Ijpot july sept 2010

Indian Journal of Physiotherapy and Occupational Therapy

An International Journal

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

Volume 4 Number 3 July - September 2010

website: www.ijpot.com

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Contentswww.ijpot.com

July-Sept. 2010Volume 4, Number 3

Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

1 Efficacy of post-isometric relaxation versus integrated neuromuscular ischaemic technique in thetreatment of upper trapezius trigger pointsAbha Sharma, R. Angusamy, Sumit Kalra, Sukhmeet Singh

6 Carpal tunnel syndrome: Influence of a comprehensive exercise program on its prevalence in dentistsSamiha M Abd-Elkader, Gehan M. Ahmed, Adel R. Ahmed

11 Comparing the efficacy of tai chi chuan and hatha yoga in type 2 diabetes mellitus patients onparameters of blood glucose control and lipid metabolismAditya Pardasany, Shweta Shenoy, Jaspal S Sandhu

17 Effect of segmental breathing exercises on chest expansion in empyema patientsAparna Sarkar, Harshita Sharma, Shaily Razdan, Suman Kuhar, Nitesh Bansal, Gunween Kaur

21 Relationship between pes planus foot type and postural stabilityPaik-Ling Harrison, Chris Littlewood

25 Agreement between timed up and go test and tinetti assessment scale in institutionalized elderlyFaizan Zaffar Kashoo, Leena Dhawan

28 Modified mobilization techniques in adhesive capsulitis of the shoulder joint: A case reportFaizan Zaffar Kashoo, T R Vijay, Hari Haran

32 Effect of muscle energy technique and static stretching on hamstring flexibility in healthy malesubjectsHashim Ahmed, Mohd. Miraj , Shveta Katyal

37 Effectiveness of strengthening exercises in the management of forward head posture amongcomputer professionalsShweta Shenoy, Jaspreet Sodhi, Jaspal S Sandhu

42 Measurement of quality of life using a locally developed questionnaire after an aerobic trainingprogram in patients with chronic respiratory diseasesPooja K Arora, Bharati Bellare

45 Effect of ultrasound and jaw opening exercises in cases of oral submucous fibrosisPooja K. Arora, Maneesha Deshpande

48 The reliability of goniometric measurements of passive trapeziometacarpal joint motionsSaini Prerna, Grover Deepak

53 Effect of lumbar stabilization exercises as home program in treatment of young women with nonspecific low back pain – a comparative studyPrity Agarwal

57 Clinical significance of electrodiagnosis In lumbar disc herniationRamanpreet Kaur, Narkeesh Arumugam

60 A comparison of flutter device and active cycle of breathing techniques in acute exacerbation ofchronic obstructive pulmonary disease patientsRicha, Rajeev Aggarwal, Md.Abu Shaphe, Chacko George, Anurag Vats

65 Calisthenic exercise-induced changes in myocardial oxygen consumption in normotensive healthysubjectsSalwa B. El-Sobkey

69 A prospective randomized controlled trial of neural mobilization and Mackenzie manipulation incervical radiculopathySanjiv Kumar

76 Trunk restraint training after stroke: A reviewSenthilkumar Jeyaraman, Ganesan Kathiresan, Kavitha Gopalsamy

82 Factors affecting the quality of life in patients with strokeSuvarna Ganvir

86 Effectiveness of plantar fasciitis taping and calcaneal taping in plantar heel pain - A randomizedclinical trialBagewadi Vishal, Metgud Santosh, B.R. Ganesh

91 Comparative effectiveness of static stretching and muscle energy technique on hamstring flexibilityin normal Indian collegiate malesMohd. Waseem, Shibili Nuhmani, C. S. Ram

95 Patellofemoral pain syndrome- a common condition among young adultsZaheen Ahmed Iqbal, Nusrat Hamdani

102 Comparison between low level laser therapy and exercise for treatment of chronic low back painZahra Al Timimi, Mohamad Suhaimi Jaafar, Mohd Zubir Mat Jafri

I

Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPY

EditorDr. Archna Sharma

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

Executive EditorDr. R.K. Sharma, New Delhi

National Editorial Advisory BoardProf. U. Singh, New DelhiDr. Dayananda Kiran, IndoreDr. J.K. Maheshwari, New DelhiDr. Nivedita Kashyap, New DelhiDr. Suraj Kumar, New DelhiDr. Renu Sharma, New DelhiDr. Veena Krishnananda, MumbaiDr. Jag Mohan Singh, PatialaDr. Anjani Manchanda, New DelhiDr. M.K. Verma, New DelhiDr. J.B. Sharma, New DelhiDr. N. Padmapriya, ChennaiDr. G. Arun Maiya, ManipalProf. Jasobanta Sethi, BangaloreProf. Shovan Saha, ManipalProf. Narasimman S., MangaloreProf. Kamal N. Arya, New DelhiDr. Nitesh Bansal, NoidaDr. Aparna Sarkar, NoidaDr. Amit Chaudhary, FaridabadDr. Subhash Khatri, BelgaumDr. S.L. Yadav, New DelhiDr. Vaibhav Aggarwal, MeerutDr. Sohrab A. Khan, Jamia Hamdard, New Delhi

International Editorial Advisory BoardDr. Amita Salwan, USA

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

Heidrun Becker, GermanyRosi Haarer Becker, Germany,

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

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

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

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

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

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

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

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

“Indian journal of physiotherapy and occupational therapy” An essential indexed double blind peer reviewed journalfor all Physiotherapists & Occupational therapists provides professionals with a forum to discuss today’s challenges -identifying the philosophical and conceptual foundations of the practics; sharing innovative evaluation and tretmenttechniques; learning about and assimilating new methodologies developing in related professions; and communicatinginformation about new practic settings. The journal serves as a valuable tool for helping therapists deal effectively withthe challenges of the field. It emphasizes articles and reports that are directly relevant to practice. The journal is nowcovered by INDEX COPERNICUS, POLAND. The journal is indexed with many international databases.The journal is registered with Registrar on Newspapers for India vide registration DELENG/2007/20988

Website : www.ijpot.comAll right reserved. The views and opinione expressedare of the authors and not of the Indian journal ofphysiotherapy and occupational therapy. The Indianjournal of physiotherapy and occupational therapy doesnot guarantee directly or indirectly the quality or efficacy ofany product or service featured in the advertisement in thejournal, which are purely commercial.

EditorDr. Archna Sharma

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Dr. Archna SharmaPrinted at

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

II

1

Efficacy of post-isometric relaxation versus integratedneuromuscular ischaemic technique in the treatment of uppertrapezius trigger pointsAbha Sharma*, R. Angusamy*, Sumit Kalra*, Sukhmeet Singh***Lecturer, **Clinical Demonstrator, Banarsidas Chandiwala Institute of Physiotherapy, New Delhi

Abstract

Objective

This study was done to compare the efficacy of post-isometricrelaxation (PIR) along with ultrasound and massage versusintegrated neuromuscular ischaemic technique (INIT) alongwith ultrasound and massage in the treatment of triggerpoint pain of the upper trapezius muscle.

Method

30 subjects having trigger points in the upper trapeziusmuscle both males and females in the age-group of 18-35years were divided into two groups: subjects in group A(n=15) were treated with PIR, massage and ultrasound andGroup B (n= 15) were treated with INIT, massage andultrasound. The VAS scores for pain, side-flexion ROM(opposite side of pain) and NPNPQ were used to assessthe improvements.

Results

There was statistically significant difference in VAS scores(p < 0.05), Neck side-flexion ROM (opposite side) andNPNPQ scores (p < 0.05) in both Group A & Group B. Thisindicates that subjects with trigger points in the uppertrapezius muscle had significant reduction in pain,improvement in ROM and reduction in scores of NPNPQ.Between the groups there was no significant improvement(p > 0.05). Within group analysis shows that both groupshad significant improvement in the variables but there wasno significant change between the groups.

Conclusion

Both treatment techniques were highly effective in thetreatment of trigger point pain in the upper trapezius muscle.

Key words

Post-Isometric Relaxation (PIR), Integrated NeuromuscularIschaemic Technique (INIT), trigger point, upper trapezius,& NPNPQ

Introduction

Neck complaints are common affecting 13% of adults atany one time and up to 30% males and 50% females in thecourse of a lifetime.1 Neck pain is one of the most commonmusculoskeletal complaints2 and is attributed as the 2ndlargest cause of time off work after low back pain.3 Faultyposture does impart trauma to numerous aspects of the

musculoskeletal system.6 Liebenson (2000) has observedthat to prevent muscle from injury and dysfunction theindividual needs to avoid undue mechanical stress while atthe same time improve flexibility and stability in order toacquire greater tolerance to strain. He further suggests thatthere is evidence that too little (or infrequent) tissue stresscan be just as damaging as too much (or too frequent, ortoo prolonged) exposure to biomechanical stress. If, overtime, as a result of too little or too much in the way of adaptivedemand, pathological changes occur in soft tissues andjoints, the consequences are likely to include altered(commonly reduced) functional efficiency, often with painfulconsequences.5 Trapezius muscle is a major source of pain.Tightness felt in the neck, upper part of shoulder bladesand back of the skull often comes from trigger points in thetrapezius. Increased use of desk job is associated withincreased upper trapezius muscle activity.9 Trapezius triggerpoints, are observed the most often of all myofascial triggerpoints in the body.7

A myofascial trigger point is a hyperirritable locus within ataut band of skeletal muscle, located in the muscular tissueand/or its associated fascia. The spot is painful oncompression and can evoke characteristic referred painand autonomic phenomenon.8 The point is wellcircumscribed area in which pressure produces acharacteristic referred pain, tenderness and autonomicphenomenon.9 An active trigger point is defined as onewith spontaneous pain or pain in response to movement. Itis tender on palpation, and may present with a referralpattern of pain, not at the site of trigger point origin. A latenttrigger point is a sensitive spot that causes pain or discomfortonly in response to compression. The palpable nodule wasrevealed as on biopsy as a large rounded darkly stainingmuscle fibres and a statistically significant increase in theaverage diameter of muscle fibers. EMG studies have shownthat trigger points have spontaneous electrical activity whileadjacent muscle fibres are silent.10 These findings led Travelland Simons to implicate dysfunctional motor end plates asthe underlying etiology of trigger points, the point wherealpha-motor neuron contact their target muscle fibres. Motorend plate dysfunction is attributed to an excessive releaseof acetylcholine from pre-synaptic motor nerve terminal,leading to a muscle action potential and muscle contraction.The excessive contraction compresses local sensorynerves, which reduces axoplasmic transport of moleculesthat normally inhibit acetylcholine release. Sustained musclecontraction also compresses local blood vessels, reducinglocal oxygen supply. There is an increased metabolicdemand generated by contracted muscles resulting in rapiddepletion of ATP. ATP directly inhibits acetylcholine release,so depletion of ATP increases acetylcholine release. Lossof ATP impairs the reuptake of calcium which increases

Abha Sharma. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

2

contractile activity – a vicious cycle. ATP energy crisiscascades into a local release of chemicals that activate orsensitize nociceptive nerves in the region accounting fortrigger point tenderness. Persistent barrage of nociceptivesignals from trigger points will eventually sensitize the CNS(central sensitization). Biomechanical factors that stressmuscles (acute trauma, repetitive micro trauma) contributeto trigger point dysfunction.10 Trigger points are thought toform in response to increased or altered muscle demands.Trigger points are reported to occur more frequently in casesof mechanical neck pain.9 Somatic dysfunction of the cervicalregion of the spine often results in increased muscle tension,sensitivity changes(eg tenderness), asymmetry, andrestriction of range of motion.11

Trigger point therapy is essentially divided into invasiveand non-invasive techniques. Non-invasive techniques arethose that have been traditionally employed by physicaland manual therapists.12 Myofascial trigger points can beinactivated by a variety of approaches, including osteopathicmanipulative treatment, massage therapy, ultrasoundtherapy, spray and stretch as well as needling (acupunctureor injection).10 Travell and Simons have shown thatwhatever initial treatment is offered to inhibit the neurologicalover- activity of the trigger point the muscle in which it lieshas to be made capable of reaching its normal resting lengthfollowing such treatment or else the trigger point willexpendably reactivate.13 Muscle energy techniques (MET’S)are a class of soft-tissue osteopathic (originally)manipulation methods that incorporate precisely directedand controlled, patient initiated, isometric and/or isotoniccontraction, designed to improve muscle function andreduce pain.14 It is an established osteopathic manipulativeintervention often used to treat somatic dysfunctions of thespine.11 Liebenson (1996) discusses the benefits andmechanism in the use of MET…. “Ability to relax anoveractive muscles and their ability to enhance stretch ofshortened muscles or its associated fascia when connectivetissue or viscoelastic changes have occurred”.15 For thepresent study ‘two different muscle energy techniques,’ Post-Isometric Relaxation, (PIR) and Integrated NeuromuscularIschaemic Technique, (INIT) were used to reduce pain andlengthen potentially shortened cervical muscles and fasciato normalize the gross cervical range of motion. Regionalrange of motion barriers of cervical spine were increasedusing muscle energy techniques.11

Massage as a treatment option for pain relief, spasmreduction and relaxation has been traditionally used.Massage alters the local circulation in such a way as toreduce or remove noxious substances thereby reducing orremoving stimuli reflected in a corresponding reduction ofresponse by the pain receptors.14 Massage Therapytechniques reduce the activity of trigger point pain.16

Ultrasound as another treatment option commonly used fortreating painful tender points. A slight stretch to the musclesbeing treated, deep pressure through the sound head, andmaximum heat permitted through slow movement of thesound head.17

The purpose of the study

The aim of the study was to compare the efficacy of post-isometric relaxation technique versus integratedneuromuscular ischaemic technique, two different forms of

muscle energy techniques along with the conventionaltreatment procedures of massage and ultrasound to reducethe trigger point pain found in the trapezius muscle (upperfibres) and to determine which would bring a faster andbetter prognosis for relieving pain and improving range ofmotion in the present study.

Methodology

Total numbers of 30 subjects, meeting the inclusion criteriawere selected for the study purpose. The subjects wererandomly divided into 2 groups, group A and group B with15 subjects in each group.Individuals with myofascial trigger points in the uppertrapezius muscle were selected with pain lasting for morethan 3 months, no physiotherapy treatment taken for anyneck problem in the last 3 months, age group of 18 – 35years of both sexes were selected and English literacy tobe able to fill–up the NPNPQ questionnaire.Individuals excluded from the study were those on any anti-inflammatory/analgesics, Cervical PIVD, Neuralgic pain &Brachialgia in the upper extremity, spondylolisthesis cases,fractures in the clavicle, scapula, cervical or thoracicvertebra or humerus, any known psychiatric or psychologicalcondition under treatment or medication, skin disorderswhich would be increased by massage or ultrasound, anymalignant or benign tumors, any recent unhealed scars orwounds, early bruising (as not safe for massage) orradiotherapy in the last 6 months.

Variables

The out come variables used for this study were Neck side-flexion ROM (to the opposite side of pain), visual analoguescale for pain measurement, and Northwick Park Neck PainQuestionnaire (NPNPQ) for neck pain. These weremeasured with Goniometer, VAS, and NPNPQ.

Procedure

The 30 selected subjects with trapezius trigger points wererandomly divided into 2 groups of 15 patients each. Patientswere explained about the nature and purpose of the studyand written informed consent was taken from those willingto participate in the study. In both the groups, trigger pointswere identified by the STAR palpation method, assessmentPerforma was filled up by the therapist and Northwick ParkNeck Pain Questionnaire duly filled by each participant asbase line measurement on the first day (pre-test scores)before starting the treatment.The patients in group A and group B received the followingtreatmentGROUP A - Post-Isometric Relaxation (PIR) + Massage +UltrasoundGROUP B - Integrated Neuromuscular Ischemic Technique(INIT) + Massage + Ultrasound

Star palpation method

Star palpation method was used to identify the trigger point.

• Sensitivity (or tenderness) was noted.

• Tissue texture changes like tissues felt different by beingtense, fibrous, swollen or different from the normal


3

tissue was assessed.

• Asymmetry – an imbalance on one side compared tothe other, but not always seen

• Range of motion was reduced.If two or three of these features were present it wastaken to confirm there is a dysfunction.15

Group A

Patient was made to sit comfortably on a stool, with neckand upper scapular region exposed. Ultrasound therapy at1.2 W/ cm2 continuous mode for 5 minutes was givenmaintaining deep pressure of the head while giving circularmovements and keeping the neck in a slightly stretchedposition. Massage techniques were done with powder as amedium. Effleurage technique was used in starting, thendeep friction strokes (15 in number), then kneading followedby effleurage again. The subject was then made to lie downon a plinth. The neck was taken to the limit of side-flexion(opposite side) by the therapist, to a point where resistanceto the movement is first noted. The therapist standing at thehead end of the plinth with one hand on the upper lateralaspect of the side of the neck to be stretched and the otheron the upper end of the shoulder . Subject was instructed toraise or elevate the shoulder (agonist contraction) usingonly 20% of his/her strength which is being resisted by thetherapist (in the direction of stretch). The contraction washeld for a count of 6 seconds. The patient was made toinhale during the effort. After the effort, patient was made to“let go” completely, and when this is achieved completelythe muscle was taken to the new barrier with all slackremoved- but no stretch – to the extent that the relaxation ofthe hypertonic muscles will now allow. Starting from thisnew barrier, the procedure was repeated 3 times.

Group B

Patients in this group also received Ultrasound treatmentand massage as described in group A. Then INIT was givenwith the patient positioned supine on the plinth. The neckwas taken to the limit of side-flexion (opposite side) by thetherapist, to a point where resistance to movement is firstnoted. The therapist standing at the head end of the plinthwith one hand on the upper lateral aspect of the side of theneck to be stretched and the other on the upper end of theshoulder. Ischaemic compression (sustained) was appliedto the trigger point until the pain changed or until a significantrelease was noted in the palpated tissues. Pressure wasapplied and patient was asked to ascribe this value of 10and then tissues were repositioned until the patient reported

a score of 2 or less. Positional release of the trigger pointtissues was done. With tissues in this folded ease positiona local focused isometric contraction of these was created.This was followed by a local stretch of the tissues housingthe trigger point, in the direction of the muscle fibres. Thewhole muscle was then isometrically contracted as in PIR.This was followed by a stretch as in all MET procedures forthe muscle. The whole process was repeated 3 times.The treatment was given for 5 days a week and 7 sessionswere carried out of the discussed procedure. VAS scores,range of motion for side-flexion were re-assessed by thetherapist and NPNPQ was filled up by each subject on theday after the completion of the treatment sessions.

Results

SPSS-15 was used for data analysis. Paired T- Test wasapplied within the group. Unpaired T-Test and Mann WhitneyU Test (wherever applicable) was applied to the continuousvariables to compare between the 2 groups.Level ofsignificance p- value < 0.05 was considered significant.The mean pre-test scores for VAS, side-flexion (oppositeside) were nearly the same for both the groups indicatingboth groups were same at the starting point.Paired t-test was applied to compare the pretest (Base linescore i.e 0 sessions) and post test (Day after completion oftreatment) for VAS, ROM and NPNPQ. The p–value wasfound to be significant (p<0.05). Within group significantimprovement seen in VAS, ROM and NPNPQ scores inboth group A and group B.

Group A: Pre and Post Test ScoresVAS SIDE - FLEXION NPNPQ

GROUP A MEAN± SD MEAN± SD MEAN± SDPRE-TEST 5.93±1.79 33.87±6.49 0.37±0.23POST-TEST 2.00±1.56 40.87±4.91 0.17±0.18t value 14.75 7.40 2.77Significance <0.05 <0.05 <0.05

Group B: Pre and Post Test ScoresVAS SIDE - FLEXION NPNPQ

GROUP B MEAN± SD MEAN± SD MEAN± SDPRE-TEST 5.93± 1.49 33.47±7.02 0.27±0.11POST-TEST 1.80± 1.01 40.33±4.98 0.09±0.07t value 10.63 7.46 12.65Significance <0.05 <0.05 <0.05

For between group analyses Un paired t-test was applied for VAS, ROM andNPNPQ scores. The p–value was found to be insignificant (p>0.05)

Independent samples test (Between Groups)VAS SIDE-FLEXION NPNPQ

t Value 0.42 0.10 0.14Sig. >0.05 >0.05 >0.05

The study results showed that not much significantimprovement between the two groups though there wassignificant improvement within each group.


Between Group Comparison of Mean VAS(Pre and Post test) Between Group Comparison of Mean Side-Flexion

(Pre and Post Test)

4

MANN-WHITNEY U TEST applied for NPNPQ scores forboth the groups.MANN-WHITNEY U TEST (NPNPQ) - Group A -96.5, GroupB– 84.

Discussion

This experimental study to determine which of the twomuscle energy techniques, Post–Isometric Relaxation orIntegrated Neuromuscular Ischaemic Technique is moreeffective in the treatment of trigger points.The data analysis revealed that there was statisticallysignificant improvement in range of motion (side-flexion),scores of Northwick Park Neck Pain Questionnaire andsignificant reduction in pain scores within the groups.However, between the groups analysis does not showstatistically significant improvement in the variablesconsidered.The improvements obtained in the study can be explainedon the following basis:-Muscle energy techniques bring about an increase in rangeof motion and decrease in pain. These therapeutic effectshave been brought about by increasing myofascialextensibility. The short and medium term changes in muscleextensibility are brought about by three mechanisms: - reflexrelaxation, viscoelastic or muscle property changes andchanges to stretch tolerance. Reflex relaxation– followingcontraction has been proposed to occur by activation of thegolgi tendon organs and their inhibitory influence on thealpha– motor neuron pool. (Kuchera & Kuchera 1992)18

Also there is neurological muscle relaxation followingisometric muscle contraction by depressed H- reflex activityfollowing isometric contraction lasting 10 seconds.Depressed H- reflex activity has an inhibitory influence onalpha motor neuron pool excitability. Viscoelastic or muscleproperty changes – Taylor et al suggests that a combinationof contractions and stretches as used in muscle energytechniques might be more effective for producingviscoelastic changes than passive stretching alone, becausethe greater forces could produce increased viscoelasticchanges and passive extensibility. Lederman proposed thatisometric contraction and stretch would place load on serieselastic components and elongate them and produceviscoelastic or plastic changes beyond that achieved bypassive stretching alone. Stretch tolerance - stretching andmuscle contraction stimulate muscle and jointmechanoreceptors and proprioceptors and is thought to bea mechanism to attenuate the sensation of pain. Accordingto Melzack and Wall’s, “gate control theory” large diametermechanoreceptors produce inhibition of incomingmessages of pain at the dorsal horn of spinal cord. METbrings about a lasting change in the stretch tolerance and

the mechanism may also involve changes in the highercentres of the CNS. The gains in the range of motion andpain reduction are mostly attributable to stretch tolerance.18

Active muscle contraction and relaxation also has a stronginfluence on lymphatic and venous drainage (Lederman1997), and MET also acts to relieve periarticular congestionto improve tissue and joint mobility.18

The muscle lengthening techniques used in PIR at theregional barrier helps to lengthen the shortened and tautmuscle band and improve the ROM. Lewit and Simonsdemonstrates that muscle lengthening utilizing PIR appearsto be successful in relieving pain due to myofascial triggerpoints.19 The effectiveness of PIR is consistent with the earlierstudies of11,20,21.It is seen that muscle such as upper trapezius, is stretchedas a whole using PIR or other stretching maneuvers. Thetissues in which the trigger point is embedded may notlengthen specifically. A method achieving precise targetingof the target tissues in terms of tonus release and subsequentstretching is achieved by integrated neuromuscularischaemic technique. Ischaemic compression stimulatesthe mechanoreceptors and brings about pain relief as wellas it causes a local ischaemia followed by a sudden gushof blood to that area on release of pressure. Earlier studiessupporting this have been done by9,10,16,19,21,22,23. Applying apress and stretch technique is believed to restore abnormallycontracted sarcomeres in the contraction knot to their normalresting length. It is an indirect technique using barrier –release concept.10 By positionally releasing the trigger pointtissues benefits by means of an automatic resetting ofmuscle spindles, which help to dictate the length and tonein the tissues. This resetting apparently occurs when themuscle housing the spindles is at ease and usually resultsin a reduction in excessive tone and release of spasm.Thereafter isometrically contracting the muscle results inreduction in the tone of the tissues and then they arestretched in INIT.24

Ultrasound treatment with deep pressure works on thepainful tissues by relieving pain, improving circulation andmicromassage effect. Massage improves local circulation,improves mobility, and relieves subcutaneous tightness.9

Effleurage, kneading and friction help by removing wastesfrom cells, relaxing muscles, diminishing pain and improvingrestricted movement.20 Massage alters the local circulationin such a way as to reduce or remove noxious substancesthereby reducing or removing stimuli reflected in acorresponding reduction of response by the painreceptors.14 Input to A beta fibres by massage blocks painsignals by pre synaptic inhibition and may reduce or preventpain transmission to conscious level.14 Therapeutic massagetechniques are known to reduce the activity of trigger points.Massage is helpful in trigger point pain as seen in the studiesof 10, 16, and 25.

The groups though randomly selected were evenlydistributed for their mean scores in pain and side-flexionlimitation at the beginning of the study. The study resultshave shown improvement in both the groups, in all aspectsof the variables selected, VAS, range of motion andNorthwick park neck pain questionnaire. Therefore withineach group there is statistically significant improvement bythe treatment protocol though not much statisticallysignificant improvement is found between each. Themarginal improvement in the scores of the NPNPQ in theintegrated neuromuscular ischaemic technique group on


Between Group Comparison of Mean NPNPQ scores(Pre and Post test)

5

re-assessment could be attributed to the findings that evensmall improvement in pain scores on the VAS scale helpsthe patient feel better on the functional activity scores in thequestionnaire.The present study shows that both the treatment techniquesare equally effective in reducing the pain and increasingthe range of motion in patients with upper trapezius triggerpoints.

Future research

As integrated neuromuscular ischaemic technique is arelatively new treatment technique of MUSCLE ENERGYTECHNIQUE protocol more studies to compare it with variedMET techniques as well as manual therapies can be donein future to gain better comparisons.Both the treatment techniques can be compared with othermanual therapies like active and passive stretching as wellas varied electrotherapy pain relieving modalities todetermine an effective technique as well as a combinationwhich gives an early prognosis.

Relevance to clinical practice

Both the treatment techniques can be used for the treatmentof trigger point pain in the trapezius muscle as statisticallysignificant improvement was seen. As trigger points arecommonly seen in clinical practice these techniques are ofmuch help in gaining improvement in patient’s pain levelscores, range of motion and neck pain questionnaires.

Conclusion

The study came to the conclusion that, both the treatmenttechniques, Integrated Neuromuscular IschaemicTechnique and Post-Isometric Relaxation are equallyeffective in the treatment of trigger points of the uppertrapezius muscle.

References

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2. Cees Vos, Arianne Verhagen et al: Management ofAcute Neck Pain In General Practice: a prospectivestudy.2007 Jan British Journal of GeneralPractice,57:23-28

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4. Rene Cailliet, Neck and Arm Pain, Ed 3, pg 72-745. Leon Chaitow: Muscle Energy Techniques: Churchill

Livingston Elsevier,2006,3 rd Edition pg 1-26. Bart N Green: A Literature review of neck pain

associated with computer users, public healthimplications, The Journal of Canadian ChiropracticAssociation 2008 Aug, Vol 52 (3) 161-167

7. Janet G Travell and David G Simons: Myofascial Painand Dysfunction The Trigger Point Manual, The UpperExtremities, Williams and Wilkins, Vol.1, pg 184

8. Janet G Travell and David G Simons: Myofascial Painand Dysfunction The Trigger Point Manual, The UpperExtremities, Williams and Wilkins, Vol.1, pg 12

9. Peter Bablis et al: Neuro Emotional Technique for theTreatment of Trigger Point Sensitivity in Chronic NeckPain Sufferers: A Controlled Clinical Trial. Chiropracticand Osteopathy 2008;16: 4 (1340-1344)

10. John M Mc Partland: Travell Trigger Points- Molecularand Osteopathic Perspectives. Journal of the AmericanOsteopathic Association 2004 Jun, Vol-104, no.6, 244-249

11. Effects Of Osteopathic Muscle Energy Technique InAsymptomatic Subjects. JAOA March 2006,Vol106,no.3,137-142

12. Lessa K Huguenin: Myofascial Trigger Points- thecurrent evidence. Physical Therapy in Sports 5, 2004 2-12

13. Leon Chaitow: Muscle Energy Techniques: ChurchillLivingston Elsevier, 2006,3 rd Edition pg 248 – 250

14. Margaret Hollis: Massage for Therapist, BlackwellScience Ltd,1998, 2nd Ed pg 36

15. Leon Chaitow: Muscle Energy Techniques: ChurchillLivingston Elsevier, 2006 3rd edition pg 8

16. Christopher Quinn et al: Massage therapy andfrequency of chronic tension headaches. AmericanJournal of Public Health, 2002 Oct, V 92(10) 1657-1661

17. Courtney Taylor – Robins: The Journal Of MyofascialTherapy 1994 1(4) : 12

18. Leon Chaitow: Muscle Energy Techniques: ChurchillLivingston Elsevier,2006,3 rd Edition pg 120

19. William P Hantel, Sharon L Olson et al: Effectivenessof Home Program of Ischemic Pressure Followed bySustained Stretch for Treatment of Myofascial TriggerPoints, Physical Therapy 2000.

20. Karen J Sherman, Marian W Dixon et al: Developmentof Massage Taxonomy to Describe MassageTreatments for Musculoskeletal Pain. BMCComplementary Alternative Medicine 2006, Vol6:24

21. K Ramachandran, R.Angusamy, S.Thiruvarangan:Effect of Post-Isometric Relaxation Technique inMyofascial Pain Syndrome (Upper Trapezius) Journalof Indian Association of Physiotherapists Mar 2005,vol1, issue 1.

22. Howard Vernon, Barry Kim Humphreys: Chronicmechanical neck pain in adults treated by manualtherapy systematic review of change scores inrandomized controlled single session. Journal ofManual and Manipulative Therapy, 2008 Vol.16(2) E42-E52

23. Simons DG, Mense S: Diagnosis and therapy ofMyofascial Trigger Points. Schmerz 2003 Dec17(6):419-424

24. Leon Chaitow: Muscle Energy Techniques: ChurchillLivingston Elsevier,2006, 3 rd pg 253

25. Christian Lemburg: Trigger Point Massage, CrossFitJournal Issue 37- sep 2005


6 Samiha Mohamed. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Carpal tunnel syndrome: Influence of a comprehensiveexercise program on its prevalence in dentistsSamiha M Abd-Elkader 1, Gehan M. Ahmed2, Adel R. Ahmed3

1Department Of Health Rehabilitation Sciences, Collage Of Applied Medical Sciences, King Saud University, 2Departmentof Neuromuscular Disorder and its Surgery, 3Department Of Basic Sciences , Faculty of Physical Therapy, Cairo University.

Abstract

Background and objective

Dental health workers reported a high incidence of workrelated musculoskeletal disorder (WRMD). In dentalprofessionals, hand/wrist complaints and Carpal TunnelSyndrome (CTS) are the most common distal upperextremity disorders in comparison with other human serviceworkers. The purpose of this study was to assess the efficacyof a comprehensive exercise program as an ergonomiceducational program for CTS in young dentists.

Subjects and methods

Eighty six dentists from both genders (41female and 27male)with age ranged from 29 to 40 years were selectedaccording to self administered questionnaire coveringpersonal, symptomatic and functional information. Alldentists were suffering from CTS and were classifiedrandomly into two equal groups. The study group receiveda comprehensive exercise program in the form of (activerange of motion of the wrist\hand joints, stretching of thewrist flexors and extensors, tendon glides and strengtheningexercises) five days per week with ten repetitions for eachexercise for six weeks. The control group did not receiveany treatment program unless wearing night splint whensymptomatic. Pain intensity, hand grip and pinch strengths,symptom severity as well as functional status for both groupswere evaluated before starting the study and after six weeks.

Results

The results revealed significant improvement in both groupsregarding pain and functional scores. The improvement ismore prominent in the group that treated with acomprehensive exercise program in comparison to the nonexercise group. The results of the study group showedadditional improvement in hand grip and pinch strengths.

Conclusion

The finding of this study reflects the importance of usingcomprehensive exercises in reducing the incidence ofWRMD, particularly CTS in young dentist.

Key words

Work related disorders- Carpal Tunnel Syndrome- Dentists-Exercises.

Introduction

A work-related musculoskeletal disorders (WRMD) isdefined as a condition where work related tasks affect thenerves, tendons, muscles, and supporting structuresassociated with exposure to risk factors1. Carpal TunnelSyndrome (CTS) is the most common peripheral nerveentrapment syndrome and is characterized by compressionof the median nerve in the carpal tunnel, nocturnal pain,parasthesias, and weakness in the area innervated by themedian nerve in the wrist or hand2.

Hand/Wrist complaints are of most importance in terms ofoccupational related musculoskeletal disorder3. CTS is themost common distal upper extremity disorders amongmiddle-aged workers based on self-report data4. Themechanisms leading to work related musculoskeletal painare multi factorials. The pain can be attributed to numerousrisk factors, including prolonged static postures (PSP),repetitive movements, suboptimal tightening, poorpositioning, mental stress, physical conditioning and age5.

Dental health workers reported a high incidence of WRMDin comparison with other human service workers. Most dentaloperators can’t avoid PSP, which leads to muscleimbalances and joints hypomobility of the hand due toprolonged muscle contractions. The course of typical work-day for dentists entails many hours of statically maintainedpositions6. The repeated identical or similar motionsperformed over a period of time could cause over-exertionand overuse of certain muscle groups, which could lead tomuscular fatigue7. Interestingly, symptoms often relate notto the tendons and muscle groups involved in repetitivemotions, but to the stabilizing or antagonistic tendon andmuscle groups used to position and stabilize the extremityin space8.

In general dentists tend to lose flexibility in the directionopposite to that which they are postured statically duringthe day. Dentists reported higher rate of hand and fingerspain in comparison with normal population5. Over time, themuscle functions become compromised and are less ableto meet the demands placed upon them due to longer thesestatic positions and adaptive shortening of normal musclelength. So, there is higher risk for acquiring an injury in themedian nerve9. Consequently, CTS leads to decreasedability to carry, move, and handle objects and diminishesquality of life10.

Increased awareness of WRMD early in the career or in theundergraduate students may ensure lower rates ofoccupational pain/discomfort11. The purpose of this studywas to assess the efficacy of a comprehensive exerciseprogram in the prevention and treatment of CTS as WRMDin young dentists.

7Samiha Mohamed. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Subjects and Methods

Subjects Selection

The participants were working at the Military Hospitals,Riyadh, Kingdom of Saudi Arabia, and selected accordingto subjective symptoms and objective electrophysiologicfindings of CTS. Subjective symptoms included a history ofparaesthesia or pain in the median nerve distribution of thehand. The procedures were adequately explained to thesubjects before filling the questionnaire. Symptoms andfunctional status were evaluated by the self administeredquestionnaire12 (the symptom-severity scale and thefunctional status scale respectively) through questionnaireswhich were distributed to 127 dentists with a cover letterwhich was attached to it. The covered letter introduced theresearchers and the aim of the study. The questionnairesincluded personal and occupational information. Personalsection involved: age, marital status, gender, the specialty,dominant hand, if the female dentist is pregnant or breastfeeding at time of questionnaire completion and also if theyare going to have vacation during the coming six weeks.Occupational section included: information about thenumber of years since graduating, number of working hoursper week, number of patients seen per day. The subjectsalso were asked about any present or past hand/wrist painand if so how long it lasted, unilateral or bilateral, awakeningduring the night, if this pain was a result from work or otherfactors and finally about sick leave due to hand pain.

Only 68 (41 female -27 male) dentists were have the selectedcriteria and participated in this study. All dentists were righthanded. They were suffering from wrist and/or hand pain inthe dominant hand with sensory manifestation(paraesthesiae in the median nerve distribution in the hand)which was considered as grade (²) CTS9,13. The duration ofsymptoms varied from eight to 48 months, the mean being18 months. Inclusion criteria were established by the levelof neurophysiological involvement2,14(compound motoraction potential CMAP median nerve distal latency <4.7ms., difference between median and ulnar sensory actionpotential latencies>0.4 ms.).The participants age rangedfrom 29 to 40 years, they were treating 10 to 20 patients perday and the working hours per week ranged between 20 to40 hours. Half of the participants were single while the otherswere married.

Subjects were excluded if they had secondary entrapmentneuropathies, diabetes mellitus, thyroid disease, anyprevious inflammatory condition, neoplasm or surgery inthe hand or wrist, peripheral neuropathy, obesity, pregnantor breast feeding women during the time of the study, if theyhad treated physically for the wrist pain or if they had regularanalgesic, anti inflammatory or corticosteriod drugs. Dentistfound to have either clinical sign for axonal degeneration ofthe median nerve(thenar atrophy) or evidence ofdegeneration(abnormal spontaneous activity in the form offibrillation and positive sharp waves) on the electromyographic examinations of the abductor pollicis brevis musclewere excluded from the study as they were considered tohave severe CTS.

The Ethical Committee of Research at Collage of AppliedMedical Sciences, King Saud University approved the studyand consent form was obtained from all participants. All the

procedures of the study complied with the Ethical Principlesfor Medical Research Involving Human Subjects.

Outcome measures

The self administered questionnaire developed by Levine12

was administered to all dentists to assess CTS severity andfunctional status. The questionnaire is involving reviewingtwo questionnaire categories which were used in a similarstudies9,13,15 and consists of 19 self-evaluation questions.The first 11 refer to symptoms severity and the last itemsconcern functional aspects. Each answer is rated on a 5-point scale from 1(mildest pain or difficulty with activities) to5 (more severe pain or hindrance in performing anyactivities).

Hand grip strength was measured with a hand/helddynamometer (Jamar, model 2A3)a and pinch strengthmeasured with a reliable and accurate16 hand- held pinchmeter between the tips of the thumb and the little fingers.Subject was positioned sitting on a chair facing the examiner,shoulders retracted, elbow flexed at 90°, forearm and wristsupported on table in the neutral position17,18. Thedynamometers were initially standard and the average forceof three consecutive trails was calculated19.

Pain was measured by means of visual analoguescale(VAS)20on which the subjects could indicate their painalong distance of 10 cm. ranging from 0 represents no painwhile10 represents extremely intense pain.All measurements were performed before the first treatmentsession(at baseline) and at the end of the treatmentprogram(after six weeks).

Intervention

All participants agreed that they would not engage in anyother hand and upper limb exercises program rather thanthe one designed for this study for the six weeks. Subjectswere randomly assigned to two equal groups• The study group (G1) received a comprehensive

exercise program for hand muscles for six weeks.• The control group (G2) did not receive any exercise

program. They were instructed to wear an easy andcomfortable neutral customized thermoplastic, lightweight, neutral- positioned wrist with the MCP jointsfrom 5-10 of flexion splint21,22 at night when symptomaticonly. The splints were fabricated by an occupationaltherapist who reviewed wearing instructions with thesubjects.

Exercise program

Each participant in the exercise group (G1) supplied by abox contains a grip master, elastic pad to stretch fingersand diary card for more accountability and accuracy. Theexercise program was done five days per week with tenrepetitions for each exercise for total six weeks19,20,22. Thedentists in the exercise group received visual and verbalinstructions on the exercises and were asked to repeat theexercise program three to four times a day beside the mainsession. The preferred position was short sitting with elbowflexed 90°, the program included

• Active free range of motion of the wrist joint, extensionwas started from pronated forearm then raises the hand


Table 2: Comparisons of mean values in the study and control groups(G1&G2) before and after treatment

G1Mean±SD G 2 Mean±SD P- valueBefore 4.6±1.3 5.1±1.9 0.51

PainAfter 0.8± 0.88 2± 0.88 0.001*

P-value 0.001* 0.01*Before 39±6.10 39 ± 6.31 0.74

Hand grip strengthAfter 48±7.25 41±7.47 0.001*

P-value 0.001* 0.95Before 14.4±2.5 14.9±2.2 0.41

Pinch strengthAfter 19.3±1.7 15.1±2.6 0.001*

P-value 0.000* 0.98Before 2.90±0.14 2.55±0.50 0.43

Symptom severity scoreAfter 1.37±0.19 2.38±0.40 0.001*

P-value 0.0004* 0.13Before 2.37±0.47 2.57±0.29 0.27

Functional status scoreAfter 0.52±0.19 1.81±0.79 0.0000*

P-value 0.001* 0.04*

Significant* at P<0.05.SD= Standard deviation.

upward, flexion was done by raising the hand upwardwhile the forearm supinated then ulnar and radialdeviation by moving the hand from side to side.

• Stretching of the wrist extensors and flexors: withkeeping elbow straight, wrist extensors was stretchedby pressing the back of the hand with the other oneand hold this position for 30 seconds, however,pressing the fingers in a backward direction was doneto stretch wrist flexors.

• Tendon gliding: Straighten out the fingers then bendingthe proximal phalangeal joints down toward the palmwith holding five seconds.

• Grip strengthening: Squeeze the grip master withholding five seconds.

• Finger stretch: squeeze the hand strongly and out tostretch the fingers with holding 30 seconds.

Data Analysis

Descriptive statistics (means and standard deviations) werecomputed for all the data. The two tailed t-test was used tocompare hand grip and pinch strengths before and afterthe end of the program within each group and to detectdifferences between the both groups. Non - parametricMann- Whitny U-tests and Wilcoxon Signed Ranks wereused to compare the measurable parameters of pain andquestionnaire. For all statistical tests, 0.05 was used as alevel of probability. All statistics were calculated by usingSPSS program (version 15.0) b for Windows.

Results

Demographic characteristics of the study and control groups(G1&G2) at baseline are summarized in table 1. Nosignificant difference was seen between the groupsregarding age, duration of symptoms and electro-physiological parameters.

Table 2. Summarizes the mean changes in measurementsof all variables before and at the end of treatment in bothstudy and control groups (G1&G2). Comparisons revealedthat there were no significant differences in mean changesof all measures between the two groups before treatment.Results of pain showed that there was a significantimprovement in pain at the end of treatment in both groupswhile there was a statistical difference (P<0.05) betweenboth groups as the study group showed a statisticalimprovement (P=0.001) against the control group.

The results of the hand grip and pinch strengths measuresshowed significant improvement in G1 (P<0.05) with nochange in G2 after treatment. Questionnaire outcomescomparisons revealed that G1 showed improved scores onboth symptom severity and functional status scores. Thesymptom severity scores decreased from 2.90 to1.37, witha mean score improvement of 1.50 while the functionalstatus scores decreased from 2.37 to 0.52, with a meanscore improvement of 1.85. Compared with these results,the questionnaire outcomes of G2 differed considerablyafter treatment with high statistical significant differencebetween both groups (P=0.0001).

Discussion

In dental professionals, hand/wrist complaints occur withhigher risk in comparison with other human service workers.Awkward postures, prolonged repetitive movements,intense work schedules or fast work pace may be the sourceof ergonomic hazards and represent important risk factorsfor WRMD. Upon several of these held positions, pain inthe hand may occur due to adaptively shortened tissuesand entrapment of median nerve23,24. Prevention of WRMDis becoming crucial and requires the identification andmodification of risk factors through a combination ofergonomic strategies, educational interventions and specificthe rapeutic programs25,26.

This study was conducted to investigate the effect of acomprehensive exercise program on pain intensity, handgrip and pinch strength as well as symptom severity andfunctional status in dentists who were suffering CTS due towork positional stress. The selected dentists assignedrandomly into two groups. The study group received acomprehensive exercise program included active range ofmotion of the wrist joint, stretching of the wrist flexors andextensors, tendon glides and strengthening exercises of thehand grip five days per week for six weeks compared to thecontrol group which received rest in the form of night splintwhen symptomatic without applying any exercise program.Analysis of the results demonstrated significant improvement(decrease in pain and symptoms severity and increase ingrip/pinch strength as well as functional status scores) in thestudy group compared to the non exercise group.

Table 1: Demographic data of subjects in the study and control groups(G1&G2).

G1 (n=34) G2 (n=34)Age, year (mean±SD) 37.8±2.3 38.1±1.0

Male 13 14Sex

Female 21 20Specialty

General dentists 9 8Orthodentist 7 7dentalhygienists 8 9Pediatric 5 4Dentistry 5 6Endodontic

Duration of symptoms 1.5±3.6 1.4±3.6Year (mean±SD)CMAP median nerve distal 3.5±0.5 3.5±0.6latency, ms(mean±SD)

SD= Standard deviation.

9Samiha Mohamed. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Intensity of pain in both groups after treatment was improvedover time with a significant difference between both groups.Reduction of pain and improvement of function in the controlgroup may be explained by the fact that the mild symptomsof CTS are related to the sensitive median nerve fibers. Thepresence of constrictive situation, i.e. increased pressurewhich provokes a physical deformation of the nerve, togetherwith a vascular situation characterized by a microcirculatoryconstriction leading to a reduction in blood supply to thenerve fibers27. By immobilization the wrist, the splint reducescarpal tunnel pressure, leading to reduced constriction andaugmented blood supply, thus promoting regression of thecondition28,29.

Improvement that occurred in the study group (reduction ofpain and symptoms severity, increase of grip/pinch strengthsand functional status scores) after six weeks of exerciseprogram may be attributed to using a program with specialdifferent exercises. Valchi and Valchi8 reported thebeneficial effects of stretching exercises and addressedthe detrimental physiological changes that can developwhile working in optimal or awkward PSP such as ischemia,nerve compression, trigger points, muscle imbalance andjoint hypo-mobility. Costa and Vieira30 stated that the use ofsoftware computer program (Stretch- Break) to remind andguide workers through a set of stretching exercises thatwere performed every 45 minutes of work and lastedbetween one and two minutes is effective in reducingstiffness and muscle ache associated with long hours at thekeyboard.

Trujillo and Zeng31 and Henning et al. 32supported the resultsof the previous work. The researchers evaluated a computerbased break reminder program (stop and stretch) onprolonged computer usage who was suffering from wristpain. The results showed that the program has a positiveeffect on the workers productivity and body discomfort.Another study33 concluded that hand and wrist stretcheshelp to relax tense muscles, improves blood flow andcirculation to muscles, increase production of joint synovialfluid, increases range of motion, reduces formation of triggerpoints, warms up the muscles before beginning to workand prevent cumulative trauma disorders. Improvement inthe exercise group which was found in this study may beoccurred also as a result of using tendon gliding exercises.This suggestion can be supported by Romaryn et al.,34 andAkalin et al.,35 who demonstrated that controlled flexion andextension finger exercises such as tendon gliding exercisesreduce pressure on carpal tunnel and provide sufficientmovement between the median nerve and the flexortendons to prevent adhesions. In turn, mobilizing the mediannerve may increase blood flow to the nerve, which helpsnerve regeneration and ultimately may improve nerveconduction.

This study also showed a significant increase in hand gripand pinch strengths in the study group, which may attributedto the beneficial effects of strengthening exercises asreported by Grritsen et al.36, and Burke et al.37, whomentioned that strengthening exercises lead to enhancemuscle performance, increase strength of connective tissues( tendon, ligaments and intramuscular connective tissues),reduce risk of soft tissue injury during physical activity,improve capacity to repair and heal damaged tissues,enhance physical performance during daily living andoccupational activities, in addition to enhance felling of

physical well being. The authors9,11,26 who are working inthe field of WRMD reported that even brief periods ofstrengthening exercises during the course of workday canincrease circulation, relieve stress and enhance overallfitness, thereby facilitating increased productivity,decreased fatigue and reducing the likelihood of mediannerve injury.

Conclusion

This study provides further evidence of the effectiveness ofregular comprehensive exercise program for preventing aswell as reducing symptoms severity and improvingfunctional status in young dentists with CTS resulting fromWRMD.

References

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11

Comparing the efficacy of tai chi chuan and hatha yoga in type 2diabetes mellitus patients on parameters of blood glucose controland lipid metabolismAditya Pardasany*, Shweta Shenoy**, Jaspal S Sandhu****Research Student, **Senior Lecturer, ***Professer and Dean, Department of Sports Medicine and Physiotherapy, GuruNanak Dev University, Amritsar, India

Abstract

Objectives

The purpose of this study is to assess the effect of Tai chichuan (TCC) and Yoga on Glycosylated Haemoglobin(HbA1C), Low Density Lipoprotein (L.D.L.), Cholesterol,Fasting blood glucose (F.B.G), Post prandal blood glucose(P.P.B.G)

Design and Methodology

Experimental Intergroup Comparative Design. 45 type 2diabetes mellitus patients of age 40 to 60 years participatedin the study and were randomly divided into 3 groups.Experimental Group1 (n=15) doing a series of 24movements extracted from Yang style Tai chi chuan shortform. Experimental Group2 (n=15) doing 12 Asanas and 7Pranayamas of Hatha Yoga. Control Group3 (n=15) doingno exercise just under Oral hypoglycemic medication.

Readings/ Machines used

Pre training readings and Post training readings were takenon the 1st day and 12th week for all the groups. Fastingblood glucose (F.B.G) and Post prandal blood glucose(P.P.B.G) was assessed by Biochemical AutomatedAnalyzer.

Results

Paired T-test was applied to find the significance level of allthe groups (p- value), One way anova to find F-value andPost Hoc Test to find out the comparative significance levelof the 3 groups. We have thus concluded that Tai chi chuangroup showed a greater % of improvement than Hatha Yogain case of the following parameters like Cholesterol, FBGand PPBG while in terms of HbA1C and LDL the %improvement in Tai chi chuan group was slightly higherthan Yoga group. The Control group did not show anyimprovement except in PPBG where it showed animprovement of 4.90%

Keywords

Yang style, Tai chi chuan, Hatha Yoga, Pranayamas, Type2 diabetes mellitus patients, Fasting blood glucose, Postprandal blood glucose, Glycosylated Haemoglobin, LowDensity Lipoprotein, Cholesterol.

Introduction

Exercise, along with diet and medication, plays an important

role in the management of type 2 diabetes. Type 2 diabetesmellitus is a chronic disorder and has become a leadingcause of death (Vincent et.al; 2007). The latest WHOestimate for the number of diabetic people is 370 million by2030 with India having 31.5 million people diabetics. Yogais an ancient mind body discipline that has been widelyused in India for the management of diabetes. Hatha Yoga,the branch of yoga approaches self realization and healingthrough the physical body and its energies (pranic/etheric)template, with a focus on breath control (Pranayamas) andspecific postures (Asanas) including both active andrelaxation poses. With no appreciable side effects yogaappears safe, easy, inexpensive and there is growingevidence that yoga practice aids in the prevention andmanagement of typeII diabetes mellitus patients (Vincentet.al; 2007). It has also been shown by researchers that 50minutes of Hatha Yoga burns 144 calories which isequivalent to a slow walk and increases the heart rate to62% of maximum heart rate providing aerobic workout(Boehde et.al; 2005). 3 controlled nonrandomized studies(Yogendra J et.al; 2004, Naruka J et.al; 1986, Schmidt Tet.al; 1997) demonstrated significant positive changes inthe blood lipid levels mainly low density lipoprotein,cholesterol following yoga based interventions that rangedfrom 6weeks to 12 months in duration in healthy patients.Similarly 2 uncontrolled studies(Jain S et.al; 1995,Bhaskaracharyulu C et.al; 1986) targeting adults withdiabetics demonstrated significant positive changes inblood lipid levels following yoga based interventions thatranged 8 days to 3 months duration.Tai chi chuan (TCC) on the other hand is described as atraditional Chinese martial art that has been practiced inChina for many centuries. TCC exercise emphasizes deepdiaphragmatic breathing and relaxation with fundamentalpostures that flow imperceptibly and smoothly from one tothe other through slow, gentle and graceful movements. Ithas been advocated for development of mind bodyinteraction, breathing regulation with body movement andhand eye coordination (Wang et.al; 2004). A 12 weeks ofTCC exercise program has shown to cause changes inlipid profile mainly Cholesterol and High DensityLipoprotein in a group of sedentary life control individuals(Tsai JC et.al 2003). TCC is classified as a moderateexercise as it does not exceed 60% of maximum heart rateand is also said to be a low impact low velocity exercise.(Verhagen et.al; 2004) but not enough studies have beendone to see the same improvement in diabetics by TCCexercise.Hence there is need to identify cost effective preventionand management strategies for type 2 diabetes mellituspatients which is provided in this study by doing a 12 weekstraining of Tai chi chuan exercise and Hatha Yoga exercise

Aditya Pardasany. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

12

and comparing the two to see which between the two lowimpact, moderate form of exercise will be a more efficientexercise in improving the glycosylated haemoglobin amethod to check the glycemic control within 3 months inpercentage, lipid profile by low density lipoprotein,cholesterol markers and also the fasting and post prandalblood glucose.

Methods

Subjects: The total number of subjects included 45 matureadults (28males and 17 females) between the age group of40 to 60 years of age. Individuals having type 2 diabeteswere recruited from Amritsar population most of whichbelonged to the local Guru Nanak Dev University populationwho were all independent community dwelling adults. Theywere randomly divided in to 3 groups- Experimental Group1(n=15) type II diabetics who performed a series of 24movements extracted from Yang style of Tai Chi short formof exercise, Experimental Group2 (n=15) type 2 diabeticswho performed 12 Asanas and 6 Pranayamas of HathaYoga exercise and Control Group3 (n=15) type diabeticsdid not perform any kind of exercise. All the groups ofindividuals consumed Oral hypoglycemics. A total of 12weeks of exercise training was given to the ExperimentalGroup. The pre and post readings of GlycosylatedHaemoglobin, Low Density Lipoprotein, Cholesterol, FastingBlood Glucose and Post prandal blood glucose was takenon the 1st day and after 12 weeks for both the experimentalgroups and the control group.

Screening, informed consent and questionnairesThe research was approved by the Ethical Committee ofGuru Nanak Dev University, Amritsar Prior to theparticipation; all the subjects were provided with an informedconsent. Pre medical Screening was done for all subjectsand they were included only if they fulfilled the inclusioncriteria. The subjects having a history of any renal disease

in the past, arthritis, high blood pressure, intermittentclaudication, foot injury, diabetic foot, foot ulcers,breathlessness any form of cardiac disease were excludedfrom the study. A Pre participation Evaluation Questionnairewas also taken prior to participation to access the level ofphysical activity the individual did, the age of onset andduration of diabetes. Information about the habits likesmoking cigarettes, chewing tobacco, drinking alcohol werenoted using a Demographic Questionnaire and otherrelevant information like changes in weight since last year,any attack of paralysis diet and medium of cooking wererecorded.

Blood chemical analysis- protocol for all the parameters,Sample collection and analysis of blood sampleA total of 7ml of venous blood was collected for biochemicalanalysis from the antecubital vein out of which 5ml wasmade to clot and was called as fasting blood sample. All theparameters were checked on the 1st day before the exerciseand after 12 weeks of exercise. HbA1C was noted in %whereas the other biochemical diabetic parameters werenoted in mg/dl. All these protocols were recorded from areputed standardized biochemical laboratory AsiaDiagnostics, Amritsar. Reagents used for HbA1C,Cholesterol and for Blood glucose were- Lysing Reagentand Ion Exchange Resign tubes, Working Reagent andGlucose Reagent respectively.

Results

All the data was analyzed using Paired T-test to find thesignificance level of all the groups (p- value) and a OneWay ANOVA was used as three groups Tai chi chuan HathaYoga and Control were compared to find out the F-value.This was followed by Post Hoc test and Scheffe’s test formultiple comparisons between groups to check thesignificance of each group when considering one parameterto find out their significance level. For all the tests, level ofsignificance used was p<0.05.z

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Fig. 1: Intra Group Comparison Between The Groups For Measuring FastingBlood Glucose. Fig. 2: Intra Group Comparison Between The Groups For Measuring PPBG.

Table 1: Intra Group Comparison Between The Groups For Measuring Fasting Blood Glucose.Sr. No. Name of Group Pre test (Day 1) Post Test (12th wk) % diff. Paired T Value p value

Mean (mg/dl) SD Mean (mg/dl) SD 1 Tai chi chuan 167.8 ±36.27 139.47 ±15.81 20.31% 3.7850** 0.0202 Hatha Yoga 173.67 ±28.45 150.67 ±23.22 15.27% 5.3790*** 0.0003 Control 183.73 ±24.83 184.13 ±41.67 -0.20% -0.0540NS 0.958

df= n-1= 15-1= 14, NS=Non-Significant; *=t (14,0.05)³ 2.145=Significant; **=t (14.0.01)³2.977=Highly Significant; ***=t (14,0.001)³4.140=Very Highly Significant.

Table 2: Intra Group Comparison Between The Groups For Measuring Post Prandal Blood Glucose. (PPBG)Sr. No. Name of Group Pre test (Day 1) Post Test (12th wk) % diff. Paired T Value p value

Mean (mg/dl) SD Mean (mg/dl) SD 1 Tai chi chuan 223 ±46.67 171.07 ±18.17 30.36% 4.6610*** 0.0002 Hatha Yoga 234.67 ±63.95 190.33 ±44.15 23.29% 2.8140* 0.0143 Control 246.87 ±66.41 235.33 ±60.64 4.90% 1.1280NS 0.278

df= n-1= 15-1= 14, NS=Non-Significant; *=t(14,0.05)³ 2.145=Significant; **=t(14.0.01)³2.977=Highly Significant; ***=t(14,0.001)³4.140=Very Highly Significant.

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Fig. 4: Intra Group Comparison Between The Groups For Measuring LDL

Fig. 4: Intra Group Comparison Between The Groups For Measuring LDL

Fig. 5: Intra Group Comparison Between The Groups For Measuring Cholesterol.

Table 3: Intra Group Comparison Between The Groups For Measuring Hba1c (Glycosylated Haemoglobin)Sr. No. Name of Group Pre test (Day 1) Post Test (12th wk) %diff. Paired T Value p value

Mean (mg%) SD Mean (mg%) SDGlycosylated Haemoglobin

1 Tai chi chuan 8.93 ±0.37 8.60 ±0.38 3.84% 4.4950*** 0.0012 Hatha Yoga 9.07 ±0.41 8.83 ±0.4 2.83% 3.9540** 0.0013 Control 9.06 ±0.27 9.07 ±0.3 -0.11% -0.2740NS 0.788

df= n-1= 15-1= 14, NS=Non-Significant; *=t(14,0.05)≥ 2.145=Significant; **=t(14.0.01)≥2.977=Highly Significant; ***=t(14,0.001)≥4.140=Very Highly Significant.

Table 4: Intra Group Comparison Between The Groups For Measuring L.D.L (Low Density Lipoprotein)Sr. No. Name of Group Pre test (Day 1) Post Test (12th wk) % diff. Paired T Value p value

Mean (mg/dl) SD Mean (mg/dl) SD

Low Density Lipoprotein

1 Tai chi chuan 107.87 ±15.68 96.8 ±10.48 11.44% 2.8560* 0.013

2 Hatha Yoga 102.4 ±13.6 93.87 ±7.98 9.09% 3.6440** 0.003

3 Control 101.4 ±9.8 106.53 ±17.38 -4.82% -1.4440NS 0.171 df= n-1= 15-1= 14, NS=Non-Significant; *=t(14,0.05)³ 2.145=Significant; **=t(14.0.01)³2.977=Highly Significant; ***=t(14,0.001)³4.140=Very Highly Significant.

Table 5: Intra Group Comparison Between The Groups For Measuring Cholesterol.Sr. No. Name of Group Pre test (Day 1) Post Test (12th wk) % diff. Paired T Value p value

Mean (mg/dl) SD Mean (mg/dl) SD Cholesterol

1 Tai chi chuan 187.6 ±16.33 167.33 ±6.42 12.11% 6.0490*** 02 Hatha Yoga 178.6 ±17.16 166.93 ±15.28 6.99% 3.7890** 0.0023 Control 187.33 ±15.27 191.33 ±20.87 -2.09% -1.7510NS 0.102

df= n-1= 15-1= 14, NS=Non-Significant; *=t(14,0.05)≥ 2.145=Significant; **=t(14.0.01)≥2.977=Highly Significant; ***=t(14,0.001)≥4.140=Very Highly Significant

On applying the Intergroup comparative One Way Anovabetween the pre exercise readings of Tai chi chuan, Hathayoga and Control groups we have concluded that HbA1CPre, Cholesterol Pre, LDL Pre, FBG Pre, PPBG Pre areNon-significant.On applying the Intergroup comparative One Way Anovabetween the post exercise readings of all the groups wehave concluded that LDL Post is significant at (p<0.05) witha F-value of 4.1600, HbA1C Post is significant at (p<0.01)

with a F-value of 6.3290, Cholesterol Post, FBG Post, PPBGPost are significant at (p<0.001) with a F-value of 12.3730,9.6240, 8.2170 respectively.Where: Pre is before the exercise.Post is after the exercise.

Post hoc test multiple comparison- scheffetest

On applying Post Hoc Test- Multiple Comparison Scheffe’sTest we can conclude that:-The Pre values for all the parameters HbA1C, LDL,Cholesterol, FBG, PPBG were Non significant whilecomparing Tai chi chuan vs Control, Hatha Yoga vs Controlor Tai chi chuan vs Hatha Yoga.

The Post values for the parameters are as follows:HbA1C: Only Tai chi chuan vs Control was significant at(p=0.004) while others were Non- significant

Cholesterol: Both Tai chi chuan vs Control and Hatha Yoga

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vs Control were significant at (p<0.001) while Tai chi chuanvs Hatha Yoga was Non- significantLDL: Only Hatha Yoga vs Control was significant at (p=0.031)while others were Non- significantFBG: Tai chi chuan vs Control and Hatha Yoga vs Controlwere significant at (p=0.001 & p=0.011) respectively whileTai chi chuan chuan vs Hatha Yoga was Non- significantPPBG: Tai chi chuan vs Control and Hatha Yoga vs Controlwere significant at (p=0.001 & p=0.030) respectively whileTai chi chuan vs Hatha Yoga was Non- significant.

Discussion

This study was done to compare the efficacy of Tai chi chuanand Hatha Yoga in improving the overall condition of Type2 diabetes mellitus patients along with a proper diet plan.Type 2 diabetes patients are associated withhyperinsulinemia. This occurs as a compensatory responseby pancreatic â-cells for the decrease in carbohydrateutilization resulting in increase in blood glucose (Kyizomet.al; 2008). A Study by Shen et.al; (2007) was done on 30Type 2 diabetics doing Tai chi chuan exercise which didnot have a control group. In our study 45 Type 2 diabetespatients were included in a control group who consumedoral hypoglycemics and did not do any exercise at all. BothHatha Yoga and Tai chi chuan are said to be moderateform of exercises Verhagen et.al; (2004) which have to bedone not exceeding 62% of the H.R max (Boehde et.al;2005). The exercises are to be done thrice a week for a totalduration of 12 weeks (Yeh SH et.al; 2007, Audette JF et.al;2006, Thornton EW et.al; 2004). In our present study thepercentage of exercise HR was fixed according to the ageof the person between 40 to 60 % of his age predicted HRmax American Diabetic Association using a polar heart ratemonitor (Yeh SH et.al; 2007, Audette JF et.al; 2006, ThorntonEW et.al; 2004). The parameters included in this presentstudy were FBG, PPBG, HbA1C, Cholesterol and LDL andthe readings were taken on the 1st day and 12weeks forboth the experimental and control group.

In terms of Fasting Blood Glucose the result of this presentstudy demonstrated statistical significant difference in meanpercentage after 12 weeks in both Tai chi chuan (p<0.01)and Hatha Yoga (p<0.001) group while Yeh et al (2007)concluded that Tai chi chuan training was not statisticallysignificant after 12 weeks of training(p=0.080). Studies haveshown that 12 weeks of yoga asanas with pranayamatraining brought about an improvement of 22.61% in theFBG (Kyizom et.al 2008) due to increase in utilization and

metabolism of glucose in the peripheral tissues and adiposetissue through enzymatic process while Gordon et.al (2008)showed a 29.48% improvement after 6 months of yoga thusconcluding that Hatha Yoga showed therapeutic effects ondiabetic patients by decreasing their oxidative stress andimproving antioxidant status. But in our study we haveconcluded that Tai chi chuan group showed a 5.04% greaterimprovement than Hatha Yoga group while the Controlgroup did not show any improvement. Thus it shows thatTai chi chuan was more effective than Yoga in improvingthe FBG of the type 2 diabetics.

In terms of Post prandal Blood Glucose the result of thispresent study demonstrated statistical significant differencein mean percentage after 12 weeks in both Tai chi chuan(p<0.001) and Hatha Yoga (p<0.05) group. Studies haveshown that 45 days of yoga had brought about a 23.64%improvement in the PPBG (Kyizom et.al 2008) due toreduction in oxidative stress and increase in metabolism ofglucose while Singh et.al (2004) showed a 37.07%improvement after 7 weeks of yoga training due to properpostural alignment and controlled breathing interaction withsomato neuro endocrine mechanism which affected themetabolic functions. In our present study Tai chi groupshowed 30.36% improvement while Hatha yoga groupshowed 23.29% improvement while the Control group alsoshowed an improvement of 4.90% after 12 weeks ofconsumption of Oral hypoglycemics. One way anova showsthat the post PPBG was significant at (p<0.001). Thus itshows that Tai chi chuan was more effective than HathaYoga in improving the PPBG of the type 2 diabetics.

In t erms of Glycosylated haemoglobin(HbA1c) is the mainindex of glycemic control. The result of this present studydemonstrated statistically significant difference in meanpercentage after 12 weeks of training in both Tai chi(p<0.001) and HathaYoga (p< 0.01) group but Lam et.al(2008), Shen et.al (2007) did not show any statisticalsignificance after the training due a small sample size anda large standard deviation. Studies have shown that 12weeks of Tai chi chuan training has brought about animprovement of 6.32% (Yeh et.al 2007). This improvementwas assumed to be due to glucose metabolism or byincreasing the number of regulatoy T-cells. (Lam et.al 2008)reported a 3.70% improvement after 6 months of trainingwhile Honkola et.al (1997) on the other hand showed nosignificant reductions after 5 months of training. In our presentstudy Tai chi chuan showed 1.01% greater improvementthan Hatha Yoga group while the Control group did notshow any significant improvement. Thus it shows that Taichi chuan and Hatha Yoga were equally efficient inimproving the HbA1C of the type 2 diabetics. Thisimprovement could be due to improved Cardiovascularfitness level.

In terms of Low Density Lipoprotein the result of this presentstudy demonstrated statistical significant difference in meanpercentage after 12 weeks in both Tai chi chuan (p<0.05)and Hatha Yoga (p<0.01) group. Studies have shown that12 weeks of Hatha Yoga and Conventional PT exercisesshowed only a 0.66% improvement in L.D.L (Gordon et.al2008). He hypothesized this improvement was due todecrease the MAO (Mono aldehyde oxidase) enzymes. Onthe other hand Kyizom et.al (2008) concluded that a 20.91%improvement was seen in L.D.L after 45 days of yogaasanas and pranayamas and attributed this was due to

Intergroup oneway anova

Parameters F value Significance

HbA1C Pre 0.7830 0.4640

HbA1C Post 6.3290 0.0040

Cholesterol Pre 1.4860 0.2380

Cholesterol Post 12.3730 0.0000

LDL Pre 1.0350 0.3640

LDL Post 4.1600 0.0220

FBG Pre 1.0660 0.3540

FBG Post 9.6240 0.0000

PPBG Pre 0.5840 0.5620

PPBG Post 8.2170 0.0010

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increased hepatic lipase and lipoprotein lipase at cellularlevel which affected the metabolism of lipoprotein leadingto an increase in uptake of triglycerides by adipose tissues.In our present study Tai chi chuan group showed 2.35%greater improvement than Hatha Yoga group while theControl group did not show any significant improvement.Thus it shows that both Tai chi chuan and Hatha Yogagroup were equally effective in improving the LDL of thetype 2 diabetics.

In terms of Cholesterol its level fluctuates depending on thediet consumed as more cholesterol is present in red meatthan egg hence the same diet plan was given to all thepatients irrespective of the group they belonged to.The result of this present study demonstrated statisticalsignificant difference in mean percentage after 12 weeks inboth Tai chi chuan (p<0.001) and Hatha Yoga (p<0.01)group Studies have shown that 6 months of yoga showed45.12% improvement in Cholesterol (Lam et.al 2008) butwas statistically non significant. On the other hand Tsaiet.al (2003) showed 8% improvement in Cholesterol after12 weeks of Tai chi chuan exercise. In our present study Taichi chuan group showed a 5.12% greater improvementthan Hatha Yoga group while the Control group did notshow any improvement at all. Thus it shows that Tai chichuan was slightly more effective than Yoga in improvingthe Cholesterol of the type 2 diabetics.

Tai chi chuan is said to be an aerobic exercise involvingpostures in standing position in which the individualsimultaneously takes steps in a continuous, rhythmical andfast manner while Yoga is said to be a fitness exercise andis not considered as aerobic (Porcari JP 2005). It involvesintermittent slow asanas and pranyamas taking a rest intervalof 5 to 10 seconds before the next step. In our research wehave made Tai chi chuan and Hatha yoga patients toexercise at < 60 to 62% of H.R max which is equivalent to36.4% of VO2max as also used by (Wang C et.al 2004). Ithas also been observed that maximum oxygen uptake indiabetics was much lesser than sedentary age matchedindividuals in doing a particular aerobic exercise (KomatsuWR et.al 2005). Oxygen consumption is an index ofmaximum aerobic capacity. It has been seen that malesconsume greater amount of maximum oxygen uptake thanfemales in a particular exercise. We had greater amount ofmales than females in the Tai chi chuan group than HathaYoga group in our study and larger number of diabeticsconsuming a non vegetarian diet in Yoga than in Tai chichuan group that is why the Cholesterol level and HbA1Chas improved to a greater extent in diabetics doing Tai chithan Yoga. HbA1C is considered as a better and firmindicator to check the glycemic control than FBG OR PPBGas it gives us an average percentage of 3 months bloodsugar whereas FBG , PPBG might change as per theprevious days diet or food intake (Yeh et.al 2007). Hencefrom our study we have concluded that Tai chi chuan exercisehad a greater percentage improvement than Yoga inimproving the FBG, PPBG and Cholesterol while in terms ofHbA1C and LDL the percentage improvement in Tai chichuan was very slightly higher or almost equal to that ofYoga group. The Control group of patients on Oralhypogycemics did not show any improvement except inPPBG upto 4.90%. So we recommend Tai chi chuanexercise to Hatha Yoga exercise for improving the overallcondition of Type II diabetic patients.

References

1. Audette JF, Jin YS, Newcomer R, Stein L, Duncan G,Frontera WR. Tai chi versus brisk walking in elderlywomen. Oxford Journal. 2006, 35(4): 388-393.

2. Boehde D, Porcari J. Does yoga do the body good.ACE FitnessMatters. 2005, 7-9.

3. http://www.americanheart.org/presenter.jhtml?identifier=4736

4. h t t p : / / w w w . a c e f i t n e s s . o r g / g e t f i t / s t u d i e s /yogastudy205.pdf

5. Damodaran A, Malathi A, Patil N, Shah N, SuryavansihiMarathe S. Therapeutic potential of yoga practices inmodifying cardiovascular risk profile in middle agedmen and women. J Assoc Physicians India 2002;50:633– 640.

6. Gordon LA, Morrison EY, McGrowder DA, Young R,Fraser YTP, Zamora EM, Alexander-Lindo RL and IrvingRR. Effect of exercise therapy on lipid profile andoxidative stress indicators in patients with type 2diabetes. BMC Complement Altern Med. 2008; 8: 21.

7. Innes KE, Bourguignon C, Taylor AG. Risk indicesassociated with Insulin Resistance Syndrome,Cardiovascular disease and possible protection withyoga. Journal Of The American Board Family Medicine.2005, 18(6): 491-519.

8. Khor SMG. Taichi Qigong for stress control andrelaxation 2006.

9. Kyizom T, Singh KP, Tandon OP, Madhu SV, Singh S.Infuence of Pranayamas and Yoga-Asanas on SerumInsuin, Blood Glucose and Lipid Profile in Type 2Diabetes. Indian Journal of Clinical Biochemisty. 2008,23(4): 365-368.

10. Lam P, Dennis SM, Diamond TH. Improving glycaemicand B.P control in Type 2 Diabetes- The effectivenessof Taichi. Australian Family Physician. Oct 2008, 37(10):884-887.

11. Madanmohan, Udupa K, Bhavanani AB, VijaylakshamiP, Surendiran A. Effect of slow and fast pranayama onreaction time and cardiorespiratory variables. Indian JPhysiol Pharmacol 2005, 49(3): 31-38.

12. McGilvery C, Mehta JMR, Mehta S. The Encyclopediaof Aromatherapy, Massage and Yoga. UltimateEditions. 1995.

13. Peters LA.S, Jones GR, Kenno KA, Jakobi JM. Strengthand Contractile Properties are similar between personswith Type 2 Diabetes and Age, Weight, Gender andPhysical Activity matched Controls. Canadian JournalOf Diabetes 2007, 31(4): 357-364.

14. Richerson SJ, Robinson CJ, Shum J. A Comparitivestudy of reaction times between typeII diabetics andnon- diabetics. Biomedical Engineering Online 2005,4(1): 4-12.

15. Ronnie Robinson. Taichi for you. Duncan BairdPublishers 2006.

16. Saudek CD, Derr RL, Kalyani RR. Assessing Glycemiain Diabetes using Self-monitoring Blood Glucose andHemoglobin A1c. Journal of American MedicalAssociation. 2006, 295(14): 1688-1697

17. Singh S, Malhotra V, Singh KP, Madhu SV, TandonOP. Role of yoga in modifying certain cardiovascularfunctions in type 2 diabetic patients. J Assoc PhysiciansIndia 2004, 52:203–206.

18. Thornton EW, Sykes KS, Tang WK. Health benefits of

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Tai chi exercise in improving balance and bloodpressure in middle aged women. Health PromotionsInternational. 2004, 19(1):33-38.

19. Tsai JC, Wang WH, Chan P, Lin LJ, Wang CH,Tomlinson B, Hsieh MH, Yang HY, Liu JC The beneficialeffects of Tai Chi Chuan on blood pressure and lipidprofile and anxiety status in a randomized controlledtrial. J Altern Complement Med. 2003 Oct;9(5):747-54.

20. Verhagen AP, Immink M, Meulen A, Bierma-ZeinstraSMA. The efficacy of Tai Chi in older adults: FamilyPractice. 2004, 21: 107-113.

21. Vincent HK, Innes KE The Infuence of Yoga-BasedPrograms on Risk Profiles in Adults with Type 2Diabetes Mellitus: A Systematic Review. eCAM. OxfordJournals 2007, 4(4): 469-486.

22. Voukelatos A, Cumming RG, Lord SR, Rissel C. ARandomized Controlled Trial of Tai Chi for thePrevention of Falls. J Am Geriatr Soc. 2007, 55(8): 1185-1191.

23. Vyas R, Dikshit N. Effect of meditation onrespiratorysystem, cardiovascular system and lipidprofile. Indian J Physiol Pharmacol 2002;46:487–91.

24. Wang C, Collet JP, Lau J. The Effect of Tai Chi onHealth Outcomes in Patients With Chronic Conditions.Arch Intern Med. 2004, 164: 493-501.

25. Xin L, Miller YD, Burton NW, Brown WJ.A preliminarystudy of the effects of Tai Chi and Qigong medicalexercise on indicators of metabolic syndrome andglycaemic control in adults with elevated blood glucose.Br J Sports Med.2008; Oct 16.

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17

Effect of segmental breathing exercises on chest expansion inempyema patientsAparna Sarkar, Harshita Sharma, Shaily Razdan, Suman Kuhar, Nitesh Bansal, Gunween KaurAmity Physiotherapy College, NODIA, Uttar Pradesh

Abstract

Objective

To prove that segmental breathing exercises help inincreasing the chest expansion in empyema patients havingdecreased lung expansion.

Methods

40 empyema patients of both genders were taken in thisstudy. Chest expansion at axillary level, 4th costal cartilageand 10th costal cartilage levels were measured before andafter performing segmental breathing exercises.

Results

An increase in mean chest expansion at all the three levelswas observed before and after exercise. It was highlysignificant at all the three levels (p < 0.001). The increase inchest expansions after segmental breathing exercises wasfound to be more in middle level than the apical and lowerlevel.

Conclusion

We conclude from this study that segmental breathingexercises play an important role in early re-expansionof lungs and hence should be an integral part in earlyrehabilitation of restrictive lung diseases as empyema.

Keywords

Segmental breathing exercises, chest expansion,empyema.

Introduction

Empyema is defined as pus in the pleural cavity and hassignificant clinical morbidity1. Most empyemas in childhoodfollow acute bacterial pneumonia. Rarer causes includespread from other sites of sepsis such as from septic emboli,lung abscess, subphrenic abscess, osteomyelitis of a rib, oras a result of a missed inhaled foreign body. Recently, somecentres in North America and Europe have seen a rise inthe incidence of empyema in children2 , 3. Empyema is acondition in which pus and fluid from infected tissue collectsin a body cavity. It results from an untreated pleural-spaceinfection that progress from free-flowing pleural fluid to acomplex collection in the pleural space. Empyema mostcommonly occurs in the setting of bacterial pneumonia.About 70% of cases of pneumonia are associated with Para

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pneumonic effusion. The goal of treatment is to cure theinfection and remove the collection of pus from the lung.Empyema should be drained immediately with chest tubeinsertion. Appropriate antibiotics should be started followedby specific drug based on culture. Some patients notresponding to this regimen may require thoracotomy to lyseadhesions. Some would require decortication, if a thickpyemic peel has formed and prevent lung expansion 4

It’s questionable whether a patient can be taught to expandlocalized areas of the lung while keeping other areas quiet.Hypoventilation does occur in certain areas of the lungsbecause of pain and muscle guarding after surgery,atelectasis and pneumonia. Therefore, it will be importantto emphasize expansion of problems areas of the lungsand chest wall under certain conditions5, 6. It is known, thathypoventilation does occur in certain areas of the lungsbecause of pain and muscle guarding afterbsurgery5.The aims of physiotherapy in empyema 7 are:

• to minimize adhesion formation within the pleura• to regain full lung expansion• to clear lung fields• to maintain good posture and thoracic mobility• to improve exercise toleranceSegmental breathing exercises are known to increase chestexpansion in myriad of cases with reduced chest excursion.The exercises are supposed to act on a variety ofmechanisms, including the stretch reflex mechanism. TheAmerican Thoracic Society has classified empyema into 3phases based on the natural history of the disease. The firstphase is the exudative phase and involves the release ofsterile pleural fluid into the pleural space in response toinflammation of the pleura. At this stage, the pleura andrelated lung are mobile. The second phase has been termedthe fibrinopurulent or transitional phase. During this stage,the pleural fluid becomes more turbid and fibrin developson the pleural surfaces. At this time, pleural fluid becomesviscous. The fibrin peel loculates the fluid collection andgradually limits expansion of the underlying lung 8-10 .In case of empyema of the pleural cavity , special factorsare present in the rigid chest wall and the collapsed lung -creating a cavity the walls of which will not collapse 11 . Thefibropurulent or transitional stage is the beginning of thetrue infection. Fibrin is deposited on both the parietal andvisceral pleura as a continuous sheet or membrane. Themembrane tends to trap and fix the lung, preventing fullexpansion 12.In case of empyema of the pleural cavity , special factorsare present in the rigid chest wall and the collapsed lung -creating a cavity the walls of which will not collapse 11 . Thefibropurulent or transitional stage is the beginning of thetrue infection. Fibrin is deposited on both the parietal andvisceral pleura as a continuous sheet or membrane. The

18 Aparna Sarkar. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

membrane tends to trap and fix the lung, preventing fullexpansion12.The third stage, called the organization or chronic stage,ischaracterized by the in growth of fibroblasts and capillariesfrom both the parietal and visceral pleural surfaces. Thisproduces an inelastic membrane called the pleural peel,which severely limits lung expansion13. Progressivedevelopment of the empyema is accompanied byprogressive localization and fibrosis, through stages I to III.Management requires both appropriate antibiotics togetherwith adequate pleural drainage14.Segmental breathing exercises are used to improve ribexcursion to restricted areas occurring following chesttrauma, atelectasis, pleurisy, or surgery. Asymmetrical chestmovement may be identified by palpating along the ribsduring inspiration and expiration. Chest mobilizationexercises are performed first to stretch intercostals softtissues. Patients are instructed to fully inspire whilestretching restricted regions and to fully expire whilecompressing restricted chest regions15.The therapy planned depends on the causative factor, stageof empyema, state of the underlying lung, presence ofbronchopleural fistula (BPF) if any, ability to obliterate thespace, and the condition of the patient. The treatment needsto be individualized. Physiotherapy and breathing exerciseswill help in early re-expansion of the lung followingevacuation of the fluid16.The aim of the study is to prove that segmental breathingexercises help in increasing the chest expansion in patientswith empyema having decreased lung expansion.

Materials & methods

Subjects selection

40 cases of empyema were taken.Gender: Both males and femalesResearch design: experimental type, before and afterwithout control groupSample design: non-probability sample design.

Inclusion criteria• Empyema patients with ICD• Decreased chest expansion• Decreased exercise tolerance• Pleural thickening

Exclusion criteria• Unbearable pain• Dyspnoea• Fever• Rib fracture

Equipment requiredA measuring tape with centimeters scale is being used formeasuring the expansion at chest levels:• Axilla• 4th costal cartilage level• 10th costal cartilage level

Segmental Breathing Exercises

The goals of this exercise are to improve ventilation,increase the effectiveness of the cough mechanism, preventpulmonary impairment, improve strength, endurance, and

coordination of respiratory muscles, correct inefficient orabnormal breathing pattern, promote relaxation. It isperformed on a segment of lung, or a section of chest wallthat needs increased ventilation or movement, e.g. postthoracotomy, trauma to chest wall, pneumonia, postmastectomy scar, post chest radiation-fibrosis17. It isquestionable whether a patient can be taught to expandlocalized areas of the lung while keeping other areas quiet.Patients position hook lying or sitting.

Procedure

• Place therapist’s hands along lateral aspect of lowerribs to fix the patient’s attention to the areas at whichmovement is to occur

• Ask pt to breathe out, and feel the rib cage movedownward and inward

• As pt breathes out, place firm pressure into the ribswith palm of hand

• Just prior to inspiration, apply a quick downward andinward stretch to the chest.

• Tell pt to expand the lower rib area against your handsas he breathes in

• Apply gentle manual pressure to lower rib area as thept breathes in and chest expands and ribs flares

• As pt breathes out, assist by gently squeezing the ribcage in a downward and inward direction.

• Teach pt to be independent with segmental breathingtechnique18.

Measure the chest expansion of the patient at three levels:• At axillary level• 4th costal cartilage level• both costal cartilage level

Segmental breathing exercises were given to the patient atthree segments:• Apical segment• Lateral basal segment• Posterior basal segmentChest expansion were measured before & afte segmentalbreathing exercise.

Statistical analysis

Paired t-test was used to analyze the effect of segmentalbreathing exercise on chest expansion. Values werepresented as mean± standard deviation. Statisticalsignificance was set at p< 0.05.

Results

Table 1: Comparison of chest expansion before & after segmentalbreathing at different levels.

S. No. Levels Chest expansion(cm) t-value P valueBefore After

Exercise Exercise1. Axillary 1.6±0.4 2.16±1.0 4.74 <0.001

level2. 4thcostal 1.9±0.1 2.56±0.9 6.28 <0.001

cartilage3. 10thcostal 1.96±0.2 2.76±1.1 7.54 <0.001

cartilage

19Aparna Sarkar. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Fig. 2: Showing mean increase in chest expansion at 4th costal cartilage levelbefore and after segmental breathing exercises.

Fig.1: Shows mean increase in chest expansion at axillary level before andafter segmental breathing exercise.

Discussion

Empyema is a common condition in medical wards. Aperson with an empyema has a collection of pus within thechest cavity, caused by an infection. The pus lies in thespace between the outside of the lung and the inside of thechest wall. The most common cause of empyema ispneumonia. An empyema can form when the infectionspreads from the inside of the lung, to the outside of thelung. In this condition apart from other things chestexpansion also get affected. Physiotherapy or CardioRespiratory physiotherapy intervention plays a vital role inmanagement of such patients. Breathing Exercisesespecially segmental breathing exercises is simple, lowcost and easy to administer technique.In the 1970’s, unilateral breathing techniques by applyingpressure with either a hand or a towel over 1 side in order tofacilitate regional lung expansion were considered to beviable treatment options19,20. Subsequent research hasshown that healthy people are able to direct inspiration toupper or lower lung regions upon instruction21,22.As per this study these exercises demonstrate benefits inrestrictive dysfunction, as they help in re-expansion of lungsto some extent. So it may help in early recovery and reducingthe late complications as pleural fibrosis. Before exerciseintervention, it was found that there was remarkabledecrease in chest expansions at all the three levels. It wasalso seen that lower lobe expansion and middle lobeexpansion were severely decreased as compared toaxillary level expansion. In most of the cases secretionswere accumulated in lower lobes, so this could have resultedin decreasing the normal expansion at this level.The segmental breathing exercises helped in relieving

patients with such restrictive disorders and increasing theirexpansions at these three levels. Segmental breathingexercises provided a quick stretch just before the initiationof inspiration, so via stretch reflex the contraction was initiatedthat assisted in inspiration. It helped in increasing inspiratorycapacity and during expiration, it helped in full expirationthereby helping the patient to relax comfortably.Thus, after intervention of segmental breathing exercisesin empyema patients, an increase in all the three levelswas observed. The mean expansion at axillary level cameout to be 2.16 cms (which was increased by 0.56 cms), at 4th

costal cartilage level, it was 2.56cms (which was increasedby 0.66 cms) and at 10th costal cartilage level it was 2.76cms(which was increased by 0.8 cms).Moreover it was found that the increase at the 10th costalcartilage level was more than the other two levels, whichcould be probably because of restriction due to accumulationof pus. The middle lobe showed a better expansion thanaxillary level. There was comparatively lesser expansion inaxillary level as this level had near to normal ranges ofexpansion in most of the cases, even prior to exerciseapplication.In this study, an improvement in chest expansion inempyema patients was noted following segmentalbreathing exercises. Therefore, early initiation of segmentalbreathing exercises should be included in regular medicalintervention for early re-expansion and better prognosis ofthe empyema patient.

Conclusion

We conclude from this study that segmental breathingexercises play an important role in early re-expansion oflungs and hence should be administered in restrictive lungdiseases as empyema.

References

1. Mangete ED, Kombo BB, Legg-Jack TE. Thoracicempyema: a study of 56 patients. Arch Dis Child 1993;69: 587–588.

2. Rees JH, Spencer DA, Parikh D, Weller P. Increasein incidence of childhood empyema in West Midlands,UK. Lancet 1997; 349: 402.

3. Donnelly LF, Klosterman LA. CT appearance ofparapneumonic effusions in children: findings are notspecific for empyema. AJR 1997; 169: 179–182.

4. Qureshi NR, Gleeson FV. Imaging of Pleural Disease.Clin Chest Med. June 2006; 27: 193-213.

Fig. 3: Showing mean increase in chest expansion at 10th costal cartilage levelbefore and after segmental breathing exercises.

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5. Kisner C, Colby LA. Therapeutic Exercise Foundationsand Techniques. Philadelphia (PA): F.A. DavisCompany; 1996: 664 – 679.

6. Hillegass EA, Sadowsky HS. CardiopulmonaryPhysical Therapy. Philadelphia (PA): Saunders;2001:659.

7. Stuart Porter, Noël Margaret Tidy .Tidy’s Physiotherapy,13 th edition. pg270.

8. Jeffrey J Rentz ,William G Austen, Suresh Koneru,.American College of Surgeons . Empyema andBronchopleural Fistula .2006, Jun 15.

9. K.d. Panton, lung expansion after acute empyema.Vancouver, B.C. pg 534 .

10. W. Parry . Empyema .Surgery (Oxford) , Volume 22 , (5):103 – 105.

11. Hillegass EA, Sadowsky HS. CardiopulmonaryPhysical Therapy. Philadelphia (PA): Saunders;2001:659,

12. Graham EA. Principles involved in the treatment of acuteand chronic empyema. 1924. J Am Coll Surg. 2005Aug201(2):157.

13. Maskell NA, Davies CW, Nunn AJ, Hedley EL, GleesonFV, Miller R, Gabe R, Rees GL, Peto TE, WoodheadMA, Lane DJ, Darbyshire JH, Davies RJ; FirstMulticenter Intrapleural Sepsis Trial (MIST1) Group.U.K. Controlled trial of intrapleural streptokinase forpleural infection. N Engl J Med. 2005 Mar 3;352(9):865-874.

14. Tsai TH, Jerng JS, Chen KY, Yu CJ, Yang PC.Community-acquired thoracic empyema in olderpeople. J Am Geriatr Soc. 2005 Jul;53(7):1203-1209.

15. Thomas E. Hyde, Marianne S. ConservativeManagement of Sports Injuries, Gengenbach, pg 447.

16. Engum, S.A. ,Minimal access thoracic surgery in thepediatric population, Seminars in Pediatric Surgery.2007; 16(1): 14-26.

17. Frownfelter, D., Dean, E. . Cardiovascular andPulmonary Physical Therapy – Evidence in Practice.St. Louis: Mosby Elsevier.2006, p.329.

18. Kisner C, Colby LA. Therapeutic Exercise Foundationsand Techniques. Philadelphia (PA): F.A. DavisCompany; 1996: 664 – 679.

19. Gaskell DV, Webber DA. The Brompton Hospital Guideto Chest Physiotherapy. 2nd ed. Oxford: BlackwellScientific Publications; 1973.

20. Cash J. Introduction to the treatment of medical chestconditions. In: Downie P, ed. Cash’s Textbook of Chest,Heart, and Vascular Disorders for Physiotherapist. 1sted. London: Faber and Faber; 1979.

21. Roussos CS, Fixley M, Genest J, et al. Voluntary factorsinfluencing the distribution of inspired gas. Am ReviewRespir Dis. 1977;116:457-467.

22. Tucker B, Jenkins S, Cheong D, et al. Effect of unilateralbreathing exercises on regional lung ventilation. NuclMed Commun. 1999;20:815-821.

Aparna Sarkar. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

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Relationship between pes planus foot type and postural stabilityPaik-Ling Harrison* , Chris Littlewood**

*BSc (Hons), Physiotherapist, **BHSC(Hons), MSc, Dip, MDT, MCSP, SRP, Senior Lecturer in Physiotherapy,Sheffield Hallam University, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK

Abstract

Objective

To investigate whether there is a correlation between thedegree of pes planus foot deformity and postural stability

Design

Prospective correlation study.

Setting

Sheffield Hallam University, UK

Participants

Eight healthy volunteers (15 feet) with pes planus foot type.Main Outcomes Measures: Pes planus was defined by theNavicular Drop test (NDT) where a drop >10mm wasregarded as pes planus. The SMS Healthcare BalancePerformance Monitor (BPM) was used to measure staticpostural stability using the mean sway number in the lateraland anterior-posterior directions where the higher the swaynumber the higher the instability.

Results

In the anteroposterior direction there is a good correlation,(spearman’s rank = 0.670) which is statistically significant(p= 0.006) indicating that as the degree of pes planusincreases the degree of postural stability decreases. In thelateral direction there is a good to excellent correlation,(spearman’s rank = 0.880) which is statistically significant(p= 0.01) indicating that as the degree of pes planusincreases the degree of postural stability decreases.

Conclusions

As the degree of pes planus deformity increases the degreeof static postural stability decreases. These findings mayhave important implications for clinical practice and futureresearch.

Key words

foot deformities, flat foot, musculoskeletal equilibrium,navicular drop, correlation study.

Introduction

Balance has been defined as; ‘the ability to maintainequilibrium by positioning our centre of gravity over our

base of support.’1. Postural adjustments involving interactionbetween the neurological system and an intactmusculoskeletal system occur to maintain thisequilibrium1,2,3. The inability to adjust or control postureeffectively may lead to an increased risk of falling and injury4.For this reason interventions to improve postural controlare frequently incorporated as part of rehabilitation andprophylactic programmes5,6.It has been proposed that different foot types may influenceour ability to maintain this equilibrium5. Three foot posturesare generally described in clinical practice:

• Pes Cavus - high arched foot• Pes Planus - low arched foot• Pes Rectus - normal5.A literature search was undertaken to identify previousstudies of value in this area. An electronic search of CINAHL(1982 to May 2008), Medline (1996 to May 2008),SPORTDiscus (1975 to May 2008), TRIP (1997 to May2008), AMED (1985 to May 2008) and Google Scholar (May2008) was conducted using the following search terms;(balance or musculoskeletal equilibrium or postural controlor postural stability or postural sway) and (foot type or footposture or flat foot or pes planus or pes cavus or pes rectus)limited to studies with adult participants only reported inEnglish. This electronic search was complemented by handsearching the reference lists of the relevant articles located.Only four relevant studies were identified4,5,7,8. Three of thesestudies report findings linking pes cavus or pes planus foottypes with reduced postural stability when compared withpes rectus foot type. All four studies consider static balance/control as a primary outcome measure using single legstance. Tsai et al8 reported reduced postural control in bothcavus and planus foot types in comparison to rectus foottypes. Cobb et al4 compared planus to rectus foot type,reporting reduced postural control in the anteroposteriordirection of planus foot types. Hertel et al5 reported reducedpostural control in cavus feet only and Cote et al7 reportedreduced postural control in planus compared to cavus foottype but this difference was not statistically significant whencompared to rectus foot types.To the authors’ knowledge no previous studies haveinvestigated whether the degree of foot deformity affectspostural stability in a linear way. This information is importantbecause it may guide clinicians and researchers to identifythose at greater risk of impaired postural stability andtherefore increased risk of falls and injury enabling a moretargeted approach to therapy and research. Thus the aim ofthis study is to investigate whether there is a correlationbetween the degree of pes planus foot deformity andpostural stability. It is expected that the results of this studywill be of direct clinical utility.

Paik-Ling Harrison. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

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Methods

Participants

A convenience sample of participants was recruited via e-mail from students of Sheffield Hallam University who metthe following inclusion/ exclusion criteria.Inclusion criteria• 18 years old.• Willing and able to participate• Pes planus foot type as defined by the Navicular

drop test (NDT) 10mm.

Exclusion criteria

• History of lower limb injury 6 months prior to testing7

• Vestibular, visual, proprioceptive or cognitive systemsdisorders (ear infection, dizziness, vertigo,Meniere’s)9,10.

• History of cerebral concussion up to 10 days prior tothe study being conducted. If individuals were 10< dayspost concussion but still presented with l i n g e r i n gsymptomatology such as headache and dizziness theywere excluded11.

• Pes rectus or cavus foot type as defined by the NDT.A total of 18 participants (10 female/ 8 male, 18-33 years)volunteered. Each foot was treated as an individual resultingin a total of 36 subjects. Following application of theinclusion/ exclusion criteria 15 subjects were eligible toenter the study. The only reason for exclusion of the 21subjects was pes rectus or cavus foot types. Ethical approvalwas gained prior to the study via Sheffield HallamUniversity.

Testing procedures

All tests were undertaken by the lead author (PH) in practicalrooms at Sheffield Hallam University, Sheffield, UK.

Assessment of foot type

The NDT was used to assess foot type. This measurementwas taken three times and the mean was subsequentlycalculated. Left and right feet were assessed individually.The NDT measures sagittal displacement of the naviculartuberosity and is an indication of the degree of subtalarjoint pronation12. The details of this test have been publishedpreviously7.The NDT is a quick and simple means ofclassifying foot posture with evidence to confirm it as areliable and valid method of measurement12.PH identified the navicular ridge by palpating the medialaspect of the foot. The distance from the navicular ridge tothe ground is measured in sitting, on the plinth first, andthen in standing where the subject stands in bilateral stancewith equal weight bearing through the feet. The differencebetween the two values represents the ‘sagittal planedisplacement of the navicular bone from a neutral positionto a relaxed standing position’13.

Assessment of postural stability

The Sandland Manufacturing Services (SMS) HealthcareBalance Performance Monitor (BPM) was used to measurepostural stability. The BPM is regarded as a valid instrument

in the measurement of postural sway with high inter-raterand intra-rater reliability14,15. It consists of one 2-axialfootplate that was connected to a feedback unit and softwarethat is IBM compatible. It provides auditory and visualfeedback of weight distribution and degrees of anterior-posterior and lateral sway (sway number) during quietstanding14,16.The BPM was set up according to the operation manual17.To enable the foot to be positioned correctly on the footplate, anatomical markers were drawn on the medialmalleolus, Achilles tendon and 5th metatarsal. PH was thenable to align the feet exactly with the lines on the forceplates18.To reflect previous studies and clinical practice this studyused single-leg stance (SLSt) as the task to challenge thestatic postural stability of the participants (see figure 1). Toreflect the real world participants completed the tasks witheyes open which is thus of greater pragmatic value.Each task lasted for 30 seconds and was performed 3 timesto maximise reliability18. A 10 second rest period occurredin-between each trial. The mean sway number in the lateraland anterior-posterior direction of the three trials for eachtask was calculated. If the contra-lateral foot touched thefloor during the task it was done again.

Outcome Measures- Sway Number

Postural stability is defined and recorded as a ‘sway number’in the lateral and anterior-posterior direction19. The higherthe sway number the higher the instability. The BPMcalculates sway number as the most accurate value of therate of deviation from the patients mean balance andindicates how steady the person is17.

Data analysis

A correlation coefficient is used to indicate the strength anddirection of a linear relationship between two random variadata.

Results

All 15 subjects completed the study. The data was analysedwith SPSS and normality of distribution was investigatedvia skewness and kurtosis and analysis of frequencydistributions20. All data sets violated the normalityassumption and thus Spearman’s rank correlation coefficientwas calculated20.

Anterior-posterior postural stability: There is a goodcorrelation, (spearman’s rank = 0.670) which is statisticallysignificant (p= 0.006) indicating that as the degree of pesplanus increases (navicular drop increases) the swaynumber increases (figure 2).

Lateral postural stability: There is a good to excellentcorrelation, (spearman’s rank = 0.880) which is statisticallysignificant (p= 0.01) indicating that as the degree of pesplanus increases (navicular drop increases) the swaynumber increases (figure 3).

Discussion

Previous studies have identified a relationship betweenfoot type and postural stability4,5,7,8. However, as far as the


23

authors’ are aware this is the first study that has investigatedand reported upon relationships between the degree ofpes planus foot deformity and degree of postural instability.In this study pes planus was classified using the NDT wherea drop of greater than or equal to 10mm equated to pesplanus foot type.The results of this study demonstrate a good positive linearcorrelation between the degree of planus deformity andstatic postural stability in the anteroposterior direction anda good to excellent positive linear correlation between thedegree of planus deformity and static postural stability inthe lateral direction. These results mean that as the degreeof pes planus increases the degree of postural stabilitydecreases as measured by sway number. These findingsbroadly concur with previous studies and appear to addfurther validity to the concept that foot type may affectpostural stability. However this data also offers further insightby highlighting an association between the degree ofdeformity and postural instability which may have importantimplication for clinical practice and further research.Previous authors have attempted to explain the apparentassociation between pes planus foot type and decreasedpostural stability. It has been suggested that the excessiveflattening of the medial-longitudinal arch of the pes planusfoot creates a hyper mobile foot which subsequently placeshigher demands on the surrounding muscles and nervescontributing to postural instability7,8,21. Contrary to this Lin etal2 suggested that people with pes planus foot type willhave better postural control due to greater somato-sensoryfeedback from higher surface contact area. Thesesuggestions are not supported by the findings from this orother studies.With an awareness of these proposed theories, previousresearch has looked at the benefits of training programmesand orthotic prescription on balance with mixed resultsRothermei et al6 concluded that traditional balance trainingappears to be more effective than balance trainingemphasising active foot positioning. Crucially this study

made no attempt to classify foot type. Kulig et al22 selectedparticipants with pes planus and demonstrate the benefitsof correction with orthoses in terms of selective activation ofthe tibialis posterior muscle which is regarded as animportant contributor to the maintenance of a neutral footposition. Mattacola et al23 classified participants accordingto foot deformity and demonstrated a significantimprovement in postural stability following the applicationof foot orthoses.In combination with the results of this study, the conclusionsfrom these other studies may begin to suggest thatclassification of foot type and degree of deformity in bothclinical and research areas may be necessary to maximisethe benefits of any proposed therapeutic interventions.

Conclusion

This study has demonstrated that as the degree of pesplanus deformity increases the degree of static posturalstability decreases. These findings may have importantimplications for clinical practice and future research.Clinicians should be mindful of these findings whendesigning and implementing programmes of rehabilitationand prophylaxis and further research should consider thedegree of foot deformity when evaluating the efficacy ofintervention.

Declaration of interest: The authors report no conflicts ofinterest. The authors alone are responsible for the contentand writing of the paper.

References

1. Browne J, O’Hare N. Review of the different methodsfor assessing standing balance. Physiotherapy. 2001:87: 489-495.

2. Lin C, Lee H, Chen J, Lee H, Kuo of a M.Developmentquantitative assessment for correlation analysis offootprint parameters to postural control in children.Physiological Measurement. 2001: 27: 119-130.


Fig.1: Single leg stance Fig. 2: Relationship between navicular drop and anteroposterior sway

Fig. 3: Relationship between navicular drop and lateral sway

Table.1: Interpreting the strength of the correlation coefficient (24).Correlation Negative PositiveLittle/ no correlation -.25 to 0 0 to .25Fair -.25 to -.50 .25 to .50Good -.50 to -.75 .50 to .75Good to excellent -.75 to -1.0 .75 to 1.0

24

3. Wrisley D, Whitney S. The effect of foot position on themodified clinical test of sensory interaction andbalance. Archives of Physical Medicine andRehabilitation. 2004: 85: 335–8.

4. Cobb S, Tis L, Johnson B, Higbie E. The effect offorefoot varus on postural stability. Journal ofOrthopaedic and Sports Physical Therapy. 2004: 34:79-85.

5. Hertel J, Gay M, Denegar C. Differences in posturalcontrol during single leg stance among healthyindividuals with different foot types. Journal of AthleticTraining. 2002: 37: 129-132.

3. Wrisley D, Whitney S. The effect of foot position on themodified clinical test of sensory interaction andbalance. Archives of Physical Medicine andRehabilitation. 2004: 85: 335–8.

4. Cobb S, Tis L, Johnson B, Higbie E. The effect offorefoot varus on postural stability. Journal ofOrthopaedic and Sports Physical Therapy. 2004: 34:79-85.

5. Hertel J, Gay M, Denegar C. Differences in posturalcontrol during single leg stance among healthyindividuals with different foot types. Journal of AthleticTraining. 2002: 37: 129-132.

6. Rothermei S, Hale S, Hertel J, Denegar C. Effect ofactive foot positioning on the outcome of a balancetraining programme. Physical Therapy in Sport. 2004:5: 98-103.

7. Cote K, Brunett M, Gansneder B, Shultz S. Effects ofPronated and Supinated Foot Postures on Static andDynamic Postural Stability. Journal of Athletic Training.2005: 40: 41-46.

8. Tsai LC, Yu B, Mercer V, Gross M. Comparison ofdifferent structural foot types for measure of standingpostural control. Journal of Orthopaedics and SportsPhysical Therapy. 2006: 36: 942-953.

9. Brandt T, Schautzer F, Hamilton DA, Bruning R,Markowitsch HJ, Kalla R, Darlington C, Smith P, StruppM. Vestibular Loss Causes Hippocampal Atrophy andImpaired Spatial Memory in Humans. Brain. 2006:128: 2732-2741.

10. Smith PF, Zheng Y, Horii A, Darlington CL. Doesvestibular damage cause cognitive dysfunction inhumans? Journal of Vestibular Research. 2005: 15: 1-9.

11. Guskiewicz K, Ross S, Marshall S. Postural Stabilityand Neuropsychological Deficits after Concussion inCollegiate Athletes. Journal of Athletic Training. 2001:36: 263–273.


12. Razeghi M, Batt M. Foot type classification: a criticalreview of current methods. Gait and Posture. 2002:15: 282–291

13. Vauhnik R, Turk Z, Pilih I, Mièetiæ-Turk D. Intra-raterreliability of the using of the navicular drop test formeasuring foot pronation. Croatian Sports MedicineJournal. 2006: 21: 8-11.

14. Haas B, Burden A. Validity of weight distribution andsway measurements of the Balance PerformanceMonitor. Physiotherapy Research International. 2000:5: 19-32.

15. Hinman M. Validity and Reliability of MeasuresObtained from the Balance performance MonitorDuring Quiet Standing, research report.Physiotherapy. 1997: 88: 579-581.

16. Sackley C, Baguley B, Gent S, Hodgson P. The use ofa balance performance monitor in the treatment ofweight-bearing and weight-transference problemsafter stroke. Physiotherapy. 1992: 78: 907-913.

17. SMS Health Care. Data Print Software Version 5.3 forBalance Performance Monitor, Operating Manual.Harlow, Elizabeth House. 1998.

18. Haas B, Whitmarsh TE. Inter- and intra-tester reliabilityof the Balance Performance Monitor in a non-patientpopulation. Physiotherapy Research International.1998: 3: 135–147

19. Collen F. The measurement of standing balance afterstroke. Physiotherapy Theory and Practice. 1995: 11:109-118.

20. Puri B. SPSS in Practice, An Illustrated Guide, 2nd

Edition. London, Arnold. 2002.21. Snook AG. The relationship between excessive

pronation as measured by navicular drop andisokinetic strength of the ankle musculature. Foot andAnkle International. 2001: 22: 234-240.

22. Kulig K, Burnfield J, Reischl S, Requejo SM, BlancoC, Thordarson. Effect of foot orthoses on tibialisposterior activation in persons with pes planus.Medicine & Science in Sports & Exercise. 2005: 37:24-29.

23. Mattacola C, Dwyer M, Miller A, Uhl T, McCrory J,Malone T. Effects of orthoses on postural stability inasymptomatic subjects with rearfoot malalignmentduring a 6 week acclimation period. Archives ofPhysical Medicine & Rehabilitation. 2007: 88: 653-660.

24. Batavia M. Clinical research fo Health Professionals, auser-friendly guide. Oxford, Butterworth Heinemann.2001.

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Agreement between timed up and go test and tinetti assessmentscale in institutionalized elderlyFaizan Zaffar Kashoo*, Leena Dhawan***Post Graduate Student, **Reader, Jamia Hamdard University, Hamdard Nagar, New Dehli

Abstract

Purpose of study

To determine the accuracy of Timed Up and Go Test, inorder to meet the increasing demand for a quick and easybalance assessment tool.

Material and method

A sample of convenience of 60 older adults took part in thisstudy. All the subjects were assessed for the inclusion andexclusion criteria of the study. If they fulfilled inclusion andexclusion criteria, they were asked to sign an informedconsent form. Then subjects were assessed on two balancetests i.e. Tinetti Assessment Scale Timed Up and Go Testand the scores were entered in the respective assessmentcharts. The whole procedure was a single sessionassessment that lasted for approximately 20 minutes for asingle subject.

Results

The (K) value analyzed between the Timed Up and Go Testand Tinetti Assessment Scale showed a significant value of88.3% with a confidence interval of (77.4- 95.17%). Overallaccuracy of the Timed Up and Go Test is 88.3% with (77.4- 95.17%) confidence interval.

Conclusion

Scores obtained on Timed Up and Go Test has shown agood agreement with scores obtained on the TinnettiAssessment Scale

Key words

Timed Up and Go Test, Tinetti Assessment Scale, Elderly,Agreement

Introduction

Identification of older persons at high risk of falling is a vitalmedical concern. Falls are extremely common among theelderly population accounting for substantial morbidity andmortality and are often potentially preventable.1 In fact eachyear in the U.S approximately one third of the populationaged 65 year and older who are living at home will fall atleast once and over two thirds of persons living in nursinghomes will fall with 10%-25% of them experiencing a seriouscomplication2,3,4. Twenty percent of community dwellingelderly persons fall each year5,7,8,9 in the U.S and this figurehas doubled in institutionalized ambulatory populations.

According to the Population Reference Bureau 2000 worlddata sheets life expectancy at birth for Indians is between60 and 61 years. Only 4% of our population is over the ageof 65 which is as huge as 60 millions. Physical mobility canbe assessed in several ways. The traditional neuromuscularexamination, while useful in establishing a diagnosis anddetermining disease severity has being shown to be a poorindicator of functional capacity14. Activities of Daily Livingquestionnaires that assess functional skills through selfreport or observer report are customarily included in ageriatric assessment14,13,12,11,15. The responses obtained maynot always be accurate however for reasons of language,culture, hearing, intellectual capacity or even pride.16

Unfortunately because of the length and complexity of thesetests, it is usually not practical to use them in a busy officesetting or to include them in the initial geriatric assessmentwhen the patient is frail. Therefore there is a great need foran assessment tool, which utilizes less time and providesthe required information needed by the physiotherapist.

Methodology

Source of data: The subjects of this study were the residentsof old age home across Delhi and NOIDA

Study design: method comparison design was used in thisstudy

Subjects: All 60 subjects met the following inclusion criteria.1. Above 65 years, able to follow one-step command2. Elderly ambulant people.3. Able to walk 9.1 m with or without assisted device.

The subjects with the following criteria were excluded fromthe study.1. Non- ambulant elderly2. Age below 65 years3. Severe cardiovascular complication4. History of orthopedic surgery in the previous 6 weeks.

Procedure

The inter rater reliability was established between theresearchers. As recommended by bio-statistician, fivesubjects were randomly selected and rated. Raters had100% agreement between the scoring. The subjects wereinvited to participate in the study. The study was explainedto the subjects in detail. If they fulfilled inclusion andexclusion criteria, they were asked to sign an informedconsent form. Then subjects were assessed on two balancetests i.e. Tinetti Assessment Scale Timed Up and Go Testand the scores were entered in the respective assessmentcharts. The whole procedure was a single sessionassessment that lasted for approximately 20 minutes for asingle subject.

Faizan Zaffar Kashoo. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

26

Timed up and go test

The Timed Up and Go test measures the time it takes asubject to stand up from a chair and walk a distance of 3 m,turn walk back to the chair and sit down. A chair of 46 cm ofseat height was used for the study. A 3 m distance wasmarked on the floor in front of the chair. The test began witheach subject sitting back against the chair, arm resting onthe lap and feet just behind the distance marked on thefloor. The subject was instructed that on the word ‘start’ heshould stand up, walk comfortably and safely to the markon the floor and sit on the chair. They were informed thattrial would be timed. Timing began at the word “start” andended when the subject back rested against the chair uponreturning. A practice trial was performed for all the subjectsbefore the recorded trial. This was to make the subjectfamiliar with the procedure. Data obtained during therecorded trial was used in data analysis.

Tinetti assessment scale

The Performance Oriented Mobility Assessment (POMA)developed by Tinetti provides a simple brief and reliableassessment of position changes and responses toperturbations and gait movements during daily activities. Itincludes both static and dynamics balance items organizedinto two subtests of balance and gait. Balance test consistof nine maneuvers. These includes sitting balance, attemptto rise, immediate, standing balance, standing balance,sternal nudge, eyes closed with feet together, turning 3600

and sitting down. The total score of balance is 16. The gaittest consists of 12 points; this includes gait initiation, steplength, foot clearance, step symmetry, step continuity, path,trunk, and base of support. Both the scores obtained inbalance subscale and gait subscale was used for dataanalysis.

ResultsThe (K) value analyzed between the Timed Up and Go Testand Tinetti Assessment Scale showed a significant value of88.3% with a confidence interval of (77.4- 95.17%). Furtherthe sensitivity, specificity, negative predictive value, positivepredictive value and overall accuracy of Timed Up and GoTest was calculated using frequency table.


Statistics were performed using the stata 7.0. A kappastatistics (k) was used to analysis the agreement betweenthe scores obtained from times up and go test and tinettiassessment scale.

Table 1: Specificity, Sensitivity, Positive Predictive Value and NegativePredictive Value Of Timed Up And Go Test.

Scale Sensitivity SpecificityPPV NPV AccuracyTUG 95.24% 84.06%CI (76.1- 99.8) (69.4- 94%)

Key words

PPV : Positive Predictive ValueNPV : Negative Predictive ValueTUG : Timed Up and Go testCI : Confidence Interval

Discussion

In our population of frail institutionalized elderly persons,the Timed Up and Go Test appears to be a practical,reliable performance test of physical mobility. Studiessuggest that it is also an objective means of followingfunctional change over time. The test is practical becauseof its simplicity. It is quick and easy to administer andrequires no special equipment. We used a stopwatch anda standard chair with armrest. Professional expertise ortraining is not required as the instructions arestraightforward and time score is objective and easy torecord. The time score on the Timed Up and Go Test is asimple measurement of physical mobility, which can beused either as a screening test or as a descriptive tool. Itmay also prove to be a useful measure to monitor changesover time.While interpreting the findings of this study, thecharacteristics of the subjects should be kept in mind. Theparticipants of the study consisted of more males (n=33)than females (n=27). The subjects were elderly people whowere institutionalized and mobile, were active and had fairlygood health. Timed up and Go Test is a dynamic balancetest. Walking puts more challenge to the balance of anindividual than basic functional activities such as getting upfrom a chair. Falls reported during basic functional activitieswere not associated with serious injury17.The choice of best clinical test to use in the examination ofelderly remains as a matter of clinical judgment and it issuggested that the choice of measurement should be basedon how well the specific problem of the given patient matchesthe purpose of the study. Timed Up and Go Test can beused to monitor changes occurring after exerciseintervention18.

Conclusion

Scores obtained on Timed Up and Go Test will show agood agreement with scores obtained on the TinnettiAssessment Scale

Graph1: Percentage of Agreement Between Timed Up And Go Test andTinetti Assessment Scale.

References

1. Campbell, Reinken J. Falls In Old. Age Aging 1981:10, 264-270.

2. Nicken H. Intrinsic Factors In Falling Among The ElderlyArch Int. Med, 1985: 145:1089-1093.

3. Hogue C Injury In Late Life, Epidemiology J Am GeriatricSoc. 1982: 30: 183-190,276 – 280.

4. Rodstein M, Accidents Among The Aged: IncidenceCause And Prevention J.Chronic Disease 1964: 17:515, 1492-1495.

5. Prudham D, Evan JG, Factors Associated With Falls In


27

The Elderly, Age Aging 1981: 10: 141-146.6. Gryfe CI, Amies A Shley MJ, A Longitudinal Study Of

Falls In An Elderly Population. Incidence And Mobility.Age Ageing, 1977: 6: 201-210.

7. Wylie CM: Hospitalization For Fractures And Bone LossIn Adults. Public Health Rep. 1977: 92: 33-38.

8. US Bureau of the Census: Statistical Abstract Of TheUnited States 1997, Ed. 117, Washington DC, 1997

9. Moen P. Gender, Age And The Life Course, In BinstockRH, George LK Binstock RH,George LK: HandbookOf Aging And The Social Science Ed. 4, San Diego,Academic Press, 1996.

10. Jette AM, Branchs IG: Impairment and Disability in theAged: J Chronic Disease1985; 38, 59-65.

11. Spence DI, Brown WW: Functional Assessment Of TheAged Person, In Granger, CU Gresham GE: FunctionalAssessment In Rehabilitation Medicine, Baltimore,Williams And Wilkins, 1984.

12. Katz S et al: Life Expectancy New Engl J. Med 1983,309, 1218-1224

13. Manton KG, Epidemiological, Demographic and SocialCorrelates Of Disability Among The Elderly Milbank1939. 67 (Supl, 1) 13-56.

14. Tinetti ME Ginter SF Identifying Mobility DysfunctionIn Elderly people. J Am Geriatric Soc1988, 259-1190.

15. Guralnik IM, Banch LG, Cunnings SR et al. PhysicalPerformance Measuring In Aging Research J.Gerontology 1989, 44; M141.

16. Clinical and Laboratory Studies Of Falls In Old People,Geriatric Med. 1985: 1 513.

17. Mary E. Tinnetti MD, factors associated with seriousinjury during falls by ambulatory nursing homeresidents. American Geriatric Society 35:644-648,1987

18. Diane podsiadlo, and Sandra Richardson, TheTimed Up and Go Test, A test for basic functionalmobility for frail elderly persons, American GeriatricSociety 1991 vol. 39. No.2

CMCL-FAIMER REGIONAL INSTITUTE,CHRISTIAN MEDICAL COLLEGE, LUDHIANA

MEDICAL EDUCATION FELLOWSHIPS-2011

A joint venture of Christian Medical College, Ludhiana, India & Foundation for Advancement of InternationalMedical Education and Research, Philadelphia, USA. The CMCL-FAIMER regional Institute’s Fellowship is a two-year fellowship program designed for Indian medical school faculties who have the potential to play a key role inimproving medical education at their institutes. The program is uniquely designed to teach education methodsand leadership skills, as well as to develop strong professional bonds with other medical educators. The fellowshipis now running in its sixth year. Twenty fellowships are on offer for the year 2011. Limited funding is available tosupport fellows’ travel, local expenses and course fee.

The application process is online at https://faimeronline2.ecfmg.org/For details, please visit our website: http://cmcl.faimerfri.org/

Important datesApplication open: 1st June, 2010

Applications close: 1st September, 2010First session of 2011 fellowship: 1st - 7th February, 2011

Dr. Tejinder Singh Dr. Dinesh BadyalProgram Director SecretaryEmail: [email protected]


Modified mobilization techniques in adhesive capsulitis of theshoulder joint: A case reportFaizan Zaffar Kashoo1, T R Vijay2, Hari Haran2

1Principal, 2Lecturer, M.M.I.P.R, Mullana, Ambala, Haryana

Abstract

Background and Purpose

The purpose of this case report is to describe the use ofmodified mobilization technique (M.M.T) in the managementof patient with adhesive capsulitis.

Case Description

One patient (63 years) with adhesive capsulitis of theglenohumeral joint (disease duration=12.3 month) wastreated with modified mobilization techniques, twice a weekfor 3 months. Indexes of pain, joint mobility were measuredby the same observer before treatment and after 3 monthsof treatment.

Outcomes

After 3 months of treatment, there was increase in activerange of motion. Abduction increased from 87 degrees to147 degrees, flexion in the sagittal plane increased from110 degrees to 144 degrees, and lateral rotation increasedfrom 12 degrees to 29 degrees. There were also increasesin passive range of motion: abduction increased from 90degrees to 151 degrees, flexion in the sagittal planeincreased from 117 degrees to 149 degrees, and lateralrotation increased from 17 degrees to 38 degrees. Patientsrated their improvement in shoulder function as excellent.

Discussion

Modified mobilization techniques appear to have role inthe treatment of adhesive capsulitis. Controlled studies areneeded to prove the effectiveness of modified mobilizationtechniques in the treatment of adhesive capsulitis.

Key Words

Adhesive capsulitis • Modified Mobilization techniques •Single-subject case report • Shoulder • Shoulder function

Introduction

Despite research in the last century, the etiology andpathology of adhesive capsulitis remain enigmatic.1

Adhesive capsulitis or frozen shoulder is characterized byprogressive loss of active and passive mobility in theglenohumeral joint presumably due to capsularcontracture2,3.Pain, particularly in the first phase of adhesive capsulitis ofthe shoulder,1–3 often keeps patients from performingactivities of daily living (ADL)which is one of the important

impairment effecting the level of functional activity. Manypatients complain about sleeping disorders due to pain andtheir inability to lie on the affected shoulder. In the secondphase of the condition, pain appears to be less pronounced,but the restrictions in active motion appear to limit the patientin personal care, ADL, and occupational activities.Observation of active shoulder motion appears to revealexcessive scapular motion and lifting of the shoulder girdle.In the third phase of the condition, there is a slow increasein mobility, which leads to full or almost full recovery.4–6

According to Reeves,4 the first phase of adhesive capsulitisof the shoulder lasts 2 to 9 months, the second phase lasts4 to 12 months, and the third phase lasts 5 to 26 months.Several authors4,7–14 have argued that adhesive capsulitisis a self-limiting disease with a duration varying from 1 to 3years, but they offered little or no peer-reviewed data tosupport this argument.The axillary recess is a pouch of the glenohumeral capsuleevolving from the inferior rim of the glenoid cavity to theinferior part of the humeral head, plays an important role inadhesive capsulitis. Capsular adhesions of the axillaryrecess hinder normal expansion during abduction resultingin diminished active and passive mobility of the shoulder.An important feature of adhesive capsulitis is the decreasedjoint capacity (ability of the capsule to move as indicated byan inability to hold fluid) due to capsular retraction, asdetermined by arthrography (the roentgenographicvisualization of the joint to determine the amount of fluid thejoint can contain)2,15–17.To regain the normal extensibility of the shoulder capsule,passive stretching of the shoulder capsule in all planes ofmotion by means of mobilization techniques has beenrecommended,19,20 but data to support the use of thesetreatments are lacking. These techniques have beendescribed by Maitland,20 Cyriax,21 and Kaltenborn,22 but theydid not base their suggestions on research. Although thesetechniques are frequently used by physical therapists andmanual therapists, few studies have described the use ofthese techniques in joints with capsular adhesions. In 3studies,23–25 the shoulder was examined. Other studiesexamined the wrist,26 the temporomandibular joint,27 theankle,28 and the metacarpophalangeal joint.29 Althoughmobilization techniques were used in the 3 studies of theshoulder, the performance of the techniques (mid-rangemobilizations combined with interscalene brachial plexusblock), duration of treatment (4–6 weeks), and utilization ofother treatment modalities (home exercises, cold packs)differs from the approach we used with our patient. We usedmodified mobilization technique without the support ofanesthetic techniques or additional modalities. In ouropinion, based on histological studies of contracted jointcapsules in animals,30,31 a remobilization period should last

28 Faizan Zaffar Kashoo. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

for at least 12 weeks to realize the remodeling of connectivetissue and to normalize ROM. To exclude possibleconcurrent effects, we did not use physical modalities suchas cold packs or heat. We examined the change in shouldermobility after M.M.Ts during a treatment period of 3 months.

Case description

A Patient with frozen shoulders was referred for treatmentby an orthopedic surgeon to the physical therapy departmentand fulfilled the following inclusion criteria: (1) having apainful stiff shoulder for at least 12 months, (2) havingrestriction of more than 50% in passive shoulder abduction,flexion in the sagittal plane, or lateral rotation comparedwith the opposite side. In the absence of a generally accepteddefinition of frozen shoulder, a consensus from a orthopedicsurgeon and physical therapists in our hospital agreed onthis set of clinical criteria for a frozen shoulder. Excludedwere patients with (1) diabetes mellitus, (2) a painful stiffshoulder after a severe trauma, or (3) the presence ofosteoarthrosis or signs of bony damage due to trauma onthe radiographs of the affected shoulder.The cause of the adhesive capsulitis (primary or idiopathic)was not known. Patient’s dominant arm was involved. Hehad received prior treatment by physical therapists in aprivate practice. These interventions consisted of massageof the shoulder region, physical modalities (ie, ultrasound,short-wave diathermy, and electrotherapy), gentle passivemobilization techniques, and active exercises. Patientreported satisfactory results (progress in mobility, pain, orADL) from the previous physical therapy.

Assessment

Assessments took place prior to treatment and after 3months of treatment. A detailed history of complaints anddisabilities in daily life (eg, sleeping disorders; disabilitiesin personal care, reaching tasks, and professional activities)was taken form patient at each assessment.We used active mobility and pain as primary outcomemeasures because we believe that they are importantfeatures in adhesive capsulitis. Patient was asked for thepresence of pain during ADL and at night. We did not,however, assess the reliability of these measurements, andthe reliability of these measurements for patients withadhesive capsulitis is not known. Our data, therefore, mustbe viewed with caution. We considered the treatment resultfor active mobility to be “excellent” if the deficit in mobilitywas 20 degrees or less in all 3 directions (abduction, flexion

in the sagittal plane, and lateral rotation) as compared withthe opposite glenohumeral joint. A “good” result was scoredif the deficit in joint mobility was between 20 and 30 degreesin 1 or more directions. This idea is similar to the scoringsystem of Heller et al32 for the evaluation of posteriorlydislocated shoulders. Maximum ROM, among othervariables, is used to classify shoulder function.32

Active and passive flexion in the sagittal plane, abduction,and lateral rotation of both shoulders was measured in astanding position using a conventional goniometer.34-36

Measurements were rounded to the nearest 5 degreesaccording to the clinical procedures for recording jointmotion used in our departmental OPD. Assessment wasperformed by the same physical therapist. This therapist,who had 5 – 6 years of experience, was not involved in thetreatment of the patients and was unaware of the previousmeasurements. The patients rated the overall progress oftheir shoulder function on a 5-point Likert scale (“muchworsened” to “much improved”). Again, caution should beused in interpreting these data because the reliability andvalidity of these measurements have not been demonstrated.

Procedure

At the start of each intervention session, the physicaltherapist examined the patient’s ROM in all directions toobtain information about the end-range position and theend-feel of the glenohumeral joint. Intervention started witha few minutes of warm up consisting of rhythmic mid-rangemobilizations with the patient in a supine position. One handof the therapist’s hands were placed close to the elbowjoint and the other hand grabbing the patients hand, andthe humerus was brought into a scapular plane initially as itis was less painful for the patient33. Elbow joint of the patientwas kept in slight flexion so as to provide variable amountof lateral rotation and distraction was provided by the handplaced near the elbow joint throughout the manipulation.After 15 to 20 repetitions of intensive mobilization techniquesin this end-range position with constant distractionthroughout the movement, the direction of mobilization wasaltered by varying the plane of elevation or by varying thedegree of rotation. In each direction of mobilization, 15 to20 repetitions were performed, and the mobilization grade(3 or 4) and the duration of prolonged stress variedaccording to the patient’s tolerance.We obtained minimal reflex muscle activity by telling thepatient to perform maximum contraction opposite to thedirection of mobilization and then patient was asked to relaxwhich induced relaxation around the affected shoulder joint.During treatment, reflex muscle activity was also monitoredby the therapist by means of palpation. Most of the time,changing the intensity or the direction of the mobilizationtechnique was sufficient, in our opinion, to decrease thereflex muscle activity. Sometimes, we believed based onour palpation, it was also necessary to move the shoulderonce or twice through the whole ROM to obtain thenecessary muscle relaxation.All the three movements were performed in supine positionwithout changing the hand position. The patient wasinstructed to inform the therapist about any pain experiencedduring and after intervention. If the therapist believed thatpain influenced the execution of the mobilization techniquesin a negative way, the therapist altered the direction ordegree of mobilization. If patient experienced a dull ache

Faizan Zaffar Kashoo. / Indian Jouanl of Physiotherapy and Occupational Therapy.July - Sept. 2010, VOL 4 NO 3 29

Table1: Demographic and Clinical Characteristics of Patient with AdhesiveCapsulitis.sex age side occupation Duration No. of

of physiotherapycomplain sessions before

participation instudy

M 63 Dominant Retired 12 12 sessionsmanager which includes

Physicalmodalities,Gentle passivemobilizations.Activeexercises.Massage.

30

and the therapist believed there was no reflex muscleactivity, mobilizations were continued. Patient was informedthat this ache could last for a few hours after the treatmentsession. If the pain worsened or continued for more than 4hours after intervention. The intensity of the mobilizationtechniques was decreased in the following session.Patient was advised to use their involved shoulder in ADLtasks when possible. The patient was not in structed inhome exercises to exclude the influence of their adherenceto the exercise protocol.

Outcome

The patient was treated 2 times a week, with an average of18 treatment sessions (Tab. 2). Patient reported no pain atassessments but he reported pain during ADL and at nightif he had to sleep on their affected shoulder. Patient reportedtheir overall progress after 3 months of therapy as “muchimproved.” Improvements were seen in pain levels and inADL, especially overhead activities. (Tab. 2).Table 2: Effect After 3 Months of Treatment.

No. of sessions Result presence Patientwith M.M.T after 3 months of pain opinion

18 excellent no Muchimproved

Table 3: Active Abduction, Flexion in the Sagittal Plane, and Lateral Rotation(in Degrees) Assessed by Goniometry after 3 Months of Treatment in aPatient with Adhesive CapsulitisMovement Before 3 months After 3 monthsflexion 110 144abduction 87 147Lateral rotation 12 29

Range of motion

Measurements of active and passive mobility of the affectedshoulder joints are shown in Tables 3.

Discussion

Gleno humeral mobility was observed after 3 months oftreatment with MMTs.patient reported, “much improved”shoulder function after 3 months of treatment.Reeves4 described the natural history of adhesive capsulitisand found a mean duration of the disease of 30 months(range= 12–42). As our patient had symptoms present for atleast 12 months, there is an indication that the changesseen after 3 months of treatment with MMTs could beattributed to the mobilization techniques rather than to thenatural history.In the acute phase of shoulder pain, it is difficult to distinguishadhesive capsulitis from other common shoulder pathologiessuch as rotator cuff tears, tendinitis, and calcific deposits.5,6,25,

These shoulder pathologies have similar symptoms suchas pain at night or when lying on the affected shoulder,limited ROM, and compensatory excessive scapularmovement for glenohumeral movement (a characteristic“girdle hunching maneuver”19). Many authors havedescribed the etiology and clinical features of and therapyfor adhesive capsulitis and disagree about the criteria fordiagnosing this disease.6

The purpose of applying MMTs in our patients was to stretchcontracted periarticular structures. Reeves4 stated that theduration of the first phase can vary from 2 to 9 months.Therefore, it is difficult to determine the turnover from the

first painful phase to the second phase in which a capsularcontracture is apparent. Mobilization techniques can onlybe performed without causing too much pain if theinflammatory (first) phase has disappeared. In our study,therefore, duration of 12 months of disorder was the key indiagnosing adhesive capsulitis and thus in timing the startof treatment of the capsular contracture with MMTs. ofadhesive capsulitis.

Limitations

Reliability of our measurements was not known and thatthere was no control group, so there is no way to know forcertain that the improvement was not due to naturalprogression of the disease or to any of a variety of othercauses.

Conclusion

In this study to prove the effectiveness of Modifiedmobilization techniques performed by physical therapistswere used in an effort to increase mobility in patients withadhesive capsulitis of the shoulder. There was an increaseof glenohumeral mobility, but in the absence of a controlgroup, we cannot be sure what led to reduced impairment.Further investigation in the form of controlled studies iswarranted to compare the therapeutic effect of thesemobilizations with the natural course of the disease or othertreatment regimens.

References

1. Bunker TD, Anthony PP. The pathology of frozenshoulder: a Dupuytren-like disease. J Bone Joint SurgBr.1995; 77:677–683

2. Neviaser TJ. Intra-articular inflammatory diseases ofthe shoulder. Instr Course Lect.1989; 38:199–204.

3. Neviaser TJ. Adhesive capsulitis. Orthop Clin NorthAm.1987; 18:439–443.

4. Reeves B. The natural history of the frozen shouldersyndrome. Scand J Rheumatol.1975; 4:193–196.

5. Nash P, Hazleman BL. Frozen shoulder. Bailliere’s ClinRheumatol.1989; 3:551–566.

6. Murnaghan JP. Frozen shoulder. In: Rockwood CA,Matsen FA, eds. The Shoulder. Philadelphia, Pa: WBSaunders Co;1990 :837–862.

7. Baslund B, Thomsen BS, Jensen EM. Frozen shoulder:current concepts. Scand J Rheumatol.1990; 19:321–325.

8. Loew M. Uber den spontanverlauf der Schultersteife.Krankengymnastik.1994; 46:432–438.

9. Grey RG. The natural history of “idiopathic” frozenshoulder. J Bone Joint Surg Br.1978; 60:564.

10. Lundberg BJ. The frozen shoulder. Clinical andradiographical observations. The effect of manipulationunder general anesthesia. Structure andglycosaminoglycan content of the joint capsule. Localbone metabolism. Acta Orthop Scand Suppl.1969;119:1–59.

11. Jayson MI. Frozen shoulder: adhesive capsulitis. BrMed J.1981; 283:1005–1006.

12. Strang MH. Physiotherapy of the shoulder complex.Bailliere’s Clin Rheumatol.1989; 3:669–680.

13. Lewit K. Manuelle Medizin. Leipzig, Germany: Johann


31

Ambrosius Barth;1977 .14. Rowe CR, Leffert RD. Idiopathic chronic adhesive

capsulitis (“frozen shoulder”). In: Rowe CR, ed. TheShoulder. New York, NY: Churchill LivingstoneInc;1988 :155–163.

15. Dalinka MK. Shoulder arthrography. In: Jacobson HG,ed. Arthrography. New York, NY: Springer-Verlag;1980:93–117.

16. Neviaser RJ, Neviaser TJ. The frozen shoulder:diagnosis and management. Clin Orthop. October1987:59–64.

17. Mao C-Y, Jaw W-C, Cheng H-C. Frozen shoulder:correlation between the response to physical therapyand follow-up shoulder arthrography. Arch Phys MedRehabil.1997; 78:857–859.

18. Neviaser JS. Arthrography of the shoulder joint: studyof the findings in adhesive capsulitis of the shoulder. JBone Joint Surg Am.1962; 44:1321–1330.

19. Wadsworth CT. Frozen shoulder. Phys Ther.1986;66:1878–1883.

20. Maitland GD. Treatment of the glenohumeral joint bypassive movement. Physiotherapy.1983; 69:3–7.

21. Cyriax J. Textbook of Orthopaedic Medicine. London,England: Ballière Tindall;1975 .

22. Kaltenborn FM. Manual Therapy for the Extremity Joints.Oslo, Norway: Olaf Norlis Bokhandel;1976 .

23. Bulgen DY, Binder AI, Hazleman BL, et al. Frozenshoulder: prospective clinical study with an evaluationof three treatment regimens. Ann Rheum Dis.1984;43:353–360.

24. Nicholson GG. The effect of passive joint mobilizationon pain and hypomobility associated with adhesivecapsulitis of the shoulder. J Orthop Sports PhysTher.1985; 6:238–246.

25. Roubal PJ, Dobritt D, Placzek JD. Glenohumeral glidingmanipulation following interscalene brachial plexusblock in patients with adhesive capsulitis. J OrthopSports Phys Ther.1996; 24:66–77.

26. Taylor NF, Bennell KL. The effectiveness of passivemobilisation on the return of active wrist extensionfollowing Colles’ fracture: a clinical trial. New ZealandJournal of Physiotherapy.1994; 4:24–28.

27. Taylor M, Suvinen T, Reade P. The effect of grade IVdistraction mobilization on patients withtemporomandibular pain-dysfunction disorder.Physiotherapy Theory and Practice.1994; 10:129–136.

28. Wilson FM. Manual therapy versus traditional exercisesin mobilisation of the ankle post-ankle fracture. NewZealand Journal of Physiotherapy.1991; 12:11–16.

29. Randall T, Portney L, Harris BA. Effects of jointmobilization on joint stiffness and active motion of themetacarpal-phalangeal joint. J Orthop Sports PhysTher.1992; 16:30–36.

30. Akeson WH, Amiel D, Abel MF, et al. Effects ofimmobilization on joints. Clin Orthop. June1987 :28–37.

31. Schollmeier G, Sarkar K, Fukuhara K, Uhthoff HK.Structural and functional changes in the canineshoulder after cessation of immobilization. Clin Orthop.February1996 :310–315.

32. Heller K, Forst J, Forst R, et al. Posterior dislocation ofthe shoulder: recommendations for a classification.Arch Orthop Trauma Surg.1994; 113:228–231.

33. Freedman L, Munro RR. Abduction of the arm in thescapular plane: scapular and glenohumeralmovements. J Bone Joint Surg Am.1966; 48:1503–1510.

34. Riddle DL, Rothstein JM, Lamb RL. Goniometricreliability in a clinical setting: shoulder measurements.Phys Ther.1987; 67:668–673.

35. Marx RG, Bombardier C, Wright JG. What do we knowabout the reliability and validity of physical examinationtests used to examine the upper extremity? J HandSurg [Am].1999; 24:185–193.

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32

Effect of muscle energy technique and static stretching onhamstring flexibility in healthy male subjectsHashim Ahmed*, Mohd. Miraj** , Shveta Katyal***

*Research Student, Jamia Hamdard University, New Delhi,**Director, IHM, OGHRC, NOIDA,***Lecturer,Jamia HamdardUniversity, New Delhi

Abstract

ObjectiveTo compare the effectiveness of Muscle Energy Techniqueand Static Stretching in improving the hamstring muscleflexibility in healthy male subjects.

Design

Pretest-posttest control group design

Participants

Forty five healthy male subjects were included in this study.Subjects were randomly placed into three groups: MuscleEnergy Technique, Static Stretching and Control group.

Setting

Outpatient physiotherapy department, ESI Hospital, Okhla,New Delhi.

Intervention

Muscle Energy Technique group received 5 secondisometric contraction followed by 3 second relaxation forfour contractions for five consecutive days. Static Stretchinggroup received 10 minutes of static stretching with the helpof pulley and weight system for five consecutive days.Control group received only moist heat for 20 minutes forfive consecutive days. All the groups were received thehome exercise program during one week follow-up.

Result

On comparing the PKE1 between 3 groups i.e. group A, Band C a significant difference was obtained (p=.000), butfurther post hoc analysis revealed an insignificant differencebetween group A and group B (p=1.00). Group B and Cshowed a significant difference (p=.000) and so did groupA and C (p=.004). On comparing the PKE5 between 3 groupsi.e. group A, B and C a significant difference was obtained(p=.000), but further post hoc analysis revealed aninsignificant difference between group A and group B(p=.156). Group B and C showed a significant difference(p=.000) and so did group A and C (p=.000). Comparisonof the final reading i.e PKE12 using one way ANOVA revealeda significant difference between the groups (p=.000), butfurther post hoc analysis revealed an insignificant differencebetween group A and group B (p=.316). Group B and Cshowed a significant difference (p=.000) and so did groupA and C (p=.000)

Conclusion

The result of this study indicates that both muscle energytechnique and static stretching are equally effective as thereis no significant difference between the improvements inrange of motion between the two groups.

Key words

Muscle Energy Technique, Static Stretching, Flexibility

Introduction

Flexibility is an important component of physical conditioningprogramme used as an adjunct to muscle strength andendurance training.19 Flexibility allows the tissue toaccommodate more easily to stress, to dissipate shockimpact and to improve efficiency and effectiveness ofmovement, thus minimizing or preventing injury.22

Flexibility is significant in performing certain skills. Recentadvances in physical medicine and rehabilitation indicatesthat flexibility or range of motion is important to generalhealth and physical fitness, hamstring flexibility exercisehave been successfully prescribed for relief of low backache,general neuromuscular tension.12

A number of factors have been identified that contribute toflexibility, including gender, age, muscle size and warm up.Females for example are more flexible than males, flexibilityalso tends to decrease with age, the loss of flexibility withage is associated a decline in functional abilities and healthstatus. It is believed that, a large portion of this loss in flexibilityis due to disuse atrophy. 14,18

Lack of flexibility results in uncoordinated or awkwardmovements and predisposes the athlete to muscle strain.Low back pain is frequently associated with tightness of themusculature in the lower spine and also of the hamstringmuscles. Most activities of daily living require relativelynormal amounts of flexibility.16

Various treatment methods have been used to improveflexibility and decrease joint stiffness such as Spray andStretch, Soft Tissue Mobilization Technique, Stretching(Static, Ballistic and PNF) Technique, and Muscle Energytechnique.1,4,13,17,20

The most widely used method for increasing joint range ofmotion is stretching.Static stretching is a method by whichsoft tissues are lengthened just past the point of tissueresistance and then held in the lengthened position for anextended period of time with a sustained stretched force. 3

Apart from Static stretching Muscle Energy Technique isalso used to improve flexibility. Muscle Energy Technique(MET) is a manual technique developed by osteopaths thatis now used in many different manual therapy professions.It is claimed to be effective for a variety of purposes, that

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includes lengthening of shortened or contractured muscle,strengthening of muscles, as a lymphatic or venous pumpto aid the drainage of fluid or blood, and increase the rangeof motion (ROM) of a restricted joint.2

Several researcher have examined the effect of contract-relax techniques (similar to MET) on hamstring flexibility,and found out that these techniques produced increasedmuscle flexibility.9,11,21 Handel et al identified significantincreases in hamstring flexibility along with an increased inpassive torque (increased in force used to stretch thehamstring) after a contract-relax exercise program.11 Wallinet al claimed that contract-relax technique was more effectivethan ballistic stretching for improving muscle flexibility overa 30 days period, where as other researchers have reportedno difference between the two techniques.21Resting tensionin skeletal muscles is taken up mainly by the myofibrils, andas the muscle stretches the limit to the range of motion isattributed to the visco-elastic elements of the connectivetissues.9

A systemic review of literature aimed to see the effect ofhamstring stretching on range of motion, concluded that itis difficult to confidingly identify the most effective hamstringstretching method. The evidence appears to indicate thathamstring stretching increases the ROM with a variety ofstretching position, and duration. The studies revealed thatstatic stretching achieve greater gains in range of motionthan group performing proprioceptive neuromusculartechnique (PNF).6

Feland et al discovered that contract-relax and staticstretching had similar benefit in improving hamstingflexibility.7

However till recently not many studies have comparedMuscle Energy Technique and static stretching in improvinghamstring flexibility. Therefore the aim of this study is tocompare the effectiveness of muscle energy technique andstatic stretching in improving the hamstring muscle flexibilityin healthy male subjects.

Methods

Subjects

A total of 45 subjects of hamstring muscles tightness wereincluded in the study. All the subjects were recruited fromthe ESI hospital and Jamia hamdard, New Delhi. The criteriafor inclusion were healthy male, age 20-30 years withhamstring muscle tightness of 20 degrees. Subjects wereexcluded if they had neurological problem at the lumbarregion, any deformity of knee, hip, and back, history ofparticipation in stretching or yoga programme for last sixmonths, history of trauma at hip, knee, back and any injuryto hamstring and other muscles in the lower limb.

Study design

A different subject pretest-posttest experimental groupdesign was selected for testing the hypothesis, where abaseline reading was taken prior to the intervention, restmeasurements were taken immediate post intervention onday 1, day 3, day 5 and after 1 week follow-up i.e. at 12th

day. These reading were then compared to find out theeffect on independent variables. The outcome measure ordependent variable, selected for this study was passiveknee extension.

Procedure

Prior to Participation each subject was given a detailedconsent form. On the basis of the criteria mentioned abovethe subjects were randomly assigned to any of the threegroups.Group A: Moist heat + METGroup B: Moist heat + Static StretchingGroup C: Moist heat OnlyData were collected pre intervention and post interventionon day 1, and post intervention on day 3rd, 5th, and lastlyafter on e week follow up.

Measurement of range of motion

Subjects were made to lie in supine position. The lateralmalleolus, lateral epicondyle and greater trochanter of thefemur of ipsilateral limb were then marked with a marker forlater goniometric measurement. After marking the referencepoints the ipsilateral hip and knee were maintained at 90degrees of flexion, the assistant stabilizing the hip. Theknee was then passively moved to the position of terminalextension by the investigator. The terminal position of kneeextension was defined as the point at which the subjectcomplained of a feeling of discomfort or tightness in thehamstring muscles or the investigator perceived resistanceto stretch. Once the terminal position of knee extension wasachieved, the investigator measured the amount of kneeextension with the goniometer. Examiner took three readingsand the mean of them was used in the study forinterpretation.15

Treatment Intervention

Moist heat

A hot pack (at temperature of 770 C) was given afterpositioning the subjects in each group in prone lying overthe posterior aspect of thigh for 20 minutes for a period offive consecutive days.8

Muscle energy technique

Each subject in group A was comfortably positioned insupine lying on a plinth with the hip fixed at 900 of flexion,and knee was extended to the first report of hamstringdiscomfort. The moderate isometric contraction(approximately 75% 0f maximal) of hamstring muscles waselicited for a period of 5 Seconds followed by 3 Seconds ofrelaxation. The technique was repeated four times in eachsession for 5 consecutive days.2

Static stretching

Each subject in group B was comfortably positioned insupine lying on a plinth and applied a splint on the anterioraspect of the knee in an effort to keep the knee in as muchextension as possible during treatment. The leg wasattached to the pulley and weight system (4.55 kg.) byapplying a cuff around the ankle that was attached to acable. This put the hamstring muscles on stretch whileproviding a constant stretch torque. The stretch wasmaintained for 10 minutes in each session for fiveconsecutive days.5

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Home exercise programme

Each subject performed self stretching of hamstring musclesby standing erect with the contra-lateral foot planted on thefloor and placed directly forward without hip medial or lateralrotation. The posterior calcaneal aspect of the ipsilateralfoot was placed on a plinth or chair with the toes of the footdirected towards the ceiling, again without hip medial orlateral rotation. The knee remained fully extended. The armswere flexed to shoulder height with the elbows fullyextended. The subjects then flexed forward from the hip,maintaining the spine in a neutral position, while reachingthe arms forward. The subjects moved forward in this positionuntil a stretch was felt in the posterior thigh. Once the subjectsachieved this position, the stretch was sustained for 30seconds. This procedure was repeated five times. All thegroups performed the home exercise programme duringfollow up period.


A pretest-posttest experimental control group design wasused for the study. The pretest values for Passive kneeextension (designated as PKE0), posttest values for Passiveknee extension (designated as PKE1) were taken on day 1.The next posttest reading were taken on day 3 (designatedas PKE3) and day 5 (designated as PKE5) and the finalreading was taken after 1 week follow-up on day12 (designated as PKE12). The data was analyzed usingthe SPSS 15.0 Software.Repeated measure ANOVA was applied for comparison ofpassive knee extension within the groups. One way ANOVAwas applied to compare the passive knee extensionbetween the groups.The tests were applied at 95% confidence interval and pvalues set at 0.05. The results were taken to be significant ifp<0.05.

Result

Results of statistical Analysis of Passive Knee Extension

(PKE). The Passive Knee Extension (PKE) was measuredon day 1 (pretest data as PKE0, posttest data as PKE1), after3 days (represented as PKE3), at the end of treatment sessioni.e after 5 days (represented as PKE5), and after 1 weekfollow-up (represented as PKE12). Between the groupsanalysis was conducted using one way ANOVA with levelof significance, á set at 0.05. Table 2 and Table 3 givesdetails of between group analyses.The pretest reading i.e PKE0 for all the three groups wasstatistically insignificant (p=0.571) (table 2). On comparinggroup A and group B the PKE0 are insignificant (p=.904).Similarly PKE0 values for group B and group C wereinsignificant statistically (p=1.00), when group A wascompared with group C for PKE0, the values come toinsignificant (p=1.00) (table 3).On comparing the PKE1 between 3 groups i.e group A, Band C a significant difference was obtained (p=.000), (table2), but further post hoc analysis revealed an insignificantdifference between group A and group B (p=1.00). Group Band C showed a significant difference (p=.000) and so didgroup A and C (p=.004) (table 3)On comparing the PKE3 between 3 groups i.e group A, Band C a significant difference was obtained (p=.000), (table2), but further post hoc analysis revealed an insignificantdifference between group A and group B (p=.487). Group Band C showed a significant difference (p=.000) and so didgroup A and C (p=.000) (table 2).On comparing the PKE5 between 3 groups i.e group A, Band C a significant difference was obtained (p=.000), (table2), but further post hoc analysis revealed an insignificantdifference between group A and group B (p=.156). Group Band C showed a significant difference (p=.000) and so didgroup A and C (p=.000) (table 3).Comparison of the final reading i.e PKE12 using one wayANOVA revealed a significant difference between thegroups(p=.000), (table 2), but further post hoc analysis revealedan insignificant difference between group A and group B(p=.316). Group B and C showed a significant difference(p=.000) and so did group A and C (p=.000) (table 3).

Discussion

This study was designed to compare the effect of muscleenergy technique and static stretching on hamstringflexibility in healthy male subjects. In this we examined theeffect of two experimental groups’ i.e. muscle energytechnique and static stretching with respect to control group.The results of our study indicate that both muscle energytechnique and static stretching are effective methods toimprove the hamstring flexibility as compared to controlgroup. The results further suggest that both the techniquesare equally effective in improving flexibility as there is no


Table 1: Details of subjects

Group A Group B Group CNo. of Subjects 15 15 15Age (Mean±SD) 24.80±2.54 24.26±3.21 25.06±3.03Weight (Mean±SD) 65.46±4.82 66.20±3.98 66.80±2.67Height (Mean±SD) 163.00±4.73 164.46±3.48 164.00±3.35BMI (Mean±SD) 24.68±1.94 24.46±1.29 24.85±1.30

Table 2: Comparison of PKE between the groups.

Group A Group B GroupC One-way(Mean±SD) (Mean±SD) (Mean±SD) ANOVA

N=15 N=15 N=15* F PPKE

027.71±3.59 29.04±3.85 28.16±2.95 .568 .571

PKE1

22.93±3.62 21.69±4.04 27.44±2.91 10.83 .000PKE

321.31±3.42 19.46±4.14 27.27±3.01 19.74 .000

PKE5

19.54±3.48 17.08±3.68 27.16±2.84 36.73 .000PKE

1219.5m3±3.49 17.46±3.71 27.01±3.12 31.68 .000

Table 3: Comparison of PKE between the Groups using p values.PKE

0‘P’ PKE

1‘P ’PKE

3‘P’ PKE

5‘P’ PKE

12‘P’

Group A V/S .904 1.00 .487 .156 .316Group BGroup B V/S 1.00 .000 .000 .000 .000Group CGroup A V/S 1.00 .004 .000 .000 .000Group C

35

significant difference between the two groups.As muscle energy technique emphasizes on the relaxationof the contractile component of the muscles while staticstretching focuses on the non-contractile viscoelasticcomponent. Thus, our study demonstrated that both thesecomponents play an equal amount of role in improving theflexibility of the muscles.There is still a paucity of studies comparing these twotechniques. An attempt has been made, to explain thesefindings.The finding of our study suggested that there was nodifference between muscle energy technique and staticstretching which concurs with other studies that have similarresults. Feland et al discovered that contract—relax andstatic stretching had similar benefits in improvingflexibility.7Gribble et al compared the effect of static andhold- relax stretching on hamstring muscles, drawing theinfluence that both were equally effective in improvinghamstring range of motion. 9

A possible explanation for this perceived phenomenon relieson the effects of autogenic inhibition. A large portion of thehold-relax stretch was an active contraction, whereas thestatic stretch was designed to be completely passive. Duringthe hold relax stretch; the active portion is performed by thehamstrings muscles. An autogenic inhibition is alsoproduced, however, during a passive stretch. Autogenicinhibition is contingent on the function of the Golgi tendonorgans, which not only detect changes in length but alsochanges in tension. Tension is produced in the antagonistswith both static and PNF hamstring-stretching techniques.Therefore, the presence of autogenic inhibition would notbe affected if the measurement technique was an active orpassive stretch or if the training method was a static or hold-relax stretch.9

Another possible explanation of the increase in range ofmotion can be due to the augmentation of stretchtolerance.This was supported by Halbertsma and Goeken,who discovered an increase in hamstring flexibility in theirstudy. Moreover, the participant reported an increase inpain tolerance at the study end. They attributed the gains inflexibility to an increase in stretch tolerance. 10

Future research

Future research is needed to look for long term follow-ups.This would help to monitor the range of motion gaineffectively. Also studies with greater sample population forthe generalization of the results. Further research comparingactive knee extension and passive knee extensionmeasurements may be useful in determining the bestmethod for testing the effectiveness of muscle energytechnique and static stretching in hamstring flexibility.It would also be of interest to observe the effect of muscleenergy technique and static stretching in subjects with ahistory of hamstring injury and low back pain. It is possiblethat such conditions involve deposition of abnormal fibroustissue and cross linkages, and may respond differently inhealthy muscles.

Clinical relevance

This study was performed on subjects who had tighthamstrings. This might have clinical relevance in treatingpatients with tight hamstring due to immobilization or

inactivity. Possible plan of treatment can also be formulatedfrom the present study. Improving hamstring flexibilityreduces the chances of low back pain and othermusculotendinous injury therefore this study will help tosignificantly decrease the costs for their management andhence should be more routinely used in the clinical setup.

Conclusion

The results of this study indicates that muscle energytechnique and static stretching produced a significantimprovement in hamstring flexibility after 5 days ofintervention and the results were sustained for 1 week postintervention. Thus both the technique is effective inimproving flexibility. This study further suggests that bothmuscle energy technique and static stretching are equallyeffective as there is no significant difference between theimprovements in range of motion between the two groups.

References

1. Andrews and Harrelson,physical rehabilitation of theinjured athlete 2008,141-164.

2. Ballantyne, F., Fryer, G., McLaughlin, P., The Effect ofMuscle Energy Technique on Hamstring Extensibility:The Mechanism of Altered Flexibility.Journal of Osteopathic Medicine, April 6 (1), 37; 2003.

3. Carolyn Kisner, Lynn Allen Colby et al; therapeuticexercise. Foundation and techniques: fourth edition;2002.

4. Chaitow.L, Liebenson C, Muscle Energy Techniques.Edinburgh, Churchill Livingstone. 1996:

5. David O Draper and Jennifer L Castro Short wavediathermy and prolonged stretching increaseshamstring flexibility more than prolonged stretchingalone. JOSPT 2004: 34(1): 13-20.

6. Decoster, LC, Celand, J, Altieri, C, Russell, P: The effectof hamstring stretching on range of motion: a systematicliterature review. J Orthop Sports Phys Ther 35:377-387, 2005.

7. Feland JB et al. Acute changes in hamstring flexibility:PNF versus static stretch in senior athletes’. PhysicalTherapy in sport, 2(4); 186-193, 2001.

8. Funk d, Dwayne Treolo, Efficacy of moist heat overstatic stretching on hamstring flexibility, J ournal ofstrenngth conditioning and research, 2001 15 (1), 123-26.

9. Gribble PA, Guskiewiez KM, Prentice WE, Shields EW.Effects of static and hold – relax stretching on hamstringrange of motion using the Flexability LE1000. Journalof Sport Rehabilitation. 1999; 8:195-208.

10. Halbertsma JP, and Goeken LN.Sport stretching; effectof passive muscle stiffness of short hamstrings. ArchPhys Med Rehabil 1994; 77:976–981.

11. Handel M, Horstmann T, Dickhuth HH, Gulch RW.Effects of contract – relax stretching training of muscleperformance in athletes. European Journal of AppliedPhysiology. 1997; 76: 400-408.

12. Hinson, M N,W C Smith(1986) Neuro muscular concept2nded:158-159.

13. Hopper D, Deacon S, Das S, Jain A. dynamic soft tissuemobilization increases hamstring flexibility in healthymale subjects. BJSM 39:594-598, 2005.

14. James W Youdas, David A, Krause, John H, Holiman,


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William S Harmsen. Influence of gender and age onhamstring muscle length in healthy adults. JournalOrthop Sports Phys Ther.2005; 35(4):246-252.

15. Prem p. Gogia, james h. Braatz, steven j. Rose, andbarbara j. Norton Reliability and Validity of GoniometricMeasurements at the Knee. Phys Ther 67 (2):192-195,1987.

16. Prentice WE. Principle of Athletic Training 10th edition.2000:75-, Lippincott co.

17. Sady SP, Wortman M, Blanke D. Flexibility training:ballistic,static or proprioceptive neuromuscularfacilitation? Arch Phys- Med Rehabil 1982; 63: 261-3

18. S. McHugh MP. Magnusson SP, Gleim GW, NicholasJA. Viscoelastic stress relaxation in hjuman skeletal

muscle. Medicine and Science in sports and Exercise.1992,24(12): 1375-1382.

19. Schuftz. P: Flexibility: Day of the static stretch. ThePhysician and Sports medicine: (11) 109-117, 1979.

20. Tanigawa MC. Comparison of the hold–relax procedureand passive mobilization on increasing muscle length.Phys Ther 1972; 52:725–735.

21. Wallin D, Ekblom B, Grahn R, Nordenborg T.Improvement in muscle flexibility. A comparisonbetween two techniques. American Journal of Sportsmedicine, 1985; 13(4): 263-8.

22. Zacazewski.J,E,improving flexibility physical therapy .1989;698-699.


37

Effectiveness of strengthening exercises in the management offorward head posture among computer professionalsShweta Shenoy*, Jaspreet Sodhi**, Jaspal S Sandhu***

Senior Lecturer*, Reserach Student**, Professer and Dean***, Department of Sports Medicine and Physiotherapy,Guru Nanak Dev University, Amritsar

Background

The most common postural abnormality in the cervical spinewith direct impact on the craniofacial area andtemporomandibular arthralgia is the forward head posture(FHP). Despite chronic neck pain associated and the highprevalence of this postural dysfunction, among computerprofessionals, very few studies have evaluated the effectsof strengthening exercise methods in treating neck disordersusing Electromyogram (EMG).

Objective

To compare the myoelectric amplitude of neck muscles,cranio vertebral (CV) angle and range of motion (R.O.M),pain score on VAS to determine the effectiveness ofstrengthening training in the management of FHP amongcomputer professional.

Methods

15 healthy subjects and 15 patients with CV angle lessthan 44° and pronounced FHP were recruited in the studyand allocated into two groups. Group I (n=15) control group,and Group II (n=15) received strengthening training for 8weeks. EMG activity was recorded from levator scapulae(LS), upper trapezius(UT), cervical erector spinae (CES)and sternocleidomastoid (SCM) muscles, while performingall neck movements before and after training. CV angle,cervical R.O.M. and pain on VAS was measured at baselineand after 8 weeks.

Results

Differences in the mean % MVIC of LS, UT, CES and SCMmuscles were found to be statistically significant (p<0.005)after intervention in training group. Significant changeswere seen in the CV angle (p<0.001), cervical ROM(p<0.001) and pain threshold on VAS (p<0.001) afterintervention.

Conclusion

Neck strengthening exercises along with the stretching andgeneral postural awareness proved to be an effectivetreatment in the management of FHP.

Keywords

Electromyography, Forward Head Posture, Craniovertebralangle, Strengthening exercises, Cervical spine, computer.

Introduction

Ideal posture in standing and sitting is defined as ‘skeletalalignment defined as a relative arrangement of the parts ofthe body in a state of balance that protects the supportingstructures of the body against injury or progressive disability(Twomey,1987).Neck and shoulder pain are a common workplace complaintworldwide with estimates of incidence ranging from 20% to50% over a 12 month period (Wilson et al, 2002). Thepatients with chronic pain frequently exhibit rigid andguarded movement patterns to compensate first for the painand later for balance disturbances that may arise frompostural asymmetries (Kreigh, 1996). Poor posture iswidespread in general population and appears to be anadaptive, self perpetuating trait that most people lack thecognitive ability or desire to correct by themselves (Dunn etal, 1995; Gonzalez et al, 1996).The most common postural abnormality in the cervical spinewith direct impact on the craniofacial area andtemporomandibular arthralgia is the forward head posture(FHP). Approximately 66% of the population or more havethe condition of anterior head translation either with orwithout symptoms (Parker et al, 1990). FHP is commonlyadopted by visual display terminal (VDT) workers involvesa combination of lower cervical flexion and upper cervicalextension and has been linked to musculoskeletaldysfunction such as upper crossed syndrome (Szeto et al,2002; Moore et al, 2004). A FHP reduces the average lengthof the muscle fibers, which contributes to extensor torqueabout the alanto-occipital joint, and it is possible that thisshortening reduces the tension-generating capabilities ofthe muscles (Limerick et al, 1998). In clinical practice it iswidely believed that a FHP contributes to development ofchronic neck and shoulder pain (Chiu et al, 2002. He foundthat approximately 60% of individuals with neck pain hadFHP. FHP is considered if CV angle is below 44o, normal ifranges from 44o-52o and retracted if ranges from 52o-60o

(Morris et al, 1992). Occupational or functional posturesrequiring leaning forward or tipping the head backward forextended periods, faulty sitting postures such as working atan improperly placed computer screen, relaxed postures,or the end result of faulty pelvic and lumbar spine postureare common causes of FHP. (Kleine et al, 1999). Posturaltraining is commonly used to treat poor posture and cervicaldysfunction and involves exercises that are performedrepeatedly within the pain free range to stretch tightenstructures and strengthen weaker ones but study by(Hardins et al, 1994) stated that postural training found tobe less effective for long term management as compared tostrengthening training in a group of patients with chronicneck pain. Strengthening exercises have been used for

Shweta shenoy. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

treatment of neck pain (Berg et al, 1994; Dyrssen et al, 1989).But only a few controlled intervention studies have beenconducted to examine active therapy for neck problems. Itis clear from the literature above that FHP is a commoncomplaint among computer professional and as thecomputer technology is advancing at the faster pace, littleis done in preventing the ailments that are associated withit use. There is lack of evidence based studies in this area.Therefore, due to an almost complete lack of empiricalevidence supporting the effectiveness of strengtheningexercises in the management of FHP among computerprofessionals, this study has being conducted.

Materials and methods

A different subject experimental design was used to analysethe activity of levator scapulae(LS), upper trapezius (UT),cervical erector spinae(CES) and sternocleidomastoid(SCM) during all cervical movements. The dependentvariables were mean % MVIC, measured by surface EMG,normalization to maximum voluntary isometric contraction(MVIC), CV angle, cervical R.O.M and pain on VAS. Thestudy was conducted in the department of sports medicineand Physiotherapy, Guru Nanak Dev University, Amritsar.A total of 15 healthy subjects and 15 patients (6 males, 9females) with CV angle less than 44° were recruited in thestudy and allocated to two groups. Group I (n=15) controlgroup received no intervention and Group II (n=15) receivedstrengthening training along with stretching and generalpostural advice for 8 weeks. EMG activity, CV angle, cervicalR.O.M and pain score on VAS was measured at baselineand at 8 weeks.General inclusion criteria includes mean age group (26.2±2.08) year, mean height (166.8± 6.8) cm and mean weight(60.4± 6.12) kg. Both genders were included. Inclusioncriteria for FHP was CV angle less than 44º, sedentaryindividuals and having at least 2-3 hrs of computer workper day. Exclusion criteria included present or past historyof neck injury or pathology, any kind of deformity of spine,neural tissue involvement such as current nerve rootentrapment, spinal cord compression, malignancy, acuteinfection and refusal to cooperate. Participants wererequired to sign an informed consent form prior to studyapproved by the institution’s research board and sanctionedby the institutional ethical committee. The data collectionwas undertaken during the period of July-Sept 2008 undercontrolled environmental conditions.The myoelectric activity of LS, UT, CES and SCM muscleswere recorded during different cervical movements.EMG data was collected using disposable bipolar Ag-Agclsurface electrodes (Trade name KENNY-1000). NORAXONUSA Inc, 1200 EMG unit was used to quantify muscle activity.The EMG signals were amplified by the amplifier systemDriver Linx with the input impedance of 10-milli ohm. Gain(fixed) = 1000 Hz, Sampling rate =1000 Hz, Keithley A/Dconvertor ± 5V input range, bandwidth=10Hz-500Hz withno notch filter.Before the application of the electrodes skin impedancewas reduced by shaving excess body hair if necessary andwiping the skin with ethyl alcohol swabs. All impedancelevels were below 5 kohm before data collection started.Pairs of electrode with a diameter of 1cm and center tocenter spacing of 2.5 cm were applied at the neck region:upper trapezius- electrodes were placed 2 cm lateral to the

midpoint of a line drawn from C7 spinous process to theposteriolateral acromian, levator Scapulae- lateral to C3-C4

spinous process between the posterior margin of SCM andinterior margin of upper trapezius. Cervical erector spinae-1 cm lateral to the C4 spinous process and forSternocleidomastoid- 2 cm distal to muscle insertion at themastoid process. All electrodes were placed parallel to thecorresponding muscle fibers. A ground electrode was placedover the seventh cervical spinous process.

Normalization task procedure

Maximum voluntary isometric contractions (MVIC) wereperformed for each muscle signal before and after theexercise intervention. It was done to compare muscle activityacross subjects and to give biologically meaningful data.This required the subject to maximally contract each muscleagainst manual resistance for ten seconds. Three trials ofMVIC were taken after adequate familiarization with theprocedures in accordance with standard Physical therapyguidelines Daniels and Worthingm. At least 2 min rest wasprovided between each MVIC contraction.The MVIC for LS was performed with the subject sittingcomfortably on a horizontal surface. The Subject thenlaterally rotated their neck to the same side and performeda static shoulder elevation against a fixed resistance(Kendall, 1993).Upper trapezius: The subject performed astatic contraction of shoulder abduction with arm at 90degree abduction and neutral rotation. Resistance providedat the elbow(Mclean et al,2003).Cervical erector spinae:subjects were made to lie prone on a couch and then madeto perform a static neck extension against fixed resistance.For Sternocleidomastod subjects were made to lie supinecomfortably on a couch. The subjects then performed astatic neck contraction with neck laterally flexed to sameside and rotated to other side. Resistance provided at theforehead (Kendall 1993).

Exercise protocol

After the baseline measurements and filling of screeningperforma, the subjects were assigned into two groups.Control group (G1) received no intervention and theStrengthening group (G2) received Strengthening exercisesalong with the stretching and general postural advice for 8weeks.Postural advice: was given to subjects to prevent badposture. Participants were advised to:

• Keep the spine upright while sitting on chair duringwork hours.

• Keep the shoulders straight and retracted.

• Take frequent breaks between work hours.

Stretchin

Chin tucks, chest stretch, wall stretch, on your back cheststretch, axial extension (cervical retraction)

Strengthening protocol

Neck isometrics, wall angels, bruegger exercise, dead bug,quadruped, upper back cat.Frequency——————4 times in a week

38 Shweta shenoy. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Duration —————8 weeks.Emg activity was recorded in three sets of cervical flexion-extension, side flexion (right to left) and rotation (right toleft). All the activities were demonstrated to the subjectsand made to perform at least 3 times before recording thesignals. The EMG activity was recorded at baseline and at8 weeks intervention.

EMG processing

Both MVIC data and myoelectric data for the two groupswere processed in the same manner. Using EMG analysisMyoresearch Software Version 2.02, the myoelectricalactivity was first demeaned then a root mean squaretechnique was used to smooth the data thus providing alinear envelop of EMG activity. Using the electrical markingsthe mean activity of the three repetitions was calculatedand was then expressed as a percentage of the peak activityfound during the maximum voluntary contraction for thecorresponding muscle.Percentage MVIC was calculated as:

100 x amplituden contractio isometric voluntaryMaximum

activity during recorded amplitudeMean MVIC Percentage =


Mean, standard deviation and standard error were used toprepare the summary of statistics. By using the student ‘t’test, the panel of significance was calculated. Thecorresponding levels of confidence were determined bythe noting of P-value at 0.05 level of confidence.On comparing the activity levels of muscles between twogroups statistically significant differences were found withintraining Group (P<0.05), shown in Table 1.On comparing the mean values of CV angles, significantchanges were seen within training group at 0 to 8th week(P< 0.001), shown in Figure 1.On comparing the mean values of flexion, extension ,sideflexion and rotation statistically significant differences werefound (p < 0.001) within training group (Group-II) after 8th

week, shown in Figure 2 and 3.On comparing the mean values of pain intensity measuredon VAS within strengthening group (Group-II) statisticallysignificant differences were found after intervention(P<0.001), shown in Figure 4.

ResultsTable 1 : Comparison of mean values and SD of % MVIC of LS, UT, CES and SCM muscles in cervical movements flexion to extension, side flexion (right to left),rotation (right to left) between control (G-I) and strengthening (G-II) group at 0 and 8th week.

% MVIC (0 week) % MVIC (8 week) p-value

Movements Muscles Mean SD Mean SDG-I G-II G-I G-II G-I G-II G-I G-II G-I G-II

F-E LS 11.68 38.58 2.594 6.209 10.79 15.63 2.276 5.670 0.041 0.00UT 3.15 39.16 0.793 7.031 3.07 16.69 0.890 3.497 0.466 0.00

CES 10.77 32.36 2.088 4.774 9.95 14.27 2.084 3.316 0.165 0.00SCM 7.16 13.48 1.347 3.387 6.97 6.01 1.343 2.502 0.475 0.01

SF (Rt-Lft) LS 8.71 36.35 2.367 6.605 8.22 20.35 1.812 4.462 0.288 0.00UT 3.42 35.35 1.452 7.691 3.28 17.36 1.551 4.311 0.111 0.00

CES 10.48 27.96 2.337 5.313 9.62 13.8 2.444 3.388 0.026 0.00SCM 6.86 13.83 1.828 4.058 6.4 7.98 1.842 3.087 0.101 0.01

ROT (Rt-Lft) LS 10.46 35.96 2.678 6.378 9.51 17.03 2.808 3.975 0.005 0.00UT 2.49 41.43 0.958 9.477 2.48 20.36 0.994 4.204 0.946 0.01

CES 9.2 29.11 2.225 5.020 8.5 12.84 2.345 2.773 0.023 0.00SCM 5.93 14.81 2.173 3.244 5.36 10.05 1.981 1.868 0.007 0.02

Significant (Pd”0.05)

Shweta shenoy. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3 39

Fig. 1: Shows comparison of mean values of CV angle in degrees between twogroups at 0 and 8th week.

Fig. 2: Shows comparison of mean values of flexion, extension, side flexionand rotation (ROM) in degrees between two groups at 0 week.

Fig. 3: Shows comparison of mean values of flexion, extension, side flexionand rotation (ROM) in degrees between two groups at 8th week.

Fig. 4: shows decline in the pain intensity measured on VAS within strengtheninggroup (group II) from 0 to 8th week.

40 Shweta shenoy. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Discussion

The current study was a clinical trial to compare the efficacyof strengthening exercises along with stretching and generalposture awareness in the management of forward headposture. The study was performed as far as predictable inaccordance with previous recommendations (Deyo et al,1994; Tulder et al, 1997), to ensure that it was scientificallysound and that the findings were statistically and clinicallyrelevant.Poor muscle endurance is correlated to increased periodsof habitual sitting and lower physical activity levels. EMG isthe study of motor unit activity, for a given activity a strongmuscle requires less motor unit recruitment and thusdemonstrates lower EMG activity, then a weak muscle whichrequire greater motor unit activation (O’ Sullivan et al, 1997).Deviation form normal alignment suggests the presence ofimbalance and abnormal strain on the musculoskeletalsystem (Yoo et al, 2006).Given that the cause of various cervical disorders is notfully understood (Takala et al,1991), treatment for chronicneck disorders vary from traditional means for painmanagement and manipulative therapy to group gymnastics,neck specific strengthening exercises, and ergonomicchanges at work.Strengthening exercises have been used for treatment ofneck pain (HE Berg et al., 1994; T Dyrssen et al., 1989), butonly a few controlled intervention studies have beenconducted to examine active therapy for neck problems.Therefore intervention should target the exercising ofcervical region muscles so as to improve the ability tomaintain a cervical posture (Falla et al, 2007).In the present study the main parameters included wereEMG normalized to mean % MVIC, CV angle, R.O.M. andpain on VAS, taken at baseline and after 8 weeks.Firstly, it was aimed to compare the activation pattern of LS,UT, CES and SCM muscles in all cervical movementsbetween patients with FHP and control group, and tocompare the effect of strengthening exercises on themyoelectric activity of these muscles involved in FHP.The result of the study have demonstrated statisticallysignificant differences between control and strengtheninggroup. The mean % MVIC for LS, UT, CES and SCM ofcontrol group at 0 week were 11.68, 3.15, 10.77 and 7.16respectively however values for strengthening group showsan increased % MVIC of 38.58, 39.16, 32.36, and 13.48respectively in the movement flexion to extension [Table1]. This shows that more motor units are recruited to performthe same task, indicating that the muscles were weak. Asignificant increase in the muscle activity to perform a similartask in seen in individuals with musculoskeletal disorderswhen compared to healthy subjects reported by Veierstedet al., 1990, Szeto et al., 2005. After intervention the mean% MVIC of same movement (flexion-extension) for LS, UT,CES and SCM shows decline to 15.63, 16.69, 14.27, 6.01in the strengthening group (Group-II) respectively thusindicating that fewer motor units, (less overall EMG activity)was seen after intervention.Similarly highly significant differences were seen in sideflexion and rotation. Mean % MVIC of LS, UT, CES andSCM decreases to 20.35, 17.36, 13.8 and 7.98 in sideflexion (Rt-Lft), and 17.03, 20.36, 12.84 and 10.05 in rotation(Rt-Lft) in group II after intervention as compare to the

baseline values at 0 week, as shown in [Table1 ]. LS showedhighest changes in activity (59.48%) in flexion-extensionwhereas UT showed highest changes (50.8%) in side flexionand CES with 55.8% change in rotation in strengtheninggroup (Group-II) after intervention. On the other hand, thecontrol group showed no changes in the EMG activity evenafter 8 week [Table 1]. These changes clearly suggest thatthe strengthening exercises are an important factor tocontribute changes in the myoelectric amplitude .Secondly it was aimed to compare the change in the CVangle, R.O.M and pain score on VAS after interventionbetween patients with FHP and control group.CV angle was measured at baseline and at 8 week period.The results of the present study shows significantimprovement in the CV angle after the 8 week ofintervention showed increase of (mean= 6.4) instrengthening group (Group-II) after intervention. Falla D etal, 2007 done a study and reported changes in the CVangle (Mean= 4.4degree) consistent with a more FHP andfollowing 6 week intervention showed significant reductionin the change in CV angle. This suggest that people withFHP could improve the head repositioning ability andexperience an improvement in cervical lordosis afterpracticing an integrated neck strengthening andproprioceptive training paradigm.R.O.M. was assessed at baseline and at 8 week period.The results of the current study showed significantimprovement in the ROM after intervention in strengtheninggroup (Group II) by 11.2% increase in flexion, 5.7% inextension 14.6% increase in side flexion and 5.9 % increasein rotation [Figure 2 and 3]. Study by Ylinen et al in 2003concluded that ROM had improved statistically significantlyin women with chronic non specific neck pain as comparedto control after an intervention of both strength andendurance training for 12 months.Pain score on VAS was measured before and after 8 weeks.Changes in the pain score has shown statisticallydiscernible differences among the groups. Result showedsignificant reduction in pain intensity threshold on VASmeasured after 8 weeks with the mean of (0.7 ± 0.6) ie;85.10% improvement in training group (Group II) ascompared to the baseline value (4.7 ± 1.8) measured at 0week. Thus its concluded that an organized and specificphysical therapy program proved to be an efficaciousmethod for improving ROM and reducing pain intensity andassist in the management of FHP In the current study, thedifferences in EMG activity, CV angle, ROM and pain onVAS is significantly observed after exercise interventionand therefore should be conducted for industrial setup forpeople with neck problems (FHP) performing Visual displayunit (VDU) tasks.Nonetheless, the present study has certain limitations. Therelatively small number of patients and the lack of long termtreatment, objective changes do not allow firm conclusionsto be made on the overall efficacy of the treatment program.Due to relatively small sample size, it was not possible toinfer patient characteristics corresponding with treatmentoutcome. Future researches essential for subjects withchronic neck pain as general population along with largesample size to further optimize clinical practice. The futureresearch should also focus on larger age group, largertreatment duration as well as follow up.

41Shweta shenoy. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Conclusion

The application of neck strengthening exercises along withthe stretching and general postural advice proved to beand efficacious method in the management of FHPcommonly seen among computer professionals.Clinical RelevanceAddition of strengthening exercises along with stretchingand postural awareness offer benefits in FHP includingimproved muscle activation patterns , pain threshold, CVangle and cervical ROM. Thus improved self experienceworking ability and train the muscle to withstand therequirements of the task.

References

1. Berg HE, Berggren G, Tesch PA. Dynamic neck strengthtraining effect on pain and function. Arch Phys. Med.Rehabil. 1994; 75:661-665.

2. Burgess-Limerick R, Plooy A, Ankrum DR. The effect ofimposed and self-selected computer monitor heighton posture and gaze angle. Clin Biomech (Bristol,Avon). 1998; 13: 584–92.

3. Chiu TT, Ku WY, Lee MH, Sum WK, Wan MP, WongCY, Yuen CK. A study on the prevalence of and riskfactors for neck pain among university academic staffin Hong Kong. J Occup Rehabil. 2002; 12: 77–91.

4. Deyo RA, Andersson G, Bombardier C, et al. Outcomemeasures for studying patients with low back pain.Spine. 1994; 19: 2032S-6S.

5. Dunn JJ, Mannheimer JS. The cervical spine. In: PertesRA, Gross SG, eds. Clinical management oftemporomandibular disorders and orofacial pain.Chicago: Quintessence. 1995; 13–34.

6. Dyrssen T, Svedenkrans M, Passikivi J. Muskelträningvid besvär i nacke ochskuldror effektiv behandling föratt. minska smärtan. Läkartidningen. 1989; 86: 2116-20.

7. Gonzale Z H, Manns A. Forward Head Posture; itsstructural and functional influence in the stomatognathicSystem, a Conceptual Study. J. Craniomandib Pract.1996; 14: 71-80.

8. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA.Incidence of common postural abnormalities in thecervical, shoulder, and thoracic regions and theirassociation with pain in two age groups of healthysubjects. Phys Ther. 1992; 72: 425–31.

9. Kendall, F.P., Kendall, Elijabeth Kendall-Macreary,Patrica. Muscle Testing and Function, Fourth ed.,Williams and Wilkins, Baltimore. 1993.

10. Kleine B.U., Schudmann N.P., Bradl I., Grieshaber R.,Scholle H.C. Surface E.M.G of shoulder and backmuscles and posture analysis in secretaries typing atvisual display units, International Achieves ofOccupational and Environmental Health. 1999;72:6:387-394.

11. McLean L et al. Effect of postural correction an muscleactivation amplitudes recorded from the cerviobactericalregion; Journal of Electromyography and Kinesiology.2005; 15(16): 527-35.

12. Moore MK. Upper crossed syndrome and itsrelationship to cervicogenic headache. J ManipulativePhysio Ther. 2004; 27: 414–20.

13. O’Sullivan PB, Phyty GD, Twomey LT, Allison GT.Evaluation of specific stabilizing exercise in thetreatment of chronic low back pain with radiologicdiagnosis of spondylolysis or spondylolisthesis. Spine.1997; 22: 2959–67.

14. Parker MW. A dynamic model of etiology intemporomandibular disorders. JADA. 1990; 120:283–90.

15. Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effectof neck exercise on sitting posture in patients withchronic neck pain. Phys Ther. 2007; 87: 408–17.

16. Jull G, Falla D, Treleaven J, Hedges P, Vicenzio B.Retraining crucial Joint position sense: the effect oftwo exercise regimes J. Orthop Res. 2007; 25(3): 404-12.

17. Szeto GP, Straker L, Raine S. A field comparison ofneck and shoulder postures in symptomatic andasymptomatic office workers. Appl Ergon 33, 75–84.

18. Takala EP. (1991) Assessment of neck shoulderdisorders in occupational health care practice. Helsinki,Finland: University of Helsinki. 2002; 69.

19. Van Tulder MW, Assendelft WJ, Koes BW, Beuter LM.Method guidelines for systemic reviews in the CochraneCollaboration Back Review group for spinal Disorders.Spine. 1997; 22:2323-30.

20. Veiersted K.B., Westgaard R.H., Anderson P. Patternof muscle activity during stereotyped work and itsrelation to muscle pain. International achieves ofoccupational and environmental health. 1990; 62 (1),31-41.

21. Ylinen J, Takala EP et al. Active neck muscle trainingin the treatment of chronic neck pain in women: arandomized controlled trail. JAMA 2003; 289(19): 2509-160

22. Yoo WG, Yi CH, Kim MH. Effects of a proximity- sensingfeedback chair on head, shoulder, and trunk postureswhen working at a visual display terminal. J OccupRehabil. 2006; 16: 631–7.

42

Measurement of quality of life using a locally developedquestionnaire after an aerobic training program in patients withchronic respiratory diseasesPooja K Arora1, Bharati Bellare 2

1Lecturer, Department of Physiotherapy, Pad. Dr. D.Y. Patil University, Navi Mumbai, 2 Hon. Professor, M.G.M. MedicalCollege, Navi Mumbai

Objectives

To Measure Quality of Life following short term, out-patientbased, aerobic training program in patients with chronicrespiratory diseases using locally developed Questionnaire.

Design

Hospital based, longitudinal study.

Methods

Study populationPatients referred from Respiratory Outpatient department.

Subjects

Inclusion criteriaPatients with Irreversible chronic pulmonary disease of morethan 3 years duration diagnosed cases by the Medicalspecialists of >14 years of age, Clinically stable on optimalmedical therapy and with no hospitalization or major surgeryin the last 2 months.Exclusion criteriaConcomitant diseases leading to incapacitation orfunctional impairments.

Study factors

HistoryBasic demographic data, disease and treatment details wererecordedLocally developed HRQoL questionnaireA pre-validated questionnaire tailored to Indian situationwas used to assess quality of life changes.InterventionTo a group of 6-8 patients supervised Aerobic exerciseswere given for a period of 6 weeks.Outcome factorsChanges in the scores of QOL questionnaire, six minutewalked distance RPE on Modified Borg’s Scale wererecorded before and after aerobic training.

Results

Thirty cases were enrolled in present study of them 20 weremales, 10 were females. Six minute walk test distanceimproved from 366.33 meters to 443.33 meters p<0.001and mean perceived exertion score improved from 5.55 to2.8.p<0.001showing overall improvement in physicalactivities. Total Quality of life score improved from 43.8 to63.5 p< 0.00.00 after aerobic training consistent withphysical and symptomatic improvements. Similar

improvements in mean scores were observed in subdomains also.

Conclusion

Locally developed HRQoL questionnaire was able to recordthe improvements in QoL scores after hospital basedaerobic training rehabilitation program in patients withChronic Pulmonary Diseases in Indian patients.

Key words

HRQoL questionnaire, aerobic training, chronic pulmonarydiseases, Six minute walk test, Modified Borg’s ScaleMeasurement of Quality of life using a locally developedQuestionnaire after an aerobic training program in patientswith Chronic Respiratory Diseases

Key words

HRQoL questionnaire, aerobic training, chronic pulmonarydiseases, Six minute walk test, Modified Borg’s Scale.

Introduction

Chronic pulmonary disease is one of the major healthproblems in India, with prevalence varying from 1% to 20%in urban non-smokers to rural smokers.1,2 Chronicpulmonary diseases has got numerous etiologies and isassociated with disabling breathlessness which causesimpairment of functional exercise capacity due to skeletalmuscle dysfunction, poor nutrition and psychosocialdisadvantage.3 This Vicious cycle affect quality of life causingnegative impact on functioning and well being. Pulmonaryrehabilitation is essential secondary preventive strategy ofmanagement in Chronic Pulmonary Diseases. QoLassessment is carried out in present study using locallydeveloped questionnaire to measure the Post aerobicexercise improvement in quality of life.

Methodology

Objectives

The study aims to Measure Quality of Life following shortterm, out-patient based, aerobic training program in patientswith chronic respiratory diseases using locally developedQuestionnaire

Research Design

The present study was a Hospital based, longitudinal study

Pooja. K Arora. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

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carried out in Department of Physiotherapy, LTMMC andGeneral Hospital, Sion, Mumbai.

Study population

The sample selected were the outpatient cases fromDepartment of Respiratory Medicine, Sion Hospital.

Subjects

Inclusion criteria1. Any individual with irreversible chronic pulmonary

disease of minimum 3 years duration, diagnosedpatients from Respiratory O.P.D and having thefollowing diagnosis- COPD/ COAD/ COLD,Bronchieactasis, Interstitial fibrosis, Post-tubercularfibrosis.

2. Both males and females above the age of 14 years.3. Clinically stable patient on optimal medical therapy

with no change in medication in the previous month.4. No hospitalization in previous two months.

Exclusion criteria1. Presence of any other disease leading to incapacitation

and functional impairments like Cardiac disorders,Musculo-skeletal disorders.

2. Patients during acute exacerbations.3. Subjects on Psychiatric treatment, impaired cognitive

status or mental retardation.4. Patient refusing to participate in the study.

Study factors

History: Basic demographic data, disease and treatmentdetails were recorded.Locally developed HRQoL questionnaire: A pre-validatedquestionnaire tailored to Indian situation was used to assessquality of life changes. HRQoL Questionnaire includedfollowing aspects of human life:Self-care: Eating, drinking, dressing, grooming, bathing,talking.Ambulation: Walking, staircase climbing up and down,transport.Occupation: Domestic jobs like cooking, washing clothes,washing utensils, brooming, moping, and carrying loads.Psychosocial domain: Sleep, mood, sexual activity,recreation and role in family or society.

Intervention

A group of 6-8 patients were given a set of exercises in anAerobic class. This included the following exercises:Aerobic exercise plan: The total duration of the exerciseprogramme was 45 minutes comprising of 10 minutes ofwarm up phase, 20-30 minutes of aerobic phase,10-15minutes of cool down phase

Warm up phase

The following exercises were included in warm up phase1. Neck exercises: Flexion-extension, Side-flexion to right

and left, Rotations to right and left2. Shoulder shrugging, protraction-retraction,

circumduction and Codman’s exercises.3. Trunk rotations to right and left, flexion-extension and

side-flexion to right and left4. Stretching: Tendo-achillis, Adductors, Rectus femoris

Aerobic phase

The following exercises were included in the aerobic phase1. Spot movements: Heel raises, Slow marching, Slow

high step marching, Forward stepping, Sidewaysstepping, Backward stepping, addition of upper limbmovements like, Forward stepping with elbow flexion-extension, Sideways stepping with elbow flexion-extension, Backward stepping with elbow flexion-extension.

2. Slow spot jogging, Fast spot jogging, Fast spot joggingwith shoulder movements, Running in circle, Fast spotmarching, Slow spot marching, Heel raises coordinatedwith overhead arm movements and breathing.

3. Wall exercises: Hip flexion, extension and abduction.

Cool down phase

The following mat exercises are given in cool down phase:1. Long sitting with back supported: Ankle dorsiflexion-

plantar flexion, circling, Static quadriceps sandHamstrings stretching.

2. Butterfly sitting- adductor stretching.3. Supine: Hip flexion with other hip- flexed foot resting

on plinth, Knee to chest one leg at a time; Knee to chestboth limbs together.

4. Crook lying: Bridging, Sideway rotations5. Side lying: Hip abduction with limb in neutral, in flexion

and in extension.6. Prone lying: Both knees flexion-extension, Hip

extension and Back extension.7. All fours position: Alternate shoulder flexion-extension,

hip-knee flexion-extension and Cat and camelexercises.

8. Shavasana - relaxation

Outcome factors

Changes in the scores of QOL questionnaire, six minutewalked distance, RPE on Modified Borg’s Scale wererecorded before and after aerobic training.

Results

Thirty cases were enrolled in present study of them 20 weremales, 10 were females. Mean age for males were 49.25years and females were 38.3 years. Of 30 patients 13patients had clinical diagnosis of post TB Bronchectesis, 9had COPD, 5 had Bronchectesis rest were Asthmatics. Sixminute walk test distance improved from 366.33 meters to443.33 meters p<0.001 and mean perceived exertion scoreimproved from 5.55 to 2.8.p<0.001showing overallimprovement in physical activities. Total Quality of life scoreimproved from 43.8 to 63.5 p< 0.00.00 after aerobic trainingconsistent with physical and symptomatic improvements.(Table I) Similar improvements in mean scores wereobserved in sub domains also.(Table II) The quality of lifescores recorded in each domain are consistent withsymptomatic and physical improvement

Discussion


44

COPD is associated with disease related myopathy anddeconditioning. The unpleasant experience like Dyspnea andleg discomfort during exertion is known to reduce the day today physical activity which in turn affects the QoL. Exercisetraining is widely regarded as the cornerstone of pulmonaryrehabilitation.4 Improvements in skeletal muscle function afterexercise training results in increases in exercise capacitydespite the absence of changes in lung function. Moreover,the improved oxidative capacity and efficiency of the skeletalmuscles leads to less alveolar ventilation for a given workrate. This reduces dynamic hyperinflation, thus potentiallyreducing exertional dyspnea.Pulmonary rehabilitation programs lasting between 6 and 12weeks have been shown to improve exercise capacity,functional ability, and quality of life. There is evidence tosuggest that prolonged lifestyle change can occur whereimprovements in health status and physical performance havebeen seen for up to two years.5,6,7 The present study was a 6weeks training program and the effect were evaluatedimmediately after training and long term effect evaluation wasnot done.J Roomi8 assessed the effect of respiratory rehabilitation on6 minute walk test in 15 subjects between the ages of 70-89years with stable COAD. Quality of life was measured usingGuyatt respiratory questionnaire. He found that 6 minutewalk distance after the rehabilitation was significantly morethan baseline. Similar results were found in our study withincrease in the ambulation scores post-training andincreased six-minute walk distance. Six minute walk testperformance and RPE scores are direct ways of measuringthe improvements in physical activity. In present studysignificant improvement in these parameters was noted andit correlated well with improvements in QoL Scores.Aerobic exercises the intervention in present study is knownto break the pattern of decrease in activity and increaseddyspnea by increasing the capillary density, altering themitochondrial and enzymatic activity and also by increasingtype I fibre decrease in type 2b fibres which is achieved bexercise training.3 These could be the physiological basisfor improvement in QoL scores. Sarah Bernard9 in arandomized control trial of 12 weeks duration of aerobictraining alone and strength training in addition to aerobictraining, in chronic obstructive pulmonary diseases,demonstrated significant improvements in peak exercisework rate, 6MWD and quality of life scores in both the groups.The improvements in sub domain scores i.e. self care,ambulation, and job related activities could be attributed totraining effects of aerobic exercises. Improvements in thePsychosocial (emotional) domain, on the other hand couldbe the outcome of group training, desensitization ofdyspnea, and regaining of self control. Subgroup analysisshowed definite improvement in scores for self care whichincreased and this could be attributed to desensitization todyspnea, better coordination of muscles and true metabolicadaptations. Similar betterment of score was also seen inscores of ambulation and occupational scores.The results of present study showed improvement inPhysical activity which is reflected well in Quality of life

scores of locally developed Questionnaire suggestingeffectivity of instrument. The need for local Questionnaire isbased on the fact that the existing QoL questionnaire usedto assess CPD patients are not in local dialect and needtranslation into local dialect which in turn could affect contentvalidity of any questionnaire. Non inclusion of importantphysical activities relevant to local population like sleep,squatting, carrying weight etc are important in assessmentof the quality of life in Indian Scenario.Important drawback of present study is that it is alongitudinal study and in order to obtain Class 1 evidencein the era of evidence based physical therapy a randomizedcontrol trial comparing the local questionnaire with one ofthe standard questionnaire is a must, and that would be thenext step in evaluation of present questionnaire as resultsof present study are quite satisfactory.

Conclusion

Locally developed HRQoL questionnaire was able to recordthe improvements in QoL scores after hospital basedaerobic training rehabilitation program in patients withChronic Pulmonary Diseases in Indian scenario.

References

1. Jindal SK. A field study on follow-up at ten years ofprevalence of COPD and PEFR. Ind J Med Resp (B)Feb. 1993; 98:20-6,

2. Malik SK. Profile of chronic Bronchitis in North India-the PGI experience (1972-1985). Lung India 1986; 4:89-100

3. Daga MK,Tiwari N, Mahajan R. Pulmonary Rehabilitationin COPD. Current Medical Trends 2001; 5:962

4. Mahler DA,Ward J, Mejia-Alfaro R. Stability of DyspneaRatings after Exercise Training in Patients with COPD.Med Sci.Sports Exerc. (2003), 35: pp. 1,083–1,087.

5. Ries AL, Kaplan RM, Limberg TM, Prewitt LM. Effectsof pulmonary rehabilitation on physiologic andpsychosocial outcomes in patients with chronicobstructive pulmonary disease. Ann Intern Med 1995;122(1): 823-832

6. Troosters T, Gosselink R, Decramer M. Short- andlongterm effects of outpatient rehabilitation in patientswith chronic obstructive pulmonary disease: arandomized trial. Am J Med 2000; 109:207–12.

7. Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V,Mullins J, Shiels K, et al. Results at 1 year of outpatientmultidisciplinary pulmonary rehabilitation: a randomizedcontrolled trial. Lancet 2000; 355:362–68.

8. J Roomi. Respiratory rehabilitation, exercise capacityand quality of life in chronic airways disease in the oldage. Age and aging. 1996 Jan; 25 (1):12-6 8670523(P,S,G,E,B)

9. Sarah B, Franchois W, Pierre L, Jean J, Roger B,Chantal B, Guy C, and Franchois M. Aerobic andstrength training in patients with chronic obstructivepulmonary disease. Am J Respir Crit Care Med; Volume159, number 3, March 1999, 896-901.


Table 1: showing changes in Parameter scores.Parameter score Before Training After training Statistical

significanceSix min walk test 366.33m 433.33m p < 0.001Perceived exertion 5.55 2.8 p < 0.001Total QoL Scores 43.8 63.5 p <0.000

Table 2: showing changes in Sub domain scoresSub-domain Before Training After training Statistical

significanceSelf -care 20.76 23.56 p < 0.001Ambulation 6.33 10.7 p <0.001psycohosoical 9.26 13.8 p <0.01

45

Effect of ultrasound and jaw opening exercises in cases of oralsubmucous fibrosisPooja K. Arora*, Maneesha Deshpande***Lecturer in Physiotherapy, Pdm Shri DY Patil College of Physiolotherapy, Nerul, Navi Mumbai, **Professor of Physiotherapy,VSPM’s College of Physiotherapy, Nagpur, Maharashtra

Abstract

Introduction

Oral submucous fibrosis (OSMF) is a chronic disablingdisease associated with habitual betel quid chewers. InIndia, 2.5 million people are suffering from OSMFcharacterized by limitation of oral opening resulting indifficulty in chewing. The pathological changes areirreversible. Physiotherapy is offering third dimension tothe management apart from medication and surgery.Therapeutic ultrasound help makes fibrous tissue morepliable and gradual stretching of oral tissues helping toimprove trismus.

Methodology

Hospital based Research questions.i) Does therapeutic ultrasound with mouth opening

exercises improve the MMO (maximum mouth opening)in patients of OSMF as palliative measure?

ii) Does therapeutic ultra sound helps in reducing oralSensitivity to spicy food as measured onVAS?

Study design: Hospital based, before & after effectevaluation case seriesCase selection: Patients with M.M.D. < 35mm & localizedor generalized O.S.M.F. diagnosed by senior ENTSurgeons patient who received other local modalities likeIntralesional injection was excluded.Study factors: Ultra sound therapy and Jaw openingexercise.Out come factors:1. Measurement of M.M.O. before & one week after treatment.2. Measurement of symptoms of burning in mouth using

VAS.

Results

Total 30 patients were enrolled in the study. The mean ageof patients was 33.56 years with range of 18- 55years and4:1 male: female ratio. Trismus was main presentingsymptom in all 30 patients and 86.66% has burning in mouthPan masala & tobacco were the main risk factors seen 63.33% & 46.66% patients. The mean M.M.O. before treatmentwas 24.06mm, which improved to 27.8mm(P=0.001) aftertreatment. The mean post therapy V.A.S.score for burningsensation in mouth came down from 6 to 3.33 (P=0.01)

Conclusion

Ultrasound therapy followed by jaw opening exercises canbe an alternate mode of treatment for palliation in OSMF toimprove trismus the main morbidity

Introduction

Oral sub mucous fibrosis (OSMF) is a chronic disablingdisease developing in 0.5% of estimated half a billionhabitual betel quid chewers1. In India, 2.5 million peopleare suffering from OSMF characterized by limitation of oralopening resulting in difficulty in chewing2. The managementof OSMF is based on avoidance of irritants followed by twomajor strategies-medical & surgical; but no treatment issuccessful due to irreversible nature of disease3,4.Considering above facts, physiotherapy is offering thirddimension to the management. It consists of application oftherapeutic ultrasound that makes fibrous tissue morepliable and gradual stretching of oral tissues helping toimprove trismus, a major morbidity of OSMF.

Methodology

The study was carried out at VSPM college of Physiotherapy& Lata Mangeshkar Hospital, Digdoh hills, Nagpur.Research questions.i) Does therapeutic ultrasound with mouth opening

exercises improve the MMO (maximum mouth opening)in patients of OSMF as palliative measure?

ii) Does therapeutic ultra sound helps in reducing oralSensitivity to spicy food as measured on VisualAnalogue Scale?

Study design: Hospital based, before & after effectevaluation case series

Study population

Case selection: Patients with M.M.O. < 35mm & localizedor generalized O.S.M.F., diagnosed by senior ENT Surgeon.Exclusion Criteria: Patient who received other localmodalities like Intralesional injection was excluded.

Study factors

Ultra sound therapy was given to the patients usingIndosonic HMS with a transducer head of 1 MHz.Transducer was placed in contact with cheek using an aquasonic gel and slow circular motions were given for 7 minutesat intervals of 0.7 watts/cm² for 7 days period followed byJaw opening exercise.Jaw opening exercisesAfter every session of ultrasound therapy the followingexercises were thought to the patient.1. Wide mouth opening and maintaining it for five

seconds— 10 repetitions.2. Lateral deviation of mandible to right and left side—10

repetitions.3. Protrusion of mandible—10 repetitions.

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4. Gradual mouth stretching by placing the left thumb overthe upper incisor and right index finger over the lowerincisor and maintaining it for five seconds—10repetitions.

Out come factors3. Measurement of M.M.O. before & one week after

treatment using a all steel Vernier Caliper by measuringthe inter incisor distance.

4. Measurement of symptoms of burning in mouth usingVAS before and after therapy.

Results

Total 30 patients were enrolled in the study. Descriptivestatistics showed, mean age of patients was 33.56 yearswith range of 18- 55years and 4:1 male: female ratio. Trismuswas main presenting symptom in all 30 patients and 86.66%has burning in mouth Pan Masala & tobacco were the mainrisk factors seen 63.33 % & 46.66% patients. On analyzingthe data using student t test, the mean M.M.O. beforetreatment was 24.06mm, which improved to 27.8mm(P=0.001) after treatment.(Table 1)(Photo 1, Photo 2) Themean post therapy V.A.S.score for burning sensation inmouth came down from 6 to 3.33 (P=0.01) (Table 2)

Discussion

OSMF is basically a disease of Indian subcontinent2.Literature search on Internet showed up 378 researchpapers; of them only one a had mentioned Physiotherapyas modality of treatment with no Physiotherapy treatmentdetails5. This show paucity of published literature on thissubject, thus prompting us to take up this pioneer, pilotstudy.Causation of OSMF is multifactorial but in present study,pan masala was the commonest offender seen in 67% ofpatients. It was shockingly noticed more in younger patientsdue to their social habit of chewing pan masala. Tobaccowas the next common etiological offender found in 50% ofthe patients. Trismus, the main morbidity of OSMF was foundin all patients. 86% of the patients had burning sensation inoral cavity mainly due to inflammatory changes andulcerations.Our dual therapy of local Ultrasound and jaw openingexercises has led to significant improvement in mouthopening measured by calculating MMO. This improvementcould be explained on the basis of the effect of pulsed

ultrasound due to the mechanical effect which causesloosening of adherent fibrous tissue probably due to theseparation of collagen fibres from each other and softeningof the cement substance thus leading to increased pliability.This phenomenon is well documented in management ofDupuytren’s contracture6 and mature scar7,8. The scar afterultrasound therapy offers a stretching window9 due to localheat and mechanical vibrations which makes the tissuemore pliable and less resistant to stretching. This opportunitylasts for 5-10 minutes following ultra sound therapy andwas the rationale of present study.Decrease in sensitivity to commonly consumed foods wasalso reduced after ultrasound therapy, which could beattributed to increase in motor and sensory nerve conductionvelocities thus decreasing the pain10. Diminution of painperception could also be due to decreased inflammatoryresponse and healing of ulcers, an effect of ultrasound.

Conclusion

Ultrasound therapy followed by jaw opening exercises canbe an alternate mode of treatment for palliation in OSMF toimprove trismus, the main morbidity. A well-plannedrandomized controlled trial will help establishing this as analternative treatment.

References

1. Canniff JP, Harvey W: The etiology of oral sub mucousfibrosis: the stimulation of collagen synthesis by extractsof areca nut. Int J Oral Surg 1981; 10(Suppl 1): 163-7

2. Cox SC, Walker DM: Oral Sub mucous fibrosis - Areview. Aust Dent J 1996 Oct; 41 (5): 294-9

3. Jayanthi V, Probert CS, Sher KS,Mayberry JF: Oralsubmucous fibrosis- a preventable disease. Gut 1992Jan; 33(1): 4-6

4. Murti PR, Bhonsle RB, Pindborg JJ, etal : Malignanttransformation rate in oral sub mucous fibrosis over aseventeen year period. Community Dent OralEpidemiol 1985 Dec; 13(6): 340-1

5. Sharma JK, Gupta AK, Mukhija RD, Nigam P: clinicalexperience with the use of peripheral vasodilator inoral disorders: Int J Oral Maxillofac Surg 1987 Dec; 16(6): 695-9

6. Patrick MK. Application of pulsed therapeuticultrasound. Physiotherapy.1978; 64(4): 103-104

Pooja K. Arora. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Table 1: Showing effect of ultrasound therapy on MMOStatus N MMO SDBefore 30 24.06mm 5.26After 30 27.8mm 5.26Difference 3.73mm

> t = — 18.387 p value= 0.001

Table 2: Showing effect of ultrasound therapy on burning sensation in mouthon VAS ScaleStatus N VAS Score SDBefore 30 6 2.33After 30 3.33 1.397Difference 2.66

,t = 11.768 p value = 0.001

Photo 1: Measurement before treatment (11mm)Photo 2: Measurement after treatment (16 mm)

47Pooja K. Arora. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

7. Hashibe M,SankarnarayananR, Thomas G, KuruvillaB, Mathew B, Somnathan T,Parkin DM, Zhang ZF: Bodymass index, tobacco chewing, alcohol drinking andrisk of oral sub mucous fibrosis in Kerala,India.1 :Cancer Causes Control.2002Feb;13(1):55-64.

8. Bierman W. Ultrasound in the treatment of scars. ArchPhys Med Rehabil.1954; 35:209.

9. Drapper DO, Richard MD. Rate of temperature decayin human muscle following 3 MHz ultrasound: thestretching window revealed. J Anth Train 1995;30:304-307

10. Kathy Henderson PT, The interdisciplinary Journal ofRehabilitation; October 2004.file://A:\ultrasound-underused.htm

48

The reliability of goniometric measurements of passivetrapeziometacarpal joint motionsSaini Prerna*, Grover Deepak***Research Student, ISIC Institute of Rehabilitation Sciences, New Delhi, **Research Guide, Senior Physiotherapist, HolyFamily Hospital, New Delhi

Background and purpose

The purpose of this study were1 to examine the intraraterand interrater reliability for goniometric measurements oftrapeziometacarpal flexion, extension, abduction andadduction passive range of motion2 to determine whethergender has any affect on trapeziometacarpal joint passiverange of motion.

Objective

To determine the degree of intrarater and interrater reliabilityof passive range of motion goniometric measurements oftrapeziometacarpal joint in male and female physicaltherapists.Design. One time observational study.

Subjects

Seventy six (50 females and 26 males) physical therapists’trapeziometacarpal joint range of motion were measured.The testers were two masters final year physical therapystudents.

Methods

Both testers measured goniometric measurements ofpassive trapeziometacarpal joint flexion, extension,abduction, adduction. The intraclass correlation coefficient(ICC) and standard error of measurement were used tocalculate interrater and intrarater reliability.

Results

The intraclass correlation coefficient demonstrated thatintratester as well as intertester reliability coefficient wasfound to be good to excellent for trapeziometacarpal passiveflexion, passive abduction , passive adduction , passiveextension. The intrarater reliability was found to beconsistently higher than interrater reliability. The results arefurther validated by the standard error of measurements. Asignificant difference has been found in passive flexion aswell as extension range of motion of passivetrapeziometacarpal motions between males and females.

Conclusion and discussion

The goniometric measurement of passivetrapeziometacarpal motions is highly reproducible.Goniometric measurement could be used to determine thepresence of joint range of motion limitation, to evaluatepatient progress toward rehabilitation goals and to assessthe effectiveness of therapeutic interventions.

Key words

Trapeziometacarpal joint, goniometry, reliability.

Introduction

The carpometacarpal joint of the thumb is important forproviding the mobility necessary for the thumb to positionitself for varied functions.1 Movement deficiencies of thethumb commonly occur after injuries to the thumb jointsarthritis as well as diseases of the nervous andmusculotendinous system. Every year, many patients withtrapeziometacarpal joint arthritis receive the arthroscopyjoint arthroplasty or joint replacement to relieve their painand maintain the movement function. However, noappropriate and objective method is available for comparingthe pre-operative and post-operative conditions. 2Thus,surgeons and physical therapists anticipated having anobjective and precise method which could be easily andefficiently performed by the clinicians to evaluate the rangeof motion for the patients.2

Universal goniometer is frequently used to measure activerange of motion and passive range of motion fordocumentation purposes and to assist in making clinicaldecisions. Without an acceptable degree of reliability, clinicalgoniometric measurements are of little value and actuallybe misleading.3

The reliability of clinical diagnostic and treatment outcomemeasurements is generally recognized as being importantin clinical research and is gaining recognition as beingimportant in clinical practice.4 Of the studies that examinedgoniometric intertester and intratester reliability, only a fewfocused on the joints of hand.5

The intrarater and interrater reliabilities of passive range ofmotion measurements of trapeziometacarpal joint have notbeen determined. The clinical reliabilities of thesemeasurements would describe the physical therapist anindication of usefulness of trapeziometacarpal passive rangeof motion measurements.The purpose of this study were1 to examine the intraraterand interrater reliability for goniometric measurements oftrapeziometacarpal flexion, extension, abduction andadduction passive range of motion2 to determine whethergender has any affect on trapeziometacarpal joint passiverange of motion.This study will decrease subjective judgments and increasethe therapists’ ability to obtain reproducible and meaningfulresults. The clinical decision-making process will beobjective, valid, and reliable.

Method

Subjects: The sample consisted of 76 volunteer physical

Saini, Prerna. / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

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therapists (50 females and 26 males). Initially 80 therapistswere approached with the proposal of the study. But 4 wereexcluded after initial screening based on inclusion andexclusion criteria. Their age ranges from 20 – 24 years.(Table 1)The subjects were male and female physicaltherapist students whose Clinical experience were not morethan 2 years i.e. final year bachelor’s students, interns,masters in physiotherapy first year students and also haveno special experience or skill in manipulative techniques.

All the included subjects were functionally right handed.Subjects with previous history of trauma to the thumbrequiring medical treatment, previously diagnosedosteoarthritis of the thumb, any history of connective tissuedisease and presence of thumb deformity6 andhypermobility and hypomobility of the thumb were excluded.

Testers: The goniometric measurements (interrater) wastaken by a second year master student from ISIC, Instituteof rehabilitation Sciences. The student had the experienceand skill in goniometric measurements comparable to theintrarater. Additionally, the student learned the goniometricmeasurement procedures prior to the testing subjects.Instrumentation: A 180 degree plastic, transparentuniversal goniometer with 6 inch movable arms is used.The scales of goniometer are marked in one degreeincrements. The accuracy of each goniometer was assessedprior to the beginning of the study by measuring 10 randomlyselected angles drawn by use of a protractor.7

Procedure: For goniometric measurements oftrapeziometacarpal Joint Flexion and Extension:8,

Recommended Testing Position: Sitting, forearm in fullsupination, wrist in 0° flexion, extension, radial & ulnarflexion. Carpometacarpal of thumb in 0° of abduction &adduction. & metacarpal and interphalangeal joint of thumbin 0° of flexion & extension. Forearm & hand rest onsupporting surfaceStabilization: Stabilize carpal bones to prevent wristmotions.Fulcrum: Palmar aspect of 1st carpometacarpal joint.Proximal Arm: Ventral midline of radius using ventralsurface of radial head & styloid for reference.Distal Arm: Ventral midline of 1st metacarpal.For goniometric measurements of trapeziometacarpal JointAbduction and AddctionRecommended Testing Position: Sitting, forearm in 0°supination-pronation, wrist in 0° flexion, extension, radial &ulnar flexion. carpometacarpal, metacarpal andinterphalangeal joint of thumb in 0° of flexion & extension.Forearm & hand rest on supporting surface.Stabilization: Stabilize carpal bones & second metacarpalto prevent wrist motions.Fulcrum: Lateral aspect of radial styloid process.Proximal Arm: Lateral midline of 2nd metacarpal.Reference center of 2nd metacarpophalageal joint.Distal Arm: Lateral midline of 1st metacarpal. Referencecenter of 1st metacarpophalageal joint.This study used a modified version of a goniometricmeasurement method originally described by Rothstein et

al. Subject was identified by one of the testing therapists.The therapist then obtained consent from the patient,collected subject data. That therapist was also the first testingtherapist.The first tester then measured the subject’s passivetrapeziometacarpal passive flexion, extension, abduction,adduction range of motion. Operational definitions wereprovided so that each of the testers could use them asguidelines. After measuring the subjects in the defined order,the first tester remeasured the same subject in the sameorder after a 30- to 60-second interval and these recordingwere noted. The second tester of the measuring pair thenrepeated all of the measurements twice. The elapsed timebetween the first tester’s and the second tester’smeasurements was 2 to 3 minutes. 10,11

Data analysis

The data was managed on an excel spreadsheet and wasanalysed using the SPSS, Version 10 software. Statisticaltest used was intraclass correlation coefficient to calculatethe interrater and intrarater reliability coefficient oftrapeziometacarpal flexion, extension, abduction andadduction motions. The standard error of measurementwhich reflects an estimate of the amount of error associatedwith individual measurements was calculated for allmovements. The standard error of measurement wascalculated as S.D x (1-ICC) where S.D. is the standarddeviation of scores of all subjects and ICC is the interclasscorrelation coefficient.13

Student t test was used to analyse difference in range ofmotion between male and female subjects.

Results

The goniometric measurements of total subjects, malesubjects, female subjects for passive range of motion oftrapezium taken by both raters are given in table 2. TheICCs for intratester reliability of measurements obtainedwith a goniometer were 0.98 for trapeziometacarpal flexion,0.9 for trapeziometacarpal extension, 0.9 fortrapeziometacarpal abduction and 0.95 fortrapeziometacarpal adduction. The ICC values for intertesterreliability of measurements obtained with a goniometerwere 0.87 for trapeziometacarpal flexion, 0.70 fortrapeziometacarpal extension,0.81 for trapeziometacarpalabduction and 0.78 for trapeziometacarpal adduction.(Figure 2).The SEM for intratester reliability of measurements obtainedwith a goniometer were 0.11 for trapeziometacarpal flexion,0.16 for trapeziometacarpal extension, 0.17 fortrapeziometacarpal abduction and 0.18 for


Table 1: Subject Characteristics(Age)Variables No of Subjects Mean (in years) S.D.(in years)Total Subjects 76 21.44 1.27Male Subjects 26 22.53 0.85Female Subjects 50 21.44 1.29

Fig. 1: Instrumentation

50

trapeziometacarpal adduction. The SEM values forintertester reliability of measurements obtained with agoniometer were 0.66 for trapeziometacarpal flexion,0.92for trapeziometacarpa extension, 0.64 fortrapeziometacarpal abduction and 0.77 fortrapeziometacarpal adduction.There was a significant difference (pd”0.05) in passiveflexion as well as extension range of motion of passivetrapeziometacarpal motions between males and females(Table 3,Figure 3).

Discussion

The intraclass correlation coefficient demonstrated thatintratester reliability coefficient was found to be excellentfor trapeziometacarpal passive flexion, passive abduction ,passive adduction , passive extension . Thus, repeatedmeasurements of the trapeziometacarpal motion by thesame therapist can be expected to be highly reliable.Intertester reliability for passive range of motionmeasurements was excellent for trapeziometacarpal flexion, passive adduction , passive adduction; good for passiveextension. The intrarater reliability was found to be greaterthan interrater reliability for all movements oftrapeziometacarpal joint except for extension movement ofmale subjects. Equivalent measurements among subjectscan cause low reliability coefficients, even if individualmeasurements are consistent, which is an inherent limitationof the ICC14. It may also be due to small sample size of malesubjects.

The intrarater reliability was found to be consistently higherthan interrater reliability, although overall reliability remainedexcellent. These results have come in accordance with theprevious joint measurements studies which have shownthe intratester reliability to be higher than intertesterreliability.3,4,710,11,14,15,16

The results of this study suggest that the goniometricmeasurement of trapeziometacarpal motions is highlyreproducible. A highly reliable goniometric measurementcould be used to determine the presence of joint range ofmotion limitation, to evaluate patient progress towardrehabilitation goals and to assess the effectiveness oftherapeutic interventions.14

The results are further validated by the standard error ofmeasurements.Previous efforts in determination of this joint motion haveincluded the biplanar roentogenography (Cooney et al)17;optoelectronic device (Goubier, Deven)18; electrogoniometry(Ebskov and Boe)19; electromagnetic device andmathematical model to evaluate the maximal workspace (Li- Chieh Kuo )20; torque controlled device (Lisa Harvey)21.With so much to choose from, a clinician must select a devicewhich is safe, easy to use, economical, clinically useful,reliable and valid. Although most of the instruments havegood reliability but these instruments have certaindrawbacks i.e these equipments are expensive, have limitedapplications and these methods are also complicated andrequire more time than conventional goniometricmeasurements. Further, they require expertise to learn andhave high maintenance cost also.

Table 3: Comparison of range of motion of trapeziometacarpal joint of male and female subjects

Males(N=26) Females(N= 50) t – value(in degrees) p value(in degrees)Mean (in degrees) S.D. (in degrees) Mean(in degrees) S.D.(in degrees)

Flexion 26.34 3.08 19.90 4.50 6.53 0.00*Extension 17.57 2.98 16.07 3.05 2.05 0.04*Abduction 18.71 2.51 18.79 3.79 -0.09 0.92Adduction 18.86 2.2 18.43 4.07 0.51 0.61

*Significant at the level of 0.05

Saini, Prerna. / Indian Jouanl of Physiotherapy and Occupational Therapy.July - Sept. 2010, VOL 4 NO 3

Fig. 3: Comparison of Range Of Motion in Male and Female Subjects.Fig. 2: Interrater And Intrarater Reliability of Passive TrapeziometacarpalMovements of Total Subjects

Total Subjects(N = 76) Male Subjects(N = 50) Female Subjects(N = 26)Variables Mean ± S.D. Range Mean ± S.D. Range Mean ± S.D. Range

(in degrees) (in degrees) (in degrees) (in degrees) (in degrees) (in degrees)Flexion

First Rater 22.10 ± 5.09 14-33 26.34 ± 3.08 18-30 19.9 ±4.51 14-33Second Rater 22.53 ± 5.31 13-37 26.34 ± 3.15 15-32 20.54 ± 5.13 13-37Extension

First Rater 16.58 ± 3.09 10-25 17.57 ± 2.98 14-25 16.07 ± 3.05 10-24Second Rater 17.21 ± 3.36 11-24 18.26 ± 3.44 14-22 16.66 ± 3.22 11-24Abduction

First Rater 18.76 ± 3.39 12-28 18.71 ± 2.51 16-28 18.79 ± 3.79 12-26Second Rater 18.84 ± 3.40 12-29 18.48 ± 2.89 15-27 19.04 ± 3.65 12-29Adduction

First Rater 18.57 ± 3.53 12-30 18.86 ± 2.21 16-26 18.43 ± 4.07 12-30Second Rater 18.73 ± 3.70 10-25 18.76 ± 3.03 15-25 18.72 ± 4.04 10-23

Table 2: Mean, standard deviation and range of motion

51

In comparison to the other instruments, goniometer is readilyaccessible, most economical, and most portable device forevaluation of range of motion. It can be in any clinical settingto assess joint range of motion, whether changes in rangeof motion occurs as the result of disease progression oroutcomes after surgical procedures like joint replacement.

The level of reliability is also dependent upon the instrument,the body region being measured and the time intervalbetween repeat measurements. We found some negativeaspects with this instrument which are worthy of note. Thestarting position must be assessed visually. Additionally,the conventional goniometer must be held with two hands,leaving neither hand free for stabilization of the body or theproximal part of the joint. The true vertical and horizontalpositions can also be only visually estimated, leading toincorrect measurements with limited repeatability. So toavoid this, two measurements were taken as prescribed byRothstein. According to Cooney, palpation of trapezium isdifficult as it is a deep bone. In a study done by Li-ChiehKuo, the feasibility of surface markers to represent thumbkinematics throughout the motion cycle was found to behigh.1

The results also revealed that males exhibit a largevariability in range of motion as compared to females. Asignificant difference has been found in passive flexion andextension motion. The result was not found to be consistentwith the findings of first metacarpophalangeal joint.52,54,55

But these results must be confirmed by evaluating in anormal population survey considering with differentoccupations, increasing sample size, considering culturalvariations. Also, gender difference for the range of motionat the trapeziometacarpal joint needs to be evaluated sothat a normal anthropometric data can be obtained for thesame that can be used as reference in ergonomics,designing instrument, tools and equipments.Relevance to clinical practice: Owing to the clinicalrelevance, the purpose of the study is to develop anobjective, accurate and discriminative method to aid clinicaldiagnosis of thumb movement dysfunction associated withdisease or injury. We may consider goniometer as a reliablemeasure to assess joint range of motion and to determinethe extent of impairment. We hope that the results of pre-post operative of the opponoplasty, arthroplasty or jointreplacement, tendon repairs or grafts and thumb lengtheningmay be compared easily with this instrument.Limitations of the study: One limitation of the present studyis that the subjects taken were physical therapy studentsand of limited age groups to conform to the need ofconvenient sampling and to maintain uniformity of task,occupation and homogenous data for our study. This studymay not be a true representative of the population; howeverwe have no reason to believe that our subjects were grosslyatypical of normal population. So in future research, aneffort must be made to sample a broad range of subjectswith different occupations in an attempt to allowgeneralization of results beyond our study.Future Research: This study assessed only PROM for wristflexion and extension. Active-range-of-motion goniometricreliability should be assessed in future studies. Futurestudies should assess trapeziometacarpal range of motionmeasurement reliability and validity in a population surveyas well as in clinical settings.

Conclusions

The goniometric measurement of passiv trapeziometacarpalmotions is highly reproducible. The intrarater reliability ishigher than the interrater reliability of passivetrapeziometacarpal joint motions. Further, a significantdifference has been found in passive flexion and extensionrange of motion of passive trapeziometacarpal motionsbetween males and females.

Acknowledgement

My due thanks to the principal Dr. Chitra Kataria and all thefaculty members of Indian Spinal Injuries Centre, New Delhi.

References

1. Li-Chieh Kuo, Fong-Chin Su, Haw-Yen Chiu (2002).Feasibility of using a video-based motion analysissystem for measuring thumb kinematics. Journal ofBiomechanics. 35; 1499-1506.

2. Kuo L.C., Su F.C., Chiu H.Y., Cooney W.P.III., AnK.N.,(2003). Quantitative Analysis of ThumbKinematics” unpublished Ph.D. Dissertation, Instituteof Biomedical Engineering, National Cheng KungUniversity, Tainan, TAIWAN,

3. Rothstein JM, Miller PJ, Roettger RF(1987).Goniometricreliability. in a clinical setting; shoulder measurements.Phys. Ther. 67 (5): 668-673

4. Stuart Love, RH Gringmuth (1998): Interexaminer andintraexaminer reliability of cervical passive range ofmotion using the CROM and Cybex 320 EDI. J CanChiropr Assoc. 42(4);222-228

5. .Jane Bear- Lehman, Beatriz Colon Abreu (1989).Evaluating the hand: issues in reliability and validity.Physical Therapy. 69(12); 1025-1033

6. M.Jenkins, H.BamBerger(1998). Thumb joint flexion.Journal of hand surgery: 23B:6; 796-797

7. M. A. Watkins, DL Riddle (1991). Reliability ofgoniometric measurements and visual estimates ofknee range of motion in a clinical setting. PhysicalTherapy. 71,2; 90-96

8. Norkin CC, White DJ(1955). Basic concepts and validityand reliability.In: Measurement of joint motion; a guideto goniometry;2nd edition; Philadelphia: FA Davis ;1-46

9. http://at.uwa.edu/gon/thumb.htm.10. Margaret M. Horger (1990). The reliability of goniometric

measurements of active and passive wrist motions. TheAmerican journal of occupational therapy. 44(4); 342 348

11. Paul C LaSteyo, Donna L Wheeler(1994). Reliability ofPassive Wrist Flexion and Extension GoniometricMeasurements: A Multicenter Study :Physical Therapy: 74, 2:162 – 176

12. M. A. Watkins, DL Riddle (1991). Reliability ofgoniometric measurements and visual estimates ofknee range of motion in a clinical setting. PhysicalTherapy. 71,2; 90-96

13. Brushoj, Langberg (2007). Reliability and normativevalues of the foot line test: A technique to assess footposition. Journal of Orthopaedic and Sports PhysicalTherapy .37,11; 703-707.

14. James W Youdas, Tom R Garrett, Vera J Suman (1992).Nomal Range of Motion of the Cervical Spine: An InitialGoniometric Study. Physical Therapy. 72; 770-780


52

15. Soren Solgaard, Agnete Carlsen (1986).Reproducibility of goniometry of the wrist: Scand JRehab Med. 18; 5-7

16. Leen T’Jonck, S. Schacke, R. Lysens, E. Witvrouw.Intertester and intratester reliability of the standardgoniometer and the cybex edi 320 for active andpassive shoulder range of motion in normals andpatients. Proceedings of the First Conference of theISG :41-47

17. William P. Cooney, Michael J. Lucca (1981). Thekinesiology of the thumb trapeziometacarpal joint.Journal of Bone and Joint Surgery. 63-A,9; 1371-1381

18. http://www.univ-valenciennes.fr/congres/3D2006/


Abstracts/110-Goubier.pdf19. Bent Ebskov, Charles Long (1967) . A method of

electromyographic kinesiology of the thumb. Arch.Phys. Med. Rehab; 78-84

20. Li-Chieh Kuo, William P. Cooney (2006). A quantativemethod to measure maximal workspace of thetrapeziometacarpal joint. .Journal of OrthopaedicResearch. 22,3 ; 600-606 [abstract]

21. Lisa Harvey, Inge de Jong(2006). A Torque-controlledDevice to Measure Passive Abduction of the ThumbCarpometacarpal Joint. Journal of Hand Therapy.19.4; 403-409

53

Effect of lumbar stabilization exercises as home program intreatment of young women with non specific low back pain – acomparative studyPrity AgarwalDepartment of Physiotherapy, Manipal College of Allied Health Sciences, Manipal, Karnataka, India

Abstract

Objective

To compare the effect of lumbar stabilization exercises alongwith back care and ergonomic advice over back care andergonomic advice alone, when given as a home programin young women with non specific low back pain.

Design

A nonrandomized clinical trial which included an exercisegroup and a control group.

Settings

Outpatient department of physiotherapy, Kasturba MedicalCollege Hospital, Manipal.

Participants

Purposive sampling was done to include 40 subjects in theexperimental group with mean age of 22.95±2.846 years.An age and gender matched control group of 28 subjectswith mean age of 21.71±2.291 years was selected.The participants were included if they were within the agegroup of 20-30 years an were having complaints of lowback pain with /without referred pain to one or both lowerlimbs but no structural pathology.

Interventions

Participants in the experimental group were given homeexercise programwhich included lumbar stabilizationexercises, flexibility training and lower extremity proximalmuscle strengthening and advice on back care andergonomics.Participants in the control group were given advice on backcare and ergonomics.

Outcome measures

Visual analog scale, Rolland Morris Questionnaire,Oswestry Disability Index.

Results

The statistical significance was set at 0.05 with 95% CI. Inthe experimental group, there was a statistically significantdecrease in pain and disability. The results for the controlgroup suggested a statistically significant decrease sores

of VAS and RMQ but not in the ODI scores. There was astatistically significant difference between the two groups.

Conclusion

The lumbar stabilization exercises along with back careand ergonomic advice is more effective than back care andergonomic advice alone when given as a home program inyoung women with NSLBP.Low back pain is a pandemic musculoskeletal disorder.Nachemson has stated that 80% of all adults havesignificant low back pain in their life time (Nachemson 1971).Non specific low back pain (NSLBP) representsapproximately 80% of primary care low back pain (LBP)presentations.1

NSLBP disorders exist where mal-adaptive movement andmotor control impairments appear to result in ongoingabnormal tissue loading and mechanically provoked pain. 2

Empirical research has shown that physiologic changes (e.gmuscle dysfunction) occur in lumbar spine in tandem withinitial episodes of pain that remain after pain has subsided.3,4

Conventional physical therapy options available are backcare advice and ergonomics, flexibility training, spinal flexion-extension exercises, spinal mobilization and manipulation,electrotherapy modalities, traction and lumbar supports.A recent focus in management of patients with LBP is onthe specific training of muscles like internal oblique andtransverse abdominus whose primary role is considered tobe the provision of dynamic stability and segmental controlof the spine. The emphasis on these muscles is based onevidence of motor control deficits in these muscles functionin individuals with low back pain (LBP).5,6

Hence, addressing muscular dysfunction by spinal stabilizationexercises along with back care and ergonomic advice willhelp in decreasing the pain and improving the function.

Operational definition

Non specific low back pain (nslbp) - Non-specific low backpain is defined as pain between the costal margins and theinferior gluteal folds, usually accompanied by painfullimitation of movement, often influenced by physicalactivities and posture, and which may be associated withreferred pain in the leg.7

Review of literature

The effects of specific exercise in the treatment of chroniclow back pain with radiologic diagnosis of Spondylolysisand Spondylolisthesis were evaluated by O’Sullivan andTowmy. After intervention, the specific exercise group

Prity Agarwal / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

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showed a statistically significant reduction in the painintensity and functional disability levels, which wasmaintained at a 30-month follow up.8

A study comparing the effects of specific stabilization exerciseswith those of manual treatment in patients with sub acute orchronic LBP was conducted by E Rasmussen et al. It wasconcluded that stabilizing training seemed to be more effectivethan manual therapy in terms of improvement of individualsand the reduced need for recurrent treatment periods.9

An RCT of combined manipulation, stabilizing exercisesand physician consultation compared to physicianconsultation alone for chronic LBP was conducted byNiemisto et al. It was concluded that manual therapy withstabilizing exercises was more effective in reducing painand disability than physician consultation alone .This studyshowed that short, specific treatment programs with properpatient information may alter the course of chronic LBP.10

A study investigating whether four weeks of training ofrepeated voluntary TrA contractions could induce long-termchanges in control of the trunk muscles was conducted byH. Tsao and P. Hodges. The results suggest that four weeksspecific motor control training is associated with consistentchanges in motor control of the trained muscle duringfunctional tasks. 11

An RCT investigating the efficiency of musculoskeletalphysiotherapy on chronic low back disorder was conductedby Lucy Jane Goldby. In this study, the patients wereenrolled in a 10 week program of specific spinal stabilizationexercises. The results indicated statistically significantimprovements in favor of the spinal stabilization group at 6month stage in pain and dysfunction and at the one yearstage in medication, dysfunction and disability.12

A systematic review of RCT’s was conducted by Berid et al toevaluate the effectiveness of segmental stabilization exercisesfor acute, sub acute and chronic LBP with regard to pain,recurrence of pain, disability and return to work 7 trials wereincluded in the review. For acute LBP, SSE were equallyeffective in reducing short term disability and pain and moreeffective in reducing long term recurrence of LBP thantreatment by GP. For chronic LBP, SSE were in the short andlong term more effective than GP treatment and may be aseffective as other PT treatment in reducing disability and pain.There was limited evidence that SSE additional to other PTtreatment are equally effective for pain and more effectiveconcerning disability than other PT treatment alone. Therewas no evidence concerning subacute LBP. 13

1. Pain severity, measured by the Visual Analog Scale-VAS

Test –retest reliability is 0.71-0.99. Smallest detectabledifference (minimal detectable change) is ±28 mm. 14

2. Functional measuresa. The Oswestry disability questionnaire: This

questionnaire is used widely to monitor treatment affectwith regard to changes in the functional mobility ofpatients with chronic low back pain, and is sufficientlysensitive to monitor these changes. 15

b. Rolland Morris disability Questionnaire:This is a 24item self report condition specific functional statusmeasure intended for clients with LBP. The minimumlevel of detectable change at 90 percent confidenceinterval is 4-5 points on the scale. 16

Methodology

Study design : A clinical trial was designed which includedan exercise group and a control group.Settings: Outpatient department of physiotherapy, KasturbaHospital, Manipal.Subjects: Convenience sampling was done to include 40subjects in the experimental group with mean age of 22.95± 2.846 years. An age and gender matched control groupof 28 subjects with mean age of 21.71 ± 2.291 years wasincluded.Inclusion criteria: Age group : 20 – 30 years, subjectscomplaining of low back pain with / without reference ofpain to one or both lower limbs.Exclusion criteria: Subjects diagnosed to havespondylolysis, spondylolisthesis and spinal stenosis,radiculopathy, pain of visceral origin, any patient onmedications during the course of study, subjects with historyof direct trauma involving the back, spinal surgery, fixed orfunctional spinal deformity, pregnant women, subjects withsuspected infections and malignancy, inflammatory arthriticand metabolic conditions.Tester: The selected subjects were evaluated and treatedby a qualified physiotherapist pursuing master’s degree inphysiotherapy (musculoskeletal conditions).

Procedure

Subjects with complaints of low back pain were screenedfor the non specific nature of LBP. A written informed consentwas obtained from the patient. The physical examination ofthe low back and lower extremity was done to identifyspecific muscular imbalance. For both groups, all threevariables (VAS,ODI & RMQ) were measured on day oneprior to treatment and after 6 weeks of intervention.

Treatment in the experimental group

Subjects in the experimental group were given homeexercise program which included lumbar stabilizationexercises, flexibility training and lower extremity proximalmuscle strengthening. The subjects were instructed to dothe exercises on all days of the week until the nextreinstruction session.The exercise program consisted of three exercises to bedone in 3 sets with 10 repetitions in each at comfortablerate. Subjects were taught stretching exercises for lowerextremity muscles as per evaluation during the first week.They were instructed to maintain the stretch position for 15-20 seconds and repeat it three times. Strengtheningexercises were started once the subject learnt the adequatecontrol of transverse abdominus. They were instructed todo the exercises as per instructions given by Kendall et aland in a set of three with 10 repetitions in each set.Subjects were taught the specific contraction of the deepabdominals, without substitution from large torque producingmuscles such as rectus abdominus and external oblique,usually the abdominal drawing in maneuver. Also, they weretrained for the specific contraction of deep abdominals withco-activation of lumbar multifidus as described byRichardson and Jull. Tactile and visual cues were used astraining strategies.If the subjects were not able to achieve the goal in oneweek, they were instructed to continue the same exercise


55

for the following week. The duration of study remained thesame for all subjects i.e. 6 weeks with subjects reachingdifferent stages of progression at the end of program.The subjects were asked to visit the therapist once a weekfor the next five weeks and gradual progression ofstabilization exercises was stated above. Home programmeincluded advice on back care and ergonomics.

Treatment in the control group

For the control group, after evaluation they were givenadvice on back care and ergonomics. They were asked tofollow these advices during their leisure as well as workinghours. They were asked to return for follow up at the end ofsix weeks and then at the end of third month.

Data analysis

Non parametric tests were used for the analysis

• Wilcoxon sign rank test was used for the comparison ofmeasurement variables (VAS, ODI, RMQ) within theexperimental and control groups.

• Mann-Whitney U test was used to compare thetreatment variables(VAS,ODI,RMQ)between thegroups.

The statistical analysis was done using SPSS 11.0 windowsfor software. The statistical significance was set at 0.05 with95% confidence interval and a p value less than or equal to0.05 was considered significant.

Results

As shown in Table 1, the number of subjects in the twogroups was not similar with more number of subjects in theexperimental group as compared to that in the control group.There was no significant difference in the mean age betweenthe groups. A significant difference was noted in the medianduration of symptoms (in months) between the groups.The results of Wilcoxon signed rank test for the experimentalgroup suggest a statistically significant decrease in painand disability (VAS, ODI and RMQ) at the end of 6 weeks.The results of Wilcoxon signed rank test for the control groupsuggest a statistically significant decrease in pain anddisability (VAS and RMQ) whereas no statistically significantdifference in ODI scores at the end of 6 weeks.Mann- Whitney’s analysis between the groups for VAS,ODI and RMQ at the end of 6 weeks suggest a statisticallysignificant decrease in pain and disability.


Table 2: Wilcoxon sign rank test at 6 weeks for the experimental groupVariables Median Percentile (25 to 75) Z statistic p valueVAS Pre 5.00 4.00 to 6.00 -5.279 0.000

Post 1 0.00 0.00 to 2.00ODI Pre 24.00 18.00 to 30.00 -5.456 0.000

Post 1 16.00 8.00 to 20.00RMQ Pre 6.50 5.00 to 9.00 -5.345 0.000

Post 1 3.00 2.00 to 4.00

Pre: Score of the variables at the baseline on day 1.Post 1: Score of the variables at the end of 6 weeks.

Table 3: Wilcoxon sign rank test at 6 weeks for the control groupVariables Median Percentile (25 to 75) Z statistic p valueVAS Pre 5.00 4.00 to 6.00 -5.279 0.000

Post 1 3.50 0.00 to 2.00ODI Pre 24.00 18.00 to 30.00 -5.456 0.000

Post 1 16.00 8.00 to 20.00RMQ Pre 6.50 5.00 to 9.00 -5.345 0.000

Post 1 3.00 2.00 to 4.00

Pre: Score of the variables at the baseline on day 1.Post 1: Score of the variables at the end of 6 weeks.Table 4: Mann – Whitney test at the end of 6 weeks for the experimental andcontrol groups.

Mean Difference Median Percentile Z statistic p valueof the variables (25 to 75)

VAS -3.000 -4.00 to -1.00 -5.327 0.000ODI -12.000 -23.00 to -10.00 -5.866 0.000RMQ -2.000 -4.75 to -1.00 -4.283 0.000

Table 1: Descriptive data.Group No of MeanAge SD Duration of symptoms SD

Subjects (years) (mean in months)Experimental 40 22.95 2.846 27.39 23.22Control 28 21.71 2.291 19.57 14.056

Discussion

Non specific low back pain is one of the most frequentailments in the world having impacts of variable degree onthe functional status of the individual with LBP.As seen in the results of this study, the two groups did notdiffer with respect to mean age but there was a significantdifference with respect to duration of symptoms. The meanduration of symptoms in experimental group was 27.39 ±23.22 (range 3 - 84) months while in the control group itwas 19.57 ± 14.056 (2 - 48) months. The large range seenin both groups was due to six outlier values of 1, 6 and 84months in experimental group and one outlier value of 2months in the control group. In this study, duration ofsymptoms was not analyzed for correlation between theduration of symptom and functional disability. Michael VonKorff et al studied the outcomes of back pain in primary carefor one year and found that pain chronicity and pain relateddisability often did not coincide. 17

The experimental and control group showed a statisticallysignificant improvement VAS and RMQ at the end of 6weeks. ODI scores had improved significantly in theexperimental group whereas no significant improvementwas noted in the control group at the end of six weeks. Ascited by Fransisco M Kovacs et al intensity of pain anddegree of disability do not correlate well and are associatedwith different risk factors in NSLBP. 18 Biomechanical factorsinfluence pain, but psychosocial factors have more of aninfluence on the development and duration of disability.In the present study, improvement of ODI scores seen in theexperimental group at the end of six weeks can be attributedto better lumbo-pelvic stability and improved posture.However this improvement was not evident in the controlgroup which could be due to lack of active intervention andreinforcement in this group. The control group in the presentstudy had improvements in VAS and RMQ scores at theend of six weeks which can be attributed to the effect ofadvice on back care and ergonomics alone as no otherintervention was given.Although both the groups improved, the difference betweenthe two groups for all the three outcome variables was foundto be statistically significant. The experimental group hadshown greater improvement as compared to the controlgroup. This significant difference in global improvementsuggests that the difference can be attributed to the additionof stabilization exercises to back care and ergonomicadvice. This is in consensus with many reviews and studiesinvestigating the effects of stabilization training program in

56 Prity Agarwal / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

patients with spondylolysis and spondylolisthesis, acute,subacute and chronic LBP. 19,20,21,22

In the present study, the improvement seen following lumbarstabilization program can be attributed to the relearning ofmotor control of these muscles. This is in accordance tostudy conducted by Gregory M Karst who used EMG asoutcome measure to study the effects of specific exerciseinstructions on abdominal muscle activity during trunk curlexercises. 23 He concluded that subjects can learn to activatetheir deeper stabilizing muscles rather than more superficialmuscles during exercise based on verbal and tactile cuesfrom a physical therapist and that they can remember thisfor at least a week between physical therapy sessions.The results of this study support the literature that specificexercise training of the stability muscles of the trunk iseffective in reducing pain and functional disability in patientswith NSLBP. This treatment approach was more effectivethan giving back care advice alone as carried out in thecontrol group.Limitations: The subjects in this study fall under the broadclassification of NSLBP. Therefore, the results of this studycannot be extrapolated with confidence to chronic LBPconditions outside of the selection criteria for this study,and especially individuals with acute or more disabling LBP.Conclusion: The results of this study provide evidence thatthe lumbar stabilization exercises along with back care andergonomic advice is more effective than back care andergonomic advice alone when given as a home program inyoung women with NSLBP.Recommendation for future research: Future researchshould be conducted with randomized controlled trial tocompare the effect of supervised lumbar stabilizationexercises over home based program. Longitudinal studycan be conducted with a larger sample size to see the carryover effects of these exercises at six months and beyond.

References

1. Diyo R, Rainvelle J, Kent D. What can the history andphysical examination tell us about low back pain?JAMA 1992; 268:760-5

2. Burnett A, Cornelius A, Dankaerts W, O’Sullivan P.Spinal kinematics and trunk muscle activity in cyclists:a comparison between healthy controls and non-specific chronic low back pain subjects. ManualTherapy 2004; 9: 211–9

3. Hides JA, Richardson CA, Jull GA. Multifidus musclerecovery is not automatic after resolution of acute, firstepisode low back pain.Spine 1996; 21: 2763-9

4. Hodges P, Richardson CA. Inefficient muscularstabilization of the lumbar spine associated with lowback pain. A motor control evaluation of transverseabdominus. Spine 1996;21: 2640-50

5. O’Sullivan P, Twomey L, Allison G, Sinclair J, Miller K.Altered patterns of abdominal muscle activation inpatients with chronic low back pain. Aust J Physiother.1997;43:91-98

6. O’Sullivan PB, Twomey L, Allison GT. Altered abdominalmuscle recruitment in patients with chronic back painfollowing a specific exercise intervention. J OrthopSports Phys Ther. 1998; 27:114-124

7. Francisco M Kovacs, Carmen Fernández, AntonioCordero, Alfonso Muriel, Luis González-Luján, María

Teresa Gil del Real, and the Spanish Back PainResearch Network Non-specific low back pain inprimary care in the Spanish National Health Service: aprospective study on clinical outcomes anddeterminants of management. BMC Health ServicesResearch 2006, 6:57 doi:10.1186/1472-6963-6-57

8. O’Sullivan P B , Twomey L ,Allison G. Evaluation ofspecific stabilization exercises in the treatment ofchronic low back pain with radiologic diagnosis ofspondylolysis or spondylolisthesis. Spine1997;22:2959-2967

9. E Rasmussen- Barr, L. Nilsson-Wikmar, I.Arvidsson.Stabilizing training compared with manual treatmentin sub acute and chronic LBP .Manual Therapy 2003;8(4):233-241

10. Leena Niemisto, Tiina Lahtinen-Suopanki, pekkaRissanen, Karl-August Lindgren, Seppo Sarna andHeikki Hurri. A RCT of combined manipulation,stabilizing exercises and physician consultationcompared to physician consultation alone for chronicLBP. Spine 2003;28:2185-2191

11. H. Tsao and P. Hodges . Specific motor control trainingis associated with long term improvements in posturalcontrol in people with recurrent low back pain. Journalof Bone and Joint Surgery - British Volume, April2006.Orthopaedic Proceedings Vol 88-B, Issue SUPPIII, 449

12. Lucy Jane Goldby, Ann P Moore, Jo Doust and MarionE Trew . A randomized controlled trial investigating theefficiency of musculoskeletal physiotherapy on chroniclow back disorder. Spine 2006; 31(10):1083-1093

13. Berid Rackwitz, Rob de Bie, Thomas Ewert and GeroldStucki. Segmental stabilizing exercises and LBP. Whatis the evidence? A systematic review of randomizedcontrolled trials.Clinical Rehab 2006(20):553-567

14. Elspeth Finch et al. Physical Rehabilitation OutcomeMeasures: A Guide To Enhanced Clinical DecisionMaking. Second edition )

15. Jeremy C.T Fairbank and Paul B.Pynsent. TheOswestry Disability Index. Spine 2000;25(22):2940-53

16. Paul Beattie and Christopher Maher, the role offunctional status questionnaire for low back pain.Australian Journal Of Physiotherapy 1997 (43): 23-98

17. Michael Von Korff, Richard A. Deyo, Daniel Cherkin,William Barlow. Back pain in primary care: outcomesat one year. Spine 1993;18(7): 855-862

18. Francisco M.Kovacs, Victor Abraira, Javier Zamora,Maria Teresa Gil del Real, Joan Llobera, CarmenFernandez and the Kovacs- Atencion Primaria group.Correlation between pain, disability and quality of lifein patients with common low back pain. Spine2004;29:206-210

19. Paul W. Hodges. Core stability exercise in chronic lowback pain. Orthop Clin N Am 2003; 34:245-254

20. Venu Akuthota, Scott F. Nadler. Core Strengthening.Arch.Phys.Med.Rehabil 2004;85(3 Suppl 1): S86-92

21. Barr KP, Griggs M, Cadby T. Lumbar stabilization. Coreconcepts and literature, part 1. Am.J. Phys.Med.Rehabil2005; 84: 473-480

22. Cheryl L, Hubley-Kozey. Training the abdominalmusculature. Physiother Can 2005;57:5-17

23. Gregory M. Karst,Gilbert M. Willett.Effects of SpecificExercise Instructions on Abdominal Muscle ActivityDuring Trunk Curl Exercises. JOSPT 2004; 34:4-12

57

Clinical significance of electrodiagnosis In lumbar disc herniationRamanpreet Kaur1, Narkeesh Arumugam2

1Lecturer, Dept. of Physiotherapy, Lyallpur Khalsa College, Jalandhar, India, 2Reader, Dept. of Physiotherapy, PunjabiUniversity, Patiala, India

Abstract

Purpose of the Study:To find out the influence of discherniation at L5-S1 level on, H-reflex latency and H/M ratio.Apparatus Used:Electrodiagnosis machine, Plinth,Measuring tape, ECGgel.

Methodology

It is experimental study of same subject design. The studywas conducted with 18 patients with disc herniationpresented with unilateral radiating pain having positive SLRbetween age group of 20-50 yrs.

Procedure

H-reflex recording was performed on subjects afterpositioning of the patient and electrodes, recording wasdone after a submaximal stimulus was given for H-reflex toposterior tibial nerve of affected and unaffected legrespectively.

Result

Paired t-test was used for data analysis, which showedsignificant changes in H -latency (p<.05) and H/Mratio(p<.05) on affected side.

Conclusion

This study concluded that there are significant changes inH latency and H/M ratio on affected side. Hence H–reflexlatency and H/M ratio can be used as diagnostic tool in L5-S1 level disc herniation.

Key Words

H-reflex, Electro diagnosis, L5-S1 Disc Herniation.

Introduction

“Back pain, an ancient curse, is now appearing as ainternational epidemic”. Low back pain, particularly inpatients with radicular symptoms is often associated withcompromise of the lumbosacral nerve roots throughmechanical or biochemical means.80% of the worldpopulation suffers from low back pain, out of which only40% of patients with low back pain have sciatica. 95% ofsciatica is due to herniated intervertebral disc. Majority ofthe disc herniations occur at three disc levels. 47% of theherniated disc occurs at L4-L5 level, 43% at L5 –S1 leveland 10% at L3-L4 level , less than 3%at L1-L2 level. Mostcommonly it involves irritation of the nerve roots at or

between L5-S1 level. This is often resulting of herniated orruptured disc material compressing or irritating the nerveroot.Intervertebral disc prolapse is the condition wherein theintervertebral disc prolapses posteriorly or posterolaterallyinto the vertebral canal. It is also known as herniated nucleuspulposus as there is rupture of the annulus fibrosis andherniation of nucleus pulposus. Lumbar disc herniation is aknown cause of low back pain. There are four types of discherniation as Protrusion, Prolapse, Extrusion, andSequestration. It appears that a herniated lumbar disc canalso cause axial low back pain through mechanical irritationof dorsal root ganglia or dorsal ramus. It has been postulatedthat compression by the herniated disc on the portion of thedorsal root ganglia, where sensory neurons from dorsalroot are located, or direct compression to the dorsal ramus,may yield to low back pain.Lumbosacral radiculopathy result from disc herniation thathas progressed to enough to cause neurologic symptomsin the areas supplied by affected nerve roots. Herniatedintervertebral disc can cause impingement, thus causingpain. The presence of disc material in the epidural space isthought to initially result in direct toxic injury to the nerveroot by biomechanical means and then exacerbation of theintraneural and extraneural swelling which results in thevenous congestion and conduction block. Nerve dysfunctionmay be present in both motor and sensory modalities thusproducing both motor weakness and sensory disturbances.Lumbosacral nerve root compromise is an importantconsideration in the differential diagnosis of the low backand leg pain. The pitfalls of inaccurate diagnosis are mostapparent in those patients with pain in the leg associatedwith a disorder of the lumbar spine. A correct diagnosis isessential to avoid unnecessary useless and harmfultreatment.Nerve root involvement characterized by radiating pain andsegmental sensorimotor abnormalities and may beconfirmed by radiologic and electrodiagnostic studies ,where the imaging and the clinical findings are not incomplete agreement eletrodiagnostic tests can provide thereliable information. Nerve conduction studies help toresolve discrepancies between clinical and imaging studies.Imaging studies visualize the structural abnormalities fromwhich the neurological sequlae may be inferred, whereasthe eletrodiagnostic methods such as nerve conductionstudies and electromyography assess the physiologicalintegrity of the nerve roots and have the added benefits ofsensitivity to the nonstructural root disease. Non – invasivenature and wide availability of nerve conductionmeasurements may facilitate their clinical use in theassessment of patient with possible nerve root compression.Electrodiagnostic studies help to delineate the distribution

Ramanpreet Kaur / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

58

of the affected muscle, localize the level and elucidate theextent and chronicity.It was therefore decided to evaluate the role ofelectrodiagnosis in diagnosis of L5-S1 disc prolapseutilizing H – reflex, this study has been undertaken.

Methodology

Study Design: This is an Experimental study. The studyinvolves the same subject design, in which there wascomparison done between values of H- Reflex of affectedand unaffected side in lumbar disc herniation involving L5-S1 root.

Population

Fifty subjects suffering from low back pain with sciaticaconstituted the population, out of which, eighteen subjectstook part in the study, selected on the basis of inclusion andexclusion criteria.

Inclusion Criteria

• Subjects lying between age group of 20- 50 yrs.• Patients who have unilateral radiation of pain affecting

either side.• Patients with sensory deficit such as tingling or pins

and needle sensation in S1 dermatome.• Patients with positive Straight leg raise test, Lasegue’s

test.• Patients with diminished/ absent ankle jerk.• Both male and female subjects.• Muscle weakness not less than grade 4.

Exclusion Criteria

• Patients with multiple level disc prolapse.• Individuals having any neuropathies.• Patients with other causes of low back pain such as

Lumbar spondylosis, Lumbar spondylolisthesis, andLumbar canal stenosis.

• Patients with bilateral radiation of pain.• Patients who undervent any spinal surgery.• Patients with muscle wasting / atrophy.

Materials used

Electrodiagnosis machine with software computer(Neuroperfect EMG/NCV/EP system certified) Cotton withalcohol swab, ph neutral ECG gel, Plinth, measuring tape

Procedure of study

Before starting the procedure the room temperature was bemaintained at 210C – 230 C. All the subjects were instructedand demonstrated about each technique.Procedure of recording H- reflexStep 1Position of subject: The subject was placed in prone lyingwith leg fully supported with feet hanging at the edge of thecouch.Step 2

Position of electrodes

Recording electrode: Active surface electrodes wereplaced at the distal edge of the soleus muscle.Ground electrode: It was placed between stimulating andrecording electrode.Stimulating electrode: At the knee in the popliteal fossaalong the flexor crease of the knee slightly lateral to themid-line of popliteal fossa.Step 3

Recording method

Apply a sub maximal stimulus at tibial nerve. Record thelatency, amplitude.

Data analysis & result

Data was analyzed by using the Software SPSS Version15.0 .Using statistical formula for a given number of subjects,Mean and S.D of H- Reflex H/M ratio of the affected andunaffected leg of the subjects has been taken. Paired t –testwas used.

Discussion

This study was designed to study the changes of H- latencyand H/M ratio in the diagnosis of L5-S1 level disc herniation.When affected side was compared with unaffected side,affected side showed statistically significant results, whichare in general agreement with earlier studies, by, SabbahiMA and Khalil M, Schuchmann JA.Sabbahi MA and Khalil M have recorded H-reflex in upperand lower limbs at C7, L4 and S1 roots. They stated that H-reflexes were 100% specific for lumbosacral segments andsoleus H- reflexes were useful and valid methods for testingS1 radiculopathy, which is in accordance with this study.Schuchmann JA evaluated H- reflex latency obtained fromtriceps surae following tibial nerve stimulation in L5-S1radiculopathy. They concluded that H- latency is a valuabletool in helping to differentiating S1 radiculopathy from L5radiculopathyThe data of this study support the concept that there aresignificant changes in, H- reflex latency, H/M ratio inunilateral S1 radiculopathy supporting the alternatehypothesis and rejecting the null hypothesis. The use ofnerve conduction studies (NCS) for this application hasseveral advantages. First, H- reflex component of NCSdirectly examines the electrophysiological function of S1root. Secondly the non – invasive and wide availability ofnerve conduction measurement may facilitate their clinicaluse in the assessment of the with possible nerve root


Table 1: Mean and standard deviation for H-reflex latencyVariables Affected side Unaffected side Difference

Mean 30.92 30.30 0.62SD 2.46 2.16 1.07

Table 2: Mean and standard deviation for H/M ratioVariables Affected side Unaffected side Difference

Mean 0.25 0.54 -0.28SD 0.27 0.61 0.53

Table 3: Comparison between affected and unaffected sideVariables t - value p - valueH- reflex 2.44 <0.05H/M ratio 2.23 <0.05

59

compression .The findings of this studies were interpretedin light of previous studies and we can say that this studywill help in the diagnosis of nerve root compression.

Conclusion

From the results of present study it was suggested that thereare significant changes in, H- latency and H/M ratio. So H-Latency and H/M ratio can be used as diagnostic tool in L5-S1 level disc herniation.

References

1. John Ebnezar “Essentials of Orthopaedics forPhysiotherapists” chap 18, p – 293, Jaypee Bros.

2. U.K Misra & J Kalita “clinical neurophysiology“. Elsevier.88 – 92, 74-76.

3. Sabbahi MA, Khalil M. Segmental H-reflex studies inupper and lower limbs of patients with radiculopathy.Arch phys med rehab. 71 (3) : 223-7. (1990)

4. Bobinac –Georgijevski A Sokolovic – Matejcic B,Graberski M. The H or F wave latencies in medialgastrocnemius in the electrodiagnostic study of sciaticapatients with suspected S1 radiculopathy. Neuro Croat40(2): 85-91. (1991).

5. Kimura J.Electrodiagnosis in diseases of nerve &muscle, 3rd edition. Oxford university press. (2001).

6. M.J. Aminoff “ Electrodiagnosis in clinical neurology.”


Graph 1: Average values of affected & unaffected H-reflex latency. Graph 2: Average values of affected & unaffected H/M ratio .

4th ed. Churchill Livingstone. 253-264.7. Braddom R.I. JOHNSON EW: Standardization of H-

reflex diagnostic use in S1 radiculopathy. Arch PhysMed Rehab 55:161. (1974)

8. Bernald T. Lumbar discography followed by computedtomography; refining the diagnosis of LBP, Spine;15(7):690-707. (1990)

9. M.J. Aminoff - “Electromyography in clinical practice.3rd edition. Churchill Livingstone. 554-555. –(1998)

10. M.Natarajan”Textbook of orthopaedics & traumatology“ 5 th ed. 133-134. ( 2002)

11. Braune HJ, Wunderlich MT “Diagnostic Value ofDifferent Neurophysiological Methods In TheAssessment Of Lumbar Nerve Root Lesions” MuscleNerve 18 (10) 1205 -7. (1995)

12. Zhu Starr A at el “soleus H- reflex to S1 nerve rootstimulation”. Electroencephalogr clin neurophysiol .109(1) : 10 - 4 . (1998)

13. Han TR at el “A study on new diagnostic criteria of H-reflex.” electromyogr clin neurophysiol june-july 37(4):241-50.

14 B.D. Chaurasia’s “ Human anatomy “volume two, 3 rdedition, CBS publishers & distributers. 100-101. (2000)

15 Tulberg at el “A pre-operative study and of the accuracyand value of electrodiagnosis in patients withlumbosacral disc herniation. Spine. June 1: 18 (7) :837 – 42 . (1994)

60

A comparison of flutter device and active cycle of breathingtechniques in acute exacerbation of chronic obstructive pulmonarydisease patientsRicha*, Rajeev Aggarwal**, Md.Abu Shaphe#, Chacko George##, Anurag Vats$

*Postgraduate Student Cardiopulmonary Physical Therapy, Hamdard University, New Delhi, **Physiotherapist,Neurosciences Centre, AIIMS, New Delhi, #Lecturer, Jamia Hamdard, New Delhi, ##Consultant Respiratory Medicine, HolyFamily & Max Hospital, New Delhi, $Lecturer & Dy. Medical Suptt, SDA College-DD Hospital, Chandigarh

Abstract

Background

Aim of the present study is to evaluate the effect of shortterm treatment of Flutter and Active Cycle of BreathingTechnique (ACBT) in patients with acute exacerbation ofChronic Obstructive Pulmonary Disease (COPD).

Materials and methods

Forty five male COPD patients with acute exacerbation wererandomly assigned into 3 groups, were trained for treatmentand the treatment was performed. The study was conductedat St. Stephen’s Hospital, Tis Hazari, New Delhi, India.Following dependent variables were measured before andafter treatment twice daily till they get discharged: PeakExpiratory Flow Rate (PEFR), Arterial Oxygen Saturation(SpO2), Respiratory Rate (RR) and Hospital stay.

Results

There was no statistically significant difference betweengroups. Within group treatment analysis showed that boththe treatments were equally effective in improvingoxygenation and peak expiratory flow rate.

Conclusion

The results of this study indicate that Flutter is as effectiveas the ACBT in improving oxygen saturation without causingany undesirable effects on respiratory rate in patients withacute exacerbation of COPD. These techniques can beused in COPD exacerbation according to patient andphysiotherapist preferences.

Key word

Active cycle of breathing technique, Flutter, Chronicobstructive pulmonary disease.Abbreviations: ACBT= Active cycle of breathing technique,COPD= Chronic obstructive pulmonary disease, PEFR=Peak expiratory flow rate,SpO2= Arterial oxygen saturation.

Introduction

COPD is a heterogeneous disorder characterized bydysfunction of the small and large airways as well as bydestruction of the lung parenchyma and vasculature that isnot fully reversible. Chronic Obstructive Pulmonary Disease(COPD) is a leading cause of morbidity and mortality. Itaffects about 4-10% of the global population2

. According to

a study published by the World Bank/ World Health

Organization, COPD is projected to rank fifth by 2020 in theburden of disease caused worldwide4.About 18 million Indians (5 percent men and 2.75 percentwomen) above the 30 years of age are already sufferingfrom this disease5. In a large multicenter study from India,the population prevalence of COPD was 41 percent of 35295subjects, with a male and female ratio of 1.56: 16.Widespread habit of smoking and use of fuel have led tosuch high prevalence of COPD. The associated loss ofphysical capacity and its adverse psychological effect ofthe disorder contribute greatly to morbidity7

.

Global initiative of chronic Obstructive Lung Disease (GOLD)defines COPD as “A preventable and treatable diseasewith some significant extra-pulmonary effects that maycontribute to the severity in individual patients. Thepulmonary component of COPD is characterized by airflowlimitation that is not fully reversible. The airflow limitation isusually progressive and associated with an abnormalinflammatory response of the lung to noxious particles orgases”.

20 COPD is often associated with exacerbations ofsymptoms. An exacerbation of COPD is defined as an eventin the natural course of the disease characterized by achange in the patient’s baseline dyspnea, cough and/ orsputum that is beyond normal day-to-day variations. Theimpact of exacerbations is significant and a patient’ssymptoms and lung function both may take several weeksto recover to the baseline values8

. The most common causesof an exacerbation are infections of the trachea-bronchialtree and air pollution13. Exacerbation may also beaccompanied by a number of nonspecific complaints suchas tachycardia, tachypnea, malaise, insomnia, sleepiness,fatigue, depression and confusion13,14

.

Chest physiotherapy is effective in clearing secretions fromthe lung of the patients with copious secretion. Deleteriouseffects have been associated with manual techniquesincluding arterial desaturation, bronchospasm, atelectasis,increased oxygen consumption and metabolic andhemodynamic disturbances15.The ACBT (Active Cycle of Breathing Technique) is statedto have good significance in airway clearance overconventional method of airway clearance according to manystudies11

.

A PEP device named Flutter is also used to clear up moresecretion instead of manual techniques16

. PositiveExpiratory Pressure (PEP) mechanism on which flutter worksis somewhat similar to pursed-lip breathing in that aresistance to expiration is applied at the mouth duringexpiration. This results in increased pressure at the mouththat is transmitted to the airways and acts to hold the airwaysopen during expiration. The increased airway pressureduring expiration is thought to prevent premature airwayclosure and thus reduce gas trapping in the lung19.

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Flutter, provides effective secretion clearance whilepromoting treatment adherence, fostering patientindependence, and minimizing physical discomfort18.Studies show that Flutter was more effective in prolongingsecretion removal in chronic bronchitis exacerbation thanwere the other manual techniques17.The available literature on both Flutter and ACBT is notvery enlightening making the interpretation tricky. Thepurpose of this study is to determine which of these twotechniques is superior for improving oxygen saturation,pulmonary function and respiratory rate and also to findwhich technique is more convenient and adaptable for thepatients of acute exacerbation of the COPD.

Methods

Patients: Forty five male COPD patient of age group 40 -70years were admitted in the hospital for the treatment of theiracute exacerbation was included in the study. Coexistentmedical problems (e.g.: Angina, neurologic deficits,orthopaedic limitations, uncontrolled diabetes mellitus,uncontrolled hypertension), Coexistent pulmonary disease(e.g.: Tuberculosis, Bronchiectasis), Indication of ventilatorysupport, Pulmonary embolism, Congestive heart failure,Severe hemodynamic instability (e.g.: Cardiacarrhythmias),Cor-pulmonale, Pneumothorax were excludedfrom the study.Interventions: Subject meeting the inclusion and exclusioncriteria randomly assigned in the groups and receivedproper training of ACBT and FLUTTER. Subjects in group Atreated with ACBT, subjects in group B treated withFLUTTER and subjects in group C were treated with generalbreathing exercises. Twice daily patients were treated inmorning and evening till they got discharged.A pre-intervention and post intervention determination ofthe dependent variables PEFR, SpO2 and RR was donedaily and recorded until the patient get discharge . In groupA after the measurement of variables patient follows ACBTconsisted of 4-6 breathing control breaths, 3-4 thoracicexpansion exercises, and the forced expiration techniqueincluding 4-6 breathing control breaths combined with 2-3huffs. The whole treatment was repeated for approximately15 minutes. Measurements of dependent variable after 5minutes of treatment were made same as before thetreatment. In group B patient was instructed to keep theflutter in an angle from floor so that maximum fluttering wasfelt. Then patient was asked to breathe in slowly and asfully as comfortably possible, really fill the lungs with air.Again perform a 2 to 3 second breath-hold. Now, patientsexhale forcefully through the Flutter, as completely and ascomfortable as possible. This cycle was performed for 15minutes per session. Measurements of dependent variable5 minutes after the treatment were done. In group C usualconventional treatment was given to the patient includingbreathing training (pursed lip breathing) for 15 minutes.Patients were asked to cough and expectorate their sputum.Measurements of dependent variable 5 minutes aftertreatment were made. Treatment was performed twice dailytill patient get discharged.Peak Expiratory flow rate (PEFR): A Mini Wright’s Peakflow meter was used. Subjects were asked to inhalecompletely, then the subjects exhaled completely withmaximal force the reading was taken as shown in the peakflow meter. This measurement was repeated for 3 times.

The best one was taken for record.Respiratory Rate (RR): Respiratory rate was recorded asobservation of number of thoracic excursion for one minute.Arterial oxygen saturation (SpO2): The content of oxygencombined with haemoglobin in arterial blood was measuredwith standard pulse oximeter.Hospital stay (HS): Total number of days each patient spentin hospital was recorded.

Data analysis

For analysis of data we used only first day morning readingand third day evening reading as three days was the minimumhospital stay by each patient. The general linear model (GLM),repeated measure analysis of variance (ANOVA) was used toexamine changes in all dependent variables for within groupanalysis. One way ANOVA (Univariant ANOVA) was used tocompare PEFR, Respiratory Rate, SpO2 and hospital stay forbetween group analyses. The significance level set for thisstudy was p<0.05.

Results

Peak Expiratory Flow Rate (PEFR)There was no significant difference in PEFR whilecomparing Group A(ACBT) and Group B(Flutter) (p>0.05).Group A shows a significant difference from GroupC(Control) on third day (p<0.001). Group B also shows asignificant difference from Control group on third day(p<0.05). Within group analysis shows a significant increasein PEFR in both Group A (p<0.001) and Group B (p<0.001).Whereas in Group C it was not significant (1st day (p=1.00)and 3rd day (p=.243)

Respiratory Rate (RR)

There was no significant difference between Group A andGroup B for the Respiratory Rate with (p>0.05). Group Awhen compared with Group C show significant differenceon 3rd day evening session after treatment (p=0.001). GroupB when compared with Group C shows no significantdifference on RR (p>0.05).Intra treatment analysis showssignificant changes when first reading was compared withother days reading (p<0.05) in Group A. Group B alsosignificant differences were measured when first readingwere compared with other days reading (p<0.03). In GroupC no significant difference were found even after repeatedtreatment (p>0.05).

Arterial Oxygen Saturation (SpO2)

There was no statistical difference in SpO2 in Group A andGroup B (p>0.05). When Group A compared with Group C

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shows significant difference on 3rd day reading (p<0.001).When Group B was compared with Group C at baseline, itshows no statistical difference but on 3rd day reading it showsa significant difference in improving SpO2 (p=0.011 andp=0.007). Within group analysis showed a significantimprovement in SpO2 in Group A (p<0.001). Both group Band group C show no significant improvement immediatelyafter treatment but a significant improvement after prolongtreatment (p<0.001).

Hospital stay (HS)

Between group comparison of group A, group B and groupC showed that Patient using flutter had less hospital staywhen compared with other groups. There was no statisticalsignificant difference in Hospital stay when comparing groupA and group B (p>0.05). Group A shows a significantdifference from Group C (p=0.047). Group B (Flutter) alsoshows a significant difference from Group C (Control)(p=0.004).

Discussion

This study was designed to compare the effectiveness ofActive cycle of breathing technique and Flutter on Peakexpiratory flow rate (PEFR), Respiratory rate (RR) andArterial oxygen saturation (SpO2) in acute exacerbation ofCOPD patients. It was a randomized parallel design study.

The results of study shows that treatment with ACBT andflutter techniques during acute exacerbation of COPD hasa significant effect on PEFR, RR and SpO2 whereas therewas no such effect of routine breathing exercise on thesevariables. The results of our study that PEFR and SpO2improves in ACBT has been well supported by literature1,3,21.While no change in respiratory rate has been observedand the same was also supported by literature which helpsus to conclude that ACBT is well tolerated by patients withacute exacerbation in COPD without causing any untowardeffects.

In group A (ACBT) the data was measured before treatmentas baseline level (Pre1m) and next reading was taken after15 minutes of treatment (Post1m) session. When thesevalues were analyzed there was statistical significant

difference in PEFR and SpO2, whereas no statisticaldifference was observed on respiratory rate. This changein PEFR and SpO2 might be due to gentle relaxed breathingat tidal volume which minimizes any potential increase inairflow obstruction and has improved oxygen saturationduring breathing control while performing ACBT.Improvement in SpO2 after ACBT is thought to be due tothoracic expansion exercises used in the ACBT whichprovides a communication among the alveoli, improveventilation, and allow air to flow behind the bronchialsecretions21. A study by Savci et’al21 on stable COPD patientscomparing ACBT and Autogenic drainage(AD) also showsan improvement in PEFR and SpO2 after ACBT.

When the effect of single session ACBT treatment wasrestudied on third day evening, reading before treatment(Pre3e) was compared with its post treatment reading(Post3e) showed a significant difference in all the threevariables. The reduction in RR may be attributed to relaxedbreathing pattern which was not observed on Day 1. It mightsuggest some learning effect of the subjects for ACBTtechnique and more acclimatized to the treatment.When baseline reading (Pre1m) was compared with 3rd

day evening post treatment reading (Post3e) there was asignificant improvement in PEFR, RR and SpO2.Improvement in PEFR in this study, improved lung functionby ensuring collateral ventilation in segments of lung notpreviously involved in ventilation. The increase in PEF couldbe the result of a larger airflow without an airway collapse,and better cooperation requirements between the patientand the physiotherapist in the ACBT technique. In ananother study by Pryor et’al (3) on effect of chestphysiotherapy on SpO2 in patients with cystic fibrosis, founda significant improvement in arterial oxygen saturation afterusing ACBT technique. It was thought that this increase inSpO2 is due to thoracic expansion exercise or pause forrelaxation and breathing control.The result of our study shows that PEFR and SpO2 doesnot improves with Flutter after single session of treatment iswell supported by documents.(17, 22,24) Result alsodemonstrate that Flutter improves PEFR and SpO2 aftermultiple sessions is also well established in literature.(9,23,10)

Results illustrate that Flutter is also an effective techniqueto improve oxygen saturation.


Comparison of PEFR within the Groups

Comparison of RR Between the Groups

Comparison of RR within the Groups

Comparison of SpO2 between the Groups

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In group B (treatment with Flutter) when data was comparedof baseline value and its post treatment value on day 1,there was no significant difference observed PEFR, RRand SpO2. Similar result was observed by Belloni et’al,(17)

their results demonstrate that oxygen saturation did notchange significantly during and after treatments. Theseresults illustrate that group B treatment is not much effectivein pre-post readings. The inability to reach significant levelin single session treatment suggest very small effect size ofFlutter device, could reach significant level if it would havebeen a large sample size. Moreover when data wereanalyzed between day 1 with day 3, all three variablesreached significance level suggesting carryover effect ofmultiple treatment sessions over the days.When baseline value (Pre1m) was compared with 3rd dayevening reading after treatment (Post3e), all the threevariables shows a significant improvement. These changesin group B may be due to physiological working of Flutter asoscillating low PEP device. In addition to holding the airwaysopen and prolonging expiratory airflow, PEP is purportedto promote movement of mucus proximally27.A study by Burioka10 to check the clinical efficacy of Flutterdevice for airway clearance showed a significant increasein peak expiratory flow after 1 week of treatment with flutter.The increased airway pressure during expiration whenflutter is used as treatment to prevent premature airwayclosure and thus reduce gas trapping in lung27 is thought tobe a mechanism to improve PEFR and Arterial oxygensaturation.In group C there was no statistical significant difference inpre and post readings. When baseline value was comparedwith last reading there was a significant improvement inPEFR and SpO2 whereas RR shows no significant differencein control group. This increase in PEFR and SpO2 valuemight be due to development of resistance during expirationwhich increases the pressure at the mouth which preventspremature closure of airway and reduces air trapping in thelungs26.On intergroup analysis, no significant difference wasobserved in Group A and Group B for all three variables;PEFR, RR and SpO2. Therefore superiority on any of themodality over the other can’t be ascertained. The selectionof individual technique or device for the same purposeshould rely on other factors like convenience of the subject,personal preferences etc. These findings suggest that theremight be an increase in alveolar ventilation and a decreasein the degree of hypoxemia as a result of increased airflowthrough bronchial generations by both techniques.In a study by Pyror and colleagues12 comparing Flutter andACBT in a prospective randomized crossover design insubjects with cystic fibrosis found no significant differencein both the treatments in SpO2 and lung functions. Thisshows that ACBT and Flutter can be considered as useful

adjunct in improving patient’s peak expiratory flow rate.When group A is compared with group C there was asignificant difference in PEFR and SpO2 but no differencein RR. This significant difference in PEFR and SpO2 showsthat Group A treatment is helpful in improving arterial oxygensaturation and peak expiratory flow rate. During thoracicexpansion exercise phase of ACBT lung volume isincreased, reducing resistance to airflow within the distalairways and collateral channels, allowing air to assist inmobilization of secretion and hence improving oxygensaturation after ACBT25. No change in RR shows that neitherof treatment group affects RR and safe in acute exacerbationof COPD patients.When group B is compared with group C a significantdifference in PEFR and SpO2 was observed. This showsthat group B treatment also improves oxygen saturationand peak expiratory flow due to its oscillating PEP basis.In our study, subjects were found to have no statisticalsignificant change in respiratory rate after the treatments.Both treatments showed that there is a small but significantdecrease in respiratory rate after few sessions of treatment.This reflects that both treatment do not cause increase inrespiratory rate and therefore may be safe in acuteexacerbation of disease.When hospital stay was compared in all the three groupswe found that patients using flutter as a treatment getdischarge earlier then ACBT group and Control group. Therewas no statistical difference was found in hospital stay whenACBT and Flutter was compared. But when these groupswere compared with Control group we found a significantdifference. Both flutter and ACBT helps to improve PEFRand SpO2. Improvement in these will further help to clearairways. This reduces the hospital stay of patient andimproves their quality of life.

Conclusion

The results of this study indicates that Flutter is as effectiveas ACBT in improving pulmonary function and oxygensaturation without causing any untoward effects onrespiratory rate in patients with acute exacerbation of COPD.Single session of ACBT showed improvement in PEFR andSpO2, while the single session of Flutter does not showsuch improvement. Both these techniques are found to behelpful in reducing the span hospital stay in comparison tocontrol group. So techniques can be used in COPDexacerbations as an adjunct to improve Peak ExpiratoryFlow Rate and Arterial Oxygen Saturation, according topatient’s and physiotherapist preferences.Acknowledgements: The author wishes to thank theAlmighty, Guides and all those who have helped in thiswork.

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References

1. Thompson CS, Harrison S, Ashley J, Day K, Smith DL.Randomised crossover study of the Flutter device andthe active cycle of breathing technique in non-cysticfibrosis bronchiectasis. Thorax 2002;57:446–448.

2. Halberd RJ. Isonaka S, Iqbal A. (2003) InterpretingCOPD prevalence estimates: What is the burden ofdisease? Chest :123; 1684-1682.

3. Pryor JA, Webber BA, Hodson ME. Effect of chestphysiotherapy on oxygen saturation in patients withcystic fibrosis. Thorax 1990; 45:77.

4. Murray CJ. Lopez AD. Evidence based health policy:lesson from the global burden of disease study.Science. 1996; 274: 740-3.

5. www.tribuneindia.com/2004/20041115/chd.html.6. Jindal SK. Emergence of Chronic Obstructive

Pulmonary Disease as an epidemic in India. IndianJournal Of Medical Research, 2006 Dec;124:619-630.

7. Virendra S, khandelwal DC, khandelwal R andAbusaria S. Pulmonary rehabilitation in patients withchronic obstructive pulmonary disease. Indian journalof Chest Disease and Allied Sciences 2003; 45: 13-17.

8. Seemungal TA, Donaldson GC, Bhowmik A, JeffriesDJ,Wedzicha JA. Time course and recovery ofexacerbations in patients with chronic obstructivepulmonary disease. Am J Respir Crit Care Med2000;161(5):1608-13.

9. Gondor M, Nixon PA, Mutich R, Paul R, David M.Comparison of flutter device and chest physical therapyin the treatment of cystic fibrosis pulmonaryexacerbation. Pediatr Pulmonol,1999; 28: 255-260.

10. Yuji S, Hisashi S, Shinji H, Hiroki C, Takao S. Clinicalefficacy of the flutter device for airway mucus clearancein patients with diffuse panbronchiolitis.(Abstract).Respirology. 1998.3(3):183-186.

11. Abebaw M, Yohannesand Martin J. Connolly, Anational survey: percussion, vibration, shaking andactive cycle breathing techniques used in patients withacute exacerbations of chronic obstructive pulmonarydisease.(Abstract). Chartered Society of PhysiotherapyPublished by Elsevier Ltd online 17 October 2006.

12. Pryor JA, Webber BA, Hodson ME, Warner JO. The FlutterVRP1 as an adjunct to chest physiotherapy in cysticfibrosis. (Abstract) Respir Med 1994;88(9):677–681.

13. Anthonisen NR, Manfreda J, Warren CP, HershfieldES,Harding GK, Nelson NA. Antibiotic therapy inexacerbations of chronic obstructive pulmonarydisease. Ann Intern Med 1987;106(2):196-204.

14. Murphy TF, Brauer AL, Grant BJ, Sethi S. Moraxellacatarrhalis in Chronic Obstructive Pulmonary Disease:

Burden of Disease and Immune Response. Am J RespirCrit Care Med 2005;172(2):195-9.

15. Connors A, Hammon W, Martin R, Rogevs RM, (1980)Chest physical therapy: The immediate effect on oxygenin acutely ill patients. Chest: 78:559-64.

16. Timothy R Myers R. Positive Expiratory Pressure andOscillatory Positive Expiratory Pressure Therapies.Respir Care 2007;52(10):1308–1326.

17. Bellone A, Lascioli R, Raschi S, Guzzi L, Adone R. Chestphysical therapy in patients with an acute exacerbation ofchronic bronchitis: effectiveness of three methods. ArchPhys Med Rehabil 2000;81 :558 60.

18. Oermann CM, Swank PR, Sockrider MM. Validation ofan instrument measuring patient satisfaction with chestphysical therapy techniques in cystic fibrosis. Chest.2000;118:92–97.

19. Joan C Darbee, Patricia J Ohtake, Brydon JB Grant,Frank J Cerny; Physiologic Evidence for the Efficacy ofPositive Expiratory Pressure as an airway ClearanceTechnique in Patients With Cystic Fibrosis; PhysicalTherapy :2004;84 :524-538.

20. Gold copd www.gold.org.com.21. Savci, S, Ince DI, Arikan, Hulya; A comparison of

autogenic drainage and the active cycle of breathingtechniques in patients with chronic obstructivepulmonary disease. 2003. Journal of CardiopulmonaryRehab 20: 36-43.

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27. Andersen J, Qvist J, Kann T. Recruiting collapsed lungthrough collateral channels with positive expiratorypressure. Scand J Respir Dis.1979;60:260–266.


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Calisthenic exercise-induced changes in myocardial oxygenconsumption in normotensive healthy subjectsSalwa B. El-SobkeyKing Saud University, College of Applied Medical Sciences, Rehabilitation Health Sciences Department, Riyadh, Kingdomof Saudi Arabia

Abstract

The product of heart rate (HR) and systolic blood pressure(SBP) provides a convenient estimate of myocardial oxygenconsumption (MVO2). This study aimed to explorecalisthenic exercise-induced changes in MVO2 in healthynormotensive subjects. Eleven college-female studentswere recruited for this study. They performed one upper-extremity and one lower-extremity one-minute calisthenicexercise. Each exercise was practiced with slow, moderateand fast cadences. Values of pre- and post-exercise HRand SBP were used to calculate pre- and post-exerciserate pressure product (RPP) (RPP= HR X SBP). Percentageof change between pre- and post-exercise RPP (% “ RPP)was used to estimate the calisthenic exercise-inducedchanges in MVO2 (% “ RPP= [(Post -exercise RPP- Pre -exercise RPP) ÷ Pre-exercise RPP] X 100). One-minutecalisthenic exercise resulted in increased post-exerciseRPP estimating increase in MVO2 demand. This increasewas influenced by the three selected exercise cadences (Pvalue is 0.029 for upper-extremity and 0.0001 for lower-extremity). Results observed that more MVO2 is requiredwith lower-extremity calisthenic exercise than with upper-extremity exercise. Progressive increase in the % “ RPPwas found through the three cadences and it was of nosignificance in upper-extremity exercise (P = 0.208) andsignificance in lower-extremity exercise (P = 0.023). Inconclusion, One-minute calisthenic exercise revealedminimal exercise-induced changes in MVO2 fornormotensive healthy female college-students especiallywith upper-extremity. If convalescing cardiac patient wouldshow the same response, One-minute calisthenic exercisewith its three cadences would be supported as a low-intensity and safe exercise for Phase I cardiac rehabilitation.

Key words

Myocardial oxygen consumption- rate pressure product-calisthenic exercise- cardiac rehabilitation

Introduction

Exercise is the most important physiological stimulus forincreased myocardial oxygen demand1 and carefullyprescribed progressive exercise programs are an importantpart of cardiac rehabilitative care of patient convalescingfrom an acute cardiac event, such as a myocardial infarction.These programs commonly consist of low-intensitycalisthenic exercises, gradually progressive ambulation,and graduated activities of daily living. The exercises andactivities are kept at low intensities to avoid placingexcessive demands on the heart. These early activity hasbeen shown to help reduce effects of bed rest such as

thromboembolic complications, pulmonary atelectasis,muscle atrophy, negative nitrogen balance, orthostatichypotension, tachycardia, and decreased physical workcapacity, and to lessen anxiety and depression in patientshospitalized for myocardial infarction2.Calisthenic exercise is a form of organized systematicrhythmic bodily exercise that is intended to increase bodystrength, endurance, flexibility and coordination3-5. It consistsof a variety of simple 4 counts movements and it may bedone in cadence. When doing exercises at slow cadence,60 counts per minute (CPM) are used, at a moderatecadence 80 CPM and at fast cadences 100 CPM are used6.Metronome is usually used to mark cadence. It works inmusic mechanism to indicate the exact tempo in which awork is to be performed4.Calisthenic exercises are used to be a part of the cardiacrehabilitation7. It is famous in phase I of cardiac rehabilitationin which exercise starting with one minute and increasingto 8 minutes8. Graded calisthenic exercises used in cardiacrehabilitation settings include upper-extremity, lower-extremity, and trunk activity exercises9.Unfortunately, little information is available concerning thephysiologic stress of calisthenic exercise and most studieson it have involved healthy young male subjects but, womenoften respond to various work loads differently than men10.In addition, many of the cardiac rehabilitation programsindicate the number of repetitions of an exercise but do notindicate the speed or time frame at which they should beperformed9.Although heart is the living pump which supplies body withblood, it needs a good supply of oxygen and nutrients inorder to work. The MVO2 depends on several factors: 1.intraparietal tension, which depends on intraventricularpressure and volume; 2. contractility: 50 per cent increasein the velocity of left ventricular contraction increases MVO2by 40 per cent; 3. heart rate; 4. external cardiac work, workaccomplished during the ejection phase; this representsabout 15 per cent of the MVO2; 5. the energy of electricalactivation; this represents about 0,5 per cent of the MVO2;6. the oxygen requirements of basal myocardial metabolismwhich represent about 20 per cent of the MVO2; 7.ventricular relaxation: is a factor to be added to thosedescribed above; this consumes about 15 per cent of thetotal energy of a cardiac beat11.The product of SBP and HR provides a convenient estimateof myocardial workload (oxygen uptake). This index ofrelative cardiac work called the double product or rate-pressure product closely reflects directly measuredmyocardial oxygen uptake and coronary blood flow inhealthy subjects over a range of exercise intensities and itis a good predictor of MVO2 during exercise in normotensivepatients with ischemic heart disease. The RPP is an

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important indicator of ventricular function which varies withexercise and its changes are frequently used to estimatethe exercise induced changes in MVO2. It computes as:RPP = SBP X HR12-18.Measuring HR and BP responses to an exercise andtranslating these measurements into RPP allows the physicaltherapist who supervises exercise program to evaluateMVO2 indirectly in order to ensure a safe exercise programfor patient2. This is specially important because althoughknowledge of the expected physiological responses for agiven exercise is necessary for physical therapist to makedecisions on safe and effective exercise programs19 littleinformation is available on MVO2 for calisthenic exercise20.This study aimed to explore calisthenic exercise-inducedchanges in MVO2 in healthy normotensive subjects.

Method

This study was approved by Rehabilitation Health Sciencedepartment- Female campus and was carried out duringApril to July 2009. Through bulletin board announcement,eleven volunteer college- female students were recruitedfrom College of Applied Medical Sciences- King SaudUniversity. The participants were normotensive (SBP= 120-129 mmHg and DBP= 80-84 mmHg), non-smokers, non-athletes, with normal weight, free from any cardiovascular,pulmonary, metabolic or musculoskeletal problems and withage ranged from 18-24 years.The purpose of the study was explained to the subjectsbefore obtaining their consents. The exercises werecarefully explained to subjects, who practiced them untilthey mastered performing them with the correct technique.Before the exercise, a heart rate monitor was worn. It consistsof a strap worn across the chest that sends an electronicsignal to a wristwatch-like device that converts the signalinto beats per minute.Each subject performed one-minute calisthenic exercisefor upper-extremity and one for lower-extremity. The upper-extremity exercise consisted of alternated right and leftshoulder flexion to 90 degrees and extension to neutralposition with elbows extended. The lower-extremity exerciseconsisted of alternated right and left hip flexion to 90degrees and extension to neutral position with knees flexed.During the exercise, a mirror was used to assure the 90degrees range of motion.Each exercise was performed for one minute at eachcadence beginning with the slowest cadence. Upper-extremity exercise always preceded lower-extremityexercise. Rest periods were provided between the threecadences until the HR returns to the pre-exercise value. Inaddition to 15 minutes between upper- and lower-extremityexercises. The cadences selected (60, 80, and 100 CPM)represented 15, 20, and 25 repetitions of the four-countmovements of practiced exercises, respectively. Theexercises were performed keeping cadence with ametronome. Subjects were monitored and encouragedduring exercise to maintain correct speed and range ofmotion.A sitting pre-exercise HR and SBP was measured. Polarwatch was used to measure HR and Welch Allyn data scopewas used to measure SBP. Post-exercise measurementsof HR and SBP were obtained within 30 sec at the end ofone-minute calisthenic exercise. Pre- and post-exercise RPPwere calculated as the product of HR and SBP. The change

in R PP (“ RPP) and the percentage of change in the RPP(% “ RPP) were calculated using the following mathematicalequations.

“ RPP = (Post -exercise RPP) – (Pre -exercise RPP)

% “ RPP= (Post -exercise RPP) – (Pre -exercise RPP) X 100(Pre-exercise RPP)

The % “ RPP was used to estimate the calisthenic exercise-induced changes in MVO2.

Data analysis

For this study, the 0.05 level was adopted as the level ofsignificance. Graph Pad InStat3 was used to carry out thestatistical analysis. One way ANOVA was used to comparemeans of pre- and post exercise RPP, “ RPP, and % “ RPPbetween the three selected cadences for upper- and lower-extremity. Tukey’s Studentized post hoc test was used toexamine differences among groups if analysis of variancerevealed significance.

Results and discussion

Aim of convalescing phase I cardiac rehabilitation is torecondition the cardiac patient after acute cardiac eventsas myocardial infarction or cardiac surgery. Exercise is anintegral part of cardiac rehabilitation. During phase I, low-intensity exercise that does not load the heart is individuallydesigned for cardiac patient. Calisthenic exercise iscommonly used during this phase. Physical therapist usescalisthenic exercise to maintain the patient vital and active,to keep muscles flexible, strong and coordinated and towork against deconditioning as thromboembolic problems.Calisthenic exercise, along with other modalities, increasespatient’s confidence and markedly decreases depressionand anxiety. It is the physical therapist responsibility tobalance between these remarkable effects of calisthenicexercise and its safety for convalescing cardiac patient.Depending on patient’s cardiovascular response to theselected exercise intensity, exercise effectiveness and safetyshould be individually adjusted and objectively monitoredfor cardiac patient. Objective measures should be used tomonitor this response and assure proper adjustment. Greeret al2 supported this view. They stated that calisthenicexercises show greatest variability in oxygen consumptionand careful monitoring of cardiovascular response isnecessary when using calisthenic exercises in therehabilitation of patients such as those with cardiaclimitations and this monitoring should provide usefulinformation for prescribing exercise. The clinical need toobjectively prescribe calisthenic exercise during cardiacrehabilitation was the rational to design calisthenic exerciseresemble to that for convalescing patients with cardiacproblems and to study its effect on MVO2.The RPP is a major determinant of cardiac oxygenconsumption4. Moreover, Nelson et al21 found that MVO2

correlated best with products of heart rate and bloodpressure regardless of whether the blood pressure wasobtained by a central aortic catheter (r = 0.88) or by a bloodpressure cuff (r = 0.85). In addition, RPP can be used toestimate the increased metabolic demand that exerciseplaces on the heart22. In practical terms, RPP can be usedas an exercise prescription guideline for cardiac patients23.


67

Although arm exercise assumes an increasingly importantrole in clinical cardiology as it is used in both exercisestesting and training of patients with coronary artery disease,the effects of arm exercise on MVO2 is not well understood;they may differ from the effects of leg exercise24. It wasessential, in the current work to design both upper- andlower-extremity calisthenic exercise to explore the MVO2in both.In present study, one-minute upper- and lower-extremitycalisthenic exercise resulted in increased post-exerciseRPP estimating increase in MVO2 (table one). Exercisecadence was an impacting factor for that increase asprogression from slow, moderate to fast cadence resultedin significant progressive increase in post-exercise RPP (Pvalue is 0.029 for upper-extremity and 0.0001 for lower-extremity). The effect of exercise cadence was moreprominent in lower-extremity exercise as the post-hoc testshould that with upper-extremity exercise, fast cadence post-exercise RPP was significantly increased more than pre-exercise RPP while with lower-extremity exercise, slow,moderate and fast cadences post-exercise RPP weresignificantly increased more than pre-exercise RPP. Inaddition, fast cadence post-exercise RPP was significantlyincreased more than slow cadence post-exercise RPP. Inthe study done by Gleeson and Protas4 they documentedthat the highest levels VO2 during different calisthenicexercise was for the hip flexion exercise. Current studyresults were attributed to the increase in HR and SBP withexercise and this increase is also influenced by the cadenceof exercise. RPP changes during incremental exercise asincreased exercise intensity raises both the HR and SBP23.The normal blood pressure response is to observe aprogressive increase in SBP25 and the immediate responseof the cardiovascular system to exercise is an increase inHR26.Because exercise cadence during one-minute upper-extremity calisthenic exercise had modest effect on post-exercise RPP, the differences between pre- and post-exercise RPP (“ RPP) of the three selected cadences were

non-significant (P = 0.092) (table two). Significant case waspresent for lower-extremity exercise (P = 0.006). Increasethe exercise cadence from slow, moderate to fast cadencesresulted in increase of the “ RPP (table two) estimatingincrease in the difference of MVO2 between pre- and post-exercise values. Post-hoc test showed that there wassignificant difference between slow cadence “RPP andmoderate cadence “ RPP (P < 0.05). Furthermore, therewas significant difference between slow cadence “RPP andfast cadence “ RPP (P < 0.01).These present study results demonstrated that more MVO2is required with lower-extremity calisthenic exercise thanwith upper-extremity exercise. Moreover, increase theexercise cadence increases the MVO2 requirement. Thethree important mechanical factors that determinemyocardial oxygen uptake are tension development withinthe myocardium also called ventricular work, myocardialcontractility, and heart rate14. These mechanical factors canexplain the increase in MVO2 accompanying the increasein exercise cadence. During exercise, the requirement ofexercising muscle for increased blood flow necessitates anincrease in cardiac output that results in increases in thethree mechanical factors and when each of these factorsincreases myocardial blood flow adjusts to balance oxygensupply within demand 1,14.The % “RPP for upper- and lower-extremity one-minutecalisthenic exercise (table three) indicated that there wasprogressive increase in the % “RPP with the progressiveincrease in the exercise cadence. This progressive increasein the % “RPP was non-significant in upper-extremityexercise (P = 0.208) and significant in lower-extremityexercise (P = 0.023). Fast cadence lower-extremity exercise% “RPP was increased more than the slow cadence lower-extremity exercise % “ RPP (P < 0.05).As % “RPP is an objective indicator for exercise-inducedchanges in MVO2, one-minute upper- and lower-extremitycalisthenic exercise is supported to be a low-intensityexercise as it caused minimum % “ RPP even with fastcadence (26.5 ± 14.5 % for upper-extremity and 65.4 ± 30.9


Table 1: Pre- and post-exercise rate pressure product (RPP) in upper- and lower-extremity one-minute calisthenic exercise.Extremity ExerciseCadence Pre-exercise RPP Post-exercise RPP P Tukey post-hoc test

Mean ± SD Mean ± SDUpper Slow 8902.5 ± 1807.5 10400.9 ± 1745.5 0.029 Pre-exercise Vs. Fast Post-exercise P< 0.05

Moderate 8902.5 ± 1807.5 10563.1 ± 1705.6Fast 8902.5 ± 1807.5 11118.6 ± 641.0

Lower Slow 8786.1 ± 1611.0 11794.4 ± 2105.7 0.0001 Pre- Vs Post- Slow P< 0.01Moderate 8786.1 ± 1611.0 13819.0 ± 2086.1 Pre- Vs Post- Moderate P< 0.001

Fast 8786.1± 1611.0 14229.0 ± 2274.5 Pre- Vs Post- Fast P< 0.001Post- Slow Vs Post- Fast P< 0.05

Table 2: Change of rate pressure product (“ RPP) in upper- and lower-extremity one-minute calisthenic exercise.Extremity ExerciseCadence “ RPP P Tukey pos-hoc tes

Mean ± SDUpper Slow 1498.3 ± 648.4 0.092

Moderate 1660.6 ± 712.9Fast 2216.1 ± 938.1

Lower Slow 3008.3 ± 1219.0 0.006 Slow “RPP Vs. Moderate “ RPP (P < 0.05)Moderate 5032.9 ± 1930.0 Slow “RPP Vs. Fast “ RPP (P< 0.01)

Fast 5442.9 ± 2056.1

Table 3: Percentage of change of rate pressure product (% “RPP) in upper- and lower-extremity one-minute calisthenic exercise.Extremity ExerciseCadence % “ RPP P Tukey pos-hoc test

Mean ± SDUpper Slow 17.9 ± 9.5 0.208

Moderate 19.7 ± 10.6Fast 26.5 ± 14.5

Lower Slow 35.2 ± 15.8 0.023 Slow % “ RPP Vs. Fast % “ RPP (P < 0.05)Moderate 60.5 ± 28.8

Fast 65.4 ± 30.9

68

% for lower-extremity). The RPP at maximal exercise is fivetimes greater than it is at rest 22. These results wouldguarantee exercise safety. If the normotensive convalescingcardiac patient would show the same response to one-minute calisthenic exercise, application of this exerciseduring phase I cardiac rehabilitation would be safe and itwill not load the heart while the patient is enjoying theexercise’s benefits. Study done by Gleeson and Protas [4]provides evidence that the energy cost of low-intensitycalisthenics is similar for 15 healthy women (aged 54.3 ±5.9 years) and 15 women with coronary artery disease (aged53.3 ± 5.1 years). Although women age in their study wasolder than the current study college-females’ age, their studysupported the possible similarity between non- and cardiacfemales.It is important to mention that the sample size for this studywas relatively small; and further investigation on a largerscale is recommended to confirm the findings and enhancetheir generalization. Also, it is recommended to re-applythe study on convalescing cardiac patients for longerduration, 2-8 minutes.

Conclusion

One-minute upper- and lower-extremity calisthenic exercisecauses minimal exercise-induced changes in MVO2 fornormotensive healthy female college-students especiallywith upper-extremity. In case convalescing cardiac patientwould show the same response, One-minute calisthenicexercise with its three cadences would be supported aslow-intensity and safe exercise for phase I cardiacrehabilitation.

References

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2. Greer M, Weber T, Dimick S, Ratliff R. PhysiologicalResponses to Low-Intensity Cardiac RehabilitationExercises. Physical Therapy. 1980; 60 (9): 1146- 1151.

3. http://en.wikipedia.org/wiki/Calisthenics Wikipedia® isa registered trademark of the Wikimedia Foundation,Inc., a non-profit organization. This page was lastmodified on 7 January 2010.

4. Gleeson PB, Protas EJ. Oxygen consumption duringcalisthenic exercise in women with coronary arterydisease. Physical Therapy 1989 April; 69(4):260-263.

5. Giam CK, Ong TC, Teh KC. Some possible benefitsand dangers of non-aerobic exercise in cardiacrehabilitation program. Ann Acad Med Singapore.1983; 12 (3):368-372.

6. Departmen of the Army Field Manual, FM 21-20Physical Fitness Training available @ Ref: http://www.army.com/apft/item/5266

7. Soleimani A, Salarifar M, Kasaian SE, Sadeghian S,Nejatian M, Abbasi A. Effect of Completion of CardiacRehabilitation on Heart Rate Recovery. AsianCardiovasc Thorac Ann 2008; 16:202-207.

8. Amundsen LR. Cardiac Rehabilitation. New York,Edinburgh, London and Melbourne: ChurchillLivingstone Press, 1981: 24, 25 and 123.

9. DiCarlo S, Leonardo J. Hemodynamic and energy costresponses to changes in arm exercise technique.Physical Therapy. 1983 Oct; 63 (10): 1585-92.

10. Pina IL, Hesich EM. Heart failure in women: a need forprospective data. J Am Coll Cardiol. 2009 Aug 4;54(6):491-8.

11. Delaye J, Mpetshi I, Durand JP. Oxygen requirementsof the myocardium. Arch Mal Coeur Vaiss. 1983; 76:7-12.

12. Adams J, Hubbard M, McCullough-Shock T, Simms K,Cheng D, Hartman J, et al. Myocardial work duringendurance training and resistance training: a dailycomparison, from workout session 1 throughcompletion of cardiac rehabilitation. Proc Bayl UnivMed Cent. 2010; 23(2): 126–129.

13. Nagpal S, Walia L, Lata H, Sood N, Ahuja GK. Effect ofexercise on rate pressure product in premenopausaland postmenopausal women with coronary arterydisease. Indian J Physiol Pharmacol. 2007; 51(3):279-283.

14. McArdle WD, Katch FI, Katch VL. Essential of exercisephysiology. Philadelphia: Lippincott Williams andWilkins Press, 2006: 339-340.

15. Gobel FL, Norstrom LA, Nelson RR, Jorgensen CR,Wang Y. The rate-pressure product as an index ofmyocardial oxygen consumption during exercise inpatients with angina pectoris. Circulation. 1978; 57:549-556.

16. Mosby’s Medical Dictionary, 8th edition. © 2009,Elsevier. Available @ http://medical-dictionary.thefreedictionary.com/rate-pressure+product

17. Kal JE, Van Wezel HB, Vergroesen I. A critical appraisalof the rate pressure product as index of myocardialoxygen consumption for the study of metabolic coronaryflow regulation. Int J Cardiol. 1999 Oct 31; 71(2):141-148.

18. Klabunde RE. Cardiovascular Physiology Concepts.Available at http://www.cvphysiology.com/CAD/CAD003.htm

19. Cassady SL, Nielsen DH. Cardiorespiratory responsesof healthy subjects to calisthenics performed on landversus in water. Phys Ther. 1992; 72:532-538.

20. Miles DS, COX MH, BOMZE JP. Cardiovascularresponses to upper body exercise in normals andcardiac patients. Med. Sci. Sports Exerc. 1989; 21 (5):S126-S131.

21. Nelson RR, Gobel FL, Jorgensen CR, Wang K, WangY, Taylor HL. Hemodynamic Predictors of MyocardialOxygen Consumption During Static and DynamicExercise. Circulation. 974; 50:1179.

22. White WB. Heart rate and the rate-pressure product asdeterminants of cardiovascular risk in patients withhypertension. Am J Hypertens. 1999; 12(2 Pt 2):50S-55S.

23. Powers SK, Howley ET. Exercise Physiology: Theoryand Application to Fitness and Performance. New York:McGraw-Hill Press, 2007: 193.

24. Balady GJ, Schick EC Jr, Weiner DA, Ryan TJ.Comparison of determinants of myocardial oxygenconsumption during arm and leg exercise in normalpersons. Am J Cardiol. 1986 Jun 1; 57(15):1385-7.

25. Kelley GA, Kelley KS. Progressive resistance exerciseand resting blood pressure: A meta-analysis ofrandomized controlled trials. Hypertension. 2000; 35:838-843.

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69

A prospective randomized controlled trial of neural mobilizationand Mackenzie manipulation in cervical radiculopathySanjiv KumarPrincipal & Professor KLES College of Physiotherapy, Hubli

Abstract

Objective

To assess the therapeutic effect of Mackenzie manipulation,Neural mobilization and conventional method, and tocompare their efficacy for treatment of cervical radiculopathy

Design

Arandomized controlled trial comparing Mackenziemanipulation, Neural mobilization and conventional method

Setting

OPD of 3different center

Sample

30 participants with cervical radiculopathy randomly allottedto 3 different groups.

Method

All three groups were given SWD and ICT. And also GroupA undergone Mackenzie manipulation, group B given withNeural mobilization and controlled group was exposed toSWD and ICT only.

Result

Group A after 5 days of treatment shown mean reduction ofpain in neck 65 % ±8.17% & by 10th day 91.5 % ±6.68%.Mean percentage of reduction in pain for right arm was72.85% on 5th day and 97.14 % on 10th days with t value9.552 and p less than 0.001.Mean percentage ofimprovement in left arm for group A was 73 % on 5th dayand 96 % in 10th day with t value 3.467 and p value lessthan 0.02. Group B achieved mean reduction in their painin neck by 50% ±16.67% and by 10th day the relief of painwas 75.50% ± 17.71%, 50% reduction in right arm pain on5th day and 85.83 % on 10th day with t value 14.628 and pless than 0.0001. Mean percentage of improvement in leftarm for group B was 44.71 % on fifth day and 87.27 % intenth day with t value 8.708 and p value less than 0.001.Group C got 50.50 % ±13.43% after 5th day of treatmentand 88.6% with 8.83 % neck pain reduction by tenth day oftreatment. In this group right arm pain reduced by 48.33%on 5th day and85.83 % by 10th day with t value 10.434 andp value less than 0.001. Mean percentage of improvementin left arm for group C was 57.5 % on 5th day and 96.67 %in 10th day with t value 9.400 and p value less than 0.001.It is clear that Group A achieved maximum improvement in

5 days and group C achieved better improvement between5th to tenth day compared to other two groups. Forestablishing the statistical significance paired t test wasperformed which gave following result; Group A resulted tvalue was 10.24 with p value) 0.0001, Group B with t value5.106 with p value 0.001 and group C with t value 14.596and p value) 0.0001.All these readings shows that treatmentmodel of A group was most effective followed by treatmentmodel of group C. The recovery of range of motion is even inall these methods Improvement level is between 90 to 100%.

Conclusion

Pain reduction and symptoms were maximum in first 5 daysin the patients treated with McKenzie method Conventionalmethod gave more relief between 5th and 10th

day of treatment, Range of motion recovery was even in allthe methods used in this study

Key words

Neural Mobilization, Mackenzie manipulation, cervicalradiculopathy, ROM, VAS pain Scale

Introduction

In the present era of modernization, every individual lives abusy life from early morning till late night. Target to completethe assignment and tight time schedule keeps theindividuals busy. If we consider a sedentary worker andtrace his suffering, we will find that it is the work, whichcontributes to most of his problems. This rush in the lifedoes not allow the individual to think about his workingplace and comfort. In turn, they tax most of their body partsunnoticed. This may lead to over stresses primarily affectmuscles and the spine. As a result of which the individuallands up either with back pain or neck pain (Thomson).Neck pain costs in the form of treatment expenditure andalso loss of manpower at work1.The cervical spine has got more mobility and pooranatomical support and hence it may lead to early changesand which in turn can gives raise to pain and discomfort (2).

Neck pain with its descent can be due to cervicalradiculopathy. Gowers3 and Elliot described about radicularsymptoms in cervical disorders (4). It is noticed that out ofevery 10 patients referred to Physiotherapy Out patientDepartment, one patient belongs to neck pain group.Considering the incidence of affliction, Salemi.G.,Savattieri.G., Meneghine F. reported that every 3.3 /1000individuals suffer from cervical radiculopathy (5). withincidence rate 0.8 case / 1000population. Cervicalradiculopathy affects both the genders equally; the afflictionis common during the fourth and fifth decade of the life.

Sanjiv kumar / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Males show early changes in cervical spine andsubsequently leading to cervical radiculopathy, where asin females, the problem arises after the menopause 6

.This problem commonly affects the C4 to C7 spinal nerveroots and symptoms occur at these sites involving neck aswell as arm radiating pain. Attack of symptoms usually lastsup to sixteen weeks and gets resolved 7

. The pain may bevery disabling and can interfere with the normal activity ofthe individuals. Hanflig noted that cervical spondylitis as acause of the pain in the shoulder and arm referred to pain inthe chest wall as an associated symptom8. Semmes andMurphy and Bury and Chenault described the productionof the radicular symptoms due to acute protrusion of thecervical inter-vertebral disc9. Spurling and Scoville reportedtwelve verified cases of ruptured cervical intervertebral discdue to degeneration10. According to Karrmer C5 root affectedin 4.1 % cases, C6 in 36.1 %, C7 34.6 % and C8 25.2%.Marinecd ,Yoss et al reported involvement of nerve rootsC7 in 69 to 70 % of cases, C6 in 19 to 25 % of cases in C8in 4 to 10 % of cases ,C5 2 % of radiculopathy cases.Involvement of C6-7 roots is secondary to lesion of C5- 6and C6 - 7 motion segments respectively, are most common(5). Predisposing factors quoted by Annthomson Skinner, JeorPissery and McNab11. are as follows, Poor posture,Occupational stress12. Mental stress, Weak neckmusculature, Body type like thin neck, broad neck, short orlong neckAgeing plays an important role in cervical spondylosis andin turn leads to cervical radiculopathy. Elvey R describedabout patho-physiology of radiculopathy in Fifth BiennialConference of Manipulation Therapist Association ofAustralia at Melbourne13. Considering the above facts ofcervical radiculopathy it is evident that the treatment modesshould target the reduction of pain, which is mostly due toneural compression in origin. Mackenzie classifies thepatient with mechanical spine pain into a. posturalsyndrome, b. Dysfunction syndrome, c. derangementsyndrome and McKenzie has adopted Quebec task forceclassification for activity related spinal disorders in thisspecific classification are recommended of disordersaccording to their symptoms. This classification is adoptedfor diagnosis and therapy for spinal disorders.Helen et.al. found that Mackenzie method gives greaterreduction in pain in the short term intervention14. Carol et.al. concluded that MDT test for neck pain demonstratedmoderate agreement when classifying the diagnosticcategory and treatment for neck pain15. Mohammad et. al.found that patient of back pain treated with manipulation/exercise shown greater improvement compared to thosewho all were receiving US/Exercise16. Richard F. Ellis et.alconcluded that neural mobilization can be used for treatmentof neurodynamic dysfunction and has positive therapeuticbenefit 17. Abdulwahab SS et. al. found in their study thatcontinuous neck flexion will increase the symptoms andrepeated retraction will decrease the pain18. Kjllman G. et.al.found that Mackenzie method gave good improvement inchronic neck pain condition than control group19. MurphyDR et. al. reported that neck pain with peripheral numbnessdecreased by extension exercise20.

Objective

This study was planned to understand the therapeutic effectof Mackenzie manipulation, Neural mobilization and

conventional method and to compare their efficacy fortreatment of cervical radiculopathy.

Material and method

Study design: It is a prospective Randomized controlledtrial study. In this study all the participant were given shortwave diathermy (SWD) and Intermittent cervical traction(ICT) as a common method of treatment and treatment forcontrolled group and is designated as conventionaltreatment and apart from this one group was given Neuralmobilization as special technique and other group givenMackenzie method.

Study Sample

Total 82 volunteer agreed to participate in this study out ofwhich 40 were found suitable on screening for this study.From them 30 patients was randomly selected consent weretaken and allotted to three different groups A,B,C. Theseentire subjects were from Physiotherapy OPD of K.L.E.Hospital and Civil hospital, Belgaum, KLES College ofphysiotherapy Hubli . All the subjects were aged between25 years to 68 years, suffering from cervical radiculopathyfor at least two months. Sex ratio of sample male to femalewas 1: 2; i.e. 10 males and 20 female. Subjects of this studywere either belonged to the light work group or moderatework group, 22 participants i.e. 73.3%had light work and 08i.e.26.7 % were engaged in moderate work. Mean BMI ofgroup A was 21.32 ±2.06. Group B BMI was 27.607 ±2.89.And group C BMI was 21.17 ±5.92.

Inclusion Criteria

Patients diagnosed as cervical radiculopathy by Neurologistor Orthopedic surgeon with the spontaneous onset painlocated at neck and its radiation to the arm, forearm, andhand.

Exclusion Criteria

The patients with Space occupying lesions, Tuberculosisof cervical spine, fracture of cervical vertebra, Pain of arthriticorigin, Patient with the history of early manipulation therapy,Myelopathy, Fatigue pain syndrome, SpondylolysthesisSpinal stenosis, Severe osteoporosis Spondylolysis, Neuraltube defects, Demyelinating diseases, Radiation to headalone, were excluded from this studies

Intervention

Following apparatus were used for the study1. Short Wave Diathermy machine 450W.2. Traction Machine Traction table unit manufactured by

Electrocare Systems and Service Private Limited, India.3. Measuring Tape: A measuring tape of total length 60-

inches/152 cm for Cervical ROM by scalar method.

Manual therapy

1. McKenzie manipulation: this manipulation is supposedto work on the phenomenon of centralization ofperipheral symptoms by position, mobilization andmanipulation. Centralization is the phenomenon

70 Sanjiv kumar / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

whereby as a result of the performance of certainrepeated movement, or the adopting of the certainposition, radiating symptoms originating from the spineand referred distally cause to move proximally towardsthe midline of the spine, centralization of the pain occursonly in derangement syndrome during the reductiveprocess. In this study various methods prescribed byMcKenzie for derangement are utilized.

2. Neural Mobilization: This method is related to oscillatorystretching of nerve roots. Neural Mobilization works onstimulating mechanical receptors, micro lengthening,and improving neural circulation at root level to reducethe edema. And hence reduce radicular symptoms.Outcome Measures: VAS for Pain assessment, %outcome scale for pain assessment, Scalarmeasurement for ROM assessment.

Procedure

Prior to the intervention the subjects, were evaluated fortheir range of motion and pain by Scalar method and VASscale respectively. Range of motion is assessed using scalarmethod Barbara F Barwell21. on 1st, 5th and 10th day. VASscale method is used (Melzack & Wall) in this; ten-centimeterscale was taken22. on 1st, 5th and 10th days by askingpatient to locate intensity of pain on the scale.

Group A subjects were treated with conventional methodalong with McKenzie’s methods (exercises / manipulation)for five to fifteen repetitions of one set done daily. Beforestarting McKenzie method all the patients were assessedproperly by McKenzie test movements for cervical spine.From test movements a particular position and movementwas selected. The movement or mobilization selected wasfrom the responses of the test movements. In cases of cervicalradiculopathy all patients will definitely have derangementsyndrome of cervical inter-vertebral disc. This technique isconsidered to reduce the derangement followed bymaintenance of reduction, recovery of function andprevention of recurrence. According to the symptoms thepatient is categorized in Qubec Task Force classificationand treated.

Group B was treated with the conventional method alongwith neural mobilization of 20 seconds oscillations of threesets during each session of the treatment. In this techniquegentle and firm movements, through and end range areused. Active or passive mobilizations were used accordingto the patient’s symptoms. In this technique the movementsegment of the upper limb and cervical spine was placed inorder to produce the minimal stretch or tension to theparticular nerve. For median nerve ULTT 2a position wasused for mobilization purpose. Grades 1 to grade 4oscillations were applied from the distal component.Duration of oscillation was 60 seconds, which was dividedin to three, equal burst. For radial nerve, ULTT 2b is used.And for Ulnar nerve ULTT 3 positions were used. Aftermobilization, patients were advised for self-mobilization

techniques.Group C was treated with short wave diathermy for twentyminutes and intermittent cervical traction with 1/10th of bodyweight for twenty minutes. All the groups were treated forten days and only one treatment session was carried everyday. The responses were recorded on first, fifth and tenthday before and after the treatment.

Results

Neck Length, Neck Circumference and Lumbar Height wasmeasured by scalar method Group A individuals werehaving neck length between 9 to 11cm with mean length10cm ± 0.67. Mean neck girth of same group was 29cm ±2.45 with range 29 to 32 cm. Length of Lumbar spine wasbetween 9 to 13cm with mean of 10.9cm ± 1.19 correlationcoefficient (r) of neck and lumbar height was 0.8353. InGroup B the mean neck length was 10.97 ± 2.25 and range9 to 13. Mean neck circumference was 32.4 ± 4.46 andrange 28 to 37. Lumbar height ranged from 9 to 14 cm withmean 10.8cm ± 1.51 correlation coefficient (r) of neck lengthand lumbar height was 0.6054. Group C participants werehaving neck length between 9 to 13 cm and mean 10.4 cm±1.69cm. Mean neck girth for the group was 31.27 ± 3.38cmand range 27 to 37cm.Lumbar length was between 9 to15cm with mean 10.7cm ±1.95cm with correlation coefficient(r) between neck length and lumbar height was 0.6629.

Vas score versus treatment days

(table 01,) Neck Pain: Mean VAS scores for neck pain ingroup A on first, fifth and tenth day were 8.1,2.7& 0.7, In-group B as 6.9, 4.1 & 1.9 and for group C 7.8, 2.07 and1,respectively. Arm pain: Average VAS scores for arm painin group A on first, fifth and tenth day were 7.25,1.65 & 0.16,in-group B 6.8,3.85 and 1.0 and in Group C as 7.8,3.25 &0.7 respectively.

Comparative outcome vas versus day oftreatment in neck and arms

(Table 02) Status of pain on the first day did not differ inthree groups in neck as well as arm (p>0.05), on the fifthday the difference was significant for neck VAS, in group Aversus B and A versus C (p< 0.01) where as in arms it wasnot significant( p> 0.05). On the tenth day, neck pain showedsignificant difference in-group A versus B and B versus Cwhere as arm pain did not reveal any significant difference(p>0.05).Vii. Outcome of pain recovery percentage: Statisticalresults show that all the methods of treatment significantlyreduced symptoms. Group A after five days of treatmentmean reduction of pain in neck was 65 % ±8.17% & bytenth day 91.5 % ±6.68% (diagram 1). Mean percentage ofreduction in pain for right arm was 72.85% on fifth day and97.14 % on tenth days with t value 9.552 and p less than

Sanjiv kumar / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3 71

Table 1: Vas score versus treatment days

Group First Day Fifth Day Tenth DayNeck Lt. Arm Rt. Arm Neck Lt. Arm Rt. Arm Neck Lt. Arm Rt. Arm

M sd M sd M sd M sd M sd M sd M sd M sd M sdA 8.1 1.66 7.2 2.17 7.71 0.95 2.7 0.67 2.2 1.48 2 0.58 0.7 0.48 .14 0.37 0.2 0.45B 6.5 2.02 6.86 2.48 6.83 2.56 4.1 2.02 4.29 2.63 3.67 2.25 1.9 1.29 1 1.15 1.17 0.95C 7.8 2.44 7.33 2.42 8.5 2.07 4 1.70 3.17 1.47 4.5 1.52 1 0.67 .33 0.52 1.17 0.43

72

0.001.Mean percentage of improvement in left arm for groupA was 73 % on fifth day and 96 % in tenth day with t value3.467 and p value less than 0.02. Group B achieved meanreduction in their pain in neck by 50% ±16.67% and bytenth day the relief of pain was 75.50% ± 17.71%, 50%reduction in right arm pain on fifth day and 85.83 % on tenthday with t value 14.628 and p less than 0.0001.

Mean percentage of improvement in left arm for group Bwas 44.71 % on fifth day and 87.27 % in tenth day with tvalue 8.708 and p value less than 0.001. Group C got 50.50% ±13.43% after fifth day of treatment and 88.6% with 8.83% neck pain reduction by tenth day of treatment. In thisgroup right arm pain reduced by 48.33% on fifth dayand85.83 % by tenth day with t value 10.434 and p valueless than 0.001. Mean percentage of improvement in leftarm for group C was 57.5 % on fifth day and 96.67 % intenth day with t value 9.400 and p value less than 0.001

It is clear that Group A achieved maximum improvement infive days and group C achieved better improvement betweenfifth to tenth day compared to other two groups. Forestablishing the statistical significance paired t test wasperformed which gave following result; Group A resulted tvalue was 10.24 with p value) 0.0001, Group B with t value5.106 with p value0.001 and group C with t value 14.596and p value 0.0001.All these readings shows that treatmentmodel of A group was most effective followed by treatmentmodel of group C.

Range of motion outcome

All three methods found statistically significant. The recoveryof range of motion is even in all these methods (diagram02). Improvement level is between 90 to 100%. And pairedt test gave significant t and p value. No difference is seen in

Table : 3 Mean percentage of pain reduction in different groupGroup Fifth day Tenth day

Neck Lt Arm Rt Arm Neck Lt Arm Rt ArmM Sd M Sd M Sd M Sd M Sd M Sd

A 65 8.17 73 19.23 72.85 11.85 91.5 6.68 96 8.94 97.14 7.56B 50 16.67 44.71 19.55 50 25.49 78.5 17.71 87.27 13.84 85.83 12.01C 50.5 13.43 57.5 9.87 48.33 11.69 88.8 8.83 96.67 5.16 85.83 4.92

range of motion recovery in the applied methods (Table 6).

Discussion

Cervical radiculopathy is one of the conditions, which canbe treated by a wide variety of Physiotherapy methods. Itcommonly affects middle age group. In the present study,Maximum number that is 21 out of 30, which is equal to 2/3rd of the sample size, was between 31 to 50 years of age.Weinner reported 3.3 per 1000 incidence in the same agegroup. The age group 41 to 50 years had incidence of 2.1cases per 1000. In our sample 12 cases of 30 belonged tothis group. Sample of present study consisted of 20 femalesand 10 males that is 2:1 in ratio, studies reported a higherpercentage of the female patients contributing it to theirmenopausal factor, whereas Stookey reported that mostlycervical spondylosis affects middle-aged males. Out of totalsample size, 73% were involved in light and 27% wereinvolved in moderate work. Harms and Ringale reportedthat intra discal pressure in cervical spine increases onforward flexion and decreases on extension23. He alsoreported that intra discal pressure also increases on axialloading with or without weight. Results of this study weredirected towards the pain and range of motion improvement.The result of this study was significant for all the methods


Table : 2 Inter group comparison (t & p values) for vas score versus daysof treatment

GROUP NECKFirst day Fifth day Tenth dayt value p value t value p value t value p value

A vs B 2.053 >.05 2.942 <.01 3.899 <.005A vs C 0.455 >.6 3.182 <.01 1.628 >.1B vs C 1.271 >.2 0.169 >.8 2.769 <.02GROUP LEFT ARMA vs B 0.246 >.8 1.592 >.1 1.461 >.1A vs C 0.093 >.9 1.086 >.3 0.438 >.6B vs C 0.344 >0.7 0.923 >.3 1.311 >.2GROUP RIGHT ARMA vs B 0.246 >.8 1.592 >.1 1.461 >.1A vs C 0.093 >.9 1.086 >.3 0.438 >.6B vs C 0.344 >.7 0.923 >.3 1.311 >.2

Table : 5 Inter group comparision for % of pain reduction versus treatmentdays

NECKGroup Fifth day Tenth day

t p t pA versus B 2.555 <0.02 2.17 <0.05B versus C 0.074 >0.09 1.646 >0.1A versus C 2.917 <0.01 0.771 >0.4

LEFT ARMGroup Fifth day Tenth day

t p t pA versus B 2.488 <0.05 1.290 >0.2B versus C 1.446 >0.1 1.565 >0.1A versus C 1.732 >0.1 0.157 >0.8

RIGHT ARMGroup Fifth day Tenth day

t p t pA versus B 2.129 >0.05 2.063 >0.05B versus C 0.146 >0.9 0 1A versus C 3.742 <0.01 3.125 <0.01

Table : 4 Pain reduction (t & p values) in different groups between 5th and10th day (paired t test)

Group Neck Left Arm Right Armt value p value t value p value t value p value

A 10.242 <0.0001 3.467 <0.02 9.552 <0.001B 5.106 <0.001 8.708 <0.001 14.628 <0.0001C 14.596 <0.0001 9.400 <0.001 10.434 <0.001

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(Table 1). It is important to note that McKenzie method gavefaster relief from the pain in the early stage of themanagement and over all relief in the later stage ofmanagement. Conventional method gave improvement inthe symptoms in the second phase of the treatment (Table3). It may be noticed that the recovery in the range of motionwas even in all the three methods. Domeston and coworkerstudied the centralization of pain in a retrospective studyinvolving 87 patients evaluated and treated by McKenzieconcept and concluded that there was high correlationbetween centralization and successful outcome of thetreatment. Study by Domston & Coworker involved largersample size and performed only McKenzie method withsuccessful outcome24. On the other hand in our study thecomparison is done in three different treatment methodsand its outcome in small sample size. Results of our studyalso indicate towards positive correlation of McKenziemethod with recovery in radicular pain by centralization.William et al studied the effect of sitting with either kyphoticor lordotic lumbar/cervical posture in cervical /lumbarradiating pain and he found that centralization was effectivein lordotic posture. Our study is in agreement with it. As inpresent study, extension position and mobilization are usedfor treatment purpose, which stimulates lordosis in cervicalregion. Both the above studies were to establish aboutMcKenzie method’s efficacy with positive outcome. But therewas no comparison done with any other manipulationmethod as in our study.

Ponte D J et al compared the efficacy of McKenzie protocolversus William protocol in treatment of Low back pain andfound both are effective in the disorders of back25. NwugaG, Nwuga V also did similar type of study to compare Williamand McKenzie protocol26. Domston Retal24. studiedcentralization phenomenon, its usefulness in evaluatingand treating referred pain. It was observed that manipulationversus neural mobilization has not been studied together.

Richer P.D. Favio expressed his concern about neuralmobilization and stated that neural mobilization cannotreduce the pain and is simply impossible. Favio stated thatneural manipulation is not useful to reduce the pain as itstretches and provokes the nerv27. In present study the pain

reduced on performing said method. As noted in this studythe rate of improvement was slower as compared to othermethod. Patients continued with some residual pain evenafter tenth day of neural manipulation. Laders studied upperlimb tension tests for effects on neural origin pain andfavorable response28. Satinder D Kapoor et al comparedneural mobilization and conventional treatment in twentypatients and gave positive results in favor of neuralmobilization. The outcome was measured for the lumbarradiculopathy condition; hence the results are notcomparable. Kruse R.A. et al studied the effect of flexiondistraction manipulation and achieved positive result witha small sample size29. Hubbak M.J. Studied the effect ofrotatory manipulation for cervical radiculopathy30. He took8 patients for study purpose, four were treated withmanipulation and four were treated with conventionalmethods. The study was partly favorable to manipulation.Hureoitzel E. L. et al in a study concluded that the cervicalmanipulation and mobilization probably provide at leastshort term benefits for radiculopathy31. Many studies aredone to add credibility of McKenzie manipulation. Therewas no such comparative study about different manipulativetherapy in the past. In this study, to understand the efficacyof treatment methods, pain and neck range of motion weretaken as parameters. Statistical analysis was done first forVAS, mean and SD taken out for individual group (Table 1).On analyzing mean VAS for neck pain, it was found thatmaximum reduction in VAS score was noted in Group A ontenth day i.e. 0.7 followed by Group C with VAS =1, thengroup B up to score 1.9.Standard deviation in Group B wassignificantly larger that is 1.29 which was double than inGroup C and three times that of Group B. This greater SDcan be contributed for larger dispersion in the subject’simprovement. Group A with 0.7 VAS score for neck pain ontenth day and arm pain 0.16 from 8.1 is in favor ofcentralization as proposed by McKenzie. Also fifth day, thetendency was seen positive for neck pain where the VASreduced to 2.7 and for arm pain it reduced to 1.65. Group Band C in this respect showed a similarity in their behavior ofrelief of neck pain as well as arm pain. Coincidently neckpain persisted on fifth day with score 4.1 and 4 respectively.Again as compared to arm pain the score on fifth day was4.1 and 3.85 that is clinically almost similar in both groups.

Table : 6 Range of motion outcome (t & p values)

Movement Groups Improvement Paired t value p % of ImprovementMean S.D.

Flexion A 2.28 0.77 9.882 <.ooo1 100B 1.70 0.63 8.833 <.ooo1 100C 2.22 1.93 3.605 <.01 70

Extension A 4.20 1.39 9.555 <.ooo1 100B 2.50 1.45 5.452 <.ooo1 90C 3.15 1.05 9.486 <.ooo1 100

Left Side Flexion A 3.80 2.20 5.462 <0.001 90B 3.65 1.72 6.711 <0.001 100C 4.35 2.23 6.168 <0.001 90

Right Side Flexion A 3.00 1.94 4.890 <0.001 90B 3.45 2.18 5.004 <0.001 100C 4.10 2.19 5.920 <0.001 90

Left Rotation A 3.10 1.45 6.761 <0.001 100B 3.85 2.00 6.087 <0.001 100C 4.10 2.23 5.814 <0.001 100

Right Rotation A 3.10 1.66 5.905 <0.001 100B 4.25 2.22 6.054 <0.001 100C 4.30 2.80 4.856 <0.001 90


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Centralization of pain was evident in McKenzie method asperipheral symptoms recovered from VAS score 8 to 0.5after 10 days of treatment. Similarly central pain reducedfrom 8.1 to 0.7 on tenth day. This gives a clear indicationtowards centralization of pain. Through the statisticalanalysis revealed that in arm pain there was no significantdifference on the tenth day, it was because of comparableexcellent groups in all the three groups. Similarly whereversignificant difference existed after tenth day in VAS for neck,it is because of difference in the pain lingering afterperipheral pain relief and centralization of pain in neck. Atthe same time no statistically significant difference in-groupA versus C is suggestive of comparability of outcome inMcKenzie group and conventional group in favor ofcredibility of routine Physiotherapy.

In McKenzie group and neck position and manipulationworks as valid factor for relief of pain i.e. peripheral referredpain being alleviated. In Neural mobilization no neckmanipulation is performed but only nerve is mobilized inthe ULTT position. Residual neck: arm pain in the groupwas 1.9:1 after the tenth day of the treatment. This mayprobably because of the provoking factor in the form ofstretch was used for therapy. The pain recovery was overallnearly 90% for all groups. At this juncture we propose thatthe future study be directed at testing VAS scores forindividual nerves in upper extremity when more than onenerves affected.

Similarly analysis of recovery in pain percentage was doneby statistical means. Mean and standard deviation ofrecovery percentage was done and found that in Group Aneck and arm symptoms improved more than 91%. GroupB recovery of pain percentage was more than 78% withlarger standard deviation. Group C recovery percentagewas above 85%. Paired t test was done to verify differencesin the methods of treatment. Scores were compared betweenfifth and tenth day recovery percentage and found that allthe methods are significant for cervical radiculopathytreatment (Table 4). Larger standard deviation for Group Bcan be contributed to slower recovery among the individualsalso to note that few patients did not recover more than fiftypercent even on tenth day in this group. Trend of VAS scorefor Group B , it was found that many patients showed scorelevel at 3 even after tenth day. The factors that might havecontributed for less recovery for Group B will be discussedin this section. In this connection body mass index has beenassessed for all the three groups and mean BMI was found.Mean BMI for Group A, B and C were 21,27 and 20respectively. Group B had higher BMI that is 27, which isslightly obese frame. This may be a factor for slowimprovement in this group. In control group, the traditionaltreatment of SWD and traction appears to be effectiveespecially towards tenth day, whereas on fifth day neckand arm pain reduced to 50 %. In the Group B the residualpain was around 20% in neck and 10 % in the arm after thetenth day of treatment.

Statistical inter group comparison of fifth and tenth days forVAS and percentage of recovery gave a mixed picture. InVAS score on fifth day A versus B and A versus C, and ontenth day A versus B and B versus gave significantdifferences and same trend followed in percentage of painrecovery (Table 2). Inter approach study is a demandingtask necessitating working knowledge and acceptable skillsin either approach. Further it is necessary to confine to a

particular approach methodology during treatment withoutany mix up, since in a clinical setting, both the approacheswere employed on the patient alternately.

The control group consisted of two traditional and commonlyused modalities in Physiotherapy namely SWD and cervicaltraction. The result showed that the control group had acomparable result to Group B, on fifth as well as the tenthday. More over, in case of central as well as peripheral painGroup B neural mobilization results and Group C (control)results were found to be comparable. Through all the threemethod’s result can be graded as excellent having morethan 85% relief. Control group having excellent result hasbeen little surprising though assuring that the routinetreatment employed by the majority in the field is equallyeffective. Though the subjective method of VAS wasemployed to assess the results, no result in any of the groupscan be attributed to placebo effects, since they have crossedthe usual 30% betterment. This situation compels us tohypothesize that the results need additional interpretation.It is reasonable to put a patient on routine Physiotherapymeasures including cervical traction irrespective of anyspecialized technique are contemplated upon, to beemployed in conjunction or following it. In this connection aperiod of a week, (5to 6 sessions) as in our study, can be astarter, which is giving an assured 50% relief in both thetype of pain. Nevertheless, the centralization of pain hastaken place in all the three groups, which appears to be aphenomenon critical in recovery common to any treatmentmethod irrespective of McKenzie approach by itself.Similarly, the NTT’s were carried out in total population(n=30) to assess the status of peripheral pain and thismethod is found to be satisfactory which is irrespective ofneural mobilization as a therapy. Over and above, whetherthe neck posture correction can be fused with routinePhysiotherapy as patient compliment and can it beassociated with neural tissue mobilization is interestingapproach indication for future studies. It is difficult to comparethe methods of manipulation, as the result will be variableaccording the patient type. It is understood that nocomparison is done in the earlier studies. Hence this studybecomes a significant initiation towards establishing thebasic guidelines in the radiculopathy management,because of inter group comparison.

Some limitations of this study were the small sample size &variable patient mass. To reach to any significant conclusionIt could be suggested that for the further prospective studycan be done with comparable patient variables withemphasis on anthropometrics as well as ergometricvariables, other than the clinical alone. This is a direnecessity in the field since a number of manipulativeapproaches are in vogue.

Conclusion

Pain reduction in first five days was maximum in patientstreated with McKenzie method and also the maximum reliefof the symptoms achieved by same method, Conventionalmethod gave more relief between fifth and tenth day oftreatment, Range of motion recovery was even in all themethods used in this study, Patient with greater BMI showsslower recovery, Neural mobilization shows poorimprovement may be because of provocation to the nerveroots.


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References

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2. Merk R & Aubigne D: The Physiology of joint, IAKapandji,vol 3,trunk & Vertebral column, 2nd Ed,Churchill Livingstone,1998.

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5. Salemi G, savettieri G, Meneghini F et al: Prevalenceof cervical spondylotic radiculopathy; a door-to-doorsurvey of Sicilian Municipality, Acta. Neurol. Scand.93,184-188,1996.

6. Radhakrishnan K, litchy W J, O’fallon M, Kurlan L T:Epidemiology of cervical radiculopathy a populationbased study from Rochestor Minneosta, 1976 through1990 Brain 117:325- 335,1994.

7. Crandal P H & Hanafee W N: Cervical spondyloticmyelopathy studied by air myelography, Amer. J.Roentenol, 92,1260,1964

8. Hanflij S S: Explained cervical spondylitis as a causeof pain in shoulder and arm, Disc Journal of AmericanMedical Association 106,523,1936.

9. Semmes& Murphy: Radicular symptoms and protrusionof cervical inter-vertebral disc, J. American MedicalAssociation, 121,1209,1943.

10. Spurling R J, Scoville W B: Relation betweendegeneration and cervical inter-vertebral disc rupture,J. Surg. Gyn. Obstet.78, 350,1944

11. McNab: The Whiplash syndrome, Symposium onDisease of The Inter-vertebral Disc; Orthopedic ClinicNorth America (2), 389,1971.

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13. Elvey R: The Pathophysiology of Radiculopathy, P-406, Proceedings of the fifth Biennial conference of themanipulative Therapist Association of Australia,Melbourn, 1987.

14. Helen A Clare, Roger Adams and Christopher G Maher,A systematic review of efficacy of Mackenzie therapyfor spinal pain Australian journal of physiotherapy, Vol50, 209-216, 2004

15. Carol P. Dionne, Ronald F. Bybee, Joe Tomaka, Inter-rater reliability of Mackenzie assessment in patientswith neck pain, Physiotherapy, 92, 75-82, 2006

16. Mohammad A Mohseni-Bandpei, Jacqueline Critchley,Thomas Staunton, Barbara Richardson, A prospectiverandomized controlled trial of spinal manipulation andUltrasound in the treatment of chronic low back pain,Physiotherapy 92, 34-42, 2006


17. Richard F. Ellis, Wayne A. Hing, Neural mobilization Asystematic review of randomized controlled trail withan analysis of therapeutic efficacy, Journal of manualand manipulative therapy, 5-9, 2009

18. Abdulwahab SS , Sabbni M; Neck retractions, cervicalroot decompression, and radicular pain, Journal oforthopedic sports physical therapy Jan30(1): 4-9, 2000.

19. Kjellman G, Oberg B; A randomized clinical trailcomparing general exercise, Mackenzie treatment anda control group in patient with neck pain Journalrehabilitation medicine 34: 183-190, 2002

20. Murphy DR, Beres JL; Is treatment in extensioncontradicted in the presence of cervical spinal cordcompression without myelopaty? A case report, Manualtherapy 13, 468-472, 2008.

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26. Nwuga G, Nwuga V: relative Therapeutic efficacy ofWilliams and McKenzie Protocol in Back PainManagement, Physiotherapy practice,1;97,1985.

27. Richard P.DiFavio: Neural mobilization The impossible,Journal of Orthopedics & Sports Physical Therapy 2001;31(5); 224-225

28. Jeffrey D, Boyling & Nigul Palastangis Forwidel: GrievesModern Manual Therapy, 2nd Ed, The Vertebral Column,Gregory P.Grieves, Churchill Livingstone, New York1994.

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Trunk restraint training after stroke: A reviewSenthilkumar Jeyaraman1, Ganesan Kathiresan1, Kavitha Gopalsamy2

1Lecturer, Physiotherapy, School of Allied Sciences, Masterskill University College, Malaysia, 2Clinical Physiotherapist

Abstract

Hemiparesis is common following stroke. The ability to reachand grasp is a necessary component of many daily lifefunctional tasks, hence reduced upper limb function has animpact on the ability to perform activities of daily living. Withthe growing number of studies on this intervention the strokepopulation, there is the need to consolidate this evidenceto determine the potential use of trunk restraint training inimproving arm reaching in neurological rehabilitationparticularly for stroke patients. A considerable research efforthad assessed the effects of trunk restraint training on therecovery of reaching movements in hemiparetic patients.This review identified 6 relevant trials in which one trial is apilot study. Among 6 trials, three trials recorded themovement kinematics (outcome measure) by OptotrakMotion analysis System, in the other two trials the movementkinematics (outcome measure) were analysed by a 6 –camera, 3D Motion analysis system and 10 – camera MotionAnalysis System respectively. The results of our reviewdemonstrated that the use of trunk restraint as a treatmentparadigm aimed at decreasing compensatory strategieshas the potential of becoming an effective therapy. Furtherstudies are necessary to determine the long term effect ofthe trunk restraint training.

Key words

Stroke, trunk restraint, reaching

Introduction

Research on the effectiveness of rehabilitation techniquesfor patients with stroke is important not only for strokesurvivors but also for care givers, treatment providers andsociety alike. The ability to reach and grasp is a necessarycomponent of many daily life functional tasks, hencereduced upper limb function has an impact on the ability toperform activities of daily living1, which is likely to reduceindependence and increase burden of care. In the monthsafter stroke, function of the paretic arm can improve asreaching; grasping and manipulating ability is regained.Improvements in function can occur in 2 ways. In one way,premorbid movement patterns may be regained becauseof true motor recovery. In another way, because of theredundancy in the number of degrees of freedom (DFs) ofthe body2, actions can be accompanied by substitution ofother DFs for movements of impaired joints. Thesealternative movements or motor compensations3 are alsoobserved in animals recovering from experimental stroke.4,5

In patients with hemiparesis, the unrestricted and unguidedrepetition of a motor task may reinforce compensatorymovements6. Patients with severe impairment tend to

improve performance (defined as movement speed,precision and smoothness) of a pointing movement after 1day of intensive training by incorporating trunk anteriordisplacement, a movement not normally needed for thetask. Thus, in the short term, although compensatorymovements may improve performance of the paretic arm,in the long term, these may be maladaptive by preventingrecovery or reappearance of more efficient arm movementpatterns.7

Although neurorehabilitation research has recentlydemonstrated that structured, specific, and intensive trainingprotocols increase the amount of hemiparetic limb use, lessattention has been given to normalizing movementstrategies poststroke.8 Hence, Michaelsen et al evaluatedmovement patterns of the hemiparetic arm made with orwithout restriction of compensatory trunk movements duringreach to grasp tasks and found restriction of compensatorytrunk movements may encourage recovery of ‘normal’reaching patterns in the hemiparetic arm when reaching forobjects placed within arm’s length. During trunk restraint,patients improved active elbow extension, shoulder rangesand interjoint coordination when reaching.9,10,11 Trunkrestraint thus allowed patients to use joint ranges that werepresent but not recruited during unrestrained reaching.Later, studies combined the trunk restraint training withadditional therapeutic interventions.12,13

Purpose of the review

With the growing number of studies on this intervention instroke population, there is a need to consolidate thisevidence to determine the potential use of trunk restrainttraining in improving arm reaching in neurologicalrehabilitation particularly for stroke patients.1. The primary aim is to assess the effectiveness of trunk

restraint training on the recovery of reachingmovements in stroke patients.

2. Secondary aim is to find out the effectiveness of trunkrestraint training combined with other therapeuticinterventions.

The review

The search yielded 6 full text articles. Among the 6 articlesincluded, one was done in Canada with 11 healthy and 11hemiparetic individuals,9 the another two studies werestudied in Canada with 28 hemiparetic patients and 30patients respectively10,11. Fourth study was done by Robertade Oliveira in Brazil with 11 hemiparetic patients35. The fifthone was done in New York with 11 patients; 12 sixth studywas done with 12 stroke patients, 5 health individuals inFlorida.13

Senthilkumar Jeyaram n / Indian Jouanl of Physiotherapy and Occupational Therapy.July - Sept. 2010, VOL 4 NO 3

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Michaelson SM et al9, 10, 11 studied the effect of trunk restrainttraining on the recovery of reaching movements in chronichemiparetic patients. Roberta de Oliveira et al35 analysedthe clinical effects of trunk restraint training in therehabilitation of the upper limb. Thielman G et al12 studiedthe task related training and resisted exercise combinedwith trunk restraint training. Woodbury ML et al13 combinedthe trunk restraint training with intensive task practice andstudied its effects on reach and function.

Participants across all the trails had similar diagnosis ofhemiparesis with more upper limb involvement. All the trailsexclude the patients with hemispatial neglect or apraxia,shoulder pain or neurologic or orthopaedic conditionsaffecting the arm or trunk. The details of the studies includedin this review are given in the tables 1, 2, and 3.Trunk restraint training and recovery of reaching :Three of the six trials studied the effect of trunk restrainttraining on reaching movements in patients with chronicstroke. All the three trials were done by Michaelsen SM 9, 10,

11 In the first trial, he included 11 healthy and 11 hemipareticindividuals. Data was collected with the use of an OptotrakMotion Analysis System. He concluded that trunk restraintis effective in uncovering latent movement patterns tomaximize arm recovery in hemiparetic patients. Kinematicanalysis of trunk restraint training in stroke patients showsthat there is increase in elbow extension (degrees) from45.2 (14.6) to 59.1 (11.2) [mean (SD)]; the shoulder flexion(degrees) increases from 19.2 (12.4) to 30.6 (8.7) [mean(SD)].9

In the second study, 28 hemiparetic were assigned into twogroups. The outcome measure was Optotrak motionAnalysis system.The author concluded that restriction ofcompensatory trunk movements during practice may leadto greater improvements in reach – to – grasp movementsin patients with chronic stroke than practice alone. Individualanalysis of hemiparetic patients in trunk restraint groupshowed an increase in elbow extension (>10 degrees)between pre-test and retention test; Anterior trunk

displacement was decreased significantly more (by 52mm)in trunk restraint patients. There is an increase in elbowextension (in degrees) from 96 (24) to 106 (24) [mean (SD)];decrease in trunk displacement (in mm) from 166 (101) to114 (68) [mean (SD)].10

In the third trial, Michaelsen randomly assigned 30 patientsinto trunk restraint group and control group. The authorconcluded that treatment should be tailored to armimpairment severity with particular attention to controllingexcessive trunk movements if the goal is to improve armmovement quality and function. Kinematic analysis revealedthat trunk restraint decreased mean trunk displacement by32.8 mm at post-test; at the same time trunk restraintincreased elbow extension by 5.9 degrees at post-test.11

Roberta de Oliveira assessed the clinical effects of trunkrestraint training in 11 patients. The author demonstratedthat trunk restraint allowed patients to make use of activejoint ranges that are present but not normally recruitedduring unrestrained arm reaching tasks. The total score inFugl-Meyer scale is increased from 30.27(19.56) to33.45(20.50) [mean (SD)].14

Trunk restraint training combined with task relatedtraining and resisted exercise : Thielman G et al in hisstudy included 5 stroke patients in task related training groupand 6 stroke patients in resisted exercise group. After thetraining, 3D Motion analysis system was used for testing.He concluded that training done by restricted truncal motionduring task related training improved the precision ofreaching more than during resisted exercise. The elbowextension increased significantly from pre-test[47.43(15.54)] to post-test [56.19 (16.27)] in task relatedtraining group (55 degrees to 64 degrees).12

Trunk restraint training combined with intensive taskpractice : ML. Woodbury et al did a pilot study in which heincluded 11 chronic stroke patients and 5 healthyindividuals. Data were collected with 10 – camera motionanalysis system. He concluded that intensive task practiceTable 2: Description of trunk restraint procedures

Senthilkumar Jeyaraman / Indian Jouanl of Physioherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Table 1: Criteria for inclusion of participants in studies

Criteria SM Michaelsen SM Michaelsen SM Michaelsen Roberta de Oliveira G Thielman et al ML Woodbury et et al 2001 et al 2004 et al 2006 et al 2007 2008 al 2009Time since 5 to 69 months 7 to 94 months 6 to 48 months >6 months 7 to 36 months 6 to 101 monthsonset of strokeAge (Years) >20 <80 <85 Mean age was 47.18 <90 18 to 90Specified diagnosis X - - X X -Specified side of Hemiplegia X X X X X XNo evidence of excessive X X - X - -SpasticityNo excessive pain X X X X - XMeasurement of reduced upper X X X X X Xlimb functionSpecified level of Balance X - - X - -Not participating in an active - X - - X -rehabilitation programNot part of other experimental - - - - X -studiesNo upper limb conditions X X X X X Xlimiting use before strokeNo other significant medical X X X X X XconditionsSpecification of hand dominance - X - - - XNo evidence of severe perceptuo X X X X X Xcognitive deficitsAble to perform reach to - X X - X Xgrasp movementNo limitations in passive - X - - - Xrange of motion

78 Senthilkumar Jeyaraman / Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Table 3: Summary of trial design features

Table 2: Description of trunk restraint procedures

Study (First author) Intensity of therapy Type of therapy Additional therapyMichaelsen 2001 20 trials. With trunk restraint and with full vision, participants reached

toward, grasped and returned the cone to the midchest region at Nila comfortable self paced speed. Reaches to target 1 and target 2repeated with trunk secured to the chair back with a harness.

Michaelsen 2004 60 trial training period Participants reached and grasped a cylinder in response to anon day 1 and in a single auditory signal. Both groups were instructed not to move the trunk Nilsession on day 2. and to use as much as elbow extension.

Michaelsen 2006 1 hour therapist With trunk restraint, repetitive functional uni- and bimanual reachsupervised program 3 to grasp tasks using objects varying in size, weight and shape. Niltimes per week for 5weeks(total = 15 sessions).

Roberta de Oliveira et 20 sessions of 45 First 15 mins were spent on extension exercises and active mobilizational 2007 minutes duration, held of upper limb and shoulder girdle and remaining 30 min on performing Nil

twice weekly. training of reaching exercises with trunk restraint.Thielman 2008 12 sessions (3 per For task related training, participants reached to contact or grasp objects Task related

week), 45 minutes per variably placed to require arm movements of different amplitudes across training andsession, 200movements all quadrants of the table top. Common objects were used that varied in resisted exercises.for each session. size, shape and weight (e.g., cups, mugs, writing, eating utensils). For

resisted exercise, repetitive movements that required proximal and distalarm muscles were carried out against the resistance of the theraband. Trunkwas restrained in both groups.

Woodbury 2009 14 day mCIMT protocol Modified CIMT protocol along with trunk restraint training. Tasksand 10 days of in clinic progressed in difficulty as a participant demonstrated success. mCIMTtask practice for 6 hoursper day.

Author Restraint ProceduresSM Michaelsen et al (2001) Trunk was secured to the chair back with the harness minimizing

shoulder girdle movement and preventing trunk flexion and rotation.SM Michaelsen et al (2004) Participants wore a harness consisting of breast and back plates

connected by adjustable straps. An electromagnet attached to thewall was locked to the back electromagnetic plate at the interscapular level.

SM Michaelsen et al (2006) Trunk movements were prevented by body and shoulder belts attachedto the chair back. Scapular elevation / protraction were not restricted.

Roberta de Oliveira et al (2007) The training session was carried out with the patient seated in a chairwith the trunk restrained by a harness that limited the movements of trunk

and shoulder girdle, allowing the reaching movement without using additionaldegrees of freedom.

G Thielman et al (2008) Restraining device (LL Bean Co, Freeport, ME) was attached to the chair’sback and had 2 padded shoulder straps that come across the glenohumeral joint,

permitting approximately 3cm of scapula motion but limiting trunk flexion.ML Woodbury et al (2009) To discourage anterior trunk displacement a custom designed trunk

restraint was placed between the participant and the table. The restraintwas placed between the participant and the table. The restraint wasconstructed on a stable base designed to fit around the outside of a

chair while allowing the chair to slide under it to the table. The restraintwas adjusted in height so that a padded shield was located anterior to

and lightly touching the participant’s sternum.

Discussion

A considerable research effort has assessed the effects oftrunk restraint training on the recovery of reachingmovements in hemiparetic patients. This review identified6 relevant trials in which one trial is a pilot study. Among 6trials, three trials recorded the movementkinematics(outcome measure) by Optotrak Motion analysisSystem, in the other two trials the movementkinematics(outcome measure) were analysed by a 6 –camera, 3D Motion analysis system and 10 – camera MotionAnalysis System respectively.

Reaching ability is an important component for independentliving. However, survivors of stroke often rely oncompensatory movement strategies to accomplish reachingtasks. Carr and shepherd15 suggest that compensatorystrategies are the result of using available movements giventhe poststroke state of the central system, which leads to

long – term functional limitations. Hence Michaelsen et alstudied the effectiveness of trunk restraint training on armrecovery in stroke patients and demonstrated that trunkrestraint is a treatment paradigm which decreases thecompensatory strategies.

The effects of trunk restraint indicate that hemipareticpatients did not use their potential joint range for free armmovements. A likely explanation stems from the findings ofLevin et al.16 They defined articular ranges in whichhemiparetic patients could make isolated elbow flexion andextension movements by using a reciprocal muscleactivation pattern. The increase in joint ranges with trunkrestraint may be partly due to an adaption involvinganticipation of changed external load conditions. Anotherpossibility is that the adaptation was triggered bysomatosensory input from the trunk or shoulder caused bythe trunk restraint.17 In other words, patients are forced tomake movements “out of synergy”, which probably involvesa focussed and greater effort on their part. This is similar to

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the strategy of constraining the unaffected arm18 to force thepatient to make more use of the affected arm with theadditional feature that reduction of compensatory movementpatterns is also targeted. This was proved by the recentfindings of ML. Woodbury et al.13 It suggests that underlying “normal” patterns of movement coordination are notentirely lost after stroke and that appropriate treatmentsmay be applied to uncover them to maximize function. Onecost of his recovery may be a short – term decrease inmovement speed.

Since task related training19, 20 and resisted exercise21

demonstrated enhanced recovery in stroke patients,Thielman et al12 compared the effects of task related trainingand resisted exercise combined with trunk restraint trainingin his recent trial. His results added one more stone in thecrown of trunk restraint training. Extensive practice usingtask related training with truncal restraint appears to be amore effective approach to rehabilitate reaching with thehemiparetic arm.The studies included in this review are descriptive, singlegroup study and only one randomized controlled trial. Hencemeta-analysis was not done in this review.

Recommendations for stroke rehabilitationresearch

Whitall J gave a list of recommendations to be consideredwhile finding new treatment techniques for stroke patients.

1. A treatment technique should follow the principlesof motor learning and neuroplasticity.

Treatment technique which involves repetitive, task-oriented, attention-demanding and rewarding activities,results not only in motor learning of the activities but also inneuroplasticity in the brain. These principles have adifferential effect based on paretic severity, lesion location,early / late recovery, etc. There are always some baselinedifferences between left and right hemiparetic patients.Though trunk restraint training obeys the above saidprinciples, the studies included in this review recruited bothleft and right hemiparesis patients with different types oflesions.

2. The relative effects of different training programswith different patients.

Experiments should be designed not necessarily to provethat one training program is better than another but that onemay be better than another for a certain type of patient. Inthis review, the reaching improvement was evident formoderate to severely impaired participants. Mildly impairedpatients in the chronic stage were benefitted little.

3. The combined effects of 2 training programs versus1 and on different patients.

The main consideration with the experiments combiningprotocols is that they should contrast the combination withboth single versions to make sure that the combination isworthwhile in effort and efficiency and not merely a result of“more is better”. Thielman G et al combined task relatedtraining and resisted exercise along with trunk restrainttraining.12 He found that the patients in trunk restraint canable to use straighter paths than those patients in resistiveexercise group. Woodbury ML et al combined mCIMT withtrunk restraint training which resulted in functionalimprovements in upper limb of the hemiparetic patients.13

4. Home based training.It is highly probable that home – based training will need tobe a standardized part of rehabilitation not only because ofeconomic considerations but also because we know thatrepetition is important, that maintenance may be requiredand that patients can improve long past their stroke. But thestudies included in this review didn’t include anymaintenance exercises in home after the trunk restrainttraining.

5. Duration (Frequency, Intensity) of training programs.Michaelsen found that the improvements attained after trunkrestraint training was maintained 24 hours after training.10

The studies included in this review were done with chronichemiparetic patients, it is also important to study time-course,frequency and intensity in patients throughout the sub-acutestage in well-designed studies.

6. Key outcome parameters to measure.More effort should be invested by researchers in determiningkey (Gold Standard) tests that can represent independentmotor functions so that rehabilitation studies can reducepatient burden and the biasing effects of initial testing. Forreaching and manipulation of objects with the hemipareticarm, the assessment should focus on the amount ofcompensatory trunk and shoulder girdle movements as wellas the range of active joint movement used. This type ofanalytical approach is not possible with the use of functionaloutcome scales such as the Barthel Index or the FrenchayArm Test that mainly assess the level of independence fortask completion.9 Hence, kinematic analysis were doneusing motion analysis system to quantify the amount of trunkdisplacement and elbow extension in hemiparetic patientsafter trunk restraint training in the studies included in thisreview.

How trunk restraint training improves armreaching?

1. The increase in joint ranges with trunk restraint may bepartly due to an adaptation involving anticipation ofchanged external load conditions.9Another possibilityis that the adaptation was triggered by somatosensoryinput from the trunk or shoulder caused by the trunkrestraint.35

2. Physical trunk restraint can be considered similar to“manual guidance,”36 in which spatial constraints areused to promote use of more optimal movementpatterns.

3. In this training paradigm, external feedback, that is,explicit information,37 was inherently built into the taskpractice with trunk restraint context both as knowledgeof results (KR) and knowledge of performance (KP).For example, the participant received KR by eitherachieving or failing to achieve the task goal.Additionally, the participant received KP via an efferentcue from trunk restraint if he/she leaned forward.13

Trunk restraint training in future

Findings of Hsu WL et al22 suggest that the muscles in theaffected ankle cannot be recruited timely and efficiently forthe reaching task in stroke patients, as with relative recoveryin lower limbs. In other words, they do not generate normalmotor recruitment patterns to accomplish the motor task. It

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has been reported that even when the recovery is scoredhigh in test situations, stroke patients do not spontaneouslyuse their paretic side in daily living situations.23 Futurestudies should emphasize some interventions to thehemiplegic lower limb while giving trunk restraint trainingto the hemiplegic upper limb.

The interaction between arm and trunk movements mayalso be altered in patients with hemiparesis due to theexcessive displacement of the trunk for arm transport ashas been previously reported during unimanual reachingand grasping.9,24,25,26 The increased role of the trunk for armtransport and problems of trunk control in individuals withhemiparesis may represent additional challenges to inter-segment coordination and result in a destabilization ofposture during tasks requiring arm movements from astanding position.27 In daily living, reaching is more likely tobe performed in a standing position.28,29 In future, werecommend to study the influence of trunk restraint trainingin arm reaching in standing position.

It has long been recognized by clinicians7, 30 that oncecompensation has been learned, it is very difficult to modify.Indeed, prolonged use of compensatory trunk movementsto reach targets placed within arm’s length may result in thesystem learning not to use arm joints for reaching andgrasping (learned nonuse).18so that recovery of independentuse of these joints would be discouraged. Compensatorymovement strategies may be very difficult to unlearn,31

frustrating efforts to improve movement for both patient andtherapist. Though all the trials included in this reviewdemonstrated positive results for trunk restraint training onarm reaching movements, for maintaining the trainingeffects for the rest of the day we suggest to study the effectsof additional usage of strapping or splints or brace withtrunk restraint training. Home based training is required inorder to maintain the trunk restraint training effects in armreaching activities during activities of daily living.

It is already known that stroke patients are deconditioned;hence training programs should combine physicalconditioning and motor learning principles which will givethe best and most permanent effect on motor recovery.32

Trunk restraint training didn’t address whether theintervention improved functional capacity of the arm,because it was expected that longer term practice would benecessary to affect change in this dimension. Hence infuture, studies on trunk restraint training can also includephysical conditioning program along with long term practice.

The participants in the studies included in this review werealways trained with trunk restraint rather than using a fadedtrunk-restraint program13. Young and Schmidt34 showed thatless retention of learning occurs when continuous feedbackis given compared with less frequent feedback. Hencefurther studies are necessary to determine the efficacy offaded trunk-restraint program.

Conclusion

The results of our review demonstrated that the use of trunkrestraint as a treatment paradigm aimed at decreasingcompensatory strategies has the potential of becoming aneffective therapy. Further researches with randomizedcontrol trials are necessary to determine the long term effectand clinical efficacy of the trunk restraint training inhemiparetic patients.

References

1. Page SJ, Sisto S, Levine P and Mcgrath RE. Efficacy ofmodified constraint – induced movement therapy inchronic stroke: A single – blinded rendomized controlledtrial. Archives of physical medicine andRehabilitation.2004;85: 14 – 18

2. Bernstein NA. The coordination and regulation ofmovement. Oxford, UK: pergamon Press; 1967

3. Cirstea MC, Levin MF. Compensatory strategies forreaching in stroke. Brain.2000; 123: 940 – 953

4. Whishaw IQ. Loss of the innate cortical engram foraction patterns used in skilled reaching and thedevelopment of behavioural compensation followingmotor cortex lesions in the rat. Neuropharmacology.2000; 39: 788 – 805

5. Friel KM, Nudo RJ. Recovery of motor function aftercortical injury in primates: compensatory movementpatterns used during rehabilitative training. SomatoSens Mot Res. 1998; 15: 173 – 189

6. Cirstea MC, Ptito A, Levin MF. Arm reachingimprovements with short term practice depend on theseverity of the motor deficit in stroke. Exp Brain Res.2003; 152: 476 – 488

7. Ada l, Canning C, Carr JH, Kilbreath SL, Shepherd RB.Task – specific training of reaching and manipulation.In: Bennet KMB, Castiello u, eds. Insights into reachand grasp movement. Cambridge, UK: Elsevier –Biosoft; 1994: 239 – 265

8. Krakauer JW. Motor learning: its relevance to strokerecovery and neurorehabilitation. Curr Opin Neurol.2006; 19: 84 – 90

9. Michelsen SM, Lutta A, Roby – Brami A, Levin MF.Effect of trunk restraint on the recovery of reachingmovements in hemiparetic patients. Stroke. 2001; 32:1875 – 1883

10. Michaelsen SM, DEA, Levin MF. Short term effects ofpractice with trunk restraint on reaching movements inpatients with chronic stroke. Stroke. 2004; 35: 1914 –1919

11. Michaelsen SM, Ruth Dannenbawn, Levin MF: task –specific training with trunk restraint on arm recovery instroke. Stroke. 2006; 37: 186 – 192

12. Thielman G, Terry Kaminski, Gentile AM: rehabilitationof reaching after stroke: comparing 2 training protocolutilizing trunk restraint. Neurorehabil Neural Repair.2008; 22: 697 – 705

13. Woodbury ML, Howland DR, Mcguirk TE, Davis Sb,Senesac CR, Kautz S, Richards LG. Effects of trunkrestraint combined with intensive task practice onpoststroke upper extremity reach and function: A pilotstudy. Neurorehabil Neural repair. 2009; 23: 78 – 91

14. Roberta de Oliveira, Enio Walker Azevedo Cacho,Guilherme Borges. Improvements in the upper limb ofhemiparetic patients after reaching movements training.International Journal of Rehabilitation Research. 2007;30 (1): 67-70.

15. Carr J, Shepherd R, editors. Movement Science:Foundations for Physical therapy in rehabilitation. 2nd

ed. Gaithersburg: Aspen Publishers; 2000.16. Levin MF, Selles RW, Verheul MHG, Meijer OG. Deficits in

the range of regulation of central control over arm movementin stroke patients. Brain Res. 2000; 853: 352 – 369

17. Adamovich SV, Archambault P, Ghafouri M, Levin MF,

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Poizner H, Feldman AG. Hand trajectory variance inreaching movements involving the trunk. Exp BrainRes. 2001; 138: 288 – 303

18. Taub E, Miller NE, Novack TA, Cook EW III, FlemingWC, Neomuceno CS, Connell JS, Crago JE. Techniqueto improve chronic motor deficit after stroke. Arch PhysMed Rehabil. 1993;74: 347 – 354

19. Dean CM, Richards CL, Malouin F. Task – related circuittraining improves performance of locomotor tasks inchronic stroke: a randomized controlled pilot trial. ArchPhys Med Rehabil. 2000; 81: 409 – 417

20. Dean CM, shepherd RB. Task related training improvesperformance of seated reaching tasks after stroke.Stroke. 1997; 28: 722 – 728

21. Morris SL, Dodd KJ, Morris ME. Outcomes ofprogressive resistance strength following stroke: asystematic review. Clin Rehabil. 2004; 18: 27 – 39

22. Hsu WL, Yang YR, Hong CT, wang RV. Ankle muscleactivation during functional reach in hemiparetic andhealthy subjects. Am J Phys Med Rehabil. 2005; 84:749 – 755

23. Andrews k, Stewart J. Stroke recovery: He can but doeshe? Rheumatol Rehabil. 1979; 18: 43 – 48

24. Cirstea CM, Levin MF. Compensatory strategies forreaching in stroke. Brain. 2000; 123: 940 – 953

25. Levin MF, Michaelsen SM, Cirstea CM, Roby – BramiA. Use of the trunk for reaching targets placed withinand beyond the reach in adult hemiparesis.Experimental Brain Research. 2002; 143: 171 – 180

26. Roby – Brami A, Feydy A, Combeaud M, Biryukova EV,Bussel B, Levin MF. Motor compensation and recoveryfor reaching in stroke patients. Acta NeurologicaScandinavica. 2003; 107: 369 – 381

27. Ustinova KL, Goussev VM, Balasubramaniam R, LevinMF. Disruption of coordination between arm, trunk andcentre of pressure displacement in patients withhemiparesis. Motor control. 2004; 8: 139 – 159

28. Carr J, Shepherd R: Stroke Rehabilitation: Guidelinesfor exercise and training to optimize motor skill. NewYork, NY, Elsevier, 2003

29. Vanvliet P, Sheriddan M, Kerwin DG et al. The influenceof functional goals on the kinematics of reachingfollowing stroke. Neurol Rep. 1995; 19: 11 -16

30. Bernstein NA. The coordination and regulation ofmovement. Oxford, UK: Pergamon Press; 1967

31. Bernstein NA, Buravtseva GR. Coordinationdisturbances and restitution of the biodynamics of gaitafter brain damage. Thesis, 7th session, Institute ofneurology, Moscow. Academy of medical science. 1954

32. Whitall J. Stroke rehabilitation research: time to answermore specific questions? Neurorehabil Neyral Repair.2004; 18: 3 – 8

33. Will Thalheimer, Samantha Cook. How to calculateeffect sizes from published research: A Simplifiedmethodology. A work-Learning Research Publication.2002, August. Retrieved November11, 2009 from http://work-learning.com/effect_sizes.htm

34. Young DE, Schmidt RA. Augmented kinematicfeedback for motor learning. J Mot Behav. 1992; 24:261-273.

35. Adamovich SV, Archambault P, Ghafouri M, Levin MF,Poizner H, Feldman AG. Hand trajectory variance inreaching movements involving the trunk. Exp BrainRes. 2001; 138: 288 – 303.

36. Lennon S, Ashburn A. The bobath concept in strokerehabilitation: a focus group study of the experiencedPhysiotherapists’ perspective. Disabil Rehabil. 2000;22: 665 – 674.Cirstea C, Levin M. Improvement of arm movementpatterns and endpoint control depends on type offeedback during practice in stroke survivors.Neurorehabil Neural Repair. 2007; 21: 398 – 411

82

Factors affecting the quality of life in patients with strokeSuvarna GanvirAsso. Prof. Ravi Niar Physiotherapy College Sawangi (M) Wardha, Maharashtra

Abstract

Objectives

To study the factors that can independently predict health-related quality of life (HRQOL) 1 year after stroke.

Methods

a total no of 58 patients over a period of 2 yrs with first everhistory of stroke were assessed for initial stroke severitywithin 48 hrs of the onset & HRQOL using the Short Form 36(SF36) 1 year after stroke. Physical (PHSS) and mentalhealth (MHSS) summary scores were derived from the eightdomains of HRQOL in the SF36. To determine independentpredictors of these scores multivariate stepwise regressionanalyses were conducted; ß coefficients with 95% CI wereobtained. Demographic and stroke risk factors, initial strokeseverity neurological impairments and cognitive impairment(MMSE <24) were included in the models. Similar analyseswere undertaken on 150 subjects 3 years post-stroke.

Results

A year after stroke, independent predictors of the worst PHSSwere of females (ß coefficient –3.3: 95% CI –5.7 to –5.8),diabetes (–4.2: –7.7 to –0.8), right hemispheric lesions(–4.9: –8.7 to –1.2), initial stroke severity (–7.8: –11.6 to –4.1) and cognitive impairment (–2.7: –5.5 to –0.1); the worstMHSS were associated with being ischaemic heart disease(–2.7: –5.4 to –0.03), cognitive impairment (–3.04: –5.8 to –0.3). Subjects aged 60–70 years (5.4: 2.5 to –8.4) had betterMHSS than those <60 years.

Conclusions

factors affecting HRQOL vary whether physical orpsychosocial aspects of HRQOL are being considered. Thisstudy provides valuable information on factors predictingHRQOL, which can be taken into consideration in audits ofclinical practice or in future interventional studies aiming toimprove HRQOL after stroke.

Keywords

stroke, factors, quality of life,

Introduction

The term ‘quality of life’ (QOL) means a great many differentthings to different people. Indeed, this difference is rejectedboth in the numerous definitions applied by researchers,and also in the many instruments used in its measurement1.

However, despite such conceptual differences, most peoplewill agree that a stroke remains one of the major chronicillnesses world-wide that health-care organisations will needto address for the next several decades. This is because itcan affect virtually all human functions2, and unlike otherdisabling conditions, the onset of stroke is sudden, leavingthe individual and the family ill-prepared to deal with itssequelae2.

A review of stroke outcome measures in 174 acute stroketrials showed that death was recorded in 76%, impairmentin 76%, disability in 42% and handicap in only 2%3.Moreover it has been reported that patients’ views of whatconstitute important outcomes are not always identical tothose of health-care professionals4. Measurement ofHRQOL after stroke would provide researchers with a moreholistic picture of stroke recovery, especially because of thewide spectrum of symptoms and impairments associatedwith stroke5,6.

Treatment strsategies provided by the professionals in strokecare will be helped by the knowledge of the factorsassociated with HRQOL after stroke so that quality of lifecan be improved.various longitudinal studies conductedhave reported that age7, depression7,8,910, cognitiveimpairment11, disability7,8,9,10, aphasia8 and poor socialnetwork 9,10, to be associated with poor HRQOL. However,these studies lacked on various grounds whether it wasthat only hospitalized patients10,11,12,13,14, were included oronly patients in stroke rehabilitation units7,9, were taken upfor the study or whether specific age groups patients weretaken into consideration8,10,15, or whether only specific strokesubtypes were selected for the study11,12. Further the studieswere so designed that the subjects were assessed at varioustimes after stroke who may be at different stages of therecovery. Usually univariate anlysis was conducted only,so that it was difficult to comment on the independentpredictors of HRQOL. Till now only one study has takencognizance of independent predictors of HRQOL16

otherwise the knowledge regarding the same is lacking.

Thus this longitudinal study aimed to identify the factorsthat may influence HRQOL 1 years after stroke.

Methodology

Patients diagnosed as first time stroke were included in thestudy. For this study, subjects who sustained stroke between1 January 1997 until 31 December 1997 were included.Institutional Ethical committee Consent was obtained priorinclusion of the patients in the study. Stroke was definedaccording to the WHO criteria17. on initial assessment datawas collected in the form of patient demographics, riskfactors, and indicators of initial stroke severity using NIHSS.

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Strokes were classified using the Oxfordshire CommunityStroke Project Classification (OCSP)17.

Subjects were followed up at 1 year after stroke. HRQOLwas evaluated using the36 item Short-Form Health Survey(SF-36)18. The HRQOL assessments were done by askingthe subjects themselves. The patients were excluded if theywere too confused or dysphasic to undergo theseassessments themselves. Eight domains of health statusare assessed: Physical Functioning–PF; Role Physical–RP;Bodily Pain–BP; General Health–GH; Vitality–VT; SocialFunctioning–SF; Role Emotional–RE; and Mental Health–MH. Each domain is scored between 0 and 100. Thesedomains were then computed to produce two summaryscales representing physical and mental health18. Domainsfor physical health summary scale (PHSS) include PF, RP,BP and GH. Mental health summary scale (MHSS) includesVT, SF, RE and MH. The summary scales are based onnorms with a mean of 50 and a standard deviation of 10.SF36 has reliably been previously used to evaluate HRQOL

long-term after stroke and in all age groups19.To identify factors affecting PHSS and MHSS at 1 yearsafter stroke, multivariable analyses were conducted usingbackward stepwise regression analyses. All factors in Table1were included. Coefficients (ß) with 95% confidenceintervals were thus obtained for those factors that weresignificant in these models.

Results

There were 58 subjects referred to PhysiotherapyDepartment between 1 January 2007 and 31 December2007. 49 patients reported regularly for follow up for 1 year,9 patients were lost during the follow up.

Hrqol 1 year after stroke

Table 1shows the univariate comparisons of the twosummary scales at 1 year after stroke. Males were betterthan females (P = 0.025) in the aspect of PHSS, non-diabetics were better than diabetics (P < 0.001). Initialimpairments associated with worse PHSS includeddysphagia, visuo-spatial neglect, urinary incontinence andcognitive impairment. Subjects aged over 75 reported bettermean MHSS than those under 65 (P = 0.004).


Table 2: Multiple backward stepwise regression analysis to determine thefactors that are independently associated with PHSS at 1year after stroke

Variable Coefficient 95% Confidence P-valueinterval

Age group <55 0 —

56–65 0.35 –3.27 to 2.65 0.908 66-70 0.25 –3.69 to 2.65

Gender Male 0 — Female –3.31 –5.70 to –0.81 0.007

Diabetes No 0 — mellitus

Yes –4.23 –7.67 to –0.79 0.016Lateralityof stroke

Absent 0 — 0.046 Right (Left –4.97 –8.73 to –1.21

hemiparesis) Cognitive No 0 —impairment(MMSE <24)

Yes –2.70 –5.52 to –0.13 0.047

One year after stroke

Subjects, n (%) PHSS mean (sd) P-value MHSS mean (sd) P-valueAge group <55 34(69.38) 35.1 (12.0) 0.62 41.6 (15.8) 0.003

56–65 10 (20.4) 35.3 (12.9) 45.5 (12.4) 66-70 05 (10.2) 36.5 (12.2) 49.9 (12.3)

Gender Male 27(53.4) 40.2 (13.4) 0.04 45.3 (13.3) 0.42 Female 22(46.6) 35.6 (10.2) 45.3 (17.9)

Past Medical History Hypertension Yes 39(71.8) 35.9 (13.2) 0.06 49.7 (13.9) 0.44

No 10-(28.2) 35.1 (12.8) 46.1 (13.7) Diabetes mellitus Yes 15 (15.6) 31.9 (10.8) <0.001 45.4 (10.9) 0.32

No 34(84.4) 26.3 (12.5) 48.6 (15.9)TIA Yes 12 (20.7) 37.8 (13.0) 0.15 49.3 (14.7) 0.54

No 37(79. 3) 37.5 (12.4) 46.7 (12.2) Laterality of stroke

Right (Left hemiparesis) 35 (43.3) 34.5 (10.8) <0.001 46.1 (12.5) 0.54 Left (Right hemiparesis) 14 (35.3) 37.6 (12.9) 46.4 (12.1)

Initial impairments Dysphasia Yes 12 (16.6) 39.3 (13.7) 0.17 46.1 (12.0) 0.52

No 37 (83.4) 39.6 (12.1) 46.7 (12.1) Visuo-spatial neglect Yes 09 (15.9) 32.9 (10.1) 0.005 45.3 (12.2) 0.49

No 40 (84.1) 37.9 (12.6) 46.8 (12.1) Cognitive status MMSE<24 (impaired) 12 (24.4) 33.1 (11.3) <0.001 44.9 (11.9) 0.061MMSE 24–30 37(75.6) 39.1 (12.4) 47.4 (12.1)

Variable Coefficient 95% confidence P-valueinterval

Age group <55 0 — 56–65 4.99 2.45 to 8.38 <0.001 66-70 5.99 3.13 to 9.45

Ischaemic No 0 — 0.048heart disease

Yes –2.72 –5.41 to –0.030 Cognitive No 0 — 0.033impairment(MMSE <24)

Yes –3.04 –5.83 to –0.25

Table 3: Multiple backward stepwise regression analysis to determine factorsthat are independently associated with MHSS at 1year after stroke

84

Multivariable analyses (Table2) showed female sex(coefficient [ß], –2.36), diabetes (ß, –3.24), and cognitiveimpairment (ß, –1.90) independently predicted worse PHSS.Compared to TACI, PACI had better PHSS (ß, 5.95). Factorsindependently predicting MHSS (Table 3) revealed thatbeing older was associated with better MHSS: subjects aged65–75 (ß, 6.05) and over 75 (ß, 6.95) had better MHSS thanthose <65 years. Other predictors of poor MHSS were beingAsian (ß, –11.8), ischaemic heart disease (ß, –2.72) andcognitive impairment (ß, –3.04).

Discussion

This is a study done to identify the factors that areresponsible for predicting quality of life in patients with strokewith the help of SF36.diferent factors are responsible forphysical & psychosocial aspects of HRQOL. Poor physicalhealth 1 year after stroke is independently associated withfemale sex, diabetic patients right hemispheric lesions &cognitive impair,ment . Independent association of MHSSis found with Poor mental health 1 year after, under 55 yrsand cognitive impairment.

Second, although widely used, SF-36 is not a stroke-specificmeasure, but a generic measure that was developed toassess HRQOL outcomes that are affected by any diseaseor treatment. SF-36 may thus not be sensitive or specificenough to detect the psychological domains of mentalhealth that are relevant to stroke 21. Third, SF-12 was usedfor some subjects instead of SF-36, though the summaryscores produced by either of them have been shown to bereplicable5. Finally, there are other potential determinantsof HRQOL that were not examined in this study such asdepression, the role of informal carers, the quality of strokecare given to these subjects, and the quality and quantity ofsocial support available.

In our study we found variations in associations of PHSSand MHSS & it may be due to the fact that these scalesessentially measure different domains of HRQOL, that is,physical and mental health. Thus, factors that are associatedwith one aspect of HRQOL may not necessarily beassociated with the other. The results of this study thusconfirm that a multidimensional approach is essential forcomplete assessment of HRQOL.

In contrast to previous studies8,15,23, this study showed thatage was inversely associated with mental health at 1 yearafter stroke. It may be due to either younger subjects beingless able to cope psychosocially with the stroke than oldersubjects, or they may have higher expectations of health,reflecting one of the definitions of HRQOL as the gapbetween our expectations of health and our experience of it24.

One of the predictors of poor HRQOL are the females as,have been previously described15,25. Lower subjective well-being in women may be due to a socio-cultural effect ofwomen routinely taking responsibility for householdmanagement until they reach an advanced age25. Hence, itmay be more difficult for their male partners to look afterthem once they are disabled by stroke, hence reducingtheir HRQOL. Lower socio-economic status and poorHRQOL has also been previously described10,15 and maybe due to the fact that the social network and resourcesavailable are limited. Further associations between stroke

risk factors including diabetes, hypertension and ischaemicheart disease and HRQOL long-term after stroke were alsoexamined. These associations may be due to the additiveeffects of the conditions themselves, and emphasise thehypothetical potential of improving HRQOL after stroke bymanaging the risk factors more effectively after stroke. right hemispheric lesions were to be significantly associatedwith poor PHSS at 1 year after stroke. This confirms previousreports that also found HRQOL to be worse in those withright-sided lesions23. This may be due to associatedneurological disturbances including neglect, anosognosiaand spatial disorientation which may have devastatingeffects on social functioning and thus on HRQOL.

Conclusion

Various factors are associated with physical & psychosocialaspects of HRQOL which if taken into consideration whileplanning the rehabilitation programmes will improve theoutcome of the programme in terms of improved quality oflife.

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17. Stewart J, Dundas R, Howard RS, et al. (1999) Ethnicdifferences in incidence of stroke: prospective studywith stroke register. BMJ 318 967–71.

18. Aho K, Harmsen P, Hatano S, et al. (1980)Cerebrovascular disease in the community: results ofa WHO collaborative study. Bull World Health Organ58 113–30.

19. Bamford J, Sandercock P, Dennis M, et al. (1991)Classification and natural history of clinically identifiablesubtypes of cerebral infarction. Lancet 337 1521–26.

20. Ware JE, Snow KK, Kosinski M, et al. (1993) SF 36 ®

Health Survey: Manual and InterpretationGuideLincoln, RI Quality Metric Incorporated.

21. Ware JE, Kosinski M, Keller SD. (1994) SF-36 Physicaland Mental Health Summary Scales: A User’sManualBoston, MA The Health Assessment Lab.

22. Hackett ML, Duncan JR, Anderson CS, et al. (2000)Health-related quality of life among long-term survivorsof stroke:results from The Auckland Stroke Study, 1991–1992. Stroke 31 440–7.

23. Ware JE, Kosinski M, Keller SD. (1998) SF-12 ®: Howto score the SF-12® Physical and Mental HealthSummary Scales 3rd edition Lincoln, RI Quality MetricInc.

24. de Haan R, Limburg M, Meulen V, et al. (1995) Qualityof life after stroke. Impact of stroke type and lesionlocation. Stroke 26 402–8.

25. Carr AJ, Gibson B, Robinson PG. (2001) Is quality oflife determined by expectations or experience? BMJ322 1240–3.

26. Carod-Artal J, Egido JA, Gonzalez JL, et al. (2000)Quality of life among stroke survivors evaluated 1 yearafter stroke. Experience of a stroke unit. Stroke 312995–3000.

27. Sneeuw KC, Aaronson NK, de Haan RJ, et al. (1997)Assessing quality of life after stroke. The value andlimitations of proxy ratings. Stroke 28 1541–9.

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Effectiveness of plantar fasciitis taping and calcaneal taping inplantar heel pain - A randomized clinical trialBagewadi Vishal,* Metgud Santosh,** B.R. Ganesh****Post Graduate Student, **Lecturer, ***Assistant Professor, K.L.E.S, J.N. Medical College Campus, Belgaum, Karnataka,India

Abstract

Purpose of study: The objective was to compare theeffectiveness of Plantar Fasciitis taping and CalcanealTaping in Plantar Heel Pain in terms of pain and functionalability.

Material and methods

60 participants with plantar heel pain were randomlyassigned to Group A (Therapeutic ultrasound + Stretching+ Calcaneal Taping) and Group B (Therapeutic ultrasound+ Stretching + Plantar Fasciitis Taping) during the studyperiod of April 2008 to January 2009. The outcomemeasures were visual analogue scale (VAS) and functionalability level in terms of Foot Function Index (FFI). Pre andpost session intervention values of outcome measures werenoted on 1st and 7th day of intervention.

Results

In this study we found that there was significant change inpain relief as per VAS score (p<0.001) and improvement infunctional ability as per FFI (p<0.0001).

Conclusion

This randomized clinical trial consisting of Plantar fasciitistaping and Calcaneal taping along with therapeuticultrasound and stretching in plantar heel pain showedimprovement following 7 days of treatment as per significantdecrease in pain as per VAS and improvement in functionalability level as per FFI and can be used as an effectivetreatment regime in participants with plantar heel pain.

Key words

Plantar Heel Pain; Calcaneal Taping; Plantar FasciitisTaping; Therapeutic Ultrasound; Stretching; FFI.

Introduction

My feet are killing me!” While our feet may not literally be“killing” us, foot and ankle problems can have a significantimpact on our general health and well-being.1 Heel pain isone of the most common foot problems, especially amongolder individuals. Mechanical causes contributeapproximately 90% and non functional etiologies constituteremaining 10% of patients.2 Plantar fasciitis is one of themost common cause of heel and foot pain experienced by10% of population.3,4 Therefore, individuals suffering fromwhat has traditionally been referred to as plantar fasciitismay be more accurately described as plantar heel pain. .

The plantar fascia acts like a bowstring to maintain andprovide support for longitudinal arch of the foot and to assistwith dynamic shock absorption. The plantar fascia plays animportant role in providing foot support and rigiditythroughout the gait cycle.5

Numerous nonsurgical treatments have been used torelieve the symptoms associated with heel pain. Theseinclude rest, exercises (stretching& strengthening) orthotics,night splints and taping. Modalities like cryotherapy,therapeutic ultra sound with and without analgesic gel,electrical stimulation, whirlpool and administration ofNSAIDS through ionotophoresis or injections.3

Stretching is a part of physical fitness and rehabilitationprograms because it is thought to positively influenceperformance and injury prevention.6 Stretching is thedeliberate act of lengthening of muscles, in order to increasemuscle flexibility and/or joint range of motion. Stretchingappears to be the easiest, most useful technique to alleviatethe symptoms associated with plantar heel pain. Stretchingof the Achilles tendon and plantar fascia, performed 3 – 5times daily, has been shown to be effective in decreasingthe pain at the plantar fascia.7 Taping is an effective methodand is widely used in a variety of diagnosis andmusculoskeletal conditions. During rehabilitation, tapingaids in healing process by supporting and protecting theinjured structures from further injury or stress. It is commonway to relieve the symptoms of plantar fasciitis and is widelyused to add support, reduce stress and relieve pain on theplantar fascia.8 Foot tapings or strappings are extremelyvaluable since they remain in place 24 hours a day for 7 to10 days. Therapeutic ultrasound is a method of applyingdeep heat to connective tissue.9 Which relieves plantar heelpain by both thermal and mechanical effect.10, 11 A recentreview of the literature for plantar heel pain interventionsconcluded that there was no quality information regardingthe effectiveness of plantar heel pain. Although limitedevidence exists, no conclusive evidence has been found todemonstrate the effectiveness of plantar fasciitis taping &calcaneal taping. Thus this study intends to compare theeffectiveness of two taping techniques in subjects withplantar heel pain.

Methodology

Source of Data: Data was collected from physiotherapyOPD of KLES Dr. Prabhakar Kore Hospital and MRC, KLESAyurved Hospital and Research Center, Belgaum duringthe study period of April 2008 to January 2009.

Study Design

The study design used for this research was randomized

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clinical trial. For this R.C.T ethical clearance was obtainedfrom the institutional ethical committee, JNMC, Belgaumbefore commencement of the study

Study sample

The study sample had 60 participants consisted of bothmale and female participants referred to the physiotherapyoutpatient department with clinical diagnosis of plantar heelpain.

Inclusion criteria

1. Clinically diagnosed cases of plantar heel pain.2. Age 18 – 65 years3. Symptoms of plantar heel pain for >1 month.4. Pain located at the heel or plantar surface of the mid

foot consistent with plantar fasciitis.

Exclusion criteria

1. Clinical disorder where therapeutic ultrasound iscontraindicated.

2. Previous surgery or treatment for plantar fasciitis in theprevious six months. (including use of pain or antiinflammatory medications)

3. History of ankle or foot fracture.4. Congenital deformities of foot or ankle.5. Spasticity throughout the lower extremity6. Impaired circulation to lower extremities7. Referred pain due to sciatica & other neurological

disorders.

Procedure

All the participants with clinically diagnosed as plantar heelpain were screened after finding their suitability as per theinclusion & exclusion criteria were requested to participatein the study & were briefed about the nature of the study &the intervention. After briefing them about the study, theirinformed written consent was taken. The demographic dataof all the participants consisting name, age, sex, height,weight & BMI were collected. The side affected and durationof symptoms was noted & initial evaluation for theircomplaints & brief focused history including history ofsmoking, claudication, previous foot infection, & ulcer wasobtained. This was followed by objective assessment of theinvolved foot for tenderness, temperature, swelling, painon plantar fascia stretch and pain intensity in terms of theVisual Analogue Scale (VAS). In addition to this functionalassessment was carried out using Foot Function Index.Following this participants were randomly allocated to twogroups.

Group A

Calcaneal Taping

a) Therapeutic ultrasound with continuous mode,intensity of 1W/cm2 & with frequency of 1MHz for fiveminutes was given in prone lying for seven sittings with1 sitting per day.

b) Passive stretching of ankle flexors & plantar fascia

was performed in supine lying. The soleus muscle wasstretched with knee flexed and gastrocnemius with kneeextended. Over pressure was placed upon the bottomof the foot while the ankle was in dorsiflexion. A passivestretch was applied to the big toe flexors to incorporatestretch to the plantar fascia. This was given for threerepetitions each held for a count of 30 seconds, sevensittings with 1 sitting per day.

c) Calcaneal Taping: Following the conventionaltreatment, Adhesive tape was applied to a clean anddry surface. Piece one of Adhesive tape was appliedjust to the lateral malleolus pulling the calcaneusmedially & is attached to the medial aspect of the footdistal to the medial malleolus. (Photograph 1) Piecetwo & three of Adhesive tape follows the same patternwith over lap of approximately one third of the tapewidth moving in the distal direction. (Photograph 2 &3)Piece four of Adhesive tape was put around the back ofthe heel starting distal to the lateral malleolus, wrappingaround the posterior aspect of the calcaneus &anchoring distal to the medial malleolus. (Photograph4) Piece four of Adhesive tape also serves as an anchorfor the first three pieces.

Group B

Plantar fasciitis taping

Following the conventional treatment with therapeuticultrasound and stretching as discussed above, with the ankleslightly plantar flexed, adhesive tape was applied at theposterior aspect of the heel & firmly pulled towards themetatarsal heads. Once adequate tension was applied theadhesive was pressed against the plantar aspect ofmetatarsal heads. (Photograph 5)

Next, a adhesive tape was applied as an anchor strip fromthe medial aspect of the first metatarsal, around the heel tothe lateral aspect of the fifth metatarsal head. (Photograph6a & 6b) Following it a 5 cm adhesive tape was appliedaround the mid foot area. This circular strip should begin onthe dorsal aspect, go lateral & continue across the plantaraspect to the foot’s medial portion, crossing the tape ends.It was closed off with a strip of tape. (Photograph 7)Outcome was assessed, at the end of 7th day of intervention,based on Foot Function Index for functional ability and painon VAS.

Results

The result of this study was analysed in terms of decreasein pain as per VAS and improvement in functional ability interms of FFI.


Statistical analysis was done by the statistical package ofsocial science (SPSS) version 13. Statistical measures suchas unpaired ‘t’ tests and paired ‘t’ tests were used to analyzethe data. The results were concluded to be statisticallysignificant with p< 0.05. Paired ‘t’ tests were used tocompare the differences of scores on day 1 and day 7th

within a single group. Unpaired ‘t’ tests were used tocompare differences between the two groups, Calcanealtaping group and the Plantar fasciitis taping group.


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Demographic profile

Each group had 30 participants each. The mean age of theparticipants in Group A was 38.5years ±15.35 years andthe mean age of the participants in Group B was 38.3years±14.1 years. The difference in mean age of two groups wasnot statistically significant (p= 0.958). The gender ratio ofGroup A was 16:14 (16 males and 14 females) and GroupB was 19:11 (19 males and 11 females) and this was notstatistically significant (÷2=0.617, p=0.432). Therefore boththe groups are matched with respect to age and gender.

Clinical parameters

The participants treated within group and between groupsshowed a statistically significant decrease in pain as perVAS p<0.001 and improvement in functional ability in termsof FFI with p<0.0001.In the Group A, the mean VAS score on 1st day presessionwas 6.9 ± 1.36 which was reduced to 2.7 ± 1.55 on postsession i.e. on the 7th day with (p=0.0001) and in Group B,it was reduced from 6.8 ± 1.36 to 4.1 ± 1.41 on the postsession i.e. on 7th day with (p=0.0001). Unpaired ‘t’ test pvalues were 0.850 and <0.001 respectively which wasstatistically significant. (Table No. 1 and Graph No. 1)In the Group A, the mean FFI on 1st day pre session was 46±12.36 which reduced to 16.2± 10.77 on post session i.e.on the 7th day with (p=0.0001). In Group B, from 45.7 ±14.72 it reduced to 27.7 ± 10.98 on post session i.e. on the7th day with (p=0.0001).Unpaired ‘t’ test p values 0.932 and 0.0001 respectivelywhich was statistically significant. (Table No. 2 and GraphNo. 2)

Discussion

The present clinical trial was conducted to compare theeffectiveness of Plantar Fasciitis Taping and CalcanealTaping in Plantar Heel Pain with a common treatment ofTherapeutic Ultrasound and Stretching to both the groups.There was significant decrease in pain in terms of VAS forboth the groups with the usage of therapeutic ultrasound inthe present study and a similar study was performed byHana Hronkova12 in 2000 and Young and Dyson13

concluded that ultrasound plays the vital role in plantarheel pain by mild heating which have the effect of reducing

pain, muscle spasm and promoting healing process.14 Inthe present study participants of both the groups receivedstretching as a part of conventional treatment and showedmarked reduction in pain and improvement in physicalfunction in both the groups and it correlates with the studywhich states that stretching appears to be the easiest, mostuseful technique to alleviate the symptoms associated withplantar heel pain. Stretching is a general term used todescribe any therapeutic maneuver designed to increasemobility of soft tissue and subsequently improve range ofmotion (ROM) by elongating (lengthening) structures thathave adaptively shortened and have become hypomobileover time.15 A study conducted on participants with chronicplantar fasciitis were treated with specific plantar fasciitisstretching programme for eight weeks & concluded thatthere is a better functional outcome and decrease in painwith first step in the morning than patients managed withstandard Achilles tendon stretching protocol.8 In the presentstudy Group A had received calcaneal taping, and the resultcorrelates with the study performed by Hyland MR(2006) inwhich, one of the group received calcaneal taping for plantarheel pain which showed significant reduction in pain.16.Group B had received plantar fasciitis taping and the resultcorrelates with the study performed by Radford JA(2006) inwhich, one of the group received plantar fasciitis taping forplantar heel pain which showed significant reduction inpain.17 Taping is applied to limit unwanted joint movement,to protect from further injury by supporting ligaments,tendons and muscles, to allow healing without stressingthe injured structures. It is common way to relieve thesymptoms of plantar fasciitis and is widely used to addsupport, reduce stress and relieve pain on the plantarfascia.8 The FFI is a self-administered index consisting ofthree domain or subscale, ie., activity limitation, pain anddisability. Participants were asked to answer the questionsrelated to their pain and activity who were asked to scoreeach question on a scale from 0 (no pain) to 10 (worst painimaginable).18 FFI was used in the present study as itincludes all the activities which are part of our daily normalfunction.

Limitation

1. Small sample size.2. Study was confined to plantar heel pain of non specific

and non traumatic conditions.

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Table No:1 Comparison of VAS between the groups

Groups Pre session Post session MeanA 6.9 ± 1.36 2.7 ± 1.55 4.2 ± 1.29B 6.8 ± 1.36 4.1 ± 1.41 2.7 ± 0.79‘t’ 0.195 3.763 5.401DF 58 58 58‘p’ value 0.850 <0.001 <0.001

Table No:2 Comparison of FFI between the groups

Groups Pre session Post session MeanA 46 ± 12.36 16.2± 10.77 29.8 ± 9.48B 45.7 ± 14.72 27.7 ± 10.98 18 ± 6.67‘t’ 0.085 4.095 5.576D F 58 58 58‘p’ value 0.932 <0.0001 <0.0001

Graph No.1 Comparison of VAS between the groups Graph No:2 Comparison of FFI between the groups

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3. Duration of the study was short.

Conclusion

On the basis of present study, it can be concluded that, therandomised clinical trial provided evidence to support theuse of physical therapy regimen in the form of PlantarFasciitis Taping and Calcaneal Taping in reduction of painand improvement in functional ability in terms of VAS andFFI respectively in the treatment of Plantar Heel Pain. Inaddition, results support that group A showed better resultscompared to group B.Calcaneal tapingPhotograph no.1

Photograph no. 2

Photograph no. 3

Photograph no. 4

Plantar fasciitis taping

Photograph no. 5

Photograph no. 6a

Photograph no. 6a

Photograph no. 7

References

1. www.apta.org/Taking Care Of Your Foot And Ankle:1996;2.

2. C. A. Selth, B. E. Francis. Review of non-functionalplantar heel painThe Foot, 2000;2:92-104.

3. Gill LH. Plantar fasciitis: diagnosis and conservativemanagement. J Am Podiatr Med Assoc. 1997; 5:109-117.

4. Ryan J. Use of posterior night splints in the treatmentof plantar fasciitis. Am Fam Physician.1995; 52: 891-898, 901-892.


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5. Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis.Etiology, treatment, surgical results, and review of theliterature. Clin Orthop. 1991; 185 196.

6. CA Knight et al, Effect of Superficial Heat, Deep Heat,and Active Exercise Warm-up on the Extensibility ofthe Plantar Flexors, Phys Ther: 2001;81(6):1206-1214.

7. Genova JM, Gross MT. Effect of foot orthotics oncalcaneal eversion during standing and treadmillwalking for subjects with abnormal pronation. J OrthopSports Phys Ther.2000; 30: 664-675.

8. Digiovanni BF, Nawoczenski DA, Lintal ME, More EA,Murray JC, Wilding GE, and Baumhaver JF J. BoneJoint Surg AM2006Aug:88;8:1775- 1781.(Pub Med)

9. Hecox B, Mehreteab TA,Weisberg J, eds. PhysicalAgents: A Comprehensive Guide for PhysicalTherapists. East Norwalk, Conn: Appleton & Lange,1994.

10. Draper DO, Ricard MD. Rate of temperature decay inhuman muscle following 3 MHz ultrasound: thestretching window revealed. Journal of AthleticTraining.1995; 30:304–307.

11. Draper DO, Castel JC, Castel D. Rate of temperatureincrease in human muscle during 1 MHz and 3 MHz


continuous ultrasound. J Orthop Sports PhysTher.1995; 22:142–150.

12. Ernst B, Walker M, Echternach J, Hoke B: Windlasstaping technique for symptomatic relief of plantarfasciitis. Phys Ther.1999; 79: 34-39.

13. Young SR and Dyson, M. “Macrophagesresponsiveness to therapeutic ultrasound”. Ultrasoundin medicine and Biology, 1990, 16, 261-269.

14. Dyson M. Mechanisms involved in therapeuticultrasound. Physiotherapy, 1987; 73, 116-20.

15. De Deyne, PG: Application of passive stretch and itsimplication for muscle fibers. Phys Ther.2001:81(2):819-827.

16. Joel A Radford, Karl B Landorf: Effectiveness of low-Dye taping for the short-term treatment of plantar heelpain: A randomised trial. BMC MusculoskeletalDisorder 2006; 7: 64.

17. Lapidus P.W, Guidotti F.P, Painful heel: Report on232 patients with 364 painful heels. Clin Ortho.1965;39:178.

18. http://www.drfoot.co.uk/heel%20pain.htm(Heel pain).

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Comparative effectiveness of static stretching and muscle energytechnique on hamstring flexibility in normal Indian collegiate malesMohd. Waseem1, Shibili Nuhmani2, C. S. Ram3

1MPT Student, 2Lect. Deptt. of Rehabilitation of Science, Jamia Hamdard University, New Delhi, 3Director, ITS PhysiotherapyCollege, Ghaziabad

Abstract

Purpose of Study

To compare the effectiveness of Static stretching and Muscleenergy technique on hamstring flexibility in normal Indiancollegiate males.

Material and Methods

20 healthy collegiate male subjects with hamstring tightnesswere randomly allocated to two study groups. Groups-Asubjects were treated with static stretching where as othergroup subjects were treated by Muscle energy technique.The treatment was given for 5 consecutive days and a follow-up measurement on 8th day. The outcome was measured interms of Popliteal angle (Active knee extension test).

Results

Independent-t test was used to compare the pretest-posttestvalues between the groups. There was a significantdifference between the subjects treated with static stretchingand subjects treated with Muscle energy technique in termsof improvement in Active knee extension range of motion/Popliteal angle (p<.007) and significance decreases inROM in the follow up measurement .

Conclusion

Static stretching is more effective than muscle energytechnique in improvement of hamstring flexibility in normalIndian collegiate males.

Key Words

Static Stretching, Muscle Energy Technique, Popliteal angle(AKE), Hamstring flexibility.Most medical professional, coaches and athletes consideraerobic conditioning, strength training and flexibility asintegral components in any conditioning program.1 Flexibilityhas been defined as the ability of a muscle to lengthenallow one joint (or more than one joint in a series) to movethrough a range of motion (Russell, 2004; Sharon, 1993; M.J. Alter, 1998).1,2,3,16

Flexibility is a physical fitness attribute and is often evaluatedfrom the joint range of motion (ROM)3, on essential elementof normal biomechanical functioning in sports. Muscle tissuelength is thought to play an important role in efficiency andeffectiveness of human movement (Richard, 1991)4.Hamstring muscle injuries are one of the most commonmusculotendinous injuries in the lower extremity.2,4 Theyoccur primarily during high speed or high intensity exercises

and have a high rate of recurrence.5 Worrel et al stated thata “lack of hamstring flexibility was the single most importantcharacteristics of hamstring injuries in athletes”.Static stretching is one of the safest and most commonlyperformed stretching methods used to measure musclelength (C. D. Weijer et al, 2003)5. This type of stretch isapplied slowly and gradually at a relatively constant forceto avoid eliciting a stretch reflex. The literature supports thata static stretch of 30 seconds at a frequency of 3 repeatedstretches per single session is sufficient to increase musclelength.6

Muscle energy technique (MET) is an manual techniquedeveloped by osteopaths that is now used in many differentmanual therapy professions.7One such approach whichtargets the soft tissues primarily (although it makes a majorcontribution towards joint mobilization) has been termedas muscle energy technique and this is also known as activemuscular relaxation technique (Ballantyne, 2003; Leon,2001).7,8 It is claimed to be effective for a variety of purposesincluding lengthening a shortened muscles, as a lymphaticor venous pump to aid the drainage of fluid or blood andincreasing the range of motion.

Methodology

Sources of data

The sources of data for this study was conducted atMajeedia Hospital, Hamdard University, New Delhi.

Study Design

Experimental study with a pretest-posttest design. The studydesign was approved by the research committee of JamiaHamdard University.

Subjects

Twenty healthy normal Indian collegiate male volunteerswere selected on the basis of the inclusion and exclusioncriteria. A written informed consent was obtained from allthose subjects who fulfilled the inclusion and exclusioncriteria.Inclusion criteriaa) Aged between 18- 25 year of age.b) Gender- Male.c) Tight hamstring (Inability to achieve greater than

160° of knee extension with hip at 90° of flexion).

Exclusion criteriaa) Acute or chronic low back pain.

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b) Acute or chronic hamstring injury.c) Inhibition to actively extend the knee fully in sitting

position.d) Visual acute swelling in the region of hamstring

muscle.

Procedure

Subject was assessed for hamstring tightness by measuringpopliteal angle i.e. active knee extension test (Fig.3)1. Thetesting was taken over 5 days period with each subjects inboth group A and B receiving one treatment session in aday for consecutive 5 days and follow up measurement on8th day. The subjects were tested approximately at the sametime of each day.

Group-A (Static stretching)

After pre-treatment range of motion measurement of Group-A subjects were asked by the investigator to endure asmuch stretching force a possible without pain when theknee was passively and gradually extended in the ActiveKnee Extension test position. Readjustment of the stretchingforce was made after 15 seconds of stretching when thesubject’s perception of maximum stretch tolerance wasdecrease considerably (Fig.1). This readjustment wasperformed to maintain the maximum stretching force duringmost of the static stretch period, which lasted for 30 seconds.This sequence was repeated 3 times per lower extremitywith 10 seconds rest intervals between each stretch.5, 12

Group-B (Muscle Energy Technique)

The muscle energy technique was applied to theexperimental group B. The subject’s knee was extended tothe position where the subject first reported of any hamstringdiscomfort and moderate isometric contraction (approx 75%of maximal) of the hamstring muscle was then elicited for aperiod of five second (Fig.2). After a period of three secondsof relaxation, the technique was repeated three times (for atotal of four contractions)7.

Results

The result of this study was analyzed in terms of gain rangeof motion (Popliteal angle) in both group-A and B subjects.

Data analysis

Statistical analysis was done by using SPSS-15 software.The results were found to be statistically significant withp<0.05.Between groups comparison was done by usingindependent-t test and within group comparison wasanalyzed by repeated measure ANOVA test.

Demographic profile

Data (Age, Height and weight) of all subjects was recorded.The mean age of Static stretching (SST) group was 22.4years with S.D. ± 1.0, the mean age of Muscle energytechnique (MET) group was 22.1 years with S.D. ± 1.1.Static stretching group subjects were having mean weight60.7 kgs with S.D. ± 10.1 and MET group was 60.4 kgs withS.D. ± 10.7. Mean height of SST was 159.9 (Cms.) with S.D.± 4.5 and MET group was 163.8 (Cms.) with S.D.± 6.8.Thereis no significant difference between groups in terms ofdemographic variables.

Popliteal angle

Within group analysis

In both groups values of Popliteal angle (degree) showsthat the mean range of motion during post test is higherthan that during pretest, follow up values is lesser than posttest value but higher than pretest value after application ofstatic stretching and Muscle energy techniques (p<.05).

Between group analysis

Group-A and B shows significant difference with p value is0.007 (lesser than 0.05). Follow Up: Group-A and B showssignificant difference with p value is .007 (lesser than .05).

Discussion

The review of existing literature regarding the role of differenttechniques in improving flexibility reveals a confusingpicture so as to which technique out of Static Stretching,Muscle Energy Technique is best for the purpose. Thereforethe current study was undertaken to compare the abovetwo techniques and to determine which is better in the longrun. For the purpose of this comparison a pre–post test,


Fig.1: Application of Static Stretching

Fig. 2: Application of Muscle energy technique

Fig 3: Popliteal Angle (Active Knee Extension test)

93

follow up (experimental study) was carried out. Hamstringwas the muscles of choice since it is the muscle that is mostprone to injuries during sporting activities, and if the flexibilityof hamstrings is adequate the incidence of hamstringsstrains can be decreased and performance can beenhanced as well. Also there are well documented, reliableand valid methods of testing flexibility of hamstring muscles,such as the measure of popliteal angle.A comparison of the pre-test and the post test values of thePopliteal angle for the groups shows that there is asignificant improvement in all the groups. Thus it may besaid that these techniques are effective individually inimproving flexibility of hamstrings.Improvement seen in static stretching (SST) group wasexpected considering the previous research studies thatprovide consistent evidence regarding the effectiveness ofSST as a technique to improve flexibility. C. D. Weijer et al(2003)5 reported that the positive effect of SST on hamstringmuscle length immediately after 15 minutes and over thecourse of 24 hours. Gorniak et al (2003)24 have also shownan increase in flexibility of hamstring and knee range afterstatic stretching as measured by active knee extension test.Whereas MET in the present study is comparable to thatseen in earlier researches Bandy et al 14,6 identified 30seconds as the optimal duration for an effective stretch;MET, which can maintain muscle elongation for this duration,may produce increase in muscle length by a combinationof creep and plastic change in the connective tissue .24

Ballantyne F et al (2003)7 reasoned that an increase inflexibility after muscle energy technique (MET) occurreddue to biomechanical or neurophysiological changes ordue to an increase in tolerance to stretching.Keitaro Kubo et al, 20009 suggested that stretchingdecreased the Viscosity of tendon structures but increasedthe elasticity i.e. the stiffness of the muscle.9 A study by C.De Weijer et al (2003)5 also shows that the static stretchingresulted in an increased flexibility due to changes inviscoelastic properties. They related the resultant increasein muscle length to viscoelastic behavior i.e. this type ofstretching may adjust the positional sensitivity of the Golgitendon organs by affecting the series elastic component ofthe muscle.

At the time of follow-up the values of Popliteal angle washigher than the pre-test values but showed a decrease fromthe post-test values. Thus an analysis of the muscle flexibilityafter 72 hours of the end of training did not reveal a significantmaintenance of flexibility. The deterioration from the post-test values at the time of follow-up can be attributed to thefact that there was no maintenance program that was beingfollowed during that period, and the subjects were notundergoing any active or passive stretching regime duringthose 72 hours.

Conclusion

It concluded that both Static stretching and Muscle energytechniques cause flexibility gains. Also out of thesetechniques, static stretching resulted in maximumimprovement in hamstring flexibility/range of motion ascompared to Muscle energy technique (MET).

References

1. Russell T, Nelson, William D Bandy: Eccentric trainingand static stretching improve hamstring flexibility ofhigh school males. Journal of Athletic Training,2004;Vol. 39; Number 3;254-258.

2. S. Sharon Wang, Susan L Whitney: Lower extremitymuscular flexibility in long distance runners. Journal ofOrthopedic Sports Physical Therapy, 1993 ;Vol. 17;Number 2;102-107.

3. Emika kato,Toshiaki Oda, Yasuo Kawakami:Musculotendinous factors influencing difference inankle joint flexibility between women and men,International Journal of Sports and Health Science,2005;Vol. 3; 218-225

4. Richard L. Gajdosik, Effect of static stretching on themaximal length and resistance to passive stretch ofshort hamstring muscles, Journal of Orthopedic SportsPhysical Therapy, December 1991; Vol. 14; Number 6,250-255.

5. C. D. Weijer, C Gorniak: The effect of static stretch andwarm up exercise on hamstring length over the courseof 24 hours, Journal of Orthopedic Sports PhysicalTherapy, 2003; Vol.33; Number 12; 727-732.

6. William D Bandy, Jean M I rion, Michelle Briggler, Effectof time on static stretch and dynamic range of motionon the flexibility of hamstring muscle, Journal ofOrthopedic Sports Physical Therapy, April 1998; Vol.27; Number 4, 295-300.


Graph.1: Within-Group Comparison

POP. 0: Pre test value of Popliteal Angle (Active Knee Extension).POP. 1: Post test value of Popliteal Angle (Active Knee Extension).POP. F: Follow up value of Popliteal Angle (Active Knee Extension).Group-A: The group that received Static Stretching intervention.Group-B: The group that received Muscle Energy Technique intervention.

Mean ± S.D.

Variable Group-A Group-B Sig.(2-tailed)POP 0 129.5 ± 2.8 130.4 ±3.8 0.564POP 1 141.4 ± 3.8 136 ± 4.0 0.007POP F 139.3 ± 3.7 134.5 ±3.3 0.007

Graph-2: Between-Group Comparison

POP 0: Pre test value of Popliteal Angle (Active Knee Extension).POP 1: Post test value of Popliteal Angle (Active Knee Extension).POP F: Follow up value of Popliteal Angle (Active Knee Extension).Group A: The group that received Static Stretching intervention.Group B: The group that received Muscle Energy Technique intervention.

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7. Ballantyne F, Fryer G, Mclaughlin P. The effect of muscleenergy technique on hamstring extensibility: themechanism of altered flexibility. Journal of OsteopathicMedicine, 2003; Vol.6; Number 2; 59-63.

8. Leon Chaitlow, Craig Liebenson: Muscle EnergyTechniques, SECOND EDITION, 2001.

9. Keitaro Kubo et al, Influence of static stretching onviscoelastic properties of human tendon structures invivo. Journal of applied physiology, 2001; 90: 520-527.

10. D Murphy, D. A. J. Connolly, B D Beynnon: Risk factorsfor lower extremity injury: a review of the literature, BritishJournal of Sports Medicine ,2003;Vol. 37; 13-29.

11. Daniel C Funk, Ann M.Swank et al, Impact ofprior exercise on hamstring flexibility: A comparisonof muscular of properioceptive neuromuscularfacilitation and static stretching .,2003; Vol . 17:IssueNo. 3: 489-492.

12. Laura C Decouster, Joshua Cleland;The effect ofhamstring stretching on range of motion ,A systemicReview, Journal of Orthopedic Sports PhysicalTherapy, 2005; Vol.35; Number 6, 377-387.

13. Ward R.C.,et al: Foundation for osteopathic medicine,1ed. Philadepia: Lippincott Williams &Wilkins, 1997.

14. Wiliam D Bandy, Michelle Briggler: The effect of timeand frequency of static stretching on flexibility of thehamstring muscles. Physical Therapy, 1997; Vol. 77;Number 10; 1090-1096.

15. Teddy W Worrell, Troy L. Smith ,Jason Winegardner:


Effect of hamstring stretchingon hamstring muscleperformance., Journal of Orthopedic Sports PhysicalTherapy, 1994; Vol. 20; Number 3; 1154-159.

16. Ross A Clark: Hamstring injuries : Risk assessmentand injury prevention., Ann Acad. Med. Singapore,2008; Vol.37; 341-6.

17. Richard L, Gajodsik, Melonie A, Rieck, and Debra K,Sulivan , Comparison of four clinical tests for assessinghamstring muscle length, Journal of Orthopedic SportsPhysical Therapy, 1993; Vol. 18; Number 5, 614-618.

18. R Bahr, I Holme et al, Risk factor for sports injuries–amethodological approach.; British journal of sportsmedicine; 2003; 37: 284-392.

19. Michael J Alter: Science of flexibility book, Third edition.20. Michael J Alter, Science of sports stretching, Human

Kinetic Books, Page No. 85-90.21. Madeleine Smith et al, A comparison of two muscle

energy techniques for increasing flexibility of thehamstring muscle group. Journal of body work andmovement therapies 2008; Vol. 12 (4); 312-317.

22. Karim khan and Bruker, Clinical sports medicine,second edition; 471.

23. Harris ML, Flexibility, Physical Therapy, 1996, 49; 591-601.

24. Freyer G et al., Muscle energy concepts: a need forchange .Journal of osteopathic medicine, 2000; 3 (2):54-59.

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Patellofemoral pain syndrome- a common condition among youngadultsZaheen Ahmed Iqbal1, Nusrat Hamdani2

1BPT Student, 2Lecturer, IRMAS, New Delhi

Aims and objectives

1. To study the anatomy and biomechanics of thepatellofemoral joint.

2. To study the etiopathogenesis, clinical features,diagnosis, investigations and differential diagnosis ofpatellofemoral pain syndrome.

3. To study and formulate a comprehensive managementplan with the special emphasis on physiotherapeuticmanagement of patellofemoral pain syndrome.

The knee joint was the centre of orthopedic attention duringthe 1980s (DIAGRAM I). It consist of a Joint between femurand tibia is a synovial joint of hinge variety (but somedegree of rotation is possible) and the joint between patellaand femur is a synovial joint of plain gliding variety. Thepatellofemoral joint is a part of knee joint. The Patellofemoraljoint has often been described as the most researched smalljoint in the body, producing pain & disability, far out ofproportion to its size. The patella articulates with the femoraltrochlea during knee flexion & extension. The patella is asesamoid bone located within the patellar ligament. PF jointpain is common in all ages of the general population, buteven more so among athletes. Hording (1983) reportedthat 10% of Swedish children sought medical advice forpatellar pain. Devereaux & lachman (1984) found thatpatellofemoral arthalgia was the complaint in 6% of allpatients attending a sports injury clinic, particularly thoseengaged in sports like running, cycling, swimming & otherracquet sports. Abnormalities of the PF joint generallyamount to 10% of knees assessed by arthroscopy.

In PF joint, quadriceps muscle force increases with kneeflexion (DIAGRAM II). During relaxed upright standingminimal quadriceps muscle is required to counter balancesmall flexion moments about the PF joint because COG ofthe body above the knee is almost directing above thecentre of rotation of PF joint. When knee angle of flexionincreases, the COG shifts away from the centre of rotation,thereby greatly increasing the flexion movement to becounter balanced by the quadriceps muscle force. Kneeflexion also influences PF JRF, because of the angulationbetween patella tendon force and the quadriceps tendonforce. Angle of the two components becomes more acutewith knee flexion, hence increases the magnitude of PFJRF. The JRF is much greater during activities that requiregreater flexion. E.g. During knee bending to 90 degree JRFreaches 2.5 to 3 times the body weight with knee flexed at90 degrees.

The PF JRF remains higher than the quadriceps muscleforce throughout the knee bending. E.g. during stair climbingand getting down from the stairs, when the knee flexion isreached approximately 60 degrees, the peak value equals3.3 times the body weight (DIAGRAM III,IV). (The physiolosy

of joints- I A Kapanji, volume 2, 5th edition)When the knee is extended lower part of tibia is againstfemur while when the knee is flexed to 90 degree. Thecontact surface between patella and femur shifts cranially.The quadriceps muscle force and the torque around the PFjoint can be extremely high when particularly the knee isflexed instantly. E.g. Basket ball players may suffer a patellarfracture due to the indirect forces from the eccentriccontraction of quadriceps, in Weight lifting – there can berupture of patellar tendon when the subject lifts the heavyweight due to creation of external torque on patella.Therefore an effective mechanism is required for reducingthese external forces to limit the amount of or percentage orinjuries.

The term “patellofemoral pain syndrome” (pfps) can beused to describe the clinical entity of activity in dues pain,pain on physical examination of the PF Joint and on at leasttwo of the following – stair climbing, squatting, pseudolocking and pain or stiffness after prolong sitting.“chondromalacia patella” was an all embracing term usedin the early literature. It is now restricted to those instanceswhere articular cartilaginous degeneration has been shownto present. Mclatchie and Lennon said chondromalaciapatella occurs in adolescents between 13 and 19 yearswith the characteristics of anterior knee pain and crepitusaggravated by prolonged sitting or holding the knee inflexon. Approximately 7% of schoolboys and 19% of schoolgirls complain of such symptoms (mac-Kechnie-Jarvis andBoobbyer, 1984). These authors also noted an associationbetween chodromalacia patellae and persistent femoralanteversion which was not confirmed by Fairbank et a,(1984), who found only that those with chondromalaciapatella enjoyed sport more than asymptomatic children.Various causative factors have been attributed to PFPS.

Biomechanical fault

Although a direct blow or a traumatic dislocation of patellamay precipitate PF pain, mal alignment of the patella (TABLEI)from the biomechanical faults is increasingly believed tobe the major contributory factor. These faults can bestructural or non structualStructural causes of mal alignment may be divided intointrinsic and extrinsic factor

Later are more common and magnify the affect of the nonstructural faults.Others include poor alignment of the extensor mechanism,poor alignment of the entire lower extremity and the patellarinstability. Prat and Hungerford (1977) described the“excessive lateral pressure syndrome” (elps) i.e. apatellar tracking abnormality associated with a tight lateralPF retinaculum. This may be the result of the action of the

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malalignment factors listed above, or to the anatomy of thecomplex and extensive lateral structures of the knee.Merchant (1988) in a detailed classification of PF disorders,places secondary chondromalacia patella (i.e. not causedby trauma) under the heading of PF dysplasias, indicatingetiology of related malalignment of lower extremity.

Q-angle

Although some investigators believe that a “large” Q angleis a predisposing factor for patellofemoral pain, othersquestion this claim. One study found similar Q angles insymptomatic and nonsymptomatic patients (DIAGRAM V,VI). Another study compared the symptomatic andasymptomatic legs in 40 patients with unilateral symptomsand found similar Q angles in each leg. Furthermore,“normal” Q angles vary from 10 to 22 degrees, dependingon the study, and measurements of the Q angle in the samepatient vary from physician to physician. Therefore, thephysician should be wary of placing too much emphasis onsuch biomechanical “variants,” as this can lead patients tobelieve that nothing can be done about their pain.Pain may be felt on the outside of patella and femur becauseof increased pressure on these contact areas. The Q angleof growing female athletes and largest as the pelvis widensduring the process of maturation, increasing the risk of PFpainPFPS described anterior or retro patellar pain in the absenceof other knee pathology. It occurs commonly withprospective cohort studies reporting incidents rate of 7 to15% in sporting and general population. (The soft tissues-trauma and sports injuries-edited by Gr Mc Latchie andCme Lennox 1996) In addition of PFPS is one of the mostcommon conditions presenting to clinicians involved in themanagement of sports injuries, amounting to 2-30% of allpresentations. Various predisposing factors have beenproposed (TABLE II). Signs and symptoms of PFPS havebeen summarized in Table III.Examination involves thorough History taking, observationand examination. Special tests form the major part of theassessment and help to rule out differential diagnosis ofPFPS.

Special tests

PF dysfunction implies there is some pathology that isinterfering with the normal mechanics of the movement ofpatella over the femoral condyles during knee flexion andextension. Commonly, patients with PF problems complainof pain when climbing or descending stairs, stepping up ordown, with prolonged sitting (movie sign), squatting, orgetting up from chair. In some cases, the pain may causereflex inhibition causing buckling or giving way of the knees.(Othopedic physical assessment, David J. Magee, 4th

edition)clarke’s sign: First the leg is fully extended and the patientrelaxes (DIAGRAM VII). The patella is then pressed downand distally, into the patellofemoral grove. The patientcontracts the quadriceps. Pain is felt with the movement,indicates positive sign. The patient should be warned tocontract the quadriceps gently.mc connell test for chondromalacia patellae: The patientis sitting with the femur laterally rotated. The patient performs

isometric quadriceps contractions at 120, 90, 60, and 0degrees, with each contraction held for 10 seconds. If painis produced during any of the contractions, the patient’s legis passively returned to full extension by the examiner. Thepatient’s leg is then fully supported on the examiner’s knee,and the examiner pushes the patella medially. The medialglide is maintained while the knee is returned to the painfulangle, and the patient performs an isometric contraction,again with the patella held medially. If the pain is decreased,the pain is patellofemoral in origin. Each angle is tested insame fashion.Patellar tilt: The examiner holds the edges of the patellabetween the thumb and index finger, thereby establishingthe axis of the patella, which should differ only slightly (10°lateral tilt) from the horizontal plane of the knee seen head-on. The patella may be said to squint (convergent ordivergent squint) (Diagram VIII). Broadly speaking, aconvergent squint tends to occur in anterior knee painsyndrome, while a divergent squint would be more likely inrecurrent dislocation.Zohler’s sign: The patient lies supine with the kneesextended. The examiner pulls the patella distally and holdsin the position. The patient is asked to contract thequadriceps. Pain is indicative of a positive test forchondromalacia patellae.Step up test: The patient stands beside a stool which is 25cm (10inches) high. The examiner asks the patient to stepup sideways onto the stool using the good leg. The test isrepeated with the other leg. Normally, the patient shouldhave no difficulty doing the test and have no pain. Inabilityto do the test may indicate patellofemoral arthalgia, weakquadriceps, or an inability to stabilize the pelvis.Other tests -active patellar grind test

-waldron test-lateral pull test

X-ray changes in PFPS have been shown in diagram IX

Differential diagnosis

1. Patellar tendinitis or periostitis.2. Bursitis. I3. Plica syndrome.4. Fat pad syndrome.5. Meniscal lesions.6. Ligamentous lesions.7. Osteochondritis disiccans.8. Chondromalacia and arthrosis.9. Systemic joint disease.10. Reflex sympathetic dystrophy. .11. Slipped femoral epiphysis.12. ELPS(excessive lateral pressure syndrome)13. GPPS(global patellar pressure syndrome)14. Osgood-Schlatter syndrome.15. Jumper’s knee.16. Patellofemoral arthritis.17. Contusion injury.18. Acute patellar dislocation.19. Patellar subluxation.20. IT band friction syndrome.

Treatment

Aims1. To releive pain and other symptoms


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Table 1: List of factors producing poor patellar alignment (Sports physiotherapy-zulugua)Factors Effect**Static*Q angle Determines tracking of Patella*Patella alta, infera, alters patellar stability &parva & dysplasias

tracking*Genu valgus, varus alter q angle*Genu recurvatum irritates fat pad*Femoral trochlear decreases the joint stability dysplasia*femoral anteversion increases q angle*Internal tibial torsion increases q angle** Dynamic*Vmo weakness allows vl to pull laterally*Gluteal weakness produces internal rotation during gait*Gastronemius and soleus produces pre-mature heel lift and footTightness pronation*Hamstrings tightness causes decreased knee extension

and increased knee flexion during gait*Iliotibial band and lateral causes lateral patellar compressionPf retinacular tightness*Poor foot posture alters q angle*Poor hip control, allows adduction of the legParticularly rotationDuring gait, incraesedQ angle

Diagram I: Anatomy Knee joint

Diagram II: Stabilizers of the patella on the right knee.Various forces are responsible for patellar movement. Theiliotibial band (not shown). Has some fibers that attach tothe lateral Aspect of the patella

Diagram III: Free body diagram of a patient ascending astep, m1 = quadriceps force; m2 = patellar tend on tension;kjr = knee joint reaction; pfjr = patellofemoral joint reaction;cg = center of gravity; x = flexor lever arm.

2. To prevent muscle spasm3. Muscle gaurding4. To gain eccentric muscle strength5. To maintain muscle flexibility6. To optimize patellar position7. To improve lower limb mechanics8. To improve patients ability to negotiate stairs without

reproducing symptoms

It is now well accepted that the conservative treatment of PFpain, malalignment and instability besides being successfulshould be fully exhausted before any operative procedureare performed. (Patellofemoral pain syndrome: a reviewand guidelines for treatment-Mark S. Juhn, D.O., Universityof Washington School of Medicine, Seattle, Washington)

Conservative management

1. Relative rest2. Ice and anti inflammatory drugs3. Taping (diagram x)- a taping technique used to relieve

pain as develop by mc. Connell has been describedand has been shown to be effective in more than 85%of cases. (Conservative treatment of patellofemoralpain syndrome-erik witvrouw, belgium)

4. Knee sleeve and brace5. Exercise and physical therapy- a rehabilitative

approach using isometric, concentric and eccentricexercises should be employed with special emphasoson vmo strengthening. According to witrow.bellermans(2000) - there is almost no difference between openand closed chain exercise in terms of pain and functionand best program would probably be combining bothopen and closed chain exercises in rehabilitation.Physical therapy with a rehabilitative exercise routineis the mainstay of treatment. Physical modalities(ultrasound or phonophoresis may decrease painsymptoms. Other modalities can be paraffin wax bath,tens, ift, pulsed swd, hvpgs, ems, etc. But these have atemporary effect. These are not of much help in thepfps, other than decreasing symptoms), activitymodification, correction of forefoot abnormalities,biofeedback, flexibility, external support (brace, taping)may be appropriate in selected patients diagram xishows some exercises to be done in patients with kneepain (unityhealth.com).

Surgical Intervention

Surgery may be useful for patients who have been compliantand were unsuccessful with a 12-month trial of conservativetherapy. Surgery may completely resolve symptomatology,partially resolve symptomatology, or may not changesymptomatology; rarely is symptomology exacerbatediatrogenically. Surgery is more successful when a specificdiagnosis has been established and when clear surgicalgoals can be defined. (Athletic injuries and rehabilitation-James)

Surgical intervention includes arthroscopy for articularcartilage shaving with or without lateral release of theretinaculum. Surgery also may include proximal or distalrealignment. Open surgical procedures include patellartendon transfer, or rarely, patellectomy.


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Diagram IV: A free body diagram of an individualdescending a step. Note the significant increase in kneeflexion required and also the change in orientation of thetibial shaft to the vertical. Cg = center of gravity; arrowindicates anterior subluxation thrust of the femur.

Diagram V: “q” angle

Diagram VI:

Diagram VII: Clarke’s Sign

Diagram VIII: Patellar tilt test

Diagram IX: Patello-femoral X-ray of Right & Left Patello-femoral joints – normal and abnormal.

Diagram X: Patellar Taping Techniques(a) Knee taped showing medial glide. Tape is applied tothe lateral aspect of the patella. The patella is glidedmedially and the tape anchored to the skin over the medialaspect of the knee. When taping is completed, skin creasesshould be evident on the inside of the knee indicatingadequate tension on the patella.

(b) Knee taped showing correction of lateral tilt. Tape isapplied to the medial aspect of the patella and secured tothe soft tissue on the inner aspect of the knee


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(c) Knee taped showing correction of rotation. Tape isapplied to the inferior pole of the patella and taken mediallyand superiorly to rotate the patella

(d) Knee taped showing correction of inferior tilt. Tape isapplied across the superior pole of the patella with sufficientfirmness to elevate the inferior pole

Diagram XI: Exercises to help knee painPatellofemoral pain can be hard to treat and knees don’tget better overnight. Some people are lucky and get betterquickly. But it might take 6 weeks or longer for your knee toget better. You’ll be less likely to get this pain again if youstay in good shape, but don’t make sudden changes inyour workouts.Here are some exercises to help your knee pain. After youdo all the exercises as shown in the drawings, reverse yourposition, and do the exercises with your other leg, so bothknees get the benefit of stretching.1. Quadriceps strengthening: isometrics. Position

yourself as shown above. Hold your right leg straightfor 10 to 20 seconds and then relax. Do the exercise 5to 10 times.

2. Quadriceps strengthening: straight leg lift. Positionyourself as shown above. Raise your right leg severalinches, and hold it up for 5 to 10 seconds. Then loweryour leg to the floor slowly over a few seconds. Do theexercise 5 to 10 times.

3. Iliotibial band and buttock stretch: (right side shown):Position yourself as shown above. Twist your trunk tothe right and use your left arm to “push” your right leg.You should feel the stretch in your right buttock and theouter part of your right thigh. Hold the stretch for 10 to20 seconds. Do the exercise 5 to 10 times.

4. Iliotibial band stretch: (left side shown): Positionyourself as shown above, with your right leg crossed infront of your left leg. Hold your hands together andmove them toward the floor. You should feel a stretchin the outer part of your left thigh. Hold the stretch for 10to 20 seconds. Do the exercise 5 to 10 times.

Zaheen Ahmed Iqbal/ Inian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Table 2: predisposing factors for patellofemoral pain (Sports physiotherapy-zulugua)Factors CauseAbnormal biomechanics femoral anteversion; increased Q angle;

patella alta, patella Baja; excessivepronation; genuvalgus, varus, recurvatum.

Soft tissue tightness Lateral retinaculum; iliotibial band; rectusfemoris; hamstrings: gastrocnemius.

Muscle imbalance Vastus medialis obliquus; hip abductors,external Rotators (gluteus medius posteriorfibers)

Training Sudden increase in mileage; increase inhill work, Stairs; Change of training surface;change of Footwear.

Table 3: clinical signs of pfps (sports injuries- diagnosis and management-norrus, 2nd edition)

Onset Running, stair/step activity particularlyeccentric component

Pain Tender Peripatellar and/or posterior, hard toNess describe peripatellar and inferior pole, may not be

palpableCrepitus Often present in severe cases

Giving way Due to quadriceps weakness or painEffusion Occasional but small

Click / clunk Often in older athletesRange of knee Decreased in severe case

Patellar Decreased medial glide due toretinaculum. tight lateral mobility

Vmo Wasting, vmo/vl imbalance and altered timingEffect of activity Pain increases with increasing activity

Retest sign Stairs, squats, duck waddle

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5. Hamstring stretch: Position yourself as shown in theleft-hand drawing above. Bend your left knee. Grip yourthigh with your hands to keep the thigh steady.Straighten your left leg in the air until you feel a stretch.Hold the stretch for 5 to 10 seconds. Do the exercise 5to 10 times.

6. Hip adductor strengthening: While sitting, squeeze arubber ball between your knees. Hold the squeeze for5 to 10 seconds. Do the exercise 5 to 10 times. (If youdon’t have a ball, put your hands or fists between yourknees and then squeeze.)

7. Hip abductor strengthening: (left side shown, frontand side views): Position yourself as shown above,standing on your left leg with the knee slightly bent.Slowly raise your right foot about 30 degrees, hold fora few seconds, and then slowly lower the foot andstraighten both legs. Do the exercise 10 times. Don’tlet your pelvis tilt (be crooked), and don’t let your kneesturn inward during bending.

8. Hip and buttock stretch (left side shown): Positionyourself as shown above, with your left leg over yourright leg, and place your hands over your left knee. Pullthe knee slightly toward you while sitting up straight.Hold the position for 20 seconds, and then rest forseveral seconds. Do the exercise 6 times.

9. Calf stretch: Position yourself against a wall as shownabove. Keep your left heel on the ground to feel theback of the leg stretch. Hold for 10 to 20 seconds. Dothe exercise 6 to 10 times.

References

The Soft Tissues- Trauma And Sports Injuries-edited By Gr Mc Latchie And Cme Lennox 1996.Sports Injuries-Diagnosis And Management - Norrus, 2nd Edition.Atheletic Injuries And Rehabilitation- James.Clinical Anatomy For Medical Students- Snells, 5th Edition.Sports Physiotherapy- Zulugua.Human Anatomy Regional And Applied- Bd Chaurasia, Volume 2, 3rd Edition.Physio Therapy In Sports And Exercise- Kolt And Mackler.The Physiolosy Of Joints- I A Kapanji, Volume 2, 5th Edition.Orthopaedic Secrets- David E. Brown, Randalld. NeumanClosed Kinetic Chain Exercises For PatellofemoralPain, American Journal Of Sports Medicine-witrow E, Lysens R, Bellermans J, Peers K,Vanderstracten G. 2000; 28(5); 687-694Muscle Strengthening In Patellofemoral Pain


101Zaheen Ahmed Iqbal/ Indian Jouanl of Physiotherapy and Occupational Therapy. July - Sept. 2010, VOL 4 NO 3

Syndrome: Testing And Training.- Suzanne Werner, SwedenHip And Vasti Activation In Management Of Pfps- Kay Crossly, AustraliaAbnormal Lower Extremity Mechanics AndPatellofemoral Dysfunction: Implication For Treatment- Christopher Powers, UsaConservative Treatment Of Patellofemoral PainSyndrome- Erik Witvrouw, BelgiumPatellofemoral Pain Syndrome: A Review AndGuidelines For Treatment-mark S. Juhn, D.o., University Of Washington School

Of Medicine, Seattle, WashingtonAnterior Knee Pain – Suprapatellar Plical Irritation-robert F. Laprade, M.d., Assistant Professor, SportsMedicine Institute, University Of Minnesota OrthopedicPhysical Assessment-david J. Magee, 4th EditionWebsites-- Emedicine.com- Medicinenet.com- Unityhealth .com-adams.com-medicalphoto.com

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Comparison between low level laser therapy and exercise fortreatment of chronic low back painZahra Al Timimi, Mohamad Suhaimi Jaafar, Mohd Zubir Mat JafriSchool of Physics, Universiti Sains Malaysia, USM, Penang, Malaysia 11800

Abstract

Background

Low back pain (LBP) is a major health problem withenormous economic and social costs. The toll that bears onindividuals, families and society make the successfulmanagement of this is common. Despite its widespreaduse, the effectiveness of low level laser therapy (LLLT) isstill controversial. Traditional treatments include drugs,physical treatment, back exercises and education, but theyare not always completely helpful. Many people seekalternative treatments, such as LLLT. Therefore main goalof this study is to determine the effect of LLLT on the intensityof chronic LBP.

Method

80 patients who had low back pain for at least 12 weekswere irradiated with low level laser. One group receivedlaser therapy alone, one received laser therapy andexercise, and the third group received placebo laser therapyand exercise. Laser therapy was performed twice a weekfor 4 weeks.

Results

72% of the active treatment group returned to work comparedto 41% of the sham group. This 31% difference betweenthe groups was significant. While the study’s findingsshowed better results on some outcomes following activetreatment, the report does not indicate the number of patientsavailable at follow-up. In addition, the study reports only thepercentage of patients who improved without clearlyreporting the extent of improvement.

Introduction

Low level laser therapy (LLLT) is a light source treatmentthat generates light of a single wavelength. LLLT emits noheat, sound, or vibration. Instead of producing a thermaleffect, LLLT may act via nonthermal or photochemicalreactions in the cells, also referred to as photobiology orbiostimulation [Carati CJ, Anderson SN, Gannon BJ, PillerNB (2003)]. Laser radiation and monochromatic light mayalter cell and tissue function. Laboratory studies suggestthat irradiation stimulates collagen production, alters DNAsynthesis, and improves the function of damagedneurological tissue. Several mechanisms underlyingtherapeutic effects with LLLT have been suggested.Theories include:1. Increased ATP production by the mitochondria and

increased oxygen consumptionon the cellular level, which may result in musclerelaxation

2. Increased serotonin and increased endorphins3. Increased anti-inflammatory effects through reduced

prostaglandin synthesis4. Improved blood circulation to the skin in cases like

neuralgia and diabetes mellitus5. Decreases permeability of the membrane of the nerve

cells for Na/K causing hyperpolarisation6. Increased lymphatic flow and decreased edema .

Low back pain (or lumbago) is a common musculoskeletaldisorders affecting 80% of people at some point in their life.It accounts for more sick leave and disability than any othermedical condition [Ferreira DM, Zangaro RA, VillaverdeAB, Cury Y, Frigo L, Piccolo G, Longo I, Barbosa DG (2005)].Lumbago can be either acute, subacute or chronic induration. Most often, the symptoms of low back pain showsignificant improvement within a few weeks from onset withconservative measures.

The causes of lower back pain are varied. A traumatic eventmay result in either muscular pain or a vertebral fractures.At the lowest end of the spine, some patients may havetailbone pain (also called coccyx pain or coccydynia)[Coderre TJ, Katz J, Vaccarino AL, Melzack R (1993)]. Othersmay have pain from their sacroiliac joint, where the spinalcolumn attaches to the pelvis, called sacroiliac jointdysfunction. Physical causes may include osteoarthritis,rheumatoid arthritis, degeneration of the discs between thevertebrae or a spinal disc herniation, a vertebral fracture(such as from osteoporosis), or rarely, an infection or tumor[Klein RG, Eek BC (1990)].

LLLT devices include the gallium arsenide (GaAs), galliumaluminum arsenide (GaAlAs) infrared semiconductor, andhelium neon (HeNe) lasers. The 632.8 nm wavelength HeNelaser emits visible red light and may have a shallowpenetration into skin. The GaAlAs infrared laser has a longerwavelength than red beam laser and may have deepertissue penetration [Gam AN, Thorsen H, Lonnberg F (1993)].Low level laser therapy may also be an effective adjunctiveor alternative treatment for chronic low back pain withavoidance of systemic drug use [Sakurai Y, Yamaguchi M,Abiko Y (2000)]. Because of the significant placeboresponse rate in clinical trials, non pharmacologictreatments require careful investigation to ascertaineffectiveness [Kreisler MB, Haj HA, Noroozi N,Willershausen B (2004)].

Design

A randomised controlled trial was conducted . Allocation of

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participants was concealed; they were divided into threegroups using block randomisation with a manual schedule.For every six participants recruited, two were assignedrandomly to each group. One group received low level lasertherapy alone, one group received laser therapy andexercise, and the third group received placebo laser therapyand exercise. Patients received laser therapy or placebolaser therapy on Sunday, Tuesday and Thursday (for 12sessions , three time in a week for 4 weeks). Both therapistand participant wore protective goggles for safety and topreserve blinding of the therapist and the participants towhether the laser therapy was real or placebo. However,the participants who received laser therapy alone were notblinded. All outcomes were measured on admission to thetrial, at week 4 (after the last session of intervention). Theprotocol was reviewed and approved by the Medical EthicsBoard in IRAQ Faculty of Medicine-University of Babylonand Hilla Surgical Hospital.

Participants

Participants were recruited from patients referred by localphysicians to the clinic of an Occupational MedicineDepartment. They were included if they were aged between20 and 60 years, had low back pain for a minimum of 12weeks and possessed the ability to give informed consent,understand instructions, and co-operate with treatment.Patients with degenerative disc disease, disc herniation,fracture, spondylosis, and spinal stenosis, neurologicaldeficits, abnormal laboratory findings, systemic orpsychiatric illness, and pregnancy were excluded. Table 1shows the type of patients involved in this research.

Intervention

Participants were taught to do exercises correctly by thephysiotherapist. Exercises done included strengthening,

stretching, mobilising, co-ordination, and stabilising of theabdominal, back. The first exercise session was conductedby a physiotherapist and thereafter the simple exercisesperformed at home without requiring any special equipmentor access to a gym or fitness facility. A family memberconfirmed that the participant carried out the exercises.A 10 mW, continuous wave Gallium-Aluminum-Arsenide(GaAlAs) laser with wavelength, » =670 nm was used toirradiate a 0.2211 cm2 spot area laser. Laser irradiationwas applied on three neigbouring points, depending onpain, the distance of each point from the adjacent point is 2cm. The power output was calibrated with a thermopilepower metre. In each session, a series of standardised fieldsincluding 6 points in the paravertebral region (L2 to S2–S3)were irradiated by a single laser probe in contact mode(Gur et al 2003) as shown in Fig.1. In the laser therapygroups, participants were irradiated with the probe emittinga dose of 40 J/cm2 while the placebo laser therapy groupwas irradiated with inactive probes. It took approximately20 minutes to cover the area for each patient.

Outcome measures

Outcomes were pain, lumbar range of motion, and disability.Participants were asked to estimate their pain severity byplacing a mark on the line with severe pain being the worstimaginable pain. Lumbar range of motion was measuredby the same investigator. Participants then bent forwardmaximally and the increase in distance between thesemarks was measured. The maximum active flexion,extension, and right and left lateral flexion was measuredwith a goniometer.

Results

72% of the active treatment group returned to work comparedto 41% of the sham group. This 31% difference betweenthe groups was significant. While the study’s findingsshowed better results on some outcomes following activetreatment, the report for lumbar range of motion, anddisability does not indicate the number of patients availableat follow-up. In addition, the study reports only thepercentage of patients who improved without clearlyreporting the extent of improvement.

Discussion

Adjunct therapies include spinal manipulation, massage,hypnosis, magnet therapy, acupuncture, transcutaneouselectrical nerve stimulation, and low level laser therapy.The rationale for the use of laser therapy as an adjuvant

Table 2: shows the percentage of patients in each study group that improvedin range of motion after irradiation with the low level laser.

Table 2: Percentage of patients improved in range of motionRange of Laser Placebo laser exercise (%) Laser therapy andmotion therapy(%) therapy andexercise (%)Flexion 11.3 1.3 14.1Extension 10.0 5.0 11.7*Radial Dev 27.3 -2.9 31.9

Table 1: Types of patients referred to the clinic.Laser therapy Placebo laser Laser therapy and

therapy and exercis eexerciseNumber of 25 30 25

patientMean age 43.1 24.6 45,6Previous 30% 20% 30%

hand surgery

Fig. 1: Sensory dermatomes


104

treatment for chronic low back pain stems from its beneficialeffects on the pain reduction and inflammation processwithout any significant complication.

The most effective plan seems to be individually designedexercise programs delivered in a supervised format (eg,home exercises with regular therapist follow-up) withadherence encouraged to achieve a high dosage.However, it seems that exercise is not enough to treat chroniclow back pain and it is necessary to combine othermodalities to obtain the best results [Andersson GB (1999)].This study showed that low level laser therapy plus exercisecould decrease pain, increase lumbar flexion, and reducedisability more than exercise alone in the long-term. Thisclinical trial has some limitations. First we could not find asuitable placebo intervention for exercise. Second, oursample size was too small to detect differences betweengroups for some outcomes. Therefore low level laser therapyshould be investigated in trials with larger sample sizesand longer follow-up periods. Biologic and simulationstudies to obtain the most appropriate energy density andwavelength and cellular responses of target tissue are alsorecommended.

Conclusion

Low level laser therapy seemed to be an effective methodof decreasing pain and reducing disability in chronic lowback pain in combination with exercise compared withexercise alone. However, we emphasise that laser therapyis an adjuvant intervention and it should be applied withappropriate exercises.

References

1. Sakurai Y, Yamaguchi M, Abiko Y (2000) Inhibitoryeffect of low-level laser irradiation on LPS-stimulatedprostaglandin E2 production and cyclooxygenase-2 inhuman gingival fibroblasts. European Journal of OralSciences 108: 29–34.

2. Ferreira DM, Zangaro RA, Villaverde AB, Cury Y, FrigoL, Piccolo G, Longo I, Barbosa DG (2005) Analgesiceffect of He-Ne (632.8 nm) low-level laser therapy onacute inflammatory pain. Photomedicine and LaserSurgery 23: 177–181.

3. Andersson GB (1999) Epidemiological features ofchronic lowback pain. Lancet 354: 581–585.

4. Coderre TJ, Katz J, Vaccarino AL, Melzack R (1993)Contribution of central neuroplasticity to pathologicalpain: review of clinical and experimental evidence. Pain52: 259–285.

5. Gam AN, Thorsen H, Lonnberg F (1993) The effect oflow-level laser therapy on musculoskeletal pain: ameta-analysis. Pain 52: 63–66.

6. Carati CJ, Anderson SN, Gannon BJ, Piller NB (2003)Treatment of postmastectomy lymphedema with low-level laser therapy: a double blind, placebo-controlledtrial. Cancer98: 1114–1122.Klein RG, Eek BC (1990) Low-energy laser treatmentand exercise for chronic low back pain: Double-blindcontrolled trial. Archives of Physical Medicine andRehabilitation 71:34–37

7. Klein RG, Eek BC (1990) Low-energy laser treatmentand exercise for chronic low back pain: Double-blindcontrolled trial. Archives of Physical Medicine andRehabilitation 71:34–37.


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