Table of Content

Chapter Title Page

- Editorial 3

1 Exploration of the History of Physiotherapy 5

2Efficacy of McKenzie Approach combined with SustainedTraction in improving the Quality of life following low Back Ache– A Case Report

9

3 Safety Positions for Healthy Sex Following Back Pain 15

4Comparison of Clinic and Home Based Exercise Programs afterTotal Knee Arthroplasty: A Pilot Study

20

5A Comparative Study on Supervised Clinical Exercise versusHome Based Exercise in Primary Unilateral Total KneeArthroplasty

33

6Comparison of the Effect of Isometric Exercise of Upper Limb onVitals between Young Males and Females

44

7Growth in Cerebral Palsy Children between 3-13 years in UrbanDharwad, India

61

8Effectiveness of Proprioceptive Training over Strength Training inImproving the Balance of Cerebral Palsy Children with ImpairedBalance

69

9Correlation of Balance Tests Scores With Modified PhysicalPerformance Test In Indian Community-Dwelling Older Adults

85

10Paraplegia with Sacral Pressure ulcer treated by Ultrasoundtherapy- A Single Case Report

109

11Electrical Muscle Stimulation (EMS) Improve FunctionalIndependence in Critically Ill Patients

118

12Effectiveness of Educational Sessions on Reducing Diabetes inWomen with PCOS— A Pilot Study

126

13Perception of students for laptop ergonomics and its use in thelearning centre of Sheffield Hallam University, U.K.

137

Editorial

It is my immense pleasure to have the opportunity to select and collect the

Physiotherapy related articles published in the all four issues of the Scientific

Research Journal of India (SRJI) 2012. Hopefully this book will help the

readers find all the research papers/ articles on one place.

Hope you’ll find it valuable.

Regards,

Dr. Krishna N. Sharma

Dr.L.Sharma Campus, Muhammadabad Gohna,

Mau, U.P., India. Pin- 276403

Exploration of the History of Physiotherapy

Dr. Krishna N. Sharma*

INTRODUCTION

Physiotherapy or Physical Therapy

or PT, is a conservative science of the

treatment and management after the

clinical examination, assessment and

diagnosis of the diseases for restoration of

the neuro-musculo-skeletal and Cardio-

pulmonary efficiencies, managing pain and

certain integumentary disorders with the

help of physical means like radiation, heat,

cold, exercise, current, waves,

manipulation, mobilization etc.

Various organizations have defines

the Physiotherapy in their own words. Few

definitions of them are given below:

The APTA defines the

physiotherapy as: “clinical applications in

the restoration, maintenance, and

promotion of optimal physical function. ” 1

The Maharashtra OT PT Council

defines the physiotherapy as: “ a branch of

medical science which includes

examination, assessment, interpretation,

physical diagnosis, planning and execution

of treatment and advice to any person for

the purpose of the preventing correcting,

alleviating and limiting dysfunction, acute

and chronic bodily malfunction including

life saving measures via chest

physiotherapy in the intensive care unites,

curing physical disorders or disability

promoting physical fitness, facilitating

healing and pain relief and treatment of

physical and psychosomatic disorders

through modulating physiological and

physical response using physical agents,

activities and devices including exercises,

mobilization, manipulation, therapeutic

ultrasound, electrical and thermal agents

Abstract: Physiotherapy or Physical Therapy or PT, is a conservative science of the treatment

and management after the clinical examination, assessment and diagnosis of the diseases for

restoration of the neuro-musculo-skeletal and Cardio-pulmonary efficiencies, managing pain

and certain integumentary disorders with the help of physical means like radiation, heat, cold,

exercise, current, waves, manipulation, mobilization etc. Many organizations describe

physiotherapy in their ways. This paper explores the historical roots of physiotherapy.

and electrotherapy for diagnosis, treatment

and prevention. ” 2

Physiotherapists use the patient’s

history and physical examination to make

the diagnosis and establish a management

plan and in necessity they incorporate the

results of laboratory, imaging studies and

Electrodiagnostic testing.

Physiotherapy is concerned with

identifying and maximizing the quality of

life and movement potential within the

spheres of promotion, prevention,

treatment or intervention, habilitation and

rehabilitation which encompasses the

physical, psychological, emotional, and

social well being.

The texts reveals that the

physiotherapy was rooted in 460 B.C.

when the physicians like Hippocrates and

later Galenus who may be believed to have

been the first practitioners of physical

therapy used to advocate massage, manual

therapy techniques and hydrotherapy to

treat people.3

In the 18th century, after the

development of orthopedics, machines like

the Gymnasticon were developed for the

treatment of gout and similar diseases by

systematic exercise of the joints, similar to

later developments in physical therapy.4

The earliest documented origin of

the actual physiotherapy is found to be in

Sweden. The Swedish word for physical

therapist is “sjukgymnast” (sick-gymnast).

Per Henrik Ling who is called he Father of

Swedish Gymnastics founded the Royal

Central Institute of Gymnastics (RCIG) in

1813 for massage, manipulation, and

exercise.

The first use of the word

physiotherapy is found in German

Language as the word “Physiotherapie” in

1851 by a military physician Dr.Lorenz

Gleich.5

Physiotherapists were given

official registration by Sweden’s National

Board of Health and Welfare in 1887

which was then followed by other

countries. The word “Physiotherapy” was

coined by an English physician Dr.Edward

Playter in the Montreal Medical Journal in

1894 after 43 years of the German term

“Physiotherapie”. In his words- “The

application of these natural remedies, the

essentials of life, as above named, may be

termed natural therapeutics. Or, if I may be

permitted to coin from the Greek a new

term, for I have never observed it in print,

a term more in accordance with medical

nomenclature than the word hygienic

treatment commonly used, I would suggest

the term, Physiotherapy” .6

In the same year four nurses Lucy

Marianne Robinson, Rosalind Paget,

Elizabeth Anne Manley and Margaret

Dora Palmerin in Great Britain formed the

Chartered Society of Physiotherapy.7

The first documented professional

institution for Physio- therapy training was

School of Physiotherapy at the University

of Otago in New Zealand which run an

entry level program in physiotherapy.8

After this the next year or in 1914

in United States, Reed College in Portland,

Oregon, graduated “reconstruction aides”.9

The establishment of the modern

physical therapy is thought to be in Britain

towards the end of the 19th century. The

American orthopedic surgeons started

treating the disable children and started

employing women trained in physical

education, massage, and remedial exercise.

It was promoted further during the Polio

outbreak of 1916 and during the First

World War when the women were

working with the injured soldiers.

The first physical therapy research

was published in the United States in

March 1921 in “The PT Review”. In the

same year, Mary McMillan organized the

physiotherapy association named the

American Women’s Physical Therapeutic

Association which is currently known as

the American Physical Therapy

Association (APTA).

Primarily in the 1940s the

treatment consisted of exercise, massage,

and traction but later in the early 1950s the

Manipulative procedures to the spine and

extremity joints began to be practiced

especially in the British Commonwealth

countries, in the early 1950s.10, 11

REFERENCES

1. http:/ / www. apta. org/ / AM/ Template.

cfm?Section=& WebsiteKey=

2. Maharashtra Act No. II of 2004.

Mharashtra Govern- ment Gazzet. 12 Jan

2994. Part 8:5-29

3. Wharton MA. Health Care Systems I;

Slippery Rock University. 1991

4. American Physical Therapy

Association. “ Discovering Physical

Therapy. What is physical therapy ”

(http://www.apta.org/AM/Template.cfm?S

ection= Consumers1& Template=/ CM/

HTMLDisplay. cfm& ContentID=39568).

American Physical Therapy Asso- ciation.

. Retrieved 2008-05-29.

5. Tertouw TJA. Letter to editor-the origin

of the term “ Physiotherapy ” . Physiother

Res Int. 2006; 11:56-57

6. Playter E. Physiotherapy First: Nature’s

medicaments before drug remedies;

particularly relating to hydrotherapy.

Montreal Medical Journal. 1894;xxii:811-

827

7. Chartered Society of Physiotherapy

(n.d.). “ History of the Chartered Society

of Physiotherapy ” (http:/ / www. csp. org.

uk/ director/ about/thecsp/ history. cfm).

Char- tered Society of Physiotherapy. .

Retrieved 2008-05- 29

8. Knox, Bruce (2007-01-29). “ History of

the School of Physiotherapy ” (http:/ /

web. archive. org/ web/ 20071224020426/

http:/ / physio.otago. ac. nz/ about/ history.

asp). School of Physiotherapy Centre for

Phys- iotherapy Research. University of

Otago. Archived from the original (http:/ /

physio. otago. ac. nz/ about/ history. asp)

on 2007-12-24. . Retrieved 2008-05-29.

9. Reed College (n.d.). “ Mission and

History ” (http:/ / www. reed. edu/

about_reed/ history. html). About Reed.

Reed College. . Retrieved 2008-05-29.

10. McKenzie, R A (1998). The cervical

and thoracic spine: mechanical diagnosis

and therapy. New Zealand: Spinal

Publications Ltd..pp. 16–20. ISBN 978-

0959774672.

11. McKenzie, R (2002). “ Patient Heal

Thyself” . World- wide Spine &

Rehabilitation 2 (1): 16–20.

CORRESPONDENCE

*Academic Chairman: Institute for Health & Wellness

Address: Institute for Health & Wellness, Dr.L.Sharma Campus, Muhammadabad Gohana,

Mau, U.P., India. Pin-276403. Email: dr.krisharma@gmail.com Cont: +91-9320699167

Efficacy of McKenzie Approach combined with Sustained Traction in

improving the Quality of life following low Back Ache – A Case Report

A.Sridhar MPT (Neuro)*, S.Vimala BPT**

Abstract: Objective: To evaluate the effectiveness of traction combined with

McKenzie approach for the sub acute low back ache (LBA) patient and evaluating

the quality of life post treatment. Design: Single Case Report Setting: PSG

Hospitals Participant: A 45 years old female with the complaint of LBA with 6

month duration, gait problem, participatory problem in social activities and also

with the impairment of function. Intervention: One hour session of physiotherapy

including traction and McKenzie exercises interrupted with rest period. Outcome

Measures: Visual Analogue Scale (VAS) (Pain), Quality of life (QOL) (American

chronic Pain Association). Result: There is a significant reduction of pain and

improvement of quality of life after one month of treatment. Conclusion:

McKenzie exercises combined with traction plays a major role in reducing pain

and improving the quality of life following Low Back Ache patient.

Key words: LBA, McKenzie, Traction, Quality of Life, Visual Analogue Scale.

INTRODUCTION

LBP affects 70–80% of adults at some

point in their lives, with peak prevalence in

the fifth decade. The drastic increase in

LBP in the past two to three decades. Low

back pain is a common disorder. Nearly

everyone is affected by it at some time.

The acute low back pain may develop to

chronic pain and disability. The treatment

of low back pain remains as controversial

today as it was fifty Years ago. Over the

years the medical profession used a wide

range of treatments, such as heat or cold,

rest or exercise, flexion or extension,

Mobilization or immobilization,

manipulation or traction. Nearly always

drugs were prescribed, even when the

disturbance proved purely mechanical in

origin. Amazingly, most of the patients

recovered, very often inspite of treatment

rather than because of it. But McKenzie

approach in LBA is on mechanical basis

and he assessed the movements of spine

and also the treatment is based on the

patient complaints of pain whether in

flexion or extension or lateral flexion. So

we had tried to apply this technique

coupled with traction for LBA patient.

METHODOLOGY:

Case History:

A 46 years old female came with the

complaints of pain in the bilateral lower

limb, difficulty in walking, getting up from

the floor, and toileting activities for 6

month duration. But she doesn’t

complaints of any sensory loss over the

bilateral lower limb and also in anal area.

Basically she is from rural area and there is

no facility for her to go for hospitals. But

she went to nearby physician and she got

some pain medications and tropical

ointments for pain relief. As time goes on

she is complaining of severe pain in the

back and unable to walk for even 10

minutes continuously. She feels weakness

of bilateral lower limb and restricted her

participation in the social activities and

also reducing the usual work what she is

doing regularly. She could not do even

carrying the drinking water from a distance

place as their primary need.

Misdiagnosis:

After she felt more discomfort she went to

various hospitals and diagnosed as GBS,

and someone diagnosed as disc herniation

and advised her to go for surgery. She was

confused and she refused to undergo

surgery. Finally she came to our hospital

and she got medications. In the mean time

we send her for the neuro consult but the

neurologist also advised her to take MRI

and after the he also advised her to go for

surgery.

Being a low economic status she could not

spend more money and she refused for

surgery and come back to our hospital with

the reports.

Our Views:

As we (Physician, Junior Doctors and

Physical therapist Team) read the MRI and

also observed her complaints of pain. We

taught that she does not need surgery at

this stage and we make her bed rest for one

day and we started our own assessment

and treatment procedures.

We underwent observational, palpation,

and examination of various movements

including reflex, muscle strength, balance,

coordination and Activities of daily living.

We came to the conclusion that she had a

derangement syndrome one with

complaints of symmetrical pain across L4,

L5, no radiating pain and no deformity so

it comes under the first type of

derangement so we decided to treat her

with McKenzie approach and traction. As

McKenzie exercises are very much

appreciated in treatment of lower back

ache population in world wide. we tried

our traditional approach of traction and

McKenzie approach

Outcome Measures:

1. Visual Analogue Scale (VAS).

2. Quality of Life (QOL).

Visual Analogue Scale:

Its is widely used to measure the severity

of pain from patient feeling of pain. Zero

indicates no pain and 10 indicate severe

not tolerable pain.

Quality of Life:

American Chronic Pain Association

created this measure with the following

explanation. Pain is a highly personal

experience. The degree to which pain

interferes with the quality of a person’s life

is also highly personal. The American

Chronic Pain Association Quality of Life

Scale looks at ability to function, rather

than at pain alone. It can help people with

pain and their health care team to evaluate

and communicate the impact of pain on the

basic activities of daily life. This

information can provide a basis for more

effective treatment and help to measure

progress over time.

Scoring system zero indicates non

functioning and ten indicates normal

quality of life.

Treatment protocol:

Traction:

Sustained Traction

This term denotes that a steady amount of

traction is applied for periods from a few

minutes up to ½ hour. This shorter

duration is usually coupled with stronger

poundage. This method is most widely

used in Europe and much of the literature

describes various applications of sustained

traction. Sustained traction is sometimes

referred to as static traction. As per the

patient’s weight we applied 15kg of

lumbar static traction for 30 minutes.

McKenzie Exercises:

This is a set of exercises we asked her to

do for 30 min.

1. Prone Lying.

2. Extension in prone lying (forearm

support).

3. Extension in prone lying ( hand

support).

4. Extension in prone lying with belt

fixation.

5. Sustained extension in tilt bed.

6. Extension in standing.

7. Extension Mobilization (Therapist

doing passively)

RESULT AND INTERPRETATION:

The assessment is taken on the first visit,

2nd week, 3rd week, and 4th week.

According to McKenzie approach at any

time of disease the particular form of

exercise may worse the condition so we

are assessed her at one week interval.

Table 1.1 Comparing the visual

analogue scale on the first visit and

4th week

Visual Analogue Scale (Pain)

1st visit 2nd

Week

3rd

Week

4th

Week

9 7 4 0.5

Graph 1.1 comparing the values of

visual analogue scale

Initially when we assess in VAS

she complaints of pain as nine and at

the end of 4th week she complaints of

0.5 which means near normal.(table

1.1)(graph 1.1)

Table 1.2 Comparing the quality

of life scale on the first visit and 4th

week

Quality of Life ( American chronic

Pain Association)

1st

visit

2nd

Week

3rd

Week

4th

Week

1 4 8 10

Graph 1.2 comparing the values of

Quality Of Life Scale

Initially when we assess in QOL she

complaints of 1, and at the end of 4th week

she complaint of 9 which means she can

work for 8 hours and she actively

participate in family and social

activities.(table 1.2) (graph 1.2)

From the above mentioned table and

graph its clearly seen that patient’s pain is

reduced and her quality of life is improved

a lot.

Thereby this case report is strongly

recommending that traction coupled with

McKenzie exercises are very much helpful

in treating the disc herniation condition.

DISCUSSION:

There are various treatment procedures are

widely used in treating the LBA cases. On

reviewing 21 papers in 1995, only one

paper was found to be of

high quality, Van der Heijden concluded

no inferences could be drawn(Phys Ther

1995).

A trial by Cherkin (N Eng J Med 1998)

compared three groups: chiropractic

manipulation, McKenzie exercise, vs

education leaflet. He did not find any

difference among the three groups with

regard to pain recurrence or days off work.

The chiropractic group performed

significantly better than the minimal

intervention group at 4 weeks, but not at 3

months and the 1-year. But as per the

complaints of the patient we have to

choose the technique and apply with

precautions and assess the patients

periodically to get the knowledge of

patients pain and related features. This

case report is a eye opening for the new

physio to apply these procedures widely

for most of the LBA patients and thereby

improving the patient condition. Static

lumbar Traction is useful for this patient as

there is narrowing of the disc space, after

applying traction there will be a reduction

of the nerve impingement. McKenzie had

classified the low back pain in 3 categories

viz. dysfunction, postural and derangement

syndrome. As this patient had complaint of

derangement symptoms so we applied the

treatment protocol for derangement

syndrome one.

Conclusion:

This case report supports that traction

combined with McKenzie exercises plays

a major role in reducing pain and

improving the quality of life.

ACKNOWLEDGEMENT

Thanks to my client & PSG Hospitals and also to our superintendent and deputy

superintendent for having confident with us in treating the patients who need physical

therapy.

REFERENCES:

1. Lumbar spine, mechanical diagnosis

and therapy,(1981) R.A. McKenzie,

pages 122-150

2. Orthopaedic rehabilitation, assessment

and enablement , John C.Y.Leong et al.

pages 481-488.

3. Low Back Pain, royal college of

practitioners pages 3-39.

4. Lumbar traction, journal of

orthopaedic and sports therapy 1979,

H.duane saunders pages 36-40

CORRESPONDENCE

*Neurophysiotherapist- TLM Naini, UP. sriarusaro@gmail.com Cont: +91-8765152734.

**Physiotherapist Trainer- TLM Naini, UP.

Safety Positions for Healthy Sex Following Back Pain

B.Arun.* MPT, CMPT

INTRODUCTION

Sex is pleasure, it is a wonderful

feeling experienced by both partners. The

interpersonal relationship between the

partners brings a firm emotional bond.

Sexual activity has not only produced by

physical, emotional aspects but also

biological aspects in human. The strong

union between the partners may be

wrecked due to a variety of causes. One of

the major causes for the breakage is

unhappiness or dissatisfaction. Pain may

produce disappointments during sexual

activity for both the partners. Pain in the

back is one of the major causes of it.1

Sexuality is an integral part of

normal and healthy relationships. It need

Abstract: Sexual rehabilitation is never a part of low back rehabilitation in India. Sex is

enjoyment, which should be liked by both the partners, around the world about eight out of

every 10 people has experiencing back pain at some time in their lives, Back pain could cause

difficulty in day-to-day activities. Crisis on partner’s relationship may occur due to

unsatisfactory sex. India a Cultural Rich & Religious country will posse’s mysterious side on

sex and people live in India have closed mouth attitude on sex. Fear about pain during sex is

the first thing which produces fear on sex. The partners should understand the facts on pain

and accommodate the new positions for happy and healthy sex. Variety of recommended

positions is there which help to alleviate pain and gives good support and satisfaction to both

partners.

Key words: Sexual Rehabilitation, Sex, Low Back Pain, Physiotherapy

not be the first thing abandoned when you

are bothered by a flare-up of Back pain.2

Though it is chronic it should not prevent

one from enjoying this part of the

relationship.

Low back pain is the most common

musculoskeletal problem encountered by

most adult population around the world.

Four out of five adults will experience

significant back pain sometime during

their life. After the common cold,

problems caused by the back are the most

frequent cause of lost work days in adults

under the age of forty-five. 3, 7

In the Indian scenario,

rehabilitation of back pain concludes when

a patient has significant reduction of pain

or he has got ability to do all ADL

activities, like day to day activities or

handling job task ect.. Very few

rehabilitation protocols followed in India

focuses on the other parts of rehabilitation.

Mostly sexual rehabilitation is not the

choice of treatment for patient living in

India.

Sexual activity is frequently

inhibited by acute pain. Sexual

dysfunctions following back pain is the

common complaint but infrequently

discussed with the therapist. The reasons

for this closed mouth attitude are multiple.

People who are suffering with it feel that

they may be the only ones having the

problem and therefore embarrassed to talk

about it, even with the doctor or to the

therapist. Some doctors do not feel

comfortable with the subject, or may not

even recognize it as a problem.4

WHY PAIN OCCURS DURING SEX?

During the sexual activity between

the partners there are number of

musculoskeletal activity happens.

Literatures supports that the physical

activity during sex produce similar stress

to back same like lifting, pulling ect.. On

while performing a vigorous movement in

the pelvic region there is an increased

stress at the back. During anterior tilting of

pelvis, the back muscles get compressed

with ligaments and other soft tissues. The

repetitive activity produces more stress to

the muscles, fascia and bones around the

back result in pain.

People with back pain are usually

aware which positions could cause pain

and they are able to find out which

positions tend to increase or provoke pain.

During vigorous sexual activity there is

more stress in the lumbar region which can

prevent active participation of the

individual and most of the time back pain

ruins their intercourse. A good scheme to

keep enjoying sex is to choose sensuality

over sexuality.

Back pain may ruin sexual life and

may wreck the relationship between the

partners. So finding the positions which

help to reduce or minimize pain is

important for a successful sexual life.

Modified positions are there to reduce

stress in the back and help in safe sex.

Conditions like herniated disk, spinal

arthritis, & Sacroiliac joint dysfunctions

need modification of the positions. 7

Fear of pain may ruin the sexual

life between the partners. Back pain

doesn’t stop the sexual relationship

between the partners. In fact it tells to

accommodate the position to get rid of

pain. Back pain is more of psychological

than physical. The most part of pain

depends on mental status of the person.

HOW TO ASSESS IT?

Various Back disability scale has

an inclusion of sexual relationship

questionnaire. Like, Oswestry has one part

which focuses on sexual relationship. The

scale by Laumann et al., 2005, has come

up with a scale to find out sexual

dysfunction in males. The scale will be

helpful in evaluating the dysfunction.

HOW TO MANAGE IT?

Learning up a new posture or pain

relieving methods like massage or ice prior

to the sex helps in reducing pain and

stress. Usually people with back pain are

aware of which positions those cause pain

and they usually avoid such positions or

movements. 1

People with Back pain should take

a proper rehabilitation measures so that to

cure pain, there are variety of treatment

measures in physiotherapy, no single

treatment is best for all patients.

Combination of various treatment

approaches help in regaining the function

as well as reducing the pain in patients.

Apart from it the modified positions will

also help to ease pain.

Physical fitness doesn’t mean that

the partner is able to handle the pain.

Mental fitness is as important as physical

fitness. Understanding the problem

between the partners is very important for

managing for the problem. Having a good

communication and developing a positive

attitude can reduce the anxiety and

apprehension between the partners. Sexual

intercourse provides a natural pelvic tilt

movement which is to be encouraged to

relieve lower back pain. Partners must

create and use of other sexual techniques

that can spare the back, like touching,

atmosphere creation and oral sex. Create

an atmosphere that is very romantic and

not be rushed, relaxed and peaceful. Begin

with oral method and followed with recommended potions.

RECOMMENDED POSITIONS

No single position is good for all.

Positions depend on the type and cause of

back pain and are best consulted with the

rehabilitation staff. Generally

recommendations include positions like

the Missionary position for both men and

women. 1

If a male partner complains of back

pain, he can be at the top of women will

help to reduce stress at back, or man can

lie at the side of woman either on the front

or at the back. If a female partner

complains, she can be at the top with

variety of positions like in bed or sitting in

a chair. 5

Depending on the type of back

pain, the position alters. For example,

patients with annular bulge will have an

increase in pain during flexion whereas for

a patient with facet problem pain will

increase with extension movements. There

are no hard and fast rules in dealing pain.

General advice given to partners are

placing a towel at the back reduce the

lumbar curvature which helps to prevent

pain. People with back pain can be advised

on good sex through illustration described

by Fahrni in 1976. These illustrations give

guidelines to people with back pain.

ILLUSTRATIONS FOR DIFFERENT

POSITIONS

REFERENCES

1. Danielle Kloeck, “Sex and Back

pain” Webb Physiotherapists Inc,

http://www.physionline.co.za.,

2010, www.spine-dr.com

2. Anthony delitto et al., “exercise

based therapy for Low back pain”

Sep 2010, uptodate.com.

3. Jerry corners, MD. “ Sex and Back

pain” Healthy back institute,

www.losethebackpain.com. 2010

4. Dr.Kraus. Back and neck pain,

www. Lowback - pain .com 2008.

5. Louise F. Lynch “Sex and back

pain information-causes, Diagnosis

and treatments”.

healthynewage.com, 2011.

6. Kamiah A Walkier, “Tips for

Better sex....even with back pain”

www.spineuniverse.com, 2008.

7. Grieves.P, “Common vertebral

joint problems, Elsevier, 2003.

CORRESPONDENCE

*Vice principal, K.G.College of Physiotherapy, Coimbatore 35. Email:

barunmpt@gmail.com, Mob: 09994576111.

Comparison of Clinic and Home Based Exercise Programs after Total

Knee Arthroplasty: A Pilot Study

Bijender Sindhu PhD, PT*, Dr.Manoj Sharma, MBBS, MS(Ortho)**, Dr.Raj K Biraynia,

MBBS, D.Ortho***

Abstract: Sixteen patients (mean age, 68+-8 years) having primary total knee

arthroplasty were assigned randomly to two rehabilitation programs: (1) clinic-

based rehabilitation provided by outpatient physical therapists; or (2) home-

based rehabilitation monitored by periodic telephone calls from a physical

therapist. Both rehabilitation programs emphasized a common home exercise

program. Before surgery, and at discharge and follow up after surgery, no

statistically significant differences were observed between the clinic and the

home-based groups on any of the following measures: (1) total score on the Knee

Society clinical rating scale; (2) total score on the ILOA level of assistance (3)

total score on the Goniometry; (4) total score of VAScale. After primary total

knee arthroplasty, patients who completed a home exercise program (home-based

rehabilitation) performed similarly to patients who completed regular outpatient

clinic sessions in addition to the home exercises (clinic-based rehabilitation).

Additional studies need to determine which patients are likely to benefit most

from clinic-based rehabilitation programs.

Key Words: Total Knee Arthroplasty, Home Based Exercise Program, Clinic

Based Exercise Program

INTRODUCTION

The aim of the arthroplasty is to resurface

the tibiofemoral joint to allow better

articulation and to reciprocate normal

kinematics of the knee (Palmer &

Cross,2004) Another aim of surgeons is to

correct valgus deformity through the

release of lateral structures (Elson &

Brenkel, 2006). The most common

approach is the medial parapatellar

approach. This has been shown to give

better radiological results, but more pain

in the short term than the minimally

invasive mid-vastus approach (Chen,

2006). Soft tissue and bony alignment can

be ensured using the Tensor/ Balancer

system (Winemaker, 2002). The Tensor/

Balancer system is important as

malalignment can lead to failure of the

operation (Winemaker,2002) Prostheses

consist of a femoral and tibial component.

The femoral or tibial component can be

cemented, hybrid (one component

cemented and the other uncemented) or

uncemented (Zavadak et al., 1995). The

type of prosthesis used depends on the

surgeons’ protocol.This question is

important because of time and cost

differences between these service delivery

settings. Clinic-based programs typically

are provided by outpatient physical

therapy clinics, and facilitate monitoring

the patient’s progress, modifying

individual programs, and providing patient

support and motivation. Home-based

programs, however, typically do not

require the patient to attend outpatient

clinic sessions or require attendance at a

minimum number of outpatient sessions,

and provide fewer opportunities for

monitoring or program modification.

Although usually developed by and taught

to patients by physical therapists, home-

based exercises typically are completed

independently by the patient at home.

The populations examined in those studies

have tended to be younger individuals

who otherwise were healthy, and with an

interest in returning to work or sporting

activities or both. The efficacy of clinic-

and home-based rehabilitation programs is

particularly important with respect to

elderly patients. Owing to the older age of

patients who have total knee arthroplasty,

the likelihood of complicating medical

conditions, the serious implications of

postoperative complications in this

population,and the medicolegal climate,

surgeons may be hesitant to prescribe non

clinically based rehabilitation programs

after hospital discharge. An often used

alternative to mandatory outpatient

physical therapy has been having all

patients complete a limited number of

clinic visits. Another alternative may be a

home-based program, monitored via

periodic telephone calls. Monthly phone

calls by therapist individuals were

associated with increased function in

patients with osteoarthritis. Although

caution must be exercised in generalizing

the findings of their study, home exercise

programs developed and monitored by

physical therapists via periodic phone

calls may provide an alternative to

mandatory clinic-based programs and to

requiring a defined number of clinic visits,

and a means to provide some monitoring

of patients during the early rehabilitation

phase.

Objective of the Study:

The purpose of the current study was to

compare two rehabilitation programs after

total knee arthroplasty: (1) clinic-based

rehabilitation delivered in outpatient

physical therapy clinics; and (2) home-

based rehabilitation monitored by a

physical therapist via periodic telephone

calls, on disease-specific, joint-specific,

and functional outcome measures.

MATERIAL AND METHODS

Inclusion and Exclusion Criteria

Patients were selected using the following

criteria: patients having primary unilateral

total knee arthroplasty as a result of

osteoarthritis, both male and female who

had a primary unilateral TKA, age 50-85.

Able to give independent informed

consent. Patients with rheumatoid arthritis

or major neurologic conditions were

excluded.

Randomization to Groups

At the time of primary total knee

arthroplasty, 32 patients were assigned

randomly to two rehabilitation programs

(1) clinic-based rehabilitation provided by

outpatient physical therapy clinics; or (2)

home-based rehabilitation, monitored by a

physical therapist via periodic telephone

calls.

Inpatient and Home Exercise.

Familiarization Period

All patients received standard inpatient

physical therapy twice daily, for 20

minutes on each occasion. Inpatient

physical therapy also included instruction

in a series of home exercises to be

completed daily after discharge, regardless

of the patient’s group assignment.

Ambulatory status on the surgical side

was weight bearing as tolerated on

discharge after surgery, at which time the

patient progressed to walking with walker.

Discharge criteria included the ability to

transfer independently, ambulate more

than 30 m using walker/crutches, and

ascend and descend at least five steps.

Medication given at discharge was pain

killer, nutrition’s and antibiotics.

Common Home Exercises (for both

groups)

The common home exercise program was

that developed for routine total knee

arthroplasty rehabilitation at the authors’

institution, and consisted of basic (Stage

1) and more advanced (Stage 2) ROM and

strengthening exercises. Each patient

received Stages 1 and 2 booklets, which

included written and pictorial descriptions

of each exercise and educational

information on using ice, controlling

swelling, walking, and ROM. They were

instructed to complete the common home

exercises three times daily until their 8-

week follow up, at which time they were

advised to continue the home exercises at

least once daily, indefinitely. Home-Based

Group A physical therapist familiar with

the common home exercises telephoned

each patient in the home-based group at

least two times ask whether the patient

was having any problems with the

exercises, to remind them of the

importance of completing the exercises,

and to provide advice on wound care, scar

treatment, and pain control. During each

telephone call, which lasted approximately

10 minutes, the patient was asked when

and how often he or she wished to be

telephoned in the future. Patients also

were provided with a contact telephone

number to call if additional questions

arose.

Variable Clinic-Based(n=16)

Home-Based(n=16)

Continuous variables: mean (standard deviation) Age (years) 65.2 (6.9)* 64.6 (7.8)Height (cm) 160.2 (9.6) 162.3 (11.1)Mass (kg) 86.4 (15.6) 85.5 (15.9)Disease duration (years) 9.8 (6.4) 9.2 (7.3)Discrete variables: frequency and percent of group(percent)

Gender—female 9 (56.25%) 5 (31.25%)Left replacement 6 (37.5%) 3 (18.75%)Contralateral knee involvement 8 (50%) 6 (37.50%)Contralateral hip involvement 3 (18.75%) 1 (6.25%)Ipsilateral hip involvement 1 (6.25%) 0 (0%)

Table 1. Patient Baseline Characteristics for the Clinic- and Home-Based Groups

Clinic-Based Group

In addition to the common home

exercises, patients in the clinic-based

group were required to attend outpatient

physical therapy after discharge to 8

weeks after surgery, for as many as three

sessions per week, for approximately 1

hour per session. Outpatient physical

therapists were provided with copies of

the Stages 1 and 2 exercise booklets, and

were asked to use these exercises as the

basic component of their rehabilitation

program. However, they were not advised

that the patient was participating in a

study comparing two rehabilitation

programs. Therapists were permitted to

modify or add exercises, use therapeutic

modalities (such as ice, heat, and

ultrasound), joint mobilizations, or other

measures as they deemed appropriate.

Patients in the clinic-based group were

requested to complete the common home

exercises at home only twice on days that

they attended clinic sessions.

Eligibility

Randomization

Clinic BasedRehabilitation

Home BasedRehabilitation

Total Knee ArthroplastyInpatient Physical TherapyCommon Home Exercise

Hospital Discharge at 5-7 days

OPD 3 session/week at 1

hour

Atleast 1telephonic call

by therapist

Stage 24 week follow up

Instruction common homeexrecise

OPD 2 session/week at 1

hour

Atleast 1telephonic call

by therapist

Stage 38 week follow up

Instruction common homeexrecise

Fig 1. The study time-sequence flow chart

is shown. Patients in both rehabilitation

groups completed the common home

exercises daily between Weeks 2 to 8.

Assessments and Measurements

In conjunction with routine orthopaedic

clinic evaluations pre surgically, and at

discharge, 8 weeks after surgery, patients

completed a series of questionnaires and

functional tests that required

approximately 1 hour. Throughout the

study, these tests were conducted by two

experienced testers who were blinded as

to the patient’s group assignment, and

gave the test results directly to the study

coordinator. The following tests were

completed: (1) total score on the Knee

Society clinical rating scale; (2) total score

on the ILOA level of assistance (3) total

score on the Gonioetry; (4) total score of

VAScale. From a position of maximum

extension, the patient slid the heel of the

test leg toward the buttocks to a position

of maximum knee flexion. The knee angle

was measured using a goniometer and

scored as the average of three repetitions.

Non directional, t tests, and tests of the

significance of the difference between two

percentages were used to compare the

clinic- and home-based groups on pre

surgical descriptive measures, and to

compare the patients who were lost to, or

dropped out of the study with those who

remained in the study, on baseline

measures. Four-way analysis of variance

(ANOVA) were used to examine the

following four criterion variables(1) total

score on the Knee Society clinical rating

scale; (2) total score on the ILOA level of

assistance (3) total score on the Gonioetry;

(4) total score of VAScale. After a

significant F-ratio, the Newman-Keuls

technique was used to compare selected

means.

Any patients who were removed from

their assigned group by the surgeons for

reasons related to the surgically treated

knee or medical conditions not related to

the surgically treated knee, or who

withdrew consent to participate, were

encouraged to continue with the home

exercises and any other therapies

prescribed, and to continue coming for

regular follow ups and testing. To take

into account that some patients were

removed or otherwise lost from their

group, but did continue to be tested at

their regular follow ups, two types of

analyses were completed: (1) a per

protocol analysis, which included all

patients who completed the study in their

assigned group; and (2) an intent to treat

analysis, in which all patients were

analyzed as having remained in their

assigned group, regardless of whether they

had completed the study in that group.

Analysis of variance tests were confined

to patients who had full data sets for the

three times of measurement (before

surgery, and discharge and 6 weeks after

surgery). In view of the number of

statistical tests computed and to minimize

the likelihood of Type 1 or alpha error, the

0.01 level was used to denote statistical

significance throughout analyses.

RESULT

Before surgery, no significant differences

were observed between the clinic- and the

home based groups on the demographic

variables shown in Table 1, or on any of

the nine criterion measures (p>0.01). No

statistically significant differences were

observed between the patients lost and

those who remained in the study (Table

2), or between the patients lost to the two

groups on the baseline scores for any of

the four criterion measures, or for age,

height, and weight (p>0.01). Length of

stay in the hospital for the patients who

completed the study in their assigned

group was 5.1+-1.5 and 5.2+-1.7 days for

the home- and clinic-based groups,

respectively. On ANOVA tests, the per

protocol and the intent to treat analyses

produced identical results for all nine

criterion measures; no treatment, surgeon,

or prosthesis-related effects were observed

(p>0.01), and only the main effect for time

(averaged over treatment, surgeon) was

significant (p<0.01) (Figs 2, 3).

Subsequent analysis of the main effect for

time indicated that the scores before

surgery, at discharge after surgery, and 6

weeks after surgery differed significantly

from one another (p<0.01); with one

minor exception. Pain before surgery,

measured via Visual analog score, was

significantly greater than that at discharge

and 8 weeks after surgery (p<0.01),

whereas there was no statistically

significant difference (p>0.01) between

the pain scores at discharge and 8 weeks,

on the per protocol and the intent to treat

analyses.

Patient Losses Clinic Based(n=16)

Home Based(n=16)

Patients lost during the inpatient period (before hospitaldischarge)

Medical issues related to the surgically treated knee 2 1Withdrawal of consent by the patient 1 2Other medical issues 2 1Totals 5 4Patients lost after hospital discharge (Weeks 2–52 aftersurgery)

Medical issues related to the surgically treated knee 0 1Withdrawal of consent by the patient 0 0Other medical issues 1 1Total losses 1 2

Table 2. Number of Patients Lost From Each Group and Reason for Loss

DISCUSSION

After primary total knee arthroplasty,

patients who completed home-based

rehabilitation performed similarly to

patients who completed clinic-based

rehabilitation during the first 4 weeks after

surgery. That all four criterion measures in

the current study produced similar results

for the per protocol and the intent-to-treat

analyses suggests that these findings apply

across a spectrum of disease-specific,

joint-specific, and functional variables.

Overall, the additional patient monitoring,

adjustment of program, and motivational

support available through clinic-based

rehabilitation was not advantageous for

the population studied. These findings

were not confounded by any interactions

with surgeon, type of prosthesis or time

since surgery. The current results extend

those of previous studies of meniscectomy

5,7,10 and anterior cruciate ligament

reconstruction1,3,4,11 populations, and

corroborate a previous retrospective study

using a total knee arthroplasty sample.

Patients who were lost to their assigned

group were not included in the per

protocol analysis, but did raise concerns

that the group comparisons may have been

affected (Table 2). Comparisons within

and between groups indicated no

differences between patients lost and those

remaining. In addition, when patients who

had been lost to their assigned group, but

continued being tested at their normal

follow-ups and had complete data sets,

were returned to their assigned group for

the intent to treat analysis, results were the

same as for the per protocol analysis. For

these reasons, patient losses were not

considered to have significantly affected

the overall results of the current study.

Fig 2 A–C. Total scores for the

(A) Range of Motion Knee Flexion

(B) ILOA level of assistance

(C) KSKS knee society knee score

Range of Motion (Knee Flexion)

ILOA Level of Assistance

Knee Society Knee Score

Visual analog Score

Between discharge and 8 weeks, four

more patients were removed from the

home-based group than from the clinic-

based group for reasons related to failure

of the surgically treated knee to progress

(Table 2). These patients then had more

intensive outpatient physical therapy than

that provided by the clinic-based program.

Four patients in the clinic-based group

were advised by their surgeon to continue

clinic-based rehabilitation after Week 12.

Although both groups of patients tended

to have poorer baseline scores on the

majority of objective measures, their

scores were not consistently low across

the same measures and tended to be within

1 standard deviation of the group mean.

The combination of poorer scores plus

subjective factors such as the patients’

attitudes, motivation, pain tolerance, and

home environment were considered in

making the decision to remove these

patients from their assigned group or to

continue clinic-based rehabilitation.

Additional studies are needed to document

psychosocial and demographic variables

to help identify patients who might derive

greatest benefit from clinic-based

rehabilitation programs.

The telephone calls to patients in the home

based group were completed by an

experienced physical therapist who had

been introduced to all of the patients

during their inpatient period. The

telephone calls focused on the home

exercises and did not introduce any new

exercises or provide unique treatment

guidance beyond that available from

similarly experienced therapists. Two

patients with potential major problem

,such as unresolved swelling, infection,

and deep vein thrombosis, were identified

via the telephone calls and were referred

to the patient’s physician or surgeon for

treatment. Whether delayed treatment of

these conditions would have resulted in

major complications is unclear. All of

these patients completed the 8 week study

in their assigned group. As a result, the

telephone calls received by the home-

based group provided a form of minimally

supervised rehabilitation, which also

enabled some monitoring of the patient’s

medical status.

The major component of the current study

was the common home exercise program,

taught to all patients during their

hospitalization after surgery and at their 8

week follow up. Outpatient clinicians used

this program as the basis for their

treatments, and determined the number

and frequency of treatments, which

averaged 15+-20 sessions; whereas the

home-based group was monitored by

periodic telephone calls from a physical

therapist, which averaged 3+-1 calls

during the first 8 weeks after hospital

discharge. At hospital discharge, patients

in the home-based group indicated when

they wished to be telephoned, and again

did so during each telephone call. Pilot

study had indicated that virtually all

patients having primary total knee

arthroplasty had previous experience with

home exercise programs and that the

majority preferred to determine the

contact schedule themselves.

In addition to the phone calls, the follow-

ups at 4 and 8 weeks after surgery

included review of the home exercises.

That no patients in the home-based group

requested additional telephone calls after

4weeks and only three patients in the

clinic-based group phoned to ask

questions about the home exercises,

suggests all patients felt competent in

doing their home exercises. Although

passive ROM was examined by the

surgeons at each follow up, active ROM

was used to compare groups, to minimize

the extent to which pain tolerance and

motivation may have affected ROM.

Compliance with the home exercises was

considered high, with only two patients in

the home-based group and one patient in

the clinic-based group considered to have

been noncompliant at discharge and 4

after surgery (where compliance was

defined as completion of the home

exercises at least 90% of the time, as per

exercise log booklets). Exercise

compliance was discussed with the

patients before surgery and at each follow

up thereafter. The sample studied was

limited to elderly patients who agreed to

be assigned randomly to one of the two

rehabilitation programs. Approximately

10% of eligible patients refused to

participate for this reason. The extent to

which a home exercise program would be

effective for patients with a more

complicated history, more limited ROM,

or less motivation, needs to be

determined.

CONCLUSION

The current study compared two

rehabilitation programs, where the basic

component of each program was a series

of common exercises to be completed

independently by all patients at home.

Because these exercises were developed

by and taught to the patients by physical

therapists, the current study might be

viewed as having compared two means of

providing physical therapy services; that

is, physical therapy monitored by

telephone calls (home-based) and physical

therapy monitored in person by outpatient

physical therapists (clinic-based). The

current study did not compare physical

therapy versus no physical therapy. There

is no significant difference in the data of

study but there is statistical difference in

both group. So this pilot studies shows

that the group of clinic based

rehabilitation after total knee arthroplasty

having more better prognosis than home

based exercise group ie. range of motion

and functional ability and pain.

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Kramer et al and Related Research

ACKNOWLEDGMENT:

The authors thank Dharam Pandey (MPT-neuro), Deepa Dabas (MSc-psycho) for assistance

throughout the study.

CORRESPONDENCE:

*Bijender Sindhu PhD,PT Research Student**Dr.Manoj Sharma, MBBS,

MS(ortho)***Dr.Raj k Biraynia, MBBS, D.ortho *School of Physical Therapy, Faculty of

Medical Science, Singhania University**Department of orthopedic surgery, Jaipur Golden

Hospital *** Department of orthopedic surgery, Sarvodaya Multispeciality Hospital. This

study was not funded through a grant from the any organization.

A Comparative Study on Supervised Clinical Exercise versus Home Based

Exercise in Primary Unilateral Total Knee Arthroplasty

Bijender Sindhu PhD, PT*, Dr.Manoj Sharma, MBBS, MS(Ortho)**, Dr.Raj K Biraynia,

MBBS, D.Ortho***

Abstract: Objective. This study was designed to investigate the effects of

supervised clinical exercise and home Based Exercise in patient with unilateral

total knee arthroplasty in sub acute phase (after 5-6 weeks of discharge). To

assess the effect on function ability of patient after primary unilateral total knee

arthroplasty. To assess the effect on knee integrity (it include pain, ROM, knee

stability)of patient after primary unilateral total knee arthroplasty. Methods. 130

subjects were recruited from OPD physiotherapy among the patient discharge

from hospital and randomly divided into supervised clinic exercise and home

based exercise. Socio demographic and clinical data, pain, range of movement

(ROM) and function of TKA patients were collected on day of discharge (ie day 5

to 8 post operation). A self designed data capture sheet, the goniometer, VAS

(Visual Analogue Scale) and ILOA (Iowa Level of Assistance) KSKS (kne society

knee score)were used to measure data. Criteria for recruitment is patient having

primary unilateral total knee replacement, having a functional hip on operated

side, both male and female and age between 50 to 80 years. Able to follow simple

verbal commands. Patient excluded from study who are suffering from

Rheumatoid Arthritis, revision TKA, bilateral knee arthroplasty. Results. The

results indicate that there is significant difference between experimental group

(supervised clinical exercise) and Control group (home based exercise). For knee

integrity measured using the Knee Society Knee Score (p=0.017)and function

measured using the ILOA Scale (p= 0.018) and goniometry (p=>0.05). The

average age was 64 years in male and 66 years in females . There were 41%

males and 59% females. There is statistical difference between pain, range of

motion, Knee integrity, Knee functional outcomes of groups that receive post-

discharge outpatient physiotherapy as compared to those who do not attend

physiotherapy. Conclusions. After primary total knee arthroplasty, patients who

completed a home based exercise program (control group) performed similarly to

patients who completed regular outpatient clinic sessions in addition to the home

exercises (supervised clinic exercise ie. experimental group). Additional studies

need to determine which patients are likely to benefit most from clinic-based

rehabilitation programs. The overall aim of this study was to establish the early

post operative status of Total knee arthroplasty patient.

Key words: Supervised clinical exercise, Home based exercise, KSKS (knee

society knee score), ILOA (ILOA level of assistance)

INTRODUCTION

Osteoarthritis is a leading cause of pain

and disability affecting joints (Marchet al

1999). Progressive loss of the articular

cartilage can result in joints that are

painful and inflamed. The joint becomes

stiffer and there is less stability in the joint

(Parmet et al 2003). These factors affect

the function of the joint which ultimately

impacts on patients’ functional ability and

their quality of life (March et al 1999).

Total knee arthroplasty has been found to

be effective in the management of pain

(Palmer & Cross, 2004), functional status

and quality of life in people suffering from

OA, rheumatoid arthritis (RA) and related

conditions (Zavadak et al., 1995).

Physiotherapists aim to prevent

contractures (Lenssen et al., 2006)

decrease pain and swelling and improve

knee and functional mobility in

preparation for discharge (Oldmeadow et

al.,2002. Post operative physiotherapy

aims to minimize the complications

following total knee replacements and to

rehabilitate the patient to full functional

recovery. Techniques such as cryotherapy,

strengthening and stretching exercises are

used (Zavadak et al 1995). Physiotherapy

in hospital also includes functional

techniques such as bed mobility, transfers,

ambulation and stair climbing. An

assumption can be made that if there is a

relationship between knee integrity and

function, physiotherapists may decide to

only work on improving function, or only

work on improving knee integrity

(improving knee range of motion,

reducing swelling, reducing pain and

improving muscle strength). Time could

then be better utilized on one aspect of

rehabilitation.

Early discharge can sometimes result in

transfer to an inpatient facility. A study by

Bozic et al. (2006), states that clinical,

demographic and socioeconomic factors

all affect the decision to discharge a

patient to an inpatient rehabilitation

centre.

Objective of the Study:

To assess the effect on knee integrity (it

include pain, ROM and knee stability) and

knee function ability. To establish

pain,ROM of the operated knee and

functional level of TKA patients. To

establish socio-demographic factors and

clinical data of TKA patients on first

follow up. To establish the relationship

amongst supervised clinical exercise as

well as home based exercise and

postoperative functional status of TKA

patients. To study this procedure can be

clinically implemented.

MATERIAL AND METHODS

Subjects: 130 subjects were recruited

from OPD physiotherapy among the

patient discharge from hospital and

randomly divided into supervised clinic

exercise and home based exercise.

Inclusion criteria:

Patient having primary unilateral total

knee replacement having a functional hip

on operated side .Both male and female

who had a primary unilateral TKA able to

give independent informed consent Patient

between the age of 50 to 80 years of age,

presented to the first follow-up session.

(This was around six to eight weeks post

operation who gave informed

constant).Able to follow simple verbal

commands

Exclusion criteria:

Any additional trauma to the lower limb,

inability to participate in the assessment

from a physical and cognitive point of

view such as dementia, confusion etc.

Inability of the patient to walk prior to the

TKA(with or without aid). Patient

suffering from Rheumatoid Arthritis.

Unwillingness to participate in the

assessments Revision TKA, Bilateral knee

arthroplasty. Inability of the patients to

walk prior to the total knee replacement

(with or without the aid of an assistive

device).

Design of study:

The study employed a randomized single

blind controlled experimental study design

consisting of two group experimental

group and control group, Subjects were

randomly assigned either to experimental

group or to control group everyday in

physiotherapy OPD before discharge ,

each time when a patient met the criteria

for inclusion a random number were

picked up between 1 to 10 using sealed

envelope method if it were an odd number

than the subject were assigned to

experimental group.

Intervention

Supervised clinical exercise: These are

exercise which are perfomed by patient

under the observation of a qualified

physiotherapist. Postoperative

rehabilitation usually consists of passive

and active knee mobilisation, quadriceps

strengthening and functional activities

(Lenssen et al., 2006). Hip and knee

flexion; hip and knee extension in neutral;

hip abduction; hip adduction to neutral;

ankle dorsi- and plantar flexion, static

quadriceps contraction and inner range

quadriceps contraction over a rolled up

towel. The physiotherapist performs anti-

inflammatory modalities on the patient

which include ultrasound, interferential

therapy, pulsed short wave diathermy,

transcutaneous electrical nerve stimulation

(TENS), laser, acutouch and heat or

cryotherapy. Myofascial release,

continuous passive mobilisation exercises,

stretching, strengthening exercises, gait

re-training, massage, patient education

and an exercise programme are also

prescribed.

Home based exercise: Home based

exercise group performed the exercise

which are explained and demonstrated by

physiotherapist in OPD at the time of

discharge to the patient for home, which

included isometric exercises for

quadriceps, knee range of motion,

strengthening exercise, effective use of

assistive devices and appliance, walking

pattern, safety & precaution, do’s and

dont’s.

Outcome Measures:

ILOA : The patients’ functional ability

was assessed using the Iowa Level of

Assistance (ILOA) Scale, which was first

described by Shields et al (1995). It was

shown to be reliable and valid.The best

overall result the patient is able to achieve

with this scale is zero. This indicates that

the patient was able to perform all five

tasks independently without the use of any

assistive device. The worst overall score

that could be achieved is fifty which

indicates that the patient was unable to

perform the tasks due to medical and

safety reasons and the assistive device

used for standing or mobilizing was a

walking frame.

KSKS: This rating system was developed

in 1989 by the American Knee Society to

provide an evaluation form for knee

integrity (Insall et al, 1989). The knee

assessment has three parameters which

measure pain, stability and range of

motion. The knee is given a score out of a

hundred. A well-aligned knee with no

pain, negligible instability and range of

motion of 125 degrees scores a hundred

points

Goniometry: It is a measuring tool used to

assess the range of motion of a joint. It

can be used as an initial assessment and it

evaluate the patient’s progress (Rothstein

et al 1983). Rothstein et al (1983) assessed

goniometric reliability and which

goniometer size was the most reliable in a

clinical setting.

DATA ANALYSIS AND RESULTS

All continuous variables were presented

by mean. The statistical significance of P

value was set at 0.05.

One-way repeated measures analysis of

variance (ANOVA) was made to compare

ILOA score, KSKS score, Goniometry

range between-groups.

130 subjects were recruited from OPD

physiotherapy among the patient

discharge from hospital and randomly

divided into supervised clinic exercise and

home based exercise. 19 patients not

fulfilled the inclusion criteria and four

patients due to prolonged hospital stay for

medical reasons, two patients for medical

conditions, two patient consented to the

socio demographic and clinical

questionnaire, but not to the goniometry

and Iowa Level of Assistance (ILOA)

testing, and therefore had to be excluded.

One patient refused to be tested · two

patient had been discharged before the

researcher had been able to collect data

(morning of day three).

The following results are presented:

Range of movement (ROM) of the

operated knee and functional level of

TKA patients, Knee integrity and Socio-

demographic factors and clinical data of

TKA patients, The relationship between

identified factors and postoperative

functional status of TKA patients in

relevance of level of assistance (ILOA) in

control group mean (home based exercise)

is11.94 and experimental group

(supervised clinical exercise) 10.01 (p=

0.018), KSKS in control group mean

(home based exercise) is74.72 and

experimental group (supervised clinical

exercise) 76.78 (p=0.017), goniometry in

control group mean (home based exercise)

is 88.06 and experimental group

(supervised clinical exercise) 95.52

(p=>0.05) found.

Graph 1: Showing the mean and

significance level of range of motion of

two group of supervised and home based

exercise.

Graph 2: Showing the mean and

significance level of IOLA(level of

assistance) of two group of supervised and

home based exercise.

Graph 3: Showing the mean and

significance level of KSKS (knee society

knee score) of two group of supervised

and home based exercise.

DISCUSSION

KSKS: 1. Pain: Fifty percent of the

patients had virtually no pain at six weeks

post operation. The other fifty percent had

pain that ranged from occasional to severe

pain Two patients (4%) had severe pain.

This indicates that the patients’ pain is not

being managed well at home after

discharge. They are perhaps not given

physiotherapy modalities which are

healing in reducing pain. Cryotherapy and

simultaneous exercise is more effective in

reducing pain than icing alone. Icing and

compression also helps to reduce pain in

patients post surgery. Transcutaneous

Electrical Nerve Stimulation (TENS)

causes a reduction of pain in 93% of

patients who undergo surgery and the

TENS group of patients consumed less

pain medication. Interferential therapy has

been shown to reduce pain in patients at

intervals of 24-hours, 48-hours, 72- hours

and at one to eight weeks post operation

(Hubbard and Denegar 2004; Jensen et al

1985; Jarit et al 2003).

2: Range of motion: People normally

require knee flexion of 45º to 105º during

various activities of daily living. To

demonstrate a normal gait pattern, 65º of

flexion is required. To ascend and descend

stairs, 90º of flexion is needed and to go

from sitting to standing, 105º of flexion is

required (Miner et al 2003). From the

results of the range of movement shows

that experimental group (mean=95.52) and

control group (mean=88.06), one can

assume that 51% of the patients (twenty

six patients) would not be able to go from

sitting to standing as they only had knee

flexion of 80º. However, from our sample

of 50-patients, 24-patients (49%) who had

90º-100 of knee flexion were able to go

from sitting to standing independently

without any assistance or assistive

devices. Patients with less than 95º of

knee flexion had worse Goniometry scores

(p<.0001). Only patients with a very stiff

knee will have function that is really

affected by ROM. Their study identified

95º of knee flexion as a clinically

meaningful cut-off point above which

ROM does not limit a patient’s normal

activities after TKR. However the long-

term effects of this limitation of ROM

could be detrimental to the normal joints,

because of the patients over compensation

when performing activities of daily living.

3. Knee Stability and alignment: The

majority of the patients had normal

stability and alignment. This indicates that

the total score of the Knee Society Knee

Score in this sample is not really affected

by the components of stability and

alignment, but mainly by pain and ROM.

Malalignment of the prosthesis could

result in stiffness which although

uncommon is a disabling problem (Jerosh

and Aldawoudy 2007). Treatment of

malalignment could include manipulation

or revision arthroplasty (Bong and Di

Cesare 2004),which has been shown to be

successful in terms of post-operative

function(Miner et al 2003).

4. Knee Flexion contracture and extension

lag: A percentage of the patients in this

study had some degree of a flexion

contracture and some degree of an

extension lag at six weeks post operation.

This could indicate that attaining full knee

extension and flexion is not that important

when it comes to functional activities such

as going from sitting to standing, walking

and stair climbing, as these same patients

performed well when assessed using the

ILOA Scale. Functional range of motion is

between 45º and 105º (Miner et al 2003).

As long as the extension lag and the

flexion contracture do not interfere with

this range of motion, the patient should

manage functionally. Patients also

compensate when performing activities by

using the other leg or their arms to assist

with transfers. The quality of the

movement being performed is not

important to the patient, what is of

importance is completing the movement

by any means possible. The long term

effect of poor ROM and poor quality of

movement is that the normal joints take

excess strain and over a prolonged period,

there is an increased risk of developing

pain and discomfort in the normal joints

due to osteoarthritis.

ILOA Score:

Most of the patients were able to go from

lying to sitting, sitting to standing and

walking 4.57 meters independently, with

minimal assistance. The patients scored

very well in these three categories. This

indicates that the ILOA Scale is not a

sensitive enough functional measuring

tool when used at six weeks post

operation. It measures basic functional

ability, not higher function. It was

developed to determine whether patients

who had had total hip and knee

replacements were ready to be discharged

from hospital (Shield et al 1995). It is the

role of physiotherapists in the hospital to

ensure that patients are able to perform

basic transfers so that they will be

independent at home, after they are

discharged from hospital. Five patient did

not use an assistive device to perform the

five functional tasks. She did however

require nearby supervision for the

walking, stairs and the speed test. Two

patients used a walking frame at six weeks

after the operation. Only one patient was

unable to climb the stairs even with

maximal assistance

CONCLUSIONS

The goal of a TKA is to provide the

patient with a stable and painless knee

with sufficient ROM to perform ADL’s

(Gandhi et al., 2006). As many studies

only focused on the long-term status of

TKA patients (Aarons et al., 1996), this

study examined the short-term status. The

value of this is to furnish patients and the

therapist with knowledge of their acute

postoperative status and appropriate

rehabilitation programme that will

influence their prognosis. integrity which

was measured using the Knee Society

Knee Score and function as measured

using the ILOA Scale, six to eight weeks

post surgery on total knee replacement.

Research Recommendations:

A functional tool should be developed that

assesses the attainment of higher

functional milestones, as well as the

quality of the movement. If a more

sensitive functional assessment tool was

used, one that looked at higher functional

levels, a more accurate functional

evaluation of the knee replacement could

be determined.

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ACKNOWLEDGMENT:

The authors thank Dharam Pandey (MPT-neuro), Deepa Dabas (MSc-psycho) for assistance

throughout the study.

CORRESPONDENCE:

*Bijender Sindhu PhD,PT Research Student**Dr.Manoj Sharma, MBBS,

MS(ortho)***Dr.Raj k Biraynia, MBBS, D.ortho *School of Physical Therapy, Faculty of

Medical Science, Singhania University**Department of orthopedic surgery, Jaipur Golden

Hospital *** Department of orthopedic surgery, Sarvodaya Multispeciality Hospital. This

study was not funded through a grant from the any organization.

Comparison of the Effect of Isometric Exercise of Upper Limb on Vitals

between Young Males and Females

Pranjal Parmar. BPT*

Abstract: Background and objective: studies on gender difference in

cardiovascular responses to isometric exercises have been numerous and

confliction the objective of this study was to determine if cardiovascular response

to upper extremities isometric exercises differ between apparently healthy male

and female subjects. Method: 60 young adults age between 18 to 22 years were

included in study. These consisted of 30 males and 30 females. The baseline

cardiovascular parameters (HR, SBP, DBP & MAP) were recorded. After two

sets of three isometric upper limbs for 3 minutes these parameters recorded at the

end of exercise and after recovery. Results:An increase in HR ,SBP , DBP&MAP

was seen in both groups after exercise .the result showed group B had more

increase in HR,SBP,DBP and MAP as compared to group A and significant rise

in MAP &SBP in group B. Conclusion: Isometric exercise of upper limb can lead

to increase in SBP, DBP, MAP &HR among apparently healthy males & females.

It is more proannounced in males as compared to females. SBP &MAP increased

in both but more in males as compared to females.

Keywords: Isometric Exercises, Cardiovascular Measures

INTRODUCTION

Exercise, a common physiological stress,

can elicit cardiovascular abnormalities not

present at rest and can be used to

determine the adequacy of cardiac

function.1 The isometric contractions are

seen in various exercises like pushing or

lifting heavy load where net displacement

of load is not, but the rising tension can be

felt in contracting muscles.3 It imposes

greater pressure than volume load on left

ventricle in relation to the body ability to

supply oxygen.4 The metabolic demands

of the exercising muscles increases,

depending upon intensity of exercises and

are met with various changes in

circulatory and respiratory system.13

The effect of isometric exercises on vitals

in between males and females may vary

with substantial anatomical, physiological

and morphological differences that exist

between men and women which may

affect their exercise capacity and influence

magnitude of response to exercise.5

The average isometric strength estimate is

generally 30% greater in men than in

women in different muscle group. Gender

difference in cardiovascular response to

static exercise is believed to be due to

differences in sympathetic –

parasympathetic or adrenal interactions at

cardiac level.

The larger the muscle group that is

involved in isometric tension the greater

the cardiovascular response.6

Response To Exercise:7

When you exercise or take part in a

strenuous sport you will notice several

changes taking place in your body:

a. Your heart beats stronger and faster

b. Your breathing quickens and deepens

c. Your body temperature increases

d. You start to sweat

e. Your muscles begin to ache

1. Heart beats stronger and faster:

During exercise it is mainly adrenaline

that produces changes in the heartbeat.

Adrenaline is a hormone which causes the

heart rate to quicker.

2. Breathing quickens and deepens:

You breathe quicker so as to get more

oxygen into the lungs. An efficient heart

can then transport this to the working

muscles. Training can be of great benefit

to the Respiratory System. The capacity of

the lungs is increased, which allows more

oxygen to be taken in per breath.

3. Temperature rises:

When we exercise, our muscles are

working and they generate heat, so our

body temperature rises. Body temperature

is regulated by heat radiating from the

skin and water evaporating by sweating.

When we shiver, our muscles are working

to produce heat in order to raise our body

temperature.

4. Start to sweat:

As we have just seen, some of our energy

is turned into heat. The body will tolerate

a small rise in temperature, but very soon

we begin to sweat. If the conditions are

hot, we sweat more and produce less

urine.

We also lose salt as well as body heat and

water. We have to replace the salt so that

the body stays the same, otherwise we will

get cramp.

5. Muscles begin to ache:

As we now know, in order to work,

muscles need energy. Energy comes from

food, which is mainly converted to

glucose. To work more efficiently muscles

also need plenty of oxygen. Glucose and

oxygen are brought to the muscles in the

blood. Wastes such as carbon dioxide are

carried away in the blood. This process of

getting energy is called respiration.

Glucose + Oxygen = Energy + CO2 +

Water

When muscles do extra work more

Glucose and Oxygen are needed, so more

blood must flow to the muscles.

Eventually it becomes impossible to get

enough oxygen to the muscles, so they use

a different method of getting energy.

Glucose is still used, but now there is a

waste product called lactic acid, which

makes muscle ache, & muscles.

Acute Cardiovascular Response to

Exercise:

As exercise intensity increases, heart rate,

stroke volume, and cardiac output increase

to get more blood to the tissues. More

blood forced out of the heart during

exercise allows for more oxygen and

nutrients to get to the muscles and for

waste to be removed more quickly. Blood

flow distribution changes from rest to

exercise as blood is redirected to the

muscles and systems that need it.

CLINCAL SIGNIFICANCE

Vitals response to exercise has been used

as major criteria in exercise prescription

for both patient and healthy population.

Thus for prescribing isometric exercise,

repetitions and frequency it would be

helpful and prevent the adverse effect on

vitals. The study would also be helpful in

prescribing exercises for those with

cardiovascular compromise. It would help

to determine the safety limits of the

exercise.

OBJECTIVES:

1. To analyze if there is any change in

vitals as a result of isometric exercises of

upper limb

2. To compare the response of upper limb

isometric exercises in young male and

female.

METHODOLOGY

Research Design: An quasi-Experimental

(comparative) study. Sample Size: 60

normal individuals. Sample Population:

60 young adults between 18 to 22 yrs.

Group A: 30 normal individuals (females)

Group B: 30 normal individuals(males)

Type of Sampling: Convenient sampling

with random assignment. Duration of

Study: one month. Study Set Up:

Physiotherapy OPD of a tertiary care

hospital.

Inclusion Criteria:

• No previous history of known

cardiovascular condition.

• Normal values of vitals at rest.

• No neurological defecit in upper

limb.

• Sex – both male and female.

• Willingnessof patient.

Exclusion Criteria:

• Fracture of upper limb bones.

• Cervical vertebrae or scapula

fracture.

• Neurogenic deficit.

• Congenital anomalies.

• Previous exercise training

• Any disability limiting to upper

limb exercise.

• Psychiatric patients.

• Non-willing patients.

Outcome Measures:

• Heart rate of patient at rest,

immediately post exercise and 3

minutes after exercise

• Blood pressure i.e. systolic and

diastolic blood pressure at rest,

immediately postexercise and 3

minutes after exercise.

• Mean arterial pressure was

calculated from the above data.

PROCEDURE

60 individuals were selected according to

the inclusion and exclusion criteria. The

need of the study and treatment

intervention was explained to the

individuals and their written consent was

taken from them. 60 individuals were

assigned into two groups, group A and

group B, 30 patients in each group.

Procedure details of group A and group

B:

Pre-measures: Heart rate and blood

pressure was measured using an electronic

sphygmomanometer in standing position.

Reading was noted.

Individual position: standing position.

Therapist position: on the individual side

in stride standing position.

Procedure: Participants in upstanding

position performed 3 upper extremities

isometric exercises i.e. 2 sets of each

exercise for each 30 second each thus total

duration of exercise for 3 minutes.

1. The exercise are pushing against the

wall with outstretched arms and were

instructed to exert maximal tension on

wall.8

2. Hands clasped together and brought to

manubrosternal level to chest while

shoulders are 60 70 degree abducted and

participants were instructed to maximally

generate tension by pressing opposite

hands against each other.8

3. Both palms on wall with participants

standing ahead arms extended and were

asked to push the wall without coming

behind and keeping elbow straight.8

Participants were instructed to avoid

valsalva maneuver by not holding breath

Thereafter participants were asked to rest

for 10 minutes before leaving. Post-

measures: Heart rate and blood pressure

was measured immediately after exercise

and 3 minutes after exercise. All patients

were comfortable after the treatment

session.

DATA ANALYSIS AND RESULT

The data collected was entered in excel

sheet and statistical analysis was done

using SPSS software. Heart rate and blood

pressure are objective data hence can be

considered for statistical analysis. This

isan interval data hence pre and post

parmeters was statistically analysed using

paired t-test, and difference in paramaters

between two groups was statistically

analysed using unpaired t- test.

Table No.1

Mean age (yrs)of study group

Group Number Age (yrs)

A 30 20.23

B 30 20.16

The above graph shows mean age of group A and group B.

Table 2

Rest Post exercise Recovery

Group A (females) 117.8 123.28 120.45

Group B (males) 123.6 134.58 128.95

Table 3

Value P value Significance

Group

A

-1.6912 3.47e-

10

Difference is

significant.

Group

B

-1.3678 3.17e-

12

Difference is

significant.

Table 4

Rest Post exercise Recovery

Value -5.46072 -10.1411 -10.0176

P value 1.64e-05 3.14e-09 2.19e-11

Table 2 shows mean of systolic blood pressure at rest in group A is 117.8 and group B IS

123.6 ,post exercise in group A is 123.28 and group B is 134.58 and recovery in group A is

120.45and group B is 128.95.

Table 3 shows p value by paired t test in group A and group B and difference is statically

significant.

Table 4 shows p value by unpaired t test in group A and group B at rest, post exercise and

recovery and difference is statically significant.

The graph shows mean of males and

females of systolic blood pressure at rest ,

post exercise and recovery.

.

The above graph shows distribution of

systolic blood pressure in males and

females at rest, post exercise and

recovery.

Diastolic Blood Pressure

Table 5

Rest Post exercise Recovery

Group A (Females) 75.6 84.25 80.20

Group B

(Males)

80 96.50 83.60

Table 6

Value P value Significance

Group

A

-1.345 3.95e-

15

Difference is

significant.

Group

B

-1.236 3.21e-

08

Difference is

significant.

Table 7

Rest Post

exercise

Recovery

Value -5.78263 -14.6703 -4.4098

P

value

1.1e-06 3.14e-09 1.58e-07

Table 5 shows mean of diastolic blood

pressure at rest in group A is 75.6 and

group B is 80, at post exercise in group A

is 84.25 and in group B is 96.50 and at

recovery in group A is 80.20 and group B

is 83.60.

Table 6 shows p value by paired t test in

group A and group B and difference is

statistically significant.

Table 7 shows p value by unpaired t test at

rest, post exercise and recovery in group

A and group B and difference is

statistically significant

The above graph shows mean of males

and females of diastolic blood pressure at

rest, post exercise and recovery.

The above graph shows distribution of

diastollic blood pressure between males

and females at rest, post exercise and

recovery.

Mean Arterial Pressure

Table 8

Rest Post exercise Recovery

Group A (Females) 89.66 97.26 93.61

Group B

(Males)

94.53 109.19 98.71

Table 9

Value P value Significance

Group A -1.327 5.78e-10 Difference is

significant

Group B -1.784 4.08e-12 Difference is

significant.

Table 10

Table 8

shows

mean of

mean

arterial pressure at rest in group A is 89.66 and in group B is 94.53,at post exercise in group

A is 97.26and in group B is 109.19 and at recovery in group A is 93.61 and group B is 98.71.

Table 9 shows p value by paired t test in group A and group B difference is statistically

significant.

Rest Post exercise Recovery

Value -7.001 -9.57881 -7.17096

P value 1.16e-09 1.91e-11 2.06e-09

Table 10 shows p value by unpaired t test at rest, post exercise and recovery in group A and

group and difference is statistically significant.

The above graph shows mean of mean arterial pressure at rest, post exercise and recovery

between group A and group B.

The above graph shows distribution of mean arterial pressure between males and females at

rest, post exercise and recovery.

Heart Rate

Table 11

Rest Post exercise Recovery

Group A (Females) 72.6 80.40 76.40

Group B

(Males)

74.4 82.95 78.65

Table 12

Value P value Significance

Group

A

0.00615 0.015E-

04

Difference

is

significant

Group

B

0.00322 0.14E-

05

Difference

is

significant

Table 13

Rest Post exercise Recovery

Value 0.00123 0.00808 0.00055

P value 0.012e-06 0.080e-05 0.055e-06

Table 11 shows mean of heart rate at rest in group A is 72.6 and in group B is 74.4, at post

exercise in group A is 80.40 and in group B is 82.95 and at recovery in group A is 76.40 and

in group B is 78.65.

Table 12 shows p value by paired t test in group A and group B and difference is statistically

significant.

Table 13 shows p value by unpaired t test at rest, post exercise and recovery in group A and

group B and difference is statistically significant.

Heart Rate

The above graph shows mean of heart rate

in males and females at rest, post exercise

and recovery.

The above graph shows distribution of

heart rate between males and females at

rest, post exercise and recovery.

DISCUSSION

The study investigated the gender

difference in cardiovascular response to

upper extremities isometric exercise

among apparently young healthy subjects.

60 participants were included in the study.

They were divided into two groups, group

A and group B. Group A included female

gender and group B included male gender.

BP, HR and MAP were taken as outcome

measure. These measures were taken pior,

immediately after test and 3 minutes after

study. The data collected was statistically

analysed. The result showed group B had

more increase in HR,SBP ,DBP AND

MAP as compared to group A and there

was significant rise in MAP and SBP in

group B. The average isometric strength

estimate is generally about thirty percent

greater in men than in women in different

muscle groups . Upon initiating isometric

tension, increases in heart rate, systolic

blood pressure, and diastolic blood

pressure occur. Mitchell and associates

and Seals et al suggested that

cardiovascular responses to isometric

exercise are greater when larger muscle

groups are involved. While heart rate

responses to sustained submaximal static

contractions tend not to be significantly

different before, during, or after exercise,

blood pressure responses to this exercise

are significantly elevated before, during,

and after exercise Gender differences in

cardiovascular responses to static exercise

are believed to be due to differences in

sympathetic-parasympathetic or adrenal

interactions at the cardiac level. The

finding of this study revealed that there

was no significant gender difference in

vitals of participants at baseline which

was statistically significant. The data

collected reveals that post exercise heart

rate, systolic blood pressure ,diastolic

blood pressure and mean arterial pressure

were higher than pre exercise values and

was statistically significant in both groups

ie group A and group B.

When values of recovery i.e. 3 minutes

after exercise when compared it was

almost same in both groups but when

compared to values at rest it was much

greater than recovery values.

The result between the two was calculated

using unpaired t test. Therefore upper

extremities isometric exercise had

significant effect on heart rate, systolic

blood pressure, diastolic blood pressure

and mean arterial blood blood pressure.

When values of group A and group B at

post exercise were compared it was seen

that male participants (group B) had

higher post exercise MAP and SBP had

level than females (group A) (p<0.05)

These result indicate that more blood is

pumped by left ventricle into aorta in

response to upper extremities isometric

exercise among males than females; while

myocardial oxygen uptake & measure of

oxygen consumption of heart muscles of

female participants in response to upper

extremities isometric exercises is higher

than that of males.

The tissues working hard during exercise

and also after the completion of exercise

require more oxygen than normal to pay

off this oxygen debt incurred during the

exercise. These results in increase in blood

supply to active muscles to supply this

extra amount of blood. At rest, muscles

receive approximately 20% of total blood

flow but during exercise blood flow to

muscles increase to 80 -85% .

Generally ,longer the duration of exercise

greater the role the cardiovascular system

plays in metabolism and performance

during exercise bout.eg an 1T00 meter

walk (little or no cardiovascular

involvement) versus a marathon(maximal

involvement).9

It has reported that release of adrenaline

and lactic acid into the blood result

increase in a heart rate.

The isometric exercises does not increase

the oxygen demand to the extend raised by

isotonic exercise thus DBP does not rise

much in isometric exercise The isometric

exercise results in pressure overload on

heart. The myocardial oxygen

consumption (mvo2) also increase due to

exercise . Higher ventricular contraction is

evoked among males leading to increase

in systolic blood pressure.

This indicates that the males have higher

myocardial oxygen demand during

isometric exercise predisposing them to

greater risk of ischemia if developing

cardiovascular risk, factor compromising

the coronary blood flow.10

It has been seen males have higher plasma

levels of all three catecholoamines out of

which plasma levels of epinephrine are

higher as compared to females .this results

in increase in MAP immediately at of

exercise.

The findings supports the results of

previous investigators than upon initiation

isometric tension increase heart rate,

systolic blood pressure and diastolic blood

pressure occur.12 The result of

investigations have been reported at best

inconsistent and do not follow definite

pattern.12

However during the recovery period the

vitals were decreased as compared to

immediately post exercise in both genders.

However the vitals were not the same as

they were at rest prior to commmencent of

exercise.

The result of study is supported by the

articles “Gender difference in

cardiovascular response to upper

extremities isometric exercise in

normotensive subjects.” By Cembada and

“Gender differences in cardiovascular

response to isometric in seated and supine

positions” by Don Melrose. The proposed

mechanisms attempting to explain gender

differences in cardiovascular responses to

isometric exercise have been numerous

and conflicting. Sanchez et al. found

differences in adrenergic patterns between

genders in response to isometric exercise

and support the study. Ettinger and

associates demonstrated attenuated

increases in blood pressure and muscle

sympathetic nerve activity compared with

men. In data also derived from static

exercise as well as temperature and

psychological stressors, Jones et al found

that gender did not influence sympathetic

neural reactivity to stressors such as

isometric handgrip exercise

Changes in posture often experienced

during exercise or sporting activities have

also been shown to elicit various

circulatory adaptations. Sagiv et al. and

Borst et al. both noted changes in

cardiovascular regulation as a result of

postural changes. Relatively fewer studies

have investigated the cardiovascular

adaptations to exercise performed when

posture does not change during the time

course of the positions.

A further study can be made:

• Comparison of vitals for larger

muscles groups to smaller muscles

group in upper limb isometric

exercises.

• Comparison of vitals in isometric

exercise for upper limb versus

lower limb.

The result can be used as

• It can be used for prescription of

exercise in those with

cardiovascular crompromise and

elderly patients.

• It can be used to determine the

safety limits during exercise

regimen.

CONCLUSION

The above study gives following

conclusion:

1. Isometric exercises of upper limb can

lead to increase in systolic blood pressure

,diastolic blood pressure ,mean arterial

pressure and heart rate among apparently

healthly males and females.

2. This was more preannounced in males

than females .Systolic blood pressure

(SBP) and Mean arterial pressure (MAP)

increased in both but more males as

compared to females

LIMITATION

1. The participants in study were young

and elderly or middle aged participants

were not included in these study.

2. All the subjects who were included in

the study were students.

3. The participants nutritional status or

BMI were not considered while selection.

4. The occupation or lifestyle of

participants was not considered.

5. The muscle mass or bulk of upper limb

was not considered.

REFERENCES:

1. Journal of Exercise Physiology

Online. Volume 8, number 5,

august 2005.

2. Therapeutic Exercise, Carolyn

Kisner & Lynn Allen Collby.Pg

No 168,5th Edition

3. Sports Fitness Advisor, Fleck

st&kramerwj(2004).

4. Husketh Mount, pg no 92-96,lord

street,merseyside, england.

5. Effect of exercise .stending

lenderg 2004

6. Gender difference in

cardiovascular response to

isometric exercise.gatzke 2005

7. Circulation, amercian heart

association,2007pg no 3 &4

8. Clinical Orthopaedic rehabilitation

,2nd editions brent brotzman,pg no

138-142

9. Cardiovascular system and

exercise physiology,aulter &amer

suleman

10. International journal of biomedical

reserach,srinath galag & ravipati

sarath volume 2,november 2011

11. Gender difference in

cardiovascular response to

isometric exercise of upper

limbs,howden et clf 2006.

12. Gender difference in

cardiovascular response to

isometric exercise,gatzke

13. The essential guide to building

muscles by phil daviee.

CORRESPONDENCE:

* Consultant Physiotherapist, Bhagwan Mahaveer Medical Centre, M.G. Road, Goregaon

(W), Mumbai.

Email: pranjalparmar38@yahoo.in

Growth in Cerebral Palsy Children between 3-13 years in Urban Dharwad,

India

Parmar Sanjay T.*. MPT (Paediatrics). Nayana A. Khobre**. MPT (Paediatrics).

Abstract: Background & Objective- Cerebral palsy is defined as a group of non-progressive

disorders of movement or posture due to a defect or lesion of the immature brain. The incidence

of cerebral palsy is 2-2.5 cases in every 1000 live births. Cerebral palsy is frequently associated

with poor growth and children with cerebral palsy tend to be shorter and lighter than their

normal counterparts. Our objective of the study is to find out growth in cerebral palsy children.

Method - A sample size of 100 children with cerebral palsy of either gender from 3-13 years

were assessed for body mass index, growth of children with cerebral palsy was found out. The

outcome measures Child Developmental Care/National Health Center Statistics growth charts

(CDC/NHCS). Results - Statistical analysis was done with statistical software (n Master 1.0).

Data analysis and results showed no statistical significance growth found in children with

cerebral palsy. The study showed that clinically all the children with cerebral palsy had low

growth when assessed on CDC/NHCS growth charts. Interpretation and conclusion - The

children with cerebral palsy had low growth compared with the other counterparts of same age

group.

Key words- Growth, Cerebral Palsy.

INTRODUCTION

Cerebral palsy (CP) is defined as

“umbrella term covering a group of non-

progressive, but often changing, motor

impairment syndromes secondary to

lesions or anomalies of the brain arising in

the early stages of its development”.

Cerebral palsy is in variably associated

with many deficits such as mental

retardation, speech and language and oral-

motor problems. The etiology of CP is

very diverse and multi-factorial. The

causes are congenital, genetic,

inflammatory, infectious, anoxic,

traumatic and metabolic. The injury to the

developing brain may be prenatal, natal or

postnatal1. The incidence of cerebral palsy

is 2-2.5 cases in every 1000 live births.

There are an estimated 4-5 million

children and people in India with cerebral

palsy2.

The incidence of malnutrition in

individuals with cerebral palsy is a

combination of factors, which directly or

indirectly result in reduced food and

nutrient intake3. Feeding problems are not

easily recognizable in children and in

order to optimally utilize the impaired

feeding potential in these children, early

identification of the incidence of

malnutrition in individuals with cerebral

palsy is necessary. It also requires regular

assessment of feeding and nutritional

status and appropriate nutritional

rehabilitation4.

While the prevalence of growth disorders

among these children is unknown, certain

observations have been made. Growth

failure has been related to the type of cp-

spastic or athetoid and to topographical

distribution, and oral-motor dysfunction

also has been associated with poorer

growth5

A study done on percent body fat, muscle

area and oral motor functions are

important factors for weight gain and

linear growth of children with cerebral

palsy. The identification of the nutritional

problem has a great potential to help

improve weight, muscle mass, decrease

irritability and circulation in order to halt

the incidence of malnutrition in children

with cerebral palsy6.

A study done on incidence of malnutrition

in children with cerebral palsy tells about

feeding problem are usually complicated

by the lack of awareness of parents of

incidence of malnutrition in cerebral palsy

children. The main reasons for lack of

awareness in parents were illiteracy,

misconception about the disease and

associated complications in cerebral palsy.

The psychological impact of having child

with severe chronic neurological disease is

so deep that parents do not appreciate the

feeding problems to the extent they should.

The study done on Growth and nutrition

disorders is common secondary health

conditions in children with cerebral palsy

(CP). Poor growth and malnutrition in CP

merit study because of their impact on

health, including psychological and

physiological function, healthcare

utilization, societal participation, motor

function, and survival. Understanding the

etiology of poor growth has led to a

variety of interventions to improve growth.

Increased recognition and understanding

of neurological, endocrinal, and

environmental factors have begun to shape

care for children with CP, as well. The

investigation of these factors relies on

advances made in the assessment methods

available to address the challenges

inherent in measuring growth in children

with CP. Descriptive growth charts and

norms of body composition provide

information that may help clinicians to

interpret growth and intervene to improve

growth and nutrition in children with CP.

Linking growth to measures of health will

be necessary to develop growth standards

for children with CP in order to optimize

health and well-being.

METHOD

A sample size of 100 children with

cerebral palsy with either gender from 3-

13 years of age was assessed for body

mass index. The study was conducted for 1

year in Physiotherapy OPD of SDM

medical hospital Dharwad Karnataka

India. Ethical clearance is obtained from

the Institutional Ethical Committee, Shri

Dharmasthala Manjunatheshwara College

of Medical Sciences and Hospital, prior to

the commencement of the study. The

children included in the study were

diagnosed cerebral palsy cases, who were

able to stand on stadiometer and weighing

machine. Children who were un-

conscious, unco-operative, who were not

able to stand and unstable Patients were

excluded.

Parents of the subjects willing to

participate were briefed about the study

and how the study would help their

children. A written consent was obtained

from the parents of the children.

Children diagnosed with cerebral palsy

were assessed for BMI by taking the

height and weight of the children. The

child was made to stand on the

Stediometer with the consideration of

physical disabilities to measure the height

and Weight was measured by making the

children stand on weighing machine.

The outcome measures was CDC/NHCS

growth charts. The growth was assessed by

height in meters and weight in kilograms

and BMI (Body Mass Index) is calculated

in weight (in kgs) by height square (in

meters). And BMI percentiles were

calculated on CDC/NHCS growth charts.

DATA ANALYSIS

Statistical analysis was done with

statistical software (n Master 1.0).

descriptive analysis was carried out using

mean and standard deviation of mean age,

height, weight, BMI, BMI percentile.

Comparison between variables is done

using unpaired t-test. The p-value is

0.5693 which shows that there is no

significant difference between boys and

girls.

RESULTS

The table1 depicts the distribution of study

subjects according to gender and different

types of cerebral palsy children. It shows

mainly spastic cerebral palsy cases more in

the present study which includes 3-13

years of age group. The table 2 depicts the

mean and standard deviation age of both

boys and girls.

The table 3, 4, 5 depicts that the mean and

standard deviation (SD) values of height,

weight, BMI and BMI percentile for

different diagnosis of cerebral palsy in

which dystonic and diplegic type have less

mean values. And by different age groups

of 3-5years, 6-8 years, 9-11 years, and 12+

years have increasing mean values as per

the age increases. The mean values of

height, weight and BMI is less in boys

than girls which was not significant. The

table 5 depicts the children in our study are

underweight with 86%.

The table 6 shows that comparison of boys

and girl children with respect to BMI

scores by t-test with mean and standard

deviation where there was no significant

difference between boys and girls.

ILLUSTRATIONS FOR DIFFERENT POSITIONS

Table 1: Distribution of study subjects according to gender by different diagnosis

Diagnosis Boys % Girls % Total

Ataxic CP 5 71.43 2 28.57 7

Dystonic CP 5 83.33 1 16.67 6

Hemiplegic CP 11 64.71 6 35.29 17

Hypotonic CP 6 100.00 0 0.00 6

Diplegic CP 17 60.71 11 39.29 28

Quadri CP 21 80.77 5 19.23 26

Triplegic CP 8 80.00 2 20.00 10

Total 73 73.00 27 27.00 100

The above table depicts Distribution of study subjects according to gender by different

diagnosis

Table2: Mean and SD total oral motor scores and its dimensions by diagnosis

Diagnosis

BMI BMI%

Means Std.Dev. Means Std.Dev.

Ataxic CP 18.1857 4.9878 63.8571 36.0159

Dystonic CP 14.3333 3.2629 35.1667 47.2035

Hemiplegic CP 15.5706 2.0784 41.0000 34.6717

Hypotonic CP 16.0500 4.2646 42.1667 46.2100

Diplegic CP 15.5429 3.0375 30.5357 35.6282

Quadri CP 16.7615 4.2477 48.6154 39.3732

Triplegic CP 17.3800 2.8197 65.5000 32.2154

All Grps 16.1910 3.5160 43.8200 38.2515

Table 3: Mean and SD total oral motor scores and its dimensions by diagnosis

Diagnosis

BMI BMI%

Means Std.Dev. Means Std.Dev.

Ataxic CP 18.1857 4.9878 63.8571 36.0159

Dystonic CP 14.3333 3.2629 35.1667 47.2035

Hemiplegic CP 15.5706 2.0784 41.0000 34.6717

Hypotonic CP 16.0500 4.2646 42.1667 46.2100

Diplegic CP 15.5429 3.0375 30.5357 35.6282

Quadri CP 16.7615 4.2477 48.6154 39.3732

Triplegic CP 17.3800 2.8197 65.5000 32.2154

All Grps 16.1910 3.5160 43.8200 38.2515

Table 4: Mean and SD of Wt, Ht and BMI by age groups

Variables Summary 3-5yrs 6-8yrs 9-11yrs 12+yrs Total

Height Means 97.0000 115.7500 130.1481 145.1250 119.6500

Std.Dev. 10.1612 7.6031 10.5492 7.0887 18.6917

Weight Means 13.2120 21.5031 28.5185 41.5563 24.5330

Std.Dev. 3.2447 5.2859 8.3176 12.2666 11.7800

BMI Means 13.7760 16.1719 16.5222 19.4438 16.1910

Std.Dev. 2.0765 3.0619 2.6963 4.6381 3.5160

The above table depicts Mean and SD of Wt, Ht and BMI by age groups

Table 5: Distribution of samples by BMI category and gender

BMI Male % Female % Total %

Under weight 61 70.93 25 29.07 86 86.00

Normal 9 90.00 1 10.00 10 10.00

Over weight 3 75.00 1 25.00 4 4.00

Total 73 73.00 27 27.00 100 100.00

The above depicts that Distribution of samples by BMI category and gender

DISCUSSION

In our study the mean age group of boys

population is 7.794 and of girls population

is 8.266 out of the total score which

showed the mean value more in age group

of 9-11years in total score which depicts

there is no significant difference in BMI in

both male and female population. As in 9-

11yrs age group 30 children were there

and in 12+yrs age group were 15 children

may be because of number of children

more in 9-11yrs group mean value was

more as comparative to other groups.

The mean values in the different variable

of our study show different mean values of

each type of cerebral palsy relatively

quadriplegic and hypotonic having lower

mean as compared to others due to smaller

sample size in them for which no statistical

analysis was been carried out.

Studies have documented that growth

patterns for patients with cerebral palsy

(CP) are different from those in the general

population. Patients with CP have below

average weight, linear growth, and muscle

mass and fat stores compared with their

peers in the general population. Bone mass

density is also reduced, especially among

patients who are non-ambulatory

Poor growth in children with CP may be

related to nutritional factors, physical

factors or factors related to the brain lesion

itself. Nutritional factors include

inadequate dietary intake, secondary to

impaired oral motor and swallowing

competence and poor nutritional status and

may impact directly on growth. Physical

factors result in decreased mechanical

stress on bones due to immobility or lack

of weight bearing.

Bone growth studies have suggested that

immobilization decreases bone formation

and longitudinal bone growth and

increases bone resorption, which

suppresses certain growth-stimulating

hormones. Factors related to the brain

lesion itself may impact on growth either

directly (via a negative neurotrophic effect

on linear growth) or indirectly (via the

endocrine system). Growth differences

between impaired and unimpaired limbs in

children with hemiplegic, support the

hypothesis that non-nutritional factors play

a significant role in reducing growth in

children with CP.

A study done on Identification of

malnutrition in children with cerebral

palsy: poor performance of weight-for-

height percentiles where explained,

undernourished children with CP have

changes in body composition and

proportion compared with normally

developing peers. Alterations include

increased total body water, severely

depleted fat stores, minimally depleted

muscle stores, severe short stature, and

decreased bone density.

CONCLUSION

All the children with cerebral palsy had

lower growth than other peer groups, when

they were assessed on CDC/NHCS growth

charts, which may be due to oral motor

dysfunction and other factors such as

neurological factors and the further studies

can be carried out by considering different

types of cerebral palsy with various other

scales and their growth pattern to find out

what oral motor dysfunction has effect on

growth.

REFERENCES

1. Bax MCO. Terminology and

classification of cerebral palsy. Dev Med

Child Neurol. 1964; 39; 295-297.

2. Chitra Sankar, Nandini Mundkar.

Cerebral Palsy- Definition, Classification,

Etiology, and Early Diagnosis. Indian J

Pediatr .2005; 72 (10) : 865-868.

3. Bell et al. A prospective, longitudinal

study of growth, nutrition and sedentary

behavior in young children with cerebral

palsy. BMC Public Health 2010, 10:176.

4. Bruce K. Shapiro, Pauline Green, Jackie

Krick, Darlene Allen, Arnold J. Capute.

Growth of severely impaired children:

neurological verse nutritional factors. Dev

Med Child Neurol.1986, 28, 729-733.

5. Kuczmarski R J, Ogdan C L et al.

Advance Data CDC Growth Chart: United

State, Number 314 December4, 2000

(Revised). U.S Department of Health and

Human Services, Centers for Disease

Control and Prevention/ National Center

for Health Statistics.

6. Incidence of malnutrition in individuals

with cerebral palsy. Available from: http.//

www.cerebralpalsysource.com/malnutritio

n/index.html

7. Okeke IB, Ojinnaka NC. Nutritional

status of children with cerebral palsy in

enugu Nigeria. European journal of

scientific research 2010; 39: 505-513.

CORRESPONDENCE

*Assistant Prof, SDM College of Physiotherapy Dharwad India. **Post graduate student,

SDM College of Physiotherapy, Dharwad India.

Effectiveness of Proprioceptive Training over Strength Training in

Improving the Balance of Cerebral Palsy Children with Impaired Balance

Kuki Bordoloi* MPT (Neuro), Nidhi Sharma** MPT (Neuro)

INTRODUCTION

Cerebral palsy is an umbrella term

encompassing a group of non-progressive

[1], non-contagious motor conditions that

cause physical disability in human

development, chiefly in the various areas

of body movement.[2] It is a non-

progressive disorder of motor function.[3]

It is caused by damage to the motor

Abstract: This is an experimental study with same subject design. Proprioceptive training and

strengthening exercises is a promising therapy to improve the balance in CP subjects with

impaired balance.The study intended to find out the effectiveness of Proprioceptive training

and strength training exercises on balance of the CP subjects and which of them is more

effective. 30 male or/and female patient of CP with impaired balance will be taken and

randomly divided in to two groups. Group A will be treated with by proprioceptive training

and group B will be treated with strength training for 12 week. Both group will assess with

Timed-Up and Go (TUG) scale and Pediatric Balance Scale (PBS) in starting and at the end of

12 weeks. The result will be statically analyzed using t-test for significance between the two

groups. After a 13-week training period, the ‘t’ test and ‘p’ values were found significant with

values 4.747 & 0.003 for TUG&PBS score respectively stating that there is significant effect

when using Proprioceptive training than giving strength training for improving balance in

geriatric subject with impaired balance. The result states that there is a significant effect when

using Proprioceptive Training than giving Strength Training for improving balance in the C.P.

subjects. So the proprioceptive training should be emphasized in the daily exercise regime of

C.P. subjects to improve their balance.

Key words: Balance, fall prevention, Strength training, Proprioceptive training.

control centers of the developing brain and

can occur during pregnancy, during

childbirth or after birth up to about age

three.[4] The motor disorders of cerebral

palsy are often accompanied by

disturbances of sensation, perception,

cognition, communication, and behaviour,

by epilepsy, and by secondary

musculoskeletal problems.[5] It used to

describe diverse group of disorders of

movement, posture and tone due to central

nervous system insult.[4] In developed

countries, the overall estimated prevalence

of CP is 2-2.5 cases per 1000 live births.

[34] The prevalence of CP among preterm

and very preterm infants is substantially

higher.[6]

Balance can be defined as a

complex process revolving the reception

and integration of sensory input, and the

planning and execution of movement, to

achieve a goal required in upright

posture.[7] The control of balance requires

the integration of information from

multiple sensory and motor systems by the

central nervous system (CNS).[8] Balance

receptors in the inner ear (vestibular

system) provide information to CNS about

the head and body movements.[9] The eye

(visual system) provides input regarding

the body’s orientation and motion within

the environment.[7] The position and

motion sensory of the muscle and joints,

and the touch receptors of the extremities

(proprioceptive system) send signals

regarding bodily position particularly in

relation to the supporting surface.[7]

The balance disorder of cerebral

palsy (CP) is expressed in a variety of

ways and to varying degrees in each

individual. Impairments present in children

with CP as a direct result of the brain

injury or occurring indirectly to

compensate for underlying problems

include abnormal muscle tone; weakness

and lack of fitness; limited variety of

muscle synergies; contracture and altered

biomechanics, the net result being limited

functional ability.[10] Other contributors

to the motor disorder include sensory,

cognitive and perceptual impairments.[10]

Proprioception is a sense produced

by the sensory receptors that are sensitive

to pressure in the tissues that surround

them.[11] They are also present in the

bones of the legs, arms or other parts of

the body and these receptors response to

stretches of the muscle surrounding them

and send impulse through the sensory

nerve fibers to the brain.[11] Decline in

dynamic position sense is associated with

decrease in the balance of C.P. children

and this decline in proprioception can be

prevented or improved by Proprioceptive

training.[12] In a study Edward R

Laskowski et al (1997) shown that

proprioception based rehabilitation

programs improved objectives

measurements of functional status,

independent of changes in joint laxity and

proprioception can be improved through

Proprioceptive training.[12]

Muscle strength is another factor

that plays an important role in balance and

mobility.[7] Muscle weakness can be

major problem for many young people

with cerebral palsy.[7] Training of muscle

strength and coordination has been

recommended to improve motor function.

[13] Bobath considered spasticity to be the

main problem in spastic C.P. and

suggested that resistance training should

be avoided, but Carr stated that it is not the

presence of spasticity but the negative

feature of weakness and loss of skills

which are the major barriers to improve

function. Many studies have reported

positive result in strength training in

spastic children.[14] Possible factors

interfering with normal gait pattern in

cerebral child includes spasticity, muscle

contracture, bony deformities loss of

selective motor and muscle weakness.[15]

Recent research has focused on

muscle weakness. ‘Wiley and Damino’

and Ross and Engsberg’ described muscle

is more pronounced distally and found

imbalance across joints. Balance control is

important for competence in the

performance of most functional skills,

helping a child to recover from unexpected

balance disturbances, either due to slips

and trips or to self induced instability

when walking a movement that brings

them towards edge of their limit of

stability.[16]

Many studies have been conducted

to show the individual effect of

Proprioceptive training and strength

training to improve the balance of C.P.

subjects. Hence this studies aims to

analyze the effectiveness of both treatment

technique and prove the better

effectiveness by comparing Proprioceptive

training and Strength training.

METHODOLOGY

Sample selection

The selection criteria are listed below.

Inclusion Criteria: CP subjects with age

group of 8-14 years, With normal I.Q.

(assessed by psychologist), Can follow

commands, Both boys and girls subjects,

CP subjects who had fall at least twice a

day, Subject who scored greater than 20

second in TUG test. Exclusion Criteria:

Children below 8 years and above 14

years, Children with any other

neurological impairment, Children with

audio visual impairment, Non ambulatory

patients.

Measurement tools

Timed up and go scale

Timed up and go scale provides a reliable

quick screening measure. Many researches

indicate that most adult can complete the

test in 10 seconds. A score of 11 to 20

seconds are considered within normal limit

for frail elderly or individual with a

disability whereas score over 20 seconds

are indicative of impaired functional

mobility. To perform this, the subject is in

sitting position and a visible object is

placed 3 meter away from the patient. The

subject is instructed to get up and walk

down till the object and return to the seat.

During this task timing is maintained with

a stopwatch and the time taken for it is

recorded. A score greater than 20 seconds

is associated with high risk in community

dwelling older adults.

Berg Balance Scale

The Pediatric Balance Scale (PBS), a

modification of Berg's Balance Scale, was

developed as a balance measure for

school-age children with mild to moderate

motor impairments.It is used to assess

balance and mobility which has 14

functional tasks commonly performed in

everyday life with scores ranging from 0-

4, with a maximum score of 56.

Procedure

Patients were selected on the assessment

and diagnosis of their condition and put on

the inclusion and exclusion criteria after

they were referred to physiotherapy

department by neurologist.

Method

The children were randomly divided in

two groups of 15 children each. All the

subjects were measured for functional

balance using Timed Up & Go Test and

Pediatric Balance Scale before start the

training period and at the end of thirteen

weeks of training.

Group A was trained with the

Proprioceptive training whereas the Group

B was trained with the Strength training.

Protocol

Strength training

All the subjects were treated with lower

extremity strengthening exercises using

weight cuff. A standardized weight of one

repetition maximum (1RM) was

considered for the subjects. 1RM was

determined before the training for all the

subjects.

A repetition of 8 to 15 times were

done for all the strengthening exercises for

duration of 30 minutes per session; with 5

minutes rest period in between for five

days a week and were continued for 13

weeks.

The following exercises were then

given and it was ensured that the position

of subjects in all form of exercises were

comfortable.

1. Side leg rising

Subjects were made to lie in side lying

position and instructed to abduct the upper

leg tied with weight cuffs slightly about 6-

12 inches. This position was held for

sometime and then the leg was lowered.

Same exercise was repeated with the other

leg.

2. Knee flexion exercise

Subjects were made to sit on high chair or

table, the knee was bent slowly as far as

possible, so that the foot with the weight

cuff was bent behind. The subject was

asked to hold the position and then the foot

was lowered slowly all the way back

down. The same procedure was repeated

with the other leg.

3. Hip Extension Exercise

Subjects were made to lie on prone

position and one leg with weight cuff was

lifted slowly straight upwards. The subject

was asked to hold the position and then the

leg was lowered. The same procedure was

repeated with the other leg.

4. Knee Extension Exercise

Sitting on the chair with back support, the

subject was asked to rest the balls of the

feet & toes on the floor. The hands were

kept on the thigh or on the side of the

chair, and then the right leg with the

weight cuff was extended slowly in front,

parallel to the floor for a period of 3

seconds. With right leg in that position, the

foot was flexed so that the toes were

pointing towards head; the foot was held in

that position for 1-2 seconds. Duration of 3

seconds was taken to lower the leg back to

the starting position, so that the balls of the

foot rested on the floor again. The same

procedure was repeated with the other leg.

5. Ankle Dorsiflexion

Sitting on the chair with back support, the

subject was asked to lift the foot tied with

a weight cuff so that the toes were pointing

towards the head. Then the subject was

asked to hold and slowly return to the

original position. The same procedure was

repeated with the other leg.

Proprioceptive Training

Subjects in Group A were given proper

warm up for 5-10 minutes before starting

the treatment in the form of simple

stretching (Quadriceps and hamstring

stretch) and free exercises (knee flexion

and extension in side lying and high

sitting).[63]

All the proprioceptive exercises

were performed for duration of 30 minutes

per session; with 5 minutes rest period in

between for three days a week and were

continued for 13 weeks.

The Proprioceptive training included the

following exercises

1. Stair climbing up and down (a

regular 3 steps staircase).

2. Standing with feet approximately

shoulder-width apart and arms

extended out slightly forward

lower than the shoulder, then

lifting both heel off the floor and to

hold the position for 10 seconds,

followed by climbing regular steps

staircase. This procedure was

performed with eyes closed also.

3. Standing with feet side by side &

holding the arms in same position

as described above, one foot is

placed on the inside of the

opposing ankle and to hold the

position for 10 seconds. Followed

by climbing regular steps staircase.

This procedure was performed with

eyes closed also.

4. To perform one leg standing with

one foot raised to the back and to

maintain the position for minimum

3 seconds. This procedure was

performed with eyes closed also.

5. Same exercise as above performed

but with one foot raised to the

front. This procedure was then

performed with eyes closed.

6. Walking heel to toes.

7. Rising from a standard chair (4

times) without arm support.

Data analysis

Data analysis was performed using

the Statistical Package for the Social

Sciences (SPSS) for windows version 17

(SPSS Inc., Chicago, U.S.A.). The data

were analyzed using parametric

(dependent‘t’ test and independent‘t’ test)

and nonparametric (Wilcoxon Signed

Ranks and Mann-Whitney Test) test to

find the significance of the interventions

used within and between the group A and

B. The significant level set for this study

was 95% (p<0.05).

RESULTS & INTERPRETATION

Thirty Cerebral Palsy patients were

part of the study. Both the groups (A and

B) included 15 patients each, with 11 male

and 4 females in group A and 12 male and

3 females in group B. Age group taken

was between 8-14 yrs with mean age of

12.33 yrs (SD=1.85). In Group A, 15

subjects with an average age of 12.4 yrs

(SD=1.96) and in Group B, 15 subjects

with an average age of 12.1 yrs (SD=1.79) completed the study.

Table 1.1: Comparison of Gender of patients in both groups

Male Female

Group A 11 4

Group B 12 3

Total 23 7

Table 1.2: Comparison of Mean and SD of Age of Patients in both groups

Mean SD

Group

A

Male 12.8 1.25

Female 11.3 3.20

Group

B

Male 11.8 1.80

Female 13 1.73

Total

Group

A12.4 1.96

Group

B12.1 1.79

Table 1.3 Descriptive statistics of TUG Tests prior to and post study

Mean N

Std.

Deviatio

n

TUGAPR 23.667 15 1.799

TUGAPS 19.933 15 1.534

TUGBPR 23.333 15 1.676

TUGBPS 21.000 15 1.414

Table 1.4 Descriptive statistics of PBS Tests prior to and post study

Mean N

Std.

Deviatio

n

PBSAP

R42.1 15 1.792

PBSAP

S47.3 15 2.086

PBSBP

R43.1 15 1.685

PBSBP

S45.9 15 1.995

Interpretation

The table 1.1 states that total 30 patients

including 7 females were kept in two

groups A and B. The group A included 11

males and 4 females whereas the group B

included 12 males and 3 females. Stating

that the mean age of total patients was 12.4

in group A and 12.1 in group B the table

1.2 shows the mean age of male and

female in group A and the male and

female in group B as 12.8, 11.3, 11.8, and

13 respectively. The table 1.3 shows the

pre and post test means values for TUG

test It clearly shows that individually both

Proprioceptive training and Strength

training produced improvement in

Cerebral palsy patients with respect to

TUG test but the improvement in the A

which had had the Proprioceptive training

showed more improvement. This is again

confirmed with the findings of PBS test in

table 1.4 which states that although both

the groups showed improvement, the

group A had better findings than group B.

.Timed Up and Go Test:

Table 2.1 Dependent ‘t’ test performed with the pre & post values of TUG test for

significance within the groups

Within Group

Paired Differences

T Df P

95% Confidence

Interval of the

Difference`

Mean SD

Std.

Error

Mean

Lower Upper

TUG A Pre –

TUG A Post3.73333 .88372 .22817 3.24395 4.22272 16.362 14 0.003*

TUG B Pre –

TUG B Post2.33333 .72375 .18687 1.93254 2.73413 12.486 14 0.002*

*-Significant

Table 2.2: Independent ‘t’ test performed with the pre & post values of TUG test for

significance between the groups

Independent Samples Test

Between Group

Levene's

Test for

Equality of

Variances

t-test for Equality of Means

95%

Confidence

Interval of the

Difference

F Sig. T Df PMean

Diff.

Std.

Error

Diff.

Lower Upper

TUG

A-

TUG

B

Equal

variances

assumed

.429 .518 4.747 28 0.003* 1.4000 .29493 .79586 2.004

*-Significant

Interpretation

The table 2.1 shows that the value of ‘t’ as

16.362 and 12.486 for TUG Test in Group

A and Group B respectively in dependent

‘t’ test. The ‘t’ value is significant at

p<0.5. Graph 4 representing the mean

values of Pre and Post values of Timed Up

& Go test show improvement within the

group A and B respectively. Hence

individually both Proprioceptive training

and Strength training produced significant

improvement in Cerebral palsy patients

within their group with respect to TUG

test.

The table 2.2 shows that the value

of ‘t’ as 4.747 in independent ‘t’ test. The

value of ‘t’ is greater even at p<0.05,

which is significant. Hence there was

significant difference in improvement

between Proprioceptive training and

Strength training in Cerebral Palsy

patients with respect to TUG test.

Pediatric Balance Scale test:

Table 3.1: Wilcoxon Signed Ranks Test

Within GroupPBSAPR -

PBSAPS

PBSBPR –

PBSBPS

Z -3.442 -3.432

P 0.002* 0.002*

*-Significant

Table 3.2: Mann-Whitney Test

*-Significant

Table 3.3: Mann-Whitney and Wilicoxon test performed with the pre & post values of

PBS test for significance between the group

Between Group PBS

Mann-Whitney U 15.500

Wilcoxon W 135.500

Z -4.083

P 0.003*

*-Significant

Interpretation:

The table 3.1 shows that the value of ‘p’

as 0.002 for Group A and Group B

when compared within the group

respectively. Graph 5 representing the

mean values of Pre and Post values of

PBS show improvement within the

group A and B respectively. Thus there

is significant improvement on PBS in

Cerebral palsy patients after

Proprioceptive training and Strength

training within their group respectively.

GRO

UPN

Mean

Rank

Sum of

Ranks

PBS

A 15 21.97 329.50

B 15 9.03 135.50

Total 30

The table 3.3 shows that the value

of ‘p’ as 0.003 and hence significant.

Hence we can state that there was

significant difference in improvement

between Proprioceptive training and

Strength training in Cerebral Palsy

patients with respect to PBS test.

Table – 4.1 Mean of improvement in all the parameters between group a & Group B

ParametersGroup

A

Group

B

TUG 3.73 2.33

PBS 5.19 2.73

Interpretation:

The above table 4.1 and the graph 6,

clearly indicates that the Proprioceptive

training produced more improvement in

the selected parameters (TUG, PBS)

when compared with Strength training in

Cerebral palsy patients.

Graph 1: Comparison of both the groups and the total on the basis of gender of Patients

Graph 2: Comparison of Mean and SD of Age of Patients between both groups and

total.

Graph 3: Comparison of Mean and SD of pre study values of both groups

Graph 4: Comparison of Mean and SD of Pre and Post values of Timed Up & Go test

Graph 5: Comparison of Mean and SD of Pre and Post values of Pediatric Balance

Scale

Graph 6: Comparison of ‘Mean of Improvement’ in all the parameters between

Group A and Group B.

DISCUSSION:

In this study, better improvements in

balance outcome were analyzed using

proprioceptive training and strength

training. This study was done on 30 CP

children with impaired balance who were

divided in to experimental Group-A

treated with Proprioceptive training and

Group-B with Strength training.

The balance was taken as the

dependant variable which was measured

using Timed Up & Go test (TUG) and

Pediatric Balance Scale (PBS). Both this

tool are standard tools to analyze balance.

Proprioceptive training exercises were

given to improve the balance by improving

the decreased sense of proprioception in

older age group where as Strength training

was given to improve the balance by

improving the strength of lower extremity

muscles.

The improvements in functional

balance due to Proprioceptive training may

be attributed to the improvement of

mechanoreceptor activation. Structural

changes in the muscle, bone and joints

during old age accounts for the decreased

efficiency of the proprioceptors.

Researchers reason that proprioceptive

training can improve the joint and

kinesthetic sensation to a greater extent

that the falls and risk of fall can be reduced

among the subjects.

Edward R Laskowski et al also

stated that the decline in dynamic position

sense is associated with decrease in the

balance of C.P. children and this decline in

proprioception can be prevented or

improved by Proprioceptive training.My

study confirms the study by Edward R

Laskowski et al (1997) which showed that

proprioception based rehabilitation

programs improved objectives

measurements of functional status,

independent of changes in joint laxity and

proprioception can be improved through

proprioceptive training. [68]

These results were in accord with

Gauchard GC et al (1999) to improve

balance by proprioceptive training. Studies

done by Pierre Gangloff et al (2003) also

supports our results, which prove that

proprioceptive training exercises, improve

balance in subjects with impaired balance.

This supports the experimental hypothesis

hence the null hypothesis was rejected.

The result of the present study

indicates that effect of proprioceptive

training had a proven effect over strength

training. All participants in the

proprioceptive training group declared that

their balance had improved and most of

them were motivated to continue with the

training. Hence proprioceptive training

should be emphasized in the daily exercise

regime of CP subjects to improve their mobility and functional status.

REFERENCES:

1. Cerebral Palsy. National Center on

Birth Defects and Developmental

Disabilities, October 3, 2002

2. Beukelman, David R.; Mirenda

(1999). Augmentative and

Alternative Communication:

Management of severe

communication disorders in

children and adults. Pat (2 ed.).

Baltimore: Paul H Brookes

Publishing Co. pp. 246–249.

3. Davis DW. Review of cerebral

palsy, part I: Description,

incidence, and etiology. Neoratel

Netw 1997; 16(3): 7-12.

4. “Cerebral Palsy – Topic

Overview”.

http://children.webmd.com/tc/cereb

ral-palsy-topic-overview. Retrieved

2008-02-06.

5. Anonymus (2007). “Definition and

classification of cerebral palsy, Feb

2007”. Developmental medicine

and child neurology 49 (8): 8.

6. Vincer MJ, Allen AC, Joseph KS,

et al. Increasing prevalence of

cerebral palsy among very preterm

infants: a population-based

study. Pediatrics. Dec 2006;118(6):

e1621-6.

7. Darcy A Umphred. Neurological

Rehabilitation. Mosby

Publications. Fourth edition. 2001.

8. Balance Procedures Manual,

National Health and Nutrition

Examination Survey, Inhanes, May

2001

9. Textbook of Medical Physiology.

Arthur C. Guyton, John E. Hall.

10th Edition. ISBN: 0721602401

10. Margaret J. Mayston. People With

Cerebral Palsy: Effects of and

Perspectives for Therapy. Neural

Plasticity. Volume 8, No. 1-2, 2001

11. Vestibular Disorders Association.

Official Website. Retriebed on

10/6/2011

12. Edward R.Laskowski, MD; Karen

newcomer-Aney, MD; Jaysmith,

MD.Refining rehabilitation

withproprioceptive training:

expecting return to play; The

physician and sports medicine;

1997 Oct;Vol.25, No. 10.

13. C Andersson et al. Adults with

cerebral palsy: walking ability after

progressive strength training.

segunda-feira, 10 de maio de 2010

14. Kramer JF, MacPhail HEA.

Relationships among measures of

walking efficiency, gross motor

ability, and isokinetic strength in

adolescents with cerebral palsy.

Pediatr Phys Ther 1994; 6:3 Á/8.

15. Phil Page.Knee osteoarthritis:

strength training for pain relief and

functional improvement; ICAA

Publication, Vol.1 No.6, September

2003.

16. Mutch LW, Alberman E, Hagberg B,

Kodama K, Velickovic MV. (1992).

Cerebral palsy epidemiology: where

are we now and where are we going?

Developmental Medicine and Child

Neurology 34: 547-555.

CORRESPONDENCE:

*Neuro-Physiotherapist, GNRC, Guwahati, Assam. Email: kukzzmail@gmail.com Cont:

+91-8822485959. **HOD, Dept of Physiotherapy, AIER, Ghaziabad, U.P., India

Correlation of Balance Tests Scores with Modified Physical Performance

Test in Indian Community-Dwelling Older Adults

Sunita Yadav* MPT (Neuro), Deepti Dhar** MPT (Paediatrics)

INTRODUCTION

Abstract: Background and Objective: There is sufficient evidence which shows significant

relationship between balance tests and other functional tests but there is lack of literature

regarding the relationship between balance tests (BBS, MDRT, BPOMA) and Modified

Physical Performance Test in different age groups of older adults. Design: An Observational

Study Subjects: 58 subjects were divided into three different age groups, having the mean age

of 65.3±3.0 (Group-A), 73.7±2.4 (Group-B), 82.6±1.4 (Group-C), mean height of 161.4±5.6

(Group-A), 164.9±10.2 (Group-B), 160.3±5.9 (Group-C) & mean weight of 68.4±4.8 (Group-

A), 72.7±6.9 (Group-B), 63.6±7.7 (Group-C) were recruited in this study from old age home

and local community. Methods: Subjects in each group performed the tests in the following

sequence: BBS (Berg Balance Scale), MDRT (Multi-Directional Reach Test), Modified-PPT

(Physical Performance Test) & BPOMA (Balance Performance-Oriented Mobility Assessment

of Tinetti) with rest period of 5-10 minutes between each scale. Result: The results suggested

that there was a significant positive correlation between balance tests and Modified Physical

Performance Test in different age groups of older adults. Conclusion: The current study

concluded that Modified physical performance test is a efficient tool to assess static and

dynamic balance and also physical function and ambulation in different age groups of older

adults. It was also observed that out of these balance tests used in the study, MDRT was the

most difficult to understand and perform by subjects above 70 years and the subjects above 80

years found it really hard to understand the procedure.

Keywords: BBS, MDRT, BPOMA, Modified PPT, Balance, Physical Function.

The number of persons above the

age of 60 years is fast growing, especially

in India. India is the second most populous

country in the world has 76.6 million

people at or over the age of 60,

constituting above 7.7% of total

population. Recurrent falls are an

important cause of morbidity and mortality

in the elderly and are a marker of poor

physical and cognitive status.2

Impaired balance and physical

function are the main causes of fall among

the older adults. Stability and orientation

are to distinct goals of the postural control

system. Postural control for stability and

orientation requires both perception and

action. Thus, postural control requires the

complex interaction of neural and

musculoskeletal systems.4

Several researchers show that as

the age increases, the changes in the neural

and musculoskeletal systems disturb the

balance and physical activities.6 As age

increases the physical activities and

physical function also decreases due to

decreased muscular power and strength.11

Both balance problems and physical

inactivity affect the quality of life of older

adults. Therefore the assessment of both

balance and physical function is necessary

for older adults in order to help establish

appropriate treatment goals, increase

awareness of fall risk and assign

appropriate assistive device and to

decrease the disability. Several such

instrument have shown satisfactory

reliability and validity in identifying older

people with balance and physical

functional problems, discriminating older

adults by their needs for different assistive

device to maintain balance or predicting

their likelihood of falls and to enhance

physical function.

The Berg Balance Scale was

developed by Kathy Berg (a Canadian

physical therapist) in1993, as a means of

measuring balance in the elderly.

Multi-directional Reach Test

(MDRT) is developed by Roberta A.

Newton in 2001. It allows for analysis of

the patient voluntary postural control.

The Performance Oriented

Mobility Assessment (POMA) scale was

originally developed by Dr. Mary E.

Tinetti and first published in 1986, is a

widely used tool for assessing mobility

and fall risk in older people. In this study

balance subscale of Tinetti assessment is

used to assess the balance of older adults.15

Brown, M, Sinacore, D.R.

developed the modified physical

performance test in 2005 to provide more

focus on gross motor function by

substituting a chair rise task and a balance

task for the writing and stimulated eating

tasks described in the original PPT. The

tool was more useful in identifying deficits

in physical function than the self- report

comparison measure, the functional status

questionnaire. The authors concluded that

the performance based measure could

assist in early identification of minor

problems in physical functioning, and

allow for opportunity for early intervention

for the patients.16

Several researchers found that

balancing exercises improve physical

function and previous studies also found

significant correlation between balance

scales and other functional tests.17,18,13,19

Therefore it is clear that there is a

relationship between balance and physical

function.

Yet there is no study to show

relationship between these scales or tests

in different age groups. Therefore the main

purpose of my study is to find out the

relationship between balance tests and

Modified physical performance test.

Second purpose is, the Modified physical

performance test assesses both balance and

physical function in older adults no other

tool is required because it measure the

both static and dynamic balance and also

physical function. It tells about fall risk,

need of assistance device and functional

limitations; additionally it takes less time

to administer as compared to other scale.

METHODOLOGY

This observational study recruited

58 subjects from old age homes and local

community of Delhi and Dehradun

meeting the inclusion criteria. Inclusion

Criteria: Age - 60 to 89 year old healthy

subjects; Gender- Both male and female;

Ability to abduct and flex the shoulder up

to 90 degrees; Ability to stand for

minimum 10 min. without any assistance;

Ability to walk at least 50 feet before

sitting to rest; Minimal use of rail or cane

while climbing. Exclusion Criteria: Use

of any assistive prosthetic device; History

of any cardiac problem confirmed by

physician; Any history of fainting spells or

extended dizziness due to unknown

reasons History of neurological; vestibular

or auditory deficit confirmed by physician;

History of any visual disorder which will

not be corrected by optical glasses as

confirmed by physician; MMSE score

below 23; History of postural hypotension;

History of recent fractures and severe

arthritic conditions; History of any major

surgeries during last 6 month; History of

any previous balance training; Moderate to

severe hypertensions

Measurement Tools

Berg Balance Scale (BBS)

The BBS was developed to measure

balance among older people with

impairment in balance function by

assessing the performance of 14 functional

tasks. The results are based on how long it

takes to complete specific tasks and how

well the tasks are performed. Each task is

measured on a five point ordinal scale

ranging from 0 to 4 (0 = unable to

perform, 4 = independent) so that the

aggregate score ranges from 0 to 56.

Multidirectional Reach Test (MDRT)

The MDRT is an inexpensive, reliable and

valid screening tool to measure the limits

of postural stability in four directions

(forward, backward, right & left) during

standing. The distance of each reach is

measured in centimetres or inches.

Balance Performance Oriented Mobility

Assessment (BPOMA)

The Tinetti assessment is a physical task-

oriented scale which measures the gait and

balance activities of older adults. In this

study BPOMA was used to assess the

balance of the community dwelling older

adults; it consists 9 tasks. 6 tasks are

measured on a three point ordinal scale

ranging from 0 to 2 and remaining three

tasks are measured on a two point ordinal

scale ranging from 0 to 1 ( 0 = unable to

perform, 1 & 2 = independent). The

maximum score is 16.

Physical Performance Test (Modified-

PPT)

An objective evaluation of overall physical

function was obtained by using modified

PPT. The severity of physical frailty in

physical functioning was assessed using a

modified PPT. It consists of 9 tasks; each

task is measured on a five point ordinal

scale ranging from 0 to 4 ( 0 = unable to

perform, 4 = independent) except 7th task

(turning 360 degrees) which ranges from 0

to 1 (0 = unsteady, 1 = steady). The

maximum score is 36.

Procedure

The subjects were recruited based on

inclusion and exclusion criteria the

subjects of different age groups 60 to 69

years of age (Group- A), 70 to 79 years of

age (Group- B), and 80 to 89 years of age

(Group- C). Subjects in each group

performed the tests in a sequence i.e. BBS,

MDRT, Modified-PPT, POMA. The

whole procedure was explained to each

subject and the subject signed a consent

form before performing the study.

Description data was collected which

included age, gender, height, weight and

number of falls in the past 6 months.

MMSE score was also assessed. All

subjects were assessed by all four scales or

tests in the following order BBS, MDRT,

Modified-PPT and BPOMA. All

components of each scale were

demonstrated to all the subjects and one

practice session was done for all the

components of four scales by all the

subjects, after that reading was taken. Each

test or scale was administered by myself.

All subjects were offered rest breaks and

water during the session and completed the

approximately 60 minute testing protocol

without complaint of fatigue or

discomfort. The resting period of 5 to 10

minute was given after performing each

scale. As a precautionary measure, blood

pressure was checked prior to beginning of

the test session and it was again taken at

the end of the last test performed. One

person was always nearby vicinity of the

subject.

Data Analysis

The data analysis was done on SPSS 11.5

software. The arithmetical mean and

standard deviation of age, height and

weight in demographic data were

evaluated. Karl pearson’s correlation test

was done to analyse the correlation

between balance tests (BBS, MDRT &

POMA) with physical performance test

(modified) among elderly people.

Statistical significance level was set at <

0.05. The data analysis was done on SPSS

11.5 software. The arithmetical mean and

standard deviation of age, height and

weight in demographic data were

evaluated. Karl pearson’s correlation test

was done to analyse the correlation

between balance tests (BBS, MDRT &

POMA) with physical performance test

(modified) among elderly people.

Statistical significance level was set at <

0.05.

RESULT AND INTERPRETATION

A sample of 58 subjects were selected on

the basis of inclusion and exclusion

criteria. Each group of older adults had 20

subjects except Group – C (81-89 years of

age) which has only 18 subjects due to

unavailability of the subjects. The mean

and standard deviation of age weight and

height of three Groups A, B and C [Table

1] was calculated. The mean and standard

deviation of balance tests and physical

performance test (modified) of Group – A

[Table 2], Group – B [Table 3], & Group –

C [Table 4], was calculated. The

correlation values of balance tests with

modified physical performance test of

Group – A [Table 5], Group – B [Table 6],

& Group – C [Table 7], were calculated.

Karl pearson’s correlation test was used to

find out the correlation between BBS,

MDRT & BPOMA with PPT (modified) in

different age groups of older adults, Group

– A (60 – 69 years of age), Group – B (70

– 79 years of age), and Group – C (80 - 89

years of age); these three groups showed

significant positive correlation between

balance tests (BBS, MDRT & BPOMA)

with physical performance test (modified).

Table 1: Mean and standard deviation of

demographic data

Group – A

N Mean

Age 20 65.3±3.0

Height 20 161.4±5.6

Weight 20 68.4±4.8

Group – B

N Mean

Age 20 73.7±2.4

Height 20 164.9±10.2

Weight 20 72.7±6.9

Group – C

N Mean

Age 20 82.6±1.4

Height 20 160.3±5.9

Weight 20 63.6±7.7

Table 1 shows mean and standard

deviation of demographic data of different

age groups. Group – (60 – 69 years of

age), Group –B (70 – 79 years of age) &

Group – C ( 80 – 89 years of age).

Table 2: (Group – A) Mean and standard deviation (SD) of balance tests (BBS, MDRT &

BPOMA) and Physical Performance Test (Modified).

Tests N Mean and SD

BBS 20 54±2.4

FR (MDRT) 20 13.6±2.6

BR (MDRT) 20 11.8±2.6

RR (MDRT) 20 12.5±2.5

LR (MDRT) 20 12.2±3.0

BPOMA 20 14.9±1.9

PPT (modified) 20 31.1±2.5

Table 2 shows mean and standard deviation of balance tests and modified physical

performance test of Group-A (60-69 Years of age).

Table 3: (Group – B) Mean and standard deviation (SD) of balance tests (BBS, MDRT &

BPOMA) and Physical Performance Test (Modified).

Tests N Mean and SD

BBS 20 27.7±5.3

FR (MDRT) 20 12.0±3.4

BR (MDRT) 20 9.9±3.9

RR (MDRT) 20 11.2±3.3

LR (MDRT) 20 11.4±4.3

BPOMA 20 12.9±2.2

PPT (Modified) 20 27.7±5.3

Table 3 shows mean and standard deviation of balance tests and physical performance test

(modified) of Group-A (70-79 Years of age).

Table 4: (Group – C) Mean and standard deviation (SD) of balance tests (BBS, MDRT &

BPOMA) and Physical Performance Test (Modified).

Tests N Mean and SD

BBS 20 42.6±3.6

FR (MDRT) 20 5.5±2.2

BR (MDRT) 20 3.2±1.9

RR (MDRT) 20 4.9±2.3

LR (MDRT) 20 4.4±2.2

BPOMA 20 10.5±1.4

PPT (modified) 20 18.0±3.5

Table 4 shows mean and standard deviation of balance tests and Modified physical

performance test of Group A (80-89 Years of age).

Figure 1: Mean and standard deviation of balance tests (BBS, MDRT, & BPOMA) with

modified physical performance test (modified) of Group A, B and C.

Table 5: (Group A) Correlations of balance tests (BBS, MDRT, & POMA) with Physical

Performance Test (Modified)

Balance Tests r value P value

BBS Vs PPT (modified) .759 .000

FR( MDRT) Vs PPT (modified) .592 .006

BR (MDRT) Vs PPT (modified) .671 .001

RR (MDRT) Vs PPT (modified) .541 .014

LR (MDRT) Vs PPT (modified) .518 .019

BPOMA Vs PPT (modified) .826 .000

Table 5 shows correlation of balance tests with physical performance test (modified), all the

balance tests show significant correlation except right and left reaches which show

moderately significant correlations with physical performance test (modified) of Group – A

(60 – 69 years of age).

Figure 2: Correlation Graph of Berg

Balance Scale (BBS) and Physical

Performance Test (Modified) of Group –

A.

Figure 2 depicts correlation between BBS

and modified PPT. It shows positive

significant correlation in 60-69 years of

age group i.e. Group – A.

Figure 3: Correlation Graph Of Forward

Reach (FR) of MDRT and Physical

Performance Test (Modified) Of Group –

A.

Figure 3 depicts correlation between FR of

MDRT and PPT (modified). It shows

positive significant correlation in 60-69

years of age group i.e. Group – A.

Figure 4: Correlation Graph of Backward

Reach (BR) of MDRT and Physical

Performance Test (Modified) Of Group –

A.

Figure 4 depicts correlation between BR of

MDRT and PPT (modified). It shows

positive significant correlation in 60-69

years of age group i.e. Group – A.

Figure 5: Correlation Graph of Right

Reach (RR) of MDRT and Physical

Performance Test (Modified) of Group -

A.

Figure 5 depicts correlation between RR of

MDRT and PPT (modified). It shows

positive significant correlation in 60-69

years of age group i.e. Group – A.

Figure 6: Correlation Graph Of Lateral

Reach (LR) of MDRT and Physical

Performance Test (Modified) of Group –

A.

Figure 6 depicts correlation between LR of

MDRT and PPT (modified). It shows

positive significant correlation in 60-69

years of age group i.e. Group – A.

Figure 7: Correlation Graph of Balance

Performance Oriented Mobility

Assessment (BPOMA) with Physical

Performance Test (Modified) of Group –

A.

Figure 7 depicts correlation between

BPOMA and Modified PPT (modified). It

shows positive significant correlation in

60-69 years of age group i.e. Group – A.

Table 6: Correlations of balance tests (BBS, MDRT, & BPOMA) with Physical Performance

Test (modified) of Group - B.

Balance Tests r value P value

BBS Vs PPT (modified) .944 < .01

FR( MDRT) Vs PPT (modified) .874 < .01

BR (MDRT) Vs PPT (modified) .893 < .01

RR (MDRT) Vs PPT (modified) .826 < .01

LR (MDRT) Vs PPT (modified) .710 < .01

BPOMA Vs PPT (modified) .856 < .01

Table 6 shows significant correlation between balance tests (BBS, MDRT & BPOMA) and

modified physical performance test in older adults [Group – B (70 – 79 years of age)].

Figure 8: Correlation graph of Berg

Balance Test (BBS) with Physical

Performance Test (Modified) Of Group

– B.

Figure 8 depicts correlation between BBS

and PPT (modified). It shows positive

significant correlation in 70-79 years of

age group i.e. Group – B.

Figure 9: Correlation graph of Forward

Reach of MDRT with Physical

Performance Test (Modified) of Group -

B.

Figure 9 depicts correlation between FR of

MDRT and PPT (modified). It shows

positive significant correlation in 70-79

years of age group i.e. Group – B.

Figure 10: Correlation graph of Backward

Reach (BR) of MDRT with Physical

Performance Test (Modified) Of Group –

B.

Figure 10 depicts correlation between BR

of MDRT and PPT (modified). It shows

positive significant correlation in 70-79

years of age group i.e. Group – B.

Figure 11: Correlation graph of Right

Reach (RR) of MDRT with Physical

Performance Test (Modified) of Group -

B.

Figure 11 depicts correlation between RR

of MDRT and PPT (modified). It shows

positive significant correlation in 70-79

years of age group i.e. Group – B.

Figure 12: Correlation graph of Left

Reach (LR) of MDRT with Physical

Performance Test (Modified) Of Group -

B.

Figure 12 depicts correlation between LR

of MDRT and PPT (modified). It shows

positive significant correlation in 70-79

years of age group i.e. Group – B.

Figure 13: Correlation graph of Balance

Performance Oriented Mobility

Assessment (BPOMA) with Physical

Performance Test (Modified) Of Group -

B.

Figure 13 depicts correlation between

POMA and PPT (modified). It shows

positive significant correlation in 71-79

years of age group i.e. Group – B

Table 7: Correlations of balance tests (BBS, MDRT, & BPOMA) with Physical Performance

Test (Modified) – Group-C.

Balance Tests r value P value

BBS Vs PPT (modified) .789 < .01

FR( MDRT) Vs PPT (modified) .822 < .01

BR (MDRT) Vs PPT (modified) .852 < .01

RR (MDRT) Vs PPT (modified) .770 < .01

LR (MDRT) Vs PPT (modified) .752 < .01

B POMA Vs PPT (modified) .651 < .01

Table 7: also shows significant correlation between balance tests ( BBS, MDRT & BPOMA)

and physical performance test (modified) in older adults [Group – C ( 80 – 89 years of age)].

Figure 14: Correlation graph of Berg

Balance Scale (BBS) with Physical

Performance Test (Modified ) Of Group -

C.

Figure 14 depicts correlation between BBS

and PPT (modified). It shows positive

significant correlation in 81-89 years of

age group i.e. Group – C.

Figure 15: Correlation graph Of Forward

Reach (FR) of MDRT with Physical

Performance Test (Modified) Of Group -

C.

Figure 15 depicts correlation between FR

of MDRT and PPT (modified). It shows

positive significant correlation in 81-89

years of age group i.e. Group – C.

Figure 16: Correlation graph of Backward

Reach (BR) of MDRT with Physical

Performance Test (Modified) of Group -

C.

Figure 16 depicts correlation between BR

of MDRT and PPT. It shows positive

significant correlation in 81-89 years of

age group i.e. Group – C.

Figure 17: Correlation graph of Right

Reach (RR) of MDRT with Physical

Performance Test (Modified) of Group -

C.

Figure 17 depicts correlation between RR

of MDRT and PPT (modified). It shows

positive significant correlation in 81-89

years of age group i.e. Group – C.

Figure 18: Correlation graph of Left

Reach (LR) of MDRT with Physical

Performance Test (Modified) of Group –

C.

Figure 18 depicts correlation between LR

of MDRT and PPT (modified). It shows

positive significant correlation in 81-89

years of age group i.e. Group – C.

Figure 19: Correlation graph of Balance

Performance Oriented Mobility

Assessment (BPOMA) with Physical

Performance Test (Modified) of Group –

C.

Figure 19 depicts correlation between

BPOMA and PPT (modified). It shows

positive significant correlation in 81-89

years of age group i.e. Group – C.

DISCUSSION

Assessing balance and physical

abilities as they relate to falls in older

adults is complex due to many social and

health related issues that may be involved.

The geriatric population above 80 years

adults presents a more complicated

situation due to a sedentary life style, a

lower level of function, and the dynamics

of their physical and emotional

environments. Any one or combination of

these factors may lead to a falls at any time

because the level of the older adult’s

performance may not meet the demands of

the environment or task at hand. The need

to reduce this functional decline is an

important health care issue. It is important

to identify those factors that contribute to

the functional decline. Balance instability

and physical inactivity in older adults

contribute to this decline in ADLs

(activities of daily living). Therefore,

effective balance and functional

assessments are needed to document

balance and functional abilities and in this

segment of the older adult population. This

information is critical to the design of all

prevention/reduction programs and to

maintain or improve the quality of life for

these individuals.25

The BBS, MDRT, & BPOMA have

documented validity and reliability to

assess balance abilities. As well as

physical performance test (modified) has

also documented validity and reliability to

assess functional abilities in community

dwelling older adults. Previous researchers

found significant relationship between

balance scales (BBS, MDRT & BPOMA)

with other functional performance tests;

Barthel mobility subscale, Time up and go

Test and Physical Performance Test

respectively 13, 25, 26. But there is little to no

documentation of relationship between

three balance scales with PPT (modified).

Thus this study was done to find out the

relationship of these three balance scales

with physical performance test (modified).

The clinical trial studied the correlation

between balance tests (BBS, MDRT, &

BPOMA) and physical performance test

(modified) among elderly people who

were divided into three age categories.

Berg Balance Scale (BBS)

The last two items of the Berg Balance

Test are considered the most difficult to

perform. These tasks are: item no. 13 & 14

(stand with feet in tandem for 30 seconds,

stand on one leg respectively), One study

found that item numbers 12, 13, & 14 are

the most difficult tasks to perform,25 but in

the current study only 6 subjects (Group B

& C) found difficulty to perform the 12th

task. All the subjects got grade 4 for the

1st, 2nd, 3rd, & 4th components of the

BBS. Not one subject reached up to 25cm

for the 8th component (Reaching forward

with outstretched arm while standing) of

the BBS.

In the current study the mean values (54,

49 & 42, as shown in tables 2, 3 & 4) of

BBS in different age groups are lower

from the findings (55,55; 53,52; & 52,48

for male and female respectively) of one

study in 3 age groups (60-69, 70-79, &

80+ years).34 This difference may be due

to age difference. They have given the

average mean of age (69); they did not

mention the mean value of age for

individual groups so the subjects of the

this study may be slightly younger than

my study; in this study the mean values for

females in each age group have lower than

males and in the current study the scores

of the tests for the females also lower and

the number of female subjects are more

than males so it could be the reason for

lowest values. Another study found mean

values of BBS in fallers (36.5) and

nonfallers (35.7) older adults;25 these

values are very low as compared to the

current study. The reasons could be one

that the mean age of this study population

is 83±8.8 years which shows very older

subjects. Secondly they examined

community dwelling older adults who

were home bound and have a neurological

or musculoskeletal diagnosis that may

disturb the balance and contribute to falls .

In another study the mean value of BBS is

48.6 and the mean age of this study is

74.1± 7.9 years which is approximately

similar to Group-B of the current study.

The mean value of BBS of the current

study is 49.65 which is slightly more, the

reason could be the age difference because

the mean age of the Group-B is 73.70 ±

2.4 which shows that the subjects were

mostly between 71 to 75 years and the

subjects of the above said study were

mostly between 68 to 81 years, so this

could be the reason for the lowest value of

BBS among 254 community-dwelling

older adults.13

A study done by Patricia S. Smith found

significant relationship between BBS and

forward reach in post acute stroke patients

(r = 0.78).27 The BBS has also been

shown to correlate with both the Tinetti

mobility index (r = 0.91) and the “get up &

go test” (r = - 0.76).28 A correlation greater

than 0.70 between total BBS and total

Fugl-Mayer-Scale (FMS) scores have been

reported in older adults.18 The above

studies shows correlations between BBS

and other functional tests. This current

study also shows significant correlation

between BBS and physical performance

test (modified), [r = 0.759, P = <0.01

(Group - A); r = 0.944, P = <0.01 (Group -

B); ); r = 0.789, P = <0.01 (Group - C); as

shown in tables 5, 6, 7 & figures 2, 8, and

14 respectively]. The reason of significant

correlation between BBS and physical

performance test (modified) could be one

that the five components are similar

between BBS and PPT (modified) and

secondly both BBS and PPT (modified)

assess static and dynamic balance and also

physical activity.

Multi-directional Reach Test (MDRT)

In MDRT backward reach is the most

difficult task to perform because most of

the subjects of the Group-C used to take a

step behind while performing this reach.

MDRT is considered the more time taking

test and most difficult to understand by the

subjects because the mostly older adults

use the spine not the ankle for the reaches.

This current study shows there is a

significant relationship between

components (FR, BR, RR & LR) of

MDRT and physical performance test

(modified) in older adults of different age

groups. It also indicates that there is a

relationship between age and height with

performance on the lateral reach test.

These results similar to the study who

reported that, similar to functional reach

performance is positively correlated with

height and negatively correlated with

age.22 The four heighted persons were

present in the current study, the values of

all the components of MDRT were greater

to these heighted persons as compared to

other subjects. Mean scores on

performance of the functional and lateral

reach tests in the present study are lower

than mean scores reported elsewhere.13,29,

30 In a sample of 14 community dwelling

elderly females (age, 70-87 years), a study

reported a mean functional reach of

26.7±8.9cm.30 In another research, with a

larger sample of 254 elderly community-

dwelling adults (mean age = 74.1±7.9

years), It was reported a mean forward,

backward, right and left reach tests scores

of 22.6±8.6cm, 11.5±7.8cm,17.5±7.6 &

16.8±7.4cm respectively.13 Yet another

study reported mean left and right lateral

reach test scores of 21.0±2.5cm and

20.0±0.5cm respectively, from 60 healthy

females over the age of 65 (mean age =

72.5±5.0 years).29 In each of the above

mentioned studies scores were defined as

the mean multiple trials which may reflect

score inflation due to learning over

multiple trials. In contrast, scores in

present study were recorded from a single

trial. Additionally, subjects used the ankle

movements rather than spine movements

which reflects the negative correlation

between age and ankle muscle strength,

sensation and ability to generate large

amounts of force at the ankle joint.31

One of studies in past have revealed that

MDRT demonstrated significant inverse

relationships with scores on the time up &

go test (TUG): [FR (r = -0.442) BR (r = -

0.333), RR (r = - 0.260), LR (r = - 0.310)

which is a functional performance test.13

Similarly current study showed significant

correlation between MDRT and modified

physical performance test which is again a

functional performance test with high

validity and reliability. Hence it can be

said that MDRT also shows good

correlation with different functional

performance tests.

Tinetti Balance Subscale

During the performance of this test, the

subjects did not find any difficulty with

any of the tasks in the balance of

performance-oriented mobility assessment

(BPOMA) of Tinetti.

One study found a mean among the

community dwelling older women with no

health problems on the balance subset of

12.6±1.7 (mean age = 74.7±6.0 years),32

which is similar to mean value (12.9±2.1,

as shown in table- 3) of Group-B of the

current study (mean age = 73.7±2.4 years,

as shown in table- 1). Another study found

mean value of 13±2.9 among females

(mean age = 83.8±7.7 years),33 which is

more as compared to mean value

(10.5±1.4, as shown in table- 4 ) of Group-

C of the current study, in fact mean age

was similar (82.6±1.3 years, as shown in

table- 1 ). The subjects for Group-C were

all above 80 and physical frailty

component was more among the subjects

of the current study while in the above said

study where mean value was 83.8±7.7

years, many subjects less than may 80

years. Hence the balance scores were

better for them.

Physical Performance Test (Modified-

PPT)

In modified physical performance test, the

Ist & 2nd tasks were considered the most

difficult task to perform by the subjects

mainly for the Groups B & C. Seven

subjects were using the assistive devices

for the 8th & 9th components (climb one

flight of stairs and climb stairs) of the

physical performance test (modified) and

four subjects climbed the stairs by holding

the one sided railing.

In one study it was found that the mean

value of the PPT (modified) score among

27 frail obese older volunteers after

treatment was 29.4±2.2 and for control

group it was 29.8±2.0.34 Mean age was

71.1±5.1for treatment group which

matched the current age of Group – B but

the mean value is lower i.e. 27.6±5.2 as

shown in table- 3, this difference is may be

due to age because in my study the mean

age for the Group - B is 73.7±2.4, which

shows that the subjects were slightly older

which reflects the negative correlation

between age and physical function.35 The

mean age of group-A of current study is

65.2±3.0 which is slightly younger than

the control group (69±4.6) of the above

study, therefore the mean value for this

group of my study is more and second

reason could be that the subjects were

obese which also reflects the negative

correlation between obesity and physical

function.35

Another study found the mean values of

physical performance test (modified) in

community dwelling older adults. The

mean values of three groups [obese

elderly, nonobese frail, and nonobese

nonfrail] were 34.4±0.5, 29.3±0.7 and

27.8±0.8 respectively.15 The second group

of above study matched with Group - B of

the current study in respect similar age,

weight and condition but the mean value

of physical performance test (modified) is

more than the current study, the reason

could be that the subjects of my study may

be more frail and reason could be the

larger number of female subject in the

current study compared to this study, there

both genders were in equal proportion

while in the current study out of 20

subjects 16 were female. It has been well

established that in females balance

component is affected due to larger body

mass in the upper segment the of body.

The age is an important factor that affects

both balance and physical function of

older adults. Declines in standing balance

have been attributed to sensory,

musculoskeletal and cognitive changes,

typically in some combination as multiple

systems fall below minimal functional

thresholds.36 The results of the balance

tests and physical performance test

(modified) are different in different age

groups of older adults, which proved that

the disturbance in balance and physical

function also differ in severity (mild,

moderate and severe for group A, B & C

respectively) among different age groups

of older adults. Thus assessment and

treatment also differ to provide effective

evaluation and treatment in different age

groups. Additionally safety measures are

necessary for the Group – C (80-89 years

of age) in the assessment and treatment

also to prevent fall.

CONCLUSION

There is a significant relationship between

balance tests and physical performance test

(modified) and physical performance test

(modified) is an efficient tool to assess

static and dynamic balance and also

physical function and ambulation in

different age groups of older adults. It was

also observed that out of the these balance

tests used in the study, MDRT was the

most difficult to understand and perform

for people above 70 years and subjects

above 80 years found it really hard to

understand the procedure. According to

this test the subject was supposed to

perform movement at the ankle joint but

more of trunkal mobility was seen in

people above 80 years while performing

this test. Hence it can be said that MDRT

is not a very feasible test for cheeking

balance in subjects above 80 years.

Clinical significance

As the Indian population over the age of

60 years continues to grow, there will be

rise in the level of functional disability and

prolonging health. It is therefore

imperative that appropriate screening

methods are developed to identify

community dwelling elderly individuals

with functional impairment who should be

referred for a detailed physical therapy

evaluation. As we have seen that PPT

(modified) incorporates all important

entities of balance and function hence,

simply administering modified physical

performance testing can well define the

functional level as well as the balance

issues in an elderly person rather than

giving other tests which are time taking,

separately for balance and functional

performance.

Limitations

In the present study, the sample size was

small. The sample size of age Group – C

(81-89 years of age) was relatively smaller

as compared to other groups. Gait subscale

of performance oriented mobility

assessment is not included in this study.

Future Research

Future study can be done with larger

sample size to see the results. Future

research is needed to find out the

reliability and validity of modified

physical performance test with balance

scales (PPT, MDRT & BPOMA) in

elderly. In my study the value of the left

lateral reach is more than right lateral

reach for the heighted person. Future study

can be done to identify that why this

difference has come and this difference is

significant or not.

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Johnson. Measures of adult general

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35. Marc Bonnefoy, Tomasz Kostka,

Marie C. Patricol, Sophic E,

Bethouze, Brono Mathian et al.

Physical activity and

dehydroepiandrosterone sulphate,

insulin-like growth 1 and

testosterone in healthy active

elderly people. J Ageing oxford

journals. 1998;27:745-751.

36. Dr. Sandra Brauer, Y Voner Burns,

Prudence Galley. Lateral reach: a

clinical measure of medio-lateral

postural stability. J Phys Ther Res

Int. 1990;4:81-88

CORRESPONDENCE

*Student, Dolphin Institute, Dehradun affiliated to H.N.B Garhwal University, Uttarakhand,

India Mob: 08882590557. **Lecturer, Dolphin Institute, Uttarakhand. India

Electrical Muscle Stimulation (EMS) Improve Functional Independence in

Critically Ill Patients

Dharam Pani Pandey PT*, Dr. Uday Shankar Sharma**,Dr. Ram Babu***

Abstract: Objective. This study was designed to investigate the effects of

electrical muscle stimulation (EMS) on strength of muscle groups stimulated and

improvement in functional independence in critically ill patients .Methods. 134

subjects were recruited among the patient admitted in multidisciplinary intensive

care units and randomly divided in to control and EMS group. Patients unable to

understand or speak English and or Hindi due to language barrier or cognitive

impairment prior to admission, unable to transfer from bed to chair at baseline

prior to hospital admission, Patient with known history of primary systemic

neuromuscular disease were excluded from study. Results. EMS group patients

achieved higher MRC scores than controls in knee extensors and ankle

dorsiflexors. Independence level was higher in EMS group Conclusions. EMS

application constitutes a promising means of muscle strength preservation and

early mobilization which can directly reflects the gain in functional independence

post ICU discharge in critically ill patients.

Key words: Electrical muscle stimulation, muscle strength, CIPNM, CIM,

functional independence

INTRODUCTION

Weakness that is acquired during

hospitalization for critical illness is

increasingly recognized as common and

important clinical problem. Weakness

acquired in the intensive care unit (ICU)

and related acquired neuromuscular

dysfunction occur in a large percentage of

critically ill patients1–3 and are associated

with increased morbidity and mortality.4,5

Critical illness polyneuromyopathy

(CIPNM) is an acquired neuromuscular

disorder observed in survivors of acute

critical illness. It is characterized by

profound muscle weakness and

diminished or absent deep tendon

reflexes1 and is associated with delayed

weaning from mechanical ventilation2

suggesting a possible relation between

limb and respiratory neuromuscular

involvement. In addition, the syndrome is

associated with prolonged hospitalization

and increased mortality.3 The diagnosis of

CIPNM requires a reliable bedside muscle

strength examination and depends on

patient's cooperation and maximal effort.4

Several risk factors have been identified

including systemic inflammatory response

and sepsis5, medications such as

corticosteroids6 and neuromuscular

blocking agents7, inadequate glycemic

control8, protracted immobility4,

hypoalbuminemia9, Gram-negative

bacteremia9 and severity of organ

dysfunction.10 Thus, looking for the

potentially reversible risk factors and

subsequent adjustment of therapy are so

far advocated as preventive measures to

decrease the risk of CIPNM.

A very few of studies available suggesting

the treatment and prevention of critical

illness myopathy these includes intensive

insulin therapy, optimal gycemic control

and minimized use of neuromuscular

blocking agents, high dose and prolong

use of corticosteroids.

OBJECTIVE OF THE STUDY

The objective of this study is to

investigate whether electrical muscle

stimulation (EMS) will improve

functional independence in critically ill

patients.

Our experimental Hypothesis was that

“EMS would beneficially affect muscle

functional status and will improve

functional independence in critically ill

patients.

MATERIAL AND METHODS

Subjects:

The 134 subjects were recruited among

the patient admitted in multidisciplinary

intensive care units during the study

period.

Exclusion criteria:

Unable to understand or speak English

and or Hindi due to language barrier or

cognitive impairment prior to admission,

unable to independently transfer from bed

to chair at baseline prior to hospital

admission (based on detail history taken

from caregivers. Patient with known

history of primary systemic

neuromuscular disease, vascular events,

organ transplant, intracranial process that

is associated with localizing weakness,

transferred from another ICU after >2

consecutive days of mechanical

ventilation, amputation of lower

extremities, any limitation of life support,

pregnancy, age under 18 years, obesity,

technical obstacles that did not allow the

implementation of EMS such as bone

fractures, skin lesions and, end-stage

malignancy were excluded from our study

Design of study:

The study employed a randomized single

blind controlled experimental study design

consisting of two group experimental

group and control group, Subjects were

randomly assigned ether to experimental

group or to control group everyday the

ICU patient admission register were

observed and with in 24 hour the

assessment were done , each time when a

patient met the criteria for inclusion a

random number were picked up between 1

to 10 using sealed envelope method if it

were an odd number than the subject were

assigned to experimental group similarly

if it even number were obtained the

subjects were assigned to control group.

Intervention:

EMS was implemented on knee

extensors, tibialis anterior and of both

lower extremities. Patients received daily

sessions. After skin cleaning, rectangular

electrodes (90 × 50 mm) were placed on

motor point of targeted muscle. The

stimulator (Unistim, HMS medical

system) delivered biphasic, symmetric

impulses of 50 Hz, 100 sec pulse

duration, 12 seconds at intensities able to

cause visible contractions. The duration of

the session was 30 minutes each muscle

group. EMS sessions were continued until

ICU discharge, both group were getting

routine physiotherapy included the passive

movements, active assisted movements

and chest physiotherapy.

Outcome Measures:

Primary Outcome Measures were the

score of barthel index, it is reliable and

valid outcome measure used to assess

functional independence.

Secondary Outcome Measures were lower

extremity strength, at ICU discharge, of 2

bilateral muscle groups which were

stimulated measured by MMT using a

composite Medical Research Council

(MRC) score.

DATA ANALYSIS AND RESULTS

All continuous variables were presented

by mean. The statistical significance of P

value was set at 0.05. One-way repeated

measures analysis of variance (ANOVA)

was made to compare MRC Grading and

barthel index score between-group. Two

hundred and thirty-eight patients were

admitted to our multidisciplinary ICU

during the eight-month study period and

104 patients fulfilled the exclusion criteria

or stayed in the ICU less than 48 hours.

The study population consisted of 134

patients of which of these patients, 70

were randomly assigned to the EMS group

and 64 to the control group. 6 patients

from EMS group and 1 patient from

control died or were discharged from the

ICU before the second measurement.

MRC muscle grading score of muscle

group being stimulated were for left knee

extensors were control group mean 3.49

and EMS group mean 3.91 (p = 0.0187),

right knee extensors control group mean

3.69 and EMS group mean 3.87 (p =

0.0387). left ankle dorsiflexors control

group mean 3.78 and EMS group mean

3.91 (p = 0.04), right ankle dorsiflexors

were observed as follows mean control

group mean 3.37 and EMS group mean

3.3.46 (p = 0.0587) found.

Barthel index score of control group was

(mean) 68.6 and EMS group (mean) 71.9

and found significant between groups (p =

0.010).

Graph 1: Showing the mean and

significance level of two group of left and

right knee extensor.

Graph 2: Showing the mean and

significance level of two group of left and

right ankle dorsiflexors.

Graph 3: Showing the mean and

significance level functional independence

level as assessed on barthel index.

DISCUSSION

The main finding of our randomized

controlled study is that EMS of lower

extremities seems to preserve the muscle

strength of critically ill patients as

assessed with MRC muscle strength

grading system. EMS of lower extremities

applied to critically ill patients upon

admission is associated with a lesser

degree of muscle strength loss of these

patients as assessed with MRC muscle

strength grading system. barthel index

score were higher in EMS group and the

patient of EMS group were more

independent.

Electrical stimulation has been used to

increase strength and endurance in

partially and fully paralyzed muscle. It has

been used for peroneal nerve stimulation10,

11 the restoration of shoulder movement12,

recovery of tendonesis grip13, and in the

use of an upper arm prosthesis.14

Electrical muscle stimulation (EMS) has

been used as an alternative to active

exercise in patients with chronic heart

failure (CHF)15 and chronic obstructive

pulmonary disease (COPD).16, 17 Many of

these patients, even those who are

clinically unstable, experience severe

dyspnea on exertion, which can prohibit

the regular application of conventional

exercise training, considered necessary for

an integrated therapeutic approach. In a

recent systematic review, EMS

implementation in most of the selected

controlled clinical trials produced

significant improvements in muscle

strength, exercise capacity and disease-

specific health status.18 Recently, an study

identified an acute systemic effect exerted

by EMS on peripheral microcirculation of

critically ill patients.19 Specifically, after

performing a 45-minute session of EMS

on the lower extremities, an improvement

in the microcirculation of the thenar

muscle as assessed by near infrared

spectroscopy technique was observed.

EMS, as a possible substitute to aerobic

and resistance exercise training in severe

CHF and COPD patients, has been shown

to improve muscle performance, aerobic

exercise capacity, and disease-specific

health status.9-11

CONCLUSIONS

EMS exercise induces beneficial effects in

muscle strength of ICU patients. These

effects mainly concern muscle groups

directly stimulated, but there is also

evidence of effects in muscle groups not

stimulated. EMS application constitutes a

promising means of muscle strength

preservation and early mobilization which

can directly reflects the gain in functional

independence post ICU discharge in

critically ill patients.

Clinical relevance & limitation

EMS is an alternative method of exercise

causing minimal discomfort to patients

who are not able to perform any form of

physical exercise, as is often the case in

critically ill patients. It is a limitation of

this study that it did not evaluated the

follow up stage and upper extremities

function. Further studies are needed to

explore the possible role of EMS as a tool

for preserving the muscle strength and

gain in functional independence post ICU

discharge with longer follow up

evaluation, the muscle properties and

preventing CIPNM in critically ill patients

and to define which patients would benefit

most from this intervention.

REFERENCES:

1. De Jonghe B, Sharshar T,

Lefaucheur JP, Authier FJ,

Durand-Zaleski I, Boussarsar M, et

al; Groupe de Reflexion et d’Etude

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FG. Risk factors for the

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ACKNOWLEDGMENT:

We would like also to acknowledge the support of all intensive care unit staff, consultants

and all the patients caregivers.

CORRESPONDENCE:

*Department Of Physiotherapy & Rehabilitation,BLK Super Speciality Hospital, Pusa Road,

New Delhi, India. **Sr. Consultant Neurologist, Department of Neurology, Jaipur Golden

Hospital,2 institutional area, sector 3, Rohini, New Delhi, India. ***Sr. Consultant Physician,

Department of Internal, Medicine, Jaipur Golden Hospital,2 institutional area, sector 3,

Rohini, New Delhi, India.

Paraplegia with Sacral Pressure ulcer treated by Ultrasound therapy- A

Single Case Report

Shanmuga Raju P. MPT *, Ramalingam P. MS, FICA, MAMS

Abstract: Pressure ulcers are important and common complications after

paraplegia. The use of therapeutic ultrasound as an adjunct to wound healing has

gained interest in recent years. An twenty five year old male reported with a two

months history of a grade two, non healing, sacral pressure ulcer. Ultrasound

therapy (UST) is simple, safe, without side effects, bedside procedure, inexpensive

with positive wound healing results for difficult to treat non healing pressure sore.

I hope that this article will encourage other wound care specialists to engage in

further research in this area.

Key Words: Paraplegia, Sacral pressure ulcer; Continuous mode of ultrasound

therapy; wound healing.

INTRODUCTION

Pressure Ulcer, also called as Decubitus

ulcers, was first seriously studied by

“Jean- Martin Charcot”, a clinician in the

19th Century (1-3). Pressure ulcer is a

serious health issue, very painful, a

significant physiological challenge, can

shorten the life of patient, an emotional

and financial burden to the patient.

Pressure sore are important and common

complications after paraplegia. An

estimated 50 – 80% of individuals

suffering from spinal cord injury develop

pressure ulcer at least once in their life

time (9). Pressure ulcer are treated by

using wound dressings, relieving pressure

on the wound, Water beds/ Alpha bed by

treating concurrent conditions which may

delay healing and by the use of physical

therapy such as electrical stimulation, laser

therapy and ultrasound (1).

Ultrasound is now the most frequently

used electrophysical agent worldwide,

used at least daily for patient treatment by

the majority of physiotherapists (4-5).The

aim of this study to investigate the effect

of ultrasound (US) therapy in sacral

pressure ulcer with paraplegia. Limited

clinical research is available and no

consensus exists regarding the efficacy of

ultrasound for treating pressure ulcer,

particularly full thickness pressure ulcers.

CASE REPORT

A twenty five year old man presented with

a two months history of a grade two, non

healing sacral pressure ulcer. He was a

former. He had history of fall from height.

His past medical history, complete

paralysis of both lower limbs, loss of

sensation, urinary and bladder

incontinence, loss of mobility and sacral

pressure ulcer for past one month. His

medical problems included spinal cord

injury and severe depression. He had

become unable to walk since two months

and was carried either in bed or in his

wheelchair. He was diagnosed as a case of

D11, and D12 wedge compression of spine

with traumatic paraplegia (American

spinal cord injury association impairment

score: A- no motor or sensory function in

the sacral segments) and sacral pressure

ulcer. Five month back, he underwent

placement of spinal fixation rods and

plates from D11 to L1 level. A thoraco

Lumbar-sacral corset was fabricated for

him. Routine hematology and

biochemistry investigations were within

normal limits. He received antibiotics and

vitamin supplements. He was referred to

department of physical medicine and

rehabilitation OPD, CAIMS, Karimnagar

on February 26th, 2011.

On physical examination, he is bed ridden

and was unable to sit without support in

the chair, had sustained the sacral pressure

ulcer. He has bedsore of 6.2 X 4.0 cm, the

depth ranging from 10mm, grade II sacrum

ulcer with necrotic slough according to

European pressure ulcer Advisory panel

(EPUAP) wound classification system

(Figure.1). His albumin count 2.4 g/dL,

haemoglobin 11.0 g/dL, temperature was

38 degree Celsius. There was no evidence

of osteomyelitis. He was put on

conservative treatment, consisting of water

bed mattress, bed postioning, regular

pressure relief, daily saline water dressing

and appropriate antibiotics.

OUTCOMES EVALUATED

Wound measurements and digital

photographs of wound beds were obtained

weekly. Wound dimension monitored and

depth measurements were obtained using a

sterile, cotton-tip applicator and ruler

(Steven JK et al, 2007). Wound surface

area was determined using Bates-Jenes

wound assessment tool.

ULTRASOUND THERAPY

INTERVENTION

On February 2011, Continuous mode of

ultrasound therapy (Electroson 709,

Chennai) treatment was performed in

sacral pressure ulcer region. The

following protocols are applied: ultrasound

machine with frequency of 3 MHz and

spatial average intensity 0.8 w/cm2 sound

head, in conjunction with a coupling media

of aquasonic ultrasound transmission gel

was used. Ultrasound was applied to the

outer surface, and edge of sacral ulcer

region (Fig. 2). Before the treatment of

CUS therapy, we splashed each wound by

oxygen spray. Sacrum ulcer was cleaned

using 2% hydrogen peroxide. The standard

normal saline (Nacl) dressing was done.

Ultrasound treatment time was 10 minutes

per session 6 days a week, for six weeks.

At the end of third week there was marked

improvement in pressure ulcer i.e size,

floor and wound margin reduced. There

was no pus discharge after treatment (Fig.

3). A healthy granulation tissue was noted

(Fig. 4). The patient made good progress

and wound was completely healed within

42 days (Fig. 5).

Table: 1 Parameter of Ultrasound

therapy treatment (McDiarmid etal, 1985)

• Ultrasound frequency: 3 MHz

• Spatial average temporal peak

intensity: 0.8 W/cm2

• Pulse duration: 2 ms

• Duty factor: 0.2

• Spatial temporal average radiating

surface area: 5.2 cm2

• Duration of treatment: 10 minutes

per session for sacral pressure ulcer

• Duration of treatment: 6 weeks

RESULT

The indolent pressure ulcer, apart from

routine therapy, continuous mode

ultrasound therapy enhanced the healing of

pressure ulcer in six weeks.

Fig: 1 On assessment, the sacral pressure

ulcer presented as non- healing grade II

pressure ulcer measuring 6.2 x 4.0 cm with

erythema.

Fig: 2 the full thickness of sacral ulcer was

treated with continuous mode ultrasound

therapy (CUST)

Fig: 3 three weeks after the treatment of

CUST

Fig: 4 Fifth weeks after CUST, the wound

size are decreased for sacral ulcer

Fig: 5 After six week of treatment, picture

showing that sacral pressure ulcer are

completely healed.

DISCUSSION

The purpose of the study was to assess the

effect of ultrasound therapy in healing of

sacrum pressure ulcer in patients with

paraplegia. Infected sores heal more

slowly than clean sores while no effect of

ultrasound clean sores were observed

ultrasound therapy appeared to improve

the rate of healing of infected sores. It is

non thermal effect produced by ultrasound

that are most significant in the stimulation

of tissue repair (Dyson, 1976). Paul et al

(1960) ultrasound was effective in

relieving congestion, cleansing necrotic

areas and promoting healing with healthy,

non-adherent skin approaching normal

thickness. Cyclic vibration effect of

ultrasound might induced a form of micro

massage which by reducing edema, might

facilitate repair, their requires further

investigations. It is also stimulate protein

synthesis infact ultrasound initiates two

processess which results in release of

energy tissue: Surface cavitation (creation

and dissipation of tiny bubbles in the

tissues) and acoustic microstreaming that

is movement of fluids along acoustic

boundaries, such as cell membrane. This

biophysical effect that are non-thermal

alternations in cellular protein synthesis

and release, blood flow and vascular

permeability, angiogenesis, and collagen

content and alignment by various workers

it as quoted as follows: 1. General protein

and collagen synthesis by fibroplasts

(Harvey etal, 1975, Webster etal. 1980). 2.

Fibroplast mobility (Miller etal, 1978). 3.

Fibroblast ultrastructure (Dyson and Pond,

1970). 4. Permeability of fibroblast

membrane (Harvey etal, 1975). 5.

Lysosomal fragilty (Tayor and Pond,

1972). 6. Tensile strength and elasticity of

scar tissue (Dyson et al, 1979). 7.

Modification of contraction in skin

wounds (Dyson et al, 1981).

With this parameters of ultrasound

treatment (frequency 3 MHz, Intensity 0.8

W/cm2, Pulse duration 2 ms, Duty cycle

0.2, effective radiating surface area 5.2

cm2, Duration of treatment 10 minute

per/session, Duration of frequency 6

weeks) pressure ulcer healed in time

without side effects. Our case study

showed that continuous mode of

ultrasound therapy treatment enhances

healing of sacral pressure ulcer. This case

study confirmed that continuous UST has

a positive effect on pressure ulcer with

paraplegia (Fig.5). No complications were

observed with application of the

continuous ultrasound. Further studies are

needed to evaluate the efficacy of

ultrasound therapy in pressure ulcers in

spinal cord injury in a large number of

patients.

CONCLUSION

Continuous mode of ultrasound therapy

was effective in the treatment of patient

with grade II pressure ulcer in young

paraplegic patient. Ultrasound therapy

treatment of pressure ulcer is less

expensive, more comfortable and can

enhance wound healing process without

side effects and complication.

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ACKNOWLEDGMENT:

I thank the men who participated in this trial. I would also like to thank chairman Sri. C.

Lakshmi Narasimha Rao, Prof. V. Suryanarayana Reddy, Director, Chalmeda Anand Rao

Institute of Medical Sciences, Karimnagar for his support and encouragement of this study.

CORRESPONDENCE:

*Asst. Professor & I/C Head, Department of Physical Medicine and Rehabilitation Chalmeda

Anand Rao Institute of Medical Sciences Karimnagar -505001, Andhra Pradesh, INDIA.

Mobile: 08790544270, Fax: 0878-2285318. E-mail: shanmugampt@rediffmail.com

Effectiveness of Educational Sessions on Reducing Diabetes in Women with

PCOS— A Pilot Study

B. Sharmila, BPT, MSc (Yoga)*, B. Arun, MPT**

Abstract: PCOS (Poly cystic ovarian syndrome) is one of the common syndromes

in females, around 10 % of females in world having PCOS. PCOS have a strong

link on Diabetes. Study is a descriptive study to find out the effect of educational

session on diabetes for women who has PCOS. Around 20 females with PCOS

were selected, an Educational session was conducted for duration of 4 weeks, and

Diabetic Questionnaire was given to analyze the knowledge of diabetes. Following

the 4 weeks of educational sessions, all participants have gained a good

knowledge on PCOS and Diabetes. This study concludes that educational session

is very important for the management of Diabetes and especially for females who

has PCOS.

Key words: Type II diabetes, PCOS, Educational Session, Diabetic Questionnaire.

INTRODUCTION

Diabetes is one of the most common health

problems in the world. India is the capital

of diabetes. Many studies conducted in

India showed that prevalence of type 2

diabetes was more and it is increasing in

urban populations1, 2. Diabetes exerts a

significant impact on the lives of

individuals and their family members due

to the constant need for decision-making

and actions to promote good glycemic

control, an outcome acknowledged as the

foremost goal in diabetes care and

treatment3.

The burden of diabetes on women is

unique, because the disease can affect both

mothers and their unborn children.

Diabetes can cause difficulties during

pregnancy such as a miscarriage or a baby

born with birth defects. Women with

diabetes are also more likely to have a

heart attack and at a younger age than

women who do not have diabetes. Type 2

diabetes is strongly associated with

Women who suffer from PCOS (Poly

cystic ovarian syndrome). PCOS is a

leading cause of menstrual irregularity and

female infertility. The Statistical links

between diabetes and PCOS are very

strong about 5%--10% of reproductive age

women have PCOS and 50% --70% of

women with PCOS also experience insulin

resistance and 20%--40% obese women

with PCOS may have insulin resistance

and diabetes.

Polycystic ovary syndrome (PCOS) is

a common endocrine disorder, affecting

women in reproductive age, characterized

by chronic anovulation and

hyperandrogenism. The etiology of PCOS

is still unknown. However, several studies

have suggested that insulin resistance

plays an important role in the pathogenesis

of the syndrome. The risk of glucose

intolerance among PCOS subjects seems

to be approximately 5 to 10 fold higher

than normal and appears not limited to a

single ethnic group. Moreover, the onset of

glucose intolerance in PCOS women has

been reported to occur at an earlier age

than in the normal population

(approximately by the 3rd-4th decade of

life). However, other risk factors such as

obesity, a positive family history of type 2

diabetes and hyperandrogenism may

contribute to increasing the diabetes risk in

PCOS4. Dr.Geoffrey Redmond said that

“There is no question about the

association” one of the problems is that

people haven’t put the pieces together” He

added that there is a strong association

between PCOS and Insulin resistance.

While focusing the infertility and

menstrual changes, health care

professionals should also look for the

chance of diabetes, and screening of

diabetes is much desirable.

Women with polycystic ovary

syndrome (PCOS) are insulin resistant,

have insulin secretory defects, and are at

high risk for glucose intolerance. PCOS

women are at significantly increased risk

for IGT and type 2 diabetes mellitus at all

weights and at a young age, The

prevalence rates are similar in 2 different

populations of PCOS women, suggesting

that PCOS may be a more important risk

factor than ethnicity or race for glucose

intolerance in young women, and the

American Diabetes Association diabetes

diagnostic criteria failed to detect a

significant number of PCOS women with

diabetes by post challenge glucose values5.

Type 2 Diabetes has pancreas that

produces little or no insulin. As the

pancreas struggles to keep up with the

body's need for more insulin, excessive

levels of glucose and insulin build up in

the blood stream, often leading directly to

Type 2 Diabetes.

Certain factors that figure in the onset of

PCOS are also implicated in the

development of Type 2 Diabetes:

excessive abdominal fat, high LDL "bad"

blood cholesterol and low HDL "good"

cholesterol, high levels of triglycerides and

hypertension (high blood pressure).

Although PCOS is much perceived as

gynecological disorder because it impairs

fertility and can cause irregular periods or

no periods at all. Evidences suggest that

PCOS is more of a disorder of the

endocrine system with gynecological

consequences.

Diabetes Prevention Program study

2001, study shows that all of the factors

associated with Insulin Resistance,

Polycystic Ovarian Syndrome and Pre-

Diabetes are interrelated. Obesity and lack

of exercise worsen Insulin Resistance,

which then has a negative effect on blood

lipid production, increasing VLDL (very

low-density lipoprotein), LDL cholesterol

(low-density lipoprotein - the "bad"

cholesterol) and triglyceride levels in the

blood stream, as well as decreasing HDL

cholesterol (high-density lipoprotein - the

"good" cholesterol.)

While there is no cure for diabetes, a

number of steps can be taken to prevent

complications. Research showed that

losing 5-7% of body fat and increasing

physical activity by taking a brisk walk 4-5

times a week can reduce risk of developing

Type 2 Diabetes by almost 60%.

DIABETES PCOS LINK

Need for the study:

It's important to understand the distinction

between Insulin Resistance and Type 2

Diabetes. Type 2 Diabetes is one of the

top fatal disorders in the World. In 2000, it

was the sixth leading cause of death and

has been associated with long term

complications affecting almost every part

of the body, including blindness, heart and

blood vessel disease, stroke, kidney

failure, amputations and nerve damage.

Obese women are particularly susceptible

to PCOS and Type 2 Diabetes. A vicious

cycle quickly forms because these

conditions, in turn, put women at

dramatically increased risk of

Cardiovascular Disease, as well as the

development of many other serious health

conditions, including stroke, kidney

damage and blindness. Overweight women

do not, however, have a monopoly of

Polycystic Ovarian Syndrome and its

related disorders because females of

normal weight and even lean women are

also prone to these conditions.

Insulin Resistance occurs when the body

produces enough insulin but its cells lack

enough receptor sites to allow the

absorption of insulin at a cellular level.

Type 2 Diabetes develops when the body

either doesn't produce enough insulin or it

can't process the insulin that is produced.

Aim of the study:

To m

Study Objectives:

To educate the patient about disease

(PCOS) and teach on link between PCOS

and Diabetes

To make the patient learn about the

preventive methods

To reduce the risk of getting diabetes

To make patient to understand the

importance of Diet, Exercises etc.

METHODOLOGY:

The study is a descriptive study design,

100 women with PCOS were examined by

the Gynecologist and 20 women were

selected for the study. The subjects were

selected based on age group of 25—

33years, Married females, Married within

2 years, Obese or female in Borderline

obesity. No history of conception, No

other gynecological problems like irregular

menstrual periods or small uterus. No

other relevant medical problems. Before

initiating the study Blood test was

conducted to check their random blood

sugar levels. Clear instructions were given

to all the participants. The educational

class is for 4 weeks of duration and the

Diabetic educator role is to make all

participants attending all the sessions.

Prior to the class a Diabetic knowledge

Questionnaire was distributed to all

individuals and to find out how much

knowledge on Diabetes and PCOS. The

questionnaire was a single paged one

which includes the questions about the

knowledge on diabetes and the knowledge

on PCOS. The participants were asked to

fill up the questionnaire with Yes or No.

Questions are valued as 1 point for Yes

and 0 point for No. Educational Classes

conducted on Every Sunday Morning (10

am —1 pm). The content of the Classes

include 1) What is PCOS 2) What are the

Causes 3) Symptoms of Diabetes with

PCOS 4) Diabetes Link with PCOS 5)

Prevention Methods. The questions asked

by the women participants were clarified.

At the end of the programme all

participants were instructed to fill up the

questionnaire and their performance was

assessed. At the end of the 4 week class

the questionnaire was repeated and

assessed the knowledge on diabetes for

women with PCOS.

RESULTS:

The demographic data about the subjects

were mentioned in Table 1.

Table 1

Demographic Data

Age

Group

25—27 28—30 31—33

7 6 7

Figure 1

The Table 2 shows the result using

students ‘t’ test.

GroupsPre

Test

Post

TestS.D

Paired ‘t’

Value

mean mean

3.8 7.85 0.28514.19

(P<0.05%)

Figure 2

Table 2 shows the paired t values of the

Diabetic Questionnaire. This shows that

the educational programme has shown

positive effect on the participant’s attitude.

It also shows that there was a significant

improvement on the knowledge on

diabetes mellitus.

DISCUSSION:

Women with PCOS are generally

Overweight or Obese. Because of obesity

they have more chance of insulin

resistance. Usually women with PCOS

don’t have a regular check up on diabetes.

But screening for diabetes is very

important in prevention of diabetes. A root

cause of Polycystic Ovarian Syndrome

(PCOS) is obesity-linked Insulin

Resistance, which can also increase the

risk of developing Pre-Diabetes and Type

2 Diabetes. All are disorders that may

result in Cardiovascular Disease leading to

a heart attack or stroke. Creating self

awareness in people with PCOS is very

important, so that the Type 2, diabetes can

be prevented as well as prevent the

complications following diabetes.

Women with PCOS (Polycystic Ovarian

Syndrome) who become pregnant may

experience more health problems than the

general population, including gestational

diabetes, pregnancy-induced high blood

pressure, miscarriage and premature

delivery.

Polycystic ovary syndrome (PCOS) is a

common endocrine disorder, affecting

women in reproductive age, characterized

by chronic anovulation and

hyperandrogenism. The etiology of PCOS

is still unknown. However, several studies

have suggested that insulin resistance

plays an important role in the pathogenesis

of the syndrome. The risk of glucose

intolerance among PCOS subjects seems

to be approximately 5 to 10 fold higher

than normal and appears not limited to a

single ethnic group. Moreover, the onset of

glucose intolerance in PCOS women has

been reported to occur at an earlier age

than in the normal population

(approximately by the 3rd-4th decade of

life). However, other risk factors such as

obesity, a positive family history of type 2

diabetes and hyperandrogenism may

contribute to increasing the diabetes risk in

PCOS

The link of PCOS with insulin resistance

was subsequently established by clinical

studies characterizing the profound insulin

resistance in obese and lean PCOS

patients. Insulin resistance,

hyperinsulinemia, and beta-cell

dysfunction are very common in PCOS,

but are not required for the diagnosis.

Polycystic ovary syndrome (PCOS) is a

major risk factor for impaired glucose

tolerance (IGT) and type 2 diabetes

mellitus (T2D). Several studies have

examined possible mechanisms related to

glucose metabolism and insulin secretion

that may be responsible for the high

prevalence of disorders of glucose

metabolism in women with PCOS. The

actual pathogenic mechanisms appear to

be complex and multifactorial, possibly

characterized by the lack of uniformity

between patients, thus reflecting the

heterogeneity of PCOS. Impaired insulin

action and/or beta-cell dysfunction and/or

decreased hepatic clearance of insulin have

been implicated so far.

The overall risk of developing diabetes

mellitus and glucose intolerance seems to

be higher in women with polycystic ovary

syndrome (PCOS) than in healthy women.

Limitations of this study include, no

control group, it was a pilot study; need a

bigger study to evaluate the effectiveness

of the programme. Blood report

investigations can show some reliable

information. Efficacy of the treatment can

also be evaluated through objective

methods.

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APPENDIX I

DIABETIC QUESTIONNAIRE

Name : Date :

Age :

Occupation :

Address :

Weight :__________ Kgs.

Height : __________CMS

BMI :

Do you have Diabetes : YES / NO

If YES, How long :___________ Months/ Years.

Are you in medications for Diabetes : YES / NO

If YES, Specify medicines : ________, ___________, ___________

Do you have PCOS : YES / NO

If YES, Since when : ____________ Months / Years

Are you in medications for PCOS : YES / NO

If YES, Specify medicines : ________, ___________, ___________

Please fill up the given statement with Yes or No.

S.No STATEMENT Yes No

1. Do you know symptoms of Diabetes

2. Do you know about PCOS

3. Do you know Obesity may cause Diabetes

4. Do you know Obesity may cause PCOS

5. Do you know relation between PCOS & Diabetes

6. Do you know the Risk factors for Diabetes

7. Do you think it is good to do Exercises regularly

8. Do you think intake of Rice may cause Diabetes

9. Do you think you can get Diabetes

10. Do your Parents or Relative have Diabetes

Signature of the Participants Signature of the

Assessor

CORRESPONDENCE:

*Physiotherapist, K.M.C.H Hospital, Coimbatore. Email: sharmibala85@gmail.com.

**Physiotherapist, K.G. Hospital, Coimbatore.

Perception of students for laptop ergonomics and its use in the learning

centre of Sheffield Hallam University, U.K.

Mayank Pushkar. BPT, MSAPT (Musculoskeletal)*, Shobhit Sagar. BPT, MSAPT

(Musculoskelatal)**

Abstract: Background and purpose: Laptop ergonomics is one of the most

concerned topics which result in high number of symptoms. The aim of this study

is to find out student’s perception about laptop ergonomics and how to make the

learning centre more laptop friendly. Methodology: A Qualitative survey with

questionnaire consisting of both open and close ended questions was used. 80

volunteer participants participated in this study. Convenience Sampling was used

for the selection of participants. Qualitative Content Analysis has been used for

the analysis of the data. Results: It was observed that most of the students use

laptop but they also get musculoskeletal problems (Laptopitis) because of the

extended use and adopting improper posture while using laptop. Poor adaptation

of posture was mainly because of unawareness about laptop ergonomics and also

because of poor set-up in the learning centre. Conclusion: Laptop can be used in

more friendly way without causing any discomfort if both the factors (awareness

and ergonomics setup) will be considered. Also the awareness about the laptop

ergonomics and proper posture should be spread among student populations as

most of students from other faculties (0ther than related with health faculty) was

not aware about the proper posture and ergonomics.

Keywords: Laptop Ergonomics, Library Setup, Workplace Ergonomics,

Laptopitis/ Laptop Related Injury

INTRODUCTION

Now a days, technological advances such

as use of personal computers directly

affect the life of people1. As per the

National Centre for Education Statistics

(2000), the number of students using

computers has increased by more than

50% between 1985 and 1999 in the United

Kingdom alone. With 98% of universities

having internet facilities, the number of

students opting for use of laptops to

conduct their activities is also

increasing2.In fact, 80% of British students

own a laptop in which 40% spends 3 – 4

hours daily on internet3. Laptops are

widely being used by professionals who

need to travel and work in different places

like office or college4. This phenomenon

is occurring largely because of the many

benefits accruing from laptops. Laptop

offers high technology performance in a

compact, light, portable and self-sufficient

with battery provided2.

It may be noted though, that the laptop was

not configured for long or constant use2.

However, since they are increasingly

replacing desktops, students do use them

for extended periods of time. This has

resulted in a series of illnesses affecting

different parts of the body which include

pain in the neck, upper back, hands and

wrists, numbness, swellings, and tingling

sensation5.Laptops induced injuries have

become so common that an all-

encompassing term has been used to refer

to them as “Laptopitis”, which includes

musculoskeletal and vision related

disorders6. Laptops construction and usage

result in users assuming improper posture

resulting in body discomfort, visual and

mental strains2. Moreover, workstations

configured for laptop computers,

unsuitable furniture faulty lightings,

further contribute to the physical injuries

resulting from use of laptops5.

Hence, there is a great need to study the

ergonomics of laptops. Laptop ergonomics

is a sub discipline under the broad

umbrella of ergonomics that postulates the

optimal manner of working on laptops and

the design of workspaces, where they are

used in order to keep related injuries to a

minimum and optimize performance7. This

study is focused on the views of students

about the laptop ergonomics and how to

modify or redesign the learning centre, so

that laptops can be used in their preferred

way in the learning centre for extended

periods of time without causing any

physical discomfort or injury.

LITERATURE REVIEW

Few studies have been previously

undertaken on ergonomics related to the

use of laptops or computers. This report

has tried to discover the perception of

participants about laptop ergonomics and

their views about the lack of resources in

learning centre for use of laptop in

ergonomic way.

Straker and Harris (2000) have completed

a mixed study with both qualitative and

quantitative data in order to establish the

physical ergonomics issues associated with

the use and carry of laptop computers by

school children. In total 314 participants

aged between 10 and 17 years participated,

and filled the questionnaire in phase 1 of

the study and 20 participants were

observed using the laptop in various

locations in second phase of study. The

result found that the participant's

discomforts were resulted from using the

laptop in a variety of non-traditional work

postures and also depend on the model of

laptop they use and carry. The study

identified the potential physical

implications associated with the use of

laptops.

Straker et al. (1997a) had studied the

adoptive posture while using laptops and

desktops. The study was a cross-over study

with 16 participants, who were

government employers. It was found that

laptop users adopt a posture with increased

neck, shoulder and elbow flexion but the

difference was not significant as compared

to desktop users. Similar results were

observed by Harbinson and Forrester

(1995). The study concluded that laptop

users required an increased forward head

inclination in order to operate the laptop

due to lack of its adjustability.

Gold et al. (2011) quantitatively studied

postural characterisation in Laptop users in

non-desk setting with 20 asymptomatic

right-hand dominant participants aged

between 18 and 25. The selected

participants were assessed in 3 postures

with two minute typing task followed by

5-minute editing task on laptop. The study

has used MaxMATE motion data analysis.

It was found that subjects reported greater

intensity of discomfort while using laptop

in prone lying.

Price and Dowell (1998) conducted a

quantitative study on 14 volunteer

participants to evaluate the effect of laptop

configuration and external input device on

posture and comfort of laptop users. Each

participant was asked to work on 6

different computer configuration and

anthropometric data and baseline Nordic

Discomfort Scale was completed before

the start of the task. The study concluded

that use of extra peripherals in laptop

seems to be more comfortable and thus

decrease the discomfort associated with

laptop usage.

Kumari and Pandey (2010) have

conducted a cross-sectional study to

analyse the health problems associated

with computer usage and role of

ergonomic factors. A total of 200

participants were selected by stratified

random sampling from different IT

industries. Close ended questionnaire were

used as data collection tool. The analysis

of the data was done by using SPSS

software. A standardized Nordic

Questionnaire was use to assess

musculoskeletal problems and Zung’s self-

rating scale was used to assess depression.

The study concluded the various problems

associated with laptops or desktops use

and also the effects of underlying factors

like- environment, lighting and setup of

the work place on laptop ergonomics.

Several studies on ergonomic research

with desktops while the same cannot be

said for laptops, through some studies have

indicated the development of physical

symptoms associated with laptop use. Few

of the researches have been done, which

found the symptoms associated with the

use of laptop2,4,5. As per the researcher’s

knowledge till now none of the studies

tried to find out the solution so that people

can use laptop in more comfortable and in

their preferred way for prolonged time

without causing any discomfort. Hence,

this study aims to focus on the ergonomics

of laptops and what modification can be

done in the learning centre of Sheffield

Hallam University, so that students can use

their laptop in learning centre in their

preferred way without any discomfort.

Ethical approval was obtained from

Dissertation Management Group

(Sheffield Hallam University). Participants

were given the information sheet and

completion of an anonymous questionnaire

was considered as consent from the

participants.

METHODOLOGY

Research Design

A Qualitative study design with

questionnaire survey was used to obtain

the student's perception about laptop

ergonomics. A qualitative research is the

best means of generating in-depth ideas

and developing hypothesis which may

eventually decide to test quantitatively8.

As the main aim of this study was to

gather in-depth information and generate

ideas so the design of the study was

chosen as a qualitative study.

Sampling

A total of 80 participants were selected

based on inclusion criteria by

‘convenience sampling’ as it was not

possible to approach all the student

population in Sheffield Hallam University.

It is practically easy and fast method of

sampling if the population is very large9.

Convenience Sampling is said to be more

appropriate for the study in which the aim

is to get in-depth information10.

TABLE 1- INCLUSION AND EXCLUSION CRITERIA:

INCLUSION CRITERIA EXCLUSION CRITERIA

Students of Sheffield Hallam University.

Students who were using Laptop/ Desktop

for

their course work.

Students who knew English Language.

Students who were not using laptop/Desktop.

Students who were not student of Sheffield

Hallam University.

Data collection:

The data was collected through the survey

method by using a tool called a

questionnaire as it is the essential form of a

survey to a large sample population11. A

questionnaire is an important method of

survey to a large sample population11. The

questionnaire consisted of both close and

open ended questions. Close ended

questions were objective and

unambiguous. Open ended questions were

used for collection of larger amounts of

information. The questionnaires were

developed on the basis of Environmental

and Occupational Health and Safety

Service (EOHSS) Computer Workstation

Ergonomics Questionnaire. Prior to the

implementation of questionnaire, they

were circulated among the colleagues to

check for content validity and suggestions

were considered while reframing the

questionnaire. The questionnaire was pilot

tested with 7 participants and the

information was taken into consideration

while making final questionnaire. Changes

were made in 7 questions after piloting of

the study. The evidence suggested that, for

the questionnaire to be valid and reliable, it

should go through the formal pilot of the

questionnaire by the same sample

population12.

Data Analysis:

The main purpose of data analysis is to

identify what the texts of participants talk

about. The qualitative content analysis is

used to process and analyse the

information given in text format or from

an open ended questions13. The data

gathered was more descriptive, hence it

was suitable for qualitative content

analysis14.

Hence, the qualitative content data

analysis15 was used for data analysis,

which involves the following steps:

1. Prepare the data: Present all the

data collected in a chart format.

2. Identifying the unit of analysis:

Identify the different

Units/keywords from the text.

3. Developing categories and a

coding scheme: It can be derived

from three sources: the data,

previous related studies, and

theories.

4. Code testing on a sample of text:

It is used for the clarity and

consistency of category definitions.

5. Code all the text: Involves coding

all the data which have been.

Different units/keywords with

similar sense were given single code

6. Assess coding consistency: This

step involves rechecking the

consistency of coding.

7. Draw conclusion from the coded

data: This step involves making

sense of themes and identified their

properties.

Rigour of analysis was enhanced by a

several-stage process of defining and

refiningthemes, by constant comparative

analysis between scripts and themes until

final themes were developed. This analysis

produced 7 key themes, which are listed

with their definition in Table 2.

TABLE- 2: Main Themes from Data Analysis.

THEMES DEFINITION

Factors which facilitates the use of

LC.

Reasons because of which students use

LC.

Preference of use of Laptop/Desktop in

LC

What’s the reason for preference of

using Laptop/Desktop.

Symptoms faced while

using Laptop/Desktop

Which all symptoms the participants

suffer and what’s its cause?

Posture Awareness Awareness about the posture in

participants.

Environment/ Infrastructure of LC How is the environment and setting of

LC for the use of laptop.

Interference with extra

Computer-accessories.

How does the extra computer-accessories

interfere the level of comfort and increase

the work efficacy.

Recommendation to Improve LC What changes can be done to improve the

LC for the use of Laptop.

RESULT:

The questions which were related were put

into similar themes and then the results

were presented on the basis of sub-themes.

Factors that facilitates use of Learning

Centre

Almost all participants were using the

learning centre for their course work

because of better facilities or resources

like- "Books, Journals, area, IT

equipment/resources, café etc.", while

many participants said that they prefer

Learning Centre because they like the

environment of Learning Centre as it is

"Quite place and easy to concentrate for

the study". Some of the participants use

Learning Centre because of the

convenience and comfort, like- they can

"use leisure hours between the lecture, the

convenient opening and closing hours of

Learning Centre and group study/work".

Few of participants said about

“psychological motivation they get in

learning centre for study”.

Preference of use of laptop or desktop in

learning centre

When the participants were asked whether

they use laptop or desktop in learning

centre, 42 participants said that they use

desktop as they feel it convenient and

comfortable. They said that they "do not

have to bring laptop and it is easy for them

to use desktop than laptop". Some of them

said that, they "prefer desktop because of

big screen of desktop and also there is less

space and plug points for laptop in

learning centre…". Few of the participants

said that it is "easy to work on desktop as

the desktop is fast and more comfortable"

and also they "can use it for prolonged

period of time…". Only 11 participants

said that they use laptop in learning centre

because they "prefer to use laptop" and

also it is "convenient for them to save their

data". Some of the participants said that

they use laptop as they "can use it

anywhere in learning centre, comfortable,

easy to use and it is more portable…".

Problems or symptoms faced by

participants while using laptop or desktop

From the result it was observed that, the

most experienced symptoms were “Tight,

sore neck and shoulder muscles”,

followed by “Pain or aching in wrists,

forearms, elbows, neck, or back followed

by discomfort”, and then “General fatigue

or tiredness”, then “Blurred or double

vision”. Also it was found that, the least

faced symptom was “Swelling or stiffness

in the hand or wrists”.

Most of the participants said that, these

symptoms are because of their bad or poor

posture like- (Keeping laptop on knee,

using laptop while lying down, Slouched

posture etc.), continuous position such as:

(Sitting for prolonged, focusing on small

screen for long period, no interval between

work etc.), and ergonomics setup like-

(Desks and chairs not adjusted, Too close

to screen for long period etc.). Some of the

participants said that there might be some

other reasons for the symptoms like- (weak

joint, poor posture throughout the day,

Back and neck pain from exercise).

Posture Awareness

Out of 80 participants, 55 participants

stated a positive response and defined

posture in their own words, while 25

participants have given negative response

as they were not aware with the correct

position or posture for the use of laptop.

The participants who were not aware about

the posture were mainly from the faculty

other than health related courses such as:

Criminology, Events management,

Information system management, Law etc.

Most of the participants said, usually

posture means: sit straight, back support,

hip and knee flexed, and screen at eye

level. Some of the statements given by the

different participants to define posture for

laptop are presented below:

“Screen in line with eyes, elbow flexed to

90°, knee at 90°, hip at 90°, shoulder

flexed.” (2)

“Back support, Hip + Knee supported,

Appropriate Height.” (39)

“Sit erect, avoid neck flexion, sitting at

comfortable distance, and avoid excessive

elbow bending.” (62)

Environment or Infrastructure of

Learning Centre (LC)

More than half of participants found

environment of learning centre to be

comfortable for the use of Laptop.

Participants found environment of learning

centre comfortable because of different

resources like- “Tables, adjustable chairs,

more space for laptop, plug points, proper

lighting and easily accessible resources”.

While less than half of the participants

found the environment of Learning Centre

is not comfortable for laptop use.

Participants said that, there is “less space,

less number of tables for laptop, tables

and chairs are not setup at proper height

or not adjustable, and also there is less

charging plug/points for laptop use”.

When asked about the infrastructure/

setting of Learning centre, most of them

said that the environment of learning

centre is comfortable because of “tables

and adjustable chairs, proper lighting and

quite area”. While one quarter of

participants did not find the infrastructure

of LC to be comfortable because of

different difficulties such as: “Limited

space around the table, uncomfortable

chairs, cold environment, chairs do not

have armrest, very much crowded”. Some

of them said that there are fewer resources

such as: “Area, less table and chairs, less

space around the table”.

Interference with extra computer-

accessories like- keyboard and mouse on

laptop work

Out of 80 participants, some of the

participants answered that, use of extra

equipment like- mouse and keyboard could

provide more comfort and can work with

greater ease. Participants answered that use

of extra equipment can provide more

comfort, free movement and also they can

modify their position accordingly. Some of

the participants said that “mouse is better

than touchpad” and they can “work faster

and in more comfortable way”. Few

participants answered that use of keyboard

and can provides “more comfort to them

and they do not have to negotiate with

posture”. While more than half of

participants answered that, they do not find

any difference in comfort level with the

use of extra keyboard and mouse in the

Laptop. Some of them said that they “do

not want to carry keyboard and mouse and

also they can manage fine without it”.

Recommendation to improve Learning

Centre for use of Laptop

Major number of participants have

suggested with different recommendation

for the use of laptops in learning centre so

that laptop can be used for extended period

of time. Most of them want “proper

ergonomic setup for laptop users, more

laptop area, more spacious table,

comfortable chairs with neck and back

support, and plug points for laptop

changing”. Some of the participants have

suggested for the “Laptop stand, specific

type of table for laptop and dock station

for laptop”. Few of the participants said

that there should be “more tables for

laptop in silent area and also individual/

separate booth/ room for laptop users”.

DISCUSSION

This qualitative study obtained student’s

perception about laptop ergonomics and its

use in the learning centre of SHU. Almost

all participants use learning centre for their

course work because of the better

environment and different types of

resources available. The environment of

learning centre provides more comfort and

motivation to the students for the study,

because the setup of the environment is

study oriented. It has also been shown that

hot and noisy environment directly affects

the work productivity and ergonomic

condition16. Student population use laptops

in the learning centre because of the many

benefits of the laptop. It is easy to carry

and use laptop as the participants can save

their data17.

It was observed that most of the

participants experienced some of the

symptoms while using either laptop or

desktop. From the data gathered by

questionnaire, it was found that the

participants faced problems related to

neck, shoulder, hand, back and eyes. The

most common symptoms were “Pain or

aching in wrists, forearms, elbows, neck,

or back followed by discomfort” (42%)

and eye strain (42%). Similar type of

results was found by Kumari and Pandey

(2010) and said that the common causes of

these symptoms were sitting for prolonged

in awkward or poor posture (Fig-1). Also

the literature suggested that the

participants should take eye break every

after 20 min to reduce strain on eye while

working on laptop18. It was also found that

participants who use laptop faced more

symptoms than the one who use desktop.

This could have been in order to adjust the

posture to use desktop and laptop in more

comfortable position3. Even evidence

proves that participants adopt poor posture

because of the lack of adjustability of the

laptop as the screen and keyboard are

attached2. This was supported by another

study by Straker et al. (1997a), they have

suggested that usually laptop users tried to

assume posture that would compromise

their posture by increased neck, shoulder

and elbow flexion. They adopt this posture

in order to see a lower screen and reach a

higher keyboard. The main factors judged

by the participants as cause of their

symptoms while using laptop or desktop

were “Sitting in same posture for

continuous long hours”, “Awkward and

poor posture”, and the “setup for laptop”

which was not ergonomically correct.

As the height of table in the learning centre

is not appropriate, and also some of the

communal table which are being used for

laptop use are of very low height so it is

difficult to adjust the chairs accordingly.

As the evidence by Straker and Harris

(2000) suggested that the participants

experienced physical discomfort because

of the physical ergonomic issues as they

use the laptop in poor posture. This was

supported by Moffet et al. (2002) in their

study; evaluated the impact of two work

station (desktop and laptop) on neck and

upper posture, muscle activity and

productivity. The study said that the

workstation setup influenced the physical

exposure variable while working on

laptop.

Fig-1: Shows the poor and good posture for Laptop.

Some of the participants who were not

related with health course, they did not

know about the correct position or posture

for the use of laptops. They have not

defined the posture. This might be because

of lack of awareness about ergonomics

among that students population. So the

participants adopt the poor posture while

working on laptop, because it has been

found that lack of knowledge about

posture can leads to symptoms as they do

not adopt the proper posture while

working on desktop or laptop5.

From the result it was also found that use

of extra computer- accessories can provide

more comfort, and can ease the symptoms

and increase the work efficacy of the

participants. This is because the extra

equipment provides the adjustability

according to the posture and the users do

not have to compromise with the posture.

This was supported by a study done by

Kumari and Pandey (2010) found that the

use of various computer accessories like-

adjustable keyboard tray, foot rest, best-fit

computer mouse design, task lighting and

docking station can help in preventing the

health related symptoms. Even some of the

participants have suggested for the use of

laptop stand or docking station (Fig-2). It

might be helpful because they can fix the

laptop and can use it in ergonomic way so

that the symptoms can be prevented.

Fig-2: Show the ideal Laptop stand/Docking station for laptop.

According to the ergonomic advice by

Stanford University, Environment Health

and Safety, the laptop workstation has

been suggested, so that the laptop could be

used as workstation if working for long

hours and the symptoms can be

minimized. Moffet et al. (2002) have

given some advices to prevent pain while

using laptop. The study has suggested the

use of docking station, so that the subjects

do not have to adopt the poor posture and

can use laptop in effective way.

The study had several limitations. Many of

the participants have not answered all the

questions which might be because of lack

of interest, lack of time or the structure of

the questions. All the analysis and

calculations were done manually so there

might be some chances of manual error. It

was not possible to explore in-depth

perception of participants as the method of

data collection was questionnaire. The

sample size (n=80) in the study was

relatively large, which was the strength of

the study. The participants were from

different faculties, which might have result

in variable data as the students from

different course have different perception

about the ergonomics. Rich informative

data were gathered through the open-ended

questionnaire, which was one of the aims

of qualitative research.

CLINICAL IMPLICATION:

Laptop ergonomics is very applicable for

all who use laptops. The result of this

study might help not only the student

populations but also the general population

who use laptop. As it was found that there

is lack of awareness about the proper

posture for laptop use among students, so

the measure should be done to spread the

awareness. Mainly the student population,

who are not from health related courses,

should be focussed. It might be very

helpful if there should be some induction

about the posture for the student

population before start of the course.

Awareness about the posture can be spread

though the means of Poster, distributing

leaflets, and induction or seminar. The

findings about the recommendation in

improving learning centre can be given

into the notice to the learning centre

authority Dept., so that they can use the

finding as feedback in improving the

learning centre for better use for students

and staffs. And also the students will be

benefited by these changes and they might

be able to use learning centre in more

efficient way.

The data of this study also has a further

clinical relevance; Symptoms are mainly

because of poor posture and wrong setup

of workstation of laptop, so in order to

prevent those symptoms, both the factors

should be corrected.

FURTHER RESEARCH:

As this was the first study to researcher's

knowledge done on the student population

in SHU about laptop ergonomics, so an

obvious need for more research in this area

is observed. More research should be done

in order to find out the actual ergonomic

setup of the working environment in the

learning centre.Also a quantitative study

could be suggested as further research in

order to find out the effectiveness of

ergonomics training program on posture

while working on laptop. Looking to the

current scenario it seems that in coming 10

years laptop or i-pad or tablet will be

replacing the desktop so the study should

be conducted in order to find out how the

learning centre should be designed

ergonomically for laptop or i-pad or tablet

use.

CONCLUSION:

From the research done, it can be seen that

students population prefer to use learning

centre because of the different facilities

and environment. But they also get

symptoms by using the resources like-

desktop or laptop, which is because of

wrong posture they adopt while working.

So these resources should be set-up on the

basis of ergonomics way and awareness

about the posture should be spread among

students.

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ACKNOWLEDGMENT

A special thanks to my family and friends for their continuous support. Also thanks to the

management of Sheffield Hallam University for giving me opportunity to complete my study.

CORRESPONDENCE:

* Sheffield Hallam University, United Kingdom. Email: physio.mayank.pushkar@gmail.com

**Sheffield Hallam University, United Kingdom

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