ISSN P - 0973-5666

ISSN E - 0973-5674

Volume 5 Number 3 July - September 2011

Indian Journal of
Physiotherapy and Occupational Therapy
An International Journal

website: www.ijpot.com
 INDIAN JOURNAL OF PHYSIOTHERAPY AND
OCCUPATIONAL THERAPY
Editor
Dr. Archna Sharma (PT)
Head, Dept. of Physiotherapy, G.M. Modi Hospital, Saket, New Delhi 110 017
E-mail: editor.ijpot@gmail.com

Executive Editor
Dr. R.K. Sharma
Dean, Saraswathi Institute of Medical Sciences, Ghaziabad (UP)
Formerly at All-India Institute of Medical Sciences, New Delhi

International Editorial Advisory Board National Editorial Advisory Board

Dr. Amita Salwan, USA
Dr. Smiti, Canada
Dr. T.A. Hun, USA
Heidrun Becker, Germany
Rosi Haarer Becker, Germany,
Prof. Dra. Maria de Fatima Guerreiro Godoy, Brazil
Dr. Venetha J. Mailoo, U.K.
Dr. Tahera Shafee, Saudi Arabia
Dr. Emad Tawfik Ahmed, Saudi Arabia
Dr. Yannis Dionyssiotis, Greece
Dr. T.K. Hamzat, Nigeria
Prof. Kusum Kapila, Kuwait
Prof. B.K. Bhootra, South Africa
Dr. S.J. Winser, Malaysia
Dr. M.T. Ahmed, Egypt
Prof. Z.W. Sliwinski, Poland
Dr. G. Winter, Austria
Dr. M. Nellutla, Rwanda
Prof. GoAh Cheng, Japan
Dr. Sema Oglak, Turkey
Dr. M. Naveed Babur, Pakistan
Prof. U. Singh, New Delhi
Dr. Dayananda Kiran, Indore
Dr. J.K. Maheshwari, New Delhi
Dr. Suraj Kumar, New Delhi
Dr. Renu Sharma, New Delhi
Dr. Veena Krishnananda, Mumbai
Dr. Jag Mohan Singh, Patiala
Dr. N. Padmapriya, Chennai
Dr. G. Arun Maiya, Manipal
Prof. Jasobanta Sethi, Bangalore
Prof. Shovan Saha, Manipal
Prof. Narasimman S., Mangalore
Kamal N. Arya, New Delhi
Dr. Nitesh Bansal, Noida
Dr. Aparna Sarkar, Noida
Dr. Amit Chaudhary, Faridabad
Dr. Subhash Khatri, Belgaum
Dr. S.L. Yadav, New Delhi
Dr. Sohrab A. Khan, Jamia Hamdard, New Delhi
Dr. Dheeraj Lamba, Haldwani
Dr. Deepak Kumar, New Delhi
Dr. Kalpana Zutshi, New Delhi

Print-ISSN: 0973-5666 Electronic - ISSN: 0973-5674, Frequency: Quarterly (4 issues per volume).
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Contents
Volume 5, Number 3 July - September 2011

1 Effect of Balance Training on Foam Platform in Geriatric Population: A randomized controlled trial
Renu Chauhan
6 Botulinum Toxin as Treatment Modality for Spastic Diplegic Cerebral Palsy Child: Our experience in 21
patients
Ritesh Runu, Vaibhav Agrawal, Arunim Swaroop, Devendra Dave
10 Is Knee Range of Movement on Discharge Important After Total Knee Replacement - A prospective
audit based study
Ross Darch, Jonathan Swan, Tom Wainwright, Robert Middleton
14 The Effect of Transcutaneous Electrical Nerve Stimulation in the Treatment of Chronic Pelvic Pain
Syndrome: An evidence based electromyographic studies
Ahmed F Samhan, Nermeen M Abd-Elhalim, Emam H Elnegmy, Mohamed M Roiah
18 Cardio Vascular and Respiratory Responses to Valsalva Maneuver, Isometric Hand Grip Exercise and
Harvard Step Test and Recovery in Healthy Individuals
Sanjiv Kumar, Shivappa B Anurshetru, Prabhker Kore
23 Effect of FAME Program on Chronic Stroke Patients in Indian Population
Shanta Pandian, Kamal Narayan Arya, Archana Kaushik
28 A Comparitive Study on the Efficacy of End Range Mobilization Techniques in Treatment of Adhesive
Capsulitis of Shoulder
K S Sharad
32 Role of Physiotherapist in the Management of On-field Sport Injuries A case study of field hockey
Suraj Kumar, Vijai P Sharma, Rakesh Shukla, Ravi Dev, Anoop Aggarwal
36 Comparison of Task Oriented Approach and Bobath Approach in Improving Balance and Reducing
Fear of Falling in Adults with Stroke
Jayachandran V, Gayathri Ethiraj
40 A Cost-effective Patient Designed Hand Splint for Rehabilitation After Two-stage Flexor Tendon
Reconstruction
Muhammad Adil Abbas Khan, Mark Gorman, Arvind Mohan, Zain A Sobani, Alastair Platt
42 Altered Current Perception Ratio: A tool to identify small fiber neuropathy in high risk Diabetic foot
Unnati Pandit, Hutoxi Witer, Bharati Bellare
46 Relationship between Depression and Cardiopulmonary Fitness in Post Cardiac Surgery Individuals
K Charan, K Asha Jyothi, P Tabitha, K Madhavi
50 Effectiveness of Physiotherapy Provision within An Occupational Health Setting
Laran Chetty
54 To Assess the Relation Between Walking Capacity and Cardio-respiratory Function in Post Polio Residual
Paralysis
Ashish V Gupta, Lata Parmar
58 Comparing the Effectiveness of Positional Release Therapy Technique & Passive Stretching on Hamstring
Muscle Through Sit to Reach Test in Normal Female Subjects
Manivannan M Kaandeepan, E S Cheraladhan, M Premkumar, Shikha K Shah
62 Comparative Study Between Efficacy of PNF Movement Patterns Versus Conventional Free Exercises
on Functional Activities Among Patients with Chronic Peri-Arthritis of Shoulder
Manobhiram Nellutla, Pramod Giri
68 Intervention Based on Dynamics of Postural Control in Children with Cerebral Palsy- An integral
approach
Meenakshi Batra, Vijai Prakash Sharma, Gyanendra Kumar Malik, Vijay Batra, Girdhar Gopal Agarwal
74 An Evaluation of Exercise Tolerance in COPD Patients Using Six Minute Walk Test- A prospective Study
T S Muthu Kumar, T Mohan Kumar
79 Pattern of Orthopaedicians Referral for Physiotherapy in a Tertiary Care Hospital: A preliminary report
Kavitha Vishal, Narasimman Swaminathan, Benjamin Varghese, Sudeep MJ Pais
83 Short Term Effect of Body Positions on Dynamic Lung Compliance in Mechanically Ventilated Patients
with Lung Pathology- A randomised cross over study
Swagata De, Narasimman Swaminathan

Indian Journal of Physiotherapy and Occupational Therapy. July - September. 2011, Vol. 5, No. 3
89 Corelation Between Knee Extensor Strength and Endurance in Dependent and Independent Elderly
Nidhi Sharma, Anish Raj, Ruchika Chugh, Sumit Kalra
96 Effectiveness of Bladder Rehabilitation Program in the Management of Urge Urinary Incontinence in Older Women
Nirupma Singh, Kamal Narayan Arya
100 EInfluence of Stair Climbing on the Self Efficacy in Post Cardiac Surgery Patients
Uchil P, Khan I, Kamath N
103 S-D Curve an Effective Diagnostic Test for Physiotherapists: A case report
Pankaj Gupta , M Satish K Paul
105 Effectiveness of Strength Training Program on Bone Mineral Density in Postmenopausal Women
Paramjot K Dhillon, Sonia Singh
110 Effectiveness of Coccygeal Manipulation in Coccydynia: A randomized control trial
Subhash M Khatri, Peeyoosha Nitsure, Ravi S Jatti
113 Effect of Warm-up and Cool-down on Delayed-onset Muscle Soreness in University Students
Bhatia P, Arun
117 Comparison of Jacobsons Progressive Muscle Relaxation and Diaphragmatic Breathing on Cardio-
Respiratory Parameters in Healthy Adults A Randomized cross over trial
Prem V, Bhamini Krishna Rao, Arun Maiya Gundmi
122 A Comparison Study of 3 Stretching Protocols on Hamstrings Length
Priya Kannan, Stanley John Winser
126 Effect of Long Term Physical Exercise Training on Auditory and Visual Reaction Time
Shashi kant Verma, Anand Mishra, Ajit Singh
130 Effect of Hamstring Static Stretch Training on Knee Flexion Concentric Torque
Amr Almaz Abdel-aziem, Osama Ragaa Abdelraouf
134 Sports Injuries: A new perspective on causation
Arunachalam Kumar
135 Effects of Different Elbow Positions on Latency and Amplitude of Motor Nerve Conduction Study of Ulnar Nerve
Kakkad Ashish
139 Effectiveness of Multidirectional Reach Test to Analyze Centre of Pressure Excursion in Healthy Geriatric
Population
Asmita Karajgi, Sujata Yardi
144 The Effect of Proprioceptive Exercises and Strengthening Exercises in Knee Osteoarthritis
Aastha Maggo, Shobhit Saxena, Shalini Grover
149 Predicting Neuromotor Outcome in Very Low Birth Weight Infants at One Year of Corrected Age Using
Movement Assessment of Infants Scale
Deepa Metgud, V D Patil, S M Dhaded
153 Comparison Among Different Head Neck Positions for the Effects on Wrist Flexor Torque Production
Dheeraj Lamba, Sapna Kharayat, Jaya Mehta, Ajay Joshi, Manish Kandpal
157 Effect of Saddle Heights on Craniovertebral Angle During Ergonomic Cycling
Dheeraj Lamba, Satish Pant, Girish Chandra
161 A Comparative Study of Cardiovascular Fitness in Normal Versus Obese Children
Gaurang D Baxi, Tushar J Palekar, M Vijayakumar, Varoon C Jaiswal
167 Test Retest Reliability and Validity of Hindi Version of Neck Disability Index in Patients with Neck Pain
Halima Shakil, Sohrab A Khan, Puja C Thakur
170 Effect of Ankle Foot Orthosis on Plantar-flexor Tone and Gross Motor Functional Abilities in Children with
Hemiplegic Cerebral Palsy
Meenakshi Batra, Vijai Prakash Sharma, Vijay Batra, Gyanendra Kumar Malik, Girdhar Gopal Agarwal
175 Normative Data of Evaluation Tool of Children Handwriting manuscript (ETCH-M)
Ganapathy Sankar U, R Riya
179 Effect of Passive Straight Leg Raise Sciatic Nerve Mobilization on Low Back Pain of Neurogenic Origin
Gurpreet Kaur, Shallu Sharma
185 Fatigue and its Correlation with Functional Outcome in Patients with Stroke
Hamdani N, Dhawan L, Maurya M
191 Effect of Exercise Rehabilitation Programme on Clinical Health Status of Osteoarthritis Knee Patients
Jagmohan Singh, Paramvir Singh, M S Sohal
199 Effect of Supervised Versus Home Based Cardiac Rehabilitation on Heart Rate Recovery in Patients with
Coronary Artery Bypass Grafting
S Shagufta, Jamal Ali Moiz, Rajeev Aggarwal

Indian Journal of Physiotherapy and Occupational Therapy. July - September 2011, Vol. 5, No. 3
Effect of Balance Training on Foam Platform in Geriatric
Population: A randomized controlled trial
Renu Chauhan
M.P.T., Neurology, Department of Physiotherapy, College of Applied Education and Health Sciences, CAEHS, Meerut

Abstract potential consequences. It results in loss of confidence,

restriction of activities, social isolation and increased
dependence on others4.
Background of Study Efforts to reduce the risk and incidence of falls in older
adults are plentiful as evidenced by intervention studies which
Fall prevention program is an important health strategy for have appeared in the literature with in the last 2 decades detailing
elderly population. Thus, there is a need to develop effective various exercise interventions intended to reduce falls 5-7.
balance training programs that improve balance in elderly. Exercise is effective in lowering falling risk in among elderly8-9.
These interventions have emphasized a variety of exercise
Purpose of Study modes including resistance training, flexibility exercises10 many
of this interventions have focused too heavily on simple
To compare the effect of balance training on foam platform maneuvers that are easier to quantify but that may not address
and on floor for the improvement of balance scores in the geriatric adequately the varied needs of different individuals.
population. However, because many different types of were studied, it
was impossible to determine which type was most effective.
Procedure Keeping this in mind this study was designed with the purpose
of improving balance in geriatric population while using foam
The study is a randomized controlled trial. 30 Elderly platform.
subjects, with age ranging from 60 75 yrs, were taken from
Outpatient Department of CAEHS, Meerut. Subjects were Methods
divided into two groups: experimental and control. Experimental
group (n=15) were given balance training on Foam Platform
and Control group (n=15) were given balance training on floor. Design of Study
All the subjects received balance training for 5 days a week for
30 minutes for 4 weeks. Balance scores of all the subjects were Experimental Study. Pre test and Post test match subject
taken in the beginning and at the end of 4 weeks using Berg design.
Balance Scale (BBS) and Functional Reach Test (FRT). Data
was analyzed using students t-test. Population
Results Geriatric subjects from old age home and outpatient
department of College of Applied Education and Health
The mean & standard deviation values of experimental Sciences, Meerut.
group for FRT on day 30 were 10.2 + 1.52 and BBS on day 30
55.26 + .96. The mean & standard deviation of control group for Sampling Technique
FRT on day 30 was 9.0 + 1.25and BBS on day 30 was 52.26
+ 2.91. The p values obtained were significant i.e. p value was Convenient sampling
less than 0.05.
Inclusion Criteria
Conclusions
Age 60- 75 years
Balance training on foam platform was found to be more
effective than balance training on floor.
Exclusion Criteria
Introduction
Any Neurological disease - stroke, hemiplegia,
WHO (World Health Organization) defines those aged 60- parkinson.
74 years as geriatric and those older as aged. The elderly are Any acute Musculoskeletal injury
the fastest growing segment of our population. In the coming Acute Congestive heart failure
years, it will become essential for more health care professionals Severe visual deficit.
to develop clinical expertise in evaluating and treating the unique Any cognitive impairment
health concerns of this group.1 Sensory impairment
Geriatric people show a decline in ability to maintain balance
when faced with the perturbations imposed by functional Instrumentation
requirements such as dividing attention between task as is
needed to keep balance when walking in a crowd2. Falling has Foam pad - 16"x 9" x2"
been associated with an increase in morbidity and mortality rate Berg balance scale
in elderly population3. Functional reach test
A person who falls or almost falls could become fearful or Standard measuring tape
anxious about subsequent falls and serious injury and associated Chair of 46 cm. of seating height

Renu Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 1
Fig. 1: Illustrate the subject is performing one of the 14 items
of Berg Balance Scale
Fig. 2: Illustrate the subject is performing one of the 14 items of
Berg Balance Scale
Ball
Procedure
The subjects were invited to participate in the study. A
detailed explanation of the procedure was given after which the
subjects on informed consent. The subjects were assessed on
the two balance scales. The Berg Balance Scale (BBS) and the
functional reach test (FRT).
Berg Balance Scale
Berg Balance Scale is an objective measure of static and
dynamic balance abilities. The scale consists of 14 items that
are scored from 0 to 4, where 0 indicates an inability to perform
Renu Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Fig. 3: Illustrate the subject is performing Functional Reach
Test
the task and 4 indicates the tasks were performed correctly and
independently. The maximum score of the test is 56. The items
range from sitting to standing, standing unsupported, sitting with
back unsupported on the floor or on the stool, transfers, standing
unsupported eyes closed, standing unsupported with feet
together, reaching forward with outstretched arm while standing,
picking up an object from the floor in standing position, turning
to look behind over the left and right shoulders while standing,
turning 360, placing alternate foot on step or stool while standing
unsupported with one foot in front and standing on one leg.
Scores obtained during the assessment were used in data
analysis.
Functional Reach Test
Reach Test was measured by attaching a leveled yardstick
to a wall with tape at the height of the right acromion process.
The subject was asked to stand in a relaxed stance with their
shoulders perpendicular to the yardistick, and was instructed
not to touch the wall but to extend the elbow with the shoulder
at 90 flexion and hold the position for 3 sec. The hand is fisted.
The placement of third metacarpal was recorded (position 1).
The subject was then asked to reach as far forward as without
losing their balance or taking a step and hold for 3 sec. A repeat
measurement is made in the forward reach position. Functional
reach was measured as the difference between positions 1 & 2
and used for data analysis.
Fig. 4: Illustrate the subject is practicing to semi tandem position.
Fig. 5: Illustrate the subject is practicing stepping in different Table 2: Comparison of Mean and SD of group A and group B
direction for FRT
FRT 0 FRT 30 T0 test
(Mean + SD, (Mean + SD,
N= 15) N= 30) t P

Group A 6.9 + 1.2 10.2 + 1.5 15.8 .000

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

Table 3: Comparison of Mean and SD of group A and group B

for Berg Balance Scale
BBS 0 BBS 30 T0 test
(Mean + SD, (Mean + SD,
N= 15) N= 30) t P

Group A 49.9 + 3.9 55.2 + 1.0 6.6 .000

Group B 48.4 + 2.6 52.2 + 2.9 6.6 .000

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

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

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

Subjects of groups A received the balance training on foam

platform, which consists of
Flexibility exercise (3 to 5 repetitions 30 sec. hold)
Hamstring stretch Graph 3: Illustrates Mean and S.D. of F.R.T. & B.B.S.
Calves stretch
Quadriceps stretch
The Balance exercises start with placing the feet in a series
of positions that gradually reduce the base of support, holding
the stance for 10-30 seconds.
Semi tandem - Stand on foam with one foot in front of
the other in semi tandem position.
Full tandem - Stand on foam with heel of one foot
directly in front of the toes of the other foot.

Table 1: Comparison of Mean and SD of age, sex, height and

weight of Group A and Group B Standing up on toes on the foam pad.
Standing on one foot on foam pad.
Age (mean No. of male Height Weight Gradually, additional exercise that to the following are
+ SD ) / female introduced.
Add dynamic movements to perturb the center of gravity,
Group 68.6 + 3.92 Male - 7 159.0 + 7.9 63.8 + 10.1 such as:
A Female - 8 - Leaning or stepping in different direction on foam pad.
- Reaching
Group 70.5 + 4.17 Male - 6 159.3 + 7.0 63.4 + 6.9 - Picking up on object on from the floor on standing on
B Female - 9 foam pad.

Renu Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 4: Comparison of Mean and SD of group A and group B
for FRT and BBS.
Group A Group B T0 test
(Mean + SD, (Mean + SD,
N= 15) N= 15) t P
FRT 0 6.93 + 1.16 7.13 + .99 .50 .61
FRT 30 10.2 + 1.52 9.0 + 1.25 2.3 .02
BBS 0 49.9 + 3.91 48.4 + 2.64 1.25 .21
BBS 30 55.26 + .96 52.26 + 2.91 3.78 .001
- Five minutes of cool down and relaxation activities.
Breathing exercises for relaxation.
Subjects of group B received the same balance training on
floor.
Data was analyzed by using SPSS software. A students t-
test was used to analyze the difference in the balance
improvements in group 1 and group 2. Intra-group analysis
between pre-intervention and post - intervention scores was also
done for both the groups. A significance level of p < .05 was
fixed.
Results
A students t-test was used to compare the performance of
subjects of group A and B on Functional Reach Test (FRT) and
Berg Balance Scale (BBS) prior to the intervention programme
Discussion
We found significant improvement in both the groups but
the subjects who participated in the balance training on foam
platform showed better improvement in balance as compared
to those subjects who participated in the balance training on
floor.
The obvious importance of being able to improve balance
has resulted in a number of balance intervention studies. Which
initially focused on task specific exercises and every day activities
such as getting in an out of a chair, or stepping up and from one
level to another (Harada et al, 1995, Judge, 2003; Lord et al,
2003, Nelson et al, 2004, Nitz and Choy, 2004, Steadman et al,
2003), demonstrated that balance could be improved greatly,
especially in rehabilitation and nursing home environments.
James, W. Bellew has shown significant effect of balance
training (Medial - lateral and anterior posterior movement and
bilateral partial squats) while standing on semi compressible
foam roller devices in older women.11
Based on the findings of the FICSIT study and others, the
specific inclusion of balance activities is warranted in exercise
interventions with goals of improving balance.12 However, many
programs reported in the literature are of significantly greater
duration and frequent and require more specialized equipment,
staff and facilities than the program reported in this study13.
This balance training program is short term, could be
performed independently and requires no expensive equipment.
This program provides a simple effective and enjoyable
opportunity for elderly to participate in exercises that are
promising in terms of preventing falls and keeping elderly more
active for a longer period of time.
Limitations of the study
A small sample size was one of the major limitations
of the study. Also, most of the participants belonged to the same
community and were leading an active lifestyle. Thus, results
4 Renu Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
obtained cannot be generalized for all population types.
Clinical implications
These data suggest that the balance training on foam
platform is more effective in improving balance in geriatric
population as compared to the balance training on floor. This
helps us to choose a better balance training program in geriatric
population above 60 years in order to improve balance
significantly even in a short time duration.
The ultimate effect of this study is to improve balance with
the aim of reducing injurious falls in elderly population.
Future Research
Future research involving a longer time period and
comparing the effects of the two intervention programs is
possible. Also the research can be oriented towards finding out
the reduction in falls following balance training in either group
by maintaining a follow up for few months to years. The relevance
of this study can be increased by taking a larger sample of
subjects.
Conclusion
This study concludes that although both balance training
on floor and balance training on foam platform show significant
improvement on balance outcome scales, the subjects who
participated in the balance training on foam platform showed
better improvement in balance as compared to those subjects
who participated in the balance training on floor. .
References
1. Falls and the elderly: Judith Mc Elhinney, R.N. GNP.
Kenneth, J. Kovl. MD and Joseph O. Zuckerman, MD Vol.
2, No. 1 winter. 1998.
2. Bloem BR, Valkenburg VV, Slabbekoom M, Willemsen, MD.
The multiple tasks test development and normal strategies.
Gait Posture 2 vol., 14 : 191-202.
3. Biomechanical assessment and Stress Test of dynamic
Postural sway to preduct falls in healthy elderly. (John D
Lioyd, CPE, lifford M Gross.
4. Psychosocial effects on an exercise program in older
persons who fall. Kevin m means, M.D., Patricia S. O
sullivan).
5. Judge Jo, Lindsey C, Underwood M, Winsemius D balance
improvement in older women. Effects of exercise training.
Phys Ther. 1993-73 : 254-265.
6. Hinman MR comparison of two short term balance training
programs for community dwelling older adults J Geriatric
physiotherapy 2002, 25 (3) : 10-15.
7. Bellew JW, Yates JW, Gater DR the initial effects of low
volume strength training on balance in untrained older men
and women J. strength cond res. 2003 :17 : 121-28.
8. Province MA, Hadley EC, Horn brook MC, Lipsitz, L.A, Niller
JP, Mulrow CD, ory MG, et al. The effects of execise on
falls in elderly patients. A preplanned metaanalysis of the
FICSIT trials. J Am Med Assoc. 1998, 273 :1341-47.
9. Gardner MM, Robertson MC Campbell AJ, exercise in
preventing falls and fall related injuries in older people : a
review of randomised controlled trials. Br J Sports Med
2000, 34 : 7-17.
10. Kromogata S, Netwton R. The effectiveness of Tai Chai on
improving balance in older adults : an evidence based
review. J Geriatricf phy. Ther. 2003; 26(2): 9-16.
11. Province MA, Hadley EC, Hornbrook MC, LIksitz, LA, Miller
 JP, Mulrow CP. ory MG, sattin RW, Tinetti ME, Wolf SL.
The effects of exercise on falls in elderly patients. J. Am.
Med Assoc. 1995, 273 : 1341-1347.
12. Tinetti M, Baker D,Garrett P,Gotts chalk M, Koch M, Horwitz
R. Yale FICSIT: risk factor abatement strategy for fall
prevention. J Am Geriatr Soc.1993; 41:315-320
13. Wolfson L, Whipple R,Judge j , Amerman P, Derby C, King
M. Training balance and strength in the elderly to improve
function. J Am Geriatr Soc .1993; 41:341-343.

Renu Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 5
Botulinum Toxin as Treatment Modality for Spastic Diplegic
Cerebral Palsy Child: Our experience in 21 patients
Ritesh Runu*, Vaibhav Agrawal**, Arunim Swaroop*, Devendra Dave***
*Assistant Professor, Orthopaedics, **Assistant Professor, Physiotherapy, ***Associate Professor, Department of Orthopaedics
and Department of Physiotherapy, Subharti Medical College and Hospital, Meerut, Uttar Pradesh
Abstract
Spasticity in cerebral palsy is one of its most important and
common clinical presentation.It produces contractures,
deformities and also hampers physiotherapy if not treated. For
treatment of spasticity there are various modalities like stretching
exercises, casts, muscle relaxants, phenol injections, intraspinal
baclofen pump and dorsal selective rhizotomy. Botulinum toxin
A, neuromuscular blocker, is a newer addition in this list. We
have done a prospective uncontrolled study in 21 patients with
diplegic spastic cerebral palsy. The toxin was injected in lower
limbs for spastic hamstrings and gastrosoleus. The average age
of patients was 6.1yrs. Average number of injection given was
one. The patients were followed up for 6 months after injection.
We conclude that Botulinum toxin A is a good muscle relaxant,
easy to administer and has negligible side effects. It improves
tolerance to cast application and physiotherapy which makes
the rehabilitation of patient easy. Except the cost of therapy and
its window period it is best modality of treatment for the spastic
diplegic cerebral palsy patients.
Key Words
Botulinum toxin A (BTX - A), Cerebral palsy (CP), Modified
Ashworth scale, Spasticity, Tardieu Scale.
Introduction
Cerebral palsy (CP) is a neuromuscular disorder
characterized by aberrant control of movement and posture due
to injury to the developing brain. It is non progressive disorder
and the symptoms appear early in life. Apart from motor deficits
the patients of CP may have sensory deficits (hearing or visual),
mental retardation, epilepsy, equilibrium problems, learning
disabilities, and emotional problem.1.
In spastic CP one limb (monoplegic), two limbs (diplegic),
four limbs (quadriplegic) or one half of body (hemiplegic) may
get affected. Due to spasticity the child is unable to attain normal
posture which causes dynamic and fixed contractures, bony
torsional deformities, truncal imbalance and delayed
development of motor skills.2. It also hampers physiotherapy due
to pain and reflex spasm of the muscles.2. Thus the rehabilitation
of the patient is delayed. For proper and adequate physiotherapy
a patient should have calm environment, relaxed mind and
muscles.3. Muscle relaxation is usually attained by medicines
(oral) and local intramuscular agents. They are usually short
acting or produce generalized muscle weakness. For adequate
muscle relaxation, the dose of medicine required is too high.
This makes a child floppy and any physiotherapy becomes
difficult.4.
Any agent producing localized muscle relaxation without
affecting brain and is reversible in nature is an ideal relaxant for
Address for correspondence:
Dr. Ritesh Runu
Assistant Professor, Orthopaedics
Subharti Medical College
Meerut, UP- 250002
6 Ritesh Renu / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
these patients. Botulinum Toxin A (BTX A) is such agent which
produces localized muscle relaxation and is reversible in nature.
It produces the chemical denervation, thereby relaxes the muscle
and helps in physiotherapy.5.
There have been few studies done in Indian subcontinent
on use of botulinum toxin A in cerebral palsy.6. Being different
population characteristics and poor socio economic condition,
we conducted a prospective study over the effect of BTX - A in
spastic diplegic CP in Indian subcontinent.
Material and Methods
This was a prospective trial on 21 randomly selected spastic
diplegic CP patients. The duration of study was from July 2008
to December 2009.
Inclusion criteria were: 1 age 29 years,2 spastic diplegia,3
community or indoor ambulator,4 No fixed musculoskeletal
deformities,5 ongoing physical therapy (PT) of a minimum of
60-minute session per week. All participants received direct
physical therapy for a minimum of 1 hour per week during the
study period. The therapy regimen was left to the discretion of
the treating physical therapist.
The patients having fixed contractures, associated
neurological disorders, mental retardation and operated cases
were excluded from the study.
The patients were selected in OPD after careful clinical
examination. Before admission the patients were clinically
evaluated twice at interval of one month. They were put on
physiotherapy at least for one hour per week. After pre anesthetic
examination and consent the patient was taken for BTX - A
injection under general anaethesia. Before injection the patient
was reevaluated. Then the target muscle area was cleaned and
needle was inserted. The dose of toxin is 3-6units per kg of
body weight for large muscles and 1-2 units per kg of body weight
for small muscle. The reconstituted toxin was given immediately.
No second dose was given. Before injection the location of
needle was confirmed by movement of the part. In hamstrings
the needle moved on flexion and extension of knee joint and in
gastrosoleus it moved on plantar flexion and dorsiflexion of the
ankle. Once needle position was confirmed, injection was given
at 2 points in hamstrings and at four points in gastrosoleus.
After injection below or above knee cast was applied. It supported
the joint at time of greatest muscular weakness and prevents
the recurrence of contracture. After two weeks the casts were
removed and the patients were put on structured vigorous
physiotherapy. For hip adductors abduction pillow was given.
For hip flexors prone lying was suggested.
Tools for patient assessment were clinical examination,
modified Ashworth grading for spasticity and Tardieu scale. The
level of significance was measured using paired t test.
Modified Ashworth scale7.: It is to determine the tonicity of the
muscle.
0- Normal,
1- Increased tone felt as catch in the range of motion
(ROM) at the end,
1+ - increased tone felt as catch with minimal resistance in
less than 50 % of ROM,
2 Increased tone felt as catch with mild resistance in
 more than 50% of ROM,
3 Marked increase in tone with passive ROM difficult,
4 Limb fixed in flexion or extension.
Tardieu scale 8.: It is to know the dynamic muscle length.
When the limb is moved across the joint fastly, the position where
catch appears is R1. Similarly appearance of catch in slow mode
i.e. range of motion is R2. The difference (R2 R1) shows the
dynamic muscle length and amount of spasticity. The patients
with more spasticity and R2 nearer to the end of ROM benefit
most from the BTA injection. Those with less value have more
of fixed deformity and they require surgery.
Observations and Results
All 21 patients were randomly selected and evaluated in
OPD. These patients were again evaluated before injection and
then at 6 weeks and 6 months after injection. The tools for
evaluation were modified Ashworth grade and Tardieu scale.
The results were classified as good, fair and poor. Good were
having significant reduction of spasticity (2 point reduction in
Ashworth grade) and better postural control( unsupported
standing for more than 30 seconds), fair were having moderate
reduction in spasticity(1 point reduction in Ashworth grade) and
better postural control and poor were having slight or no
reduction in spasticity and poor postural control..
The average age of patients was 6.1yrs (2yrs 9 yrs). 15
were male and 6 were female patients. The commonly injected
muscles in lower limb were gastrosoleus and hamstrings. The
Ashworth grading was assessed pre injection and then at every
visit (6wks, 12 wks and 24 wks) post injection for each muscle
group. The change in ashworth grading was measured. The
maximum change in grade was seen at 6 weeks which was
lower than the pre injection state. At end of 6 months the change
in ashworth grading for Gastrosoleus (n= 26) was 1.80. This is
approx 2 point improvement in the muscle spasticity. Similarly
the improvement in the spasticity of hamstrings (n=32) was 1.59.
The overall improvement in spasticity was noted in both the
muscles. At 6 months the spasticity recurred in 32% patients
(including both gastrosoleus and hamstrings). The grade
increased but the level was still lower than the pre injection status.
The significance of this change was measured using paired t
test. Comparing the pre injection data with the post injection
data, we found significant (p value < 0.05%) change in ashworth
grade.
The change in spasticity was clinically correlated with the
increase in range of motion that is, change in Tardieu scale. It
was measured in every patient for each muscle group. For
gastrosoleus the maximum dorsiflexion possible with sudden
jerk (R1) and maximum dorsiflexion with sustained force (R2)
was recorded. Similarly for hamstrings the R1 and R2 for
popliteal angle was noted. For gastrosoleus (TA) and hamstrings
(HAMS), post BTX-A injection the change in range of motion
was noted. The ROM increased in 2 patients (Right TA), 1 patient
(Left TA), 3 patients (Right hams) and 3 patients (Left hams).
No change occurred in 4(right TA), 5(left TA), 2(right hams) and
2 patients (left Hams). The ROM reduced in remaining patients.
We found consistently no change or marginal change in the R2.
We compared the pre injection ROM with the post injection ROM
by paired t-test. It showed insignificant change in the ROM (p
value < 0.05%).
Out of 21 patients 9 were community ambulators and 12
were home ambulators. All ambulators required orthosis and
physical support for walking. The ambulation was started at 2
weeks after removal of casts. Then it was observed at every
visit. All 9 community ambulators who were able to walk before
injection, deteriorated at 2 weeks after injection. At 12 weeks all
patients required orthotic support for walking and at 6 months 5
patients were able to walk without physical support.
Ritesh Renu / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
In the home ambulator group, 7 patients were able to
become community ambulator. They were able to walk with
orthotic support.
Parental assessment is a crude method of assessment.
The parental assessment was found to be different compared
to clinical parameters. It was due to slight improvements, high
expectation, unrealistic approach and illiterate parents.
Out of 21, six had good, thirteen had fair and two had poor
results at the end of 6 months.
Discussion
Cerebral palsy, a common chronic disabling condition,
occurs in 1.5 to 3/1000 live births with similar prevalence rate in
adolescence and adulthood.9. Among various types, spastic
cerebral palsy is the commonest seen in 70 80% cases.10.
Topographically it is classified into hemiplegic, diplegic and
tetraplegic types according to the involvement of body part.
Diplegic CP is a condition where lower limbs are affected
more than upper limbs with fair to good trunk and head control
and little or no bulbar involvement. It is the most common form
of spastic CP.11. Due to spasticity the muscles do not relax fully,
producing abnormal pull over the soft bones of children. This
leads to bony deformity.
The main goal of treatment in these patients is to maximize
the function, minimize the contractures and deformity, delay the
need of surgery, develop good posture control and balance so
that they can equally participate in activities with peers, can
develop good cognitive skills, social skills, and can have
emotional control and vocational potential. These goals can be
attained only by reduction of spasticity, physiotherapy training
and avoidance of secondary insults to brain.12. In younger age
group, the spasticity is more while fixed deformity is less. Hence
early intervention has better results.
After first therapeutic use of Botulinum Toxin- A for treatment
of strabismus in 1980 several studies have been conducted
regarding its use in spastic cerebral palsy.13,14. The effect and
use of BTX-A in CP is only for reduction of spasticity. This
reduction in spasticity is dose dependent.15. Hence the dose
should be measured and planned. Usually the dose has been
defined for each muscle by the members of the Spasticity Study
Group. This dose is again changed according to patient weight,
duration of therapy, muscle bulk, number of muscles injected at
one sitting, Ashworth score and muscle weakness.1
Apart from CP the indications have been extended in adult
orthopaedic problems. For example; multiple sclerosis 16 stroke17
head injury18 lateral epicondylitis.19
The mode of action of BTX-A is focal chemodenervation of
the spastic muscles20,21,22. With time, through diffusion, the toxin
produces chemodenervation and muscular relaxation. This
chemodenervation due to BTX-A is not permanent. Within four
weeks, restoration of the SNARE protein complex allows
exocytosis of Acetylcholine to resume. This reestablishes the
nerve conduction, initially by new axonal sprouting and
elongation of the end plates and eventually by retraction of the
new axonal sprouts.15. Thus a spastic muscle is temporarily
chemodenervated and relaxed for 12 to 16 weeks. This window
period is clinically used for physiotherapy. This period is usually
of 8 weeks.15. The return of spasticity may take longer time. 24.
There have been several studies showing beneficial effects
of BTX A in CP patients with lower limb spasticity.25,26,27. Most
of the studies have been done on lower limb spasticity specially
equinus deformity.2 Koman et al and other authors have shown
reduction in spasticity and improvement in gait and balance
following BTX-A for dynamic foot and ankle deformities.2,28,29.
Studies shows that children with more of spastic deformities,
show most dramatic and long lasting effect of BTX-A.2
Due to spasticity, cerebral palsy patients develop a dynamic
deformity which causes pain with orthosis. Judy Leach claim
that the use of BTX injection allows the patient to use the orthosis
7
which was previously impractical to use.30.
The effect of BTX-A on spasticity is not consistent. The
spasticity recurs with time due to nerve sprouting. There are
different observations which show spasticity returns either to
the previous level or less. Ozlem et al found significant reduction
in spasticity (modified Ashworth Scale) following BTX-A injection.
This reduction in spasticity gradually decreased with time, but
the spasticity was still less than the base line findings. 26,28,29,31,32.
Contrary to these reports there are studies showing no or
limited benefit of using BTX-A in CP patients15,28,31,32. Studies
also show that spasticity returns to pre injection level.28
An important limitation of using spasticity as a clinical
endpoint is that it cannot be correlated with functional change.
This has been shown that Tardieu score is more reliable and
sensitive than Ashworth scale.33,34. Higher dose of BTA produces
greater reduction of spasticity but substantial functional decline
occurs simultaneously. Hence reduction of ashworth score
cannot be correlated with improvement.
In our study, we found significant change in Ashworth grade
in patients. The patients were able to do physiotherapy and were
able to use the orthosis. But the Pre injection and post injection
change in Tardieu score was insignificant. This was because
the change in R2 was less. The ROM for the joint improved but
the end point did not change much. Comparing with Ashworth
scale, due to BTX- A the initial spasticity subsided but the total
length of the muscle did not increase. Hence Ashworth grading
improved but the Tardieu grade changed little. More importantly
there was significant improvement in ambulatory status.
Limitation of our study was small sample size and the short
duration of study. The non inclusion of Gross Motor Function
Control Scale and gait analysis reduced the objectivity of the
study. Cost of medicine was the biggest hurdle in our study.
Due to low socioeconomic status and no insurance coverage
for this disease, it was very difficult to persuade the parents for
this injection. Other difficulty was lack of physiotherapist and
low motivation level in parents to take their child to
physiotherapist. Lack of awareness among primary physician
was also found to be a hurdle regarding this treatment modality.
In assessing the net outcome in CP patients it is essential
to know and document the baseline functional capabilities of
the patient. All the patient cannot achieve the same level of motor
skills after 6 months. Hence individual counseling is must. The
outcome also depends on the age of intervention, previous
physiotherapy given or not, parents dedication, amount of
spasticity at the age of first intervention, and economic status of
the patient.
Our field of work was western Uttar Pradesh in India where
maximum population is rural based and level of literacy is low.
This study is significant because no similar study has been done
in this region of Asia.
Conclusion
A CP child develops their own skill as per the deficit. They
achieve the milestones which is new for them contrary to
neurologically compromised adult who had already experienced
all the abilities for some time. BTX - A injection can be used for
patients with dynamic contractures in less than 3 muscle groups
hindering the rehabilitation of the patient. Cost is the prohibitive
factor for its use. But considering the disability and social burden
of cerebral palsy the use of this drug is very much cost effective.
References
1. Barry S. Russman, Ann Tilton, Mark E. Gormley. Cerebral
palsy: A rational approach to a treatment protocol and the
role of botulinum toxin in treatment. Muscle and nerve
supplement 1997; 20 (suppl 6): S 181 193.
2. Roslyn B, Graham HK. Botulinum toxin A in the
management of children with cerebral palsy: indications
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4. Verrotti A, Greco R, Spalice A, Chiarelli F, Iannetti P.
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5. Koman LA, Mooney JFIII, Smith B, Goodman A, Mulvaney
T. Management of cerebral palsy with botulinum A toxin :
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6. Chitnis A, Johari A, Doshi L, Agrawal T. Botulinum toxin
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Physiotherapy 2002;vol 1,Issue 1: 5 10.
7. Ashworth B: Priliminary trial of carisoprodal in multiple
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8. Tardieu G, Shentoub S, Delarue R. A la recherch dune
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9. Morton RE, Hankinson J, Nicholson J. Botulinum toxin for
cerebral palsy; where are we now? Arch Dis Child.
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10. Ozlen P, Can K, Leyla L, Ozgur B, Haluk B. J child neurology
2006; no12: 1009-1012.
11. Blair E,Stanley FJ. Issues in the classification and
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Res Rev. 1997;3: 184-193.
12. Russman Barry S, Tilton Ann, Gormley Mark E. Cerebral
palsy: A Rational Approach to a Treatment Protocol; and
the Role of Botulinum Toxin in treatment. Muscle and
Nerve, Suppl 6; 1997: S 181- 192.
13. Scott AB. Botulinum toxin injection of eye muscles to correct
strabismus. Trans Am Opthalmol Soc 1981; 79: 734- 770.
14. Bjornson K, Hays R, Graubert C, Price R, Won F,
McLaughlin JF, et al. Botulinum Toxin for Spasticity in
children with cerebral palsy: A comprehensive evaluation.
Paediatrics 2007; 120(1): 49 58.
15. Eames NW, Baker R, Hill N, Graham K, Taylor T, Cosgrove
A. The effect of botulinum toxin A on gastrocnemius length:
magnitude and duration of response. Dev Med Child Neurol.
1999; 41: 226 32.
16. Hyman N, Barnes M, Bhakta B, et al. Botulinum Toxin
(Dysport) treatment of hip adductor spasticity in multiple
sclerosis: a prospective, randomized, double blind, placebo
controlled, dose ranging study. J Neurol Neurosurg
Psychiatry 2000; 68: 707- 12.
17. Miscio G, Delconte C, Pianca D, et al. Botulinum Toxin in
post stroke patients: stiffness modification and clinical
implications. J Neurol 2004; 251:189-196.
18. FockJ, Galea MP, Stillman BC, Rawicki B, Clarke M.
Functional outcome following Botulinum Toxin A injection
to reduce spastic equinus in adults with traumatic brain
injury. Brain Inj 2004; 18: 57-63.
19. Morre HH, Keizer SB, Van os JJ. Treatment of chronic tennis
elbow with Botulinum toxin. Lancet 1997; 349: 1746.
20. Arnon SS, Schechter R, Inglesby TV, et al. Botulinum Toxin
as a biological weapon: medical and public health
management. JAMA 2001; 285: 1059- 70.
21. Koman LA, Smith BP, Shilt JS. Cerebral palsy. Lancet 2004;
363: 1619- 23.
22. Blasi J, Chapman E, Link E, et al. Botulinum neurotoxin A
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23. De Paina A, Meunier FA, Molgo J, Aoki KR, Dolly JO.
Functional repair of motor end plates after Botulinum
Neurotoxin Type A poisoning: biphasic switch of synaptic
activity between nerve sprouts and their parent terminals.
Proc natl Acad Sci USA 1999; 96: 3200-5.
24. To EW, Ahuja AT, Ho WS, King WW, Wong WK, Pang PC,
 Hui AC. A prosapective study of the effect of botulinum toxin
A on masseteric muscle hypertrophy with ultrasonographic
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54: 197 200.
25. Baker R, Jasinski M, Maciag- Tymecka I, et al. Botulinum
toxin treatment of spasticity in diplegic cerebral palsy: a
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26. Koman LA, Mooney JF 3rd, Smith BP, Walker F, Leon JM.
Botulinum Toxin Type A neuromuscular blockade in the
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randomized, double blind, placebo controlled trial: BOTOX
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27. Sutherland DH, Kaufman KR, Wyatt MP, Chambers HG,
Mubarak SJ. Double blind study of botulinum A toxin
injections into the gastrocnemius muscle in patients with
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AT, Thomason P, et al. Functional outcome of botulinum
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29. Cosgrove AP, Graham HK. Botulinum Toxin A in the
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30. Judy Leach. Children undergoing treatment with botulinum
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Randomised Double blind placebo controlled trial of the
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33. Boyd RN, Graham HK: Objective measurement of clinical
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9
Is Knee Range of Movement on Discharge Important After Total
Knee Replacement - A prospective audit based study
Ross Darch*, Jonathan Swan**, Tom Wainwright***, Robert Middleton****
*Orthopaedic Physiotherapist, **Orthopaedic Therapy Team Leader/ Extended Scope Practitioner Physiotherapist, ***Clinical
Researcher in Orthopaedics, ****Consultant Orthopaedic Surgeon, The Royal Bournemouth and Christchurch Hospitals NHS
Trust, England, The Royal Bournemouth Hospital Visiting Associate, CoPMRE, Bournemouth University, U.K.
Abstract
Questions
Is knee range of movement on discharge important after
total knee replacement? Is there a difference in flexion over 6
weeks post TKR between sub-groups based on varying flexion
scores on discharge?
Design
A prospective audit utilising a repeated measures design
was adopted, using a 6-week follow-up period to allow for initial
post-op tissue healing and a physiotherapy treatment
intervention to commence.
Participants
A convenience sample of 24 patients undergoing TKR was
measured prior to discharge and then at their routine 6-week
follow-up.
Intervention and Outcome Measures
A standard hand-held goniometer was used to measure
subjects knee flexion and extension on discharge and at a six-
week follow-up in both sitting on the edge of a plinth and
supported long sitting respectively using 5 measurement
intervals.
Results
During the first six-weeks post TKR, all patients significantly
increased their knee flexion (CI 95%, P<0.0001). It is also
apparent that knee excursion also significantly increased over
the same time period regardless the patients movement at
discharge. There was a statistically significant change in knee
extension scores in all patients post TKR (CI 95%, P<0.004).
This showed a reduced ability to extend the knee after a TKR.
There was no significant difference in flexion scores between
groups over the six weeks (CI 95%, P<0.5).
Conclusion
This study supports the notion that range of movement at
discharge is not essential as all patients improved their knee
flexion and total movement over a six-week follow-up and
differences between groups were not significant. Further
research is needed to support the outcome of reduced knee
extension post TKR and the implications it has on rehabilitation
post TKR.
Address for correspondence:
Mr Ross Darch
BSc (Hons) MCSP
Orthopaedic Physiotherapist, The Royal Bournemouth and
Christchurch Hospitals NHS Trust, England
ross.darch@rbch.nhs.uk
10 Ross Darch / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Introduction
There is supportive evidence to suggest that total knee
replacement (TKR) is an effective treatment intervention for
osteoarthritis and that it not only relieves pain but also greatly
improves mobility in 90% of patients.1 Arthritis can limit active
range of movement (AROM) at one or both extremes of range.2
The goal of TKR is to provide the best possible outcome for the
patient by relieving pain and substantially improving patients
mobility and quality of life (QOL).2
Knee range of movement is a major component of most
joint-specific scoring outcome measures3,4 as it is widely used
due to its simplicity to understand and as it directly measures
the joints condition 4, 5. It is therefore important to evaluate the
effectiveness of objective outcome measures such as active
range of movement. From this an evaluation of surgical success
and its impact on a patients QOL can be made. Clinically, a
threshold of 95 has been documented as the minimum amount
of knee flexion required to perform activities of daily living. 3, 4,
although another study indicated that a range of activities four
month post TKR required between 54-69 flexion to complete
competently6. This study suggests figures would suggest a
flexion angle of much less than ninety would be sufficient to
continue with normal daily activities.
Contrastingly, Rowe et al.,2 state that more than 90 is
needed to complete some daily activities. This study also reports
that patients who require more than 90 flexion may not achieve
this with a TKR and may therefore affect their QOL. It concluded
that the most common outcome for TKR is likely to be a loss of
AROM from pre-operation and therefore a reduced ability to
perform functional activities, with the primary benefit of TKR
being reduced pain.
There is sparse research into the relationship between
AROM and QOL. There is also conflicting evidence to support
the net gains in AROM from TKR. There is limited grade Ia and
Ib levels of evidence to clarify the flexion gains post TKR. The
purpose of this study is to determine if there is a difference
between patients in knee movement at six weeks depending on
their movement at discharge. The experimental hypothesis is
that there will be a significant difference in flexion scores at six
weeks post TKR between groups of varying flexion scores at
discharge.
Methods
Design
This study used a quantitative approach, employing a
repeated measures design. This increased the generalisability
of the data collected and allowed for more objective and
measurable outcomes when establishing a relationship between
AROM on discharge and at a 6-week follow-up. The data
collector at the 6-week follow up was blinded to the results on
discharge from hospital.
Participants
Twenty-four subjects were enrolled to the study using a
convenience sampling method. Patients were included who had
undergone a TKR at the Derwent Unit (Royal Bournemouth and
Christchurch Hospitals NHS Trust, RBCH). There were no
withdrawals and no subjects refused to be re-measured at the
second data collection. The participants were aged 58-72 with
a mean age of 65.
Measures were taken by the use of a standard one-degree
interval goniometer, using bony landmarks previously tested by
Lenssen et al.8 Measurements were recorded at five-degree
intervals as supported by Holm et al.,9 who states that measuring
lower limb range of movement using 5-degree intervals has a
high reliability between researchers.

Intervention Data Analysis

All participants underwent a TKR procedure with a A sample size calculation of 18 subjects using a power
standardised rehabilitation process as an in-patient. All subjects frequency of 0.8 was taken. The study used an actual sample
had their maximal knee flexion and extension scores measured size of 24 to allow for withdrawals.
prior to discharge. Flexion and extension were measured in Descriptive statistical methods were used to analyse the
sitting and supported sitting respectively. Following the recording extension and flexion movements of all subject groups both on
of base-line measurements at discharge, all participants
underwent a physiotherapy programme at their nearest hospital.
Table 1: Allocation of subjects
All participants were given a standard series of knee range of
movement and quadriceps strengthening exercises and were Flexion on
instructed to complete these three times a day. 7 All patients Group D/C No. Male Female
were given advice on PRICE principles to help limit the
complication of swelling and pain, which could potentially have 1 75>79 9 4 5
limited improvements in knee range of movement at the 6-week
follow-up. All patients were re-measured at a routine 6-week 2 80>84 6 2 4
follow up appointment. Flexion and extension scores were re-
measured in the same positions. 3 85>89 6 3 3

Outcome Measures 4 90> 3 2 1

Table 2: Knee movement results

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

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

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

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

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

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

Comparison of knee flexion between sub-groups

Graph 1: Comparison of knee flexion

Ross Darch / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 11
discharge and at a routine 6-week follow-up.
Normality of all data was tested, using the Shapiro-Wilk
test and was found not to be significantly different from normal
(P= 0.241 to 0.36), therefore the data was analysed using
Comparison of knee extension between sub-groups
Graph 2: Comparison of knee extension
parametric statistical analysis. An independent ANOVA was used
to detect any significant differences over time. A repeated
measures ANOVA was used to detect a between-group change
in the movement excursion post TKR. All data was analysed at
a level of statistical significance of 0.05 and a power of 0.95.
Results
Comparison of total knee movement between sub-groups
Graph 3: Knee movement changes over 6-weeks
Flow of Participants Through the Study
A total of 24 patients participated in this study. At baseline,
patients were sub categorised based on their flexion they
achieved on discharge scores (Table 1). There were no
participant withdrawals, 9 (37.5%) achieving 75-79 flexion, 6
(25%) 80-84, 6 (25%) 85-89 and 3 (12.5%) 90 and over on
discharge. Table 2 shows the characteristics of the sub groups
range of movement at baseline and at 6 weeks follow-up.
Graph 1 shows that all subject groups increased knee
flexion from baseline measurements at discharge to the six-
week follow-up. Patients who achieved greater flexion on
discharge also achieved a greater amount of flexion at 6-weeks.
Although all patient groups experience improvements in
flexion (Graph 1), it appears that active knee extension worsens
in the first six weeks after discharge following a TKR procedure.
Graph 2 highlights those that had the least amount of flexion on
discharge (Group1) had the biggest losses in knee extension.
This means that those who struggled to flex their knee on
discharge lost the ability to extend their knee more than other
patients six weeks post TKR.
These results show that knee flexion increases but
12 Ross Darch / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
extension is lost over the first six weeks following discharge,
irrespective of knee flexion on discharge.
Graph 3 shows that knee flexion scores over a six-week
period increase more in groups of patients who have less knee
flexion at discharge (Groups 1 and 2). In summary, those who
have poor knee flexion on discharge gain more knee flexion in
the first six-weeks post operation but still have less flexion that
those who were discharged with 90 knee flexion. Those patients
who have the most knee flexion on discharge still improve their
knee flexion during the first six-weeks post TKR but at a slower
rate.
Knee flexion for all subject groups showed a significant
increase (CI 95%, P<0.0001) over a six-week follow up period.
The patients ability to extend their knees showed a significant
decrease (CI 95%, P<0.004) over a six-week follow up period.
Total knee excursion for all subjects showed a significant
increase (CI 95%, P<0.0001) over a six-week follow-up period.
There was no significant difference for between group changes
for end knee flexion, extension and excursion over a six-week
period.
Discussion
Importance of Knee Flexion
When analysing the descriptive data, significant increases
in knee flexion scores were demonstrated in all TKR patients in
their first 6 weeks. However there was no statistical difference
in flexion at 6 weeks between patients grouped by flexion ROM
at discharge. It can therefore be interpreted that despite a
difference in ROM on discharge, patients continue to improve
knee flexion no matter how much flexion they achieved on
discharge.
When extrapolating the results of the study clinically, this
study could be used to challenge the theory that 90 flexion
range of movement is required at discharge 2, as all patients
improved their knee flexion at six-week follow-up regardless of
their range on discharge. A minimum flexion range of 75 could
have positive implications for patient length of stay and pain
control. Chiu et al.3 reported that increases in pain levels are
likely to increase length of stay. By lowering the threshold of 75
this may allow patients to be better pain controlled and reduce
length of stay.
Although all patients improved their flexion at 6 weeks,
descriptive data indicates that the group with 75 on discharge
did not achieve, on average, 90 or over at 6 week follow up.
Rowe et al. 2 found that 50% of TKR patients could not flex their
knee beyond 90 at a one-year follow-up. Rowe et al. 2 supports
over 90 as a threshold by stating that more than 90 is needed
to competently complete some activities of daily living. In the
current study, 79% of patients were able to achieve this range
at a 6-week follow up. Other research indicates that a threshold
of 95 is the minimum knee flexion required to be able to rise
from a chair, climb stairs and walk normally.3,4 In the current
study, 46% of patients reached this threshold recommendation
of knee flexion at 6 weeks.
In contrast to other studies, Myles et al6 recommended that
patients require only 69 to complete most activities of daily living.
All flexion scores of the current study surpass the
recommendations of Myles et al.6 and further support the notion
that patients could be discharged from hospital post TKR with
less than 75. If patients continue to make significant gains
over the first 6 weeks after being discharged with 75 flexion (as
in the current study) then a strong case for challenging the
discharge criteria for knee replacements can be made. This is
further supported by evidence indicating that mobilisation under
anaesthetic (MUA) is most commonly performed on patients
with flexion of less than 80 1 year post TKR10,11. The current
study demonstrates flexion greater than 80 at a 6-week follow-
up for all patients, which is superior to that reported in the MUA
studies.10, 11
It seems reasonable to suggest that further follow-up
intervals at 3, 6 and 12 months, would be beneficial to help
identify if the improved range at 6 weeks is continued at longer
term follow up. This would also enable further analysis of the
trend of reducing flexion in the 75 group demonstrated in the
descriptive data. From this a change to the discharge criteria
for flexion post operatively could be suggested, which could have
benefits for both the patient and resources, without any long-
term limitations to function. In addition to longer term follow up,
a larger sample size would benefit future studies. Although
greater than the number needed from a sample power
calculation, a larger sample size would improve the study.
Importance of AROM as a Discharge Criteria
It is important to note that knee flexion is just one aspect of
being able to competently complete a functional task and that
there are many other factors including hip movement, lower limb
strength and knee extension. This further highlights the
importance to assess a surgical outcome such as TKR with a
functional measure that incorporates more than just knee flexion.
When analysing the descriptive data it was also found that
all TKR subjects demonstrated a loss in active knee extension
over the first post-operative 6 weeks. This was found to be
statistically significant. This could be due to a lack of compliance
with PRICE principles leading to poor management of post-op
swelling. This could also be due to physiological tightening of
the joint capsule and hamstrings or the varying rehabilitation
that patients received post TKR. There is no research to the
authors knowledge reporting loss of knee extension post TKR.
In conclusion, this study could be used to support the notion
that high flexion range of movement at discharge is not essential
as all patients improved their knee over a six-week follow-up. It
also reports that not all patients reach the common surgeon
based goal of 90 flexion at their six-week follow-up. Evaluation
of the literature suggests that high AROM is not necessarily an
important discharge criteria or outcome measure post TKR;
however, further research is required to evaluate minimum flexion
required to give a good functional outcome.
Ross Darch / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
References
1. Woolhead G, Donovan J, Dieppe P. Outcomes of total knee
replacement: a qualitative study. Rheumatology.
2005;44:1032103.
2. Rowe P, Myles C, Nutton R. The effect of total knee
arthroplasty on joint movement during functional activities
and joint range of motion with particular regard to higher
flexion users. Journal of Orthopaedic Surgery.
2005;13(2):131-138.
3. Chiu K, Ng T, Tang W, Yau W. Review article: Knee flexion
after total knee arthroplasty. Journal of Orthopaedic Surgery.
2000;10(2):194202.
4. Miner A, Lingard E, Wright E, Sledge C, Katz J. Knee range
of motion after total knee arthroplasty. How important is
this as an outcome measure? The Journal of Arthroplasty.
2003;18(3):286-294.
5. Murray R, Fitzpatrick K, Rogers H, Pandit D, Beard J, Carr
J, Dawson J. The use of the Oxford hip and knee scores.
Bone Joint Surgery. 2007;89(B):1010-14.
6. Myles C, Rowe P, Walker C, Nutton R. Knee joint functional
range of movement prior to and following total knee
arthroplasty measured using flexible electrogoniometry. Gait
and Posture. 2002;16:46-54.
7. Beaupre L, Lier D, Davies D, Johnston B. The effect of a
preoperative exercise and education program on functional
recovery, health related quality of life, and health service
utilization following primary total knee arthroplasty. The
Journal of Rheumatology. 2004;31(6):1166-1172.
8. Lenssen A, Van Dam E, Crijns Y, Verhey M, Geesink R,
Van den Brandt P, De Bie R. Reproducibility of goniometric
measurement of the knee in the in-hospital phase following
total knee arthroplasty. BMC Musculoskeletal Disorders.
2007;8:83.
9. Holm I, Bolstad B, Lutken T, Ervik A, Rokkum M, Steen H.
Reliability of goniometric measurements and visual
estimates of hip ROM in patients with osteoarthritis.
Physiotherapy Research International. 2000;5(4): 241-248.
10. Esler C, Lock K, Harper W, Gregg P. Manipulation of total
knee replacements. Is the flexion gained retained? The
journal of bone & joint surgery. 1999;81(1):27-29.
11. Namba R, Inacio M. Early and late manipulation improve
flexion after total knee arthroplasty. The Journal of
Arthroplasty. 2007;22(6):58-61.
13
The Effect of Transcutaneous Electrical Nerve Stimulation in the
Treatment of Chronic Pelvic Pain Syndrome: An evidence based
electromyographic studies
Ahmed F Samhan1, Nermeen M Abd-Elhalim1, Emam H Elnegmy2, Mohamed M Roiah3
1
Physical Therapy Department, New Kasr El-Aini Teaching Hospital, Faculty of Medicine, Cairo University, 2Physical Therapy
Department for Growth and Developmental Disorders in Children and Its Surgery, Faculty of Physical Therapy, Cairo University,
3
Andrology and STDs Department, Faculty of Medicine, Cairo University, Egypt
Abstract
Background and Objective
Chronic Pelvic Pain Syndrome type III or chronic non-
bacterial prostatitis (CP/CPPS) is characterized by Lower Urinary
Tract Symptoms, discomfort or pain in the pelvic region for at
least 3 months of duration and sexual dysfunction. The purpose
of the study was to evaluate the efficacy of TENS in the treatment
of CPPS.
Subjects and Methods
Forty male volunteer patients, suffering from non-bacterial
CPPS, participated in the study their age was ranging from 35
to 55 years. Patients were randomly assigned into 2 groups of
equal number study (group 1) and control (group 2). Patients in
group 1 received TENS plus traditional medical treatment in
the form of antibiotics (ofloxacin 300 mg t.d.s.), and analgesics
(ibuprofen 400 mg b.d.). Patient in group 2 received placebo
TENS plus the traditional medical treatment as in group 1. The
parameters investigated including EMG activity at rest, and NIH-
CPSI pain domain questionnaire scores.
Results
The results revealed no significant difference between the
two groups in all parameters (EMG activities at rest and NIH-
CPSI pain, domain questionnaire) before treatment while after
the treatment, significant improvement was recorded in all
parameters in group 1 and non-significant was recorded in group
2.
Conclusion
It could be concluded that TENS is an effective means of
non-invasive symptomatic treatment of CPPS and the results
of this study was based on the changes of electrical activity of
pelvic floor muscles by EMG.
Key Words
Transcutaneous Electrical Nerve Stimulation (TENS),
Chronic Pelvic Pain Syndrome (CPPS), Electromyography
(EMG).
Introduction
Prostatitis is defined as painful inflammation of the prostate
that is often associated with lower urinary tract symptoms
(LUTS), such as urinary burning, hesitancy, and frequency, as
well as with sexual dysfunction or discomfort, including erectile
dysfunction, painful ejaculation, and postcoital pelvic
discomfort; adverse sexual effects are reported in
approximately half of men with prostatitis1 .The International
Prostatitis Collaborative Network and the National Institutes
of Health (NIH) have established a classification system for
prostatitis. The systems four categories, describe acute and
chronic infectious forms (NIH categories I and II) as well as
14 Ahmed F Samhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
the more prevalent forms that have not been correlated with
infectious etiologies (NIH categories III and IV) 2.
Chronic Pelvic Pain Syndrome type III or chronic non-
bacterial prostatitis (CP/CPPS) is characterized by LUTS,
discomfort or pain in the pelvic region for at least 3 months of
duration and sexual dysfunction. Over the last decade this benign
entity has attracted much attention due to the high prevalence,
socio-economic impact and severe impact on the quality of life
of a CP/CPPS patient. However, knowledge about the etiology,
the pathophysiology and proper therapy for CP/CPPS is still
lacking 3.
The use of antibiotics in NIH category III is based on the
uncertain etiology and the possibil-ity that a potential pathogen
or a cryptic non-cultur-able organism may be causative.
Combination of analgesics, alpha-blockers, antibiotics, and
muscle relaxants coupled with prostatic massage and supportive
therapy (perineal support, pelvic floor physiotherapy, biofeedback
and relaxation therapy) has been reported to yield higher cure
rate and relief of pain and voiding symptoms compared to
antibiotics alone and is the treatment option favored by most
urologists 4.
TENS was introduced as an alternatively therapy to
pharmacological treatments for chronic pain. TENS currently is
one of the most commonly used forms of electro analgesia5.
The use of EMG studies shows that CPPS sufferers as
compared to normal are manifest preliminary resting baseline
instability. Initial resting baseline hypertonicity, instability, and
decreased endurance contractile capacity statistically
significantly categorize men as more likely to suffer from CPPS.
These findings indicate that pelvic floor muscle (PFM) status
likely plays a role in at least some subset of CPPS sufferers and
that PFM evaluation with EMG can help identify this population
as those who may benefit PFM rehabilitation 6.
The needs for the treatment of pain in CP/CPPS with a
non-invasive, non phar-macological, non-addictive technique
such as TENS clearly exist. Instability in the PFM in patients
presenting with type III CP/CPPS has been reported by EMG.
The purpose of the present study was therefore to determine
the efficacy of TENS in the treatment of CP/CPPS.
Subjects and Methods
Subjects Selection
Forty male CP/CPPS type III non-bacterial prostatitis
patients participated in this study. They were selected from Kasr
El-Aini Hospital and Department of Andrology and STDs at Cairo
University Hospitals. The inclusion criteria were randomly
selected men age between 35-55 years, previously diagnosed
as category III CP/CPPS. Exclusion criteria were prostate and
other urogenital cancer and infec-tion, loss of skin sensation at
and around painful area, previous exposure to TENS and other
electro analgesia. The forty patients were randomly assigned
into two groups of equal number.
Outcome Measures
Measurement of Myogenic Activity (EMG activities) of PFM:
Using Toennies NeuroScreen Plus system EMG biofeedback
unit to examine the patients muscle activity at rest (Amplitude Table 1: The statistical analysis of differences (t-test) of (A/T)
per turn A/T in mV for right and left side of PFM). The surface on right side:
electrodes were placed 3 cm from the anal sphincter on both A/T on Group Mean Standard P-value
sides. Surface EMG/biofeedback evaluation was done as part right side deviation
of the overall physical therapy evaluation6.
Assessment of NIH-CPSI pain, domain questionnaire: The Pre-treatment Group 1 0.2090 0.02315 0.701
NIH-CPSI is a commonly used 13-item questionnaire for the Group 2 0.2065 0.01725
assessment of symptom severity in men with CP/CPPS. NIH
chronic prostatitis symptom index questionnaire, the pain Post-treatment Group 1 0.0965 0.0722 0.002
do-main (1a, 1b, 1c, 1d, 2a, 2b, 3, and 4) describing the location, Group 2 0.1925 0.0522
frequency and severity of pain was presented to each patient
and instruction was given to indicate the pain characteristics
level 7. The total score of pain domain questionnaire is ranging Table 2: The statistical analysis of differences (t-test) of (A/T)
from 0 to 21. Evaluation was conducted twice before the first on left side:
session of treatment (Pre-treatment) and after 4 weeks of A/T on Group Mean Standard P-value
treatment (Post-treatment). right side deviation

Treatment Procedures Pre-treatment Group 1 0.2085 0.02231 0.612

Group 2 0.2115 0.01387
The TENS plus Medical Treatment Group (Group 1):
Twenty patients were used TENS application, patients were Post-treatment Group 1 0.0970 0.07349 0.002
comfort-ably positioned based on the painful area (to cover the Group 2 0.1955 0.05246
perineal-suprapubic region) for electrode place-ment. It was
ascertained that sensitivity of the area was intact, and that there
was no resistance, this allowed for effective stimulation. TENS Fig. 1: The mean difference values of (A/T) on both sides.
gel was applied on the surface of the electrodes to aid maximum
transmission of cur-rent. Electrodes were placed on the skin
overlying the painful area and held firmly in position. The machine
was switched on; a suitable and comfortable frequency and pulse
width were selected on the stimulator by turning the appropriate
knobs. Patients were stimulated with TENS daily for an average
of 20 minutes, mean frequency, pulse width and intensity of
100Hz, 100s and 25mA respectively for a mean duration daily,
5 times per week for 4 consecutive weeks. The medical treatment
was in the form of antibiotics (ofloxacin 300 mg t.d.s.), and
non-significant difference. After 4 weeks of the treatment, mean
analgesics (ibuprofen 400 mg b.d.).
values of A/T at rest was 0.0970 0.07349 mV and 0.1955
The placebo TENS plus Medical Treatment Group
0.05246 mV in group 1 and group 2, respectively. P-value was
(Group2): Twenty patients were used TENS application with
0.002, which means a significant difference in favor of group 1.
the machine off, as a placebo treatment, patients were
Figure 1 demonstrates the mean values difference of A/T on
comfort-ably positioned with the electrodes placement over the
both sides pre-treatment and post-treatment between group 1
painful area for a mean duration of 20 minutes daily, 5 times
and group 2.
per week for 4 consecutive weeks. Patients were received
As presented in table 3, the mean values of NIH-CPSI pain,
traditional medical treatment as in group 1.
domain questionnaire scores pre-treatment was 0.2090
0.02315 and 17.402.23371 in group 1 and group 2, respectively.
Data Analysis P-value was 0.612, which means a non-significant difference.
After 4 weeks of the treatment, mean values of pains scores
Collected data were fed into computer for the statistical was 2.20 5.19717 and 17.45 2.13923 in group 1 and group 2,
analysis; parametric test for determination of EMG activities of respectively. P-value was 0.000*, which means a highly
PFM at rest (A/T in mV for right and left side of the pelvic-floor significant difference in favor of group 1. Figure 2 demonstrates
muscles) and the NIH-CPSI pain, domain questionnaire. A the mean values difference of NIH-CPSI pain, domain
comparison was made by student t-test to compare between questionnaire scores before pre-treatment and post-treatment
two independent means. between group 1 and group 2.

Results Discussion
There was non-significant difference between patient CPPS is a common urologic occurrence in men less than
characteristics before treatment in study group and control group, 50 and accounts for a large number of urologist visits each year8.
thus the patients selection was homogenous.
In the present study, the effect of TENS in the treatment of Table 3: The statistical analysis of differences (t-test) of NIH-
CP/CPPS was investigated. As shown in table 1, the mean CPSI pain, domain questionnaire scores
values of A/T in mV on right side at rest pre-treatment was
0.2090 0.02315 mV and 0.20650.01725 mV in group 1 and A/T on Group Mean Standard P-value
group 2, respectively. P-value was 0.701, which means a non- right side deviation
significant difference. After 4 weeks of the treatment, mean
values of A/T at rest was 0.0965 0.0722 mV and 0.1925 0.0522 Pre-treatment Group 1 17.40 2.23371 0.612
mV in group 1 and group 2, respectively. P-value was 0.002, Group 2 17.70 1.38031
which means a significant difference in favor of group 1. As shown
in table 2, the mean values of A/T in mV on left side at rest pre- Post-treatment Group 1 2.20 5.19717 0.000*
treatment was 0.2085 0.02315 mV and 0.2115 0. mV in group Group 2 17.45 2.13923
1 and group 2, respectively. P-value was 0.612, which means a

Ahmed F Samhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 15
Fig. 2: The comparison between group 1 and group 2 the mean
values of NIH-CPSI pain, domain questionnaire scores.
CPPS negatively affects quality of life and sexual function in
men of all ages 9. The treatment of men with CP/CPPS is difficult
because the pathogenesis is unclear. Several treatment
modalities such as antimicrobial agents, analgesics, anti-
inflammatory agents, muscle relaxants, alphablockers, 5-alpha-
reductase inhibitors, heat therapy, surgery, and biofeedback
physical therapy have been proposed and investigated 10. Pelvic
floor tension myalgia may contribute to the symptoms of CPPS.
Therefore, measures that diminish PFM spasm may improve
these symptoms 11.
A study by Hetrick et al., 2006 6 proved that, CPPS patients
manifest PFM instability compared to normals. Pre-baseline
resting hypertonicity and instability along with endurance
contraction weakness reliably predicts subject membership in
the CPPS vs. normal group. EMG activity of PFM may be a
valuable screening tool to identify patients with CPPS who may
benefit from therapies aimed at correcting PFM dysfunction.
Another similar study was conducted by Martinez and Diaz, 2008
12
suggested that EMG with cutaneous patches can be of
diagnostic use in CP/CPPS patients, and open the possibility of
using alternative PFM therapies such as biofeedback,
neuromodulation and Botulinic toxin use.
The result of the present study was in agreement with a
similar non invasive complementary and alternative medicine
(CAM), reported by Capidice et al., 2007 13; they investigated
the ef-fect of acupuncture in 10 men diagnosed as CP/CPPS
(category IIIA or IIIB). Acupuncture was applied for 30 minutes,
twice weekly for 6 weeks. They reported significant decrease in
NIH-CPSI for pain and LUTS and quality of life. Another study
was conducted by Sikiru et al., 2008; 24 patients diagnosed
with CP/CPPS were referred for physiotherapy from the Urology
department. The pain level was assessed using the NIH-CP
(pain domain) index. The TENS group received TENS treatment
and all subjects were placed on antibiotics throughout the
treatment period. The findings of the study revealed significant
effect of TENS on CP/CPPS pain at p < 0.05.
TENS may be indicated in the management of chronic
pros-tatitis pain; a similar visceral organ as labor pain. With any
symptomatic therapy, however, ef-ficacy must be weighed with
the risks involved. TENS might be preferable to large amount of
analgesics and their side effects. Also, TENS is readily available
to both patients and therapists, cheaper and easy to apply
compared to other non invasive, non pharmacological
complementary and alternative medicine therapies14.
A study by El-Nashaar et al., 200615 consisted of 80
consecutive male patients affected by CPPS and 80 healthy
controls who were asked to complete the Arabic version of the
NIH-CPSI. The translation was performed by a group consisting
of an andrologist and professional translators. The results of
the 160 subjects enrolled, 82 (50 patients and 32 controls)
completed the study. The total Arabic NIH-CPSI scores and the
scores of each subscale differed significantly between the two
16 Ahmed F Samhan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
groups with good discriminant validity. The questionnaire had
also a high internal consistency and the authors concluded that,
the Arabic version of the NIH-CPSI and recognize it as a valid
and reliable tool in the assessment of local patients with CPPS.
In the present study, more than one method of evaluation
was used to find definite reasons about the efficacy of TENS in
the treatment of CP/CPPS evidence based EMG studies as it is
the 1st time to use TENS and measuring the EMG activity which
in turn demonstrated the tone the PFM. Using placebo TENS
with the traditional medical treatment in the form of antibiotics
and analgesics in the control group (group 2) was non-significant,
but use of TENS with the medical treatment gave a highly
significant improvement (group 1). The results of this randomized
controlled crossover parallel arm trial contribute to the existing
body of knowledge. Evidence has shown that EMG studies A/T
in mV on both right and left side of PFM gave a significant
difference in favor of group 1. The traditional medical treatment
in the treatment of CPPS is not sufficient treatment as pain is
still present after treatment in group 2. Physiotherapists could
be one of the medical staff in treating CPPS with TENS and
other physical therapy modalities (biofeedback and heat
modalities) in conjunction with oral medication or other treatment
chronic pelvic pain syndrome.
Conclusion
In this study, we used TENS in treatment of patients
suffering from CPPS. After application of TENS plus medical
treatment in the form of antibiotics (ofloxacin 300 mg t.d.s.),
and analgesics (ibuprofen 400 mg b.d.) in group 1, pain was
relieved and electrical activity of PFM was returned to normality.
It can be satisfactory concluded that TENS is an effective means
of non-invasive symptomatic physiotherapeutic management of
CPPS and the results of this study was based on the changes
of electrical activity of PFM by EMG.
References
1. Potts J and Payne RE: Prostatitis: Infection, neuromuscular
Disorder, or Pain Syndrome? Proper Patient Classification
is Key. Cleveland Clinic Journal of Medicine 2007; 74(3):
S63-S71.
2. Krieger JN, Nyberg LJ, and Nickel JC: NIH Consensus
Definition and Classification of Prostatitis [Letter]. JAMA
1999; 281: 236-237.
3. Cornel EB, Van Haarst EP, et al: The Effect of Biofeedback
Physical Therapy in Men with Chronic Pelvic Pain
Syndrome Type III. European Urology 2005; 47: 607-611.
4. Barbalias GA, Nikiforidis G and Liatsikos EN: Alpha-
Blockers for the Treatment of Chronic Prostatitis with
Antibiotics. J Urol. 1998; 159: 883-887.
5. Sikiru L, Shmaila H, and Muhammed SA: Transcutaneous
Electrical Nerve Stimulation (TENS) in the Symptomatic
Management of Chronic Prostatitis/Chronic Pelvic Pain
Syndrome: A Placebo-Control Randomized Trial.
International Braz J Urol. 2008; 34(6): 708-714.
6. Hetrick DC, Glazer H, Liu Y-W, Turner JA, Frest M and
Berger RE: Pelvic Floor Electromyography in Men with
Chronic Pelvic Pain Syndrome: A Case-Control Study.
Neurology and Urodynamics 2006; 25: 46-49.
7. Clemens JQ, Calhoun EA, Litwin MS, et al: Rescoring the
NIH Chronic Prostatitis Symptom Index: Nothing New.
Prostate Cancer and Prostatic Diseases 2009; 12: 285-
278.
8. Rossi PJ and Dickey JL: Chronic Pelvic Pain Syndrome.
The AAO Journal 2004: 23-25.
9. Van Alstyne LS, Harrington KL, and Haskvitz EM: Physical
Therapy Management Chronic Proatatitis/ Choronoc Pelvic
Pain Syndrome. Phys Ther. 2010; 90: 1795-1806.
10. Cornel EB, Van Haarst EP, Browning RW Schaarsberg B
and Geels J: The Effect of Biofeedback Physical Therapy
in Men with Chronic Pelvic Pain Syndrome Type III.
European Urology 2005; 47: 607-611.
11. Zhang-Qun YE, Dan CAI, Guang-Hui DU, et al: Biofeedback
Therapy for Chronic Pelvic Pain Syndrome. Asian J Androl.
2003; 5: 155-158.
12. Martinez CP and Vargas Aiaz IB: Case-Control Study of
Pelvic Floor Electromyography in Patients with Chronic
Pelvic Pain. Rev Mex Urol. 2008; 68(4): 225-228.
13. Capodice JL, Jin Z, Bemis DL, Samadi D, Stone BA, Kapan
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S, and Katz AE: A Pilot Study on Acupuncture for Lower
Urinary Tract Symptoms Related to Chronic Prostatitis/
Chronic Pelvic Pain. Chin Med. 2007; 2: 1.
14. American College of Obstetrician and Gynecologists
Committee on Practice Bulletins Gynecology. ACOG
Practice Bulletin No. 51 Chronic pelvic pain. Obstet
Gynecol. 2004; 103: 589-605.
15. El-Nashaar A, Fathy A, Zeedan A, Al-Ahwany A, Shamloul
R: Validity and Reliability of the Arabic Version of the
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Index. Urol Int. 2006; 77: 227-231.
17
CardioVascular and Respiratory Responses to Valsalva
Maneuver, Isometric Hand Grip Exercise and Harvard Step Test
and Recovery in Healthy Individuals
Sanjiv Kumar*, Shivappa B Anurshetru**, Prabhker Kore
*Principal & Professor, KLES Institute of Physiotherapy, Belgaum, **Consulting Cardio-Thoracic Surgeon and Associate Professor,
KLESH & MRC, Nehru Nagar, Belgaum
Abstract
Objective
To assess the responses of Cardiovascular and respiratory
system to Valsalva maneuver, Isometric handgrip exercise, and
isotonic Harvard step test in healthy individuals.
Design
Randomized design used in this study to find out the effect
of 3 different physical stressors on healthy individual.
Setting
OPD of KLES College of Physiotherapy Hubli.
Sample
300 Healthy individuals randomly allotted into 3group (A,
B, C) with homogeneous gender distribution and of age group
16 year to 30 years.
Method
Group A underwent Valsalva maneuvers, Group B was
exposed to Isometric exercise sustained handgrip, and Group
C performed Isotonic exercise Harvard step test.
Result
Inter and Intra group analysis for significance was done
taking pre and post Exercise value and ANOVA and found the
following. Intra group within A (A1, A2, A3) none of the value
found significant, also the values of B group does not show any
significance with present data. In-group C Systolic Blood
pressure(BP), Rate pressure product(RPP) and Double product
(DoP) shown great significance may be attributed to age and
stress level. Stress level may be more appropriate as it effecting
Systolic BP and in turn RPP and DoP. Inter group analysis
through ANOVA shows other then Pulse rate of A1, B1, C1
nothing found significant.
Conclusion
The greater stress levels have significant changes in
parameter even in normal young individual. Few individual have
shown poor cardio-vascular responses during exercise and at
recovery period. Hence risk for sub clinical heart aliment cannot
be overruled just by looking the baseline parameter at rest.
Sedentary individual were slow to recover then active individual.
Key Words
Valsalva maneuvers, sustained handgrip exercise, Harvard
step test, Healthy individuals, and Outcome measures.
18 Sanjiv Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Introduction
Cardio-Vascular respiratory System is a most vital system
in the body and responds to any alteration in physical, mental
and social changes. On application of physical stress the cardio
vascular system responds by increasing cardiac output up to
maximum of 8 folds of the normal. Exercise facilitates the
muscular activities, which in turns demands more oxygen and
nutrition to full fill the demand, local vasodilatation and increase
sympathetic stimulation takes place. This facilitation of circulation
removes metabolites, waste products and facilitates kidney
functions. In this study the cardio vascular system is exposed
to physical strain of three different activities. The study was
designed to compare the responses of cardio vascular system
to these activities. The activities include Valsalva maneuver,1
isometric sustained handgrip2 and isotonic Harvard step test.
These stressors are used, to understand the functional capacity
of heart and lung and help to diagnose the heart related problem,
and introduced to individuals who have no symptoms to assess
the capacity of heart and lung.
The study is planned after it becomes known to medical
field that the heart conditions are no more old age problems.
Many young individuals are now developing cardiac diseases
like M.I or even cardiac arrest though they were clinically normal
in prior examination. This study was targeted towards the normal
healthy individual with intention to identify the risk individuals
and sub clinical problems among them. This study intended to
find out the cardio vascular responses in healthy individuals and
compare the effect of physical stressors between the groups
and responses in the genders.
Aims and Objectives of Study
To assess the responses of Cardiovascular and respiratory
system to Valsalva maneuver, Isometric handgrip exercise, and
isotonic Harvard step test in healthy individuals. And To compare
the responses of all three physical stress factors in healthy
individuals, inter group and intra group.
Material and Methods
Study design for this study was randomized design to find
out the effect of 3 different physical stressors on healthy
individual. The subjects participated in this study were from
different educational institution of Hubli. Medical ethical
committee of KLE Universitys Research ethical board approved
the procedure of physical stressors before commencement of
the study. The healthy individuals of age group 16-30 years were
included in the study and a informed consent was taken from
them. Simple random sampling method was followed. Healthy
Individuals were allotted into groups by simple lottery method
through chits. And the size of the sample was 300 Healthy
individuals. Inclusion Criteria: In this study only healthy
individuals were included. No major illness in last three months
and must be physically sound to perform the exercise. Exclusion
Criteria: Any individual who does not satisfy the above criteria
were excluded from the study. Instruments used in this study
was Digital BP machine, Disposable syringe, hand
Dynamometer, stopwatch, and metronome, Step of 20" height,
GSR Equipment, Height scale, Weight scale.
Procedure
The subjects were randomly allotted into 3 groups with
homogeneous gender distribution and age group 16 year to 30
years each group was further sub divided in sub group 1,2,3.
Group A consists of 100 healthy individuals who were
exposed to valsalva maneuver. In this the individual were asked
to blow through the disposable syringe end to the
sphygmomanometer and sustain it for 15 sec such that the
mercury column shows a reading of 40mmHg in sitting position.
This is followed by assessment of cardiovascular responses by
the investigator. Group B participants were asked to perform
sustained handgrip exercise using manual dynamometer. The
grip should be 30% of maximal contraction for 5 minute was
used. Group C participants were asked to performed isotonic
exercise in the form of Harvard steps test as sub maximal
exercise. In this the participants performed stepping up and down
on 20" tall step at the speed 30 repetitions per minute for five

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

A1 A2 A3 B1 B2 B3 C1 C2 C3

Mean 1.62 1.59 1.607 1.610 1.6 1.7 1.63 1.62 1.59

Sd 0.093 0.090 0.083 0.089 0.084 0.075 0.65 0.88 0.075

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

A1 A2 A3 B1 B2 B3 C1 C2 C3

Mean 54.3 54.6 58.2 52.3 54.07 55.6 57.4 55.1 56.3

Sd 9.7 12.2 9.2 7.1 9.03 7.4 9.9 9.05 7.45

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

A1 A2 A3 B1 B2 B3 C1 C2 C3

Mean 20.79 21.2 22.4 20.4 20.9 21.7 21.3 20.65 21.9

Sd 3.41 4.12 2.13 2.86 2.14 2.4 3.25 2.69 1.77

minute. Outcome measures before and after exercise - Pulse Fig. 2: Systolic Blood Pressure
rate, Systolic BP, Diastolic BP, RPP (Rate pressure product)
=(HR X SP) / 100, DoP(Double product)= HR X MP, Respiratory
Rate, GSR Actual, GSR Basal.

Results
Fig. 1: Pulse rate

Mean of Post exercise pulse rate was maximum in C3,

152.2 with SD 12.4 and minimum was noted in 72.8 A3 with
SD5.7 (Table-4 and Figure 1)
Before exercise mean value of Systolic BP maximum was
noted is 121.4 with SD 11.4 in A2 and minimum was reported in

Fig. 3: Diastolic Blood Pressure

The analysis revealed some significant finding. Mean height

and SD was calculated and it was found that minimum height
was recorded in C3 1.59Mt with 0.075SD (Table-1). Maximum
height was noted in Group B3 1.7 Mt with SD 0.075.The mean
weight of B1 was 52.3 KG with SD 7.1 and was minimum among
groups and mean Maximum weight recorded was of A3 group
58.2KG with SD 9.2 (Table-2). BMI of B1 was 20.4 with SD 2.86
which was least among groups and 22.4 with SD 2.13 of Group
A3 was maximum. (Table-3)
In analysis pre and post exercise data of Pulse rate was
analyzed and it was found that Mean pulse rate of A1 was
maximum 80.3 with SD 14.35 and B3 was minimum recorded
with 70.03 and SD 5.7(Table and Figure 4) in pre exercise
condition

Sanjiv Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 19
Table 4: Showing Mean Pulse Rate with SD of individual in various group
A1 A2 A3 B1 B2 B3 C1 C2 C3

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

Sd 14.35 10.54 5.647 10.651 10.25 5.7 11.5 11.9 6.2

Post Mean 83.91 77.54 72.8 80.3 79.6 74.4 135.3 149.5 152.2

Sd 16.08 12.1 5.7 9.3 8.47 5.9 22.1 19.2 12.4

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

A1 A2 A3 B1 B2 B3 C1 C2 C3

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

Sd 9.35 11.4 8.4 8.4 10.9 7.45 10.5 10.6 7.2

Post Mean 121.6 125.8 119.9 122.6 123.03 122.5 156.91 163.7 163.3

Sd 10.2 11.6 11.9 8.35 11.97 8.84 15.1 10.8 8.41

Table 6: Showing Mean Diastolic BP with SD of individual in various group
A1 A2 A3 B1 B2 B3 C1 C2 C3

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

Sd 7.5 8.19 6.63 6.47 7.20 12.4 8.04 7.17 6.09

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

Sd 7.2 7.7 6.49 9.54 9.02 6.68 11.9 9.01 8.04

115.1 with SD 8.4 in A3. After exercise the maximum value was
recorded in 163.7 with SD 8.41 in C2 and 119.9 with SD 11.9 in
A3 group (Table-5 and Figure 2)
Mean Diastolic BP of B3 was maximum 78.81 with SD 12.4
and C1 was minimum recorded with 71.9 and SD 8.04) in pre
exercise condition.
Table 7: Intra group ANOVA P-Value
Mean of Post exercise Diastolic BP was maximum in C3
87.3 with SD 8.04 and minimum was noted in B1 72 with SD
9.54 (Table - 6 and Figure 3)
Significant changes in respiratory rate developed in Group
A and C found though the GSR outcome were inconsistence
and none significant.Inter and Intra group analysis for

Pulse SBP DBP RPP DoP GSR Actual GSR Basal

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

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

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

Table 8: Inter group ANOVA P-Value

Pulse SBP DBP RPP DoP GSR Actual GSR Basal

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

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

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

significance was done for pre and post Exercise value using
ANOVA and found the following (Table 7 &8). Intra group within
A (A1, A2, A3) none of the value found significant, also the values
of B group was also does not show any significance with present
data. In-group C Systolic BP, RPP and DoP shown great
significance may be attributed to age and stress level. Stress
level may be more appropriate as it effecting Systolic BP and in
turn RPP and DoP. Inter group analysis through ANOVA shows
other then Pulse rate of A1, B1, C1 nothing found significant.
Discussion
Valsalva maneuver produces initial rise in systolic and
diastolic pressure followed by fall in blood pressure and pulse
pressure with increased heart rate then sudden transient fall in
blood pressure at the termination of expiration. Response of
this stressor has effect on the neurovascular system. Valsalva
in diabetes mellitus alters the autonomic function responses of
the cardio vascular system.3. The study was performed on normal

20 Sanjiv Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
healthy individual hence it has no effect on such system and
can be proved by consistence in outcomes. Outcome of BMI
also suggests consistence in the participant features.
The heart rate outcome was significant and toward higher
only in C group and can be contributed to the stress level of the
exercise or deconditioned attitude of individual. The higher heart
rate in exercise where arm was used above the level of heart
was the expression of larger static and postural component4.
The change in pulse rate was least in the group in which the
stress level was least. It is likely that smaller muscle mass and
vasculature of arms offers greater resistance to blood flow then
the larger muscle mass and vasculature of the legs blood flow
to the arms during exercise. This would therefore require much
larger systolic blood pressure. Clearly this form of exercise
represents greater cardiovascular strain because the work of
the heart is increased considerably. For individuals who have
cardiovascular dysfunction these observations support the use
of exercise that requires large muscle group such as walking,
bicycling, and running, in contrast to unregulated exercise that
engages a rather limited muscle mass such as shoveling
overhead hammering or even arm ergometery.5 In our study
step test could produce maximum change in blood pressure
then other as the large musculature were exposed for strenuous
activity then other two. Autonomic function assessment was done
in diabetic patients using valsalva and sustained handgrip.
Significant rise in pulse rate and blood pressure were noted in
the participants.6 there were changes noted in vlasalva and hand
grip exercise even in our study but were not significant
asDiastolic blood pressure increase in participants of step test
in this study.
Hand grip stress also shown changes in base line reading
but was very insignificant compare to step test Sustained hand
grip exercise at 30% of maximum voluntary force used on normal
healthy individual and has shown increased diastolic blood
pressure 7Sustained Isometric handgrip exercise was found to
be producing significant increase in systolic and diastolic blood
pressure & heart rate. 8 Isometric exercise at 50% of maximal
voluntary contraction was applied for 60 seconds and it was
found that there is significant rise in arterial pressure.9Exercise
responses during the wall pulley exercise verses bicycle
ergometer work, the heart rate response was greater for arm
exercise than for leg exercise. The systolic blood pressure
response was greater for arm exercise than bicycle ergometer10.
Effect of exercise speed on heart rate, systolic blood
pressure and rate pressure product during upper extremity
ergometry was done and significant difference in immediate post
exercise heart rate pressure product across the exercise speed
was found. No significant difference was found in immediate
post exercise systolic blood pressure. A moderate speed
exercises produced least cardiovascular stress.11
Effect of tread mill exercise in normal individual was
assessed and compared with sustained handgrip. It was found
that isotonic tread mill exercises resulted in enhanced diastolic
filling with increased heart rate and blood pressure compare to
isometric hand grip exercise.12
Effect of leg exercise and arm exercise in sitting and
standing body position on energy out put and on same cardio
respiratory parameters was studied. Significant higher heart rate
and blood pressure was found in arm cranking in cycling at sub-
maximal workload. Only postural difference in arm work was
13% higher workload achieved at maximal effort when standing
than compared to sitting.13
Yoga training of six weeks duration modulates sweating
response to dynamic exercise and improves respiratory
pressure, Handgrip strength and handgrip endurance and found
that attenuation of the sweating response to step test by yoga
training. Yoga training for a short period of six weeks can produce
significant improvements in respiratory muscle strength and
Sanjiv Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
endurance.4Exercise lasting longer than a minute or two a
cardiac output and heart rate linearly increased with peripheral
oxygen uptake. The mean systemic arterial pressure increases
and vascular resistance in active muscles falls, leading to large
increase in blood Flow to the muscle. Blood is pumped back to
the heart by muscular contraction, and the cardiac output is
determined by venous return. Cardiac output and heart rate
recorded at maximal exercise have been viewed at maximal
limiting values, but both increased when exercise by arms is
added to maximal leg exercise. Thus increasing energy demands
dominate increase in cardiovascular responses. This study
supports our present data as same trend of cardiac response
noted in them.14
The outcomes of hand grip exercise have minimal effect
on cardio vascular system and insignificant changes in
respiratory system. However significant increase in tidal volume,
respiratory rate, minute ventilation, O2 consumption CO2
production occurred during unsupported low intensity upper limb
exercise in normal subjects.6 which actually not in tandem with
our result and may be attributed to intensity of exercise. We do
not made any attempt to assess the body temperature after or
before exercise though it was evident from the response of
Isometric handgrip exercise and dynamic two leg bicycle
exercise increases in skin temperature and blood circulation.15
The step test provided greater intensity and stress and shown
greater CVTS responses. C V responses to moderate intensities
of static contraction can be produced primarily by motor
command, but that both motor command and muscle chemo-
reflexes contribute to CV responses at higher intensities of static
exercise.16
The sustained hand grip a form of isometric exercise also
shown in terms of increased heart rate and blood pressure and
changes in DoP and RPP, however none of the value was
statically significant. Upper extremity exercise tended to evoke
greater demand on the CVS like that of isometric component
exercise.17
The variability of homodynamic and cardiovascular
parameters obtained during upper body exercise found that the
RPP varied with duration and intensity of exercise.18 Effects of
dynamic and static handgrip exercises on hand and wrist volume
found that After dynamic and static handgrip exercises, hand
and wrist volume increased significantly, the elevation of hand
and wrist volume after dynamic exercise was significantly higher
than that after static exercise. 23 Ventilatory responses to static
handgrip exercise found that progressive increases in mean tidal
volume inspiratory ventilation, heart rate and arterial BP no
significant changes in respiratory frequency .19Isometric handgrip
exercise does not increases base line sympathetic activity from
resting levels it significantly diminished increase of sympathetic
activity during neck suction.20 C V responses to moderate
intensities of static contraction can be produced primarily by
motor command, but that both motor command and muscle
chemo-reflexes contribute to CV responses at higher intensities
of static exercise.16
The study was conducted for relating various stress level
and its responses in normal individual and could correlate the
same. However many individual could not completed the
exercise which it self signify the status of their CVS. And the
study also could locate that approximately 5% of individual could
not recover their CVS parameter on time which puts them in
risk group. The individuals failed to complete also makes
susceptible group of CVS risk and conditioning recommended.
The study does not provided any significant outcome, however
it also does not overrules the sub clinical risk in individual. The
study has limitation inform of small sample size as for
generalization of the result a larger sample size at multiple
centers need have to be assessed. It is the need of the hour to
address the most rapidly spreading life style illness which is
taking toll of health and cost related to it.
21
Conclusion
The greater stress levels shows significant changes in
parameter even in normal young individual. Few individual have
shown poor cardio-vascular responses during exercise and at
recovery period. Hence risk for sub clinical heart aliment cannot
be overruled just by looking the baseline parameter at rest.
Sedentary individual were slow to recover then active individual
References
1. Bhatia S.G., sainani G.S., Nayak N. J. and Diwate P.G.
Valsalva maneuver as atest of autonomic neuropathy in
Diabetes Mellitus. Jr. Asso. Phys. Ind. Vol.24 Feb1976, 89-
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2. Kamiya Atsunori, Kichikami daisaku et.al. Static handgrip
exercise modifies arterial baroreflex control of vascular
sympathetic outflow in humans. J Appl Physiol 94:2212-
2216, 2003.
3. Mikes D S Cardiovascular responses to upper body
exercise in normal and cardiac patients. Med. Sci. Sports
Exercise 21:5126,1989
4. Madanmohan, Sivasubramniyank. et.al. Effect of six weeks
yoga training on weight loss following step test, respiratory
pressure, handgrip strength and handgrip endurance in
young healthy subject. Department of physiotherapy,
JIPMER.
5. Ikeda, Elizabeth R et.al. The valsalva maneuver revisited:
the influence of voluntary breathing on isometric muscle
strength. The journal of strength and conditioning research,
2008.
6. Petta A C, Jenkins S.C and Allison G Ventilator and
cardiovascular responses to unsupported low intensity
upper limb exercise in normal subject, Australian journal of
physiotherapy Vol. 44 No. 2 1998; 123-129
7. Helfant Richard H., Devilla Maria A., Meister Steven G.
Effect of sustained isometric handgrip exercise on left
ventricular performance. Pub Med 1971
8. Haskell W L, Savin WM, Schroeder J S Alderman E A Ingles
N B et. al. Cardiovascular responses to hand grip isometric
exercise in patients following cardiac transplantation.
Circ.Res. 1981 Jun;48 (6Pt2):1156-61.
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9. . Amundsen L R , Takashi M, Carter C L, Exercise response
during wall pully versus bicycle ergometer work, Phy. Ther.
1981 Feb 60 (2) 173-178
10. Mac master V. Harned and Pamela P W. Effect of exercise
speed on heart rate, Systolic blood pressur, and rate
pressure product during upper extremity ergometery. Phy.
Ther. Vol-67 No-7 July 1987: 1085-1088
11. Mizushige K, Mastsuo H, Nozaki S, Kwan O l, DeMaria
AN. Differential responses in left ventricular diastolic filling
dynamics with isometric handgrip versus isotonic treadmill
exertion. Am. Heart J. 1996 Jan; 131 (1) : 131-7
12. Voka s Z Bell H et. al Oxygen uptake , heart rate relationship
in leg and arm exercise in sitting and standing J. Appl.
Physiol. 1975July 39(1):54-59
13. Tandon R. Bajpait H.S., Agarwal J K. A comprehensive study
of autonomic nervous system dysfunction in diabetes
mellitus. JAPI 1985, Vol. 33, No-4
14. Marino Nino, DePasquale Eugene et al: Physiology in
sports, text principles of sports medicine editor W normann
Scott, William and wilkins 1993.
15. Taylor W F, Johnson J M, Kosiba W A, and Kwan,
Cutaneous vascular responses to isometric handgrip
exercise. Journal of applied physiology, Vol 66, Issue 4,
1989, 1586-1592.
16. Gandevia S C and Hobbs S F Cardiovascular responses
to static exercise in man, Journal of Physiology Vol 430,
1990, pp 105-117
17. Greer M, Weber T et al: Physiological responses to low
intensity cardiac rehabilitation exercise. Physical therapy
1980: sept;60(9): 1146-1151
18. Craig P.J., Otto R.M. et al: The variability of homodynamic
and cardiovascular parameters obtained during upper body
exercise. American college of sports medicine 45th Annual
meeting June 3-6, 1998; Orange county convention center
Orlando, Florida.
19. Muza S R , Lee L Y , Wiley R L , S McDonald, F W Zechman
Ventilatory responses to static handgrip exercise Journal
of applied physiology: respiratory, environmental and
exercise, physiology.01/07/1983;54(6):1457-62.ISSN:
0161-7567
20. Eckberg D L and Wallin B G, Isometric exercise modifies
autonomic baroreflex responses in humans, Journal of
Applied Physiology, Vol 63, Issue 6, 1987, 2325-2330.
Effect of FAME Program on Chronic Stroke Patients in Indian
Population
Shanta Pandian*, Kamal Narayan Arya**, Archana Kaushik***
*Superintendent OT, OPD, **Sr Occupational Therapist, ***Occupational Therapist, PDU Institute for the Physically Handicapped,
University of Delhi, Ministry of Social Justice & Empowerment, Govt. of India. New Delhi
Abstract
Background
Stroke is a leading cause of disability among adults
worldwide. Many stroke survivors have chronic deficits that limit
physical activity and cause subsequent physical deconditioning,
which propagates disability and worsens cardiovascular disease
risk. Evidence suggests that exercise following stroke has a
positive impact on functional outcomes even after years. Fitness
and Mobility exercise (FAME) is evidence based group exercise
program developed in Canada for people with chronic stroke. It
includes task specific activities and exercises that promote
fitness and mobility and help prevent further strokes, heart
attacks or falls that can cause significant functional declines.
Aims & Objectives
To examine its effectiveness on fitness, balance, mobility
and overall impact of stroke.
Methodology
Design Pretest Post test Single group
Sample size 10 (both male & female)
Outcome Measures The performance- oriented mobility
assessment, Stroke
Impact scale, Functional Reach Test, Time Up and Go test
& 6 Minute Walk Test
Procedure The program was administered for 6 weeks,
twice a week (12 sessions).
Results
There was significant difference between pre and post
assessments.
Conclusion
The FAME program is beneficial for improving some of
the functional deficits resulting from chronic stroke.
Introduction
Stroke is a leading cause of long-term disability, and 90
percent of people living with stroke have some functional
limitations, including muscle weakness, pain, spasticity, cognitive
dysfunction, poor balance, and frequent falls. These impairments
can lead to reduced activity and sedentary lifestyles, with further
declines in function and disability status. Rate of recovery of all
impairments maximizes with in first 2 weeks of stroke and slows
down after 2-3 months and probably stops after 6-12 months.
Many stroke survivors have chronic deficits that limit physical
activity and cause subsequent physical deconditioning, which
propagates disability and worsens cardiovascular disease risk.
Exercise can improve ambulatory function and fitness even years
after stroke.
Usually rehabilitation focuses more on improving motor
control and use adaptive methods for such clients; ill effects of
Shanta Pandian / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
sedentary life style and reduction in over all fitness are missed.
Fitness and Mobility Exercise Program (FAME) is an
evidence based group exercise program developed in Canada
for people with chronic stroke. It includes task specific activities
and exercises that promote fitness and mobility and help prevent
further strokes, heart attacks or falls that can cause significant
functional declines. The FAME Program addresses multiple
domains, including balance, muscle strength, bone health,
mobility, cardiovascular fitness and depression. It has been
tested in three trials with people with chronic stroke in Canada
by Janice Eng, Andrew Dawson Daniel Marigold and Marco
Pang. The trials have shown improvements in balance function,
balance confidence, walking speed, leg muscle strength, and
quality of life.
Marco Y. C. Pang et al (2005) examined the effects of a
community-based group exercise program for older individuals
with chronic stroke. The intervention was community-based. The
FAME program was feasible and beneficial for improving some
of the secondary complications resulting from physical inactivity
in older adults living with stroke. It may serve as a good model
of a community-based fitness program for preventing secondary
diseases in older adults living with chronic conditions.
Similarly, Alain Leroux (2005) concluded that an exercise
program offered by a community organization can lead to
improvement in motor performance of individuals with chronic
stroke. To prevent decline in motor performance, community-
based exercise programs should thus be made available for
stroke patients discharged from rehabilitation services.
Further, Kathleen M. Michal et al (2006) discussed the
relationship of Fatigue after stroke with mobility, fitness,
ambulatory activity, social support and fall efficacy. They studied
53 community dwelling stroke patients and found that fatigue
was common and persistent in common stroke survivors. Yet, it
was not known how mobility deficits, fitness and other factors
such seen as social support, relate to fatigue severity of fatigue
was examined and relationship among fatigue and other factors
was identified.
Also, Richard F. Macko, et al (2008) investigated the effects
of an adaptive physical activity (APA) program on mobility
function and quality of life (QOL) in 20 chronic stroke patients.
APA has the potential to improve gait, balance, and basic but
not instrumental activities of daily living profiles in individuals
with chronic stroke. Also, in improving stroke related quality of
life.
Mary Stuart, Sarah Chard, Suzanna Roettger, (2008)
emphasized on growing evidence on the efficacy of exercise
models for improving multiple domains of physiological health
and fitness in people with chronic stroke. The use of a structure-
process-outcome framework is suggested to facilitate exchange
between international research teams regarding development
of evolving stroke exercise models.
In addition, Richard F. Macko, Joseph Hidler, (2008) focused
on exercise models which can be targeted to affect multiple
physiological systems that determine long-term health and
functional outcomes in both stroke and Spinal Cord Injury (SCI).
Findings support a rationale for regular exercise to reduce insulin
resistance and improve cardiovascular health and fitness for
individuals with SCI and stroke-related disabilities.
More recently, Rose Galvin et al (2008) conducted a
randomized controlled trial to evaluate the impact of additional
23
family assisted exercise therapy in people with acute stroke. It
was a prospective multi-centre single blind randomized
controlled trial. Forty patients with acute stroke were randomized
into either an experimental or control group. The experimental
group received routine therapy and additional lower limb exercise
therapy in the form of family assisted exercises. The control
group received routine therapy with no additional formal input
from their family members. Participants were assessed at
baseline, post intervention and followed up at three months using
a series of standardized outcome measures.
Furthermore, Janice J. Eng, Marco Y. C. Pang Maureen C.
Ashe (2008) recommended the role of exercise in reducing the
risk of fragility fractures, which would be a relatively new
application in stroke rehabilitation. The promising treatment also
has potential to reduce incidence of falls as well as maintain or
improve bone health. Given the many health benefits associated
with exercise, it should be considered an important modality for
the management of falls and maintenance of bone health
following stroke.
Literature review shows that there are very few studies done
on determining the effect of exercises in chronic stroke patients.
There are hardly any such studies in Indian context. The present
study focuses the need.
Aims & Objectives
To implement FAME program on chronic stroke
patients.
To examine its effectiveness on fitness, balance,
mobility and overall impact of stroke.
Methodology
Design Pretest Post test Single group
Sample size 10 (8 male & 2 female)
Place of Work Department of Occupational Therapy, Pt.
DDU Institute for the Physically Handicapped, New Delhi
Inclusion Criteria:
People with stroke with mobility problems ranging from very
slow walking speeds of 0.3 m/s to fairly normal walking speed
of 1.0 m/s walk short distances (e.g., 3 meters) with minimal
supervision).
May do the exercise program with support of chair or walker.
Should have near-normal cognition
Exclusion Criteria: Those who cannot perform standing
exercises while holding onto a support.
Outcome Measures
The performance- oriented mobility assessment (POMA):
The performance- oriented mobility assessment
developed by Tinetti provides a brief and reliable measure of
both static and dynamic balance. Items are organized into two
subtests of balance and gait. POMA I has a total possible score
of 28.
Timed Get Up and Go Test (TUG):
Timed Get Up and Go Test developed by Podsialdo and
Richardson is a quick measure of dynamic balance and mobility.
Research indicates that most adults can complete the test in
less than 10 seconds. Scores between 11 to 20 seconds are
considered within normal limits for frail elderly or individuals
with a disability; scores over 30 seconds are indicative of
impaired functional mobility.
Functional Reach Test (FRT):
Developed by Duncan et al provide a quick screen of
balance problems in older adults. It is a performance-based
test to assess postural responses to voluntary movement
performed during a daily activity. It is a measurement of the
maximal distance one can reach forward beyond arms length
24 Shanta Pandian / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
(in the horizontal plane) while maintaining a fix base in the
standing position.
Six meter walk test (6MWT): developed by RJA Butland,
is important for examination of postural control and functional
mobility. It is a performance base test distance walked in 6
minutes is measured and reported in meters or feet. A greater
distance indicates a better performance.
Stroke Impact Scale(SIS): (developed by PW Duncan &
colleagues) SIS (Version 3.0) is a disease specific evaluative
instrument that measure impact of stroke in multiple domains,
including physical, emotional, memory/thinking, communication
and social participation. The purpose of stroke impact scale is
to evaluate how stroke has impacted patients health and life. It
further asses patients perception of stroke how stroke has
affected you & your quality of life?
Procedure
The program was administered for 6 weeks, twice a week
(12 sessions).
Participants were screened for the general health
conditions.
Pre-Assessments were done using the outcome measures
before the initiation of the program.
Duration of Program
Each session lasts 1 hour. The program has been tested
with a frequency of 3X/week and has been successfully tested
with durations of 8-19 weeks. Ideally, a 3-4 month program is
recommended to achieve sustainable benefits. We recommend
a minimum of 8 weeks if undertaken 3X/week and a longer
duration (12 weeks) if only 2X/week. In addition, we recommend
an additional home exercise day if the group program is only
2X/week. If appropriate screening (e.g., stress test) and a
cardiovascular component is used (e.g., training. Exercises were
stopped if participant faces any adverse effects eg. Pain or
fatigue, dizziness, chest pain and breathlessness is seen.
Maximizing adherence and having fun: Adhering to
regular exercise is difficult for everybody. There is no doubt that
a charismatic instructor can make a huge difference in motivating
participants. However, a number of initiatives can be done to
maximize adherence. Encourage socialization! Encourage fun!
Re-assessing
The Participants were re-examined on the outcome
measures to analyze progress.
Data Analysis & Results
Data was taken from excel spread sheet and was analyzed
by SPSS version 11 for alpha value < 0.05 as significant.
Results are summarized in table no. 1 to 8 & Figure 1 to 10
SIS (total score) pre mean was 108+23.8, post mean
276.1+25.72, found to be significant (p value < 0.025).
SIS (recovery) on a scale of 0 to 100 as perceived by patients
was found to be significant (p< 0.025) pre mean 59+16.46post
mean77.5+13.3.
Subcategories of SIS- Physical problems, mood & emotions,
communication and community mobility were found to be
significant (refer tables)
While subcategories of SIS- Memory & thinking, Activities of
typical day, Hand ability and Participation in life were not found
significant.
POMA pre mean 20.3 + 4.42 post mean 26.7 +1.76 was not
found to be significant.
TUG pre mean 17.29+ 4.20 seconds post mean 14.9+ 3.7
seconds, was found to be highly significant (p < 0.0005)
6MWT pre mean 105.3+28.15 meters post mean 128.1+22.9
Table 1: Difference Pre Post S I S Table 8: Difference Pre Post SIS6
Pre Post Pre Post
Mean + SD 184 + 276 + Mean + SD 26.6+2.16 37.4+3.56
23.8 25.72
t value - 1.88
t value - 2.272
p value 0.05
p value < 0.025 (significant)
(significant)
Fig.1:
Table 2: Difference Pre Post SIS %
Pre Post
Mean + SD 59 + 77.5+
16.46 13.3

t value - 2.68

p value < 0.025

(significant)

Table 3: Difference Pre Post FRT

Pre Post
Mean + SD 10.24 14.27+
+2.89 2.59

t value - 1.8

p value < 0.05

(significant)
Fig.2:
Table 4: Difference Pre Post TUG
Pre Post
Mean + SD 17.29+4.20 14.95+3.7

t value 4.816

p value < 0.0005

(significant)

Table 5: Difference Pre Post SIS 1

Pre Post
Mean + SD 7.3+1.82 14.8+2.44

t value - 2.8

p value < 0.01

(significant)
Fig.3:
Table 6: Difference Pre Post SIS 3
Pre Post
Mean + SD 26.6+3.4 47.4+3.34

t value - 1.92

p value < 0.05

(significant)

Table 7: Difference Pre Post SIS4

Pre Post
Mean + SD 26.6+2.16 37.4+3.56

t value - 1.88

p value 0.05 meters was not found significant.

(significant) FRT pre mean 10.24+2.89 inches post mean+2.59 inches found
to be significant (p value <0.05)
Fall frequency was reduces in most of the subject. It was

Shanta Pandian / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 25
Fig.4: Fig.8:

Fig.5: Fig.9:

Fig.6: Fig.10:

Fig.7:
assessed by 3 point scale never -1, occasionally-2 & frequently-
3.
Pre FAME there was two, three & five subjects respectively in
never, occasionally & frequently group. Post FAME there was
five, five & zero subjects respectively.

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

26 Shanta Pandian / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
persons etc. during therapy.
Depression is always a challenging problem in different
stages of stroke. Depression is not measured particularly but
mood and emotions were much better clinically as well as found
statistically significant. That was the main motive of group therapy
program, where patients could interact with each other and
therapists during therapy session. Improved Mood & emotion
would further prevent fatigue as discussed and conclude by
Kathllen Michal et al (2006).
Balance was improved both clinically and statistically as
measured by FRT. This achievement could be attributed to
components of FAME based on balance and coordination
activities. Marco Y. C. Pang et al (2005) studied effect of FAME
program on chronic stroke patient; significant improvement in
balance, mobility and cardio respiratory fitness was founded. In
the present study balance was improve which further prevent
secondary complication like fall risks, fracture in chronic stroke
and improve bone health in such patients, same was also
supported by Marco Y. C. Pang et al (2005), Alain Leroux (2005)
& Janice J Eng. Et al (2008).
Since the program was given in group in which every subject
had opportunity to lead the session and to encourage
socialization as recommended in FAME program. Usually
whenever stroke patients take therapy or management
everybody talks about the related impairment and dysfunction.
This program emphasized on the normal socialization even with
any extent of impairment which explains the significant
improvement in SIS-4 (Communication & conversation).
Components of FAME such as one leg standing, tandem
standing & tandem walking, quick wait shifts, slow & fast
marching were individually practiced in every therapy session,
this could explain the significant improvement in mobility at home
and community(SIS-6)
Physical endurance in some cases also improved clinically
but statistically it was not found significant which could attribute
to small sample size and could also be due to measurements
taken in meters. Though as per the guidelines of 6MWT readings
can also be taken in feet.
Though the result of TUG was statistically highly significant
with mean decrease of 2.5 seconds in performance of the test,
functionally this amount of difference does not show much
achievement.
POMA has subpart of different components of gait while
FAME does not emphasize in individual physical components
which could explain the non significant statistical results. Further
there was not much difference between pre and post mean due
to small sample size and gait components of POMA.
Limitation of the Study
1. Sample size was small
2. Large group could not be taken due to space problem.
3. Natural environment like garden could not be used during
therapy
4. Music as recommended by FAME could not be used during
therapy session.
5. Due to transportation problem in metropolitan cities like
Delhi some patients were either irregular or were not able
to come as per our schedule.
Shanta Pandian / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Recommendation for Future Research
1. Long term study by using measure like bone densitometry,
force / pressure sensors, motion analyzer can be done.
2. Effect of home program based on FAME could be studied.
3. Cardiopulmonary endurance testing should be considered.
4. Prevention of second stroke should be studied.
Conclusion
The FAME program is beneficial for improving some of the
functional deficits resulting from chronic stroke.
FAME program is beneficial for chronic stroke patients in
improving quality of life and balance. Mobility and fitness also
improves up to certain extent.
Acknowledgement
1. Dr. Dharmendra Kumar, Director, PDUIPH.
2. HOD (OT) and all our Seniors & Juniors of Dept. of OT.
3. All our Patients and their family members
References
1. Alain Leroux, Exercise training to improve motor
performance in chronic stroke: effects of a community-
based exercise program, International Journal of
Rehabilitation Research 2005;(28) 1.
2. Galvin R, Cusack T, Stokes E. A randomized controlled
trial evaluating family mediated exercise (FAME) therapy
following stroke, BMC Neurol 2008; (8) 22.
3. Gresham GE, Fitzpatrick TE, Wolf PA, McNamara PM,
Kannel WB, Dawber TR. Residual disability in survivors of
strokeThe Framingham study. N Engl J Med. 1975;
(293)19.
4. Janice J. Eng, Marco Y. C. Pang Maureen C. Ashe V
Balance, falls, and bone health: Role of exercise in reducing
fracture risk after stroke. JRDD;2008(2).
5. Kathleen M. Michal et.al. Fatigue after Stroke, Rehab
Nursing, 2006, (31).
6. Lamb SE, Ferrucci L, Volapto S, Fried LP, Guralnik JM;
Womens Health and Aging Study. Risk factors for falling in
home-dwelling older women with stroke: The Womens
Health and Aging Study. Stroke. 2003;34(2).
7. Marco Y. C. Pang et al A Community-Based Fitness and
Mobility Exercise Program for Older Adults with Chronic
Stroke: A Randomized, Controlled Trial, Journal of the
American Geriatrics Society;2005,(53)10.
8. Mary Stuart, Sarah Chard, Suzanna Roettger, Exercise for
chronic stroke survivors: A policy perspective JRRD; (45), 2.
9. Richard F. Macko et al, Adaptive physical activity improves
function and quality of life in chronic hemiparesis. JRRD,
2008, (2).
10. Richard F. Macko, et al, Adaptive physical activity improves
mobility function and quality of life in chronic hemiparesis
JRRD; 2008. (45).
11. Richard F. Macko, Joseph Hidler, Exercise after stroke and
spinal cord injury: Common biological mechanisms and
physiological targets of training, JRRD, 2008; (45), 2. (Guest
editorial).
27
A Comparitive Study on the Efficacy of End Range Mobilization
Techniques in Treatment of Adhesive Capsulitis of Shoulder
K S Sharad
Asst. Professor, Department of Physiotherapy, National Institute for the Orthopaedically Handicapped, Kolkata-700 090
Abstract
Exercises and ultrasound therapy is the widely used
treatment for chronic adhesive capsulitis and has ample research
literature support while the same is not true regarding the claims
pertaining to the applicability of Manual Mobilization Techniques
in resolution of clinical complaints associated with adhesive
capsulitis. This randomised control trail was conducted to assess
the effectiveness of End Range Mobilization Techniques in the
treatment of chronic adhesive capsulitis. A matched subject size
of 22 patients with frozen shoulder was divided into two groups
of 11 subjects each and named Experimental (Age Range 41
to 55 years, Mean age 46.5 Years S.D 4.44) and Control group
(Age Range 40 to 56 years, Mean age 47.45 years S.D
5.49).
Both groups were treated for 3 weeks with Exercises and
Ultrasound and the experimental group was given the End
Range Mobilization Techniques also. The outcome measures
taken were variation in Active and Passive ROM (Manual
Goniometric measurement) and pain (Visual analog scale).
The data obtained was statistically analysed using Students
t test and ANACOVA (F ratio).Analysis showed that there was
no difference between the groups in the amount of pain reduction
obtained ( p< 0.05), but the Experimental group was considerably
better ( p< 0.05), than control group in terms of gaining active
and passive ranges of motion among the subjects.
Introduction
Shoulder joint is one of the most common joint to be treated
in a physiotherapy department among which the diagnosis of
adhesive capsulitis also known as frozen shoulder is very often
seen. Adhesive capsulitits is a condition characterised by an
insidious, painful and progressive loss of active and passive
mobility of glenohumeral joint1, 2 due to capsular contracture and
presents a typical pattern in range of motion restriction with
capsular end feel in later stages3, 4.
The condition has been observed to be clinically divisible
into three stages known as freezing, frozen and thawing stages.
In Acute stage pain and discomfort in function are the chief
complaints while in chronic stage the chief complaint is the loss
of mobility of the Glenohumeral joint4.
Review of literature shows that various authorities on the
basis of their studies have incriminated different structures as
being the culprit. It was first described by Dupley in 1972 as
scapulohumeral periarthritis, Neviaser2 in 1945 suggested the
name Adhesive capsulitits based on his surgical explorations.
In1934 Codman used the term frozen shoulder for the first time
but did so in association with tendonitis of the rotator cuff and
stated that even the most severe cases recover with or without
treatment in 2 years.
Omari and Bunker6 confirmed that fibroblast proliferation
consistently altered both the rotator cuff interval and the
coracohumeral ligament by depositing a dense matrix of type III
collagen.. Suzuki and colleagues7 suggested that pathologic
alterations in the shoulder capsule are important contributors to
the symptoms in Adhesive capsulitis.
One common observation was that the capsule becomes
contracted and adherent to itself and the humeral head and
with the progression of the condition rotator cuff, Bicipital tendon
28 K S Sharad / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
its sheath, fascial covering, all become involved at various
stages.
Literature shows lack of agreement over the best method
of preventing and treating it. However there is agreement over
treatment goals these are, pain relief and restoration of
movements. The presently used interventions are
Transcutaneous Electrical Nerve Stimulation (T.E.N.S),
Ultrasound, Cryotherapy and Heat in the form of Diathermy,
along with Exercises and Passive movements. The Exercises
are performed actively with or without mechanical aids and
Passive Movement are applied in the form of general stretching
or in the specialised form of Manual Mobilization Techniques.1,4,8
Zancan.A Gialanella.B. et al9 carried out instrumental
evaluation of ultrasound therapy in patients with periarthritis of
the shoulder, to find the real effectiveness of anti inflammatory
action of ultrasound. The results demonstrated a real influence
of ultrasound therapy on periarthritis of shoulder, in favour of
application of Ultra sound.
Cyriax recommends that the exercises should be prescribed
according to the stage of the disease, the end feel and pain
resistance sequence3. Although the use of exercises in acute
stage is not advisable, in chronic stage active and passive
exercises are recommended to be performed vigorously.
Active exercises allow more patient control than do
mechanical exercise such as done using shoulder wheels,
pulleys and wands. Muscle re-education may be needed to
restore normal physiological balance to the entire shoulder
complex and spine. Strengthening exercises are not advisable
until near normal range of motion is achieved.1, 12
Thus the use of ultrasound and active exercises has been
well supported in the literature and the research studies, but the
same is not true for the use of mobilization techniques.
It is believed that exercises done only in cardinal planes do
not deal with the laws of Joint play and therefore often provoke
pain and do little to increase shoulder joint Range of Motion.
Authorities such as Maitland and cyriax have recommended
passive stretching in all functional planes by means of Graded
Manual Mobilization Techniques to regain normal extensibility
of the shoulder joint capsule but data to support the use of these
techniques is lacking. Mobilization grades recommended for the
chronic stage of adhesive capsulitits are grades III and IV since
only these grades touch the movement barrier hence are also
known as End of the Range Mobilization techniques (ERMT).3,
12
Few studies which did explore the use of mobilization14,15
did so using widely variable parameters and hence presented
mixed results and some associated their use with less
satisfactory outcomes. Bulgan, Binder et al 1984 in their study
on 42 patients with frozen shoulder compared Intra articular
steroids, Mobilization, Ice therapy and no treatment and
concluded that there is little long term advantage in any of the
treatment regimens but steroid injections may benefit pain and
ROM in early stage of the condition.
H.M.Vermeulen Obermann W.R et al 200013 in their study
of 7 subjects with frozen shoulder found no adverse effects on
the recovery of the patients when treated with end range
mobilization techniques and found significant increase in joint
capacity and humeral mobility after 3 months of treatment. They
recommended a case control study so as to verify the
effectiveness of Mobilization techniques.
 This study is thus aimed at assessing the effectiveness of Outcome Measurment
end range manual mobilization techniques, as an adjunct to the
standard treatment by ultrasound therapy and exercise for the The outcome measures used were variations in Shoulder
treatment of chronic adhesive capsulitits of shoulder joint. Mobility using a half circle six inch Goniometer and the variation
in perceived level of Shoulder pain as assessed using a Visual
Material and Methodology Analog Scale. External Rotation in Horizontal plane, Abduction
in scapular plane and Flexion in sagital plane were used for
measurement of outcome.
Study Design A Visual Analog Score (VAS) was used to measure pain or
discomfort at and around the shoulder joint. All outcome
A prospective experimental study design of matched
measures were taken on day one before the treatment and were
subjects was used consisting of a sample size of 22 subjects
then measured a day after the last treatment. All measurements
with adhesive capsulitis. The study was conducted in the
were taken by the researcher himself, each measure was taken
Physiotherapy department of the Indore Institute of Medical
thrice and the mean used for calculations.
Sciences, M.P. from July 2007 to December 2007.
The subjects were patient aged between 40 to 60 years,
who were selected if they had insidious onset of the condition Statistical Analysis
with duration of symptoms more than three months and a
presentation of movement restrictions in all planes by at least
25 percent. Demographic Data
Subjects with early onset of pain in the Range Pain
Resistance Ratio assessment, history of Diabetes or any other Study sample characteristics
concurrent disorder which may interfere with the treatment were Experimental group n= 11
excluded from the study. Written informed consent was obtained Age: range 41 to 55 years, Mean age 46.5 years with
from each subject and they were randomly ascribed to either standard deviation of 4.44. Duration of disease: Range 3 to 7
Control or Experimental group. months Mean duration 4.9 Months with standard deviation of
1.17 Sex: 46 % subjects were male and 54% subjects were
females.
Procedures Control group n = 11
Age: range 40 to 56 years, Mean age 47.45 years with
standard deviation of 5.49. Duration of disease: Range 3 to 6
Control Group months Mean duration 4.63 Months with S.D of 1.05
Sex: 37 % subjects were male and 63% subjects were females.
On the first day following the basic assessments the patient
in control group were treated with
Outcome Measurements
1. Ultrasound Therapy The Outcome measure data collected from the study was
statistically analysed using
Patient supine, Ultrasound at 2 Watt/cm2 for 10 minutes to
1. Students paired and unpaired t test
the glenohumeral joint anteriorly, posterior and inferiorly with
2. Analysis of covariance (ANACOVA)
arm abducted. A machine with 1MHz frequency and an output
of 0 to 3.5 Watt/cm2 with Head size 2.5cm2 was used.
1. Alteration In Shoulder Pain
2. Active Glenohumeral Exercises
These were self stretching exercises preceded by warm 2. Alteration In Shoulder ROM
up exercises and ending with a cool down phase, done under Table 1: Showing mean visual analog scale (VAS) values
therapists supervision and guidance. No mechanical exercises
were given. VAS Mean Pre Mean Post
treatment value treatment value
3. Home Exercises
Experimental 3.60 0.9
Simple stretching exercises were chosen to be done at Group
home once daily.
The exercises were progressed and modified as per the Control Group 3.72 1.09
patient response.
The treatment was given five days per week for three weeks.
Fig.1: Comparing the mean VAS values between the two groups

Experimental Group
The experimental group patients were treated with the same
treatment as for the control group, in addition they were given a
course of End Range Mobilization Techniques which were carried
out immediately following the application of ultrasound. Initially
a few minutes of warming up was given using mid range
mobilization with the patient positioned supine. Following which
intensive end rage mobilisation techniques, Grades 3 and 4 as
described by Maitland12,13 in all the movement planes were given,
interspersed with accessory movements (glides). Effort in each
direction had ten to fifteen repetitions. The rhythm speed and
duration were varied in accordance with patient presentation
and tolerance.
K S Sharad / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 29
Table 2: Results of statistical analysis of change in pain
Visual Pre t/t VAS Independent Post t/t Independent Dependent
Analog Score mean t test value VAS mean t test value t test value

Control group 3.72 0.147 1.09 0.44 9.31 p< 0.05

P > .05 p > 0.05
Experimental group 3.6 0.9 7.86 p< 0.05

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

Table 3: Showing gain in Mean Active ROMs Table 4: Comparison of gain in Mean Passive ROMs

Gain in Experimental Group Control Group Gain in Experimental Group Control Group

Mean External 16.18 9.3 Mean External 19.64 12.37

Rotation Rotation

Mean abduction 40.26 22.00 Mean abduction 44.73 22.45

Mean flexion 36.82 21.18 Mean flexion 50.27 21.73

Fig.2: Comparison of gain in mean Active ROMs in experimental Fig. 3: Comparison of gain in mean Passive ROMs in
and control group experimental and control group

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

Active ROM Passive ROM

ROM Adjusted variance between F ratio Adjusted variance between F ratio

samples / within samples samples / within samples

External Rotation 178.21/28.43 6.26 505.13/28.92 17.46

Abduction 2123/265.38 8.03 3058.24/214.57 14.25

Flexion 1175.218/134.43 8.73 1189.62/149.82 7.94

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

Discussion glenohumeral joint.

This randomized control trial yielded results which show
that the gain in ROM was more in the group which received
mobilization however the reduction in pain was similar in both
the groups.
This could have been so because there was localization of
stretch at the glenohumeral joint capsule by mobilization. It
enables resolution of adhesions in the restricted portions of the
capsule. Mobilization also enables restoration of accessory
movements and joint play by emphasizing the gliding component
of joint motion hence restoring the normal mechanics at the
Exercises done following mobilization are proposed to have
greater effectiveness in gaining mobility due to availability of
accessory movements improved by the preceding mobilization
techniques and hence the possibility that the exercises were
carried out with better joint mechanics would have contributed
to the gain in ranges of motion.
The raise in temperature of the tissues by application of
ultrasound prior to mobilization allows a greater amount of
deformation of the tissues using the low deformation force.
The use of mobilization also brings in normal mechanism
of function at the shoulder complex reducing the amount of

30 K S Sharad / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
abnormal potentially pain producing stresses on the related soft
tissues. All these factors must have interacted in the outcome
of this particular treatment method.
Thought the reduction in pain was not more in the
experimental group it did as well as the control group and in
addition showed greater gain in mobility than the control group
and hence ERMT can be considered successful in providing
greater relief to the patients.
The reason for absence of difference in the amount of pain
reduction between groups may be that ERMT requires forceful
entry in to the restriction barrier and hence breakage of
adhesions formed by the contracted joint capsule which by itself
is noxious.
The findings of this study are in accordance with the multiple
subject case report by H.M.Vermeulen et al. (2000), however
they had no control group in their study. These results do not
agree to those found in the study by Bulgan and Binder et al.
(1984) who found that use of manual mobilisation was associated
with less satisfactory out comes in the treatment of frozen
shoulder.
The time required for treatment session by inclusion of these
techniques was increased but amount of gain for the patient in
terms of amount of resolution of the condition is considerable.
There is also definite benefit of greater satisfaction on patients
side due to hands on caring by the therapist thus it is rational
enough to consider these techniques as essential part in the
treatment protocol for the stage II of chronic idiopathic adhesive
capsulitis.
There were certain limitations in the study such as small
sample size and limited measures of outcome were used. No
follow ups were carried, and no blinding was done this could
have biased the results. Hence the generalisability of the results
is limited and should be cautiously done.
Conclusion
It can be concluded that this study provides evidence that
End Range Mobilisation Techniques, when used as an adjunct
to application of Ultrasound and Exercises, provide better results
in terms of gain in shoulder ranges of motion and reduction of
shoulder pain in patients with chronic adhesive capsulitis and
hence should be a part of the treatment regimen for the same.
K S Sharad / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
References
1. Donatelli RA Physical Therapy of the shoulder 2nd Edition
Churchill Livingstone New York 1997
2. Julias.S. Neviaser. Adhesive capsulitis of shoulder: A study
of the pathological findings in periarthritis of shoulder.
Journal of Bone and Joint Surgery Am, 1945; 27: 211-222
3. Cyriax J. Text book of orthopaedic medicine 7th Edition Vol.1
Balliere Tindall London 1978
4. Calliet R Shoulder Pain 2nd Edition F.A Davis Philadelphia
1981
5. Neviaser JS. Adhesive capsulitis and the stiff painful
shoulder. Orthop Clin North Am 1980; 11(2):327-331.
6. Omari A, Bunker TD. Open surgical release for frozen
shoulder: surgical findings and results of the release. J
Shoulder Elbow Surg 2001;10(4):353-357.
7. Suzuki K, Attia ET, Hannafin JA, et al. The effect of cytokines
on the migration of fibroblasts derived from different regions
of the canine shoulder capsule. J Shoulder Elbow Surg
2001;10(1):62-67.
8. John Low and Ann Reed. Electrotherapy Explained, 3rd
ed. Publisher-Butterworth Heinemann. 2000.
9. Zancan.A, Gialanella.B, Luisa.A, Casale.R, et al
comparative clinical assessment of the treatment of
shoulder periarthritis using ultra sound. Med Lav 1993 Jan
July 15 (1-4) 55-8
10. Roger J. Allen. Physical agents use in the management of
chronic pain by physical therapists. Physical Medicine and
Rehabilitation Clinic N Am, 17 (2006) 315-345
11. Therapeutic Exercise: Foundations And Techniques Book:
Therapeutic Exercise: FoundationsAnd Techniques
Carolyn Kisner, Lynn Allen Colby F. A. Davis Company.
2007
12. Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, Rozing
PM and van den Ende CH (2000): End-range mobilization
techniques in adhesive capsulitis of the shoulder joint
13. Elly Hengeveld, Kevin Banks. Maitlands Peripheral
Manipulation. 4th Edition.Elsevier.2007
14. Bulgen A.I, Binder D.Y et al F.S: a long term prospective
study.Ann of Rheum. Dis. 1984 Jun 43(3):353-60.
15. Bulgen A.I, Binder D.Y et al F.S: Prospective clinical study
with an evaluation of three
treatment regimens. Ann. of Rheum. Dis. 1984 43(3):353.
31
Role of Physiotherapist in the Management of On-field Sport
Injuries A case study of field hockey
Suraj Kumar1, Vijai P Sharma2, Rakesh Shukla3, Ravi Dev4, Anoop Aggarwal5
1
Master in Physiotherapy, Senior Research Fellow, 2Professor and Head, Department of PMR, 3Professor, Department of Neurology,
4
Professor, Department of Neurosurgery, Chatrapati Sahuji Maharaj Medical University, Lucknow- 226018, India, 5Physiotherapist,
Pt DDU Institute for Physically Handicapped, New Delhi
Abstract
Study Design
Prospective cohort study of Indian women field hockey
players.
Background
On ground sports injuries have become a challenging task
for physiotherapists around the world and lack of literature data
makes it more difficult. In India it is still in growing phase. This
is the first case study which provides the basic base line data
regarding potential areas of injury, their types, treatments and
outcome of the treatment on subjects and on game results.
Case Description
This study belongs to 16 Indian women field hockey players
participated in 15th Asian games held at Doha from 1st Dec to 15
Dec, 2006 where they played total 7 matches, each of 70
minutes.
Outcomes
Throughout the tournament, 39.3% of total players got
injured. Three body parts affected by 7 different types of injuries
and rehabilitated according to symptoms by using physical
therapy which is cost effective. Occurrence of muscle related
injury was the highest (35%) and cut injury at head and eye
were the least (2%). Forwards were at highest risk (43%) while
goal keeper the least (0%). The effect of treatment was 100%
and recovery time ranged from 5 min to 35 min. Out of 22 total
scored, forward scored the maximum (19 goals-86%) followed
by midfielder (2 goals-9%) and defender (1 goal-5%). After
rehabilitation, injured player scored significantly (p<0.01) more
goals (68%) than the not injured (32%) shows physiotherapy
enhanced the game performance.
Discussion
Muscular related injuries which were found most may be
due to running or less flexibility in the muscles. Forwards affected
most may be due to their quick responses and chasing the ball
at both the end goals.
Key Words
Field hockey, sports injury, physiotherapy, rehabilitation
Address for correspondence:
Suraj Kumar (Ph.D. Scholar)
Senior Research Fellow (ICMR)
C/o Sanjay Kumar
RZF 587/1, Raj Nagar II,
Palam Colony, New Delhi 77
E.Mail :- surajdr2001@yahoo.com
Mobile no.:+ 91-98890-92835
32 Suraj Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Background
Physiotherapy has become an integral part of many sports
around the world. Management of on ground injuries is a
challenging task for physiotherapists and lack of literature &
documented data make it more difficult. In India, it is still in
growing phase.
Sports physiotherapy is a well recognized profession which
demonstrates advanced competencies in the promotion of safe
physical activity participation, provision of advice and adaptation
of rehabilitation and training intervention, for the purposes of
preventing injury, restoring optimal function, and contributing to
the enhancement of sports performance, in athletes of all ages
and abilities, while ensuring a high standard of professional and
ethical practice.1 Sports physiotherapy is a combination of
manual techniques and other therapies including manipulation
and mobilization, massage, hydrotherapy, exercise programmes,
electrotherapy (ultrasound and interferential therapy).
Physiotherapists not only treat the problem but also help to
prevent the recurrence of problem. The purpose of physiotherapy
is to decrease body dysfunctions, reduce pain caused either by
trauma, inflammation, degeneration and surgery.
Sports medicine, sports physiotherapy and nutrition are the
newer fields, and yet to be utilized to their potential. During recent
past, sports have now become very competitive and much of
scientific research and support towards sports teams found to
be rewarding. The team doctors, team sports physio services
have become very essential for most of the teams, health, SPA
(sports physiotherapy for all) and health gymnasiums.
Hockey is an ancient sport thought to be the forerunner of
all stick and ball games, played in most of the countries around
the world. It is a game of strength, speed and skill. It is among
the most difficult to master, the costliest to equip, the fastest to
watch and the most dangerous to play. It requires a combination
of power, endurance and flexibility. It is game of control and lack
of control, both of emotions and flying objects.
Epidemiological studies have consistently shown that
injuries in hockey are numerous and can be serious. Most serious
injuries result from being struck by the stick or the ball. Overuse
injuries to the ankles and lower back are also occurred
frequently.4,5 Most injuries presenting to hospitals are to the upper
limb (mostly injuries to the hand and forearm), face (mostly struck
by stick or ball) and lower limb (mostly ankle, foot and knee
injuries). Injuries to the eyes are infrequent, although tend to be
severe.14
In literature, most of the studies describes single case report
with specific injury and its treatment and did not show much
about group injuries (team) especially on ground injuries during
game.15,16,17 For the first time, this case study was aimed which
explore on ground injuries related to hockey and out come of
treatments. Beside this the effect of treatments on game result
was also observed. Basic data of this case study may be helpful
for other physiotherapist.
Case Description
This case study belongs to 16 Indian women hockey players
participated in 15th Asian games13 held at Doha from 1st Dec to
15 Dec, 2006. The players characteristics are presented in Table
1. As this case study is about on ground injuries during the game,
the details of injury occurred; their treatments and outcome of respectively. Similarly, no of match played (international) and
the treatments were summarized in Table 2 and date wise goal scored in this tournament ranged from 7-162 and 0-8
individual injury and game result in Table 3. Players age, height respectively with an average 55.19 and 1.31 respectively. Out
and weight ranged from 15-18 yrs, 1.53-1.68 m and 46-61 kg of 16, 2 were goal keepers, 3 mid fielders, 7 forwards and 5
respectively with an average 22.44 yrs, 1.60 m and 54.13 kg defenders and among these 5 were reserved (interchangeable)
Table 1: Players characteristics who participated in 15th Asian games held at Doha, 2006
Player no/ Age Height Weight Position of International Match Tournament goal
Jersey no (yrs) (m) (kg) play played (no) scored (no)

1 26 1.57 60 goal keeper 71 0

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

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

03 6 Knee pain (1) Taping, Ultrasound Improved, Fit to play

Ankle pain (1) Ice, Crape bandage Improved, Fit to play
Muscle pain (3) Taping Improved, Fit to play
Low back pain (1) Taping, DMST, TENS Improved, Fit to play

05 6 Knee pain (1) Taping, Ultrasound Improved, Fit to play

Ankle pain (1) Ice, Crape bandage Improved, Fit to play
Thigh muscle pain (2) Taping, Improved, Fit to play
Cut injury at eye (1) Stitching, antibiotics,
analgesic
Low back pain (1) Taping, DMST, TENS, Improved, Fit to play

06 7 Knee pain (1) Taping, Ultrasound Improved, Fit to play

Ankle pain (1) Ice, Crape bandage Improved, Fit to play
Thigh muscle pain (3) Taping Improved, Fit to play
Low back pain (1) + Taping, DMST, TENS, Improved, Fit to play
Cut injury at head (1) Antibiotics, analgesic

08 7 Knee pain (1) Taping, Ultrasound Improved, Fit to play

Ankle pain (1) Ice, Crape bandage Improved, Fit to play
Thigh muscle pain (3) Taping Improved, Fit to play
Low back pain (1) Taping, DMST, TENS Improved, Fit to play
Wrist injury (1) Taping Improved, Fit to play

09 7 Knee pain (1) Taping, Ultrasound Improved, Fit to play

Ankle pain (2) Ice, Crape bandage Improved, Fit to play
Thigh muscle pain (2) Taping Improved, Fit to play
Low back pain (1) Taping, DMST, TENS Improved, Fit to play
Wrist injury (1) Taping Improved, Fit to play

11 6 Knee pain (1) Taping, Ultrasound Improved, Fit to play

Ankle pain (1) Ice, Crape bandage Improved, Fit to play
Thigh muscle pain (2) Taping Improved, Fit to play
Low back pain (1) Taping, DMST, TENS Improved, Fit to play
Wrist injury (1) Taping Improved, Fit to play

13 6 Knee pain (1) Taping, Ultrasound Improved, Fit to play

Ankle pain (2) Ice, Crape bandage Improved, Fit to play
Thigh muscle pain (1) Taping Improved, Fit to play
Low back pain (1) Taping, DMST, TENS Improved, Fit to play
Wrist injury (1) Taping Improved, Fit to play
Suraj Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 33
players (P4, P8, P12, P13 and P14).
Physiotherapist joined 15 days before the tournament in
India. In his first screening 5 players (P5, P9, P13, P20 and P3)
had chronic injuries (low back pain, knee pain, ankle injury and
thumb injury) even though they were fit in their daily activities
including play. According to symptoms, they were rehabilitated
before the tournament. These players also joined general
physiotherapy rehabilitation programme with others while their
stay in India. None of the participants had had a systematic
intensive course of physiotherapy before. During game at Doha,
individuals injury and type of injury was recorded by the
physiotherapist. Individual who suffered multiple injuries of same
kind was counted as 1. The injured player rehabilitated on the
ground and off the ground. This study did not require any patients
consent.
Table 3: Player wise each day injuries and game results
Date P1 P3 P4 P5 P8 P9 P10 P12 P13 P14 P18 P20 P23 P24 P25 P30 Result
ball; head and eye injuries, when penalty was called.
Except hit injuries, the rehabilitation of other injury was done
by physiotherapist. According to symptoms, treatments were
given as taping, mobilization, manipulation, dynamic muscular
stabilization technique (DMST), cold therapy, ultrasound, TENS,
stretching exercises and relaxation exercises, crape bandage
and strengthening exercises. Except ultrasound, TENS and
relaxation exercises other treatments were given on the ground
during the game. In all the intervention, rate of recovery was
100% and the time of recovery was from 5 min to 35 min.
Area wise distribution of injuries (Fig. 1) shows that the
occurrence of muscle (thigh and calf) related injury was the
highest (35.6%) and hit and cut injury at head and eye were the
least (2.2%). Ankle injury was the second highest (20.0%)

3 0 0 0 1 0 1 1 0 1 0 0 1 0 0 0 1 1
5 0 0 0 1 0 1 1 0 1 0 0 1 0 0 0 1 0
6 0 0 0 1 0 1 1 0 1 0 0 1 0 0 0 1 1
8 0 0 0 1 0 1 1 0 1 0 0 1 1 0 0 1 1
9 0 0 0 1 0 1 0 0 1 0 1 1 1 0 0 1 0
11 0 0 0 1 0 1 0 0 1 0 0 1 1 0 0 1 0
13 0 0 0 1 0 1 0 0 1 0 0 1 1 0 0 1 1

0- not injured/loss, 1-injured/win Fig. 3: Position wise distribution of goal scored.

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

Fig. 2: Position wise distribution of injuries (%) during the game.
Outcomes
followed by low back pain and knee injury (15.6%) and wrist
injury (8.9%). Similarly, position wise distribution of injury (Fig.
2) shows that forwards were the highest at risk (31.8%) while
goal keeper the least (0%). Midfielders were second highest at
risk (31.8%) followed by defenders (25%).
Out of 22 total scored goals, forward scored the maximum
(19 goals-86.4%) followed by midfielder (2 goals-9.1%) and
defender (1 goal-4.5%) (Fig. 3). Comparing goal scored between
not injured and injured players, the ratio of goal scored by injured
players (17) was significantly high (p<0.01) than the not injured
(5). Interestingly, out of 22 total scored goals, 5 players (31.3%)
who were injured before the tournament and their injury remains
throughout the tournament, scored 15 goals (68.2%) shows
physiotherapy not only rehabilitate their injury and improve their
playing skill and power but also enhanced mental, physical
strength and game performance.

During their stay at Doha, players played 7 matches, each

of 70 minutes. In 7 matches, India scored total 22 goals, won in
four along with bronze medal. Out of 112 (16 players X 7 games),
total 44 players (39.3%) get injured. During the tournament, total
7 types of injuries occurred which were low back injury (pain),
ankle injury, knee injury, wrist injury, muscle injury, and hit and
cut injury at head and corner of eye. Eight players did not get
injured throughout the tournament. Only one player (P20) had
multiple injuries (low back pain and cut injury at head) during 3rd
match of the tournament. Most of the injuries occurred when
the player was near the goal or within the 25-yd line and were
caused by contact with stick or ball or with players, chasing the
Discussion
Case research plays an important role in gathering evidence
for more efficient practice, especially in relation to physiotherapy,
where it is common to find interventions that are context-
dependent and multifaceted.2 Exercise therapy is generally
prescribed to be a specialist clinical skill and the most complex
and difficult part of physiotherapy 7. This case report has
described the rapid recovery of an athlete in case of ground
injury and her achievement and satisfaction with the outcome
after physiotherapy intervention. It has been suggested that
physiotherapist should, at the initial examination, identify the

34 Suraj Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
patients goals and objectives in order to maximize outcomes of
physiotherapy intervention. Core aspects of physiotherapy
management in ground injuries are to reduction in pain
improvement in function and prevention to further deterioration.
All the physiotherapeutic intervention (taping, mobilization,
manipulation, dynamic muscular stabilization technique (DMST),
cold therapy, ultrasound, TENS, stretching exercises and
relaxation exercises, crape bandage and strengthening
exercises) provided during the tournament are well
documented6,8,9,10,11 and practitioners uses these in their daily
treatments. These treatments may blocks pain pathways,
mobiles bound neurological structures or enhance the
musculoskeletal efficiency.12
In this case study, 39.3% total players get injured. Three
body parts affected by 7 different types of injuries and
rehabilitated according to symptoms. Occurrence of muscle
related injury was the highest (35%) and cut injury at head and
eye were the least (2%). Forwards were at highest risk (43%)
while goal keeper the least (0%). The effect of treatment was
100% and recovery time ranged from 5 min to 35 min. After
rehabilitation, injured player scored significantly (p<0.01) more
goals (68%) than the not injured (32%) which shows
physiotherapy enhance the game performance. Muscular related
injuries which were found most may be due to running or less
flexibility in the muscles. Forwards affected most may be due to
their quick responses and chasing the ball at both the end goals.
This case study strongly recommends that all hockey
players should undergo at least a pre-season fitness screening
for general strength, flexibility and endurance. Coaches should
be trained to screen players and to refer them on to appropriate
professionals if problems are evident. Equipment (requiring
helmets and padded gloved) and rule changes (to decrease
field congestion near the goal) as well as evidence-based injury
prevention interventions (prophylactic ankle taping/bracing,
neuromuscular balance exercise programs) may be viable
prevention initiatives for reducing injury rates in womens as
well as mens field hockey players.18
The objective of physiotherapist while rehabilitating the on
ground injured sports person is to make player fit for play within
the shortest possible time. In this study it varied from 5 min to
35 min. The other possible physiotherapeutic interventions with
optimal time may be highly imperative. The basic baseline data
of this case study may be beneficial in future to other
physiotherapist.
Acknowledgement
First author of this study was as a physiotherapist of Indian
women field hockey team who participated in 15th Asian games
held at Doha from 1st Dec to 15 Dec, 2006, wants to thank
coaches (Mr. M.K. Kausik, A.B. Subbaiah and Anurita Saini),
team manager (Mrs. Rajbeer Rai) and all the players. Author
also want to thank Director, Sport Authority of India, Lucknow,
Women Hockey Federation of India and Government of India
for honoring as a physiotherapist.
Suraj Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
References
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rehabilitation in an elite level athlete following L4-S1
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exercises would you prescribe? Man Ther 1995; 1: 2-10.
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Bjerg AM, Krogsgaard K. Effectivness of active physical
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353: 439-443.
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Physiotherapy- For Treatment and Rehabilitation.
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A Review of Field Hockey Injuries and Countermeasures
for Prevention.
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in international field hockey. Br J Sports Med. 1987; 21:
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17. Boden BP, Prior C. Catastrophic spine injuries in sports.
Curr Sports Med Rep. 2005; 4: 45-49.
18. Dick R, Hootman JM, Agel, J, Vela L, Marshall SW, Messina
R. Descriptive Epidemiology of Collegiate Womens Field
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35
Comparison of Task Oriented Approach and Bobath approach in
Improving balance and Reducing Fear of Falling in adults with
Stroke
Jayachandran V,* Gayathri Ethiraj**
*Lecturer, **Assistant Professor, University of Technology Mara (UiTM), SRM University, Malaysia, India
Abstract
Objective
To find out the effectiveness of Task Oriented Approach
and Bobath approach in improving balance and reducing fear
of falling in adults with Stroke.
Methods
Quantitative research design was employed across 20
subjects, each 10 in both control (bobath) group and
experimental (Task Oriented Approach) group. Treatment was
given, one hour per day on alternate days for 30 days in
department of Occupational Therapy, Vijaya hospital & S.R.M.
hospital, Chennai. Dependent variables were balance and the
subjects confidence level about their fear of falling during daily
activities. Berg Balance Scale (BBS) and Falls Efficacy Scale
(FES) were used as outcome measures. Data analysis was done
by using Mann-Whitney U test and Wilcoxont test.
Results
Shows that significant improvement in balance, in both
control (p=0.007) and experimental (p=0.005) group. Similarly,
there was significant reduction in the fear of falling in both control
(p=0.005) and experimental group (p=0.005). However, the
improvement in experimental group [BBS (m) =49.30; FES (m)
=88.50%] is more marked, when compared to the control group
[BBS (m) =24.90; FES (m) =31.70%]
Discussion
The more marked improvement in experimental group was
attributed to the generalizing effects of Task Oriented Approach
when compared to the bobath approaches. Task Oriented
Approach gives emphasis on practicing the whole task rather
practicing the task progression from part by part. Previous
researches also stated that random practice is always better
than the blocked practice. Hence, there was marked
improvement in experimental group than the control group.
Conclusion
Task Oriented Approach may be more effective than the
Bobath approach. Occupational therapists are encouraged to
use task specific activities and changing the task requirement
according to the environmental contexts to enhance functional
performance.
Key Word
Task oriented approach, Bobath approach, Stroke, Fear
of falling and Balance
Introduction
Stroke is the leading causes of activity limitations in adults.
36 Jayachandran V / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
It is a common clinical problem with significant on its survivor
and on the society. It often present as a disabling illness involving
many aspects of patients life, especially, on the ability to perform
activities of daily living and ambulation.
Stroke is the third leading cause of death in the United
States and is the most common causes of chronic disability
among adults. Incidence of stroke is age related being
uncommon under age 50 but doubling each decade after the
age of 55 years. Incidence of stroke in India is 1-2 per thousands
with a prevalence of 5 per thousand and recurrence rate of 20%
- 30%. Some common impairment after stroke is impaired motor
function sensory perceptual deficits, impaired balance cognitive
limitation, aphasia and depression1. But disability in balance is
very common after stroke. It has also been postulated in research
that balance cannot be separated from action of which it is an
integral component 1. Therefore balance is considered as
Foundation for all voluntary motor skill.
Since controlling the bodys position in space is an essential
part of functional skills restoration of balance is a critical part of
the recovery of ability after stroke2. The exact demands on the
balance control system are determined both by the task itself
and by the environment, in which it is performed and different
tasks and environment alter the biomechanical and information
processing required for balance control3.
Fear of falling is more in stroke patients4. Incidence of fall
in stroke rehabilitation unit and their frequency are increased
and it leads to decreases functional outcomes and impairments.
Fear of falling may thus lead to a debilitating spiral, marked by
loss of confidence and reduced activity ultimately resulting in
loss of independence. So, the identification and prevention of
patients risk of fall may be the first step towards the rehabilitation
program5.
A patient with central nerve system (CNS) dysfunction
evaluation primarily focus on the sensorimotor and cognitive
components of muscle tone reflexes and abnormal movement
patterns, postural control, sensation, perception, memory and
judgment psychological components and environmental context
would rarely be evaluated. Treatment using a traditional
approach focuses on remediating whatever components were
identified as impaired on evaluation. Common treatment
techniques include the use of various sensory stimuli to inhibit
spasticity, abnormal reflex and abnormal movement patterns
and to facilitate normal, muscle tone, equilibrium response and
movements patterns6.
It emerges from the system model of motor control and
influenced by contemporary developmental and motor learning
and skill acquisition theories7. It is based on the assumption
that the CNS is heterarchically organized. Occupational therapist
would collaborate with clients in determining which tasks were
problematic and important to evaluate given clients role in
environmental context. The therapist would observe clients
performing selected functional task in varied context8, this would
provide information about the role of environmental context on
performance as well as clues about the interaction of system
and subsystem that were contributing to functional deficits.
Treatment using a contemporary approach focuses on helping
the clients find the optimal strategy for achieving functional goals.
However, studies, which talk about the remediation of balance
control following Stroke by using Task Oriented Approach, are
limited.
 Research is needed to determine whether Task Oriented
Approach is better than bobath approaches. Hence this study
has been undertaken to compare the effectiveness of Task
Oriented Approach and traditional approaches in improving
balance and thereby reducing fear of falling in adult with Stroke
Methodology
Study Design
It was a Quantitative research design. The participants were
selected by using a convenience sample from occupational
therapy department of SRM and Vijaya Hospital. 20 Patients
with stroke were selected from occupational therapy department
(S.R.M. Hospital and Vijaya Hospital, Chennai) out of 20 patients
17 were males and 3 were females and the age group ranging
between 30-70 years in that 10 were right hemiplegia and 10
were left hemiplegia, duration of illness range from 0-2 year.
Inclusion Criteria
1. Subjects diagnosed as stroke as per CT/MRI Scan.
2. Right and Left hemiplegia and having the first onset of
stroke.
3. Both genders.
4. Subjects scoring 19 and above in mini mental status
examination.
5. Subjects scoring 6 - 15 in National Institute of health stroke
scale.
6. Subject with expressive aphasia.
Exclusion Criteria
1. Subjects with the previous history of any other neurological
problems like Head injury, Parkinson, Multiple sclerosis etc.
2. Subjects with the history of any other cardiac and respiratory
problem.
3. Subjects with bilateral stroke.
4. Subjects with severe internal capsule bleed as mentioned
in the CT scan and MRI Report.
Test used
All the patients were assessed using a Falls Efficacy Scale
(FES Tinetti, 1990) and Berg Balance Scale (BBS Kathy Berg,
1992) validity and reliability of scale were studied in various
studies early. The FES consists of Visual analog ratio scale.
Having 10 ADL activities and the scale extended from 1 to 10
points which measure the level of confidences of the subjects
on falls. The BBS consist of 14 items rated from 0 to 4. There
were 14 items deals about various level of balance from sitting
to standing balance zero means patients had difficultly in doing
particular item, four means highly independent in doing particular
item total score is 56.
Procedure
Consent forms were obtained prior to the study from all 20
subjects. After they concord, pretest was done by using Berg
balance scale and falls efficacy scale. Ten subjects in control
groups were under went traditional occupational therapy
treatment and 10 subjects in experimental group were under
gone Task oriented approach.
Task oriented approach was given for the period of 30 days.
Fourteen activities were selected based on the Task oriented
approach. Activities were graded from simple to complex.
Specific activities were chosen for each subject according to
Jayachandran V / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
their ability. The activities are,
1. In sitting, forward reach and takes peg and keep it back.
2. In sitting, transferring pegs to opposite side.
3. In sitting, sideward reach and takes pegs and keep it back.
4. Ball throwing and catching in the back supported chair and
then to back unsupported stool.
5. Transfer the pegs from sitting position to standing position
with various level of stool.
6. Ball throwing and catching in standing unsupported.
7. Simulating the soaping activity to face.
8. Catching and throwing ball with feet together.
9. In standing, pickup object in front with forward reach.
10. In standing, pickup the shoe placed in front of feet.
11. Transfer pegs from back to back.
12. Kicking ball in standing position in forward backward and
sideward direction.
13. Lower half dressing in standing position.
14. Climbing up and down stair with alternate steps.
The intervention period is carried over for 30 days, one
hour per day on alternate days. After the intervention period
subjects were underwent post therapy evaluation.
Results
Statistical Analysis
Statistical analysis was done by the SPSS version 16.
Statistical measure such as Mann Whitney u test and Wilcoxon
sing rank test were used to analyze the data. The results were
concluded to statistically significant with p < 0.05.
The Wilcoxon sing rank tests were used to compare the
difference of pre and post test of each group. Mann Whitney u
tests were used to compare differences between the two groups,
(bobath and task oriented group).
Balance
All the pre and post test scores of Berg Balance Scale in
both control and experimental group were compared. Before
the intervention patients balance mean score were 20.50 and
13.40 in control and experimental group respectively. But after
intervention the balance mean score was 24.90 and 49.30 in
control and experimental group respectively. When comparing
post test scores of control and experimental group, task oriented
activities are improve balance more markly than the bobath
techniques.
Falls Efficacy Scale
All the patients were assessed using a structured
questionnaire instrument of falls efficacy scale to find a
confidences level of patients in day to day activities. When
comparing pre and post test scores in control and experimental
group confidences level of patient is improved in both cases
but more markedly in experimental group. Correlation between
balance and confidence level in ADL without fall. The post test
scores of Berg Balance Scale and fall efficacy shows that there
is positive correlation. When balance increases confidence level
of the patients are also increased.
Table 1 shows the comparison of control and experimental
group in pre and post tests scores of Berg Balance Scale.
Wilcoxon Singned rank test was used to compute the results. It
shows that there is stastically significant difference between
post test scores of control and experimental group at 0.05 levels.
Hence, the experimental group has the marked improvement
in balance. When compared to the control group.
37
Table 1: Pre and Post test scores of BBS in control and Table 3: Correlation between the Berg Balance Scale and Falls
experimental group Efficacy Scale
S. No. Groups in BBS N Mean S.D S. Post Test N Spearmans Correlation(rs)
No. Level of Significance
1. Control group Pretest 10 20.50 6.43
Post test 10 24.90 5.65 1. Berg Balance 10
Scale
2. Experimental Pretest 10 13.40 9.94 0.739 0.015
group 2. Falls Efficacy 10
Post test 10 49.30 4.95 Scale

Discussion
The purpose of this study was to compare the effectiveness
of task oriented approach and traditional approaches in
improving balance and there by reducing fear of falling in patients
with stroke. Results of pre and post test scores in control group
showed improvement in balance by using traditional approach.
According to Gordon, etal (1987) improvement was seen in
traditional treatment but that does not necessarily carry over to
improvement in functional performances. Like wise subjects in
the control group showed improvement but it doesnt show any
effect on the functional performances. This has been proved by
falls efficacy score of subjects in control group. Their confidences
level in doing the ADL is very low (FES=31.70%) Schmidt, et al
1988, indicated that blocked practice was better than random
practice and progression from part of the whole tasks was
desirable for motor learning. Hence the blocked practice of
Table 2: Pre and Post test scores of FES in control and traditional activities may have contributed to the improvement
experimental group in balance in the control group. Results of pre and post test
S. No. Groups in BBS N Mean S.D scores of experimental group showed improvement in balance
by using task oriented approach. According to shea etal, 1979,
1. Control group Pretest 10 18.40 6.54 random practice is better than blocked practice practicing the
Post test 10 31.70 8.59 whole task is effective than practicing the task progression from
part by part. Contemporary task oriented approach focuses on
2. Experimental Pretest 10 18.00 7.38 helping the clients find out the optimal strategy for achieving
group functional goals. Hence, in this study those subjects involved in
Post test 10 88.50 13.60 task oriented activities have showed increased confidence level
(FES=88.50%) in their daily activities when compared to the
Table 2 shows the comparison of control and experimental group control group. This was supported by Salbach, etal (2004),
in pre and post tests scores of falls efficacy Scale. Wilcoxon proved that task oriented intervention is enhancing walking
Singned rank test was used to compute the result. It shows that distances and speed in the first year post stroke for the people
there is stastically significant difference between post test scores with moderate walking deficits. When comparing the results of
of control and experimental group at 0.05 levels. Hence the control and experimental group significant differences in balance
experimental group has the marked improvement in their were found. The improvement in balance in experimental group
confidence level. When compared to the control group. (m=49.30) is more marked when compared to the control group
(m=24.90). Hence, the task oriented approach is more effective
in improving balance than the traditional approach. Krutulyte,
etal, 2003, stated that task oriented physical activities will be
more effective than the facilitation and inhibition strategies such
as the bobath programme in the rehabilitation of stroke.
Mathiowetz, etal, 1994, stated that in task oriented approach,
the generalization will be more for the patients, i.e. they will adapt
to the functional activity easily. Burton, etal 1992 suggested that
therapist may alter task requirements or the environment context
to enhance performances. Hence specific and the task
requirements were also changed according to the environmental
context. There fore in this study the subjects who have
participated in the experimental group have performed more
functional oriented tasks in different environmental contexts,
which may contribute to the improvement in balance. The
subjects in the experimental group had more confidence level
and less fear of falling during daily activities when compared to
Table 3 shows the correlation between the Berg Balance Scale the control group after intervention.
and Falls Efficacy Scale spearmans correlation test was used Few limitations of this study included small number samples
to compute the result. It shows that there is positive correlation size. Convenience sampling was used for the selection of the
between the post test scores of berg balance scale and falls participants. 60 subjects were not selected according to the
efficacy scale is experimental group (r = 0.739, P<0.015) at 0.05 geographical location, race, ethnicity and other factors so this
level. result cannot be generalized.

38 Jayachandran V / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
 Hence it is recommended that future research can be done
with large number of samples. Randomized control trail studies
can be used to find the effectiveness of Task Oriented Approach
to get an accurate result. We also recommended to Task oriented
approach can also be used to identify the effectiveness of other
factors like, co-ordination, gait and hand function.
Conclusion
This study concluded that there is statistically significant
difference in balance and reducing fear of falling by using bobath
and task oriented approach. However, improvement in
experimental group is more marked than the improvement in
control group. Hence, task oriented approaches may be more
effective than bobath approaches further researcher are
recommended to find the effectiveness of task oriented approach
by using randomized control trail model and sufficient number
of samples from various geographical location
References
1. Carry JH, Shepherd RB. Neurological rehabilitation:
optimizing motor performance oxford butterworth -
Heinemann Ltd. 1998; 154-181.
2. Shumway Cook A, Woollawt MH. Abnormal postural control.
Motor control: theory and practical applications - Lippincott
Williams & Wilkens. 2001; 163-191.
Jayachandran V / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
3. Huxham FE, Goldie PA, Patla AE. Theoretical consideration
in balance assessment. Austr. J. Physiother. 2001; 47:89-
100.
4. Hellstrom K., Lindmark B. Fear of falling in patients with
Stroke: A reliability study. Clinical Rehabilitation.1999;
13:509-517.
5. Tinetti ME, SpeechleyM, GinterSF. Risk factors for fall
among elderly person living in the community. N Engl J
Med. 1988; 319:1701-1707.
6. Mathiowetz V. Role of physical performance component
evaluations in Occupational Therapy functional
assessment. AJOT. 1993; 47: 225-230.
7. Horak FB. Assumptions underlying motor control for
neurological rehabilitation; contemporary management of
motor control problems. Proceedings.1991
8. Burton AW, Davis WE. Optimizing the involvement and
performance of children with physical impairments in
movement activities. Pediatric exercise science.1992;
4:236-248
9. Garland SJ, Willems DA. Recovery of standing balance
and functional mobility after stroke. APMR 2003: 84; 1753-
1759.
10. Krutulyte G, Kimtys A. The effectiveness of physical therapy
methods (Bobath and motor relearning program) in
rehabilitation of stroke patients of medicine (Kaunas). 2003;
39-9: 889-895.
39
A Cost-effective Patient Designed Hand Splint for Rehabilitation
After Two-stage Flexor Tendon Reconstruction
Muhammad Adil Abbas Khan*, Mark Gorman*, Arvind Mohan*, Zain A Sobani**, Alastair Platt***
*Plastic Surgery Trainee, **Medical Student, ***Plastic Surgery Consultant, University Hospital of North Staffordshire NHS Trust,
Stoke-on-Trust, United Kingdom, Castle Hill Hospital, Hull, United Kingdom
Abstract
Background
A number of splints have been described to aid in the
rehabilitation after two-stage flexor tendon reconstruction. We
present an innovative splint design by a motivated patient to
assist in his own functional recovery in a cost-effective manner.
Case
A 45 year old male engineer underwent a traumatic motor
bike injury to the volar aspect of his left middle finger at the level
of the distal interphalangeal (DIP) joint. He was found to have a
segmental loss of the distal segment of the flexor digitorum
profundus (FDP) that prevented a primary repair. He was
planned for a two stage repair with physiotherapy. After consulting
with the therapist, the patient designed a device to aid himself
with the flexion of the DIP, PIP and MCP joints of his affected
digit which he used during this period. His post operative recovery
was remarkable with excellent functional recovery scoring 95%
of normal movement on the Stricklands Adjusted system.
Conclusion
In combination with a hand therapy regime, we recommend
this innovative patient designed splint as a simple and
inexpensive alternative to existing splints for rehabilitation for
two-stage flexor tendon reconstructions.
Key Words
Ocupational therapy; flexor tendon reconstruction; splint;
FDP (flexor digitorum profundus); FDS (flexor digitorum
superficialis); PIP (proximal interphalangeal) joint; DIP (distal
interphalangeal).
Introduction
A number of splints have been described to aid in the
rehabilitation after two-stage flexor tendon reconstruction. We
present an innovative splint design by a motivated patient. The
novel aspect is that in this case the well informed patient came
up with the idea which was recognized by the clinical team and
hand therapist who allowed the patient to assist in his own
functional recovery in a cost-effective manner.
Address for correspondence:
Muhammad Adil Abbas Khan
Plastic Surgical Trainee
10 Harvey Lodge
Admiral Walk
London W9 3TH
United Kingdom
Phone: 0044 786 333 2517
Email: adilaku@hotmail.com, adilkakar@yahoo.com
40 Muhammad Adil Abbas Khan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Case Report
A 45 year old male engineer underwent a traumatic motor
bike injury to the volar aspect of his left middle finger at the level
of the distal interphalangeal (DIP) joint and underwent a primary
debridement of a surgically contaminated wound. He was found
to have a segmental loss of the distal segment of the flexor
digitorum profundus (FDP) that prevented a primary repair. After
consulting with the therapist, the patient designed a device to
aid himself with the flexion of the DIP, PIP and MCP joints of his
affected digit. He also underwent a standard protocol of digital
exercises supervised by hand therapists in the three months
leading to his first stage flexor reconstruction with a silicone
rod. Postoperatively he remained compliant with physiotherapy
and continued wearing his splint. Three months later at the time
of his second stage reconstruction, he was observed to have
90 degrees of flexion at the DIPJ and PIPJ of the affected digit.
After the second stage reconstruction he was again
assessed by the hand therapist and a week later started wearing
his designed splint again for another four weeks. His post
operative recovery was remarkable with excellent functional
recovery scoring 95% of normal movement on the Stricklands
Adjusted system [(PIP + DIP) flexion extension deficit x 100/
175 degrees].
The Splint - Design and Application
The splint designed by the patient consisted of a Velcro
hood constructed by stitching together two Velcro straps (wire
securing Velcro bought from an electrical store). This hood
covered the tip of the digit and was secured to the wrist with
elastic bands that passed as adjustable straps through a slit on
each side of the hood. The elastic straps were secured distally
with knots allowing the elastic band length to be adjusted (if it
became loose secondary to overstretching) by simply pulling
the band distally through the slits and securing the newly adjusted
length with a new knot. The distal segment of the band could
then be cut off enabling this design to be used successfully in
digits of all lengths with easy adjustment.
The elastic straps chosen by the patient were soft and the
splint design allowed the fulcrum to rest of the dorsum of the
hand (just distal to the wrist joint) (Figure 1) enabling passive
assisted flexion of the digit at both the DIPJ and PIPJ after each
active extension (Figure 2). Despite allowing full extension of
the finger against the elastic, there was still enough tension
remaining to provide sufficient traction when flexed. There was
no restriction imposed on the the volar surface of the hand by
the device. The elastic straps despite not having a base did not
dig into the wrist or the finger webs and hence did not pose a
risk for neuropraxia or pressure. The splint was worn fulltime by
the patient prior to first stage reconstruction and in the interim
period between the first and second stages (when it kept the
PIP, DIP and MCP joints in flexion), and also after a few days of
the second stage of reconstruction (when it allowed both passive
flexion as well as extension against some resistance).
It could also be easily removed and washed for hygiene
purposes and the total cost price of the Velcro and elastic bands
was described by the patient to be 0.40 pounds sterling
(approximately US $ 0.65).
Fig. 1: Dorsal view of the worn splint.
Fig. 2: Lateral view of splint with flexed PIP, DIP and MCP
joints.
Discussion
Prior to a two stage flexor reconstruction, it is wise to start
the patient on a range-of motion and scar softening therapy
program to attain maximum preoperative passive range of
motion.1-3 After stage one of flexor reconstruction, passive motion
exercises are started 2 3 days after surgery. 4 In the
postoperative therapy after stage two of flexor reconstruction,
there has been a steady trend toward early active mobilization.1,
5, 6
There are several splint designs and splinting protocols
including the Duran and the Kleinart rubber traction, the Brooke
Muhammad Adil Abbas Khan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Army palmer-bar modification, the Mayo clinic synergistic wrist
splint, Evans short arc motion, and the Strickland hinged wrist
splint and active tenodesis. The splints can vary in design from
simple elastic straps around PIP and DIP joints, elastic straps
of various designs around the palm and distal phalanx, flexion
gloves with elastic traction or with an extra strap around the
distal phalanx and palm. Other alternatives include palm based
dynamic finger flexion splints or sticking hook-Velcro to the nail
plate and attaching a loop or elastic from the palm to the wrist.
Most of these alternatives are complex in design and have
to be custom made by occupational therapists and can have a
substantial cost and time factor involved in the manufacturing
process. Full details of the treatment protocol, the rationale for
why splints are used and how the different existing designs
address specific treatment objectives such as early protected
mobilization are beyond the scope of this manuscript.
The patient designed splint acted as a flexion strap which
allowed him to regain flexion at the DIP and PIP joints. The fact
that the patient had an excellent outcome may not be enough
evidence that this splint is generally effective, but the splint
designed by the patient proved to be innovative, simple,
inexpensive and fulfilled the requirements of therapy. The design
has since been used to help other patients with good outcome.
Conclusion
In combination with a hand therapy regime, we recommend
this innovative patient designed splint as a simple and
inexpensive alternative to existing splints for rehabilitation for
two-stage flexor tendon reconstructions.
Acknowledgements
The patient has given consent to them being presented as
a case and we would like accredit
Mr. Ian Tomkins for the splint he has designed.
Authors Statement
All authors have contributed to the conception and drafting
of the above mentioned article. All the authors have seen and
agreed to the submitted version of the paper, and bear
responsibility for it.
All who have been acknowledged as contributors or as
providers of personal communications have agreed to their
inclusion, the material is original and has been neither published
elsewhere nor submitted for publication simultaneously.
None of the authors have any conflicts of interests or any
financial disclosures to make. No funding was required for this
manuscript.
References
1. Mackin EJ, editor. Physical therapy and the staged tendon
graft: Preoperative and postoperative management. AAOS
Symposium on Tendon Surgery in the Hand; 1975; St.
Louis, CV: Mosby.
2. Mackin EJ. Therapists management of staged flexor
tendon reconstruction. . In: Hunter JM SL, Mackin EJ,,
editor. Rehabilitation of the Hand. 2nd ed. St. Louis, CV:
Mosby; 1984.
3. Mackin EJ, Maiorano L. Postoperative therapy following
staged flexor tendon reconstruction. In: Hunter JM SL,
Mackin EJ,, editor. Rehabilitation of the Hand. St. Louis,
CV: Mosby; 1978.
4. Cannon NM, Strickland JW. Therapy following flexor
tendon surgery. Hand Clin. 1985 Feb;1(1):147-65.
5. Hunter JM, Blackmore S, Callahan AD. Flexor tendon
salvage using the Hunter tendon implant. J Hand Ther
1989;2:107-13.
6. Stanley BG. Flexor tendon injuries: late solution. Therapists
management. Hand Clin. 1986 Feb;2(1):139-47.
41
Altered Current Perception Ratio: A tool to identify small fiber
neuropathy in high risk Diabetic foot
Unnati Pandit*, Hutoxi Witer**, Bharati Bellare***
*Associate Prof., Dept. of Physiotherapy Pad. Dr DY Patil University, Nerul, Navi Mumbai, **Prof & HOD, School of Physiotherapy,
TN Medical College, Mumbai, ***Hon. Prof. M.G.M. School of Physiotherapy, Kamothe, Navi Mumbai
Abstract
Background
Diabetics neuropathy & associated vascular affection is
known to cause high risk of foot ulceration. This comparative
pilot study was therefore aimed to explore whether the ratios of
distal to proximal sensory threshold [RST] & pain threshold [RPT]
respectively can serve as diagnostic tools to identify small fiber
diabetic neuropathy & indicators of risk of foot ulceration.
Methodology
25 subjects [15males & 10 females] within the age of 45 to
60 years were studied as per selection criteria. 25 age & sex
matched healthy subjects volunteered as Controls. Plain faradic
current stimulus was used to pick up sensory & pain thresholds
of sural nerve at ankle [distal]& lateral cutaneous nerve of calf
[proximal ] & distal to proximal RST & RPT were determined.
In addition ABI was also assessed. SPSS-16 soft ware was used
to compare RST & RPT & ABI between controls & study group
using independent t test.
Result
SPT, RPT & ABI showed significant affection [reversal] in
study group [ t = 3.97 , 8.25 & 9.16 respectively & p<0.000 in all
three].
Conclusion
RST & RPT serve as effective tools to identify small fiber
diabetic neuropathy & the same with ABI can serve as effective
indicators of risk for foot ulceration in diabetic subjects.
Introduction
Diabetes mellitus has reached epidemic proportions
worldwide as we have entered the new millennium. The World
Health Organization (WHO) has commented that there is an
apparent epidemic of diabetes which is strongly related to lifestyle
and economic status. The prevalence of diabetes for all age-
groups worldwide was estimated to be 2.8% in the year 2000
and predicted to be 4.4% in the year 2030. 1
G Said et al [2007]2 reported that diabetic neuropathy which
is the most common neuropathy in industrialized countries, is
associated with a wide range of clinical manifestations.Nidal
A.Yunus et al [1999] 3 report that Neuropathy is the major etiologic
component of most diabetic ulcerations; involving more than
80% diabetics. Loss of protective sensation[LOPS] is the primary
factor in foot ulceration in diabetics3,4,5 As per R Gary Sibbard et
al [2009]5 LOPS in those with diabetic neuropathy, through
combination of high planter pressure & repetitive stress during
daily activity, may wear a hole in their foot just as one would
wear a hole in stocking.
As per Arendt-Nielsen L [2009]6 Quantitative sensory testing
[QST] provides psychophysical methods that systematically
document alterations & recognition in peripheral nervous system
42 Unnati Pandit / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
functions & in particular, the nociceptive system. Concept of
Current perception threshold [CPT] is already established as
one of the assessment methods of QST 7,8,9 having its reliability
& reproducibility already established [1989] 8
Affection of distal to proximal gradients of various
parameters related to peripheral neuropathies are reported in
literature, . J P Conomy-[1979] 10 reported alteration in the Distal
to proximal cutaneous sensation in diabetes mellitus-; where
as Gary L. Pittenger et al [2004] 11 observed that intra-epidermal
nerve fiber density (IENF) progressively decreases (P < 0.001]
from proximal to distal sites in patients with diabetic neuropathy.
Similar findings in various parameters specifically related to
diabetic neuropathy are also reported 11,12,13,14,15,16 Maria
Nebuchennykh et al [2009]17, further recommend that the reversal
of gradients to be considered as strict criteria for the diagnosis
of small fiber neuropathy; which is seconded by Bashar Katirji18
Sensory & Pain thresholds can serve as parameters of CPT,
hence assessment of Distal to proximal ratios of sensory
threshold [RST] & Pain threshold [RPT] respectively can be
hypothesized as synonymous tools to assess distal to proximal
gradients in cutaneous perception
Vascular disease can independently pose as a risk factor
for ulcers. More over it is frequently associated with distal
diabetic neuropathy.2,3,4,5,19,20,21,22,23. Atherosclerosis is accelerated
in diabetic patients compared to nondiabetics. It commonly
involves the tibial and peroneal arteries20,21,22,23. The concomitant
presence of neuropathy and ischemia predisposes the foot to
minor trauma, which is often the precipitating factor for
ulceration4.
Eearly detection of diabetic neuropathy with associated
vascular insufficiency if any forms an essential tool in
prevention of ulceration in diabetic foot. Therefore this pilot
study was aimed with a hypothesis that distal to proximal ratios
of sensory & pain threshold [RST & RPT] respectively studied
in lower limbs along with ABI can serve as effective diagnostic
tools to detect small fiber diabetic neuropathy & high risk of
foot ulceration respectively.
Methodology
It was an exploratory cross sectional pilot study .For the
study group, 62 Diabetic subjects from In & Out-patient depts.
at BYL Nair hospital were screened & 25 subjects [15Males +
10 females] between the age group of 40-65years-[mean value
52 + 3.98 years] were selected as per the following inclusion /
exclusion criteria
Inclusion Criteria
Medically monitored -H/O diabetes for more than 10 years
with at least 4 out of following 7 components evident on the skin
of the foot indicating trophic changes 1) absent sweating 2) dry
scaly skin, 3) distended dorsal veins, 4)- thin and shiny skin, 5)
scars and calluses, 6) inter-digitation, 7)- fungal nails Those
with unilateral foot ulcer were also included.
Exclusion Criteria
Subjects who were irregular in taking medication, evidence
of Diabetic ulcers [healed /unhealed] on both the feet or a known
History of smoking,-Alcoholism, open injury/ ulceration on either
foot due to trauma or any other pathology having potential for
peripheral vascular disease or neuropathy.
The Control group included age & sex matched 25 healthy
individuals from the staff of BYL Nair hospital & relatives
accompanying the patients who volunteered to participate in
the study. Informed consent was obtained from each subject.
Detailed evaluation was conducted & status of ulcer if any, trophic
changes, fresh Blood sugar values were noted. for each subject
from Study group, including the details of pain in the feet if any.
Assessment of Sensory & Pain Threshold
Concept of Current perception threshold [CPT]was
popularized by Katim JJ et al as promising tool for initial
screening of patients with sensory neuropathies .[1987] 7, they
established the reliability & reproducibility of this tool [1989] 8
RST & RPT are the two parameters of CPT. Literature reports
about a specific type of current for CPT. A constant current type
of electrical stimulator is recommended with a provision of sine
wave current with facility to select three frequencies i.e- 2000
Hz for large myelinated fiber function, 250Hz for small myelinated
fibers & 5Hz for non-myelinated fibre function respectively.
24,25,26,27,28,29,30
The clinical policy bulletin on Sensory testing
methods [1999], declared Neurometer which is patented as
Neurotron; as reliable, valid & approved tool for the CPT
assessment & sustained this policy after its review again in 2009.
29
Though use of Electrical currents forms a major therapeutic
& diagnostic [Strength duration curves] component in
Physiotherapy practice, perhaps due to lack of awareness about
CPT amongst Physiotherapy practitioners in this country, there
is no demand for Neurometer , hence it is neither manufactured
indigenously, nor imported. A traditional diagnostic stimulator
available here is a constant voltage type which does not provide
recommended frequencies for CPT .Therefore in this study there
was no option left but to use any safe current available in the
traditional diagnostic electrical stimulator. Since normative
values of sensory & pain thresholds using specific traditional
electrical current are not available ; in order to eliminate the
biases if any in this study, the ratios were used for comparison
of distal to proximal gradients in sensory & pain perception ,in
stead of actual values of Sensory & Pain threshold
In this study a well calibrated digital stimulator [model :
Microstim-Genius manufactured by M/s Electrocare systems &
services PVT LTD, Chennai ] was used . For CPT, plain Faradic
type of current i.e- monophasic rectangular pulse of 1
milliseconds width & 50Hz frequency was used & intensity
required for the sensory threshold [ST] & pain threshold[PT]
was noted in millivolts. A pair of silver disc electrodes routinely
used for the nerve conduction studies were used. The area
selected for the respective nerve stimulation was fist rubbed
well with solvent ether to minimize the resistance. The electrodes
was cleaned with ether & then placed on the selected area using
EKG gel to overcome the resistance, & fastened with Velcro
strap maintaining distance of 5 mm between each electrode.
For Distal CPT -Cutaneous distribution of sural nerve was used
& the active electrode was fixed postero-inferior to Lateral
malliolus. Where as for the proximal CPT, lateral cutaneous nerve
of calf was selected & the active electrode was fixed at the
junction of upper 1/3rd & lower 2/3rd of postero-lateral aspect of
the leg. The electrical stimulus was then applied by increasing
the intensity slowly & the subject was instructed to report at the
following
1. The moment he/she felt the current This intensity was
noted as sensory threshold(ST).
2. The moment current sensation turned painful-which was
noted as pain threshold(PT)
Ratios of Distal to Proximal Sensory Threshold [RST] &
Unnati Pandit / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Pain threshold RPT] respectively were then calculated for both
the groups.
Assessment of Ankle Brachial Index[ABI]
Beth D Weatherley et al [ 2006]31 established the reliability
for the ABI based on single ankle and arm. In their study, SBPs
was 0.61 (95% CI: 0.50, 0.70) and the reliability of the ABI
computed as the ratio of the average of two ankle Systolic Blood
pressure [SBPs] to two arm SBPs was estimated from simulated
data as 0.70. The literature widely supports on use of ABI as
one of the investigation tools in Diabetes related vascular lesions
20,21,22,23
For the assessment of ABI., the subject was asked to rest
in supine position on a plinth. Systolic blood pressure of posterior
Tibial artery at Rt ankle & Brachial artery at Right Arm was noted
for each subject with the Hg manometer at ankle and arm
respectively. The ratio of Systolic pressure of Post tibial artery
vs Brachial artery was calculated as Ankle Brachial Index[ABI].
Statistical analysis of the data collected was done using
independent sample t test on SPSS-16. The values of distal to
proximal RST, RPT, & ABI were compared between the control
& study group.
Result
The age of Control group [ 51 + 5.6 years] matched well
with the Study group 52 + 7.8 years]. In the study group History
of Diabetes was 14.41+ 3.36 years ; Fasting & PP Blood glucose
levels were 160.3 + 75.99 & 263.3 + 97.58.respectively.
21 out of 25 diabetic subjects had established symptoms
of pain /burning sensations in feet, where as 6 subjects had
healing ulcer on the opposite foot . Average skin score of entire
study group was 4.3 + 0.03. The statistical analysis of RST,
RPT & ABI was as follows-
In the Control group, RST & RPT were 0.91 + 0.21 & 0.72
+ 0.19 respectively, where as in the study group they were 1.47
+ 0.67 & 2.9 + 1.31 respectively. ABI in the controls & Study
group was 1.36 + 0.29 & 0.81+ 0.06 respectively. Comparison
of the values between Controls & Study group showed high
significant reversal of ratios [ RST : t= -3.86 p =0.000 / RPT:
t = -8.051; p=0.000 / ABI : t = 9.17;p = 0.000] which confirmed
the distal to proximal pattern of affection.
Discussion
Table 1: Comparison of Distal to Proximal RST, RPT & ABI
Controls Study group
n=25 n=25 t value p value
RST 0.91 + 0.21 1.47 + 0.67 - 3. 86 **0.001
RPT 0.72 + 0.19 2.9 + 1.31 - 8.051 ** 0.000
ABI 1.36 + 0.29 0.81 + 0.06 9.17 **0.000
** highly significant
As per .Marc M. Treihaft et al [2002] 32, Peripheral
neuropathies involve different populations of nerve fibers.
Majority of patients with peripheral neuropathy exhibit evidence
of large fiber or IA fibre involvement. who subserve motor
function, position, and vibration sensation , hence. associate
with reduced vibratory and position senses & complain of
numbness, tingling, and muscle weakness. Where as small Fiber
Neuropathy[SBN] ,which mainly affects thinly myelinated A
delta and unmyelinated C fiber ,hence shows clinical
manifestation of burning pain but diminished thermal and
pain perception
G Said et al [2007]2 reported diabetic neuropathy as the
43
most common neuropathy in industrialized countries which
exhibits a wide range of clinical manifestations. More than 80%
diabetics have distal symmetrical form of neuropathy which
remains highly pronounced in feet-indicating longest nerve fibers
being more vulnerable. This is a small fiber type of axonopathy
that progresses in a fiber-length-dependent pattern[Length
dependent diabetic polyneuropathy [LDDP], with sensory and
autonomic manifestations predominating as pain & trophic
changes in the feet This pattern of involvement ,because of small
fibers being heavily affected & large ones are spared, projects
Psudo- syringomyelic type of diabetic neuropathy 2
As such for the diagnostic studies of peripheral nerve
affection, EMG & Nerve conduction studies are considered to
be ideal . However , as per Menkes D. L. et al [2000]30, they
are suitable only for the demyelinating polyneuropathies which
tend to affect larger myelinated fibers ; where as for axonal
polyneuropathies which tend to affect smaller fibers before larger
fibers, in a distal to proximal gradient , NC studies have a lot of
limitation. Findings of Menkes et al are supported strongly in
the literature15,32,33,34 In fact in such cases CPT is recommended
to distinguish demyelinating from axonal polyneuropathies30,
Our study group manifested typical symptoms of small
fiber LDDP, in the form of burning pain in feet & high skin score,
justifying use of RST & RPT as appropriate assessment tools
Even though intra-epidermal nerve fiber density (IENF), is
established as an authentic tool in identifying small fiber
neuropathy,11,15 it is an invasive mode & may not be easily
available or would be costly if available for routine assessment
to detect risk factors of diabetic ulcers. RST & RPT are simple
noninvasive & easily available methods to assess small fiber
type of peripheral nerve affection, specially the LDDP type. Highly
significant reversal of RST & RPT found in our study group
proved this method to be an effective mode for diagnosis.
However, this study needs to be extended by correlating the
values of RST & RPT [after establishing the same on larger
population] with other authentic parameters though as per Grazia
Devigili et al[2008]15, no gold standard is defined yet for clinical
practice or research in identification of small fiber neuropathy.
Diabetes is known to be an important risk factor for severe
peripheral arterial disease which predominantly involves distal
vessels & in combination with diabetic neuropathy contributes
to the higher rates of limb loss35,36 Our study also showed
associated arterial insufficiency , confirming that RST,RPT along
with ABI can serve as effective detector tools to identify risk of
ulceration in diabetic foot..
Conclusion
Distal to proximal RST & RPT confirmed to be effective
tools for identification of Small fiber type of diabetic neuropathy.
& these parameters along with ABI proved to be the effective
indicators of high risk of ulceration in the diabetic foot considered
for assessment. Physiotherapy professionals expertise in
utilizing Bioelectrical agents for therapeutics & diagnostics.
However the diagnostic expertise is not expanded enough
beyond motor studies [Strength Duration.curves]. This pilot study
is therefore expected to give incentive to the Physiotherapy
researchers to explore & establish norms with various therapeutic
currents which can not only serve as diagnostic tools but can
also serve as objective assessment tools during clinical trials
for evidence based practice.
References
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3. Nidal A. Younes, Abla M. Albsoul; and Hamzeh Awad, A
prospective study of risk factors for diabetic foot ulcer. The
Seattle Diabetic Foot Study. Diabetes Care.
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Charles Patout Jr., A Review of Causes of Foot Ulceration
in Patients with Diabetes Mellitus Publications-
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5. R. Gary Sibbald ; David G. Armstrong, and Heather L.
Orsted, ; Pain in Diabetic Foot Ulcers Ostomy E Wound,
management:October 4, 2009
6. Arendt-Nielsen L,Yarnisky D, Experimental & clinical
applications of quantitative sensory testing applied to skin
,mucosa & viscera[2009];J pain Jun,10[6]:552-72
7. Katims JJ, Naviasky EH, Rendell MS, Ng LKY, Bleeker ML:
Constant current sine wave transcutaneous nerve
stimulation for the evaluation of peripheral neuropathy. Arch
Phys Med Rehabil 1987; 68:210-213
8. Katims JJ, Rouvelas P, Sadler BT, Weseley SA: Current
perception threshold. Reproducibility and comparison with
nerve conduction in evaluation of carpal tunnel syndrome.
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9. Katims JJ, Taylor DN, Wallace JI, Bekesi JG, Masdeu JC:
Current perception threshold in HIV-positive patients, in
Proceedings of the Neurological and Neuropsychological
Complications of HIV Infection, Satellite Conference of the
5th International Conference on AIDS. 1989, p 39.
10. J P Conomy, K L Barnes, J M Conomy , Cutaneous sensory
function in diabetes mellitus.[ [1979 ]J Neurol Neurosurg
Psychiatry;42:656-661-
11. Gary L. Pittenger, Madhumita Ray, Niculina I. Burcus, ,et
al Intraepidermal nerve fiber density (IENF may prove a
useful end point in therapeutic trials for neuropathy Diabetes
Care August 2004 vol. 27 no. 8 :1974-1979
12. Ka Meh & Miro Deni- Subclinical neuropathy in type-I
diabetic children;[Jun1998] ,Clinical Neurophysiology /
Electromyography & motor control,vol109,issue3:274-80
13. Aaron I. Vinik, Diabetic Neuropathy: A Small-Fiber Disease;
07/24/2001 Medscape CME- : processing....Small-Fiber
Dysfunction
14. Kristine Orstavik, Barbara Namer, Roland Schmidt et al
,Abnormal function of C fibers in patients with Diabetic
Neuropathy ;[2006] J Neuroscience, 26[44]:11287-94
15. Grazia Devigili1, Valeria Tugnoli2, Paola Penza3, The
diagnostic criteria for small fibre neuropathy: from symptoms
to neuropathology ,Brain 2008 131(7):1912-1925
16. Amanda Peltier, MD 1, A. Gordon Smith, MD 2 3, James W.
Russell, MD, MS et al ,Reliability of quantitative sudomotor
axon reflex testing and quantitative sensory testing in
neuropathy of impaired glucose regulation,[3Mar
2009]Muscle & Nerve, vol 39, issue 4, Pages 529 535
17. Maria Nebuchennykh, Sissel Lseth, Sigurd Lindal and
Svein Ivar Mellgren et al; The value of skin biopsy with
recording of intraepidermal nerve fiber density and
quantitative sensory testing in the assessment of small fiber
involvement in patients with different causes of
polyneuropathy, Journal of Neurology[2009] Volume 256,
Number 7 / July,
18. Bashar Katirji, Diabetic neuropathies Last reviewed July
27, 2009, Medlink, Neurology: Clinical summery-Pre-view
19. Richard M Stillman, Diabetic ulcers, [2009]emedicine-
medscap updated: Oct 28.
20. Matthew A. Allison, William R. Hiatt, Alan T. Hirsch, A High
Ankle-Brachial Index Is Associated With Increased
Cardiovascular Disease Morbidity and Lower Quality of Life,
J Am Coll Cardiol, 2008; 51:1292-1298,
21. Vincente Lahoz C, Taboada M, Laguna F et al Ankle
Brachial Indexin patients with diabetes mellitus : Prevalence
& risk factors, Rev Clin Esp [2006]May,206[5] :225-9-
22. Yoshimura T, Suzuki E, Sakaguchi M, : Impaired peripheral
circulation in lower-leg arteries caused by higher arterial
stiffness and greater vascular resistance associates with
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Prevalence of Peripheral Occlusive Disease in Diabetic
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Mrczy V, Kdr , Vargha P: Evaluation of current
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765-768.
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Ischemia: Diagnosis, Treatment and Prognosis, April 1 1999;
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2007, 8:59
45
Relationship Between Depression and Cardiopulmonary Fitness
in Post Cardiac Surgery Individuals
K Charan*, K Asha Jyothi*, P Tabitha*, K Madhavi**
*MPT II Year, **Principal (i/c), College of Physiotherapy, SVIMS University, Tirupathi
Abstract
Objective
To know the relationship between depression and
cardiovascular fitness in post cardiac surgery patients after
phase 1of cardiac rehabilitation.
Methodology
Observational study was done on 30 samples. The patients
who underwent cardiac surgery were taken up for the study.
After phase 1 of cardiac rehabilitation, samples were screened
for depressive symptoms using CES-D scale and the 6 minute
walk test to predict peak oxygen consumption (VO2peak).
Results
Correlation analysis was done between CES-D and VO2peak.
The negative correlation coefficient of -0.951, with significance
at p<0.000 was obtained.
Conclusion
There exists a negative relationship between depression
and cardiopulmonary fitness.
Introduction
Depression is the term which describes a spectrum of mood
disturbance ranging from mild to severe and from transient to
persistent. Depressive symptoms are continuously distributed
in any population but are judged to be of clinical significance
when they interfere with normal activities and persist for at least
two weeks, in which case a diagnosis of a depressive illness or
disorder may be made..1 Significant depressive symptomatology
are found 43% preoperatively and 23% postoperatively in cardiac
patients.2
It is noted that 50% of the patients who were depressed
before surgery were also depressed 1 month after surgery 3,
and about one in six patients who has a myocardial infarction
developed major depression. The occurrence of depression has
been found to be independently associated with poor outcome,
including poor quality of life, increased heart disease, and
probably increased mortality. There is some evidence that those
who have a severe heart disease are at greatest risk of an
adverse outcome attributable to depression. Depression is an
important independent contributor to medical and psychosocial
morbidity up to 6 months after CABG.4
The causes of development of depression in cardiac
disease can be attributed to the stress after surgery and
development of depression in reaction to the illness 5. Stress
has been shown to be one of the most potent triggers or inducers
of depression 6 . With stress, the hypothalamicpituitary-
adrenocortical (HPA) axis and the sympatheticadrenomedullary
(SA) system are activated, which leads to release of
Catecholamines (epinephrine and norepinephrine).
Catecholamines increase alertness. Especially epinephrine
46 K Charan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
usually evokes more anxiety and fear.7 With resolution of stress,
these 2 systems should return to their basal states. Genetic
predisposition, such as specific serotonin transporter gene
polymorphisms, coupled with gene environment interaction may
explain why some individuals recover from life stressors and
others develop depression.8
Another possibility is that depression is a secondary
development in cardiac patients, whereby patients with more
severe cardiac disease or a heavier burden of comorbid
conditions may become depressed in reaction to their illnesses.
In this case, adverse outcome is the result of the greater disease
burden but not of depression itself.9
Many of the studies have done on depression in myocardial
infarction (MI) and chronic diseases. It is revealed from various
studies that depression is associated with 50% of mortality and
morbidity. But neither physician nor patient recognize the
importance of management of depression.10Considering the
above facts, depressed individuals will have decreased physical
activity level and decreased exercise capacity. Depression also
affects cardiopulmonary fitness. Depression is an independent
prognostic factor for mortality, readmission, and cardiac events
after CABG.11
Since a primary focus of cardiac rehabilitation (CR) is to
improve cardiopulmonary fitness, VO2 max is a reliable indicator
of cardiopulmonary fitness it can be taken as an outcome
measure for cardiopulmonary fitness.12
Need of the Study
Many previous studies have examined the relationship
between depression and cardiopulmonary fitness after second
phase of cardiac rehabilitation few studies are available which
studied the relationship at the time of discharge. Studying the
relationship between cardiopulmonary fitness and depression
at the time of discharge will help us to understand the complex
interaction among various factors within the hospital influencing
the outcomes after phase 1 of cardiac rehabilitation. This will in
turn help us to plan the first phase of CR more effectively to
improve the exercise capacity.
Aim
To analyze the relationship between cardiopulmonary
fitness and depressive symptoms in post surgical cardiac surgery
individuals.
Objectives
To study the depressive symptoms in relation to the
cardiopulmonary fitness, age, sex, BMI and length of hospital
stay.
To compare mildly the depressed (group 1) and the
significantly depressed (group 2) in relation to cardiopulmonary
fitness, age, sex, BMI and length of hospital stay in post surgical
cardiac surgery individuals.
Methodology
This observational study was conducted in the
cardiothoracic ward in a tertiary care center Sri Venkateswara
institute of medical sciences university in Tirupathi city of Andhra Table 1: Patient Characteristics
Pradesh in Republic of India. The study was conducted for six
Parameter Min. Max. Mean SD
months. The Sample size taken was 30. Individuals aged
between 20 60 years of age, who have completed phase 1 of
Gender
cardiac rehabilitation after an open heart surgery, CES-D score
Male 17
of greater than 16 and showing their willingness to participate in
Female 13
the study were included. Patients were excluded if they were
Total = 30
unable to fill CES-D scale i.e. if more than 5 questions were left
Age 26 54 38.14286 10.23904
unanswered or if they were unable to complete six minute walk
CES-D score 18 38 25.66667 6.127008
test (6MWT) or if they were suffering from any severe
VO2peak 13.18 19.4 16.1475 1.635242
neurological diseases which may limit subjects ability to
BMI 14.2 20.89 17.475 2.430732
complete 6MWT.
No. of days of 09 19 12.43333 2.775302
hospital stay
Procedure
inclusive criteria. Correlation analysis was done to find the
Written informed consent was taken from successive correlation between CES-D scores and other parameters. The
patients between the age 20-60yr entering cardiac rehabilitation results are shown in the table 2.
after open heart surgery, they were assessed at the end of phase
1 of cardiac rehabilitation for the following outcome measures. Table 2: correlation between CES-D score and VO2peak, age,
Depressive symptoms are measured as score using a translated BMI, Length of stay in hospital.
Telugu version of The Center for Epidemiologic Studies
VO2peak AGE BMI LENGTH
Depression Scale (CES-D), cardiopulmonary fitness is measured
OF STAY
as VO2peak in ml/kg/minute using a 6MWT and VO 2peak was
estimated using the regression equation. VO2peak = [0.03 X
CES Pearson -0.951** 0.951** 0.943** 0.625**
6MWD (meters)] + 3.98; where 6MWD - Six Minute Walk
-D Correlation
Distance and length of hospital stay were noted from hospital
records.
Sig. (2-tailed) .000 .000 .000 .000
The Center for Epidemiologic Studies Depression Scale
(CES-D) is a 20-item, self-report depression scale developed
N 30 30 30 30
to identify depression. It was designed to cover the major
symptoms of depression identied in the literature, with an *indicates that values are statistically significant at 0.001 level.
emphasis on affective components: depressed mood, feelings
of guilt and worthlessness, feelings of helplessness and All the parameters showed a significant correlation with
hopelessness, psychomotor retardation, loss of appetite, and CES-D.Further analysis was performed to test the significance
sleep disorders. CES-D were selected from existing scales, difference of the CES D-Score. the patients(n= 30) were divided
including Becks Depression Inventory (BDI), Zungs Self-rating into two groups based on the CES-D scores. Patients with a
Depression Scale (SDS), Raskins Depression Scale, and the score of <22 (n= 14) were included in mildly depressed group
Minnesota Multiphasic Personality Inventory.13 (group 1) and patients with e22 (n= 16) were included in
The CES-D is normally self-administered but may be used significantly depressed group (group 2). The impact of CES D-
in an interview. Items of this questionnaire refer to the frequency score was observed in various parameters such as BMI, VO2
of symptoms experienced by the patient during the past week. Peak, Duration and Age. For this the suitable statistical tool used
Each question uses a 0 to 3 response scale; except for the four is independent samples t test and descriptive measures were
positive questions, a higher score indicates greater depression. also reported for each parameter.
Questions 4, 8, 12, and 16 were worded positively, in part to In table below, a comparison is made to observe the impact
discourage a response set, and their scores are reversed by of CES- D score in all the parameters. Results showed that in
subtracting the score from 3. Question scores are then summed all the parameters there exists statistical significance between
to provide an overall score ranging from 0 to 60. 14 the groups 1 and 2. Mean and standard error values are reported
Radloff had reported alpha coefficients of 0.85 for general along with t-statistic and p-value. If we observe the statistical
population samples and of 0.90 for a patient sample; Similar measure, the mean response of subjects in group 2 have higher
results were obtained by Himmelfarb and Murrell. The concurrent mean than that of subjects in group 1. For visualization of the
validity, construct validity and reliability of the CES-D have also statistical measures, line diagram representation is made with
been established in community samples. Okun et al. reported whiskers. The graphs are displayed below the table 3.
on the content validity of the CES-D, which covers seven of the Table 3: Comparison between group 1 and group 2 for impact
nine DSMIV symptoms of major depressive episode. The of CES-D score on all the parameters.
sensitivity and specificity of the CES-D have been frequently
reported and generally appear to be very good.( Weissman et Parameter Status N Mean Std. t Sig.(2
al., Shinar et al., and Parikh et al.).15 CES-D Error -tailed)
Mean
Results Age < 22 14 26.71 0.997 -7.001 0.000*
e 22 16 42.81 1.963

Statistical Analysis VO2 Peak < 22 14 17.55 0.215 -6.302 0.000*

e 22 16 14.95 0.288
Diagnosis: ASD-07, VSD- 02, ICR- 01, AVR- 05, MVR- 06,
DVR- 03 and CABG-06. BMI < 22 14 15.47 0.271 -6.719 0.000*
After collecting the data, the data was processed using e 22 16 19.23 0.467
SPSS 17.0 statistics package. Microsoft 2007 spread sheet was
used to tabulate the date and to plot graphs. Duration < 22 14 11.14 0.678 -2.610 0.014*
A total of 87 patients were screened for depression using e 22 16 13.56 0.632
CES-D scale of which 30 patients were found to fit into the

K Charan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 47
comparatively higher than that of males. So it can be concluded
Graph 1: Comparison of CES-D score between group 1 and
group 2
Graph 2: Comparison of VO2 peak between group 1 and group 2
Graph 3: Comparison of BMI between group 1 and group 2
Graph 4: Comparison of Length of hospital stay between group
1 and group 2
*indicates that values are statistically significant at 0.001 level.
Female gender has high depression score when compared
to male. There exists significant impact of depression score in
females rather than in males. The mean response of females is
48 K Charan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 3: Comparison of depression scores between male and
female
Sex N Mean Std.Error t-statistic and
Mean sig. (2 tailed)
CES- D Male 17 23.47 1.033 -2.427
score
Female 13 28.54 1.976 (0.022*)
*indicates that values are statistically significant at 0.001 level.
that depression score will be higher in females than that of males.
Discussion
All parameters showed a high correlation with CES-D score.
The negative correlation between CES- D score and VO2peak (-
0.951) suggests that with the increase of depression there will
be more reduction in the VO2peak. There are two mechanisms
previously proposed to explain the relationship between the
development of depression and stress, one is related to problem
with the regulation of hypothalamic adrenaocortical axis (HPA)
activation and the other with development of secondary
depression owing to co morbidities in cardiac disease. This
reduction in the VO2peak can be attributed to the disease itself.
The greater the severity of disease greater will be the stress on
the individual and subsequently resulting in depression.
When we compared the two groups in relation to the age,
sex,BMI, VO2peak and length of hospital stay, The significantly
depressed group had a higher mean value except for VO2peak.
Results of this study are in concurrence with previous studies
by Walter Swardfager (2008).11 Low physical activity level related
to depressive symptoms may be the cause for a decreased
VO2peak and an increased BMI in these individuals. Low values
of VO2peak in group 2 may also be due to the patients level of
interest and motivation, which may be significantly influenced
by the depression.
A mean BMI of 15.47 and 19.23 was seen in group 1 and 2
respectively. On comparison between the two groups, group 2
is found to be having an increased BMI. This was in concurrence
with the report by Elizabeth Johnson (2004). Relation between
depression and obesity will depend not only on the measures
used to assess the obesity for e.g. Robert et.al. found that using
a BMI > 85th percentile as a cutoff point for obesity result in a
significant relationship between depression and obesity. Where
as using BMI > 30 did not. We did not use any cut off point for
obesity. Instead we have seen the variation of BMI score between
group 1 and group 2.
We also studied the relationship between depression and
length of hospital stay. We found that people who were in the
significant depression group had a longer stay in the hospital
when compared with people with mild depression. This may be
due to high symptom burden in the significantly depressed
individuals. SM Saravay (1990) in his study on general medical
and surgical patients and Verbosky LA (1993) in hip fracture
patients.
We also studied the sex difference in the development of
depression and found that women are more likely to develop
depression than men. This may be due to lack of emotional
support from the close relatives like siblings, parents and spouse.
Women were found to be more sensitive regarding the
development of depression if they did not get emotional support
from the family which is limited at the hospital. As HPA
dysregulation is the most consistant neuroendocrine abnormality
in depression, depressive disorder occurs twice as commonly
in women than in men.16 It was also noted that women having
major depression show a greater HPA axis dysrgulation and
than depressed men.
Significant correlation between depression and other factors
(VO2peak, BMI, age, length of stay) may not be generalized to the
whole cardiac surgery population due to a relatively small sample
size 17. But it is warranting a further research with a large sample
size covering a wide range of cardiac surgeries. Depressive
people are less likely to complete cardiac rehabilitation.18
Irrespective of mechanism, several arguments can be made
that depression should be detected and treated in cardiac
patients:
Depression is prevalent as a co morbid illness in cardiac
patients and itself is characterized by tremendous morbidity
(eg, hopelessness, poor quality of life), as well as increased
mortality risk through suicide.
Depression is unhappily under recognized and undertreated
in medical populations overall and certainly within
cardiovascular populations.
If depression is linked to cardiovascular disease through
physiological mechanisms, then recognition and treatment
may lead to improved patient outcomes through
modification of the adverse physiological changes that
accompany depression.
If depression is linked to cardiovascular disease through
behavioral mechanisms, then appropriate recognition and
treatment may help remove the depression barrier and
improve adherence to medications, lifestyle changes, self
management, and receipt of appropriate testing and follow-
up.
By treating depression, we can improve the quality of life
of our patients and we may improve adherence to cardiac care
recommendations.5
Conclusion
There exists a significant negative relationship between
depression and cardiopulmonary fitness. So patients should be
screened for depression before and during the cardiac
rehabilitation. Stress management should be incorporated in to
the phase 1 cardiac rehabilitation.
Study Limitations
This study has several possible limitations. The first one is
its sample size. With a small sample size we can not generalize
the results to the whole population. We did not have a clinical
diagnosis of depression but rather assessed severity of
depressive symptoms using the CES-D scale. Study results
could be affected by response bias because willingness to
participate was an inclusion criterion. It is also possible that
patients with depressive symptoms were more likely to report
more physical limitations as a consequence of their depressed
mood rather than actual worse health status.
References
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Selnes OA: Depression and cognitive decline after coronary
artery bypass grafting. Lancet 1997; 349:12821284
4. Matthew m. burg, M.Cristina Benedetto, Roberta
Rosenberg and Robert Soufer. Psychosomatic Medicine
65:111118 (2003) Presurgical Depression Predicts Medical
Morbidity 6 Months After Coronary Artery Bypass Graft
Surgery
5. John S. Rumsfeld and P. Michael Ho Depression and
Cardiovascular Disease: A Call For Recognition Circulation
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6. Kendler KS, Karkowski LM, Prescott CA. Causal
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Oh, Alex Kiss,and Krista L. Lanctt. Relationship between
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49
Effectiveness of Physiotherapy Provision within an Occupational
Health Setting
Laran Chetty
Senior Physiotherapist, Royal Free Hospital, Health and Work Centre, National Health Service, United Kingdom
Abstract
Background
An occupational health physiotherapy service was set up
in May 2008 for staff at an occupational health centre based at
an acute London NHS hospital. This service was set up following
a service review in 2006-7.
Aim
To evaluate the effectiveness of physiotherapy provision
within an occupational health setting as part of a quality
improvement exercise.
Methods
A 1-year retrospective study was performed to evaluate
outcomes following discharge from physiotherapy. All data were
captured on the computerised cohort database system and
analysed descriptively.
Results
The mean number of physiotherapy consultations before
discharge was 3.9 sessions. There was a high attendance rate
of 72.9%. The average waiting time for a physiotherapy initial
assessment was 6.56 days. Spinal injuries contributed to the
highest proportion of musculoskeletal injuries (57%). The largest
staff group seen was staff nurses (24%). Injuries made worse
by work contributed to the highest number of cases (46%). 76%
were advised to remain at work after discharge from
physiotherapy. A financial analysis showed significant cost saving
when benchmarked against other physiotherapy providers.
Conclusions
The physiotherapy service has demonstrated productivity,
value of money and positive outcomes. The improved outcomes
are attributed to an innovative, rapid access service together
with multidisciplinary input.
Key Words
Physiotherapy, Effectiveness, Occupational Health.
Introduction
Musculoskeletal disorders (msds) account for 49 percent
of sickness absence from work, the biggest health problem facing
contemporary workforces. 1-2 In terms of occupational
Address for correspondence:
Laran Chetty
Senior Physiotherapist
Royal Free Hospital, Health and Work Centre, National Health
Service, United Kingdom
E-mail: laranchetty@gmail.com
50 Laran Chetty / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
musculoskeletal injury, the bone and joint decade asserts that
the whole population should be considered at risk.3 The drive to
tackle musculoskeletal sickness absence is not only to reduce
pressure on public funding, but also to improve peoples health,
wellbeing and quality of life, and to tackle poverty and social
exclusion.4 There is a growing recognition that musculoskeletal
sickness absence is best managed by occupational health
services that are proactive in early intervention.5 It is in this
context that the focus of musculoskeletal disorders on work is
requiring increased attention from all stakeholders, including
clinicians and policymakers.6
Background
In May 2008, an occupational health (OH) physiotherapy
service was set up for staff at an acute London National Health
Service (NHS) hospital. This service was set up following a
service review in 2006-7. This service was implemented in
response to the high number of musculoskeletal cases referred
to the OH department and the associated high levels of sickness
absence and workplace restrictions. In the past, staff that sought
physiotherapy services had to endure long waiting times for
treatment and most often referred via their General Practitioner.
It was envisaged that a physiotherapy service dedicated to
staff would improve waiting times for musculoskeletal cases in
order to enable the employee to return-to-work earlier or to
reduce the possibility of chronic conditions developing and to
positively impact on sickness absence and litigation claims. In
addition, the service would contribute to the development of
multidisciplinary working practices, resulting in the
implementation of appropriate return-to-work rehabilitation
packages. This service is supported by the recommendations
of several national guidelines targeting early physiotherapy
intervention to reduce the impact of disability from
musculoskeletal injury, the reduction in sickness absence and
the overall health promotion of staff.4-5, 7
The OH physiotherapy service provides care for
approximately 5000 staff at the hospital. The physiotherapy
service is well advertised and is accessible to all staff. The
physiotherapy service runs for 37.5 hours per week from Monday
to Friday. One full-time physiotherapist, employed by the OH
centre manages the service. The service broadly consists of
two clinic days dedicated to initial physiotherapy assessments
and three clinic days for follow-up appointments per week. Staff
may be referred to the service via management or self-referral.
The OH centre also offers specialist medical consultancy, nursing
advisory and clinical psychology services and receives
administrative support.
Purpose
The purpose of this study was to evaluate the effectiveness
of physiotherapy provision within an OH setting as part of a
quality improvement exercise.
Methodology
A retrospective study design was used, in which injury data
over a 1-year period was reviewed. All employees that attended
their OH physiotherapy appointment during the review period
were included in the analysis. Data was extracted using a
computerised Cohort database system from 2009, 01 April to
2010, 31 March and analysed using Microsoft Excel. The
database was used to extract information pertaining to age,
gender, body part affected, type and stage of injury, mode of
referral, staff user groups, attendance rate, waiting times and
return to work (RTW) outcomes at the time of discharge.
RTW outcomes were further defined by the
recommendations given on discharge i.e. remain at work, return
to work, unfit to work, go off sick. A financial analysis was
performed to estimate the direct cost saved related to
physiotherapy treatment compared against the national
benchmark and corporate sector. The comparative savings per
individual staff member was also calculated. The cost of each
physiotherapy session was standardised at 90 per session.
The data was reduced to percentages and presented
descriptively. In order to ensure reliability and accuracy of the
data extracted, all information was validated by a second

Table 1 depicts the different staff groups seen and the total number of physiotherapy treatment sessions. The highest staff groups
seen were staff nurses (n=56, 24%), domestic assistants (n=28, 12%) and healthcare assistants (n=20, 9%). The highest number of
physiotherapy sessions were received by staff nurses (n=208, 24%), with domestic assistants and administration both receiving 100
physiotherapy sessions in total.

Total number Total number of PT!

Staff Groups of staff % sessions %

Administration 16 6% 100 11%

Adviser 4 2% 10 1%
Assistant Manager 2 1% 10 1%
Biochemist 2 1% 8 1%
Biochemist Scientist 10 4% 56 6%
Clinical Nurse Specialist 2 1% 8 1%
Deputy Director 2 1% 18 2%
Dietician 4 2% 18 2%
Domestic Assistant 28 11% 100 11%
Healthcare Assistant 20 8% 54 6%
Maintenance 8 4% 36 4%
Manager 4 2% 6 1%
Midwife 2 1% 8 1%
MTO 2 1% 4 0.5%
Nurse Specialist 4 2% 8 1%
Occupational Therapist 8 4% 36 4%
ODP 2 1% 4 0.5%
Palliative Care Nurse 2 1% 8 1%
Pharmacist 8 4% 46 4%
Physiologist 2 1% 18 1%
Physiotherapist 4 2% 4 0.5%
Porter 4 2% 10 2%
Practice Development Nurse 2 1% 6 1%
Radiographer 8 4% 38 4%
Research Technician 2 1% 2 1%
Senior Nurse Manager 2 1% 2 1%
Sister/Charge Nurse 4 1% 12 1%
Specialist Nurse 6 3% 20 3%
Specialist Registrar 2 1% 16 1%
Staff Nurse 56 23% 208 23%
Student Nurse 4 2% 14 2%
Supervisor 2 1% 4 0.5%
Technician 2 1% 6 1%
Trainee Clinical Scientist 2 1% 4 0.5%
Ward Clerk 2 1% 6 1%
Total Individuals Seen 234
Total Appointments 908
!
Physiotherapy
reviewer. with the remaining 27% being males. All cancelled sessions
were excluded from the analysis. This indicates a 72.9%
Results attendance rate.

Demographic Data
A total of 1246 physiotherapy sessions were booked during
the review period, of which 908 were attended and 338 were
cancelled. The mean age for this group was 43.5 years and the
range was 20 to 78 years. Self-referrals made up 87% of referrals
and the remaining 13% were referred by management. With
regards to gender, the majority of the caseload was female (73%)
Service Provision
The average waiting time for an OH initial physiotherapy
assessment was 6.56 days. A total of 234 physiotherapy initial
assessments and 614 follow-up sessions were attended. The
average number of physiotherapy consultations before discharge
was 3.9 sessions. Spinal injuries contributed to the highest
proportion of musculoskeletal injuries (57%), followed by lower
limb injuries (23%) and upper limbs injuries (20%). Work-related

Laran Chetty / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 51
injuries were recorded in 24% of cases, injuries made worse by
work in 46% of cases and non work-related injuries in 30%.
58% of injuries were in the acute stage, while 42% presented in
the chronic stages. Only eight staff members (3%) were re-
referred back to physiotherapy after discharge.
Fig. 1: depicts the outcomes from OH physiotherapy after
discharge. The recommendations given on discharge were as
follows: 76% to remain at work, 1% to return to work, 19% were
unfit to work and 4% to go off sick.
Occupational health physiotherapy outcomes.
Projected Savings
A financial analysis was performed to estimate the potential
for direct treatment cost savings for the employer of staff treated
at the OH centre. The formulas based on the TriHealth Business
Model were used to determine this cost saving.8 On average,
clients seen at the OH physiotherapy clinic were discharged 2.9
sessions and 1.24 sessions sooner than the national benchmark
and corporate sector respectively. This amounts to a reduction
of 61074 and 26114, yielding a saving of 252 and 112 per
injured staff treated respectively.
Discussion
Physiotherapy is an integral part of occupational
rehabilitation, contributing to areas such as musculoskeletal
treatment, injury prevention advice, health promotion, functional
capacity evaluations, restorative exercises, work hardening and
conditioning, pre-work screening, ergonomics and case
management.9 Since the introduction of the OH physiotherapy
service the waiting times for referrals that would have traditionally
gone to physiotherapy outpatients, orthopaedic clinics,
rheumatology clinics or directly into secondary care has been
lowered significantly. The majority of staff are seen within 6 days.
This compares favourably against national waiting times for
physiotherapy which was 5 months in 2008 and 6 months in
2009.10-11
The high attendance rate indicates that the OH
physiotherapy service is valued by its users who are gaining
some benefit from attending. The OH physiotherapy service
follows the bio-psychosocial model of care, offering injury
prevention advice, to providing therapy and rehabilitation and
empowering employees to maintain their own health through
health promotion campaigns, while communicating with
employers and the larger multidisciplinary team. The low re-
referral rate has shown that staff members are appropriately
discharged and the advice and resources given was adequate
to encourage self manage in the event of an injury recurrence
or exacerbation of symptoms.
Spinal injuries contributed to the highest proportion of
musculoskeletal injuries and so legitimately the service needs
to promote the management of these injuries through health
promotion initiatives, such as spinal fitness pamphlets or back
52 Laran Chetty / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
care seminars. The recent NICE (2009) guidelines for the
management of non-specific low back pain, with acupuncture,
mobilisations/manipulation and tailor exercises being endorsed,
must also be considered in the context of service delivery.12
This service review has highlighted key areas for future
development including targeting poor work practices in
problematic areas for the identified staff groups. The assumption
that a service design can simply roll forward from one year to
another with few marginal changes is becoming increasing
extinct. The OH physiotherapy service is continuously
progressive and has demonstrated real service impact and has
done so by addressing the national framework of priorities,
including meeting rising service expectations and access
together with financial gain.
The improved RTW outcomes are due to an innovative
and rapid access approach. The decisions regarding
physiotherapy interventions and the need for subsequent follow-
up appointments are made by the OH physiotherapist at each
session. This differs from the tradition physiotherapeutic model
which is normally heavily prescriptive in frequency and duration.
The added benefit of OH physiotherapy is assessing the
functional capabilities of the employee in relation to their job
tasks and the ability to communicate the advice directly with the
line manager and other members of the multidisciplinary team,
which is perhaps the key driver in achieving these successful
RTW outcomes.
Considering the multi-factorial nature of work-related
musculoskeletal disorders, it is advantageous for occupational
health services to have physiotherapists, because of the health
synergies they promote. Even greater outcomes could be
achieved by increasing the involvement of the physiotherapist
in the decision making process within this occupational health
setting. The integration of the physiotherapists unique skills set,
together with the knowledge and ability of the rest of the
multidisciplinary team would only enhance the effectiveness of
a truly bio-psychosocial approach to the management and
prevention of musculoskeletal disorders. Furthermore, the
commitment of line managers is essential in the prevention of
musculoskeletal disorders, and their implementation of OH
recommendations should be seen as an investment rather than
a cost as this promotes a healthier and more motivated
workforce.13
A new physiotherapy role and a new way of working has
emerged, and at the same time historical and traditional
physiotherapy care models are being challenged and changed.
The OH physiotherapy service, with its solution-focused, person-
centered approach, is ideally placed to play a major role in
occupational health service delivery.
Limitations
This study is limited in that the author was unable to
establish form the computerised Cohort database, the exact date
for return to work in order to determine the actual reduction in
days off work. Therefore the additional savings reflected in the
reductions of lost working days could not be determined. A
further study addressing this limitation is warranted. In addition,
the treatment of many staff involved the simultaneous use of
physiotherapy with other interventions provided by different
services offered by the OH department, and therefore it is not
possible to determine which intervention contributed more to
the improvement in outcomes.
Conclusion
The OH physiotherapy service is committed to the provision
of a high quality, dedicated and professional services for staff
with musculoskeletal conditions, centered on clinical
assessment, treatment and adequate case management plans.
This service evaluation has highlighted the need for
physiotherapy provision within an occupational health setting
and has clarified the unique contribution of the profession. The
data collated in this study demonstrates clearly the benefits
physiotherapy can bring to an organisation and the complete
package of care to staff. The OH physiotherapy service has
demonstrated productivity, value of money and positive
outcomes. In the current changing political climate in the UK,
and the radical shift in healthcare provision, a positive approach
is essential. It would seem appropriate to begin developing key
relationships with relevant stakeholders to show what OH
physiotherapy can offer. This paper lays the foundation for a
business plan by showing both clinical and financial
effectiveness.
Conflict of Interest
None declared.
References
1. Fit for Work? Musculoskeletal disorders in the European
workforce (2009). The Work Foundation.
2. Reilly T, editor (2002). Musculoskeletal disorders in health-
related occupations. Amsterdam: IOS Press
3. Bone and Joint Decade website: www.boneand-
jointdecade.org. (Accessed 28/04/10).
Laran Chetty / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
4. Dame Carol Blacks review of the health of Britains working
age population (2008). Working for a healthier tomorrow
5. The Boormans review of NHS workforce health and
wellbeing (2009). The final report
6. Department for Work and Pensions (2006). Security in
retirement: towards a new pensions system
7. Professor the Lord Darzi of Denham KBE (2008). High
quality care for all: NHS Next Stage Review final report
8. Douglas H et al (2002) Effectiveness of occupational
medicine centre-based physical therapy. Journal of
Occupational and Environmental Medicine 44(1): 48-53
9. Isernhagen SJ (1991) Physical therapy and occupational
rehabilitation. Journal of Occupational Rehabilitation 1(1):
71-82
10. Hunt L (2008) Minister spells out plans to cut waits for
physiotherapy. Physiotherapy frontline 14(19): 6-7
11. Hart (2009) The Bevan Legacy. Physiotherapy frontline
15(9): 17-19
12. National Institute for Health and Clinical Excellence (2009)
Early management of persistent non-specific low back pain
13. Foster NE, Dziedzic KS, van der Windt DA, Fritz JM, Hay
EM (2009) Research priorities for non-pharmacological
therapies for common musculoskeletal problems: nationally
and internationally agreed recommendations.BMC
Musculoskeletal Disorders 10:3 PMID: 19134184.
53
To Assess the Relation Between Walking Capacity and Cardio-
respiratory Function in Post Polio Residual Paralysis
Ashish V Gupta*, Lata Parmar**
*Lecturer, **Principal, K.M. Patel Institute of Physiotherapy, Shree Krishna Hospital, Gokal Nagar, Karamsad 388 325, Gujarat, India
Abstract
Background
Poliomyelitis is on edge of eradication, but more than 50
lakhs residual polio survival are reported in India, moreover, in
view of reported PPS, it is necessary that PPRP patients should
be followed up with regards to their functional status.
Objectives
To identify and determine the relation between walking
capacity and cardiorespiratory function in PPRP, and to compare
the same with normals.
Method
30 participants of PPRP and 30 healthy, age matched
participants were recruited. A baseline evaluation inclusive of
MMT was done for the study group. In both the groups, walking
capacity was assessed by 12 MWT and cardiorespiratory
function were assessed by measuring the vitals viz. PR, RR,
BP, RPP, PR Recovery Time and RPP.
Results
The distance covered by study group participants was
significantly less (p=0.00). No significant change was seen
regards to change in PR, RR, BP, RPP and PR recovery time,
however post test RPE was significantly high in study group
(p=0.003).The study group showed negative correlation between
change in RPE and12MWD (p=0.014), at the same time change
in RPE positively correlated with change in PR (p=0.006) and
change in RPP(r=0.522, p=0.003). Further sum of paretic limb
muscle strength did not show any significant correlation.
Conclusion
Walking capacity is severely compromised in the PPRP.
The cardio respiratory parameter did not show any significant
difference, RPE however was significantly higher in PPRP.
Key Words
Polio, cardiorespiratory fitness, submaximal exercise
testing.
Introduction
Poliomyelitis although not typically a life threatening
condition, it has potency to cause significant deformity and
disability1. There are number of Studies which have correlated
6 minute walk test (6MWT) distance and lower extremities
muscle strength2 in polio, and energy cost of walking is shown
to be strongly related to the extent of muscle weakness in the
lower extremities3,4. Poliomyelitis is on edge of eradication, but
more than 50 lakhs residual polio survivors are reported in India5,
moreover, in view of reported post polio syndrome (PPS), it is
54 Ashish V Gupta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
necessary that post polio residual paralysis (PPRP) patients
should be followed up with regards to their functional status.
This study therefore aimed to assess the walking capacity and
cardiorespiratory function and relation between two with
hypothesis that cardiorespiratory parameters are not the
responsible factors for limited walking capacity of PPRP patients.
Material and Methods
The study proposal was approved by the Human Research
Ethic Committee, of the institute. The study design was an
observational case control study. 30 participants of PPRP were
recruited arbitrarily, based on their satisfying inclusion and
exclusion criteria and, 30 healthy (self declared, not on any
medication) age matched participants were recruited from vicinity
of the study center.
Inclusion Criteria
1) Known case of PPRP predominantly affecting one lower
limb.2) Participants independently ambulatory with or without a
walking aid/ orthosis .3) All age group both males & females
with minimum of 2 years after the onset of poliomyelitis.4) Ability
to understand and follow the commands and capable to provide
informed consent.
Exclusion Criteria
1) Acute poliomyelitis. 2) Neurological, musculoskeletal and
cardiovascular-respiratory conditions other than PPRP.3) More
than one lower limb involved, unable to walk.
Informed consent was obtained from every participant; the
participants who were willing to participate were interviewed for
their medical history and demographic data. All the participants
claimed no known cardiorespiratory, musculoskeletal and
neurological (other than polio) pathology affecting their walking
capacity and were able to walk independently with or without
orthosis/walking aids.
For PPRP participants, Muscle strength was measured by
manual muscle testing (MMT), according to the medical research
council Scale. Muscle group tested by MMT were hip flexors,
hip extensors, hip abductors, hip adductors, knee extensors,
knee flexors, dorsi flexors and planter flexors. To achieve score
that indicates the functional values of muscle strength, MMT
values 3 and below 3 was set at 0. MMT value 4 was set as 1
and MMT value 5 was set as 2. Thus resulting in values for
each muscle group in the range from 0 to 2. By adding the scores
of all 8 muscles group of tested one affected leg (strength sum)
was obtained in the way similar to Nollet 19991.
For both the groups, walking capacity was measured by 12
minute walk test (12MWT). The test procedure was exactly the
same as recommended by Mcgevin6. PR, RR and BP were
measured using standard methods. Rate of perceived exertion
(RPE) was assessed by 16 points Borg scale7, while Rate
pressure product (RPP)8 was measured by a product of PR
Systolic BP. Participants were advised to wear comfortable
cloths, shoe, orthosis/walking aids and then instructed to walk
as far as possible with their comfortable speed around a 30
meter long corridor. Post test immediately the said parameters
were measured. Recovery time for PR was measured at the
end of 3 minutes, 5 minutes and 7 minutes. These values were Table 2: Comparison of 12 minute walk test between two groups
recorded under two groups i.e. d5mins and >5mins.
Subjects Distance (meter) t-value P value
For statistical analysis, SPSS software was used. Statistical
method used in the analysis were Unpairedt test, Chi-square
Normal 1043.8316.07 10.022 0.000*
and Pearsons correlation. The statistical significance level for
each comparison was considered at 5% Level (P < 0.05).
PPRP 685.6431.92

Results *P < 0.05

The descriptive statistics are as shown in table 1a. The 12 minute Walk Test
mean BMI for both groups is seen to fall within normal limits.
As shown in table 2, PPRP participants covered significantly
Characteristics of study group are as given in table 1 b.
less distance during 12 MWT compared to control group (p =
Age ranges for study group was between 10 to 60 years.
0.00).
Seven participants of study group used walking aids in the form
Table 3a & 3b show that although the changes in
of cane and crutch while only one participant used Knee Ankle
hemodynamic parameters were higher in PPRP participants
Foot orthosis.
compared to normal on observation, the change in PR, RR,
The range of sum of muscle strength of affected limb for
RPP, BP and recovery time for PR was not statistically significant
study group was 0/16 - 10/16.
between two groups.
Table 1a: Characteristics of the study population With regards to RPE, as shown in table 3c, the significant
Characteristics of Normal PPRP Total difference in resting RPE and post test RPE was seen between
participants study and control groups (p<0.05). However change in RPE
between the two group was not statically significant (p=0.052).
Number of 30 30 60 Change in RPP and the change in RPE level was negatively
participants correlated (p= 0.028), (p= 0.014) resp. with 12 minute walk
distance (12MWD) in PPRP participants as seen in Table 4a,
Sex (M/F) 26/4 26/4 52/8 4b.

Mean age SE 30.63 2.34 29.2 2.21 - Table 3a: Comparison of different hemodynamic variables
between two groups
Mean BMI SE 20.58 0.6531 19.9107 - Change in
0.6191 hemodynamic Normal PPRP t- value p-
parameter value
Table 1b:
Characteristics of post polio residual population Change in PR 17.44 2.31 21.4 2.60 1.14 0.259

SR AGE SEX BMI ORTHOSIS SUM OF Change in RR 6.17 0.56 7.24 0.78 1.11 0.271
No MMT
(Affected Change in SBP 10.53 1.00 14.3 2.12 1.620 0.111
Leg)
1 10 F 13.73 - Right 3/16 Change in DBP 3.33 0.75 4.00 1.04 0.521 0.605
2 14 M 16.45 Stick Right6/16
3 15 M 14.22 Crutch Right 3/16 Change in RPP 30.04 3.58 40.44 5.15 1.65 0.103
4 16 M 15.15 Stick Left 6/16
5 16 M 15.35 - Right 4/16 Change in RPE 3.97 0.39 5.20 0.48 1.98 0.052
6 16 M 14.4 Stick Right 0/16
7 17 M 15.14 - Right 3/16 *P < 0.05
8 17 M 17.74 Stick Right 2/16
9 18 M 18.01 KAFO Right 5/16 Change in RPP and change in PR however was positively
10 18 F 20.7 - Left 7/16 correlated with change in RPE (p= 0.003), (p =0.006) resp. Only
11 22 M 18.75 - Left 10/16 in the study group (table 5a, 5b).
12 26 M 22.22 Stick Left 3/16 In the present study there was no statistically significant
13 26 F 22.22 - Left 3/16 relation seen between the sum of paralytic limb muscle strength
14 28 F 20.93 - Left 2/16 to distance walked and / or with RPE (table 6 & 7).
15 29 M 21.33 - Right 1/16 With regards to RPE, as shown in table 3c, the significant
16 30 M 21.33 - Left 3/16 difference in resting RPE and post test RPE was seen between
17 31 M 22.14 - Right 8/16 study and control groups (p<0.05). However change in RPE
18 32 M 23.43 - Right 1/16 between the two group was not statically significant (p=0.052).
19 33 M 20 - Left 5/16 Change in RPP and the change in RPE level was negatively
20 33 M 21.63 - Left 0/16 correlated (p= 0.028), (p= 0.014) resp. with 12 minute walk
21 34 M 19.45 - Left 3/16 distance (12MWD) in PPRP participants as seen in Table 4a,
22 36 M 22.5 - Left 2/16 4b.
23 39 M 25.39 - Right 5/16 Change in RPP and change in PR however was positively
24 40 M 23.87 - Left 1/16 correlated with change in RPE (p= 0.003), (p =0.006) resp. Only
25 41 M 25.71 - Right 6/16 in the study group (table 5a, 5b).
26 42 M 20.76 - Right 0/16 In the present study there was no statistically significant
27 42 M 20.82 - Right 5/16 relation seen between the sum of paralytic limb muscle strength
28 49 M 24 Stick Left 1/16 to distance walked and / or with RPE (table 6 & 7).
29 50 M 18.67 - Left 8/16
30 56 M 21.28 - Left 4/16

Ashish V Gupta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 55
Table 3b:
Duration Normal PPRP Total Pearson Chi-Square P value

Recovery < 5min 25(83.3%) 23(76.7%) 48(80%)

time (PR) 0.417 0.519
> 5min 5(16.7%) 7(23.3%) 12(20%)

Table 3c: Comparison of RPE between two groups

MeanRPE Normal PPRP t-value P value

Resting RPE 60 6.83 0.23 3.54 0.001*

Post test RPE 9.96 0.39 12.03 0.53 3.10 0.003*

Change in RPE 3.97 0.39 5.20 0.48 1.98 0.052

Table 4a: Correlation of various change in parameters with 12 minute walk distance

Participants Change in RPP Distance (MeanSE) Correlation value P value

(MeanSE)

Normal 30.04 + 3.58 1043 + 16.07 0.386 0.035*

PPRP 40.44 + 5.15 685 + 31.92 -0.402 0.028*

*P < 0.05
Table 4b:

Participants Change in RPP Distance (MeanSE) Correlation value P value

(MeanSE)

Normal 3.97 + 0.39 1043 + 16.07 0.212 0.260

PPRP 5.20 + 0.48 685 + 31.92 -0.445 0.014*

*P < 0.05
Table 5a: Correlation of various change in parameters with change in RPE level

Participants Change in RPP Distance (MeanSE) Correlation value P value

(MeanSE)

Normal 17.44 + 2.31 3.97 0.39 0.129 0.496

PPRP 21.4 + 2.60 5.20 0.48 0.489 0.006*

*P < 0.05
Table 5b:

Participants Change in RPP Distance (MeanSE) Correlation value P value

(MeanSE)

Normal 30.04 + 3.58 3.97 0.39 0.036 0.851

PPRP 40.44 + 5.15 5.20 0.48 0.522 0.003*

*P < 0.05
Table 6: Correlation of Sum of paretic limb muscle strength with 12 minute walk distance
Participants Sum of paretic Distance (MeanSE) Correlation value P value
limb muscle

PPRP 3.66 + 0.47 685 + 31.92 -0.024 0.9

Table 7: Correlatio of sum of paretic limb muscle strength with change in RPE level

Participants Sum of paretic Distance (MeanSE) Correlation value P value

limb muscle

PPRP 3.66 + 0.47 5.20 0.48 0.086 0.650

56 Ashish V Gupta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Discussion
The PPRP participants covered 34.27% less distance than
control group. According to Dean & Ross9 the performance in
submaximal exercise test depends on two factors: 1) movement
economy, 2) cardiorespiratoty fitness. These both factors reflect
different physiological entities in physically disabled group;
excessive oxygen cost at submaximal work rates is a hallmark
of reduced movement economy. While for cardiorespiratory
fitness a suboptimal relationship between HR and VO2 during
exercise is required. An excessive HR for a given VO2 is a
hallmark of cardiorespiratory deconditioning.
In present study the cardiorespiratory fitness was assessed
during 12MWT, although post test hemodynamic variables such
as change in PR RR, RPP and recovery time for PR were higher
in PPRP participants, statistically no significant change was
found suggesting that cardiorespiratory response to 12MWT was
similar in both the groups. However, it is noteworthy that the
cardiorespiratory responses were similar in both groups despite
a drastic difference between the distances walked. Also review
of literature suggest that on submaximal level the polio
participants show cardiorespiratory changes mainly in
association with reduce muscle capacity, which is most likely a
factor that predisposes polio participants to premature fatigue
in sustained activity3,10 thus it is assumed that the higher values
of hemodynamic variables after 12MWT seen in PPRP group
may have resulted due to reduced muscle capacity/movement
economy.
With regards to RPE, PPRP participants had more RPE
after 12MWT (P=0.003), also the change in RPE was negatively
correlated with distance walked in 12MWT (p=0.014). There was
no such correlation seen in control group suggesting that high
RPE level in study group can be a cause of limited distance
covered in 12MWT. Again, it has been reported that impaired
cardiorespiratory function and impaired movement economy
highly influences the RPE11, because of its heterogeneous origin,
subjective in nature and influenced by psychological factors,
none of these factors have been formally tested in controlled
trials but possible argument for increasing RPE are stated to
be probably due to limited number of motor neurons, change in
fiber type of polio with increasing in type1cross sectional area
with low capillary density12 and decrease in oxidative and
glycolytic enzyme13, low anaerobic threshold14, increasing energy
cost of walking because of neuromuscular and musculoskeletal
impairment4. Since the study group did not show significant
difference in cardiorespiratory parameters, increase in RPE level
cannot be attributed to poor cardiorespiratory fitness.
The present study is in agreement with the March of dimes
birth defect foundation15 that RPE could be used as valid tool of
self measure by the polio population to limit/pace the activities
of daily living, as change in RPE was seen to be correlated
with change in PR & RPP in PPRP group.
The distance walked by the PPRP participants was 34.27%
less compared to control group, the similar result were found in
number of studies 2, 16 who used 6MWT, they found that
neuromuscular and musculoskeletal impairment in people with
chronic poliomyelitis is a primary cause of limitation to the
distance walk in 6MWT as they got no relation between the
physiological measure and 6 minute walk test distance. The
present study didnt find any association between sum of paretic
limb muscle strength and distance covered. A number of studies
tried to find out relation between walking speed and muscle
strength and have found significant correlation10,17. The present
study however have studied walking capacity at comfortable
speed only.
In the PPRP group all participants could successfully
complete the 12MWT, except 4 individuals who completed the
Ashish V Gupta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
test with few minutes of rest in between. These individuals also
traversed less distance with high RPE score, this was seen
despite the sum of paretic limb muscle strength similar to others
in the group. The cause may be difficult to establish as number
of factors viz BMI, severe deformities, sedentary life or
progression toward PPS could have influenced the above results,
future studies are necessary to establish association.
Conclusion
Walking capacity was significantly compromised in polio
participants while cardiorespiratory response to 12 minute walk
test was almost same in both the groups, except RPE which
was found to be significantly high in polio subjects.
References
1. Nollet F et al. Disability and functional assessment in former
patients with and without post polio syndrome. Arch Phys
Med Rehabil.1999; 80:136-43.
2. Sif Gylfadottir et al.The relation between walking capacity
and clinical correlates in survivors of chronic spinal
poliomyelitis. Arch Phys Med Rehabil.2006; 87:944-52.
3. Nollet F et al. Submaximal exercise capacity and maximal
power output in polio subjects. Arch Phys Med
Rehabil.2001; 82:1678-85.
4. Merel-Anne Brehm et al. Energy demands of walking in
persons with post-poliomyelitis syndrome: Relationship with
Muscle Strength and Reproducibility. Arch Phys Med
Rehabil.2006; 87:136-40.
5. Punarbhava- National interactive portal on disability. census
data on disability. http://www.punarbhava.in/index.php?
option=com_content&task=view&id=229&Itemid=537.
6. McGavin CR et al. Dyspnoea, disability and distance
walked: A comparison of estimates of exercise performance
in respiratory disease. Br Med J. 1978; 2: 241-43.
7. Borg GV, Psycho physical basis of perceived exertion. Med
Sci Sports Exer,1982;14: 377-81.
8. Richard R, Nelson et al. Hemodynamic predictors of
myocardial O2 consumption during static and dynamic
exercise. Circulation. 1974; 50: 1179-89.
9. Dean E & J Ross. Movement energetic of individual with a
history of poliomyelitis. Arch Phys Med Rehabil, 1993; 74:
478-83.
10. Davies CT et al. Effect of training on physiological
responses to one and two leg work. J Appl Physiol. 1957;
38: 377-85.
11. McGavin et al. A higher PRE has been to be related to
shorter 12 minute distance. Br Med J. 1976; 822-23.
12. Borg K, Borg J. Motorneurone firing and isomyosin type of
muscle fibers in prior polio. J Neurol Neurosurg Psychiatry.
1989; 52: 1141-48.
13. Borg k et al. Prior poliomyelitis- reduce capillary supply and
metabolic enzyme content in hypertrophic slow twitch muscle
fibers. J Neurol Neurosurg Psychiatry. 1991;54:236-40.
14. Willen C et al. Physical performance in individual with late
effect of polio. Scand J Rehabil Med.1999; 31: 244-49.
15. March of Dimes International Conference on post polio
syndrome.2000 may19-20.
16. Vanessa K, Noonan et al. The relationship between self
reported and objective measures of disability in patients
with late sequelae of poliomyelitis: a validation study. Arch
Phys Med Rehabil. 2000;81: 422- 27.
17. Carin Willen et al. How is walking speed related to muscle
strength? A study of healthy person and person with late
effects of polio. Arch Phys Med Rehabil. 2004; 85: 1923-28.
57
Comparing the Effectiveness of Positional Release Therapy
Technique & Passive Stretching on Hamstring Muscle Through
Sit to Reach Test in Normal Female Subjects
Manivannan M Kaandeepan*, E S Cheraladhan*, M Premkumar*, Shikha K Shah
*Assisstant Professor, KJ Pandya College of Physiotherapy, Sumandeep Vidyapeetth , Pipariya, Waghodia Taluk, Vadodara- Gujarat
391760, India
Abstract
Aim
To find out the effectiveness of Positional Release Therapy
and Passive Stretching Techniques on lumbar flexion muscle
range of motion flexibility outcome measurement in normal
female subjects.
Methods
A total of 40 asymptomatic subjects among student
community within 18 to 25 years of age were selected from
vadodara city and from the department of physiotherapy,
Sumandeep Vidyapeeth University, sampling method through
convenient sampling. The subjects were randomly divided in
two groups i.e. Group-1 given positional release therapy
technique and Group-2 given passive stretching technique on
hamstrings muscle respectively. Active lumbar flexion range was
measured by Sit to Reach Test before and after the intervention.
The data were collected and analyzed by Paired and unpairedt
test method.
Results
Thet showed a significant (p=0.000) post test
measurement values for both the groups.
Conclusion
When comparing the results of both group post values, it
shows p-value [0.933]. No statistically significant differences
were found in between two groups post test values in bringing
lumbar flexion movement flexibility more beneficial. Both
techniques are equally effective in bringing lumbar flexion range
of motion flexibility.
Key Words
Flexibility, Stretching, Positional Release Therapy, Sit to
reach test.
Introduction
Flexibility is the ability to move a single joint or series of
joints smoothly and easily through an unrestricted, pain-free
range of motion. Flexibility is related to the extensibility of
musculo-tendinous units that cross a joint based on their ability
to relax or deform and yield to a stretch force. 1 It is important
both inflexibility and hyper-flexibility can result in higher risks of
injury. In addition, an imbalance in flexibility could predispose
the individual to an increased risk of injury. 2 Mobility is
maintained in most individuals by routine, daily use of their limbs
and joints in normal daily activities. However, adaptive shortening
can occur in those who spend long periods in single posture
[e.g. sitting most of the day] and mobility can be lost. Normal
mobility includes adequate joint range of motion and muscle
58 Manivannan M Kaandeepan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
range of motion. Progressive adaptive shortening of the soft
tissue occurs as the body responds to decreased loading. This
shortening limits mobility and function, reducing the patients
ability to carry out normal activities of daily living, work or leisure
activities. The patient accommodates these limitations by
substituting other joints or limbs to achieve functional goals, there
by contributing to the disuse.3 Forward bending is a coupled
movement combining lumbar flexion and pelvic rotation, the so-
called lumbarpelvic rhythm. It results from coordinated activity
between the back extensor muscles (erector spinae) and the
hip extensor muscles (gluteus and hamstrings).4 The hamstrings
are example of muscle groups that have a tendency to shorten5.
Stiffness in the hamstrings is often compensated by lumbar spine
motion, placing more load on the spine. Lengthening the
hamstrings minimizes the stress placed on the spine and is the
basis for hamstring stretching, an approach used by some
persons to remedy back pain.3 Muscle tightness can be present
without a joint contracture. Multi joint muscles are particularly
vulnerable to developing tightness, especially in those individuals
who do not regularly perform stretching exercises. 6 During
forward bending, stiff hamstrings can restrict pelvic forward
rotation, resulting in flexion stress on the lumbar spine.7 When
limitation of joint motion is because of soft tissue shortening,
stretching have been found to be effective6 and Positional
Release Therapy is also a highly effective technique that helps
reduce pain and restore function to muscles, bones, and joints8.
Numerous researchers have compared various stretching
techniques to determine which technique is most effective for
increasing joint range of motion (ROM). Static stretching is a
commonly used method of stretching in which soft tissue are
elongated just past the point of tissue resistance and then held
in the lengthened position with a sustained stretch force over a
period of time. Static stretching is an effective form of stretching
to increase flexibility and a safer form.9 Positional release therapy
is method of total body evaluation and treatment using tender
points and a position of comfort (POC) to resolve the associated
dysfunction. Positional Release Therapy is an indirect (the body
part moves away from the resistance barrier, i.e. the direction of
greatest ease) and passive (the therapist performs all the
movements without help from the patient) method of treatment.
As a result of treatment using PRT, there is a decrease in muscle
tension, facial tension, and joint hypo-mobility. These changes
in turn result in a significant increase in functional range of motion
and decrease in pain. [10] It is a hands-on treatment that alleviates
muscle and connective tissue tightness by the use of very
specific treatment positions held for 90-120 seconds. [8] Many
authors have studied different approaches of muscle stretching
and the duration of application of such procedures but no studies
were there in comparing the significant effect in relation to our
topic.
Methodology
A total of 40 young female subjects among student
community within 18 to 25 years of age were selected. This
study was comparative study using convenient sampling.
Orthopedics problem around hip, knee and spine, subjects with
hamstring strain or contusion, Obesity, any congenital conditions
or diseases in lower extremity are excluded. Subjects were
volunteers and signed an approved informed consent statement.
Two groups were divided each into 20 and Group-1: were given
positional release therapy technique, Group-2: were given
passive stretching. First to check hamstring flexibility, the subjects
did Sit to Reach Test and measurement were taken. Second,
for group-1, positional release therapy technique was given in
hamstring muscles and for group-2 passive stretching given.
Again subjects did sit to reach test and measurement are
recorded. Sit to reach test procedure is a test involves sitting on
the floor with legs stretched out straight ahead. Shoes should
be removed. The soles of the feet are placed flat against the
box. Both knees should be locked and pressed flat to the floor -
the tester may assist by holding them down. With the palms
facing downwards, and the hands on top of each other or side
by side, the subject reaches forward along the measuring line
as far as possible. Ensure that the hands remain at the same
level, not one reaching further forward than the other. After some
practice reaches, the subject reaches out and holds that position
for at one-two seconds while the distance is recorded.11 In
Positional release technique procedure, the subject lies supine
with thigh extended and abducted off the edge of the plinth
slightly, and then the knee was flexed passively to 40 degrees
and adds slight adduction (varus force) and marked internal
Table 1: Comparison of pre and post values for group-1 using paired t-test
rotation of the tibia. These positions were held for exactly 90
second and measured using a standard watch time and then
limb were returned to the resting position. 12 In Passive stretching
procedure, therapist kneels on plinth. With the subjects knee
fully extended, supporting the subjects lower leg on therapist
arm or shoulder. Stabilize the opposite extremity along the
anterior aspect of the thigh with one hand. With the knee at
zero degree extension, and the hip in neutral rotation, flex the
hip as far as possible. These positions were held for exactly 60
seconds and were measured using a standard watch time and
then limb was returned to the resting position. 13, 15
Data Analysis
Descriptive statistics including numbers, proportions, mean
and standard deviations were used to present data. Student t-
test (paired and unpaired) were used to compare data within
group and in-between the two groups. A probability level of
p<0.05 will be accepted as statistically significant. SPSS version
16 will be used to analyze the data.

BEFORE Positional Release AFTER Positional Release t-value

Technique Technique

MEAN Standrad Standrad MEAN Standrad Standrad -10.384

Deviation Error Deviation Error

24.1000 7.50018 1.67709 27.5500 7.13387 1.59518

Table 2: Comparison of pre and post values for group-2 using paired t-test

BEFORE Positional Release AFTER Positional Release t-value

Technique Technique

MEAN Standrad Standrad MEAN Standrad Standrad -6.909

Deviation Error Deviation Error

23.6500 9.50083 2.12445 27.7750 9.56622 2.13907

Table 3: Comparison of both group-1 and group-2 post test values using unpaired t-test

AFTER Positional Release AFTER PASSIVE t-value Sig 2(tailed)

Technique STRECTHING

MEAN Standard Standard MEAN Standard Standard -.084 .933

Deviation Error Deviation Error

24.1000 7.50018 1.67709 27.7750 9.56622 2.13907

Results Group 1: Pre-test and Post-test values for Positional Release

Technique in hamstrings muscle in Group-1
The data were collected and analyzed with Paired t-test
and unpaired t-test methods. In group-1the results shows that
there were statistically difference in bringing hamstring flexibility
(p=0.000). In group-2 the results.

Findings
Flexibility is an important physiological component of
physical fitness, and reduced flexibility can cause inefficiency in
the workplace and is also a risk factor for low back pain.
Increasing hamstring flexibility was reported to be an effective
method for increasing hamstring muscle performance on
selective isokinetic conditions(Worrell et al, 1994).[14]
In our study, Subjects were not involved in any exercise
activity at the start of the study and agreed to avoid lower-
extremity exercises and activities other than those advised.

Manivannan M Kaandeepan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 59
Group 2: Pre-test and Post-test values for Static Stretching
Technique in hamstrings muscle in Group-2
Muscle tightness is one of the limiting factors for restricted range
of motion and reduced flexibility of joint. Especially hamstring
muscles are more prone for tightness in sedentary life because
of prolonged sitting posture and cause reduction in flexibility of
lumbar movement in future days. The technique of relieving
hamstring tightness used in this study was to passively and
statically stretch the hamstring muscles. The outcome of this
study revealed that both applications of static stretching as well
as positional release technique procedures resulted in significant
improvement in hamstrings muscle flexibility in the intervention
groups. We selected this topic because many studies showed
regarding static stretching beneficial effects and only few studies
are there regarding positional release therapy. Both the
techniques are easier for application. But when comparing the
time and application methodology, static stretching was best
then positional release therapy. Static stretching can be applied
instantly but positional release therapy needed couch and more
time because of positioning. Other side when viewing positional
release therapy we can apply this technique to old age patients
because the application method was easier, smooth manner
and not forceful. The implication of this finding was that
individuals with hamstrings tightness would benefit the same
effect. The similarities between the post values of both group
studies could be a result of the difference in the frequency and
the duration for which the static stretching and positional release
therapy were carried out, the procedure were carried out once
in each subjects in our study and not continued for next day or
weeks by several authors who did the same techniques on
hamstring muscle. Our study was limited to the effects of
stretching the hamstring muscles on lumbar flexion range of
motion. Although 60-second, three times, single time bout of
static stretching the hamstring muscles was found to be as
effective, similarly positional release therapy was found to be
as effective, studies are needed to evaluate the effects of various
durations and of frequencies in stretching the hamstring muscle
and on other muscles like back extensor muscles etc., We only
examined static stretching of up to 60 seconds in duration and
the positional release technique given for 90 seconds .Additional
research is needed to evaluate whether durations of seconds
or frequency of applications for few days will provide more
flexibility. Because, the sample we taken for this study was
relatively young, with a mean age of 26 years. Future research
is needed on subjects in different age groups, sports injuries
related conditions, OA knee patients, back pain patients etc.,
Conclusion
There were no difference in effects between static stretching
and positional release therapy with post test values. Both the
techniques are equally effective in bringing lumbar flexion range
60 Manivannan M Kaandeepan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Group 3: Post-test values of Positional Release Technique
Group-1 and Static Stretching technique Group-2 in hamstrings
muscle.
of motion flexibility. The results from this study will be helpful for
individuals who desire to increase the flexibility in an attempt to
increase lumbar flexion motion.
Acknowledgement
The authors are thankful to Sumandeep Vidyapeeth
University, Vadodara, K J Pandya College of physiotherapy
Department, for providing facility to do this research work. The
authors are very thankful for the subjects who participated in
this study for completing this research work in limited time.
References
1. Carolyn kisner, Lynn Allen Colby., Therapeutic Exercise 5th
Edition. Stretching for impaired mobility.
Page no:66, chapter-4.
2. Lan jeffregs, Essentials of strength Training and
conditioning. Warm up and stretching. Page no: 297,
chapter-13.
3. Lan jeffregs, Essentials of strength Training and
conditioning. Warm up and stretching. Page no: 114,
chapter-7.
4. C.M. Norris, M. Matthews Correlation Between Hamstring
Muscle Length And Pelvic Tilt Range During Forward
Bending In Healthy Individuals: An Initial Evaluation.
Journal of Bodywork and Movement Therapies (2006) 10,
122126. Page-2.
5. Turner D, Gossman R. M., Nicholosn C.G, Comparison Of
Cyclic And Sustained Passive Stretching Phys Ther69
(3):314-320.
6. Frances E. Huber, Chris L. wells. Therapeutic Exercise.
Treatment planning for progression. Page-73, chapter-3.
7. Carrie M.Hall, Lori Thein Brody. Therapeutic Exercise.
Moving Towards Function 2nd edition. Page-363, chapter-
18.
8. BarryKrost, Positional Release Is Effective Therapy.
Article:Http://Ezinearticles.Com/Expert=Barry_ Krost.
9. Carolyn kisner, Lynn Allen Colby., Therapeutic Exercise 5th
Edition. Stretching for impaired mobility.
Page no:79, chapter-4.
10. Prasant N.P; Comparison Of Muscle Energy Technique
And Positional Release Technique In Acute Low Back Pain-
RCT Indian Journal Of Physiotherapy And Occupational
Therapy Year:2010,Volume:4,Issue:2.
11. Brain Mackenzie - Book author 101 Performance
Evaluation tests.
12. Trevor B. Birmingham, Julie Kramer, jim Lumsden, Kathy
D. Obright, john F.Kramer. Effect of a positional release
therapy technique on hamstring flexibility. Canada
 physiotherapy, volume 56, number 3, page no ; 168.
13. Carolyn kisner, Lynn Allen Colby., Therapeutic Exercise 5th
Edition. Stretching for impaired mobility.
Page no:99, chapter-4.
14. Worrell, T. W., Smith, T. L. and Winegardner, J. W. (1994).
Effect of hamstring stretching on hamstring muscle
performance. J. Orthop. Sports Phys. Ther. 20: 154-159.
15. William D Bandy, Jean M Irion, and Michelle Briggler, The
Effect of Time and Frequency of Static Stretching on
Flexibility of the Hamstring Muscles Physical Therapy
October 1997 77:1090-1096.

Manivannan M Kaandeepan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 61
Comparative Study between Efficacy of PNF Movement Patterns
Versus Conventional Free Exercises on Functional Activities
Among Patients with Chronic Peri-Arthritis of Shoulder
Manobhiram Nellutla*, Pramod Giri**
*Lecturer, Physiotherapy Department Kigali Health Institute, Faculty of Allied Health Sciences, P.O. Box 3286, Kigali, Rwanda,
**Former Principal and Guide, Laxmi Memorial College of Physiotherapy, AJ Towers, Balmatta, Mangalore, Karnataka, India
Abstract
Objective
To investigate the efficacy of Proprioceptive Neuromuscular
Facilitation (PNF) movement patterns in improving functional
independence in patients with Chronic Peri-Arthritis (PA) of the
shoulder.
Subjects
40 Patients diagnosed with PA of the shoulder were
randomly and equally allocated (n=20) into a control (receiving
conventional free exercises) and an experimental group
(receiving PNF movement patterns).
Methods
Assessment was done to check functional independence
both prior to and after the treatment programme. Descriptive
statistics were used to enumerate the positive responses for
each question on functional activities on the Simple Shoulder
Test (SST) for each patient. Neers Criteria was used to classify
the patients into different groups based on their Constants
Shoulder Functional Score (CSFS).
Results
There was improvement in the functional independence of
participants in both groups based on t test results for both within
the group and between groups. Though there was no significant
change in both the groups post treatment scores, there were
more participants from the experimental group who showed
change in both Neers criteria of CSFS and Yes responses to
SST.
Conclusion
PNF movement patterns when included in the routine
treatment of chronic PA of the shoulder may be as efficacious in
increasing the function of the involved shoulder when compared
with the treatment by conventional free exercises.
Key Words
Peri-Arthritis Shoulder, Functional Activities, Proprioceptive
Neuromuscular Facilitation (PNF), Conventional Free Exercises,
Simple Shoulder Test, Constant Shoulder Functional Score.
Address for correspondence:
Manobhiram Nellutla
P.O. Box 5532
Kigali. Rwanda
Mobile: +250788733663
manu@khi.ac.rw
62 Manobhiram Nellutla / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Introduction
Grubbs defined frozen shoulder as a soft tissue capsular
lesion accompanied by painful and restricted active and passive
motion at the glenohumeral joint1. Neviaser2 in 1946 surgically
explored Peri-Arthritis (PA) shoulder cases, finding an absence
of the glenohumeral synovial fluid, a redundant axillary fold of
the capsule, as well as thickening and contraction of the capsule,
which had become adherent to the humeral head, hence he
used the term Adhesive Capsulitis.
Cyriax3 clarified that arthritis exhibits limitation of passive
motion in characteristic proportions, which he called the capsular
pattern. The capsular pattern of PA of the shoulder is most limited
in external rotation, followed by abduction, and by internal
rotation. Abduction is limited by the loss of the inferior redundant
fold and limited external rotation.
Periarthritis of the shoulder has three classical stages4.The
first stage is the freezing phase, characterized by the onset of
an aching pain in the shoulder. The second stage is the
progressive stiffness or frozen phase. Pain at rest usually
diminishes during this stage, leaving the patient with a shoulder
that has restricted motion in all planes. The final stage is the
resolution or thawing phase. This stage is characterized by a
slow recovery of motion. The duration of the condition is variable
and dependent on multiple factors, such as age, underlined
medical conditions like diabetes mellitus, and on timing of
intervention before resolution.
PA shoulder most commonly occurs in patients above 40
years of age, with a higher incidence in females. The idiopathic
form in uncommon. It is estimated that in a one-year incidence
in patients in general, it ranges from 2:1,000 to 2:100. The
prevalence in the elderly population has been shown to be less
than 1/100. The secondary form may be more common. The
most significant association is with insulin-dependent diabetes.
Bilateral disease occurs in approximately 10% of patients, but
can be as high as 40% in patients with a history of insulin-
dependent diabetes4.
Although there is little agreement on PA shoulders
treatment when it occurs, there is agreement on the treatment
goals; pain relief and restoration of normal shoulder movement.
The normal procedures of treatment for chronic PA of the
shoulder include giving emphasis on increasing Range of Motion
(ROM) of the shoulder5. Most of the treatment modalities to
achieve this include mobilizations, active exercises and reducing
the inflammatory process through the use of ultrasound.
Proprioceptive Neuromuscular Facilitation (PNF) helps in
activating the agonist muscles and at the same time stretching
the antagonist muscles so that they activate a stronger
contraction and hence stronger movement6. PNF facilitates
mass movement patterns against resistance in a spiral or
diagonal motion during flexion and extension. This technique is
thought to alter the responses of muscle spindles to increase
the maximum range of motion, although it may also do so by
stimulating an increase in the force produced by each muscle7.
It also stretches the capsule while the movement is done in a
diagonal pattern thereby increasing joint ROM 6,8. Simliar spiral
and diagonal movement patterns are later used for functional
activities and walking9. Joshi and Kotwal5 advocated graduated
relaxed sustained stretching based on PNF principles, which
may increase the ROM of the shoulder joint and hence functional
independence.
The purpose of this study was therefore to determine the
efficacy of PNF movement patterns in improving function among
patients with chronic Peri-Arthritis of the shoulder.
referred by an orthopaedic surgeon. Only patients who had mild
or no pain on the constant shoulder functional score (CSFS) i.e.
score of 10 or 15 were included in the study, (pain is not a clinical
feature of chronic PA and only patients with chronic stage of PA
were selected).

Methods
The study was conducted in the physiotherapy clinic of the
Laxmi Memorial College of Physiotherapy, the outpatient
physiotherapy department of the A.J. Hospital and Research
Center as well as the outpatient physiotherapy department of
the Government Wenlock District Hospital. All three research
sites are located in Mangalore, India.
Participants
Study participants were selected from patients who were
treated between January 2003 and December 2003. Both men
and women aged between 40 and 70 years were selected.
Double Blinded Random sampling was used to select patients
diagnosed with chronic frozen shoulder with restricted joint ROM
and limitations in activities of daily living (ADL). Patients were
Table 1: Simple Shoulder Test
Twelve questions of the SST are:
Instrumentation
1. An assessment chart was used to record the patients
history, subjective and objective physical examination,
differential diagnosis, and treatment plan and outcome
measures.
2. An x-ray of the involved shoulder was taken and analyzed
to rule out some of the exclusion criteria e.g. biceps tendon
rupture.
3. The Simple Shoulder Test (SST)10 was executed. Because
of the critical importance of systematic documentation of
shoulder function, a series of 12 questions were asked of
patients about the function of the involved shoulder. YES
or NO responses to these questions provided a
standardized way of recording the function of a shoulder
before and after treatment.(Table I)
4. Constant Shoulder Functional Score11. This scale consists

1) Is your shoulder comfortable with your arm at rest by your side?

2) Does your shoulder allow you to sleep comfortably?
3) Can you reach the small of your back to tuck in your shirt with your hand?
4) Can you place your hand behind your head with the elbow straight out to the side?
5) Can you place a coin on a shelf at the level of your shoulder without bending your elbow?
6) Can you lift one pound ( a full pint container) to the level of your shoulder without bending your elbow?
7) Can you lift eight pounds ( a full gallon container) to the level of the top of your head without bending your elbow?
8) Can you carry 20 pounds at your side with the effected extremity?
9) Do you think you can toss a softball underhand 10 yards with the affected extremity?
10) Do you think you can throw a softball overhand 20 yards with the affected extremity?
11) Can you wash the back of your opposite shoulder with the affected extremity?
12) Would your shoulder allow you to work full-time at your usual job?

of pain, ADL, ROM, and Shoulder Power. Each item has a
respective score, adding to a total of 100 points for the
scale. (Table II)
Pain score (15 points) measured subjectively. Severe Pain
(0 points), moderate pain (5 points), mild pain (10 points)
or no pain (15 points)
Activities of Daily Living. The patient is asked what activities
they can do and each is scored to total 20 points. Some of
the activities included are ability to perform full work with
the involved shoulder (4 Points), full recreation or sports (4
points) whether sleep is unaffected (2 points) and questions
regarding the quantity of hand movement - up to waist (2
points), up to xiphoid process (4 points), up to the top of
the head (8points), or above the head (10 points).
Range of Motion in the CSFS is calculated after the
goniometric readings by using an Universal Goniometer12.
A total of 40 points is assigned to ROM abduction, flexion,
external rotation and internal rotation, each movement
having 10 points. Points for abduction and flexion are given
such that 180 = one point, for external rotation 90 = one
point; for internal rotation 80 = 1 point. These points were
given according to the normal ROM occurring at the
shoulder for each movement divided by 10 points. In this
way the ROM points are calculated for each movement
based on the amount of movement the patient makes.
The CSFS has 25 points for shoulder power. This was
calculated by asking the patient to lift a 4lb dumbbell for 10
repetitions. For each lift the patient was awarded 2.5 points.
Procedure
Ethical clearance was obtained from the Ethical Committee
of the Laxmi Memorial College of Physiotherapy. Permission
was sought and granted by the health facilities used as study
sites. Written informed consent was obtained from participants.
The patients were then randomly allocated into two groups, one
control group and one experimental group.
The number of YES or NO responses for the 12
questions in the SST and the total number of points obtained on
the CSFS were recorded and noted on Neers Criteria for all the
patients on the first day (at recruitment) and after three weeks
of treatment.
Treatment Intervention
Participants in both groups received the following treatment
procedures:
1. Ultrasound: A dosage of 0.8 watts/square cm, with a pulse
ratio of 1:2 for 8 minutes was administered for each session
that is 6days a week for 3 weeks.
2. Maitland Mobilizations: Grade 3 for a) the Glenohumeral
joint caudal glide (to improve abduction), posterior glide
(to improve flexion and internal rotation), anterior glide (to
improve external rotation) were given. For the
Acromioclavicular joint anterior glide (to increase joint
mobility) was given.b) the sternoclavicular joint - posterior
glide to (increase retraction), anterior glide (to increase
protraction), inferior glide (to increase elevation) and

Manobhiram Nellutla / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 63
 superior glide (to increase depression) were given. c) rotate the wheel both anteriorly and posteriorly whilst standing
though the scapula-thoracic articulation is not a true joint, sideways with the shoulder level with the axis of the wheel. Ten
the scapula was lifted and moved in the desired direction repetitions were performed for each movement. They were
to obtain normal shoulder girdle mobility13. Regular cautioned not to exert as this could cause further pain or
oscillations at 2 or 3 per second for 1-2 minutes were given discomfort.
followed by rest. 5 repetitions were performed in each Abduction and flexion on the finger ladder were the next
session. exercises. These were done with the patient standing sideways
facing the ladder. Each movement was repeated 10 times.
Table 2: Constant Shoulder Functional Score Finally, home exercises were taught to the patient which
Item Score included simple Codmans exercises with an iron box in hand
and finger wall exercises and all the active movements around
PAIN 15 the shoulder joint. They were told to repeat each movement 10
None 15 times. They were advised to perform these home exercises twice
Mild 10 daily once in the early morning before coming for the treatment
Moderate 5 and once in the evening as this would aid recovery.
Severe 0
Treatment for Participants in the Experimental
ACTIVITIES OF DAILY LIVING 20 Group
Full Work 20
Full recreation/Sports 4 In addition to ultra sound therapy and mobilization, the
Unaffected Sleep 4 experimental group also received PNF6 movement patterns as
Hand Position exercise as follows: The patients were first made to lie down on
Up to waist 2 the bed in supine and taken into D1 and D2 patterns for the
Up to xiphoid 4 upper limb by the therapist. This was done so that the patient
Up to top of head 8 could understand the amount of stretch required at the end range
Above head 10 and the components of the whole exercise movement.
o Shoulder Flexion, Abduction and External Rotation that
RANGE OF MOTION 40 was started at Shoulder Extension, Adduction and Internal
Abduction 10 Rotation.
Forward Elevation 10 o Shoulder Flexion, Adduction and External Rotation that
Internal Rotation 10 was started at Shoulder Extension, Abduction and Internal
External Rotation 10 Rotation.
This was performed till the patient understood how he
SHOULDER POWER 25 should be performing the patterns within the available range.
Pounds to Resist The patients were made to perform in front of a mirror for
feedback and to demonstrate the movement to the therapist.
TOTAL 100 The patient was advised to perform these patterns 10 repetitions,
thrice daily in each set and 2 sets for each session, and advised
NEERS CRITERIA FOR SHOULDER: not to overstretch or fatigue the muscles.
Excellent = 89-100 Participants in both groups underwent treatment for three
Good = 71-88 weeks.
Poor = 51-69
Data Analysis
Treatment for Participants in the Control
Microsoft Excel was used to enter data. CSFS scores were
Group analyzed by paired t test for within group of both control and
experimental at 1st day and after 3 weeks of treatment. Both
In addition to the ultra sound therapy and mobilization, the
groups post treatment date were analyzed by a unpaired t test.
control group also received conventional free exercises which
Scores from the SST and Neers Criteria of CSFS were analyzed
included finger ladder exercises, Codmans exercises, and
descriptively.
overhead shoulder pulley and shoulder wheel.14,15
Codmans exercises or pendulum exercises were
performed by the patient with gravity assisting, the patient was Results
bent at the waist with the upper extremity dangling, the weight
of the extremity producing joint traction. The patient was given Forty patients (20 in each group) with chronic PA of the
a 4lb dumbbell to hold in the hand for additional traction. Then shoulder participated in the study. The mean age of participants
the patient was advised to move the shoulder forwards and was 56.15 8.71 with 24 male participants and 16 female
backwards, medial to lateral and circular motions made with the participants.
entire extremity. Ten repetitions were performed in each set of
movements. A total of 2 sets for each movement8,13,16 were Results of paired t test for CSFS scores of
performed. Control Group
The patients were then asked to sit under the shoulder
pulley and first had to place the hand sideways and then lift the t= 14.8
arms into abduction by pulling the other side of the rope. This degrees of freedom = 19
helps in stretching and increasing abduction. The patient was
then asked to move the arms and place them forward and pull The probability of this result,
the ropes thus aiding flexion movement at the shoulder joint. assuming the null hypothesis, is 0.00
This was also done for 10 repetitions in all the sets of movements
and with a total of 2 sets for each session.
Patients were taken to the shoulder wheel and were told to

64 Manobhiram Nellutla / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 3: CSFS Scores (out of 100) of Control Group treated
No. of Control Group
with Conventional Free Exercises.
Patients
No. of Control Group 1st Day 3rd Week
Patients
1st Day 3rd Week 1. 65 86

1. 51 79 2. 59 84

2. 48 75 3. 58 90

3. 73 88 4. 62 83

4. 77 89 5. 62 80

5. 67 79 6. 58 86

6. 53 82 7. 62 88

7. 58 75 8. 67 91

8. 53 84 9. 60 80

9. 61 85 10. 71 86

10. 74 87 11. 59 86

11. 69 85 12. 52 87

12. 52 80 13. 64 89

13. 72 91 14. 50 73

14. 60 82 15. 60 82

15. 68 88 16. 65 82

16. 57 82 17. 72 85

17. 60 82 18. 57 89

18. 56 86 19. 54 83

19. 61 92 20. 68 94

20. 69 85 Exercises
Results from Table III show a significant increase in the CSFS Table V shows that prior to treatment none of the patients
scores after 3 weeks of treatment in the Control Group. in either group could be classified as excellent according to
Table 4: CSFS scores (out of 100) of Experimental Group treated Neers criteria of CSFS. After treatment no patients were
with PNF movement Patterns. classified as poor according to Neers criteria. However there
were two more participants classified as excellent after
Results of paired t test for CSFS scores of treatment in the experimental group compared to the control
Experimental Group group.

t= 18.5 The following graph shows the frequencies of Yes

degrees of freedom = 19
The probability of this result, assuming the null
hypothesis, is 0.000
Results from the post treatment scores of CSFS from both
the groups were then analyzed using an unpaired t test and
the results showed that there was no significant difference
between the two groups. Hence stating that both the treatment
methods were significant and that PNF movement patterns when
included in the exercise are as effective as the Conventional
Free
responses Simple Shoulder Test SST) by participants from
both groups regarding shoulder function, prior to and after
treatment.
For all 12 questions there were more participants
responding positively to functional ability of the shoulder on the
SST (Table IV). It was also observed that there were twice as
many patients in the experimental group able to; place their
hand behind the head with the elbow straight out to the side.
Discussion
The improvement in the functional activities of all
movements in both groups may be attributed to the increase in

Manobhiram Nellutla / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 65
Table 5: Neers Criteria of Constant Shoulder Functional Score (CSFS)
Score for Neers Criteria Control Group Experimental Group

1st Day 3rd Week 1st Day 3rd Week

Excellent (89-100) 0 3 0 5

Good (71-88) 4 17 2 15

Poor (51-70) 16 0 18 0

Graph 1: Comparison of YES Responses to Simple Shoulder Test in Both Groups after 3 Weeks

Table 4: Participants Responses to the SST

Question Control Group (n = 20) Experimental Group (n = 20)

No. of Yes responses No. of Yes responses

1st Day After 3 weeks 1st Day After 3 weeks

1. Is your shoulder comfortable 11 18 12 18

with your arm at rest by your side?
2. Does your shoulder allow you to 8 10 7 11
sleep comfortably?
3. Can you reach the small of your 12 14 10 14
back to tuck in your shirt with your
hand?
4. Can you place your hand behind 4 6 4 12
your head with the elbow straight
out to the side?
5. Can you place a coin on a shelf 12 14 12 16
at the level of your shoulder without
bending your elbow?
6. Can you lift one pound (a full pint 7 8 8 12
container) to the level of your
shoulder without bending your elbow?
7. Can you lift eight pounds (a full gallon 5 8 6 10
container) to the level of the top of your
head without bending your elbow?
8. Can you carry 20 pounds at your side 4 8 6 12
with the effected extremity?
9. Do you think you can toss a softball 8 12 10 18
underhand 10 yards with the affected
extremity?
10. Do you think you can throw a softball 2 8 3 14
overhand 20 yards with the affected extremity?
11. Can you wash the back of your opposite 12 16 12 19
shoulder with the affected extremity?
12. Would your shoulder allow you to work 4 10 5 14
full-time at your usual job?

66 Manobhiram Nellutla / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
ROM due to the common treatment given to both the groups -
mobilization and ultrasound therapy. Clinically, ultrasound
therapy is used for its thermal and mechanical effects on tissue.
In PA of the shoulder, it is often used prior to stretching of the
capsule17.
Research also shows that mobilization is most effective in
reversing the changes that occur in connective tissue following
immobilization. Mobilization is designed to restore joint play
motions of roll glide and joint separation. Gentle mobilization
glides help to break down the collagen formed in the capsule,
which is responsible for restriction of joint motion. The glides
when given daily help to increase joint play18.
The control group received conventional free exercises like
overhead pulley, shoulder wheel, finger ladder and Codmans
exercises. These are often the standard exercises in treating
PA of the shoulder. Active exercises allow more patient control
than do mechanical exercises. Active exercises are essential in
maintaining the capsular extensibility obtained through
manipulation. Active exercises help in maintaining joint and soft
tissue integrity, enhance synovial movement for cartilage nutrition
and diffusion of materials in the joint to maintain mechanical
elasticity of muscle19.
Unfortunately, these do not address the loss of joint play.
Murray19 outlines disadvantages of these exercises as there is
no stabilization of the scapula to avoid excessive abduction and
upward rotation, there is no force to depress the humeral head,
and there is a tendency for the patient to extend the spine to
increase glenohumeral motion.
PNF exercises allow more patient control and hence when
the patient does the movement through the pattern he applies a
stretch at the end of the range. This helps to effectively stretch
the rotational ranges as it is this rotation that is present at the
end of range (terminal rotation).
In the experimental group where PNF was given, there was
a significant improvement in the range of motion of external
rotation as reflected in the scores of CSFS. This may be due to
the combinational movements that are present in PNF patterns.
The stretch present at the end of range stretches the antagonist
muscle and activates the agonist muscle. This will in turn activate
the antagonist muscle for a greater contraction and hence
greater movement. The capsule may also get stretched during
these combined patterns and thus allow more movement
observed in the significant increase in the external rotation20.
The overall functional activity of the involved shoulder also
showed improvement in both groups on the SST and CSFS.
However more patients in the experimental group demonstrated
greater improvements. We postulate that the greater
improvement in shoulder function may be attributed to the
improvement of range of external rotation found to be significant
in the experimental group. An analysis of the patterns of
movements that assume great importance in the execution of
ADLs demonstrate the significance of the external rotational
component. The proportion of patients that was able to perform
the hand behind head movement on the SST in the experimental
group was double the number in the control group, thereby
illustrating the significance of external rotation during abduction
of the shoulder in the outer range.
Improvements were also observed in all functional activities
by participants in both groups of patients with PA shoulder. More
patients receiving PNF were classified as excellent according
to Neers criteria on the Constant Shoulder Function Score after
treatment. It is postulated that the improvement in their functional
Manobhiram Nellutla / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
activities was as a direct result of the improvement of the external
rotation range of motion.
This study concludes that PNF may be as efficacious as
conventional free exercises when included in the routine
treatment of Chronic PA of the shoulder, where external rotation
ROM and shoulder function are implicated.
References
1. Hazleman BL. The painful stiff shoulder. Rheumatology
Phys Med 1972; 11:413.
2. Neviaser JS. Adhesive Capsulitis of the shoulder study of
pathological findings in periarthritis of shoulder. J Bone Joint
Surg 1945; 27:211.
3. Cyriax J. Textbook of Orthopaedic Medicine. 7th Edition,
Vol. 1, London: Bailliere Tindall; 1978.
4. Brotzman B, Wilk K. Clinical Orthopaedic Rehabilitation.
2nd Edition, Mosby; 2003, p.227-231.
5. Joshi J, Kotwal P. Essentials of Orthopaedics and Applied
Physiotherapy. Churchill Livingstone; 1999, p.473-477.
6. Knott M, Voss D. Proprioceptive Neuromuscular Facilitation,
Patterns and Techniques. 2nd Edition, Harper and Low;
1968.
7. Lieberman J, Cafarelli E. Physiology of range of motion in
human joints: A critical review. Crit Rev Phys Rehab Med
1994; 6: 131-160.
8. Donatelli A. Physical Therapy of the Shoulder. 3rd Edition,
Churchill Livingstone; 1997.
9. Dobkin HB. Neurologic Rehabilitation, Contemporary
Neurology Series. Vol. 47, F.A.Davis Company; 1996, p. 64.
10. Lippitt SB, Harryman II DT, Matsen III FA: A Practical Tool
for Evaluating Function: The Simple Shoulder Test. In
Matsen III FA, Fu FH, Hawkins RJ (eds). The Shoulder: A
Balance of Mobility and Stability. Rosemont, IL, The
American Academy of Orthopaedic Surgeons; 1993 p.545
559.
11. Hsieh KH, Lee PY, Lee TS, Yang DJ. Functional
Assessment for Shoulder Impingement Syndrome after
Anterior Acromioplasty. Chin Med J (Taipei) 1997; 59:354-8.
12. Norkin C, White J. Measurement of Joint Motion: A Guide
to Goniometry. 2nd Edition, Jaypee; 1995.
13. Kisner C, Colby LA. Therapeutic Exercise, Foundations and
Techniques. 3rd Edition, Jaypee Brothers; 1995.
14. OKane JW, Jackins S, Sidles JA, Smith KL, Matsen FA.
Simple Home Program for Frozen Shoulder to improve
patients assessment of Shoulder Function and Health
Status. J Am Board Fam Pract 1999; 12:270-277.
15. Macnab I. Rotator Cuff tendonitis. Ann R Coll Surg Eng
1973; 53:271.
16. Codman EA. The Shoulder. Krieger, Malabar, FL; 1934.
17. Quin CE. Humeroscapular Periarthritis, Observation on the
effects of X-Ray therapy and ultrasonic therapy in cases of
frozen shoulder. Ann Phys Med 1967; 10:64.
18. Frank C, Akeson WH, Woo SL, Amiel D, Coutts RD.
Physiology and therapeutic value of passive joint motion.
Clin Orthop 1984; 185:113.
19. Murray W. The Chronic Frozen Shoulder. Physical Therapy
1960; Rev 40:866.
20. Mao CY, Jaw WC, Cheng HC. Frozen Shoulder: Correlation
between the response to physical therapy and follow up
shoulder arthrography. Arch Phys Med Rehabil 1997;
78:857-59.
67
Intervention Based on Dynamics of Postural Control in Children
with Cerebral Palsy- An integral approach
Meenakshi Batra1, Vijai Prakash Sharma2, Gyanendra Kumar Malik3, Vijay Batra4, Girdhar Gopal Agarwal5
1
PhD Scholar, 2Director Professor & Head, Department of PMR, RALC, 3Director Professor & Head Department of Paediatrics,
4
Senior Research Fellow, Chhatrapati Shahuji Maharaj Medical University, Department of Physical Medicine and Rehabilitation,
Rehabilitation and Artificial Limb Centre (RALC), Nabiullah Road, Near Daliganj Bridge, Lucknow- 226018, Uttar Pradesh, India,
5
Department of Statistics, Lucknow university, Lucknow-226007
Abstract
Objective
To see the effectiveness of Intervention based on dynamics
of postural control as key element over Conventional approach
in children with cerebral palsy
Method
A total of 38 subjects coming to OPD, Dept of Physical
Medicine and Rehabilitation with a diagnosis of cerebral palsy
were included and baseline evaluation was done for Postural
reaction score sheet, and Gross Motor Functional Abilities (using
GMFM-66 and GMFCS). The subjects were allocated equally
among group A and group B by simple random sampling
scheme. In group A, intervention based on Dynamics of postural
control and in group B, conventional treatment were used for a
period of 12 weeks followed by re-evaluation.
Result
The two groups were compared for their scores. These
were found to be statistically significant with p value <.0001.
Conclusions
It can be concluded that Intervention incorporating
dynamics of postural control is more effective than conventional
approach for development / modification of postural reaction in
children with Cerebral Palsy.
Key Words
Cerebral Palsy; Postural reaction; Postural control;
Dynamics of postural control; Gross motor functional abilities.
Introduction
Cerebral palsy describes a group of developmental
disorders of movement and posture [S. Ashwal et al, 2004;
Sankar Chitra and Mundkur Nandini, 2005], dominated by
muscle weakness, poor selective motor control, abnormal motor
sequences and synergies [Mayston J Margaret, 2001] causing
activity restrictions or disability that is attributed to disturbances
Address for correspondence:
Meenakshi Batra
PhD Scholar, Chhatrapati Shahuji Maharaj Medical University
(Erstwhile King George Medical College and University),
Department of Physical Medicine and Rehabilitation,
Rehabilitation and Artificial Limb Centre (RALC), Nabiullah Road,
Near Daliganj Bridge, Lucknow- 226018, Uttar Pradesh, India
Telephone: +919868038335, +919868019077, +91-11-
25280121
Fax: +91-522-2611091
Email: minaxibatra@yahoo.com, meenakshibatras@gmail.com
68 Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
occurring in the fetal or infant brain. Postural problems play a
central role in the motor dysfunction of children with cerebral
palsy (CP) thereby affecting development of motor control [Eva
Brogren Carlberg and Mijna Hadders-Algra, 2005].
The beginning of motor development is found in reflexive
movement. The reflexes are integrated to allow normal motor
development during child maturity. When the primitive reflexes
disappear, developmental Postural reactions emerge. The
Postural reactions develop during first year of life and constitute
a complex group of reactions which are important for regulation
of posture, establishment and maintenance of upright position,
and the orientation of the body and its parts in space.
Development of postural control facilitates blending of mobility
and stability patterns and also provides an insight into the motor
potential of children with CP.
The postural reactions are markedly delayed; immature and
disorganized in children with CP, and interferes with the
acquisition of postural control thereby affecting normal motor
development. Impaired postural control affects both qualitative
and quantitative aspects of motor control resulting in poor
functional performance and delayed acquisition of motor
milestones. So development of postural reactions should be the
key element for postural control, which is critical for efficient
and effective performance of all goal directed activities.
Currently available techniques do not specifically target
postural reactions as key elements for development of postural
control in children with cerebral palsy.
So the study was done with an aim to incorporate
components based on dynamics of postural control and see its
effectiveness over conventional approach for the development/
modification of postural reactions in children with cerebral palsy.
The research question was whether the Intervention
incorporating dynamics of postural control as elementary unit is
more effective than conventional approach in children with
cerebral palsy.
Many studies have been done on postural reactions (PR)
and it was found that the spastic cerebral palsy children
demonstrate significantly abnormal response in comparison to
normal children and postural reactions can be a useful
quantitative and qualitative diagnostic screening tool for high-
risk infants [Zafeiriou DI et al 1998]. The importance of inter-
sensory interactions had also been emphasized and it was found
that the multi-segmental structure of the body, allowing local
control of inter-segmental joints, uses one global reference
system. The need for future research under considerations of
inter-sensory interaction and dynamic control mechanisms had
been emphasized [Mergner
References and further reading may be available for this
article. To view references and further reading you must purchase
this article.Thomas et al 1998].
To summarize, the use of an integrated approach by
incorporating components of dynamics of postural control as
key element for the development of postural control should be
targeted.
Method
A total of 38 participants with a diagnosis of cerebral palsy
in the age range 2 - 7 years with Intelligent Quotient of 50 and
above coming to the department of Physical Medicine and
rehabilitation were included. The children with dystonic
presentation, contractures and deformities and sensory
impairment were excluded.
The ethical clearance and approval was granted by
institutional human ethical research committee of Chhatrapati
Shahuji Maharaj Medical University. The informed consent form
was signed by parents (/ guardians) then baseline evaluation
was done for gross motor functional ability status [using Gross
Motor Function Measure-66 (GMFM-66) and Gross Motor
Function Classification System (GMFCS)] and Postural response
at varying intensities on static and dynamic support surface
(using Postural response score sheet). Postural response
evaluation included Righting reaction, Protective extension and
Equilibrium reaction. Righting reaction and Protective extension
were assessed by giving manual stimulus in the form of sudden
push to the child; while Equilibrium reaction was assessed on
vestibular board at slow and fast perturbations in lying and sitting
position using forward-backward and lateral translation of
support surface and scoring was done accordingly [Insert Table
1 key to score for Postural response here].
Simple random sampling method was used to divide the
subjects into two groups. With group A, intervention based on
Dynamics of postural control and with Group B, conventional
treatment were used. It was a single blinded study in which
treatment allocation was concealed using sealed envelopes to
minimize the bias. The intervention was given for 12 weeks
followed by re-evaluation. The duration and frequency of
intervention was kept constant for both groups that is 3 session
per week of 40 minutes duration each.
Treatment Protocol
Intervention based on Dynamics of postural control
The intervention based on Dynamics of postural control
was specially formulated (/designed) based on the principles of
postural dynamics with an aim to elicit adaptive postural
response.
The intervention was divided into two phases.
Phase 1 has two components (Preparatory and
Variability)
Preparatory component aimed at normalizing tonal
characteristics, increasing passive and active mobility of body
structure and promoting symmetry and alignment via facilitatory,
and inhibitory techniques, and positioning.
While Variability component aimed at eliciting static and
dynamic postural responses, and promoting postural stability
and task related performances by altering spatial and temporal
characteristics of support surface configuration, using: Neuro-
facilitatory orientation of bodily segments (with reference to
trunk); and Limb maneuvers to augment central stability, and
facilitate / reinforce normal motor behavior, thereby Increasing
Postural awareness and control.
Phase 2 (Modulation Phase) aimed at modulation of
postural behaviors by altering interaction dynamics and
perturbation characteristics (at varying degrees, angles and
intensities) thereby influencing Anticipatory Postural Adjustment
(APA) and Reactive Postural Adjustment (RPA) responses. This
phase incorporates principles of interaction dynamics for
optimizing modulation of dynamic postural behavior using Neuro
Facilitatory contact points, Vestibular, Proprioceptive and
kinesthetic input (as key element in training motor control),
Recruiting trunk musculature (by Co activation and Reflex
inhibition), and Facilitating righting & equilibrium reactions (using
graded intensities in different planes of movement using support
surfaces) to give variety of exposure to learn movement
experiences temporally and spatially for the development /
modification of postural control.
So the intervention based on Dynamics of postural control
alters the order or control parameters, by varying: interaction
Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
dynamics, internal reference of correction, Interlimb and intralimb
coordination, stimulus characteristics (internal and external), and
recruitment order with respect to support surface perturbation
in stable & semi stable pattern.
Conventional Treatment
The Conventional treatment incorporated Positioning,
Handling at Therapeutic key points, Using Inhibitory and
Facilitatory techniques (such as using developmental positions,
stretching exercise etc.), and incorporating Weight shifting and
weight bearing in developmental position.
Results
Statistical Analysis
Between Group Comparison
The two groups were compared with each other for their
difference of scores (pre-intervention and post-intervention) for
Postural response at varying intensities on static and dynamic
support surface (on Postural response score sheet), and gross
motor functional abilities using nonparametric Mann Whitney U
test. Nonparametric test was used because sample size was
small, distributions were skewed and scoring was done on ordinal
scale. For each variable, Median and Inter-quartile range was
calculated. Most of these scores were statistically significant
with p value < .0001 [Insert Table 2 Comparison between two
groups i.e. Group A and Group B (Pre and post-intervention)
here]
Within Group Comparison
Subjects within each group were compared on the pre-
intervention and post-intervention scores of Postural response
score sheet and gross motor functional abilities using Wilcoxon
sign rank test to see the effectiveness of intervention.
Although both Intervention based on Dynamics of postural
control and Conventional approach were found to be effective
in children with cerebral palsy, but subjects in Group A showed
better results than Group B in terms of Equilibrium reaction
responses in lying and sitting positions on lateral and Forward
backward tilt at Fast perturbation, and GMFM score [Insert Table
3: Comparison within Group A (Pre and post-intervention) and
Table 4 Comparison within Group B (Pre and post-intervention)]
Discussion
The group with whom intervention incorporating
components of dynamics of postural control as key element was
used showed better results in terms of postural control (i.e.
Postural response at varying intensities on static and dynamic
support surface on Postural response score sheet), and gross
motor functional abilities.
The postural control undergoes the stages of postural
ontogenesis [Mijna Hadders- Algra 2005]. It requires the
integration and interaction of sensory, motor, and neurological
inputs. [Insert Figure 1 about Stages of Postural Ontogenesis
here]
Postural development starts with a repertoire of direction
specific adjustments and suggests that basic level of control
has an innate origin [Jolanda C et al 2005]. Automatic postural
responses to surface translations are triggered by
somatosensory information. Automatic postural responses to
surface translations are not reflexively driven by simple feedback
control mechanisms, but rather the muscle that is functionally
relevant to the appropriate corrective response is activated first.
Muscles are recruited synergistically in response to external
perturbations, but the muscle synergies can be altered in a
flexible task dependent manner to accommodate for changes
69
Table 1: key to score for Postural response
Postural response Scoring Criteria

1. Righting reaction 0 = Not Testable

2. Protective extension
1 = Absent
2 = Partial Inappropriate and delayed
3 = Spontaneous but Inappropriate
4 = Spontaneous but partially appropriate
5 = Appropriate / Normal Response

3. Equilibrium reaction 0 = Not Testable

1 = No Response
2 = Reflexive response (Child cannot initiate the response)
3 = Delayed Response (child can only Initiate but cannot maintain the C.O.G.
4 = Spontaneous inappropriate response (child lowers the C.O.G. and shows abnormal
body posturing
5 = Spontaneous inappropriate response (child tries to maintain C.O.G. in upright position
with support
6 = Spontaneous inappropriate response (child tries to maintain C.O.G. in upright position
with extra efforts
7 = Spontaneous appropriate response but need extra effort to maintain C.O.G.
8 = Normal Response
Table 2: Comparison between two groups (Group A and Group B)
(Pre and post-intervention)
Variable Difference of Scores Z P Value

Group A Group B
Median I Q range Median IQ
range
Postural Response score sheet

Righting Reaction 16.0 2.0 2.0 0.0 -5.071 <.0001

Protective Extension 12.0 2.0 2.0 2.0 -5.203 <.0001

Equilibrium Reaction

Lying

Lateral Tilt

Slow Perturbation 4.0 1.0 2.0 1.0 -4.426 <.0001

Fast Perturbation 2.0 2.0 0.0 1.0 -3.799 <.0001

Forward Backward Tilt

Slow Perturbation 4.0 1.0 2.0 0.0 -4.657 <.0001

Fast Perturbation 1.0 1.0 0.0 1.0 -4.426 <.0001

Sitting

Lateral Tilt

Slow Perturbation 4.0 2.0 1.0 1.0 -4.637 <.0001

Fast Perturbation 2.0 1.0 1.0 1.0 -4.807 <.0001

Forward Backward Tilt

Slow Perturbation 4.0 1.0 1.0 0.0 -4.401 <.0001

Fast Perturbation 3.0 1.0 0.0 0.0 -4.839 <.0001

GMFM -1.0 0.0 0.0 0.0 -5.129 <.0001

GMFCS 44.9 8.7 7.0 5.4 -4.556 <.0001

I Q range = Inter-quartile range

70 Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 3: Comparison within Group A (Pre and post-intervention)
Variable Difference of Scores Z P Value

Before After
Median I Q range Median IQ
range
Postural Response score sheet

Righting Reaction 12.0 2.0 30.0 2.0 -3.859 <.0001

Protective Extension 7.0 3.0 19.0 2.0 -3.841 <.0001

Equilibrium Reaction

Lying

Lateral Tilt

Slow Perturbation 2.0 1.0 7.0 1.0 -3.890 <.0001

Fast Perturbation 2.0 0.0 4.0 2.0 -3.773 <.0001

Forward Backward Tilt

Slow Perturbation 2.0 0.0 7.0 1.0 -3.903 <.0001

Fast Perturbation 2.0 0.0 3.0 1.0 -3.901 <.0001

Sitting

Lateral Tilt

Slow Perturbation 2.0 0.0 7.0 2.0 -3.879 <.0001

Fast Perturbation 1.0 1.0 4.0 1.0 -3.880 <.0001

Forward Backward Tilt

Slow Perturbation 2.0 0.0 6.0 1.0 -3.853 <.0001

Fast Perturbation 1.0 0.0 4.0 1.0 -3.676 <.0001

GMFM 4.0 1.0 3.0 1.0 -4.123 <.0001

GMFCS 25.7 4.7 68.4 9.6 -3.824 <.0001

I Q range = Inter-quartile range
in biomechanical constraints of the musculoskeletal system /
task. Automatic Postural muscle responses to surface
translations are not hard wired, fixed synergies, but can be
altered by prior experience, intent, initial alignment, and surface
configurations [Winter David A. et al 1990; Xu, Dali; Carlton,
Les G. and Rosengren, Karl S. 2004].
Children with cerebral palsy demonstrate poor postural
control, inability to maintain postural alignment, inability to
perform rapid weight shifts and respond to external perturbations.
It had been observed that the basic organization of responses
in children with spastic cerebral palsy remains intact but their
modulation is deficient, and demonstrate abnormalities of the
basic organization of postural adjustments. This modulation can
be achieved in various ways by changing the order in which
agonist muscles are recruited, by modifying the size of muscle
contraction or by altering degree of antagonist activation. Hence
the children with cerebral palsy get benefited from the therapy
incorporating dynamics of postural control approach as
elementary unit.
The dynamic components of the treatment approach used
in group A induced automatic postural adjustment responses at
various stimulus intensities, and support surface configuration
thereby producing necessary variability in motor behavior. To
generate behaviour, the brain transforms sensory information
into signals that are appropriate to control movement.
The sensory information plays a role in shaping muscle
activation patterns to postural perturbations by varying velocity,
amplitude, or duration of the perturbing stimulus. The spatial
and temporal organization of automatic postural responses gets
organized independently of response intensity. Within a particular
spatial-temporal pattern, the amount of muscle activation
appears to be adjusted by sensory information, which specifies
velocity and amplitude of the perturbation.
Spatial tuning patterns of the automatic postural response
are elicited by support surface translations in multiple directions.
Muscle synergies therefore reflect a neural control strategy at
the level of functional variables specific to the particular motor
task at hand [Torres-Oviedo Gelsy, Macpherson Jane M and
Ting Lena H. 2006; Ting Lena H., and McKay J. Lucas 2008].
The conditions under which postural responses were elicited,
was modified in two ways: altering the configuration of the limbs
during support surface translations and changing the
perturbation characteristics. These task specific manipulations
helped in inducing variability in the automatic postural responses
[Fay B Horak 2006].
The various types of postural perturbations evoked widely

Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 71
Table 4: Comparison within Group B (Pre and post-intervention)
Variable Difference of Scores Z P Value

Before After
Median I Q range Median IQ
range
Postural Response score sheet

Righting Reaction 12.0 2.0 14.0 2.0 -3.547 <.0001

Protective Extension 7.0 3.0 9.0 3.0 -3.872 <.0001

Equilibrium Reaction

Lying

Lateral Tilt

Slow Perturbation 2.0 1.0 4.0 1.0 -3.827 <.0001

Fast Perturbation 2.0 0.0 2.0 1.0 -2.456 <.0014

Forward Backward Tilt

Slow Perturbation 2.0 0.0 4.0 1.0 -4.014 <.0001

Fast Perturbation 2.0 0.0 2.0 1.0 -2.121 <.034

Sitting

Lateral Tilt

Slow Perturbation 2.0 0.0 4.0 1.0 -3.804 <.0001

Fast Perturbation 1.0 1.0 2.0 1.0 -3.207 <.001

Forward Backward Tilt

Slow Perturbation 2.0 0.0 3.0 0.0 -3.625 <.0001

Fast Perturbation 1.0 0.0 4.0 1.0 -1.732 <.0001

GMFM 4.0 1.0 3.0 1.0 -1.000 <.317

GMFCS 26.1 5.5 34.2 4.8 -3.824 <.0001

I Q range = Inter-quartile range
differing sensory input signals in muscle spindles, Golgi tendon
organs, and vestibular organs [Nashner 1976; Ting Lena H. and
Macpherson Jane M. 2004]. Postural control requires the
coordination of multiple muscles to achieve both endpoint force
production and postural stability. Multiple muscle activation
patterns generated produced the required force by preferentially
activating muscles with feed forward stabilizing properties. Such
a strategy helped in increasing intrinsic postural stability.
Conclusion
It can be concluded that Intervention incorporating dynamics
of postural control is more effective than conventional approach
for development / modification of postural reaction in children
with Cerebral Palsy.
Declaration of Interest
The authors report no conflicts of interest.
References
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prior knowledge on automatic and voluntary postural
adjustments in healthy and hemiplegics subjects ;
Physiotherapy: 67 (10) 1495 1500
2. Brogren Eva, Forssberg Hans, Mijna Hadders Algra
(2001). Influence of two different sitting positions on postural
adjustments in children with spastic diplegia, 43: 534 546.
3. Carlberg Eva Brogren and Mijna Hadders-Algra (2005).
Postural Dysfunction in Children with Cerebral Palsy: Some
Implications Therapeutic Guidance, Neural Plasticity: 12
(2-3): 221-228.
4. Dimitrios I Zafeiriou (2004). primitive reflexes and postural
reactions in the Neurodevelopmental examination, Journal
of Pediatric Neurology, 31 (1): 1-8
5. Fay B. Horak (2006). Mechanistic and Physiological aspects
Postural orientation and equilibrium: what do we need to
know about neural control of balance to prevent falls, Age
and Ageing 2006; 35-S2: ii7ii11.
6. Forssberg Hans, Nashner M Lewis (1982). Ontogenetic
development of postural control in man: Adaptation to
altered support and visual conditions during stance, The
Journal of Neuroscience, 2 (5): 545 552.
7. Jolanda C., Heide Vander and Hadders-Algra Mijna (2005).
Postural Muscle Dyscoordination in Children with Cerebral

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Fig. 1: Stages of Postural Ontogenesis
Palsy, Neural Plasticity, 12 (2-3):197-203.
8. Mandich M, Simons CJ, Ritchie S, Schmidt D, Mullett M
(1994). Motor development, infantile reactions and postural
responses of preterm, at-risk infants, Dev Med Child Neurol.
36 (5):397-405.
9. Mayston J Margaret (2001). People with C.P.: Effect of and
Perspective for therapy, Neural Plasticity, 8 (1-2): 51:69.
10. Mijna Hadders Algra, Eva Brogren (1991). Periventricular
Leucomalacia and preterm birth have different detrimental
effects on postural adjustments, Brain, 122: 727 740.
11. Mijna Hadders Algra (2005). Development of postural
control during the first 18 months of life, Neural Plasticity,12
(2) 3; 99:108.
12. Ohlweiler Lygia (2002). Parachute and Lateral propping
reactions in preterm children, Arq Neuropsiquiatr: 60 (4) :
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13. Otten (2005). Multiple dynamics and the development of
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14. Palma Gunsolus, Carol Welsh (1975). Equilibrium
reactions in the feet of children with spastic cerebral palsy
and of normal children, Developmental Medicine and Child
Neurology, 17: 580 591.
15. S. Ashwal., Russman B. S., Blasco P.A., Miller G., Sandler
A. Shevell M. et al (2004). Practice parameter: Diagnostic
assessment of the child with Cerebral Palsy. Neurology
(American Academy of Neurology), 62(3): 851-863.
16. Sankar Chitra and Mundkur Nandini (2005). Cerebral
Palsy definition, Classification, etiology and early
diagnosis; Indian Journal of Pediatrics, 72 (10): 865-868.
17. Ting Lena H. and Macpherson Jane M. (2004). Ratio of
Shear to Load Ground-Reaction Force May Underlie the
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Directional Tuning of the Automatic Postural Response to
Rotation and Translation, J Neurophysiol 92: 808823.
18. Ting Lena H. and Macpherson Jane M. (2005). A Limited
Set of Muscle Synergies for Force Control during a
Postural Task, J Neurophysiol 93: 609613.
19. Ting Lena H., McKay J. Lucas (2008). Functional muscle
synergies constrain force production during postural tasks,
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20. Torres-Oviedo Gelsy, Macpherson Jane M and Ting Lena
H.(2006). Muscle Synergy Organization Is Robust Across
a Variety of Postural Perturbations, J Neurophysiol, 96:
15301546.
21. Umphred A Darcy (2007); Neurological Rehabilitation: 5th
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23. Weerdesteyn Vivian, Laing Andrew C. and Robinovitch
Stephen N. (2008). Automated postural responses are
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(1990). Assessment of balance control in Humans, Medical
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25. Xu, Dali; Carlton, Les G. and Rosengren, Karl S. (2004).
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73
An Evaluation of Exercise Tolerance in COPD Patients Using Six
Minute Walk Test- A prospective study
T S Muthu Kumar1, T Mohan Kumar 2
1
Sr Lecturer, Lovely Professional University Punjab, 2Head Institute of Pulmonary Medicine Sri Ramakrishna Hospital Coimbatore
Abstract
Background
Functional exercise tolerance in patients with chronic
obstructive pulmonary disease patients (COPD) is often
assessed by the 6 minute walking test. Impairment of exercise
tolerance is an important feature of COPD. Physical
deconditioning and impaired lung function are main causes of
decreased exercise tolerance. This study explored the evaluation
of exercise tolerance in COPD patients using simple six minute
walk test.
Design
A prospective 4 week quasi experimental study design.
Setting
Institute of Pulmonary medicine and research, Sri
Ramakrishna Hospital Coimbatore India
Patients
10 patients of moderate and severe cases of COPD were
included in the study.
Interventions
Patients who were admitted in Pulmonology general ward
because of acute exacerbations and well responded to medical
treatment were screened for Borg Scale Rate of Perceived
exertion and Six minute walk test on 3rd day of hospital stay and
the post test measurements were taken at 7th day. The statistical
analysis was done using paired t test at the level of significance
= 0.05
Results
We compared the Borg scale of perceived exertion and six
minute walk test on 3rd day of hospital stay and at 7th day. The
result showed significant improvement in terms of reduced
exertional dyspnea and increased six minute walk distance.
Conclusion
In the light of assessing exercise tolerance in COPD
patients, it has been concluded that six minute walk test was a
useful tool in evaluating exercise tolerance in COPD patients
since it was easy to perform and very cost effective.
Key Words
COPD, Borg Scale, Six minute Walk test
Background
Functional exercise tolerance in patients with chronic
74 Kavitha Vishal / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
obstructive pulmonary disease (COPD) is often assessed by
the 6 min walking test (6MWT)1.Impairment of exercise tolerance
in COPD patients has important implications on health related
quality of life, hospitalization rate and survival2.The impaired
exercise tolerance may be due to peripheral muscle dysfunction
characterized by atrophic muscle and reduced fatigue
resistance.3.As much as 70% of COPD patients may be affected
by impaired exercise tolerance.3
Impaired exercise tolerance may lead to energy cost while
doing activities of daily living in COPD patients.4This may affect
psychological well being and would increase sickness
absenteeism in their work places. Recommendations on exercise
testing in lung function laboratory settings are well established,
and the role of incremental cardiopulmonary cycling exercise
as the gold standard for evaluation of exercise tolerance is
acknowledged.5How ever a wide spread clinical use of simple
exercise protocols are effective because of their simplicity,
applicability and low cost.6-8Moreover timed walking tests have
been shown to predict survival9 and utilization of health care
resources10 in COPD. Based on this hypothesis we conducted
this study to evaluate the exercise tolerance in COPD patients
using six minute walking test (6MWT).Therefore, it is suggested
that simple exercise tests may be useful for staging of the disease
.11
The six minute walk test (6MWT) has been widely used
and accepted as a simple, cost-effective means of clinically
assessing the functional status of COPD patients. The 6MWT
has proven reliable in providing reproducible data to serve as
measures of pre and post treatment comparisons12-17 in the
assessment of functional status 18-20 and in predicting morbidity
and mortality for various disease states.21-23 Distance testing was
first advocated by Balke 24 in 1983 by means of assessing
physical fitness. McGavin 25used a 12 min walk test to assess
disability in patients with COPD. Subsequent work determined
the effectiveness and reliability of shorter- distance walk testing
and eventually the 6MWT became the most widely accepted
protocol. The 6MWT is a sub maximal, self paced test used to
evaluate the exercise tolerance in COPD patients in this study.
Material and Methods
This study in accordance with the research design as stated
by C.R.Kothari 26 was prospective 4 weeks quasi experimental
study design in which convenient sampling method was used.25
patients admitted in Pulmonology General Ward at Sri
Ramakrishna Hospital Coimbatore India were selected for the
study, informed consent was obtained and 10 moderate and
severe patients who were medically stable met with an Inclusion
criterion as follows FEV 1 /FVC< 0.70,50%d FEV 1< 80%
predicted for moderate and FEV1/FVC < 0.70, 30% d FEV1 <
50 % predicted for severe, pre bronchodilator to post response
of > 20%, baseline dyspnea grade 2 using MRC, good left
ventricular ejection fraction and age group of 40 70 years of
both male and female, ex smoker and stable vital signs.
The exclusion criterion were acute exacerbation not
responding to medical treatment, intermittent claudication,
associated cardiac failure, osteoarthritis, Musculoskeletal pain,
syncope and dyspnea at rest.
Baseline evaluation for Borg Scale of Rate of perceived
exertion and 6MWT was taken at 3rd day of hospital stay since
they received conventional chest physiotherapy techniques such
as repatterning techniques, breathing exercises, strategies to
reduce increased respiratory rate and relaxation techniques. The
six minute walk test was carried out according to American
Thoracic Society guidelines27 2002.The safety issues for
conducting 6MWT as mentioned in American Thoracic Society
guidelines was adopted. The patients were asked to take
bronchodilator therapy28, 29 before 2 hours of walking. Pre and
post test measurements were assessed using paired t test at
p=0.05 and analysis was done using SPSS 17.
the disease is distinctly more common in males. The male to
female ratio had varied from 1.32:1 to 2.6:1 in different studies
with a median ratio of 1.6:1.In our study the total number of
patients in age group of 41-50, 51-60, 61-70 were 1, 3, 6
respectively and it is shown in figure 1 and the gender ratio is
shown in figure 2.
Fig. 1: Demograhic Data

Measurements
Conventional chest physiotherapy was given to patients
exactly two hours before the start of 6MWT to gain relaxation
and to reduce respiratory rate and to gain confidence of the
patients.The conventional chest physiotherapy was given twice
daily for seven days After the patients underwent chest
physiotherapy, vital signs were checked including Blood
pressure, heart rate, respiratory rate, temperature and saturation
of percentage of oxygen using Pulse oxymetry. The rate of
perceived exertion was assessed using Borg Scale (20 point
scale) before the commencement of 6MWT to assess exertional Fig. 2: Gender Ratio
dyspnea. Six minute walk test was conducted after brief
explanation to the patients. They were instructed to walk in a
100 m corridor where Emergency Department was accessed
easily to avoid any adverse effects. However a trolley consisting
of Defibrillator, emergency medications including atropine and
mobile oxygen therapy unit was kept in the corridor for safety
issues. The rest periods were included in the study as per
American Thoracic Society Guidelines 27 and the distance was
measured in meters. Base line six minute walk distances was
measured during 3 rd day of hospital stay and post test
measurements were taken at 7th day of hospital stay. The stop
watch was used to record the time travelled by the patients and
mechanical lap counter was used.

Results
The Six minute walk distance in meters showed good
improvement in terms of increased walking distance when we
compared pre and post test readings as mean distance was
243277 and standard deviation was 141.3143.1 and the t
value 10.854 was more than the critical value at p=0.05 level of
significance. This ensured that six minute walk test was a good
indicator for measuring exercise tolerance in COPD patients.
The Borg Scale of perceived exertion also showed
moderate improvement as compared to Six minute walk distance
in meters since its mean value was 11.413.6 and standard
deviation was 4.594.42 and the t value 11 was more than the
critical value at p = 0.05.
Discussion
Reduced exercise tolerance is generally accepted as an
unavoidable complication of advanced COPD; the presence of
different degrees of physical limitation in patients with
comparable lung function impairment, however suggests a
multifactorial origin for this phenomenon. Although air ways
obstruction has classically been considered the most important
of these pathogenetic factors, studies aimed at comparing lung
function impairment and exercise tolerance in COPD failed to
establish a clear correlation between the two parameters 28,
29
probably difference in age groups or gender ratio and also the
differences in study population.
In this study, 9 male patients and 1 female patient were
participated since males were more affected than females in
India due to their personal habits of smoking and other socio-
economic history. Jindal S.K. et al. reported the prevalence of
COPD 30in males and females in India and they concluded that
Killian J et al (1992)31 et al. postulated that lower limb fatigue
is another factor contributing to exercise intolerance; this is
particularly in deconditioned elderly patients due to a variable
degree of muscle atrophy leading to a significant reduction in
muscle strength and endurance. Initially the patients were
uneasiness towards six minute walk test because they thought
that it would exaggerate the symptoms probably the fatigue and
after careful explanation they realized that it would benefit
psychological well being and other positive benefits. The self
paced 6MWT didnt cause any exertional dyspnea while walking
but after the test 75% of the patients experienced dyspnea and
light dizziness due to work load imposed on respiratory muscles
especially the age group of 51-60 and 61-70.This might not
altered any results but psychologically it caused some
troublesome to the patients.
The use of the 6MWT as a single measurement of the
exercise tolerance for COPD patients was widely accepted as
stated by Redelmeier et al.32In their study, they conducted 6
MWT in 119 patients (mean age=67) and concluded that 6MWT
was significantly correlated with patients ratings of their walking
ability relative to other patients (r = 0.59, 95% confidence interval
[CI] 0.54 to 0.63). They suggested that differences in functional
status can be statistically significant but below the threshold at
which patients notice a difference in themselves relative to
others; an awareness of the smallest difference in walking
distance that is noticeable to patients may help clinicians interpret
the effectiveness of symptomatic treatments for COPD.
In this study, the mean age was 57.6 and the improvements
in walking distance was quite significant and the mean distance
was 243277 and standard deviation was 141.3143.1and graph
was shown in figure 3 and figure 4 respectively. The

Kavitha Vishal / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 75
determination of what constitutes a significant clinical change
as a result of an intervention has been debated with generally
well-accepted parameters for patients with COPD. The minimal
important clinical difference in patients with COPD is reported
to be approximately 55 m for cohorts,33 and 86 m for individuals.34
Our participants also showed significant differences in walking
distance as compared to pre and post test measurements and
the values were statistically significant at p=0.05.
The pre and post test measurements of 6MW distance is
shown in figure 5. Out of 10 patients, only 3 patients got less
Fig. 3: Mean Distance
Fig. 4: Standard deviation of 6MWT distance
improvement in terms of walking distance since they were
belonging to age group of 61-70 and probably the age might be
the limiting factor as postulated by Killian30 and his colleague in
their research studies. There always a debate exists of
relationship between exertional dyspnea and 6MWT.Since the
speculation arises in every mind that submaximal exercise tests
such as 6MWT also causes exertional dyspnea. In our study,
we used Borg Scale Rate of Perceived exertion to evaluate
exertional dyspnea.
Sue C.Jenkins 35 stated that dyspnea during activities of
daily living is frequently reported by patients with COPD and
can result in inactivity and the associated problems of
deconditioning and muscle weakness. As far as we were
concerned there was only one article measured daily physical
activity in COPD patients (n=50) and compared the findings to
data obtained in age and gender matched healthy controls
(n=25).36, 37Compared to the healthy controls, COPD patients
spent significantly less time standing and walking during daily
activities (P<0.001, for both).
The mean score of Borg Scale was 11.413.6 and standard
deviation was 4.594.42. Based on the mean value of Borg Scale
we would state that patients were at the score of 11 which
indicated fairly light and 13 indicated somewhat hard with
reference to 15 point Borg Scale.38 One of the potential reasons
for exertional dyspnea is hyperinflation of the lungs with air
trapping in the alveoli and leads to an increased residual volume
and as a consequence increases breathlessness on exertion.
As a result of hyperinflation of the lungs, the natural dome of
76 Kavitha Vishal / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
the diaphragm gets flattened. This requires more effort to
breathe, which places a burden on the accessory muscles during
respiration. Consequently any activity such as walking, bending
to tie shoelaces or shopping will worsen the breathlessness.39
The pre and post test measurements of Borg Scale is
shown in Figure 6. The reliability and reproducibility of Borg Scale
had been investigated by many researchers. Wilson RC, Jones
PW40 stated that Borg Scale provides a reliable technique for
studying the sensation of breathlessness in short and extended
periods of time. O Donell DE41 et al. evaluated the intratester
Fig. 5: 6MWT Distance in meters
and inters tester reliability of Borg Scale and concluded that it
was good indicator of measuring exertional dyspnea. Though
numerous studies supported the reliability of the Borg Scale, its
subjective nature would alter test results and this could be one
of the limitations in this study.
The possible mechanism that how our patients got
improvement in walking distances using 6MWT would be the
greater muscle mass especially quadriceps involved in walking
that increase muscular O2 extraction thereby inducing a
substantial decrease in venous pressure of O2 42and also
improved overall oxidative capacity of the individuals since
COPD patients are more dependent on anerobic metabolism
rather than aerobic metabolism during walking and other
exercises.43Clinical recommendations for exercise training in
COPD patients include a component of sub maximal intensity,
at 60% peak exercise capacity, lower limb endurance training
with the aim of eliciting some physiological training effects.44 To
achieve this, 6MWT was used in this study.
According to Frank I.Katch and Victor L. Katch, 45 several
weeks of walking training at sub maximal intensity reduces the
ventilator equivalent for oxygen (VE/VO2) and lowers the
percentage of the total exercise oxygen cost attributable to
breathing. They also added that reduced oxygen consumption
Fig. 6: Borg Scale Pre and Post Test
by the ventilator musculature enhances exercise endurance for
two reasons :1 it reduces the fatiguing effects of exercise on the
ventilator musculature and 2 any oxygen freed from use by the
respiratory musculature becomes available to the active
locomotor muscles. This would support our hypothesis that
6MWT improves endurance and evaluates exercise tolerance
in COPD patients. Since we didnt measure VO2 Max to estimate
the Oxygen Capacity, this might be our one of the limitations in
our study.
The reliability and validity of the 6MWT was well established
in number of studies. In one study, the validity of the 6MWT is
demonstrated by the moderate to good relationship (re0.5)
between 6MWD and peak oxygen consumption (VO2 peak)
measured during a laboratory-based incremental exercise test
to peak work capacity in patients with COPD.46-49 The relationship
tends to be strongest (r> 0.7) in patients with more severe
functional limitation because a self paced walking test in these
individuals more closely represents maximal exercise
performance.46,50.Absence of the control group in our study is
considered to be one of the study weaknesses, as there are no
published data in normal predicted distance of 6MWT in Indian
population.
Conclusion
Based on the available resources and our research
experience in conducting 6MWT, the best rationale for use of
the 6MWT lies in the practicality and simplicity of the test itself.
The 6MWT is a cost effective procedure that may be performed
in nearly any clinical location without the need for either direct
physician involvement or invasive, and often expensive,
monitoring equipment. As a self-paced and sub maximal exercise
procedure employing the familiar activity of walking, the 6MWT
is well tolerated by patients over a wide span of fitness levels
and debility. The 6MWT in comparison to other functional walking
tests is felt to offer advantages that include established standards
for testing, reference values, and correlation with the capacity
to perform activities of daily living.17 In summary 6MWT is a
reliable, and valid method for evaluating exercise tolerance and
also improving exercise tolerance for COPD patients owing to
its simple method.
Ethical Approval
The ethical committee of Sri Ramakrishna Hospital
Coimbatore India had approved this thesis. There are no ethical
issues.
Funding
We have not received any funding from any organization
Conflict of Interest
There is no conflict of Interest.
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test: a quick measure of functional status in elderly adults.
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walk test predicts peak oxygen uptake and survival in
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24. Balke B. A simple field test for the assessment of physical fitness:
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Pattern of Orthopaedicians Referral for Physiotherapy in a Tertiary
Care Hospital: A preliminary report
Kavitha Vishal*, Narasimman Swaminathan**, Benjamin Varghese*, Sudeep MJ Pais*
*Lecturer in Musculoskeletal and Sports Physiotherapy, **Associate Professor and Head, Department of Physiotherapy Father
Muller Medical College, Mangalore - 575002
Abstract
Background
Orthopaedic surgeons are considered to be the primary
source of referral for physiotherapy services. It is believed that
the referring physician should have adequate knowledge
regarding physiotherapy. Physiotherapy is a dynamic profession
in the present era and is marching towards autonomy. In the
current scenario clinical decision making regarding therapy
should not be dictated by other health care professionals.
In this context, the present study was designed to assess
the reference pattern by orthopaedic surgeons in a tertiary care
hospital. As per our knowledge this is the first study in the Indian
setup designed to explore this important issue.
Method
In this Descriptive Study, The referral forms of the patients
referred to the outpatient department of physiotherapy, Father
Muller Medical College, Mangalore from January to March 2009
were retrospectively analyzed for the following criteria: Number
of cases referred for physiotherapy, Pattern of referral, diagnosis
of the referring surgeon, and the Surgeons preference of the
modality of treatment.
Results
This report analyzed 184 referral forms, with various
musculoskeletal disorders. There were marked differences
between the orthopaedic surgeons in prescribing physical
modalities. Reference for technical procedures was much more
than professional modes of therapy.
Conclusion
This preliminary report emphasizes that the therapists
should involve themselves in inter-professional discussion in
order to improve knowledge of physical therapy procedures
among referring surgeons.
Key Words
Pattern of Referral, Autonomy, Physiotherapy.
Introduction
Physiotherapy is a health care profession that provides
services to enhance, facilitate, maintain and restore maximum
movement and function throughout the lifespan of an individual.
This includes providing treatment in situations where normal
movement patterns and function are threatened by aging, injury,
disease or environmental factors. 1 This encompasses the
physical, psychological, emotional, and social aspects of health
and wellbeing. It involves the interaction between the physical
therapist (PT), patients/clients, other health professionals,
families, care-givers, and the community in a process where
movement potential is assessed and goals are agreed upon,
Kavitha Vishal / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
using knowledge and skills unique to physical therapists.1
Health care services all over the globe depend on an
interdisciplinary approach to provide the best and cost-effective
treatment for its clients. In an interdisciplinary approach,
members of the team work in a coordinated manner to bring out
the best for their clients. Members of the team may vary and will
depend on the patients needs and the condition or disease being
treated. In a multidisciplinary team every member has the right
to assess, set goals and provide prognosis for the case. This
requires good communication between health care professionals
and adequate information about each others skills and services.
Referring a client for physiotherapy services will directly influence
the quality of care as well as the cost of the care2.
Physiotherapy is a dynamic profession constantly striving
towards autonomy. Physical therapy has many specialties
including cardiopulmonary, geriatric, neurologic, orthopaedic,
paediatric, industrial and womens health. Physiotherapy has a
vital role in the management of musculoskeletal impairment and
has been accepted throughout the world. Therapists working in
with clients with musculoskeletal problems are involved in
physical diagnosis through sound clinical reasoning underpinned
with a veritable knowledge base.
Orthopaedic surgeons and general practitioners form the
principal source of referral for physiotherapy. Appropriate
referrals to physiotherapy can only be made if the referring
surgeon has adequate knowledge about what physiotherapy
can offer these patients. Lack of knowledge may in turn lead to
delay or inappropriate referrals3.4. Ehrmann-Feldman D and
colleagues concluded in their cohort study that judicious
reference to physical therapy will reduce the cost improve the
quality of health care5. Through a web based survey Archer KR
et al found that the reference pattern of orthopedic surgeons
mostly depended upon their expectations about physical and
motor outcomes6.
To our knowledge, there have been no efforts made to
find out the pattern of referral for physiotherapy in the Indian
scenario, and this is important in the wake of autonomy of this
profession. This preliminary report will strengthen the body of
knowledge regarding the referral pattern.
Methodology
Study Design: Retrospective Qualitative
Setting: the study was conducted in the department of
physiotherapy, Father Muller Medical College, Mangalore, India.
It is a teaching hospital with a 1050 bedded multispecialty
hospital. The physiotherapy department is well established and
runs both bachelors and masters programmes in physiotherapy.
It is closely associated with the entire department including full-
fledged orthopaedic department. Data was obtained from the
outpatient records.
The records of the patients referred to the department of
physiotherapy from January to March 2009 were retrieved and
analysed. Two independent therapists retrieved the following
information from the outpatient records in a predesigned
proforma: Number of cases referred for physiotherapy, Pattern
of referral, Diagnosis of the condition, Surgeons preference of
the modality of treatment. The retrieved data was analyzed using
79
descriptive statistics. Fig. 3: Areas referred for physiotherapy

Results
We retrieved data of patients referred to the department of
physiotherapy from January to March 2009. There were a total
of 556 patients that were referred to the department during this
period. The Figure below shows the average cases that were
received over these months.
The most preferred modality was definitely electrical
Fig. 1: Number of cases referred for physiotherapy

Most of the referrals received were pertaining to the low back

and neck while the hip was least referred for physiotherapy.
The shoulder was another area for which physiotherapy was
often sought.

Fig. 4: Conditions of the shoulder that was referred for

physiotherapy.

The table below shows the age distribution of the patients

referred for physiotherapy service
Table 1: average age of the patients referred

Age (Yrs) Number Percentage

(%)

10-19 11 3

20-29 48 14
Periarthritis of shoulder was the condition that was most
30-39 59 17
commonly referred for physiotherapy, followed by tendinitis. Most
of the cases were referred under the diagnosis of shoulder pain.
40-49 76 23
Fig. 5: Conditions of the wrist/hand that were referred for
50-59 77 23
physiotherapy.
60-69 44 13

70-80 10 7

Fig. 2: Gender distribution of the patients

A vast majority of the hand cases referred were for stiffness of

the hand following trauma. Wrist pain was the second most
common diagnosis referred.

Female patients were marginally higher in number than the The Maximum number of knee joint cases referred was of
male patients referred. osteoarthritis knee. Ligament injury constituted a very small
proportion of the cases that were referred. Sprains and strains
of the knee joint were also among the referred cases.

80 Kavitha Vishal / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Fig. 6: Conditions of the knee referred for physiotherapy
Fig. 7: Conditions of the elbow that was referred for
physiotherapy
Tennis elbow was unmistakably the most common elbow
condition that was referred for therapy
Fig.8: Conditions of the back and neck referred for
physiotherapy
Fig. 9: Conditions of the back referred for physiotherapy
Kavitha Vishal / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Spinal conditions (cervical and lumbar regions) were referred
the most for physiotherapy, spondylosis being the most common
among them. Nonspecific low back pain and lumbosacral strain
were the other common lumbar spine conditions referred.
Similarly, in the cervical spine, non specific neck pain was the
second most referred condition.
Fig. 10: Orthopaedic surgeons preference of therapeutic
modality
therapies in the form of IFT and TENS. Ultrasound and SWD
were equally preferred followed by traction and wax. Exercise
was also one of the prescribed methods of treatment.
Discussion
This study aimed to find out the referral patterns to the
physiotherapy department of a tertiary level hospital. It was
observed that majority of the patients referred for musculoskeletal
physiotherapy typically fell into the older age group. This may
be due to the prevalence of degenerative disorders in this group
as well as the tendency to move towards more conservative
therapies in this age group. Our findings are in line with other
studies.
Female patients were more than male patients in this study
indicating that musculoskeletal complaints are more commonly
seen in the female gender. Our results are in contrast to those
of Ahmad RY et al1.
Conditions of the spine were common when compared to
peripheral conditions. Among the peripheral joints, the knee joint
was the most referred followed by the shoulder. The hip was
least referred. The population under study essentially fell into
the sedentary category in which the occurrence of lumbar and
cervical pain is much more than the athletic population.
Moreover the efficacy of physiotherapy in these conditions is
well documented which may have led to an increase in the
referrals when it came to therapy in these areas. In the knee
joint osteoarthritis invited the highest number of referrals
indicating again the effectiveness of physiotherapy as well as
the surgeons knowledge of alternative modes of treatment.
Few of the patients did not fall into specific diagnostic groups
and were referred as non specific regional pain conditions. It
was therefore the responsibility of the physiotherapist to make
a detailed evaluation as to what was the impairment of the patient
and deliver beneficial treatment for the same.
Surgeons primarily preferred electrotherapy modalities over
exercises for most of the patients in this study. But what is
interesting to note is that there were references made for
exercises too. This shows that there has been a shift towards
professional expertise rather than technical modes of treatment.
A study done by Robin Moremen7 reported references mainly
for technical modes of treatment. There has been a definite
change in the attitude and recognition for manual modes of
treatment. There is a reference for specialised forms of treatment
which only the therapist can deliver.
81
Conclusion
This preliminary report emphasizes that the therapists
should involve themselves in inter-professional discussion in
order to improve knowledge of physical therapy procedures
among referring surgeons. The pattern of referral should be
audited regularly to improve the professional autonomy.
References
1. Ahmad R Y, Hanif S M, Kodzo P, Chroma IM, Lamina S.
Pattern of referral to physiotherapy department ,Amino
Kano teaching hospital Kano. Journal of Medicine and
Rehabilitation 2007;1(1):25-27
2. Michelle CB Physician Referral to Physical Therapy in a
Cohort of Workers Compensated for Low Back Pain.
(Invited commentary) 1996; 76(2): 157
3. Stanton PE, Fox FK, Frangos KM, et al. Assessment of
resident physicians knowledge of physical therapy. Phys
The 1985; 65:27-30.
4. Ritchey FJ, Pinkston D, Goldbaum JE, Heerten ME.
Perceptual correlates of physician referral to physical
82 Kavitha Vishal / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
therapists: implications for role expansion. Sor Sci Med.
1989; 28:69-80.
5. Ehrmann-Feldman D, Rossignol M, Abenhaim LA, Gobielle
D. Physician referral to physical therapy in a cohort of
workers compensated for low back pain. Phys Ther.
1996;76: 150-157.
6. Archer KR, MacKenzie EJ, Bosse MJ, et al. Factors
associated with surgeon referral for physical therapy in
patients with traumatic lower-extremity injury: results of a
national survey of orthopedic trauma surgeons. Phys Ther.
2009; 89:893905.
7. Robin Moremen Uili, Katerine F. Shepard, and Emil Savinar.
Physician Knowledge and Utilization of Physical Therapy
Procedures. 1984;64(10):1523-1530
Acknowledgement
The authors express their sincere thanks to the
management and orthopaedic surgeons of Father Muller Medical
College Hospital, Mangalore and Ms Shalet Montero,
Department secretary for her valuable contribution in collecting
the data.
Short Term Effect of Body Positions on Dynamic Lung Compliance
in Mechanically Ventilated Patients with Lung Pathology- A
randomised cross over study
Swagata De*, Narasimman Swaminathan**
*Postgraduate student, **Associate Professor & Head, Department of Physiotherapy, Father Muller Medical College, Mangalore,
Karnataka, India
Abstract
Background
Mechanical ventilators are used to prevent hypoxemia
caused due to inadequate ventilation. It can also lead to retention
of secretions and alveolar collapse due to improper ventilation
of the dependent lung. Positioning has direct effect on optimizing
the respiratory mechanics and improving the ventilation. This
study was conducted to determine the effect of various body
positions on dynamic compliance in such patients.
Study Design
Randomized cross over study.
Method
Total 19 subjects with various lung pathologies on
mechanical ventilator, fulfilling the inclusion criteria were
included. Each patient was positioned in the randomized
sequence of four positions (supine, right lateral, left lateral and
erect). Each position was maintained for 45 minutes. Dynamic
compliance was measured at the interval of every 15 minutes
by the formula dynamic compliance= delivered tidal volume/
(peak inspiratory pressure-PEEP). Hemodynamic parameters,
respiratory rate, SpO2 were monitored in each position.
Results
The highest values of the dynamic compliance in supine,
right lateral, left lateral and erect position were 31.88 ml/cm
H2O after 45 minutes, 28.33ml/cmH2O after 15 minutes, 25.22ml/
cmH2O at the beginning and 29.67 ml/cmH2O after 45 minutes
respectively. There was no significant difference in the dynamic
compliance (p=0.229), heart rate, respiratory rate, SpO2 in the
four positions.
Conclusion
There was no significant difference in the dynamic
compliance among all the positions. The results of the study
cannot be generalized because of the small size. This provided
the insight into the effect of body position.
Key Words
Dynamic Compliance, Body Positioning, Chest
Physiotherapy.
Address for correspondence:
Narasimman Swaminathan
Associate Professor & Head
Department of Physiotherapy
Father Muller Medical College,
Mangalore
naraswamin2001@gmail.com
Swagata De / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Introduction
Patients with acute respiratory failure and pulmonary
pathology, who experience excessive effort of breathing,
inadequate alveolar ventilation and severe hypoxemia require
ventilator support, intensive care monitoring and therapy. The
main aim of mechanical ventilation is to reduce the work of
breathing and to improve alveolar ventilation and arterial
oxygenation 1, 2. Chest physiotherapy has been recognized to
have a considerable role in the intensive care to prevent
complications associated with mechanical ventilation.
Traditionally, chest physiotherapy has focused on removal of
retained secretion and improvement of lung ventilation. But
comparatively less attention has been given to optimizing lung
function and matching of alveolar ventilation with capillary blood
flow (ventilation perfusion) as a treatment priority 3.
Positioning is one of the effective interventions used by the
physiotherapists. The concept of positioning which is governed
primarily by the influence of gravity was based on the principles
of the West lung model 4. Thus, the principles of body positioning
has direct effect on optimizing the respiratory mechanics and
thereby enhancing gas exchange, oxygenation and ventilation
perfusion matching in mechanically ventilated patients in ICU5,6
In the upright position, the top of the pleural space is
relatively more negative. Pleural pressure is more positive in
the dependent basilar lung regions because of the downward
acting weight of the lung. The lung is easier to inflate at low
volumes than at high volumes, where it is stiffer. Since the
expanding pressure at the base of the lung is small and has a
small resting volume. Thus, it expands well on inspiration. The
apex of the lung has a large expanding pressure, a big resting
volume, small change in volume in ventilation. The base of the
lung has larger change in volume and smaller resting volume
than the apex. Thus, its ventilation is greater. Therefore, the
base of the lung is poorly expanded but better ventilated. The
different regional lung compliance is responsible for the
dependent alveoli being relatively compliant and non dependent
alveoli being relatively noncompliant. Thus, most of the tidal
volume is preferentially distributed to dependent alveoli because
they expand more per unit pressure change than nondependent
alveoli do. Thus erect sitting may increase the lung compliance4
Static and dynamic compliance are the two important
parameters measured. The modern ventilators are able to
display basic ventilatory variables such as tidal volume, airway
pressure and flow (analog) waveform and digital (numeric) output
which make it possible to monitor respiratory mechanics at the
bedside7, 8. In critically ill mechanically ventilated patients, the
respiratory system compliance can be routinely monitored at
the bedside by the use of ventilator waveforms. This study was
done to investigate the short term effect of body positioning on
lung compliance. Such work may help to identify the role of
judicious positioning in therapeutic exercise regimen.
Methodology
This Randomized cross over study was performed on 19
patients admitted in Medical intensive care unit at Father Muller
Medical College Hospital with lung pathology, requiring ventilator
support and fulfilling the inclusion criteria. Subjects with bilateral
or unilateral lung pathology on chest radiograph, Intubated and
83
mechanically ventilated, On SIMV mode (pressure controlled),
and hemodynamically stable were included in this study.
Subjects with the contraindications to lateral or upright position,
unstable spinal fractures, chest wall deformities, pneumothorax,
pulmonary edema, pleural effusion and neurological disorders
were excluded.
Procedure
Subjects connected with mechanical ventilator, with lung
pathology were selected on the basis of the inclusion and
exclusion criteria by purposive sampling. Ethical approval for
the study was obtained from the institutional ethics committee.
Prior to the study demographic data, present history, past history
and hemoglobin levels were obtained from the patients chart.
Vitals blood pressure, pulse rate respiratory rate and temperature
were recorded from the monitor. Mode of ventilator support, set
tidal volume, respiratory rate, FiO2 and SpO2 were recorded from
the pulseoximeter. Ventilator parameters like delivered tidal
volume, peak pressure(Ppeak),plateau pressure(Pplat) ,mean
pressure(Pmean), positive end expiratory pressure(PEEP),minute
ventilation were recorded at the beginning in supine position.
Patients were positioned according to the sequence four
preplanned random positions as given in the randomised order
Fig. 1: Patient positioned in supine position.
Fig. 3: Patient position left lateral position
Statistical analysis
The dynamic compliance of the four positions was
compared by the two way ANOVA for the repeated measures.
To evaluate the pair wise difference among different time point
in four different positions were done by multiple comparisons
by Bonferronis test. The heart rate, respiratory rate and SpO2 of
the four positions and in different orders were compared by the
one way ANOVA. Multiple comparisons were done by
Bonferronis test. The data analysis was done by using SPSS
version 13.
84 Swagata De / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
table obtained from www.randomization.com. Each position was
maintained for 45 minutes,during which hemodynamic
parameters, respiratory rate, SpO2 were monitored.
Measurement
Dynamic lung compliance was measured by using the
formula Vte/Ppeak- PEEP at intervals of every 15 minutes. The
patients positions were secured by using pillows which were
placed at the back of the patient. At the end of 45 minutes,
patients were turned to the subsequent position. Hemodynamic
parameters like blood pressure, pulse rate, respiratory rate were
recorded. Ventilator parameters like delivered tidal volume, peak
pressure (Ppeak), plateau pressure (Pplat) , mean pressure(Pmean),
positive end expiratory pressure(PEEP),minute ventilation were
recorded. After every 15 minutes hemodynamic parameters,
respiratory rate, SpO2 and compliance were recorded. After 45
minutes the position was changed to the next. Same parameters
were recorded at the base line. At the interval of every 15 minutes
hemodynamic parameters, respiratory rate, SpO 2 and
compliance were measured. Any therapeutic maneuvers such
as tracheal suctioning were done within first few minutes.
Ventilator settings were not changed.
Fig.2: Patient positioned in right lateral position
Fig. 4: Patient positioned in erect position
Results
A total of 19 subjects were included in the study with the
mean age of 60.00. Dynamic compliance (ml/cm H2O), heart
rate (beats per minute), respiratory rate (breaths per minute)
and SpO2 (%age) were evaluated in different positions in 12
females and 7 males at the interval of 15 minutes.
Discussion
The mean age of the subjects who were included in the
Fig. 5: Comparison of dynamic compliance in supine position Fig. 6: Comparison of dynamic compliance in right lateral position
at the interval of 15 minutes at the interval of 15 minutes

Swagata De / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 85
Fig. 7: Comparison of dynamic compliance in left lateral position study was 60. All the patients selected for this study had different
at the Interval of 15 minutes lung pathologies that are commonly encountered in our intensive
care unit but without any pleural involvement. The dynamic
compliance was calculated by using the formula mentioned
earlier in the study. The main reason for performing this study
was to find out the effect of positioning on dynamic compliance
in elderly patients on mechanical ventilator with lung pathologies
since it is known that the lung compliance reduces with age.
Age related muscle weakness and presence of lung pathology
may result in decreased lung compliance.
The respiratory system undergoes a significant change with
aging. It was found that the age-related loss of the lung static
recoil forces, stiffening of the chest wall and diminished alveolar
surface area lead to a decrease in vital capacity, an increase in
residual volume, decrease in expiratory flows and increased
ventilation-perfusion heterogeneity. Respiratory muscle strength
Fig. 8: Comparison of dynamic compliance in erect position at consistently declines with age further increasing the work of
the interval of 15 minutes breathing. Thus a patient on mechanical ventilator due to
decreased respiratory muscle strength may have altered lung
mechanics 10. In any pulmonary manifestation, the lung
mechanics are altered. 11
Positioning has direct effect on the respiratory compliance.
Positioning may help in improving the dynamic compliance.
Thus, when an individual is connected to ventilator, it is
mandatory to monitor the respiratory mechanics to decide which
position is effective in improving the lung compliance and
oxygenation status of the patient. It helps in understanding which
position is appropriate in optimizing the lung compliance, the
variation of the compliance with time and the duration for which
each position should be maintained.
Dynamic compliance was one of the outcomes used in this
study. Previous studies have analysed the effect of position on
static compliance which reflects only the pulmonary parenchymal
Fig. 9: Comparison of dynamic compliance among the different
compliance. Dynamic compliance takes into account the airway
positions
pressure during inflation, which is influenced by volume, thoracic
(lung and chest wall) compliance and the thoracic resistance to
flow during inflation 12.
It was a repeated measure study in which the same
participants were positioned in all the four positions and the
outcome was measured. In this study the effect of independent
variables that is the different positions are seen within participants
in a single group rather than between groups. Here the
participants act as their own control and received all the positions.
To prevent the introduction of extraneous variables like the effect
of one position over the other, randomization of the positions
were done.
The finding of this study was that the dynamic compliance
was more in the supine position after 45 minutes. However the
increase in the lung compliance in the erect position and in the
supine position did not show significant difference. In both the
positions the dynamic compliance achieved the highest value
Table 1: SpO2 (%) in different positions after 45 minutes after 45 minutes. In the erect position, the increase in the dynamic
compliance may be due to the effect of gravity on diaphragm
Positions Mean S.D which pulls the pleura downwards creating a more negative intra
pleural pressure causing the base of the lung to expand more
Supine 97.793.066 at lower pressure thereby increasing the compliance of the base
of the lung. Moreover the erect position increases the vertical
Right lateral 97.422.457 length of the chest cavity. The diaphragm being in a mechanically
advantageous position allows better excursion.
Left lateral 97.842.455 In this study, most of the patients were placed on water
bed. While assessing the compliance in erect position on water
Erect 97.582.775 bed, the posture was slumped rather than upright since while
lifting the head end of the bed up the water inside the bed used
to shift towards the leg. Hence maintaining sitting posture was
No significant difference was found in heart rate (p=0.946), difficult. Since complete erect position could not be achieved in
respiratory rate(p=0.607) and SpO2(p=0.961) in different patients on water bed, this may have compromised the increase
positions. On comparing the effect of one position with the other in dynamic compliance. In slumped sitting, the thoracic kyphosis
position on the heart rate, respiratory rate and SpO2 was not increases which will reduce the chest wall compliance. Slight
significant (p=1.00) neck flexion in this posture may restrict the airflow, which may
increase the airway pressure.13,14 This in turn may increase the

86 Swagata De / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
peak inspiratory pressure thereby reducing the dynamic
compliance.
The dynamic compliance in lateral positions decreased over
a period of time. The dynamic compliance reduction may be
attributed to the compression of the lung tissues by the heart 15.
The inferior part of the diaphragm is pushed upwards by the
abdominal viscera 16. This mechanical disadvantage makes the
alveoli less distensible and offers a greater resistance to airflow
17
. Decrease in tidal volume and increase in the peak inspiratory
pressure. Studies have shown that greater compliance of
respiratory system in lateral position because the weight of the
mediastinum and displacement of abdominal contents contribute
to gradient of vertical pleural pressure,18,19,20
In this study, dynamic compliance is the highest in the
supine position. Dynamic compliance decreases in supine
posture in young normal people. In supine position, static
mechanics data did not appear modified by the gravitational
effect of this posture. There is a very loose attachment of the
pericardium to the sternum or diaphragm. The compression of
the lung tissue due to weight of the heart creates a greater
transpulmonary pressure gradient. This results in change in the
shape of the lung. Thus the lung tissues displace as the heart
moves rather than compressed beneath the heart 21 . This may
be the reason for high dynamic compliance in supine position.
SpO2 was the highest in the left lateral position. In this
position the right lung which has greater surface area is the
topmost which increases the alveolar arterial oxygen difference.13
In the lateral position the intrathoracic gravitational forces
responsible for ventral distribution of the tidal volume. Though
there were difference in the dynamic compliance among the
four positions but the difference was not significant to conclude
that any particular position is effective in increasing the dynamic
compliance.
However Porto and coworkers in their study compared the
static compliance in four positions that is in supine, lateral
decubitus, erect. They found that static compliance is the highest
in the erect position after two hours of positioning. 22 Thus
prolonged positioning would have improved the compliance in
the erect sitting. Although great care was taken while positioning
a patient on water bed, upright position was difficult to maintain
when patients were on water bed. Patients included in the study
were having different lung pathologies. PEEP and FiO2 values
were not constant for all the patients. Measurement of static
compliance would have improved the quality of study. But static
compliance was not measured due to difficulty in the method.
Clinical Implication
Since positioning affects the respiratory mechanics, it is
important for the therapists to monitor the respiratory system
compliance. Though there are many sophisticated methods to
measure the lung compliance, but by using this simple formula,
the respiratory compliance can be easily calculated at the
bedside. Estimation of the compliance will help us to decide
which position is effective in improving the compliance.
Conclusion
By this study the effect of positioning on the dynamic
compliance, and SpO2 were evaluated. It was found that positions
affect the dynamic compliance. But the results were not
significant to recommend which position is effective in improving
the compliance. Studies with a larger sample size and
homogeneous subjects may improve further knowledge in this
regard.
References
1. Kim MJ, Hwang HJ ,Song HH. A randomized trial on the
effects of body positions on lung function with acute
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respiratory failure patients. International Journal of nursing
studies 2002 ; 39: 549-555
2. Sud S, Sud M, Friedrich JO, Adhikari NKJ. Effect of
mechanical ventilation in the prone position on clinical
outcomes in patients with acute hypoxemic respiratory
failure: a systematic review and meta-analysis. CMAJ
2008;178(9):1153-1161
3. Dean E. Effect of Body Position on Pulmonary Function.
Physical Therapy, 1985; 65(5):613-618
4. West J. Respiratory physiology-the essentials. 8th edition.
Baltimore Maryland:Lippincott Williams and Wilkins,2008
5. Thomas PJ, Paratz JD, Lipman J, Stanton WR. Lateral
positioning of ventilated intensive care patients: A study of
oxygenation, respiratory mechanics, hemodynamics, and
adverse events. Heart Lung 2007; 36(4): 277286.
6. Bigatello LM, Davignon KR, Stelfox HT. Respiratory
mechanics and ventilator waveforms in the patients with
acute lung injury. Respiratory Care 2005; 50(2): 235-244.
7. Lucangelo U, Bernabe F, Blanch L. Respiratory mechanics
derived from signals in the ventilator circuit. Respiratory
Care 2005; 50(1): 55-65
8. Sprung J, Galic O, Warner D O.Review article:age related
alterations in respiratory functions-an anaesthetic
consideration. Can J Anaesth 2006;53(12):1244-57.
9. Gupta D, Aggarwal AN, Sud A, Jindal SK. Static lung
mechanics in patients of progressive systemic sclerosis
without obvious pulmonary involvement. Indian J Chest Dis
Allied Sci 2001;43:97-101.
10. Grinnan DC, Truwit JD. Clinical review:Respiratory
mechanics in spontaneous and assisted ventilation. Critical
Care 2005; 9(5): 472-484
11. Anthonisen NR, Bartlett D, Tenney SN. Postural effect on
ventilator control. J App Physiology 1965; 20: 191-196
12. Narasimman S, Rajeev A, Reshma P. Commonly adopted
body positions on pulmonary functions in normal males of
different age groups Physiotherapy and Occupational
therapy Journal 2009; 2 (4) 183 - 193.
13. Pryor JA, Prasad SA. Physiotherapy for respiratory and
cardiac problems adults and pediatrics. 3rd edition. New
Delhi:Elsevier publications,2004.
14. Numa AH, Hammer J, Newth CJ. Effect of prone and supine
positions on functional residual capacity, oxygenation, and
respiratory mechanics in ventilated infants and children.
Am J Respir Crit Care Med. 1997; 156(4 Pt 1):1185-9.
15. Kenyon CM, Pedley TJ, Higenbottam TW. Adaptive
modeling of the human rib cage in median sternotomy. J
Appl Physiol. 1991; 70(5):2287-302.
16. Pelosi P, Bottino N, Chiumello D, Caironi P, Panigada M,
Gamberoni C, et al. Sigh in supine and prone position during
acute respiratory distress syndrome. Am J Respir Crit Care
Med. 2003; 167(4):521-7.
17. Blanch L, Mancebo J, Perez M, Martinez M, Mas A, Betbese
AJ, et al. Short-term effects of prone position in critically ill
patients with acute respiratory distress syndrome. Intensive
Care Med. 1997; 23(10):1033-9.
18. Tawhai MH, Nash MP, Hoffman EA. Supine and prone
differences in regional lung density in the human lung with
constant shape. J Appl Physiol 2009;107:912-920.
19. Palmon S C, Kirsch J R, Depper J A. The effect of prone
position on pulmonary mechanics is frame dependent.
Anesth Analg 1998;87:1175-80.
20. Tzoufi M, Mentzelopoulos SD, Roussos C, Armaganidis
A. The effect of nebulised salbutamol, external positive end-
expiratory pressure and their combination on respiratory
mechanics, hemodynamic and gas exchange in
mechanically ventilated chronic obstructive pulmonary
disease patients .Anesth Analg 2005;101:843-50
21. Bein T, Ploner F, Ritzka M, Pfeifer M, Schlittz H J, Graf B H.
No change in the regional distribution of tidal volume during
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Kumpels C. Comparative analysis of respiratory system
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Acknowledgements
The Authors expresses their sincere gratitude to all the
MICU Nurses of Father Muller Medical College Hospital and
the Management of Father Muller Medical College, for their
support.
Note: This paper was awarded first prize during National
Physiotherapy Conference at AIIMS.

88 Swagata De / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Corelation Between Knee Extensor Strength and Endurance in
Dependent and Independent Elderly
Nidhi Sharma*, Anish Raj**, Ruchika Chugh*, Sumit Kalra*
*Lecturer, Banarsidas Chandiwala Institute of Physiotherapy Kalkaji ,New Delhi, **Lecturer, D.A.V. College of Physiotherapy &
Rehabilitation Jallandhar, Punjab
Abstract
Purpose of the study
To correlate the difference in strength and endurance of
knee extensor muscles between dependent and non dependent
elderly.
Methodology
Strength in the form of maximum isometric voluntary
contraction for the quadriceps in hip & Knee 90 degree flexion
in High sitting position using strain Gauge. The data collected
consisted of subjects score on the strength and endurance of
knee extensors, by dividing the subjects into two groups
dependent and independent elderly. The score for strength was
determined by recording maximum voluntary isometric
contraction of right knee extensor and score for endurance was
determined by calculating number of sit stands in 30 seconds.
Result
The result of the study proves that there is statistically
significant correlation between strength and endurance of knee
extensor among dependent and independent elderly.
Keywords
Endurance, Strength, Strain Gauge.
Introduction
The age-related deterioration of physiological capacities
such as muscle strength and balance is associated with
increased dependence.
Ageing is associated with a deterioration of various
physiological capacities, such as muscle strength, aerobic
capacity, neuro-motor coordination, and flexibility. These age-
related declines result in a host of negative outcomes, including
functional limitations and therefore loss of independence.
Ageing is accompanied by both structural and functional
changes in muscles, including loss of dynamic and isometric
muscle strength. If functionality and strength are decreased,
maintaining independence in activities of daily living (ADLs) may
be hindered, as physical function is an integral constituent of
ADLs.3 Nearly a quarter of men and women have some degree
of physical limitation, often relating to ambulation by the age of
65yrs.4
Data from the National Health Interview study indicates that
15% of older (65-69yrs) men and women have difficulty with
self care or walking.5
Reduced endurance, strength and range of motion are
perceived as the most limiting intrinsic factors affecting
ambulation with advancing age. Thus there is age related
changes in skeletal muscle function.6,7
Physiological evidence indicates that there is 30-40%
decline in isometric forces and 18-20% reduction in muscle mass
between 2nd-7th decade of life.8,9,10
Nidhi Sharma / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Muscle strength decline with advancing age,11 is best seen
at the beginning of 6th decade.12
This age related strength decrease has been reported to
be faster in lower extremity than in upper body. (Asmunssen
and Heeboll-neilsen,1962, Bemben et al, 1991). The proximal
muscles of lower limb have been reported to be especially
affected by muscle fiber atrophy during ageing. 8,5
Lexell et al, 1988 has suggested loss of type II fast twitch
motor units contributing to strength decrease besides their
atrophy in old age.13
Simmonson (1947) found leg strength declines more rapidly
with age than handgrip.
Joel reported that muscle strength of hamstring, soleus and
gastrocnemius is correlated with activities of daily living.14
Denise reported that slow and fast speed of walking
improved with increased knee extensor strength.15 Aniansson
reported that quadriceps is related to walking ability in healthy
women.16
Several studies have demonstrated a positive association
between muscle strength of the lower extremities and mobility
tasks such as rising from a chair.
Maximal isometric strength correlated significantly with
maximal walking speed among both sexes, which accords with
the results of Fiatarone et al. They observed a statistically
significant correlation between dynamic quadriceps strength as
measured by a functional test, and maximal walking speed as
well as time taken to rise from a chair among frail institutionalized
subjects aged 86-96 years.17
Differences in isometric strength and leg extensor power
over the age range were equivalent to losses of 1-2% per annum
and 31/2% per annum respectively. Studies also prove that
isometric knee extensor strength influences chair rise time. 18
Summarisingly, there is age related decline of maximum
isometric force of knee extensors5 that also affects endurance.
It is therefore imperative that appropriate screening methods
are developed to identify elderly who should be referred for a
detailed physical therapy evaluation.
Experimental Hypothesis
There is statistically significant correlation between strength
and endurance of knee extensor among dependent and
independent elderly.
Review of Literature
The ageing process includes a slowing of time and rate of
relaxation29 of skeletal muscle that is evident in both animals
30,31.32
and humans 33,34. However, the mechanisms of age-
associated slowing of muscle relaxation are not well understood.
In 60-70 yr olds, the ankle dorsiflexor, plantar flexor, and
thenar muscle groups are reported to be 20-43% slower than
those in young adults 34,35,36 whereas in men and women over
80 yr old the ankle dorsiflexors 34 and the adductor pollicis 33 are
reported to be 49-56% slower.
Slowing of Aged Muscle and SR Ca2+ Uptake
Relaxation times and rates of the quadriceps in the elderly
women were 31% slower than that in the young women. These
findings are consistent with other studies that have used
electrically evoked twitch or tetanic contractions to demonstrate
89
a slowing of relaxation in elderly human muscle 35,36,33,34 women aged 19 to 90. They found stronger correlations between
knee extension strength and functional mobility, both in men (r
Ageing = -.60) and in women (r = -.71)

The process of aging in humans is characterized by a Subjects

multitude of changes in all bodily systems that ultimately result
in a decreased capacity to function.
in each group)
Muscular Strength and Endurance
A major concern facing older adults and researchers
studying aging is the loss of skeletal muscle mass, known as Inclusion Criteria
sarcopenia, 51 and the associated loss of voluntary strength.
Deterioration of Function with Age
Samson et. al. (2000) 18 agrees with the decline in
functionality with age.. These studies indicate that functionality
does decline with age.
Samson et. al. (2000)18 investigated isometric knee extensor Exclusion Criteria
strength, handgrip strength, and leg extensor power, and noted
a progressive decline with age (for men: 42%, 34%, and 49%
respectively; for women:46%, 34%, and 61% respectively). This
is representative of the literature, Vandervoort (1992)67 agrees
with the decline in strength with age, as well as, Doherty (2001)68.
With respect to maximal oxygen consumption (VO2max), Booth
et. al. (1994)69 reported that by age 65 mean VO2max decreases
to roughly 70% of that of a 25 year-old. They suggest that the
VO2max decreases at a rate of approximately 0.45 ml.kg-1.min-
1.yr-
Muscle strength has been reported to reach peak values
between 25 and 35 yr of age, is maintained or is slightly lower
between 40 and 49 yr of age, and then is 12-14% decade less
after 50yr of age.75, 76 these age-associated differences in
strength are highly correlated with age differences in muscle
mass.77
As demonstrated by, Booth and colleagues (1994),69 muscle
Fig. 1: Muscle Mass Deterioration with Age: Line of best-fit
showing howmuscle mass is decreased with age.
60 subjects were selected & assigned into two groups (30
A Dependent Elderly
B Independent Elderly
Both male and female, age group-60-80yrs.
Independent elderly is defined as being able to go into the
community without the need for assistive devices.4
It is defined with respect to Barthel index. (Appendix D) ie
walking 50 yards without assistance.
Symptomatic osteoarthritis.80
Inflammatory arthropathies like Gouty arthritis, Rheumatoid
arthritis etc.18
History of neurological disorders eg. Cerebrovascular
accident18
History of any heart disease.
Body Mass Index>30kg/m2 82
Any history of lower extremity pathology within the past
2 years.
Presence of any disorder that can account for problem
in balance such as lower limb joint replacements
TKR,THR
Absent propioception and / or abnormal tone.
History of vestibular disorder
If experienced any unexplained fall within 6 months
Malignancies of lower extremities
Any active illness that may interfere with the study like
Tuberculosis
Diabetes with neuropathy in lower extremities.

Instruments And Tools Used

1. Fixed strain gauge.
2. Comfortable quadriceps table so that it provides for
adequate stabilization and proper positioning of the subject.
3. Comfortable chair of adjustable height without arm support
so that it provides for adequate stabilization and proper
positioning of the subject.
4. Stop watch.
5. Steel chain.
6. Weighing machine.
7. Stadiometer for height measurement.
8. Camera (Sony Cybershot 7.2 mega pixels)

area decreases tremendously with ageand can lead to
impairment.
Larsson and colleagues (1978) noted that quadriceps
strength increased up to the age of 30 years, remained
ratherconstant to the age of 50 years, and then decreased with
increasing age, a decrease of 24-36% between the ages of 50
and 70 years. Vandervoort and McComas (1986)34 also note a
reduction in force production and demonstrated that the
contraction was significantly longer for women then for men and
for the older subjects then for the younger subjects.
Samson et al. investigated the correlation between knee
extensor strength and functional mobility (the timed get-up-and-
go test, comparable to a combination of walking velocity and
chair rise performance in the present study) in healthy men and
Procedure
Design
This study is a co-relational study which intends to measure
the correlation between strength and endurance of knee extensor
muscle among dependent and independent elderly.
Protocol
Testing was performed only after informed consent was
taken from the subject. The subjects were assessed and
demographic data such as height and weight were measured
and noted. After this, subjects underwent strength and endurance

90 Nidhi Sharma / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
measurement using strain gauge and sit and stand test. Data
was collected on a data collection form.
Preliminary measurements, taken prior to beginning the
study, included the measurements of body parameters using
standardized techniques.
Total Body Weight: Subject in minimal clothing stood straight
on a standardized weighing machine without looking down or
carrying any object that may falsely add to the weight.
Standing Height: The subjects stood straight with shoes
off, against an upright wall with a stadiometer, touching the wall
with the back, buttock and both heels. The head oriented in a
Frankfurt plane, i.e. the lower border of the eye socket and upper
border of the ear opening should be on a horizontal line. The
subject was asked to stretch upwards and take and hold a full
breath. The ruler was lowered until it touched the vertex firmly.
Then marking at the vertex was noted.
Basal metabolic index- it was found using the formula
weight/height*height ie kg/m2.
Methodology
For Strength Measurement
Proposed Standardization procedure for measurement of
maximum voluntary isometric contraction (MVIC) Position18,82,83,84
Subjects were strapped to quadriceps table in a seated
position with 90deg of flexion at hip and knee.
Setting was adjusted individually to ensure minimal hip and
knee joint movement and to minimize vertical displacement
between the lower back and back rest during muscular force
exertion.
Rigid leg cuff that was adjusted on the lower leg
approximately 3cm above medial malleoli was connected
to strain gauge through a stiff steel chain.
Cuff and steel chain were adjusted such that the direction
of force is perpendicular to the long axis of lower leg.
To ensure identical cuff placement between sessions, and
furthermore, to obtain the external knee joint moment arm,
the distance from the cuff to the knee joint line was
measured.
Defining the measurement
The subjects were carefully instructed to contract as fast
and forceful as possible.
The highest contraction was recorded, rather than the
average of two trials to eliminate the effect of fatigue or
other errors.
Instruction to the Patient85
Patients were instructed of the intent of the test.
Objective and consistent instructions that achieve a
consistent level of motivation was given.
Subject was asked to build force to a maximum over a 2sec
period and maintain the maximum effort for 5sec. and push
the ankle cuff.
Environmental Factors
Test was performed in a private and quiet room which
eliminated any factor that might affect instrument
performance and patient cooperation.
Advantages83
MVIC correlates well with the number of firing motor units
Nidhi Sharma / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
and thus is the most suitable measure of muscle force in
clinical trials.
Performed under controlled condition, with velocity and
length held constant, thereby enhancing reproducibility.
It is safe as no motion is produced hence no injury.
Fatigue is not induced.
Disadvantages83
Measures static force, a parameter not directly related to
function.
Methodology
For Measuring Endurance86
Position
Subject seated in a position with 90deg of flexion at hip
and knee.
Setting is adjusted individually according to height of
individual
Comfortable, painless, secure and safe position was
maintained.
Defining the Measurement
Subject was asked to sit-stand from the chair.
Number of sit-stand are counted in 30sec and recorded.
Instruction to the Patient
Patients were instructed of the intent of the test.
Objective and consistent instructions that achieve a
consistent level of motivation was given.
Patient was instructed to stand up and sit down on the chair
without taking support of the chair.
If the patients feel uncomfortable during the test they were
allowed to stop in between.
Environmental Factors
Test would be performed in a private and quiet room which
eliminates any factors that might affect instrument
performance and patient cooperation.
Data Analysis
All data was collected and analyzed using SPSS 15. The
data collected consisted of subjects score on the strength and
endurance of knee extensors, by dividing the subjects into two
groups dependent and independent elderly. The score for
strength was determined by recording maximum voluntary
isometric contraction of right knee extensor and score for
endurance was determined by calculating number of sit stands
in 30 seconds. Data was analysed for both the groups using
independent t test and significance was set at 95% confidence
level.
Results
In the study 60 subjects were taken, 30 dependent and 30
independent based on inclusion and exclusion criteria. Their
physical characteristics ie age, weight and height were
measured. BMI was calculated using the formula weight/height
2
in kg/m2 People having BMI>30 kg/m2 were excluded. Physical
Characteristics of the Subjects were matched statistically so that
91
two groups were comparable. age related deterioration of physiological capacities93 such as
Since the difference between age and BMI of dependent muscle strength of the lower extremity and balance which also
and independent is non significant that is P > 0.05 there fore on affect the sit to stand performance.
the basis of these two physical characteristics the two groups Our study that shows a clear cut difference between mean
are comparable. Strength and endurance of dependent and strength of dependent ( 6.90) and independent (12.92) and
independent subjects was measured using their respective endurance of dependent (4.87) and independent (9.90) suggest
methods and compared statistically using independent t test. highly significant correlation between the two parameters which
defines their importance in maintaining ADL function.
Strength N Mean S.D P Value Thus reduced muscle strength or power and endurance
may be associated with decreased function in various ADLs.9
Dependent 30 6.90 2.75 <0.001 Similar studies have been conducted by Bassey72 who
Highly found leg extensor power significantly related to walking speed,
Independent 30 12.92 4026 Significant rising from chair, and climbing stairs. Avlund et al and Hyatt et
al18 found that a reduction in muscle strength and power might
Endurance N Mean S.D P Value be associated with a reduced function in various activities of
daily living.
Dependent 30 4.87 2.8244 <0.001 Similar study conducted by Samson et al found higher
Highly correlation between muscle strength and functional mobility in
Independent 30 9.90 2.32 Significant women than men.
All such studies confirm the extreme importance of
Comparison of muscle strength and Endurance (Sit to quadriceps muscle strength for activities of daily living, including
stand) test scores between independent and dependent groups. standing up, sitting down and stair climbing, as also done by
This table shows a comparison of muscle strength on knee Sami.85 and hence its loss may result in loss of independence.
extension and sit to stand test score as muscle endurance, Muscle weakness in elderly because of ageing was already
between the independent and dependent group. Muscle strength causing muscle function deterioration which now after loss of
of knee extensors in the independent group was 12.92 + 4.26 independence acts synergistically with disuse94 and causes
and that in the dependent group was 6.90 + 2.75.These results further loss of skeletal muscle function.
shows that muscle strength in the independent group was Hence the cause of dependence now becomes the side
significantly higher than dependent group ( P < 0.001) effect of dependence and leads to decrease in general activity
The sit to stand test score as muscle endurance of the levels in the elderly which in turn elevates the risk of osteoporosis
independent group was 9.90 + 2.32, while that of dependent due to decrease in overall loading of the skeleton.95
group was 4.87 + 2.86 times. There was significant difference Therefore it is important to break this cause-effect
relationship and this can be achieved through extensive training
program.
Muscle strength training has been reported for improving
ADL ability. Lester89 showed that a group participating in a
strength building exercise program for 12 weeks showed
improved walking ability with increased quadriceps strength and
endurance. It shows how regular exercise can improve
parameters such as dressing and walking performance important
for independent living in old women.
Fiatarone90,91 provided evidence that improvements in
quadriceps femoris and hip extensors muscle strength resulted
in improved walking and stair climbing ability. Thus recent reports
have stressed the effect of muscle strength training for
maintaining ability in ADL.
Muscle strength training is now being actively encouraged
in the elderly.91,92

Future Research
Future studies may consider association between
independent walking and various other muscle functions like
hip extensors, ankle plantar flexors. And quantitatively evaluate
the variables needed to maintain functional independence like
balance.
Focus can be on establishing minimal strength and
endurance for independent walking.

Relevance to Clinical Practice

on the test score between independent and dependent group
(P < 0.001).
Discussion
Functional disability in walking leads to such undesirable
consequences as fear of falling, loss of confidence, loss of
independence and lowered quality of life. 87 This functional
disability in terms of independent ambulation is associated with
Strength and endurance of knee extensor has been proved
to be important for independent walking, therefore it can be used
an objective way defining dependence and important criteria
for selecting the walking aid. It serves as an important quotient
to make a dependent elderly independent.
Conclusion
The result of the study proves that there is statistically

92 Nidhi Sharma / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
significant correlation between strength and endurance of knee
extensor among dependent and independent elderly.
Limitations of Study
The study has following limitations:
Small sample size.
Only knee extensor strength is measured.
Lack of computerized and technically accurate instruments.
Use of mechanical spring type strain gauge.
Pretest physical condition of the subject was not considered.
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95
Effectiveness of Bladder Rehabilitation Program in the
Management of Urge Urinary Incontinence in Older Women
Nirupma Singh*, Kamal Narayan Arya**
*Physiotherapist, Deptt. of Rehabilitation Sciences, Jamia Hamdard, New Delhi, **Sr. Occupational Therapist, Pt.DDU Institute for
the Physically Handicapped, New Delhi
Abstract
Background
Urinary incontinence is a common and treatable problem.
Aims and Objectives
To study the effectiveness of Bladder Rehabilitation
Program in the management of urge urinary incontinence and
urge predominant mixed incontinence in older women aged
between 55yrs 70 yrs.
Methodology
Twelve motivated, non-dementic (MMSE > 24) and
ambulatory subjects were taken for the study with history of urge
incontinence or urge predominant mixed incontinence persisting
at least 3 months with a frequency of at least 2 or more episodes
per week.
Outcome Measures
Reduction in the frequency of incontinent episodes as
determined by Bladder Diary ,Incontinence Impact Questionnaire
(IIQ) Overactive Bladder Questionnaire (OABq).
Intervention
Subjects were taught Bladder Rahabilitation Program
through Urge Suppression and Scheduled Voiding. At the end
of eighth week posttest scores of Bladder Diary, IIQ and OABq
were noted.
Result
Statistical difference between pretest and posttest scores
was found.
Conclusion
Bladder Rehabilitation Program is a safe and effective
conservative intervention that should be made more easily
available to patients as first line treatment of urge urinary
incontinence.
Key Words
Urge suppression, incontinence, bladder rehabilitation,
scheduled voiding, non dementic, ambulatory.
Introduction
Urge incontinence caused by detrusor overactivity is the
most common form of incontinence in older women1. Patients
with this condition typically experience sudden, unexpected loss
of large volumes of urine or leakage associated with a sudden
urge to urinate that cannot be controlled2.
96 Nirupma Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
The bladder diary is a common method used to evaluate
the frequency and characteristics of incontinence episodes in
both research and clinical practice3, 4, 5.
Bladder rehabilitation for detrusor instability is based on
the assumption that the underlying pathophysiology is the escape
of the detrusor from the cortical control over micturition that had
previously been established during childhood toilet-training. The
object of bladder retraining is to reestablish the authority of the
cerebral cortex over bladder function. This is performed through
a regimen of timed voiding, gradually increasing the intervals
between voids until the cycle of urgency, frequency, and urge
incontinence is broken.6 Studies have shown that the prevalence
of over active bladder and urge incontinence among women in
Asia is relatively high as compared to Western figures . Despite
the high prevalence , however, treatment treatment seeking is
not common ( M C Lapiton et al, 2001).
Occupational Therapists assists people of all ages to
achieve health and life satisfaction by improving their ability to
carry out the activities that they need to do or choose to do in
their daily lives. Maintaining ones own toileting needs is one of
the most basic of everyday activities, and therefore should be
an integral aspect of functional aspect. Occupational therapy
plays an important role in enhancing the quality of life of patients
affected with urinary incontinence especially in urge type.
Review of Literature
1. Soern Hagstroem et al , 2005 did a study to evaluate the
effect of bladder rehabilitation with idiopathic overactive
bladder to clarify whether the effect of the treatment is
increased by addition of a programmable timer.7
2. L Lewis Wall (1988) writes that UI is always treatable. It
can almost always be improved and frequency can be
cured, often using relatively simple, nonsurgical
interventions8
3. D.C Dutta, Urge Incontinence due to detrusor instability
(DI) is the commenest in elderly group..The condition
is largely functional or psychological in
originBladder retraining is useful in idiopathic
group when combined with stress incontinence, unstable
bladder is to be treated first.9
4. M C Lapitan and P L H Chye, 2001, did a questionnaire
based survey was performed in 5502 females from 11
countries to establish the prevalence over active bladder..
The overall prevalence was 53.1% .The most common
symptom was urgency (65.4%). The majority (75.4%) ware
not significantly bothered by the condition10.
5. Neil M Resnick et al (1985) writes that Aging may effect the
lower urinary tract in several ways . Bladder capacity , ability
to postpone voiding, urethral and bladder compliance are
all probably reduced11,12.
6. Yarnell J W G et all (1979) writes that Incontinence in elderly
is usually a remedial condition. It is transient in as many as
50% of patients. Of the remainders , as many as two thirds
can be cured or improved13,14.
Aims and Objectives
1. To formulate Bladder Rehabilitation Program for Urge
Incontinence.
2. To study the effectiveness of Bladder Rehabilitation void.
Program in management of Urge Incontinence. After eight weeks Bladder Diary , OABq and UIIQ were
filled again. Bladder Diary was again ticked for one week (either
Methodology by subject or with the help of care giver) to determine number
of incontinent episodes and frequency of urination posttest.
Twelve motivated, non demented (Mini Mental State Pretest and posttest data was statistically analysed using SPSS
Examination >24) (29 , 30) and ambulatory , community dwelling software.
subjects were taken for the study between age group of 55
years -70 years (N = 12). Statistical Analysis And Results
Study design: Prospective, experimental, convenient
sampling, community based efficacy study. The data analysis of this study was done using SPSS
software. Total number of subjects were twelve (n=12) between
Inclusion Criteria age group of 55 yrs -70 yrs (minimum age = 55 yrs, maximum
age = 70 yrs) with mean age = 63.75 yrs.
1. Urge Incontinence or Urge predomiant mixed incontinence
persisting for atleast three months with frequency of at least Descriptive Statistics
2 or more episodes per week.
Table 1: Showing descriptive statistics of all four variables
2. Experience of involuntary loss of urine associated with
strong desire to void. N Mini Maxi Mean Std.
mum mum Devia
Exclusion Criteria tion
AGE 12 55 70 63.75 5.172
1. Having urinary tract infection OABq(a) 12 11 15 13.17 1.267
2. Treatment for incontinence PIIQ(a) 12 9 14 11.58 1.676
3. MMSE <24 PIIQ(b) 12 6 8 7.08 .669
4. Any disease affecting symptom of incontinence. OABq(b) 12 9 11 9.75 .754
5. Severe uterine prolapse past the vaginal introitus. Fr.of incont epi. 12 8 14 11.08 2.392
per week (a)
Fr.of incont 12 5 10 7.50 1.977
Outcome Measures
epis.per week (b)
Bladder Diary Fr. of urination 12 10.8 11.7 11.317 .3433
Overactive Bladder Questionnaire (OABq) per day (a)
Patient Incontinence Impact Questionnaire (PIIQ) Fr, of urination 12 9.0 9.4 9.200 .1595
per day (b)
Written consent was taken from each subject. All subjects
filled the demographic data. All subjects ticked the Bladder Diary OABq a =Pretest scores of Overactive Bladder Questionnaire
for one week by themselves or with the help of caregiver to OABq b =Posttest scores of Overactive Bladder Questionnaire
determine number of incontinent episodes (per week) and PIIQ a =Posttest scores of Patient Incontinence Impct
frequency of urination (per day) pretest. Scores of OABq and Questionnaire
UIIQ were also noted. These scores were used as baseline data. PIIQ b =Posttest scores of Patient Incontinence Impact
Bladder Rehabilitation Program (BRP) was prepared after Questionnaire.
doing extensive research. Suggestions of two senior Occpational Frequency of incontinent episodes per week pretest
Therapists and two senior Gynaecologists were taken. This Frequency of incontinent episodes per week posttest
program included scheduled voiding and urge suppression Table 1 shows the descriptive statistics of age of all subjects
techniques. Suggestion about fluid manipulation was also given. and pre test and post test scores of all variables (Overactive
Goals were set regarding increasing the time interval between Bladder Questionnaire, Patient Incontinence Questionnaire,
each void. Frequency of incontinent episodes per week and Frequency of
Scheduled Voiding was carried out as follows - incontinent episodes per week).
1. The subject was instructed to void on a timed schedule,
starting with a relatively frequent interval of every hour while
she is awake. Table 2: Showing mean, standard deviation and standard error
2. At night, the patient is allowed to void only when she is of all variables
awakened from sleep by the need to do so.
3. When she can maintain this schedule for 1 week, the voiding Mean N Std. Std.
interval is increased by 15 minutes. It is increased gradually Devia Error
by 15 minutes every week until a normal voiding interval of tion Mean
2.5 3 hours has been established. OABq(a) 13.17 12 1.267 .366
OABq(b) 9.75 12 .754 .218
Urge Supression Technique PIIQ(a) 11.58 12 1.676 .484
PIIQ(b) 7.08 12 .669 .193
To get control over the bladder : Fr.of incont epi. 11.08 12 2.392 .690
1. Stand quietly or sit still. per week(a)
2. Take slow relaxed breaths. Fr.of incont epis. 7.50 12 1.977 .571
3. Contract the pelvic floor muscles rapidly. This helps keep per week(b)
the urethra closed ,to prevent urine leakage and calms the Fr. of urination 11.317 12 .3433 .0991
bladder. per day(a)
4. Concentrate on making the urge go away. Use mental Fr, of urination 9.200 12 .1595 .0461
distraction to reduce the awareness of the discomfort of per day(b)
the urge. Hum a tune or dobackward counting (50 to 1)
5. When the urge subsides, do not use toilet until the next

Nirupma Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 97
Table 3: Showing the difference of mean of pretest and posttest scores of all variables
Paired Differences t df Sig. (2-tailed)

Mean Std. Std. 95% Confidence

Devia Error Interval of the
tion Mean Difference
Lower Upper
OABq(a) -
OABq(b) 3.42 1.165 .336 2.68 4.16 10.164 11 .000
PIIQ(a) -
PIIQ(b) 4.50 1.567 .452 3.50 5.50 9.950 11 .000
Fr.of incont epi.
per week(a)
Fr.of incont epis. 3.58 .669 .193 3.16 4.01 18.567 11 .000
per week(b)
Fr. of urination
per day(a) - Fr, 2.117 .3186 .0920 1.914 2.319 23.013 11 .000
of urination per
day(b)
Interpretation: It is clear from table 3 that there is a significant difference in all scores of all variables; P=.000 (significant)

Graph 1: Showing pretest mean (13.17) and posttest mean Graph 3: Showing pretest mean (11.31) and posttest mean
(9.75) of Overactive Bladder Questionnaire (OABq) (9.20) of Frequency of Incontinence Episodes per Week

Graph 4: Showing pretest mean (2.117) and posttest mean

Graph 2: Showing pretest mean (11.58) and posttest mean (.3186) of Frequency of Urination per Day
(7.08) of Patient Incontinence Impact Questionnaire (PIIQ)

Discussion scores of Overactive Bladder Questionnaire was found (pretest

Urge Urinary Incontinence, perhaps the most common type
of incontinence in elderly women, occurs when involuntary
voiding is preceeded by awareness of a few seconds to a few
minutes. It is found that people usually do not seek treatment
for this problem mainly due to two reasons: 1. It is believed that
nothing can be done for this problem, and 2. people feel too
embarrassed to talk about it. Though incontinence in elderly is
a treatable condition.
Self monitoring of voiding behavior by using a bladder
diary was found to be effective. It offers the advantage of
assessing the severity of urinary symptoms in the individuals
own environment and under actual daily life conditions.
Significant difference between means of pretest and posttest
mean =3.42 , posttest mean =1.165, p= .000) (Jean F Wyman
et al, 1988).
The impact of urge incontinence on quality of life is
emphasized. The difference of pretest and post test scores of
Patient Incontinence Impact Questionnaire was also found to
be significant (p= .000) (M C Lapitan et al, 2001).
Frequency of incontinence per week and frequency of
urination per day was calculated by one week bladder diary
(Robb SS ,1985 and Burton JR, 1988) . Significant difference
was found between Pretest and posttest scores of Frequency
of incontinence per week (pretest mean=11.08, posttest mean
=7.50). Although condition was not completely cured but there
was some improvement in all subjects. The possible reason for
the improvement was perhaps better control over the bladder.

98 Nirupma Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
 Normal frequency of urination per day in a normal individual
is 7-8 voids per day. In this study the pretest scores of frequency
of urination per day was 11.317 . After intervention it had reduced
to 9.200. Although is more than the normal range but atleast
some improvement was shown by each subject. This difference
also denotes that voiding interval for each subject was increased
, although this was not statistically analysed. Increase in voiding
interval also meant the increased bladder capacity (for more
urine holding ) (L Lewis Wall, ).
Limitations of the Study
1. Sample size was small and hence results cannot be
generalized.
2. Objective measures like Urodynamics, uroflometry and post
void residual volume were not used.
Future Recommendations
1. Study can be done on disabled women.
Conclusion
Urinary Incontinence is the most common issue among
women. But due to embarrassment this health problem is kept
hidden and not talked about. Maintaining ones own toileting
need is one of the most basic of everyday activities thus
Occupational Therapists (O.T) have very strong role to play in
managing UI. Bladder Rehabilitation Program was found to be
very effective in managing Urge Urinary Incontinence in women.
This study also broadens the scope of O.T in Urogynaecology,
which is emerging as a field in India.
References
1. http://www.netdoctor.co.uk/health_advice/seniorshealth/sui/
ui_005139.htm
2. Wall LL. Diagnosis and management of urinary
incontinence due to detrusor instability. Obstet Gynecol
Nirupma Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Surv 1990;45:1S-47S.
3. Fantl JA, Newman DK, colling J, et al. Urinary Incontinence
in Adults: Acute and Chronic Management, Clinical Practice
Guideline, No 2, 1996 Update. Rockville , MD : US
Department of Health and Human Services Public Health
Sercice; 1996. Agency for Health Care Policy and Research
AHCPR publications. 96-0682.
4. Abrams P, Saad K, Wein A, eds. Incontinence. Proceedings
of the 1st International Consultation on Incontinence-June
28- July 1, 1998-Monaco . St. Helier , England : Health
Publications Ltd, 1999.
5. Abrams P, Blaivas JG, Stanton SL, Andersen JT. The
standardization of terminology of lower urinary tract function
recommended by the international Continence Society. Int.
Urogynecol J. 1990;45-58.
6. Burgio KL, Locher JL, Goode PS, et al. 1998. Behavioral
vs drug treatment for urge urinary
incontinence. JAMA 280:1995-2000.
7. Wyman JF ET AL , 1988. The Urinary in the Evaluation of
Incontinent women : a test retest analysis, Obsterics and
Gynecology 71: 812-817
8. Soern Hagstroem, 2005 , Programmable Timer in the
Bladder Rehabilitation Treatmentof OAB, Clinic Trials.gov
9. J S Berek, 1988, Novaks Gynaecology, Twlevfth edition,
Incontinence, prolapse and disorders of the pelvic floor ,
chapter 20, page 628 ,639)
10. M C Lapitan and P L H Chye, The Epidimiology of Over
Active Bladder among Females in Asia : A Questionnaire
Survey, Int Urogynaecol J 2001: 226-231
11. Broklehurst JC et al . Studies of the female bladder in old
age . Gerontol Clin.1966, 8: 285-305
12. Anderson JT et al. Bladder functions in healthy elderly
males, Scand J Nephrol 1978 , 12: 123-7
13. Yarnell J W G et al. The prevalence severity and factors
associated with urinary incontinence in random sample of
elderly . Age Aging 1979 , 8: 81-5
14. Willigton F L , Problems of urinary incontinence in elderly
Gerontol Clin (Basel ) 1969, 11:330-56.
99
Influence of Stair Climbing on the Self Efficacy in Post Cardiac
Surgery Patients
Uchil P*, Khan I**, Kamath N***
*Post Graduate Student, **Physiotherapist, ***Lecturer, Department of Physiotherapy, Manipal College of Allied Health Sciences,
Manipal
Abstract
The psychosocial aspect of cardiac rehabilitation is one of
the factors which help a patient to continue into phase two
cardiac rehabilitation. Self-efficacy is a psychological construct
based on socialcognitive theory, which describes the interaction
between behavioral, personal, and environmental factors in
health and chronic disease. Stair climbing is considered to be
important to decrease the risks of cardiovascular disease.
Objective
To assess the influence of stair climbing on the self efficacy
in post cardiac surgery patients.
Design
Pre and post test design.
Setting
Kasturba hospital, Manipal.
Population
30 post cardiac surgery patients, (mean age 48.65 years,
SD + 11.69 years).
Intervention
Patients were administered the cardiac self efficacy
questionnaire pre and post stair climbing on the fifth to seventh
post operative days (mean 6.4 SD + 1.43 days).
Outcome Measure
The self efficacy components of control of symptoms and
maintaining function were assessed and recorded pre and post
stair climbing.
Results
A significant change was observed in the patients
confidence to control their symptoms such as chest pain (p =
0.014, p<0.05) and to call their doctor (p = 0.034) post stair
climbing. Under the physical activity component a highly
significant change was observed in the confidence towards
performing regular aerobic exercise (p = 0.004), activities with
family (p = 0.008), usual social activities (p = 0.016).
Conclusion
We concluded from this study that stair climbing has a
significant influence on the self efficacy in post cardiac surgery
patients which aids in improving their confidence levels towards
control of their symptoms and maintaining their physical activity.
100 Uchil P / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Key Words
Social-cognitive theory, phase one cardiac rehabilitation,
physical activity
The World Health Organization defines Cardiac
rehabilitation (CR) the rehabilitation of cardiac patients is the
sum of all the activities required to ensure cardiac patients the
best possible physical, mental and social conditions so that they
may, by their own effort, regain as normal a place in the
community, and lead an active life.1
The psychosocial aspect of cardiac rehabilitation is one of
the factors which help a patient to continue into phase two cardiac
rehabilitation. Cardiac patients have lower self confidence;
underestimate their capabilities and thus limit themselves from
doing high intensity activities. Such patients even drop out from
the cardiac rehabilitation program as soon as they are discharged
from the hospital. These negative psychological states make
completion of cardiac rehabilitation difficult.
Self-efficacy is a psychological construct based on social
cognitive theory, which describes the interaction between
behavioral, personal, and environmental factors in health and
chronic disease. The theory of self-efficacy proposes that
patients confidence in their ability to perform certain health
behaviors influences their engagement in and actual
performance of those behaviors (e.g., diet and exercise
adherence), which in turn will influence their health outcomes.2,
3
Stair climbing is considered to be important as it has been
found to decrease the risks of cardiovascular disease.4 Due to
dearth in literature regarding changes in self efficacy with respect
to stair climbing on the cardiac status during phase one
rehabilitation, our study aimed to observe any relative change
in the self efficacy in relation to the cardiac status in post cardiac
surgery patients pre and post stair climbing.
Material and Methods
The study design used was a pre and post test design.
Thirty post cardiac surgery patients, between the age group of
18 to 65 years were recruited from the Kasturba Hospital, Manipal
through convenience sampling.
Patients with atrial or ventricular arrhythmias, uncontrolled
diabetes mellitus (random blood glucose > 400 mg/dL) , cognitive
impairments, orthopedic problems leading to difficulty in stair
climbing and uncontrolled hypertension (systolic blood pressure
>180mmHg and diastolic blood pressure>120 mm Hg or
hypotension (20mmHg drop in systolic blood pressure with
symptoms of lightheadedness or dizziness) at rest were excluded
from the study.
Instrument / Outcome Measure
The instrument used was the cardiac self efficacy scale .
The objective of cardiac self efficacy scale is to examine the
role of self efficacy in the physical and role function for patients
with coronary heart disease after controlling factors of anxiety
and depression.
The cardiac self efficacy scale has two components, the
first component containing 7 items pertaining to control of
symptoms and the second component containing 4 items
pertaining to maintaining function. Patients had to rate their 0.014) and to call their doctor (p = 0.034) post intervention. Under
confidence with knowing or acting on each of the 11 statements the physical activity component in the scale a highly significant
on a 5- point Likert scale (0= not at all confident, 1= somewhat change was observed in their confidence towards performing
confident, 2= moderately confident, 3=very confident, 4= regular aerobic exercise (p = 0.004), activities with family (p =
completely confident) 0.008), usual social activities (p = 0.016). (Table 2)
The cardiac self efficacy scale has two factors (Control of
symptoms and maintaining function) with high internal Table 1: Descriptive characteristics of the sample
consistency and good convergent and discriminant validity. n = 30 Mean Std. Deviation
Cronbachs alphas for the two factors were 0.90 and 0.87
respectively.5, 6, 7 Age 48.65 + 11.69
Postoperative day 6.4 + 1.43
Procedure Gender
Male : Female 19 : 11
The questionnaire was translated into two languages, Types of surgery
Kannada and Malayalam, which were the common dialects Coronary artery 19
spoken in the area of study. Back translation was carried out by bypass grafting
individuals blinded from the study. Valve replacements 6
An informed consent for stair climbing was obtained from Septal defect closures 5
the post cardiac surgery patients on the 5th to 7th post operative Others 0
days. The patients were blinded about the procedure.
Demographic details of the same were documented. Patients
Table 2: Level of significance of the 11 itemed Cardiac self
were explained to mark against the components of the Cardiac
efficacy scale
self efficacy scale questionnaire before stair climbing. Following
this, stair climbing of 20 steps was performed. First the patient Components Level of
climbed 10 steps following 2 minutes rest on a flat surface and significance
then climbed another flight of 10 stairs (Fig.1). Vital parameters (p<0.05)
before stair climbing, during and after stair climbing were Confidence in controlling symptoms
documented. Patients were asked to mark against the
components on the Cardiac self efficacy scale again after stair Chest pain by change in physical activity *0.014
climbing. Any complaints during stair climbing were noted.
Breathlessness by change in physical activity 0.157
Fig.1:
Chest pain by medications 0.340

Breathlessness by medications 0.914

Call or visit doctor *0.034

Explain doctor regarding condition 0.180

Take cardiac medications 1.000

Confidence in maintaining physical activities

Usual social activities *0.016

Usual home activities with family *0.008

Usual home activities with spouse 0.564

Get regular aerobic exercise *0.004

* (p value < 0.05)

Data Analysis
The data was analyzed using SPSS ver.16.0 software. The
Wilcoxon signed ranks test was used to analyze the pre and
post test values in the 11 item cardiac self efficacy scale.
Results
30 patients recruited for the sample varied from 18 to 65
yrs (mean 48.65 + 11.69 yrs). Post operative days extended
from the fifth to the seventh day after the cardiac surgery (mean
6.4 + 1.43). Nineteen males and eleven females participated in
this study. Out of the 30 cardiac surgeries performed, the sample
consisted of 19 CABG surgeries, 6 valve replacement surgeries,
and 5 septal defect closures (Table 1).
A significant change was observed in the patients
confidence to control their symptoms such as chest pain (p =
Discussion
After an acute coronary event, phase I cardiac rehabilitation
(CR) is important in assisting the patients pathway to recovery.
The content of phase I CR has traditionally included assessment,
education and exercise/mobilization. Mobilization may include
graduated exercise, walking programs and stair practice.8 The
National Service Framework for Coronary Heart Disease (CHD)
states that the aim of this phase is to offer high-quality cardiac
rehabilitation before discharge from hospital, and this should
begin as soon as possible after someone is admitted with CHD.9
As a component during mobilization in phase I CR, stair
use is inexpensive and can be easily integrated into everyday
life by most of the population. Stair climbing represents vigorous-
intensity physical activity with oxygen uptake reaching

Uchil P / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 101
approximately 80 percent of maximal values in young healthy
adults, corresponding up to approximately 10 metabolic
equivalents (METs) of energy expenditure sufficient to improve
cardiorespiratory fitness.10,11
Our study showed that self efficacy improved in terms of
the post cardiac surgery patients confidence to report episodes
of symptoms such as chest pain with any change in physical
activity, and to call or visit his or her physician after stair use. A
significant improvement was also seen with respect to their
confidence in performing activities of daily living at home and in
society. Stair climbing markedly improved their confidence in
performing regular aerobic exercise after their surgery and prior
to discharge from the hospital.
Both ward ambulation and inpatient exercise based cardiac
rehabilitation have been found to be equally effective in improving
self efficacy scores of activities for routine physical daily living
tasks over the first 28 days after return to home.12
Stair climbing can thereby be implemented as a major
component in the home based exercise program for the Indian
population who have undergone cardiac surgical procedures
and are unable to avail the benefits of phase two CR in an
exercise based cardiac rehabilitation centre. As stair use is less
expensive, and easily accessible, it can be integrated into the
daily living activities of the patients belonging to the rural sectors
in India.
Certain limitations were observed during the course of this
study. The study conducted was a pilot on a small sample
including only cardiac surgery patients from one centre, with
limited time constraints. Further studies could be implemented
by recruiting a larger sample size from various cardiac
rehabilitation and hospital centres. Larger samples with a more
heterogenous cardiac diseased population can be studied
including surgical, non surgical and interventional cases.
Conclusion
We thus concluded from this study that stair climbing has a
significant influence on the self efficacy in post cardiac surgery
patients. This novel concept would aid in improving their
confidence levels towards control of their symptoms and
maintaining their physical activity.
102 Uchil P / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
References
1. World Health Organization: Rehabilitation of patient with
cardiovascular disease: Report of a WHO expert committee.
WHO Technical Report series No.270; 1964.
2. Bandura. Self-efficacy: The exercise of control. New York:
W. H. Freedman and Co.; 1997.
3. Lorig, K, & Holman, H. Self-management education: History,
definition, outcomes, and mechanisms. Annals of
Behavioral Medicine, 2003; 26: 17.
4. Froelicher VF, Myers J. Effect of Exercise on the Heart and
the Prevention of Coronary Heart Disease. Exercise and
the heart. 5th ed. Philadelphia, Pennsylvania: Saunders;
2006. p. 419459.
5. Arnold R, Ranchor AV, DeJongste MJL, Koeter GH, Ten
Hacken NHT, Aalbers R, Sanderman R. The relationship
between self efficacy & self reported physical functioning
in chronic obstructive pulmonary disease & chronic heart
failure. Behavioural Medicine 2005; 31(3):107-15
6. Gardener JK, McConnell TR, Klinger TA, Herman CP,
Hauck CA, Laubach CA Jr. Quality of life and self efficacy
gender & diagnosis considerations for management during
cardiac rehabilitation. Journal of cardiopulmonary
rehabilitation 2003; 23(4): 299-306.
7. Sulivan MD, Andrea Z, Russo J, Katon WJ. Self Efficacy
and Self Reported Functional status in coronary heart
disease: A six month prospective study. Psychosomatic Med
1998; 60(4): 473-478.
8. Proudfoot C, Thow M. Exercise leadership in cardiac
rehabilitation. An evidence based approach. New York: John
Wiley & Sons Ltd; 2006. p. 1-18.
9. National Service framework for coronary heart disease,
modern standards and service models: Department of
Health (DoH); 2000. Available from: http:/www.doh.gov.uk/
nsf/coronary
10. Teh KC, Aziz AR. Heart rate, oxygen uptake, and energy
cost of ascending and descending the stairs. Med Sci Sports
Exerc 2002; 34: 695- 699.
11. American College of Sports Medicine, Position stand. The
recommended quantity and quality of exercises for
developing and maintaining cardiorespiratory and muscular
fitness and flexibility in healthy adults. Med Sci Sports Exerc
1998; 30: 975- 991.
12. Self efficacy and inpatient cardiac rehabilitation. Am J
Cardiol 1990; 66(3): 362-365.
S-D curve an Effective Diagnostic Test for Physiotherapists: A
case report
Pankaj Gupta*, M Satish K Paul**
*Physiotherapist TLM Community Hospital Nandnagri, Delhi-93, **POD, Coordinator TLM India, Delhi-93

Abstract clearly justifies the clinical findings that the cause of claw finger
was not nerve involvement.
With increasing confidence of patients in physiotherapy
profession we are serving the community as first contact
professional1, 6. So, it becomes a responsibility of a consultant
physiotherapist to justify his/her diagnosis with related diagnostic
test. This paper presents a case report on scleroderma (an auto-
immune connective tissue disorder) and effectiveness of plotting
S-D curve in making correct diagnosis of this patient.

Key Words
S-D curve, scleroderma, effectiveness.

Introduction
Scleroderma (progressive systemic sclerosis) is an auto-
immune disorder which is characterized by progressive fibrosis.
The main clinical features of the disease are claw-like flexion
deformity of hands and other symptoms like Raynauds
phenomenon, malabsorption, pulmonary hypertension and along
with other symptoms2. The purpose of this report is to show the
efficacy and cost effectiveness of the plotting S-D curve.

Case Description
A 36 year old female reported to, The leprosy mission
community hospital, Nandnagri Delhi-93. The patient came with
Discussion
claw hand deformity of both hands and ulcer on right toe of left With increasing role of physiotherapists and with increasing,
foot. On history taking she gave the history of anti-leprosy
confidence of patients to consult physiotherapists as first contact
treatment for three months about six months ago. The main
allied health professionals over the decades6.
Fig. 1: Claw finger in scleroderma patient It is always important to support the clinical findings of the
patients with diagnostic test. This case study clearly shows the
importance and effectiveness of the S-D curve in making
diagnosis of patients. S-D curve can be plotted with minimum
manpower time and money in contrast to other diagnostic means
like nerve conduction velocity, which requires sophisticated
equipments, more time and money.

reason of the patient to come for consultation in leprosy hospital
was for re-starting the anti-leprosy treatment which she had left.
On examination it revealed that the claw finger is not
because of ulnar nerve involvement. Because there was no
hyper-extension of at MCP joint and on palpation ulnar nerve
found to be normal3. So, it was confirmed that the cause of
deformity is not ulnar nerve involvement4. So, in order to relate
the clinical findings with diagnostic test it was decided to plot S-
D curve for the patient. When curve was plotted on paper it
revealed normal innervation of rt. Ulnar and median nerve5. This
References
1. Petty NJ, Moore AP. Neuromusculoskeletal examination
and assessment. Great Britain: Churchill Livingstone; 1998
p.28
2. Mohan H. Text book of pathology.3rd ed. New Delhi: Jaypee
Brothers; 1998 p. 71-75.
3. Jopling WH. Handbook of leprosy. 3rd ed. London: William
Heinmann Medical Books Publishing Ltd; 1984
4. Schwarz R, Brandsma W. Surgical reconstruction &
rehabilitation in leprosy and other neuropathies. Nepal: Ekta
Books Distributors Pvt. Ltd; 2004
5. Forster A, Palastanga N. Claytons electrotherapy: Theory
& practice. 9th ed. Delhi: A.I.T.B.S Publishers & Distributors;

Pankaj Gupta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 103
 1999 p.85-93 professionals. New York: McGraw-Hill; 1998 p.xvii-xix.
6. Prentice WE. Therapeutic modalities for allied health

104 Pankaj Gupta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Effectiveness of Strength Training Program on Bone Mineral
Density in Postmenopausal Women
Paramjot K Dhillon1*, Sonia Singh2
1
Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar-144001, India, 2Department of Physiotherapy, Punjabi University,
Patiala-147002, India
Abstract
The effect of strength training program on bone mineral
density in postmenopausal women has been studied.
Osteoporosis is a common crippling bone disease affecting
mainly postmenopausal women. Mechanical factors that affect
bone remodeling include muscular contraction and gravity. In
this study subjects were divided into three groups i.e. control
group, strength training group and calcium supplementation
group. Bone mineral density was found to increase significantly
in strength training group and decrease significantly in strength
training group, whereas the changes in calcium supplementation
group were non-significant.
Key Words
Osteoporosis, Strength training, calcium, Bone mineral
density, Postmenopausal women.
Introduction
Osteoporosis is a condition characterized by low bone mass
and poor bone architecture. The incidence of osteoporotic
fractures is about double in women compared with men which
is due in part to a generally lower bone density across life
span1.With aging, remodeling tends to remain uncoupled in the
pockets of bone which has been removed during resorption.
Thus, in older individuals, the rate of resorption exceeds the
rate of remodeling resulting in a net loss of bone or osteoporosis.
The peak bone mass is usually attained by the age of 30 years,
thereafter a decline in bone mass and structural integrity starts
and becomes evident e around 50 years of age. Bone
densiometry is used to establish the diagnosis of osteoporosis,
to assess the risk of osteoporotic fractures, to identify candidates
for therapeutic intervention and to assess the effects of treatment
on bone loss.2 The testing procedure measures the density of
the bone of the spines, pelvis, lower arms and thigh. Bone
densiometry testing may be done using X-Rays (dual energy X-
Rays absorbitometry or DEXA) or quantitative CT Scanning
using special software. The portable testing is done using either
a DEXA or a quantitative ultrasound unit. Both types of portable
testing may use radius, wrist, finger or heel. The recommended
intake of elemental calcium is 1200 mg. day for adults over the
age of 50 years [Food and Nutrition Board Dietary Reference
Intake]. The amount of calcium retained in the body is related to
dietary intake, intestinal absorption and excretory losses.
Intestinal calcium absorption and the ability to adapt to low
calcium diet decline with aging and highlight the importance of
adequate calcium intakes in elderly people. Poor bone
development is common in individuals and groups with low
weight bearing activity because intermittent overloading of bone
is essential to maintain bone mass. Association between physical
activity and bone mass are generally stronger than those
between calcium intake and bone mass. High intensity resistance
training, in contrast to traditional pharmacological and nutritional
approaches for improving bone health in older adults, has added
benefits of influencing multiple risk factors for Wolffs law states
that stress or mechanical loading applied to a bone via muscle
or tendon has a direct effect on bone formation and
remodeling.3Simple squeezing of a tennis ball for 30 seconds a
day has a significant benefits in non-injured forearm of women
Paramjot K Dhillon/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
who had already sustained a colles fracture.4 In addition, a set
of dynamic bone loading exercise for the distal forearm results
in increased bone strength at the wrist.5
Methods
This study is comparative in nature. A sample of thirty
women who aged between 50-70 years volunteered to
participate who met the inclusion criteria were assigned to three
different groups. Sample was collected from the population of
300 subjects after holding three camps. Three camps were
organized at Amar Hospital, Health Center, Punjabi university
and geriatric Physiotherapy clinic, Model Town, Patiala. Study
was performed at geriatric Physiotherapy Clinic, Model Town,
Patiala.
Inclusion Criteria
Subjects aged 50-70 years residing in and around Patiala,
one clinically relevant outcome measure i.e. BMD showing
osteopenia or osteoporosis, subjects with sedentary lifestyle,
subjects not involved in any other physical activity program which
could effect BMD, subjects with normal BMI and Subjects
reported no mensuration for at least a year before study.
Exclusion Criteria
Subjects with history of trauma or fracture or surgery within
6 months or long term immobilization, subjects with diabetes,
hyperthyroidism, renal disease, connective tissue disorder, and
hysterectomy, subjects with radiating pain, subjects suffering
from severe visual or vestibular disturbances, subjects having
sensory disturbances and subjects having hypertension or
cardiac problem and subjects on steroid or radiotherapy.
Instrumentation
1. Quantitative ultrasound densiometry. (IGEA
Ultrasonometer)
2. Jamar Dynamometer.
3. Dumbbells.
4. Therabands.
5. Squeeze Balls.
6. Weight Cuffs.
7. Mini Vector
Methodology
The subjects were randomly assigned to three different
groups; 10 in each, Group A received no treatment, Group B
was put on calcium supplementation as prescribed by physician
and Group C on strength training program for upper and lower
limb for 3 months .Training was done for 5 days a week for 1
hour duration. Pretest measurement was taken using portable
quantitative ultrasound unit.
Strengthening Exercises for Upper Limb
Shoulder flexion and abduction with weight cuffs, elbow
flexion and extension with dumbbells, Wrist flexion and extension
105
with therabands, wrist pronation and supination with dumbbells, Fig. 4.1: BMD changes in control group
grip strengthening exercise with hand gripper and squeezing
ball for 30 second.

Strengthening Exercise for lower limb

Hip flexion and extension with weight cuffs, hip abduction
with weight cuffs, knee flexion and extension with weight cuffs
&Leg press with mini vector.

Protocol

0-3 weeks
1. One set of 15 repetitions at 50% of 1RM for 5 days a week
for upper limb.
2. One set of 15 repetitions at 50% of 1 RM for 5 days a week
for lower limb.

3-6 weeks
1. One set of 15 repetitions at 60 % of 1RM for 5 days a
week for upper limb.
2. One set of 15 repetitions at 60% of 1RM for 5 days a week Bmd Changes in Calcium Group
for lower limb.
On applying T-paired test on pre and post mean of -2.55
and -2.440, with t value 0.182, results obtained are insignificant
6-9weeks and are shown in the Table 1.2 and Fig.1.2.
1. One set of 15 repetitions at 70% of 1RM for 5 days a week for Table 1.2
upper limb.
2. One set of 15 repetitions at 70% of 1RM for 5 days a week for Test Number Mean S.D. S.E.M. t value
lower limb.
Pre 10 -2.55 1.08 0.344
0.182
9-12 weeks Post 10 -2.440 1.51 0.480
1. One set of 15 repetitions at 80% of 1 RM for 5 days a week
for upper limb. Fig. 1.2: Bmd Changes In Calcium Group
2. One set of 15 repetitions at 80% of 1RM for 5 days a week
for lower limb.
Post test assessment was taken using portable quantitative
ultrasound.

Reliability and Validity

Reliability coefficient for quantitative ultrasound is 0.62 in
women.6

Results and Analysis

Data was analysed with T-test and ANOVA using Sigmastat
software.

Bmd Changes in Control Group

On applying T-paired test on pre and post mean of -2.71
and -3.36, with t value 2.807, results obtained are significant
and are shown in the Table 1.1 and Fig.1.1

Table 1.1:
Bmd Changes in Strength Training Group
Test Number Mean S.D. S.E.M. t value
On applying T-paired test on pre and post mean of 1.71
Pre 10 -2.71 1.05 0.334 and 0.91, with t value 4.202, results obtained are significant
2.807 and are shown in the Table 1.3 and Fig.1.3.
Post 10 -3.36 1.04 0.330

106 Paramjot K Dhillon/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 1.3 Comparison Between Group B And C
Test Number Mean S.D. S.E.M. t value On applying unpaired T test on mean diff. of -0.11 and -
0.76, with t value 1.031, results obtained are insignificant and
Pre 10 -3.43 1.17 0.373 are shown in the Table 1.5 and Fig.1.5
4.202
Table 1.5
Post 10 -2.67 0.91 0.290
Test Number Mean S.D. S.E.M. t value
Fig 1.3: BMD changes in Strength training group
Pre 10 -0.11 1.90 0.604
1.031
Post 10 -0.76 0.57 0.181

Fig. 1.5: Comparison of Group B and Group C

Comparison of Group A and Group B

On applying unpaired T test on mean diff. of 0.65 and -
0.11, with t value 1.175, results obtained are insignificant and
are shown in the Table 1.4 and Fig.1.4. Comparison of Group A and Group C
Table 1.4: On applying unpaired T test on mean diff. of 0.65 and -
0.76, with t value 4.799, results obtained are significant and are
Test Number Mean S.D. S.E.M. t value shown in the Table 1.6 and Fig.1.6
Table 1.6:
Pre 10 0.65 0.73 0.232
1.175 Test Number Mean S.D. S.E.M. t value
Post 10 -0.11 1.90 0.604
Pre 10 -0.65 0.73 0.232
4.799
Fig.1.4: Comparison Between Group A And Group B Post 10 -0.76 0.57 0.181

Fig.1.6: Comparison Between Group A And C

Paramjot K Dhillon/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 107
Comparison of all the Three Groups
On applying ANOVA on mean diff. of 0.65, -0.11 and -0.76,
with F value 3.314, results obtained are insignificant and are
shown in the Table 1.7 and Fig.1.7
Table 1.7:
Group Number Mean S.D. S.E.M. F P
Diff. value value
Group A 10 0.65 0.73 0.232
Group B 10 -0.11 1.90 0.604 3.314 4.799
Group C 10 -0.76 0.57 0.181
Fig. 1.7: Comparison of All the Three Groups
Discussion
This study was conducted on 30 postmenopausal women.
They were divided into three groups of 10 subjects each. Group
A control group, Group B on calcium supplementation and Group
C on strength training. Statistically significant change in BMD
was seen in the subjects undergoing strength training.
Improvement in exercise group is according to Wolffs law, which
states that stress or mechanical loading applied to a bone via
muscle or tendon has a direct effect on bone formation and
remodeling. While no significant improvement in BMD was
observed the subjects on calcium supplementation. This is
attributed to decreased calcium absorption. There was significant
decrease in BMD in control group due to lack of weight bearing.
The results obtained between control group and calcium
supplementation were insignificant while between control and
strength training group were significant. The results obtained
between group B and group C were statistically insignificant
though marginal difference was found. However, when three
groups were analysed, the results obtained were insignificant.
This can be due to small sample size and short intervention
period. Bone is slow to adapt and seems more responsible to
impact forces. Possibly 12 week time is insufficient to show
statistically significant changes and therefore training periods
should be extended. Though, our study indicates that strength
training may be important in preventing the negative health
outcomes associated with age related loss of bone density.
Similar results were recorded in study conducted by Chow et al
7
studied the effect of two randomized exercise programmes on
bone mass of healthy postmenopausal women. Both exercise
groups showed a significantly increased bone mass compared
with controls. Similarly, Kelley et al8 reported that resistance
108 Paramjot K Dhillon/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
training had a positive effect on BMD in the lumbar spine of
women of all ages and at the femur and radius sites for
postmenopausal women. The study conducted by Going 9
supported the benefit of resistance exercises demonstrating
slowed bone loss and often an increase of 1%to 3% in regional
bone mineral density, especially in women. In a randomized
controlled trial of resistance training at 70-50% of 1RM, the total
weight lifted was significantly associated with the improvement
in femur trochanter BMD. The association between volume of
training and BMD change was examined by Cusseler et al10.
Rhodes et al reported that statistically significant changes were
evident in effect of one year resistance training on relation
between muscular strength and bone density in muscle function
performances, from the results for the bench press, double leg
press, biceps curl, triceps extension and quadricep extension.
In the another study conducted by Taffe et al11 it was indicated
that dynamic muscle strength is an independent predictor of
mineral density in older women accounting for 11-12% of the
variance in regional and whole body BMD. According to the study
on the effect of high intensity resistance exercise on bone mineral
density and muscle strength of 40-50 year old women
emphasized loading the hips and lower back, with muscle
strength gains being a secondary consideration, conducted by
Doremann et al12, the resistance exercise program produced
some positive, but marginal, effects on vertebral bone density
after 6 month training. Barclay and Desiree13 founded that many
elderly are not compliant with calcium supplementation.
However, in the another study conducted by Maddalozzo et al14
comparing high intensity and moderate intensity training on
BMD concluded that moderate intensity can produce similar
changes to high intensity training in older adults but a higher
magnitude is necessary to stimulate osteogenesis at the spine.
In the another study by Heffron et al15, effect of strength training
for 10 weeks in postmenopausal women did not show significant
changes in BMD at forearm, lumbar and hip regions but showed
positive effect on skeletal status at oscalcis level. There is paucity
of data available on short term strength training in
postmenopausal women. Although very little research has been
found that shows short term strength training significantly
influences bone strength. It has been reported that normal
muscle function and load bearing are necessary to prevent or
retard bone loss in people with activity restriction.
Conclusion
Statistically significant improvement in bone mineral density
has been found after 12 weeks of strength training. While, there
was a statistically significant decrease BMD in control group
after 12 weeks. However, in group on calcium supplementation,
we could not find significant improvement. In the present study,
it was concluded that strength training causes increase in BMD
more than calcium supplementations.
References
1. Rutherford O.M.1999. Is there a role for exercise in
prevention of osteoporotic fractures? British Journal Sports
Medicine; 33:378-386
2. Multani N K and Verma SK 2007, Principles of Geriatric
Physiotherapy, 1st ED. Jaypee Brothers, 87-88.
3. Chamay A, Tshantz P 1972 Mechanical influences in bone
remodeling. Experimental research on Wolffs law.
Biomechanics 5, 173-180 that stresses the skelton.British
Medical Journal; 299:233-235.
4. Beverely M.C., Rider T.A., Evans M.J, and Smith R.
1989.Local Bone Mineral response to brief exercises
5. Ayalon J, Simkin A, LeihterI and Raifmann S 1987. Dynamic
bone loading exercises for postmenopausal women: effect
on the density of the distal radius. J Arch Phys Med Rehab;
8(5):80-283.
6. Zochling J, Nguyen T.V., March L.M. and Sambrook P.N.
2004. Quantitative ultrasound measurements of bone:
measurement discordance, and their effects on longitudinal
studies: Osteoporosis International; 15:619-624.
7. Chow R, Harrison J.E. and Notarius C. 1987. Effect of two
randomized exercise programmes on bone mass of healthy
postmenopausal women .British Medical Journal; 295:441-
1444
8. Kelley G A, Kelley K S and Tran Z V 2000. Exercise and
bone mineral density in men: a meta-analysis. J Applied
Physiology; 88(5):1730-1736.
9. Going S.B. 2009. Osteoporosis and Strength training.
American Journal of Lifestyle Medicine;3(4):310-319
10. Cussler E.L., Lohman T.G., Going S.B., Houtkooper l.B.,
Metcalfe L.L., Flint-Wagner H.G., Harris R.B. and Teixeira
P.J. 2003. Weight lifted in strength training predicts bone
change in postmenopausal women. Medicine and Science
in sports; 5(1):10-17
Paramjot K Dhillon/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
11. Taffe D.R., Pruitt B., Lewis R., and Marcus R.1995. Dynamic
muscle strength as a predictator of bone mineral density in
elderly women. Journal Sports Medicine Physical Fitness;
35: 136-142
12. Dornemann T.M., Mcmurray R.G., Renner J.B. and
Anderson J.J.B. 1997. Effects of high intensity resistance
exercise on bone mineral density and muscle strength of
40-50 year women. Journal Sports Medicine Physical
Fitness; 37:246-251
13. Barclay L and Lie D. 2006. Many elderly are not compliant
with calcium supplementation: Arch Intern Med; 66:869-
875
14. Maddalozzo, G.F., and C.M. 2000.High intensity resistance
training: Effects on bone in older men and women. Calcified
Tissue International; 6:9-404.
15. Heffron M, Davery R and Cochrane T 1997.Weight training
and bone mass. J Sports Exercise and Injury; 3(3):143-
149.
109
Effectiveness of Coccygeal Manipulation in Coccydynia: A
randomized control trial
Subhash M Khatri*, Peeyoosha Nitsure**, Ravi S Jatti***
*Principal, MGM Physiotherapy College, New Building, Nehru Nagar, Belgaum-590010, **Lecturer, ***Associate Professor, in
Physiotherapy Division, Dept. of Orthopaedics, J.N. Medical College, Nehru Nagar, Belgaum-590010
Abstract
Purpose
The purpose of this study was to find out the effectiveness
of coccygeal manipulation in the management of coccydynia.
Design
Randomized control trial where the subjects were randomly
allocated to control & experimental groups.
Setting
Physiotherapy outpatient department of KLES Hospital,
Belgaum, Karnataka state, India - 590010.
Participants
Subjects with idiopathic coccydynia.
Interventions
Phonophoresis, TENS & coccygeal manipulation.
Main Outcome Measures
Intensity of pain on visual analogue scale & pain free sitting
time.
Methods
Control group subjects were treated with phonophoresis,
use of coccygeal pillow and TENS only. Experimental group
subjects were treated with coccygeal manipulation in addition to
above protocol of the treatment.
Results
Subjects treated with coccygeal manipulation had
statistically and clinically better out come in terms of pain relief
and pain free sitting time at the end of tenth treatment session.
Conclusions
Idiopathic coccydynia is somewhat common in obese
individuals as it determines the way a subject sits. Coccygeal
manipulation could be of help and can be used as an addition to
the conventional physiotherapy treatment.
Address for correspondence:
Dr. Peeyoosha Nitsure
KLE Societys Institute of Physiotherapy,
New Building, Behind District Stadium,
Belgaum 590010, Karnataka, India
Email: kats003@India.com
Ph: +91 9844821355 Fax: +91831 24733333
110 Subhash M Khatri/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Key Words
Coccydynia, manipulation, physiotherapy.
Introduction
The sacrococcygeal junction remains movable throughout
life but, rarely, may fuse. Because of its muscular attachments,
the coccyx is in constant motion, particularly in the act of
defecation. Pressure is exerted against the posterior aspect of
the bone in sitting, the coccyx acting as a shock absorber and
moving forward. Pain about the coccyx results from local
conditions or is referred from other regions. Coccydynia or
coccygeal pain is a well-known but rarely studied painful
syndrome affecting the coccyx region.1
Coccydynia is one of the painful conditions that limits sitting.
Patients with traumatic injuries of the coccyx present with clear-
cut picture such as acute pain and tenderness localized to the
coccyx. At other times the symptoms are so obscure that the
patients are considered neurasthenics. In addition to the pain
while sitting on hard surfaces, individuals who suffer from
coccydynia may complain of pain on passing hard stool and on
sit to stand transfers, possibly because of gluteal muscles
contraction or sacroiliac dysfunction.2 Coccydynia may occur
due to various causes such as fall on the bottom of seat, a kick,
obstetric trauma, passage of hard stool, hyper mobility of the
sacroiliac joint, idiopathic 3,4, coccygeal fracture, coccgeal
subluxation & dislocation 5, obesity6, sacral haemangioma7,
anatomical variation8,9 and avascular necrosis of the coccyx10.
Most of these causative factors may strain or tear the
sacrococcygeal ligaments and the condition becomes chronic
because the acts of sitting and defecation continually strain the
already injured ligaments. A constant annoying discomfort is
experienced and accentuated when sitting on a hard surface or
during defecation. Occasionally, bending forward is painful. The
sacrococcygeal joint is tender, and movement of the coccyx on
rectal examination reproduces the pain11, 12.
Healthcare practitioners and patients themselves have tried
different clinical & non-clinical interventions so as to alleviate
the symptoms of coccydynia with variable outcomes. These
interventions include NSAIDS, tropical application of analgesic
ointment, local anesthetic injection, local steroid injection13,
manipulations14,15, coccygectomy16,17, Cryoanalgesia18, stiz
bath19, coccygeal pillow, coccyx cushions (donut, doughnut, ring,
roof rack) inflatable ring, bottom up sits, chairs (directors chair,
reclining chairs, kneeling chairs, chairs with coccyx cut outs,
collapsible wheelchairs, use of two chairs without arms), stools
(folding, tripod), sitting modifications (reclining, side sitting),
advice on how to politely deny sitting and work more in standing
and physiotherapy.
However, the conservative treatment approaches like
physiotherapy is well accepted. Physiotherapy treatment
interventions like Diathermy with rectal electrode20, Levator anus
massage15, joint mobilization 15, or mild levator stretch 15,
ultrasound therapy, phonophoresis20,21 and TENS have been
used with variable outcomes.
Although physiotherapists in India witness and treat
coccydynia victims, there is very little information available about
incidence, prevalence & methods of treatment used and their
efficacy. The present trend suggests that many of the
physiotherapists use local application of ultrasound, days of treatment. Patients were also strictly advised not to take
phonophoresis, TENS & advice to avoid prolonged sitting and any sort of heat therapy till the completion of the study.
use of coccygeal pillow. However, the use of manual therapy
techniques such as levator anus massage, coccygeal Results
manipulation & mild levator stretch etc are not commonly
practiced due to varieties of reasons such as unawareness by The results of study were assessed in terms of the pain
various clinicians who refer these patients, lack of practical skill relief on VAS scale and pain free sitting time in minutes. For
on Physiotherapists part & the reluctance by these patients to statistical analysis Graph pad InStat 3 demo software was used.
undergo these manual therapy techniques. Hence it was planned The study results revealed average reduction of pain by 1.4
to study the effectiveness of coccygeal manipulation as one of 1.126 in control and 5.3 1.768 in experimental group and the
the manual therapy technique in the physiotherapy management average pain free sitting time in control group was 23 13.351
of coccydynia. minutes while as it was 47 7.981in experimental groups. BMI
in male subjects 31.8 2.7 and in female subjects it was 33.4
Method 3.5.
Table 1: Analyses for differences between the groups for
outcome measures
Subjects
Statistic Pain relief Pain free sitting time
Thirty-six male & female subjects aged 20 to 55 years (VAS score) (mins)
(mean age 31.06 8.87) who had clinical diagnosis of idiopathic
coccydynia without any radiological change and referred to Analysis Control Experi- Control Experi-
physiotherapy outpatient department at KLE Hospital & Medical mental mental
Research Center, Belgaum, India 590010 during 21.04.2001 to
28.2.2007 participated in this study. The duration of symptoms Mean 1.4 5.3 23 47
was in the range of 15 days to 2 years with an average of 576
days. These subjects were selected in a consecutive manner. SD 1.126 1.768 11.351 7.981
However they were randomly allocated to either control or
experimental group. The inclusion criteria used was subjects N 18 18 18 18
with idiopathic coccyx pain and who were willing to undergo
coccygeal manipulation if required. Subjects were excluded if SEM 0.3981 0.6251 4.013 2.822
they were unwilling to undergo coccygeal manipulations, had
local anesthetic injection in past three months and coccygeal Unpaired 5.263 4.892
fracture. t test value
(df,14)
Procedure
p value 0.0001* 0.0002*
All the subjects were assessed prior to the intervention
and if they satisfied the inclusion criteria then their pain intensity * = Statistically significant
score in Visual Analogue Scale was noted and their sitting time
without pain was noted. Subjects were randomly assigned to Graph 1: VAS score difference between Control and
control group or experimental group. Control group subjects were Experimental groups
treated with phonophoresis and TENS. For phonophoresis
purpose, pulsed therapeutic ultrasound with 1MHz frequency
and output of 0.5 W/cm for 3 minutes in acute cases or 1W/cm
for 8minutes in chronic cases along with Pirox gel as a coupling
medium. For TENS, High Frequency TENS (Normal mode) was
given for 20 minutes in acute cases and Low Frequency TENS
(Normal mode) was given for 30minutes in chronic cases. The
treatment was continued for ten successive days with an
exception of one weekly holiday. Experimental group subjects
were treated with coccygeal manipulation22 in addition to above
protocol of the treatment with phonophoresis and TENS. For
coccygeal manipulation a member of the subjects sex
accompanied the investigator. During manipulation subject were
instructed to relax and take few deep breaths then the gloved
and lubricated index finger of the right hand of investigator was
inserted into the anal passage so that it comes to rest against
the anterior surface of the coccyx. The thumb of the other hand
of the investigator, also gloved but not lubricated was placed on Discussion
the dorsum of the coccyx to get a good grasp between the two
fingers. The actual technique consisted of distraction of the The results of this study show highly significant difference
coccyx along its long axis for initial few treatments and then between experimental and control group. The experimental
subsequently an attempt was done to correct the alignment by group subjects that were treated with coccygeal manipulation
controlled force in coronal plane. Both the group participants had better outcome in terms of pain relief on VAS score and
were advised to use the coccygeal pillow as early as possible increased pain free sitting time. This could be because of the
and continue it for 3 months in future. All the participants who mechanical or neurophysiological effects of coccygeal
participated in the study were advised to take Dolonex-DT 20mg manipulation that could modulate the pain through the stimulation
(dispersible tablet) once a day at night which was an oral of articular receptors type I & II. Alternatively it could be because
analgesic for ten days and the topical application of Pirox gel of correction of mal alignment of coocygeal vertebrae that could
whenever they felt that their pain was severe during the ten have been the cause of mechanical pain22 and also due to the

Subhash M Khatri/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 111
Graph 2: Pain Free Sitting Time in minutes
possibility of placebo effect. However, it was not possible to study
the cause and the effect relationship. It was also noted that the
BMI was slightly higher in all the subjects. These findings are in
accordance with Maigne JY, Doursounian L, Chatellier G (2000)6
who studied the role of body mass index and found that body
mass index which represents the obesity as one of the risk factor
in coccydynia as it (BMI) determines the way a subject sits down.
However these findings are not in accordance with Wray CC,
Easom S, Hoskinson J (1991)10 who reported that Physiotherapy
was of little help but found that manipulation and injection was
more successful and cured about 85% of their subjects. But the
details about their subjects are unknown and their intervention
was combined with local anesthtc injection.
This study had few limitations like smaller sample size and
there was no 100% follow up of these subjects after the study.
However, it is recommended that similar study can be done with
larger sample size with an added follow up for at least
considerable period of time.
Conclusion
Idiopathic coccydynia is somewhat common in obese
individuals as it determines the way a subject sits. Coccygeal
manipulation could be of help and can be used as an addition
to the conventional physiotherapy treatment.
References
1. Jose De Andrs and Santiago Chaves. Coccygodynia: A
proposal for an algorithm for treatment. Journal of Pain
2003; 6(4): 5.
2. Carrie M Hall & Lori Thein Brody.Therapeutic exercises-
Moving Towards Function. Lippincott Williams & Wilkins,
Philadelphia 1999; 353-385.
3. Maigne J, Guedj S, Straus C (1994). Idiopathic
coccygodynia Spine, vol. 19 No.8: P.930-34
4. Postacchini F, Massobrio M (1983). Idiopathic
Coccygodynia. Analysis of Fifty-one Operative Cases and
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a Rabiographic Study of a Normal Coccyx. Journal of Bone
and Joint Surgery.Vol: 65, P.1116-24
5. Maigne JY, Lagauche D, Doursounian L (2000): Instability
of the coccyx in coccydynia, J Bone Joint Surg Br Sep;
82(7): 1038-41.
6. Maigne JY, Doursounian L, Chatellier G (2000). Causes
and mechanisms of common coccydynia: role of body mass
index and coccygeal trauma, Spine 2000 Dec 1; 25(23):
3072-9
7. Latha R, Rajshekhar V and Chacko G. Sacral haemangioma
as a cause of coccydynia. Neuroradiology 1989; 40(8): 524-
6.
8. Lourie J, Young S. Avascular necrosis of the coccyx: a cause
of coccydynia? Case report and histological findings in 16
patients. Br J Clin Pract 1985; 39(6): 247-8.
9. Falzoni P, Boldorini R, Zilioli M, Sorrentino G (1995) The
human tail. Report of a case of coccygeal retro position in
childhood, Minerva Pediatr 1995 Nov; 47(11): 489-91
10. Wray CC, Easom S, Hoskinson J.Coccydynia. Etiology and
treatment. J Bone Joint Surg Br 1991;73(2): 335-8
11. Polsdorfer Ricker (1992), Three case studies:
Coccygodynia and the Orthopaedic Rectal Examination.
Journal of Orthopaedic medicine vol; 14: 1-13.
12. Traycoff RB, Crayton H, Dodson R (1989). Sacrococcygeal
Pain Syndromes: Diagnosis and Treatment. Orthopedics.
Oct.12 (10). P.1371-77.
13. Fogel GR, Cunningham PY 3rd, Esses SI (2004):
Coccygodynia: evaluation and management, J Am Acad
Orthop Surg, Jan-Feb; 12(1): 49-54.
14. Beckenstein L (1969). Coccygodynia. ACA Journal of Chiro
practic. 1969 Sept., Vol.: 6(9). P.57-61.
15. Maigne JY, Chatellier G.Comparison of three manual
coccydynia treatments: a pilot study. Spine 2001; 26(20):
E479-83, E484.
16. Saris SC, Silver JM, Vieira JF, Nashold BS Jr (2000):
Sacrococcygeal rhizotomy for perineal pain, Midwifery 2000
Jun; 16(2): 155-60
17. Pennekamp PH, Kraft CN, Wallny T, Schmitt O, Diedrich O
(2003): Coccygectomy in the treatment of coccygodynia,
Zeitschrift fur Orthopadie und ihre Grenzgebiete, Sep-Oct;
141(5): 578-82.
18. Evans PJ, Lloyd JW, Jack TM. Cryoanalgesia for intractable
perineal pain. J R Soc Med Nov 1981; 74(11): 804-9.
19. Duncan GA (1937). Painful coccyx, Arch Surg, 14,1088-
1104, in Kovacs R: Electrotherapy and light therapy, Lea
and Febiger, Philadelphia, 1949.
20. Kovacs R. Electrotherapy and light therapy. Lea and
Febiger, Philadelphia 1949; 242 & 559.
21. Thiele GH. Coccygodynia. Jour Am Med Assn 1937; 109:
16, in Kovacs R: Electrotherapy and light therapy, Lea and
Febiger, Philadelphia, 1949.
22. Polkinghorn BS; Colloca CJ (1999): Chiropractic treatment
of coccygodynia via instrumental adjusting procedures
using activator methods chiropractic technique, J
Manipulative Physiol Ther, Jul, 22:6, 411-6.
Effect of Warm-up and Cool-down on Delayed-onset Muscle
Soreness in University Students
Bhatia P*, Arun**
*Associate Professor, Department of Physiotherapy, Guru Jambheshwar University of Science and Technology, Hisar, **BPT Final
year student
Objective
The objective of this study is to determine the effects of
warm-up and cool-down on muscle soreness following eccentric
exercise.
Participants
A total 40 healthy university students were participated in
the study (17-27 years).
Methods
Physical Activity Readiness Questionnaire was taken from
participants and Response as No to all questions was
considered as inclusion criteria. All participants were divided in
four groups equally. Warm-up and cool down was done on
treadmill. The exercise was designed to induce muscle soreness
in the gastrocnemius muscle. Each exercise included 20
repetitions in three sets (320 repetitions).
Outcome Measures
Muscle soreness was measured on a visual analogue scale
and 10-point numerical rating scale.
Results
Analysis shows that Warm-up is more effective than Cool
down in reducing Delayed onset muscle soreness.
Conclusion
Warm-up performed prior to eccentric exercise produces
small reductions in delayed-onset muscle soreness but cool-
down performed after does not.
Key Words
DOMS,Warmup,Cooldown,Eccentric exercise.
Introduction
All forms of exercise, if carried out vigorously enough, can
become painful. But only one form of exercise, eccentric
exercise, if we are unaccustomed to it, leaves us stiff and sore
the next day. This sore is called muscle soreness. Exercise -
induced muscle soreness can be classified as either acute onset
or delayed onset. Acute onset muscle soreness occurs during
exercise and may last up to 4 to 6 hours before subsiding.
Delayed onset muscle soreness (DOMS) has onset 8 to 24 hours
postexercise, with soreness peaking 24 to 48 hours
postexercise. DOMS is thought to be a result of microscopic
muscle fiber tears and is more common after eccentric exercise
(the muscle must lengthen or remain the same length against a
weight) rather than concentric exercise (the muscle can shorten
against a weight load). While DOMS is not a disease or disorder,
it can be painful and is a concern for athletes because it can
limit further exercise in the days following an initial training. In
Bhatia P/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.2
most cases, DOMS will resolve spontaneously within 3 to 7 days.
There is some evidence that ibuprofen, naproxen, and massage
may accelerate the resolution of DOMS.
Treatment strategies have often integrated multiple
therapeutic approaches such as cryotherapy, ultrasound,
compression therapy, stretching and deep tissue massage. In
addition, several dietary supplements have been tested in the
treatment of DOMS including protein, vitaminC, proteases
(enzymes), phosphatidylserine, chondroitin sulfate, and fish oil,
all with variable success. There is no clear consensus in the
extent literature on a method or discipline that can effectively
relieve pain following eccentric exercise.
Warm-up (gentle exercise preceding vigorous physical
activity) is said to reduce muscle strain injuries by increasing
muscle temperatures, and hence muscle compliance. The
effects of heating on the contractile properties of skeletal muscle
have been studied extensively. Also it has been shown that
increasing muscle temperature increases the speed of muscle
contraction, thereby decreasing both time to peak tension and
half relaxation time. The warm-up can assist in injury prevention
and is seen as an integral part of the coaching session or match.
It can set the tone and attitude for the coaching session or match
that will follow. The functional dynamic warm-up has been
defined as a comprehensive approach to training or
rehabilitation that addresses all performance components (i.e.
strength, power, balance, vision, coordination, reaction, agility,
acceleration and deceleration) necessary to achieve success
in any target activity.
Cool-down (gentle exercise after vigorous physical activity;
also called warm-down) should occur immediately after activity
as part of the recovery process, and while the athletes still have
an elevated body temperature. Through many studies have been
done and various methods are used to reduce delayed onset
muscle soreness (DOMS), they are inconclusive. So the present
is study focuses on evaluating the efficacy of warm-up and cool-
down on delayed onset muscle soreness (DOMS).
Method
Subject and Design
A total 40 healthy university students (17-27 years) were
allocated timely and sampled with simple random sampling to
one of four groups (10 participants per group). Each participant
was allocated to one of four groups: a warm-up and cool-down
group, a warm-up only group, a cool-down only group, or No
warm-up and cool-down group.
A Physical Activity Readiness Questionnaire was also taken
and Response as No to all questions was considered as
inclusion criteria.
They were excluded if Prior to randomization they:-
-Were already experiencing delayed onset muscle soreness
(DOMS).
-Did not consider themselves capable of performing the
exercises.
-And Response as Yes to one or more questions on the
Physical Activity Readiness Questionnaire.
113
Procedure down only on VAS (visual analogue scale) and NRS (10-point
numerical rating scale) as proved through ANOVA and T-test at
Each participant was allocated to one of four groups. Each significant level of <0.05.
group contained 10 participants. Each participant was rested in The mean scores evaluated at VAS (visual analogue scale)
a seated position for 10 minutes. Participants in the two warm- were as follows:
up groups performed the 10-minute warm-up on treadmill. Then In first group where Warm-up and Cool down both were
participants performed eccentric exercise to induce muscle given the mean scores were 0.3 at 10 minutes and were
soreness. Immediately after the exercise, participants in the two maximum (32.9) after 48 hrs. Similarly for 2nd (Warm-up only)
groups that cooled down performed the 10-minute cool-down and 4th (No Warm-up and Cool down) groups, VAS (visual
on treadmill similar to the warm-up. Participants in the two groups analogue scale) scores were found to be maximum at 48 hrs.
that did not cool down rested in sitting for further 10 minutes. In the 3rd group where only Cool down was given, VAS
Muscle soreness was induced using unaccustomed (visual analogue scale) scores tend to be maximum at all the
eccentric exercise. The exercise was designed to induce muscle intervals when compared to other groups.
soreness in the gastrocnemius muscle of the right leg and
Eccentric calf-muscle loading with the knee straight. From an Table 1: Visual Analogue Scale (VAS) mean scores of all groups
upright body position and standing with all body weight on the at different time intervals.
ventral half-part of the right foot, with the ankle joint in plantar Groups 10 mint. 24 Hr. 48 Hr. 72 Hr.
flexion lifted by the left leg, the calf-muscle was loaded
eccentrically by having the participants to lower the heel beneath Warm-up and 0.3 24.2 32.9 14.2
the lever. Each of the two exercises included 20 repetitions in Cool down
three sets (320 repetitions).
Warm-up only 0.8 23.6 34.7 17.3
Fig. 1: Participant performing eccentric exercise
Cool down only 2.3 28 42.2 20

No Warm-up and 1.4 27.8 41.4 18.6

Cool down

Graph 1: Comparison of Delayed Onset Muscle Soreness on

Visual Analogue Scale (VAS)

Outcome Measures
Soreness was rated on two scales: a 100-mm visual
analogue scale anchored at no pain and most severe pain and
a 10-point numerical rating scale anchored at none, and worst
possible. Tenderness was measured 10 minutes, 24, 48 and
72 hours after exercise.
Data Analysis
The experimental study was conducted to know the effect
of Warm-up and Cool down on delayed onset muscle soreness.
Statistical analysis using ANOVA and T-test is conducted
for each follow-up time (10 minutes and 24, 48, 72 hours). All
groups ( a warm-up and cool-down group, a warm-up only group,
a cool-down only group, or No warm-up and cool-down group)
are analyzed at four time intervals(10 minutes and 24, 48, 72
hours) on two different scales VAS (visual analogue scale) and
NRS (10-point numerical rating scale) and Compared at 48 hr.
The statistical analysis is performed with significant level p<0.05.
The mean scores evaluated at NRS (10-point numerical
rating scale) were as follows:
In first group where Warm-up and Cool down both were
given, the mean scores were 0 at 10 minutes and were maximum
(3.6) after 48 hrs. Similarly for 2nd (Warm-up only) and 4th (No
Warm-up and Cool down) group NRS (10-point numerical rating
scale) scores were found to be maximum at 48 hrs. The scores
are 3.7 and 4.2 respectively.
In the 3rd group where only Cool down was given, NRS
(10-point numerical rating scale) scores tend to be maximum at
all the intervals when compared to other groups. The mean
scores were 0.3 at 10 minutes and were maximum i.e. 4.4 after
48 hrs.
Analysis throws light on the fact that Warm-up is more
effective than Cool down in reducing Delayed onset muscle
soreness occurring after eccentric exercises.

Results Discussion
The analysis prove that the results of group Warm-up and This study was to determine the effects of warm-up and
Cool down are significantly different from results of group Cool cool-down on muscle soreness following eccentric exercise.

114 Bhatia P/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 2: 10 Point Numerical Rating Scale (NRS) mean scores
of all groups at different time intervals
Groups 10 mint. 24 Hr. 48 Hr. 72 Hr.
Warm-up and 0 2.3 3.6 1.2
Cool down
Warm-up only 0 2.4 3.7 1.7
Cool down only 0.3 2.9 4.4 1.9
No Warm-up and 0.1 2.6 4.2 1.8
Cool down
Graph 2: Comparison of Delayed onset Muscle Soreness on
10 Point Numerical Rating Scale (NRS)
Our results showed that warm-up produced a small
reduction in muscle soreness that was most apparent 48 hours
after exercise. Cool-down only did not reduce muscle soreness.
Roberta YW Law and Robert D Herbert (2007) noticed the
effect of warm-up and cool down on delayed onset muscle
soreness and their results were in accordance with the present
study. They said that warm-up could reduce delayed-onset
muscle soreness: the increase in muscle temperature associated
with warm-up could increase the compliance of structures in
series with myofibrils. This would reduce the degree of stretch
experienced by myofibrils, which could decrease the myofibrillar
damage that occurs with unaccustomed exercise and the
resulting muscle soreness. They demonstrated that cool-down
performed immediately following eccentric exercise does not
reduce delayed-onset muscle soreness because Cool-down is
performed after the events that initiate eccentric exercise-
induced muscle damage.
Similarly William Kirk Isabell et al (1992) studied the effect
of exercise on prevention and treatment of delayed onset muscle
soreness and found there was no significant difference of
exercises with or without ice massage on delayed onset muscle
soreness.
Previous study by Craig A. Smith (1994) is in accordance
with the results showing that a mild warm-up period should
precede the stretching exercises. He adds that warmer muscles
are more extensible, leading to less injury when stretched as
well as increased gains in flexibility. This rationale has further
supporting evidence. He also demonstrated that heat alone did
not cause an increase in hip range of motion (ROM), and that
stretching resulted in to movements being increased, while heat
and stretching combined resulted in the greatest increase in
flexibility.
Fu-Shiu Hsieh (2009) also did a related study and he
explained that Warm-up before exercise could increase blood
flow of whole body, increase muscles and skin temperature,
Bhatia P/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
prevent injury within exercise.
Passive warm-up can increase temperature of muscles as
active warm-up do, but it wont cause the muscle fatigue. The
adequate warm up before exercise, not only decreased muscle
damage occurred but also elevated skin and body temperature
through increased whole blood volume in athletes, and improved
exercise performance.
All these studies support the effect of warm-up in reducing
muscle soreness. The cool down is performed after the event
that initiate eccentric exercise induce muscle damage. The
present study demonstrates that cool down has no appreciable
effect on muscle soreness.
Conclusion
This study concluded that the Warm-up is more effective in
reducing Delayed onset muscle soreness than Cool down in
university students.
References
1. Charles D Clccone, Brian G Leggln, John J Callamaro
Effects of Ultrasound and Trolamine Salicylate
Phonophoresis on Delayed-Onset Muscle Soreness,
Physical Therapy volume 71, 9 September 1991.
2. Craig A. Smith The Warm-up Procedure: To Stretch or not
to Stretch. A Brief Review, Volume 19 Number I January
1994 JOSPT.
3. Erin E. Krebs, Timothy S. Carey, and Morris Weinberger
Accuracy of the Pain Numeric Rating Scale as a Screening
Test in Primary Care J Gen Intern Med 22(10):14538.
4. Fu-Shiu Hsieh et al, The Effects of Passive Warm-Up With
Ultrasound in Exercise Performance and Muscle Damage
ICBME, 2009, 23, pp.11491152.
5. Jay K Udani, Betsy B Singh, Vijay J Singh and Elizabeth
Sandoval Bounce Back capsules for reduction of DOMS
after eccentric exercise: a randomized, double-
blind,placebo-controlled, crossover pilot study, Journal of
the International Society of Sports Nutrition 2009, 6:14.
6. John n. Howell, Gary Chleboun and Robert
Conatser(1993)Muscle stiffness, strength loss, swelling
and soreness following exercise-induced injury in humans,
Journal of Physiology, 464, pp. 183-196.
7. Kisner C., Colby L.A., Therapeutic Exercise-foundation and
techniques 4th edition, p 100.
8. M J Cleak and R G Eston Muscle soreness, swelling,
stiffness and strength loss after intense eccentric exercise,
J Sports Med 1992, 26: 267-272.
9. N. Mafi R. Lorentzon, H. Alfredson Superior short-term
results with eccentric calf muscle training compared to
concentric training in a randomized prospective multicenter
study on patients with chronic Achilles tendinosis Knee
Surg, Sports Traumatol, Arthrosc (2001) 9, 4247.
10. Roberta YW Law and Robert D Herbert(2007)Warm-up
reduces delayed-onset muscle soreness but cool-down
does not: a randomized controlled trial, Australian Journal
of Physiotherapy 2007 Vol. 53.
11. Stephan du Toit Practical guidelines for the warm-up and
cool-down in rugby, Copyright BookSmart 2009.
12. Susan Gray, Myra Nimmo Effects of active, passive or no
warm-up on metabolism and performance during high-
intensity exercise, Journal of Sports Sciences 2001, 19,
693-700.
13. U. Proske and D. L. Morgan Muscle damage from eccentric
exercise: mechanism, mechanical signs, adaptation and
clinical applications Journal of Physiology (2001), 537.2,
pp.333345.
14. Wewers M.E. & Lowe N.K. A critical review of visual
analogue scales in the measurement of clinical
phenomena, research in Nursing and Health 13, 227-236.
115
15. William Kirk Isabell, Earlene Durrant, William Myrer, Shauna Training Volume 27,Number 3,1992.
Anderson, The Effects of Ice Massage, Ice Massage with 16. Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein
Exercise, and Exercise on the Prevention and Treatment ML, Schwartz P, Wongs Essentials of Pediatric Nursing,
of Delayed Onset Muscle Soreness Journal of Athletic ed. 6, St. Louis, 2001, pp.1301.

116 Bhatia P/ Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Comparison of Jacobsons Progressive Muscle Relaxation and
Diaphragmatic Breathing on Cardio-respiratory Parameters in
Healthy Adults A Randomized cross over trial
Prem V*, Bhamini Krishna Rao*, Arun Maiya Gundmi**
*Associate Professor, **Professor, Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal University,
Manipal, Karnataka, India
Abstract
Introduction
To compare the effectiveness between diaphragmatic
breathing exercise (DBE) and Jacobsons progressive muscle
relaxation (JPMR) technique compared to control supine lying
on cardiorespiratory parameters in healthy men.
Material and Methods
Randomized cross-over study design. Thirty healthy male
volunteers were randomly assigned by block randomization into
three groups (Group A, B and C). Subjects in each group were
exposed to three experimental relaxation techniques in three
different sequences with one week of washout period. The three
techniques used for the study were JPMR, DBE and supine
lying was chosen as a control technique. Subjects underwent
two sessions of relaxation technique in a day followed by
washout period of one week, then followed by other two
relaxation techniques according to assigned groups. The cardio-
respiratory parameters selected for measurement were Systolic
Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Heart
rate (HR) and Respiratory Rate (RR).
Findings
Two- way ANOVA for repeated measure showed a decrease
of SBP by 8.4mmHg, DBP by 3.6mmHg, HR by 6.20
beats\minute, and RR by 4.57 breaths\minute following 12
minutes of diaphragmatic breathing exercise with p<0.0001.
Multiple comparison with bonferroni method showed DBE had
significant decrease in all the variables measured, compared to
JPMR and control supine lying with p< 0.05.
Conclusion
Diaphragmatic breathing technique is effective in the
reduction of cardiorespiratory parameters compared to
jacobsons progressive muscle relaxation and control supine
lying in healthy men.
Key Words
Diaphragmatic breathing, Jacobsons progressive muscle
relaxation, relaxation, stress management.
Introduction
Stress is commonest cause of health problems in modern
societies. 1 Stress has been reported to account for 80% of
Address for correspondence:
Mr. Prem V
M.P.T, Associate Professor
Department of Physiotherapy, Manipal College of Allied Health
Sciences, Manipal University, Manipal, Karnataka, India
Email: prem.v@manipal.edu
Prem V / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
modern day diseases and at least 75% of general practitioner
consultation.2
Stress results in stimulation of two endocrine response
systems, the hypothalamic-pituitary- adrenocortical axis (HPA)
and the sympathetic-adrenal-medullary (SAM) system.
Prolonged or repeated activation of HPA and SAM systems can
interfere with their control of other physiological systems,
resulting in increased risk for physical and psychiatric disorders.
Conditions associated stress includes four major diseases:
clinical depression, cardiovascular disease (CVD), human
immunodeficiency virus (HIV)/AIDS, and cancer.3
The impact of stress on the health of people has caused
rising interest among health professionals, resulting in an
increased amount of research into particular strategies for
promoting stress reduction, including relaxation techniques. 4
Jacobsons Progressive Muscle Relaxation (JPMR) is a
commonly used technique among physiotherapists to induce
relaxation. JPMR, the most popular approach in practice
comprising diaphragmatic breathing and systematic sequence
of isometric contractions, which progresses slowly throughout
the body.5 JPMR has been shown effective in various clinical
settings such as cardiac rehabilitation programs6, pulmonary
rehabilitation programs 7, neurological rehabilitation 8, and pain
management. 9
Breathing exercise is widely used as an aid in reducing
anxiety states. It has been shown effective in some cases of
essential hypertension, angina, functional chest disorder, chronic
obstructive pulmonary disease (COPD) and cardiac
rehabilitation.10 Most of the studies on hypertension have shown
significant reduction in blood pressure 11-17 whereas few studies
have shown no significant difference in blood pressure. 18-21
Further, it has been shown to be effective in heart failure patients
22
, and ineffective following post myocardial infarction or post
coronary artery bypass grafting on autonomic function. 23
Comparison of progressive muscle relaxation and breathing
exercise on psychological effects revealed greater relaxation in
progressive muscle relaxation group. 24 There is no published
data to the best of our knowledge, comparing progressive
relaxation to the diaphragmatic breathing on cardiorespiratory
parametres. The cardiorespiratory parameters reported to be
influenced by relaxation were systolic and diastolic blood
pressure, heart rate and respiratory rate.4, 25, 26 This study aims
to compare the effectiveness of Jacobsons progressive muscle
relaxation, diaphragmatic breathing exercise and control-supine
lying on cardiorespiratory parameters in normal subjects.
Material & Methods
Subjects
This study was a randomized crossover design and subjects
acted as their own control. Thirty healthy men aged 20-25 years
who volunteered were included for the study. Subjects were
excluded if they had family history of diabetes mellitus, stroke,
myocardial infarction, cardiovascular disease, and also
diagnosed psycho physiological disorders, history of smoking,
alcoholism and previous relaxation training. The study was
approved by University Ethics Committee and all subjects gave
informed consent. Subjects were randomly assigned to three
117
groups (A, B and C) with 10 subjects in each group through Findings
block randomization. Subjects in each group were exposed to
two relaxation techniques and the control technique of supine The Mean data of pre-intervention showed no significant
lying in three different sequences. (p>0.05) difference between the three experimental groups prior
to any of the intervention methods, confirming the homogeneity
Treatment of the sample and the randomization of allocation. Two- way
ANOVA for repeated measure result shows that there is
During the first week of the study, group A received two significant difference between pre and post treatment and
sessions of 25-mins of supine lying. Following the completion amount of difference is significantly different between the groups
of two sessions of the intervention, a one-week rest period was for all the parameters. Further, multiple comparison shows that
implemented. This was done to minimize any carry-over effect amount of change in pre to post is highly significant in all the
of the treatment sessions. JPMR of two sessions of 25-min three groups and in all the parameters Table 1.
duration and diaphragmatic breathing exercise of two sessions Table 1: Multiple comparisons by bonferroni method to
of 12-minute duration was given during second and third week investigate differences (Diff), standard deviation (SD) between
respectively. It has been shown that sizeable effects of relaxation pre and post in SBP, DBP, HR and RR following intervention
training can be seen after only two treatment sessions.27 Group
B and C underwent three interventions in different sequence SBP mm DBP mm HR beats RR breaths
with study period of three weeks each, as listed earlier. To Hg Hg /min /min
minimize variability, the same environment was chosen for the Diff (SD) Diff (SD) Diff (SD) Diff (SD)
whole duration of the study, and all measurements were taken
by the same person. Data were collected at the same time Diaphra 8.47 3.60 6.20 4.57
each day and in the same order. Instructions for relaxation gmatic (3.30) * (3.94) * (4.58) * (2.32) *
techniques were given through a recorded cassette, in order to
avoid bias. Jacobson 5.73 4.13 2.80 1.00
(2.19) * (4.10) * (4.91) * (2.15) *
Jacobsons Progressive Relaxation Control 3.47 1.40 3.73 1.70
The relaxation lesson gives orders to the subject regarding supine (1.73) * (1.90) * (4.25) * (1.66) *
scheme of instructions incorporating contraction and relaxation lying
of all major muscle groups for 20 minutes, followed by 5mins of P<0.0001*
diaphragmatic breathing. Further attempt was made to compare changes in all the
groups by performing multiple comparisons by Bonferroni test
Diaphragmatic Breathing in table 2. It was observed comparison of Jacobsons progressive
relaxation and diaphragmatic breathing showed significant
Subjects were positioned in crook-lying position with a pillow amount of increase in systolic blood pressure (14.20 mmHg,
for head support. The following instructions were given over the p<0.0001), diastolic blood pressure (7.73 mmHg, p<0.0001),
tape recorder: I would like you to breathe diaphragmatically. heart rate (9.00 beats/ min, p<0.0001) and respiratory rate (3.56
First, place your left hand on your abdomen. Now breathe breaths/min, p<0.0001) in Jacobsons progressive relaxation. It
through your nose so that your hand rises as you inhale and was observed comparison of Jacobsons progressive relaxation
falls as you exhale. Try not to move your upper chest. Let the and control supine lying showed significant amount of increase
air out slowly. Subjects were instructed to breathe in systolic blood pressure (9.20 mmHg, p<0.0001), diastolic
diaphragmatically for 1minute interspersed with an interval of blood pressure (5.73 mmHg, p<0.0001), heart rate (6.53 beats/
1minute for a period of twelve minutes .28 min, p<0.0001) and no significant difference in respiratory rate
(0.70 breaths/min, p=0.20) in Jacobsons progressive relaxation.
Control Supine Lying It was observed comparison of diaphragmatic breathing and
control supine lying showed significant amount of decrease in
Subjects were requested to lie supine with legs uncrossed,
Table 2: Multiple comparison Bonferroni method to investigate
head and neck supported by a single pillow for 25 minutes.
differences (Diff), Standard error (SE) between three treatment
methods
Assessment procedures
SBP mm DBP mm HR beats RR breaths
An acclimatization period of ten minutes was used to Hg Hg /min /min
minimize natural fluctuations in body temperature and heart rate Diff SE Diff SE Diff SE Diff SE
due to prior activity. Systolic and diastolic pressures were
measured on the dominant arm, using a manual Control
sphygmomanometer. Heart rate was measured over 30 seconds supine 9.20 5.53 6.53 0.70(0.54)
by palpating the pulse at the radial artery. Respiratory rate was lying VS (0.42) * (0.84) * (1.12) * (P=0.207) *
measured visually by recording inspiratory excursions over one Jacobson
minute. Control
supine 5.00 2.20 2.46 2.86
lying VS (0.64) * (0.61) * (1.01) * (0.53) *
Statistical Analysis Diaphra
Statistical analysis was performed using the Statistical gmatic
Package for Social Science (SPSS) version 13.0 software, p- Jacobson
value of <0.05 with confidence interval of 95% was considered VS 14.20 7.73 9.00 3.56
statistically significant. Two way ANOVA was performed to Diaphra (0.78) * (0.97) * (1.10) * (0.57) *
analyse the data within the group and between the groups. gmatic
Multiple comparisons were performed using bonferroni method. P < 0.05

118 Prem V / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
systolic blood pressure (5.00 mmHg, p<0.0001), diastolic blood
pressure (2.20 mmHg, p<0.0001), heart rate (2.46 beats/ min,
p<0.02) and respiratory rate (2.86 breaths/min, p<0.0001) in
diaphragmatic breathing group.
Discussion
The analysis showed that the order in which the
interventions were received did not influence the reductions in
the physiological parameters of three treatment techniques
(p>0.05), which ensured that differences recorded were as a
result of the intervention received.
According to Benson, relaxation response occurs when BP
is reduced by 5 mm Hg, HR is by 3 beats/minute and RR by 2
breaths /minute.29 The present study showed a significant
decrease in systolic blood pressure (8.4mmHg), diastolic blood
pressure (3.6mmHg), heart rate (6.20 beats\minute) and
respiratory rate (4.57 breaths\ minute) following diaphragmatic
breathing exercise. Thus the amount of decrease in
cardiorespiratory parameters suggest occurrence of relaxation
response following diaphragmatic breathing, which is in
accordance with the Bensons relaxation response.
Jacobsons progressive relaxation resulted in significant
increase in blood pressure compared to supine lying group. The
findings of the present study contradicts earlier study showing
significant reduction in blood pressure following Jacobsons
progressive relaxation 27,30-33 and in accordance with studies
revealing significant increase in blood pressure.34,35,36 Several
variables that are assumed to be critical for the success of a
Jacobsons progressive relaxation technique are difficult to
measure. For example, the type of therapy and the clinical skills
of the therapist. Even more difficult to assess, are the patients
characteristics and interactions with the therapist, which could
have influenced the outcome of the study.34
In diaphragmatic and the control group, there was a
significant reduction in blood pressure and heart rate. It is
possible that the observed effects were consequence of reduced
physical activity, as heart rate and blood pressure are known to
be correlated with the level of activity. At rest, approximately
two-thirds of blood volume is stored in the veins, as non-active
tissues require fewer nutrients than active tissues, and produce
less metabolic waste. Parasympathetic activity increases,
liberating acetylcholine and reducing heart rate. In the present
study, a ten minute rest period was given prior to intervention,
and as heart rate returns to pre exercise level in approximately
two minutes, 37 it is unlikely that further reduction in blood
pressure would result from rest alone. The findings from our
study suggest that, supine lying of 25 minutes duration, elicited
a relatively small reduction in blood pressure, compared to the
significant reductions in diaphragmatic breathing with treatment
duration of 12 minutes. This ensures reduction in blood pressure
is due to diaphragmatic breathing alone and not an effect of
physical inactivity.
The present study shows a drop of SBP by 8.4mmHg and
DBP by 3.6mmHg, following 12 minutes of diaphragmatic
breathing exercise. The amount of decrease is similar to the
pharmacology treatment of hypertension which results in
reduction of SBP by 9.1 mmHg and DBP by 5mmHg.38
Reduction in blood pressure by 8/3 mmHg in the present
study is substantial when compared to other accepted
nonpharmocology therapies. Independent and combined effects
of weight loss and aerobic exercises on blood pressure and
reduced salt dietary intake reduced BP by 6/5 and 6/2 mmHg,
respectively.39, 40
The possible mechanism to modulate blood pressure is
through slow and regular breathing affecting reflex control of
cardiovascular system. More specifically lung inflation which
increases with decreasing respiratory rate, stimulates slowly
adapting pulmonary stretch receptors. This neural activity acts
as an input to the medulla and is integrated with the information
Prem V / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
about BP level generated by the arterial baroreceptors. As an
acute response to BP elevation and/or lung inflation, heart rate
is decreased and vasodilatation occurs in a number of vascular
territories, such as the limbs, skin, muscles, kidney and
splanchnic vascular bed.12
The central mechanism responsible for relaxation response
is due to stimulation of the trophotropic center in the
hypothalamus resulting in generalized parasympathetic activity.
The role of the cardiovascular system in homeostasis can be
only achieved adequately, if there is integration of cardiovascular
and respiratory function. This occurs due to the close anatomic
location of the cardiovascular receptors, respiratory receptors
and pulmonary receptors in the medulla. Parallel changes occur
in cardiac output, and respiratory minute volume in relation to
the change in level of activity, and metabolic demand. Large
bodies of evidence indicate that extensive interactions occur
between those reflexes that provide, moment by moment
regulation of the cardiovascular system, and respiratory system.
The primary sites of interaction of arterial chemoreceptors,
receptors within the heart as well as the airway and lungs within
the central nervous system is at the level of nucleus tractus
solitarius the potential site of cardiorespiratory integration.41
Recent study has shown diaphragmatic breathing exercise
resulted in decrease of cortisol level. Thereby DBE is able to
alter the hypothalamic- pituitary- adrenocortical axis, which
causes stress related diseases. 42 This could be an other
possible mechanism leading to decrease in blood pressure
and heart rate following diaphragmatic breathing exercise.
Further heart rate reduction could be attributed to the
inspiratory stage of diaphragmatic breathing, causing increase
in thoracic volume resulting in flattened diaphragm. This causes
increase in intra abdominal pressure and compresses abdominal
veins increasing venous blood flow towards the heart. Thus,
the improved venous return increases stroke volume causing a
reduction in heart rate to maintain cardiac output at an
appropriate level.43
Peddicord suggested that breathing techniques could be
used alone for stress reduction, and do not need to be
incorporated into generalized relaxation techniques to elicit the
relaxation response.4 Further study by Bell comparing Mitchells
relaxation and diaphragmatic breathing concluded that
diaphragmatic breathing can be used alone to induce relaxation
and need not be incorporated into generalized relaxation
procedures.44 The findings of our study are consistent with their
research. Diaphragmatic breathing is a more efficient breathing
pattern with less muscle work causing relaxation of neck and
shoulder muscles during breathing. Further Jacobsons
progressive relaxation is time consuming and needs effort to
follow the instructions by the subjects compared to diaphragmatic
breathing exercise. DBE is quicker, more cost effective, and
easier to learn by the subjects.
Conclusion
This study provides evidence of reduction in
cardiorespiratory parameters following diaphragmatic breathing
technique compared to jacobsons progressive muscle relaxation
and control supine lying in healthy men.
Acknowledgements
I would like to thank the faculty and the department of
physiotherapy, Manipal College of Allied Health Sciences,
Manipal University.
Conflict of Interest
There is no conflict of interest.
119
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the implications of evidence-based medicine. Complement
Ther Nurs Midwifery 2001; 7: 59-65.
33. Sheu S, Irvin BL, Lin HS, Mar CL. Effects of progressive
muscle relaxation on blood pressure and psychosocial
status for clients with essential hypertension in Taiwan.
Holist Nurs Pract 2003; 17:41-7.
34. Van Montfrans GA. Relaxation therapy and continous
ambulatory blood pressure in mild hypertension: A
Controlled Study. BMJ 1990; 300: 1368-72.
35. Hahn YB, Ro YJ, Song HH, Kim NC, Kim HS, Yoo YS. The
effect of thermal biofeedback and progressive muscle
relaxation training in reducing blood pressure of patients
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36. Costa F, Biaggioni I. Role of adenosine in the sympathetic
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39. Dengel DR, Galecki AT, Hagberg JM, Pratley RE. The
independent and combined effects of weight loss and
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121
A Comparison Study of 3 Stretching Protocols on Hamstrings
Length
Priya Kannan*, Stanley John Winser*
*Physiotherapy Lecturer, Masterskill University College of Health Science (MUCH), Malaysia
Abstract
Objective
Hamstring stretching is an important part of treatment
programs aimed at decreasing the likelihood of hamstring injury.
The purpose of this study was to determine whether application
of cryostretch, or cryostretch following Hold relax PNF, or only
static stretch increases the extensibility of hamstrings among
healthy subjects.
Methodology
Design- 3 group comparison study, Sample size- 10 in each
group, Sampling method- random sampling (lottery method),
Study period- 1 year, Method- this study examined 30 male
subjects, aged 17-28. Subjects received the following treatments:
Go 1(Group 1) - 30 seconds of only manual stretching for
hamstrings muscle,. Go 2- 10 minutes of ice application followed
by 30 seconds of hamstring stretching Go 3- 10 minutes of ice
application followed by 30 seconds of stretching using hold-relax
PNF technique. All the 3 groups underwent hamstring stretch 3
times. 5 sessions were given.
Outcome Measure
Pre- and post-treatment measurements of hamstring length
were obtained using AKE test and SLR test.
Results
Baseline charters were explained, the three study groups
were compared using Kruskal-wallis test. A p value of less than
0.05 was considered statistically significant. Go1 and Go2
showed a statistically significant improvement in the mean rise
of both SLR and AKE. In the comparison made between the
variables it was found that SLR showed a statistically significant
rise between treatment periods among all subjects.
Discussion and Conclusion
Application of manual stretch alone or cryostretch can be
used as a handy therapeutic technique in improving hamstrings
flexibility among healthy young adults.
Key Words
Stretch, cryotherapy, PNF- Hold relax.
Address for correspondence:
Priya Kannan
Physiotherapy Lecturer
Masterskill University College of Health Science (MUCH),
Malaysia
Email: priyakannan_pt@yahoo.com
122 Priya Kannan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Introduction
Muscles undergo adaptive shortening when maintained in
a shortened position for a long time. Clinically it has been
proposed that a muscle which does not undergo periodic
lengthening will develop a decreased resting length and
extensibility. A series of studies have been done in the field of
methods to improve muscle flexibility which have shown
contradicting results. Hence we wanted to identify the best
adjuncts to stretching in improving the length of hamstrings
muscle among healthy subjects. The objective of this study was
to compare the effectiveness of stretching, cryostretching and
stretching using ice with hold relax PNF technique.
Background of the Study
A shortened muscle may create imbalance in joints and
faulty postural alignment that may lead to injury and joint
dysfunction. A lack of flexibility in the hamstrings is thought to
spike the risk of hamstring injury 1. Indeed, research has
suggested that athletes who have a history of hamstring injury
have significantly less hamstring flexibility compared to uninjured
fellow athletes, and are also very prone to the recurrence of
hamstring troubles. Thus there has been considerable interest
that upgrade hamstring in athletes. Stretching is used as part of
physical fitness and rehabilitation programs because it is thought
to positively influence performance and injury prevention.
Numerous studies have been conducted to investigate the
effectiveness of stretching2. Regardless of the type of program,
the goal of stretching is often to change the physical
characteristics of connective tissue. Connective tissue is a
viscoelastic structure capable of plastic and elastic changes.
The viscous property of connective tissue allows it to go through
a permanent change in structure. Elastic properties refer to the
connective tissues ability to regain its original length. When an
applied stretch to a connective tissue is removed, the elastic
components recover their original length and the viscous
components remain deformed .The amount of elastic and
viscous deformation can vary considerably, depending on the
amount of applied force, and tissue temperature. Theoretically,
stretching protocols produce deformational changes that
lengthen the connective tissue and increase joint ROM.
The application of cold prior to stretching is known as
cryostretching. Cryostretching has been advocated to decrease
muscle tone and make the muscle less sensitive during stretch
in healthy subjects 3,4,5. The superficial application of cold causes
specific physiological reactions, such as decrease in metabolic
function, decreased conduction velocity, and muscle spasm and
an increase in local anesthetic effect6. All these factors are
thought to enhance the gains realized with modified PNF. When
a small surface area is exposed to cold temperature,
vasodilatation by the deeper vascular system attempts to
compensate for the cold, resulting in increased blood flow to
the tissues underlying the site of exposure. This reaction occurs
to maintain a relatively constant deep tissue temperature. The
gains reported using ice and modified PNF are due to increased
vascular flow7
PNF uses the concept of muscle relaxation being
fundamental to elongation of muscle tissue. In theory it is
performed in a way that uses the proprioceptive abilities of the
GTO (golgi tendon organ) and muscle spindle to relax or inhibit having the axis of the goniometer over the lateral joint line of
the muscle in order to gain a more effective stretch8. It does so the knee, movable arm parallel to the long axis of fibula and
using autogenic inhibition and reciprocal inhibition. When muscle immovable arm parallel to the long axis of femur, as shown in
is stretched and the subject voluntarily performs an isometric figure 1. Assistance was taken to record the reading. The right
contraction, it is thought that the Golgi tendon organs reflexes lower limb was tested for all individuals and the testing protocol
are stimulated inhibiting or relaxing the muscle and thereby was kept constant for all participants. The assessor who
allowing the muscle to elongate. Hold - relax (HR) is one of the performed the outcome measures was blinded for the testing
techniques of PNF where the muscle to be stretched is passively groups. The test was done at the beginning of the trial, and then
taken to the end range and maximum contraction of the muscle the subjects underwent a 1 week stretching program depending
to be stretched is performed against resistance (usually by on their allotment of groups. Stretching was given from Monday
another person). In this form of contraction, the muscle does to Friday and thus each subject underwent 5 treatment sessions.
not shorten during its isometric contraction. This is continued The intervention was administered by a single researcher for all
for at least six seconds (allowing autogenic inhibition to occur). the 3 groups.
The muscle is then relaxed to a new range and held for about
20 seconds. This can be repeated 3-4 times9. Fig. 1: Showing evaluation of joint range using goniometry
Studies have produced conflicting results as to the optimal
duration of static stretch necessary to achieve the viscoelastic
changes to increase ROM10. According to Bandy et al, Borms et
al, and Gajdosik, the optimal time for maintaining the stretch
varies. The use of a 30 sec stretch , 10 sec stretch, and 15 sec
stretch resulted in an increase in ROM of the hamstring
musculature, as demonstrated by Bandy et al, Borms et al and
Gajdosik, repectively. In the majority of these studies, however,
the hamstring muscles ability was studied, and we believe the
findings cannot necessarily be generalized to other muscle
groups.

Material and Methods

Subjects
This study was approved by the Institutional review board Stretching Protocol
and ethical Committee. The background of this 3 group
comparison study was explained to the subjects in their language Stretching maneuvers and verbal commands were
and the subjects who were willing to participate were inducted previously standardized with the researchers being involved in
into the study following an informed written consent. The sample the study protocol. The participants were instructed on the
was limited to the male sex due to the subjects availability of maneuver before the procedure. Go 1 underwent stretching
this gender. The subjects who full filled the inclusion criteria alone and the Stretching was performed by having the participant
were, healthy males between 17 and 28 years & those with in supine position and left thigh stabilized by the researcher
active Knee Extension ROM not less than 160 degrees. Subjects
with the aid of a towel. The researcher passively flexed the
excluded were those with history of higher cortical lesions eg.
Trauma, paralysis, presence of adhesions and scar tissue, participants right hip to 90 degrees and then extended knee up
spasticity, hamstring repair or surgery, any recent hip or knee to his/ her pain threshold and position in which discomfort in the
injury, knee deformities eg. genu varum, genu valgum, genu hamstrings was reported was marked as the starting position,
recurvatum , hypermobile joints & tendon transfers. at this starting point a static manual stretch was given for a period
of 30 second, as shown in figure 2.
Procedure Fig. 2: Showing the technique of stretching
The study was done at the Physiotherapy Department, for
a period of 1 year. The sample size was calculated to be 10 in
each group. The subjects were randomly allotted to one of the
groups using lottery method. Subjects in each of the groups
received the following treatments: Go 1(Group 1) - 30 seconds
of only manual stretching for hamstrings muscle,. Go 2- 10
minutes of ice application followed by 30 seconds of hamstring
stretching Go 3- 10 minutes of ice application followed by 30
seconds of stretching using hold-relax PNF technique. For all
the 3 groups the hamstring stretch was repeated 3 times.

Outcome Measure
Flexibility of Hamstrings muscle in the form of passive
straight leg raising (SLR) and active knee extension (AKE) with
hip flexed to 90 degrees in supine was recorded using
goniometer before and after the treatment protocol. SLR was
assessed by positioning the subject in supine, having the subject
to relax completely, the hip was passively flexed to 90 degrees
and knee was extended to its end range. At the end range a
standard goniometer was placed over the lateral aspect of knee

Priya Kannan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 123
Fig. 3: Showing application of cryotherapy. terms of mean, as shown in table 1. Descriptive statistics (Mean,
SD, Median and ranges) were obtained for the study variables
(SLR, AKE). The three study groups (Go 1, Go 2 and Go 3)
were compared using Kruskal-wallis test. A p value of less than
0.05 was considered statistically significant. Data was entered
Table 1: Showing baseline characters
CHARECTERS Go 1 Go 2 Go 3

Age 20.39 23.43 21.67

Height (m) 1.54 1.59 1.51

Weight (kg) 60.35 59.45 51.45

BMI 20.69 21.73 20.98

Go 2 subjects underwent a 10 minutes ice application prior
to the stretching protocol as shown in figure 3 and the technique
involved was the same as adopted for Go 1. Go 3 subjects
underwent 10 minutes of ice application prior to the PNF hold
relax. To perform PNF hold relax technique the subject was
positioned in supine lying, right lower limb was flexed to
90degrees and the knee was extended to its end range. At the
end range the subject was instructed to perform and isometric
contraction of the hamstrings for 7 seconds followed by
concentric contraction of quadriceps (knee extension) for 5
seconds and the procedure was repeated again from the
obtained new range for 3 times.
Results
Baseline characters were explained for all three groups in
Number of sub. 10 10 10
in MS Excel and analyzed using SPSS 11.0.
The data were assessed for group differences in knee range
between and within each group. Comparison of mean increase
in SLR range of motion of the three groups showed that Go 1
(median = 15; Range=7-20) and Go 2(median=10; Range=3-
24) are comparatively more effective than Go 3 (median=5.5;
Range=2-15) in increasing mean straight leg raising range of
motion with p value less than 0.005 as shown in table 2.
Comparison of mean increase in AKE range of motion of
three groups revealed a statistically significant increase among
Go 1 & 2, and a statistically insignificant rise among subjects of
Go 3, as shown in table 3.

Table 2: showing the difference in SLR between pre and post intervention

Group Pre test Post test Mean Standard P50(median) Min Max p value
(Mean) (Mean) difference deviation

Go 1 138 151.2 13.2 4.05 15 7 20 0.0031

Go 2 127.2 140.4 13.2 6.75 10 3 24 0.0032

Go 3 139.4 145.6 6.2 3.88 5.5 2 15 0.15

Table 3: Showing difference in AKE between pre and post intervention

Group Pre test Post test Mean Standard P50(median) Min Max p value
(Mean) (Mean) difference deviation

Go 1 152 161.1 9.1 5.36 8.5 1 15 0.0042

Go 2 163.5 171.1 7.6 4.81 5.5 2 15 0.0034

Go 3 159 164 5 2.67 5 2 10 0.243

A comparison made between the mean increase in SLR
and AKE among the 3 groups showed, the rise in SLR was
statistically significant with a p value of 0.01 and the rise in the
other variable was found to have a p value of 0.211 which cannot
be accepted as a statistical significant rise.
Discussion
The two main findings of our study were, 1. Manual stretch
and manual stretch with ice application were found to be more
effective in improving the length of hamstrings muscle among
healthy young aged adults when compared to stretching using
PNF hold relax technique with ice application, 2. Using the above
techniques SLR showed a quicker increase in terms of knee
range when compared to AKE.
The literature is inconclusive regarding which stretching
method is best for increasing muscle length. Previous studies
support greater increases in ROM with PNF stretching
techniques than with passive, static, or ballistic stretching
methods. 11,12,13 However, some studies 14 suggest no difference
between PNF and other stretching techniques. Several
methodologic differences in the studies and the statistical
manipulation of the data confound this issue.
It is not surprising that each group experienced increase in
knee extension from pre to post test. Joint ROM has been shown
to increase somewhat regardless of the stretching method used.
Manual stretch and cryostretch were found to yield superior
results. We hypothesized ice with hold-relax PNF technique to
be most effective in increasing SLR and AKE range of motion.
We were not able to explain the reason for why use of ice reduces

124 Priya Kannan / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
the efficiency of the technique, so further researches are
warranted to identify the phenomenon underlying.
The reasoning behind the second finding of our study can
be explained in terms of muscle work and muscle insufficiency
i.e. when SLR is done passively there is minimal to no fatigue
experienced by the subjects on checking the range of motion.
On the other hand, AKE is done actively so it is very likely that
the subjects experienced muscle fatigue, causing a possible
decrease in the ROM that was recorded. More over having the
hips flexed to 90 degrees the quadriceps is not in a
biomechanically efficient position to overpower the hamstrings
muscle to pull knee into full extension. Therefore these 2 factors
could have caused a poor yield of the target muscle.
There were few limitations in our study which includes 1.
The temperature of the ice packs used for each subject, may
have differed since, the temperature was not recorded prior to
use. 2. There were subjects who were not able to attend for 5
consecutive days. Finally future studies can be undertaken with
subjects of both gender.
Conclusion
Mean difference between the pre and post intervention
knee range obtained during SLR and AKE have shown that
application of manual stretch and manual stretch with ice
application to be more effective than cryostretch with hold relax
PNF technique. Ease of administration of these techniques
ensures its frequent usage in clinical practice. Thus we conclude
that application of manual stretch alone or cryostretch can be
used as a handy therapeutic technique in improving hamstrings
flexibility among healthy young adults.
Reference
1. Taylor BF, Waring CA, Brashear TA. The effects of
therapeutic application of heat or cold followed by static
stretch on hamstring muscle length. J Orthop Sports Phys
Ther. 1995 May;21(5):283-6.
2. Bandy WD, Irion JM, Briggler M. Effect of static stretch and
dynamic ROM training on flexibility of hamstrings. J Orthop
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Sports Phys Ther. 1998 27(4): 295-300
3. Chang Gung Uni, Kweishan, Taoyuan. Effect of thermal
therapy in improving passive ROM: comparison of cold and
superficial heat application. Clinical Rehabilitation 2003;
17(6) : 618-23.
4. Ian Shrier, Kav Kossal. Myths and Truths of Stretching.
The Physician and Sports Medicine volume 28-no.8; 2000.
5. Taylor BF, Waring CA, Breshear TA. Effects of therapeutic
application of heat or cold followed by static stretch on
hamstring muscle length. J Orthop Sports Phys Ther 1995
May; 21(5); 283-6
6. Hardy M, Woodall W. Therapeutic effects of heat, cold, and
stretch on connective tissue. J Hand Ther. 1998 Apr-
Jun;11(2):148-56.
7. Lin YH. Effects of thermal therapy in improving the passive
range of knee motion: comparison of cold and superficial
heat applications. Clin Rehabil. 2003 Sep;17(6):618-23.
8. Davis DS, Ashby PE, McCale KL, McQuain JA, Wine JM.
The effectiveness of 3 stretching techniques on hamstring
flexibility using consistent stretching parameters. J Strength
Cond Res. 2005 Feb;19(1):27-32.
9. Scott G, Spernoga, Timothy L, Brent L, Arnold, Bruce M,
Gansneder. Duration of a maintained hamstring flexibility
after a one time modified hold relax stretching protocol.
Journal of Athletic Training 2001; 36(1): 44-48
10. Bandy WD, Irion JM. The effect of time on static stretch on
the flexibility of the hamstring muscles. Phys Ther. 1994
Sep;74(9):845-50; discussion 850-2.
11. Prentice WE. A comparison of static stretching and PNF
stretching for improving hip joint flexibility. J Athl Train.
1983;18:5659.
12. Tanigawa MC. Comparison of the hold-relax procedure and
passive mobilization on increasing muscle length. Phys
Ther. 1972;52:725735.
13. Hardy L. Improving active range of hip flexion. Res Q.
1985;56:111114.
14. Worrell TW, Smith TL, Winegardner J. Effect of hamstring
stretching on hamstring muscle performance. J Orthop
Sports Phys Ther. 1994;20:154 159.
125
Effect of Long Term Physical Exercise Training on Auditory and
Visual Reaction Time
Shashi Kant Verma*, Anand Mishra**, Ajit Singh***
*Assistant Professor, Department of Physiology, **Associate Professor, Department of Anatomy, ***Associate Professor, Department
of Orthopedics, Rohilkhand Medical College and Hospital, Bareilly, India 243006
Abstract
Objective
The present work was planned to determine long term
physical exercise has any beneficial effect on central neural
processing, by studying its effect on reaction time.
Methods
In present study 20 male and 20 female, young medical
students practiced exercise (15 min sessions) for 3 months on
alternate day basis. Outcome assessments of auditory reaction
time (ART) and visual reaction time (VRT) were performed at
baseline and after the 3 month of exercise training.
Results & Discussion
In both male & female, there was a statistically significant
(P<.001) decrease in ART and VRT. Also ART and VRT values
were more in females than in males both before and after
physical exercise training. This probably attributed to the
differences in processing strategy in males and females. This
decrease in ART and VRT after exercise practices may be due
to physiologically relaxed state but increased mental alertness,
improved concentration, and/ or increased CRH & cortisol
secretion in response to a challenge. .
Conclusion
RT is of applied value in situations requiring faster reactivity
regarding serious safety concern such as in day today driving to
avoid road traffic accidents, in sports for recommendation of
safety limits, machine operations and in specialized surgery. So
we suggest that the physical exercise is a lifestyle factor that
might lead to increased physical and mental health and
performance that can be used as an effective means of training
people involving such tasks.
Key Words
Physical exercise, Reaction time, Central neural processing
Introduction
Simple reaction time is defined as the interval between
the onset of the stimulus and the response under the condition
that the subject has been instructed to respond as rapidly as
possible.1
Reaction time (RT) is an indirect index of the processing
ability of central nervous system and a simple means of
determining sensory motor association and performance.2 RT
involves central neural mechanisms and its study is of
Address for correspondence:
Dr Ajit Singh
Associate Professor, Orthopaedic department, RMCH, Bareilly.
E-mail ajitsingh2409@gmail.com
126 Shashi kant Verma / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
considerable physiological interest. In 1983 Spirduso proposed
RT as a measure of the overall integrity of central nervous
system.3 Also there is evidence that cardiovascular fitness exerts
a positive influence in the psychomotor domain. RT has been
used as primary index of psychomotor performance.4 RT is
sensitive and reproducible test and its measurement can be
done with simple apparatus and set up. It has also been
suggested that RT can be used as a simple and objective method
to determine the cognitive and motor performance effects of
various exercise trainings.4
Over the past several decades there has been an increasing
interest in the influence of exercise on motor performance. A
number of studies have reported improvement in performance
in terms of reaction time (RT) with physical training5-7 while some
research showed no effect on RT.8-10 So, we planned to see the
effect of long term exercise training on reaction time. Additionally,
we try to make a hypothesis on neurophysiological mechanism
behind the changes in RT after long term exercise.
Material and Methods
The present study was conducted in Department of
Physiology, RMCH, Bareilly on forty (40), 1st year MBBS students.
Detailed information was collected on pre-designed proforma.
Complete general, anthropometric and systemic examinations
were carried out. Subjects with previous regular athletic activity
or yogic training/ meditation were excluded from study. After
briefing about the study protocol, consent was obtained. These
two groups of male (n=20) and female (n=20) students performed
physical exercise on bicycle ergometer till target heart rate
between 100-150 beats/minute (moderate exercise) was
obtained. This exercise was done for 3 months on alternate day
basis in peaceful, lighted and well - ventilated hall between 7.00
AM to 8.00 AM at room temperature. Clothing was minimal and
very loose. The ART and VRT were recorded initially at the onset
of the study (Baseline reading) and again after 3 months of
physical exercise training.
Instrument
An electronic instrument (Fig. 1 and Fig. 2) was used to
measure reaction time both auditory and visual, whose sensitivity
was to take readings from 0 to 999 milliseconds (ms). This
instrument consisted of 4 boards. One board was on the
examiners side (which subjects cannot see) in which there were
3 switches: first switch was to change the circuit between auditory
or visual signal productions, second switch was to open the
circuit as opted by first switch and third switch was to reset the
LCD counter. Second board had the LCD for counting the
reaction time (0 to 999 ms).The third board had a buzzer and a
bulb. The second and third boards were placed in between the
subject and the examiner. The fourth board on the subjects
side had a switch to break the circuit after receiving the stimulus
either auditory or visual. All the switches used in instrument were
micro-switches that were very sensitive to touch.
No warning signal was given and to avoid the effect of
lateralized stimulus, visual and auditory signals were given from
the front of the subjects who were instructed to use their dominant
hand while responding to signal.
Fig 1: Reaction Time measuring Instrument
Fig. 2: Circuit of Reaction Time Instrument
Recording of Auditory Reaction Time
Subjects were blindfolded and instructed to cut off the circuit
by pressing the switch as soon as they hear the buzzer. The
observer selects the auditory circuit by the switch provided and
switches on this circuit at varying time intervals to avoid guess
work by subject. As soon as subject hears the sound, he cut off
the circuit by pressing the switch. The subsequent time taken
was recorded as auditory reaction time (ART) of that particular
subject. Three such readings of each subject were taken and
the mean was calculated.
Recording of Visual Reaction Time
The above procedure was repeated by choosing the visual
circuit instead of auditory circuit, where the subject is instructed
to use ear plug and responds by pressing the switch as soon as
he visualizes the lighted bulb (40 watt). The subsequent time
taken is the visual reaction time (VRT) of that particular subject.
Three such readings of each subject were taken and the mean
Shashi kant Verma / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
was calculated.
Data Collection and Analysis
The baseline readings were taken at start of the study and
then compared with that of final readings at the end of 3 month
training in both male and female groups. The paired t-test was
used for statistical analysis, a P-value of <0.05 was considered
statistically significant. RT analysis excluded erroneous key
presses.
Results
All the students were unmarried and Hindu. 60% (24)
students were vegetarian, and the remaining 40% (16) gave
history of taking non-vegetarian diet occasionally. Anthropometric
data of subjects are summarized in Table 1.
None of the subject gave any history of yogic training or
physical exercise of any kind. Also no history of any addiction
(alcohol, guthka or cigarette smoking) is found.
127
 Paired t test was used to analyze the data. For statistical Discussion
analysis, the software SPSS version 17.0 was used. The
confidence interval of 95% was set for all comparisons and a P Effect of exercise on processing ability of central nervous
valve of less than 0.05 was accepted as indicating significant system in terms of reaction time is debatable as some studies
difference between the compared values. Data are expressed shown no effect8-10 while other reported a decrease5-7 in it.
by using mean and standard deviation. The finding of our study revealed that RT for auditory &
Before Exercise training, in males ART was 148.10 25.538 visual reaction stimuli was found to be faster in subjects having
ms and after performing three months training, ART decreased exercise training as compared to pre-training RT status.
to 122.90 13.799 ms, the decrease being statistically highly In our study we have also found that ART and VRT was
significant (P<0.001). (Table 2) more in females than in males, which is in conformity with
Before Exercise training, in females ART was 160.25 previous studies11-13. This probably attributed to the differences
28.325 ms and after performing three months training, ART in processing strategy in males and females14. Also the auditory
decreased to 134.30 17.391 ms, the decrease being reaction time was faster than the visual reaction time both in
statistically highly significant (P<0.001). (Table 2) males and females that is in line with previous studies13.
Before Exercise training, in males VRT was 167.55 26.916 This faster RT in aerobic exercises is due to improved
ms and after performing three months training, VRT decreased concentration, alertness, better muscular co-ordination and
to 137.00 18.186 ms, the decrease being statistically highly improved performance in the speed and accuracy task15, 16.
significant (P<0.001). (Table 3) These factors leads to reduce tension and develops alertness
Before Exercise training, in females VRT was 177.95 and better coordination of mind with body, which seems to be
24.831 ms and after performing three months training, VRT responsible for better performance of the individual15, 17. Aerobic
decreased to 149.80 14.898 ms, the decrease being exercise training affects various organ systems including
statistically highly significant (P<0.001). (Table 3) Cardiovascular, respiratory, CNS & skeletal muscles etc. These
trainings leads to an increase in cardiac stroke output associated
Table 1: Anthropometric data of the volunteers with more complete emptying of heart during systole. There is
Male Female also a reduction in the ventilation minute volume at high rates of
(Mean SD) (Mean SD) work, on account of an improved muscle blood flow and an
increase in intracellular enzymes15. There is increased vagal
Age (Yrs) 22.9 1.141 21.5 1.732 tone in athletes, with greater muscle tension and behavioral
features which distinguish the trained from the untrained and
Height (cm) 179.0 5.254 156.05 2.999 favours establishment of new motor performance16, 17.
Exercise training bring out an increase in stores of creatine
Weight (kg) 58.6 3.720 48.55 3.649 phosphate as well as glycogen. Creatine kinase activity is
SD = Standard Deviation, Yrs = Years, cm = Centimeter and kg increased and so is the activity of mitochondrial enzymes leading
= Kilogram to enhanced respiratory capacity of skeletal muscles18. This
causes sparing of glycogen and increased capacity to oxidise
Table 2: Comparison of auditory reaction time in males and fatty acid, thus improved work time, delayed fatigue, increasing
females before and after the 3 months of exercise practice oxidation of ketones and increased removal15, 19. Thus, these
Before After 3 months Signifi- beneficial effects in aerobic exercisers are responsible for their
Ex practice of Ex practice cance faster reaction time performance.
(ms) (ms) Some studies had shown no significant change in reaction
time after long term aerobic and resistance training8, 9, 10, 20, 21.
Male 148.10 122.90 HS However this inconsistency may due to differing in subject
(Mean SD) 25.538 13.799 selection, mode of exercise (strength/ endurance), the timing of
(n=20) RT measurement (Immediate after exercise or during exercise)
or sensitivity of RT instrument.
Female 160.25 134.30 HS A decrease in RT is known to improve the sensorimotor
(Mean SD) 28.325 17.391 performances. Thus RT could be used either for screening the
(n=20) large population for physical fitness22, in sports physiology23, 24,
as a therapeutic intervention in certain type of medical conditions
SD = Standard Deviation, Ex = Exercise, ms = millisecond and like depression25, cardiovascular diseases and diabetes26, to train
HS = Highly significant (P<.001). mentally retarded children and older sports persons who have
prolonged RT27, as an index of cortical arousal28 or to assess
Table 3: Comparison of visual reaction time in males and cognitive impairment after an accident29.
females before and after the 3 months of Exercise practice Exercise training leads to increased CRH (corticotropin
releasing hormone) 30 and cortisol secretion in response to a
Before After 3 months Signifi-
challenge as compared to the control subjects 31 but the baseline
Ex practice of Ex practice cance
levels during rest are reduced 32. So when a challenge is
(ms) (ms)
presented in form of pressing the key as soon as possible in
response to light or buzzer there is increased CRH and cortisol
Male 167.55 137.00 HS
secretion. While testing RT, the individual being tested is in a
(Mean SD) 26.916 18.186
state of stress/ challenge as he has to press the key in the
(n=20)
shortest possible time in response to an auditory /visual signal.
To do so the nerve impulse has to be processed faster in the
Female 177.95 149.80 HS
auditory/visual neuronal pathways and its association fibers to
(Mean SD) 24.831 14.898
frontal cortex. The reaction time also depends on the quick
(n=20)
activity of skeletal muscle. Both these factors depend on the
SD = Standard Deviation, Ex = Exercise, ms = millisecond and blood flow to the particular organ i.e. central nervous system
HS = Highly significant (P<.001) and skeletal muscle. Exercise has been shown to increase
cerebral33, 34 and skeletal muscle blood flow18 by increasing
cortisol level in blood during stress31.

128 Shashi kant Verma / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
 So we want to hypothesize that this dual action of exercise
both on CNS as well as skeletal muscle are the possible
mechanisms that lead to markedly decrease reaction time as
compared to control subjects. Further studies are required to
substantiate this.
Conclusions
This shortening of RT after regular exercise training is of
applied value in situations requiring faster reactivity regarding
serious safety concern such as in day today driving to avoid
road traffic accidents, sports, for recommendation of safety limits,
machine operations and in specialized surgery. So we suggest
that regular physical activity should be promoted and access to
sports facilities should be facilitated especially in people involving
such tasks.
Acknowledgement
The authors thank Dr Mrs Sharda Gupta, Professor and
Head, Department of physiology, RMCH, Bareilly and other
faculty members for their support.
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7. McMorris T, Delves S, Sproule J, Lauder M, Hale B. Effect
of incremental exercise on initiation and movement times
in a choice response, whole body psychomotor task. Br J
Sports Med. 2005; 39:537541.
8. Nakamoto H, Mori S. Sport-specific decision-making in a
go/no go reaction task: difference among nonathletes and
baseball and basketball players. Perceptual and Motor
Skills. 2008; 106(1): 163-171.
9. Davranche K, Audiffren M, Denjean A. A distributional
analysis of the effect of physical exercise on a choice
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Welford (Ed.), Reaction Times. Academic Press, New York.
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J, Wright J. Effects of age on late components of the ERP
and reaction time. Experimental Aging Research. 1999;
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129
Effect of Hamstring Static Stretch Training on Knee Flexion
Concentric Torque
Amr Almaz Abdel-aziem, Osama Ragaa Abdelraouf
Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Egypt
Abstract
Objectives
To determine the chronic effect of static stretching program
of hamstring on knee flexors concentric torque.
Methods
Twenty four volunteers male participants (age = 24.08
2.6 years, height 171 5.6 cm, weight = 66.5 5.8 kg). The
participants performed a 30 sec static stretch for 6 weeks (three
times / week). The knee extension range of motion (ROM) and
hamstring concentric torque was measured before and after
the static stretching program, ROM measured by universal
goniometer. The hamstring concentric torque was evaluated by
Biodex Multi-joint System 3, measurements performed at
angular velocities 30 and 60/sec.
Results
Statistical analysis revealed significant increase in the
concentric hamstring torque at angular velocities 30 and 60/
sec, also there is significant increase in the ROM due to static
stretch.
Conclusion
Static stretching program for the hamstring muscle was
effective in increasing the concentric torque of the knee flexors
at both angular velocities, also, induced increases in the
amplitude of knee extension.
Key Words
Hamstring flexibility; Static stretch; Concentric contraction.
Introduction
For many years stretching has been a controversial issue
in regards to its effect on both muscle strength and elongation.
Stretching has been used as a warm-up technique to increase
joint range ROM, enhance joint performance and aid in the
prevention of injuries. However, Marek et al. 1 has reported that
stretching leads to a decrease in peak torque production after
completion of a stretching session.
Three types of stretching have been traditionally defined
to increase flexibility: ballistic stretching, proprioceptive
neuromuscular facilitation (PNF), and static stretching. Static
stretching, considered the gold standard for measuring flexibility,
is elongating a muscle to tolerance and sustaining the position
for a length of time.2
Bandy et al.3 and Bandy and Irion4 proved that a 30 sec
duration is an effective time duration to sustain a hamstring
muscle stretch in order to increase ROM. The use of stretching
exercises to improve the flexibility is a widespread practice
among competitive and recreational athletes. Many studies have
analyzed the acute post-stretching muscle responses and found
130 Amr Almaz Abdel-aziem / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
that stretching exercises preceding the main strength activity
significantly decreased performance.1,5-8
Very few studies have looked into the chronic effects of
stretching on strength performance. Worrel et al.9 used static
and PNF contract-relax methods to train the flexibility of the
hamstrings; exercises were performed five times a week, for 3
consecutive weeks, the study showed no significant gains in
flexibility, but 11.2% increase in concentric peak torque at 120/
sec, without increase in concentric torque at 60/sec. Even
though, there is a lack of data related to the latter stretching
effects. So, this study was conducted to determine the prolonged
or chronic effect of static stretching program applied to knee
flexors on hamstring concentric peak torque.
Material and Methods
Subjects
Twenty four volunteers male participants (age = 24.08
2.6 years, height 171 5.6 cm, weight = 66.5 5.8 kg). The
subjects should demonstrate the following characteristics: a)
have a sedentary lifestyle; b) and a minimum of 20 of the
dominant member knee extension is lost with the hip in 90o of
flexion during the active knee extension. Participants were
excluded if they had a history of hip, knee, or ankle surgical
repair on their dominant lower extremity. Prior to participation in
the study, participants received an explanation of the study
procedures and they signed a participation consent form.
Procedures
Hamstring muscles flexibility was measured with a
goniometer that was a double-armed, full-circle protractor made
of transparent plastic marked of in 1-degree increments. Each
subject was positioned supine with the right hip and knee flexed
to 90 degrees. The lateral malleolus, lateral epicondyle of the
femur, and greater trochanter of the right lower extremity were
then marked with a felt-tipped pen for later goniometric
measurement. Ninety degrees of hip flexion was maintained by
one researcher, while the tibia of the knee was passively moved
to the terminal position of knee extension by the second
researcher. The terminal position of knee extension was defined
as the point at which the subject complained of a feeling of
discomfort or tightness in the hamstring muscles or the
experimenter perceived resistance to stretch. Once the terminal
position of knee extension was reached, the second examiner
measured the amount of knee extension with the universal
goniometer. Zero degree was considered to be full extension of
the knee.
The subjects received instruction in performing the static
stretch for six weeks, three times a week. All stretching was
performed with the right lower extremity. The stretch was
performed standing, facing a padded evaluation table with the
heel of the right limb placed on the edge of the table in relaxed
plantar flexion. Neutral right hip rotation was maintained by
keeping the foot pointed straight up. The standing leg left foot
was perpendicular to the table. The subject was then instructed
to bend forward at the waist. During the stretch, the subject
maintains a flat back with the pelvis in relative anterior rotation,
neutral position of the head, and full extension of the stretched Fig. 1: Effect of static hamstring stretch on knee extension ROM
leg. Each subject bent forward and stopped when a stretch
sensation was experienced in the posterior thigh.10 This position
was maintained for 30 sec, measured with a stop watch. The
stretching sessions were to be performed between 10 a.m. and
5 p.m. A minimum of 60 and a maximum of 72 hours existed
between the last bout of stretching and the posttest.
Isokinetic dynamometer (Biodex Multi-joint System 3,
Shirley, NY, USA) used to measure the hamstring concentric
torque. The hamstring torque was evaluated using a ROM of
60 starting from 90 of knee flexion. The concentric program
was used to evaluate the knee flexor muscles. These evaluations
were performed at speeds of 30o and 60/sec. Five consecutive
movements of knee flexion were performed at each speed, with
a rest interval of two minutes. The evaluation always started at
a speed of 30/sec. It is also important to state that five sub-
maximum contractions were performed before the maximum Fig. 2: Effect of static hamstring stretch on knee flexion
tests in order for the subjects to get used to the equipment. All concentric peak torque (Nm) at angular velocities 30o and 60o/
tests were carried out before and after the static stretching sec
program. On each testing day, the machine was calibrated in
accordance with the manufacturers manual. The Biodex
software compensated for the effect of gravity as part of the
setup with the subject positioned appropriately.
Participants were familiarized with the testing procedure 3-
4 days before the main testing session. During this period,
subjects performed 5 warm-up trials for hamstring at the speed
45/sec. On the testing day, each participant performed a 3 min
warm-up on a cycle ergometer followed by stretching exercises
for the lower limbs. Subjects were positioned seated with the
backrest at a 90 degrees angle. Straps were placed over the
shoulders and across the waist to ensure the torso was stable.
An adjustable lever arm was attached to the subjects leg by a
padded cuff, just proximal to the lateral malleolus. The axis of
rotation of the dynamometer arm was positioned lateral femoral
epicondyle. During the concentric test, the subjects continuously
pushed the lever arm of the isokinetic device down. Table 1: Mean and standard deviation of extension ROM,
hamstring concentric peak torque (Nm) at angular velocities
30o and 60o/sec pre and post stretch.
Statistical Analyses
Variables Pre-test Post-test P value
Data was analyzed by using statistical package for social
(X SD) (X SD)
sciences (SPSS version 16). MANOVA with repeated measure
used to examine the effect of static stretching program on
ROM 38.98 28.7 4.33 0.0001
extension ROM and hamstring concentric torque (Nm). ANOVA
2.86
with repeated measures used to investigate the effect of angular
velocities on peak torque. The level of significant was set at
Peak at (30/sec) 111.87 117.66 0.0001
0.05 for all statistical tests.
10.59 11.43

Results Torque at (60/sec) 112.62 122.75 0.0001

MANOVA with repeated measures revealed that there was
significant effect of static stretch training (f = 108.6, p = 0.0001)
on extension ROM which improved from 38.98 2.86 to 28.70
4.33 (fig.1), the hamstring peak concentric torque at angular
velocity 30/sec improved from 111.87 10.59 to 117.66 11.43
(p < 0.05), and hamstring peak concentric torque at angular
velocity 60/sec improved from 112.62 11.62 to 122.7512.03
(p < 0.05), these values explained in the following table and
illustrated in fig.2.
ANOVA with repeated measures proved that there was
significant effect of velocity (f = 27, p = 0.0001) on hamstring
peak concentric torque. Moreover, Univariate tests revealed that
there was no significant difference between both velocities pre
treatment values (p > 0.05) while there was significant difference
post treatment values (p < 0.05), the increase in hamstring peak
concentric torque at angular velocity 60/sec was higher than
hamstring peak concentric torque at angular velocity 30/sec.
Discussion
The results of this study indicated that the knee flexor static
11.62 12.03
P value less than 0.05 means significant difference.
stretching program for 30 sec was effective in increasing knee
extension ROM that coincident with the findings of Bandy et al.3
and Bandy and Irion4 who proved that a 30 sec duration is an
effective amount of time to sustain a hamstring muscle stretch
in order to increase the ROM, and no increase in flexibility
occurred when the duration of stretching was increased from
30 to 60 sec, or when the frequency of stretching was increased
from one to three times per day. The gains in the knee extension
amplitude might have been caused by changes in muscular
length due to increases in the number of sarcomeres in series.11,12
The torque amount produced by the muscle depends on
the number of motor units activated, the muscle length, and the
moment arm of the muscle.9 The results revealed that the static
stretching of hamstring increased the knee flexors torque at
angular velocities 30 and 60/sec. The increase in knee flexor
concentric torque that was observed in this study might have
been caused by increases of the elastic components, since there
were increases in the flexibility of the knee flexors which is

Amr Almaz Abdel-aziem / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 131
supported by the findings of Taylor et al.13 reported that after
stretching, some viscoelastic properties of the muscular
conjunctive tissue change, the resistance tension diminishes
and the muscle becomes more complacent.
In addition, Herzog and Leonard14 stated that most of the
improvements in strength after stretching is due to the passive
components as well as the contractile and active components
of the muscles. Worrell et al.9 also observed increases in
concentric knee flexor torque after the performance of stretching
programs. They attributed these increases to a greater ability of
the stretched muscle to store elastic potential energy absorbed
during the eccentric contractions which precede the concentric
contractions, this would improve the later strength of the
concentric contractions.
Worrell et al.9 proved that there was significant increase
concentric contraction at angular velocity 120o/sec after both
types of stretch, which support the result of this study. However,
no significant increase in concentric contraction at angular
velocity 60o/sec that is against the results of our study which
can be attributed to their short duration of stretching program
that failed to increase hamstring flexibility and improve the knee
extension ROM. So, we measured the concentric contraction at
slow angular velocities 30o and 60o/sec, and after longer duration
of stretching program to explore the effect of hamstring flexibility
improvement on the concentric torque at slow angular velocities.
The results proved that the long term or chronic effect of
static stretching improves the concentric strength of the
hamstring which is different than the acute effects of static
stretching that elicit a strength deficit in concentric muscle
actions.1,5-8 Moreover, Fowles et al.15 found a reduction in
maximal isometric plantar flexion torque about the ankle joint
after the plantar flexors were passively stretched. Kokkonen et
al.16 found that maximal performance of both knee flexion and
knee extension one-repetition maximum lifts declined (by 7.3%
and 8.1%, respectively) significantly when executed 10 min after
static stretching of the quadriceps and hamstring muscle groups.
In contrast, Shrier 17 proved that a muscle that contracts
immediately after a stretch (e.g., jumping up immediately after
landing from a short jump) produces more force than a muscle
that was not stretched.
Although the immediate effects of stretching decrease visco-
elasticity and increase stretch tolerance, the effect of stretching
over 3 to 4 weeks appears to affect only stretch tolerance, with
no change in visco-elasticity.18 The mechanism by which regular
long term stretching improves performance is likely related to
stretch-induced hypertrophy. When a muscle is stretched 24
hours per day, some hypertrophy occurs even though the muscle
has not been contracting.19
The increase of concentric torque after hamstring flexibility
improvement can be explained by the findings of Yamashita et
al.20 reported that stretching a rat soleus muscle by 10 and 20%
increased posttetanic potentiation of the miniature end-plate
potential, which indicates increased Ca2+ conductance in the
nerve terminal. This increase in intracellular free Ca2+ facilitates
neurotransmitter release. Theoretically, muscle force generation
should increase as a result of increased transmitter release.
Therefore, the increase in the hamstring concentric torque may
be due in part to factors other than changes in series elastic
component stiffness and flexibility.
However, there was no significant difference between both
velocities pre treatment torque values but there was significant
difference in post treatment torque values, the increase in
hamstring concentric torque at angular velocity 60/sec was
higher than hamstring concentric torque at angular velocity 30/
sec, that is not consistent with Duncan et al.21 findings, proved
that the concentric force-velocity relationship is inverse
relationship in which peak torque decrease as velocity increases.
This result indicates that static stretch changes the concentric
force-velocity relationship.
132 Amr Almaz Abdel-aziem / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Limitations
The gender in this study was limited to male only. So, the
appropriateness of generalizing the results is confined to this
specific population. The hamstring torque measured in the open
kinetic chain was investigated in this study caution must be used
when generalizing these results to closed kinetic chain activities.
Additional studies are needed to determine the chronic or
prolonged effect of static stretch on hamstring torque during
closed kinetic chain activities.
Conclusion
The static stretching program for the hamstring was effective
in increasing concentric torque of the knee flexors at angular
velocities 30 and 60/sec. Moreover, the increase in hamstring
concentric torque at angular velocity 60/sec was higher than
hamstring concentric torque at angular velocity 30/sec. Thus,
accompanied with improvement in the hamstring flexibility which
increasing the amplitude of knee extension ROM.
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133
Sports Injuries: A new perspective on causation
Arunachalam Kumar
Professor of Anatomy, K. S. Hegde Medical Academy, Nitte University, Mangalore 575018 India
Introduction
More often than not, sports field, injuries are mainly
restricted to the anatomical elements of the appendicular
skeleton. Axial incapacitations are fewer and are restricted to
particular disciplines of the sports such as gymnastics or
weightlifting.
Among the appendicular injuries, lacerations, contusions,
tears, sprains, strains, cramps, avulsions of the muscle or its
tendinous or aponeurotic components apart from injuries to joint
complexes such as capsules, ligaments, bursae, cartilages or
tendons, are more common. Injuries to skeletal elements are
fewer, and again, restricted to some games or sports.
Here is presented a new perspective on why most
incapacitations accrued on the field, involve muscular or fascial
soft tissues preferentially. While it is a reasonable assumption,
that the softer components are more susceptible to damage
than the harder osseous tissues, in my view other factors, such
as described here, may contribute to the selective nature of
sports injuries and their target preferences.
Observations & Discussion
Muscles are essentially linear elastic myofibril bundles.
Muscle action and effect produced by its contraction is largely
dependent on the size, power, arrangement of fibres, direction
of bundles and the articular structures it spans. Each muscle,
especially of the appendicular skeleton, has a wide fixed proximal
origin, and a distal smaller localized area of insertion.
The pinnate structure of muscles and the fact that their
distal insertions are often converted into tendons composed of
compacted converging muscle mass, serve to increase the
mechanical efficiency of articulations and kinetics. Applying the
physical tenets of biomechanics governing the first, second or
third class of levers, one can easily perceive that the speed and
distance produced at the long-resistance arm of the lever is
directly proportional to amount of force exerted at the short-
force arm. Maximal mechanical efficiency however, is drastically
compromised when the reverse is applied.
Muscle origin areas are anatomically larger than insertions,
a factor well adapted to deriving full potential of force generated
at origin to produce speed and distance towards insertion.
Muscle anatomy is modulated, not just through evolution and
use, but also by the principles of physics and physiology defining
the use.
Most sports disciplines mandate application of normal laws
of biomechanics in so far as muscular effort is concerned. The
speed, range, and rapidity of interaction between synergic,
agonists and antagonistic muscle groups are chiefly determined
by the reaction time and stimulus generated by situations on
field.
Evolution and adaptation influence motion and mechanisms
of volition induced locomotory responses. Physiology and
134 Arunachalam Kumar / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
physics exert their tenets to derive maximal mechanical
advantage from energy expended to work performed. When
however, work done is in contradiction to these principles of
kinetics, strains and stresses are bound to ensue such exertions.
Visualize yourself pulling down a head level rigid bar
towards yourself. Elbow flexion is the action required with all
the flexors of the humero-ulnar hinge coming brought into play
and the bar is moved towards you. Now repeat the exercise
with a fixed bar, and attempt the same pull towards you. Elbow
flexion is enacted with all the flexor group of muscles contracting;
as the bar is fixed it stays in position, but the exertion of your
flexors, if strong enough, will actually draw you towards the bar.
In the first exercise, your long flexors (e.g. biceps brachii) are
contracting, bringing insertion to origin, but in the second, the
same elbow flexion, brings the biceps brachii origin towards its
insertion.
The paradox is, whilst the elbow hinge is used in both, the
direction of contractile forces travel is reversed in the latter
example. By translocating the resistance-arm (insertion) of the
lever, even maximizing contractile muscular potential often
cannot produce movement, power or speed at the short-arm
(origin). The muscles, now strain to overcome the resistance
force on it by the reversed direction of action-and as
consequence pays a penalty- in form of injury or laceration. The
stresses generated by the redirected forces of contraction,
militate against the postulates of the laws of motion.
In inference, I believe that a muscle, designed for
performance of a set of actions, performs best and at maximum
efficiency and to its peak mechanical advantage only when it is
allowed to contract in the manner nature has intended it to. When
muscles are coerced by demands and dictates of particular
disciplines of sports, to act counter to the laws of physics and
motion breakdowns are caused. The injuries may involve,
besides the mycological tissues, any or all other adjunct and
adjacent soft tissue structures that abet muscular action.
Conclusions
In this new theory on cause of sports injuries, it is proposed
that in a majority of soft tissue injuries, the trauma is primarily
due to unnatural stresses and strains imposed on muscular
actions. It is postulated that the frequent demands made on
muscle masses to reverse their direction of contractile forces
generated, is root cause of injury.
In our view, a better understanding of the laws of motion
and mycology as applied to articular biomechanics and kinetics
may throw more light in these nebulous areas of sports medicine.
Reference
Rasch P J & Burke K R, Kineseology and Applied Anatomy,
2nd Ed., Lea & Febiger, Philadelphia, 1965.
Effects of Different Elbow Positions on Latency and Amplitude of
Motor Nerve Conduction Study of Ulnar Nerve
Kakkad Ashish
Lecturer, Shri K. K. Sheth Physiotherapy College, Rajkot
Abstract
Context
Ulnar nerve is formed by the branches of Medial cord of
the brachial plexus and is one of the main nerves of upper limb.
Ulnar nerve passes posterior to medial epicondyle of humerus
so may be stretched or compressed in elbow movement.
Objective
To assess the ability of ulnar nerve motor fibers to pass
stimulus in three different position of elbow joint (0o, 90 o, 120 o
of elbow flexion).
Material and Methods
The cross-sectional observational study was conducted on
30 normal healthy individuals (aged between 18 to 25 years) in
Government Spine Institute, Civil Hospital, Ahmedabad. Subjects
exposed to factors affecting nerve conduction velocities e.g.
smokers, alcoholic, diabetic etc. were not included in the study.
Subjects were selected by random sampling technique. Subjects
were given supine lying position to measure latency (from artifact
to first negative deflection) and amplitude (peak to peak) of right
ulnar nerve from above and below elbow in three different
positions of elbow (0 o, 90 o, 120 o of flexion) using EMG
instrument (RMS EMG EP MK-II, Version 1.1), measuretape,
thermometer, weighing-machine, height-scale, universal-
goniometer, sketchpen, spirit, pen, electrode gel, cotton and
micropore adhesivetape.
Results
Statistical analysis was done with ANNOVA test. F values
for below elbow latency, above elbow latency, below elbow
amplitude, above elbow amplitude are 0.0699, 0.1534, 0.1488,
and 0.2336 respectively. Results showed insignificant difference
at 0.05significance level in latency and amplitude of ulnar nerve
in three different positions of elbow.
Conclusion
Study concludes that there is no effect of elbow positions
on latency and amplitude during ulnar motor nerve conduction.
Key words
Nerve Conduction Study, Ulnar nerve, Different Elbow
Positions
Introduction
Ulnar nerve is formed by the branches of Medial cord of
the brachial plexus. Root value of the ulnar nerve is C7, C8,
and T1. It runs on the medial side of the brachial artery up to the
level of insertion of the coracobrachialis, where it pierces the
medial intermuscular septum and enters the posterior
Kakkad Ashish / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
compartment of the arm. It is accompanied by the superior ulnar
collateral vessels. At the elbow, it passes behind the medial
epicondyle where it can be palpated with a finger. The ulnar
nerve is palpated behind the medial epicondyle. At the elbow it
lies behind the medial epicondyle of the humerus. It enters the
forearm by passing between the two heads of the flexor carpi
ulnaris. In the forearm, it runs between the flexor digitorum
profundus and the flexor digitorum superficialis laterally. It enters
the palm by passing superficial to the flexor retinaculum lateral
to the pisiform bone. At the wrist, the ulnar neurovascular bundle
lies between the flexor carpi ulnaris and the flexor digitorum
superficialis. The bundle enters the palm by passing superficial
to the flexor retinaculum lateral to the pisiform bone.1 Most
commonly tested nerves in upper limb are median nerve, ulnar
nerve and in the lower limb peroneal, tibial nerve.2
This condition is evaluated, in part, by calculating motor
nerve conduction velocity (MNCV) across the elbow segment.
At present the position of the elbow during the test has not been
standardized. Although illustrations in books on electrophysiology
refer to sites of stimulation for the ulnar nerve with a fully
extended elbow, the texts do not explain why the elbow is pictured
that way.3,6
Books do not refer to the possible effect that the elbow
position might have on the conduction capabilities of the ulnar
nerve. The position of the elbow, however, appears to influence
the conduction velocity of the motor axons of the ulnar nerve;
MNCV of the ulnar nerve has been found to be slow when the
elbow is in full extension.7, 8 Various explanations have been
offered for the phenomenon of diminished across-elbow
velocities when the elbow is fully extended. For example, error
in measuring the nerve length as it passes through the ulnar
groove may be a factor. The ulnar nerve has considerable slack
when the elbow is fully extended.7 If the length of the ulnar nerve
across the fully extended elbow is estimated by surface
measurement, the measured length will be less than the true
length. Such an error can lead to incorrect computation of
conduction velocity.
When the elbow is in midflexion (70-90), the MNCV
becomes more consistent with the other segments of the ulnar
nerve.7,9,10 Thus, a position of elbow flexion might seem to be
best for evaluating MNCV of the ulnar nerve across the elbow.
Several investigators, however, have suggested that elbow
flexion can induce stretch or compression of the ulnar nerve.6,
10-12 Thus the assessment of the MNCV of the ulnar nerve
might not be accurate with the elbow in flexion. Because of this
paradox, this study was undertaken to find the optimal elbow
position for determining ulnar MNCV across the elbow. To
achieve this purpose, the latency of a compound muscle action
potential (CMAP) evoked by supramaximal stimulation of the
ulnar nerve above the elbow and the specific characteristics of
the evoked action potential were studied with the elbow in three
different positions.
Unlike conduction velocity, latency is not dependent on
surface distance measurement. If a pressure block or stretch of
the ulnar nerve does not occur with elbow flexion, the proximal
(above-elbow) stimulation latency of CMAP should be the same
regardless of elbow position. If a pressure block or stretch of
the nerve is induced by elbow flexion, however, proximal
stimulation latency of CMAP should increase. 11 The distal
135
(below-elbow) stimulation should remain consistent regardless
of elbow position. A pressure block or stretch may also change
CMAP; that is, the amplitude of the potential may decrease. 12
Method
Instruments Used
Cross-sectional Observational Study was done at
Government Physiotherapy College, Government Spine Institute,
Civil Hospital, Ahmedabad by using EMG instrument (RMS EMG
EP MK-II, Version 1.1), measuretape, thermometer, weighing-
machine, height-scale, sketchpen, spirit, pen, electrode gel,
cotton, micropore adhesivetape, universal goniometer and couch
thirty normal healthy students of Government Physiotherapy
College, Ahmedabad were selected as subjects by random
sampling.
The inclusion and exclusion criteria are described below:
Inclusion Criteria
1. Normal healthy individuals who is willingly ready to
participate in the study aged between 18 and 25 years of
age (mean 21.65 years)
Exclusion Criteria
1. If person is exposed to known neurotoxins like alcohol
2. If they had medical condition known to be associated with
peripheral neuropathy (Diabetes or Uremia)
3. Family history of Neuropathy
4. Person already on medication known to be associated with
peripheral neuropathy (Antiretroviral therapy, other drugs
like Vincristine, Isoniazide)
Each subject lay supine with a pillow under his head for
comfort. The right arm was arbitrarily chosen as the limb to
examine, inasmuch as no significant difference in MNCV exists
between dominant and nondominant limbs.13, 14 The borders of
the abductor digiti minimi muscle were located by palpation when
the subject forcefully abducted the little finger against resistance.
The recording electrodes were surface disks, the intraelectrode
distances were constant (3 cm from center to center) for all
subjects. After the overlying skin was cleaned the active electrode
was placed over the center of the muscle belly. The inactive
electrode lay over the tendon at the metacarpophalangeal joint.
The ground electrode was placed on the dorsum of the wrist
over the ulnar styloid process. The subjects arm was positioned
in slight flexion (10-15) and a mark was made on the skin 4 cm
above and 4 cm below the medial epicondyle, approximating
the path of the ulnar nerve. These marks served as the sites of
electro stimulation. The tests were performed with shoulder 45
abducted, laterally rotated, the elbow in three different angles
of elbow flexion (0, 90, and 120), and wrist neutral. 15 Elbow
range of motion was performed with universal goniometer.(16)
Below elbow stimulation was done and evoked MAPs reported
for each angle of flexion in order to provide a basis for comparison
and to maintain consistency within the experiment.
The nerve was stimulated at the two sites described above
for each of the three angles of flexion. The following
characteristics of the CMAP were measured:
1. Latency (msec) from the stimulus artifact to the initial
negative deflection of the CMAP
2. Peak to peak amplitude (mV) from the bottom of the positive
phase to the top of the negative phase
Results

Table 1: Mean, Standard Deviation, Range of below elbow and above elbow latency
Site of stimulation Angle of elbow flexion Latency (ms)
Mean Standard Deviation Range

Below elbow 0o 6.390 0.5688 4.90-7.50

Below elbow 90 o 6.352 0.5883 5.00-7.29

Below elbow 120 o 6.336 0.5693 5.00-7.29

Above elbow 0o 8.101 0.7201 6.46-9.54

Above elbow 90 o 8.174 0.7301 6.77-9.69

Above elbow 120 o 8.202 0.7318 6.67-9.89

Table 2: Mean, Standard Deviation, Range of below elbow and above elbow amplitude
Site of stimulation Angle of elbow flexion Latency (ms)
Mean Standard Deviation Range

Below elbow 0o 10.173 2.805 3.90-15.7

Below elbow 90 o 10.443 3.123 3.60-16.4

Below elbow 120 o 10.583 2.940 4.30-16.1

Above elbow 0o 9.547 2.623 3.60-15.8

Above elbow 90 o 9.817 2.910 3.60-15.8

Above elbow 120 o 10.067 3.272 4.30-18.6

136 Kakkad Ashish / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 3: Gender Distributions of the Subjects Graph 3: Below elbow amplitude
Gender Normal Group

Male count 10
% 66.66%

Female count 10
% 33.33%

Total 30

Table 4: Age Distribution of the Subjects

N Mean (Years) SD (Years)

30 21.76 2.09569

The means, standard deviations, and ranges of the latency

and amplitude of CMAP for both above-elbow and below-elbow
stimulation are shown in Table 1 and Table 2 respectively.

Graph 1: Below elbow latency

Graph 4: Above elbow amplitude

Graph 2: Above elbow latency

Discussion
Results suggest that there is no significant difference among
group for below elbow latency, above elbow latency, below elbow
amplitude, above elbow amplitude for different three groups.
This proves that latency and amplitude of CMAP of ulnar nerve
do not depend on the position of elbow joint.
The results of this study suggest that the slow ulnar MNCV
reported with elbow extension could be caused by errors in
measuring the length of the ulnar nerve. In addition, stretch or
compression of the ulnar nerve does not appear to be an
important factor influencing the conduction of motor axons when
the elbow is in flexion. Two variables are used to calculate MNCV:
latency measures and distance measurements between the two
sites of nerve stimulation. In this study, latency and amplitude
of CMAP with above-elbow and below-elbow stimulation was
unaffected by elbow position. Thus, the discrepancy in the
reported conduction velocity of the ulnar nerve when the elbow

Kakkad Ashish / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 137
is in extension may be caused by errors in distance
measurement. In this study the latency measures suggest that
the nerve fibers were probably not blocked (by compression or
stretch) during elbow flexion. This conclusion is also supported
by the consistency in the characteristics of CMAP in all elbow
positions for above-elbow stimulation. The below-elbow values
in CMAP characteristics are all very similar to the above-elbow
values.
The midposition of elbow flexion (90) should be used when
measuring MNCV of the ulnar nerve. The straight elbow may
not yield valid measurements because of the difficulty in
measuring the actual length of the nerve. Assuming that surface
measurements of the distance between the sites of stimulation
do not portray an accurate estimate of true distance, calculated
velocities will be in error. Therefore, to avoid unknown errors,
the straight elbow should be avoided. The other option is to use
the position of maximal flexion for the MNCV calculation. Another
type of uncontrolled error might confound the results in this flexed
position. The aponeurotic sheath between the two heads of the
flexor carpi ulnaris muscle (that is, the cubital tunnel) may
compress the ulnar nerve as it passes between them. Some
individuals may exhibit more compression than others but the
amount of the compression is unknown. Therefore, the maximal
position of elbow flexion should also be avoided.
Limitations
In the present study sample size is very small.
Results of the study could not be generalized to all age
groups because study age group was between 18-25 years
so it is not studied what is status of peripheral nerve
involvement in person having age less than 18 years and
more than 25 years.
Room temperature was not controlled but all the nerve
conduction studies were performed at the same time of the
day so as to ensure as identical environmental conditions
as possible.
Future research
If elbow position is standardized for the performance of
MNCV in all ulnar nerve segments then future research could
be devoted to collecting normative data on the velocities. In
addition, the sensory component, which is often more sensitive
than the motor component as an indicator of early neural
involvement, could be evaluated in a normal population.
Conclusion
Electro stimulation of the ulnar nerve in 30 normal healthy
individuals revealed that:
1. The below elbow latency and above elbow latency of CMAP
did not vary appreciably as a function of elbow position.
2. The amplitude of CMAP did not vary as a function of elbow
position.
3. The absence of alteration in motor nerve conduction as a
function of elbow position appears to shift the reason for
reported slow velocities across the fully extended elbow to
errors in external factors (viz: measurement) and away from
internal factors such as stretch or compression of the nerve.
4. The midflexion position (90) appears to be the position
from which to perform and calculate MNCV along the course
of the ulnar nerve.
138 Kakkad Ashish / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Clinical implication
From this study it is proved that during clinical practice there
is no need to consider elbow position. If the patient is not
comfortable in any position either because of symptoms,
tightness or stiffness given by different authors we can give
alternate position of elbow joint for clinical findings.
Aknowlegement
I would like to acknowledge my P.G. guide Mrs. Anjali Bhise,
Yagna Shukla for guiding me and all staff members of
Government Physiotherapy College, Civil Hospital, Ahmedabad
and my senior Dhruv Dave and also my friends who participated
for me in this study.
Referrence
1. Chaurasia B. D. Huamn Anatomy. Regional and Applied
Dissection and Clinical. Volume 1. Upper limb and Thorax.
Satish Kumar Jain for CBS. Publisher & Distributors, New
Delhi. 2005: p 52, 90,110,111.
2. Jagmohan Singh. Text book of Electrotherapy. Jaypee
Brothers, Medical Publishers (P) Ltd, New Delhi. 2005: p
276.
3. McGowan AJ: The results of transposition of the ulnar nerve
for traumatic ulnar neuritis. J Bone Joint Surg [Br] 32, 1950:
p 293- 296,
4. Goodgold J, Eberstein A: Electrodiagnosis of
Neuromuscular Diseases, ed 2. Baltimore, Williams &
Wilkins Co, 1977: p 100, 121
5. Smorto MP, Basmajian JV: Electrodiagnosis: Handbookfor
Neurologists. New York, Harper & Row, Publishers, 1977:
p 944.
6. Smorto MP, Basmajian JV: Clinical Electroneurography.
Baltimore, Williams & Wilkins Co, 1972: p 97
7. Checkles NS, Russakov AD, Piero DL: Ulnar nerve
conduction velocity: Effect of elbow position on
measurement. Arch Phys Med Rehabil 52, 1971: p 362-
365
8. Tascon-Alonzo M: Amplitude and Duration of Evoked Action
Potentials in Human Hand Muscles in Health and Disease.
Thesis. Edmonton, Canada, University of Alberta, 1963
9. Kaeser HE: Nerve conduction velocity measurements. In
Vinken PJ, Bruyn GW (eds): Handbook of Clinical
Neurology, vol 7, part 1. Amsterdam, North Holland
Publishing Co, 1970: p 117-127
10. Payan J: Electrophysiological localization of ulnar nerve
lesions. J Neurol Neurosurg Psychiatry 32, 1969: p 208-
220
11. Zankel HT: Effect of physical agents on motor conduction
velocity of the ulnar nerve. Arch Phys Med Rehabil 47, 1966:
p 787- 792
12. Ruskin AP, Tanyag-Jocson A, Rogoff JB: Effect of ischemia
on conduction of nerve fibers of varying diameters. Arch
Phys Med Rehabil 48, 1967:p 304-310,
13. Shubert HA: A study of motor nerve conduction:
Determination of velocity. South Med J 56,1963: p 666-
668
14. Polak O, Grof D: The relationship between preference of
the upper extremity and the conduction velocity of motor
fibers in nerve ulnaris. Act Nerve Super (Praha) 8, 1966: p
207-208
15. Cynthia C., Measurement of Joint Motion. A guide to
Goniometry. F. A. Davis Company. First edition. 2003: p 41
Effectiveness of Multidirectional Reach Test to Analyze Centre
of Pressure Excursion in Healthy Geriatric Population
Asmita Karajgi1, Sujata Yardi2
1
Assoc Prof., 2Professor & Head, Department of Physiotherapy, Pad.Dr.D.Y.Patil University, Navi Mumbai

Abstract Impairments in postural control system and fear of falling cause

Background
Generally hi tech equipments like force platforms are
required to measure the excursion of centre of pressure for
balance assessment. The purpose of our study was to find the
effectiveness of a simple measure like Multidirectional reach
test routinely used in the clinical set up to analyze centre of
pressure excursion in healthy geriatric population.
Objective
To correlate readings of multidirectional reach test with that
of centre of pressure excursion on the balance master.
Material and Method
30 healthy elderly above 65 years of age participated in
this study. Multidirectional reach test required a yardstick
mounted on the wall that could be adjusted at the height of the
acromian process of the subject. The subjects were asked to
stand on the force platforms shoulder distance apart and reach
in forward, backward, right and left directions with one arm
(shoulder flexed to 90 degrees and elbow in extension) along
the yardstick without moving feet or taking a step. Average of
three readings of the reach distance in each direction was
calculated and corresponding centre of pressure excursion in
each direction was measured using balance master.
self-limitation and a less active lifestyle. This deconditioning
effect exacerbates the risk for falls. Timely intervention is effective
in reducing risk of falling & cost of health care thus improving
quality of life in aging population.
Thus identification of older adults with balance deficit is a
vital medical concern. As physiotherapists, we routinely use
various balance assessment tools. One of the important
assessments of dynamic stability is stability limits
Postural stability or balance is the ability to keep centre of
mass (COM) within the base of support which is achieved by
the nervous system through continuously generated muscular
forces. The centre of pressure is the centre of the distribution
of this total force applied to the supporting surface. Centre of
pressure (COP) continuously moves around centre of mass
(COM) to maintain balance during any mobility task like reaching,
picking up an object from floor, transitioning from sitting to
standing, walking etc. e.g. reaching in forward direction to pick
up telephone requires anterior displacement of centre of
pressure.
Fig. 1: Anterior displacement of centre of pressure

Result
The readings of Multidirectional reach test on the yardstick
were correlated with the centre of pressure excursion on the
balance master. We found no significant correlation between
the two parameters.

Conclusion
The study shows that at present centre of pressure
excursion cannot be effectively analyzed using Multidirectional
reach test in healthy geriatric population as there is no
importance given to the specific instruction regarding postural
strategy to be used.
Key Words
Centre of pressure, Multidirectional reach test and geriatric
population
Introduction
There is increased awareness of quality of life of the older
adults in recent years as the proportion of geriatric population
continues to rise worldwide. Along with the visible signs of aging
and the obvious declines in the cardiovascular, respiratory, and
musculoskeletal systems, body slowly assembles a collection
of deficits that significantly reduce the ability to maintain balance.
Balance control can be reactive (in response to external
forces that displace the COM) or anticipatory (voluntary or in
automatic anticipation of internally generated forces during gait
or performance of movements, such as raising an arm) . It
depends on the capability of the CNS to predict and detect
instabilities and program appropriate patterns of muscle
activation. Stability limits refer to the maximum distance a person
can intentionally displace their centre of mass without losing
balance
Direct way to assess stability limits is by investigating
location and path of COP. More sophisticated instrumentation
like force plates are required to measure centre of pressure.
Pressure cells have been incorporated into force platforms to
measure oscillations unnoticed by the human eye. Using two
force platforms allow the evaluation of the relative contribution
of each leg in balance control. But it is expensive and not suitable
for OPD set up or community settings
Indirect way to assess stability limits by administering a
functional scale. There are many clinical tests available to
evaluate balance..Functional reach test by Duncan et al is an

Asmita Karajgi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 139
inexpensive and easy to use tool to assess stability limits in yardstick One practice trial was given. If the feet moved or step
forward direction. Duncan considered reaching task to be more taken, the trial was discarded.Average of three readings of the
functional than leaning task. But forward is not the only direction reach distance in each direction was taken. The readings of the
we move. Older adults also fall backward and laterally. Later on net centre of pressure movements in limits of stability test on
Multi-directional Reach Test was developed by Roberta Newton the balance master recorded for the respective reach. Balance
in 2001.Dr Newton describes it as an inexpensive screening master calculates the forces and converts into a visual image.
tool to measure limits of stability in four directions. Software of the balance master analyzes the data. Test was
The purpose of our study was to find the effectiveness of a recorded with a video camera for kinematic analysis.
simple measure like Multidirectional reach test routinely used
in the clinical set up to analyze centre of pressure excursion in
healthy geriatric population.
Hypothesis-Multidirectional reach test effectively analyzes
centre of pressure excursion in healthy geriatric population
Alternate hypothesis-Multidirectional reach test does not
effectively analyze centre of pressure excursion in healthy
geriatric population.

Aim and Objective

To correlate readings of multidirectional reach test with that
of centre of pressure excursion on the balance master

Methodology

Study Design
Correlation study
Results
Inclusion Criteria
Readings of Multidirectional reach test.
30 healthy elderly individuals above 65 years with no
known neurological or musculoskeletal pathology& no history
of fall in past 6 months

Exclusion Criteria
Hip/knee replacement
Pain/restriction of range of motion of ankle, knee, hip or
shoulder joint

Material
Yardstick for the reach test
Smart balance master (Neurocom)

Methodology
Multidirectional reach test is described as follows
Evaluation- Subjects perform maximal reaches with Forward Backward Right Left
outstretched arm forward (FR), to right (RR), to left (LR), & reach reach reach reach
backward (BR),with feet flat on floor (mean, SD) (mean, SD) (mean, SD) (mean, SD)
Reliability & validity established only for elderly population
Score = distance (in. or cm) that patient can reach in each 24.31 17.67 18.07 19.80
direction. +/- 6.87 +/- 6.90 + /- 5.64 +/- 6.55
Limitations-Not described.
ICF Level and domain-Activities(limitations to activity- Readings of centre of pressure excursion
disability): changing & maintaining body position (d4106, shifting Discussion
bodys center of gravity)
30 healthy older adults above 65 years from the local senior Stability limits are boundaries of an area of space in which
citizen group participated. A yardstick was horizontally mounted body can maintain its position without changing the base of
on the wall. It could be adjusted at the height of the acromian support. The CNS has an internal representation of stability limits
process of the subject. The subjects were asked to stand barefoot and uses it to determine how to move and maintain balance.
on the force platform shoulder distance apart and instructed to These are not fixed boundaries but change according to the
reach in forward, backward, right and left directions with one task. Each task in Multidirectional reach test has orientation
arm (shoulder flexed to 90 degrees and elbow in extension) ) demand of maintaining upper extremity in forward or lateral
Instructions were precise as described by Dr.Newton direction and stability demand of maintaining balance while
without moving your feet or taking a step, reach as far reaching. The subject needs to use appropriate postural strategy
(direction given) as you can and try to keep your hand along the to maintain balance while reaching.

140 Asmita Karajgi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
 Anterior Posterior Right Left
COP COP COP COP
(mean, SD) (mean, SD) (mean, SD) (mean, SD)

67.83 70.23 82.9 73.27

+/- 20.69 +/- 27.19 + /- 20.06 +/- 20.77
We correlated the reach distance with the corresponding centre
of pressure excursion in each direction.

Pearson correlation (r) values showed low correlation between

reach distance and corresponding centre of pressure excursion

and uses it to determine how to move and maintain balance.

There are three basic postural control strategies described
by Nashner and colleagues. The ankle strategy is more effective
at keeping the trunk in a vertical position during small
perturbations while standing. The hip strategy is excellent for
faster and larger CM movements.
Discussion
Stability limits are boundaries of an area of space in which
body can maintain its position without changing the base of
support. The CNS has an internal representation of stability limits
These are not fixed boundaries but change according to the
task. Each task in Multidirectional reach test has orientation
demand of maintaining upper extremity in forward or lateral
direction and stability demand of maintaining balance while
reaching. The subject needs to use appropriate postural strategy
to maintain balance while reaching.
There are three basic postural control strategies described
by Nashner and colleagues. The ankle strategy is more effective
at keeping the trunk in a vertical position during small
perturbations while standing. The hip strategy is excellent for
faster and larger CM movements.
Ankle strategy restores Centre of Mass within Base of
Support by body movements centered at the ankle
Hip strategy by large movements at the hip with antiphase
rotations of ankles and
Stepping strategy by taking a rapid step
It is a known fact that there is a difference in the strategy
used in the young and elderly. Hip strategy is preferred over
ankle strategy in older adults. We compared kinematics of reach
between young and older adults as seen in pictures. It clearly
shows preference for different postural strategies.
During forward reach, we expected dorsiflexion at the
ankles causing anterior displacement of centre of pressure. But
observed the following movements -scapular protraction ,trunk
and hip flexion with backward movement of tibia i.e. there was
ankle plantar flexion instead of dorsiflexion in older adults. We
got a low correlation between forward reach and anterior centre
of pressure excursion. Similarly there was little movement at
the ankles during backward reach leading to not much posterior
displacement of centre of pressure. The subjects showed
scapular retraction with hip extension. When subjects were asked
to reach laterally they bent the trunk laterally but adequate lateral

Asmita Karajgi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 141
Fig.1: Comparison of forward reach between old and young adults

Fig.2: Comparison of backward reach between old and young adults

Fig.3: Comparison of lateral reach between old and young adults

142
Asmita Karajgi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
weight shift not observed.
The reaching task in Multidirectional reach test is an
example of self initiated disturbance of center of gravity to
accomplish a goal. These are volitional postural movements
which are under conscious control. They are strongly modified
by instructions. Dr Newton emphasized on the maximum reach
distance without moving feet or taking a step. But there is no
specific instruction regarding postural strategy to be used in the
multidirectional reach test. Further research is required by
modifying the instructions as theoretically leaning task appears
to be more valuable in measurement of COP excursion.
Conclusion
The study shows that centre of pressure excursion cannot
be effectively analyzed using Multidirectional reach test in
healthy geriatric population as there is no importance given to
the specific instruction regarding postural strategy to be used.
Thus at present analysis of centre of pressure measurement by
force platforms cannot be substituted by Multidirectional reach
test.
References
1. Newton RA, Balance screening of an inner city older adult
population. Arch Phys Med Rehabil. 1997;78(6):587
2. Muir SW, Berg K, Chesworth B, Klar N, Speechley M
Balance impairment as a risk factor for falls in community-
dwelling older adults who are high functioning: a prospective
study
3. Roberta A. Newton, Validity of the Multi-Directional Reach
Test,A Practical Measure for Limits of Stability in Older
Adults Journal of Gerontol A Biol Sci Med Sci. 2001
Apr;56(4):M248-5
4. Beckman, e. billek-sawhney, b. holbein-jenny, ma, & t.
smitha comparison of the sub-tests of the multidirectional
Asmita Karajgi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
reach test in personal care home residents. journal of am
geriatr soc. 2004 jul;52(7):1168-73s
5. Ben Achour Lebib S, Missaoui B, Miri I, Ben Salah FZ,
Dziri C. [Role of the Neurocom Balance Master in
assessment of gait problems and risk of falling in elderly
people] Ann Readapt Med Phys. 2006 Jun;49(5):210-7.
Epub 2006 Apr 7.
6. WallmanN HW, Comparison of elderly nonfallers and fallers
on performance measures of functional reach, sensory
organization, and limits of stability. J Gerontol A Biol Sci
Med Sci. 2001 Sep;56(9):M580-3.
7. Holbein-Jenny MA, Billek-Sawhney B, Beckman E, Smith
T.Balance in personal care home residents: a comparison
of the Berg Balance Scale, the Multi-Directional Reach Test,
and the Activities-Specific Balance Confidence Scale J
Geriatr Phys Ther. 2005;28(2):48-53.
8. Jonsson E, Henriksson M, Hirschfeld H.Does the functional
reach test reflect stability limits in elderly people? J Rehabil
Med. 2003 Jan;35(1):26-30.
9. Liao CF, Lin SI., Effects of different movement strategies
on forward reach distance. Gait Posture. 2008 Jul;28(1):16-
23. Epub 2007 Nov 7
10. Clark et al, Difference in the strategy used is seen in reach
and lean task with respect to COP excursion in older adults
J Aging phys act,2005
11. Cavanaugh et al ,Kinematic characterization of standing
reach-comparison of younger vs. older subjects J Biomech
1999 may
12. Clark S, Iltis PW, Anthony CJ, Toews A.Comparison of
older adult performance during the functional-reach and
limits-of-stability tests. J Aging Phys Act. 2005 Jul;
13(3):266-75.
13. Anne Shumway-Cook, Marjorie H. Woollacott Motor
control: translating research into clinical practice
14. Stephanie Hart Huges, Balance assessment handbook
143
The Effect of Proprioceptive Exercises and Strengthening
Exercises in Knee Osteoarthritis
Aastha Maggo, Shobhit Saxena, Shalini Grover
Department of Physiotherapy, Faridabad Institute of Technology, Faridabad, Haryana
Abstract
Study Design
The study was a randomized controlled trial.
Objective
To compare the effectiveness of proprioceptive exercises
and strengthening exercises in treatment of osteoarthritis of knee
in terms of pain and functional disability.
Background
Few investigations include both strengthening and
proprioceptive exercises in the treatment of knee osteoarthritis.
Though previous studies give us some insight in to the role of
proprioceptive exercises in knee OA but none of the studies
have studied the combined effect of strengthening exercises
and proprioceptive exercises in knee OA. Thus, it is intended to
check the efficacy of proprioceptive and strengthening exercises
in knee OA to reduce pain and functional disability and improve
joint position sense.
Methods
In this study 24 subjects who met the inclusion criteria
were randomized into three groups three groups. Group A were
given conventional treatment (SWD and static
quadriceps).Group B were given strengthening exercises along
with SWD. Group C; which were given strengthening exercises
and proprioceptive exercises along with SWD. Outcome
measures were pain, functional disability and joint position
sense.
Results
All the groups significantly improved in VAS and WOMAC
scores after intervention pd.05, knee reposition error score
(Joint position sense) only improved in proprioceptive exercises
group. The proprioceptive exercises group demonstrated greater
improvement in VAS and WOMAC scores as compared to other
two groups.
Conclusion
This study between three groups comparing conventional
treatment to strengthening and proprioceptive exercises suggest
that combination of the two brings better relief to the subjects of
knee OA in reducing pain and functional disability.
Introduction
Osteoarthritis (OA) is the most common joint disorder, a
prevalence that increases with age and sex specifications2,3.
Among adults 45-74 years of age or older, symptomatic disease
occurs in approximately 12.1% population4.Before 50 years of
age the prevalence of OA in most joints is higher in men than in
144 Aastha Maggo / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
women. After about 50 years of age, women are often affected
with hand, foot and knee OA than men3. In subjects with no joint
pain who have radiographic changes of OA, quadriceps
weakness predicts radiograph progression and pain6.These
findings suggest that the weakness may occur before arthritic
damage.
Nevertheless, exercises to strengthen the quadriceps
relieve joint pain in persons with OA of knee7. The strengthening
exercises are beneficial for knee OA by several pathways,
improving strength, improving psychological well-being. All of
these may interact and have an additive effect on the symptoms
of OA7.Barret et al, (1991) has reported impaired proprioception
for the patients suffering from knee osteoarthritis. Few
investigations have investigated the relationship between
impaired proprioception and performance or other measures of
functional status in OA. In addition Birmingham et al, (2001)
stated that quadriceps sensory dysfunction that is, decreased
proprioceptive acuity, has recently been demonstrated in patients
with knee OA and proposed as a factor in the pathogenesis or
progression of the condition. If correct, restoration of these
sensorimotor deficits with strengthening may retard progression
of knee OA and reduce disability. Although it is generally
accepted that a rehabilitation program improves the functional
capacity, pain and sensoriomotor function of patients, there is
lack of agreement about what such a rehabilitation program
should include (Roddy et al., 2005). Many previous studies have
generally used sophisticated and expensive apparatus, which
limits their application to a community setting 8,9,10.Though the
above mentioned studies give us some insight in to the role of
proprioceptive exercises in knee OA but none of the studies
have studied the combined effect of strengthening exercises
and proprioceptive exercises in knee OA. Thus, in this study it
is intended to check the efficacy of proprioceptive and
strengthening exercises in knee OA to reduce pain, functional
disability and improve joint position sense.
Patients and Methods
Under convenience sampling, 32 subjects were recruited
from the physiotherapy department of Sanjay Gandhi Memorial
Hospital (Delhi). The subjects were screened by means of a
screening form one of the three groups- group A (conventional
treatment group), group B (strengthening exercise treatment
group) and group C (strengthening exercise and proprioceptive
exercise) by simple randomization method.
Inclusion Criteria
1. Diagnosed cases of osteoarthritis grade 2 and 3 (As
reported by radiologist).
2. Age group-45 to 60 years.
3. Bilateral osteoarthritis.
4. Gender-both male and female
5. Patients should able to demonstrate sufficient English skills.
Exclusion Criteria
1. Neurologic disorder (e.g. Parkinsons disease, Alzheimers
disease)
2. Steroid injection in past 2 months
3. Inflammatory arthritis toes pointing inwards after a short rest repeat it once
4. Metal implants in lower limb again(Fig c)
5. Osteoporosis d) Heel walking - Walking for 20 meters on heels with toes
6. Knee ligament/Meniscal injury pointing straight ahead, walking on heels with toes pointing
out and walking on heels with toes pointing in. After a short
rest, the procedure was repeated once more(Fig d)
Group A received short wave diathermy and static
e) Cross leg body swing-Leaning slightly forward with hands
quadriceps exercise, Group B received short wave diathermy
on wall for support and weight on affected leg, other leg
and strengthening exercises and Group C received short wave
was swung in front of the body pointing toes upwards as
diathermy, strengthening exercises and proprioceptive exercises.
foot reaches its farthest point of motion. Then swing this
unaffected leg back to the unaffected side as far as
Intervention comfortably possible, again pointing toes up as foot reaches
its final point of movement. Repeat this overall motion 15
1. Before starting the exercises, patients were given treatment
times with erect body posture and good balance, rest for a
for pain reduction by short wave diathermy. The patients
few seconds, and then 15 similar repetitions with the
were positioned supine and comfortably on the treatment
unaffected leg as weight- bearing limb was performed (Fig
plinth. Patient in each group received 20 min of SWD thrice
e).
a week for four weeks (12 treatments) applied by malleable
electrodes by contraplanar method (Chitra, 2007)11. The
intensity of the SWD was based on each subjects tolerance
but all the subjects were advised that they should feel just
comfortable warmth (Low and Reed, 2000).

2. Strengthening exercises (Gail D,2005)12Static quadriceps

in knee extension- Patient is positioned fully supine. Patient
contracts the quadriceps femoris muscle and pushes knee
down while maintaining the foot in full dorsiflexion, each
contraction is held for 6 sec with a 10 sec rest between
repetitions. 10 repetitions are done.

Standing terminal knee extension- Patient stands with a

resistive band behind a slightly flexed knee. Patient contracts
the gluteal and quadriceps femoris muscle to fully straighten
the hip and knee. Each contraction is held for 3 seconds, 10
repetitions were done and resistance is increased as tolerated
by the patient.
Closed chain exercise, one of the two exercises is (a) (b)
performed 3 times per week. Patient should progress to the
most challenging activity that he or she can successfully
complete with minimal or no pain.
a. Seated leg press- Patient is seated holding a resistive band
in both the hands
A patient places his or her foot against the band, then
straightens the knee by straightens the knee by pushing
the foot down and forward by contracting the gluteal and
quadriceps femoris muscles. Each contraction is held for 3
seconds with knee as straight as possible, patient slowly
return to the starting position and repeat for 30 sec bout.
Progression is made by using bands of high resistance and
additional bouts.
b. Partial squats - Patient stands with arm support as needed,
patient performs a partial squat, keeping the knees centered
over the feet return to standing by contracting the
quadriceps femoris and gluteal muscles. Each contraction
is held for 3 seconds with hips and knees as straight as
possible. Progress to full body weight without support and
(c) (d)
additional bouts.
3. Proprioceptive exercises. (Chita et al, 2007)11
a. One leg balance-it involved standing on affected foot with
relaxed upright posture and other leg flexed at knee, hip
and ankle, this position was held for one minute followed
by rest for 10 to 20 seconds and was repeated twice more. (e)
After a brief rest three similar repetitions were carried out
for unaffected leg(Fig a).
b. Blind advanced one leg balance-It was same like one leg
balance, expect that the patient was asked to keep his/her
eyes completely closed while performing the routine, and
then was repeated twice again (Fig b).
c. Toe walking-Here the patient was made to walk for 20
meters high up on the toes with toes pointing straight ahead,
then walk with toes pointing outwards and then walk with

Aastha Maggo / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 145
 Treatment was given three times per week for four weeks.
In this study the outcome measures were-:
All outcome measures were measured at baseline, end of week
1, end of week 2, end of week 3 and end of week 4.
Pain was measured using the visual analogue. Functional
disability-was measured using the Western Ontario and
McMaster Universities Osteoarthritis Index (WOMAC) Joint
position sense-was measured using inclinometer by Reposition
error test (Higgins and Perrin, 2000).
Procedure for reposition error test- all the subjects were
familiarized with the procedure by explanation, demonstration
and adequate practice repetition. Inclinometer was attached to
the distal thigh of dominant extremity approximately one inch
above knee joint line. Patient is standing with back against wall
and is blindfolded to eliminate visual cues, Patient squats to 30
degree of knee flexion and maintains this position for 15 sec,
return to starting position of 0 degree extension, Following a 15
sec rest period patient then attempts to reposition themselves
at the predetermined angle, degree of error from 30 degree knee
flexion target angle is recorded and average over three trials is
used for data analysis (Higgins and Perrin, 2000)13.
Inclinometer for assesing joint position sense(Reposition
error test)
Statistical Analysis
A total of 32 patients were screened for possible study
eligibility. 28 patients satisfied the eligibility criteria, were recruited
into study and underwent baseline measurement. Four patients
in this study did not complete the treatment. There were two
dropouts from Group A, one each from Group B and Group C.
Total of 24 subjects, including both males and females,
completed the study. Age of subjects in this study was between
45-60 years. The mean age of subjects in Group A was
51.5(4.30) years, Group B was 49.5(2.44) years, and Group
C was 51.62 (3.96) years. There was no significant difference
between the mean ages of all the three groups. Group A had 5
females and 3 male patients, Group B had 6 females and 2
male patients, Group C had 6 female and 2 male patients. In
total there were 17 female and 9 male patients.
Readings of the variables taken at the baseline and at the
146 Aastha Maggo / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
end of first , second , third and fourth week were analyzed for
intragroup differences using repeated measure ANOVA and
paired samples t-test with Bonferroni correction. Intergroup
differences were analyzed using one way ANOVA.
For intergroup differences result was considered significant
if p value d 0.05 and for intragroup differences result was
considered significant if p-valued0.01.
Results
Within Group Analysis of pain scores - The repeated
measures ANOVA results for VAS scores revealed a significant
difference within all groups.
Between group analysis of pain scores - The analysis of
VAS scores Between all the groups suggested that there were
no significant differences at the baseline (p=0.397) and at the
end of 1st week (p=0.052).At the end of 2nd week there was
significant difference between the groups (p=0.002), at the end
of 3rd week there was significant difference between the groups
(p=0.000), at the end of 4th week there was significant difference
between the groups (p=0.000).
Within Group Analysis of WOMAC scores-the results of
repeated ANOVA and post-hoc t-test showed significant
differences in WOMAC scores in all the groups.
Between group Analysis of WOMAC Scores-The analysis
of WOMAC score between the groups suggested that there were
no significant differences between baseline (p=0.110) and week1
(p=0.467).At the end of 2nd week there was significant difference
between the groups (p=0.003). At the end of 3rd week there
was significant difference between the groups (p=.000). At the
end of 4th week there was significant difference between all the
groups (p=.000).
Graph 1: Comparison between mean values of VAS
Graph 2: Comparison of mean values of WOMAC
 Within Group Analysis of Reposition Error Test scores -
The results of repeated ANOVA and post-hoc t-test showed no
significant differences in Reposition scores in group A and B.
But in Group C there was statistically significant improvement
in baseline and week 4.
Between Group Analysis of Reposition error test - The
analysis of reposition error score between the groups suggested
that there were no significant differences between baseline
(p=0.193), week1 (p=0.144), week2 (p=0.135), week 3 (p=0.095)
and week 4 (p=0.113).
Graph 3: Comparison of mean values of Reposition error scores
Graph 4: Comparison of percentage improvements in all
outcome measures
Table 1: Percentage of improvement in all outcome measures across the three groups
Outcome measure Percentage of improvement
Group A
(conventional
treatment)
Pain(VAS) 24.64%
Disability(WOMAC) 41.03%
Joint position sense(RET) 2.70%
research hypothesis. Both the treatment groups A and B resulted
in significant improvements in all the variables compared to the
conventional therapy group. A study by Felson et al (2009) states
that proprioceptive acuity as assessed by the accuracy of
reproduction of the angle of knee flexion has modest effects on
pain and physical function limitation in knee osteoarthritis. This
could be due to pain relief, reduction in stiffness, increased
lubrication of joint, gain in strength of weak muscles, correct
Aastha Maggo / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Discussion
The purpose of this study was to determine the
effectiveness of Proprioceptive exercises along with
strengthening exercises in improving pain and disability in
patients with knee osteoarthritis. In all the three groups- pain,
disability and joint position sense were taken as the dependent
variables to assess the improvement between the groups and
within the group. The findings of the present study suggest that
the addition of proprioceptive exercises and strengthening
exercises reduces patients pain and disability more effectively
than strengthening exercises or conventional physiotherapy
alone over a 4 week period. Statistical analysis revealed no
significant differences in key demographic variables and baseline
measurements of pain, disability and active angle replication
test suggesting that all the groups had homogenous distribution
of patients.
In this study VAS was used to measure pain. A statistically
significant difference was found between all the groups.
Maximum reduction of pain was in group C (370.02mm). This
is in favor of our research hypothesis. Pain relief in this group is
in accordance with a case report of 70 year old lady with
osteoarthritis of knee who found moderate pain relief by
proprioceptive exercises as done by Childs et al(2002) 14.
Reduction in pain in Group A (conventional treatment) and B
(strengthening exercise group) is consistent with previous
findings which state that both dynamic and isometric resistance
training reduced perceived knee joint pain15.Proprioceptive
training activities provide patient with an opportunity to adapt
to potentially destabilizing loads on the knee during rehabilitation,
give additional exposure to pivoting, quick starting and stopping
and quick changes in direction and challenge their balance
capabilities. Strengthening exercises are recommended to
reduce pain and improve physical function in knee OA, but there
is minimal information on its long term impact8.It is theorized
that because elevated plasma endorphin, a neuro transmitter
inhibitory to pain signal, has been observed in response to
prolonged rhythmic exercise (Thoren et al, 1990) leading to
increased endorphin production might decrease pain
experienced by persons with osteoarthritis17.
In the present study WOMAC Score was used to asses
overall knee function since its validity and reliability is already
established 16. The analysis of disability score reveals no
significant difference at baseline. There was significant
improvement in Group B (Strengthening exercises) and C
(Strengthening exercise and Proprioceptive exercises) as
compared to Group A(conventional treatment ) but maximum
difference in mean score of Group C (52 mm), supporting our
Group B Group C
(strengthening (strengthening and
exercises) proprioceptive
Exercises)
35.72% 44.71%
57.60% 68.48%
3.08% 9.35%
mechanical loading, improved joint stability and thus increased
quality of movement and improved proprioception which in turn
provides participants an opportunity to adapt to potentially
destabilizing load on knee during the study period9. Hurley et al
(2004) have reported that proprioception is closely related to
functional performance and walking speed. This is in accordance
with this study which shows greater mean difference in
proprioceptive exercises group than with other two groups.
147
 In this study joint position sense was measured by reposition
error test (RET).The analysis of RET at baseline reveals no
significant differences between all the three groups. At the end
of 4th week mean differences were not significant between all
the groups. There was improvement in all the groups which
supports the study that proves general exercise training can
increase proprioceptive performance (Bernauer et al,
1994).Maximum reduction in mean was in Group C (0.48). The
difference between the moderate improvement in other two
groups as compared to Group C and greater improvement in
this group was probably due to specific proprioceptive exercises.
Proprioceptive information alone (without visual feedback) can
correct up to 95% of velocity and timing errors associated with
sudden perturbation in resistance during a multi-joint movement
sequence10.
Group A (conventional treatment), Group B (strengthening
exercises) and Group C (proprioceptive and strengthening
exercises) does not show any statistically significant difference
at the end of 4 week study period. This is in accordance with a
study done by Sekir et al, 2005 in which 6 weeks of proprioceptive
and balance training was given to treatment group while the
control group did not receive any exercise but there was no
significant differences by the end of training in weight bearing
joint position sense. Therefore, it may be concluded that
proprioceptive acuity takes longer duration to show significant
improvement.
Sample size was small and data was collected from limited
place that limits the generalizability of the results. The duration
of study was short (4 weeks) therefore long term effectiveness
of proprioceptive exercises was not evaluated. Neither the
subjects nor the therapist were blinded to group assignment.
The cohort of patients with knee osteoarthritis were
predominately female, hence generalizability of our findings may
not necessarily be applicable to the entire population of
individuals with osteoarthritis.
This study showed that patients affected with OA knee,
when performed proprioceptive exercises along with
strengthening exercises showed significant reduction in pain and
functional disability and improvement in proprioception as
compared to patients performing strengthening exercises alone.
Thus proprioceptive exercises can be incorporated along with
strengthening exercises in patients of knee osteoarthritis.
Conclusion
Management of osteoarthritis, which deteriorates with
imbalance between the stress applied to the articular cartilage
of the joint and its ability to withstand it, requires being more
extensive than mere analgesics. This study between three
groups comparing conventional treatment to strengthening and
strengthening and proprioceptive exercises suggest that
combination of the two (proprioceptive and strengthening
exercises) brings better relief to the subjects of knee
osteoarthritis in reducing pain and functional disability. However,
reposition error scores (joint position sense) did not improve
significantly in proprioceptive and strengthening exercise group
than other two groups. These results partly accept and partly
reject the experimental hypothesis suggesting that using
proprioceptive exercises and strengthening exercises together
will produce statistically significant difference in pain, disability
and but joint position sense may take longer duration to show
significant differences.
148 Aastha Maggo / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
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4. Leon Sokoloff; Some highlights in the emergence of modern
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5. Slemenda C, Heilman DK; Reduced quadriceps strength
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Predicting Neuromotor Outcome in Very Low Birth Weight Infants
at One Year of Corrected Age Using Movement Assessment of
Infants Scale
Deepa Metgud*, V D Patil**, S M Dhaded***
*Assistant Professor, KLE Universitys Institute of Physiotherapy, Belgaum, **Professor and Principal, ***Professor and HOD,
Department of Pediatrics, J.N.Medical College, Belgaum
Abstract
Purpose
The purpose of this study was to find the validity of MAI in
predicting neuromotor outcome in Very Low Birth Weight Infants
(VLBW) at one year of corrected age.
Method
Infants(n=40) born with birth weightd1500gms and
admitted to NICU were assessed at 4 months of corrected age
using MAI scale and follow up evaluation for motor and mental
development was done with a neuropschycological tool, Bayley
Scale of Infant Development (BSID II) at 12 months of corrected
age .
Results
The predicted neuromotor outcome at 12months on motor
items of BSID were 70% sensitivity, 83.3% specificity, 58.3%
positive predictive value and 89.3% negative predictive valve
and for mental items were 60% sensitivity, 74.3% specificity,
25% positive predictive value and 92.8% negative predictive
valve with a cutoff score of e10 on MAI.
Conclusion
The MAI administered at 4 month is a useful clinical tool
with high specificity and acceptable sensitivity in predicting
neuromotor outcome at one year of corrected age in VLBW
infants.
Key Words
Movement Assessment of Infants scale, Very low birth
weight infants, Neuromotor development.
Introduction
Very low birth weight (<1500grams) is an important risk
factor for neurological outcome in at-risk infants 1. Low birth
weight babies face serious health problems as newborns, and
are at increased risk of long-term problems such as
developmental delay, mental retardation, cerebral palsy,
impairment of lung function, visual and hearing impairment. In
India the incidence of low birth weight is estimated to be around
40%2,3. The disparity of low birth weight in India has ranged from
a prevalence of 10% (for the privileged high socio-economic
class) to 56% (for the poor urban slum community) 4, 5.
Studies of the predictive diagnosis of Cerebral Palsy (CP)6,7
emphasize the relationship between prematurity and low birth
weight with the diagnosis of CP and recommend that preterm
infants with very low birth weight or who have suffered
neurological complications, as neonates be monitored from birth8
to prevent possible delays or be treated early, the consequences
being more severe. Given the importance of detection of CP, in
addition to neurological examination, were created several tests
Deepa Metgud / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
for early diagnosis9,10. In the area of Physical and Occupational
Therapy, one of the most known test to assess motor behavior
in infants at high risk for developmental disorder, is the Movement
Assessment of Infant (MAI), developed by Chandler, Andrews
and Swanson in 198011.It is used for monitoring programs in the
United States, and is subjected to various studies of validity and
reliability.
There are no predictive validity studies of MAI tool for high
risk infants (VLBW) in Indian population. Hence the purpose of
the present study was to evaluate the ability of MAI administered
at 4months, to predict neuromotor development in VLBW infants
at one year of corrected age against BSID-II, a gold standard
assessment and also to find the usefulness of MAI as screening
tool in clinical practice for VLBW infants in India.
Material and Methods
Subjects were infants of VLBW (<1500gms) born from
January 2008 to December 2008, who were admitted to neonatal
intensive care unit of KLES Dr Prabhakar Kore hospital and
medical research center, Belgaum Karnataka, India. During that
period 45 infants of VLBW were randomly selected from those
who were born on odd number days. After discharge from the
NICU, the infants were recruited for the study that was approved
by the KLE Universitys ethics committee and an informed
consent was obtained from the primary caregiver. Infants
attended physiotherapy clinic where a standard neurological
evaluation was performed by the investigator and demographic
data of the mother and child with clinical details of obstetric history
and neonatal problems were recorded. Then the infants were
evaluated at 4 months of corrected age using the MAI scale by
two experienced and trained pediatric physiotherapists.
The MAI evaluation was performed as per the instructions
in the MAI training DVD and the instructions mentioned in the
MAI manual. The reliability coefficients were established through
a joint assessment between pair of examiners for at least 10
infants, until it reached a minimum of 80% agreement between
the scores. Periodically, joint evaluations were made to re-check
the reliability. The scoring for the 65 test items on MAI was done
on the 4 months MAI profile score sheet and the total high risk
points were calculated. Score less than 10 was considered low
risk, and score more than 10 was considered as high risk for
neuromotor development that is cerebral palsy.
A neuropsychological examination, Bayley scale of infant
development (BSID-II) was administered by the investigator and
a clinical Psychologist at 12 months of corrected age. The mental
development index (MDI) and psychomotor development index
(PDI) were calculated .The predictive values for a score at -2
SD below the mean on the BSID II at 12 months were considered
as mild delay and scores at -1SD below the mean were
considered as cerebral palsy and were referred for regular
physiotherapy intervention.
Instrument
The MAI is a neuromotor assessment tool comprising 65
items in four areas: muscle tone, primitive reflexes, automatic
reactions, and volitional movement. Items in the muscle tone
section evaluate spontaneous movement in three antigravity
postures, extensibility or range of motion of the extremities,
149
consistency of muscle tissue, and passivity of hands and feet. Table 2: Motor outcome (MDI) at 12 months with MAI risk score
The primitive reflex section includes items to examine the relative at 4months
presence or absence of reflexes that usually are present during
infancy. Assessment of righting reactions, equilibrium reactions, MAI TRS score
at 4 months
and protective extension responses is included in the section
on automatic reactions. The volitional movement section
samples a wide variety of items, including visual following and Bayleys <10 >10 Total
peripheral vision, hearing, fine motor skills and the achievements Motor
of developmental gross motor milestones. Each MAI item is scale
scored independently using a numerical scale with specific
PDI>84 25 05 30
behavioral criteria. Based on normative data collected on a small
sample of 4 month old infants, an MAI 4month profile was
developed indicating which scores for each item are considered PDI<84 3 07 10
to be deviant, which identify an infant to be at risk. Any item for
which a 4-month-old infants score identifies him as being at 28 12 40
risk then is circled and becomes a risk score. After the entire Sensitivity: 70%, Specificity: 83.3%,
examination has been administered and scored, the categorical PPV: 58.3%, NPV: 89.3%
risk scores are obtained for each area. The four categorical risk
scores then are summed to yield a total risk score. The lower MAI total risk score of the study infants at 4months are
the risk score, the more optimal the infants prognosis for shown in table2 and table3.Of the 12 with TRS greater than 10,
development.Thus, qualitative assessment of the infants seven showed abnormal motor development on BSID II motor
movement is incorporated into a quantitative scoring system for items. Their performance on mental items of BSID II was, of the
each item.11 12 with TRS greater than 10, three showed abnormal mental
development. Abnormal motor and mental development at 12
months on BSID included infants with both mild and significant
Statistical Analysis delay. The sensitivity of MAI for predicting motor delay with the
cut-off point of more than 10 was 70%, specificity was 83.3%,
The predictability of MAI was measured in terms of
positive predictive value was 58.3% and negative predictive
sensitivity, positive predictive value (PPV) and Negative
value was 89.3%.Similarly for predicting mental delay, sensitivity
predictive value (NPV) to determine its accuracy in detecting
was 60%,specificity was 74.3%, positive and negative predictive
neuromotor abnormality in VLBW infants. The relationship
values were 25% and 92.8% respectively(Table-2&3).
between 4-month MAI risk scores to Bayleys score (MDI&PDI)
at 12 months was examined using Pearsons product moment Table 3: Mental outcome (MDI) at 12 months with MAI risk score
correlation test. at 4months
MAI TRS score
Results at 4 months

Table1 presents mother and infant demographic and clinical Bayleys <10 >10 Total
characteristics. Data was available for only 40 subjects as one Motor
infant died (3.3%), one developed hydrocephalus (3.3%) and scale
three were lost to follow up (9.9%).
Table 1: Demographic data of the mother and child PDI>84 26 09 35

% Mean SD Range PDI<84 2 03 05

Age of 25.8 4.75 18-37 28 12 40

mother(yrs)
Sensitivity: 60%, Specificity: 74.3%,
Gestational 32.3 2.16 28-40 PPV: 25%, NPV: 92.8%
Age(weeks) The relationship between 4month MAI risk scores to
Bayleys motor and mental score (MDI and PDI) at 12 months
Birth weight 1363.5 150.20 1000- are presented in Table -4 .All correlations of the MAI total risk
(gms) 1500 score with Bayleys outcome measure at one year were highly
significant (p<.0000).For the categorical risk scores, all were
No of days 21.7 12.09 5-60 significant at p<0.01 except for primitive reflexes with MDI at
in NICU one year (.09).
Sex-
Males(24) 60 Discussion
Females(16) 40
The results of this study demonstrates that MAI has clinical
No of fetus utility in early detection of neurodevelopment abnormality that
in the womb is cerebral palsy in very low birth weight infants as early as 4
Single(37) 92.5 months of age in Indian population. However, the test was more
Twins(2) 5 specific to discriminate children with normal development than
Triplets(1) 2.5 to identify children with abnormal neuromotor development. The
frequency of 25% of the cases with abnormal motor development
Among the 40 infants entering the study, 25% of them had and 12.5% of cases with abnormal mental development in this
abnormal motor development and 12.5% had abnormal mental study is higher than that reported in other studies with the MAI
12,13,14
development at one year based on their scores on the mental . This fact could probably be due to very low birth weight
and motor developmental index of Bayleys scale >10. (<1500gms), which is high risk and also large number of the
sample belonged to very low socio-economic status and poor

150 Deepa Metgud / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 4: Pearsons Product- Moment correlation of 4 month MAI with 12 month BSID

MAI at 4 months Mental(MDI) At 12months P value Motor (PDI) At 12months P value

Total risk score -.542 0.000* -.714 0.000*

Muscle Tone -.430 0.000* - .584 0.000*

Primitive Reflex -.272 0.090 NS - .378 0.016s

Automatic reaction -.567 0.000* - .685 0.000*

Volitional Movement - .495 0.001* - .694 0.000*

*Highly significant .S-significant.
NS- Not significant
educational background. It has been reported in the study by
Marcia swanson1992 that low birth weight infants social and
familial context has significant influence on outcome. The
predictive validity of the MAI obtained in our study and the trends
indicated by earlier MAI studies on low birth weight infants 12, 15,
16
are similar, suggesting that the same basic relationship of
predictive validity exits. The results obtained in this study could
be because the sample was of VLBW as compared to LBW in
other studies and also the duration of outcome was 12months.
The sensitivity of MAI at four months was 70%, which
indicates that about 70% of VLBW infants who will have
abnormal outcome can be recognized as early as four months
of age. The results of our study signify the importance of
implementing MAI as a neuromotor assessment tool in Indian
infants of VLBW at four months of age. Though the test has
acceptable sensitivity, but has high specificity of 83.3% and
negative predictive value of 89.3% which is consistently reported
in most of the studies of MAI.14,16 These values indicate that
MAI provides reliable reassurance to the families whose infants
are determined to be at low risk and will have good prognosis,
which is a critical factor for stressed parents .The relatively high
rate of false positives in this study could be an accurate reflection
of clinical phenomenon observed among low birth weight infants
which cannot be resolved altogether by quantitative adjustments.
The clinical explanations for resolution of abnormal findings could
be the condition of transient dystonia which has been observed
in 25 to 40 percent of low birth weight infants, who have transient
abnormalities of muscle tone and posture in the first months of
life. Although these deviant movements are suggestive of early
cerebral palsy, typically they resolve by one to two years of age.17,
18
About 45%(18) of the infants in our study had more than 5
neonatal problems and the mean duration of stay in NICU was
21.7 days, which could also be the reason for more number of
false positives at 4 month evaluation.
The Pearsons product moment correlation of the MAI total
risk score was highly significant for both MDI and PDI score of
BSID II at 12 months as indicated in table-4.12, 19, 20 This result is
similar to the finding of other studies, however the only difference
was in our study BSID II was used. This indicates that the
correlation of MAI with BSID II is equally strong as BSID I. It
was found that though MAI is primarily a neuromotor evaluation
tool, highly significant correlations were found with mental scale
of BSID II and also the sensitivity of 60%, which indicate that
MAI has potential in identifying mental delay. This could be
because it has items like reaching for red ring, picking up cube,
pincer grasp for pellet, vision, hearing etc which are similar to
items on the mental scale of BSID II.21, For the categorical risk
scores, all were significant at p<0.01 except for primitive reflexes
which was less strong with PDI and not significant with MDI at
12 months (p<.09).This suggests that reflexes are the least
reliable and valid predictors of later motor handicap.22Strong
correlation with the motor outcome measures was found for
volitional movement which confirms the importance of including
assessment of developmental function as well as neurological
signs in examination of high risk infants.23,24
Conclusion
MAI is a potentially useful clinical tool for identifying
neuromotor abnormalities in VLBW infants with high specificity
and acceptable sensitivity. Although with some limitations, MAI
gives the therapist an objective frame work for assessment of
risk babies. Future research with sequential follow up using 6
and 8 month MAI profile would be useful in longitudinal
monitoring of development in VLBW babies and also predictive
validity studies of MAI for Indian children who are born at term
and exposed to perinatal and social risk would be considered
for future studies.
References
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Comparison Among Different Head Neck Positions for the Effects
on Wrist Flexor Torque Production
Dheeraj Lamba*, Sapna Kharayat**, Jaya Mehta**, Ajay Joshi**, Manish Kandpal**
*Incharge, ** Interns, Dept. of Physiotherapy, IAHSET Medical College, Haldwani, Uttarakhand

Introduction Methodology
The influence of head and neck (H-N) position on the
behavior of limb muscles was first reported over 75 years ago. Sample
In 1951, Tokizane published the results of a study, that
demonstrated in relaxed healthy subjects the electromyography Thirty subjects were participated in this study according to
activity of limb muscles varies with rotation of the H-N, based inclusion and exclusion criteria and were selected randomly from
on tonic neck reflex (T.N.R).The existence of the TNR was Sushila Tiwari Memorial Hospital, Haldwani. Their mean age
demonstrated first by Magnus and de Klein in 1912 TNR is was (21.93 2.01) yrs, mean height (155.16 3.98) cms, and
normally present during infancy and become integrated by the mean weight was (51.70 5.25) kgs.
CNS at an early age. Once integrated, these reflexes are not
generally recognized in adults in their pure form. They however Inclusion Criteria
continue as adaptive fragments of behavior, underlying normal
motor control. Studies have been done which proves 1. Healthy female subjects
that T.N.R can be elicited in normal healthy adults along 2. Age - 19-25 years
with infants and neurogically impaired persons. Although this 3. Height - 149-167 cms
reflex may affect all four limbs, its influence is greater on the 4. Weight - 40-62 kgs
upper extremities than on the lower extremities. The TNR has 5. Subjects with left as nondominant hand.
both a symmetrical and an asymmetrical component. The
symmetrical tonic neck reflex (STNR) configuration,affecting both
Exclusion Criteria
upper limbs, increases flexor muscle tone when the head and
neck are flexed and conversely increases extensor muscle tone 1. History of fracture of upper extremity
when the head and neck are hyper extended. The classic 2. History of neurological disorders affecting cervical spine or
asymmetrical tonic neck reflex (ATNR) pattern involves elbow upper extremity.
extension and shoulder abduction on the chin side and elbow 3. History of muscle strain of upper extremity or cervical spine.
flexion and shoulder adduction on the back of the head side. 4. Any deformity of upper extremity.
when the head and neck are rotated. 5. Instability of wrist joint
The strength evaluation of a joint is very important for the
clinician as it gives a valuable or fundamental information about
athletic and human performance. Strength testing has been used
Study Design
to examine the integrity and function of the musculoskeletal Comparative study design.
system. It would also make it easier to find follow up effect of
exercise therapy and in the field of sports specific training or
rehabilitation. Isometric evaluation with an isokinetic machine Instrumentation
provides reliable and valuable source of muscle strength. A
Humac Norm (CSMi) testing and isokinetic rehabilitation
recent trend of measuring joint strength in clinical setup is by
system.
using isokinetic machine. The reliability of this machine is well
established. Although many studies have been done on the
influence of different H-N positions and its effect on joint strength Protocol
production but there is no consensus in the literature regarding
Minimum of 30 female subjects were included in the study
the influence of different H-N positions for the effects on wrist
based on inclusion and exclusion criteria. The subjects were
flexor strength measurement, hence there is a need for proper
randomly selected and left wrist flexor torque was measured in
protocol development when evaluating isometric wrist flexor
different head and neck (H-N) positions viz: Neutral position:
strength using an isokinetic machine and higher level of accuracy
Subject was asked to look straight in the front, at the point marked
in isokinetic muscle evaluation would be incorporated in
in the wall (NP). Sagittal plane: H-N positions in flexion (SPF)
professional rehabilitation strategies.
and extension (SPE).
Horizontal plane: H-N positions in rotation left (HPRL) and
Aims and Objective rotation right (HPRR). Combined plane: H-N positions in the
combination of both sagittal and horizontal planes i.e. rotation
To compare the wrist flexor torque production in different
right with flexion (CRRF) and extension (CRRE) and rotation
head and neck positions (Neutral position, Sagittal plane,
left with flexion (CRLF) and extension (CRLE).
Horizontal plane and Combination of both Sagittal and Horizontal
planes).
Procedure
Hypothesis At first, the whole procedure was explained to the subjects
and each subject willing to participate, was made to sign a
Head-neck rotation (horizontal plane) has a greater
consent form. After informed consent was obtained, each
influence on wrist flexor muscle torque production than the
subjects height, weight, age, were recorded. 30 female subjects
movements in neutral position, sagittal plane, and combination
included in the study were randomly tested in different head
of both sagittal and horizontal planes.

Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 153
and neck (H-N) positions. The left, nondominant hand 2, 10 (p=0.890), SPE Vs CRLE (p=0.261). These showed no
was used for the study, tested in Humac Norm (CSMi) isokinetic significant differences [Table-5.2]
rehabilitation system, to measure the maximal isometric torque, Paired sample t-test was done to compare the mean values
during isometric wrist flexion, for all the subjects with different of peak torque between HPRR Vs HPRL, HPRR Vs CRRF,
H-N positions. HPRR Vs CRRE, HPRR Vs CRLF, HPRR Vs CRLE. The
The different H-N positions made by the subject, were comparison showed significant difference (p=0.001).
according to their maximum limit. The positions were - neutral Comparison between HPRL Vs CRRF (p=0.862), HPRL Vs
position, where the subject was asked to look straight in the CRRE (p=0.257), HPRL Vs CRLF (p=0.307), HPRL Vs CRLE
front, at the point marked in the wall. In sagittal plane, the subjects (p=0.068) showed no significant difference [Table-5.3]
were instructed to have the H-N positions in flexion and extension Paired sample t-test was done to compare the mean values
.In horizontal plane, they were instructed to have the H-N of peak torque between CRRF Vs CRRE (p=0.125), CRRF Vs
positions in rotation left and rotation right. Similarly in combined CRLF (p=0.248), CRRF Vs CRLE (p=0.027), CRRE Vs CRLF
plane, the H-N positions were in the combination of both sagittal (p=0.662), CRRE Vs CRLE (p=0.115), CRLF Vs CRLE (p=0.119)
and horizontal planes i.e. rotation right with flexion and extension .These showed no significant differences. [Table-5.4]
and rotation left with flexion and extension. Table -5.1: Paired sample t test between NP and other head
The subject was comfortably positioned in sitting, in the neck positions
isokinetic analyzer chair with hips and knees at 90 flexion. The
hips, shoulders and forearm were firmly secured by Velcro straps Comparison t value p value
for stabilization. The dynamometer height was then adjusted
next to the chair, so that the subject could position the arm NP SPF 1.204 0.238
comfortably with the shoulder in 10 to 15 degree of flexion, at
about 15 of abduction and neutral rotation. The elbow was at NP SPE 0.389 0.700
90 flexion and the forearm in neutral supination, resting in a V-
shaped stabilizing platform and was secured to the dynamometer NP HPRR 8.047 0.001
with straps, to prevent the forearm from rising out of the platform.
The limb length was adjusted and the axis of the dynamometer NP HPRL 1.156 0.257
centered at the wrist joint. The mechanics of the dynamometer
were explained to the subject prior to testing. The required limb NP CRRF 1.048 0.303
action was also demonstrated.
The wrist angle (30 degree of wrist flexion) was registered NP CRRE 0.104 0.918
on the isokinetic dynamometer. Range of motion stops were
applied. During the isometric (static) tests, the tension applied NP CRLF 0.261 0.796
was held for six seconds. Each subject performed three test
repetitions of each contraction under each H-N condition with a NP CRLE 0.415 0.681
minimum of one minutes rest interval between each contraction.
Verbal encouragement was given with the intent of pushing each Table 5.2: Paired sample t test between different head neck
subject to her true maximum torque capabilities by asking them position
to give their best effort for the test. Lastly, the maximum isometric
peak torque of wrist flexors were measured and recorded for Comparison T value p value
data analysis.
SPF SPE 1.581 0.125
Data Analysis SPF HPRR 8.657 0.001
The data was analysed by using SPSS Version 12.0
SPF HPRL 1.000 0.326
software.Paired sample t-test was done to calculate the level of
significance of wrist flexor torque in different head and neck
SPF CRRF 0.115 0.909
positions.
The level of significance was set at 0.05.
SPF CRRE 1.190 0.244

Results SPF CRLF 1.077 0.290

Paired sample t-test was done to compare the mean values
SPF CRLE 1.900 0.067
of peak torque between Neutral position (NP) Vs Sagittal plane
flexion (SPF) (p=0.238), NP Vs Sagittal plane extension (SPE)
SPE HPRR 9.950 0.001
(p=0.700), NP Vs Horizontal plane rotation left (HPRL) (p=0.257),
NP Vs Combined rotation right flexion (CRRF) (p=0.303), NP
SPE HPRL 1.508 0.142
Vs Combined rotation right extension (CRRE) (p=0.918), NP
Vs Combined rotation left flexion(CRLF) (p=0.796) and NP Vs
SPE CRRF 0.982 0.334
Combined rotation left extension (CRLE) (p=0.681).These
comparisons showed no significant differences. Comparison
SPE CRRE 0.362 0.720
between NP Vs Horizontal plane rotation right (HPRR) showed
significant difference (p=0.001) [Table-5.1].
SPE CRLF 0.140 0.890
Paired sample t-test was done to compare the mean values
of peak torque between SPF Vs HPRR and SPE Vs HPRR.
SPE CRLE 1.146 0.261
The comparison showed significant difference (p=0.001).
Comparison was made between SPF Vs SPE (p=0.125), SPF
Vs HPRL (p=0.326), SPF Vs CRRF (p=0.909), SPF Vs CRRE Discussion
(p=0.244), SPF Vs CRLF (p=0.290), SPF Vs CRLE (p=0.067),
Muscle testing is an integral part of physical examination,
SPE Vs HPRL (p=0.142), SPE Vs CRRF (p=0.334), SPE Vs
it provides information usually not obtained by other procedures
CRRE (p=0.720), SPE Vs CRLF

154 Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 5.3: Paired sample t test between different head neck and machine related factors (stabilization, lever arm distance,
position axis fixation etc) among which, the major factor is positioning
which can significantly effect the result of torque in an isometric
Comparison T value p value
muscle testing in isokinetic machine. Various authors studied
the above-mentioned factor. al in his study concluded that the
HPRR HPRL 8.874 0.001
head neck position may influence the tension which is produced
by the elbow flexor muscles and apparently, head-neck rotation
HPRR CRRF 7.139 0.001
(horizontal plane) may have a greater influence than movements
in the sagittal plane, particularly when movements in the
HPRR CRRE 8.710 0.001
horizontal and sagittal planes are combined. In another study
by Berntson and Torello showed that head rotation away from
HPRR CRLF 8.692 0.001
the active hand results in a significant increment in flexor strength
of distal muscles of prehension when examined by the hand
HPRR CRLE 10.156 0.001
dynamometer, in accord with the tonic neck reflex pattern.
A review of the literature has revealed the existence of the
HPRL CRRF 0.175 0.862
TNR in healthy, young adults which can be used in the
rehabilitation of upper extremity. But, there is no consensus in
HPRL CRRE 1.155 0.257
the literature till now on the effects of different head neck position
in wrist flexor muscle torque production that confirms the need
HPRL CRLF 1.039 0.307
of the study.
So, the purpose of this study was to investigate and
HPRL CRLE 1.893 0.068
compare the different head neck positions for the effects on
Table 5.4: Paired sample t test within combined plane. wrist flexor muscle torque production in healthy, young females.
It was hypothesized that head-neck rotation (horizontal plane)
Comparison T value p value do have a greater influence on wrist flexor muscle torque
production than the movements in neutral position, sagittal plane
CRRF CRRE 1.581 0.125 and combination of both sagittal and horizontal planes. The result
obtained by the data analysis showed significant difference in
CRRF CRLF 1.178 0.248 head-neck rotation-HPRR (horizontal plane).
When compared within sagittal plane, mean value of SPF
CRRF CRLE 2.332 0.027 (7.93) was found greater than SPE (7.5). In comparison within
horizontal plane, mean value of HPRR(11.2) was greater than
CRRE CRLF 0.441 0.662 HPRL(7.9) and CRRF(8.00) showed the greater mean value
than the rest of the combined head-neck position, when
CRRE CRLE 1.624 0.115 comparison was done within combined plane. Deutsch et al
supports our result, in few ways where head-neck rotation
CRLF CRLE 1.606 0.119 (horizontal plane) appeared to have a greater influence on elbow
flexor muscle torque production than movements in the sagittal
Fig. 5.1: Comparison of peak torque of wrist flexors in different plane, particularly when movements in the two planes were
head and neck positions combined. These cascades of impulses then stimulates the
motor neurons to evoke selective activation of neck musculature,
sufficient to modify the position of the head autonomously and
to stimulate the receptive field (first three cervical joints) activating
tonic neck reflexes. The recruitment of reserve motor units
augment the sensory input via synaptic arrangement and
operates in the absence of cortical interference. According to
Luhan, eliminating the influence of gravity would facilitate the
TNR effects. In the present study, head-neck rotation-HPRR
(horizontal plane) showed the significant difference (p=0.001).
This may have occurred as there was no influence of gravity in
HPRR unlike SPF and CRRF, thus facilitating the tonic neck
reflex effects.

that is useful in differential diagnosis and prognosis of
neuromuscular disorders. It is essential to determine muscle
strength before prescribing therapeutic exercise because most
of these exercise are designed either to stretch shorten muscle
or to strengthen weak muscle. Evaluation of muscle strength by
isometric contraction of the muscle is one of the evaluation tool
used by therapist frequently in day-to-day clinical practice, the
new trend of evaluating muscle performance is by using
isokinetic dynamometry, and it is widely accepted but many
factors that may influence the outcome of the measurement like
subject related factors (age, sex, weight, height, positioning)
Conclusion
The study concluded that the tonic neck reflex have an
effect on different head- neck positions influencing the wrist flexor
torque and the head neck rotation (horizontal plane) has a greater
influence than the movements in neutral position, sagittal plane
and combination of both sagittal and horizontal planes. Thus
head-neck position should be considered during strengthening
programme of the upper extremity
References
1. Carol A.Oatis: Kinesiology-the mechanics and
pathomechanics of human movement, Lippincott Williams
and Wilkins, second edition, pg-242
2. Hall and Brody: Therapeutic Exercise, Lippincott Williams
and Wilkins, second edition, 2005, 626-634

Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 155
3. Kessler et al: Management of Musculoskeletal Disorders,
Lippincott Williams and Wilkins, third edition, pg-243.
4. Salter and Cheshire: Hand Therapy, Butterworth
Heinemann, first edition, 2000, pg-13
5. Luke E. Thomas: lsokinetic Torque Levels for Adult
Females-Effects of Age and Body Size, JOSPT, Vol. 6, No.1,
1984
6. Jessie Marie Vanswearingen: Measuring Wrist Muscle
Strength, JOSPT, Vol. 4, No. 4, 1983
7. Anderson and Rutt: The Effects of Counterforce Bracing
on Forearm and Wrist Muscle Function, JOSPT, Volume
15, Number 2, February 1992
8. Morse, Jung, Bashford, Hallbeck: Maximal dynamic grip
156 Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
force and wrist torque- The effects of gender, exertion
direction, angular velocity, and wrist angle, Applied
Ergonomics, 37, 2006, 737742
9. Dale Richard Stonecipher et al: The effect of a forearm
Strap on wristextensor strength, JOSPT, Vol. 6, No. 3,
1984
10. G.Y.F. Ng, Chan: The Immediate Effects of Tension of
Counterforce Forearm Brace on Neuromuscular
Performance of Wrist Extensor Muscles in Subjects With
Lateral Humeral Epicondylosis, J Orthop Sports Phys Ther,
Volume 34, Number 2, February 2004
11. Smith, Weiss, Lehmkuhl: Brunnstroms Clinical
Kinesiology, Jaypee Brothers, fifth edition, pg-146.
Effect of Saddle Heights on Craniovertebral Angle During
Ergonomic Cycling
Dheeraj Lamba*, Satish Pant**, Girish Chandra**
*Incharge, **Interns, Dept. of Physiotherapy, IAHSET Medical College, Haldwani

Introduction men and women during Ergonomic cycling.

Statement of Question
The bicycle is the vehicle most used in world, and also the Does the craniovertebral angle change while the change
fastest growing in number of users, both with the purpose of in saddle heights during Ergonomic cycling?
recreation, physical training, rehabilitation or practice competitive Hypothesis
purpose. Various publications have reported that 30-70% of There will be significant change in craniovertebral angle in
cyclists suffer from cervical, dorsal or lumbar back pain which young men and women during ergonomic cycling with change
causes recreational cyclists to abandon cycling. But for many in saddle heights.
others (such as in china), cycling is their only, means of urban
transportation. The choice of the position in which the individual Sample
cycles is important to consider because the biomechanics and
efficiency of cycling in adults have been shown to be affected A total of 60 male and female subjects, with a mean age of
by saddle height, crank arm length and foot position. It might be 24, were recruited for the study. They were recruited from Sushila
expected that with the amount of time spent on bicycles during Tiwari Memorial Hospital, Haldwani.
training and racing, recreational, age-group triathletes would
have acquired their correct saddle height through trial and error.
Inclusion Criteria
Even so, these athletes may not be operating at an efficient
saddle height. when cycling is utilized for exercise of patients Healthy male and female subjects
with different needs it is valuable to know the range of motion Age: 18-25 years
required for various adjustments of the bicycle ergometer such Pain free cervical range of motion.
as workload, speed, or saddle height or cycling technique (pedal Height of subjects- 158-165 cm.
foot position) used. Subjects had ordinary daily and recreational cycling
Individuals with physical disabilities may benefit from cycling experience.
interventions, which could address impairments such as
decreased muscle strength (force-producing capacity), range
of motion, and fitness while potentially minimizing stress to joints.
Exclusion Criteria
Improvements in impairments may then have an impact on H/O postural abnormality, limb length discrepancy
mobility, activity and participation. Many factors, however, need H/O any musculoskeletal disorder
to be considered in designing a cycling intervention and H/O saddle sorea, perineal nodules, or perineal numbness
information learned from studies examining cycling in adults and H/O cardiovascular or respiratory conditions
children who are healthy as well as in adults with disabilities H/O forward head posture
can provide some insight into these factors. H/O low back pain, neck pain, leg pain, shoulder pain and
It is well known that factors such as the tilt of the pelvis, the impairment to the limbs
adoption of a sitting, or standing position, the shape of backrest H/O neurological disease
when sitting, and the head position can all influence the sagittal H/O any spinal injuries
curve of the cervical spine. Head posture can be described on
the basis of craniovertebral angle. Dean H Watson, Patricia H
Trott found in their study that craniovertebral angle in headache Instrumentation
group had a smaller angle than the non-headache group. The
Weighting Machine
symptomatic group revealed a significant Forward head posture
Used for measuring weight of the subject.
when compared to the non-headache group. There is a the direct
Height Measuring Stand
correlation between change in head neck posture and neck pain.
Used for measuring the height of the subject
The Craniovertebral angle provides a convenient and
reliable method of measuring head protraction and could be
used more extensively in conjunction with other head/neck Adhesive Markers
posture measures like flexion, extension, or ear-eye line angles
The circular adhesive markers of diameter 05mm were
to better evaluate working postures, especially those involving
used to denote the anatomical points of subjects to capture the
computer work and visual inspection tasks.
postural information on body segments. A reflective ball of about
Head/neck posture is defined as the angle between the
half inch was placed on C7 spinous process.
horizontal line passing through C7 and a line extending from
the tragus of the ear to C7.head/neck posture angle is called
craniovertebral angle or C7-tragus angle. A smaller Digital Video Camera
craniovertebral angle indicated a greater forward head posture.
A previous paper reported the reliability of this procedure as A digital Nikon (Cool pix L10) camera, with 5 megapixel,
high (ICC=0.88). mounted on a tripod was used to take the still photographs of
the subjects.
Motion analysis software
Aim and Objective Motion analysis were basically use in clinical settings. The
software was employed to calculate the angle from each
The aim of the present study is to determine the effect of
anatomical landmark from photographs.
different saddle heights on the craniovertebral angle in young

Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 157
 Stationary bicycle ergometer
An adjustable stationary bicycle ergometer with attached
kilometer was used.
Tools
Measuring tape
Plumb bob
Stop watch
Protocol
60 male and female subjects were included in the study
based on the inclusion and exclusion criteria the measurement
was taken in three phases according to the saddle height.
Phases 1- Subjects were made to cycle with saddle in MID
height position (113% of the distance between the ischial
tuberosity and the medial malleolus).
Phases 2- Subjects were made to cycle with saddle in LOW
height position (102 % of the distance between the ischial
tuberosity and the medial malleolus).
Phases 3- Subjects were made to cycle with saddle in HIGH
height position (120 % of the distance between the ischial
tuberosity and the medial malleolus).
Each subject performed the entire test. In all phases subject
sat on an ergonomic bicycle which was set according to subject
stature.
Study Design
Observational study design.
Procedure
Before taking part in the study, participants read and signed
an informed consent form approved by the institutions ethical
committee. Assessment of the subjects was done, all the
subjects were given the explanation of the procedure of the study
and all their questions were satisfactorily answered. Subjects
sat on the adjustable bicycle ergometer. Adjustments were made
according to the subject height and limb length. Changes were
be made to the saddle height, foot position; handle bar and
saddle tilt according to the Standardized Ergometer cycling.
Standardized Ergometer Cycling
The adjustment of mid-saddle height and anterior foot
position was defined as Standardized Ergometer cycling. The
handlebar was kept level with the saddle.
Mid saddle height is the 113 % of the distance between the
ischial tuberosity and the medial malleolus. The saddle
height was measured as the greatest distance from saddle
surface to the center of the upper pedal surface in a straight
line along saddle pillar and crank.
Anterior foot position was defined as the contact with the
head of the second metatarsal (ball of foot).
Once the cycle was set, all variables were kept constant
except saddle height.
Subjects wore bathers or tight bike shorts and a sleeveless
T-shirt top so that the neck will be exposed. Hair was tied back
to ensure the cervical region is visible. With the subject sitting
on the ergonomic cycle, two lateral anatomical landmarks were
marked by adhesive Binbis contrasting to skin colour. They
will comprise:
the tragus of the ear,
and a projecting reflective ball will placed posteriorly on
the spinous process of C7.
The digital camera was positioned on a tripod at a distance
of 0.8 m. The axis of the lens of the camera was placed
orthogonal to the sagittal plane of the patient at a height that
158 Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
corresponded with the seventh cervical vertebra. With its optic
axis perpendicular to the subjects (sagittal plane) and illumination
directed for reflecting equipment. Reflective markers were placed
on the anatomical points.
All subjects were allowed to warm up and become
accustomed to cycling on the specially instrumed bicycle
Ergometer. Subjects were asked to sit on the bicycle. Then
subject were asked to choose self selected cycling speed and
cycle for 30 sec while looking straight a head and photographs
will be taken during the last 10 sec. Before taking photographs,
position of subjects were checked. Same procedure was followed
for all three phases with the adjustment being done only to the
saddle height as described in the protocol. These three exercise
bouts were separated by a 5-min rest period and were
randomized to prevent an order effect. The anatomical markers
and the position of subjects were rechecked prior to second
and third photograph to ensure that they were securely in plane.
Measurement of Craniovertebral Angle
The Craniovertebral angle was measured from a line drawn
from the tragus of the ear to the seventh cervical vertebra
subtended to the horizontal. The software produced a horizontal
line perpendicular to the vertical plumb line captured in the
background of the image.
Comparison was performed on the Craniovertebral angle
obtained during all three phases of cycling for all subjects
Data Analysis
The data analysis was done using statistical package of
social science- SPSS (Version-11) software. The arithmetic
mean values and standard deviation of variables age & height
were calculated. ne way analysis of variance (ANOVA) was
applied to compare Craniovertebral angle at different saddle
heights. post Hoc analysis of multiple comparison tests were
applied to compare between craniovertebral angles of there of
three different saddle heights Paired sample t test applied to
compare the craniovertebral angle of three different saddle
height. Significance level was set at (0.05).
Results
The mean & standard deviation of age & height was
calculated for subjects were as follows: Age = 23.43 1.59,
height = 159.58 4.91 and weight = 56.18 5.77 (Table 5.1).
Paired sample correlation test was done to find out the difference
in craniovertebral angle obtained at various saddle heights (Table
5.2). Craniovertebral angle at Low saddle height LSH mean value
is 33.7593.197. When compared with craniovertebral angle
obtained the mid saddle height (MSH) with mean value 29.867
3.085. The result was found to be statistically significant (p
=.000) (Table 5.3a). Craniovertebral angle at Low saddle height
LSH mean value is 33.7593.197. When compared with
craniovertebral angle obtained the high saddle height (HSH)
with mean value 26.347 3.011. The result was found to be
statistically significant (p =.000) (Table 5.3b). Craniovertebral
angle at Mid saddle height MSH mean value is 29.8673.085.
When compared with craniovertebral angle obtained the High
saddle height (HSH) with mean value 26.347 3.011. The result
was found to be statistically significant (p =.000) (Table 5.3c).
Correlation analysis for craniovertebral angle between low
saddle height and mid saddle height showed significant
correlation R= .965. Correlation analysis for craniovertebral angle
between low saddle height and High saddle height showed
significant correlation R= .780. Correlation analysis for
craniovertebral angle between Mid saddle height and High
saddle height showed significant correlation R= .810 (Table 5.4).
Table 5.1: Mean and SD of Age, Height and Weight for the rehabilitation. Lots of studies have shown that different saddle
subjects included in the study heights are used depending on the goal of rehabilitation. The
Variable Mean Standard deviation mid saddle height position is set in standard Ergometer cycling
position. Whereas if a patient has a knee flexion contracture a
Age 23.43 1.59 lower seat height may be needed to allow seat height may be
needed to allow that individual to cycle. A lower seat height also
Height 159.58 4.91 may be for a patient with pulmonary or cardiac concerns. If the
desire is to strengthen the calf muscles or to obtain greater
Weight 56.18 5.77 extension range of motion, a higher seat height may be the better
choice. A higher seat height also may better challenge the cardio
Table 5.2: comparison of mean values for Craniovertebral Angle respiratory system during exercise, potentially leading to exercise
(CVA) at Low (LSH), Mid (MSH) and High Saddle heights (HSH) effects such as an improvement in maximum oxygen
between the groups consumption.5 From posture height as well as posture length
we can obtain a comprehensive picture of the proper adjustment
Variable Mean Standard F value P value of saddle and handlebars. There two variables, both
deviation independently and in relation to each others, are of crucial
importance for a correct cycling posture. As well as the problems
CVA LSH 33.75 3.19 caused by incorrect posture height, many cyclists have problems
related to incorrect posture length. In most cases this is due to
CVA MSH 29.86 3.08 85.875 0.000 in sufficient reach, the distance between the rear of the saddle
and the transverse part of the handlebars. It should be
CVA HSH 26.34 3.01 appreciated that no matter what cycling posture is adopted the
upper body is used in an unnatural manner. If the posture is too
Table 5.3: (a) Comparison of Craniovertebral angles obtained short, it places too much stress on the natural form of the
at Low saddle height and Middle saddle height. vertebral column, in particular the lumbar and cervical part and
may cause lower back pain and neck complaints.
C VA Mean SD t value p value
The results of this study indicates that craniovertebral angle
was maximum in low saddle height position (33.753.19), least
LSH 33.759 3.197 35.736 .000
in the high saddle height position that is (26.343.01) and in
the mid saddle height position it was mid way between the two
M SH 29.8673.085
(29.863.08).
Table 5.3: (b) Comparison of Craniovertebral angles obtained Szeto et al found that hyperextension of the neck or
at Low saddle height and H igh saddle height. increased cervical lordosis is a common consequence of forward
head position.
C VA Mean SD t value p value A sustained forward flexion posture of the spine has been
associated with increased cervical compressive loading and a
LSH 33.759 3.197 27.788 .000 creep response in the connective tissue.
According to Burgess Limerick with the trunk in an upright
M SH 26.347 3.011 position, both atlanto-occipital and cervical flexion increases the
torque required of the extensor musculature to maintain static
Table 5.3: (c) Comparison of Craniovertebral angles obtained equilibrium.
at Mid saddle height and High saddle height. Researches also have shown that changes in bicycle
settings like saddle height and handlebar reach may cause neck
C VA Mean SD t value p value problems but the exact underlying mechanism has not yet we
fully explained the results of this study may provide a clue as to
LSH 29.867 3.085 14.486 .000 the possible mechanism.

M SH 26.347 3.011 Conclusion

Table 5.4: Comparison of mean value of Craniovertebral Angle Change in different saddle heights affects the
at Low, Mid and High Saddle height for the subjects craniovertebral angle uring Ergometer cycling. They are such a
Craniovertebral angle R value p value significant factor that they can produce change in biomechanics
of spine. Hence saddle height should be considered as an
LSH Vs MSH .965 .000 important factor in rehabilitation for professionals who prescribe
cycling as an intervention.
LSH Vs HSH .780 .000
References
MSH Vs HSH .81 0 .000
1. Elisandro Dassisi Martins, Frederick dagnese, Julio
Francisco Kleinpaul,Felipe Pivetta Carpes, Carlos Bolli
Discussion Mota, (2007) Principais erros no posicionamento de ciclistas
de diferentes niveis de condicionamento, (Major error
The purpose of this study was to determine the effect of
position of different levels of conditioning) XII Congresso
different saddle heights on the craniovertebral angle in young
Brasileirde Biomecnica s in eter Cycling, The journal 5. ,
men and women during Ergometer cycling. The results of the
p.495-500,So Paulo. 2.
present study indicate that the change in saddle height has effect
2. M Salai, T Brosh,A Blankstein,A Oran and A Chechik
on craniovertebral angle, there by supporting the hypothesis.
(1999).Effect of changing the saddle angle on the incidence
There is also evidence that any change in saddle height during
of low back pain in recreational bicyclists: British Journal of
rehabilitation program of lower extremity also creates a change
Sports Medicine, 33,398-400.
in neck posture. Ergometer cycling is common tools of
3. Therese E Johnston (2007), Biomechanical Considerations

Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 159
 for cycling interventions in rehabilitation, Physical Therapy,
v. 87,n. 9,1243-1252
4. 4. Mats 0. Ericson, Ralph Nisell, Gunnar Nemeth ,(1988)
Joint Motions of the lower limb during Ergom of
Orthopaerdic and Sports Physical Therapy , vol. 9,No. 8
5. Nordeen-Snyder KS: (1977), The effect of bicycle seat
height variation upon oxygen consumption and lower limb
kinematics. Medicine and Science in Sports and exercise
2:113-117
6. Deborah Falla, Gwendolen Jull, Trevor Russell, Bill
Vicenzino, Paul Hodges,(april2007),Effect of Neck Exercise
on Sitting posture in Patients With Chronic Neck Pain,
Physical Therapy , 87 ( 4), 408-417
160 Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
7. Dean H Watson, Patricia H Trott (1993), Cervical headache:
an investigation of natural head posture and upper cervical
flexor muscle performance, Cephalalgia, 13:272-84
8. D.Grob. H. Frauenfelder .A.F. Mannion, (2007), The
association between cervical spine curvature and neck pain,
European Spine Journal, 16:669-678. 63
9. Dennis R. Ankrum, Kristie J. Nemeth (2000), Head and
neck posture at computer workstations- whats neutral?
Proceedings of the 14th triennial congress of the international
ergonomics association, 5, 565-568
10. Cesar Fernandez-de-las-penas, Cristina Alonso-Blanco,
Maria Luz Cuadrado, Robert D.Gerwin , Juan A.Pareja,
(2003)Trigger points in the subocci headache, Headache;
46:454-460.
A Comparative Study of Cardiovascular Fitness in Normal Versus
Obese Children
Gaurang D Baxi1, Tushar J Palekar2, M Vijayakumar3, Varoon C Jaiswal4
1
Lecturer, 2Principal and Professor, 3Associate Professor, Padmashree Dr. D.Y. Patil College of Physiotherapy, Pimpri, Pune, 4Lecturer,
MAEERS College of Physiotherapy, Talegaon Dabhade, Pune
Abstract
Introduction
Childhood overweight and obesity are dramatically
increasing worldwide. Overweight or obese children are at a
high risk of experiencing a range of co-morbidities affecting
almost every body system. Environmental factors such as diet,
physical activity and metabolic status are major contributors to
obesity. Physical activity among children has declined in recent
decades and the corresponding increase in obesity prevalence
may be the direct result of this decline. An important component
of physical fitness is cardiorespiratory endurance or cardio-
respiratory fitness. This study was done to evaluate
cardiovascular fitness in children and to compare it between
normal and obese children.
Methods
102 boys in the age group of 9-11 years, studying in
nearby schools in were taken for the study. The height and weight
were taken and the Body Mass Index (BMI) was calculated.
According to their BMI, they were divided into three groups-
normal, overweight or obese. The children were then made to
run the Cooper 12 minute run test. The distance covered in 12
minutes was noted. The VO2 max was calculated using prediction
equation for the Cooper 12 minute run test. The data of children
having a normal BMI was then compared against those having
a BMI falling into the overweight or obese category. Inter and
intra group analysis was done.
Results
The results of this study showed a significant reduction of
33.87% in the cardiovascular fitness levels of overweight and
obese boys, as compared to those with a normal BMI. Also, the
children having a normal BMI also did not have adequate fitness
levels.
Conclusion
Cardiovascular fitness of overweight and obese boys in
the age group of 9 to 11 years is significantly less as compared
to those boys having a normal BMI. Also, those boys having a
normal BMI did not have recommended fitness levels. Further
research has to be carried out to find out fitness standards for
Indian children.
Key Words
Obesity in children, VO2 max in children, peak VO2 in
children, cardiovascular fitness in children.
Address for correspondence:
Dr. Gaurang D. Baxi
Lecturer, Padmashree Dr. D. Y. Patil College of Physiotherapy,
Sant Tukaran Nagar, Pimpri, Pune 411018.
Email: gaurangbaxi82@gmail.com
Gaurang D Baxi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Introduction
Obesity can be defined as excessive body mass for stature,
and more specifically an excessive body fat content.1 It is a
condition of concern because it is in and of itself socially and
physically debilitating and it represents a risk factor for increased
morbidity and mortality rate. For more than a hundred years,
the life insurance industry has pointed out that increased body
weight is associated with excess mortality.2 This has been one
stimulus for including body weight, stature and occasionally
skinfolds on epidemiological studies on the factors associated
with the development of cardiovascular disease and cancer.3
In recent years, fat distribution has also been included. It is now
clear that a high body mass for height or a high body fat level
and upper body obesity plus weight gain in adult life are
associated with the risk of developing severe chronic diseases.
Overweight, obesity and adiposity are the commonly used
expressions for increased body fat and have replaced the older
terms such as corpulence, polysarcie and embonpoint. 4
Overweight can be expressed as relative weight or ratios of
weight o height. Relative weight is the ratio of actual to standard
weight as determined from a table of reference body weights
expressed relative to height, frequently as a percentage. Weight
to height ratios can also be expressed as the body mass index
(BMI) or Quetelet index, which is body weight (in kilograms)
divided by the square of the height (in meters).5 The BMI is
more highly correlated with body fat than with other indices of
height and weight.6
Childhood Obesity: An emerging epidemic
The World Health Organization (WHO) International Obesity
Task Force estimated that 30-45 million children worldwide are
obese and approximately 155 million are overweight.7 Childhood
overweight and obesity are increasing dramatically, both in the
developed world and in many developing countries.8-11 This
dramatic increase in the prevalence of childhood obesity within
the last decade has changed the view on it and the condition is
now seen as one of the top 10 global health problems. The
increasing prevalence of childhood overweight and obesity is a
global trend and is of concern as overweight or obese children
are at a high risk of experiencing a range of health problems in
the immediate, short and long term.12
Obesity in childhood is not simply of cosmetic or even
psychological concern, but these children suffer co-morbidities
affecting almost every body system. Immediate health problems
of overweight and obese children include social isolation and
potential psychological dysfunction. 13-15 Young overweight
children have been described by their peers as ugly, stupid,
dishonest and lazy16 and they may experience teasing and social
isolation as a result.17
Such children are also at a greater risk of co-morbidities
than their lean counterpart. For example, children who are
overweight and obese are at a greater risk of asthma, and when
they have it they have been shown to use more medicine,18,19
wheeze more, have more unscheduled visits to the hospital18
and miss more school days as a result of asthma than their lean
asthmatic counterparts.19
In the short term, overweight and obese children are more
likely to develop certain gastrointestinal, cardiovascular,
161
endocrine and orthopedic problems than their lean peers that
may be exacerbated in the long term. Furthermore, overweight
and obese girls are more likely to develop reproductive system
abnormalities, such as early onset of puberty and menarche,
and polycystic ovary syndrome. 14,15, 20,21
In the long term, cardiovascular risk factor prevalence
increases greatly over time in overweight and obese children.
20, 22-24
Furthermore, a number of studies suggest that the mortality
rate in adulthood of subjects who were overweight or obese
during childhood and adolescence is increased. 25-28 In short,
remaining obese from childhood through adolescence and into
adulthood places the individual at a higher risk of associated
morbidities. 29-31
Need of the Study
Various studies have been done comparing the aerobic
fitness and body composition in children. In a study done to
assess the cardiorespiratory fitness of obese boys in West
Bengal, India, it was found that VO2max per kg of body mass
was significantly higher among non-obese boys. 32 A study on
Finnish children has shown that high cardiorespiratory fitness is
associated with lower overall and abdominal fat. 33 A study
conducted in Taiwan showed that the overweight/obese and unfit
children had a greater risk of hypertension than other children.
34
A study done on Greek primary schoolchildrens fitness levels
suggested that overweight and obesity are limiting factors for
fitness performance.35 A study on the relationship between
activity levels, aerobic fitness, and body fat in 8- to 10-yr-old
British children concluded that low fitness and increased body
fat were related. 36 A study among Portuguese children has
also shown the beneficial impact of low BMI values on
cardiorespiratory fitness. 37
All of the above studies suggest that as the body fat levels
increase, the fitness levels go down. However, some studies do
not suggest the same. In a study to compare variables of
metabolism, physical activity and fitness to body composition in
normal and overweight German children, no significant group
differences were found for submaximal VO2, as well as the fat-
free mass- or muscle mass-adjusted values for aerobic fitness.
38
A dearth of relevant literature on the issue pertaining to the
Indian scenario has been observed. Hence, this study was
designed to find out the cardiovascular fitness for Indian children,
and also, to find out the effect of obesity on the same. By doing
the study, promoting awareness on the issue of childhood
overweight and obesity was also achieved.
Aim
To evaluate cardiovascular fitness in children and to
compare it between normal and obese children.
Materials
A weighing scale certified by SGS to have an accuracy of +
1 kg, a 50 meter yard tape, a 5 feet measuring tape, a lap counter
and a stopwatch.
Methodology
This cross sectional study was conducted on children aged
between 9 to 11 years and studying at schools in Pune. After
obtaining permission from the Principals to proceed with the
study, informed consent of the parents was taken through the
children. The children were taken for the study during their
physical education classes. Out of the target population, 120
prepubescent boys in the age group of 9 to 11 years were
randomly selected and taken as the sample population. This
age group was selected to eliminate the influence of hormonal
162 Gaurang D Baxi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
and physiological changes on the body mass and body
composition which occur during puberty.
Children having any history of trauma, recent illness,
orthopedic or neurological injury or any medical condition which
has caused any permanent impairment in the normal anatomy
& physiology of the body were excluded. Girls were
excluded from the study. The height and weight were taken and
the body mass index (BMI) was calculated. According to their
BMI, they were classified as normal, overweight or obese.
The Cooper 12 minute run test (R=0.90) 39 was selected
for the study. 40 A lap of 100 meters was demarked in the school
ground. All possible obstacles on the running lap were removed,
so that the boys could get a clear path for running. The boys
were explained the procedure of the Cooper 12 minute run test.
They were instructed to cover the maximum distance they can
for twelve minutes, either by running and if they get tired, then
by walking. After a brief warm up, the Cooper 12 minute run test
was then conducted on the children. Then they were made to
run/walk as far as possible in 12 minutes in the school ground.
The number of laps run was noted. The distance covered to the
nearest 10 meters was taken. A cool down was then conducted.
Initially, the test was conducted by making 3 boys run at
the same time. But it was observed that this gave rise to a
competitive environment and the children tried to outrun each
other, tiring them early in the bargain. Due to this, they were
unable to complete the stipulated time of 12 minutes. To eliminate
this from happening, subsequently each boy was made to run
individually. As the run progressed, the children used to slow
down; they had to be constantly motivated to keep up the pace
and at least walk, if not run.
The VO2 max was calculated as follows using prediction
equation for the Cooper 12 minute run test. 40
VO2 max = (Distance covered in meters - 504.9) 44.73
The data of boys having a normal BMI was then compared
against those having a BMI falling into the overweight or obese
category. Correlation coefficients were found for the BMI,
distance run and the VO2 max for both the groups. Unpaired t-
test was used to compare the weight, height, BMI, distance run
and VO2 max of the boys between the two groups.
Data Analysis
Data analysis was done and the mean and standard
deviation of age, weight, height, BMI, distance run and VO2 max
were calculated for all the boys, and are shown in Table 1 below.
Discussion
This study examined the cardiovascular fitness in normal
BMI and overweight and obese BMI children 9 to 11 years of
age using VO2 max as the outcome measure.
Those children who had a normal BMI had much better
VO2 max compared to those who had an overweight and obese
BMI. As seen in table 1, the mean BMI and the mean VO2 max
of the normal BMI group boys was 20.63 1.35 and 36.94
3.53 mL.kg-1.min-1 while that of the overweight and obese group
boys was 27.71 1.72 and 24.43 1.82 ml.kg -1.min -1
respectively.
The 33.87% difference in the VO2 max between the two
groups was highly significant (p<0.001). The results are in
agreement with the previous studies by other researchers who
have also independently shown that overweight and obese
children have less cardiovascular fitness than their normal
counterparts. 32-35, 41 This difference between the two groups of
children is seen because peak VO2 is strongly related to body
size, with correlation coefficients describing its relationship with
body mass or stature typically exceeding r = 0.70. 42
The peak VO2 of boys in the age group of 8-18 years has
been shown to be ranging between 48-50 mL.Kg-1.min-1, while
for girls in the age group of 8-18 years, it ranges between 35-45
Table 1: Data of 102 subjects in two groups
Parameter Mean SD Unpaired t-test

t value p value

Age Normal 9.789 0.72 - -

Overweight / Obese 10.04 0.77

Weight Normal 34.44 6.236 11.043 0.0001

Overweight / Obese 46.84 4.7575

Height Normal 128.7 8.713 0.803 0.4326

Overweight / Obese 130 6.970

BMI Normal 20.635 1.3464 23.301 <0.0001

Overweight / Obese 27.71 1.722

Distance Normal 2157.89 158.08 21.592 <0.0001

Run
Overweight / Obese 1598 81.4

VO2 max Normal 36.94 3.53 21.589 <0.0001

Overweight / Obese 24.43 1.82

Fig. 1: Mean BMI Fig. 2: Mean VO2 max

Correlation Coefficient of BMI, Distance Run and VO2 max in the two groups.
Table 2: Correlation Coefficient of BMI, Distance Run and VO2 max in the two groups.

Correlation Coefficient (c)

Parameters
Normal BMI Overweight / Obese BMI

BMI and distance run -0.03 -0.85

distance run and VO2 max 0.999 0.999

BMI and VO2 max -0.0301 -0.85

Gaurang D Baxi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 163
mL.Kg-1.min-1. 42 However, in prepubescent girls and boys, there
is not a significant difference in peak oxygen consumption. The
differences emerge during and after puberty. 43 In boys less than
13 years of age, the VO2 max has been shown to be 42 6
mL.Kg-1.min-1 while for girls of 11 years or less, the VO2 max has
been shown to be 38 7 mL.Kg-1.min-1.
In this study, the mean VO2 of boys having normal BMI
was found to be 36.94 3.53 mL.kg-1.min-1. Thus the fitness
levels of the healthy BMI group children are just touching the
lower borderline of the recommended levels. This is suggestive
of low fitness. Again this is supported by a weak negative
correlation between the BMI and the Distance run and also
between the BMI and the VO2 max, as seen in table 1, in the
normal BMI children.
However, since these children are touching the lower
borderline of the recommended levels, its probable that these
are the fitness standards of the children in the western part of
India. The comparative figures are from the western countries
where there are differences in the body composition and
anthropometric measurements compared to children here.
These differences can lead to this deviation in the observed
standards of fitness.
The correlation coefficient between BMI, distance run and
the VO2 max within each group was calculated. As seen in table
2, a significant correlation was seen between BMI and the
distance run, BMI and the VO2 max and distance run and VO2
max in the overweight and obese BMI group.
In the obese and overweight children, the distance run and
their VO2 max are not only inversely related with the BMI, but
they correlate strongly with the BMI. This shows that as the BMI
increases, the distance run and the VO2 max decrease. Now,
we know that BMI is a function of height and weight. There was
a significant difference found in the weights of the two groups,
but no such significant difference was seen in the heights of the
two groups. This shows that the significant differences in the
values of BMI in the two groups were due to significant
differences in the weights of the subjects, and not due to their
heights. Thus, the significant negative correlation between BMI
and VO2 max is due to significant differences in the weights of
the subjects.
However in both the groups, there is a very strong positive
correlation between the distance run and the VO2 max, as seen
in table 2. Thus, the distance run and the VO2 max are directly
related, and show a very strong correlation. But this is due to
the fact that VO2 max is a direct function of the distance run,
and it is calculated from the distance run using a prediction
equation.
There were a few dropouts which need to be discussed
here. A total of 120 boys (60 in each group) were initially taken
for the study. 5 students from the normal BMI group and 113
from the overweight and obese BMI group dropped out within 5
to 7 minutes of starting the run. The all complained of tiredness
and fatigue after running for that small duration. Hence, they
were excluded from the data analysis.
However, from this, it can be inferred that those children
unfit not only from the cardiovascular point of view, but they
also had poor muscular endurance and they had decreased
overall fitness. This could be the probable reason for the dropout.
Also, the incidence of this was high in the overweight and obese
category.
Thus, from all of the above discussions, it is evident that
there is significant reduction in cardiovascular fitness in obese
Indian children compared to those who have a normal BMI. Also,
the overall fitness levels of Indian children are also not at par
with the standard desired levels.
Results and Conclusion
The mean BMI and the mean VO2 max of the normal BMI
group was 20.63 1.35 and 36.94 3.53 ml.kg -1.min -1
164 Gaurang D Baxi / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
respectively.
The mean BMI and the mean VO2 max of the overweight
and obese group children was 27.71 1.72 and 24.43 1.82
ml.kg-1.min-1 respectively.
The cardiovascular fitness levels of the overweight and
obese boys were 33.87% less than that of normal BMI boys.
The boys having a normal BMI also do not have adequate
fitness levels.
Recommendations
All children should be encouraged to be physically active.
Physical activity opportunities may be a part of play, school
physical education, sport, games, active transport (for example
walking and cycling to school), recreation and planned exercise.
Activities may be undertaken in the context of the family, school
and wider community setting.
Children should engage in physical activity of at least
moderate intensity for 60 minutes each day. Minimum
recommendations suggest 60 minutes of physical activity at least
3 times a week. 44, 45
Children should avoid extended periods of inactivity. This
includes sedentary behaviors such as watching television,
videos, playing computer games and surfing the internet.
Compulsory physical education programs should be
implemented in schools. Special programs should be directed
towards overweight and obese children. The school should
provide counseling for students and parents about the harmful
effects of obesity, and the importance of fitness. Diet counseling
for the parents of obese children should be done. Schools should
regularly organize sports meets, physical education sessions
and promote extracurricular sports. Schools can take advantage
of these sports meets to promote an active lifestyle for children,
either through modeling by school teachers, peers and coaches
or by trained students to acquire positive knowledge and attitudes
about physical activity and sport and activity skills to keep healthy.
Facilities like playgrounds, open squares, and sports clubs
should be made available in the community, so that children
can make use of them. In todays world where automobiles
dominate transport on the roads, there is a lack of safe and
convenient pedestrian paths and bicycle trails. Providing these
in the civic infrastructure will help promote a healthy active
lifestyle.
To summate, parental involvement in exercise with children,
school curriculum, neighborhood safety concerns and the
availability of recreational facilities are a few of the factors which
need to be addressed in order to promote physical activity in
children and to reduce the prevalence of childhood obesity.
Last, but not the least, further studies needs to be undertaken
for formulating the standard values for fitness for Indian children.
Studies done in a lab setting are more accurate in terms of
predicting the cardiovascular fitness levels as compared to field
tests. For children, to measure body composition, skinfolds and
circumferences, and bioelectrical impedance analysis (BIA)
should be preferred over BMI due to the drawback of using BMI
in this age group.
Limitations of the Study
1. Sample size was relatively small.
2. Field test was used to predict the cardiovascular fitness.
3. Results were based on the motivation of the children to
continue running.
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Test Retest Reliability and Validity of Hindi Version of Neck
Disability Index in Patients with Neck Pain
Halima Shakil*, Sohrab A Khan**, Puja C Thakur***
*Postgraduate Student, Physiotherapy (Orthopedics) Hamdard University, New Delhi, **Assistant Professor, Jamia Hamdard, New
Delhi, ***Physiotherapist AIIMS, New Delhi
Abstract
Study Design
Non-Experimental Methodological design.
Objectives
To translate and culturally adapt the Hindi version of Neck
Disability Index and check its test retest reliability and validity
in patients with neck pain.
Summary of Background Data
The NDI is one of the most widely used reliable and valid
instrument for assessing functional disabilities in NP patients.
However, no reliable and valid tool is available in Hindi
language.
Methods
The study was carried out in three phases: the first was
translation into Hindi and cultural adaptation of the
questionnaire, the second was a pilot study to assess the
comprehensibility of the pre final version; third was the reliability
and validity study of the final version of the questionnaire. The
Hindi version was tested on 150 patients with neck pain. Test
retest reliability and internal consistency were investigated.
Results
Test retest reliability was assessed with 150 patients with
a time interval of 48 hours. The intra class correlation coefficient
of test retest reliability was 0.98 with all items having individual
ICC scores ranging from 0.868 to 0. 986. Reliability estimated
by the internal consistency reached a Cronbachs alpha of
0.995. The NDI subscales showed excellent test retest reliability
with Cronbachs alpha ranging from 0.929 to 0.993.The
Wilcoxon non parametric test was done for chance error which
was negligible for almost all items.
Conclusion
The results of this study indicate that the Hindi version of
the NDI is a reliable and valid tool for measuring disability
caused due to neck pain in Hindi speaking Indian population.
The authors recommend this Hindi version of the NDI for use
in further future clinical studies in India.
Key Words
Neck disability index, reliability, validity.
Neck Pain (NP) is one of the major complaints among the
cervical spine disorders and is a common complaint among most
communities. It is highly prevalent and experienced health
problem facing the work place and health care communities1. It
is the second most common regional pain syndrome next to
Halima Shakil / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
back ache and is also an important occupational related problem.
The increased frequency of neck pain and its impact on
functioning including work performance makes this an important
health issue for the individual the employer, the health care
sector and the society at large 2
To our knowledge, 5 questionnaires measuring disability
on a patients life due to neck pain have been developed and
validated3
Neck disability Index (NDI)
Neck Pain and Disability Scale (NPDS)
The Northwick Park Neck Pain Questionnaire
The Copenhagen Neck Functional Disability Scale
The Patient-Specific Functional scale
The Neck Disability Index is the most commonly used
questionnaire assessing disability in patients with neck pain. It
is a self-administered questionnaire that was adapted from the
Oswestry Disability Index by Vernon et al at 1991.4 It was the
first instrument designed to assess self-rated disability in
patients with neck pain.
The Neck Disability Index is a relatively short, paper-pencil
instrument that is easy to apply in both clinical and research
settings. It has strong psychometric characteristics and has
proven to be highly responsive in clinical trials. As of late 2007,
it has been used in approximately 300 publications; it has been
translated into many languages, and it is endorsed for use by
a number of clinical guidelines.5
The Neck Disability Index has already been translated into
Dutch 6, Brazilian7, Greek 8, Spanish 9, Turkish10, Korean 11,
French, Finnish 12 and Iranian 13 and used in a number of
research studies. Reliability and validity of the NDI has been
reported in previous studies. It has been revalidated in several
study population and has shown stable psychometric properties
[4]
However, till date no Hindi version of Neck Disability Index
has been developed. These reasons in addition to the lack of
a standard reliable and valid instrument in Hindi for measuring
disability in neck pain, led us to prepare and test the reliability
and validity of the Hindi translation of neck disability index
among Hindi speaking Indian patients with neck pain.
Methods
The study was carried out in three phases: the first was
translation into Hindi and cultural adaptation of the
questionnaire; the second was a pilot study to assess the
comprehensibility of the pre final version; third was the reliability
and validity study of the final version of the questionnaire.
Translation and Cultural Adaptation
For the translation we used the recent guidelines for cross
cultural adaptation.[7] Two translations of the original Neck
Disability Index from English to Hindi were performed by two
bilingual translators whose mother tongue is Hindi, allowing
detection of errors and divergent interpretations of items with
ambiguous meaning in the original instrument. The first
translation was done by a translator of medical background (at
a private clinic in jafarabad) who was aware of the process and
purpose. The other translation was done by a nave translator
from non medical background (at the Supreme court of India).
167
He was unaware of the translation objectives and this was useful group comprised of 61 males and 87 females. Reliability
in eliciting unexpected meanings from the original tool. Both the estimated by the internal consistency reached a Cronbachs
Hindi translations were then compared for inconsistencies and alpha of 0.995. The test retest reliability was assessed on two
a pre final version of the two translations was synthesized occasions separated by a time interval of 48 hours. The intra
working from the original questionnaire as well as the first and class correlation coefficient of test retest reliability was 0.990.
second translators versions. The pre final version was then back
translated by two nave English speakers who were able to read
and understand Hindi. Each translation was then compared with
the original English neck disability index and checked for Table 2: ICC and test retest reliability of all items of the NDI,
inconsistencies. total score and disability.
The Hindi version was then reviewed by the expert Item ICC Cronbachs alpha
committee, including the translators, physiotherapists etc. to
assure semantic and idiomatic equivalence (i.e. to check for Pi-RPi 0.978 0.996
ambiguous words or inappropriately translated colloquialisms)
and to address any peculiarities specific to the cultures Pc-RPc 0.977 0.996
examined between the Hindi and English versions of the
questionnaire. This was done to fine tune it for use among Lt-RLt 0.986 0.988
Hindi speaking Indian patients. The committee members also
compared the Hindi version with the original English version Rd-RRd 0.975 0.993
to detect errors of interpretation and nuances that might have
been missed. The final stage of the adaptation process was Had-RHad 0.968 0.987
the test of the pre final version.
Ctn-RCtn 0.978 0.984
Pilot Study and Modification of the Pre Final
Wk-RWk 0.982 0.989
Version
The answer to an item may appear adequate yet can be Drvg-RDrvg 0.979 0.991
consistently misunderstood. So, to check for any errors in
interpretation, a pilot study was done on a sample of 30 patients. Slpg-RSlpg 0.980 0.989
The patients were selected on the basis if inclusion and
exclusion criteria. The patients were asked to fill the Recn-RRecn 0.868 0.990
questionnaire. later, they were asked to give feedback and
comments regarding the questions and identify words or TSc-RTSc 0.990 0.929
sentences that were difficult to understand at the end of filling
of the questionnaire. on the basis of their reviews the final D-RD 0.990 0.995
version of the index was developed which was again checked
and approved by the committee. Discussion
Patient oriented assessment methods are of paramount
Reliability and Validity Study
importance in the evaluation of treatment outcome. The Neck
The study was carried out at the physiotherapy department Disability Index is one of the condition specific scales
of the ESI hospital Okhla New Delhi, Hindurao Hospital, New recommended for use with neck pain patients. It is short, easily
Delhi and various other hospitals. The study included 150 comprehended and simple to complete.
patients with neck pain on the basis of inclusion exclusion Neck pain studies in India lacked a reliable and valid
criteria. Each patient was asked to fill the NDI questionnaire assessment instrument. So, the purpose of the study was to
twice with a time interval of 48 hours. On their first day in develop and cross culturally adapt a Hindi version of the NDI
physiotherapy department, the patient was assessed and NDI and to test retest its reliability and validity for its use in Hindi
was administered. The second administration was given after speaking Indian patients with neck pain.
48 hours in order to assess test retest reliability of the The process of translation and cross cultural adaptation of
questionnaire. the NDI into Hindi was done in an attempt to produce a reliable
The test retest reliability measures stability over time, by and valid adaptation of the questionnaire that would show an
administering the same test to the same subjects at two points agreement with the original English version of the scale.
in time. It was measured by comparing the results of first and For the vast majority of questions in the NDI, dealing with
second administrations of the NDI. We used intra class simple activities and participation, no doubt seems warranted
correlation coefficient (ICC) to evaluate test retest reliability. about their meaning in either language. So, the translating the
The internal consistency of a scale relates to its homogeneity original English version into Hindi did not present any problem.
and hence, Cronbachs alpha was used to evaluate the same. Moreover, at the end of the pre final version, the Hindi version
Face and content validity (item relevance and adequacy did not require any vast changes. The patients were able to
for intended use) was judged by health professionals. It was complete the questionnaire easily concluding that the
also assessed by examining the completeness of item questionnaire was easily comprehensible to the Hindi speaking
responses, the distribution of the scores and magnitude of Indian population. In addition, the ease of developing translated
ceiling and floor effects i.e. a proportion of the best and worst and culturally adapted versions that are as reliable as the original
possible scores, respectively. scale is a factor to be taken into account for considering a scale
Criterion and construct validity could not be tested due to as an international standard.
absence of a standard Hindi language disability measure for Face validity is concerned with whether a measurement
cervical spine. seems to be assessing the intended parameters in the given
situation. In this study, translation of the questionnaire seemed
to be valid and the instrument was well accepted by the patients
Results as well as approved by the committee comprising of translators,
The study enrolled 150 patients with neck pain. The mean physiotherapists etc. The layout of the questionnaire and clear
age of patients was calculated as 35.12 + 11.52SD. The study
168 Halima Shakil / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
structure and clarity of the questions enhanced its face validity.
The internal consistency of the NDI was examined using
Cronbachs alpha, an item correlation test that reflect the
homogeneity of all items. The alpha coefficients were calculated
of 150 subjects resulting in total index alpha of 0.995 with all
items having individual alpha scores above 0.8 indicating high
internal consistency.
Owing to a coefficient of the Cronbachs alpha of 0.995,
which even exceeds the score of English version of NDI (0.89),
levels of reliability were slightly higher than those found
elsewhere. For example, Cronbachs alpha was found to be 0.94,
0.88 and 0.85 by Andrade Ortega et al,9 Mousavi Sayed et al13 ,
Marianna Howard8 et al respectively.
Internal consistency of the NDI-H was acceptable,
according to recommended standards.
The NDI is a simple and rapid scale that is quite easy to
use. In this respect, ICC of 0.990 is an excellent measure of
reliability indicating high correlations between the baseline and
retest questionnaires of the Hindi version of the NDI representing
a very high level of test retest reliability, allowing for its clinical
use. This result is in concordance with Portney and Watkins
who claim that, for most clinical measurements, reliability should
exceed 0.90 to ensure reasonable validity.
Both the reliability scores measured in the NDI-Hindi show
that the translated version is reliable with a low standard error
of measurement. In the present study, the retest questionnaire
had been administered approximately after 48 hours. Mousavi
Sayed et al13 found similar scores for the 24 hour interval and
suggested that testing of reliability was done within a short time
interval to minimize changes in the clinical status of patient. Our
results show the high agreement between measurements
recorded on 2 occasions over a 48-hour period. The value of
ICC in our study was more than the original English version of
NDI. One reason for this difference could be the long time interval
between the baseline and retest administration of the
questionnaires by the original authors in their study. It is seen
that ICC values decrease with the increase in the time interval
between the two administrations of the questionnaire. In the
studies of Salo P;Yelinen J and Marianna5,9 it was seen that the
ICC values decreased in the retest scores as the test retest
interval was extended to 7 days. Such an observation could be
because of the natural change in the physical and health status
of the individual.
According to statistical analysis of this study, this Hindi
version of the Neck Disability Index showed similar results to
those presented in the original English version of the Neck
Disability Index as well as in other versions of 7 different
languages. 7-13
To our knowledge, this Hindi version of the NDI is the first
condition specific outcome instrument for NP to have been
validated in Hindi. Development and validation of multiple-
language versions of existing validated questionnaires plays a
key role in standardizing the outcome measurement and
increasing the statistical power of clinical studies. Our results
demonstrate that the NDI was successfully, cross culturally
translated into Hindi and at the same time retains its properties
of the original version, thereby standardizing the outcome
measurement further. Thus, it is concluded that this Hindi version
of NDI is a reliable and valid tool for assessment of functional
status in patients with neck pain.
Since this Hindi version of the NDI represents a valuable
Halima Shakil / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
instrument for assessing functional limitations in patients with
neck pain in Hindi speaking Indian population, it can be
recommended in future clinical studies and research in India.
Overall, NDI is easy to conceive and quick to complete. It allows
the patients with neck pain to grade their activities and limitations
in an accurate manner. Because of its easy scoring, high
sensitivity towards change and wide acceptance by the patients,
the NDI Hindi can be recommended for clinical trials in
investigating the effectiveness of the therapeutic interventions
the patients is undergoing in clinical set ups.
References
1. Shappert S.M.: National Ambulatory Medical Care Survey:
Summary Advance Data from Vital and Health Statistics,
no. 273, Hyatts Ville, MD; National Centre for Health
Statistics, 1996.
2. Rand S Swenson: Therapeutic modalities in the
management of nonspecific neck pain: Physical Medicine
and Rehabilitation Clinics of North America: 14(2003) 605-
627.
3. Ricardo and Richardson: Standard scales for measurement
of functional outcome for cervical pain or dysfunction a
systematic review: Vol.27 (5), Spine Journal, 1 march 2002;
515-522.
4. Vernon H, Mior S: The NDI-a study of reliability and validity:
Journal of Manipulative Physiotherapy 1991 Sep;
14(7):409-15.
5. Howard Vernon DC Phd: The Neck Disability index: State-
of-the-Art, 1991-2008
Journal of Manipulative Physiological Therapeutics 2008
September, 31(7): 491-502.
6. Cees J. Vos et al: Reliability and responsiveness of Dutch
version of NDI in patients with acute neck pain in general
practice: European Spine Journal 2006 15:1729-1736; 3
May.
7. Cook, Richardson et.al: Cross cultural adaptation and
validation of Brazilian Portuguese version of NDI and NPDS:
Vol 31(14), Spine Journal; 15 June 2006.1621-1627.
8. Marianna, Howard et al: Translation of NDI and validation
of Greek version in a sample of neck pain patients: BioMed
Central Musculoskeletal Disorders: 22 July 2008.
9. Andrade Ortega JA, Delgado Martnez AD, Almcija Ruiz
R: Validation of a Spanish version of the Neck Disability
Index: Med Clin (Barc). 2008 Feb 2; 130(3):85-9.
10. Aslan, Arianne et al: The cultural adaptation-reliability and
validity of NDI in patients with neck pain- a Turkish version
study: vol33 (11), Spine Journal;15 may 2008-E362-E365.
11. Kyung-Jin Song, Byung-Wan Choi, Sul-Jeon Kim, and Sun-
Jung Yoon: Cross-Cultural Adaptation and Validation of the
Korean Version of the Neck Disability Index: Journal of
Korean Orthopedic Association 2009; 44: 350-359.
12. Salo, Petri; Ylinen, Jari; Kautiainen, Hannu; Arkela-
Kautiainen, Marja; Hkkinen, Arja: Reliability and Validity
of the Finnish Version of the Neck Disability Index and the
Modified Neck Pain and Disability Scale: Spine: 1 March
2010 - Volume 35 - Issue 5 - pp 552-556.
13. Mousavi, Sayed et al.: Translation and validation study of
Iranian version of NDI and NPDS: vol 32(26), Spine Journal;
15 Dec2007 E825-E831.
14. portney and Watkins-
169
Effect of Ankle Foot Orthosis on Plantar-flexor Tone and Gross Motor
Functional Abilities in Children with Hemiplegic Cerebral Palsy
Meenakshi Batra1, Vijai Prakash Sharma2, Vijay Batra3, Gyanendra Kumar Malik4, Girdhar Gopal Agarwal5
1
PhD Scholar, 2Director Professor & Head, 3Senior Research Fellow, 4Professor & Head of Pediatrics, Department of PMR, RALC,
Department of Physical Medicine and Rehabilitation, Rehabilitation and Artificial Limb Centre (RALC), Nabiullah Road, Near Daliganj
Bridge, Chhatrapati Shahuji Maharaj Medical University, Lucknow- 226018, Uttar Pradesh, India, 5Professor, Department of Statistics,
Lucknow university, Lucknow-226007
Abstract
Objective
To see the effectiveness of Ankle Foot Orthosis on plantar-
flexor tone and gross motor functional abilities in children with
hemiplegic cerebral palsy
Method
A total of 30 subjects coming to OPD, Dept of Physical
Medicine and Rehabilitation and Paediatrics with a diagnosis of
hemiplegic cerebral palsy were included and baseline evaluation
was done for tone in ankle and lower extremity (using MAS)
and gross motor functional abilities (using GMFM-66). The
subjects were allocated equally among group A and group B by
convenient sampling scheme with 15 subjects each. In group
A, Ankle Foot orthosis (AFO) along with conventional therapy
and in group B, conventional treatment with no Ankle Foot
orthosis were used for a period of 3 months followed by re-
evaluation. Result: The two groups were compared for their
scores. These were found to be statistically significant with p
value ranging from .003 to < .0001. Conclusions: It can be
concluded that Ankle Foot orthosis (AFO) helps in normalizing
the tone in ankle (plantar-flexors) and lower extremity and can
be used as an adjunct to the treatment / therapeutic process to
enhance gross motor functional abilities in hemiplegic cerebral
palsy children.
Key Words
Cerebral Palsy; Tone; Ankle foot orthosis; Postural reaction;
Postural control; Gross motor functional abilities.
Introduction
The Cerebral palsy is mainly a motor disorder8, 12-13 generally
classified based on muscle tone or the area of distribution. Based
on muscle tone it can be spastic, athetoid, ataxic or mixed type
while depending on area of distribution it can be hemiplegic
(Involvement of upper and lower extremity of one side of body),
diplegic (upper extremity involved more than lower extremity),
quadriplegic (involvement of all the four limbs including trunk,
neck and face), triplegic (involvement of both lower extremities
and either of one upper extremity) or monoplegic (involvement
Address for correspondence:
Meenakshi Batra
PhD Scholar
Chhatrapati Shahuji Maharaj Medical University (Erstwhile King
George Medical College and University), Department of Physical
Medicine and Rehabilitation, Rehabilitation and Artificial Limb
Centre (RALC), Nabiullah Road, Near Daliganj Bridge, Lucknow-
226018, Uttar Pradesh, India
Telephone: +919868038335, +919868019077, +91-11-
25280121
Fax: +91-522-2611091
Email: minaxibatra@yahoo.com, meenakshibatras@gmail.com
170 Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol. 5, No. 3
of one side of body).
Cerebral palsy is primarily a group of developmental
disorders of movement and posture12-13, dominated by persistent
primitive and pathological reflexes, muscle weakness, poor
selective motor control, abnormal motor sequences and
synergies8, and postural reaction deficits3 causing activity
restrictions or disability that is attributed to disturbances occurring
in the fetal or infant brain. These primary characteristics often
lead to structural deficits (such as bony deformities, muscle
contractures), as well as functional deficits (such as postural
and gait abnormalities; gross and fine motor functional abilities;
and delayed motor milestones).
The beginning of motor development is found in reflexive
movement. The reflexes are integrated to allow normal motor
development during child maturity. When the primitive reflexes
disappear, developmental / Postural reactions emerge3, 7- 9. The
Postural reactions are important for regulation of posture,
establishment and maintenance of upright position, and the
orientation of the body and its parts in space. Development of
postural control facilitates blending of mobility and stability
patterns and also provides an insight into the motor potential of
children with CP7- 9.
In hemiplegic cerebral palsy children one side of upper and
lower extremity is affected and is mainly characterised by tonal,
postural and gait abnormalities, motor dysfunction and impaired
postural control2, 3, 5, 9, 10 resulting in poor gross motor functional
performance and abilities; and delayed acquisition of motor
milestones.
The Clinical presentation of a hemiplegic Cerebral palsy
(CP) child is mainly characterized by persistent unwanted
primitive reflexes, hyperreflexia, clonus, increased muscle tone
primarily in ankle plantar flexors, abnormal muscle synergies,
postural asymmetry, postural reaction deficits cicumductory gait,
toe walking, contractures, delayed developmental milestones.
The intervention mainly aims at normalizing muscle tone,
correcting postural and gait abnormalities, and improving gross
motor functional abilities via positioning, stretching, active and
passive exercises and activities, weight bearing and weight
shifting in developmental positions, use of orthotic aids and
appliances1, 6, 11, 14 such as ankle foot orthosis etc.
Ankle-foot orthoses (AFOs) are commonly used in
hemiplegic cerebral palsy children. They control the ankle
directly, and can be designed to control the knee joint indirectly
as well. AFOs provide support to weak and spastic muscle, and
position the limb (with tight and contracted muscles) into a more
normal position. The AFO is mainly intended to normalize muscle
tone, maintain proper alignment, increase range of motion,
stabilize ankle joint, control position and motion of the ankle,
prevent deformity, correct / modify base of support, facilitate
training in skills, improve the efficiency of gait, minimize gait
abnormalities, optimize foot to ground contact and dynamics of
walking1, 4, 6, 11, 14. But the utility of AFO is still a matter of debate.
Some studies have reported the improvement in gait
characteristics11 in terms of increased stride length, decreased
cadence, and reduced excessive ankle plantar flexion with AFO
while others reported no improvement14 in static foot alignment
in the majority of feet in children with cerebral palsy who were
able to walk. Similarly a study on effect of ankle-foot orthoses
on walking efficiency and gait in children with cerebral palsy4
concluded that the use of an ankle-foot orthosis resulted in a
significant decrease in the energy cost of walking of quadriplegic
children with cerebral palsy, compared with barefoot walking,
whereas it remained unchanged in hemiplegic and diplegic
children with cerebral palsy.
The prescriptions of ankle foot orthosis is still a controversial
issue and there are mixed opinions from researchers of various
fields; hence the study was conducted with a primary research
question to see the effect of Ankle Foot orthosis on plantar-
flexor tone and its implication over gross motor functional abilities
in hemiplegic cerebral palsy children.
Methodology
30 Cerebral palsy children coming to the Department of
Physical Medicine and rehabilitation (PMR), and Department of
Paediatrics of Chhatrapati Shahuji Maharaj Medical University
(Formerly King George Medical College) Lucknow were
included. This was the experimental research study and
convenient sampling was done. The informed consent was
obtained from the parents /guardians of the child. The spastic
hemiplegic cerebral palsy children of age range 2 to 7 years
were included while the children with contracture or fixed
deformity, severe and profound mental retardation and diagnosis
other than Spastic hemiplegic cerebral palsy were excluded from
the study.
The baseline evaluation was done for tone in ankle, tone
in lower extremity and gross motor functional abilities. Tone was
assessed using Modified Ashworth Score (Annexure A) while
gross motor functional abilities were assessed using Gross Motor
Function Measure (GMFM-66) and. Tone score for ankle and
Total tone score(Lower extremiy) in percentile was calculated
(Insert Table 1 Showing calculation of percentile Tone score for
Ankle and Lower extremity). Convenient sampling was done
and the subjects were allocated into two groups i.e. group A
and group B with 15 subjects each. The children were matched
on age, sex, tone and gross motor functional level (GMFCS
levels). With children in group A, Ankle Foot orthosis (AFO) was
used along with conventional therapy. The parents were asked
to make the child wear Ankle Foot orthosis (AFO) for 6-8 hours
per day with intermittent rest intervals. With group B conventional
treatment with no Ankle Foot orthosis (AFO) was used. The
intervention was given for 3 months and re-evaluation was done.
Both Between and within group analysis was done using Mann
Whitney U test and Wilcoxon sign rank test.
Table 1: Showing calculation of percentile Tone score for Ankle
and Lower extremity
Spasticity Code Tone score Total Tone
(MAS grades) Score
0 0
1 1
1+ 2
2 3
3 4
4 5
Statistical Analysis
Between Group Comparison
The two groups were compared with each other for their
difference of scores (pre-intervention and post-intervention) for
tone in ankle and lower extremity (on Modified Ashworth Score),
Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol. 5, No. 3
and gross motor functional abilities [on Gross Motor Function
Measure (GMFM-66)] using nonparametric Mann Whitney U test.
Nonparametric test was used because sample size was small,
distributions were skewed and scoring was done on ordinal
scale. For each variable, Median and Inter-quartile range was
calculated. Most of these scores were statistically significant
with p value ranging from .003 to < .0001. The Median and
Interquartile range of group A at baseline for tone in Ankle, tone
in Lower extremity (Total tone score) and Gross motor functional
abilities [GMFM (total score)] were (30.0 & 10.0); (20.0 & 6.67);
and (48.57 & 20.52) while for group B they were (20.0 & 10.0);
(20.0 & 3.33); and (46.29 & 20.54) respectively. The Median
and Interquartile range of group A for tone in Ankle, tone in Lower
extremity (Total tone score) and Gross motor functional abilities
[GMFM (total score)] after 3 months of intervention were (10.0
& 10.0); (6.67 & 6.67); and (83.40 & 30.47) while for group B
they were (20.0 & 0.0); (15.56 & 4.44); and (53.31 & 18.97)
respectively. [Insert Table 2 Comparison between two groups
i.e. Group A and Group B (Pre and post-intervention) here]
Within Group Comparison for Group A
Subjects within each group were compared on the pre-
intervention and post-intervention scores for tone in Ankle, tone
in Lower extremity (on Modified Ashworth Score), and Gross
motor functional abilities [on Gross Motor Function Measure
(GMFM-66)] using Wilcoxon sign rank test to see the
effectiveness of each intervention. For group A, p value was
found to be very significant with value < .0001. The Median and
Interquartile range at baseline for tone in Ankle, tone in Lower
extremity (Total tone score) and Gross motor functional abilities
[GMFM (total score)] were (25.0 & 10.0); (20.56 & 3.61); and
(46.29 & 19.89) respectively and after 3 months of intervention
they were (20.0 & 10.0); (14.44 & 11.39); and (61.87 & 33.84)
respectively. [Insert Table 3 Comparison of scores within Group
A (Pre and post-intervention) here]
Within Group Comparison for group B
Subjects within each group were compared on the pre-
intervention and post-intervention scores for tone in Ankle, tone
in Lower extremity (on Modified Ashworth Score), and Gross
motor functional abilities [on Gross Motor Function Measure
(GMFM-66)] using Wilcoxon sign rank test to see the
effectiveness of each intervention. For group B, p value was
found to be very significant with value ranging from 0.025 to <
.0001. The Median and Interquartile range of group B at baseline
for tone in Ankle, tone in Lower extremity (Total tone score) and
Gross motor functional abilities [GMFM (total score)] were (20.0
& 10.0); (21.11 & 3.33); and (46.29 & 20.54) respectively and
after 3 months of intervention they were (20.0 & 0.0); (17.78 &
4.44); and (53.31 & 18.97) respectively. [Insert Table 4
Comparison of scores within Group B (Pre and post-intervention)
here]
Result
Although both the Intervention groups i.e. group A and group
B were found to be effective in hemiplegic cerebral palsy children
for most of the variables, but subjects in Group A showed better
results than Group B. There was significant change in group A
than group B (Table 2) It was observed that the muscle tone at
ankle and lower extremity was normalized more in group A I
than group B. Also better improvement in gross motor functional
abilities was observed in group A than group B [Insert Table 3:
Comparison of scores within Group A (Pre and post-intervention)
and Table 4 Comparison within Group B (Pre and post-
intervention) here]
171
Table 2: Comparison between two groups (Group A and Group B) (Pre and post-intervention)
Variable Difference of Scores Z P Value
Group A Group B
Median I Q range Median I Q range

GMFM (Component)
I Baseline 70.59 13.73 70.59 13.72 -.439 0.661
Final 94.12 9.8 38.46 13.72 -2.981 .003

II Baseline 63.33 15.00 58.33 16.66 -.813 0.416

Final 93.33 16.67 84.31 7.14 -2.645 .008

III Baseline 38.10 23.81 40.48 21.43 -.209 0.834

Final 85.71 30.96 52.38 7.69 -3.429 .001

IV Baseline 43.59 38.47 22.22 32.9 -.957 0.338

Final 89.74 46.15 48.72 25.64 -2.785 .005

V Baseline 23.61 19.44 70.0 20.84 -.312 0.755

Final 43.06 51.39 27.78 18.05 -3.017 .003

GMFM (Total Score)

Baseline 48.57 20.52 46.29 20.54 -.249 0.803
Final 83.40 30.47 53.31 18.97 -2.967 .003
Tone
Hip Baseline 20.0 10.0 16.67 3.33 -.453 0.651
Final 6.67 10.0 16.67 3.34 -3.976 <.0001

Knee Baseline 20.0 0.00 20.0 10.0 -.334 .739

Final 10.0 10.0 10.0 10.0 -4.015 <.0001

Ankle Baseline 30.0 10.0 20.0 10.0 -.484 0.629

Final 10.0 10.0 20.0 0.00 -4.472 <.0001

Tone score Baseline 20.0 6.67 20.0 3.33 -.231 .817

Final 6.67 6.67 15.56 4.44 -4.551 <.0001
I Q range = Inter-quartile range,
Tone score = Sum total of all the tone Scores of hip, knee and ankle

Discussion
From the analysis of result it was found that the application
of an AFO helps in normalizing muscle tone at ankle thereby
improving stability. The orthosis (AFO) was prescribed with a
goal of normalizing plantar flexors muscle tone and preventing
or correcting contractures. Although AFO can impose additional
activity limitations by restricting movement but they were found
more beneficial for the cerebral palsy children.
The contractures and deformities are generally caused by
relative shortening of muscles and soft tissues. These mobile
joint deformities are caused by gravity or unbalanced muscle
forces which can be corrected by positioning the ankle in normal
anatomical alignment using AFO. Ensuring that muscles spend
4 to 6 hours per day in an elongated position may help to prevent
or reduce the rate of progressive contractures . However,
stretching muscles using active forces for shorter periods may
be effective for maintaining a static position to increase muscle
length and hence the available range of motion at joints 1, 6, 11, 14.
The subjects in group A were having additional advantage over
group B in terms of ensured positioning of limb with the muscles
spending almost 4 to 6 hours per day in an elongated position
along with the conventional therapy.
Moreover, stability in any of these positions i.e. lying, sitting,
or standing requires consideration of both intrinsic and extrinsic
factors. Intrinsic stability involves controlling the position of the
center of mass within the body. Extrinsic stability involves
maintaining the center of mass within the supporting area. The
AFO improves stability by increasing the size of the support
area. It also maintains the optimum biomechanical alignment of
body segments encased within the orthosis. These effects may
enable children to overcome activity limitations by focusing
training on unrestricted parts of their bodies over which they
have better control1, 4, 6, 11, 14. AFO also influences external
movements acting around proximal joints by altering the line of
action of the ground reaction force during standing and walking.
Hence the children in group A with whom Ankle Foot orthosis
(AFO) was used showed better results.
Conclusion
Ankle Foot orthosis (AFO) helps in normalizing the tone in
ankle (plantar-flexors) and lower extremity and can be used as
an adjunct to the treatment / therapeutic process to enhance
gross motor functional abilities in hemiplegic cerebral palsy
children.
Acknowledgement
We are thankful to our Patients and their family members
for their kind cooperation.
Declaration of Interest
The authors report no conflicts of interest.
References
1. Abel, M. F., Juhl, G. A., Vaughan, C. L. & Damiano, D. L.
(1998). Gait assessment of fixed ankle-foot orthoses in

172 Meenakshi Batra / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 3: Comparison within Group A (Pre and post-intervention)
Variable Difference of Scores Z P Value
Before After
Median I Q range Median I Q range

GMFM (Component)
I 70.59 12.75 87.25 18.14 -4.79 <.0001

II 62.5 15.00 81.66 27.5 -4.77 <.0001

III 39.29 22.03 59.52 38.69 -4.79 <.0001

IV 39.74 35.90 55.13 48.07 -4.79 <.0001

V 22.92 19.80 29.86 43.06 -4.71 <.0001

GMFM (Total Score) 46.29 19.89 61.87 33.84 -4.78 <.0001

Tone
Hip 18.33 3.33 11.67 10.0 -4.61 <.0001

Knee 20.0 2.5 10.0 10.0 -4.25 <.0001

Ankle 25.0 10.0 20.0 10.0 -3.90 <.0001

Tone score 20.56 3.61 14.44 11.39 -4.55 <.0001

I Q range = Inter-quartile range,

Tone score = Sum total of all the tone Scores of hip, knee and ankle

Table 4: Comparison within Group B (Pre and post-intervention)

Variable Difference of Scores Z P Value

Before After
Median I Q range Median I Q range

GMFM (Component)
I 70.59 13.73 84.31 13.72 -3.42 0.001

II 58.33 16.66 70.00 16.67 -3.37 0.001

III 40.48 21.43 52.38 23.81 -3.42 0.001

IV 38.46 35.90 48.72 25.64 -3.42 0.001

V 22.22 20.84 27.78 18.05 -3.32 0.001

GMFM (Total Score) 46.29 20.54 53.31 18.97 -3.41 0.001

Tone
Hip 16.67 3.33 16.67 3.34 -3.36 0.001

Knee 20.0 10.00 20.00 10.00 -2.53 0.011

Ankle 20.00 10.00 20.0 0.00 -2.24 0.025

Tone score 21.11 3.33 17.78 4.44 -3.10 0.002

I Q range = Inter-quartile range,

Tone score = Sum total of all the tone Scores of hip, knee and ankle
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E. (1997). A comparison of gait with solid, dynamic, and no
ankle-foot orthoses in children with spastic cerebral palsy.
Physical Therapy, 77(4), 395-409.
12. S. Ashwal., Russman B. S., Blasco P.A., Miller G., Sandler
A. Shevell M. et al (2004). Practice parameter: Diagnostic
assessment of the child with Cerebral Palsy. Neurology
(American Academy of Neurology), 62(3): 851-863.
13. Sankar Chitra and Mundkur Nandini (2005). Cerebral Palsy
definition, Classification, etiology and early diagnosis; Indian
Journal of Pediatrics, 72 (10): 865-868.
14. Westberry, D. E., Davids, J. R., Shaver, J. C., Tanner, S.
L., Blackhurst, D. W. & Davis, R. B. (2007). Impact of ankle-
foot orthoses on static foot alignment in children with
cerebral palsy. The Journal of Bone and Joint Surgery.
American Volume, 89(4), 806-13.]
Normative Data of Evaluation Tool of Children Handwriting
Manuscript (ETCH-M)
Ganapathy Sankar U*, R Riya**
*Vice Principal, **Occupational Therapist, SRM College of Occupational Therapy, Kancheepuram, Tamil Nadu
Abstract
Objective
The purpose of this study was to establish normative data
of Evaluation Tool for Children Handwriting (ETCH-M) for
Chennai children.
Method
Six hundred (n= 600) children, aged 6 to 10 years (mean
age = 7.55 years 1.11 years) were included through
convenience sampling from normal school located in the North
Chennai, South Chennai and Central Chennai inorder to avert
geographical variation. . ETCH-M was administered individually
to assess handwriting speed and legibility.
Results
It shows that there is statistically significant difference
between the age groups on the performance of ETCH M
(F=5.9,pd0.001; F=14.57, pd0.001; F=2.9,pd0.05for letter
legibility, word legibility and numerical legibility respectively).
There is statistically significant difference between the age
groups on the performance of ETCH-M for speed in Near Point
Copying and Far Point Copying. This depicts that as the age
increases the children handwriting legibility and speed also
increases.
Conclusion
The normative data obtained from this study can be used
as cut-off score for screening the children with handwriting
difficulties and it can be used as assessment tool as well as
outcome measures.
Introduction
Many children begin to scribble on paper shortly after they
are able to grasp a writing tool, and if not supervised, will
eventually write on any available surface. As a child matures,
their scribbling evolves into the handwriting skills specific to their
culture1.Handwriting needs to be taught appropriately and
consistently from an early age. It can be enhanced through
developing specific perceptual and motor skills appropriate to
the requirements of handwriting. Handwriting is an important
functional task used frequently in every grade beginning in
kindergarten. Children are expected to gain skills gradually in
handwriting legibility as formal instruction is introduced in the
kindergarten and first-grade curriculum 2.
Some children may be ready for writing at age 4, and others
may not be ready until age 6 3,4.The readiness factors needed
for writing requires the integrity of a number of sensorimotor
systems. A number of authors5,6 have stressed the importance
of mastery of writing readiness skills before handwriting
instruction is initiated. Letter formation requires the integration
of the visual, motor, sensory and perceptual systems. Sufficient
fine motor co-ordination is also needed to form letters accurately.
Ganapathy Sankar U / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Lamme (1979) identified six prerequisites that children must
have before handwriting instruction begins. These are1 Small
muscle development 2 Eye-hand co-ordination, 3 Ability to old
utensils or writing tools,4 Capacity to smoothly for basic strokes
such as circles and lines5 Letter perception, including the ability
to recognize forms, notice likenesses and differences, infer the
movement necessary for the production of form, and give
accurate verbal description.6 Orientation to printed language,
which involves the visual and of letters and words and right left
discrimination.
Types of handwriting include cursive and manuscript writing.
Cursive is any style of handwriting that is designed for writing
down notes and letters quickly by hand. A manuscript is any
document that is written by hand, as opposed to being printed
or reproduced in some other way. A generally accepted sequence
for handwriting instruction is manuscript writing for use in grades
1 & 2, with children transitioning to cursive writing at the end of
grade 2 or the beginning of grade 3 7.The need for manuscript
writing may continue throughout life, when students label maps
and posters, adolescents complete job or college applications
and adults complete official or legal forms. In manuscript, children
become accustomed to having the paper square to the edge of
the desk in order to write. The DNealian manuscript program
is unique in that letters are practiced with the paper positioned
at an angle to take advantage of the wrist flexors in down stroking.
This angling is beneficial only when the radial side of the hand
is used to guide the pencil to write. The DNealian manuscript
program has been the most successful in reducing segmentation
of lines for letter formation8 (Benbow, 1995).
Manuscript is Endorsed for the Following
Reasons
Letter forms are simpler and hence easier to learn.
It closely resembles the print of textbooks and school
manuals.
It is needed throughout adult life for documents and
applications.
Ball and stick strokes of manuscript letter formation are
more developmental appropriate than cursive letter for
young children.
Beginning manuscript writing is more readable than cursive.
Manuscript letters are easier to discriminate visually than
cursive letters9,10,11.
Need for the Study
A childs ability to write in a manner that is both legible and
efficient, directly affects his or her school performance and
academic advancement12. When handwriting skills are deficient,
children suffer various consequences related to their academic
performance and social interactions, thus limiting their successful
participation in everyday school activities13.
Handwriting is an important area of evaluation for pediatric
occupational therapist. Problems with handwriting performance
is one of the most common reasons for referring school- aged
children to Occupational Therapy14,15.Although handwriting
instruction is mostly the responsibility of teachers, an
Occupational Therapist plays an important role in determining
175
the underlying postural, motor, sensory integrative and Methodology
perceptual deficits that may be a cause of bad writing. Some of
the handwriting assessment tools are: Childrens Handwriting
Evaluation Tool for Manuscript Writing, Childrens Handwriting Sample
Evaluation Scale, Denver Handwriting Analysis, Minnesota
Handwriting Test, Test of Legible writing. Quantitative research design, Cross-sectional study. Six
The Evaluation Tool of Childrens Handwriting - Manuscript hundred children (n = 600) aged 6 -10 years (mean age = 7.55
(ETCH - M) is used to assess the handwriting speed and legibility. years, S.D= 1.11 years ) were recruited by means of convenience
Addis, 16 has done normative data studies for handwriting sampling procedure from normal schools located in North, South,
legibility and speed ranges among first graders in Temple Central Chennai in order to maintain geographical distribution.
University, Philadelphia. Chan17 has reported the influence of
culture on visual motor coordination and visual perception and Screening Criteria
they concluded that norms should be established for specific
culture groups. Hence the current study was carried out to
establish norms for ETCH- M in Chennai children. A. Inclusion Criteria
Aim Good knowledge in manuscript writing
Age 6-10 years
To establish normative data for ETCH- Manuscript Both gender
Normal or corrected vision
Objectives Normal or corrected hearing

To find out Chennai children performance on ETCH B. Exclusion Criteria

Manuscript
To find out the relationship between age and handwriting Poor visual foundation skills
speed Poor comprehension skills
To find out the relationship between age and handwriting Frequent failures in the academic performance.
legibility Motor disabilities (upper limb).

Table 1: Normative data of letter legibility for ETCH M

Age Letter Word Numerical Speed in NPC Speed in FPC
interval legibility% legibility% legibility% (lt/min) (lt/min)

6.0- 6.11 90.08 6.4 86.74 11.8 92.93 7.6 18.27 6.8 19.66 6.7

7.0- 7.11 90.62 6.1 90.77 9.4 94.81 6.8 21.69 9.3 22.03 8.2

8.0- 8.11 91.23 5.8 92.58 9.1 94.85 6.0 23.19 8.2 24.76 9.9

9.0- 9.11 92.75 4.6 93.51 7.7 93.69 6.1 28.73 12.3 30.92 15.2
NPC = Near point copying
FPC = Far point copying
Instrument
Table 2: The correlation between age and legibility components
of ETCH M

Legibility components r The Evaluation Tool of Childrens Handwriting

- Cursive (ETCH-M)
Letter legibility .159
The Evaluation Tool of Childrens Handwriting-Manuscript
Word legibility .241 (ETCH-M) is a criterion-referenced tool designed to evaluate
Manuscript handwriting skills of children in grades 1 to 6. Its
Numerical legibility .037 focus is to assess a students legibility and speed of handwriting
tasks similar to those required of students in the classroom.
r = Pearson correlation coefficient The administration time is 20-30 minutes. ETCH - M legibility
Table 3: The correlation between age and speed of ETCH M scores were correlated with handwriting grades from teachers
to establish concurrent validity, the results indicated that there
Task R is significantly moderate correlation existed between cursive
legibility percentage scores & teacher assigned handwriting
Near point copying .369 grade and moderate correlation between legibility percentage
scores of ETCH-M and classroom worksheets.
Far point copying .367
Materials used
r = Pearson correlation coefficient
Pearson correlation coefficient was used to find the ETCH manual, response booklet, pencil, and stopwatch.
correlation between age and speed in handwriting .The results
showed that there is positive correlation for near point copying Data collection procedure
(r = .369) and far point copying (r = .367).
The study was conducted in regular schools in North

176 Ganapathy Sankar U / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Chennai, South Chennai and Central Chennai. Before the study
was conducted, the purpose of study was explained to the head
of the institutions and the consent forms were obtained from
respective parents. The general information about the subjects
academic performance has been collected from the respective
class teacher. Subjects were seated on a chair and table,
appropriate for their height. ETCH-M was administered in a
separate class room with good ventilation and lighting as per
guidelines given in manual. A stop watch was used to record
the time taken to perform near point and far point copying. The
legibility is calculated in percentages and speed in minutes.
Data Analysis
One way ANOVA was used to find out difference in letter
legibility, word legibility and numerical legibility between the age
groups. Pearson correlation coefficient was used to identify
relationship between the age and legibility components & age
and Speed components of ETCH-M. The datas were analyzed
using SPSS (15.0 version)
Results
The results showed that there is statistically significant
difference between the age groups in letter legibility (F (3, 596)
= 5.969, pd .001), word legibility (F (3,596) = 14.575, p< .001),
numerical legibility(F (3,596) = 2.944, p< .05), and handwriting
speed in Near Point Copying (F (3,596) = 32.377, p< .001)and
Far Point copying (F (3,596) = 32.060, p< .001). The correlation
between age and legibility components of ETCH results revealed
that positive correlation (Table 6 ) for letter legibility (r=.159),
word legibility (r=.241) and no correlation for numerical legibility
(r= .037). The correlation between age and speed components
of ETCH results indicated that positive correlation(Table 7) for
near point copying (r= .369) and far point copying (r= .367).
Discussion
Written language is a highly complex form of
communication. It is both skill and a means of self expression. It
integrates visual, motor and conceptual abilities and is a major
means through which students demonstrate their knowledge
of advanced academic subjects. The writing skill includes
competence in writing, spelling, punctuation, knowing the
alphabet and distinguishing one letter from another. The purpose
of this study was to establish normative data of ETCH-M for
Chennai children.
There is statistically significant difference between the age
group of 6-10 years for letter legibility, word legibility and
numerical legibility and positive correlation for letter and word
legibility. Literature 18 found that letter legibility score increased
with age. Jackson et al19 found that the legibility increased with
grade level. Ziviani20 (1983) found that the degree of index finger
flexion and degree of forearm pronation, supination have
developmental trends which depicts as age increases the child
grasp pattern also improves.
There is no correlation for numerical legibility. Since the
numbers are taught from the kindergarten, the child has no
confusion between the numbers as in case of alphabets (cursive
or manuscript). This has influenced the result.
There is statistically significant difference between the age
groups for near point copying and far point copying and positive
correlation for speed components. The result of this study was
supported by literature. Tseng21 found that handwriting speed
increases with age. Various researchers 22,23 concluded that
visual motor integration plays an important role in handwriting
speed.
Ergonomic factor should be considered. Norms can be
established for various geographical areas. Further studies can
be performed to find out relationship between pencil grasp and
legibility & pencil grasp and speed.
Ganapathy Sankar U / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Conclusion
Norms has been established for legibility and speed for
ETCH M among Chennai children between 6 to 10 years. The
normative data obtained from this study can be used as cut-off
score to screen the children with illegible and slow handwriting.
It can be used as assessment tool, research tool and outcome
measures to identify the effectiveness of intervention program.
Acknowledgement
I pay my sincere thanks to the chairman of SRM group of
institutions and SRM University. I express my sincere thanks to
Mr.Christopher Amalraj V, Biostatistician and all the participants
who have been the real pillars of this study. Last but not least, I
thank all of them whose names have inadvertently fails my
memory and who in their own unique way have made this project
a reality.
References
1. Amundson, Susan, & Weil, Marsha. Prewriting and
handwriting skills. In Jane Case-Smith, Anne Allen, & Pat
N. Pratt (Eds.), Occupational therapy for children (3rd ed.,
pp. 524-541). St. Louis: Mosby-Year Book,1996.
2. Marr, D., & Cermak, S. Consistency of handwriting in early
elementary students. American Journal of Occupational
Therapy, 2003; 57,
3. Lamme, L.L. Handwriting in an early childhood curriculum.
Young Children, 1979, 35, 20 27.
4. Laszlo, J. I., & Bairstow, P. J. Handwriting: Difficulties and
possible solutions. School Psychology International, 1984;
5, 207-213.
5. Alston, Jean, & Taylor, Jane (Eds.). Handwriting: Theory,
research, and practice. London: Croom Helm, 1987.
6. Wright, J.P. & Allen, E.G. Ready to write! Elementary School
Journal, 1975, 75,430 435.
7. Bergman, K.E. & Mc. Laughlin, T.F. Remediating
handwriting difficulties with learning disabled students: a
review. Journal of Special Education, 1988; 12, 101 120.
8. Benbow, M. Principles and Practices of teaching
handwriting. In A. Henderson & C. Pehoski (Eds.). Hand
functions in the child : Foundations for remediation. Chapter
14. St. Louis, MO: Mosby Year Book, Inc. 1995.
9. Barbe, W.B., Milone, M.J., & Wasylyk, T. Manuscript is the
write start Academic Therapy, 1983; 18, 397 405.
10. Graham,S. & Miller, L. Handwriting research and practice:
a unified approach. Focus on Exceptional Children, 1980;
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11. Hagin, R.A. Write right left: a practical approach to
handwriting.Journal of Learning Disabilities, 1983; 15, 266
271.
12. Rosenblum, S., Parush, S., & Weiss, P.L. Computerized
temporal handwriting characteristics of proficient and non
proficient handwriters. American Journal of Occupational
Therapy, 2003; 57.
13. Preminger, F., Weiss, P.L., & Weintraub, N. Predicting
Occupationalperformance: Handwriting versus
keyboarding. American Journal of Occupational Therapy,
2004; (58).
14. Cerkak, S. Somatosensory dyspraxia. In A. Fisher, E.A.
Murray & A.C Bundy (Eds). Sensory Integration: Theory
and Practice (pp. 138 170). Philadelphia: F. A Davis,1991.
15. Oliver, C.E. A sensorimotor program for improving writing
readiness skills in elementary- age children. American
Journal of Occupational Therapy,1990; 44, 111 124.
16. Addis, B. Handwriting legibility and speed ranges among
first graders. Unpublished masters thesis, Temple
University, Philadelphia, 1999.
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17. Chan, P.W. Comparison of visual motor development in
Hong Kong and the USA assessed on the qualitative scoring
system for the modified Bender Gestalt test. Psychol Rep,
2001; 88(1), 236 40.
18. Dennis, J. L., & Swinth, Y.Pencil grasp and childrens
handwriting legibility during different-length writing tasks.
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19. Jackson, AD. A comparison of speed and legibility of
manuscript and cursive handwriting of intermediate grade
pupils. Thesis/Dissertation: Manuscript Archival materia,
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20. Ziviani, J.Qualitative changes in dynamic tripod grips
between 7 and 14 years of age. Developmental Medicine
and Child Neurology, 1983; 25, 778- 782.
21. Tseng, Mei Hui, & Murray, Elizabeth A.Differences in
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handwriting. Occupational Therapy Journal of Research,
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22. Sovik, N. Developmental cybernetics of handwriting and
graphic behaviour. Boston: Universities for laget, 1975.
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Effect of Passive Straight Leg Raise Sciatic Nerve Mobilization
on Low Back Pain of Neurogenic Origin
Gurpreet Kaur*, Shallu Sharma**
*
MPT- Musculoskeletal (candidate), **Research Guide, MPT (Orthopaedics and Manual therapy), Lecturer, ISIC Institute of Health
and Rehabilitation Sciences, New Delhi
Abstract
Neural mobilization has emerged as a significant adjunct
to assessment and treatment of neurogenic pain syndromes.
However, clinical trials utilizing Passive Straight Leg Raise
(PSLR) neural mobilization for low back pain treatment are
lacking. The present study aimed to study and compare the
effectiveness of neural mobilization and conventional therapy
in patients with neurogenic low back pain.
Subjects and Methods
A sample of 27 patients, aged 18-45 years, with sub-acute
neurogenic LBP were randomized into Experimental (n=12) and
Conventional group (n=15) respectively. The experimental group
underwent PSLR neural mobilization while the conventional
group therapy included Patient Education in form of advice and
exercise for treatment duration of 10 sessions in 2 weeks. The
outcome variables assessed include: pain (VAS), hip flexion
ROM (inclinometer), symptom distribution (Wernekes Overlay
Template) and disability (Modified Oswestry Disability Index).
Results
Within group analysis using Wilcoxin Signed Ranks test
revealed significant improvement (pd0.05) in both groups for
all variables. Between groups comparison was done using Mann
Whitney U-Test. The results demonstrated that statistically
significant improvement occurred in both groups; however the
improvement was greater in experimental group than the
conventional group for all the studied variables.
Discussion and Conclusion
PSLR neural mobilization is more effective than
conventional therapy for improving pain and disability in patients
with neurogenic pain syndrome. However the benefits of
conventional therapy cannot be neglected. Therefore both these
treatment modalities should be integrated in the management
of patients with neurogenic low back pain syndrome.
Key Words
Neural mobilization, Straight leg raise, Low back pain.
Introduction
Low back pain related leg pain or sciatica1 is found to be
present in 57% of patients suffering from low back pain2,3. Leg
pain associated with low back pain can arise from disorders of
neural or musculoskeletal structures of the lumbar spine 4,5,6. In
relation to neural structures, pain in sciatic nerve distribution is
the commonest variation of neurogenic LBP recognized in
clinical practice4. Neurogenic LBP in the distribution of sciatic
nerve has been characterized clinically by abnormal tension in
the nerve and its nerve roots leading to symptoms production7.
In neurogenic LBP, the dominant feature is that of increased
neural tissue mechanosensitivity which suggestive of altered
neurodynamics; which can be assessed using neurodynamic
tests8,9. Selective mobilization of the neural tissue has recently
Gurpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
emerged as an adjunct to assessment and treatment of
neurogenic pain syndromes9. Straight leg raise neurodynamic
test produces movement and tension in lumbosacral nerve roots
and can be used to mobilize the sciatic nerve continuum
specifically10. Releasing pressure or tension in nerve improves
its physiology and clinically correlates with reduced irritation of
nerve structure providing pain relief and reduced disability13.
Preliminary evidence for straight leg raise neural mobilization
has shown to improve lumbar flexion and extension ROM in
both acute and chronic low back pain8. It has also been used
successfully in case studies or single subject design studies
describing patients with signs and symptoms of increased neural
tissue mechanosensitivity in combination with lumbar and lower
extremity symptoms15,23. In contrast a randomized controlled trial
has clearly demonstrated that it does not provide any additional
benefit to standard post operative care, in patients after lumbar
surgery14. Hence, an effort to conduct high quality randomized
clinical trials is justified to accumulate evidence for the effect of
straight leg raise sciatic nerve mobilization in treatment of
neurogenic low back pain. Due to lack of scientific evidence
reporting benefits of neural mobilization, conservative treatment
options like analgesics, bed rest, spinal manipulation and electro-
therapeutic modalities are still being used for treatment of
neurogenic LBP16. However, the scientific evidence regarding
efficacy of each of these interventions is limited or provides
conflicting results. Li and Bombardier et al in a survey of
Canadian physical therapists found that 80% to 99% of the
therapists preferred a combination of patient education and
exercise for a patient with acute low back pain and sciatica18,19.
With an intention to treat, the conventional therapy group (acting
as a control in the current study) was designed in accordance
with the available evidence; as an ideal control would have
ethically devoid the patients from receiving any treatment. Thus,
the aims and objectives of the study were to study and compare
the effectiveness of neural mobilization and conventional therapy
in patients with neurogenic low back pain.
Methods
Twenty seven patients aged between 18-45 years, with a
history of mild to moderate pain (VASd6) and disability (Modified
Oswestry Disability Index score d 40%) presenting in sub-acute
(2 to 12 weeks) phase of neurogenic low back pain participated
in the study. For the study neurogenic low back pain has been
defined as the pain in lower lumbar region with or without
radiation to lower limb (buttocks or posterior thigh or calf); pain
and paraesthesia being referred to sciatic nerve distribution;
without any neurological deficits (altered/absent reflexes,
reduced muscle strength, and loss of sensations). To be
included, the patients should report a positive Straight Leg Raise
neurodynamic test, with dorsiflexion acting as a sensitizing
maneuver. Patients with a history of any trauma or surgery to
spine, hip, knee and ankle or any potential red flags associated
with low back pain were excluded.
Starting position for PSLR neurodynamic
testing in both groups
The patient lies supine, with head, trunk and hips in neutral.
This inclinometer was strapped in place, aligned 10 cm proximal
179
to lateral femoral condyle on a hypothetical line joining the
femoral condyle and greater trochanter.(Figure1)
Experimental Group
Fig.1: Showing Starting Position for Both groups
teaching the exercises on day of initial evaluation, PSLR testing
was done to record baseline hip flexion ROM for the patients in
this group. Due to the nature of intervention (self help strategy)
given in this group, it was not feasible to call the patients everyday
for outcome measure assessment. Therefore all the dependent
variables (VAS, Hip Flexion ROM, SD, and MODI) were
assessed on the first and the last day of treatment protocol.

Data Analysis
Fig. 2: Showing PSLR Sciatic Nerve Mobilization

PSLR Testing
For the patients left symptomatic leg the investigating
therapist stood next to patients left limb in a stride standing
position. The leg to be examined was fixed into knee extension
by examiners hand right hand placed on thigh proximal to knee
joint. The leg was lifted (with hip flexed and knee extended) in
neutral rotation and hip flexion was progressed until the range
at which the patient first reports his/her symptoms (P1 response).
An independent observer took a note of this angle. At this P1
range of motion, the examiner passively dorsiflexes the ankle
to determine any aggravation in patients symptoms. This was
the baseline hip flexion ROM during neurodynamic testing and
was recorded before and after each treatment session for ten
sessions.
Fig. 3: Showing Pelvic Tilting Exercise
PSLR Mobilization
For mobilization of the sciatic nerve, the examiner lowered
the hip flexion angle, below the P1 range for 5-10 degrees till
the symptoms disappeared, which was noted by an independent
observed. The ankle joint was then taken passively into
dorsiflexion and plantar flexion alternately within the available
as the maneuver to mobilize the sciatic nerve tract. This
oscillatory technique of nerve mobilization was done in 3 sets of
10 repetitions each with a gap of 10 seconds between each set.
At the end of session, the examiner again performed the PSLR
test after a gap of 5 minutes, to ascertain any change in the
range at which P1 was reported. This hip flexion ROM was used
to identify and calculate the difference in pre-test and post-test
values at the end of each treatment session for this group. A
total of 10 treatment sessions were given in 2 weeks. Pain, ROM
and Symptom distribution were assessed before and after each
treatment session for all 10 sessions. Modified Oswestry Fig. 4: Showing Back Extension Exercise
Disability Index was assessed before starting with treatment
protocol and after finishing treatment protocol.

Conventional Group
Patients recruited in this group, were explained about their
condition and were asked to perform a set of exercises and
follow advice on good posture for duration of two weeks. The
advice consisted of maintenance of correct posture during
activities of daily living, ergonomic advice, how to lift heavy weight
correctly, along with some specific back exercises and most
importantly the patient was advised to stay as active as possible
as per their pain tolerance. The exercises (Pelvic tilting exercise,
Back extension exercise and Cat and Camel excises) were
demonstrated on a model and the patients were asked to
replicate them during the teaching session (Figure 3 to 6). After

180 Gurpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Fig. 5: Showing Cat Position in the Exercise
Fig. 6: Figure showing Camel position of exercise
The data was analyzed using SPSS (version 17) software.
Due to the nature of the outcome measures, non-parametric
statistical tests were used. The descriptive statistics (Median
values) were computed for all the variables in both groups. For
within group comparison and between groups comparison of
pain (VAS), ROM (Hip Flexion) and disability (Modified Oswestry
Disability Index) Wilcoxon Signed Ranked Test and Mann
Whitney U-Test were used respectively. The difference between
pre and post intervention measurement of Symptom
Distribution29 (SD) and between groups comparison was done
using Chi square statistics. The level of significance was fixed
at p d 0.05 for data analysis.
Results
A comparison of pre-intervention data points of dependent
variables (VAS, Hip ROM, SD and MODI) in both groups,
demonstrated homogeneity of variables at the baseline. (Table1).
From the results of within group analysis, it can be inferred that
there was significant improvement (p d0.05) in all the study
variables (VAS, Hip ROM, and MODI) from pre-intervention
(session1) till post intervention (session10) in both groups
respectively (Table2). Between groups analysis of all the
variables demonstrated a significant post-intervention difference
(p d0.05) in patient reported VAS scores, hip flexion ROM and
disability scores. A comparison of median value of the variables
demonstrated greater improvement in the experimental group
as compared to the conventional group (Table1). A statistically
significant reduction in the area of reported symptoms (observed
from overlay body template) following the neural mobilization
was observed within the experimental group but not in
conventional group. Secondary analysis of the area of symptom
distribution (using UTHSCA image tool) in both groups,
Gurpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
demonstrated that the area reduced by 50.3% and 25.1% in the
experimental and conventional groups respectively.
Discussion
The statistically significant improvement in pain scores, hip
flexion ROM and disability within the conventional group can be
attributed to the intervention, which included patient education
regarding posture and exercise. Previous studies have
documented that patient education comprising of neuro-
physiological mechanisms have been effective in reducing the
reactivity of pain neuromatrix20. This change of mal-adaptive
pain behaviors lead to a reduction in subjective VAS scores
(10mm) as well as subsequent increase in hip ROM seen (6
degrees) within the conventional group, in the current study20,21.
The conventional group exhibited lesser gain in ROM when
compared to experimental group. This could possibly be the
result of specific and directive intervention in accordance with
inclusion of subcategory of neurogenic pain in the experimental
group. The patients of the present study represented sub-acute
stage with symptom predominance proportional to the pathology
of neurogenic LBP. This could have resulted in patients not
complying with therapeutic exercise because of pain persistence.
The acute benefits of advice and exercise seen over the
treatment duration were not followed up after the completion of
study protocol. It needs to be seen whether this type of
intervention has any different response when given over a longer
duration of time as documented in neck pain
literature22.Therefore long term research into the benefits of
postural advice and exercise should be undertaken to make
any definitive conclusion regarding this intervention in
management of neurogenic LBP patients. The results of the
study support the hypothesis that SLR sciatic nerve mobilization
has acute benefits when given for duration of ten days, in early
management of neurogenic LBP. In the experimental group a
statistically and clinically significant reduction in pain scores (30
mm) was reported (Table1, 2). For VAS to show clinically
sensitive changes in LBP it needs to have 10-28 mm decrease
in scores23. In accordance with these findings the present study
reported 30 mm decrease, thus reiterating the use of VAS in the
current study. Pain reduction in the experimental group can be
attributed to inhibition of temporal summation mediated with C-
fibers 24, as well as reduced mechanosensitivity of the neural
tissue8,9. In this group, only a few patients reported absolute
zero on VAS at the end of 10 days, while rest of the patients
reported some form of residual pain even after completion of
study protocol. Therefore the adequacy of 8-10 sessions of
treatment cannot be affirmed. Hence it is proposed that after
pain reduction to minimal scores on VAS scores, a modification
of the treatment technique is pertinent to reduce residual pain
reported in this group. An improvement of 16.5 degrees after
neural mobilization is suggestive of concordance in the results
of current study with previous literature22. This increase in ROM
in this group can be attributed to the direct elongation of the
nerve bed as well as mechanical interface (Hamstrings)
secondary to the nerve mobilization technique used. The
mobilization technique used in the current study was better
tolerated by the patient as done below P1 range, compared to
neural tensioning maneuver which is used at end range of
available motion to mobilize the nerve. Reduction in patient
reported area of symptom distribution was two times greater in
experimental group as compared to conventional group which
can also be attributed to decreased neural tissue sensitivity to
movement26. The experimental group reported both statistically
and clinically significant post-intervention scores of Modified
Oswestry Disability Index (6.4 points), whereas the conventional
group reported a decrease of only 2 points which was found to
be clinically insignificant. This emphasizes the fact that the
statistically and clinically significant changes of VAS and ROM
had successfully reflected in greater improvement of MODI in
181
Table 1: Comparison of Variables at Baseline and Post-Intervention in Experimental and Conventional groups using Mann Whitney
U-Test and Chi Square Statistics.

Variable Experimental group Conventional group Respective Significance

(Median) (Median) Level

Number of subjects 12 15
6 Males 6 Females 8 Males 7 Females

Age 35 years 29 years Z= -0.88NS

PrVAS1 5 5 Z= -0.34NS
PrHIP1 52.5 57 Z= -1.08NS
PrMODI1 19.5 20 Z= -0.71NS
PrSD1 3.5 2 2 = 7.78NS
PoVAS10 2 4 Z= -3.13*
PoHIP10 74.5 60 Z= -3.16*
PoMODI10 11 19 Z= -3.67*
PoSD10 2 2 2 = 9.30*
TdfVAS -2.6 -1.0 Z= -4.94 *
TdfHIP -16.5 -6.0 Z= -5.01*
TdfMODI -6 -2 Z= -5.02*
TdfSD -1.5 0 2 = 2.74*
* denotes that the Z-value or 2 value is significant at p d 0.05 score on Day10
NS: denotes that the Z-value or 2 value is non significant at p PoSD10: Post-intervention Symptom Distribution score on
d 0.05 Day10
PrVAS1: Pre-intervention VAS score on Day1 TdfVAS: Difference between pre-intervention (day1) and post-
PrHIP1: Pre-intervention passive Hip Flexion Range of Motion intervention (day10) median values of VAS.
on Day1 TdfHIP: Difference between pre-intervention (day1) and post-
PrMODI1: Pre-intervention Modified Oswestry Disability Index intervention (day10) median values of Hip flexion ROM.
score on Day1 TdfMODI: Difference between pre-intervention (day1) and post-
PrSD1: Pre-intervention Symptom Distribution score on Day1 intervention (day10) median values of Modified Oswestry
PoVAS10: Post-intervention VAS score on Day10 Disability Index.
PoHIP10: Post-intervention passive Hip Flexion Range of TdfSD: Difference between pre-intervention (day1) and post-
Motion on Day10 intervention (day10) of median values of Symptom Distribution
PoMODI10: Post-intervention Modified Oswestry Disability Index scores

Table 2: Pre-Intervention (Day1) and Post-Intervention (Day 10) Comparison of Variables within Experimental and Conventional
groups respectively using Wilcoxon Signed Ranks Test
Group Variable Pre-intervention Post-intervention Respective
(Day1) (Day10) Significance
(Median) (Median) Level

Experimental VAS 5.00 2.00 Z= -3.06*

Hip Flexion ROM 52.5 74.5 Z= -3.06*

MODI 19.5 10 Z= -3.06*

SD 3.5 2 2= 7.80*

Conventional VAS 5.00 4.00 Z= -3.31*

Hip Flexion ROM 57 60 Z= -3.20*

MODI 20 19 Z= -2.07*

SD 2 2 2=24.41NS
*denotes that the Z-value or value is significant at p d 0.05
2

NS: denotes that the Z-value or 2 value is non significant at p d 0.05

the experimental group as a result of improved nerve mobility
and physiology leading to subsequent improvement in functional
status of the patient.
The results of this technique cannot be compared to slump
stretching utilized in previous studies for LBP treatment as it is
non-specific technique which was used in a variety of non-
homogenous diverse population28. The use of slump technique
is questionable as it elongates and produces tension in the entire
neuro-meningeal tract, which might exacerbate the symptoms
of patients in a more irritable state8,9,28. In contrast the PSLR
technique is biased towards sciatic nerve continuum which can
selectively mobilize the nerve without producing excessive
tension in the other part of the nervous system and is better
controlled by the therapist. Performance of straight leg raise
neurodynamic test to the first onset of symptoms (P1 response)
is a highly reliable method (ICC= 0.78- 0.96) on same day as
well as repeated testing in subsequent sessions27. This allows
for identification of meaningful differences in tests outcomes
through use of sensitizing maneuvers and can be used in more
irritable condition, as opposed to resistance (R1 response)

182 Gurpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
measurement which is dependent on therapist perception and
is difficult to quantify. The oscillatory technique of neural
mobilization used in this study slowly engages the resistance of
the movement, associated with protective muscle guarding
resulting in decreased symptoms experienced by the subjects
after the treatment.
A subsequent randomized allocation secondary to
screening strengthen the internal validity of the study suggesting
that neural mobilization is more effective in management of
patients with Neurogenic LBP as opposed to patient education
and exercise. However, based on a small sample size it is difficult
to generalize the findings to a large sample population of
neurogenic LBP. Moreover convenience sampling done in the
study reduces the external validity of the findings. Compliance
of the patients in the conventional group was taken at face value,
thus resulting in reduced reported benefits.
Clinical Significance
Passive SLR neural mobilization has shown acute benefits
on patient reported pain, hip flexion ROM, symptom distribution
and disability associated with neurogenic LBP as it specifically
targets the sciatic nerve continuum. Moreover it is a safe and
effective technique to mobilize the sciatic nerve selectively.
However the benefits of the postural advice and exercise cannot
be undermined and are recommended to be used as an adjunct
in management of neurogenic LBP.
Future Research
Neural mobilization is a relatively new concept of manual
therapy and its applications in treatment of neurogenic pain
syndromes especially low back pain should be explored further
with more double blinded, randomized controlled studies to
reduce the confounding effects of patient and therapist bias.
Clinical studies with adequate follow up (6 months to 1 year)
should be undertaken to assess the carry over effects of these
techniques.
Conclusion
The study is concluded by supporting acute treatment
benefits of PSLR neural mobilization for improving pain, hip
flexion ROM, decreasing symptom distribution and reducing
disability compared to the conventional group. However the effect
of the patient education handout containing postural advice,
ergonomic advice along with exercise cannot be neglected.
Therefore both these measures can be integrated to achieve a
more beneficial and positive effect on symptoms of patients with
neurogenic low back pain.
Acknowledgement
I wish to thank my research guide Ms Shallu Sharma, for
her guidance, precious time, and contributions made during the
course of the study. I must also convey my sincere thanks to
Ms. Chitra Kataria, Principal, ISIC Institute of Health and
Rehabilitation Sciences, New Delhi, for making it possible for
me to conduct this work in the institution.
Contact Information
Gurpreet Kaur, MPT-Musculoskeletal (candidate), Indian
Spinal Injuries Center, New Delhi, India. Email:
gkgurpreetarora@gmail.com.
Gurpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
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Fatigue and its Correlation with Functional Outcome in Patients
with Stroke
Hamdani N*, Dhawan L**, Maurya M***.
*Asst. Professor Neurophysiotherapy Jamia Hamdard New Delhi, **Consultant Physiotherapist Amar Jyoti College of Physiotherapy,
***Incharge Physiotherapy, Jamia Hamdard, Dept. of Allied Health Sciences, New Delhi-110 062
Abstract
Fatigue is a common complaint in neurological diseases.
Yet, few studies have been done to asses fatigue in patients
post stroke particularly during the acute stages of recovery. Also,
whether the fatigue affects the functional outcome during the
acute stages of recovery is not known. The purpose of the study
was to know the prevalence of fatigue and its correlation with
the functional outcome during the acute stage of recovery in
patients with stroke. Method: a random sample of 30 patients
(mean age=49.76,standard deviation=10.40) with stroke was
taken .The subjects were either in or out patients at the All
India Institute of Medical Sciences and G.B.Pant Hospital,
New Delhi, India. After a detailed neurological assessment and
confirming the diagnosis by CT/MRI only those patients with
MMSE>27 were taken.Results: A correlation analysis was done
and pearsons correlation r value was calculated. Also, strain, an overwhelming feeling of exhaustion, which leads to
association between the variables was seen using chi-square
tests. A principle component factor analysis method using
Varimax method was done for the items (1-10) on the BNI scale.
BNI overall index was found to significantly correlate with BNI
total score, functional outcome measures (i.e Barthels index
and MAS). No correlation was found between BNI total score and
the functional outcome measures. However, a strong association
was found between both BNI scale categories and Barthels
categories. Factor analysis revealed two-factor solution .The
internal consistency of the BNI scale was found to be high.
Conclusion
Post stroke fatigue is multidimensional and might affect
the functional outcome as is shown by its strong association
with the latter, during the acute stages of recovery.
Key Words
Fatigue, Stroke, Functional outcome
Fatigue is a common complaint in clinical practice1.
Fatigue after Stroke
Fatigue is often one of the first signs of early brain disease
and is usually a pronounced problem immediately following the
acute stages of sudden onset brain conditions such as trauma
or CVA. In progressive conditions the patient increasingly tires
more easily as once automatic activities and functions begin to
break down and require more and more concentrated effort for
their performance4. Fatigue is particularly evident during the early
stages of recovery from brain injury and has been shown to
have serious functional and emotional consequences5 .Although,
there is a trend towards improvement in fatigue over time, and
several studies have documented its presence for up to 6 years
at long term follow-up 6. While fatigue is often clinically observed
in brain injured patients during the acute stages of learning,
there is dearth of studies on this topic 5.
In our experience, stroke patients frequently complain about
fatigue, and therapists often report that sessions of therapy are
limited by fatigue.
The relevance of fatigue to poststroke rehabilitation and
recovery of function has not yet been examined. Fatigue poses
Hamdani N / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
one of the greatest barriers to rehabilitation and has negative
impact on quality of life 7.
Hypothesis
Fatigue exists in patients following stroke and might affect
the functional outcome measure, during the acute stages of
recovery.
Operational Definitions
Fatigue
Defined as a reversible decrease or loss of abilities
associated with a heightened sensation of physical or mental
inability or difficulty to sustain even routine activities 3
Functional outcome: measures performance in activities
of daily living (ADL) using a weighted scale (Barthels index)
Acute stage of recovery: within three months of onset of
first ever stroke.
Limitations of the Study
The study cannot be generalized because of small sample
group, individual variances within the group and individual
differences related to territory of involvement.
Review of Literature
Fatigue is a common complaint after stroke 1,3,9.Using
interviews or mailed questionnaires in recent studies 10-13
examined fatigue as an independent phenomenon and found
that the frequency of occurrence can range from 30% to 68% of
stroke survivors.
Severity and Functional Implications
Little is known about the fatigue severity and the overall
impact that it has on poststroke recovery and return to activities
of daily living (ADLs).Interestingly, stroke survivors with less
severe physical or cognitive disability after stroke tend to rate
fatigue as a more severe symptom. 10, 3, 15
Method
A minimum of 30 post stroke subjects were included in the
study.
Inclusion criteria: Patients with acute stroke that had been
admitted to the hospital or discharged and coming to the
rehabilitation department as outpatients.
Patients were identified according to the following criteria:
- they had a cerebral infarct (confirmed by computed
tomography [CT]/ magnetic resonance imaging [MRI] or
inferred from the clinical picture when CT scan was negative
- they were able to participate in daily treatments including
therapies and meetings.
- they had a Mini Mental Scale examination score [MMSES]
185
 of 27/30 (8). A correlation analysis was done between BNI total score
(i.e, total score of items 1 -10) (Mean=27.50, SD=15.53) , BNI
Exclusion criteria overall score (item 11) (Mean= 4.76,SD=2.23), Barthels index
score (Mean=69.73,SD=25.18), MAS
Patients were excluded from the sample if: score(Mean=32.16,SD=9.85) and Age (Mean=49.76,SD=10.40),
- they had suffered another stroke or major medical illnesses pearson correlation was calculated for each .( table 1b)
since the time of their initial admission to the hospital.
- they had another neurological disease or systemic illness.
- they had decreased levels of consciousness, dysphasia or
severe cognitive impairment (or MMSS<27), such that they
were unable to answer questions or complete the fatigue
questionnaire.
- Patients taking antidepressants or antipsychotic
medications.
- sub-arachnoid hemorrhage (SAH) not included because
of their different etiology and course.

Design
Non-experimental,co relational design.

Instrumentation
Fatigue score: measured by the BNI fatigue scale.5
Barthels index 17 It was found that BNI total score showed highly significant
correlation with BNI overall score (r = 0.795, p<0.01),
Motor assessment scale (MAS): Highly significant correlation was found between BNI
Designed by Carr and Shephard18, 19.The MAS consists of overall and Barthels index score ( r = -0.512, p =.000).
8 items representing the areas of motor behavior. Each item is Also a highly significant correlation was found between
scored on a 7-point (range 0-6) hierarchical scale. 20,21 BNI overall score and MAS score ( r = -0.473, p<0.01).
MMSE 1,8,16 No correlation was found between BNI total score and
Barthels score (r = -0.337,ns).and MAS score ( r = -0.179, ns).
Location: jamia hamdard new delhi Barthels index score and MAS score showed highly
significant correlation. (r = 0.727, p< .000) Scatter plots 2a
show the correlation pattern of variables :
Protocol for Data collection
Participants data was collected by myself and an informed
consent form was signed by the patient.
Instructions to the patients:
The patients were informed about the study and explained
about the questionnaire when needed.
Time consumed: 1 year
Procedure:-first the selected subjects were briefed about
the study , then were made to sign the informed consent form,
then a detailed history and assessment using the Motor
assessment scale was taken and finally the patients were given
the BNI fatigue scale questionnaire. For those patients who were
not able to write with their hand due to affected hand function
following stroke ,the scores were written by myself as told to
me by these patients & then the scores were assigned for each
item of ADL given in the Barthels index, on the basis of
performance and information from spouse/caretakers.

Results
The mean and standard deviations of the BNI score , BNI
overall score , Barthels Index, MAS scale and Age are given
in the table 1a.
On further analysis by taking a cut off score for fatigue
problem on the BNI scale as 28 (mean score), patients were
divided into two categories as BNISCAT-1 and BNISCAT-2.
BNISCAT-1: patients scoring below28 (no problem) to
(occasional problem) with fatigue BNISCAT-2: patients scoring
above 28 (frequent problem) to (most of the time problem) with
fatigue.
Similarly, with the Barthels index (which measures the level
of dependence in activities of daily living) taking a cut off score
of 60 (21 ), patients were divided into two categories as BARCAT-
1 and BARCAT-2.
BARCAT-1: patients with scores below 60 (totally to
severely dependent),

186 Hamdani N / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
 BARCAT-2: patients with scores above 60- (moderate to
minimally dependent).
After analysis 21 patients came under BNICAT1 and 9
patients came under BNICAT2. Also , 3 patients came under
BARCAT1 and 27 came under BARCAT2.
The findings were significant (p= 0.03) by Fishers exact
test.
Out of a total sample of 30 patients 74.1% were found to
be under BARCAT2 and BNISCAT1. This means 74.1% of
patients with score above 60 on the Barthels scale had scores
below 28 on the BNI total score. i.e. patients who were moderate
to minimally dependent on the ADLs had none to occasional
problem with fatigue.
Also, 30% of patients came under the BARCAT1 and
BNISCAT2.This means 30% of patients with scores below 60
on the Barthels scale had scores above 30 on the BNI total
score. i.e. patients who were totally to severely dependent on
ADLs had frequent to most of the time problem with fatigue.
To explore further BNI overall score (item11) was also given
a cut off score of 5 (mean score) for rating fatigue problem as
less problem to more problem. The two categories are:
BNIOCAT-1: patients scoring below 5 (less problem).
BNIOCAT-2: patients scoring above 5 (more problem)
Its association with the Barthels score categories
(BARCAT-1 and BARCAT-2) was found significant by Fishers
exact test. (p = 0.03) .74.1% of patients (n=30) came under
BARCAT-2 and BNIOCAT-1, and 30% of patients (n=30) came
under BARCAT-1 and BNIOCAT-2.This means 74.1% of patients
who were moderately to minimally dependent had less problem
of fatigue and 30% of patients were totally to severely dependent
had more problem with fatigue.
The association between BNISCAT-1, BNISCAT-2 and
BNIOCAT-1, BNIOCAT-2 was also found to be significant by
Fishers exact test (p=0.005).
The results showed 85% sensitivity and 70% specificity of
the BNI scale.
An inter item Pearsons correlation was calculated and the
findings were highly significant. (p < 0.01).
To know the pattern of relationship between the items, the
items were subjected to KMO and Bartlets test .The findings
were significant (p <0.01).On this basis the items were subjected
to factor analysis to find the most important variables.
Factor analysis attempts to identify underlying variables,
or factors, that explain the pattern of correlations within a set of
observed variables.
The factor analysis was done by Principal component
extraction method. The result yielded two factors .The solution
was rotated using varimax rotation so that interpretation would
be easier. The factors had an eigenvalue of 6.34, which
accounted for 63.4% of variance.
The two factors yielded after rotation grouped the items
according to their pattern of significant correlation with each other
as shown in the factors plot graphs below. Items 10, 6, 8, 5, 9,
1 were found to be highly correlated under factor 1, and items 2,
3, 4, 7 were highly correlated under factor 2 (p < 0.01). (See
plot)
The Rotated component matrix table below shows the
highest correlation value for item 10 under factor 1 and item 2
under factor 2.
This means item 10 and 2 are most important variables
among item 1-10 and account for most of the variance shown.
Each of the items 1-10 were also found to be highly
correlated with item 11
(p< 0.01).

Reliability
Since factor analysis yielded 2 factors internal consistency
(Cronbach coefficient alpha) was calculated for each.

Hamdani N / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 187
 The reliability of factor 1 Alpha = 0 .8785.
The reliability of factor 2 Alpha = 0 .7950.
Discussion
Results of this study document the factor structure and
internal consistency of the BNI fatigue scale and its correlation
with functional outcome of a sample of stroke patients during
acute neurorehabilitation.
All 10 of the items loaded on two factors. The loadings
were robust and accounted for a relatively large percentage of
variance. Thus, these findings suggest that the 10 items appear
to represent the difficulty in lasting the day without taking a nap
(item 10) and difficulty to participate in activities because of
fatigue (item 2), which reflects a patients endurance level.
Thus, it can be interpreted from the above findings that the
BNI scores obtained for the sample of patients actually revealed
their endurance problems effecting their ability to participate in
activities because of fatigue, which necessitates the rest time
they need via a nap, any time of the day when they feel fatigued.
This finding supports our operational definition, which
defined fatigue as a reversible decrease or loss of abilities
associated with heightened sensation of physical or mental
strain, an overwhelming feeling of exhaustion, which leads to
inability or difficulty to sustain even routine activities.( It can
further be interpreted or verbally expressed as a loss of drive.)
On rotating the solution after principal component factor
analysis method, it was found that the factor 1 correlated highly
with items 10,6,8,5,9, 1 in the decreasing order. (See table). On
a closer look at the BNI scale it is found that all these items ask
for the difficulty faced with- lasting the day without taking a nap
(item 10), energy level in the morning (item 6), stay alert during
activities (item 5) and when not involved in something (item 8),
attend to something without feeling sleepy (item 9), and
maintaining energy throughout the day time (item 1).
(i.e. with the issues of day somnolence, energy levels and
alertness.) Studies have shown that post-stroke sleep
disturbances, may influence the development of fatigue 1,3,7,10,11,22
,this supports my results. Sleep disordered breathing (SDB) and
sleep wake disorders (SWD) are frequent after stroke because
of several reasons. First, brain damage per se can impair the
regulation of sleep wake and breathing control mechanisms.
Second, consequences of stroke (immobilization, pain, hypoxia,
depression etc) may affect these same mechanisms. Third,
cerebrovascular diseases, sleep disordered breathing and
SWDs can arise from similar pre-disposing / risk factors. It is
thus important to recognize the sleep disturbances after stroke
as they have a negative impact on rehabilitation and daily
functioning 23.
In a study, on mental fatigue in patients with supratentorial
lacunar infarcts Van Zandvoort et al 15 found that despite very
good neurological recovery and normal cognitive abilities, the
patients showed a decrement of performances (compared to
controls) in demanding tasks, which seemed to be linked to
subtle attentional deficits.
The factor 2 was found to correlate significantly with items-
2, 4, 3 and 7 in decreasing order (see table). A significant relation
between item 2 (difficulty to participate in activities because of
fatigue) and item 4 (difficulty in completing a task without
becoming tired) means more or less the same thing and may
be because of the feeling of exhaustion that overwhelms the
patient. Again the significant relation between item 3 (difficulty
to stay awake during the day) and item 7 (difficulty to stay out of
bed during the day) may be pointing towards or mean the same
thing. Again the above items may be related , the difficulty to
participate in activities may be same as difficulty to complete a
task without becoming tired and when tiredness overcomes the
patient feels sleepy and thus unable to stay out of bed. It may
be interpreted either as physical or mental tiredness.
188 Hamdani N / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
It may be concluded from the above that patients have
reported difficulty with lack of energy levels or physical exhaustion
or mental tiredness which may be related to their difficulty to
participate in activities (item 2) and and the difficulty to last the
day without taking a nap (item 10).which in turn may be
consequential to the sleep disorders or subtle attentional deficits
following stroke due to interruption of neuronal networks such
as reticular activating system 1. Therefore, the main unanswered
question posed by several studies on fatigue seems to be
answered from the above discussion that there is an association
between mental effort and fatigue. If it is assumed that BNI
measures the psychological domain of fatigue then patients
scoring high on this scale are assumed to have a greater
psychological component of fatigue which may force them to
produce additional mental effort to match prior performances.
Even with apparent total recovery, performing at the former level
may be possible only at higher psychophysiological costs.
Furthermore, the attempt to mask or overcome deficits can lead
to psychological stress, with subsequent fatigue. It is obvious
that some patients experience physical fatigue as a consequence
of motor deficits. Thus, it is critical to distinguish objective physical
fatigue, which has a clear, specific cause (for example
hemiparesis), from the feeling of fatigue 3.
Again from the above discussion it appears that the difficulty
to sustain attention or lack of energy for activities / tasks conforms
to the definition of fatigue including both mental and physical
domains.
Then does it mean that the BNI score measures the central
fatigue experienced post-stroke? Because, central fatigue 24
is defined as t he failure to initiate / sustain attentional tasks
(mental fatigue) and physical activities (physical fatigue) requiring
self motivation as opposed to external stimulation. 24
In essence, central fatigue represents a failure of physical
and mental tasks that require self-motivation and internal cues
in the absence of demonstrable cognitive failure or motor
weakness.
Study conducted by Ingles et al 10 in which fatigue is defined
as a feeling of tiredness or lack of energy. FIS was used to assess
fatigue FIS evaluates the impact of fatigue on daily cognitive,
physical and psychosocial functioning. Functional impairment
measured by the Barthels Index did not seem to play a role in
fatigue.
In our findings also the BNI total score did not show any
correlation with the functional outcome measures of Barthels
Index and MAS.
It may be because of the subjective nature of the BNI scale.
Fatigue as a subjective phenomenon or feeling state is
much more difficult to define and study , as it may be independent
of objective or behavioral aspects. 3
Moreover, BNI scale items 1-10 asks the patients about
their difficulty levels in areas which may not necessarily interfere
with the outcome measures on the Barthels index. Also, it may
be that experienced fatigue is perhaps not a truly objective
indication of physical fatigue, and possibly reflects merely extra
effort needed to compensate for disability 1 or patients capacity
to recognize problems may be reduced (i.e anosognosia,
unawareness) leading to imprecise or unreliable presentation
of their symptoms. 13
Not only reduced self-awareness can comprise the changes
reported by patients, the psychological coping style known as
denial may be involved. 13
The higher frequency and highly significant correlation of
the item 11 (which asks patients directly to report their overall
level of fatigue) with functional outcome measures shows firstly,
the consistency with most of the studies 1,3,6,7,10,11,22 on the
prevalence of fatigue post-stroke.
As such, it shows that self reporting of overall level of fatigue
may be an important aspect of fatigue measurement that may
have a great impact on daily functioning of the patients. 11
Leegard14 examined 44 survivors of cerebral infarction
below the age of 70 years, fully active and in good health at the
time of stroke. All patients were autonomous for walking and
able to manage in their own home and only 17 had neurological
deficits.
Between 6 and 26 months after stroke the patients were
questioned about 13 general symptoms, including fatigue
emotional liability, forgetfulness and concentration difficulties.
Over half of them reported at least 5 of the 13 symptoms, fatigue
being particularly evident.
The fatigue reported was found to be independent of age.
Even though the patient population studied was younger than
in the study by Ingles et al. 10
Secondly, it may be argued here that this high correlation
of BNIoverall (item 11) with both measures of functional outcome
(Barthels index and MAS) may be either because BNIoverall
(item 11) measures psychological or physical attributes of fatigue.
The fatigue checklist indivisual strength which was used in the
study by Van der werf et al (11) is an instrument which essentially
assesses the physical component of fatigue. This may explain
why the authors found such a strong relation between fatigue
score on this scale and physical impairment. 1
Association between Fatigue Scale (BNI Total Score-
BNISCAT1&2) and (BNI Overall Score-BNIOCAT1&2)
categories and Barthels Categories (BARCAT1&2).
It may be interpreted from the previous discussion that the
causes leading to feeling of fatigue after stroke may be varied.
Whether the underlying feeling is identical whatever the
underlying condition, seems to be obvious more or less in this
study by the strong association between BNI total score
categories (BNISCAT1 and BNISCAT2) and Barthels categories
(BARCAT1 and BARCAT2) 74.1% of the patients with none to
occasional problems with fatigue were moderate to minimally
dependent in ADLs and 30% with frequent to most of the time
problems with fatigue were totally to severely dependent in ADLs.
The same percentage of association was shown by the BNI
overall (item 11) categories (BNIOCAT1 and BNIOCAT2)
probably because both BNI total score (item 1-10) and BNI
overall score (item11) showed significant positive correlation
( r=0.795,p<0.01).
It can be further concluded from the above that in the 74.1%
of patients whether the problem is occasional (BNI score
categories) or less (BNI overall categories) fatigue is a
PROBLEM. You cannot ignore it! And it is this problem that
persists as sequelae in the chronic stages post stroke as has
been shown in several studies conducted in the chronic stages
post stroke. It was found in these studies that even though the
patients did not show very severe neurological disturbance or
functional impairment, fatigue was still reported with a higher
frequency .(3,6,10,11,13) The BNI scale does NOT ask the patients
about the EXTENT to which fatigue interferes with their ABILITY
to carry out a specific activity ,it only asks the patients to describe
their level of DIFFICULTY on 10 fatigue-related items. It can
again be argued that no correlation found between BNI total
score and functional out come may be because of this underlying
fact that even though the performance of activities might have
been difficult to different degrees but still the patients performed
them with varying degrees of assistance or compensatory
statergies and that is precisely what the Barthels index
measures- the level of independence /dependence with varying
degrees of assistance or compensatory stratergies. It further
reinforces our earlier point that may be the patients have
underreported /underestimated/misunderstood their fatigue
problems because of the acute stage of recovery especially for
the less impaired patients who because of their greater
awareness of deficits and social pressure to resume previous
activities may deny this problem. Or it may be a deficiency on
the part of the scale itself, because questions are ambiguous
and repetitive or may be because of the small sample size.
Hamdani N / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Future research
The extent to which fatigue interferes with the functional
outcome should be considered in future research. Also further
work is required to develop tools to measure objectively the
extent to which fatigue interferes in therapy 12. Additional research
on post stroke fatigue is required in areas such as diagnosis,
prevalence, severity, duration and association factors to better
understand causal mechanisms and predisposing factors7.
Relevance To Clinical Practice
The identification of effective therapeutic strategies for post
stroke fatigue is critical to optimize recovery and rehabilitation.
The recognition of fatigue as a genuine post stroke disorder
requiring assessment and treatment is the first step toward the
development of a comprehensive therapeutic program to
address the problem 7.It is important that the patient is made
aware that it is a real and not imagined symptom. Recognition
by the patient, caregivers and family members that it is a genuine
symptom of disease can be crucial to psychological well being
of the patient 25. It also ensures that the patient does not feel as
if fatigue is simply to be endured, but that strategies may in fact
reduce or alleviate it 26.
Conclusion
It may be concluded from the previous discussion that
fatigue is a problem post stroke, which cannot be ignored, and
the mental, physical and psychological factors may contribute
to it. Fatigue is important to be recognized post stroke as it might
affect the functional outcome as is shown in the study by its
strong association with the latter. Both the above hence prove
the hypothesis of this study.
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Effect of Exercise Rehabilitation Programme on Clinical Health
Status of Osteoarthritis Knee Patients
Jagmohan Singh*, Paramvir Singh**, M S Sohal**
*Gian Sagar College of Physiotherapy, Ram Nagar, Banur, Distt. Patiala,**Punjabi University, Patiala
Abstract
Background and Objectives
Osteoarthritis (OA) is a common rheumatological disorder.
It is a degenerative joint disorder characterized by destruction
of articular cartilage and formation of a new bone at the joint
surfaces. Its onset is usually in older age group. Both men and
women are affected, but symptoms in women occur earlier and
appear to be more severe than in men. Knee joint is the most
commonly affected region of the body. Predominant feature is
pain along with decrease in the range of motion. One of the
worst things about OA is its negative effect on the quality of life.
The aim of this study is to find out prevalence of OA knee in
different age groups & in different sexes and effect of exercise
rehabilitation program on pain, range of motion, strength,
cardiovascular fitness and functional level of patients with OA
knee.
Methods
A group of 200 patients of established osteoarthritis of knee
ranging in age from 40-65 years were included in the study.
Patients were randomly divided into two groups: Group A
(Experimental Control Group, n=100) and Group B (Experimental
Group, n=100). Patients of experimental control group were
treated with conventional physiotherapy program and patients
of experimental group were treated both with conventional
physiotherapy program and exercise rehabilitation program
which includes mild intensity long duration exercise program.
Both the groups were treated for two months. Following
parameters were assessed at the start of exercise rehabilitation
program, in the middle (after 1 month) of the study and at the
end (after 2 months) of exercise rehabilitation program: Weight,
BMI, pulse, HR, BP, pain, range of motion, strength of muscles,
cardiovascular fitness & functional level.
Results
The results showed that there is a frequency of 15.5%,
46% & 38.5% of osteoarthritis knee patients in the age group of
40-50 years, 51-60 & > 60 years respectively and prevalence in
males & females is 31% & 69% respectively. The mean values
of weight & BMI at 0 month was 71.81 6.62 and 27.65 2.47
(in males) and 73.24 6.32 and 28.06 3.33 (in females) which
was reduced to 63.00 7.07 and 24.24 2.49 (in males) and
63.37 6.15 and 24.26 2.91 (in females) after 2 months of
exercise rehabilitation program. There is significant reduction
in level of pain whereas range of motion, strength, cardiovascular
fitness and functional level were improved significantly.
Conclusion
It is concluded that exercise rehabilitation program which
includes mild intensity long duration exercise program causes
significant decrease in weight & BMI in knee OA patients along
with reduction in level of pain whereas range of motion, strength,
cardiovascular fitness and functional level were improved.
Jagmohan Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Key Words
Knee OA, exercise rehabilitation program, pain, range of
motion, cardiovascular fitness, functional level
Introduction
Osteoarthritis (OA) is a common rheumatological disorder.
It is a degenerative joint disorder characterized by destruction
of articular cartilage and formation of a new bone at the joint
surfaces. Its onset is usually in older age group i.e., beyond 40
years of age. Both men and women are affected, but symptoms
in women occur earlier and appear to be more severe than in
men (Lawrence et al, 1998). Knee joint is the most commonly
affected region of the body. Predominant feature is pain along
with decrease in the range of motion. As the disease progresses,
movement in the affected joint becomes increasingly limited,
initially as a result of pain and muscular spasm, followed by
capsular fibrosis, osteophyte formation and remodeling of bone.
One of the worst things about OA is its negative effect on
the quality of life. Patients with OA, especially of the weight
bearing joints, are less active and tend to be less fit with regard
to musculoskeletal and cardiovascular status than normal
controls (Minor et al, 1988; Philbin et al 1995 and Reis et al,
1995). Various medical conditions are found to be associated
with secondary OA and are potential risk factors for osteoarthritis
(Al-Arfaz, 2003; Hart et al, 1995; Sun et al, 2000). These medical
conditions include diabetes mellitus (Sturmer et al, 2001) and
obesity (Bliddal and Christensen, 2006). The aim of this study
is to find out prevalence of OA knee in different age groups & in
different sexes and effect of exercise rehabilitation program on
pain, range of motion, strength, cardiovascular fitness and
functional level of patients with OA knee.
Material & Methods
A group of 200 patients of established osteoarthritis of knee
ranging in age from 40-65 years were included in the study.
Patients were randomly divided into two groups: Group A
(Experimental Control Group, n=100) and Group B (Experimental
Group, n=100).
Patients with a history of condition known to preclude
exercise were excluded from the study. Such conditions are
coronary heart disease, myocardial infarction, unstable angina,
chronic bronchitis, emphysema, peripheral vascular disease,
thrombophlebitis, embolism, kidney failure, uncontrolled
hypertension etc. Patients were explained the study protocol
and written consent was taken before the start of study program.
In order to make the groups more homogenous,
they were further subdivided into males and females.
The Treatment Program
Both the groups were treated for two months. Patients of
experimental control group were treated with conventional
physiotherapy program and patients of experimental group were
treated both with conventional physiotherapy program and
exercise rehabilitation program based on guidelines given by
Arthritis Foundation (Gordon, 1993).
191
 Conventional physiotherapy program included application Functional status: Functional status was assessed by using
of hot packs, isometric exercises to quadriceps and hamstrings, the WOMAC (Western Ontario and McMaster Universities) Index
range of motion exercises, stretching exercises, joint mobilization of Osteoarthritis.
exercises and progressive resisted exercises.
For exercise rehabilitation program along with conventional Results
physiotherapy program, mild intensity long duration aerobic
conditioning exercises (at 60% of MHR) were given. Aerobic Table 1: Prevalence of Osteoarthritis knee in different age
warm up was given for 5-10 minutes. It included swinging of groups.
arms and legs (upwards, sideways, backwards & laterally).
Walking was given for 5 -10 minutes and cycling was given for Age Group Frequency Percentage
15-20 minutes (at 60% of MHR), 5 times a week. Aerobic
exercises were followed by cool down exercises for 5-10 minutes. 40-50 31 15.5%
Following parameters were assessed at the start of exercise
rehabilitation program, in the middle (after 1 month) of the study 51-60 92 46%
and at the end (after 2 months) of exercise rehabilitation program:
> 60 years 77 38.5%

1. The Physical Characteristics Total 200 100%

1. Age
Table 2: Prevalence of Osteoarthritis knee in males and females
2. Sex
3. Height Sex Group Frequency Percentage
4. Weight
5. Body mass index Males 62 31%
2. The clinical health status:
1. Pulse Females 138 69%
2. Heart rate
3. Blood pressure Total 200 100%
3. The health related fitness:
1. Level of Pain The values of physical characteristics, clinical health status
2. Range of motion of knee joint and health related fitness were recorded in the data sheets.
3. Strength of muscles Their means, S.D. and t-values were calculated with the help of
4. Cardiovascular fitness Microsoft Excel and SPSS software.
5. Functional status Table 1 shows prevalence of osteoarthritis knee in different
age groups. Different age groups 40-50 years, 51-60 years and
Methods of Measurement of Various > 60 years were taken. Their frequencies were recorded as 31,
92 and 77 with percentage 15.5%, 46% and 38.5% respectively.
Parameters
Table 2 shows prevalence of osteoarthritis knee in different
sex groups of males and females. The frequencies were
recorded as 62 in males and 138 in females with percentage
Measurement of Physical Characteristics 31% and 69% respectively.
Height: The height of the subjects was measured by using Table 3 shows mean differentials of physical characteristics
an Anthropometric rod. of males belonging to experimental control group and
Weight: Weight of the patient was measured by a weighing experimental group of osteoarthritis knee patients at 0 month,
machine. after 1 month & after 2 months. The mean value of age recorded
Body mass index: Body mass index of the patient was in experimental control group was 54.73 6.77 and in
calculated by the following formula: experimental group was 53.47 6.54 which was statistically not
Body mass index = Body weight (Kgs) significant during the whole study period. The mean value of
Height (meters)2 height recorded in experimental control group was 1.62 0.06
and in experimental group was 1.61 0.07 which was also
statistically not significant during the whole study period.
Measurement of Clinical Health Status The mean values of weight at 0 month, after 1 month &
Pulse: Pulse was measured by using manual method on after 2 months in experimental control group were 71.17 6.72,
radial artery. 69.27 6.51 & 67.63 6.79 and in experimental group were
71.81 6.62, 67.22 6.64 & 63.00 7.07 respectively which
Heart rate: Heart rate was measured by using POLAR Heart
were statistically not significant at 0 & 1 month but significant at
rate monitor.
2 months. The mean values of body mass index (BMI) at 0
Blood pressure: Blood pressure was measured by using a
sphygmomanometer. month, after 1 month & after 2 months in experimental control
group were 27.22 2.84, 26.51 2.85 & 25.85 2.63 and in
experimental group were 27.65 2.47, 25.88 2.48 & 24.24
Measurement of Health Related Fitness 2.49 respectively which were statistically not significant at 0 &
after 1 month but significant after 2 months.
Level of Pain: Pain was calculated by using Visual Analog
Table 4 shows mean differentials of physical characteristics
Scale (VAS).
of females belonging to experimental control group and
Range of motion (ROM): ROM was assessed by
experimental group of osteoarthritis knee patients at 0 month,
goniometric method.
after 1 month & after 2 months. The mean value of age recorded
Strength measurement: Isometric strength was measured
in experimental control group was 58.14 5.40 and in
by using Back-leg-chest dynamometer. Isotonic strength was
experimental group was 57.40 5.47 which was statistically not
measured by using weight cuffs.
significant during the whole study period. The mean value of
Cardiovascular fitness: Cardiovascular fitness was
height recorded in experimental control group was 1.59 0.06
assessed by using Crompton test.
and in experimental group was 1.58 0.07 which was also

192 Jagmohan Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 3: Mean differentials of physical characteristics of males belonging to experimental control group and experimental group of
knee osteoarthritis patients at different time intervals

Experimental Control Experimental t-value

Period Group (MeanSD) Group (MeanSD)

At 0 After 1 After 2 At 0 After 1 After 2 At 0 After 1 After 2

month month months month month months month month months

Age 54.73 54.73 54.73 53.47 53.47 53.47 0.74 0.74 0.74
(in years) 6.77 6.77 6.77 6.54 6.54 6.54

Weight 71.17 69.27 67.63 71.81 67.22 63.00 0.38 1.22 2.63*
(in kgs) 6.72 6.51 6.79 6.62 6.64 7.07

Height 1.62 1.62 1.62 1.61 1.61 1.61 0.60 0.60 0.60
(in meters) 0.06 0.06 0.06 0.07 0.07 0.07

BMI 27.22 26.51 25.85 27.65 25.88 24.24 0.63 0.93 2.49*
2.84 2.85 2.63 2.47 2.48 2.49
*p<0.05
Table 4: Mean differentials of physical characteristics of females belonging to experimental control group and experimental group
of knee osteoarthritis patients at different time intervals

Experimental Control Experimental t-value

Period Group (MeanSD) Group (MeanSD)

At 0 After 1 After 2 At 0 After 1 After 2 At 0 After 1 After 2

month month months month month months month month months

Age 58.14 58.14 58.14 57.40 57.40 57.40 0.80 0.80 0.80
(in years) 5.40 5.40 5.40 5.47 5.47 5.47

Weight 70.66 67.63 65.50 73.24 67.68 63.37 1.32 0.05 1.97*
(in kgs) 6.74 6.63 6.56 6.32 6.25 6.15

Height 1.59 1.59 1.59 1.58 1.58 1.58 0.9 0.9 0.9
(in meters) 0.06 0.06 0.06 0.07 0.07 0.07

BMI 27.91 26.70 25.85 28.06 25.92 24.26 0.36 1.61 3.60*
2.74 2.58 2.13 3.33 3.08 2.91

*p<0.05

Table 5: Mean differentials of clinical health status of males belonging to experimental control group and experimental group of
knee osteoarthritis patients at different time intervals

Experimental Control Experimental t-value

Parameter Group (MeanSD) Group (MeanSD)

At 0 After 1 After 2 At 0 After 1 After 2 At 0 After 1 After 2

month month months month month months month month months

Pulse 67.80 66.07 64.37 66.63 63.56 60.38 0.81 2.11* 3.21*
4.97 6.14 5.17 6.33 5.64 4.58

Heart Rate 69.40 69.32 66.07 68.59 66.63 62.31 0.54 1.97* 2.75*
5.39 4.34 5.49 6.35 6.33 5.26

B.P 151.40 146.40 137.33 154.00 152.31 145.37 0.87 2.21* 2.96*
(Systolic) 6.75 7.65 7.70 13.2 12.85 13.13

B.P 86.90 85.80 85.20 87.40 83.88 81.50 1.01 4.03* 6.04*
(Diastolic) 1.91 1.92 2.76 2.28 1.83 1.97

*p<0.05

Jagmohan Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 193
Table 6 : Mean differentials of clinical health status of females belonging to experimental control group and experimental group of
knee osteoarthritis patients at different time intervals.
Experimental Control Experimental t-value
Parameter Group (MeanSD) Group (MeanSD)

At 0 After 1 After 2 At 0 After 1 After 2 At 0 After 1 After 2

month month months month month months month month months

Pulse 71.20 72.69 68.53 72.62 68.97 64.04 0.88 2.26* 3.08*
9.04 9.69 9.05 9.83 5.64 4.58

Heart Rate 69.64 71.57 68.73 69.37 67.89 64.37 0.16 2.27* 2.71*
9.43 9.24 9.08 9.79 9.79 9.79

B.P 151.60 145.74 140.34 155.00 150.47 146.44 1.74 2.54* 3.04*
(Systolic) 9.54 8.71 8.09 13.11 12.74 13.14

B.P 87.34 86.00 85.43 87.53 83.91 81.50 0.37 5.38* 9.61*
(Diastolic) 3.68 2.64 2.73 2.29 1.88 2.03

*p<0.05
Table 7 :Mean differentials of health related fitness of males belonging to experimental control group and experimental group of
knee osteoarthritis patients at different time intervals
Experimental Control Experimental t-value
Parameter Group (MeanSD) Group (MeanSD)

At 0 After 1 After 2 At 0 After 1 After 2 At 0 After 1 After 2

month month months month month months month month months

Pain 6.67 5.53 4.73 6.81 4.28 2.63 0.34 4.04* 8.25*
1.52 1.31 1.14 1.69 1.11 0.83

R.O.M. 85.23 93.57 104.80 83.56 103.44 120.19 0.51 2.88* 4.84*
12.51 12.55 14.54 13.2 14.39 9.88

Strength 250.83 338.50 478.50 252.19 382.19 532.19 0.12 3.91* 4.80*
(Isometric) 45.94 44.20 44.20 43.81 43.81 43.81

Strength 1.80 2.47 2.67 1.84 2.84 4.13 0.18 3.26* 6.01*
(Isotonic) 3.68 2.64 2.73 2.29 1.88 2.03

C.V. 2.63 2.76 2.83 2.59 1.75 1.06 0.32 9.14* 21.52*
Fitness 0.49 0.43 0.38 0.50 0.44 0.25

Functional 3.40 2.49 1.39 3.35 2.05 0.85 0.56 4.75* 5.82*
status 0.33 0.35 0.35 0.37 0.38 0.38

*p<0.05
statistically not significant during the whole study period.
The mean values of weight at 0 month, after 1 month &
after 2 months in experimental control group were 70.66 6.74,
67.63 6.63 & 65.50 6.56 and in experimental group were
73.24 6.32, 67.68 6.25 & 63.37 6.15 respectively which
were statistically not significant at 0 & 1 month but significant at
2 months.. The mean values of body mass index (BMI) at 0
month, after 1 month & after 2 months in experimental control
group were 27.91 2.74, 26.70 2.58 & 25.83 2.13 and in
experimental group were 28.06 3.33, 25.92 3.08 & 24.26
2.91 respectively which were statistically not significant at 0 & 1
month but highly significant at 2 months.
Table 5 shows mean differentials of clinical health status of
males belonging to experimental control group and experimental
group of osteoarthritis knee patients at 0 month, after 1 month &
after 2 months. The mean values of pulse recorded in
experimental control group at 0 month, after 1 month & after 2
months were 67.80 4.97, 66.07 6.14 & 64.37 5.17 and in
experimental group were 66.63 6.33, 63.56 5.64 & 60.38
4.58 respectively which were statistically not significant at 0
month but significant after 1 month and after 2 months.
The mean value of heart rate recorded in experimental
control group at 0 month, after 1 month & after 2 months were
69.40 5.39, 69.32 4.34 & 66.07 5.49 and in experimental
group were 68.59 6.35, 66.63 6.33 & 62.31 5.26
respectively which were statistically not significant at 0 month
and 1 month but significant after 2 months.
The mean values of blood pressure (systolic) at 0 month,
after 1 month & after 2 months in experimental control group
were 151.4 6.75, 146.40 7.65 & 137.33 7.70 and in
experimental group were 154 13.2, 152.31 12.85 & 145.37
13.13 respectively which were statistically not significant at 0
month but significant after 1 month and after 2 months.
The mean values of blood pressure (diastolic) at 0 month,
after 1 month & after 2 months in experimental control group
were 86.90 1.91, 85.8 1.92 & 85.20 2.76 and in
experimental group were 87.4 2.28, 83.88 1.83 & 81.5
1.97 respectively which were statistically not significant at 0
month but significant after 1 month and at 2 months.
Table 6 shows mean differentials of clinical health status of

194 Jagmohan Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
Table 8: Mean differentials of health related fitness of females belonging to experimental control group and experimental group of
knee osteoarthritis patients at different time intervals
Experimental Control Experimental t-value
Parameter Group (MeanSD) Group (MeanSD)

At 0 After 1 After 2 At 0 After 1 After 2 At 0 After 1 After 2

month month months month month months month month months

Pain 7.21 5.66 4.23 7.02 4.35 3.00 0.88 7.85* 7.36*
1.26 1.09 1.21 1.25 0.86 0.69

R.O.M. 85.90 93.83 109.83 85.28 103.87 122.49 0.27 4.30* 5.88*
13.56 13.13 12.62 13.0 14.25 12.27

Strength 256.79 342.43 484.43 250.81 380.81 530.81 0.70 4.52* 5.47*
(Isometric) 49.73 49.46 49.38 50.19 50.19 50.19

Strength 1.86 2.24 2.62 1.87 2.90 4.06 0.07 5.00* 9.87*
(Isotonic) 0.81 0.77 0.92 0.81 0.78 0.79

C.V. 2.53 2.64 2.76 2.60 1.69 1.02 0.83 11.87* 32.57*
Fitness 0.50 0.48 0.43 0.49 0.47 0.12

Functional 3.35 2.46 1.36 3.36 2.07 0.87 0.16 6.45* 8.11*
status 0.37 0.36 0.36 0.35 0.35 0.35

*p<0.05
females belonging to experimental control group and
experimental group of osteoarthritis knee patients at 0 month,
after 1 month & after 2 months. The mean values of pulse
recorded in experimental control group at 0 month, after 1 month
& after 2 months was 71.20 9.04, 72.69 9.69 & 68.53 9.05
and in experimental group was 72.62 9.83, 68.97 9.63 &
64.04 8.09 respectively which were statistically not significant
at 0 month but significant after 1 month and after 2 months.
The mean value of heart rate recorded in experimental
control group at 0 month, after 1 month & after 2 months were
69.64 9.43, 71.57 9.24 & 68.73 9.08 and in experimental
group were 69.37 9.79, 67.89 9.79 & 64.37 9.79
respectively which was statistically not significant at 0 month
but significant after 1 month and after 2 months.
The mean values of blood pressure (systolic) at 0 month,
after 1 month & after 2 months in experimental control group
were 151.60 9.54, 145.74 8.71 & 140.34 8.09 and in
experimental group were 155 13.11, 150.47 12.74 & 146.44
13.14 respectively which was statistically not significant at 0
month but significant after 1 month and after 2 months.
The mean values of blood pressure (diastolic) at 0 month,
after 1 month & after 2 months in experimental control group
were 87.34 3.68, 86.00 2.64 & 85.43 2.73 and in
experimental group were 87.53 2.29, 83.91 1.88 & 81.5
2.03 respectively which was statistically not significant at 0 month
but significant after 1 month and after 2 months.
Table 7 shows mean differentials of health related fitness
of males belonging to experimental control group and
experimental group of osteoarthritis knee patients at 0 month,
after 1 month & after 2 months. The mean values of pain
recorded in experimental control group at 0 month, after 1 month
& after 2 months were 6.67 1.52, 5.53 1.31 & 4.73 1.14
and in experimental group were 6.81 1.69, 4.28 1.11 & 2.63
0.83 which was statistically not significant at 0 month but
significant after 1 month and after 2 months.
The mean values of range of motion at 0 month, after 1
month & after 2 months recorded in experimental control group
were 85.23 12.5, 93.57 12.55 & 104.80 14.54 and in
experimental group were 83.56 13.29, 103.44 14.39, 120.19
9.88 respectively which was statistically not significant at 0
month but significant after 1 month and after 2 months.
The mean values of strength (isometric) at 0 month, after 1
month & after 2 months in experimental control group were
250.83 45.94, 338.50 44.20 & 478.50 44.20 and in
experimental group were 252.19 43.81, 382.19 43.81 &
532.19 43.81 respectively which was statistically not significant
at 0 month but significant after 1 month and after 2 months.
The mean values of strength (isotonic) at 0 month, after 1
month & after 2 months in experimental control group were 1.80
0.87, 2.47 0.86 & 2.67 1.03 and in experimental group
were 1.84 0.86, 2.84 0.88 & 4.13 0.87 respectively which
was statistically not significant at 0 month but significant after 1
month and after 2 months.
The mean values of cardiovascular fitness at 0 month, after
1 month & after 2 months in experimental control group were
2.63 0.49, 2.76 0.43 & 2.83 0.38 and in experimental group
were 2.59 0.50, 1.75 0.44 & 1.06 0.25 respectively which
was statistically not significant at 0 month but significant after 1
month and after 2 months.
The mean values of functional status at 0 month, after 1
month & after 2 months in experimental control group were 3.40
0.33, 2.49 0.35 & 1.39 0.35 and in experimental group
were 3.35 0.37, 2.05 0.38 & 0.85 0.38 respectively which
was statistically not significant at 0 month but significant after 1
month and after 2 months.
Table 8 shows mean differentials of health related fitness
of females belonging to experimental control group and
experimental group of osteoarthritis knee patients at 0 month,
after 1 month & after 2 months. The mean values of pain
recorded in experimental control group at 0 month, after 1 month
& after 2 months were 7.21 1.26, 5.66 1.09 & 4.23 1.21
and in experimental group were 7.02 1.25, 4.35 0.86 & 3.00
0.69 respectively which were statistically not significant at 0
month but significant after 1 month and after 2 months.
The mean value of range of motion recorded at 0 month,
after 1 month & after 2 months in experimental control group
were 85.90 13.56, 93.83 13.13 & 109.83 12.62 and in
experimental group were 85.28 13.05, 103.87 14.25, 122.49
12.27 respectively which was statistically not significant at 0
month but significant after 1 month and after 2 months.
The mean values of strength (isometric) at 0 month, after 1
month & after 2 months in experimental control group were
256.79 49.73, 342.43 49.46 & 484.43 49.38 and in
experimental group were 250.81 50.19, 380.81 50.19 &

Jagmohan Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 195
530.81 50.19 respectively which was statistically not significant
at 0 month but significant after 1 month and after 2 months.
The mean values of strength (isotonic) at 0 month, after 1
month & after 2 months in experimental control group were 1.86
0.81, 2.24 0.77 & 2.62 0.92 and in experimental group
were 1.87 0.81, 2.90 0.78 & 4.06 0.79 respectively which
was statistically not significant at 0 month but significant after 1
month and after 2 months.
The mean values of cardiovascular fitness at 0 month, after
1 month & after 2 months in experimental control group were
2.53 0.50, 2.64 0.48 & 2.76 0.43 and in experimental group
were 2.60 0.49, 1.69 0.47 & 1.02 0.12 respectively which
was statistically not significant at 0 month but significant after 1
month and after 2 months.
The mean values of functional status at 0 month, after 1
month & after 2 months in experimental control group were 3.35
0.37, 2.46 0.36 & 1.36 0.36 and in experimental group
were 3.36 0.35, 2.07 0.35 & 0.87 0.35 respectively which
was statistically not significant at 0 month but significant after 1
month and after 2 months.
Discussion
Onset of osteoarthritis is usually in older age group. This
has been stated in several studies like Lawrence et al, 1966;
Downie 1993; Adams and Hamlen, 1996; Joshi and Kotwal,
2000; Haslett et al, 2000; Braunwald et al, 2001; OSullivan and
Schmitz, 2001. Table 1 of our study tallies with the above studies
in which 46% of patients falls under the age group of 50-60
years.
Both men and women are affected, but symptoms in women
occur earlier and appear to be more severe than in men
(Lawrence et al, 1998). About two-third to three-fourth of adults
with osteoarthritis knee are women (Jordan et al, 1995).
Prevalence of osteoarthritis knee in males and females as shown
in Table 2 of our study also indicates that osteoarthritis knee is
more frequently found in females than in males. 69% of our
patients were females and only 31% were males. This finding is
also supported by Moskowitz et al, 1992 who reported that
osteoarthritis knee occurs more commonly in women during later
part of their life.
Body mass index (BMI) is associated with onset and
progression of osteoarthritis of the knee was studied by Reijman
et al, 2007 in his famous The Rotterdam study. They
investigated the relationship between body mass index and the
incidence and progression of radiological knee osteoarthritis,
they studied 3585 individuals aged e 55 years. A high body
mass index > 27 kgs/m2 was found to be associated with
incidence and progression of osteoarthritis knee. Table 3 and 4
of our study shows similar findings in which BMI at the starting
of exercise rehabilitation program is 27.22 in males and 27.91
in females.
Weight reduction programs helps in the management of
osteoarthritis knee. Several studies revealed the effect of
exercises in reducing pain and disability in patients of
osteoarthritis knee. The studies done by Bliddal and Christensen,
2006; Rogind et al, 1998 suggests the importance of reducing
weight in the management of osteoarthritis knee. Huang et al,
2000 also evaluated the effect of weight reduction on the
rehabilitation of patients with knee osteoarthritis and obesity.
Weight reduction was found to be a practical adjuvant treatment
in the rehabilitation of patients with knee osteoarthritis. Table 3,
4, 7 & 8 of our study also tallies with the study of Huang et al,
2000 which indicates that weight reduction reduces pain &
improves functional status in patients of osteoarthritis knee.
Cornelissen et al, 2009 studied the effects of aerobic training
intensity on resting, exercise and post-exercise blood pressure,
heart rate and heart-rate variability. They aimed to investigate
the effects of endurance training intensity on systolic blood
pressure (SBP) and heart rate (HR) at rest before exercise, and
196 Jagmohan Singh / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
during and after a maximal exercise test; and on measures of
heart rate variability at rest before exercise and during recovery
from the exercise test. The results showed that in the three
conditions, endurance training at lower and higher intensity
reduced systolic blood pressure significantly. In conclusion, in
participants at higher age, both training programmes exert similar
effects on systolic blood pressure at rest, during exercise and
during post-exercise recovery. Tables 5 & 6 of our study showed
similar results on pulse, heart rate, systolic and diastolic blood
pressures.
The effect of regular physical exercise for reducing pain,
increasing range of motion of joints and improving strength of
muscles is now evident (American College of Rheumatology,
2000; Deyle et al, 2000; Holden et al, 2008; Roddy et al, 2005;
Thomas et al, 2002). Several studies have revealed the effects
of regular physical exercise on various health related fitness
parameters in osteoarthritis of knee patients (Fransen et al, 2007;
Jan et al, 2009; Jordan et al, 2004; Smidt et al, 2005; Taylor et
al, 2007).
Cameron et al (2006) studied the outcomes on patients
with osteoarthritis treated with manual physical therapy and
exercise. There was increase in total passive range of motion of
joints. Numeric pain rating scores decreased by a mean of 5
points (range 2 7 points) on 0 to 10 point scale. All patients
exhibited reductions in pain and increases in passive range of
motion as well as a clinically meaningful improvement in function.
Table 7 & 8 of our study shows similar type of effects on pain
and range of motion. After 2 months of exercise rehabilitation
program, pain reduced significantly and range of motion
improved significantly in both males and females.
Kladny (2005) studied the role of physical therapy on
osteoarthritis. Physical therapy is used as a part of guidelines
and recommendations in the treatment of osteoarthritis. Different
methods were used in the treatment of osteoarthritis. There is
evidence that manual physical therapy and exercise improve
function and reduce pain in osteoarthritic joints. Table 7 & 8 of
our study shows improvement in functional status of our patients.
Several studies have revealed decreased cardiovascular
fitness in the patients of osteoarthritis (Braunwald et al, 2001;
McArdle et al, 1991; Minor et al, 1988; Philbin et al, 1995; Reis
et al, 1995). Cardiovascular fitness is defined as the ability to
continue or persist in strenuous task involving large group of
muscles for extended period of time (American College of Sports
Medicine, 1995; Baroonwaski et al, 1992; Heyward, 1991). This
cardiovascular deconditioning results decreased efficiency in
delivery of oxygen to the skeletal muscles (Perry, 1985). The
inactivity resulted from reduced cardiovascular fitness has further
consequences of leading to aggravation of symptoms in the
patients of osteoarthritis knee.
Minor et al (1989) studied a group of 120 patients with
rheumatoid arthritis and osteoarthritis volunteered to be subjects
for this study of aerobic versus non-aerobic exercise. Patients
were randomized into an exercise program of aerobic walking,
aerobic aquatics or non-aerobic range of motion exercise.
Exercise tolerance, disease-related measures and self-reported
health status were assessed. The aquatics and walking exercise
groups showed significant improvement over the control group
in aerobic capacity, 50-foot walking time, depression, anxiety
and physical activity after the exercise program. Table 7 & 8 of
our study showed similar results.
LaMantia and Marks (1995) studied the efficacy of aerobic
exercises for treating patients of osteoarthritis of the knee.
Supervised walking programmes and aquarobics combined with
stretching and strengthening routines with patient education were
given for experimental group. Control group received a non
aerobic exercise programme with stretching and strengthening
activities with routine patient care. The study revealed decreased
pain, increased functional and aerobic capacity in experimental
group followed by 12 weeks physical conditioning programme
when compared with controls receiving a non aerobic exercise
programme. Table 7 & 8 of our study showed similar results.
Conclusion
It is concluded that exercise rehabilitation program which
includes mild intensity long duration exercise program causes
decrease in weight & BMI in knee OA patients along with
reduction in pain whereas range of motion, strength,
cardiovascular fitness and functional level were improved
significantly.
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Effect of Supervised Versus Home Based Cardiac Rehabilitation
on Heart Rate Recovery in Patients with Coronary Artery bypass
Grafting
S Shagufta*, Jamal Ali Moiz**, Rajeev Aggarwal***
*Post Graduate Student, Cardiopulmonary Physiotherapy, Jamia Hamdard, New Delhi, **Assistant Professor, Centre for Physiotherapy
and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, ***Physiotherapist, Neuro Science Centre, AIIMS, New Delhi
Abstract
Purpose
The autonomic dysfunction is known to adversely affect
clinical outcome in patients with cardiovascular disease, and
exercise has been shown to modify the symparthovagal control
of heart rate. The purpose of this study was to investigate the
effects of four weeks supervised and home based phase II
cardiac rehabilitation (CR) on Heart rate recovery (HRR) in
patient with coronary artery bypass grafting (CABG) after 6
minute walk test.
Design
A prospective, randomized, comparative study.
Setting
Cardiopulmonary Physical therapy Department, National
Heart Institute (All India Heart Foundation ) East of Kailash,
New Delhi.
Methods
Thirty patients having undergone CABG were randomly
assigned to two groups. Group A (n=15) included patients who
underwent a supervised exercise program at physiotherapy
outpatient department, and Group B (n=15) included patients
who underwent home exercise program at their residence. HRR
was measured at discharge (baseline test) and after four weeks
of phase II CR ( follow up test) following a 6 minute walk test.
Results
Data was analyzed using SPSS 15.0. At follow up, both
the groups had a significantly higher recovery of heart rates
over 2 minutes ( p<0.05) compared to their baseline
measurements.
Conclusion
Our results point out that a four weeks phase II cardiac
rehabilitation program has positive effect on HRR in patients
having undergone CABG in both the groups and is consistent
with autonomic improvement. Home based phase II CR is
equally effective in improving heart rate reserve as compared
to supervised exercise group. Similar improvements of HRR in
both the groups strengthens the rationale for promoting home
Address for correspondence:
Jamal Ali Moiz
Assistant Professor,
Centre for Physiotherapy and Rehabilitation Sciences,
Jamia Millia Islamia, New Delhi
Email : jmoiz@jmi.ac.in
Phone No: 011 26981208
S Shagufta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
based exercise program , as the patients need not have to visit
hospital regularly for a supervised exercise program.
Key Words
Coronary artery bypass surgery, Cardiac rehabilitation,
Heart rate recovery.
Introduction
Cardiovascular disease is the prevailing non communicable
cause of death and disability in Indian subcontinent, and will
become the prevailing overall cause of mortality among the
inhabitants of south Asia in the next 20 years1. This lead to an
increase in coronary artery revascularization surgery (CABG).
Today it accounts for more than 60%, and every year 25,000
CABGs are being carried out2.
There is substantial evidence to conclude cardiac
rehabilitation (CR) is reasonable and necessary following CABG
surgery. Phase II cardiac rehabilitation programs are associated
with significantly improved exercise tolerance and functional
capacity ,increasing psychosocial well being, alleviating activity
related symptom reducing disability and decreasing
cardiovascular morbidity andmortality3.
Exercise training has been a core component of CR
programs, regular exercise training in person with cardiovascular
disease results in changes in muscular, neurohormonal
systems4.
Heart rate recovery (HRR) is defined as [maximum/ peak
HR at specific time period after exercise] and represented as
the drop in heart rate during that time interval 5.It has been
demonstrated that HRR may be used as an outcome measure
in stratifying the risk of the patients after completion of cardiac
rehabilitation programs, especially after phase II. The
investigations of the effect of home based exercise program
and supervised exercise program on HRR after a short term
cardiac rehabilitation program (4weeks) has not been clearly
demonstrated. In this study consideration has been given to the
incorporation of HRR into routine exercise test interpretation
use of those findings to confirm the results, and expand the
prognostic importance of HRR in patients with CABG undergoing
sub maximal exercise test, as proposed to symptom limited
exercise testing after four week phase II cardiac rehabilitation.
Statement of Question
Will a short term phase II supervised exercise program
improves HRR better than a home based exercise program in
patient with CABG after sub maximal exercise testing?
Material and Methods
Inclusion Criteria
1. Age group : 40-65years
2. No previous CABG surgery
3. Left ventricular ejection fraction(EF) >50%
4. Absence of ventricular ectopics
199
 5. No neuromuscular, skeletal impairments that would
prohibit exercise.
6. Uncomplicated clinical course in hospital (not>12hours
on ventilator, not >48hours in ICU, infection, shock)
7. Sinus rhythm.
Exclusion Criteria
1. Resting HR> 120 BPM
2. Resting SBP >200mmHg
DBP> 100mmHg
3. Orthostatic BP drop by 20 mmHg or more.
4. Acute systemic illness or fever.
5. Uncontrolled arterial or ventricular dysrhythmias
6. Uncontrolled CHF
7. III degree AV block
8. Coexisting vavular and /or peripheral vascular diseases,
thrombophlebitis
9. Recent embolism.
10. Uncontrolled diabetes
11. Unstable angina
12. Those that could not complete test at discharge or after
four weeks of CR
Study Design
Pretest and posttest experimental design.
Variables
Dependant variable: Heart rate recovery
Independent variable: Cardiac rehabilitation
Instrumentation
Location: a 15 meter straight level corridor
Equipment: pulse oximeter (PM50-MINDRAY) , Inch tape,
stopwatch, chalk marker, cones, wheel chair
Procedure
Thirty eligible patients having undergone CABG who were
referred by cardiovascular surgeons participated in the study.
There were 90% males and 10% females. All of them completed
phase I cardiac rehabilitation program such as early mobilization,
walking etc under supervision after surgery on transfer to an
ICU and wards. Before baseline exercise test at discharge, these
30 patients were randomly assigned to one of the following two
groups for four weeks. The subjects in any of the group were
blinded to the interventions of the other group and the
experimental procedure and risk of exercise were fully explained
to each subject and signed informed consent was obtained.
Protocol
Patient who were assigned to phase II cardiac rehabilitation
at discharge into a supervised and a home exercise group were
given exercise intervention accordingly
Group A (Supervised cardiac rehabilitation
group)
Group B (Home based cardiac rehabilitation
group)
Patients randomized to this group (n=15) were instructed
to conduct a home based exercise program with an intensity
corresponding to RPE of 4 to 6 on a 10 point scale. Patients
were advised to exercise three times a week, for 45 minutes
(average). Exercise training involved ROM exercise, walking,
and stair climbing. To control for their adherence to exercise,
the subjects and their family were asked to document the
exercise in an exercise log/ monitoring chart. Individually
prescribed home based exercise was given and updated by
telephonic consultation every week by the researcher. Both the
groups were given education and counseling. Dietician gave
them advice on balance diet in hospital and after discharge in
the form of diet chart
Exercise Testing Protocol
The participants underwent a sub maximal exercise testing,
i.e. 6MWD at discharge and 4weeks follow up at national heart
institute according to ATS guidelines7.
Heart Rate Recovery
After achieving peak HR at the end of 6MWT, patients went
into a recovery phase for at least 5minutes. The reduction in
HR from immediately after peak exercise to the HR after 2min
was defined as HRR5. All subjects in two groups received sub
maximal exercise test at discharge, (baseline test) and 4weeks
later ( follow up test)
Data Analysis
Data analysis was performed using SPSS version15.0. The
descriptive variables were expressed as, mean + SD. The main
outcome measure, heart rate recovery expressed in beats per
minutes, between two groups at the time of discharge and after
four weeks follow up were analyzed and compared using Levens
t- test to examine the differences. Statistical significance within
groups from baseline to follow up was evaluated using paired t-
test. Statistical significance was assumed at p <0.05.
Table1: Demographic Characteristics of patients
Supervised group Home exercise group
Group A Group B
Number of 15 15
subjects
Age (years) 56.358.07 58.877.87
Height 1.660.07 1.640.08
(meters)
Weight (Kg) 65.7813.40 68.3710.12

Patient randomized to this group (n=15) were enrolled in a BMI, Kg/m2 22.944.08 25.072.38
45 minutes (average time) exercise session. ROM exercises,
walking, and stair climbing with self controlled exercise intensity Ejection 56.215.35 57.315.41
set at level of 4-6 on Borgs 10 point RPE scale (safe range fraction, %
recommended for cardiac patient6 ) ,was used to train the
patients. Exercises were supervised by researcher during the Number of 3.00.75 3.00.84
exercise session. The training frequency was 3 times /week (24 grafts
sessions) for 4 weeks.
Results
Thirty patients were analyzed for the study (n=15 in each
group).The sample consisted of 90% males and 10% females.

200 S Shagufta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3
The demographic data is as shown in table 1. Table 4: Exercise testing parameters (6MWT), comparison
Heart rate recovery expressed in beats per minute (bpm) between the groups
was measured at discharge (HRR b) and after four weeks (HRR
f) of phase II Cardiac Rehabilitation in supervised exercise group Parameters Group A Group B p value
Table 2: HRR comparison within the groups (n=15) (n=15)

Groups HRRb HRRf RHR,bpm Baseline 90.410.16 88.412.86 0.652

n=15 n=15 Paired t test
Follow 84.910.10 85.411.91 0.909
t p up
PHR,bpm Baseline 119.316.10 121.217.38 0.763
Group A 30.210.5 35.79.5 6.11 0.001
Follow 124.515.70 123.8618.29 0.916
Group B 29.58.9 34.49.9 7.75 0.001 up
HRR,bpm Baseline 30.210.53 29.58.99 0.839
(Group A) and home exercise group (Group B). There was no
significant difference in HRR at baseline [Group A 30.210.5, Follow 35.79.66 34.49.95 0.726
up
Table 3: HRR comparison between the groups
Mean change in HRR 5.83.40 5.22.73 0.640
Variable Group Group Indepen follow from baseline
A B dent test and up testing, bpm

t p values. The improvements at follow up in the supervised and

HRRb 30.210.5 29.58.9 0.205 0.839
n = 15
HRRf 35.79.5 34.49.9 0.345 0.726
n = 15
Group B 29.58.9; p<0.05] and HRR at follow up, [Group A
35.79.5, Group B 34.49.9; p<0.05] within the groups as shown
in table 2.
There was no significant difference in HRR between the
Fig. 1: Comparison of Heart Rate Recovery between Groups
groups (p<0.05) at follow up test as shown in table 3.
After 4 weeks of CR, HRR improved in both the groups
when compared to their baseline values. The mean improvement
being 5.83.40 bpm in group A and 5.22.73 bpm (p=0.640) in
group B from baseline to follow up as shown in Figure.1.
At baseline testing, there was no significant difference in
resting heart rates between the groups (mean SD, Group A
90.410.16, Group B 88.412.86; p=652). After 4 weeks, both
the groups showed lowered resting heart rates at follow up
testing (Group A 84.910.10, Group B 85.411.91; p=0.909)
and there was no significant difference between them.(p<0.05)
as shown in table 4.
Discussion
The results of this study showed significant improvements
in heart rate recovery in patients having undergone CABG after
a four weeks phase II Cardiac Rehabilitation in both supervised
and home based exercise group compared to their baseline
home exercise group are consistent with that in previously
published study by Legramante8. The parasympathetic tone
predominates at rest, and heart rate increases during exercise
in response to a combination of sympathetic activation and
parasympathetic withdrawal, with inverse occurring during
recovery after exercise3,9. The autonomic dysfunction is known
to have adverse effects on subsequent clinical outcome in
patients with coronary artery disease10.
The resting heart rates in the supervised exercise group
and home exercise group had significantly reduced at follow
up test, when compared to their baseline test values (p=0.652).
This was consistent with the previous work done by Legramante
and Shinji Sato et al 8,11. The possible explanation being that the
patients with coronary heart disease are subjected to activation
of neurohumoral mechanisms, especially the adrenergic
activation from sympathetic activity in early recovery phase after
cardiac events9,10. Reduced resting heart rate lowers the risk of
sudden cardiac death through increased vagal tone, which is a
parasympathetic activity9.
The recoveries of heart rate over 2 minutes at follow up
also showed significant improvement in both the study groups
and coincided with the previous work8. Legramante8 measured
HRR after 1 and 2 minutes, his findings showed that HRR in the
2nd minute after the cessation of cycle-ergometer exercise test
improved and showed a positive effect. The value of HRR in the
present study was in consistent with his results.
Exercise training during CR was associated with an
improvement in HRR, which may represent an improvement of
autonomic tone. These findings were consistent with the previous
studies that evaluated the effect of exercise-based CR on HRR
and showed a positive result. Study done by Tiukinhoy12 and
colleagues reported a significant improvement in HRR in the
intervention subjects (who underwent structured phase II CR,
6- 9 months time between exercise tests using treadmill Bruce
protocol); Sen-Wei13 and colleagues also reported a significant
improvement in HRR in CR group (training given using stationary
bicycle or walking on treadmill, 36 sessions for 3 months) from
baseline to follow up. In the present study there was no significant
difference in HRR between the supervised and home exercise
groups after 4 weeks phase II CR (24 sessions of ROM
exercises, walking, stair climbing, after 6 MWT). Thus, HRR
might provide an additional simple marker of effectiveness of
physical training programs in cardiac patients.
The improvements in HRR may be related to the molecular
mechanisms underlying the regulation of HR recovery.
Chromosome CHRM2 plays a fundamental role in cardiac
autonomic regulation. Activation of cardiac vagal efferents leads

S Shagufta / Indian Journal of Physiotherapy and Occupational Therapy. July-Sep., 2011, Vol.5, No.3 201
to release of acetylcholine, which acts on cardiac CHRM2 to
decrease HR14. Another possible explanation for the increase
in HRR after CR is the effect of beta blockers. Beta blocking
medication decrease resting heart rate and reduce the ability to
achieve maximum heart rate. Previous studies have been
inconsistent over the effects of beta blockers on HRR. Desai15
and colleagues reported that beta blockers affect HR in recovery
most likely through an indirect effect by reduction of
chronotropism.
Future Research
HRR has been shown to be a predictor of mortality, and
this study demonstrated that HRR improved in a sample of
patients who completed CR. It is not known whether improving
HRR will have a meaningful effect on survival. Future research
is needed to more adequately address whether improving HRR
improves mortality. T he effect of beta-blockers on HRR also
needs to be investigated further.
Conclusion
Four weeks supervised phase II Cardiac Rehabilitation
significantly improved Heart Rate Recovery in low risk population
after CABG surgery; home based phase II Cardiac Rehabilitation
in the similar population was equally effective and showed
significant improvements in Heart Rate Recovery. There was
no significant difference in Heart Rate Recovery between the
supervised group and home exercise group after the completion
of four weeks phase II Cardiac Rehabilitation. Thus, the null
hypothesis has been supported.
Acknowledgements
The authors would like to thank to all the doctors, nursing
staff, and physiotherapists at National Heart Institute (All India
Heart Foundation) East of Kailash, New Delhi for their support
to conduct this research.
Interest of Conflict
The authors have no conflicts of interest to declare.
References
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disease in the Indian subcontinent. Indian J Med Res 124,
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Bansal,N Trehan.Prevelence of cardio vascular risk factors
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H. Makikakillio, Heikki V Huikuri, Claude Bouchard, and
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