Rajiv Gandhi University of Health Science

Bangalore, Karnataka.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate

and Address

PRIYANKA GANESH PATIL

A/403, Shiv-Shakti appt, Sangitawadi,

Shivmandir road, Dombivli (E) 401201.

2. Name of the Institution

and Address

K.T.G. COLLEGE OF PHYSIOTHERAPY

Hegganahalli cross, Vishwaneedam Post,

Sunkadakatte via Magai Road.

Bangalore- 560 091

3. Course of study and subject MASTER OF PHYSIOTHERAPY

(Musculoskeletal Disorders and Sports

Physiotherapy)

4. Date of admission to course 7th April 2012

5. TITLE OF THE TOPIC:

A COMPARATIVE STUDY ON MUSCLE ENERGY TECHNIQUE AND

POSITIONAL RELEASE THERAPY IN ACUTE LOW BACK ACHE

6. Brief resume of the intended work:

6.1 Need for the study :

Low back pain is the largest cause of sick leave and half of the population will have

experienced a significant incident of low back pain by age of 30. In India its incidence has been

reported to be 23.09%. They are classically stratified into acute, sub acute and chronic, with

respective cut-offs of <6 weeks, 6–12 weeks and >12 weeks. Acute low back pain is usually the

result of various causes, such as postural abnormalities, muscle dysfunction (imbalances,

shortening or weakening of muscle), overuse, instability, and articular dysfunction in the lower

back, injury or accident, most often road vehicle accidents. 85-90% of all episodes of low back

pain are non specific in nature.1 This is the most common type of back pain. About 19 in 20 cases

of acute (sudden onset) low back pain are classed as non-specific. This is the type of back pain

that most people will have at some point in their life. It is called non-specific because it is usually

not clear what is actually causing the pain. In other words, there is no specific problem or disease

that can be identified as to the cause of the pain. The severity of the pain can vary from mild to

severe.2

The treatment of patients with back pain can be extremely interesting and rewarding.

However, some patients with low back pain can be difficult to treat and care of these patients is

quite often challenging. People who report LBP often have reduced spinal motion. When motion

is limited, spinal extension is more restricted than flexion. Reduced spinal extension can be result

of pain or stiffness and can be classified as being either general (total spine) or segmental (one

vertebral level). The function and co-ordination of the muscles that stabilize the lumbar

spine, especially the back extensor muscles are often impaired in patients with low back pain.

Sorensen found that good endurance of back extensor muscles in men appeared to protect them

from low back pain. Erector spinae strain and fatigue is one of the causes of back pain. In general,

positional release therapy and muscle energy techniques are the forms of manual therapy that are

used in an effort to reduce pain and improve range of motion.1

Muscle Energy Technique is a direct technique originally developed by Fred Mitchel, Sr.,

DO. The purpose of this technique is to treat joint hypomobility (stiffness) and restore proper

biomechanical and physiological function to the joint.  Different patient positions are utilized to

engage the restriction before asking the patient to perform an isometric contraction to pull the

restricted segment into a new motion barrier. The isometric contraction is performed in a precisely

controlled direction against a precisely controlled counterforce by the therapist. The result is

improved spinal mobility without the need for passive manipulation. Muscle Energy Technique is

effective for mobilizing restricted joints, relaxing hypertonic and spastic muscles as well as

facilitating neuromuscular reorganization. It is an appropriate technique for patients whose

symptoms are aggravated by certain postures or bodily positions.2 Greenman defined muscle

energy technique as a manual medical treatment procedure controlled direction, at varying levels

of intensity against a distinctly executed counter force applied by the operator. The goal is to

increase joint mobilization and lengthen contracted muscles.1 Each treatment session begins and

ends with a screening technique to assess the outcome of the manual techniques. This can be

rewarding for the patient as the experience changes in mobility with concomitant reduction in

pain.3

Positional Release Therapy is a manual technique that restores a muscle to its normal

resting tone. Assessment of trigger points allows identification of hypertonic muscles that are

creating somatic dysfunction. The tender point is used as a guide and the position of comfort is

maintained.1 These efferent impulses were attempting to protect the tissue from being over

stretched. By interrupting this pathway, the patient’s muscle is allowed to relax and assume a

normal resting tone. The process is completed by slowly and passively returning the patient to an

anatomical neutral position without firing of the muscle spindle.4 This position of minimal

discomfort is usually a position where the muscle is at its shortest length. The position is held for

90 seconds and the joint is slowly and passively returned to the neutral position. This prolonged

shortening of the muscle causes shortening of both the intrafusal (muscle spindle) and extrafusal

fibers. These changes in turn result in a significant increase in function range of motion and a

decrease in pain.1 Patients are placed in positions that approximate the origin and insertion of the

hypertonic muscle. In doing so the muscle spindle activation is inhibited thereby decreasing the

amount of afferent impulses to the brain. This leads to less efferent impulses to the same muscle.

The patient is then instructed in appropriate.5

Even though both muscle energy technique and positional release therapy are beneficial

for management of acute low back pain, optimal treatment intervention is not agreed upon till

date. Hence, further research is necessary to find the most effective treatment option in the

management of patients with acute low back pain. Therefore the purpose of the study is to

compare the effectiveness of Muscle energy technique and Positional release therapy for reduction

of pain and improving functional ability in subjects with acute low back pain.

Research Question:

Which form of manual therapy is more effective in improving functional ability and reducing pain

in subjects with acute low back pain – Muscle Energy Technique or Positional Release Therapy?

Hypothesis:

Null hypothesis:

There will be no significant difference between Muscle Energy Technique and Positional Release

Therapy in improving functional ability and reducing pain in subjects with acute low back pain.

Alternate hypothesis:

There will be significant difference between Muscle Energy Technique and Position Release

Therapy in improving functional ability and reducing pain in subjects with acute low back pain.

6.2 Review of Literature:

P Naik Prashant, A Heggannavar et. al. (2010): studied the effects of MET and PRE on low

back pain and concluded that both were helpful in improving lumbar mobility and decreasing pain

in non specific low back pain.1

Wilson E, Payton O, Donegan-Shoaf L, Deck K et. al. (2003):studied effects of MET on non

specific low back pain in a perspective pilot clinical trial on 20 subjects over a 4 week period and

found that MET combined with supervised motor control and resistance exercises may be

superior to neuromuscular re-education and resistance training for decreasing disability and

improving function in patients with acute low back pain2

Nogelle M Selkow, Terry L Grindstaff, Kevin M Cross, Kelli Pugh, Jay Hertel, Susan Saliba

K et. al. (2003): studied effects of MET in non specific lumbopelvic pain in a randomized control

trial. The main finding of this study was that the MET group demonstrated a decrease in VAS

worst pain. This technique can be accomplished without causing further pain or harm to the

patient.3

Wong, Christopher Kevin, Schauer, Carrie e.t. al (2004): studied effect of Positional Therapy

on pain and strength in hip musculature on 50 volunteers. They have concluded in their study that

positional release therapy definitely reduces pain which indeed improves strength.4

Kerry J.D’Ambrogio, George B. Roth e.t. al (1997): suggested Positional release therapy also

known as ‘’counter strain’’ is a helpful tool for Assessment & Treatment of Musculoskeletal

Dysfunction. Although positional release was invented as a structural technique, physiologically it

can be seen as a way of resetting proprioceptors, primarily at tendon-osseous junctions.5

S Stander- Acta Derm Venerol . et. al. (2012): studied validity and reliability of Visual

Analogue Scale in comparison to Numerical Rating Scale and Verbal Rating Scale. They

concluded that VAS is more sensitive and reliable tool than NRS and VRS for pain assessment.6

Boonstra, Anne M. Reneman, Michiel F. , Posthumus, Jitze B. , Stewart, Roy E. , Schiphorst

Preuper, Henrica R. et. al. (2008):conducted a study to determine the reliability and concurrent

validity of a visual analogue scale (VAS) for disability as a single-item instrument measuring

disability in chronic pain patients. 52 patients in the reliability study, 344 patients in the validity

study were selected. They concluded that the reliability of the VAS for disability is moderate to

good.7

Julie M Fritz and James J Irrgang et. al. (2008): did a comparative study on reliability of

Modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability

Scale on 60 subjects over a 4-week period and found that results for the modified OSW were

superior than for the QUE. The modified OSW was more responsive than the QUE as assessed by

GRI and in correlations between change scores and the global rating of change.8

H Breivik, S. M. Allen et. al. (2008): studied importance of validity and reliability of pain

assessment. They concluded that any assessment of pain must take into account other factors, such

as cognitive impairments or dementia and assessment tools validated in the specific patient group

being studied. 9

6.3 Objectives:

To compare the effects of Muscle energy technique and Positional release therapy in Acute Low

Back Ache on pain and disability.

7. Material and Methods

7.1 Study design:

Comparative Study design with two groups- Group A(HMP+MET) and Group B(HMP+PRT)

7.2 Methodology:

Study subject :

Subjects with non specific low back pain for less than 3weeks.

Sample size:

Study will be done on 30 subjects (15 in Group A and 15 in Group B)

Study setting and source of data

Study will be conducted in K.T.G. Hospital, Bangalore and other Rehabilitation Centres.

Sampling method

Simple random sampling method.

Study duration:

2weeks study : daily sessions

Sample selection:

Inclusion Criteria:

Both male and females.1

Age group between 20 to 65 years.1

Non specific low back pain.1

Symptoms less than 3 weeks.1

Subjects who willing to participate.1

Low back pain without radiation to buttock, thigh or leg.1

Exclusion Criteria:

History of spinal surgery.1

Motor weakness .1

Spinal fractures or tumors.1

Lumbar radiculopathy.1

Altered sensation such as paraesthesia, numbness,hyperaesthesia, anesthesia.1

Altered deep tendon reflexes.1

Subjects receiving muscle relaxants.1

Material used:

Couch with pillow.

Assessment Performa

Measuring Tape

Pen and paper

7.3 Method of data collection:

Ethical Clearance-

As the study includes human subjects ethical clearance is obtained from ethical community

of K.T.G college of Physiotherapy.

Subjects who meet the inclusion criteria will be assigned to two groups based on simple

random sampling.

Group A : Hot moist pack and Muscle energy technique

Group B : Hot moist pack and Position release therapy

Pre interventions measurements such as pain using VAS, ROM and functional ability using

MODQ will be measured.

Group A – In this group, subjects will be given Hot moist pack and Muscle energy technique.

Patients first will receive hot moist pack. The study participant was made to lie prone on the

couch comfortably. Hot moist pack was kept on the participant’s lumbar region for a period

of

10 minutes.1

Muscle energy technique - After receiving hot moist pack therapy for 10 minutes, muscle energy

technique for erecter spinae was performed on the participant for 10 hold with 20 seconds

relaxation for 9 times i.e. total of 270 seconds in following way:

The participant sits with back to therapist on treatment couch, legs hanging over side and

hands

clasped behind the neck. The therapist places knee on the couch close to the participant, at

the

side towards which side bending and rotation will be introduced. The therapist passes a hand

in

front of participant’s axilla on the side to which the participant is to be rotated, across the

front

of participant’s neck, to rest on the shoulder opposite. The participant is drawn into flexion,

side bending and rotation over the therapist’s knee. The therapist’s free hand monitors the

area

of tightness and ensures that the various forces localize at the point of maximum

contraction/tension. When the participant has been taken to a comfortable limit of flexion, is

asked to look towards the direction from which rotation has been made, whilst holding the

breath for 7 to 10 seconds, or to do this while also introducing a very slight degree of effort

towards rotating back to upright position, against firm resistance from the therapist. The

patient

is then asked to release the breath, completely relax and to look towards the direction in which

side bending/ rotation is being introduced (i.e. towards the resistance barrier). The therapist

waits

for the participant’s second full exhalation and then takes the participant further in all the

direction of restriction, towards new barrier, not through it.1.2.3

Group B – In this group, subjects will be given Hot moist pack and Position release therapy.

Patients first will receive hot moist pack. The study participant was made to lie prone on the

couch comfortably. Hot moist pack was kept on the participant’s lumbar region for a period

of

10 minutes.

Position release therapy- After receiving hot moist pack therapy for 10 minutes, positional release

therapy for erecter spinae for 90 seconds with 3 repetitions i.e. total of 270 seconds was given in

following way. The participant is prone with trunk laterally flexed towards the tender side. The

therapist stands on the side of the tender point. The therapist places his or her knee on the table

and rests the participants affected leg on the therapist’s thigh. The participant’s hip is extended

and adducted and slight rotation is used to fine tune.1,4,5

VAS score and lumbar range of motion (extension) were measured pre and immediately post

intervention. All the participants will receive the selected treatment daily over a period of 2

weeks. After 8 days of intervention, post treatment outcome measures will be recorded.

Subjects

will be reevaluated. As pain using VAS , lumbar extension ROM by Schobers method and

functional ability using MODQ will be measured.

The measured date will be used for analysis.

Outcome measures:

Visual analogue Scale (VAS) for pain. (Annexure-1)6,7,9

Modified Oswestry Disability Questionnaire for functional ability.(Annexure-2)8

Statistical test:

Statistical analysis will be performed by using SPSS software for window (version 16) and

p-value will be set as 0.05.

Statistical measures such as unpaired‘t’ tests and paired‘t’ tests were used to analyze the

data. The results were concluded to be statistically significant with p< 0.05.

Paired‘t’ tests were used to compare the differences of scores on day 1 and day 8th within

a single group. Unpaired‘t’ tests were used to compare differences between the two groups,

MET group and the PRT group.

Repeated measures ANOVA as a parametric Fredmans ANOVA as a non parametric will

be used to analyse the variables within the group.

7.4 Ethical Clearance:-

As this study involves human subjects, the ethical clearance has been obtained from the

ethical Committee of K.T.G college of Physiotherapy, Bangalore as per the ethical guidelines for

Bio-medical research on human subjects, 2000 ICMR, New Delhi. Also a written consent will be

taken from each subject who participates in the study.

8. List of References:

1. Capt. Eric Wilson, Otto Payton, Lisa Donegan-Shoaf,Katherine Dec: Muscle energy

technique in patients with low back pain: A pilot clinical trial JOSPT.2003:33(9):502-

5102. Sharma SC, Singh R, Sharma AK, Mittal R: Incidence of low back pain in work age

adults in rural North India. Medical journal of India.2003:57:4: 145-147

2. Jouhua A. Cleland et al: The use of lumbar spine manipulation technique by physical

therapists in patients who satisfy clinical prediction rule: a case series. JOSPT.2006:36:4

3. George E. Ehrlich: Bulletin of the World Health Organization; Special Theme –Bone and

Joint Decade 2000 –2010; 2003; 81:671-676

4. White AH, Anderson R. "The challenge of conservative care." In: White AH, Anderson R.

Conservative Care of Low Back Pain. Baltimore: Williams & Wilkins,1991:427-434.

5. McGregor A, Anderson L, Gedroyc W. the assessment of intersegmental motion and

pelvic tilt oarsmen.Med Sci Sports Exerc. 2002;34:1143-1149

6. Burton Ak, Battie MC, Gibbions L, et al. Lumbar disc degeneration and saggital

flexibility. J Spinal Disorder.1996;9:418-424.

7. Latimer J, Lee M, Adams R, Moran CM. An investigation of relationship low back pain

and lumbar postero-anterior stiffness. J Manipulative Physical Ther.1996; 19: 587-591

8. Troup JD, Foreman TK, Baxter CE, Brown D. 1987 Volvo award in clinical sciences: the

perception of back pain and role of psychophysical tests of lifting capacity. Spine. 1987;

12:645-657

9. 10. Melllin G. Decreased joint and spinal mobility associated with low back pain in young

adults. J Spinal Disord. 1990; 3:238-243

10. Pearcy M, Portek I, Shepherd J. the effect of low back ache on lumbar spine movements

measured by three dimensional X-ray analysis. Spine. 1985; 10:150-153

11. Julie Moreland, Elspeth Fiinoh et al: Interater reliability of Six tests of Trunk Muscle

Function and Endurance.J OrthoSportsPhys Ther.1997;26(4):200-208.

12. Jorgensen K, Nicolaisen et al: Trunk Extensor Endurance Determination and Relation

to Low Back Trouble. J Orthop Sports Phys Ther 1987; 30: 259-267.

13. Kerry J.D’Ambrogio, George B. Roth.Positional release therapy Assessment &Treatment

of Musculoskeletal Dysfunction. Mosby publication: Philadelphia:1997:2025

14. DiGiovanna EL, Martinke DJ, Dowling DJ. Introduction to osteopathic medicine. An

Osteopathic Approach to Diagnosis and Treatment. Philadelphia: JB Lippincott;1991:1-31.

Naik Prashant P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June

2010, Vol. 4, No. 2 35

15. Heilig D. The 1984 Thomas L. Northup memorial address: osteopathic manipulative care

in preventive medicine. J Am Osteopath Assoc. 1986;86:645651.

16. Leon Chaitow, Judith Walker Delany. Clinical application of neuromuscular techniques.

Vol 2.London: Elsevier Health Science. 2000

17. Leon Chaitow, Ed Wilson, Dylan Morrissey, John M. McPartland. Positional Release

Techniques. 2 Edi. London: Elsevier Health Sciences, 2002

18. Korr IM: The neural basis of the osteopathic lesion JAOA 1947; 47:191-198

19. John V. Basmajian, Rich Nyberg: Rational Manual Therapies. Manipulation, Spinal

Motion, and Soft Tissue Mobilization: Williams & Wilkins : University of Michigan:1993:

301-313

20. http://www.centerimt.com/ejournal/articles/ej00037.htm

21. Sjolie, Astrid N, Ljunggren et al: The Significance of High Lumbar Mobility and Low

Lumbar Strength for Current and Future Low Back Pain In Adolescents. Spine.

2001;26(23):2629-2636

22. Fritz and Irrgang: A Comparison of a Modified Oswestry Low Back Pain Disability

23. Questionnaire and the Quebec Back Pain Disability Scale.

PhysicalTherapy.2001;81(2):7767

9. Signature of Candidate

10. Remarks of the Guide

11. Name and Designation of

11.1 Guide :

11.2 Signature

11.3 Co-Guide :

11.4 Signature

11.5Head of Department :

11.6 Signature

12. 12.1Remarks of the Chairman & Principal

12.2Signature

ANNEXURE -1

CONSENT FORM

I MISS. PRIYANKA GANESH PATIL have explained to..... (Subject name).... the purpose of the research,

the procedures required, and the possible risks and benefits to the best of my ability.

......................................... ...............................................

Investigator Signature Date

College: K.T.G. COLLEGE OF PHYSIOTHERAPYPlace: Bangalore

CONSENT TO PARTICIPATE IN THE STUDY

Purpose of Research

I .........................have been informed that this study will be for COMPARISON OF MUSCLE ENERGY

TECHNIQUE AND POSITIONAL RELEASE THERAPY IN SUBJECTS WITH ACUTE LOW BACK

PAIN. Both approaches /techniques are acceptable Physiotherapy intervention for this problem. This study

will help physiotherapy better understand the use of Physiotherapy services in management of Acute Low

Back Pain with comparative study of Muscle Energy Technique and Position Release

Procedure

I understand that I will be assigned by lot to receive exercise therapy. I will be expected to attend

Physiotherapy treatment sessions two to three times in a week in addition to doing exercises at home.

I am aware that in addition to ordinary care received, I will be examined and asked a series of questions by a

research Physiotherapist. The Physiotherapist examination consists of measuring Visual analog scale (VAS)

for Pain and Modified Oswestry Disability Questionnaire for functional ability. I have been asked to

undergo these tests at the beginning of the study, and after the study.

Risk and Discomforts

I understand that I may experience some pain or discomfort during the examination or during my treatment.

This is mainly the result of my condition, and the procedures of this study are not expected to exaggerate

these feelings which are associated with the usual course of treatment.

Benefits

I understand that my participation in the study will have no direct benefit to me other than potential benefit

of the treatment which is planned to reduce my pain and increase my hand function. The major potential

benefit is to find out which treatment program is more effective.

Confidentiality

I understand that the information produced by this study will became part of my research record and will be

subject to the confidentiality and privacy regulation, but will be stored in the investigator’s research file.

If the data are used for publication in the literature or for the teaching purpose, no names will be used, and

other identifiers, such as photographs and audio or videotapes, will be used with my special written

permission.

Refusal or Withdrawal of Participation

I understand that my participation is voluntary and that I may refuse to participate or may withdraw consent

and discontinue participation in the study at any time without prejudice to my present or future care at the

Hospital. I also understand that Miss. Priyanka Ganesh Patil may terminate my participation in this study at

any time after She explained the reasons for doing so.

I confirmed that Miss. Priyanka Ganesh Patil has explained to me the purpose of the research, the study

procedures that I will undergo, and the possible risks and discomforts as well as benefits that I may

experience. Alternatives to my participation in the study have also been discussed. I have read and I

understand this consent form. Therefore, I agree to give my consent to participate as a subject in this

research project.

............................................... ..........................................

Participant Signature Date

.............................................. ..........................................

Witness to Signature Date

ANNEXURE -2

Visual Analog Scale (VAS):

VAS is presented as 10cm line.

No pain at one end and worst imaginable pain at other end

Patient is asked to mark a 100mm line to indicate pain intensity

ANNEXURE -3

Patient's Name__________________________________________________ Number_____________Date_____________________

Modified Oswestry Disability QuestionnaireThis questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which MOST CLOSELY describes your problem

Section 1 - Pain Intensity

I can tolerate the pain without having to use painkillers

The pain is bad but I can manage without taking painkillers.

Painkillers give complete relief from pain.

Painkillers give moderate relief from pain.

Painkillers give very little relief from pain.

Painkillers have no effect on the pain and I do not use them.

Section 2 - Personal Care (Washing, Dressing, etc.)

I can look after myself normally without causing extra pain.

I can look after myself normally but it causes extra pain.

It is painful to look after myself and I am slow and careful.

I need some help but manage most of my personal care.

I need help every day in most aspects of self care.

I do not get dressed, I wash with difficulty and stay in bed.

Section 3 – Lifting

I can lift heavy weights without extra pain

I can lift heavy weights but it gives extra pain.

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently

positioned, for example on the table

Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are

conveniently positioned

I can lift very light weights

I cannot lift or carry anything at all.

Section 4 - Walking

Pain does not prevent me from walking any distance

Pain prevents me from walking more than one mile

Pain prevents me from walking more than one half mile

Pain prevents me from walking more than one quarter mile

I can only walk using a stick or crutches

I am in bed most of the time and have to crawl to toilet

Section 5 – Sitting

I can sit in chair as long as I like

I can only sit in my fav chair as long as I like

Pain prevents me from sitting more than one hour

Pain prevents me from sitting more than 30 minutes

Pain prevents me from sitting more than 10 minutes

Pain prevents me from sitting almost all the time.

Section 6 – Standing

I can stand as long as I want without extra pain .

I can stand as long as I want but it gives extra pain

Pain prevents me from standing more than 30 minutes

Pain prevents me from standing more than 10 minutes

Pain prevents me from standing at all

Section 7 – Sleeping

Pain does not prevent me from sleeping well

I can sleep well only by using tablets

Even when I take tablets I have less than 6 hrs sleep

Even when I take tablets I have less than 4 hrs sleep

Even when I take tablets I have less than 2 hrs sleep

Pain prevents me from sleeping at all

Section 8 – Social Life

My social life is normal and gives me no extra pain

My social life is normal but increases the degree of pain

Pain has no significant effect on my social life apart from limiting my more energetic interests

e.gdancing

Pain has restricted my social life and I do not go out as often

Pain has restricted my social life to my home

I have no social life because of pain

Section 9 – Travelling

I can travel anywhere without extra pain

I can travel anywhere but it gives me extra pain

Pain is bad but I manage journeys over 2 hours

Pain is bad but I manage journeys less than 1 hour

Pain restricts me to short necessary journeys under 30 minutes

Pain prevents me from travelling except to doctor or hospital

Section 10 – Changing degree of pain

My pain is rapidly getting better

My pain fluctuates but overall it is definitely getting better

My pain seems to be getting better improvement is slow at the present

My pain is neither getting better nor worse

My pain is gradually worsening

Scoring: Questions are scored on a vertical scale of 0-5. Total scores and multiply by 2. Divide by

number of sections answered multiplied by 10. A score of 22% or more is considered significant activities

of daily living disability. (Score___ x 2) / (____Sections x 10) = _____________ % ADL

Comments : ____________________________________________________