

Score for Neer’s Criteria Control Group Experimental Group

1st Day 3rd Week 1st Day 3rd Week

Excellent (89-100) 0 3 0 5

Good (71-88) 4 17 2 15

Poor (51-70) 16 0 18 0

Table 4: Participants Responses to the SSTQuestion Control Group (n = 20) Experimental Group (n = 20)

No. of “Yes” responses No. of “Yes” responses

1st Day After 3 weeks 1st Day After 3 weeks

1. Is your shoulder comfortable 11 18 12 18with your arm at rest by your side?

2. Does your shoulder allow you to 8 10 7 11sleep comfortably?

3. Can you reach the small of your 12 14 10 14back to tuck in your shirt with yourhand?

4. Can you place your hand behind 4 6 4 12your head with the elbow straightout to the side?

5. Can you place a coin on a shelf 12 14 12 16at the level of your shoulder withoutbending your elbow?

6. Can you lift one pound (a full pint 7 8 8 12container) to the level of yourshoulder without bending your elbow?

7. Can you lift eight pounds (a full gallon 5 8 6 10container) to the level of the top of yourhead without bending your elbow?

8. Can you carry 20 pounds at your side 4 8 6 12with the effected extremity?

9. Do you think you can toss a softball 8 12 10 18underhand 10 yards with the affectedextremity?

10. Do you think you can throw a softball 2 8 3 14overhand 20 yards with the affected extremity?

11. Can you wash the back of your opposite 12 16 12 19shoulder with the affected extremity?

12. Would your shoulder allow you to work 4 10 5 14full-time at your usual job?


Graph 1: Comparison of ‘YES’ Responses to Simple Shoulder Test in Both Groups after 3 Weeks

67

ROM due to the common treatment given to both the groups -mobilization and ultrasound therapy. Clinically, ultrasoundtherapy is used for its thermal and mechanical effects on tissue.In PA of the shoulder, it is often used prior to stretching of thecapsule17.

Research also shows that mobilization is most effective inreversing the changes that occur in connective tissue followingimmobilization. Mobilization is designed to restore joint playmotions of roll glide and joint separation. Gentle mobilizationglides help to break down the collagen formed in the capsule,which is responsible for restriction of joint motion. The glideswhen given daily help to increase joint play18.

The control group received conventional free exercises likeoverhead pulley, shoulder wheel, finger ladder and Codman’sexercises. These are often the standard exercises in treatingPA of the shoulder. Active exercises allow more patient controlthan do mechanical exercises. Active exercises are essential inmaintaining the capsular extensibility obtained throughmanipulation. Active exercises help in maintaining joint and softtissue integrity, enhance synovial movement for cartilage nutritionand diffusion of materials in the joint to maintain mechanicalelasticity of muscle19.

Unfortunately, these do not address the loss of joint play.Murray19 outlines disadvantages of these exercises as there isno stabilization of the scapula to avoid excessive abduction andupward rotation, there is no force to depress the humeral head,and there is a tendency for the patient to extend the spine toincrease glenohumeral motion.

PNF exercises allow more patient control and hence whenthe patient does the movement through the pattern he applies astretch at the end of the range. This helps to effectively stretchthe rotational ranges as it is this rotation that is present at theend of range (terminal rotation).

In the experimental group where PNF was given, there wasa significant improvement in the range of motion of externalrotation as reflected in the scores of CSFS. This may be due tothe combinational movements that are present in PNF patterns.The stretch present at the end of range stretches the antagonistmuscle and activates the agonist muscle. This will in turn activatethe antagonist muscle for a greater contraction and hencegreater movement. The capsule may also get stretched duringthese combined patterns and thus allow more movementobserved in the significant increase in the external rotation20.

The overall functional activity of the involved shoulder alsoshowed improvement in both groups on the SST and CSFS.However more patients in the experimental group demonstratedgreater improvements. We postulate that the greaterimprovement in shoulder function may be attributed to theimprovement of range of external rotation found to be significantin the experimental group. An analysis of the patterns ofmovements that assume great importance in the execution ofADLs demonstrate the significance of the external rotationalcomponent. The proportion of patients that was able to performthe ‘hand behind head’ movement on the SST in the experimentalgroup was double the number in the control group, therebyillustrating the significance of external rotation during abductionof the shoulder in the outer range.

Improvements were also observed in all functional activitiesby participants in both groups of patients with PA shoulder. Morepatients receiving PNF were classified as ‘excellent’ accordingto Neer’s criteria on the Constant Shoulder Function Score aftertreatment. It is postulated that the improvement in their functional

activities was as a direct result of the improvement of the externalrotation range of motion.

This study concludes that PNF may be as efficacious asconventional free exercises when included in the routinetreatment of Chronic PA of the shoulder, where external rotationROM and shoulder function are implicated.

References

1. Hazleman BL. The painful stiff shoulder. RheumatologyPhys Med 1972; 11:413.

2. Neviaser JS. Adhesive Capsulitis of the shoulder study ofpathological findings in periarthritis of shoulder. J Bone JointSurg 1945; 27:211.

3. Cyriax J. Textbook of Orthopaedic Medicine. 7th Edition,Vol. 1, London: Bailliere Tindall; 1978.

4. Brotzman B, Wilk K. Clinical Orthopaedic Rehabilitation.2nd Edition, Mosby; 2003, p.227-231.

5. Joshi J, Kotwal P. Essentials of Orthopaedics and AppliedPhysiotherapy. Churchill Livingstone; 1999, p.473-477.

6. Knott M, Voss D. Proprioceptive Neuromuscular Facilitation,Patterns and Techniques. 2nd Edition, Harper and Low;1968.

7. Lieberman J, Cafarelli E. Physiology of range of motion inhuman joints: A critical review. Crit Rev Phys Rehab Med1994; 6: 131-160.

8. Donatelli A. Physical Therapy of the Shoulder. 3rd Edition,Churchill Livingstone; 1997.

9. Dobkin HB. Neurologic Rehabilitation, ContemporaryNeurology Series. Vol. 47, F.A.Davis Company; 1996, p. 64.

10. Lippitt SB, Harryman II DT, Matsen III FA: A Practical Toolfor Evaluating Function: The Simple Shoulder Test. InMatsen III FA, Fu FH, Hawkins RJ (eds). The Shoulder: ABalance of Mobility and Stability. Rosemont, IL, TheAmerican Academy of Orthopaedic Surgeons; 1993 p.545–559.

11. Hsieh KH, Lee PY, Lee TS, Yang DJ. FunctionalAssessment for Shoulder Impingement Syndrome afterAnterior Acromioplasty. Chin Med J (Taipei) 1997; 59:354-8.

12. Norkin C, White J. Measurement of Joint Motion: A Guideto Goniometry. 2nd Edition, Jaypee; 1995.

13. Kisner C, Colby LA. Therapeutic Exercise, Foundations andTechniques. 3rd Edition, Jaypee Brothers; 1995.

14. O’Kane JW, Jackins S, Sidles JA, Smith KL, Matsen FA.Simple Home Program for Frozen Shoulder to improvepatient’s assessment of Shoulder Function and HealthStatus. J Am Board Fam Pract 1999; 12:270-277.

15. Macnab I. Rotator Cuff tendonitis. Ann R Coll Surg Eng1973; 53:271.

16. Codman EA. The Shoulder. Krieger, Malabar, FL; 1934.17. Quin CE. Humeroscapular Periarthritis, Observation on the

effects of X-Ray therapy and ultrasonic therapy in cases of“frozen shoulder”. Ann Phys Med 1967; 10:64.

18. Frank C, Akeson WH, Woo SL, Amiel D, Coutts RD.Physiology and therapeutic value of passive joint motion.Clin Orthop 1984; 185:113.

19. Murray W. The Chronic Frozen Shoulder. Physical Therapy1960; Rev 40:866.

20. Mao CY, Jaw WC, Cheng HC. Frozen Shoulder: Correlationbetween the response to physical therapy and follow upshoulder arthrography. Arch Phys Med Rehabil 1997;78:857-59.


68

Intervention Based on Dynamics of Postural Control in Childrenwith Cerebral Palsy- An integral approachMeenakshi Batra1, Vijai Prakash Sharma2, Gyanendra Kumar Malik3, Vijay Batra4, Girdhar Gopal Agarwal5

1PhD Scholar, 2Director Professor & Head, Department of PMR, RALC, 3Director Professor & Head Department of Paediatrics,4Senior Research Fellow, Chhatrapati Shahuji Maharaj Medical University, Department of Physical Medicine and Rehabilitation,Rehabilitation and Artificial Limb Centre (RALC), Nabiullah Road, Near Daliganj Bridge, Lucknow- 226018, Uttar Pradesh, India,5Department of Statistics, Lucknow university, Lucknow-226007

Abstract

Objective

To see the effectiveness of Intervention based on dynamicsof postural control as key element over Conventional approachin children with cerebral palsy

Method

A total of 38 subjects coming to OPD, Dept of PhysicalMedicine and Rehabilitation with a diagnosis of cerebral palsywere included and baseline evaluation was done for Posturalreaction score sheet, and Gross Motor Functional Abilities (usingGMFM-66 and GMFCS). The subjects were allocated equallyamong group A and group B by simple random samplingscheme. In group A, intervention based on Dynamics of posturalcontrol and in group B, conventional treatment were used for aperiod of 12 weeks followed by re-evaluation.

Result

The two groups were compared for their scores. Thesewere found to be statistically significant with p value <.0001.

Conclusions

It can be concluded that Intervention incorporatingdynamics of postural control is more effective than conventionalapproach for development / modification of postural reaction inchildren with Cerebral Palsy.

Key Words

Cerebral Palsy; Postural reaction; Postural control;Dynamics of postural control; Gross motor functional abilities.

Introduction

Cerebral palsy describes a group of developmentaldisorders of movement and posture [S. Ashwal et al, 2004;Sankar Chitra and Mundkur Nandini, 2005], dominated bymuscle weakness, poor selective motor control, abnormal motorsequences and synergies [Mayston J Margaret, 2001] causingactivity restrictions or disability that is attributed to disturbances

Address for correspondence:Meenakshi BatraPhD Scholar, Chhatrapati Shahuji Maharaj Medical University(Erstwhile King George Medical College and University),Department of Physical Medicine and Rehabilitation,Rehabilitation and Artificial Limb Centre (RALC), Nabiullah Road,Near Daliganj Bridge, Lucknow- 226018, Uttar Pradesh, IndiaTelephone: +919868038335, +919868019077, +91-11-25280121Fax: +91-522-2611091Email: [email protected], [email protected]

occurring in the fetal or infant brain. Postural problems play acentral role in the motor dysfunction of children with cerebralpalsy (CP) thereby affecting development of motor control [EvaBrogren Carlberg and Mijna Hadders-Algra, 2005].

The beginning of motor development is found in reflexivemovement. The reflexes are integrated to allow normal motordevelopment during child maturity. When the primitive reflexesdisappear, developmental Postural reactions emerge. ThePostural reactions develop during first year of life and constitutea complex group of reactions which are important for regulationof posture, establishment and maintenance of upright position,and the orientation of the body and its parts in space.Development of postural control facilitates blending of mobilityand stability patterns and also provides an insight into the motorpotential of children with CP.

The postural reactions are markedly delayed; immature anddisorganized in children with CP, and interferes with theacquisition of postural control thereby affecting normal motordevelopment. Impaired postural control affects both qualitativeand quantitative aspects of motor control resulting in poorfunctional performance and delayed acquisition of motormilestones. So development of postural reactions should be thekey element for postural control, which is critical for efficientand effective performance of all goal directed activities.

Currently available techniques do not specifically targetpostural reactions as key elements for development of posturalcontrol in children with cerebral palsy.

So the study was done with an aim to incorporatecomponents based on dynamics of postural control and see itseffectiveness over conventional approach for the development/modification of postural reactions in children with cerebral palsy.The research question was whether the Interventionincorporating dynamics of postural control as elementary unit ismore effective than conventional approach in children withcerebral palsy.

Many studies have been done on postural reactions (PR)and it was found that the spastic cerebral palsy childrendemonstrate significantly abnormal response in comparison tonormal children and postural reactions can be a usefulquantitative and qualitative diagnostic screening tool for high-risk infants [Zafeiriou DI et al 1998]. The importance of inter-sensory interactions had also been emphasized and it was foundthat the multi-segmental structure of the body, allowing localcontrol of inter-segmental joints, uses one global referencesystem. The need for future research under considerations ofinter-sensory interaction and dynamic control mechanisms hadbeen emphasized [Mergner

References and further reading may be available for thisarticle. To view references and further reading you must purchasethis article.Thomas et al 1998].

To summarize, the use of an integrated approach byincorporating components of dynamics of postural control askey element for the development of postural control should betargeted.

Method

A total of 38 participants with a diagnosis of cerebral palsyin the age range 2 - 7 years with Intelligent Quotient of 50 andabove coming to the department of Physical Medicine and

Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

69

rehabilitation were included. The children with dystonicpresentation, contractures and deformities and sensoryimpairment were excluded.

The ethical clearance and approval was granted byinstitutional human ethical research committee of ChhatrapatiShahuji Maharaj Medical University. The informed consent formwas signed by parents (/ guardians) then baseline evaluationwas done for gross motor functional ability status [using GrossMotor Function Measure-66 (GMFM-66) and Gross MotorFunction Classification System (GMFCS)] and Postural responseat varying intensities on static and dynamic support surface(using Postural response score sheet). Postural responseevaluation included Righting reaction, Protective extension andEquilibrium reaction. Righting reaction and Protective extensionwere assessed by giving manual stimulus in the form of suddenpush to the child; while Equilibrium reaction was assessed onvestibular board at slow and fast perturbations in lying and sittingposition using forward-backward and lateral translation ofsupport surface and scoring was done accordingly [Insert Table1 key to score for Postural response here].

Simple random sampling method was used to divide thesubjects into two groups. With group A, intervention based onDynamics of postural control and with Group B, conventionaltreatment were used. It was a single blinded study in whichtreatment allocation was concealed using sealed envelopes tominimize the bias. The intervention was given for 12 weeksfollowed by re-evaluation. The duration and frequency ofintervention was kept constant for both groups that is 3 sessionper week of 40 minutes duration each.

Treatment Protocol

Intervention based on Dynamics of postural controlThe intervention based on Dynamics of postural control

was specially formulated (/designed) based on the principles ofpostural dynamics with an aim to elicit adaptive posturalresponse.

The intervention was divided into two phases.Phase 1 has two components (Preparatory and

Variability)Preparatory component aimed at normalizing tonal

characteristics, increasing passive and active mobility of bodystructure and promoting symmetry and alignment via facilitatory,and inhibitory techniques, and positioning.

While Variability component aimed at eliciting static anddynamic postural responses, and promoting postural stabilityand task related performances by altering spatial and temporalcharacteristics of support surface configuration, using: Neuro-facilitatory orientation of bodily segments (with reference totrunk); and Limb maneuvers to augment central stability, andfacilitate / reinforce normal motor behavior, thereby IncreasingPostural awareness and control.

Phase 2 (Modulation Phase) aimed at modulation ofpostural behaviors by altering interaction dynamics andperturbation characteristics (at varying degrees, angles andintensities) thereby influencing Anticipatory Postural Adjustment(APA) and Reactive Postural Adjustment (RPA) responses. Thisphase incorporates principles of interaction dynamics foroptimizing modulation of dynamic postural behavior using NeuroFacilitatory contact points, Vestibular, Proprioceptive andkinesthetic input (as key element in training motor control),Recruiting trunk musculature (by Co activation and Reflexinhibition), and Facilitating righting & equilibrium reactions (usinggraded intensities in different planes of movement using supportsurfaces) to give variety of exposure to learn movementexperiences temporally and spatially for the development /modification of postural control.

So the intervention based on Dynamics of postural controlalters the order or control parameters, by varying: interaction

dynamics, internal reference of correction, Interlimb and intralimbcoordination, stimulus characteristics (internal and external), andrecruitment order with respect to support surface perturbationin stable & semi stable pattern.

Conventional Treatment

The Conventional treatment incorporated Positioning,Handling at Therapeutic key points, Using Inhibitory andFacilitatory techniques (such as using developmental positions,stretching exercise etc.), and incorporating Weight shifting andweight bearing in developmental position.

Results


Between Group ComparisonThe two groups were compared with each other for their

difference of scores (pre-intervention and post-intervention) forPostural response at varying intensities on static and dynamicsupport surface (on Postural response score sheet), and grossmotor functional abilities using nonparametric Mann Whitney Utest. Nonparametric test was used because sample size wassmall, distributions were skewed and scoring was done on ordinalscale. For each variable, Median and Inter-quartile range wascalculated. Most of these scores were statistically significantwith p value < .0001 [Insert Table 2 Comparison between twogroups i.e. Group A and Group B (Pre and post-intervention)here]

Within Group ComparisonSubjects within each group were compared on the pre-

intervention and post-intervention scores of Postural responsescore sheet and gross motor functional abilities using Wilcoxonsign rank test to see the effectiveness of intervention.

Although both Intervention based on Dynamics of posturalcontrol and Conventional approach were found to be effectivein children with cerebral palsy, but subjects in Group A showedbetter results than Group B in terms of Equilibrium reactionresponses in lying and sitting positions on lateral and Forwardbackward tilt at Fast perturbation, and GMFM score [Insert Table3: Comparison within Group A (Pre and post-intervention) andTable 4 Comparison within Group B (Pre and post-intervention)]

Discussion

The group with whom intervention incorporatingcomponents of dynamics of postural control as key element wasused showed better results in terms of postural control (i.e.Postural response at varying intensities on static and dynamicsupport surface on Postural response score sheet), and grossmotor functional abilities.

The postural control undergoes the stages of posturalontogenesis [Mijna Hadders- Algra 2005]. It requires theintegration and interaction of sensory, motor, and neurologicalinputs. [Insert Figure 1 about Stages of Postural Ontogenesishere]

Postural development starts with a repertoire of directionspecific adjustments and suggests that basic level of controlhas an innate origin [Jolanda C et al 2005]. Automatic posturalresponses to surface translations are triggered bysomatosensory information. Automatic postural responses tosurface translations are not reflexively driven by simple feedbackcontrol mechanisms, but rather the muscle that is functionallyrelevant to the appropriate corrective response is activated first.Muscles are recruited synergistically in response to externalperturbations, but the muscle synergies can be altered in aflexible task dependent manner to accommodate for changes


70

Table 2: Comparison between two groups (Group A and Group B)(Pre and post-intervention)

Variable Difference of Scores Z P Value

Group A Group BMedian I Q range Median I Q

rangePostural Response score sheet

Righting Reaction 16.0 2.0 2.0 0.0 -5.071 <.0001

Protective Extension 12.0 2.0 2.0 2.0 -5.203 <.0001

Equilibrium Reaction

Lying

Lateral Tilt

Slow Perturbation 4.0 1.0 2.0 1.0 -4.426 <.0001

Fast Perturbation 2.0 2.0 0.0 1.0 -3.799 <.0001

Forward Backward Tilt



Sitting

Lateral Tilt






GMFM -1.0 0.0 0.0 0.0 -5.129 <.0001

GMFCS 44.9 8.7 7.0 5.4 -4.556 <.0001I Q range = Inter-quartile range

Table 1: key to score for Postural responsePostural response Scoring Criteria

1. Righting reaction 0 = Not Testable2. Protective extension 1 = Absent

2 = Partial Inappropriate and delayed3 = Spontaneous but Inappropriate4 = Spontaneous but partially appropriate5 = Appropriate / Normal Response

3. Equilibrium reaction 0 = Not Testable1 = No Response2 = Reflexive response (Child cannot initiate the response)3 = Delayed Response (child can only Initiate but cannot maintain the C.O.G.4 = Spontaneous inappropriate response (child lowers the C.O.G. and shows abnormal

body posturing5 = Spontaneous inappropriate response (child tries to maintain C.O.G. in upright position

with support6 = Spontaneous inappropriate response (child tries to maintain C.O.G. in upright position

with extra efforts7 = Spontaneous appropriate response but need extra effort to maintain C.O.G.8 = Normal Response


71


Before AfterMedian I Q range Median I Q





Lying

Lateral Tilt






Sitting

Lateral Tilt






GMFM 4.0 1.0 3.0 1.0 -4.123 <.0001

GMFCS 25.7 4.7 68.4 9.6 -3.824 <.0001

Table 3: Comparison within Group A (Pre and post-intervention)

I Q range = Inter-quartile range

in biomechanical constraints of the musculoskeletal system /task. Automatic Postural muscle responses to surfacetranslations are not hard – wired, fixed synergies, but can bealtered by prior experience, intent, initial alignment, and surfaceconfigurations [Winter David A. et al 1990; Xu, Dali; Carlton,Les G. and Rosengren, Karl S. 2004].

Children with cerebral palsy demonstrate poor posturalcontrol, inability to maintain postural alignment, inability toperform rapid weight shifts and respond to external perturbations.It had been observed that the basic organization of responsesin children with spastic cerebral palsy remains intact but theirmodulation is deficient, and demonstrate abnormalities of thebasic organization of postural adjustments. This modulation canbe achieved in various ways by changing the order in whichagonist muscles are recruited, by modifying the size of musclecontraction or by altering degree of antagonist activation. Hencethe children with cerebral palsy get benefited from the therapyincorporating dynamics of postural control approach aselementary unit.

The dynamic components of the treatment approach usedin group A induced automatic postural adjustment responses atvarious stimulus intensities, and support surface configurationthereby producing necessary variability in motor behavior. To

generate behaviour, the brain transforms sensory informationinto signals that are appropriate to control movement.

The sensory information plays a role in shaping muscleactivation patterns to postural perturbations by varying velocity,amplitude, or duration of the perturbing stimulus. The spatialand temporal organization of automatic postural responses getsorganized independently of response intensity. Within a particularspatial-temporal pattern, the amount of muscle activationappears to be adjusted by sensory information, which specifiesvelocity and amplitude of the perturbation.

Spatial tuning patterns of the automatic postural responseare elicited by support surface translations in multiple directions.Muscle synergies therefore reflect a neural control strategy atthe level of functional variables specific to the particular motortask at hand [Torres-Oviedo Gelsy, Macpherson Jane M andTing Lena H. 2006; Ting Lena H., and McKay J. Lucas 2008].The conditions under which postural responses were elicited,was modified in two ways: altering the configuration of the limbsduring support surface translations and changing theperturbation characteristics. These task specific manipulationshelped in inducing variability in the automatic postural responses[Fay B Horak 2006].

The various types of postural perturbations evoked widely


72

differing sensory input signals in muscle spindles, Golgi tendonorgans, and vestibular organs [Nashner 1976; Ting Lena H. andMacpherson Jane M. 2004]. Postural control requires thecoordination of multiple muscles to achieve both endpoint forceproduction and postural stability. Multiple muscle activationpatterns generated produced the required force by preferentiallyactivating muscles with feed forward stabilizing properties. Sucha strategy helped in increasing intrinsic postural stability.

Conclusion

It can be concluded that Intervention incorporating dynamicsof postural control is more effective than conventional approachfor development / modification of postural reaction in childrenwith Cerebral Palsy.

Declaration of Interest

The authors report no conflicts of interest.

References

1. Badke Beth Mary, Duncan W Pamela (1987). Influence of


Before AfterMedian I Q range Median I Q





Lying

Lateral Tilt






Sitting

Lateral Tilt






GMFM 4.0 1.0 3.0 1.0 -1.000 <.317

GMFCS 26.1 5.5 34.2 4.8 -3.824 <.0001

I Q range = Inter-quartile range

Table 4: Comparison within Group B (Pre and post-intervention)

prior knowledge on automatic and voluntary posturaladjustments in healthy and hemiplegics subjects ;Physiotherapy: 67 (10) 1495 – 1500

2. Brogren Eva, Forssberg Hans, Mijna Hadders – Algra(2001). Influence of two different sitting positions on posturaladjustments in children with spastic diplegia, 43: 534 – 546.

3. Carlberg Eva Brogren and Mijna Hadders-Algra (2005).Postural Dysfunction in Children with Cerebral Palsy: SomeImplications Therapeutic Guidance, Neural Plasticity: 12(2-3): 221-228.

4. Dimitrios I Zafeiriou (2004). primitive reflexes and posturalreactions in the Neurodevelopmental examination, Journalof Pediatric Neurology, 31 (1): 1-8

5. Fay B. Horak (2006). Mechanistic and Physiological aspectsPostural orientation and equilibrium: what do we need toknow about neural control of balance to prevent falls, Ageand Ageing 2006; 35-S2: ii7–ii11.

6. Forssberg Hans, Nashner M Lewis (1982). Ontogeneticdevelopment of postural control in man: Adaptation toaltered support and visual conditions during stance, TheJournal of Neuroscience, 2 (5): 545 – 552.

7. Jolanda C., Heide Vander and Hadders-Algra Mijna (2005).Postural Muscle Dyscoordination in Children with Cerebral


73

Palsy, Neural Plasticity, 12 (2-3):197-203.8. Mandich M, Simons CJ, Ritchie S, Schmidt D, Mullett M

(1994). Motor development, infantile reactions and posturalresponses of preterm, at-risk infants, Dev Med Child Neurol.36 (5):397-405.

9. Mayston J Margaret (2001). People with C.P.: Effect of andPerspective for therapy, Neural Plasticity, 8 (1-2): 51:69.

10. Mijna Hadders – Algra, Eva Brogren (1991). PeriventricularLeucomalacia and preterm birth have different detrimentaleffects on postural adjustments, Brain, 122: 727 – 740.

11. Mijna Hadders – Algra (2005). Development of posturalcontrol during the first 18 months of life, Neural Plasticity,12(2) – 3; 99:108.

12. Ohlweiler Lygia (2002). Parachute and Lateral proppingreactions in preterm children, Arq Neuropsiquiatr: 60 (4) :964 – 966.

13. Otten (2005). Multiple dynamics and the development ofmotor control, Neural Plasticity, 12 (2-3): 89 – 98.

14. Palma Gunsolus, Carol Welsh (1975). Equilibriumreactions in the feet of children with spastic cerebral palsyand of normal children, Developmental Medicine and ChildNeurology, 17: 580 – 591.

15. S. Ashwal., Russman B. S., Blasco P.A., Miller G., SandlerA. Shevell M. et al (2004). Practice parameter: Diagnosticassessment of the child with Cerebral Palsy. Neurology(American Academy of Neurology), 62(3): 851-863.

16. Sankar Chitra and Mundkur Nandini (2005). CerebralPalsy definition, Classification, etiology and earlydiagnosis; Indian Journal of Pediatrics, 72 (10): 865-868.

17. Ting Lena H. and Macpherson Jane M. (2004). Ratio ofShear to Load Ground-Reaction Force May Underlie the

Directional Tuning of the Automatic Postural Response toRotation and Translation, J Neurophysiol 92: 808–823.

18. Ting Lena H. and Macpherson Jane M. (2005). A LimitedSet of Muscle Synergies for Force Control during aPostural Task, J Neurophysiol 93: 609–613.

19. Ting Lena H., McKay J. Lucas (2008). Functional musclesynergies constrain force production during postural tasks,Journal of Biomechanics, 41:299–306.

20. Torres-Oviedo Gelsy, Macpherson Jane M and Ting LenaH.(2006). Muscle Synergy Organization Is Robust Acrossa Variety of Postural Perturbations, J Neurophysiol, 96:1530–1546.

21. Umphred A Darcy (2007); Neurological Rehabilitation: 5th

Edition, Mosby Elsvier22. Washington Kathleen, Cook Shumway Ann (2004). Muscle

responses to seated perturbations for typically developinginfants and those at risk for motor delays, DevelopmentalMedicine and Child Neurology, 46: 681 – 688.

23. Weerdesteyn Vivian, Laing Andrew C. and RobinovitchStephen N. (2008). Automated postural responses aremodified in a functional manner by instruction, Exp BrainRes 186:571-580.

24. Winter David A. , Patla Aftab E. and Frank James S.(1990). Assessment of balance control in Humans, Medicalprogress Through Technology, 16: 31-51.

25. Xu, Dali; Carlton, Les G. and Rosengren, Karl S. (2004).Anticipatory Postural Adjustments for Altering DirectionDuring Walking, Journal of Motor Behavior, 36(3): Sept:316 – 326.


Fig. 1: Stages of Postural Ontogenesis

74

An Evaluation of Exercise Tolerance in COPD Patients Using SixMinute Walk Test- A prospective studyT S Muthu Kumar1, T Mohan Kumar 2

1Sr Lecturer, Lovely Professional University Punjab, 2Head Institute of Pulmonary Medicine Sri Ramakrishna Hospital Coimbatore

Abstract

Background

Functional exercise tolerance in patients with chronicobstructive pulmonary disease patients (COPD) is oftenassessed by the 6 minute walking test. Impairment of exercisetolerance is an important feature of COPD. Physicaldeconditioning and impaired lung function are main causes ofdecreased exercise tolerance. This study explored the evaluationof exercise tolerance in COPD patients using simple six minutewalk test.

Design

A prospective 4 week quasi experimental study design.

Setting

Institute of Pulmonary medicine and research, SriRamakrishna Hospital Coimbatore India

Patients

10 patients of moderate and severe cases of COPD wereincluded in the study.

Interventions

Patients who were admitted in Pulmonology general wardbecause of acute exacerbations and well responded to medicaltreatment were screened for Borg Scale Rate of Perceivedexertion and Six minute walk test on 3rd day of hospital stay andthe post test measurements were taken at 7th day. The statisticalanalysis was done using paired t test at the level of significanceá= 0.05

Results

We compared the Borg scale of perceived exertion and sixminute walk test on 3rd day of hospital stay and at 7th day. Theresult showed significant improvement in terms of reducedexertional dyspnea and increased six minute walk distance.

Conclusion

In the light of assessing exercise tolerance in COPDpatients, it has been concluded that six minute walk test was auseful tool in evaluating exercise tolerance in COPD patientssince it was easy to perform and very cost effective.

Key Words

COPD, Borg Scale, Six minute Walk test

Background

Functional exercise tolerance in patients with chronic

obstructive pulmonary disease (COPD) is often assessed bythe 6 min walking test (6MWT)1.Impairment of exercise tolerancein COPD patients has important implications on health relatedquality of life, hospitalization rate and survival2.The impairedexercise tolerance may be due to peripheral muscle dysfunctioncharacterized by atrophic muscle and reduced fatigueresistance.3.As much as 70% of COPD patients may be affectedby impaired exercise tolerance.3

Impaired exercise tolerance may lead to energy cost whiledoing activities of daily living in COPD patients.4This may affectpsychological well being and would increase sicknessabsenteeism in their work places. Recommendations on exercisetesting in lung function laboratory settings are well established,and the role of incremental cardiopulmonary cycling exerciseas the gold standard for evaluation of exercise tolerance isacknowledged.5How ever a wide spread clinical use of simpleexercise protocols are effective because of their simplicity,applicability and low cost.6-8Moreover timed walking tests havebeen shown to predict survival9 and utilization of health careresources10 in COPD. Based on this hypothesis we conductedthis study to evaluate the exercise tolerance in COPD patientsusing six minute walking test (6MWT).Therefore, it is suggestedthat simple exercise tests may be useful for staging of the disease.11

The six minute walk test (6MWT) has been widely usedand accepted as a simple, cost-effective means of clinicallyassessing the functional status of COPD patients. The 6MWThas proven reliable in providing reproducible data to serve asmeasures of pre and post treatment comparisons12-17 in theassessment of functional status 18-20 and in predicting morbidityand mortality for various disease states.21-23 Distance testing wasfirst advocated by Balke 24 in 1983 by means of assessingphysical fitness. McGavin 25used a 12 min walk test to assessdisability in patients with COPD. Subsequent work determinedthe effectiveness and reliability of shorter- distance walk testingand eventually the 6MWT became the most widely acceptedprotocol. The 6MWT is a sub maximal, self paced test used toevaluate the exercise tolerance in COPD patients in this study.


This study in accordance with the research design as statedby C.R.Kothari 26 was prospective 4 weeks quasi experimentalstudy design in which convenient sampling method was used.25patients admitted in Pulmonology General Ward at SriRamakrishna Hospital Coimbatore India were selected for thestudy, informed consent was obtained and 10 moderate andsevere patients who were medically stable met with an Inclusioncriterion as follows FEV1/FVC< 0.70,50%d” FEV1< 80%predicted for moderate and FEV1/FVC < 0.70, 30% d” FEV1 <50 % predicted for severe, pre bronchodilator to post responseof > 20%, baseline dyspnea grade 2 using MRC, good leftventricular ejection fraction and age group of 40 – 70 years ofboth male and female, ex smoker and stable vital signs.

The exclusion criterion were acute exacerbation notresponding to medical treatment, intermittent claudication,associated cardiac failure, osteoarthritis, Musculoskeletal pain,syncope and dyspnea at rest.

Baseline evaluation for Borg Scale of Rate of perceivedexertion and 6MWT was taken at 3rd day of hospital stay since

Kavitha Vishal / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

75

they received conventional chest physiotherapy techniques suchas repatterning techniques, breathing exercises, strategies toreduce increased respiratory rate and relaxation techniques. Thesix minute walk test was carried out according to AmericanThoracic Society guidelines27 2002.The safety issues forconducting 6MWT as mentioned in American Thoracic Societyguidelines was adopted. The patients were asked to takebronchodilator therapy28, 29 before 2 hours of walking. Pre andpost test measurements were assessed using paired t test atp=0.05 and analysis was done using SPSS 17.

Measurements

Conventional chest physiotherapy was given to patientsexactly two hours before the start of 6MWT to gain relaxationand to reduce respiratory rate and to gain confidence of thepatients.The conventional chest physiotherapy was given twicedaily for seven days After the patients underwent chestphysiotherapy, vital signs were checked including Bloodpressure, heart rate, respiratory rate, temperature and saturationof percentage of oxygen using Pulse oxymetry. The rate ofperceived exertion was assessed using Borg Scale (20 pointscale) before the commencement of 6MWT to assess exertionaldyspnea. Six minute walk test was conducted after briefexplanation to the patients. They were instructed to walk in a100 m corridor where Emergency Department was accessedeasily to avoid any adverse effects. However a trolley consistingof Defibrillator, emergency medications including atropine andmobile oxygen therapy unit was kept in the corridor for safetyissues. The rest periods were included in the study as perAmerican Thoracic Society Guidelines 27 and the distance wasmeasured in meters. Base line six minute walk distances wasmeasured during 3rd day of hospital stay and post testmeasurements were taken at 7th day of hospital stay. The stopwatch was used to record the time travelled by the patients andmechanical lap counter was used.

Results

The Six minute walk distance in meters showed goodimprovement in terms of increased walking distance when wecompared pre and post test readings as mean distance was243±277 and standard deviation was 141.3±143.1 and the tvalue 10.854 was more than the critical value at p=0.05 level ofsignificance. This ensured that six minute walk test was a goodindicator for measuring exercise tolerance in COPD patients.

The Borg Scale of perceived exertion also showedmoderate improvement as compared to Six minute walk distancein meters since its mean value was 11.4±13.6 and standarddeviation was 4.59±4.42 and the t value 11 was more than thecritical value at p = 0.05.

Discussion

Reduced exercise tolerance is generally accepted as anunavoidable complication of advanced COPD; the presence ofdifferent degrees of physical limitation in patients withcomparable lung function impairment, however suggests amultifactorial origin for this phenomenon. Although air waysobstruction has classically been considered the most importantof these pathogenetic factors, studies aimed at comparing lungfunction impairment and exercise tolerance in COPD failed toestablish a clear correlation between the two parameters 28,

29probably difference in age groups or gender ratio and also thedifferences in study population.

In this study, 9 male patients and 1 female patient wereparticipated since males were more affected than females inIndia due to their personal habits of smoking and other socio-economic history. Jindal S.K. et al. reported the prevalence ofCOPD 30in males and females in India and they concluded that

the disease is distinctly more common in males. The male tofemale ratio had varied from 1.32:1 to 2.6:1 in different studieswith a median ratio of 1.6:1.In our study the total number ofpatients in age group of 41-50, 51-60, 61-70 were 1, 3, 6respectively and it is shown in figure 1 and the gender ratio isshown in figure 2.

Killian J et al (1992)31 et al. postulated that lower limb fatigueis another factor contributing to exercise intolerance; this isparticularly in deconditioned elderly patients due to a variabledegree of muscle atrophy leading to a significant reduction inmuscle strength and endurance. Initially the patients wereuneasiness towards six minute walk test because they thoughtthat it would exaggerate the symptoms probably the fatigue andafter careful explanation they realized that it would benefitpsychological well being and other positive benefits. The selfpaced 6MWT didn’t cause any exertional dyspnea while walkingbut after the test 75% of the patients experienced dyspnea andlight dizziness due to work load imposed on respiratory musclesespecially the age group of 51-60 and 61-70.This might notaltered any results but psychologically it caused sometroublesome to the patients.

The use of the 6MWT as a single measurement of theexercise tolerance for COPD patients was widely accepted asstated by Redelmeier et al.32In their study, they conducted 6MWT in 119 patients (mean age=67) and concluded that 6MWTwas significantly correlated with patients’ ratings of their walkingability relative to other patients (r = 0.59, 95% confidence interval[CI] 0.54 to 0.63). They suggested that differences in functionalstatus can be statistically significant but below the threshold atwhich patients notice a difference in themselves relative toothers; an awareness of the smallest difference in walkingdistance that is noticeable to patients may help clinicians interpretthe effectiveness of symptomatic treatments for COPD.

In this study, the mean age was 57.6 and the improvementsin walking distance was quite significant and the mean distancewas 243±277 and standard deviation was 141.3±143.1and graphwas shown in figure 3 and figure 4 respectively. The


Fig. 1: Demograhic Data

Fig. 2: Gender Ratio

76

determination of what constitutes a significant clinical changeas a result of an intervention has been debated with generallywell-accepted parameters for patients with COPD. The minimalimportant clinical difference in patients with COPD is reportedto be approximately 55 m for cohorts,33 and 86 m for individuals.34

Our participants also showed significant differences in walkingdistance as compared to pre and post test measurements andthe values were statistically significant at p=0.05.

The pre and post test measurements of 6MW distance isshown in figure 5. Out of 10 patients, only 3 patients got less

improvement in terms of walking distance since they werebelonging to age group of 61-70 and probably the age might bethe limiting factor as postulated by Killian30 and his colleague intheir research studies. There always a debate exists ofrelationship between exertional dyspnea and 6MWT.Since thespeculation arises in every mind that submaximal exercise testssuch as 6MWT also causes exertional dyspnea. In our study,we used Borg Scale Rate of Perceived exertion to evaluateexertional dyspnea.

Sue C.Jenkins 35 stated that dyspnea during activities ofdaily living is frequently reported by patients with COPD andcan result in inactivity and the associated problems ofdeconditioning and muscle weakness. As far as we wereconcerned there was only one article measured daily physicalactivity in COPD patients (n=50) and compared the findings todata obtained in age and gender matched healthy controls(n=25).36, 37Compared to the healthy controls, COPD patientsspent significantly less time standing and walking during dailyactivities (P<0.001, for both).

The mean score of Borg Scale was 11.4±13.6 and standarddeviation was 4.59±4.42. Based on the mean value of Borg Scalewe would state that patients were at the score of 11 whichindicated fairly light and 13 indicated somewhat hard withreference to 15 point Borg Scale.38 One of the potential reasonsfor exertional dyspnea is hyperinflation of the lungs with airtrapping in the alveoli and leads to an increased residual volumeand as a consequence increases breathlessness on exertion.As a result of hyperinflation of the lungs, the natural dome of

the diaphragm gets flattened. This requires more effort tobreathe, which places a burden on the accessory muscles duringrespiration. Consequently any activity such as walking, bendingto tie shoelaces or shopping will worsen the breathlessness.39

The pre and post test measurements of Borg Scale isshown in Figure 6. The reliability and reproducibility of Borg Scalehad been investigated by many researchers. Wilson RC, JonesPW40 stated that Borg Scale provides a reliable technique forstudying the sensation of breathlessness in short and extendedperiods of time. O’ Donell DE41 et al. evaluated the intratester

and inters tester reliability of Borg Scale and concluded that itwas good indicator of measuring exertional dyspnea. Thoughnumerous studies supported the reliability of the Borg Scale, itssubjective nature would alter test results and this could be oneof the limitations in this study.

The possible mechanism that how our patients gotimprovement in walking distances using 6MWT would be thegreater muscle mass especially quadriceps involved in walkingthat increase muscular O2 extraction thereby inducing asubstantial decrease in venous pressure of O2 42and alsoimproved overall oxidative capacity of the individuals sinceCOPD patients are more dependent on anerobic metabolismrather than aerobic metabolism during walking and otherexercises.43Clinical recommendations for exercise training inCOPD patients include a component of sub maximal intensity,at 60% peak exercise capacity, lower limb endurance trainingwith the aim of eliciting some physiological training effects.44 Toachieve this, 6MWT was used in this study.

According to Frank I.Katch and Victor L. Katch, 45 severalweeks of walking training at sub maximal intensity reduces theventilator equivalent for oxygen (VE/VO2) and lowers thepercentage of the total exercise oxygen cost attributable tobreathing. They also added that reduced oxygen consumption


Fig. 3: Mean Distance

Fig. 4: Standard deviation of 6MWT distance

Fig. 5: 6MWT Distance in meters

Fig. 6: Borg Scale Pre and Post Test

by the ventilator musculature enhances exercise endurance fortwo reasons :1 it reduces the fatiguing effects of exercise on theventilator musculature and 2 any oxygen freed from use by therespiratory musculature becomes available to the activelocomotor muscles. This would support our hypothesis that

77

6MWT improves endurance and evaluates exercise tolerancein COPD patients. Since we didn’t measure VO2 Max to estimatethe Oxygen Capacity, this might be our one of the limitations inour study.

The reliability and validity of the 6MWT was well establishedin number of studies. In one study, the validity of the 6MWT isdemonstrated by the moderate to good relationship (re”0.5)between 6MWD and peak oxygen consumption (VO2 peak)measured during a laboratory-based incremental exercise testto peak work capacity in patients with COPD.46-49 The relationshiptends to be strongest (r> 0.7) in patients with more severefunctional limitation because a self paced walking test in theseindividuals more closely represents maximal exerciseperformance.46,50.Absence of the control group in our study isconsidered to be one of the study weaknesses, as there are nopublished data in normal predicted distance of 6MWT in Indianpopulation.

Conclusion

Based on the available resources and our researchexperience in conducting 6MWT, the best rationale for use ofthe 6MWT lies in the practicality and simplicity of the test itself.The 6MWT is a cost effective procedure that may be performedin nearly any clinical location without the need for either directphysician involvement or invasive, and often expensive,monitoring equipment. As a self-paced and sub maximal exerciseprocedure employing the familiar activity of walking, the 6MWTis well tolerated by patients over a wide span of fitness levelsand debility. The 6MWT in comparison to other functional walkingtests is felt to offer advantages that include established standardsfor testing, reference values, and correlation with the capacityto perform activities of daily living.17 In summary 6MWT is areliable, and valid method for evaluating exercise tolerance andalso improving exercise tolerance for COPD patients owing toits simple method.

Ethical Approval

The ethical committee of Sri Ramakrishna HospitalCoimbatore India had approved this thesis. There are no ethicalissues.

Funding

We have not received any funding from any organization


There is no conflict of Interest.

References

1. Henk F,van Stel, Jan M.Boggard, Lous H. Multivariableassessment of the 6-min walking test in patients with COPD.Am J Repir Crit Care Med 2001; 163:1567-1571.

2. Donner CF,Muir JF.Selection criteria and programmes forpulmonary rehabilitation in COPD patients.Rehabilitationand Chronic Care Scientific Group of the EuropeanRespiratory Society.Eur Respir J 1997;10:744-757.

3. Milo A Puhan,Gilbert Busching, Evelien Van Oort,ChristianZaugg, Holger J Schunemann and Martin Frey.Intervalexercise versus continuous exercise in patients withmoderate to severe COPD- study protocol for a randomizedcontrolled trial. BMC Pulmonary Medicine 2004; 4:1471-2466/4/5.

4. Michael I.Polkey Muscle Metabolism and ExerciseTolerance in COPD Chest 2002; 121:131S-135S.

5. Pauwels RA,Buist AS,Calverly PM,et al.Global Strategy forthe diagnosis, management and prevention of

COPD.NHLBI/WHO Global Initiative for Chronic ObstructiveLung Disease (GOLD) Workshop Summary.Am J RespirCrit Care Med 2003;167:211-277.

6. ATS statement: guidelines for the sixminute walk test. AmJ Respir Crit Care Med 2002; 166:111-117.

7. Solway S, Brooks D,Lacasse Y,et al.A qualitative systematicoverview of the measurement properties of the functionalwalk tests used in the cardio respiratory domain. Chest2001; 119:256-270.

8. Ambrosino N. Filed tests in pulmonary disease.Thorax1999; 54:191-193.

9. Gerardi DA,Lovett L, Benoit-Connors ML, et al.Variablesrelated to increased mortality following out-patientpulmonary rehabilitation. Eur Respir J 1996;9:431-435

10. Garcia-Aymerich J, Farrero E,Felez Ma,et al. Risk factorsof readmission to hospital for a COPD exacerbation:aprospective study.Thorax 2003;58:100-105.

11. Celi BR,Cote CG,Marin JM, et al.Combining6MWD,FEV1,MRC dyspnea and BMI is Better predictor ofmortality than FEV1.Am J Respir Crit Care Med2001;163(suppl):A504.

12. Holden DA, Rice TW, StelmachK, et al.Exercise Testing,6-min walk, and stair climb in the evaluation of patients athigh risk for pulmonary resection. Chest 1992; 102:1774-1779.

13. Kadkar A,Maurer J,KestenS.The six-minute walk test: aguide to assessment for lung transplantation. J Heart LungTransplant 1997; 16:313-319.

14. Paggiaro PL, Dahle R, Bakran I,et al. Multicentrerandomized placebo-controlled trial of inhaled fluticasoneproportionate in patients with COPD. Lancet 1998; 351:773-780.

15. Sciurba FC,Rogers RM, Keenan RJ,et al. Improvement inpulmonary function and elastic recoil after lung reductionsurgery for diffuse emphysema. N Engl J Med 1996;334:1095-1099.

16. Sinclair DJ,Ingram CG.Controlled trial of supervisedexercise training in chronic bronchitis. Br.Med J 1980;280:519-521.

17. Brown CD,Wise RA.Field tests of exercise in COPD:thesix-minute walk test and the shuttle walk test. COPD 2007;4:217-223.

18. Enright PL, McBurnie MA, Bittner V, et al. The 6-min walktest: a quick measure of functional status in elderly adults.Chest 2003; 123:387-398.

19. Hajiro T, Nishimura K, Tsukino M, et al. Comparison ofdiscriminative properties among disease-specificquestionnaires for measuring health-related quality of lifein patients with chronic obstructive pulmonary disease. AmJ Respir Crit Care Med 1998; 157:785-790.

20. Zugck C, Kruger C, Durr S, et al. Is the 6-minute walk testa reliable substitute for peak oxygen uptake in patients withdilated cardiomyopathy? Eur Heart J 2000; 21:540-549.

21. Bittner V, Weiner DH, Yusuf S, et al. Prediction of mortalityand morbidity with a 6-minute walk test in patients with leftventricular dysfunction. JAMA 1993; 270:1702-1707.

22. Cahalin LP, Mathier MA, Semigran MJ, et al. The six-minutewalk test predicts peak oxygen uptake and survival inpatients with advanced heart failure. Chest 1996; 110:325-332.

23. Casanova C, Cote C, Marin JM, et al. Distance and oxygendesaturation during the 6-min walk test as predictors oflong-term mortality in patients with COPD. Chest 2008;134:746-752

24. Balke B. A simple field test for the assessment of physical fitness:rep 63-6. Rep Civ Aeromed Res Inst US 1963; 53:1-8

25. McGavin CR, Gupta SP, McHardy GJ. Twelve-minutewalking test for assessing disability in chronic bronchitis.Br Med J 1976; 1:822-823.

26. Kothari CR. Research Methodology New Delhi: New Age


78

International Publishers,2008.27. ATS Statement: Guidelines for the Six-Minute Walk Test.

Am J Respir Crit Care Med 2002; 166: 111-117.28. Hay JG, Stone P, Carter J, Church S, Eyre-Brook A, et

al.Bronchodilator reversibility, exercise performance andbreathlessness in stable COPD. Eur Respir J 1992; 5: 659-664.

29. Grove A, Lipworth BJ, Reid P, et al. Effects of regularsalmeterol on lung function and exercise capacity in patientswith COPD Thorax 1996; 51: 689-693.

30. Jindal SK,Aggarwal AN, Gupta DA. A review of populationstudies from India to estimate national burden of COPDand its association with smoking. Indian J Chest Dis AlliedSci. 2001; 43: 139-147.

31. Killian KJ,Leblanc P, Martin H, et al. Exercise capacity andventilatory, circulatory, and symptom limitation in patientswith chronic airflow limitation. Am Rev Respir Dis 1992;146:935-940.

32. Redelmeier DA, Bayoumi AM, Goldstein RS, et al.Interpreting small differences in functional status: the sixminute walk test in chronic lung disease patients. Am JRespir Crit Care Med 1997; 155:1278-1282.

33. Lacasse Y, Wong E, Guyatt GH, et al. Meta-analysis ofrespiratory rehabilitation in chronic obstructive pulmonarydisease. Lancet 1996; 348:1115-1119.

34. Wise RA, Brown CD. Minimal clinically important differencesin the six-minute walk test and the incremental shuttlewalking test. COPD 2005; 2:125-129.

35. Jenkins C. Sue. 6 Minute walk test in patients with COPD:clinical applications in pulmonary rehabilitation.Physiotherapy 2007;93: 175-182.

36. Pitta F, Troosters T, Spruit MA, Probst VS, DecramerM,Goselink R. Characteristics of physical activities in dailylife in COPD. Am J Respir Crit Care Med 2005;171:972-7.

37. Pitta F Troosters T, Spruit MA, Decramer M, Goselink R.Activity monitoring for assessment of physical activities indaily life in COPD patients. Arch Phys Med Rehabil 2005;86: 1979-85.

38. Borg G. Psychophysical bases of perceived exertion. MedSci Sports Exerc 1982; 14:377-81.

39. Barnet Margaret COPD in Primary Care.NewYork; JohnWiley and Sons Ltd: 2006.

40. Wilson RC,Jones PW.Long Term Reproducibility of BorgScale estimates of breathlessness during exercise. ClinSci(London) 1998;80(4): 309-12.

41. O’Donnell, Denis et al. Measurement of Symptoms,LungHyperinflation,and endurance during exercise in COPD AmJ Respir Crit Care Med 1998; 158:1557-1565.

42. Jones NL.Clinical exercise testing. Philadelphia; PA: WBSaunders, 1988.

43. Levison H, Cherniack RM. Ventilatory cost of exercise inchronic obstructive airways disease. J Appl Physiol 1968;25:21-7.

44. Punzal PA, Ries AL,Kaplan RM, Prewitt LM. Maximumintensity exercise training in patients with COPD. Chest1991; 100:618-23.

45. Katch Frank I, Katch Victor L, McArdle William D. ExercisePhysiology.Philadelphia; Lippincott Williams & Wilkins:2007.

46. Cahalin L, Pappagianopoulos P, Prevost S,Wain J, GinnsL.The relationship of the 6-min walk test to maximal oxygenconsumption in transplant candidates with end stage lungdisease. Chest 1995; 108: 452-9.

47. Chuang M-L, Lin I-F, Wasserman K. The body weight-walking distance product as related to lung function,anerobic threshold and peak VO2 in COPD patients. RespirMed 2001; 95:618-26.

48. Carter R, Holiday DB,Nwasurba C, Stocks J,Grothues C,Tiep B. 6-minute walk work for assessment of functionalcapacity in patients with COPD. Chest 2003; 123:1408-15.

49. Turner SE, Eastwood PR,Cecins NM, et al. Physiologicresponses to incremental and self paced exercise in COPD.A comparison of three tests. Chest 2004; 126:766-73.

50. Patel SA, Sciurba FC, Emerging concepts in outcomeassessment for COPD clinical trials. Semin Respir Crit CareMed 2005; 26:253-62.


79

Pattern of Orthopaedicians Referral for Physiotherapy in a TertiaryCare Hospital: A preliminary reportKavitha Vishal*, Narasimman Swaminathan**, Benjamin Varghese*, Sudeep MJ Pais**Lecturer in Musculoskeletal and Sports Physiotherapy, **Associate Professor and Head, Department of Physiotherapy FatherMuller Medical College, Mangalore - 575002

Abstract

Background

Orthopaedic surgeons are considered to be the primarysource of referral for physiotherapy services. It is believed thatthe referring physician should have adequate knowledgeregarding physiotherapy. Physiotherapy is a dynamic professionin the present era and is marching towards autonomy. In thecurrent scenario clinical decision making regarding therapyshould not be dictated by other health care professionals.

In this context, the present study was designed to assessthe reference pattern by orthopaedic surgeons in a tertiary carehospital. As per our knowledge this is the first study in the Indiansetup designed to explore this important issue.

Method

In this Descriptive Study, The referral forms of the patientsreferred to the outpatient department of physiotherapy, FatherMuller Medical College, Mangalore from January to March 2009were retrospectively analyzed for the following criteria: Numberof cases referred for physiotherapy, Pattern of referral, diagnosisof the referring surgeon, and the Surgeon’s preference of themodality of treatment.

Results

This report analyzed 184 referral forms, with variousmusculoskeletal disorders. There were marked differencesbetween the orthopaedic surgeons in prescribing physicalmodalities. Reference for technical procedures was much morethan professional modes of therapy.

Conclusion

This preliminary report emphasizes that the therapistsshould involve themselves in inter-professional discussion inorder to improve knowledge of physical therapy proceduresamong referring surgeons.

Key Words

Pattern of Referral, Autonomy, Physiotherapy.

Introduction

Physiotherapy is a health care profession that providesservices to enhance, facilitate, maintain and restore maximummovement and function throughout the lifespan of an individual.This includes providing treatment in situations where normalmovement patterns and function are threatened by aging, injury,disease or environmental factors.1 This encompasses thephysical, psychological, emotional, and social aspects of healthand wellbeing. It involves the interaction between the physicaltherapist (PT), patients/clients, other health professionals,families, care-givers, and the community in a process wheremovement potential is assessed and goals are agreed upon,

using knowledge and skills unique to physical therapists.1

Health care services all over the globe depend on aninterdisciplinary approach to provide the best and cost-effectivetreatment for its clients. In an interdisciplinary approach,members of the team work in a coordinated manner to bring outthe best for their clients. Members of the team may vary and willdepend on the patient’s needs and the condition or disease beingtreated. In a multidisciplinary team every member has the rightto assess, set goals and provide prognosis for the case. Thisrequires good communication between health care professionalsand adequate information about each other’s skills and services.Referring a client for physiotherapy services will directly influencethe quality of care as well as the cost of the care2.

Physiotherapy is a dynamic profession constantly strivingtowards autonomy. Physical therapy has many specialtiesincluding cardiopulmonary, geriatric, neurologic, orthopaedic,paediatric, industrial and women’s health. Physiotherapy has avital role in the management of musculoskeletal impairment andhas been accepted throughout the world. Therapists working inwith clients with musculoskeletal problems are involved inphysical diagnosis through sound clinical reasoning underpinnedwith a veritable knowledge base.

Orthopaedic surgeons and general practitioners form theprincipal source of referral for physiotherapy. Appropriatereferrals to physiotherapy can only be made if the referringsurgeon has adequate knowledge about what physiotherapycan offer these patients. Lack of knowledge may in turn lead todelay or inappropriate referrals3.4. Ehrmann-Feldman D andcolleagues concluded in their cohort study that judiciousreference to physical therapy will reduce the cost improve thequality of health care5. Through a web based survey Archer KRet al found that the reference pattern of orthopedic surgeonsmostly depended upon their expectations about physical andmotor outcomes6.

To our knowledge, there have been no efforts made tofind out the pattern of referral for physiotherapy in the Indianscenario, and this is important in the wake of autonomy of thisprofession. This preliminary report will strengthen the body ofknowledge regarding the referral pattern.

Methodology

Study Design: Retrospective Qualitative

Setting: the study was conducted in the department ofphysiotherapy, Father Muller Medical College, Mangalore, India.It is a teaching hospital with a 1050 bedded multispecialtyhospital. The physiotherapy department is well established andruns both bachelors and masters programmes in physiotherapy.It is closely associated with the entire department including full-fledged orthopaedic department. Data was obtained from theoutpatient records.

The records of the patients referred to the department ofphysiotherapy from January to March 2009 were retrieved andanalysed. Two independent therapists retrieved the followinginformation from the outpatient records in a predesignedproforma: Number of cases referred for physiotherapy, Patternof referral, Diagnosis of the condition, Surgeon’s preference ofthe modality of treatment. The retrieved data was analyzed using


80

descriptive statistics.

Results

We retrieved data of patients referred to the department ofphysiotherapy from January to March 2009. There were a totalof 556 patients that were referred to the department during thisperiod. The Figure below shows the average cases that werereceived over these months.

The most preferred modality was definitely electrical

The table below shows the age distribution of the patientsreferred for physiotherapy service

Female patients were marginally higher in number than themale patients referred.

Most of the referrals received were pertaining to the low backand neck while the hip was least referred for physiotherapy.The shoulder was another area for which physiotherapy wasoften sought.

Periarthritis of shoulder was the condition that was mostcommonly referred for physiotherapy, followed by tendinitis. Mostof the cases were referred under the diagnosis of shoulder pain.

A vast majority of the hand cases referred were for stiffness ofthe hand following trauma. Wrist pain was the second mostcommon diagnosis referred.

The Maximum number of knee joint cases referred was ofosteoarthritis knee. Ligament injury constituted a very smallproportion of the cases that were referred. Sprains and strainsof the knee joint were also among the referred cases.


Fig. 1: Number of cases referred for physiotherapy

Table 1: average age of the patients referred

Age (Yrs) Number Percentage(%)

10-19 11 3

20-29 48 14

30-39 59 17

40-49 76 23

50-59 77 23

60-69 44 13

70-80 10 7

Fig. 2: Gender distribution of the patients

Fig. 3: Areas referred for physiotherapy

Fig. 4: Conditions of the shoulder that was referred forphysiotherapy.

Fig. 5: Conditions of the wrist/hand that were referred forphysiotherapy.

81

Tennis elbow was unmistakably the most common elbowcondition that was referred for therapy

Spinal conditions (cervical and lumbar regions) were referredthe most for physiotherapy, spondylosis being the most commonamong them. Nonspecific low back pain and lumbosacral strainwere the other common lumbar spine conditions referred.Similarly, in the cervical spine, non specific neck pain was thesecond most referred condition.

therapies in the form of IFT and TENS. Ultrasound and SWDwere equally preferred followed by traction and wax. Exercisewas also one of the prescribed methods of treatment.

Discussion

This study aimed to find out the referral patterns to thephysiotherapy department of a tertiary level hospital. It wasobserved that majority of the patients referred for musculoskeletalphysiotherapy typically fell into the older age group. This maybe due to the prevalence of degenerative disorders in this groupas well as the tendency to move towards more conservativetherapies in this age group. Our findings are in line with otherstudies.

Female patients were more than male patients in this studyindicating that musculoskeletal complaints are more commonlyseen in the female gender. Our results are in contrast to thoseof Ahmad RY et al1.

Conditions of the spine were common when compared toperipheral conditions. Among the peripheral joints, the knee jointwas the most referred followed by the shoulder. The hip wasleast referred. The population under study essentially fell intothe sedentary category in which the occurrence of lumbar andcervical pain is much more than the athletic population.Moreover the efficacy of physiotherapy in these conditions iswell documented which may have led to an increase in thereferrals when it came to therapy in these areas. In the kneejoint osteoarthritis invited the highest number of referralsindicating again the effectiveness of physiotherapy as well asthe surgeons’ knowledge of alternative modes of treatment.

Few of the patients did not fall into specific diagnostic groupsand were referred as non specific regional pain conditions. Itwas therefore the responsibility of the physiotherapist to makea detailed evaluation as to what was the impairment of the patientand deliver beneficial treatment for the same.

Surgeons primarily preferred electrotherapy modalities overexercises for most of the patients in this study. But what isinteresting to note is that there were references made forexercises too. This shows that there has been a shift towardsprofessional expertise rather than technical modes of treatment.A study done by Robin Moremen7 reported references mainlyfor technical modes of treatment. There has been a definitechange in the attitude and recognition for manual modes oftreatment. There is a reference for specialised forms of treatmentwhich only the therapist can deliver.


Fig. 6: Conditions of the knee referred for physiotherapy

Fig. 7: Conditions of the elbow that was referred forphysiotherapy

Fig.8: Conditions of the back and neck referred forphysiotherapy

Fig. 9: Conditions of the back referred for physiotherapy

Fig. 10: Orthopaedic surgeons’ preference of therapeuticmodality

82

Conclusion

This preliminary report emphasizes that the therapistsshould involve themselves in inter-professional discussion inorder to improve knowledge of physical therapy proceduresamong referring surgeons. The pattern of referral should beaudited regularly to improve the professional autonomy.

References

1. Ahmad R Y, Hanif S M, Kodzo P, Chroma IM, Lamina S.Pattern of referral to physiotherapy department ,AminoKano teaching hospital Kano. Journal of Medicine andRehabilitation 2007;1(1):25-27

2. Michelle CB Physician Referral to Physical Therapy in aCohort of Workers Compensated for Low Back Pain.(Invited commentary) 1996; 76(2): 157

3. Stanton PE, Fox FK, Frangos KM, et al. Assessment ofresident physicians’ knowledge of physical therapy. PhysThe 1985; 65:27-30.

4. Ritchey FJ, Pinkston D, Goldbaum JE, Heerten ME.Perceptual correlates of physician referral to physical

therapists: implications for role expansion. Sor Sci Med.1989; 28:69-80.

5. Ehrmann-Feldman D, Rossignol M, Abenhaim LA, GobielleD. Physician referral to physical therapy in a cohort ofworkers compensated for low back pain. Phys Ther.1996;76: 150-157.

6. Archer KR, MacKenzie EJ, Bosse MJ, et al. Factorsassociated with surgeon referral for physical therapy inpatients with traumatic lower-extremity injury: results of anational survey of orthopedic trauma surgeons. Phys Ther.2009; 89:893–905.

7. Robin Moremen Uili, Katerine F. Shepard, and Emil Savinar.Physician Knowledge and Utilization of Physical TherapyProcedures. 1984;64(10):1523-1530

Acknowledgement

The authors express their sincere thanks to themanagement and orthopaedic surgeons of Father Muller MedicalCollege Hospital, Mangalore and Ms Shalet Montero,Department secretary for her valuable contribution in collectingthe data.


83

Short Term Effect of Body Positions on Dynamic Lung Compliancein Mechanically Ventilated Patients with Lung Pathology- Arandomised cross over studySwagata De*, Narasimman Swaminathan***Postgraduate student, **Associate Professor & Head, Department of Physiotherapy, Father Muller Medical College, Mangalore,Karnataka, India

Abstract

Background

Mechanical ventilators are used to prevent hypoxemiacaused due to inadequate ventilation. It can also lead to retentionof secretions and alveolar collapse due to improper ventilationof the dependent lung. Positioning has direct effect on optimizingthe respiratory mechanics and improving the ventilation. Thisstudy was conducted to determine the effect of various bodypositions on dynamic compliance in such patients.

Study Design

Randomized cross over study.

Method

Total 19 subjects with various lung pathologies onmechanical ventilator, fulfilling the inclusion criteria wereincluded. Each patient was positioned in the randomizedsequence of four positions (supine, right lateral, left lateral anderect). Each position was maintained for 45 minutes. Dynamiccompliance was measured at the interval of every 15 minutesby the formula dynamic compliance= delivered tidal volume/(peak inspiratory pressure-PEEP). Hemodynamic parameters,respiratory rate, SpO2 were monitored in each position.

Results

The highest values of the dynamic compliance in supine,right lateral, left lateral and erect position were 31.88 ml/cmH2O after 45 minutes, 28.33ml/cmH2O after 15 minutes, 25.22ml/cmH2O at the beginning and 29.67 ml/cmH2O after 45 minutesrespectively. There was no significant difference in the dynamiccompliance (p=0.229), heart rate, respiratory rate, SpO2 in thefour positions.

Conclusion

There was no significant difference in the dynamiccompliance among all the positions. The results of the studycannot be generalized because of the small size. This providedthe insight into the effect of body position.

Key Words

Dynamic Compliance, Body Positioning, ChestPhysiotherapy.

Address for correspondence:Narasimman SwaminathanAssociate Professor & HeadDepartment of PhysiotherapyFather Muller Medical College,[email protected]

Introduction

Patients with acute respiratory failure and pulmonarypathology, who experience excessive effort of breathing,inadequate alveolar ventilation and severe hypoxemia requireventilator support, intensive care monitoring and therapy. Themain aim of mechanical ventilation is to reduce the work ofbreathing and to improve alveolar ventilation and arterialoxygenation 1, 2. Chest physiotherapy has been recognized tohave a considerable role in the intensive care to preventcomplications associated with mechanical ventilation.Traditionally, chest physiotherapy has focused on removal ofretained secretion and improvement of lung ventilation. Butcomparatively less attention has been given to optimizing lungfunction and matching of alveolar ventilation with capillary bloodflow (ventilation perfusion) as a treatment priority 3.

Positioning is one of the effective interventions used by thephysiotherapists. The concept of positioning which is governedprimarily by the influence of gravity was based on the principlesof the West lung model 4. Thus, the principles of body positioninghas direct effect on optimizing the respiratory mechanics andthereby enhancing gas exchange, oxygenation and ventilationperfusion matching in mechanically ventilated patients in ICU5,6

In the upright position, the top of the pleural space isrelatively more negative. Pleural pressure is more positive inthe dependent basilar lung regions because of the downwardacting weight of the lung. The lung is easier to inflate at lowvolumes than at high volumes, where it is stiffer. Since theexpanding pressure at the base of the lung is small and has asmall resting volume. Thus, it expands well on inspiration. Theapex of the lung has a large expanding pressure, a big restingvolume, small change in volume in ventilation. The base of thelung has larger change in volume and smaller resting volumethan the apex. Thus, its ventilation is greater. Therefore, thebase of the lung is poorly expanded but better ventilated. Thedifferent regional lung compliance is responsible for thedependent alveoli being relatively compliant and non dependentalveoli being relatively noncompliant. Thus, most of the tidalvolume is preferentially distributed to dependent alveoli becausethey expand more per unit pressure change than nondependentalveoli do. Thus erect sitting may increase the lung compliance4

Static and dynamic compliance are the two importantparameters measured. The modern ventilators are able todisplay basic ventilatory variables such as tidal volume, airwaypressure and flow (analog) waveform and digital (numeric) outputwhich make it possible to monitor respiratory mechanics at thebedside7, 8. In critically ill mechanically ventilated patients, therespiratory system compliance can be routinely monitored atthe bedside by the use of ventilator waveforms. This study wasdone to investigate the short term effect of body positioning onlung compliance. Such work may help to identify the role ofjudicious positioning in therapeutic exercise regimen.

Methodology

This Randomized cross over study was performed on 19patients admitted in Medical intensive care unit at Father MullerMedical College Hospital with lung pathology, requiring ventilatorsupport and fulfilling the inclusion criteria. Subjects with bilateralor unilateral lung pathology on chest radiograph, Intubated and

Swagata De / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

84

mechanically ventilated, On SIMV mode (pressure controlled),and hemodynamically stable were included in this study.Subjects with the contraindications to lateral or upright position,unstable spinal fractures, chest wall deformities, pneumothorax,pulmonary edema, pleural effusion and neurological disorderswere excluded.

Procedure

Subjects connected with mechanical ventilator, with lungpathology were selected on the basis of the inclusion andexclusion criteria by purposive sampling. Ethical approval forthe study was obtained from the institutional ethics committee.Prior to the study demographic data, present history, past historyand hemoglobin levels were obtained from the patients’ chart.Vitals blood pressure, pulse rate respiratory rate and temperaturewere recorded from the monitor. Mode of ventilator support, settidal volume, respiratory rate, FiO2 and SpO2 were recorded fromthe pulseoximeter. Ventilator parameters like delivered tidalvolume, peak pressure(Ppeak),plateau pressure(Pplat) ,meanpressure(Pmean), positive end expiratory pressure(PEEP),minuteventilation were recorded at the beginning in supine position.

Patients were positioned according to the sequence fourpreplanned random positions as given in the randomised order

table obtained from www.randomization.com. Each position wasmaintained for 45 minutes,during which hemodynamicparameters, respiratory rate, SpO2 were monitored.

Measurement

Dynamic lung compliance was measured by using theformula Vte/Ppeak- PEEP at intervals of every 15 minutes. Thepatients’ positions were secured by using pillows which wereplaced at the back of the patient. At the end of 45 minutes,patients were turned to the subsequent position. Hemodynamicparameters like blood pressure, pulse rate, respiratory rate wererecorded. Ventilator parameters like delivered tidal volume, peakpressure (Ppeak), plateau pressure (Pplat) , mean pressure(Pmean),positive end expiratory pressure(PEEP),minute ventilation wererecorded. After every 15 minutes hemodynamic parameters,respiratory rate, SpO2 and compliance were recorded. After 45minutes the position was changed to the next. Same parameterswere recorded at the base line. At the interval of every 15 minuteshemodynamic parameters, respiratory rate, SpO2 andcompliance were measured. Any therapeutic maneuvers suchas tracheal suctioning were done within first few minutes.Ventilator settings were not changed.

Statistical analysis

The dynamic compliance of the four positions wascompared by the two way ANOVA for the repeated measures.To evaluate the pair wise difference among different time pointin four different positions were done by multiple comparisonsby Bonferroni’s test. The heart rate, respiratory rate and SpO2 ofthe four positions and in different orders were compared by theone way ANOVA. Multiple comparisons were done byBonferroni’s test. The data analysis was done by using SPSSversion 13.

Results

A total of 19 subjects were included in the study with themean age of 60.00. Dynamic compliance (ml/cm H2O), heartrate (beats per minute), respiratory rate (breaths per minute)and SpO2 (%age) were evaluated in different positions in 12females and 7 males at the interval of 15 minutes.

Discussion

The mean age of the subjects who were included in the


Fig. 1: Patient positioned in supine position. Fig.2: Patient positioned in right lateral position

Fig. 3: Patient position left lateral position Fig. 4: Patient positioned in erect position

85Swagata De / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Fig. 5: Comparison of dynamic compliance in supine positionat the interval of 15 minutes

Fig. 6: Comparison of dynamic compliance in right lateral positionat the interval of 15 minutes

86

study was 60. All the patients selected for this study had differentlung pathologies that are commonly encountered in our intensivecare unit but without any pleural involvement. The dynamiccompliance was calculated by using the formula mentionedearlier in the study. The main reason for performing this studywas to find out the effect of positioning on dynamic compliancein elderly patients on mechanical ventilator with lung pathologiessince it is known that the lung compliance reduces with age.Age related muscle weakness and presence of lung pathologymay result in decreased lung compliance.

The respiratory system undergoes a significant change withaging. It was found that the age-related loss of the lung staticrecoil forces, stiffening of the chest wall and diminished alveolarsurface area lead to a decrease in vital capacity, an increase inresidual volume, decrease in expiratory flows and increasedventilation-perfusion heterogeneity. Respiratory muscle strengthconsistently declines with age further increasing the work ofbreathing. Thus a patient on mechanical ventilator due todecreased respiratory muscle strength may have altered lungmechanics 10. In any pulmonary manifestation, the lungmechanics are altered. 11

Positioning has direct effect on the respiratory compliance.Positioning may help in improving the dynamic compliance.Thus, when an individual is connected to ventilator, it ismandatory to monitor the respiratory mechanics to decide whichposition is effective in improving the lung compliance andoxygenation status of the patient. It helps in understanding whichposition is appropriate in optimizing the lung compliance, thevariation of the compliance with time and the duration for whicheach position should be maintained.

Dynamic compliance was one of the outcomes used in thisstudy. Previous studies have analysed the effect of position onstatic compliance which reflects only the pulmonary parenchymalcompliance. Dynamic compliance takes into account the airwaypressure during inflation, which is influenced by volume, thoracic(lung and chest wall) compliance and the thoracic resistance toflow during inflation 12.

It was a repeated measure study in which the sameparticipants were positioned in all the four positions and theoutcome was measured. In this study the effect of independentvariables that is the different positions are seen within participantsin a single group rather than between groups. Here theparticipants act as their own control and received all the positions.To prevent the introduction of extraneous variables like the effectof one position over the other, randomization of the positionswere done.

The finding of this study was that the dynamic compliancewas more in the supine position after 45 minutes. However theincrease in the lung compliance in the erect position and in thesupine position did not show significant difference. In both thepositions the dynamic compliance achieved the highest valueafter 45 minutes. In the erect position, the increase in the dynamiccompliance may be due to the effect of gravity on diaphragmwhich pulls the pleura downwards creating a more negative intrapleural pressure causing the base of the lung to expand moreat lower pressure thereby increasing the compliance of the baseof the lung. Moreover the erect position increases the verticallength of the chest cavity. The diaphragm being in a mechanicallyadvantageous position allows better excursion.

In this study, most of the patients were placed on waterbed. While assessing the compliance in erect position on waterbed, the posture was slumped rather than upright since whilelifting the head end of the bed up the water inside the bed usedto shift towards the leg. Hence maintaining sitting posture wasdifficult. Since complete erect position could not be achieved inpatients on water bed, this may have compromised the increasein dynamic compliance. In slumped sitting, the thoracic kyphosisincreases which will reduce the chest wall compliance. Slightneck flexion in this posture may restrict the airflow, which mayincrease the airway pressure.13,14 This in turn may increase the


Fig. 7: Comparison of dynamic compliance in left lateral positionat the Interval of 15 minutes

Fig. 8: Comparison of dynamic compliance in erect position atthe interval of 15 minutes

Fig. 9: Comparison of dynamic compliance among the differentpositions

No significant difference was found in heart rate (p=0.946),respiratory rate(p=0.607) and SpO2(p=0.961) in differentpositions. On comparing the effect of one position with the otherposition on the heart rate, respiratory rate and SpO2 was notsignificant (p=1.00)

Table 1: SpO2 (%) in different positions after 45 minutes

Positions Mean± S.D

Supine 97.79±3.066

Right lateral 97.42±2.457

Left lateral 97.84±2.455

Erect 97.58±2.775

87

peak inspiratory pressure thereby reducing the dynamiccompliance.

The dynamic compliance in lateral positions decreased overa period of time. The dynamic compliance reduction may beattributed to the compression of the lung tissues by the heart 15.The inferior part of the diaphragm is pushed upwards by theabdominal viscera 16. This mechanical disadvantage makes thealveoli less distensible and offers a greater resistance to airflow17. Decrease in tidal volume and increase in the peak inspiratorypressure. Studies have shown that greater compliance ofrespiratory system in lateral position because the weight of themediastinum and displacement of abdominal contents contributeto gradient of vertical pleural pressure,18,19,20

In this study, dynamic compliance is the highest in thesupine position. Dynamic compliance decreases in supineposture in young normal people. In supine position, staticmechanics data did not appear modified by the gravitationaleffect of this posture. There is a very loose attachment of thepericardium to the sternum or diaphragm. The compression ofthe lung tissue due to weight of the heart creates a greatertranspulmonary pressure gradient. This results in change in theshape of the lung. Thus the lung tissues displace as the heartmoves rather than compressed beneath the heart 21 . This maybe the reason for high dynamic compliance in supine position.

SpO2 was the highest in the left lateral position. In thisposition the right lung which has greater surface area is thetopmost which increases the alveolar arterial oxygen difference.13

In the lateral position the intrathoracic gravitational forcesresponsible for ventral distribution of the tidal volume. Thoughthere were difference in the dynamic compliance among thefour positions but the difference was not significant to concludethat any particular position is effective in increasing the dynamiccompliance.

However Porto and coworkers in their study compared thestatic compliance in four positions that is in supine, lateraldecubitus, erect. They found that static compliance is the highestin the erect position after two hours of positioning. 22 Thusprolonged positioning would have improved the compliance inthe erect sitting. Although great care was taken while positioninga patient on water bed, upright position was difficult to maintainwhen patients were on water bed. Patients included in the studywere having different lung pathologies. PEEP and FiO2 valueswere not constant for all the patients. Measurement of staticcompliance would have improved the quality of study. But staticcompliance was not measured due to difficulty in the method.

Clinical Implication

Since positioning affects the respiratory mechanics, it isimportant for the therapists to monitor the respiratory systemcompliance. Though there are many sophisticated methods tomeasure the lung compliance, but by using this simple formula,the respiratory compliance can be easily calculated at thebedside. Estimation of the compliance will help us to decidewhich position is effective in improving the compliance.

Conclusion

By this study the effect of positioning on the dynamiccompliance, and SpO2 were evaluated. It was found that positionsaffect the dynamic compliance. But the results were notsignificant to recommend which position is effective in improvingthe compliance. Studies with a larger sample size andhomogeneous subjects may improve further knowledge in thisregard.

References

1. Kim MJ, Hwang HJ ,Song HH. A randomized trial on theeffects of body positions on lung function with acute

respiratory failure patients. International Journal of nursingstudies 2002 ; 39: 549-555

2. Sud S, Sud M, Friedrich JO, Adhikari NKJ. Effect ofmechanical ventilation in the prone position on clinicaloutcomes in patients with acute hypoxemic respiratoryfailure: a systematic review and meta-analysis. CMAJ2008;178(9):1153-1161

3. Dean E. Effect of Body Position on Pulmonary Function.Physical Therapy, 1985; 65(5):613-618

4. West J. Respiratory physiology-the essentials. 8th edition.Baltimore Maryland:Lippincott Williams and Wilkins,2008

5. Thomas PJ, Paratz JD, Lipman J, Stanton WR. Lateralpositioning of ventilated intensive care patients: A study ofoxygenation, respiratory mechanics, hemodynamics, andadverse events. Heart Lung 2007; 36(4): 277–286.

6. Bigatello LM, Davignon KR, Stelfox HT. Respiratorymechanics and ventilator waveforms in the patients withacute lung injury. Respiratory Care 2005; 50(2): 235-244.

7. Lucangelo U, Bernabe F, Blanch L. Respiratory mechanicsderived from signals in the ventilator circuit. RespiratoryCare 2005; 50(1): 55-65

8. Sprung J, Galic O, Warner D O.Review article:age relatedalterations in respiratory functions-an anaestheticconsideration. Can J Anaesth 2006;53(12):1244-57.

9. Gupta D, Aggarwal AN, Sud A, Jindal SK. Static lungmechanics in patients of progressive systemic sclerosiswithout obvious pulmonary involvement. Indian J Chest DisAllied Sci 2001;43:97-101.

10. Grinnan DC, Truwit JD. Clinical review:Respiratorymechanics in spontaneous and assisted ventilation. CriticalCare 2005; 9(5): 472-484

11. Anthonisen NR, Bartlett D, Tenney SN. Postural effect onventilator control. J App Physiology 1965; 20: 191-196

12. Narasimman S, Rajeev A, Reshma P. Commonly adoptedbody positions on pulmonary functions in normal males ofdifferent age groups Physiotherapy and Occupationaltherapy Journal 2009; 2 (4) 183 - 193.

13. Pryor JA, Prasad SA. Physiotherapy for respiratory andcardiac problems adults and pediatrics. 3rd edition. NewDelhi:Elsevier publications,2004.

14. Numa AH, Hammer J, Newth CJ. Effect of prone and supinepositions on functional residual capacity, oxygenation, andrespiratory mechanics in ventilated infants and children.Am J Respir Crit Care Med. 1997; 156(4 Pt 1):1185-9.

15. Kenyon CM, Pedley TJ, Higenbottam TW. Adaptivemodeling of the human rib cage in median sternotomy. JAppl Physiol. 1991; 70(5):2287-302.

16. Pelosi P, Bottino N, Chiumello D, Caironi P, Panigada M,Gamberoni C, et al. Sigh in supine and prone position duringacute respiratory distress syndrome. Am J Respir Crit CareMed. 2003; 167(4):521-7.

17. Blanch L, Mancebo J, Perez M, Martinez M, Mas A, BetbeseAJ, et al. Short-term effects of prone position in critically illpatients with acute respiratory distress syndrome. IntensiveCare Med. 1997; 23(10):1033-9.

18. Tawhai MH, Nash MP, Hoffman EA. Supine and pronedifferences in regional lung density in the human lung withconstant shape. J Appl Physiol 2009;107:912-920.

19. Palmon S C, Kirsch J R, Depper J A. The effect of proneposition on pulmonary mechanics is frame dependent.Anesth Analg 1998;87:1175-80.

20. Tzoufi M, Mentzelopoulos SD, Roussos C, ArmaganidisA. The effect of nebulised salbutamol, external positive end-expiratory pressure and their combination on respiratorymechanics, hemodynamic and gas exchange inmechanically ventilated chronic obstructive pulmonarydisease patients .Anesth Analg 2005;101:843-50

21. Bein T, Ploner F, Ritzka M, Pfeifer M, Schlittz H J, Graf B H.No change in the regional distribution of tidal volume duringlateral posture in mechanically ventilated patients assessed


88

by electrical impedance tomography. Imaging (2010) 30,234–240

22. Porto EF, De Castro AAM, De Oliveira J R, Miranda SV,Kumpels C. Comparative analysis of respiratory systemcompliance in three different positions (lateral, supine andsitting) of patients on long-term invasive mechanicalventilation. Rev Bras Ter Intensiva. 2008; 20(3):213-219

Acknowledgements

The Authors expresses their sincere gratitude to all theMICU Nurses of Father Muller Medical College Hospital andthe Management of Father Muller Medical College, for theirsupport.

Note: This paper was awarded first prize during NationalPhysiotherapy Conference at AIIMS.


89

Corelation Between Knee Extensor Strength and Endurance inDependent and Independent ElderlyNidhi Sharma*, Anish Raj**, Ruchika Chugh*, Sumit Kalra**Lecturer, Banarsidas Chandiwala Institute of Physiotherapy Kalkaji ,New Delhi, **Lecturer, D.A.V. College of Physiotherapy &Rehabilitation Jallandhar, Punjab

Abstract

Purpose of the study

To correlate the difference in strength and endurance ofknee extensor muscles between dependent and non dependentelderly.

Methodology

Strength in the form of maximum isometric voluntarycontraction for the quadriceps in hip & Knee 90 degree flexionin High sitting position using strain Gauge. The data collectedconsisted of subjects score on the strength and endurance ofknee extensors, by dividing the subjects into two groups’dependent and independent elderly. The score for strength wasdetermined by recording maximum voluntary isometriccontraction of right knee extensor and score for endurance wasdetermined by calculating number of sit stands in 30 seconds.

Result

The result of the study proves that there is statisticallysignificant correlation between strength and endurance of kneeextensor among dependent and independent elderly.

Keywords

Endurance, Strength, Strain Gauge.

Introduction

The age-related deterioration of physiological capacitiessuch as muscle strength and balance is associated withincreased dependence.

Ageing is associated with a deterioration of variousphysiological capacities, such as muscle strength, aerobiccapacity, neuro-motor coordination, and flexibility. These age-related declines result in a host of negative outcomes, includingfunctional limitations and therefore loss of independence.

Ageing is accompanied by both structural and functionalchanges in muscles, including loss of dynamic and isometricmuscle strength. If functionality and strength are decreased,maintaining independence in activities of daily living (ADL’s) maybe hindered, as physical function is an integral constituent ofADL’s.3 Nearly a quarter of men and women have some degreeof physical limitation, often relating to ambulation by the age of65yrs.4

Data from the National Health Interview study indicates that15% of older (65-69yrs) men and women have difficulty withself care or walking.5

Reduced endurance, strength and range of motion areperceived as the most limiting intrinsic factors affectingambulation with advancing age. Thus there is age relatedchanges in skeletal muscle function.6,7

Physiological evidence indicates that there is 30-40%decline in isometric forces and 18-20% reduction in muscle massbetween 2nd-7th decade of life.8,9,10

Muscle strength decline with advancing age,11 is best seenat the beginning of 6th decade.12

This age related strength decrease has been reported tobe faster in lower extremity than in upper body. (Asmunssenand Heeboll-neilsen,1962, Bemben et al, 1991). The proximalmuscles of lower limb have been reported to be especiallyaffected by muscle fiber atrophy during ageing. 8,5

Lexell et al, 1988 has suggested loss of type II fast twitchmotor units contributing to strength decrease besides theiratrophy in old age.13

Simmonson (1947) found leg strength declines more rapidlywith age than handgrip.

Joel reported that muscle strength of hamstring, soleus andgastrocnemius is correlated with activities of daily living.14

Denise reported that slow and fast speed of walkingimproved with increased knee extensor strength.15 Anianssonreported that quadriceps is related to walking ability in healthywomen.16

Several studies have demonstrated a positive associationbetween muscle strength of the lower extremities and mobilitytasks such as rising from a chair.

Maximal isometric strength correlated significantly withmaximal walking speed among both sexes, which accords withthe results of Fiatarone et al. They observed a statisticallysignificant correlation between dynamic quadriceps strength asmeasured by a functional test, and maximal walking speed aswell as time taken to rise from a chair among frail institutionalizedsubjects aged 86-96 years.17

Differences in isometric strength and leg extensor powerover the age range were equivalent to losses of 1-2% per annumand 31/2% per annum respectively. Studies also prove thatisometric knee extensor strength influences chair rise time. 18

Summarisingly, there is age related decline of maximumisometric force of knee extensors5 that also affects endurance.It is therefore imperative that appropriate screening methodsare developed to identify elderly who should be referred for adetailed physical therapy evaluation.

Experimental Hypothesis

There is statistically significant correlation between strengthand endurance of knee extensor among dependent andindependent elderly.

Review of Literature

The ageing process includes a slowing of time and rate ofrelaxation29 of skeletal muscle that is evident in both animals30,31.32 and humans 33,34. However, the mechanisms of age-associated slowing of muscle relaxation are not well understood.

In 60-70 yr olds, the ankle dorsiflexor, plantar flexor, andthenar muscle groups are reported to be 20-43% slower thanthose in young adults 34,35,36 whereas in men and women over80 yr old the ankle dorsiflexors 34 and the adductor pollicis 33 arereported to be 49-56% slower.

Slowing of Aged Muscle and SR Ca2+ UptakeRelaxation times and rates of the quadriceps in the elderly

women were 31% slower than that in the young women. Thesefindings are consistent with other studies that have usedelectrically evoked twitch or tetanic contractions to demonstrate

Nidhi Sharma / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

90

a slowing of relaxation in elderly human muscle 35,36,33,34

Ageing

The process of aging in humans is characterized by amultitude of changes in all bodily systems that ultimately resultin a decreased capacity to function.

Muscular Strength and Endurance

A major concern facing older adults and researchersstudying aging is the loss of skeletal muscle mass, known assarcopenia, 51 and the associated loss of voluntary strength.

Deterioration of Function with Age

Samson et. al. (2000)18 agrees with the decline infunctionality with age.. These studies indicate that functionalitydoes decline with age.

Samson et. al. (2000)18 investigated isometric knee extensorstrength, handgrip strength, and leg extensor power, and noteda progressive decline with age (for men: 42%, 34%, and 49%respectively; for women:46%, 34%, and 61% respectively). Thisis representative of the literature, Vandervoort (1992)67 agreeswith the decline in strength with age, as well as, Doherty (2001)68.

With respect to maximal oxygen consumption (VO2max), Boothet. al. (1994)69 reported that by age 65 mean VO2max decreasesto roughly 70% of that of a 25 year-old. They suggest that theVO2max decreases at a rate of approximately 0.45 ml.kg-1.min-1.yr-

Muscle strength has been reported to reach peak valuesbetween 25 and 35 yr of age, is maintained or is slightly lowerbetween 40 and 49 yr of age, and then is 12-14% decade lessafter 50yr of age.75, 76 these age-associated differences instrength are highly correlated with age differences in musclemass.77

As demonstrated by, Booth and colleagues (1994),69 muscle

area decreases tremendously with ageand can lead toimpairment.

Larsson and colleagues (1978) noted that quadricepsstrength increased up to the age of 30 years, remainedratherconstant to the age of 50 years, and then decreased withincreasing age, a decrease of 24-36% between the ages of 50and 70 years. Vandervoort and McComas (1986)34 also note areduction in force production and demonstrated that thecontraction was significantly longer for women then for men andfor the older subjects then for the younger subjects.

Samson et al. investigated the correlation between kneeextensor strength and functional mobility (the timed ‘get-up-and-go’ test, comparable to a combination of walking velocity andchair rise performance in the present study) in healthy men and

women aged 19 to 90. They found stronger correlations betweenknee extension strength and functional mobility, both in men (r= -.60) and in women (r = -.71)

Subjects

60 subjects were selected & assigned into two groups (30in each group)

A –Dependent Elderly B –Independent Elderly

Inclusion Criteria

• Both male and female, age group-60-80yrs.• Independent elderly is defined as being able to go into the

community without the need for assistive devices.4

• It is defined with respect to Barthel index. (Appendix D) iewalking 50 yards without assistance.

Exclusion Criteria

• Symptomatic osteoarthritis.80

• Inflammatory arthropathies like Gouty arthritis, Rheumatoidarthritis etc.18

• History of neurological disorders eg. Cerebrovascularaccident18

• History of any heart disease.• Body Mass Index>30kg/m2 82

• Any history of lower extremity pathology within the past 2 years.

• Presence of any disorder that can account for problem in balance such as lower limb joint replacements –TKR,THR

• Absent propioception and / or abnormal tone.• History of vestibular disorder• If experienced any unexplained fall within 6 months• Malignancies of lower extremities • Any active illness that may interfere with the study like

Tuberculosis• Diabetes with neuropathy in lower extremities.

Instruments And Tools Used

1. Fixed strain gauge.2. Comfortable quadriceps table so that it provides for

adequate stabilization and proper positioning of the subject.3. Comfortable chair of adjustable height without arm support

so that it provides for adequate stabilization and properpositioning of the subject.

4. Stop watch.5. Steel chain.6. Weighing machine.7. Stadiometer for height measurement.8. Camera (Sony Cybershot 7.2 mega pixels)

Procedure

Design

This study is a co-relational study which intends to measurethe correlation between strength and endurance of knee extensormuscle among dependent and independent elderly.

Protocol

Testing was performed only after informed consent wastaken from the subject. The subjects were assessed anddemographic data such as height and weight were measuredand noted. After this, subjects underwent strength and endurance


Fig. 1: Muscle Mass Deterioration with Age: Line of best-fitshowing howmuscle mass is decreased with age.

91

measurement using strain gauge and sit and stand test. Datawas collected on a data collection form.

Preliminary measurements, taken prior to beginning thestudy, included the measurements of body parameters usingstandardized techniques.

Total Body Weight: Subject in minimal clothing stood straighton a standardized weighing machine without looking down orcarrying any object that may falsely add to the weight.

Standing Height: The subjects stood straight with shoesoff, against an upright wall with a stadiometer, touching the wallwith the back, buttock and both heels. The head oriented in aFrankfurt plane, i.e. the lower border of the eye socket and upperborder of the ear opening should be on a horizontal line. Thesubject was asked to stretch upwards and take and hold a fullbreath. The ruler was lowered until it touched the vertex firmly.Then marking at the vertex was noted.

Basal metabolic index- it was found using the formulaweight/height*height ie kg/m2.

Methodology

For Strength Measurement

Proposed Standardization procedure for measurement ofmaximum voluntary isometric contraction (MVIC) Position18,82,83,84

• Subjects were strapped to quadriceps table in a seatedposition with 90deg of flexion at hip and knee.

• Setting was adjusted individually to ensure minimal hip andknee joint movement and to minimize vertical displacementbetween the lower back and back rest during muscular forceexertion.

• Rigid leg cuff that was adjusted on the lower legapproximately 3cm above medial malleoli was connectedto strain gauge through a stiff steel chain.

• Cuff and steel chain were adjusted such that the directionof force is perpendicular to the long axis of lower leg.

• To ensure identical cuff placement between sessions, andfurthermore, to obtain the external knee joint moment arm,the distance from the cuff to the knee joint line wasmeasured.

Defining the measurement

• The subjects were carefully instructed to contract as fastand forceful as possible.

• The highest contraction was recorded, rather than theaverage of two trials to eliminate the effect of fatigue orother errors.

Instruction to the Patient85

• Patients were instructed of the intent of the test.• Objective and consistent instructions that achieve a

consistent level of motivation was given.• Subject was asked to build force to a maximum over a 2sec

period and maintain the maximum effort for 5sec. and pushthe ankle cuff.

Environmental Factors

• Test was performed in a private and quiet room whicheliminated any factor that might affect instrumentperformance and patient cooperation.

Advantages83

• MVIC correlates well with the number of firing motor units

and thus is the most suitable measure of muscle force inclinical trials.

• Performed under controlled condition, with velocity andlength held constant, thereby enhancing reproducibility.

• It is safe as no motion is produced hence no injury.• Fatigue is not induced.

Disadvantages83

• Measures static force, a parameter not directly related tofunction.

Methodology

For Measuring Endurance86

Position

• Subject seated in a position with 90deg of flexion at hipand knee.

• Setting is adjusted individually according to height ofindividual

• Comfortable, painless, secure and safe position wasmaintained.

Defining the Measurement

• Subject was asked to sit-stand from the chair.• Number of sit-stand are counted in 30sec and recorded.

Instruction to the Patient

• Patients were instructed of the intent of the test.• Objective and consistent instructions that achieve a

consistent level of motivation was given.• Patient was instructed to stand up and sit down on the chair

without taking support of the chair.• If the patients feel uncomfortable during the test they were

allowed to stop in between.

Environmental Factors

• Test would be performed in a private and quiet room whicheliminates any factors that might affect instrumentperformance and patient cooperation.

Data Analysis

All data was collected and analyzed using SPSS 15. Thedata collected consisted of subjects score on the strength andendurance of knee extensors, by dividing the subjects into twogroups dependent and independent elderly. The score forstrength was determined by recording maximum voluntaryisometric contraction of right knee extensor and score forendurance was determined by calculating number of sit standsin 30 seconds. Data was analysed for both the groups usingindependent t test and significance was set at 95% confidencelevel.

Results

In the study 60 subjects were taken, 30 dependent and 30independent based on inclusion and exclusion criteria. Theirphysical characteristics ie age, weight and height weremeasured. BMI was calculated using the formula weight/height2 in kg/m2 People having BMI>30 kg/m2 were excluded. PhysicalCharacteristics of the Subjects were matched statistically so that


92

two groups were comparable.Since the difference between age and BMI of dependent

and independent is non significant that is P > 0.05 there fore onthe basis of these two physical characteristics the two groupsare comparable. Strength and endurance of dependent andindependent subjects was measured using their respectivemethods and compared statistically using independent t test.

Strength N Mean S.D P Value

Dependent 30 6.90 2.75 <0.001Highly

Independent 30 12.92 4026 Significant

Endurance N Mean S.D P Value

Dependent 30 4.87 2.8244 <0.001Highly

Independent 30 9.90 2.32 Significant

Comparison of muscle strength and Endurance (Sit tostand) test scores between independent and dependent groups.

This table shows a comparison of muscle strength on kneeextension and sit to stand test score as muscle endurance,between the independent and dependent group. Muscle strengthof knee extensors in the independent group was 12.92 + 4.26and that in the dependent group was 6.90 + 2.75.These resultsshows that muscle strength in the independent group wassignificantly higher than dependent group ( P < 0.001)

The sit to stand test score as muscle endurance of theindependent group was 9.90 + 2.32, while that of dependentgroup was 4.87 + 2.86 times. There was significant difference

on the test score between independent and dependent group(P < 0.001).

Discussion

Functional disability in walking leads to such undesirableconsequences as fear of falling, loss of confidence, loss ofindependence and lowered quality of life.87 This functionaldisability in terms of independent ambulation is associated with

age related deterioration of physiological capacities93 such asmuscle strength of the lower extremity and balance which alsoaffect the sit to stand performance.

Our study that shows a clear cut difference between meanstrength of dependent ( 6.90) and independent (12.92) andendurance of dependent (4.87) and independent (9.90) suggesthighly significant correlation between the two parameters whichdefines their importance in maintaining ADL function.

Thus reduced muscle strength or power and endurancemay be associated with decreased function in various ADLs.9

Similar studies have been conducted by Bassey72 whofound leg extensor power significantly related to walking speed,rising from chair, and climbing stairs. Avlund et al and Hyatt etal18 found that a reduction in muscle strength and power mightbe associated with a reduced function in various activities ofdaily living.

Similar study conducted by Samson et al found highercorrelation between muscle strength and functional mobility inwomen than men.

All such studies confirm the extreme importance ofquadriceps muscle strength for activities of daily living, includingstanding up, sitting down and stair climbing, as also done bySami.85 and hence its loss may result in loss of independence.

Muscle weakness in elderly because of ageing was alreadycausing muscle function deterioration which now after loss ofindependence acts synergistically with disuse94 and causesfurther loss of skeletal muscle function.

Hence the cause of dependence now becomes the sideeffect of dependence and leads to decrease in general activitylevels in the elderly which in turn elevates the risk of osteoporosisdue to decrease in overall loading of the skeleton.95

Therefore it is important to break this cause-effectrelationship and this can be achieved through extensive trainingprogram.

Muscle strength training has been reported for improvingADL ability. Lester89 showed that a group participating in astrength building exercise program for 12 weeks showedimproved walking ability with increased quadriceps strength andendurance. It shows how regular exercise can improveparameters such as dressing and walking performance importantfor independent living in old women.

Fiatarone90,91 provided evidence that improvements inquadriceps femoris and hip extensors muscle strength resultedin improved walking and stair climbing ability. Thus recent reportshave stressed the effect of muscle strength training formaintaining ability in ADL.

Muscle strength training is now being actively encouragedin the elderly.91,92

Future Research

Future studies may consider association betweenindependent walking and various other muscle functions likehip extensors, ankle plantar flexors. And quantitatively evaluatethe variables needed to maintain functional independence likebalance.

Focus can be on establishing minimal strength andendurance for independent walking.

Relevance to Clinical Practice

Strength and endurance of knee extensor has been provedto be important for independent walking, therefore it can be usedan objective way defining dependence and important criteriafor selecting the walking aid. It serves as an important quotientto make a dependent elderly independent.

Conclusion

The result of the study proves that there is statistically


93

significant correlation between strength and endurance of kneeextensor among dependent and independent elderly.

Limitations of Study

The study has following limitations:• Small sample size.• Only knee extensor strength is measured.• Lack of computerized and technically accurate instruments.• Use of mechanical spring type strain gauge.• Pretest physical condition of the subject was not considered.

References

1. US Census,20002. Spirduso WW. Physical Dimensions of Aging. Human

Kinetics Champaign, IL: Human Kinetics 1995.3. Cress ME, Buchner DM, Questad KA, Esselman PC,

deLateur BJ, and Schwartz RS. Continuous-Scale PhysicalFunctional Performance in Healthy Older Adults: AValidation Study. Archives of Physical Medical Rehabilitation1996; 77: 1243-1250.

4. Brown, Marybeth, Kern, Fran, Barr, John How Do WeLook? Functional Aging within the Physical TherapyCommunity. Journal of Geriatric Physical Therapy 2003

5. Glenn N Williams, Michael J Higgins and Michael D Lewek,Aging Skeletal Muscle: Physiologic Changes and the Effectsof Training Physical Therapy Vol. 82, No. 1, January 2002,pp. 62-68

6. WJ and Roubenoff R, Ageing of skeletal muscle: a 12yrlongitudinal study. Journal of Applied Physiology 88:1321-26,2006.

7. Sadashiv, Deepak Kumar Lower extremity muscle strengthand balance performance in Indian community dwellingelderly men aged 50yrs and above. Indian Journal ofPhysiotherapy and Occupational therapy,2006.

8. Doherty Invited Review: Ageing and Sarcopenia J ApplPhysiol 95: 1717-1727, 2003.

9. Susan A, The role of Physical Activity in the Developmentand Maintainence of Bone Health Throughout the lifecycle.

10. Hurley M, Rees J, Newham D. Quadriceps function,proprioceptiveacuity and functional performance in healthyyoung, middle-aged and elderly subjects.Age Ageing1998;27:55-62.

11. Surakka J, Power type strength training in middle aged menand women.Journal of sports science and medicine. Vol 4.Supplementation 9, 2005,1-35.

12. Sadashiv Ram Aggarwal, Deepak Kumar, Effects of ageand training on skeletal muscle physiology andperformance. Physical therapy Vol. 74, No. 1, January 1994,pp. 71-81.

13. Joel et al: Physical determinants of Independence in MatureWomen. Archive Physical medicine and rehabilitation,76:373-380,1995.

14. Denise M C et al: Improvement in knee extensor strengthof institutionalized elderly women after exercise with ankleweights. Physio Canada,47: 15-23, 1995

15. Aniansson A et al: Evaluation of functional capacity ADL in70yrs old men and women.Scandinavian Journal ofRehabilitation Medicine 12:145-157,1980.

16. Dawn A. Skelton,Carolyn A.Greig, Janet M. Davies, ArchieYoung Strength, Power and Related Functional ability ofhealthy people aged 65-89yrs.Age and ageing, 23, Nov5,371-377.

17. Fiatarone MA and Evans WJ. The Etiology and Reversibilityof Muscle Dysfunction in the Aged. The Journals ofGerontology 1993; 48 (special issue): 77-83.

18. Samson MM, Meeuwsen IBAE, Crowe A, Dessens JAG,Duursma SA, and Verhaar HJJ.Relationships betweenphysical performance measures, age, height and body

weight in healthy adults. Age and Ageing 2000; 29: 235-242

19. Taina Rantanen, Pertti Era, Eino Heikkinen , Maximalisometric strength and mobility among 75-year-old men andwomenAge and Ageing, March, 1994.

20. Susan V. Brooks, Current topics for teaching Skeletalmuscle Physiology Adv Physiol Educ 27:171-182, 2003

21. Rüegg C, Veigel C, Molloy JE, Schmitz S, Sparrow JC,and Fink RHA. Molecular motors: force and movementgenerated by single myosin II molecules. News Physiol Sci17: 213–218, 2002.

22. Vale RD and Milligan RA. The way things move: lookingunder the hood of molecular motor proteins. Science 288:88–95, 2000.

23. Ruff C, Furch M, Brenner B, Manstein DJ, and MeyhoferE. Single-molecule tracking of myosins with geneticallyengineered amplifier domains. Nat Struct Biol 8: 226–229,2001

24. Geeves MA and Holmes KC. Structural mechanisms ofmuscle contraction. Annu Rev Biochem 68: 687–728, 1999.

25. Uyeda TQP, Abramson PS, and Spudich JA. The neckregion of the myosin motor domain acts as a lever arm togenerate movement. Proc Natl Acad Sci USA 93: 4459–4464, 1996.

26. Goldspink G. Changes in muscle mass and phenotype andthe expression of autocrine and systemic growth factorsby muscle in response to stretch and overload. J Anat 194:323–334, 1999.

27. Faulkner JA. Terminology for contractions of muscles duringshortening, while isometric, and during lengthening. J ApplPhysiol 95: 455–459, 2003.

28. Lin J, Wu H, Tarr PT, Zhang CY, Wu Z, Boss O, Michael LF,Puigserver P, Isotani E, Olson EN, Lowell BB, Bassel-DubyR, and Spiegelman BM. Transcriptional co-activator PGC-1 drives the formation of slow-twitch muscle fibres. Nature418: 797–801, 2002.

29. Sandra Hunter. Human Skeletal sarcoplasmic reticulumcalcium uptake and muscle function with ageing andstrength training. J Physiol 86:1858-1865

30. Fitts, R. H., J. P. Troup, F. A. Witzmann, and J. O. Holloszy.The effect of ageing and exercise on skeletal musclefunction. Mech. Ageing Dev. 27: 161-172, 1984.

31. Larsson, L., and G. Salviati. Effects of age on calciumtransport activity of sarcoplasmic reticulum in fast- and slow-twitch rat muscle fibres. J. Physiol. (Lond.) 419: 253-264,1989.

32. Phillips, S. K., S. A. Bruce, and R. C. Woledge. In mice, themuscle weakness due to age is absent during stretching.J. Physiol. (Lond.) 437: 63-70, 1991.

33. Narici, M. V., M. Bordini, and P. Cerretelli. Effect of agingon human adductor pollicis. J. Appl. Physiol. 71: 1277-1281,1991.

34. Vandervoort, A. A., and A. J. McComas. Contractile changesin opposing muscles of the human ankle joint with aging.J. Appl. Physiol. 61: 361-367, 1986..

35. Cupido, C. M., A. L. Hicks, and J. Martin.Neuromuscularfatigue during repetitive stimulation in elderly and youngadults. Eur. J. Appl. Physiol. 65: 567-572, 1992.

36. Doherty, T. J., A. A. Vandervoort, A. W. Taylor, and W. F.Brown. Effects of motor unit losses on strength in oldermen and women. J. Appl. Physiol. 74: 868-874, 1993.

37. McDonagh, M. J. N., M. J. White, and C. T. M. Davies.Different effects of ageing on the mechanical properties ofhuman arm and leg muscles. Gerontology 30: 49-54, 1984.

38. Dux, L. Muscle relaxation and sarcoplasmic reticulumfunction in different muscle types. Rev. Physiol. Biochem.Pharmacol. 122: 69-147, 1993

39. Briggs, F. N., J. L. Poland, and R. J. Solaro. Relativecapabilities of sarcoplasmic reticulum in fast and slowmammalian skeletal muscle. J. Physiol. (Lond.) 266: 587-


94

594, 197740. Fryer, M. W., and I. R. Neering. Relationship between

intracellular calcium concentration and relaxation of rat fastand slow muscles. Neurosci. Lett. 64: 231-235, 1989

41. Gafni, A., and K. M. Yuh. A comparative study of the Ca2+-Mg2+ dependent ATPase from skeletal muscles of young,adult and old rats. Mech. Ageing Dev. 49: 105-117, 1989.

42. Gollnick, P. D., P. Korge, J. Karpakka, and B. Saltin.Elongation of skeletal muscle relaxation during exercise islinked to reduced calcium uptake by the sarcoplasmicreticulum in man. Acta Physiol. Scand. 142: 135-136, 1991

43. Ferrington, D., T. Jones, T. Squier, and D. Bigelow. Theeffect of senescence on the conformational stability ofskeletal muscle sarcoplasmic reticulum Ca-ATPase(Abstract). Biophys. J. 64: A305, 1993.

44. Krainev, A. G., D. Ferrington, T. D. Williams, T. Squier, andD. Bigelow. Adaptive changes in lipid composition of skeletalsarcoplasmic reticulum membranes associated with aging.Biochimica et Biophysica Acta 1235: 406-418,1995.

45. Klitgaard, H., S. Ausoni, and E. Damiani. Sarcoplasmicreticulum of human skeletal muscle: age-related changesand the effect of training. Acta Physiol. Scand. 137: 23-31,1989

46. Bellew, James W, Symons, T Brock, Vandervoort, AnthonyGeriatric Fitness: Effects of Aging and Recommendationsfor Exercise in Older Adults Cardiopulmonary PhysicalTherapy Journal, Mar 2005

47. Howley, Edward T. American College of Sports Medicine.Position stand on exercise and physical activity for olderadults. Med Sci Sports Exerc. 1998;30:992-1008.

48. Nakamura E, Moritani T, Kanetaka A. Biological age versusphysical fitness age. Eur J Appl Physiol 1989;58:778-785.

49. Bellew JW. Non-pathological changes in the neuromuscularsystem as a function of aging. Issues on Aging. 1998;21:3-9.

50. Nadel ER, DiPietro L. Effects of physical activity onfunctional ability in older people: translating basic sciencefindings into practical knowledge. Med Sci Sports Exerc1995;26:s

51. Evans WJ. What is sarcopenia? J Gerontol Biol Sci MedSci. 1995;50:A5-8.

52. Vandervoort AA, Symons TB. Functional and metabolicconsequences of sarcopenia. Can J Appl Physiol.2001;26:90-101.

53. Roubenoff R. Origins and clinical relevance of sarcopenia.Can J Appl Physiol. 2001;26:78-89.

54. Lexell J. Human aging, muscle mass, and fiber typecomposition. J Gerontol A Biol Sci Med Sci. 1995;50:11-16.

55. Bellew JW. Age-related motor unit remodeling and its effectson muscle performance. Strength Cond J. 2004;26:34-37.

56. Kent-Braun JA, Ng AV, Young K. Skeletal muscle contractileand noncontractile components in young and older womenand men. J Appl Physiol. 2000;88:662-668.

57. Overend TJ, Cunningham DA, Kramer JF, Lefcoe MS,Paterson DH. Knee extensor and knee flexor strength. JGerontol A Bio Sci Med Sci. 1992;12:629-4

58. Rice CL, Cunningham DA, Paterson DH, Lefcoe MS. Armand leg composition determined by computed tomographyin young and elderly men. Clin Physiol. 1989;9:207-220.

59. Frontera WR, Hughes VA, Fielding RA, Fiatarone MA,Evans WJ, Roubenoff R. Aging of skeletal muscle: a 12-yrlongitudinal study. J Appl Physiol. 2000;88:1321-1326.

60. Porter MM, Vandervoort AA, Lexell J. Aging of humanmuscle: structure, function and adaptability. Scand J MedSci Sports. 1995a;5:129-42

61. Vandervoort AA. Aging of the human neuromuscularsystem. Muscle Nerve. 2002;25:1 7-25

62. Brooks SV and Faulkner JA. Skeletal muscle weakness inold age: underlying mechanisms. Med Sci Sports Exerc

26: 432–439, 1994.63. Faulkner JA, Brooks SV, and Zerba E. Muscle atrophy and

weakness with aging: contraction-induced injury as anunderlying mechanism. J Gerontol A Biol Sci Med Sci 50:B124–B129, 1995.

64. Kadhiresan VA, Hassett C, and Faulkner JA. Properties ofsingle motor units in medial gastrocnemius muscles of adultand old rats. J Physiol 493: 543–552, 1996.

65. Evans WJ. Reversing sarcopenia: How weight training canbuild strength and vitality.Geriatrics 1996; 51(5): 46-53.

66. York JL and Biederman I. Effects of age and sex onreciprocal tapping performance.Perceptual and Motor Skills1990; 71: 675-684.

67. Vandervoort AA. Effects of ageing on human neuromuscularfunction: Implications forexercise. Canadian Journal ofSport Sciences 1992: 17(3): 178-184.

68. Doherty TJ. The influence of aging and sex on skeletalmuscle mass and strength.Current Opinion in ClinicalNutrition and Metabolic Care 2001; 4: 503-508

69. Booth FW, Weeden SH, and Tseng BS. Effect of aging onhuman skeletal muscle and motor function. Medicine andScience in Sports and Exercise 1994; 26(5): 556-560.

70. N A Lynch, Metter, Hurlry. Muscle quality. Age associateddifferences between arm and leg muscle groups.J ApplPhysiol86:188-194.

71. Dutta, Lexell. Sarcopenia and physical performance in oldage:overview. Muscle Nerve Suppl.5:S5-S9,1997.

72. Bassey EJ, et al: Leg extensor power and functionalperformance in very old men and women. Clin Sci 82: 321-327, 1992.

73. Lipsitz,Gagnon,Hirayama.Muscle strength and fall ratesamong residents of Japnese and American nursing homes.JAm Geriatr Soc. 42:953-959,1994.

74. Buchner, Cress, Latuer, Price. The effect of strength andendurance training on gait ,balance, fall risk and healthservices use in community living adults. J Geron A Biol SciMed 52:218-224,1997.

75. Asmussen, Neilson. Isometric strength in relation to agein men and women. Ergonomics 5:167-169,1992.

76. Larsson L, Grimby G, and Karlsson J. Muscle strength andspeed of movement in relation to age and musclemorphology. J Appl Physiol 46: 451–456, 1979.

77. Lindle, Tobin, Fozard Roy. Age and gender comparisons ofmuscle strength in 654 women and men aged 20-93. J OfAppl Physiol83:1581-1587,1997.

78. Klitgaard H, Mantoni M, Schiaffino S, Ausoni S, Gorza L,Laurent-Winter C, Schnohr P,and Saltin B. Function,morphology and protein expression of ageing skeletalmuscle: across-sectional study of elderly men with differenttraining backgrounds. ActaPhysiologica Scandinavica 1990;140: 41-54.

79. Bruce SA, Newton D, and Woledge RC. Effect of age onvoluntary force and crosssectional area of human adductorpollicis muscle. Quarterly Journal of ExperimentalPhysiology 1989; 74: 359-362.

80. John Dixon and Tracey Howe. Quadriceps force generationin patients with osteoarthritis knee and asymptomaticparticipants during patellar tendon reactions, an exploratorycross sectional study. BMC muscular skeletal disorder2005;6, 46.

81. Paul et al body mass index as a measure of body fatness,age and sex specific predictions formulas. British Journalof Nutrition 1991,65, 105-114.

82. James R. Brinkman, Guidelines for the use andperformance of quantitative outcome measures in ALSclinical trials World Federation of Neurology, ResearchGroup on Neuromuscular Diseases WFN Airlie HouseWorkshop On Therapeutic Trials in ALS, at Airlie House,Warrenton, Va., April 29 - May 1, 1994.

83. Muscle performance during maximum isometric and


95

dynamic contraction is influenced by the stiffness oftendinous structures. Journal of applied Physiology,99:986:994,2005

84. Edwards, Young A et al Human Skeletal Muscle function,Description of tests and values. Clin Sci Molec med1977;53;283-290

85. Sami et al The effects of ageing on muscle strength andfunctional ability of healthy Saudi Arabian Males. Ann SaudiMed 1999;19(3);211-215.

86. Stephen R. Lord, Susan M. Murray, Kirsten Chapman,Bridget Munro and Anne Tiedemann, Sit to Standperformance depends on sensation, Speed, Balance andPsychological status in Addition to strength in older people.Journal of Gerontology Series: A Biological sciences andmedical sciences, 57: M539-M543, 200.

87. KimberlyY, Joseph M, Cauley. Correlates of decline in lowerextremity performance in older women: A 10 year follow-up study. J geron Series A: Biological Sciences and MedicalSciences.

88. Brown M, et al: The relationship of strength to function inthe older adult. J Gerontol A Biol Sci Med Sci 50 (SpecialIssue): 55-59, 1995.

89. Lester R, et al: A clinical trial of strengthening and aerobicexercise to improve gait and balance in elderly male nursinghome residents. Am J Phys Med Rehabil 71: 333-342, 1992.

90. Fiatarone MA, et al: Exercise training and nutritionalsupplementation for physical frailty in very elderly people.New Engl J Med 330: 1769-1775, 1994.

91. Fiatarone MA, et al: High-intensity strength training innonagenarians. JAMA 263: 3029-3034, 1990.

92. Skelton DA, et al: Effects of resistance training on strength,power, and selected functional abilities of women aged 75and older. J Am Geriatr Soc 43: 1081-1087, 1995.

93. Amika Singh, Marijke Paw, Rudd Bosscher: Cross sectionalrelationship between physical fitness components andfunctional performance in older persons living in long-termcare facilities. BMC Geriatrics 2006,6:2318-6-4.

94. Gisuseppe, Maria, Carmine et al The effect of ageing andimmobilization on structure and function of human skeletalmuscle fibres. J Physiol 2003; 552;499-511.

95. M S F Clarke. The effects of exercise on skeletal muscle inthe aged. J Musculoskel Neuron Interact 2004;4(2);175-178.


96

Effectiveness of Bladder Rehabilitation Program in theManagement of Urge Urinary Incontinence in Older WomenNirupma Singh*, Kamal Narayan Arya***Physiotherapist, Deptt. of Rehabilitation Sciences, Jamia Hamdard, New Delhi, **Sr. Occupational Therapist, Pt.DDU Institute forthe Physically Handicapped, New Delhi

Abstract

Background

Urinary incontinence is a common and treatable problem.

Aims and Objectives

To study the effectiveness of Bladder RehabilitationProgram in the management of urge urinary incontinence andurge predominant mixed incontinence in older women agedbetween 55yrs – 70 yrs.

Methodology

Twelve motivated, non-dementic (MMSE > 24) andambulatory subjects were taken for the study with history of urgeincontinence or urge predominant mixed incontinence persistingat least 3 months with a frequency of at least 2 or more episodesper week.

Outcome Measures

Reduction in the frequency of incontinent episodes asdetermined by Bladder Diary ,Incontinence Impact Questionnaire(IIQ) Overactive Bladder Questionnaire (OABq).

Intervention

Subjects were taught Bladder Rahabilitation Programthrough Urge Suppression and Scheduled Voiding. At the endof eighth week posttest scores of Bladder Diary, IIQ and OABqwere noted.

Result

Statistical difference between pretest and posttest scoreswas found.

Conclusion

Bladder Rehabilitation Program is a safe and effectiveconservative intervention that should be made more easilyavailable to patients as first line treatment of urge urinaryincontinence.

Key Words

Urge suppression, incontinence, bladder rehabilitation,scheduled voiding, non dementic, ambulatory.

Introduction

Urge incontinence caused by detrusor overactivity is themost common form of incontinence in older women1. Patientswith this condition typically experience sudden, unexpected lossof large volumes of urine or leakage associated with a suddenurge to urinate that cannot be controlled2.

The bladder diary is a common method used to evaluatethe frequency and characteristics of incontinence episodes inboth research and clinical practice3, 4, 5.

Bladder rehabilitation for detrusor instability is based onthe assumption that the underlying pathophysiology is the escapeof the detrusor from the cortical control over micturition that hadpreviously been established during childhood toilet-training. Theobject of bladder retraining is to reestablish the authority of thecerebral cortex over bladder function. This is performed througha regimen of timed voiding, gradually increasing the intervalsbetween voids until the cycle of urgency, frequency, and urgeincontinence is broken.6 Studies have shown that the prevalenceof over active bladder and urge incontinence among women inAsia is relatively high as compared to Western figures . Despitethe high prevalence , however, treatment treatment seeking isnot common ( M C Lapiton et al, 2001).

Occupational Therapists assists people of all ages toachieve health and life satisfaction by improving their ability tocarry out the activities that they need to do or choose to do intheir daily lives. Maintaining one’s own toileting needs is one ofthe most basic of everyday activities, and therefore should bean integral aspect of functional aspect. Occupational therapyplays an important role in enhancing the quality of life of patientsaffected with urinary incontinence especially in urge type.


1. Soern Hagstroem et al , 2005 did a study to evaluate theeffect of bladder rehabilitation with idiopathic overactivebladder to clarify whether the effect of the treatment isincreased by addition of a programmable timer.7

2. L Lewis Wall (1988) writes that UI is always treatable. Itcan almost always be improved and frequency can becured, often using relatively simple, nonsurgicalinterventions………8

3. D.C Dutta, Urge Incontinence due to detrusor instability(DI) is the commenest in elderly group……..The conditionis largely functional or psychological inorigin……………Bladder retraining is useful in idiopathicgroup when combined with stress incontinence, unstablebladder is to be treated first.9

4. M C Lapitan and P L H Chye, 2001, did a questionnairebased survey was performed in 5502 females from 11countries to establish the prevalence over active bladder..The overall prevalence was 53.1% .The most commonsymptom was urgency (65.4%). The majority (75.4%) warenot significantly bothered by the condition10.

5. Neil M Resnick et al (1985) writes that Aging may effect thelower urinary tract in several ways . Bladder capacity , abilityto postpone voiding, urethral and bladder compliance areall probably reduced11,12.

6. Yarnell J W G et all (1979) writes that Incontinence in elderlyis usually a remedial condition. It is transient in as many as50% of patients. Of the remainders , as many as two thirdscan be cured or improved13,14.

Aims and Objectives

1. To formulate Bladder Rehabilitation Program for UrgeIncontinence.

Nirupma Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

97

2. To study the effectiveness of Bladder RehabilitationProgram in management of Urge Incontinence.

Methodology

Twelve motivated, non demented (Mini Mental StateExamination >24) (29 , 30) and ambulatory , community dwellingsubjects were taken for the study between age group of 55years -70 years (N = 12).

Study design: Prospective, experimental, convenientsampling, community based efficacy study.

Inclusion Criteria

1. Urge Incontinence or Urge predomiant mixed incontinencepersisting for atleast three months with frequency of at least2 or more episodes per week.

2. Experience of involuntary loss of urine associated withstrong desire to void.

Exclusion Criteria

1. Having urinary tract infection2. Treatment for incontinence3. MMSE <244. Any disease affecting symptom of incontinence.5. Severe uterine prolapse past the vaginal introitus.

Outcome Measures

Bladder DiaryOveractive Bladder Questionnaire (OABq)Patient Incontinence Impact Questionnaire (PIIQ)

Written consent was taken from each subject. All subjectsfilled the demographic data. All subjects ticked the Bladder Diaryfor one week by themselves or with the help of caregiver todetermine number of incontinent episodes (per week) andfrequency of urination (per day) pretest. Scores of OABq andUIIQ were also noted. These scores were used as baseline data.

Bladder Rehabilitation Program (BRP) was prepared afterdoing extensive research. Suggestions of two senior OccpationalTherapists and two senior Gynaecologists were taken. Thisprogram included scheduled voiding and urge suppressiontechniques. Suggestion about fluid manipulation was also given.Goals were set regarding increasing the time interval betweeneach void.

Scheduled Voiding was carried out as follows -1. The subject was instructed to void on a timed schedule,

starting with a relatively frequent interval of every hour whileshe is awake.

2. At night, the patient is allowed to void only when she isawakened from sleep by the need to do so.

3. When she can maintain this schedule for 1 week, the voidinginterval is increased by 15 minutes. It is increased graduallyby 15 minutes every week until a normal voiding interval of2.5 – 3 hours has been established.

Urge Supression Technique

To get control over the bladder :1. Stand quietly or sit still.2. Take slow relaxed breaths.3. Contract the pelvic floor muscles rapidly. This helps keep

the urethra closed ,to prevent urine leakage and calms thebladder.

4. Concentrate on making the urge go away. Use mentaldistraction to reduce the awareness of the discomfort ofthe urge. Hum a tune or dobackward counting (50 to 1)

5. When the urge subsides, do not use toilet until the next

void.After eight weeks Bladder Diary , OABq and UIIQ were

filled again. Bladder Diary was again ticked for one week (eitherby subject or with the help of care giver) to determine numberof incontinent episodes and frequency of urination posttest.Pretest and posttest data was statistically analysed using SPSSsoftware.

Statistical Analysis And Results

The data analysis of this study was done using SPSSsoftware. Total number of subjects were twelve (n=12) betweenage group of 55 yrs -70 yrs (minimum age = 55 yrs, maximumage = 70 yrs) with mean age = 63.75 yrs.

Descriptive StatisticsTable 1: Showing descriptive statistics of all four variables

N Mini Maxi Mean Std.mum mum Devia

tionAGE 12 55 70 63.75 5.172OABq(a) 12 11 15 13.17 1.267PIIQ(a) 12 9 14 11.58 1.676PIIQ(b) 12 6 8 7.08 .669OABq(b) 12 9 11 9.75 .754Fr.of incont epi. 12 8 14 11.08 2.392per week (a)Fr.of incont 12 5 10 7.50 1.977epis.per week (b)Fr. of urination 12 10.8 11.7 11.317 .3433per day (a)Fr, of urination 12 9.0 9.4 9.200 .1595per day (b)

OABq a =Pretest scores of Overactive Bladder QuestionnaireOABq b =Posttest scores of Overactive Bladder QuestionnairePIIQ a =Posttest scores of Patient Incontinence ImpctQuestionnairePIIQ b =Posttest scores of Patient Incontinence ImpactQuestionnaire.

Frequency of incontinent episodes per week pretestFrequency of incontinent episodes per week posttestTable 1 shows the descriptive statistics of age of all subjects

and pre test and post test scores of all variables (OveractiveBladder Questionnaire, Patient Incontinence Questionnaire,Frequency of incontinent episodes per week and Frequency ofincontinent episodes per week).

Table 2: Showing mean, standard deviation and standard errorof all variables

Mean N Std. Std.Devia Errortion Mean

OABq(a) 13.17 12 1.267 .366OABq(b) 9.75 12 .754 .218PIIQ(a) 11.58 12 1.676 .484PIIQ(b) 7.08 12 .669 .193Fr.of incont epi. 11.08 12 2.392 .690per week(a)Fr.of incont epis. 7.50 12 1.977 .571per week(b)Fr. of urination 11.317 12 .3433 .0991per day(a)Fr, of urination 9.200 12 .1595 .0461per day(b)


98

Table 3: Showing the difference of mean of pretest and posttest scores of all variables

Paired Differences t df Sig. (2-tailed)

Mean Std. Std. 95% ConfidenceDevia Error Interval of thetion Mean Difference

Lower UpperOABq(a) -OABq(b) 3.42 1.165 .336 2.68 4.16 10.164 11 .000PIIQ(a) -PIIQ(b) 4.50 1.567 .452 3.50 5.50 9.950 11 .000Fr.of incont epi.per week(a)Fr.of incont epis. 3.58 .669 .193 3.16 4.01 18.567 11 .000per week(b)Fr. of urinationper day(a) - Fr, 2.117 .3186 .0920 1.914 2.319 23.013 11 .000of urination perday(b)

Interpretation: It is clear from table 3 that there is a significant difference in all scores of all variables; P=.000 (significant)

Discussion

Urge Urinary Incontinence, perhaps the most common typeof incontinence in elderly women, occurs when involuntaryvoiding is preceeded by awareness of a few seconds to a fewminutes. It is found that people usually do not seek treatmentfor this problem mainly due to two reasons: 1. It is believed thatnothing can be done for this problem, and 2. people feel tooembarrassed to talk about it. Though incontinence in elderly isa treatable condition.

Self monitoring of voiding behavior by using a bladderdiary was found to be effective. It offers the advantage ofassessing the severity of urinary symptoms in the individualsown environment and under actual daily life conditions.Significant difference between means of pretest and posttest

scores of Overactive Bladder Questionnaire was found (pretestmean =3.42 , posttest mean =1.165, p= .000) (Jean F Wymanet al, 1988).

The impact of urge incontinence on quality of life isemphasized. The difference of pretest and post test scores ofPatient Incontinence Impact Questionnaire was also found tobe significant (p= .000) (M C Lapitan et al, 2001).

Frequency of incontinence per week and frequency ofurination per day was calculated by one week bladder diary(Robb SS ,1985 and Burton JR, 1988) . Significant differencewas found between Pretest and posttest scores of Frequencyof incontinence per week (pretest mean=11.08, posttest mean=7.50). Although condition was not completely cured but therewas some improvement in all subjects. The possible reason forthe improvement was perhaps better control over the bladder.


Graph 1: Showing pretest mean (13.17) and posttest mean(9.75) of Overactive Bladder Questionnaire (OABq)

Graph 2: Showing pretest mean (11.58) and posttest mean(7.08) of Patient Incontinence Impact Questionnaire (PIIQ)

Graph 3: Showing pretest mean (11.31) and posttest mean(9.20) of Frequency of Incontinence Episodes per Week

Graph 4: Showing pretest mean (2.117) and posttest mean(.3186) of Frequency of Urination per Day

99

Normal frequency of urination per day in a normal individualis 7-8 voids per day. In this study the pretest scores of frequencyof urination per day was 11.317 . After intervention it had reducedto 9.200. Although is more than the normal range but atleastsome improvement was shown by each subject. This differencealso denotes that voiding interval for each subject was increased, although this was not statistically analysed. Increase in voidinginterval also meant the increased bladder capacity (for moreurine holding ) (L Lewis Wall, ).

Limitations of the Study

1. Sample size was small and hence results cannot begeneralized.

2. Objective measures like Urodynamics, uroflometry and postvoid residual volume were not used.

Future Recommendations

1. Study can be done on disabled women.

Conclusion

Urinary Incontinence is the most common issue amongwomen. But due to embarrassment this health problem is kepthidden and not talked about. Maintaining one’s own toiletingneed is one of the most basic of everyday activities thusOccupational Therapist’s (O.T) have very strong role to play inmanaging UI. Bladder Rehabilitation Program was found to bevery effective in managing Urge Urinary Incontinence in women.This study also broadens the scope of O.T in Urogynaecology,which is emerging as a field in India.

References

1. http://www.netdoctor.co.uk/health_advice/seniorshealth/sui/ui_005139.htm

2. Wall LL. Diagnosis and management of urinaryincontinence due to detrusor instability. Obstet Gynecol

Surv 1990;45:1S-47S.3. Fantl JA, Newman DK, colling J, et al. Urinary Incontinence

in Adults: Acute and Chronic Management, Clinical PracticeGuideline, No 2, 1996 Update. Rockville , MD : USDepartment of Health and Human Services Public HealthSercice; 1996. Agency for Health Care Policy and ResearchAHCPR publications. 96-0682.

4. Abrams P, Saad K, Wein A, eds. Incontinence. Proceedingsof the 1st International Consultation on Incontinence-June28- July 1, 1998-Monaco . St. Helier , England : HealthPublications Ltd, 1999.

5. Abrams P, Blaivas JG, Stanton SL, Andersen JT. Thestandardization of terminology of lower urinary tract functionrecommended by the international Continence Society. Int.Urogynecol J. 1990;45-58.

6. Burgio KL, Locher JL, Goode PS, et al. 1998. Behavioralvs drug treatment for urge urinaryincontinence. JAMA 280:1995-2000.

7. Wyman JF ET AL , 1988. The Urinary in the Evaluation ofIncontinent women : a test retest analysis, Obsterics andGynecology 71: 812-817

8. Soern Hagstroem, 2005 , Programmable Timer in theBladder Rehabilitation Treatmentof OAB, Clinic Trials.gov

9. J S Berek, 1988, Novak’s Gynaecology, Twlevfth edition,Incontinence, prolapse and disorders of the pelvic floor ,chapter 20, page 628 ,639)

10. M C Lapitan and P L H Chye, The Epidimiology of OverActive Bladder among Females in Asia : A QuestionnaireSurvey, Int Urogynaecol J 2001: 226-231

11. Broklehurst JC et al . Studies of the female bladder in oldage . Gerontol Clin.1966, 8: 285-305

12. Anderson JT et al. Bladder functions in healthy elderlymales, Scand J Nephrol 1978 , 12: 123-7

13. Yarnell J W G et al. The prevalence severity and factorsassociated with urinary incontinence in random sample ofelderly . Age Aging 1979 , 8: 81-5

14. Willigton F L , Problems of urinary incontinence in elderlyGerontol Clin (Basel ) 1969, 11:330-56.


100

Influence of Stair Climbing on the Self Efficacy in Post CardiacSurgery PatientsUchil P*, Khan I**, Kamath N****Post Graduate Student, **Physiotherapist, ***Lecturer, Department of Physiotherapy, Manipal College of Allied Health Sciences,Manipal

Abstract

The psychosocial aspect of cardiac rehabilitation is one ofthe factors which help a patient to continue into phase twocardiac rehabilitation. Self-efficacy is a psychological constructbased on social–cognitive theory, which describes the interactionbetween behavioral, personal, and environmental factors inhealth and chronic disease. Stair climbing is considered to beimportant to decrease the risks of cardiovascular disease.

Objective

To assess the influence of stair climbing on the self efficacyin post cardiac surgery patients.

Design

Pre and post test design.

Setting

Kasturba hospital, Manipal.

Population

30 post cardiac surgery patients, (mean age 48.65 years,SD + 11.69 years).

Intervention

Patients were administered the cardiac self efficacyquestionnaire pre and post stair climbing on the fifth to seventhpost operative days (mean 6.4 SD + 1.43 days).

Outcome Measure

The self efficacy components of control of symptoms andmaintaining function were assessed and recorded pre and poststair climbing.

Results

A significant change was observed in the patientsconfidence to control their symptoms such as chest pain (p =0.014, p<0.05) and to call their doctor (p = 0.034) post stairclimbing. Under the physical activity component a highlysignificant change was observed in the confidence towardsperforming regular aerobic exercise (p = 0.004), activities withfamily (p = 0.008), usual social activities (p = 0.016).

Conclusion

We concluded from this study that stair climbing has asignificant influence on the self efficacy in post cardiac surgerypatients which aids in improving their confidence levels towardscontrol of their symptoms and maintaining their physical activity.

Key Words

Social-cognitive theory, phase one cardiac rehabilitation,physical activity

The World Health Organization defines Cardiacrehabilitation (CR) “the rehabilitation of cardiac patients is thesum of all the activities required to ensure cardiac patients thebest possible physical, mental and social conditions so that theymay, by their own effort, regain as normal a place in thecommunity, and lead an active life”.1

The psychosocial aspect of cardiac rehabilitation is one ofthe factors which help a patient to continue into phase two cardiacrehabilitation. Cardiac patients have lower self confidence;underestimate their capabilities and thus limit themselves fromdoing high intensity activities. Such patients even drop out fromthe cardiac rehabilitation program as soon as they are dischargedfrom the hospital. These negative psychological states makecompletion of cardiac rehabilitation difficult.

Self-efficacy is a psychological construct based on social–cognitive theory, which describes the interaction betweenbehavioral, personal, and environmental factors in health andchronic disease. The theory of self-efficacy proposes thatpatient’s confidence in their ability to perform certain healthbehaviors influences their engagement in and actualperformance of those behaviors (e.g., diet and exerciseadherence), which in turn will influence their health outcomes.2,

3

Stair climbing is considered to be important as it has beenfound to decrease the risks of cardiovascular disease.4 Due todearth in literature regarding changes in self efficacy with respectto stair climbing on the cardiac status during phase onerehabilitation, our study aimed to observe any relative changein the self efficacy in relation to the cardiac status in post cardiacsurgery patients pre and post stair climbing.


The study design used was a pre and post test design.Thirty post cardiac surgery patients, between the age group of18 to 65 years were recruited from the Kasturba Hospital, Manipalthrough convenience sampling.

Patients with atrial or ventricular arrhythmias, uncontrolleddiabetes mellitus (random blood glucose > 400 mg/dL) , cognitiveimpairments, orthopedic problems leading to difficulty in stairclimbing and uncontrolled hypertension (systolic blood pressure>180mmHg and diastolic blood pressure>120 mm Hg orhypotension (20mmHg drop in systolic blood pressure withsymptoms of lightheadedness or dizziness) at rest were excludedfrom the study.

Instrument / Outcome Measure

The instrument used was the “cardiac self efficacy scale “.The objective of cardiac self efficacy scale is to examine therole of self efficacy in the physical and role function for patientswith coronary heart disease after controlling factors of anxietyand depression.

The cardiac self efficacy scale has two components, thefirst component containing 7 items pertaining to control ofsymptoms and the second component containing 4 items

Uchil P / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

101

pertaining to maintaining function. Patients had to rate theirconfidence with knowing or acting on each of the 11 statementson a 5- point Likert scale (0= not at all confident, 1= somewhatconfident, 2= moderately confident, 3=very confident, 4=completely confident)

The cardiac self efficacy scale has two factors (Control ofsymptoms and maintaining function) with high internalconsistency and good convergent and discriminant validity.Cronbach’s alphas for the two factors were 0.90 and 0.87respectively.5, 6, 7

Procedure

The questionnaire was translated into two languages,Kannada and Malayalam, which were the common dialectsspoken in the area of study. Back translation was carried out byindividuals blinded from the study.

An informed consent for stair climbing was obtained fromthe post cardiac surgery patients on the 5th to 7th post operativedays. The patients were blinded about the procedure.Demographic details of the same were documented. Patientswere explained to mark against the components of the Cardiacself efficacy scale questionnaire before stair climbing. Followingthis, stair climbing of 20 steps was performed. First the patientclimbed 10 steps following 2 minutes rest on a flat surface andthen climbed another flight of 10 stairs (Fig.1). Vital parametersbefore stair climbing, during and after stair climbing weredocumented. Patients were asked to mark against thecomponents on the Cardiac self efficacy scale again after stairclimbing. Any complaints during stair climbing were noted.

Data Analysis

The data was analyzed using SPSS ver.16.0 software. TheWilcoxon signed ranks test was used to analyze the pre andpost test values in the 11 item cardiac self efficacy scale.

Results

30 patients recruited for the sample varied from 18 to 65yrs (mean 48.65 + 11.69 yrs). Post operative days extendedfrom the fifth to the seventh day after the cardiac surgery (mean6.4 + 1.43). Nineteen males and eleven females participated inthis study. Out of the 30 cardiac surgeries performed, the sampleconsisted of 19 CABG surgeries, 6 valve replacement surgeries,and 5 septal defect closures (Table 1).

A significant change was observed in the patientsconfidence to control their symptoms such as chest pain (p =

0.014) and to call their doctor (p = 0.034) post intervention. Underthe physical activity component in the scale a highly significantchange was observed in their confidence towards performingregular aerobic exercise (p = 0.004), activities with family (p =0.008), usual social activities (p = 0.016). (Table 2)

Table 1: Descriptive characteristics of the samplen = 30 Mean Std. Deviation

Age 48.65 + 11.69Postoperative day 6.4 + 1.43GenderMale : Female 19 : 11Types of surgeryCoronary artery 19bypass graftingValve replacements 6Septal defect closures 5Others 0

Table 2: Level of significance of the 11 itemed Cardiac selfefficacy scale

Components Level ofsignificance

(p<0.05)Confidence in controlling symptoms

Chest pain by change in physical activity *0.014

Breathlessness by change in physical activity 0.157

Chest pain by medications 0.340

Breathlessness by medications 0.914

Call or visit doctor *0.034

Explain doctor regarding condition 0.180

Take cardiac medications 1.000

Confidence in maintaining physical activities

Usual social activities *0.016

Usual home activities with family *0.008

Usual home activities with spouse 0.564

Get regular aerobic exercise *0.004

* (p value < 0.05)

Discussion

After an acute coronary event, phase I cardiac rehabilitation(CR) is important in assisting the patient’s pathway to recovery.The content of phase I CR has traditionally included assessment,education and exercise/mobilization. Mobilization may includegraduated exercise, walking programs and stair practice.8 TheNational Service Framework for Coronary Heart Disease (CHD)states that the aim of this phase is to offer high-quality cardiacrehabilitation before discharge from hospital, and this shouldbegin as soon as possible after someone is admitted with CHD.9

As a component during mobilization in phase I CR, stairuse is inexpensive and can be easily integrated into everydaylife by most of the population. Stair climbing represents vigorous-intensity physical activity with oxygen uptake reaching


Fig.1:

102

approximately 80 percent of maximal values in young healthyadults, corresponding up to approximately 10 metabolicequivalents (METs) of energy expenditure sufficient to improvecardiorespiratory fitness.10,11

Our study showed that self efficacy improved in terms ofthe post cardiac surgery patient’s confidence to report episodesof symptoms such as chest pain with any change in physicalactivity, and to call or visit his or her physician after stair use. Asignificant improvement was also seen with respect to theirconfidence in performing activities of daily living at home and insociety. Stair climbing markedly improved their confidence inperforming regular aerobic exercise after their surgery and priorto discharge from the hospital.

Both ward ambulation and inpatient exercise based cardiacrehabilitation have been found to be equally effective in improvingself efficacy scores of activities for routine physical daily livingtasks over the first 28 days after return to home.12

Stair climbing can thereby be implemented as a majorcomponent in the home based exercise program for the Indianpopulation who have undergone cardiac surgical proceduresand are unable to avail the benefits of phase two CR in anexercise based cardiac rehabilitation centre. As stair use is lessexpensive, and easily accessible, it can be integrated into thedaily living activities of the patients belonging to the rural sectorsin India.

Certain limitations were observed during the course of thisstudy. The study conducted was a pilot on a small sampleincluding only cardiac surgery patients from one centre, withlimited time constraints. Further studies could be implementedby recruiting a larger sample size from various cardiacrehabilitation and hospital centres. Larger samples with a moreheterogenous cardiac diseased population can be studiedincluding surgical, non surgical and interventional cases.

Conclusion

We thus concluded from this study that stair climbing has asignificant influence on the self efficacy in post cardiac surgerypatients. This novel concept would aid in improving theirconfidence levels towards control of their symptoms andmaintaining their physical activity.

References

1. World Health Organization: Rehabilitation of patient withcardiovascular disease: Report of a WHO expert committee.WHO Technical Report series No.270; 1964.

2. Bandura. Self-efficacy: The exercise of control. New York:W. H. Freedman and Co.; 1997.

3. Lorig, K, & Holman, H. Self-management education: History,definition, outcomes, and mechanisms. Annals ofBehavioral Medicine, 2003; 26: 1–7.

4. Froelicher VF, Myers J. Effect of Exercise on the Heart andthe Prevention of Coronary Heart Disease. Exercise andthe heart. 5th ed. Philadelphia, Pennsylvania: Saunders;2006. p. 419–459.

5. Arnold R, Ranchor AV, DeJongste MJL, Koeter GH, TenHacken NHT, Aalbers R, Sanderman R. The relationshipbetween self efficacy & self reported physical functioningin chronic obstructive pulmonary disease & chronic heartfailure. Behavioural Medicine 2005; 31(3):107-15

6. Gardener JK, McConnell TR, Klinger TA, Herman CP,Hauck CA, Laubach CA Jr. Quality of life and self efficacygender & diagnosis considerations for management duringcardiac rehabilitation. Journal of cardiopulmonaryrehabilitation 2003; 23(4): 299-306.

7. Sulivan MD, Andrea Z, Russo J, Katon WJ. Self Efficacyand Self Reported Functional status in coronary heartdisease: A six month prospective study. Psychosomatic Med1998; 60(4): 473-478.

8. Proudfoot C, Thow M. Exercise leadership in cardiacrehabilitation. An evidence based approach. New York: JohnWiley & Sons Ltd; 2006. p. 1-18.

9. National Service framework for coronary heart disease,modern standards and service models: Department ofHealth (DoH); 2000. Available from: http:/www.doh.gov.uk/nsf/coronary

10. Teh KC, Aziz AR. Heart rate, oxygen uptake, and energycost of ascending and descending the stairs. Med Sci SportsExerc 2002; 34: 695- 699.

11. American College of Sports Medicine, Position stand. Therecommended quantity and quality of exercises fordeveloping and maintaining cardiorespiratory and muscularfitness and flexibility in healthy adults. Med Sci Sports Exerc1998; 30: 975- 991.

12. Self efficacy and inpatient cardiac rehabilitation. Am JCardiol 1990; 66(3): 362-365.


103

S-D curve an Effective Diagnostic Test for Physiotherapists: Acase reportPankaj Gupta*, M Satish K Paul***Physiotherapist TLM Community Hospital Nandnagri, Delhi-93, **POD, Coordinator TLM India, Delhi-93

Abstract

With increasing confidence of patients in physiotherapyprofession we are serving the community as first contactprofessional1, 6. So, it becomes a responsibility of a consultantphysiotherapist to justify his/her diagnosis with related diagnostictest. This paper presents a case report on scleroderma (an auto-immune connective tissue disorder) and effectiveness of plottingS-D curve in making correct diagnosis of this patient.

Key Words

S-D curve, scleroderma, effectiveness.

Introduction

Scleroderma (progressive systemic sclerosis) is an auto-immune disorder which is characterized by progressive fibrosis.The main clinical features of the disease are claw-like flexiondeformity of hands and other symptoms like Raynaud’sphenomenon, malabsorption, pulmonary hypertension and alongwith other symptoms2. The purpose of this report is to show theefficacy and cost –effectiveness of the plotting S-D curve.

Case Description

A 36 year old female reported to, The leprosy missioncommunity hospital, Nandnagri Delhi-93. The patient came withclaw hand deformity of both hands and ulcer on right toe of leftfoot. On history taking she gave the history of anti-leprosytreatment for three months about six months ago. The main

reason of the patient to come for consultation in leprosy hospitalwas for re-starting the anti-leprosy treatment which she had left.

On examination it revealed that the claw finger is notbecause of ulnar nerve involvement. Because there was nohyper-extension of at MCP joint and on palpation ulnar nervefound to be normal3. So, it was confirmed that the cause ofdeformity is not ulnar nerve involvement4. So, in order to relatethe clinical findings with diagnostic test it was decided to plot S-D curve for the patient. When curve was plotted on paper itrevealed normal innervation of rt. Ulnar and median nerve5. This

Pankaj Gupta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Fig. 1: Claw finger in scleroderma patient

clearly justifies the clinical findings that the cause of claw fingerwas not nerve involvement.

Discussion

With increasing role of physiotherapists and with increasing,confidence of patients to consult physiotherapists as first contactallied health professionals over the decades6.

It is always important to support the clinical findings of thepatients with diagnostic test. This case study clearly shows theimportance and effectiveness of the S-D curve in makingdiagnosis of patients. S-D curve can be plotted with minimummanpower time and money in contrast to other diagnostic meanslike nerve conduction velocity, which requires sophisticatedequipments, more time and money.

References

1. Petty NJ, Moore AP. Neuromusculoskeletal examinationand assessment. Great Britain: Churchill Livingstone; 1998p.28

2. Mohan H. Text book of pathology.3rd ed. New Delhi: JaypeeBrothers; 1998 p. 71-75.

3. Jopling WH. Handbook of leprosy. 3rd ed. London: WilliamHeinmann Medical Books Publishing Ltd; 1984

4. Schwarz R, Brandsma W. Surgical reconstruction &rehabilitation in leprosy and other neuropathies. Nepal: EktaBooks Distributors Pvt. Ltd; 2004

5. Forster A, Palastanga N. Clayton’s electrotherapy: Theory& practice. 9th ed. Delhi: A.I.T.B.S Publishers & Distributors;

104 Pankaj Gupta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

1999 p.85-936. Prentice WE. Therapeutic modalities for allied health

professionals. New York: McGraw-Hill; 1998 p.xvii-xix.

105

Effectiveness of Strength Training Program on Bone MineralDensity in Postmenopausal WomenParamjot K Dhillon1*, Sonia Singh2

1Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar-144001, India, 2Department of Physiotherapy, Punjabi University,Patiala-147002, India

Abstract

The effect of strength training program on bone mineraldensity in postmenopausal women has been studied.Osteoporosis is a common crippling bone disease affectingmainly postmenopausal women. Mechanical factors that affectbone remodeling include muscular contraction and gravity. Inthis study subjects were divided into three groups i.e. controlgroup, strength training group and calcium supplementationgroup. Bone mineral density was found to increase significantlyin strength training group and decrease significantly in strengthtraining group, whereas the changes in calcium supplementationgroup were non-significant.

Key Words

Osteoporosis, Strength training, calcium, Bone mineraldensity, Postmenopausal women.

Introduction

Osteoporosis is a condition characterized by low bone massand poor bone architecture. The incidence of osteoporoticfractures is about double in women compared with men whichis due in part to a generally lower bone density across lifespan1.With aging, remodeling tends to remain uncoupled in thepockets of bone which has been removed during resorption.Thus, in older individuals, the rate of resorption exceeds therate of remodeling resulting in a net loss of bone or osteoporosis.The peak bone mass is usually attained by the age of 30 years,thereafter a decline in bone mass and structural integrity startsand becomes evident e around 50 years of age. Bonedensiometry is used to establish the diagnosis of osteoporosis,to assess the risk of osteoporotic fractures, to identify candidatesfor therapeutic intervention and to assess the effects of treatmenton bone loss.2 The testing procedure measures the density ofthe bone of the spines, pelvis, lower arms and thigh. Bonedensiometry testing may be done using X-Rays (dual energy X-Rays absorbitometry or DEXA) or quantitative CT Scanningusing special software. The portable testing is done using eithera DEXA or a quantitative ultrasound unit. Both types of portabletesting may use radius, wrist, finger or heel. The recommendedintake of elemental calcium is 1200 mg. day for adults over theage of 50 years [Food and Nutrition Board Dietary ReferenceIntake]. The amount of calcium retained in the body is related todietary intake, intestinal absorption and excretory losses.Intestinal calcium absorption and the ability to adapt to lowcalcium diet decline with aging and highlight the importance ofadequate calcium intakes in elderly people. Poor bonedevelopment is common in individuals and groups with lowweight bearing activity because intermittent overloading of boneis essential to maintain bone mass. Association between physicalactivity and bone mass are generally stronger than thosebetween calcium intake and bone mass. High intensity resistancetraining, in contrast to traditional pharmacological and nutritionalapproaches for improving bone health in older adults, has addedbenefits of influencing multiple risk factors for Wolff’s law statesthat stress or mechanical loading applied to a bone via muscleor tendon has a direct effect on bone formation andremodeling.3Simple squeezing of a tennis ball for 30 seconds aday has a significant benefits in non-injured forearm of women

who had already sustained a colle’s fracture.4 In addition, a setof dynamic bone loading exercise for the distal forearm resultsin increased bone strength at the wrist.5

Methods

This study is comparative in nature. A sample of thirtywomen who aged between 50-70 years volunteered toparticipate who met the inclusion criteria were assigned to threedifferent groups. Sample was collected from the population of300 subjects after holding three camps. Three camps wereorganized at Amar Hospital, Health Center, Punjabi universityand geriatric Physiotherapy clinic, Model Town, Patiala. Studywas performed at geriatric Physiotherapy Clinic, Model Town,Patiala.

Inclusion Criteria

Subjects aged 50-70 years residing in and around Patiala,one clinically relevant outcome measure i.e. BMD showingosteopenia or osteoporosis, subjects with sedentary lifestyle,subjects not involved in any other physical activity program whichcould effect BMD, subjects with normal BMI and Subjectsreported no mensuration for at least a year before study.

Exclusion Criteria

Subjects with history of trauma or fracture or surgery within6 months or long term immobilization, subjects with diabetes,hyperthyroidism, renal disease, connective tissue disorder, andhysterectomy, subjects with radiating pain, subjects sufferingfrom severe visual or vestibular disturbances, subjects havingsensory disturbances and subjects having hypertension orcardiac problem and subjects on steroid or radiotherapy.

Instrumentation

1. Quantitative ultrasound densiometry. (IGEAUltrasonometer)

2. Jamar Dynamometer.3. Dumbbells.4. Therabands.5. Squeeze Balls.6. Weight Cuffs.7. Mini Vector

Methodology

The subjects were randomly assigned to three differentgroups; 10 in each, Group A received no treatment, Group Bwas put on calcium supplementation as prescribed by physicianand Group C on strength training program for upper and lowerlimb for 3 months .Training was done for 5 days a week for 1hour duration. Pretest measurement was taken using portablequantitative ultrasound unit.

Strengthening Exercises for Upper Limb

Shoulder flexion and abduction with weight cuffs, elbowflexion and extension with dumbbells, Wrist flexion and extension

Paramjot K Dhillon/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

106

with therabands, wrist pronation and supination with dumbbells,grip strengthening exercise with hand gripper and squeezingball for 30 second.

Strengthening Exercise for lower limb

Hip flexion and extension with weight cuffs, hip abductionwith weight cuffs, knee flexion and extension with weight cuffs&Leg press with mini vector.

Protocol

0-3 weeks

1. One set of 15 repetitions at 50% of 1RM for 5 days a weekfor upper limb.

2. One set of 15 repetitions at 50% of 1 RM for 5 days a weekfor lower limb.

3-6 weeks

1. One set of 15 repetitions at 60 % of 1RM for 5 days aweek for upper limb.

2. One set of 15 repetitions at 60% of 1RM for 5 days a weekfor lower limb.

6-9weeks

1. One set of 15 repetitions at 70% of 1RM for 5 days a week forupper limb.

2. One set of 15 repetitions at 70% of 1RM for 5 days a week forlower limb.

9-12 weeks

1. One set of 15 repetitions at 80% of 1 RM for 5 days a weekfor upper limb.

2. One set of 15 repetitions at 80% of 1RM for 5 days a weekfor lower limb.

Post test assessment was taken using portable quantitativeultrasound.

Reliability and Validity

Reliability coefficient for quantitative ultrasound is 0.62 inwomen.6

Results and Analysis

Data was analysed with T-test and ANOVA using Sigmastatsoftware.

Bmd Changes in Control Group

On applying T-paired test on pre and post mean of -2.71and -3.36, with t value 2.807, results obtained are significantand are shown in the Table 1.1 and Fig.1.1

Table 1.1:

Bmd Changes in Calcium Group

On applying T-paired test on pre and post mean of -2.55and -2.440, with t value 0.182, results obtained are insignificantand are shown in the Table 1.2 and Fig.1.2.

Test Number Mean S.D. S.E.M. ‘t’ value

Pre 10 -2.71 1.05 0.3342.807

Post 10 -3.36 1.04 0.330

Table 1.2

Bmd Changes in Strength Training Group

On applying T-paired test on pre and post mean of 1.71and 0.91, with t value 4.202, results obtained are significantand are shown in the Table 1.3 and Fig.1.3.


Pre 10 -2.55 1.08 0.3440.182

Post 10 -2.440 1.51 0.480


Fig. 4.1: BMD changes in control group

Fig. 1.2: Bmd Changes In Calcium Group

107

Comparison of Group A and Group B

On applying unpaired T test on mean diff. of 0.65 and -0.11, with t value 1.175, results obtained are insignificant andare shown in the Table 1.4 and Fig.1.4.

Table 1.3


Pre 10 -3.43 1.17 0.3734.202

Post 10 -2.67 0.91 0.290

Comparison Between Group B And C

On applying unpaired T test on mean diff. of -0.11 and -0.76, with t value 1.031, results obtained are insignificant andare shown in the Table 1.5 and Fig.1.5

Table 1.4:


Pre 10 0.65 0.73 0.2321.175

Post 10 -0.11 1.90 0.604

Comparison of Group A and Group C

On applying unpaired T test on mean diff. of 0.65 and -0.76, with t value 4.799, results obtained are significant and areshown in the Table 1.6 and Fig.1.6

Table 1.5


Pre 10 -0.11 1.90 0.6041.031

Post 10 -0.76 0.57 0.181

Table 1.6:


Pre 10 -0.65 0.73 0.2324.799

Post 10 -0.76 0.57 0.181


Fig 1.3: BMD changes in Strength training group

Fig.1.4: Comparison Between Group A And Group B

Fig. 1.5: Comparison of Group B and Group C

Fig.1.6: Comparison Between Group A And C

108

Comparison of all the Three Groups

On applying ANOVA on mean diff. of 0.65, -0.11 and -0.76,with F value 3.314, results obtained are insignificant and areshown in the Table 1.7 and Fig.1.7Table 1.7:Group Number Mean S.D. S.E.M. F P

Diff. value value

Group A 10 0.65 0.73 0.232

Group B 10 -0.11 1.90 0.604 3.314 4.799

Group C 10 -0.76 0.57 0.181

Discussion

This study was conducted on 30 postmenopausal women.They were divided into three groups of 10 subjects each. GroupA control group, Group B on calcium supplementation and GroupC on strength training. Statistically significant change in BMDwas seen in the subjects undergoing strength training.Improvement in exercise group is according to Wolff’s law, whichstates that stress or mechanical loading applied to a bone viamuscle or tendon has a direct effect on bone formation andremodeling. While no significant improvement in BMD wasobserved the subjects on calcium supplementation. This isattributed to decreased calcium absorption. There was significantdecrease in BMD in control group due to lack of weight bearing.The results obtained between control group and calciumsupplementation were insignificant while between control andstrength training group were significant. The results obtainedbetween group B and group C were statistically insignificantthough marginal difference was found. However, when threegroups were analysed, the results obtained were insignificant.This can be due to small sample size and short interventionperiod. Bone is slow to adapt and seems more responsible toimpact forces. Possibly 12 week time is insufficient to showstatistically significant changes and therefore training periodsshould be extended. Though, our study indicates that strengthtraining may be important in preventing the negative healthoutcomes associated with age related loss of bone density.Similar results were recorded in study conducted by Chow et al7 studied the effect of two randomized exercise programmes onbone mass of healthy postmenopausal women. Both exercisegroups showed a significantly increased bone mass comparedwith controls. Similarly, Kelley et al8 reported that resistance

training had a positive effect on BMD in the lumbar spine ofwomen of all ages and at the femur and radius sites forpostmenopausal women. The study conducted by Going9

supported the benefit of resistance exercises demonstratingslowed bone loss and often an increase of 1%to 3% in regionalbone mineral density, especially in women. In a randomizedcontrolled trial of resistance training at 70-50% of 1RM, the totalweight lifted was significantly associated with the improvementin femur trochanter BMD. The association between volume oftraining and BMD change was examined by Cusseler et al10.Rhodes et al reported that statistically significant changes wereevident in effect of one year resistance training on relationbetween muscular strength and bone density in muscle functionperformances, from the results for the bench press, double legpress, biceps curl, triceps extension and quadricep extension.In the another study conducted by Taffe et al11 it was indicatedthat dynamic muscle strength is an independent predictor ofmineral density in older women accounting for 11-12% of thevariance in regional and whole body BMD. According to the studyon the effect of high intensity resistance exercise on bone mineraldensity and muscle strength of 40-50 year old womenemphasized loading the hips and lower back, with musclestrength gains being a secondary consideration, conducted byDoremann et al12, the resistance exercise program producedsome positive, but marginal, effects on vertebral bone densityafter 6 month training. Barclay and Desiree13 founded that manyelderly are not compliant with calcium supplementation.However, in the another study conducted by Maddalozzo et al14

comparing high intensity and moderate intensity training onBMD concluded that moderate intensity can produce similarchanges to high intensity training in older adults but a highermagnitude is necessary to stimulate osteogenesis at the spine.In the another study by Heffron et al15, effect of strength trainingfor 10 weeks in postmenopausal women did not show significantchanges in BMD at forearm, lumbar and hip regions but showedpositive effect on skeletal status at oscalcis level. There is paucityof data available on short term strength training inpostmenopausal women. Although very little research has beenfound that shows short term strength training significantlyinfluences bone strength. It has been reported that normalmuscle function and load bearing are necessary to prevent orretard bone loss in people with activity restriction.

Conclusion

Statistically significant improvement in bone mineral densityhas been found after 12 weeks of strength training. While, therewas a statistically significant decrease BMD in control groupafter 12 weeks. However, in group on calcium supplementation,we could not find significant improvement. In the present study,it was concluded that strength training causes increase in BMDmore than calcium supplementations.

References1. Rutherford O.M.1999. Is there a role for exercise in

prevention of osteoporotic fractures? British Journal SportsMedicine; 33:378-386

2. Multani N K and Verma SK 2007, Principles of GeriatricPhysiotherapy, 1st ED. Jaypee Brothers, 87-88.

3. Chamay A, Tshantz P 1972 Mechanical influences in boneremodeling. Experimental research on Wolff’s law.Biomechanics 5, 173-180 that stresses the skelton.BritishMedical Journal; 299:233-235.

4. Beverely M.C., Rider T.A., Evans M.J, and Smith R.1989.Local Bone Mineral response to brief exercises

5. Ayalon J, Simkin A, LeihterI and Raifmann S 1987. Dynamicbone loading exercises for postmenopausal women: effecton the density of the distal radius. J Arch Phys Med Rehab;8(5):80-283.


Fig. 1.7: Comparison of All the Three Groups

109

6. Zochling J, Nguyen T.V., March L.M. and Sambrook P.N.2004. Quantitative ultrasound measurements of bone:measurement discordance, and their effects on longitudinalstudies: Osteoporosis International; 15:619-624.

7. Chow R, Harrison J.E. and Notarius C. 1987. Effect of tworandomized exercise programmes on bone mass of healthypostmenopausal women .British Medical Journal; 295:441-1444

8. Kelley G A, Kelley K S and Tran Z V 2000. Exercise andbone mineral density in men: a meta-analysis. J AppliedPhysiology; 88(5):1730-1736.

9. Going S.B. 2009. Osteoporosis and Strength training.American Journal of Lifestyle Medicine;3(4):310-319

10. Cussler E.L., Lohman T.G., Going S.B., Houtkooper l.B.,Metcalfe L.L., Flint-Wagner H.G., Harris R.B. and TeixeiraP.J. 2003. Weight lifted in strength training predicts bonechange in postmenopausal women. Medicine and Sciencein sports; 5(1):10-17

11. Taffe D.R., Pruitt B., Lewis R., and Marcus R.1995. Dynamicmuscle strength as a predictator of bone mineral density inelderly women. Journal Sports Medicine Physical Fitness;35: 136-142

12. Dornemann T.M., Mcmurray R.G., Renner J.B. andAnderson J.J.B. 1997. Effects of high intensity resistanceexercise on bone mineral density and muscle strength of40-50 year women. Journal Sports Medicine PhysicalFitness; 37:246-251

13. Barclay L and Lie D. 2006. Many elderly are not compliantwith calcium supplementation: Arch Intern Med; 66:869-875

14. Maddalozzo, G.F., and C.M. 2000.High intensity resistancetraining: Effects on bone in older men and women. CalcifiedTissue International; 6:9-404.

15. Heffron M, Davery R and Cochrane T 1997.Weight trainingand bone mass. J Sports Exercise and Injury; 3(3):143-149.


110

Effectiveness of Coccygeal Manipulation in Coccydynia: Arandomized control trialSubhash M Khatri*, Peeyoosha Nitsure**, Ravi S Jatti****Principal, MGM Physiotherapy College, New Building, Nehru Nagar, Belgaum-590010, **Lecturer, ***Associate Professor, inPhysiotherapy Division, Dept. of Orthopaedics, J.N. Medical College, Nehru Nagar, Belgaum-590010

Abstract

Purpose

The purpose of this study was to find out the effectivenessof coccygeal manipulation in the management of coccydynia.

Design

Randomized control trial where the subjects were randomlyallocated to control & experimental groups.

Setting

Physiotherapy outpatient department of KLES Hospital,Belgaum, Karnataka state, India - 590010.

Participants

Subjects with idiopathic coccydynia.

Interventions

Phonophoresis, TENS & coccygeal manipulation.

Main Outcome Measures

Intensity of pain on visual analogue scale & pain free sittingtime.

Methods

Control group subjects were treated with phonophoresis,use of coccygeal pillow and TENS only. Experimental groupsubjects were treated with coccygeal manipulation in addition toabove protocol of the treatment.

Results

Subjects treated with coccygeal manipulation hadstatistically and clinically better out come in terms of pain reliefand pain free sitting time at the end of tenth treatment session.

Conclusions

Idiopathic coccydynia is somewhat common in obeseindividuals as it determines the way a subject sits. Coccygealmanipulation could be of help and can be used as an addition tothe conventional physiotherapy treatment.

Address for correspondence:Dr. Peeyoosha NitsureKLE Society’s Institute of Physiotherapy,New Building, Behind District Stadium,Belgaum 590010, Karnataka, IndiaEmail: [email protected]: +91 9844821355 Fax: +91831 24733333

Key Words

Coccydynia, manipulation, physiotherapy.

Introduction

The sacrococcygeal junction remains movable throughoutlife but, rarely, may fuse. Because of its muscular attachments,the coccyx is in constant motion, particularly in the act ofdefecation. Pressure is exerted against the posterior aspect ofthe bone in sitting, the coccyx acting as a shock absorber andmoving forward. Pain about the coccyx results from localconditions or is referred from other regions. Coccydynia orcoccygeal pain is a well-known but rarely studied painfulsyndrome affecting the coccyx region.1

Coccydynia is one of the painful conditions that limits sitting.Patients with traumatic injuries of the coccyx present with clear-cut picture such as acute pain and tenderness localized to thecoccyx. At other times the symptoms are so obscure that thepatients are considered neurasthenics. In addition to the painwhile sitting on hard surfaces, individuals who suffer fromcoccydynia may complain of pain on passing hard stool and onsit to stand transfers, possibly because of gluteal musclescontraction or sacroiliac dysfunction.2 Coccydynia may occurdue to various causes such as fall on the bottom of seat, a kick,obstetric trauma, passage of hard stool, hyper mobility of thesacroiliac joint, idiopathic3,4, coccygeal fracture, coccgealsubluxation & dislocation 5, obesity6, sacral haemangioma7,anatomical variation8,9 and avascular necrosis of the coccyx10.

Most of these causative factors may strain or tear thesacrococcygeal ligaments and the condition becomes chronicbecause the acts of sitting and defecation continually strain thealready injured ligaments. A constant annoying discomfort isexperienced and accentuated when sitting on a hard surface orduring defecation. Occasionally, bending forward is painful. Thesacrococcygeal joint is tender, and movement of the coccyx onrectal examination reproduces the pain11, 12.

Healthcare practitioners and patients themselves have trieddifferent clinical & non-clinical interventions so as to alleviatethe symptoms of coccydynia with variable outcomes. Theseinterventions include NSAIDS, tropical application of analgesicointment, local anesthetic injection, local steroid injection13,manipulations14,15, coccygectomy16,17, Cryoanalgesia18, stizbath19, coccygeal pillow, coccyx cushions (donut, doughnut, ring,roof rack) inflatable ring, bottom up sits, chairs (director’s chair,reclining chairs, kneeling chairs, chairs with coccyx cut outs,collapsible wheelchairs, use of two chairs without arms), stools(folding, tripod), sitting modifications (reclining, side sitting),advice on how to politely deny sitting and work more in standingand physiotherapy.

However, the conservative treatment approaches likephysiotherapy is well accepted. Physiotherapy treatmentinterventions like Diathermy with rectal electrode20, Levator anusmassage15, joint mobilization15, or mild levator stretch15,

ultrasound therapy, phonophoresis20,21 and TENS have beenused with variable outcomes.

Although physiotherapists in India witness and treatcoccydynia victims, there is very little information available aboutincidence, prevalence & methods of treatment used and theirefficacy. The present trend suggests that many of the

Subhash M Khatri/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

111

physiotherapists use local application of ultrasound,phonophoresis, TENS & advice to avoid prolonged sitting anduse of coccygeal pillow. However, the use of manual therapytechniques such as levator anus massage, coccygealmanipulation & mild levator stretch etc are not commonlypracticed due to varieties of reasons such as unawareness byvarious clinicians who refer these patients, lack of practical skillon Physiotherapists part & the reluctance by these patients toundergo these manual therapy techniques. Hence it was plannedto study the effectiveness of coccygeal manipulation as one ofthe manual therapy technique in the physiotherapy managementof coccydynia.

Method

Subjects

Thirty-six male & female subjects aged 20 to 55 years(mean age 31.06± 8.87) who had clinical diagnosis of idiopathiccoccydynia without any radiological change and referred tophysiotherapy outpatient department at KLE Hospital & MedicalResearch Center, Belgaum, India 590010 during 21.04.2001 to28.2.2007 participated in this study. The duration of symptomswas in the range of 15 days to 2 years with an average of 57±6days. These subjects were selected in a consecutive manner.However they were randomly allocated to either control orexperimental group. The inclusion criteria used was subjectswith idiopathic coccyx pain and who were willing to undergococcygeal manipulation if required. Subjects were excluded ifthey were unwilling to undergo coccygeal manipulations, hadlocal anesthetic injection in past three months and coccygealfracture.

Procedure

All the subjects were assessed prior to the interventionand if they satisfied the inclusion criteria then their pain intensityscore in Visual Analogue Scale was noted and their sitting timewithout pain was noted. Subjects were randomly assigned tocontrol group or experimental group. Control group subjects weretreated with phonophoresis and TENS. For phonophoresispurpose, pulsed therapeutic ultrasound with 1MHz frequencyand output of 0.5 W/cm² for 3 minutes in acute cases or 1W/cm²for 8minutes in chronic cases along with Pirox gel as a couplingmedium. For TENS, High Frequency TENS (Normal mode) wasgiven for 20 minutes in acute cases and Low Frequency TENS(Normal mode) was given for 30minutes in chronic cases. Thetreatment was continued for ten successive days with anexception of one weekly holiday. Experimental group subjectswere treated with coccygeal manipulation22 in addition to aboveprotocol of the treatment with phonophoresis and TENS. Forcoccygeal manipulation a member of the subject’s sexaccompanied the investigator. During manipulation subject wereinstructed to relax and take few deep breaths then the glovedand lubricated index finger of the right hand of investigator wasinserted into the anal passage so that it comes to rest againstthe anterior surface of the coccyx. The thumb of the other handof the investigator, also gloved but not lubricated was placed onthe dorsum of the coccyx to get a good grasp between the twofingers. The actual technique consisted of distraction of thecoccyx along its long axis for initial few treatments and thensubsequently an attempt was done to correct the alignment bycontrolled force in coronal plane. Both the group participantswere advised to use the coccygeal pillow as early as possibleand continue it for 3 months in future. All the participants whoparticipated in the study were advised to take Dolonex-DT 20mg(dispersible tablet) once a day at night which was an oralanalgesic for ten days and the topical application of Pirox gelwhenever they felt that their pain was severe during the ten

days of treatment. Patients were also strictly advised not to takeany sort of heat therapy till the completion of the study.

Results

The results of study were assessed in terms of the painrelief on VAS scale and pain free sitting time in minutes. Forstatistical analysis Graph pad InStat 3 demo software was used.The study results revealed average reduction of pain by 1.4 ±1.126 in control and 5.3 ± 1.768 in experimental group and theaverage pain free sitting time in control group was 23 ± 13.351minutes while as it was 47± 7.981in experimental groups. BMIin male subjects 31.8 ±2.7 and in female subjects it was 33.4±3.5.Table 1: Analyses for differences between the groups foroutcome measures

Statistic Pain relief Pain free sitting time (VAS score) (mins)

Analysis Control Experi- Control Experi-mental mental

Mean 1.4 5.3 23 47

SD 1.126 1.768 11.351 7.981

N 18 18 18 18

SEM 0.3981 0.6251 4.013 2.822

Unpaired 5.263 4.892t test value(df,14)

p value 0.0001* 0.0002*

* = Statistically significant

Discussion

The results of this study show highly significant differencebetween experimental and control group. The experimentalgroup subjects that were treated with coccygeal manipulationhad better outcome in terms of pain relief on VAS score andincreased pain free sitting time. This could be because of themechanical or neurophysiological effects of coccygealmanipulation that could modulate the pain through the stimulationof articular receptors type I & II. Alternatively it could be becauseof correction of mal alignment of coocygeal vertebrae that couldhave been the cause of mechanical pain22 and also due to the


Graph 1: VAS score difference between Control andExperimental groups

112

possibility of placebo effect. However, it was not possible to studythe cause and the effect relationship. It was also noted that theBMI was slightly higher in all the subjects. These findings are inaccordance with Maigne JY, Doursounian L, Chatellier G (2000)6

who studied the role of body mass index and found that bodymass index which represents the obesity as one of the risk factorin coccydynia as it (BMI) determines the way a subject sits down.However these findings are not in accordance with Wray CC,Easom S, Hoskinson J (1991)10 who reported that Physiotherapywas of little help but found that manipulation and injection wasmore successful and cured about 85% of their subjects. But thedetails about their subjects are unknown and their interventionwas combined with local anesthtc injection.

This study had few limitations like smaller sample size andthere was no 100% follow up of these subjects after the study.However, it is recommended that similar study can be done withlarger sample size with an added follow up for at leastconsiderable period of time.

Conclusion

Idiopathic coccydynia is somewhat common in obeseindividuals as it determines the way a subject sits. Coccygealmanipulation could be of help and can be used as an additionto the conventional physiotherapy treatment.

References

1. Jose De Andrés and Santiago Chaves. Coccygodynia: Aproposal for an algorithm for treatment. Journal of Pain2003; 6(4): 5.

2. Carrie M Hall & Lori Thein Brody.Therapeutic exercises-Moving Towards Function. Lippincott Williams & Wilkins,Philadelphia 1999; 353-385.

3. Maigne J, Guedj S, Straus C (1994). Idiopathiccoccygodynia Spine, vol. 19 No.8: P.930-34

4. Postacchini F, Massobrio M (1983). IdiopathicCoccygodynia. Analysis of Fifty-one Operative Cases and

a Rabiographic Study of a Normal Coccyx. Journal of Boneand Joint Surgery.Vol: 65, P.1116-24

5. Maigne JY, Lagauche D, Doursounian L (2000): Instabilityof the coccyx in coccydynia, J Bone Joint Surg Br Sep;82(7): 1038-41.

6. Maigne JY, Doursounian L, Chatellier G (2000). Causesand mechanisms of common coccydynia: role of body massindex and coccygeal trauma, Spine 2000 Dec 1; 25(23):3072-9

7. Latha R, Rajshekhar V and Chacko G. Sacral haemangiomaas a cause of coccydynia. Neuroradiology 1989; 40(8): 524-6.

8. Lourie J, Young S. Avascular necrosis of the coccyx: a causeof coccydynia? Case report and histological findings in 16patients. Br J Clin Pract 1985; 39(6): 247-8.

9. Falzoni P, Boldorini R, Zilioli M, Sorrentino G (1995) Thehuman tail. Report of a case of coccygeal retro position inchildhood, Minerva Pediatr 1995 Nov; 47(11): 489-91

10. Wray CC, Easom S, Hoskinson J.Coccydynia. Etiology andtreatment. J Bone Joint Surg Br 1991;73(2): 335-8

11. Polsdorfer Ricker (1992), Three case studies:Coccygodynia and the Orthopaedic Rectal Examination.Journal of Orthopaedic medicine vol; 14: 1-13.

12. Traycoff RB, Crayton H, Dodson R (1989). SacrococcygealPain Syndromes: Diagnosis and Treatment. Orthopedics.Oct.12 (10). P.1371-77.

13. Fogel GR, Cunningham PY 3rd, Esses SI (2004):Coccygodynia: evaluation and management, J Am AcadOrthop Surg, Jan-Feb; 12(1): 49-54.

14. Beckenstein L (1969). Coccygodynia. ACA Journal of Chiropractic. 1969 Sept., Vol.: 6(9). P.57-61.

15. Maigne JY, Chatellier G.Comparison of three manualcoccydynia treatments: a pilot study. Spine 2001; 26(20):E479-83, E484.

16. Saris SC, Silver JM, Vieira JF, Nashold BS Jr (2000):Sacrococcygeal rhizotomy for perineal pain, Midwifery 2000Jun; 16(2): 155-60

17. Pennekamp PH, Kraft CN, Wallny T, Schmitt O, Diedrich O(2003): Coccygectomy in the treatment of coccygodynia,Zeitschrift fur Orthopadie und ihre Grenzgebiete, Sep-Oct;141(5): 578-82.

18. Evans PJ, Lloyd JW, Jack TM. Cryoanalgesia for intractableperineal pain. J R Soc Med Nov 1981; 74(11): 804-9.

19. Duncan GA (1937). Painful coccyx, Arch Surg, 14,1088-1104, in Kovacs R: Electrotherapy and light therapy, Leaand Febiger, Philadelphia, 1949.

20. Kovacs R. Electrotherapy and light therapy. Lea andFebiger, Philadelphia 1949; 242 & 559.

21. Thiele GH. Coccygodynia. Jour Am Med Assn 1937; 109:16, in Kovacs R: Electrotherapy and light therapy, Lea andFebiger, Philadelphia, 1949.

22. Polkinghorn BS; Colloca CJ (1999): Chiropractic treatmentof coccygodynia via instrumental adjusting proceduresusing activator methods chiropractic technique, JManipulative Physiol Ther, Jul, 22:6, 411-6.


Graph 2: Pain Free Sitting Time in minutes

113

Effect of Warm-up and Cool-down on Delayed-onset MuscleSoreness in University StudentsBhatia P*, Arun***Associate Professor, Department of Physiotherapy, Guru Jambheshwar University of Science and Technology, Hisar, **BPT Finalyear student

Objective

The objective of this study is to determine the effects ofwarm-up and cool-down on muscle soreness following eccentricexercise.

Participants

A total 40 healthy university students were participated inthe study (17-27 years).

Methods

Physical Activity Readiness Questionnaire was taken fromparticipants and Response as ‘No’ to all questions wasconsidered as inclusion criteria. All participants were divided infour groups equally. Warm-up and cool down was done ontreadmill. The exercise was designed to induce muscle sorenessin the gastrocnemius muscle. Each exercise included 20repetitions in three sets (3×20 repetitions).

Outcome Measures

Muscle soreness was measured on a visual analogue scaleand 10-point numerical rating scale.

Results

Analysis shows that Warm-up is more effective than Cooldown in reducing Delayed onset muscle soreness.

Conclusion

Warm-up performed prior to eccentric exercise producessmall reductions in delayed-onset muscle soreness but cool-down performed after does not.

Key Words

DOMS,Warmup,Cooldown,Eccentric exercise.

Introduction

All forms of exercise, if carried out vigorously enough, canbecome painful. But only one form of exercise, eccentricexercise, if we are unaccustomed to it, leaves us stiff and sorethe next day. This sore is called muscle soreness. Exercise -induced muscle soreness can be classified as either acute onsetor delayed onset. Acute onset muscle soreness occurs duringexercise and may last up to 4 to 6 hours before subsiding.Delayed onset muscle soreness (DOMS) has onset 8 to 24 hourspostexercise, with soreness peaking 24 to 48 hourspostexercise. DOMS is thought to be a result of microscopicmuscle fiber tears and is more common after eccentric exercise(the muscle must lengthen or remain the same length against aweight) rather than concentric exercise (the muscle can shortenagainst a weight load). While DOMS is not a disease or disorder,it can be painful and is a concern for athletes because it canlimit further exercise in the days following an initial training. In

most cases, DOMS will resolve spontaneously within 3 to 7 days.There is some evidence that ibuprofen, naproxen, and massagemay accelerate the resolution of DOMS.

Treatment strategies have often integrated multipletherapeutic approaches such as cryotherapy, ultrasound,compression therapy, stretching and deep tissue massage. Inaddition, several dietary supplements have been tested in thetreatment of DOMS including protein, vitaminC, proteases(enzymes), phosphatidylserine, chondroitin sulfate, and fish oil,all with variable success. There is no clear consensus in theextent literature on a method or discipline that can effectivelyrelieve pain following eccentric exercise.

Warm-up (gentle exercise preceding vigorous physicalactivity) is said to reduce muscle strain injuries by increasingmuscle temperatures, and hence muscle compliance. Theeffects of heating on the contractile properties of skeletal musclehave been studied extensively. Also it has been shown thatincreasing muscle temperature increases the speed of musclecontraction, thereby decreasing both time to peak tension andhalf relaxation time. The warm-up can assist in injury preventionand is seen as an integral part of the coaching session or match.It can set the tone and attitude for the coaching session or matchthat will follow. The functional dynamic warm-up has beendefined as “a comprehensive approach to training orrehabilitation that addresses all performance components (i.e.strength, power, balance, vision, coordination, reaction, agility,acceleration and deceleration) necessary to achieve successin any target activity”.

Cool-down (gentle exercise after vigorous physical activity;also called warm-down) should occur immediately after activityas part of the recovery process, and while the athletes still havean elevated body temperature. Through many studies have beendone and various methods are used to reduce delayed onsetmuscle soreness (DOMS), they are inconclusive. So the presentis study focuses on evaluating the efficacy of warm-up and cool-down on delayed onset muscle soreness (DOMS).

Method

Subject and Design

A total 40 healthy university students (17-27 years) wereallocated timely and sampled with simple random sampling toone of four groups (10 participants per group). Each participantwas allocated to one of four groups: a warm-up and cool-downgroup, a warm-up only group, a cool-down only group, or Nowarm-up and cool-down group.

A Physical Activity Readiness Questionnaire was also takenand Response as ‘No’ to all questions was considered asinclusion criteria.

They were excluded if Prior to randomization they:- -Were already experiencing delayed onset muscle soreness

(DOMS). -Did not consider themselves capable of performing the

exercises. -And Response as ‘Yes’ to one or more questions on the

Physical Activity Readiness Questionnaire.

Bhatia P/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.2

114

Procedure

Each participant was allocated to one of four groups. Eachgroup contained 10 participants. Each participant was rested ina seated position for 10 minutes. Participants in the two warm-up groups performed the 10-minute warm-up on treadmill. Thenparticipants performed eccentric exercise to induce musclesoreness. Immediately after the exercise, participants in the twogroups that cooled down performed the 10-minute cool-downon treadmill similar to the warm-up. Participants in the two groupsthat did not cool down rested in sitting for further 10 minutes.

Muscle soreness was induced using unaccustomedeccentric exercise. The exercise was designed to induce musclesoreness in the gastrocnemius muscle of the right leg andEccentric calf-muscle loading with the knee straight. From anupright body position and standing with all body weight on theventral half-part of the right foot, with the ankle joint in plantarflexion lifted by the left leg, the calf-muscle was loadedeccentrically by having the participants to lower the heel beneaththe lever. Each of the two exercises included 20 repetitions inthree sets (3×20 repetitions).

Outcome Measures

Soreness was rated on two scales: a 100-mm visualanalogue scale anchored at ‘no pain and most severe pain’ anda 10-point numerical rating scale anchored at ‘none’, and ‘worstpossible’. Tenderness was measured 10 minutes, 24, 48 and72 hours after exercise.

Data Analysis

The experimental study was conducted to know the effectof Warm-up and Cool down on delayed onset muscle soreness.

Statistical analysis using ANOVA and T-test is conductedfor each follow-up time (10 minutes and 24, 48, 72 hours). Allgroups ( a warm-up and cool-down group, a warm-up only group,a cool-down only group, or No warm-up and cool-down group)are analyzed at four time intervals(10 minutes and 24, 48, 72hours) on two different scales VAS (visual analogue scale) andNRS (10-point numerical rating scale) and Compared at 48 hr.The statistical analysis is performed with significant level p<0.05.

Results

The analysis prove that the results of group Warm-up andCool down are significantly different from results of group Cool

down only on VAS (visual analogue scale) and NRS (10-pointnumerical rating scale) as proved through ANOVA and T-test atsignificant level of <0.05.

The mean scores evaluated at VAS (visual analogue scale)were as follows:

In first group where Warm-up and Cool down both weregiven the mean scores were 0.3 at 10 minutes and weremaximum (32.9) after 48 hrs. Similarly for 2nd (Warm-up only)and 4th (No Warm-up and Cool down) groups, VAS (visualanalogue scale) scores were found to be maximum at 48 hrs.

In the 3rd group where only Cool down was given, VAS(visual analogue scale) scores tend to be maximum at all theintervals when compared to other groups.

The mean scores evaluated at NRS (10-point numericalrating scale) were as follows:

In first group where Warm-up and Cool down both weregiven, the mean scores were 0 at 10 minutes and were maximum(3.6) after 48 hrs. Similarly for 2nd (Warm-up only) and 4th (NoWarm-up and Cool down) group NRS (10-point numerical ratingscale) scores were found to be maximum at 48 hrs. The scoresare 3.7 and 4.2 respectively.

In the 3rd group where only Cool down was given, NRS(10-point numerical rating scale) scores tend to be maximum atall the intervals when compared to other groups. The meanscores were 0.3 at 10 minutes and were maximum i.e. 4.4 after48 hrs.

Analysis throws light on the fact that Warm-up is moreeffective than Cool down in reducing Delayed onset musclesoreness occurring after eccentric exercises.

Discussion

This study was to determine the effects of warm-up andcool-down on muscle soreness following eccentric exercise.

Table 1: Visual Analogue Scale (VAS) mean scores of all groupsat different time intervals.

Groups 10 mint. 24 Hr. 48 Hr. 72 Hr.

Warm-up and 0.3 24.2 32.9 14.2Cool down

Warm-up only 0.8 23.6 34.7 17.3

Cool down only 2.3 28 42.2 20

No Warm-up and 1.4 27.8 41.4 18.6Cool down


Fig. 1: Participant performing eccentric exercise

Graph 1: Comparison of Delayed Onset Muscle Soreness onVisual Analogue Scale (VAS)

115

Table 2: 10 Point Numerical Rating Scale (NRS) mean scoresof all groups at different time intervals

Groups 10 mint. 24 Hr. 48 Hr. 72 Hr.

Warm-up and 0 2.3 3.6 1.2Cool down

Warm-up only 0 2.4 3.7 1.7

Cool down only 0.3 2.9 4.4 1.9

No Warm-up and 0.1 2.6 4.2 1.8Cool down

Our results showed that warm-up produced a smallreduction in muscle soreness that was most apparent 48 hoursafter exercise. Cool-down only did not reduce muscle soreness.

Roberta YW Law and Robert D Herbert (2007) noticed theeffect of warm-up and cool down on delayed onset musclesoreness and their results were in accordance with the presentstudy. They said that warm-up could reduce delayed-onsetmuscle soreness: the increase in muscle temperature associatedwith warm-up could increase the compliance of structures inseries with myofibrils. This would reduce the degree of stretchexperienced by myofibrils, which could decrease the myofibrillardamage that occurs with unaccustomed exercise and theresulting muscle soreness. They demonstrated that cool-downperformed immediately following eccentric exercise does notreduce delayed-onset muscle soreness because Cool-down isperformed after the events that initiate eccentric exercise-induced muscle damage.

Similarly William Kirk Isabell et al (1992) studied the effectof exercise on prevention and treatment of delayed onset musclesoreness and found there was no significant difference ofexercises with or without ice massage on delayed onset musclesoreness.

Previous study by Craig A. Smith (1994) is in accordancewith the results showing that a mild warm-up period shouldprecede the stretching exercises. He adds that warmer musclesare more extensible, leading to less injury when stretched aswell as increased gains in flexibility. This rationale has furthersupporting evidence. He also demonstrated that heat alone didnot cause an increase in hip range of motion (ROM), and thatstretching resulted in to movements being increased, while heatand stretching combined resulted in the greatest increase inflexibility.

Fu-Shiu Hsieh (2009) also did a related study and heexplained that Warm-up before exercise could increase bloodflow of whole body, increase muscles and skin temperature,

prevent injury within exercise.Passive warm-up can increase temperature of muscles as

active warm-up do, but it won’t cause the muscle fatigue. Theadequate warm up before exercise, not only decreased muscledamage occurred but also elevated skin and body temperaturethrough increased whole blood volume in athletes, and improvedexercise performance.

All these studies support the effect of warm-up in reducingmuscle soreness. The cool down is performed after the eventthat initiate eccentric exercise induce muscle damage. Thepresent study demonstrates that cool down has no appreciableeffect on muscle soreness.

Conclusion

This study concluded that the Warm-up is more effective inreducing Delayed onset muscle soreness than Cool down inuniversity students.

References

1. Charles D Clccone, Brian G Leggln, John J Callamaro“Effects of Ultrasound and Trolamine SalicylatePhonophoresis on Delayed-Onset Muscle Soreness”,Physical Therapy volume 71, 9 September 1991.

2. Craig A. Smith “The Warm-up Procedure: To Stretch or notto Stretch. A Brief Review”, Volume 19 Number I January1994 JOSPT.

3. Erin E. Krebs, Timothy S. Carey, and Morris Weinberger“Accuracy of the Pain Numeric Rating Scale as a ScreeningTest in Primary Care” J Gen Intern Med 22(10):1453–8.

4. Fu-Shiu Hsieh et al, “The Effects of Passive Warm-Up WithUltrasound in Exercise Performance and Muscle Damage”ICBME, 2009, 23, pp.1149–1152.

5. Jay K Udani, Betsy B Singh, Vijay J Singh and ElizabethSandoval “Bounce Back™ capsules for reduction of DOMSafter eccentric exercise: a randomized, double-blind,placebo-controlled, crossover pilot study”, Journal ofthe International Society of Sports Nutrition 2009, 6:14.

6. John n. Howell, Gary Chleboun and RobertConatser(1993)”Muscle stiffness, strength loss, swellingand soreness following exercise-induced injury in humans”,Journal of Physiology, 464, pp. 183-196.

7. Kisner C., Colby L.A., “Therapeutic Exercise-foundation andtechniques” 4th edition, p 100.

8. M J Cleak and R G Eston “Muscle soreness, swelling,stiffness and strength loss after intense eccentric exercise”,J Sports Med 1992, 26: 267-272.

9. N. Mafi R. Lorentzon, H. Alfredson “Superior short-termresults with eccentric calf muscle training compared toconcentric training in a randomized prospective multicenterstudy on patients with chronic Achilles tendinosis KneeSurg”, Sports Traumatol, Arthrosc (2001) 9, 42–47.

10. Roberta YW Law and Robert D Herbert(2007)”Warm-upreduces delayed-onset muscle soreness but cool-downdoes not: a randomized controlled trial”, Australian Journalof Physiotherapy 2007 Vol. 53.

11. Stephan du Toit “Practical guidelines for the warm-up andcool-down in rugby”, Copyright BookSmart 2009.

12. Susan Gray, Myra Nimmo “Effects of active, passive or nowarm-up on metabolism and performance during high-intensity exercise”, Journal of Sports Sciences 2001, 19,693-700.

13. U. Proske and D. L. Morgan “Muscle damage from eccentricexercise: mechanism, mechanical signs, adaptation andclinical applications” Journal of Physiology (2001), 537.2,pp.333–345.

14. Wewers M.E. & Lowe N.K. “A critical review of visualanalogue scales in the measurement of clinicalphenomena”, research in Nursing and Health 13, 227-236.


Graph 2: Comparison of Delayed onset Muscle Soreness on10 Point Numerical Rating Scale (NRS)

116

15. William Kirk Isabell, Earlene Durrant, William Myrer, ShaunaAnderson, “The Effects of Ice Massage, Ice Massage withExercise, and Exercise on the Prevention and Treatmentof Delayed Onset Muscle Soreness” Journal of Athletic

Training Volume 27,Number 3,1992.16. Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein

ML, Schwartz P, Wong’s Essentials of Pediatric Nursing,ed. 6, St. Louis, 2001, pp.1301.


117

Comparison of Jacobson’s Progressive Muscle Relaxation andDiaphragmatic Breathing on Cardio-respiratory Parameters inHealthy Adults – A Randomized cross over trialPrem V*, Bhamini Krishna Rao*, Arun Maiya Gundmi***Associate Professor, **Professor, Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal University,Manipal, Karnataka, India

Abstract

Introduction

To compare the effectiveness between diaphragmaticbreathing exercise (DBE) and Jacobson’s progressive musclerelaxation (JPMR) technique compared to control supine lyingon cardiorespiratory parameters in healthy men.


Randomized cross-over study design. Thirty healthy malevolunteers were randomly assigned by block randomization intothree groups (Group A, B and C). Subjects in each group wereexposed to three experimental relaxation techniques in threedifferent sequences with one week of washout period. The threetechniques used for the study were JPMR, DBE and supinelying was chosen as a control technique. Subjects underwenttwo sessions of relaxation technique in a day followed bywashout period of one week, then followed by other tworelaxation techniques according to assigned groups. The cardio-respiratory parameters selected for measurement were SystolicBlood Pressure (SBP), Diastolic Blood Pressure (DBP), Heartrate (HR) and Respiratory Rate (RR).

Findings

Two- way ANOVA for repeated measure showed a decreaseof SBP by 8.4mmHg, DBP by 3.6mmHg, HR by 6.20beats\minute, and RR by 4.57 breaths\minute following 12minutes of diaphragmatic breathing exercise with p<0.0001.Multiple comparison with bonferroni method showed DBE hadsignificant decrease in all the variables measured, compared toJPMR and control supine lying with p< 0.05.

Conclusion

Diaphragmatic breathing technique is effective in thereduction of cardiorespiratory parameters compared tojacobson’s progressive muscle relaxation and control supinelying in healthy men.

Key Words

Diaphragmatic breathing, Jacobson’s progressive musclerelaxation, relaxation, stress management.

Introduction

Stress is commonest cause of health problems in modernsocieties. 1 Stress has been reported to account for 80% of

Address for correspondence:Mr. Prem VM.P.T, Associate ProfessorDepartment of Physiotherapy, Manipal College of Allied HealthSciences, Manipal University, Manipal, Karnataka, IndiaEmail: [email protected]

modern day diseases and at least 75% of general practitionerconsultation.2

Stress results in stimulation of two endocrine responsesystems, the hypothalamic-pituitary- adrenocortical axis (HPA)and the sympathetic-adrenal-medullary (SAM) system.Prolonged or repeated activation of HPA and SAM systems caninterfere with their control of other physiological systems,resulting in increased risk for physical and psychiatric disorders.Conditions associated stress includes four major diseases:clinical depression, cardiovascular disease (CVD), humanimmunodeficiency virus (HIV)/AIDS, and cancer.3

The impact of stress on the health of people has causedrising interest among health professionals, resulting in anincreased amount of research into particular strategies forpromoting stress reduction, including relaxation techniques. 4Jacobson’s Progressive Muscle Relaxation (JPMR) is acommonly used technique among physiotherapists to inducerelaxation. JPMR, the most popular approach in practicecomprising diaphragmatic breathing and systematic sequenceof isometric contractions, which progresses slowly throughoutthe body.5 JPMR has been shown effective in various clinicalsettings such as cardiac rehabilitation programs6, pulmonaryrehabilitation programs 7, neurological rehabilitation 8, and painmanagement. 9

Breathing exercise is widely used as an aid in reducinganxiety states. It has been shown effective in some cases ofessential hypertension, angina, functional chest disorder, chronicobstructive pulmonary disease (COPD) and cardiacrehabilitation.10 Most of the studies on hypertension have shownsignificant reduction in blood pressure 11-17 whereas few studieshave shown no significant difference in blood pressure.18-21

Further, it has been shown to be effective in heart failure patients22, and ineffective following post myocardial infarction or postcoronary artery bypass grafting on autonomic function. 23

Comparison of progressive muscle relaxation and breathingexercise on psychological effects revealed greater relaxation inprogressive muscle relaxation group. 24 There is no publisheddata to the best of our knowledge, comparing progressiverelaxation to the diaphragmatic breathing on cardiorespiratoryparametres. The cardiorespiratory parameters reported to beinfluenced by relaxation were systolic and diastolic bloodpressure, heart rate and respiratory rate.4, 25, 26 This study aimsto compare the effectiveness of Jacobson’s progressive musclerelaxation, diaphragmatic breathing exercise and control-supinelying on cardiorespiratory parameters in normal subjects.

Material & Methods

Subjects

This study was a randomized crossover design and subjectsacted as their own control. Thirty healthy men aged 20-25 yearswho volunteered were included for the study. Subjects wereexcluded if they had family history of diabetes mellitus, stroke,myocardial infarction, cardiovascular disease, and alsodiagnosed psycho physiological disorders, history of smoking,alcoholism and previous relaxation training. The study wasapproved by University Ethics Committee and all subjects gaveinformed consent. Subjects were randomly assigned to three

Prem V / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

118

groups (A, B and C) with 10 subjects in each group throughblock randomization. Subjects in each group were exposed totwo relaxation techniques and the control technique of supinelying in three different sequences.

Treatment

During the first week of the study, group A received twosessions of 25-mins of supine lying. Following the completionof two sessions of the intervention, a one-week rest period wasimplemented. This was done to minimize any carry-over effectof the treatment sessions. JPMR of two sessions of 25-minduration and diaphragmatic breathing exercise of two sessionsof 12-minute duration was given during second and third weekrespectively. It has been shown that sizeable effects of relaxationtraining can be seen after only two treatment sessions.27 GroupB and C underwent three interventions in different sequencewith study period of three weeks each, as listed earlier. Tominimize variability, the same environment was chosen for thewhole duration of the study, and all measurements were takenby the same person. Data were collected at the same timeeach day and in the same order. Instructions for relaxationtechniques were given through a recorded cassette, in order toavoid bias.

Jacobson’s Progressive Relaxation

The “relaxation lesson” gives orders to the subject regardingscheme of instructions incorporating contraction and relaxationof all major muscle groups for 20 minutes, followed by 5mins ofdiaphragmatic breathing.

Diaphragmatic Breathing

Subjects were positioned in crook-lying position with a pillowfor head support. The following instructions were given over thetape recorder: “I would like you to breathe diaphragmatically.First, place your left hand on your abdomen. Now breathethrough your nose so that your hand rises as you inhale andfalls as you exhale. Try not to move your upper chest. Let theair out slowly”. Subjects were instructed to breathediaphragmatically for 1minute interspersed with an interval of1minute for a period of twelve minutes .28

Control Supine Lying

Subjects were requested to lie supine with legs uncrossed,head and neck supported by a single pillow for 25 minutes.

Assessment procedures

An acclimatization period of ten minutes was used tominimize natural fluctuations in body temperature and heart ratedue to prior activity. Systolic and diastolic pressures weremeasured on the dominant arm, using a manualsphygmomanometer. Heart rate was measured over 30 secondsby palpating the pulse at the radial artery. Respiratory rate wasmeasured visually by recording inspiratory excursions over oneminute.


Statistical analysis was performed using the StatisticalPackage for Social Science (SPSS) version 13.0 software, p-value of <0.05 with confidence interval of 95% was consideredstatistically significant. Two way ANOVA was performed toanalyse the data within the group and between the groups.Multiple comparisons were performed using bonferroni method.

Findings

The Mean data of pre-intervention showed no significant(p>0.05) difference between the three experimental groups priorto any of the intervention methods, confirming the homogeneityof the sample and the randomization of allocation. Two- wayANOVA for repeated measure result shows that there issignificant difference between pre and post treatment andamount of difference is significantly different between the groupsfor all the parameters. Further, multiple comparison shows thatamount of change in pre to post is highly significant in all thethree groups and in all the parameters Table 1.

Further attempt was made to compare changes in all thegroups by performing multiple comparisons by Bonferroni testin table 2. It was observed comparison of Jacobson’s progressiverelaxation and diaphragmatic breathing showed significantamount of increase in systolic blood pressure (14.20 mmHg,p<0.0001), diastolic blood pressure (7.73 mmHg, p<0.0001),heart rate (9.00 beats/ min, p<0.0001) and respiratory rate (3.56breaths/min, p<0.0001) in Jacobson’s progressive relaxation. Itwas observed comparison of Jacobson’s progressive relaxationand control supine lying showed significant amount of increasein systolic blood pressure (9.20 mmHg, p<0.0001), diastolicblood pressure (5.73 mmHg, p<0.0001), heart rate (6.53 beats/min, p<0.0001) and no significant difference in respiratory rate(0.70 breaths/min, p=0.20) in Jacobson’s progressive relaxation.It was observed comparison of diaphragmatic breathing andcontrol supine lying showed significant amount of decrease in

Table 1: Multiple comparisons by bonferroni method toinvestigate differences (Diff), standard deviation (SD) betweenpre and post in SBP, DBP, HR and RR following intervention

SBP mm DBP mm HR beats RR breathsHg Hg /min /min

Diff (SD) Diff (SD) Diff (SD) Diff (SD)

Diaphra 8.47 3.60 6.20 4.57gmatic (3.30) * (3.94) * (4.58) * (2.32) *

Jacobson 5.73 4.13 2.80 1.00(2.19) * (4.10) * (4.91) * (2.15) *

Control 3.47 1.40 3.73 1.70supine (1.73) * (1.90) * (4.25) * (1.66) *lying

P<0.0001*

Table 2: Multiple comparison Bonferroni method to investigatedifferences (Diff), Standard error (SE) between three treatmentmethods

SBP mm DBP mm HR beats RR breathsHg Hg /min /min

Diff SE Diff SE Diff SE Diff SE

Controlsupine 9.20 5.53 6.53 0.70(0.54)lying VS (0.42) * (0.84) * (1.12) * (P=0.207) *JacobsonControlsupine 5.00 2.20 2.46 2.86lying VS (0.64) * (0.61) * (1.01) * (0.53) *DiaphragmaticJacobsonVS 14.20 7.73 9.00 3.56Diaphra (0.78) * (0.97) * (1.10) * (0.57) *gmatic

P < 0.05


119

systolic blood pressure (5.00 mmHg, p<0.0001), diastolic bloodpressure (2.20 mmHg, p<0.0001), heart rate (2.46 beats/ min,p<0.02) and respiratory rate (2.86 breaths/min, p<0.0001) indiaphragmatic breathing group.

Discussion

The analysis showed that the order in which theinterventions were received did not influence the reductions inthe physiological parameters of three treatment techniques(p>0.05), which ensured that differences recorded were as aresult of the intervention received.

According to Benson, relaxation response occurs when BPis reduced by 5 mm Hg, HR is by 3 beats/minute and RR by 2breaths /minute.29 The present study showed a significantdecrease in systolic blood pressure (8.4mmHg), diastolic bloodpressure (3.6mmHg), heart rate (6.20 beats\minute) andrespiratory rate (4.57 breaths\ minute) following diaphragmaticbreathing exercise. Thus the amount of decrease incardiorespiratory parameters suggest occurrence of relaxationresponse following diaphragmatic breathing, which is inaccordance with the Benson’s relaxation response.

Jacobson’s progressive relaxation resulted in significantincrease in blood pressure compared to supine lying group. Thefindings of the present study contradicts earlier study showingsignificant reduction in blood pressure following Jacobson’sprogressive relaxation 27,30-33 and in accordance with studiesrevealing significant increase in blood pressure.34,35,36 Severalvariables that are assumed to be critical for the success of aJacobson’s progressive relaxation technique are difficult tomeasure. For example, the type of therapy and the clinical skillsof the therapist. Even more difficult to assess, are the patientscharacteristics and interactions with the therapist, which couldhave influenced the outcome of the study.34

In diaphragmatic and the control group, there was asignificant reduction in blood pressure and heart rate. It ispossible that the observed effects were consequence of reducedphysical activity, as heart rate and blood pressure are known tobe correlated with the level of activity. At rest, approximatelytwo-thirds of blood volume is stored in the veins, as non-activetissues require fewer nutrients than active tissues, and produceless metabolic waste. Parasympathetic activity increases,liberating acetylcholine and reducing heart rate. In the presentstudy, a ten minute rest period was given prior to intervention,and as heart rate returns to pre exercise level in approximatelytwo minutes, 37 it is unlikely that further reduction in bloodpressure would result from rest alone. The findings from ourstudy suggest that, supine lying of 25 minutes duration, eliciteda relatively small reduction in blood pressure, compared to thesignificant reductions in diaphragmatic breathing with treatmentduration of 12 minutes. This ensures reduction in blood pressureis due to diaphragmatic breathing alone and not an effect ofphysical inactivity.

The present study shows a drop of SBP by 8.4mmHg andDBP by 3.6mmHg, following 12 minutes of diaphragmaticbreathing exercise. The amount of decrease is similar to thepharmacology treatment of hypertension which results inreduction of SBP by 9.1 mmHg and DBP by 5mmHg.38

Reduction in blood pressure by 8/3 mmHg in the presentstudy is substantial when compared to other acceptednonpharmocology therapies. Independent and combined effectsof weight loss and aerobic exercises on blood pressure andreduced salt dietary intake reduced BP by 6/5 and 6/2 mmHg,respectively.39, 40

The possible mechanism to modulate blood pressure isthrough slow and regular breathing affecting reflex control ofcardiovascular system. More specifically lung inflation whichincreases with decreasing respiratory rate, stimulates slowlyadapting pulmonary stretch receptors. This neural activity actsas an input to the medulla and is integrated with the information

about BP level generated by the arterial baroreceptors. As anacute response to BP elevation and/or lung inflation, heart rateis decreased and vasodilatation occurs in a number of vascularterritories, such as the limbs, skin, muscles, kidney andsplanchnic vascular bed.12

The central mechanism responsible for relaxation responseis due to stimulation of the trophotropic center in thehypothalamus resulting in generalized parasympathetic activity.The role of the cardiovascular system in homeostasis can beonly achieved adequately, if there is integration of cardiovascularand respiratory function. This occurs due to the close anatomiclocation of the cardiovascular receptors, respiratory receptorsand pulmonary receptors in the medulla. Parallel changes occurin cardiac output, and respiratory minute volume in relation tothe change in level of activity, and metabolic demand. Largebodies of evidence indicate that extensive interactions occurbetween those reflexes that provide, moment by momentregulation of the cardiovascular system, and respiratory system.The primary sites of interaction of arterial chemoreceptors,receptors within the heart as well as the airway and lungs withinthe central nervous system is at the level of nucleus tractussolitarius the potential site of cardiorespiratory integration.41

Recent study has shown diaphragmatic breathing exerciseresulted in decrease of cortisol level. Thereby DBE is able toalter the hypothalamicpituitary- adrenocortical axis, whichcauses stress related diseases. 42 This could be an otherpossible mechanism leading to decrease in blood pressureand heart rate following diaphragmatic breathing exercise.

Further heart rate reduction could be attributed to theinspiratory stage of diaphragmatic breathing, causing increasein thoracic volume resulting in flattened diaphragm. This causesincrease in intra abdominal pressure and compresses abdominalveins increasing venous blood flow towards the heart. Thus,the improved venous return increases stroke volume causing areduction in heart rate to maintain cardiac output at anappropriate level.43

Peddicord suggested that breathing techniques could beused alone for stress reduction, and do not need to beincorporated into generalized relaxation techniques to elicit therelaxation response.4 Further study by Bell comparing Mitchell’srelaxation and diaphragmatic breathing concluded thatdiaphragmatic breathing can be used alone to induce relaxationand need not be incorporated into generalized relaxationprocedures.44 The findings of our study are consistent with theirresearch. Diaphragmatic breathing is a more efficient breathingpattern with less muscle work causing relaxation of neck andshoulder muscles during breathing. Further Jacobson’sprogressive relaxation is time consuming and needs effort tofollow the instructions by the subjects compared to diaphragmaticbreathing exercise. DBE is quicker, more cost effective, andeasier to learn by the subjects.

Conclusion

This study provides evidence of reduction incardiorespiratory parameters following diaphragmatic breathingtechnique compared to jacobson’s progressive muscle relaxationand control supine lying in healthy men.

Acknowledgements

I would like to thank the faculty and the department ofphysiotherapy, Manipal College of Allied Health Sciences,Manipal University.


There is no conflict of interest.


120

References

1. Brigitte MK, Stefan WS. Human models in acute and chronicstress: Assessing determinants of individual hypothalamus–pituitary–adrenal axis activity and reactivity. Stress 2010;13: 1–14.

2. Looker T, Gregson O. Stress wise: A practical guide fordealing with stress, Stooter and Hollis, London, 1989: 3.

3. Cohen S, Janicki-Deverts D, Miller GE. Psychological stressand disease. JAMA 2007; 298: 1685–87.

4. Peddicord K. Strategies for promoting stress reduction andrelaxation. Nurs Clin North Am 1991; 26: 867-75.

5. Jacobson E. Progressive relaxation, 2nd edn, University ofChicago press, 1939.

6. Dehdari T, Heidarnia A, Ramezankhani A, Sadeghian S,Ghofranipour F. Effects of progressive muscular relaxationtraining on quality of life in anxious patients after coronaryartery bypass graft surgery. Indian J Med Res 2009; 129:603-8.

7. Singh VP, Rao V, Prem V, Sahoo RC, Pai KP. Comparisonof the effectiveness of music and progressive musclerelaxation for anxiety in COPD— A randomized controlledpilot study. Chron Respir Dis 2009; 6: 209-16.

8. Mackereth PA, Booth K, Hillier VF, Caress AL. Reflexologyand progressive muscle relaxation training for people withmultiple sclerosis: a crossover trial. Complement Ther ClinPract 2009; 15: 14-21

9. Emery CF, France CR, Harris J, Norman G, VanarsdalenC. Effects of progressive muscle relaxation training onnociceptive flexion reflex threshold in healthy young adults:a randomized trial. Pain 2008; 138: 375-9

10. Gilbert C. Clinical applications of breathing regulation.Beyond anxiety management. Behav Modif 2003; 27:692-709.

11. Mourya M, Mahajan AS, Singh NP, Jain AK. Effect of slow-and fast-breathing exercises on autonomic functions inpatients with essential hypertension. J Altern ComplementMed 2009; 15: 711–17.

12. Schein MH, Gavish B, Herz M, Rosner-Kahana D, NavehP, Knishkowy B, et al. Treating hypertension with a devicethat slows and regularises breathing: A randomised, double-blind controlled study. J Hum Hypertens 2001; 15: 271–78.

13. Grossman E, Grossman A, Schein MH, Zimlichman R,Gavish B. Breathing-control lowers blood pressure. J HumHypertens 2001 ;15: 263-9

14. Rosenthal T, Alter A, Peleg E, Gavish B. Device-guidedbreathing exercises reduce blood pressure: Ambulatory andhome measurements. Am J Hypertens 2001; 14: 74–76.

15. Viskoper R, Shapira I, Priluck R, Mindlin R, Chornia L, LasztA, et al. Nonpharmacologic treatment of resistanthypertensives by device-guided slow breathing exercises.Am J Hypertens 2003; 16:484 - 87.

16. Meles E, Giannattasio C, Failla M, Gentile G, Capra A,Mancia G. Nonpharmacologic treatment of hypertensionby respiratory exercise in the home setting. Am J Hypertens2004;17:370–74.

17. Elliot WJ, Izzo JL Jr, White WB, Rosing DR, Snyder CS,Alter A, et al. Graded blood pressure reduction inhypertensive outpatients associated with use of a deviceto assist with slow breathing. J Clin Hypertens 2004; 6:553–59.

18. Schein MH, Gavish B, Baevsky T, Kaufman M, Levine S,Nessing A, et al. Treating hypertension in type II diabeticpatients with device-guided breathing: A randomizedcontrolled trial. J Hum Hypertens 2008; 13: 1–7.

19. Logtenberg SJ, Kleefstra N, Houweling ST, Groenier KH,Bilo HJ. Effect of device-guided breathing exercises on

blood pressure in hypertensive patients with type 2 diabetesmellitus: A randomized controlled trial. Journal ofHypertension 2007; k25: 241–46.

20. Parati G, Carretta R. Device-guided slow breathing as anonpharmacological approach to antihypertensivetreatment: Efficacy, problems and perspectives. J Hypertens2007; 25: 57–61.

21. Altena MR, Kleefstra N, Logtenberg SJ, Groenier SJ,Houweling ST, Bilo HJ. Effect of device-guided breathingexercises on blood pressure in patients with hypertension:A randomized controlled trial. Blood Pressure 2009; 18:273–79.

.22. Parati G, Malfatto G, Boarin S, Branzi G, Caldara G, GiglioA, Bilo G, Ongaro G, Alter A, Gavish B, Mancia G. Device-guided breathing in the home setting: effects on exercisecapacity, pulmonary and ventricular function in patients withchronic heart failure: a pilot study. Circ Heart Fail 2008; 1:178-83.

23. Adams J, Julian P, Hubbard M, Hartman J, Baugh S,Segrest W, Russell J, McDonnell J, Wheelan K. Arandomized controlled trial of a controlled breathing protocolon heart rate variability following myocardial infarction orcoronary artery bypass surgery. Clin Rehabil 2009 ;23: 782-9.

24. Mia M, Smith JC. Progressive muscle relaxation, breathingexercises, and ABC relaxation theory. J Clin Psychol 2001;57: 1551- 57.

25. Benson H. Systematic hypertension and the relaxationresponse. N Engl J Med 1972; 296: 1152-56.

26. Hertling D and Jones D. Relaxation and related techniques”in: Hertling, D and Kessler, Management of CommonMusculoskeletal disorders, Philadelphia, Lippincott, 1990.

27. Agras SW, Taylor CB, Kraemer HC, Allan RA, SchneiderJA. Relaxation training-twenty-four-hour blood pressurereduction. Arch Gen Psychiatry 1980; 37: 859-63.

28. Bacon M and Poppen R. A behavioral analysis ofdiaphragmatic breathing and it’s effects on peripheraltemperature. J Behav Ther Exp Psychiatry 1985; 16: 15-21.

29. Benson H, Klipper MZ. How to bring forth the relaxationresponse. In: The Relaxation Response. 1st ed. New York:Churchill Livingstone; 1975. p. 162-3.

30. McGrady A. Effects of group relaxation training and thermalbiofeedback on blood pressure and related physiologicaland psychological variables in essential hypertension.Biofeedback Self Regul 1994; 19: 51-66.

31. Salt VL, Kerr KM. Mitchell’s simple physiological relaxationand Jacobson’s progressive relaxation techniques: Acomparison. Physiotherapy 1997; 83: 200-07.

32. Yung P, French P, Leung B. Relaxation training ascomplementary therapy for mild hypertension control andthe implications of evidence-based medicine. ComplementTher Nurs Midwifery 2001; 7: 59-65.

33. Sheu S, Irvin BL, Lin HS, Mar CL. Effects of progressivemuscle relaxation on blood pressure and psychosocialstatus for clients with essential hypertension in Taiwan.Holist Nurs Pract 2003; 17:41-7.

34. Van Montfrans GA. Relaxation therapy and continousambulatory blood pressure in mild hypertension: AControlled Study. BMJ 1990; 300: 1368-72.

35. Hahn YB, Ro YJ, Song HH, Kim NC, Kim HS, Yoo YS. Theeffect of thermal biofeedback and progressive musclerelaxation training in reducing blood pressure of patientswith essential hypertension. Image J Nurs Sch 1993; 25:204-7.

36. Costa F, Biaggioni I. Role of adenosine in the sympatheticactivation produced by isometric exercise in humans. J ClinInvest 1994; 93: 1654-60.

37. Mc cardle WD, Katch FI, Katch VL. Exercise physiology:


121

Energy, nutrition and performance, Lea and Febiger,Philadelphia, 1986.

38. Law M, Wald N, Morris J. Lowering blood pressure toprevent myocardial infarction and stroke: A new preventivestrategy Health Technology Assessment 2003.

39. Dengel DR, Galecki AT, Hagberg JM, Pratley RE. Theindependent and combined effects of weight loss andaerobic exercise on blood pressure and oral glucosetolerance in older men. Am J Hypertens 1998; 11:1405–12.

40. Midgley JP, Matthew AG, Greenwood CMT. Effect ofreduced dietary sodium on blood pressure a meta analysisof randomized controlled trials. JAMA 1996; 275: 1590–

97.41. Mathias CJ, Bannister SR. Autonomic Failure. A Textbook

of Clinical Disorders of the Autonomic Nervous System. 4th

ed. Oxford University Press 1999: 49-51.42. Martarelli D, Cocchioni M, Scuri S, Pompei P. Diaphragmatic

breathing reduces exercise induced oxidative stress. EvidBased Complement Alternat Med 2009; 1- 9.

43. Solomon EP, Schmidt RR, Adragna PJ. Human Anatomyand Physiology, 2nd edn, Saunders College Publishing,1990: 449,724.

44. Bell JA, Saltikov JB. Mitchell. Relaxation technique: Is iteffective? Physiotherapy 2000; 86: 473-78.


122

A Comparison Study of 3 Stretching Protocols on HamstringsLengthPriya Kannan*, Stanley John Winser**Physiotherapy Lecturer, Masterskill University College of Health Science (MUCH), Malaysia

Abstract

Objective

Hamstring stretching is an important part of treatmentprograms aimed at decreasing the likelihood of hamstring injury.The purpose of this study was to determine whether applicationof cryostretch, or cryostretch following Hold relax PNF, or onlystatic stretch increases the extensibility of hamstrings amonghealthy subjects.

Methodology

Design- 3 group comparison study, Sample size- 10 in eachgroup, Sampling method- random sampling (lottery method),Study period- 1 year, Method- this study examined 30 malesubjects, aged 17-28. Subjects received the following treatments:Go 1(Group 1) - 30 seconds of only manual stretching forhamstrings muscle,. Go 2- 10 minutes of ice application followedby 30 seconds of hamstring stretching Go 3- 10 minutes of iceapplication followed by 30 seconds of stretching using hold-relaxPNF technique. All the 3 groups underwent hamstring stretch 3times. 5 sessions were given.

Outcome Measure

Pre- and post-treatment measurements of hamstring lengthwere obtained using AKE test and SLR test.

Results

Baseline charters were explained, the three study groupswere compared using Kruskal-wallis test. A p value of less than0.05 was considered statistically significant. Go1 and Go2showed a statistically significant improvement in the mean riseof both SLR and AKE. In the comparison made between thevariables it was found that SLR showed a statistically significantrise between treatment periods among all subjects.

Discussion and Conclusion

Application of manual stretch alone or cryostretch can beused as a handy therapeutic technique in improving hamstringsflexibility among healthy young adults.

Key Words

Stretch, cryotherapy, PNF- Hold relax.

Address for correspondence:Priya KannanPhysiotherapy LecturerMasterskill University College of Health Science (MUCH),MalaysiaEmail: [email protected]

Introduction

Muscles undergo adaptive shortening when maintained ina shortened position for a long time. Clinically it has beenproposed that a muscle which does not undergo periodiclengthening will develop a decreased resting length andextensibility. A series of studies have been done in the field ofmethods to improve muscle flexibility which have showncontradicting results. Hence we wanted to identify the bestadjuncts to stretching in improving the length of hamstringsmuscle among healthy subjects. The objective of this study wasto compare the effectiveness of stretching, cryostretching andstretching using ice with hold relax PNF technique.

Background of the Study

A shortened muscle may create imbalance in joints andfaulty postural alignment that may lead to injury and jointdysfunction. A lack of flexibility in the hamstrings is thought tospike the risk of hamstring injury1. Indeed, research hassuggested that athletes who have a history of hamstring injuryhave significantly less hamstring flexibility compared to uninjuredfellow athletes, and are also very prone to the recurrence ofhamstring troubles. Thus there has been considerable interestthat upgrade hamstring in athletes. Stretching is used as part ofphysical fitness and rehabilitation programs because it is thoughtto positively influence performance and injury prevention.Numerous studies have been conducted to investigate theeffectiveness of stretching2. Regardless of the type of program,the goal of stretching is often to change the physicalcharacteristics of connective tissue. Connective tissue is aviscoelastic structure capable of plastic and elastic changes.The viscous property of connective tissue allows it to go througha permanent change in structure. Elastic properties refer to theconnective tissues ability to regain its original length. When anapplied stretch to a connective tissue is removed, the elasticcomponents recover their original length and the viscouscomponents remain deformed .The amount of elastic andviscous deformation can vary considerably, depending on theamount of applied force, and tissue temperature. Theoretically,stretching protocols produce deformational changes thatlengthen the connective tissue and increase joint ROM.

The application of cold prior to stretching is known ascryostretching. Cryostretching has been advocated to decreasemuscle tone and make the muscle less sensitive during stretchin healthy subjects 3,4,5. The superficial application of cold causesspecific physiological reactions, such as decrease in metabolicfunction, decreased conduction velocity, and muscle spasm andan increase in local anesthetic effect6. All these factors arethought to enhance the gains realized with modified PNF. Whena small surface area is exposed to cold temperature,vasodilatation by the deeper vascular system attempts tocompensate for the cold, resulting in increased blood flow tothe tissues underlying the site of exposure. This reaction occursto maintain a relatively constant deep tissue temperature. Thegains reported using ice and modified PNF are due to increasedvascular flow7

PNF uses the concept of muscle relaxation beingfundamental to elongation of muscle tissue. In theory it isperformed in a way that uses the proprioceptive abilities of the

Priya Kannan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

123

GTO (golgi tendon organ) and muscle spindle to relax or inhibitthe muscle in order to gain a more effective stretch8. It does sousing autogenic inhibition and reciprocal inhibition. When muscleis stretched and the subject voluntarily performs an isometriccontraction, it is thought that the Golgi tendon organs’ reflexesare stimulated inhibiting or relaxing the muscle and therebyallowing the muscle to elongate. Hold - relax (HR) is one of thetechniques of PNF where the muscle to be stretched is passivelytaken to the end range and maximum contraction of the muscleto be stretched is performed against resistance (usually byanother person). In this form of contraction, the muscle doesnot shorten during its isometric contraction. This is continuedfor at least six seconds (allowing autogenic inhibition to occur).The muscle is then relaxed to a new range and held for about20 seconds. This can be repeated 3-4 times9.

Studies have produced conflicting results as to the optimalduration of static stretch necessary to achieve the viscoelasticchanges to increase ROM10. According to Bandy et al, Borms etal, and Gajdosik, the optimal time for maintaining the stretchvaries. The use of a 30 sec stretch , 10 sec stretch, and 15 secstretch resulted in an increase in ROM of the hamstringmusculature, as demonstrated by Bandy et al, Borms et al andGajdosik, repectively. In the majority of these studies, however,the hamstring muscle’s ability was studied, and we believe thefindings cannot necessarily be generalized to other musclegroups.


Subjects

This study was approved by the Institutional review boardand ethical Committee. The background of this 3 groupcomparison study was explained to the subjects in their languageand the subjects who were willing to participate were inductedinto the study following an informed written consent. The samplewas limited to the male sex due to the subjects’ availability ofthis gender. The subjects who full filled the inclusion criteriawere, healthy males between 17 and 28 years & those withactive Knee Extension ROM not less than 160 degrees. Subjectsexcluded were those with history of higher cortical lesions – eg.Trauma, paralysis, presence of adhesions and scar tissue,spasticity, hamstring repair or surgery, any recent hip or kneeinjury, knee deformities – eg. genu varum, genu valgum, genurecurvatum , hypermobile joints & tendon transfers.

Procedure

The study was done at the Physiotherapy Department, fora period of 1 year. The sample size was calculated to be 10 ineach group. The subjects were randomly allotted to one of thegroups using lottery method. Subjects in each of the groupsreceived the following treatments: Go 1(Group 1) - 30 secondsof only manual stretching for hamstrings muscle,. Go 2- 10minutes of ice application followed by 30 seconds of hamstringstretching Go 3- 10 minutes of ice application followed by 30seconds of stretching using hold-relax PNF technique. For allthe 3 groups the hamstring stretch was repeated 3 times.

Outcome Measure

Flexibility of Hamstrings muscle in the form of passivestraight leg raising (SLR) and active knee extension (AKE) withhip flexed to 90 degrees in supine was recorded usinggoniometer before and after the treatment protocol. SLR wasassessed by positioning the subject in supine, having the subjectto relax completely, the hip was passively flexed to 90 degreesand knee was extended to its end range. At the end range astandard goniometer was placed over the lateral aspect of knee

having the axis of the goniometer over the lateral joint line ofthe knee, movable arm parallel to the long axis of fibula andimmovable arm parallel to the long axis of femur, as shown infigure 1. Assistance was taken to record the reading. The rightlower limb was tested for all individuals and the testing protocolwas kept constant for all participants. The assessor whoperformed the outcome measures was blinded for the testinggroups. The test was done at the beginning of the trial, and thenthe subjects underwent a 1 week stretching program dependingon their allotment of groups. Stretching was given from Mondayto Friday and thus each subject underwent 5 treatment sessions.The intervention was administered by a single researcher for allthe 3 groups.

Stretching Protocol

Stretching maneuvers and verbal commands werepreviously standardized with the researchers being involved inthe study protocol. The participants were instructed on themaneuver before the procedure. Go 1 underwent stretchingalone and the Stretching was performed by having the participantin supine position and left thigh stabilized by the researcherwith the aid of a towel. The researcher passively flexed theparticipant’s right hip to 90 degrees and then extended knee upto his/ her pain threshold and position in which discomfort in thehamstrings was reported was marked as the starting position,at this starting point a static manual stretch was given for a periodof 30 second, as shown in figure 2.


Fig. 1: Showing evaluation of joint range using goniometry

Fig. 2: Showing the technique of stretching

124

Go 2 subjects underwent a 10 minutes ice application priorto the stretching protocol as shown in figure 3 and the techniqueinvolved was the same as adopted for Go 1. Go 3 subjectsunderwent 10 minutes of ice application prior to the PNF holdrelax. To perform PNF hold relax technique the subject waspositioned in supine lying, right lower limb was flexed to90degrees and the knee was extended to its end range. At theend range the subject was instructed to perform and isometriccontraction of the hamstrings for 7 seconds followed byconcentric contraction of quadriceps (knee extension) for 5seconds and the procedure was repeated again from theobtained new range for 3 times.

Results

Baseline characters were explained for all three groups in

Table 1: Showing baseline characters

CHARECTERS Go 1 Go 2 Go 3

Age 20.39 23.43 21.67

Height (m) 1.54 1.59 1.51

Weight (kg) 60.35 59.45 51.45

BMI 20.69 21.73 20.98

Number of sub. 10 10 10

terms of mean, as shown in table 1. Descriptive statistics (Mean,SD, Median and ranges) were obtained for the study variables(SLR, AKE). The three study groups (Go 1, Go 2 and Go 3)were compared using Kruskal-wallis test. A p value of less than0.05 was considered statistically significant. Data was entered

in MS Excel and analyzed using SPSS 11.0.The data were assessed for group differences in knee range

between and within each group. Comparison of mean increasein SLR range of motion of the three groups showed that Go 1(median = 15; Range=7-20) and Go 2(median=10; Range=3-24) are comparatively more effective than Go 3 (median=5.5;Range=2-15) in increasing mean straight leg raising range ofmotion with p value less than 0.005 as shown in table 2.

Comparison of mean increase in AKE range of motion ofthree groups revealed a statistically significant increase amongGo 1 & 2, and a statistically insignificant rise among subjects ofGo 3, as shown in table 3.

Table 2: showing the difference in SLR between pre and post intervention

Group Pre test Post test Mean Standard P50(median) Min Max p value (Mean) (Mean) difference deviation

Go 1 138 151.2 13.2 4.05 15 7 20 0.0031

Go 2 127.2 140.4 13.2 6.75 10 3 24 0.0032

Go 3 139.4 145.6 6.2 3.88 5.5 2 15 0.15

Table 3: Showing difference in AKE between pre and post intervention

Group Pre test Post test Mean Standard P50(median) Min Max p value (Mean) (Mean) difference deviation

Go 1 152 161.1 9.1 5.36 8.5 1 15 0.0042

Go 2 163.5 171.1 7.6 4.81 5.5 2 15 0.0034

Go 3 159 164 5 2.67 5 2 10 0.243

A comparison made between the mean increase in SLRand AKE among the 3 groups showed, the rise in SLR wasstatistically significant with a p value of 0.01 and the rise in theother variable was found to have a p value of 0.211 which cannotbe accepted as a statistical significant rise.

Discussion

The two main findings of our study were, 1. Manual stretchand manual stretch with ice application were found to be moreeffective in improving the length of hamstrings muscle amonghealthy young aged adults when compared to stretching usingPNF hold relax technique with ice application, 2. Using the abovetechniques SLR showed a quicker increase in terms of kneerange when compared to AKE.

The literature is inconclusive regarding which stretchingmethod is best for increasing muscle length. Previous studiessupport greater increases in ROM with PNF stretchingtechniques than with passive, static, or ballistic stretchingmethods. 11,12,13 However, some studies 14 suggest no differencebetween PNF and other stretching techniques. Severalmethodologic differences in the studies and the statisticalmanipulation of the data confound this issue.

It is not surprising that each group experienced increase inknee extension from pre to post test. Joint ROM has been shownto increase somewhat regardless of the stretching method used.Manual stretch and cryostretch were found to yield superiorresults. We hypothesized ice with hold-relax PNF technique tobe most effective in increasing SLR and AKE range of motion.We were not able to explain the reason for why use of ice reduces


Fig. 3: Showing application of cryotherapy.

125

the efficiency of the technique, so further researches arewarranted to identify the phenomenon underlying.

The reasoning behind the second finding of our study canbe explained in terms of muscle work and muscle insufficiencyi.e. when SLR is done passively there is minimal to no fatigueexperienced by the subjects on checking the range of motion.On the other hand, AKE is done actively so it is very likely thatthe subjects experienced muscle fatigue, causing a possibledecrease in the ROM that was recorded. More over having thehips flexed to 90 degrees the quadriceps is not in abiomechanically efficient position to overpower the hamstringsmuscle to pull knee into full extension. Therefore these 2 factorscould have caused a poor yield of the target muscle.

There were few limitations in our study which includes 1.The temperature of the ice packs used for each subject, mayhave differed since, the temperature was not recorded prior touse. 2. There were subjects who were not able to attend for 5consecutive days. Finally future studies can be undertaken withsubjects of both gender.

Conclusion

Mean difference between the pre and post interventionknee range obtained during SLR and AKE have shown thatapplication of manual stretch and manual stretch with iceapplication to be more effective than cryostretch with hold relaxPNF technique. Ease of administration of these techniquesensures its frequent usage in clinical practice. Thus we concludethat application of manual stretch alone or cryostretch can beused as a handy therapeutic technique in improving hamstringsflexibility among healthy young adults.

Reference

1. Taylor BF, Waring CA, Brashear TA. The effects oftherapeutic application of heat or cold followed by staticstretch on hamstring muscle length. J Orthop Sports PhysTher. 1995 May;21(5):283-6.

2. Bandy WD, Irion JM, Briggler M. Effect of static stretch anddynamic ROM training on flexibility of hamstrings. J Orthop

Sports Phys Ther. 1998 27(4): 295-3003. Chang Gung Uni, Kweishan, Taoyuan. Effect of thermal

therapy in improving passive ROM: comparison of cold andsuperficial heat application. Clinical Rehabilitation 2003;17(6) : 618-23.

4. Ian Shrier, Kav Kossal. Myths and Truths of Stretching.The Physician and Sports Medicine volume 28-no.8; 2000.

5. Taylor BF, Waring CA, Breshear TA. Effects of therapeuticapplication of heat or cold followed by static stretch onhamstring muscle length. J Orthop Sports Phys Ther 1995May; 21(5); 283-6

6. Hardy M, Woodall W. Therapeutic effects of heat, cold, andstretch on connective tissue. J Hand Ther. 1998 Apr-Jun;11(2):148-56.

7. Lin YH. Effects of thermal therapy in improving the passiverange of knee motion: comparison of cold and superficialheat applications. Clin Rehabil. 2003 Sep;17(6):618-23.

8. Davis DS, Ashby PE, McCale KL, McQuain JA, Wine JM.The effectiveness of 3 stretching techniques on hamstringflexibility using consistent stretching parameters. J StrengthCond Res. 2005 Feb;19(1):27-32.

9. Scott G, Spernoga, Timothy L, Brent L, Arnold, Bruce M,Gansneder. Duration of a maintained hamstring flexibilityafter a one time modified hold relax stretching protocol.Journal of Athletic Training 2001; 36(1): 44-48

10. Bandy WD, Irion JM. The effect of time on static stretch onthe flexibility of the hamstring muscles. Phys Ther. 1994Sep;74(9):845-50; discussion 850-2.

11. Prentice WE. A comparison of static stretching and PNFstretching for improving hip joint flexibility. J Athl Train.1983;18:56–59.

12. Tanigawa MC. Comparison of the hold-relax procedure andpassive mobilization on increasing muscle length. PhysTher. 1972;52:725–735.

13. Hardy L. Improving active range of hip flexion. Res Q.1985;56:111–114.

14. Worrell TW, Smith TL, Winegardner J. Effect of hamstringstretching on hamstring muscle performance. J OrthopSports Phys Ther. 1994;20:154– 159.


126

Effect of Long Term Physical Exercise Training on Auditory andVisual Reaction TimeShashi Kant Verma*, Anand Mishra**, Ajit Singh****Assistant Professor, Department of Physiology, **Associate Professor, Department of Anatomy, ***Associate Professor, Departmentof Orthopedics, Rohilkhand Medical College and Hospital, Bareilly, India 243006

Abstract

Objective

The present work was planned to determine long termphysical exercise has any beneficial effect on central neuralprocessing, by studying its effect on reaction time.

Methods

In present study 20 male and 20 female, young medicalstudents practiced exercise (15 min sessions) for 3 months onalternate day basis. Outcome assessments of auditory reactiontime (ART) and visual reaction time (VRT) were performed atbaseline and after the 3 month of exercise training.

Results & Discussion

In both male & female, there was a statistically significant(P<.001) decrease in ART and VRT. Also ART and VRT valueswere more in females than in males both before and afterphysical exercise training. This probably attributed to thedifferences in processing strategy in males and females. Thisdecrease in ART and VRT after exercise practices may be dueto physiologically relaxed state but increased mental alertness,improved concentration, and/ or increased CRH & cortisolsecretion in response to a challenge. .

Conclusion

RT is of applied value in situations requiring faster reactivityregarding serious safety concern such as in day today driving toavoid road traffic accidents, in sports for recommendation ofsafety limits, machine operations and in specialized surgery. Sowe suggest that the physical exercise is a lifestyle factor thatmight lead to increased physical and mental health andperformance that can be used as an effective means of trainingpeople involving such tasks.

Key Words

Physical exercise, Reaction time, Central neural processing

Introduction

Simple reaction time is defined as “the interval betweenthe onset of the stimulus and the response under the conditionthat the subject has been instructed to respond as rapidly aspossible”.1

Reaction time (RT) is an indirect index of the processingability of central nervous system and a simple means ofdetermining sensory motor association and performance.2 RTinvolves central neural mechanisms and its study is of

Address for correspondence:Dr Ajit SinghAssociate Professor, Orthopaedic department, RMCH, Bareilly.E-mail – [email protected]

considerable physiological interest. In 1983 Spirduso proposedRT as a measure of the overall integrity of central nervoussystem.3 Also there is evidence that cardiovascular fitness exertsa positive influence in the psychomotor domain. RT has beenused as primary index of psychomotor performance.4 RT issensitive and reproducible test and its measurement can bedone with simple apparatus and set up. It has also beensuggested that RT can be used as a simple and objective methodto determine the cognitive and motor performance effects ofvarious exercise trainings.4

Over the past several decades there has been an increasinginterest in the influence of exercise on motor performance. Anumber of studies have reported improvement in performancein terms of reaction time (RT) with physical training5-7 while someresearch showed no effect on RT.8-10 So, we planned to see theeffect of long term exercise training on reaction time. Additionally,we try to make a hypothesis on neurophysiological mechanismbehind the changes in RT after long term exercise.


The present study was conducted in Department ofPhysiology, RMCH, Bareilly on forty (40), 1st year MBBS students.Detailed information was collected on pre-designed proforma.Complete general, anthropometric and systemic examinationswere carried out. Subjects with previous regular athletic activityor yogic training/ meditation were excluded from study. Afterbriefing about the study protocol, consent was obtained. Thesetwo groups of male (n=20) and female (n=20) students performedphysical exercise on bicycle ergometer till target heart ratebetween 100-150 beats/minute (moderate exercise) wasobtained. This exercise was done for 3 months on alternate daybasis in peaceful, lighted and well - ventilated hall between 7.00AM to 8.00 AM at room temperature. Clothing was minimal andvery loose. The ART and VRT were recorded initially at the onsetof the study (Baseline reading) and again after 3 months ofphysical exercise training.

Instrument

An electronic instrument (Fig. 1 and Fig. 2) was used tomeasure reaction time both auditory and visual, whose sensitivitywas to take readings from 0 to 999 milliseconds (ms). Thisinstrument consisted of 4 boards. One board was on theexaminer’s side (which subjects cannot see) in which there were3 switches: first switch was to change the circuit between auditoryor visual signal productions, second switch was to open thecircuit as opted by first switch and third switch was to reset theLCD counter. Second board had the LCD for counting thereaction time (0 to 999 ms).The third board had a buzzer and abulb. The second and third boards were placed in between thesubject and the examiner. The fourth board on the subject’sside had a switch to break the circuit after receiving the stimuluseither auditory or visual. All the switches used in instrument weremicro-switches that were very sensitive to touch.

No warning signal was given and to avoid the effect oflateralized stimulus, visual and auditory signals were given fromthe front of the subjects who were instructed to use their dominanthand while responding to signal.

Shashi kant Verma / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

127

Recording of Auditory Reaction Time

Subjects were blindfolded and instructed to cut off the circuitby pressing the switch as soon as they hear the buzzer. Theobserver selects the auditory circuit by the switch provided andswitches on this circuit at varying time intervals to avoid guesswork by subject. As soon as subject hears the sound, he cut offthe circuit by pressing the switch. The subsequent time takenwas recorded as auditory reaction time (ART) of that particularsubject. Three such readings of each subject were taken andthe mean was calculated.

Recording of Visual Reaction Time

The above procedure was repeated by choosing the visualcircuit instead of auditory circuit, where the subject is instructedto use ear plug and responds by pressing the switch as soon ashe visualizes the lighted bulb (40 watt). The subsequent timetaken is the visual reaction time (VRT) of that particular subject.Three such readings of each subject were taken and the mean

was calculated.

Data Collection and Analysis

The baseline readings were taken at start of the study andthen compared with that of final readings at the end of 3 monthtraining in both male and female groups. The paired t-test wasused for statistical analysis, a P-value of <0.05 was consideredstatistically significant. RT analysis excluded erroneous keypresses.

Results

All the students were unmarried and Hindu. 60% (24)students were vegetarian, and the remaining 40% (16) gavehistory of taking non-vegetarian diet occasionally. Anthropometricdata of subjects are summarized in Table 1.

None of the subject gave any history of yogic training orphysical exercise of any kind. Also no history of any addiction(alcohol, guthka or cigarette smoking) is found.


Fig 1: Reaction Time measuring Instrument

Fig. 2: Circuit of Reaction Time Instrument

128

Paired ‘t’ test was used to analyze the data. For statisticalanalysis, the software SPSS version 17.0 was used. Theconfidence interval of 95% was set for all comparisons and a Pvalve of less than 0.05 was accepted as indicating significantdifference between the compared values. Data are expressedby using mean and standard deviation.

Before Exercise training, in males ART was 148.10 ± 25.538ms and after performing three months training, ART decreasedto 122.90 ± 13.799 ms, the decrease being statistically highlysignificant (P<0.001). (Table 2)

Before Exercise training, in females ART was 160.25 ±28.325 ms and after performing three months training, ARTdecreased to 134.30 ± 17.391 ms, the decrease beingstatistically highly significant (P<0.001). (Table 2)

Before Exercise training, in males VRT was 167.55 ± 26.916ms and after performing three months training, VRT decreasedto 137.00 ± 18.186 ms, the decrease being statistically highlysignificant (P<0.001). (Table 3)

Before Exercise training, in females VRT was 177.95 ±24.831 ms and after performing three months training, VRTdecreased to 149.80 ± 14.898 ms, the decrease beingstatistically highly significant (P<0.001). (Table 3)

Table 1: Anthropometric data of the volunteersMale Female

(Mean ± SD) (Mean ± SD)

Age (Yrs) 22.9 ± 1.141 21.5 ± 1.732

Height (cm) 179.0 ± 5.254 156.05 ± 2.999

Weight (kg) 58.6 ± 3.720 48.55 ± 3.649SD = Standard Deviation, Yrs = Years, cm = Centimeter and kg= Kilogram

Table 2: Comparison of auditory reaction time in males andfemales before and after the 3 months of exercise practice

SD = Standard Deviation, Ex = Exercise, ms = millisecond andHS = Highly significant (P<.001).

Before After 3 months Signifi-Ex practice of Ex practice cance(ms) (ms)

Male 148.10 122.90 HS(Mean ± SD) ± 25.538 ± 13.799(n=20)

Female 160.25 134.30 HS(Mean ± SD) ± 28.325 ± 17.391(n=20)

Table 3: Comparison of visual reaction time in males andfemales before and after the 3 months of Exercise practice

Before After 3 months Signifi-Ex practice of Ex practice cance(ms) (ms)

Male 167.55 137.00 HS(Mean ± SD) ± 26.916 ± 18.186(n=20)

Female 177.95 149.80 HS(Mean ± SD) ± 24.831 ± 14.898(n=20)

SD = Standard Deviation, Ex = Exercise, ms = millisecond andHS = Highly significant (P<.001)

Discussion

Effect of exercise on processing ability of central nervoussystem in terms of reaction time is debatable as some studiesshown no effect8-10 while other reported a decrease5-7 in it.

The finding of our study revealed that RT for auditory &visual reaction stimuli was found to be faster in subjects havingexercise training as compared to pre-training RT status.

In our study we have also found that ART and VRT wasmore in females than in males, which is in conformity withprevious studies11-13. This probably attributed to the differencesin processing strategy in males and females14. Also the auditoryreaction time was faster than the visual reaction time both inmales and females that is in line with previous studies13.

This faster RT in aerobic exercises is due to improvedconcentration, alertness, better muscular co-ordination andimproved performance in the speed and accuracy task15, 16.These factors leads to reduce tension and develops alertnessand better coordination of mind with body, which seems to beresponsible for better performance of the individual15, 17. Aerobicexercise training affects various organ systems includingCardiovascular, respiratory, CNS & skeletal muscles etc. Thesetrainings leads to an increase in cardiac stroke output associatedwith more complete emptying of heart during systole. There isalso a reduction in the ventilation minute volume at high rates ofwork, on account of an improved muscle blood flow and anincrease in intracellular enzymes15. There is increased vagaltone in athletes, with greater muscle tension and behavioralfeatures which distinguish the trained from the untrained andfavours establishment of new motor performance16, 17.

Exercise training bring out an increase in stores of creatinephosphate as well as glycogen. Creatine kinase activity isincreased and so is the activity of mitochondrial enzymes leadingto enhanced respiratory capacity of skeletal muscles18. Thiscauses sparing of glycogen and increased capacity to oxidisefatty acid, thus improved work time, delayed fatigue, increasingoxidation of ketones and increased removal15, 19. Thus, thesebeneficial effects in aerobic exercisers are responsible for theirfaster reaction time performance.

Some studies had shown no significant change in reactiontime after long term aerobic and resistance training8, 9, 10, 20, 21.However this inconsistency may due to differing in subjectselection, mode of exercise (strength/ endurance), the timing ofRT measurement (Immediate after exercise or during exercise)or sensitivity of RT instrument.

A decrease in RT is known to improve the sensorimotorperformances. Thus RT could be used either for screening thelarge population for physical fitness22, in sports physiology23, 24,as a therapeutic intervention in certain type of medical conditionslike depression25, cardiovascular diseases and diabetes26, to trainmentally retarded children and older sports persons who haveprolonged RT27, as an index of cortical arousal28 or to assesscognitive impairment after an accident29.

Exercise training leads to increased CRH (corticotropinreleasing hormone) 30 and cortisol secretion in response to achallenge as compared to the control subjects 31 but the baselinelevels during rest are reduced32. So when a challenge ispresented in form of pressing the key as soon as possible inresponse to light or buzzer there is increased CRH and cortisolsecretion. While testing RT, the individual being tested is in astate of stress/ challenge as he has to press the key in theshortest possible time in response to an auditory /visual signal.To do so the nerve impulse has to be processed faster in theauditory/visual neuronal pathways and its association fibers tofrontal cortex. The reaction time also depends on the quickactivity of skeletal muscle. Both these factors depend on theblood flow to the particular organ i.e. central nervous systemand skeletal muscle. Exercise has been shown to increasecerebral33, 34 and skeletal muscle blood flow18 by increasingcortisol level in blood during stress31.


129

So we want to hypothesize that this dual action of exerciseboth on CNS as well as skeletal muscle are the possiblemechanisms that lead to markedly decrease reaction time ascompared to control subjects. Further studies are required tosubstantiate this.

Conclusions

This shortening of RT after regular exercise training is ofapplied value in situations requiring faster reactivity regardingserious safety concern such as in day today driving to avoidroad traffic accidents, sports, for recommendation of safety limits,machine operations and in specialized surgery. So we suggestthat regular physical activity should be promoted and access tosports facilities should be facilitated especially in people involvingsuch tasks.

Acknowledgement

The authors thank Dr Mrs Sharda Gupta, Professor andHead, Department of physiology, RMCH, Bareilly and otherfaculty members for their support.

References

1. Teichner WR. Recent studies in Simple Reaction Time.Psychol Bull. 1954; 51: 128-149.

2. Dash M, Telles S. Yoga training and motor speed based ona finger tapping task. Indian J Physiol Pharmacol. 1999;43(4): 458-462.

3. Spiruso WW. Exercise and aging brain. Research quarterlyfor exercise and sport. 1983; 54: 208-218.

4. Hillman CH, Weiss EP, Hagberg JM, Hatfield BD. Therelationship of age and cardiovascular fitness to cognitiveand motor processes. Psychophysiology. 2002; 39: 303–312.

5. Pesce A, Tessitore A, Casella R, Pirritano M, Capranica L.Focusing of visual attention at rest and during physicalexercise in soccer players. Journal of sports sciences. 2007;25(11): 1259-1270.

6. Lemmink KA, Visscher C. Effect of intermittent exercise onmultiple chioce reaction times of soccer players. Perceptualand motor skills. 2005; 100: 85-95.

7. McMorris T, Delves S, Sproule J, Lauder M, Hale B. Effectof incremental exercise on initiation and movement timesin a choice response, whole body psychomotor task. Br JSports Med. 2005; 39:537–541.

8. Nakamoto H, Mori S. Sport-specific decision-making in ago/no go reaction task: difference among nonathletes andbaseball and basketball players. Perceptual and MotorSkills. 2008; 106(1): 163-171.

9. Davranche K, Audiffren M, Denjean A. A distributionalanalysis of the effect of physical exercise on a choicereaction time task. Journal of Sports Sciences. 2006; 24(3):323-330.

10. Welford AT. Choice reaction time: Basic concepts. In A. T.Welford (Ed.), Reaction Times. Academic Press, New York.1980; 73-128.

11. Bahramali H, Gordon E, Lagopoulos J, Lim CL, Li W, LeslieJ, Wright J. Effects of age on late components of the ERPand reaction time. Experimental Aging Research. 1999;25(1): 69-80.

12. Dane S, Erzurumluoglu A. Sex and handedness differencesin eye-hand visual reaction times in handball players.International Journal of Neuroscience. 2003; 113(7): 923-929.

13. Misra N, Mahajan K, Maini BK. Comparative study of visualand auditory reaction time of hands and feet in Males andfemales. Indian J Physiol Pharmacol. 1985; 29(4): 213-218.

14. Adam JJ, Paas FG, Buekers MJ, Wuyts IJ, Spijkers WA,

Wallmeyer P. Gender differences in choice reaction time:evidence for differential strategies. Ergonomics. 1999;42(2): 327-335.

15. Cotes JE, Meade F. Physical training in relation to theenergy expenditure of walking and to factors controllingrespiration during exercise. Ergonomics. 1959; 2: 195.

16. Grim BY, L Hannertz. Recruitment order of motor units onvoluntary contractions changes induced by propioceptiveafferent activity. J Neurol Neurosurg Psychiatry. 1965; 31:563-73.

17. Joki E, Lexington KY, Anand RL. Advances in exercisephysiology. Record Physiology, S Karger. 1974; 9: 18, 21,22.

18. Bijlani RL. Physiology of exercise In: Understanding medicalphysiology, 3rd ed. Jaypee brothers medical publishers ltd,New Delhi. 2004; 644 and 637.

19. Winder WW, Baldwin KM, Holloszy JO. Enyme involvedin ketone utilisation in different types of muscle: adaptationto exercise. Eur J Biochem. 1974; 47(3): 461-467.

20. Panton L B, Graves J E, Pollock M L, Hagberg J M, andChen W: Effect of aerobic and resistance training onfractionated reaction time and speed of movement. JGerontol. 1990; 45(1): M26-31.

21. Simonen RL, Videman T, Battie MC, Gibbons LE. The effectof lifelong exercise on psychomotor reaction time: a studyof 38 pairs of male zygotic twins. Med Sci Sports Exerc.1998; 30(9): 1445-50.

22. Borker AS, Pednekar JR. Effect of pranayam on visualand auditory reaction time. Indian J Physiol Pharmacol.2003; 47(2): 229-230.

23. Gharote ML. Effect of yogic training on physical fitness.Yoga Mimamsa. 1973; 15(4): 31-35.

24. Bhanot JL, Sindhi LS. Reaction time in Indian hockeyplayers with reference to three level of participation. J sportsmed. 1979; 19: 199-204.

25. Bieliauskasab LA, Lambertyc GJ. Simple reaction time anddepression in the elderly. Aging, Neuropsychology, andCognition. 1995; 2(2): 128-131.

26. Richerson SJ, Robinson CJ, Shum J. A comparative studyof reaction times between type II diabetics and non-diabetics. Biomed Eng Online. 2005; 4: 12.

27. Un N, Erbahceci F. The evaluation of reaction time onmentally retarded children. Pediatr Rehabil. 2001; 4: 17–20.

28. Malathi A, Parulkar VG. Effect of yogasanas on the visualand auditory reaction time. Indian J PhysiolPharmacol.1989; 33(2): 110-112.

29. Warden DL, Bleiberg J, Cameron KL, Ecklund J, Walter J,Sparling MB, Reeves D, Reynolds KY, Arciero R. Persistentprolongation of simple reaction time in sports concussion.Neurology. 2001;57(3):524–26.

30. Inder WJ, Hellemans J, Swanney MP, Prickett TC, DonaldRA. Prolonged exercise increases peripheral plasma ACTH,CRH, and AVP in male athletes. J Appl Physiol. 1998; 85(3):835-41.

31. Harte JL, Eifert GH, Smith R. Effects of running andmeditation on beta-endorphin, corticotropin-releasinghormone and cortisol in plasma and on mood. BiologicalPsychology. 1995; 40(3): 251-265.

32. Duclos M, Corcuff JB, Pehourcq F, Tabarin A. Decreasedpituitary sensitivity to glucocorticoids in endurance-trainedmen. European Journal of Endocrinology. 2001; 144: 363-68.

33. Dustman RE, Emmerson RY, Ruhling RO, Shearer DE,Steinhaus LA, Johnson SC, Bonekat HW, Shigeoka JW.Age and fitness effects on EEG, ERPs, visual sensitivity,and cognition. Neurobiology of Aging, 1990; 11:193–200.

34. Rogers RL, Meyer JS, Mortel KF. After reaching retirementage physical sustains cerebral perfusion and cognition.Journal of the American Geriatric Society. 1990; 38:123–128.


130

Effect of Hamstring Static Stretch Training on Knee FlexionConcentric TorqueAmr Almaz Abdel-aziem, Osama Ragaa AbdelraoufDepartment of Biomechanics, Faculty of Physical Therapy, Cairo University, Egypt

Abstract

Objectives

To determine the chronic effect of static stretching programof hamstring on knee flexors concentric torque.

Methods

Twenty four volunteers male participants (age = 24.08 ±2.6 years, height 171 ± 5.6 cm, weight = 66.5 ± 5.8 kg). Theparticipants performed a 30 sec static stretch for 6 weeks (threetimes / week). The knee extension range of motion (ROM) andhamstring concentric torque was measured before and afterthe static stretching program, ROM measured by universalgoniometer. The hamstring concentric torque was evaluated byBiodex Multi-joint System 3, measurements performed atangular velocities 30° and 60°/sec.

Results

Statistical analysis revealed significant increase in theconcentric hamstring torque at angular velocities 30° and 60°/sec, also there is significant increase in the ROM due to staticstretch.

Conclusion

Static stretching program for the hamstring muscle waseffective in increasing the concentric torque of the knee flexorsat both angular velocities, also, induced increases in theamplitude of knee extension.

Key Words

Hamstring flexibility; Static stretch; Concentric contraction.

Introduction

For many years stretching has been a controversial issuein regards to its effect on both muscle strength and elongation.Stretching has been used as a warm-up technique to increasejoint range ROM, enhance joint performance and aid in theprevention of injuries. However, Marek et al. 1 has reported thatstretching leads to a decrease in peak torque production aftercompletion of a stretching session.

Three types of stretching have been traditionally definedto increase flexibility: ballistic stretching, proprioceptiveneuromuscular facilitation (PNF), and static stretching. Staticstretching, considered the gold standard for measuring flexibility,is elongating a muscle to tolerance and sustaining the positionfor a length of time.2

Bandy et al.3 and Bandy and Irion4 proved that a 30 secduration is an effective time duration to sustain a hamstringmuscle stretch in order to increase ROM. The use of stretchingexercises to improve the flexibility is a widespread practiceamong competitive and recreational athletes. Many studies haveanalyzed the acute post-stretching muscle responses and found

that stretching exercises preceding the main strength activitysignificantly decreased performance.1,5-8

Very few studies have looked into the chronic effects ofstretching on strength performance. Worrel et al.9 used staticand PNF ‘contract-relax’ methods to train the flexibility of thehamstrings; exercises were performed five times a week, for 3consecutive weeks, the study showed no significant gains inflexibility, but 11.2% increase in concentric peak torque at 120°/sec, without increase in concentric torque at 60°/sec. Eventhough, there is a lack of data related to the latter stretchingeffects. So, this study was conducted to determine the prolongedor chronic effect of static stretching program applied to kneeflexors on hamstring concentric peak torque.


Subjects

Twenty four volunteers male participants (age = 24.08 ±2.6 years, height 171 ± 5.6 cm, weight = 66.5 ± 5.8 kg). Thesubjects should demonstrate the following characteristics: a)have a sedentary lifestyle; b) and a minimum of 20° of thedominant member knee extension is lost with the hip in 90o offlexion during the active knee extension. Participants wereexcluded if they had a history of hip, knee, or ankle surgicalrepair on their dominant lower extremity. Prior to participation inthe study, participants received an explanation of the studyprocedures and they signed a participation consent form.

Procedures

Hamstring muscles flexibility was measured with agoniometer that was a double-armed, full-circle protractor madeof transparent plastic marked of in 1-degree increments. Eachsubject was positioned supine with the right hip and knee flexedto 90 degrees. The lateral malleolus, lateral epicondyle of thefemur, and greater trochanter of the right lower extremity werethen marked with a felt-tipped pen for later goniometricmeasurement. Ninety degrees of hip flexion was maintained byone researcher, while the tibia of the knee was passively movedto the terminal position of knee extension by the secondresearcher. The terminal position of knee extension was definedas the point at which the subject complained of a feeling ofdiscomfort or tightness in the hamstring muscles or theexperimenter perceived resistance to stretch. Once the terminalposition of knee extension was reached, the second examinermeasured the amount of knee extension with the universalgoniometer. Zero degree was considered to be full extension ofthe knee.

The subjects received instruction in performing the staticstretch for six weeks, three times a week. All stretching wasperformed with the right lower extremity. The stretch wasperformed standing, facing a padded evaluation table with theheel of the right limb placed on the edge of the table in relaxedplantar flexion. Neutral right hip rotation was maintained bykeeping the foot pointed straight up. The standing leg “left foot”was perpendicular to the table. The subject was then instructedto bend forward at the waist. During the stretch, the subjectmaintains a flat back with the pelvis in relative anterior rotation,

Amr Almaz Abdel-aziem / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

131

neutral position of the head, and full extension of the stretchedleg. Each subject bent forward and stopped when a stretchsensation was experienced in the posterior thigh.10 This positionwas maintained for 30 sec, measured with a stop watch. Thestretching sessions were to be performed between 10 a.m. and5 p.m. A minimum of 60 and a maximum of 72 hours existedbetween the last bout of stretching and the posttest.

Isokinetic dynamometer (Biodex Multi-joint System 3,Shirley, NY, USA) used to measure the hamstring concentrictorque. The hamstring torque was evaluated using a ROM of60° starting from 90° of knee flexion. The concentric programwas used to evaluate the knee flexor muscles. These evaluationswere performed at speeds of 30o and 60°/sec. Five consecutivemovements of knee flexion were performed at each speed, witha rest interval of two minutes. The evaluation always started ata speed of 30°/sec. It is also important to state that five sub-maximum contractions were performed before the maximumtests in order for the subjects to get used to the equipment. Alltests were carried out before and after the static stretchingprogram. On each testing day, the machine was calibrated inaccordance with the manufacturer’s manual. The Biodexsoftware compensated for the effect of gravity as part of thesetup with the subject positioned appropriately.

Participants were familiarized with the testing procedure 3-4 days before the main testing session. During this period,subjects performed 5 warm-up trials for hamstring at the speed45°/sec. On the testing day, each participant performed a 3 minwarm-up on a cycle ergometer followed by stretching exercisesfor the lower limbs. Subjects were positioned seated with thebackrest at a 90 degrees angle. Straps were placed over theshoulders and across the waist to ensure the torso was stable.An adjustable lever arm was attached to the subject’s leg by apadded cuff, just proximal to the lateral malleolus. The axis ofrotation of the dynamometer arm was positioned lateral femoralepicondyle. During the concentric test, the subjects continuouslypushed the lever arm of the isokinetic device down.

Statistical Analyses

Data was analyzed by using statistical package for socialsciences (SPSS version 16). MANOVA with repeated measureused to examine the effect of static stretching program onextension ROM and hamstring concentric torque (Nm). ANOVAwith repeated measures used to investigate the effect of angularvelocities on peak torque. The level of significant was set at0.05 for all statistical tests.

Results

MANOVA with repeated measures revealed that there wassignificant effect of static stretch training (f = 108.6, p = 0.0001)on extension ROM which improved from 38.98° ± 2.86° to 28.70°± 4.33° (fig.1), the hamstring peak concentric torque at angularvelocity 30°/sec improved from 111.87 ± 10.59 to 117.66 ± 11.43(p < 0.05), and hamstring peak concentric torque at angularvelocity 60°/sec improved from 112.62 ± 11.62 to 122.75±12.03(p < 0.05), these values explained in the following table andillustrated in fig.2.

ANOVA with repeated measures proved that there wassignificant effect of velocity (f = 27, p = 0.0001) on hamstringpeak concentric torque. Moreover, Univariate tests revealed thatthere was no significant difference between both velocities pretreatment values (p > 0.05) while there was significant differencepost treatment values (p < 0.05), the increase in hamstring peakconcentric torque at angular velocity 60°/sec was higher thanhamstring peak concentric torque at angular velocity 30°/sec.

Discussion

The results of this study indicated that the knee flexor static

stretching program for 30 sec was effective in increasing kneeextension ROM that coincident with the findings of Bandy et al.3and Bandy and Irion4 who proved that a 30 sec duration is aneffective amount of time to sustain a hamstring muscle stretchin order to increase the ROM, and no increase in flexibilityoccurred when the duration of stretching was increased from30 to 60 sec, or when the frequency of stretching was increasedfrom one to three times per day. The gains in the knee extensionamplitude might have been caused by changes in muscularlength due to increases in the number of sarcomeres in series.11,12

The torque amount produced by the muscle depends onthe number of motor units activated, the muscle length, and themoment arm of the muscle.9 The results revealed that the staticstretching of hamstring increased the knee flexors torque atangular velocities 30° and 60°/sec. The increase in knee flexorconcentric torque that was observed in this study might havebeen caused by increases of the elastic components, since therewere increases in the flexibility of the knee flexors which is


Fig. 1: Effect of static hamstring stretch on knee extension ROM

Fig. 2: Effect of static hamstring stretch on knee flexionconcentric peak torque (Nm) at angular velocities 30o and 60o/sec

Table 1: Mean and standard deviation of extension ROM,hamstring concentric peak torque (Nm) at angular velocities30o and 60o/sec pre and post stretch.

P value less than 0.05 means significant difference.

Variables Pre-test Post-test P value(X ± SD) (X ± SD)

ROM 38.98 28.7 ± 4.33 0.0001 ± 2.86

Peak at (30°/sec) 111.87 117.66 0.0001 ± 10.59 ± 11.43

Torque at (60°/sec) 112.62 122.75 0.0001± 11.62 ± 12.03

132

supported by the findings of Taylor et al.13 reported that afterstretching, some viscoelastic properties of the muscularconjunctive tissue change, the resistance tension diminishesand the muscle becomes more complacent.

In addition, Herzog and Leonard14 stated that most of theimprovements in strength after stretching is due to the passivecomponents as well as the contractile and active componentsof the muscles. Worrell et al.9 also observed increases inconcentric knee flexor torque after the performance of stretchingprograms. They attributed these increases to a greater ability ofthe stretched muscle to store elastic potential energy absorbedduring the eccentric contractions which precede the concentriccontractions, this would improve the later strength of theconcentric contractions.

Worrell et al.9 proved that there was significant increaseconcentric contraction at angular velocity 120o/sec after bothtypes of stretch, which support the result of this study. However,no significant increase in concentric contraction at angularvelocity 60o/sec that is against the results of our study whichcan be attributed to their short duration of stretching programthat failed to increase hamstring flexibility and improve the kneeextension ROM. So, we measured the concentric contraction atslow angular velocities 30o and 60o/sec, and after longer durationof stretching program to explore the effect of hamstring flexibilityimprovement on the concentric torque at slow angular velocities.

The results proved that the long term or chronic effect ofstatic stretching improves the concentric strength of thehamstring which is different than the acute effects of staticstretching that elicit a strength deficit in concentric muscleactions.1,5-8 Moreover, Fowles et al.15 found a reduction inmaximal isometric plantar flexion torque about the ankle jointafter the plantar flexors were passively stretched. Kokkonen etal.16 found that maximal performance of both knee flexion andknee extension one-repetition maximum lifts declined (by 7.3%and 8.1%, respectively) significantly when executed 10 min afterstatic stretching of the quadriceps and hamstring muscle groups.In contrast, Shrier 17 proved that a muscle that contractsimmediately after a stretch (e.g., jumping up immediately afterlanding from a short jump) produces more force than a musclethat was not stretched.

Although the immediate effects of stretching decrease visco-elasticity and increase stretch tolerance, the effect of stretchingover 3 to 4 weeks appears to affect only stretch tolerance, withno change in visco-elasticity.18 The mechanism by which regularlong term stretching improves performance is likely related tostretch-induced hypertrophy. When a muscle is stretched 24hours per day, some hypertrophy occurs even though the musclehas not been contracting.19

The increase of concentric torque after hamstring flexibilityimprovement can be explained by the findings of Yamashita etal.20 reported that stretching a rat soleus muscle by 10 and 20%increased posttetanic potentiation of the miniature end-platepotential, which indicates increased Ca2+ conductance in thenerve terminal. This increase in intracellular free Ca2+ facilitatesneurotransmitter release. Theoretically, muscle force generationshould increase as a result of increased transmitter release.Therefore, the increase in the hamstring concentric torque maybe due in part to factors other than changes in series elasticcomponent stiffness and flexibility.

However, there was no significant difference between bothvelocities pre treatment torque values but there was significantdifference in post treatment torque values, the increase inhamstring concentric torque at angular velocity 60°/sec washigher than hamstring concentric torque at angular velocity 30°/sec, that is not consistent with Duncan et al.21 findings, provedthat the concentric force-velocity relationship is inverserelationship in which peak torque decrease as velocity increases.This result indicates that static stretch changes the concentricforce-velocity relationship.

Limitations

The gender in this study was limited to male only. So, theappropriateness of generalizing the results is confined to thisspecific population. The hamstring torque measured in the openkinetic chain was investigated in this study caution must be usedwhen generalizing these results to closed kinetic chain activities.Additional studies are needed to determine the chronic orprolonged effect of static stretch on hamstring torque duringclosed kinetic chain activities.

Conclusion

The static stretching program for the hamstring was effectivein increasing concentric torque of the knee flexors at angularvelocities 30° and 60°/sec. Moreover, the increase in hamstringconcentric torque at angular velocity 60°/sec was higher thanhamstring concentric torque at angular velocity 30°/sec. Thus,accompanied with improvement in the hamstring flexibility whichincreasing the amplitude of knee extension ROM.

References

1. Marek SM, Cramer AL, Fincher LL, Massey SMDangelmaier S, Purkayastha KA, Fitz JY. Acute effects ofstatic and proprioceptive neuromuscular facilitationstretching on muscle strength and power output. J Athl Train.2005; 40: 94-103.

2. Anderson B, Burke ER. Scientific, medical, and practicalaspects of stretching. Clin Sports Med. 1991; 10: 63-86.

3. Bandy WD, Irion JM, Briggler M. The effect of time andfrequency of static stretching on flexibility of the hamstringmuscles. Phys Ther. 1997; 77: 1090-1096.

4. Bandy WD, Irion JM. The effect of time on static stretch onthe flexibility of the hamstring muscles. Phys Ther. 1994;74:845-852.

5. Yamaguchi T, Ishii K, Yamanaka M, Yasuda K. Acute effectof static stretching on power output during concentricdynamic constant external resistance leg extension. JStrength Cond Res. 2006; 20: 804-810.

6. Power K, Behm D, Cahill F, Carroll M, Young W. An acutebout of static stretching: effects on force and jumpingperformance. Med Sci Sports Exerc. 2004; 36 (8): 1389-1396.

7. Behm DG, Bradbury EE, Haynes AT, Hodder, JN, Leonard,AM, Paddock NR. Flexibility is not related to stretch-induceddeficits in force or power. J Sports Sci Med. 2006; 5: 33-42.

8. Brandenburg JP. Duration of stretch does not influence thedegree of force loss following static stretching. J SportsMed Phys Fitness, 2006; 46 (4): 526-534.

9. Worrell TW, Smith TL, Winegarder J. Effect of hamstringstretching on hamstring muscle performance. J OrthopSports Phys Ther. 1994; 20: 154-159.

10. DePino GM, Webright WG, Arnold BL. Duration ofmaintained hamstring flexibility after cessation of an acutestatic stretching protocol. J Athl Train. 2000; 35(1): 56-59.

11. Tabary JC, Tabary C, Tardieu G, Goldspink G. Physiologicaland structural changes in the cat’s soleus muscle due toimmobilization at different lengths by plaster casts. JPhysiol. 1972; 224(1): 231-44.

12. Williams PE, Goldspink G. Changes in sarcomere lengthand physiological properties in immobilized muscle. J Anat.1978; 127(3): 459-68.

13. Taylor CD, Brooks DE, Ryan JB. Viscoelastic characteristicsof muscle: passive stretching versos muscular contractions.Med Sci Sports Exerc. 1997; 29(12): 1619-1624.

14. Herzog W, Leonard TR. Force enhancement followingstretching of skeletal muscle: a new mechanism. J Exp Biol.2002; 205:1275-1283.

15. Fowles JR, Sale DG, MacDougall JD. Reduced strength


133

after passive stretch of the human plantarflexors. J. ApplPhysiol. 2000; 89: 1179-1188.

16. Kokkonen J, Nelson, AG, Cornwell A. Acute musclestretching inhibits maximal strength performance. ResearchQuarterly for Exercise and Sport, 1998; 69, 411-415.

17. Shrier I. Does stretching improve performance? Asystematic and critical review of the literature. Clin.J.SportMed. 2004; 14: 267-273.

18. Halbertsma JPK, Goeken LNH. Stretching exercises. effecton passive extensibility and stiffness in short hamstrings ofhealthy subjects. Arch Phys Med Rehabil. 1994; 75:976-

981.19. Goldspink DF, Cox VM, Smith SK, Eaves LA,. Osbaldcston

NJ, Lee DM, Mantle D. Muscle growth in response tomechanical stimuli. Am J Physiol. 1995; 268: 288-297.

20. Yamashita T, lshii S, Oota I. Effect of muscle stretching onthe activity of neuromuscular transmission. Med Sci SportsExerc. 1993; 24: 80-84.

21. Duncan PW, chandler JM, Cavanaugh Dk, Jonson KR,Buehler AG. Mode and speed specificity of eccentric andconcentric exercise training. J Orthop Sports phys Ther.1989; 11:70-75.


134

Sports Injuries: A new perspective on causationArunachalam KumarProfessor of Anatomy, K. S. Hegde Medical Academy, Nitte University, Mangalore 575018 India

Introduction

More often than not, sports field, injuries are mainlyrestricted to the anatomical elements of the appendicularskeleton. Axial incapacitations are fewer and are restricted toparticular disciplines of the sports such as gymnastics orweightlifting.

Among the appendicular injuries, lacerations, contusions,tears, sprains, strains, cramps, avulsions of the muscle or itstendinous or aponeurotic components apart from injuries to jointcomplexes such as capsules, ligaments, bursae, cartilages ortendons, are more common. Injuries to skeletal elements arefewer, and again, restricted to some games or sports.

Here is presented a new perspective on why mostincapacitations accrued on the field, involve muscular or fascialsoft tissues preferentially. While it is a reasonable assumption,that the softer components are more susceptible to damagethan the harder osseous tissues, in my view other factors, suchas described here, may contribute to the selective nature ofsports injuries and their target preferences.

Observations & Discussion

Muscles are essentially linear elastic myofibril bundles.Muscle action and effect produced by its contraction is largelydependent on the size, power, arrangement of fibres, directionof bundles and the articular structures it spans. Each muscle,especially of the appendicular skeleton, has a wide fixed proximalorigin, and a distal smaller localized area of insertion.

The pinnate structure of muscles and the fact that theirdistal insertions are often converted into tendons composed ofcompacted converging muscle mass, serve to increase themechanical efficiency of articulations and kinetics. Applying thephysical tenets of biomechanics governing the first, second orthird class of levers, one can easily perceive that the speed anddistance produced at the long-resistance arm of the lever isdirectly proportional to amount of force exerted at the short-force arm. Maximal mechanical efficiency however, is drasticallycompromised when the reverse is applied.

Muscle origin areas are anatomically larger than insertions,a factor well adapted to deriving full potential of force generatedat origin to produce speed and distance towards insertion.Muscle anatomy is modulated, not just through evolution anduse, but also by the principles of physics and physiology definingthe use.

Most sports disciplines mandate application of normal lawsof biomechanics in so far as muscular effort is concerned. Thespeed, range, and rapidity of interaction between synergic,agonists and antagonistic muscle groups are chiefly determinedby the reaction time and stimulus generated by situations onfield.

Evolution and adaptation influence motion and mechanismsof volition induced locomotory responses. Physiology and

physics exert their tenets to derive maximal mechanicaladvantage from energy expended to work performed. Whenhowever, work done is in contradiction to these principles ofkinetics, strains and stresses are bound to ensue such exertions.

Visualize yourself pulling down a head level rigid bartowards yourself. Elbow flexion is the action required with allthe flexors of the humero-ulnar hinge coming brought into playand the bar is moved towards you. Now repeat the exercisewith a fixed bar, and attempt the same pull towards you. Elbowflexion is enacted with all the flexor group of muscles contracting;as the bar is fixed it stays in position, but the exertion of yourflexors, if strong enough, will actually draw you towards the bar.In the first exercise, your long flexors (e.g. biceps brachii) arecontracting, bringing insertion to origin, but in the second, thesame elbow flexion, brings the biceps brachii origin towards itsinsertion.

The paradox is, whilst the elbow hinge is used in both, thedirection of contractile forces travel is reversed in the latterexample. By translocating the resistance-arm (insertion) of thelever, even maximizing contractile muscular potential oftencannot produce movement, power or speed at the short-arm(origin). The muscles, now strain to overcome the resistanceforce on it by the reversed direction of action-and asconsequence pays a penalty- in form of injury or laceration. Thestresses generated by the redirected forces of contraction,militate against the postulates of the laws of motion.

In inference, I believe that a muscle, designed forperformance of a set of actions, performs best and at maximumefficiency and to its peak mechanical advantage only when it isallowed to contract in the manner nature has intended it to. Whenmuscles are coerced by demands and dictates of particulardisciplines of sports, to act counter to the laws of physics andmotion breakdowns are caused. The injuries may involve,besides the mycological tissues, any or all other adjunct andadjacent soft tissue structures that abet muscular action.

Conclusions

In this new theory on cause of sports injuries, it is proposedthat in a majority of soft tissue injuries, the trauma is primarilydue to unnatural stresses and strains imposed on muscularactions. It is postulated that the frequent demands made onmuscle masses to ‘reverse’ their direction of contractile forcesgenerated, is root cause of injury.

In our view, a better understanding of the laws of motionand mycology as applied to articular biomechanics and kineticsmay throw more light in these nebulous areas of sports medicine.

Reference

Rasch P J & Burke K R, Kineseology and Applied Anatomy,2nd Ed., Lea & Febiger, Philadelphia, 1965.

Arunachalam Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

135

Effects of Different Elbow Positions on Latency and Amplitude ofMotor Nerve Conduction Study of Ulnar NerveKakkad AshishLecturer, Shri K. K. Sheth Physiotherapy College, Rajkot

Kakkad Ashish / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Abstract

Context

Ulnar nerve is formed by the branches of Medial cord ofthe brachial plexus and is one of the main nerves of upper limb.Ulnar nerve passes posterior to medial epicondyle of humerusso may be stretched or compressed in elbow movement.

Objective

To assess the ability of ulnar nerve motor fibers to passstimulus in three different position of elbow joint (0o, 90 o, 120 o

of elbow flexion).


The cross-sectional observational study was conducted on30 normal healthy individuals (aged between 18 to 25 years) inGovernment Spine Institute, Civil Hospital, Ahmedabad. Subjectsexposed to factors affecting nerve conduction velocities e.g.smokers, alcoholic, diabetic etc. were not included in the study.Subjects were selected by random sampling technique. Subjectswere given supine lying position to measure latency (from artifactto first negative deflection) and amplitude (peak to peak) of rightulnar nerve from above and below elbow in three differentpositions of elbow (0 o, 90 o, 120 o of flexion) using EMGinstrument (RMS EMG EP MK-II, Version 1.1), measuretape,thermometer, weighing-machine, height-scale, universal-goniometer, sketchpen, spirit, pen, electrode gel, cotton andmicropore adhesivetape.

Results

Statistical analysis was done with ANNOVA test. F valuesfor below elbow latency, above elbow latency, below elbowamplitude, above elbow amplitude are 0.0699, 0.1534, 0.1488,and 0.2336 respectively. Results showed insignificant differenceat 0.05significance level in latency and amplitude of ulnar nervein three different positions of elbow.

Conclusion

Study concludes that there is no effect of elbow positionson latency and amplitude during ulnar motor nerve conduction.

Key words

Nerve Conduction Study, Ulnar nerve, Different ElbowPositions

Introduction

Ulnar nerve is formed by the branches of Medial cord ofthe brachial plexus. Root value of the ulnar nerve is C7, C8,and T1. It runs on the medial side of the brachial artery up to thelevel of insertion of the coracobrachialis, where it pierces themedial intermuscular septum and enters the posterior

compartment of the arm. It is accompanied by the superior ulnarcollateral vessels. At the elbow, it passes behind the medialepicondyle where it can be palpated with a finger. The ulnarnerve is palpated behind the medial epicondyle. At the elbow itlies behind the medial epicondyle of the humerus. It enters theforearm by passing between the two heads of the flexor carpiulnaris. In the forearm, it runs between the flexor digitorumprofundus and the flexor digitorum superficialis laterally. It entersthe palm by passing superficial to the flexor retinaculum lateralto the pisiform bone. At the wrist, the ulnar neurovascular bundlelies between the flexor carpi ulnaris and the flexor digitorumsuperficialis. The bundle enters the palm by passing superficialto the flexor retinaculum lateral to the pisiform bone.1 Mostcommonly tested nerves in upper limb are median nerve, ulnarnerve and in the lower limb peroneal, tibial nerve.2

This condition is evaluated, in part, by calculating motornerve conduction velocity (MNCV) across the elbow segment.At present the position of the elbow during the test has not beenstandardized. Although illustrations in books on electrophysiologyrefer to sites of stimulation for the ulnar nerve with a fullyextended elbow, the texts do not explain why the elbow is picturedthat way.3,6

Books do not refer to the possible effect that the elbowposition might have on the conduction capabilities of the ulnarnerve. The position of the elbow, however, appears to influencethe conduction velocity of the motor axons of the ulnar nerve;MNCV of the ulnar nerve has been found to be slow when theelbow is in full extension.7, 8 Various explanations have beenoffered for the phenomenon of diminished across-elbowvelocities when the elbow is fully extended. For example, errorin measuring the nerve length as it passes through the ulnargroove may be a factor. The ulnar nerve has considerable slackwhen the elbow is fully extended.7 If the length of the ulnar nerveacross the fully extended elbow is estimated by surfacemeasurement, the measured length will be less than the truelength. Such an error can lead to incorrect computation ofconduction velocity.

When the elbow is in midflexion (70-90°), the MNCVbecomes more consistent with the other segments of the ulnarnerve.7,9,10 Thus, a position of elbow flexion might seem to bebest for evaluating MNCV of the ulnar nerve across the elbow.Several investigators, however, have suggested that elbowflexion can induce stretch or compression of the ulnar nerve.6,10-12 Thus the assessment of the MNCV of the ulnar nervemight not be accurate with the elbow in flexion. Because of thisparadox, this study was undertaken to find the optimal elbowposition for determining ulnar MNCV across the elbow. Toachieve this purpose, the latency of a compound muscle actionpotential (CMAP) evoked by supramaximal stimulation of theulnar nerve above the elbow and the specific characteristics ofthe evoked action potential were studied with the elbow in threedifferent positions.

Unlike conduction velocity, latency is not dependent onsurface distance measurement. If a pressure block or stretch ofthe ulnar nerve does not occur with elbow flexion, the proximal(above-elbow) stimulation latency of CMAP should be the sameregardless of elbow position. If a pressure block or stretch ofthe nerve is induced by elbow flexion, however, proximalstimulation latency of CMAP should increase. 11 The distal

136

(below-elbow) stimulation should remain consistent regardlessof elbow position. A pressure block or stretch may also changeCMAP; that is, the amplitude of the potential may decrease. 12

Method

Instruments Used

Cross-sectional Observational Study was done atGovernment Physiotherapy College, Government Spine Institute,Civil Hospital, Ahmedabad by using EMG instrument (RMS EMGEP MK-II, Version 1.1), measuretape, thermometer, weighing-machine, height-scale, sketchpen, spirit, pen, electrode gel,cotton, micropore adhesivetape, universal goniometer and couchthirty normal healthy students of Government PhysiotherapyCollege, Ahmedabad were selected as subjects by randomsampling.

The inclusion and exclusion criteria are described below:

Inclusion Criteria

1. Normal healthy individuals who is willingly ready toparticipate in the study aged between 18 and 25 years ofage (mean 21.65 years)

Exclusion Criteria

1. If person is exposed to known neurotoxins like alcohol2. If they had medical condition known to be associated with

peripheral neuropathy (Diabetes or Uremia)3. Family history of Neuropathy4. Person already on medication known to be associated with

peripheral neuropathy (Antiretroviral therapy, other drugslike Vincristine, Isoniazide)

Each subject lay supine with a pillow under his head forcomfort. The right arm was arbitrarily chosen as the limb toexamine, inasmuch as no significant difference in MNCV existsbetween dominant and nondominant limbs.13, 14 The borders ofthe abductor digiti minimi muscle were located by palpation whenthe subject forcefully abducted the little finger against resistance.The recording electrodes were surface disks, the intraelectrodedistances were constant (3 cm from center to center) for allsubjects. After the overlying skin was cleaned the active electrodewas placed over the center of the muscle belly. The inactiveelectrode lay over the tendon at the metacarpophalangeal joint.The ground electrode was placed on the dorsum of the wristover the ulnar styloid process. The subject’s arm was positionedin slight flexion (10-15°) and a mark was made on the skin 4 cmabove and 4 cm below the medial epicondyle, approximatingthe path of the ulnar nerve. These marks served as the sites ofelectro stimulation. The tests were performed with shoulder 45°abducted, laterally rotated, the elbow in three different anglesof elbow flexion (0°, 90°, and 120°), and wrist neutral. 15 Elbowrange of motion was performed with universal goniometer.(16)Below elbow stimulation was done and evoked MAPs reportedfor each angle of flexion in order to provide a basis for comparisonand to maintain consistency within the experiment.

The nerve was stimulated at the two sites described abovefor each of the three angles of flexion. The followingcharacteristics of the CMAP were measured:

1. Latency (msec) from the stimulus artifact to the initialnegative deflection of the CMAP

2. Peak to peak amplitude (mV) from the bottom of the positivephase to the top of the negative phase

Results

Table 1: Mean, Standard Deviation, Range of below elbow and above elbow latency

Site of stimulation Angle of elbow flexion Latency (ms)Mean Standard Deviation Range

Below elbow 0o 6.390 0.5688 4.90-7.50

Below elbow 90 o 6.352 0.5883 5.00-7.29

Below elbow 120 o 6.336 0.5693 5.00-7.29

Above elbow 0o 8.101 0.7201 6.46-9.54

Above elbow 90 o 8.174 0.7301 6.77-9.69

Above elbow 120 o 8.202 0.7318 6.67-9.89

Table 2: Mean, Standard Deviation, Range of below elbow and above elbow amplitude

Site of stimulation Angle of elbow flexion Latency (ms)Mean Standard Deviation Range

Below elbow 0o 10.173 2.805 3.90-15.7

Below elbow 90 o 10.443 3.123 3.60-16.4

Below elbow 120 o 10.583 2.940 4.30-16.1

Above elbow 0o 9.547 2.623 3.60-15.8

Above elbow 90 o 9.817 2.910 3.60-15.8

Above elbow 120 o 10.067 3.272 4.30-18.6


137

Table 3: Gender Distributions of the Subjects

Gender Normal Group

Male count 10% 66.66%

Female count 10% 33.33%

Total 30

Table 4: Age Distribution of the Subjects

N Mean (Years) SD (Years)

30 21.76 2.09569


The means, standard deviations, and ranges of the latencyand amplitude of CMAP for both above-elbow and below-elbowstimulation are shown in Table 1 and Table 2 respectively.

Discussion

Results suggest that there is no significant difference amonggroup for below elbow latency, above elbow latency, below elbowamplitude, above elbow amplitude for different three groups.This proves that latency and amplitude of CMAP of ulnar nervedo not depend on the position of elbow joint.

The results of this study suggest that the slow ulnar MNCVreported with elbow extension could be caused by errors inmeasuring the length of the ulnar nerve. In addition, stretch orcompression of the ulnar nerve does not appear to be animportant factor influencing the conduction of motor axons whenthe elbow is in flexion. Two variables are used to calculate MNCV:latency measures and distance measurements between the twosites of nerve stimulation. In this study, latency and amplitudeof CMAP with above-elbow and below-elbow stimulation wasunaffected by elbow position. Thus, the discrepancy in thereported conduction velocity of the ulnar nerve when the elbow

Graph 4: Above elbow amplitude

Graph 1: Below elbow latency

Graph 2: Above elbow latency

Graph 3: Below elbow amplitude

138

is in extension may be caused by errors in distancemeasurement. In this study the latency measures suggest thatthe nerve fibers were probably not blocked (by compression orstretch) during elbow flexion. This conclusion is also supportedby the consistency in the characteristics of CMAP in all elbowpositions for above-elbow stimulation. The below-elbow valuesin CMAP characteristics are all very similar to the above-elbowvalues.

The midposition of elbow flexion (90°) should be used whenmeasuring MNCV of the ulnar nerve. The straight elbow maynot yield valid measurements because of the difficulty inmeasuring the actual length of the nerve. Assuming that surfacemeasurements of the distance between the sites of stimulationdo not portray an accurate estimate of true distance, calculatedvelocities will be in error. Therefore, to avoid unknown errors,the straight elbow should be avoided. The other option is to usethe position of maximal flexion for the MNCV calculation. Anothertype of uncontrolled error might confound the results in this flexedposition. The aponeurotic sheath between the two heads of theflexor carpi ulnaris muscle (that is, the cubital tunnel) maycompress the ulnar nerve as it passes between them. Someindividuals may exhibit more compression than others but theamount of the compression is unknown. Therefore, the maximalposition of elbow flexion should also be avoided.

Limitations

• In the present study sample size is very small.• Results of the study could not be generalized to all age

groups because study age group was between 18-25 yearsso it is not studied what is status of peripheral nerveinvolvement in person having age less than 18 years andmore than 25 years.

• Room temperature was not controlled but all the nerveconduction studies were performed at the same time of theday so as to ensure as identical environmental conditionsas possible.

Future research

If elbow position is standardized for the performance ofMNCV in all ulnar nerve segments then future research couldbe devoted to collecting normative data on the velocities. Inaddition, the sensory component, which is often more sensitivethan the motor component as an indicator of early neuralinvolvement, could be evaluated in a normal population.

Conclusion

Electro stimulation of the ulnar nerve in 30 normal healthyindividuals revealed that:1. The below elbow latency and above elbow latency of CMAP

did not vary appreciably as a function of elbow position.2. The amplitude of CMAP did not vary as a function of elbow

position.3. The absence of alteration in motor nerve conduction as a

function of elbow position appears to shift the reason forreported slow velocities across the fully extended elbow toerrors in external factors (viz: measurement) and away frominternal factors such as stretch or compression of the nerve.

4. The midflexion position (90°) appears to be the positionfrom which to perform and calculate MNCV along the courseof the ulnar nerve.

Clinical implication

From this study it is proved that during clinical practice thereis no need to consider elbow position. If the patient is notcomfortable in any position either because of symptoms,tightness or stiffness given by different authors we can givealternate position of elbow joint for clinical findings.

Aknowlegement

I would like to acknowledge my P.G. guide Mrs. Anjali Bhise,Yagna Shukla for guiding me and all staff members ofGovernment Physiotherapy College, Civil Hospital, Ahmedabadand my senior Dhruv Dave and also my friends who participatedfor me in this study.

Referrence

1. Chaurasia B. D. Huamn Anatomy. Regional and AppliedDissection and Clinical. Volume 1. Upper limb and Thorax.Satish Kumar Jain for CBS. Publisher & Distributors, NewDelhi. 2005: p 52, 90,110,111.

2. Jagmohan Singh. Text book of Electrotherapy. JaypeeBrothers, Medical Publishers (P) Ltd, New Delhi. 2005: p276.

3. McGowan AJ: The results of transposition of the ulnar nervefor traumatic ulnar neuritis. J Bone Joint Surg [Br] 32, 1950:p 293- 296,

4. Goodgold J, Eberstein A: Electrodiagnosis ofNeuromuscular Diseases, ed 2. Baltimore, Williams &Wilkins Co, 1977: p 100, 121

5. Smorto MP, Basmajian JV: Electrodiagnosis: HandbookforNeurologists. New York, Harper & Row, Publishers, 1977:p 944.

6. Smorto MP, Basmajian JV: Clinical Electroneurography.Baltimore, Williams & Wilkins Co, 1972: p 97

7. Checkles NS, Russakov AD, Piero DL: Ulnar nerveconduction velocity: Effect of elbow position onmeasurement. Arch Phys Med Rehabil 52, 1971: p 362-365

8. Tascon-Alonzo M: Amplitude and Duration of Evoked ActionPotentials in Human Hand Muscles in Health and Disease.Thesis. Edmonton, Canada, University of Alberta, 1963

9. Kaeser HE: Nerve conduction velocity measurements. InVinken PJ, Bruyn GW (eds): Handbook of ClinicalNeurology, vol 7, part 1. Amsterdam, North HollandPublishing Co, 1970: p 117-127

10. Payan J: Electrophysiological localization of ulnar nervelesions. J Neurol Neurosurg Psychiatry 32, 1969: p 208-220

11. Zankel HT: Effect of physical agents on motor conductionvelocity of the ulnar nerve. Arch Phys Med Rehabil 47, 1966:p 787- 792

12. Ruskin AP, Tanyag-Jocson A, Rogoff JB: Effect of ischemiaon conduction of nerve fibers of varying diameters. ArchPhys Med Rehabil 48, 1967:p 304-310,

13. Shubert HA: A study of motor nerve conduction:Determination of velocity. South Med J 56,1963: p 666-668

14. Polak O, Grof D: The relationship between preference ofthe upper extremity and the conduction velocity of motorfibers in nerve ulnaris. Act Nerve Super (Praha) 8, 1966: p207-208

15. Cynthia C., Measurement of Joint Motion. A guide toGoniometry. F. A. Davis Company. First edition. 2003: p 41


139

Effectiveness of ‘Multidirectional Reach Test’ to Analyze Centreof Pressure Excursion in Healthy Geriatric PopulationAsmita Karajgi1, Sujata Yardi2

1Assoc Prof., 2Professor & Head, Department of Physiotherapy, Pad.Dr.D.Y.Patil University, Navi Mumbai

Abstract

Background

Generally hi tech equipments like force platforms arerequired to measure the excursion of ‘centre of pressure’ forbalance assessment. The purpose of our study was to find theeffectiveness of a simple measure like ‘Multidirectional reachtest ‘routinely used in the clinical set up to analyze centre ofpressure excursion in healthy geriatric population.

Objective

To correlate readings of multidirectional reach test with thatof centre of pressure excursion on the balance master.

Material and Method

30 healthy elderly above 65 years of age participated inthis study. ‘Multidirectional reach test’ required a yardstickmounted on the wall that could be adjusted at the height of theacromian process of the subject. The subjects were asked tostand on the force platforms shoulder distance apart and reachin forward, backward, right and left directions with one arm(shoulder flexed to 90 degrees and elbow in extension) alongthe yardstick without moving feet or taking a step. Average ofthree readings of the reach distance in each direction wascalculated and corresponding centre of pressure excursion ineach direction was measured using balance master.

Result

The readings of ‘Multidirectional reach test’ on the yardstickwere correlated with the centre of pressure excursion on thebalance master. We found no significant correlation betweenthe two parameters.

Conclusion

The study shows that at present centre of pressureexcursion cannot be effectively analyzed using ‘Multidirectionalreach test’ in healthy geriatric population as there is noimportance given to the specific instruction regarding posturalstrategy to be used.

Key Words

Centre of pressure, Multidirectional reach test and geriatricpopulation

Introduction

There is increased awareness of quality of life of the olderadults in recent years as the proportion of geriatric populationcontinues to rise worldwide. Along with the visible signs of agingand the obvious declines in the cardiovascular, respiratory, andmusculoskeletal systems, body slowly assembles a collectionof deficits that significantly reduce the ability to maintain balance.

Impairments in postural control system and fear of falling causeself-limitation and a less active lifestyle. This deconditioningeffect exacerbates the risk for falls. Timely intervention is effectivein reducing risk of falling & cost of health care thus improvingquality of life in aging population.

Thus identification of older adults with balance deficit is avital medical concern. As physiotherapists, we routinely usevarious balance assessment tools. One of the importantassessments of dynamic stability is ‘stability limits’

Postural stability or balance is the ability to keep centre ofmass (COM) within the base of support which is achieved bythe nervous system through continuously generated muscularforces. The ‘centre of pressure’ is the centre of the distributionof this total force applied to the supporting surface. Centre ofpressure (COP) continuously moves around centre of mass(COM) to maintain balance during any mobility task like reaching,picking up an object from floor, transitioning from sitting tostanding, walking etc. e.g. reaching in forward direction to pickup telephone requires anterior displacement of centre ofpressure.

Asmita Karajgi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Balance control can be reactive (in response to externalforces that displace the COM) or anticipatory (voluntary or inautomatic anticipation of internally generated forces during gaitor performance of movements, such as raising an arm) . Itdepends on the capability of the CNS to predict and detectinstabilities and program appropriate patterns of muscleactivation. Stability limits refer to the maximum distance a personcan intentionally displace their centre of mass without losingbalance

Direct way to assess stability limits is by investigatinglocation and path of COP. More sophisticated instrumentationlike force plates are required to measure centre of pressure.Pressure cells have been incorporated into force platforms tomeasure oscillations unnoticed by the human eye. Using twoforce platforms allow the evaluation of the relative contributionof each leg in balance control. But it is expensive and not suitablefor OPD set up or community settings

Indirect way to assess stability limits by administering afunctional scale. There are many clinical tests available toevaluate balance..Functional reach test by Duncan et al is an

Fig. 1: Anterior displacement of centre of pressure

140

inexpensive and easy to use tool to assess stability limits inforward direction. Duncan considered reaching task to be morefunctional than leaning task. But forward is not the only directionwe move. Older adults also fall backward and laterally. Later onMulti-directional Reach Test was developed by Roberta Newtonin 2001.Dr Newton describes it as “an inexpensive screeningtool to measure limits of stability in four directions.”

The purpose of our study was to find the effectiveness of asimple measure like ‘Multidirectional reach test’ routinely usedin the clinical set up to analyze centre of pressure excursion inhealthy geriatric population.

Hypothesis-Multidirectional reach test effectively analyzescentre of pressure excursion in healthy geriatric population

Alternate hypothesis-Multidirectional reach test does noteffectively analyze centre of pressure excursion in healthygeriatric population.

Aim and Objective

To correlate readings of multidirectional reach test with thatof centre of pressure excursion on the balance master

Methodology

Study Design

Correlation study

Inclusion Criteria

30 healthy elderly individuals above 65 years with noknown neurological or musculoskeletal pathology& no historyof fall in past 6 months

Exclusion Criteria

Hip/knee replacementPain/restriction of range of motion of ankle, knee, hip or

shoulder joint

Material

Yardstick for the reach testSmart balance master (Neurocom)

Methodology

‘Multidirectional reach test’ is described as followsEvaluation- Subjects perform maximal reaches with

outstretched arm forward (FR), to right (RR), to left (LR), &backward (BR),with feet flat on floor

Reliability & validity established only for elderly populationScore = distance (in. or cm) that patient can reach in each

direction.Limitations-Not described.ICF Level and domain-Activities(limitations to activity-

disability): changing & maintaining body position (d4106, shiftingbody’s center of gravity)

30 healthy older adults above 65 years from the local seniorcitizen group participated. A yardstick was horizontally mountedon the wall. It could be adjusted at the height of the acromianprocess of the subject. The subjects were asked to stand barefooton the force platform shoulder distance apart and instructed toreach in forward, backward, right and left directions with onearm (shoulder flexed to 90 degrees and elbow in extension) )Instructions were precise as described by Dr.Newton

‘without moving your feet or taking a step, reach as far(direction given) as you can and try to keep your hand along the

yardstick’ One practice trial was given. If the feet moved or steptaken, the trial was discarded.Average of three readings of thereach distance in each direction was taken. The readings of thenet centre of pressure movements in ‘limits of stability test’ onthe balance master recorded for the respective reach. Balancemaster calculates the forces and converts into a visual image.Software of the balance master analyzes the data. Test wasrecorded with a video camera for kinematic analysis.


Results

Readings of Multidirectional reach test.

Readings of centre of pressure excursion

Discussion

Stability limits are boundaries of an area of space in whichbody can maintain its position without changing the base ofsupport. The CNS has an internal representation of stability limitsand uses it to determine how to move and maintain balance.These are not fixed boundaries but change according to thetask. Each task in Multidirectional reach test has orientationdemand of maintaining upper extremity in forward or lateraldirection and stability demand of maintaining balance whilereaching. The subject needs to use appropriate postural strategyto maintain balance while reaching.

Forward Backward Right Leftreach reach reach reach(mean, SD) (mean, SD) (mean, SD) (mean, SD)

24.31 17.67 18.07 19.80+/- 6.87 +/- 6.90 + /- 5.64 +/- 6.55

141

There are three basic postural control strategies describedby Nashner and colleagues. The ankle strategy is more effectiveat keeping the trunk in a vertical position during smallperturbations while standing. The hip strategy is excellent forfaster and larger CM movements.

Discussion

Stability limits are boundaries of an area of space in whichbody can maintain its position without changing the base ofsupport. The CNS has an internal representation of stability limits

We correlated the reach distance with the corresponding centreof pressure excursion in each direction.

and uses it to determine how to move and maintain balance.These are not fixed boundaries but change according to thetask. Each task in Multidirectional reach test has orientationdemand of maintaining upper extremity in forward or lateraldirection and stability demand of maintaining balance whilereaching. The subject needs to use appropriate postural strategyto maintain balance while reaching.

There are three basic postural control strategies describedby Nashner and colleagues. The ankle strategy is more effectiveat keeping the trunk in a vertical position during smallperturbations while standing. The hip strategy is excellent forfaster and larger CM movements.• Ankle strategy restores Centre of Mass within Base of

Support by body movements centered at the ankle• Hip strategy by large movements at the hip with antiphase

rotations of ankles and• Stepping strategy by taking a rapid step

It is a known fact that there is a difference in the strategyused in the young and elderly. Hip strategy is preferred overankle strategy in older adults. We compared kinematics of reachbetween young and older adults as seen in pictures. It clearlyshows preference for different postural strategies.

During forward reach, we expected dorsiflexion at theankles causing anterior displacement of centre of pressure. Butobserved the following movements -scapular protraction ,trunkand hip flexion with backward movement of tibia i.e. there wasankle plantar flexion instead of dorsiflexion in older adults. Wegot a low correlation between forward reach and anterior centreof pressure excursion. Similarly there was little movement atthe ankles during backward reach leading to not much posteriordisplacement of centre of pressure. The subjects showedscapular retraction with hip extension. When subjects were askedto reach laterally they bent the trunk laterally but adequate lateral


Anterior Posterior Right LeftCOP COP COP COP(mean, SD) (mean, SD) (mean, SD) (mean, SD)

67.83 70.23 82.9 73.27 +/- 20.69 +/- 27.19 + /- 20.06 +/- 20.77

Pearson correlation (r) values showed low correlation betweenreach distance and corresponding centre of pressure excursion

142

Fig.1: Comparison of forward reach between old and young adults

Fig.2: Comparison of backward reach between old and young adults

Fig.3: Comparison of lateral reach between old and young adults


143

weight shift not observed. The reaching task in Multidirectional reach test is an

example of self initiated disturbance of center of gravity toaccomplish a goal. These are volitional postural movementswhich are under conscious control. They are strongly modifiedby instructions. Dr Newton emphasized on the maximum reachdistance without moving feet or taking a step. But there is nospecific instruction regarding postural strategy to be used in themultidirectional reach test. Further research is required bymodifying the instructions as theoretically leaning task appearsto be more valuable in measurement of COP excursion.

Conclusion

The study shows that centre of pressure excursion cannotbe effectively analyzed using ‘Multidirectional reach test’ inhealthy geriatric population as there is no importance given tothe specific instruction regarding postural strategy to be used.Thus at present analysis of centre of pressure measurement byforce platforms cannot be substituted by Multidirectional reachtest.

References

1. Newton RA, ‘ Balance screening of an inner city older adultpopulation’. Arch Phys Med Rehabil. 1997;78(6):587

2. Muir SW, Berg K, Chesworth B, Klar N, Speechley M‘Balance impairment as a risk factor for falls in community-dwelling older adults who are high functioning: a prospectivestudy’

3. Roberta A. Newton, ‘Validity of the Multi-Directional ReachTest,A Practical Measure for Limits of Stability in OlderAdults’ Journal of Gerontol A Biol Sci Med Sci. 2001Apr;56(4):M248-5

4. Beckman, e. billek-sawhney, b. holbein-jenny, ma, & t.smitha comparison of the sub-tests of the multidirectional

reach test in personal care home residents. journal of amgeriatr soc. 2004 jul;52(7):1168-73s

5. Ben Achour Lebib S, Missaoui B, Miri I, Ben Salah FZ,Dziri C. [Role of the Neurocom Balance Master inassessment of gait problems and risk of falling in elderlypeople] Ann Readapt Med Phys. 2006 Jun;49(5):210-7.Epub 2006 Apr 7.

6. WallmanN HW, ‘Comparison of elderly nonfallers and fallerson performance measures of functional reach, sensoryorganization, and limits of stability’. J Gerontol A Biol SciMed Sci. 2001 Sep;56(9):M580-3.

7. Holbein-Jenny MA, Billek-Sawhney B, Beckman E, SmithT.’Balance in personal care home residents: a comparisonof the Berg Balance Scale, the Multi-Directional Reach Test,and the Activities-Specific Balance Confidence Scale ‘JGeriatr Phys Ther. 2005;28(2):48-53.

8. Jonsson E, Henriksson M, Hirschfeld H.Does the functionalreach test reflect stability limits in elderly people? J RehabilMed. 2003 Jan;35(1):26-30.

9. Liao CF, Lin SI., ‘Effects of different movement strategieson forward reach distance’. Gait Posture. 2008 Jul;28(1):16-23. Epub 2007 Nov 7

10. Clark et al, ‘Difference in the strategy used is seen in reachand lean task with respect to COP excursion in older adults’J Aging phys act,2005

11. Cavanaugh et al ,’Kinematic characterization of standingreach-comparison of younger vs. older subjects’ J Biomech1999 may

12. Clark S, Iltis PW, Anthony CJ, Toews A.’Comparison ofolder adult performance during the functional-reach andlimits-of-stability tests’. J Aging Phys Act. 2005 Jul;13(3):266-75.

13. Anne Shumway-Cook, Marjorie H. Woollacott ‘Motorcontrol: translating research into clinical practice’

14. Stephanie Hart –Huges, ‘Balance assessment handbook’


144 Aastha Maggo / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

The Effect of Proprioceptive Exercises and StrengtheningExercises in Knee OsteoarthritisAastha Maggo, Shobhit Saxena, Shalini GroverDepartment of Physiotherapy, Faridabad Institute of Technology, Faridabad, Haryana

Abstract

Study Design

The study was a randomized controlled trial.

Objective

To compare the effectiveness of proprioceptive exercisesand strengthening exercises in treatment of osteoarthritis of kneein terms of pain and functional disability.

Background

Few investigations include both strengthening andproprioceptive exercises in the treatment of knee osteoarthritis.Though previous studies give us some insight in to the role ofproprioceptive exercises in knee OA but none of the studieshave studied the combined effect of strengthening exercisesand proprioceptive exercises in knee OA. Thus, it is intended tocheck the efficacy of proprioceptive and strengthening exercisesin knee OA to reduce pain and functional disability and improvejoint position sense.

Methods

In this study 24 subjects who met the inclusion criteriawere randomized into three groups three groups. Group A weregiven conventional treatment (SWD and staticquadriceps).Group B were given strengthening exercises alongwith SWD. Group C; which were given strengthening exercisesand proprioceptive exercises along with SWD. Outcomemeasures were pain, functional disability and joint positionsense.

Results

All the groups significantly improved in VAS and WOMACscores after intervention pd”.05, knee reposition error score(Joint position sense) only improved in proprioceptive exercisesgroup. The proprioceptive exercises group demonstrated greaterimprovement in VAS and WOMAC scores as compared to othertwo groups.

Conclusion

This study between three groups comparing conventionaltreatment to strengthening and proprioceptive exercises suggestthat combination of the two brings better relief to the subjects ofknee OA in reducing pain and functional disability.

Introduction

Osteoarthritis (OA) is the most common joint disorder, aprevalence that increases with age and sex specifications2,3.Among adults 45-74 years of age or older, symptomatic diseaseoccurs in approximately 12.1% population4.Before 50 years ofage the prevalence of OA in most joints is higher in men than in

women. After about 50 years of age, women are often affectedwith hand, foot and knee OA than men3. In subjects with no jointpain who have radiographic changes of OA, quadricepsweakness predicts radiograph progression and pain6.Thesefindings suggest that the weakness may occur before arthriticdamage.

Nevertheless, exercises to strengthen the quadricepsrelieve joint pain in persons with OA of knee7. The strengtheningexercises are beneficial for knee OA by several pathways,improving strength, improving psychological well-being. All ofthese may interact and have an additive effect on the symptomsof OA7.Barret et al, (1991) has reported impaired proprioceptionfor the patients suffering from knee osteoarthritis. Fewinvestigations have investigated the relationship betweenimpaired proprioception and performance or other measures offunctional status in OA. In addition Birmingham et al, (2001)stated that quadriceps sensory dysfunction that is, decreasedproprioceptive acuity, has recently been demonstrated in patientswith knee OA and proposed as a factor in the pathogenesis orprogression of the condition. If correct, restoration of thesesensorimotor deficits with strengthening may retard progressionof knee OA and reduce disability. Although it is generallyaccepted that a rehabilitation program improves the functionalcapacity, pain and sensoriomotor function of patients, there islack of agreement about what such a rehabilitation programshould include (Roddy et al., 2005). Many previous studies havegenerally used sophisticated and expensive apparatus, whichlimits their application to a community setting 8,9,10.Though theabove mentioned studies give us some insight in to the role ofproprioceptive exercises in knee OA but none of the studieshave studied the combined effect of strengthening exercisesand proprioceptive exercises in knee OA. Thus, in this study itis intended to check the efficacy of proprioceptive andstrengthening exercises in knee OA to reduce pain, functionaldisability and improve joint position sense.

Patients and Methods

Under convenience sampling, 32 subjects were recruitedfrom the physiotherapy department of Sanjay Gandhi MemorialHospital (Delhi). The subjects were screened by means of ascreening form one of the three groups- group A (conventionaltreatment group), group B (strengthening exercise treatmentgroup) and group C (strengthening exercise and proprioceptiveexercise) by simple randomization method.

Inclusion Criteria

1. Diagnosed cases of osteoarthritis grade 2 and 3 (Asreported by radiologist).

2. Age group-45 to 60 years.3. Bilateral osteoarthritis.4. Gender-both male and female5. Patients should able to demonstrate sufficient English skills.

Exclusion Criteria

1. Neurologic disorder (e.g. Parkinson’s disease, Alzheimer’sdisease)

2. Steroid injection in past 2 months

145

3. Inflammatory arthritis4. Metal implants in lower limb5. Osteoporosis6. Knee ligament/Meniscal injury

Group A received short wave diathermy and staticquadriceps exercise, Group B received short wave diathermyand strengthening exercises and Group C received short wavediathermy, strengthening exercises and proprioceptive exercises.

Intervention

1. Before starting the exercises, patients were given treatmentfor pain reduction by short wave diathermy. The patientswere positioned supine and comfortably on the treatmentplinth. Patient in each group received 20 min of SWD thricea week for four weeks (12 treatments) applied by malleableelectrodes by contraplanar method (Chitra, 2007)11. Theintensity of the SWD was based on each subject’s tolerancebut all the subjects were advised that they should feel justcomfortable warmth (Low and Reed, 2000).

2. Strengthening exercises (Gail D,2005)12Static quadricepsin knee extension- Patient is positioned fully supine. Patientcontracts the quadriceps femoris muscle and pushes kneedown while maintaining the foot in full dorsiflexion, eachcontraction is held for 6 sec with a 10 sec rest betweenrepetitions. 10 repetitions are done.

Standing terminal knee extension- Patient stands with aresistive band behind a slightly flexed knee. Patient contractsthe gluteal and quadriceps femoris muscle to fully straightenthe hip and knee. Each contraction is held for 3 seconds, 10repetitions were done and resistance is increased as toleratedby the patient.

Closed chain exercise, one of the two exercises isperformed 3 times per week. Patient should progress to themost challenging activity that he or she can successfullycomplete with minimal or no pain.a. Seated leg press- Patient is seated holding a resistive band

in both the handsA patient places his or her foot against the band, thenstraightens the knee by straightens the knee by pushingthe foot down and forward by contracting the gluteal andquadriceps femoris muscles. Each contraction is held for 3seconds with knee as straight as possible, patient slowlyreturn to the starting position and repeat for 30 sec bout.Progression is made by using bands of high resistance andadditional bouts.

b. Partial squats - Patient stands with arm support as needed,patient performs a partial squat, keeping the knees centeredover the feet return to standing by contracting thequadriceps femoris and gluteal muscles. Each contractionis held for 3 seconds with hips and knees as straight aspossible. Progress to full body weight without support andadditional bouts.

3. Proprioceptive exercises. (Chita et al, 2007)11

a. One leg balance-it involved standing on affected foot withrelaxed upright posture and other leg flexed at knee, hipand ankle, this position was held for one minute followedby rest for 10 to 20 seconds and was repeated twice more.After a brief rest three similar repetitions were carried outfor unaffected leg(Fig a).

b. Blind advanced one leg balance-It was same like one legbalance, expect that the patient was asked to keep his/hereyes completely closed while performing the routine, andthen was repeated twice again (Fig b).

c. Toe walking-Here the patient was made to walk for 20meters high up on the toes with toes pointing straight ahead,then walk with toes pointing outwards and then walk with

toes pointing inwards after a short rest repeat it onceagain(Fig c)

d) Heel walking - Walking for 20 meters on heels with toespointing straight ahead, walking on heels with toes pointingout and walking on heels with toes pointing in. After a shortrest, the procedure was repeated once more(Fig d)

e) Cross leg body swing-Leaning slightly forward with handson wall for support and weight on affected leg, other legwas swung in front of the body pointing toes upwards asfoot reaches its farthest point of motion. Then swing thisunaffected leg back to the unaffected side as far ascomfortably possible, again pointing toes up as foot reachesits final point of movement. Repeat this overall motion 15times with erect body posture and good balance, rest for afew seconds, and then 15 similar repetitions with theunaffected leg as weightbearing limb was performed (Fige).

Aastha Maggo / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

(a) (b)

(c) (d)

(e)

146

Treatment was given three times per week for four weeks.In this study the outcome measures were-:

All outcome measures were measured at baseline, end of week1, end of week 2, end of week 3 and end of week 4.

Pain – was measured using the visual analogue. Functionaldisability-was measured using the Western Ontario andMcMaster Universities Osteoarthritis Index (WOMAC) Jointposition sense-was measured using inclinometer by Repositionerror test (Higgins and Perrin, 2000).

Procedure for reposition error test- all the subjects werefamiliarized with the procedure by explanation, demonstrationand adequate practice repetition. Inclinometer was attached tothe distal thigh of dominant extremity approximately one inchabove knee joint line. Patient is standing with back against walland is blindfolded to eliminate visual cues, Patient squats to 30degree of knee flexion and maintains this position for 15 sec,return to starting position of 0 degree extension, Following a 15sec rest period patient then attempts to reposition themselvesat the predetermined angle, degree of error from 30 degree kneeflexion target angle is recorded and average over three trials isused for data analysis (Higgins and Perrin, 2000)13.

Inclinometer for assesing joint position sense(Repositionerror test)


A total of 32 patients were screened for possible studyeligibility. 28 patients satisfied the eligibility criteria, were recruitedinto study and underwent baseline measurement. Four patientsin this study did not complete the treatment. There were twodropouts from Group A, one each from Group B and Group C.Total of 24 subjects, including both males and females,completed the study. Age of subjects in this study was between45-60 years. The mean age of subjects in Group A was51.5(±4.30) years, Group B was 49.5(±2.44) years, and GroupC was 51.62 (±3.96) years. There was no significant differencebetween the mean ages of all the three groups. Group A had 5females and 3 male patients, Group B had 6 females and 2male patients, Group C had 6 female and 2 male patients. Intotal there were 17 female and 9 male patients.

Readings of the variables taken at the baseline and at the

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

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

Results

Within Group Analysis of pain scores - The repeatedmeasures ANOVA results for VAS scores revealed a significantdifference within all groups.

Between group analysis of pain scores - The analysis ofVAS scores Between all the groups suggested that there wereno significant differences at the baseline (p=0.397) and at theend of 1st week (p=0.052).At the end of 2nd week there wassignificant difference between the groups (p=0.002), at the endof 3rd week there was significant difference between the groups(p=0.000), at the end of 4th week there was significant differencebetween the groups (p=0.000).

Within Group Analysis of WOMAC scores-the results ofrepeated ANOVA and post-hoc t-test showed significantdifferences in WOMAC scores in all the groups.

Between group Analysis of WOMAC Scores-The analysisof WOMAC score between the groups suggested that there wereno significant differences between baseline (p=0.110) and week1(p=0.467).At the end of 2nd week there was significant differencebetween the groups (p=0.003). At the end of 3rd week therewas significant difference between the groups (p=.000). At theend of 4th week there was significant difference between all thegroups (p=.000).


Graph 1: Comparison between mean values of VAS

Graph 2: Comparison of mean values of WOMAC

147

Within Group Analysis of Reposition Error Test scores -The results of repeated ANOVA and post-hoc t-test showed nosignificant differences in Reposition scores in group A and B.But in Group C there was statistically significant improvementin baseline and week 4.

Between Group Analysis of Reposition error test - Theanalysis of reposition error score between the groups suggestedthat there were no significant differences between baseline(p=0.193), week1 (p=0.144), week2 (p=0.135), week 3 (p=0.095)and week 4 (p=0.113).

Table 1: Percentage of improvement in all outcome measures across the three groups

Outcome measure Percentage of improvementGroup A Group B Group C(conventional (strengthening (strengthening and treatment) exercises) proprioceptive

Exercises)

Pain(VAS) 24.64% 35.72% 44.71%

Disability(WOMAC) 41.03% 57.60% 68.48%

Joint position sense(RET) 2.70% 3.08% 9.35%

Discussion

The purpose of this study was to determine theeffectiveness of Proprioceptive exercises along withstrengthening exercises in improving pain and disability inpatients with knee osteoarthritis. In all the three groups- pain,disability and joint position sense were taken as the dependentvariables to assess the improvement between the groups andwithin the group. The findings of the present study suggest thatthe addition of proprioceptive exercises and strengtheningexercises reduces patient’s pain and disability more effectivelythan strengthening exercises or conventional physiotherapyalone over a 4 week period. Statistical analysis revealed nosignificant differences in key demographic variables and baselinemeasurements of pain, disability and active angle replicationtest suggesting that all the groups had homogenous distributionof patients.

In this study VAS was used to measure pain. A statisticallysignificant difference was found between all the groups.Maximum reduction of pain was in group C (37±0.02mm). Thisis in favor of our research hypothesis. Pain relief in this group isin accordance with a case report of 70 year old lady withosteoarthritis of knee who found moderate pain relief byproprioceptive exercises as done by Childs et al(2002)14.Reduction in pain in Group A (conventional treatment) and B(strengthening exercise group) is consistent with previousfindings which state that both dynamic and isometric resistancetraining reduced perceived knee joint pain15.Proprioceptivetraining activities provide patient with an opportunity to adaptto potentially destabilizing loads on the knee during rehabilitation,give additional exposure to pivoting, quick starting and stoppingand quick changes in direction and challenge their balancecapabilities. Strengthening exercises are recommended toreduce pain and improve physical function in knee OA, but thereis minimal information on its long term impact8.It is theorizedthat because elevated plasma â endorphin, a neuro transmitterinhibitory to pain signal, has been observed in response toprolonged rhythmic exercise (Thoren et al, 1990) leading toincreased â endorphin production might decrease painexperienced by persons with osteoarthritis17.

In the present study WOMAC Score was used to assesoverall knee function since its validity and reliability is alreadyestablished16. The analysis of disability score reveals nosignificant difference at baseline. There was significantimprovement in Group B (Strengthening exercises) and C(Strengthening exercise and Proprioceptive exercises) ascompared to Group A(conventional treatment ) but maximumdifference in mean score of Group C (52 mm), supporting our

research hypothesis. Both the treatment groups A and B resultedin significant improvements in all the variables compared to theconventional therapy group. A study by Felson et al (2009) statesthat proprioceptive acuity as assessed by the accuracy ofreproduction of the angle of knee flexion has modest effects onpain and physical function limitation in knee osteoarthritis. Thiscould be due to pain relief, reduction in stiffness, increasedlubrication of joint, gain in strength of weak muscles, correct

mechanical loading, improved joint stability and thus increasedquality of movement and improved proprioception which in turnprovides participants an opportunity to adapt to potentiallydestabilizing load on knee during the study period9. Hurley et al(2004) have reported that proprioception is closely related tofunctional performance and walking speed. This is in accordancewith this study which shows greater mean difference inproprioceptive exercises group than with other two groups.


Graph 3: Comparison of mean values of Reposition error scores

Graph 4: Comparison of percentage improvements in alloutcome measures

148

In this study joint position sense was measured by repositionerror test (RET).The analysis of RET at baseline reveals nosignificant differences between all the three groups. At the endof 4th week mean differences were not significant between allthe groups. There was improvement in all the groups whichsupports the study that proves general exercise training canincrease proprioceptive performance (Bernauer et al,1994).Maximum reduction in mean was in Group C (0.48°). Thedifference between the moderate improvement in other twogroups as compared to Group C and greater improvement inthis group was probably due to specific proprioceptive exercises.Proprioceptive information alone (without visual feedback) cancorrect up to 95% of velocity and timing errors associated withsudden perturbation in resistance during a multi-joint movementsequence10.

Group A (conventional treatment), Group B (strengtheningexercises) and Group C (proprioceptive and strengtheningexercises) does not show any statistically significant differenceat the end of 4 week study period. This is in accordance with astudy done by Sekir et al, 2005 in which 6 weeks of proprioceptiveand balance training was given to treatment group while thecontrol group did not receive any exercise but there was nosignificant differences by the end of training in weight bearingjoint position sense. Therefore, it may be concluded thatproprioceptive acuity takes longer duration to show significantimprovement.

Sample size was small and data was collected from limitedplace that limits the generalizability of the results. The durationof study was short (4 weeks) therefore long term effectivenessof proprioceptive exercises was not evaluated. Neither thesubjects nor the therapist were blinded to group assignment.The cohort of patients with knee osteoarthritis werepredominately female, hence generalizability of our findings maynot necessarily be applicable to the entire population ofindividuals with osteoarthritis.

This study showed that patients affected with OA knee,when performed proprioceptive exercises along withstrengthening exercises showed significant reduction in pain andfunctional disability and improvement in proprioception ascompared to patients performing strengthening exercises alone.Thus proprioceptive exercises can be incorporated along withstrengthening exercises in patients of knee osteoarthritis.

Conclusion

Management of osteoarthritis, which deteriorates withimbalance between the stress applied to the articular cartilageof the joint and its ability to withstand it, requires being moreextensive than mere analgesics. This study between threegroups comparing conventional treatment to strengthening andstrengthening and proprioceptive exercises suggest thatcombination of the two (proprioceptive and strengtheningexercises) brings better relief to the subjects of kneeosteoarthritis in reducing pain and functional disability. However,reposition error scores (joint position sense) did not improvesignificantly in proprioceptive and strengthening exercise groupthan other two groups. These results partly accept and partlyreject the experimental hypothesis suggesting that usingproprioceptive exercises and strengthening exercises togetherwill produce statistically significant difference in pain, disabilityand but joint position sense may take longer duration to showsignificant differences.

References

1. Lennart TH Jacobsson; Definitions of osteoarthritis in theknee and hand. Ann Rheum Dis.1996,55(9):656-8.

2. E M Badley and A Tennant: Changing profile of jointdisorders with age: findings from a postal survey of thepopulation of Calderdale, West Yorkshire, United Kingdom.Ann Rheum Dis. 1992 March; 51(3): 366–371.

3. Felson T.D., Zhang Y; Osteoarthritis: New Insight Part I:TheDisease and its risk factors. Ann. ofInter.Med.2000,133:635-646

4. Leon Sokoloff; Some highlights in the emergence of modernconcepts of osteoarthritis Seminars in Arthritis andRheumatism Volume 31, Issue 2, October 2001, Pages71-107

5. Slemenda C, Heilman DK; Reduced quadriceps strengthrelative to body weight: a risk factor for knee osteoarthritisin women? Arthritis Rheum. 1998 Nov; 41(11):1951-9.

6. Charles Slemenda, Dr. PH; Kenneth D. Brandt, et al,Quadriceps Weakness and Osteoarthritis of the Knee, AnnIntern Med. 1997; 127:97-104.

7. Fischer N. M. ; Gresham G. E. Quantitative effects ofphysical therapy on muscular and functional performancein subjects with osteoarthritis of the knees Archives ofphysical medicine and rehabilitation 1993, vol. 74, pp. 840-84

8. Ufuk Sekir and Hakan Gür Amulti-station proprioceptiveexercise program in patients with bilateral kneeosteoarthosis; functional capacity, pain and sensorimotorfunction. A Randomized Controlled Trial. Journal of SportsScience and Medicine (2005) 4, 590-603

9. David T. Felson, MD, MPH, K Douglas Gross, PT, ScD Theeffects of impaired joint position sense on the developmentand progression of pain and structural damage in kneeosteoarthritis Arthritis Rheum. Author manuscript; availablein PMC 2009 October 6.

10. Da-Hon Lin, Chien-Ho Janice Lin, Efficacy of 2 Non–Weight-Bearing Interventions, Proprioception TrainingVersus Strength Training, for Patients With KneeOsteoarthritis: A Randomized Clinical Trial J Orthop SportsPhys Ther 2009;39(6):450-457

11. Gupta Abhishek Rajendra, Jeba Chitra, Khatri Subhash: Arandomized controlled trial to study the effectiveness ofproprioceptive exercises in osteoarthritis knee: The journalof Indian Association of Physiotherapists,2007: Vol-3;2: Oct:47-52

12. Gail D Deyle et al Physical Therapy Treatment Effectivenessfor Osteoarthritis of the Knee: A Randomized Comparisonof Supervised Clinical Exercise and Manual TherapyProcedures Versus a Home Exercise Program physicaltherapy Vol. 85, No. 12,2005, December, pp. 1301-1317

13. Scott M. Lephart, Freddie H. FU, Proprioception andneuromuscular control in joint stability 2000, Pg349-59.

14. Fitzgerald GK, Childs JD, Ridge TM, Agility and perturbationtraining for a physically active individual with kneeosteoarthritis. Phys Ther. 2002 Apr; 82(4):372-82.

15. Robert Topp, Woolley S, et al, The effect of dynamic versusisometric resistance training on pain and functioning amongadults with osteoarthritis of the kneeArch.Phys.Med.Rehab,2002,Volume 83, Issue 9, Pages1187-1195

16. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, StittLW, Validation study of WOMAC: a health status instrumentfor measuring clinically important patient relevant outcomesto anti-rheumatic drug therapy in patients with osteoarthritisof the hip or knee. J Rheumatoy.1988, Dec; 15(12):33-40.

17. Ray Marks; Peripheral articular mechanisms in painproduction in osteoarthritis, Australian Journal ofPhysiotherapy1992, 38; 289-298.1.


149

Predicting Neuromotor Outcome in Very Low Birth Weight Infantsat One Year of Corrected Age Using Movement Assessment ofInfants ScaleDeepa Metgud*, V D Patil**, S M Dhaded****Assistant Professor, KLE University’s Institute of Physiotherapy, Belgaum, **Professor and Principal, ***Professor and HOD,Department of Pediatrics, J.N.Medical College, Belgaum

Abstract

Purpose

The purpose of this study was to find the validity of MAI inpredicting neuromotor outcome in Very Low Birth Weight Infants(VLBW) at one year of corrected age.

Method

Infants(n=40) born with birth weightd”1500gms andadmitted to NICU were assessed at 4 months of corrected ageusing MAI scale and follow up evaluation for motor and mentaldevelopment was done with a neuropschycological tool, BayleyScale of Infant Development (BSID II) at 12 months of correctedage .

Results

The predicted neuromotor outcome at 12months on motoritems of BSID were 70% sensitivity, 83.3% specificity, 58.3%positive predictive value and 89.3% negative predictive valveand for mental items were 60% sensitivity, 74.3% specificity,25% positive predictive value and 92.8% negative predictivevalve with a cutoff score of e”10 on MAI.

Conclusion

The MAI administered at 4 month is a useful clinical toolwith high specificity and acceptable sensitivity in predictingneuromotor outcome at one year of corrected age in VLBWinfants.

Key Words

Movement Assessment of Infants scale, Very low birthweight infants, Neuromotor development.

Introduction

Very low birth weight (<1500grams) is an important riskfactor for neurological outcome in at-risk infants 1. Low birthweight babies face serious health problems as newborns, andare at increased risk of long-term problems such asdevelopmental delay, mental retardation, cerebral palsy,impairment of lung function, visual and hearing impairment. InIndia the incidence of low birth weight is estimated to be around40%2,3. The disparity of low birth weight in India has ranged froma prevalence of 10% (for the privileged high socio-economicclass) to 56% (for the poor urban slum community) 4, 5.

Studies of the predictive diagnosis of Cerebral Palsy (CP)6,7

emphasize the relationship between prematurity and low birthweight with the diagnosis of CP and recommend that preterminfants with very low birth weight or who have sufferedneurological complications, as neonates be monitored from birth8

to prevent possible delays or be treated early, the consequencesbeing more severe. Given the importance of detection of CP, inaddition to neurological examination, were created several tests

Deepa Metgud / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

for early diagnosis9,10. In the area of Physical and OccupationalTherapy, one of the most known test to assess motor behaviorin infants at high risk for developmental disorder, is the MovementAssessment of Infant (MAI), developed by Chandler, Andrewsand Swanson in 198011.It is used for monitoring programs in theUnited States, and is subjected to various studies of validity andreliability.

There are no predictive validity studies of MAI tool for highrisk infants (VLBW) in Indian population. Hence the purpose ofthe present study was to evaluate the ability of MAI administeredat 4months, to predict neuromotor development in VLBW infantsat one year of corrected age against BSID-II, a gold standardassessment and also to find the usefulness of MAI as screeningtool in clinical practice for VLBW infants in India.


Subjects were infants of VLBW (<1500gms) born fromJanuary 2008 to December 2008, who were admitted to neonatalintensive care unit of KLE’S Dr Prabhakar Kore hospital andmedical research center, Belgaum Karnataka, India. During thatperiod 45 infants of VLBW were randomly selected from thosewho were born on odd number days. After discharge from theNICU, the infants were recruited for the study that was approvedby the KLE University’s ethics committee and an informedconsent was obtained from the primary caregiver. Infantsattended physiotherapy clinic where a standard neurologicalevaluation was performed by the investigator and demographicdata of the mother and child with clinical details of obstetric historyand neonatal problems were recorded. Then the infants wereevaluated at 4 months of corrected age using the MAI scale bytwo experienced and trained pediatric physiotherapists.

The MAI evaluation was performed as per the instructionsin the MAI training DVD and the instructions mentioned in theMAI manual. The reliability coefficients were established througha joint assessment between pair of examiners for at least 10infants, until it reached a minimum of 80% agreement betweenthe scores. Periodically, joint evaluations were made to re-checkthe reliability. The scoring for the 65 test items on MAI was doneon the 4 months MAI profile score sheet and the total high riskpoints were calculated. Score less than 10 was considered lowrisk, and score more than 10 was considered as high risk forneuromotor development that is cerebral palsy.

A neuropsychological examination, Bayley scale of infantdevelopment (BSID-II) was administered by the investigator anda clinical Psychologist at 12 months of corrected age. The mentaldevelopment index (MDI) and psychomotor development index(PDI) were calculated .The predictive values for a score at -2SD below the mean on the BSID II at 12 months were consideredas mild delay and scores at -1SD below the mean wereconsidered as cerebral palsy and were referred for regularphysiotherapy intervention.

Instrument

The MAI is a neuromotor assessment tool comprising 65items in four areas: muscle tone, primitive reflexes, automaticreactions, and volitional movement. Items in the muscle tonesection evaluate spontaneous movement in three antigravitypostures, extensibility or range of motion of the extremities,

150

consistency of muscle tissue, and passivity of hands and feet.The primitive reflex section includes items to examine the relativepresence or absence of reflexes that usually are present duringinfancy. Assessment of righting reactions, equilibrium reactions,and protective extension responses is included in the sectionon automatic reactions. The volitional movement sectionsamples a wide variety of items, including visual following andperipheral vision, hearing, fine motor skills and the achievementsof developmental gross motor milestones. Each MAI item isscored independently using a numerical scale with specificbehavioral criteria. Based on normative data collected on a smallsample of 4 month old infants, an MAI “4–month profile” wasdeveloped indicating which scores for each item are consideredto be deviant, which identify an infant to be at risk. Any item forwhich a 4-month-old infant’s score identifies him as being atrisk then is circled and becomes a “risk score.” After the entireexamination has been administered and scored, the categoricalrisk scores are obtained for each area. The four categorical riskscores then are summed to yield a “total risk score.” The lowerthe risk score, the more optimal the infant’s prognosis fordevelopment.Thus, qualitative assessment of the infant’smovement is incorporated into a quantitative scoring system foreach item.11


The predictability of MAI was measured in terms ofsensitivity, positive predictive value (PPV) and Negativepredictive value (NPV) to determine its accuracy in detectingneuromotor abnormality in VLBW infants. The relationshipbetween 4-month MAI risk scores to Bayleys score (MDI&PDI)at 12 months was examined using Pearson’s product momentcorrelation test.

ResultsTable1 presents mother and infant demographic and clinical

characteristics. Data was available for only 40 subjects as oneinfant died (3.3%), one developed hydrocephalus (3.3%) andthree were lost to follow up (9.9%).


Table 1: Demographic data of the mother and child

% Mean SD Range

Age of 25.8 4.75 18-37mother(yrs)

Gestational 32.3 2.16 28-40Age(weeks)

Birth weight 1363.5 150.20 1000- (gms) 1500

No of days 21.7 12.09 5-60in NICUSex-Males(24) 60Females(16) 40

No of fetusin the wombSingle(37) 92.5Twins(2) 5Triplets(1) 2.5

Among the 40 infants entering the study, 25% of them hadabnormal motor development and 12.5% had abnormal mentaldevelopment at one year based on their scores on the mentaland motor developmental index of Bayleys scale >10.

MAI total risk score of the study infants at 4months areshown in table2 and table3.Of the 12 with TRS greater than 10,seven showed abnormal motor development on BSID II motoritems. Their performance on mental items of BSID II was, of the12 with TRS greater than 10, three showed abnormal mentaldevelopment. Abnormal motor and mental development at 12months on BSID included infants with both mild and significantdelay. The sensitivity of MAI for predicting motor delay with thecut-off point of more than 10 was 70%, specificity was 83.3%,positive predictive value was 58.3% and negative predictivevalue was 89.3%.Similarly for predicting mental delay, sensitivitywas 60%,specificity was 74.3%, positive and negative predictivevalues were 25% and 92.8% respectively(Table-2&3).

Table 2: Motor outcome (MDI) at 12 months with MAI risk scoreat 4months

Sensitivity: 70%, Specificity: 83.3%,PPV: 58.3%, NPV: 89.3%

MAI TRS score at 4 months

Bayleys <10 >10 TotalMotorscale

PDI>84 25 05 30

PDI<84 3 07 10

28 12 40

Table 3: Mental outcome (MDI) at 12 months with MAI risk scoreat 4months

MAI TRS score at 4 months

Bayleys <10 >10 TotalMotorscale

PDI>84 26 09 35

PDI<84 2 03 05

28 12 40

Sensitivity: 60%, Specificity: 74.3%,PPV: 25%, NPV: 92.8%

The relationship between 4month MAI risk scores toBayleys motor and mental score (MDI and PDI) at 12 monthsare presented in Table -4 .All correlations of the MAI total riskscore with Bayleys outcome measure at one year were highlysignificant (p<.0000).For the categorical risk scores, all weresignificant at p<0.01 except for primitive reflexes with MDI atone year (.09).

Discussion

The results of this study demonstrates that MAI has clinicalutility in early detection of neurodevelopment abnormality thatis cerebral palsy in very low birth weight infants as early as 4months of age in Indian population. However, the test was morespecific to discriminate children with normal development thanto identify children with abnormal neuromotor development. Thefrequency of 25% of the cases with abnormal motor developmentand 12.5% of cases with abnormal mental development in thisstudy is higher than that reported in other studies with the MAI12,13,14. This fact could probably be due to very low birth weight(<1500gms), which is high risk and also large number of thesample belonged to very low socio-economic status and poor

151Deepa Metgud / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Table 4: Pearson’s Product- Moment correlation of 4 month MAI with 12 month BSID

MAI at 4 months Mental(MDI) At 12months P value Motor (PDI) At 12months P value

Total risk score -.542 0.000* -.714 0.000*

Muscle Tone -.430 0.000* - .584 0.000*

Primitive Reflex -.272 0.090 NS - .378 0.016s

Automatic reaction -.567 0.000* - .685 0.000*

Volitional Movement - .495 0.001* - .694 0.000*

*Highly significant .S-significant.NS- Not significanteducational background. It has been reported in the study byMarcia swanson1992 that low birth weight infants social andfamilial context has significant influence on outcome. Thepredictive validity of the MAI obtained in our study and the trendsindicated by earlier MAI studies on low birth weight infants 12, 15,

16 are similar, suggesting that the same basic relationship ofpredictive validity exits. The results obtained in this study couldbe because the sample was of VLBW as compared to LBW inother studies and also the duration of outcome was 12months.

The sensitivity of MAI at four months was 70%, whichindicates that about 70% of VLBW infants who will haveabnormal outcome can be recognized as early as four monthsof age. The results of our study signify the importance ofimplementing MAI as a neuromotor assessment tool in Indianinfants of VLBW at four months of age. Though the test hasacceptable sensitivity, but has high specificity of 83.3% andnegative predictive value of 89.3% which is consistently reportedin most of the studies of MAI.14,16 These values indicate thatMAI provides reliable reassurance to the families whose infantsare determined to be at low risk and will have good prognosis,which is a critical factor for stressed parents .The relatively highrate of false positives in this study could be an accurate reflectionof clinical phenomenon observed among low birth weight infantswhich cannot be resolved altogether by quantitative adjustments.The clinical explanations for resolution of abnormal findings couldbe the condition of transient dystonia which has been observedin 25 to 40 percent of low birth weight infants, who have transientabnormalities of muscle tone and posture in the first months oflife. Although these deviant movements are suggestive of earlycerebral palsy, typically they resolve by one to two years of age.17,

18 About 45%(18) of the infants in our study had more than 5neonatal problems and the mean duration of stay in NICU was21.7 days, which could also be the reason for more number offalse positives at 4 month evaluation.

The Pearson’s product moment correlation of the MAI totalrisk score was highly significant for both MDI and PDI score ofBSID II at 12 months as indicated in table-4.12, 19, 20 This result issimilar to the finding of other studies, however the only differencewas in our study BSID II was used. This indicates that thecorrelation of MAI with BSID II is equally strong as BSID I. Itwas found that though MAI is primarily a neuromotor evaluationtool, highly significant correlations were found with mental scaleof BSID II and also the sensitivity of 60%, which indicate thatMAI has potential in identifying mental delay. This could bebecause it has items like reaching for red ring, picking up cube,pincer grasp for pellet, vision, hearing etc which are similar toitems on the mental scale of BSID II.21, For the categorical riskscores, all were significant at p<0.01 except for primitive reflexeswhich was less strong with PDI and not significant with MDI at12 months (p<.09).This suggests that reflexes are the leastreliable and valid predictors of later motor handicap.22Strongcorrelation with the motor outcome measures was found forvolitional movement which confirms the importance of includingassessment of developmental function as well as neurological

signs in examination of high risk infants.23,24

Conclusion

MAI is a potentially useful clinical tool for identifyingneuromotor abnormalities in VLBW infants with high specificityand acceptable sensitivity. Although with some limitations, MAIgives the therapist an objective frame work for assessment ofrisk babies. Future research with sequential follow up using 6and 8 month MAI profile would be useful in longitudinalmonitoring of development in VLBW babies and also predictivevalidity studies of MAI for Indian children who are born at termand exposed to perinatal and social risk would be consideredfor future studies.

References

1. Protection of the Developing Brain of Very Low Birth WeightInfants, 2/1995 UCP: Research & Educational Foundation,February 1995.available from: vrl: http://www.ucpresearch.org/ fact-sheets/protection-developing-brain.php

2. Gopalan C. Nutrition Research in South East Asia - TheEmerging Agenda of the Future. Regional Office for South- East Asia, World Health Organization, New Delhi, 1994:p 13-31.

3. Sachdev HPS. Low birth weight in South Asia. In:Malnutrition in South Asia: A regional profiel. Ed. GillespieS. United Nations Children Fund, Regional office for SouthAsia, Publication No. 5, 1997; pp 43-75.

4. Bhargava SK. Recent trends in perinatal health in SouthAsia. 2. India. In: Improving Health of the Newborn Infantin Developing Countries. Ed.Costello A, 1997 (in press).

5. Bhargava SK, Singh KK, Saxena BN. A NationalCollaborative Study of Identification of High Risk Families,Mothers and Outcome of Their Offsprings With ParticularReference to the Problem of Maternal Nutrition, Low BirthWeight, Perinatal and Infant Morbidity and Mortality in Ruraland Urban Slum Communities.A Task Force Study. NewDelhi, Indian Council of Medical Research, 1990.

6. Levine MS. Cerebral palsy diagnosis in children over age1 year: standard criteria.Arch Phys Med Rehabil 1980;61:385-389.

7. Cans C. Surveillance of cerebral palsy in Europe: acollaboration of cerebral palsy surveys and registers. DevMed Child Neurol 2000; 42:816-824.

8. Magalhães LC, Araújo AR, Paixão ML, Mancini MC,Barbosa VM. Influence of biological risk factors in the scoresof a test for detection of cerebral palsy in preterm infants.Themes 2001; 10:5-12.

9. Dargassies SAS. Méthode d’examen neurologique dunouveau-né. Etudes Neonat 1954;3:101-124.

10. Campbell SK, Kolobe TH, Osten ET, Girolano GL, LemkeM. Test of Infant Movement Performance.Research edition.

152

Chicago: University of Illinois, 1995. 11. Chandler LS, Andrews MS, Swanson MW, Larson AH.

Movement Assessment of Infants: A Manual. Washington:Rolling Bay; 1980

12. Swanson MW, Bennett FC, Shy KK, WhitfieldMF.Identification of neurodevelopmental abnormality at fourand eight months by the movement assessment of infants.Dev Med Child Neurol 1992; 34: 321–37

13. Darrah J, Piper MC, Watt J. Assessment of gross motorskills of atrisk infants: predictive validity of the Alberta InfantMotor scale.Dev Med Child Neurol 1998; 40: 495–91

14. Cardoso AA, Magalhaes LC, Amorim RH, Paixao ML,Mancini MC, Rossi LD.Predictive validity of the MovementAssessment of Infants (MAI) for Brazilian pretermchildren.Arq Neuropsiquiatr 2004;62(4):1052-7.

15. Harris.S.R.Early detection of cerebral palsy: Sensitivity andspecificity of two motor assessment tools, Jr ofperinatology1987; 7: 11-15.

16. Salokorpi.T,Rajantie,Irmeli,Haajanen, Ritva,RajantieJukka.Predicting neurological disorders in infants withextremely low birth weight using Movement Assessmentof infants.Pediat phys ther 2001;13(3):106-109,

17. Drillien CM:Abnormal neurologic signs in the first year oflife in low birth weight infants:possible prognostic

significance.Dev Med Child Neurol 1972; 14:575-584.18. Saint -Anne Dargassies S.Normality and normalization as

seen in long term neurological follow up of 286 trulypremature infants,Neupadiatrie 1979;10,226-244.

19. Rose-Jacobs R, Cabral H, Beeghly M, Brown ER, FrankDA. The Movement Assessment of Infants (MAI) as apredictor of two-year neurodevelopmental outcome forinfants born at term who are at social risk. Pediat PhysTher 2004; 16: 212–21.

20. Harris SR, Swanson MW, Andrews MS, et al. Predictivevalidity of the ‘Movement Assessment of Infants’. J DevBehav Pediatr 1984; 5: 336–342.

21. Bayley N. The Bayley Scales of Infant Development. 2ndedn. New York: The Psychological Corporation, 1993.

22. Harris SR,Haley SM, Tada WL, Swanson MW:Reliability ofobservational measures of the Movement Assessment ofInfants.Phys Ther 1984; 64:471-475.

23. Marstrander J: The prognostic value of neurological signsin infancy. A preliminary result of a follow up study ofprematures with birth weight less than 2,000g. Acta Pediatr1965; 159(suppl):81-84.

24. Paine RS: Early recognition of neuromotor disability ininfants of low birth weight. Dev Med ChildNeurol1969;11:455-459.


153

Comparison Among Different Head Neck Positions for the Effectson Wrist Flexor Torque ProductionDheeraj Lamba*, Sapna Kharayat**, Jaya Mehta**, Ajay Joshi**, Manish Kandpal***Incharge, ** Interns, Dept. of Physiotherapy, IAHSET Medical College, Haldwani, Uttarakhand

Introduction

The influence of head and neck (H-N) position on thebehavior of limb muscles was first reported over 75 years ago.In 1951, Tokizane published the results of a study, thatdemonstrated in relaxed healthy subjects the electromyographyactivity of limb muscles varies with rotation of the H-N, basedon tonic neck reflex (T.N.R).The existence of the TNR was

demonstrated first by Magnus and de Klein in 1912 TNR isnormally present during infancy and become integrated by theCNS at an early age. Once integrated, these reflexes are notgenerally recognized in adults in their pure form. They howevercontinue as adaptive fragments of behavior, underlying normalmotor control. Studies have been done which proves

that T.N.R can be elicited in normal healthy adults alongwith infants and neurogically impaired persons. Although thisreflex may affect all four limbs, its influence is greater on theupper extremities than on the lower extremities. The TNR hasboth a symmetrical and an asymmetrical component. Thesymmetrical tonic neck reflex (STNR) configuration,affecting bothupper limbs, increases flexor muscle tone when the head andneck are flexed and conversely increases extensor muscle tonewhen the head and neck are hyper extended. The classicasymmetrical tonic neck reflex (ATNR) pattern involves elbowextension and shoulder abduction on the chin side and elbowflexion and shoulder adduction on the back of the head side.when the head and neck are rotated.

The strength evaluation of a joint is very important for theclinician as it gives a valuable or fundamental information aboutathletic and human performance. Strength testing has been usedto examine the integrity and function of the musculoskeletalsystem. It would also make it easier to find follow up effect ofexercise therapy and in the field of sports specific training orrehabilitation. Isometric evaluation with an isokinetic machineprovides reliable and valuable source of muscle strength. Arecent trend of measuring joint strength in clinical setup is byusing isokinetic machine. The reliability of this machine is wellestablished. Although many studies have been done on theinfluence of different H-N positions and its effect on joint strengthproduction but there is no consensus in the literature regardingthe influence of different H-N positions for the effects on wristflexor strength measurement, hence there is a need for properprotocol development when evaluating isometric wrist flexorstrength using an isokinetic machine and higher level of accuracyin isokinetic muscle evaluation would be incorporated inprofessional rehabilitation strategies.

Aims and Objective

To compare the wrist flexor torque production in differenthead and neck positions (Neutral position, Sagittal plane,Horizontal plane and Combination of both Sagittal and Horizontalplanes).

Hypothesis

Head-neck rotation (horizontal plane) has a greaterinfluence on wrist flexor muscle torque production than themovements in neutral position, sagittal plane, and combinationof both sagittal and horizontal planes.

Methodology

Sample

Thirty subjects were participated in this study according toinclusion and exclusion criteria and were selected randomly fromSushila Tiwari Memorial Hospital, Haldwani. Their mean agewas (21.93 ± 2.01) yrs, mean height (155.16 ± 3.98) cms, andmean weight was (51.70 ± 5.25) kgs.

Inclusion Criteria

1. Healthy female subjects2. Age - 19-25 years3. Height - 149-167 cms4. Weight - 40-62 kgs5. Subjects with left as nondominant hand.

Exclusion Criteria

1. History of fracture of upper extremity2. History of neurological disorders affecting cervical spine or

upper extremity.3. History of muscle strain of upper extremity or cervical spine.4. Any deformity of upper extremity.5. Instability of wrist joint

Study Design

Comparative study design.

Instrumentation

Humac Norm (CSMi) testing and isokinetic rehabilitationsystem.

Protocol

Minimum of 30 female subjects were included in the studybased on inclusion and exclusion criteria. The subjects wererandomly selected and left wrist flexor torque was measured indifferent head and neck (H-N) positions viz: Neutral position:Subject was asked to look straight in the front, at the point markedin the wall (NP). Sagittal plane: H-N positions in flexion (SPF)and extension (SPE).

Horizontal plane: H-N positions in rotation left (HPRL) androtation right (HPRR). Combined plane: H-N positions in thecombination of both sagittal and horizontal planes i.e. rotationright with flexion (CRRF) and extension (CRRE) and rotationleft with flexion (CRLF) and extension (CRLE).

Procedure

At first, the whole procedure was explained to the subjectsand each subject willing to participate, was made to sign aconsent form. After informed consent was obtained, eachsubject’s height, weight, age, were recorded. 30 female subjectsincluded in the study were randomly tested in different head

Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

154

and neck (H-N) positions. The left, nondominant hand 2, 10was used for the study, tested in Humac Norm (CSMi) isokineticrehabilitation system, to measure the maximal isometric torque,during isometric wrist flexion, for all the subjects with differentH-N positions.

The different H-N positions made by the subject, wereaccording to their maximum limit. The positions were - neutralposition, where the subject was asked to look straight in thefront, at the point marked in the wall. In sagittal plane, the subjectswere instructed to have the H-N positions in flexion and extension.In horizontal plane, they were instructed to have the H-Npositions in rotation left and rotation right. Similarly in combinedplane, the H-N positions were in the combination of both sagittaland horizontal planes i.e. rotation right with flexion and extensionand rotation left with flexion and extension.

The subject was comfortably positioned in sitting, in theisokinetic analyzer chair with hips and knees at 90° flexion. Thehips, shoulders and forearm were firmly secured by Velcro strapsfor stabilization. The dynamometer height was then adjustednext to the chair, so that the subject could position the armcomfortably with the shoulder in 10 to 15 degree of flexion, atabout 15° of abduction and neutral rotation. The elbow was at90° flexion and the forearm in neutral supination, resting in a V-shaped stabilizing platform and was secured to the dynamometerwith straps, to prevent the forearm from rising out of the platform.The limb length was adjusted and the axis of the dynamometercentered at the wrist joint. The mechanics of the dynamometerwere explained to the subject prior to testing. The required limbaction was also demonstrated.

The wrist angle (30 degree of wrist flexion) was registeredon the isokinetic dynamometer. Range of motion stops wereapplied. During the isometric (static) tests, the tension appliedwas held for six seconds. Each subject performed three testrepetitions of each contraction under each H-N condition with aminimum of one minute’s rest interval between each contraction.Verbal encouragement was given with the intent of pushing eachsubject to her true maximum torque capabilities by asking themto give their best effort for the test. Lastly, the maximum isometricpeak torque of wrist flexors were measured and recorded fordata analysis.

Data Analysis

The data was analysed by using SPSS Version 12.0software.Paired sample t-test was done to calculate the level ofsignificance of wrist flexor torque in different head and neckpositions.

The level of significance was set at 0.05.

Results

Paired sample t-test was done to compare the mean valuesof peak torque between Neutral position (NP) Vs Sagittal planeflexion (SPF) (p=0.238), NP Vs Sagittal plane extension (SPE)(p=0.700), NP Vs Horizontal plane rotation left (HPRL) (p=0.257),NP Vs Combined rotation right flexion (CRRF) (p=0.303), NPVs Combined rotation right extension (CRRE) (p=0.918), NPVs Combined rotation left flexion(CRLF) (p=0.796) and NP VsCombined rotation left extension (CRLE) (p=0.681).Thesecomparisons showed no significant differences. Comparisonbetween NP Vs Horizontal plane rotation right (HPRR) showedsignificant difference (p=0.001) [Table-5.1].

Paired sample t-test was done to compare the mean valuesof peak torque between SPF Vs HPRR and SPE Vs HPRR.The comparison showed significant difference (p=0.001).Comparison was made between SPF Vs SPE (p=0.125), SPFVs HPRL (p=0.326), SPF Vs CRRF (p=0.909), SPF Vs CRRE(p=0.244), SPF Vs CRLF (p=0.290), SPF Vs CRLE (p=0.067),SPE Vs HPRL (p=0.142), SPE Vs CRRF (p=0.334), SPE VsCRRE (p=0.720), SPE Vs CRLF

(p=0.890), SPE Vs CRLE (p=0.261). These showed nosignificant differences [Table-5.2]

Paired sample t-test was done to compare the mean valuesof peak torque between HPRR Vs HPRL, HPRR Vs CRRF,HPRR Vs CRRE, HPRR Vs CRLF, HPRR Vs CRLE. Thecomparison showed significant difference (p=0.001).Comparison between HPRL Vs CRRF (p=0.862), HPRL VsCRRE (p=0.257), HPRL Vs CRLF (p=0.307), HPRL Vs CRLE(p=0.068) showed no significant difference [Table-5.3]

Paired sample t-test was done to compare the mean valuesof peak torque between CRRF Vs CRRE (p=0.125), CRRF VsCRLF (p=0.248), CRRF Vs CRLE (p=0.027), CRRE Vs CRLF(p=0.662), CRRE Vs CRLE (p=0.115), CRLF Vs CRLE (p=0.119).These showed no significant differences. [Table-5.4]

Table -5.1: Paired sample t test between NP and other headneck positions

Comparison t value p value

NP – SPF 1.204 0.238

NP – SPE 0.389 0.700

NP – HPRR 8.047 0.001

NP – HPRL 1.156 0.257

NP – CRRF 1.048 0.303

NP – CRRE 0.104 0.918

NP – CRLF 0.261 0.796

NP – CRLE 0.415 0.681

Table 5.2: Paired sample t test between different head neckposition

Comparison T value p value

SPF – SPE 1.581 0.125

SPF – HPRR 8.657 0.001

SPF – HPRL 1.000 0.326

SPF – CRRF 0.115 0.909

SPF – CRRE 1.190 0.244

SPF – CRLF 1.077 0.290

SPF – CRLE 1.900 0.067

SPE – HPRR 9.950 0.001

SPE – HPRL 1.508 0.142

SPE – CRRF 0.982 0.334

SPE – CRRE 0.362 0.720

SPE – CRLF 0.140 0.890

SPE – CRLE 1.146 0.261

Discussion

Muscle testing is an integral part of physical examination,it provides information usually not obtained by other procedures


155

Table 5.3: Paired sample t test between different head neckposition


HPRR – HPRL 8.874 0.001

HPRR – CRRF 7.139 0.001

HPRR – CRRE 8.710 0.001

HPRR – CRLF 8.692 0.001

HPRR – CRLE 10.156 0.001

HPRL – CRRF 0.175 0.862

HPRL – CRRE 1.155 0.257

HPRL – CRLF 1.039 0.307

HPRL – CRLE 1.893 0.068

Table 5.4: Paired sample t test within combined plane.


CRRF – CRRE 1.581 0.125

CRRF – CRLF 1.178 0.248

CRRF – CRLE 2.332 0.027

CRRE – CRLF 0.441 0.662

CRRE – CRLE 1.624 0.115

CRLF – CRLE 1.606 0.119

and machine related factors (stabilization, lever arm distance,axis fixation etc) among which, the major factor is positioningwhich can significantly effect the result of torque in an isometricmuscle testing in isokinetic machine. Various authors studiedthe above-mentioned factor. al in his study concluded that thehead neck position may influence the tension which is producedby the elbow flexor muscles and apparently, head-neck rotation(horizontal plane) may have a greater influence than movementsin the sagittal plane, particularly when movements in thehorizontal and sagittal planes are combined. In another studyby Berntson and Torello showed that head rotation away fromthe active hand results in a significant increment in flexor strengthof distal muscles of prehension when examined by the handdynamometer, in accord with the tonic neck reflex pattern.

A review of the literature has revealed the existence of theTNR in healthy, young adults which can be used in therehabilitation of upper extremity. But, there is no consensus inthe literature till now on the effects of different head neck positionin wrist flexor muscle torque production that confirms the needof the study.

So, the purpose of this study was to investigate andcompare the different head neck positions for the effects onwrist flexor muscle torque production in healthy, young females.It was hypothesized that head-neck rotation (horizontal plane)do have a greater influence on wrist flexor muscle torqueproduction than the movements in neutral position, sagittal planeand combination of both sagittal and horizontal planes. The resultobtained by the data analysis showed significant difference inhead-neck rotation-HPRR (horizontal plane).

When compared within sagittal plane, mean value of SPF(7.93) was found greater than SPE (7.5). In comparison withinhorizontal plane, mean value of HPRR(11.2) was greater thanHPRL(7.9) and CRRF(8.00) showed the greater mean valuethan the rest of the combined head-neck position, whencomparison was done within combined plane. Deutsch et alsupports our result, in few ways where head-neck rotation(horizontal plane) appeared to have a greater influence on elbowflexor muscle torque production than movements in the sagittalplane, particularly when movements in the two planes werecombined. These cascades of impulses then stimulates themotor neurons to evoke selective activation of neck musculature,sufficient to modify the position of the head autonomously andto stimulate the receptive field (first three cervical joints) activatingtonic neck reflexes. The recruitment of reserve motor unitsaugment the sensory input via synaptic arrangement andoperates in the absence of cortical interference. According toLuhan, eliminating the influence of gravity would facilitate theTNR effects. In the present study, head-neck rotation-HPRR(horizontal plane) showed the significant difference (p=0.001).This may have occurred as there was no influence of gravity inHPRR unlike SPF and CRRF, thus facilitating the tonic neckreflex effects.

Conclusion

The study concluded that the tonic neck reflex have aneffect on different head- neck positions influencing the wrist flexortorque and the head neck rotation (horizontal plane) has a greaterinfluence than the movements in neutral position, sagittal planeand combination of both sagittal and horizontal planes. Thushead-neck position should be considered during strengtheningprogramme of the upper extremity

References

1. Carol A.Oatis: Kinesiology-the mechanics andpathomechanics of human movement, Lippincott Williamsand Wilkins, second edition, pg-242

2. Hall and Brody: Therapeutic Exercise, Lippincott Williamsand Wilkins, second edition, 2005, 626-634

that is useful in differential diagnosis and prognosis ofneuromuscular disorders. It is essential to determine musclestrength before prescribing therapeutic exercise because mostof these exercise are designed either to stretch shorten muscleor to strengthen weak muscle. Evaluation of muscle strength byisometric contraction of the muscle is one of the evaluation toolused by therapist frequently in day-to-day clinical practice, thenew trend of evaluating muscle performance is by usingisokinetic dynamometry, and it is widely accepted but manyfactors that may influence the outcome of the measurement likesubject related factors (age, sex, weight, height, positioning)


Fig. 5.1: Comparison of peak torque of wrist flexors in differenthead and neck positions

156

3. Kessler et al: Management of Musculoskeletal Disorders,Lippincott Williams and Wilkins, third edition, pg-243.

4. Salter and Cheshire: Hand Therapy, ButterworthHeinemann, first edition, 2000, pg-13

5. Luke E. Thomas: lsokinetic Torque Levels for AdultFemales-Effects of Age and Body Size, JOSPT, Vol. 6, No.1,1984

6. Jessie Marie Vanswearingen: Measuring Wrist MuscleStrength, JOSPT, Vol. 4, No. 4, 1983

7. Anderson and Rutt: The Effects of Counterforce Bracingon Forearm and Wrist Muscle Function, JOSPT, Volume15, Number 2, February 1992

8. Morse, Jung, Bashford, Hallbeck: Maximal dynamic grip

force and wrist torque- The effects of gender, exertiondirection, angular velocity, and wrist angle, AppliedErgonomics, 37, 2006, 737–742

9. Dale Richard Stonecipher et al: The effect of a forearmStrap on wrist–extensor strength, JOSPT, Vol. 6, No. 3,1984

10. G.Y.F. Ng, Chan: The Immediate Effects of Tension ofCounterforce Forearm Brace on NeuromuscularPerformance of Wrist Extensor Muscles in Subjects WithLateral Humeral Epicondylosis, J Orthop Sports Phys Ther,Volume 34, Number 2, February 2004

11. Smith, Weiss, Lehmkuhl: Brunnstrom’s ClinicalKinesiology, Jaypee Brothers, fifth edition, pg-146.


157

Effect of Saddle Heights on Craniovertebral Angle DuringErgonomic CyclingDheeraj Lamba*, Satish Pant**, Girish Chandra***Incharge, **Interns, Dept. of Physiotherapy, IAHSET Medical College, Haldwani

Introduction

The bicycle is the vehicle most used in world, and also thefastest growing in number of users, both with the purpose ofrecreation, physical training, rehabilitation or practice competitivepurpose. Various publications have reported that 30-70% ofcyclists suffer from cervical, dorsal or lumbar back pain whichcauses recreational cyclists to abandon cycling. But for manyothers (such as in china), cycling is their only, means of urbantransportation. The choice of the position in which the individualcycles is important to consider because the biomechanics andefficiency of cycling in adults have been shown to be affectedby saddle height, crank arm length and foot position. It might beexpected that with the amount of time spent on bicycles duringtraining and racing, recreational, age-group triathletes wouldhave acquired their correct saddle height through trial and error.Even so, these athletes may not be operating at an efficientsaddle height. when cycling is utilized for exercise of patientswith different needs it is valuable to know the range of motionrequired for various adjustments of the bicycle ergometer suchas workload, speed, or saddle height or cycling technique (pedalfoot position) used.

Individuals with physical disabilities may benefit from cyclinginterventions, which could address impairments such asdecreased muscle strength (force-producing capacity), rangeof motion, and fitness while potentially minimizing stress to joints.Improvements in impairments may then have an impact onmobility, activity and participation. Many factors, however, needto be considered in designing a cycling intervention andinformation learned from studies examining cycling in adults andchildren who are healthy as well as in adults with disabilitiescan provide some insight into these factors.

It is well known that factors such as the tilt of the pelvis, theadoption of a sitting, or standing position, the shape of backrestwhen sitting, and the head position can all influence the sagittalcurve of the cervical spine. Head posture can be described onthe basis of craniovertebral angle. Dean H Watson, Patricia HTrott found in their study that craniovertebral angle in headachegroup had a smaller angle than the non-headache group. Thesymptomatic group revealed a significant Forward head posturewhen compared to the non-headache group. There is a the directcorrelation between change in head neck posture and neck pain.

The Craniovertebral angle provides a convenient andreliable method of measuring head protraction and could beused more extensively in conjunction with other head/neckposture measures like flexion, extension, or ear-eye line anglesto better evaluate working postures, especially those involvingcomputer work and visual inspection tasks.

Head/neck posture is defined as the angle between thehorizontal line passing through C7 and a line extending fromthe tragus of the ear to C7.head/neck posture angle is calledcraniovertebral angle or C7-tragus angle. A smallercraniovertebral angle indicated a greater forward head posture.A previous paper reported the reliability of this procedure ashigh (ICC=0.88).

Aim and Objective

The aim of the present study is to determine the effect ofdifferent saddle heights on the craniovertebral angle in young

men and women during Ergonomic cycling.Statement of QuestionDoes the craniovertebral angle change while the change

in saddle heights during Ergonomic cycling?HypothesisThere will be significant change in craniovertebral angle in

young men and women during ergonomic cycling with changein saddle heights.

Sample

A total of 60 male and female subjects, with a mean age of24, were recruited for the study. They were recruited from SushilaTiwari Memorial Hospital, Haldwani.

Inclusion Criteria

• Healthy male and female subjects• Age: 18-25 years• Pain free cervical range of motion.• Height of subjects- 158-165 cm.• Subjects had ordinary daily and recreational cycling

experience.

Exclusion Criteria

• H/O postural abnormality, limb length discrepancy• H/O any musculoskeletal disorder• H/O saddle sorea, perineal nodules, or perineal numbness• H/O cardiovascular or respiratory conditions• H/O forward head posture• H/O low back pain, neck pain, leg pain, shoulder pain and

impairment to the limbs• H/O neurological disease• H/O any spinal injuries

Instrumentation

Weighting MachineUsed for measuring weight of the subject.Height Measuring StandUsed for measuring the height of the subject

Adhesive Markers

The circular adhesive markers of diameter 0·5mm wereused to denote the anatomical points of subjects to capture thepostural information on body segments. A reflective ball of abouthalf inch was placed on C7 spinous process.

Digital Video Camera

A digital Nikon (Cool pix L10) camera, with 5 megapixel,mounted on a tripod was used to take the still photographs ofthe subjects.

Motion analysis softwareMotion analysis were basically use in clinical settings. The

software was employed to calculate the angle from eachanatomical landmark from photographs.


158

Stationary bicycle ergometerAn adjustable stationary bicycle ergometer with attached

kilometer was used.

Tools

• Measuring tape• Plumb bob• Stop watch

Protocol

60 male and female subjects were included in the studybased on the inclusion and exclusion criteria the measurementwas taken in three phases according to the saddle height.

Phases 1- Subjects were made to cycle with saddle in MIDheight position (113% of the distance between the ischialtuberosity and the medial malleolus).

Phases 2- Subjects were made to cycle with saddle in LOWheight position (102 % of the distance between the ischialtuberosity and the medial malleolus).

Phases 3- Subjects were made to cycle with saddle in HIGHheight position (120 % of the distance between the ischialtuberosity and the medial malleolus).

Each subject performed the entire test. In all phases subjectsat on an ergonomic bicycle which was set according to subjectstature.

Study Design

Observational study design.

Procedure

Before taking part in the study, participants read and signedan informed consent form approved by the institution’s ethicalcommittee. Assessment of the subjects was done, all thesubjects were given the explanation of the procedure of the studyand all their questions were satisfactorily answered. Subjectssat on the adjustable bicycle ergometer. Adjustments were madeaccording to the subject height and limb length. Changes werebe made to the saddle height, foot position; handle bar andsaddle tilt according to the “Standardized Ergometer cycling”.

Standardized Ergometer Cycling

The adjustment of mid-saddle height and anterior footposition was defined as “Standardized Ergometer cycling”. Thehandlebar was kept level with the saddle.• Mid saddle height is the 113 % of the distance between the

ischial tuberosity and the medial malleolus. The saddleheight was measured as the greatest distance from saddlesurface to the center of the upper pedal surface in a straightline along saddle pillar and crank.

• Anterior foot position was defined as the contact with thehead of the second metatarsal (ball of foot).Once the cycle was set, all variables were kept constant

except saddle height.Subjects wore bathers or tight ‘bike’ shorts and a sleeveless

T-shirt top so that the neck will be exposed. Hair was tied backto ensure the cervical region is visible. With the subject sittingon the ergonomic cycle, two lateral anatomical landmarks weremarked by adhesive “Binbis” contrasting to skin colour. Theywill comprise:• the tragus of the ear,• and a projecting reflective ball will placed posteriorly on

the spinous process of C7.The digital camera was positioned on a tripod at a distance

of 0.8 m. The axis of the lens of the camera was placedorthogonal to the sagittal plane of the patient at a height that

corresponded with the seventh cervical vertebra. With its opticaxis perpendicular to the subjects (sagittal plane) and illuminationdirected for reflecting equipment. Reflective markers were placedon the anatomical points.

All subjects were allowed to warm up and becomeaccustomed to cycling on the specially instrumed bicycleErgometer. Subjects were asked to sit on the bicycle. Thensubject were asked to choose self selected cycling speed andcycle for 30 sec while looking straight a head and photographswill be taken during the last 10 sec. Before taking photographs,position of subjects were checked. Same procedure was followedfor all three phases with the adjustment being done only to thesaddle height as described in the protocol. These three exercisebouts were separated by a 5-min rest period and wererandomized to prevent an order effect. The anatomical markersand the position of subjects were rechecked prior to secondand third photograph to ensure that they were securely in plane.

Measurement of Craniovertebral Angle

The Craniovertebral angle was measured from a line drawnfrom the tragus of the ear to the seventh cervical vertebrasubtended to the horizontal. The software produced a horizontalline perpendicular to the vertical plumb line captured in thebackground of the image.

Comparison was performed on the Craniovertebral angleobtained during all three phases of cycling for all subjects

Data Analysis

The data analysis was done using statistical package ofsocial science- SPSS (Version-11) software. The arithmeticmean values and standard deviation of variables age & heightwere calculated. ne way analysis of variance (ANOVA) wasapplied to compare Craniovertebral angle at different saddleheights. post Hoc analysis of multiple comparison tests wereapplied to compare between craniovertebral angles of there ofthree different saddle heights Paired sample ‘t’ test applied tocompare the craniovertebral angle of three different saddleheight. Significance level was set at (0.05).

Results

The mean & standard deviation of age & height wascalculated for subjects were as follows: Age = 23.43 ± 1.59,height = 159.58 ± 4.91 and weight = 56.18 ± 5.77 (Table 5.1).Paired sample correlation test was done to find out the differencein craniovertebral angle obtained at various saddle heights (Table5.2). Craniovertebral angle at Low saddle height LSH mean valueis 33.759±3.197. When compared with craniovertebral angleobtained the mid saddle height (MSH) with mean value 29.867±3.085. The result was found to be statistically significant (p=.000) (Table 5.3a). Craniovertebral angle at Low saddle heightLSH mean value is 33.759±3.197. When compared withcraniovertebral angle obtained the high saddle height (HSH)with mean value 26.347 ± 3.011. The result was found to bestatistically significant (p =.000) (Table 5.3b). Craniovertebralangle at Mid saddle height MSH mean value is 29.867±3.085.When compared with craniovertebral angle obtained the Highsaddle height (HSH) with mean value 26.347 ± 3.011. The resultwas found to be statistically significant (p =.000) (Table 5.3c).Correlation analysis for craniovertebral angle between lowsaddle height and mid saddle height showed significantcorrelation R= .965. Correlation analysis for craniovertebral anglebetween low saddle height and High saddle height showedsignificant correlation R= .780. Correlation analysis forcraniovertebral angle between Mid saddle height and Highsaddle height showed significant correlation R= .810 (Table 5.4).


159

Table 5.1: Mean and SD of Age, Height and Weight for thesubjects included in the study

Variable Mean ± Standard deviation

Age 23.43 ± 1.59

Height 159.58 ± 4.91

Weight 56.18 ± 5.77

Table 5.2: comparison of mean values for Craniovertebral Angle(CVA) at Low (LSH), Mid (MSH) and High Saddle height’s (HSH)between the groups

Variable Mean ± Standard F value P valuedeviation

CVA – LSH 33.75 ± 3.19

CVA – MSH 29.86 ± 3.08 85.875 0.000

CVA – HSH 26.34 ± 3.01

Table 5.3: (a) Comparison of Craniovertebral angle’s obtainedat Low saddle height and Middle saddle height.

C VA Mean ± SD t value p value

LSH 33.759 ± 3.197 35.736 .000

M SH 29.867±3.085

Table 5.3: (b) Comparison of Craniovertebral angle’s obtainedat Low saddle height and H igh saddle height.


LSH 33.759 ± 3.197 27.788 .000

M SH 26.347 ± 3.011

Table 5.3: (c) Comparison of Craniovertebral angle’s obtainedat Mid saddle height and High saddle height.


LSH 29.867 ± 3.085 14.486 .000

M SH 26.347 ± 3.011

Table 5.4: Comparison of mean value of Craniovertebral Angleat Low, Mid and High Saddle height for the subjects

Craniovertebral angle R value p value

LSH Vs MSH .965 .000

LSH Vs HSH .780 .000

MSH Vs HSH .81 0 .000

Discussion

The purpose of this study was to determine the effect ofdifferent saddle heights on the craniovertebral angle in youngmen and women during Ergometer cycling. The results of thepresent study indicate that the change in saddle height has effecton craniovertebral angle, there by supporting the hypothesis.There is also evidence that any change in saddle height duringrehabilitation program of lower extremity also creates a changein neck posture. Ergometer cycling is common tools of

rehabilitation. Lots of studies have shown that different saddleheights are used depending on the goal of rehabilitation. Themid saddle height position is set in “standard Ergometer cycling”position. Whereas if a patient has a knee flexion contracture alower seat height may be needed to allow seat height may beneeded to allow that individual to cycle. A lower seat height alsomay be for a patient with pulmonary or cardiac concerns. If thedesire is to strengthen the calf muscles or to obtain greaterextension range of motion, a higher seat height may be the betterchoice. A higher seat height also may better challenge the cardiorespiratory system during exercise, potentially leading to exerciseeffects such as an improvement in maximum oxygenconsumption.5 From posture height as well as posture lengthwe can obtain a comprehensive picture of the proper adjustmentof saddle and handlebars. There two variables, bothindependently and in relation to each others, are of crucialimportance for a correct cycling posture. As well as the problemscaused by incorrect posture height, many cyclists have problemsrelated to incorrect posture length. In most cases this is due toin sufficient reach, the distance between the rear of the saddleand the transverse part of the handlebars. It should beappreciated that no matter what cycling posture is adopted theupper body is used in an unnatural manner. If the posture is tooshort, it places too much stress on the natural form of thevertebral column, in particular the lumbar and cervical part andmay cause lower back pain and neck complaints.

The results of this study indicates that craniovertebral anglewas maximum in low saddle height position (33.75°±3.19°), leastin the high saddle height position that is (26.34°±3.01°) and inthe mid saddle height position it was mid way between the two(29.86°±3.08°).

Szeto et al found that hyperextension of the neck orincreased cervical lordosis is a common consequence of forwardhead position.

A sustained forward flexion posture of the spine has beenassociated with increased cervical compressive loading and acreep response in the connective tissue.

According to Burgess Limerick with the trunk in an uprightposition, both atlanto-occipital and cervical flexion increases thetorque required of the extensor musculature to maintain staticequilibrium.

Researches also have shown that changes in bicyclesettings like saddle height and handlebar reach may cause neckproblems but the exact underlying mechanism has not yet wefully explained the results of this study may provide a clue as tothe possible mechanism.

Conclusion

Change in different saddle heights affects thecraniovertebral angle uring Ergometer cycling. They are such asignificant factor that they can produce change in biomechanicsof spine. Hence saddle height should be considered as animportant factor in rehabilitation for professionals who prescribecycling as an intervention.

References

1. Elisandro D’assisi Martins, Frederick dagnese, JulioFrancisco Kleinpaul,Felipe Pivetta Carpes, Carlos BolliMota, (2007) Principais erros no posicionamento de ciclistasde diferentes niveis de condicionamento, (Major errorposition of different levels of conditioning) XII CongressoBrasileirde Biomecânica s in eter Cycling, The journal 5. ,p.495-500,São Paulo. 2.

2. M Salai, T Brosh,A Blankstein,A Oran and A Chechik(1999).Effect of changing the saddle angle on the incidenceof low back pain in recreational bicyclists: British Journal ofSports Medicine, 33,398-400.

3. Therese E Johnston (2007), Biomechanical Considerations


160

for cycling interventions in rehabilitation, Physical Therapy,v. 87,n. 9,1243-1252

4. 4. Mats 0. Ericson, Ralph Nisell, Gunnar Nemeth ,(1988)Joint Motions of the lower limb during Ergom ofOrthopaerdic and Sports Physical Therapy , vol. 9,No. 8

5. Nordeen-Snyder KS: (1977), The effect of bicycle seatheight variation upon oxygen consumption and lower limbkinematics. Medicine and Science in Sports and exercise2:113-117

6. Deborah Falla, Gwendolen Jull, Trevor Russell, BillVicenzino, Paul Hodges,(april2007),Effect of Neck Exerciseon Sitting posture in Patients With Chronic Neck Pain,Physical Therapy , 87 ( 4), 408-417

7. Dean H Watson, Patricia H Trott (1993), Cervical headache:an investigation of natural head posture and upper cervicalflexor muscle performance, Cephalalgia, 13:272-84

8. D.Grob. H. Frauenfelder .A.F. Mannion, (2007), Theassociation between cervical spine curvature and neck pain,European Spine Journal, 16:669-678. 63

9. Dennis R. Ankrum, Kristie J. Nemeth (2000), Head andneck posture at computer workstations- what’s neutral?Proceedings of the 14th triennial congress of the internationalergonomics association, 5, 565-568

10. Cesar Fernandez-de-las-penas, Cristina Alonso-Blanco,Maria Luz Cuadrado, Robert D.Gerwin , Juan A.Pareja,(2003)Trigger points in the subocci headache, Headache;46:454-460.


161

A Comparative Study of Cardiovascular Fitness in Normal VersusObese ChildrenGaurang D Baxi1, Tushar J Palekar2, M Vijayakumar3, Varoon C Jaiswal4

1Lecturer, 2Principal and Professor, 3Associate Professor, Padmashree Dr. D.Y. Patil College of Physiotherapy, Pimpri, Pune, 4Lecturer,MAEERS College of Physiotherapy, Talegaon Dabhade, Pune

Abstract

Introduction

Childhood overweight and obesity are dramaticallyincreasing worldwide. Overweight or obese children are at ahigh risk of experiencing a range of co-morbidities affectingalmost every body system. Environmental factors such as diet,physical activity and metabolic status are major contributors toobesity. Physical activity among children has declined in recentdecades and the corresponding increase in obesity prevalencemay be the direct result of this decline. An important componentof physical fitness is cardiorespiratory endurance or cardio-respiratory fitness. This study was done to evaluatecardiovascular fitness in children and to compare it betweennormal and obese children.

Methods

102 boys in the age group of 9-11 years, studying innearby schools in were taken for the study. The height and weightwere taken and the Body Mass Index (BMI) was calculated.According to their BMI, they were divided into three groups-normal, overweight or obese. The children were then made torun the Cooper 12 minute run test. The distance covered in 12minutes was noted. The VO2 max was calculated using predictionequation for the Cooper 12 minute run test. The data of childrenhaving a normal BMI was then compared against those havinga BMI falling into the overweight or obese category. Inter andintra group analysis was done.

Results

The results of this study showed a significant reduction of33.87% in the cardiovascular fitness levels of overweight andobese boys, as compared to those with a normal BMI. Also, thechildren having a normal BMI also did not have adequate fitnesslevels.

Conclusion

Cardiovascular fitness of overweight and obese boys inthe age group of 9 to 11 years is significantly less as comparedto those boys having a normal BMI. Also, those boys having anormal BMI did not have recommended fitness levels. Furtherresearch has to be carried out to find out fitness standards forIndian children.

Key Words

Obesity in children, VO2 max in children, peak VO2 inchildren, cardiovascular fitness in children.

Introduction

Obesity can be defined as excessive body mass for stature,and more specifically an excessive body fat content.1 It is acondition of concern because it is in and of itself socially andphysically debilitating and it represents a risk factor for increasedmorbidity and mortality rate. For more than a hundred years,the life insurance industry has pointed out that increased bodyweight is associated with excess mortality.2 This has been onestimulus for including body weight, stature and occasionallyskinfolds on epidemiological studies on the factors associatedwith the development of cardiovascular disease and cancer.3

In recent years, fat distribution has also been included. It is nowclear that a high body mass for height or a high body fat leveland upper body obesity plus weight gain in adult life areassociated with the risk of developing severe chronic diseases.

Overweight, obesity and adiposity are the commonly usedexpressions for increased body fat and have replaced the olderterms such as corpulence, polysarcie and embonpoint.4

Overweight can be expressed as relative weight or ratios ofweight o height. Relative weight is the ratio of actual to standardweight as determined from a table of reference body weightsexpressed relative to height, frequently as a percentage. Weightto height ratios can also be expressed as the body mass index(BMI) or Quetelet index, which is body weight (in kilograms)divided by the square of the height (in meters).5 The BMI ismore highly correlated with body fat than with other indices ofheight and weight.6

Childhood Obesity: An emerging epidemic

The World Health Organization (WHO) International ObesityTask Force estimated that 30-45 million children worldwide areobese and approximately 155 million are overweight.7 Childhoodoverweight and obesity are increasing dramatically, both in thedeveloped world and in many developing countries.8-11 Thisdramatic increase in the prevalence of childhood obesity withinthe last decade has changed the view on it and the condition isnow seen as one of the top 10 global health problems. Theincreasing prevalence of childhood overweight and obesity is aglobal trend and is of concern as overweight or obese childrenare at a high risk of experiencing a range of health problems inthe immediate, short and long term.12

Obesity in childhood is not simply of cosmetic or evenpsychological concern, but these children suffer co-morbiditiesaffecting almost every body system. Immediate health problemsof overweight and obese children include social isolation andpotential psychological dysfunction.13-15 Young overweightchildren have been described by their peers as ugly, stupid,dishonest and lazy16 and they may experience teasing and socialisolation as a result.17

Such children are also at a greater risk of co-morbiditiesthan their lean counterpart. For example, children who areoverweight and obese are at a greater risk of asthma, and whenthey have it they have been shown to use more medicine,18,19

wheeze more, have more unscheduled visits to the hospital18

and miss more school days as a result of asthma than their leanasthmatic counterparts.19

In the short term, overweight and obese children are morelikely to develop certain gastrointestinal, cardiovascular,

Address for correspondence:Dr. Gaurang D. BaxiLecturer, Padmashree Dr. D. Y. Patil College of Physiotherapy,Sant Tukaran Nagar, Pimpri, Pune 411018.Email: [email protected]

Gaurang D Baxi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

162

endocrine and orthopedic problems than their lean peers thatmay be exacerbated in the long term. Furthermore, overweightand obese girls are more likely to develop reproductive systemabnormalities, such as early onset of puberty and menarche,and polycystic ovary syndrome. 14,15, 20,21

In the long term, cardiovascular risk factor prevalenceincreases greatly over time in overweight and obese children.20, 22-24 Furthermore, a number of studies suggest that the mortalityrate in adulthood of subjects who were overweight or obeseduring childhood and adolescence is increased. 25-28 In short,remaining obese from childhood through adolescence and intoadulthood places the individual at a higher risk of associatedmorbidities. 29-31

Need of the Study

Various studies have been done comparing the aerobicfitness and body composition in children. In a study done toassess the cardiorespiratory fitness of obese boys in WestBengal, India, it was found that VO2max per kg of body masswas significantly higher among non-obese boys. 32 A study onFinnish children has shown that high cardiorespiratory fitness isassociated with lower overall and abdominal fat. 33 A studyconducted in Taiwan showed that the overweight/obese and unfitchildren had a greater risk of hypertension than other children.34A study done on Greek primary schoolchildren’s fitness levelssuggested that overweight and obesity are limiting factors forfitness performance.35 A study on the relationship betweenactivity levels, aerobic fitness, and body fat in 8- to 10-yr-oldBritish children concluded that low fitness and increased bodyfat were related. 36 A study among Portuguese children hasalso shown the beneficial impact of low BMI values oncardiorespiratory fitness. 37

All of the above studies suggest that as the body fat levelsincrease, the fitness levels go down. However, some studies donot suggest the same. In a study to compare variables ofmetabolism, physical activity and fitness to body composition innormal and overweight German children, no significant groupdifferences were found for submaximal VO2, as well as the fat-free mass- or muscle mass-adjusted values for aerobic fitness.38

A dearth of relevant literature on the issue pertaining to theIndian scenario has been observed. Hence, this study wasdesigned to find out the cardiovascular fitness for Indian children,and also, to find out the effect of obesity on the same. By doingthe study, promoting awareness on the issue of childhoodoverweight and obesity was also achieved.

Aim

To evaluate cardiovascular fitness in children and tocompare it between normal and obese children.

Materials

A weighing scale certified by SGS to have an accuracy of +1 kg, a 50 meter yard tape, a 5 feet measuring tape, a lap counterand a stopwatch.

Methodology

This cross sectional study was conducted on children agedbetween 9 to 11 years and studying at schools in Pune. Afterobtaining permission from the Principals to proceed with thestudy, informed consent of the parents was taken through thechildren. The children were taken for the study during theirphysical education classes. Out of the target population, 120prepubescent boys in the age group of 9 to 11 years wererandomly selected and taken as the sample population. Thisage group was selected to eliminate the influence of hormonal

and physiological changes on the body mass and bodycomposition which occur during puberty.

Children having any history of trauma, recent illness,orthopedic or neurological injury or any medical condition whichhas caused any permanent impairment in the normal anatomy& physiology of the body were excluded. Girls wereexcluded from the study. The height and weight were taken andthe body mass index (BMI) was calculated. According to theirBMI, they were classified as normal, overweight or obese.

The Cooper 12 minute run test (R=0.90) 39 was selectedfor the study. 40 A lap of 100 meters was demarked in the schoolground. All possible obstacles on the running lap were removed,so that the boys could get a clear path for running. The boyswere explained the procedure of the Cooper 12 minute run test.They were instructed to cover the maximum distance they canfor twelve minutes, either by running and if they get tired, thenby walking. After a brief warm up, the Cooper 12 minute run testwas then conducted on the children. Then they were made torun/walk as far as possible in 12 minutes in the school ground.The number of laps run was noted. The distance covered to thenearest 10 meters was taken. A cool down was then conducted.

Initially, the test was conducted by making 3 boys run atthe same time. But it was observed that this gave rise to acompetitive environment and the children tried to outrun eachother, tiring them early in the bargain. Due to this, they wereunable to complete the stipulated time of 12 minutes. To eliminatethis from happening, subsequently each boy was made to runindividually. As the run progressed, the children used to slowdown; they had to be constantly motivated to keep up the paceand at least walk, if not run.

The VO2 max was calculated as follows using predictionequation for the Cooper 12 minute run test. 40

VO2 max = (Distance covered in meters - 504.9) ÷ 44.73The data of boys having a normal BMI was then compared

against those having a BMI falling into the overweight or obesecategory. Correlation coefficients were found for the BMI,distance run and the VO2 max for both the groups. Unpaired t-test was used to compare the weight, height, BMI, distance runand VO2 max of the boys between the two groups.

Data Analysis

Data analysis was done and the mean and standarddeviation of age, weight, height, BMI, distance run and VO2 maxwere calculated for all the boys, and are shown in Table 1 below.

Discussion

This study examined the cardiovascular fitness in normalBMI and overweight and obese BMI children 9 to 11 years ofage using VO2 max as the outcome measure.

Those children who had a normal BMI had much betterVO2 max compared to those who had an overweight and obeseBMI. As seen in table 1, the mean BMI and the mean VO2 maxof the normal BMI group boys was 20.63 ± 1.35 and 36.94 ±3.53 mL.kg-1.min-1 while that of the overweight and obese groupboys was 27.71 ± 1.72 and 24.43 ± 1.82 ml.kg-1.min-1

respectively.The 33.87% difference in the VO2 max between the two

groups was highly significant (p<0.001). The results are inagreement with the previous studies by other researchers whohave also independently shown that overweight and obesechildren have less cardiovascular fitness than their normalcounterparts. 32-35, 41 This difference between the two groups ofchildren is seen because peak VO2 is strongly related to bodysize, with correlation coefficients describing its relationship withbody mass or stature typically exceeding r = 0.70. 42

The peak VO2 of boys in the age group of 8-18 years hasbeen shown to be ranging between 48-50 mL.Kg-1.min-1, whilefor girls in the age group of 8-18 years, it ranges between 35-45


163

Table 1: Data of 102 subjects in two groups

Parameter Mean SD Unpaired t-test

t value p value

Age Normal 9.789 0.72 —- —-

Overweight / Obese 10.04 0.77

Weight Normal 34.44 6.236 11.043 0.0001


Height Normal 128.7 8.713 0.803 0.4326

Overweight / Obese 130 6.970

BMI Normal 20.635 1.3464 23.301 <0.0001


Distance Normal 2157.89 158.08 21.592 <0.0001Run

Overweight / Obese 1598 81.4

VO2 max Normal 36.94 3.53 21.589 <0.0001


Correlation Coefficient of BMI, Distance Run and VO2 max in the two groups.

Correlation Coefficient (c) Parameters

Normal BMI Overweight / Obese BMI

BMI and distance run -0.03 -0.85

distance run and VO2 max 0.999 0.999

BMI and VO2 max -0.0301 -0.85

Table 2: Correlation Coefficient of BMI, Distance Run and VO2 max in the two groups.


Fig. 1: Mean BMI Fig. 2: Mean VO2 max

164

mL.Kg-1.min-1. 42 However, in prepubescent girls and boys, thereis not a significant difference in peak oxygen consumption. Thedifferences emerge during and after puberty. 43 In boys less than13 years of age, the VO2 max has been shown to be 42 ± 6mL.Kg-1.min-1 while for girls of 11 years or less, the VO2 max hasbeen shown to be 38 ± 7 mL.Kg-1.min-1.

In this study, the mean VO2 of boys having normal BMIwas found to be 36.94 ± 3.53 mL.kg-1.min-1. Thus the fitnesslevels of the healthy BMI group children are just touching thelower borderline of the recommended levels. This is suggestiveof low fitness. Again this is supported by a weak negativecorrelation between the BMI and the Distance run and alsobetween the BMI and the VO2 max, as seen in table 1, in thenormal BMI children.

However, since these children are touching the lowerborderline of the recommended levels, it’s probable that theseare the fitness standards of the children in the western part ofIndia. The comparative figures are from the western countrieswhere there are differences in the body composition andanthropometric measurements compared to children here.These differences can lead to this deviation in the observedstandards of fitness.

The correlation coefficient between BMI, distance run andthe VO2 max within each group was calculated. As seen in table2, a significant correlation was seen between BMI and thedistance run, BMI and the VO2 max and distance run and VO2max in the overweight and obese BMI group.

In the obese and overweight children, the distance run andtheir VO2 max are not only inversely related with the BMI, butthey correlate strongly with the BMI. This shows that as the BMIincreases, the distance run and the VO2 max decrease. Now,we know that BMI is a function of height and weight. There wasa significant difference found in the weights of the two groups,but no such significant difference was seen in the heights of thetwo groups. This shows that the significant differences in thevalues of BMI in the two groups were due to significantdifferences in the weights of the subjects, and not due to theirheights. Thus, the significant negative correlation between BMIand VO2 max is due to significant differences in the weights ofthe subjects.

However in both the groups, there is a very strong positivecorrelation between the distance run and the VO2 max, as seenin table 2. Thus, the distance run and the VO2 max are directlyrelated, and show a very strong correlation. But this is due tothe fact that VO2 max is a direct function of the distance run,and it is calculated from the distance run using a predictionequation.

There were a few dropouts which need to be discussedhere. A total of 120 boys (60 in each group) were initially takenfor the study. 5 students from the normal BMI group and 113from the overweight and obese BMI group dropped out within 5to 7 minutes of starting the run. The all complained of tirednessand fatigue after running for that small duration. Hence, theywere excluded from the data analysis.

However, from this, it can be inferred that those childrenunfit not only from the cardiovascular point of view, but theyalso had poor muscular endurance and they had decreasedoverall fitness. This could be the probable reason for the dropout.Also, the incidence of this was high in the overweight and obesecategory.

Thus, from all of the above discussions, it is evident thatthere is significant reduction in cardiovascular fitness in obeseIndian children compared to those who have a normal BMI. Also,the overall fitness levels of Indian children are also not at parwith the standard desired levels.

Results and Conclusion

The mean BMI and the mean VO2 max of the normal BMIgroup was 20.63 ± 1.35 and 36.94 ± 3.53 ml.kg-1.min-1

respectively.The mean BMI and the mean VO2 max of the overweight

and obese group children was 27.71 ± 1.72 and 24.43 ± 1.82ml.kg-1.min-1 respectively.

The cardiovascular fitness levels of the overweight andobese boys were 33.87% less than that of normal BMI boys.

The boys having a normal BMI also do not have adequatefitness levels.

Recommendations

All children should be encouraged to be physically active.Physical activity opportunities may be a part of play, schoolphysical education, sport, games, active transport (for examplewalking and cycling to school), recreation and planned exercise.Activities may be undertaken in the context of the family, schooland wider community setting.

Children should engage in physical activity of at leastmoderate intensity for 60 minutes each day. Minimumrecommendations suggest 60 minutes of physical activity at least3 times a week. 44, 45

Children should avoid extended periods of inactivity. Thisincludes sedentary behaviors such as watching television,videos, playing computer games and surfing the internet.

Compulsory physical education programs should beimplemented in schools. Special programs should be directedtowards overweight and obese children. The school shouldprovide counseling for students and parents about the harmfuleffects of obesity, and the importance of fitness. Diet counselingfor the parents of obese children should be done. Schools shouldregularly organize sports meets, physical education sessionsand promote extracurricular sports. Schools can take advantageof these sports meets to promote an active lifestyle for children,either through modeling by school teachers, peers and coachesor by trained students to acquire positive knowledge and attitudesabout physical activity and sport and activity skills to keep healthy.

Facilities like playgrounds, open squares, and sports clubsshould be made available in the community, so that childrencan make use of them. In today’s world where automobilesdominate transport on the roads, there is a lack of safe andconvenient pedestrian paths and bicycle trails. Providing thesein the civic infrastructure will help promote a healthy activelifestyle.

To summate, parental involvement in exercise with children,school curriculum, neighborhood safety concerns and theavailability of recreational facilities are a few of the factors whichneed to be addressed in order to promote physical activity inchildren and to reduce the prevalence of childhood obesity.Last, but not the least, further studies needs to be undertakenfor formulating the standard values for fitness for Indian children.Studies done in a lab setting are more accurate in terms ofpredicting the cardiovascular fitness levels as compared to fieldtests. For children, to measure body composition, skinfolds andcircumferences, and bioelectrical impedance analysis (BIA)should be preferred over BMI due to the drawback of using BMIin this age group.


1. Sample size was relatively small.2. Field test was used to predict the cardiovascular fitness.3. Results were based on the motivation of the children to

continue running.

References

1. Bray GA, Bouchard C, James WPT. Definitions andproposed current classification of obesity. In: Bray GA,Bouchard C, James WPT (Editors) Handbook of obesity.New York: Marcel Dekker Inc., 1998.


165

2. Bray GA. Commentary on classics in obesity. Life insuranceand overweight. Obesity Research. 1995; 3: 97-99.

3. Dawber TR. The Framingham study: The epidemiology ofatherosclerotic disease. Cambridge: Harvard UniversityPress, 1980.

4. Bray GA. Obesity: historical development of scientific andcultural ideas. International Journal of Obesity and RelatedMetabolic Disorders. 1990; 14(2):6.

5. Quetelet A. Sur l’homme et le developpement de sesfacultes, ou essai de physique sociale. Paris: Bachelier,1835.

6. Benn RT. Some mathematical properties of weight-for-height indices used as measures of obesity. British Journalof Preventive Sociology and Medicine. 1971; 25:42-50.

7. Lobstein T, Baur L, Uauy R. Obesity in children and youngpeople: a crisis in public health. Obesity Reviews. 2004;5(Suppl.1): 4-85.

8. Kriemler S, Manser-Wenger S, Zahner L, Braun-FahrländerC, Schindler C, Puder JJ. Reduced cardiorespiratory fitness,low physical activity and an urban environment areindependently associated with increased cardiovascular riskin children. Diabetologia. 2008; 51(8):1408-15.

9. Livingstone MB. Childhood obesity in Europe: A growingconcern. Public Health Nutrition. 2001; 4: 109-16.

10. Martorell R, Khan LK, Hughes ML, Grummer-Strawn LM.Overweight and Obesity in preschool children fromdeveloping countries. International Journal of Obesity. 2000;24:959-67.

11. Reilly JJ. Descriptive epidemiology and healthconsequences of childhood obesity. Best Practice andResearch Clinical Endocrinology Metabolism. 2005; 19:327-341.

12. World Health Organization. Obesity, Preventing andManaging the Global Epidemic: Report of the WHOConsultation of Obesity, Geneva: World HealthOrganization, 1997.

13. Friedman SA, Story M, Perry CL. Self-esteem and Obesityin Children and Adolescents: a literature review. ObesityResearch. 1995; 3:479-490.

14. Must A. Morbidity and mortality associated with elevatedbody weight in children and adolescents. The AmericanJournal of Clinical Nutrition. 1996; 63:S445-S447.

15. Must A, Strauss RS. Risks and consequences of childhoodand adolescent obesity. International Journal of Obesity.1999; 23(Suppl2): S2-11.

16. Staffieri JR. A study of social stereotype and of body imagein children. Journal of Personality and Social Psychology.1967; 7:101-104.

17. Stunkard A, Burt V. Obesity and the Body Image: II. Age atonset of disturbances in the body image. American Journalof Psychiatry. 1967; 123:1443-7.

18. Belamarich PF, Luder E, Kattan M, Mitchell H, Islam S,Lynn H, Crain EF. Do obese inner-city children with asthmahave more symptoms than non-obese children withasthma? Pediatrics. 2000; 106:1436-42.

19. Luder E, Melnik TA, DiMaio M. Association of beingoverweight with greater asthma symptoms in inner city blackand Hispanic children. Journal of Pediatrics. 1998; 132:699-703.

20. Goran MI. Metabolic precursors and effects of obesity inchildren: A decade of progress, 1990-1999. The AmericanJournal of Clinical Nutrition. 2001; 73:158-71.

21. Taitz LS. The Obese Child, Boston, MA: Blackwell ScientificPublications, 1983.

22. Oren A, Vos LE, Uiterwaal CS, Gorissen WH, Grobbee DE,Bots ML. Change in body mass index from adolescence toyoung adulthood and increased carotid intima thickness at28 years of age: The Atherosclerosis Risk in Young Adultsstudy. International Journal of Obesity and RelatedMetabolic Disorders. 2003; 27: 1383-90.

23. Wright CM, Parker L, Lamont D, Craft AW. Implications ofchildhood obesity for adult health: findings from thousandfamilies cohort study. British Medial Journal. 2001; 323:1280-8.

24. Zwiauer KF, Pakosta R, Mueller T, Widhalm K.Cardiovascular risk factors in obese children in relation toweight and body fat distribution. Journal of the AmericanCollege of Nutrition. 1992; 11 Suppl: 41S-50S.

25. Gunnell DJ, Frankel SJ, Nanchahal K, Peters Tj, DaveySG. Childhood obesity and adult cardiovascular mortality:A 57 year follow-up study based on the Boyd Orr cohort.American Journal of Clinical Nutrition. 1998; 67: 1111-18.

26. Mossberg HO. 40 year follow-up of overweight children.Lancet. 1989; 2: 491-3.

27. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Longterm morbidity and mortality of overweight adolescents. Afollow-up of the Harvard Growth Study of 1922 to 1935.New England Journal of Medicine. 1992; 327: 1350-5.

28. Nieto FJ, Szklo M, Comstock GW. Childhood weight andgrowth rates as predictors of adult mortality. AmericanJournal of Epidemiology. 1992; 136: 201-13.

29. Guo SS, Chumlea WC. Tracking of body mass index inchildren in relation to overweight in adulthood. TheAmerican Journal of Clinical Nutrition. 1999; 70: 145-8.

30. Magarey AL, Daniels LA, Boulton TJC, Cockington RA.Predicting obesity in early adulthood from childhood andparental obesity. International journal of Obesity. 2003; 27:505-13.

31. Morinder G, Larsson UE, Norgren S, Marcus C. Insulinsensitivity, VO(2)max and body composition in severelyobese Swedish children and adolescents. Acta Paediatrica.2008. [Epub ahead of print]

32. Chatterjee S, Chatterjee P, Bandyopadhyay A.Cardiorespiratory fitness of obese boys. Indian Journal ofPhysiology and Pharmacology. 2005; 49(3):353-7.

33. Stigman S, Rintala P, Kukkonen-Harjula K, Kujala U, RinneM, Fogelholm M. Eight-year-old children with highcardiorespiratory fitness have lower overall and abdominalfatness. International Journal of Pediatric Obesity. 2008;3:1-9.

34. Chen LJ, Fox KR, Haase A, Wang JM. Obesity, fitness andhealth in Taiwanese children and adolescents. EuropeanJournal of Clinical Nutrition. 2006; 60(12):1367-75.

35. Tokmakidis SP, Kasambalis A, Christodoulos. Fitness levelsof Greek primary schoolchildren in relationship tooverweight and obesity. European Journal of Pediatrics.2006; 165(12):867-74.

36. Rowlands AV, Eston RG, Ingledew DK. Relationshipbetween activity levels, aerobic fitness, and body fat in 8- to 10-yr-old children. Journal of Applied Physiology. 1999;86(4):1428-1435.

37. Mota J, Flores L, Flores L, Ribeiro JC, Santos MP.Relationship of single measures of cardiorespiratory fitnessand obesity in young schoolchildren. American Journal ofHuman Biology. 2006; 8(3):335-41.

38. Müller MJ, Grund A, Krause H, Siewers M, Bosy-WestphalA, Rieckert H. Determinants of fat mass in prepubertalchildren. The British Journal of Nutrition. 2002; 88(5):545-54.

39. Cooper, KH. A means of assessing maximal oxygen intake.JAMA: The Journal of the American Medical Association.1968; 203:201-204.

40. Heyward VH. Advanced Fitness Assessment & ExercisePrescription. (3rd edition). Champaign: Human kinetics,1984.

41. Brunet M, Chaput JP, Tremblay A. The association betweenlow physical fitness and high body mass index or waistcircumference is increasing with age in children: the‘Québec en Forme’ Project. International Journal of Obesity.2007; 31(4):637-43.


166

42. Armstrong N, Fawkner SG. Aerobic Fitness. In: ArmstrongN, (Ed.). Pediatric Exercise Physiology. Philadelphia:Churchill Livingstone-Elsevier, Chapter 8, 2007.

43. Stephens P, Paridon SM. Exercise testing in pediatrics.Pediatric Clinics of North America. 2004; 51: 1569-1587.

44. Nader PR, Bradley RH, Houts RM, McRitchie SL, O’Brien

M. Moderate-to-vigorous physical activity from ages 9 to15 years. JAMA: The Journal of the American MedicalAssociation. 2008; 300(3):295-305.

45. McArdle, W.D., Katch, F.I., Katch, V.L. Exercise Physiology-Energy, Nutrition and Human Performance. (6th Ed.).Baltimore: Lippincott Williams & Wilkins, 2007.


167

Test Retest Reliability and Validity of Hindi Version of NeckDisability Index in Patients with Neck PainHalima Shakil*, Sohrab A Khan**, Puja C Thakur****Postgraduate Student, Physiotherapy (Orthopedics) Hamdard University, New Delhi, **Assistant Professor, Jamia Hamdard, NewDelhi, ***Physiotherapist AIIMS, New Delhi

Abstract

Study Design

Non-Experimental Methodological design.

Objectives

To translate and culturally adapt the Hindi version of NeckDisability Index and check its test retest reliability and validityin patients with neck pain.

Summary of Background Data

The NDI is one of the most widely used reliable and validinstrument for assessing functional disabilities in NP patients.However, no reliable and valid tool is available in Hindilanguage.

Methods

The study was carried out in three phases: the first wastranslation into Hindi and cultural adaptation of thequestionnaire, the second was a pilot study to assess thecomprehensibility of the pre final version; third was the reliabilityand validity study of the final version of the questionnaire. TheHindi version was tested on 150 patients with neck pain. Testretest reliability and internal consistency were investigated.

Results

Test retest reliability was assessed with 150 patients witha time interval of 48 hours. The intra class correlation coefficientof test retest reliability was 0.98 with all items having individualICC scores ranging from 0.868 to 0. 986. Reliability estimatedby the internal consistency reached a Cronbach’s alpha of0.995. The NDI subscales showed excellent test retest reliabilitywith Cronbach’s alpha ranging from 0.929 to 0.993.TheWilcoxon non parametric test was done for chance error whichwas negligible for almost all items.

Conclusion

The results of this study indicate that the Hindi version ofthe NDI is a reliable and valid tool for measuring disabilitycaused due to neck pain in Hindi speaking Indian population.The authors recommend this Hindi version of the NDI for usein further future clinical studies in India.

Key Words

Neck disability index, reliability, validity.

Neck Pain (NP) is one of the major complaints among thecervical spine disorders and is a common complaint among mostcommunities. It is highly prevalent and experienced healthproblem facing the work place and health care communities1. Itis the second most common regional pain syndrome next to

back ache and is also an important occupational related problem.The increased frequency of neck pain and its impact on

functioning including work performance makes this an importanthealth issue for the individual the employer, the health caresector and the society at large 2

To our knowledge, 5 questionnaires measuring disabilityon a patient’s life due to neck pain have been developed andvalidated3

• Neck disability Index (NDI)• Neck Pain and Disability Scale (NPDS)• The Northwick Park Neck Pain Questionnaire• The Copenhagen Neck Functional Disability Scale• The Patient-Specific Functional scale

The Neck Disability Index is the most commonly usedquestionnaire assessing disability in patients with neck pain. Itis a self-administered questionnaire that was adapted from theOswestry Disability Index by Vernon et al at 1991.4 It was thefirst instrument designed to assess self-rated disability inpatients with neck pain.

The Neck Disability Index is a relatively short, paper-pencilinstrument that is easy to apply in both clinical and researchsettings. It has strong psychometric characteristics and hasproven to be highly responsive in clinical trials. As of late 2007,it has been used in approximately 300 publications; it has beentranslated into many languages, and it is endorsed for use bya number of clinical guidelines.5

The Neck Disability Index has already been translated intoDutch 6, Brazilian7, Greek 8, Spanish 9, Turkish10, Korean 11,French, Finnish 12 and Iranian 13 and used in a number ofresearch studies. Reliability and validity of the NDI has beenreported in previous studies. It has been revalidated in severalstudy population and has shown stable psychometric properties[4] However, till date no Hindi version of Neck Disability Indexhas been developed. These reasons in addition to the lack ofa standard reliable and valid instrument in Hindi for measuringdisability in neck pain, led us to prepare and test the reliabilityand validity of the Hindi translation of neck disability indexamong Hindi speaking Indian patients with neck pain.

Methods

The study was carried out in three phases: the first wastranslation into Hindi and cultural adaptation of thequestionnaire; the second was a pilot study to assess thecomprehensibility of the pre final version; third was the reliabilityand validity study of the final version of the questionnaire.

Translation and Cultural Adaptation

For the translation we used the recent guidelines for crosscultural adaptation.[7] Two translations of the original NeckDisability Index from English to Hindi were performed by twobilingual translators whose mother tongue is Hindi, allowingdetection of errors and divergent interpretations of items withambiguous meaning in the original instrument. The firsttranslation was done by a translator of medical background (ata private clinic in jafarabad) who was aware of the process andpurpose. The other translation was done by a naïve translatorfrom non medical background (at the Supreme court of India).

Halima Shakil / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

168

He was unaware of the translation objectives and this was usefulin eliciting unexpected meanings from the original tool. Both theHindi translations were then compared for inconsistencies anda pre final version of the two translations was synthesizedworking from the original questionnaire as well as the first andsecond translator’s versions. The pre final version was then backtranslated by two naïve English speakers who were able to readand understand Hindi. Each translation was then compared withthe original English neck disability index and checked forinconsistencies.

The Hindi version was then reviewed by the expertcommittee, including the translators, physiotherapists etc. toassure semantic and idiomatic equivalence (i.e. to check forambiguous words or inappropriately translated colloquialisms)and to address any peculiarities specific to the culturesexamined between the Hindi and English versions of thequestionnaire. This was done to fine tune it for use amongHindi speaking Indian patients. The committee members alsocompared the Hindi version with the original English versionto detect errors of interpretation and nuances that might havebeen missed. The final stage of the adaptation process wasthe test of the pre final version.

Pilot Study and Modification of the Pre FinalVersion

The answer to an item may appear adequate yet can beconsistently misunderstood. So, to check for any errors ininterpretation, a pilot study was done on a sample of 30 patients.The patients were selected on the basis if inclusion andexclusion criteria. The patients were asked to fill thequestionnaire. later, they were asked to give feedback andcomments regarding the questions and identify words orsentences that were difficult to understand at the end of fillingof the questionnaire. on the basis of their reviews the finalversion of the index was developed which was again checkedand approved by the committee.

Reliability and Validity Study

The study was carried out at the physiotherapy departmentof the ESI hospital Okhla New Delhi, Hindurao Hospital, NewDelhi and various other hospitals. The study included 150patients with neck pain on the basis of inclusion exclusioncriteria. Each patient was asked to fill the NDI questionnairetwice with a time interval of 48 hours. On their first day inphysiotherapy department, the patient was assessed and NDIwas administered. The second administration was given after48 hours in order to assess test retest reliability of thequestionnaire.

The test retest reliability measures stability over time, byadministering the same test to the same subjects at two pointsin time. It was measured by comparing the results of first andsecond administrations of the NDI. We used intra classcorrelation coefficient (ICC) to evaluate test retest reliability.The internal consistency of a scale relates to its homogeneityand hence, Cronbach’s alpha was used to evaluate the same.

Face and content validity (item relevance and adequacyfor intended use) was judged by health professionals. It wasalso assessed by examining the completeness of itemresponses, the distribution of the scores and magnitude ofceiling and floor effects i.e. a proportion of the best and worstpossible scores, respectively.

Criterion and construct validity could not be tested due toabsence of a standard Hindi language disability measure forcervical spine.

ResultsThe study enrolled 150 patients with neck pain. The mean

age of patients was calculated as 35.12 + 11.52SD. The study

group comprised of 61 males and 87 females. Reliabilityestimated by the internal consistency reached a Cronbach’salpha of 0.995. The test retest reliability was assessed on twooccasions separated by a time interval of 48 hours. The intraclass correlation coefficient of test retest reliability was 0.990.

Item ICC Cronbach’s alpha

Pi-RPi 0.978 0.996

Pc-RPc 0.977 0.996

Lt-RLt 0.986 0.988

Rd-RRd 0.975 0.993

Had-RHad 0.968 0.987

Ctn-RCtn 0.978 0.984

Wk-RWk 0.982 0.989

Drvg-RDrvg 0.979 0.991

Slpg-RSlpg 0.980 0.989

Recn-RRecn 0.868 0.990

TSc-RTSc 0.990 0.929

D-RD 0.990 0.995

Table 2: ICC and test retest reliability of all items of the NDI,total score and disability.

Discussion

Patient oriented assessment methods are of paramountimportance in the evaluation of treatment outcome. The NeckDisability Index is one of the condition specific scalesrecommended for use with neck pain patients. It is short, easilycomprehended and simple to complete.

Neck pain studies in India lacked a reliable and validassessment instrument. So, the purpose of the study was todevelop and cross culturally adapt a Hindi version of the NDIand to test retest its reliability and validity for its use in Hindispeaking Indian patients with neck pain.

The process of translation and cross cultural adaptation ofthe NDI into Hindi was done in an attempt to produce a reliableand valid adaptation of the questionnaire that would show anagreement with the original English version of the scale.

For the vast majority of questions in the NDI, dealing withsimple activities and participation, no doubt seems warrantedabout their meaning in either language. So, the translating theoriginal English version into Hindi did not present any problem.Moreover, at the end of the pre final version, the Hindi versiondid not require any vast changes. The patients were able tocomplete the questionnaire easily concluding that thequestionnaire was easily comprehensible to the Hindi speakingIndian population. In addition, the ease of developing translatedand culturally adapted versions that are as reliable as the originalscale is a factor to be taken into account for considering a scaleas an international standard.

Face validity is concerned with whether a measurementseems to be assessing the intended parameters in the givensituation. In this study, translation of the questionnaire seemedto be valid and the instrument was well accepted by the patientsas well as approved by the committee comprising of translators,physiotherapists etc. The layout of the questionnaire and clear


169

structure and clarity of the questions enhanced its face validity.The internal consistency of the NDI was examined using

Cronbach’s alpha, an item correlation test that reflect thehomogeneity of all items. The alpha coefficients were calculatedof 150 subjects resulting in total index alpha of 0.995 with allitems having individual alpha scores above 0.8 indicating highinternal consistency.

Owing to a coefficient of the Cronbach’s alpha of 0.995,which even exceeds the score of English version of NDI (0.89),levels of reliability were slightly higher than those foundelsewhere. For example, Cronbach’s alpha was found to be 0.94,0.88 and 0.85 by Andrade Ortega et al,9 Mousavi Sayed et al13 ,Marianna Howard8 et al respectively.

Internal consistency of the NDI-H was acceptable,according to recommended standards.

The NDI is a simple and rapid scale that is quite easy touse. In this respect, ICC of 0.990 is an excellent measure ofreliability indicating high correlations between the baseline andretest questionnaires of the Hindi version of the NDI representinga very high level of test retest reliability, allowing for its clinicaluse. This result is in concordance with Portney and Watkinswho claim that, for most clinical measurements, reliability shouldexceed 0.90 to ensure reasonable validity.

Both the reliability scores measured in the NDI-Hindi showthat the translated version is reliable with a low standard errorof measurement. In the present study, the retest questionnairehad been administered approximately after 48 hours. MousaviSayed et al13 found similar scores for the 24 hour interval andsuggested that testing of reliability was done within a short timeinterval to minimize changes in the clinical status of patient. Ourresults show the high agreement between measurementsrecorded on 2 occasions over a 48-hour period. The value ofICC in our study was more than the original English version ofNDI. One reason for this difference could be the long time intervalbetween the baseline and retest administration of thequestionnaires by the original authors in their study. It is seenthat ICC values decrease with the increase in the time intervalbetween the two administrations of the questionnaire. In thestudies of Salo P;Yelinen J and Marianna5,9 it was seen that theICC values decreased in the retest scores as the test retestinterval was extended to 7 days. Such an observation could bebecause of the natural change in the physical and health statusof the individual.

According to statistical analysis of this study, this Hindiversion of the Neck Disability Index showed similar results tothose presented in the original English version of the NeckDisability Index as well as in other versions of 7 differentlanguages. 7-13

To our knowledge, this Hindi version of the NDI is the firstcondition specific outcome instrument for NP to have beenvalidated in Hindi. Development and validation of multiple-language versions of existing validated questionnaires plays akey role in standardizing the outcome measurement andincreasing the statistical power of clinical studies. Our resultsdemonstrate that the NDI was successfully, cross culturallytranslated into Hindi and at the same time retains its propertiesof the original version, thereby standardizing the outcomemeasurement further. Thus, it is concluded that this Hindi versionof NDI is a reliable and valid tool for assessment of functionalstatus in patients with neck pain.

Since this Hindi version of the NDI represents a valuable

instrument for assessing functional limitations in patients withneck pain in Hindi speaking Indian population, it can berecommended in future clinical studies and research in India.Overall, NDI is easy to conceive and quick to complete. It allowsthe patients with neck pain to grade their activities and limitationsin an accurate manner. Because of its easy scoring, highsensitivity towards change and wide acceptance by the patients,the NDI Hindi can be recommended for clinical trials ininvestigating the effectiveness of the therapeutic interventionsthe patients is undergoing in clinical set ups.

References

1. Shappert S.M.: National Ambulatory Medical Care Survey:Summary Advance Data from Vital and Health Statistics,no. 273, Hyatts Ville, MD; National Centre for HealthStatistics, 1996.

2. Rand S Swenson: Therapeutic modalities in themanagement of nonspecific neck pain: Physical Medicineand Rehabilitation Clinics of North America: 14(2003) 605-627.

3. Ricardo and Richardson: Standard scales for measurementof functional outcome for cervical pain or dysfunction – asystematic review: Vol.27 (5), Spine Journal, 1 march 2002;515-522.

4. Vernon H, Mior S: The NDI-a study of reliability and validity:Journal of Manipulative Physiotherapy 1991 Sep;14(7):409-15.

5. Howard Vernon DC Phd: The Neck Disability index: State-of-the-Art, 1991-2008Journal of Manipulative Physiological Therapeutics 2008September, 31(7): 491-502.

6. Cees J. Vos et al: Reliability and responsiveness of Dutchversion of NDI in patients with acute neck pain in generalpractice: European Spine Journal 2006 15:1729-1736; 3May.

7. Cook, Richardson et.al: Cross cultural adaptation andvalidation of Brazilian Portuguese version of NDI and NPDS:Vol 31(14), Spine Journal; 15 June 2006.1621-1627.

8. Marianna, Howard et al: Translation of NDI and validationof Greek version in a sample of neck pain patients: BioMedCentral Musculoskeletal Disorders: 22 July 2008.

9. Andrade Ortega JA, Delgado Martínez AD, Almécija RuizR: Validation of a Spanish version of the Neck DisabilityIndex: Med Clin (Barc). 2008 Feb 2; 130(3):85-9.

10. Aslan, Arianne et al: The cultural adaptation-reliability andvalidity of NDI in patients with neck pain- a Turkish versionstudy: vol33 (11), Spine Journal;15 may 2008-E362-E365.

11. Kyung-Jin Song, Byung-Wan Choi, Sul-Jeon Kim, and Sun-Jung Yoon: Cross-Cultural Adaptation and Validation of theKorean Version of the Neck Disability Index: Journal ofKorean Orthopedic Association 2009; 44: 350-359.

12. Salo, Petri; Ylinen, Jari; Kautiainen, Hannu; Arkela-Kautiainen, Marja; Häkkinen, Arja: Reliability and Validityof the Finnish Version of the Neck Disability Index and theModified Neck Pain and Disability Scale: Spine: 1 March2010 - Volume 35 - Issue 5 - pp 552-556.

13. Mousavi, Sayed et al.: Translation and validation study ofIranian version of NDI and NPDS: vol 32(26), Spine Journal;15 Dec2007 E825-E831.

14. portney and Watkins—-


170

Effect of Ankle Foot Orthosis on Plantar-flexor Tone and Gross MotorFunctional Abilities in Children with Hemiplegic Cerebral PalsyMeenakshi Batra1, Vijai Prakash Sharma2, Vijay Batra3, Gyanendra Kumar Malik4, Girdhar Gopal Agarwal5

1PhD Scholar, 2Director Professor & Head, 3Senior Research Fellow, 4Professor & Head of Pediatrics, Department of PMR, RALC,Department of Physical Medicine and Rehabilitation, Rehabilitation and Artificial Limb Centre (RALC), Nabiullah Road, Near DaliganjBridge, Chhatrapati Shahuji Maharaj Medical University, Lucknow- 226018, Uttar Pradesh, India, 5Professor, Department of Statistics,Lucknow university, Lucknow-226007

Abstract

Objective

To see the effectiveness of Ankle Foot Orthosis on plantar-flexor tone and gross motor functional abilities in children withhemiplegic cerebral palsy

Method

A total of 30 subjects coming to OPD, Dept of PhysicalMedicine and Rehabilitation and Paediatrics with a diagnosis ofhemiplegic cerebral palsy were included and baseline evaluationwas done for tone in ankle and lower extremity (using MAS)and gross motor functional abilities (using GMFM-66). Thesubjects were allocated equally among group A and group B byconvenient sampling scheme with 15 subjects each. In groupA, Ankle Foot orthosis (AFO) along with conventional therapyand in group B, conventional treatment with no Ankle Footorthosis were used for a period of 3 months followed by re-evaluation. Result: The two groups were compared for theirscores. These were found to be statistically significant with pvalue ranging from .003 to < .0001. Conclusions: It can beconcluded that Ankle Foot orthosis (AFO) helps in normalizingthe tone in ankle (plantar-flexors) and lower extremity and canbe used as an adjunct to the treatment / therapeutic process toenhance gross motor functional abilities in hemiplegic cerebralpalsy children.

Key Words

Cerebral Palsy; Tone; Ankle foot orthosis; Postural reaction;Postural control; Gross motor functional abilities.

Introduction

The Cerebral palsy is mainly a motor disorder8, 12-13 generallyclassified based on muscle tone or the area of distribution. Basedon muscle tone it can be spastic, athetoid, ataxic or mixed typewhile depending on area of distribution it can be hemiplegic(Involvement of upper and lower extremity of one side of body),diplegic (upper extremity involved more than lower extremity),quadriplegic (involvement of all the four limbs including trunk,neck and face), triplegic (involvement of both lower extremitiesand either of one upper extremity) or monoplegic (involvement

Address for correspondence:Meenakshi BatraPhD ScholarChhatrapati Shahuji Maharaj Medical University (Erstwhile KingGeorge Medical College and University), Department of PhysicalMedicine and Rehabilitation, Rehabilitation and Artificial LimbCentre (RALC), Nabiullah Road, Near Daliganj Bridge, Lucknow-226018, Uttar Pradesh, IndiaTelephone: +919868038335, +919868019077, +91-11-25280121Fax: +91-522-2611091Email: [email protected], [email protected]

of one side of body).Cerebral palsy is primarily a group of developmental

disorders of movement and posture12-13, dominated by persistentprimitive and pathological reflexes, muscle weakness, poorselective motor control, abnormal motor sequences andsynergies8, and postural reaction deficits3 causing activityrestrictions or disability that is attributed to disturbances occurringin the fetal or infant brain. These primary characteristics oftenlead to structural deficits (such as bony deformities, musclecontractures), as well as functional deficits (such as posturaland gait abnormalities; gross and fine motor functional abilities;and delayed motor milestones).

The beginning of motor development is found in reflexivemovement. The reflexes are integrated to allow normal motordevelopment during child maturity. When the primitive reflexesdisappear, developmental / Postural reactions emerge3, 7- 9. ThePostural reactions are important for regulation of posture,establishment and maintenance of upright position, and theorientation of the body and its parts in space. Development ofpostural control facilitates blending of mobility and stabilitypatterns and also provides an insight into the motor potential ofchildren with CP7- 9.

In hemiplegic cerebral palsy children one side of upper andlower extremity is affected and is mainly characterised by tonal,postural and gait abnormalities, motor dysfunction and impairedpostural control2, 3, 5, 9, 10 resulting in poor gross motor functionalperformance and abilities; and delayed acquisition of motormilestones.

The Clinical presentation of a hemiplegic Cerebral palsy(CP) child is mainly characterized by persistent unwantedprimitive reflexes, hyperreflexia, clonus, increased muscle toneprimarily in ankle plantar flexors, abnormal muscle synergies,postural asymmetry, postural reaction deficits cicumductory gait,toe walking, contractures, delayed developmental milestones.The intervention mainly aims at normalizing muscle tone,correcting postural and gait abnormalities, and improving grossmotor functional abilities via positioning, stretching, active andpassive exercises and activities, weight bearing and weightshifting in developmental positions, use of orthotic aids andappliances1, 6, 11, 14 such as ankle foot orthosis etc.

Ankle-foot orthoses (AFOs) are commonly used inhemiplegic cerebral palsy children. They control the ankledirectly, and can be designed to control the knee joint indirectlyas well. AFOs provide support to weak and spastic muscle, andposition the limb (with tight and contracted muscles) into a morenormal position. The AFO is mainly intended to normalize muscletone, maintain proper alignment, increase range of motion,stabilize ankle joint, control position and motion of the ankle,prevent deformity, correct / modify base of support, facilitatetraining in skills, improve the efficiency of gait, minimize gaitabnormalities, optimize foot to ground contact and dynamics ofwalking1, 4, 6, 11, 14. But the utility of AFO is still a matter of debate.Some studies have reported the improvement in gaitcharacteristics11 in terms of increased stride length, decreasedcadence, and reduced excessive ankle plantar flexion with AFOwhile others reported no improvement14 in static foot alignmentin the majority of feet in children with cerebral palsy who wereable to walk. Similarly a study on effect of ankle-foot orthoseson walking efficiency and gait in children with cerebral palsy4

concluded that the use of an ankle-foot orthosis resulted in a

Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol. 5, No. 3

171

significant decrease in the energy cost of walking of quadriplegicchildren with cerebral palsy, compared with barefoot walking,whereas it remained unchanged in hemiplegic and diplegicchildren with cerebral palsy.

The prescriptions of ankle foot orthosis is still a controversialissue and there are mixed opinions from researchers of variousfields; hence the study was conducted with a primary researchquestion to see the effect of Ankle Foot orthosis on plantar-flexor tone and its implication over gross motor functional abilitiesin hemiplegic cerebral palsy children.

Methodology

30 Cerebral palsy children coming to the Department ofPhysical Medicine and rehabilitation (PMR), and Department ofPaediatrics of Chhatrapati Shahuji Maharaj Medical University(Formerly King George Medical College) Lucknow wereincluded. This was the experimental research study andconvenient sampling was done. The informed consent wasobtained from the parents /guardians of the child. The spastichemiplegic cerebral palsy children of age range 2 to 7 yearswere included while the children with contracture or fixeddeformity, severe and profound mental retardation and diagnosisother than Spastic hemiplegic cerebral palsy were excluded fromthe study.

The baseline evaluation was done for tone in ankle, tonein lower extremity and gross motor functional abilities. Tone wasassessed using Modified Ashworth Score (Annexure A) whilegross motor functional abilities were assessed using Gross MotorFunction Measure (GMFM-66) and. Tone score for ankle andTotal tone score(Lower extremiy) in percentile was calculated(Insert Table 1 Showing calculation of percentile Tone score forAnkle and Lower extremity). Convenient sampling was doneand the subjects were allocated into two groups i.e. group Aand group B with 15 subjects each. The children were matchedon age, sex, tone and gross motor functional level (GMFCSlevels). With children in group A, Ankle Foot orthosis (AFO) wasused along with conventional therapy. The parents were askedto make the child wear Ankle Foot orthosis (AFO) for 6-8 hoursper day with intermittent rest intervals. With group B conventionaltreatment with no Ankle Foot orthosis (AFO) was used. Theintervention was given for 3 months and re-evaluation was done.Both Between and within group analysis was done using MannWhitney U test and Wilcoxon sign rank test.

and gross motor functional abilities [on Gross Motor FunctionMeasure (GMFM-66)] using nonparametric Mann Whitney U test.Nonparametric test was used because sample size was small,distributions were skewed and scoring was done on ordinalscale. For each variable, Median and Inter-quartile range wascalculated. Most of these scores were statistically significantwith p value ranging from .003 to < .0001. The Median andInterquartile range of group A at baseline for tone in Ankle, tonein Lower extremity (Total tone score) and Gross motor functionalabilities [GMFM (total score)] were (30.0 & 10.0); (20.0 & 6.67);and (48.57 & 20.52) while for group B they were (20.0 & 10.0);(20.0 & 3.33); and (46.29 & 20.54) respectively. The Medianand Interquartile range of group A for tone in Ankle, tone in Lowerextremity (Total tone score) and Gross motor functional abilities[GMFM (total score)] after 3 months of intervention were (10.0& 10.0); (6.67 & 6.67); and (83.40 & 30.47) while for group Bthey were (20.0 & 0.0); (15.56 & 4.44); and (53.31 & 18.97)respectively. [Insert Table 2 Comparison between two groupsi.e. Group A and Group B (Pre and post-intervention) here]

Within Group Comparison for Group A

Subjects within each group were compared on the pre-intervention and post-intervention scores for tone in Ankle, tonein Lower extremity (on Modified Ashworth Score), and Grossmotor functional abilities [on Gross Motor Function Measure(GMFM-66)] using Wilcoxon sign rank test to see theeffectiveness of each intervention. For group A, p value wasfound to be very significant with value < .0001. The Median andInterquartile range at baseline for tone in Ankle, tone in Lowerextremity (Total tone score) and Gross motor functional abilities[GMFM (total score)] were (25.0 & 10.0); (20.56 & 3.61); and(46.29 & 19.89) respectively and after 3 months of interventionthey were (20.0 & 10.0); (14.44 & 11.39); and (61.87 & 33.84)respectively. [Insert Table 3 Comparison of scores within GroupA (Pre and post-intervention) here]

Within Group Comparison for group B

Subjects within each group were compared on the pre-intervention and post-intervention scores for tone in Ankle, tonein Lower extremity (on Modified Ashworth Score), and Grossmotor functional abilities [on Gross Motor Function Measure(GMFM-66)] using Wilcoxon sign rank test to see theeffectiveness of each intervention. For group B, p value wasfound to be very significant with value ranging from 0.025 to <.0001. The Median and Interquartile range of group B at baselinefor tone in Ankle, tone in Lower extremity (Total tone score) andGross motor functional abilities [GMFM (total score)] were (20.0& 10.0); (21.11 & 3.33); and (46.29 & 20.54) respectively andafter 3 months of intervention they were (20.0 & 0.0); (17.78 &4.44); and (53.31 & 18.97) respectively. [Insert Table 4Comparison of scores within Group B (Pre and post-intervention)here]

Result

Although both the Intervention groups i.e. group A and groupB were found to be effective in hemiplegic cerebral palsy childrenfor most of the variables, but subjects in Group A showed betterresults than Group B. There was significant change in group Athan group B (Table 2) It was observed that the muscle tone atankle and lower extremity was normalized more in group A Ithan group B. Also better improvement in gross motor functionalabilities was observed in group A than group B [Insert Table 3:Comparison of scores within Group A (Pre and post-intervention)and Table 4 Comparison within Group B (Pre and post-intervention) here]


Between Group Comparison

The two groups were compared with each other for theirdifference of scores (pre-intervention and post-intervention) fortone in ankle and lower extremity (on Modified Ashworth Score),

Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol. 5, No. 3

Table 1: Showing calculation of percentile Tone score for Ankleand Lower extremity

Spasticity Code Tone score Total Tone(MAS grades) Score

0 0

1 1

1+ 2

2 3

3 4

4 5

172

Discussion

From the analysis of result it was found that the applicationof an AFO helps in normalizing muscle tone at ankle therebyimproving stability. The orthosis (AFO) was prescribed with agoal of normalizing plantar flexors muscle tone and preventingor correcting contractures. Although AFO can impose additionalactivity limitations by restricting movement but they were foundmore beneficial for the cerebral palsy children.

The contractures and deformities are generally caused byrelative shortening of muscles and soft tissues. These mobilejoint deformities are caused by gravity or unbalanced muscleforces which can be corrected by positioning the ankle in normalanatomical alignment using AFO. Ensuring that muscles spend4 to 6 hours per day in an elongated position may help to preventor reduce the rate of progressive contractures. However,stretching muscles using active forces for shorter periods maybe effective for maintaining a static position to increase musclelength and hence the available range of motion at joints 1, 6, 11, 14.The subjects in group A were having additional advantage overgroup B in terms of ensured positioning of limb with the musclesspending almost 4 to 6 hours per day in an elongated positionalong with the conventional therapy.

Moreover, stability in any of these positions i.e. lying, sitting,or standing requires consideration of both intrinsic and extrinsicfactors. Intrinsic stability involves controlling the position of thecenter of mass within the body. Extrinsic stability involvesmaintaining the center of mass within the supporting area. TheAFO improves stability by increasing the size of the supportarea. It also maintains the optimum biomechanical alignment of

body segments encased within the orthosis. These effects mayenable children to overcome activity limitations by focusingtraining on unrestricted parts of their bodies over which theyhave better control1, 4, 6, 11, 14. AFO also influences externalmovements acting around proximal joints by altering the line ofaction of the ground reaction force during standing and walking.Hence the children in group A with whom Ankle Foot orthosis(AFO) was used showed better results.

Conclusion

Ankle Foot orthosis (AFO) helps in normalizing the tone inankle (plantar-flexors) and lower extremity and can be used asan adjunct to the treatment / therapeutic process to enhancegross motor functional abilities in hemiplegic cerebral palsychildren.

Acknowledgement

We are thankful to our Patients and their family membersfor their kind cooperation.

Declaration of Interest

The authors report no conflicts of interest.

References

1. Abel, M. F., Juhl, G. A., Vaughan, C. L. & Damiano, D. L.(1998). Gait assessment of fixed ankle-foot orthoses in

Table 2: Comparison between two groups (Group A and Group B) (Pre and post-intervention)

Variable Difference of Scores Z P ValueGroup A Group BMedian I Q range Median I Q range

GMFM (Component)I Baseline 70.59 13.73 70.59 13.72 -.439 0.661

Final 94.12 9.8 38.46 13.72 -2.981 .003

II Baseline 63.33 15.00 58.33 16.66 -.813 0.416Final 93.33 16.67 84.31 7.14 -2.645 .008

III Baseline 38.10 23.81 40.48 21.43 -.209 0.834Final 85.71 30.96 52.38 7.69 -3.429 .001

IV Baseline 43.59 38.47 22.22 32.9 -.957 0.338Final 89.74 46.15 48.72 25.64 -2.785 .005

V Baseline 23.61 19.44 70.0 20.84 -.312 0.755Final 43.06 51.39 27.78 18.05 -3.017 .003

GMFM (Total Score)Baseline 48.57 20.52 46.29 20.54 -.249 0.803Final 83.40 30.47 53.31 18.97 -2.967 .003

ToneHip Baseline 20.0 10.0 16.67 3.33 -.453 0.651

Final 6.67 10.0 16.67 3.34 -3.976 <.0001

Knee Baseline 20.0 0.00 20.0 10.0 -.334 .739Final 10.0 10.0 10.0 10.0 -4.015 <.0001

Ankle Baseline 30.0 10.0 20.0 10.0 -.484 0.629Final 10.0 10.0 20.0 0.00 -4.472 <.0001

Tone score Baseline 20.0 6.67 20.0 3.33 -.231 .817 Final 6.67 6.67 15.56 4.44 -4.551 <.0001

I Q range = Inter-quartile range,Tone score = Sum total of all the tone Scores of hip, knee and ankle


173

Table 3: Comparison within Group A (Pre and post-intervention)


Variable Difference of Scores Z P ValueBefore AfterMedian I Q range Median I Q range

GMFM (Component)I 70.59 12.75 87.25 18.14 -4.79 <.0001

II 62.5 15.00 81.66 27.5 -4.77 <.0001

III 39.29 22.03 59.52 38.69 -4.79 <.0001

IV 39.74 35.90 55.13 48.07 -4.79 <.0001

V 22.92 19.80 29.86 43.06 -4.71 <.0001

GMFM (Total Score) 46.29 19.89 61.87 33.84 -4.78 <.0001

ToneHip 18.33 3.33 11.67 10.0 -4.61 <.0001

Knee 20.0 2.5 10.0 10.0 -4.25 <.0001

Ankle 25.0 10.0 20.0 10.0 -3.90 <.0001

Tone score 20.56 3.61 14.44 11.39 -4.55 <.0001

Variable Difference of Scores Z P ValueBefore AfterMedian I Q range Median I Q range

GMFM (Component)I 70.59 13.73 84.31 13.72 -3.42 0.001

II 58.33 16.66 70.00 16.67 -3.37 0.001

III 40.48 21.43 52.38 23.81 -3.42 0.001

IV 38.46 35.90 48.72 25.64 -3.42 0.001

V 22.22 20.84 27.78 18.05 -3.32 0.001

GMFM (Total Score) 46.29 20.54 53.31 18.97 -3.41 0.001

ToneHip 16.67 3.33 16.67 3.34 -3.36 0.001

Knee 20.0 10.00 20.00 10.00 -2.53 0.011

Ankle 20.00 10.00 20.0 0.00 -2.24 0.025

Tone score 21.11 3.33 17.78 4.44 -3.10 0.002

Table 4: Comparison within Group B (Pre and post-intervention)


children with spastic diplegia. Archives of Physical Medicineand Rehabilitation, 79(2), 126-33.]

2. Badke Beth Mary, Duncan W Pamela (1987). Influence ofprior knowledge on automatic and voluntary posturaladjustments in healthy and hemiplegics subjects ;Physiotherapy: 67 (10) 1495 – 1500

3. Batra Meenakshi, Sharma VP, Malik G. K. Batra Vijay, (2010)Targeting Postural reaction deficits in children with Cerebralpalsy - A Single Case study, Sri Lanka Journal of childHealth (Accepted on 24th June 10) (In Press).

4. Brehm MA, et al (2008), Effect of Ankle foot orthoses onwalking efficiency and gait in children with cerebral palsy. J


174

10. Otten (2005), Multiple dynamics and the development ofmotor control, Neural Plasticity, 12 (2-3): 89 – 98.

11. Radtka, S. A., Skinner, S. R., Dixon, D. M. & Johanson, M.E. (1997). A comparison of gait with solid, dynamic, and noankle-foot orthoses in children with spastic cerebral palsy.Physical Therapy, 77(4), 395-409.

12. S. Ashwal., Russman B. S., Blasco P.A., Miller G., SandlerA. Shevell M. et al (2004). Practice parameter: Diagnosticassessment of the child with Cerebral Palsy. Neurology(American Academy of Neurology), 62(3): 851-863.

13. Sankar Chitra and Mundkur Nandini (2005). Cerebral Palsydefinition, Classification, etiology and early diagnosis; IndianJournal of Pediatrics, 72 (10): 865-868.

14. Westberry, D. E., Davids, J. R., Shaver, J. C., Tanner, S.L., Blackhurst, D. W. & Davis, R. B. (2007). Impact of ankle-foot orthoses on static foot alignment in children withcerebral palsy. The Journal of Bone and Joint Surgery.American Volume, 89(4), 806-13.]

Rehabil Med 2008; 40: 529–5345. Carlberg Eva Brogren and Mijna Hadders-Algra (2005).

Postural Dysfunction in Children with Cerebral Palsy: SomeImplications Therapeutic Guidance, Neural Plasticity: 12(2-3): 221-228.

6. Carlson, W. E., Vaughan, C. L., Damiano, D. L. & Abel, M.F. (1997). Orthotic management of gait in spastic diplegia.American Journal of Physical Medicine and Rehabilitation,76(3), 219-25.

7. Dimitrios I Zafeiriou (2004). primitive reflexes and posturalreactions in the Neurodevelopmental examination, Journalof Pediatric Neurology, 31 (1): 1-8

8. Mayston J Margaret (2001). People with C.P.: Effect of andPerspective for therapy, Neural Plasticity, 8 (1-2): 51:69.

9. Mijna Hadders – Algra (2005). Development of posturalcontrol during the first 18 months of life, Neural Plasticity,12(2) – 3; 99:108.


175Ganapathy Sankar U / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Normative Data of Evaluation Tool of Children Handwriting –Manuscript (ETCH-M)Ganapathy Sankar U*, R Riya***Vice Principal, **Occupational Therapist, SRM College of Occupational Therapy, Kancheepuram, Tamil Nadu

Abstract

Objective

The purpose of this study was to establish normative dataof Evaluation Tool for Children Handwriting (ETCH-M) forChennai children.

Method

Six hundred (n= 600) children, aged 6 to 10 years (meanage = 7.55 years ± 1.11 years) were included throughconvenience sampling from normal school located in the NorthChennai, South Chennai and Central Chennai inorder to avertgeographical variation. . ETCH-M was administered individuallyto assess handwriting speed and legibility.

Results

It shows that there is statistically significant differencebetween the age groups on the performance of ETCH – M(F=5.9,pd”0.001; F=14.57, pd”0.001; F=2.9,pd”0.05for letterlegibility, word legibility and numerical legibility respectively). There is statistically significant difference between the agegroups on the performance of ETCH-M for speed in Near PointCopying and Far Point Copying. This depicts that as the ageincreases the children handwriting legibility and speed alsoincreases.

Conclusion

The normative data obtained from this study can be usedas cut-off score for screening the children with handwritingdifficulties and it can be used as assessment tool as well asoutcome measures.

Introduction

Many children begin to scribble on paper shortly after theyare able to grasp a writing tool, and if not supervised, willeventually write on any available surface. As a child matures,their scribbling evolves into the handwriting skills specific to theirculture1.Handwriting needs to be taught appropriately andconsistently from an early age. It can be enhanced throughdeveloping specific perceptual and motor skills appropriate tothe requirements of handwriting. Handwriting is an importantfunctional task used frequently in every grade beginning inkindergarten. Children are expected to gain skills gradually inhandwriting legibility as formal instruction is introduced in thekindergarten and first-grade curriculum 2.

Some children may be ready for writing at age 4, and othersmay not be ready until age 6 3,4.The readiness factors neededfor writing requires the integrity of a number of sensorimotorsystems. A number of authors5,6 have stressed the importanceof mastery of writing readiness skills before handwritinginstruction is initiated. Letter formation requires the integrationof the visual, motor, sensory and perceptual systems. Sufficientfine motor co-ordination is also needed to form letters accurately.

Lamme (1979) identified six prerequisites that children musthave before handwriting instruction begins. These are1 Smallmuscle development 2 Eye-hand co-ordination, 3 Ability to oldutensils or writing tools,4 Capacity to smoothly for basic strokessuch as circles and lines5 Letter perception, including the abilityto recognize forms, notice likenesses and differences, infer themovement necessary for the production of form, and giveaccurate verbal description.6 Orientation to printed language,which involves the visual and of letters and words and right leftdiscrimination.

Types of handwriting include cursive and manuscript writing.Cursive is any style of handwriting that is designed for writingdown notes and letters quickly by hand. A manuscript is anydocument that is written by hand, as opposed to being printedor reproduced in some other way. A generally accepted sequencefor handwriting instruction is manuscript writing for use in grades1 & 2, with children transitioning to cursive writing at the end ofgrade 2 or the beginning of grade 3 7.The need for manuscriptwriting may continue throughout life, when students label mapsand posters, adolescent’s complete job or college applicationsand adults complete official or legal forms. In manuscript, childrenbecome accustomed to having the paper square to the edge ofthe desk in order to “write”. The D’Nealian manuscript programis unique in that letters are practiced with the paper positionedat an angle to take advantage of the wrist flexors in down stroking.This angling is beneficial only when the radial side of the handis used to guide the pencil to write. The D’Nealian manuscriptprogram has been the most successful in reducing segmentationof lines for letter formation8 (Benbow, 1995).

Manuscript is Endorsed for the FollowingReasons

√ Letter forms are simpler and hence easier to learn.√ It closely resembles the print of textbooks and school

manuals.√ It is needed throughout adult life for documents and

applications.√ Ball and stick strokes of manuscript letter formation are

more developmental appropriate than cursive letter foryoung children.

√ Beginning manuscript writing is more readable than cursive.√ Manuscript letters are easier to discriminate visually than

cursive letters9,10,11.

Need for the Study

A child’s ability to write in a manner that is both legible andefficient, directly affects his or her school performance andacademic advancement12. When handwriting skills are deficient,children suffer various consequences related to their academicperformance and social interactions, thus limiting their successfulparticipation in everyday school activities13.

Handwriting is an important area of evaluation for pediatricoccupational therapist. Problems with handwriting performanceis one of the most common reasons for referring school- agedchildren to Occupational Therapy14,15.Although handwritinginstruction is mostly the responsibility of teachers, anOccupational Therapist plays an important role in determining

176

the underlying postural, motor, sensory integrative andperceptual deficits that may be a cause of bad writing. Some ofthe handwriting assessment tools are: Children’s HandwritingEvaluation Tool for Manuscript Writing, Children’s HandwritingEvaluation Scale, Denver Handwriting Analysis, MinnesotaHandwriting Test, Test of Legible writing.

The Evaluation Tool of Children’s Handwriting - Manuscript(ETCH - M) is used to assess the handwriting speed and legibility.Addis, 16 has done normative data studies for handwritinglegibility and speed ranges among first graders in “TempleUniversity”, Philadelphia. Chan17 has reported the influence ofculture on visual motor coordination and visual perception andthey concluded that norms should be established for specificculture groups. Hence the current study was carried out toestablish norms for ETCH- M in Chennai children.

Aim

To establish normative data for ETCH- Manuscript

Objectives

To find out Chennai children performance on ETCH –ManuscriptTo find out the relationship between age and handwritingspeedTo find out the relationship between age and handwritinglegibility

Methodology

Sample

Quantitative research design, Cross-sectional study. Sixhundred children (n = 600) aged 6 -10 years (mean age = 7.55years, S.D= 1.11 years ) were recruited by means of conveniencesampling procedure from normal schools located in North, South,Central Chennai in order to maintain geographical distribution.

Screening Criteria

A. Inclusion Criteria

Good knowledge in manuscript writingAge 6-10 yearsBoth genderNormal or corrected visionNormal or corrected hearing

B. Exclusion Criteria

Poor visual foundation skillsPoor comprehension skillsFrequent failures in the academic performance.Motor disabilities (upper limb).

Table 1: Normative data of letter legibility for ETCH – M

Age Letter Word Numerical Speed in NPC Speed in FPC interval legibility% legibility% legibility% (lt/min) (lt/min)

6.0- 6.11 90.08 ± 6.4 86.74 ± 11.8 92.93 ± 7.6 18.27 ± 6.8 19.66 ± 6.7

7.0- 7.11 90.62 ± 6.1 90.77 ± 9.4 94.81 ± 6.8 21.69 ± 9.3 22.03 ± 8.2

8.0- 8.11 91.23 ± 5.8 92.58 ± 9.1 94.85 ± 6.0 23.19 ± 8.2 24.76 ± 9.9

9.0- 9.11 92.75 ± 4.6 93.51 ± 7.7 93.69 ± 6.1 28.73 ± 12.3 30.92 ± 15.2

NPC = Near point copyingFPC = Far point copyingTable 2: The correlation between age and legibility componentsof ETCH – M

r = Pearson correlation coefficient

Legibility components r

Letter legibility .159

Word legibility .241

Numerical legibility .037

Table 3: The correlation between age and speed of ETCH – M

Task R

Near point copying .369

Far point copying .367

r = Pearson correlation coefficientPearson correlation coefficient was used to find the

correlation between age and speed in handwriting .The resultsshowed that there is positive correlation for near point copying(r = .369) and far point copying (r = .367).

Instrument

The Evaluation Tool of Children’s Handwriting- Cursive (ETCH-M)

The Evaluation Tool of Children’s Handwriting-Manuscript(ETCH-M) is a criterion-referenced tool designed to evaluateManuscript handwriting skills of children in grades 1 to 6. Itsfocus is to assess a student’s legibility and speed of handwritingtasks similar to those required of students in the classroom.The administration time is 20-30 minutes. ETCH - M legibilityscores were correlated with handwriting grades from teachersto establish concurrent validity, the results indicated that thereis significantly moderate correlation existed between cursivelegibility percentage scores & teacher assigned handwritinggrade and moderate correlation between legibility percentagescores of ETCH-M and classroom worksheets.

Materials used

ETCH manual, response booklet, pencil, and stopwatch.

Data collection procedure

The study was conducted in regular schools in North

Ganapathy Sankar U / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

177

Chennai, South Chennai and Central Chennai. Before the studywas conducted, the purpose of study was explained to the headof the institutions and the consent forms were obtained fromrespective parents. The general information about the subject’sacademic performance has been collected from the respectiveclass teacher. Subjects were seated on a chair and table,appropriate for their height. ETCH-M was administered in aseparate class room with good ventilation and lighting as perguidelines given in manual. A stop watch was used to recordthe time taken to perform near point and far point copying. Thelegibility is calculated in percentages and speed in minutes.

Data Analysis

One way ANOVA was used to find out difference in letterlegibility, word legibility and numerical legibility between the agegroups. Pearson correlation coefficient was used to identifyrelationship between the age and legibility components & ageand Speed components of ETCH-M. The data’s were analyzedusing SPSS (15.0 version)

Results

The results showed that there is statistically significantdifference between the age groups in letter legibility (F (3, 596)= 5.969, pd” .001), word legibility (F (3,596) = 14.575, p< .001),numerical legibility(F (3,596) = 2.944, p< .05), and handwritingspeed in Near Point Copying (F (3,596) = 32.377, p< .001)andFar Point copying (F (3,596) = 32.060, p< .001). The correlationbetween age and legibility components of ETCH results revealedthat positive correlation (Table 6 ) for letter legibility (r=.159),word legibility (r=.241) and no correlation for numerical legibility(r= .037). The correlation between age and speed componentsof ETCH results indicated that positive correlation(Table 7) fornear point copying (r= .369) and far point copying (r= .367).

Discussion

Written language is a highly complex form ofcommunication. It is both skill and a means of self expression. Itintegrates visual, motor and conceptual abilities and is a majormeans through which student’s demonstrate their knowledgeof advanced academic subjects. The writing skill includescompetence in writing, spelling, punctuation, knowing thealphabet and distinguishing one letter from another. The purposeof this study was to establish normative data of ETCH-M forChennai children.

There is statistically significant difference between the agegroup of 6-10 years for letter legibility, word legibility andnumerical legibility and positive correlation for letter and wordlegibility. Literature 18 found that letter legibility score increasedwith age. Jackson et al19 found that the legibility increased withgrade level. Ziviani20 (1983) found that the degree of index fingerflexion and degree of forearm pronation, supination havedevelopmental trends which depicts as age increases the childgrasp pattern also improves.

There is no correlation for numerical legibility. Since thenumbers are taught from the kindergarten, the child has noconfusion between the numbers as in case of alphabets (cursiveor manuscript). This has influenced the result.

There is statistically significant difference between the agegroups for near point copying and far point copying and positivecorrelation for speed components. The result of this study wassupported by literature. Tseng21 found that handwriting speedincreases with age. Various researchers22,23 concluded thatvisual motor integration plays an important role in handwritingspeed.

Ergonomic factor should be considered. Norms can beestablished for various geographical areas. Further studies canbe performed to find out relationship between pencil grasp andlegibility & pencil grasp and speed.

Conclusion

Norms has been established for legibility and speed forETCH – M among Chennai children between 6 to 10 years. Thenormative data obtained from this study can be used as cut-offscore to screen the children with illegible and slow handwriting.It can be used as assessment tool, research tool and outcomemeasures to identify the effectiveness of intervention program.

Acknowledgement

I pay my sincere thanks to the chairman of SRM group ofinstitutions and SRM University. I express my sincere thanks toMr.Christopher Amalraj V, Biostatistician and all the participantswho have been the real pillars of this study. Last but not least, Ithank all of them whose names have inadvertently fails mymemory and who in their own unique way have made this projecta reality.

References

1. Amundson, Susan, & Weil, Marsha. Prewriting andhandwriting skills. In Jane Case-Smith, Anne Allen, & PatN. Pratt (Eds.), Occupational therapy for children (3rd ed.,pp. 524-541). St. Louis: Mosby-Year Book,1996.

2. Marr, D., & Cermak, S. Consistency of handwriting in earlyelementary students. American Journal of OccupationalTherapy, 2003; 57,

3. Lamme, L.L. Handwriting in an early childhood curriculum.Young Children, 1979, 35, 20 – 27.

4. Laszlo, J. I., & Bairstow, P. J. Handwriting: Difficulties andpossible solutions. School Psychology International, 1984;5, 207-213.

5. Alston, Jean, & Taylor, Jane (Eds.). Handwriting: Theory,research, and practice. London: Croom Helm, 1987.

6. Wright, J.P. & Allen, E.G. Ready to write! Elementary SchoolJournal, 1975, 75,430 – 435.

7. Bergman, K.E. & Mc. Laughlin, T.F. Remediatinghandwriting difficulties with learning disabled students: areview. Journal of Special Education, 1988; 12, 101 – 120.

8. Benbow, M. Principles and Practices of teachinghandwriting. In A. Henderson & C. Pehoski (Eds.). Handfunctions in the child : Foundations for remediation. Chapter14. St. Louis, MO: Mosby – Year Book, Inc. 1995.

9. Barbe, W.B., Milone, M.J., & Wasylyk, T. Manuscript is thewrite start Academic Therapy, 1983; 18, 397 – 405.

10. Graham,S. & Miller, L. Handwriting research and practice:a unified approach. Focus on Exceptional Children, 1980;13, 1 – 16.

11. Hagin, R.A. Write right – left: a practical approach tohandwriting.Journal of Learning Disabilities, 1983; 15, 266– 271.

12. Rosenblum, S., Parush, S., & Weiss, P.L. Computerizedtemporal handwriting characteristics of proficient and non– proficient handwriters. American Journal of OccupationalTherapy, 2003; 57.

13. Preminger, F., Weiss, P.L., & Weintraub, N. PredictingOccupationalperformance: Handwriting versuskeyboarding. American Journal of Occupational Therapy,2004; (58).

14. Cerkak, S. Somatosensory dyspraxia. In A. Fisher, E.A.Murray & A.C Bundy (Eds). Sensory Integration: Theoryand Practice (pp. 138 – 170). Philadelphia: F. A Davis,1991.

15. Oliver, C.E. A sensorimotor program for improving writingreadiness skills in elementary- age children. AmericanJournal of Occupational Therapy,1990; 44, 111 – 124.

16. Addis, B. Handwriting legibility and speed ranges amongfirst graders. Unpublished master’s thesis, TempleUniversity, Philadelphia, 1999.


178

17. Chan, P.W. Comparison of visual motor development inHong Kong and the USA assessed on the qualitative scoringsystem for the modified Bender Gestalt test. Psychol Rep,2001; 88(1), 236 – 40.

18. Dennis, J. L., & Swinth, Y.Pencil grasp and children’shandwriting legibility during different-length writing tasks.American Journal of Occupational Therapy, 2001;55, 175-183.

19. Jackson, AD. A comparison of speed and legibility ofmanuscript and cursive handwriting of intermediate gradepupils. Thesis/Dissertation: Manuscript Archival materia,1970.

20. Ziviani, J.Qualitative changes in dynamic tripod gripsbetween 7 and 14 years of age. Developmental Medicineand Child Neurology, 1983; 25, 778- 782.

21. Tseng, Mei Hui, & Murray, Elizabeth A.Differences inperceptual-motor measures in children with good and poorhandwriting. Occupational Therapy Journal of Research,1994;14(1), 19-36.

22. Sovik, N. Developmental cybernetics of handwriting andgraphic behaviour. Boston: Universities for laget, 1975.

23. Tseng, M. H., & Hsueh, I. P. Performance of school childrenon a Chinese handwriting speed test. Occupational Therapyjournal of research, 1997; 4, 294 – 303.


179Gurpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Effect of Passive Straight Leg Raise Sciatic Nerve Mobilizationon Low Back Pain of Neurogenic OriginGurpreet Kaur*, Shallu Sharma***MPT- Musculoskeletal (candidate), **Research Guide, MPT (Orthopaedics and Manual therapy), Lecturer, ISIC Institute of Healthand Rehabilitation Sciences, New Delhi

Abstract

Neural mobilization has emerged as a significant adjunctto assessment and treatment of neurogenic pain syndromes.However, clinical trials utilizing Passive Straight Leg Raise(PSLR) neural mobilization for low back pain treatment arelacking. The present study aimed to study and compare theeffectiveness of neural mobilization and conventional therapyin patients with neurogenic low back pain.


A sample of 27 patients, aged 18-45 years, with sub-acuteneurogenic LBP were randomized into Experimental (n=12) andConventional group (n=15) respectively. The experimental groupunderwent PSLR neural mobilization while the conventionalgroup therapy included Patient Education in form of advice andexercise for treatment duration of 10 sessions in 2 weeks. Theoutcome variables assessed include: pain (VAS), hip flexionROM (inclinometer), symptom distribution (Werneke’s OverlayTemplate) and disability (Modified Oswestry Disability Index).

Results

Within group analysis using Wilcoxin Signed Ranks testrevealed significant improvement (pd”0.05) in both groups forall variables. Between groups comparison was done using MannWhitney U-Test. The results demonstrated that statisticallysignificant improvement occurred in both groups; however theimprovement was greater in experimental group than theconventional group for all the studied variables.

Discussion and Conclusion

PSLR neural mobilization is more effective thanconventional therapy for improving pain and disability in patientswith neurogenic pain syndrome. However the benefits ofconventional therapy cannot be neglected. Therefore both thesetreatment modalities should be integrated in the managementof patients with neurogenic low back pain syndrome.

Key Words

Neural mobilization, Straight leg raise, Low back pain.

Introduction

Low back pain related leg pain or sciatica1 is found to bepresent in 57% of patients suffering from low back pain2,3. Legpain associated with low back pain can arise from disorders ofneural or musculoskeletal structures of the lumbar spine 4,5,6. Inrelation to neural structures, pain in sciatic nerve distribution isthe commonest variation of neurogenic LBP recognized inclinical practice4. Neurogenic LBP in the distribution of sciaticnerve has been characterized clinically by abnormal tension inthe nerve and its nerve roots leading to symptoms production7.

In neurogenic LBP, the dominant feature is that of increasedneural tissue mechanosensitivity which suggestive of alteredneurodynamics; which can be assessed using neurodynamictests8,9. Selective mobilization of the neural tissue has recently

emerged as an adjunct to assessment and treatment ofneurogenic pain syndromes9. Straight leg raise neurodynamictest produces movement and tension in lumbosacral nerve rootsand can be used to mobilize the sciatic nerve continuumspecifically10. Releasing pressure or tension in nerve improvesits physiology and clinically correlates with reduced irritation ofnerve structure providing pain relief and reduced disability13.Preliminary evidence for straight leg raise neural mobilizationhas shown to improve lumbar flexion and extension ROM inboth acute and chronic low back pain8. It has also been usedsuccessfully in case studies or single subject design studiesdescribing patients with signs and symptoms of increased neuraltissue mechanosensitivity in combination with lumbar and lowerextremity symptoms15,23. In contrast a randomized controlled trialhas clearly demonstrated that it does not provide any additionalbenefit to standard post operative care, in patients after lumbarsurgery14. Hence, an effort to conduct high quality randomizedclinical trials is justified to accumulate evidence for the effect ofstraight leg raise sciatic nerve mobilization in treatment ofneurogenic low back pain. Due to lack of scientific evidencereporting benefits of neural mobilization, conservative treatmentoptions like analgesics, bed rest, spinal manipulation and electro-therapeutic modalities are still being used for treatment ofneurogenic LBP16. However, the scientific evidence regardingefficacy of each of these interventions is limited or providesconflicting results. Li and Bombardier et al in a survey ofCanadian physical therapists found that 80% to 99% of thetherapists preferred a combination of patient education andexercise for a patient with acute low back pain and sciatica18,19.With an intention to treat, the conventional therapy group (actingas a control in the current study) was designed in accordancewith the available evidence; as an ideal control would haveethically devoid the patients from receiving any treatment. Thus,the aims and objectives of the study were to study and comparethe effectiveness of neural mobilization and conventional therapyin patients with neurogenic low back pain.

Methods

Twenty seven patients aged between 18-45 years, with ahistory of mild to moderate pain (VASd”6) and disability (ModifiedOswestry Disability Index score d” 40%) presenting in sub-acute(2 to 12 weeks) phase of neurogenic low back pain participatedin the study. For the study neurogenic low back pain has beendefined as the pain in lower lumbar region with or withoutradiation to lower limb (buttocks or posterior thigh or calf); painand paraesthesia being referred to sciatic nerve distribution;without any neurological deficits (altered/absent reflexes,reduced muscle strength, and loss of sensations). To beincluded, the patients should report a positive Straight Leg Raiseneurodynamic test, with dorsiflexion acting as a sensitizingmaneuver. Patients with a history of any trauma or surgery tospine, hip, knee and ankle or any potential red flags associatedwith low back pain were excluded.

Starting position for PSLR neurodynamictesting in both groups

The patient lies supine, with head, trunk and hips in neutral.This inclinometer was strapped in place, aligned 10 cm proximal

180

to lateral femoral condyle on a hypothetical line joining thefemoral condyle and greater trochanter.(Figure1)

Experimental Group

PSLR Testing

For the patient’s left symptomatic leg the investigatingtherapist stood next to patient’s left limb in a stride standingposition. The leg to be examined was fixed into knee extensionby examiner’s hand right hand placed on thigh proximal to kneejoint. The leg was lifted (with hip flexed and knee extended) inneutral rotation and hip flexion was progressed until the rangeat which the patient first reports his/her symptoms (P1 response).An independent observer took a note of this angle. At this P1range of motion, the examiner passively dorsiflexes the ankleto determine any aggravation in patient’s symptoms. This wasthe baseline hip flexion ROM during neurodynamic testing andwas recorded before and after each treatment session for tensessions.

PSLR Mobilization

For mobilization of the sciatic nerve, the examiner loweredthe hip flexion angle, below the P1 range for 5-10 degrees tillthe symptoms disappeared, which was noted by an independentobserved. The ankle joint was then taken passively intodorsiflexion and plantar flexion alternately within the availableas the maneuver to mobilize the sciatic nerve tract. Thisoscillatory technique of nerve mobilization was done in 3 sets of10 repetitions each with a gap of 10 seconds between each set.At the end of session, the examiner again performed the PSLRtest after a gap of 5 minutes, to ascertain any change in therange at which P1 was reported. This hip flexion ROM was usedto identify and calculate the difference in pre-test and post-testvalues at the end of each treatment session for this group. Atotal of 10 treatment sessions were given in 2 weeks. Pain, ROMand Symptom distribution were assessed before and after eachtreatment session for all 10 sessions. Modified OswestryDisability Index was assessed before starting with treatmentprotocol and after finishing treatment protocol.

Conventional Group

Patients recruited in this group, were explained about theircondition and were asked to perform a set of exercises andfollow advice on good posture for duration of two weeks. Theadvice consisted of maintenance of correct posture duringactivities of daily living, ergonomic advice, how to lift heavy weightcorrectly, along with some specific back exercises and mostimportantly the patient was advised to stay as active as possibleas per their pain tolerance. The exercises (Pelvic tilting exercise,Back extension exercise and Cat and Camel excises) weredemonstrated on a model and the patients were asked toreplicate them during the teaching session (Figure 3 to 6). After

teaching the exercises on day of initial evaluation, PSLR testingwas done to record baseline hip flexion ROM for the patients inthis group. Due to the nature of intervention (self help strategy)given in this group, it was not feasible to call the patients everydayfor outcome measure assessment. Therefore all the dependentvariables (VAS, Hip Flexion ROM, SD, and MODI) wereassessed on the first and the last day of treatment protocol.

Data Analysis

Gurpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Fig.1: Showing Starting Position for Both groups

Fig. 4: Showing Back Extension Exercise

Fig. 3: Showing Pelvic Tilting Exercise

Fig. 2: Showing PSLR Sciatic Nerve Mobilization

181

The data was analyzed using SPSS (version 17) software.Due to the nature of the outcome measures, non-parametricstatistical tests were used. The descriptive statistics (Medianvalues) were computed for all the variables in both groups. Forwithin group comparison and between groups comparison ofpain (VAS), ROM (Hip Flexion) and disability (Modified OswestryDisability Index) Wilcoxon Signed Ranked Test and MannWhitney U-Test were used respectively. The difference betweenpre and post intervention measurement of SymptomDistribution29 (SD) and between groups comparison was doneusing Chi square statistics. The level of significance was fixedat p d” 0.05 for data analysis.

Results

A comparison of pre-intervention data points of dependentvariables (VAS, Hip ROM, SD and MODI) in both groups,demonstrated homogeneity of variables at the baseline. (Table1).From the results of within group analysis, it can be inferred thatthere was significant improvement (p d”0.05) in all the studyvariables (VAS, Hip ROM, and MODI) from pre-intervention(session1) till post intervention (session10) in both groupsrespectively (Table2). Between groups analysis of all thevariables demonstrated a significant post-intervention difference(p d”0.05) in patient reported VAS scores, hip flexion ROM anddisability scores. A comparison of median value of the variablesdemonstrated greater improvement in the experimental groupas compared to the conventional group (Table1). A statisticallysignificant reduction in the area of reported symptoms (observedfrom overlay body template) following the neural mobilizationwas observed within the experimental group but not inconventional group. Secondary analysis of the area of symptomdistribution (using UTHSCA image tool) in both groups,

demonstrated that the area reduced by 50.3% and 25.1% in theexperimental and conventional groups respectively.

Discussion

The statistically significant improvement in pain scores, hipflexion ROM and disability within the conventional group can beattributed to the intervention, which included patient educationregarding posture and exercise. Previous studies havedocumented that patient education comprising of neuro-physiological mechanisms have been effective in reducing thereactivity of pain neuromatrix20. This change of mal-adaptivepain behaviors lead to a reduction in subjective VAS scores(10mm) as well as subsequent increase in hip ROM seen (6degrees) within the conventional group, in the current study20,21.The conventional group exhibited lesser gain in ROM whencompared to experimental group. This could possibly be theresult of specific and directive intervention in accordance withinclusion of subcategory of neurogenic pain in the experimentalgroup. The patients of the present study represented sub-acutestage with symptom predominance proportional to the pathologyof neurogenic LBP. This could have resulted in patients notcomplying with therapeutic exercise because of pain persistence.The acute benefits of advice and exercise seen over thetreatment duration were not followed up after the completion ofstudy protocol. It needs to be seen whether this type ofintervention has any different response when given over a longerduration of time as documented in neck painliterature22.Therefore long term research into the benefits ofpostural advice and exercise should be undertaken to makeany definitive conclusion regarding this intervention inmanagement of neurogenic LBP patients. The results of thestudy support the hypothesis that SLR sciatic nerve mobilizationhas acute benefits when given for duration of ten days, in earlymanagement of neurogenic LBP. In the experimental group astatistically and clinically significant reduction in pain scores (30mm) was reported (Table1, 2). For VAS to show clinicallysensitive changes in LBP it needs to have 10-28 mm decreasein scores23. In accordance with these findings the present studyreported 30 mm decrease, thus reiterating the use of VAS in thecurrent study. Pain reduction in the experimental group can beattributed to inhibition of temporal summation mediated with C-fibers 24, as well as reduced mechanosensitivity of the neuraltissue8,9. In this group, only a few patients reported absolutezero on VAS at the end of 10 days, while rest of the patientsreported some form of residual pain even after completion ofstudy protocol. Therefore the adequacy of 8-10 sessions oftreatment cannot be affirmed. Hence it is proposed that afterpain reduction to minimal scores on VAS scores, a modificationof the treatment technique is pertinent to reduce residual painreported in this group. An improvement of 16.5 degrees afterneural mobilization is suggestive of concordance in the resultsof current study with previous literature22. This increase in ROMin this group can be attributed to the direct elongation of thenerve bed as well as mechanical interface (Hamstrings)secondary to the nerve mobilization technique used. Themobilization technique used in the current study was bettertolerated by the patient as done below P1 range, compared toneural tensioning maneuver which is used at end range ofavailable motion to mobilize the nerve. Reduction in patientreported area of symptom distribution was two times greater inexperimental group as compared to conventional group whichcan also be attributed to decreased neural tissue sensitivity tomovement26. The experimental group reported both statisticallyand clinically significant post-intervention scores of ModifiedOswestry Disability Index (6.4 points), whereas the conventionalgroup reported a decrease of only 2 points which was found tobe clinically insignificant. This emphasizes the fact that thestatistically and clinically significant changes of VAS and ROMhad successfully reflected in greater improvement of MODI in


Fig. 6: Figure showing Camel position of exercise

Fig. 5: Showing Cat Position in the Exercise

182

the experimental group as a result of improved nerve mobilityand physiology leading to subsequent improvement in functionalstatus of the patient.

The results of this technique cannot be compared to slumpstretching utilized in previous studies for LBP treatment as it isnon-specific technique which was used in a variety of non-homogenous diverse population28. The use of slump techniqueis questionable as it elongates and produces tension in the entireneuro-meningeal tract, which might exacerbate the symptomsof patients in a more irritable state8,9,28. In contrast the PSLR

Table 1: Comparison of Variables at Baseline and Post-Intervention in Experimental and Conventional groups using Mann WhitneyU-Test and Chi Square Statistics.

* denotes that the Z-value or χ2 value is significant at p d” 0.05NS: denotes that the Z-value or χ2 value is non significant at pd” 0.05PrVAS1: Pre-intervention VAS score on Day1PrHIP1: Pre-intervention passive Hip Flexion Range of Motionon Day1PrMODI1: Pre-intervention Modified Oswestry Disability Indexscore on Day1PrSD1: Pre-intervention Symptom Distribution score on Day1PoVAS10: Post-intervention VAS score on Day10PoHIP10: Post-intervention passive Hip Flexion Range ofMotion on Day10PoMODI10: Post-intervention Modified Oswestry Disability Index

Variable Experimental group Conventional group Respective Significance (Median) (Median) Level

Number of subjects 12 156 Males 6 Females 8 Males 7 Females

Age 35 years 29 years Z= -0.88NS

PrVAS1 5 5 Z= -0.34NS

PrHIP1 52.5 57 Z= -1.08NS

PrMODI1 19.5 20 Z= -0.71NS

PrSD1 3.5 2 χ2 = 7.78NS

PoVAS10 2 4 Z= -3.13*PoHIP10 74.5 60 Z= -3.16*PoMODI10 11 19 Z= -3.67*PoSD10 2 2 χ2 = 9.30*TdfVAS -2.6 -1.0 Z= -4.94 *TdfHIP -16.5 -6.0 Z= -5.01*TdfMODI -6 -2 Z= -5.02*TdfSD -1.5 0 χ2 = 2.74*

score on Day10PoSD10: Post-intervention Symptom Distribution score onDay10TdfVAS: Difference between pre-intervention (day1) and post-intervention (day10) median values of VAS.TdfHIP: Difference between pre-intervention (day1) and post-intervention (day10) median values of Hip flexion ROM.TdfMODI: Difference between pre-intervention (day1) and post-intervention (day10) median values of Modified OswestryDisability Index.TdfSD: Difference between pre-intervention (day1) and post-intervention (day10) of median values of Symptom Distributionscores

Table 2: Pre-Intervention (Day1) and Post-Intervention (Day 10) Comparison of Variables within Experimental and Conventionalgroups respectively using Wilcoxon Signed Ranks Test

*denotes that the Z-value or χ2 value is significant at p d” 0.05NS: denotes that the Z-value or χ2 value is non significant at p d” 0.05

Group Variable Pre-intervention Post-intervention Respective(Day1) (Day10) Significance(Median) (Median) Level

Experimental VAS 5.00 2.00 Z= -3.06*

Hip Flexion ROM 52.5 74.5 Z= -3.06*

MODI 19.5 10 Z= -3.06*

SD 3.5 2 χ2= 7.80*

Conventional VAS 5.00 4.00 Z= -3.31*

Hip Flexion ROM 57 60 Z= -3.20*

MODI 20 19 Z= -2.07*

SD 2 2 χ2=24.41NS

technique is biased towards sciatic nerve continuum which canselectively mobilize the nerve without producing excessivetension in the other part of the nervous system and is bettercontrolled by the therapist. Performance of straight leg raiseneurodynamic test to the first onset of symptoms (P1 response)is a highly reliable method (ICC= 0.78- 0.96) on same day aswell as repeated testing in subsequent sessions27. This allowsfor identification of meaningful differences in tests outcomesthrough use of sensitizing maneuvers and can be used in moreirritable condition, as opposed to resistance (R1 response)


183

measurement which is dependent on therapist perception andis difficult to quantify. The oscillatory technique of neuralmobilization used in this study slowly engages the resistance ofthe movement, associated with protective muscle guardingresulting in decreased symptoms experienced by the subjectsafter the treatment.

A subsequent randomized allocation secondary toscreening strengthen the internal validity of the study suggestingthat neural mobilization is more effective in management ofpatients with Neurogenic LBP as opposed to patient educationand exercise. However, based on a small sample size it is difficultto generalize the findings to a large sample population ofneurogenic LBP. Moreover convenience sampling done in thestudy reduces the external validity of the findings. Complianceof the patients in the conventional group was taken at face value,thus resulting in reduced reported benefits.

Clinical Significance

Passive SLR neural mobilization has shown acute benefitson patient reported pain, hip flexion ROM, symptom distributionand disability associated with neurogenic LBP as it specificallytargets the sciatic nerve continuum. Moreover it is a safe andeffective technique to mobilize the sciatic nerve selectively.However the benefits of the postural advice and exercise cannotbe undermined and are recommended to be used as an adjunctin management of neurogenic LBP.

Future Research

Neural mobilization is a relatively new concept of manualtherapy and its applications in treatment of neurogenic painsyndromes especially low back pain should be explored furtherwith more double blinded, randomized controlled studies toreduce the confounding effects of patient and therapist bias.Clinical studies with adequate follow up (6 months to 1 year)should be undertaken to assess the carry over effects of thesetechniques.

Conclusion

The study is concluded by supporting acute treatmentbenefits of PSLR neural mobilization for improving pain, hipflexion ROM, decreasing symptom distribution and reducingdisability compared to the conventional group. However the effectof the patient education handout containing postural advice,ergonomic advice along with exercise cannot be neglected.Therefore both these measures can be integrated to achieve amore beneficial and positive effect on symptoms of patients withneurogenic low back pain.

Acknowledgement

I wish to thank my research guide Ms Shallu Sharma, forher guidance, precious time, and contributions made during thecourse of the study. I must also convey my sincere thanks toMs. Chitra Kataria, Principal, ISIC Institute of Health andRehabilitation Sciences, New Delhi, for making it possible forme to conduct this work in the institution.

Contact Information

Gurpreet Kaur, MPT-Musculoskeletal (candidate), IndianSpinal Injuries Center, New Delhi, India. Email:[email protected].

References

1. John C. Licciardone. The epidemiology and medicalmanagement of low back pain during ambulatory medicalcare visits in the United States. Osteopathic Medicine andPrimary Care, 2008, volume 2, number 11:1-17

2. Peter M Kent et al. Review-The epidemiology of low backcare in primary care. Chiropractic and Osteopathy, 2005,volume 13:1-7

3. Jeremy Walsh. Agreement and correlation between straightleg raise and slump test in subjects with leg pain. Journalof Manipulative and Physiological Therapeutics, volume 32,number 3:184-192

4. Axel Schafer, Toby Hall, Kathy Briffa et al. Classification oflow back-related leg pain: A proposed patho-mechanism-based approach. Manual Therapy, April 2009, volume 14,Issue 2 : 222-230

5. Kate M Dunn. Sciatica. Review of Epidemiological studiesand prevalence estimates. Spine 2008,volume 33, number22: 2464-2472

6. Grieves Modern Manual Therapy, the Vertebral Column,third edition. Edited by Jefferey D Boyling, GA Jull, 2004.

7. Gary L.K. Shum et al. Movement Coordination of lumbarspine and hip during a picking up activity in low back painsubjects. European Spine Journal, 2007 volume16:749-758

8. David S.Butler. Mobilization of the Nervous System.Churchill Livingstone, reprinted 1996. ISBN 0- 443- 04400-7

9. Michael Shacklock. Book on “Clinical Neurodynamics”Elseviers, 2001.

10. Breig et al. Biomechanical considerations in straight legraise test. Spine, 1979, volume 4, number 3:242-250

11. Smith SA et al. Straight leg Raising: anatomical effects onthe spinal nerve root without and with spinal fusion. Spine,1993, volume 18:992-999

12. Kobayashi S. Changes in nerve root motion and intra-radicular blood flow during intra-operative straight leg raisingtest. Spine, 2003, volume 28:1427-34

13. Richard F. Ellis et al. Neural Mobilization: A systemic reviewof Randomized Clinical Trials with an Analysis ofTherapeutic Efficacy. Journal of Manual and ManipulativeTherapy, 2008, volume 16, number 1:8-22

14. Sally V. Scrimshaw et al. Randomized Controlled Trial ofNeural Mobilization after Spinal Surgery. Spine, 2001,volume 26, number 24:2647-2652

15. Mc Cracking. Burns SA. AAOMPT conference, 2008.Journal of Manual and Manipulative Therapy, 2008, volume16, number 3, 161-181

16. Dianne V Jewell, Daniel L Riddle et al. Interventions thatincrease or decrease the likelihood of a meaningfulimprovement in physical health in patients with sciatica.Physical Therapy. vol 85, no11. November 2005 1139-1150

17. Hall and Elvey et al. Nerve Trunk pain: Physical Diagnosisand treatment , Manual therapy, 1999, volume 4:63-73

18. Li LC, Bombardier C. Physical therapy management of lowback pain: an exploratory survey of therapist approaches.Phys Ther. 2001; 81:1018–1028

19. Van Tulder MW, Malmivaara A, Esmail R, Koes BW.Exercise Therapy for Low Back Pain (Cochrane Review)[Update software]. Oxford, United Kingdom: The CochraneLibrary; 2004:1

20. David J Butler eta l. Management of peripheral neuropathicpain: integrating neurobiology, neurodynamics, and clinicalevidence. Physical therapy in Sport, 2006, vol 7:36-49

21. John Albright et al. Philadelphia Panel Evidence basedclinical guidelines on selected rehabilitation intervention forlow back pain. Physical Therapy, 2001,volume 81, number10:1641-1674

22. Haines T, Gross A, Burnie SJ, Goldsmith CH, Perry L et al.Patient education for neck pain with or without radiculopathy


184

(Review). The Cochrane Library 2010, Issue 3. http://www.thecochranelibrary.com

23. Joshua Cleland et al. Effectiveness of Neural Mobilizationin the Treatment of a Patient with Lower ExtremityNeurogenic Pain: A Single-Case Design. The Journal ofManual & Manipulative Therapy, Vol. 12 No. 3 (2004), 143-152.

24. Beneciuk JM, Bishop MD, George SZ. Effects of UpperExtremity Neural Mobilization on Thermal Pain Sensitivity:A Sham Controlled Study in Asymptomatic Participants. JOrthop Sports Phys Ther. 2009; 39(6): 428-438. PMID:19487826

25. Benjamin Boyd et al. Structure and Biomechanics ofperipheral nerves: nerve responses to physical stress and

implication for physical therapist practice. Physical therapy,vol 86, no. 1. 2006

26. Fritz JM et al. a comparison of modified Oswestry low backdisability questionnaire and quebac back pain disabilityscale. Physical therapy 2001, vol81, 776-88

27. Benjamin Boyd. Mechanosensitivity of the lower extremitynervous system during straight leg raise neurodynamictesting in healthy individuals. JOSPT vol39, no11.

28. Joshua A. Cleland et al. Slump stretching in themanagement of non-radicular low back pain: a pilot study.Manual Therapy, 2006, volume 11:279-286

29. Mark Werneke et al. A descriptive study of the centralizationphenomenon. Spine vol 24, no7, pg 676-683.


185Hamdani N / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Fatigue and its Correlation with Functional Outcome in Patientswith StrokeHamdani N*, Dhawan L**, Maurya M***.*Asst. Professor Neurophysiotherapy Jamia Hamdard New Delhi, **Consultant Physiotherapist Amar Jyoti College of Physiotherapy,***Incharge Physiotherapy, Jamia Hamdard, Dept. of Allied Health Sciences, New Delhi-110 062

Abstract

Fatigue is a common complaint in neurological diseases.Yet, few studies have been done to asses fatigue in patientspost stroke particularly during the acute stages of recovery. Also,whether the fatigue affects the functional outcome during theacute stages of recovery is not known. The purpose of the studywas to know the prevalence of fatigue and it’s correlation withthe functional outcome during the acute stage of recovery inpatients with stroke. Method: a random sample of 30 patients(mean age=49.76,standard deviation=10.40) with stroke wastaken .The subjects were either ‘in’ or ‘out’ patients at the” AllIndia Institute of Medical Sciences “and “G.B.Pant Hospital”,New Delhi, India. After a detailed neurological assessment andconfirming the diagnosis by CT/MRI only those patients withMMSE>27 were taken.Results: A correlation analysis was doneand pearson’s correlation ‘r’ value was calculated. Also,association between the variables was seen using chi-squaretests. A principle component factor analysis method using‘Varimax’ method was done for the items (1-10) on the BNI scale.BNI overall index was found to significantly correlate with BNItotal score, functional outcome measures (i.e Barthel’s indexand MAS). No correlation was found between BNI total score andthe functional outcome measures. However, a strong associationwas found between both BNI scale categories and Barthel’scategories. Factor analysis revealed two-factor solution .Theinternal consistency of the BNI scale was found to be high.

Conclusion

Post stroke fatigue is multidimensional and might affectthe functional outcome as is shown by its strong associationwith the latter, during the acute stages of recovery.

Key Words

Fatigue, Stroke, Functional outcomeFatigue is a common complaint in clinical practice1.

Fatigue after Stroke

Fatigue is often one of the first signs of early brain diseaseand is usually a pronounced problem immediately following theacute stages of sudden onset brain conditions such as traumaor CVA. In progressive conditions the patient increasingly tiresmore easily as once automatic activities and functions begin tobreak down and require more and more concentrated effort fortheir performance4. Fatigue is particularly evident during the earlystages of recovery from brain injury and has been shown tohave serious functional and emotional consequences5 .Although,there is a trend towards improvement in fatigue over time, andseveral studies have documented its presence for up to 6 yearsat long term follow-up 6. While fatigue is often clinically observedin brain injured patients during the acute stages of learning,there is dearth of studies on this topic 5.

In our experience, stroke patients frequently complain aboutfatigue, and therapists often report that sessions of therapy arelimited by fatigue.

The relevance of fatigue to poststroke rehabilitation andrecovery of function has not yet been examined. Fatigue poses

one of the greatest barriers to rehabilitation and has negativeimpact on quality of life 7.

Hypothesis

Fatigue exists in patients following stroke and might affectthe functional outcome measure, during the acute stages ofrecovery.

Operational Definitions

Fatigue

Defined as a reversible decrease or loss of abilitiesassociated with a heightened sensation of physical or mentalstrain, an overwhelming feeling of exhaustion, which leads toinability or difficulty to sustain even routine activities 3

Functional outcome: measures performance in activitiesof daily living (ADL) using a weighted scale (Barthels index)

Acute stage of recovery: within three months of onset offirst ever stroke.


The study cannot be generalized because of small samplegroup, individual variances within the group and individualdifferences related to territory of involvement.


Fatigue is a common complaint after stroke 1,3,9.Usinginterviews or mailed questionnaires in recent studies10-13

examined fatigue as an independent phenomenon and foundthat the frequency of occurrence can range from 30% to 68% ofstroke survivors.

Severity and Functional Implications

Little is known about the fatigue severity and the overallimpact that it has on poststroke recovery and return to activitiesof daily living (ADLs).Interestingly, stroke survivors with lesssevere physical or cognitive disability after stroke tend to ratefatigue as a more severe symptom. 10, 3, 15

Method

A minimum of 30 post stroke subjects were included in thestudy.

Inclusion criteria: Patients with acute stroke that had beenadmitted to the hospital or discharged and coming to therehabilitation department as “outpatients”.

Patients were identified according to the following criteria:- they had a cerebral infarct (confirmed by computed

tomography [CT]/ magnetic resonance imaging [MRI] orinferred from the clinical picture when CT scan was negative

- they were able to participate in daily treatments includingtherapies and meetings.

- they had a Mini Mental Scale examination score [MMSES]

186

of 27/30 (8).

Exclusion criteria

Patients were excluded from the sample if:- they had suffered another stroke or major medical illnesses

since the time of their initial admission to the hospital.- they had another neurological disease or systemic illness.- they had decreased levels of consciousness, dysphasia or

severe cognitive impairment (or MMSS<27), such that theywere unable to answer questions or complete the fatiguequestionnaire.

- Patients taking antidepressants or antipsychoticmedications.

- sub-arachnoid hemorrhage (SAH) not included becauseof their different etiology and course.

Design

Non-experimental,co relational design.

Instrumentation

Fatigue score: measured by the BNI fatigue scale.5

Barthels index 17

Motor assessment scale (MAS):Designed by Carr and Shephard18, 19.The MAS consists of

8 items representing the areas of motor behavior. Each item isscored on a 7-point (range 0-6) hierarchical scale. 20,21

MMSE 1,8,16

Location: jamia hamdard new delhi

Protocol for Data collection

Participants – data was collected by myself and an informedconsent form was signed by the patient.

Instructions to the patients:The patients were informed about the study and explained

about the questionnaire when needed.Time consumed: 1 year Procedure:-first the selected subjects were briefed about

the study , then were made to sign the informed consent form,then a detailed history and assessment using the Motorassessment scale was taken and finally the patients were giventhe BNI fatigue scale questionnaire. For those patients who werenot able to write with their hand due to affected hand functionfollowing stroke ,the scores were written by myself as told tome by these patients & then the scores were assigned for eachitem of ADL given in the Barthels index, on the basis ofperformance and information from spouse/caretakers.

Results

The mean and standard deviation’s of the BNI score , BNIoverall score , Barthel’s Index, MAS scale and Age are givenin the table 1a.

A correlation analysis was done between BNI total score(i.e, total score of items 1 -10) (Mean=27.50, SD=15.53) , BNIoverall score (item 11) (Mean= 4.76,SD=2.23), Barthel’s indexscore (Mean=69.73,SD=25.18), MASscore(Mean=32.16,SD=9.85) and Age (Mean=49.76,SD=10.40),pearson correlation was calculated for each .( table 1b)

It was found that BNI total score showed highly significantcorrelation with BNI overall score (r = 0.795, p<0.01),

Highly significant correlation was found between BNIoverall and Barthel’s index score ( r = -0.512, p =.000).

Also a highly significant correlation was found betweenBNI overall score and MAS score ( r = -0.473, p<0.01).

No correlation was found between BNI total score andBarthel’s score (r = -0.337,ns).and MAS score ( r = -0.179, ns).

Barthel’s index score and MAS score showed highlysignificant correlation. (r = 0.727, p< .000) Scatter plot’s 2ashow the correlation pattern of variable’s :

On further analysis by taking a cut off score for fatigueproblem on the BNI scale as 28 (mean score), patients weredivided into two categories as BNISCAT-1 and BNISCAT-2.

BNISCAT-1: patients scoring below28 (no problem) to(occasional problem) with fatigue BNISCAT-2: patients scoringabove 28 (frequent problem) to (most of the time problem) withfatigue.

Similarly, with the Barthel’s index (which measures the levelof dependence in activities of daily living) taking a cut off scoreof 60 (21 ), patients were divided into two categories as BARCAT-1 and BARCAT-2.

BARCAT-1: patient’s with scores below 60 (totally toseverely dependent),

Hamdani N / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

187

BARCAT-2: patient’s with scores above 60- (moderate tominimally dependent).

After analysis 21 patients came under BNICAT1 and 9patients came under BNICAT2. Also , 3 patient’s came underBARCAT1 and 27 came under BARCAT2.

The finding’s were significant (p= 0.03) by Fisher’s exacttest.

Out of a total sample of 30 patient’s 74.1% were found tobe under BARCAT2 and BNISCAT1. This means 74.1% ofpatients with score above 60 on the Barthel’s scale had scoresbelow 28 on the BNI total score. i.e. patients who were moderateto minimally dependent on the ADL’s had none to occasionalproblem with fatigue.

Also, 30% of patients came under the BARCAT1 andBNISCAT2.This means 30% of patients with scores below 60on the Barthel’s scale had score’s above 30 on the BNI totalscore. i.e. patients who were totally to severely dependent onADL’s had frequent to most of the time problem with fatigue.

To explore further BNI overall score (item11) was also givena cut off score of 5 (mean score) for rating fatigue problem asless problem to more problem. The two categories are:

BNIOCAT-1: patient’s scoring below 5 (less problem).BNIOCAT-2: patient’s scoring above 5 (more problem)It’s association with the Barthel’s score categories

(BARCAT-1 and BARCAT-2) was found significant by Fisher’sexact test. (p = 0.03) .74.1% of patients (n=30) came underBARCAT-2 and BNIOCAT-1, and 30% of patients (n=30) cameunder BARCAT-1 and BNIOCAT-2.This means 74.1% of patientswho were moderately to minimally dependent had less problemof fatigue and 30% of patient’s were totally to severely dependenthad more problem with fatigue.

The association between BNISCAT-1, BNISCAT-2 andBNIOCAT-1, BNIOCAT-2 was also found to be significant byFisher’s exact test (p=0.005).

The results showed 85% sensitivity and 70% specificity ofthe BNI scale.

An inter item Pearson’s correlation was calculated and thefinding’s were highly significant. (p < 0.01).

To know the pattern of relationship between the item’s, theitems were subjected to KMO and Bartlets test .The finding’swere significant (p <0.01).On this basis the item’s were subjectedto factor analysis to find the most important variable’s.

Factor analysis attempts to identify underlying variables,or factors, that explain the pattern of correlations within a set ofobserved variables.

The factor analysis was done by Principal componentextraction method. The result yielded two factors .The solutionwas rotated using varimax rotation so that interpretation wouldbe easier. The factors had an eigenvalue of 6.34, whichaccounted for 63.4% of variance.

The two factors yielded after rotation grouped the itemsaccording to their pattern of significant correlation with each otheras shown in the factor’s plot graph’s below. Items 10, 6, 8, 5, 9,1 were found to be highly correlated under factor 1, and items 2,3, 4, 7 were highly correlated under factor 2 (p < 0.01). (Seeplot)

The Rotated component matrix table below show’s thehighest correlation value for item 10 under factor 1 and item 2under factor 2.

This means item 10 and 2 are most important variablesamong item 1-10 and account for most of the variance shown.

Each of the items 1-10 were also found to be highlycorrelated with item 11

(p< 0.01).

Reliability

Since factor analysis yielded 2 factors internal consistency(Cronbach coefficient alpha) was calculated for each.


188

The reliability of factor 1 Alpha = 0 .8785.The reliability of factor 2 Alpha = 0 .7950.

Discussion

Results of this study document the factor structure andinternal consistency of the BNI fatigue scale and its correlationwith functional outcome of a sample of stroke patients duringacute neurorehabilitation.

All 10 of the items loaded on two factors. The loadingswere robust and accounted for a relatively large percentage ofvariance. Thus, these findings suggest that the 10 items appearto represent the difficulty in lasting the day without taking a nap(item 10) and difficulty to participate in activities because offatigue (item 2), which reflects a patient’s endurance level.

Thus, it can be interpreted from the above findings that theBNI scores obtained for the sample of patients actually revealedtheir endurance problems effecting their ability to participate inactivities because of fatigue, which necessitates the rest timethey need via a nap, any time of the day when they feel fatigued.

This finding supports our operational definition, whichdefined fatigue as “a reversible decrease or loss of abilitiesassociated with heightened sensation of physical or mentalstrain, an overwhelming feeling of exhaustion, which leads toinability or difficulty to sustain even routine activities”.( It canfurther be interpreted or verbally expressed as a loss of drive.)

On rotating the solution after principal component factoranalysis method, it was found that the factor 1 correlated highlywith items 10,6,8,5,9, 1 in the decreasing order. (See table). Ona closer look at the BNI scale it is found that all these items askfor the difficulty faced with- lasting the day without taking a nap(item 10), energy level in the morning (item 6), stay alert duringactivities (item 5) and when not involved in something (item 8),attend to something without feeling sleepy (item 9), andmaintaining energy throughout the day time (item 1).

(i.e. with the issues of day somnolence, energy level’s andalertness.) Studies have shown that post-stroke sleepdisturbances, may influence the development of fatigue 1,3,7,10,11,22

,this supports my results. Sleep disordered breathing (SDB) andsleep wake disorders (SWD) are frequent after stroke becauseof several reasons. First, brain damage per se can impair theregulation of sleep wake and breathing control mechanisms.Second, consequences of stroke (immobilization, pain, hypoxia,depression etc) may affect these same mechanisms. Third,cerebrovascular diseases, sleep disordered breathing andSWD’s can arise from similar pre-disposing / risk factors. It isthus important to recognize the sleep disturbances after strokeas they have a negative impact on rehabilitation and dailyfunctioning 23.

In a study, on mental fatigue in patients with supratentoriallacunar infarcts Van Zandvoort et al 15 found that despite verygood neurological recovery and normal cognitive abilities, thepatients showed a decrement of performances (compared tocontrol’s) in demanding tasks, which seemed to be linked tosubtle attentional deficits.

The factor 2 was found to correlate significantly with items-2, 4, 3 and 7 in decreasing order (see table). A significant relationbetween item 2 (difficulty to participate in activities because offatigue) and item 4 (difficulty in completing a task withoutbecoming tired) means more or less the same thing and maybe because of the feeling of exhaustion that overwhelms thepatient. Again the significant relation between item 3 (difficultyto stay awake during the day) and item 7 (difficulty to stay out ofbed during the day) may be pointing towards or mean the samething. Again the above items may be related , the difficulty toparticipate in activities may be same as difficulty to complete atask without becoming tired and when tiredness overcomes thepatient feel’s sleepy and thus unable to stay out of bed. It maybe interpreted either as physical or mental tiredness.

It may be concluded from the above that patients havereported difficulty with lack of energy levels or physical exhaustionor mental tiredness which may be related to their difficulty toparticipate in activities (item 2) and and the difficulty to last theday without taking a nap (item 10).which in turn may beconsequential to the sleep disorders or subtle attentional deficitsfollowing stroke due to interruption of neuronal networks suchas reticular activating system 1. Therefore, the main unansweredquestion posed by several studies on fatigue seems to beanswered from the above discussion that there is an associationbetween mental effort and fatigue. If it is assumed that BNImeasures the psychological domain of fatigue then patientsscoring high on this scale are assumed to have a greaterpsychological component of fatigue which may force them toproduce additional mental effort to match prior performances.Even with apparent total recovery, performing at the former levelmay be possible only at higher psychophysiological costs.Furthermore, the attempt to mask or overcome deficits can leadto psychological stress, with subsequent fatigue. It is obviousthat some patients experience physical fatigue as a consequenceof motor deficits. Thus, it is critical to distinguish objective physicalfatigue, which has a clear, specific cause (for examplehemiparesis), from the feeling of fatigue 3.

Again from the above discussion it appears that the difficultyto sustain attention or lack of energy for activities / tasks conformsto the definition of fatigue including both mental and physicaldomains.

Then does it mean that the BNI score measures the “central”fatigue experienced post-stroke? Because, “central” fatigue 24

is defined as t he failure to initiate / sustain attentional tasks(mental fatigue) and physical activities (physical fatigue) requiringself motivation as opposed to external stimulation. 24

In essence, central fatigue represents a failure of physicaland mental tasks that require self-motivation and internal cuesin the absence of demonstrable cognitive failure or motorweakness.

Study conducted by Ingles et al 10 in which fatigue is definedas a feeling of tiredness or lack of energy. FIS was used to assessfatigue –FIS evaluates the impact of fatigue on daily cognitive,physical and psychosocial functioning. Functional impairmentmeasured by the Barthels Index did not seem to play a role infatigue.

In our findings also the BNI total score did not show anycorrelation with the functional outcome measures of Barthel’sIndex and MAS.

It may be because of the subjective nature of the BNI scale.Fatigue as a subjective phenomenon or feeling state is

much more difficult to define and study , as it may be independentof objective or behavioral aspects. 3

Moreover, BNI scale items 1-10 asks the patients abouttheir difficulty levels in areas which may not necessarily interferewith the outcome measures on the Barthels index. Also, it maybe that experienced fatigue is perhaps not a truly objectiveindication of physical fatigue, and possibly reflects merely extraeffort needed to compensate for disability 1 or patients capacityto recognize problems may be reduced (i.e anosognosia,unawareness) leading to imprecise or unreliable presentationof their symptoms. 13

Not only reduced self-awareness can comprise the changesreported by patients, the psychological coping style known as“denial” may be involved. 13

The higher frequency and highly significant correlation ofthe item 11 (which asks patients directly to report their overalllevel of fatigue) with functional outcome measures shows firstly,the consistency with most of the studies 1,3,6,7,10,11,22 on theprevalence of fatigue post-stroke.

As such, it shows that self reporting of overall level of fatiguemay be an important aspect of fatigue measurement that mayhave a great impact on daily functioning of the patients. 11

Leegard14 examined 44 survivors of cerebral infarction


189

below the age of 70 years, fully active and in good health at thetime of stroke. All patients were autonomous for walking andable to manage in their own home and only 17 had neurologicaldeficits.

Between 6 and 26 months after stroke the patients werequestioned about 13 general symptoms, including fatigueemotional liability, forgetfulness and concentration difficulties.Over half of them reported at least 5 of the 13 symptoms, fatiguebeing particularly evident.

The fatigue reported was found to be independent of age.Even though the patient population studied was younger thanin the study by Ingle’s et al. 10

Secondly, it may be argued here that this high correlationof BNIoverall (item 11) with both measures of functional outcome(Barthel’s index and MAS) may be either because BNIoverall(item 11) measures psychological or physical attributes of fatigue.The fatigue checklist indivisual strength which was used in thestudy by Van der werf et al (11) is an instrument which essentiallyassesses the physical component of fatigue. This may explainwhy the authors found such a strong relation between fatiguescore on this scale and physical impairment. 1

Association between Fatigue Scale (BNI Total Score-BNISCAT1&2) and (BNI Overall Score-BNIOCAT1&2)categories and Barthels Categories (BARCAT1&2).

It may be interpreted from the previous discussion that thecauses leading to feeling of fatigue after stroke may be varied.Whether the underlying feeling is identical whatever theunderlying condition, seems to be obvious more or less in thisstudy by the strong association between BNI total scorecategories (BNISCAT1 and BNISCAT2) and Barthel’s categories(BARCAT1 and BARCAT2) 74.1% of the patients with none tooccasional problems with fatigue were moderate to minimallydependent in ADL’s and 30% with frequent to most of the timeproblems with fatigue were totally to severely dependent in ADL’s.The same percentage of association was shown by the BNIoverall (item 11) categories (BNIOCAT1 and BNIOCAT2)probably because both BNI total score (item 1-10) and BNIoverall score (item11) showed significant positive correlation( r=0.795,p<0.01).

It can be further concluded from the above that in the 74.1%of patients whether the problem is occasional (BNI scorecategories) or less (BNI overall categories) fatigue is aPROBLEM. You cannot ignore it! And it is this problem thatpersists as sequelae in the chronic stages post stroke as hasbeen shown in several studies conducted in the chronic stagespost stroke. It was found in these studies that even though thepatients did not show very severe neurological disturbance orfunctional impairment, fatigue was still reported with a higherfrequency .(3,6,10,11,13) The BNI scale does NOT ask the patient’sabout the EXTENT to which fatigue interferes with their ABILITYto carry out a specific activity ,it only asks the patients to describetheir level of DIFFICULTY on 10 fatigue-related items. It canagain be argued that no correlation found between BNI totalscore and functional out come may be because of this underlyingfact that even though the performance of activities might havebeen difficult to different degrees but still the patients performedthem with varying degrees of assistance or compensatorystatergies and that is precisely what the Barthel’s indexmeasures- the level of independence /dependence with varyingdegrees of assistance or compensatory stratergies. It furtherreinforces our earlier point that may be the patients haveunderreported /underestimated/misunderstood their fatigueproblems because of the acute stage of recovery especially forthe less impaired patients who because of their greaterawareness of deficits and social pressure to resume previousactivities may deny this problem. Or it may be a deficiency onthe part of the scale itself, because questions are ambiguousand repetitive or may be because of the small sample size.

Future research

The extent to which fatigue interferes with the functionaloutcome should be considered in future research. Also furtherwork is required to develop tools to measure objectively theextent to which fatigue interferes in therapy 12. Additional researchon post stroke fatigue is required in areas such as diagnosis,prevalence, severity, duration and association factors to betterunderstand causal mechanisms and predisposing factors7.

Relevance To Clinical Practice

The identification of effective therapeutic strategies for poststroke fatigue is critical to optimize recovery and rehabilitation.The recognition of fatigue as a genuine post stroke disorderrequiring assessment and treatment is the first step toward thedevelopment of a comprehensive therapeutic program toaddress the problem 7.It is important that the patient is madeaware that it is a real and not imagined symptom. Recognitionby the patient, caregivers and family members that it is a genuinesymptom of disease can be crucial to psychological well beingof the patient 25. It also ensures that the patient does not feel asif fatigue is simply to be endured, but that strategies may in factreduce or alleviate it 26.

Conclusion

It may be concluded from the previous discussion thatfatigue is a problem post stroke, which cannot be ignored, andthe mental, physical and psychological factors may contributeto it. Fatigue is important to be recognized post stroke as it mightaffect the functional outcome as is shown in the study by itsstrong association with the latter. Both the above hence provethe hypothesis of this study.

Refrences

1. Adams RD,Victor M,Ropper AH. In:Principles of neurology5th ed,New York:Mc Graw Hill.pp.497-507.

2. Fabienne staub,Julien Bogousslavsky:Poststrokedepression or Fatigue?2001:Eur neurol 45:3-5.

3. Staub.Fatigue after stroke:a major but neglectedissue.Cerebrovascular Disc.2001:12:75-81.

4. Lezak:Subtle sequelae of brain damage: Perplexity,distractibility and fatigue. American Journal of PhysicalMedicine,57:9-15,1978.

5. Susan R.Borgaro, Susan gierok et al:Fatigue after braininjury:initial reliability study of the BNI fatigue scale:july2004:Brain injury,vol 18.no.7:685-690.

6. Halvor Naess,Harald I,Nyland et al:Fatigue at long -termfollow up in young adults with cerebral infarction.Cerebrovascular dis 2005:20:245-250.

7. Marleen H,de Groot,Stephen et al.Fatigue associated withstroke and other neurological conditions,Implications forstroke rehabilitation.Arch Phy Med Rehabil 2003:84:1714-1720.

8. Appelros P(2005),Characteristics of Mini –Mental stateExamination 1 year after stroke.Acta Neurol Scand:112:88-92

9. Micheal K.Fatigue and stroke.Rehabilitation nursing2002:27:89-94,103.

10 .Ingles JL,Eskes GA Phillips SJ.(1999) Fatigue afterstroke.Arch Physical Med Rehabil;80:173-8.

11. Van der werf SP,van der Broek HL,Anten HW,et al (2001)Experience of severe fatigue long after stroke and its relationto depressive symptoms and disease characteristics. Eurneurol 2001;45:28-33.

12. Staub F:Annoni JM, Bogousslavsky J.Fatigue after stroke:a pilot study[abstract].cerebrovascular diseases 2000;10:62

13. Glader EL,Stegmayr B,Asplund K.Poststroke fatigue:a 2


190

year follow- up study of stroke patients inSweden.Stroke;2002:33:1327-33

14. Leegard OF.Diffuse cerebral symptoms in concvalescentsfrom cerebral infarction and myocardial infarction.ActaNeurolScand 1983;67:348-55.

15. Van Zandvoort MJ,Kappelle LJ,Alga A,De HaanEH.Decreased capacity for mental effort after singlesupratentorial lacunar infarct may affect performance ineveryday life.J Neurol Neurosurg Psychaitry 1998;65:697-702.

16. Lezak,M.DSubtle sequelae of brain damage:perplexity,distractibility and fatigue.American Journal of PhysicalMedicine,57:9-15,1978.

17. Carl V,Granger,et al:Stroke rehabilitation:Analysis ofRepeated Barthel Index Measures,Phy Med Rehabil,1979,16,14-17.

18. Carr JH,Shephard RB,Nordholm etal.Investigations of anew motor assessment scale for stroke patients.Phy Ther1985,65,175-80.

19. Carr J,Shephard R,Motor assessment scale for strokeamended version.Sydney(Aust):Sch of Physiotherapy,Faculty of health sciences ,univ,Sydney:1994.

20. Sabari JS.Optimising motor control using the Carr and

Shephard approach.In:Trombly C, Radomski MK, editors.occupational therapy for physical dysfunction.5th

ed.Philadelphia: Lippincott.21. Duff S,Shumway cook A,Woollacott M.Clinical Management

of the patient with reach grasp and manipulation disorders.InShumway-cookA,Wollacott MH,editors,Motor control,theoryand practical applications.2nd ed,Philadelphia:LippincottWilliams & Wilkins:2001,p.537.

22. J.Bogousslavsky,MD, William Fienberg lecturer. Emotions,Mood and Behavior after Stroke; Stroke: 2003:34:1046-50.

23. Claudio L,Bassetti,MD.Sleep and Stroke .Seminars inNeurology;Stroke:34:1046-1050.

24. Abhijit chaudhuri,Peter O Behan.Fatigue and Basalganglia.(Review).Journal of Neurological sciences2000:179:34-42.

25. Comi G,Leocani L,Rossi P et al.Pathophysiology andtreatment of fatigue in Multiple sclerosis.J.Neurol:248:174-9.

26. Groopman JE.Fatigue in cancer and HIV/AIDS. Oncology(Huntington) 1998:12:335-44

26. Groopman JE.Fatigue in cancer and HIV/AIDS. Oncology(Huntington)1998:12:33.


191Jagmohan Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Effect of Exercise Rehabilitation Programme on Clinical HealthStatus of Osteoarthritis Knee PatientsJagmohan Singh*, Paramvir Singh**, M S Sohal***Gian Sagar College of Physiotherapy, Ram Nagar, Banur, Distt. Patiala,**Punjabi University, Patiala

Abstract

Background and Objectives

Osteoarthritis (OA) is a common rheumatological disorder.It is a degenerative joint disorder characterized by destructionof articular cartilage and formation of a new bone at the jointsurfaces. Its onset is usually in older age group. Both men andwomen are affected, but symptoms in women occur earlier andappear to be more severe than in men. Knee joint is the mostcommonly affected region of the body. Predominant feature ispain along with decrease in the range of motion. One of theworst things about OA is its negative effect on the quality of life.The aim of this study is to find out prevalence of OA knee indifferent age groups & in different sexes and effect of exerciserehabilitation program on pain, range of motion, strength,cardiovascular fitness and functional level of patients with OAknee.

Methods

A group of 200 patients of established osteoarthritis of kneeranging in age from 40-65 years were included in the study.Patients were randomly divided into two groups: Group A(Experimental Control Group, n=100) and Group B (ExperimentalGroup, n=100). Patients of experimental control group weretreated with conventional physiotherapy program and patientsof experimental group were treated both with conventionalphysiotherapy program and exercise rehabilitation programwhich includes mild intensity long duration exercise program.Both the groups were treated for two months. Followingparameters were assessed at the start of exercise rehabilitationprogram, in the middle (after 1 month) of the study and at theend (after 2 months) of exercise rehabilitation program: Weight,BMI, pulse, HR, BP, pain, range of motion, strength of muscles,cardiovascular fitness & functional level.

Results

The results showed that there is a frequency of 15.5%,46% & 38.5% of osteoarthritis knee patients in the age group of40-50 years, 51-60 & > 60 years respectively and prevalence inmales & females is 31% & 69% respectively. The mean valuesof weight & BMI at 0 month was 71.81 ± 6.62 and 27.65 ± 2.47(in males) and 73.24 ± 6.32 and 28.06 ± 3.33 (in females) whichwas reduced to 63.00 ± 7.07 and 24.24 ± 2.49 (in males) and63.37 ± 6.15 and 24.26 ± 2.91 (in females) after 2 months ofexercise rehabilitation program. There is significant reductionin level of pain whereas range of motion, strength, cardiovascularfitness and functional level were improved significantly.

Conclusion

It is concluded that exercise rehabilitation program whichincludes mild intensity long duration exercise program causessignificant decrease in weight & BMI in knee OA patients alongwith reduction in level of pain whereas range of motion, strength,cardiovascular fitness and functional level were improved.

Key Words

Knee OA, exercise rehabilitation program, pain, range ofmotion, cardiovascular fitness, functional level

Introduction

Osteoarthritis (OA) is a common rheumatological disorder.It is a degenerative joint disorder characterized by destructionof articular cartilage and formation of a new bone at the jointsurfaces. Its onset is usually in older age group i.e., beyond 40years of age. Both men and women are affected, but symptomsin women occur earlier and appear to be more severe than inmen (Lawrence et al, 1998). Knee joint is the most commonlyaffected region of the body. Predominant feature is pain alongwith decrease in the range of motion. As the disease progresses,movement in the affected joint becomes increasingly limited,initially as a result of pain and muscular spasm, followed bycapsular fibrosis, osteophyte formation and remodeling of bone.

One of the worst things about OA is its negative effect onthe quality of life. Patients with OA, especially of the weightbearing joints, are less active and tend to be less fit with regardto musculoskeletal and cardiovascular status than normalcontrols (Minor et al, 1988; Philbin et al 1995 and Reis et al,1995). Various medical conditions are found to be associatedwith secondary OA and are potential risk factors for osteoarthritis(Al-Arfaz, 2003; Hart et al, 1995; Sun et al, 2000). These medicalconditions include diabetes mellitus (Sturmer et al, 2001) andobesity (Bliddal and Christensen, 2006). The aim of this studyis to find out prevalence of OA knee in different age groups & indifferent sexes and effect of exercise rehabilitation program onpain, range of motion, strength, cardiovascular fitness andfunctional level of patients with OA knee.

Material & Methods

A group of 200 patients of established osteoarthritis of kneeranging in age from 40-65 years were included in the study.Patients were randomly divided into two groups: Group A(Experimental Control Group, n=100) and Group B (ExperimentalGroup, n=100).

Patients with a history of condition known to precludeexercise were excluded from the study. Such conditions arecoronary heart disease, myocardial infarction, unstable angina,chronic bronchitis, emphysema, peripheral vascular disease,thrombophlebitis, embolism, kidney failure, uncontrolledhypertension etc. Patients were explained the study protocoland written consent was taken before the start of study program.

In order to make the groups more homogenous,they were further subdivided into males and females.

The Treatment Program

Both the groups were treated for two months. Patients ofexperimental control group were treated with conventionalphysiotherapy program and patients of experimental group weretreated both with conventional physiotherapy program andexercise rehabilitation program based on guidelines given byArthritis Foundation (Gordon, 1993).

192

Conventional physiotherapy program included applicationof hot packs, isometric exercises to quadriceps and hamstrings,range of motion exercises, stretching exercises, joint mobilizationexercises and progressive resisted exercises.

For exercise rehabilitation program along with conventionalphysiotherapy program, mild intensity long duration aerobicconditioning exercises (at 60% of MHR) were given. Aerobicwarm up was given for 5-10 minutes. It included swinging ofarms and legs (upwards, sideways, backwards & laterally).Walking was given for 5 -10 minutes and cycling was given for15-20 minutes (at 60% of MHR), 5 times a week. Aerobicexercises were followed by cool down exercises for 5-10 minutes.

Following parameters were assessed at the start of exerciserehabilitation program, in the middle (after 1 month) of the studyand at the end (after 2 months) of exercise rehabilitation program:

1. The Physical Characteristics

1. Age2. Sex3. Height4. Weight5. Body mass index2. The clinical health status:1. Pulse2. Heart rate3. Blood pressure3. The health related fitness:1. Level of Pain2. Range of motion of knee joint3. Strength of muscles4. Cardiovascular fitness5. Functional status

Methods of Measurement of VariousParameters

Measurement of Physical Characteristics

Height: The height of the subjects was measured by usingan Anthropometric rod.

Weight: Weight of the patient was measured by a weighingmachine.

Body mass index: Body mass index of the patient wascalculated by the following formula:

Body mass index = Body weight (Kgs)Height (meters)2

Measurement of Clinical Health Status

Pulse: Pulse was measured by using manual method onradial artery.

Heart rate: Heart rate was measured by using POLAR Heartrate monitor.

Blood pressure: Blood pressure was measured by using asphygmomanometer.

Measurement of Health Related Fitness

Level of Pain: Pain was calculated by using Visual AnalogScale (VAS).

Range of motion (ROM): ROM was assessed bygoniometric method.

Strength measurement: Isometric strength was measuredby using Back-leg-chest dynamometer. Isotonic strength wasmeasured by using weight cuffs.

Cardiovascular fitness: Cardiovascular fitness wasassessed by using Crompton test.

Functional status: Functional status was assessed by usingthe WOMAC (Western Ontario and McMaster Universities) Indexof Osteoarthritis.

Results

Table 1: Prevalence of Osteoarthritis knee in different agegroups.

Age Group Frequency Percentage

40-50 31 15.5%

51-60 92 46%

> 60 years 77 38.5%

Total 200 100%

Table 2: Prevalence of Osteoarthritis knee in males and females

Sex Group Frequency Percentage

Males 62 31%

Females 138 69%

Total 200 100%

The values of physical characteristics, clinical health statusand health related fitness were recorded in the data sheets.Their means, S.D. and t-values were calculated with the help ofMicrosoft Excel and SPSS software.

Table 1 shows prevalence of osteoarthritis knee in differentage groups. Different age groups 40-50 years, 51-60 years and> 60 years were taken. Their frequencies were recorded as 31,92 and 77 with percentage 15.5%, 46% and 38.5% respectively.

Table 2 shows prevalence of osteoarthritis knee in differentsex groups of males and females. The frequencies wererecorded as 62 in males and 138 in females with percentage31% and 69% respectively.

Table 3 shows mean differentials of physical characteristicsof males belonging to experimental control group andexperimental group of osteoarthritis knee patients at 0 month,after 1 month & after 2 months. The mean value of age recordedin experimental control group was 54.73 ± 6.77 and inexperimental group was 53.47 ± 6.54 which was statistically notsignificant during the whole study period. The mean value ofheight recorded in experimental control group was 1.62 ± 0.06and in experimental group was 1.61 ± 0.07 which was alsostatistically not significant during the whole study period.

The mean values of weight at 0 month, after 1 month &after 2 months in experimental control group were 71.17 ± 6.72,69.27 ± 6.51 & 67.63 ± 6.79 and in experimental group were71.81 ± 6.62, 67.22 ± 6.64 & 63.00 ± 7.07 respectively whichwere statistically not significant at 0 & 1 month but significant at2 months. The mean values of body mass index (BMI) at 0month, after 1 month & after 2 months in experimental controlgroup were 27.22 ± 2.84, 26.51 ± 2.85 & 25.85 ± 2.63 and inexperimental group were 27.65 ± 2.47, 25.88 ± 2.48 & 24.24 ±2.49 respectively which were statistically not significant at 0 &after 1 month but significant after 2 months.

Table 4 shows mean differentials of physical characteristicsof females belonging to experimental control group andexperimental group of osteoarthritis knee patients at 0 month,after 1 month & after 2 months. The mean value of age recordedin experimental control group was 58.14 ± 5.40 and inexperimental group was 57.40 ± 5.47 which was statistically notsignificant during the whole study period. The mean value ofheight recorded in experimental control group was 1.59 ± 0.06and in experimental group was 1.58 ± 0.07 which was also

Jagmohan Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

193

Table 3: Mean differentials of physical characteristics of males belonging to experimental control group and experimental group ofknee osteoarthritis patients at different time intervals

Experimental Control Experimental t-value Period Group (Mean±SD) Group (Mean±SD)

At 0 After 1 After 2 At 0 After 1 After 2 At 0 After 1 After 2month month months month month months month month months

Age 54.73 54.73 54.73 53.47 53.47 53.47 0.74 0.74 0.74(in years) ±6.77 ±6.77 ±6.77 ±6.54 ±6.54 ±6.54

Weight 71.17 69.27 67.63 71.81 67.22 63.00 0.38 1.22 2.63*(in kgs) ±6.72 ±6.51 ±6.79 ±6.62 ±6.64 ±7.07

Height 1.62 1.62 1.62 1.61 1.61 1.61 0.60 0.60 0.60(in meters) ±0.06 ±0.06 ±0.06 ±0.07 ±0.07 ±0.07

BMI 27.22 26.51 25.85 27.65 25.88 24.24 0.63 0.93 2.49*±2.84 ±2.85 ±2.63 ±2.47 ±2.48 ±2.49

*p<0.05

Experimental Control Experimental t-value Period Group (Mean±SD) Group (Mean±SD)


Age 58.14 58.14 58.14 57.40 57.40 57.40 0.80 0.80 0.80(in years) ±5.40 ±5.40 ±5.40 ±5.47 ±5.47 ±5.47

Weight 70.66 67.63 65.50 73.24 67.68 63.37 1.32 0.05 1.97*(in kgs) ±6.74 ±6.63 ±6.56 ±6.32 ±6.25 ±6.15

Height 1.59 1.59 1.59 1.58 1.58 1.58 0.9 0.9 0.9(in meters) ±0.06 ±0.06 ±0.06 ±0.07 ±0.07 ±0.07

BMI 27.91 26.70 25.85 28.06 25.92 24.26 0.36 1.61 3.60*±2.74 ±2.58 ±2.13 ±3.33 ±3.08 ±2.91

Table 4: Mean differentials of physical characteristics of females belonging to experimental control group and experimental groupof knee osteoarthritis patients at different time intervals

*p<0.05

Table 5: Mean differentials of clinical health status of males belonging to experimental control group and experimental group ofknee osteoarthritis patients at different time intervals

*p<0.05

Experimental Control Experimental t-value Parameter Group (Mean±SD) Group (Mean±SD)


Pulse 67.80 66.07 64.37 66.63 63.56 60.38 0.81 2.11* 3.21*±4.97 ±6.14 ±5.17 ±6.33 ±5.64 ±4.58

Heart Rate 69.40 69.32 66.07 68.59 66.63 62.31 0.54 1.97* 2.75*±5.39 ±4.34 ±5.49 ±6.35 ±6.33 ±5.26

B.P 151.40 146.40 137.33 154.00 152.31 145.37 0.87 2.21* 2.96*(Systolic) ±6.75 ±7.65 ±7.70 ±13.2 ±12.85 ±13.13

B.P 86.90 85.80 85.20 87.40 83.88 81.50 1.01 4.03* 6.04*(Diastolic) ±1.91 ±1.92 ±2.76 ±2.28 ±1.83 ±1.97


194

statistically not significant during the whole study period.The mean values of weight at 0 month, after 1 month &

after 2 months in experimental control group were 70.66 ± 6.74,67.63 ± 6.63 & 65.50 ± 6.56 and in experimental group were73.24 ± 6.32, 67.68 ± 6.25 & 63.37 ± 6.15 respectively whichwere statistically not significant at 0 & 1 month but significant at2 months.. The mean values of body mass index (BMI) at 0month, after 1 month & after 2 months in experimental controlgroup were 27.91 ± 2.74, 26.70 ± 2.58 & 25.83 ± 2.13 and inexperimental group were 28.06 ± 3.33, 25.92 ± 3.08 & 24.26 ±2.91 respectively which were statistically not significant at 0 & 1month but highly significant at 2 months.

Table 5 shows mean differentials of clinical health status ofmales belonging to experimental control group and experimentalgroup of osteoarthritis knee patients at 0 month, after 1 month &after 2 months. The mean values of pulse recorded inexperimental control group at 0 month, after 1 month & after 2months were 67.80 ± 4.97, 66.07 ± 6.14 & 64.37 ± 5.17 and inexperimental group were 66.63 ± 6.33, 63.56 ± 5.64 & 60.38 ±4.58 respectively which were statistically not significant at 0



Pulse 71.20 72.69 68.53 72.62 68.97 64.04 0.88 2.26* 3.08*±9.04 ±9.69 ±9.05 ±9.83 ±5.64 ±4.58

Heart Rate 69.64 71.57 68.73 69.37 67.89 64.37 0.16 2.27* 2.71*±9.43 ±9.24 ±9.08 ±9.79 ±9.79 ±9.79

B.P 151.60 145.74 140.34 155.00 150.47 146.44 1.74 2.54* 3.04*(Systolic) ±9.54 ±8.71 ±8.09 ±13.11 ±12.74 ±13.14

B.P 87.34 86.00 85.43 87.53 83.91 81.50 0.37 5.38* 9.61*(Diastolic) ±3.68 ±2.64 ±2.73 ±2.29 ±1.88 ±2.03

Table 6 : Mean differentials of clinical health status of females belonging to experimental control group and experimental group ofknee osteoarthritis patients at different time intervals.

*p<0.05Table 7 :Mean differentials of health related fitness of males belonging to experimental control group and experimental group ofknee osteoarthritis patients at different time intervals



Pain 6.67 5.53 4.73 6.81 4.28 2.63 0.34 4.04* 8.25*±1.52 ±1.31 ±1.14 ±1.69 ±1.11 ±0.83

R.O.M. 85.23 93.57 104.80 83.56 103.44 120.19 0.51 2.88* 4.84*±12.51 ±12.55 ±14.54 ±13.2 ±14.39 ±9.88

Strength 250.83 338.50 478.50 252.19 382.19 532.19 0.12 3.91* 4.80*(Isometric) ±45.94 ±44.20 ±44.20 ±43.81 ±43.81 ±43.81

Strength 1.80 2.47 2.67 1.84 2.84 4.13 0.18 3.26* 6.01*(Isotonic) ±3.68 ±2.64 ±2.73 ±2.29 ±1.88 ±2.03

C.V. 2.63 2.76 2.83 2.59 1.75 1.06 0.32 9.14* 21.52*Fitness ±0.49 ±0.43 ±0.38 ±0.50 ±0.44 ±0.25

Functional 3.40 2.49 1.39 3.35 2.05 0.85 0.56 4.75* 5.82* status ±0.33 ±0.35 ±0.35 ±0.37 ±0.38 ±0.38

*p<0.05


month but significant after 1 month and after 2 months.The mean value of heart rate recorded in experimental

control group at 0 month, after 1 month & after 2 months were69.40 ± 5.39, 69.32 ± 4.34 & 66.07 ± 5.49 and in experimentalgroup were 68.59 ± 6.35, 66.63 ± 6.33 & 62.31 ± 5.26respectively which were statistically not significant at 0 monthand 1 month but significant after 2 months.

The mean values of blood pressure (systolic) at 0 month,after 1 month & after 2 months in experimental control groupwere 151.4 ± 6.75, 146.40 ± 7.65 & 137.33 ± 7.70 and inexperimental group were 154 ± 13.2, 152.31 ± 12.85 & 145.37± 13.13 respectively which were statistically not significant at 0month but significant after 1 month and after 2 months.

The mean values of blood pressure (diastolic) at 0 month,after 1 month & after 2 months in experimental control groupwere 86.90 ± 1.91, 85.8 ± 1.92 & 85.20 ± 2.76 and inexperimental group were 87.4 ± 2.28, 83.88 ± 1.83 & 81.5 ±1.97 respectively which were statistically not significant at 0month but significant after 1 month and at 2 months.

Table 6 shows mean differentials of clinical health status of

195



Pain 7.21 5.66 4.23 7.02 4.35 3.00 0.88 7.85* 7.36*±1.26 ±1.09 ±1.21 ±1.25 ±0.86 ±0.69

R.O.M. 85.90 93.83 109.83 85.28 103.87 122.49 0.27 4.30* 5.88*±13.56 ±13.13 ±12.62 ±13.0 ±14.25 ±12.27

Strength 256.79 342.43 484.43 250.81 380.81 530.81 0.70 4.52* 5.47*(Isometric) ±49.73 ±49.46 ±49.38 ±50.19 ±50.19 ±50.19

Strength 1.86 2.24 2.62 1.87 2.90 4.06 0.07 5.00* 9.87*(Isotonic) ±0.81 ±0.77 ±0.92 ±0.81 ±0.78 ±0.79

C.V. 2.53 2.64 2.76 2.60 1.69 1.02 0.83 11.87* 32.57*Fitness ±0.50 ±0.48 ±0.43 ±0.49 ±0.47 ±0.12

Functional 3.35 2.46 1.36 3.36 2.07 0.87 0.16 6.45* 8.11* status ±0.37 ±0.36 ±0.36 ±0.35 ±0.35 ±0.35

Table 8: Mean differentials of health related fitness of females belonging to experimental control group and experimental group ofknee osteoarthritis patients at different time intervals

*p<0.05

females belonging to experimental control group andexperimental group of osteoarthritis knee patients at 0 month,after 1 month & after 2 months. The mean values of pulserecorded in experimental control group at 0 month, after 1 month& after 2 months was 71.20 ± 9.04, 72.69 ± 9.69 & 68.53 ± 9.05and in experimental group was 72.62 ± 9.83, 68.97 ± 9.63 &64.04 ± 8.09 respectively which were statistically not significantat 0 month but significant after 1 month and after 2 months.

The mean value of heart rate recorded in experimentalcontrol group at 0 month, after 1 month & after 2 months were69.64 ± 9.43, 71.57 ± 9.24 & 68.73 ± 9.08 and in experimentalgroup were 69.37 ± 9.79, 67.89 ± 9.79 & 64.37 ± 9.79respectively which was statistically not significant at 0 monthbut significant after 1 month and after 2 months.

The mean values of blood pressure (systolic) at 0 month,after 1 month & after 2 months in experimental control groupwere 151.60 ± 9.54, 145.74 ± 8.71 & 140.34 ± 8.09 and inexperimental group were 155 ± 13.11, 150.47 ± 12.74 & 146.44± 13.14 respectively which was statistically not significant at 0month but significant after 1 month and after 2 months.

The mean values of blood pressure (diastolic) at 0 month,after 1 month & after 2 months in experimental control groupwere 87.34 ± 3.68, 86.00 ± 2.64 & 85.43 ± 2.73 and inexperimental group were 87.53 ± 2.29, 83.91 ± 1.88 & 81.5 ±2.03 respectively which was statistically not significant at 0 monthbut significant after 1 month and after 2 months.

Table 7 shows mean differentials of health related fitnessof males belonging to experimental control group andexperimental group of osteoarthritis knee patients at 0 month,after 1 month & after 2 months. The mean values of painrecorded in experimental control group at 0 month, after 1 month& after 2 months were 6.67 ± 1.52, 5.53 ± 1.31 & 4.73 ± 1.14and in experimental group were 6.81 ± 1.69, 4.28 ± 1.11 & 2.63± 0.83 which was statistically not significant at 0 month butsignificant after 1 month and after 2 months.

The mean values of range of motion at 0 month, after 1month & after 2 months recorded in experimental control groupwere 85.23 ± 12.5, 93.57 ± 12.55 & 104.80 ± 14.54 and inexperimental group were 83.56 ± 13.29, 103.44 ± 14.39, 120.19± 9.88 respectively which was statistically not significant at 0month but significant after 1 month and after 2 months.

The mean values of strength (isometric) at 0 month, after 1

month & after 2 months in experimental control group were250.83 ± 45.94, 338.50 ± 44.20 & 478.50 ± 44.20 and inexperimental group were 252.19 ± 43.81, 382.19 ± 43.81 &532.19 ± 43.81 respectively which was statistically not significantat 0 month but significant after 1 month and after 2 months.

The mean values of strength (isotonic) at 0 month, after 1month & after 2 months in experimental control group were 1.80± 0.87, 2.47 ± 0.86 & 2.67 ± 1.03 and in experimental groupwere 1.84 ± 0.86, 2.84 ± 0.88 & 4.13 ± 0.87 respectively whichwas statistically not significant at 0 month but significant after 1month and after 2 months.

The mean values of cardiovascular fitness at 0 month, after1 month & after 2 months in experimental control group were2.63 ± 0.49, 2.76 ± 0.43 & 2.83 ± 0.38 and in experimental groupwere 2.59 ± 0.50, 1.75 ± 0.44 & 1.06 ± 0.25 respectively whichwas statistically not significant at 0 month but significant after 1month and after 2 months.

The mean values of functional status at 0 month, after 1month & after 2 months in experimental control group were 3.40± 0.33, 2.49 ± 0.35 & 1.39 ± 0.35 and in experimental groupwere 3.35 ± 0.37, 2.05 ± 0.38 & 0.85 ± 0.38 respectively whichwas statistically not significant at 0 month but significant after 1month and after 2 months.

Table 8 shows mean differentials of health related fitnessof females belonging to experimental control group andexperimental group of osteoarthritis knee patients at 0 month,after 1 month & after 2 months. The mean values of painrecorded in experimental control group at 0 month, after 1 month& after 2 months were 7.21± 1.26, 5.66 ± 1.09 & 4.23 ± 1.21and in experimental group were 7.02 ± 1.25, 4.35 ± 0.86 & 3.00± 0.69 respectively which were statistically not significant at 0month but significant after 1 month and after 2 months.

The mean value of range of motion recorded at 0 month,after 1 month & after 2 months in experimental control groupwere 85.90 ± 13.56, 93.83 ± 13.13 & 109.83 ± 12.62 and inexperimental group were 85.28 ± 13.05, 103.87 ± 14.25, 122.49± 12.27 respectively which was statistically not significant at 0month but significant after 1 month and after 2 months.

The mean values of strength (isometric) at 0 month, after 1month & after 2 months in experimental control group were256.79 ± 49.73, 342.43 ± 49.46 & 484.43 ± 49.38 and inexperimental group were 250.81 ± 50.19, 380.81 ± 50.19 &


196

530.81 ± 50.19 respectively which was statistically not significantat 0 month but significant after 1 month and after 2 months.

The mean values of strength (isotonic) at 0 month, after 1month & after 2 months in experimental control group were 1.86± 0.81, 2.24 ± 0.77 & 2.62 ± 0.92 and in experimental groupwere 1.87 ± 0.81, 2.90 ± 0.78 & 4.06 ± 0.79 respectively whichwas statistically not significant at 0 month but significant after 1month and after 2 months.

The mean values of cardiovascular fitness at 0 month, after1 month & after 2 months in experimental control group were2.53 ± 0.50, 2.64 ± 0.48 & 2.76 ± 0.43 and in experimental groupwere 2.60 ± 0.49, 1.69 ± 0.47 & 1.02 ± 0.12 respectively whichwas statistically not significant at 0 month but significant after 1month and after 2 months.

The mean values of functional status at 0 month, after 1month & after 2 months in experimental control group were 3.35± 0.37, 2.46 ± 0.36 & 1.36 ± 0.36 and in experimental groupwere 3.36 ± 0.35, 2.07 ± 0.35 & 0.87 ± 0.35 respectively whichwas statistically not significant at 0 month but significant after 1month and after 2 months.

Discussion

Onset of osteoarthritis is usually in older age group. Thishas been stated in several studies like Lawrence et al, 1966;Downie 1993; Adams and Hamlen, 1996; Joshi and Kotwal,2000; Haslett et al, 2000; Braunwald et al, 2001; O’Sullivan andSchmitz, 2001. Table 1 of our study tallies with the above studiesin which 46% of patients falls under the age group of 50-60years.

Both men and women are affected, but symptoms in womenoccur earlier and appear to be more severe than in men(Lawrence et al, 1998). About two-third to three-fourth of adultswith osteoarthritis knee are women (Jordan et al, 1995).Prevalence of osteoarthritis knee in males and females as shownin Table 2 of our study also indicates that osteoarthritis knee ismore frequently found in females than in males. 69% of ourpatients were females and only 31% were males. This finding isalso supported by Moskowitz et al, 1992 who reported thatosteoarthritis knee occurs more commonly in women during laterpart of their life.

Body mass index (BMI) is associated with onset andprogression of osteoarthritis of the knee was studied by Reijmanet al, 2007 in his famous “The Rotterdam study”. Theyinvestigated the relationship between body mass index and theincidence and progression of radiological knee osteoarthritis,they studied 3585 individuals aged e” 55 years. A high bodymass index > 27 kgs/m2 was found to be associated withincidence and progression of osteoarthritis knee. Table 3 and 4of our study shows similar findings in which BMI at the startingof exercise rehabilitation program is 27.22 in males and 27.91in females.

Weight reduction programs helps in the management ofosteoarthritis knee. Several studies revealed the effect ofexercises in reducing pain and disability in patients ofosteoarthritis knee. The studies done by Bliddal and Christensen,2006; Rogind et al, 1998 suggests the importance of reducingweight in the management of osteoarthritis knee. Huang et al,2000 also evaluated the effect of weight reduction on therehabilitation of patients with knee osteoarthritis and obesity.Weight reduction was found to be a practical adjuvant treatmentin the rehabilitation of patients with knee osteoarthritis. Table 3,4, 7 & 8 of our study also tallies with the study of Huang et al,2000 which indicates that weight reduction reduces pain &improves functional status in patients of osteoarthritis knee.

Cornelissen et al, 2009 studied the effects of aerobic trainingintensity on resting, exercise and post-exercise blood pressure,heart rate and heart-rate variability. They aimed to investigatethe effects of endurance training intensity on systolic bloodpressure (SBP) and heart rate (HR) at rest before exercise, and

during and after a maximal exercise test; and on measures ofheart rate variability at rest before exercise and during recoveryfrom the exercise test. The results showed that in the threeconditions, endurance training at lower and higher intensityreduced systolic blood pressure significantly. In conclusion, inparticipants at higher age, both training programmes exert similareffects on systolic blood pressure at rest, during exercise andduring post-exercise recovery. Tables 5 & 6 of our study showedsimilar results on pulse, heart rate, systolic and diastolic bloodpressures.

The effect of regular physical exercise for reducing pain,increasing range of motion of joints and improving strength ofmuscles is now evident (American College of Rheumatology,2000; Deyle et al, 2000; Holden et al, 2008; Roddy et al, 2005;Thomas et al, 2002). Several studies have revealed the effectsof regular physical exercise on various health related fitnessparameters in osteoarthritis of knee patients (Fransen et al, 2007;Jan et al, 2009; Jordan et al, 2004; Smidt et al, 2005; Taylor etal, 2007).

Cameron et al (2006) studied the outcomes on patientswith osteoarthritis treated with manual physical therapy andexercise. There was increase in total passive range of motion ofjoints. Numeric pain rating scores decreased by a mean of 5points (range 2 – 7 points) on 0 to 10 point scale. All patientsexhibited reductions in pain and increases in passive range ofmotion as well as a clinically meaningful improvement in function.Table 7 & 8 of our study shows similar type of effects on painand range of motion. After 2 months of exercise rehabilitationprogram, pain reduced significantly and range of motionimproved significantly in both males and females.

Kladny (2005) studied the role of physical therapy onosteoarthritis. Physical therapy is used as a part of guidelinesand recommendations in the treatment of osteoarthritis. Differentmethods were used in the treatment of osteoarthritis. There isevidence that manual physical therapy and exercise improvefunction and reduce pain in osteoarthritic joints. Table 7 & 8 ofour study shows improvement in functional status of our patients.

Several studies have revealed decreased cardiovascularfitness in the patients of osteoarthritis (Braunwald et al, 2001;McArdle et al, 1991; Minor et al, 1988; Philbin et al, 1995; Reiset al, 1995). Cardiovascular fitness is defined as the ability tocontinue or persist in strenuous task involving large group ofmuscles for extended period of time (American College of SportsMedicine, 1995; Baroonwaski et al, 1992; Heyward, 1991). Thiscardiovascular deconditioning results decreased efficiency indelivery of oxygen to the skeletal muscles (Perry, 1985). Theinactivity resulted from reduced cardiovascular fitness has furtherconsequences of leading to aggravation of symptoms in thepatients of osteoarthritis knee.

Minor et al (1989) studied a group of 120 patients withrheumatoid arthritis and osteoarthritis volunteered to be subjectsfor this study of aerobic versus non-aerobic exercise. Patientswere randomized into an exercise program of aerobic walking,aerobic aquatics or non-aerobic range of motion exercise.Exercise tolerance, disease-related measures and self-reportedhealth status were assessed. The aquatics and walking exercisegroups showed significant improvement over the control groupin aerobic capacity, 50-foot walking time, depression, anxietyand physical activity after the exercise program. Table 7 & 8 ofour study showed similar results.

LaMantia and Marks (1995) studied the efficacy of aerobicexercises for treating patients of osteoarthritis of the knee.Supervised walking programmes and aquarobics combined withstretching and strengthening routines with patient education weregiven for experimental group. Control group received a nonaerobic exercise programme with stretching and strengtheningactivities with routine patient care. The study revealed decreasedpain, increased functional and aerobic capacity in experimentalgroup followed by 12 weeks physical conditioning programmewhen compared with controls receiving a non aerobic exerciseprogramme. Table 7 & 8 of our study showed similar results.


197

Conclusion

It is concluded that exercise rehabilitation program whichincludes mild intensity long duration exercise program causesdecrease in weight & BMI in knee OA patients along withreduction in pain whereas range of motion, strength,cardiovascular fitness and functional level were improvedsignificantly.

References

1. Adams. J. C. and Hamblen, D. L. (1996) Outline ofOrthopaedics. 12th Ed., Churchill Livingstone.

2. Al-Arfaj, A. S. (2003) Radiographic osteoarthritis and serumcholesterol. Saudi Med. J. 24 (7): 745-747.

3. American College of Rheumatology (2000)Recommendations for the medical management ofosteoarthritis of hip and knee. Arthritis Rheum. 2000; 43:1905-1915.

4. American College of Sports Medicine (1995) Guidelinesfor graded exercise testing and exercise prescription. 5th

Ed. Baltimore, M. D.: Lea and Febiger.5. Baroonwaski, T. and Bouchard C. (1992) Assessment,

prevalence and cardiovascular benefits of physical activityand fitness in youth. Med. Sci. Sports Exercise. 24 (6) 237-246.

6. Bliddal, H. and Christensen, R. D. (2006) Osteoarthritis andobesity. Prognosis and treatment possibilities. Ugeskr.Laeger. 168(2): 190-193.

7. Braunwald, E., Fauci, A. S., Kasper, D. L., Hauser, S. L.,Longo, D. L. and Jameson, J. L. (eds) (2001) Harrison’sPrinciples of Internal Medicine. 15th ed. Vol. 2. McGraw Hill.

8. Cameron, W. M., Julie, M. W., Joshua, A. C., Marcia, S.and Hugo, L. H. (2006) Clinical outcomes following manualphysical therapy and exercise for hip osteoarthritis: A caseseries. J. Orthop. Sports Phys. Ther. 36 (8) 588-599.

9. Cornelissen, V.A., Verheyden, B., Aubert, A. and Fagard,R.H. (2009) Effects of aerobic training intensity on resting,exercise and post exercise blood pressure, heart rate andheart rate variability. J. Hypertens. 27: 753-762.

10. Deyle, G. D., Henderson, N. E., Matekel, R. L., Ryder, M.G., Garber, M. B. and Allison, S. C. (2000) Effectiveness ofmanual Physical Therapy and exercise in osteoarthritis ofthe knee. A randomized, controlled trial. Ann InternMedicine. 132: 173-181.

11. Downie, P. A. (Eds.) (1993) Cash’s Textbook ofOrthopaedics and Rheumatology for Physiotherapists. 1st

Indian Ed. New Delhi: Jaypee Brothers.12. Frensen, M., McConnell, S. and Bell, M. (2007) Exercise

for osteoarthritis of the hip or knee (Review). The CochraneDatabase of Systematic Reviews. Issue 2.

13. Gordon, N. F. (1993) Arthritis your complete exercise guide.The Cooper clinic and research institute fitness series,Dallas Texas: Human Kinetics Publishers.

14. Hart, D. J., Doyle, D. V. and Spector, T. D. (1995) Associationbetween metabolic factors and knee osteoarthritis inwomen: the Chingford Study. J. Rheumatol. 22 (6): 1118-23.

15. Haslett, C., Chilvers, E. R., Hunter, J. A. A. and Boon, N. A.(eds.) (2000) Davidson’s Principles and Practice ofMedicine. 18th ed. Churchill Livingstone.

16. Heyward, V. H. (1991) Advanced fitness assessment andexercise prescription. 2nd Ed. Champaign, I. L.: HumanKinetics Books.

17. Holden, M. A., Nicholls, E. E., Hay, E. M. and Foster, N. E.(2008) Physical therapists use of therapeutic exercises forpatients with clinical knee osteoarthritis in the UnitedKingdom: In line with current recommendations. PhysicalTherapy. 88 (10): 1109-1123.

18. Huang, M. H., Chen, C. H., Chen, T. W., Weng, M. C., Wang,

W. T. and Wang, Y. L. (2000) The effects of weight reductionon the rehabilitation of patients with knee osteoarthritis andobesity. Arthritis Care and Res.13 (6): 398-405.

19. Jan, M. H., Lin, C. H., Liau, Y. F., Lin, J. J. and Lin, D.H.(2009) Effects of weight bearing versus non-weight bearingexercise on function, walking speed and position sense inparticipants with knee osteoarthritis: A randomizedcontrolled trial. Arch. Phys. Med. Rehabil. 90: 897-904.

20. Jordan, J. M., Linder, G. F., Renner, J. B. and Fryer, J. G.(1995) The impact of arthritis in rural populations. ArthritisCare and Research. 8(4): 242-250.

21. Jordan, K.M., Sawyer, S., Coakley, P., Smith, H.E., Cooper,C. and Arden, K.N. (2004) The use of conventional andcomplementary treatments for knee osteoarthritis in thecommunity. Rheumatology 43: 381-384.

22. Joshi, J and Kotwal, P. (2000) Essentials of Orthopaedicsand applied physiotherapy. New Delhi: B. I. ChurchillLivingstone.

23. Kladny, B. (2005) Physical therapy of Osteoarthritis. J.Rheumatol. 64 (7): 448-455.

24. LaMantia, K. and Marks, R. (1995) The efficacy of aerobicexercises for treating osteoarthritis of the knee. NewZealand Journal of Physiotherapy. 23 (2): 23-30.

25. Lawrence, J. S., Bremner, J. M. and Bier, F. (1966)Osteoarthrosis. Prevalence in the population andrelationship between symptoms and X ray changes. Ann.Rheum. Dis. 25: 1-24.

26. Lawrence, R. C., Helmick, C. G. and Arnett, F. C. (1998)Estimates of the prevalence of arthritis and selectedmusculoskeletal disorders in the United States. ArthritisRheum. 41(5): 778-799.

27. McArdle, W. D., Katch, F. I. and Katch, V. L. (1991) ExercisePhysiology: Energy, Nutrition and Health Performance. 3rd

Ed. Lea & Fabiger.28. Minor, M. A., Hewett, J. E., Webel, R. R., Anderson, S. K.,

and Kay, D. R. (1989) Efficacy of physical conditioningexercise in patients with rheumatoid arthritis andosteoarthritis. Arthritis Rheum. 32 (11): 1396-1405.

29. Minor, M. A., Hewett, J. E., Webel, R. R., Dreisinger, T. E.and Kay, D. R. (1988) Exercise tolerance and diseaserelated measures in patients with rheumatoid arthritis andosteoarthritis. J. Rheumatol. 15(6):905-911.

30. Moskowitz, R. W., Howell, D. S., Goldberg, V. M. andMankin, H. J. (1992) Osteoarthritis, Diagnosis and Medical-Surgical Management. 2nd Ed. Harcourt Brace Jovanovich,Inc.: W. B. Saunders Company.

31. O’Sullivan, S. B. and Schmitz, T. J. (2001) PhysicalRehabilitation: Assessment and Treatment. 4th Ed. NewDelhi: Jaypee Brothers.

32. Perry, S.V. (1985) The biochemistry and physiology of themuscle cell. Proc. Nutr. Soc. 44(2):235-243.

33. Philbin, E. F., Groff, G. D, Ries, M. D. and Miller T. E. (1995)Cardiovascular fitness and health in patients with end-stageosteoarthritis. Arthritis Rheum. 38 (6): 799-805.

34. Reijman, A., Pols, H. A., Bergink, A. P., Hazes, J. M., Belo,J. N., Lievense, A. M. and Bierma-Zeinstra, S. M. (2007)Body mass index associated with onset and progressionof the knee but not of the hip- the Rotterdam study. Ann.Rheum. Dis. 66 (2): 158-162.

35. Reis, M. D., Philbin, E. F. and Groff, G. D. (1995)Relationship between severity of gonarthrosis andcardiovascular fitness. Clin. Orthop. 313: 169-176.

36. Roddy E., Zang W. and Doherty M. (2005) Evidence basedrecommendations for the role of exercise in themanagement of osteoarthritis of the hip or knee- The MOVEconsensus. Rheumatology 44: 67-73.

37. Rogind, H., Bibow, N. B., Jensen, B., Moller, H. C., Frimodt,M. H. and Bliddal, H. (1998) The effects of a physical trainingprogram on patients with OA of the knees. Arch. Phys. Med.Rehabil. 79 (11): 1421-1427.


198

38. Smidt, N., Henrica, C.W., Bouter, L. M. and Dekker, J. (2005)Effectiveness of exercise therapy: A best-evidencesummary of systematic reviews. Aust. J. of PhysiotherapyVol 51: 71-85.

39. Sturmer, T., Brenner, H., Brenner, R. E. and Gunther, K. P.(2001) Non-insulin dependent diabetes mellitus (NIDDM)and patterns of osteoarthritis. The Ulm osteoarthritis study.Scand. J. Rheumatol. 30 (3): 169-71.

40. Sun, Y., Brenner, H., Sauerland, S., Gunther, K. P., Puhl W.and Sturmer, T. (2000) Serum Uric acid and patterns ofradiographic osteoarthritis-the Ulm osteoarthritis study.

Scand. J. Rheumatol. 29 (6): 380-386.41. Taylor, N.F., Dodd, K. J., Shields, N. and Bruder, A. (2007)

Therapeutic exercise in physiotherapy practice is beneficial:a summary of systematic reviews 2002-2005. Aust. J. ofPhysiotherapy 53: 7-16.

42. Thomas, K.S., Muir, K.R., Doherty, M., Jones, A.C., Reilly,S.C.O. and Bassey, E.J. (2002) Home based exerciseprogramme for knee pain and knee osteoarthritis:randomised controlled trial. British Medical Journal. 325:1-5.


199S Shagufta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

Effect of Supervised Versus Home Based Cardiac Rehabilitationon Heart Rate Recovery in Patients with Coronary Artery bypassGraftingS Shagufta*, Jamal Ali Moiz**, Rajeev Aggarwal****Post Graduate Student, Cardiopulmonary Physiotherapy, Jamia Hamdard, New Delhi, **Assistant Professor, Centre for Physiotherapyand Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, ***Physiotherapist, Neuro Science Centre, AIIMS, New Delhi

Abstract

Purpose

The autonomic dysfunction is known to adversely affectclinical outcome in patients with cardiovascular disease, andexercise has been shown to modify the symparthovagal controlof heart rate. The purpose of this study was to investigate theeffects of four week’s supervised and home based phase IIcardiac rehabilitation (CR) on Heart rate recovery (HRR) inpatient with coronary artery bypass grafting (CABG) after 6minute walk test.

Design

A prospective, randomized, comparative study.

Setting

Cardiopulmonary Physical therapy Department, NationalHeart Institute (All India Heart Foundation ) East of Kailash,New Delhi.

Methods

Thirty patients having undergone CABG were randomlyassigned to two groups. Group A (n=15) included patients whounderwent a supervised exercise program at physiotherapyoutpatient department, and Group B (n=15) included patientswho underwent home exercise program at their residence. HRRwas measured at discharge (baseline test) and after four weeksof phase II CR ( follow up test) following a 6 minute walk test.

Results

Data was analyzed using SPSS 15.0. At follow up, boththe groups had a significantly higher recovery of heart ratesover 2 minutes ( p<0.05) compared to their baselinemeasurements.

Conclusion

Our results point out that a four weeks phase II cardiacrehabilitation program has positive effect on HRR in patientshaving undergone CABG in both the groups and is consistentwith autonomic improvement. Home based phase II CR isequally effective in improving heart rate reserve as comparedto supervised exercise group. Similar improvements of HRR inboth the groups strengthens the rationale for promoting home

Address for correspondence:Jamal Ali MoizAssistant Professor,Centre for Physiotherapy and Rehabilitation Sciences,Jamia Millia Islamia, New DelhiEmail : [email protected] No: 011 26981208

based exercise program , as the patients need not have to visithospital regularly for a supervised exercise program.

Key Words

Coronary artery bypass surgery, Cardiac rehabilitation,Heart rate recovery.

Introduction

Cardiovascular disease is the prevailing non communicablecause of death and disability in Indian subcontinent, and willbecome the prevailing overall cause of mortality among theinhabitants of south Asia in the next 20 years1. This lead to anincrease in coronary artery revascularization surgery (CABG).Today it accounts for more than 60%, and every year 25,000CABGs are being carried out2.

There is substantial evidence to conclude cardiacrehabilitation (CR) is reasonable and necessary following CABGsurgery. Phase II cardiac rehabilitation programs are associatedwith significantly improved exercise tolerance and functionalcapacity ,increasing psychosocial well being, alleviating activityrelated symptom reducing disability and decreasingcardiovascular morbidity andmortality3.

Exercise training has been a core component of CRprograms, regular exercise training in person with cardiovasculardisease results in changes in muscular, neurohormonalsystems4.

Heart rate recovery (HRR) is defined as [maximum/ peakHR at specific time period after exercise] and represented asthe drop in heart rate during that time interval 5.It has beendemonstrated that HRR may be used as an outcome measurein stratifying the risk of the patients after completion of cardiacrehabilitation programs, especially after phase II. Theinvestigations of the effect of home based exercise programand supervised exercise program on HRR after a short termcardiac rehabilitation program (4weeks) has not been clearlydemonstrated. In this study consideration has been given to theincorporation of HRR into routine exercise test interpretationuse of those findings to confirm the results, and expand theprognostic importance of HRR in patients with CABG undergoingsub maximal exercise test, as proposed to symptom limitedexercise testing after four week phase II cardiac rehabilitation.

Statement of Question

Will a short term phase II supervised exercise programimproves HRR better than a home based exercise program inpatient with CABG after sub maximal exercise testing?


Inclusion Criteria

1. Age group : 40-65years2. No previous CABG surgery3. Left ventricular ejection fraction(EF) >50%4. Absence of ventricular ectopics

200

5. No neuromuscular, skeletal impairments that wouldprohibit exercise.

6. Uncomplicated clinical course in hospital (not>12hourson ventilator, not >48hours in ICU, infection, shock)

7. Sinus rhythm.

Exclusion Criteria

1. Resting HR> 120 BPM2. Resting SBP >200mmHg

DBP> 100mmHg3. Orthostatic BP drop by 20 mmHg or more.4. Acute systemic illness or fever.5. Uncontrolled arterial or ventricular dysrhythmias6. Uncontrolled CHF7. III degree AV block8. Coexisting vavular and /or peripheral vascular diseases,

thrombophlebitis9. Recent embolism.10. Uncontrolled diabetes11. Unstable angina12. Those that could not complete test at discharge or after

four weeks of CR

Study Design

Pretest and posttest experimental design.VariablesDependant variable: Heart rate recoveryIndependent variable: Cardiac rehabilitationInstrumentationLocation: a 15 meter straight level corridorEquipment: pulse oximeter (PM50-MINDRAY) , Inch tape,

stopwatch, chalk marker, cones, wheel chair

Procedure

Thirty eligible patients having undergone CABG who werereferred by cardiovascular surgeons participated in the study.There were 90% males and 10% females. All of them completedphase I cardiac rehabilitation program such as early mobilization,walking etc under supervision after surgery on transfer to anICU and wards. Before baseline exercise test at discharge, these30 patients were randomly assigned to one of the following twogroups for four weeks. The subjects in any of the group wereblinded to the interventions of the other group and theexperimental procedure and risk of exercise were fully explainedto each subject and signed informed consent was obtained.

Protocol

Patient who were assigned to phase II cardiac rehabilitationat discharge into a supervised and a home exercise group weregiven exercise intervention accordingly

Group A (Supervised cardiac rehabilitationgroup)

Patient randomized to this group (n=15) were enrolled in a45 minutes (average time) exercise session. ROM exercises,walking, and stair climbing with self controlled exercise intensityset at level of 4-6 on Borg’s 10 point RPE scale (safe rangerecommended for cardiac patient6 ) ,was used to train thepatients. Exercises were supervised by researcher during theexercise session. The training frequency was 3 times /week (24sessions) for 4 weeks.

Group B (Home based cardiac rehabilitationgroup)

Patients randomized to this group (n=15) were instructedto conduct a home based exercise program with an intensitycorresponding to RPE of 4 to 6 on a 10 point scale. Patientswere advised to exercise three times a week, for 45 minutes(average). Exercise training involved ROM exercise, walking,and stair climbing. To control for their adherence to exercise,the subjects and their family were asked to document theexercise in an exercise log/ monitoring chart. Individuallyprescribed home based exercise was given and updated bytelephonic consultation every week by the researcher. Both thegroups were given education and counseling. Dietician gavethem advice on balance diet in hospital and after discharge inthe form of diet chart

Exercise Testing Protocol

The participants underwent a sub maximal exercise testing,i.e. 6MWD at discharge and 4weeks follow up at national heartinstitute according to ATS guidelines7.

Heart Rate Recovery

After achieving peak HR at the end of 6MWT, patients wentinto a recovery phase for at least 5minutes. The reduction inHR from immediately after peak exercise to the HR after 2minwas defined as HRR5. All subjects in two groups received submaximal exercise test at discharge, (baseline test) and 4weekslater ( follow up test)

Data Analysis

Data analysis was performed using SPSS version15.0. Thedescriptive variables were expressed as, mean + SD. The mainoutcome measure, heart rate recovery expressed in beats perminutes, between two groups at the time of discharge and afterfour weeks follow up were analyzed and compared using Leven’st- test to examine the differences. Statistical significance withingroups from baseline to follow up was evaluated using paired t-test. Statistical significance was assumed at p <0.05.

Table1: Demographic Characteristics of patients

Supervised group Home exercise groupGroup A Group B

Number of 15 15subjects

Age (years) 56.35±8.07 58.87±7.87

Height 1.66±0.07 1.64±0.08(meters)

Weight (Kg) 65.78±13.40 68.37±10.12

BMI, Kg/m2 22.94±4.08 25.07±2.38

Ejection 56.21±5.35 57.31±5.41fraction, %

Number of 3.0±0.75 3.0±0.84grafts

Results

Thirty patients were analyzed for the study (n=15 in eachgroup).The sample consisted of 90% males and 10% females.

S Shagufta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3

201

The demographic data is as shown in table 1.Heart rate recovery expressed in beats per minute (bpm)

was measured at discharge (HRR b) and after four weeks (HRRf) of phase II Cardiac Rehabilitation in supervised exercise group

Table 2: HRR comparison within the groups

(Group A) and home exercise group (Group B). There was nosignificant difference in HRR at baseline [Group A 30.2±10.5,

Groups HRRb HRRfn=15 n=15 Paired t test

t p

Group A 30.2±10.5 35.7±9.5 6.11 0.001

Group B 29.5±8.9 34.4±9.9 7.75 0.001

Table 3: HRR comparison between the groups

Variable Group Group Indepen A B dent test

t p

HRRb 30.2±10.5 29.5±8.9 0.205 0.839n = 15

HRRf 35.7±9.5 34.4±9.9 0.345 0.726n = 15

Group B 29.5±8.9; p<0.05] and HRR at follow up, [Group A35.7±9.5, Group B 34.4±9.9; p<0.05] within the groups as shownin table 2.

There was no significant difference in HRR between the

groups (p<0.05) at follow up test as shown in table 3.After 4 weeks of CR, HRR improved in both the groups

when compared to their baseline values. The mean improvementbeing 5.8±3.40 bpm in group A and 5.2±2.73 bpm (p=0.640) ingroup B from baseline to follow up as shown in Figure.1.

At baseline testing, there was no significant difference inresting heart rates between the groups (mean± SD, Group A90.4±10.16, Group B 88.4±12.86; p=652). After 4 weeks, boththe groups showed lowered resting heart rates at follow uptesting (Group A 84.9±10.10, Group B 85.4±11.91; p=0.909)and there was no significant difference between them.(p<0.05)as shown in table 4.

Discussion

The results of this study showed significant improvementsin heart rate recovery in patients having undergone CABG aftera four weeks phase II Cardiac Rehabilitation in both supervisedand home based exercise group compared to their baseline

Table 4: Exercise testing parameters (6MWT), comparisonbetween the groups

Parameters Group A Group B p value (n=15) (n=15)

RHR,bpm Baseline 90.4±10.16 88.4±12.86 0.652

Follow 84.91±0.10 85.4±11.91 0.909up

PHR,bpm Baseline 119.3±16.10 121.2±17.38 0.763

Follow 124.5±15.70 123.86±18.29 0.916up

HRR,bpm Baseline 30.2±10.53 29.5±8.99 0.839

Follow 35.7±9.66 34.4±9.95 0.726up

Mean change in HRR 5.8±3.40 5.2±2.73 0.640follow from baselineand up testing, bpm

values. The improvements at follow up in the supervised andhome exercise group are consistent with that in previouslypublished study by Legramante8. The parasympathetic tonepredominates at rest, and heart rate increases during exercisein response to a combination of sympathetic activation andparasympathetic withdrawal, with inverse occurring duringrecovery after exercise3,9. The autonomic dysfunction is knownto have adverse effects on subsequent clinical outcome inpatients with coronary artery disease10.

The resting heart rates in the supervised exercise groupand home exercise group had significantly reduced at followup test, when compared to their baseline test values (p=0.652).This was consistent with the previous work done by Legramanteand Shinji Sato et al 8,11. The possible explanation being that thepatients with coronary heart disease are subjected to activationof neurohumoral mechanisms, especially the adrenergicactivation from sympathetic activity in early recovery phase aftercardiac events9,10. Reduced resting heart rate lowers the risk ofsudden cardiac death through increased vagal tone, which is aparasympathetic activity9.

The recoveries of heart rate over 2 minutes at follow upalso showed significant improvement in both the study groupsand coincided with the previous work8. Legramante8 measuredHRR after 1 and 2 minutes, his findings showed that HRR in the2nd minute after the cessation of cycle-ergometer exercise testimproved and showed a positive effect. The value of HRR in thepresent study was in consistent with his results.

Exercise training during CR was associated with animprovement in HRR, which may represent an improvement ofautonomic tone. These findings were consistent with the previousstudies that evaluated the effect of exercise-based CR on HRRand showed a positive result. Study done by Tiukinhoy12 andcolleagues reported a significant improvement in HRR in theintervention subjects (who underwent structured phase II CR,6- 9 months time between exercise tests using treadmill Bruceprotocol); Sen-Wei13 and colleagues also reported a significantimprovement in HRR in CR group (training given using stationarybicycle or walking on treadmill, 36 sessions for 3 months) frombaseline to follow up. In the present study there was no significantdifference in HRR between the supervised and home exercisegroups after 4 weeks phase II CR (24 sessions of ROMexercises, walking, stair climbing, after 6 MWT). Thus, HRRmight provide an additional simple marker of effectiveness ofphysical training programs in cardiac patients.

The improvements in HRR may be related to the molecularmechanisms underlying the regulation of HR recovery.Chromosome CHRM2 plays a fundamental role in cardiacautonomic regulation. Activation of cardiac vagal efferents leads


Fig. 1: Comparison of Heart Rate Recovery between Groups

202

to release of acetylcholine, which acts on cardiac CHRM2 todecrease HR14. Another possible explanation for the increasein HRR after CR is the effect of beta blockers. Beta blockingmedication decrease resting heart rate and reduce the ability toachieve maximum heart rate. Previous studies have beeninconsistent over the effects of beta blockers on HRR. Desai15

and colleagues reported that beta blockers affect HR in recoverymost likely through an indirect effect by reduction ofchronotropism.

Future Research

HRR has been shown to be a predictor of mortality, andthis study demonstrated that HRR improved in a sample ofpatients who completed CR. It is not known whether improvingHRR will have a meaningful effect on survival. Future researchis needed to more adequately address whether improving HRRimproves mortality. T he effect of beta-blockers on HRR alsoneeds to be investigated further.

Conclusion

Four week’s supervised phase II Cardiac Rehabilitationsignificantly improved Heart Rate Recovery in low risk populationafter CABG surgery; home based phase II Cardiac Rehabilitationin the similar population was equally effective and showedsignificant improvements in Heart Rate Recovery. There wasno significant difference in Heart Rate Recovery between thesupervised group and home exercise group after the completionof four week’s phase II Cardiac Rehabilitation. Thus, the nullhypothesis has been supported.

Acknowledgements

The authors would like to thank to all the doctors, nursingstaff, and physiotherapists at National Heart Institute (All IndiaHeart Foundation) East of Kailash, New Delhi for their supportto conduct this research.

Interest of Conflict

The authors have no conflicts of interest to declare.

References

1. Abhinav Goyal & Salim Yusuf. The burden of cardiovasculardisease in the Indian subcontinent. Indian J Med Res 124,September 2006, pp 235-244.

2. R R Kasliwal, A Kulshreshttha, Shweta Aggarwal,M

Bansal,N Trehan.Prevelence of cardio vascular risk factorsin Indian patients undergoing CABG surgery .JAPI., 54;371-3.

3. Wu s-K, Lin Y-W, Chen C-L, Tsai S-W: Cardiac rehabilitationverses home exercise after CABG: comparison of HRR.Am J Phys Med Rehabil 2006; 85:711-717.

4. Julie S. Macmillan, MSN, RN, ANP-C, Leslie L. Davis, MSN,RN, ANPC,Carol F. Durham, MSN, RN, EdD, and ElizabethS. Matteson, MAb. Exercise and heart rate recovery. HeartLung 2006; 35:383–390.

5. Katherine Shetler, MD, Rachel Marcus, MD, Victor F.Froelicher, MD, Shefali Vora, MD, Damayanthi Kalisetti,MD, Manish Prakash, MD, Dat Do, MD, Jonathan Myers,PHD. Heart Rate Recovery: Validation and MethodologicIssues .J Am Coll Cardiol 2001; 38:1980 –7.

6. Pullock, Welch, James Exercise prescription for cardiacrehabilitation, 1997. Cardiac rehabilitation; Human KineticsIII:243-276.

7. ATS guidelines for 6MWT 2002.8. Legramante JM, Ferdinando Ielliamo, Michele Massaro,

Sergio Sacco, and Alberto Galante, Effects of residentialexercise training on HRR in CABG .Am J Physio HeartCirc Physio 2007 ;292:H510-59.

9. Pierpont GL, Stolpman DR, Gornick CC. Heart rate recoverypost-exercise as an index of parasympathetic activity. JAuton Nerv Syst 2000; 80:169–74.

10. Daniel Lucini, Richard, Milan, Giorgi Costantino, Carl, Lavie,Alberto, Massimo. Effects of CR and exercise training onautonomic regulation in patients with CAD. Am Heart J2002; 143:977-83.

11. Shinji Sato, PhD; Shigeru Makita, MD; Misturu Majima, MD.Additional physical During Cardiac Rehabilitation leads toan improved HRR in patients after CABG. Circ J; 2005;69:69-71.

12. Tiukinhoy S, Beohar N, Hsie M. Improvement in heart raterecovery after cardiac rehabilitation. J Cardiopulm Rehabil.2003; 23: 84-7.

13. Sen-Wei Tsai, Yi-Wen Lin, Shyi-Kuen. The effect of cardiacrehabilitation on HR over one after exercise in patients withCABG surgery. Clinical Rehabilitation 2005; 19:843-849.

14. Arto J Hautala,Touma Rankinen,Antti M. Kiviniemi, TimoH. Makikakillio, Heikki V Huikuri, Claude Bouchard, andMikko P.Tulppo. HRR after sub maximal exercise isassociated with Ach Receptor M2 (CHRM2) genepolymorphism. American Journal of Physio Heart CircPhysiol 2006. 291; H459-H466.

15. Milind Y. Desai; Erasmo De la Peña-Almaguer; Finn Mannting Abnormal Heart Rate Recovery after Exercise: AComparison with Known Indicator. Cardiology; 2001; 96:38-44.


Call for Papers / Article SubmissionIndian Journal of Physiotherapy and Occupational Therapy has commenced publication since 2006. IJPOT will he published four times in a year.

Purpose & Scope: IJPOT is a multidisciplinary refereed journal devoted to disseminating rigorous research on all aspects of the physiotherapy and occupational therapy to enhance learning. The journal seeks to be a catalyst for multidisciplinary dialogue amongst researchers and practitioners worldwide in the fields of learning and cognition, education, and technology, with a view to improving practice and achieving real-world impact in technology enhanced learning.

The journal encourages research from theoretical perspectives, research reports of evidence based practice as well as praxis research work that focuses on the interface between theory and practice and how each can support the other. In addition, the journal strongly encourages reports of research carried out within or involving countries in the Asia— Pacific region.

Invitation to submit papers: A general invitation is extended to authors to submit journal papers for publication in IJPOT.

The following guidelines should be noted:• The article must be send by E-mail in word only as attachment. Hard copy need not be send.• The article should be accompanied by a declaration from all authors that it is an original work and has not been

sent to an other journal for publication.• As a policy matter, journal encourages articles regarding new concepts and new information.• Article should have a Title• Names of authors• Your Affiliation (designations with college address)• Abstract• Key words• Introduction or back ground• Material and Methods• Findings• Conclusion• Acknowledgements• Interest of conflict• References in Vancouver style.• Please quote references in text by superscripting• Word limit 2500-3000 words, MSWORD Format, single file

Indian Journal of Physiotherapy & Occupational TherapyDr Archna Sharma, Editor IJPOT

Aster-06/603, Supertech Emerald CourtSector - 93 A, Expressway, NOIDA 201 304

Uttar PradeshMobile: 09891098542

Email: [email protected] • Website: www.ijpot.com

CALL FOR SUBSCRIPTIONS

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

An essential journal for all Physiotherapists & Occupational therapists provides professionals with a forum in which to discuss today’s challenges-identifying the philosophical and conceptural foundations of the practice; sharing innovative evaluation and treatment techniques; learning about and assimilating new methodologies developing in related professions; and communicating information about new practice settings. The journal serves as a valuable tool for helping therapists deal effectively with the challenges of the field. It emphasizes articles and reports that are directly relevant to practice. The journal is internationally indexed and is also covered by Index Copernicus (Poland).

Note for SubscribersAdvance payment required by Cheque / Draft in the name of “Indian Journal of Physiotherapy and Occupational Therapy” payable at New DelhiConcellation not allowed except for duplicate payment.Claim must be made within six months from issue date.A free copy can be forwarded on request.

SEND REMITTANCE TO:Dr. Archna Sharma, Editor, IJPOT

Indian Journal of Physiotherapy and Occupational TherapyAster-06/603, Supertech Emerald Court, Sector – 93 A

Expressway, NOIDA 201 304, UTTAR PRADESHMobile: +91-9891098542

Email: [email protected], Website: www.ijpot.com

Subscription Information

Journal Title Pricing of Journals

IJPOT Print Only Print+Online Online Only

Indian INR 6000 INR 8000 INR 4500

Foreign USD 400 USD 500 USD 300

Ijpot july sept 2011

Health & Medicine

girdhar gopal agarwal

gyanendra kumar malik

kamal narayan arya

total knee replacement

balance training onfloor

semi tandem position

vijai prakash sharma

increased tone felt