ndian Journal ofijpot.com/scripts/April-June 2009 issue.pdf · expansion at three levels were measured pre-operatively, post-operatively on the 3rd and 7th day. Results There was

Indian Journal of Physiotherapy and Occupational Therapy

An International Journal

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

Volume 3 Number 2 April - June 2009

website: www.ijpot.com

Contentswww.ijpot.com

April - June 2009Volume 3, Number 2

Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2 I

01 Comparative study of post-operative pulmonary mechanics between subcostaland midline laparotomyAnuprita Thakur, Sujata Yardi

06 Comparison of helium neon laser with gallium arsenide laser therapy on painand functional ability in patients with trigger points (Upper trapezius muscle)Dheeraj Lamba

12 Comparative evaluation of physiotherapy and pharmacotherapy in themanagement of temporomandibular joint myofascial painVenkatesh G Naikmasur, Kruthika S.Guttal, Puneet Bhargava, Renuka J Bathi

18 Comparative analysis on the efficacy of G.D. Maitland’s concept of mobilization& muscle energy technique in treating sacroiliac joint dysfunctionKanchan Rana, Nitesh Bansal, Savita

22 Activity, participation and quality of life after stroke: A 6-month follow-up ofcommunity-dwelling Nigerian stroke survivorsGrace O. Peters, Talhatu K. Hamzat

27 Effect of strength training using one’s own body weight in sarcopenia-a singleblind studyJ Madhana Gopal, D Arun, N Padma Priya, M Dhinesh Kumar,C Elanchezian, V S Natrajan

31 Physiotherapy assessment findings may not correlate with MRI findings inneurologically impaired patient – A case reportJojo K George, Kavitha Vishal, Narasimman.S.

34 Effect of a structured antenatal physiotherapy program on back painAgrawal Neha, Raja Kavitha, Pereira Daphne

37 Physiotherapy Central Council: An updateNitesh Bansal

39 Effect of neurodevelopmental therapy in gross motor function of children withcerebral palsySenthilkumar CB, Deepa B, Ramadoss K

43 Effect of exercise on non-exercising premenopausal and postmenopausalwomen– A comparative studyRazdan Shaily, Sarkar Aparna, Kuhar Suman, Bansal Nilesh, Khurana Sonal

47 Efficacy of dynamic muscular stabilization techniques (DMST) over conventionaltechniques in patients with chronic low back painSuraj Kumar, Vijai P. Sharma, H K Tripathi, Mahendra P.S. Negi, G.Venu Vendhan

54 Study of the level of fitness in under – 16 male football players & effects ofpuberty on fitnessVijaya. Vishwanathan, Chhaya. Verma

59 Comparison between straight leg raise & bent leg raise stretching techniquesfor increasing hamstring flexibilityNeha Jain, G.L.Khanna, Amit Chaudhary

61 The effectiveness of moblization with movemental along with phonosphoresisand exercises in subacute phase of tennis elbowRekha Wadhwa, G.L.Khanna, Amit Chaudhary

Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2

INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPY

EditorDr. Archna Sharma

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

Executive EditorDr. R.K. Sharma, New Delhi

National Editorial Advisory BoardProf. U. Singh, New DelhiDr. Dayananda Kiran, IndoreDr. J.K. Maheshwari, New DelhiDr. Nivedita Kashyap, New DelhiDr. Suraj Kumar, New DelhiDr. Renu Sharma, New DelhiDr. Veena Krishnananda, MumbaiDr. Jag Mohan Singh, PatialaDr. Anjani Manchanda, New DelhiDr. M.K. Verma, New DelhiDr. J.B. Sharma, New DelhiDr. N. Padmapriya, ChennaiDr. G. Arun Maiya, ManipalProf. Jasobanta Sethi, BangaloreProf. Shovan Saha, ManipalProf. Narasimman S., MangaloreProf. Kamal N. Arya, New DelhiDr. Nitesh Bansal, NoidaDr. Aparna Sarkar, NoidaDr. Amit Chaudhary, Faridabad

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.R. Hamzat, Nigeria

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

“Indian journal of physiotherapy and occupational therapy” An essential indexed peer reviewed journal for allPhysiotherapists & Occupational therapists provides professionals with a forum to discuss today’s challenges - identifyingthe 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 informationabout new practic settings. The journal serves as a valuable tool for helping therapists deal effectively with the challengesof the field. It emphasizes articles and reports that are directly relevant to practice. The journal is now covered by INDEXCOPERNICUS, POLAND. The journal is indexed with many international databases.The journal is registered with Registrar on Newspapers for India vide registration DELENG/2007/20988

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II

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Comparative study of post-operative pulmonary mechanicsbetween subcostal and midline laparotomyAnuprita Thakur*, Sujata Yardi***Assoc. Prof, **Professor & Dean, Dr D.Y. Patil Institute of Physiotherapy, Navi Mumbai

Abstract

BackgroundCommonly two incisions are used in Upper Abdominal

Surgeries (UAS): Midline and Subcostal. Following either ofthe surgeries patients develop significant alteration inbreathing pattern due to the restrictive type of pulmonarydysfunction.

Aims & objectives

To compare the effects of both the incisions on pulmonarymechanics, assess which of the two incisions affect thepulmonary mechanics more than the other and to accordinglymodify the post-operative Chest Physiotherapy treatmentplan.

Materials and methods

10 subjects in each group (subcostal and midline incision)were selected. Parameters like diaphragm excursion onU.S.G., Peak Expiratory Flow Rate (PEFR) and chestexpansion at three levels were measured pre-operatively,post-operatively on the 3rd and 7th day.

Results

There was a decrease in the diaphragm excursion, PEFRand chest expansion at umbilical level on post-operative day3 but the decrease was much more in the midline groupthan the subcostal group. The above parameters improvedon post-operative day 7 as compared to post-operative day3 in both the groups but the improvement was much more inthe subcostal group than the midline group. Both the resultswere statistically significant.

Conclusion

The study shows that the pulmonary mechanics areaffected post-operatively in both the groups, the affectionbeing more in the midline group than in the subcostal group.Also the return of function to the pre-operative values wasearlier in the subcostal group as compared to the midlinegroup.

Hence administration of Chest Physiotherapy post-operatively should be modified accordingly to improve thefunction especially in the midline group.

Key words

Upper Abdominal Surgery, Median Laparotomy,Subcostal Laparotomy, Diaphragm, PEFR, Chest Expansion

Introduction and background

The two common Laparotomies performed in UpperAbdomen include mainly the Midline and Subcostal incisions.Patients undergoing Upper Abdominal Surgery develop arestrictive pattern of Pulmonary Dysfunction1 and significantalteration in breathing pattern mainly due to abnormaldiaphragm mechanics in the immediate post-operativeperiod. These can lead to certain respiratory complicationspost-operatively.

Conventional Chest Physiotherapy includes techniqueslike breathing exercises, coughing & huffing techniques,postural drainage etc. and is an established mode oftreatment for pulmonary complications following abdominalsurgery.

The following study compares effects of both the incisionson post-operative pulmonary mechanics and accordinglydecides an effective Chest Physiotherapy treatmentapproach.

Anatomy of respiratory apparatus2,3,4

Chest wall is considered to consist of 3 parts:1. Rib cage or thoracic cavity with its musculature2. Diaphragm3. Abdomen and its musculature

Rib cageThe rib cage provides rigid protection to the thoracic

structures and comprises of manibruiosternum, 12 pairs ofribs, costal cartilages and 12 thoracic vertebrae and theirintervertebral discs.

Ventilatory musclesDiaphragm: Fig 1

It is the primary muscle of respiration and accounts for70% of the inspired tidal volume. It is a dome shaped musclewith 3 origins namely-Costal, Sternal and Crural All thesefibres converge and insert into the central tendon, whichlies immediately below the pericardium and blends with it.

The other inspiratory muscles (depending on whetherinspiration is forced or at rest) are Internal intercostals,External intercostals, Scalenes, Sternocleidomastoid,Pectorals, Serratus anterior, Latissimus dorsi.

Expiratory musclesThese are the abdominal muscles: rectus abdominus,

internal and external obliques, transverse abdominus. Thesemuscles also play an important role in inspiration.

Zone of appositionThis is that part of the diaphragm that is apposed to the

inner aspect of the rib cage.

Anuprita Thakur et al/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2

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Biomechanics of normal respiration

Action of diaphragmIts inspiratory action has three components:1. When the diaphragm contracts, the central tendon is

pulled down increasing the vertical diameter of thorax.2. Appositional component: When the diaphragm

contracts, it descends to compress the abdominalcomponents increasing the intra-abdominal pressure.This increased pressure is transmitted via the zone ofapposition to cause lower rib cage to expand (pumphandle mechanism)

3 Insertional component: The contraction of costal fibresis facilitated by the abdominal muscle tone whichincreases the intra-abdominal pressure and thisprovides a fulcrum for the diaphragm to lift the lowerribs upwards and outwards thus increasing thetransverse diameter of lower rib cage (bucket handlemechanism)

Thus the diaphragm increases all the threediameters of the rib cage

Action of expiratory musclesContractions of the abdominals decrease the size of rib

cage and cause expiration. The abdominals push theabdominal contents cranially, decreasing lung volumes andlengthening the diaphragm at end-expiration.

These muscles also facilitate diaphragmatic contractionduring inspiration as mentioned above.

Thus the abdominal muscles play an importantrole during both inspiration and expiration

Incisions

The commonly used incisions in the upper abdominal

surgeries are Subcostal and Midline incisions. Fig 2Subcostal incision starts in the midline just below the xiphoidprocess and runs downwards and laterally about 2cms belowand parallel to the costal margin. All the muscles includingthe Rectus Abdominus are divided along the line of incision.

Midline incision extends vertically from below the xiphoidprocess and divides the linea alba vertically.

Materials and methodology

Materials1. U.S.G. machine2. Gel3. Wright’s Peak Flowmeter4. Measure tape

Selection of subjectsTotal 20 subjects between age group of 45-65 years who

had undergone Upper Abdominal Surgery in B.Y.L. Nair Ch.Hospital, Mumbai, 10 with Midline incision and 10 withSubcostal incision were selected. A written consent wastaken from all the patients to carry out the study.

None of the subjects had any previous history of cardiacor respiratory (either restrictive or obstructive) illness.

None of the subjects had history of smoking,hypertension, diabetes mellitus.

MethodologyA) Pre-operative diaphragm excursion on U.S.G., Peak

Expiratory Flow Rate (PEFR) and Chest Expansionmeasurements were recorded.

For diaphragm excursion5 Fig 3Subject lies supine. The level of hepatic vasculature structureis recorded at the end of forced expiration and then at theend of forced inspiration. The cephalo-caudal displacementof the hepatic vasculature structure is measured incentimeters, which is considered as the diaphragmexcursion. (Fig 4) during inspiration.

For PEFR (Fig 5)Subject is asked to take a deep inspiration and then blow ashard and as fast as possible into the peak flowmeter. Thisrecords the peak expiration in litres/minute.

For chest expansion (Fig 6)Measurements are done at 3 levels: 2 inches above

Fig. 1: Fig. 2:


3

umbilicus, nipple level and axillary level. Subject is asked toexpire completely. Then take a deep inspiration and expirecompletely. Measurement is done from complete expirationto complete inspiration using a measure tape.B) The above parameters were checked again post-

operatively on day 3.C) The above parameters were checked again post-

operatively on day 7.

Results

The results of both the groups were comparedResults show a decrease in diaphragm excursion, PEFR

and chest expansion at umbilical level on post-operative day3 compared to pre-operative values in both the groups.However, all the parameters are more affected in midline

group as compared to the subcostal group and the resultswere statistically significant.

Also the results show that all 3 parameters on post-operative day 7 have considerably improved and have comeclose to normal values in subcostal group which is not so inthe midline incision group. The results were statisticallysignificant.

Results also show an increase in the post-operativevalues at the nipple and axillary levels in both the groups onpost-operative day 3.

Discussion

The results confirm alterations in the post-operativepulmonary mechanics in both the groups. All the parameters

Table 2: Comparison of PEFR in both groups.Pre-op Post-op Post-op % Difference between

Day 3 Day 7 Pre –op and Pre-op andPost-op Day3 Post-op Day 7

Subcostal 312 188 288 61% 93%(+/-72.5) (+/-64.77) (+/- 74.98)

Midline 316 134 226 48% 72% (+/- 74.47) (+/- 36.81) (+/- 65.99)

Fig. 3:

Fig. 4: E - During Expiration, I – During Inspiration

Fig. 5:

Fig. 6:

Table 1: Comparison of diaphragm excursion in both groups.Pre-op Post-op Post-op % Difference between

Day 3 Day 7 Pre –op and Pre-op andPost-op Day3 Post-op Day 7

Subcostal 3.74 2.31 3.48 62% 94%(+/-0.625) (+/- 0.47) (+/- 0.614)

Midline 3.77 1.8 2.78 48% 65%(+/- 0.93) (+/- 0.515) (+/- 0.814)


4

Table 3: Comparison of chest expansion in both groups.Pre-op Post-op Day 3 Post-op Day 7 % difference between

Pre –op and Pre-op andPost-op Day 3 Post-op Day 7

Subcostal 2" above 2 1.05 1.85 53% 93%umbilicus (+/-0.4) (+/-0.397) (+/- 0.411)

Nipple 1.75 1.95 1.75 11% Nolevel (+/-0.353) (+/-0.437) (+/- 0.353) increase change

Axillary 1.75 2 1.6 14% 2%level (+/-0.353) (+/-0.333) (+/- 0.349) increase increase

Midline 2" above 1.95 0.4 1.1 32% 57%umbilicus (+/-0.368) (+/-0.436) (+/-0.21)

Nipple 1.75 2.2 2.15 25% 22%level (+/-0.353) (+/-0.258) (+/-0.337) increase increase

Axillary 1.75 2.2 2.15 25% 22%level (+/-0.353) (+/-0.258) (+/-0.337) increase increase

Table 4: Comparison of all three parameters in Subcostal and Midline group.Post-op day 3 Post-op Day 7

Diaphragm excursion t=2.2 t=2.134PEFR t=2.29 t=2.15

Chest expansion at 2" t=3.3 t=5.17above umbilicus

Nipple level t=1.5 t= 2.6Axillary level t=1.5 t= 2.3

0

0.5

1

1.5

2

2.5

3

3.5

4

Subcostal Midline

Pre-op

Post-op day 3

Post-op day7

Fig. 7: Comparison of Diaphragm excursion in both the groups.

0

50

100

150

200

250

300

350

Subcostal Midline

Pre-op

Post-op day 3

Post-op day 7

Fig. 8: Comparison of PEFR in both groups.

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Subcostal

- 2"

Midline-

2"

Pre-op

Post-op day 3

Post-op day 7

Fig. 9: Comparison of chest expansion at umbilical level in both groups.

(except chest expansion at nipple level and axillary levels)were decreased on post-operative day 3 in both the groups.However, the decrease was more in the midline group ascompared to the subcostal group and the return to the pre-operative values was much better in the subcostal group.

The alterations in pulmonary mechanics in the post-operative groups can be attributed to the fact that-

The distracting force on an incision during activity in thepost-operative period leads to stretching kind of pain, whichlimits diaphragm excursion6. During normal diaphragmatic

breathing the abdomen moves out and this outwardmovement stretches the incision and leads to pain. Thisleads to reduced diaphragmatic excursion, PEFR andthoracic expansion at umbilical level.

It is observed that the parameters are more affected inthe midline group as compared to subcostal group. Thiscould be attributed to the following additional factors–

A reflex mechanism wherein the midline incision impingeson and transects the abdominal visceral afferents whichinhibit inspiratory motor neurons and leads to phrenic nerveinhibition resulting in diaphragm dysfunction despite normalintrinsic diaphragm contractility7,8.

Also the distracting force on the midline incision duringpost-operative period is nearly as twice as great as on thaton a transverse (subcostal) incision6, thus the associatedpain is also more.

The integrity of the linea alba is important for the efficientfunctioning of the Rectus Abdominus muscle. Once the lineaalba is cut due to midline incision, functional impairment ofthe Rectus Abdominus on both the sides may contribute toalteration in diaphragm mechanics9.

The contraction of the abdominal muscles causes closingof the subcostal incision and hence less pain. This is thereverse of normal diaphragmatic breathing where theabdominal wall is stretched. This is confirmed in a study bySloan10.

Also studies have shown that the analgesia required post-operatively was more in the midline incision group ascompared to the subcostal group suggesting more painexperienced by the patients undergone midline incision14.

Thus all the factors namely altered diaphragm


5

mechanics, surgical muscular injury and pain lead toimpaired ability to deep breath, cough and sigh, more so inthe midline group than in the subcostal group. This makesthe patient vulnerable to complications of atelectasis andpneumonia especially in the lower lobes of the lungs15 asthe diaphragm is largely responsible for ventilation of themost dependent portions of the lungs. Post-operativediaphragm dysfunction produces shift of ventilation awayfrom lower lung fields. In the present study also it wasobserved that the chest expansion at the umbilical level wasdrastically reduced and was compensated by expansionsat nipple and axillary levels. The study by Tahir et al alsosupports this16.

Identical Chest Physiotherapy is conventionally practicedfor patients with both the types of incisions. However, thepresent study suggests the need for a revised approach ofPhysiotherapy to midline incision group including additionalmeasures to relieve pain using electrical modalities likeTENS, Ultrasound, guarding of the muscle and alsostrengthening of abdominals should be emphasized upon.This will facilitate diaphragmatic excursion and promoteabdominal muscle as an efficient expiratory muscle.

Conclusion

The study shows that the pulmonary mechanics areaffected post-operatively with both the incisions. However,the affection is more in the midline group than in the subcostalgroup. Also, the return of function after a week is near aboutpre-operative values in the subcostal group while it stillremains reduced even in the midline group. Hence thePhysiotherapy approach towards midline incision groupshould be modified.

References

1. Duruiel B, Cantineau J. P., Desmonts J. M., “Effects ofupper or lower abdominal surgery on diaphragmaticfunction” Br. Jr of Anesthesia 1987; 59; 1230-1235

2. Cynthia Zadai, Pulmonary Management in PhysicalTherapy

3. Barbara Webber, The Bromptom Hospital Guide to

Chest Physiotherapy4. Kappandji, The physiology of Joints (Vol 3)5. Simmoneau G., Vivien A., Satene R., Kustlinger F.,

Samii K., Naziant Y., Duroux P., “Diaphragm dysfunctioninduced by upper abdominal surgery”. American Reviewof Respiratory Disease, 1983; 128; 899-903

6. Letwin E., George R. B., Weill H., Adriani J., “Theexperimental healing of soft tissues” J. R. Coll. Surg.Edinb. 1967; 12; 121-132

7. Duruiel B., Vires n., Cantineau J.P., Marty C., AubierM., Desmonts J. M., “Diaphragmatic contractility afterupper abdominal surgery”

8. Halasz N. A., Torrance, Calif “Vertical versus horizontallaparotomies” Archives of surgery, 1964; 88; 911-914

9) Ali J., Ali Khan T. “The comparative effects of muscletransaction and median upper abdominal surgery onpost-operative pulmonary function” Surg., Gynec.,Obst., 1979; 148; 863-866

10. Sloan G.A., “Newer upper abdominal incisions” Surg.,Gynec., Obst., 1927; 45; 678

11. Prabhakar N.R., Marek W., Loeschcke H.H., “Alteredbreathing patterns elicited by stimulation of abdominalvisceral afferents” Jr. of Applied Physiology, 1989; 58;1755-1760

12. Okinaka A. “Post-operative patterns of breathing andcompliance” Archives of Surgery, 1966; 92; 887-891

13. Latiner R. G., Dickman M., day W. C., Gunn M.L.,Schmidt C.D. “Ventilatory patterns and pulmonarycomplications after upper abdominal surgery determinedby pre-operative and post-operative computerizedspirometry and blood gas analysis.

14. Garcia-Valdecasas J.C., Almenara R., Cabrer C., LacyA.M., Sust M., Fuster J., “Subcostal incision versusmidline laparotomy in gallstone surgery: a prospectiveand randomized trial” Brit. Jr. Surg. 1988; 75; 473-4754

15. Weisel R.D., Layug A.B., Kripke B.J., Hectan H.B., “Consequences of post-operative alterations inrespiratory mechanics” Am. Jr. Surg., 1974; 128; 376

16. Tahir A. H., George R.B., Weill H., Adriani J. “Effects ofabdominal surgery opun diaphragm function andregional ventilation” Int. Surg. 1973; 58; 337-340


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Comparison of helium neon laser with gallium arsenide lasertherapy on pain and functional ability in patients with trigger points(Upper trapezius muscle)Dheeraj LambaIncharge/Lecturer Department of Physiotherapy, Institute of Allied Health (Paramedical) Services Education & TrainingIAHSET, Uttarakahnd Forest Hospital Trust & Medical College, Haldwani

Abstract

Key words/ AbbreviationsMPS: Myofascial Pain Syndrome, Trapezius muscle, He-Ne: Helium Neon, Ga-As: Gallium Arsenide, TP: TriggerPoints LLLT: Low Level Laser Therapy, VAS: Visual AnalogScale, NDI: Neck Disability Index, Tr P: Trigger Point

Purpose

The efficacy of low level laser therapy (LLLT) in myofacialtrigger points seems controversial. The aim was to clarifythe effect of Helium Neon or Gallium Arsenide Laser on painand functional ability in patients with trigger points in theupper trapezius muscle.

Methodology

The study has an experimental design.Thirty subjects (14 female, 16 male) with myofascial pain

in the upper trapezius muscle were taken and randomlyassigned to one of the three groups.

Based on inclusion and exclusion criteria, subjects wereincluded in the study.

Convenient sampling with random allocation to the threegroups (A, B, & C).

Group A (Experimental Group) received Helium NeonLaser therapy for 3 min followed by stretching exercises for30 sec twice a day for10 days during a period of 2 weeks.

Group B (Experimental Group) received Gallium Arsenidelaser therapy followed by stretching exercises in the similarway as group A.

Group C (Controlled Group) received only stretchingexercises as

The patients filled the VAS and NDI scale on zero, fifthand tenth day respectively to check the level of improvement.

Results

The data was analysed using the software SPSS 12.0.No significant difference was seen in VAS and NDI from 0to 2nd week between the 3 groups.

In result between the groups, Group C was found moreeffective than the other two groups. Stretching alone haspositive, therapeutic effect on the underlying musculoskeletaltrigger points.

Within the groups, group B i.e. He-Ne laser withStretching showed significant results from 0 to 2nd weekand from 1st to 2nd week.

Group A i.e. Ga-As with stretching showed significantimprovement from 0 to 2nd week.

Conclusion

The study concludes that n o significant difference in theeffects of He-Ne laser application with stretching and Ga-As laser with stretching when compared to stretching alone.

This study does not conclude that stretching is aneffective intervention as significant difference in the rate ofimprovement was found in group which received He-Ne laserwith stretching.

The duration over which accumulation of rate ofimprovement took place was small.

Clinical significance

No significant rate of improvement in patients receiving(He-Ne + Stretching) and (Ga-As + Stretching). Thus, boththe modalities are not beneficial for the treatment ofmyofascial trigger points. However, stretching is the mainstay as the treatment of myofascial trigger point. It can begiven as an auto therapy to patients as home programme.

Introduction

The myofascial pain syndrome constitute the largestgroup of unrecognized and misunderstood acute and chronicmedical problems in clinical practice and are among the mostcommon over looked causes of chronic pain and chronicdisability in clinical medicine. Myofascial trigger point is acharacteristic of myofascial pain syndrome (MPS) which isthe most common muscle pain disorder. MPS is pain arisingfrom one or more trigger points (TP) which are hyperirritablespots in skeletal muscle that are associated withhypersensitive palpable nodule in taut bands. The spots arepainful on compression and can give rise to characteristicreferred pain, tenderness, motor dysfunction and autonomicphenomena. There are lot of perpetuating factors for it likepostural, mechanical, environmental stresses, emotionalstresses and external compression. MPS has a highprevalence among individuals with regional pain complaints.The prevalence varies from 21% of patients seen in generalorthopaedic clinic to 30% of general medicine clinic patientswith regional pain, to as high as 85% to 93% of patientspresenting to pain management centres.

Trigger points can arise in virtually any muscle grouphowever the trapezius muscle appears to be the mostfrequently citied in clinical settings. 12 Four muscles trapezius,levator scapulae, infraspinatus and scalenus accounts for84.7% of TP. Out of these muscles, trapezius account for34.7% and levator scapulae constitute 19.7% of TP. Themajor goal of MTP therapy is to relieve pain and decreaseTP sensitivity. Common treatments consist of drugs, nonsteroidal anti-inflammatory drugs (NSAID) and epidural

Dheeraj Lamba/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2

7

injection. Various physical modalities include intermittent coldand stretch, thermotherapy, massage therapy, post isometricrelaxation, dry needling, trigger point injections, ischemiccompression, TENS, ultrasound, laser and elimination ofcausative factors.

Currently used treatments include complementarymethods of which LLLT is one of the most common method.One of the most fascinating development within the field ofelectrotherapy in recent years has been introduction of lowpower lasers Since then lasers have become a populartherapy modality.

In a double blind controlled trial conducted by Gur A. etal on patients with chronic myofascial pain syndrome in neckevaluated the effects of infrared low level 904 GA-As lasertherapy on clinical and quality of life. He revealed that LLLTis effective in pain relief and improvement of functional abilityand quality in patients with myofascial pain syndrome.

F. Ceccherelli et al in his study on diode laser in cervicalmyofascial pain confirmed that diode laser is effective andresult in pain attenuation. On the contrary, Altan L. et alwho investigated the effect of Ga-As laser therapy in cervicalmyofascial pain syndrome with a placebo controlled doubleblind prospective study. He did not find any superiority ofGa-As laser therapy over placebo. A double blind controlledon low energy laser treatment and exercise for chronic lowback pain conducted by Robin G. Klein et al concluded thatlow energy laser stimulation under short term conditions doesnot appear to provide any advantage over exercise alone.

The study undertaken by Synder-Mackler et al, toascertain the effects of He-Ne laser on resistance of skinresistance overlying musculoskeletal trigger point, showedsignificant increase in skin resistance and assumed toaccompany the resolution of pathological condition. In adouble blind study, repeated irradiation with a low powerhelium neon laser produced relief in subjects with chronicpain as concluded by J. Walker whereas no statisticaldifference was found when subjects were treated with lowoutput He-Ne laser therapy against placebo for chronicmyofascial pain.

Ali Gur et al advocated that there are differences intechnology and in the devices, and differences between thegeometry of the laser beam, the divergence of the beamand the system of collimation of the diode laser equipment.Because of the large number of positive reports and theinnocuous nature of the therapies, further clinical evaluationof laser therapy is warranted. Therefore, as mentioned abovemany researches have been done on Helium Neon laserand Gallium Arsenide laser individually. Thus, a need arisesto follow up the already acclaimed treatment in a comparativestudy.

Methodology

30 subjects (14 female, 16 male) with myofascial pain inthe upper trapezius were taken for this experimental studyto see the efficacy of LLT in releasing pain and increasingfunctional ability in patients with Myofascial trigger points.

Subjects recruited randomly.Selection on the basis of inclusion and exclusion criteria.

Inclusion criteria

1. Both male and female.2. Age group 18- 55 years.

3. Palpable taut band in the upper Trapezius muscle.4. Active trigger point in the upper Trapezius.

Exclusion criteria

1. Fibromyalgia.2. Neoplasias.3. Neck or shoulder surgery in past one year.4. History of disc disease.5. Degenerative joint disease.6. Fracture or dislocation in the cervical vertebrae.7. Cardiac conditions.8. Congenital anomalies.9. Neurological deficit.

Design

The design is experimental comparing He-Ne laser withGa-As laser therapy on pain and functional ability in patientswith trigger points in the upper Trapezius muscle.

Mechanism of laser

PHOTONS

�

�

Singlet Oxygen Production

�

�

PHYSIOLOGICAL CHANGES

The effects of low energy, red and infra-red light arephotochemical (not thermal). It triggers normal

cellular function.

Absorbed in Cytochromes & Porphyrins within theMitochondria and at the cell membrane

(Visible red light absorbed within mitochondria)(infra-red light at the cell membrane)

(Rate limiting mechs operate to prevent excess singletOxygen formation)

Formation of proton gradients across cell membraneand across membrane of mitochondria

Changes inCell MembranePermeability

IncreasedATP levels

DNAProduction


8

Instrumentation

1. Helium Neon Laser.2. Gallium Arsenide Laser.3. VAS.4. NDI.

V.A.S

Visual Analogue Scale (VAS) has been shown to be aneffective and reliable instrument for measuring patientssubjective interpretation of pain. Pain intensity has beenmeasured by subjects using 0-10 cm scale, in which 0indicates no pain and 10 indicates worst pain. VAS provideda reliable, responsive measurement and was easilyunderstood by patients.

Example of a VAS

N.D.I

Neck Disability Index (NDI) is a questionnaire designedto give us information as to how subject neck pain hasaffected his ability to manage in everyday life. For eachsection, the total possible score is 5 if the first statement ismarked the section score is zero, if the last statement ismarked score is 5. If all 10 sections are completed the scoreis calculated over 50. If anyone section is missed or notapplicable the score is calculated over 45.

Protocol

Based on inclusion and exclusion criteria, subjects wereincluded in the study. convenient sampling with randomallocation to the three groups (A, B, & C). Group A(Experimental Group) received Helium Neon Laser therapyand stretching exercises. Group B (Experimental Group)received Gallium Arsenide laser therapy and stretchingexercises. Group C (Controlled Group) received onlystretching exercises.

Clinical examination

Before starting the treatment, patient’s upper Trapeziusmuscle was palpated for the trigger point with the help ofpincher grip and flat palpation L.T.R. and jump sign wererecorded. Subjects having more than one active trigger point.The most hypersensitive point was selected and marked byusing a permanent marker. The patients filled the VAS andNDI scale on zero, fifth and tenth day respectively to checkthe level of improvement.

Group A (Experimental Group)All patients in this group received Helium Neon laser

therapy for 3 min followed by stretching exercises of theupper trapezius muscle. The treatment was given twice aday for 10 days during a period of 2 weeks.

Subject was made to sit to obscure viewing of laser.

Helium Neon laser device had a scanner with 0.1 cm beamdiameter and emitted laser beam with 632.8 nm wavelength.For 3 minutes, He-Ne laser was applied over the trigger pointin the upper trapezius at a maximum intensity of 0.75 mwproducing a low level output of (14-29 mJ) and no tissueheating.

Stretching exercises of the upper trapezius was givenfor 30 sec in 2 daily sessions with subject supine lying withhead over the end of the plinth and therapist positioned witharm/head cradling patients head in full lateral flexion, slightposition towards with varying angle of forward flexion andpushing scapula down and back with the other hand.

Group B (Experimental Group)All the patients in this group received gallium Arsenide

laser therapy followed by stretching exercises for the uppertrapezius muscle in the similar way as group A.

The patient is either in prone lying or in sitting position toobscure view of laser with skin at right angle. GalliumArsenide laser device emitted laser beam of 905 nmwavelength at frequency of 3000 Hz with 11.2 mw averagepower for 3 min twice a day for 10 days during a period of 2weeks.

Stretching exercises for the upper trapezius muscle wasgiven in the similar way as for group A.

Group C (Controlled Group)All subjects received stretching exercises for the upper

trapezius muscle as described above.

Data analysis

Data analysis was done using SPSS software version12.0.

All variables of age, weight, height, VAS and NDI wereanalyzed using One way ANOVA between Group A, Band C.

Analysis of variance was used to determine the VAS andNDI at 0, 1 and 2 week between the groups A, B and C.

Variables of VAS and NDI were analyzed using One wayANOVA between 0, 5 and 10th day within the group A, B andC.

Post Hoc test using LSD was done for pair wisecomparison of the variables of VAS and NDI between 0, 5and 10th day within the group A, B and C.

Level of significance was set as 0.05.

Results

Analysis of age between groups A, B and C using Oneway ANOVA showed significance difference (p < 0.05).Analysis of weight and height between the group showedno significance difference (p > 0.05) (Table 5.1)

Analysis of variance for VAS and NDI at 0, 1 and 2nd

week showed no significance difference between the groups.(p> 0.05) (Table 5.2)

Variables of VAS and NDI using One way ANOVAbetween 0, 5 and 10th day showed significant differencewithin the group (p < 0.05) (Table 5.3).

Post Hoc analysis using LSD showed significantdifference between 0, 5 and 10th day within the group (p <0.05) (Table 5.4).

Results showed no significant difference in VAS and NDIfrom 0 to 2nd week in all the three groups i.e. group A, B andC indicating that rate of improvement in all the three groups


9

was alike. Hence, concluding a minimal contribution oftherapeutic modalities for pain relief and increasing functionalability.

On analyzing the data with in the groups A, B and C,VAS showed significant results only in group A and B whereas NDI showed significant results in all the three groups A,B and C.

In Group A (He-Ne + Stretching) VAS score showedsignificant improvement from 5th day to 10th day and 0 dayto 10th day but there was no significant improvement from 0day to 5th day.

Group B (Ga-As + Stretching) showed no significantimprovement in VAS score from 0 to 5th day and 5th to 10th

day, but significant improvement was seen from 0 to 10th

day.Group C showed no significant improvement in VAS

score.Whereas on analyzing NDI significant improvement was

seen from 0 day to 10th day in all the three groups A, B andC.

Discussion

Myofascial pain syndrome is a common source ofdiscomfort and disability for many patients. However it isgenerally ignored or misdiagnosed leading to chronic painfulconditions. The aim of the treatment in MPS is to decrease

trigger point sensitivity46 till date, a lot of treatments methodshas been introduced and practiced.

Various physical modalities such as ice, heat, spray,Ultrasound, TENS, Ischemic Compression, dry needling andmassage have been used to treat trigger points. Despite ofthe wide use of therapeutic modalities, Hanten et al10 claimedthat the quality of the studies on the efficacy of thesemodalities were low and the supporting results reported onlytemporary relief from any modality. Simunovic reportedfunctional recovery and decrease of spontaneous pain withLLLT on trigger points. In the past many researches havebeen done on He-Ne and Ga-As laser for the treatmentshave been proved effective individually thus, a need arisesto follow up the already acclaimed treatments in comparativestudy.

Implication of the present study is that no significantdifference was found in VAS and NDI from 0 to 2nd weekbetween the three groups i.e. group A (He-Ne + stretching),group B (Ga-As + stretching) and group C (stretching alone).

On analyzing the results between the groups, Group Cwas found more effective than the other two groups i.e. GroupA and B, concluding a minimal contribution of therapeuticmodalities in pain relief and increasing functional ability.

Thus, stretching alone has positive, therapeutic effecton the underlying musculoskeletal trigger points. Stretchingexercises form the basis of exercise treatment of myofascialpain by addressing the muscle tightness, shortening thatare closely associated with pain in this disorder and permits

Table 5.1: Comparison of Age, Weight and Height between Group A, B and C.VARIABLES F Value P Value

AGE 6.475 0.005WEIGHT 0.143 0.868HEIGHT 2.96 0.068

Table 5.2: Comparison between VAS and NDI at 0 day, 5th day and 10th daybetween the groups.

VARIABLES DAYS F Value P Value0 0.270 0.766

VAS 5 0.135 0.87510 0.245 0.7850 1.763 0.191

NDI 5 1.293 0.29110 2.013 0.153

Table 5.3: Comparison of VAS and NDI within group A, B and Cone 0, 5th and10th day.

VARIABLES F Value P ValueVAS A 3.194 0.057VAS B 4.904 0.015VAS C 1.946 0.162NDI A 6.039 0.007NDI B 3.379 0.049NDI C 3.365 0.050

Table 5.4: Comparison of rate of improvement in VAS and NDI within GroupA, B and C from 0 day to 10th day.VARIABLES DAYS MEAN STANDARD P VALUE

DIFFERENCE ERROR0 to 5th day 0.7500 0.7573 0.331

VAS A 5th to 10th day 1.150 0.7573 0.1410 to 10th day 1.900 0.7573 0.0180 to 5th day 0.450 0.456 0.333

VAS B 5th to 10th day 0.950 0.456 0.0470 to 10th day 1.400 0.456 0.0050 to 5th day 0.6500 0.5605 0.256

VAS C 5th to 10th day 0.4500 0.5605 0.4290 to 10th day 1.100 0.5605 0.0050 to 5th day 0.1020 0.6365 0.121

NDI A 5th to 10th day 0.1190 0.6365 0.0720 to 10th day 0.220 0.6365 0.0020 to 5th day 0.0730 0.6803 0.293

NDI B 5th to 10th day 0.1030 0.6803 0.1420 to 10th day 0.1760 0.6803 0.0150 to 5th day 0.0850 0.5763 0.152

NDI C 5th to 10th day 0.064 0.5763 0.2770 to 10th day 0.1490 0.5763 0.015

Fig. 5.1: Graphical Representation of VAS in group A, B and C on 0 day, 5th

day and 10th day.

VAS

0

2

4

6

0 Day 5 Day 10 Day

Days

VA

S(i

ncm

s)

Group A

Group B

Group C

Fig. 5.2: Graphical representation of Neck Disability Index in group A, B and Con 0 day, 5th day and 10th day.

NDI

0

20

40

60

0 Day 5 Day 10 Day

Days

ND

I(%

) Group A

Group B

Group C


10

gradual restoration of normal activity. The contracture of thesarcomeres in the contraction knots of the TrP must bereleased. Lengthening of these contracted sarcomeres bygentle sustained stretch with augmentation techniquesapparently induces a gradual reduction in the overlapbetween actin and myosin molecules and reduces the energybeing consumed. This breaks an essential link in the energycrisis vicious circle. The key to treating TrP is to lengthenthe muscle fibres that are shortened by TrP mechanism.When the muscle is being stressed golgi tendon organs(GTO) promotes the stretch in the muscle and in turnlengthening occurs. A controlled, blind study by Hanten etal compared the effects of 5 day home programme of musclestretching exercises and self massage with an active ROMprogramme for neck and back myofascial pain. Stretchingprogramme showed significantly more improvement thansubjects in active ROM concluding that stretching of theeffected muscle is believed to be an integral part of TPtherapy.

On the other hand, when analyzing the results within thegroups, group A i.e. He-Ne laser with stretching showedsignificant results from 0 to 2nd week and from 1st to 2nd weekof treatment period. The findings substantiate the previousfindings of Synder-Mackler et al demonstrating a reductionin pain due to increase in the latency of the superficial radialnerve in healthy subjects that correspond to a decrease insensory in nerve conduction velocity after application of He-Ne laser. Walker et al suggested that this type of laser mayeffect serotonin metabolism, because of large increase inurinary excretion of 5 hydroxyindoleactic acid (5 HIAA) andbetter oxygenation of tissue resulting from increased localcirculation hence leading to reduction of pain. According tothe literature, minimum three treatments has been suggestedfor assessing the efficacy of laser treatment and a 10 sessioncourse has been recommended for those patients whoseems to benefit from the treatment. The slight carry overeffect noted in the present study i.e. from 1st to 2nd week ofgroup B was augmented to the point of statisticallysignificance when a 10 session paradigm is used.

Similarly, analyzing within the group, Group B i.e. Ga-Aswith stretching showed significant improvement from 0 to2nd week which could be due to decrease in muscle spasm, increase in ATP production and other possible mechanismspredicted are effects on endomrphin level gate control ofpain given by Melzack and Wall.

Ali Gur et al advocated that significant and clinically usefuleffects in management of chronic neck pain related to MPSis due to reduction in local tenderness. In support to thisFernendo Sornano in his study on LBP suggested that thetherapy with Ga-As diode laser can release pain in 70- 90%of the cases. Similarly, Sarac et al found significantimprovement in patients when treated with Ga-As laser withrespect to parameters such as pain, functional ability andQuality of life (QoL) which is in accordance to present study.

Conclusion

Result of the present study reported no significantdifference in the effects of He-Ne laser application withstretching and Ga-As laser with stretching when comparedto stretching alone on pain relief and functional ability. Butthis study does not conclude that stretching is an effectiveintervention as significant difference in the rate ofimprovement was found in group which received He-Ne laser

with stretching. Since the duration over which accumulationof rate of improvement took place was small thus it couldnot produce any significant difference over all at the end.

Refrences

1. Simon DG, Travell JG, Myofascial pain and dysfunction,the trigger point manual vol. 1, upper half of body, 2nd

ed. Baltimore, William and Wilkins, 1999.2. Joanne Borg- Stein, David G, Myofascial pain: A focused

review. Arch. Phys Med Rehab, 83 supple 1, S 40-47,2002.

3. Noramn B. Rosen,. The Myofascial Pain Syndrome.Phys. Med. Rehab. North America, 4, 41-63, 1993.

4. Robert G. Klein, Bjorn,. Low energy laser treatment andexercise for chronic low back pain: A double blindcontrolled trial. Arch Phys Maed and Rehab, 71, 34-37,1990.

5. Leesa K. Huguenin,. Myofascial trigger points: thecurrent evidence. Physical Therapy in Sport, 5, 2-12,2004.

6. Gur A., Sarac AJ, Cevik R, Altindag O, Sarac S., Efficacyof 904 nm Gallium Arsenide low level laser therapy inthe management of chronic myofascial pain in the neck:A double-blind and randomize-controlled trial. Lasersin Surgery and Medicine 35(3), 229-235, 2004.

7. Chang-Zern Hong,. Pathophysiology of MyofascialTrigger Point. J Formos Med Assoc, 95(2), 93-104,1996.

8. Samunel A. Skootsky, Bernadette Jaeger, Robert K.Oye,. Prevalence of myofascial pain in general internalmedicine practice. West Journal of Medicine, 151, 157-160, 1989.

9. T. Micheal Cummings, Adrian R. White,. Needlingtherapies in the management of myofascial trigger pointpain: A systematic review. Arch Phys Med Rehab, 82,986-992, 2001.

10. William P. Hanten, Sharon L. Olson, Nicole L. Butts,Aimee L. Nowicki,. Effectiveness of a home programeof Ischemic Compression by sustained stretch fortreatment of Myofascial Trigger Point. Physical Therapy,80(10), 997-1003, 2000.

11. Lynn Synder-Mackler, Christopher Bork, BarbaraBourbon, David Trumbore,. Effect of Helium Neon Laseron Musculoskeletal Trigger Points. Physical Therapy,66(7), 1087-1090, 1986.

12. Veronica M. Sciotti, Veronica L. Mittak, Lisa DiMarco,Lillian M. Ford, et al,. Clinical precision of myofascialtrigger point location in the Trapezius muscle. Pain, 93,259-266, 2001.

13. Hakguder A, Birtane M, Gurcan S, Kokino S, Turan FN,.Efficacy of low level laser therapy in myofascial painsyndrome: An algometric and thermographic evaluation.Lasers in Surgery and Medicine, 33, 339-343, 2003.

14. Ali Gur, Mehmet Karakoc, Remzi Cevik, Kemal Nas,Aysegul Jale Sarac, Meral Karakoc,. Efficacy of lowpower laser therapy and exercise on pain and functionsin chronic low back pain. Lasers in Surgery andMedicine, 32, 233-238, 2003.

15. Donald D. Price, Patricia A. Mc Grath, Amir Rafii,Barbara Buckingham,. The validation of visual analoguescale as ratio scale measures for chronic andexperimental pain. Pain, 17, 45-56, 1983.

16. Leon Chaitow, Judith Walker DeLany,. Clinical


11

Application of Neuromuscular Techniques. Vol. 1, Theupper body, Trigger Points, 65-84, Churchill Livingstone,2000.

17. Arne N. Gam, Susan Warming, Lone H. Larsen, BenteJensen et al,. Treatment of myofascial trigger pointswith ultrasound combined with massage and exercise:A randomized controlled trial. Pain, 77, 73-79, 1998.

18. Altan L., Bingol U., Aykac, Yurtkuran M., Investigationof the effect of GaAs laser therapy on cervical myofascialpain syndrome. Rheumatology International, 25(1), 23-27, 2003.

19. Lale Altan, Umit Bingol, Merih Yurtkuran,. Low-PowerLaser treatment for shoulder pain. Photomedicine andLaser Surgery, 23 (5), 459-464, 2005.

20. F. Ceccgerelli, L. Altafini, G. Lo. Castro, A. Avila, F.Ambrosis, G. P. Giron,. Diode laser in cervicalmyofascial pain: A double blind study versus placebo.The Clinical Journal of Pain. 5, 301-304, 1989.

21. David Hubbard, Gregory M. Berkoff,. Myofascial triggerpoints show spontaneous needle EMG activity. Spine,18(13), 1803-1807, 1993.

22. Simons DG, Hong CZ,. Endplate potentials are commonto midfiber myofascial trigger points. Am J Phys MedRehab, 81(3), 212-222, 2002.

23. Chang Z. Hong, Ta-Shen Kuan, Jo-Tong Chen, Shu-Min Chen,. Referred pain elicited by palpation and byneedling of myofascial trigger points: A Comparison.Arch Phys Med Rehab, 78, 957-960, 1997.

24. Randy S. Roth, Karyn Horowitz, Jan E. Bachman,.Chronic Myofascial Pain: Knowledge of Diagnosis andSatisfaction with Treatment. Arch Phys Med Rehab, 79,966-970, 1998.

25. John Low and Ann Reed, Electrotherapy Explained:Principles and Practice, 3rd ed. , Laser Therapy, 356-375, Butterworth Heinemann, 2000.

26. George W. Waylonis, Sue Wilke, Donald O’ Tole, DavidA. Waylonis, Daniel B. Waylonis,. Chronic MyofascialPain: Management of low output Helium Neon lasertherapy. Arch Phys Med Rehab, 69, 1017-1020, 1988.

27. William P. Cheshire, Sandra W. Abashian, J. DouglasMann,. Botulinum toxin in the treatment of myofascialpain syndrome. Pain, 69, 65-69, 1994.

28. Lars Bendtsen, Rigmor Jensen, Jes Olesen,.Qualitatively altered nociception in chronic myofascialpain. Pain, 65, 259-264, 1996.

29. J. Walker,. Relief from chronic pain by low power laserirradiation. Neuroscience Letters, 43, 339-344, 1983.

30. O. Komiyama, M. Kawara, M. Arai, T. Asano, K.Kobayashi,. Posture correction as part of behavioraltherapy in treatment of myofascial pain with limitedopening. Journal of Oral Rehabilitation, 26, 428-435,1996.

31. George H. Kraft, Ernest W. Johnson, Myron M. LaBan,.The Fibrosotis Syndrome,. Arch Phys Med Rehab, 9,155-162, 1968.


12

Comparative evaluation of physiotherapy and pharmacotherapyin the management of temporomandibular joint myofascial painVenkatesh G Naikmasur*, Kruthika S.Guttal**, Puneet Bhargava***, Renuka J Bathi*****Professor and Head, **Assistant Professor, ***Former Post-graduate, ****Former Professer, Department of Oral Medicineand Radiology, SDM College of Dental Sciences and Hospital, Dharwad 580 009

Correspondence Author:

Dr. Kruthika SatyabodhAssistant Professor, Department of Oral Medicine and Radiology, SDMCollege of Dental Sciences and Hospital, Dharwad 580 009Karnataka, IndiaPhone: 91 836-2467676, Fax: 91 836-2467612E-mail: [email protected]

Abstract

Objectives

The present study is a prospective study carried out toevaluate the efficacy of physiotherapy methods likeultrasound, transcutaneous electrical nerve stimulation, lowintensity light amplification by stimulated emission ofradiation and compare the same with pharmacotherapycomprising of analgesics and muscle relaxants, in themanagement of temporomandibular joint myofascial pain.

Methods

A total of 40 patients included in the study. Subjects wererandomly assigned to one of the two groups, each groupconsisting of 20 subjects. Subjects of Group A received acombination of muscle relaxants and analgesics and GroupB subjects received, ultrasound, transcutaneous electricalnerve stimulation, or light amplification by stimulatedemission of radiation. All the patients were evaluated forsubjective and objective symptoms at baseline and thenfollowing one, four, eight, and 16 weeks post treatment. Allthe subjects were evaluated with visual analog scale, GlobalPain Impact scale scores, number of tender muscles, andmaximum comfortable mouth opening.

Results

The parameters evaluated revealed significantimprovement in Group B following treatment and also duringthe follow period as compared to Group A subjects.

Conclusion

Physiotherapy, having the advantages of better patientcompliance and lack of adverse side effects, can beconsidered as primary treatment modality of patients withmyofascial pain.

Key words

Myofascial pain, physiotherapy, pharmacotherapy,Ultrasound, LASER, TENS.

Introduction

The term “temporomandibular disorder” [TMD] wassuggested by Bell1. It is a collective term embracing a numberof clinical problems that involve the masticatory musculature,the TMJ, and associated structures, or both2.

Temporomandiublar joint disorders have beenrecognized as the most common non-tooth related chronicorofacial pain conditions that confront dentists3. Symptomsassociated with TMDs are common in general populationwith 20 to 85 percent of the population known to presentwith symptoms like pain in the TMJ and masticatory muscles,and restricted mouth opening4. To date, there have beenmany synonyms for myofascial pain, including facialarthromylagia, TMJ dysfunction syndrome, myofascial paindysfunction syndrome, craniomandibular dysfunction, andmyofascial pain dysfunction1. Currently the preferred term,according to the Research Diagnostic Criteria developedby Dworkin and co-workers5 is “Myofascial pain”. Myofascialpain [MFP] is the most common disorder causing chronicpain in head6. Accordingly MFP is pain of muscle originincluding a complaint of pain as well as pain associatedlocalized areas of tenderness to palpation in muscle5.

The dentist plays a significant role, in the diagnosis andmanagement of such patients, as most patients present withvariety of symptoms ranging from pain in and around theorofacial region to restriction of mouth opening. Appropriatediagnosis is essential to differentiate pain of dental originfrom that of TMJ and masticatory muscles to chart out theappropriate treatment plan fro such patients. Many times aninterdisciplinary approach will be required.

The conservative treatment modalities to manage suchpatients include occlusal splints, analgesics, musclerelaxants, tranquilizers, exercises, joint and muscleinjections, physical therapy, psychological counseling, andplacebo7. Irrespective of the chosen modality of treatment,the goal of treating would be to decrease pain, reduce loadingof the masticatory system, and restore mandibularmovements and oral function8.

Physiotherapy is chosen for the treatment of dysfunctionsin the orofacial region for its unique reasons; it is relativelysimple and non-invasive, has a low cost as compared withother treatments, and allows for an easy self-managementapproach which means that the patient is actively involvedin his own treatment, being responsible for his or her well-being. It allows good communication with the patient,improving the patient’s confidence in the care provider, beingthe basis of a positive coping2. The various forms ofphysiotherapy include rest, thermal modalities [superficialheat and cryotherapy], ultrasound, shortwave diathermy,transcutaneous electrical nerve stimulation [TENS],transcutaneous muscle stimulation, biofeed back training,

Venkatesh G Naikmasur et al/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2

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massage, active movements [exercise], passive movements,acupuncture, and low intensity light amplification bystimulated emission of radiation [LASER]9.

The present study was aimed to assess the effectivenessof physiotherapy methods like TENS, ultrasound, lowintensity LASERS and exercises, massage, and hotcompresses in myofascial pain patients and to comparesame with pharmacotherapy comprising of a combinationof muscles relaxants and nonsteroidal anti-inflammatorydrugs [NSAID].


Subject selectionThe prospective study was conducted in the Department

of Oral Medicine and Radiology SDM Dental college andDepartment of Physiotherapy SDM Medical collegeDharwad. The experimental protocol for this study underwentreview and approval by the ethical committee of theinstitution. Each patient was fully informed about thecondition consent was obtained before inclusion in the study.

Subjects to participate in the study were to have a primarydiagnosis of MFP of masticatory muscles according to RDCTMD5. Patients diagnosed with myofascial pain, approachingthe outpatient department, were selected for the study fromthe period of November 2004 to March 2006.Patients havingthe condition for at least three months were included in thestudy. All the patients presented with three or more of thefollowing signs and symptoms: pain on palpation ofassociated muscles [muscles of mastication,sternocleidomastoid, trapezius muscles], limited mouthopening, intermittent clicking of the joint, and absence ofradiographic changes in the TMJ.

Patients excluded from the study were those with occlusaldisharmony, were undergoing orthodontic treatment and/orocclusal corrections, had undergone treatment for the samewithin six months of present diagnosis, had any form ofarthritis affecting the TMJ, or failed to attend regular follow-up.

Screening ProcedureA detailed history regarding onset, duration, and progress

of symptoms was recorded at the time of diagnosis. Thedata also included type of pain, its severity and pain responseto chewing, speech, and swallowing. Intensity rates of painwere recorded on a visual analog scale of 100mm longcontinuum and the extremes were labeled as no pain andworst possible pain10. The impact of pain on the globalfunctional ability related to jaw use was assessed using asix-point Global Pain Impact [GPI] scale11. This was followedby a thorough examination of the TMJ, muscles ofmastication, and neck muscles, recording of Maximumcomfortable mouth opening. Temporomandibular jointexamination included assessment of clicking, tendernessat rest and during various jaw movements and deviation ofthe jaw during opening and closing movements. Tendernessof muscles of mastication and the neck muscles wasassessed by means of digital palpation, resistance testing,and functional manipulation of muscles12. The tendernessin the muscle was recorded as being present or absent.

40 patients meeting the criteria were randomly assignedinto two groups, Group A or Group B. Group A patientsreceived a drug combination of muscle relaxants andanalgesics comprising of ibuprofen 400mg, paracetamol

325mg, and chlorzoxazone 250 mg, orally as twice dailydosage for a period of five days. Following which the patientswere asked to terminate the intake of medication. Duringthe follow up weeks, patients reporting with episodes of painwere advised to continue the same medication with priorconsent from the clinician. All patients received the samecombination of medication.

Group B patients were treated with either one orcombination of the three treatment modalities, TENS,ultrasound, or LASER. The appropriate modality to beinstituted was decided by the physiotherapist. Four patientsreceived TENS, four received ultrasound, 11 receivedhelium-neon [He-Ne] LASER therapy, and one of themreceived a combination of ultrasound and TENS.

Transcutaneous Electrical Nerve StimulationThe TENS unit with four electrode attachments was

employed. Electrodes were placed over the area of maximummuscle tenderness. The current frequency set at 2Hz andpulse duration of 0.02ms. The pulse strength was increasedslowly, until the patient could tolerate without pain. Maximumbenefit was obtained after 25 to 30 minutes at which timethe treatment was terminated.

Ultrasound- 0.8W/cm2 of frequency in pulsed mode of3MHz was applied for four minutes. The applicator wasmoved in smooth overlapping sweeps or circles at rates offew cm/sec over areas of 25 to 40cm2 it was applied for threemost tender points.

Helium-Neon LASERThe trigger points were identified by palpation. The

wavelength of LASER was 632.8nm which was used in apulsed mode of 30-40HZ. The dose range was between 2-4J/cm2. The head of the instrument was held perpendicularto and in slight contact with skin. The treatment was appliedover three or more Trigger points (TrPs).

The treatment duration was five days for all the modalitiesfollowing which the patients were advised to practiceexercises, massaging of muscles and to apply moist heat tothe affected regions during exacerbations of symptoms.

Massage TherapySelf-massage was limited to the painful or tense masseter

and temporalis muscles [ease of accessibility]. The patientswere also asked to apply moist heat pads on the painfularea when the symptoms exacerbate. Heat application[moderately warm] was advised to be applied bilaterally for20 minutes once a day2.

The oral physician who diagnosed the condition wasinstrumental in the follow-up, and the prior mentionedparameters were assessed at baseline, one week [followingcompletion of treatment session], four, eight, and 12 weeksfollowing treatment sessions, for all the subjects.

StatisticsThe statistical evaluation of data was performed with data

program stat 9.2 version. All the data was analyzed by oneblinded researcher.

First means and standard deviations of VAS, GPI scores,and number of tender muscles were determined [Table 1].The baseline values of maximum comfortable mouth openingbetween the two groups were tested by one way analysis ofvariance [Table 2a]. Analysis of co-variance was used toassess significant difference between the two groups takingbaseline scores as covariance [Table 2b]. Student’s t-test[paired and unpaired] was used to compare the treatment


14

outcome between the two groups. The level of statisticalsignificance was set as a two-tailed P value of 0.05. P<0.05was considered to be significant. The values are presentedin Table 1.

Results

The mean age of the patients was 35.85 and 33.67 yearsin Group A and Group B, respectively. Group A comprisedof 40% males and 60% females. Group B comprised of 45%males and 55% females.

The comparison of mean VAS and GPI scores betweenthe two groups showed significant reduction in Group Bduring the follow-up period [Fig 1 and 2, respectively]. TheGroup B patients showed significant reduction in number oftender muscles and significant improvement in mouthopening during post treatment follow-up period [Fig 3, 4].

Discussion

The various treatment modalities for TMDs mainly aim

to relieve the symptoms of the patient as treatment aimed atcorrection of the exact cause is questionable. Selecting anappropriate treatment option for an individual patient posesgreat challenge to the clinician and depends on various

Table 1: Comparison of Mean Scores Between Two Groups at Various Time Intervals.Groups Group A Group B

Mean Mean Std.Dev. Mean Std.Dev. T value P value SignificanceVAS scores Baseline 6.0000 1.0761 6.4000 0.9947 -1.2207 0.2297 NS

1 week 4.0000 1.3377 3.9500 0.9987 0.1339 0.8942 NS4 weeks 4.8500 1.6631 3.5500 0.9987 2.9970 0.0048 S8 weeks 4.8500 1.6631 3.4000 0.9403 3.3942 0.0016 S12 weeks 5.0500 1.3169 3.3000 0.8013 5.0769 0.0000 S

Mean Baseline 1.9500 0.6048 2.1500 0.5871 -1.0611 0.2953 NSGPI scores 1 week 1.0000 0.5620 1.0000 0.6489 0.0000 1.0000 NS

4 weeks 1.4000 0.5982 0.5500 0.5104 4.8338 0.0000 S8 weeks 1.4000 0.5982 0.7500 0.5501 3.5767 0.0010 S12 weeks 1.6000 0.5026 0.6000 0.5982 5.7235 0.0000 S

Mean of Baseline 1.9500 0.6048 2.1500 0.5871 -1.0611 0.2953 NSnumber of Baseline 2.4 0.0463 2.25 1.118 0.4381 0.6638 NS

tender muscles 1 week 1.3 0.8013 0.9 0.553 1.8379 0.0739 NS4 weeks 1.5 0.8272 0.6 0.598 3.9428 0.0003 S8 weeks 1.55 0.7592 0.8 0.523 3.638 0.0008 S12 weeks 1.45 0.8256 0.55 0.605 3.9329 0.0003 SBaseline 2.4 0.0463 2.25 1.118 0.4381 0.6638 NS

Table 2b: Analysis of covariance (ANCOVA) with baseline as a covariate.1 week Effect 20.9457 1 20.9457 7.4039 0.0099 S

Error 104.6726 37 2.82904 weeks Effect 33.6901 1 33.6901 9.3650 0.0041 S



Error 132.6569 37 3.5853

Table 2a: F- Test and ANCOVA for comparison of mouth opening betweentwo groups at various time intervals.F-test between variances of Group A and Group B with respect tobaseline value Group Mean Std. Dev. F-value P value Significance

forvariancesGroup A 42.7500 6.6560 1.0024 0.9959 NSGroup B 44.2500 6.6481

Fig. 1: Comparison of Mean Visual Analog Scale Scores of Group A andGroup B.

Fig. 2: Comparison of Mean Global Pain Impact Scores Group A and Group B.

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factors like, economic feasibility, patient compliance andacceptance of treatment. The various conservative treatmentmodalities available for TMD include occlusal splints,analgesics, muscle relaxants, tranquilizers, exercises, jointand muscle injections, physical therapy, psychologicalcounseling, and placebo13. Choosing a specific conservativetreatment modality for myofascial pain patients depends onclinician’s expertise, patient presentation, and eliminationof possible etiologic factors. Physiotherapy modalities maybe used as patient’s sole treatment or as combination withother therapies like occlusal correction, splint therapy, etc14.The present study has used physiotherapy as one of thesole treatment modalities in one of the groups.

A meta-analysis of various physiotherapy modalities usedfor the treatment of myofascial pain has shown promisingresults with regards to benefit of patient and relief of pain15.The present study is an attempt to evaluate the efficacy ofphysiotherapy, compared with pharmacotherapy which isnot only a conservative treatment modality, but also acommonly preferred treatment option by many clinicians.

Greider and co-workers16 have first reported theapplications of ultrasound for TMD. The guidelines onappropriate use and treatment with ultrasound are not clearfrom literature17. The therapeutic ranges of ultrasound include0.75 to 3MHz. The present study employs ultrasound of0.8W/cm2 being used for four minutes for a period rangingfrom five to seven days. All the patients in our study showedsignificant reduction in VAS, GPI scores, increase in mouthopening, and reduction in number of tender muscles ascompared to the pharmacotherapy group. Esenoyl et al.18

have used an ultrasound of 1.5W/cm2 for six minutes andtheir patients showed reduction in pain intensity and increasein range of motion and these effects improved even afterthree months after the treatment. Various authors (Gray etal.19, Talaat et al.20, and Majlesi et al21 have supported theuse of ultrasound for myofascial pain. The subjects ofphysiotherapy group of present study have shownimprovement post treatment and during the follow-up period.

In the present study a total of four patients received TENSof 2Hz and pulse duration of 0.02ms. These patients haveresponded positively with decrease in VAS and GPI scoresand increase in mouth opening and reduction in the numberof tender muscles. One patient was treated with both TENSand ultrasound, owing to unsatisfactory response to initialTENS therapy for five days.

There are no reports of adverse effects due to use ofultrasound available in the literature. Hotta et al.22 havereported that their patient initially treated with TENS,complained of head pain, hypertension, and nervousness

and later it was substituted with ultrasound. None of thepatients in the present study have reported any discomfortor adverse effects due to TENS therapy. The switching overfrom TENS to ultrasound in one of the patients in the presentstudy was due to non responsiveness to treatment but notdue to any adverse effect.

In the present study eleven patients received He-NeLASER therapy in a pulsed mode of 30 to 40HZ over theTrPs continuously for five days with significant improvementin symptoms and there was no adverse effects caused byLASER therapy. Similar to our study Simunovic et al.23 havereported pain relief, restored mobility, and decreased rigidityin myofascial pain patients with He-Ne laser treatment. Noneof the patients did require any repetition of treatmentsessions.

Non steroidal anti-inflammatory analgesics are knownto be effective in the management of mild-moderateinflammatory conditions, particularly of the musculoskeletalsystem24. Muscle relaxants are administered to reduceskeletal muscle tone and are often administered to patientswith muscle tone with chronic orofacial pain to help preventor alleviate the increased muscle activity25. They act bydecreasing the muscle tone without impairment of motorfunction by depressing the central polysynaptic reflexes.Literature review shows that very few studies have usedmuscle relaxants solely or in combination with analgesicsfor the treatment of TMD. Greene and Laskin26 have usedmeprobamate in the treatment of myofascial pain dysfunctionsyndrome and have concluded that drugs like meprobamatecan reduce or eliminate the psychic tension and muscularspasm. Singer et al.27 in their randomized double blindcontrolled clinical trial have evaluated Ibuprofen andDiazepam for chronic orofacial muscle pain and their studysupports the efficacy of diazepam in the short–termmanagement of chronic orofacial pain.

The previous studies available regardingpharmacotherapy for TMD is based on heterogenouspopulation i.e. patients with myogenous pain, often notdistinguished in clinical trials from those who have TMJdisorders such as degenerative arthritis or displacement ofmeniscus25. The present study is an attempt to evaluate theeffectiveness of a combination analgesics and musclerelaxants as compared to physiotherapy in patients purelywith myofascial pain. The duration of pharmacotherapy isalso variable according to different authors and there is nosingle treatment duration that is suggested for these patients.

Dias de Andrade28 has reported the pharmacologicalguidelines for treatment of TMD. Accordingly, for acutespasm or myofascial pain, muscle relaxant can beadministered three times daily for two days, whereas NSAIDsby oral route can be given for five to seven days for myositisand TMJ inflammatory disorders. A lack of therapeutic effectafter a seven- to 10-day trial or the development of anygastrointestinal symptoms should prompt discontinuation ofthe drug25.

Due to lack of standard recommended dosages of anyform of pharmacotherapy, the present study employed acommercially available combination of muscle relaxant andanalgesic consisting of ibuprofen 400mg, paracetamol325mg, and chlorzoxazone 250 mg administered orally astwice daily dosage for a period of five days initially. Whenthe patients reported with recurrence of pain or symptomsduring the post-treatment follow up, they were advised torepeat the same treatment regimen.

Fig. 4: Comparison of Mean of Mouth Opening Between Group A and Group B.

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In the present study patients in pharmacotherapy grouphave reported with reduction in symptoms [VAS and GPIscores] initially following five days of treatment, but therewas no significant improvement during the follow-up period.This is in accordance with Talaat et al.20 report that the musclerelaxant group had only a mild reduction of pain and musclespasm, but no effect on TMJ clicking as compared toultrasound short wave diathermy groups. In contrast toabsence of side effects in the physiotherapy group, fivepatients of the pharmacotherapy group reported with mildgastrointestinal symptoms during the follow-up, but thesesymptoms did not persist after discontinuation of drugs. Thepresent study being a follow-up study enables theassessment of improvement in myofascial pain treated withphysiotherapy and pharmacotherapy. Group A subjects hadsignificant reduction in VAS and GPI scores and reductionin number of tender muscles only following a course of anti-inflammatory and muscle relaxant treatment. But the sameresults did not continue during the follow-up as comparedto Group B. The practice of appropriate exercises withmassaging of the muscles following the variousphysiotherapy modalities indicates the persistentimprovement in symptoms of the GroupB during the follow-up period also.

To our knowledge there are very few studies comparingphysiotherapy and pharmacotherapy in the management ofTMD20,29. Earlier studies indicate that ultrasound, TENS, andLASERS exercises prove to be effective in the managementof myofascial pain. In the current study the physiotherapistmade the decision about the mode therapy for individualpatient based on patient compliance and economicfeasibility. Hence physiotherapy modalities were consideredas a single group and its efficacy of treatment comparedwith pharmacotherapy.

The present study, infers that physiotherapy one of theconservative treatment modalities is useful in reduction ofpain, tenderness in muscles, and improvement in mouthopening in patients with myofascial pain.

Commonly observed adverse effects with the use ofNSAID group of drugs include nausea, dyspepsia, ulceration,enteropathy, strictures, bleeding, and perforations30. It hasto be noted that if an NSAID is administered concomitantlywith an anticoagulant, the potential for bleeding increasesmarkedly. Furthermore this group of drugs may becontraindicated in patients on diuretics and in patients withsevere renal disease. Therefore the clinician should notoverlook benefit versus risk while administering these drugs,especially for a longer period of time. Appropriate motivationof patients to practice mouth opening exercises or simplemethods like hot compresses might have great benefits tothe patients. This can ensure frequent change of therapiesand also saves the patient from suffering with the adverseeffects of the drugs.

Conclusion

The treatment outcome with any from of therapy for TMDis not completely predictable. In view of the adverse effectscaused by long term use of various NSAIDs, it is advisableto choose a safer form of therapy in the management ofpatients with chronic musculoskeletal pain. The advantagesof physiotherapy observed in the present study were betterlong-term results, fewer side effects, cost effectiveness, anda better patient compliance. This does not totally preclude

this modality from certain limitations such as, lack of totaleffectiveness in inaccessible muscles like lateral and medialpterygoid. Despite this limitation physiotherapy still remainsas a better and safe treatment option in patients with chronicpain condition like myofascial pain. But furthermorerandomized controlled trials are necessary to validate theeffectiveness physiotherapy in a larger sample.

Acknowledgements

The authors would like to acknowledge Dr. C BhaskerRao, Principal SDM College of Dental Sciences Dharwadfor his encouragement, Ms Kiran Bhat Principal and MsSharmila Dudhani former post graduate SDM College ofPhysiotherapy Dharwad for the help rendered towards thestudy.

References

1. Okeson J P: Current terminology and diagnosticclassification schemes. Oral Surgery Oral Medicine OralPathology Oral Radiology Endodontology 1997;83:61-4.

2. Michelotti A, De Wijer A, Steenks M, Farella M: Homeexercise regimes for the management of non-specifictemporomandibular disorders. Journal of OralRehabilitation 2005; 32: 779–785.

3. McNeill C: Management of Temporomandibulardisorders: Concepts and controversies. Journal ofProsthetic Dentistry 1997; 77: 510-22.

4. Nicolakis P, Erdogmus B, Kopf A, Nicolakis, PiehslingerE: Effectiveness of exercise therapy in patients withmyofascial pain dysfunction syndrome. Journal of OralRehabilitation 2002; 29: 362-368.

5. Dworkin SF, LeResche L, DeRouen T, Von Korff M:Research Diagnostic criteria for Temporomandibulardisorders: review, criteria, examinations, andspecifications and critique. The Journal ofCraniomandibular Disorders 1992; 6:310-315.

6. Mulet M, Decker KL, Look J O, Lenton P A, SchiffmanE L: A Randomized clinical trial assessing the efficacyof adding 6x6 exercises to self-care for the treatment ofmasticatory myofascial pain. Journal of Orofacial Pain2007; 21:318-328.

7. Shankland W E: Temporomandibular disorders:Standard treatment options. General Dentistry 2004;349- 355.

8. De laat A: Scientific basis of masticatory disorders.Scientific Basis of Eating. Edited by Linden RWA. FrontOral Biol, Karger, 1998, pp 122-134.

9. Selby A: Physiotherapy in the management oftemporomandibular disorders. Australian Dental Journal1985; 30:273- 280.

10. Springer SP, Greenberg SM: Temporomandibulardisorders. Burket’s oral medicine diagnosis andtreatment 9th edition. Edited by Greenberg MS, GlickM. BC Decker, Ontario, 2003, pp 310.

11. Stegenga B, de Bont LGM, Boering G:Temporomandibular joint pain assessment. Journal ofOrofacial Pain 1993; 7: 23-37.

12. Okeson JP: Management of Temporomandibulardisorders and occlusion 5th edition. Mosby, St. Louis2003, pp 260-272.

13. Greene CS, Laskin DM: Long–term evaluation ofconservative treatment for myofascial pain dysfunction


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syndrome. Journal of American Dental Association1974; 89: 1365-1368.

14. Murphy JG: Physical medicine modalities and triggerpoint injections in the management ofTemporomandibular disorders and assessing treatmentoutcome. Oral Med Oral Pathol Oral RadiolEndodontology 1997; 83: 118- 122.

15. Feine JS, Lund JP: An assessment of physical therapyand physical modalities for the control of chronicmusculoskeletal pain. Pain 1997; 71:5-23.

16. Greider A, Vinton PV, Cinotti WR, Kanjur TT: Anevaluation of ultrasonic therapy for tempormandibularjoint dysfunction. Oral Surgery Oral Medicine OralPathology Oral Radiology Endodontology 1971;31:25-31.

17. Mohl DN, Ohrbach KR, Crow CH, Gross JA: Devicesfor the diagnosis and treatment of tempormandibulardisorders. Part III: Thermography, ultrasound, electricstimulation, and electromyographic biofeed back.Journal of Prosthetic Dentistry 1990; 63: 472-7.

18. Esenyel M, Caglar N, Aldemir T: Treatment ofMyofascial Pain. American Journal of Physical Medicineand Rehabilitation 2000; 79: 48-52.

19. Gray R.J.M, Quayle AA, Hall CA, Schofield MA:TemporomandibuIar Pain Dysfunction: CanElectrotherapy Help? Physiotherapy 1995; 81: 47-51.

20. Talaat AM, EL- Dibany MM, EL- GARF A: Physicaltherapy in the management of Myofascial paindysfunction syndrome. Annals of Otology RhinologyLaryngology 1986 ; 95: 225-227.

21. Majlesi J, Unalan H: High-Power Pain ThresholdUltrasound Technique in the Treatment of ActiveMyofascial Trigger Points: A Randomized, Double-Blind,Case-Control Study. American Journal of PhysicalMedicine and Rehabilitation 2004; 85: 833-836.

22. Hotta TH, Vincente MFR, Candido dos Reis A, BezzonOL, Bataglion C, Bataglion C: Combination therapiesin the treatment of temporomandibular disorders: Aclinical report. Journal of Prosthetic Dentistry 2003;89:536-9.

23. Simunovic Z: Low level laser therapy with trigger pointstechnique: a clinical study on 243 patients. Journal ofClinical Laser Medicine and Surgery 1996; 14: 163-167.

24. Dimitroulis G, Gremillion HA, Dolwick MF, Walter JH:Temporomandibular disorders.2. Non- surgicaltreatment. Australian Dental Journal 1995; 40: 372-6.

25. Dionne RA: Pharmacologic treatments fortemporomandibular disorders: Oral Surgery OralMedicine Oral Pathology Oral Radiology Endodontology1997; 83: 134-42.

26. Greene CS and Laskin DM: Meprobamate therapy forthe myofascial pain-dysfunction syndrome (MPD)syndrome: a double–blind evaluation. Journal ofAmerican Dental Association 1971; 82: 587-590.

27. Singer E, Dionne R: A controlled evaluation of Ibuprofenand Diazepam for chronic Orofacial Muscle Pain.Journal of Orofacial Pain 1997; 11: 139-146.

28. Andrade EDD, Barbosa CMR, Pinheiro MLP:Pharmacological guidelines for managingtemporomandibular disorders. Brazilian Journal of OralSciences 2004; 3: 503-505.

29. Ismail F, Demling A, Hebling K, Fink M, Stiesch-scolzM: Short term efficacy of physical therapy compared tosplint therapy in treatment of arthrogenous TMD. J ofOral Rehab 2007; 34: 807-813.

30. Barkin L R: Acetaminophen, Aspirin, or Ibuprofen inCombination Analgesic Products. American Journal ofTherapeutics 2001; 8:433–442.


18

Comparative analysis on the efficacy of G.D. Maitland’s conceptof mobilization & muscle energy technique in treating sacroiliacjoint dysfunctionKanchan Rana1, Nitesh Bansal2, Savita3

1Postgraduate Student, Amity University, Uttar Pradesh, 2Assistant Director, Amity University, Uttar Pradesh, 3Lecturer &Incharge, Physiotherapy Department, Amar Jyoti Institute of Physiotherapy

Study design

A randomized experimental study.

Objective

The following study is a comparative analysis to checkthe efficacy of Muscle energy technique & G.D. Maitland’sconcept of mobilization in decreasing pain and improvingfunctional ability in patients with sacroiliac joint dysfunction.Hence prove the effectiveness of either technique as atreatment option to treat Sacroiliac Joint Dysfunction.

Methods and measures

A total of 45 subjects with chronic low back pain wererecruited in the study, with total mean age of 22.82. Subjectswere randomly grouped into 3 group’s viz. Group I (n=15)Muscle energy technique and exercises, Group II (n=15) G.D. Maitland mobilization and Exercises and Group III (n=15)control. The 2 experimental groups participated in a 6session of Muscle energy technique and G. D. Maitlandmobilization respectively. The outcome measures werebased on self evaluated pain (thermometer pain rating scale),disability (Oswestry disability index) and hip range of motion(Goniometry)

Results

Mean+SD decrease of visual analogue thermometer atbase line for group treated with muscle energy techniquewas from 3.53+0.51 at base line to 0.20+0.41 post 6sessions. Similarly for Group II decreased from 3.73+0.7 atbaseline to 0.33+0.48 post 6 sessions.

The mean Oswestry disability index score within the threegroups at base line are, Group I=0.296+0.05, Group II=0.27+0.05, Control= 0.28+0.05, the mean decrease post 6sessions was 0.024, 0.067 and 0.23.

Medial rotation of hip was significantly improved insubjects in Group I from 21.27+4.5 at base line to 37.93+2.05post 6 sessions of treatment.

Conclusion

The results of this study showed that along with activeexercises Muscle energy technique (MET) is moderatelysignificant over the G.D.Maitland’s technique of mobilizationin improving functional ability and increasing the medialrotation of hip joint in mechanical chronic low back paincaused due to sacroiliac joint dysfunction, while both theexperimental groups were highly significant in decreasingpain and improving functional ability.

Key words

Sacroiliac joint dysfunction, Muscle Energy Technique,G.D .Maitland Mobilization.

Sacroiliac joint has been known as an under appreciatedpain generator1. Therefore SI joint itself and the specificdiagnosis of SI joint dysfunction are both under appreciatedcauses of pain in low back, pelvis and the proximal lowerextremities2.

In the 1st part of the 20th century SI joint syndrome wasthe most common diagnosis for LBP, or lumbago. Before1932, SI joint dysfunction was a particularly populardiagnosis. It was actually called “Era of SI joint’’ because somany physicians felt that the SI joint was the cause of mostback problems. Any pain in the low back, buttock or adjacentleg was usually referred to as SI joint syndrome.

In 1932, the discovery of the herniated (or ruptured) discled many physicians to assume that most pain in the backwas the result of this new problem. Thus, was born the“Dynasty of the disc” &the SI joint some what for gotten3.

In late 1980’s, many physicians “rediscovered” the SIjoint as a possible source of back pain.

Lately SI joint has been considered as a significant sourceof pain in patients with chronic low back pain4.

In the process of evolution and transition from quadrupedto biped, appeared to be an evolutionary weakness. In thequadruped most weight is taken on front legs, e.g. In thehorse the distribution is about 65:35 front to hind. Thus,quadruped SI joint takes a good deal less than half theanimal’s weight, while in man the SI joint takes 100%4.

Studies have validated the use of ‘Manual therapy’ astreatment for SI joint dysfunction. The purpose of this studyis to investigate the efficacy of 2 different manual therapytechniques i.e. Muscle energy technique & G.D.Maitland’sconcept of mobilization in different subgroups of patientswith SI joint dysfunction5.

Over the past decade there has been considerableattention and debate about the sacroiliac joint and its role inLBP and pelvis pain. Through multidisciplinary discussionand research, a consensus is arising as to the causes andtreatment of sacroiliac joint dysfunction.The integrated approach of the joint function presented byLee and Vleeming (1998) has 4 components- Form Closure (structure)- Force Closure (forces produced by myofascial action)- Motor Control (specific timing of muscle action in action

during loading)- Emotions

The proposal is that joint mechanics can be influencedby multiple factors including articular, neuromuscular andemotional factors and therefore management of dysfunctionrequires attention to all these elements.

Kanchan Rana et al/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2

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So therefore the aim of the following study acomparative analysis to check the efficacy of Muscle energytechnique & G.D. Maitland’s concept of mobilization indecreasing pain and improving functional ability in patientswith sacroiliac joint dysfunction. Hence prove theeffectiveness of either technique as a treatment option totreat Sacroiliac Joint Dysfunction.


Study designIt was a randomized controlled study with a total of 45

subjects with chronic low back pain, of mean age 22.82+2.9were recruited in the study. Patients, who agreed toparticipate after being explained about the aim of the studyand the procedure they would be undergoing, were askedto sign an informed consent document approved by theInstitutional Review Board, Amity Institute of physiotherapy.All patients meeting the inclusion and exclusion criteria,eligible for participation i.e.Inclusion criteria• Age group 18-30 years.• Chronic low back pain for more than 3 months.• There should not be any associated neurological

symptoms.• Disability scoring on the Oswestry disability index

above 20% but below 80%.Exclusion criteria• Traumatic conditions• Infectious conditions• Tumors

Were randomly assigned into three groups, Group A(Muscle energy techniques + Exercises), Group B(Maitland’s mobilization + Exercises), Group C (Exercises)consisting of 15 subjects each.

Procedure

All examination was carried out by a physical therapistand manual therapist. Demographic data, including age,sex, employment status, and sports and leisure activities,were recorded at baseline. A history was taken concerningthe duration of complaints (months), previous treatments(injections, physical therapy, etc.), and current painmedication. Concomitant diseases and the use ofmedications were registered.

Subjects in Group A were treated using Muscle EnergyTechniques for the type of Dysfunction the subject wasdiagnosed for. Group B was treated with Maitland’s conceptof mobilization for the particular diagnosed sacroiliac jointdysfunction. Group C, the Control group was givenexercises designed to gently move the sacroiliac joint6. Thesame set of exercises are performed for ‘group A’ and ‘groupB’ post applying the techniques respectively assigned forthat group i.e. Muscle energy technique and G.D.Maitland’smobilization techniques.

The above treatment protocol was given for a total of 6sittings. The readings of all dependent variables wererecorded at the base line and after the 6th sitting.

Active ROM and passive ROM were measured with aconventional Goniometer for flexion, abduction, adduction,internal rotations, external rotations for hip joint and spinalrange of motion were taken using a measuring tape forflexion, extension, and side flexion.

Disability was measured by means of ‘Oswestrydisability index’. The ODI is a self administeredquestionnaire including, pain intensity, personal care, lifting,walking, sitting, standing, sleeping, sex life (if applicable),and social life.

Pain was measured using the ‘Thermometer Pain ratingScale’.

Statistical analysis

To assess changes within each group after theintervention period and between groups, the raw data wereused and analyzed with the student’s-test and One WayAnalysis of Variance (ANOVA). For statistical analysis, the

Palpation of PSIS movement during the sacral fixation“Gillett’s Test”.

Long axis distraction technique for correction of superioriliac shear (Upslip)

MET for Posterior Innominate Dysfunction.


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software SPSS 12.0 was used. The level of significancewas set at p=0.05 for all comparisons.

Results

The descriptive statistics of the visual analoguethermometer of the 3 groups, the mean of the ExperimentalGroup (1) =3.53, Experimental Group (2)=3.73, ControlGroup(3)=3.53, at the baseline.

Post 6 sittings the mean of all three groups are 0.20,0.33, and 3.67 respectively.

The mean of the Oswestry disability index within thethree groups at the base line are as following; Experimentalgroup (1): 0.29; Experimental group (2): 0.27; Control group(3): 0.28

The mean changes after the 6 sittings are: 0.02, 0.06,and 0.23 respectively.

Table 1, one way ANOVA of Hip Flexion ROM (HFROM),Hip Medial Rotation ROM (HMRROM), Hip Lateral RotationROM (HLRROM) within three groups describes the level ofsignificant changes in Hip Flexion ROM with base line valueof 0.712 which is comparable to significant change withvalue of 0.000 post 6 sitting, which is highly significant.

Similarly, for Hip Medial Rotation ROM, baseline value0.83 which is comparable and significant change post 6sittings with significance value of 0.00.

For Hip Lateral Rotation ROM, baseline value of 0.02which is significant at baseline itself and value of highsignificance of 0.00 post 6 sittings.

Discussions

Sacroiliac joint has been known as an under appreciatedpain generator1. Therefore SI joint itself and the specificdiagnosis of SI joint dysfunction are both under appreciatedcauses of pain in low back, pelvis and the proximal lowerextremities7.

Lately SI joint has been considered as a significantsource of pain in patients with chronic low back pain4. Overthe years the sacroiliac joint dysfunction have been ignored,forgotten and missed.

Mechanical dysfunction can be caused by one or moreof the following: acute strain, motion restriction, muscle,

imbalance, compensatory strain, hyper mobility, orpositional faults5.

Dysfunction at the sacroiliac joint is common in females.They have a smaller joint surface and a gentle topographywithin the joint. The hormone relaxin influences this jointby relaxing the ligaments on a monthly basis and by relaxingand allowing the ligaments to stretch prior to the child birth.It is interesting to note that relaxin continues to be releasedin the system as long as the mother is breast feeding.Females have the strains of child birth, habitual unilateralstanding, and also intercourse strains.

The basic response of body to trauma is inflammationwhich causes nociceptors to fire and this bombards thecord with arrant stimulus resulting in an efferent responseof increased muscle tension.

The mean significant decrease in the pain intensity inexperimental Group (1) and experimental Group (2) showsthe efficacy of the manual therapy techniques i.e. Muscleenergy technique and G.D.Mailtland’s concept ofmobilization, in treating sacroiliac joint dysfunction causeddue to mechanical causes.

The Oswestry disability index readings were found tobe highly significant of both the experimental groupscompared to the control group, while moderate significancewas found between experimental Group (1) overexperimental Group (2), hence proving efficacy of muscle

Graph 1: Represents the mean values of VAT1 (baseline) and VAT2 (posttreatment) within the 3 groups.

Graph 2: Represents the mean values of ODI1 (baseline) and ODI2 (posttreatment) within the 3 groups.

Experimental Group -Muscle Energy

Technique+Exercise

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% C ha n ge inH F R O M - A fte r 6s ittin g to B a se lin e

% C ha n ge inH M M R O M - A fte r 6s ittin g to B a se lin e

% C ha n ge inH L LR O M - A fte r 6s ittin g to B a se lin e

% C ha n ge inH F R O M - A fte r 6s ittin g to B a se lin e


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energy technique over G.D.Maitland’s concept ofmobilization in improving functional ability.

Solonen11 noted that the sacroiliac joint is normally in astate of stable equilibrium and that much force is requiredto disturb this equilibrium. He further pointed out that thestrongest muscle in the body surround the sacroiliac jointbut that none have the primary function of moving it. Thus,he concluded, there are no voluntary movements do occurare weight changes and postural influences. Suchmovements are referred to by some as joint play motion12,13

or accessory joint motions14.Some authorities14,15,16 believe that the following muscles

or muscle group can impart forces on the sacroiliac joint,either through their primary actions or by their reverseactions, depending on the points of fixation: the iliopsoas,

rectus femoris, hip abductors, and adductors, sartorious,external rotators and piriformis, gluteus maximus,hamstrings, abdominals, quadrates lumboram, andmultifidus.

Agreeing similarly with the above studies the muscleenergy technique proved to be moderately significany overG.D.Maitland’s mobilization.

While comparing the “hip range of motion” i.e. hip flexionrange of motion, hip medial rotation range of motion, hiplateral rotation range of motion, the improvement was highlysignificant in the experimental groups compared to thecontrol group, while comparing both the experimental group,there was moderate significant change in the values of‘medial rotation range of motion’ in the experimental Group(1) treated by muscle energy technique to experimentalGroup (2) treated by G..D.Maitland’s concept ofmobilization.

Michael Cibulka15 in 1998 found that there is unilateralhip rotation range of motion asymmetry in patients withsacroiliac joint regional pain. It was evident in the base linevalues in the study too, where a significant loss of range ofmotion in medial rotation and lateral rotation was found.

According to Diane Lee excessive compression of thejoints of the pelvis can be caused due to inappropriatemuscle forces. The specific muscles that are weak mustbe strengthened; those which are tight must belengthened17.

Further studies on the effect of newer manual therapytechniques such as MET (Muscle Energy Technique),Myofascial Release, mobilization techniques on chronic lowback pain due to sacroiliac joint dysfunction and theircomparison with conventional physiotherapy is required.Since this study was done on a very small population morenumber of subjects can also be incorporated. The effectsof the techniques can be analyzed on more objectivevariables such as electromyography changes. Also,treatment with more follow up may be necessary tocomment on the functional outcome and to establish thatthe improvement was a permanent one. Researches onthe optimal dosage of these manual therapy techniquescan also be done. In addition, further studies can be donewhich address the duration of pain relief associated withthe control, of contributing factors. These areas could formthe basis of future research project.

Relevance to clinical practice

Chronic low back pain constitutes the largest group ofchronic medical problems in clinical practice, and sacroiliac

joint dysfunction is among the most overlooked causes ofchronic low back pain and disability. This study resulted inbenefits of manual therapy techniques such as, MuscleEnergy Technique, G.D.Maitland’s concept of mobilizationin improving the pain and functional ability and increasingthe hip range of motion’s, in chronic low back pain causeddue sacroiliac joint dysfunction so that the most effectivetreatment plan can be extracted from this study.

References

1. Stoddard A. Condition of sacroiliac joint and theirtreatment. Physiotherapy;1958, 97-101.

2. Bogduk N. Low back pain. Australian FamilyPhysician.1985, 14:1168.

3. Mens J, Vleeming A, Snijders c, and Stam H. ActiveStraight leg raising: A clinical approach to the loadtransfer function of the pelvic girdle, 2nd interdisciplinaryworld congress on low back pain, 1,207- 219, 1995.

4. Donatelli Wooden. Orthopeadic physical thearapy, 3rd

edition.5. Cibulka MT, Koldehoff R. Clinical usefulness of cluster

of sacroiliac joint tests in patients with and without lowback pain. J Orthop Sports Phys Ther.1999; 29(2): 83.

6. Stoddard A. Condition of sacroiliac joint and theirtreatment.Physiotherapy.1958, 97-101.

7. Bogduk N. Low back pain. Australian familyPhysician.1985, 14:1168.

8. Richard Don Tigny. Evaluation, Manipulation andmanagement of anterior dysfunction of SI joint. 1973Sept, 14; 1-8.

9. Maigne JY, Aivalikis A. Results of sacroiliac jointdysfunction and value of SI joint Provocation tests in54 patients with low back pain. Spine.1996; 21:1889-1892.

10. Mooney V. understanding, examining and treatingsacroiliac pain. J Musculosk. Med. 1993: 37- 47.

11. Strusson B, Uden A, Vleeming A. A radiostereometricanalysis of movements of the sacroiliac joints duringthe standing hip flexion test. Goldwait K.Spine.2000;vol.3, 364-368.

12. Luo X, Pietrobon R, Sun SX, Hey L. Estimates andpatterns of direct health care expenditure amongindividuals with low back pain in the UnitedStates.Spine.2004;29(1): 79- 86.

13. Gold wait JE, Osgood RB. A consideration of the pelvicarticulations from an anatomical, pathological, andclinical stand point. Boston Med Surg J.1905; 152: 593-601.

14. Kapandji IA: The physiology of the joints.2nd Ed. Vol.III. The trunk and the vertebral column. ChurchillLivingstone, Edinburgh, 1974.

15. Cibulka MT, Sinacore DR, Cromer GS, Delitto A.Unilateral hip rotation range of motion asymmetry inpatients with sacroiliac joint regional pain. Spine.1998,23, 9; 1009- 1015.

16. Don Tigny, Richard L. Dysfunction of the sacroiliac jointand its treatment. The Journal of Orthopedic and SportsPhysical Therapy.1979, 1(1):22-35.

17. Diane Lee.The Pelvic girdle: An approach to theexamination and treatment of the lumbopelvic hipregion. Churchill Livingstone publishers, 1989.


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Activity, participation and quality of life after stroke: A 6-monthfollow-up of community-dwelling Nigerian stroke survivorsGrace O. Peters, Talhatu K. HamzatDepartment of Physiotherapy, College of Medicine, University of Ibadan, Nigeria


Dr T.K. HamzatDepartment of Physiotherapy, College of Medicine,University of Ibadan. PMB 5017 GPO Dugbe Ibadan NigeriaTel.: +234-8052457016/28708056E-mail: [email protected], [email protected]

Abstract

BackgroundStroke outcomes are best understood through follow-up

assessments of the survivors, yet limited longitudinal dataexist on stroke survivors in Nigeria.

Aims

This study therefore assessed the trend of activity,participation and quality of life (QoL) of Nigerian strokesurvivors over a period of 6 months postonset and therelationship among the 3 constructs were explored at the1st and 6th months post stroke onset.

Methods

Consecutive stroke survivors were recruited from atertiary hospital in Nigeria. Activity, participation and QoL ofparticipants were assessed monthly with the Modified RankinScale (mRS), London Handicap Scale (LHS) and WorldHealth Organization’s WHOQoL-BREF questionnairerespectively monthly for 6 months after stroke onset.Friedman’s ANOVA was used to explore the trend of eachvariable across the study period, while their relationship wascomputed with the Spearman’s correlation coefficient.

Results

Nine males and 7 females completed the study (meanage; 60.68 + 9.76). Activity and participation of strokesurvivors improved progressively over the study period whilequality of life displayed an inconsistent pattern ofimprovements and deteriorations across six months poststroke onset. Activity and participation were also found tocorrelate poorly with quality of life over the study period.

ConclusionIt may be important to consider other factors that may

positively influence the QoL of stroke survivors sinceimproved activity and participation did not result in improvedQoL in this group of people.

Key wordsStroke survivors; activity, participation; quality of life;

Africans

Introduction

Individuals who survive a stroke often have impairmentsthat impede independent performance of the basic activitiesof daily life1. It is in view of this that the quantification ofstroke outcome should include information on functionalstatus of the victims which broadly covers their ability toperform activities of daily living and participate in societalactivities2.

The World Health Organization (WHO) described activityas the execution of a task or action by an individual whileparticipation refers to an individual’s involvement in lifesituations3. These two constructs are defined in the contextof learning and applying knowledge; general tasks anddemands; communication; mobility; self-care; domestic life;interpersonal interactions and relationship; major life areas;community, social and civic life3. Over the years, the impactof stroke has been under-estimated by clinicians andresearchers who merely used measures of activity thuscausing non-availability of information necessary tocharacterize the well-being of stroke survivors in terms ofparticipation and quality of life4. Quality of life (QoL) is animportant outcome which may facilitate a broader descriptionof stroke recovery5.

A number of studies have been carried out on activity,participation and QoL of stroke survivors. Hartman-Maier etal6 reported that community-dwelling stroke survivorsdemonstrated long-standing dissatisfaction one-year postonset, and this was found to correlate with activity limitationand restricted participation. Quality of Life of stroke survivorswas observed to deteriorate over a period of time post stroke,with such deterioration occurring in spite of stable functionalability7. In a study where the effect of reduction of lower limbspasticity on activity, participation and QoL in hemipareticstroke survivors was investigated, activity (walking) wasfound to improve while participation and QoL remainedunchanged8. Deficits in general physical functioning,participation and QoL were observed by Lai et al4 amongstroke survivors who were considered to have improvedactivity. Deterioration in physical functioning and QoL ofstroke survivors at 3rd, 6th and 12th month post stroke wasalso reported by Suenkeler et al9. Reports of studiesexploring the interrelationships of activity, participation andQoL among African stroke survivors are however notavailable.

Aims

The aims of this study were: (a) to assess the patterns ofactivity, participation and quality of life among community-dwelling Nigerian-African stroke survivors over a 6-monthperiod;

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(b) evaluate the relationships among the 3 constructs(activity, participation and quality of life) at the 1st and 6thmonth post stroke onset.

Methods

ParticipantsTwenty consecutive male and female patients who hadsuffered a stroke for not more than 4 weeks as at the time ofthis study and receiving health care at the University CollegeHospital (UCH), a tertiary health facility in Ibadan, Nigeriatook part in this study. They were those with first incidenceunilateral stroke and who did not have cognitive impairmentassessed using Mini Mental State Examination and co-morbidities affecting functioning, and who granted informedconsent to participate in the study. They also met the criterionof being those residing within Ibadan, an urban communityin South-Western Nigeria. This was to ensure easy follow-up by the researchers.

ProcedureEthics of the study was approved by the Joint Institutional

Review Committee of the University of Ibadan/UniversityCollege Hospital, Nigeria. The protocol for the study wasexplained to all consenting patients. The age, gender, strokelaterality, type of stroke and residential addresses (for thepurpose of follow-up) were documented as clinical anddemographic information. Activity, Participation and Qualityof Life were assessed using the Modified Rankin Scale(mRS), the London Handicap Scale (LHS) and the WorldHealth Organization’s Quality of Life BREF questionnaire(WHOQoL-BREF) respectively at baseline (within 4 weeksof stroke onset) and monthly for 6 months post stroke onset.Follow-up monthly evaluation took place at each patient’splace of abode, and all measurements were carried out bythe same assessor.

The Modified Rankin Scale (mRS) was used to measurethe overall functional independence of the patients. It is ascale that allows comparison between patients with differentkinds of neurologic deficits which adds a further dimensionby referring to previous activities. It contains 7 items, graded0 to 6, with a score of 6 indicating patient is dead and lowerscores reflect better functioning10. The mRS is an intervieweradministered scale which is widely used in clinical trials; itpossesses good inter- and intra-rater reliability and is a goodscale for differentiating between changes in mild to moderatedisability11.

The London Handicap Scale (LHS) has six items ondimensions of handicap (participation restriction): mobility,physical independence, occupation, social integration andeconomic self-sufficiency. There are six response optionsfor each item. Respondents completed the questionnaireby selecting one option per item indicating their perceivedlevel of disadvantage (on a 6-point scale from “none” to“extreme”). The LHS scoring could be by un-weighted simplesummation of scores or use of weighted scoring12,13. Theun-weighted scoring system was used in this study tocalculate the total handicap score with obtainable valuesranging from 0 (maximum disadvantage) to 100 (nodisadvantage). This simple summation procedure has aconstruct validity of 0.81 reported to be similar to that of thetraditional weighted scoring.13 For the LHS, a higher scoreindicates higher level of functioning and it is self-administered, acceptable and easy to understand by

patients12.Quality of life was assessed using the WHOQoL-BREF.

This is a self-reported 26- item scale rated on a 5-point Likert-response scale. The first 2 items are labeled as over-allQuality of Life and over-all health while the remaining 24items are grouped into 4 domains namely Physical health,Psychological health, Social relationship, and Environment14.In cases where participants are unable to write due todisability, the scale could be interviewer-assisted.

Data analysesClinical and socio-demographic data were summarized

with descriptive statistics of mean, standard deviation andpercentages. The pattern of activity, participation and QoLof stroke survivors were analyzed with Friedman’s ANOVAto test the null hypothesis that there would be no significantchange in these constructs across the 6-month period.Where significant difference was observed, the Wicoxon’sSigned Rank test was computed to identify the pair that wassignificantly different. Relationships among the mRS, LHSand WHOQoL-BREF scores were analyzed with theSpearman’s Correlation Coefficient and the alpha level wasset at 0.05. Statistical analysis was performed using theSPSS version 13.0 for Windows.

Results

Twenty stroke survivors consented to take part in thestudy over the 9 month recruitment period out of which 16(60.68 + 9.76 years) completed the 6 months follow-up. Forthe 4 individuals who did not complete the study; one eachdied, developed cognitive deficits; refused furtherinvolvement in the study, while one changed his place ofabode and could not be located for follow-up. The meanage of the 16 (9 males and 7 females) people that completedthe 6 months follow-up was 60.68+9.76 years.

Based on the statistical analysis carried out, theFriedman’s ANOVA of 39.38 (p= 0.00) and 41.87 (p= 0.00)indicate significant differences in the mean rank of each ofthe mRS, and LHS scores respectively across the six-monthstudy period. Further analysis of multiple comparisonsbetween pairs of the means across six months showed thatthere was significant difference in mRS between each pairof months (p< 0.05) except between the 2nd and 3rd, andbetween the 4th and 5th month. For the LHS significantdifference was observed between LHS scores for each pairof months except between 4th and 5th; 4th and 6th andbetween 5th and 6th .time frames. For the QoL scores,significant change in score was observed only in the over-all health item of the WHOQoL-BREF while the scores ofthe overall quality of life item and the remaining 4 domaindid not change significantly over the six-month study period(Table 1).

Results of correlation analysis showed statisticallysignificant correlation at baseline (1st month post stroke)between activity (mRS) and participation (LHS); and betweenactivity (mRS) and each of psychological health andenvironment domains of the WHOQoL-BREF and betweenparticipation (LHS) and environment domain of theWHOQoL-BREF. At the 6th month post-stroke, there wasno significant correlation among the 3 constructs exceptbetween participation (LHS) and physical health domain ofthe WHOQoL-BREF.


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Discussion

Activity, participation and Quality of Life are importantoutcomes used to track recovery after a stroke. Thepeculiarities of these constructs to characteristics of strokevictims such as race and place of residence suggest a needto investigate their pattern among stroke survivors in differentcommunities. It is however challenging to carry out alongitudinal study in Ibadan, Nigeria due to many limitationsincluding difficulties in locating patients for follow-up afterdischarge from hospital. This is as a result of poor houseidentification system and reluctance of patients to have theirroutine distorted at home by researchers. However this studyassessed how activity, participation and QoL changes, if atall over a 6 month period among community-dwellingNigerian-African stroke survivors living in Ibadan, an urbansettlement in South-Western Nigeria. Gender distribution inthis study showed a preponderance of males, a pattern thatis similar to that reported in previous prospective studies7,9,15.

Activity pattern of the stroke survivors showed aprogressive improvement throughout the 6 months period.This result is comparable to the outcome of a longitudinalstudy which compared functional recovery of stroke survivorsin four different European rehabilitation centres where aconsistent pattern of improvement of activity in the first 6months following stroke was recorded16. Althoughassessment of a stroke survivor’s activity often providesinformation on tasks and actions executed by the individual3,such assessment does not specifically test recovery fromhemiplegia. Therefore, improvement in activity performancecould be attributed to behavioural compensation strategiessuch as performance of self care with one hand (unaffectedarm) and might not specifically reflect the performance ofthe side of the body affected by stroke16. Nevertheless,activity is considered a more important outcome of strokeand stroke survivors have been reported to place morerelevance on their activity performance than on motorfunction status post-stroke11.

Table 1: Analysis of Trend of Quality of Life across Six Months.WHOQoL Mean Rank for six monthsItems & Domains MH1 MH2 MH3 MH4 MH5 MH6 X2p-valueItem 1 (Overall QoL) 3.17 3.17 3.08 3.63 4.08 3.88 5.81

0.33Item 2 (Overall Health) 2.08 2.75 3.00 4.75 4.22 4.00 25.26*

0.00Domain 1 (Physical Health) 2.96 3.08 3.08 3.88 3.71 4.21 5.87

0.32Domain 2 (Psychological Health) 3.38 2.96 2.92 3.83 4.00 3.92 4.56

0.47Domain 3 (Social Relationship) 3.04 4.08 3.54 3.42 3.04 3.88 4.61

0.47Domain 4 (Environment) 2.92 3.04 3.08 4.38 3.79 3.79 6.69

0.24KeyMH- Month.WHOQoL Items and Domains: The 2 items and 4 domains of the WHOQoL-BREF Questionnaire.* - Significant at p< 0.05X2-Friedman’s Analysis of Variance

Table 2: Relationship among Activity (mRS), Participation (LHS) and Quality of Life (WHOQoL-BREF) at the 1st and 6th month Post Stroke using SpearmanRank Order Correlation (n=16).

VariablesVariables WHOQoL-BREF

Items DomainsMRS LHS Q1 Q2 1 2 3

4mRS1st Mth 1.00 0.63* 0.19 0.17 0.23 0.66* 0.36

0.77*6th Mth 1.00 0.18 0.11 0.13 -0.08 0.02 0.10

0.06LHS1st Mth 0.63* 1.00 0.48 0.33 0.28 0.79 0.12

0.68*6th Mth 0.18 1.00 0.58* 0.93 0.16 0.21 0.04

0.10*Significant at p< 0.05WHOQoL-BREF Items mRS: Modified Rankin ScaleQ1 - Item on overall Quality of Life LHS: London Handicap ScaleQ2 - Item on overall health WHOQoL-BREF- WHO Quality of Life Abbreviated VersionWHOQoL-BREF Domains Mth: Month1 - Physical Health2 - Psychological Health3- Social Relationship4 - Environment


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The findings of this study showed improvement in theover-all participation level of the stroke survivors over a 6-month period. Post Hoc analysis revealed that the statisticallysignificant improvement observed occurred during the first4 months post stroke. The non-significant difference inparticipation from the 4th to 6th month suggests a plateauin recovery of this ability or stagnancy in adjustment to thecommunity life after stroke among the survivors. Participationhas been reported to deteriorate with advancing age andconsidering the mean age of the stroke survivors who tookpart in this study (mean age 60.68+ 9.76 years), deteriorationof participation following a stroke may be expected18. Thefindings of this present study as regards participationhowever, is comparable with the report of Desrosiers et al18

which indicated a significant increase in participation ofstroke survivors in the first 3 months after hospital discharge.

Many investigators have studied Quality of Life (QoL) ofstroke survivors across different time frames5,7,9 and havereported varying findings. In this present study, looking atthe values obtained foe the WHOQol-BREF, the QoLdomains of Physical health, Psychological health, Socialrelationship and Environmental domains and items on overallquality of life and overall health varied over time and showedalternate deteriorations and improvements across the sixmonths study period. This implies that there was noconsistency in the trend of QoL across the study period.However, the overall health item showed a statisticallysignificant improvement across six months. This finding issimilar to that of a study of stroke survivors exposed tooptimal care in stroke units which were characterized byearly treatment and rehabilitation and yet the results showedno improvement in QoL19.

It is noteworthy that while activity and participationimproved among stroke survivors in this present study, theimprovement did not result in corresponding improvementin QoL. In a study where stroke survivors experienced goodrecovery in activities of daily living, social activities, and returnto work, Carod-Artal et al7 reported that significant deleteriouseffects persisted in the QoL of these patients because theydid not achieve the level of function they enjoyed before thestroke. A follow-up study at the 3rd, 6th, and 12th monthpost stroke onset also reported a deterioration of QoL ofstroke survivors9 while Sturm et al20 reported that strokepatients experienced substantially poor QoL 2 years afterstroke. Conversely, a study reported improvement in somedomains of QoL post-stroke in which such recovery trendswere attributed to adaptation of the stroke survivors to theirnew life situation15. These divergent reports may in literaturebe due to the different time points of assessment of QoL bythe various researchers21.

Findings of this study showed that while a non-statisticallysignificance correlation existed among the 3 constructsexcept between participation (LHS) and over-all health itemof the WHOQoL-BREF at the 6th month post stroke, apositive correlation between activity and participation onlyat the 1st month post stroke onset. This contrasts with thereport of an earlier study which showed a strong correlationbetween activity and participation at 6th month post stroke22.Significant correlations between activity and each of thePsychological Health and the Environment domains ofWHOQoL-BREF were observed at the 1st month only whilea significant correlation was observed between participationand the overall Quality of life item at the 6th month post

stroke onset. A trend similar to the findings of de Haan etal22 who reported handicap (participation restriction) as beingthe closest determinant of stroke survivors’ Quality of Lifewhen compared to impairment and disability.

From the findings of this study, it could be inferred thatimproved functioning in terms of activity and participationdid not result in improved Quality of Life of stroke survivors.This is a pointer that among community-dwelling NigerianAfrican stroke survivors, factors other than activity andparticipation are probably influencing their quality of life.

Although all the stroke survivors who took part in hisstudy satisfied the eligibility criteria for the study and thuswere similar in characteristics at the point of enrolment, thefact that the type of medical and rehabilitation (e.g.physiotherapy) services received by these patients whilethe study lasted were not standardized could havesignificantly affected the findings of the study. This is animportant limitation of the study, aside the relativley smallsample. The strength of the study however includes the factthat we could not find evidence in literature of any longitudinalstudy involving stroke victims receiving physiotherapy inNigeria.

References

1. Martins T, Ribeiro JP, Garrett C. Disability and qualityof life of stroke survivors: evaluation nine months afterdischarge. Rev Neurol 2006; 42: 655-59

2. Woo J, Yu Chan S, Sum MC, Wong E, Chui YM. In -patient stroke rehabilitation efficiency: Influence oforganization of service delivery and staff numbers.http://www.biomedcentral.com/1472-6963/8/86 on 18/6/08 (accessed on June 18, 2008)

3. WHO (2001) International classification of functioning,disability and health (ICF) www3.who.int/icf/onlinebrowser/icf.cfm?parentlevel-2&childlevel(accessed on Jan 22, 2007)

4. Lai S, Studenski S, Pamela W. Duncan PW, Perera S.Persisting consequences of stroke measured by thestroke impact scale. Stroke 2002; 33: 1840-44

5. Nichols- Larsen PS, Clark PC, Zeringue A, GreenspanA, Blanton S. Factors influencing stroke survivors’Quality of life during subacute recovery. Stroke 2005;36: 1480-88

6. Hartman-Maeir A, Soroker N, Ring H, Avni N, Katz N.Activities, participation and satisfaction one-year poststroke. Disabil Rehabil 2007; 29: 559-66.

7. Carod-Artal J, Egido JA, Gonzalez JL, Varela E. Qualityof life among stroke survivors evaluated 1 year afterstroke: experience of a stroke unit. Stroke 2000; 31:2995-3000.

8. Caty GD, Detrembleur C, Bleyenheuft C, Deltombe T,Lejeune TM. Effect of simultaneous botulinum toxininjections into several muscles on impairment, activity,participation, and quality of life among stroke patientspresenting with a stiff knee gait. Stroke 2008; 29: 2803-08.

9. Suenkeler IH, Nowak M, Misselwitz B et al. Time courseof health-related Quality of life determined 3, 6 and 12months after stroke. Relationship to neurological deficit,disability and depression. J Neurol 2002; 248:1160-67.

10. Van Swieten JC, Koudstal PJ, Visser Mc, Schouten HJA,van Gijn J. Inter-observer agreement for the assessmentof handicap in stroke patients. Stroke 1988;19:604-07.


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11. Weimar C, Kurth T, Kraywinkel K et al. Assessment offunctioning and disability after ischemic stroke. Stroke2002; 33: 2053-59

12. Harwood RH, Gompertz P, Ebraim S. Handicap oneyear after a stroke: validity of a new scale. J NeurolNeurosurg and Psychiatry 1994; 57: 825-29.

13. Jenkinson C, Mant J, Carter J, Wade D, Winner S. TheLondon handicap scale: a re-evaulation of its validityusing standard scoring and simple summation. J NeurolNeurosurg and Psychiatry 2000; 68: 365-67.

14. WHOQoL Group (1996): WHQOL-BREF. Introduction,administration, scoring and generic version of theassessment; field trial version. www.who.int/mental-health/media/en/76/pdf on 18/2/07 (accessed on Feb18, 2007)

15. Jonsson AC, Lindgren I, Hallstrom B, Norving B,Lindergren A. Determinants of quality of life in strokesurvivors and their informal caregivers. Stroke 2005;36: 803-08.

16. De wit L, Putman K, Schuback B, et al. Motor andfunctional recovery after stroke: A comparison of 4European rehabilitation centers, Stroke 2007;38:2101-07.

17. Desrosiers J, Bourbonnais D, Norea L, Brao G, Annick

B. Participation after stroke compared to normal aging.J Rehabil Med 2005; 37: 353-57.

18. Desrosiers J, Demers L, Robichaud L, Vincent C,Belleville S, Ska B. Short-term changes in and predictorsof participation of older adults after stroke followingacute care or rehabilitation Neurorehabil Neural Repair2008; 22: 288-97.

19. Stavem K, Ronning OM. Quality of life 6 months afteracute stroke: impact of initial treatment in a stroke unitand general medical wards. Cerebrovasc Dis 2007; 23:417-23.

20. Sturm JW, Donnan GA, Dewey HM, Macdonett RA,Gilligian AK, Srikanth V. Quality of life after stroke: thenorth east Melbourne stroke incidence study(NEMESIS) Stroke 2004; 35: 2340-45.

21. Patel MD, Mckevitt C, Lawrence E, Rudd AG, WolfeCD. Clinical determinants of long term after stroke. AgeAgeing 2007; 36: 316-22

22. de Haan R, Horn J, Limburg MD,Van Der Meulen J,Bossuyt P. A comparison of five stroke scales withmeasures of disability, handicap and quality of life.Stroke 1993; 24: 1178-81.


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Effect of strength training using one’s own body weight insarcopenia-a single blind studyJ Madhana Gopal1, D Arun2, N Padma Priya3, M Dhinesh Kumar4, C Elanchezian5, V S Natrajan6

1,2,4,5Lecturer, Meenakshi College of Physiotherapy & Hospital, Chennai, India, 3Principal, Meenakshi College ofPhysiotherapy & Hospital, Chennai, India, 6Geriatrician, Madras Medical College & Hospital (Retd), Chennai, India

Abstract

Background and Purpose: Sarcopenia is partly reversiblewith appropriate exercise interventions. Most of the exerciseinterventions have focused only on Strength training usingexternal resistance prescribing the intensity of exercisebased on 1 RM (Repitition Maximum). In this procedure too,there may arise a risk of aggravating a pre-existing healthcondition while basing the intensity of exercise on 1 RM andadverse effects of 1 RM testing on elderly people have beenwell documented which includes exacerbation ofosteoarthritis, minor strains, tendonitis, and inguinal hernia.So, the purpose the study is to find out the effectivenessand safety of strength training using one’s own body weighton sarcopenia.

Methodology

Thirty six healthy older adults were recruited and randomlyassigned to either one’s own body weight training group ornon training group. Subjects trained thrice per week fortwelve weeks using one’s own body weight.

Results

Parametric‘t’ test was used to analyze the effect of exerciseon muscle strength, lower body strength & gait speed. Intraining group, the post test mean value of all the variableswere improved than the pretest mean value at p<0.05 thanthe control group.

Conclusion

The results demonstrate that the training group showed asignificant improvement in muscle strength of quadricepsand calf strength, lower body strength and gait speed. Thus,suggesting that this exercise protocol is effective and easyto implement to reverse the sarcopenia.

Key words

Sarcopenia, strength training using one’s own bodyweight

Introduction

Sarcopenia is defined as age related loss of muscle

mass, strength, and function1, 2. This condition appears tobegin in the fourth decade of life; adult loses 3% to 5% ofmuscle mass per decade3, rate of decline that increases to1% to 2% per year after age 50 years4 Although there is nospecific level of lean body mass or muscle mass to indicateof presence of sarcopenia5, any loss of muscle mass is ofimportance because there is a strong relationship betweenmuscle mass and strength6.

Sarcopenia causes less force production, less precisecontrol of movements and slowing of muscle mechanics5,6,the well recognized functional consequences of sarcopeniainclude gait and balance problems and increased risk offall. Ultimately, these impairments eventually lead to physicaland functional dependence7,4.

Current strategy of management of sarcopenia involvesadministration of Testosterone, Growth Hormone, Estrogen,Strength training and adequate nutrition8. Although thisstrategy is found to be effective in retarding the progress ofsarcopenia, the adverse effects of Testoterone, GrowthHormone & oestrogen therapy are worrisome and deservesome serious considerations; the adverse effects oftestosterone comprise of fluid retention, gynaecomastia,worsening of sleep aponea, polcythemia and accelerationof beningn or malignant prostatic tumour and those of Growthhormone comprise of carpel tunnel syndrome, fluid retention,arthralgia, orthostatic hypotension and lower bodyoedema9. In view of these reports, exclusive schedule ofResistance training remains the most effective and highlysafer intervention for increasing muscle mass and strengthin older people6, 10.

Sarcopenia is partly reversible with appropriate exerciseinterventions11. Exercise interventions are not only useful toprevent the scaropenia but also to reverse the sarcopenia10.Most of the exercise interventions have focused only onStrength training using external resistance prescribing theintensity of exercise based on 1 RM ( Repitition Maximum).In this procedure too, there may arise a risk of aggravatinga pre-existing health condition while basing the intensity ofexercise on 1 RM12. Recently, it was found that the adverseeffects of 1 RM testing on elderly people have been welldocumented which includes exacerbation of osteoarthritis,minor strains, tendonitis, and inguinal hernia13.

It is to be notified that strength training using externalresistance is expensive and requires a lot of direct technicalassessment and supervision and lack of these facilities mightprove to be a deterrent, in applying if to a rural population.On the other hand, strength training using one’s own bodyweight is inexpensive and easily practicable and can be donein any setting when compared to strength training usingexternal resistance. It has been found that strength trainingusing one’s own body weight is effective to improve Calfmuscle strength among elderly women with osteoporosis


Madhana Gopal JLecturer, Meenakshi College of Physiotherapy & Hospital, ChennaiE-mail: [email protected].: 9894890462

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by using BIODEX 2 isokinetic dynamometer14.The objective of the present study is to investigate the

efficacy and safety of the procedure of strength training usingone’s own body weight in retarding the progressivesarcopenia in elderly people. If the training group is foundeffective, this procedure can be advocated as an inexpensiveand easily practicable procedure to the aging population inrural areas which forms a significant segment of populationin developing countries like India. Thus, this study is basedon premise that this procedure shall prolong the active lifeof the elderly by improving their health status which mayeventually prove to be of great public health relevance andcontribute to the economic progress of developing country.

Methodology

Study DesignThis study was a controlled trial in which participants

were randomly allocated either to training or to a non-traininggroup and was conducted in old age home for a period of12 weeks.

Study PopulationSeventy seven subjects were interested to participate in

the study and undergone a thorough assessment bygeriatrician to rule out the contraindications to exercise, fortyfour subjects were fit to participate in the exercise program.Inclusion criteria were; Both sexes, Age of the individualfrom 70 to 80, Subjects who are independent in activities ofdaily living and not affected by neurological disease andheart problems, gait speed less than 1m per second.Exclusion Criteria were; Depression, dementia and delirium,Pain in the lower limb joints and low back at the time ofstudy and Cachexia. Each participant were explained andagreed to participate and study was approved by MeenakshiUniversity Human Ethics Committee.

Testing procedureTesting of all outcome measures were conducted before

participate in exercise program and after 12 weeks ofexercise program by a two physiotherapist. They weretrained to measure the lower body strength, muscle strengthof quadriceps and calf muscle and gait speed and blindedabout the study.

Isometric Knee Extensors Strength (IKES) and plantarflexors strength

The modified sphygmomanometer was used to measurethe IKES. It consists of a sphygmomanometer folded bladderinside a sewn bag as described by Helewa et al. Thesphygmomanometer was inflated to a baseline reading onthe aneroid scale (20 mmHg) and the tester placed the sewnbag on the subjects leg and stabilized until the readingshows 40 mmHg in aneroid scale to minimize the readingvariation among the subjects during stabilization and takenas a baseline value. The subject was asked to attempt toinduce movement by exerting force against the tester. A“break” in movement or a tremor indicated maximal isometriccontraction. Strength was recorded three times and averageof three measures was taken as muscle strength.

Lower body strengthParticipants were instructed to sit in an adult chair and

fold their arms across the chest. Participants were asked todo sit to stand as fast as possible for a period of 30 sec andstop watch was used to measure a 30 seconds. The subjects

had done a three times sit to stand at a interval of 2 minutesand highest value was taken as lower body strength. The30 sec chair stand test provides a reasonably reliable andvalid indicator of lower body strength in older adults15.

Gait speedThe subjects were asked to walk at a normal pace and

fast pace as fast as possible across an eight meter. Thepace timed from two to eight meter was taken as gait speedin order to exclude the speed variation during accelerationand measured using stop watch. Gait speed has been shownto be a reliable and valid measure of monitor mobility and toscreen for falls in older adults16,17,18.

Training InterventionTraining group subjects were received a strength training

using one’s own body weight for a period of three months.Control group subjects didn’t receive exercise training. Thetraining group subjects had undergone a progressivestrengthening exercise to strength the quadriceps and calfmuscles i.e., intensity of body weight passed through thelower limb is gradually increased which was presented in atabular column.

Quadriceps & Calf Period of exerciseStrengthening Exercise.

• Basic chair squat, 1 -4 weeks.

• Heel rising with holdingthe chair

• Half Squatting

• Heel rising withoutholding chair 5 -8 weeks.

• Static Lunges.

• Single leg standing, theheel will rise from theground by holding thechair15. 9 -12 weeks.

The subjects were trained 3 times per week, 4 sets perday19, 8-12 repetition per set19 and 1-2 minute rest was givenbetween each set19. The subjects in the control group wereinstructed to maintain the usual activities of daily living.Questioner was used to document the adverse effect ofstrength training during the course of training and after twelveweeks of training,

Have you ever suffered knee and ankle pain during theperiod of exercise?

All the participants reported that no pain in lower limbjoints during the period of exercise

Statistical analyzes

All the statistical analysis was performed using SPS software package, values were presented as means+ standarddeviation, student t test were used to analyze the effect ofstrength training using one’s own body weight an outcomevariables. Statistical significance was accepted at p<0.05.

Results

Of the 44 subjects initially participated into the study, 8subjects failed to complete the study and the data analysesdone for 36 subjects. Mean value and standard deviation ofvariables before and after treatment was shown in table 1


29

Discussion

This study evaluated the effect of strength training usingone’s own body weight on sarcopenia. The statistical analyzefound that the significant improvement obtained in the musclestrength, lower body strength and gait speed in training groupthan the control group and the participants in control groupshowed a little reduction in their performance.

The results showed that the rate of decline in musclestrength and functional strength and the accompanying lossof functional mobility can be reduced or reversed by exercisetraining.

The improvement obtained in this study might be becauseof increased production of strength probably occurs as aresult o f training the neural adaptations. It has been reportedthat these neural adaptations are primary source of gains inproduced force observed over the first 8 weeks of training,whereas increase in muscle cross sectional area arebelieved to be the primary source of gain observed thereafter.

The quadriceps and calf has been chosen to strengthensince this muscles plays a major role in getting from thechair and walking and also to progress the intensity ofexercise might not be possible for the other muscles of thelower limb. In this study, the muscle mass was not includedas an outcome measure because of lack of availability ofmuscle mass measuring instruments.

The position used to measure the strength of quadricepsand calf muscle as described by William Andrew et al (1996).while stabilizing the cuff of modified sphygmomanometeron a testing part, there was a rise in reading in aneroid scaleand it was stabilized till the reading shows 40mmHg andtaken as a baseline value for muscle strength measurement.

During the course of the study, there was a drop out of 8subjects (4 in training and 4 in non-training group). In traininggroup, the 3 subjects had relocated to other old age homesand 1 subject had a neck of femur fracture. In non-traininggroup, the 2 subjects had neck of femur fracture due to fallon a slippery surface and 2 subjects had relocated to theirnative place.

The limitations of the study are small sample size andmuscle mass not included as an outcome measure. Thisstudy suggest that muscle mass can be included as anoutcome measure and may be done with large sample sizein the future studies.

Conclusion

The results demonstrate that the strength training usingone’s own body weight is effective and safe to retard theprogress of sarcopenia and this study suggest that theexercise using one’s own body weight can be used as a

alternative for using external weights or equipment to reversesarcopenia.

References

1. Waters, D.L., R.N. Baumgartner & P.J. Garry. 2000.“Sarcopenia: Current Perspectives.” The Journal ofNutrition, Health & Aging 4(3):133-139

2. Vandervoort, A.A. & T.B. Symons. 2001. “Functionaland Metabolic Consequences of Sarcopenia.” CanadianJournal of Applied Physiology 26(1):90-101

3. Nair, K.S. 1995. “Muscle Protein Turnover:Methodological Issues and the Effect of Aging.” TheJournals of Gerontology 50A:107-114

4. Marcell TJ. Sarcopenia: causes, consequences, andpreventions. J Gerontol A Biol Sci Med Sci. 2003;58(10): M911-M916

5. Roubenoff, R. 2001. “Origins and Clinical Relevance ofSarcopenia.” Canadian Journal of Applied Physiology26(1):78-89

6. Roth, S.M., R.E. Ferrel, & B.F. Hurley. 2000. “StrengthTraining for the Prevention and Treatment ofSarcopenia.” The Journal of Nutrition, Health & Aging4(3):143-155

7. Chhandra Dutta. 1997. Significance of sarcopenia inelderly. American society for nutritional sciences : 0022-3166/97

8. Stephen E.Borst 2004. Interventions for sarcopenia andmuscle weakness in older people. Journal of Age andAgeing Vol 33 No.6 548-555

9. Papadakis MA, Grady D , Black D et al . Growth hormonereplacement in healthy older men improves bodycomposition but not functional mobility. Ann Intern Med1996; 124; 708-16

10. Roubenoff, R. & V.A. Hughes. 2000. “Sarcopenia:Current Concepts.” The Journals of Gerontology55A(12):M716-24

11. Latham N.K., D.A. Bennett, C.M. Stretton and C.S.Anderson. 2004. Syestamatic review of progressiveresistance strength training in older adults . Journal ofGerontology: Medical Sciences 59 A(1): 48-61

12. Porter, M. M. 2000. “Resistance Training Recommen-dations for Older Adults.” Topics in GeriatricRehabilitation 15(3): 60-69.

13. Nathan J.de Vos , Nalin A.Singh et al .2005. Optimalload for increasing muscle power during explosiveresistance training in older adults. Journal ofGerontology; Vol.60 A , No5 638-647

14. Aveiro Mc 1, Granito Rn 1, Navega Mt 1,2, Driusso P 1E Oishi J. 2006. Influence Of A Physical TrainingProgram On Muscle Strength, Balance And Gait Velocity

The comparison of these values reveals that the training showed an improvement in muscle strength, lower body strength &gait speed than the control group.Training group Non-training groupN=18 (mean age -75.55) N=18 (mean age -74.08)

Variables Mean+SD Baseline Mean+SD Follow up p value Mean+SD Baseline Mean+SD Follow up pvalueMSQ(Rt) 184+31.08 196.72+32.58 0.000 169.72+36.36 164.78+35.73 0.001MSQ(Lt) 177.44+39.57 188.67+38.25 0.000 160.50+33.41 156.50+33.72 0.000MSC(Rt) 135.11+39.57 146.78+33.05 0.000 122.06+28.96 117.44+28.45 0.001MSC(Lt) 125.33+31.77 136.61+33.20 0.000 115.78+28.96 113.33+28.19 0.009LBS 12.11+3.708 13.33+2.808 0.003 11.44+3.989 10.94+4.065 0.015GS(H) 0.894 + 0.190 1.131+ 0.180 0.000 0.945+0.335 0.945+0.385 0.296GS(F) 0.662+0.940 0.888+0.330 0.000 0.715+0.635 0.701+0.385 0.980

MSQ(Rt)-Muscle Strength of Quadriceps right side, MSQ(Lt) -Muscle Strength of Quadriceps left side, MSC(Rt)- Muscle Strength of calf right side, MSC(Lt) -Muscle Strength of calf left side, LBS- Lower body strength, GS(H)- Gait speed (habitual), GS(F)–Gait speed (fast)


30

Among Women With Osteoporosis. Rev. bras. fisioter.,São Carlos, v. 10, n. 4, p. 441-448.

15. Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand testas a measure of lower body strength in community-residing older adults. Res Q Exerc Sport 1999Jun;70(2):113-9

16. Imms F, Edholm O. Studies of gait and mobility in theelderly. Age Aging. 1981;10:147–156

17. Tager IB, Swanson A, Satariano WA. Reliability ofphysical performance and self-reported functional

measures in an older population. J Gerontol. 1998;53:M295–M300.

18. VanSwearingen JM, Paschal KA, Bonino P, Chen T.Assessing recurrent fall risk of community-dwelling, frailolder veterans using specific tests of mobility and thePhysical Performance Test of function. J Gerontol ABiol Sci Med Sci. 1998;53:M457–M464.

19. Nied RJ, Franklin B. Promoting and prescribing exercisefor the elderly. Am Fam Physician. 2002; 65(3): 419-426.


31

Physiotherapy assessment findings may not correlate with MRIfindings in neurologically impaired patient – A case reportJojo K George, Kavitha Vishal, Narasimman.S.Department of Physiotherapy, Father Muller Medical College, Mangalore

Abstract

Clinical Decision making makes an important part ofneuro rehabilitation and requires cognitive and Metacognitive skills of the therapist. Most of the time investigationsmay not correlate with the clinical findings. Appropriateselection of outcome measures also mandatory in designingthe rehabilitation protocol.

Background

Physiotherapy assessment based on the sound clinicalreasoning forms the central pillar of successful outcome ofany neuro rehabilitation. In the recent past variousapproaches of clinical reasoning in neuro rehabilitation hasbeen explained. Patient centered clinical decision makingexplained by Schenkman et al1 is found be useful in findingout the impairments, Activity limitations and participatoryrestrictions. Investigations used in the diagnosis ofneurological deficits are accepted through the world.Magnetic resonance image (MRI), has been considered asone of the gold standard procedure. It has beenrecommended by the authorities that the findings of theinvestigations should be correlated with the clinicalpresentation. This case study explains the importance ofclinical examination in a neurologically impaired patients andthe lack correlation between the assessment findings andMRI.

Case description

45 year old female patient referred to physiotherapy withthe chief complaints of inability to walk, loss of balance anddifficulty to do daily activities since 3 days. Patient wasapparently normal, when she experienced the sudden onsetof giddiness while washing clothes, which forced her to sitdown on the floor. On attempt to get up, she was unable todo so and called out for help. She was immediately taken toa local physician who referred her to a super specialtyhospital, the MRI that followed the admission revealednormal study of the brain.

Patient was started on with medications for her presentcomplaints and was referred for physiotherapy for themanagement of weakness. Patient was a known case ofhypertension on medication for the past five years. She hadundergone surgery for carcinoma breast five years back andwas married with five children. Patient was co operative andmotivated but anxious about her present condition.

After the detailed history, the therapist was led to thehypothesis that the impairment might be due tocerberovascular accident. This was further strengthenedwhen reviewed the patients past history which weresuggestive of similar episodes in the past.

Past history

She had a First episode at the age of fifteen when shewas doing work; suddenly she felt weak and had an episodeof giddiness Second episode was at the age of 22, whenshe was pregnant at eighth month (patient was not a knowncase of hypertension) of pregnancy, felt giddy and had a falldue to which she was taken for emergency labor. Patienthad a normal delivery and was uneventful. Since then shewas leading a normal healthy life.

The therapist went into a detailed review of the systems.The systems were namely the cardiopulmonary,musculoskeletal, neurological and integumentary.Thecardiopulmonary system review revealed stable vitals whichwere as follows -Vitals: - BP: 120 /80 mm Hg, RR: 20 timesper minute, HR: 76 beat/ minute, Temperature: 98.6 F.musculoskeletal assessment showed no relevant findings.Integumentary system remained intact.

With the above subjective examination and systemsreview, therapist was directed to perform a detailedneurological examination which is as follows.

On observation the therapist found the trunk was deviatedfrom midline towards left side during sitting and Standingwith walker.

Attitude of limbs were Normal.On examination higher mental functions were assessed

with mini mental score. Cranial nerve examination revealedtransient diplopia and evoked horizontal nystagmus to rightside with correction to the left, patient also presented withptosis. This denoted the involvement of Brain stem. Alldimensions of sensations were intact including the corticalsensations.

Motor examination commenced with tone evaluationusing modified ashworth scale. Patient did not exhibit anytonal abnormalities and a detailed strength testing of themuscles revealed no strength deficits in the extremity butimpaired in the trunk muscle strength. Reflexes were normaland no clonus was elicited.

Her balance and postural control2,3 was assessed usingberg balance scale and the following problems wereidentified.

Static in sitting – patient is in left aligned with increasedtendency to fall to left side but able to maintain the staticbalance. Patient exhibited delayed / slower protectivereaction on left side compared to right side.

Standing able to maintain static balance but withoutconsistency. Unable to take any form of challenge patientdefinitely requires assistance.

Co ordination was assessed using equilibrium and nonequilibrium tests which revealed the patient with severeataxia and was unable to stand without manual support.

As part of the evaluation of bed mobility patient was askedthe following activities:

Jojo K George et al/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2

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Rolling to right side was better when compared to theleft side

Supine to sit and sit to supine is independentSitting to standing – moderate assistance with high

guardingTransfer – maximal guarding and assistance requiredImpairment in the trunk was assessed with the help of

trunk impairment scale and postural assessment scale forstroke patients and trunk control test4, 5, 6,7,8,9.

Gait assessment of the patient revealed that she wasunable to ambulate and needed maximal assistance (twotherapists), she leaned heavily on her left side and hadsevere ataxia of the left lower limb. In addition she alsorequired a walker for assistance.

Functional evaluation of patients revealed that patient

requires maximal assistance for all her activities except forcognitive and social functioning10, 11.

Impairment /problem list

Impaired bed mobilityAbnormal sitting postureImpaired dynamic balance in sitting and static and

dynamic in standingDeficits in equilibriumSevere ataxia

Activity limitation

Dependent in all activities of daily livingWhen the physiotherapy assessment was correlated with

the MRI, there was no abnormality.

Discussion

This case was primarily referred for strengthening ofbilateral lower limbs, physiotherapy assessment found noweakness in the lower limbs. But patient presented withimpaired bed mobility, abnormal sitting posture, impaireddynamic balance in sitting and static and dynamic instanding, deficits in equilibrium, severe ataxia. The MRIreported normal study of the brain. A structured and detailedpatient oriented clinical reasoning method proved to effectivein identifying the neurological impairment. Appropriateselection of outcome measures will keep the therapist indesigning the rehabilitation protocol, since the componentsof them addresses mainly functional impairments.

Berg Balance scale was used since it has five levels ofmeasurements including the psychometric properties and itmeasures the balance during functional tasks. Trunk controlhas been shown to be valid predictor of stroke rehabilitation


33

outcome and to correlate positively with establishedfunctional and motor assessment7,8,9. Functionalindependence measure is an 18 item seven level ordinalscale which we used to assess dysfunction in, progressive,reversible or fixed neurological disorders. in addition torecognizing cognitive impairment it is also a good predictorof functional level12.

This Case study emphasizes the importance of physicaltherapy examination with appropriate outcome measures13

to quantify the patient’s impairments and to plan out anindividualized rehabilitation program.

References

1. Margaret Schenkman, Judith E Deutsch, Kathleen MGill-BodyAn Integrated Framework for Decision Makingin Neurologic Physical Therapist Practice, Phys Ther.2006; 86: 1681–1702.

2. Charles B, Perunnou DA, Villy J, Rousseax M, PelissierJY, Validation of a Standardized assessment of Posturalcontrol in Stroke patients. The postural assessmentscale for stroke patients. Stroke 1999; 30:1862-1868

3. Bohannon R W, Leary KM. standing balance andfunction over course of acute rehabilitation. Arch of PhyMed Rehabil 1995;76: 994-996

4. Hsieh CL, Sheu CH, Hsueh IP, Wang CH. Trunk controlas an early predictor of comprehensive activities of dailyliving in stroke patients. Stroke 2002; 33:2626-2630.

5. Verheyden G, Nieuwboer a, Van de winckle A andDeweerdt WO. Clinical tools measure trunk performanceafter stroke: a systematic review of literature. Clinicalrehabilitation 2007; 21:387-394.

6. Franchignoni F.P, Tesio, Ricupero, Martino. Trunkcontrol test as an early predictor of stroke rehabilitationoutcome. Stroke 1997; 28 (7): 1382 -1385

7. Duarte E; Macro E; Muniesa JM ; Belmonte R ; Diaz P;Tejero M; Escalad F. Trunk control test as a functionalpredictor in Stroke patient. Journal of rehabilitationmedicine 2002; 34: 267-272

8. Fujiwara T, Liu M, Tsuji T, Sonoda S, Mizuno K,Akaboshi K, Hase k, Masakado Y, Chino N. Develop-ment of a New measure to assess Trunk impairmentafter stroke. Its psychometric properties. AM J Phys MedRehabil 2004;83:681 -688

9. Verheyden G, Nieuwboer A, Wit LD, Feys H, SchubackB. Trunk performance after stoke an eye catchingpredictor of functional outcome. J Neurology NeurosurPsychiatry 2007;78:694-698

10. Ottenbacher KJ, Hsu Y, Carl V, Granger, Fielder RC.The reliability of the functional independence measure;a quantitative review. Arch of Phy Med Rehabil1997;77:1226-32

11. Galski T, Bruno RL, Zorowitz R, Walker J. Predictinglength of stay, functional outcome, and after care in therehabilitation of stroke patients. Stroke 1993;24:1794-1800

12. Putten JJMF, Hobart JC, Freeman JA, Thompson AJ.Measuring change in disability after inpatientsrehabilitation. Comparison of responsiveness of BarthelIndex and the functional independence measure. Jneurol Neurosurg Psychiatry. 1999; 66: 480-484

13. Herndon RM. Neurological scales and quantitative testsfor clinician’s.The Neurologist 1999; 5:159-169.

Appendix

Outcome measure Obtained/max.score Interpretation1. Mini mental scale 26/30 normal limits2. Modified ashworth scale 1/4 no tonal abnormality3. MMT

Trunk flexors 2/5 able to lift scapula of the bedTrunk extensors 3/5 able to lift sternum of the bed

4. Berg balance scale 10/56 wheelchair bound5. Co ordination

Romberg’s test 1/4 Activity impossibleTandem standing 1/4 Activity impossibleStanding in normal 1/4 Activity impossiblePostureStanding in narrow base 1/4 Activity impossibleof support

6. Trunk control test 61/100 moderate impairment7. Postural assessment for 18/36 moderate impairment

Scale for stroke patients


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Effect of a structured antenatal physiotherapy program on backpainAgrawal Neha, Raja Kavitha, Pereira DaphneManipal College of Allied Health Sciences, Manipal, Karnataka, India


Neha AgrawalPlot no. 1225, Road no. 62Jubilee hills, Hyderabad (A.P) – 500033Phone: +91 9399339633E-mail: [email protected]

Key words

Antenatal, physiotherapy, exercise, pregnancy, backpain.

Objective

To assess the effect of a structured, antenatal exerciseprogram on low back pain during pregnancy, in primi andsecond gravidae.

Methods

Twenty-six low risk pregnancies with no previous orpresent history of back pain were identified at 20 weeksgestation and were randomly assigned into experimentaland control group for 20 weeks. The experimental groupreceived specific exercises and ergonomics. The controlgroup received only ergonomic advice. Intensity of backpainwas assessed at eight intervals during the course ofpregnancy with Visual Analog Scale. Mann-Whitey test wasused to assess the differences between both the groups.

Results

The specific exercise group, after intervention showedstatistically and clinically significant lower pain intensity whencompared to the group that received only ergonomic advice.

Conclusion

A structured antenatal exercise program begun earlyduring pregnancy, and before the onset of backpain, cansignificantly reduce the intensity of pain experienced duringthe course of pregnancy and postpartum.

Introduction

Pregnancy is a time of increased vulnerability for themusculoskeletal system. Pre-existing dysfunctions areaggravated and new problems may be created by thechanges that occur in a woman’s body during the childbearing years1.

Back pain during pregnancy is a common symptomreported by approximately 50% of women at some timeperiod during their pregnancy. Of them 9-15% of the casesrate their back pain as severe. Lumbo-pelvic pain affects

daily life and has an impact on health- related quality of life2,3.

Changes in posture have often been implicated as acause for the development of back pain. The gravid uterusplaces a lot of strain on the lower back. The pelvis tends torotate about the sacrum. The sacroiliac ligament resistsforward rotation and during pregnancy the tendency forrotation is increased as lumbar lordosis increases. Thiscauses the centre of gravity to shift anteriorly causing strainon the low back and the sacroiliac joints4.

The main goal of physical therapy in this population is torestore optimal biomechanics. Lumbo-pelvic stabilization canbe achieved with proper posture and enhanced musclefunction. Very few studies have been done on theeffectiveness of physical therapy interventions in low backpain during pregnancy and the postnatal period2. The mainaim of the present study was to evaluate the effect of astructured antenatal exercise programme that would help inthe reduction of pregnancy related low back pain.


The study protocol was reviewed and approved by theinstitutional research committee of our University. Subjectswere selected from the outpatient clinic of the Obstetricsand Gynecology department of the University hospital. Primiand second gravidae in the age group between 20 to 30years, who were healthy and free of any medicalcomplications, were included in the study. The subjectsexcluded for the study were women in whom congenitalabnormalities in the fetus were detected in the anomaly scan,those who had preterm rupture of membranes, anincompetent cervix and any other complication determinedby the obstetrician. Any subjects with pre-existing back painwere also excluded.

The procedure was explained in detail following which,a written informed consent was taken from the patients.Subjects were selected by convenience sampling andgrouped into control and experimental groups by blockrandomization.

The subjects in the experimental group were givenspecific exercises and those in the control group receivedonly ergonomic advice. A total sample size of 26 subjectswere included, 14 in the study group and 12 in the controlgroup.

The subjects were not blinded to the treatment theyreceived. Emphasis was placed on blinding them from anyexpectation bias with regard to efficacy of the differenttreatments. All subjects were followed up routinely over aperiod of 20 to 22 weeks.

The treatment was started after the anomaly scan donebetween 18 to 22 weeks of gestation.

Agrawal Neha et al/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2

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Subjects’ socio-demographic factors (e.g. age, height,weight, education, economic status) were taken.

The main focus in the experimental group was onexercise and training. The program was based on specificexercises to improve core stability, endurance and flexibility.

Exercises were done under supervision until the subjects’demonstrated correct performance and then they wereinstructed to continue the same protocol at home. Thesubjects maintained a log. The subjects were seen atintervals when the exercises were reviewed and the subjectswere encouraged to continue the exercises.

Subjects were asked to use the talk test and Borg’s ratingof perceived exertion as their termination criteria forcessation of exercise. The exercise protocol is described inthe appendix.

The control group received ergonomic advice aloneduring the 20th week of gestation.All parameters were measured for both the groups at thefollowing time intervals:a) Once a month till week 32 of gestation.b) Once in two weeks from week 32 to week 36 of

gestation.c) Once in a week from week 36 until the time of delivery.d) Post delivery after 6 weeks.

The outcome measure was back pain measured byVisual Analog Scale.

Data analysis of group differences at different points ofassessment were done using the Mann-Whitney test. A two-tailed alpha error of 0.05 was taken, power of the study being0.75. The software SPSS version 11.0. was used for all theanalysis.

Results

Out of the 14 subjects in the study group, five wereexcluded. Of the five, one subject delivered prematurely,one was detected to have an HIV positive status at 35 plusweeks of gestation, one developed gestational diabetes, onehad placenta previa in the last trimester and the other movedout of the study area. Out of the 12 subjects in the controlgroup, one dropped out during the study. The subjectdemographic characteristics are as shown below in table 1.

There were no significant differences between groups inany of the outcome measures at the beginning of the trial.After the intervention and at follow up there was a statisticallysignificant difference between the two groups in favor of theexperimental group as can be seen in table 2. The womenwho underwent a supervised exercise program experiencedsignificantly less low back pain clinically at all points of timeduring evaluation as can be seen in fig. 1. Statisticallysignificant differences were seen at 34, 36 and 38 weeks ofgestation with the experimental group reporting less pain.Clinically, decrease in pain was seen in the postpartumperiod in the subjects in the experimental group. However,this was not statistically significant.

Discussion

Our study was aimed at specific exercises and ergonomicadvice during the antenatal period, without the use of anyexternal aid to prevent low back pain in pregnancy. The mainfinding in our study was that, a treatment program havingspecific exercises was found to be more effective in reducingpain thus, improving the health related quality of life.

The only other study to our knowledge that has evaluatedthe effect of exercise on the intensity of low back pain in thesecond trimester and the beginning of the third trimesterwas that done by Garshasbi and Faghih5. The rationalebehind the dosage of exercise was not explained in the study.Our study had a training period of 20 weeks which was inkeeping with the guidelines from American College of SportsMedicine for increasing muscle strength and endurancewhich are considered to be important factors for improvementas well. It included general aerobic exercises, specificexercises for core strength and lower extremity flexibility, allof which contribute to reducing loads on the back, help ingeneral fitness and ergonomics in improving proper bodyposture and simplifying work with work modification.

Wikmar et al evaluated three different physical therapyprograms on pain and activity in pregnant women with afollow up at 3, 6 and 12 months postpartum. All groupsshowed beneficial results but their study found no additionalvalue of exercises when treating pregnant women. Exerciseswere done twice a week and the average compliance was16 times in the median time period of 16 weeks forintervention. Compliance was low and the training time wasinsufficient, which may have caused them to conclude thatexercises had no greater effect than information given alone.

Table 1: Demographic details of the study group (n= 20).Group Number of Age Gravida

subjects (Mean ± SD)Primigravida Second

gravidaExperimental 9 26.88 ± 1.76 7 2Control 11 26.27 ± 2.19 10 1

Table 2: Comparison of pain scores between the two groups at differentintervals during the antenatal and the postnatal period.

Time of evaluation Experimental Control Z Pgroup (n=9) group(n= 11)

Week 34 Median 0.00 3.00 -3.380 0.001IQR 0-0 2-5

Week 36 Median 0.00 4.00 -2.536 0.011IQR 0-0 0-5

Week 38 Median 0.00 3.00 -2.290 0.022IQR 0-2 0-5

6 weeks Median 0.00 2.00 NS postpartum

IQR 0-2 0-4

Fig. 1: Pain patterns in the experimental and the control group.

Period of gestation

6 weeks38363432282420

VA

SS

co

re

10

8

6

4

2

0

Groups

ControlGroup

Experiment group


36

6 Compliance is a key factor for the effectiveness of anyintervention program. Written logs given to the subjects’ inour study helped us measure the compliance and monitorthe subjects which led to a positive outcome in our study.The subjects in the experimental group did, on an average75% of the exercises three times a week either at home orin the hospital. This was considered higher than the previousstudy. The training period was longer and started earlierduring pregnancy and may have contributed to an increasecompliance and effect.

The timing of measurement of pain during pregnancyand pain location may influence results2. Our study measuredthe pain intensity at eight intervals during pregnancy whichhas not been reported in any study before and hence bettersensitivity to change in the pattern of pain with the effect ofexercises could be detected. These findings may have beenmissed if other studies where pain measurement was doneat one or two intervals during pregnancy and then followedat different intervals postpartum. Pain is also showed to havea decline in the last weeks of pregnancy.

The effect of antenatal exercises could be seenpostnatally too in our study, when compared to the controlgroup showing a carry over effect. Caution should beemployed in interpreting this, as the follow-up period wasshort. Future studies investigating the long term effectsshould be employed to substantiate these findings. We wereunable to do this due to loss of subjects to follow up beyondthis time period.

Studies have investigated various therapies likeacupuncture, diagonal trunk muscle exercises, watergymnastics, massage therapy, controlled progressivemuscle relaxation therapy, back school programs, effect ofpelvic belts all of which were said to be effective in reducingthe pain intensity during pregnancy. None of the studies gaveevidence in favor of a particular exercise program2. Ourprotocol which is simple to follow and specific to the backappears to have been beneficial. Further studies arewarranted before we comment on its efficacy over otherestablished treatments.

In India, this study assumes more significance, asresources available for therapy are minimal. Most of the workinvolved is mainly active and physically demanding, both ofwhich have been shown to be associated with an increasedrisk of low back pain and pelvic pain. Antenatal exercisesare not yet a part of regular antenatal programs in India.This could either be due to lack of awareness among subjectsand health professionals or due to cultural restraints of painbeing considered a part of pregnancy.

The sample size in our study was small even though theduration of the study period was one and half years. Subjectsagreeing for a long duration therapy when there were nosymptoms of pain, cultural restraints, fear of developingcomplications and therapy not being a part of the antenatal

program, made recruiting subjects for the study difficult.There was also reluctance on the part of health professionalsfor referring the subjects for antenatal programs. Futurestudies with a larger sample size would help in a moreconclusive outcome.

Frequency

Three times a week.

Time and duration of exercise

Aerobic exercise: 20 minutes of brisk walking with 10 minutesof warm up and 10 min of cool down. The duration of theexercise was decided based on the following criteria:a) 12-14 on Borg’s rating of perceived exertion ( 12 to 14

“somewhat hard” which approximately equals a heartrate of 120 to 140 beats per minute)

b) Talk test – At any point of time during the exercise, thesubject should be comfortable and be able to carry outa conversation.

Exercise was terminated if any signs of discharge fromthe vagina, sudden swelling of the ankles, face or hands,persistent headache, pain and redness in the calf of oneleg, excessive fatigue, palpitation, insufficient weight gain (less than 1 Kg per month during the last two trimesters)were noted.

References

1. Araujo D. Expecting questions about exercise andpregnancy? The Physician And Sports Medicine 1997;25: 85-93.

2. Stuge B, Hilde G, Vollestad N. Physical therapy forpregnancy- related low back and pelvic pain: asystematic review. Acta Obstet Gynecol Scand 2003;82: 983-90.

3. Stuge B, Laerum E, Kirkesola G, Vollestad N. TheEfficacy of a treatment program focusing on specificstablising exercises for pelvic girdle pain afterpregnancy. A randomized controlled trial. Spine 2004;29:351-59.

4. Ritchie J. Orthopedic considerations during pregnancy.Clin Obstet Gynecol 2003; 46: 456-66.

5. Garshasbi A, Zadeh FS. The effect of exercise on theintensity of low back pain in pregnant women.International Journal of Gynecology and Obsetrics 2005;88:271-275.

6. Nilsson-Wikmar L, Holm K, Oijerstedt R, Harms-Ringdahl. Effect of three different physical treatmentson pain and activity I pregnant women with pelvic girdlepain: a randomized clinical trial with 3,6 and 12 monthsfollow-up postpartum. Spine 2005; 30(8): 850-856.

Appendix

EXERCISES1. Deep breathing exercises2. Ankle toe movements3. Kegel’s exercises4. Leg slides5. Stretching6. Strengthening of hip abductors

7. Strengthening of hip adductors8. Strengthening of quadriceps9. Pelvic tilts10. Ergonomic advice11. Brisk walking


37

Physiotherapy Central Council: An updateNitesh BansalDirector of Amity Physiotherapy College, Noida; Convener of IAP, Noida Branch and Ex-Member of National Council ActCommittee of [email protected].

The regulatory mechanism for all allied health caredisciplines was being considered by the Ministry since itsway back in 1995 with the setting up of Dr.S.D.SharmaCommittee, which proposed to set up an Omnibus CouncilAct for all paramedical disciplines which was endorsed in ameeting of Health Secretaries held on the 28th May, 1995.The Act was proposed to be an umbrella Act under whichthere was to be a number of independent CentralProfessional Councils with uniform constitution for all. Theproposal to constitute the Omnibus Council was delayeddue to various reasons. Meanwhile, the Ministry of SocialJustice and Empowerment in exercise of the powersconferred by Section 2 of the Rehabilitation Council of IndiaAct, 1992 issued a notification dated the 13th October, 1998including Physiotherapists under this Act. The IndianAssociation of Physiotherapists (IAP) took serious objectionto inclusion of Physiotherapists under the RehabilitationCouncil of India Act. After prolonged efforts, the Ministry ofSocial Justice and Empowerment rescinded the saidnotification through their Notification dated the 25th June,1999. After which with all due diligence and consultationswith all the stakeholders, the Centre proposed a ParamedicalCouncil Bill, 2001 which was sent to the Department of LegalAffairs for their concurrence. Ministry of Law was of theopinion that the profession of physiotherapy should not becovered within the meaning of the term ‘paramedical’. TheIndian Association of Physiotherapists had also beenrepresenting themselves and through other channels to theMinistry to be excluded from the proposed ParamedicalCouncil.

The present Paramedical and Physiotherapy CentralCouncils Bill-2007 was introduced in the Lok Sabha on the4th December, 2007 by Union Minster of Health & FamilyWelfare, Dr.Anbumani Ramdoss and the Speaker of LokSabha Sh.Somnath Chatterjee referred to the Department-related Parliamentary Standing Committee on Health andFamily Welfare on the 14th December, 2007 for examinationand recommendations. The main objectives of this Bill areto provide for the constitution of Central Councils of theParamedical (Medical Laboratory Technology), Paramedical(Radiology Technology) and the Physiotherapy, thecoordinated development in the education of paramedicaland physiotherapy with a view to regulating and maintainingstandards of such education, maintenance of Register ofParamedics and Physiotherapists and for matters connectedtherewith or incidental thereto. In view of the objectivesbehind the proposed legislation and also its impact ondiverse categories of ancillary professions associated withhealth sector, the Committee decided to acquaint itself withall shades of opinion on the Bill. The Committee, accordingly,gave wide publicity to the Bill through a Press Release,inviting views/ suggestions from all the stakeholders and

general public. An overwhelming response to the PressRelease was received by the Committee (thanks to allenthusiastic Physios). A very large number of organizations/stakeholders/ individuals/ associations/forums submittedmemoranda containing their views. The Committee heldextensive interactions with representatives of associations/organizations as well as renowned experts/ professionalsfrom physiotherapy and made the following observations &recommendations:1. This Act may be called the Allied Health Professions

Central Councils Act, 2007.2. The physiotherapy education over the years has made

significant advancements and has evolved as a distinctprofession seems to be well established. This isstrengthened by the considered opinion of Ministry ofLaw that physiotherapy profession should not beequated with the paramedical professions.

3. A definition should only describe the professionenumerating its different characteristics and not itsadministrative part thus; the definition given in the DelhiCouncil of Physiotherapy and Occupational TherapyAct, 1997; may be included with the replacement of thewords ‘physiotherapeutic system of medicine’ by theword ‘therapy’ or ‘health care profession’.

4. An independent profession with entirely different courseof study, mode of treatment and approach in treatmentand rehabilitation of patients cannot be included underanother profession, hence recommended to formOccupational Therapy Central Council as a separatebody altogether.

5. A specific and categorical provision is to be made inthe Bill itself that, after the term of the first Council i.e.two years expires, the next Council coming intoexistence will be an elected body.

6. The Chairperson and the Vice Chairperson of the nextCouncils shall be elected by the members of therespective Councils from amongst themselves and theperson so elected and his qualifications should bedirectly relevant to the discipline of the concernedCouncil in such a way that he should be eligible to beenrolled on the register of the concerned Council.

7. The Clause 3(4) (i); (j); (k) & (l) be amended to ensurethat the members of the first Councils appointed underthese clauses should be from amongst the qualifiedprofessionals of eminence and after the expiry of theterm of the first Council, appointments under theseClauses should be made from amongst the qualifiedprofessionals of eminence, who are enrolled on theregister of the concerned Council.

8. A provision to be made in the present Bill to nominatetwo MPs from Lok Sabha and one M.P. from RajyaSabha elected by the respective Houses.

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9. It would not be in the larger public interest to allow awholly nominated body to continue for five years. TheCommittee is of the considered view that tenure of twoyears should be sufficient for the first Council to lay downand frame requisite rules and regulations thus suggeststhat a member of the first Council shall hold office for aterm of two years and thereafter the term of Member ofan elected Council shall be five years.

10. The provisions to be made in the Bill, specificallyindicating the powers and duties of the ExecutiveCommittees, so that there is complete clarity about therole of the Executive Committee and occasions foroverlapping of powers and duties of the ExecutiveCommittee with other Committees of the Council do notarise.

11. In view of the yawning mismatch between demand andsupply of health care services in the country, theCommittee feels that the Central Councils could play avital role in terms of acquainting the Government withrequirements of allied health professionals in thecountry; as the Delhi Council for Physiotherapy andOccupational Therapy Council Act, 1997 mandates theDelhi Council to inter alia advise the Government inmatters relating to the requirements of manpower inthe field of physiotherapy

12. A detailed provisions, as made in the Indian MedicalCouncil Act, 1956 and the Delhi Council forPhysiotherapy and Occupational Therapy Act, 1997regarding establishing an institution, opening a new orhigher course of study or training, increasing admissioncapacity in any course of study or training, procedurefor submission of an application for grant of permissionetc, to be made in the said act also.

13. The proposed provision in the Bill does not make anyreference to a schedule (where-under all the recognizedqualifications of relevant professions are to be included),very vital aspects like non-recognition of qualificationin certain cases, time for seeking permission for certainexisting colleges/institutions in the Bill, upgrading theskills of professionals through in service/ education/training programmes and most important the fate of theCouncils/ Board in existence in few States.

We all will be happy to know that the learned committeeobserved & documented that, there is a lot of dissatisfactionamong the allied health professionals particularlyphysiotherapists with regard to their pay scales as the entryinto Government service after completion of four and a halfyears degree course in Physiotherapy is not addressedproperly. The report also states that “General perceptionwas that discriminatory treatment was being meted out tothem as their pay scales did not commensurate with theirstatus and responsibility”. Considering the fact that, thePhysiotherapists plays a crucial role in the field of medicineand physical rehabilitation the Committee, therefore, stronglyrecommended that our legitimate interests should be takencare of and the existing pay structure may be revisedaccording to qualifications and duration of the coursePhysiotherapists have to put in before entering into aGovernment Jobs.

Let’s pull our muscles to get the support from maximumnumbers of Members of Parliament, for getting this report ofthe Department-related Parliamentary Standing Committeeon Health and Family Welfare accepted by the UnionMinstery of Health & Family Welfare and making thenecessary changes in the Bill.

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Effect of neurodevelopmental therapy in gross motor function ofchildren with cerebral palsySenthilkumar CB*, Deepa B**, Ramadoss K****MPT Student, **Assistant Professor, Department of Paediatric Physiotherapy, PSG Hospitals, Coimbatore, ***Head andProfessor, Department of Neurology, PSG Hospitals, Coimbatore

Abstract

Background: Neurodevelopmentaltherapy (NDT) refers tothose activities that enable the child to practice the perfectskills. These types of exercises are used to improvemovement and postural reactions; thereby it improves grossmotor function in children with cerebral palsy. The specificobjective of the study is to evaluate the effect of NDT ingross motor function of children with cerebral palsy.

Methods

This study is a one group pre test post test design. 10children with cerebral palsy were selected and assigned inone group. Pre-test value of gross motor function wasmeasured on first day of the NDT program. NDT was giventhree sessions a week, for three months. At the end of theNDT program, post-test gross motor function was measured.

Major findings

A mean improvement in gross motor function after NDTwas 10.84 with SD of 6.84 and the t value of 5.012 wasobserved in this study. The obtained t value was significantat the level of p<0.001.

Introduction

Cerebral palsy is defined as “a disorder of movementand posture due to a defect or nonprogressive lesion of theimmature brain” (Bax M C O, 1964).

“Cerebral palsy describes a group of disorders of thedevelopment of movement and posture, causing activitylimitation that is attributed to non-progressive disturbancesthat occurred in the developing foetal or infant brain. Themotor disorders of cerebral palsy are often accompanied bydisturbances of sensation, cognition, communication,perception, and/or behaviour, and/or by a seizure disorder”(Martin Bax, 2005).

Cerebral palsy lesion is non progressive and causesvariable impairment of the co-ordination of muscle action,with resulting inability of the child to maintain normal posturesand perform normal movements (Martin C O Bax, 1980).

Cerebral palsy is classified clinically in terms of the partof the body involved likely monoplegia, hemiplegia, diplegia,


Senthilkumar C BMPT (Paediatric Neurology), Lecturer,Department of Physiotherapy,Lovely Professional University, Phagwara, Punjab, IndiaMob.: +91(0)9988361696E-mail: [email protected].

quadriplegia and by the clinical perceptions of tone andinvoluntary movement like spastic, ataxic, athetoid (RobertB. Shepherd, 1995).

The heterogeneous spectrum of clinical syndromescharacterized by alteration in muscle tone, deep tendonreflexes, primitive reflexes, and postural reactions (BlascoPA, 1994).

The range of gross motor skill outcomes for specific typesof cerebral palsy with the gross motor function classificationsystem (GMFCS) is a better indicator of gross motorfunctional impairment than the traditional categorization ofcerebral palsy that specifies the number of limbs withneurologic impairment (Betty R. Vohr et al, 2005).

Among the scales available for assessing gross motorfunction in paediatric population, the gross motor functionalmeasure scale is a useful and reliable instrument forassessing motor function and treatment outcome in cerebralpalsy (Nordmark E, Hagglund G, Jarnlo GB, 1997).

Lack of isolated or discrete movements and fine motorcoordination are delayed in younger able – bodied childrenas well as in older children with spastic type of cerebral palsy(Sophie Levitt, 2004).

Neurodevelopmental/Bobath therapy (NDT) wasdeveloped by Dr.Karel Bobath and Mrs. Berta Bobath as a“living concept”. The NDT approach is not a set of techniquesbut more an understanding of the developmental processof motor control and the motor components which make upfunctional motor tasks. (Davis S, 1997).

Large diameter firm ball made of heavy rubber andprovide mobile surface that aid in facilitating postural controland postural preparation of the child. The direction in whichball moved and the position of the child on ball can be variedto facilitate movement (Jane Styer Acevedo, 1992).

Methods

3.1 Study designOne group pre test post test design – A quasi

experimental design.A group of subjects was selected and pre tests for the

gross motor function measures were taken. After that thechildren would undergo NDT program. After 3 monthsfollowing NDT post test values for the gross motor functionmeasures were taken. The values before and after theintervention were compared.

3.2 Study settingThe study was conducted in the Department of Pediatric

rehabilitation, P.S.G.Hospitals an 810 bedded multi specialtyhealth care system, P.S.G.Urban health centre,Ramakrishna mission vidhyalaya (IHRDC), Coimbatoreamong the children with cerebral palsy for experimentalgroup.

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3.3 Population and samplingThe totality or aggregate of all individuals with the

specified characteristic is known as population. Samplingrefers to the choosing of a sample from a population.

In this study sample children were selected from thecerebral palsy population of Department of PaediatricPhysiotherapy, P.S.G.Hospitals, P.S.G.Urban health centre,Ramakrishna mission vidhyalaya (IHRDC), Coimbatore.Sampling method used is sampling free technique.

3.4 Criteria for sample selection

3.4.1 Inclusive criteriaAge 1 year to 8 years.Spastic cerebral palsy.Children with monoplegic, hemiplegic, diplegic,

quadriplegic types of cerebral palsy.Gross motor function classification system levels I, II and

III.

3.4.2 Exclusive criteriaChildren with contractures and deformities.Severe mental retardation.Uncontrolled epilepsy.

3.5 Instrument and tool for data collectionThe gross motor function measure scale is a disease

specific measure for child, consisting of 88 items in fivedomains (lying & rolling, sitting, crawling & kneeling,standing, walking running & jumping). It scores from 0 to 3for each item. Total score is calculated by percentile ofdimensional score.

3.6 Technique of data collectionIn this study, the selected subjects were evaluated for

gross motor function measure during the first visit. Followingthe first assessment the patients were administered NDTprogram (Annexure 5) which aims at improving gross motorfunction.

After 3 month follow up, assessments were taken at theend of 3 months after the first visit. The treatment durationfor a child was 3 session per week into 3 months. Themeasures of gross motor function were compared beforeand after the administration of NDT program.

3.7 Technique of data analysis and interpretationData collected were analyzed using paired ‘t’ test to

measure the changes between the pre and post test valueswithin the group.

Data analysis and interpretation

Ten children received NDT was assessed with grossmotor function measure scale before and after 3 months oftreatment. The data are presented in the table and mean,standard deviation and t test were calculated.

In this study 4 female, 6 male children participated andage ranged from 1 to 8 years.

Data interpretation

Paired ‘t’ test was used to analyze the significantdifference between the mean of the pre test values and meanof the post test values to determine the outcome of the NDTprogram given after a period of 3 months. The statisticalanalysis was done for the measures collected by gross motorfunction measure scale.

From the Table 1, Graph 1and 2 it is inferred that therewas gradual improvement in the gross motor functioncovered by the children after the NDT program. On analyzingthe pre test and the post test values by paired ‘t’ test, thereis significant mean difference of 10.84 with StandardDeviation of 6.84 and the t value of 5.012 at p<0.001.

Results and discussion

The study aims to evaluate the effect of NDT programon the children with cerebral palsy. Among the 10 selectedsubjects 4 are female and 6 are male children.

The selected outcome measures are gross motor functionmeasure scores. Data are collected at the baseline and 3months after NDT program. The obtained data is analyzedby using the paired ‘t’ test.

Results shows that there is significant improvement inthe gross motor function capacity as the calculated t value(5.012) for the gross motor function measure is in the tablevalue at p<0.001.

The overall score of the gross motor function measurescale also shows similar trends of improvements. Thisindicates the change in gross motor function of children afterNDT program.

Evidence shows that large number of cerebral palsychildren experience gross motor function impairments dueto the abnormal movement and postural reactions. Thisabnormal movement and postural pattern is referred as motordysfunction. We also know that there are effectiveinterventions for these abnormal movement and posturalreactions.

NDT aimed at correcting the abnormality of movementand posture pattern in children with cerebral palsy is beingadvocated. Effect of such an intervention on health relatedmotor functional capacity is being evaluated in the study.With the obtained results, it is evident that health relatedgross motor functional capacity is significantly improved.

The gross motor functional measure test is a simple yetan effective measure of gross motor functional capacity. Ithas been shown that even a unit in cerebral palsy gross

Table 1: Gross motor function measure sclae (n = 10).S No Pretest Posttest Difference(D)

1 32.34 54.55 22.212 30.48 42.11 11.633 83.08 93.02 09.944 71.16 86.10 14.945 14.94 15.00 00.066 35.25 35.40 00.157 47.57 56.58 09.018 71.75 86.65 14.909 66.33 81.89 15.5610 64.15 74.13 09.98

Mean=10.84 S.D=6.84 t value=5.012

Fig. 1: Gross motor function measure (GMFM-88).

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10

NUMBER OF CHILDREN

G

M

F

M

S

C

O

R

E


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motor function is clinically significant.A significant improvement in gross motor function

capacity of cerebral palsy children is evident after 3 monthsof NDT program in this study.

Improvements in gross motor function measures noticedin this study may be due to the reason that NDT programwould have helped to reduce the disease symptoms andthereby improving the gross motor functional status inchildren with cerebral palsy.

5.1 LimitationsSmall number of participantsOther activities in school, family and therapy schedule

were not controlled.

5.2 RecommendationsBased on the outcome of the statistical analysis, it is

suggested that the future studies can be modified toaccommodate the following changes

To use same form of treatment for other types of cerebralpalsy.

Other forms of motor function scales can be used forassessment.

EMG can be used for assessment.Possible neural mechanism can be studied after NDT.This study can be done for children with mental

retardation also.

Summary and conclusion

Based on the analysis of data it can be interpreted thatNDT produces significant improvement. In correlating withliterature and statistical analysis, this study concludes thatNDT has produced significant improvement in gross motorfunction in children with Cerebral palsy.

It is evident that such an intervention is effective and ithelps in reducing disease symptoms and improves thegeneral functional well being among these children withcerebral palsy.

In the future, further studies regarding NDT program willdefinitely strengthen growing body of knowledge. Therefore,from the literature available and statistical analysis of thedata, it accepted and stated as, “There is significant effectof Neurodevelopmentaltherapy in gross motor function ofchildren with cerebral palsy”.

References

1. Abel MF, Damiano DL, CP Motor Study Group.Relationship among musculoskeletal impairments andfunctional health status in ambulatory cerebral palsy. JPediat Orthop 2003:23: 535–541.

2. Bayley N. The Bayley Scales of lnfant Development.New York, the Psychological Corporation; 1969.

3. Beate Carriere, The Swiss Ball, First edition, Germany,Springer-Verlag Berlin Heidelberg, 1998:321-325.

4. Beckung E, Hagberg G. Correlation between ICIDHhandicap code and Gross Motor Function ClassificationSystem in children with cerebral palsy. Dev Med ChildNeurology 2000: 42: 669–673.

5. BK Mahajan. Methods in Biostatistics. 6th Ed. New Delhi:Jaypee Broth; 2004.

6. Boyce M’F’, Gowland C, Rosenbaum PL, et al.Measuring quality of movement in cerebral palsy: areview. Phys There. 1991:813-819.

7. Boyce WF et al. The Gross Motor PerformanceMeasure: validity and responsiveness of diseasemeasure of quality of movement. Phys There 1995: 75:603–613.

8. C.R. Kothari. Research Methodology – Methods andTechniques. 2nd Ed. New Delhi: New Age International(P) Ltd; 2004.

9. Damiano DL, Abel MF. Relation of gait analysis to grossmotor function in cerebral palsy. Dev Med ChildNeurology 1996: 38: 389–396.

10. Dennis J Matthews, Cerebral palsy, PediatricRehabilitation, Third Edition, Philadelphia, Hanley &Belfus.

11. Girolami GL. Evaluating the Effectiveness of aNeurodevelopmental Training Program to ImproveMotor Control of High-Risk Preterm Infants. ChapelH111, NC: University of North Carolina at Chapel Hill;1987.Master’s thesis.

12. Haley SM, Coster WJ, Ludlow LH, et al. PediatricEvaluation of Disability Inventory: Development,Standardization, and Administration Manual. Bopton,Mass: New England Medical Hospitals; 1992.

13. Harris SR. Early intervention: does developmentaltherapy make Coronary Heart Disease difference Topicsin Ear 4 Childhood Education. 1988; 7:20-32.

14. Jane Styer –Acevedo, Physical therapy for the child withcerebral palsy, Pediatric Physical Therapy, ThirdEdition, Philadelphia, Lippincott Williams and Wilkins,1992:107 – 162.

15. Lois Bly, Baby Treatment, first edition, USA, TherapySkill Builders, 1999, 185-192.

16. Martin Bax et al, Proposed definition and classificationof cerebral palsy, Developmental Medicine & ChildNeurology August 2005,47:571-576.

17. Morris C, Galuppi BE, Rosenbaum PL, Reliability offamily report for the Gross Motor Function ClassificationSystem.2004 July, 46(7): 455-460.

18. Morris C. (2002) A review of the efficacy of lower limborthoses used for cerebral palsy. Dev Med ChildNeurology 2002:44: 205–211.

19. Nancy Burns and Susan K. Grove. The practice ofNursing research conduct critique and utilization. 5th Ed.Pennsylvania: Elsevier; 2005.

20. Nordmark E, Hagglund G, Jarnlo GB. Reliability of theGross Motor Function Measure in cerebral palsy. ScandJ Rehabilitation Med 1997: 29: 25–28.

21. Nordmark E, Jarnlo GB, Hagglund G. Comparison ofthe Gross Motor Function Measure and PaediatricEvaluation of Disability Inventory in assessing motorfunction in children undergoing selective dorsalrhizotomy. Dev Med Child Neurology. 2000:42:245–252.

22. Palisano R, Campbell S, Harris S. Clinical decision-making in pediatric physical therapy. In: Campbell SK,Vander Linden DW, Palisano RJ, editors. PhysicalTherapy for Children: Philadelphia: WB Saunders.1994:P183–185.

23. Palisano RJ et al. Validation of a model of gross motorfunction for children with cerebral palsy. Phys There2000: 80: 974–985.

24. Palisano RJ, Rosenbaum PL, Walter S, et al.Development and reliability of a system to classify grossmotor function in children with cerebral palsy. Dev MedChild Neurology. 1997:39:214-223.


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25. Rosenbaum PL, Walter SD, Hanna SE, Palisano RJ,Russell DJ, Raina P, Wood E, Bartlett DJ, Galuppi BE.Prognosis for gross motor function in cerebral palsy:creation of motor development curves. JAMA 2002: 288:1357–1363.

26. Russell DJ, Avery LM, Rosenbaum PL, Raina PS,Walter SD, Palisano RJ. Improved scaling of the GrossMotor Function Measure for children with cerebral palsy.Phys There 2000:80: 873–885.

27. Russell DJ, Rosenbaum PL, Avery LM, Lane M. GrossMotor Function Measure (GMFM-66 & GMFM-88)User’s Manual. Clinics in Developmental Medicine No.159. London: Mac Keith Press 2002.

28. Sandra J.Olney et al, Cerebral palsy, Physical therapyfor Children, second edition, Philadelphia,

W.B.Saunders Company, Suzann K.Campbell, 2000.29. Stern FM, Gorga D. Neurodevelopmental treatment

(NDT): therapeutic intervention and its efficacy. Infantsand Young Children. 1988; l: 22-32. Inc; 1954:335-373.

30. Susan B.O’Sullivan, Strategies to improve motor controland motor learning, Physical rehabilitation, Fourthedition, New Delhi, Jaypee Brothers, 2001.

31. Wood E, Rosenbaum P. The Gross Motor FunctionClassification System for cerebral palsy: a study ofreliability and stability over time. Dev Med ChildNeurology 2000:42: 292–296.

32. World Health Organization ICF: InternationalClassification of Functioning, Disability and Health.Geneva: World Health Organization 2001.


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Effect of exercise on non-exercising premenopausal andpostmenopausal women– A comparative studyRazdan Shaily, Sarkar Aparna, Kuhar Suman, Bansal Nilesh, Khurana SonalLecturer, Sr. Lecturer, Lecturer, Intern, Amity Physiotheraphy Col lege, Noida, Uttar Pradesh

Abstract

Purpose: This study examined the effect of aerobicexercise on blood pressure and heart rate in premenopausaland postmenopausal women.

Methods

Sedentary women (n=32) who were 35 to 55 years ofage were participated in exercise training protocol (20minutes of moderate-intensity aerobic activity, 2 times a dayfor 2 weeks). Blood pressure, heart rate, weight, height, andB.M.I. were measured at baseline and after 2 weeks.

Results

Using a paired sample t-test, significant changes (p<0.05)was observed from pre- to post- training in blood pressure,and heart rate. In Premenopausal females, systolic bloodpressure averaged 124.88 +/- 10.01 mmHg and decreasedto 121.38 +/- 8.02 mmHg at post-training. Diastolic bloodpressure averaged 82.63 +/- 6.47 mmHg and decreased to80.75 +/- 6.20 mmHg. In Postmenopausal females, systolicblood pressure averaged 137.75 +/- 9.60 mmHg anddecreased to 136.38 +/- 8.86 mmHg at post-training. Diastolicblood pressure averaged 86.13 +/- 5.91 mmHg anddecreased to 85.13 +/- 5.21 mmHg. An inverse correlationwas identified between age at menopause and systolic bloodpressure or diastolic blood pressure and a positivecorrelation was found between postmenopausal period andeither systolic or diastolic blood pressure. The B.M.I. of boththe samples was decreased after 2 weeks of exercise. Aninverse correlation was identified between B.M.I. of both thesamples and the distance walked by them.

Conclusion

Two-weeks of aerobic exercise training are effective andcan elicit changes in the cardiovascular variables ofpremenopausal and postmenopausal women. Our resultssuggest that aerobic exercise is an important strategy forprevention and treatment of high blood pressure. The bloodpressure and heart rate were found to be reduced more inpremenopausal females as compared to postmenopausalfemales.

Key words

Blood pressure; heart rate; body mass index; aerobicexercise; menopause.

Introduction

Menopause is a sudden event in most women’s lives asit marks the end of a woman’s natural reproductive life.Menopause normally occurs between the ages of 45-50years (average 47 years)1-2. During the Climacteric Period,which is defined as “the stage of transition from thereproductive period to the sterile period”, the so calledClimacteric disorder appears3.

The perimenopausal and early Postmenopausal periodis typically characterized by falling levels of endogenousestrogen, which can give rise to symptoms that are severeand disruptive. Estrogen deficiency leads to decrease in levelof high density lipoprotein (HDL) and increase in low densitylipoprotein (LDL) and triglycerides. Therefore, can causeincrease risk of atherosclerosis, ischaemic heart disease,myocardial infarction and hypertension. The protective effectof estrogens on cardiovascular and neuroendocrineresponses to mental stress reduces in postmenopausalwomen4. Postmenopausal women have larger increase inheart rate and systolic blood pressure than thepremenopausal women.

Moderate exercise has been known to be effective inalleviating and preventing postmenopausal osteoporosis andheart diseases3. Aerobic exercises provide cardiovascularconditioning. It strengthens the heart and lungs and improvesthe body’s ability to use oxygen. Overtime, aerobic exercisecan help to decrease heart rate, blood pressure and improvebreathing. The previous studies suggested that aerobicexercise can result in improvement in blood pressure,coronary risk factors, body composition and climactericsymptoms in postmenopausal women5-9. Therefore, the mainaims of this study were to determine the changes incardiovascular variables (Blood pressure & Heart rate) thatmay occur after a two-week aerobic exercise trainingprogramme in females and to compare the changes incardiovascular variables (Blood pressure & Heart rate) inpremenopausal and Postmenopausal women after a two-week aerobic exercise training programme.

Physical activity help in lowering blood pressure,cholesterol, triglycerides, BMI, skin folds & fasting insulin10.

Forjaz et al has found the post exercise ambulatory bloodpressure fall observed in normo-tensive and hypertensivehumans depends on individual characteristics. Moreover inboth normotensive & hypertensive humans post exerciseambulatory hypotension is greater in subjects with higherinitial blood pressure levels11.


Dr. Shaily RazdanContact no.:9818770299E-mail: [email protected]

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Subjects and methods

It was an experimental and non-randomized controlledanalysis of the effect of aerobic exercise on the bloodpressure and heart rate of the premenopausal andpostmenopausal women of age group 35-55years.

Subject description

A total of thirty-two premenopausal (n=16) andpostmenopausal (n=16) women between the ages of 35-55years participated in the study. In order to qualify toparticipate in the study, the participants had to meet thefollowing inclusion criteria: aged 35 to 55 years; able tounderstand English or Hindi, as the medium of instructions& communications; Sedentary lifestyles; ready to takephysical tests, during the course of study; absence ofmedication that influence cardiovascular system; Non-smokers; no medication known to influence biological riskfactors under study e.g. estrogen, insulin, antihypertensiveand psychotropic medications; absence of all other knowndiseases that affect blood pressure; women who havespontaneous (natural) menopause.

The primary reasons for exclusion were current use ofmenopausal hormone therapy; perimenopausal women;having any habits of substance abuse such as cigarette,smoking or tobacco use in any form; having lower limb jointinjuries; having any respiratory disease; with history ofgynecological cancer; stage 3 of hypertension and thesubject must not be previously declared unfit for any type ofexercise or physical activity.

To determine their physical activity the PAR-QQuestionnaire was used.

Exercise training protocol

The Exercise Training Protocol consisted of twentyminute sessions, two times in a day for two weeks. Bloodpressure, heart rate, weight and height were recorded as apre-exercise testing. The exercise began with a 5 minutesof warm-up by walking slowly followed by 10 minutes ofaerobic exercise i.e. walking at the intensity of 60-80% oftheir individually determined maximal heart rate and then 5minutes of cool down by decreasing the intensity of exercise.Blood pressure, heart rate and weight were measured aftera week at rest i.e. after 5 hours of exercise and then measureagain after a week of exercise as a post-exercise testing.

Study measures

At baseline, data were collected on demographicinformation, personal history and information, past medicalhistory, gynecological history, obstetrical history, andmedication use. Weight and height were measured. TheMenopause type Questionnaire was used to determine theclimacteric symptoms of postmenopausal women.

Stastical analysis

The changes in cardiovascular variables from pre-aerobicexercise training protocol to post-aerobic exercise trainingprotocol were analyzed using a paired samples t-test. Alldescriptive statistics are expressed as means +/- standarddeviation. Pearson correlations were used to determine the

similarity between the B.M.I. (body mass index) and walkingdistance; blood pressure and age at menopause; and bloodpressure and postmenopausal period. The level ofsignificance was set at P<0.05.

Results

Subject Characteristics16 premenopausal and 16 postmenopausal females of

mean age 40.00 and 50.56 respectively participated in thisstudy. At baseline, the mean value of B.M.I. ofpremenopausal and postmenopausal females is 25.23 kg/m2 and 24.31 kg/m2 respectively. Systolic blood pressurewas significantly higher in postmenopausal females than pre-menopausal females. Heart rate & blood pressure both inpre & post menopausal females before & after exercise weresummarized in table 1 .In postmenopausal females, systolicblood pressure averaged 137.75 mmHg and diastolic bloodpressure averaged 86.13 mmHg. Both systolic and diastolicblood pressures changed significantly with menopausalstatus. An inverse correlation was identified between age atmenopause and systolic blood pressure or diastolic bloodpressure (r = -0.119, -0.032 respectively), and a positive

Fig. 1 a) & b): Comparison of the Mean Blood pressure & Heart rate betweenPre-exercise values and Post-exercise values of Premenopausal females andpost menopausal females respectively.

Table 1: Heart rate & blood pressure both in pre & post menopausal femalesbefore & after exercise.

Premenopausal Females Postmenopausal FemalesPre-Exercise Post-Exercise Pre-Exercise Post-ExerciseEvaluation Evaluation Evaluation Evaluation

Heart Rate 79.06 +/- 5.14 75.88 +/- 3.97 79.25 +/- 4.28 77.94 +/- 4.57(beats/min)Systolic 124.88 +/- 10.011 21.38 +/- 8.02 137.75 +/- 9.60 136.38 +/- 8.86BloodPressure(mmHg)Diastolic 82.63 +/- 6.47 80.75 +/- 6.20 86.13 +/- 5.91 85.13 +/- 5.21BloodPressure(mmHg)

0

20

40

60

80

100

120

140

Pre-

Exercise

Post-

Exercise

Mean Age

Mean Systolic Blood pressure

Mean Diastolic Blood pressure

Mean Heart rate


45

correlation was found between postmenopausal period andeither systolic or diastolic blood pressure (r = 0.062, 0.475respectively).

Exercise interventionThe changes were observed in pre-training and post-

training in two variables in both the groups as demonstratedin figure in 1a & 1b. In premenopausal females fig 1a , systolicblood pressure averaged 124.88 +/- 10.01 mmHg anddecreased to 121.38 +/- 8.02 mmHg at post-training. Diastolicblood pressure averaged 82.63 +/- 6.47 mmHg anddecreased to 80.75 +/- 6.20 mmHg. Heart rate averaged79.06 +/- 5.14 beats/min and decreased to 75.88 +/- 3.97beats/min at post-training. In postmenopausal females Fig1b, systolic blood pressure averaged 137.75 +/- 9.60 mmHgand decreased to 136.38 +/- 8.86 mmHg at post-training.Diastolic blood pressure averaged 86.13 +/- 5.91 mmHg anddecreased to 85.13 +/- 5.21 mmHg. Heart rate averaged79.25 +/- 4.28 beats/min and reduced to 77.94 +/- 4.57 beats/min at post-training. However, there were also three subjectswhere increase in blood pressure occurred either in systolicor diastolic from pre- to post-training.

It was observed from Fig 2 that the B.M.I of both thesamples was decreased after 2 weeks of exercise. The B.M.I.of premenopausal females was reduced from 25.23 kg/m2

to 24.31 kg/m2. The B.M.I. of postmenopausal females wasreduced from 26.85 kg/m2 to 26.22 kg/m2. The mean distancewalked by premenopausal females in 20min was 2187.5 +/- 3.15 m and the mean distance walked by postmenopausalfemales in 20min was 1875 +/- 1.85 m. as demonstrated inFig 3. An inverse correlation was identified between B.M.I.of both the samples and the distance walked by them (r = -0.075, -0.044 respectively).

Discussion

The key findings from the present investigation were thatthe healthy postmenopausal females have elevated bloodpressure and this may be due to an estrogen deficiency thatmay affect cardiovascular system. Reduced level of estrogenmediates changes in body fat distribution. Results clearlydemonstrated that higher blood pressure levels inpostmenopausal women depends on age at menopause andpostmenopausal period.Yoichi Izumi et at demonstrated thathigher blood pressure levels in post menopausal femaledepend on age at menopause & postmenopausal period

but not on subject’s age, suggesting that a longer absenceof female gonadal steroids represents a major contributingfactor to increased blood pressure in elderly women12.Postmenopausal females (62%) are found to be more obese

0

20

40

60

80

100

120

140

Pre-

Exercise

Post-

Exercise

Fig. 2: Comparison of the B.M.I. between Premenopausal and Postmenopausalfemales, observed before and after two weeks of the aerobic exercise at rest.

Fig. 3: Comparison of the Mean Distance walked in 20 minutes betweenPremenopausal and Postmenopausal females.

25.23

26.85

24.31

26.22

23

23.5

24

24.5

25

25.5

26

26.5

27

Pre-

Exercise

Values

Post-

Exercise

Values

Premenopausal femalesPostmenopausal females

2187.5

1875

1700

1750

1800

1850

1900

1950

2000

2050

2100

2150

2200

Mean

Distance

Walked

(Meters)

Premenopausal femalesPostmenopausal females


46

than premenopausal females (50%). In the present studysome postmenopausal females have climacteric symptoms.They experience physical and mental changes whichinclude:- hot flushes, sweating, insomnia, headache, skindryness, psychological (mood swings, lack of concentration,irritability, depression) and hypertension.

The aerobic exercise training lowers blood pressure andheart rate in both hypertensive and normotensive females.The results of this study provide evidence that healthy butsedentary females who take up a programme of regular briskwalking improves several known risk factors ofcardiovascular disease such as hypertension. The bloodpressure and heart rate were found to be reduced more inpremenopausal females as compared to postmenopausalfemales. Consequences of the hormonal changes ofmenopause lead to dramatically impact on long-term health.Therefore, estrogen levels decreased and since, it is notaffected by exercise so the decrease in blood pressure inpostmenopausal females is less as compared topremenopausal females.Comelissen et al concluded aerobicexercise training decreases blood pressure through areduction of vascular resistance, in which the sympatheticnervous system & rennin angiotensin systemappear to beinvolved, and favourably affects the concomitantcardiovascular risk factosr13.

Conclusion

The purpose of this study was to use an aerobic exercise-training program to elicit hemodynamic response and todetermine the changes in cardiovascular variables that mayoccur after a two-week aerobic exercise training programmein females. Our results suggest that aerobic exercise is animportant strategy for prevention and treatment of high bloodpressure. Exercise can decrease the risk of cardiovasculardisease that occurs as women experience the cessation ofmenstrual and beyond. Exercise results in a significantreduction in systolic and diastolic blood pressure and heartrate in postmenopausal females and premenopausalfemales. The aerobic exercise training lowers blood pressureand heart rate in both hypertensive and normotensivefemales. The blood pressure and heart rate were found tobe reduced more in premenopausal females as comparedto postmenopausal females.

The results of this study provide evidence that an aerobicphysical activity should be considered an importantcomponent of lifestyle modification for prevention andtreatment of high blood pressure. Aerobic exercise extendslifespan, maintain mobility and help to stay independent. Ithelps to lose weight or maintain a healthy weight. It helps toimprove blood flow to all parts of the body more efficiently.

Some limitations of the study were that socioeconomicfactors and dietary factors of the subjects were not takeninto account. Time and date of menstruation cycle was notcontrolled and therefore, were unable to demonstrate trueheart rate values4 and Climacteric symptoms inpostmenopausal women were not observed after exercise.

References

1. Shaw, Textbook of Gynecology, New Delhi, Jaypeepublications, pp 56-62.

2. Polden Margaret and Mantle Jill, Physiotherapy inObstetrics and Gynecology, New Delhi, jaypeepublications, pp 281-288.

3. Ueda Masumi, Tokunaga Mikio, Effects of exercise inthe life stages on climacteric symptoms for females.Journal of physiological anthropology and appliedhuman science. 2000, vol. 19, pp 181-189

4. Tchhernof A., Poehlman E. T., Despres J. P., Body fatdistribution, the menopause transition, and hormonereplacement therapy. Diabetes & Metabolism (paris),2000, vol. 26, pp 12-20.

5. Moreau, K. L., Degarmo R., Langley J., Mchmahon C.,Howley E. T., Bassett D. R., Thompson D. L., Increasingdaily walking lowers blood pressure in postmenopausalwomen. Med. Sci. Sports Exerc, 2001 Vol. 33, No. 11,pp. 1825-1831.

6. Seals D. R, Silverman H. G., Reiling M. J., Davy K. p.,Effect of regular aerobic exercise on elevated bloodpressure in postmenopausal women. The Americanjournal of cardiology, 1997, Vol. 80, pp. 49-55.

7. Monson J. E., Greenland P., LaCroix A. Z., StefanickM. L., Mouton C. P., Oberman A., et al, Walkingcompared with vigorous exercise for the prevention ofcardiovascular events in women. N Engl J Med. 2002,vol. 347, pp 716-25

8. Williams J., Effects of ten-week aerobic exercise trainingprogram on cardiovascular variables: assessed topredict change of blood pressure in prehypertensiveAfrican American women. Sports Med. 2006.

9. Frank L. L., Sorensen B. E., Yasui Y., Tworoger S. S.,Schwartz R. S., Ulrich C. M., Irwin M. L., Rudolph R. E.,Rajan K. B., Potter J. D., McTiernam A., Effects ofexercise on metabolic risk variables in overweightpostmenopausal women: a randomized clinical trial.Obes res., 2005, vol. 13, pp 615-625.

10. Owes J. F., Matthews K. A., Wing R. R., Kuller L. H.,Physical activity and cardiovascular risk: A cross-sectional study of middle-aged Premenopausal women.2004

11. Forjaz Claudia L. M., Ortega Katia C., Danilo F., MioDecio, Negrao Carlos E., Factors affecting post-exercisehypotension in normotensive and hypertensive humans.Blood Pressure Monitoring, October 2000, vol. 5, pp255-262.

12. Tully Mark, Cupples M. E., Hart N., McGlade K. J.,Young I. S., The effect of an unsupervised, home-basedwalking programme on cardiovascular risk factors andfitness. pp92.

13. Cornelissen V. A., fagarad R. H., Effects of endurancetraining on blood pressure, blood pressure – regulatingmechanisms, and cardiovascular risk factors.Hypertension 2005, vol. 46, pp 667-675.


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Efficacy of dynamic muscular stabilization techniques (DMST) overconventional techniques in patients with chronic low back painSuraj Kumar1, Vijai P. Sharma2, H K Tripathi3, Mahendra P.S. Negi4, G.Venu Vendhan5

1PhD Scholar, Department of Physical Medicine and Rehabilitation, Chatrapati Shahuji Maharaj Medical University, U.P.,Lucknow 226018, India, 2Prof. & Head, Department of Physical Medicine and Rehabilitation, Chatrapati Shahuji MaharajMedical University, U.P., Lucknow 226018, India, 3Senior Occupational Therapist, Department of Physical Medicine andRehabilitation, Chatrapati Shahuji Maharaj Medical University, Lucknow 226018, India, 4Biometry & Statistics Division,Central Drug Research Institute, Lucknow- 226001, India, 5Lecturer, Department of Physiotherapy, CSJM University, Kanpur,India


Suraj Kumar (Ph.D. Scholar)Senior Research Fellow (ICMR)Deptt of Physical Medicine and Rehabilitation,Chatrapati Shahuji Maharaj Medical University, U.P., Lucknow, India.Phone: +91-522-2611055, Fax: +91-522-2329408E-mail: [email protected] (Suraj Kumar)

Abstract

Background: The low back pain (LBP) is a multifactorial,its treatment varies considerably. It includes medication,physical therapy modalities and exercise therapy with eachhaving several interventions. In spite of their effectiveness,their head-to-head comparisons are limited. This study wasaimed for one such comparison.

Methods

A total of 77 patients, 20-40 years of age, with sub-acuteor chronic LBP were randomized in two groups and treatedeither by Conventional treatment a combination of two electrotherapy (ultrasound and short wave diathermy) and oneexercise therapy (lumbar strengthening exercises) anddynamic muscular stabilization techniques (DMST) an activeapproach of stabilizing training.

Results

The average demographic characteristics such as Age,Weight, Height, Waist circumference, Hip circumference,Body mass index, Blood pressure systolic, Blood pressurediastolic, Duration and Rest due to LBP at baseline of twogroups were found to be similar (P>0.05). The average levelof pain, back pressure changes, abdominal pressurechanges, walking, stair climbing, stand ups and quality oflife improved more (P<0.01) in DMST than CONV. The DMSTalso improved sexual frequency (14.97%) and decreasedrecurrence (55.12%) more than conventional.

ConclusionStudy concluded that both treatments are effective in the

management of LBP but recommends DMST interventionin their daily clinical practices.

KeywordsBack pain, Abdominal Muscle pressure, Physiotherapy,

Stabilization, Strengthening Exercises

Clinical significanceThe clinical significance of DMST intervention over

Conventional treatment is that it restores pain, physicalstrength, quality of life and sexual frequency more in themanagement of low back pain. The rate of recovery wasalso high in DMST than the Conventional. The reason maybe due to the contraction, strength, co-ordination and timingof Transversus Abdominis (TA) and Multifidus (M) muscleswhich are important in stabilizing the low back improvesmore, and particular muscles may be one of the factorscapable of preventing and reducing LPB in generalpopulation.

Introduction

Low back pain (LBP) is a major health issue due to itshigh prevalence in the general population and adverseeffects on health. Low back pain is a general termcharacterized by acute (< 6 weeks), sub acute (6-12 weeks)or chronic (> 12 weeks) which are duration dependent andlocation specific. In health care profession LBP is known byvarious names and their treatment differs accordinglyRefshauge K M and Mahar C G. (2006).

The LBP is a multifactorial disorder with many possiblecauses. Treatment for LBP varies considerably. It includesmedication, physical therapy modalities and exercise therapy(Scheer SJ, et al., 1996) with each having severalinterventions. Practice guidelines recommended varioustypes of exercises and manipulative therapy for chronic LBPbut there have been few head-to-head comparisons of theseinterventions (Manuela LF, et al., 2007). In recent years,multidisciplinary pain programs were seen to successfullytreat patients by basing treatment on a combination ofphysical exercise and psychological interventions (PfingstenM, et al., 1997). However, in spite of their effectiveness, itstill remains to be clarified exactly which features of theseprograms were responsible for patient improvement(Pfingsten M, et al., 1997). Interventions such as theapplication of heat, short wave and massage etc alone haveinsufficient evidence to support their effectiveness at present,but found to be effective and less cost effective than nointervention.

Due to injury the deep stabilizing muscles of the lowerback will remain impaired for 4-6 weeks until pain subsides.In LBP impaired deep stabilizing muscles provide poorsegmental stiffness, and thus predisposes back to re-injuryand return to pain. Therapeutic exercise, as part ofrehabilitation for patient with LBP, is one of the treatmentmodalities most commonly used by physiotherapist (MartinP, et al., 1986). In the management of such cases, thedynamic muscular stabilization techniques (DMST) were alsofound to be effective (Lucy JG, et al., 2006). In DMST,adequate dynamic control of lumbar spine forces is achievedwhich reduces the repetitive injury to the structures of the

Suraj Kumar et al/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2

48

spinal segments and related structures. Specific stabilizingexercises with cocontraction of deep abdominal (transversusabdominis) and lumbar multifidus muscles enhance thespinal segmental support and control Richardson CA andJull CA (1995). In recent clinical trials, physical exerciseshave proved effective in the management of LBP both inshort term and long term Hides JA, et al., (2001).

There has been no randomized comparisons of theeffects of general exercises and spinal manipulative therapyspecifically for the management of chronic LBP and so itwas not clear which of the treatment is most effective(Manuela LF, et al., 2007). There is, still no evidence as towhich exercises or which training is best for different subgroups (Mannion AF, et al., 2001, Nordin M, and CampelloM 1999). In clinical reality, modalities and training are oftenused in combination, to relieve pain and better function.Patients often get better but the pain recurs frequently andmany patients are to undergo treatment again and againeven surgery.

Keeping the above facts in mind and with best of ourknowledge, for the first time in general population, thecombination of two electro therapy (ultrasound and shortwave diathermy) and one exercise therapy (lumbarstrengthening exercises) was named as “Conventional” andcompared with “DMST” is an active approach of stabilizingtraining. We hypothesized that DMST may be more effectivethan Conventional in the management of sub-acute orchronic low back pain.

Methods

SubjectA total 105 LBP patients from Department of Physical

Medicine and Rehabilitation, CSM Medical University,Lucknow, aged 20-40 years who were diagnosed clinicallyby the physicians with no neurological involvement buthaving symptomatic (overuse, overload or overstretching)nonspecific, sub-acute or chronic low back pain (CLBP) wereincluded for this study. After randomization, in group A(Conventional) and Group B (DMST) only 38 in conventionaland 39 in DMST were completed follow up, considered forthe analysis. The present study has the approval of theInstitutional Review Board and informed consent wasobtained from all the subjects.

Study Flow Diagram

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Approach

The subjects were randomized equally in two groups bylottery method. For this, two hundred folded papers of sameshape and size were marked either Conventional or DMSTwere kept in a box and mixed thoroughly before and afterwithdrawing a paper from the box. Marking on the paperdrawn by the patients allocate their mode of treatment. TheAge, Weight, Height, Waist circumference (WC), Hipcircumference (HC), Body mass index (BMI), Blood pressure(BP) systolic, BP diastolic, Pulse rate, Duration of LBP andRest taken due to LBP of the two groups were assessed atbaseline. Outcome variables such as pain, back pressurechanges (BPC), abdominal pressure changes (APC),walking, stairs climbing, stand ups, quality of life (QOL) wereobserved by same tester and same physiotherapistsupervising the test procedure at base line as well as onday 10, 20, 90 and 180. Sexual frequency was taken atbaseline and day 180 whereas recurrence was taken at day180 only. Test and retest of the two groups were conductedin the same place and environment and at same time of theday. Before experimentation, all subjects were well taughtabout the measurement variables and their outcomes. Thepatients were also informed about the experimental risks, ifany.

Procedure

After group allocations, respective subjects were treatedeither with Conventional (CONV) or DMST. Both thetreatment was given as individual treatment by the samephysiotherapist with the same intensity and capacity on 20regular days and follow up for 180 days. The duration ofeach individual treatment session was about 40 minutes perday. The subjects did not allow getting any other treatmentincluding pain killers. The brief description of both thetreatments used as follows:

Conventional treatment: Ultrasound, Short wave diathermyand the lumber strengthening exercises.

Ultrasound (US): For the purpose of this study as atreatment for chronic condition a frequency of 1 MHz wasused rather than 3 MHz which penetrates least and absorbedsuperficially (Forster A, and Palastanga N 1985). Continuouspattern ultrasound is recommended for use in chroniccondition at intensity 1.2W per cm square for a period of 5minutes for 20 sitting in 20 regular days. Ultrasoundequipment was used from Medichem Electronics which hasInternational standard certification.

Short Wave Diathermy (SWD): It is a deep heatingmodalities used in pain relieving. It is also used to enhancedflexibility, blood flow, and inflammation. Short wave formsare used for selected patients without neurological lesion(Chahade WH, et al., 2001). Continuous mode of SWD isused for 15 minutes with 20 sitting in 20 regular days. TheSWD was used from Medichem Electronics which hasInternational standard certification.

Lumbar strengthening exercises (LSE): The use of LSEare well documented (Kraus H. 1994) which consist spinalextension exercises and strengthen trunk extensor musclesexercise. The LSE were given 10 repetitions each exercises(prone lying leg elevation, prone lying chest elevation andsupine lying bridging) for days.


49

Dynamic muscular stabilization treatment (DMST): InDMST, muscles with direct attachment to lumbar spinalsegments are stabilize the joints ‘neutral zone’ and preventexcessive deflection (Crisco JJ III and Panjabi MM 1990).Exercise is given in four stages (Fig. 1) in the following order:i. Ist Week - isolation and facilitation of target muscles -

Verbal instruction such as drawing in and hollowing thelower abdomen, drawing the naval up and in towardsthe spine or feeling the muscle tighten at the waist. Fromthe beginning patient learn to breathe normally whileactivating or holding the muscular contraction (MillerMI and Medeiros JM 1987). The patient is in supinehook lying position and instructed to perform abdominalhollowing (in which the patient is instructed to make thelower abdomen cave in) or abdominal bracing (in whichthe patient is instructed to contract the abdominals byactively flaring out laterally in the region of the waistjust above the iliac crest) (Fig. 1.1).

ii. IInd Week- training of trunk stabilization under staticconditions of increased load – The patient position andmaintain the concentration pattern same as 1st week,the individual is then asked to hold the position whileload is added via the weight of the lower limbs beingmoved passively into a loaded position (Fig. 1.2).

iii. IIIrd Week- development of trunk stabilization during slowcontrolled movement of the lumbar spine. Once stabilitytrained through static procedure, the movement of thetrunk with appropriate activation of the supportingmuscle. The first step is to produce and explorelumbopelvic movement and learn abdominal hollowingor bracing in a variety of position: sitting, quadruped,standing, supine, kneeling and inclination by degree tocontrol loading (Fig. 1.3).

iv. 4-5th Week- lumbar stabilization during high speed andskilled movement – High speed phasic exercisesrecommended to the patient along with abdominalhollowing or bracing in a variety of position.

Outcome variables

The level of Pain was assessed by Visual Analogue Scale

(VAS: 0-10cm) (Jensen MP, et al., 2002). The BPC and APCwere measured by pressure measuring device (Kumar S, etal., 2008) while functional ability (Walking, Stair climbingand Stand up) were measured according to Waddlefunctional evaluation test (Waddell G 1998). The measuringdetails of variables in brief are summarized as follows:

Visual Analogue Scale (VAS): This is a 10 cm calibratedline with 0 representing no pain and 10 representing worstpain. The subjects were asked to make a mark or point onthe scale that best represents his intensity of painexperienced.

5 minutes of Walking: The distance walk up and downbetween marks 10 meter apart in 5 minute. The corridorwas quiet and empty with non-slip surface or hard carpet.Patient can not use any walking aid but can use the wallsfor support or can sit down for a rest. Regular informationabout the time was given to the patient between walking.

One minute Stair Climbing: Climbing up and down ofstandard stairs with one handrail and opposite wall withineasy reach were used. Stair climbing counts of a patient

Fig. 1: Figures (1.1- 1.3) showing some of DMST exercises used in the study:

Fig. 1.1: Abdominal bracing (a) and hollowing (b) in supine lying positions.

Fig. 1.2: Load added via the weight of lower limb by one leg in knee extended(a) and both legs with knee flexed (b).

Fig. 1.3: Activation of stabilizer muscle with movement of trunk with one lowerlimb elevation (a) and one upper limb along with diagonal lower limb (b).


50

was taken as total steps ups and downs completed in oneminute for example a patient can up stairs 10 steps anddown 18 steps, the total counts are 28.

One minute Stand ups: The number of times the patientcan stand up from a chair in 1 minute is his score. The chairwas firm, upright with a back rest but no arm rest. The seatheight of chair was 45 centimeter. During stand up therewas no any support within reach so that patient can not useany support.

SF–36 quality of life: It is a multipurpose, self administered,short form (SF) health survey with 36 questions whichmeasures generic health status in the general population.These questions consists physical functioning, rolefunctioning, bodily pain, general health, vitality, socialfunctioning, role functioning and mental health. Responsechoices are numbered from left to right, starting with 1. Themaximum scores obtained from 36 questions were 151represents worst QOL whereas minimum score 36represents the best. In this study we considered the scoreof QOL of normal as 36.

Sexual Frequency (SF): It is a sexual activity questionnairecovering frequency of intercourse in a month. All subjectsof this study were married and their age of marriage wasmore than one year. This study subjects were either husbandor wife. The number obtained from subjects represents theirSF value.

Statistical analysis

Demographic characteristics of two treatment groups erecompared by Student’s independent t-test. Efficacies of twotreatments on different days were compared by Student’sindependent t-test. Before analysis, homogeneity of variancebetween groups was tested by Bartlett’s test. The varianceof walking between groups was found to be heterogeneousand thus analyzed after transforming the observations bysquare root transformation. A two-tailed probability valueless than 0.05 (P < 0.05) was considered to be statisticallysignificant. Microsoft EXCEL (MS Office 97-2003), GraphPadPrism (version 5) and STATISTICA (version 7) were usedfor the analysis.

Results

The demographic base line characteristics of two groupswere summarized in Table 1. On comparing, averagecharacteristics of two groups at baseline did not differedsignificantly (P>0.05) i.e. found to be statistically the same.

The Pain, BPC, APC, Walking, Stair climbing, Stand upsand QOL at different days of two treatment groups aresummarized in Fig. 2. On comparing, the average levels ofall variables in two treatments at baseline were found to besimilar i.e. did not differed significantly (P>0.05). All variablesimproved significantly (P<0.01) in all observed days (10, 20,90 and 180) in DMST than CONV except Stair climbing andStand ups which did not change in two treatments at day10.

The sexual frequency and recurrence of LBP in twotreatment groups were shown in Fig. 3. On comparing, sexualfrequency in both the treatments improved significantly(P<0.01) after 180 days of post treatment as compared tobase line but the improvement in DMST was found to 14.97% more than CONV. The recurrence decreased significantly

(P<0.01) in DMST than conventional and the decrease wasobserved 55.12% more in DMST than CONV.

Discussion

In the present study both therapies (Conventional andDMST) are found to be effective in the early recovery ofpatients with sub-acute or chronic low back pain especiallyin pain control. The hypothesis that the treatment DMST ismore effective than the Conventional was found to be true.The mechanism by which these treatments improved LBPis not clear. We think that in Conventional treatment, limitedmuscle groups were involved and not aimed at improvingthe strength. In DMST the more improvement may be dueto restore muscle strength in combination with balance,posture, position and coordination in presence of pain andfunctional disability.

Previously comparative study among stabilizing trainingwith manual treatment shows that the individual of stabilizinggroup more improved than the manual treatment group (EvaRB, et al., 2003). A systematic review of efficacy of McKenzietherapy also results in a greater decrease in pain anddisability in the short term than other standard therapies(Clare H, et al., 2004). In one comparative study, themanipulative treatment with stabilizing exercises was foundmore effective in reducing pain intensity and disability thanthe physician consultation alone (Niemisto L, et al., 2003).In another study, pulsed SWD was compared withcontinuous SWD in LBP and pulse SWD was found to bemore effective than continuous SWD (Mintaze K, et al.,2004). A study was done to compare cognitive interventionand exercise in patients with chronic LBP and the effect ofboth the treatments were found similar (Brox JI, et al., 1990).A study which compares manipulative therapy with massageand SWD, the effect of manipulative therapy was slightlybetter than placebo therapy, no treatment, massage andSWD (Manuela LF, et al., 2007). A comparative study wasdone on manipulation and stabilization exercises in patientswith LBP suggests that patients with lumbar hypo mobilityexperienced grater benefit from manipulation and thosehaving hyper mobility were more benefited by stabilizationexercises (Fritz JM, et al., 2005). One study showed thatpatients with chronic low back pain demonstrated a reductionin performance of trunk extensor and flexor muscles whencompared with control group while using conventional trunkstrengthening exercises. This study also suggests backextensor muscles deficiency should be considered in

Table 1: Summary (Mean ± SD) of demographic characteristics of two groupsDemographic Conventional DMST t-valueCharacteristics (n=38) (n=39)

Mean ± SD Mean ± SDAge (Year) 35.74 ± 5.71 35.77 ± 5.31 0.03ns

Weight (Kg) 65.88 ± 11.48 69.09 ± 11.62 1.22ns

Height (cm) 161.98 ± 8.57 165 ± 9.93 1.43ns

WC (cm) 88.20 ± 10.59 89.60 ± 9.22 0.62ns

HC (cm) 48.50 ± 6.34 49.94 ± 5.18 1.09ns

BMI 25.10 ± 3.93 25.34 ± 3.44 0.29ns

BP Systolic 130.26 ± 8.46 128.08 ± 9.00 1.01ns

BP Diastolic 85.92 ± 5.68 84.18 ± 6.40 1.26ns

Pulse Rate 78.03 ± 6.06 80.54 ± 7.54 1.61ns

Duration (Month) 24.95 ± 32.43 23.46 ± 21.04 0.24ns

Rest due to LBP 10.79 ± 19.24 10.05 ± 12.91 0.73ns

(Days)WC= Waist Circumference, HC= Hip Circumference, BMI= Body Mass Indexns= Not Significant (P<0.05)


51

planning rehabilitation programs for chronic low back patientsand recommends that if passive modalities fail to restorefunction in 1 month then active care or stabilizer muscleactivation through stabilization exercises is needed (MayerTG, et al., 1985).

All guidelines consistently report that acute LBP typicallyhas an excellent prognosis because most cases (up to 90%)recover within six weeks (Refshauge KM and Maher CG,2006, Waddell G, et al., 1996). Musculoskeletalphysiotherapy has been an increase in the prescription of

exercise to rehabilitate spinal stability in patients with chroniclow back disorder Richardson CA and Jull CA (1995).However, the prognosis for acute low back pain during playactivity has been investigated and has been confidentlyreported as excellent in all current clinical practice guidelinefor the management of acute low back pain (Koes B, et al.,2001).

Physiotherapy programme have shown efficacy inpatients with chronic low back disorder (Furlan AD, et al.,2001). The spinal physiotherapy programme was concerned

Fig. 2: Figures shows average level of Pain (a), BPC (b), APC (c), Walking (d), Stair climbing (e), Stand ups (f) and QOL (g) in patients treated with Conventionaland DMST. Asterisk shows comparison between days and are significantly different at respective days either at P<0.05 or P<0.01.

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52

Fig. 3: Figures shows average sexual frequency (a) and recurrence (b) inpatients treated with Conventional and DMST. Asterisk shows comparisonbetween groups and are significantly different at respective groups at P<0.01.

CONV DMST0.0

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with the physiotherapy of muscles, and the progression ofimplementation contraction of these muscles into every daypostures and positions, especially those associated with painor functional disability. As a component of musculoskeletalphysiotherapy, the spinal stabilization programme is moreeffective than manually applied therapy or an educationbooklet in treating low back disorder over time (Lucy JG, etal., 2006).

Correct and timely rehabilitation is a vital component ofthe treatment of LBP patients. The goals of rehabilitationinclude restoring function, restoring pain free full range ofmotion, and achieving full muscle strength and endurance.This paper discuss the rehabilitation of LBP with theapplication of DMST special focus on the transversesabdominus (TA) and multifidus (MF) muscles which isnecessary part of Physical Therapy for low back pain.Literature review suggests that there is need of this type ofcomparative study for in LBP rehabilitation. Exerciseprograms may play an important role in muscle strengtheningand prevention of future or recurrent injuries, which mayhave psychologic benefits also. Lumbar stabilizationexercises are aimed at sensorimotor reprogrammation ofspine stabilizer muscles intended to improve their motorcontrol skill and delay of response and consequently tocompensate for weakness of the passive stabilizationsystem. Our results can be generalized to LBP patients.Before implementing on general population it should beconfirmed on more subjects, which is our future objective.

Acknowledgement

Authors thankful to Dr. R. Tully, Director, CDRI, for givingpermission to author (MPSN) to analyze the data andconsidering this as a collaborative work. We acknowledge

Mr. Vishal and Mr. Lal Bahadur for their help during differentphases of work. Authors want to acknowledge all theparticipants who participated in the study. Author (SK)acknowledge to ICMR, New Delhi for providing fellowshipas Senior Research fellow (letter no. 3/1/2/1/ADR/2007-NCD-I). This study has no conflict of interest.

Referance

1. Refshauge K M and Mahar C G. Low back paininvestigations and prognosis: a review. Br J Sports Med2006; 40:494-498.

2. Scheer SJ, Radack KL, O’Brien Jr DR. Randomizedcontrolled trials industrial low back pain relating to returnto work. Part2: Discogenic low back pain. Arch PhysMed Rehabil 1996; 77: 1189-1197.

3. Manuela LF, Paulo HF, Jane L, Robert DH, Paul WH,Matthew DJ, Christopher GM and Kathryn MR.Comparison of general exercise, motor control exerciseand spinal manipulative therapy for chronic low backpain: A randomized trial. Pain 2007; 131: 31-37.

4. Pfingsten M, Hildebrandt J, Leibing E, Franz C, Saur P.Effectiveness of a multimodal treatment program forchronic low-back pain, Pain 1997; 73: 77-85.

5. Martin P, Rose M, Nichols P, Russell P, Hughes I.Physiotherapy exercises for low back pain process andclinical outcome. International Rehabilitation Medicine1986; 8: 261-287.

6. Lucy JG, Ann PM. A randomized controlled trialinvestigating the efficacy of musculoskeletalphysiotherapy on chronic low back pain, Spine 2006;3: 1083-1093.

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

8. Hides JA, Jull GA, Richardson CA. Long term effects ofspecific stabilizing exercises for first-episode low backpain. Spine 2001; 11: 243-248.

9. Mannion AF, Muntener M, Taimela S, Dvorak J.Comparison of three active therapies for chronic lowback pain: Result of a randomized clinical trail with oneyear follow-up. Rheumatology 2001; 40: 772-778.

10. Nordin M, Campello M. Physical therapy. Exercise andthe modalities: When, what and why? Neurologicalclinics of North America 1999; 1: 75-89.

11. Forster A, Palastanga N. Clayton’s electrotherapy theoryand practical, London: Bailliere Tindall, 1985.

12. Chahade WH, Battistella LR, Biasoli MC. Low back pain(LBP) Physical therapy approach. Temas DeReumatologia Clinica 2001; 2: 24-32.

13. Kraus H. Myofacial pain and fibromialgia, Muscledeficiency In: Rachlin, ES (Ed.) St. Louis Mosby 1994;385-414.

14. Crisco JJ III, Panjabi MM. Postural biomechanicalstability and gross muscular architecture in the spine.In: Winters JM, Woo SL-Y (eds). Multiple MuscleSystem. Springer-Verlag, (New York) 1990; 438-450.

15. Miller MI, Medeiros JM. Recruitment of internal obliqueand transversus abdominis muscles during the eccentricphase of the curl-up exercise. Phys Ther 1987; 67: 1213.

16. Jensen MP, Chen C, Bruger AM. Postsurgical painoutcome assessment. Pain 2002; 99: 101-109.

17. Kumar S, Negi MPS, Sharma VP, Shukla R. The spinal


53

column and abdominal pressure changes and theirrelationship with pain severity in patients with low backpain. Nigerian Journal of Medical Rehabilitation 2008;Accepted.

18. Waddell G, Functional capacity evaluation, The backpain revolution. New York, Churchill L, 1998; 41.

19. Eva RB, Lena NW, Inga A. Stabilizing training comparedwith manual treatment in sub-acute and chronic lowback pain. Manual therapy 2003; 8: 233-241, 2003.

20. Clare H, Adams R, Mahar CG. A systematic review ofefficacy of McKenzie therapy for spinal pain. AustralianJournal of Physiotherapy 2004; 50: 209-216.

21. Niemisto L, Lahtinen-Suopanki T, Rissanen P, LindgrenK, Sarna S, Hurri H. A Randomized Trial of CombinedManipulation, Stabilizing Exercises, and PhysicianConsultation Compared to Physician Consultation Alonefor Chronic Low Back Pain. Spine 2003; 28(19): 2185-2191.

22. Mintaze K, Kezban Y. Effect of continous and pulsedshort-wave diathermy in low back pain. The pain clinic2004; 14: 55-59.

23. Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, KellerA, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, RiiseR, Reikeras O. Randomized clinical trial of lumbar

instrumented fusion and cognitive intervention andexercises in patients with chronic low back pain anddisc degeneration. Orthop Rev 1990; 19(8): 691-700.

24. Fritz JM, Whitman JM, Childs JD. Lumbar spinesegmental mobility assessment: an examination ofvalidity for determining intervention strategies in patientswith low back pain. Arch Phys Med Rehabil 2005; 86:1745-1752.

25. Mayer TG, Smith SS, Keeley, J and Mooney V.Quantification of lumbar function part 2: Sagital strengthin chronic low back pain patients. Spine 1985; 10: 765-772.

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

27. Waddell G, Feder G, Mclntosh A, Lewis M andHutchinson A. low back pain evidence review 1st ed.London; Royal college of general practitioners, 1996.

28. Koes B, Van Tulder M, Ostelo R. Clinical guideline forthe management of low back pain in primary care. Aninternational comparison. Spine 2001; 26: 2504-2514.

29. Furlan AD, Clarke J, Esmail R, Sinclair S, Irvin E. Acritical review of reviews on the treatment of chroniclow back pain. Spine 2001; 26: E155-62.


54

Study of the level of fitness in under – 16 male football players &effects of puberty on fitnessVijaya Vishwanathan*, Chhaya Verma***Project Investigator, **Associate Professor, Department of Physiotherapy, L.T.M.M.C & L.T.M.G.H, Sion, Mumbai 400022

Abstract

Objectives

The purpose of this study was:1. To find the fitness levels in under 16 male football

players.2. To compare the fitness levels between children of same

age group & the team players.3. To find the effects of puberty on fitness.

Method

60 Students were included–30 undergoing training forsoccer & 30 not undergoing any training. The age groupselected was 14 – 15 years.

Inclusion criteria

1. Players with regular training.2. Children playing football as a recreational activity.

Exclusion criteria

1. History of sports injury in the last 3 months.2. Underlying medical and surgical condition.3. Performance enhancing drug consumption.

Their fitness levels were assessed based on the followingparametersAerobic–Harvard step test Anaerobic – 35 meter Sprint testAgility – T test Flexibility test – Sit and ReachtestCo-ordination test for Goalkeepers – Alternate wall handtossStrength test – Squat test Equilibrium/ Balance test – Storktest.

The outcome was measured in terms of the fitness scoresof each test. A comparison was done between the trained &untrained individuals & effects of puberty on fitness werenoted.

Results

The data was analyzed, the results observed were –Pooraerobic scores, Very Good anaerobic scores, Good agilityscores, Fair flexibility scores, Excellent co-ordination &Strength scores & Average Static balance scores in traininggroup.

Comparison between students undergoing training &those not trained showed that the untrained group had lowerfitness levels. Pubertal effects played an important role inimprovement of the functions of the various parametersinvolved in fitness.

Conclusion

The study confirms the fact that training plays animportant role in the fitness levels of the students.

The students undergoing training showed a greatincrease in their fitness levels compared to those notundergoing any training.

But among the team players, there is a marked decreasein their Aerobic capacities whereas the other parametersrange between fair to excellent scores. Hence, Aerobicfitness training should be emphasized upon.

Fitness levels cannot be used to judge a player’sperformance in the game, as other factors such as TeamWork, Skill, Psychological & Mental Spirit, Tactics & a smallamount of Good Fortune plays a very important role todetermine the winner.

Key words

Fitness Assessment, Football, Puberty

Introduction

Football / Soccer- is the world’s most popular sport. Thegame’s most famous international competition, World Cup,is held every four years watched by millions on television.FIFA {Federation Internationale de Football Association} isthe governing body for world football, organizing thematches4.Game – two teams of 11 players take part in the matchattempting to send the round ball into their opponents’ goal.A successful attempt is called ‘scoring a goal’. Team scoringmost goals in two 45-min periods (full time) with an intervalof 5 min (half time) wins the game. Players use their feet,head, or any other part of the body except hands & arms topropel or control the ball. Only the goalkeeper can handlethe ball, but restricted to the goal area4.Football pitch / Field – is rectangular & marked by lines.Corners are marked by flags; goals stand on the center ofgoal line (7.32m wide & 2.44m high). Ball is spherical havinga circumference of 68-71cm & 396 -435 gm in weight4.

Positons in a soccer game

Goalkeeper: plays a significant role during the game. Herequires sharp reflexes, agility, speed, ball handling abilityetc. to prevent the other team from scoring4.

Defence: is an important asset to the goalkeeper. Defendershelp to keep the opponents away from the goal area bytackling opponents or intercepting their passes4.

Midfield: is the place of maximum play. Midfielders attack& also defend thus requiring highest amounts of endurance.

Vijaya. Vishwanathan et al/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2009, Vol. 3, No. 2

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There are generally 3-4 midfielders — the Anchorman, whowins the ball, Midfield general /strategist, through runners &withdrawn wingers (right / left)4.

Attack: consists of central striker & winger who help to scorea goal against the other4.

Fitness in football

Physical fitness is a set of attributes a person has inregards to a person’s ability to perform physical activitiesthat require aerobic fitness, endurance, strength, or flexibilityand is determined by a combination of regular activity andgenetically inherited ability3.

The components that comprise to the definition ofphysical fitness:

Aerobic fitness: Football player has to run to and fro onthe field for an entire period of 90 minutes, with very lesstime given for rest, thus the athletes aerobic capacity is taxed.Aerobic fitness refers to the ability to sustain work forprolonged period, Greater the aerobic fitness, lesser fatigueis experienced3.

Anaerobic fitness: is determined by the ability to exertmaximum muscular contraction instantly in an explosiveburst of movements (sprint starting). A footballer requiressudden, fast movements while passing the ball, dribbling,shooting towards the goal etc. The players frequently sprintin order to control the ball for scoring, feinting, or even fordefense3.

Agility: is the ability to perform a series of explosive powermovements in rapid succession in opposing directions(Zigzag running or cutting movements). The ability to quicklychange direction is very important in soccer3.

Co-ordination: is the ability to execute smooth, accurate,controlled motor responses. Co-coordinated movements arecharacterized by appropriate speed, distance, direction,timing & muscle tension extremely important for goalkeepersto prevent opposing team from scoring3.

Flexibility: The ability to achieve an extended range ofmotion without being impeded by excess tissue, i.e. fat ormuscle. Flexibility is important in terms of being injury freeand being able to move freely around the court3.

Strength: The extent to which muscles can exert force bycontracting against resistance (holding or restraining anobject or person). in basketball there is equal involvementof upper limb and lower limb and a considerable amount ofstrength is involved to through and control the ball3.

Indian football

The Indian Football teams are formed from the teamsoriginating from schools & colleges. Players from theseteams are then picked up to form the District, State & Nationalteams. The teams are formed with age groups of under 10,under 12, under 14, under 16, under 18, senior groupsetc.There is also an increased prevalence of injuries in IndianFootballers related to decreased physical fitness in theathletes.

The training of players is also influenced by experiences& coaching techniques which plays an important role inmaintaining the overall fitness.

Puberty in males

Stages

• Stage One (approximately between ages nine and 12):No visible signs of development occur, but, internally,male hormones become a lot more active. Sometimesa growth spurt begins at this time.

• Stage Two (approximately between ages nine to 15):Height increases and the shape of the body changes.Muscle tissue and fat develop at this time. The aureole,the dark skin around the nipple, darkens and increasesin size. The testicles and scrotum grow

• Stage Three (approximately between ages 11 and 16):Pubic hair is getting darker and coarser and spreadingto where the legs meet the torso. The penis starts togrow during this stage. Also, boys continue to grow inheight, and even their faces begin to appear moremature. The shoulders broaden, making the hips looksmaller. Muscle tissue increases and the voice startsto change and deepen. Finally, facial hair begins todevelop on the upper lip.

• Stage Four (approximately 11 to 17): The testicles andscrotum continue to grow. Underarm and facial hairincreases as well. Skin gets oilier, and the voicecontinues to deepen.

• Stage Five (approximately 14 to 18): Boys reach theirfull adult height. Pubic hair and the genitals look like anadult man’s do. Some young men continue to grow pastthis point, even into their twenties

Methodology

Sample size: 60 students from Don Bosco School, Matunga,and O.L.P.S, Chembur.

• 30 Students undergoing training for soccer.

• 30 Students not undergoing any training.Age group: 14 – 15 YEARS OF AGE.Date: The study was conducted in the month of Novemberand December 2007.

Inclusion criteria

a. Players with regular training.b. Children playing football as a recreational activity.

Exclusion criteria

a. History of sports injury in the last 3 months.b. Underlying medical and surgical condition.c. Performance enhancing drug consumption.

Selection of the test

Following are the tests on which the football player hasbeen evaluated:AEROBIC FITNESS: HARVARD STEP TEST.ANAEROBIC TEST: 35 METER SPRINT TEST.AGILITY TESTING: T – TEST.CO – ORDINATION: ALTERNATE WALL – HAND TOSS.FLEXIBLITY TESTING:SIT AND REACH TEST.STRENGTH: SQUAT TESTEQUILIBRIUM / BALANCE: STORK TEST


56

Results

Of the tests conducted are as follows:AEROBIC FITNESS

AEROBIC FITNESS PLAYERS(30) PERCENTAGESCOREExcellent - -

Good - -High Average - -Low average 2 6.66%

Poor 28 93.33%INFERENCE: Aerobic fitness score is poor.

ANAEROBIC FITNESSANAEROBIC SCORE PLAYERS(30) PERCENTAGE

Very Good 9 30%Good 8 26.66%

Average 3 10%Fair 5 16.66%Poor 5 16.66%

INFERENCE: Anaerobic test score is very good.

AGILITY TEST:AGILTIY TEST SCORE PLAYERS(30) PERCENTAGE

Excellent 4 13.33%Good 13 43.33%

Average 7 23.33%Poor 6 20%

INFERENCE: Agility test score is good.

CO-ORDINATION TEST:CO-ORDINATION PLAYERS(4) PERCENTAGE

TEST SCOREExcellent 2 50%

Good 2 50%Average - -

Fair - -Poor - -

INFERENCE: alternate wall hand toss test for goalkeepers is excellent & good.

FLEXIBILITY TEST:FLEXIBILITY TEST PLAYERS(30) PERCENTAGE

SCORESuper Excellent - -

Excellent 5 16.66%Good 7 23.33%

Average 7 23.33%Fair 11 36.66%Poor - -

Very Poor - -INFERENCE: Flexibility of the players is fair.

STRENGTH TEST:SQUAT TEST SCORE PLAYERS(30) PERCENTAGE

Excellent 10 33.33%ood 8 26.66%

Above Average 8 26.66%Average 2 6.66%

Below Average 2 6.66%Poor - -

INFERENCE: Strength of the players is excellent.

EQUILIBRIUM TEST:STORK TEST SCORE PLAYERS(30) PERCENTAGE

Excellent - -Good - -

Average 16 53.33%Fair 14 46.66%Poor - -

INFERENCE: Static balance of the players is average.

Comparision between students undergoingtraining & those not being trained

Aerobic test scores

0

20

40

60

80

100

%

E H.A P

SCORE

TEAM

OTHERS

• On comparing the Aerobic fitness scores, there ismarked difference in the scores. 93.33% of the teamplayers have POOR aerobic fitness, whereas 46.66%of other students were unable to complete the test.

Anaerobic test scores

0

10

20

30

40

V.G A P

TEAM

OTHERS

• On comparing the levels of Anaerobic fitness it revealsthat in team players about 30% players have the scoreof Very Good as compared to 13.33% of others with ascore of Good.

Agility scores

0

10

20

30

40

50

E G A P

TEAM

OTHERS

• On comparing the graphs between the team and otherplayers there is marked evidence of 13.33% of teamplayers scoring excellent scores, whereas the otherplayers have 30% in the Good score.


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Flexibility test

0

10

20

30

40

S.E G F V.P

TEAM

OTHERS

• On comparing the flexibility results both the team & otherplayers have a 16.66% Excellent and 13.33% good levelof flexibility respectively.

Co-ordination test

0

20

40

60

80

E G A F P

TEAM

OTHERS

• Comparison between the team & other players showsthat the goalkeeper’s co-ordination test has 50% ofExcellent & Good scores by the team while the othershave 33.33% & 66.66% average & fair scoresrespectively

Strength test

0

5

10

15

20

25

30

35

40

E A.A B.A V.P

TEAM

OTHERS

• Comparison between the team & other players withregards to strength shows that 33.33% & 16.66% hadExcellent scores respectively.

Equilibrium/balance test

0

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20

30

40

50

60

E G A F P

TEAM

OTHERS

• Comparison with regards to equilibrium test, teamplayers had 53.33% while the others show 23.33% ofaverage scores.

Discussion

The Fitness test results highlighted the areas of highertest scores in certain variables and areas of deficits in others.

The fitness levels obtained are an impression of the kindof training a player achieves. The physical conditioning aplayer has undergone reflects in the player’s physical fitnessparameters.

The aerobic levels have been demonstrated to be in amajority poor; due to lack of training in aerobic capacity.There is no formal recording of the heart rate or any kind offormal aerobic training in the athletes. There is no conceptinvolving achievement of target heart rates.

The anaerobic capacity, agility, strength & balance skillsvary from very good, good, excellent to average respectively.

The flexibility of the players is fair due to the pubertalchanges & growth spurts occurring.

Co-ordination of goalkeepers ranges between excellent& good.

Effects of puberty

Aerobic Capacity: Aerobic power increases with age duringchildhood in both sexes and is quite similar. From the ageof 14 years on, aerobic power in boys is significantly higherby about 15%. The maximal aerobic performance capacityin boys increases up to the age of 18 years. Thus, eventhough the aerobic capacity is fully developed aerobicperformance continues to improve. That is because othergrowth factors, such as larger levers, greater musculature,etc. are still developing and govern the effectiveness andmechanical efficiency of aerobic activities. There is anincreased trainability of the heart and circulatory systemaround puberty in males5.

Anaerobic Capacity: Unlike aerobic capacity, the anaerobiccapacity of children expressed per Kg of body weight is muchsmaller than adults. It is lowest in children and increasesprogressively with age in both boys and girls5.

Strength: In the prepubescent age, muscle weight is about27% of the total body weight and the effect of training onmuscle hypertrophy is small so that strength gains are morethe result of an improvement in co-ordination. After sexualmaturation [the onset of the adolescent growth spurt],muscular development is influenced by androgenic


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hormones and the percentage of muscle weight thenincreases to over 40%. Testosterone influencesdevelopment of muscles in terms of strength5.

Flexibility: There is a gradual increase in flexibility with ageas measured on the sit-and-reach test. However,generalization is not clear because of the absence of studiesand data that take into account growth spurts andanthropometrical size changes (e.g., longer arms producea better sit-and-reach measure)5.

Coordination and Skill Learning: The sensitive skilllearning period is between 9 and 16 years5.

Conclusion

The study confirms the fact that training plays animportant role in the fitness levels of the students.

The students undergoing training showed a greatincrease in their fitness levels compared to those notundergoing any training.

But among the team players, there is a marked decreasein their Aerobic capacities whereas the other parameters

range between fair to excellent scores.Hence, Aerobic fitnesstraining should be emphasized upon

Fitness levels cannot be used to judge a player’sperformance in the game, as other factors such as TeamWork, Skill, Psychological & Mental Spirit, Tactics & a smallamount of Good Fortune plays a very important role todetermine the winner.

Referance

Books referred1. Textbook of medical physiology; Guyton.2. Concise physiology Chaudary3. Exercise physiology Mac Ardle4. World book encyclopedia5. Borms, J. (1986). The child and exercise: an overview.Journal of Sports Sciences, 4, 3-20.Internet sites visited1. www.topendsports.com2. www.pubmed.gov


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Comparison between straight leg raise & bent leg raise stretchingtechniques for increasing hamstring flexibilityNeha Jain , G.L.Khanna , Amit ChaudharyFaridabad Institute of Technology, Faridabad, Haryana

Introduction

The ability of an individual to move smoothly dependson his flexibility, an attribute that enhances both safety andoptimal physical activities. Hamstrings are an example ofthose muscle groups that have a tendency to shorten. Manypeople suffer with tight hamstrings. Usually it does not causea problem but can be more prone to tears and also limit thesporting activity and predispose to postural problems andback pain as they tend to pull the pelvis out of normalposition.

The relationship between hamstring injury and hamstringflexibility is another area of great debate. Worrel et al (1991),stated that hamstring flexibility is the single most importantfeature in the hamstring injury player.

Hamstring strains are a common athletic injury with atendency to recur. Lack of flexibility has been suggested asa predisposing factor to hamstring strain. Clinicians havegenerally considered flexibility training to be an integralcomponent in the prevention and rehabilitation of injuriesas well as a method of improving one’s performance in dailyactivities and sports.

Flexibility is an important physiological component ofphysical fitness, and reduced flexibility can cause inefficiencyin the workplace and is also a risk factor for low back pain(Worrel et al,1994). Young patients with lumbar discherniation sometimes show hamstring tightness on straightleg raising with no associated pain.

Despite the widespread use of stretching techniques insports and rehabilitation, limited knowledge exists withrespect to mechanism and efficacy of stretching of the humanmuscle tendon unit in vivo. Various stretching techniquesare known namely ballistic stretching, static stretching,contract-relax stretching and contract-relax agonist contractthe latter two of which are commonly referred to asproprioceptive neuromuscular facilitation (PNF) stretchtechniques. PNF stretch techniques have been shown tobring about greater improvement in joint range of motion byreducing the EMG activity & thereby the resistance in themuscle undergoing stretch.

Contract relax stretch method was used in this researchto perform bent leg raise technique. “Brian Mulligan” hasadvocated the use of Bent Leg Raise for stretching hamstringto improve flexibility by increasing the range of motion. Thisintervention consists of contract relax cycles applied tohamstrings that provides peripheral somatic input by the wayof contracting muscles and the cutaneous contact of thetherapist. Changes in alpha and gamma motor neuronactivity (influencing the hamstring muscles) at a segmentallevel are likely following this technique that are similar tothose effects observed following the implementation of PNFtechniques and this may affect the subject’s perception oftheir straight leg raise limit.

Mulligan’s Bent Leg Raise (BLR) technique is a painlesstechnique, when indicated and can be tried on any patientwho has limited or painful straight leg raise (SLR). It can betried even if patient feels leg pain above the knee, and canbe extremely useful when therapist is confronted with oneof those patients who have a great bilateral limitation ofstraight leg raise. If BLR cannot be executed without painthen it is not to be used.

Another method used here was static stretching in whichthe muscle is slowly elongated to tolerance and the positionheld with the muscle in its greatest tolerated length. Literaturesupports the fact that static stretching increases flexibility ofmuscles. A great deal of variability exists, concerning thelength of time a static stretch should be sustained.

Both isometric contraction and passive stretchingincreases the joint range of motion. Passive stretchinghowever appears to be the safest and best stretchingmethod. Considering the discrepancy in the outcomes ofmany studies, it still seems unclear whether or not it ispossible to lengthen the short hamstrings by performingstretching exercises. Moreover the mechanism responsiblefor achieving lengthening of short hamstring muscles is stillunclear.

The purpose was to find out the more effective techniquebetween Straight Leg Raise and Bent Leg Raise techniquefor increasing hamstring flexibility.

Method

30 healthy female subjects ranging from 18 – 25 years,volunteered to participate in this study. Subjects wereselected from Faridabad Institute Of Technology (FIT) andManav Rachna Educational Society(MRES) hostel,Faridabad. Subjects included in the study were normalfemales with tight hamstring muscles (inability to extend theknee up to terminal 20O of extension with hip stabilized at90O flexion).

Subjects were excluded from the study if there washistory of low back ache, neurological symptoms involvinglumbar spine and lower extremity, soft tissue and bonypathology around lumbar spine, hip and knee region or kneejoint flexion contracture. Instruments used were a standarddouble – armed universal Goniometer with full circleprotractor for hamstring flexibility measurement and hippositioning for the active knee extension test and kneemotion.

Measurement, a cross bar was used to maintain theproper placement of hip and thigh during active kneeextension measurement. Straps were used to prevent anymovement of contralateral limb and a stop watch to measurethe duration of treatment.

Subjects were selected on the basis of screening processto establish hamstring tightness and were randomly allocated

60

to both the experimental groups – Group A (Straight LegRaise) and Group B (Bent Leg Raise). Subjects in the studyparticipated voluntarily. Aim and procedure of the study wereexplained and informed consent was taken from all subjects.Pre-intervention measurement of active knee extension wastaken. The baseline knee extension deficiency wasmeasured using a double armed Goniometer. Each subjectwas positioned supine on the plinth and the hip of the lowerlimb being assessed was flexed to 90O. The distal part ofanterior surface of the thigh was placed in contact with cross-bar of a specially constructed wooden frame; the subjectwas instructed to actively extend the knee to the point wherethey started feeling a stretch. The knee extension deficiencywas measured using the goniometer (90O of knee flexionwas recorded as 0O i.e. starting position). Zero degree wasconsidered to be full extension of the knee. During testingprocedure, patients were instructed to maintain the lumbarspine flat against the table and slowly extend the knee.

Stretching protocol: After determining the baseline value,subjects were taken through the stretching exercise trainingspecified to them i.e. Group A (Straight Leg Raise) or GroupB (Bent Leg Raise).

For SLR stretching technique, the subject assumed fullsupine lying position on a plinth with his feet pointingupwards. The contralateral lower limb was securely strappedto the plinth across the thigh and over the anterior superioriliac spine to stabilize the pelvis. The lower limb beingstretched was passively moved into flexion up to the limitwhere the subject felt a stretch at the posterior aspect of thethigh. This placed the hamstring muscle at a stretched length.Straight Leg Raise stretch was performed for an equalduration of single Bent Leg Raise procedure followed by 2minute rest, repeated for 3 times. This was followed by Postintervention measurement. Stretching was performed 3 daysin a week i.e. alternate days for 4 weeks. ROMmeasurements were taken at both pre and post 1st, 7th and14th interventions.

For BLR stretching technique, after taking baselinemeasurement, the subject’s lower limb was passively flexedat hip joint and extended at knee joint till subject reportedmild stretch sensation and held for 7 seconds, then subjectmaximally isometrically contracted the hamstring for 7seconds by attempting to push his leg against the resistanceof the therapist. After the contraction, the subject relaxedfor 5 seconds. The therapist then passively stretched themuscle until a mild stretch sensation was again reportedand held for another 7 seconds. This sequence was repeated5 times in the experimental group (BLR group). The durationwas noted followed by 2 minute rest and this whole procedurewas repeated for 3 times. Post intervention measurementswere taken same as for SLR group.

Six readings were taken as pre and post scores of rangeof motion during 1st, 7th and 14th interventions.

Results

Pre and post intervention scores of ROM were analyzedby using mean, standard deviation and ANOVA test. Paired‘t’test was used to find out any significant difference betweenpre and post test scores to assess which interventionsignificantly increased the hamstring flexibility. The meanbaseline value of SLR group was 121.5o where as that ofBLR group was 123.00 and their comparison gave a nonsignificant value of 0.228. Straight Leg Raise stretching groupshowed a mean improvement of 2.920 between pre and postintervention after 1st, 7th, 14th sessions, in knee extensionrange of motion, where as Bent Leg Raise stretching groupshowed a mean improvement of 5.060. Total improvementin range of motion after SLR stretching following 14th

intervention on alternate days were 33.60 where as that ofBLR group was 47.40 which indicates that both SLR andBLR improves hamstring flexibility to a great extent but BLRis definitely better.

With in group analysis was done to observe the gain inthe range of motion either by SLR stretching technique orBLR stretching technique. Results obtained showedimprovements in range of motion, when compared baselinemeasurement (121.5±2.9 ) with Post intervention of 1st, 7th,and 14th (i.e. 125.0.±3.0,140.0 ±3.6,155.1± 5.1 respectively)for SLR group and found a significant value of 0.000. ForBLR group, when baseline measurement (123.0 ±3.7) wascompared with post intervention of 1st, 7th and 14th (i.e.129.2±3.3, 147.2±7.1, 170.4±7.1), obtained a highlysignificant value of 0.000.

The results of ANOVA test for SLR group was, F= 409.77which showed highly significant value i.e. p=0.000 andresults for group BLR was, F=237.83. The result obtainedfor BLR group was also significant i.e. p=0.000.ANOVAcalculated to assess if any difference existed across thePre and Post test scores, with in two groups.

Post hoc analysis was done for multiple comparisonswith in groups and results obtained indicated that valuesobtained were highly significant (0.000).

The percentage value showing overall improvement inSLR group was 27.6% and BLR group was 38.5%.Whenthese percentage values were compared a highly significantdifference (0.000) showing that the improvement in Activeknee extension Range of motion in BLR group was greaterin comparison to SLR group.

Conclusion

Bent Leg Raise stretching technique is better thanStraight Leg Raise stretching technique for improvinghamstring flexibility immediately when both of them areadministered at the same duration and frequency.

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Introduction

Tennis elbow originally called lawn tennis elbow wasfirst described by Runge as ‘Writer’s Cramp’ (Gellman 1992,Verhaar et al 1993). It is one of the most frequent lesionsof the arm. The origin of Extensor Carpi Radialis Brevis(ECRB) is the most commonly affected structure. Tenniselbow is defined as a pathologic condition of the wristextensor muscles at their origin on the lateral humeralepicondyle and is a degenerative or failed healing tendonresponse characterized by vascular compromise with forceoverload causing angio-fibrotic changes. The dominant armis commonly affected, with a prevalence of 1% in men and4% in women. The peak prevalence of tennis elbow isbetween 35-50 years.

The main symptoms are pain on the lateral side of theelbow and posterior aspect of forearm, sometimes referredto the wrist and into dorsum of the hand that is aggravatedwith movements of the wrist or by contraction of theextensor muscles of the wrist. Point tenderness is presentover lateral epicondyle and reduction in grip strength mayalso be present. Diagnosis can be confirmed by tests thatreproduce similar pain, such as resisted wrist extension.

However, many therapeutic interventions have beenused in the treatment of the tennis elbow. These includesurgical procedure, drug therapies, physical therapies andstrategies to correct factors which are presumed tocontribute to the etiology of the disorder. To date no specificinterventions have been proved efficacious.

One of the physiotherapy treatments for tennis elbowis Mulligan’s mobilization with movement, which is a systemof manual therapy interventions. The concept involvesmanual application of forces which guide the motionsegment in such a manner that superimposed functionalmovement, with previously produced pain, can occurwithout pain. Therein lays the fundamental rule of thisapproach that is the technique should reduce pain if it is tobe successful. In case of tennis elbow, the functional activemovements which produce pain are usually either grippingor wrist/finger (middle finger) extension. The manual forceapplied to the medial aspect of the proximal forearm toproduce a lateral glide of elbow joint can be applied duringthe performance of a pain producing functional movement.Some clinicians recommend the use of phonophoresis for5 minutes and exercises along with mobilization withmovement. To our knowledge, there have been no studiesof the latter. The aim of this study was to compare theclinical results of the use of phonophoresis and exercisesalong with mobilization with movement with those ofphonophoresis and exercises alone in patients duringsubacute phase of tennis elbow.

MethodsA controlled, monocentre trial was conducted in a

clinical setting to assess the effectiveness of phonophoresisand exercises alone or with mobilization with movement inpatients of tennis elbow. A randomized clinical trial designwas used. The investigator evaluated the patients to confirmtennis elbow diagnosis, performed 1st, 7th, 14th session preand post intervention assessments and obtained informedconsent.

Patients between 18 to 65 years of age with lateralelbow pain were examined and evaluated in a privateoutpatient Arya Samaj Physiotherapy Centre, Sector-15 inFaridabad. All patients were either self referred or referredby their doctor or physiotherapist.

Patients were included in the study if, at the time ofpresentation, they had been evaluated as having clinicallydiagnosed tennis elbow for more than 3 weeks. Patientswere included in the study if they were Cozen’s test positive.

Patients were excluded from the study if they had oneor more of the following conditions: (a) Bilateral tenniselbow; (b) lateral elbow pain due to pain originating fromneck, shoulder and wrist; (c) Previous fracture of the arm,forearm- causing limitations in upper limb function; (d) hadreceived a corticosteroid injection in the last 12 monthsbefore inclusion; (e) Rheumatoid arthritis; (f) Malignancy;(g) Neurological abnormalities;(h) Pregnancy.

The exercise program consisted of slow progressiveeccentric exercises of the wrist extensors and staticstretching exercises of the extensor carpi radialis brevistendon. Phonophoresis with Volini Gel via pulsedultrasound (1:1) at 1MHz frequency and intensity of 1.5watts/cm2 for a period of 5 minutes was applied. Inexperimental group, along with phonophoresis and exerciseprogram, mobilization with movement, consisting of alaterally-directed manual pressure to proximal medialforearm was applied while patient performed comparablesign motion.

Pain, pain free grip strength (PFGS) and maximum gripstrength (MGS) were measured in this study. Each patientwas evaluated at 1st, 7th, and 14th session both pre andpost intervention.

Differences between groups were determined using theMann-Whitney test. Wilcoxon –Signed Rank test was usedfor within-group analyses.

Results

28 patients met with the inclusion criteria. When bothgroups were compared for pain score, pain free grip strengthand maximum grip strength at baseline, there was no

The effectiveness of moblization with movemental along withphonosphoresis and exercises in subacute phase of tennis elbowRekha Wadhwa , G.L.Khanna , Amit ChaudharyFaridabad Institute of Technology, Faridabad, Haryana

62

significant difference. But there was significant differencewhen both groups were compared for pain score (p=0.000),pain free grip strength (p=0.000) and maximum grip strength(p=0.001) after the completion of treatment.

When within-group analysis was done, there wasstatistically significant difference among all variables i.e. painscore, pain free grip strength and maximum grip strengthimmediately after the intervention on the same session inexperimental group but not in another group. When overallimprovement was observed, both groups showed

improvement in all variables but experimental group hadgreater improvement.

Conclusion

Mobilization with movement reduces pain and improves painfree and maximum grip strength in patients with tennis elbowimmediately after the intervention on same session and alsoat the end of overall treatment.

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