Indian Journal of Physiotherapy and Occupational Therapy

EDITOR-IN-CHIEF
Archna Sharma
Ex- Head. Dept. of Physiotherapy, G. M. Modi Hospital, Saket, New Delhi - 110 017
Email : editor.ijpot@gmail.com

Executive Editor
Prof. R K Sharma
Dean (R&D), Saraswathi Institute of Medical Sciences, Hapur, UP, India
Formerly at All India Institute of Medical Sciences, New Delhi

Sub Editor
Kavita Behal Sharma
MPT (Ortho)

INTERNATIONAL EDITORIAL ADVISORY BOARD NATIONAL EDITORIAL ADVISORY BOARD

1. Vikram Mohan (Lecturer) Universiti Teknologi MARA,
Malaysia
2. Angusamy Ramadurai (Principal) Nyangabgwe Referral
Hospital, Botswana
3. Faizan Zaffar Kashoo (Lecturer) College Applied Medical
Sciences, Al-Majma'ah University, Kingdom of Saudi Arabia
4. Amr Almaz Abdel-aziem (Assistant Professor) of
Biomechanics, Faculty of Physical Therapy, Cairo University,
Egypt
5. Abhilash Babu Surabhi (Physiotherapist) Long Sault,
Ontario, Canada
6. Avanianban Chakkarapani (Senior Lecturer) Quest
International University Perak, IPOH, Malaysia
7. Manobhiram Nellutla (Safety Advisor) Fiosa-Miosa Safety
Alliance of BC, Chilliwack, British Columbia
8. Jaya Shanker Tedla (Assistant Professor) College of Applied
Medical Sciences, Saudi Arabia
9. Stanley John Winser (PhD Candidate) at University of Otago,
New Zealand
10. Salwa El-Sobkey (Associate Professor) King Saud University,
Saudi Arabia
11. Saleh Aloraibi (Associate Professor) College of Applied
Medical Sciences, Saudi Arabia
12. Rashij M, Faculty-PT Neuro Sciences College of Allied Health
Sciences, UAE
13. Mohmad Waseem, (Exercise Therapist) Alberta- CANADA
14. Muhammad Naveed Babur (Principle & Associate Professor)
Isra University, Islamabad, Pakistan
15. Zbigniew Sliwinski (Professor) Jan Kochanowski University
in Kielce
16. Mohammed Taher Ahmed Omar (Assistant professor) Cairo
University, Giza, Egypt
17. Ganesan Kathiresan (DBC Senior Physiotherapist) Kuching,
Sarawak, Malaysia
18. Kartik Shah (Health Consultant) for the Yoga Expo, Canada
19. Shweta Gore (Senior Physical Therapist) Narayan
Rehabilitation, Bad Axe, Michigan, USA
20. Ashokan Arumugam (PhD Candidate School of
Physiotherapy) University of Otago,,Dunedin, New Zealand
1. Charu Garg (Incharge PT) , Sikanderpur Hospital
(MJSMRS),Sirsa Haryana, India
2. Vaibhav Madhukar Kapre (Associate Professor) MGM
Institute of Physiotherapy, Aurangabad (Maharashtra)
3. Amit Vinayak Nagrale (Associate Professor) Maharashtra
Institute of Physiotherapy, Latur,Maharashtra
4. Manu Goyal (Principal), M.M University Mullana, Ambala,
Haryana, India
5. P.ShanmugaRaju (Asst.Professor & I/C Head) Chalmeda
AnandRao Institute of Medical Sciences, Karimnagar, Andhra
Pradesh
6. Sudhanshu Pandey (Consultant Physical Therapy and
Rehabilitation) Department \Base Hospital, Delhi
7. Khatri Subhash Maniklal (Professor & Principal) College of
Physiotherapy, Pravara Institute of Medical Sciences, Ahmed
Nagar, Maharashtra
8. Aparna Sarkar (Associate Professor) AIPT, AMITY
UNIVERSITY, Noida
9. Jasobanta Sethi (Professor & Head) Lovely Professional
University, Phagwara, Punjab
10. Patitapaban Mohanty (Assoc. Professor & H.O.D)
SVNIRTAR, Cuttack, Odisha
11. Suraj Kumar (HOD and Lecturer) Physiotherapy Rural
Institute of Medical Sciences & Research, Paramedical Vigyan
Mahavidhyalaya Saifai, Etawah,UP
12. U.Ganapathy Sankar (Vice Principal) SRM College of
Occupational Therapy, Kattankulathur,Tamil Nadu
13. Hemant Juneja (Head of Department & Associate Professor)
Amar Jyoti Institute of Physiotherapy, Delhi
14. Sanjiv Kumar (I/C Principal & Professor) KLEU Institute of
physiotherapy, Belgaum, Karnataka
15. Shaji John Kachanathu (Associate Professor) Jaipur
Physiotherapy College, Rajasthan, India
16. Narasimman Swaminathan (Professor, Course Coordinator
and Head) Father Muller Medical College, Mangalore
17. Pooja Sharma (Assistant professor) AIPT, Amity university,
Noida
18. Nilima Bedekar (Professor, HOD) Musculoskeletal Sciences,
Sancheti Institute College of Physiotherapy, Pune.

IFC PAGE FINAL.pmd 2 7/22/2013, 6:59 PM

 Indian Journal of Physiotherapy and Occupational Therapy
NATIONAL EDITORIAL ADVISORY BOARD SCIENTIFIC COMMITTEE
19. N.Venkatesh (Principal and Professor) Sri Ramachandra 1. Gaurav Shori (Assistant Professor) I.T.S College of
university, Chennai Physiotherapy
20. Meenakshi Batra (Senior Occupational Therapist), Pandit 2. Baskaran Chandrasekaran (Senior Physiotherapist) PSG
Deen Dayal Upadhyaya Institute for The Physically Hospitals, Coimbatore
Handicapped, New Delhi 3. Dharam Pandey (Sr. Consultant & Head of Department) BLK
21. Shovan Saha, T (Associate Professor & Head) Occupational Super Speciality Hospital, New Delhi
therapy School of allied health sciences,Manipal 4. Jeba Chitra (Associate Professor) KLEU Institute of
university,Manipal,, karnataka, Physiotherapy Belgaum, Karnataka
22. Akshat Pandey (Sports Physiotherapist) Indian Weightlifting 5. Deepak B.Anap (Associate Professor) PDVPPF's, College
Federation/ Senior Men and Woman / SAI NSNIS Patiala of Physiotherapy, Ahmednagar. ( Maharashtra)
23. Dr. Jagatheesan A (HOD-Paediatric Physiotherapy & 6. Shalini Grover (Assistant Professor) HOD-FAS,MRIU
Associate Professor) Saveetha College of Physiotherapy, 7. Vijay Batra (Lecturer) ISIC Institute of Rehab. Sciences
Thandalam, Chennai 8. Ravinder Narwal (Lecturer) Himalayan Hospital, HIHIT
24. Maneesh Arora (Professor and as Head of Dept) Sardar Medical University, Dehradun-UK.
Bhagwan (P.G.) Institute of Biomemical Sciences, Balawala, 9. Abraham Samuel Babu (Assistant Professor) Manipal
Dehradun, UK College of Allied Health Sciences, Manipal
25. Jayaprakash Jayavelu (Chief Physiotherapist) Medanta The 10. Anu Bansal (Assistant Professor and Clinical Coordinator)
Medicity, Gurgaon Haryana AIPT , Amity university, Noida
26. Deepak Sharan (Medical Director and Sole Proprietor) 11. Bindya Sharma (Assistant Professor) Dr. D. Y. Patil College
RECOUP Neuromusculoskeletal Rehabilitation Centre, New Of Physiotherapy, Pune
Delhi 12. Dheeraj Lamba (Lecturer) Institute of Allied Health
27. Vaibhav Agarwal (Incharge, Dept of Physiotherapy) HIHT, (Paramedical) Services, Education & Training (IAHSET) Govt. Medical
Dehradun 13. Soumya G (Assistant Professor) (MSRMC)
28. Shipra Bhatia (Assistant Professor) AIPT, Amity university, 14. Nalina Gupta Singh (Assistant Professor) Physiotherapy,
Noida Amar Jyoti Institute of Physiotherapy, University of Delhi
29. Jaskirat Kaur (Assistant Professor) Indian Spinal Injuries 15. Gayatri Jadav Upadhyay (Academic Head) Academic
Center, New Delhi Physiotherapist & Consultant PT, RECOUP Neuromusculoskeletal
Rehabilitation Centre, Bangalore
30. Prashant Mukkanavar (Assistant Professor) S.D.M College
of Physiotherapy, Dharwad, Karnataka 16. Nusrat Hamdani ( Asst.Professor and Consultant)
Neurophysiotherapy (Rehabilitation Center, Jamia Hamdard) New Delhi
31. Chandan Kumar (Associate Professor & HOD) Neuro-
physiotherapy, Mahatma Gandhi Mission's Institute of 17. Ramesh Debur Visweswara (Assistant Professor) M.S.
Physiotherapy, Aurangabad, Maharashtra Ramaiah Medical College & Hospital, Bangalore
18. Nishat Quddus (Assistant Professor) Jamia Hamdard, New Delhi

“Indian Journal of Physiotherapy and Occupational Therapy” An essential indexed peer reviewed journal for all physiotherapists &
occupational therapists provides professionals with a forum to discuss today’s challenges- identifying the philosophical and conceptual
foundations of the practice; sharing innovative evaluation and treatment techniques; learning about and assimilating new methodologies
developing in related professions; and communicating information about new practice settings. The journal serves as a valuable tool for
helping therapists deal effectively with the challenges of the field. It emphasizes articles and reports that are directly relevant to practice.
The journal is now covered by INDEX COPERNICUS, POLAND and covered by many internet databases. The Journal is registered with
Registrar of Newspapers for India vide registration number DELENG/2007/20988

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

Website: www.ijpot.com
© All Rights reserved The views and opinions expressed are of Editor
the authors and not of the Indian Journal of Physiotherapy and Archna Sharma
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IFC PAGE FINAL.pmd 3 7/22/2013, 6:59 PM

 I

Indian Journal of Physiotherapy and

Occupational Therapy
www.ijpot.com
Contents
Volume 07 Number 03 July-September 2013

1. Effect of Brief Intense TENS and Cryotherapy on the Symptoms Associated with Delayed ............................................ 01
Onset of Muscle Soreness in Healthy Male Subjects
S Aadil Rashid, Nishat Quddus, Belsare

2. The effect of Topical Application of Extra Virgin Olive Oil on Alleviating Knee ................................................................ 06
Pain in Patients with Knee Osteoarthritis: A Pilot Study
Abdul-Majeed Al Malty, Saja Hamed, Hashem AbuTariah, Mohammad Jebril

3. A Study to Compare the effectiveness of Treadmill and Cycle Ergometer on ..................................................................... 12

Endurance in Normal Subjects
Sharma Abhishek, Shah Arpita, Dey Sushant, Sharma Urvi

4. Effect of Aerobic Exercises on Serum IgE and Pulmonary Functions in Children with Bronchial Asthma ................... 15
Aisha A Hagag, Naglaa A Zaky

5. Efficacy of Scapular Movement with Mobilization in Patients with Shoulder Impingement .......................................... 20
Ajit Dabholkar, Tejashree Dabholkar, Sujata Yardi

6. Effect of Hip Position and Gender on Active Hip Internal Rotation and External ............................................................. 25
Rotation on the Dominant Side
Amit Agarwal, Amrit Kaur, Ganesh MSP

7. Electrophysiological Assessment of Clinically Diagnosed Patients of Carpal Tunnel ....................................................... 29

Syndrome in Western Maharashtra (India)
Joshi A G, Gargate A R, Patil S N

8. Effectiveness of Core Muscle Stabilization Training on Dynamic Balance in ...................................................................... 34

Mechanical Low Back Pain Patients
Apeksha O Yadav, Ketaki G Deshmukh

9. Effect of Knee Chest Position in Primary Dysmenorrhea- A Randomized Controlled Trial ............................................. 40
Arati Mahishale, Dinika Mascarenhas, Shobhana Patted

10. The effect of Strength Training on Normalizing the Tone and Strength of Spastic ............................................................. 45
Elbow Flexors in Subjects with Stroke
Bharath Kumar P V S R, V Sri Kumari, K Madhavi

11. Comparison of Supervised Rehabilitation vs. Home Based Unsupervised Rehabilitation ............................................... 50
Programs after Total Knee Arthroplasty: A Pilot Study
Bijender Sindhu, Manoj Sharma, Raj K Biraynia

12. Supervised V/s Unsupervised Constraint Induced Movement Therapy in Improving .................................................... 54
Upper Extremity Function in Spastic Hemiparetic Cerebral Palsy Children
Charu Chopra, Jaskirat Kaur

13. Effect of Proprioceptive Neuromuscular Facilitation in Hemiplegic Gait a Randomized ................................................. 59

Trial of 4 Weeks and a Follow up after 2 Weeks
Damaneek Kaur Mann, N A Ramasubramia Raja, Nidhi Bhardwaj, Jagmohan Singh

Content Final.pmd 1 8/1/2013, 8:32 AM

 II

14. Comparison of effects of Sitting-up using Rope Ladder versus Manual Supported .......................................................... 65
Sitting-up on Haemodynamic Variables in Patients after Coronary Artery Bypass Grafting
Deepti Garnawat, Faizan Ahmed, Muhammed Abid Geelani
15. Electrical Muscle Stimulation (EMS) Preserve Muscle Strength in Critically ill Patients- A Pilot Study ........................ 71
Dharam Pani Pandey, Ram Babu, Uday Shanker Sharma

16. Effect of Core Stability Exercises Versus Conventional Treatment in Chronic Low Back Pain ......................................... 76
Dheeraj Lamba, Suneeti Kandpal, Monika Joshi, Mamta Koranga, Neeta Chauhan

17. Efficacy of Electromyography Biofeedback Training on Trunk Stability in Chronic Low Back Pain .............................. 81
Hashim Ahmed, Amir Iqbal, Md Abu Shaphe

18. A Comparative Study between the effects of Static Somatosensory Balance Training and ............................................... 87
Static Vestibular Balance Training on Dynamic Balance and Fear of Fall in Institutionalized Elderly
Jyoti Laroia, Nusrat Hamdani, Majumi Mohammad Noohu

19. Efficacy of Eccentric Training and Muscle Energy Technique on Hamstring Flexibility in ............................................... 93
Sedentary College Students
Gurpreet Kaur, M Kashif Reza

20. Efficacy of Taping in Bell's Palsy ................................................................................................................................................... 98

Kaushal M, Saini S S, Singh N, Ghotra P K

21. Effect of Aerobic Exercises on Plasma Lipid Profile and Cardiorespiratory Fitness in Obese Women ......................... 104
Aisha A Hagag

22. Effect of Postoperative Ambulation on the Quality of Life in a Transtibial Amputee ...................................................... 109
Amit Saraf, Ankita Gupta, Jeewan S Prakash, Jedidiah S Prakash

23. Effect of High Power Pain Threshold Static Ultrasound Combined with Transverse ...................................................... 113
Friction Massage and Stretching on Upper Trapezius Myofascial Trigger Point
Hari Haran R, Singh Anand Kumar

24. Efficacy of Muscle Energy Technique in Combination with Strain-counterstrain ............................................................ 118
Technique on Deactivation of Trigger Point Pain
Amir Iqbal, Hashim Ahmed, Md Abu Shaphe

25. A Case Review of Perceptual Deficit in PRES: Detailed Perceptual Evaluation ................................................................ 124
is a Key to Definite Goal Achieving Techniques
Moushami S Kadkol

26. Perceived Stress, Sources and Severity of Stress among Physiotherapy Students in an Indian College ...................... 128
Tushar J Palekar, M G Mokashi

27. Effect of High Frequency, Low Magnitude Vibration on Bone Density and Lean ............................................................ 134
Content in Children with Down Syndrome
Naglaa A Zaky, Amira E Elbagalaty

28. A Comparative Study between Relaxation Technique and Aerobic Exercise in ................................................................ 140
Fatigue During Chemotherapy in Acute Lymphoblastic Leukemia in Children
Dhoriyani Narendra B, Bhatt Kaushal D, Smitha D

29. Predictors of Job Satisfaction among Physiotherapy Professionals ..................................................................................... 146

Nidhi Gupta, Shabnam Joshi

30. Cervico-thoracic Mobilization to Address LBA for a Patient with Lumbar Spondylolisthesis ...................................... 152
P P Mohanty, B Kuanar, B K Behera

31. Relationship of Cervicothoracic Curvature with Muscle Strength and ............................................................................... 156
Endurance in Subjects with Neck Pain
Parminder Kaur, Monalisa Pattnaik, Patit Paban Mohanty

Content Final.pmd 2 8/1/2013, 12:37 PM

 III

32. A Study on the Impact of Body Mass Index on Lower Back Extensor Endurance in ....................................................... 162
Apparently Healthy Subjects
V Pasupatham, Mohan Vikram, V Swaminathan, S Reka Rani

33. Study of the efficacy of the Mulligan's Movement with Mobilization and Taping ........................................................... 167
Technique as an Adjunct to the Conventional Therapy for Lateral Ankle Sprain
Punam Ghadi, Chhaya Verma

34. Comparative Study between the efficacy of Muscle Energy Technique and Static ........................................................... 172
Passive Stretching on Hamstring Flexibility in Healthy Indian College Athletes
Pratik A Gohil

35. Effect of Maitland Spinal Mobilization Therapy Versus Conventional ......................................................................... 177
Therapy in Lumbar Spondylosis with Radiculopathy
Priya Igatpurikar

36. Importance of Screening in 0-18 Months Infants by using INFANIB at Tertiary Hospital ............................................. 184
Parmar Sanjay, Praveen S Bagalkoti, Netravati Shettar, Rajlaxmi Kubasadgoudar

37. Effect of Stroke on Mantainence of Balance and Sense of Equilibrium .............................................................................. 187
Nidhi Kashyap, Savita Tamaria

38. Accessory Inspiratory Muscles Energy Technique effect on Pulmonary Function in COPD Subjects .......................... 192
Akanksha Anand, Ravinder Narwal, Girish Sindhwani
39. A Randomized Comparison of effectiveness of Clinical Exercises and Manual Therapy ............................................... 198
Procedures Versus Clinical Exercises alone in the Treatment of Osteoarthritis of Knee
Sapna S Sharma

40. Comparing the effects of Manipulation of Wrist and Ultrasound, Friction Massage and ............................................... 205
Exercises on Lateral Epicondylitis: A Randomized Clinical Study
Sharvari Joshi, Santosh Metgud, Ebnezer C

41. The effect of Tra Training alone and in Combination with Pelvic Floor Muscle Training in ........................................... 210
Women with Stress Urinary Incontinence
Chandan Kaur Khandpur, Shipra Bhatia

42. Comparison of Two Sit and Reach Tests for Measurement of Hamstring Flexibility in .................................................. 216
Female University Physiotherapy Students
Nidhi Kathuria, Sumit Kalra

43. Home Based Exercise Program for Frozen Shoulder- Follow-up of 36 Idiopathic Frozen Shoulder Patients ............. 221
Shishir S M, Manoj Abraham M, Kanagasabai R, Syed Najimudeen, James J Gnanadoss

44. Effect of Vibration on Skin Blood Flow in Type 2 Diabetes Mellitus ................................................................................... 227
Everett B Lohman, Kanikkai Steni Balan Sackiriyas, Gurinder S Bains, Kulbhushan H Dhamane,
Kinjal J Solani, Chandip K Raju, Howard W Sulzle

45. Immediate Effect of Jacobson's Progressive Muscular Relaxation in Hypertension ......................................................... 234
Nisha Shinde, Shinde KJ, Khatri SM, Deepali Hande

46. Chronic Abdominal Wall Pain in Children may be Improved by Physiotherapy ............................................................. 238
Siba Prosad Paul, Gina Farmer, Krishna Soondrum, David CA Candy

47. Functional Status and Disability in Stroke Survivors of North India .................................................................................. 240
AGK Sinha, Divya Dhamija, Supreet Bindra

48. Kinetic Chain Exercise for Patello Femoral Pain Syndrome - A Randomised Control Study ......................................... 245
Suresh Kumar T, Leo Rathinaraj A S, Jeganathan A, Vignesh Waran Vellaichamy

49. Effect of Mechanical Low Back Pain on Postural Balance and Fall Risk ............................................................................. 250
Ibrahim M M, Shousha T M, Alayat MS

Content Final.pmd 3 8/1/2013, 8:32 AM

 IV

50. Alteration in Pelvic Inclination & its Correlation with Lumbar Lordosis in Pregnant Women ...................................... 255
Madhura M Inamdar, Unnati Pandit, Bharati V Bellare

51. Barriers Associated with Community Access by Stroke Patients in Indian Population .................................................. 260
Mohammad Usman Akhtar, Shubha Arora, Man Mohan Mehndiratta

52. Immediate effects of Taping of Upper Back on Peak Expiratory Flow Rate (PEFR) ......................................................... 265
in Stable Chronic Obstructive Pulmonary Disease (COPD) Subjects
S Kimothi, V K Nambiar, B Yadav

53. Functional Status in Post-CABG Patients Following Physiotherapy- A Retrospective Analysis ................................... 270
Vinod K Ravaliya

54. Effect of Cross Training Techniques in Novice Runners ......................................................................................................... 275

Vishesh Garg, M Neethi, S K Joshi, Jagmohan Singh

55. A Study on efficacy of different Therapeutic Modalities to Alleviate Pain due to Knee Osteoarthritis ........................ 279
Bibek Adhya, Anu Gupta, Mandeep Singh Dhillon, Upendra Goswami, Vijay Kumar

56. A Comparative Study of effectiveness of Balance Training with and without Visual ...................................................... 285
Cues on Activities of Daily Living in Stroke Patients
Dhoriyani Narendra B, Patel Fagun B, Smitha D, Kagathra Shailesh, Bhatt Kaushal

57. Correlation among Cervical Pain, Neck Disability Index and Health Related Quality of ............................................... 291
Life for Subjects Suffering from Cervical Pain of Age Group 20 to 75 Years
Ms. Shubha Arora, Mrs. Taruna Mathur

58. Profile of Older Adults in Memory Outpatients' Clinic Setting and effectiveness of Novel ........................................... 297
Occupational Therapy Intervention in Patients with Mild to Moderate Dementia
Prakash Kumar, SC Tiwari, V Sreenivas, Nand Kumar, R K Tripathi, Dey AB

Content Final.pmd 4 8/1/2013, 8:32 AM

 DOI Number: 10.5958/j.0973-5674.7.3.054

Effect of Brief Intense TENS and Cryotherapy on the

Symptoms Associated with Delayed Onset of Muscle
Soreness in Healthy Male Subjects

S Aadil Rashid1, Nishat Quddus2, Belsare3

1
Jr. Physiotherapist, JMI New Delhi, 2Assistant Professor Jamia Hamdard New Delhi, 3Incharge Physiotherapy
Department Majeedia Hospital, New Delhi

ABSTRACT
Objective: The study investigated the effect of brief intense TENS and ice on pain relaxed elbow
extension angle.
Design and setting: Three sets of concentric and eccentric action induced delayed onset of the elbow
flexors of non dominant hand. Pre exercise measures were recorded for relaxed elbow extension
range and perceived muscle pain. Group A received ice treatment for 15 minutes, group B received
brief intense TENS (100 Hz, 100 milliseconds, maximum tolerable intensity), Group C received sham
TENS treatments after 48 hours of post-exercise.
Subjects: Forty five healthy male subjects
Measurements: Relaxed elbow extension angle and perceived muscle pain was recorded before
exercise, before treatment after 48 hours post exercise and after treatment.
Results: Readings were compared for difference using ANOVA it was found that there was statistically
significant difference p=0.045 (p<0.05) in VAS with the scores taken after Cryotherapy.
Conclusion: Cryotherapy was effective in reducing the perceived pain in elbow flexors after eccentric
bouts
Keywords: Pain, TENS, Relaxed Elbow Extension Angle, Delayed Onset Muscle Soreness

INTRODUCTION Numerous studies have been published describing

It has been well-established that exercise-induced
muscle damage occurs following intense exercise
involving eccentric contractions. The damage results
in a dull, aching pain, known as delayed onset muscle
soreness (DOMS). DOMS, the most common type of
muscle pain is characterized by pain/soreness that
begins to occur 8-24 hours post-exercise.67 and increases
in intensity until it peaks at 24-72 hours and subsides
5-7 days post exercise.2, 10 Other clinical signs associated
with DOMS are consistent and include swelling, a
reduction in muscle strength and a decreased range of
motion, all of which can contribute to an impaired
ability to perform routine daily activities. 2,18,20
Individuals who are not accustomed to regular
physical are more likely to develop DOMS than highly
trained athletes.2
various strategies and interventions (i.e. nutritional
supplementation, pharmaceutical treatments, and
therapeutic modalities) to prevent the signs and
symptoms of DOMS from developing or to alleviate
them once present. These studies have been met with
limited success and a sound and consistent treatment
for DOMS has not yet been established.
Even though DOMS is a commonly experienced
phenomenon that can occur in any individual
independent of fitness level, the exact mechanism(s)
responsible for DOMS are not completely understood.
A number of theories have been proposed in an
attempt to explain the underlying mechanism(s)
responsible for DOMS. These theories include the
following: lactic acid, muscle spasm, connective tissue
and muscle damage, enzyme efflux, and inflammation.

1. aadil --1--5.pmd 1 8/1/2013, 8:31 AM

 2 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
To date, no research has been able to conclusively
attribute any one mechanism as the primary cause of
DOMS or its related sensations; however, much
research conducted involving exercise-induced muscle
damage has documented events similar to those
associated with acute inflammation response.
Aims and Objectives of Study
The purpose of the study was to investigate the
effects of ice and brief intense TENS on the following
symptoms associated with DOMS; decrease range of
motion and muscle pain.
Materials and Method
The study investigated the effects of ice and brief
intense TENS on muscle pain and relaxed elbow
extension angle. The design of this study consisted of
pre-test assessment, exercise protocol, post exercise
measurement, treatment protocol, and post treatment
measurement.
Participants
A minimum of 45 healthy subjects of age 25+5 years
were included in the study. Participants read and
signed consent form, which outlined the procedures
of the study. All participants reported pain-free range
of motion about their elbow and no arm pain before
the three months. The subjects were allowed to
perform their normal activities of daily living during
the testing period but were asked not to stretch, take
pain medication, or receive any other therapy. The
subjects were randomly assigned into three groups.
Group A received ice, group B received TENS, and
group C received sham TENS. The study was approved
by Research Committee of Jamia Hamdard.
Instrumentation
Visual analogue scale (VAS) was used to assess pain
(muscle soreness). Full circle goniometer was used to
measure relaxed elbow extension angle. Preacher curl
bench and dumbbell were used for the induction of
DOMS. Transcutaneous electrical stimulation and
crushed ice securing plastic produce bags was applied
on the elbow flexors after 48 hours of eccentric exercise
bouts.
Pre Exercise Measures
Participants subjectively reported the perceived
soreness in their elbow flexors using the following
1. aadil --1--5.pmd 2 8/1/2013, 8:31 AM
soreness rating scale 0 (none), 10 (extreme). The
subjects performed active flexion extension of the
elbow and rated any type of the soreness according to
the scale18.
Next relaxed-elbow extension angle which is
defined as ‘the angle between humerus and ulna when
subject is standing with the arm hanging by her side
in a semi pronated position’ was assessed. The
therapist using a permanent marker, to label
anatomical reference points on the arm, at the lateral
edge of the acromion at the shoulder, at the lateral
epicondyle of the elbow and radial styloid process of
the wrist. Goniometer was placed over the lateral
epicondyle of the humerus with the measurement
arms of goniometer aligned along the lateral markers
on the shoulder and wrist. The reliability (r=0.9) of this
measurement procedure using a standard goniometer
has been previously established.
Induction of Delayed Onset Muscle Soreness
Repeated eccentric contractions were used to
induce delayed onset muscle soreness in the elbow
flexors of non dominant hand. The elbow flexors were
isolated by using a preacher curl bench. This device
enables the subject to sit with his arms resting on a
padded board and positioned in front of the body at
45 degree angle downwards from axilla. Resistance
was applied to the elbow flexors of non dominant hand
by having the subject grasp a dumbbell and alternately
flex and extend the elbow throughout range of motion.
Subject was positioned on the preacher curl device, a
one repetition maximum of the elbow flexors was
determined. The one repetition maximum represented
the amount weight the subject could lift concentrically
one time before the elbow flexors become fatigued.
Using a weight equivalent to one repetition maximum,
the subject performed repeated eccentric contractions
of the elbow flexors. Each subject performed only
eccentric contractions by slowly lowering the dumbbell
from fully flexed to a fully extended elbow position.
After each contraction the weight was returned to a
starting position of fully elbow flexion by the therapist.
Each subject performed 3 sets of 10 repetitions of the
exercise, with 2 minutes rest between each set.
Post Exercise Measures
Post-exercise measurement was taken to assess the
muscle pain in the elbow flexors and relaxed elbow
extension angle immediately after 48 hours of post
exercise.
 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 3

Treatment Protocols A permanent marker was used to label anatomical

Group A received cold treatment by securing plastic
produce bags filled with crushed ice over the elbow
flexor muscle group for 15 minutes. The treatment was
given after 48 hours of exercise. Group B received the
treatment by brief intense TENS of duration 0.2ms,
frequency 100 Hz, duration 15 minutes, and at highest
tolerable intensity. A bipolar placement of two
rectangular carbon electrodes, gel secured with elastic
wraps were used. One electrode was placed over
musculo-tendinous junction of the biceps brachii and
second over the area of greatest soreness, which was
usually over the belly of brachialis. The treatment was
given after 48 hours of exercise. For group C placebo
transcutaneous electrical nerve stimulation was given.
The electrode placement was same as above. The
parameters were set as: pulse rate=2 pulse/second,
phase duration=20 microseconds, intensity to
approximately 110 milliampere, and duty cycle set for
an ‘off’ time of 99 seconds and ‘on’ time of 1 seconds.
ASSESSMENT
Assessments for perceived muscle soreness, loss of
motion were performed before and after each
treatment. Visual analogue scale was used to evaluate
muscle soreness by making a cross (X) on the
horizontal scale at their level of perceived pain.
Relaxed elbow extension angle was assessed after the
treatment.
reference points on the arm at the lateral edge of the
acromion at the shoulder, the lateral epicondyle of the
elbow and radial styloid process of the wrist. The
subjects were in the standing position with arm
hanging by the side and goniometer was placed over
the lateral epicondyle of the humerus with the
measurement arms of goniometer aligned along the
lateral markers on the shoulder and wrist. The relaxed
elbow extension angle was measured.
RESULTS
The exercise protocol produced significant
differences over time for muscle pain and relaxed
elbow extension angle. There was no significant
interaction between time and group, nor were there
significant difference among groups for the symptoms
of DOMS.
Pain When both the readings were compared for
difference using ANOVA it was found that there was
statistically significant difference p=0.045 (p<0.05) in
VAS with the scores taken after cryotherapy, TENS
and placebo TENS. When the scores were compared
using Post Hoc it was found that there was statistically
significant difference (p<0.05) in VAS scores when
comparing values of VAS post between cryotherapy
and placebo TENS. No such significant difference was
found when comparing cryotherapy with TENS and
with placebo TENS

Table 1: Comparison of Pain recorded between the groups

Cryotherapy TENS Placebo TENS Repeated Post-Hoc

(n=15)M ± SD (n=15)M ± SD (n=15)M ± SD Measures ANOVA Analysis (P=)
F P 1 vs. 2 1 vs. 3 2 vs. 3
VAS Pre 4.7+0.9 4.2+1.1 4.53+.77 .782 .464 NA NA NA
VAS Post 3.42+1.1 3.9+1.1 4.4+.84 3.351 .045 .645 .04 .573

Table 2: Comparison of Relaxed Elbow Extension Angle between the groups

Cryotherapy TENS Placebo TENS Repeated

(n=15)M ± SD (n=15)M ± SD (n=15)M ± SD Measures ANOVA
F P
Relaxed Elbow Extension 161±2.1 160.8±2.24 160.1±1.64 .763 .473
Relaxed Elbow Extension Pre 138±8.82 139.1±8 141.6±7.5 .776 .467
Relaxed Elbow Extension Post 144±9.5 142.7±7.9 142.1±7.7 .296 .746

Relaxed elbow extension angleWhen the readings readings taken after cryotherapy, TENS and placebo
were compared for difference using ANOVA it was TENS. When the readings were compared for
found that there was statistically significant difference differences using Post Hoc it was found that there was
(p<0.05) in relaxed elbow extension angle with the also statistically significant difference (p<0.05) in

1. aadil --1--5.pmd 3 8/1/2013, 8:31 AM

 4 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
relaxed elbow extension angle with readings taken
after cryotherapy and TENS. However the readings
for placebo TENS were not found significant
DISCUSSION
The aim of this study was to assess the effectiveness
of cryotherapy, brief intense TENS and placebo TENS
on delayed onset muscle soreness. The analysis
conform the induction of DOMS in the selected muscle
group. The increased discomfort, decreased relaxed
elbow extension indicates that DOMS was successfully
induced. This investigation showed significant time
effects in the muscle pain and relaxed elbow extension
angle indicating that exercise induced muscle damage
was evident. These data concur with previous research
and lend further evidence that unaccustomed eccentric
exercise results in elevation of indirect markers of
muscle damage and soreness.81 Peak soreness at 48
hours concur with others who have shown maximum
readings ranging between 24 to 48 hours post exercise.
Discrepancy between time of maximal occurrence (24
or 48 hours) may be attributed to the different types
exercise, muscle groups involved, and other factors
such as gender, age, previous conditioning levels, and
overall strength levels of the subjects.24
Eccentric bouts successfully produced the
symptoms of delayed onset muscle soreness in the
study. One of the possible causes of muscle damage
may be due to disruption of the Z band. Clarkson and
Sayers in1999 in their study stated that during the
eccentric muscle contractions there are fewer motor
units, thus fewer muscle fibers, activated. This may
lead to an increase in tension taken through the cross
bridges of the muscle fiber resulting in disruption of
the Z band causing Z streaming.19
It is difficult to assess and quantify pain and the
analgesic response to therapeutic intervention.
However, the descriptive data and significant
differences between the cryotherapy group and
placebo TENS indicate that the treatment had real
analgesic effects. Interestingly, sham TENS resulted in
decrease in perceived pain suggesting a small placebo
response to TENS.24
In this study, the improvement in VAS score was
found to be statistically significant in cryotherapy
group as compared to placebo TENS. However, the
cryotherapy group could not show its supremacy on
brief intense TENS group in reducing the pain (VAS).
There are many studies favoring the effect of
cryotherapy on DOMS. Jane Kennet et al in 2007
1. aadil --1--5.pmd 4 8/1/2013, 8:31 AM
concluded that crushed ice and ice- water immersion
have greatest cooling efficiency and can sustain
decreased skin surface temperatures post application,
indicates that these agents are potentially the most
clinically beneficial.82
Cryotherapy was found effective on muscle pain
in this study, concurring with earlier work by Eston
and Peters in 1999, they reported reduced muscle
soreness following repeated cryotherapy (cold water
immersion)81 and also concurs with the results by Craig
Denegar and David Perrin in 1992 they reported cold,
TENS and combination treatment resulted in
significant decreases in perceived pain.24 However this
result contrasts with those of Yackzan et al in 1984,
they reported single treatment of ice massage had no
sustain effect on perceived pain.81 William Isabell et al
in 1992 suggested that use of ice massage, ice massage
with exercise, or exercise alone was not effective in
significantly reducing the symptoms of delayed onset
muscle soreness. They also suggested ice massage
administered repeatedly over 96 hours post exercise
may be contraindicated in the treatment of exercise-
induced muscle damage.36 In this study, cryotherapy
was not found to be more effective than brief intense
TENS and placebo TENS in improving relaxed elbow
extension range probably because of single
intervention. There is a study by Yackzan et al in 1984;
they found no positive effect as a result of a single
application of cryotherapy36 However within group
there was an increase in relaxed elbow extension angle
after the application of ice and brief intense TENS to
the biceps muscle. The increase in elbow extension
range following treatment with cold suggests
interruption of a pain-spasm cycle as proposed by de
Varies in 1966. Pain originating in the sensory motor
chain leads to reflex muscular spasm. The elimination
of pain has been associated with muscular relaxation.
In within group analysis, TENS was found to be
effective in treating the symptoms of DOMS
significantly, concurring with earlier work by Craig R
Denegar et al in1992 suggested that cold, TENS and
combined treatment were effective in treating the pain
and muscle spasm associated with DOMS, and that
decreased pain may not be an accurate indicator of
the recovery of muscle strength.24
CONCLUSION
Conclusion can be made that cryotherapy is more
effective than placebo TENS in improving perceived
pain after eccentric training but fails to show its
superiority in improving relaxed elbow extension
 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 5
angle, thus partially proves the alternate hypothesis.
However it could not prove that cryotherapy is more
effective than brief intense TENS in improving
perceived pain and relaxed elbow extension angle,
therefore, rejecting the experimental hypothesis
ACKNOWLEDGEMENT
I am grateful to Dr. Fuzail Ahmed PT for helping
me out in the statistical analysis of my data. Also, I
would like to thank my parents for their unconditional
support. Lastly, I am highly grateful to all the subjects
for their co-operation.
REFERENCES
1. Smith LL, (1991). Acute inflammation: the
underlying mechanism in delayed onset muscle
soreness. Medicine and Science in Sports and
Exercise, 23(5), 543-551.
2. Armstrong, R.B. (1984). Mechanisms of exercise-
induced delayed onset muscular soreness: a brief
review. Medicine and Science in Sports and
Exercise, 16(6), 529-538.
3. Bobbert, M.F., Hollander A.P. & Huijing P.A.
(1986). Factors in delayed onset muscular
soreness of man. Medicine and Science in Sports
and Exercise, 18(1), 75-81.
4. Clarkson, P.M., Nosaka, K. & Braun, B. (1992).
Muscle function after exercise-induced muscle
damage and rapid adaptation. Medicine and
Science in Sports and Exercise, 24(5), 512-520.
5. Clarkson, P.M. & Hubal M.J. (2002). Exercise-
induced muscle damage in humans. American
Journal of Physical Medicine and Rehabilitation,
81(11), S52-S69.
6. Assmussen, E. (1956). Observations on
experimental muscle soreness. Acta Rheumatol
Scandinavica, 1, 109-116.
7. DeVries, H.A. (1961). Prevention of muscular
stress after exercise. Research Quarterly, 32, 177.
8. Stauber, W.T. (1989). Eccentric action of muscles:
physiology, injury and adaptation. Exercise and
Sport Sciences Reviews, 17, 157-185.
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9. Abraham, W.M. (1977). Factors in delayed muscle
soreness. Medicine and Science in Sports, 9(1),
11-20.
10. Jeffrey C David O Draper, Earlene Durrant, (1998)
Pulsed ultrasound fails to diminish Delayed-
onset muscle soreness symptoms; Journal of
Athletic Training 33(4): 341-346
11. Ciccone D.C, Leggin B.G, Callmaro J.J (1991);
Effect of ultrasound and trolamine salicylate
phonophoresis on delayed onset muscle soreness.
Physical Therapy 71(9), 39-51.
12. Denegar, C.R. & Perrin, D.H. (1992). Effect of
transcutaneous electrical nerve stimulation, cold,
and a combination treatment on pain, decreased
range of motion, and strength loss associated with
delayed onset muscle soreness. Journal of Athletic
Training, 27(3), 200-206.
13. Howartson G, Gaze D, Van Someren K.A (2005).
The efficiency of ice massage in the treatment of
exercise muscle damage. Med Sci Sports and
Exercise 15(6), 416-422.
13. 14.Clarkson, PM & Sayers, S. (1999). Etiology of
exercise-induced muscle damage. Canadian J
Appl Physiology, 24: 512-520
15. Jane Kennet, Natalic Hardaker, Sarah Hobbs
(2007) cooling efficiency of 4 common cry therapy
agents. Journal of Athletic Training 42(3) 343-348
16. Isabell, W.K., Durrant E., Myrer, W. & Anderson,
S. (1992). The effects of ice massage, ice massage
with exercise, and exercise on prevention and
treatment of delayed onset muscle soreness.
Journal of Athletic Training, 27(3), 208-217.
17. De Vries HA.(1966) Quantitative
electromyographic investigation of the spasm
theory of muscle pain.American Journal of
Physical Medicine; 45(3):119–34.
18. Mattacola, C.G., Perrin, D.H., Gansneder, B.M.,
Allen, J.D., Mickey, C.A. (1997). A comparison of
visual analog and graphic rating scales for
assessing pain following delayed onset muscle
soreness. Journal of Sport Rehabilitation, 6:38-46.
 DOI Number: 10.5958/j.0973-5674.7.3.055
6 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

The effect of Topical Application of Extra Virgin Olive Oil

on Alleviating Knee Pain in Patients with Knee
Osteoarthritis: A Pilot Study

Abdul-Majeed Al Malty1, Saja Hamed1, Hashem AbuTariah1, Mohammad Jebril1

1
Assistant Professor, Physical and Occupational Therapy Department, Faculty of Allied Health Sciences,
Hashemite University

ABSTRACT
Objective: To investigate and compare the effect of topical application of extra virgin olive oil (EVOO)
on the pain of osteoarthritic knee (s) with the effect of non-steroidal anti-inflammatory drugs.
Participants: A convenient sample of thirty patients with knee(s) osteoarthritis (16 females and 14
males) were randomly assigned to three groups; Group A (n=10) treated with topical application of
EVOO and exercise, group B (n=10) received topical non-steroidal anti-inflammatory drugs
(Ketoprofen gel) over the knee(s) and exercise, and group C received therapeutic exercise only.
Method: Treatment was carried out in physical therapy outpatient clinic for 5 days a week for two
weeks. Group A received topical EVOO (3ml) and group B received topical ketoprofen gel (3 cm2)
three times a day followed by therapeutic exercise. Group C received therapeutic exercise only three
times a day. Pain visual analog scale (VAS) and Western Ontario and McMaster (WOMC) universities
index measurement were taken at baseline and after two weeks of treatment.
Results: All groups showed significant improvement (p<0.001) in VAS and WOMC index after two
weeks of treatment compared to the baseline. Group comparison showed no significant difference in
both scales between groups A and B (p>0.05), however, both groups significantly experienced less
pain than group C (p<0.001).
Conclusion: Topical application of EVOO showed to be effective in alleviating the symptoms of
patients diagnosed with knee osteoarthritis compared to topical application of NSAID.
Keywords: Physical Therapy, Osteoarthritis, Olive Oil, Knee Pain, NSAID, ketoprofen

INTRODUCTION year of 2050 compared to 2003.3 Longevity and course

of the disease makes OA a major burden on
Osteoarthritis (OA) is the most common
individuals, society, and heath care system resources.4
degenerative joint disease that affects musculoskeletal
system among rheumatic diseases.1 In United States, The knee joint has the highest incidence (40%) of
Approximately 27 million people were affected by OA developing OA compared to the other joinds.5 The
2
and it’s prevalence will increase by 1.6 fold in the primary signs and symptoms associated with knee
osteoarthritis include pain, stiffness and swelling. As
Corresponding author: knee osteoarthritis progresses, symptoms generally
Abdul-Majeed Almalty become more severe and pain may become continuous
Assistant Professor rather than only during weight-bearing activities.5
Physical and Occupational Therapy Department
Hashemite University The treatment of knee osteoarthritis targets the
P.O. Box 330018 symptoms of the disease and slowing down the disease
Zarqa, 13133, Jordan progression. 5 The pharmacological interventions
Tel :(+962) (5) 3903333, Ext. 5411
include topical or oral analgesics, non-steroidal anti-
E-mail: abedmalty@hu.edu.jo

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 7

inflammatory drugs (NSAIDs) and intra-articular
injection (e.g. corticosteroids and hyaluronan).6 The use
of non-pharmacological interventions may be
concurrent with pharmacological intervention and
include; patient education, life style modification,
physical therapy, or traditional (folks) medicine.6-8
Physical therapy modalities relief symptoms, but
sometime do not satisfy the patient’s needs. About 60–
90% of people with rheumatic diseases more likely to
seek complementary or alternative medicine and 50%
of them used botanical medicine.8
Traditionally and historically, extra virgin olive oil
(EVOO) in Jordan is widely used as a botanical
medicine and highly consumed because of its high
nutritional values. Many studies have shown that
antioxidant effects of the olive oil contribute to prevent
a number of chronic diseases such as coronary heart
disease, 9 cancers 10 and joint arthritis because of its
suppressive effect to the free-radical production of
reactive oxygen species.11
Recently, a new discovery of (-) oleocanthal, a
compound found in EVOO that has a similar
composition as Ibuprofen may have the potential of
being a NSAID-like drug.12 The NSAIDs are the most
common medications used in treating osteoarthritis.1
Long-term oral administration of NSAIDs can cause
adverse effects.13 Therefore, topical NSAIDs such as
Ibuprofen, Ketoprofen and Diclofenac Sodium have
been used to minimize these adverse effects.14 The use
of topical Ketoprofen has shown superiority in
relieving symptoms of musculoskeletal problems
compared to the other topical NSAIDs.14
Since it’s believed that (-) oleocanthal compound
in the EVOO possess the same features as NSAID, and
then topical application of EVOO may have the same
effects as topical NSAID in relieving the symptoms of
osteoarthritic knee(s). 14 We hypothesized that topical
application of EVOO combined with therapeutic
exercise would have the same effect as topical NSAID
(Ketoprofen) combined with exercise.
METHOD
Thirty patients (16 female, 14 male) diagnosed with
knee(s) OA who met the inclusion and exclusion
criteria were recruited from different rheumatology
clinics (Table 1).

Table 1: Baseline measurement for all groups.

Group (A)(N=11) Group (B)(N=10) Group (C)(N=9)

Mean SD Mean SD Mean SD p
Age 60.1 6.6 57.9 7.6 54.1 4.9 0.1
Weight 85.4 5.5 83.9 8.3 79.7 8.6 0.2
Height 169.4 5.6 167.7 5.0 166.3 6.2 0.5
BMI 29.8 2.1 30.0 3.8 28.9 3.2 0.7
VAS 69.1 7.0 60.0 13.3 61.0 7.4 0.1
WOMAC Pain 65.9 8.3 67.0 13.0 64.0 7.7 0.8
WOMAC Stiffness 77.3 12.3 63.8 13.8 67.5 14.7 0.1
WOMAC Function 64.8 6.9 60.9 4.1 66.4 10.2 0.2
WOMAC Sum Index 69.3 7.0 63.9 9.0 66.0 10.1 0.4

(A): Olive Oil Group; (B) Ketoprofen Group; (C) Exercise GroupNo significant difference has been found between the groups.

Inclusion criteria Exclusion Criteria

Symptomatic knee(s) for at least six months with 1. History of trauma, surgery, varicose veins,
moderate to severe knee(s) OA according to: paralysis, polyneuropathy, congenital
abnormalities of the lower extremities, chronic
1. Clinical and radiographical criteria of the
back pain and painful hip joint
American College of Rheumatology 15
2. Underwent knee arthroscopy, intra-articular
2. Third or fourth OA grade according to Kellgren-
Hyaluronan or corticosteroids injections during the
Lawrence Grading Scale. 16
past 3 months.

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 8 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
3. Start taking NSAID medication, and/or received
surgical or intra-articular injection procedures.
The study procedures were explained to each
subject, who then signed the approved informed
consent by the Institutional Review Board of the
Hashemite University. All participants were asked to
come to the physical therapy clinic for ten days over a
period of two weeks, five days/week.
Subjects were assigned randomly to one of three
groups; group A received topical EVOO and exercise,
group B received topical ketoprofen gel and exercise,
and the control group C received exercise only. The
study was a single blind — the data collector therapist
was not aware of subjects’ group. A one week washout
period prior to the enrollment in this study was given
for all subjects who were taking NSAID. Participants
were allowed to take or continue taking Paracetamol
medication when needed.
Instrumentation
1. Pain visual analog scale (VAS).
2. Validated Arabic version of Western Ontario and
McMaster universities (WOMAC).17
PROCEDURES
Each subject received a booklet of all therapeutic
exercises and full explanation and demonstration of
each exercise was performed by the therapist. After
explaining the procedures to all participants, baseline
measurements were taken. No significant differences
were found among the groups in the baseline
measurements (Table 1).
The exercise program consisted of: 1) Quadriceps
isometric contraction, 2) knee extension with resistance
using sand bag as tolerated, 3) Full flexion and
extension range of motion exercise and 4) Dynamic
stepping exercise by walking up and down on one
flight stairs or using the training step. Ten repetitions
of the therapeutic exercises were performed once every
time the patient comes to the clinic and twice at home.
Subjects were asked to document the exercises
repetition each day and compliance was graded based
on the number of exercises and repetitions.
2. Abdul Jordon--6-11.pmd 8 8/1/2013, 8:31 AM
Three milliliters of EVOO were topically applied
to the participant’s knee in group A with a calibrated
syringe. Subjects in group B were supplied with two
100 gm. pump dispenser of Ketoprofen 2.5% w/w gel.
Each subject applied 3 cm2 on a knee by pressing the
dispenser two times. The EVOO and the Ketoprofen
gel were spread over the knee joint and followed by
the therapeutic exercise regimen. Subjects in groups A
and B were taught to follow the same procedure at
home three times a day. Subjects in group C performed
the exercise regimen as above with no topical
application over the knee(s) three times a day for two
weeks. The second measurements were obtained at the
end of the 2nd week.
DATA ANALYSIS
The mean values of VAS and WOMAC index were
calculated and the changes within subjects were
analyzed using paired t-test. The changes within the
groups were analyzed using one way ANOVA. All data
were analyzed using the Statistical Package for the
Social Sciences (SPSS, Inc., Chicago,IL) version 16
software.
RESULTS
All subjects adherence to the exercises regimen has
been rated between 85-90% for groups A and B, and
80-84% for group C. No significant difference was
found between the groups.
Visual Analog Scale.
After two weeks of treatment, the pain had
significantly decreased (p<0.01) for all groups (Table
2) on visual analog scale by 73% (50.9±0.7 mm) for
group A, 68% (60.0±13.3 mm) and 57% (61.0±7.4 mm)
for groups B and C respectively. The comparison
between the groups using one way ANOVA showed
no significant difference between the groups (p=0.09).
However, the mean difference of pain scores between
the baseline and week two measurements for group A
was significantly greater (p=0.01) than group C and
no significant difference had been noticed between
group A and B or group B and C (p>0.05).
 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 9

Table 2: The mean and standard deviation of all groups of VAS, WOMAC subscales and the total score
of WOMAC Index

Group (A)(N=11) Group (B)(N=10) Group (C)(N=9)

Baseline Post Wk 2 Difference Baseline Post Wk 2 Difference Baseline Post Wk 2 Difference
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
VAS 69.1 7.0 18.2* 7.5 50.9‡ 7.0 60.0 13.3 19.0* 12.0 41.0 18.5 61.0 7.4 26.0* 5.2 35.0 5.3
‡ ‡
WOMAC 65.9 8.3 25.0* 6.3 36.4 2.3 67.0 13.0 27.0* 18.9 40.0 14.7 64.0 7.7 41.5* 2.4 22.5 6.8
Pain
WOMAC 77.3 12.3 26.1* 6.7 51.1‡ 13.1 63.8 13.8 21.3* 6.0 42.5‡ 18.8 67.5 14.7 55.0* 14.7 12.5 0.0
Stiffness
WOMAC 64.8 6.9 19.2* 5.4 45.6‡ 9.3 60.9 4.1 21.8* 15.7 39.0‡ 16.9 66.4 10.2 43.8* 4.7 22.6 7.9
Function
WOMAC 69.3 7.0 25.0* 6.6 44.4‡ 6.2 63.9 9.0 23.4* 11.6 40.5‡ 12.9 66.0 10.1 46.8* 5.7 19.2 4.7
Global
Index

The mean and the standard deviation (SD) of the visual analog scale are expressed in millimeter (mm) for analog scale and WOMAC
Index sub- and global scale.*significantly different at (p<0.001) pre and post treatment, ‡ Significantly different at p<0.001 on groups
comparisons with C group. No difference had been foundbetween group A and B.

WOMAC index.
The mean values of WOMAC subscales (pain,
stiffness, and function) and global scale were
significantly decreased for all groups (p<0.001) after
two weeks of treatment using paired t-test (Table 2). A
high correlation has been found between the VAS and
WOMAC pain subscale for the second week (r=0.8)
and medium correlation at the baseline (r=0.5).
After two weeks of treatment, the groups’
comparison of all WOMAC subscales and WOMAC
global scale had shown no significant different
between A and B groups (p>0.05), however, both
groups A and B were significantly different compared
to group C (p<0.001). Furthermore, the mean
differences of the scores between baseline and after
the second week for all groups had shown significant
improvement for groups A and B compared to group
C using one-way ANOVA.
DISCUSSION
The results of this study revealed that the symptoms
of pain, stiffness and function were significantly
improved for all three groups. However, the
Ketoprofen gel group showed a non-significant
improvement over the EVOO group and both
practically showed significant improvement over the
exercise only group according to outcome measures.
Accordingly, our hypothesis has been met and proved
that the topical application of EVOO has similar effects
as topical application of NSAID.
Symptoms of knee OA interferes with clients’
performance of daily life activities and may affect the
quality of their lives.2 Due to the side effects of NSAID,
people with knee OA started looking for other
alternatives to treat the symptoms of the disease. The
selection of EVOO in treating the symptoms of knee
OA was based on the potentiality of EVOO to work as
NSAID.12 The (-) oleocanthal compound in the EVOO
seems to have the similar effect like NSAID as a
nonselective cyclo-oxygenase inhibitor that suppress
the prostaglandin E2 production and relieve joint
inflammation. 13 In addition, the oleic acid
(monounsaturated fatty acid) is a compound found in
olive oil may contribute to alleviate joint inflammation
in rheumatic disease 11 and increase the skin
permeability 18 that may enhance the absorption of
other compound such as (-) oleocanthal.
Therapeutic exercises are the most common
procedure used in treating knee OA, and they are more
effective if combined with NSAID or natural NSAID-
like substance. 19 All subjects showed very good
adherence to the exercises regimen proposed in this
study. Apparently, simplicity of chosen knee exercises
enhanced patient compliance in performing these
exercises on a daily basis. Furthermore, combining
those therapeutic exercises with NSAID motivated the
participants to initiate and adhere to these exercises
and to overcome the fear barrier of causing further pain
or damage to the knee joint. 20
Alleviating the suffering of patients diagnosed with
knee OA may positively affect their activity
performance, sense of adequacy and improve their
quality of life. Introducing olive oil as a natural
treatment to OA symptoms that is accessible, easily
applicable and affordable, with no known side effects

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 10 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
can be considered as a breakthrough achievement.
Most of the NSAIDs cannot be obtained without
medical prescription; however, EVOO requires no
medical practitioner to prescribe it. In addition, such
findings can have a big value in decreasing the costs
of treating such patients as the current cost of treatment
is high.3
We concluded that topical applications of EVOO
most likely produces similar effects as topical NSAID
on alleviating the symptoms of patients with knee(s)
OA. Topical application of extra virgin oil in therapy
requires further investigation. These encouraging
findings open new avenues in treating patients with
knee OA and considered as a preliminary step in a long
way process of proving the effectiveness of using extra
virgin oil in therapy for other rheumatic diseases. It
should be followed up with more extensive studies
including larger sample sizes or combining different
physical therapy modalities in treating patients with
knee OA.
ACKNOWLEDGMENTS
This work was funded by the Hashemite University
and we would like to thank all physicians and clinics
for their help in referring our participant and we extend
our thanks to all patients who participated in the study.
Conflicts of Interest
We have no real or apparent conflict of interest to
report.
Ethical Clearance
This study has been approved by the Research and
Ethical Committee of Physical and Occupational
Therapy Department and College of Allied Medical
Science then by the Institutional Review Board of the
Hashemite University.
REFERENCES
1. Robbins, L., Burckhardt CS,. Hannan MT and.
DeHoratius RJ. Clinical Care in Rheumatic
Diseases, 2nd Edition. Atlanta: American College
of Rheumatology; 2001. p.225-230.
2. Lawrence RC, Felson DT, Helmick CG, et al.
National Arthritis Data Workgroup. Estimates of
the prevalence of arthritis and other rheumatic
conditions in the United States. Part II. Arthritis
Rheum. 2008; 58(1):26-35.
2. Abdul Jordon--6-11.pmd 10
3. Fontaine K, Haaz S, Heo M Projected prevalence
of US adults with self-reported doctor-diagnosed
arthritis, 2005 to 2050. Clin Rheumatol. 2007;
26:772–4.
4. Centers for Disease Control and Prevention.State
prevalence of self-reported doctor-diagnosed
arthritis and arthritis-attributable activity
limitation—United States, 2003. MMWR Morb
Mortal Wkly Rep. 2006; 55:477–81.
5. Woolf AD, Pfleger B. Burden of major
musculoskeletal conditions. Bull World Health
Organ. 2003; 81(9):646-56.
6. Barron M, Rubin B. Managing osteoarthritic knee
pain. J Am Osteopath Assoc. 2007; 107:ES21–27.
7. Hsieh J, Dominick K. Use of non-pharmacological
therapies among patients with osteoarthritis.
Aging Clin. 2003; Exp Res 15:419–25.
8. Rao JK, Mihaliak K, Kroenke K, Bradley J, Tierney
WM, Weinberger M. Use of complementary
therapies for arthritis among patients of
rheumatologists. Ann Intern Med. 1999;
131(6):409-16.
9. Lopez J, Badimon L, Bonanome A et al.
Monounsaturated fat and cardiovascular risk.
Nutr Rev. 2006; 64:S2–S12.
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Spiegelhalder B, Bartsch H. Olives and olive oil
in cancer prevention. Eur J Cancer Prev.
2004;13(4):319-26.
11. Darlington L, Stone T. Antioxidants and fatty
acids in the amelioration of rheumatoid arthritis
and related disorders. Br J Nutr. 2001; 85:251–69.
12. Beauchamp G, Keast R, Morel D et al.
Photochemistry: ibuprofen-like activity in extra-
virgin olive oil. Nature. 2005; 437:45–6.
13. Bjordal J, Ljunggren A, Klovning A, Slordal L.
Non-steroidal anti-inflammatory drugs,
including cyclo-oxygenase-2 inhibitors, in
osteoarthritic knee pain: meta-analysis of
randomized placebo controlled trials. BMJ. 2004;
329:1317–20.
14. Mason L, Moore RA, Edwards JE, Derry S,
McQuay HJ. Topical NSAIDs for acute pain: a
meta-analysis. BMC Fam Pract. 2004; 5:10.
15. Altman R, Asch E, Bloch D. Development of
criteria for the classification and reporting of
osteoarthritis. Classification of osteoarthritis of
the knee. Diagnostic and Therapeutic Criteria
Committee of the American Rheumatism
Association. Arthritis Rheum 1986; 29:1039–49.
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16. Kellgren JH, Lawrence JS. Radiological
assessment of osteo-arthrosis. Ann Rheum Dis.
1957; 16:494–502.
17. Guermazi M, Poiraudeau S, Yahia M, et al.
Translation, adaptation and validation of the
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osteoarthritis index (WOMAC) for an Arab
population: the Sfax modified WOMAC.
Osteoarthritis Cartilage. 2004; 12(6):459-68.
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induced Skin Penetration Effects of a Lamellar
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19. Petersen SG, Beyer N, Hansen M, Holm L,
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 DOI Number: 10.5958/j.0973-5674.7.3.056
12 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Study to Compare the effectiveness of Treadmill and

Cycle Ergometer on Endurance in Normal Subjects

Sharma Abhishek1, Shah Arpita2, Dey Sushant3, Sharma Urvi4

1
Lecturer, SPB Physiotherapy College, Surat, Gujarat, India, 2Physiotherapist, haruch, Gujarat, India, 3Lecturer, SPB
Physiotherapy College, Surat, Gujarat, India, 4Physiotherapist, Masoom Hospital, Surat, Gujarat, India

ABSTRACT
Objective: Endurance is the ability to work for prolonged period of time. Individuals of all ages can
improve their general fitness & Endurance by participating in activities that include walking, biking,
cycling, running, swimming, stair climbing, and weight training etc2. In rehabilitation centers we
come across several patients for improvement of their general fitness & endurance. We used to give
them training on Treadmill & Cycle Ergometer. The aim of the study was to compare the effectiveness
of treadmill with cycle ergometer on endurance in normal subjects.
Material and Method: Total 20 subjects divided in group A & group B (10 subjects in each group)
Training using treadmill and cycle ergometer respectively was for continuous 30 days with progression
regularly. 12 minute walk test walk distance was used to measure the endurance after training.
Results: There is no significant difference in effectiveness of treadmill & cycle ergometer on endurance
in normal subjects. The value of tc obtained for walk distance for treadmill & cycle trainee
is 0.1998 0.2
Conclusion: The study concluded that Bicycle Ergo meter is appropriate alternative to Treadmill for
training in healthy volunteers. Training programme should be individualized.
Keywords: Endurance, Treadmill, Cycle Ergometer

INTRODUCTION systems are as Phosphagen or ATP – PC system;

Endurance is the ability to work for prolonged
period of time & the ability to resist fatigue. It includes
cardiovascular endurance and muscular endurance9.
Cardiovascular endurance refers to ability to perform
large muscle, dynamic exercise such as walking,
swimming or biking for prolonged period of time 2.
Muscular endurance refers to ability of an isolated
muscle or muscle group to perform repeated
contractions over a period of time.
Energy systems provide energy to work. They
depend upon intensity and duration of activity. Energy
Corresponding author:
Abhishek Sharma
Lecturer
SPB Physiotherapy College, Near Bhesan Jakatnaka,
Ugat Bhesan road Surat, 395005.
M: 09879828368
E-mail: drabhi2700@gmail.com
Anaerobic or Glycolytic system and Aerobic system.
Increase in energy requirements during exercise
requires circulatory adjustments to meet the increased
need for O2 and nutrients, to remove end products of
metabolism, such as lactic acid,CO2 and to dissipate
excess of heat3,9. The shift in metabolism occurs due to
co-coordinated activity of all systems of body.
The exercise testing is the part of assessment & a
measure for improvement to see the effect of
cardiopulmonary study on subjects 16.The exercise test
may be used for diagnostic, prognostic & therapeutic
applications especially in regard to exercise
prescription. Concept of Maximal versus sub maximal
exercise test depends largely on reasons for the test,
type of subject to be tested and availability of
appropriate equipment & personal6. Field tests are 12
minute walk test and 6 minute walk test7. Sub maximal
exercise test are Cycle Ergo meter Test, Treadmill Test
and Step test.

3. Abhishek--12-14.pmd 12 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 13
MATERIALS AND METHOD
Research Design was comparative study with
Simple Random Sampling Method.Study was
conducted on college students with age group between
20-25 years and mean BMI is 20-29. Subjects with age
group below 20 and above 25 years, subjects with
history of cardiovascular or pulmonary disease,
anemia, recent musculoskeletal injury, low back ache,
intervertebral or facet joint pathology, metabolic
disorder and smoking habit were excluded from the
study.A total of 20 subjects including 10 male and 10
female volunteered to participate in study who were
divided in group A and group B (10 subjects in each
group) with training for continuous 30 days.
COLLECTION OF DATA
Before starting study, subjects were informed about
the purpose, aim & design of study. Age, Height and
Weight of all subjects were taken before study. Before
commencement of training on treadmill or cycle ergo
meter, all 20 subjects were tested on 12 minute walk
test. 12 minute walk test was conducted on cemented,
even surface at College of Physiotherapy, Anand. Test
was performed in morning or in afternoon with 2 hours
gap before & after lunch. Subjects were asked to cover
maximum distance as comfortably as they can. 30
meter area was measured with measure tape & marked
with chalk stick at starting point & at end point. Subject
touching end point & coming back to starting point is
considered as he/she has covered 60 meter (1 turn).
During 12 minute, every turn covered by subjects were
counted. Then at the end, the turns wore converted
into distance into kilometer. (1 turn = 60 meter). After
completing 12 minute walk test distance covered was
measured which is the outcome measure for endurance
after training.
TRAINING PROGRAM
Total 10 subjects from Group A were randomly
selected with training on treadmill for 4 days /week
with speed of 6-7 km/hour and total duration of 10
minutes daily including 5 minutes of warm up and 5
minutes of cool down period. Total 10 subjects from
Group B were randomly selected with training on cycle
for 4 days /week with speed of 30-35 km/hour. and
total duration of 10 minutes daily including 5 minutes
of warm up and 5 minutes of cool down period6,10.After
15 days of training on treadmill & cycle ergo meter, all
20 subjects were again tested on 12 minute walk test
& new data of walk distances were collected.
3. Abhishek--12-14.pmd 13
PROGRESSION
For both groups frequency & intensity are same but
duration is increased from 10 to 15 minutes with 5
minute of warm up and 5 minute of cool down
period.After training for further 15 days, all 20 subjects
were tested on 12 minute walk test & walk distances
are collected15. At the end of 30 days of training, walk
distances were recorded 3 times includes; before
training , 15 days after training and 30 days after
training
DATA ANALYSIS
Unpaired t-test comparisons were used to test the
significance of difference (improvement) in pretraining
walk distances & after 30 days training walk distances
between subjects trained with treadmill & cycle
ergometer. Critical alpha value of 0.05 is used.
RESULTS
Table 1: Mean of walk distance (km) in 12 min.
walk test
Sr.No. Training of Walk distance Group A Group B
1 Pre training 12.46 km 12 km
2 after 15 days 13.24 km 12.73 km
3 after 30 days 13.62 km 13.08 km
The value of t c obtained for walk distance for
treadmill & cycle trainee is 0.1998 @ 0.2 & value of
tt = 2.11
So there is no significant difference (improvement)
in walk distances of subjects trained on treadmill &
cycle ergometer.
DISCUSSION
From the results it is clear that, there is no significant
difference in effectiveness of treadmill & cycle
ergometer on endurance. From the study, it was
noticed that subjects with low endurance showed
better improvement than the subjects with high
endurance, because the subjects with high endurance
need more vigorous & high intensity exercise program
for training as their aerobic threshold is high 10 .
Comparing the results between boys trained on
treadmill & cycle ergo meter shows that there is slight
better improvement in walk distance in subjects
trained on treadmill 12. Comparison between girls
shows the end results are same & have no significant
difference13, 14.
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 14 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
CONCLUSION
The study concluded that Bicycle Ergo meter is
appropriate alternative to Treadmill for training in
healthy volunteers10, 11. As the maximum heart rate
remains same on treadmill & bicycle ergo meter. But
individual maximum heart rate is different. So, for
every person/subject the aerobic exercise program
must be individualized.
ACKNOWLEDGEMENTS
We are sincerely grateful to the god who showered
his blessings and his helping hand for our research.
From the bottom of our heart we are thankful to our
principal Dr. C. G. Padole for his guidance & support
& encouragement during my study. We are happy to
place on record sincere gratitude to guide Dr.
Manojkumar for his valuable guidance, supervision
& constructive suggestions. We are glad to express our
sincere thanks to Dr. Manan Bhatt for his help during
study. The knowledge he shared with us and his
encouragement helped us a lot. We would like to
mention special thanks to my entire faculty who were
always a standing rock for our great work. We are
privilege to thank our patients without whom this
research was not been possible.
Conflict of Interest: None
REFERENCES
1. Kenneth R. Turley, Jack H. Wilmore.
Cardiovascular responses to treadmill and cycle
Ergometer exercise in children and adults. Journal
of Applied Physiology September 1, 1997; 83 3:
948-957.
2. Paul D. Thompson, MD; David Buchner, MD;
Ileana L. Piña, MD; Exercise and Physical Activity
in the Prevention and Treatment of
Atherosclerotic Cardiovascular Disease.
Circulation. 2003; 107: 3109-3116.
3. Carolyn kisner, Lynn Allen Colby. Therapeutic
Exercise-Foundations &techniques.
4. Susan B. O’ Sullivan, Thomas J. Schmits.Physical
Rehabilitation-assessment & Treatment.
5. BK Mahajan.Methods in Biostatistics.Jaypee; 6th
Edition.
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6. ATS Statement. Guidelines for Cardio respiratory
endurance American Journal of Respiratory and
critical care medicine. January 15, 2003; 167 2:
211-277.
7. ATS Statement. Guidelines for the Six-Minute
Walk Test American Journal of Respiratory and
critical care medicine July 1, 2002; 166 1: 111-117.
8. Niels B. J. Vollaard, Dimitru Constantin-Teodosiu,
Katarina Fredriksson Systematic analysis of
adaptations in aerobic capacity and submaximal
energy metabolism provides a unique insight into
determinants of human aerobic performance.
Journal of Applied Physiology May 2009 ;106 5
:1479-1480.
9. McArdle WD, Katch FI and Katch VL. (2000)
Essentials of Exercise Physiology: 2nd Edition
Philadelphia, PA: Lippincott Williams & Wilkins.
10. Higginbotham MB, Morris KG, Williams RS,
McHale PA, Coleman RE, Cobb FR. Regulation
of stroke volume during submaximal and
maximal upright exercise in normal man.
Circulation. 1986 Feb; 58 2:281-91.
11. Hermansen L, Ekblom B, Saltin B. Cardiac output
during submaximal and maximal treadmill and
bicycle exercise. Journal for Applied Physiology.
1970 Jul; 29 1:82-6.
12. Clausen JP. Effects of physical training on
cardiovascular adjustments to exercise in man.
Physiological Reviews. 1977; 57:779-816
13. Kelley GA, Kelley KS, Tran ZV. Aerobic exercise
and lipids and lipoproteins in women: a meta-
analysis of randomized controlled trials. 2005
Mar; 14 2:198.
14. Seamus P. Whelton; Ashley Chin,; Xue Xin et
al.Effect of Aerobic Exercise on Blood Pressure.
A Meta-Analysis of Randomized, Controlled
Trials.Annals of Internal Medicine. April 2, 2002;
136 7: 493-50.
15. De Greef MH, Sprenger SR, Elzenga CT.
Reliability and validity of a twelve-minute
walking test for coronary heart disease
patients.Perceptual and Motor Skills.2005
Apr;100(2):567-75.
16. Gerald F. Fletcher, Gary J. Balady, Ezra A.
Amsterdam. AHA Scientific Statement Exercise
Standards for Testing and Training. Circulation.
2001; 104: 1694-1740.
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 DOI Number: 10.5958/j.0973-5674.7.3.057
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 15

Effect of Aerobic Exercises on Serum IgE and Pulmonary

Functions in Children with Bronchial Asthma

Aisha A Hagag1, Naglaa A Zaky2

1
Department of Physical Therapy for Cardiovascular/Respiratory Disorders and Geriatrics, Faculty of Physical
Therapy, Cairo University, Egypt, 2Department of Physical Therapy for Growth and Development Disorders in
Children and its Surgery, Faculty of Physical Therapy, Cairo University, Egypt

ABSTRACT
Purpose: The aims of present study was to evaluate the effect of aerobic exercise training on serum
IgE and pulmonary functions in asthma children before and after exercise program.
Subjects: 60 children with asthma participated in this study and divided randomly to exercise and
control groups.
Procedure: Fasting serum IgE and some markers indicative of respiratory functions (FEV1, FVC, and
FEV1/FVC) were measured before and after the study in both groups. Statistical analysis was
performed with the SPSS software version 15.0 using an independent paired t-test.
Results: Compared to pre-training, serum IgE decreased significantly and pulmonary function
markers increased significantly (≥0.05) after exercise program. All variables remained without change
in control group (≥0.05).
Conclusion: Aerobic exercise program was associated with a significant decrease in serum level of
IgE and improvement of pulmonary functions in asthmatic children.
Keywords: Immunoglobulin E(IgE), pulmonary functions, Asthma, Aerobic exercise

INTRODUCTION tendency to produce excessive amounts of IgE

Asthma, a leading cause of chronic illness in
childhood, can have a considerable impact on the daily
life of children 1, 2. Apart from the lower exercise
capacity and symptoms such as shortness of breath,
cough and wheeze, these children are also affected by
physical, social, educational and emotional
impairments3. It has been reported that asthmatic
children have significantly poorer health-related
quality of life (QoL) than other children4.
Chronic inflammation of the respiratory pathways
in patients with asthma is often associated with high
levels of immunoglobulin E (IgE) and bronchial
eosinophils.5, 6
Asthma is defined as a chronic disease of the entire
lung and asthma attacks may either be immediate
delayed or dual in onset. There is a strong association
between exposure of allergens and development of
asthmatic symptoms. The single most important risk
factor for development of asthma is atopy. Atopy is a
antibodies when exposed to allergens.7
World Health Organization defines asthma as a
chronic inflammatory disease of the respiratory
pathways and some cells, especially mastocytes;
eosinophil and T lymphocytes play an important role
in the spread of it 8. IgE is produced by B cells in
response to allergens and has a short half-life 9. Recent
evidence suggests that asthma has an allergic source
10,11
and IgE has a key role in the initiation of both
allergic and non-allergic asthma 12,13, although its role
in the pathogenesis of asthma is not yet fully identified.
Immunoglobulins are a heterogeneous group of
proteins of the im-mune system. All immunoglobulins
are composed of four polypep-tide chains: two light
(L) and two heavy (H), joined by disulfide bonds in
macromolecular compound. Based on structural
differences in constants heavy chains,
im-munoglobulins have been divided into five classes
(isotypes): IgG, IgA, IgM, IgD, and IgE14.

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 16 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Human studies over have shown a close association
between asthma the excessive response of respiratory
routes and levels of IgE serum 15. Scientific studies also
indicate increased IgE in asthmatic patients 7. Some
studies also suggest that patients with atopic and
asthma have relatively higher serum IgE levels than
healthy individuals (16,17). These studies point out
that increased IgE levels are often associated with
bronchus excessive response and reduced FEV1
(forced expiratory volume within a second) as a
determinant of asthma intensity in these patients 18.
The chronic airway inflammation present in asthma
is a predominantly helper T-cell type 2 (Th2) response
characterized by high levels of total and allergen-
specific IgE, bronchial eosinophilia, CD41 T cell
infiltrate in the airways 5,19. There is considerable
evidence that immunologic stimulus leading to
degranulation of human mast cells is their activation
when the immunoglobulin E (IgE) molecules on their
surfaces bind a relevant antigen 20. IgE is produced by
B cells in response to allergens and has a short half-
life 9 . Human studies over have shown a close
association between asthma the excessive response of
respiratory routes and levels of IgE serum 21. Scientific
studies also indicate increased IgE in asthmatic patients
7
. Some recent studies found a high positive association
between increased IgE and asthma intensity 22. Also
serum total IgE level is a strong predictor of allergy in
asthmatic children 23.
Several studies have proven that exercise, if
sufficiently intense, leads to a highly stereotyped
immune response in healthy subjects, mediated by
interplay of metabolic, endocrine and immunological
factors 24.
Published reports recommend regular physical
activity and participating in sports to be considered in
the management of asthma 25. Evidence-based analysis
identifies exercise training as the most effective part
of pulmonary rehabilitation (PR) programs, which
comprise multidisciplinary therapy.
In recent years, much research was aimed at
explaining how the exercise affects the immune
system. It is known that stress in-duced by sport
training causes changes in the lymphatic system, but
so far it is not sufficiently clear what other changes
occur in the hu-man body.
Aim of the study
The purpose of this study was to evaluate the effects
of three months aerobic training on serum IgE levels
4. Aisha Egypt-15-19.pmd 16
and on markers indicative of respiratory functions
including the forced expiratory volume in 1st
second(FEV1), forced vital capacity(FVC) and the ratio
of FEV1/FVC before or after exercise training in
asthmatic children.
METHOD
Subjects
Sixty male children with moderate degree of
bronchial asthma were recruited from out patient’s
clinic of Pediatric (Abo-Elreesh teaching) hospital, their
ages ranged from 10-15 years old. They were randomly
divided into exercise and control groups. The study
had local research and ethics committee approval and
all subjects’, parents gave written consent.
Inclusion and exclusion criteria
Inclusion criteria to study for asthma group were
as existing asthma for at least 3 years. All subjects had
not participated in regular exercise/diet programs for
the preceding 6 months. Subjects with a history or
clinical evidence of type 1 diabetes, orthopedic
abnormalities, immunosuppression, and other lung
diseases like pulmonary tuberculosis, lung abscess,
brochiectasis, tropical pulmonary eosinophilia, and
chest wall abnormalities, were excluded.
All patients underwent anthropometrical
measurements, a resting spirometry testing and fasting
blood sampling for measuring serum IgE.
The measurements for weight, height and other
anthropometrical indexes were taken pre and post-
exercise training. Body weight and height were
measured with a standard physician’s scale and a
stadiometer, respectively when subjects were in a
fasting state when the participant had thin clothes on
and was wearing no shoes. Body mass index (BMI)
was calculated using weight divided by squared
height.
Fasting blood samples and spirometry was
performed before and after an aerobic exercise
program (48 h after last exercise session) in two groups.
Blood sampling were collected in order to measuring
serum IgE and spirometry test was performed
measuring FEV1, FVC, FEV1/EVC the markers of
respiratory functions in both groups. Subjects were
asked to refrain from tea, coffee, chocolates and
caffeinated soft-drinks on the day of recording
spirometry. Intervention group performed the
modified exercise test to exclude airway hyper-
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 17

responsiveness and exercise induced bronchospasm RESULTS

and then participated in an exercise training program.
The control group subjects only took part in 1-General Characteristics of both groups
measurements and were asked not to change their
No significant differences between groups in age,
habitual physical activity during the study
weight and height, BMI and duration of asthma.
course.Control and intervention groups did not receive
any nutritional recommendations. Table 1. Base line characteristics of the patients in
exercise and control groups
Modified exercise test
Item Exercise Control p-value
In this study, using a motorized treadmill (n=30) (n=30)
mean±SD mean±SD
(COSMED, Italy) a modified exercise test was carried
Age(years) 10.40±2.2 10.43±2.1 p> 0.05
out by the intervention group to exclude airway hyper-
Height(cm) 140.83±11.7 142.76±11.9 p> 0.05
responsiveness and exercise induced bronchospasm17.
Weight (kg) 50.6±3.4 51.4±4.6 p>0.05
Heart rate was monitored with a Polar heart rate
BMI(Kg/m2) 19.5±3.6 18.7±3.4 p> 0.05
device. The subjects ran continuously for 15 minutes
Duration of asthma 4.42±2.3 4.65±1.88 p> 0.05
on the treadmill (%0 incline) and at a minimum speed
required to achieve 75-85% of predicted maximum BMI=body mass index
heart rate (max HR=220-age [year]). Post exercise FEV1
Table(2): Mean, slandered deviation and significance
was measured 1, 7, and 15 minutes after the exercise of serum IgE and pulmonary function test
and the percentage of changes from baseline were
Parameter Exercise Control P value
calculated. Measurements were considered abnormal,
group group
if FEV1 decreased 10% or more from the baseline value
Serum IGE(IU/ml)
17
. No significant change was observed in subjects of (pre training) 358 ± 46 365 ± 51 NS
the intervention (Post-training) 201±11** 369 ± 45 P< 0.05
FVC(%)
Exercise training protocol pre-training 84.3 ± 6.13 82.6 ± 6.5 NS
Post-training 93.7 ± 7.3** 83 ± 5.6 P <0.05
The intervention group participated in the exercise FEV1(%)
training program which was composed of 12 weeks(3 Pre-training 75.3 ± 5.6 76.1 ± 5.8 NS
Post-training 84.3 ± 7.6** 75.8 ± 4.2 P <0.05
days a week) of continuous treadmill
FEV1/FVC
running(grade=0%), at a minimum speed required to Pre-training 68.3 ± 4.11 69.2 ± 3.11 NS
achieve75-85% of predicted maximum heart rate.The Post-training 75.3 ± 6.8** 68.4 ± 4.6 P <0.05
running time was 15 minutes at the first
**p 0.01 within group between pre- and post-training (paired t -
session,increasing by one minute every 2 sessions up test); #p value between exercise and control group. FEV1, forced
to a maximum of 30 minutes. Once the running time expiratory volume in 1s; FEV1/FVC: forced expiratory volume in
reached 30 minutes, it was maintained till the final 1s/forced vital capacity, FVC: forced vital capacity
session. The speed of running was adjusted according
to target heart rate zone (75-85% HR max). A warm up DISCUSSION
period of 10 minutes was allocated prior to the start of
The aim of this study was to investigate the effects
each exercise session.
of aerobic exercise program on serum IgE levels and
Statistical analysis to determine pulmonary functions response to this
program. These markers are indicative of respiratory
Experimental data are presented as means ± SD and functions before and after exercise training in asthmatic
were analyzed with the SPSS software version 15.0. children.
For the descriptive statistics after having checked the
homogeneity of participants. Baseline characteristics Findings of this study support the positive effects
were compared by using independent t-tests. Student’s of submaximal aerobic exercise on serum IgE and
paired‘t’ test was applied to compare the pre and post pulmonary functions in children with asthma. Twelve
training values. An alpha-error below 5% was weeks of regular submaximal treadmill training is an
considered as statistically significant effective alternative.26

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 18 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
IgE has been proven to be responsible for the release
of various inflammatory mediators in asthma, such as
histamine, prostaglandins, and leukotriens. These
inflammatory mediators increase airway narrowing
due to excessive mucus production, airway smooth
muscle spasm, and edema of the airway mucosa. 27-28
The body’s response to exercise is also associated
with regulation of the production and secretion of
cytokines. Cytokines play an im-portant role in the
modulation of changes in the immune system during
and after exercise.29
Our results may have clinical implications, since a
post exercise decrease in IgE are indicative of the
existence of temporal immunosuppression. This in
accordance with the observation s on decreased
immune responses in overtrained athletes.30
The relationship between physical activity and the
suppression of the immune system is not fully
understood, but it is known that moderate intensity
exercise can improve immune defenses, while the
extreme effort can reduce them by creating an
increased risk of upper respiratory tract infection.
Improvement of pulmonary functions reported in
this study is consistent with the current literature
concerning aerobic improvement as well as
symptomatic improvement and medication reduction
with physical training in asthma. Neder et al. 31
investigated the short-term effects of aerobic training
in moderate-to-severe asthma and detected aerobic
improvement with a significant reduction in the
medication score. Effects of an exercise program
consisting of regular group exercises and home
exercises for a period of 3 months on aerobic capacity,
endurance and coping with asthma were evaluated
by Van Veldhoven et al. 32. They also found significant
improvements in exercise parameters and coping with
asthma.
Children with asthma should been courage to
engage in sports and lifetime exercise. However,
further randomized controlled trials using larger
samples are needed to confirm these findings and to
assess the long-term effects of physical training on
serum IgE in asthmatic children as well as to determine
which form of exercise training is most beneficial.
CONCLUSION
Based on the finding of the current study, the three-
month aerobic exercise program was associated with
4. Aisha Egypt-15-19.pmd 18
a significant improvement of pulmonary functions in
asthmatic children and a decrease in the level of IgE.
While insignificant changes in pulmonary functions
were observed in levels of these markers in the control
group.
ACKNOWLEDGMENT
The authors would like to express their appreciation
to all children and their parents who participated in
this study with all content and cooperation.
ETHICAL CLEARANCE
All subjects were informed about the study
procedure and signed consent forms approved by the
local research ethical Committee for the Protection of
Human Subjects, at Faculty of physical therapy, Cairo
University.
Conflict of Interest
There is no conflict of interest with any
organization, and this research is not funded.
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White J (1999). Upregulation of FcepsilonRI on
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(1999). The role of allergy in the development of
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Jenkins D, Jones NS (2003). ‘Entopy’: localized
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systemic responses for atopy. Clinical &
Experimental Allergy 33(10): 1374–1379.
13. Ying S, Humbert M, Meng Q (2001). Local
expression of epsilon germline gene transcripts
and RNA for the epsilon heavy chain of IgE in
the bronchial mucosa in atopic and nonatopic
asthma. Journal of Allergy and Clinical
Immunology 107(4): 686–92.
14. Czy|ewska-BuczyDska A., Lewandowicz-
UszyDska A., Jankowski A. IgA, an essential part
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J, Hamilton RG, Neas L (2010). Increased plasma
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31. Nieman D.C. Does exercise alter immune
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 DOI Number: 10.5958/j.0973-5674.7.3.058
20 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Efficacy of Scapular Movement with Mobilization in

Patients with Shoulder Impingement

Ajit Dabholkar1, Tejashree Dabholkar2, Sujata Yardi3

1
Associate Professor, 2Assistant Professor, 3Professor and Director, Pad. Dr. D. Y. Patil University,
Nerul, NaviMumbai

ABSTRACT
Background & Purpose of the study: Scapular kinematic alterations have been demonstrated in
subjects with impingement syndrome. These scapula movement alterations are believed to decrease
the subacromial space by failing to move the acromion away from the humeral head during arm
elevation resulting in increased compressive loads on the tendons of rotator cuff or long head of the
biceps muscle. Mulligan's movement with mobilization (M.W.M) hypothesize that positional
malalignment can be corrected with appropriate gliding. Thus this research investigates the efficacy
of scapular movement with mobilization in patients with shoulder impingement.
Aim: Efficacy of scapular movement with mobilization in patients with shoulder impingement
Objective: Assess immediate effect of scapular movement with mobilization in shoulder impingement
Research design: Exploratory study
Methodology: Scapula M.W.M was given to the patient, 10 repetitions thrice were repeated.
Outcome measures: Visual analogue scale was used to assess pain, Range of Motion in Scaption
plane was assessed by using Goniometer, Supraspinatus strength assessment was assessed in Scaption
plane, Shoulder pain and disability index (SPADI) was assessed
Data collection and analysis: Baseline data recorded for the outcome measures and post intervention
data was statistically analyzed for the level of significance. Paired t-test was done for the same.
Results: Significant differences were observed with respect to various outcome measures studied.
Visual analogue scale Mean difference is 2.880,Standard deviation difference is 1.447,95% confidence
interval difference is 2.283 to 3.477,(p<0.0001).Range of motion Mean difference is 21.28,Standard
deviation difference 11.150,95% confidence interval difference is 25.886 to 16.682, (p<0.0001).
Supraspinatus strength Mean difference is 4.40kgs, Standard deviation difference is 1.528, 95%
confidence interval difference is 5.031 to 3.769 (p<0.0001) and Shoulder pain and disability index
score (SPADI) Mean difference is 22.375, Standard deviation difference is 7.840,95% confidence interval
difference is 19.139 to 25.611,(p<0.0001).
Conclusion: Scapular movement with mobilization proved to be effective in patients with shoulder
impingement
Keywords: Impingement Shoulder, Scapular Alteration, Movement with Mobilization

INTRODUCTION sub-acromial bursae, or long head of the biceps tendon

beneath the anterior undersurface of the acromion,
Shoulder “impingement” was described by Neer
coracoacromial ligament, or undersurface of the
in 19721. Shoulder impingement is one of the most
acromioclavicular joint dur-ing elevation of the arm.
common conditions that affect the shoulder and
Another possible mechanism of impingement can be
accounts for 44–65% of all cases of shoulder pain2.
attributed to intrinsic breakdown of the rotator cuff
Impingement usually refers to compression and
tendons as a result of tension overload3.
mechanical abrasion of the rotator cuff tendons,

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 21
Serratus anterior and lower trapezius are the most
susceptible to the effects of inhibition and are most
frequently involved in early phases of shoulder
pathology4
The scapula serves many roles in order for proper
shoulder function to occur (W. Ben Kibler, Br J Sport
Med 2010).Scapular kinematic alterations have been
demonstrated in subjects with impingement
syndrome5.
MRI study by Solem – Bertoft et al revealed that
anterior opening of the subacromial space narrowed
as the shoulder moved from a retracted to a protracted
position6
Mulligan’s movement with mobilization (M.W.M)
hypothesize that positional malalignment can be
corrected with appropriate gliding. Thus this research
investigates the efficacy of an innovative method i.e.
Scapular movement with mobilization in patients with
shoulder impingement.
MATERIAL AND METHODOLOGY
Fig. 1
Materials: Goniometer, Push-Pull Dynamometer
(Baseline), Visual Analogue scale Pen ,Paper
Study Design: Exploratory, one group pre-test and
post-test study
Inclusion Criteria: Patients with impingement of
shoulder, Hawkin’s Kennedy and Neer’s test was
positive. Scapula repositioning/Scapula retraction test
positive
Exclusion Criteria: Rotator cuff tear, frozen
shoulder, Shoulder instability
5. Ajit Dabolkar--20--24.pmd 21
METHODOLOGY
Institutional ethics committee approval was taken
to start the study.
Written consent was taken from all the subjects who
participated in the study.
30 subjects were selected according to the inclusion
criteria as mentioned above.
Outcome measures: Visual analogue scale was
used to assess pain, Range of Motion in Scaption plane
was assessed by using Goniometer, Supraspinatus
strength assessment was assessed in scaption plane,
Shoulder pain and disability index (SPADI) was
assessed.
Procedure for scapular movement with
mobilization as shown in Fig 2 & 3(Innovative
method):
The patient was made to sit on a stool. The therapist
stands behind the patient on the affected side. The
therapist’s left hand holds the scapula in a way that
the fingers are on the medial border of the scapula,
web space on inferior border and the thumb on the
lateral border of the scapula. The right hand is on the
superior part of the clavicle. The right hand thumb is
on the spine of the scapula and the fingers anterior to
the clavicle. The patient is told to do the offending
movement in the scaption plane with the thumb
facing up. The therapist’s moves/assists the scapula
in upward rotation (left hand) and posterior tilting the
scapula (right hand) as the patients goes into the end
range of motion actively elevating the shoulder.
Scapula M.W.M was given to the patients, 10
repetitions thrice were repeated (48 hour follow up was
studied)
Fig. 2
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 22 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

upward rotation and posterior tilt (Lin JJ et al, J

.Electromyography Kinesiology2005,Sports Ex. Med
2008)

Studies have demonstrated that sub-jects with

shoulder impingement may present with decreased
scapular upward rotation and posterior tilt, and
increased scapular internal rotation during arm
elevation. 17, 18 . Nociceptive input may influence
peripheral and central motor control (Pain 2001).
Studies demonstrated difference in EMG activity in
particular upper and lower trapezius between people
with SIS and healthy controls (BMC Musculoskeletal
Disorders 2010)

Correctional mobilisation (a repositioning) is

sustained, pain free function is restored and several
repetitions will begin to bring lasting improvements
(Mulligan)

Inman, Saunders and Abbott 19 stated that

Fig. 3 coor-dinated activity in scapular muscles for smooth
movement of the scapula during arm motions. They
Data collection and Analysis: Baseline and Post studied raw EMG data from various muscles and
intervention data was recorded for the outcome described trapezius and lower serratus anterior as the
measures and statistically analyzed for the level of prime movers for scapular upward rotation.
significance. Paired t-test was done for the same
Overall, trapezius has been found to be more active
dur-ing abduction as compared to flexion, 20 .
RESULTS AND OBSERVATIONS Consistent with less scapular internal rotation present
Outcome Mean Mean Std Std P Value in scapular plane abduction as compared to
pre post Dev pre Devpost
flexion21, 22
VAS 7.84 4.96 1.18 1.40 <0.0001*
SUPRASPINATUS The middle and lower serratus anterior are aligned
STRENGTH 4.32 8.72 1.70 2.30 <0.0001*
with a substantial mechanical advantage for scapular
SCAPTION ROM 88.19 109.48 17.89 17.71 <0.0001*
upward rotation23, in combination with the ability to
SPADI 78.44 56.06 7.85 10.19 <0.0001*
posteriorly tilt and externally rotate the scapula
*Indicates Extremely significant
The middle and lower serratus anterior are the only
DISCUSSION scapulotho-racic muscles with the capability to both
upwardly rotate and posteriorly tilt the scapula on the
Alterations in scapula positions and motions occur thorax. Their line of action will also directly
in 68% to 100% of patients with shoulder injury (W. approximate the scapula to the thorax, which can serve
Ben Kibler).Visible alterations in scapular position and as a stable base. The functions of serratus anterior make
motion patterns have been termed scapular dyskinesis. its contribution to normal scapular kinematics during
Several investigators 8-14 have studied 3-D (3- arm elevation very significant in reducing risk for
dimensional) shoulder kinematics during arm scapular alterations identified with shoulder
elevation, including how abnormal motion may relate impingement symptoms, including reduced upward
to shoulder impingement. It has been described that rotation or posterior tilting, or in-creased scapular
during elevation of the arm in healthy subjects the internal rotation.
scapula should upwardly rotate and posterior tilt15, 16
Force couples are pre-programmed to interact with
In subjects with impingement less serratus anterior glenohumeral muscle to provide scapular position and
muscle activation and greater upper and lower stability for arm motion (Journal of Biomech1995)
trapezius activation were found with less scapular

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 23
Position and control of the scapula on the thorax
play a critical role in normal function of the shoul-der.
Stabilization is provided through the scapulothoracic
musculature by approximating or compressing the
scapula to the thorax. Scapular motions on the thorax
align the glenoid fossa with the humeral head
maximizing joint congruency and providing a stable
base for humeral motion7. Normal External rotation
of scapula during scaption coordinated action of all
parts of trapezius and serratus anterior. (Muscle and
Nerve 2006
Correction of asynchronous muscle activity,
improve dynamic stability and thereby decrease pain
and increase function (Michener et al, J of Hand
Therapy 2004, Desmeule SF et al, Sports Med 2003)
Fig. 4. Alignment-impairment Model
As shown in the above Model, Alignment deviation
leads to impairment. Therefore, selecting Mulligan’s
M.W.M for correcting the positional malalignment
would give lasting benefits. According to the present
study, pain was alleviated improving range of motion
and supraspinatus strength, thus decreasing the
disability in patients of shoulder impingement.
Normal kinematics of the shoulder is believed
critical to preserving the subacromial space and
preventing impingement during arm elevation. The
length-tension relationship and load of the rotator cuff
and scapular muscles and tendons are also believed
to be influ-enced by normal kinematics.
5. Ajit Dabolkar--20--24.pmd 23
CONCLUSION
Scapular movement with mobilization proved to
be effective in patients with shoulder impingement
Clinical Implications: Scapular movement with
mobilization can be used in patients with impingement
shoulder demonstrating abnormal behaviour.
Acknowledgement: None
Funding: Nil
Conflict of Interest: None
REFERENCES
1. Neer CS. Anterior acromioplasty for the chronic
impingement syndrome in the shoulder: a
preliminary report. J Bone Joint Surg Am. 1972;
54(1):41-50.
2. Van der Windt DA, Koes BW, de Jong BA,
Bouter LM. Shoulder disorders in general
practice: Incidence patient characteristics, and
management. Ann Rheum Dis. 1995; 54(12):
959-964.
3. Soslowsky LJ, Thomopoulos S, Esmail A,
Flanagan CL, Iannotti JP, Williamson JD 3rd, et
al. Rotator cuff tendinosis in an animal model:
Role of extrinsic and overuse factors. Ann Biomed
Eng. 2002; 30(8):1057-63.
4. Michael L. Voight, DPT, OCS, SCS, ATC; Brian C.
Thomson SPT, The Role of the Scapula in the
Rehabilitation of Shoulder Injuries, Journal of
Athletic Training 2000; 35(3):364–372
5. Ludewig PM, Cook TM. Alterations in shoulder
kinematics and associated muscle activity in
people with symptoms of shoulder
impingement. Phys Ther. 2000; 80: 276-291
6. Solem-Bertoft E, Thuomas KA, Westerberg CE.
The influence of scapular retraction and
protraction on the width of the subacromial
space. Clin Orthop Relat Res. 1993; 99-103
7. Kibler WB, McMullen J. Scapular dyskinesis and
its relation to shoulder pain. J Am Acad Orthop
Surg. 2003; 11(2):142-51.
8. Lukaseiwicz AC, McClure P, Michener L, Pratt
N, Sennett B. Comparison of 3-dimensional
scapular position and orientation between
subjects with and without shoulder
impingement. J Orthop Sports Phys Ther. 1999;
29(10):574-83
9. Ludewig PM, Cook TM. Alterations in shoulder
kinematics and associated muscle activity in
people with symptoms of shoulder impingement.
Phys Ther. 2000; 80(3):276-91.
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10. Endo K, Ikata T, Katoh S, Takeda Y. Radiographic
assessment of scapular rotational tilt in chronic
shoulder impingement syndrome. J Orthop Sci.
2001; 6(1):3-10.
11. Hebert LJ, Moffet H, McFadyen BJ, Dionne CE.
Scapular behaviour in shoulder impingement
syndrome. Arch Phys Med Rehabil. 2002;
83(1):60-9.
12. Ludewig PM, Cook TM. Translations of the
humerus in persons with shoulder impingement
symptoms. J Orthop Sports Phys Ther. 2002;
32(6):248-59.
13. Laudner KG, Myers JB, Pasquale MR, Bradley JP,
Lephart SM. Scapular dysfunction in throwers
with pathologic internal impingement. J Orthop
Sports Phys Ther. 2006; 36(7):485-94.
14. McClure PW, Michener LA, Karduna AR.
Shoulder function and 3-dimensional scapular
kinematics in people with and without shoulder
impingement syndrome. Phys Ther. 2006;
86(8):1075-90.
15. Ludewig PM, Cook TM, Nawoczenski DA.
Three-dimensional scapular orientation and
muscle activity at selected positions of humeral
elevation. J Orthop Sports Phys Ther. 1996;
24(2):57-65.
16. McClure PW, Michener LA, Sennett BJ, Karduna
AR. Direct 3-dimensional measurement of
scapular kinematics during dynamic movements
in vivo. J Shoulder Elbow Surg. 2001; 10(3):
269-277.
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17. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J,
Kennedy R. Scapulothoracic motion in normal
shoulders and shoulders with glenohumeral
instability and impingement syndrome: A study
using moire topographic analysis. Clin Orthop
Rel Res. 1992; 285:191-9.
18. Lin JJ, Hanten WP, Olson SL, Roddey TS, Soto-
quijano DA, Lim HK, et al. Functional activity
characteristics of individuals with shoulder
dysfunctions. J Electromyogr Kinesiol. 2005;
15(6):576-86.
19. Inman VT, Saunders JB, Abbott LC. Observations
on the function of the shoulder joint. J Bone Joint
Surg. 1944; 26A:1-30.
20. Wiedenbauer MM, Mortensen OA. An
electromyographic study of the trapezius muscle.
Am J Phys Med. 1952; 31(5):363-72
21. McClure PW, Michener LA, Sennett BJ, Karduna
AR. Direct 3-dimensional measurement of
scapular kinematics during dynamic movements
in vivo. J Shoulder Elbow Surg. 2001; 10(3):
269-277.
22. Ludewig PM, Phadke V, Braman JP, Hassett DR,
Cieminski CJ, LaPrade RF. Motion of the shoulder
complex during multiplanar humeral elevation.
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 DOI Number: 10.5958/j.0973-5674.7.3.059
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 25

Effect of Hip Position and Gender on Active Hip Internal

Rotation and External Rotation on the Dominant Side

Amit Agarwal1, Amrit Kaur2, Ganesh MSP3

1
B.P.T, NDMVP College of Physiotherapy, Nashik, 2Assisstant Professor, NDMVP College of Physiotherapy, Nashik,
3
Associate Professor, NDMVP College Of Physiotherapy , Nashik

ABSTRACT
Objective: This study was designed to establish the influence of gender and hip flexion position on
active range of motion of the hip in external and internal rotation.
Method: 100 (50 Males & 50 Females) healthy college-age subjects with no previous hip problems
were studied. Mean age was 21.8 years with a range of 18-27 years. Hip rotation of the dominant leg
of each subject was measured in the prone (hip near 0" of flexion) and seated (hip near 90" of flexion)
positions using a standard goniometer.
Result: Data were analyzed using t test. Our results indicate Mean values of active hip ROM for
college aged students is 27.85 for internal rotation and 34.61 for external rotation in seated position &
Mean values of active hip ROM for college aged students is 35.35 for internal rotation & 42.57 for
external rotation in prone position.Females had statistically more active hip internal and external
rotation than males.
Conclusion: These findings are clinically significant and stress the importance of documenting
measurement position.
Keywords: Hip, Gender, Joint Motion

INTRODUCTION Normal range of motion values for hip internal

rotation (IR) and external rotation (ER) are reported
In physical therapy practice, the measurement of
as 40" and 50°, respectively.4 The American Academy
joint range of motion is an intrinsic component of the
of Orthopedic Surgeons5 reports normal hip IR and
evaluation and treatment of patients. The objective
ER to be 45" when rotation is measured, both with the
assessment of joint mobility is useful to determine
hip flexed at 90" and with the hip in the anatomical
deficits in flexibility, monitor patient progress, and
neutral position. However, no information is provided
influence alterations of treatment protocol. Properly
regarding the origin of the data in terms of number of
developed normative values for active and passive
subjects measured, the subjects’ gender, or the subjects’
joint range of motion can provide population-specific
age5. Norkin and White’s textbook on the measurement
references to which patients can be compared.
of joint motion is another commonly used source of
Reliability and validity of range of motion
normative values.3 Although Norkin and White use a
measurements using goniometers has been established
variety of sources to tabulate expected hip IR and ER
in previous literature.1,2,3
by both gender and age, no detailed information is
Hip range of motion can be measured in two ways, presented regarding the measurement position or type
in the high sitting position and prone position 3. of range of motion (active or passive) for which these
however there has been a significant difference in the data were obtained.3
ranges obtained in the two positions. Especially
The present study serves to improve the data
varying according to the gender. A general lack of
available for hip active range of motion in rotation by
descriptive details exists for measurements of Hip
establishing the influence of gender and patient
Rotations Range Of Motion.
position on these measurements.

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 26 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
PURPOSE OF STUDY
The purpose of this study was to determine the
amount of hip active range of motion in IR and ER of
male and female college-aged students in two
positions: prone and seated. These positions were
chosen since they are most commonly used to measure
hip rotation in the physical therapy clinic. These
positions differ in that the hip is in approximately 90"
of flexion when seated, while it is near its neutral
anatomical position of 0" of flexion in prone.
Objective of this study determined whether:
1) Is measurements of active hip IR and ER are
influenced by the position (seated vs. prone) and
2) To find the influence of Gender on hip internal and
external rotation.
METHOD
100 healthy college students with no previous hip
problems (50 males and 50 females) volunteered to
participate in this study. Subjects’ mean age was 21.8
years with a range of 18-27 years. All subjects signed
an informed consent form approved by the NDMVP
medical college ethical Committee before
participating.
Exclusion criteria was- any Hip and knee
pathology, Limb length discrepancy greater than1cm,
Previous history of fracture around hip or knee, SI joint
dysfunction, Sciatic nerve tension, Femoral
Antiversion, Valus & Valgus deformity and pregnancy.
All the subjects selected for study were in
comfortable clothing that permits unrestricted
movements at hip & free visual access to Anatomical
landmarks required to make the ROM measurements.
The dominant side has been determined by the leg
chosen to kick the soccer ball & will be subsequently
used for all measurements. Active ROM of Hip in
Internal Rotation & External Rotation is measured by
using standard goniometer. Each subject were
measured for active hip Internal Rotation & External
Rotation in both seated and prone position.3 The
subjects were instructed to rotate the hip of his/her
dominant leg Internally & Externally using their
maximum effort. For each testing position(prone &
seated) & movement direction (IR & ER) AROM were
performed a total of 3 times, twice to provide a
6. amit agrawal--25--28.pmd 26
standard stretch & warm up , the third time for the
measurement
The following anatomical landmarks were
identified for each measurement as described by
Norkin and White 3. Specifically, the movable arm of
the goniometer was centered over the anterior midline
of the lower leg, using the tibia1 crest and a point
midway between the malleoli as reference points. The
axis of rotation was centered over the anterior aspect
of the patella. The stationaly arm of the metal
goniometer hung in the vertical plane , so that it
remained perpendicular to the floor. At the end of hip
rotation, the measurement was made to the nearest
degree.For the measurements, the subject’s pelvis was
stabilized in both the prone and seated position as
described below.
Prone: A subject’s legs and hips were stabilized by
a standard belt positioned over the center of the
buttocks and around the table. In addition, a subject’s
hips were stabilized by manual pressure over the
dominant leg buttock to prevent the hip from lifting
off the table.
Seated: A subject’s hips were stabilized by a
standard belt draped over the upper thighs and
secured around the table. In addition, the dominant
leg was then stabilized with loosely applied manual
pressure just proximal to the knee.
A soft fixation with the belt and manual pressure
was provided to prevent compensation
with hip flexion and abduction while allowing the
thigh to move freely in the rotation direction.
The results for each subject and each position were
recorded. Data were analyzed by using t test.
RESULTS
No statistically significant difference existed
between males and females with regard to their age.
The average age of men and women studied was 21.8
. The subjects’ ages ranged from 18-27.mean age of
females was 21.6 and males was 22.their
anthropometric measurements were not taken into
consideration. Our results indicate that the mean
values of active hip ROM of 27.85 for internal rotation
and 34.61 for external rotation in seated position &
Mean values of active hip ROM of 35.35 for internal
rotation & 42.57 for external rotation in prone position.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 27

Table 1. Comparison of Hip IR & ER ROM in high in physiotherapy clinic. This position differ in that hip
sitting and prone positions (MALE) is in approximately 90degree of flexion. When seated
INTERNAL ROTATION while it is near its neutral anatomical position of
MEAN OF DIFFERENCE 8.16 0degree flexion in prone.
SD 4.28
When the data from 100 subjects were pulled
SE 0.605
together we have seen that there is statistically
CAL T 13.48
significant difference. Mean values of active hip ROM
TAB T 2.02
of 27.85 for internal rotation and 34.61 for external
EXTERNAL ROTATION
rotation in seated position & Mean values of active
MEAN OF DIFFERENCE 10.32
hip ROM of 35.35 for internal rotation & 42.57 for
SD 3.644
external rotation in prone position.
SE 0.515
CAL T 20.03 The gender main effect indicates that, on average,
TAB T 2.02 women have greater hip rotation than men (p < 0.05).
Table 2. Comparison of Hip IR & ER ROM in high
This difference is greater for hip IR, with women
sitting and prone positions. (FEMALE) having 1.5" and 0.17" more rotation than men in the
seated and prone positions, respectively. For hip ER,
Internal Rotation
women have only 2.5" & 0.3 more rotation than men
MEAN OF DIFFERENCE 6.84
in both the seated and prone positions. The findings
SD 3.58
of greater hip active range of motion for IR in females
SE 1.76
are consistent with the results of Walker et al6 and
CAL T 3.88
James and Parker7 .Due to the numerous anatomical
TAB T 2.02
structures that may affect the amount of hip rotation,
EXTERNAL ROTATION
providing a detailed explanation of why the amount
MEAN OF DIFFERENCE 7.6
of hip ER is reduced in sitting and the amount of hip
SD 4.03
IR is only minimally affected by the change in position
SE 0.507 may be difficult. With the hip near a neutral anatomical
CAL T 13.33 position (in prone), ER of the hip is accompa- nied by
TAB T 2.02 an anterior glide of the fem- oral head, and rotation
Table 3. COMPARISON BETWEEN GENDERS would be lim- ited by tension in the anterior capsule
and the iliofemoral ligament8. In this same position,
INTERNAL ROTATION
IR of the hip results in a posterior glide of the femoral
SD 3.92
head, and rotation would be limited by tension in the
SE 0.392
posterior capsule and the ischiofemoral liga- ment.
CAL T 3.367
With flexion of the hip, most ligamentous structures
TAB T Approx 1.98
(p value
loosen 8 . In seated position, hip ER is now
for 120=1.98) accompanied by a superior glide of the femoral head,
EXTERNAL ROTATION with the rotational movement being limited by the
SD 3.84 superior capsule and the iliofemoral ligament8. Hip
SE 0.384 IR, performed seated, is accompanied by an inferior
CAL T 7.083 glide of the femoral head and the rotational movement
TAB T Approx 1.98 would be limited by tension in the inferior capsule and
(p value superior ischiofemoral ligament8. The relative tension
for 120= 1.98)
of these capsuleoligamentous structures when moving
from the prone to the seated position is not known.
DISCUSSION
Based on our results, since IR was only minimally
In this study we have seen the amount of hip active affected by the change in measurement posi- tion, the
ROM in Internal rotation & External rotation of males capsuloligamentous structures limiting IR would have
and Females College aged students in two positions a similar relative tension. For ER, the
prone and seated these positions were chosen since capsuloligamentous structures limiting ER would be
they are most commonly used to measure Hip rotation in greater tension in the seated position. In addition to

6. amit agrawal--25--28.pmd 27 8/1/2013, 8:31 AM

 28 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
the passive tension of the capsule, passive tension of
the musculature surrounding the hip must also be
considered. A 90" change in the hip flexion position
will undoubtedly change the available length of many
of the hip muscles which would passively limit motion
in rotation if already placed in a stretched position by
the flexed or extended hip. Active insufficiency of the
hip rotators and the influence of gravity must also be
considered as possible explanations for the change in
active range of motion at the hip between the seated
and prone positions. Moving the hip from a near 90"
flexed position to a near neutral anatomical position
in the sagittal plane changes the length and orientation
of the muscles which surround the hip. Excessive
shortening of any number of muscles participating in
hip rotation could result in their decreased ability to
generate a torque and rotate the hip. The fact that hip
rotation measured prone is gravity-assisted and hip
rotation measured seated is performed against gravity
could compound this factor. In this study, efforts were
made to control for measurement errors that could be
associated with unwanted movement of the hip in
flexion, abduction, or adduction. Adequate
stabilization of the lower extremity was judged
necessary to improve both the reliability and accuracy
of the measurements. For this purpose, external
stabilization with the use of straps and manual contact
were used. While such stabilization is unlikely to be
common practice in the clinical setting (due to time
constraints), clinicians should pay close attention to
possible substitutions which may affect their
measurements.
CONCLUSION
This study provides information as to the difference
in hip active
range of motion in rotation mea- sured seated vs.
prone, the two most common measurement positions
used in the clinic. In general, women had greater total
hip rotation than males, with most of this difference
being attributable to an increase in hip IR.
6. amit agrawal--25--28.pmd 28
ACKNOWLEDGMENTS
The authors would like to acknowledge all the
voluntaries for their help with the data collection.
Conflict of Interest: In this study BMI is not taken into
consideration. Future studies can be done by taking
anthropometric measurements into consideration.
Source of Funding: Self
REFRENCES
1. Gajdosik RL, Bohannon RW: Clinical
measurement of range of motion: Review of
goniometry emphasizing reliability and validity.
Phys Ther 67(72):1867- 1872, 1987
2. Miller PJ: Assessment of joint motion. In:
Rothstein JM (ed), Measurement in Physical
Therapy, pp 103-135. New York, NY: Churchill
Livingstone, 1985
3. Norkin CC, White Dl: Measurement of Joint
Motion: A Guide to Goniometry (2nd Ed),
Philadelphia, PA: F.A. Davis Company, 1985
4. American Medical Association: Guides to the
Evaluation of Permanent lmpairment (3rd Ed),
Milwaukee, WI: American Medical Association,
7 990
5. American Academy of Orthopedic Surgeons:
Joint Motion: Method of Measuring and
Recording, Chicago, IL: American Academy of
Orthopedic Surgeons, 1965
6 Walker JM, Sue D, Miles-Elkousy N, Ford G,
Trevelyan H: Active mobility of the extremities
in older subjects. Phys Ther 64(6):9 1 9-923, 1984
7. James B, Parker A W: Active and pas- sive
mobility of the lower limb joints in elderly men
and women. Am J Phys Med Rehabil68(4): 162-1
67, 1989
8. Fuss FK, Bacher A: New aspects of the
morphology and function of the human hip joint
ligaments. Am J Anat 192: 1- 13, 1991
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 DOI Number: 10.5958/j.0973-5674.7.3.060
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 29

Electrophysiological Assessment of Clinically Diagnosed

Patients of Carpal Tunnel Syndrome in Western
Maharashtra (India)

Joshi A G1, Gargate A R2, Patil S N2

1
Professor, Department of Physiology, 2Associate Professor, Department of Physiology, Krishna Institute of Medical
Sciences Deemed University, Karad, Maharashtra, India

ABSTRACT
Objective: To find out most sensitive electrophysiological indictors of carpal tunnel Syndrome.
Materials and method: 45 normal subjects and 125 clinically diagnosed patients of carpal tunnel
syndrome (CTS) were studied. Sensory and motor conduction of Median nerve was studied bilaterally.
Sensory and motor conduction of Ulnar nerve was studied bilaterally.
Results: Compared to controls, in patients following changes were observed on both the sides:
Distal sensory latencies (DSL) and distal motor latencies (DML) of median nerve were
increased.
Sensory nerve conduction velocity (SNCV) of median nerves was reduced.
Differences between DSL of median and ulnar nerves were increased.
Differences between DML of median and ulnar nerves were increased.
Compound Muscles Action Potentials (CMAP) and Sensory nerve action potentials
(SNAP) were not significantly reduced.
Median nerve conduction abnormalities were also observed in asymptomatic hands.
Conclusion: Difference between DSL of median and ulnar nerves, difference between DML of median
and ulnar nerves and SNCV of median nerve are very sensitive indicators for diagnosis of CTS.
CTS is bilateral disorder.
Keywords: Carpal Tunnel Syndrome, Median Nerve Conduction, Ulnar Nerve Conduction

INTRODUCTION CTS has also been reported to be the commonest

entrapment neuropathy in western countries. In
Carpal tunnel syndrome (CTS) is most common
Rochester, Minnesota, the prevalence of CTS was
entrapment neuropathy in upper extremity. The carpal
estimated at 125 per 100,000 in 1976-80. Earlier hospital
tunnel is bounded by carpal bones and transverse
based studies from India reported CTS rarely. In recent
ligaments which are attached to Scaphoid, trapezoid
study from South India CTS accounted for 7% of
and Hamate bones. The diameter of carpal tunnel is 2
patients with peripheral nerve disorders and 84% of
to 2.5cm and median nerve passes through it along
entrapment neuropathies referred for electro
with nine digital flexor tendons. Some degree of
diagnostic evaluation 3. Early diagnosis of CTS may
compression of median nerve and focal nerve
help to plan the treatment in early stage before
conduction slowing is common at this level which is
structural damage to median nerve occurs. The results
more pronounced 2-3 cm distal to the origin of the
of electro diagnostic studies have been found to be
ligament. Autopsy study has also confirmed focal
highly sensitive and specific 3. In Maharashatra,
abnormality in median nerve in 5 out of 12
especially in Western Maharashtra very little research
asymptomatic subjects.1, 2

7. Anand Joshi --29--33.pmd 29 8/1/2013, 8:31 AM

 30 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
work is available on electro diagnosis of CTS. Hence,
objectives for present study were:
I) To find out the electrophysiological parameters
which are more sensitive for early detection of CTS.
ii) Most of our patients were having unilateral
symptoms. There was possibility that they may get
complaints suggestive of CTS in asymptomatic hand
later. So another purpose of the study was to find out
whether there are electrophysiological changes of CTS
in asymptomatic hands also.
In present study bilateral sensory and motor
median nerve conduction studies were carried out in
clinically diagnosed patients of CTS to find out electro
physiologic changes in median nerve conduction.
Comparison of median palm-to-wrist latency with
ulnar palm-to-wrist latency is more sensitive indicator
for diagnosis of CTS 2, 4. So bilateral sensory and motor
ulnar nerve conduction studies were also carried out
and compared with that of median nerve.
MATERIALS AND METHOD
Nerve conduction study was conducted on 125
(250 hands) patients referred to electrophysiology
laboratory of Department of Physiology in Krishna
Institute of Medical Sciences Karad, Maharashtra
(India)
Inclusion criteria :Patients having symptoms
suggestive of CTS i.e.- aching pain in hand and arm
(especially at night), parasthesia in thumb, index finger
and middle finger for more than 4 weeks 5, Phalan’s
test positive, Tinel’s sign positive.
Exclusion criteria: Patients having clinical or
laboratory diagnosis of radiculopathy, neuropathy,
diabetes, rheumatoid arthritis, trauma,
hypothyroidism and pregnancy were excluded from
the study 5
Nerve conduction study was also performed on 45
age matched controls those were selected from medical
students and faculty members.
Institutional ethical committee approval was taken
for the study. Patients and subjects were informed the
detailed procedure of nerve conduction study and
written consent was taken. Electro diagnostic study
included motor and sensory nerve conduction of
Median and Ulnar nerves on both sides by
conventional method 1.
7. Anand Joshi --29--33.pmd 30
Following parameters were measured: Motor
conduction
Distal motor latency of Median nerve and ulnar
nerve Motor conduction velocity Amplitude of
compound muscle action potential.
Difference between distal motor latencies of
median and ulnar nerves.
Sensory conduction: Distal sensory latency of Median
nerve and ulnar nerve Sensory conduction velocity
Amplitude of sensory nerve action potential.
Difference between distal sensory latencies of
median and ulnar nerves.
For recording sensory and motor nerve
conduction, surface metal electrodes were used. For
recording motor conduction of Median nerve,
recording electrode was placed close to the motor point
of Abductor Pollicis Brevis and reference electrode 3cm
distal to it at first metacarpophalangeal joint. A
supramaximal stimulus was given at wrist and at
elbow near volar crease of brachial pulse.
For recording motor conduction of Ulnar nerve,
recording electrode was placed close to the motor point
of Abductor Digiti Minimi and reference electrode 3cm
distal to it at fifth metacarpophalangeal joint. A
supramaximal stimulus was given at wrist and at
elbow in cubital tunnel behind medial epicondyle. For
ulnar nerve stimulation at elbow arm position was
maintained at 1350.1
Care was taken to keep same distance between
stimulating and recording electrodes for both median
and ulnar nerves at wrist so that distal latencies of
Median and Ulnar nerves could be compared.1
For orthodromic sensory conduction of median
nerve, surface recording electrode was placed 3cm
proximal to distal wrist crease and reference electrode
at 3cm proximal to recording electrode. For stimulation
ring electrodes were fixed on second digit.
For orthodromic sensory conduction of ulnar
nerve, recording electrode was placed 3cm proximal
to distal palmer crease and reference electrode at 3cm
proximal to recording electrode. For sensory
stimulation ring electrodes were fixed on fifth digit.
Cathode is placed at first interphalangeal joint and
anode at 3cm distal to cathode. For both median and
ulnar sensory conduction, 20 supramaximal stimuli
were delivered and average was recorded. During both
median and ulnar sensory conduction recording,
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 31

ground electrode was placed between recording and parameters in patients and controls unpaired‘t’ test
stimulating electrodes. Care was taken to keep same was applied. The difference was considered to be
distance between stimulating and recording electrode highly significant when p value was <0.001 and
for both median and ulnar nerves at wrist. significant when p was < 0.05.

During nerve conduction study, laboratory
temperature was maintained between 21o C to 230C.
When skin temperature of limb was below 340C, the
limb was immersed in a warm water to correct the
temperature.1
For nerve conduction studies, Recorder and
Medicare System (RMS) machine from Chandigarh
(India) was used.
Statistical Analysis
To compare difference between various study
95% normality range (Mean ±2 S.D.) was
determined for each study parameter from
observations made on controls. In patients number of
observations for each study parameter lying outside
this normality range were measured and its percentage
was calculated.
RESULTS
125 patients and age matched 45 normal subjects
were subjected to bilateral median and ulnar, sensory
and motor nerve conduction.

Table 1. Sensory Nerve Conduction Study

Parameter Mean ± SD Control n=45 Mean ± SD Patients n=125 T value P value

Median Rt.SNCV Lt.( m/s) 54.92 ± 4.52 53.61 ± 5.86 39.80 ± 9.63 44.14 ± 9.3 10.0786.310 < 0.0010.000987
Median Rt.DSL Lt. ( ms) 2.38 ± 0.242.45 ± 0.35 3.24 ± 0.77 2.90 ± 0.64 7.1614.275 < 0.001< 0.001
Median Rt.SNAP Lt.( uV) 30.92 ± 8.7927.82 ± 12.82 13.66 ± 10.3919.83 ± 12.82 9.6545.631 0.1965270.043069
Difference Rt.In DSL Lt. 0.12 ± 0.18 0.18 ± 0.23 1.12 ± 0.780.83 ± 0.61 8.4956.873 < 0.001< 0.001

SNCV: Sensory nerve conduction velocity; DSL- Distal sensory latency of median nerve was
Distal sensory latency; SNAP- Sensory nerve action prolonged. It was statically highly significant with p
potential value <0.001.

Compared to control group, in patients following SNCV of median nerve was reduced. Decrease was
changes were observed in sensory conduction on both highly significant with p value < 0.001 on Rt. Sides
the sides (Table No. 1): and p < 0.05 on Lt. side.

Difference between DSL of median and ulnar In 24% of patients sensory response from median
nerves was increased. It was statistically highly nerve was absent.
significant with p value < 0.001.

Table 2. Motor Nerve Conduction Study

Parameter Mean ± SD Control(n=45) Mean ±SD patients (n=125) T value P value

Median Rt.DML Lt.( ms) 2.98 ± 0.335 2.90 ± 0.453 3.92 ± 1.31 3.57 ± 0.90 5.0044.778 < 0.0010.000005
Median Rt.CMAP Lt.(mv) 15.13 ± 3.39 16.40 ± 3.929 10.98 ± 4.82 12.41 ± 4.56 5.3205.222 0.0079580.240942
Difference Rt.in DML Lt. 0.83 + 0.30 0.76 ± 0.30 1.76 ± 1.24 1.45 ± 0.91 4.9364.927 < 0.001< 0.001

MNCV: Motor nerve conduction velocity; DML-
Distal motor latency; CMAP- Compound muscle
action potential
Compared to control group, in patients following
changes were observed in motor conduction on both
the sides (Table No. 2):
Difference between DML of median and ulnar
nerves was increased. It was statistically highly
significant on both the sides with p value < 0.001
DML was prolonged in patients. Increase was
highly significant with p value < 0.001.
Changes in amplitude of CMAP and SNAP were
not statistically significant.

7. Anand Joshi --29--33.pmd 31 8/1/2013, 8:31 AM

 32 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table No:3 Percentage of patients with electrophysiological abnormalities

Parameter Right Left

1) No. of Patients having Median DML > Normality range 62 (49.6%) 33 (26.4%)
2) No. of Patients having Median MNCV < Normality range 16 (12.8%) 20 (16%)
3) No. of Patients having Median CMAP amplitude < Normality range 36 (28.8%) 22 (17.6%)
4) No. of Patients having difference in DML of Med.& Uln. > Normality range 66 (52.8%) 46 (36.8)
1) No. of Patients having Median DSL > Normality range 60 (48%) 35 (28%)
2) No. of Patients having Median SNCV < Normality range 64 (51.2%) 38 (30.4%)
3) No. of Patients having Median SNAP amplitude < Normality range 57 (45.6%) 38 (30.4%)
4) No. of Patients having difference in DSL of Med. & Uln. > Normality range 64 (51.2%) 50 (40%)

51.2% of patients were having increased difference
between DSL on Rt. side and 40% were having on Lt.
side. 48% of the patients on Rt. side and 28% on Lt.
side were having prolonged median nerve DSL. 51.2%
of patients were having reduced SNCV on Rt. side and
30.4% were having on Lt. side.
52.8% of patients were having increased difference
between DML on Rt. side and 36.8% were having on
Lt. side. 62% of patients were having increased DML
on Rt. side and 33% were having on Lt. side.
DISCUSSION
across the carpal tunnel (Table No. 2). In severely
affected patients sensory response was absent (24%).
There was significant decrease in SNCV of the patients,
on both sides. The previous reports from researchers
show same results.2, 7
Distal sensory latencies and distal motor latencies
of median nerve across the carpal tunnel were
prolonged significantly on both sides as they were
measured across the carpal tunnel. But this was
observed in relatively less number of patients as shown
in Table no. 1, 2 & 3. Our finding are consistent with
previous reports.1,6,11

For diagnosis of CTS electrophysiological studies
are more sensitive than clinical findings.3
The electrophysiological diagnosis of CTS is based
on conduction abnormalities across carpal tunnel as
median nerve gets compressed in carpal tunnel 1, 3
Characteristic findings in the electrophysiological
diagnosis of CTS were slowing sensory conduction of
median nerve, decrease in SNAP amplitude, and
increase in DSL and DML in median nerve 6, 7, 8. As
ulnar nerve does not pass through carpal tunnel and
passes lateral to tunnel its DML and DSL are expected
to be normal. So difference between DML and DSL of
median and ulnar nerve may be considered as very
sensitive indicator of CTS 2, 7, 9. The findings in our study
also show that the difference between DML and DSL
of median and ulnar nerves was highly significant and
also observed in maximum number of patients as
noted in Table No.4
The American Association of Electro diagnostic
Medicine (AAEM) has concluded that median nerve
sensory transmission is also more sensitive indicator
for diagnosis of CTS 10. In this study median nerve
sensory velocity was reduced as it was measured
Compared to controls, amplitudes of CMAP and
SNAP of median nerve in patients were not reduced
significantly.
To conclude, difference between DSLs of median
and ulnar nerves is the most sensitive indicator of CTS.
Difference between DMLs of median and ulnar nerves
is also the most sensitive indicator of CTS. Reduction
in SNCV of median nerve is sensitive indicator while
DSL and DML are less sensitive indicators. Amplitudes
of SNAP and CMAP are not sensitive indicators. In
our study 80% patients were having complaints only
on Rt. Side. However, electrophysiological findings
showed bilateral changes. The high prevalence of
abnormal median conduction without corresponding
symptoms may suggest presence of sub clinical CTS
12, 13
. If corrective measures are taken in time we would
be able to prevent progression of CTS in asymptomatic
hands.
The present study has limitation that the number
of patients is small. Larger studies are needed to
strengthen the interpretations. For the present study
patients from Western Maharashtra were studied,
more patients should be evaluated from other parts of
Maharashtra to generalise the interpretations.

7. Anand Joshi --29--33.pmd 32 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 33
ACKNOWLEDGMENT
The authors are thankful to vice chancellor,
KIMSDU and Principal, KIMSDU, Karad for kindly
providing laboratory and hospital facilities to carry out
this work.
REFERENCES
1) Mishra U.K., Kalita J. Clinical neurophysiology,
2nd Ed. Reed Elsevier India Private Limited, 2008;
32-40.
2) Gilliatt R.W. Sensory conduction studies in early
recognition of nerve disorders Muscle nerve 1978;
1: 35
3) Murthy J.M.; Meena A.K., Carpal tunnel
syndrome- Electrodiagnostic aspects of fifty
seven symptomatic hands. Neurology India,
1999: 47: 272-275.
4) Atroshi I., Gummesson C., Johnson R, Ornsteir
E. Diagnostic properties of nerve conduction tests
in population- based Carpal tunnel syndrome:
BMC Musculoskeletal Disorders, 2003,4:9
5) Oxford handbook of clinical medicine, Indian
edition, 8th edition page:507
6) Thomus J.M., Xuan Kong, Shai N. Gozani. Utility
of nerve conduction studies for Carpal Tunnel
Syndrome by Family Medicine, Primary care and
Internal Medicine Physicians: The Journal of the
American Board of Family Medicine, 2007: 20:
60-64.
7. Anand Joshi --29--33.pmd 33
7) Aydyn G., Keles I., Ozbudak Demir S., Baysal A.
Y. Sensitivity of median sensory conduction tests
in digital branches for diagnosis of carpal tunnel
syndrome. Phys. Med Rehabil 2004; 83: 17-21
8) Padua L., Lo Monaco M., Valente E.M., Tonali P.A.
A useful electrophysiological parameter for
diagnosis of carpal tunnel syndrome. Muscle
Nerve 1996; 19
9) Jackson D.A., Cliford J.C. Electrodiagnosis of mild
carpal tunnel syndrome. Phys.Med. Rehabil 1989;
70: 199-204
10) Tokcaer B Ayse, Gogus Feride, Gullap Sumer,
Keles Isik, Gokce Mustafa. Role of sensory nerve
conduction study of palmer cutaneous nerve in
diagnosis of Carpal tunnel syndrome in patients
with polyneuropathy: Neurology India, 2007: 55,
17-21.
11) Recep Aygul, Hizir Ulvi, Dilcan Kotan, Mtlu
Kuyucu. Sensitivities of conventional and new
electrophysiologic techniques in carpal tunnel
syndrome and their role in body mass index:
Journal of Brachial Plexus And Peripheral Nerve
Injury, 2009: 4: 2-12
12) Bagatur Erdem A., Merter Yalcinkaya. Unilateral
carpal tunnel syndrome caused by an occult
palmer lipoma: ORTHOPEDICS, 2009; 32: 777
13) Bingham R.C., Rosecrance J.C., Cook T.M.
Prevalence of median nerve conduction in
applicants of industrial job: Am.J.Ind.Med., 1996
Sep;30(3): 355-61
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 DOI Number: 10.5958/j.0973-5674.7.3.061
34 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effectiveness of Core Muscle Stabilization Training on

Dynamic Balance in Mechanical Low Back Pain Patients

Apeksha O Yadav1, Ketaki G Deshmukh2

1
Asst. Professor, 2Intern. Ravi Nair Physiotherapy College, DMIMS (DU) Sawangi (M) Wardha

ABSTRACT
Objective: To assess & find the effect of core muscle stabilization training on dynamic balance in
mechanical low back pain patients.
Design: Prospective Experimental Study.
Participants and Outcome Measure: 30 Subjects with Mechanical Low Back Pain were selected and
Core Muscle Stability Training was given. Outcome measures were recorded pre & post training
program using STAR Excursion test.
Result: Data was collected & analysed using Student's paired t-test to determine changes in dynamic
balance, whereas correlation was done amongst right & left lower limb in each direction pre & post
training, it showed a significant difference in anterior, anterolateral, lateral, posterolateral, posterior
& anteromedial directions of right lower limb and anterior, anterolateral, lateral, posterolateral,
posterior, posteromedial and anteromedial directions of left lower limb.
Conclusion: Core stabilisation training is significantly effective in improving dynamic balance in
mechanical low back pain patients.
Keywords: Core muscle stabilization training, Dynamic balance, STAR Excursion Test

INTRODUCTION • Active system constitutes muscle and tendon

Back pain is the most prevalent condition affecting
adults and thus hampering their daily living activities.
The incidence of back pain in adults has been estimated
to be as high as 60%–80% (1).
surrounding & acting on the spinal columns.
• Neural system constitutes nerves and CNS which
directly controls the active system in providing
dynamic stability (6).

Spinal instability is defined in terms of region of
laxity around the neutral resting position of spinal
segment called the “Neutral Zone” or “Neutral Spine”.
This neutral zone is said to be larger with
intersegmental injury and intervertebral disc
degeneration and smaller with simulated muscle
forces across a motion segment. In this way, size of
neutral zone is considered to be an important measure
of spinal stability (8).
It is influenced by the interaction between passive,
active and neutral control systems:
• Passive system constitutes the vertebrae,
intervertebral discs, zygoapophyseal joints and
ligaments.
“Core stability” describes the ability to control the
position and movement of central portion of the body.
It targets muscles deep within the abdomen which
connect to the spine, pelvis and shoulders, assist in
maintenance of good posture & provide foundation
for all arm and leg movements and thus play vital role
in maintenance of dynamic balance (5). The core can be
described as a muscular box with the abdominals in
front, paraspinals and gluteals in back, diaphragm as
roof, and pelvic floor and hip girdle musculature as
bottom to stabilize the spine, pelvis, and kinetic chain
during functional movements. The core is particularly
important in sports because it provides ‘‘proximal
stability for distal mobility’’. It appears that a
coordinated contraction of all deep and superficial core
muscles is needed for optimal spinal stabilization (5).

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 35
Good core stability can help maximize running
performance and prevent injury. It helps reduce risk
of injury resulting from bad posture. Power is derived
from trunk region of the body and properly
conditioned to control that power, allowing for
smoother more efficient and better co-ordinated
movements in the limbs (5).
Core functions to maintain postural alignment &
dynamic postural equilibrium during functional
activities, which helps to avoid serial distortion
patterns. Core stability is the motor control and
muscular capacity of the lumbo-pelvic-hip complex.
Normal function of the stabilizing system is to provide
sufficient stability to the spine to match the
instantaneously varying stability demands due to
changes in spinal posture, and static and dynamic
loads (3).
Core strengthening & stabilization training helps
to increase levels of functional strength and dynamic
balance leading to better control of balance and
improve athletic performance and prevent injuries to
alleviating low back pain(5).
MATERIAL AND METHODOLOGY
This is a Prospective experimental study carried out
in Physiotherapy OPD in Tertiary Care Hospital.
Materials used were Swiss Ball, Medicine Ball,
Therabands, Coloured Tapes, Measuring Tape,
Sphygmomanometer as Pressure Biofeedback Unit. 30
Subjects were selected with Mechanical Low Back Pain.
Both genders were included. Patients with Radiating
pain, Pregnancy, diagnosed Psychiatric illness, any
abdominal surgery, history of lower limb fracture or
trauma and patients who have undergone Core muscle
stabilisation training programme in past 6 months
were excluded. Study was explained & written consent
was taken from them to undergo treatment for four
weeks. Observations were recorded by measuring the
excursion of each of the eight directions using STAR
Excursion Balance test pre treatment and post
treatment i.e. one week before and after the completion
of training program. The SEBT involved a star pattern
with 8 projections each at 45 degrees from each other,
on an even surface. Subjects placed their non-dominant
foot on mid of the star pattern, while their dominant
foot reached as far as possible in each 8 excursions
while maintaining a single leg stance & reaching with
the opposite leg to touch as far as possible along a
chosen excursion. They were then instructed to touch
the farthest point possible, & as light as possible, along
8. apeksha yadav--34--39.pmd 35
a chosen excursion with the most distal part of their
reach foot. Then they returned to a bilateral stance
while maintaining their balance. Six practice sessions
for each excursion followed by a minute rest & the
farthest measurement was recorded. Additionally, leg
length of the subject’s dominant extremity was used
to normalize their dynamic balance scores (excursion
length/leg length x 100 for a percentage of an excursion
distance in relation to the subject’s leg length) and used
for data analysis.
SEBT with Right limb stance SEBT with Left limb stance:
A: anterior excursion; AM: anteromedial excursion;
M: medial excursion; PM: posteromedial excursion; P:
posterior excursion; PL: posterolateral excursion; L:
lateral excursion; AL: anterolateral excursion.
Core stabilisation training programme exercises
Level 1: week 1
Day 1-3: Abdominal Muscle Contraction. Subject
is in supine with knees bent so that feet lie flat on floor.
They will be instructed to contract their abdominals,
drawing in their navel without rotating pelvis.
Abdominal Muscle Contraction: Subject in
quadruped position is instructed to contract their
abdominals, drawing their bellybutton towards the
ceiling without rotating their pelvis.
Abdominal Muscle Contraction: Subject in a
sideways posture will bear their weight on right
forearm and right foot. Then will maintain a straight
alignment while contracting the right oblique muscle.
Same will be repeated on other side.1x6/each side
(10sec holds).
Dying Bug: Subject in supine with upper and lower
extremities facing straight toward the ceiling.
Instructed to maintain an abdominal contraction while
simultaneously moving their extremities toward the
torso in slow controlled movements (Figure 1).
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 36 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Fig. 1. Dying Bug.
Bridging: Subject in quadruped position, instructed
to contract their Abdominals while simultaneously
extending one leg back as straight as possible in a slow
controlled manner, and then bringing it back to starting
position. Continue same for opposite leg.
Fig. 2. Seated Medicine Ball Rotation.
Level 2:Week 3
Day 1-3: Abdominal Muscle Contraction.
Seated on Swiss Ball: Subject sits on a Swiss Ball
in an upright posture & will contract their abdominals
without rotating their pelvis and simultaneously
maintaining balance.
Squat with Swiss Ball: Subject will squat with a
Swiss Ball in between the subjects back and wall and
instructed to maintain a proper squatting posture while
contracting their abdominals during squat.
8. apeksha yadav--34--39.pmd 36
Seated Medicine Ball Rotation: Subject sits upright
on floor with knees bent at 45 degrees. Then will hold
a medicine ball in both hands and will rotate their
upper torso with the arms extended while maintaining
abdominal contraction (Figure 2).
Superman: Subject will lie on their stomach with
upper and lower extremities positioned straight out
and fully extended. They will be instructed to raise
both extremities at the same time & not to exceed the
onset of extreme low back arching. Return to the
starting position in a controlled manner.
Level 2: Week 4
Day 4-6: Abdominal Muscle Contraction.
Multidirectional Lunge: Subject will stand in
upright posture with both hands on their hip. Then
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 37

they lunge with their right knee and hip flexed to 90
degrees and their left knee flexed to 90 degrees and
left hip at 180 degrees. The lunge will be directed
straight ahead. After going back to the starting
position, the lunge will be repeated with similar
posture 45 degrees to the right. The same movement
will be repeated for left leg.
Oblique Pulley with Side Shuffles: A theraband
is tied at one end while the other end is held with both
hands in an extended position. Then the subject will
do side shuffles to the point of minimal resistance &
will then pull horizontally toward the tied up side,
and then will side shuffle back to the starting position.
Level 3:Week 5
Day 1-3: Abdominal Muscle Contraction.
Twists on Swiss Ball: Subject will have both feet
planted on floor while their upper back supported on
a Swiss Ball with their arms extended toward the
ceiling over their chest, holding a medicine ball. They
will then stabilize their lower body while moving their
extended arms to one side of the body, and then back
to the starting position, then repeat the same for
opposite side.
Core Stabilization: Training Program Protocol
Week 1 to Week 5
Specific prescribed sets and repetitions will be
performed for each exercise with one minute rest in
between sets. Subjects will progress to next level of
core stabilization training program according to the
exercise protocol.

Diagonal Curls on Swiss Ball: Subject will have
both feet planted on floor while their upper back
supported on a Swiss Ball and their arms crossed over
their chest. They will be instructed to raise their upper
body using their trunk muscles and turn towards
opposite knee, then return to the starting position. The
same action will be repeated for the opposite knee.
Statistical Analysis: Data was assessed as follows-
mean difference was taken for pre and post training
measurements for each direction and student’s paired
t test was used to determine the changes in dynamic
balance, whereas correlation was done amongst right
and left lower limb in each direction pre and post
training.

RESULT
Table 1: Comparison of directions of pre and post treatment of Right Lower Limb

Direction Paired Differences t df p-value

Mean Std. Std. Error 95% Confidence
Deviation Mean Interval of
the Difference
Lower Upper
Anterior 0.82 1.29 0.23 -1.30 -0.34 3.48 29 0.002 S
Anterolateral 2.35 2.01 0.36 -3.10 -1.60 6.412 29 0.000 S
Lateral 2.06 4.79 0.87 -3.85 -0.27 2.356 29 0.025 S
Posterolateral 2.60 2.83 0.51 -3.66 -1.55 5.04 29 0.000 S
Posterior 0.90 1.08 0.19 -1.31 -0.50 4.58 29 0.000 S
Posteromedial 0.42 1.30 0.23 -0.91 0.05 1.795 29 0.083 NS
Medial 0.29 11.93 2.17 -4.15 4.75 0.13 29 0.892 NS
Anteromedial 0.49 1.52 0.27 -1.06 0.07 1.759 29 0.089 NS

Comparison of directions of pre and post treatment
of right lower limb is:
• The mean excursion for anterior direction at pre-
treatment was 81.30 ± 11.64 and post-treatment was
• The mean excursion for lateral direction at pre-
82.13 ± 11.68 with mean difference of 0.82 ± 1.29.
Showing significant improvement in balance (t =
3.48, p= 0.002).
• The mean excursion for anterolateral direction at
pre-treatment was 88.14 ± 8.46 and post-treatment
was 90.50 ± 8.90 with mean difference of 2.35 ±2.01.
Showing significant improvement in balance (t =
6.412, p= 0.000).
treatment was 85.85 ± 7.70 and post-treatment was
87.91 ±11.23 with mean difference of 2.06 ±4.79.
Showing significant improvement in balance
(t =2.356, p= 0.025).

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 38 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

• The mean excursion for posterolateral direction at
pre-treatment was 82.96 ± 9.68 and post-treatment
was 85.57 ±9.64 with mean difference of 2.60 ±2.83.
Showing significant improvement in balance (t
=5.04, p= 0.000).
• The mean excursion for posterior direction at pre-
treatment was 72.91 ± 18.42 and post-treatment
was 73.81 ± 18.67 with mean difference of 0.90
±1.08. Showing significant improvement in balance
(t =4.58, p= 0.000).
• The mean excursion for posteromedial direction
at pre-treatment was 68.87 ± 16.81and post-
treatment was 69.30 ±16.84 with mean difference
of 0.42 ±1.30. Showing non-significant
improvement in balance (t =1.795, p= 0.083).
• The mean excursion for medial direction at pre-
treatment was 67.65 ± 14.45 and post-treatment
was 67.35 ± 10.16 with mean difference of 0.29
±11.93. Showing non-significant improvement in
balance (t =0.13, p= 0.892).
• The mean excursion for anteromedial direction at
pre-treatment was 79.21 ± 10.40 and post-treatment
was 79.70 ± 10.55 with mean difference of 0.49
±1.52. Showing non-significant improvement in
balance (t =1.759, p= 0.89).

Table 2: Comparison of directions of pre and post treatment of Left Lower Limb

Direction Paired Differences t df p-value

Mean Std. Std. Error 95% Confidence
Deviation Mean Interval of
the Difference
Lower Upper
Anterior 2.08 1.78 0.32 -2.74 -1.41 6.397 29 0.000S
Anterolateral 4.67 7.45 1.36 -7.45 -1.89 3.43 29 0.002 S
Lateral 3.78 4.12 0.75 -5.32 -2.24 5.02 29 0.000 S
Posterolateral 4.04 5.03 0.91 -5.92 -2.16 4.397 29 0.000 S
Posterior 1.97 4.47 0.81 -3.64 -0.30 2.422 29 0.022 S
Posteromedial 0.88 1.79 0.32 0.21 1.54 2.69 29 0.012 S
Medial 0.51 3.28 0.59 -0.71 1.73 0.858 29 0.398 NS

Comparison of directions of pre and post treatment
of left lower limb is:
• The mean excursion for anterior direction at pre-
treatment was 84.55 ± 7.18 and post-treatment was
86.63 ± 7.85 with mean difference of 2.08 ± 1.78.
Showing significant improvement in balance (t =
6.397, p= 0.000).
• The mean excursion for anterolateral direction at
pre-treatment was 77.37 ± 8.52 and post-treatment
was 82.04 ± 10.04 with mean difference of 4.67 ±
7.45. Showing significant improvement in balance
(t = 3.43, p= 0.002).
• The mean excursion for lateral direction at pre-
treatment was 87.56 ± 8.43 and post-treatment was
91.34 ±9.20 with mean difference of 3.78 ±4.12.
Showing significant improvement in balance
(t =3.43, p= 0.002).
• The mean excursion for posterolateral direction at
pre-treatment was 82.83 ± 8.98 and post-treatment
was 86.87 ± 11.12 with mean difference of 4.04 ±
5.03. Showing significant improvement in balance
(t =4.397, p= 0.000).
• The mean excursion for posterior direction at pre-
treatment was 79.01 ± 12.05 and post-treatment
was 80.99 ± 14.70 with mean difference of 1.97 ±
4.47. Showing significant improvement in balance
(t =2.422, p= 0.022).
• The mean excursion for posteromedial direction
at pre-treatment was 76.78 ± 10.40 and post-
treatment was 75.90 ±9.33 with mean difference of
0.88 ± 1.79. Showing significant improvement in
balance (t =2.69, p= 0.012).
• The mean excursion for medial direction at pre-
treatment was 63.42 ± 8.26 and post-treatment was
67.35 ± 10.16 with mean difference of 0.51 ±3.28.
Showing non-significant improvement in balance
(t =0.858, p= 0.398).

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 39

• The mean excursion for anteromedial direction at Showing significant improvement in balance
pre-treatment was 85.23 ± 9.65 and post-treatment (t =2.46, p= 0.020).
was 82.81 ± 6.32 with mean difference of 2.42 ±5.38.

Table 3: Correlation between Right and Left Lower Limb Pre treatment

Directions Right Lower Limb Left Lower Limb Correlation ‘r’ p-value
Anterior 81.30 84.55 0.49 0.006S,p<0.05
Anterolateral 88.14 77.37 -0.43 0.31NS,p>0.05
Lateral 85.85 87.56 0.65 0.000 S,p<0.05
Posterolateral 82.96 82.83 0.25 0.18 NS,p>0.05
Posterior 72.91 79.01 0.55 0.002 S,p<0.05
Posteromedial 68.87 76.78 0.13 0.47 NS,p>0.05
Medial 67.65 63.42 0.66 0.000 S,p<0.05
Anteromedial 79.21 85.23 0.44 0.014 S,p<0.05

Table 4: Correlation between Right and Left Lower Limb Post treatment

Directions Right Lower Limb Left Lower Limb Correlation ‘r’ p-value
Anterior 82.13 86.63 0.51 0.004S,p<0.05
Anterolateral 90.50 82.04 0.33 0.06NS,p>0.05
Lateral 87.91 91.34 0.53 0.002 S,p<0.05
posterolateral 85.57 86.87 0.34 0.06 NS,p>0.05
Posterior 73.81 80.99 0.49 0.005 S,p<0.05
Posteromedial 69.30 75.90 0.06 0.73 NS,p>0.05
Medial 67.35 62.91 0.57 0.001 S,p<0.05
Anteromedial 79.70 82.81 0.29 0.11 NS,p>0.05

CONCLUSION Adaptation, and Enhancement. J Spinal Disord.

Core stabilisation training is significantly effective
in improving the dynamic balance in mechanical low
back pain patients.
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1. D.P. Rodriguez, T.Y. Poussaint. Imaging of Back
Pain in Children. AJNR 2010; 31: 787-802.
2. Anthony B. Piegaro, Jr., BS, ATC. The
Comparative Effects of Four-Week Core
Stabilization & Balance-Training Programs on
Semidynamic & Dynamic Balance. 2003.
3. Kimberly M. Samson, BS, ATC, PES. The Effects
of a Five-Week Core Stabilization Training
Program on Dynamic Balance in Tennis Athletes.
2005.
4. Venu Akuthota, MD, Scott F. Nadler, DO. Core
Strengthening. Arch Phys Med Rehab 2004; 85:
86-92.
5. Venu Akuthota, Andrea Ferreiro, Tamara Moore,
Michael Fredericson. Core Stability Exercise
Principles. Curr. Sports Med. Rep. 2008; 7: 39-44.
6. Manohar M Punjabi. The Stabilizing System of
the Spine, Part I; Function, Dysfunction,
1992; 5:383-9.
7. Jaana Suni, Marjo Rinne, Antero Natri, Matti
Pasanen, Jari Parkkari, and Hannu Alaranta.
Control of the Lumbar Neutral Zone Decreases
Low Back Pain and Improves Self-Evaluated
Work Ability. Spine. 2006; 31: E 611-20.
8. Alyson Filipa, Robyn Byrnes, Mark V. Paterno,
Gregory D. Myer and Timothy E. Hewett.
Neuromuscular Training Improves Performance
on the Star Excursion Balance Test in Young
Female Athletes. J Orthop Sports Phys Ther. 2010;
40:551-8.
9. Hodges PW & Richardson CA. Core stability
exercise in chronic low back pain. Orthop Clin N
Am. 2003; 34: 245-54.
10. Vezina MJ, Kozey CL, Muscle activation in
therapeutic exercises to improve trunk stability.
American Academy of Physical Medicine and
Rehabilitation, 2000; 81:1370-9.
11. Famin Farzaneh Hessari, Ali Asghar Norasteh,
Hassan Daneshmandi, Solmaz Mahdavi
Ortakand. 8 Weeks Core Stabilization Training
Program on Balance in Deaf Students. Medicina
Sportiva. 2011; 15: 56-61.

8. apeksha yadav--34--39.pmd 39 8/1/2013, 8:31 AM

 DOI Number: 10.5958/j.0973-5674.7.3.062
40 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of Knee Chest Position in Primary Dysmenorrhea-

A Randomized Controlled Trial

Arati Mahishale1, Dinika Mascarenhas2, Shobhana Patted3

1
Assistant Professor, Institute of Physiotherapy, 2(MPT) OBG Physiotherapy, Institute of Physiotherapy, KLE
University, Belgaum, 3Professor, OBG Department, J.N. Medical College, KLE University, Belgaum, Karnataka

ABSTRACT
Background and objectives: Dysmenorrhea is a painful symptom that accompanies the menstrual
cycles. Although exercise is generally thought to alleviate the symptoms of menstrual pain the scientific
literature displays mixed evidence. The main objective of this research was to determine the effect of
knee chest position on primary dysmenorrhea.
Materials and method: 30 female participants were recruited from KLE's Institute of Physiotherapy,
Belgaum and randomly allocated to control and experimental group after obtaining an informed
consent and clearance from the institutional ethical committee. Visual analogue scale (VAS) and
Moos menstrual distress questionnaire (MMDQ) were used as primary and secondary outcome
measures. Control group received hot moist pack for 10 mins and the experimental group received
hot moist pack (HMP) for 10 mins and knee chest position for 10 repetitions with 20 seconds hold.
The intervention was carried out for 2 days beginning from the first day of menses. Outcome measures
were documented using VAS on both the days pre intervention and post intervention and MMDQ
on 1st day pre intervention and 2nd day post intervention respectively.
Results: The results showed statistically significant reduction in VAS and MMDQ scores in the
experimental group when compared to the control group with p<0.05.
Conclusion: Intervention with Knee chest position can be used in conjunction with HMP for reducing
pain and menstrual distress in primary dysmenorrhea.
Keywords: Primary Dysmenorrhea, Visual Analogue Scale, Moos Menstrual Distress Questionnaire, Knee
Chest Position

INTRODUCTION decreasing the efficiency and quality of life among

Dysmenorrhoea is defined as pain associated with
menstruation of sufficient magnitude so as to affect
day-to-day activities. 1 According to Dawood
dysmenorrhea is the common gynaecological
complaint that can affect 50% of women with 10% of
these women suffering severely enough to render them
to incapacitate for one to three days of each menstrual
cycle .2 This condition not only has a significant impact
on personal health but also has a global economic
impact.2 Pain is a subjective symptom and cannot be
accurately estimated by an outside observer since
different women perceive pain with different severity
and tolerance. 3 The incidence of primary
dysmenorrhea is about 45-50%. It is the major cause
of absenteeism from work amongst women thus
women. 1,4-11 The pain begins on the first day of
menstruation and lasts for a few hours to even two
days. Pain is usually described as cramping in nature
and pain is felt mainly in the hypogastrium and
radiates to the inner and front aspect of the thighs.3
Women who exercise have a reduced incidence of
dysmenorrhea which could be due to exercise related
hormonal effects on the lining of the uterus or increased
level of circulating endorphins.12 Exercise acts as a non-
specific analgesic for short-term relief of pain.13,14
Dysmenorrhea is classified into three types namely
Primary or spasmodic dysmenorrhea (essential/
intrinsic/functional) which is defined as painful
menstruation in the absence of pelvic pathology.
Membranous dysmenorrhea is actually a type of
spasmodic dysmenorrhea characterised by the passage

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 41
of an endometrial or decidual cast. Secondary
dysmenorrhea is painful menses secondary to an
underlying organic disease of the pelvic organs.3
The management of primary dysmenorrhea
includes various medical and surgical procedures.
With the advent of oral contraceptives and non
steroidal anti inflammatory drugs there is marked
relief in pain. Various exercises and positions have been
proposed which are targeted in between the menstrual
cycle but not evaluated during active menstrual period
although literature suggests that perimenstrual
exercises or positions are indicated for primary
dysmenorrhea, no specific therapy has been studied
or recommended for clinical implication. To the best
our knowledge of literature search knee chest position
for primary dysmenorrhea has not been studied and
hence the present study aims to evaluate the effect of
knee to chest position on pain and menstrual distress
in primary dysmenorrhea.
METHODOLOGY
Study Design
The present study is designed as a randomized
controlled trial to evaluate the effect of knee chest
position in primary dysmenorrhea.
Source of data
Primary data was collected from KLE’S DR.
Prabhakar Kore hospital and medical research centre,
Belgaum-Karnataka from September 2011 to
November 2011.
PARTICIPANTS
30 female participants with complain of primary
dysmenorrhea from the Institute of Physiotherapy
Belgaum and those referred to Physiotherapy O.P.D,
KLE’S DR. Prabhakar Kore Hospital and Medical
Research Centre, Belgaum were recruited for the study.
PROCEDURE
Participants fulfilling the eligibility criteria were
considered for the study and informed consent was
signed from the study participants prior to the
commencement of study. Demographic details like
name, age, height, weight, address and contact details
were recorded. The subjects were randomly allocated
to one of the two groups using envelope method to
Group A (control) receiving HMP and Group B
9. Arati Mahashale-40-44.pmd 41
(experimental) receiving HMP and knee chest position.
Inclusion Criteria
Females aged between 18-35years, regular menses
with complaint of primary dysmenorrhea and those
who were willing to participate in the study.
Exclusion Criteria
Participants under medications like painkillers or
others, intermenstrual bleeding, subjects with urinary
tract infection, postpartum women (during puerperal
age), those with intrauterine contraceptive device and
subjects who were breast feeding.
Intervention
Intervention was given for two days beginning
from the first day of menses. The control group
received only HMP for 10 minutes. Those in
experimental group received HMP for 10 minutes
which was placed on their lower abdomen and were
made to perform alternate knee chest position. In this
position the subjects were made to lie in supine
position on the treatment table and alternate knee to
chest position was made to perform for duration of
20seconds and frequency of 10 repetitions each twice
a day.
Outcome measures
VAS was used as primary and MMDQ was
secondary outcome measures. The Visual Analogue
Scale is a 10cm horizontal line drawn on a paper where
start symbolizes no pain and end symbolizes the worst
thinkable or tolerable pain and participants will be
asked to mark a point on this line as per severity of
their pain which will indicate the pain level.15MMDQ
was proposed by Rudolf H Moos. It is a standard
method for measuring cyclical perimenstrual
symptom. It is a 46-item self-report inventory for use
in the assessment and treatment of premenstrual and
menstrual symptoms. MMDQ can distinguish cyclical
from non-cyclical changes in physical symptoms,
mood and behaviour and arousal. It identifies type and
intensity of symptoms, mood and behaviour and
arousal women experience during each phase of
menstrual cycle and can aid researchers and clinicians
in specifying effect of therapeutic interventions.16 Total
scores were calculated for this and then the pre and
post test scores were compared. The primary outcome
measure VAS was taken on both the days before and
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 42 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

after treatment whereas the secondary outcome VAS Score

measure MMDQ was taken on first day pre
intervention and second day post intervention.
Data Analysis
Data was computed and analyzed using SPSS
(statistical package for social sciences) software version
16. For different quantitative parameters mean and SD
were calculated. Tests of significance namely Mann-
Whitney Test and Wilcoxon signed-rank test were used
to compare between pre and post intervention and to
compare between control and experimental group.
RESULTS
The result of the study showed statistically
significant difference in pain and menstrual distress
as measured using VAS and MMDQ in experimental
group as compared to control group. The demographic
profile showed no statistical difference between the
parameters like age, height, weight, BMI between the
control and the experimental group which signifies
that the characteristics of participants in both the
groups were well matched. (Table 1)
The pre-intervention VAS score in control group
on the 1st day was 8.3±1 and experimental group was
8.2±0.88 and on 2nd day the control group was 7.4±1.13
and experimental group was 7±1.70. The post
intervention VAS score in control group was 5.6±2.11
and experimental group was 4.3±1.13 on the 1st day
whereas on the 2nd day it was 4.9±1.98 in the control
group and 3.1±1.42 in the experimental group. There
was statistically significant difference in VAS score on
1st day as well as 2nd day post intervention with p=0.037
(day 1) and p=0.015 (day 2) suggesting better pain
reduction in experimental group as compared to
control group. (Table 2)
MMDQ Score
The pre-intervention MMDQ value was 133.2±30.49
in control group and 138.8±34.32 in experimental
group on day 1 and 95.5±20.22 and 101.1 respectively
in the control and experimental group on day 2.
MMDQ values showed statistically significant
difference within the groups in both control and
experimental group with p<0.05. (Table 3)

TABLE: 1 (Demographic Profile)

AGE (yrs) HEIGHT (mats) WEIGHT (kgs) BMI

Control Group 23.4±4.62 1.61±.09 56.2±11 21.81±5.13
Experimental Group 23.2±4.62 1.62±.07 56.9±11.06 21.73±4.11
t 0.079 0.225 0.190 0.049
DF 28 28 28 28
P 0.938 0.824 0.850 0.961

No difference in mean of age, weight, height and BMI

TABLE 2. Visual Analog Scale

DAY -1 DAY-2
Groups Pre Post Diff Pre Post Diff
Control 8.3±1 5.6±2.11 2.7±1.47 7.4±1.13 4.9±1.98 2.5±1.05
Experimental 8.2±.88 4.3±1.31 3.9±1.82 7±1.70 3.1±1.42 3.9±1.47
Mann-WhitneyTest (p) 0.624 0.026 0.037 0.486 0.004 0.015

Significant differences in the VAS scores is seen between the groups and within the groups

TABLE: 3 (Moos Menstrual Distress Questionnaire)

Groups Pre Post Difference

Control 133.2±30.49 95.5±20.22 37.7±29.62
Experimental 138.8±34.32 101.1 37.7±25.72

The values of MMD are statistically significant within the groups for both control and experimental with p < 0.05

9. Arati Mahashale-40-44.pmd 42 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 43

DISCUSSION potent vasoconstrictor and causes increased

myometrial contractility, whereas PGE2 increases
The present study results show that knee chest
sensitivity to the nerve endings. PGI2 is a vasodilator
position along with hot moist pack have significantly
which decreases prior to menstruation leading to
reduced pain and menstrual distress in subjects with
ischemia which further causes hypoxia and therefore
primary dysmenorrhea as shown by VAS and MMDQ.
results in pain.3 The hormonal effects of exercise act
A study where continuous, low level, heat wrap
on the lining of the uterus as well as leads to an increase
therapy was used as a non medical self help therapy
in the level of circulating endorphins. An interesting
applied over suprapubic region was significantly
element of relationship between exercise and
superior to acetaminophen.17 Topically applied heat
dysmenorrhea is the involvement of stress. Exercise is
has proved subjective relief of pain in primary
widely accepted as a mean of moderating stress and
dysmenorrhea. Thermotherapy works by increasing
biochemical changes in the immune system. A
the blood flow thereby supplying protein, nutrients
mechanism by which exercise may improve the
and oxygen at the site of injury. Increased blood flow
symptoms of dysmenorrhea has been articulated by
facilitates tissue healing by increase in metabolism.
Gannon in 1986.14 The experimental group received
This increase in metabolism aids the healing process
both HMP and knee chest position and has shown
by increasing both catabolic and anabolic reactions
significant reduction in pain as compared to the control
needed to degrade and remove metabolic by-products.
group which signifies the cumulative effect of both
The reduction in pain in the control group of our study
HMP and exercise. This combined effect can be used
who received HMP could be consistent with the
in clinical practice to overcome the discomforts of
physiological basis as explained above.18
primary dysmenorrhea .
Exercises are recommended in primary
dysmenorrhea with supporting literature since more CONCLUSION
than 15-20 years. These exercises are recommended
Knee chest position along with hot moist pack is
even during perimenstrual period19. Several exercises
effective in reducing pain and relieving the discomforts
such as Cat stretch, lower trunk rotation, buttock/hip
of primary dysmenorrhea aiding in pain free menses.
stretch, abdominal strengthening and bridge position
have been stated in literature but not implemented
LIMITATIONS
clinically and lacks literature support.20 It has also been
said that at least 15minutes of exercises done daily as Sample size was small, data was collected only at
well as between menstrual periods relieve pain during one menstrual cycle and no follow up was done.
dysmenorrhea. These exercises include floor polishing
movements, bending, twisting, swaying, rowing REFERENCES
movements.3
1. D.C. Dutta Textbook oo Gynecology 4th Edition,
The effect of knee chest exercise in the present study ISBN-7381-174
in relieving pain due to primary dysmenorrhea is 2. Proctor M, Murphy PA. Herbal and dietary
consistent with other studies where pelvic girdle therapies for primary and secondary
exercises were used in primary dysmenorrhea. dysmenorrhoea. Cochrane Database of
Systematic Reviews 2001, Issue 2. Art. No.:
Golub et al studied the effectiveness of exercise CD002124. DOI: 10.1002/14651858.CD002124
namely Golub’s exercise on the frequency of 3. Sabaranam Arulkumaran, V Sivanesaratnam,
premenstrual difficulties and dysmenorrhea among Alokendu Chatterjee, Pratap Kumar. Essentilas
high school girls over a 3-year period, at the end of of Gynecology.1st Edition New Delhi: Jaypee
which 39% of the exercise group suffered from Brothers Medical Publishers 2005 p55-58
4. Parsons. Primary Dysmenorrhea. Text book of
dysmenorrhea compared with 61% of the control
Gynaecology 2nd ed, 325-29.
group (P<0.05).The investigators however did not
5. Novak. Pelvic Pain and Dysmenorrhea. Berek J
differentiate between primary and secondary (Eds) General Gynaecology 6th ed, Williams and
dysmenorrhea.21 Willians; 408-14.
6. Kistner. The Menstrula Cycle. Kistner ’s
Dysmenorrhea is caused due to elevated levels of
Gynaecology 6th ed, USA; Harcourt Brace and
menstrual stimulant that is prostaglandins. These are Co., 1995;44-46.
three namely: PGF2á, PGE2 and PGI2. PGF2á is a

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 44 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
7. Shaw R. Disorders of Menstruation. Shaw’s
textbook of Gynaecology 12th ed. New Delhi;
Churchill Livingstone, 1999;227-29.
8. Dawood YM. Dysmenorrhea. Clinical Obstet and
Gynecol 1983;26(3): 719-27.
9. Lumsden MA. Dysmenorrhea. Progress in
Obstetrics and Gynaecology 5:276-89.
10. McLure Browne. Dysmenorrhea. Post graduate
Obstetrics and Gynaecology, 3rd ed 89-99.
11. Balbi C, Musone R, Menditto A, Di Prisco L,
Cassese E, D’Ajello M, Ambrosio D, Cardonel A.
Influence of menstrual factors and dietary habits
on menstrual pain in adolescence age. Eur J
Obstet Gynecol Reprod Biol 2000;91:143-48.
12. Abbaspour Z. MSc, Rostami M. MSc, Najjar Sh.
MSc. The Effect of Exercise on Primary
Dysmenorrhea; J Res Health Science, Vol 6, No 1,
pp.26-31,2006.
13. Bonen A, Keizer H. Athletic menstrual cycle
irregularity endocrine response to exercise and
training. Physician Sports Med. 1984;12:78-93
14. Ganon. L. The potential of exercise in the
alleviation of menstrual disorders and
menopausal symptom. Women Health. 1986;
142(2):105-7.A.
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15. Linacre J.M. Rasch. Visual Analog Scales.
Measurement Transactions; 1998; 12(2):639.
16. Rosemary A. Markum, MS Assessment of
reliability of and the effect of neutral instructions
on the symptom ratings on the Moos Menstrual
Distress Questionnaire, Psychosomatic Medicine
Vol. 38, No.3 (May-June 1976)
17. Akin, Mark D, Weingand, Kurt W, Hengehold,
David A, Goodale, Mary Beth, Hinkle, Robert T,
Smith, Roger. Continuous low-level topical heat
in the treatment of dyamenorrhea. Obstetrics and
Gynecology Vol. 97-Issue 3 p 343-349 March 2001.
18. Scott F.N , Roger J.The Physiologic Basis And
Clinical Applications of Cryotherapy and
Thermotherapy for the pain practitioner. Pain
Physician 2004; 395-399, ISSN 1533-3159
19. Billig HE Jr. Dysmenorrhoea, the result of a
postural defect. Archives of Surgery 1943;46:611.
20. R Baranitharan, V Mahalakshmi, V Kokila.
Physiotherapy Care For Women’s Health. 2010
1st ed. Jaypee Brothers Medical Publishers Ltd.
pp.37-41
21. Golub Lm, Solidum. A, Warren M. Primary
dysmenorrheal and physical activity. Sport Exc
Med. 1998;30: 906-9
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 DOI Number: 10.5958/j.0973-5674.7.3.063
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 45

The effect of Strength Training on Normalizing the Tone

and Strength of Spastic Elbow Flexors in Subjects with
Stroke

Bharath Kumar P V S R1, V Sri Kumari2, K Madhavi3

1
Post graduation student, Master of physiotherapy in Neurology, 2Assistant Professor, College of Physiotherapy,
3
Professor & Principal, College of Physiotherapy, SVIMS, Tirupati

ABSTRACT
Objectives: This study is designed to find out whether strength training can normalize the tone in
spastic upper extremity muscles and improve the strength of the spastic upper extremity muscles.
Materials and Method: The study was conducted on 30 subjects with elbow flexors spasticity and
were divided into experimental and control groups. Both the groups received conventional
physiotherapy and Experimental group received strength training in addition. The parameters like
strength and spasticity were measured isokinetically.
Result: The strength training program had no statistical significant effect on tone of the spastic elbow
flexors between the two groups. t value 0.48 at p value 0.636(not significant)
There is a statistically significant difference between two groups in the strength with the improvement
in the experimental group. t value 6.03 at p value <0.05(significant)
Conclusion: This study concludes that strengthening program has minimal effect on spasticity &
effective in improving the strength without deleterious effect on spasticity.
Keywords: Stroke, Spasticity, Strength, BIODEX, Active torque, Passive torque

INTRODUCTION of intensive therapeutic efforts5. This unfortunate state

Stroke is the 3rd most common cause of death in
the western world and the most common cause of long
term adult disability1. A study by the World Health
Organisation (WHO), which was released in June 2009,
says that the incidence of stroke in India is around 130
per 100,000 people every year.
Petrasovits and Nair2 reported that stroke is a major
cause of disability and economic cost. It is recognized
that the negative motor impairments following stroke,
e.g. loss of strength and dexterity, contribute most to
disability3 . It now appears that weakness i.e. the loss
of ability to generate normal amounts of force is the
major contributor to limitation of physical activity4.
One of the most devastating and common
consequences of stroke is loss of the use of the arm
and hand. Only about 5% of individuals paralyzed by
stroke regain full arm and hand function, and about
20% regain no functional use5. The prognosis for upper
limb recovery following stroke remains dismal in spite
calls for renewed efforts to examine the theoretical
basis of the factors impeding upper-limb recovery and
their clinical implications
Strength training is necessary after stroke to
improve the force generating capacity and efficiency
of weak muscles to improve functional motor
performance6.
The potential risk of an increase in muscle tone in
patients with pre-existent muscle spasticity is still a
major point of contention. As a result, muscle weakness
of central origin is mainly treated by physiotherapy,
i.e., by different functional approaches like the Bobath
techniques or proprioceptive neuromuscular
facilitation (PNF). These techniques are thought to
empower patients in activities of daily living by
improving normal motor patterns. But motor functions
in activities of daily living require both strength and
endurance7, so that strength building exercises appear
to be well justified.

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 46 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

However, it is even more important that both the METHODOLOGY

evaluation of the severity of spasticity and the
measurement of possible pathophysiological
mechanisms are far from optimal with the techniques
currently available. A detailed quantification of
spasticity is difficult to obtain clinically and the
available Modified Ashworth scale appears not to
provide a very accurate and reproducible measure of
the severity of spasticity8,9,10 .

In our opinion, a correlation between change in

activity in any of the mechanisms that have been
implicated in the pathophysiology of spasticity and
the severity of spasticity should not be ruled out until
more optimal techniques for evaluation of spasticity
have been developed. Biomechanical dynamometers,
which permit standardized muscle stretches at
sufficiently high velocities to elicit stretch reflex
activity, seem promising as a basis for such a
technique11,12.

There is some concern among clinicians that

strength training may not be appropriate in the
presence of spasticity or elevated muscle tone. Such
training may enhance the spastic restraint and thus
interfere with coordination and reinforce abnormal
muscle activation patterns. Thus the relationship
between spasticity and strength training after stroke Conventional treatment
is an area of continued interest.
• Cryotherapy : Duration: 10-15 min

MATERIALS AND METHOD • Stretching

30 subjects with unilateral stroke who had residual • Position of patient: Supine lying, arm held out of
spasticity of their affected upper limb were recruited the couch
from department of physiotherapy, SVIMS, Tirupati,
Andhra Pradesh. Subjects of age group 45years to 65 • Stretch for elbow flexor muscles
years were screened to ensure that they can perform • Number of repetitions: 4 – 5
antigravity movement of elbow flexion of the affected
side, modified ashworth score not more than 3, without • Active movements: 30 repetitions in 3 sets with 10
affected elbow contractures, deformities or fractures, of each
stable hemodynamics, without sensory perceptual and
psychosomatic disorders were randomly divided into Strengthening program
control group and experimental group with 15 each Progressive resistance training
by simple random sampling. Subjects who undergone
any invasive anti-spastic therapy were excluded for Position of patient: Half lying
the homogeneity among the subjects. The written
informed consent was taken from successive patients/ Macqueen protocol
patient attendants whom cannot give a written 10 lifts with 10 RM
consent.
10 lifts with 10 RM

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 47

10 lifts with 10 RM Peak value of extension torque (ET) recorded from

5 repetitions.
10 lifts with 10 RM
Value derived from difference between 90°/sec &
40 lifts, 3 times weekly, 30°/sec
Progress 10 RM every 1-2 weeks
FINDINGS
The outcome measures
Statistical analysis was done using software ‘SPSS
During initial evaluation both active torque and 16.0 version’. For this purpose the data was entered
passive torque were measured comparing at various into Microsoft excel spread sheet, tabulated and
angular velocities. All the measures are objective subjected to statistical analysis.
measures.
Of the 30 subjects, 15 were randomized into
Active torque: experimental group and 15 were randomized into
control group. All the subjects completed the entire
Measurement in N-M for strength assessment with
study protocol as defined, by 8 weeks in the training
BIODEX System4pro (Isokinetic analyzer)
sessions.
Test conducted in isokinetic mode at 60°/sec
Pretest – posttest values of passive torque are
angular velocity.
measured on BIODEX for spasticity grading.
Peak torque value recorded from 5 repetitions.
Pretest – posttest values of active torque are
Passive torque measured on BIODEX for strength assessment.

Measurement in N-M for spasticity grading with
BIODEX System4pro (Isokinetic analyzer)
In isokinetic mode at 30°/sec & 90°/sec angular
velocities.
To compare the pre and post treatment effect within
the group paired sample t-test was used to compare
the pre and post treatment effect between the groups,
unpaired t-test was used.

Table 1: Analysis of Control group with Pre and Post intervention

Parameter N Mean SD t value Df p value
Passive torque(spasticity) Pre 15 2.08 0.76 10.267 14 0.0013*
Post 15 1.76 0.69
Active torque(strength) Pre 15 3.97 0.72 10.664 14 0.001*
post 15 4.46 0.82

*indicates significant at 5% level

To test the significance of the pre and post p value of the parameters is < 0.05, there is a notable
intervention of the parameters Spasticity and Strength, significance. It is observed that the post intervention
the paired t-test has been used. Since the corresponding had shown significant impact on the subjects.

Table 2: Analysis of Experimental group with Pre and Post intervention

Parameter N Mean SD t value Df p value
Passive torque(spasticity) Pre 15 2.22 0.76 6.237 14 0.001*
Post 15 1.66 0.51
Active torque(strength) Pre 15 3.9 0.67 13.263 14 0.001*
post 15 6.24 0.79

*indicates significant at 5% level

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 48 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
To test the significance of the pre and post
intervention of the parameters Spasticity and Strength,
the paired t-test has been used. Since the corresponding
Table 3: Comparison of both Passive torque & Active torque between the groups
Torque N Mean
Passive(spasticity) Exp post 15
Cont Post 15
Active(strength) Exp Post 15
Cont post 15
*indicates significant at 5% level
To test the significance of the pre and post
intervention mean values between the groups, the
unpaired t-test has been used. Since the corresponding
p value of the active torque is < 0.05, there is a notable
significance. It is observed that the post intervention
had shown significant impact on the subjects.
Chart 1: Mean differences between Experimental &
Control groups
RESULTS
After a 8 week treatment period, the subjects in
control group (conventional physiotherapy) and
experimental group (conventional and strength
training) had shown improvement with the out come
measures; but on comparing experimental group with
control group, experimental group had shown a
statistically significant improvement at 0.05 level with
the out come measures – spastic elbow flexors strength
(p=0.001), and a statistically non significant and
minimal improvement in elbow flexors spasticity
(p=0.725).
DISCUSSION
This study was to determine the effect of strength
training on normalizing tone and strength of spastic
elbow flexors in subjects with stroke.
10. bharath kumar--45-49.pmd 48
p value of the parameters is < 0.05, there is a notable
significance. It is observed that the post intervention
had shown significant impact on the subjects.
SD t value Df p value
1.66 0.51 0.48 28 0.725
1.76 0.69
6.24 0.79 6.03 28 0.001*
4.46 0.82
The results revealed significant difference in
strength in the experimental group when compared
with control group. There also existed a minimal
difference in elbow flexor spasticity in both the groups,
where experimental group shown slightly higher
difference compared to control group.
Subjects who received strength training and
conventional physiotherapy showed improvement in
the strength and spasticity. But on comparing these
two, strength training seems to be beneficial.
The positive results with strength training might
have occurred because of the underlying physiology
that, the repetitive strengthening exercises might
decrease spastic stiffness both by improving the neural
control of muscle and by maintaining the extensibility
of muscle.
Nativ stated that, dynamic or isokinetic resistance
training invokes both autogenic and reciprocal
inhibition and it should therefore, lengthen stiff,
shortened spastic muscles. He points out that the
process of repeatedly contracting a muscle against
resistance then stretching it should help increase rather
than decrease the range of motion around the targeted
joint. He explains that, it occurs by way of reciprocal
inhibition to the antagonist muscle, followed by
autogenic inhibition to the eccentrically working
agonist.
Otis et al also states that, the dynamic stretching
that occurs during active exercise may play a part in
decreasing reflex hyper excitability and increasing
muscle compliance.
These results strongly support the earlier findings
of Teixeria – Salmela et al13 (1999) who examined the
effect of strengthening in subjects with chronic stroke
and found a significant improvement in strength in
the affected muscle groups, as well as an increase in
8/1/2013, 8:31 AM
 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 49
gait speed and rate of stair climbing after training.
Improvements in strength were not associated with
an increase in either quadriceps or ankle flexor
spasticity
Inaba et al14 in their randomized study on 176
patients in 3 groups of functional training and
stretching; active exercise plus functional training and
stretching; and progressive resistive exercise plus
functional training and stretching, has concluded that,
the resistive exercise group improved significantly
more in strength and gross motor function .
15
Sharp and Brouwer in their pretest-posttest cohort
study of 15 individuals with stroke of more than 6
months in duration, given isokinetic strength training
for 6 weeks. They found statistically significant
changes in peak torque of the knee extensors and the
knee flexors,walking speed, and the Human Activity
Profile (a subjective measure of activity). This study is
important because it found that spasticity did not
increase with muscle strengthening exercises.
This study and also the clinical research has shown
that effort applied in strength training does not increase
spasticity, associated movements, co-contraction and
resistance to passive movement. Strength training
results in increased muscle strength and decreased
spasticity.
The result of the present study indicates that
strength training has higher beneficial effects over
conventional physiotherapy on elbow flexor spasticity
in subjects with stroke.
ACKNOWLEDGEMENT
The authors are thankful to Director, Dr. B.
Vengamma. Sri Venkateswara Institute of Medical
sciences (SVIMS), Tirupati for kindly providing all the
facilities to carry out this work.
REFERENCES
1. Bath PMW (2005) Prostacyclin and analogues for
acute ischaemic stroke [Systematic Review].
Cochrane Stroke Group Cochrane Database of
Systematic Reviews 1.
2. Petrasovits A, Nair C. Epidemiology of stroke in
Canada. Health Rep 1994;6:39-44. Comment in:
Health Rep 1994;6:9-12.
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3. Burke D (1988) Spasticity as an adaptation to
pyramidal tractinjury. Advances in Neurology 47:
401–418.
4. Louise Ada, Simone Dorsch and Colleen G
Canning, Strengthening interventions increase
strength and improve activity after stroke: a
systematic review Australian Journal of
Physiotherapy 2006 Vol. 52 pg 241-248
5. Basmajian JV, Gowland C, Brandstater M, et al.
EMG feedback treatment of upper limb in
hemiplegic stroke patients: a pilot study. Arch phys
Med Rehabil. 1982;63:613-615
6. CARR, J & SHEPERD, R (1998) Neurological
Rehabilitation: Optimising Motor Performance
Butterworth Heinemann, Oxford pp
7. M. Radlinger, Krafttraining, Stuttgart – N.Y. 1998,
G-Thieme Verlag.
8. Haas, B.M., Bergstrom, E., Jamous, A. & Bennie,
A. 1996. The inter rater reliability of the original
and of the modified Ashworth scale for the
assessment of spasticity in patients with spinal
cord injury. Spinal Cord 34, 560–564.
9. Blackburn, M., van Vliet, P. & Mockett, S.P. 2002.
Reliability of measurements obtained with the
modified Ashworth scale in the lower extremities
of people with stroke. Phys Ther 82, 25–34.
10. Platz, T., Eickhof, C., Nuyens, G. & Vuadens, P.
2005. Clinical scales for the assessment of
spasticity, associated phenomena, and function:
a systematic review of the literature. Disabil
Rehabil 27, 7–18.
11. Knutsson & Martensson 1976, Action of
dantrolele sodium in spasticity with low
dependence on fusimotor drive. J Neurol Sci 29,
195-212
12. Burridge, J.H., Wood, D.E., Hermens, H.J. et al.
2005. Theoretical and methodological
considerations in the measurement of spasticity.
Disabil Rehabil 27, 69–80.
13. Luci Fuscaldi Teixeira-Salmela, Effects of muscle
strengthening and physical conditioning training
on temporal, kinematic and kinetic variables
during gait in chronic stroke survivors. J Rehab
Med 2001; 33: 53–60
14. Inaba M, Edberg E, Montgomery J, Gillis MK.
Effectiveness of functional training, active
exercise and resistive exercise for patients with
hemiplegia. Phys Ther 1973;53:28-30.
15. Sharp SA, Brouwer BJ. Isokinetic strength training
of the hemiparetic knee: effects on function and
spasticity. Arch Phys Med Rehabil 1997;78:1231-6.
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 DOI Number: 10.5958/j.0973-5674.7.3.064
50 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Comparison of Supervised Rehabilitation vs. Home Based

Unsupervised Rehabilitation Programs after Total Knee
Arthroplasty: A Pilot Study

Bijender Sindhu1, Manoj Sharma2, Raj K Biraynia3

1
Research Scholar, Singhania University, 2MS (Ortho), Research Supervisor, 3D. Ortho, DNB(Ortho), Singhania
University

ABSTRACT
Objective: The purpose of the current study was to compare two rehabilitation programs post primary
total knee arthroplasty (1) Supervised rehabilitation delivered by qualified physiotherapist and (2)
home-based unsupervised rehabilitation monitored by a physiotherapist via periodic telephone calls.
Method: Twenty patients having primary total knee arthroplasty were assigned randomly to two
rehabilitation program (1) supervised rehabilitation program group (2) home-based unsupervised
rehabilitation program group. Outcome measures used to assess the outcome were (1) Knee Society
Knee score for knee integrity (2) ILOA for level of assistance (3) Goniometry for ROM and (4) VAS
Scale for pain.
Results: The significant difference were observed in the score of all outcome scale used for assessment.
The subjects in supervised rehabilitation program group performed better compared to home-based
unsupervised rehabilitation program group.
Conclusions: This pilot study shows that the supervised rehabilitation after total knee arthroplasty
having better prognosis than home-based unsupervised rehabilitation program on range of motion
and functional ability and pain.
Keywords: TKA, Home Based Exercises, Supervised Exercises

INTRODUCTION assess the effectiveness of both are lacking thus there

Home-based unsupervised rehabilitation programs
typically do not require the patient to attend clinic
sessions or attendance to minimum number of
outpatient sessions, thus provide fewer opportunities
for monitoring or program modification. Although
home-based unsupervised exercises rehabilitation
program developed and taught to patients by
physiotherapists and typically completed
independently by the patient at home. In contrast the
supervised rehabilitation program provides better
opportunities for monitoring or program modification.
Various previous studies have examined the effects of
these exercise program but the comparative study to
is need to assess the most effective model of exercises
program for post-operative rehabilitation after total
knee arthroplsty.
OBJECTIVE OF THE STUDY
The purpose of current study was to compare two
rehabilitation programs after total knee arthroplasty
(1) supervised rehabilitation program delivered by
qualified physiotherapist (2) home-based
unsupervised rehabilitation program monitored by a
physiotherapist via periodic telephone calls.
MATERIAL AND METHOD

Inclusion and Exclusion Criteria

Corresponding author:
Bijender Sindhu Patients having primary unilateral total knee
Ph.D (Research Scholar) arthroplasty as a result of osteoarthritis, both male and
139/14, Sector-20, Rohini, Delhi-86 female who had a primary unilateral TKA, age 50-85
Telephone: +919871487673 were included in study. Patients who had rheumatoid
Email: bjsindhu@gmail.com arthritis or major neurologic conditions were excluded.

11. Bijender Snadhu--50-53.pmd 50 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 51
Randomization to Groups
20 patients were randomly assigned to two
rehabilitation program (1) supervised rehabilitation
program group (2) home-based unsupervised
rehabilitation program group.
Intervention
Home based unsupervised rehabilitation program
group
The Home based unsupervised rehabilitation
program was targeted to strengthen the lower limb
muscles, to improve ROM and facilitate walking
pattern. We provided a booklet consisted of pictorial
and written descriptions of each exercise and necessary
instructions about precaution, using ice and controlling
swelling. All patients were instructed to complete the
home exercises three times daily until their 6-week
follow up. A physiotherapist familiar with the home
exercises made telephone to each patient of home-
based unsupervised rehabilitation group at least two
times in a week asked whether the patient was having
any problems with the exercises, to remind them the
importance of completing exercises, and to provide
advice on wound care, scar care, and pain control.
Patients were also provided with a contact telephone
number to call if additional questions arise.
Supervised rehabilitation program group
The supervised rehabilitation program was
targeted to strengthen the lower limb muscles, to
Table 1: Showing mean and p value of ILOA score, KSKS score, goniometry score of two groups.
Home based unsupervised rehabilitation program group
Supervised rehabilitation program group
DISCUSSION
The subjects in supervised rehabilitation program
group performed better compared to home based
supervised rehabilitation program group. Score of all
outcome measures in the current study suggests that
the supervised rehabilitation program is better when
considering a spectrum of functional variables.
Overall, the additional patient monitoring, adjustment
of program and motivational support available
through supervised rehabilitation may had an
advantage. For these reasons the supervised
11. Bijender Snadhu--50-53.pmd 51
improve ROM and facilitate walking pattern. All
exercises were done in supervision and assistance of a
qualified physiotherapist, therapists were permitted
to modify or add exercises, use therapeutic modalities
(such as ice, heat, and ultrasound) or other measures
as they deemed appropriate.
OUTCOME MEASURES
The following tests were completed (1) Knee
Society Knee score (2) ILOA level of assistance (3)
Goniometry; (4) VAS scale.
Findings
RESULTS
32 subjects were recruited among the patient
discharge from hospital postoperatively and randomly
divided into supervised rehabilitation program group
and home based unsupervised rehabilitation program
group. 8 patients do not fulfilled the inclusion criteria
thus excluded from study. 3 patients excluded from
study due to prolonged hospital stay for medical
reasons and 1 patient refused to be tested was also
excluded. Total 20 patients were available for final
assessment.
There was significant difference observed in the
score of three outcome scale used for assessment.
Subjects in supervised rehabilitation program group
performed better compared to home based
unsupervised rehabilitation program group. The
numerical data are mentioned below in table 1
ILOA KSKA Goniometry
Mean p=value Mean p=value Mean p=value
11.94 0.018 74.72 0.017 88.06 0.05
10.01 76.78 95.52
rehabilitation program post TKA may have
advantageous outcome.
The current pilot study compared two
rehabilitation programs, where in home based
unsupervised rehabilitation program was a series of
exercises to be completed independently by patients
at home. These exercises were developed and taught
to the patients by physiotherapists, supervised
rehabilitation program was targeted to strengthen the
lower limb muscles, to improve ROM and facilitate
walking pattern. All exercises were done in supervision
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 52 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
and assistance of a qualified physiotherapist, therapists
were permitted to modify or add exercises, use
therapeutic modalities (such as ice, heat, and
ultrasound), or other measures as they deemed
appropriate.
Fig. 1. (A) Showing means score of ROM of Knee Flexion
Fig. 1. (B) Showing means score of ILOA level of assistance
measures.
Fig. 1. (C) Showing means score of (KSKS) knee society knee score
CONCLUSIONS
This pilot study shows that the group of supervised
rehabilitation after total knee arthroplasty having
better prognosis than home based exercise group i.e.
range of motion and functional ability and pain. We
believe that patients in supervised rehabilitation group
11. Bijender Snadhu--50-53.pmd 52
had advantage of regular monitoring and appropriate,
timely and customised progression. One of measure
limitation in this study was a very small subject
population other limitation may be that the booklet
provided to patient were in English language. We
conclude that this pilot study gives very strong ground
for future randomised study with more specific
methodology and more number of subjects.
ACKNOWLEDGMENTS
The authors thank Dharam Pandey (MPT), Deepa
Dabas MSc (Psychology) for assistance throughout the
study.
Conflict of Interest
Authors declare that they have no conflict of
interest.
Source of Funding
This study was self-finance and authors have no
financial interest.
REFERENCES
1. Manual of Orthopedics, 6th Edition- Editors:
Swiontkowski, Marc F.; Stovitz, Steven D. page
No. 342, 345, 346.
2. Physiotherapy in Orthopedics -A problem-
solving approach Karen Atkinson MSC M C S P
Cert.Ed. DipTP Senior. Page No. 233, 253, 255,
258.
3. Catherine Jane minns lowe, the university of
Birmingham, 2009: The effectiveness of
physiotherapy following discharge from hospital
after primary total knee arthroplasty for
osteoarthritis. Page No. 25, 33.
4. John F. Kramer, PhD, 2003 Lippincott Williams
& Wilkins: Comparison of Clinic- and Home-
Based Rehabilitation Programs After Total Knee
Arthroplasty. Clin Orthop Relat Res. 2003
May;(410):225-34.
5. Neeta Khandoo, Johannesburg, 2008: The
postoperative status of total knee arthroplasty
(TKA) patients on discharge from an acute setting
in Johannesburg hospitals, South Africa. URI:
http://hdl.handle.net/10539/7391
6. Candace Lally, Johannesburg, 2007: The
relationship between knee integrity and function
post total knee replacement. URI: http://
hdl.handle.net/10539/5743
7. Beard DJ, Dodd CAF: Home or supervised
rehabilitation following anterior cruciate
ligament reconstruction: A randomized
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 53
controlled trial. J Orthop Sports Phys Ther 27:134–
143, 1998.
8. Insall JN, Dorr L, Scott RD, Scott WN: Rationale
of the Knee Society clinical rating system. Clin
Orthop 248:13–14, 1989.
9. Jokl P, Stull PA, Lynch JK, and Vaughan V:
Independent home exercise versus supervised
rehabilitation following arthroscopic knee
surgery: A prospective randomized trial.
Arthroscopy 5:298–305, 1989.
11. Bijender Snadhu--50-53.pmd 53
10. Mahomed NN, Koo See Lin MJ, Levesque L, Lan
S, Bogoch ER: Determinants and outcomes of
inpatient versus home-based rehabilitation
following elective hip and knee replacement. J
Rheumatol 27:1753–1758, 2000.
11. Operative Orthopedics – Eleventh Edition by
Campbell’s Page No. 259, 262, 278.
12. Orthopaedics Rehabilitation by Dr.Brotzmen.
Page No. 251, 253.
13. Research Methodology Practice by Petter Laake,
Haakon Breien Benestad. page No. 93-99.
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 DOI Number: 10.5958/j.0973-5674.7.3.065
54 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Supervised V/s Unsupervised Constraint Induced

Movement Therapy in Improving Upper Extremity
Function in Spastic Hemiparetic Cerebral Palsy Children

Charu Chopra1, Jaskirat Kaur2

1
Astt. Professor at Banarsidas Chandiwala Institute of Physiotherapy, New Delhi, 2Astt. Professor at ISIC, Institute of
Rehab Sciences, NewDelhi

ABSTRACT
Objective: Constraint Induced Movement Therapy has been found to be a promising treatment for
substantially improving the use of extremities affected by neurologic injuries such as stroke and
traumatic brain injury in adults. The purpose of this study was to determine the applicability of a
child friendly form of CI Therapy on young children with cerebral palsy.
Method: Thirty Children with hemiplegic Cerebral Palsy age 4-8 years received CI Therapy and
completed evaluations. They were randomized to either Group A or Group B. In both the groups
children wore mitt as restraint on their non-involved upper extremity and the involved upper extremity
was engaged into play & functional activities for six hours per day for ten week days. In Group A all
the activities done by children were under the supervision of therapist where as Group B was more
of home based program although activities were therapist guided. Changes in upper extremity
function were evaluated with Quality of Upper Extremity Skills Test. The evaluations took place at
the onset of intervention and after completing two weeks of intervention.
Results: Children in both the groups demonstrated significant improved functional efficiency of
their involved upper extremity (p<0.05). However, children in Group A had improved significantly
more than the children in Group B (p<0.05).
Conclusion: Results suggest that the CI Therapy can improve motoric function among children with
hemiparesis and that this efficacy is more in a therapist supervised CIMT program.
Keywords: Cerebral Palsy, Constraint Induced Movement Therapy, Restraint, Hemiparesis

INTRODUCTION intervention originated from the observation that

Hemiplegic Cerebral Palsy is the result of early
brain damage, including brain malformations,
periventricular brain lesions, Middle cerebral artery
infarctions and non-progressive postnatal injuries.1 The
resulting movement impairments are largely
lateralized to one side, with the upper extremity
usually being affected more than lower extremity.1
Often the integrity of the motor cortex and
corticospinal pathways, necessary for precision
grasping & fine control of the fingers and hand are
compromised. Consequently skilled independent
finger movements and hand skills do not develop
normally. In addition, there may be reduced strength
as well as tactile & proprioceptive disturbances which
may further impact on fine motor skills.1 Constraint
Induced Movement Therapy (CIMT) was developed
in 1986, by Edward Taub & associates. 2 The
unilaterally deafferented monkeys normally do not
make use of the deafferented limb, but can be induced
to do so by restricting movement of intact limb, and
they will continue to use the limb even when the
movement restriction ceases.2, 3 CIMT in humans is
based on the hypothesis that in hemiplegia, disuse of
the affected arm can occur as a result of learned ‘Non
Use’.4 The Nonuse, in turn, leads to contraction of the
cortical representation of the affected extremity in the
chronic phase of a patient’s recovery. So CIMT was
developed to help patients overcome this nonuse.5
Neuroimaging and Transcranial magnetic stimulation
(TMS) studies of the brain prior to and after CIMT have
demonstrated differences in cortical organization
around the infarct site after the intervention.6 However,
unlike adults a child with hemiplegic cerebral palsy
may have neural tissue that is underutilized, although

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 55
the mechanisms for this underutilization may differ
from the mechanism in adults i.e. rather than learned
Nonuse, for example a child may not develop neural
pathways involved in movement because of lack of
ability to experience age appropriate sensorimotor
stimuli that lead to development of upper extremity
skills.5 Recent evidence suggests that children with
hemiplegic cerebral palsy may improve motor
performance if provided with sufficient opportunities
to practice.6 Taub & Crago first hypothesized in 1995
that CIMT might be especially well suited for use with
children because of great capacity for plasticity in the
developing Nervous System & may result in an even
better outcome.5 Taub et al (2004) randomly assigned
eighteen children aged between 7 months & 96 months
to treatment & control groups. In the treatment group
a bivalved plaster cast was applied to the unaffected
arm for 21 days and functional training was given to
the affected arm for six hours a day. Results
demonstrated improvements in both amount of use &
functional abilities in the treatment group.4 Hence the
purpose of this study was to find the effects of CIMT
on spastic hemiparetic cerebral palsy children and to
see whether the Supervised or Unsupervised program
was effective in improving upper extremity function
in these children.
METHOD
Subjects and Recruitment
30 subjects with spastic hemiparetic cerebral palsy
who met the inclusion criteria were selected for the
study. The subjects were taken from ESI Hospital,
Basaidarapur, New Delhi and Meena child
rehabilitation centre, New Delhi. The inclusion criteria
was
(1) Subjects with a diagnosis of spastic hemiparetic
cerebral palsy.4Age between 4-8 years.7
(2) Ability to follow verbal instructions8.
(3) Ability to extend the wrist at least 20o and the
fingers at least 10 o from full flexion at the
metacarpophalangeal joints.3,9
(4) Spasticity not more than 3 on Modified Ashworth
Scale.9
(5) Sensory integrity intact. Children were excluded
who had
(1) Any other neurological condition leading to spastic
hemiplegia except cerebral palsy.4
(2) Any other impairment e.g. Visual or auditory.9
Children were randomly assigned to either Group
12. charu Chopra--54--58.pmd 55
A or Group B, with 15 subjects in each group. This
was achieved by assigning subjects according to
the group designation indicated on a folder piece
of paper, taped closed and drawn from a jar set up
before the beginning of subject enrollment.10
INTERVENTION
GROUP A: The intervention was carried out in a
child-friendly environment in which the therapy
included play/functional activities 3,11.During the
intervention children wore a mitt on the unaffected
hand and the affected upper extremity was engaged
in structured practice (Shaping and Repetitive task
Practice) under the supervision of the Therapist.3 The
total treatment protocol consisted of six hours of
training per day for ten weekdays over a period of
two weeks.3, 12 During the therapist directed period the
child’s affected upper extremity was engaged into play
and functional activities like playing card game (Uno),
releasing Puzzles, arts and crafts (Paintings with
brushes on paper), gross motor (shoulder flexion and
abduction), eating, playing connect four game,
bowling, cleaning table, and drawing.3, 12. The activities
were appropriate for the age of the child and all could
be perform unimanually. The tasks were made
progressively more difficult as the child improved in
performance by requiring greater speed, accuracy,
increased movement repetition, or performance
sensitive adaptations.3 The tasks constraints were
adapted to allow success and were removed as one’s
skill improved. Only positive reinforcement was used
in the form of primary verbal praises, smiles, cheers,
clapping and supportive gestures. When the child
showed signs of fatigue or reduced interest, the
activities were adapted but not stopped. 10 The time
spent on each activity was approximately 15-20
minutes.
GROUP B: The intervention was carried out in a
child- friendly environment in which the therapy
included play/functional activities 11. During the
intervention children wore a mitt on the unaffected
hand and the affected upper extremity was engaged
in structured practice (Shaping and Repetitive task
Practice).3 This Group B was more of home based
program i.e. supervised by parents although activities
were therapist guided. The Parents were instructed to
encourage the use of mitt at home and were responsible
for accomplishing these activities on a daily basis for
ten weekdays over a two weeks period.8, 13 Parents kept
on maintaining logs to monitor compliance.4 Children
in this group were treated with similar number of
hours, approach and activities as that of Group A.
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 56 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Pre and Post intervention Assessment

Assessment was done at the beginning of the study

and after completing two weeks of intervention. Upper
limb function of the subjects was assessed using quality
of upper extremity skills test (QUEST).4

QUEST supplies information related to fine motor

function, movement, postural responses as well as
quality of upper limb function. The test has four
domains:-a) Dissociated movements, b) Grasps, c)
Weight bearing, d) Protective extension.

Fig. 1 Mitt used as Restraint RESULTS

Thirty subjects with spastic hemiparetic cerebral

palsy, 16 males and 14 females with mean age of 5.95
years, 17 right hemiparetics and 13 left hemiparetics
were included. Independent t-test was used for
analyzing post treatment scores of QUEST for group
A and group B which showed that, tstat (2.27) > tc (1.70).
[at 5% level of significance and degrees of freedom
28]. In both the Groups, post treatment mean QUEST
score (Group A-67.69 & Group B-61.31) was better than
pre treatment mean score (Group A-42.01 & Group B-
39.93). Likewise Post Treatment mean QUEST score of
Group A (67.69) was better than post treatment mean
QUEST score of Group B (61.31).

Fig. 2 A Child playing Uno game

Fig. 4. Comparison between Post Treatment QUEST Score for

Group A and Group B.
Fig. 3 A Child painting on a paper

12. charu Chopra--54--58.pmd 56 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 57

DISCUSSION

Rehabilitation Techniques for hemiplegic

cerebral palsy have focused on teaching and

Fig. 5 Comparison between Pre and Post treatment mean QUEST
score for Group A.
Fig. 6 Comparison between Pre and Post treatment QUEST score
for Group B.
reinforcing compensatory strategies that encourage
use of the noninvolved upper extremity to decrease
functional limitations.6 However, recent studies have
suggested that promoting early motor activity through
intensive practice may enhance the development of
corticospinal tract, and thereby optimize
developmental motor skill potential.7 This intensive
practice could be provided with CIMT. In this study
the approach was made child friendly by reducing the
number of hours that children were restrained, by
incorporating the movements in the context of games
or age appropriate functional tasks and by combining
home practice under the supervision of parents, yet
maintaining two major elements of adult CIMT namely
repetitive task practice and shaping to improve motor
performance of the involved upper extremity. 3,8
Children initially had difficulty using the involved
hand during the intervention period. For e.g. it took
them time to initiate and coordinate the grasp to drop
the disk into the slot in Connect four game. But this
became easier with practice & once they were efficient
or their performance improved the task was made
more challenging taking into consideration his/her
abilities by varying temporal, spatial and/or accuracy
constraints.3 Practice at home was advantageous, since
it was a child friendly environment in which number
of new variables introduced could be reduced and also
parents could continue the regime. The results of this
study showed that in Group A post treatment mean
value (67.69) was better than pre treatment mean value
(42.01), likewise in Group B post treatment mean value
(61.31) was better than pre treatment mean value
(39.93). This might be presumably due to large use-
dependent cortical reorganization. The use of restraint
has been debated over time since it may have
disadvantages like breakdown of skin integrity, muscle
wasting, reduced range of motion, and falls due to
imbalance. The type of restraint used for the
noninvolved hand in pediatric population is extremely
important. Mitt was chosen in this study because it
has few advantages like it is less restrictive than other
restraints, cost effective, easy donning and doffing and
also addresses concerns about the loss of balance and
falls by allowing the wearer to be able to use the
noninvolved upper extremity for protective extension.6
The results of this study also showed that the post
treatment mean value of Group A (67.69) was better
than that of Group B (61.31) and furthermore, t-test

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 58 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
analysis of post treatment QUEST scores of Group A
and Group B revealed that tstat (2.27) was more than tc
(1.70), showing that Group A performed better than
Group B. These results might have been due to the
reasons that active practice is the important variable
in the treatment efficacy; it is related to the intensity of
practice. Since the study involved home practice in
Group B i.e. therapist guided activities supervised
under parents so there might have been a possibility
that the children in this group were not adequately
supervised by their parents during the performance
of activities as compared to the children in the Group
A in which the children were supervised by the
therapist while performing the activities. Although the
parents maintained the logs to monitor compliance and
the study was designed to know about the feasibility
of this unsupervised method of CIMT by the therapist
where in all children were in a friendly home
atmosphere under parents guidance for activities, still
it can be of research further to club this supervised
and unsupervised so that the children can do some
activities under therapist supervision and rest as home
based program and therefore benefited from both the
protocols.
CONCLUSION
The application of CIMT with children with CP has
only recently been investigated. This study suggests
that CIMT may be effective in improving upper
extremity impairments in this population and that
supervised CIMT application is beneficial for the
children.
REFERENCES
1. Andrew M Gordon: Development of hand arm
bimanual intensive training (HABIT) for
improving bimanual coordination in children
with hemiplegic cerebral palsy. Dev Med and
Child Neurol 48:931-936, 2006.
2. Elizabeth A. Noser: Constraint induced
movement therapy. Stroke 35:2699-2701, 2004.
12. charu Chopra--54--58.pmd 58
3. Gordon et al: Methods of Constraint induced
movement therapy for children with hemiplegic
cerebral palsy: Development of a child-friendly
Intervention for improving upper extremity
function. Arch Phys Med Rehabil 86:837-844,
2005.
4. CE Naylor: Modified Constraint Induced
Movement Therapy for young children with
hemiplegic cerebral palsy: a pilot study. Dev Med.
and Child Neurol 47:365-369, 2005.
5. De Luca et al: Pediatric constraint induced
movement therapy for a young child with
cerebral palsy: Two episodes of care. Phys ther
83:1003-1013, 2003.
6. Charles et al: A critical review of constraint
induced movement therapy and forced-use in
children with hemiplegia. Neural plasticity
12:245-261, 2005.
7. Charles et al: Efficacy of a child friendly form of
Constraint- Induced Movement Therapy in
hemiplegic cerebral palsy: a randomized control
trial. Dev Med and Child Neurol 48:635-642, 2006.
8. Eliasson et al: Effects Constraint- Induced
Movement Therapy in young children with
hemiplegic Cerebral Palsy: an adapted model.
Dev Med and Child Neurol 47:266-275, 2005.
9. Andrew M et al: Efficacy of Constraint induced
movement therapy on involved upper extremity
use in children with hemiplegic cerebral palsy is
not age dependent. Pediatrics 117:363-373, 2006.
10. E. Taub et al: Efficacy of Constraint induced
movement therapy for children with cerebral
palsy with asymmetric motor impairment.
Pediatrics 113:305-312, 2004.
11. Lavinder et al: Effects of constraint induced
therapy on hand-function in children with
hemiplegic cerebral palsy: Ped Phys Ther 13:68-
76, 2001.
12. Kelly et al: Case report: a modified constraint
induced movement therapy program for upper
extremity of person with chronic stroke. Phys
Ther and Prac 21:243-256, 2005.
13. Pierce et al: Constraint induced therapy for a child
with hemiplegic cerebral palsy: A case report.
Arch Phys Med Rehabil 83, 1462-1463, 2002.
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 DOI Number: 10.5958/j.0973-5674.7.3.066
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 59

Effect of Proprioceptive Neuromuscular Facilitation in

Hemiplegic Gait a Randomized Trial of 4 Weeks and a
Follow up after 2 Weeks

Damaneek Kaur Mann1, N A Ramasubramia Raja2, Nidhi Bhardwaj2, Jagmohan Singh3

1
Student, M.P.T (Neurology), 2Associate Professor, 3Professor & Principal, Gian Sagar College of Physiotherapy,
Ram Nagar, Rajpura (Punjab), India

ABSTRACT
Background and Objectives: Stroke is the most disabling condition with 30% to 66% of individuals
lose their functional ability and gait is the most occurred motor impairment in stroke. Gait is a major
determinant of independent living, therefore, walking function is the most commonly stated priority
of stroke survivors. Proprioceptive Neuromuscular Facilitation technique is a motor learning approach
used in neuro-motor development training to improve motor function and facilitate maximal muscular
contraction. The present study aimed to evaluate the effect of Proprioceptive Neuromuscular
Facilitation & its sustained improvement in hemiplegic gait. And the objective is to improve the gait
pattern in hemiplegic gait.
Keywords: Hemiplegic gait, Proprioceptive Neuromuscular Facilitation, Spatial parameters of gait, Wisconsin
Gait Scale

INTRODUCTION Gait is a major determinant of independent living,

Worldwide incidence of Stroke has been quoted as
2/1000 population per annum about 4/1000 in people
aged 45-80 years. In India the incidence of Cerebro-
Vascular accident was found to be 13/100,000
population per year conducted at Rohtak1.
Stroke is associated with the highest odds of
reporting severe overall disability2.
Stroke is the most disabling condition with 30% to
66% of individuals lose their functional ability3.
Gait is the most Motor impairment in stroke
typically involves paresis of the side of the body
opposite to the site of the brain lesion. Gait is one of
the most common and complex of human movements4.
Ability to walk is generally associated with the
achievement of four related tasks: maintenance of
upright posture; balance or stance stability during the
stance phase of the gait cycle; clearance of the swinging
foot during the swing phase of the gait cycle; and the
supply of sufficient energy to the body with each stride
to ensure efficient forward progression5.
therefore, it is not surprising that improvement of
walking function is the most commonly stated priority
of stroke survivors6.
In persons with hemiplegia, posture tone and
coordinate reciprocal movements, which are required
for normal gait, are usually impaired. Normal
reciprocal pelvic movement is often replaced by a fixed
pelvic retraction, which makes it difficult for patients
to swing the affected lower extremity forward. The
resulting gait is slow, with short step length and
asymmetric steps, often called “Hemiplegic gait”7,8.
This slow gait can be observed in clinical settings as a
decrease in gait speed and cadence. Improvement of
the quality of gait is often a major goal of physical
therapy for patients with hemiplegia. Proprioceptive
Neuromuscular Facilitation (PNF) is one approach
commonly used to improve the gait of patients with
hemiplegia 9. Various PNF procedures have been used,
depending on the affected site10. Among these PNF
techniques is facilitation of pelvic motion to improve
control of the pelvis, because the pelvis has been
described as a “key point of control” for maintaining
a gait pattern, techniques designed to affect the pelvis

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 60 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
are widely used very few studies however, have
documented the therapeutic effects of facilitation of
pelvic motion in patients with hemiplegia.
Proprioceptive Neuromuscular Facilitation
Is a motor learning approach used in neuro-motor
development training to improve motor function and
facilitate maximal muscular contraction. It was
developed by Dr. Herman Kabat and Maggie Knot in
late 1940’s and early 1950’s.
Basis of PNF philosophy is the idea that all human
beings, including those with disabilities have untapped
existing potential11.
The PNF approach to treatment uses the principle
(based on early phylo-genetic and embryologic
observations) that control the motion proceeds from
proximal to distal body regions. Facilitation of trunk
control, therefore is used to influence the extremities.
If this paradigm is valid, gaining control of and
strengthening “normal” pelvic motions should
improve lower extremity function.
PNF exercises are based on the stretch reflex which
is caused my stimulation of the golgi tendon and
muscle spindles. This stimulation results in impulses
being sent to the brain, which leads to the contraction
and relaxation of the muscles. When a body part is
injured, there is a delay in the stimulation of the muscle
spindles and the golgi tendons resulting in weakness
of the muscle. PNF exercises help to re-educate the
motor units which are lost due to the injury/
impairment.
Proprioceptive Neuromuscular Facilitation is one
approach commonly used to improve the gait of
patients with hemiplegia. Various PNF procedures
have been used, depending on the affected side.
Among these PNF techniques is facilitation of pelvic
motion to improve the control of the pelvis. Because
the pelvis has been described as the key point of control
for maintaining a gait pattern, techniques designed to
affect the pelvis are widely used12.
MATERIALS AND METHOD
Type of Study
Experimental group study,
Comparative in nature.
Sample Size
13. Damneek kaur-59--64.pmd 60
30 subjects suffering from hemiplegic gait were
selected, following random sampling method from a
finite population.
Duration of study
6 months
Inclusion criteria
Diagnosis of hemiplegia secondary to
cerebrovascular accident, with symptoms lasted from
less than 12 months from the incidence of stroke, The
ability to walk at least 60 ft (18.3 m) without manual
assistance with or without an assistive device, at ones
preferential speed, No previous PNF treatment could
have been given to the pelvic region, The patients have
intact kinesthesia for the Hip, Knee, and Ankle as
determined by the evaluator, Patients having
hemiplegia and suffering from Hemiplegic Gait on the
basis on Brunnstorm Stages of Recovery of lower
extremities, Both males and females included, Age (45-
65 years), Patients who are able to follow simple
instructions, Patients who have suffered from first time
stroke with right or left side involvement.
Exclusion criteria
Patients with a history of visual and auditory
deficits, Patients with a history of lower limb
pathology, Patients with a history of Previous knee and
Hip surgeries, Patients with a history of recent
significant injury to the Hip, knee or ankle, Patients
with a history of Brain tumor, Patients with a history
of more than one stroke incident, Patients with
contracture and deformities of the lower limb, Patients
taking anti-spastic medication.
Procedure
1. After the approval from the ethical committee of
Gian Sagar Medical College and Hospital.
2. 30 hemiplegic patients suffering from
circumduction gait in case of hemiplegia secondary
to cerebrovascular accident were selected on the
basis of brunnstrom’s stages of recovery for lower
extremities (Stage 3, 4 and 5)9.
3. The patient’s ability to walk at least 18.3 m (60 ft.)
without manual assistance, with or without an
assistive device, at ones preferential speed.
4. The patient’s intact kinesthesia is evaluated before
the selection.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 61
5. For the evaluation of kinesthesia-.The patient’s hip,
knee, and ankle are tested three times.
• The therapist places the patient’s hip in medial or
lateral rotation, asking the patient whether the toes
are “in” or “out.”
• The therapist places the patient’s body region to
be considered as knee in flexion or extension,
asking the patient whether the lower extremity is
“bent” or “straight.”
• To test the ankle, the therapist places hemiplegic
patient’s foot in dorsi-flexion or plantar flexion and
asks the patient whether the foot is “up” or
“down.”
To carry out these tests, the physical therapist
always puts one hand around the patient’s knee
and the other hand around the patient’s ankle. The
patient must give correct response, on all three
trials for each body region to be considered as
having intact kinesthesia.
6. After the selection process was completed the total
of 30 subjects were selected, these patients were
duly informed about the treatment protocol and
informed consent was taken from them.
7. PNF techniques were administered on the patient’s
for 4 weeks.
8. Techniques of PNF administered on the patients
were Rhythmic Initiation, Slow Reversal, and
Agonistic Reversals. The sequence was rhythmic
initiation first for 10 minutes, followed by slow
reversal and agonistic reversal each again for 10
minutes4.
• Rhythmic initiation- The position of the patient
was in side lying, neck slightly flexed and the
pelvis was moved through the available range of
motion of anterior elevation and then to return the
pelvis through the posterior depression pattern.
• Slow reversal- The patients body part moved to
the lengthened range of the anterior elevation later
switching the manual contacts to the posterior
depression.
• Agonistic reversal- The therapist moves the
subjects body part to the point at which the muscle
will be lengthened in the desired pattern (anterior
elevation)
13. Damneek kaur-59--64.pmd 61
9. They received a total of 12 sessions of PNF (three
times a week) with each treatment session lasting
for 30 minutes.
10. Readings at week 0 and readings at week 4 were
recorded by Wisconsin Gait Scale and Spatial
parameters (foot prints were taken and the changes
between both the readings were measured).
11. In a follow up after 2 weeks the readings at week 6
were measured and recorded to determine the
sustenance in the improvement from functional
ability in circumduction gait.
12. The PNF sessions were given for 4 weeks. 3
sessions weekly, cumulative of 12 sessions.
Outcome measures
WGS is a useful tool to rate
Qualitative alterations of post-stroke hemiplegic
subjects and assess changes over time during
rehabilitation training13.
Documented gait improvement at walking
performance and to point out the correlations between
patterns in patients with hemi paresis using the
Wisconsin gait scale (WGS) which is a visual gait
analysis system that examines 14 observable variables
related to the hemiplegic gait deviations. Rodrigues
provided validation for the newly developed scale, an
instrument of gait measurement that may assist in
comparing outcomes14.
Footprint method involves the application of ink
to the soles of the patient’s shoes or feet and walking
along strips of paper. This method is easy to apply, is
not time consuming and has high reproducibility.
Quantitative analysis of movements in specialized gait
laboratories is expensive and unaffordable in most
clinics in Africa15.
RESULTS
Statistical analysis of data using paired t-test
comparing the week0 & week 4 and week 4 & week 6
and week0 & week6 values of Spatial parameters of
gait analysis (Step length, Stride length, Toe-out angle,
Base of support) and one way ANOVA to compare the
values of week0, week 4 and week 6 of the
experimental group. Similarly non parametric
Wilcoxon signed rank test for week0 & week4 and
week 4 & week 6 and Friedman’s test for comparing
the interrelation of week0,4& 6.
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 62 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Wisconsin Gait Scale- Gait Improved. Wilcoxon test

– for 0 week & 4 weeks= 4.7 (p<0.05), 4weeks & 6
weeks= 1.4 (p>0.05), 0 week & 6 week = 4.5 (p<0.05)
Friedman test (0 weeks, 4 weeks & 6 weeks)= 39.7
(p<0.05). Spatial Parameter of gait analysis- Step
length- t-test for 0 weeks & 4weeks= 20.7 (p<0.05),4
weeks & 6 weeks=.273 (p>0.05), 0 week & 6 week =
22.0 (p<0.05) ANOVA (0 weeks, 4 weeks & 6
weeks)F=72.5 (p<0.05), Stride length- t-test for 0 week
& 4 week =18.9 (p<0.05), 4week & 6 week =1.4 (p>0.05),
0 week & 6 week = 19.62 ( p<0.05) ANOVA- F=102.42
(p<0.05), Toe out angle- t-test- for 0 week & 4 week =
10.20 (p< 0.05), 4 weeks & 6 weeks=.44 (p>0.05), 0
weeks & 6 weeks = 9.8 (p<0.05), ANOVA-F=26.0
(p<0.05), Base of support- t-test for 0 weeks & 4 weeks
=2.2 (p<0.05), 4 weeks & 6 weeks =.29 (p>0.05), 0 weeks Fig. 3. Mean of stride length
& 6 weeks = 1.6 (p>0.05) ANOVA- F= .64 (p>0.05).
Paired t-test was applied to examine the changes in
dependent variable from base-line to after completion
of intervention in the group. Level of significance was
defined at p< 0.05 and confidence interval of 95% was
taken.

Fig. 4. Mean of Toe out angle

Figure 1: Mean of Wisconsin gait scale

Fig. 5. Mean of Base of support

DISCUSSION

It is found from the present study that the PNF

procedures for the pelvic region are highly beneficial
Fig. 2. Mean of Step length for patients suffering from hemiplegic gait. This study

13. Damneek kaur-59--64.pmd 62 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 63
aimed at evaluating the effect of Proprioceptive
Neuromuscular Facilitation in subjects with
hemiplegic gait after 4 weeks and also to evaluate the
sustained improvement on the gait pattern in a follow
up after 2 weeks from the cessation of the
Proprioceptive Neuromuscular Facilitation treatment
protocol.
The following discussion intends to explain the
observations made and the results obtained through
this study in the light of the available scientific
evidence. The subjects who suffered from hemiplegic
gait following an incidence of cerebrovascular accident
(Stroke) symptoms lasted less than 12 months from
the incidence of stroke were taken in this study with
accordance to brunnstrom stages of recovery, as the
improvement of gait is a major goal of physical therapy
for patients with hemiplegia.
Gait is one of the most common of all human
movement’s. It exists to transport the body safely and
efficiently across ground level4.
Hence, retraining of walking is a major goal in a
rehabilitation program for persons with stroke 5.
Proprioceptive Neuromuscular Facilitation (PNF) is
one approach commonly used to improve the gait of
patients with hemiplegia9.
The gait of patients with hemiplegia is
characterized by several abnormal features such as
asymmetry of stride time and length, reduced velocity,
poor joint and posture control, muscle weakness,
abnormal muscle tone, abnormal muscle activation
patterns and altered energy expenditure, mostly
affecting the paretic side13. Hence according to the data
collected in this research, via the spatial parameters of
gait and Wisconsin gait scale. The inference gathered
from the results is such that the t-test between the
values of Step length, Stride length and the Toe-out
angle from week 0 to week 4 is significant with p<0.05
suggesting overall improvement in the gait pattern,
probability in the reduction of spasticity in the stronger
antagonist muscle groups, releasing of the abnormal
synergy pattern and strengthening and reeducation of
the weaker agonist set of muscle group. Proprioceptive
Neuromuscular Facilitation procedures facilitate the
near normal range of motion and continues practice
helped the patient implement the newly learned
pattern into the daily life.
From the statistical data present the base of support
unlike the rest of the parameters showed the least
13. Damneek kaur-59--64.pmd 63
amount of improvement from the treatment protocol
the reason for that could be inability to assess the
patient in the premorbid conditions. The patients in
this study presented with highly variable base of
support.
CONCLUSION
It is concluded statistically from the research that
Proprioceptive Neuromuscular Facilitation techniques
when applied on the patients with hemiplegic gait,
improves the gait pattern, leading the patient one step
closer to functional independence. Also after the
cessation of the treatment the effect of the technique is
maintained by the patient’s lower extremity. The
difference in week 4 and week 6 was not statistically
significant hence suggesting sustenance in the
improvement of hemiplegic gait, prior to cessation of
treatment.
Conflict of Interest
There is no conflict of interest amongst authors to
prepare this manuscript.
REFERENCE
1. Banerjee, T K, Das, S K (2006) Epidemiology of
stroke in india. Neurology Asia, 11:1-4
2. Adamson, J, Berwick, A and Ebrahim, S (2004)
Department of health sciences, University of
York, Heslington, United Kingdom. J Stroke
Cerebrovasc, Jul-Aug; 13(4): 171-7
3. Stacy L.Fritz et.al. Active finger extension predicts
outcomes after constraint-induced movement
therapy for individuals with hemiparesis after
stroke. Stroke. 2005;36:1172-1177.
4. Winter, D.A. (1991). The Biomechanics and Motor
Control of Human Gait: Normal, Elderly and
Pathological. Waterloo, Canada: University of
Waterloo Press.
5. Olney, S J & Richards C (1996) Hemiparetic gait
following stroke. Part 1: characteristics. Gait
Posture, 4:136-148
6. Bohannon, R.W., Horton, M.G. & Wikholm, J.B.
(1991). Importance of Bobath, B (1990) Adult
hemiplegia: Evaluation and treatment. London,
England: Willian Heinemann Ltd, 16-144.
7. Perry, J (1969) The mechanics of walking in
hemiplegic. Clin orthop, 63:23-31
8. Sullivan, P E, Markos, P D and Minor M D (1982)
An integrated approach to Therapeutic Exercise:
Theory and Clinical Applicatioon. Reston, Va:
Reston Ltd, 199-254.
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 64 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
9. Wang R Y (1994) Effect of Proprioceptive
Neuromuscular Facilitation on Gait of Patients
with Hemiplegia of Long and Short Duration.
Phys Ther., 74:25-32.
10. Four variables of walking to patients with stroke.
International Journal of Rehabilitation research,
14(3), 246-250.
11. Kabat, H (1950) Studies on neuromuscular
Dysfuction XIII: New Concepts and tecniques of
neuromuscular re-education for paralysis.
Permanente Fdn med. Bull., 8, 121.
12. Assunti Pizzi, Giovanna Carlucci, Catuscia
Falsini, Francesco Lunghi, Sonia Verdesca and
13. Damneek kaur-59--64.pmd 64
Antomello Grippo 2007 Gait in hemiplegia:
Evaluation of clinical features with Wisconsin gait
scale. J Rehabilitation Med, 39: 170-174.
13. Turani, N, Meten Karatas and Ridwan Ozlar 2004,
Assessment of hemiplegic gait using Wisconsin
gait scale. Scand. Journal of caring science, 18(1):
103-108
14. Zverev, Y., Adeloye, A. & Chisi, J. (2002).
Quantitative analysis of gait pattern in
hemiparetic patients. East African Medical
Journal, 79, (8), 420-422.
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.067
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 65

Comparison of effects of Sitting-up using Rope Ladder

versus Manual Supported Sitting-up on Haemodynamic
Variables in Patients after Coronary Artery Bypass
Grafting

Deepti Garnawat1, Faizan Ahmed2, Muhammed Abid Geelani3

1
Physiotherapist, Dr.R.M.L Hospital, New Delhi, 2Assistant Professor, Faculty of Rehabilitation Science, Jamia
Hamdard, New Delhi, 3Professor, Department of CTVS, G.B.Pant Hospital, New Delhi

ABSTRACT
Objective: To evaluate haemodynamic effects of using rope ladder for sitting-up by patients after
Coronary Artery Bypass Graft(CABG) surgery.
Background: Rope ladders are provided to patients to sit-up after cardiac surgery. Sitting-up using
rope ladder requires a combination of isotonic and isometric efforts. Combined isotonic and isometric
activities cause some cardiovascular/hemodynamic alterations.
Method: Study was conducted on 2nd post-operative day. Measurement of Heart Rate (HR), Systolic
Blood Pressure(SBP), Diastolic Blood Pressure(DBP), Rate Pressure Product(RPP) and Post-operative
pain were obtained for all subjects in supine, immediately on sitting-up, after 5 minutes and 10
minutes of sitting with either using rope ladder or manual support.
Results: Sitting-up using rope ladder immediately resulted in an increase in DBP, HR and Post-
operative pain scores and decrease in SBP and RPP. The significance level was set at p< 0.05.
Conclusion: Sitting-up using rope ladder results in slightly greater alterations in hemodynamic
variables.
Keywords: Isometric, Isotonic, Haemodynamics, Coronary Artery Bypass Grafting

INTRODUCTION move and change positions without excessively

Coronary Artery Bypass Surgery is a mainstay of
therapy for patients with severe coronary artery
disease1. Post-operative physiotherapeutic regimen
includes emphasis on frequent and regular change in
body position while the patient is in bed to promote
early recovery after surgical procedure2,3. During early
post-operative period, it is also difficult for patient
himself, to change position, get out of bed because of
post-operative pain, chest tubes and lines in situ, and
fear of increasing pain associated with movement4.
Rope ladders are provided to patients to properly
Corresponding author:
Deepti Garnawat
MPT (Cardio-Pulmonary), Physiotherapist, Dr. R.M.L
Hospital, New Delhi.
Email: deeptigarnawat@yahoo.co.in
putting the load on the upper extremities during
transfer activities 2,5. It also reduces the patient’s
reliance on nursing or medical staff to be mobile when
confined to the bed2.
Sitting-up using rope ladder requires a combination
of both dynamic(isotonic) and static (isometric) efforts.
Both isotonic and isometric activity causes some
cardiovascular/ haemodynamic alterations. Various
studies have shown that the circulatory responses to
dynamic exercises are characterized by increase in
oxygen consumption, HR, SBP with maintenance or
slight decrease in DBP6,7. Thus dynamic exercises
impose primarily a volume load on myocardium6. In
contrast an isometric action has been shown to impose
a pressor response on myocardium which is
characterized by a marked increase in SBP, DBP, HR,
Mean Arterial Pressure and a moderate increase in

14. Deepti --65--70.pmd 65 8/1/2013, 8:31 AM

 66 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
oxygen consumption7,8. But a combination of both
dynamic and static exercise results in a predominant
pressor response9.
Patients are encouraged to use rope ladders for
sitting-up in the immediate post-operative period by
staff of many hospitals2,5. In contrast certain hospitals
do not encourage the use of rope ladder in the
immediate post-operative period. As it is well
documented that isometric and dynamic exercises are
associated with an increase in BP and HR6,7,8. For this
reason, some health care professionals question the
safety of using rope ladder in immediate post-
operative phase as they are cautious about the
isometric and dynamic responses which could be
evoked during sitting-up using rope ladder. There is
lack of evidence regarding the use of static and
dynamic exercise in the immediate post-operative
period in CABG patients. The safety of using rope
ladder in the immediate post-operative phase is also
unknown. Pure isometrics are not recommended by
American Heart Association guidelines for patients
with cardiovascular disease & post CABG surgery
within 3 months of surgery as the safety and efficacy
of pure isometric exercise have not been established
in such patients10. Thus it was important to evaluate
the physiological effects of isometric and isotonic
efforts of upper extremities which inadvertently occur
during rope pulling task which often goes unnoticed.
METHOD
SUBJECTS
This was same subject study with 30 male post
CABG surgery. Characteristics of sample are described
in Table.1. On second post-operative day all subjects
were on intravenous infusion of inotropes,
vasodilators, nitrates, oral administration of diuretics,
antibiotics and diabetic patients were on insulin. All
patients underwent Off-pump CABG surgery. Subjects
were excluded if they showed unstable cardiovascular
condition as defined by a Mean Arterial Pressure <65
mmHg11,12 and/or HR >130.13
Table.1 Patient Characteristics
Characteristics Mean±Standard Deviation
Age(yrs) 52.73±7.23
Height(mtr) 1.67±0.04
Weight(kg) 64.73±9.65
Body Mass Index(kg/m2) 23.03±3.25
Ejection Fraction(%) 49.33±8.78
14. Deepti --65--70.pmd 66
PROCEDURE
Preoperative CABG patients were assessed on a
standard institutional Performa which included
examination of the muscle strength and range of
motion so as to rule out any orthopedic or neurological
impairment which could limit the gripping of rope
ladder. Sitting-up using rope ladder and with manual
support was demonstrated and explained to the
patients preoperatively. After surgery the patients were
again examined on second post-operative day. All
subjects were requested to sign the written informed
consent forms. The study and consent form were
approved by the institutional ethics review committee.
Nursing staff were trained to give manual support for
sitting-up and were blind to the procedure as they were
not aware of the research hypothesis.
On the second post-operative day, sitting-up using
rope ladder or with manual assistance was again
explained to the patients. First fifteen patients were
made to sit-up with manual support on second post-
operative day initially & after 2 hours with using rope
ladder on the same day. Next fifteen patients were
made to sit-up using rope ladder on 2nd post-operative
day initially & after 2 hours with manual assistance
on the same day. The resting SBP, DBP, HR, RPP &
Post-operative pain level were recorded in supine
position (the head end of bed was elevated to 10
degree) and then patient’s were made to sit (90 degree
upright position with legs horizontal) either with the
help of nursing staff or using rope ladder. The pressure
transducers were zeroed and aligned to the
midthoracic level (angle of Louis) in the supine
position and at the level of 4th inter-costal space in
sitting position. After recording the supine
hemodynamics, the patient position was changed to
the upright position. Hemodynamic measurements
were again repeated immediately on sitting-up, after
five minutes and after 10 minutes of sitting. HR and
BP were measured directly from the bed side Philips
(Intillivue MP40,Netherland) monitors since all the
patients had an intra-arterial line in situ. Continuous
monitoring (HR, BP and ECG) was ensured
throughout the procedure so that sitting activity could
be terminated before any alarming sign. Visual
Analogue Scale (VAS) was the tool used for self
reporting of post-operative pain which was a
horizontal line scale of 0 to 10 cm. Zero was defined as
“no pain” & 10 was referred as “worst pain
imaginable”. Patients were asked to rate their pain
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 67

levels in supine position, immediately on sitting-up
with either rope ladder or manual support, after 5 and
10 minutes of sitting. The subjects were also instructed
to breathe throughout the sitting procedure and not to
perform breath holding to avoid valsalva maneuver.
The ACSM guidelines were followed to terminate the
activity 14. Patients were continuously monitored
during both type of sitting-up for any ST segment
depression/elevation, premature ventricular
contraction, atrial ectopics. Neither type of sitting
produced ST segment elevation/depression, any
significant ectopics which could compromise the
cardiovascular system.
Descriptive statistics (Mean and Standard
Deviations of variables) were computed for all
demographic variables of the 30 patients. Paired t–test
was used for comparison of dependable variables
between the two interventions. Changes within the
group were analyzed using repeated measures
ANOVA (Analysis of Variance) with Bonferroni
adjustments. The significance level for this study was
set at p<0.05.
RESULTS
Mean values and Standard Deviations of the
outcome variables during both type of sitting-up are
displayed in Table.2 and Table.3.
Sitting-up using rope ladder immediately resulted
in significant fall in SBP, significant rise in HR and
nonsignificant rise in DBP and Post-operative pain
scores. After 5 min of sitting SBP and DBP showed
significant rise, RPP showed nonsignificant rise
whereas HR, showed a significant fall and post-
operative pain showed nonsignificant fall. After 10
minutes of sitting SBP, DBP and RPP were found to be
decreased with no changes in HR and pain scores.
Whereas sitting up using manual assistance
immediately resulted in significant rise in DBP, HR,
RPP & Post-operative pain scores. SBP also showed a
nonsignificant rise immediately on sitting-up. After 5
minutes of sitting SBP and DBP nonsignificantly
increased while HR significantly decreased towards
the base line values, RPP was also decreased and pain
scores remained same. After 10 minutes of sitting SBP,
DBP, HR and RPP were significantly decreased.
Sitting-up using rope ladder resulted in slightly
greater alterations in hemodynamic variables (without
any immediate complication/adverse effects on
cardiovascular system) in comparison to manually
assisted sitting-up.

Table 2. Mean±Standard Deviation values of outcome variables during sitting-up using rope ladder

Dependable Baseline Immediately After 5 minutes After 10 minutes

Variables (Supine position) After sitting-up of sitting-up of sitting-up
SBP(mmHg) 131.47±12.77 123.03±12.27(*) 133.0±13.58(*) 129.20±12.16(*)
DBP(mmHg) 67.23±11.1 68.73±11.13 71.73±9.86(*) 69.90±10.27(*)
HR(bpm) 102.37±15.76 109.40±14.83(*) 102.53±16.19(*) 102.23±15.31
RPP 134.96±25.12 134.43±21.36 136.72±26.43 132.31±24.18(*)
Pain(cm) 0.90±0.71 1.47±0.81(*) 1.43±0.77 1.43±0.77

(*)- The mean difference is significant at p< 0.05.

Table 3. Mean±Standard Deviation values of outcome variables during sitting-up with manual assistance

Dependable Baseline Immediately After 5 minutes After 10 minutes

Variables (Supine position) After sitting-up of sitting-up of sitting-up
SBP(mmHg) 130.17±14.32 133.87±15.87 136.57±15.87 132.90±14.31(*)
DBP(mmHg) 66.80±10.63 71.83±10.85(*) 72.97±10.09 71.33±10.07(*)
HR(bpm) 102.97±15.11 109.03±15.37(*) 104.93±15.52(*) 104.03±15.76
RPP 134.20±25.12 146.37±28.45(*) 143.84±29.86 138.61±27.20(*)
Pain(cm) 0.83±0.87 1.07±0.86(*) 1.07±0.86 1.07±0.86

(*)- The mean difference is significant at p<0.05.

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 68 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
DISCUSSION
Rope ladders are given to patients in post-operative
period to aid mobility2,5. Since literature is unclear
about effects of using rope ladder in the immediate
post-operative phase after CABG, the present study
was undertaken to investigate the physiological
responses of isometric and isotonic efforts elicited
during pulling of rope ladder.
The results of sitting-up using rope ladder showed
that there was a significant fall (p=0.01) in mean SBP
of about 6.41% immediately on sitting, which
significantly (p=0.01) increased after 5 minutes of
sitting and after 10 minutes it decreased significantly
(p=0.04). These findings are in contrast to previous
studies of Louhevaara et al7, Bezucha et al9, Lind et
al15, done on isometric and isotonic exercises with
diverse patient population which mainly showed an
increase in SBP response with exercises. They observed
an increase in HR which solely increased the cardiac
output which was accompanied by widespread
vasoconstriction resulting in an increased BP
response7,9,15. Whereas, Sprangers et al16 observed an
immediate fall in BP during active work than passive
head up tilt. He postulated that the fall in BP was
perhaps due to the metabolic effect in the active
muscles by direct activation of afferent nerves in the
contracting muscles or by central nervous system i.e.
muscular effort was responsible for the fall in BP.
During manual supported sitting-up the mean SBP
was non-significantly increased. This result was similar
to findings of Dean et al17 & Prakash et al18. The non-
significant changes found were probably due to little
or no gravitational pooling of blood in the legs. As legs
of patients were in horizontal position and not
substantial hemodynamics responses were observed19.
We speculate that the differences in responses in
present study in sitting-up using rope ladder were due
to the timing of measurement or the clinical status of
the subjects, as previously none of the researchers have
studied the effect of isometric and isotonic exercises
in patients immediately after CABG surgery. In the
previous studies7,15 all the exercises were done at a
particular maximum voluntary contraction and for
particular duration of time ranging minimally from a
period of 1 minute to the limit of fatigue or a particular
number of contractions were performed. Whereas the
maximum time to sit-up using rope ladder was 5
second and the strength of contraction of various
muscles during rope pulling was also not known. This
14. Deepti --65--70.pmd 68
very brief period of combined isometric and isotonic
effort simultaneously with change of posture from
supine to upright might have resulted in fall in BP. In
the present study sitting-up using rope ladder required
muscular effort in comparison of the manually assisted
sitting-up so one of the possible reasons for the fall in
BP could be activation of afferent nerves in the
contracting muscles or the Central Nervous System17.
The mean DBP was increased immediately during both
the type of sitting procedures but significant (p=0.001)
rise was observed during manually supported sitting-
up.
Both type of sitting-up procedures resulted in
immediate increase in HR. The difference between the
two was found to be non-significant but mean HR of
rope ladder supported sitting-up was greater than
manual assisted sitting-up. An initial increase to HR
response during isometric and isotonic exercise was
also observed by Petro et al19 and Borst et al20. In the
light of previous studies the possible reason for
increase in HR could be an increase in sympathetic
activity19,20. The use of rope ladder produced less
demand on heart as measured by RPP, than manual
supported sitting. The lower RPP observed during
rope pulling task is primarily due to lower SBP
response.
The post-operative pain levels were increased
during both type of sitting-up procedures. The patients
reported more pain with the use of rope ladder in the
immediate post-operative period but none of the
patient had difficulty in sitting-up using rope ladder.
The increase in pain level was transient as patients
reported decreased pain after 5 and 10 minutes of
sitting-up with either type of sitting. An analogy to
our finding of greater post-operative pain during
mobility activities was also observed by Migrom et al4.
The present study showed that sitting-up using
rope ladder resulted in slightly greater changes in
haemodynamic variables in comparison to manually
assisted sitting. It was found that the changes observed
did not produce any haemodynamic instability or
compromise cardiovascular system. Also decreased
RPP indicate decreased myocardial oxygen
consumption. Since the changes observed in sitting-
up using rope ladder did not produce any
haemodynamic instability, rope ladders can be a used
as mobility aid for patients during immediate post-
operative period. Thus, sitting-up using rope ladder
is a better alternative than manually supported sitting-up.
8/1/2013, 8:31 AM
 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 69
Fig.1 Between intervention comparisons for SBP.
Supine- SBP in supine position.
Sitting- SBP immediately after sitting-up
After 5 min- SBP after 5 minutes of sitting-up.
After 10 min- SBP after 10 minutes of sitting-up.
Fig.2 Between intervention comparisons for DBP
Supine- DBP in supine position.
Sitting- DBP immediately after sitting-up.
After 5 min- DBP after 5 minutes of sitting.
After 10 min- DBP 10 minutes of sitting.
14. Deepti --65--70.pmd 69
Fig.3 Between intervention comparisons for HR
Supine- HR in supine position.
Sitting- HR immediately after sitting-up.
After 5 min- HR after 5 minutes of sitting.
After 10 min- HR after 10 minutes of sitting.
Fig.4 Between intervention comparisons for Post-Operative Pain
Scores
Supine- Post-operative pain in supine position.
Sitting- Post-operative pain immediately after
sitting-up.
After 5 min- Post-operative pain after 5 minutes of
sitting.
After 10 min- Post-operative pain after 10 minutes
of sitting.
ACKNOWLEDGEMENT:
The author acknowledges the mentorship of Dr.
M.A.Geelani and support of other staff of G.B. Pant
Hospital.
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 70 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Conflict of Interest: There is no conflict of interest.
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7. Louhevaara L, Smolander J, Aminoff T, Korhonen
O, Shen N. Cardiorespiratory Responses to
Fatiguing Dynamic and Isometric Handgrip
Exercise. Eur J Appl Physiol. 2000;82:340-344.
8. Marjorie G, Susan D, Stephanie B. Heart Rate and
Blood Pressure Response to Several Method of
Strength Training. Physical Therapy. 1984;
64(2):179-183.
9. Bezucha G, Lenser M, Hanson P, Nagle F.
Comparison of Hemodynamic Responses to
Static and Dynamic Exercise. J Appl Physiol.
1982;82:1589-1593.
10. Pollock M, Franklin B, Balady J et al. Resistance
exercise in individual with and without
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11. Heinemann B. Hypotension and Low Cardiac
Output- Recognizing and Treating
Hemodynamic Instability, Sidebotham
Cardiothoracic Critical care.1st edition: Elsevier’s
Publications;2007.
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12. Savian C, Paratz J, Davies A. Comparison of the
effectiveness of manual and ventilator
hyperinflation at different levels of positive end-
expiratory pressure in artificially ventilated and
intubated intensive care patients. Heart & Lung.
Sep-Oct;2006,35(5):334-41.
13. Berney S, Denehy L. A comparison of the effects
of manual and ventilator hyperinflation on static
lung compliance and sputum production in
intubated and ventilated intensive care patients.
Physiother Res Int. 2002;7(2):100-8.
14. Franklin B, Balady G. ACSM’s guidelines for
exercise testing and prescription. sixth edition:
Lippincott Williams and Wilkins;2000.
15. Lind A, McNicol G. Circulatory Responses to
Sustained Hand-Grip Contractions Performed
during other Exercise, both Rhythmic and Static.
Journal of Physiology. 1967;192: 595-607.
16. Sprangers R, Lieshout J, Karemaker J, Wesseling
K, Wielling W. Circulatory Responses to Stand
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Respiration, Orthostasis and Exercise. Clinical
Physiology. 1991;11:221-230.
17. Jones A, Dean E. Body Position Change and its
Effect on Hemodynamic and Metabolic Status.
Heart & Lung. 2004;33(5):281-290.
18. Prakash R, Parmley W, Dikshit K, Forrester J,
Swan H. Hemodynamic Effects of Postural
Changes in Patients With Acute Myocardial
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 DOI Number: 10.5958/j.0973-5674.7.3.068
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 71

Electrical Muscle Stimulation (EMS) Preserve Muscle

Strength in Critically ill Patients- A Pilot Study

Dharam Pani Pandey1, Ram Babu2, Uday Shanker Sharma3

1
Ph.D Scholar, Singhania University, Pacheri, Rajasthan, India, 2Research Supervisor, Sr. Consultant Internal
Medicine, Jaipur Golden Hospital, Rohini, New Delhi, 3Sr. Consultant Neurologist, Jaipur Golden Hospital,
Rohini, New Delhi

ABSTRACT
Introduction: Weakness that is acquired during hospitalization for critical illness is increasingly
recognized as common and important clinical problem. Weakness acquired in the intensive care unit
(ICU) and related acquired neuromuscular dysfunction occur in a large percentage of critically ill
patients and are associated with increased morbidity and mortality.
Objective: This study was designed to investigate the effects of electrical muscle stimulation (EMS)
on strength of muscle groups stimulated in critically ill patients.
Method: 134 subjects were recruited among the patient admitted in multidisciplinary intensive care
units and randomly divided in to control and EMS group. Patients unable to understand or speak
English and or Hindi due to language barrier or cognitive impairment prior to admission, unable to
independently transfer from bed to chair at baseline prior to hospital admission, Patient with known
history of primary systemic neuromuscular disease, vascular events, organ transplant, intracranial
process that is associated with localizing weakness, transferred from another ICU after >2 consecutive
days of mechanical ventilation, amputation of lower extremities were excluded from study.
Results: EMS group patients achieved higher MRC scores than controls in knee extensors
(left ≤ 0.018), (right P ≤ 0.038) and ankle dorsiflexors (left ≤ 0.04), (right P ? 0.05)
Conclusions: EMS has beneficial effects on the strength of critically ill patients mainly affecting muscle
groups stimulated, it can be considered as a potential effective means of muscle strength preservation
and early mobilization in this patient population.
Keywords: Electrical Muscle Stimulation, Muscle Strength, CIPNM, CIM, ICU-AW

INTRODUCTION Critical illness polyneuromyopathy (CIPNM) is an

Weakness that is acquired during hospitalization
for critical illness is increasingly recognized as common
and important clinical problem. Weakness acquired in
the intensive care unit (ICU) and related acquired
neuromuscular dysfunction occur in a large percentage
of critically ill patients1–3 and are associated with
increased morbidity and mortality.4,5
Corresponding author:
Dharam Pani Pandey
Ph.D Scholar, Singhania University, Pacheri,
Rajasthan, India
Physiotherapy & Rehabilitation
BLK Super Speciality Hospital
Pusa Road, New Delhi- 110085. (India)
Telephone: +911130653154 (Off) +919818911195 (Mob)
Email: drdprehab@gmail.com
acquired neuromuscular disorder observed in
survivors of acute critical illness. It is characterized by
profound muscle weakness and diminished or absent
deep tendon reflexes 1 and is associated with delayed
weaning from mechanical ventilation 2 suggesting a
possible relation between limb and respiratory
neuromuscular involvement. In addition, the
syndrome is associated with prolonged hospitalization
and increased mortality 3. The diagnosis of CIPNM
requires a reliable bedside muscle strength
examination and depends on patient’s cooperation and
maximal effort 4 . Several risk factors have been
identified including systemic inflammatory response
and sepsis5, medications such as corticosteroids6 and
neuromuscular blocking agents7, inadequate glycemic
control8, protracted immobility 4, hypoalbuminemia 9,
Gram-negative bacteremia 9 and severity of organ
dysfunction 10.

15. Dharam Pandey--71--75.pmd 71 8/1/2013, 8:31 AM

 72 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
A very few of studies available suggesting the
treatment and prevention of critical illness myopathy
these includes intensive insulin therapy, optimal
glycemic control and minimized use of neuromuscular
blocking agents, high dose and prolong use of
corticosteroids.
OBJECTIVE OF THE STUDY
The objective of this study was to investigate
whether electrical muscle stimulation (EMS) would
decrease the incidence of ICU-associated muscle
weakness
Our experimental Hypothesis was that “EMS
would beneficially affect muscle functional status and
preserve muscle strength in the critically ill patients.
MATERIAL AND METHOD
Subjects: The 134 subjects were recruited among
the patient admitted in multidisciplinary intensive care
units during the study period.
Exclusion criteria
Unable to understand or speak English and or
Hindi due to language barrier or cognitive impairment
prior to admission, unable to independently transfer
from bed to chair at baseline prior to hospital
15. Dharam Pandey--71--75.pmd 72
admission (based on detail history taken from
caregivers. Patient with known history of primary
systemic neuromuscular disease, vascular events,
organ transplant, intracranial process that associated
with localizing weakness, transferred from another
ICU after >2 consecutive days of mechanical
ventilation, amputation of lower extremities, any
limitation of life support, pregnancy, age under 18
years, obesity, technical obstacles that did not allow
the implementation of EMS such as bone fractures, skin
lesions and, end-stage malignancy were excluded from
our study.
DESIGN OF STUDY
The study employed a randomized single blind
controlled experimental study design consisting of two
group experimental group and control group, Subjects
were randomly assigned ether to experimental group
or to control group everyday the ICU patient
admission register were observed and with in 24 hour
the assessment were done , each time when a patient
met the criteria for inclusion a random number were
picked up between 1 to 10 using sealed envelop
method if it were an odd number than the subject were
assigned to experimental group similarly if even
number were obtained the subjects were assigned to
control group.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 73
INTERVENTION
EMS was implemented on knee extensors, tibialis
anterior and of both lower extremities. Patients
received daily sessions. After skin cleaning, rectangular
electrodes (90 × 50 mm) were placed on motor point
of targeted muscle. The stimulator (Unistim, HMS
medical system) delivered biphasic, symmetric
impulses of 50 Hz, 100 ìsec pulse duration, 12 seconds
at intensities able to cause visible contractions. The
duration of the session was 30 minutes each muscle
group. EMS sessions were continued until ICU
discharge, both group were getting routine
physiotherapy included the passive movements, active
assisted movements and chest physiotherapy.
OUTCOME MEASURES
Primary Outcome Measures were lower extremity
strength, at discharge from ICU, of 2 bilateral muscle
groups which were stimulated measured by MMT
using a composite Medical Research Council (MRC)
score.
Table:1 Showing numerical values of results
Knee extensors
Left
Mean p Mean
EMS Group 3.91 0.018
Control Group 3.49
Graph 1: Showing the mean and significance level of two group
of left and right knee extensor.
DISCUSSION
The main finding of our randomized controlled
study is that EMS to lower extremities seems to
preserve the muscle strength in critically ill patients
15. Dharam Pandey--71--75.pmd 73
FINDINGS
Data analysis and Results
All continuous variables were presented by mean.
The statistical significance of P value was set at 0.05.
One-way repeated measures analysis of variance
(ANOVA) was made to compare MRC Grading
Between-group
Two hundred and thirty-eight patients were
admitted to our multidisciplinary ICU during the
eight-month of study period. 104 patients fulfilled the
exclusion criteria or stayed in the ICU less than 48
hours. The study population consisted of 134 patients
of which of 70 were randomly assigned to the EMS
group and 64 to the control group. 6 patients from EMS
group and 1 patient from control group died or were
discharged from the ICU before the second
measurement.
The final results shows significant difference (MRC
muscle grading score of muscle being stimulated)
between two groups, EMS group showed preserved
muscle strength at time of discharged from ICU as
compared to control group. Numerical data is
summarized in table 1 below.
Ankle dorsiflexors
Right Left Right
p Mean p Mean p
3.87 0.0387 3.91 0.04 3.46 0.058
3.69 3.78 3.37
Graph 2: Showing the mean and significance level of two group
of left and right ankle dorsiflexors.
as assessed with MRC muscle strength grading system
. EMS of lower extremities applied to critically ill
patients upon admission is associated with a lesser
degree of muscle strength loss of these patients as
assessed with MRC muscle strength grading system.
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 74 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Electrical stimulation has been used to increase
strength and endurance in partially and fully
paralyzed muscle. It has been used for peroneal nerve
stimulation 10,11 the restoration of shoulder movement
12
, recovery of tendonesis grip 13, and in the use of an
upper arm prosthesis 14. Electrical muscle stimulation
(EMS) has been used as an alternative to active exercise
in patients with chronic heart failure (CHF) 15 and
chronic obstructive pulmonary disease (COPD) 16,17.
Many of these patients, even those who are clinically
unstable, experience severe dyspnea on exertion,
which can prohibit the regular application of
conventional exercise training, considered necessary
for an integrated therapeutic approach. In a recent
systematic review, EMS implementation in most of the
selected controlled clinical trials produced significant
improvements in muscle strength, exercise capacity
and disease-specific health status 18. Recently, an study
identified an acute systemic effect exerted by EMS on
peripheral microcirculation of critically ill patients 19.
Specifically, after performing a 45-minute session of
EMS on the lower extremities, an improvement in the
microcirculation of the thenar muscle as assessed by
near infrared spectroscopy technique was observed.
EMS, as a possible substitute to aerobic and
resistance exercise training in severe CHF and COPD
patients, has been shown to improve muscle
performance, aerobic exercise capacity, and disease-
specific health status 9–11.
CONCLUSIONS
EMS exercise induces beneficial effects in muscle
strength of ICU patients. These effects mainly concern
muscle groups directly stimulated, but there is also
evidence of effects in muscle groups not stimulated.
EMS application constitutes a promising means of
muscle strength preservation and early mobilization
in critically ill patients.
Clinical relevance & limitation
EMS is an alternative method of exercise causing
minimal discomfort to patients who are not able to
perform any form of physical exercise, as is often the
case in critically ill patients. It is a limitation of this
study that it did not evaluate the effect of EMS on the
functional recovery related Further studies are needed
to explore the possible role of EMS as a tool for
preserving the muscle strength, the muscle properties
15. Dharam Pandey--71--75.pmd 74
and preventing CIPNM in critically ill patients and to
define which patients would benefit most from this
intervention.
ACKNOWLEDGEMENTS
We would like to acknowledge the support of all
intensive care unit staff, consultants and all the patients
caregivers.
Conflict of Interest
Authors declares that they have no conflict of
interest.
Source of Funding: This study was self-finance
and authors has no financial interest.
REFERENCES
1. De Jonghe B, Sharshar T, Lefaucheur JP, Authier
FJ, Durand-Zaleski I, Boussarsar M, et al; Groupe
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Garmendia JL, Ortiz- Leyba C, Jimenez-Jimenez
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Bowles A. Neuromuscular causes of prolonged
ventilator dependency. Muscle Nerve
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Angus E, Beis S, Zarowitz BJ. Economic impact
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7. Latronico N, Peli E, Botteri M. Critical illness
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Verwaest C, Bruyninckx F, Schetz M, et al.
Intensive insulin therapy in the critically ill
patients. N Engl J Med 2001;345(19):1359–1367.
10. Tennila A, Salmi T, Pettila V, Roine RO, Varpula
T, Takkunen O. Early signs of critical illness
polyneuropathy in ICU patients with systemic
inflammatory response syndrome or sepsis.
Intensive Care Med 2000;26(9):1360–1363.
11. Rabuel C, Renaud E, Brealey D, Ratajczak P,
Damy T, Alves A, et al. Human septic myopathy:
induction of cyclooxygenase, heme oxygenase
and activation of the ubiquitin proteolytic
pathway. Anesthesiology 2004;101(3):583–590.
12. MacFarlane IA, Rosenthal FD. Severe myopathy
after status asthmaticus (letter). Lancet
1977;2(8038):615.
13. Witt NJ, Zochodne DW, Bolton CF, Grand’Maison
F, Wells G, Young GB, Sibbald WJ. Peripheral
nerve function in sepsis and multiple organ
failure. Chest 1991;99(1):176–184.
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14. Knox AJ, Mascie-Taylor BH, Muers MF. Acute
hydrocortisone myopathy in acute severe asthma.
Thorax 1986;41(5):411–412.
15. Hund E, Genzwurker H, Bohrer H, Jakob H,
Thiele R, Hacke W. Predominant involvement of
motor fibres in patients with critical illness
polyneuropathy. Br J Anaesth 1997;78(3):274–278.
16. Thiele RI, Jakob H, Hund E, Tantzky S, Keller S,
Kamler M, et al. Sepsis and catecholamine
support are the major risk factors for critical
illness polyneuropathy after open heart surgery.
Thorac Cardiovasc Surg 2000;48(3):145–150.
17. Garnacho-MonteroJ, Amaya-Villar R, Garcia-
Garmendia JL,Madrazo- Osuna J, Ortiz-Leyba C.
Effect of critical illness polyneuropathy on the
withdrawal from mechanical ventilation and the
length of stay in septic patients. Crit Care Med
2005;33(2):349–354.
18. Bolton CF. Sepsis and the systemic inflammatory
response syndrome: neuromuscular
manifestations. Crit Care Med 1996;24(8):
1408–1416.
19. Latronico N, Fenzi F, Recupero D, Guarneri B,
Tomelleri G, Tonin P, et al. Critical illness
myopathy and neuropathy. Lancet 1996;
347(9015):1579–1582.
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 DOI Number: 10.5958/j.0973-5674.7.3.069
76 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of Core Stability Exercises Versus Conventional

Treatment in Chronic Low Back Pain

Dheeraj Lamba1, Suneeti Kandpal2, Monika Joshi2, Mamta Koranga2, Neeta Chauhan2
1
Incharge, Dept of Physiotherapy, 2Interns, Dept of Physiotherapy, IAHSET,Govt. Medical College Haldwani

ABSTRACT
Aims and Objectives: To determine whether the use of core stability exercises on Swiss ball for
LBPgives better results.
Hypothesis: Core stability exercises on Swiss ball will be more effective in long term improvement in
chronic low back pain.
Study Design: Experimental.
Subjects: 30 subjects with chronic low back pain participated in the study.
Methodology: Based on the inclusion and exclusion criteria subjects were included in the study.
Convenient samplings was done for patients with random allocation into the following two groups:
GROUP A : (Experimental Group) exercises on the Swiss ball (15 patients).
GROUP B : ( Control Group) conventional treatment (15 patients).
Conclusion: The present study reported significant rate of improvement with exercises done on the
Swiss ball. Hence the study concludes that core stabilization exercises on Swiss ball are safe and
effective in long term management of chronic low back pain.
Keywords: LBP, Low Back Pain, VAS, Visual Analogue Scale, ODI, Oswestry Disability Index

INTRODUCTION Various etiological factors leading to LBP include

Low back pain (LBP) is the most common health
problems in the industrialized world and in adult
working age population 2. Epidemiological studies
have shown that 50% to 80% of the population is
affected by low back pain at least once in a lifetime.
Prevalence among adults in different studies ranges
from 15% to 30%. About 2% to 5% of the population
receives medical care or loses time from work every
year as a result of back pain. The peak age shown for
adults was between 45-65 years secondly only to
arthritis. Across sectional study done on Danish
population of individuals of 12-14 years of age, more
than 50% had experienced at least one episode of LBP.
The overall incidence was higher in women compared
to men.
Studies suggest that LBP is associated with heavy
manual occupations in which repeated forward
bending and lifting may induce pain for patients 4
.There is also evidence suggesting that jobs requiring
manual material handling, frequent bending/ twisting,
and static work posture are associated with back pain.
prolapsed disc, disc degeneration, osteoarthritis of
apophyseal joints, fractures and dislocations of
vertebrae, osteoporosis, spondylolisthesis, lumber
canal stenosis and previous back surgery. General level
of physical activity, diet, heredity, posture, body build,
presence of other disease, previous use of medications
and autoimmune mechanism have been suggested as
predisposing agents in these various diseases.
The recent evidences suggest that patients with
chronic low back pain exhibit deficits in proprioception
and trunk motor control. LBP is thought to occur when
spinal load exceeds the tissue tolerance 6. Dysfunction
of ventral and dorsal muscle of the trunk have been
studied in low back pain. Insufficiency of muscle
function leads tostress and undue load on the joints
and ligaments of the spine, because of inherent
instability of the lumbar spine, failure of
intersegmental rotation is required to produce micro
trauma of the structures of the lumbar spine.
Stability of lumbar spine require both passive

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 77

support trough the osseous and ligamentous structures 3. Age group : 25-40 years.
and active trough muscles. Spinal instability occurs
4. Weight: 50-100 kg.
when either of these components is disturbed. Gross
instability is true displacement of vertebrae while 5. A traumatic Origin.
functional instability is due to relative increase in range
of neutral zone 1 .Active stability can be achieved Exclusion Criteria
through muscular contraction. By recruiting 1. Patients with neurological deficit.
antagonists cocontractions of trunk muscles ,spinal
stability can be improved thus allowing the structure 2. Spondylolysis.
to withstand extreme compressive loads safely. 3. Spondylolisthesis.
Cocontractions may add protection against low back
disorders by improving spinal stability. This 4. Spinal fracture.
cocontractions significantly influences spinal load 5. Spinal tumors.
accounting for 26% to 45% of local compressive load.
6. Spinal surgery.
Core strengthening has been discovered in
rehabilitation. This term has come to define lumbar 7. Pregnancy.
stabilization and other therapeutic exercise regimes. 8. Disc prolapsed.
The “core” has been described as a box with the
abdominals anterolaterally , paraspinal and gluteals 9. Scoliosis.
in the back, the diaphragm as the roof and pelvic floor
Instrumentation
and hip girdle musculature as the bottom.
Rehabilitation of chronic low back pain using a 1. Swiss Ball.
multidimensional approach has achieved wide
2. Visual Analogue Scale.
acceptance since 1970’s.
3. Oswestry Disability Index.
Core stability is a recent generic description for
training transverse abdominis and lumbar multifidus 4. Measuring Tape.
which are local stabilizers, but no focus has been
carried out yet on inclusive of global muscles in core PROTOCOL
stabilization training on long term management of
chronic LBP 2.

STUDY DESIGN

METHODOLOGY

Sample size

30 subjects with chronic low back pain participated

in the study. The subjects were recruited from
Department of physiotherapy, Sushila Tiwari Govt
Hospital Haldwani. Subjects were randomly allocated
into two groups. The mean age, height and weight of
the subjects in Group A were (34.3 + 1.19) yrs. (166.8+
1.93) cms, (68.4+ 1.59) kgs respectively, likewise in
Group B it was (31.5+1.02) yrs, (162.9+1.75) cms,
(64.7+1.25) kgs respectively.

Inclusion Criteria PROTOCOL

1. Patients with chronic low back pain ( duration of Based on the inclusion and exclusion criteria
3 months or more). subjects were included in the study. Convenient
samplings was done for patients with random
2. No radiation to leg.
allocation into the following two groups:

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 78 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
GROUP A : (Experimental Group) exercises on the
Swiss ball (15 patients).
GROUP B : ( Control Group) conventional treatment
(15 patients).
PROCEDURE
All the patients in group A were demonstrated with
abdominal hallowing exercises to make them aware
of the procedure. The maximum extent of patients
ability to hold the tummy in was recorded for each
patient and they were asked hold the tummy in for
about 3/4th of maximum extent in all the following
exercises. The patient were instructed to maintain
normal breathing pattern while doing the exercises.
GROUP A: (Experimental Group)
Full examination of posture, movement of lumbar
spine, confirmatory tests were done and recorded.
Patients were made to fill VAS and ODI on the starting
day, 2nd week, 4th week and 6th week without any
intervention given 4th and 6th week.
All the patients in group A received abdominal
hallowing exercises in supine lying , crook lying and
quadruped position during 1st week. From 2nd week
onwards core stabilization exercises were given on
Swiss ball. The exercises were performed once a day
with 10 repetitions, 6 times a week for a total duration
of 4 weeks. The height of the ball differed for each
individual .
Selection of ball height: Patients were asked to stand
and the distance between posterior aspect of heel of
the foot and the popliteal crease was measured using
measuring tape.
SUPINE LYING
Patient was made to lie supine and tuck in the
tummy for about 3/4th of the maximum extent.
CROOK LYING
Patient was in supine lying with hip 45 degree
flexed and knee 90 degree flexed and instructed tuck
in the tummy for about 3/4th of the maximum extent.
QUADRUPED EXERCISES
Patient was made to lie in all four positions, knee
was kept at shoulder width apart and elbow was
16. Dheeraj Lamba--76--80.pmd 78
extended. Patient were asked to tuck in tummy for
about 3/4th of the maximum extent. Progression of this
exercise was done by asking the patient to take out
one upper extremity with the tummy in. Furthermore,
progression was made the by asking the patient to
simultaneously take out one upper extremely and
contra lateral leg.
UPPER BODY ROLL OUT
In prone roll position, the subject was made to lie
with the lower leg and feet contact with the surface of
the ball. The hands were positioned in line with the
shoulders, with the fingers facing forward. The trunk
was perpendicular to upper extremity (manually
measured with goniometer).
INCLINED PRESS UP
The top position of the inclined press up was the
starting point in which hands were placed on the ball,
elbow was extended and trunk was inclined on the
floor. Hands were about shoulder width apart. Position
of each subject’s feet was marked. Then the patient
was asked to lower the trunk by flexing the elbow joints
to approximately 90degree to hip and knee flexion.
Then the patient was asked to extend the knee, and
then extend the hip inline with the trunk.
Contralateral Single Leg Hold
Subject was made to lie supine on high surface with
only trunk supported. Right foot was kept on the floor
at 90 degrees to trunk throughout the task. Left leg
was assisted manually to approximately 90 degree to
hip and knee flexion. Then the patient was asked to
extend the knee, and then extend the hip in line with
the trunk.
Quadruped Exercises
Patient was kept in quadruped position with hips
90 degrees flexed, knees and hands on the floor i.e.
hip 90 degrees and beneath the shoulder joint. Then
the patient was instructed to take out one arm and
contra lateral leg simultaneously until both upper and
lower body segments were parallel to the trunk.
Group B (Control Group)
Full examination of posture, movement of lumbar
spine, confirmatory tests were done and recorded.
Patients were made to fill VAS and ODI on the starting
day, 2nd week, 4th week and 6th week without any
intervention given 4th and 6th week. In this group
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 79
patients received conventional treatment in the form
of modalities and spinal exercises.
a) Ultrasound:
Patient Position: Prone
Ultrasound was applied with intensity of 1.5 to 2w/
cm square on lower back for 7 minutes.
b) Transcutaneous electrical nerve stimulation
(TENS)
Patient Position: Prone
Tens was applied along the site of pain with
frequency of 2-4 Hz, output intensity of 50M A , pulse
rate at 2 pulse/ sec and pulse width between 30-60
minutes.
c) Diathermy: Drum electrodes or induction
electrodes can be used, continuous mode was used
patient position- supine, duration – 10 minutes.
d) Spinal Traction: Intermittent lumbar traction was
used, traction force 10-25lbs is adequate for pain
relief.
e) Spinal Exercises: Patient position- prone back
extensor exercises were done by the patient 10
times a day.
DATA ANALYSIS
The data analysis was done using SPSS software
version 11.0.
RESULTS
The results of VAS showed insignificant difference
at starting day but significant differences were seen at
2nd week, 4th week and 6th week. For ODI the results
were insignificant at starting day, 2nd week, 4th week
but showed significant improvement at 6th week.
Multiple comparisons within groups for VAS in
group A showed significant improvement between
starting day and 2nd week, starting day and 4th week,
starting day and 6th week, 2nd and 4th week, 2nd and
6 th week but there was insignificant differences
between 4th and 6th week. In group B, VAS showed
insignificant results between starting day and 2nd week
and 4 th and 6 th week but there was significant
improvement between starting day 4th week, starting
day and 6th week, 2nd and 4th week 2nd and 6th week
respectively.
16. Dheeraj Lamba--76--80.pmd 79
Multiple comparisons within groups for ODI was
performed showed significant improvement between
starting day and 2nd week, starting day and 4th week,
starting day and 6th week, 2nd and 4th week, 6th week,
starting day and 6th week but there was insignificant
differences between 4th and 6th week for group A . In
group B, results showed significant improvement
between starting day and 2nd week starting day and
4th week, starting day and 6th week , 2nd and 6th week
but the results were insignificant between 4th and 6th
week.
Improvement in VAS and ODI was calculated in %
for both the groups from starting day to the 6th week.
Group A showed 70.78% improvement in VAS and
79.71% improvement in ODI whereas Group B showed
48.56% improvement in VAS and 60.25% improvement
in ODI.
DISCUSSION
Low back pain is the commonest problem in
industrialized world. Till date lot of treatment method
have been introduced and successfully practiced. The
principle of core stabilization exercises on and off Swiss
ball is well known 8 . Its applicability to relief of chronic
low back pain has been generally overlooked. Previous
studies have been done to see the effect of core
stabilization exercises on chronic LBP. O’ Sullivan et
al 5 found that specific training of deep abdominal
muscles, with co contractions of lumbar multifidus
there is significant reduction in pain intensity and
functional disability. The significant results for VAS in
group A are supported by the study done by Natasa
Kavcic et al . They quantified tissue load and spine
stability while performing low back stabilization
exercises. Higher the compression, higher the stability.
Georgory J Lehmann et al recorded the EMG
activity of trunk muscles during bridging exercises on
and off Swiss bal, they stated that stability is achieved
through the co contraction of trunk muscles therefore
endurance training is beneficial in training trunk
muscles to provide stability .A physio ball also
improves proprioception, which provides increased
balance and stability. As this study included only
young chronic LBP patients, this can also be the reason
for significant improvement.
Further significant improvement in group A can
also be attributed to the study done by G.D Maitland
and Richerdson et al 7 found that co contraction of
multifidus and transverse abdominis tenses the
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 80 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
thoracolumbar facia and leads to increased intra
abdominal pressure. This provides segmental stability
to the spine hence improves LBP. The above reasons
are also responsible for significant improvement in
disability up to 4th week in both the groups A and B.
The insignificant result at 6th week can be due to the
continuation of occupation without any exercise
sessions.
Paul Marshall et al stated that the long term
relevance of core stability exercise programs is not
neglected the synergistic relation between the muscles
of the global and local stability systems, for any
movement task that involves trunk region, only one
specific muscle system is not actively involved. One
single muscle cannot be identified as being more
important for lumbar stability than the other. This can
also be the reason for significant improvement in group
A, insignificant improvement in group B.
CONCLUSION
The present study reported significant rate of
improvement with exercises done on the Swiss ball.
Hence the study concludes that core stabilization
exercises on Swiss ball are safe and effective in long
term management of chronic low back pain.
REFERENCES
1. Punjabi M.M, The stabilizing systems of the spine,
part II, neutral zone and instability hypothesis.
Journal of Spinal Disorders, 5,4,390-397,1992.
2. Tesh K.M. et at, The abdominal muscles and
vertebral stability, Spine 12,5,1987.
16. Dheeraj Lamba--76--80.pmd 80
3. Kinser C, Colby L.A. Therapeutic exercise
foundation and techniques, 3rd edition, Jaypee
Brothers Medical Publishers (P) Ltd.
4. Miller R.S. Exercises ball therapy for low back
pain. JAMA October 22, 2003.
5. O’ Sullivan et at, Evaluation of specific stabilizing
exercise in the treatment of chronic low back pain
with radiology diagnosis of spondylolysis and
spondylolisthesis. Spine 22,24,2959-2967, 1997.
6. Foster N, Thompson K Baxter G, Allen J.
Management of non specific low back pain by
physiotherapists in Britain and Ireland, a
descriptive questionnaire of current clinical
practice. Spine 1999; 24: 1332-42.
7. Chiradejnant A, Maher C, Latimer J. Efficacy of
therapist selected versus randomly selected
mobilization techniques for the treatment of low
back pain: a randomized controlled trail. Aust J
Physiotherapy 2003; 49: 233-41.
8. Rasmussen-Barr E, Nilsson-Wikmar L, Arvison
I. Stabilizing training compared with manual
treatment in sub-acute chronic low back pain.
Manual Therapy 2003; 8(4): 233-41.
9. Cairns M, Foster N, Wright C. Randomized
controlled conventional physiotherapy for
recurrent low back pain. Spine 2006; 31(19): E6
70-81.
10. Hurwitz E, Morgenstern H, Harber P et al. Second
prize the effectiveness of physical modalities
among patients with low back pain randomized
to chiropractic care: findings from the UCLS low
back pain study. J. Manipulative Physio Therapy
2002; 25(1): 10-20.
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 DOI Number: 10.5958/j.0973-5674.7.3.070
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 81

Efficacy of Electromyography Biofeedback Training on

Trunk Stability in Chronic Low Back Pain

Hashim Ahmed1, Amir Iqbal2, Md Abu Shaphe3

1
Head Department of Physiotherapy, Shreya Hospital,Shalimar Darden Extension, Ghaziabad,U.P., 2Head Department
of Physiotherapy, Taneja Hospital, Preet Vihar, Delhi, 3Associate Professor, Faculty of Applied Medical Sciences, Jazan
University, KSA

ABSTRACT
Objectives: The purpose of this study was to investigate the effect of trunk stabilization exercise
using a gym ball with or without electromyography biofeedback for people with chronic low back
pain.
Design: Pretest-posttest Experimental - control group design.
Method: 30 subjects were randomly assigned into two groups. Experimental group received trunk
stabilization exercise along with the electromyography biofeedback whereas control group received
trunk stabilization exercise without electromyography biofeedback. Endurance and Pain was
measured at 0 week, 2nd week, 4th week and 6th week.
Results: Trunk stabilization exercise along with Electromyography biofeedback significantly improves
the endurance and reduces pain.
Conclusion: from the result we may conclude that trunk stabilization exercise along with the
electromyography biofeedback is more effective than trunk stabilization exercise without
electromyography biofeedback in rehabilitation of patient with chronic low back pain.
Keywords: Trunk Stabilization Exercise, Electromyography Biofeedback, Endurance, Pain

suffering from low back pain are between the age of

INTRODUCTION
Low back pain(LBP) is one of the most common
musculoskeletal disorder(1) and is closely related to
functional disability of the trunk muscles, such as the
back extensor and abdominal muscles (2,3,4). The deep
abdominals, in particular the transversus abdominis
(TA) are primarily involved in the maintenance of intra
abdominal pressure, while imparting tension to the
lumbar vertebrae through the thoracolumbar fascia(6).
The trunk muscles are vital to the maintenance of
the spinal stability (5, 6). The spinal column is unable to
carry normal physiological loads without the support
of trunk muscles (7). Such functions of the trunk muscles
such as strength, endurance, and coordination provide
this stability.
20 and 55(11). Out of occupational factors like heavy
physical work, lifting, stooping, bending or static work
postures (e.g. prolong sitting, standing), pushing ,
pulling ,carrying etc have been found to be
significant(12,13).
There are various treatment techniques available
in treating low back pain, includes the correct body
mechanics and ergonomics training, postural
awareness training, strengthening exercise, trunk
stabilization exercise, stretching exercise. Activities of
daily living (ADL) training, therapeutic massage, joint
mobilization and manipulation, McKenzie, Williams
Flexion exercises, mechanical traction, EMG-
biofeedback, (TENS), superficial and deep thermal
modalities, and work hardening(15).

Epidemiologic studies have indicated that about
80% of population experience low back pain during
their active lives (8, 9, 10). Patient with low back pain have
weaker trunk muscles then the normal population.
It has been noted that the majority of patients
In 90% of patients LBP resolves within 6 weeks. In
other 5% of patients the pain resolves by 12 weeks after
initiation (14).
Trunk stabilization Exercise is those exercises that
activate the stabilizing muscles of trunk.

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 82 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
EMG biofeedback is to enable the patient to
reacquire voluntary control over striated musculature.
In clinical EMG biofeedback training a patient is made
aware of minute or over exaggerated muscle
contractions through visual and auditory feedback
from muscle.
In the last several years a numbers of authors have
reported the use of EMG biofeedback in the treatment
of LBP by relaxation training of frontalis or Para
vertebral muscles(16, 17).
There is number of experiment suggested that EMG
biofeedback significantly work as add on therapy in
various relaxation training to reduce the standing level
of Para vertebral muscle tension and exercise
programme to strengthen the back muscles.
So, far no previous study had been done on specific
topic, thus it inspired me to look deeper in to various
aspect of the utility of EMG biofeedback in increasing
lumbar muscles stability along individual with chronic
low back pain and thereby reduce their pain and
improve endurance.
The rational for employing biofeedback is to
provide visual feedback to the patient exercise
performance in the form of maximum voluntary
contraction of Para vertebral muscles during exercises.
I focus my study to evaluate the effectiveness of
EMG biofeedback as add on therapy, thereby to
standard stabilization training in increasing the
stability of trunk muscles in chronic low back pain.
METHOD
30 subjects were randomly assigned into two
groups. The criteria for inclusion were Gender –Male,
age 30- 40 years, Subject to low back pain as a primary
complaint, due to mechanical cause, Low Back Pain
of more than 3 months. Subjects were excluded if they
are diagnosed as having a tumor, infection, or
inflammatory disease affecting the spine,have spinal
or lower limb surgery,have spinal fractures or
structural deformities such as spondylolisthesis, have
contradictions to exercise therapy) e.g: uncontrolled
hypertension, previous myocardial infarction,
cerebrovascular disease, peripheral vascular disease,
respiratory disorder), have sign of nerve root
compression, defined as decreased tendon reflexes,
sensory loss and motor deficits, Severe
osteoporosis.,Lumbar canal stenosis, acute disc
herniation, and Lack of motivation.
17. hashim--81--86.pmd 82
STUDY DESIGN
A different subject pretest-posttest experimental
group design was selected for testing the hypothesis.
Data were collected pre intervention at 0 week, and
post intervention on 2nd, 4thand 6th week. The outcome
measure selected for this study was endurance and
pain.
PROCEDURE
The Subjects were screened first according to
inclusion and exclusion criteria. All the subjects who
met the inclusion criteria were included in the study.
Prior to participation all subjects were given consent
form. On the basis of the inclusion criteria mentioned
above the subjects were randomly assigned to group
A and group B, and their baseline measurement were
carried out for pain by VAS and endurance by pressure
biofeedback.
Group A: Experimental group (trunk stabilization
exercises with EMG Biofeedback)
Group B: Control group (trunk stabilization exercises
without EMG Biofeedback)
INTERVENTION
Interventions were conducted over 6 weeks, twice
a week, each session lasting 40 minutes. Sessions was
supervised by the investigator, and participants were
instructed to report any adverse event, whether it was
related to the exercises or not. Participants were
instructed not to participate in any other physical
program during the study.
Warm up exercise component
Aerobic work: exercise bicycle for 5 minutes at
moderate pace.
Stretching exercises
Back stretches
Leg stretches: Hip flexor, Hamstring, Calf,
Adductor Stretch.
Electrode placement: A disposable silver/silver
chloride electrode with a recording diameter of 1 cm
was used. The EMG signals was recorded from the
upper & lower rectus abdominals, The upper rectus
abdominis (3 cm lateral and 5 cm superior to to the
umbilicus), the lower rectus abdominis (3 cm lateral
and 5 cm inferior to the umbilicus), the upper back
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 83
extensors (2 cm lateral to the midline running through
the T9 spinal process), the lower back extensors (2 cm
lateral to the midline running through the L5 spinal
process).
For Group A: After the electrode placement all the
subjects were made to perform activities with the gym
ball in different positions. Before doing these activities
in any of the positions, they were instructed to draw
the abdomen inwards to activate the deep muscles.
The activities performed by subjects in stage 1 and 2
in various positions are as under:
1. Subjects lifted the gym ball up and held it between
their legs with both knees flexed in supine position.
2. Subjects lifted the pelvis up to the bridged position
and held it, while supporting themselves with both
legs on the gym ball and with the knees extended
in supine position.
3. Subjects placed both the hand on the gym ball and
their knees flexed on the floor, maintaining four-
point kneeling position.
4. Subjects control sitting posture on the gym ball.
5. Subjects did a curl-up on the gym ball in half sitting
position.
6. Subjects lifted the body up to the push up position
and held it, while supporting themselves with both
legs on the gym ball and hands on the floor in
prone position.
Stage 2 of the exercise program involved increasing
the complexity of the exercise by progressing and
exercises targeting coordination of trunk and limb
movement, maintenance of optimal trunk stability,
and improvement of posture and movement
patterns.
7. Subjects lifted the gym ball up and held it between
their legs with knee extended in supine position.
8. Subjects lifted the pelvis up to the bridged position
and held it, while supporting their head on the gym
ball and with their feet on the floor, with both knees
flexed in supine position.
9. Subjects in four -point kneeling position with one
arm and leg in extension.
17. hashim--81--86.pmd 83
10. Subjects control sitting posture on the gym ball
while rhythmically extending alternate legs.
11. Subjects did a curl-up on the gym ball in half sitting
position while one leg extended.
12. Subjects lifted the body up to the push up position
and held it, while supporting themselves with their
hand on the gym ball and their toes on the floor in
prone position.
The patient was instructed that during muscular
contraction a beep sound appear, so the contraction
was performed with its maximum volume as he can
perform.
For each exercise subjects perform 10 repetitions
(10 second holds and 5 second rest).
Patient was given 1 to 2 minute rest in between each
type of exercise.
Group B: The same exercise was performed
without EMG biofeedback.
DATA ANALYSIS
Statistical analysis was performed by using SPSS
16 version software. Repeated measure ANOVA
(multivariate test) was done to find differences within
group A and B for all variables i.e. VAS and END. Post
hoc Boneferrion was done to find pair wise differences.
Independent T test was done to compare difference
for all variables.
The alpha (probability) level has been taken as 0.05
RESULT
Endurance
Within Group analysis
Endurance was significantly improved at the end
of the second week in both the groups, (p=0.00) which
was maintained till end of treatment (p=0.00) in both
the groups
Between Group analysis
Endurance was significantly improved in Group A
as compared to Group B at end of 2nd week (p= 0.00),
4th week (p=0.00) and the end of 6th week (p= 0.00)
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 84 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table.1: Between groups comparison of endurance

Variables Group A Group B Mean difference t value p valve

END0-END2 6.29+2.30 3.39+1.13 2.89 4.53 0.00
END0-END4 11.39+2.60 5.80+1.39 5.58 7.46 0.00
END0-END6 15.19+2.69 7.54+1.23 7.69 9.87 0.00

PAIN

Within group analysis

VAS score was significantly decreased at the end

of the second week in both the groups, (p=0.00) which
was maintained till end of treatment (p=0.00) in both
the groups.

Between group analysis

Pain was significantly reduce in Group A as

Fig. 1.Comparison between pre-test and post-test value of
compared to Group B at end of 2nd week (p= 0.032), 4th
endurance between the groups(0 to 2, 0 to 4 and 0 to 6 weeks). week (p=0.042) and the end of 6th week (p= 0.025)

Table.2: Between groups comparison of pain

Variables Group A Group B Mean difference t value p valve

V0 – V2 1.29+0.69 0.80+0.56 0.52 2.19 0.028
V0 – V4 2.49+0.64 1.93+0.76 0.59 2.12 0.038
V0 – V6 4.42+0.78 3.73+0.70 0.65 2.27 0.027

stabilization exercise brought greater gains in all

outcome measures, including endurance and pain
intensity.

The analysis showed that the 6 weeks of

intervention period brought significant improvement
in both the groups. The experimental group shows
more improvement than control group which was
statistically significant.

Within Group, Improvement in endurance

Fig. 2. Comparison between pre-test and post-test value of pain
between the groups (0 to 2, 0 to 4 and 0 to 6 weeks).
DISCUSSION
The study was designed to determine the efficacy
of trunk stabilization exercise with or without EMG
biofeedback in patient with chronic low back pain. The
purpose of study was to assess the effectiveness of
EMG biofeedback as an adjunct to trunk stabilization
exercise in order to increase the endurance and
decreasing pain.
The result of study demonstrated that a
combination of EMG biofeedback and trunk
According to Kines and Hollusuzy et al (1994),
within group improvement in endurance is due to
effect of exercise which increases the capillary density
(6)
and oxidative capacity of muscle fibres (7) which
then enhance oxygen unloading resulting in increased
VO2 diffusion by 7%.
Mole, Holloszy et al revealed that muscle
mitochondria undergoes major adaptive changes in
response to exercise and they increased respiratory
control, hypermia, oxidative phosphorylation and
more ATP production,(7) so that the supply of energy
is for longer duration which could lead to
enhancement of endurance.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 85
Grieves et al (2000) showed that exercises leads to
increase in major glucose transporter (GLUT-4) and
lipoprotein lipase (LPL) in skeletal muscles, these
GLUT-4 and LPL act as source of energy fuel.(17,18) This
can leads to increase in blood flow and help in the
reduction of lactate level. This can leads to reduction
in muscle fatigue and hence improve endurance and
muscle work,
Between Group, improvement of endurance
The data showed that 6 weeks of training period
brought significant improvement in both the groups.
In between group analysis the improvement of
endurance in EMG-biofeedback group was greater
than those of control group at the end of training
period. Difference in endurance gains by EMG-
biofeedback group may be explained by the following
complimentary theories:
Basmajian has demonstrated that with the help of
auditory and visual cues, subjects could control the
recruitment as well as the frequency of discharge of
motor units.10 in terms of the present study, one might
hypothesize that the visual and auditory cues from
the biofeedback unit enabled Group A to consciously
and precisely control the exercise at submaximal
thereshold level. Therefore increase firing rate of small
motor units, or the frequency of discharge of the active
motor neurons. Therefore, one could hypothesize from
the work of Brasmajian that because more fibres were
firing and possibly faster rate, Group A produced
greater gains in endurance.
Neural factor have been described by Moritiani and
Devries, (19) as a facilitation or disinhibitation occuring
as a result of neurological reorganization. Although
not yet clearly understood, this may be hypothesized
that persistent recruitment of increased number of
motor units via biofeedback causes a reorganization
of facilitation pattern. This reorganization may be
responsible for either the increase firing rate of slow
motor neuron or the increase number of motor units
recruited, as demonstrated by the significant increased
in endurance.
Pain intensity
The data revealed that 6 th weeks intervention
brought significant reduction in pain in both the
groups. This significant improvement in both the
groups may be attributed to improvement in back
endurance and there by spinal instability which leads
to reduction in pain.
17. hashim--81--86.pmd 85
Barr K.P, Griggs et al stated that improvement in
endurance and lumbar stability reduced pain. (20)
Hartingan et al concluded that exercise reduce
anxiety and fear which help in reduction of back
pain.(20)
The experimental group shows more improvement
than control group which was statistically significant.
A possible explanation for this improvement may be
due to EMG biofeedback can make the patient feel
more in control of the experienced pain, since there
appears to be a way to influence and thus reduce pain
levels. Thus, biofeedback promotes active participation
and motivates the patient, which is arguably the most
critical element for pain management.
CONCLUSION
From the result we can concluded that the addition
of electromyographic biofeedback to trunk
stabilization exercise programme has shown greater
gains in endurance and reduction of pain intensity.
Future research is needed to look for long term follow-
ups.
REFERENCE
1. Liebenson C Rehabilitation of the spine Baltimore
Williams and Wilkins 1996 Churchill Livingstone
2. R A McKenzie, the lumbar spine: mechanical
diagnosis and therapy spinal publication New
Zealand 1983
3. Claus Manniche,et al. Clinical trial of intensive
muscle training for chronic low back pain. The
Lancet, 31 december 1988 volume 332, issue 8626.
Pages 1473-1476
4. D Gute, C. et al. Regional changes in capillary
supply in skeletal muscle of high- intensity
endurance trained rats. Journal of applied
physiology 1996: 81 (2) 619-626
5. Laughlin M H. cardiovascular response to
exercise. Advance in physical education 1999;
22:1:5244-5259
6. Bente Kiens, et al. Skeletal muscle substrate
utilization during submaximal exercises in man.
Journal of physiology 1993:469:459-478
7. Holloszy J O biochemical adaptation in muscle.
Effect of exercise on mitochondrial oxygen uptake
and respiratory enzymes activity in skeletal
muscle. Journal of biochemical chemistry 1967;
242:2278-2282
8. Panjabi MM. The stabilizing system of the spine,
part I: function, dysfunction, adaptation, and
enhancement. J Spinal Disord. 1992; 5: 383-389
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 86 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
9. Rozemberg S, low back pain: Deffinition and
treatment, Rev Prat,2008, 15; 58:265-72
10. Basmajian JV, ed. Biofeedback: Principles and
Practice for Clinicians. 2nd ed. Baltimore, MD:
Williams and Wilkins; 1983.
11. Nielson WR, Weir R. Biopsychosocial approaches
to the treatment of chronic pain. Clin J Pain. 2001;
17(4 suppl):S114-127.
12. Middaugh SJ, Kee WG. Advances in
electromyographic monitoring and biofeedback
in the treatment of chronic cervical and low back
pain. Adv Clin Rehabil. 1987; 1:137-172.
13. Neblett R, Gatchel RJ, Mayer TG. A clinical guide
to surface-EMG-assisted stretching as an adjunct
to chronic musculoskeletal pain rehabilitation.
Appl Psychophysiol Biofeedback. 2003; 28(2):147-610.
14. Arokoski JP, Valta T, Airaksinen O et al (2001)
Back and abdominal muscle function during
stabilization exercises. Arch Phys Med Rehabil
82:1089–1098
15. Silfies SP, Maurer P et al (2005) Trunk muscle
recruitment patterns in specific chronic low back
pain populations. Clin Biomech 20:465–473
17. hashim--81--86.pmd 86
16. Moffroid MT. Endurance of trunk muscles in
persons with chronic low back pain: assessment,
performance, and training. Journal of Rehab.
Research and Development 2006: vol.34, no.4, oct-
1997, page 440-52.
17. Greiwe J S, Holloszy JO et al Exercise induced
lipoprotein lipase and GLUT-4 protein in muscle,
independent of adrenergic receptor signalling.
Journal of applied physiology 2000; 89:1:176-181
18. Houmard J, Hickey M et al. Seven days of
exercise increase GLUT-4 protein content in
human skeletal muscle. Journal of applied
physiology 1995; 97:1936-1938
19. Moritani T, Davries H A neural factor in
hypertrophy in the time course of muscle strength
gain. Am. Jr. Of Physi. Med. 1979; 58:115-130
20. Barr KP, Griggs M et al. Lumbar stabilization. A
review of core concept and current literature. Part
2 American Journal of Phys Med Rehabil. 2007;
86:1:72-78
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 DOI Number: 10.5958/j.0973-5674.7.3.071
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 87

A Comparative Study between the effects of Static

Somatosensory Balance Training and Static Vestibular
Balance Training on Dynamic Balance and Fear of Fall in
Institutionalized Elderly

Jyoti Laroia1, Nusrat Hamdani2, Majumi Mohammad Noohu3

1
Master of Physiotherapy, Student, 2Assistant Professor, Jamia Hamdard, New Delhi, 3Assistant Professor, Jamia Milia
Islamia, New Delhi

ABSTRACT
Purpose: To determine carry over effects of static somatosensory balance training or static vestibular
balance training on dynamic balance and fear of fall in institutionalized elderly.
Subjects: Forty subjects aged 60 to 80 years.
Method: Subjects were selected according to inclusion and exclusion criteria and were divided into
two groups. Group 1 underwent static vestibular balance training and group 2 underwent static
somatosensory balance training. The subject's dynamic balance was measured with the help of
functional reach test (FRT) and Timed Up and Go test (TUG) and fear of fall was measured by Activities
Specific Balance Confidence Scale (ABC). Measurements were taken at baseline, immediately after
four weeks of intervention and after four weeks of follow up from intervention. Frequency of falling
was also determined by noting the number of falls that occurred during the follow up period.
Independent t-test was used to compare the difference between the group as well as one-way Anova
and Post hoc bonferroni were used to compare the outcomes within the two groups.
Results: The results documented that static balance training has carry over effects on dynamic balance;
this was justified by significant difference in the scores of functional reach test when between groups
comparison was done. Also there was significant improvement in fear of fall in elderly subjects, as
evidenced by statistically significant difference in the scores of activities specific balance confidence.
The p-value of ABC was 0.01 in group 1 and group 2 when between groups comparison was done.
Conclusion: Static balance training has carry over effect on dynamic balance this was documented
by statistically significant scores of FRT and ABC. The significant results between the two groups
hypothesize that static balance training could be an effective part of rehabilitation settings. Despite
the many age-related changes occurring in the multiple systems that contribute to good balance and
mobility, growing evidence suggests that we can reverse, or at least slow, the rate of decline occurring
in some or all of these systems.1
Keywords: Balance, Fear of Fall, Institutionalized elderly, Activities Specific Balance Confidence

INTRODUCTION popular country in the world has 76.6 million people

The number of persons above the age of 60 years is
fast growing, especially in India. The problems faced
by this segment of population are numerous owing to
the social and structural changes that are taking place
within the Indian society. Falls are one of the major
problems in the elderly and are considered one of the
“Geriatric Giants”.2 The highest fall incidence occurs
in the institutional long-term-care setting where 50%
to 75% of the 1.63 million nursing-home residents
experience a fall yearly.2 India as the second most
at or above the age of 60, constituting above 7.7 % of
total population. In a Multi – centric Community study,
evaluating Health Problems in the Elderly, in 10 states
across India covering a total population of 10200
elderly with, the incidence of falls was found to
be 14 %.2
Myers et al identified more than 130 different fall
risk factors. History of falls is associated with increased
risk. Carter et al., suggested that most of the falls risk
associated with advancing age can be attributed to

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 88 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
changes in three sensory systems: the vestibular, the
visual and the somatosensory.3 Fallers tend to be less
active and may inadvertently cause further atrophy
of muscle around an unstable joint through disuse.4
Exposure to risk is also one of the factors contributing
to falls. One trial found that brisk walking may increase
the risk of falls5 others found that increased physical
activity was associated with a decreased risk of falls,
but an increased risk of suffering a serious injury.6
Poor balance is a known risk factor for falls,
investigating methods to improve balance and prevent
falling among older people is a high priority issue.7
Balance function has been reported to decline with age,
as evidenced by increased postural sway and
decreased stability.8 The age – related changes in
subsystems involved in balance control contribute to
the poorer balance performance of older adults
compared with younger people.7 Improvement of
balance may be a desired functional outcome for many
patients, for this proper assessment plays an important
role.8 The high prevalence of dysmobility in older
individuals requires that geriatric assessment include
a reliable, easily administered measure of balance9.
A study done by Shimada H determined the
effectiveness of treadmill gait training in
institutionalized disabled elderly. The study seemed
to be beneficial in improving balance and reaction
time.1
Fear of falls has been recognized as a negative
consequence of falls.Tinetti and Powell defined fear
of falling as an ongoing concern about falling that
ultimately limits the performance of daily activities.10
Assessment of falls is considered equally important
as balance. Many fall risk screening tools have been
introduced into clinical practice in the United Kingdom
in recent years.11 Clinically, the Tinetti Gait and Balance
Assessment (TGBA) have been widely used to assess
the risk of falls in elderly by examining balance and
gait.12.Questionnaires such as the Activities Specific
Balance Scale provide self- report information
regarding functional status.
Prescribing the right treatment requires an
understanding of the processes which lead to falls, and
knowledge of the modifiable risk factors.13 The key
message revealed to us is that falls are not just due to
age, many falls can be prevented, and some simple
questions about presence of common falls risk factors
should be reviewed that indicate the need for a health
practitioner review.
18. Jyoti Laroia--87--92.pmd 88
The purpose of this study is to find out the carry
over effect of static balance training on dynamic
balance and to compare the two interventions of static
balance training that is vestibular and somatosensory
in institutionalized elderly aged 60 to 80 years of age
having a fall history within 6 months. That if training
one aspect of balance (static) has effect on other aspect
then why spending time in offering complex time
consuming dynamic training protocols in
institutionalized elderly. This time could be entailed
in other domains of balance problems or offering
services for limiting disability by throwing light on
other important risk factors. This research involves
determining fear of falls in institutionalized elderly as
well as reduction in the number of falls as the
secondary aim, as subjects who have a fall history have
a greater prevalence of fear of falling
METHOD
Subjects: 40 institutionalized elderly aged 60 to 80
years were taken.
Inclusion Criteria
1. Institutionalized elderly
2. Male /Female between 60-80 years of age.
3. Cognitively intact (MMSE>24)
4. Berg Balance Scale 35-40
5. Able to walk independently at least 10 meters.
6. At least 1 fall in the previous 6 months (not
resulting from a violent blow; loss of
consciousness, paralysis, or seizure).
7. Independent in ambulation.
Exclusion Criteria
1. Uncooperative patients.
2. Patients with any neurological deficit or cerebellar
dysfunction.
3. Patients with severe cardiac or pulmonary disease
terminal illness, dementia, medical unresponsive
depression.
4. The subjects with visual problems or severe
auditory problems.
5. Elderly who used assisted walking devices or who
were unable to walk independently at least 10
meters.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 89

Instruments both the groups 1 and 2. Then group 2 was subjected

Stop watch , Chair , Yard stick , Wobble Board
,Foam Roller and Marker
PROCEDURE
Institutionalized elderly subjects who were willing
and fulfilling inclusion criteria were taken for the
study. The subjects were selected by sample of
convenience and were randomly allocated into two
groups. Group 1 underwent static musculoskeletal and
static vestibular balance training and group 2 was
subjected to static musculoskeletal and static
somatosensory balance training. Their dynamic
balance measurements were obtained by (TUG) and
(FRT) as well as fear of fall scores were taken by
activities-specific balance confidence questionnaire
(ABC) before the commencement of the training. Their
frequency of falls was also noted. The Balance Training
Program consisted of 40 minutes of exercises per
session, 5 days a week for 4 weeks. Group 1 and group
2 were given static musculoskeletal exercises namely
one foot standing balance, one foot standing balance14
with hip flexion and side lateral raise for balance15,
these exercises targeted on ankle strategy. These
exercises were preceded by two foot standing balance
with forward bending and two foot standing balance
on foam roller. These exercises targeted on improving
ankle strategy. Then static strengthening exercises16 like
ankle plantar flexion, dorsiflexion, knee flexion, hip
flexion, hip extension and side leg raise were given to
to somatosensory exercises i.e. anterior-posterior tilts
on wobble board, medial lateral tilts, knee flexion,
tandem stance and standing on roller and hard surface.
Similarly group 1 was subjected to static vestibular
exercises17 namely looking straight ahead on the target,
turning head 45 degrees towards right and then
towards left, active eye-head movements between two
targets, and visualization of imaginary targets.
Dynamic balance measurements were taken by FRT
and TUG test and fear of fall was measured by
activities specific balance confidence scale immediately
after the four week intervention period and again after
four weeks of follow-up period. Frequency of falls was
reassessed by taking record of subjects through phone
8 weeks after baseline measurements.
DATA ANALYSIS
Independent t-test was used to compare the
differences between the two groups. One-way Anova
was used to compare the outcomes of each variable at
baseline, after intervention and after follow-up. A post
hoc comparison was made by post hoc bonferroni with
a significant level at p<0.05.
RESULTS
The demographic data shows insignificant
difference between group 1 and group 2 in terms of
age and weight. P-value has been taken as <0.05 which
is considered significant.

Table 1: Between group comparison of PI (TUG, FRT & ABC) i.e. post- intervention (After 4 weeks from baseline)
and FU (TUG, FRT & ABC) i.e. follow up intervention (After 8 weeks from baseline) in group 1 & group 2.

Variable Group 1 Group 2 t-value p-value

PI TUG(Mean + SD) 11.01+1.01 10.95+0.56 0.21 0.82
FU TUG(Mean + SD) 11.86+1.03 11.65+0.74 0.71 0.48
PI FRT(Mean + SD) 8.30+1.30 7.05+1.73 2.58 0.01
FU FRT(Mean + SD) 7.25+0.85 6.10+1.48 3.00 0.005
PI ABC(Mean + SD) 66.54+5.48 71.97+7.35 -2.64 0.01
FU ABC(Mean + SD) 61.71+3.77 66.69+7.81 -2.56 0.01

Table 2: Between group comparison of pre intervention and follow-up intervention of falls.

PRE FALLS (Mean + SD) 1.35+0.81 1.20+0.69 0.627 0.53

FU FALLS(Mean + SD) 0.100+0.30 0.100+0.30 0.00 1.0

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 90 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Graph 1: The graph compares the timed up and go scores between
the two groups before intervention (Pre), after intervention (PI
TUG) and after follow-up (FU TUG).
Graph 2: The graph compares FRT before intervention (Pre FRT),
after intervention (PI FRT) and after follow-up (FU FRT).
Graph 3: The above graph illustrates comparison of ABC before
intervention (Pre ABC), after four weeks of intervention (PI ABC)
and after four weeks of follow-up (FU ABC).
Graph 4: The graph shows comparison of falls between groups 1
and 2 prior to intervention (PRE FALLS) and after four weeks
follow-up (FU FALLS). The p-values were not significant.
18. Jyoti Laroia--87--92.pmd 90
DISCUSSION
The results of the study indicate that static balance
training forms an important and essential component
that needs to be highlighted in the rehabilitation
settings when designing protocols for balance training
mainly for the “specific age group’ i.e. older adults.
The primary objective of this study was to ascertain
the carry over effects of static balance training on
dynamic balance. It is useful to us because the foremost
worry for any health professional working with
unstable older adult is that the person falls whilst
exercising or taking part in any activity. Physical
activity generally involves the use of large movements
that displace the body’s center of gravity and therefore
taxes balance.18 In the present study participation in a
4 week static balance training exercise programme
(both vestibular and somatosensory) is effective and
had significant carry-over effect on dynamic balance
as indicated by the changes in the scores of functional
reach test between the two groups. Although we are
aware that balance training serves a very essential and
significant role in the rehabilitation of older adults and
subjecting older adults to either strength training or
flexibility interventions could not impart the benefit
equivalent to balance interventions. This view was
supported by Melzer et al., where the subjects who
participated in the balance training obtained 64%
improvement in 3 months in comparison to the group
subjected to muscular strength training.19
Consistent with the above findings, in the present
study static balance exercises formed the main frame
of intervention in older subjects who were the part of
the study. To document the effect of balance training
in elderly aged 60 to 80 years having a fall history, both
the groups 1 and 2 were subjected to a similar static
musculoskeletal training protocol. This was consistent
with the findings from other studies that hypothesize
that programs that emphasize balance training are
more effective at improving balance than other
interventions that emphasized on muscular strength
or flexibility exercises.20Taking in view the role of work
done earlier on standing balance training as evidenced
by earlier researches, 21 the present study utilized static
balance training as the only means to document its
effect on dynamic activities. Most of the studies that
were done earlier, highlighted on a generalized balance
training protocol.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 91
Improvement in motor performance constitutes an
important aspect of independent living and
autonomous quality of life. This study successfully
aimed to measure the change in dynamic aspect of
balance by subjecting the older subjects to static
balance protocol.
In the present study significant carry over effect
was seen in both the groups. The present study
highlighted on the fear of fall problem and the effect
static balance training had on it. The study revealed a
significant change in the scores of Activities specific
balance confidence scale and hypothesized the role of
static balance training on improved functional mobility
as well as better performance in ADLs. Also the effect
on fear of fall remained after the follow-period
suggesting the study not only has an immediate but
also a long-term effect being documented by the
improved ABC scores after follow-up when
comparison was done with baseline scores.
Falls constitutes the other most important focus of
attention in the present study. Earlier research had
hypothesized that altered balance is the greatest
collaborator towards falls in the elderly.14 The present
study hypothesized the effect of static exercises on fall
risk when within group comparison was done. This
study documented the role of static exercise and fall
reduction however the role of exercise in fall reduction
is consistent with previous researches.3,22
REFERENCES
1. Debra J Rose. Fall Proof! A comprehensive
balance and mobility training programme. 2nd
edition. Sherridon books; 2003.
2. Dr. B. Krishna swami, Dr. Gnanasambandam.
Falls in Oder People. Kerala Aging Survey.
Available from https://docs.google.com/viewer.
3. John Unsworth, Anthony Mode. Preventing falls
in older people: Risk factors and primary
prevention through physical activity. British
Journal of Community Nursing. 2003, 8 (5):
214-220.
4. Todd, Skelton D. What are the main risk factors
amongst older people and what are the most
effective interventions to prevent these falls?
World Health Organization; Europe. 2004 March;
6-10.
18. Jyoti Laroia--87--92.pmd 91
5. Shah Ebrahim, Paul W. Thompson. Randomized
placebo-controlled trial of brisk walking in the
prevention of postmenopausal osteoporosis. Age
and Ageing. 1997 Apr; 26: 253- 260.
6. Mary E. Tinetti, Carlos F. Mendes de Leon. Fear
of Falling and Fall-Related Efficacy in
Relationship to Functioning Among Community-
Living Elders. Journal of Gerontology. 1994 Apr;
49. (3): 140-147.
7. Sanna Sihvonen. Postural balance and aging.
Studies in Sports Physical Education and Health.
2004 September 29; 11-18.
8. Laura Wegener, Carolyn Kisner. Static and
Dynamic Balance Responses in Persons with
Bilateral Knee Osteoarthritis. Journal of
Orthopedic & Sports Physical Therapy. 1997
January; 25 ( 1 ) : 13-18.
9. Pamela W. Duncan, Debra K. Weiner. Functional
Reach: A New Clinical Measure of Balance.
Journal of Gerontology; Medical Sciences. 1990
Apr; 45 (6): 192-197.
10. Kristine Legters. Fear of Falling. Phys Ther. 2002
March; 82: 264-272.
11. Simon Gates, Lesley A. Smith. Systematic review
of accuracy of screening instruments for
predicting fall risk among independently living
older adults. Journal of Rehabilitation Research
& Development. 2008 45 (8): 1105-1116.
12. R. C. King, L. Atallah. Elderly Risk Assessment
of Falls. Research Gate. 2010 June: 30-35.
13. A. John Campbell, M. Clare Robertson.
Implementation of multifactorial interventions
for fall and fracture prevention. Age and Ageing
2006 March; 35-52: ii60-ii64.
14. Faezeh Zamanian. Effects of Balance Training
Program On falling Risk and Static Balance of
Elderly Women. International Journal of Sport
Studies. 2011. 1 (4): 180-185.
15. William D. Bandy, Barbara Sanders. Therapeutic
Exercise for Physical Therapist Assistants. 2nd ed.
Lippincott Williams & Wilkins; 2008.
16. Laurence Z. Rubenstein, Karen R. Josephson.
Effects of a Group Exercise Program on Strength,
Mobility, And Falls Among Fall – Prone Elderly
Men. Journal of Gerontology: Medical Sciences
2000 55 (6): 317-321.
17. Nathan, D. Zesler I. Katz, and Ross D Zafonte:
Brain injury medicine: principles and practice.
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 92 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Demos Medical Publishing. 3rd Ed. 1992; 6 (5):
411-418.
18. Dawn A. Skelton. Effects of physical activity on
postural stability. Age and Ageing. 2001; 30-S4:
33-39.
19. Melzer I, Benjuya N; Effect of physical training
on postural control of elderly. Harefuah 2005, 114:
839-844.
20. Rogers ME, Fernandez JE; Training to reduce
postural sway and increase functional reach in
the elderly. J Occup Rehabil 2001, 11:291-298.
18. Jyoti Laroia--87--92.pmd 92
21. Crystal O. Kean, David G. Behm; Fixed foot
balance training increases rectus femoris
activation during landing and jump height in
recreationally active women. Journal of Sports
Science and Medicine 2006 March; 5, 138-148.
22. Anne Barnett, Ben Smith; Community-based
group exercise improves balance and reduces falls
in at-risk older people: A randomized controlled
trial. Age and Ageing 2003; 32: 407-414.
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 DOI Number: 10.5958/j.0973-5674.7.3.072
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 93

Efficacy of Eccentric Training and Muscle Energy

Technique on Hamstring Flexibility in Sedentary College
Students

Gurpreet Kaur1, M Kashif Reza2

1
MPT Student, 2Lecturer, College of Applied Education and Health Sciences, A-122 Gangotri Colony,
Roorkee Road, Meerut, UP, India

ABSTRACT
Purpose of study: Muscular flexibility is an important aspect of normal human function . Limited
flexibility has been shown to affect a person's level of function. Purpose of the study is to investigate
the effectiveness of Eccentric Training and Muscle Energy Technique on hamstring flexibility in
sedentary college students and to compare the effect between the boys and girls.
Methodology: 40 healthy college students between the age groups of 18- 25 years were selected and
were randomly assigned to two study groups. Group 1 (n= 20) subjects were treated with Eccentric
Training where as Group 2 (n= 20) subjects were treated with Muscle Energy Technique. And each
Group comprising of equal ratio of boys and girls. Treatment was given for 14 consecutive days and
a follow up measurement was done one week after cessation of intervention. The outcome was
measured in terms of Active knee extension test and Sit and reach test. Each intervention was
performed for duration of 30 sec.
Results: There was a significant difference in range of motion in Active knee extension test between
both the groups with (p= 0.005) in right side and left side (p=0.10), whereas in Sit and reach test there
is no significant difference between both the groups with (p= 0.219) according to the paired and
unpaired t- test.
Conclusion: Results indicate that muscle energy technique is significantly improving hamstring
flexibility. But there is no statically significant difference in muscle flexibility between boys and girl.
Keywords: Active knee extension, Sit and reach, Static Stretch

INTRODUCTION Inadequate hamstring muscle length has

The ability of an individual to move smoothly
depends on his flexibility, an attribute that enhances
both safety and optimal physical activities. 1 Most
medical professionals, coaches and athletes consider
aerobic conditioning, strength training and flexibility
are integral components in any conditioning program.2
Limited flexibility has been shown to predispose a
person to several musculoskeletal overuse injuries and
significantly affect a person’s level function.3 Muscle
tightness is caused by a decrease in the ability of the
muscle to deform, resulting in a decrease in the range
of motion at the joint on which it acts.4
There are two ways to measure flexibility; by linear
or angular measurements to directly determine the
extreme limits of range of motion. Linear measurement
measures length quantitatively, and angular measures
angle such as with a goniometer is similar to protector.5
historically been thought of as a possible cause of
hamstring injury. 6 Hamstring strain injuries are
common in sporting arena, and frequently occur in
activities which involve running, sprinting, jumping
or kicking. Incidence rates of hamstring strain range
between 7.7% and 30% with relatively high recurrence
rates between 18% and 34%.3
Gajdosik and Lusin designed a test to measure
hamstring length by the angle of knee flexion after knee
extension [AKE] while the hip was stabilized at 90
degree flexion.6
Static stretching of hamstring muscle has been
shown to be efficient for gain in flexibility.7
Eccentric training that allows the muscle to elongate
naturally and in its relaxed state this elongation is
achieved by having the subject eccentrically contract
the antagonist muscle to move the joint through the

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 94 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

full available range in slow controlled manner to SAMPLE DESIGN

stretch the agonist muscle group.8 Eccentric strength
training resulted in improving the hamstring flexibility, Convenient sampling
producing a gain of 12.8 degree in range of motion.9 CRITERIA FOR SAMPLING
One such approach which targets the soft tissues INCLUSION CRITERIA
primarily although it makes a major contribution
towards joint mobilization has been termed as muscle • Age group- 18-25 years
energy technique and is also known as active muscular
relaxation technique.2 • Both Males and females

Muscle energy technique is a form of manual • Clinical Diagnosis of hamstring flexibility

therapy frequently used, herein the patient voluntarily
contracts specific muscles against the resistance of the
clinician.10
It is defined as resistive duction, which is defined
as a series of muscle contraction against resistance.
Muscle energy technique is used to lengthen a
shortened or spastic muscle, to strengthen a
physiologically weakened muscle.11
The theory behind muscle energy technique
suggest that the technique is used to correct an
asymmetry by targeting a contraction of the hamstring
and moving the innominate in a corrected direction.10
confirmed by history, physical examination.
• Tight hamstring of 30 degree knee extension deficit
• Subjects had no warm up before data collection
• Extremity had no history of impairment to knee,
thigh, hip.
EXCLUSION CRITERIA
• Subject unwilling to be a part of the study.
• Patient with weakness around articular joint.
• Acute or chronic low back pain.

• Acute or chronic hamstring injury.

AIMS AND OBJECTIVES
• Visible acute swelling in the region of hamstring
To compare the Efficacy of Eccentric Training and
muscle.
Muscle Energy Technique on hamstring flexibility in
sedentary college students. TOOLS FOR DATA COLLECTION
NULL HYPOTHESIS (H0): There will be no 1. Stop watch
significant difference between the Eccentric training
and Muscle energy technique on hamstring flexibility 2. Theraband
in sedentary college students.
3. Sit and reach box

4. Double arm Goniometer

ALTERNATE HYPOTHESIS (H1): There will be a
significant difference between the Eccentric training
and Muscle energy technique on hamstring flexibility
in sedentary college students.
MATERIAL AND METHOD
STUDY DESIGN
Experimental design comparative in nature.
SOURCE OF DATA
The subjects were recruited from the College of
Applied Education and Health Sciences.
5. Cross bar
6. Treatment table
PROCEDURE
The research work has been approved by the
research committee of the College of Applied
Education Health Sciences.
Subjects were selected from the College of Applied
Education and Health Sciences and were screened for
the inclusion and exclusion criteria. Subjects were
oriented about the procedure and intervention.
Informed consent was obtained from each subject.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 95

The subjects were randomly assigned into two Table 2- Table comparing the pre, post and retention
groups as Group 1 and Group 2. values of knee extension deficit of right side between
the Eccentric training and Muscle energy technique
Group 1: Eccentric training with static stretch only. group.
Group 2: Muscle energy technique with static The analysis by SPSS 15 software shows that there
stretch only. is no significance difference in sit and reaches values
Pre and post measurements were collected on the between Eccentric training and Muscle energy
0 day and on the 14th day, followed by measurement technique groups as shown in table 3.
after one week of cessasation of intervention.Following Sig.(2-tailed),
investigations were performed. p-value
STRPRE Equal variances assumed 0.797
1. Active knee extension test with double arm Equal variances not assumed 0.797
goniometer. STRPOST Equal variances assumed 0.554
Equal variances not assumed 0.554
2. Sit and reach box test with a measuring scale
STRRET Equal variances assumed 0.218
Findings: Equal variances not assumed 0.219

The data analysis was done by using software SPSS Table 3: Table comparing the pre, post and retention
15, using the paired t- test and unpaired t- test. values of sit and reach between the Eccentric training
The statistical analysis shows that there is a and Muscle energy technique group
significant improvement in knee extension deficit The statistical analysis shows that there is no
range of motion in left side retention with a p value significant difference in knee extension deficit values
(p= 0.005) between Eccentric training and Muscle of both left and right side and sit and reach values in
energy technique group as shown in table 1. both boys and girls between the Eccentric training and
Sig.(2-tailed), Muscle energy technique group.
p-value
Sig.(2-tailed),
KEDLTPRE Equal variances assumed 0.407
p-value
Equal variances not assumed 0.408
KEDLTPRE1 Equal variances assuwmed .855
KEDLTPOST Equal variances assumed 0.070
Equal variances not assumed .855
Equal variances not assumed 0.070
KEDLTPOST1 Equal variances assumed .540
KEDLTRET Equal variances assumed 0.005
Equal variances not assumed .540
Equal variances not assumed 0.005
KEDLTRET1 Equal variances assumed .768
Equal variances not assumed .768
Table 1. Table comparing the pre, post and retention
KEDRTPRE1 Equal variances assumed .847
values of knee extension deficit of left side between
Equal variances not assumed .847
the Eccentric training and Muscle energy technique
KEDRTPOST1 Equal variances assumed .776
group.
Equal variances not assumed .776
The statistical analysis shows that there is a KEDRTRET1 Equal variances assumed .302
significant improvement in knee extension deficit Equal variances not assumed .302
range of motion of right side in retention period with STRPRE1 Equal variances assumed .809
the p value (p= 0.010) between Eccentric training and Equal variances not assumed .810
Muscle energy technique group as seen in table 2. STRPOST1 Equal variances assumed .605
Sig.(2-tailed) Equal variances not assumed .606
p-value STRRET1 Equal variances assumed .396
KEDRTPRE Equal variances assumed 0.973 Equal variances not assumed .397
Equal variances not assumed 0.973 KDLTPRE2 Equal variances assumed .192
KEDRTPOST Equal variances assumed 0.415 Equal variances not assumed .192
Equal variances not assumed 0.415 KEDLTPOST2 Equal variances assumed .935
KEDRTRET Equal variances assumed 0.10 Equal variances not assumed .935
Equal variances not assumed 0.10

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 96 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Sig.(2-tailed), Hence the active knee extension test showed a

p-value statistically significant improvement after 2 weeks of
KEDLTRET2 Equal variances assumed .725 treatment between both the rehabilitation groups and
Equal variances not assumed .725 there is no significant difference in the sit and reach
KEDRTPRE2 Equal variances assumed .493 values between the groups. But there is a significant
Equal variances not assumed .494 difference in the values of sits and reaches in centimetre
KEDRTPOST2 Equal variances assumed .433 within the groups that is in the pre, post and retention
Equal variances not assumed .433 values.
KEDRTRET2 Equal variances assumed .619
Equal variances not assumed .620 The study is in agreement with Odunaiya N.A et al
STRPRE2 Equal variances assumed .831 investigated the static stretch duration on the flexibility
Equal variances not assumed .831 of hamstring muscle. The study showed a significant
STRPOST2 Equal variances assumed .089 reduction in the knee extension deficit (KED) after 6
Equal variances not assumed .090 weeks.1
STRRET2 Equal variances assumed .163
Mack D Rubley et al examined the flexibility
Equal variances not assumed .164
retention 3 weeks after a 5- day training regime. The
Table 3 : Table shows the comparision of knee study showed that gains in flexibility are retained for
extension deficit and sit and reach values between the at least 3 weeks after a stretching program. 12
boys and girls.
It is believed that this form fascilitates the golgi
tendon organ which produces an autogenic inhibition
CONCLUSION
of muscle that is being stretched.5
A total of 40 subjects completed the 2 weeks of
The study is in contrast with Depino GM, Webright
rehabilitation program with the retention of 1 week.
et al investigated the duration of maintained hamstring
According to the analysis there is a statistically flexibility after cessation of an acute static stretching
significant difference between the groups in post and protocol.13
retention values of knee extension deficit (KED) in left
Study is in agreement with Mohd. Wassem et al
and right side both, where as there is no statistically
did a study to compare the effect of static stretching
significant difference between the groups in sit and
and eccentric training on popliteal angle and revealed
reach test in post and retention values in sedentary
that these techniques are effective individually in
college students.
improving flexibility of hamstrings. As the skeletal
The p: value of active knee extension in group 1 muscle has a large adaptation potential induced by
receiving eccentric training of left side is (p<0.05) and eccentric contraction and morphological changes are
for the right side, p value is (p< 0.05) and for the group related to addition of sarcomeres in series. On repeated
2 receiving muscle energy technique of left side and contraction (eccentric) leads to disruption and
right side, p value is (p>0.005) in the post period where membrane damage, this lead to uncontrolled ca+
as in the pre and retention period p value is (p<0.05), movements and the development of localized
however the patients reported a significant increase contracture, this could be a reason in improvement of
in their flexibility subjectively. hamstring flexibility. 8

The p: value for sit and reach in group 1 receiving
the eccentric training is (p<0.05) and that for group 2
receiving muscle energy technique is (p> 0.05). Both
of which are non – statistically significant in subjects
with hamstring tightness.
According to the independent sample test there is
no statistically significant difference between the
effects of Eccentric training and Muscle energy
technique on both the boys and girls.
Study is in accordance with Madelaine Smith et al
investigated the comparison of two muscle energy
techniques for increasing flexibility of the hamstring
muscle group. 14 When a muscle contracts, the length
and tone is altered, which influences biomechanical,
biochemical and immunologic function, muscle
contraction requires energy and the metabolic process
results in carbon dioxide, lactic acid and other
metabolic waste products that must be transported and
metabolized.15

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 97
There is a statistically significant difference between
both the groups in improvement in active knee
extension range of motion in retention period in
hamstring flexibility. Whereas there is no statistically
significant difference between both the groups in sit
and reach test performed in college sedentary students.
Conflict of Interest: NIL
REFERENCES
1. Odunaiya N.A., Hamzat T.K., Ajayi O.F. The
effects of static stretch duration on the flexibility
of hamstring muscles.African journal of
biomedical research 2005; 8( 2): 79-82
2. Mohd. Waseem, Shibill Nuhmani, C.S. Ram.
Efficacy of muscle energy technique on hamstring
muscles flexibility in normal Indian collegiate
males. Calicut medical journal 2009; (7): e4
3. Nagarwal A.K., Zustshi K, Ram C.S., Zafar R.
Improvement of hamstring flexibility: A
comparision between two PNF stretching
techniques. 2010(04);1:025-033.
4. Influence of age on hamstring tightness in
apparently healthy Nigerians. Journal of Nigeria
society of physiotherapy,2005 October
5. The effect of static stretching on a of sample 18-
25 year – old students at Saint Martin’s University.
Saint Martin’s university biology journal, 2006
may; 1.
6. Andrew rolls, Keith George. The relationship
between hamstring muscle injuries and
hamstring muscle length in young elite
footballers. Physical therapy in sports 5 (2004) :
179 – 187
7. Daniela nice Ferreira, Janaina Luciano Labanca,
Michelle Figueiredo Silva, Aikelton Figueiredo
Silva, Marco dos Anjos Cristiane Guimaraes
Pessoa, Geraldo Fabiano Moraes, Natalia
Bittencourt. Analysis of the influence of static
stretching and eccentric training on flexibility of
hamstring muscles. XXV ISBS Symposium 2007.
8. Mohd. Waseem, Shibili Nuhmani, C.S. Ram,
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Faheem Ahmed. A comparative study : static
stretching versus eccentric training on popliteal
angle in normal health Indian collegiate males.
Internation journal of sports science and engineer
2009 ;03(03): 180-186.
9. Luiz Antonio Moreira Junior, Elder Lopes
Bhering Henrique C. Peixoto, Juliana Castro
Bergamini, Hans- Joachim Menzel, Antonio
Eustaquio Pertence, Mauro Heleno Chagas.
Range of motion and strength tolerance after
eccentric strength training. XXV ISBS Symposium
2007.
10. Noelle M. Selkow, Terry L. Grindstaff, Kevin M.
Cross, Kelli Pugh,Jay Hertel, Susan Saliba. Short
– term effect of muscle energy technique on pain
in individuals with non – specific lumbopelvic
pain : a pilot study. J Man Manip Ther. 2009; 17(1):
E14-E18.
11. Grubb ER, Hagedom EM,Inous N, Leake MJ,
Lounsberry NL, Love SD,Matus JR, Morris LM,
Stafford KM, Staton GS,Waters CM. Muscle
energy. University of Kentucky, 2010
12. Mack D Rubley, Jody B Brucker, Kenneth L
Knight,Mark D Richard and David O Draper.
Flexibility retention 3 weeks after a 5 – day
training regime. journal sports rehabilitation,
2001 ; 10: 105- 112.
13. Glen M. Depino, William G. Webright and Brent
L. Arnold. Duration of maintained hamstring
flexibility after cessation of an acute static
stretching protocol. Journal of athletic training,
2000; 35(1):56-59.
14. Madeleine smith, B. Clin. Sc.(osteo) a, Gary
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 DOI Number: 10.5958/j.0973-5674.7.3.073
98 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Efficacy of Taping in Bell's Palsy

Kaushal M1, Saini S S2, Singh N3, Ghotra P K4

1
Physiotherapist, 2Assoc. Prof., 3Prof. Medicine, 4Asstt. Prof.,COP,CMCH, Ludhiana

ABSTRACT
Objectives: To study &compare the efficacy of taping protocol/Technique over Conventional
treatment technique protocol in Bells Palsy.
Materials and Method: The study was conducted on 30 subjects. Subjects were divided into two
groups. One group was given Electrical stimulation and exercises and other group was given electrical
stimulation , facial exercises and taping.
Results- There exists significant difference between post-treatment scores of both the groups. The
study concluded that the treatment of Es+facial exercise+tapping is effective in curing bell's palsy
Conclusion: Group B protocol is more effective for functional retraining than conventional treatment
in subjects with Bells Palsy.
Keywords: Bell's Palsy, Taping, Electrical Stimulation, Facial exercises

INTRODUCTION 1. Rapid recovery group

Bell’s palsy, also known as acute idiopathic facial
paresis, is an idiopathic neuropathy of the facial nerve
(cranial nerve VII). It is a rapid onset facial paralysis
that is not life-threatening. While acute immune
demyelination triggered by a viral infection may be
responsible for Bell’s palsy, its exact cause is still
unclear. Bell’s palsy is usually self-limiting with the
majority of patients recovering spontaneously without
treatment within 6 months of onset of the disorder.
However, a recent study by Kanazawa et al (2007)
reported that recovery from Bell’s palsy in diabetics is
delayed, and the facial movement score remains low
in comparison with non-diabetics.1Facial paralysis has
been primarily considered a cosmetic inconvenience
with associated functional problems such as speech,
eating, facial asymmetry, drooling, and an inability to
close the eye on the paralyzed side .The patient with
facial paralysis cannot convey the normal social signals
of interpersonal communication. Incidence of Bell’s
Palsy is about 23/100000/annum.
Facial nerve is responsible for voluntary facial
movements,& can be tested by asking a patient to
perform movements such as wrinkling the brow,
showing teeth, frowning, closing the eyes tightly,
pursing the lips and puffing out the cheeks & noticing
asymmetry. The recovery phases of Bell’s palsy tends
to follow one of two pathways2
2. Delayed / partial recovery
The treatment options available for Bell’s palsy
includes (Medical & Surgical Management)
• Eye drops & Eye lubricants or viscous ointments,
• Therapeutic injections of botulism toxin & vitamin
B12 supplements,
• Anti-inflammatory & Antiviral medication,
• Alternative treatment,
• Facial massage and exercises,
• Acupuncture,
• Chiropractic manipulation,
• Surgery.
The diagnosis of Bell’s palsy is primarily one of
exclusion, however certain features in the history and
physical examination can aid in distinguishing it from
facial paralysis as a consequence of other conditions.
These clinical features include abrupt onset with
complete, unilateral facial weakness at 24 to 72 hours,
and, on the affected side, numbness or pain around
the ear, a reduction in taste, and hypersensitivity to
sounds.3

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 99
The objectives of facial retraining therapy are: (i)
to normalize movement of facial muscles, (ii) to
increase symmetrical movement patterns of the face,
(iii) to increase volitional movements of the face, (iv)
to inhibit undesired movements and synkinesis, and
(v) to normalize muscular tone.
Most cases of Bell’s palsy resolve uneventfully in
children, some do not. It is possible that rehabilitation,
including retraining the brain through facial exercises
or even surgical correction for weakened facial muscles
can be necessary in extreme cases. In the early stage of
Bell’s palsy, when facial muscles are the most flaccid,
it is desirable to allow the muscles to simply rest and
recover on their own. Gentle massage and moist
warmth may provide pain relief and improve
circulation, but stronger interventions should wait.
Usually facial exercises will not be necessary for
children with Bell’s palsy unless the paralysis does not
resolve itself and there is long-term damage to nerves.
However facial exercises such as wrinkling the
forehead, flaring and sniffling the nostrils, curling and
puckering the lips, and several others may be used to
retrain the brain’s messages to facial muscles. Even
younger children can often be taught to do these
exercises, and they can be presented by parents or
therapists as playing a game—making faces in the
mirror. Sessions of facial exercise should be brief and
performed two to three times a day. A surgical
procedure involving decompression of the facial nerve
through extremely delicate microsurgery has, in severe
cases, also been done. But its effectiveness in Bell’s
palsy remains at issue among child health-care
providers. Benefits of this surgery are considered by
some child health specialists to be insufficient
compared to the risks involved.
Nutritional concerns
Because compromise of the immune system is so
often a facet of children contracting Bell’s palsy, good
nutrition is necessary to rebuild and strengthen that
immune system. This involves following the American
Dietetic Association (ADA) nutritional guidelines for
children, and possibly the addition of a multivitamin
if the pediatrician feels it is advisable. Semi-solid foods
such as yogurt, jello, pudding, or ice cream may be
easier to take in than liquids if the child is experiencing
swallowing difficulty.
ADA nutritional guidelines for children include
• Grain group: Six servings per day. Includes, per
serving, one slice of bread, one-half cup cooked
20. Mayank Kaushal--98--103.pmd 99
rice or pasta, one-half cup cooked cereal or 1 oz
(28 g) of ready-to-eat cereal.
• Vegetable group: Three servings per day. Includes,
per serving, one-half cup of chopped raw or
cooked vegetables, one cup of raw, leafy
vegetables.
• Fruit group: Two servings per day. Includes, per
serving, one piece of fruit or melon wedge, three-
quarters cup of fruit juice, one-half cup of canned
fruit, onequarter cup of dried fruit.
• Milk group: Two servings per day. Includes, per
serving, one cup of milk or yogurt, or 2 oz (57 g) of
cheese.
• Meat group: Two servings per day. Includes, per
serving, 2–3 oz (57–85 g) of cooked lean meat,
poultry or fish, one-half cup of cooked dry beans,
one egg, or two tablespoons of peanut butter.
• Fats and sweets group: Should be limited as much
as possible.
Prognosis
The potential outcome from Bell’s palsy is quite
hopeful. NINDS notes that the majority of all Bell’s
palsy sufferers improve dramatically, with or without
treatment, within two weeks. The Bell’s Palsy
Information Site notes that half of all people
contracting this condition recover completely within
“a short time,” and another 35 percent have “good
recoveries within a year.” The outlook for children is
better. Eighty-five percent of children with this disease
recover completely. Ten percent of the children who
contract Bell’s palsy will have mild weakness
remaining afterward, and 5 percent will have severe
residual facial weakness. Statistically, 7 percent of all
children that develop Bell’s palsy will have a recurrent
episode in the future.4
AIMS AND OBJECTIVES
To study& compare the efficacy of taping protocol/
Technique over Conventional treatment protocol.
HYPOTHESIS
Null Hypothesis (Ho)
Both taping protocol/Technique and Conventional
treatment protocol are equally effective in subjects with
Bell’s palsy .
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 100 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Alternate Hypothesis (Ha)
(1) Taping protocol/Technique is more effective than
Conventional treatment protocol in subjects with
Bell’s palsy
(2) Conventional treatment protocol is more effective
than Taping protocol/Technique in subjects with
Bell’s palsy.
Review of Literature
Vijay Batra and Meenakshi Batra 2007 study
conducted on 30 subjects with diagnosis of bells palsy
showed VM functional dynamic taping protocol is
more effective functional retraining then conventional
treatment in subjects with bells palsy.
Ross, et al (1991), compared two treatment groups
with a third control group received no treatment. After
comprehensive evaluation, one group was trained with
EMG and mirror feedback, while the second group
used mirror feedback alone. Patients were re evaluated
after one year of treatment .A significant difference was
found between the treatment groups and the control
group.7
Cederwall E, Olsen MF, Hanner P, Fogdestam
(2006) I did a study on evaluation of physiotherapeutic
treatment intervention in Bell’s facial palsy.In
conclusion, patients with remaining symptoms of Bell,s
palsy appear to exterience positive effects from a
specific training program.5
Dalla Toffola, BossiD,BuonocoreM,Montomli C,
Petrucci L, Alfonsi E(4) did a study on Usefulness of
BFB/EMG infacial palsy rehabilitation. The objective
of study was toanalyze and to compare the recovery
and the development of synkinesis in patients with
idiopathic facial palsy (Bell’spalsy) following treatment
with two methods ofrehabilitation, kinesitherapy (KT)
and biofeedback/EMG (BFB/EMG). It was concluded
that BFB/EMG seems to bemore useful than KT in
Bell’s palsytreatment.6
METHODOLOGY
Design: Randomised Controlled trial
SUBJECTS
Subjects taken were 30 with age group 18-45 years
with a diagnosis of bell’s palsy of non-traumatic onset.
Subject pool was taken from CMC & Hospital
&consent form signed by them. Subjects were divided
20. Mayank Kaushal--98--103.pmd 100
into two groups Group A: Electrical Stimulation and
Facial Exercises Group B: Conventional (Group A
Protocol) and Taping. Subjects were taken from
Christian Medical College and Hospital, Ludhiana and
consent form was signed by them.
Inclusion criteria: Subjects with age group 15-45
years, Acute onset (1-3 week), Diagnosed case of Bells
palsy, Non-traumatic onset, No other neurological
deficit.
Exclusion Criteria: Psychiatric illness, UMN lesion,
Neurotmesis, Skin infection & open wounds
Hypersensitive skin, Skin Allergy to micropore.
PHYSIOTHERAPY TREATMENT
A. ELECTICAL STIMULATION
Facial muscles and nerve trunks are stimulated at
their motor points.
B. FACIAL STRAPPING
It is a procedure to correct the deviation of the angle
of the mouth by correcting the hyper action of
antagonistic commonly used technique.
PROCEDURE
Two strips of adhesive tape are cut and one is
sticked near to chin below the lower lip and is pulled
unto lower part of ear whereas the other strip is taken
part of the ear.
MATERIAL USED
• SURGICAL TAPE
• MICROPORE TAPE
• ELASTOPLAST
C. FACIAL MASSAGE
The patients often derive great comfort from
massage. The following manipulation can be
given:
1. STROKING
It should be given from the chin upward to the
temple from middle of the forehead downward
toward the ear.
2. FINGER KNEADING
Small circular all over the affected side of the face
,care being taken not to stretch the muscles.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 101

3. TAPOTEMENT Although Both taping protocol/ technique &

Conventional treatment protocol were effective for
May be administrated in the from of tapping with functional retraining but subjects in Group B showed
the finger tips quickly & lightly. better recovery than Group A.
D. FACIAL EXERCISES TEST 1: Ex+Facial Exercises
1. Drink all liquids through a straw. You’ll be Ho: There exists no significant difference between
dribbling all over yourself for a few days. But it pre-treatment and post treatment scores of group I
does help the muscles around the mouth.
H1: There exists no significant difference between
2. Sniff strongly. Wrinkle nose. Flare nostrils. pre-treatment and post treatment scores of group I
3. Curl upper lip up and raise and protrude upper Applying t-test we get
lip. Try to touch nose.
Pre Post
4. Using your index finger and thumb pull the Mean 117.8667 143.2
corners of your lips in toward the center. Variance 155.2667 184.7429
Observations 15 15
5. Chew gum. Pearson Correlation 0.333768

6. Chew and suck on ice. Hypothesized Mean Difference 0

Df 14
For the eye t Stat 6.512843
P(T<=t) one-tail 6.86E-06
1. Placing 4 finger tips on the eyebrow rub using a
t Critical one-tail 1.761309
firm slow stroke up to the hairline. Return
P(T<=t) two-tail 1.37E-05
downward to the eyebrow.
t Critical two-tail 2.144789
2. Using finger tips placed on the cheek tap lightly The test reveals that the calculated value is higher
and slowly along the bone under the eye to the
than the table value. Hence, the Ho is rejected. Thus,
face. there exists significant difference between pre-
3. Try to close the eye slowly. treatment and post-treatment scores of group I. The
treatment of Es+facial exercise is effective in curing.
RESULTS TEST 2: Ex+Facial Exercises+Tapping
Student t test was used to compare quantitative Ho: There exists no significant difference between
characteristic & baseline outcome variables. Statistical pre-treatment and post treatment scores of group II
analysis was done & P value (< .05) was found to be
significant for group B H1: There exists no significant difference between
pre-treatment and post treatment scores of group II

Applying t-test we get

Variable 1 Variable 2
Mean 142.2 172.0667
Variance 309.3524 370.8857
Observations 15 15
Pearson Correlation 0.879939
Hypothesized Mean Difference 0
Df 14
t Stat 12.61168
P(T<=t) one-tail 2.46E-09
t Critical one-tail 1.761309
P(T<=t) two-tail 4.93E-09
t Critical two-tail 2.144789

20. Mayank Kaushal--98--103.pmd 101 8/1/2013, 8:31 AM

 102 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

The test reveals that the calculated value is higher 69 78

than the table value. Hence, the Ho is rejected. Thus, 72 78
there exists significant difference between pre- 72 74
treatment and post-treatment scores of group II. The 90 100
treatment of Es+facial exercise+tapping is effective 95 88
in curing Bell,s Palsy
85 98
Comparative Results of Group I and Group II
DISCUSSION
The objective of the study was to examine whether
Es+facial exercise + tapping is more effective in On the basis of analysis of result the alternating
curing the Bell’s Palsy. For this purpose, the hypothesis stating that Group B taping protocol is more
hypothesis was framed and then post treatment effective than conventional treatment protocol subjects
results of group I and that of group II were compared with bell’s palsy. Although both Group B taping
and t-values were calculated. protocol & conventional treatment protocol were
Ho: There exists no significant difference between effective for retraining but subjects in group b showed
post-treatment scores of both the groups better recovery than Group A in term of facial
symmetry & ability to perform functional activities
H1: There exists significant difference between post- such as chewing, balloon blowing & speech. But taping
treatment scores of both the groups protocol being more effective , sequential & systematic
show better results. Also the intricacy of the movement
Applying t-test we get
that can be achieved by the facial muscles should
Group I Group II preclude the use of maximum effort, gross exercises
Mean 143.2 172.0667 where motor units other than those targeted are
Variance 184.7429 309.3524 recruited due to overflow. Basically taping help to
Observations 15 15 retrain paralyzed facial muscle maintaining symmetry
Hypothesized Mean Difference 0 & facilitating the paralyzed muscle thereby preventing
Df 28 over activity of normal muscle and act as a normal
t Stat 5.02964 mechanism by promoting the desired symmetrical
P(T<=t) one-tail 1.55E-05 movement pattern that need to be repetitively
t Critical one-tail 1.705616 reinforced before it will be learned.
P(T<=t) two-tail 3.11E-05
Conflict of Interest: No conflict of study is reported
t Critical two-tail 2.055531
for this study.
The test reveals that the calculated value is higher
than the table value. Hence, the Ho is rejected. Thus, Source of Funding: No source of funding is reported
there exists significant difference between significant for this study
difference between post-treatment scores of both the
groups. Ethical Clearance: Approved had been taken.

From the above analysis, it can be concluded that REFERENCES

the treatment of Es+facial exercise+tapping is effective
in curing bell’s palsy
Comparison results of Group 1 and Group 2
1. Kanazawa A, Haginomori S, Takamaki A, et al.
Prognosis for Bell’s palsy: A comparison of
diabetic and nondiabetic patients. Acta
Otolaryngol. 2007;127(8):888-891
2. Batra V and Batra M, (2007) To Study and
compare the efficacy of taping protocol /
technique over conventional treatment protocol
in Bell’s Palsy .2007;39(2):35-40
3. Ahmed A. When is facial paralysis Bell palsy?
Current diagnosis and treatment. Cleve Clin J
Med. 2005;72(5):398-401, 405.
4. Schonbeck, joan 2006,Gale Encyclopedia of
children health: Infancy through adolescence.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 103
5. Cederwall E, Olsen MF, Hanner P, Fogdestam I
Department of Physiotherapy, Skene lasarett,
Skene, Sweden (2006); Evaluationof a
physiotherapeutic treatment intervention in
“Bell’s” facial palsy.Physiotherapy Theory Pract.
Jan 22(1): 43-52.
6. Dalla Toffola, Bossi D, BuonocoreM, Montomli
C, Petrucci L, AlfonsiE (2005); Usefulness of BFB/
20. Mayank Kaushal--98--103.pmd 103
EMG in facial palsy rehabilitation, Disabil
Rehabil. Jul 22; 27(14): 809-15.
7. Ross B, Nedzelski JM, McLean JA (1991): Efficacy
of feedback training in long- standing facial nerve
paresis. Laryngoscope 101:744-750.
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 DOI Number: 10.5958/j.0973-5674.7.3.074
104 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of Aerobic Exercises on Plasma Lipid Profile and

Cardiorespiratory Fitness in Obese Women

Aisha A Hagag
Lecturer at Department of Physical Therapy for Cardiovascular/Respiratory Disorders and Geriatrics, Faculty of Physical
Therapy, Cairo University, Egypt

ABSTRACT
Purpose: The present study was designed to evaluate the effects of aerobic training on metabolic
parameters like cholesterol, high density lipoprotein (HDL)and triglycerides and cardiorespiratory
fitness parameters including maximum oxygen consumption, minute ventilation, systolic and diastolic
blood pressures in obese women.
Method: This study was performed as an experimental study, in which subjects were randomly
selected. There were sixty obese women, aged between 35-45yrs with body mass index (BMI) of
above 30. Subjects were grouped into control (n=30) and aerobic training (n=30). Aerobic training
was given for four days a week at 60-70% of maximum HR for 12weeks. blood lipids and
cardiorespiratory fitness parameters were measured before and after study period in both groups.
Results: The findings of the study indicate statistically significant differences in lipid profile including
total cholesterol, very low-density lipoprotein(VLDL), serum triglycerides(TG), and high density
lipoproteins(HDL) levels in aerobic training group . body mass index (BMI) and cardio respiratory
fitness parameters showed significant improvements in aerobic group.
Conclusion: Aerobic training is an effective method in improving lipid profile and cardiovascular
fitness in obese women and can be used as a preventive measure in patients who are at risk of
developing cardiovascular diseases due to obesity.
Keywords: Obesity, Cardiorespiratory Fitness, Lipid Profile, Aerobic Exercises

INTRODUCTION Being obese refers to an excess accumulation of

body fat, which is defined by a Body Mass Index of 30
Obesity refers to excess of body fat. It is due to
and above. Body mass index (BMI) is the method used
greater energy intake compared with energy
to assess the body fat content which is defined as a
expenditure. It has also been reported that with
person’s weight in kilograms divided by the square of
massive obesity there is an increased prevalence of
height in meters(1)
cardiovascular disease, hypertension, diabetes
mellitus, pulmonary disorder and Gall stones(1). Weight reduction in obesity brought about by
physical training has been associated with numerous
The metabolic defects that ensue in obesity include
metabolic adaptations including preservation of lean
increased levels of free fatty acids resulting from
body mass (LBM), improved muscle endurance,
insulin resistance, increased LDL-cholesterol, VLDL
increased insulin sensitivity, improved high-density
and triglycerides and decrease in HDL-cholesterol(2)
lipoprotein cholesterol, low-density lipoprotein
According to WHO estimation in 2005, 400 million cholesterol ratio and improved ability of the muscle
adults (9.8%) are obese, with higher rates of obesity cell to take up glucose and metabolize fat(4).
among women than men. Increased weight gain,
Moderate to high intensity aerobic training results
which is associated with increased lean and fat mass,
in an improvement in the blood lipid profile(5). The
along with the associated increase in total blood
most recent studies in patients with established heart
volume may be accompanied by an increase in stroke
disease suggest that a relatively high intensive, yet
volume, cardiac output and circulatory preload and
aerobic exercise training improves the intrinsic pump
afterload that can lead to left ventricular hypertrophy
capacity of the myocardium.
and sustained rise in blood pressure(3)

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 105
Aerobic training is characterized by the execution
of cyclic exercises that carried out with large muscle
groups contracting at mild to moderate intensities for
a long period of time.(6)
AIM OF THE STUDY
The main objective of the present study was to
assess the efficacy of aerobic training in improving
cardiovascular parameters as maximum oxygen
consumption (VO2max) , anthropometric parameters
as BMI and percent body fat percentage and blood
lipid profile as high density lipoprotein (HDL),
cholesterol and triglycerides in obese women. The
hypothesis of the study was that aerobic exercise may
prove to be beneficial method in improving plasma
lipid profile and cardiovascular fitness of obese
women.
METHODOLOGY
Subjects
Sixty obese female with mild obesity were recruited
from out patient’s clinic of Elkasr Elini teaching
hospital, their ages ranged from 35-45 years old. They
were randomly divided into exercise (n=30) and
control (n=30) groups. The study had local research
and ethics committee approval and all subjects gave
written consent .
Inclusion and exclusion criteria
Only healthy subjects without any history of
pathologic or orthopedic limitation were included in
the study. No subject was currently engaged in any of
the other exercise programs. Subjects with a body mass
index of above 30 were chosen and instructed not to
take fried products and foods with high sugar content.
All patients underwent anthropometrical
measurements, and cardio respiratory fitness testing.
The measurements for weight, height and other
anthropometrical indexes were taken pre and post-
study. Body weight and height were measured with a
standard physician’s scale and a stadiometer,
respectively when subjects were in a fasting state when
the participant had thin clothes on and was wearing
no shoes. Body mass index (BMI) was calculated using
weight divided by squared height.
21. Aisha Egypt --104--108.pmd 105
Estimation of Lipid Profiles
Fasting blood samples were collected from both
exercise and control groups for a series of laboratory
investigations using standard protocols for estimation
of lipid profiles. The lipid profile was done using
standard kit method in the semi auto analyzer.
Blood samples for lipid analysis (10 ml) were drawn
only at baseline (fasting). After the sample was drawn,
it was centrifuged at 3000 rpm for 5 min. Subsequently,
the serum was drawn off and placed in a small tube
and then was kept at 4 degrees Celsius. Serum
cholesterol and triglyceride concentrations were
measured with an automated analyzer using standard
enzymatic techniques. HDL was measured after
removal of very low density lipoprotein (VLDL) and
low density lipids (LDL) from samples.
Lipid profile testing was done before starting the
training program and then after the three months of
training.
Cardiopulmonary exercise test procedure
Before conducting the exercise tolerance test, all
subjects had to visit the laboratory to be familiarized
with the equipment in order to be cooperative during
conducting the test. Each subject underwent
continuous progressive exercise tolerance test
according to Bruce standard protocol which consists
of warming up phase and five active phases and
recovery phase in order to determine the maximum
oxygen consumption (VO2max).
Systolic blood pressure (SBP), diastolic blood
pressure (DBP), heart rate (HR), minute ventilation
(VE) and Maximum oxygen consumption (VO2max)
obtained for both groups before and after the exercise
program.
The aerobic exercise training program
The aerobic treadmill-based training program was
started with a 5-minute warm-up phase performed on
the treadmill at a low load, Active phase of the training
session was gradually increased from 20 to 40 minutes
in the form of walking/running on electronic treadmill
with zero inclination four times per week for twelve
weeks, its intensity gradually from 60% to 70% of the
maximum heart rate (HRmax) achieved in a reference
exercise testing performed according to a modified
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Bruce protocol. This rate was defined as the training Table 3. Mean, standard deviation and significance of
heart rate (THR) and ended with 5-minute recovery cardiorespiratory fitness parameters.
and relaxation phase. All patients performed four Variable Exercise group Control group #p
weekly sessions over a 3-month period.(7) VO2max(ml/kg/min)
Pre 21.8±0.16 20.9±0.13 Ns
Statistical analysis
Post 26.7±0.14** 20.8±0.11 P <0.05
The mean values of data ob-tained for both groups VE(ml/min)
before and after the study period were compared using Pre 51±9.1 52±9.1 Ns
paired “t” test. Independent “t” test was used for the Post 60±11.5** 51±8.7 P <0.05
comparison between the two groups (p<0.05). HR(beat/min)
Pre 82.14±2.78 83.22±3.4 Ns
RESULTS Post 73.25±3.76** 85.43±5.6 P <0.05
SBP(mmHg)
Table 1. Mean, standard deviation and significance of
Pre 136.11±5.97 137.33±4.5 Ns
anthropometric measurements.
Post 124.32±6.3** 138.11±2.2 P <0.05
Variable Exercise group Control group #p DBP (mmHg)
Weight(kg) Pre 87.4±4.4 88.3±4.5 Ns
pre 76.30±5.87 77.00±5.53 Ns Post 88.9±3.7** 89.5±6.2 P <0.05
post 72.40±6.22** 78.76±4.49 P< 0.05
**p 0.05 within group between pre- and post-training (paired t
BMI(kg/m2) -test); #p value between exercise and control group.
Pre 31.93±1.46 31.82±1.503 Ns
VO2max:maximum oxygen consumption, VE: minute ventilation,
Post 30.32±1.53** 32.11±1.378 P <0.05
HR: heart rate, SBP: systolic blood pressure, DBP: diastolic blood
**p 0.05 within group between pre- and post-training (paired t pressure.
-test); #p value between exercise and control group.
DISCUSSION
BMI: Body Mass Index\

Table 2. Mean, standard deviation and significance of Obesity is a serious public health problem in both
plasma lipid profile. developed and developing countries. According to
world health organization, Overweight and obesity,
Variable Exercise group Control group #p
had taken the fifth rank of leading risk factors cause
Chol(mg/dl)
of death in 2004(8)
Pre 241.70±21.1 243.70±11 Ns
Post 229.00±17.4** 244.30±13 P <0.05 Obesity is considered to be one of the primary risk
TG(mg/dl) factors in chronic diseases including cardiovascular
Pre 140.00±7.07 143.90±6.226 Ns diseases, hypertension, and non-insulin dependent
Post 134.30±3.80** 145.0±7.659 P <0.05 diabetes mellitus(9). It is known that physical exercise
HDL(mg/dl) is of benefit to the treatment of obesity.
Pre 45.40±3.53 44.80±4.54 Ns
post 53.60±3.13** 44.50±5.31 P <0.0
In view of hyperlipidemia and
VLDL(mg/dl)
hypercholesterolemia that occur in obesity, it is a risk
Pre 28.10±1.41 28.78±1.24 ns
factor for atherosclerosis. In fact, obesity is associated
Post 26.86±0.73** 29.00±1.53 P <0.05
with an increase in the incidence of coronary heart
disease, congestive heart failure and strokes(2)
**p 0.05 within group between pre- and post-training (paired t
-test); #p value between exercise and control group Physical inactivity is one of the factors for the
Chol: Cholesterol; Trig-Triglycerides; HDL: High Density Lipids; increases of obesity and its complications. Physical
VLDL: Very Low Density Lipids inactivity levels are rising in many countries with
major implications for increases in the prevalence of

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 107
non-communicable diseases and the general health of
the population worldwide(8)
Sedentary lifestyle is one of the risk factors for
obesity epidemic. Many studies revealed that physical
activities made significant improvement on aerobic
performance and strength capacity.(9) In the present
study significant improvement in cardiovascular
fitness including VO2max was observed in exercise
group at the end of training. Independent studies have
conducted to examine the effect of aerobic and
resistance exercise training(10). In these studies, aerobic
training group showed greater VO2max record than
the resistance group.
The role of aerobic exercise training on
cardiovascular diseases is well documented Studies
have conducted to examine the effect of physical
activities on blood pressure and metabolic variables.
Independently the effect of aerobic training and
resistance training on these variables was assessed.
After intervening independent aerobic and resistance
training a significant reduction is reported in systolic
(p=0.004) and diastolic (p=0.002) blood pressure in
aerobic group and systolic (p=0.002) and diastolic
(p=0.007) blood pressure in resistance group after the
intervention(11). A consistent result was observed in our
study. At the end of the training a significant reduction
in systolic (p<0.05) and diastolic (p<0.05) blood
pressure was resulted. Moreover, we assessed the
effects of the intervention on metabolic variables. Pre
and post training test was done on these metabolic
variables. The result showed Significant (p<0.05)
reduction change on total cholesterol , triglycerides
and very low density lipoproteins at the end of the
intervention. The result supports the previous studies
that advocate the preventative and/or curative effects
of regular physical training.
Our results showed significant reduction in BMI
after training. Related studies showed significant
changes on these variables. Even though, the duration
of intervention is different significant changes was
observed. A related previous study reported a 4.07 %(
p<0.001) and 3.35 %( p=0.002) decrease on BMI in
aerobic group (10). On another previous study a 5.04%
and 2.24% reduction on BMI in aerobic and resistance
group respectively was observed(12)
CONCLUSION
Intervening aerobic training for three months
resulted in significant improvement on body weight,
21. Aisha Egypt --104--108.pmd 107
body mass index, plasma lipid profile, systolic and
diastolic blood pressure and aerobic performance
capacity in obese women. . Based on our study results,
it is therefore recommended that obese individuals
should perform regular physical training in form of
aerobic exercises so that the body improves both
cardio-respiratory fitness and metabolic parameters
simultaneously. Further studies need to be done on
how the combination of aerobic exercise training and
diet restriction affects body weight, plasma lipid profile
and cardiorespiratory fitness on obese individuals.
ACKNOWLEDGMENTS
The author is grateful for the cooperation and
support of all subjects who participated in this study.
Ethical clearance
All subjects were informed about the study
procedure and signed consent forms approved by the
local research ethical Committee for the Protection of
Human Subjects, at Faculty of physical therapy, Cairo
University.
Conflict of Interest
There is no conflict of interest with any
organization, and this research is not funded.
REFERENCES
1. Surajit Kumar MukhopadhyayStudy of Lipid
Profile in Obese Individuals and the Effect of
Cholesterol Lowering Agents on Them, Al Ame
en J Med S c i (2 012 )5 (2 ) :1 4 7 -1 5 1.
2. Equsa G, Beltz WF, Grundy SM, Influence of
obesity on metabolism of apolipoprotein B in
humans. J Clin Invest. 1985; 76: 596-600
3. Peter G. Kopelman Obesity as a medical problem.
Nature. 2000; Pp:404
4. Thomas DP, Belko AZ, Mulroy GL, et al.
combined effects of exercise and restriction of
energy intake on moderately obese Women. Br J
Sports Med. 1986;20:84-8.
5. Leon AS, Sanchez OA. Response of blood lipids
to exercise training alone or combined with
dietary intervention. JAm College of Sports Med.
2001;33:S502-515.
6. Kemi, OJ, Wisloff U. High-intensity aerobic
exercise training improves the heart in health and
disease. J Cardiopulm Rehabil Prev. 2010;30:2-11.
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 108 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
7. Perna F, Bryner R, Yeater R. Effect of diet and
exercise on quality of life and fitness parameters
among obese in¬dividuals. J Exercise Physiol
1999;2:125-31.
8. World health organization. Global health risks:
Mortality and burden of disease attributable to
selected major risks, (2009).
9. Junichi K, masarou K. evaluation of physical
fitness on cycle ergometer in obese patients.
J.phy.ther.sci. 1995, 7:53-55.
10. Sarsan A., Ardic F., Ozgen M., Topuz O. and
Sermez Y., The effects of aerobic and resistance
exercises in obese women, Clin.Reh., 2006; 20,
773-782.
21. Aisha Egypt --104--108.pmd 108
11. Mengistie Alemayehu Belay1, Reddy R.C.1 and
Syam Babu M, The Effects of Combined Aerobic
and Resistance Exercise Training on Obese,
Adults, Northwest Ethiopia Res.J.Recent Sci,
2013; Vol. 2(1), 59-66, January
12. Chaudhary Sarika, Manpreet Kaur Kang and
Sandhu J.S., The Effects of Aerobic Versus
Resistance Training on Cardiovascular Fitness in
Obese Sedentary Females, Asian J. Sp. Med., 2010;
1(4), 177-184
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.075
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 109

Effect of Postoperative Ambulation on the Quality of Life

in a Transtibial Amputee

Amit Saraf1, Ankita Gupta2, Jeewan S Prakash3, Jedidiah S Prakash4

1
Assistant Professor, Dept. of Orthopaedics, 2Resident, Dept. of Medicine, 3Principal, Dept. of Physiotherapy, 4Resident,
Dept. of Surgery, Christian Medical College, Ludhiana

ABSTRACT
Background: Quality of life of a transtibial (TT) amputee is not only determined by his functional
rehabilitation but also social, economical and psychological rehabilitation. A number of studies have
analyzed the influence of lower limb amputation on these factors. This study analyses the effect of
functional recovery on other parameters of quality of life in a TT amputee.
Material and method : The present study followed 160 patients of TT amputation. Their postoperative
ambulatory status was calculated using Pinzur's ambulatory level. Their quality of life was determined
on the basis of answers to five point questionnaire. These parameters were correlated to assess the
influence of functional recovery on quality of life.
Results: All the amputees with Pinzur's 0-1 level of ambulation suffered loss of income consequent
to loss of job. All of them felt increased level of depression and anxiety after amputation. 50% of them
felt socially neglected. Comparatively much less percentage of amputees with 5-6 level of ambulation
suffered economic, social and psychological crisis.
Conclusions: Postoperative ambulation level directly affects the quality of life of a TT amputee.
Keywords: Ambulation Level, Quality of Life, Transtibial Amputee

remainder had to change occupation. Bruins et al

INTRODUCTION
Lower limb amputation is carried out for a variety
of reasons including peripheral vascular disease,
diabetes, trauma, tumour, infections etc1. TT or below
knee (BK) amputation is the most common major
amputation (51.2%) followed by transfemoral (17.5%)2.
Trauma is the leading cause of leg amputation in
developing countries and is second only to peripheral
arterial disease in developed countries3.
Most patients who lose a limb as a result of trauma
or surgical procedure encounter a number of social,
economical and psychological problems along with
physical inactivity1. All these factors together reflect
on the quality of life an amputee leads.
(2003) reported that 50% patients had to change their
occupation after amputation.
Hawamdeh et al (2008) reported that 55.4% of
amputees in their study did not get social support.
They reported that patients who lost social support,
had more/deeper psychological involvement.
These studies 1,4,5,6 suggest that any major
amputation generally influences the quality of life of
the patient. This study makes an attempt to find out if
ambulation level of a TT amputee has any effect on
other parameters of quality of life of the amputee.
MATERIAL AND METHOD

Shukla et al (1982) noted that depression is the most
common psychological reaction and 50% of all
amputees need some sort of psychological
intervention.
Burger et al (2007) reported 66% return to work rate
after a lower limb amputation. Between 22% and 67%
of the subjects retained the same occupation, while the
This was a 10 year retrospective and two year
prospective study done between 1996-2007 in
Department of Orthopaedics, Christian Medical
College, Ludhiana. A total of 190 patients between 18-
60 years were enrolled in this study. Of these 190
patients, 16 were lost to follow up and 14 patients
expired before 6 months. These patients were excluded
thereby leaving us with a study of 160 patients. Patients

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 110 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

with amputation of ipsilateral / contralateral upper point questionnaire (Table 2). These outcome/answers
limbs, contralateral lower limbs, neurological deficit, were in turn correlated with the ambulatory level of
physical disability hampering mobility were also each patient to assess the influence of functional
excluded from this study. rehabilitation on the quality of life of a TT amputee.

All the patients were followed upto a minimum
period of 6 months after stump closure. The mean
duration of follow up was two and half years. During
this period ambulatory level of the amputees was
graded by using Pinzur et al (1993) ambulatory scale
(Table1). Patients were assessed for their quality of life
on psychological, economical and sociological aspects.
This assessment was based on their answers to a five
Table 1 : Pinzur et al (1993) ambulatory scale
Level Walking capacity
6 Independent community ambulator
5 Limited community ambulator
4 Unlimited household ambulator
3 Limited household ambulator
2 Supervised household ambulator
1/0 Transfer- bedridden

Table 2 : Five point questionnaire for quality of life

Question Answer
Have you changed your occupation/lost job after amputation? Yes No
Is there an income declineafter amputation? Yes No
Do you feel socially neglected? Yes No
Do you feel more depression after amputation? Yes No
Has your anxiety increased after amputation? Yes No

RESULTS Out of 56 patients with Pinzur ’s level 2-4

Of 160 patients who were followed up, 83 (51.9%)
amputees suffered a loss of occupation/ change in
occupation. 98 (59.4%) patients suffered an income
decline during rehabilitation. 48 (30%) patients
reported loss of social support. 109 (68.1%) patients
were observed to have increased depression and 84
(52.5%) increased anxiety after amputation.
It was observed that 8 patients with Pinzur’s level
0-1 ambulation suffered a 100% loss of income
consequent to loss of job. 50% (4) of these patients felt
socially neglected. All patients in this group felt that
their anxiety and depression level had increased
following amputation.
ambulation, 75% (42) lost or changed their jobs. 83.9%
(47) amputees suffered an income decline after
amputation. 57.1% (32) patients complained of loss of
social support during post surgery rehabilitation.
Increase in depression and anxiety level was 51% (49)
and 31.3% (30) in this group.
34.4% (33) out of 96 patients with Pinzur’s level 5-
6 of ambulation needed to change their job after
amputation. 41.7% (40) amputees in this group suffered
an income loss. 12.5% (12) of these patients lost their
social support. Increase in depression level was 51%
(49) and anxiety level 31.3% (30) in this group
postoperatively (Table 3).

Table 3 : Correlation of ambulatory scale and quality of life

Questionnaire Answer Ambulation level

0-1(n=8) 2-4(n=56) 5-6(n=96) Total(N=160)
Occupation change/lost job Yes 100% (8) 75% (42) 34.4% (33) 51.9% (83)
No 0% (0) 25% (14) 65.6% (63) 48.1% (77)
Income decline Yes 100% (8) 83.9% (47) 41.7% (40) 59.4% (95)
No 0% (0) 16.1% (9) 58.3% (56) 40.6% (65)
Loss of social support Yes 50% (4) 57.1% (32) 12.5% (12) 30% (48)
No 50% (4) 42.9% (24) 87.5% (84) 70% (112)
Increase in depression Yes 100% (8) 92.9% (52) 51% (49) 68.1% (109)
No 0% (0) 7.1% (4) 49% (47) 31.9% (51)
Increase in anxiety Yes 100% (8) 82.1% (46) 31.3% (30) 52.5% (84)
No 0% (0) 17.9% (10) 68.7% (66) 47.55 (76)

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 111

DISCUSSION ambulation could do most of their work themselves.

This group thus neither needed social support nor did
Health is defined as “a state of complete physical,
they face so much of social neglect.
mental, and social well-being and not merely the
absence of disease or infirmity”8,9. Thus quality of life
of a TT amputee is determined not only by his
functional rehabilitation but also social, economical
and psychological factors.

Economic aspect

Of 160 patients, 51.9% changed/ lost their jobs after

amputation. This change was in 100% patients in poor
ambulatory level of 0-1 as compared to only 34.4% in
level 5-6 of ambulation which was significant
(Figure 1). This proves that after TT amputation,
ambulatory level had a significant effect on the job
status of the patient. Patients with poor ambulatory
level often had to quit their jobs.
Fig. 2. Social effect of ambulatory level on amputees

Psychological aspect

There was increase in depression and anxiety

feelings in all the patients with ambulatory level of 0-
1 as compared to 51% and 31.3% respectively in those
with ambulatory level of 5-6 (Figure 3). Patients with
poor ambulation could not involve themselves actively
in social activities. Further they were dependent on
others for most of their activities of daily living.
Together this led to an omnipresent feeling of
depression and anxiety. Thus there was a higher level
of depression and anxiety in TT amputees with poor
ambulatory level.
Fig. 1. Economical effect of ambulatory level on amputees

It was also noted that all the patients with 0-1 level
suffered a loss of income as compared to 41.7% patients
with 5-6 level of ambulation. This is because patients
with poor ambulatory level had to either quit their
job or change it to a low profile job with less income.

Social aspect

50% of patients with 0-1 level lost social support

after amputation as compared to 12.5% patients with
level 5-6 (Figure 2). Reason for this finding was that
amputees with poor functional level were fully
dependent on others and thus in general people Fig. 3. Psychological effect of ambulatory level on amputees
around them gradually started shirking their
responsibilities. This aspect of quality of life is CONCLUSIONS
especially important in a developing country like India
where there is a dearth of social welfare or security From this study we thus conclude that post
system. On the other hand patients who had better operative functional outcome significantly affects the

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 112 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
quality of life of an amputee. An amputee with better
ambulation level fares better economically,
psychologically and socially in comparison to an
amputee with poor ambulatory outcome.
Conflict of Interest: None
Ethical Adherence: Yes
Disclaimers: None
Source of Funding: None
REFERENCES
1. Hawamdeh,Z.M , Othman,Y.S., Ibrahim,A.I.
(2008). Assessment of anxiety and depression
after lower limb amputation in Jordanian
patients. Neuropsychiatr Dis Treat, 4(3), 627-33.
2. AL- Worikat. (1996). Amputees referred to the
royal medical services- Jordan. JCRPO, 2, 129-36.
22. Amit Saraf--109--112.pmd 112
3. Perkins, Z.B., De'Ath, H.D., Sharp,G., Tai,N.R.M.
(2012). Factors affecting outcome after traumatic
limb amputation. Br J Surg, 99, S1, 75-86.
4. Shukla,G.D., Sahu,S.C., Tripathi,R.P., Gupta,D.K.
(1982). A psychiatric study of amputees. Br J
Psychiatry, 141, 50-3.
5. Burger,H., Marincek,C. (2007). Return to work
after lower limb amputation. Disabil Rehabil,
15,29(17), 1323-9.
6. Bruins,M., Geertzen,J.H., Groothoff,J.W.,
Schoppen,T. (2003). Vocational reintegration after
a lower limb amputation: a qualitative study.
Prosthet Orthot Int, 27(1), 4-10.
7. Pinzur,M.S., Larsen,J., Smith,D. (1993). Functional
outcome of BK amputation in peripheral vascular
insufficiency. Clin Orthop Relat Res, 286, 247- 249.
8. WHO. (1978). Health for All, Sr.No.1
9. WHO. (1979). Health for All, Sr.No.2
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.076
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 113

Effect of High Power Pain Threshold Static Ultrasound

Combined with Transverse Friction Massage and
Stretching on Upper Trapezius Myofascial Trigger Point

Hari Haran R1, Singh Anand Kumar2

1
Assistant Professor, 2M.P.T, Orthopaedics, Department of Physiotherapy, Maharishi Markandeshwar University,
Mullana, Ambala

ABSTRACT
Objective: To investigate the additional effect of HPPT static ultrasound when combined with TFM
and stretching on myofascial trigger point of upper trapezius muscle fibre.
Materials and method: This study was done on the 30 subjects who were divided randomly into 2
groups. 15 subjects were included in each group and treated as follows:
Group A - HPPT Static Ultrasound + TFM + Static Stretching of upper trapezius muscle.
Group B - TFM + Static Stretching of upper trapezius muscle.
Group A and B were given intervention 2 times per week for 4 weeks. Only pre-test, after 2 week and
post-test measures were taken of LFROM, NPRS and NPDI.
Results: Study shows that there is significant difference in group A and group B in reducing trigger
point, pain and improving function. Group A shows greater significant difference in outcome measure
in comparison to group B.
Conclusion: Physical therapy interventions focusing on high power pain threshold static ultrasound,
transverse friction massage and static stretching exercise should be indicated for patients presenting
with myofascial trigger points as it relieves pain, improves the ROM and function.
Keywords: HPPT (high power pain threshold), LFROM (lateral flexion range of motion), TFM (transverse
friction massage), NPRS (numeric pain rating scale), NPDI (neck pain disability index)

INTRODUCTION response, or by jumping away from the examiner.

Muscle without TPs, or normal muscle, is not tender
Travell defined a TrP as “a hyperirritable spot in
upon palpation and does not produce a “jump
skeletal muscle that is associated with a hypersensitive
sign8, 9, 7.
palpable nodule in a taut band1, 2, 3, 4, 5, 6. The spot is
tender when pressed and can give rise to characteristic Trigger points are classified as being active or latent,
referred pain, motor dysfunction and autonomic depending on their clinical characteristics. An active
phenomena”1, 5, 7. trigger point causes pain at rest. It is tender to palpation
with a referred pain pattern that is similar to the
A myofascial TP has been described as an area of
patient’s pain complaint. This referred pain is felt not
hyperirritability located in a taut band of muscle,
at the site of the trigger-point origin, but remote from
variously described as resembling a small pea or as a
it. The pain is often described as spreading or radiating.
rope-like nodular or crepitant (crackling, grating) area
Referred pain is an important characteristic of a trigger
within the muscle that is painful upon palpation and
point. It differentiates a trigger point from a tender
refers pain, tenderness, and an autonomic (functionally
point, which is associated with pain at the site of
independent) response to a remote area. Some authors
palpation only2.
contend that when pressure is applied to a TP, a “jump
sign” or “jump response” is elicited whereby the The energy crisis theory is the earliest explanation
patient reacts with facial grimacing, by a verbal of trigger point formation. This theory postulates that

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 114 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
increased demand on a muscle (increased neural
input), macro trauma, or recurrent micro trauma leads
to increased calcium release from the sarcolemma and
prolonged shortening of the sarcomeres. Prolonged
shortening compromises the circulation, with the
subsequently reduced oxygen supply leaving the cells
unable to produce enough ATP to initiate the active
process of relaxation. Ischemic by-products of
metabolism accumulate being in part responsible for
some of the pain produced, by sensitisation and direct
stimulation of sensory nerves. Unfortunately, there are
no studies to date that can confirm such muscle injury
as the initiating factor3, 11.
The concept of altered muscle metabolism
underlying the changes at trigger point sites was
investigated by Bengtsson. Muscle energy stores can
be measured by the levels of various phosphate
containing compounds. Adenosine triphosphate,
phosphocreatine, and adenosine di-phosphate are
compounds capable of donating their phosphate
moiety and releasing energy for muscle activity.
Adenosine monophosphate and free creatine are the
remaining compounds after this process and are,
therefore, low energy molecules. In a biopsy study of
patients with fibromyalgia, it was found that the levels
of high-energy phosphates were reduced and low
energy phosphates increased at trigger point sites in
patients when compared to non-tender muscle points
in both patients and controls. This supports the idea
of a metabolic derangement at trigger point sites.
However, lactate and pyruvate are the products of
anaerobic muscle metabolism, and their levels were
not increased. Therefore, although a pure ischaemic
cause is unlikely, there is some evidence to suggest a
metabolic abnormality at trigger point sites3, 10. The
energy crisis theory could well co-exist with the motor
end plate hypothesis.
Ultrasound is being used in physical medicine to
relieve pain and increase joint mobility. Many papers
have been published on the issues of the effect of
ultrasound in musculoskeletal disorders. Many
researches has been done on trigger point in which
massage, stretching and static ultrasound is used as
interventions alone and two interventions combined
with each other but in this study all these interventions
are combined for the treatment of myofascial trigger
point, to see the combined effect of these intervention
and additional effect of static ultrasound.
23. Anand Kumar Singh--113--117.pmd 114
MATERIALS AND METHOD
30 subjects were selected by means of convenience
sampling based on inclusion and exclusion criteria,
with signs and symptoms of myofascial trigger point.
Myofascial trigger point was confirmed by the
following diagnostic criteria16.
Primary criteria (all 5 needed)
1. Regional pain complaint.
2. Pain complaint or altered sensation in the expected
distribution of referred pain from a trigger point.
3. Taut band palpable in an accessible muscle.
4. Exquisite spot tenderness at 1 point along the
length of the taut band.
5. Some degree of restricted range of motion.
Secondary criteria (1 of 3 needed)
1. Reproduction of clinical pain complaint, or altered
sensation, by pressure on the tender spot.
2. Local twitch response elicited by snapping
palpation at the tender spot or by needle insertion
into the tender spot.
3. Pain alleviated by elongating (stretching) the
muscle or by injecting the tender spot.
Patients are included in the study with following
inclusion criteria: Age between 18 and 45, both genders
are included, Unilateral upper trapezius myofascial
trigger point, Trigger points in the course of upper
trapezius muscle fibre and having duration more than
3 months with an intensity disturbing normal daily
activity, Reproduction of pain complain by palpation
of trigger points, The number of trigger point less than
10, The patient shall be capable of following the
demands inherent in the trial and patient are excluded
with following exclusion criteria: Signs of cervical disc
prolapse, systemic disorder or migraine, Patients on
medication for trigger point or physiotherapy
treatment taken for myofascial trigger point 3 weeks
prior to the participation in the study, Pregnancy.
Design: Prospective Randomized clinical trial.
Independent Variable: HPPT static Ultrasound,
TFM, Static stretching and Conceptual dependent
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 115

variable: Pain, LF ROM of the cervical spine, Function C. Stretching

and Operational Dependent variables are: NPRS,
goniometer, NPDI.
STUDY PROTOCOL
30 subjects were divided randomly into 2 groups.
15 subjects were included in each group and treated
as follows:
• Group A – HPPT + TFM + Static Stretching of
upper trapezius muscle.
• Group B - TFM + Static Stretching of upper
trapezius muscle.
PROCEDURES
Group A was given high power pain threshold
static ultrasound, transverse friction massage and
stretching of upper trapezius muscle and group B was
given transverse friction massage and static stretching
of upper trapezius muscle.
A. High Power Pain Threshold Static Ultrasound
Technique
It is applied in watts/cm2 in continuous mode to
treat the patients of group A, with the probe placed
directly on the trigger point and held motionless.
To elicit threshold pain, the ultrasound probe must
be kept static on the trigger point. Intensity will
be gradually increased to the level of maximum
pain the patient could bear. It is kept at that level
for 4-5 seconds and then reduced to half- intensity
level for another 15 seconds. This procedure is
repeated 3 times. Each patient will receive the
treatment 2 days a week for 4 week. Patients were
instructed to continually reporting their pain level,
its localization and nature11.
B. Transverse friction massage
Transverse friction massage is followed by HPPT
Static ultrasound. The maximum duration of this
was 2 minutes for each trigger point16.
All the patients were given passive stretching of
the upper trapezius muscle in supine lying. It is
given to muscle tendon unit by slowly placing it
in a maximal position of stretch and sustaining it
there for an extended period of time this maximal
stretching position is determined by discomfort
and/or pain that patient experience. 15 This
procedure was repeated three times with 30-
second rest intervals in between. This is given 2
days a week for 4 week.
Data Analysis
SPSS 17 is used for the statistical calculations,
MANOVA was used to compare the between group
values and repeated measure ANOVA was used to
calculate the within group values. Level of significance
was set at 5% (p < 0.05).
RESULTS
Demographic data of subjects in group A and
Group B at baseline are summarized in table 1. There
was no significant difference in demographic
characteristics between groups at the baseline.
Table 1: Demographic characteristics of subjects in
group A and B
Group A Group B
Age ± S.D 23.93±4.23 26.00±4.55
Side affected 10 Right & 5 Left 9 Right & 6 Left
Gender 7 Male & 8 Female 6 Male & 9 Female
Within group analysis: There was a significant
difference within both the groups in NPRS, NPDI, and
LFROM at 2 weeks and 4 weeks when compared with
the baseline measure.
Between group analysis: Result obtained after 2
weeks was not significant but after 4 weeks there was
significant difference but in comparison to group B
there was more improvement in group A and result
was significant at p < 0.05 (Table 2)

Table 2: Within group and between group comparisons

Group A Group B
Baseline 2 week 4 week baseline 2 week 4 week
NPRS 6.8±0.94 4.6±0.81 3.0 ±.65 6.8±.774 5.1±.639 3.5±.516
NPDI 34.3±4.51 38.8±3.44 41.4±2.29 34.2±3.97 37.4±2.69 39.8±1.5
LFROM 67.0±3.53 37.4±4.92 20.6±3.97 67.0±3.53 41.6±2.29 26.2±3.9

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 116 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
DISCUSSION
Findings of this trial indicate that subjects in both
the groups had significant decrease in pain, increase
in function and ROM at cervical spine. However, out
of two groups, the group received high pain threshold
static ultrasound as a supplement to transverse friction
massage and stretching had a higher percentage of
change in pain intensity, function and ROM at cervical
spine, as compare to transverse friction massage and
stretching alone. The results obtained after the data
analysis did not support the null hypothesis and thus
it was rejected and the alternate hypothesis was
accepted.
Result of this study goes with the accordance with
previous studies, which tells that the high power pain
threshold static ultrasound is helpful in decreasing the
pain and breaking of adhesion which are formed due
to trigger points. Care must be taken not to apply high-
power, static ultrasound on trigger points in the
vicinity of bony and neural structures. Patients will
report discomfort and unbearable pain and burning
when ultrasound waves meet periosteum, sympathetic
chains and peripheral nerves, good knowledge of
anatomy is very useful for this assessment14.
According to Michelle H and Cameron 14 High
power, pain threshold, static ultrasound increases the
temperature of soft tissues temporarily to increase their
extensibility, increasing the length gained for the same
force of stretch while also reducing the risk of tissue
damage. The increase in soft tissue length is also
maintained more effectively if the stretching force is
applied while the tissue temperature is elevated. This
increased ease of stretching is thought to be the result
of altered viscoelasticity of collagen and alteration of
collagen matrix.
High-power, pain-threshold, static ultrasound
technique resolves trigger points more rapidly than
does treatment with conventional ultrasound
technique. Someday it may be found more cost
effective because it significantly decreases the number
of PT treatment sessions13.
High-power, static ultrasound, technique applied
to trigger points before stretching the muscle was more
effective than conventional ultrasound and it also
significantly decreased the length of therapy. They
reported that no patient reported any short or long
term adverse effects17.
23. Anand Kumar Singh--113--117.pmd 116
The two groups had equal number of subjects and
there were no significant differences with respect to
their gender distribution and age which could have
altered the results of the study. As transverse friction
massage and stretching was given in both the groups
& there was a significant decrease in pain & increase
in function and ROM in both groups after 4weeks of
intervention. The significant improvement in the
Group A can be attributed to physiological and
therapeutic effects of high power pain threshold static
ultrasound.
Clinical Implication
The results of the present study enlighten the use
of combination therapy approach (HPPT+TFM+Static
stretching) as more effective approach than the either
intervention alone in the clinical settings for the
management of myofascial trigger point patients.
Limitations of the study
Objective outcome measure (pressure algometer)
was not used for trigger point and follow up was not
done. Another limitation of the study was blinding of
patient was not done because of ethical concern.
Future Research Suggestions
Future research can be done using objective
outcome measures and the blinding of both the patient
and researcher should be done to overcome the bias
effect. There should be long term follow up of the
patient to determine the sustained effects of
combination therapy (HPPT+TFM+Static stretching).
CONCLUSION
This study describes the management of patients
with complaints and findings consistent with
myofascial trigger point of upper trapezius muscle
fibre, who responded favourably to an intervention
program focused on high power pain threshold static
ultrasound, transverse friction massage and static
stretching exercise.
REFERENCES
1. Simons DG, Travell JG, Simons LS.Travell and
Simons’ Myofascial pain and dysfunction: The
trigger point manual, vol 1, Upper half of body.
2nded, Pennsylvania,Baltimore, Md: Williams and
Wilkins;1999.
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2. Alvarez J David, Rockwell G Pamella. Trigger
point: Diagnosis and management. American
family physian.2002 Feb; 65:653-660.
3. Huguenin K Leesa. Myofascial trigger point: The
current evidence. Physical therapy in sports.2003
Nov; 5:2-12.
4. Shah J. P, Danof J. V. Biochemical associated with
pain and inflammations are elevated in sites near
to and remote from active myofascial trigger
points. Arch phys med rehab.2008 Jan; 89(1):
157-159.
5. Lavelle ED,Lavelle W, Myofascial trigger point.
Anesthesiology clinics.2007; 25:841-851.
6. Hoyle Jeffrey A, Marras William S. Effect of
postural and visual stressor on myofascial trigger
point development and motor unit rotation
during computer work. Journal of
electromyography and kinesiology.2011; 21:41-48.
7. Balbis Peter, Pollard Henry. Neuroemotional
technique for the treatment of trigger point
sensitivity in chronic neck pain sufferers: A
controlled clinical trial. Chiropractic and
osteopathy.2008; 16(4).
8. Hanten P William, Oslon L Sharon, Butts L Nicole.
Effectiveness of a home program of ischaemic
pressure followed by sustained stretch for
treatment of myofascial trigger point.2000 Oct;
80:997-1003.
9. Hong Chang-zern. Myofascial trigger point:
Pathophysiology and correlation with
acupuncture points. Acpuncture in
medicine.2000; 18(1):41-47.
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10. Dommerholt Jan, Baron Caral. Myofascial trigger
point: An evidenced-informed review. The
journal of manual and manipulative
therapy.2006; 14(4):203-221.
11. Huijbregts Peter A. Myofascial trigger point and
myofascial pain syndrome:a critical review of
recent literature an introduction by the editor in
chief. The journal of manual and manipulative
therapy.2006; 14(4):124-171.
12. Simons David G. Understanding effective
treatment of myofascial triggers point. Journal of
bodywork and movement therapy.2002; 6(2):
81-88.
13. Javed Majlesi, MD, HalilUnalal, MD. High-power
pain threshold Ultrasound technique in the
treatment of active Myofascial trigger points: a
randomized, double-blind, case- control study.
Archives Physical Medicine Rehabilitation.2004;
85:833-6.
14. Michelle H. Cameron. Physical agents in
Rehabilitation -2nd Edition, 1999:196.
15. Kisner Carolyn, Colbey Lynn Allen. Therapeutic
exercise foundation and techniques.4th edition.
New delhi: Jaypee brothers medical publisher.
16. Gamn Arne N, Warming S. Treatment of
myofascial trigger-points with ultrasound
combined with massage and exercise – a
randomized controlled trial. Pain.1998; 77(1):
73–79.
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 DOI Number: 10.5958/j.0973-5674.7.3.077
118 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Efficacy of Muscle Energy Technique in Combination

with Strain-counterstrain Technique on Deactivation of
Trigger Point Pain

Amir Iqbal1, Hashim Ahmed2, Md Abu Shaphe3

1
Head Department of Physiotherapy, Taneja Hospital, Preet Vihar, Delhi, 2Head Department of Physiotherapy, Shreya
Hospital, Shalimar Garden Extension, Ghaziabad, U.P, 3Associate Professor, Faculty of Applied Medical Sciences, Jazan
University, KSA

ABSTRACT
Objective: To establish the best possible long term effective choice of treatment program for
deactivating MTrP's by using the combination of muscle energy technique with strain-counterstrain
technique
Design: Pretest-Posttest control group design
Setting: Outpatient physiotherapy department, Taneja Hospital, Preet Vihar New Delhi.
Patients: Fourty five subjects (only male) with Myofascial Trigger Points Pain. Subjects were randomly
placed into three groups: Experimental group A (n=15), Experimental group B (n=15) and a Control
group C (n=15).
Intervention: The experimental group A received muscle energy technique in combination with strain-
counterstrain technique and experimental group B received muscle energy technique alone whereas
control group received conventional treatment only.
Main Outcome Measures: Pain pressure threshold was assessed with the pressure threshold meter
(PTM). Pain and functional status of the patients were measured by a visual analogue scale (VAS)
and the Neck Disability Index scores respectively.
Results: Within group analysis revealed significant improvement in pain pressure threshold, functional
status and reduction in pain intensity in all groups. Between group analysis revealed significant
difference between group A, group B and group C. Further post hoc analysis revealed significant
difference between group A and B, group A and C and group B and C for all variables even after one
week of follow up after the termination of intervention.
Conclusion: The combination of muscle energy technique with strain-counterstrain has been shown
to produce greater improvement in pain pressure threshold on pressure threshold meter, function
status on neck disability index scores and reduction in pain intensity on visual analogue scores even
after one week of the termination of intervention. This shows the long term effectiveness of
combination of two manual techniques deactivating the myofascial trigger point's pain.
Keywords: Myofascial Trigger Points Pain, Pain Pressure Threshold, Pressure Threshold Meter, Muscle
Energy Technique, Strain-Counterstrain Technique

INTRODUCTION The spots are painful on compression and can

Musculoskeletal disorders are the main cause of
disability in the working-age population and are
among the leading causes of disability in other age
groups.(1) Myofascial pain syndrome is a common
painful muscle disorder caused by myofascial trigger
points.(3).
produce referred pain, referred tenderness, motor
dysfunction, and autonomic phenomena.(4)
Trigger points are classified as being active or latent,
depending on their clinical characteristics. (5) An active
trigger point causes pain at rest. It is tender to palpation
with a referred pain pattern that is similar to the

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 119
patient’s pain complaint. (6) The pain is often described
as spreading or radiating. (7) It differentiates a trigger
point from a tender point, which is associated with
pain at the site of palpation only. (8)
Many researchers agree that acute trauma or
repetitive micro trauma may lead to the development
of a trigger point. Lack of exercise, prolonged poor
posture, vitamin deficiencies, sleep disturbances, and
joint problems may all predispose to the development
of trigger points.(5)
There are many treatments approach are available
in physical therapy to deactivate the MTrPs (12) such as
Ischaemic compression technique, spry and stretch
technique, Strain -Counter strain technique, Trigger
point pressure release technique, Ultrasound deep heat
therapy, Thermo Therapy, Laser Therapy, Needling
Therapies, Transverse Friction massage, Post isometric
relaxation (MET), Electrical muscle stimulator,
Stretching etc.
Muscle Energy Technique (MET) is claimed to be
effective for a variety of purposes that includes
lengthening of shortened or contractured muscle,
strengthening of muscles, as a lymphatic or venous
pump to aid the drainage of fluid or blood, and
increase the range of motion (ROM) of a restricted joint.
Muscle energy technique emphasizes on the relaxation
of the contractile component of the muscles.(2)
Strain-Counterstrain (S-CS) is a gentle, indirect
manipulative technique for the treatment for the
treatment of somatic dysfunction. It is one of several
treatment approaches where positioning of the body
is used to evoke a therapeutic effect. These approaches
have been categorize and “positional release” and
include “functional technique” and “facilitated
positional release”.
Simon and Travell suggested that a therapeutic
approach which effectively deactivates tender points
should beneficially influence the other trigger points
also. Therefore, Leon Chaitow(13) suggested that clinical
evidence also support this supposition, especially
when the positional release method is combined with
other approaches such as ischaemic compression, MET,
etc. which have good track record in trigger point
deactivation..
24. hashim--118--123.pmd 119
Although muscle energy technique used in various
studies has been proven to be effective in the
management of trigger points, but only short-term
effects have been established with this manual
technique. Also no research till date has been
attempted to reveal the combined effectiveness of
muscle energy technique with any other manual
technique for the complete resolution of trigger points.
Therefore the study has designed to establish the best
possible long term effective choice of treatment
program for deactivating MTrPs by using the
combination of muscle energy technique with strain-
counterstrain technique.
METHOD
Total 45 male subjects those met the inclusion
criteria were recruited from the Taneja hospital, Preet
Vihar, Delhi. Inclusion criteria was limited to male only
having age 19-38 years, maximum 3-5 active MTrPs
which when palpated replicated their chief complaints
in the upper trapezius muscle (unilateral), subjects
didn’t receive any treatment for their trigger points
before one month prior to the study. Patients were
excluded when they had diagnosed case of
fibromyalgia syndrome according to American college
of Rheumatology (Wolf et al 1990), presented active
MTrPs in bilateral Upper trapezius muscles, history
of whiplash injury, history of cervical spine surgery,
diagnosis of cervical radiculopathy or myelopathy
determined by the primary health care physician, had
undergone myofascial pain therapy within the past one
month before the study, exhibited inadequate co-
operation.
STUDY DESIGN
Pretest: Posttest control group design was used in
the study.
PROCEDURE
Prior to participation each subject were required to
read and sign an informed consent form. The entire
subject who met the inclusion criteria was assigned
randomly into any of the three groups. Pressure Pain
Threshold (PPT), and Visual Analogue Scale (VAS)
scores were taken pre-intervention and after 2 min. of
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 120 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
post-intervention at day 1, day 3 and day 5 and one
week of follow up after the termination of intervention.
Neck Disability Index (NDI) score assessment were
taken but limited to pre intervention at day 1 , post
intervention at day 5 day and one week of follow up
after the termination of intervention.
MEASUREMENTS
The pressure threshold meter (“WAGNER FORCE
DIAL) FDK 20” was used to assess the pain pressure
sensitivity of myofascial trigger point pain as
suggested by Fischer.17 The trigger point with lowest
pressure pain threshold value was designated the
primary trigger point. Subjects were advised that they
would feel some pressure over the trigger points and
that they should indicate when the sensation changed
from one of pressure to one of pain by saying ‘there’ /
‘yes’. Three consecutive measurements were obtained
by the same assessor and the mean was considered in
further analysis. At least 1 minute elapsed between
the 2 consecutive measurements, as suggested by
Fischer.17 After the pre-treatment data of the PPT, a
second application of 2.5 kg/cm2 of pressure was
applied by the physiotherapist. Subjects were told to
rate their pain on the VAS, assessing local pain evoked
by the application of that amount of pressure. A
functional questionnaire “Neck Disability Index
(NDI)” was provided to the subjects to assess their
functional limitations due to myofascial trigger points
pain.
INTERVENTION
All the three groups received Hot Packs (750C for
20 minutes) and Active Stretching (Slow, 5 repetition
per session, 10 seconds hold and 10 seconds relaxation
between two repetition) followed by group A was
treated with muscle energy technique along with strain
counter-strain technique, and group B was treated only
with muscle energy technique and group C was treated
with only conventional treatment.
Muscle energy technique
The patient will lie supine with cervical spine in
opposite lateral flexion to the treating part so that the
upper trapezius muscle fibers will be in a lengthen
position. 13 The moderate isometric contraction
(approximately 75% 0f maximal) of upper trapezius
muscles was elicited for a period of 5 Seconds followed
24. hashim--118--123.pmd 120
by 3 Seconds of relaxation. The technique was repeated
four times in each session.
Strain counter-strain technique
The part (upper trapezius muscle) was exposed and
the subject was in supine position with the cervical
spine in neutral position. The Physiotherapist located
the active MTrPs in the Upper Trapezius muscle using
“pincer palpation” method. A mechanical Pressure
Threshold Meter was used to find out the most active
trigger point among all MTrPs. Once located, the
Physiotherapist applied gradually increasing pressure
to the MTrP until the sensation of pressure became one
of pressure to one of pain. Followed by subject was
then passively placed in a position that reduced the
tension under the palpating fingers and caused a
subjective reduction of pain by around 75%. In the
present study, the position that reduced pain was
usually ipsi-lateral side-flexion of the cervical spine in
addition to a slightly contra lateral cervical rotation
i.e. 5–80. The subject upper extremity was previously
passively positioned in 900 of abduction. That position
was maintained for 90seconds. Finally, the subject was
slowly passively placed in a neutral position (13).
DATA ANALYSIS
Statistical analysis was done using SPSS 15.0
Software. Repeated measure ANOVA was used for
within group analysis and one way ANOVA was used
for between group analysis for all the variables.
RESULTS
Within group: All the three group showed the
significant improvement for all variables at day 1
postintervention and final day 5 postintervention
when compared with their respective baseline. Only
group C showed insignificant improvement after one
week of follow up when compared with their baseline
value.
Between group analysis revealed significant
difference between group A, group B and group C.
Further post hoc analysis revealed significant
difference between group A and B, group A and C and
group B and C for all variables even after one week of
follow up after the termination of intervention. Further
details are given in following tables:
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 121

Table 1: Between group post hoc Bonferroni analysis for PPT

PPT 0 'p' PPT 1 'p' PPT 3 'p' PPT 5 'p' PPT 6 'p'
Group A
Vs Group B 1.000 0.108 .000 .000 .000
Group B
Vs Group C 1.000 .379 .007 .000 .000
Group A
Vs Group C 1.000 .002 .000 .000 .000

Table 2: Between group post hoc Bonferroni analysis for VAS

PPT 0‘p’ PPT 1‘p’ PPT 3‘p’ PPT 5‘p’ PPT 6‘p’
Group A Vs Group B 1.000 0.108 .000 .000 .000
Group B Vs Group C 1.000 .379 .007 .000 .000
Group A Vs Group C 1.000 .002 .000 .000 .000

Table 3: Between group post hoc Bonferroni analysis for NDI

Variables NDI0‘p’ NDI5‘p’ NDI6‘p’

Group A Vs Group B 1.000 0.006 .001
Group B Vs Group C 1.000 .002 .003
Group A Vs Group C 1.000 .000 .000

Figure.3: Between group comparison of NDI.

Fig.1. Between group comparison of VAS
DISCUSSION

The study was designed to find out the efficacy of

muscle energy technique in addition to strain-
counterstrain in managing upper trapezius myofascial
trigger point pain. The inter group comparison of the
study reveal that trigger point sensitivity was
significantly reduced when muscle energy technique
was combined with strain-counterstrain technique
than muscle energy technique alone.

The results of this study can be discussed with the

previous studies done by Hong et al., 1993; Hanten et
al 2000; Freyer and Hodgson, 2005. The results
obtained by these authors are similar to those obtained
Fig. 2. Between group comparison of PPT in this present study.

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 122 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Muscle energy technique (MET) emphasizes on the
relaxation of the contractile component of the muscles
which play a role in improving the flexibility of the
muscles thus reducing pain and improving function
of the muscles.
The study explained that muscle energy technique
may bring flexibility which results in analgesia and
increase pressure pain threshold by following
mechanism.
Pain relief from muscle energy technique may
result from a spinal reflex mechanism for the relief of
muscle spasm. (21). It may equalize the length of
sarcomeres in the involved MTrP and consequently
decrease pain. (18 )and offer effective stretching and
mobilization of the taut bands.(20)
Fryer and Hodgson (2005,) who recently
demonstrated that decreased local MTrPs tenderness
was due to a change in tissue sensitivity rather than
any unintentional release of pressure by the
practitioner.(12)
The muscle energy technique can also be explained
by the concept of the “barrier release” in which the
therapist gradually applies counter force to the muscle
until a definitive increase in resistance is perceived,
i.e. the barrier, which is usually perceived as not being
painful by the subject.(20)
Hence it can be concluded that muscle energy
techniques might be helpful in reducing pain,
increasing pain pressure threshold and in turn
improving functional status in subjects with myofascial
trigger points.
The mechanism relief of pain and increased pain
pressure threshold by Strain-Counterstrain technique
is also thought to achieve its benefits by means of an
automatic resetting of muscle spindles which would
help to dictate the length and tone into the affected
tissues (13) . Finally, there is emerging evidence
supporting the activation of descending inhibitory
pathways with the application of manual interventions
(Ferna´ndez-de-las-Pen˜as et al., 2007; Skyba et al.,
2003). Hence, different mechanisms would probably
act at the same time.
The improvement in the control group is attributed
to the effects caused by stretching and hot packs.
Stretching of the affected muscle is believed to be an
integral part of trigger point therapy. Lewit and Simons
demonstrated that “muscle lengthening” utilizing
post-isometric relaxation appears to be effective in
24. hashim--118--123.pmd 122
reducing trigger point sensitivity and pain intensity,
without the use of vapocoolant spray (20). Jaeger and
Reeves, who reported the effectiveness of spray and
stretch in decreasing pain intensity and increasing
pressure pain threshold, indicated that vapocoolant
spray could not produce anesthesia in the
subcutaneous tissues or muscle because of the depth
of the tissue.
They hypothesized that decreasing MTrPs pain
utilizing spray and stretch is due to the elongation of
the muscle to its full normal length. (12) Moist heat tend
to relax the underlying muscles and to diminish the
tension on the TrPs, thereby reducing referred pain and
local tenderness to pressure(12).
Since, the group A received all the techniques such
as muscle energy technique, strain-counterstrain, so
the higher gain in pain relief and increase pain pressure
threshold may be attributed to the above mechanism
explained and supported by different previous
studies.(12, 13, 18, 19, 20)
CONCLUSION
The study concluded that “muscle energy
technique in combination with Strain-counterstrain
technique is more effective than muscle energy
technique alone in deactivating upper trapezius
myofascial trigger point pain.
Future research is required to support the
hypothesis of pain relief by quantifiable histochemical
analysis.
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sensitivity. Archives of Physical and Medical
Rehabilitation 82, 1406-1414.
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.078
124 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Case Review of Perceptual Deficit in PRES: Detailed

Perceptual Evaluation is a Key to Definite Goal Achieving
Techniques

Moushami S Kadkol
Assistant Professor (Occupational Therapy), Seth GSMC & KEMH, Mumbai

ABSTRACT
In an average adult, visual, perceptual and cognitive skills are highly developed. Following a cerebro
vascular accident, because of the damage to the brain at its integrative level, certain perceptuo-
cognitive deficits may result depending on whether the affectation is in only the right or left hemisphere
or in both of them. These integrative affectations may be present in absence of any gross physical
impairment in the form of Apraxias, Body scheme and Image deficits, Spatial relation syndrome,
Agnosias or a combination. The resultant of these deficits is seen as difficulties in performing the
ADL (Activities of Daily Living) to variable intensities. This affects not only the lifestyle of the
individual but severely affects his confidence to be a productive member of the society. There are a
variable battery of tests used for evaluation of these deficits that may or may not be standardized but
are adequate for the clinician to understand the impact and specify the deficit so that the rehabilitative
management is goal oriented and specific. Depending on the nature of the deficit is the treatment
approach decided. The specific the rehabilitation technique used earlier is the independence gained.
The present article discusses the use of OSOT (Ontario Society of Occupational Therapy) battery of
test to evaluate the deficits and how the exact evaluation and understanding of the problem area
would make the therapeutic intervention more definitive in terms of using appropriate technique for
rehabilitation.
Keywords: Perception, Rehabilitation, Apraxia, Activities of Daily Living (ADL)

INTRODUCTION between objects or between self and two or more

objects. This includes disabilities like figure ground,
The physical affectation following Cerebro vascular
form constancy, position in space, spatial relations,
accident may not as much maim an individual as the
topographical disorientation and depth and distance
cognitive perceptual disorders may. These
perceptual deficits.3,4
dysfunctions result probably from brain damage at the
cortical integrative level for sensory input.1 Agnosias deals with the patients lack of recognition
of familiar objects perceived by the senses like visual,
Apraxia is the inability to perform certain skilled
tactile, auditory and proprioceptive.3,4
purposeful movements in the absence of loss of motor
power, sensation or coordination. They may result
from lesions of either or both hemispheres and have METHODOLOGY
been described to take several forms like construction,
Case description and evaluation
motor, ideomotor, ideational, verbal and dressing. Two
or more types usually occur and it is less likely to find Client was a 25 year old female with history of
one in isolation.2 eclampsia. Postpartum over one year she observed
difficulty to dress, carry out her Activities of Daily
Body image and body scheme disturbances are
Living and perform her work as beautician although
thought to result in an alteration of the way a person
she could very well understand the concept of the
understands himself .i.e. his illness, his body or its
activity to be performed. She then underwent MRI
parts.3,4
scanning which revealed hyper intensities in bilateral
The Spatial relations syndrome poses varied parietal lobes. She was diagnosed as PRES (Posterior
problems in perceiving spatial relations and distances Reversible Encephalopathy Syndrome). She was then

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 125
referred to Occupational Therapy services for
rehabilitative management.
The Occupational therapist did a preliminary
evaluation of the client that included mental status,
speech, vision, hearing, motor function, balance and
ADL. It was observed that the client had no physical
deficits. Her motor power i.e. muscle strength was
grade 5 according to Oxford method. She had good
voluntary control and did not exhibit any speech
deficit. She was observed for simple activities like
coming in the department, removing footwear and
pulling out the chair and sit. She seemed to look
puzzled and struggled when she had to sit. Also she
reported moderate to severe difficulty in performance
of basic and instrumental ADL. Her cognitive
functions of attention, memory were not found to have
any affectation. She was then administered the OSOT
test for evaluation of her perceptual deficit.
OSOT Test5:
This battery is developed for study of the brain
damaged adults. It evaluates perception and the
battery includes tests in following areas:
Sensation
Scanning
Apraxia
Body awareness
Spatial relations
Visual Agnosia
Scoring system of the test
It has a 4 part scoring system to measure perceptual
dysfunction through certain predetermined
performance tasks. Initially this test was more
subjective but was subsequently reported to be
standardized and reliable. It is suggested that a normal
individual would take the test in half an hour. The
structure of the scoring system is:
4. Intact perceptually for basic functioning
3. Minimal dysfunction
2. Moderate dysfunction
1. Severe dysfunction
25. Moshuiami--124--127.pmd 125
Score and findings post OSOT administration
The client was subjected to the test and was
observed in terms of approach to the task, quantitative
and qualitative response to the task. The total time
taken to complete the test was also recorded.
The client scored as follows
Sensory function : 33/40
Scanning : 2/8
Apraxia : 9/20
Body Awareness : 11/16
Spatial Relations : 8/16
Visual Agnosia : 12/16
The total time required for the client to complete
the test was 1hour 15 minutes.
It was inferred from the test that the client had
major affectation in the area of apraxia; especially the
motor type that was affecting her performance
wherever use of kinaesthetic patterns or motor
planning and execution were concerned. She also
showed spatial neglect on right side. The body
awareness was affected for solving body puzzle in
which although the client knew where to place the
body parts of the puzzle she could not locate the exact
space to put them. She had difficulty in manipulating
peg board design, drawing, and figure ground
perception. But significantly did not exhibit body
neglect, body part recognition and laterality deficits.
Interpretation and Discussion
It was observed that the client had poor score on
constructional component of apraxia and motor
planning component of apraxia. She scored well on
ideational and ideomotor component where she was
asked to imitate gestures, make purposeful use of tool
and imitate it. Constructional apraxia is the
impairment in producing designs in two or three
dimensions, by copying, drawing or constructing
whether upon command or spontaneously. It results
from lesions in either cerebral hemisphere and limits
the clients’ ability to perform purposeful acts while
using objects in their environment. They lack the
perspective of exact location of a figure in space and
the ability to analyze parts in relation to each other.
They overall exhibit an execution or planning
problem6. Therefore irrespective of whether they are
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 126 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
able to see things in correct perspective, they have
trouble initiating a planned sequence of movement
when trying to construct. The impact of this deficit
was magnified when the client was subjected to tests
for scanning, body awareness and spatial relation.
Performance was affected on the tests like scanning
for a specific alphabet on the sheet, drawing a man,
fixing body parts puzzle, peg board design activities,
completing the clock face. Interestingly, the client did
not exhibit body neglect, affectations in body part
recognition and laterality. The occurrence of omissions
on the scanning sheet would otherwise suggest
unilateral neglect related to ignorance of any stimuli
or input from the side to which the omissions are
present i.e. right side in this case. But with the client
scoring adequate on all other tests of body scheme and
spatial relation the deficit could be understood under
light of peripersonal neglect which is a form of
unilateral neglect of spatial relation that deals with the
behavior manifested in reaching space 7.
Also the client showed affectation in the area of
visual agnosia further suggesting that visuospatial
impairments can selectively disrupt the ability to
represent visual information in a body centered
reference frame in the absence of any defect of visual
exploration.7,8
All these findings supported the view that the client
exhibited more of planning, sequencing and execution
problem i.e. praxis without affectation of the ability to
understand the purpose of the activity and imitate the
tool use.
The different techniques that are suggested in
rehabilitation literature are9,10,11,12.
Strategy training in daily living activities: this
technique teaches internal (for example, the patient is
taught to verbalize and implement the task steps at
the same time) or external (for example, when aids
are used to overcome a functional barrier)
compensatory strategies that enable a functional task
to be completed.
Sensory stimulation: Stimulations including deep
pressure, sharp and soft touch are applied to the
patients’ limbs (Butler 1994)
Proprioceptive stimulation: The patient leans on
and puts weight through their upper and lower limbs
Cueing, verbal or physical prompts: Given to
enable each stage of the task to be completed
25. Moshuiami--124--127.pmd 126
Chaining (forward or backward): the task is broken
down into its component parts. Using backward
chaining the task is completed with facilitation from
the therapist apart from the final component, which
the patient carries out unaided. If successful next time
further steps are introduced. Forward chaining is the
reverse of backward chaining
Normal movement approaches: the therapist
facilitates the body through normal movement
patterns.
In light of the evaluation and the inference it would
be advisable to make use of the last 3 techniques to
get goal specific rehabilitation and enable the client to
achieve early independence. The therapist can make
use of normal movement as a preparatory strategy so
that the transfer of training occurs smoothly. Cueing
or providing a physical prompt for the task can ease
the performance of the client as the understanding of
the concept is unaffected .e.g. labeling the back of the
dress so that the right side is put in front.
Chaining can be taught for activities like sitting on
chair, cooking, walking on road, crossing etc. where
the task is broken in to sequences and the client goes
from one step to other. Also imitation can be used
which is unaffected in the patient. In case of the
ideomotor component being present it would have
been advisable to go for strategy training approach
with use of sensory stimulation to get an enhanced
adaptive response.
CONCLUSION
The use of OSOT (Ontario Society of Occupational
Therapy) battery of test allows for the exact evaluation
and understanding of the problem area that would
make the therapeutic intervention more definitive in
terms of using appropriate technique for rehabilitation.
Thus it is a worthwhile exercise to go in for a detailed
evaluation of the cognito perceptual components to
offer efficient rehabilitation.
ACKNOWLEDGEMENTS
I would like to thank the Dean, Seth G.S. Medical
College and my students for their cooperation.
Statement for conflict of interest
I, Moushami S. Kadkol, am taking full
responsibility for the data, the analyses and
interpretation, and the conduct of the research and that
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 127
I have full access to all of the data; and have the right
to publish any and all data separate. I declare no
conflict of interest.
Financial disclosure statement
This is to state that the above mentioned study, “A
Case Review of Perceptual Deficit in PRES : Detailed
perceptual evaluation is a key to definite goal
achieving techniques”, is not funded or sponsored by
any financial resources.
Ethical clearance
This is to state that patient consent is obtained for
the concerned evaluation. As it was a case review,
according to the Institutional Ethics Board ethics
clearance was not required.
REFERENCES
1. Burt M: Perceptual Deficits in Hemiplegia : Am J
of Nursing 70:1026-1029, 1970
2. Hopkins HL : Occupational Therapy
management of Cerebro Vascular Accidents and
Hemiplegia. In Willard H, Spackman C:
Occupational Therapy (10 th Edition).
Philadelphia, J. B. Lippincott Company,2003
3. Zoltan B, Siev E, Freishtat B : Perceptual and
Cognitive dysfunction in the adult stroke patient
Ed.2, Thorofare NJ, 1986, Charles B Slack
4. Golisz Kathleen, Toglia Joan: Perception &
Cognition: Willard & Spackmans Occupational
Therapy 10 th Edition, Lippincott William &
Wilkins, 2003.
25. Moshuiami--124--127.pmd 127
5. Boys M, Fisher P, Holzberg C, Reid DW.: The
OSOT Perceptual Evaluation: a research
perspective: Am J Occup Ther. 1988 Feb;42(2):
92-8.
6. Giuseppe Vallar: Constructional Apraxia and
Spatial Disorders of Drawing: CNS Spectr.
2007;12(7):527-536
7. Prudence Plummer, Meg E Morris and Judith
Dunai: Assessment of Unilateral Neglect: PHYS
THER. 2003; 83:732-740.
8. Zoltan B: Vision, Perception and Cognition Ed.3
(rev), Thorofare, NJ, 1996 Slack
9. West C, Bowen A, Hesketh A, Vail A:
Interventions for motor apraxia following stroke
(Review): The Cochrane Library 2008, Issue 1
10. Susan D. Ryerson : Hemiplegia: Neurological
Rehabilitation, Darcy Umphred, 5th ed. , Mosby
2007
11. Carol J. Wheatley : Evaluation and Treatment of
Perceptual and Perceptual Motor Deficits :
Occupational Therapy Practice Skills for Physical
Dysfunction, Pedretti, Early; 5th Edition 2001 ,
Mosby
12. Quaintana Lee: Remediating Perceptual
Impairments: Occupational Therapy for Physical
Dysfunction, 4th Edition: William & Wilkins, 1997
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 DOI Number: 10.5958/j.0973-5674.7.3.079
128 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Perceived Stress, Sources and Severity of Stress among

Physiotherapy Students in an Indian College

Tushar J Palekar1, M G Mokashi2

1 2
Principal, Professor Emeritus, Padmashree Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune

ABSTRACT

Objective: To study the Perceived stress in physiotherapy students as per questionnaire along with
assessment of corroborative clinical parameters and perceived stress score.

Method: A cross-sectional, questionnaire based survey was carried out among undergraduate
physiotherapy students of Padmashree Dr. D. Y. Patil college of physiotherapy, Pune, India. Perceived
stress was assessed using the perceived stress scale (PSS 10). A 27-item questionnaire was used to
assess sources of stress and their severity. Another 11-item questionnaire was used to find possible
institutional stress reducing factors.

Results: Of the physiotherapy students who were administered the questionnaire, 71 (74%)
respondents participated in this study. The mean age ± standard deviation (SD) of the study
participants was 19.39 ± 1.12 years, with a range of 18-23 years. Out of the 71 students, 57 (80.3%)
were female students and 14 (19.7%) were male students. The mean PSS score was 20.50 (SD 5.96).
The main sources of stress were found to be related to physical, emotional and academic factors. The
main institutional stress reducing factors were picnics (59.2%), vacations (56.3%), interaction with
friends (52.1%), and personal hobbies (54.9%).

Conclusion: High levels of perceived stress were found in Physiotherapy students. The physical,
emotional and academic factor causes stress in little to great extent.
Keywords: Stress, Undergraduate physiotherapy students, Institutional stress reducing factors, Stress inducing
factors

INTRODUCTION rarely tendency of suicide9,10 among medical students.

The presence of emotional distress affects student’s
Stress is defined as the body’s non-specific response
performance in class room as well as in their clinical
to demands made upon it, or to disturbing events in
practice.11,12 It also increases the risk of stress-induced
the environment.1,2 It is not just a stimulus or a response
disorders and deteriorating performance.11,12 Presence
but rather, it is a process by which we perceive and
of current mental distress and further health problems
cope with environmental threats and challenges.3
was found to be high in those having perceived
Personal and environmental events that cause stress
medical stress.13,14
are referred to as stressors.4 Recently incidence of stress
during professional courses is increasingly being The present curriculum of the Physiotherapy course
reported in published articles.5 ,6 is comprehensive and large. The course is demanding
in terms of students’ effort. Competition for post
Previous studies have shown fairly high incidence
graduate seats in best clinical setups as well as other
of distress, such as symptoms of depression7,8 and even
social and emotional factors influences students’
mental health. Hence the student undergoing this
Corresponding author: course is predisposed to stress. The purpose of present
Tushar J Palekar study is to find out Stress in Physiotherapy students
Principal by using self-reported questionnaires, clinical
Padmashree Dr. D. Y. Patil College of Physiotherapy,
parameters and perceived stress score.
Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune-18
Email: principal.physio@dpu.edu.in

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 129

METHOD perceived stress scale (PSS 10).15 We also assessed

Setting and Participants
The present study was undertaken at Padmashree
Dr. D.Y. Patil Physiotherapy College, Dr. D. Y. Patil
Vidyapeeth, Pune. Each year 60 students have taken
admission in Bachelor of Physiotherapy (BPT). As per
their curriculum, the students have to appear for two
internal examinations namely the Terminal and the
preliminary examinations. Therefore, they are likely
to undergo stress twice in an academic year, beginning
from entry level throughout the physiotherapy course.
The students of second, third and fourth year BPT were
invited to participate in this study.
PROCEDURE
The design of this study was a cross-sectional
survey using self-administered questionnaire. This
study has approval of Institutional ethical committee
of Dr. D. Y. Patil Vidyapeeth, Pune. A total of 95
Physiotherapy undergraduate students were
participants in this study. The students were asked to
complete a 27-item questionnaire to assess sources of
stress and their severity. Another 11-item questionnaire
was used to find possible institutional stress reducing
factors. Perceived stress was assessed using the
Table 1: Demographic Data
clinical parameters which include Pulse rate,
Respiratory rate, Blood Pressure and Body Mass Index.
DATA ANALYSIS
The data was analyzed using SPSS 15.0 version. The
mean scores of perceived stress were calculated. The
number and percentage of response of each stress
factors were calculated. Descriptive statistics were
considered for severity of stressors.
RESULTS
Demographic characteristics and perceived stress
score of the respondents
Of the physiotherapy students who were
administered the questionnaire, 71 (74%) respondents
participated in this study. The mean age ± standard
deviation (SD) of the study participants was 19.39 ±
1.12 years, with a range of 18-23 years. The majority of
participants were female (80.3%). Mean PSS score in
the study population was 20.50 (SD 5.96) (Table 1).
Mean PSS score in II BPT was 20.02 (SD 6.68), III BPT
23.80 (SD 3.94) and IV BPT it was 18.62 (SD 4.48)
(Table 2).

Class Number Percent Gender Number Percent

BPT II 40 56.3 MALE 14 19.7
BPT III 15 21.1 FEMALE 57 80.3
BPT IV 16 22.5

Table 2: Clinical Data and Perceived Stress Score

Pulse RR BP (Systolic) BP (Diastolic) Weight (Kg.) Height (cm) BMI PSS

Mean 84.26 19.78 114 70 60.59 166 24.32 20.50
SD 12.53 4.23 9.02 8.10 11.44 17.61 6.56 5.96

Stress inducing factors [28(39.4%)], ‘Other students performances being better

The most frequent [number of respondents
(percentages)] contributing factors for the sources of
stress reported by the students as “great extent/
considerable extent” were, ‘Unpredictability of
examinations’ [40 (56.6%)], ‘Fear of failure’ [35 (49.3%)],
‘Staying away from family’ [32(45.1%)], ‘High
expectations of parents for my performance’
[30(42.3%)], ‘Shortage of equipment/ lab. Facilities,
[30(42.3%)], ‘Change in the methods of study from 12th
standard’ [29(40.8%)], ‘Staying away from friends’
than mine’ [27(38%)], ‘Competition for postgraduate
seats’ [26 (36.6%)]. (Table 3, 4, 5, 6)
Stress reducing factors
The most frequent [number of respondents
(percentages)] contributing factors for reducing stress
reported by the students as “very much/considerable”
were, ‘Interaction with friends and group members’
[64 (90.1%)], ‘Personal hobbies like music, sports’ [55
(77.4%)], ‘field visits’ [52 (73.3%)], ‘Vacations and

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 130 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

holidays’ [50(70.4%)], ‘Free time during college hours’ ‘Teacher’s affection and care, [36 (50.7%)], ‘Beautiful
[45 (63.4%)], ‘Help from senior students’ [44 (62%)], campus of the college’ [(34 47.9%)] (Table 7).

Table 3: Response pattern of Academic factors

Great extent Considerable Moderate Little None

extent extent
N % N % N % N % N %
Change in the methods of study 3 4.2 26 36.6 25 35.2 10 14.1 7 9.9
from 12th standard
Unpredictability of examinations 20 28.3 20 28.3 13 18.2 8 11.3 10 14.1
Too many mid-term and unit tests 2 2.8 19 26.8 22 31 22 31 6 8.5
Too many lectures and clinics 14 19.7 11 15.5 23 32.4 17 23.9 6 8.5
Inability/ difficulty to cope with 2 2.8 4 5.6 2 2.8 28 39.4 35 49.3
English medium
Other students performances 13 18.3 14 19.7 13 18.3 23 32.4 8 11.3
being better than mine
Competition for postgraduate seats 13 18.3 13 18.3 7 9.9 9 12.7 29 40.8

Table 4: Response pattern of Physical factors

Great extent Considerable Moderate Little None

extent extent
N % N % N % N % N %
Living conditions in hostel 8 11.3 11 15.5 7 9.9 24 33.8 21 29.6
Noisy classrooms and surroundings 7 9.9 13 18.3 14 19.7 29 40.8 8 11.3
Shortage of equipment/ lab. Facilities 12 16.9 18 25.4 12 16.9 16 22.5 13 18.3
Every day travel to college and back 6 8.5 9 12.7 12 16.9 28 39.4 16 22.5
Food in canteen and hostel 9 12.7 6 8.5 19 26.8 14 19.7 23 32.4
lack of quiet surroundings / environment 9 12.7 8 11.3 21 29.6 15 21.1 18 25.4
Inadequate library facilities 12 9.9 16 18.3 8 12.7 18 42.3 17 16.9

Table 5: Response pattern of Social factors

Great extent Considerable Moderate Little None

extent extent
N % N % N % N % N %
Inability to speak in group or public 7 9.9 13 18.3 9 12.7 30 42.3 12 16.9
High expectations of parents for 11 15.5 19 26.8 15 21.1 15 21.1 11 15.5
my performance
Interference in study by parents 2 2.8 9 12.7 6 8.5 34 47.9 20 28.2
Staying away from family 19 26.8 13 18.3 10 14.1 14 19.7 15 21.1
Trouble from senior students 2 2.8 5 7 9 12.7 20 28.2 35 49.3
Having to do household work after 3 4.2 5 7 13 18.3 23 32.4 27 38
returning from college
Inadequate social/ financial support 1 1.4 5 7 6 8.5 29 40.8 30 42.3

Table 6: Response pattern of Emotional factors

Great extent Considerable Moderate Little None

extent extent
N % N % N % N % N %
Feeling that you do not have time 14 19.7 10 14.1 15 21.1 20 28.2 12 16.9
for personal hobbies and sports
Getting involved in love affairs 3 4.2 0 0 6 8.5 20 28.2 42 59.2
Not accepted by other students 1 1.4 4 5.6 7 9.9 20 28.2 39 54.9
Conflicts with colleagues 3 4.2 6 8.5 15 21.1 24 33.8 23 32.4
Fear of failure 19 26.8 16 22.5 6 8.5 21 29.6 9 12.7
Indifferent behavior of teachers 9 12.7 10 14.1 10 14.1 12 16.9 30 42.3
Staying away from friends. 14 19.7 14 19.7 11 15.5 16 22.5 16 22.5

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 131

Table 7: Response pattern of stress reducing factors

Very much Considerable Some what little None

N % N % N % N % N %
Beautiful campus of the college 11 15.5 23 32.4 15 21.1 17 23.9 5 7
Teachers’ affection and care 17 23.9 19 26.8 13 18.3 16 22.5 6 8.5
Interaction with your friends 37 52.1 27 38 5 7 2 2.8 0 0
and group members
Vacations and holidays 40 56.3 10 14.1 14 19.7 7 9.9 0 0
Field visits 42 59.2 10 14.1 4 5.6 12 16.9 3 4.2
Student - mentor programme 9 12.7 11 15.5 14 19.7 27 38 10 14.1
Personal hobbies like music, sports 39 54.9 16 22.5 6 8.5 7 9.9 3 4.2
Help from senior students 20 28.2 24 33.8 7 9.9 16 22.5 4 5.6
Free time during college hours 33 46.5 12 16.9 8 11.3 16 22.5 2 2.8
Attending Workshops/Conferences 8 11.3 13 18.3 18 25.4 18 25.4 14 19.7
outside the college campus
Educational tours 17 23.9 13 18.3 18 25.4 12 16.9 11 15.5

DISCUSSION
In our study, we evaluated perceived stress among
physiotherapy students including its sources and
severity, which may be of importance to both
physiotherapy teachers and a psychologist. To our
knowledge such a detailed study has not been reported
in physiotherapy students in the country.
In our study, physiotherapy students reported a
higher level of perceived stress, which was higher
among second and third year BPT students. Academic
and social stressors were reportedly more common
both in terms of frequency of occurrence and severity.
The main institutional stress reducing factors were
field visits (59.2%), vacations (56.3%), interaction with
friends (52.1%), and personal hobbies (54.9%). Life of
health care professional can be very stressful. Mild,
moderate and high levels of stress and even burnout
have been reported amongst medical students and
healthcare professional from different countries.16, 17,18
The amount and severity of stress experienced by
health professional students may vary according the
settings of the college, the curricula, examination
pattern etc. Previous studies from medical schools in
different countries have reported varying levels of
stress. A study from Pakistan University has reported
that more than 90% of its students experienced stress
during their course.19 Similarly 73% students had
perceived stress at Indian medical college during
medical schooling.20 In Thai medical school 61.4% of
Students had reported incidence of stress as calculated
by the Thai stress test.21 These studies have used
different instruments to assess stress. This limits the
comparability among these studies. However, we
chose the PSS 10 since this scale has been documented
for its reliability and validity.15
Most students had experienced academic, social
and emotional stressors. Among academic stressors,
‘Unpredictability of examinations’ and ‘Change in the
methods of study from 12th standard’ were the chief
sources of stress. Although examinations are important
in the health care training as a standard for evaluation/
assessment, examinations also facilitate student’s
learning and give feedback to the teachers. Yet,
previous studies have also reported that examinations
are frequent sources of stress among medical
students.19,20,21
There may be a need to study the examination
system to make it less stressful to the students. It is
obvious that most of the students feel that ‘Change in
the methods of study from 12th standard’ is one of the
sources of stress. Lack of command over English
language did not pose any problem in almost 90%
students. Those students whose method of study in
12th standard was not English may put to stress. Other
important source of stress was related to social and
emotional factors. This may be due to lack of time for
self, family, friends and entertainment owing to
demands of physiotherapy curriculum. Another
reason could be high expectation from the parents
(62.9%) and fear of failure as reported by the students
(57.8%).
Present study also investigates institutional stress
reducing factors. The main institutional stress reducing
factors were field visits, vacations, interaction with
friends, and personal hobbies. Similarly study done
by A N Supe reported that friends, Gymkhana and

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 132 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
personal hobbies were the most common stress
relieving factor in medical students.20
Limitations
The information provided by the students was
based on self-reported questionnaire in this cross-
sectional survey. Therefore, there is some potential for
reporting bias which may have occurred because of
the respondents’ interpretation of the questions or
desire to report their emotions in a certain way or
simply because of inaccuracies of responses. In
addition, the study took place at only one college,
which could differ in the generalizability to other
institutions.
CONCLUSION
High levels of perceived stress were found in
(60.5%) Physiotherapy students. The Academic, social
and emotional factors causes ‘No to little stress in
(28.03%) students while Moderate stress in (16.3%)
students. ‘Considerable to a great extent’ stress was
found in (13.78%) students. We encourage building up
and adopting institutional stress reducing factors to
relieve stress among these students. Especially,
‘Teachers’ perceived affectionate attitude has scope for
improvisation since almost 40% students felt
‘Indifferent behavior of teachers’. Similarly forming
self-support groups within the students has great scope
since only 22% felt trouble from Sr. students, while over
70% had help from them. This aspect should be
improved to reduce stress by including good senior
students in ‘Student Mentor programme’ which
appeared to be appreciated by less than 50% students.
There is need that examinations must be perceived as
student-friendly and parental support should be
healthier.
ACKNOWLEDGEMENT
We are very thankful to Dr. Shahnawaz Anwer (PT),
Assistant Professor, Padmashree Dr. D. Y. Patil College
of Physiotherapy, Pune, for his valuable suggestions
and contributions for making out this manuscript.
Conflict of Interest: None Declared
Funding: None
REFERENCES
1. Selye H. Stress without Distress. New York:
Harper & Row. 1974.
26. MS-TJP-Stress--128--133.pmd 132
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5. Aktekin M, Karaman T, Senol YY, Erdem S,
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14. Tyssen R, Vaghum P, Gronvold NT, Ekeberg O.
Factors in medical school that predict
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measure of perceived stress. J Health Soc Behav
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commitment, career plans, and perceived stress:
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 DOI Number: 10.5958/j.0973-5674.7.3.080
134 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of High Frequency, Low Magnitude Vibration on

Bone Density and Lean Content in Children with Down
Syndrome

Naglaa A Zaky1, Amira E Elbagalaty1

1
Department of Physical Therapy for Growth and Development Disorders in Children and its Surgery, Faculty of Physical
Therapy, Cairo University, Egypt

ABSTRACT

Purpose: to examine the effects of high frequency, low magnitude vibration on bone density and
muscle content in children with Down syndrome.

Design: Experimental study (randomized control trial)

Subjects: Thirty children with DS from both sexes, ranging in age from 4 to 7 years. They were
divided randomly into two groups of equal number A (control) and B (study)

Procedure: Evaluation before and after three months of treatment for each child of the two groups
was conducted via using dual X-ray absorptiometry (DXA). Group A received a selected exercise
program, while group B received the same exercise program given to group A in addition to
proprioceptive stimulation in the form of whole body vibration (WBV) training.

Results: Significant improvement was observed in the two groups when comparing their pre and
post-treatment mean values. The mean ± SD of BMD post treatment for control group was 0.75 ± 0.03
and that for study group was 0.79 ± 0.03. The mean difference between both groups was -0.04. There
was a significant difference between control and study groups in BMD post treatment.

Conclusion: mechanical vibration seems to improve BMD and muscular content in DS children
making the treatment of osteoporosis possible.
Keywords: Down Syndrome (DS), Bone Mineral Density (BMD), Vibration

INTRODUCTION significant delays in the onset of motor skills, including

Peak bone mass, which is achieved soon after the
end of sexual development, is the most important
determinant of bone mass and osteoporosis later in
life 1-2. Children with disabilities such as cerebral palsy
(CP) and Down syndrome are particularly vulnerable
to deficits in bone mass accretion due to decreased
mobility and weight-bearing which reduces
mechanical loading of the skeleton. 3-4
BACKGROUND
qualitative differences in movement patterns,
compared with the typical development in children
without DS.8-9
Most patients with Down syndrome require
treatment during childhood because of mental or
growth retardation. Hypotonia, and nutritional and
hormonal deficiencies at critical times of bone-mass
accretion, namely in infancy and adolescence, have a
major role in the impairment of peak bone-mass
accrual and correlate with osteoporosis.10

Down syndrome (DS) is one of the few disabilities
that carries with it the certainty of delays in all of the
developmental domains.5 In the United States, DS
occurs approximately 1.36 times in every 1,000 live
births. 6 Down syndrome is a common cause of
cognitive deficits in childhood 7 and results in
Whole body vibration has shown promise as an
alternative method for stimulating both increases in
bone mass and improvements in muscle
performance11-12. Animal studies have demonstrated
that low-magnitude, high-frequency vibration can
increase bone mass and bone strength and prevent

27. Nagala egypt--134--139.pmd 134 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 135

bone loss 13-14. Studies in humans have also shown a proprioceptive stimulation in the form of whole body
benefit to bone in post-menopausal women 11 and a vibration (WBV) training using a special device for 3
benefit to both bone and muscle in young women, ages months.
15-20 years, with low bone density 15. In children with
disabilities, a small pilot study found those 6 months
of low-magnitude; high-frequency (0.3g, 90 Hz) whole
body vibration increased in bone density and
prevented bone loss in the proximal tibias of a
heterogeneous group of participants 16.However whole
body vibration (WBV) seems to be beneficial to
improve BMD in disabled children13-14

The purpose of this study was to examine the effects

of high frequency, low magnitude vibration on bone
and muscle in children with Down syndrome. We were
interested in this group because they are at the age
which is considered critical period at which children
have the most potential to accumulate bone 17.
Fig. 1. Whole Body Vibration Device.
METHOD
Whole Body Vibration (WBV) Device (Fig.1) (serial
Participants
no. 0251460, manufactured in China 2005), designed
Thirty infants with DS of both sexes from the to provide vibration and proprioceptive stimulation.
Outpatient Clinic of The Faculty of Physical Therapy It enables the therapist to check the time and speed
and The National institute of Neuromotor disorders through display. It consists of the following parts:
were recruited to participate in the study. They were
(a) Transverse frame.
divided into two groups of equal numbers (control
group and study group). (b) Platform board.

Inclusion criteria: (c) Right and left handles.

The participants were children with DS ages 4-7
years who were able to stand for 10 minutes without
handheld support.
Exclusion criteria
- The presence of a seizure disorder
- Vision problems.
- Any other medical conditions that would severely
limit a child’s participation in the vibration
intervention.
Each child in both groups was evaluated before and
after three months of treatment by Dual Energy X-ray
Absorptiometry (DEXA) (for measuring bone mineral
density of total body and total body lean content by
using a standard technique for measuring bone
mineral content with very low dose of radiation of
acceptable precision using bone mineral content in
grams (gm) by area of bone measured (cm2) and will
express density as grams/ cm2.

INTERVENTION

Children in the control group received a specially

selected physiotherapy program for 3 months which
include: facilitation of equilibrium and protective
reactions, stimulatory techniques and muscle
strengthening & endurance training.

Children in the study group received the same

selected physiotherapy program in addition to Fig. 2. Bone mineral density testing apparatus (DXA)

27. Nagala egypt--134--139.pmd 135 8/1/2013, 8:31 AM

 136 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
RESULTS
Comparisons of pre and post treatment mean
values of BMD and lean content for control group and
Test Parameters
Mean
Pre
BMD 0.70 ± 0.01
Lean content 5.79 ± 0.2
Post treatment mean values of BMD for both groups
(control and study) were compared .The mean value
± SD of BMD post treatment for control group was
0.75 ± 0.03 and that for study group was 0.79 ± 0.03.
The mean difference between both groups was -0.04.
There was a significant difference between control and
study groups in BMD post treatment (p = 0.007). (figure 3).
Fig (3): Post treatment mean values of BMD in control and study
groups.
Post treatment mean values of Lean for both groups
(control and study) were compared. The mean value
± SD of lean post treatment for control group was 6.42
± 0.3 and that for study group was 6.67 ± 0.25. The
mean difference between both groups was -0.25. There
was a significant difference between control and study
groups in lean post treatment (p = 0.02). (figure 4).
Fig (4): Post treatment mean values of lean in control and study
groups.
27. Nagala egypt--134--139.pmd 136
study group revealed significant improvement.(Table
1, figure 3).
Table (1)
Control group Study group
P Mean P
Post Pre Post
0.75 ± 0.03 0.0001 0.71 ± 0.02 0.79 ± 0.03 0.0001
6.42 ± 0.3 0.0001 5.8 ± 0.17 6.67 ± 0.25 0.0001
DISCUSSION
In this study, the primary purpose was to
investigate whether the vibration intervention in
children with Down syndrome is beneficial to bone
mineral density and muscular content or not.
Low bone mass and the associated increased
fracture rates are clinical features that complicate
DS10.As the life expectancy of individuals with DS has
increased to greater than age 50 18-19, the bone health of
DS patients has become an important medical issue.
With the increasing life expectancy, many concerns
regarding the risk of osteoporosis have been raised 20-
21-22
. In fact, the accrual of bone mass during childhood
and adolescence may reduce osteoporosis risk later in
life and low bone mass in young adulthood is a strong
risk factor for later osteoporosis and fracture 23-24.
Several investigators reported that, adults (and
children) with DS have lower bone mass, expressed
as BMD, especially in the lumbar spine, compared with
their peers without mental retardation or with mental
retardation but without DS. 20-25-26-27-28
Dual radiograph absorptiometry (DXA) is the most
widely used method for assessment of BMD and is
considered the “gold standard”. DXA uses 2 different
radiographic energies to record attenuation profiles at
2 different photon energies. Attenuation is largely
determined by tissue density and thickness. At a low
energy, bone attenuation is greater than soft tissue
attenuation. At high energy, they are similar. This
allows the distinction between bone and soft tissue.
The energy absorption of the 2 different energy
radiographic beams is used to provide estimates of the
amounts of bone mineral29
The results of the current study at the end of
treatment period, showed a significant improvement
in the measuring variables in both study groups, but
in favor to study group. Also the percentage of
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 137
improvement of the measuring variables was higher
in study group than control group.
Mechanical vibration is a traditional and safe
physical therapy modality that is widely accepted in
diagnosis and treatment of the disease, rehabilitation
and sports medicine.30-31.In the skeletal system, the
diagnosis and treatment is mainly based on cytological
and zoological research. Previous animal experiments
showed that mechanical vibration with appropriate
frequency can affect energy metabolism, gene
activation, secretion of growth factors, and cell matrix
synthesis of bone cells.32-33 Theoretically, mechanical
vibration can increase bone mass in the human
skeleton as well.
It was showed that the 8-month course of vibratory
exercise using a reciprocating plate is effective to
improve hip BMD and balance. A few studies have
shown recently the effectiveness of the up-and-down
plate for increasing bone mineral density (BMD). 34
With appropriate frequency, mechanical vibration
can affect energy metabolism of bone cell, gene
activation and secretion of growth factors, and
synthesis of other cell matrix.35-36.Under appropriate
conditions, vibration can increase the synthesis of DNA
in cultured cartilage cells and polysaccharide protein,
and the proliferation and differentiation of osteoblasts
also can be greatly accelerated[37,38] making the
treatment of osteoporosis and osteoarthritis possible.39
Whole body vibration (WBV) has become a popular
method of neuromuscular training due to the recent
emergence in the benefits of vibration on
neuromuscular performance. These benefits have
included improved strength, jump height, power,
flexibility, and balance 40-41.For this reason, it is believed
that strength training with WBV may provide superior
training outcomes (i.e., increased strength
development) compared to traditional strength
training methods alone 42-43. However, many of the
studies that indicated beneficial outcomes were either
acute studies or training studies that used direct
methods of vibration applied to the muscle belly or
tendon as opposed to WBV. Therefore, little is known
about the training-related effects of WBV on strength
development and neural activation.
CONCLUSION
Recently, there has been increased interest in the
use of vibration as a form of exercise training for
handicapped children. This study found that children
27. Nagala egypt--134--139.pmd 137
with Down syndrome exposed to vibration showed
improvements in BMD and lean content as compared
to traditional exercise programs and that vibration
provides additional benefit to traditional exercise
programs. Additional studies are needed to determine
safe and effective parameters for vibration training in
different age groups.
ACKNOWLEDGEMENT
The authors would like to express their appreciation
to all children and their parents who participated in
this study with all content and cooperation.
Ethical clearance
All subjects were informed about the study
procedure and signed consent forms approved by the
local research ethical Committee for the Protection of
Human Subjects, at Faculty of physical therapy, Cairo
University.
Conflict of Interest
There is no interest of conflict with any
organization, and this research is not funded.
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 DOI Number: 10.5958/j.0973-5674.7.3.081
140 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Comparative Study between Relaxation Technique and

Aerobic Exercise in Fatigue During Chemotherapy in
Acute Lymphoblastic Leukemia in Children

Bhatt Kaushal D1, Dhoriyani Narendra B2, Smitha D3

1
Physiotherapist & CEO, KIDS Paediatric Physiotherapy Clinic, Bhavnagar, 2Tutor Cum Physiotherapist, Government
Physiotherapy College, Jamangar, 3Assistant Professor, Shree Devi College of Physiotherapy, Mangalore

ABSTRACT

Background: Cancer is most common cause of death in children. Acute lymphoblastic leukemia
affecting around 83% of childhood cancer. Children receiving chemotherapeutic drug like Vincirstine,
Predisome and L-asparaginase are suffering from side effects like fatigue, peripheral neuropathy,
decreased in muscle strength etc. To reduce Fatigue, two method Aerobic exercise & Relaxation
technique can be given in different groups. So to compare the efficacy of Aerobic exercise and
Relaxation technique to reduce fatigue during chemotherapy in acute lymphoblastic leukemia in
children.

Materials and Method: 40 patients refereed by private oncologist, from government Wenlock hospital
were randomly divided in two groups: Group-A received Aerobic exercise, Group-B received
Jacobson's Relaxation technique. Each group received 20 min of intervention daily for a period of 3
weeks. Pre test fatigue level assessment done by Piper Fatigue Scale. After 3 weeks of Exercise protocol
given for both groups, fatigue level assessment was again done by Piper Fatigue Scale.

Results: There was a significant reduction in level of fatigue in both groups, but more reduction is
seen in group receiving Relaxation technique. So this study is highly significant in favor of Group B.
(p < 0.01).

Discussion and Conclusion: Relaxation technique helps them to reduce disease related or treatment
related stress and possibly Relaxation technique is easy to perform for children and children enjoy
doing that. This study concludes that Relaxation technique is more effective in reduction of fatigue
than Aerobic exercise in children.
Keywords: Acute Lymphoblastic Leukemia, Fatigue, Aerobic exercise, Relaxation technique

INTRODUCTION 375 BC Hippocrates of Cos coined the word

The incidences of malignant disease vary with age,
sex, and geographic locations. Both females and males
have almost the same proportion of cancer. Pediatrics
cancers are far less than what is seen in adults, but it is
growing in importance in terms of mortality. Cancer
is a leading cause of death in children up to 14 years
in the developed world.1 In a historical sense, in 460-
Corresponding author:
Dhoriyani Naredra B
Tutor Cum Physiotherapist
Mahendranagar, Ta: Morbi , Rajkot, Gujarat, India. Ph:
+91-987-971-8851
E-mail: Narendra41067@yahoo,com
‘Carcinomas’. The Latin word ‘Cancrum’ which means
‘crab’ might have origin to the word “Cancer”.1 In
recent times in medical field the word cancer has been
replaced by Neoplasm; it indicates an abnormal type
of new growth, not only evident in the intact animal,
but which can also be seen in tissue culture.
Acute Leukemia is a heterogeneous group of
neoplasm arising from clonal, neoplastic proliferations
of immature cells of the hematopoietic system, which
are characterized by aberrant or arrested
differentiation.2 Viral infection, Oncogens, like t(8;14)
for Acute Lymphoblastic Leukemia ionizing radiation,
chemical agents like Benzene, Congenital
chromological abnormalities, Immunological

28. Narendra--140--145.pmd 140 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 141
deficiency syndrome are some of the etiological factors
responsible for Leukemia.3 Leukemia is regarded as a
condition in which there is clonal proliferation of
malignant stem cell in the bone marrow. Leukemia is
classified Chronic and Acute leukemia. Chronic
Leukemia is further classified as Chronic Myelocytic
Leukemia(CML) and Chronic Lymphoblastic
Leukemia(CLL) whereas Acute leukemia is further
classified as Acute Myelocytic Leukemia(AML) and
Acute Lymphoblastic Leukemia(ALL)2
Acute Lymphoblastic Leukemia is most common
in children with its highest incidence between 1 to 5
years 3 & it accounts for 80% of childhood leukemia.2
The phases of treatment are: Induction drug therapy,
consolidation therapy, CNS prophylaxis and remission
maintenance therapy. The side effects of chemotherapy
are phlebitis or extravasations at injection site, acute
and chronic weakness and fatigue, hypoxia, myopathy,
peripheral neuropathy and cardiomyopathy. The late
side effects are pulmonary fibrosis and secondary
malignancy.
The most common complaints of people suffering
from cancer are Fatigue, especially those who are
receiving chemotherapy. It is difficult to describe and
patient express it in a variety of ways, using terms such
as tired, weak, exhausted, weary, worn-out, fatigued,
heavy or slow. It is the condition characterized by
distress and decreased functional status. Fatigue
usually affects the physical performance and activity
of daily living.
Fatigue is the most important and often untreated
side effects in cancer today. Cancer related fatigue is
largely a subjective experience, and relies on self
reporting. Also, physician and patients alike many
view cancer related fatigue as something to be
endured, rather than true symptoms that require an
intervention. It may be too easy to overlook a symptom
such as fatigue when focusing on aggressive
management of the tumor to ensure the patient’s
survival. There are many factors, both physical and
emotional, which can cause fatigue. This includes
disease itself, treatment, medications, pain, nutritional
deficits, anxiety and depression.6 Various physical
therapy interventions like Aerobic exercises,
Strengthening exercises, Stretching, and Relaxation
techniques are used to reduce fatigue in cancer
patients. Among all these Aerobic exercises and
Relaxation techniques are preferred widely by the
therapist.
28. Narendra--140--145.pmd 141
Aerobic Exercise
Aerobic exercise is defined as sub maximal,
rhythmic, repetitive exercise of large muscle group,
during which the needed energy is supplied by
inspired oxygen. Main fuel source for aerobic exercise
are glycogen, fat and protein. ATP is resynthesized in
mitochondria of the muscle cell. The ability to
metabolize oxygen & other substrates is related to the
number & concentration of the mitochondria & cells.
Maximal capacity of the aerobic system is great (90.0
mol ATP) but maximal power of the system is small
(1.0molATP/min). The system predominates over the
other energy systems after the second minute of
exercise.7 Activity that is of sub maximal intensity
lasting 30 minutes or more taxes a high percentage of
the aerobic system & develops endurance. Other
benefit of exercise are increase endurance, improve
appetite improve heart’s pumping ability etc.7
Relaxation techniques: 8,9,10
“State of consciousness characterized by feeling of
peace and release from tension anxiety and fear.” In
1970’s Herbert Benson, MD use word ‘relaxation
response’. This response moderates sympathetic
arousal and produces health benefit like: Decrease
heart rate and blood pressure, lowered lipid level,
decrease levels of circulating stress hormones,
improved immune functioning. Various Relaxation
techniques are Jacobson’s Progressive muscle
relaxation, Meditation, Guided imagery or
visualization. There are studies available which proved
effect of Aerobic exercise and Relaxation techniques
in the management of fatigue for the cancer patients
receiving chemotherapy but as concluded in a study
by P Jacobson, limited support available for these type
of interventions.11
There is lack of evidence in comparing both
interventions to reduce level of fatigue in cancer
patients who is receiving chemotherapy treatment.
This study is proposed to compare the efficacy of
Aerobic exercise and the efficacy of Relaxation
technique in fatigue during chemotherapy in Acute
Lymphoblastic Leukemia in children.
MATERIALS AND METHODOLOGY
A randomized control study was conducted at
Physiotherapy Department of Govt. Wenlock hospital
and Shree Devi College of Physiotherapy. 40 Acute
Lymphoblastic Leukemia patients of 8 to 16 years were
referred by an Oncologist to the Physiotherapy
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 142 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
department, who were screened using Oncology
screening assessment for general health status and
Piper Fatigue Scale to assess fatigue. Patients who
scored 4–6 and above in the Piper Fatigue Scale were
eligible for the study. The total number of eligible
patients during the study was 36(31 Boys, 5 Girls)
based on the inclusion and exclusion criteria. The
inclusion criteria were, Patient diagnosed with acute
lymphoblastic leukemia by the consulting oncologist
and who have already completed first dose of
chemotherapy and complaining fatigue. The patients
were excluded if they had unstable cardio-vascular
parameters, patients who have undergone recent
surgery or any cardiac disease-illness. Subjects were
randomly divided into two groups using sealed
envelope method. Both groups were explained about
their respective procedure which they would be
undergoing for a period of 3 weeks and were made to
sign a consent form.
The subjects of both groups attended 1 session per
day for 5 days / week for 3 weeks. All vital parameters
were measured to confirm that the subjects were stable.
Patients were called to department before their meal
or 2 hours after meal. Pre study fatigue level was
measured by Piper fatigue scale in the wards if they
were in patients, or in oncologist’s clinic if on OPD
basis.
Group A(Aerobic Exercise Group) subjects were
explained general warm-up exercise, cycling on static
bicycle followed by walking on treadmill were
Table 1.1. Comparison of level of fatigue from Pre to Post intervention for Group A (Aerobic exercise)
Aerobic exercise
PRE-POST
In Group A mean difference of fatigue is 1.17 and t-
value is 5.19 and p < 0.05, so in Group A (Aerobic
Table 1.2. Comparison of level of fatigue from Pre to Post intervention for Group B (Relaxation technique)
Relaxation technique
PRE-POST
In group B mean difference of fatigue 1.98. t-value
12.94 and p< 0.05 so in Group B (Relaxation technique)
there is very highly significant difference in fatigue
level after relaxation technique.
Table 1.3. Comparison between Mean Difference of Group A (Aerobic exercise) and Group B (Relaxation technique)
Aerobic exercise & Relaxation technique
28. Narendra--140--145.pmd 142
demonstrated. After the demonstration the
participants were instructed to follow the same.
(Warm-up exercise for 5 minutes, cycling for 5 minutes
and treadmill walking for 5 minutes.) Time was then
measured by stop watch. This session was followed
by cool down period for 5 minutes. All sessions were
conducted under observation and in presence of
subject’s caretaker. Vital parameters were checked
during and after the study. In Group B (Relaxation
Technique Group) a well ventilated, quiet and peaceful
room was chosen. Jacobson’s relaxation technique was
demonstrated to the subjects of this group. Then they
were encouraged to perform same technique for 15
minutes. All sessions were conducted under
observation and in presence of subjects care taker. Vital
parameters were checked during and after the study.
Post-intervention outcome measures were
reassessed at the end of 3 weeks of exercise protocol.
Pre to post comparison of outcome measure of each
group was done by students paired‘t’ test. Comparison
between the two groups i.e. group A and group B was
done using students unpaired‘t’ test. Mean and
standard deviation were calculated and data were
subjected to statistical analysis using SPSS software.
RESULTS
From the table 1.1 and table 1.2 it is understood
that there was highly significant pre to post changes
was found in scores of Piper Fatigue Scales in both the
groups.
Mean Difference t-value p-value Result
1.17 5.197 0.000 P<0.05 HS
exercise) there is highly significant difference in fatigue
level after aerobic exercise.
Mean Difference t-value p-value Result
1.98 12.94 0.000 P<0.05 HS
It shows that the interventions, Aerobic exercise and
Relaxation technique are good to decrease fatigue.
Mean Difference t-value p-value RESULT
A 1.17B 1.98 2.96 0.005 P<0.001 VHS
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 143
In Group A the mean difference of pre to post is
1.17 and in Group B the mean difference of pre to post
is 1.98. When this two groups mean difference were
compared it is found that there is very highly
significant (P<0.001) difference between the groups.
Group B (Relaxation technique group) had better
recovery from fatigue then the Group A (Aerobic
Exercise Group).
DISCUSSION AND CONCLUSION
According to Seattle Cancer Care Alliance, Physical
therapy department, Ease. cancer patients with
complain of fatigue and who need strength training
and cardio-vascular education is referred to physical
therapy department.12 Patients with cancer frequently
suffer from extreme stress over a long period of time,
causing them to spend energy and experience high
level fatigue. Other factors that causing fatigue are
anemia, medications, anorexia, metabolic
disturbances, hormone deficiency, pain or infection.
Anemia, a decrease in the red blood cells, which
leads to fatigue. An important part of red blood cells
is hemoglobin. When hemoglobin is low, oxygen
levels decrease and it becomes difficult to sustain its
normal activity level.27 Aerobic exercise is helpful to
increase red blood cell counts which ultimately
increase Hb level and oxygen carrying capacity of
blood so that reduce fatigue after chemotherapy.
Cycling, home based or institute based walking on
treadmill are ways to activate aerobic system of the
body. 28 Exercise training can increase functional
capacity, leading to reduced effort and decreased
fatigue.29 This way aerobic exercise reduce fatigue,
improve physical performance and improve quality
of life.
The result of this study indicates that Group A’s
level of fatigue was reduced from 4.36 to 3.19 with
p<0.05. So reduction of level of fatigue is 1.17 and
Group B’s fatigue level was reduced from 4.37 to 2.39
with p<0.05. So reduction in level of fatigue for Group
B is 1.98. This indicates that both the exercise helps to
reduce fatigue significantly. When the mean difference
of both the group where compared it indicates very
highly significant(P<0.001) improvement is seen in
Group B(Relaxation Technique) than Group A(Aerobic
Exercise Group). The reason for improvement may be
the Relaxation technique helps to reduce stress in
cancer patients. Relaxation technique may help
patients to achieve a physical restfulness that reduces
their anxiety and reactivity of unpleasant stimuli. This
28. Narendra--140--145.pmd 143
leads them to mental peacefulness. “The American
cancer society’s” guideline to cope up with cancer
related fatigue; it is mentioned that relaxation
technique may help to reduce stress in cancer
patients.30, 31
Relaxation technique helps them to reduce disease
related or treatment related stress and possibly
Relaxation technique is easy to perform for children
and we observed that children enjoy doing that. That
could be a reason for relaxation technique show better
result. Thus, from the study result it is concluded that
Relaxation technique is better that the Aerobic Exercise
to reduce fatigue in Acute Lymphoblastic Leukemia.
The limitations of study were as it was done on
smaller sample size and treatment protocol was of
smaller duration and it is done on patients of 8-16 years
age group. There may be different result if Aerobic
exercise were given for longer duration and can be
given after relaxation technique. This study can be
further extended by conducting on different types of
cancer with different types of physical therapy
interventions.
ACKNOWLEDGEMENTS
The authors are thankful to Principal and Board of
Trustee, Shree Devi College for providing laboratory
facility and funding for study.
Ethical Clearance: The study was approved by
Research and Development and Ethical committee of
Shree Devi college of Physiotherapy.
Source of Funding: The study was sponsored by Shree
Devi College.
Conflict of Interest: The study was partly sponsored
by Shree Devi College, however it does not had any
role in study design, in collection, analysis or
interpretation of the data; or in writing the manuscript
or the decision to publish the results.
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 DOI Number: 10.5958/j.0973-5674.7.3.082
146 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Predictors of Job Satisfaction among Physiotherapy

Professionals

Nidhi Gupta1, Shabnam Joshi2

1
Consultant Physiotherapist, Ayushman Hospital, Hisar, 2Incharge, Department of Physiotherapy, Guru Jambheshwar
University of Science & Technology, Hisar, Haryana

ABSTRACT

Background: The aim of the study was to find out the best predictors of job satisfaction and to
investigate the level of job satisfaction among physiotherapists.

Method: A self-administrated questionnaire survey was conducted in December 2008.

Data were collected from 196 physiotherapists in government and private health care settings,
institutions located in northern regions of India. The response rate was 77.55%.

Results: 72 women (51.43%) and 68 men (48.57%) participated in the study. The percentage of satisfied
physiotherapists was 56.4%. Logistic regression analysis showed that the most important predictors
of job satisfaction were: (1) Salary (OR=3.694, 95% CI 2.340-5.832), (2) Interesting (OR=1.937, 95% CI
1.009-3.719), (3) Fulfilling (OR=1.679, 95% CI 0.009-2.835). Job satisfaction dimensions indicate that
highest dissatisfaction levels occur in the area of salary and job security. The percentage of satisfaction
ratings was higher in men (65.3%) than in women (47.1%). Post graduate professionals were found to
be more satisfied (70.7%) as compared to their graduate counterparts.

Conclusion: This study concludes that salary, interest in work and fulfillment in job are important
predictors of job satisfaction among physiotherapy professionals. The result shows that a total of 79
(56.4%) physiotherapists were globally satisfied with their job. The percentage of satisfaction ratings
was higher in men (65.3%) than in women (47.1%).
Keywords: Physiotherapy, Job Satisfaction, Predictors

INTRODUCTION profession that is undergoing dynamic and sometimes

Physiotherapy is referred to as physical therapy,
involves evaluating, diagnosing, and treating a range
of diseases, disorders, and disabilities using
physical means. Employment opportunities for
physiotherapists are tremendous as it is a career where
the demand exceeds supply.
In India the demand is rapidly increasing. It is
estimated that one physiotherapist is required per
10,000 people.[2]
Satisfaction with one’s profession can affect
motivation at work, career decisions, personal health
and relationship with others. Those working in a
unpredictable changes can be especially susceptible
to uncertainty and reduced professional satisfaction.
Behavioral and social science research suggests that
job satisfaction and job performance are positively
correlated . [5] Job satisfaction and morale among
medical practitioners is a current concern
worldwide.[17,31] Poor job satisfaction leads to increased
physician turnover, adversely affecting medical care
.[7,26] Recent research into some determinants of job
satisfaction has examined individual factors as well
as the organization’s role .[15] Calnan et al [9] showed
that people respond differently to similar working
conditions.

29. Nidhi Gupta--146--151.pmd 146 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 147
Job satisfaction is one of the central variables in
work and organizational psychology and is seen as an
important indicator of working life quality. [14,35]
Satisfied employees tend to be more productive and
creative.
Job demands and job control have been reported
to have several interactive effects on employee well-
being and health in specific occupational groups.[11,12]
Karasek and colleagues observed that a level of high
control over work is accompanied by positive health
characteristics, whereas heavy burdens at work lead
to increased disturbances in health[20]. A few factors like
autonomy, pay, task demands and organizational
policies are known to have a significant effect on job
satisfaction.[8,30]
MATERIALS AND METHOD
A self-administrated questionnaire survey was
conducted in December 2008. 196 respondents were
selected from physiotherapists practicing in Delhi,
Gurgaon, Haryana and Chandigarh by purposive
sampling method.
Physiotherapists who were in profession with the
minimum qualification of Bachelor ’s degree were
included and those who were either diploma holders
or involved in research or were inactive at the time of
the survey were excluded from the study.
Instrumentation: A self-administered
questionnaire survey was selected as the appropriate
tool for data collection. The questionnaire consisted
of two parts. In Part 1 of the survey sought
demographic information: gender, years of
professional experience and professional status. Part
2 consisted of fifteen statements which were
considered important in the assessment of job
satisfaction in the professional practice of
physiotherapy. A literature review was conducted to
create a list of dimensions and the fifteen most common
were chosen for inclusion in the questionnaire. These
included: leadership, mental stress, relationships with
co-workers and superiors, working conditions,
achievement, recognition, salary, advancement
opportunities, interesting, fulfilling, autonomy,
paperwork, improvement in work, job security,
physical demanding and workload distribution.
29. Nidhi Gupta--146--151.pmd 147
Procedure and Participants: The framed
questionnaire was presented to a group of
physiotherapists for comments and criticisms. After
that, the items were modified to improve the
questionnaire and make it easier.
42 surveys out of total 196 were mailed to the
participants with a letter of explanation concerning the
purpose of the study with a stamped addressed reply
envelope. 98 surveys were collected in hand with
attached consent form copies.
Scoring: In the questionnaire, the respondents were
asked to rate their level of agreement or disagreement
for each statement on a five-point Likert-type scale on
a continuum from strongly disagree to strongly agree.
(1=strongly disagree, 2=disagree, 3= neutral 4=agree,
5=strongly agree). Agreement score of 5 indicated the
highest degree of satisfaction and score of 1, the highest
dissatisfaction. Thus, the maximum possible
agreement score would be 75, and lowest disagreement
score would be 15.
Reliability estimates: An alpha value of 0.70 or
higher was considered as acceptable reliability for
group comparisons [13,24]. The overall questionnaire had
a coefficient alpha value of 0.75.
Data Analysis: In this study SPSS version 15.0 for
statistical analyses was used. The missing values were
checked prior to further statistical analysis. Missing
data analysis showed that 140 (71.42%) respondents
had no missing values. Nine (4.59%) respondents had
one missing value, three (1.53%) respondents had two
missing values.
The correlation coefficients were calculated to
evaluate the relationship between variables. Forward
conditional logistic regression analysis was used to
identify the most important predictor domains in
global satisfaction. For this, those who indicated they
were either satisfied or very satisfied in the global
satisfaction question were re-coded as “1=satisfied”
while all others were re-coded as “0=dissatisfied”.
Data were presented as the mean standard
deviation (SD) and percentage. The significant level
was set at P value less than 0.05.
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 148 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

FINDINGS
Table 1.1. Distribution of scores of various dimensions

N Minimum Maximum Mean Std. Deviation Variance

Interesting 140 1 5 3.84 .833 .695
Improving 140 1 5 4.16 .732 .536
Fulfilling 140 1 5 3.56 .954 .910
Autonomy 140 1 5 3.63 .984 .969
Advancement 140 1 5 3.76 .903 .815
Recognition 140 1 5 3.59 .857 .734
Security 140 1 5 2.67 .909 .827
Salary 140 1 5 2.61 1.180 1.391
Stress 140 1 5 3.09 1.017 1.034
Demanding 140 1 5 2.48 1.109 1.230
Workload 140 1 5 3.25 .841 .707
Paperwork 140 1 5 3.47 .860 .740
Relations 140 2 5 3.99 .725 .525
Conditions 140 1 5 3.83 .758 .575
Leadership 140 1 5 3.49 .971 .942
Valid N (listwise) 140

Table 1.2. Comparison of overall job satisfaction with gender

Overall1 Total
0 1 0
Gender F Count 36 32 68
Expected Count 29.6 38.4 68.0
% within Gender 52.9% 47.1% 100.0%
M Count 25 47 72
Expected Count 31.4 40.6 72.0
% within Gender 34.7% 65.3% 100.0%
Total Count 61 79 140
Expected Count 61.0 79.0 140.0
% within Gender 43.6% 56.4% 100.0%

TABLE 1.3. Comparison of overall job satisfaction with qualification

Overall1 Total
0 1 0
Qualification 0 Count 49 50 99
Expected Count 43.1 55.9 99.0
% within quali 49.5% 50.5% 100.0%
1 Count 12 29 41
Expected Count 17.9 23.1 41.0
% within quali 29.3% 70.7% 100.0%
Total Count 61 79 140
Expected Count 61.0 79.0 140.0
% within quali 43.6% 56.4% 100.0%

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 149

Table 1.4 Summary of logistic regression analysis for variables predicting job satisfaction

B S.E. Wald Df Sig. Exp(B) 95.0% C.I.

for EXP(B)
Lower Upper Lower Upper Lower Upper Lower Upper
Step 1(a) Salary 1.318 .223 35.029 1 .000 3.737 2.415 5.783
Constant -3.025 .573 27.868 1 .000 .049
Step 2(b) Fulfilling .680 .254 7.151 1 .007 1.973 1.199 3.248
Salary 1.283 .229 31.474 1 .000 3.609 2.305 5.650
Constant -5.334 1.118 22.751 1 .000 .005
Step 3(c) Interesting .661 .333 3.952 1 .047 1.937 1.009 3.719
Fulfilling .518 .267 3.764 1 .052 1.679 .995 2.835
Salary 1.307 .233 31.465 1 .000 3.694 2.340 5.832
Constant -7.370 1.640 20.204 1 .000 .001

a. Variable(s) entered on step 1: Salary.

b. Variable(s) entered on step 2: Fulfilling.

c. Variable(s) entered on step 3: Interesting.

RESULTS (0.000). The Hosmer and Lemeshow’s goodness of fit

The study population consisted of 72 women and
68 men. The ages ranged from 21 to 53 yr. the mean
age was 27.02 ± 0.395.
Kruskal-Wallis and chi-square tests revealed that
total satisfaction scores significantly differ between
gender and professional qualification respectively.
47.1% were satisfied and 52.9 % females were
dissatisfied with their profession while 65.3% were
satisfied and 34.7 % males were dissatisfied and
constituting a total of 56.4% satisfied and 43.6%
physiotherapists dissatisfied with their job (c2 =4.721,
P=0.03 i.e. P < 0.05). (Table 1.2)
There was significant difference between the job
satisfaction and professional qualification (c2 = 4.824,
P= 0.028 i.e. p<0.05). Professionals with bachelor’s
degree were less satisfied (50.5%) than the
professionals with masters degree (70.7%).(Table 1.3)
The participants scored lowest in the salary (2.61 ±
1.180) followed by job security (2.67 ± 0.909) but scores
were highest in learning and improvement in work
(4.16 ± 0.732) and interpersonal relationships (3.99 ±
0.725). (Table 1.1)
A total of 79 (56.4%) physiotherapists were globally
satisfied with their job. The percentage of satisfaction
ratings was higher in men (65.3%) than in women
(47.1%).(Table 1.2)
A summary of the logistic regression analysis is
shown in Table 1.4. The Omnibus test in the model
row had a chi-square value (65.179) and a small p-value
test was greater than 0.05 (X=4.647, df=8, p =0.795).
Logistic regression analysis showed that the most
important predictors of job satisfaction were: (1) Salary
(OR=3.694, 95% CI 2.340-5.832), (2) Interesting
(OR=1.937, 95% CI 1.009-3.719), (3) Fulfilling
(OR=1.679, 95% CI 0.009-2.835).
DISCUSSION
Job satisfaction is a complex phenomenon which
is measured to evaluate an individual’s attitude to his
work. The primary objective of the present study was
to find the predictors which influence the job
satisfaction among physiotherapy professionals. The
results revealed that among various factors- salary,
interesting work and fulfilling job constitutes the main
predictors of job satisfaction among physiotherapy
professionals.
Numerous studies carried out in several countries
showed that there is a significant correlation between
income and job satisfaction. [10,37] In a study Job
satisfaction of health care at health centres in Turkey’
conducted by Bodur in Turkey, it has been
demonstrated that income and working conditions
were the most important factors for dissatisfaction of
health care providers working at public health centers.
Likewise, according to the study done by H. Sur et al
on Factors affecting dental job satisfaction in Turkey,
monthly salary is one of the significant predictors of
job satisfaction among Turkish dentists .[16] The results
of the study indicate that there was a significant
association between job satisfaction and salary which
is consistent with the findings of previous studies.

29. Nidhi Gupta--146--151.pmd 149 8/1/2013, 8:31 AM

 150 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
A study conducted on Influence of working
conditions on job satisfaction in anesthetists by J. F.
Kinzl et. al reveals that a job that is interesting and
that permits to contribute their skills and ideas is very
important to anesthetists.[19] The study of Speakman
et al. on The Job Satisfaction of Physical Therapists also
received high scores in the statement concerned with
interesting job and fulfilling nature of the job. [34]
Adetoyeje Y. Oyeyemi, in his study Nigerian Physical
Therapists Job Satisfaction: A Nigeria - U.S.A.
Comparison, recorded a significantly higher
importance scores on statements relating to physical
demand, fulfillment and interesting job. The statement
regarding the interesting nature of the job was rated
highest in importance by subjects.
A second objective of this study was to assess
whether physiotherapists were satisfied with their job.
The analysis of the study reveals that more than fifty
percent of physiotherapists are satisfied with their jobs.
These findings are consistent with the results of
previous study by APTA on Recruitment and Retention
of Physical Therapists in Hospital Settings.[1]
In the present study there are significant differences
between the groups of gender and qualification. The
results of the study reveal that the percentage of
satisfaction ratings is higher in men than in women.
Similarly, there are significant differences between the
satisfaction levels stratified on the basis of
qualification. Post graduate professionals have been
found to be more satisfied as compared to their
graduate counterparts. In a study Predictors of job
satisfaction among physiotherapy professionals
conducted by Levent et al in 2004 there were no
significant differences between gender and age
groups.[33]
Interesting work is one of the main predictors of
job satisfaction showing a positive correlation with the
overall job satisfaction. Further, the results of the
present study showed that salary is one of the best
predictors of job satisfaction
The positive correlation between overall
satisfaction and salary indicates that if the
physiotherapists are not paid sufficiently can lead to
high levels of dissatisfaction among them. Areas of
dissatisfaction are signals for change. An interesting
job as the sole factor would not suffice for adequate
job satisfaction. Various other factors such as learning
and improvement in the job, good interpersonal
relationships at workplace and enablement to utilize
29. Nidhi Gupta--146--151.pmd 150
one’s abilities in his profession can positively affect
the aspects of job satisfaction.
CONCLUSION
This study concludes that salary, interest in work
and fulfillment in job are important predictors of job
satisfaction among physiotherapy professionals. The
result shows that a total of 79 (56.4%) physiotherapists
were globally satisfied with their job. The percentage
of satisfaction ratings was higher in men (65.3%) than
in women (47.1%).
Conflict of Interest
• There are currently no empirical data on job
satisfaction of Indian physiotherapists, therefore,
it is recommended that this study be repeated in
the future.
• On the other hand, the findings should be
interpreted with caution since the participants
were physiotherapists from a particular region of
north India and do not represent all
physiotherapists in India.
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Quarterly AOTA, 14 (4), 1998, pp.12.
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10. D Grembowski, et al: Managed care and primary
physician satisfaction. J Am Board Fam Pract 16,
383–393 (2003)
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cross-sectional study. Soc Sci Med. 2000; 50: 1317–
27[CrossRef]
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applications. Newbury Park: Sage Publications,
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15. Firth-Cozens J. Individual and organizational
predictors of depression. Br Jour Gen Prac
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16. H Sur, O Hayran, et al: Factors affecting dental
job satisfaction: a cross-sectional survey in Turkey.
Eval Health Prof 27, 152–164 (2004)
17. Huby G, Gerry M, et al. Morale among general
practitioners: qualitative study exploring
relations between partnership arrangements,
personal style, and work load. BMJ 2002;325:140.
18. Shimpachiro Ogiwara , Hitomi Araki. Job
Satisfaction among physiotherapists in Ishikawa
Prefecture , Japan, J.Phys . Ther.Sci.18:127-132
19. J. F. Kinzl, et al: Influence of working conditions
on job satisfaction in anaesthetists ,British Journal
of Anaesthesia 2005 94(2):211-215
20. Karasek RA, Theorell T. Stress, Productivity, and
the Reconstruction of Working Life. New York:
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physiotherapy , Jobs and careers, THE TRIBUNE
Tuesday, September 14, 2004
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physical and mental health, and to the work
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23. Neuwirth ZE. An essential understanding of
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8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.083
152 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Cervico-thoracic Mobilization to Address LBA for a

Patient with Lumbar Spondylolisthesis

P P Mohanty1, B Kuanar2, B K Behera3

1
Associate Professor, Head of the Department (PT), Swami Vivekananda National Institute of Rehabilitation Training and
Research, Olatpur, Cuttack, Orissa, 2Retired Professor & H.O.D, Department of Neurology, 3Professor & H.O.D,
Department of Orthopedics, SCB Medical College, Cuttack

ABSTRACT

Background and Purpose: This case report describes the examination, intervention and outcome of
a patient with lumbar spondylolisthesis. The patient was managed by myofascial release of levator
scapulae and cervico-thoracic central PA mobilization. There is no literature found describing these
interventions for lumbar spondylolisthesis.

Case Description: The patient was a 43 years old woman with LBA with radiating pain to left lower
limb due to lumbar spondylolisthesis. She received stretching of levator scapulae, piriformis & rectus
femoris, cervico-thoracic central PA mobilization, passive lumbar flexion mobilization, core
strengthening exercises. Treatment was given 5 days a week for 20 sittings.

Outcomes: Percentage of slippage.

Conclusion: Stretching of levator scapulae and cervico-thoracic central PA mobilization may help in
reducing forward slippage in lumbar spondylolisthesis.
Keywords: Mobilisation, Cervico-Thoracic Dysfunctions, Myofascial Pain Syndrome, Spondylolisthesis,
Muscle Energy Technique, Maitland

INTRODUCTION CASE DESCRIPTION

The term spondylolisthesis was first described in
1854 by Kilian as a slow displacement of superior
vertebral segment over the inferior vertebra 1 .
Approximately 2-5% of general populations have
spondylolisthesis, of which 50% are asymptomatic2.
Spondylolisthesis in adult population is associated
with radiculopathy in 62%3, activity related lower back
pain and neurological claudication4. Spondylolisthesis
can be diagnosed using plain radiography (oblique
and lateral view) and CT scan5. There are five types of
spondylolisthesis: dysplastic, isthmic, degenerative,
traumatic and pathologic 6 . Severity of
spondylolisthesis is graded on the basis of the
percentage of translation of one vertebra on the caudal
vertebra7. In low slip spondylolisthesis grade I (up to
25%) and grade II (26 - 50%), conservative treatment
including physiotherapy is the first treatment of
choice8.
The patient was a 43 year old woman reported to
the physiotherapy outpatient Department of
SVNIRTAR with the complaint of LBA radiating down
to left lower limb since about 3 months. Pain more on
standing and walking relieved in lying with hips &
knees flexed. She lived with her husband & was a
housewife. She wanted to perform her household
activities as usual.
Examination: The physical examination revealed
pain score 9 by visual analogue scale 9, increased
lumbar lordosis without any side deviation, lumbar
flexion was grossly restricted; extension was terminally
painful with segmental hypermobility at L4-5 level.
Bilateral pirifomis tightness was present (left greater
than right), SLR left -70, right-75 with sciatic tension.
Myofascial pain syndrome as characterized by taut
band with trigger point was present in left levator

30. P P Mohanty--152--155.pmd 152 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 153
scapulae, compression of which reproduced the
original low back & leg pain10, 11. Maitland’s central PA
pressure over C7, T1, T2 reproduced the original
symptoms and segment hypomobility of cervico-
thoracic spines were present12. X- ray lumbar spine
lateral view showed anterior slippage of L4 over L5
vertebral body. Percentage of vertebral slip was
measured in lateral radiograph by using AutoCAD
2006 software program. Meyerding classified the
grades of vertebral slip7; Tillard (1954) formulated a
simple equation to calculate the percent slip. Percent
slip = the displacement of L4 on L5/width of L5 X 100.
The percentage of slip was 35.2 %. There was no
neuromuscular deficit.
The physical diagnosis was L4 lumbar
spondylolisthesis with lumbar flexion dysfunction and
cervicothoracic extension dysfunction.
The plan of Physiotherapy management was
developed to address the lumbar flexion and
cervicothoracic extension dysfunctions, tight
piriformis, rectus femoris, levator scapulae and weak
abdominals.
INTERVENTIONS
The patient was treated with bilateral piriformis
stretching in supine with hips and knees flexed, thighs
crossed with the painful left thigh over the right11, 13.
Muscle energy technique with resisted hip adduction
while breathing in was followed by relaxation and
stretching by adducting the thighs. 10 repetitions
followed by 30 seconds sustained stretch was applied11.
Rectus femoris was stretched in supine towards the
edge of the bed, so that the side to be stretched
remained out of the bed. Patient was asked to hold
the leg above the ankle and opposite hip & knee flexed
towards the abdomen by the other hand. Therapist
standing by the side of the patient pressed the thigh
towards the abdomen to obliterate the lumbar lordosis
and extended the thigh to be stretched to the end
range14. Muscle energy technique with resisted hip
flexion while breathing in was followed by relaxation
and stretching by extending the thigh. 10 repetitions
followed by 30 seconds sustained stretch were applied
to both the sides11.
Lumbar flexion was given in supine with hips and
knees flexed, fingers clasped and hands behind the
neck. Therapist standing by the side of the patient
30. P P Mohanty--152--155.pmd 153
pressed the bent elbows and raised the upper trunk,
so that trunk flexion was obtained with the bent elbow
in front of the chest acting as fulcrum15. 30 seconds
mobilization followed by rest for 30 seconds were
applied for 4 times.
Stretching of levator scapulae was applied in prone
with the arms crossed across the chest. Physiotherapist
standing at head end with the thumbs inserted
underneath the superior angles of scapulae to which
levators are attached16, 34. Muscle energy technique
with resisted submaximal contraction of levators while
breathing in was followed by relaxation and further
stretching. 10 repetitions followed by 30 seconds
sustained stretch were applied to both the sides.
Central PA pressure over C7, T1, T2, T3 & T4 with
the amplitude that reproduced the patient’s original
symptom and tolerated by the patient were applied
for 30 seconds each12.
The patient was advised to do static abdominal
exercises at home, 5 seconds contraction followed by
10 seconds relaxation, 10 repetitions 5 times daily.
After 7th sittings no leg pain was reproduced while
stretching levator scapulae and after 10 sittings no leg
pain was reproduced while applying central PA
pressure. After 10 sittings the pain score improved
from 9 to 3. After 10 sittings all stretching, lumbar
flexion mobilization were continued. Cervico-thoracic
central PA mobilization with greater amplitude was
applied to all upper thoracic spines; those were found
to be hypomobile. After 20 sittings there was no
original pain, but soreness in the back due to
mobilization was present. X rays LS spine lateral view
showed reduction of anterior slippage from 35.2 % (fig)
to 15.63% .
Fig. X-ray L-S (pre-intervention) X-ray L-S (post-intervention)
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 154 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
OUTCOMES
The patient received stretching of piriformis, rectus
femoris, levator scapulae and strengthening of
abdominals, passive physiological lumbar flexion
mobilization and cevicothoracic central PA
mobilization for 20 sittings. The initial anterior
displacement of L4 on L5 was 35.2 %, after 20 sittings
it was reduced to 15.63%.
DISCUSSION
The case was grade II spondylolisthesis with
radiculopathy. Laxity at L4, L5 results in hyper-
extension and pain. Stabilisation at this level can reduce
the pain and improve the functions.
The thoraco-lumbar fascia acts as nature’s “back
belt”. It spans the area from the iliac crest and sacrum
up to the thoracic cage. The superficial lamina gets
tensed by contraction of various muscles, such as the
Latissimus dorsi, Gluteus maximus and Erector
muscle. It has extensive attachments starting from
posterior nuchal fascia, levator scapulae muscle
cephalically to the biceps femoris & soleus muscle
caudally. It also helps in transference of load through
the trunk to lower extremities and as a result effectively
deloads the spine if functioning appropriately.19
Inefficient functioning of TL fascia can be due to
many causes like weakness of muscles attached to
fascia, fibrotic changes of muscle with loss of elastic
properties. This leads to an increased load transferred
through the spine gradually leading to extension
loading & degeneration. Improving length of the
fibrotic muscles will improve the mobility of the
lumbar spine and may help in pain relief. Stretching
of the levator scapulae helps in back pain with or
without radiating pain.
The more the thoracic kyphotic curvature, the more
lumbar and cervical lordosis or tendency for such20.
With regard to the lumbar spine, the lower lumbar
regions at L-4 and L-5 levels are most affected.
Hypomobility and restriction of extension at proximal
levels can lead to compensatory hyperextension below
it. Extension is associated with posterior to anterior
gliding of vertebral body, so compensatory
hyperextension at lower lumbar spine may precipitate
the spondylolisthesis and low back pain21.Central PA
mobilisation 22, 23, 24, 25, 26, 27 of the cervico-thoracic
hypomobile segments, which reproduces the original
back pain and/ or radiating pain, to increase thoracic
30. P P Mohanty--152--155.pmd 154
extension may reduce compensatory hyperextension
at lower lumbar spine, so is helpful in LBA.
Hypomobile spine must be mobilized so that an even
distribution of movement is achieved21.
Raymond & John Evans (1997) measured the
intervertebral movements of the lumbosacral spine
produced by PA mobilization - an in vivo radiographic
study, which strongly suggests that the spine is
subjected to 3-point bending under the application of
mechanical loads. Under the mobilization load the
lumbar motion segments were found to extend. In a
series of cadaveric studies, Lee and Evans (1992, 1994)
noted that spinal PA mobilization produced extension
moments and shear forces to lumbar motion segments.
McCollam and Benson (1993) reported an increase in
extension range of movement following spinal PA
mobilization22.
Drawback of myofascial release technique, central
PA mobilisation of Cervicothoracic spine includes
some found difficulty to tolerate the position and some
complained of shoulder pain.
In Conclusion Low back pain due to
spondylolisthesis associated with myofascial pain
syndrome of periscapular muscles and cervicothoracic
extension dysfunction may be benefited by stretching
of periscapular muscles and mobilisation of
cervicothoracic spine.
Conflict of Interest
The researchers have not received or undertaken
or had no interest in any of the following from/for/of
the study during the study period : Payment or receipt
of honoraria, Research grant, travel grant or conference
expenses and other remuneration or benefit.
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 DOI Number: 10.5958/j.0973-5674.7.3.084
156 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Relationship of Cervicothoracic Curvature with Muscle

Strength and Endurance in Subjects with Neck Pain

Parminder Kaur1, Monalisa Pattnaik2, Patit Paban Mohanty3

1
Assistant Professor, Amar Jyoti Institute of Physiotherapy, Delhi, 2Assistant Professor, 3Associate Professor & HOD, Swami
Vivekanand National Institute of Rehabilitation Training and Research, Orissa

ABSTRACT

Purpose: The purpose of the study is to determine the changes seen in cervicothoracic curvature
with increasing age in normal and neck pain subjects and also to study, relationship of cervicothoracic
curvature with deep neck flexor muscle function and pain level.

Material & Method: A group of 10 normal subjects were recruited for reliability study of photographic
method. Age and sex matched 30 normal and 30 neck pain subjects were also recruited. Both the
groups were divided into three age groups i.e.31-40, 41-50 and 51-60 years with 10 subjects in each.
To determine cervicothoracic curvature, lateral profile photographs were taken for both the groups
and using AutoCAD software cervicothoracic kyphosis angles were measured at C6 (C4 - C6- T4), C7
(C4 - C7- T4) and T1 (C4 - C6- T4) levels. For neck pain subjects, the angle average (of all the 3 levels)
was compared with deep flexor muscle strength, endurance and pain level.

Results : The intraclass correlation coefficients for Interrater reliability indicated high reliability with
ICC at C6=0.86, at C7=0.80 and at T1=0.88. Statistical analysis was done using one-way ANOVA &
Tukey's HSD at all three levels for both the groups. Cervicothoracic kyphosis was increased with age
and the increase was more prominent in subjects with neck pain. At C7, angle showed early changes
i.e. in forth decade in neck pain subjects compared to normal. The pain intensity and muscle functions
were correlated with average cervicothoracic angle using Pearson's co-relation in neck pain subjects.
There was statistically significant positive correlation between cervicothoracic angle average and
deep flexor muscle strength (r=.598, p=.000). However, no statistically significant relationship was
established for muscle endurance and pain intensity.

Conclusion: It was concluded that degenerative changes at C7 vertebra were progressed early in
neck pain subjects and their deep flexors strength reduces as the cervicothoracic kyphosis increases.
Keywords: Cervicothoracic Angles, Deep Flexor Muscles, Forward Head Posture

INTRODUCTION are the levator scapulae, upper trapezius,

The problem of neck pain in working people
between the ages of 25-29yrs have been reported to
range between 25-30% & for those older than 45yrs
rises to 50%. The cervical structures can be affected by
degenerative disc diseases, trauma and/or
inflammatory disorders, resulting into neck pain. The
commonest dysfunction involves loss of lower cervical
extension1. It is proposed that atraumatic cervical
spondylosis in the presence of forward head posture
is the result of midcervical hypermobility &
suboccipital / cervicothoracic hypomobility. The
muscles most often affected in forward head posture
sternocleidomastoid and suboccipital and deep neck
flexor muscles. It was demonstrated that there are only
2 levels C6-7 & C7-T1 which demonstrate movement
during extension from neutral position. This forwardly
placed position of the head puts increased stress in
cervicothoracic region2.
Weakness of deep neck flexor muscles has been
proposed to contribute to neck pain. Harms –Ringdahl3
showed that healthy volunteers who maintained
flexion of the lower cervical and upper thoracic
perceived pain within 2 – 15 minutes, forcing them to
discontinue the posture. Very few studies have been

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 157
done regarding cervicothoracic posture. Boyle J 4
studied the influence of age on cervicothoracic spinal
curvature, in an ex vivo radiographic survey & found
that the mean location of the cervicothoracic curve
inflexion point moved from T3 towards C7-T1 with
increasing age.
A review of literature revealed paucity of studies
that have seen effect of increasing age on
cervicothoracic curvature and also its association with
the neck muscles function. The purpose of the study
thus, was to record the effect of increasing age over
cervicothoracic kyphosis in normal and neck pain
patients and its relation with deep neck flexor muscles
strength, endurance and pain intensity, if any in neck
pain patients.
METHODOLOGY
A group of 10 normal subjects (20-30 yrs) were
recruited for reliability study of photographic method.
A total 30 subjects with neck pain (15 M, 15F) with
mean age of 47.24 ± 8.98 and meeting the inclusion
and exclusion criteria were recruited from the OPD of
the Swami Vivekanand National Institute of
Rehabilitation Training and Research. Age matched 30
normal subjects (15 M, 15F) with the mean age of 44.96
± 9.56 were also recruited. Informed consent was
obtained from the recruited subjects. Both normal and
neck pain group were again divided into three age
groups i.e.31-40, 41-50 and 51-60 years with 10 subjects
in each age group.
Group I: Normal subjects
Group II: Subjects with neck pain
Inclusion Criteria
1. Neck pain (with or without radiation) of more than
3 months
2. Age range- 30-60yrs.
3. Forward head posture (grade1 & 2 according to
Griegel-Morris measurement of Forward Head
Posture)
4. Decrease in lower cervical extension with pain at
the end range
5. Central PA over C7/T1reproduces original
symptoms
31. parminder kaur--156--161.pmd 157
Exclusion Criteria
1. Traumatic cervical spine injury
2. Any previous spinal surgery
3. Medical conditions affecting cervical spine
mobility
4. Infective & Neurological conditions
5. H/O low back pain in past 6 months.
Instrumentation
1. Photographs - Left sided profile photograph was
taken to obtain measurement of cervicothoracic
kyphosis angle at 3 levels i.e. C6, C7 and T1 in
saggital plane. For taking photograph, spinous
processes of C4, C6, C7, T1 and T4 were first
palpated. Adhesive skin markers, light plastic rods,
30mm in length were attached to these marked
levels. Next, the subjects were made to stand on
sheet of paper of 42×30cm and the distance
between the subject and the wall was also
measured and was kept constant. A Cannon
3mpixel digital camera with 35 to 70mm zoom lens
was mounted on a tripod, the camera was placed
3m from the subject. The subject was
approximately in the centre of the lens. The camera
was placed perpendicular to the ground and was
approximately leveled with the C7 level. 3
photographs were taken for every subject. Compaq
desktop system and AutoCAD software was used
to measure the cervicothoracic angle by drawing
lines from C4 to any one level (C6, C7 and T1) and
then from that level to T4 (fig: 1).
2. The Modified Sphygmomanometer- Maximal
muscle strength of deep neck flexors was measured
using a modified sphygmomanometer. It was
preinflated with 20 mmHg and placed
suboccipitally. The subjects were taught to perform
upper cervical flexion as pure nodding movement
with maximal strength (fig: 2).
3. Stopwatch- Muscle endurance of the deep neck
flexors was measured by stopwatch. In hook lying
position, with retracted chin subjects had to raise
their head 2cm from the plinth. Holding time was
measured using stopwatch (fig: 3).
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4. Visual analog scale (VAS) was used to measure

subjective pain intensity.

Fig. 3. Deep neck flexors endurance testing

PROCEDURE

A pilot study was done 10 normal subjects to

determine the interrater reliability for the photographic
method. 3 Lateral profile photographs were taken per
subject by 2 examiners at a gap of 1 week.

To determine the changes seen in cervicothoracic

curvature with increasing age (in all the age groups)
in normal and neck pain subjects. 3 Lateral profile
photographs were taken for each subject for both the
groups and mean cervicothoracic kyphosis angles were
measured at 3 different levels – C6, C7 &T1.

1. Angle at C6 level; is measured between

C4 – C6– T4

2. Angle at C7 level; is measured between

Fig. 1. Placement of markers for cervicothoracic kyphosis angle C4 – C7 – T4
measurement
3. Angle at T1 level; is measured between
C4 – T1– T4.

For neck pain group detailed examination was done

following which, 3 lateral profile photographs were
taken and this group was also assessed for pain level,
deep neck flexor muscles strength and endurance.

Data Analysis and Results

Data was analyzed using the SPSS statistical

Fig. 2. Deep neck flexors strength testing using modified
sphygmomanometer
package (version 11.5). Interclass correlation coefficient
(ICC) was measured for reliability group at 3 levels
C6, C7 and T1. The data were analyzed using a one-
way ANOVA with three levels: cervicothoracic
kyphosis angles at C6 (C4-C6-T4), C7 (C4-C7-T4) and
T1 (C4-T1-T4), for both normal and neck pain group.
The angles average of all the three levels were

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 159

correlated with pain intensity, muscle strength and angle at T1 when compared to the 31-40 yrs age group.
endurance for neck pain group using Pearson ‘r’. There was however no significant difference between
41-50 and 51-60 yrs of age group.
Normal Subjects
The mean deep neck flexor strength was 29.392
Interrater reliability data indicated high reliability mmHg. The strength of deep neck flexor muscles had
of the photographic measurement procedures with a significant positive correlation with the angle average
ICC at C6= 0.86, ICC at C7= 0.80 and ICC at T1= 0.88. for neck pain group, r =.598 and p= .000 (Graph 3).
At all the angles there was progressive decline with The mean deep neck flexor endurance was 28.79567
increasing age i.e. 31-40, 41-50 and 51-60 yrs age groups seconds and the mean for pain level was 6 on VAS.
for normal subjects (graph 1). For cervicothoracic angle Both the deep neck flexor muscles endurance and pain
at C6, there was main effect for the group didn’t have a significant correlation with the angle
F(2, 27, .05) = 14.498, P<.000. Tukey’s HSD showed that average for neck pain group, r =.182 and p= .000 and
there was statistically lowered angle at 51-60 yrs age r= 0.057, p=0.764 respectively (graph 2 & 3).
group when compared with 31-40 and 41-50 yrs age
group. However, there was no significant difference
between 31-40 and 41-50 yrs age group. For
cervicothoracic angle at C7, there was main effect for
the group F (2, 27,.05) = 17.575, P<.000.Tukey’s HSD
showed that there was both 41-50 and 51-60 yrs of age
group had significantly lesser angle when compared
to the 31-40 yrs of age. However, there was significant
difference between 41-50 and 51-60 yrs of age group.
For cervicothoracic angle at T1, there was main effect
for the group F(2, 27, .05) = 10.878, P<.000.Tukey’s HSD
showed that both the groups (41-50 and 51-60 yrs) had
statistically significant lesser angle at T1 when
compared to the 31-40 yrs age group. There was
however no significant difference between 41-50 and
51-60 yrs of age group.

Neck Pain Subjects Graph 1. Mean peak and standard deviation of cervicothoracic
kyphosis angle (degrees) at C6, C7 and T1 level in different age
groups 31-40, 41-50, 51-60 for normal subjects.
At all the angles there was progressive decline with
increasing age i.e. 31-40, 41-50 and 51-60 yrs age groups
for neck pain subjects (graph 2). For cervicothoracic
angle at C6, there was main effect for the group
F(2, 27, .05) = 12.938, P<.000.Tukey’s HSD showed that
51-60 yrs age group had significantly lesser kyphosis
angle at C6 when compared with 31-40 and 41-50 yrs
age group. However, there was no statistically
significant difference between 31-40 and 41-50 yrs age
group. For cervicothoracic angle at C7, there was main
effect for the group F(2, 27,.05) = 19.700, P<.000.Tukey’s
HSD showed that both, 41-50 and 51-60 yrs of age
group had significantly lesser angle when compared
to the 31-40 yrs of age group and there was no
statistically significant difference between 41-50 and
51-60 yrs of age group. For cervicothoracic angle at
T1, there was main effect for the group F(2, 27, .05) = 11.308,
Graph 2. Mean peak and standard deviation of cervicothoracic
P<.000.Tukey’s HSD showed that both the groups (41- kyphosis angle (degrees) at C6, C7 and T1 levels in different age
50 and 51-60 yrs) had statistically significant lesser groups 31-40, 41-50, 51-60 for neck pain subjects.

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 160 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Graph 3. Cervico-thoracic Kyphosis angle average at C6, C7 & T1
(ANAV) versus neck flexor muscle strength (NFSTR) in mmHg
for neck pain patients.
Graph 4. Cervico-thoracic Kyphosis angle average at C6, C7 & T1
(ANGAV) versus deep neck flexor muscle endurance (DPNFXEN)
in seconds for neck pain patients.
Graph 5. Cervico-thoracic Kyphosis angle average at C6, C7 & T1
(ANGVG) versus pain level on (VAS) for neck pain patients.
31. parminder kaur--156--161.pmd 160
DISCUSSION
The overall result of this study showed that
cervicothoracic kyphosis angle measured at C6
showed significant decline in late years i.e. after fifth
decade, in both neck pain and normal groups.
Cervicothoracic kyphosis angle measured at C7
showed significant progressive decline with increasing
age in normal subjects, however in neck pain subjects
the decline was seen significant somewhere after forth
decade and no significant changes were seen in later
years. In both the groups, cervicothoracic angle when
measured at T1 also showed significant decline
somewhere after 40yrs, but no significant changes were
seen in late years.
In both groups cervicothoracic kyphosis angle at
C6 level started reducing after fifth decade i.e. 51-
60years age group. The change is more in neck pain
subjects. The cervicothoracic junction is the transition
zone between highly mobile cervical spine and very
stable thoracic spine. The facet relationship of C6 on
C7 allows C6 to be relatively mobile5. Moreover the
C5-C6 articulation is the most frequent site to show
transition in superior articular facet and the mean
segmental mobility at C5-C6 decreases after 55 yrs of
age. Neck pain is commonly associated with forward
head posture, producing early degenerative changes
which might be responsible for the more decline seen
in cervicothoracic angle measured at C6 level in neck
pain patients. The segmental mobility of C5-C6 is more
in earlier years and reduces movements in later years5.
In normal subjects the cervicothoracic angle at C7
showed significant progressive decline with increasing
age, however at T1 the decline occurred somewhere
after forth decade i.e. 41-50 yrs of age but no significant
changes observed in later years i.e. 51-60yrs of age.
The progressive decline in cervicothoracic angle at C7
might be due highly mobile C6-C7 segment and also
due to the change seen in posture with increasing age.
Moreover, it was found that there is a significant
tendency for a forward head posture to occur with
increasing age, occurring greatly in fourth and sixth
decade. It is possible that sustaining such postures
changes the length-tension relationship of the muscle
which control posture, leading to muscle imbalance.
Forward head posture is associated upper cervical
extension which may facilitate shortening of the
suboccipital connective tissues. As T1 is very stable
compared to lower cervical spine and introduction of
the ribs also significantly reduces the amount of motion
available at this segment. It was also found that with
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 161
advancing age, at around 40yrs women exhibit an
increase in upper thoracic incline. Along with the
change in posture this might be reason for the decline
observed in cervicothoracic angle at T1 level in 41-50
yrs age group.
In neck pain subjects cervicothoracic kyphosis angle
at both C7 and T1 level showed significant decline in
forth decade i.e. 41-50yrs age group, however no
significant decline observed in fifth decade, this might
again be due to forward head posture, putting stress
on cervicothoracic junction. It was found that in neutral
position the induced load moment of the C7-T1 motion
segment was 1.2Nm in a flexing direction forward
head posture the load moment was 3.7Nm and there
was increase in myoelectric activity of trapezius and
cervical erector spinae. The anterior vertebral neck
flexors remain in elongated position and show
weakness6.
This study shows that as the cervicothoracic
curvature reduces deep neck flexor strength also
reduces. The impaired activation of the deep cervical
flexor muscles, the longus colli and longus capitis is
found in people with neck pain and their strengthening
reduces the neck symptoms7.The deep cervical flexors
over time tends to get weaken, atrophied and inhibited
due to the overactivity of the antagonists
(Sherrington’s law). This forwardly placed position of
the head is commonly associated with either a localized
cervicothoracic kyphosis so puts increased stress in this
region. This study showed no significant correlation
between the deep neck flexor endurance and average
angle of the cervicothoracic kyphosis in the neck pain
group. The neck flexor synergy in neck pain group had
higher measures of EMG signal amplitude in the
sternocleidomastoid compared to control subject, this
may be a measurable compensation for poorer active
contractile capacity of the deep cervical flexors8. It is
known that nociceptive inputs can alter motor neuron
pool net excitability, which could modify motor unit
31. parminder kaur--156--161.pmd 161
recruitment. This study showed no significant
correlation between the pain level and average angle
of the cervicothoracic kyphosis in the neck pain group.
The results could be attributed to factors like patient’s
occupation, body build, age, individual experience of
pain intensity and difficulty in pain quantification due
to its subjective nature affecting the degree of pain
reported. There is no association of common postural
abnormalities in cervical, shoulder and thoracic region
with severity and frequency of pain.
REFERENCES
1. McKenzie RA. The cervical and thoracic spine:
mechanical diagnosis and treatment. Spinal
publications :( N. Z.) Ltd; 1990.
2. Harms-Ringdahl K. On assessment of shoulder
exercises & load elicited pain in cervical spine:
biomechanical analysis of load EMG
methodological studies pain provoked by
extreme position. Scand J Rehab Med.1986; 14:1.
3. Boyle J. Influence of age on cervicothoracic spinal
curvature: an ex vivo radiographic survey.
Clinical Biomechanics 2002; 17: 361-367.
4. Phillip SE. Assessment of spine: the
cervicothoracic junction. 1 st ed. Churchill
Livingstone: 2004; 159-176.
5. Placzek JD. The influence of the cervical spine
on chronic headache in women: a pilot study. J of
manipulative and physiologic therapeutics.1999;
7: 33-39.
6. Kendall, FP, McCeary EK. Muscle testing and
function with posture and pain. 5th ed. Williams
and Wilkins: Baltimore; 1982.
7. Jull G, Trott P, Potter H. A randomized control
trial of exercise & manipulative therapy for
cervicogenic headache. Spine 2002; 27: 1835 –43.
8. Cholewicki J, Punjabi NM. A stabilizing function
of the trunk flexion-extension muscle around a
neutral spine. Spine 1997; 22: 2207-2212.
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 DOI Number: 10.5958/j.0973-5674.7.3.085
162 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Study on the Impact of Body Mass Index on Lower Back

Extensor Endurance in Apparently Healthy Subjects

V Pasupatham1, Mohan Vikram2, V Swaminathan3, S Reka Rani4

1
Lecturer in Physiotherapy, DPM&R, RMMC & H, Annamalai University, Annamalai Nagar, Tamil Nadu, 2Lecturer in
Physiotherapy, Faculty of Health Sciences, Universiti Teknologi MARA, Kampus Puncak Alam, Puncak Alam,
Selangor-42300, Malaysia, 3Reader in Physiotherapy, DPM&R, RMMC&H, Annamalai University,
Annamalai Nagar-608002, Tamil Nadu, India, 4Student (Final year BPT), DPM&R, RMMC&H, Annamalai University,
Annamalai Nagar 608002, Tamil Nadu, India

ABSTRACT

This study has been carried out with the objective of finding out whether the body mass index has
any influence on lower back extensor endurance in apparently healthy subjects. 180 healthy subjects
participated in the study and they were categorized into three groups based on the values of their
body mass index as underweight, normal weight and overweight. The lower back extensor endurance
was tested using prone double straight leg raise test, and the data collected were analyzed statistically
for correlation and the results were found to be -0.561,-0.557,-0.579 for overall, males and females
respectively and all of them were significant. The equality of the level of endurance for the three
groups namely under weight, normal weight and overweight was tested by ANOVA procedure and
the F statistic was found to be 34.619 with a corresponding p value 0. Therefore it has been inferred
that greater the BMI lesser will be the lower back extensor endurance and the average endurance
level of the three groups is not the same.
Keywords: Body Mass Index, Lower Back Extensor Endurance

negative impact on endurance of trunk muscles

INTRODUCTION
Low back pain is one of the most common
complaints in the society today, and the studies
indicated that about 70-80% of the population had at
least one episode of low back pain in their life time2,
17,18
. Though there are many factors which contribute
to low back pain, muscle is a potential source of low
back pain and endurance of those is one of the
important parameters of health related physical
fitness8. Muscle endurance is defined as the ability of
a muscle to perform repeated contraction at a certain
output or to sustain a contraction over time at a certain
level. Static endurance of the trunk muscles is
important for mechanical support. These muscles must
have the ability to sustain an isometric contraction to
support the trunk in any given position. The back
extensors are particularly important postural muscles
which function to help to stabilize the whole vertebral
column9. Hence, poor endurance of the lumbar para
vertebral muscles is one of the contributing factors in
acquiring idiopathic low back pain and a predictor for
first time occurrence of low back injuries 11. The
induces strains on the passive structures of the lumbar
spine, leading eventually to low back pain and is
associated with prolonged or recurrent back pain.14,16
Hence, the endurance training of the trunk extensor
muscles in people with sub-acute low back pain is
effective in reducing pain and improving
performance 4,10 . Doymaz, et al. indicated that
increasing age, mass; body mass index and waist hip
ratio are important factors which cause decrease in the
trunk muscle endurance in healthy subjects 7 .
Bayramoglu, et al. conducted a study on the
relationship among chronic low back pain and obesity
and trunk muscle strength and declared that the
increase in body mass index and decrease in muscle
strength are directly associated with low back pain3.
However, only a few studies are available in the area
of relationship between lower back extensor endurance
and body mass index as observed by the author of this
article. So, this study has been initiated under the
assumption that body mass index and lower back
extensor endurance are inter-related and inversely
proportional to each other. Therefore the objective of

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 163
the present study is to find out whether the body mass
index has any influence on lower back extensor
endurance.
METHODOLOGY
For the purpose of experimental study, a stratified
random sample of 180 normal subjects in the two strata
namely males and females, who are the students of
the physical medicine rehabilitation division of
RMMC&H and the Faculty of Engineering of
Annamalai University, were selected using the lottery
method. Students suffering from back pathology and
musculoskeletal disorders were excluded from the
selection process. Out of the 180 respondents, 90 were
males and 90 were females of the age group 19- 25
years. They were divided into three groups based on
their body weight, under weight, normal weight and
overweight as recommended in the BMI classification.
Each group consists of 60 members, 30 males and 30
females. For all the 180 subjects, the lower back
extensor endurance was tested by prone double
straight leg raise test, as followed by Chad E. Moreau,
et al.6 The superiority of this test has been discussed
by Amir M. Arab, et al.1and Ismaeil Ebrahimi, et al.12
For the prone double straight leg raise test, the
subject begins lying in prone position, hip extended,
hands underneath forehead and arms perpendicular
to the body. The subjects were then instructed to raise
both legs until the knee clearance is achieved. The knee
clearance has been monitored by sliding a hand under
the thighs. The time taken has been recorded in seconds
and the test has been terminated when the subject is
no longer able to maintain knee clearance.
Statistical methods used
The statistical analysis has been made by using
SPSS 11.5 for windows. To find out the intensity of
relationship between body mass index and endurance
level, Karl Pearson’s product moment correlation co-
efficient was computed. Test for the equality of two
correlation co-efficients for male and female was
carried out using ‘Z’ test. To find out whether there is
a significant difference in the average endurance time
for the three groups viz., under weight, normal weight
and overweight, ANOVA one way classification
procedure was used.
Data analysis and Results
With a view to examine the nature of relationship
between body mass index and endurance, the
correlation coefficient between them was computed.
32. pasupatham--162--166.pmd 163
It has been found that the co-efficient of correlation
between BMI and endurance is found to be r = -0.561,
and the correlation coefficient is significant since p=0.
The negative correlation indicates that as the BMI
increases, the level of endurance decreases.
It is further proposed to examine the nature of the
relationship and also its intensity by dividing the
respondents into three groups viz., the BMI of those
who are under weight, the BMI of normal weight and
the BMI of overweight. The correlation coefficient
between the two variables was computed separately
for the three groups and the results are given in
table 1.
Table 1. Correlation Coefficients between BMI and
lower back extensor endurance
Groups Pearson’s Sig. (p)
correlation
co-efficient
Under weight -0.132 0.314
Normal weight -0.258* 0.046
Over weight -0.265* 0.041
The correlation coefficient between BMI and
endurance level was negative, for all the three groups
and the correlation coefficients were significant except
in the case of underweight group. Hence, it implies
that as the BMI increases, the level of endurance
decreases. The magnitude of the negative correlation
coefficient is on the increase as the BMI increases. It
implies that greater the BMI less would be the
endurance level. To ascertain whether the correlation
between the two variables was the same between males
and females, Correlation coefficients were computed
separately for males and females with no classification
under the three groups based on weight, and they are
given in table 2.
Table 2. Gender wise correlation coefficient between
BMI and lower back extensor endurance
Gender Pearson’s Sig. (p)
correlation
co-efficient
Male -0.557** 0
Female -0.579** 0
Table 2 shows that there is a negative correlation
between the two variables as it has been observed
previously and also the correlation co-efficient was
more or less the same and significant in both the cases.
Further it was proposed to find out whether these two
correlation coefficients differ significantly. For this
purpose, the Z test for equality of correlation
coefficients has been carried out and the Z statistic was
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 164 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
equal to 0.2148. Since this is less than 1.96, the
correlation coefficients do not differ significantly.
In order to find out whether the level of lower back
extensor endurance differs significantly between the
Table 3. ANOVA for test of equality of means of lower back extensor endurance for three groups
Between groups
Within groups
Total
The value of ‘F’ statistic was found to be 34.619 with
corresponding p=0. Hence the means of the three
groups differ significantly. This implies that the
endurance levels of the three groups based on the BMI
are not the same, on the average.
The average lower back extensor endurance time
in seconds and the standard deviation values for the
three groups viz, under weight, normal weight and
overweight are presented in the following table 4.
Table 4. Descriptive Statistics
Mean Std deviation
Under weight 63.41
Normal weight 56.18
Over weight 44.15
From this table 4, it can be observed that the
endurance level is the highest for the underweight
group and it is the lowest for the overweight group.
So as the BMI increases the average level of lower back
extensor endurance decreases. The standard deviations
are more or less equal for the three groups.
DISCUSSION
The purpose of this study was to investigate the
influence of body mass index on lower back extensor
endurance in 180 healthy subjects and the results show
the correlation between the body mass index and the
lower back extensor endurance was negative and
significant. This result is found to be in agreement with
that of the results of the study by Doymaz, et al.7 They
investigated the effects of physical characteristics
including age, gender, mass, height, body mass index
and waist hip ratio, on trunk muscle endurance in 200
healthy subjects. They concluded that increase in age,
mass, body mass index, waist hip ratio is an important
factor which causes a decrease in trunk muscle
endurance in normal subjects.
32. pasupatham--162--166.pmd 164
3 groups namely under weight, normal weight
and over weight, ANOVA one way classification
procedure was made and the results are given in
table 3.
Sum of squares df Mean square F Sig.
11366.533 2 5683.267 34.619 0.00
29057.217 177 164.165
40423.750 179
A reliability and feasibility study carried out by
Ismaeil Ebrahimi, et al.12, on the five types of clinical
tests such as Sorensen test, prone isometric chest raise
test, prone double straight leg raise test, supine
isometric chest raise test and supine double straight
leg raise test to measure endurance of the trunk
muscles in subjects with and without low back pain,
shows that prone double straight leg raise test has more
association with low back pain than other tests.
Moffroid, et al.15 conducted a study on the endurance
training of the trunk extensor muscles and suggested
that the Sorenson test fatigues the biceps femoris more
than lower erector spinae and that it indicates more
13.65
about the endurance of the hip extensors than that of
12.51
trunk extensors. Another issue that should be
12.22
considered in clinical use of the Sorenson test
procedure is its difficulty. In Biering – Sorensen’s
study5, 24 % of the sample could not complete the test
and Latika, et al.13also reported a 50% of failure rate in
doing the Sorenson test. Hence, in this study we
selected prone double straight leg raise test as an
outcome measure for testing the lower back extensor
endurance. Beverley Chok, et al. 4 suggested that
muscle weakness causes decrease in muscle endurance
which may eventually lead to low back pain and found
that endurance training of trunk extensor muscles was
effective in relieving low back pain and improving
function. However, in this study the average level of
lower back extensor endurance was higher in
underweight groups and there exists a relation
between body mass index and lower back extensor
endurance. Hence, it is obvious that keeping a control
level of body mass index may be a preventive measure
which may account in preventing back problem by
enhancing lower back extensor endurance. The
constraint about this methodology adopted in the
present study is that all the sampled respondents are
in the age group 19-25. But in selecting a sample of
respondents, the age restriction can be relaxed and the
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 165
impact of age on the lower back extensor endurance
can be studied by taking persons in different age
groups. It would be informative to investigate whether
the BMI and low back pain are associated with each
other. If there is any association, then it would be
interesting to examine their combined influence as well
as the intensity of relationship over the level of
endurance. Further this study can be extended by
investigating the effects of lower back extensor
endurance training on the obese as well as low back
pain patients.
CONCLUSION
The body mass index and lower back extensor
endurance are negatively correlated, that is as the BMI
increases, it has a negative impact on the level of lower
back extensor endurance. Hence, if BMI is higher, the
level of endurance will be proportionally lower. Also
the impact of BMI on the endurance level of lower back
extensor was not influenced by gender. The average
level of endurance differs significantly between the
three groups’ viz., under weight, normal weight and
overweight.
ACKNOWLEDGEMENT
The authors are thankful to Dr.P.G.
Chandrashekaran Nair, Professor and Head, PM&R
division; DR.V.K. Mohandoss Kurup, professor PM&R
division; and DR. R. Sathiyamoorthi , former Head of
the department of statistics, Annamalai university, for
their valuable suggestions.
REFERENCES
1. Amir M Arab, Mahyar Salavati, Ismaeil Ebrahimi,
Mohammad E Mousavi, ‘Sensitivity, specificity
and predictive value of the clinical trunk muscle
endurance tests in low back pain’. Clinical
Rehabilitation; 2007,Vol.2, No7, Page 640-647.
2. Amir M Arab, Leila Ghamkhar, Mahnaz Emami,
Mohammad R Nourbakhsh ‘Altered muscular
activation during prone hip extension in women
with and without low back pain’. Chiropr Man
Therap; 2011, Vol 19: No.18.
3. Bayramoglu M, Akman MN, Kilinc S, Cetin N,
Yavuz N, Ozker R, ‘Isokinetic measurement of
trunk muscle strength in women with chronic low
back pain’. American journal of physical
medicine and rehabilitation; Sep.2001, 80(9) page
650-655.
32. pasupatham--162--166.pmd 165
4. Beverley Chok, Raymond Lee, Jane Latimer,
Seang Beng Tan, ‘Endurance training of the trunk
extensor muscles in people with subacute low
back pain’. Physical therapy; Nov. 1999 Vol 79,
No.11, Page 1032-1042.
5. Biering-Sorensen F. ‘Physical measurements as
risk indicators for low- back trouble over a one-
year period’. Spine; 1984, vol 9 No.2.
Page 106-119.
6. Chad E. Moreau, Bart N Green, Claire D Johnson,
Susen R Moreau, ‘Isometric back extension
endurance tests – A review of literature’. Journal
of manipulative and physiological therapeutics;
Feb. 2001,Vol.24, No. 2.
7. Doymaz F, Cavlak U, Kucuk M, Telli O, Bas Aslan
U. ‘Analyzing the effects of physical
characteristics on trunk muscles endurance in
healthy Turkish subjects’. Medicine sportive;
2006, No. 6
8. Gonzales E. ‘Physiological basis of Rehabilitation
Medicine’. Butter worth Hehemen Wasen USA,
2001, Chapter 24 Page 563-264.
9. Greg McIntosh, Lynda Wilson, Michael Affleck,
Hamilton Hall,‘Trunk and lower extremity
muscle endurance: Normative data for Adults’.
Jour of Rehabilitation outcomes measurement;
1998, Vol.2 No.4 Page 20-39.
10. Handa N, Yamamoto H, Tani T, Kawakami T,
Takemasa R, ‘The effect of trunk muscle exercises
in patients over 40 years of age with chronic low
back pain’. Jour. Orthop. Sci; 2000 Vol. 5(3) 210-6
11. Heyward VH. ‘Advanced fitness and exercise
prescription’. Third edition New mexico: Human
kinetics; 1997. Quoted in; Doymaz et al,
‘Analyzing the effects of physical characteristics
on trunk muscles endurance in healthy Turkish
subjects’. Medicine sportiva No.6 (2006).
12. Ismaeil Ebrahimi, Gholam Reza Shah Hosseini,
Mahyar Salavati, Hosseini Farahini, Massoud
Arab, ‘Clinical trunk muscle endurance tests in
subjects with and without low back pain’.
Medical Journal of the Islamic Republic of Iran;
Aug. 2005, Vol 19, no.3, page 95-101,
13. Latikka P,Battie MC, Videman T, Gibbsons LE, ‘
Correlation of isokinetic and psychological back
lift and static back extensor endurance test in
men’. Clinical biomech; 1995, 10, page 325-330.
14. Lee, JH, Hoshino Y, Nakamura K, Kariya Y, Saita
K, Ito K, ‘Trunk muscle weakness as a risk factors
for low back pain. A 5 year prospective study.
Spine 1; Jan. 1999, 24(1) 54-57.
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15. Moffroid MT, Haugh LD, Haig AJ, Henry SM,
Pope MH, ‘Endurance training of trunk extensor
muscles’. Physical therapy; 1993, 73; page 3-10.
16. Nourbakhsh MR, Arab AM. ‘Relationship
between mechanical factors and incidence of low
back pain’. Jour. Orthop. Sports phys. Ther; 2002,
Vol. 32(9) Page 447-60.
17. Shari A Rone-Adams, Eric Shamus, Melissa
Hileman, ‘Physical therapists Evaluation of the
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Trunk Flexors in patients with low back pain’.
The internet journal of allied health sciences and
practice; April. 2004, Vol.2, No.2.
18. Svensson H, Anderson G, Johansson S,
Wilhelmson C, Vedin A, ‘ A retrospective study
of low back pain in 38 to 64 year old women’.
Frequency of occurrence and impact on medical
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 DOI Number: 10.5958/j.0973-5674.7.3.086
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 167

Study of the efficacy of the Mulligan's Movement with

Mobilization and Taping Technique as an Adjunct to the
Conventional Therapy for Lateral Ankle Sprain

Punam Ghadi1, Chhaya Verma2

1
Consulting Physiotherapist, Jaslok Hospital & Research Centre, Mumbai, 2Professor, Seth G. S Medical College & KEM
Hospital, Mumbai

ABSTRACT

Objective: This study was designed to assess the efficacy of the Mulligan's Movement with
mobilization & taping technique in functional recovery of lateral ankle sprain when used as an adjunct
to conventional therapy & thus establish the role of the hypothesis of positional fault in lateral ankle
sprain.

Study Design: Cohort study involving 30 patients diagnosed with grade 1 & 2 lateral ankle sprain
divided randomly in 2 groups of 15, one control group & another experimental group.

Methodology: Control group received conventional therapy which involved RICE or ultrasound &
home exercise program according to the stage of healing, while experimental group received
Mulligan's MWM & taping along with conventional therapy. Duration of the treatment was 6 days or
till VAS on walking reduces to 1.

Results: VAS on walking & tender point palpation showed significantly greater reduction in
experimental group (p<0.01) than control group. Duration of Single Leg Stance improved to
significantly greater extent (p<0.005) in experimental group, while the duration of the treatment was
found to be reduced significantly when Mulligan's technique was used.

Conclusion: When Mulligan's ankle technique & fibular taping is used along with the conventional
therapy, there is a faster functional recovery. This study highlights the importance of positional fault
concept in clinical practice.
Keywords: Lateral Ankle Sprain, Mulligan's Ankle Technique, Mwm, Fibular Taping

INTRODUCTION There are 3 major contributors to the stablity of the

Ankle injuries are one of the most common
orthopaedic injuries (over one million each year).
Approximately 85 % of these injuries are ankle sprains3,
2
. While incidence of ankle sprain is increasing, the
treatment protocol has been same over the years9 i.e.
RICE followed by ROM exercises, stretching of
musculotendinous tissues, efforts to improve the
neuromuscular control & strengthening exercises. But
even after this treatment, the reinjury rate after lateral
ankle sprain has been reported to be as high as 80% in
athletes & previous injury has been identified as a
strong predictor of reinjury8.
ankle joint10.
1. Congruity of the articular surfaces when joints are
loaded.
2. Static ligamentous restraints
3. Musculotendinous unit which allow for dynamic
stabilization of joints
In weight bearing position, when hind-foot is
pronated, joints of both hind & midfoot are free to make
compensatory changes required to maintain contact
of the foot to the ground. But with the supination of

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 168 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
hind foot, forefoot is also locked & there is no chance
for compensation1. In normal gait, this facilitates
weight transfer during the second half of stance phase.
But when hind foot has been supinated by uneven
terrain, locking of hind & midfoot blocks any
compensatory movement in foot causing entire medial
border of the foot to lift & unless the muscles on lateral
side of the foot are active, the supination sprain of
lateral ligament occurs1.
When the locked talocalcaneonavicular (TCN) and
transverse-tarsal (TT) joints are unable to absorb the
rotation superimposed by the weight bearing limb or
by uneven ground, the forces are dissipated at the
ankle and may result in injury to the ankle joint
structure. Joint dysfunction found in patients with
ankle sprain has been attributed to hypermobility or
hypomobility.
With this pre-existing background, Brian Mulligan
in 1995 introduced his ‘Positional Fault’ theory and
claimed that anterior subluxation of the fibula on tibia
at distal tibio-fibular joint may be the cause of painfully
restricted inversion after lateral ankle sprain and hence
the reason for reinjury4. At the same time he introduced
movement with mobilization (MWM) for ankle joint
followed by the fibular taping technique to treat lateral
ankle sprain. The technique is claimed to accelarate
the rehabilitation of lateral ankle sprain and gives
whole new direction to physiotherapeutic approach
towards lateral ankle sprain.
Though the Mulligan’s technique has been
introduced long back & there have been some
experimental studies based on the concept, there are
few studies done to test the clinical efficacy of the
technique. Hence this is a clinical trial done with the
aim to study the clinical efficacy of the Mulligan’s
MWM & taping technique as an adjunct to the
conventional therapy in the functional rehabilitation
of the lateral ankle sprain.
MATERIAL AND METHODOLOGY
This was a cohort study done with sample size of
30 subjects. Adult patients diagnosed with lateral ankle
sprain grade 1 & 2 by orthopaedic surgeon were
included in the study irrespective of their age and
sex, while patients having fracture associated with the
ankle sprain &/or grade 3 ankle sprain were excluded
from the study. Consent of all the subjects in this study
was taken. The sample size of the 30 patients was
divided into 2 groups
• Control Group- These patients received
conventional therapy (RICE or ultrasound
according to the phase of healing) + home exercise
33. Poonam Ghadi--167--171.pmd 168
(ROM exercise + self stretching + strengthening
exercise + proprioception exercise + functional
activities)
• Experimental group- These patients received
Mulligan’s ankle technique (MWM + Taping)
along with conventional therapy
Duration of the study was 6 days of treatment or
VAS on walking less than or equal to one,
whichever comes first. Parameters studied where
VAS on walking, VAS on tender point palpation
and duration of the single leg stance (SLS) on the
injured leg
Material used was plinth, dermaplast adhesive
bandage, micropore tape, ultrasound unit & ether
solvent.
• Mulligan’s ankle mobilization with movement &
taping technique- Patient is in supine position on
the plinth with the ankle out of the plinth.
Therapist holds the distal end of the fibula with
the base of the thumb & glides it posteriorly &
superiorly. Holding this position ask the subject
to do inversion & plantarflexion of the ankle
(Fig 1). Ten repetitions of such MWM is given. At
the end of the mobilization, fibula is taped in glide
position. First the part of the leg is cleaned with
ether solvent. Distal end of the fibula is glided in
posterior & superior direction and the position is
maintained by micropore tape. Tape starts anterior
to lateral malleolus going posterior & superior in
spiral direction to end on antero-medial aspect of
distal tibia. Now reinforcement is done by
dermaplast tape in the similar manner(Fig 2). Tape
should be maintained in position for 24 hours &
removed on next day. Tape should be reapplied
everyday while mobilzation technique used every
alternate day.
Fig. 1. Inversion & Plantarflexion of the ankle
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 169

(both legs & then affected leg), stepping, standing on

toes, treadmill, biking, jump rope, jogging & then
running, cutting exercise e.g. running in figure of 8,
crossover walking.

DATA ANALYSIS

30 patients with lateral ankle sprain were studied

by dividing into 2 groups of 15 each & observed over
the specified treatment period. Both the groups were
comparable with respect to basic criteria such as mean
age, male to female ratio & proportion of acute &
chronic cases.

Fig. 2. Reinforcement done by dermaplast tape
Conventional therapy- Exercise program
• Phase I
1. Protection of ankle in splint or crepe bandage
2. Rest for approximately 24 hours with only
movements of toes & ankle in pain free range
3. Ice application for 20 minutes for every 2 hours
for first 48 - 72 hours
4. Compression by crepe bandage
5. Elevation- Elevate the foot higher than the waist
to reduce swelling and pain
Parameters analyzed were VAS on walking & on
palpation taken every day & duration of SLS taken on
1st & last day. From the data collected mean & standard
deviation of the parameters were calculated.
Comparison of the improvement of the VAS scores &
SLS duration pre & post treatment was done between
the 2 groups using unpaired t-test and p<0.05 was
taken as significant.
RESULTS
Analysis of the data shows that VAS on tender point
palpation and on walking was reduced to significantly
greater extent (p<0.01- highly significant) when
Mulligan’s technique was used as an adjunct.
(Fig 3 & 4)
Fig 3. Comparison of VAS on tender point palpation

• Phase II: Starts when pain & swelling lessens VAS Mulligan’s & Conventional
Conventional
1. Stretching - Before & after activity, vigorous calf Pre Mean 7.9 8.23
stretches initiated ASAP with moderate pull but SD 1.69 1.47
no pain, ankle movements, toe curls. Post Mean 0.38 3.6
SD 1.02 2.28
2. Strengthening-Begin with isometric exercise &
progress to isotonic exercises in a pain free range Fig 4. Comparison of VAS on Walking
with an elastic band. Start working in all 4
VAS Mulligan’s & Conventional
directions along with heal raise within pain limit Conventional

3. Proprioception- Loss of proprioception causes loss Pre Mean 6.58 6.8

of balance hence start early weight bearing on the SD 1.95 2.22

ankle progressing to standing with eyes closed & Post Mean 0.43 2.92

standing on injured leg with eyes closed. SD 1.12 1.98

Fig 5. Comparison of duration of treatment

• Phase III- Full functional level
VAS Mulligan’s & Conventional
It includes full ROM exercises, 80-90% strength Conventional
exercises, swimming, running in pool, full weight Pre Mean 3.47 5.86
bearing, lunges forward & sideways, pain free hopping SD 1.55 0.35

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 170 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Fig 6. Comparison of SLS duration
SLSDuration(sec) Mulligan’s & Conventional
Conventional
Pre Mean 4.87 4.67
SD 1.64 1.68
Post Mean 15.8 8.47
SD 3.19 2.64
Fig 5 shows that the treatment duration required
to reduce pain was significantly shorter in case of
Mulligan’s group (p<0.01)
Results also show that the performance of the
patient on SLS test(Fig 6) improved significantly when
Mulligan’s technique was used along with
conventional therapy (p<0.005).
DISCUSSION
The present study was conducted to evaluate the
efficacy of the Mulligan’s MWM technique followed
by fibular taping for lateral ankle sprain. The concept
of positional fault & effect of Mulligan’s MWM
Technique has been studied in the past by various
researchers
The Findings of Hethrington B (1996), O’Brien T.,
Vicenzino B. (1998) present preliminary evidence for
‘Positional Fault’ theory, by showing evidence of
restriction of posterior filbular glide after lateral ankle
sprain, suggesting that lateral malleolus may be
subluxated in anterior direction7, 11. Kavanagh (1999)
supported this assertion by demonstrating the
difference in mobility at tibio-fibular joint between
subjects with & without ankle sprains6.
Schoening S (2004) clinically implemented
Mulligan’s technique for two chronic ankle sprain
patients to get the improvement consistent with
Mulligan’s theory14. Merlin DJ (2005) proved with the
help of MRI scan that subjects with lateral ankle sprain
showed significant displacement of the tip of the fibula
& the same was relocated in a superior direction with
MWM technique5.
Thus this study strongly supports the experimental
data5, 6, 7 which says that, in lateral ankle sprain there
is positional fault at the distal tibio fibular joint and
Mulligan’s MWM technique corrects the same,
accelerating the clinical recovery. We can see from the
results & analysis that, pain on tender point palpation
& on walking (as taken on VAS scale) has reduced
rapidly & to a significant greater extent. This finding
has been confirmed objectively by significantly
increased SLS duration.
33. Poonam Ghadi--167--171.pmd 170
Lateral ankle sprain does not cause isolated
ligament injury, but along with the ligaments of the
ankle joint, joint mechanics of the subtalar joint & tibio-
fibular articulation are also often affected15. According
to Mulligan, in case of lateral ankle sprain, there is
positional fault at distal tibio fibular joint. There is
anterior & inferior subluxation of fibular tip4. This
subluxation prevent normal excursion of fibula &
limits posterior translation of talus in relation to the
mortise during dorsiflexion12, 13 and thus restricts the
dorsiflexion at the ankle.
If the lateral malleolus is stuck in this displaced
position, the Anterior Tibio-Fibular Ligament (ATFL)
may be slacker in its resting position. Thus when the
rearfoot begins to supinate, the talus can go through a
greater ROM before ATFL becomes taut and can result
in episodes of recurrent instability, leading to repetitive
ankle sprains.
Unaddressed hypomobility at the injured joint may
result in compromised tissue repair & compensatory
motions at other joints. Thus, if the fibula remains
subluxed anteriorly & inferiorly during healing, the
inferior tibio-fibular interosseous ligament may be
stressed during healing, thereby compromising
mortise stability and resulting in chronic instability
syndrome15.
The inability of the fibula to move may also
compromise the stable base from which the peroneus
longus and brevis muscles act to plantarflex the first
ray, transfer weight across the metatarsals &
dynamically stabilize the ankle15. Hence, in case of
lateral ankle sprain, peronei are shown to have delayed
reaction time18,19,20.
By Mulligan’s technique, we are correcting the
positional fault at the distal tibio-fibular joint &
restoring the normal accessory joint motions at the
distal tibio-fibular joint. At the same time, conventional
therapy protects the damaged ligaments from stresses
that compromise the repair at the anatomical length16,17.
The taping technique that follows the mobilization
helps the following mechanisms21
• Taping aids in the reduction of mechanical ankle
instability
• It limits the extent of ankle motion, that may occur
during physical activity
• Taping when applied appropriately can shorten the
reaction time of the peronei muscles
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 171
• By affecting the proprioceptive function of the
ligament and joint capsule around the ankle joint
and the muscles of the lower leg
• It also helps by maintaining posterior & superior
glide of fibula which normalizes the
arthrokinematics of the distal tibiofibular joint.
• It reduces abnormal proprioceptive inputs to the
CNS & thus normalizing reflex patterns.
• It provides cutaneous sensory stimulation affecting
the joint position sense & hence better ankle
stability.
From the results of this study one can say that,
Mulligan’s technique provides rapid relief of pain
which increases the ability to bear weight on the
sprained ankle and hence faster functional recovery.
CONCLUSION
Mulligan’s MWM and taping technique is highly
efficient in immediate treatment of the lateral ankle
sprain, when used as an adjunct to conventional theory.
It significantly shortens the duration of the treatment
resulting in faster functional recovery. Thus the study
establishes the importance of Mulligan’s concept of
positional fault in clinical practice.
ACKNOWLEDGEMENT
I am thankful to my family whose valuable support
gave me courage & confidence throughout the study.
I extend my sincere thanks to Mr Kailash
Gandewar, PSM Department for helping me in the
statistical analysis.
Last but not the least I would like to thank all the
subjects of my study without whom this task would
not have been possible.
REFERENCES
1. Levangie, P. K.; Norkin, C C. 3rd Edition FA Davis
Co; Philadelphia, PA: 2001. Joint Structure &
Function: A Comprehensive Analysis; pp.379-415.
2. www.podiatry.curtin.edu.au/encyclopedia/
ankle2
3. w w w. s t e a d m a n - h a w k i n s . c o m / a n k l e /
overview.asp
4. Mulligan, B R 3rd ed Plane view Services Ltd,
Wellington New Zealand 1995. Manual therapy:
“NAGS”, “SNAGS”, “MWMS”, etc pp 95-101.
33. Poonam Ghadi--167--171.pmd 171
5. Merlin DJ, McEwan I, Thom JM.XIV international
congress on sports rehabilitation & traumatology,
2005.
6. Kavangh J Is there a positional fault at the inferior
tibio fibular joint in patients with acute chronic
ankle sprains compared to normals?Man Ther
1999; 4:19-24
7. Hethrington B Case study: lateral ligament strains
on the ankle. Do they exist? Man Ther, 1996; 1:274-
275
8. Milgrom C, Shlamkovich N, FinestoneA et al.
Risk factors fpr lateral ankle sprain: a prospective
study among military recruits. Foot Ankle 1991;
12:26-30
9. www.wrongdiagnosis.com/a/amkle_sprain/
intro.htm
10. www.Ankle%20sprain/articlerender.fci8.htm
11. O Brien T, Vicenzino B. A Study of the effects of
Mulligan’s mobilization with movement
treatment of lateral ankle sprain using a case
study design. Man Ther. 1998; 3:78-84.
12. Meadows, J TS. McGraw-Hill; New York, NY:
1999. Orthopedic differential diagnosis in
Physical Therapy: A Case Study Approach; pp.
114-115.
13. Dananberg S J, Shearstone J, Guillano M.
Manipulation method for treatment of Ankle
equinus. J AM Podiatr Med Association, 2000;
90:385-389.
14. Schoeing S, Physical Therapy, Feb 2004.
15. Craig R.Denegar & Sayers J Miller, III. J Athletic
training 2002 Oct -Dec; 37(4):430-435.
16. Hertel J. The role of non steroidal anti
inflammatory drugs in the treatment of acute soft
tissue injuries. J Athl Train. 1997; 32:352-358.
17. Low & Reed, Electrotherapy explained. pg 172-
211
18. Bullock Saxton J E. Sensory changes associated
with servers ankle sprain. Scand J Rehab Med.
1995; 27:161-167.
19. Konradson L, Ravn J B.Ankle Instability caused
by prolonged peroneal reaction time Acta Ortho
Scand. 1990; 61:388-390.
20. Lynch S A, Eklund U, Go ttlieb D Renstrom PA,
Beynnon B. Electromyographic latency changes
in the ankle musculature during inversion
moments. Am J Sports Med 1996; 24:362-369.
21. Karlsson J, Sward L & Andresson G 1993. The
effect of taping on ankle instability Sports
Medicine, 6(3), pp 210-215
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 DOI Number: 10.5958/j.0973-5674.7.3.087
172 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Comparative Study between the efficacy of Muscle Energy

Technique and Static Passive Stretching on Hamstring
Flexibility in Healthy Indian College Athletes

Pratik A Gohil
M.P.T Musculoskeletal and sports physiotherapy, KIMS, Physiotherapy, Bangalore

ABSTRACT

Background: Success in sports depends on athlete's ability to develop and produce a specific set of
coordination and joint range of motion/flexibility. Purpose of the study is to compare efficacy of
muscle energy technique and static passive stretching on hamstring flexibility in healthy Indian college
athletes.

Subjects: The subjects were healthy Indian college athlete from Bangalore metropolitan area.

Method: 30 healthy college athlete subjects with hamstring tightness were randomly allocated to
two study groups. Groups-A (n=15) subjects were treated with Muscle energy technique (Isometric
contraction - using post isometric relaxation, approximately 30% of patient's strength, Duration of
contraction is 20 seconds, muscle is taken to its new restriction barrier and held in this position for at
least 60 seconds, three repetition with 15 second of rest interval) where as other group-B (n=15) were
treated with static passive stretching (No warm up was allowed prior stretching, Subjects received
three stretches of 60 seconds). The treatment was given for 1 day.

Outcome Measure: Subjects were assessed for hamstring flexibility by measuring straight leg raise
angle i.e. active straight leg raising range of motion prior and immediately after intervention.
Measurement was done by standard universal goniometer.

Results: Paired Samples t -Test showed that Muscle Energy Technique and static Passive Stretching
both the treatments are significant (P=0.000). Mann-Whitney Test showed a statistically significant
improvement in the Muscle Energy technique group when compared to static passive stretching.

Conclusion: A muscle energy technique is more effective than static passive stretching for
improvement in hamstring flexibility.
Keywords: Muscle Energy Technique, Static Passive Stretching, Straight Leg Raise Angle, Hamstring
Flexibility

INTRODUCTION menisci injuries, Chondromalacia patella, and poor

posture often come from tight hamstrings also; altered
Most medical professionals, coaches and athletes
flexibility of the hamstring may produce significant
consider aerobic conditioning, strength training and
postural deviations and affect the functionality of the
flexibility as integral components in any conditioning
hip joint and lumbar spine 5. Hamstring muscle injuries
program 1. Flexibility has been defined as the capacity
are seen primarily during high speed or high intensity
to move a joint through its available range of motion
exercises and have a high rate of recurrence 6. Lack of
(R.O.M), without producing excessive myo-tendinous
hamstring flexibility was the single most important
stress 2. Flexibility is a physical fitness attribute and is
characteristics of hamstring injuries in athletes 7.
often evaluated from the joint range of motion (ROM)
3
Muscle energy technique (MET) is a manual technique
, an essential element of normal biomechanical
developed by osteopaths and is now used in many
functioning in sports 4. Soft tissue injuries, knee pain,

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 173
different manual therapy professions 8. It is claimed to
be effective for a variety of purposes including
lengthening a shortened muscles, as a lymphatic or
venous pump to aid the drainage of fluid or blood and
increasing the range of motion 8, 9. Static passive
stretching of 60 second is claimed to be effective 10.
When soft tissue is stretched, elastic, viscoelastic, or
plastic changes occur. During passive stretch both
longitudinal and lateral force transduction occurs 11.
When initial lengthening occurs in the series elastic
(connective tissue) component, tension rises sharply.
After a point, there is mechanical disruption
(influenced by neural and biochemical changes) of the
cross-bridges as the filaments slide apart, leading to
abrupt lengthening of the sarcomeres, 11, 12, 13 sometimes
referred to as sarcomere give 12.
METHODOLOGY
SOURCES OF DATA: The subjects were healthy
Indian college athlete from Bangalore metropolitan
area, Karnataka, India.
STUDY DESIGN
Experimental study with a pretest-posttest design
was conducted. The study design was approved by
the research and ethical committee of Kempegowda
institute of medical science – Physiotherapy
department.
SUBJECTS
Thirty healthy Indian college athlete volunteers
were selected on the basis of the inclusion and
exclusion criteria. A written informed consent was
obtained from all those subjects who fulfilled the
inclusion and exclusion criteria.
Inclusion Criteria
a) Aged between 18- 25 year of age.
b) Gender- Both Male and female.
c) Tight hamstring (the finger-ground distance had
to be greater than zero cm means unable to touch
the floor when bending forward and the passive
straight leg raising range was not to exceed 80°).
Exclusion Criteria
a) Acute or chronic low back pain with or without
radiculopathy.
b) Acute or chronic hamstring injury.
34. Pratik Gohil--172--176.pmd 173
c) Previous history of spinal or lower limb fractures.
d) Any lower limb surgery in past one year.
e) Skin disease on treatment area.
PROCEDURE
Thirty healthy collegiate subjects with hamstring
tightness were randomly allocated to two study
groups. Subjects were assessed for hamstring flexibility
by measuring pelvic femoral angle i.e. passive straight
leg raising range of motion (Fig.1). Groups-A (n=15)
subjects were treated with Muscle energy technique
where as other group-B (n=15) were treated with static
passive stretching. The subjects were tested prior and
immediately after intervention for one day. The
outcome was measured in terms of straight leg raise
angle i.e., active straight leg raising range.
Straight Leg Raise Angle / Acive Straight Leg Raising
Range
A straight leg raise angle is measured by making
the subject lie flat on a plinth with their knee fully
extended position. And then with knee extended
position the hip gradually flexed up to the onset of
discomfort at back of thigh. While performing test the
other limb is fixed. Now hip R.O.M measured with
the standard universal goniometer. Three repetitions
were performed and an average of the three was taken
as the final reading for straight leg raise angle 15.
Group-A (Muscle Energy Technique) The muscle
energy technique was applied to the group A. Isometric
contraction – using post isometric relaxation,
approximately 30% of patient’s strength, Duration of
contraction is 20 seconds, muscle is taken to its new
restriction barrier and held in this position for at least
60 seconds, three repetitions with 15 second of rest
interval 8.
Group-B (Static Passive stretching) The static
passive stretching technique was applied to the group
B. While stretching, each subject’s knee was
maintained in extension with ankle at neutral position
without internal or external rotation of the hip, and
the extremity was raised in respect to patient’s
feedback about stretching pain. No warm up was
allowed prior stretching; Subjects received three
stretches of 60 seconds 10, 14.
DATA ANALYSIS
Statistical analysis was done by using SPSS-16
software.
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 174 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

RESULTS

The result of this study was analyzed in terms of

gain range of motion (straight leg raise angle values)
in and between both group-A and B subjects.

Demographic Profile: Age of all subjects was

recorded. The mean age of Muscle Energy Technique
group was 22.6 years with S.D. ± 1.0; the mean age of
Static Passive Stretching group was 22.0 years with S.D.
± 0.6. There is no significant difference between groups
in terms of demographic variables. Graph: 1 Mean range of motion

Within Group Analysis: In both groups values Table 1 and Table 2 have represented that muscle
(graph 1) of straight leg raise angle (Degrees) shows energy technique and Static Passive Stretching have
that the mean range of motion during posttest is higher shown statistically significant (P<0.05) improvement
than that during pretest. from baseline for hamstring flexibility.

Table 1. Paired Samples Test for Group- A (Muscle Energy Technique)

Paired Differences
Mean Std. Std. Error 95% Confidence t df Sig.
Deviation Mean Interval of the Difference (2-tailed)
Lower Upper
7.93333 1.48645 .38380 8.75650 7.11017 20.671 14 .000

Table. 2. Paired Samples Test for Group- B (Static Passive Stretching)

Paired Differences
Mean Std. Std. Error 95% Confidence t df Sig.
Deviation Mean Interval of the Difference (2-tailed)
Lower Upper
6.26667 1.75119 .45216 5.29689 7.23644 13.860 14 .000

Between Group Analysis of Mean and Standard deviation suggesting that

Muscle energy technique is more effective compared
Mann-Whitney Test shows significant difference to Static Passive stretch for hamstring flexibility.
between Group-A and B with p value is 0.000. So values

Table 3: Between Group Analysis by Mann-Whitney Test

Group N Mean Std. Deviation Std. Error Mean

Difference A 15 7.9333 1.48645 .38380
B 15 6.2667 1.75119 .45216

DISCUSSION hamstring flexibility in healthy Indian college athletes.

To improve hamstring flexibility muscle energy
technique, passive stretch, and other many more
techniques were used by therapist but there is no much
research literature available which shows which one
is more efficient way to improve flexibility. Therefore
the current study was undertaken to compare Muscle
Energy Technique and Static Passive Stretching on
For the purpose of this comparison a pre–posttest,
experimental study was carried out. Hamstring was
the muscles of choice since it is the muscle that is most
prone to injuries during sporting activities, and if the
flexibility of hamstrings is adequate the incidence of
hamstrings strains can be decreased and performance
can be enhanced as well. Also there are well
documented, reliable and valid methods of testing

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 175
flexibility of hamstring muscles, such as the straight
leg raise angle 15. Hamstring flexibility was measured
by straight leg raise angle i.e., Straight leg raising range
as hip angle could be the parameter for hamstring
flexibility test based on the direct relation of the
hamstring with the pelvis and hip’s functionality So
using this test we can come to know a minimal change
in the hamstring flexibility16. A comparison of the pre-
test and the posttest values of the straight leg raise
angle showed that there was a significant improvement
in the both groups following treatment. Whereas
comparison between group A and group B has shown
significant improvement in group-A. Thus it may be
said that Muscle Energy Technique is effective
individually in improving flexibility of hamstrings
muscle in Indian college Athletes. Improvement seen
in Static Passive Stretching (SPS) group was expected
with considering the previous research studies that
provide consistent evidence regarding the effectiveness
of Static Passive Stretching to improve flexibility. C.
D. Weijer et al (2003) reported that the positive effect
of Static passive Stretching on hamstring muscle length
immediately after 15 minutes and over the course of
24 hours17. But according to Patrick McLaughlin et al
(2003) studied the effect of muscle energy technique
on hamstring extensibility: the mechanism of altered
flexibility. And reported a significant increase in range
of motion was observed at the knee (p<0.019) following
a single application of MET to hamstring muscle in
the experimental group. No change was observed in
the control group 18. K L Lenehan (2003) presented
research report on the effect of Muscle Energy
Technique on gross trunk range of motion. This study
examined whether a single application of thoracic MET
could significantly increase the range of motion in
asymptomatic volunteers 19.
CONCLUSION
On the basis of present study, it can be concluded
that all the subjects belonging to group–A and group
– B were able to increase the straight leg raise angle
i.e. improvement in the hamstring flexibility. However
on the basis of statistic analysis we can clearly say that
Muscle energy technique is more efficient technique
in improving hamstring muscle flexibility compared
to static passive stretching for Indian athletes. This
study can further be extended on to varying age group
populations also with follow up to see the time period
34. Pratik Gohil--172--176.pmd 175
of maintenance of results. Muscle Energy Technique
is very simple and can be easily used on those who
are experiencing lack of muscle flexibility.
REFERENCES
1. Russell T N, William DB. Eccentric training and
static stretching improve hamstring flexibility of
high school males. J Athletic Training. 2004: 39:
254-8
2. RL Carregaro. Comparison between two clinical
tests for the evaluation of posterior thigh muscles
flexibility. Rev. Bras. Fisioter. 2007: 11(2).
3. Hopper D, Decan S, Das S, Jain A, Riddell D, Hall
T. Dynamic soft tissue mobilization increases
hamstring flexibility in healthy male subjects. Br
J Sports Med. 2005: 39: 594-8.
4. Murphy DF, Connolly DAJ, Beynnon BD. Risk
factors for lower extremity injury: a review of the
literature. Br J Sports Med. 2003: 37: 13-29.
5. Taylor DC, Dalton JD, Seaber AV, Garrett WE.
Viscoelastic properties of muscle-tendon units:
The biomechanical effects of stretching. Am j
sports med.1990: 18:300–309.
6. Ballantyne F, Fryer G, Mclaughlin P. The effect of
muscle energy technique on hamstring
extensibility: The mechanism of altered flexibility.
J Osteopathic Medicine. 2003: 6: 59-63.
7. Chaitlow L, Liebenson C (Ed) In: Muscle Energy
Techniques. 2001: 2nd Edition, Donald R Murphy,
London. Pg. 95-106.
8. Ballantyne F, Fryer G, Mclaughlin P. The effect of
muscle energy technique on hamstring
extensibility: The mechanism of altered flexibility.
J Osteopathic Medicine. 2003: 6: 59-63.
9. Freyer G. et al. Muscle energy concepts: a need
for change. J osteopathic medicine. 2000: 3: 54-
59.
10. Carolyn kisner, Lynn Allen Colby: Therapeutic
Exercise Foundations and Techniques. 2002: 5th
Edition, F. A. Davis Company, US. Pg. 99
11. De Deyne. Application of passive stretch and its
implications for muscle fibers. Phys Ther.
2001:81(2):819–827.
12. Flitney, FW, Hirst, DG: Cross bridge detachment
and sarcomere “give” during stretch of active
frog’s muscle. J Physiol 1978: 276:449.
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13. Lieber, RL, Boodine-Fowler, SC: Skeletal muscle
mechanisms: Implications for rehabilitation. Phys
Ther. 1993: 73:844–856.
14. Yuktasir, Kaya. Investigation into the long-term
effects of static and PNF stretching exercises on
range of motion and jump performance. Journal
of Bodywork and Movement Therapies. 2009: 13
(1):11-21.
15. Jan P.K. Halbertsma, Annette I. van Bolhuis,
Ludwig N.H. Goeken. Sport stretching: Effect on
passive muscle stiffness of short hamstrings.
Archives of Physical Medicine and Rehabilitation.
1996: 77 (7):688-692.
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16. Gajdosik RL, Rieck MA, Sullivan DK, Wightman
Se. Comparison of four clinical tests for assessing
hamstring muscle length. J orthop sports phys
ther. 1993: 18(5):614-8.
17. C. D. Weijer, C Gorniak: The effect of static stretch
and warm up exercise on hamstring length over
the course of 24 hours, Journal of Orthopedic
Sports Physical Therapy, 2003; Vol.33; Number
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 DOI Number: 10.5958/j.0973-5674.7.3.088
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 177

Effect of Maitland Spinal Mobilization Therapy Versus

Conventional Therapy in Lumbar Spondylosis with
Radiculopathy

Priya Igatpurikar
Lecturer - N.D.M.V.P'S college of Physiotherapy, Nashik, Maharashtra

ABSTRACT

Objectives: To compare SMT with conventional therapy in lumbar spondylosis with radiculopathy.

Design : Randomized controlled trial.

Material : Inch tape, pen , goniometer, SWD , lumbar traction unit , Hot packs.

Method: A RCT was done and patients with lumbar spondylosis were allocated in two group.
Gr. I received Maitland's mobilization in P-A , rotational and transverse mobilization with hot
packs and core stabilization. Gr. 2 received lumbar traction, Shortwave diathermy and core
stabilization.

Each group had 20 patients and they were evaluated on day one pre treatment and day 30 post
treatment. Outcome measures used for assessment were pain on VAS scale, spinal ROM by Schober's
test SLR and Oswestry Disability Scale for functional evaluation.

Results: Spinal mobilization and conventional therapy both showed improvement in pain and spinal
ROM but spinal mobilization however mobilization therapy showed significant improvement than
conventional group (t value = 2.149, p < 0.05). SLR & ODI showed improvement within group but
not between the two groups.

Conclusion : Spinal mobilization is better than routine conventional therapy .

Keywords: Lumbar Spondylosis, Maitland spinal Mobilization, PA glide, Transverse glide, Rotational
mobilization, SWD

INTRODUCTION Out of various conditions affecting low back,

The loss of youth is melancholy enough : but to
enough into through the gate of infirmity, most
dishearting”16
Horace Walpole, 1765
Although backache with or without sciatica is a
benign, often self-limiting condition, it drains upto $
60 billion dollars per year from American
Government’s health care budget.16,11
degeneration of spine is the most common cause.
Spondylosis affects intervertebral disc, facet joints,
bones and ligament. Unfortunately as we age, our
intervertebral disc lose their flexibility , elasticity and
shock absorbing characteristics. 6,10 The annulus
fibrosis become brittle & nucleus pulposus begin to
dessicate. The combination of damage to intervertebral
disc, development of bony spurs, and gradual
thickening of ligaments that support the spine can all

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 178 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
contribute to degenerative arthritis of lumbar spine.
This can cause several symptoms including back pain,
leg pain and weakness due to compression of nerve
roots.11
There are few studies done by Sims Williams et al
(1978,79) Rasmussen (1979) , Bergquist – Ullman
(1977), Christman et al (1964) , Doran and Newel
(1975), Coxhiah et al (1981) as well as Farrell and
Towmey (1982) documented that SMT is superior than
any other conventional therapies. Dr.P.Senthil Kumar,
Dr. Preeth John Cherian, MAHE, has done studies on
Maitland’s mobilization versus conventional therapy
in treatment of lumbar disc herniation and showed that
Maitland’s mobilization had significant results as
compared to conventional therapy . Thus this study
was taken to update the effectiveness of Maitland
spinal mobilization in degenerative spines in Indian
populations.
MATERIAL AND METHODOLOGY
1. Selection of Cases
Kamala Nehru Hospital and Sancheti Hospital’s
P.T.O.P.D.
2. Age Group: 45 to 60 years.
3. Inclusion Criteria: Patients diagnosed as having
lumbar spondylosis with radiculopathy.
Both sexes included.
VAS 6 to 10
4. Exclusion Criteria: spondylolysis
spondylolisthesis.
Spinal tumors.
Infective spinal condition.
Severe canal stenosis.
Ankylosing spondylosis.
Spinal fractures.
Spinal surgeries.
Pregnancies.
Severe sensory or motor weakness.
Disease of spinal cord and cauda equine.
Scoliosis.
35. priya igatpurikar--177--183.pmd 178
Blood coagulation disorders.
Severe osteoporosis.
Sacroiliac diseases.
1. Method of Collection of Data: Randomized
controlled trial.
2. Sample Size: Total patients :- 40
Group A: 20 patients receiving Maitland
Mobilization Therapy, hot packs and core
stabilization.
Group B: 20 Patients receiving conventional
therapy (traction and SWD) and core stabilization.
3. Materials or Equipment Used :
• Inch tape
• Traction table
• SWD
• Hot packs
4. Outcome Measures
• VAS for pain
• ROM
• SLR
• Oswestry Disability Index
PROCEDURE
and
Patients included in this study were known case
of lumbar spondylosis with radiculopathy. Consent
was taken and patients were randomly allocated
for treatment.
Group 1: Received Maitland spinal mobilization
(grade 1 to 4) Hot packs and core stabilization.
Group 2: SWD, Intermittent lumbar traction & core
stabilization.
• Pain on VAS , number of past and present
complaints was taken. Spinal ROM was assessed
by Modified Schober Test and side flexion and
rotations was assessed by tape method . MMT
was done according to Kendall method for
abdominals , back extensors and lower limb
muscles. Sensory evaluation, reflex testing and
special tests such as neural tissue tension test
and sacroiliac joint test was also done.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 179

Group A : This consists of experimental group
in which subjects were given hot packs for
relaxation prior to mobilization therapy.
Maitland’s gr1 to gr.4 central , unilateral ,
transverse ,rotational mobilization was given to
the affected vertebra and one vertebra above
and one vertebra below.
1. The amplitude used initially was Gr. I and II for
pain relief & grade III and IV was used to
improve ROM, slow speed, smooth rhythm & 2
to 3 oscillations /sec for 30 sec. 2 to 3 sets for each
vertebra.
2. Mobilization was followed by core stabilization
exercises .
3. Patients were treated for 4 weeks and
assessment and outcome measures were taken
on 1st and 30th day .
Group B: the other group received intermittent
lumbar traction , Short wave diathermy and core
stabilization and flexibility exercises .
ILT parameters: As per the study done by Lee and
Evans
Patient was taken in supine with hip-knee in 90-90
and leg supported on stool with pillows. Angle of pull
was adjusted between 18 to 34 degrees & weight
applied was slightly less than 50 % of body weight
Hold and relax time: 15/15 min. duration of treatment:
15 min.
SWD : Patient was taken in supine with hip- knee
flexed position and coplanar method of application
was used.
Statistical Analysis
Data Collection: The study was conducted
between May 2005 to 15 October .2006.
Statistical Analysis: A paired‘t’ test was done to
analyze the results within group for pain in VAS, spinal
ROM and SLR.
Unpaired t test was done to analyse the results
between the two groups for VAS, spinal ROM and
SLR. The p level was set to 0.05.
Oswestry disability index results were analyzed
by Mann-Whitney test.

Table 1. Demographic Data

Patient Characteristics
Sr No Variables Experimental Grouop Control Group
(N = 20) (N = 20)
1 Mean Age 50.75 50.35
2 Male / Female 6 M / 14 F 7 M / 13 F
3 Mean Duration Of Symptoms (Months) 1.45 1.3
4 Number Of Patients With Past Episodes 13 9
5 Occupation Distribution
• Light Work • 12 • 10
• Moderate Work •6 •7
• Heavy Work •2 •3

Table 2. Vas Score

Experimental Control Unpaired

T Test
Pre mean_+ S.d. Post mean _+ S.d. Paired T Test Pre mean_+Sd Post mean_+Sd Paired T Test
7.55_+0.88 1.45_+0.51 24.375* 7.5_+0.688 2.05_+0.68 32.1056* 2.1495*

* Indicates P < 0.05 (Significant Difference)

Table 3. SLR

Experimental Control Unpaired

T Test
Premean_+ S.d. Postmean _+ S.d. T Value Premean_+Sd Postmean_+Sd T Value
51_+ 5.98 94.5_+ 5.1 33.1* 51_+ 5.938 91_+ 5.53 22.6* 1.703

* Indicates P < 0.05 (Significant Difference)

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 180 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 4. Spinal Rom

Movement Group Mean Rom S.d. T Unpaired T Test

Flexion Exp 4.55 0.944 21.54*
Cont 3.275 0.525 22.6* 5.276*
Extension Exp 1.75 0.5 15.62*
Cont 1.85 0.609 12.6* 0.567
Rt. Side Flexion Exp 3.75 0.786 21.35*
Cont 3.15 0.75 18.9* 2.171*
Lt. Side Flexion Exp 3.75 1.164 14.36*
Cont 2.65 1.03 11.39* 0.9839
Rt. Rotation Exp. 0.975 0.8 5.44*
Cont. 1.45 0.551 11.58* 2.476*
Lt. Rotation Exp. 1.25 0.769 6.46*
Cont. 1.45 0.483 13.39 3.1513*

* Indicates P < 0.05 (Significant Difference)

Table 5. Oswestry Disability Index

Experimental Control
Grade Pre Post Pre Post
Minimum - 20 - 20
Moderate 6 - 6 -
Severe 11 - 14 -
Crippled 3 - - -
Bed Bound - - - -

Oswestry Disability ( Mean ± Sd) And U Value :-

Experimental Control U Value

Mean 36.2 30.5 145
Sd 10.758 5.226

Critical U Value – 127, Results Higher Than 127 Indicate Insignificant Values.

Fig. 1. Rotational mobilization Fig. 2. Transverse glide

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 181
Fig. 3. Central P-A glide
Fig. 4. Unilateral P-A glide
DISCUSSION
Low back pain is the most common ailment and
every one in life experiences it due to one or the other
reason. Out of the various reasons lumbar spondylosis
is the third leading cause of disability in people above
45 years. 12
The rational for using Spinal manipulative
therapy in the hypomobile joint in lumbar spondylosis
is that these joints place excessive stress or strain
on neighboring joint and may if long standing
promote hypermobility in neighboring joints similar
to translational hypermobility.13, 14 ,16
Janda noted that altered joint function affects the
quality of muscle function across the involved joint
. Jull and Janda stated that the proprioceptive
input required for good motor control may be
35. priya igatpurikar--177--183.pmd 181
diminished when there is pain or stiffness in a
lumbar segment. Neurological deficits associated with
radicular pain are thought to arise from mechanical
compromise , ischemia , or inflammation of spinal
and dorsal root ganglia complex (Hause 1993)
possibly associated with intervertebral disc lesion or
osteophytic encroachment.
Pain showed improvement in both the groups i.e
(P<0.05) There was however more improvement in
the experimental group than the control group. This
could be attributed to the stimulation of
mechanoreceptors in the joint capsule , ligament, disc
etc there by causing stimulation of large diameter
that block the transmission of nociceptive impulses
(Paris 1979 , Wyke 1985) Thus closing the gate of pain
(Melzack and Wall ) The other mechanism of
relief of pain is by reducing the swelling containing
neurotransmitter such as substance P , histamine
and gentle oscillations may also raise the threshold
of nociceptors (Zusman 1986)
Similarly radicular pain reduction in control group
is attributed to the mechanical effects of ILT and
thermal effects of SWD . Since SWD causes deep
heating , increased circulation and extensibility of
collagen and induces relaxation and reduces muscle
spasm. Traction separation of vertebra thus
increases diameter of vertebral foramen and is
responsible for reduction of pain and normalize
neurological deficits by directing relieving pressure
(Colachis and Stroem 1969, Twomey 1985) It is also
said to reduce disc protrusion and stimulate
mechanoreceptors by intermittent movement. (Martin
Krause 2000)
Core stabilization also plays important role in
reducing pain and it was given to both the groups.
Core exercises helps motor control training & patient
learns to activate his natural lumbar corset of body
and stabilize the spine during various activities. When
deep segmental muscles are activated , there is
improved motor control, endurance, and thus less fear
of re-injury.
There was statistically significant improvement in
SLR in both the groups. (Exp t- 33.13 and control t-
25.29) but no significance was found between the
two groups.
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 182 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
When spinal movements are considered , both the
groups showed improvement in ROM. (P<0.05)
Oswestry Disability Index did not show statistical
significance ,(U=145) but there was clinical
improvement in both the group. Thus
after analyzing the results , it can be concluded
that , both spinal mobilization therapy and
conventional therapy had significant improvement
but spinal mobilization therapy showed better
outcome than conventional group in pain reduction
& improving ROM where as no much difference in
SLR and disability index. Since the patients had
improvement in few functions , the study should be
carried out for a longer time to have a better outlook
on the effect of mobilization therapy in functional
improvement of the patients. Thus although evidence
is lacking for manual therapy as a sole intervention, it
can be used with other therapies such as exercises,
cortico-steriods and physical therapy in routine
clinical practice to have better and cost effective
outcomes.
CONCLUSION
From this study it is concluded that
Spinal mobilization therapy and conventional
group showed improvement in pain , SLR , spinal
ROM and functions. (p<0.05) However experimental
group showed little more statistical significant than
control group. (t-2.149 ,p<0.05).
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Design and feasibility fo randomized trial of
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 183
traction in patients of lumbar radiculopathy .
Mannual therapy 3 :203 -211: 1998
20. O’Sullivan,Twomey 1998. Altered abdominal
muscle recruitment in patients with chronic low
back pain following a specific exercise
intervention.JOSPT;27;Feb 1998.
21. Ricardson CA,Hides JA.1996. Multifidus muscle
recovery is not automatic after resolution of
acute,first-episode low back pain.Spine;21;2763-
69;1996.
22. Spinal manipulation therapy for low back pain:
an updated systematic review of RCT. Spine 21,
35. priya igatpurikar--177--183.pmd 183
(24), 2860-2871, dec 15 1996. Koes, Bart W,
Assendelft, Van der Heijden et.
23. Twomey,O’Sullivan 1997 Altered patterns of
abdominal muscle activation in patients with
chronic low back pain.Australian journal of
physiotherapy;43;Mar;1997.
24. VAS reliability –Ong K.S. Seymour R A Pain
measured in humans 2004: 2 15 -25(7_)
25. Wordon R E ,Humprey T L therapeutic effect of
spinal traction on digit of body .Arch Physical
Med Rehabil 45, 318-320, 1964
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 DOI Number: 10.5958/j.0973-5674.7.3.089
184 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Importance of Screening in 0-18 Months Infants by using

INFANIB at Tertiary Hospital

Parmar Sanjay1, Praveen S Bagalkoti2, Netravati Shettar2, Rajlaxmi Kubasadgoudar3

1
Assistant Professor, Department of Physiotherapy, 2Associate Professor, Department of Pediatrics, SDM College of Medical
Sciences and Hospital, Dharwad, 3Consultant Pediatric Physiotherapist, Regional Neuroscience Centre, Hubli, Karnataka

ABSTRACT

Objectives: Child development is a dynamic process and is often hard to measure by its very nature.
The various streams of development, including gross motor, fine motor, language, cognitive, and
adaptive behaviour, are interrelated and complex within themselves. Developmental delay refers to
when a child's development lags behind established normal ranges for his or her age. The prevalence
of developmental delay, deviation, disability or deformity in India is 2.5%. So the objective of this
study was to screen the infants at Tertiary hospital and to categorize them as normal, transiently
abnormal & abnormal neurologic development according to the INFANIB score.

Design: Cross sectional study

Method: 639 subjects were included in this study. According to the INFANIB manual guidelines,
screening test was administered and infants were categorized as normal, transiently abnormal and
abnormal neurologic development. Then, the data was evaluated statistically and results were
obtained.

Results: In Group 1(age of less than 4 months) as per INFANIB score out of 194 samples there were
161(82.99%) normal, 24(12.37%) transiently abnormal and 9(4.64%) abnormal neurologic development
infants. Group 2 (age of 4-8 month) had 162(86.63%) normal, 12(6.42%) transiently abnormal and
13(6.95%) abnormal neurologic development infants out of 187 samples. In Group 3(age of 8 months
or more) out of 258 samples there were 205(79.46%) normal, 18(6.98%) transiently abnormal and
35(13.57%) abnormal neurologic development infants. When all three age groups were considered,
there were 528(82.63%) normal, 54(8.45%) transiently abnormal, 57(8.92%) abnormal neurologic
development infants.

Conclusion: On INFANIB screening, there were 8.45% transiently abnormal and 8.92% abnormal
neurologic development infants at the Tertiary hospital.
Keywords: Screening, INFANIB, 0-18 month's Children

INTRODUCTION more areas of development.1,2 Various pre, peri &

neonatal factors contributed to the developmental
The term “high-risk infant” is used to those infants
delay. To increase survival rate of neonates and
whose perinatal medical course might contribute to
effectiveness of early intervention, the risk factors
motor, cognitive or social deficits. The term high risk
could be considered as a valuable clue. Neuro
infant designates infants who should be under close
developmental screening for neonates and infants for
observation by experienced physicians & nurses. It is
early detection of neuro developmental delays is
well known that the incidence of developmental delay
highly recommended. The prevalence of
in high-risk infants is higher. Developmental delay
developmental delay, deviation, disability or deformity
refers to when a child’s development lags behind
in India is 2.5%.4 Screening is a “brief assessment
established normal ranges for his or her age.1
procedure designed to identify children who should
At least 8% of all children from birth to six years receive more intensive diagnosis or assessment.”
have developmental problems and delayed in one or Developmental screening is aimed at identifying

36. Rajlaxmi --184--186.pmd 184 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 185

children who may need more comprehensive
evaluation.5 There are various developmental
screening test which are used to assess the newborn.
Some of them are:
1. Denver Developmental Screening Test 2.
2. Alberta Infant Motor Scale.
3. Assessment of Movement Activity in Infants.
4. Movement Assessment of Infants.
5. Milani Comparetti Motor Developmental
Screening Test.
6. Primitive Reflex Profile.
exclusion criteria, infant’s parents were requested to
participate in the study. Subject’s parents who were
willing their child to participate in the study were
briefed about the study and their informed consent
was taken.
Inclusion Criteria
0-18 months of children of either gender.
Exclusion Criteria
No parental consent, unco-operative subjects,
infants admitted for unstable medical conditions,
infants under the effect of drugs acting on CNS E.g:
Phenobarbitone.

7. The Brazelton Neonatal Behavioural Assessment PROCEDURE

Scale.
8. Infantile Neurological International Battery
(INFANIB).6
Infantile neurological international battery
(INFANIB) is a developmental screening test used to
determine tone and posture of 0-18 months infant. It
is used to evaluate infants who are born prematurely,
treated in neonatal intensive care, affected by sickness
such as meningitis and heart failure or infants whose
development is slow. It is used to distinguish infants
with normal neuromotor function from those with the
abnormal findings and to predict the need for follow
up treatment. This scale does not require any special
training for the therapist to administer.6
METHOD
In this study 639 subjects were taken using
systematic random sampling method. Their
demographic data was collected and infants were
screened and scored as per INFANIB manual
guidelines. INFANIB has 20 items that assesses the
infant’s motor development in supine, prone, standing,
and suspended positions for reflexes and French angles
as well as muscle tone and body posture. Scoring was
based on age groups.
Infants with age less than 4 months score of less
than or equal to 48 was considered abnormal, 49-65 as
transient and e” 66 as normal. Age group of 4-8 month
less than or equal to 54 was abnormal, 55-71 as
transient and e”72 was normal. Age group 8 month or
more score less than or equal to 68 was abnormal, 69-
82 was transient and e”83 was considered as normal.

For this study, ethical clearance was obtained from
SDM institutional ethical committee, Dharwad before
commencement of the study. All infants age between
0-18 months visiting Department of Physiotherapy &
Department of Pediatrics Shri Dharmasthala
Manjunatheshwara College of Medical Sciences &
Hospital (SDMCMS & H) Dharwad were screened.
After finding their suitability as per inclusion and
Statistical Analysis
Statistical analysis was done by using SPSS 16.0
version statistical software. Chi square test was used
to categorize the infants as normal, transiently
abnormal and abnormal neurologic development. This
categorization was done according to age groups and
gender.

RESULTS
Table1. Distribution of samples according to groups and degree of normality and abnormality.

Group Normal % Transient % Abnormal % Total

Less than 4 months 161 82.99 24 12.37 9 4.64 194
4 to 8 months 162 86.63 12 6.42 13 6.95 187
8 months or more 205 79.46 18 6.98 35 13.57 258
Total 528 82.63 54 8.45 57 8.92 639

Chi-square= 16.8272 df=4 p=0.0020, S

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 186 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Table 1 shows the number and percentage of
normal, transiently abnormal and abnormal neurologic
development. In Group 1 as per INFANIB score out of
194 samples, there were 161(82.99%) normal,
24(12.37%) transiently abnormal and 9(4.64%)
abnormal neurologic development infants. Group 2
had 162(86.63%) normal, 12(6.42%) transiently
abnormal and 13(6.95%) abnormal neurologic
development infants out of 187 samples. In Group 3
out of 258 samples there were 205(79.46%) normal,
18(6.98%) transiently abnormal and 35(13.57%)
abnormal neurologic development infants. When all
three age groups were considered, there were
528(82.63%) normal, 54(8.45%) transiently abnormal,
57(8.92%) abnormal neurologic development infants.
DISCUSSION
The purpose of this study was to screen the infants
at Tertiary Hospital and to categorize them as normal,
transiently abnormal and abnormal neurologic
development as per INFANIB scoring.
A study was done to know the neuromotor
outcome in risk infants using Infant Neurological
International Battery (INFANIB). Correlation between
INFANIB results and neuromotor outcome for 2 years
in 70 risk infants was also studied. All the infants of
the abnormal result group (29 cases) on the initial
INFANIB examination grew into either cerebral palsy
(26 cases) or minor neural dysfunction group (3 cases)
on the follow-up examinations. All the infants of the
normal results group (12 cases) appeared to be in
normal developmental outcomes on the follow up.
However, the transient results group (29 cases) showed
variable outcomes, which were 9 cases of cerebral
palsy, 6 cases of minor neural dysfunctions, and 11
cases of normal development. INFANIB test results of
the infants were highly sensitive and specific. Normal
INFANIB results can be used to reassure parents of
risk infants and an early intervention programs can
be started to abnormal INFANIB infants. It can be used
as a reliable screening tool for suspicious
neurologically deviant neonates and infants.
With this study we come to know that as per routine
screening on INFANIB scale subjects who visited at
tertiary hospital there are normal, abnormal and
transiently abnormal children. So routine screening of
the children is required and early intervention to be
started to improve the score on INFANIB scale.7
LIMITATIONS OF THE STUDY
Follow up of the subjects was not considered.
36. Rajlaxmi --184--186.pmd 186
FUTURE RECOMMENDATIONS:
 Causative factor for abnormal neurologic
development in children can be studied in future.
 Children who categorized under transient
abnormal neurologic development can be followed up
after few months to know whether they fall under
normal or abnormal neurologic development category.
 Children who categorized under transient and
abnormal neurologic development, early intervention
can be started and reapplication of screening can be
done.
CONCLUSION
On INFANIB screening, there were 8.45%
transiently abnormal and 8.92% abnormal neurologic
development infants at the Tertiary hospital. So we
recommend regular screening of infants who are
visiting to health profession and if required
appropriate early intervention to be undertaken.
REFERENCES
1. Developmental delay. Encyclopedia of children’s
health 2005 Available from URL: http://
w w w. e n o t e s . c o m / c h i l d r e n s - h e a l t h
encyclopedia/ developmental-delay.
2. Tervo R. Identifying Patterns of Developmental
Delays Can Help Diagnose Neurodevelopmental
Disorders. A Paediatric Perspective 2003
july;12(3):1-6.
3. Soleimani F, Vameghi R, Hemmati S, Roghani RS.
Perinatal and Neonatal Risk Factors for
Neurodevelopmental Outcome in Infants in
Karaj. Arch Iran med 2009 March;12(2):135-139.
4. MKC Nair, Babu G, Padmamohan J, Sunitha RM,
Resmi VR et al. Developmental delay and
disability among under -5 children in a rural ICDs
blocks. Indian Paediatrics 2009 Jan;46:75-77.
5. Aly Z, Taj F, Ibrahim S. Missed opportunities in
surveillance and screening systems to detect
developmental delay: A developing country
perspective. J braindev 2010;32:90-97.
6. Wilhelm IJ. Physical therapy assessment in early
infancy. New York: Churchill Livingstone; 1993.
p.46-48.
7. Sung IY, Kang W. Infant Neurological
International Battery (INFANIB) as a Predictor
of Neuromotor Outcome in Risk Infants. J Korean
Acad Rehabil Med 1997 April;21(2):406-413.
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.090
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 187

Effect of Stroke on Mantainence of Balance and Sense of

Equilibrium

Nidhi Kashyap1, SavitaTamaria1

1
Lecturer, Banarsidas Chandiwala Institute of Physiotherapy, Chandiwala Estate, Kalkaji, New Delhi, India

ABSTRACT

Introduction: Perception of the visual vertical (SVV) is affected by cerebral hemispheric lesions.
Knowledge of this disturbance is of interest for the study of its possible relation to balance disturbances
and sense of equilibrium.

Aims and Objective: To see the effect of stroke on balance and vestibular component.

Methodology: Ten subjects were included in the study. Subjects were asked to perform time up and
Go test, MSQ and Dynamic Gait Index.

Results: The mean value of MSQ for 10 subjects was found to be 49.4. Vestibular component is affected
moderately in 7 of 10 patients. The mean value of TUG is 51.86.

Conclusion: On the basis of the present study we concluded that, the orientation of vertical position
and balance is affected in stroke patients.
Keywords: Stroke, Vestibular Component, Hemiplegia

INTRODUCTION Many vestibular reflexes are controlled by process

Stroke or brain attack is the sudden loss of
neurological function caused by an interruption of the
blood flow to the brain .The term cerebrovascular
accident (CVA) is used interchangeably with stroke to
refer to the vascular conditions of the brain.
Ischemic stroke- Ischemic stroke is the most
common type, affecting about 80 percent of individuals
with stroke, and results when a clot blocks or impairs
blood flow, depriving the brain of essential oxygen and
nutrients.
Hemorrhagic stroke- occurs when blood vessels
rupture, causing leakage of blood in and around the
brain.1
Vestibular system consists of peripheral and central
vestibular system. The three primary functions of
vestibular system are stabilization of the visual images
on the on the fovea of the retina during head movement
to allow clear vision, maintaining postural stability;
especially during movement of the head, providing
information used for spatial orientation.2
that exists primarily with in the brainstem. Extensive
connections between the vestibular nuclei and the
reticular formation, thalamus and cerebellum,
connections with vestibular cortex, thalamus and
reticular formation enable the vestibular system to
contribute to the integration of arousal and conscious
awareness of the body, as well to discriminate between
movement of self and environment2.
Central nervous system (CNS) injuries can affect
the vestibular system .Cerebrovascular insults
involving the anterior –inferior cerebellar artery
(AICA),posterior- inferior cerebellar artery (PICA) and
vertebral artery may cause vertigo ,though other signs
associated with these infarcts are present may clarify
the site of pathology. Lesions of the vertebral artery
may affect the cerebellum only and can mimic a
peripheral vestibular hypo function in its clinical
presentation.3
Perception of the visual vertical (SVV) is affected
by cerebral hemispheric lesions. Knowledge of this
disturbance is of interest for the study of its possible
relation to balance disturbances.

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 188 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
METHODOLOGY
Sample size of ten subjects was taken. .The patient
included had recently experienced their first
And only cerebral hemispheric stroke, resulting at
least in initial motor and balance impairment,
The time since stroke was no longer than three
months, Subjects to be chosen with either side
involved. .Patients was excluded if they had perturbed
vigilance, a history of neurological disturbances,
vertigo or vestibular dysfunction, amblyopia or severe
aphasia, if they had received pharmacological
medication (analgesic, anticonvulsant or sedative), had
deficient from earlier brainstem events, prior to the
onset of disease, and showed acute multiple lesions of
the brainstem and or the hemispheres.
INSTRUMENTATION
Instruments and Tool used
1. Arm chair
2. Tape measure
3. Tape
4. Stop watch
5. Plinth
PROCEDURE
The purpose of the study was explained to the
subjects and they were encouraged to participate in
the study. Subjects for this study were recruited on the
basis of inclusion and exclusion criteria.
The study was initiated only after taking an
informed consent from the subject After this, the
demographic data was collected which included age
(years), weight (kg), height (cm) etc.
• Baseline assessment of the subject was done prior
to the start of the study.
• Following this, the subjects were asked to perform
TUG test, MSQ test and Dynamic Gait Index.
Timed Up and Go (TUG) Test
The timed up and go test is a clinical balance test
that examines functional limitation related to balance.
The individual rises from the chair and walks 30meters
and then returns to the chair. It uses time as an outcome
37. Nidhi Kasyap--187--191.pmd 188
measure. Score within ten seconds are normal for most
adults; score of 11 to 20 seconds are within normal
limits for disabled patients; score greater than 20
seconds are considered abnormal Sample size of ten
subjects was taken4.
MOTION SENSITIVITY QUOTIENT
The motion sensitivity quotient (MSQ) was
developed to provide subjective score of an
individual’s dizziness. The test involves placing
patients into positions incorporating head or entire
body motions to determine whether the movement
reproduces dizziness. Each subject was instructed to
indicate the onset and offset of any dizziness that
occurred in each position. The duration of dizziness,
which was recorded with a stopwatch, was assigned
the following values: 1 point for 5 s to 10 s of dizziness,
2 points for 11 s to 30 s of dizziness, and 3 points for
>30 s of dizziness. Once the duration was recorded
for a position, the subject was asked to rate verbally
the intensity (severity) of the dizziness just experienced
on a scale of 0 to 5 (0 = no symptoms; 5 = severe
dizziness). By adding the duration score to the intensity
score, investigators calculated a raw score for each
position. The maximum raw score for each of the 16
positions is 8 points (3 points for dizziness lasting >30
s and a score of 5 points for severe dizziness); the total
possible MST raw score is 128 (8 points × 16 positions).
The MST quotient was calculated with the use of the
formula 5.
Dynamic Gait Index
It has 8 items: walking, walking while changing
speed, walking while turning the head horizontally
and vertically, walking with pivot turn, walking over
and around obstacles and stair climbing. The scoring
of DGI is based on a 4 point scale ranging from 0-36.
RESULTS
The effect on balance and vestibular component
was assessed on three parameters: Dynamic Gait
Index, Motion Sensitivity quotient and Time up and
Go Test respectively. The mean value of DGI is 8.40
.The mean value of MSQ for 10 subjects was found to
be 49.4. The mean value of Time Up and Go Test is
51.86.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 189
Table1. Shows mean value and standard deviation of
DGI, TUG and MSQ in stroke patients.
VARIABLES MEAN S.D
DYNAMIC GAIT INDEX 8.40 .984
TIMEUP AND GO TEST 51.86 4.31
MOTIONSENSTIVITY QUOTIENT 49.4 .987
DISCUSSION
The vestibule -ocular reflex (VOR) is responsible
for maintaining stability of an image of an image on
the fovea of the retina during rapid head movements.
Then VOR generate rapid compensatory eye
movements in the direction opposite to the head
rotation. The VOR achieves this with connectivity in
the central pathways. In the most basic form pathways
controlling the VOR can be described as a three neuron
arc.7
In the case of anterior SCC, primary vestibular
afferents from the anterior SCC synapse in the
ipsilateral vestibular nuclei8. Secondary vestibular
neurons receiving innervations from the ipsilateral
labyrinth decussate and synapse in the contralateral
occulomtor nucleus. Motorneurons from the
occulomotor nucleus then synapse at the
neuromuscular junction of the ipsilateral superior
rectus and the contralateral inferior oblique muscle.
Similar pattern of connectivity exist for the vertical SCC
and the eye muscles that receive innervations from
them for insertions of the ocular muscles.9
Normally as the head moves in one direction, the
eyes move in opposite direction with equal velocity.
This relation of eye velocity to head velocity is
expressed as the gain (VOR gain) of the vestibular
system. Since there is a direct relationship between
vestibular receptors in the inner eye and eye
movements produced by the VOR, the examination
of the eye movements can be of primary importance
in defining and localizing vestibular pathology10.
Nystagmus is the primary diagnostic indicator
used in identifying most peripheral and central
vestibular lesions .An in voluntary eye movement,
nystagmus due to peripheral vestibular lesions is
composed of both slow and fast component eye
movements. For individual with a unilateral vestibular
lesions , the slow component is due to relative
excitation of one side of the vestibular system. The fast
component is generated from the parapontine reticular
formation in the brainstem repositions the eye to the
centre of the orbit, for example, in left beating
37. Nidhi Kasyap--187--191.pmd 189
nystagmus , the eyes move slowly to the right (VOR),
and the resetting eye movement is to the left (fast
component). Nystagmus due a vestibular lesion is
most commonly after an acute unilateral insult,
spontaneous (at rest) nystagmus12 .
Patients with acute unilateral thalamic infarctions
that only lesions of the poster lateral region cause
transient vestibular signs and symptoms such as
perceptual deficits with ipsi- or contralateral tilts of
the subjective visual vertical and corresponding
deviations of stance and gait. However, they cause no
ocular motor deficits. These signs and symptoms of
vestibular imbalance are probably identical with the
syndrome called earlier ‘thalamic stasis’, a condition
of irresistible falls without paresis or sensory or
cerebellar signs.6 Like these earlier findings of a tonic
vestibular deficit in patients with posterolateral
infarctions, our patients also presented with ipsi- or
contralateral tilts of the SVV and postural imbalance1.
In addition, seven of eight patients had mild
contralateral hemiparesis and one contralateral
hemiataxia, signs of which were due to ischaemic or
oedema of the adjacent internal capsule, which is
regularly seen in combination with the vestibular signs.
Thus, this combination of signs and symptoms was
compatible with a lesion of the vestibular relay station
within the posterolateral thalamus, the function of
which was described earlier in humans and animals.13
Neurophysiological data and tracer studies of the
posterolateral thalamus in cats and monkeys describe
these subnuclei as a relay station for vestibular cortex
areas, since vestibular stimulation of the animals
elicited corresponding responses in their neurons.
Most ascending vestibular fibres in the subnuclei such
as VPL were in close contact, intermingled with
proprioceptive relay cells, and also responded to opto
kinetic stimuli; this finding argues for an integration
of vestibular and proprioceptive information at the
thalamic level. Electrical stimulation of the
posterolateral thalamic subnucleus in humans elicited
a rotation or spinning of the body, head or eyes either
counter clockwise (more often) or clockwise. These
signs during stimulation of thalamic neurons were in
agreement with the human ‘vestibular thalamic
deficits’ described earlier in patients with
posterolateral thalamic infarctions as well as the
patients in our current stud. However, anatomical
differences and divergent nomenclature make it
difficult to correlate human and animal thalamic
structures directly. Jones compared monkey and
human data and proposed a carefully revised
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 190 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
nomenclature for the ventral nuclei, according to
which the ‘vestibular’ thalamic nuclei in humans were
considered to be the ventral parts of nucleus
ventrolateralis, pars posterior (VLp), nucleus
ventroposteriorlateralis, pars posterior (VPLp) and
nucleus ventroposterior inferior (VPI) . The preferably
affected subnuclei in the current study were the VPLp
and dorsal and ventral parts of the VLp12.
Multisensory neurons tuned to both vestibular and
visual motion (optic flow) signals are found in several
cortical areas in the dorsal visual stream. HuiMeng and
Dora E. examine whether such convergence occurs
subcortically in the macaque thalamus. They searched
the ventral posterior nuclei, including the anterior
pulvinar, as well as the ventro-lateral and ventral
posterior lateral nuclei, areas that receive vestibular
signals from brain stem and deep cerebellar nuclei.
Approximately a quarter of cells responded to three-
dimensional (3D) translational and/or rotational
motion. More than half of the responsive cells were
convergent, thus responded during both rotation and
translation. The preferred axes of translation/rotation
were distributed throughout 3D space7. The majority
of the neurons were excited, but some were inhibited,
during rotation/translation in darkness. Only a couple
of neurons were multisensory being tuned to both
vestibular and optic flow stimuli. They conclude that
multisensory vestibular/optic flow neurons, which are
commonly found in cortical visual and visuomotor
areas, are rare in the ventral posterior thalamus13.
Pusher ’s syndrome- The researchers found an
altered perception of the body’s orientation in relation
to gravity by using a seating device that allowed tilting
the patient to the right or to the left without ground
contact. After a random tilt to the left or to the right of
at least 35 degrees, the patients were required to
indicate when they reached upright body orientation.
On the average, patients with controversies pushing
experienced their body as oriented “upright” when
actually tilted 18 degrees to the side of the brain lesion.
Surprisingly, the same patients showed no disturbed
orientation perception of the visual world (visual
vertical). Thus, in contrast to their disturbed perception
of upright body posture, patients with pusher
syndrome could align their longitudinal body axis to
earth vertical upright when using visual cues from the
laboratory’s surrounding. In addition, without a visual
surround in complete darkness, these patients could
correctly determine visual vertical when sitting upright
as well as when tilted in the position that is perceived
as “upright.” The latter results indicate that processing
37. Nidhi Kasyap--187--191.pmd 190
of visual and vestibular inputs for the determination
of visual vertical was unaffected by the lesion.
Consequently, when patients with pusher syndrome
sit upright, they experience a mismatch between visual
vertical, based on vestibular and visual inputs on the
one side, and their perception of tilted body orientation
relative to the vertical.11
Clinical Relevance: The study concluded that there
is effect of stroke on balance and vestibular component.
So in the rehabilitation protocol of stroke patient must
include the rehabilitation of vestibular component.
CONCLUSION
Based on the results of this study, it can be
concluded that the stroke moderately affects the
vestibular component. Hemispheric stroke affects
subjective visual vertical perception, which closely
related to visuospatial neglect. Hence affects the
balance and coordination.
Conflict of Interest: Nil
Source of Funding: Nil
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1. Alain P. Yelnik, MD; Frederique O. Lebreton, MD,
Isabelle V. Bonan, MD, Florence M.C. Colle,
MD, Francesca A. Meurin, MD, Jean Pierre
Guichard, MD, Eric Vicaut, MD: Perception of
the vertility after recent cerebral hemispheric
stroke. American Journal of Physical Medicine
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2. HuiMeng, Dora E. Angelaki : Responses of
ventral posterior thalamus neurons to three
dimensional vestibular and optic flow
stimulation. Journal of neurophysiology.2009;
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3. Lee H , Kim HJ, Koo JW : Superior divisional
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4. Hans ottokarnath, Susanne Ferber : The neural
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5. Kim HA ,Lee SR ,Lee H :Acute peripheral
vestibular syndrome of a vascular cause . Journal
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6.. M.Dieterich, P.Bartenstein: Thalamic infarctions
cause side specific suppression of vestibular
cortex activations. Journal of neurophysiology.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 191
7. Lee H, Ahn BH, Baloh RW: Sudden deafness with
vertigo as a sole manifestation of anterior inferior
cerebellar artery infarction, J Neuro Sci .1999;
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8. Andrew H Clarke: Perspectives for the
comprehensive examination of semicircular canal
and otolith function.Journal of Neurology. 2000;
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10. Berlit.P: Isolated vertigo in vertebrobasilar
ischemia especially in the first symptom of
cerebellar ischemia or basilar artery occlusive
disease. J Neuro Sci .2001;15-22.
37. Nidhi Kasyap--187--191.pmd 191
11. Baloh RW: vertibrobasilar insufficiency and
stroke. vertigo is the most common symptom of
transient ischemia within the vertibrobasilar
systemotolaryngol .head neck Surg.1998;23-25.
12. P Patil et al :Effects of theraband elastic resisted
gait training in stroke patients: a pilot study
.European Journal of Physical and rehabilitation
medicine ; Vol- 47 ,2011.
13. Yang YR, Yen G : Gait outcomes after additional
backward training in patients with stroke
.Clinical Rehab .2000;265-267.
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 DOI Number: 10.5958/j.0973-5674.7.3.091
192 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Accessory Inspiratory Muscles Energy Technique effect on

Pulmonary Function in COPD Subjects

Akanksha Anand1, Ravinder Narwal2, Girish Sindhwani3

1
Physiotherapist, Ram Pyari Orthopaedic Hospital, Ranchi, JHA, 2Lecturer, 3Pulmonary Medicine, Head of Department,
HIHT University, Dehradun, UK

ABSTRACT

Aim & Objectives: Chronic Obstructive Pulmonary Disease (COPD) accounts 17 million lives in
India, which will rise to 22 million by 2016 & it kills 250 people every hour. Global initiative for
Obstructive Lung Disease (GOLD) portrayed skeletal muscle dysfunction as a significant contributor
to severity in these patients resulting in reduced exercise capacity and impaired Quality of life. Muscle
Energy technique (MET) had been a well known treatment in musculoskeletal disorders, yet literature
supporting its use in chronic respiratory disorders is limited. So the present research is design to
study the effects of MET on pulmonary function in COPD subjects and describes its impact on
Conventional chest Physiotherapy.

Method: 30 Moderate & Severe staged COPD patients in 40-60 years age group were allocated into
two groups: Conventional Chest Physiotherapy (CPT) and Conventional Chest Physiotherapy with
MET(CPT + MET) group. Chest expansion, Dyspnea, Exercise tolerance, Respiratory rate, Heart rate,
Oxygen saturation and Quality of life were the variables that recorded prior and after the intervention
for three days.

Results: Significant improvement was seen in both groups on all 3 days with greater improvements
in CPT with MET group in form of increased chest expansion, reduced Dyspnea, increased exercise
tolerance, regulation of autonomic dysfunction and improved Quality of life.

Discussion: Study reveals the potential benefits of MET on pulmonary function and its efficacy in
upgrading the Conventional chest Physiotherapy in COPD subjects. It also recognizes the importance
of management of Accessory Inspiratory muscle dysfunction in providing a better Quality of life in
COPD patients.

Conclusion: MET proved to be a highly magnificent technique in improving pulmonary function

and must be thus incorporated as a basic part of pulmonary rehabilitation in COPD subjects.
Keywords: COPD, Chronic Obstructive Pulmonary Disease, MET- Muscle Energy Technique, Accessory
Inspiratory muscle dysfunction, CPT- Conventional Chest Physiotherapy

INTRODUCTION Respiratory compromised conditions like COPD

disrupted the breathing states. Dynamic lung
Chronic Obstructive Pulmonary Disease (COPD)
hyperinflation, as a result of chronic expiratory airflow
is currently estimated to be the fifth leading cause of
limitation in COPD patients, impairs Diaphragm
death worldwide and will rank third by 2030.It
efficiency for inspiration leading to its functional
accounts 17 million lives in India, which will rise to 22
weakness, dysfunction and overuse of Accessory
million by 2016 & it kills 250 people every hour. Global
Inspiratory muscles. Campbell (1955) stated that
initiative for Obstructive Lung Disease (GOLD)
Scalene and Sternocleidomastoid (SCM) were the first
portrayed skeletal muscle dysfunction as a significant
among accessory muscles to be recruited and that
contributor to severity in these patients resulting in
spastic state of these accessory muscles was a
reduced exercise capacity and impaired Quality of life.1

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 193
contributory cause of Dyspnea in chronic respiratory
patient. 2
This leads to Thoraco-abdominal dys-synchrony
which further results in biomechanical changes
characterized by chest wall muscles shortening,
weakness and fascia restriction contributing to
increased work of breathing and reduced exercise
capacity. As severity of the disease increases, patients
develop Barrel shaped chest leading to elevated,
protracted, rounded shoulders and kyphotic spinal
deformities. These postural deformities places
Pectorals and other chest wall muscles in a shortened
position increasing the chest wall resistance to
expansion, further increasing the Work of Breathing
and thus reduced exercise capacity. Moreover these
muscles, Scalene, SCM and Pectorals, are also required
for the movement of Upper limb and neck in daily
activities.2,3
These Musculoskeletal complications increase the
work of breathing and adversely affect patients’
Quality of life in the way that they start to associate
Dyspnea on exertion with disease and no longer
consider it as a normal response to exertion leading to
a vicious cycle of physical inactivity. This results in
deconditioning of respiratory and peripheral muscles
leading to impaired exercise tolerance and reduced
Quality of Life.4
Recently, GOLD guidelines identified improved
Exercise tolerance and Quality of Life as important
clinical goals of treatment for patients with COPD.
Medical management mainly emphasizes on
pulmonary function but may not necessarily have an
effect on functional exercise tolerance and quality of
life. Pulmonary rehabilitation and chest physiotherapy
thus becomes an important part of a comprehensive
management and rehabilitation program in COPD
patients.5
Recommendations for pulmonary rehabilitation for
chronic respiratory impairment have limited literature
studies regarding the Accessory Inspiratory muscle
dysfunction. Manipulative therapists developed
Muscle Energy technique (MET) as a highly effective
treatment for musculoskeletal dysfunction. Review of
various studies indicated that improvements made to
musculoskeletal mechanics of the thoracic region result
in improvement of pulmonary function.11 Despite of
all these facts there is a dearth of literature investigating
38. Ravin narwal--192--197.pmd 193
the effects of MET in treating Musculoskeletal
dysfunction associated with COPD.6 So The current
study aims to explore the effects of MET of Accessory
Inspiratory muscles on pulmonary function and their
impact on Conventional chest physiotherapy
management in patients with COPD.
METHODOLOGY
This single-blinded experimental design study was
based on population of 120 COPD patients & out of
them 30 COPD subjects were taken for study on the
basis of Inclusion and Exclusion criteria. All the
subjects were randomly allocated into two groups :
Conventional Chest Physiotherapy group (CPT) and
Conventional Chest Physiotherapy with MET group
(CPT with MET). CPT group received Diaphragmatic
controlled breathing, Pursed lip breathing, Postural
drainage and Thoracic expansion exercises. CPT with
MET group received MET of Scalene,
Sternocleidomastoid and Pectoralis major muscles in
addition to exercises mentioned for CPT group.
Inclusion criteria: Male and female subjects
between age 40-70 yrs were taken suffering from
moderate to severe staged COPD.
Exclusion criteria: Subjects with Musculoskeletal
disorders affecting spine and shoulder, all cardiac
conditions, Pulmonary conditions except COPD, any
Systemic pathologies interfering with pulmonary
rehabilitation, e.g. unstable Hypertension, Recent post-
operative patients, , Patient underwent pulmonary
rehabilitation programme since 1 month &
uncooperative subjects were excluded from the study.
Independent Variable: Muscle Energy Technique
(MET).
Dependent variables :Chest wall expansion
(CE),Dyspnea, Oxygen saturation (SpO2), Respiratory
rate (RR),Heart rate (HR),Six Minute Walk Distance
(6MWD), Quality of Life (QoL).
Instrumentation: Cloth Inch tape, Pulse Oximeter,
Stethoscope, Stopwatch, Modified Borg rating scale,
Clinical COPD Questionnaire (CCQ), Six minute walk
test.
DATA COLLECTION
Data was collected pre and post intervention daily
for 3 days of both groups.
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 194 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Procedure Flowchart

DATA ANALYSIS RESULTS

The Data was analyzed by the statistical package
of SPSS -13, Graphical Pad software as required and
significant level was set at pd”0.05 and confidence
interval was 95%. The comparison analyses of
dependent variables were done by parametric “t-test”
test in consecutive 1 to 3 days in form of pre and post
intervention.
The study sample had an average mean age of 61
years with 90% males and 10% females & this
illustrating the fact that our study was male
dominated.
The baseline comparison of both groups by the
outcome variables in the form of Age (yrs), CE (cm),
Dyspnea (Borg), SpO2 (%), 6MWD (m), HR (beats/
min.), RR (breaths/min.), CCQ score showed no
statistical significant differences

Table1 .Comparision of Both groups at Baseline on the basis of outcome variables.

Variables Mean ± S.D T value P value

CPT group CPT +MET group
Age (yrs) 61.53 ± 7.94 61.20 ± 5.84 0.124 0.903
CE (cm) 1.39 ± 0.39 1.56 ± 0.41 -1.221 0.242
Dyspnea (Borg) 5.40 ± 0.63 5.20 ± 0.67 0.676 0.510
SpO2 (%) 88.00 ± 2.50 88.60 ± 2.26 -0.854 0.407
6MWD (m) 149.06 ± 41.1 167.73 ± 43.64 -1.211 0.246
HR (beats/min.) 98.26 ± 3.51 97.26 ± 4.11 0.697 0.497
RR (breaths/min.) 23.86 ± 1.06 23.46 ± 0.99 0.972 0.348
CCQ score 3.8 ± 0.40 3.49 ± 0.79 1.547 0.144

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 195

Table2. Comparison b/w both groups by following variables after 3Days

Variables Mean ± S.D T value P value

After Day3 Post-intervention CPT group CPT + MET group
Chest Expesion 1.95 + 0.48 2.59 + 0.37 -5.184 0.001
Dyspnoea 3.86 + 0.63 2.40 + 0.63 7.643 0.001
SpO2 97.33 + 2.49 99.60 + 1.12 -3.745 0.002
Functional exercise capacity 240.26 + 65.86 393.73 + 53.67 -10.197 0.001
Respiratory rate 21.46 + 0.99 20.40 + 0.82 3.096 0.008
Heart Rate 81.26 + 2.71 76.00 + 4.78 3.445 0.004
Quality of life 2.25 + 0.72 1.32 + 0.61 3.726 0.002

Fig. 1. Comparison b/w both groups on Chest expansion from

Fig. 6. Comparison b/w both groups on Heart rate from Day1-Day3
Day1- Day3

Fig. 2. Comparison b/w both groups on Dyspnea from Day1-Day3 Fig. 7. Comparison b/w both groups on Quality of Life from
Day 1 - Day 3

DISCUSSION

The results suggested that our study is based on

the sample of elder population and is male dominated.
This can be correlated with findings of GOLD
Fig. 3. Comparison b/w both groups on SpO2 from Day1-Day3
guidelines on COPD which states that the disease is
more prevalent in 45 years and above age group and
with males more commonly affected than females.7

The results have been discussed by taking a no. of

Fig. 4. Comparison b/w both groups on Functional exercise
capacity from Day1 – Day3
variables in the study: Chest expansion, Dyspnea,
Functional exercise capacity, Respiratory rate (RR),
Heart rate (HR), Oxygen saturation and Quality of life,
because of two reasons: firstly, previous studies
conducted so far included either of the variables and
not all. Secondly, all the variables are inter-related with
one another and will provide a better understanding
for a composite view of Respiratory, cardiovascular
and musculoskeletal systems.

The Baseline comparison of both groups on all

Fig. 5. Comparison b/w both groups on Respiratory rate from outcome variables showed no significant differences
Day1-Day3 and so we can say that both the groups were at same

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 196 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
level of CE, Dyspnea, SpO2, 6MWD, RR, HR and QoL
prior to the manipulation of interventions.
Within the group comparison shows significant
improvement in both the groups in all outcome
variables on all 3 days of our intervention. On
comparing both the groups improvements were much
greater in CPT with MET group on all 3 days. This
reveals the fact that MET contributes significantly in
improving pulmonary function and increases the
efficacy of Conventional chest Physiotherapy in
patients with COPD.
1.Chest Expansion: The role of Diaphragmatic
breathing exercises in increasing chest expansion is
well established in the literature. Lenehan, Fryer and
McLaughlin8 stated that single sessions of thoracic
MET effectively increased trunk ROM as a result of
viscoelastic and plastic changes in myofascial
connective tissue elements following isometric
contraction by MET. So we can say that MET increased
chest expansion by increasing thoracic ROM.9
2.Dyspnea: Pursed lip breathing exercises are very
effective in relieving Dyspnea by reducing dynamic
hyperinflation and thus have always been a part of
Conventional physiotherapy management in COPD
patients. However, results also suggested the role of
MET in reducing Breathlessness. The mechanics
behind this improvement can be explained by the fact
that MET stretching of accessory inspiratory muscles
relaxes them and decreases the rate of muscle spindle
firing in lengthening phase. This reduces the central
respiratory motor command required for given
ventilation and consequently alleviates Dyspnea.9
3.Oxygen saturation (SpO 2 ): Apart from
Diaphragmatic breathing and Pursed lip breathing
exercises Postural drainage plays a significant role in
increasing arterial Oxygen saturation by clearing
secretions from the airways and increasing Ventilation-
Perfusion matching. Nitz and Burke et al. highlighted
the fact that PNF technique increased SpO 2 by
improving musculoskeletal mechanics of thoracic
region.10
Since MET and PNF techniques are similar in their
principle to stretch and facilitate specific muscles or
joints (Voss, Ionta and Meyers,1985) , so we can say
that MET can also increase SpO2. On top of it MET
also corrects Accessory Inspiratory muscle dysfunction
and respiratory mechanics thus making
Diaphragmatic breathing more effective. This
improves Ventilation especially in lower lobes where
38. Ravin narwal--192--197.pmd 196
there is greatest perfusion. As a result, V/Q matching
increases resulting in an increase in SpO2. 11
4.Functional exercise capacity: This was determined
by the distance walked in six minutes by Six minute
walk test. Dyspnea and reduced SpO2 have been
described as major contributing factors to reduced
exercise capacity by Lam Pui. 12 So by relieving
Dyspnea and increasing arterial Oxygen saturations
by above said mechanisms Conventional chest
physiotherapy and MET techniques increase
Functional exercise capacity. In addition to Dyspnea
and reduced SpO2, increased Work of breathing was
also reported to limit exercise capacity. Upper chest
breathing as a consequence of accessory muscles
overuse expend up to 30% of body’s energy in
comparison to Diaphragmatic breathing which
requires less than 5% of body’s energy. MET thus by
eliminating upper chest breathing and optimizing
Diaphragmatic breathing reduces Work of Breathing
in these patients and thus increases Functional exercise
capacity more effectively.13
5.RR and HR: One of the important findings of our
study was the regulation of autonomic function in our
body in form of reduced RR and HR by Conventional
chest physiotherapy and MET. Breathing cycle reflects
a balance between Parasympathetic and Sympathetic
divisions of Autonomic Nervous system (ANS).
Diaphragmatic breathing and pursed lip breathing
exercises regulate RR via Hering- Breuer reflex.13
Slowing of RR leads to a relative increase in vagal
tone and further reduction in sympathetic activity,
thereby reducing HR. In addition to the above
mechanism of autonomic regulation Gail Dubinsky 14
emphasized the fact that there exists a bi-directional
relationship between breathing pattern and ANS. He
described that Sympathetic nervous system
stimulation leads to, and is stimulated by, upper chest
breathing. Thus, MET by eliminating upper chest
breathing and making Diaphragmatic breathing more
effective optimizes breathing pattern of the patient and
accordingly regulates RR and HR more effectively.
6. Quality of Life: The improvement in Quality of
Life, as determined by Clinical COPD Questionnaire
(CCQ) scoring, depends on three factors: Symptomatic
relief, improvement in functional state and
improvement in emotional state. In the past era
Conventional Chest physiotherapy in COPD patients
has successfully improved Quality of life in a long run.
The present study explains the efficacy of MET in
providing a better Quality of life by upgrading
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 197
Conventional chest physiotherapy in form of better
symptomatic relief, enhanced functional state and
improved mental status in these patients. Moreover,
the current study also illustrates the short-term effects
on Quality of life.15, 16
Conflict of Interest
Thus in the light of the varied results from the
current study we suggested that MET is a highly
magnificent technique in improving pulmonary
function and in escalating the efficiency of
Conventional chest physiotherapy. Thus it must be
incorporated as a basic part of pulmonary
rehabilitation programs in COPD patients.
Conclusion and Future Research
Thus, from the above discussions we conclude that
MET of Accessory Inspiratory muscles increases the
effectiveness of Conventional chest physiotherapy and
promises better results in context of patient recovery
in form of increased chest mobility, reduced
breathlessness, increased arterial Oxygen saturation
levels, improved functional exercise capacity, regulated
Autonomic functioning and ultimately an improved
Quality of life in COPD patients. This also holds a
viewpoint which identifies the role of correction of
Accessory inspiratory muscle dysfunction associated
with COPD. The study also describes the short-term
benefits of MET and Conventional chest physiotherapy
on pulmonary function in patients with COPD.
It is recommended in future to conduct studies
with large sample sizes investigating long-term effects
of MET on pulmonary function. Moreover, effect on
spirometric variables is recommended for further
studies to provide direct assessment of lung functions.
REFERENCES
1. Global initiative for Obstructive Lung Disease
(GOLD). Global strategy for the diagnosis,
prevention and management of COPD. 2010; pp:
225-229.
2. Campbell EJM. The role of Scalene and SCM
muscles in breathing in normal subjects. An EMG
study. J Anat 1955; 89: 378-386.
3. Porth CM. Respiratory function. In:
Pathophysiology: concepts of altered health
states. 6th edition. London: Lippincott Williams
& Wilkins, 2002; pp:585-589
4. Gosselink R. Controlled breathing and Dyspnea
in patients with COPD. JRRD 2003. DOI: 10.1682.
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5. Dantzker DR, MacIntyre NR, Bakow ED.
Pathophysiological principles in COPD. In:
Comprehensive respiratory care. Saunders WB
1995; pp: 694.
6. Putt MT, Watson M, Seale H, Paratz JD. Muscle
stretching technique increases vital capacity and
Range of motion in patients with COPD. Arch
Phys Med Rehab. 2008; 89: 1103-7.
7. Gosselink R, Troosters T, Decramer M. Exercise
testing in COPD patients: the basic questions.
Review. Eur. Respir. J. 1997; 10: 2884-2891.
8. Lenehan KL, Fryer G, Mc Laughlin P. The effect
of muscle energy technique on gross trunk Range
of motion. Journal of Osteopathic medicine 2003;
6(1): 13-18.
9. Leelarungrabyub D, Pothongsunum P, Yankai A
et al. Acute clinical benefits of chest wall
stretching exercise on expired tidal volume,
dyspnea and chest expansion in a patient with
COPD: a single case study. J Bodywork Mov Ther
Oct’2009; 13(4): 338-343.
10. Nitz J, Burke B. A study of the facilitation of
respiration in Myotonic dystrophy.
Physiotherapy Research International 2002; 7(4):
228-238.
11. Voss, Ionta and Meyers et al. Effect of a muscle
stretching program using the Global postural Re-
education method on respiratory muscle strength
and thoraco-abdominal mobility of sedentary
young males. J Bras Pneumol 2007; 33(6): 679-686.
12. Lam Pui LS et al. Exercise testing in COPD
patients. Hong Kong Resp. medicine updated
August’2010; 23(13).
13. Chan D, Chan G, Cheung C et al. Physiotherapy
Practice guidelines for COPD. PTCOC March
2000.
14. Gail Dubinsky et al. Effects of respiratory muscle
stretch gymnastics in COPD patients. Showa
Univ J Med Sci. 1996; 8: 63-71.
15. Hosking SW. The effect of Osteopathic
manipulative techniques on diaphragm
movement and respiratory function in
asymptomatic subjects. Unitec Institute of
technology 2009.
16. Minoguchi H, Shibuya M, Miyagawa T et al.
Cross-over comparison between Respiratory
muscle stretch gymnastics and Inspiratory
muscle training. Internal medicine 2002; 41:
805-812.
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 DOI Number: 10.5958/j.0973-5674.7.3.092
198 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Randomized Comparison of effectiveness of Clinical

Exercises and Manual Therapy Procedures Versus Clinical
Exercises alone in the Treatment of Osteoarthritis of Knee

Sapna S Sharma
Lecturer as Physiotherapist, Smt. Kamlaben P. Patel Institute of Physiotherapy and Occupational therapy, APMS, Opp. New
Bus Stand, Anand, Gujrat

ABSTRACT

Aim: This study is designed to compare the effectiveness of clinical exercises and manual therapy
procedures with clinical exercises alone for reducing pain and improving physical function in OA
knee patients. To know particularly the effectiveness of manual therapy procedures for the
management of OA knee patients.

Study design: Experimental study, Randomized Control Trial.

Method: 40 patients of OA knee were recruited into two groups .Experimental Group (n=20) received
Manual Therapy which included passive physiological and accessory movements (Maitland), muscle
stretching and soft tissue mobilization along with clinical exercises as strengthening ,muscle
stretching, range of motion exercises of knee joint and stationary bicycle. Control Group (n=20) received
clinical exercises alone which included strengthening, muscle stretching, range of motion exercises
of knee joint and stationary bicycle with detailed evaluation including WOMAC, ROM and all
parameters of 6-minute walk test were taken as baseline as well as after 4 week of treatment.

Results: Both the groups showed clinically and statistically significant improvement in WOMAC
and 6- minute walk test at 4-weeks .WOMAC scores had improved by 52% in experimental group
and by 41% in control group. Average 6- minute walk had improved about 10% in both the groups.

Conclusion: There was significant improvement in both the groups; however the manual therapy
and clinical exercises group was more effective in reducing pain and improving knee ROM for patients
of Osteoarthritis of knee as compared to clinical exercises group.
Keywords: Knee Osteoarthritis, Manual therapy, Clinical Exercises

INTRODUCTION It was influenced by work involving heavy lifting,

kneeling, climbing stairs or ladders, or kneeling/
Osteoarthritis of the knee joint is a major
squatting combined with heavy lifting.8
musculoskeletal problem in elderly and reported to
be a major health problem worldwide.1, 2 The prevalence of knee OA increases with age
throughout the elderly and obesity 5-7. Females have a
In 2007, Osteoarthritis (OA) was India’s No. 1
higher prevalence and incidence of knee OA. 9 The
ailment3. The overall prevalence of OA in elderly
disability and pain associated with knee OA correlate
population of Union Territory, Chandigarh was 56.6%4
with a loss of quadriceps femoris muscle strength. 10
and in rural areas of Amritsar was 60.6%5.
In 2007, NICE does not advocate the use of electro-
Symptomatic OA is associated with joint
acupuncture , glucosamine and intra-articular
degeneration, chronic pain, muscle atrophy, decreased
hyaluronon injections for treatment of OA.11 Cold packs
mobility, restriction in activities of daily living,
decrease swelling and hot packs are not effective to
decreased quality of life, poor balance and physical
reduce oedema in patients with knee OA. 12
disability.6, 7

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 199
Well-designed studies show that modalities like
laser and transcutaneous electrical nerve stimulation
(TENS) decrease the pain associated with OA.13
Benefits have been reported with manual therapy
techniques used in combination with joint mobility and
strengthening exercises 14,15 .Falconer et al found
improvements in motion, pain, and gait speed after 12
treatments of stretching, strengthening and mobility
exercises combined with manual therapy procedures
over 4 to 6 weeks. A comparison group that received
the same exercise and manual therapy interventions
plus therapeutic doses of ultrasound demonstrated no
additional improvement.15
Deyle et al found twice the improvements of
physical function and reduction of pain in the clinic
treatment group compared to home exercise group
over 4 week period, the clinic treatment group received
supervised exercise, manual therapy and home
exercise program. Subjects in the home exercise group
received the same home exercise program. A
comparison group that received the home exercises
demonstrated no additional improvement. 16
There is no sufficient data available to check
effectiveness of clinical exercises and manual therapy
procedures with clinical exercises alone in the
treatment of OA knee. So, there was need to study it
MATERIAL AND METHODOLOGY
Universe: OA knee patients coming to department of
College of Physiotherapy, Anand.
Type of Study: Experimental study
Sampling Technique: Simple random sampling
technique.
Sample Size: 40.
20 subjects in each group
The experimental procedure was ethically revised
and approved by the Research and Ethical committee
of College of Physiotherapy.
Inclusion Criteria
1. Subjects with age group between 40-70 years were
included.
2. Both the genders were included.
3. Subjects with duration of knee pain more than 1
month and less than 1 year.
Exclusion Criteria
1. Subjects with any recent surgery at knee joint, any
intra –articular injections or medications.
39. sapna Sharma--198--204.pmd 199
2. Any knee deformity such as genu varus, genu
valgus or fixed flexion at knee.
3. Subjects could not attend required number of
visits.
4. Subjects with knee pain duration more than 1 year.
Instrument for Data Collection
1. WOMAC questionarrie
2. Universal Goniometer
3. Stop watch
4. Measure tape
5. Resistant band
6. Weighing machine
7. Red ink
8. Paper sheet for foot print
After meeting suitable criteria, the written informed
consent, baseline parameters had been measured
before allocating them into two groups.
OUTCOME MEASURES
Primary outcome measure
Western Ontario and McMaster Universities
(WOMAC) Osteoarthritis Index. (includes 24 questions
to measure patient’s pain, stiffness and physical
function)
There are 3 sub division of WOMAC index:
a) Pain consists of 5 questions
b) Stiffness consists of 2 questions
c) Physical function consists of 17 questions
Each question was answered and grading done as
given below
0- none 1-mild 2-moderate 3-extreme 4- severe
Secondary outcome measure
1) 6 minute walk test (to measure functional exercise
capacity).
- distance measured in metres
- walking velocity measured in metres/second
- cadence
- step length measured in centimeters
- stride length measured in centimeters
2) Range of motion of knee joint measured using
goniometer.
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 200 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

METHODOLOGY Grade III: Large amplitude movement performed

into resistance or up to the limit of the range..Grade
Baseline data includes demographics (age in years, IV: Small - amplitude movement performed well into
height in meter, weight in kg, BMI in kg/m2, resistance.
occupation, address), history of present & past problem
,posture, knee ROM, knee muscle power, reflexes, For Tibiofemoral joint
sensations, WOMAC,6 minute walk test were taken. • Subjects with active loss of knee flexion .
i. Knee flexion with abduction
ii. Knee flexion with adduction
iii. Anteroposterior movement
iv. Medial rotation
• Subjects with loss of active knee extension.
a) Knee extension with abduction
b) Knee extension with adduction
c) Knee Extension
d) Posteroanterior movement
Repetition: 2-6 bouts of 30 sec per manual technique

Fig. 1. Flow chart describing the progress of subjects through the

trial.

PROCEDURE

Subjects were randomisly divided into 2 equal

groups:

Group 1: EXPERIMENTAL GROUP received

Manual Therapy 16 which includes passive
physiological and accessory movements (Maitland) 17,
muscle stretching and soft tissue mobilization along
with clinical exercises 16 as strengthening, muscle
stretching and range of motion (mobilization) exercises
of knee joint and stationary bicycle.
Fig. 2: Tibiofemoral flexion
Group 2: CONTROL GROUP received clinical
exercises 16 alone which include strengthening, muscle
stretching, range of motion (mobilization) exercises of
knee joint and stationary bicycle.

On day 1, pre-test measurements were taken for

both the groups which include WOMAC, Range of
Motion and 6-minute walk test. Then exercise regime
was started for both the groups. At the end of the 4th
week, post test measurements were taken for both the
groups as similar to the pre-test measurements.

GROUP 1: Experimental Group

1) Manual Therapy

A) Passive physiological and accessory movements

Fig. 3: Tibiofemoral anteroposterior with abduction
(Maitland) movement, Grade IV.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 201

For Patellar femoral articulation B) Muscle stretching:

• Subjects with loss of patellar glides. - Assessment was done to check muscle tightness
of quadriceps femoris, hamstring, gastrocnemius,
I. Transverse movements medially adductors, iliopsoas, tensor fascia latae and
iliotibial band.
II. Transverse movements laterally
- Method: sustained manual stretch at end length
of muscle
III. Longitudinal movement caudad
- Duration: 12-30 second
IV. Longitudinal movement cephalad
- Repetition: 1-3 times per muscle.
Repetition: 2-6 bouts of 30 sec per manual technique
C) Soft Tissue Mobilization
- Assessment for soft tissue tightness was done in
suprapatellar and peripatellar regions, medial and
lateral joint capsule and popliteal fossa.
- Method: circular fingertip and palm pressure
mobilization at the depth of the capsule or
retinaculum
- Repetition: 1-3 bouts of 30 second per area.
2) Clinical Exercises
It includes
i. Stretching exercises
ii. Range of motion exercises
iii. Strengthening exercises
Fig. 4. Patellar femoral articulation: Longitudinal movement
caudad
iv. Stationary bicycle

Table 1: Stretching Exercises

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 202 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 2: Range of Motion Exercises

Table 3: Strengthening Exercises

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 203

GROUP 2: CONTROL GROUP value of experimental group is significantly higher

than control group.
The subjects received the clinical exercises alone as
treatment regime: For knee extension ROM,

Stretching exercises shown above in table 1 Number of subjects having restricted extension
ranges were 13 (32.5%) out of 40.
Range of motion exercises shown above in table 2
Due to less observation, stastical test is not applied
Strengthening exercises shown above in table 3 for knee extension. There is improvement of knee
Stationary bicycle extension ROM in affected subjects involving both
bilateral and unilateral sides .
All exercises were progressed only if the symptoms
Table 6: 6. minute walk test for distance, cadence ,
and signs of OA were decreasing.
walking velocity, step and stride length for bilateral
(right and left) sides and unilateral (affected) side
All above clinical exercises were given as home
between the two groups.
exercise program twice a day in both groups.
Unpaired t-test
DATA ANALYSIS 6-minute walk test ‘t’ calculated value P- value
Step length
To find out homogeneity of two groups for all the bilateral(right side) 2.199 0.041
parameters at baseline and to compare the outcome Bilateral(left side) 2.201 0.041
measurement data between two groups, we have used Unilateral(affected side) 2.280 0.035
unpaired ’ t’ test. Stride length
Bilateral(right side) 2.160 0.044
In present study, P- value is used to test two tailed
Bilateral(left side) 2.226 0.039
hypothesis at 5% level of significance. i.e if P-value is
Unilateral(affected side) 2.203 0.041
less than0.05, the difference is significant otherwise not.
Statistical software SPSS had been used. P < 0.05 .There is significant difference for all
parameters of 6-minute walk test i.e. Mean of all
Table 4: WOMAC scale between both the groups.
parameters value in 6-minute walk test of
Unpaired t-test experimental group is significantly higher than control
WOMAC ‘t’ calculated value P- value group.
Pain subscale 2.161 0.037
Stiffness subscale 2.884 0.006 RESULTS
Physical Function 2.178 0.003
subscale Results obtained from the study after 4-week
Total 3.538 0.001 intervention program showed that :
P < 0.05 .There is significant difference between the There was significant reduction in WOMAC pain,
groups for all subscale and total WOMAC score. i.e stiffness and physical function subscale and total score
Mean WOMAC score of experimental group shows between the groups (experimental and control) , knee
significantly higher reduction than control group. flexion ROM for bilaterally and unilaterally affected
side and also in 6 –minute walk test for distance,
Table 5: Knee flexion ROM for bilateral (right and
cadence , walking velocity, step and stride length of
left) sides and unilateral (affected) side between both
the groups both bilateral and unilateral affected side.

Unpaired t-test However, the experimental group showed

Knee ROM flexion ‘t’ calculated value P-value significantly higher reduction compared with control
Bilateral (right side) 2.458 0.024 group after intervention between the groups.
Bilateral (left side) 2.630 0.017
Unilateral (affected side) 2.370 0.029 CONCLUSION

P < 0.05 .There is significant difference for bilateral Results of the study concluded that there was
(right and left) sides and unilaterally (affected) knee significant improvement in both the groups; however
flexion ROM between the groups. i.e. Mean flexion the manual therapy and clinical exercises group was

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 204 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
more effective in reducing pain and improving knee
ROM for patients of Osteoarthritis of knee as compared
to clinical exercises group.
ACKNOWLEDGEMENTS
There are no words to gratitude sufficient enough
to thank my honorable Prof. C.G. Padole, Dr.Setu
Sharma, Dr.K.Vaittianadane for his help, direction,
supports and encouragement for my work.
REFERENCES
1. Corti MC, Rigon C. Epidemiology of
osteoarthritis: prevalence, risk factors, and
functional impact. Aging Clin Exp Res.2003;
15:359–363.
2. De Filippis L, et al. Epidemiology and risk factors
in osteoarthritis: literature review data from
“OASIS” study [in Italian]. Reumatismo.2004;
56:169–184.
3. Times of India newspaper. 6th sept. ,2007
4. MK Sharma, HM Swami, et al. An
Epidemiological Study of Correlates of Osteo-
Arthritis in Geriatric Population of UT
Chandigarh. Indian Journal of Community
Medicine.2007; 32.
5. Padda AS,et al. Health profile of the aged persons
in urban and rural field practice areas of Medical
College, Amritsar. Indian J of Community
Medicine 1998; 23:72-76.
6. Nutrition Research Newsletter. Knee
osteoarthritis; exercise capacity and quality of life
in obese individuals.2007
7. Robert F. Zoeller et al, Physical Activity: Physical
Activity in the Management of Osteoarthritis of
the Knee and Hip, American Journal of Lifestyle
Medicine,2007 ;Vol. 1: 4, 264-266
8. L K Jensen et al. Knee osteoarthritis: influence of
work involving heavy lifting, kneeling, climbing
39. sapna Sharma--198--204.pmd 204
stairs or ladders, or kneeling/squatting combined
with heavy lifting. Occupational and
Environmental Medicine 2008;65:72-89
9. Lawrence RC,et al.Estimates of the prevalence of
arthritis and selected muscluskeletal disorders in
united states .Arthritis Rheum .1998:41(5):778-99
10. Fitzgerald GK, et al. Quadriceps activation failure
as a moderator of the relationship between
quadriceps strength and physical function in
individuals with knee osteoarthritis. Arthritis
Rheum.2004; 51:40–48.
11. NICE Clinical Guideline. The care and
management of osteoarthritis in adults.
Osteoarthritis: Jan 2008
12. Brosseau L, et al. Thermotherapy for treatment
of osteoarthritis. Cochrane Database Syst
Rev.2003; (4):
13. Gro Jamtvedt et al. Physical Therapy
Interventions for Patients with Osteoarthritis of
the Knee: An Overview of Systematic Reviews.
Phys Ther. 2008 :88, 1; 123-136
14. Nancy E. Henderson ,et al. Effectiveness of
manual physical therapy and exercise in
osteoarthritis of the knee: a randomized,
controlled trial. Ann Intern Med.2000; 132:
173–181.
15. Falconer J,et al. Effect of ultrasound on mobility
in osteoarthritis of the knee: a randomized clinical
trial. Arthritis Care Res.1992; 5:29–35.
16. G D Deyle,et al. Physical Therapy Treatment
Effectiveness for Osteoarthritis of the Knee: A
Randomized Comparison of Supervised Clinical
Exercise and Manual Therapy Procedures versus
a Home Exercise Program. Physical
Therapy,2005: 85
17. Maitland GD. Peripheral Manipulation. Boston,
Mass: Butterworth Heinemann; 1991:1–128,
221–289.
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 DOI Number: 10.5958/j.0973-5674.7.3.093
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 205

Comparing the effects of Manipulation of Wrist and

Ultrasound, Friction Massage and Exercises on Lateral
Epicondylitis: A Randomized Clinical Study

Sharvari Joshi1, Santosh Metgud2, Ebnezer C3

1
Student, Professor, KLE Institute of Physiotherapy, 3HOD, Metas of Seventh Day Adventist College of
2

Physiotherapy, Surat, Gujrat

ABSTRACT

Background and Purpose: Lateral epicondylitis ("tennis elbow") is a common entity. Several
nonoperative interventions, with varying success rates, have been described. The aim of this study
was to compare the effectiveness of 2 protocols for the management of lateral epicondylitis: (1)
manipulation of the wrist and (2) ultrasound, friction massage, and muscle stretching and
strengthening exercises.

Design: A Randomized Clinical Study.

Subjects and Method: Ten subjects with a history and examination results consistent with lateral
epicondylitis participated in the study. The subjects were randomly assigned to either a group that
received manipulation of the wrist (group 1) or a group that received ultrasound, friction massage,
and muscle stretching and strengthening exercises (group 2). Follow-up was at 3 weeks. The primary
outcome measure was a global measure of improvement, as assessed on a 10-point scale. Analysis
was performed using independent t tests, Mann-Whitney U tests, and Fisher exact tests.

Results: Differences were found for 2 outcome measures: success rate and decrease in pain at 3
week. Both findings indicated manipulation was more effective than the other protocol. After 3 weeks
of intervention, the success rate in group 1 was 62%, as compared with 20% in group 2. Also,
improvement in pain as measured on a 10-point numeric scale was 5.2 (+ 2.4) in group 1, as compared
with 3.2 (+ 2.1) in group 2.

Conclusion: Manipulation of the wrist appeared to be more effective than ultrasound, friction massage,
and muscle stretching and strengthening exercises for the management of lateral epicondylitis when
there was a short-term follow-up.
Keywords: Tennis Elbow, Manipulation, Ultrasound, Stretching

INTRODUCTION Manipulation has frequently been used

Lateral epicondylitis is characterized as pain on the
lateral side of the elbow that is aggravated with
movements of the wrist, by palpation of the lateral side
of the elbow or by contraction of the extensor muscles
of the wrist (1).It is a self limiting complaint and the
symptoms will resolve within 8-12 months even
without intervention (2, 3).
The basic anatomical cause is sudden and often
repeated use of the forearm extensor muscles, which
previously had not been much used.
successfully for management of back and neck
complaints (4, 5) and is thought to, (1) free motion
segments that have undergone disproportionate
displacement or are felt to be hypomobile and (2) cause
muscle relaxation (6, 7). These mechanisms are thought
to be associated with distribution of abnormal stresses
within the joint, resulting in pain, restriction of motion,
and potential inflammation. Manipulation of the wrist
also has been described previously, however its
effectiveness for management of lateral epicondylitis
has not been demonstrated. The aim of this study was

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 206 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
to compare the effectiveness of manipulation of the
wrist with the effectiveness of an intervention
consisting of friction massage, ultrasound and muscle
stretching and strengthening exercises for the
management of lateral epicondylitis.
Deep transverse friction massage is a specific type
of connective tissue massage developed by Cyriax. It
is applied with the fingers and transverse to the muscle
fiber direction. It is vital that transverse massage be
performed only at the site of the lesion. The effect is so
local that unless, the finger is applied to the exact site
and friction given in the right direction, relief cannot
be expected.
Ultrasound increases blood flow and oxygen to the
affected area by raising the temperature of the muscles.
Clinical studies show it has limited effectiveness in
reducing the disability caused by tennis elbow.
However, when ultrasound is combined with physical
therapy such as massage and strengthening and
stretching exercises, its effectiveness increases.
METHOD AND MATERIALS
Method
The present study was conducted in a
physiotherapy department during the time period
from January 2010 to July 2010 on 10 patients
diagnosed with lateral epicondylitis by the physician.
The study design used for the study was randomized
controlled trial and the sampling design used was non
probability convenient sampling.
Inclusion Criteria
Lateral epicondylitis with complains being present
for at least 6 weeks and no longer than 6 months.
Exclusion Criteria
1) No limitation in range of motion.
2) Bilateral complains.
3) A definite decrease in pain for the last 2 weeks as
described by the patient.
- Severe neck or shoulder problems likely to cause
or maintain the elbow complaints.
MATERIALS
Measurement tools
1. Hand dynamometer
40. sharvari Joshi--205--209.pmd 206
2. Visual Analogue Scale (VAS) for pain.
Where
0 - No pain
5 - Minimum pain with tolerance
10 - Maximum pain without tolerance
3. Goniometer (for ROM).
Intervention tools
1. Dumbells.
2. Elastic resistance bands (therabands).
3. Rubber bands.
4. Soft ball.
PROCEDURE
Group 1: Subjects in this group were treated 2 times
per week, with a maximum of 5 intervention sessions
over the 3 weeks period of the study. All intervention
sessions were conducted by the same physical
therapist, experienced in this manipulative procedure.
As soon as the symptoms resolved the maneuver was
stopped. The manipulative procedure was a thrust
technique and was done as follows. Each subject rested
the forearm of his/her affected side on a table with
the palmar side of the hand facing down towards the
floor. The therapist sat at right angle to the subject’s
affected side and gripped the subject’s scaphoid bone
between the thumb and index finger. The therapist then
placed the thumb and index finger of the other hand
on the top of them. The therapist then extended the
subject’s wrist dorsally and at the same time the
scaphoid was manipulated ventrally. This part of the
maneuver was repeated approximately 10 times,
alternated by either forced passive extension of the
wrist or extension against the resistance. The duration
of a treatment session was 15-20 minutes. This
maneuver was done according to maneuver described
by Lewit (9).
Group 2: Subjects in this group were using a
protocol that was previously used for lateral
epicondylitis (12). During the 3 weeks intervention
period, the subjects underwent a total of 5 intervention
sessions. Every session included a 7 minutes pulsed
ultrasound treatment around the lateral humeral
epicondyl, at an intensity of 2 W/cm2 (10). In addition,
subjects were treated with friction massage for
approximately 10 minutes by the physical therapist.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 207

Position of the patient: Statistical Analysis

- Patient sits with elbow 90 degrees flexed with arm Table 1: Baseline Values
supported on a table Characteristics Group 1 Group 2
No. of subjects 5 5
- Massage across the muscle fibers in a
Pain at the moment 4.0 5.4
Counterclockwise direction. SD 2.7 2.8
MEAN 2-8 2-8
- Do not use any oils, creams or lotions for massage.
Pain during the day 5.5 5.5
- Pain tolerance should be 6 out of 10 for this. SD 1.5 1.4
MEAN 6-8 6-8
- This maneuver can be done everyday for 10 - 20 Inconvenience 6 7.5
minutes. SD 2.4 1.4
MEAN 3-10 3-10
When pain subsided, subjects were instructed in Pain Free Grip Force (PFGF) (Kg) 20.7 14.9
muscle stretching and strengthening exercises by the SD 10.7 11.0
physical therapist and were instructed to perform MEAN 3.6-39 3.5-38.6
those exercises twice daily at home (11). These exercises Maximum Grip Force (MGF) (Kg) 33 29
consisted of movements against resistance, rotational SD 13.7 14.4
exercises and occupational exercises. These exercises MEAN 5.8-53.6 2.0-50.2
were intensified in four steps, with increasing
(The measurements were taken using a 10 point
resistance. Subjects were allowed one step up if all
scale, with 0-10 values on it. SD - Standard Deviation)
exercises could be performed without pain. Subjects
were instructed to use the affected elbow to the pain
threshold. When pain had resolved the intervention
was stopped.

Stretching exercises:

- Elbow is extended and the arm is straight.

- Keeping the arm straight increase the range of

stretch.

- Hold each stretch for 10 seconds and repeat it 2-3

times.
Graph 1: Shows the difference in the outcome measures of pain
and inconvenience after 3 weeks of treatment with the 2
- Stretch only to the point of comfortable motion. interventions.

Strengthening exercises:

- Movements like wrist flexion, extension, ulnar

deviation, radial deviation, forearm supination,
pronation, elbow flexion, elbow extension and
finger extension are performed using dumbells,
elastic resistance bands, rubber bands and other
strengthening devices.

- Gradually increase the amount of work that you

are doing. Begin with a very light weight. Begin
with performing 10 movements in a row. Repeat
this sequence 3 times, do 3 sets of 10 repetitions. Graph 2: Shows the difference in the outcome measures of grip
strength between the 2 groups after 3 weeks of treatment.

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 208 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Table 2: Outcome Measures: (After 3 Weeks Treatment)
Characteristics Group 1 Group 2
No. of subjects 5 5
Pain at the moment 1 1.5
Pain during the day 2.5 1.7
Inconvenience 3.5 2.3
PFGF (kg) 5.8 3.7
MGF (kg) 1.8 0.5
(All values except PFGF and MGF are taken out of
10 on a 0-10 scale)
Data were analyzed using SPSS version 10.0.
Differences in continuous outcome measures were
compared using independent t tests in case of normal
distribution. Distribution was normal in severity of the
patients’ main complaint (pain during the examination
and pain during the day). In case the distribution was
not normal, the Mann-Whitney U test was applied.
This was the case in inconvenience during daily
activities, pain-free grip force, and maximum grip
force.
RESULTS
The initial baseline measurements were similar
between the 2 groups. After 3 weeks of intervention,
our primary outcome measurements differed between
2 groups, indicating that manipulation was more
effective than the other intervention used in the study.
Moreover the decrease in Visual Analogue Scale (VAS)
scores for the main complaint, pain at the moment,
pain during the day and inconvenience also differed
between the 2 groups.
DISCUSSION
The study was conducted to compare the effects of
manipulation of the wrist with the most commonly
used interventions like ultrasound, friction massage
and stretching and strengthening exercises, for lateral
epicondylitis. Considering the outcome measures of
pain and inconvenience, differences were noted in the
2 groups. The results showed that, manipulation of
wrist was more effective than the other interventions.
One drawback of the study was that, only short
term effects were considered. Long term effects were
not considered, because patients did not turn up for
follow up and the patients expected a faster recovery,
which was achieved with manipulation of the wrist.
With ultrasound, friction massage and stretching and
strengthening exercises the recovery time would be
prolonged. In a recent study by Hay et al (13) comparing
40. sharvari Joshi--205--209.pmd 208
corticosteroid injections with non-steroidal anti-
inflammatory drugs, the initial advantage of injections
subsided at long-term follow-up.
Also, the manipulation of the wrist has to be done
by an experienced manual therapist, to have its exact
effects. Thus, this technique should not be performed
by a less experienced manual therapist, so that any
adverse effects of the manipulation can be avoided.
Despite its broad application, the mechanism by
which manipulation may work is poorly understood.
Manual therapy is used quite often for the spine and
peripheral joints, despite of the inability of clinicians
to accurately diagnose the pathway at which a
manipulation is targeted. In people with low back pain
and neck pain, spinal manipulation is thought to free
motion segments that have undergone
disproportionate displacements and to relax muscles
by sudden stretching.(14-16). Unwanted muscle activity
in people with low back pain, in theory, can cause a
limited range of motion to protect against sudden
movements. Pain in these individuals often can be
elicited by palpation on the insertion of these
paravertebral muscles 17. Thus our study was to find
out the effects of similar type of manipulation on pain
in lateral epicondylitis.
Another drawback of this study is that, there is very
less literature supporting the effects of manipulation
of the wrist as a treatment of lateral epicondylitis. Thus,
there is no strong evidence to prove that manipulation
of wrist helps treat the symptoms of tennis elbow.
There is an ample of literature showing the effects of
ultrasound, friction massage and exercises on lateral
epicondylitis.(11, 12).
The advantages of the manipulation of the wrist
are the potential effectiveness over the short term and
the ability for the patient to maintain his or her daily
activities without restrictions. In addition,
manipulation might be more cost-effective due to a
reduction in the number of treatments needed.
Considering the relatively high prevalence of the
injury, this cost-effectiveness might lead to a major cost
reduction for payers.
LIMITATIONS
1. Sample size was small.
2. No follow up to see long term effects of wrist
manipulation.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 209
CONCLUSION
Manipulation of the wrist is more effective than
ultrasound, friction massage and stretching and
strengthening exercises for lateral epicondylitis, when
short term effects are considered. However, more study
is required to be done to further prove the effectiveness
of manipulation of wrist on lateral epicondylitis
symptoms and also the long term effects must be
considered.
REFERENCES
1. Friedlander HL, Reid RL, Cape RF. Tennis elbow.
Clin Orthop. 1967;51:109–116.
2. Hamilton PG. The prevalence of humeral
epicondylitis: a survey in general practice. J R Coll
Gen Pract. 1986;36(291):464–465.
3. Bailey RA, Brock BH. Hydrocortisone in tennis
elbow: a controlled series. J R Soc Med. 1957;
50:389–390.
4. Cyriax JH. The pathology and treatment of tennis
elbow. J Bone Joint Surg Am. 1936; 4:921–940.
5. Koes BW, Assendelft WJ, van der Heijden GJ, et
al. Spinal manipulation and mobilisation for back
and neck pain: a blinded review. BMJ. 1991; 303
(6813) : 1298–1303.
6. Shekelle PG, Adams AH, Chassin MR, et al.
Spinal manipulation for low-back pain. Ann
Intern Med. 1992;117:590–598.
7. Cooperstein R, Perle SM, Gatterman MI, et al.
Chiropractic technique procedures for specific
low back conditions: characterizing the literature.
J Manipulative Physiol Ther. 2001;24:407–424.
40. sharvari Joshi--205--209.pmd 209
8. Triano JJ. Studies on the biomechanical effect of
a spinal adjustment. J Manipulative Physiol Ther.
1992;15:71–75.
9. Wilder DG, Pope MH, Frymoyer JW. The
biomechanics of lumbar disc herniation and the
effect of overload and instability. J Spinal Disord.
1988;1:16–32.
10. Lewit K. Manuelle Medizin: Im Rahmen der
Medizinischen Rehabilitation. Leipzig, Germany:
Auflage Johan Ambrosius Barth; 1977.
11. Binder A, Hodge G, Greenwood AM, et al. Is
therapeutic ultrasound effective in treating soft
tissue lesions? BMJ (Clin Res
Ed).1985;290(6467):512–514.
12. Pienimaki TT, Tarvainen TK, Siira PT, Vanharanta
H. Progressive strengthening and stretching
exercises and ultrasound for chronic lateral
epicondylitis. Physiotherapy. 1996;82:522–530.
13. Hay EM, Paterson SM, Lewis M, et al. Pragmatic
randomized controlled trial of local corticosteroid
injection and naproxen for treatment of lateral
epicondylitis of elbow in primary care. BMJ. 1999;
319 (7215) : 964–968.
14. Solveborn SA. Radial epicondylalgia (“tennis
elbow”) – treatment with stretching or forearm
band: a prospective study with long-term follow-
up including range-of-motion measurements.
Scand J Med Sci Sports. 1997;7:229–37.
15. Koes BW, Bouter LM, van Mameren H, et al.
Randomised clinical trial of manipulative therapy
and physiotherapy for persistent back and neck
complaints: results of one year follow up. BMJ.
1992; 304 : 601–605.
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.094
210 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

The effect of Tra Training alone and in Combination with

Pelvic Floor Muscle Training in Women with Stress
Urinary Incontinence

Chandan Kaur Khandpur1, Shipra Bhatia2

1 2
PT, MPT, Assistant Professor, Amity Institute of Physiotherapy, Amity University,
K- Block, Sector-44, Noida

ABSTRACT

Objective: To study the effect of TrA training alone and in combination with PFM training in women
with stress urinary incontinence.

Methodology: 45 female patients with mean age of 39.31±4.6 years, having stress urinary incontinence
were selected and divided into three groups. Group A was given TrA training alone, group B was
given "knack" advice, and group C was given TrA training in combination with PFM exercises for
two consecutive weeks. The outcome measures were VAS score, TrA strength, pad weight and number
of leaks and data was collected on Day 0, 7 and 14 of treatment.

Results: TrA training was found to be more effective than control in treating women with stress
urinary incontinence. There was no statistically significant difference between the effects of TrA training
alone and TrA training in combination with the PFM training. Both the trainings were found to be
better than the control group.

Conclusion: TrA training alone & in combination with PFM training produces significant results in
women with stress urinary incontinence. Therefore, both the exercises can be utilized as a treatment
option in patients with stress urinary incontinence.
Keywords: Stress Urinary Incontinence, Pelvic Floor Muscles, Transversus Abdominis

INTRODUCTION abdominal pressure is increased by contraction of the

abdominal muscles5. The timing of the PFM activity is
The international continence society defines Stress
critical in maintaining continence during straining
Urinary Incontinence (SUI) as the complaint of any
activities. In normal cases with straining activities like
involuntary leakage of urine that occurs with physical
coughing, urethral pressure increases before the
exertion and a rise in abdominal pressure1. Postnatal
increase in bladder pressure by 200 to 250ms5. This
stress urinary incontinence is an important social and
early increase of urethral pressure does not occur in
health problem affecting between 3% and 24% of adult
most women with stress incontinence.
women2. In an Indian study, it was found that only
8.6% women have heard about PFM exercises and 72% It is believed that anticipatory activity of PFM
had UI for more than 1yr3. Still, the consultation rate contraction cannot be a reflex response to afferent input
for UI was low in the north Indian women4. from muscle stretch as a result of increased intra-
abdominal pressure, because it precedes such an
PFM have been suggested in the initial conservative
increase in abdominal pressure. Rather, it is considered
management of SUI because the levator ani muscle
to be pre-programmed by the central nervous system
contributes to continence by providing support to
in preparation for the increase in intra-abdominal
pelvic organs, by increase in urethral closure pressure
pressure to maintain continence. Thus, the timely
and by elevating the bladder neck PFM enhance
contraction of PFM is the key to preventing leakage of
urethral enclosure 1,13 . Activation of the PFMs is
urine in SUI5.
essential in maintaining continence when intra-

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 211
Recently, in 2009, a theoretical model involving
training of deep abdominal muscles in particularly
TrA, to initiate tonic PFM activity has been introduced6.
This approach was based on the understanding that
synergistic activity of the PFM and TrA occurs in
normal trunk activity6 and hence, can be utilized to
activate PFM contraction in patients with SUI.
Sapsford advocates the use of the independent TrA
contraction to gain PFM co-contraction as the
foundation of PFM rehabilitation for urinary
incontinence7. He suggests that, TrA contraction is
supposed to facilitate more tonic PFM activity in
patients with SUI and helps in counteracting gravity
and intra-abdominal pressure. He found that similar
increase in urethral pressure occurs with instructions
to contract either the PFM or TrA separately8. It has
also been proved that contraction of the TrA instead
of PFM is useful as many women are not able to
contract PFM and, therefore, contraction of TrA is one
way of activating the PFM6.
Thompson and O’Sullivan found that during PFM
contraction, all the abdominal muscles were more
active than the PFM in symptomatic women with
mixed incontinence compared to asymptomatic
women, and that the incontinent group increased the
intra-abdominal pressure more than the continent
group during PFM contraction9.Also, Smith et al using
EMG compared co-contraction activity of the TrA and
PFM contractions in those with and without continence
showed that there was an alteration in the balance
between PFM and TrA contractions in women with
UI, with severely incontinent women using more TrA
and less PFM actively during a postural task3. Hence,
based on these studies which show that a co-
contraction of PFM occurs with TrA contraction in
healthy women, it is recommended that all females
with urinary incontinence be trained with TrA
contraction.
There is limited literature available evaluating
whether TrA alone can treat or improve SUI and
studying the effect of combining PFM & TrA together
in patients with SUI. Therefore, the primary aim of
the study was to find out the effect of TrA training alone
in patients with SUI & the secondary aim was to study
the effect of combining TrA & PFM training in patients
with stress urinary incontinence.
41. shipra bhatia--210--215.pmd 211
METHODOLOGY
Inclusion Crieteria
1) Females aged 30-45yrs
2) Subjects with symptomatic urinary incontinence
as diagnosed by a gynaecologist.
3) Continuous symptoms of incontinence present at
least once per week for 3 months or more9
4) Multiparous women
5) Pregnancy > 1yr back
6) Patients showing positive pad test (more than
2gm)6
Exclusion Crieteria1
1) Any prior treatment taken for urinary incontinence
(collagen injection, vaginal cones etc.)
2) Pacemaker fixation
3) Using intrauterine device
4) Having medical history of vaginal cancer
5) Severe endometrium, neurologic or metabolic
disorders likely to impair bladder function
6) vaginal prolapse
7) Any neurological impairments
8) Pelvic inflammatory disease
PROCEDURE
45 Subjects fulfilling the inclusion criteria were
taken from different hospitals in NCR region and
Chandigarh. They signed a consent form and were
assessed & randomly allocated using chit method to
one of the following three groups:
Group A: TrA training group (TrA)
Group B: Control group
Group C: Pelvic floor exercises and TrA training group
Each subject was given treatment for 2 weeks. A
baseline measure was taken before starting the
treatment. Patients were asked to maintain a
frequency-volume chart for each day and the data was
collected on Day 0, Day 7 and Day 14.
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 212 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

1) Group A: TrA strengthening exercises other end ‘always wet’18.

Patient was made to lie supine on couch and a 4) TrA strength: was measured using the
sphygmomanometer pressure cuff was placed under sphygmomanometer cuff reading.
their lumbar spine and mercury was raised to 40mm
Hg and patient was asked to maintain this pressure RESULTS
by giving her the command “tuck your tummy in”
and patient was made to see the mercury level all the One way repeated measures ANOVA was used to
time throughout the exercise protocol. While doing statistically analyse the data for between group
exercises the initial range of mercury was maintained differences and significant improvement was seen in
as per patient’s strength and the patient was asked to VAS score, Pad test, TrA strength & no. of leaks on
maintain the same level throughout10. Day 14 at p<0.05. Also, paired t-test showed significant
improvement within groups A & C in all the outcome
Three types of TrA strengthening exercises were measures, however, no difference was found in group
given for a period of 2 weeks with 10 repetitions each B. No statistically significant difference was found
in one set. The command was given to “tuck your between group A & C.
tummy in” while performing the exercises:
TABLE 1: Baseline Characteristics
11
a) Leg lift in supine Groups Age (In years)Mean+S.D. Number of
PregnanciesMean±S.D.
12,14
b) Leg lift in prone
Group A: TrA 38.93±5.09 2.33±1.11
c) Curl ups from supine 15
Group B: control group 40.47±5.58 2.6±1.35
2) Group B: Control group Group C: TrA+PFM 38.53±2.72 2.13±0.51

Subjects in this group were given only “knack” TABLE 2: Effect on VAS score:
advice to contract her pelvis before any of the events Groups VAS Day 0Mean±S.D. VAS Day 7Mean±S.D.
e.g. Coughing, sneezing, laughing, nose blowing, VAS Day 14Mean±S.D. Intra Group P-Value
lifting, running or jumping or a strong desire to void.
Group A TrA 4.33±1.63 2.80±1.26 1.40±0.82 0.00*
3) Group C: Pelvic floor plus TrA training group Group B control 4.07±1.16 4.00±1.25 3.93±1.16 0.164

TrA strengthening exercises along with PFM Group C: TrA+PFM 4.60±1.40 2.93±1.33 1.33±0.97
0.00*
exercises. Subjects while lying supine on bed were told
to contract their PFMs by giving the command “try to Inter Group P-Value F-ratio=111.13 P<0.05*
stop passing urine”. The subjects were asked to hold
A significant improvement was seen in VAS score on Day 14 at
each contraction for 6-8 seconds and to complete 3or 4 p<0.05. Also, paired t-test showed significant improvement within
additional quick contractions at the end of 6-8seconds. groups A & C.
The subjects performed 3 sets of 10 contractions twice
daily for two weeks 17.
TABLE 3: Effect on pad weight (in grams)

OUTCOME MEASURES Groups Day 0 Mean±S.D. Day 7 Mean±S.D. Day 14

Mean±S.D. Intra Group P-Value
1) Pad test: Patient was provided with pre-weighed
Group A TrA 12.93±1.03 11.60±0.83
pads and were asked to wear continuously for 10.47±0.51 0.00*
24hrs and were put in plastic bag and returned on
respective days to be weighed18. Group B control 12.67±1.49 12.67±1.49
12.67±1.49 No change found
2) Number of leaks: Patient was given a frequency- GroupC:TrA+PFM 13.87±1.24 12.47±0.99
volume chart and was asked to record the number 10.60±0.63 0.00*
of leaks in last 24 hours on it 18. Inter Group P-Value F-ratio =102.52 p<0.05*

3) Visual analogue scale: The patient was asked to The results showed significant decrease in Pad
put appropriate score at the point on a 10cm line, weight on Day 14 at p<0.05. Also, significant
starting marked with “no problem’, and at the improvement was found within groups A & C,

41. shipra bhatia--210--215.pmd 212 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 213
however, no difference was found in group B. No
statistically significant difference was found between
group A & C.
Fig. 1. Comparison of TrA strength (in mm Hg) between the groups
A significant improvement was seen in TrA strength
on Day 14 at p<0.05. However, no statistically
significant difference was found between group
A & C.
Fig. 2. Comparison of Number of Leaks (NOL) between the groups
A significant improvement was seen in no. of leaks
on Day 14 at p<0.05. However, no difference was found
in group B.
DISCUSSION
The results demonstrate that TrA training group
showed significantly better improvement on all
41. shipra bhatia--210--215.pmd 213
outcome measures than the control group. This could
be attributed to a theoretical model involving training
of deep abdominal muscles in particularly TrA, to
initiate tonic PFM activity16. There is an automatic
response of PFM to a TrA manoeuvre as indicated by
cranio-ventral displacement of the ano-rectal angle19.
In another study done by Madill SJ et al, it was found
that during voluntary maximal PFM contractions, TrA
was activated to 224.30%20.
According to Sapsford, with SUI it appears that a
TrA contraction is supposed to facilitate more tonic
PFM activity to counteract gravity and intra-
abdominal pressure. Another reason is that if
maximum or close to maximum PFM contraction is
only possible with abdominal co-contraction19, such
co-contraction must be allowed during training, as
close to maximum contraction is important in building
muscle volume and strength. It has also been proposed
that contraction of the TrA instead of PFM is useful as
many women are not able to contract the PFM and,
therefore, contraction of TrA is one way of activating
PFM6.
Another important factor in the continence
mechanism is that the PFM should contract
automatically with correct timing and with sufficient
strength to counteract the downward impact on the
pelvic floor from the abdominal muscle contraction.
Hence, a co-contraction of the PFM during abdominal
contraction in continent women is expected and
normal. While there is also some evidence that PFM
contraction occurs during TrA contraction in continent
women, data suggests that this co-contraction is lost
or altered in some women with SUI. Thus, by training
both PFM & TrA together, motor learning occurs,
leading to better timing of the PFM contraction and
TrA contraction and increased perception of
contraction. This corrects the timing of PFM
contraction in patients with SUI. Hence, the co-
contraction of PFM occurs during TrA contraction as
an anticipatory activity & prevents leakage of urine in
patients with SUI following pelvic floor rehabilitation
programmes.
Study done by Sapsford et al proved that a
maximum PFM contraction does not seem to be
possible without a co-contraction of the abdominal
muscles especially the TrA19. Hence, by training both
PFM and TrA better closure of sphincter can be
achieved in patients with SUI.
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 214 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
The significant improvement seen with both the
training programmes in our study are not consistent
with the findings of Dumoulin et al, whose primary
objective was to assess the effectiveness of PFM in
postnatal SUI. Their results have shown no additional
benefit of adding abdominal training to PFM training2.
However, the present study shows statistically
significant results with TrA training.
LIMITATIONS & FUTURE SCOPE
• PFM strength was not taken.
• Short-term follow-ups & small sample size.
• EMG study measuring the activation of PFM and
TrA simultaneously.
CONCLUSION
TrA training is more effective than control in
treating women with urinary incontinence. There was
no statistically significant difference between the
effects of TrA training alone and TrA training in
combination with the PFM training, however, both the
exercises were found to be better than the control
group. Therefore, both the exercises can be utilized as
a treatment option in patients with stress urinary
incontinence.
REFERENCES
3. Diane F Borello-France, Halina M Zycynski,
Patricia A Downey. Effect of PFM Exercise
Position on Continence and Quality-of Life
Outcomes in Women with Stress Urinary
Incontinence.Phys Ther. 2006; 86:974-986.
2. Chantale Dumoulin, Phd, Pt.Physiotherapy for
Persistant Postnatal Stress Urinary Incontinence:
A Randomised Control Trial.American College
of Obstetricians and Gyneacologists.Vol.104,
NO.3, SEPTEMBER 2004.
3. Smith MD, Coppieters MW, Hodges PW. Postural
response of the pelvic floor and abdominal
muscles in women with and without
incontinence. Neurourol Urodyn 2007; 26:377-84.
4. Santosh Kumari, AJ Singh, Vanita Jain. Treatment
seeking behaviour for urinary incontinence
among north Indian women. Indian J of Medical
Sciences.2008: Volume 62; issue: 9; 352-356.
41. shipra bhatia--210--215.pmd 214
5. Ruth R. Sapsford, DipPthy, Paul W. Hodges, PhD.
Contraction of the PFMs during abdominal
maneuvers. APMR; August 2001. Volume: 82;
issue 8:1081-1088.
6. Kari Bo, Siv Morkved, Helena Frawley and
Margaret Sherburn. Evidence for Benefit of TrA
Training Alone or in Combination With PFM
Training to Treat Female Urinary Incontinence:
A Systematic Review. Neurol Urodynam. 2009.
7. Bo K, Sherburn M, Allen T. Tranabdominal
ultrasound measurement of PFM activity when
activated directly or via a TrA muscle contraction.
New Zealand J of Physiotherapy. 2004 November.
8. Sapsford RR, Hodges PW, Richardson CA. Co-
activation of the abdominal and pelvic floor
mucles during voluntary exercises. Neurology
and Urodynamics.2001, 20(1):31-42.
9. Thompson J, O Sullivan P. Levator plate
movement during voluntary PFM contraction in
subjects with incontinence and prolapse: A cross-
sectional study and review. Int Urogynecol J
Pelvic floor Dysfunct 2003; 14:84-8.
10. Cheri L. Drysdale, Jennifer E. Earl, and Jay Hertel.
Surface Electromyographic Activty of the
Abdominal Muscles during Pelvic-Tilt and
Abdominal Hollowing.J Athi Train. 2004 Jan-
Mar;39(1):32-36
11. Kaul Rohini, Thakral Gaurav, Sandhu Jaspal
Singh. Omparison of eefects of Specific
Stabilization Exercises and Conventional Back
Extension exercises in Management of Chronic
Disc prolapse. IJPOT. 2007; Vol.1: No.3 (07-09).
12. Fontana FE, Bressel E. Effort of surface stability
on core muscle activity for dynamic resistance
exercises. Int J Sport Physiol Perform. 2009
Mar;4(1):97-109.
13. Di Benedetto P, Coidessa A, Floris S. Rationale of
PFMs training in women with urinary
incontinence. Minerva Ginecol. 2008 Dec;
60(6):529-41.
14. Fabio Renovato Franca, Thomas Nogueira Burke.
Segmental stabilization and muscular
strengthning in chronic low back pain – a
comparative study. Clinics. 2010; 65(10):1013-1017
15. Willardson JM, Fontana FE, Bressel E. Effort of
surface stability on core muscle activity for
dynamic resistance exercises. Int J Sport Physiol
Perform. 2009 Mar; 4(1):97-109.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 215
16. Manoj K Poonia, Ginpreet Kaur, Meena
Chintamaneni. New insights into molecular
targets for urinary incontinence. Ind J of
Pharmacology. Year 2010; volume: 42, isuue 5:
261-266.
17. Kimberley Fisher, Lisa Riolo. Clinical question:
What is the evidence regarding specific methods
of pelvic floor exercise for a patient with urinary
incontinence and mild anterior vaginal prolapse?
Case Study. Physical therapy.2004
August.Volume 84. Number 8.
41. shipra bhatia--210--215.pmd 215
18. Margaret Polden and Jill Mantle. Physiotherapy
in Obstetrics and Gynaecology. P.B. No. 7153.
354-358.
19. K Bo, Pt, PhD, M Sherburn, PT, M.Evaluation of
female pelvic-floor muscle function and strength.
Physical therapy Journal. 2005 March
20. Madill SJ, McLean L. Relationship between
abdominal and pelvif floor muscle activation and
intravaginal pressure during PFM contractions
in healthy continent women. Neurourol Urodyn.
2006;25(7):722-30.
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.095
216 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Comparison of Two Sit and Reach Tests for Measurement

of Hamstring Flexibility in Female University
Physiotherapy Students

Nidhi Kathuria1, Sumit Kalra2

1 2
Student, Masters of Physiotherapy, Assistant Professor, Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji,
New Delhi, India

ABSTRACT

Background: Sit and reach test is commonly used for measuring the flexibility for hamstrings muscle.
Objective: To compare two sit and reach test for measurement of hamstrings flexibility in 60 females
physiotherapy students.

Method: Sit and Reach test, Back Saver Sit and Reach test and Straight leg measurements were taken
that was administrated after 5 minutes warm-up and stretching on the same day with rest period of
20 minutes in between the tests.

Results: The value of correlation between hamstring flexibility and BSSR Test of Right leg (r) is 0.51
and value of correlation between hamstring flexibility and BSSR Test of Left leg is (r) is 0.57 whereas
the value of correlation between hamstring flexibility of Right leg and SR Test (r) is 0.24 and value of
correlation between hamstring flexibility of Left leg and SR Test is (r) is 0.56.

Conclusion: The results indicated that back saver sit and reach test produces reasonably accurate
and stable measures of hamstring flexibility. Moreover, it appeared that this test was safe and acceptable
alternative to the sit and reach test as a measure of hamstring flexibility in young females.
Keywords: Sit and Reach Test, Hamstrings, Flexibility, Students

INTRODUCTION The test is designed to measure the extensibility of the

Flexibility is a key component for injury prevention
and rehabilitation. 1, 2According to the American
Alliance for Health, Physical Education, Recreation,
and Dance , the flexibility test is important because
decreased flexibility, particularly in the hamstring
muscles and the back, is thought to contribute to the
development of low back pain 3 and it is a predisposing
factor to hamstring strains.4,5,6 The Sit-and-Reach Test
(SRT), proposed initially by Wells and Dillon on the
50s, is commonly used for measuring the flexibility of
the lumbar spine and hamstring muscles. The interest
in researching the hamstring muscles and the
measurement of its length is due to the possible
dysfunctions and lesions caused by alteration in its
flexibility. Not only are there injuries caused by the
muscle itself, there are also biomechanical alterations
that may lead to femoro-patellar dysfunction, pubic
and lumbar pain, tendonitis and postural deviations.7
hamstrings muscles and the lower back articulations
by evaluating the maximal reach an individual can
make in a seated position.8 The purpose of the study is
to compare two different sit and reach test as a
measurement of hamstring Flexibility in female
physiotherapy students.
Russell T. Nelson and William D. Bandy9 et al
concluded that flexibility gains achieved in range of
motion of knee extension with eccentric training of 6
weeks in high school males were equal to those made
by statically stretching the hamstrings muscles. Barlow
10
et al concluded that a single massage of the hamstring
muscle group was not associated with any significant
increase in sit and reach performance immediately
after treatment in physically active young men(n=5).
Cornbleet SL, Woolsey NB11 et al did a study to
describe hamstring muscle length as reflected by use

42. Nidhi kathuria--216--220.pmd 216 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 217
of the SRT and the hip joint angle (HJA) in children, to
examine the correlation between SRT and HJA
measurements, and to examine gender differences for
both measures. Each child performed the SRT. In the
final position, the SRT score was obtained and the HJA
was measured using an inclinometer placed over the
sacrum. A mean SRT value of 24 cm and a mean HJA
value of 81 degrees were obtained for all subjects. There
was a difference between boys and girls for both
measures.
Bandy WD, Irion JM, Briggler M 12indicated that
the change in flexibility appeared to be dependent on
the duration and frequency of stretching and It was
suggested that a 30-second duration was an effective
amount of time to sustain a hamstring muscle stretch
in order to increase Range of motion. Also it was found
that no increase in flexibility occurred when the
duration of stretching was increased from 30 to 60
seconds or when the frequency of stretching was
increased from one to three times per day.
Bandy Wd, Irion Jm13 et al suggested that duration
of 30 seconds was an effective time of stretching for
enhancing the flexibility of the hamstring muscles and
also it was found that no significant difference existed
between stretching for 30 seconds and for 1 minute.
Scott G. Spernoga14 et al concluded that a sequence of
5 modified hold-relax stretches produced significantly
increased hamstring flexibility that lasted 6 minutes
after the stretching protocol ended.
James W. Youdas 15 et al did a study did a study in
which it was concluded that there was a statistically
significant correlation between performance on the sit-
and-reach test as measured by hip joint angle and the
supine passive straight-leg raise, but the sit-and-reach
test only accounted for 35% of the variability in the
supine passive straight-leg raise.
METHODOLOGY
60 healthy females were taken.
The study was conducted at Banarsidas
Chandiwala Institute of Physiotherapy, New Delhi.
Asymptomatic healthy females with age between
20-24 years with no history of low backache in last 3
months, no musculoskeletal disorders, no neurological
disorder and also with no psychiatric and
psychological disorder were included in the
study.10, 16, 17
42. Nidhi kathuria--216--220.pmd 217
Subjects with low backache, having apparent and
true length shortening that would limit performance
in these tests, athletes and subjects with any of the
contraindications of stretching were excluded in the
study.13, 18, 19
Instruments and tools used
Sit and reach box- box approximately 12 inches high
and measuring scale; universal goniometer; stop
watch.
PROCEDURE
Subjects fulfilling inclusion criteria were taken into
consideration. The procedure was explained to the
subjects and a written consent was taken after
explaining the benefits and clearing the doubts of the
subject regarding study. Goniometric measurement, Sit
and Reach Test16 and Back Saver Sit and Reach Test16,
were performed and scores were recorded. After that,
subjects were asked to perform a 5-minute warm up
and static stretch routine in which subject had to go
for 2 minutes of jogging followed by rest period for
one minute and again subjects were asked to go for
next 2 minutes, emphasizing lower body. Immediately
after which, the flexibility tests were performed on the
same day with rest period of 20 minutes in between
tests and scores were recorded. After demonstration,
one practice trial and three tests were performed for
each of measures. Average of three test trials was used
for all tests.
Goniometric Measurement16 is done during passive
straight leg raise. The axis is aligned with axis of hip
joint. Stationary arm is in line with the trunk and
moveable arm is in line with the femur. With knees
held straight, her leg was moved passively into hip
flexion until tightness was felt. In both test, static
position was held for 2 seconds while the
physiotherapist recorded the reached score using a
measuring scale positioned parallel to the lower leg.
DATA ANALYSIS
• Pearson correlation coefficient is used to analyze
the data.
• Excel 2000 is used for calculating Correlation.
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 218 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 1: Mean and Standard Deviation values of Sit Table 2: Mean and Standard deviation values of Sit
and Reach, Back Saver Sit and Reach Tests and and Reach, Back Saver Sit and Reach Tests and
Goniometer measured flexibility at Pre Intervention. goniometer measured flexibility at Post
Intervention.
Pre Intervention Mean Standard
Deviation Pre Intervention Mean Standard
ROMR 58.99 12.39 Deviation
ROML 59.89 13.88 SRT 7.85 3.35
SRT 6.83 3.20 BSSRR 8.08 2.83
BSSRR 7.017 2.75 BSSRL 8.08 2.88
BSSRL 8.79 18.32 ROMR 67.81 13.35
ROML 67.67 12.40
KEYWORDS: ROMR: Range of Motion of Right leg, ROML: Range
of Motion of Left. SRT: Sit and Reach test. BSSRR: Back Saver Sit
and Reach Test for Right leg. BSSRL: Back Saver Sit and Reach Test
for Left Leg

Table 3: Intercorrelations of sit and reach, and back saver sit and reach tests with goniometer measured flexibility
in all participants (n=60)

ROMR ROML SRT BSSRR BSSRL SRT BSSRR BSSRL ROMR ROML
ROMR - .71 .48 .42 .20 .24 .51 .42 82 .56
ROML .71 - .46 .59 .35 .56 .59 .57 .77 .84
SRT .48 .55 - .83 .28 .97 .80 .83 .62 .62
BSSRR .42 .59 .83 - .34 .84 .97 .97 .60 .64
BSSRL .24 .35 .28 .34 - .30 .36 .38 .29 .33

PRE POST

RESULTS

The value of correlation between Hamstring

flexibility and BSSR Test of Right leg (r) is 0.51 and
value of correlation between Hamstring flexibility and
BSSR Test of Left leg is (r) is 0.57 whereas the value of
correlation between Hamstring flexibility of Right leg
Graph 1: Comparison of Mean between SLR ROM values at pre
and post intervention.
and SR Test (r) is 0.24 and value of correlation between
Hamstring flexibility of Left leg and SR Test is (r)
is 0.56.

DISCUSSION

SR and BSSR tests are the most commonly used

field measures of hamstring flexibility in current fitness
test batteries. The purpose of this study was to
Graph 2: Comparison of Mean between Sit and reach test (SRT)
values at pre intervention and post intervention.
determine the relations between the two SR tests and
hamstring flexibility because the test is used as a
measure of hamstring flexibility in young females.

This study indicates that both the traditional SR and

Graph 3: Comparison of Mean between Back Saver Sit and Reach
Test (BSSR) at pre intervention and post intervention.
BSSR tests are related to hamstring flexibility. The value
of correlation between Hamstring flexibility and BSSR
Test of Right leg (r) is 0.51 and value of correlation
between Hamstring flexibility and BSSR Test of Left
leg is (r) is 0.57 whereas the value of correlation
between Hamstring flexibility of Right leg and SR Test

42. Nidhi kathuria--216--220.pmd 218 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 219
(r) is 0.24 and value of correlation between Hamstring
flexibility of Left leg and SR Test is (r) is 0.56.
These results support the findings of Jackson and
Baker and Chung and Yuen. However, they concluded
that hamstring flexibility can only be measured by the
traditional SR test, but we have provided evidence that
the BSSR test can be used instead of the traditional SR
test in young females. Although the SR tests do not
satisfactorily measure lower back flexibility and are
only moderately valid measures of hamstring
flexibility, they are still the only field tests that are
practical and easy to administer. Moreover, Jackson et
al reported that the SR test was not related to reported
lower back pain in either a cross sectional or
prospective sample of adults. Evidence of the relation
between hamstring flexibility or lower back flexibility
and lower back health is not documented. Future
studies are needed to explore the influence of
hamstring flexibility on lower back health.12
Studies have shown that the classical sit-and-reach
(CSR) test, the modified sit-and-reach (MSR), and the
newly developed back-saver sit-and-reach (BS) test
have poor criterion-related validity in estimating low-
back flexibility but yielded moderate criterion-related
validity in hamstring flexibility. The V sit-and-reach
(VSR) test was found to be practical but the validity
has not been established so still the choice of test to
check hamstring flexibility is sit-and-reach test and
back saver sit and reach test. But as shown by the
present study we can rely more on Back saver sit and
reach test.
CONCLUSION
The results indicate that this back saver sit and reach
test produce reasonably accurate and stable measures
of hamstring flexibility. Moreover, it appeared that this
test is safe and acceptable alternative to the sit and
reach test as a measure of hamstring flexibility in
young females.
Therefore, results have proved the experimental
hypothesis as positive.
ACKNOWLEDGEMENT
It is my pleasure and privilege to record my deep
sense of gratitude to all those who helped me during
this dissertation. It is my pleasant duty to acknowledge
all the subjects participated in my study that allowed
me to learn.
42. Nidhi kathuria--216--220.pmd 219
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13. William D Bandy, Jean M Irion. The effect of time
on static stretch on flexibility of hamstring
muscles. Physical Therapy 1994 Sep; 74(9):
845-852.
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14. Scott G. Spernoga, Timothy L. Uhl, Brent L.
Arnold, Bruce M.Gansneder. Duration of
maintained hamstring flexibility after a one time,
hold relax stretching protocol. Athletic Training
2001 Jan–Mar; 36(1): 44–48.
15. Youdas JW, Krause DA, Hollman JH. Validity of
hamstring muscle length assessment during the
sit-and-reach test using an inclinometer to
measure hip joint angle, Research journal of
NSCA,ISSN 1064-8011,Pages 303-309.
16. G. Baltaci, N Un, V Tunay, A Besler, S Gerceker.
Comparison of three sit and reach test for
measurement of hamstrings flexibility in female
university students. British journal of sports
Medicine.2003 February; 37(1): 59-61
17. Volkert C. de Weijer, Gerard C. GorniakEric
Shamus. The Effect of Static Stretch and Warm-
up Exercise on Hamstring Length over the
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Course of 24 Hours. Journal of Orthopaedic &
Sports Physical Therapy.
18. J Brent Feland, J William Myrer, Shane, S
Schulthies, Gill W Fellingham, Gary W Measom.
The Effect of Duration of Stretching of the
Hamstring Muscle Group for Increasing Range
of Motion in People Aged 65 Years or Older.
Physical Therapy 2001 May; 81(5): 1110-7.
19. David O. Draper, Jennifer L. Castro, Brent Feland,
Shane Schulthies, Dennis Eggett. Shortwave
Diathermy and Prolonged Stretching Increase
Hamstring Flexibility More Than Prolonged
Stretching Alone. The Journal of Orthopaedic and
Sports Physical Therapy. Volume 34, Number 1,
January 2004.
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 DOI Number: 10.5958/j.0973-5674.7.3.096
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 221

Home Based Exercise Program for Frozen Shoulder-

Follow-up of 36 Idiopathic Frozen Shoulder Patients

Shishir S M1, Manoj Abraham M2, Kanagasabai R3, Syed Najimudeen4, James J Gnanadoss5
1
Assistant Professor, Department of Orthopaedics, 2Tutor, Department of Physical Medicine & Rehabilitation, 3Professor,
Department of Orthopaedics, 4Professor and Head of Department, Department of Orthopaedics, 5Professor, Department
of Orthopaedics, Pondicherry Institute of Medical Sciences, Pondicherry

ABSTRACT

Introduction: Adhesive capsulitis or frozen shoulder is a condition characterized by generalized

pain and stiffness with progressive global restricted motion of the shoulder1. There are many variations
of physical therapy protocol .Most of the protocols are extensive and do not suite the Indian scenario
as most of the patients are not involved in active sports or high end activities. Furthermore, the
compliance of the patient is not good and cost of physiotherapy is high.

Hence, we decided to develop and validate a Shoulder Accelerated Rehabilitation Protocol (SHARP)
for patients with frozen shoulder in our Indian scenario.

Method and Material: Thirty six consecutive idiopathic frozen shoulder patients with a painful
shoulder of more than 4 weeks and less than 6 months duration and with limitation of active and
passive range of movement greater than 25% in abduction and external rotation compared with the
other shoulder were selected and subjected to the SHARP protocol.

RESULTS: The mean constant shoulder score at the start of protocol was 26.69 (SD- 8.522), which
improved to 98.58 (SD-2.892) at 15 months. Maximum patients reached a constant shoulder score of
100 at 15 months (22 patients).

The mean VAS score for pain at the start of the protocol was 7.14 (SD-1.222) which improved to 0 at
18 months.

Conclusion: SHARP is a non-invasive, easy to follow and reproduce, home based exercise program
effective in early improvement of pain and disability in patients with frozen shoulder
Keywords: Adhesive Capsulitis, Frozen Shoulder, Shoulder Accelerated Rehabilitation Protocol (SHARP)

INTRODUCTION It is most commonly observed in patients in their fifth

and sixth decades of life1. The incidence is 2-5% in
Adhesive capsulitis or frozen shoulder is a
general population with a much higher frequency in
condition characterized by generalized pain and
women (as high as 70% in some reports).3 There is
stiffness with progressive global restricted motion of
recent literature to support a relationship between
the shoulder1. This entity is unique to shoulder joint.2
hormonal changes in women during menopause and
frozen shoulder4. There is a much higher incidence in
Corresponding author: patients with diabetes mellitus (10-35%) and an
Shishir. S M increased incidence in people with Parkinson’s disease,
Assistant Professor, previous injury to the shoulder, immobilization of the
Department of Orthopaedics arm and closed head trauma4. There is some evidence
Pondicherry Institute of Medical Sciences, Pondicherry of increased frequency in those with thyroid disease,
shishir100@gmail.com cardiopulmonary disease, cervical spine degenerative
Telephone No. : +91 8870135734

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 222 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
disc disease, and personality disorders although no
specific causal relationship has been clearly
established5-12.
1
Natural History and Phases of Adhesive Capsulitis
The natural history of adhesive capsulitis is
uncertain. Some believe it is a self-limiting disorder
lasting as little as 6 months2, whilst others suggest it is
a more chronic disorder leading to longer term
disability 3.
In general there are three phases of frozen shoulder
depending on the presenting symptoms and
examination findings.
The Inflammatory Phase or Freezing Phase
The patient has a spontaneous and gradual onset
of aching pain at rest which progresses to pain with
use. As the pain worsens, there is night pain which
interferes with the patient’s ability to sleep
comfortably. It is common for patients to associate the
development of symptoms with a trivial trauma;
however, there is usually no causal relationship.
During this phase the patient has significant pain and
a gradual increase in stiffness. This phase typically lasts
between 3 and 9 months and is characterized by an
acute synovitis of the glenohumeral joint.
The Frozen Phase or Transitional Stage
The patient has a slow improvement in rest pain
but little change in the range of motion and stiffness
or the pain at the extremes of motion. This phase
characteristically lasts 4-12 months.
The Thawing Phase
Lasts anywhere from 12 to 42 months and is defined
by a gradual return of shoulder mobility. The patients
with uncontrolled diabetes mellitus take a longer time
to recover4.
Initial treatment of adhesive capsulitis is usually
conservative involving physical therapy, anti-
inflammatory medication, and corticosteroid
injections. Intra-articular steroid injections are used to
help with pain relief by limiting the inflammatory
process that occurs with frozen shoulder13.
There are many variations of physical therapy
protocol .Most of the protocols are extensive and do
not suite the Indian scenario as most of the patients
are not involved in active sports or high end activities.
43. Shishir --221--226.pmd 222
Furthermore, the compliance of the patient is not good
and cost of physiotherapy is high.
Hence, we decided to develop and validate a
Shoulder Accelerated Rehabilitation Protocol (SHARP)
for patients with frozen shoulder in our Indian
scenario.
METHOD AND MATERIALS
Data were reported as means ± the standard
deviation of the mean (SD) and were analyzed using
SPSS software. Repeated-measures ANOVAs were
used to analyze the constant score measured at
different time point. Results were considered
significant at an α level of 0.05. The study was
conducted between November 2010 and March 2013
in Pondicherry Institute of Medical Sciences.
Inclusion Criteria
1. Patient with a painful shoulder of more than 4
weeks and less than 6 months duration with
limitation of active and passive range of movement
greater than 25% in abduction and external rotation
compared with the other shoulder were selected.
Patients were excluded if their pain was less than
4 weeks duration as such patients may have had
spontaneous recovery in the early stages.
2. The presence of restriction of active and passive
range of movement in both external rotation and
glenohumeral abduction was taken to indicate a
diagnosis of capsulitis as opposed to rotator cuff
tendinopathy.
3. Patients with normal shoulder radiographs, with
exception of evidence of Osteopenia.
4. Patient with minimum follow-up of two years.
Exclusion criteria
1. Patients who received previous intra-articular
injection or prior physiotherapy before the start of
the protocol were also excluded as it could
influence the outcome of the study.
2. Patients with limitation of movement in one plane
only.
3. Lack of tenderness on palpation of
acromioclavicular joint excluded the pain
originating from this joint. Cross chest adduction
test was done to rule out AC joint arthritis.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 223

4. Patients presenting with frozen shoulder
secondary to some other disease or having co
morbidity, e.g. Diabetes mellitus, Parkinson’s
disease, hyper or hypothyroidism.
5. Those with bilateral adhesive capsulitis.
6. Patients with evidence of glenohumeral
osteoarthritis on plain X-ray, clinical evidence of a
complete rotator cuff tear (i.e. positive empty can
test, full can test and drop-off sign), clinical
evidence of significant cervical spine disease,
history of significant trauma to the shoulder or a
history of inflammatory joint disease or of a
cerebrovascular accident affecting the study.
Thirty six patients with idiopathic unilateral frozen
shoulder, 23 male and 13 female were included in the
study. The age range was 33 to 73 years (mean age of
49.69 years). All the patients were in phase 1 of frozen
shoulder. Out of the 36 cases, 21 were right side and
rest 15 on the left side. Range of movements at shoulder
joint was recorded; especially active and passive
forward flexion, abduction, internal and external
rotation. The shoulder movements were checked while
patients were standing and were measured using a
goniometer. All the patients were followed up for a
period of 24 months with 3 month interval. Data of
each patient was recorded at every visit by an observer
who was not connected to this study to avoid bias.
Patients were asked to follow the SHARP protocol.
We demonstrated the exercises to the patients in
the out-patient department and a hand out were given
to them. They were advised to do the entire set of
exercises, each 15 minutes per session. This protocol
was advised for a minimum of 5 sessions per day with
a gap of minimum 1 hour between each session.
The SHARP protocol which we devised and used
for the study has been described in table1.

Table 1: SHARP–Shoulder Accelerated Rehabilitation Protocol

TREATMENT GOAL
Phase – I Month 0-3 • Shoulder range of motion, mobilization exercise at
physiological end range
• Codman's pendulum exercises
• Arm slides
• Shoulder abductors and rotation stretch To achieve 60% to full Range of Motion
• Finger ladder exercise
• Towel exercise
• Wand Exercise
• Active assisted Range of motion
• Exercise hot water bag, moist heat may be used.
Phase - II Month 4-6 • Continue Phase I
• Shoulder range of motion, mobilization exercise at To achieve 80% to full Range of Motion
physiological end range.
• Shoulder abductors and rotation stretch exercises AROM, PROM & G-H jt. mobility
• Shoulder shrugs and scapular retraction
• Passive range of motion exercise & shoulder Normal scapulo-humeral meaning
joint mobility No compensations seen with
• Active assisted Range of motion raising arm overhead
• Isometrics and scapular strengthening exercises using
therabands.
Phase - III • Progress strengthening program to isotonics. Should have more than 90% or
• Work specific rehabilitation if functional with ADL's, full range of motion and be
Month 7 onwards • Progress to strengthening exercises functional with ADL's

RESULTS 8.03) at 9 months, 93.81 (SD- 5.98) at 12 months, 98.58

Repeated-measures ANOVA found that there were
no significant changes between gender on constant
score F(1, 34) = 0.026, p=0.872.All the patients were
subjected to SHARP protocol. NSAID’s and Opiods
were given for pain relief on SOS basis. The mean
constant shoulder score14 at the start of protocol was
26.69 (SD- 8.52), which improved to 55.14 (SD-14.08)
at 3 months, 75.83 (SD-11.99) at 6 months, 87.39 (SD-
(SD-2.89) at 15 months, 99.72 (SD-1.66) at 18 months
and 99.78 (SD-1.33) at 21 and 24 months (Figure 2).
The mean VAS score for pain at the start of the
protocol was 7.14 (SD-1.22) which improved to 4.17
(SD-0.81) at the end of 6 months, 0.89 (SD- 0.74) at 1
year, 0.19 (SD-0.40) at 15 months and 0 at 18 months.
No additional changes were seen at the end of 24
months (Table 4).

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 224 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Maximum patients reached a constant shoulder Table 2: Sex Distribution of Patients

score of 100 at 15 months (22 patients). At the end of SEX FREQUENCY PERCENT
18 months 35 patients reached a score of 100 (Figure Female 13 36.1
1). One patient reached a maximum score of 92 at the Male 23 63.9
end of 24 months of follow up. Total 36 100.0

Table 3: Mean distribution of forward elevation, abduction and external rotation at different duration of
follow –up

Duration Forward elevation Total (n=36) Abduction Total (n=36) External rotation Total (n=36)
Mean (±SD) score Mean (±SD) score Mean (±SD) score
0 month 59.44 (±15.34) 64.44 (±15.98) 8.89 (±10.01)
3 months 96.67 (±23.84) 103.89 (±25.72) 20.00 (±10.76)
6 months 132.36 (±29.46) 133.75 (±25.92) 31.25 (±13.80)
9 months 159.44 (±21.31) 158.33 (±20.74) 41.11 (±15.26)
12 months 173.47 (±9.32) 173.33 (±12.76) 53.75 (±15.96)
15 months 179.03 (±2.62) 177.22(±6.15) 71.39 (±11.06)
18 months 179.58 (±1.84) 178.47 (±3.74) 77.22 (±9.89)
21 months 179.58 (±1.84) 178.61 (±3.70) 81.25 (±8.34)
24 months 179.72 (±1.67) 178.61 (±3.70) 82.36 (±8.74)

Fig. 1. Number of Patients Attaining Constant Score of 100 by the

Time Period

Fig. 3. Constant Score Attained by the Time Period by Gender

Fig. 2. Constant Score attained by the Time Period (Overall)

Table 4: Showing the Descriptive Statistics of VAS Score at Various Intervals

Duration Sex Mean Std. Deviation

0 month Female 7.54 0.77
Male 6.91 1.37
Total 7.14 1.22
3months Female 5.77 1.23
Male 5.13 1.18
Total 5.36 1.22

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 225

Table 4: Showing the Descriptive Statistics of VAS Score at Various Intervals (Contd.)

Duration Sex Mean Std. Deviation

6months Female 4.31 0.63
Male 4.09 0.90
Total 4.17 0.81
9 months Female 2.23 0.92
Male 2.43 0.84
Total 2.36 0.86
12months Female 0.62 0.65
Male 1.04 0.76
Total 0.89 0.74
15months Female 0.15 0.37
Male 0.22 0.42
Total 0.19 0.40
18months Female 0.00 0.00
Male 0.00 0.00
Total 0.00 0.00
21 months Female 0.00 0.00
Male 0.00 0.00
Total 0.00 0.00
24 months Female 0.00 0.00
Male 0.00 0.00
Total 0.00 0.00

DISCUSSION Widiastuti-Samekto and Sianturi claimed that

Frozen shoulder has an insidious onset and follows
a protracted course. The pathogenesis is unclear, but
it is thought to be a progression of inflammation and
fibrosis1. It has many similar features to Dupuytren’s
disease, including the presence of adhesions.2, 3.
There are many methods of treating frozen shoulder
and variable success has been claimed. Symptoms of
frozen shoulder show much improvement when
treated with deep heating and stretching exercise
combined.13, 14 Superficial heating alone has proven less
effective.15 Traditionally, stretching exercises have been
used to stretch the shoulder capsule. Continuous
passive motion has shown more promising results as
compared to this traditional practice.15 Combining oral
steroids, non steroid anti-inflammatory drugs and
physiotherapy, is said to provide good pain relief, that
usually does not extend beyond six weeks. 16
Manipulation under anaesthesia and surgical
(arthroscopic or open) release can often restore motion
and obtain pain relief for patients with refractory
cases.17 Although patients who initially present with
frozen shoulder should always be treated non-
operatively while allowing a chance for recovery
without surgical intervention.18
intraarticular steroid injection gave rapid relief when
compared to oral route.19 Dudkiewicz I et. al (2004), in
their study of 54 patients, with mean follow up 9.2
years , claimed that conservative primary treatment
for frozen shoulder i.e., physiotherapy and intra-
articular steroid injection was an effective long term
treatment method.20
Farrell CM et al, reported that, in patients with
persistent severe stiffness, manipulation of shoulder
under general anaesthesia improves range of
movement at shoulder joint for a mean period of 15
years after treatment21. Some authors have claimed that
this does not add to the benefit of exercise program.
In our study, patients who followed the home
exercise programme properly were early to recover
and had good results even at the end of 2 years of
follow up. All the patients improve with physical
therapy (SHARP) alone. Home based heat therapy was
advised as per the patient tolerance to pain especially
after a session of exercises. Patients who presented to
us in phase 2 or 3 of frozen shoulder were subjected to
multi-modality approach of treatment using a
combination of physical therapy, anti-inflammatory
medications, intra-articular corticosteroid injections,

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 226 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
manipulation under anaesthesia or arthroscopic
release of the tight capsule.
CONCLUSION
SHARP is a non-invasive, easy to follow and
reproduce, home based exercise program effective in
early improvement of pain and disability in patients
with frozen shoulder. It helps the patient to get back
to the pre-disease status as early as possible.
ACKNOWLEDGEMENT
We sincelry thank MR. RAVICHANDRAN,
Lecturer, Department of biostatistics, Pondicherry
Institute of Medical Sciences for having analysed the
data statistically.
CONSENT
Informed consent has been taken from all the
patients for this publication. ”The author(s) declare
that they have no competing interests’’. No funding
received from any source for this study.
Ethical clearance from the ethical committee has
been obtained for the above study.
REFERENCES
1. Reeves B. The natural history of the frozen
shoulder syndrome. Scand J Rheumatol 1975;
4:193–6
2. Grubbs N. Frozen shoulder syndrome: a review
of literature. J Orthop Sports Phys Ther 1993;18:
479–87
3. Binder AI, Bulgen DY, Hazleman BL, Roberts S.
Frozen shoulder: a long-term prospective study.
Ann Rheum Dis 1984;43:361–4
4. Bridgman JF. Periarthritis of the shoulder and
diabetes mellitus. Ann Rheum Dis. 1972;31:
69–71.
5. Wohlgethan J. Frozen shoulder in
hyperthyroidism. Arthritis Rheum. 1987;30:
936–939
6. Bowman C, Jeffcoate WJ, Pattrick M, Doherty M.
Bilateral adhesive capsulitis, oligoarthritis and
proximal hypothyroidism.Br J Rheum.
1988;27:62–4
7. Choy E, Corkill M, Gibson T, Hicks B. Isolated
ACTH deficiency presenting with bilateral frozen
shoulder. Br J Rheum. 1991;30:226–227
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8. Riley D, Lang A, Blair R, Birnbaum A, Reid B.
Frozen shoulder and other shoulder disturbances
in Parkinson’s disease. J Neurol Neurosurg.
1989;52:63–6
9. Boyle-Walker K, Gabard GL, Bietsch E, Masek-
Van Arsdale DM, Robinson DL. A profile of
patients with adhesive capsulitis. J Hand Ther.
1997;10:222–228
10. Tuten HR, Young DC, Douoguih WA, Lenhardt
KM, Wilkerson JP, Adelaar RS, et al. Adhesive
capsulitis of the shoulder in male cardiac surgery
patients. Orthopedics. 2000; 23:693–696
11. Jayson M. Frozen shoulder: Adhesive capsulitis.
Br Med J.1981;283:1005–1006
12. Reeves B. The natural history of the frozen
shoulder syndrome.Scand J Rheumatol
1975;4:193-196
13. Wadsworth C. Frozen shoulder. Phys Ther.
1986;66:1878–83
14. Constant CR, Murley AG. A clinical method of
functional assessment of the shoulder. Clin
Orthop Relat Res 1987; 214: 160–164.
15. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay
M. The resistant frozen shoulder. Manipulation
versus arthroscopic release. Clin Orthop
1995;319:238-248.
16. Steinbrocker O, Argyros TG. Frozen shoulder:
treatment by local injections of depot
corticosteroids. Arch Phys Med Rehabil
1974;55:209-213.
17. Thomas D, Williams RA, Smith DS. The frozen
shoulder: a review of manipulative treatment.
Rheumatol Rehabilitation 1980; 19:173-179
18. Rizk TE, Gavant ML, Pinals RS. Treatment of
adhesive capsulitis (frozen shoulder) with
arthrographic capsular distension and
rupture.Arch Phys Med Rehabil 1994;75:803-807
19. M M Widiastuti-Samekto, GP Sianturi. Frozen
shoulder syndrome: comparison of oral route
corticosteroids and intra-articular corticosteroid
infection. Med J Malaysia 59(3);312-6 (2004),
PMID.
20. Dudkiewicz I,Oran A, Salai M, Palti R, Pritsch
M. Idiopathic adhesive capsulitis : long term
results of conservative treatment. Isr Med Assoc
J. 2004; 6:524-6.
21. Farrell CM, Sperling JW, Cofield RH.
Manipulation for frozen shoulder: long-term
results. J Shoulder Elbow Surg 2005; 14:480-4
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.097
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 227

Effect of Vibration on Skin Blood Flow in Type 2 Diabetes

Mellitus

Everett B Lohman1, Kanikkai Steni Balan Sackiriyas2, Gurinder S Bains3, Kulbhushan H Dhamane2,
Kinjal J Solani2, Chandip K Raju2, Howard W Sulzle4
1
Professor, 2Student, 3Primary Research Coordinator, 4Assistant Professor, Department of Physical Therapy, Loma Linda
University, Loma Linda-92350, California, USA

ABSTRACT

Background: Recent researches support the use of passive vibration (PV) to increase circulation
without the risk of burns. The aim of this study is to determine the effect of short duration vibration
on skin blood flow (SBF) in Type 2 diabetics.

Materials and Method: 18 subjects with Type 2 diabetes mellitus between 47-74 years of age, and 18
age matched controls between 50-75 years of age received PV on the anterior aspect of forearm and
on plantar aspect of first three metatarsal heads. SBF was measured before, after and 10 minutes post
vibration.

Results: There was a significant difference in the foot and forearm SBF across time for both groups.
However, there was no significant difference in foot and forearm SBF across time between the groups.
Greatest percent increase was seen in the diabetic foot SBF (118.53%) from baseline to end of vibration
vs. non diabetic foot (37.62 %). Also, looking 10 minutes post, there was a less change in diabetic foot
SBF (-15.25%) vs. non diabetic foot (-27.64%). There was only a slight increase from the start to the
end of the vibration in diabetic subjects (129.78%) vs. non diabetic subjects (127.97%). There was no
significant change on the foot SBF vs. the forearm at the baseline, at the end of vibration and at 10
minutes post between the groups (F=.679, P=.476).

Conclusion: The diabetes mellitus group with fair to good glucose control responded similarly to PV
as compared to non-diabetes mellitus group although there was no significant difference in foot and
forearm SBF across time between the groups.
Keywords: Vibration, Blood Flow, Aging, Diabetes Mellitus, Nitric Oxide

INTRODUCTION circulating levels of endogenous insulin are present in

the body and in some cases elevated (1), (2) (Type 2),
Diabetes Mellitus (DM) is a group of metabolic
leading to high blood glucose levels. Type 2 diabetes
diseases in which the beta cells of the pancreas do not
(T2D) is the most common (90% to 95%) in the
produce insulin (Type 1) or insulin resistance where
USA(2),(1), (3).
target cells fail to use insulin properly even though
It is a major health care problem in America
affecting millions each year (4). It is the leading cause
Corresponding author:
of stroke and heart disease and is the 7th leading cause
Everett B LohmanIII
Professor of death (1). Medical expenses and risk of death in
Department of Physical Therapy, Loma Linda diabetics is two times higher than people of similar
University, Loma Linda, CA 92350 age without diabetes (1). Prevalence of diabetes in the
Telephone: 001-(909) 558-1000 United States is 8.3% of the total population (25.8
Fax: 001-(909) 558-0459 million) and 26.9% of people e” 65 years (10.9
Email: elohman@llu.edu million)(1).

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 228 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
CIRCULATION
Blood circulation plays a significant role in tissue
healing (5). Aging and diabetes adversely affect
autonomic and endothelial function (6), (5), (7) which leads
to impaired healing and ulcerations(8).
Damage to the autonomic nervous system occurs
before clinical symptoms of diabetes are evident (9), (10).
Damage to endothelial cells in DM reduces their ability
to produce Nitric oxide (NO) and decreases their
sensitivity to NO leading to decreased SBF (11), (12), (9)
and increases the risk of ulcerations (13). Coagulation
defects and impaired fibrinolysis in diabetes mellitus
lead to increased blood viscosity and platelet adhesion
(14), (15)
. Increased blood flow is associated with
improved wound healing and increased soft tissue
repair (16), (17).
SBF
The glabrous skin (palms, soles) is mainly
innervated by sympathetic vasoconstrictor nerves (18),
(19).
It has numerous thick walled atriovenous
anastomoses (AVA) with low resistance and high blood
flow. The nonglabrous skin (dorsal area of hand) has
fewer AVA and is controlled by both the sympathetic
vasoconstrictor and vasodilator nerves (20), (21). The
superficial skin has more nutritive (NUTR) perfusion
and is influenced by small capillaries. Numerous larger
diameter arterioles and venules are found in areas such
as the face and the toes (18), (22), (23) allows for low
resistance, high blood flow directly from the arterioles
to venules (18), (24). Opening and closing of AVA has
substantial changes in SBF (19). The SBF rate is different
between AVA and NUTR sites in response to posture
induced pressure, heat, and diseases. Posture induced
pressure change is larger in large upstream arteries
and is greater in AVA sites than NUTR sites (25), (26). Heat
induced blood flow rate is greater in AVA sites than
NUTR sites. Decreased SBF due to aging and diabetes
are not very common in the AVA but NUTR sites(18), (27).
Since all of the organs in the body need blood to
function effectively, measuring their resting blood flow
provide the health status of these organs(28).
44. Steni Balan--227--233.pmd 228
Vibration
Mechanical oscillations applied randomly or
periodically are known as vibration. Vibration can be
divided into active (AV) and passive vibration (PV).
Vibration is delivered vertically to the body part and
requires active participation in AV(29).
PV does not require the patient to weight bear and
mechanical oscillations are delivered horizontally with
the subjects relaxed (29). Studies conducted on vibration
reported changes associated with vibration such as
increase in SBF(6), (30). Physical therapists may use
vibration to improve SBF without significantly
increasing the risk of burns in health individuals.
Lohman et al., (2007) demonstrated that PV at a
frequency of 30 Hz (high) and high amplitude (5-6mm)
for a short duration (3 minutes) applied to the posterior
calf muscles improved SBF significantly in healthy
subjects (6). A follow up study performed on the
forearm muscles demonstrated that 50 Hz was more
effective than 30 Hz (31). These studies suggest that PV
significantly increases SBF in extremities on hairy skin;
however, these studies were performed on non-
diabetics.
PURPOSE
The purpose of this study was to find how PV
affects SBF in T2D. The hypothesis was that Type 2
diabetics will exhibit vibration induced increase in
upper and lower extremity SBF; however less than age
and gender matched controls following the short -
duration, high frequency, and high amplitude PV.
A secondary hypothesis was that vibration will
increase SBF more significantly in hairy than non-hairy
skin in both diabetics and non-diabetics.
MATERIAL AND METHOD
Study population
18 subjects (10 females and 8 males) with T2D aged
between 18 to 75 years and 18 age matched NDM
controls (8 females and 10 males) between 18 to 75
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 229

years were recruited (Table 1). Research subjects were Diabetes Treatment Center at Loma Linda University
identified from the Diabetes support group and in the (LLU) Medical Centre (LLUMC).

Table 1: Demographic data between DM versus NDM groups.

Groups Average age Average Average Average body Average

(years) height (cm) weight (kg) mass index hemoglobin
(BMI) A1c (%)
DM 64.1 ± 7.3 168.4 ± 9.5 85.6 ± 19.1 30.3 ± 7.2 6.8 ± 0.9
NDM 64.4 ± 6.6 166.2 ± 9 73.6 ± 14.9 26.6 ± 4.9 —

Subjects with overt neurological, orthopedic

conditions (e.g., recent fractures, inability to sit for 5
minutes), documented cardiovascular diseases,
bleeding disorders and history of deep vein
thrombophlebitis, Hemoglobin A1C (Hb A1C) level
of e” 9% (Estimated Average Glucose (eAG) = 212),
documented history of diabetic neuropathy (DN) with
or without treatment, failed to sense vibration and
monofilament testing, leg ulcer, chronically exposed
to vibration stimulus and pregnant females were
excluded. Fig. 1. SBF measurement of foot.

The subjects were assigned into two groups:

Group 1 = T2D and Group 2 = Control. Subjects
received PV on their foot and on forearm of opposite
extremity on same day. The institutional review board
at LLU approved all procedures and subjects signed
statement of informed consent.
Instrumentation
Physio Plate ® was used to deliver mechanical
vibration. It is a vibration platform (Physio Plate®,
Domino S.R.L, San Vendemiano, Italy) with frequency
settings ranging from 15-70 Hz. In this study, vibration
frequency of 50 Hz at high amplitude (5-6 mm
displacement) with peak acceleration of 7g was
delivered. MV was applied for bouts of 60 seconds
working time with a rest period of 2 seconds for a total
number of 5 cycles for forearm and 10 cycles for foot.
Prior to subjects entering the laboratory, MOOR
Laser Doppler Imager (MLDI) warmed up for 30
minutes. Skin blood flow was measured by MLDI
produced by MOOR Instruments, Inc. (MOOR FLPI
V 2.1, Oxford, England). The MLDI scanner was placed
perpendicular to the forearm and foot (Figure 1). The
machine can provide blood perfusion images at the
rate of as high as 25 images per second.
The MLDI uses a red laser beam to capture the
reflected energy of blood flow. The instrument has
captured SBF and produced pictures at the rate of 4ms/
pixels. The flow was measured in “flux” unit.
Cutaneous sensation of the foot was assessed non-
invasively using Semmes-Weinstein Monofilament
(SWM) Touch-Test® Sensory Evaluators produced by
North Coast Medical, Inc (North Coast, Morgan Hill,
CA, USA). SWM is simple, inexpensive, valid, and a
reliable clinical tool to assess sensation (32), (33).
PROCEDURE
Screening
The room was pre-warmed and maintained at
22°-24°C for approximately 30 minutes. Procedures
were explained and all subjects signed the informed
consent form. The subject’s age, weight and height
were recorded. A subjective examination was carried
out for exclusion. Although relatively rare, annual
incidence of deep vein thrombosis in diabetic and non-
diabetic individuals is 0.4% and 0.08% respectively (14),
subjects were screened for possible deep vein
thrombophlebitis (DVT) prior to receiving vibration.

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 230 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Calf pain, swelling, erythema, warmth and
difference in calf diameter were examined. A Well’s
criteria score was calculated for each potential
subject(34). A score of d” 0 was considered as low risk
(3% probability of DVT), 1 to 2 as moderate risk (17%
probability of DVT), and e” 3 as high risk (75%
probability of DVT) for individuals with signs and
symptoms of DVT and scores of e” 2 were excluded.
for ten minutes (Figure 5). Subjects immediately
returned to the plinth for post vibration SBF
measurement. A third measurement was taken 10
minutes following vibration. Next the subjects were
positioned in long sitting with their forearm pronated
and resting on the vibration platform for five minutes
(Figure 5). Similar SBF measurements were repeated.

Cutaneous sensation of the foot was then

performed by using SWM in a quiet room with subjects
being asked to look away. The areas of the foot were
randomly tested by pressing the monofilament at a
90° angle against the skin. The monofilament was
placed in each area for 1.5 seconds. The stimulus was
checked with the six different evaluator sizes: 2.83
(0.07g), 3.61 (0.4g), 4.31 (2g), 4.56 (4g), 5.07 (10g), and
6.65 (75g). The stimulus was checked three times in
the same location for the filament sizes of 2.83 to 3.61
and one time for 2g to 75g. Sensory responses, color
on the handle, notation were noted on the sensory foot
mapping form (Appendix 1).

Vibratory sensation assessment (128 MHz tuning

fork)

Vibration sense is first affected in peripheral

Fig. 5. Foot PV
neuropathy(35). A strong vibration stimulus was applied
to the hallux and compared with examiner’s wrist
dorsally (36). A score of 0 (normal) was given if both the
subject and examiner simultaneously noted the
sensation had stopped. A score of 1 (reduced) if the
examiner can feel when subject reports it as ceased.
Absent sensation or a score of 2 was given when the
subject does not feel the vibration stimulus. The 128
Hz TF is a valid and reliable clinical tool to assess
DP(37), (38).

Testing

Subjects were positioned in supine on the plinth. A

square shaped scan area of 3cm×3cm was marked on
the anterior aspect of the forearm 2.54 cm distal to the
midpoint of the cubital crease. Four points on the
corners of the square were marked and was scanned
to measure SBF. The same procedure was applied on Fig. 6. Forearm PV
the plantar aspect of first three (1-3) metatarsal heads
for measuring the blood. The baseline SBF recordings RESULTS
were measured and then the subjects received
vibration. Mixed factorial ANOVA was used to compare the
effect of vibration. Bonferroni test was used to further
Subjects were asked to sit erect with their hip and identify the significance of group, time and site of
knee at 90° and foot placed on the vibration platform application.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 231

Tables 2 and 3 show a significant difference in foot
SBF across time for both DS and NDS (P<.001). There
was no significant difference across time between
groups (P=.102). Table 4 shows the percent change in
mean foot SBF across time for both groups. The greatest
percent was seen in the diabetic foot (118.53%) from
baseline to end of vibration vs. non diabetic foot (37.62
%). When looking from the end of the vibration
intervention to 10 minutes post, there was a less of
percentage change in the blood flow in the diabetic
foot (-15.25%) vs. the non diabetic foot (-27.64%).
Table 2 shows a significant difference in the forearm
SBF across time for both groups (P=.000). There was
no significant difference in forearm SBF across time
between the groups (P=.102). Table 4 shows the mean
forearm SBF across time for both the groups. There
was only a slight percentage change increase from the
start to the end of vibration in the DS (129.78%) vs. the
NDS (127.97%).
Comparison Between Time, Location and Diabetes
Status.
Table 2 shows the BF comparisons between location
of vibration vs. Diabetes status at baseline, vibration
end and 10 minutes post. There was no significant
change in BF on the foot vs. the forearm at baseline,
vibration end and 10 minutes post vibration between
groups (F=.679, P=.476).

Table 2. Comparison of significance of BF between time, location and diabetes status

Source F Sig.
Site Sphericity Assumed 1.376 .249
Site *Group Greenhouse-Geisser .740 .396
Time Greenhouse-Geisser 29.960 .000
Time *Group Greenhouse-Geisser 2.515 .102
Site *Time Greenhouse-Geisser .574 .525
Site * Time * Group Greenhouse-Geisser .679 .476

* Mixed-factorial ANOVA

Table 3. Bonferroni test for between subject effects

Source F Sig.
Group .000 .996

Table 4. Percent change in mean SBF (Flux) ± (SD) across time for each location.

Location Start (S) End (E) 10 min post (P) % change (S-E) % change (S-P) %change (E-P)
Foot DM 72.3 (8.1) 158.0 (17.0) 133.9 (13.8) 118.53 85.20 -15.25
NDM 117.5 (11.7) 161.7 (13.7) 117.0 (17.2) 37.62 -0.43 -27.64
Forearm DM 67.5 (14.8) 155.1 (7.6) 112.4 (7.9) 129.78 66.52 -27.53
NDM 61.5 (9.4) 140.2 (9.4) 88.1 (7.4) 127.97 43.25 -37.16

DISCUSSION (230%) vs. NDS (228%). No significant difference post

intervention suggesting that both groups had similar
Any small improvement in microcirculation
capacities to respond to PV. At 10 minutes post PV,
without stressing the thermoregulatory and
forearm SBF in both groups remained elevated but was
cardiovascular system will be beneficial to diabetes
beginning to decrease. The diabetics had a 27.5%
subjects. PV increases SBF without significantly
reduction while non diabetics had a 37.2% reduction
increasing skin temperature (ST) and blood pressure
in forearm SBF from the end of intervention as
(BP) in healthy adults (6), (30). There was no study
compared to 10-minutes post. In other words, forearm
performed on the effect of PV in diabetics. This study
SBF was maintained for longer time in diabetics than
focused on the effect of vibration on SBF in hairy vs.
non diabetics 10 minutes post vibration. However,
non hairy skin in T2D subjects.
there was no significant difference in the forearm SBF
There was no significant difference at baseline in between the groups.
SBF for the forearm (hairy) between the groups. The
On contrary to hairy skin, there was a decrease in
percentage change in forearm SBF more than doubled
non hairy (foot) SBF in the DS (72.3 ± 8.1 Flux) vs. the
from the start to the end of the vibration in both DS

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 232 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
NDS (117.5 ± 11.7 Flux) at the baseline. The diabetics
had a significantly lower baseline SBF on the plantar
surface of the foot. This is the most common site for
skin ulcers in this population. The greatest percent
increase of SBF was seen in the diabetic foot from
baseline to end of vibration (218.53%) vs. non diabetic
foot (137.62 %). In other words the non-diabetic foot
only increased by approximately one-third in response
to PV while the diabetics foot’s SBF more than doubled.
At the end of 10 minutes post, the non-hairy foot blood
flow in diabetics (- 15.25%) was maintained for longer
time than the non diabetics (- 27.64%). In other words,
foot skin blood flow was maintained for a shorter
period of time in the NDS than the DS 10 minutes post
vibration. However, there was no significant difference
in foot SBF between DS and NDS.
Although there was a significant difference in foot
and forearm SBF across time within the groups, there
was no significant difference in foot and forearm SBF
at baseline, vibration end and 10 minutes post between
the groups.
Recommendations
Future studies can focus on the activity level and
body fat percent with vibration and can compare
1. good control (A1c <7.5%) versus poor control (A1c
>9%) diabetics(39)
2. moderately active (3 to 6 METs) vs. vigorously
active (> 6 METs) T2D subjects
CONCLUSION
There is no difference in SBF in the forearm and
foot at the baseline, vibration end and 10 minutes post
vibration between DS (fair to good control) and NDS.
However, diabetics in fair to good control responded
similarly to PV as compared to non-diabetics.
Acknowledgement: Nil
Conflict of Interest: Nil
Source of funding: Nil
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8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.098
234 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Immediate Effect of Jacobson's Progressive Muscular

Relaxation in Hypertension

Nisha Shinde1, Shinde KJ2, Khatri SM3, Deepali Hande4

1
Associate Professor, College of Physiotherapy, 2Professor & HOD, Dept. of ENT, 3Professor & Principal, College of
Physiotherapy, 4Lecture, College of Physiotherapy, Pravara Institute of Medical Sciences, Loni, Ahmednagar, District,
Maharashtra State, India

ABSTRACT

Objective: To study the effectiveness of Jacobson's relaxation techniques as an adjunct therapy in

control of hypertension.

Design: A Experimental study.

Setting: Constituent colleges of Pravara Institute of Medical Sciences (Deemed University) and the
colleges of Pravara Rural Education Society in the vicinity. Cardio-respiratory Physiotherapy
Department, College of Physiotherapy & Pravara Rural Hospital (Tertiary Hospital), Loni, Tal-
Rahata, Dist- Ahmednagar , Maharashtra State, India- 413 736.

Participants: A total of 250 college teachers were screened for hypertension. Out of which 105 subjects
were found suitable and willing for participation in the study.

Interventions: Jacobson's progressive muscle relaxation lying in supine position for 30 minutes.

Main outcome measures: Blood pressure and Heart rate.

Results: Significant difference was noted in systolic & diastolic blood pressure and heart rate
immediately after 30 minutes of Jacobson's progressive muscular relaxation technique.

Conclusions: Jacobson's progressive muscular relaxation may be used as an adjuvant therapy for
immediate control of hypertension.

Clinical Trial Registration Number: (PMT/PIMS/RC/ 2012/06)

Keywords: Hypertension, Relaxation, Blood pressure and Heart rate

INTRODUCTION cerebral and renal disease. 2 Hypertension experts still

Hypertension is ranked as fourth top most disease
on the basis of its prevalence1. Since most of the
individuals who suffer from hypertension do not have
specific symptoms related to their elevated blood
pressure, it is often called as the silent killer disease.2
probably, hypertension is a major health problem and
biggest of the challenges of the 21st century. It affects
approximately one billion individuals worldwide. 3 In
India, the prevalence of hypertension in adult
population varies from 3 to 10% and the average figure
is 4.8%. The population at risk above the age of 20 years
is 330 million as per 1981 population figures.4 High
blood pressure is major risk factor for causing cardiac,
debate the level of blood pressure considered
abnormal. A great deal of effort has been devoted to
search for a dividing line between normal tension and
hypertension. Systolic blood pressure above 140 mm
Hg and or diastolic blood pressure above 90 mmHg
are the currently accepted dividing line based on
epidemiological and interventional studies. From 1983
onwards, World Health Organization recommended
the use of non-pharmacological approaches in the
treatment of hypertension 5 . Various Non-
pharmacological measures for hypertension includes;
life style modification, weight reduction, regular
physical exercises, cessation of smoking, tobacco use

45. Nisha Shinde --234--237.pmd 234 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 235
cessation, increase in intake of fruits & vegetable,
reduction in alcohol, sodium intake and potassium
supplementation. Beneficial effects of Jacobson’s
progressive relaxation technique has been reported by
various authors 6,7. However, there is hardly any study
that has investigated the immediate effectiveness of
this technique since it is believed that the information
about immediate effectiveness may increase the
hypertensive individuals’ adherence to this technique
and may serve as a non-pharmacological option for
immediate control of hypertension.
Relaxation can be highly beneficial if practiced
routinely in one’s everyday life. Techniques involving
relaxation are widely used by people to reduce anxiety
and cope with stress-related problems. There are
countless methods used to achieve relaxation, but the
procedures that are most commonly practiced in the
clinical setting are Jacobson’s (1938) Progressive
Muscular Relaxation, Schultz and Luthe’s (1969)
Autogenic Training, and Benson’s (1975) Relaxation
Response (Weiten & Lloyd, 1998). In the last few
decades, a substantial amount of data has been
collected on many factors relating to relaxation such
as: specific effects of different methods of relaxation;
individual differences in response to treatment;
variables that increase adherence to treatment and
relaxation therapy effects on specific health problems.10
“Silent water, It is said that they are deep and
dangerous”, “A volcano is also quiet till interrupts with
devastating results”. High blood pressure is somewhat
such a situation and if left undetected and untreated it
results in brain attack (stroke), heart attack, heart
enlargement, heart failure and kidney failure. Unlike
volcano, which cannot be predicted, high blood
pressure can be detected in the silent phase and if
treated adequately the hypertension volcano can be
prevented from eruption.
The goal in treating high blood pressure is to reduce
the risk of serious complications, including heart
disease and stroke, by getting blood pressure under
control, ideally which means reducing blood pressure
upto 120/80 mm Hg. However, even a partial lowering
of blood pressure may bring major benefits. There is a
need of medication prescriptions to treat hypertension,
but changes in lifestyle including diet, exercise, and
relaxation are also needed. 12 . for control of
hypertension.
METHOD
The study was designed as an experimental study.
45. Nisha Shinde --234--237.pmd 235
SUBJECTS
A total of one hundred and five subjects with
primary hypertension without any known associated
major health problem and who were working as
teachers in various colleges in the vicinity of the place
of study during September 2011 to December 2011.
Subjects who were not regular in taking medications
and who reported about aggravation of any symptom
due to exercise were excluded from the study.
Outcome measures
The outcome measures used in the study were
systolic blood pressure, diastolic blood pressure
measured and heart rate.
PROCEDURE
The study received approval from Ethical
Committee of Pravara Institute of Medical Sciences,
Loni. Participants were screened based on the inclusion
and exclusion criteria and those willing to participate
were briefed about the nature of the study and
intervention in the language best understood by them
and written informed consent was obtained. They were
encouraged to clarify questions regarding the study,
if any. Each subject underwent a standardized history
and physical examination. As well as the data was
collected for the baseline blood pressure measurement
and heart rate. Systematic technique developed by Dr.
Edmund Jacobson (1938), used for achieving a deep
state of relaxation. All subjects received supervised
Jacobson’s relaxation ( JPMR). For Jacobson’s
Progressive muscular relaxation, the investigator
demonstrated technique to contract and relax various
groups of muscles, to coordinate contractions and
relaxations with deep breaths and to perform the entire
procedure with eyes closed in supine lying down
position. After the trial session every subject performed
this supervised Jacobson,s progressive muscular
relaxation for 30 min. After 30 min of training,
Outcome measures were reassessed immediately after
the JPMR that is Blood Pressure and Heart Rate. The
data, thus obtained were considered for statistical
analysis.
RESULTS
Statistical analysis was done by using Statistical
Package of Social Sciences (SPSS) 13.0 using various
statistical measures such a mean, standard deviation
(SD) and tests of significance such as unpaired ‘t’ test.
The results were concluded to be statistically
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 236 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

significant with p <0.05 and highly significant with p
< 0.01. Unpaired ‘t’ test was used to compare
differences between the Pre and post session of
relaxation. (Table 1) The score showed statistically
significant difference in pre and post measurement in
systolic blood pressure. There was statistically
significant difference in the mean and SD of systolic
blood pressure. Table 2 shows statistically significant
difference in pre and post measurement in diastolic
blood pressure. There was statistically significant
difference in the mean and SD of diastolic blood
pressure.
Table 3 shows statistically significant difference in
pre and post measurement in heart rate There was
statistically significant difference in the mean and SD
of the heart rate.

TABLE 1. Mean deviation and standard deviation of systolic BP.

Pre Treatment Post Treatment ‘P’value ‘T’value Result

mean± Sd mean± Sd
147 ± 1.721 142 ± 2.231 <0.01 2.883 Highly significant

TABLE 2. Mean deviation and standard deviation of Diastolic BP.

Pre Treatment Post Treatment ‘P’value ‘T’value Result

mean± Sd mean± Sd
96 ± 1.291 94 ± 1.412 < 0.05 0.1187 Highly Significant

TABLE 3. Mean deviation and standard deviation of HR

Pre Treatment Post Treatment ‘P’value ‘T’value Result

mean± Sd mean± Sd
98 ± 1.157 94 ± 1.412 < 0.05 2.742 Highly Significant

DISCUSSION between the findings on anxiety and those on sustained

attention. Previous work has also observed
This study shows that Jacobson,s progressive
improvements in sustained attention as a result in
musculer relaxation techniques helps in better control
anxiety reduction, resulting in decreased distraction.
of blood pressure in hypertensive patients, regardless
Significant anxiety reduction was great and anxiety
of their initial level of hypertension. New research
reduction is responsible for some of the improvement
shows that the simple act of becoming relaxed can have
on the attention. The results of the three measures
surprising health benefits. In addition to the obvious
reported in present study show that anxiety reduction
psychological effects of relieving stress and mental
may have an effect on blood pressure.16.
tension, the new findings indicate that the deep
relaxation, if practiced regularly, can strengthen the The main idea of initiating the relaxation response
immune system and produce a host of other medically in this way is to take control of the voluntary muscles
valuable physiological changes.5 through creation of tension in them, followed by
forcing them into a state of relaxation. When the body
The greatest reduction was found in blood pressure.
is aware of the presence of the tension, it will respond
Blanchard et. al. (1988). The present findings are
by triggering the muscles to relax, where the rest of
consistent with the cross cultural studies conducted
the other components of the relaxation response will
on USA & USSR populations. There are several types
naturally follow 15. In addition to the findings, this
of relaxation therapies such as stretch release relaxation
study demonstrates a number of possibilities for the
(SRR),Jacobson,s progressive muscle relaxation
implementation of complementary therapies in an
(JPMR), cognitive imagery relaxation (COG), and some
evidence-based medicine environment. The existing
types of meditations. Here, the JPMR technique is used
evidence can be validated in practice in the form of
because of its better reported results, its simplicity in
small-scale studies in the context of implementation.
performance and easy independent practice at home.
The research process can be used as a structured form
The deep relaxation technique produces an immediate
of monitoring the effects of complementary practice.
reduction in state of anxiety 6 .The possible relationship

45. Nisha Shinde --234--237.pmd 236 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 237
These observations encourage the belief that such
small-scale studies can be replicated or maintained on
a long-term basis as a part of everyday practice.19 The
data thus obtained are amenable to meta-analysis at a
later date, and as such make it more likely that
complementary therapies are included in the
systematic reviews.
CONCLUSION
Jacobson’s progressive muscle relaxation may be
used as an adjunct to conventional physiotherapy in
hypertension.
ACKNOWLEDGEMENTS
Ethical approval: Ethical Committee of Pravara
Institute of Medical Sciences, Loni, Maharashtra state,
India. (PMT/PIMS/RC/2012/06)
Funding: No funding was gained for the study.
Conflict of interest: None declared.
REFERENCES
1. Khadilkar HA, Ghattargi CH, Thite GH.(2004)
Study of Prevalence of hypertension and
sociodemographic factors in a rural community
of Maharashtra. South Asian Journal of
Preventive Cardiology; 8(4): 205-210
2. Contractor A.(Jul-Sep 2002) Role of exercise in
prevention and treatment of hypertension.
Hypertension India; 18(3):52-63
3. Maiya M.(2002) Improving Hypertension
Control: A Challenge. Hypertension
India;17(4):83-88
4. Gupta R. Hypertension in Indian Scenario.
Hypertension India; 15(1):5-12
5. Wallace JP.(2003) Exercise in Hypertension: A
Clinical Review. Sports Med;33(8):1-12.
6. Khatri SM, Singharvelan RM, Romi HN(2012):
Effectiveness of Jacobson’s Relaxation Technique
in Hypertension: IJHSR:1:2:16-21.
7. Sheu, Sheila RN, PhD; Irvin, Barbara L. RN,
PhD(2003); Lin, Huey-Shyan; Mar, Chun-Lin:
Effects of Progressive Muscle Relaxation on Blood
Pressure and Psychosocial Status for Clients with
Essential Hypertension in Taiwan: Holistic
Nursing Practices:17:1:41-47.
8. Linda Brookers, Robert Rowan, Constance
Schrader,(1997) Control of Hypertension,
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Community health Science. DASH Collaborative
Research Group. NEJM ;336:1117-24.
9. NC VI- (1997) The sixth Report of the Joint
National Committee on prevention,. Detection,
Evaluation and Treatment of High Blood
Pressure. Arch Intern Med.; 15fl4 13-46.
10. George M. Manesh,(2000) Bombardier C. et at
Clinical Approach to Hypertension. Harvard
publication. 43:1520-1528.
11. Pescatello, Linda S, Franklin, Barry A. (March
2004) Exercise and Hypertension. Medicine &
Science in Sports & Exercise. 36(3):533-553.
12. Lesniak, Karen T.; Dubbert, (November 2001)
Exercise and hypertension Patricia Current
Opinion in Cardiology. 16(6):356-359.
13. Stephen Archer, MD; Stuart Rich, MD (2000)
Primary Pulmonary Hypertension. A Vascular
Biology and Translational Research “Work in
Progress”. Clinical Cardiology: New Frontiers;
Circulation; 102:2781-2791.
14. Gupta R. (1999) Hypertension in India–definition,
prevalence and evaluation. Journal of Indian
Medical Association ; 97(3): 74-80.
15. F.Ranjbar, F. Akbarzadeh, B. Kazemi, A.
Safaeiyan, (Feburary 11,2007,Accepted:May
1,2007) Relaxation therapy in the background of
standard antihypertensive drug treatment is
effective in management of moderate to severe
essential hypertension.
16. Bernstein PL, Jacobson BF, Connor MD, Becker
PJ. (Epub Nov 2008,Feb 15, 2009)
17. Aspirin resistance in South African Caucasian
patients with thrombotic cerebrovascular events.
J Neurol Sci.;277(1-2):80-2.
18. Yung P, French P, Leung B.(2001) Relaxation
training as complementary case for mild
hypertension control and the implications of
evidence-based medicine. Complementary
Therapy Nursing Midwifery ;7:59- 65.
19. Gregory L. (1997): Exercise Management for
Persons with Chronic Diseases and Disabilities.
American College of Sports Medicine. Human
Kinetics: Illinois, pp. 59-63.
20. David Zieve, MD, MHA, and David R. Eltz. (Sept
26,2010) Solutions Acupuncture, a private
practice specializing in complementary and
alternative medicine, , AZ. Review provided by
VeriMed Healthcare Network , Phoenix.
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.099
238 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Chronic Abdominal Wall Pain in Children may be

Improved By Physiotherapy

Siba Prosad Paul1, Gina Farmer2, Krishna Soondrum3, David CA Candy4

1
ST4 in Paediatrics, 2Paediatric Physiotherapist, 3Specialist Registrar in Paediatrics, 4Professor, Consultant Paediatric
Gastroenterologist, St Richard's Hospital, Chichester, PO19, 6SE, United Kingdom

ABSTRACT

Functional abdominal pain is common in children and a proportion of these children suffer from
chronic abdominal wall pain (CAWP). CAWP is suggested when a positive Carnett's sign is elicited
in a child where the pain gets worsened by movement. Analgesics are generally not helpful in children
with CAWP. We describe a novel approach with physiotherapy (by core stability programme) for
managing children with this condition. The therapy was delivered by a paediatric therapist after
other organic causes of abdominal pain were ruled out. Forty two out of 49 children (85%) showed
improvement with this therapy. As the improvement was noticed during the therapy and sustained
thereafter we suggest that this therapy is helpful in children in CAWP.
Keywords: Chronic abdominal wall pain, Carnett's sign, Straight leg raising test, Physiotherapy, Children

INTRODUCTION to posture such as lying, sitting, standing, and

exercise3,4,5. A localised tenderness may be identified,
A significant proportion of children experiences
however, the pain often radiates over the periphery of
chronic abdominal pain. The child’s quality of life and
the abdomen where abdominal muscles join the
often school attendance are adversely affected 1,2.
skeleton.
Managing these patients can be challenging and can
lead to unnecessary invasive investigations and Abdominal wall pain is suggested by a positive
tertiary paediatric gastroenterology clinic referrals2,3. Carnett’s sign when the abdominal pain increases
when the abdominal muscles are flexed3,4 by straight
Abdominal pain-related functional gastrointestinal
leg raising (SLR) or lifting head and shoulders while
disorders (FGIDs) include functional dyspepsia,
the child lies supine. Abdominal wall pain could result
irritable bowel syndrome, and abdominal migraine.
from referred pain from the spine or myofascial pain.
Children whose non-organic abdominal pain does not
The pain can also result from structural conditions,
have the clinical features of these syndromes are said
such as localised endometriosis or rectus sheath
to have functional abdominal pain (FAP). FAP is
hematoma, or from incisional or other abdominal wall
characterised by episodic or continuous abdominal
hernias which need to be excluded3,4.
pain with insufficient criteria for other FGIDs and
which does not have evidence of an inflammatory,
METHOD
anatomic, metabolic, or neoplastic process to explain
the child’s symptoms. These criteria should be fulfilled We describe the use of paediatric physiotherapy as
at least once per week for at least 2 months before a a novel approach for treating CAWP in children on
diagnosis is made1. We suggest that, in a proportion the basis that the pain is of musculoskeletal or neural
of children, FAP is due to chronic abdominal wall pain tension in origin and is made worse by poor posture.
(CAWP).
The study group
CAWP is suggested by a chronic and unremitting
abdominal pain, with minimal or no relationship to The single centre cohort consisted of 60 children
food intake or defecation but can have a relationship out of which there were 46 girls (76%).

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 239
The children were aged between 6 to 16 years and
were referred to the paediatric gastroenterology clinic.
CAWP was suspected after the organic causes of
abdominal pain were ruled out and these children were
then referred to the physiotherapy clinic.
Forty nine children were adjudged to have a CAWP
after a physiotherapy assessment.
These children had abdominal pain made worse
by movement without gastrointestinal symptoms and
were started on the therapy and are included in the
analysis; 46 children completed the full course of
physiotherapy.
Physiotherapy assessment and treatment
The rationale for the use of physiotherapy and the
expected benefits were discussed by a paediatric
physiotherapist with the family before commencing
the therapy, which was continued for 8 weeks.
Treatment comprised of a core stability programme
spread over six sessions of physiotherapy, home
exercise programme and a telephone follow-up 4
weeks after the last clinic session.
The exercise programme in the clinic consisted of
correcting the eccentric use of abdominal muscles
(lordotic posture and protruding abdomen “like
holding cup from the inside” or trying to support the
spine by bracing outwards) and retraining the
abdominal muscles (work concentrically providing
better support with less effort). The home exercise
programme involved maintaining a neutral spine:
practicing standing, sitting, walking and good posture
being integrated into everyday situations with a
muscular effort of 30% maximum.
RESULTS
At initial assessment all children had poor posture
and a limited SLR. Three out of 49 children did not
tolerate the therapy and complained of back pain;
hence, the therapy was discontinued early. Forty two
children (85%) with CAWP responded to the
physiotherapy program of treatment and the results
are shown in figure 1. The group of children, who
responded well to the physiotherapy programme, also
had improved SLR at discharge.
46. Siba Paul--238--239.pmd 239
Fig. 1. Response to physiotherapy on CAWP
DISCUSSION
This case series suggests that CAWP might be a
cause of FAP in the paediatric population and is
amenable to treatment in the majority of affected
children with physiotherapy. The finding that the
symptoms did not improve while the children were
waiting for treatment and that the improvement was
sustained during follow up suggests that the
interventions were therapeutic, rather than the CAWP
improved spontaneously.
Being mindful of the placebo effect of interventions
in CAWP, a randomised controlled trial of
physiotherapy versus an alternative treatment such as
relaxation therapy is required.
REFERENCES
1. Rasquin A, Di Lorenzo C, Forbes D, Guiraldes E,
Hyams JS, Staiano A, et al (2006). Childhood
functional gastrointestinal disorders: child/
adolescent. Gastroenterology, 2006; 130(5):1527-37.
2. Lindley KJ, Glaser D, Milla PJ. Consumerism in
healthcare can be detrimental to child health:
lessons from children with functional abdominal
pain. Arch Dis Child, 2005; 90:335–7.
3. Fishman MB, Aronson MD, Chacko MR (2010).
Evaluation of the child and adolescent with
chronic abdominal pain. Available at
h t t p : / / w w w. u p t o d a t e . c o m / c o n t e n t s /
evaluation-of-the-child-and-adolescent-with-
chronic-abdominal-pain accessed on 3rd Feb, 2012
4. Suleiman S, Johnston DE. The abdominal wall:
an overlooked source of pain. Am Fam Physician,
2001; 64(3):431-8.
5. Srinivasan R, Greenbaum DS. Chronic abdominal
wall pain: a frequently overlooked problem.
Practical approach to diagnosis and management.
Am J Gastroenterol. 2002; 97(4):824-30.
8/1/2013, 8:31 AM
 DOI Number: 10.5958/j.0973-5674.7.3.100
240 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Functional Status and Disability in Stroke Survivors of

North India

AGK Sinha1, Divya Dhamija2, Supreet Bindra3

1
Head & Reader, MPT Student, 3PhD Scholar, Department of Physiotherapy, Punjabi University, Patiala
2

ABSTRACT

Stroke is one of the leading causes of morbidity and mortality. It is necessary to not only focus on the
medical aspect of the disease but to also cater the disabilities associated with it. The study investigated
the complexity of factors that influence the functional status and disability following stroke using
qualitative interviews. It was found that majority of stroke patient's fall in the age group of 60-75
years. Occurrence of stroke was found to be more among high income group; those living in joint
families and urban dwelling, but the post of disabilities were more severe in rural dwellers. The
percentage of motor disability was highest followed by cognitive and social. A majority of stroke
patients were leading a poor quality of life with male sufferer's leading a comparatively better life.
Disability increased with the increase in level of spasticity and decrease in balance status Majority of
subjects who received physiotherapy were mildly dependent for their daily activity and on the other
hand those who did not receive were moderate to very severely dependent, depicting that
physiotherapy is essential during rehabilitative phase of stroke management.

INTRODUCTION Inclusion criteria

Stroke is currently the third leading cause of death 1. Patients who were diagnosed with stroke at least
in the Western world, ranking after heart disease and 1 year before.
cancer and is responsible for a large proportion of 2. Patient’s with either hemorrhagic or ischemic
disability and reduced quality of life, becoming more stroke.
frequent with increasing age¹. There is limited data
3. Patient’s aged between 30-90 years.
available on stroke mortality in India, however it is
estimated that stroke represented 1.2% of the total Exclusion criteria
deaths in the country, when all ages were included². 1. Patients with recurrent stroke
The incidence of stroke increases exponentially from
30 years of age, and etiology varies by age³. 2. Patient’s with any significant past medical history
of cardiac disease, malignancy, head injury, severe
Complications following stroke have been shown road traffic accident, and any other neurological
to impede rehabilitation, leading to poor functional problem which may hamper patient’s functional
outcome, and increased cost of care4. It is observed that status.
less work has been done on chronic stroke patients to
Tools of data collection
assess their functional status and disability in
developing countries. Considering the paucity of 1. Interview Schedule Technique
literature on stroke in India, present study would 2. Clinical Evaluation form.
supplement the existing knowledge of stroke.
3. Patient’s Medical Records.
Study Design and Methodology 4. Modified Ashworth Scale (MAS)
The study was conducted on a random sample of 5. Berg Balance Scale (BBS)
50 post stroke subjects from various multi specialty
6. Modified Barthel Index (MBI)
hospitals, private clinics and organizations in North
India (Yamunanagar district of Haryana, Jagadhari 7. Functional Assessment Measure (FAM)
(Haryana) and Patiala district of Punjab). 8. Disability Assessment Schedule II (WHO DAS 2.0)

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 241

Protocol 32% of the subjects took ayurvedic, 14%

homeopathic, 24% traditional form and 30% did not
Each subject was interviewed and clinically take any kind of treatment, besides taking the
examined individually using tools for data collection; allopathic one. Out of total subjects 72% received
however no award or incentive was given to any physiotherapy whereas 28% did not (Table 2).
subject. Those found afflicted with severe disability
were referred to nearby physiotherapy clinics or Table 2: Distribution of subjects on the basis of treatment
hospitals. Also some of the therapeutic exercises, Treatment Total Male Female
ergonomic advice and other measures to be taken were (%) (%) (%)
told to the majority of the subjects by the investigator. Ayurvedic 32 12 20
Homeopathic 14 6 8
The data so collected was then organized in a Traditional 24 8 16
tabular form, for all the variables studied. The Nil 30 22 8
Arithmetic mean and Percentages were used for Physiotherapy Treatment
summarizing the data and drawing inferences. Received 72 34 19
Not Received 28 14 7
RESULTS
56% of the subjects were found to have mild and
The minimum age of the study subjects was 30 4% maximal spasticity on assessment using MAS. 28%
years and maximum 85 years. Minimum duration of of the subjects were found to have good balance and
stroke was 1 year and maximum 6 years. 16% of the 20% had poor balance when assessed on BBS. Majority
subjects were illiterate, 38% of the subjects belonged of the subjects (90%) required minimal to moderate
to high income and 32% to low income group. 56% of assistance following stroke when measured using
subjects belonged to nuclear families and 64% subjects FAM. 48% of the subjects were mildly dependent and
resided in urban areas (Table 1). 22% were moderately dependent when level of
Table 1: Distribution of subjects on the basis of dependence was measured on MBI. 69.28% subjects
had motor, 44.33% cognitive and 22.12% had social
Demographic Features
disability following stroke. 20% of the subjects were
Parameter Total Male Female
(%) (%) (%)
mildly disabled, 34% moderately (male (22%) and
Age Group female (12%) Table 4) and 34% severely disabled
30-45 12 6 6 following stroke when measured using WHO DAS 2.0
46-60 28 10 18 (Table 3).
61-75 48 26 22
Table 3: Distribution of subjects on the basis of
76-90 12 6 6 Assessment Scales
Premorbid Education level*
Parameter Subjects (%)
Illiterate 16 2 14
Level of Spasticity (MAS)
Literate 46 2 24
Nil 20
Educated 38 24 14
Mild 56
Socioeconomic status**
Moderate 20
HIG 38 20 18
Maximal 4
MIG 30 12 18 Balance (BBS)
LIG 32 16 16 Good 28
Family Type Acceptable 52
Joint 56 26 30 Poor 20
Nuclear 44 22 22 Level of Assistance (FAM)
Place of Dwelling Minimal 62
Urban 64 32 32 Moderate 28
Rural 36 16 20 Maximal 6
Level of Dependence (MBI)
*Illiterate: never studied; Literate: passed 10th standard; Educated:
passed 12th or more Minimal 14
Mild 46
**HIG high income group: above 1 lac; MIG medium income
group: 50000-1lac; Moderate 22
Severe 4
LIG low income group: below 50000

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 242 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 3: Distribution of subjects on the basis of Table 7: Distribution of subjects in various levels of
Assessment Scales (Contd.) disability according to Socioeconomic status

Type of Disability Disability HIG (%) MIG (%) LIG (%)

Motor 69.28 No 2 0 0
Cognitive 44.33 Mild 12 6 2
Social 22.12 Moderate 12 16 6
Level of Disability Severe 10 6 18
No 2 Very Severe 2 2 6
Mild 20 Total 38 30 32
Moderate 34
Table 8: Distribution of subjects in various levels of
Severe 34 disability according to Premorbid Education level
Table 4: Distribution of subjects according to Level of Disability Illiterate Literate Educated
Disability measured on WHO DAS 2.0 (%) (%) (%)

Disability Male (%) Female (%) No 0 2 0

No 2 0 Mild 0 4 16

Mild 12 8 Moderate 4 14 16

Moderate 22 12 Severe 10 20 4

Severe 10 24 Very Severe 2 6 2

Very Severe 2 8 Total 16 36 38

Total 48 52 In subjects with mild disability, 12% had mild and

Among the subjects who resided in urban areas 16% 8% had no spasticity. In subjects with severe disability,
were mildly and 12% were severely disabled while 22% had mild and 8% had moderate spasticity (Table
those in rural areas 4% were mildly and 22% were 9). In subjects with mild disability 12% had poor
severely disabled (Table 5). Among those who lived in balance and 8% had acceptable balance. In subjects
nuclear families 14% were mildly and 12% were with severe disability 22% had acceptable and 10% had
severely disabled and those living in joint family 6% poor balance (Table 10).
were mildly and 22% severely disabled (Table 6). 10% Table 9: Distribution of subjects in various levels of
were severely disabled in high income group, 6% in disability according to Level of Spasticity using MAS
medium and 18% in low income group (Table 7). 10%
Disability Nil Mild Moderate Maximal
were severely disabled among illiterate subjects, 20% (%) (%) (%) (%)
among literate and 4% among educated subjects No 2 0 0 0
(Table 8). Mild 8 12 0 0
Moderate 6 20 8 0
Table 5: Distribution of subjects in various levels of
Severe 2 22 8 2
disability according to Dwelling place
Very Severe 2 2 4 2
Disability Urban (%) Rural (%) Total 20 56 20 4
No 2 0
Mild 16 4 Table 10: Distribution of subjects in various levels of
disability according to Balance status using BBS
Moderate 30 4
Severe 12 22 Disability Good Acceptable Poor
Very Severe 4 6 (%) (%) (%)

Total 64 36 No 2 0 0
Mild 12 8 0
Table 6: Distribution of subjects in various levels of Moderate 12 20 2
disability according to Type of Family
Severe 2 22 10
Disability Nuclear (%) Joint (%) Very Severe 0 2 8
No 2 0 Total 28 52 20
Mild 14 6
Moderate 14 20 In subjects with mild disability 20% required
Severe 12 22 minimal assistance. Subjects with very severe disability
Very Severe 2 8 required maximal to total assistance (Table 11). 8%
Total 44 56 subjects with mild disability were found to be

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 243

minimally dependent and 12% were mildly DISCUSSION

dependent. 12% subjects with severe disability were
While analyzing the data grossly it was found that
moderately dependent and 10% were severely
majority of stroke patient’s fall in the age group of 60-
dependent (Table 12).
75 years. Similar results have been given by Ellekjaer
Table 11: Distribution of subjects in various levels of et al. (1997)³. It was found that the premorbid level of
disability according to Level of Assistance required education posed no threat on the prevalence of stroke
measured by FAM
whereas socioeconomic status proved to be a
Disability Minimal Moderate Maximal Total significant factor with occurrence of stroke to be more
(%) (%) (%) (%)
among high income group. Engstram etal. (2002)5 also
No 2 0 0 0
gave the same statement that majority of people with
Mild 20 0 0 0
good income suffers with diabetes, hypertension and
Moderate 28 6 0 0
habit of smoking thus contributing factors of stroke. It
Severe 12 20 2 0
is also observed that more number of stroke sufferers
Very Severe 0 2 4 4
belonged to joint families and resided in urban areas.
Total 62 28 6 4

Table 12: Distribution of subjects in various levels of While examining the physical status of the subjects
disability according to Level of Dependence required on the ground of spasticity and balance, it was found
measured by MBI that 80% were suffering from mild to maximum level
Disability Minimal Mild Moderate Severe Total
of spasticity. Salem (2010)6 in his study determined 68%
(%) (%) (%) (%) (%) of subjects as spastic. In present study it was
No 2 0 0 0 0 established that 28% subjects had good and 20% had
Mild 8 12 0 0 0 poor balance. The results are similar with the finding
Moderate 0 26 8 0 0 of Tyson (2006)7 who in his study concluded that 25%
Severe 4 8 12 10 0 of the subjects had good balance and 75% had
Very Severe 0 2 2 4 2 considerable balance deficit following stroke. While
Total 14 48 22 14 2 examining the level of assistance it was found that 62%
of subjects required minimal assistance and 38%
12% were severely disabled following Ayurvedic
required moderate to maximal assistance even 1 year
and 6% following Homeopathic and traditional
after stroke. Also while examining the level of
treatment (Table 13). Among those who took
dependency it was found that 48% of the subjects were
physiotherapy, 22% were severely disabled and those
mildly dependent and 22% were moderately
who did not 10% were moderately, 12% severely and
dependent for the completion of their ADL’s.
6% were very severely disabled (Table 14).

Table 13: Distribution of subjects in various levels of It was found that motor disability owns the highest
disability according to treatment value which is similar to the results of Mercier et al. in
20018. Majority of women in the study suffered with
Disability Ayurvedic Homeopathic Traditional Nil
(%) (%) (%) (%) severe and very severe form of disability and majority
No 0 0 0 2 of men suffered with mild and moderate form of
Mild 6 2 4 8 disability. Jonathan et al. (2004)9 following his study
Moderate 10 4 12 8 stated that women were more prone to greater
Severe 12 6 6 10 disability owing to delay in seeking medical and
Very Severe 4 2 2 2 rehabilitative treatment and ignorance for self care
Total 32 14 24 30 activities. It is also observed that more severe form of
disability occurs among those dwelling in rural areas
Table 14: Distribution of subjects in various levels of
disability according to Physiotherapy received or not than those in urban areas with finding being consistent
with that of Sethi et al. in 200710. The results revealed
Disability Received (%) Not received (%)
that low and medium income group was more
No 2 0
disabled. Kapral et al. (2002) 11 studied that
Mild 20 0
socioeconomic status affects mortality and access to
Moderate 24 10
Severe 22 12 some health services after stroke leading to marked
Very Severe 4 6 residual disability.
Total 72 28

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 244 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Majority of subjects belonging to nuclear families
had mild to moderate form of disability while those
from joint families had moderate to very severe form
of disability and thus higher dependency on other
family members. It was found that more severe form
of disability exists among illiterate subjects, less severe
among literate ones.
In establishing the physical factors affecting the
level of post stroke disability, it was found that
disability increased with the level of spasticity and this
finding has been supported by Watkins (2002)12. The
balance status also generated similar results.
Acceptable and poor balance was associated with
moderate to very severe form of disability. Tyson
(2006)7 in his study also produced similar results. The
present study also determined that the assistance
required by the subject (FAM) and the level of
dependency (MBI) are directly proportional to the level
of disability (WHO DAS).
The majority of the subjects who did not receive
physiotherapy were suffering from moderate to very
severe form of disability and those who received had
no or mild form of disability and thus were living a
nearly independent life. Pound et al. (1994)13 also gave
similar results and stated that the impact of
physiotherapy is not confined to reducing physical
disability but may also affect well being. The study
focused on the fact that total 78% of subjects received
ayurvedic, homeopathic and other traditional forms
of treatment plus physiotherapy and 24% took only
ayurvedic, homeopathic and other traditional forms
of treatment and out of those 23% had moderate to
very severe form of disability (Table 13). This shows
that other forms of treatment did not bless any extra
visible or affective benefit to the victims and efficient
results of physiotherapeutic intervention as far as level
of disability is concerned.
CONCLUSION
The results of the study conclude that among
demographic factors except premorbid level of
education, all other factors affect the incidence of
stroke. The prevalence of stroke was more among
urban population but the post of disabilities were more
severe in rural dwellers. Male sufferers were living a
comparatively better life than females. The percentage
of motor disability was highest followed by social and
cognitive. Disability increased with the increase in level
of spasticity and decrease in balance status.
Physiotherapy proved to be a boon for patients as far
as level of disability is concerned.
47. Supreet Bindra--240--244.pmd 244
REFERENCES
1. Davidson. Principles and Practice of Medicine.
18 ed. New York: Churchill Livingstone. 1999;
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2. Anand K, Chowdhury D, Singh KB, Pandav CS
and Kapoor SK. Estimation of mortality and
morbidity due to strokes in India. J.
Neuroepidemiology 2001; 20(3): 208-11.
3. Ellekjaer H, Holmen J, Indredavik B and Terent
A. Epidemiology of stroke in Innherred, Norway,
1994 to 1996: Incidence and 30-Day Case Fatality
Rate. J. Stroke 1997; 8(11): 2180-2184.
4. Sackley CM, Baguley BI, Gent S and Hodgson P.
The use of a balance performance monitors in the
treatment of weight bearing and weight
transference problems after stroke. J.Stroke 1992;
78:907-913.
5. Engstram G, Berglund G, Hedblad B, Janson L,
Jerntop I and Rasmussen H. Geographic
distribution of stroke incidence within an urban
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risk factors. J. Stroke 2001; 32(5): 1098-103.
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7. Tyson SF, Tallis RC, Chillala J, Hanley M. and
Selley A. Balance disability after stroke. J. Phys
Ther 2006; 86(1): 30-8.
8. Mercier L, Rochette A, Audet T, Dubios MF and
Hacbert R. Impact of motor, cognitive, and
perceptual disorders on ability to perform
activities of daily living after stroke. J.Stroke 2001;
32(11):2602-8.
9. Jonathan W, Amanda K, Geoffrey A, Dewey P,
Donnan MD, Helen M, Richard A, Sturm PD,
Macdonnel MD, and Velandi S. Quality of life
after stroke. J. Stroke 2004; 35:2340.
10. Sethi N, Anand I, Ranjan R., Sethi P, and
Torgovnickn J. Stroke: The neglected epidemic,
an Indian perspective. The Internet Journal of
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11. Kapral MK, Mamdani M and Wang H. Effect of
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 DOI Number: 10.5958/j.0973-5674.7.3.101
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 245

Kinetic Chain Exercise for Patello Femoral Pain

Syndrome - A Randomised Control Study

Suresh Kumar T1, Leo Rathinaraj A S2, Jeganathan A3, Vignesh Waran Vellaichamy4
1
Assistant Professor, Maharashtra Institute of Physiotherapy, Latur, 2Lecturer, Department of Physical Therapy, COAMS,
University of Hail, Saudi Arabia, 3Professor, MAEER's Physiotherapy College, Talegaon, Pune, 4Lecturer, Santosh College of
Physiotherapy, Ghaziabad

ABSTRACT

Objective: The objective was to compare the effect of open kinetic chain exercise and closed kinetic
chain exercise in quadriceps strength and pain in patients with patella femoral pain syndrome.

Introduction: Patello femoral pain syndrome [PFPS] can be defined as retropatellar pain or peri
patellar pain resulting from physical and biochemical change in patella femoral joint. The patients
with patello femoral pain syndrome have anterior knee pain, which typically occurs during activity
and often worsens with descending stairs and also triggered by prolonged sitting. Patello femoral
pain syndrome is due to the degeneration in the articular cartilage of the knee cap. PFPS is the most
prevalent disorder involving the knee and can be misdiagnosed sometime as bursitis, meniscus, and
ligament instability. Osteoarthritis, chondromalacia patella produce more stress on the patella femoral
mechanism.

Materials & Methodology: After getting the ethical clearance for this study 30 patients with PFPS
were selected and randomized into 2 groups after due consideration of the inclusive and exclusion
criteria. The patients consent for this study was taken and documented. Procedure: Group A and
Group B subjects were given with open kinetic chain [OKC] and closed kinetic chain [CKC] exercises
respectively. The dosimetry of these exercises was 30 minutes duration every alternate day for 4
weeks. Data collected for statistical analysis included Maximal Isometric Voluntary Contraction
[MVIC] using surface EMG on Vastus Medialis [quadriceps muscle] and Pain by visual analog scale
[VAS] before and after exercise.

Result: Data collected were statistically analyzed using the SPSS 11 version for t-test. The paired t-
test value for both CKC and OKC shows that there is a significant improvement in the quadriceps
strength and pain reduction in both the groups. The unpaired t-test between the groups for quadriceps
interference [3.45] and pain score in VAS scale [2.89] with p value at 0.01 shows that closed kinetic
chain [CKC] exercise is better than the open kinetic chain [OKC] exercise in improving the strength
and reducing the pain among PFPS patients.

Conclusion: To conclude, though both OKC and CKC exercises are beneficial in PFPS patients, CKC
proved to be better than the OKC in improving the quadriceps muscle strength and reducing the
pain. This study proves this statement statistically with significance.
Keywords: Patello Femoral Pain Syndrome [PFPS], Open Kinetic Chain Exercise, Closed Kinetic Chain
Exercise, Kinetic Exercises

INTRODUCTION typically occurs with activity and often worsens with

Patello femoral pain syndrome [PFPS], a
retro-patellar pain or peri-patellar pain resulting from
physical and biochemical change in patella femoral
joint. PFPS patient complains anterior knee pain which
descending stairs and is triggered by prolonged sitting.
PFPS is one of the most prevalent disorders involving
the knee1. Patella, the largest sesamoid bone articulates
with femoral grove to form the patella-femoral joint.

48. Suresh Kumar--245--249.pmd 245 8/1/2013, 8:31 AM

 246 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Normal function of patellofemoral joint depends upon
passive stabilizer; the chief one is vastus medialis
muscle which realign the patella medially.
Insufficiency of this muscle leads to patella mal-
alignment, causing articular cartilage breakdown and
leading to patella femoral pain syndrome. The
symptoms of PFPS are caused by structural orbio-
mechanical changes of the joint, exacerbated by
activities such as going up and down stairs, sitting for
a prolonged period, squatting or kneeling, resulting
in increased compressive forces in the patella-femoral
joint. PFPS are also associated with patellar crepitus,
swelling, and joint blockage2.
PFPS may be caused by patellar malalignment,
increased Q angle, high or low patella, excessive
subtalar pronation, lateral rotation of the tibia, femoral
anteversion, knee valgus or varus, shortening of the
lateral retinaculum, muscle hamstrings and iliotibial
tract3. The inappropriate behavior of the patella can
cause pain in the anterior knee 4. Previous study
showed that the combination of factors, such as
abnormal lower limb biomechanics, soft tissue tension,
muscle weakness and excessive exercise may result in
increased stress on the cartilage and subchondral bone
leads to the patellar misalignment and resulted in the
development of pathology of PFPS5.
Quadriceps muscle is the main structure
responsible for activating the forces exerted on the
patella, which controls the position of the patella on
the femoral groove, medially by the oblique fibers of
vastus medialis [VM] and laterally by vastus lateralis
[VL]6. Vastus Medialis muscle is divided into two
portions, a proximal one called the vastus medialis
longus (VML) whereas the distal portion is the vastus
medialis oblique (VMO). Both these parts differs
anatomically, functionally, histochemically and also in
the pattern of innervation7. VMO originates mainly
from tendon of adductor magnus muscle and inserted
at an angle of 50-55 degrees in the longitudinal axis of
the femur8 and it is considered as the primary dynamic
medial stabilizer of the patella-femoral joint9.
Primary goal in treating a patient with PFPS is to
reduce the pain, improve the function and thereby
enhance their quality of life. Though management of
PFPS involves multidisciplinary approach like
pharmacological intervention, use of physical
modalities [cryotherapy, diathermy, TENS, cold
LASER], therapeutic exercises [strengthening,
stretching, mobilization] and behavioural treatment,
exercise to retrain the quadriceps muscle plays an vital
role in the management of PFPS.
48. Suresh Kumar--245--249.pmd 246
Kinetic chain is sequential activation of the
segments of the limb, allowing it to generate force,
stabilization of the limb and transfer force to the distal
end of the chain10. Open kinetic chain exercise [OKC]
is an activity in which the distal part of the end is not
fixed, but free 11, providing a motion segment in
isolation and usually considered as an exercise with
no weight bearing. Closed kinetic chain [CKC]
exercises involving multi-joint movements performed
with fixed distal extremity, often associated with
weight bearing 12. CKC exercises generate muscle co-
contraction of agonists and antagonists, in order to
provide greater articular surface13,14, producing still
lower shear load of the tibia, the compression force
increasing and decreasing the tibia-femoral
compressive forces near patella-femoral the
extension15.
Proprioception is also an influential factor in the
choice of these exercises, since it is believed that the
feedback is more efficient due to the compressive forces
of the body and the foot contact with the ground, and
reproduce functional movements commonly
performed activities of daily living16.
In addition several methods have reported patella
femoral pain syndrome, it is generally agrees that
patella femoral pain syndrome should be managed
initially by conservative rather than operative means.
The basis of conservative treatment is strengthening
of quadriceps and soft tissue stretching of quads
musculature. The most successful rehabilitation
program should emphasize progression to without
increasing symptoms keeping exercise intensity and
patella femoral stress low and repetition relatively high
will help to reduce pain in patella femoral pain
syndrome.
NEED FOR STUDY
Exercise to strengthening the quadriceps is
considered the best option for the treatment of PFPS.
Both CKC and OKC exercises are used to strengthen
the quadriceps muscle fibre and choosing this is still
confusing. Thus the current study is done to find a
solution and to identify the superiority among these
exercise programs.
MATERIALS AND METHODOLOGY
After obtaining the ethical approval for this study,
30 patients with PFPS attended the outpatient
physiotherapy department of YCRH, Latur were
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 247
divided into 2 groups with 15 patients in each by
simple random sampling method, after due
consideration to the inclusive and exclusion criteria.
Inclusion criteria were both sexes are included, age
between 18 to 35 years, VMO insufficiency, Patello
femoral pain syndrome patients. Exclusion criteria
were patients with fixed deformities, peri-patellar
subluxation and dislocation, fracture of patella, any
recent knee surgery, knee ligament injury, any intra
articular pathology, disorders of patella like bipartite
patella. The pathology, exercise program and its effects
were explained to these patients and their informed
consent for the study was taken and documented.
Evaluation: Before the evaluation, the subjects
signed an informed consent form. In the first and last
sessions, the following elements were evaluated:
electromyographic activity - Maximal Isometric
Voluntary Contraction [MVIC] and pain. The lower
limb showing the greater clinical complaint was chosen
for evaluation. Pain was measured using a visual
analogue scale [VAS] with values between zero and
10cm. EMG muscular activity was detected using an
8-channel EMG equipment interfaced with a computer
and data collection software – Neuro Perfect plus with
sweep -10ms, sensitivity 100 micro volts, low cut
100Hz, high cut 5 KHz, pulse / sec - 1, pulse width -
0.02ms. The surface electrodes [SEMG] were placed
on the muscle motor point, located by electrical
stimulation, to allow the reproduction of this study
after treatment. Surface electrodes were positioned on
the muscle belly, 2 cm apart, and fixed with adhesive
tape. The EMG activity of the VM muscles was
measured during three repetitions of isometric knee
extension and documented [MVIC].
Table 1: Comparison of the outcome measures between group A and group B.
Evaluation Parameters Group
Maximal Voluntary Isometric Group A
Contraction [MVIC]
Group B
Pain Group A
Group B
DISCUSSION
In open kinetic chain exercise, the quadriceps
muscle works in isolation, increasing the
patellofemoral compressive forces 17. In this type of
exercise, the center of gravity is in front of the knees,
so that the strength in flexion is greater than 90 degrees
48. Suresh Kumar--245--249.pmd 247
Intervention: Group A given with Open kinetic
chain exercise of 30 minutes for 4 weeks with warm
up and cool down exercise. Patient advised to do High
sitting quadriceps exercise [90 to 0 degree knee
extension], standing Hamstring curl, Straight leg
raising with holding for 5 seconds.
Group B given with Closed kinetic chain exercise
for 30 minutes for 4 weeks with warm up and cool
down exercise. Patient advised to do mini squats,
forward lunge, lateral step ups, standing wall slides.
Data & Statistical analysis: The VAS values were
measured in the first [before] and last [after] sessions,
obtaining values between zero and 10 cm. The EMG
signal was processed by means of the software and
the maximum EMG activity – MVIC was selected with
the MUAP of the rectified signal calculated in the
selected period. The mean of the three attempts was
analyzed. The collected data were then statistically
analyzed using the SPSS version 11 for ‘t’ test with the
level of significance set at á<0.01.
RESULTS
The application of the paired t-test for the outcome
exhibited a highly significant reduction in the pain and
improvement of MVIC in both OKC [group A] and
CKC [group B]. The Analysis of the post intervention
parameters between OKC and CKC group exhibited a
highly significant [á < 0.01] reduction in the pain and
improvement of MVIC in CKC [group B] as compared
to the OKC [group A] (Tab.1).
Mean Value ± SD Result [Un-paired ‘ t’ value]
Pre-test Post-test
26.8 ±4.64 32.3 ±4.05 3.45 [Highly significant with
p < 0.01]
26.7 ±4.30 37.3 ±3.75
6.05 ± 0.69 2.95 ± 0.16 2.89 [Highly significant with
p < 0.01]
5.90 ± 0.81 2.1 ± 0.70
to 0° extension. Up to 30º, the angle between the forces
is too small to generate high compressive stress
between the patella and the condyles and the contact
area of articulating surface decreases from 90° to 0°.
With a larger force and a smaller contact area, there is
increased stress in the articulating surface that can
delay the recovery.
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 248 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
According to Pattyn E the last degrees of knee
extension exercise in open kinetic chain, provide lower
articular contact and therefore less instability. There is
also higher patellofemoral stress, since the contact
angle is less and therefore the compressive forces
although smaller, are distributed over a smaller contact
area, increasing the stress18.
In CKC type of exercise there is greater amplitude
of the signal of the VMO compared with the open
kinetic chain exercises. However, the signal VMO is
lower than that of VL, both in open and closed kinetic
chain19. To selectively strengthen the VMO muscle,
which seeks not only the range of motion that shows
more activity, but also offers greater stability, higher
compressive strength and greater activation in relation
to the lateral components.
Selfe J et al. (2006) recorded improvement in
passive proprioceptive test evaluated during 40° knee
flexion and 50° knee extension in patients with PFPS
at the end of the isokinetic treatment of 6 weeks20 . In
this study, improvement was observed in concentric
phase proprioceptive senses of patients in both groups
at the end of the active proprioception evaluation at 0-
45° knee flexion angle. The improvement in
proprioceptive senses provided by CKC exercise
programs may be associated with the increase in
muscle strength and the decrease in patellofemoral
joint reaction strengths.
Based on literature review & statistical analysis
results of our study shows that the subjects who
participated in Group B shown good improvement in
quadriceps strengthening and reduce pain than
Group A.
The reason for improving quadriceps strength in
closed kinetic chain exercise is that they are having
less shear force but more compressive force. Closed
kinetic chain exercise is a multi joint movement with
controlled co-contraction synergist and antagonistic
muscle which increases sensory motor co-contraction.
CKC exercises contains more eccentric muscle work
and because it is known that eccentric exercise develop
more tension in the muscle and there by obtain greater
effect.
In addition, it has been suggested that closed kinetic
chain exercises are safer than open kinetic chain
exercises because the former place minimal stress on
the patellofemoral joint in the functional range of
motion. Therefore, patients with patellofemoral pain
48. Suresh Kumar--245--249.pmd 248
syndrome may tolerate closed kinetic chain exercises
better and consequently may exhibit better functional
results after such a rehabilitation program21. The reason
for reduction of pain close kinetic chain exercise may
be the increases in circulation to local area which clears
metabolites away from that area and causes
stimulation of endorphins there by reducing pain.
CONCLUSION
Based on the statistical analysis the results of these
study shows that there was a significant improvement
in both the groups between pre and post exercise
session. Further between groups analysis shows that
the subject who participated in CKC [group B] has
shown more reduction of pain than OKC [group A].
So this study concluded that closed kinetic chain
exercise were beneficial for improving quadriceps
muscle strength and pain reduction.
Conflict of Interest: There is no conflict of interest
between the authors
Source of Funding: Nil
Ethical Clearance
This research study is given clearance under Ethical
committee headed by Prof Dr. Koti Reddy, Principal,
Maharashtra Institute of Physiotherapy, Latur.
ACKNOWLEDGEMENTS
The authors are thankful to Prof Dr.Koti Reddy
M.P.T, Principal Maharashtra Institute of
Physiotherapy for kindly providing laboratory
facilities to carry out these works. A special thanks to
my senior Dr.Lenin, for being the source of inspiration.
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G.B .Functional and EMG responses to a physical
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2. Tunay, V.B.,et al. Treatment of patellar tracking
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3. Martin MC et al. Patellofemoral morphometry in
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4. Doucette SA, Goble EM. The effect of exercise on
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syndrome. Am J Sports Med 1992;20:434-40.
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8. Thatiana Lacerda Nobre et al: Comparison of
Exercise Open Kinetic Chain and Closed Kinetic
Chain in The Rehabilitation of Patellofemoral
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Medicine and Diagnostics 2012, 2(3): 7-11
9. Donell S. Patellofemoral dysfunction-Extensor
mechanism malalignment. Curr Orthop
2006;20:103-111.
10. Escamilla RF et al. Biomechanics of the knee
during closed kinetic chain and open kinetic chain
exercises. Medicine and Science in Sports and
Exercise. 1998; 30 [4]: 556 – 569.
11. Fagan V, Delahunt E. Patellofemoral pain
syndrome: a review on the associated
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13. Boucher, J.P., King, M.A., Lefebvre, R., and Pépin,
A. Quadriceps femoris muscle activity in
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of Sports Medicine. 1992;20(5): 527-32.
14. Connolly KD, Differences in patellofemoral
contact mechanics associated with patellofemoral
pain syndrome. Journal of Biomechanics. 2009;
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15. Fleming Bc, Oksendahl H, Beynnon Bd. Open-
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 DOI Number: 10.5958/j.0973-5674.7.3.102
250 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of Mechanical Low Back Pain on Postural Balance

and Fall Risk

Ibrahim M M1, Shousha T M2, Alayat MS3

1
Associate Professor, Faculty of Physical Therapy, Physical Therapy Department for Musculoskeletal Disorders, Cairo
University, Department of Physical Therapy, Faculty of Applied Medical Sciences, Umm al QURA UNIVERSITY
2
Associate Lecturer, Physical Therapy Department for Musculoskeletal Disorders, Faculty of Physical Therapy,
3
Lecturer, Physical Therapy Department for Basic Sciences, Faculty of Physical Therapy, Cairo University

ABSTRACT

Objective: To evaluate the effect of mechanical low back pain on postural balance and fall risk.

Materials and Method: This study was conducted on 20 mechanical low back pain (MLBP) subjects
compared with 20 norms using the Biodex Balance System to evaluate balance as the dependent
variable including postural stability, fall risk and limits of stability.

Result: There were significantly differences between both groups in the postural stability test
(p=0.0008), fall risk test (p=0.0093) and limits of stability test (p= 0.0001) revealing the increase in fall
risk with MLBP.

Conclusion: It could be concluded that balance exercises are essential and should be considered
during rehabilitation of LBP patients.
Keywords: Low Back Pain, Fall Risk, Balance, Biodex

INTRODUCTION of displacement under physiologic loads so there is

Low back pain (LBP) is a common medical problem.
There is a 50–70% chance of an individual having LBP
pain during his or her lifespan. (1) With a prevalence of
about 18% in the industrialized societies. (2) The Exact
causes for most LBP conditions are not known.
Although negative social interaction (for example,
dissatisfaction at work) has been found to relate to
chronic LBP, a significant portion of the problem is of
mechanical origin. It is often referred to as clinical
spinal instability. (3) However several patients with low
back pain are referred to physical therapy, which starts
with a thorough evaluation involving observation
and/or measurement of range of motion, strength,
overall function, posture, and body mechanics. (4,5) So
it is not easy to rule out the source of LBP because it is
often complicated by psychological, social and
economic factors.
The symptoms of mechanical low back pain
(MLBP) are normally aggravated by Physical activity,
specially bending, extending, twisting and lifting. (6, 7)
Clinical spinal instability is not well understood. White
and Panjabi defined clinical instability of the spine as
the loss of the spine’s ability to maintain its patterns
no initial or additional neurologic deficit, no major
deformity, and no incapacitating pain.(8) Several studies
show that LBP patients have poorer postural stability
than healthy subjects.(9,10) The maintenance and control
of balance, in static or dynamic situations, is an
important requirement for physical and daily
activities.(11) So well-functioning postural balance is
essential to maintain normal daily life (12).
Postural stability is a subdivision of postural
balance defined by the ability to maintain a specific
posture and repeatedly described by changes in center
of pressure (COP).(13) In contrast to the previous,
Kathleen et al, showed that no difference was found
between unilateral low back pain patient and control
group in limits of stability test (14).
However good balance is needed for carrying out
normal activities of daily living, it is important for
physical therapists to evaluate balance in patients with
potential impairments to keep balance during normal
activities, a persistent relation is required between
central and peripheral components of the nervous
system that controls the center of gravity within the
base of support (15,16), therefore, the purpose of the

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 251
present study was to evaluate the effect of mechanical
low back pain on postural balance and fall risk in an
attempt to avoid the falling complications which are
dangerous including fractures and head trauma.
MATERIALS AND METHOD
Twenty MLBP subjects were compared with twenty
matched norms using The Biodex Balance System to
evaluate balance as the dependent variable including
postural stability, fall risk, limit of stability. During the
test each subject was instructed to keep a cursor on
the screen of the Biodex system, directly in the middle
while balancing on the platform, after adoption of a
proper position on the platform and accordingly results
were conducted.
Collection of Sample:
Forty subjects aged from 20 to 30 years participated
in this study. The mechanical low back pain patients
(MLBP) group consisted of twenty patients (mean age
21.85 ± 0.93 years) while the control group consisted
of twenty subjects (mean age 21.8 ± 0.83 years). The
Biodex Balance System was used to evaluate balance
as the dependent variable including postural stability,
fall risk, limit of stability. During the test each subject
was instructed to keep a cursor on the screen directly
in the middle while balancing on the platform, after
adoption of a proper position on the platform.
The Biodex Balance System (BBS)
The Biodex Balance System (BBS) (Biodex Medical
Systems, Inc., Shirley, New York) (fig1) was used to
evaluate balance indicators as the dependent variables.
The platform of BSS allowed movements in a 360
degrees range and up to 20 degrees of tilt at any point
in the range. The BBS uses a circular platform that is
free to move about the anterior-posterior (AP) and
medial-lateral (ML) axes simultaneously.
This BBS measures the degree of tilt about each axis
during dynamic conditions. The BBS level indicates
the stiffness or stability of the foot platform, with level
12 being the most stable and level 1 the most unstable.
The stability settings of 12 through 1 allow the foot
platform a full 20 degrees of deflection from level in
any direction. The platform is interfaced with
computer software, which enables the device to serve
as an objective assessment of balance.
The fall risk test result includes over all stability
index (OSI) score. The high score in the index indicates
49. Tamer cairo--250--254.pmd 251
poor balance and increased fall risk. The BSS provides
visual feedback that allows individuals to relate to and
reproduce specified motion patterns
Testing Procedures
The platform balance task required the subject to
stand barefooted in a comfortable upright position. The
participants instructed to adjust feet positions until
they found a position at which they were able to
maintain a moving point in the center or near the center
of the cir-cles, with the difficulty level of 6 resulting in
a moderately unstable platform. Then the platform was
locked and the feet placement was recorded and saved
for assessing trials in all testing sessions. Foot position
coordinates were constant throughout the test sessions.
During Postural stability and fall risk tests the subject
was instructed to keep the cursor directly in the middle
of the screen while balancing on the platform. During
the test, the subjects tried to maintain their balance by
themselves looking at a target on a screen and keeping
a dot marker at the center of the target. Three 20-second
practice trials were performed and a 10-second rest
period was allowed between trials. The Biodex limit
of stability (LOS) test prompts participants to move a
cursor, by leaning toward a target while standing on
the fully unstable platform (level 6). Participants were
instructed to “complete the test as accurately as
possible. The LOS test measures the time and accuracy
with which participants transfer their estimated COG,
moving the cursor to intercept each of 8 successive
targets on the display screen. The participant reaches
the target by leaning and returning to the center
position before the next target is selected and displayed
on the screen. The test is complete when all 8 targets
have been reached.
OBSERVATION & RESULTS
Table 1: Comparison between groups in postural
stability test.
Postural stability
Mean±SD T sig
Normal 1.07±0.4 3.6 0.0008
Patients 1.8±0.8
Table 2: Comparison between groups in Fall Risk test
Fall Risk
Mean±SD T sig
Normal 1.9±0.6 2.7 0.0093
Patients 3.3±2.2
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 252 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Table 3: Comparison between groups in Limit of
Stability test.
Limit of Stability
Mean±SD T sig
Normal 37.8±12.1 4.5 0.0001
Patients 22.8±8.1
DISCUSSION
The etiology of LBP in most patients is not known,
as mentioned earlier. It may be hypothesized that a
certain percentage of these patients may have
suboptimal neuromuscular control, especially under
dynamic conditions. The results of this study suggest
there are differences in balance reactions for those who
suffer from mechanical low back pain compared to
those with no history of low back pain. At the time of
the study, all of the subjects with low back pain
subjectively had relatively low levels of pain; their
balance reactions were different from their pain-free
counterparts. A few studies have specifically looked
at this aspect of LBP. An increase in body sway of low
back pain patients has been previously reported by
Byl and Sinnott, (12) who demonstrated that subjects
with low back pain tended to keep their center of force
posterior compared with healthy subjects. They
suggested that this posterior shift causes a relaxation
of the subject’s trunk muscles, an increase in lumbar
lordosis, and greater compressive forces to the
vertebrae and neural foramina (12).
It is unknown whether this shift is a cause or a result
of the impaired balance, but this postural
compensation may cause greater mechanical stress and
muscle imbalance, thus continuing the progression of
low back pain. Further studies mentioned that, subjects
with low back pain had an outwardly low level of
dysfunction, yet they subjectively felt that chronic low
back pain was adversely affecting the quality of their
lives (17).
They suggested that patients who have a higher
level of pain and/or a lower level of function would
have more severely impaired static balance, resulting
in greater postural sway and a continuing cycle of
muscular imbalances, chronic pain, and dysfunction.
,they also suggest that subjects with low back pain
would most likely show deficits in dynamic balance
reactions compared with normal subjects as well.(17)
Another study revealed that it is possible that impaired
balance is present in just a subgroup rather than in all
LBP patients, meaning that some patients should not
be expected to experience any change in balance.(18).
49. Tamer cairo--250--254.pmd 252
As no reference values exist, we have no firm
knowledge on this point.
In that study of concurrent and predictive validity
of postural balance in LBP patients, no association was
found between Center of pressure measures and pain,
fear of pain, and physical function. Correlations were
not clinically relevant, and most were even non-
significant. Furthermore, no differences were found
in Center of pressure measures at baseline when
comparing patients with clinically relevant
improvements and patients with no change in back-
specific function and pain. (18)
It is certain that LBP subjects present deficits in the
sense of position for of the hip region, and then they
evoke an ankle strategy to keep the standing posture.
The influence of muscle fatigue due to change in trunk
position combined to pain would may lead to
increased instability in low back subjects, even for
those subjects with chronic pain.(19)
Considering LBP as the only factor related to
changes in postural control, this change in normal
standing posture leads to increase muscle activation
of back muscles, which will result in an increased
fatigue rate. These changes in the pattern of back
muscle activation have been suggested as a strategy
to limit spine movements regardless of the pain
intensity.(20) Harding et al,(21) designed a 30-sec 1-leg
stance test for low back pain patients in which the
number of times the non-weight bearing foot touched
the ground and the elapse time to the first touch was
recorded. Their test showed poor test-retest reliability.
These findings are in line with previous work showing
the largest differences between CLBP patients and
healthy subjects. It is important to rule out that pain
itself is not directly responsible for the observed
modification of the control of balance.
The absence of acute pain in our patients during
testing conditions does not necessarily rule out the
possibility of some activity arising from nociceptive
afferents,(22) Muscle pain can cause marked decrease
in position sense, (23) possibly through increased
presynaptic inhibition of muscle afferents at spinal
level or by a down-regulation of cortical proprioceptive
processing.
Granat et al, suggest that direction of systems
involved in sway angle may be an important indicator
of instability, especially in patients with pathology (24).
It has been claimed that balance dysfunction in patients
with CLBP may be due to altered proprioceptive
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 253
feedback from the lumbar spine. (25, 26) This suggestion
has been made on the basis of trunk exact CLBP
assessment rather than measures of whole body
performance.(27)
Sensory dysfunction may increase the threshold to
movement detection at the level of the ankle joint.
Ankle muscle input and, possibly, cutaneous input
from the foot sole contributes to the control of human
erect posture. (28) It seems then reasonable to suggest
that when the proprioceptive system is stressed small
differences in sensory discrimination in the CLBP
group, compared to the healthy group, may become
important for sway control.
Finally it should be pointed out that care must be
taken when evaluating individual CLBP patients since
a wide range of balance responses exists between
individuals and balance exercise is essential and
should be considered during rehabilitation of LBP
patient.
Conflict of Interest
There are no financial and personal relationships
with other people or organizations that could
inappropriately influence this work.
FUNDING
This research received no specific grant from any
funding agency in the public, commercial, or nonprofit
sectors.
Ethical Clearance
This research work was approved by the physical
therapy department council, faculty of applied medical
sciences, Umm Al-Qurra University.
ACKNOWLEDGMENT
The authors would like to express their deepest
appreciations to all participants for their sincere
cooperation.
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5. Battie M.C, Cherkin D.C, Dunn R, Ciol M.A,
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7. Rensick D.K, Choudhri T.F, Dailey A.T, Groff
M.W, Khoo L,Matz P.G, et al. Guidelines for the
performance of fusion procedures for
degenerative disease of the lumbar spine .Part
8:lumbar fusion for disc herniation and
radiculopathy. J Neurosurg: spine. 2005; 2:
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8. White, A.A. Panjabi,M.M: Clinical biomechanics
of the spine, 1990; 2nd ed, JB Lippincott,
Philadelphia, PA,.
9. Della Volpe R, Popa T, Ginanneschi F et al
Changes in coordination of postural control
during dynamic stance in chronic low back pain
patients. Gait Posture. 2005; 24(3): 349–355
10. Ruhe A, Fejer R, Walker B. Center of pressure
excursion as a measure of balance performance
in patients with non-specific low back pain
compared to healthy controls: a systematic review
of the literature.2011; 3: 358-68
11. Massion J, Alexandrov A, Frolov A. Why and how
are posture and movement coordinated? Prog
Brain Res 2004;143:13–27.12
12. Byl N.N, Sinnott P.L. Variations in balance and
body sway in middle-aged adults. Subjects with
healthy backs compared with subjects with low-
back dysfunction. Spine 1991;16(3): 325–330.
13. Pollock A.S, Durward B.R, Rowe P.J, Paul J.P.
What is balance? Clin Rehabil 2000; 14(4):402–406.
14. Kathleen M. Alexander, M.S, Tanya L. Kinney
LaPier. Differences in Static Balance and Weight
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Subjects With Chronic Unilateral Low Back Pain.
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15. Hain T.C, Hillman M.A. Anatomy and
physiology of the normal vestibular system. In:
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16. Umphred D.A. Neurological Rehabilitation, St.
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17. Maribo T, Schiøttz C.B, Jensen L.D, Andersen N.T,
Stengaard P.K. Postural balance in low back pain
patients: criterion-related validity of centre of
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18. Gill, K.P, Callaghan M.J. The measurement of
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19. Brumagne S, Cordo P, Verschueren S.
Proprioceptive weighting changes in persons
with low back pain and elderly persons during
upright standing. Neurosci Lett. 2004; 366(1):
63–66.
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21. Harringe, M.L, Halvorsen, K., Renstro¨m, P,
Werner, S. Postural control measured as the center
of pressure excursion in young female gymnasts
with LBP or lower extremity injury. Gait and
Posture 28 2008; 1:38-45.
22. Rossi A, Decchi B, Groccia V, Della Volpe R,
Spidalieri R. Interactions between nociceptive
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and non-nociceptive afferent projections to
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23. Rossi A, Decchi B, Ginanneschi F. Presynaptic
excitability changes of group Ia fibres to muscle
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24. Granat M.H, Barnett R.W, Kirkwood C.A,
Andrews B. Technique for calculating the
direction of postural sway. Med Biol Eng Comput
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25. Mok N.W, Brauer S.G, Hodges P.W. Hip strategy
for balance control in quiet standing is reduced
in people with low back pain. Spine 2004;
29:E107–12.
26. Brumagne S, Cordo P, Lysens R, Verschueren S,
Swinnen S. The role of paraspinal muscle spindles
in lumbosacral position sense in individuals with
and without low back pain. Spine 2000; 25: 989–
994.
27. Mientjes M.I, Frank J.S. Balance in chronic low
back pain patients Compared to healthy people
under various conditions in upright standing.
Clin Biomech, 1999; 14:710–6.
28. Kavounoudias A, Roll R, Roll J.P. Foot sole and
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 DOI Number: 10.5958/j.0973-5674.7.3.103
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 255

Alteration in Pelvic Inclination & its Correlation with

Lumbar Lordosis in Pregnant Women

Madhura M Inamdar1, Unnati Pandit2, Bharati V Bellare3

1
Lecturer, Dept of Physiotherapy, MAEER'S Physiotherapy College, Talegaon (D), Pune, 2Associate Prof , Dept. of
Physiotherapy, Padmashree Dr. D.Y. Patil University, Nerul, Navi Mumbai, 3Retd Professor & HOD, Dept of
Physiotherapy, L. T. M. Medical College, Sion, Mumbai

ABSTRACT

Background: A cross sectional comparative study to explore whether pelvic inclination angle [PIA]
alters during third trimester & correlates with associated alteration if any in lumbar lordosis angle
[LLA] in primigravid women

Method: PIA & LLA were measured with pelvic inclinometer & Flexirular respectively in a convenient
sample of 100 Primigravid healthy women carrying single foetus in third trimester of pregnancy
within age group of 21.61 + 2.29 years & 100 healthy age matched [22.07 + 2.41years] nulliparous
controls . SPSS 16 soft ware was used to calculate unpaired t value with 95% confidence interval for
comparing PIA & LLA respectively between two groups and Intra-group Correlation coefficient [r
value ] between PIA & LLA in both groups .

Result : PIA in study & Control groups was found to be 3.340 2.57 & 5.140 2.82 respectively where
as LLA was 37.750 12.87 & 44.880 12.36 respectively. Comparison of PIA & LLA between groups
showed highly significant decrease [p < 0.0000 & p < 0.0001respectively ] in both variables in study
group suggesting posterior tilt associated with lumbar flattening. In both groups Intra-group
correlation showed moderate correlation between PIA & LLA [ r=0.66 in study group & 0.6 in
controls]

Conclusion: Study showed significant decrease in PIA & LLA in Pregnant women. The LLA &
PIA correlated moderately in both the groups.
Keywords: Lumbar Lordosis Angle, Flexirular, Pregnancy, Pelvic Inclination, Pelvic Inclinometer

INTRODUCTION
There are wide ranges of postural and physiological
adaptations to the endocrine, musculoskeletal,
circulatory and metabolic changes experienced by
women during pregnancy. The changes of pregnancy
are chiefly the direct result of the interaction between
hormonally mediated changes in collagen and
involuntary muscles due to action of relaxin,
progesterone, estrogen and cortisol; the growth of the
foetus resulting in consequent enlargement and
displacement of the uterus; the increase in body and
adaptive changes in the centre of gravity and posture.1
Postural adaptations appear to be a natural
consequence of pregnancy. The most obvious physical
features in pregnancy influencing the woman’s posture
are the alterations in the body mass and the consequent
changes in the centre of gravity, retention of fluid, and
laxity in supporting structures. Apart from the growth
of the foetus, the woman’s body mass increases
because of growth uterus, placenta and membranes
and the increased volume of amniotic fluid and
circulating blood. 2
Postural adaptations to these physiological changes
usually entail in alteration in the loading and alignment
of, and muscle forces along the vertebral column and
in the weight bearing joints. 3
Conflicting findings are documented in the
literature about alterations in the lumbar lordosis.
Some studies report about the aggravated LLA 4, 5, 6, 7,
where as some report about the flattening of

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 256 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
LLA8,9,13,14, Colliton10 stated that lumbar lordosis remains
the same or increases only slightly. Standerson 11
reported increase in lumbar lordosis during pregnancy,
but this is a misconception. Gilleard12 reported that no
significant effect of pregnancy on the upper-body
posture, although there was a tendency in some subjects
for a flatter thoracolumbar spinal curve in sitting as
pregnancy progressed.
It was hypothesized that alterations in the LLA
are associated with the alteration in the PIA. Levin &
Whittle 16 investigated whether the manoeuvre of
altering the PIA while standing is effective in changing
the LLA. Their findings showed an average PIA of 11.4
degrees increased by an average of 10.8 degrees
[p<0.001]with anterior pelvic tilt & decreased by an
average of 9.0 degrees with posterior pelvic tilt .
Since our earlier findings15 supported the
literature evidence of flattening of lumbar spine during
advance pregnancy, the research question was whether
the Lumbar flattening is also associated with the
compensatory posterior pelvic tilt –i.e decrease in PIA.
The secondary research question was to verify
whether the PIA correlates with the LLA.
MATERIAL & METHOD
It was a cross sectional comparative exploratory
study. 1000 pregnant women in the third trimester
registered for delivery & attending Out patient
department of the Obstetrics & Gynaecology unit of
the LTMG hospital, Sion ,Mumbai were screened
within a period of 15days . A convenient sample of
100 healthy primi-gravid women carrying single foetus
with age group of 18 to 25 [21.61 + 2.29 ] years was
selected as a study group . An equal number of age
matched healthy controls [22.07+2.41 years] were
selected from the working women‘s hostel ,Matunga
[w] & known college going students. After the
approval of the ethical committee, of the LTMM
College, the informed consent was obtained from all
the subjects included as samples.
A mechanical pelvic inclinometer was used for the
assessment of pelvic tilt. Reliability & validity of the
pelvic inclinometer is well documented. Crowell RD17
studied the intra-tester and inter-tester reliability and
validity of measures taken with a pelvic inclinometer.
The intra-class correlation coefficient (ICC) for repeated
measures of the pelvic inclinometer fixed to a
mechanical model was 0.99. In measures of 20 male
subjects by three testers, the ICC for intertester
reliability was 0.95 and the range of ICCs for intratester
50. Unanti Pandit--255--259.pmd 256
measures was 0.92-0.96. Measures by the inclinometer
had a high degree of reliability compared with the
criterion roentgenographic measure, ICC = 0.93.
Martha L Walker 18 measured of pelvic tilt with an
inclinometer as used in their study had a high degree
of reliability when repeated measurements with one-
minute rest intervals were taken by the same examiner.
A Lumbar flexible ruler (flexi-rular) was used to
measure the lumbar lordosis
Reliability & validity of flexirular is also widely
documented. Hart et al 19 found high reliability of
flexirular, with ICC 0.97 which is well supported in
the literature. 20, 21 , 22
The assessment of LLA & PIA was conducted in a
relaxed standing posture in a room which provided
good privacy . After exposing the area to be tested ,
each subject was instructed to assume natural standing
posture with weight distributed evenly & feet parallel
to each other and slightly apart. Each foot was
approximately in line with the respective acetabulum.
The upper limbs were maintained in the normal
position, hanging relaxed and by the side of the body.
The subject was asked to look straight ahead.
For measuring pelvic inclination, Right Anterior &
posterior superior iliac spines were palpated and
marked. Pelvic tilt (pelvic inclination) was measured
by placing one arm of inclinometer over Anterior
superior iliac spine[ASIS] and other arm was placed
over Posterior superior iliac spine[PSIS] and the
reading over the dial was noted 17
For the determination of the LLA, the spinous
processes of L1 & S 2 were marked as upper & lower
bony land marks respectively as reference points based
on study done by Link et al 22. The subject was asked
to expose Lumbar area & was made to assume bare
footed relaxed standing position with her back facing
the investigator. The spinous processes of the spine
were palpated. First the lower point S2 was marked
with a marker pen at the intersecting line joining both
PSIS. Then palpating six segments proximally, L1 was
marked. The flexible ruler was placed against the
subject’s bare back, spanning the length between L1
and S2. The curve of the ruler, representing the lumbar
curve, then was traced onto paper for further analysis,
noting where the two reference points for L1 and S2
were located. The method for determining the degree
of lumbar curvature (theta)was measured as done by
Hart and Rose 19. Two points on the curve, representing
L1 and S2 were connected by a line (l) a perpendicular
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 257

line (h) representing the height of the lumbar curve,

bisected line l. Length of each line was determined in
millimetres (mm) and the values were inserted into
the formula:

Ø= 4 X arctan (2h/l) 22

SPSS -16 soft ware was used for statistical

calculation to compare PIA & LLA respectively Graph 1. Moderate correlation between PIA & LLA in control
group [r=0.6 ]
between two groups by using unpaired t test at 95%
confidence interval & for correlating[ r value] intra-
group LLA with PIA for both the groups.

FINDINGS

The mean age of the Control & Study groups

matched well [ t =1.3837, p=0.1680 ,standard error of
difference = 0.332]
Graph 2 : Moderate correlation between PIA & LLA in study
Table 1. presents the details of statistical analysis group[r=6.66]
of the PIA & LLA in both the groups

Table 1. Comparison of Pelvic tilt & Lumbar lordosis

During pregnancy the corpus luteum releases the
between Control & Study groups
hormone Relaxin that softens the ligaments by
Groups Pelvic Lumbar Lordosis altering the ground substance and by digesting the
Tiltn=100 angle n=100
collagen fibres. Effects of relaxin account for the
Study group 3.34 ± 2.57 37.75 ± 12.87
postural changes associated with pregnancy 8, 23.
Control 5.14 ± 2.82 44.88 ± 12.36
Pregnant women may gain as much as quarter of their
t value 4.7177 3.9958
body weight. Their center of gravity (COG) shifts,
p Value * 0.0000 *0.0001
requiring changes in posture to maintain balance.
Standard Errorof 0.382 1.784
difference
These changes are not same in all women.24

* Highly significant The postural behaviours adapted by pregnant

The PIA in the study & Control groups was found
to be 3.34 ± 2.57 & 5.14 ± 2.82 respectively .The
comparison showed highly significant decrease of PIA
[ t = 4.7177 ; p = 0.0000] in the study group. Where as
the LLA in study group was found to be 37.75 ± 12.87
were as the same in Controls was 44.88 ± 12.36
.Comparison of LLA showed highly significant
decrease [ t =3.9958;P= 0.0001] in the study group.
Thus the findings suggested that the postural
adjustment was done by the concomitant flattening
of lumbar spine & associated posterior pelvic tilt by
primigravid women in advance pregnancy
women during quiet standing must maintain
equilibrium about the vertebral and hip joints.8 In non-
pregnant individuals this involves balancing the flexor
moments generated by both super-incumbent weight
and the activity of the iliopsoas muscle with the
extensor moments generated by the activity of the
trunk and hip extensor musculature. During pregnant
status, based on the anatomical arrangement of the
lumbodorsal fascia, a relaxation of this tissue would
tend to straighten out the lumbar spine. Similarly, since
the vertebral ligaments preload the intervertebral disc,
their relaxation may also lead to straightening of the
lumbar spine.8

Graph 1 & 2 show graphical presentation of Colliton[1996] 10 suggested that during pregnancy,
firstly, pregnant women can, in fact compensate at least
correlation between PIA & LLA between Controls &
in part for the additional flexion moment by counter-
Study group respectively. The Intra-group Pearson
balancing it through extension of the upper trunk, head
Correlation Coefficient between PIA & LLA showed
and neck. Apparently pregnant women compensate
moderately positive correlation in both the groups
for the flexion moment by hip extension rather than
(Study group r = 0.66 & Controls r = 0.6).
lumbar spine extension.

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 258 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Hinman[2003-04] 21 reported that the Pelvis is in
posterior tilt and sways forwards in relation to the
stationary feet causing the hip joint to extend. The effect
is equivalent to extending the leg backwards with the
pelvis stationary. With posterior pelvic tilt, the lumbar
spine flattens. Also there is backward deviation of the
upper trunk.. This observation is also supported by
Britnell et al[2005] 3 ,. Hinman 21 further reported that
due to this the long curve in the thoraco-lumbar region
is mistakenly referred to as lordosis. (The term sway
back posture is appropriate label and requires that the
word ‘sway back’ is not used synonymously used with
the word ‘lordsis’).
In our study, lumbar lordosis and pelvic inclination
was reduced significantly in pregnant women when
compared with normal control subjects. These findings
are supported by Snijder (1976) 13, Moore (1990) 8 and
Ostgaard (1993)9, Standerson (1996)11 In the studies
by Levin & Whittle[1996] 16 pelvic movement was
shown to be associated with change in the LLA;
posterior tilt causing decrease & visa versa with
Anterior pelvic tilt which was supported by Franklin
et al[1998] 7 Our findings on reduced PIA [Posterior
pelic tilt] is supported by Okanishi et al [March 2012]25
in their study on 15 pregnant women, 17-34weeks into
pregnancy standing posture was evaluated in the
saggital plane with static digital pictures Two angles
were measured with image analysis soft ware i]-
between trunk & pelvis ,ii]-between the trunk & lower
extremity . They found out that 11 out of 15 women
showed lumbar kyphosis with sacral posterior
inclination.
Our findings showed moderate intragroup
correlation between PIA &LLA. Which was supported
by Raphaël Vialle (2005) 26, Yasukouchi (1995) 27, Penny
(2000)28 respectively
This study supported our previous findings that
the LLA gets flattened during advanced pregnancy.
Further,.
CONCLUSIONS
This study showed statistically significant
decrease in both, the PIA as well as LLA in the gravid
women .Thus supported our previous findings15 of
lumbar flattening as a postural alteration during
advance pregnancy & also accepted our hypothesis
of associated decrease in PIA causing posterior tilt .
where as correlation between PIA & LLA in both the
groups was found to be moderately positive
50. Unanti Pandit--255--259.pmd 258
ACKNOWLEDGEMENT
We are very much thankful to the dept of
Obstetrics & gynaecology ,LTMG hospital for referring
their patients for our study .We also thank the
volunteers who participated in our study as a control
group. .
Conflicts of Interest: Nil
Source of Funding: Nil
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10. Julie Colliton (1996) Back Pain and Pregnancy:
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 259
12. Wendy L, Gilleard J and Mark M Brown (1996)
Structure and function of the abdominal muscles
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Ottawa, Canada :670-67
14. Hummel P -Changes in posture during
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de Amsterdam Academisch Pragshrift.
15. Pandit U.N, BellareB.V, Yardi S.S.[2009]: Study on
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of IAP,
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Tillman LJ (1994) Intratester and intertester
reliability and validity of measures of innominate
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 DOI Number: 10.5958/j.0973-5674.7.3.104
260 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Barriers Associated with Community Access by Stroke

Patients in Indian Population

Mohammad Usman Akhtar1, Shubha Arora2, Man Mohan Mehndiratta3

1
Tutor (OT), Deptt of Rehab, HIMSR, Jamia Hamdard, 2Assistant Professor, Deptt of Rehab, HIMSR, Jamia Hamdard,
3
Director, Janakpuri Super-specialty Hospital, New Delhi

ABSTRACT

A study was done to perform a survey on unilateral stroke survivors to determine their perceived
barriers to exercise participation and community access. 91 subjects with unilateral stroke of mean
age 52.87 were selected through convenient sampling from different government and non government
hospitals in New Delhi. Outcome measures used for assessments were 1) Barriers to physical activity
and disability survey, 2) Folstein Mini Mental Status Examination. Major barriers reported by our
participants were lack of transportation followed by lack of accessible facility and least reported
barriers were lack of interest and too old to exercise. Data was analyzed and P-value interpreted was
0.05 which indicates that our study was significant.
Keywords: Barriers, Community Access, Unilateral Stroke, Assistive Devices

INTRODUCTION with a physical disability. 4 Physical activity

Stroke is a leading cause of disability that results
not only in persistent neurological deficits, but also
profound physical deconditioning that propagates
disability.1
Exercise is normal human function that can be
undertaken with a high level of safety by most of the
people, including stroke survivors. Many stroke
patients will not have equipments or facilities in their
homes to sustain interest in an exercise program in the
long term they will need to seek assistance, equipments
and facilities in the community. To enhance exercise
compliance the issue of social isolation will need to be
actively addressed and resolved.3
Tasks such as transferring from a wheelchair to an
automobile, ascending a ramp or walking with braces
can be become major obstacles for individuals aging
Corresponding author:
Mohammad Usman Akhtar
Tutor (OT)
Deptt of Rehabilitation Sciences
Hamdard Institute of Medical Sciences and Research,
Jamia Hamdard, New Delhi-110062
Office Phone: 011-26059681
Mobile: 9891810989, 8860069786
E-mail: usman.akhtr@gmail.com
participation among people with stroke and other
disabling conditions is substantially lower than in the
general population. Inadequate amounts of exercise
can accelerate a person’s functional decline and limit
his or her ability to work, recreate, and engage in
community events. 5, 6 Studies of leisure activities
persuaded by stroke patients have found transport to
be one of the factors hindering participation in
activities outside the home.7 Options for exercise and
recreation are often limited by numerous personal (e.g.,
motivation, self efficacy) and environmental or facility
barriers (e.g., inaccessible programs, equipments, and
services offered in community recreation facilities). A
systematic examination of the personal and
environmental /facility mediators of physical activity
in persons with stroke requires a better understanding
of the contextual factors associated with this
population’s participation in physical activity.
Recommendations developed for the general
population are likely to be effective for individuals
with stroke since reduced mobility, health conditions
associated with stroke, and existing barriers to
community access often limit these individual
opportunities to engage in physical activity.5 this study
examined the multidimensional nature of barriers to
physical activity reported by people with stroke.

51. Usman Akhtar--260--264.pmd 260 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 261
RATIONALE
This study will help to know why number of stroke
survivors is less in rehabilitation department.
Secondly limited work has been done in India about
the barriers that are faced by unilateral stroke survivors
to participate in exercise programs or community
events.
This study will also help rehab professionals to
build a structured community based exercise program
that will incorporate more number of stroke survivors
and will focus in their long term adherence to the
program.
The Aim of this study was to perform a survey on
unilateral stroke survivors so as to determine perceived
barriers with exercise and community access
METHODOLOGY
Research design: Survey
Sample design:
Sampling type: Convenient Sampling
Sample size: 91 subjects
Source: various community and government hospitals
Site of study: G.B. Pant Hospital, New Delhi
L.N.J.P Hospital, New Delhi
HAHC Hospital, New Delhi
AIIMS, New Delhi
Time period of data collection: 5-6 months
Age Group: 30-70 years
Inclusion Criteria
• Subjects not below 30 years of age and not more
than 70 years of age.
• Subjects should be able to walk at least 50 feet
without assistance.
• Subjects should be post stroke at least 3-6 months.
• Subjects using or not using an assistive aid such
as cane, walker, brace, and/or wheelchair were
also included.
• Score of 24 or more on the mini mental state
examination.
51. Usman Akhtar--260--264.pmd 261
Exclusion criteria
• Score of 23 or less on the mini mental state
examination.
• Subjects should not have primary disability (other
major medical, psychiatric, psychological disorder)
unrelated to stroke.
• Subjects having speech related deficits/disorders.
Outcome Measures
1. Barriers to Physical Activity and Disability Survey
The barriers to physical activity and disability
survey (B-PADS) were used to collect data on the
types of barriers (personal or environmental/
facility) that individuals with disabilities
experience related to exercise participation.
The B-PADS consists of 34 items, 31 of which have
two response choices: yes or no. The remaining 3
items are open-ended, and 2 of these are follow-
up questions that ask participants to explain a
previous “yes” response.
2. Folstein Mini mental state examination.
PROCEDURE
Consent regarding the use of B-PADS was taken
from the Author
Subjects (n=91) of unilateral (Rt or Lt) stroke were
selected using convenient sampling from various
community and government hospitals to determine
their perceived barriers associated with community
access and exercise in India.
Before participating in a study, written consents
were taken from subjects or caregivers.
At first all the participants were screened according
to FMMSE, subjects scoring 24 or more on FMMSE
were selected.
They were assessed on the basis of age, gender,
marital status, assistive devices used, side affected and
annual house hold income.
These subjects were asked series of questions
related to BPADS n=91 were divided into two groups
based on annual household income. Barriers to
physical activity participation were than tabulated and
compared between lower and higher income groups.
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 262 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Data collected was than analyzed on the basis of
SPSS17 statistical software.
RESULTS
Data were summarized with the descriptive
statistics of mean, percentage and cumulative
frequency values for each item and analyzed with the
graphical methods of bar-graphs and pi-charts.
subjects followed by “health concerns prevents me
from exercising” (33%), “pain that prevents me from
exercise” (31.9%) and “lack of energy” (24.2%). Barriers
least reported were patients elderliness i.e., subjects
reported “I am too old” to exercise 12.1% and “Lack of
interest” 7.7%.

Table 1. illustrates/depicts demographic

parameters.

Total of 91 stroke subjects were selected (mean age

52.87 yr; SD ± 11.5) out of which 80(87.9%) were
married, 1(1.1%) unmarried, 9(9.9%) widowed and
1(1.1%) divorced. Many of them used assistive devices
such as cane 20(22%), walker 7(6.6%), wheelchair
1(1.1%) and 63 (70.3%) did not reported any use of Our findings represented that out of 91 subjects
assistive devices. Out of 91 subjects, 45(49.5%) were 58(63.7%) showed willingness to participate in an
Right side affected and 46(50.5%) were Left side exercise program. Whereas 83(91.2%) of all subjects
affected. When analyzing socio economic status annual felt that an exercise program would help them in
household income were divided into lower and higher treatment (recovery). 63(69.2%) out of 91 were
income groups which included 65(71%) and 26(29%) encouraged for post stroke rehabilitation exercises, and
participants respectively. about 29(31.9%) of the subjects were aware of the
fitness facility in the community and about same
Table 1 illustrates/depicts demographic parameters. number of subjects were afraid to leave there homes
Characteristics No of subjects Percentage
after stroke disability.
Marital Status By applying the Pearson chi square test, the P-value
Married 80 87.9 was evaluated to be 0.057. Which is statistically nearest
Unmarried 1 1.1 to the threshold expectance level i.e., 0.05. Therefore
Widowed 9 9.9 the data can be considered clinically significant.
Divorced 1 1.1
Assistive Devices Used DISCUSSION
Cane 20 22
Walker 7 6.6 Findings in our study revealed that a group of
Wheelchair 1 1.1 predominantly males (78%) and females (22%) with
None 63 70.3 stroke who resided in and near to the national capital
Side Affected territory of Delhi reported multiple barriers to
Right 45 49.5 participate in an exercise program or to community
Left 46 50.5 events.
Annual Household Income
The few major barriers reported were lack of
Lower Income <100000 65 71
transportation to a fitness facility, lack of accessible
Higher Income >100000 26 29
facility, not knowing where and how to exercise and
Histogram below describes barrier of physical cost associated with exercise program which was
activity reported by participants which represents why supported by Rimmer.et.al, they found that cost
patients might not involve in exercise program. The associated with joining a fitness facility and
most common barriers reported in decreasing transportation to a fitness facility were major barriers
hierarchy were –”lack of transportation” (71.4%), “lack reported by the participants.5 lack of time, was also
of accessible facility” (68.1), “don’t know how to one of the major barrier in our study, however the most
exercise” (61.5%), and “don’t know where to exercise” of the participants were either not employed or retired,
(57.1%). “Lack of time” and “lack of attendant” were time constrain as a major barrier to exercise was also
another major barriers reported by about 40.7% of the reported in two other studies (Rimmer.et.al 2000,

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 263
Mackeen.et.al 1983)21, 26 , these findings reveal the
perception of those who were self employed and still
manage to work post-stroke.
Our findings were, in general consistent with
previous researches (creveston.et.al 2000) that involved
a predominantly African-American group of women
with physical disabilities, including stroke. In their
study, the common barriers were transportation
(60.5%), and not knowing where to exercise (57.9%).21
Large no of our participants also reported that they
are unaware of the appropriate fitness facilities in the
neighborhood (68.1%). One of the most significant
barriers faced by many individuals aging with a
physical disability is the lack of information about
programs that are available in their community (Riley
& Wang).14
An environmental barrier reported by nearly 32%
of our participants was similar to what Lee found in a
population of older Australian women, where 34%
were reluctant to go out alone.21 other barriers reported
by our subjects were health concerns stopping from
exercise (33%). O’ Neil and Reid reported barrier data
on a older population of Canadians (55-90 yrs), 28 they
found 40% of their sample mentioning illness or
handicap as a barrier to exercise participation,
Rimmer.et.al also found the same percentage in their
sample when they evaluated health concerns as a
barrier for exercises.21
12% of subjects in our study reported too old to
exercise, increasing age may be associated with
decreased outcome and may become a barrier to
physical activity. Rimmer also reported Lack of energy
as a major barrier, however in our study we have 24.2
of them felt it as a barrier.
The B-PADS is a relatively short instrument that
can help professionals identify these key barriers to
exercise participation. Identifying these barriers will
help the professionals formulate a home or
community- based exercise plan founded on the
participant’s response pattern. B-PADS was used by
James Rimmer in 2008 on 83 adults to determine
perceived barriers to participation in physical activity
and it was validated in 2001 by Riley & Rimmer and
had reliability of 0.62.19
The perception of these barriers that our
participants with stroke reported to their exercise
participation helped us to make several suggestions
51. Usman Akhtar--260--264.pmd 263
for helping individuals with stroke and their caregivers
overcome these barriers and rehabilitation
professionals to make a customized post-stroke
community-based rehabilitation program.
First, healthcare professionals must systematically
identify barriers to exercise when referring patients
with stroke from rehabilitation to community based
exercises. Second, while our participants expressed in
participating in an exercise program (63.7%) they were
unable to participate because of the structured exercise
programs, the preponderance of research on the fitness
levels of people with stroke indicates that they are
unlikely to be participating in a structured physical
activity program and as a group, are considered
severely deconditioned 1,3,11.
Finally customizing physical activity programs for
persons with stroke is clearly needed to remove as
many personal and environmental/facility barriers as
possible. Barrier identification and removal should be
based on the various impairments and/or activity
limitations associated with stroke severity.
Environmental assessment tools that measure barriers
in the built environment (e.g., home neighborhood,
community fitness center) are available to help
professionals identify barriers before initiating an
exercise program for this population 5, 29.
The combined identification and removal of
personal and environmental/facility barriers may
effectively tailor the program to the individual and his
or her environment and enhance the likelihood that
he or she will successfully participate in a structured
exercise program. Programs needs to be tailored to suit
Indian communities especially poor’s.2 significant
improvements in the fitness were obtained by Nicola
in 2000 when significant barriers to participation were
eliminated (i.e., free transportation, no cost off the
program) 20.
RECOMMENDATIONS
The aging of the population and the resulting
expected increase in stroke survivors accentuates the
need for further research to define strategies to
eliminate barriers to exercise to improve health, fitness
and functions.
Further study to evaluate the correlation between
age, gender, and disability status and income groups
with perceived barriers to exercises by participants can
be done.
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 264 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
Grouping of the age can also be done to yield better
results.
Other precise standardized tools can yield much
better results.
ACKNOWLEDGEMENT
The authors are thankful to Mr. James H Rimmer
for his tremendous support in providing the B-PADS
and the Dean, Dr. (Prof) Jain, Deptt of Rehabilitation,
HIMSR, Jamia Hamdard for providing necessary
permission and facilities to carry out this work. We
would also like to thank Dr. Ona P Desai, Head, Deptt
of Rehabilitation, HIMSR, Jamia Hamdard for her
continuous support and guidance throughout the
study.
Conflict of Interest: I have shown the article to my
both other guides before submitting it to you, and it is
after their permission that I am sending it for the
publication therefore it does not have conflict of any
means between the Authors.
Source of Funding: This study was part of the
curriculum for the award of Degree of M.O.T and
therefore it was self funded.
Ethical Clearance: this is a survey it does not have
a treatment protocol that is followed on human subjects
and was only a observational study, therefore ethical
clearance was not needed.
REFERENCES
1. Ivey FM, Hafer-Macko CE, Macko RF, Exercise
rehabilitation after stroke. NeuroRX 2006; 3
(4):439-50
2. Jeraraj D. Pandian, Velandai Srikanth, Stephen J
Read. Stroke. 2007; 38: 3063-69.
3. Gordan NF, Gulanick M, Costa F, Fletcher G,
Franklin BA, Roth EJ, Shephard T; Physical
activity and exercise recommendations for stroke
survivors. Circulation. 2004; 109 (16): 2031-41.
4. Rimmer JH, Exercise and physical activity in
persons aging with a physical disability. Phys
Med Rehabil Clin’ N Am. 2005; 16 (1): 41-56.
5. Rimmer JH, Wang E, Smith D. Barriers associated
with exercise and community access for
individuals with stroke. JRRD 2008; 45(2):
315-322.
6. Kelly Jo, Kilbreath SL, Davis GM, Zeman B,
Raymond J. Cardio respiratory fitness and
walking ability in sub acute stroke patients. Arch
Phys Med Rehabil 2003; 84 (12): 1780-85.
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7. PA Logan, JRF Gladman and KA Radford. The
Use of Transport by stroke Patients. Br JOT 2001;
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8. Ariane B, Sascha R, Anita B, Martien L, Frans V.
How predictive is the MMSE for cognitive
performance after stroke? J Neurol 2010; 257:
630-637.
9. Sarah Mc Adam. Stroke survivors in rural areas
seek better local service. Commission for Rural
Communities, News Release 2010.
10. Annie MC and Sandy M. Delivering evidence
based outdoor journey intervention to people
with stroke: Barriers and enablers experienced by
community rehabilitation teams. BMC Health
Services Research. 2010, 10:18.
11. Shaughnessy M, Resnick BM, Macko RF. Testing
a model of post-stroke exercise behavior. Rehabil
Nurs. 2006; 31(1): 15-21.
12. Rimmer JH. Use of the ICF in identifying factors
that impact participation in physical activity/
rehabilitation among people with disabilities.
Disabil Rehabil. 2006; 28(17):1087-95.
13. Hammel J, Jones R, Gossett A, Morgan E.
Examining barriers and supports to community
living and participation after a stroke from a
participatory action research approach. Stroke
Rehabil 2006.
14. Rimmer JH, Riley B, Wang E, Rauworth A,
Jurkowski J. Physical activity participation
among persons with disabilities: barriers and
facilitators. Am J Prev Med. 2004; 26(5):419-25.
15. Chu KS, Eng JJ, Dawson AS, Harris JE, Ozkaplan
A, Glyfadottir S. Water-Based exercise for
cardiovascular fitness in people with chronic
stroke: A randomized controlled trial. Arch Phys
Med Rehabil. 2004; 85(6):870-74.
16. Rimmer JH, Riley B. Validation of the Barriers to
Physical Activity and Disability Survey for older
individuals with disabilities. 2001; Oct(5).
17. Rimmer JH, Riley B, Creviston T and Nicola T.
Exercise training in a predominantly African-
American group of stroke survivors. Med Sci
Sports Exerc. 2000; 32(12):1990-96.
18. Rimmer JH, Rubin SS, Braddock D. Barriers to
exercise in African American women with
disabilities. Arch Phys Med Rehabil. 2000: 81(2);
182-88.
19. O’Neil KO, Reid G. Barriers to physical activity
by older adults. Can J Public Health 1991; 82:
392-396.
20. Rimmer JH, Riley B, Wang E, Rauworth A.
Development and Validation of AIMFREE:
Accessibilty Instruments Measuring Fitness and
Recreation Environments. Disabil Rehabil. 2004;
26(18):1087-95.
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 DOI Number: 10.5958/j.0973-5674.7.3.105
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 265

Immediate effects of Taping of Upper Back on Peak

Expiratory Flow Rate (PEFR) in Stable Chronic
Obstructive Pulmonary Disease (COPD) Subjects

S Kimothi1, V K Nambiar2, B Yadav3

1
Master in Clinical Physiotherapy, International School of Physiotherapy. GEF-CU Collaborative Programme,
MSR Nagar, Bangalore, 2Associate Professor, Dept. of Physiotherapy, M.S.R.M.T.H, Bangalore, 3Lecturer, International
School of Physiotherapy, GEF-CU Collaborative Programme, MSR Nagar, Bangalore

ABSTRACT
Background: The activation of respiratory muscles is influenced by a change in gravitational force
and length-tension variations. Many studies have shown the influence of posture on respiratory
muscles in normal adults. The proprioceptive facilitation of musculoskeletal system has shown
improvement in pulmonary functions of normal adults. The lack of evidence on the effect of posture
in COPD subjects suggested a need to see the immediate effects of proprioceptive facilitation of
upper back on peak expiratory flow rate (PEFR) through taping on stable COPD subjects.
Objectives of the study: To determine the PEFR values pre and post-taping in experimental group, to
determine the PEFR values pre and post-taping in control group, to compare the PEFR values pre and
post-taping within the groups and to compare the PEFR values pre and post-taping between the groups.
Methodology: 34 stable COPD subjects were recruited through convenience sampling. All the subjects
were randomly allocated to experimental group (17) and control group (17). The PEFR was measured
by peak flow meter as baseline data for both the groups. The experimental group was given
proprioceptive facilitation through taping of upper back by instructing the subjects to erect their
spine and retract their shoulders whereas control group was given sham taping. The PEFR for both
the groups was measured pre and post taping.
Results: Paired t test was done to compare the PEFR values within the groups and independent t test
was used for comparison between the groups.
Interpretation: On analyzing the test, significant results were seen in the experimental and control
group. The experimental group showed significant improvement in PEFR value(p<0.024) when mean
difference of the two groups were compared.
Conclusion: The results suggest that proprioceptive facilitation of upper back through taping in
COPD subjects improves pulmonary function.
Keywords: PEFR, posture, respiratory muscle activity in COPD

INTRODUCTION recent study showed an increase in prevalence of

Chronic obstructive pulmonary disease (COPD) is
ranked 13th in leading cause of burden of disease
worldwide and it is expected to become 5th by 20201. A
Corresponding author:
Bhagwathi Yadav
Lecturer
International School of Physiotherapy
GEF-CU Collaborative Programme
MSR Nagar, MSRIT Post, Bangalore-54
bhagwathi@gmail.com
COPD in Tamil Nadu by 2.44% and the prevalence was
seen higher in biomass fuel users and 2 times higher
in women who spend more than 2 hours in kitchen1.
The disease is known for early mortality rate and high
death rates over the worldwide. The prevalence of
COPD depends on geographical area, age and sex2.
According to GOLD classification, COPD can be
defined as ‘a disease characterized by the airflow
limitation that is not fully reversible’. The airflow
limitation is progressive and associated with abnormal
inflammatory response of the lungs to noxious

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 266 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
particles or gases3 and is often associated with co
morbidities.
According to Trevor4 cigarette smoking is one of
the major risk factor in COPD, but a variety of other
factors like exposure to bio mass fuel plays
contributing factor for the risk in developing COPD
.In COPD there is an increased inflammatory response,
which is associated with the increase production of
mucus, cycles of resolution, fibrosis and proteolysis.
The pathology of COPD involves large central airways
known as chronic bronchitis and lung parenchyma
known as emphysema. The diaphragmatic (costal)
fibers transmit the abdominal pressure to pleural space
and expand the abdominal rib cage to adjust the
increased lung volume during inspiration. The
dynamics of chest wall in normal adults is well
coordinated between respiratory muscles (i.e.
diaphragm, abdominal muscles and rib cage muscles).
In subjects with COPD, thoracic cage is placed in hyper
inflated position, caused by the loss of elastic recoiling
of the lungs5. There is an increase in the anterior-
posterior diameter of the chest wall. The positioning
of the ribs changes from an oblique to a more
horizontal position 6. Thus hyperinflation causes
change in chest wall geometry by making it more barrel
shaped. There is also a reduction in zone of apposition
and operating length7, which alters the diaphragm
function and causes an increase in mechanical load and
work of breathing8. Schroeder 8 also reported that
alteration in diaphragm function leads to use of
accessory muscles to increase their lung volume. The
accessory muscles used by COPD patients are mainly
- latissimus dorsi9, levator scapulae10, upper trapezius
and stenocleidomastoid11.
Dias5 suggested that use of accessory muscles leads
to alteration in the posture, bringing about an increase
in thoracic kyphosis , increase in the elevation of
scapula and protraction of head and there have been
high prevalence of pain located majorly to chest,
shoulders, neck and thorax in COPD patients.
Sharp12suggested sitting with forward bending of the
trunk as one of the major change in posture of COPD
patients, which can be closely related to the features
mentioned in above reference.
There are structural changes occurring in
diaphragmatic fibers due to mechanical workload,
leading to the alteration in the ratio of type 1 and type
2 fibers in the muscles and increases the type 1 fibers
that makes it highly resistance to the fatigue13. The
expiratory muscles are recruited both at rest14 and
52. veena kiran---265--269.pmd 266
during activity in COPD patients. The recruitment of
abdominal muscles occurs in COPD patients because
it prevents the distortion of the ribs and helps in
unloading of diaphragm. The abdominal muscles also
play an important role in movement of the chest wall
during breathing by reducing the end expiratory
volume13. Macklem13 suggested a thesis in a point:
counterpoint study which reported that the dynamic
hyperinflation and reduced oxidative capacity are
secondary factors resulting from the increase in energy
demand combined with a decrease in supply caused
by the excessive recruitment of expiratory muscles. In
COPD patients, there is a reduction in strength and
endurance of abdominal muscles, which suggests that
they have a poor control on their posture. Thus there
is a workload on the accessory muscles of respiration,
which leads to the change in their
posture10.Kera15suggested that the gravitational force
and the length-tension of the respiratory muscles
change with the variation in the posture. Kera15also
concluded that in standing position, the activity of
internal oblique muscle increases in both inspiration
and expiration and expiratory reserve volume is
reduced as compared to other positions. John 16
suggested that erecting the spine through
proprioceptive facilitation enhances respiratory
muscular function and improves PEFR in normal
adults. Barrett17 reported that abdominal muscles
activity was more in standing position than in supine
and also concluded that the lowest load required to
activate the abdominal muscles is in 90-degree head-
up position, which means the threshold for activation
of abdominal muscles is low. This shows that by
erecting the upper back there is increase in respiratory
muscle activity of abdominal muscles, which improves
the pulmonary function.
Thus the use of accessory muscles and weakness
of respiratory muscles leads to poor control and
alteration in the posture of COPD patients. It can be
also said that forward bending of the trunk is the most
preferable position for COPD patients as it enhances
the expansion of upper thoracic cage, but this position
causes an overload on the body and initiates a vicious
cycle of increased fatigue and dyspnea 10 .
Proprioceptive facilitation of posture effects the activity
of respiratory muscles and the minimum load required
to activate the abdominal muscle is 90degrees head
up position. This suggests that the standing with erect
spine posture increases the activity of abdominal
muscles and improve the pulmonary functions of
abdominal muscles in normal subjects. However, the
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 267
evidences for the effect of posture on pulmonary
functions in COPD patients are very rare. Therefore
the need of the study was to find the effect of
proprioceptive facilitation of upper back on PEFR in
COPD patients.
MATERIALS AND METHOD
Materials Used: Peak flow meter was used to
measure the PEFR. Rigid leucoplast tape was used for
taping of upper back.
34 clinically stable COPD subjects were recruited
through convenience sampling from MS Ramaiah
Memorial Hospital and the hospital nearby it. The
subjects were recruited based on Inclusion criteria: -
Male individuals of 30 years or above diagnosed as
stable COPD with no history of lower respiratory tract
infection or pneumonia in the last 3 months. All the
subjects were asked to perform the pulmonary
function test to obtain their FEV1/FVC value or the
previous test value, which the patient had undergone,
was taken in the study. The subjects recruited for the
study were in mild to moderate stage of COPD based
on GOLD classification of stages of COPD. Individuals
with allergy to taping, other types of lung diseases or
neurological disorders and clinical history of scoliosis,
any spinal or cardio-thoracic surgery, ankylosing
spondylitis and fixed spinal deformity were excluded
from the study.
Procedure of data collection: An ethical clearance
was obtained from the ethical committee of M.S.
Ramaiah Medical College. Male COPD patients
satisfying the inclusion and criteria were selected for
the study. The purpose of the study was explained and
an informed consent was obtained from the subjects.
The clinically stable COPD patients were recruited in
the study through convenience sampling. An
assessment chart was performed on each sample prior
to the allocation to the groups. The digit number on
the assessment sheet randomly allocated the subjects
to two different groups. The sheets with odd numbers
were considered as experimental group and even
numbered sheets as control group. 17 samples were
recruited in each group. PEFR was measured for the
samples in each group, pre and post-taping of upper
back. The samples of experimental group actively
erected their spine and retracted their scapula in a
standing position following the demonstration of the
movement by a physiotherapist. The tape was pre -
tensioned and applied bilaterally from T1 spinous
process to T12 spinous process and from the center of
52. veena kiran---265--269.pmd 267
the spine of both scapulae, diagonally to T12 spinous
process. The taping for the control group was sham
taping in which subjects were asked to erect their spine
and no movement was performed at scapula. The
taping procedure was same as the experimental group.
The subjects were asked to stand in their normal
posture during the pre taping measurement of the
PEFR in both the groups. The procedure for
performing the test for the measurement of the PEFR
was explained to the samples prior to the data
collection in which they were instructed to inspire the
air from their nose and then they were instructed to
exhale the air out as forcefully and maximally with
maximum effort by holding the mouth piece of the
peak flow meter in the mouth as tight as possible to
avoid any leakage of air. No instructions were given
during the procedure of the test and the best of the
three trials was recorded.
Statistical analysis: Student paired t-test was used
to compare the PEFR values within the group.
Independent sample t test was used to compare the
homogeneity for demographic data (age, height and
weight) and baseline data (i.e. PEFR and FEV1/FVC)
between the groups. The difference in PEFR value, pre
and post-taping in both the groups were compared by
student unpaired t test. The confidence interval was
95% in both the groups. p<0.05 was considered as
statistically significant.
FINDINGS
The two groups were matched for age, height, and
weight as shown in Table 1. The comparison of baseline
data i.e. FEV1/FVC and PEFR value in Table 2 of both
the groups shows the p>0.05 which suggest that the
baseline data were matched in both the groups.
comparison within the group showed significant
increase (p<0.05) in PEFR value after taping in
experimental group and the paired t test done for the
comparison of data within the control group showed
significant decrease in the PEFR value after taping as
shown in Table 3.
Table 1: Comparison of demographic data (age, height,
and weight) between the two groups
Experimental Control P value
group group
Age in years 58.88±6.42 57.53±5.08 0.501
Height in cm 164.29±3.85 162.71±3.60 0.223
Weight in kg 70.41±18.37 63.41±13.24 0.212
The above table shows p>0.05 for (age, height, and weight) which
suggests that the two groups were matched for demographic data.
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 268 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 2: Comparison of baseline data (FEV1/FVC and CONCLUSION

PEFR) between the two groups.
The results of the present study concludes that the
Experimental Control P value
group group proprioceptive facilitation of upper back by taping can
FEV1/FVC (%) 59.16±2.57 58.57±2.25 0.487
enhance the posture in individuals with COPD subjects
Pre-taping 281.76±59.50 247.65±57.83 0.100
and can improve the peak expiratory flow rate.
PEFR(l/min)
ACKNOWLEDGEMENT
The above table shows p<0.05 which suggests that the baseline
data was matched for both the groups.
I owe my sincere thanks to Prof Savita Ravindra,
Table 3: Comparison of PEFR value within and Course Director for the support and encouragement.
between the groups (pre and post-taping) and the My gratitude to Dr. Uma Maheshwari (Department of
comparison of the difference in both the groups.
Chest Medicine), M.S. Ramaiah Medical College for
PEFR(l/min) Experimental Control P value referring the patients for the study. I wish to express
group group my sincere thanks to Dr. Suresh K P (Statistician), for
Pre-taping 281.76±59.50 247.65±57.83 0.100 providing technical assistance and statistical guidance
Post taping 290.59±63.88 240.00±60.83 0.024* for the study. .I would like to express my gratefulness
Difference 8.823 -7.647 <0.001** to all the Patients who contributed their valuable time
95%CI 4.80 to12.84 -11.06 to-4.23 - towards the study.
P value <0.001** <0.001** -

The table shows a significant improvement (p=0.024) in REFERENCES

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differences of two groups showed significant improvement in
PEFR value in the experimental group.
Graph 1: The comparison of PEFR value between
and within experimental and control group after
taping.
The graph shows improvement in PEFR value,
post-taping in the experimental group.
Table 3: The comparison of the PEFR value pre and
post-taping between the groups showed a statistical
significant change (p=0.024) in PEFR value in
experimental group. On comparing the differences in
experimental and control group, it showed statistical
significant improvement in the experimental group
(p<0.01).Effect size of 2.20 (Very Large effect) of taping
was seen in experimental group when compared to
control group, which is statistically significant.
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 DOI Number: 10.5958/j.0973-5674.7.3.106
270 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Functional Status in Post-CABG Patients Following

Physiotherapy- A Retrospective Analysis

Vinod K Ravaliya
MPT, K. M. Patel Institute of Physiotherapy, Karamsad, Anand, Gujarat, India

ABSTRACT
Background of objectives: Following CABG, various pulmonary complications may result with
significant affection of functional recovery of the patients. This adds into the cost of treatment,
prolonged length of stay in the hospital, increased morbidity and mortality . Therefore present study
was undertaken to determine the efficacy of physiotherapy treatment in functional recovery of the
patients following Coronary artery bypass grafting surgery.
Materials & Method: This was a retrospective study, total 65 participants' data were considered for
the analysis, which was retrieved from the medical record department of Shree Krishna hospital. The
demographic status, physiotherapy treatment program, functional recovery, average walking distance
and length of stay in the hospital were analyzed.
Results: In the present study, the medical record of 65 subjects (84% male and 16% female) were
analyzed and average of walking distance, flight of stairs and length of stay was recorded. All the
subjects were given preoperative physiotherapy which included chest physiotherapy in the form of
deep breathing exercise, thoracic mobility exercise, forced expiratory technique and incentive
spirometry as well as post operative physiotherapy regimen taught. Out of 65 subjects, 90% (n=58)
had no post operative complications and 10% (n=7) had eventful CABG with associated complications
like cardiac arrhythmias in 3 patients, uncontrolled diabetes in 1 patients, long term ionotropic support
in 2 patients and pleural effusion in 1 patient etc. The average length of stay of the subjects in hospital
following uncomplicated CABG was 6 PODs and 90% of the subjects were discharged by 6th POD.
Conclusion: It had been concluded that all the subjects with uneventful CABG (80%) following
physiotherapy became functionally independent on 6th POD, whereas subjects with eventful CABG
(10%) on 11th POD.
Keywords: CABG, Functional Status, Post-operative Day, Length of Stay

INTRODUCTION Several complications are associated with CABG

surgery, commonly pulmonary complications like
When the heart is at ease, the body is healthy.
atelectasis, pneumonia and pleural effusion along with
Cardiovascular disorders are the leading cause of
circulatory complications like deep vein thrombosis
morbidity and mortality accounting for almost 50% of
and postural hypotension. There are certain negative
all deaths annually.1 Coronary heart disease is the most
physiologic consequences associated with bed rest
common type of the cardiovascular disease in India
like; decreased plasma and ventricular volume, resting
with the prevalence range from 1.3 to 4.6 million, with
and maximum stroke volume, maximum cardiac
an annual incidence of 0.5 to1.8 million. It is caused
output, maximal oxygen uptake along with increased
by risk factors like sedentary life style, male gender,
heart rate at rest and submaximal levels of activity,
excessive alcohol consumption, chronic smoking, long
venous compliance, and loss of muscle mass, strength
term stress and a positive family history of heart
and endurance.12
attack at an early age.2
Postoperative exercise program is the mean of
CABG is the preferred treatment for CAD involving
optimizing the surgical results and exercise capacity,
left anterior descending artery(LAD), left circumflex
return to work and quality of life in patients who have
artery(LCX), right coronary artery(RCA), to relieve
undergone bypass surgery.12 Immediate post operative
angina and reduce the risk of death from coronary
phase is also called phase 1 cardiac rehabilitation,
artery disease.4

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 271

which is beneficial in certain aspects like
reconditioning the patient sufficiently enough to allow
him or her to resume customary activities, decreasing
the risk of sudden cardiac arrest or reinfarction,
limiting the physiologic effects of heart disease,
enhancing psychological status of the patients which
in turn helps to improve overall quality of life. 1
Therefore to reduce the morbidity resulting from the
surgical intervention, physiotherapy is found to be
very effective in its prevention in immediate post
operative phase.
This program begins while patients are still in the
hospital. It includes a visit by a member of the cardiac
rehabilitation team, education regarding the disease
and the recovery process, personal encouragement,
and inclusion of family members in classroom group
meetings. In the coronary care unit, assisted range-of-
motion exercises can be initiated within the first 24-48
hours. Low-risk patients should be encouraged to sit
in a bedside chair and to begin performing self-care
activities (eg, shaving, oral hygiene, sponge bathing).
On transfer to the step-down unit, patients should, at
the beginning, try to sit up, stand, and walk in their
room.1
Subsequently, they should start to walk in the
hallway at least twice daily either for certain specific
distances or as tolerated. Standing heart rate and blood
pressure should be obtained. Walking, often with
assistance, is resumed, with a target heart rate of less
than 20 beats above the resting heart rate and an RPE
of less than 14. Starting with 5-10 minutes of walking
each day, exercise time gradually can be increased to
up to 30 minutes daily.1
The study proposal was submitted and approved
by Human Research Ethics Committee.
After an official permission taken from the Medical
Record department of Madhuben and Bhanubhai
cardiac center, Karamsad a retrospective analysis of
the medical records of the patients who underwent
CABG was carried out. From the medical records
various variables were noted down including
demographic status, diagnosis, risk factors, pre
operative PT, post-operative physiotherapy, length of
stay in the hospital and functional status at the time of
discharge.
DATA ANALYSIS
The variables such as age, gender, body mass
index(BMI), hypertension, diabetes mellitus, obesity,
diagnosis, preoperative physiotherapy, post-operative
physiotherapy program, functional status of the
patient at discharge and average length of stay in
hospital were analyzed.
Descriptive statistical analysis and mean are used.
RESULTS
In the present study, out of 75 subjects who
underwent CABG 10 subjects expired during their
hospital stay. Hence the medical records of remaining
65 subjects were analyzed and average of walking
distance, flight of stairs and length of stay was
recorded.
Table 1. showing baseline characteristics of the
subjects with CABG surgery

Average Age (years) 58

In Anand Kheda district, Madhuben and
Gender (n=65)
Bhanubhai Cardiac Center cater its services to the
Male 84% (n=54)
patients suffering from cardiac diseases. In the last 2
Female 16% (n=11)
years, about 75 patients has undergone CABG and
Diagnosis
treated with physiotherapy till the discharge from the
SVD 7% (n=4)
hospital. Therefore, the present study aims to find out
DVD 23% (n=15)
the functional status of CABG patients achieved till
TVD 70% (n=46)
the discharge following physiotherapy.
Risk factors
HTN 80% (n=52)
METHODOLOGY
DM 54% (n=35)
Place of study: Karamsad. Obesity 48% (n=30)

Study design: Retrospective study.
Sampling size: Medical record of all patients who
underwent CABG.
All the subjects were given preoperative
physiotherapy which included chest physiotherapy in
the form of deep breathing exercise (DBE), thoracic
mobility exercise (TME), forced expiratory technique
(FET) and incentive spirometry along with teaching

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 272 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
of post operative regimen. Out of 65 subjects, 90%
(n=58) had no post operative complications and 10%
(n=7) had eventful CABG with associated
complications like cardiac arrhythmias in 3 patients,
uncontrolled diabetes in 1 patients, long term inotropic
support in 2 patients and pleural effusion in 1 patient
etc.
The average length of stay of the subjects in hospital
following uncomplicated CABG was 6 PODs and 90%
of the subjects were discharged by 6th POD.
It has been analyzed that no subjects developed
deep vein thrombosis following CABG surgery till
discharge from the hospital.
70% of the subjects were given home advice like
explanation regarding level of physical activity, target
heart rate and RPE scale, avoidance of personal habits
and regular follow up.
DISCUSSION
Madhuben and Bhanubhai Cardiac Center is a well
equiped specialized center in Anand district. On an
average 32 patients with coronary artery disease(CAD)
underwent CABG over a year. Postoperative
physiotherapy helps to optimize the surgical results,
enhance exercise capacity, return to work, quality of
life in patients who have undergone bypass surgery.10
Therefore the functional status of the patients with
CABG following physiotherapy was retrospectively
analyzed and hence records of these subjects were
analyzed.
Amongst the 65 subjects, 84% of population was
male and 16% was female. It has been widely studied
that the males are more prone to develop CAD than
females due to personal habits like smoking, excessive
alcohol consumption and increased stress level7, 25.
The age group of the population was between 41
to 85 years. It has been found that the common age
group is 45-54 years 24, 25 . The co-morbid factors
associated with CAD were hypertension (80%),
diabetes mellitus(54%) and obesity(48%) are the very
common risk factors responsible for CAD.2
In present study, all the subjects were given 1
session of preoperative physiotherapy. Out of them,
90% were discharged on 6th POD. It had been studied
by Erik H et.al. that preoperative physiotherapy
reduces the incidence of post operative pulmonary
complications and the average length of stay in the
53. Vinod K ravaliya--270--274.pmd 272
hospital19. Following CABG surgery, 87% of subjects
were treated with physiotherapy on 1st POD shortly
after extubation and 3% of subjects received chest
physiotherapy under emergency circumstances on 0th
POD. The remaining subjects (10%) were not treated
from 1st postoperative day due to severe hemodynamic
instability. As soon as subjects became stable on 2nd
postoperative day, 100% of population underwent
physiotherapy.
On the 1st POD, all the subjects were treated with
DBE, TME,FET with splinting over median sternotomy
site using small cushion(cardiac pillow), Incentive
Spirometry (IC 900cc EC 900cc), DVT prophylaxis,
sitting with support, eating and drinking
independently.
On the 2nd POD, the external aids like chest drains,
arterial lines, and femoral lines were removed.
Therefore, all of them could achieve the following
functional status upto sitting edge of bed (EOB)
independently, standing with minimal assistance and
walking indoor with minimal assistance along with
the same protocol followed on the 1st POD.
On the 3rd POD subjects could achieve functional
status up to walking independently approximately
75meters along with same protocol followed on 1st and
2nd POD with IS 1200cc and ES 900cc
Up to 3 rd POD, the emphasis was on chest
physiotherapy maximally with the frequency of
treatment five times/day because chest pain at the
incision site inhibit the patient breathing therefore
patient breathe at low tidal volume which result into
derecruitment of the alveoli and thereby
microatelectasis may occur. Therefore, to prevent post
operative respiratory complications, intensive chest
physiotherapy for initial 3 days is crucial for prevention
of post-operative pulmonary complications. 20
However, from 4th POD onwards, the need of chest
physiotherapy emphasized only for prophylactic
purpose up to 6th POD and gradual increase in walking
progressed from moderate assistance to independent
level.
With regards to early mobilization, it was started
from 3rd POD with free active exercises involving upper
and lower body exercise and walking. The walking
was gradually increased over a period of time day by
day up to 6th POD with further increase in intensity of
activity to staircase climbing and descending. The early
mobilization helps to rectify the deleterious
hemodynamic effects of bed rest, including decreased
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 273
exercise capacity, are due to loss of upright exposure
to gravity rather than inactivity. The reasons
supporting the concept that much of these alterations
are caused by the: a) Supine exercise does not prevent
deconditioning effects of being in the bed. b) There is
greater decrease in maximal oxygen uptake after a
period of bed rest measured during upright versus
supine exercise. To limit the decrease in functional
capacity after the surgery have emphasized low level
activities but studies suggest that simple exposure to
gravitational stress substantially accomplishes this29.
The average length of stay extended up to 6th POD
and 90% of the subjects with uneventful CABG surgery
were discharged on that day with mean walking
distance 171 meter and 2 flight of stairs independently.
However 10% of subjects with CABG had certain
complications like cardiac arrhythmias, uncontrolled
diabetes, long term inotropic support, pleural effusion
and were given physiotherapy treatment as per their
specific problems. They had gradual improvement in
their functional status and became functionally
independent by the 11th POD.
CONCLUSION
It has been concluded that the 80% subjects with
uneventful CABG following physiotherapy became
functionally independent i.e. sit, stand, walk, climb up
stairs on 6th POD, whereas 10% with eventful CABG
could achieve on 11th POD.
The emphasis on chest physiotherapy was given
shortly after extubation and five times in a day up to
3rd POD followed by extended prophylactic chest care
twice in a day up to 6th POD.
Conflict of Interest: Nil
ACKNOWLEDGEMENT
The author thanks the faculty members of
Madhuben and Bhanubhai Cardiac Center, Shree
Krishna Hospital, Karamsad for their valuable help.
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22. Proposal and validation of a new functional
ambulation classification scale for clinical use II
mediterranean congress of physical medicine and
rehabilitation,May 2000,spain.
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23. William L. Haskell et al.,physical activity and
public health:updated recommendation for
adults from American college of sports medicine
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Exerc.,vol.39,No.8,pp.1423-1434,2007.
24. Serruys P.W. et al., PCI versus CABG for severe
CAD, N Engl J Med 360(10): 961-72, march 2009.
25. Heart attack and cardiac arrest in men, men’s
health, april 2011.
26. Women and coronary artery disease, heart
disease health center, may 2009.
27. Sansone GR.et al., newyork, analysis of FIM
instrument scores for patients admitted to an
inpatient cardiac rehabilitation program. Arch,
phys Med Rehabil 2002, apr,83(4): 506-12.
28. KongKH et al., department of physical medicine
and rehabilitation, usa, functional outcome of
patients on a rehabilitation unit after open heart
surgery, J Cardiopulm Rehabil. 1996, nov-dec;
16(6): 413-8.
29. Convertino VA: effect of orthostatic stress on
exercise performance after bed rest: relation to
in- hospital rehabilitation: J cardiopulm rehabil
1983;3:660-663.
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 DOI Number: 10.5958/j.0973-5674.7.3.107
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 275

Effect of Cross Training Techniques in Novice Runners

Vishesh Garg1, M Neethi2, S K Joshi3, Jagmohan Singh4

1
Student MPT (Sports), Associate Professor, 3Athletics Coach, Sports Department Chandigarh, India, 4Professor &
2

Principal, Gian Sagar College of Physiotherapy, Ram Nagar, Rajpura (Punjab), India

ABSTRACT
Background and Objectives: Running is the most common sports event worldwide. Sprints are
short running events in athletics and track and field. Races over short distances are amongst the
oldest running competitions. Runners are trained with different training protocols to perform at
their best. One of the training protocols is known as "cross training techniques" in which athletes are
trained with a variety of exercises which are not specific to their sport. The present study was aimed
to evaluate the effect of cross training exercises in runners. The objectives of the study were to find
the effects of cross training on muscle strength, muscle power and running speed of the runners.
Materials and Method: 60 novice runners were randomly selected and divided in two groups, one
experimental and one control group. Control group was trained only with sports specific exercises
while in experimental group a non sports specific exercise was added. Athletes were trained for 8
weeks. After 8 weeks effects of cross training were observed on the speed of the runners.
Results: The mean values of muscle strength, muscle power and speed for control group are 4.5±4.01,
0.016±0.029 and 0.73±0.069 respectively. The mean values of muscle strength, muscle power and
speed for experimental group are 8.83±5.031, 0.038±0.053 and 0.205±0.0156 respectively.
Unpaired T-test was used to compare results of control group and experimental group. The results of
unpaired t-test were as follows:
Muscle strength: 3.62 (≤0.05)≤
Muscle power: 1.948 (≤0.05)
Speed: 4.13 (≤0.05)
Conclusion & Clinical Significance: It has been concluded on the basis of outcome measures and
statistical results that cross training exercises will help runners to improve their muscle strength,
muscle power and speed.
Keywords: Running, Cross Training, Cycling, Elliptical Training, Muscle Strength, Muscle Power, Running
Speed

INTRODUCTION end of the stadium to the other. There are three

Biewener1 described the term running in athletics
as “a gait in which at regular points during the running
cycle both feet are off the ground”. This is in contrast
to walking, where one foot is always in contact with
the ground, the legs are kept mostly straight and the
center of gravity vaults over the legs in an inverted
pendulum fashion.
Sprints are short running events in athletics and
track and field. Races over short distances are among
the oldest running competitions. The first 13 editions
of the Ancient Olympic Games featured only one
event—the stadion race, which was a race from one
sprinting events which are currently held at the
Summer Olympics and outdoor World
Championships: the 100 meters, 200 meters, and 400
meters.
Hay2 described at the professional level, sprinters
begin the race by assuming a crouching position in
the starting blocks before leaning forward and
gradually moving into an upright position as the race
progresses and momentum is gained. The set position
differs depending on the start. Body alignment is of
key importance in producing the optimal amount of
force. Ideally the athlete should begin in a 4-point
stance and push off of both legs for the most force

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 276 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
production. There are three main types of crouch start-
the bunch or bullet, medium and elongated. In bunch
start the toes of the back foot are placed approximately
with the heel of the front foot. The toe to toe distance
is therefore of the order of 25-30 cm. in medium start
the knee of the back leg is placed so that it is opposite
a point in front half of the front foot when the athlete
is in “on your marks” position. such placement yields
a toe to toe distance of between 40-55 cm. in elongated
start the knee of the back leg is placed level with or
slightly behind the heel of the front foot in the “on
your mark” position. The resulting toe to toe distance
is of the order of 60-70 cm
Conventional wisdom says all training is specific-
you improve the skills you practice. Runners, then,
improve endurance with regular long, slow runs, and
improve speed with periodic spells of faster running.
Yet most dedicated runners who train for an occasional
triathlon don’t seem to hurt their running. What’s
more, some trainers and coaches recommend cross
training for runners. They feel one-sport runners often
are in poor skeletal shape above the waist, and could
use additional workouts for better overall fitness.
Secondly, they believe that running less and spending
the time saved on other sports reduces the risk of the
impact injuries associated with running.
But then there are the other trainers and coaches
who stick to the old “training is specific” concept;
runners should run, and cross training won’t improve
their running
3 distance Test: Subjects will perform a single leg
According to Morgan and McGlynn Cross-training
in sports and fitness refers to the combining of exercises
to work various parts of the body. Often one particular
activity works certain muscle groups, but not others;
cross-training aims to eliminate this. Both beginners
and experienced runners can benefit from cross-
training.
Best cross training activities for runners are:
cycling, swimming, elliptical training
MATERIALS AND METHOD
Type of Study: The study was experimental and
comparative in nature.
Sample Size- 60 runners were selected randomly
by their coach.
Duration of study: 6 months
Inclusion Criteria
Both males and females novice runners between
age group 18 to 28 years were included in the study.
54. Vishesh Garg--275--278.pmd 276
Exclusion criteria
Subject with any musculoskeletal injury or any
surgery in lower limb within 1 year, subject with any
neurological impairment, subject with any history of
tumor And subject declared unfit by his/her physician.
PROCEDURE
Runners were divided in two groups. Group A
(control group) and group B (experimental group).
Group A was trained using basic training techniques
(1 mile running, plyometrics and squats).
In group B along with basic training cross training
techniques were also included.
Cycling and elliptical training are used as cross
training.
Elliptical Training: 10 min session. Alternate
between 2 min forward and 2 min backward
maintaining 90 strides/min. 3 days a week for 8 weeks.
Cycling: 20 to 30 min. session. (Cadence maintained
at 90/min). 3 days a week for 8 weeks.
Outcome measures
1) Lower limb Speed test: 30 meter dash Test, This
test requires the athlete to sprint as fast as possible
over 30 meters.
2) Lower limb muscle power test: Triple Hop
triple hop for distance with each lower extremity.
3) Lower limb strength test: Squats test: This test
requires the athlete to complete as many squats as
possible with no rest.
Measurement tools: Chair, measuring tape, stop watch
and cones
All these parameters were measured one day prior
to the training period and one day after the training
period is over.
All the results were analyzed using standard
statistical tools (Paired and unpaired T-tests.)
RESULTS
The mean values of muscle strength, muscle power
and speed for control group are 4.5±4.01, 0.016±0.029
and 0.73±0.069 respectively. The mean values of muscle
strength, muscle power and speed for experimental
group are 8.83±5.031, 0.038±0.053 and 0.205±0.0156
respectively.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 277

Unpaired T-test was used to compare results of DISCUSSION

control group and experimental group. The results of
unpaired t-test were as follows: According to Whytesides4, Running is a physically
demanding sport. Researchers have estimated that 37
Muscle strength: 3.62 (pd”0.05) to 56% of regularly training runners sustain an injury
Muscle power: 1.948 (pd”0.05) each year. Many athletes find that alternating other
forms of aerobic exercise into their routine allows them
Speed: 4.13 (pd”0.05) to train at greater volumes or intensities without
getting injured. Once an injury has occurred cross
training allows the athlete to maintain or even improve
their performance during recovery.

Tanaka5 describes it as the conveyance of training

Fig. 1. Comparison of muscle strength
effects from one limb to the contralateral or ipsilateral
limb. Irrespective of the definition the primary goal of
cross-training is performance enhancement or
maintenance. Anecdotally performance enhancement
from cross-training may be obtained through a number
of mechanisms: (i) direct improvement in performance
from an alternative mode of exercise; (ii) improved
training compliance associated with a more
interesting/diverse training programme; (iii) reduced
incidence of overuse injury; (iv) maintained training
stimulus during rehabilitation from injury.

In present study effects of cross training are thought

to be result of improved training compliance associated
with more diverse training programme and direct
improvement in running speed from alternative mode
of exercise.

Alexander 6 justified the relationship between

muscle strength and sprint kinematics in elite sprinters.
Significant relationships were noted between sprinting
times for the 100 m and peak torque scores (N.m/kg)
for males for fast concentric knee extension and slow
eccentric dorsiflexion.

Fig. 2. Comparison of muscle power Fitzgerald7 said Cross training by participating in

nonimpact forms of cardiovascular exercise such as
cycling or swimming can not only speed your recovery
but also help you prevent injuries in the first place.

Burke8 advocated the benefits of cross training are

numerous. A sensible cross training programme
enables one to develop the five major components of
fitness: cardiorespiratory capacity, muscular
endurance, muscular strength, flexibility and fitness.
The emphasis is on comprehensive conditioning of
whole body.

Millet9 said the endurance athlete will use cross-

Fig. 3. Comparison of speed training mainly to break the boredom of usual routine

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 278 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
regime as a preventive method to minimize the injuries
due to a weight-bearing activity to maintain a general
fitness while the athlete has been forced to stop training
in his primary activity because of injury or even to
limit overtraining during high-volume periods.
However, the cross-training method requires
redefining the overall training program, while addition
of new exercises increases the risks of injuries and
overtraining
CONCLUSION
It is concluded statistically from the research
performed that cross training technique when applied
in conjunction with specific training for runners
improve muscle strength, muscle power and speed.
Conflict of Interest: There is no conflict of interest
amongst authors to prepare this manuscript.
REFERENCES
1. Biewener, A A, 2003, Animal Locomotion, Oxford
University Press, USA
2. Hay, J G, 1973, The biomechanics of sports
techniques, Prentice Hall, Eaglewood Cliffs New
Jersey.
54. Vishesh Garg--275--278.pmd 278
3. Morgan, G and McGlynn, G 1997, Cross-Training
for Sports: Programs for 26 sports, USA
4. Bryan whytesides (2010) The runners guide to
cross training. www.betterrunner.com
5. Tanaka H, 1994 Effects of cross-training. Transfer
of training effects on VO2max between cycling,
running and swimming. Sports medicine
18(5):330-9
6. Alexander MJ, 1989 The relationship between
muscle strength and sprint kinematics in elite
sprinters. Canadian journal of sports medicine;
14(3):148-57
7. Fitzgerald M, 2004 Runner’s World Guide to
Cross-Training Rodale inc, USA
8. Burke E, 1994 The wisdom of cross training.
Strength and conditioning, 58-60
9. Millet GP, Candau RB, Barbier B. Busso T,
Rouillon JD, Chatard JC, 2001 Modeling the
transfer effects of training on performance of elite
triathletes. International journal of sports
medicine; 23: 55–63
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 DOI Number: 10.5958/j.0973-5674.7.3.108
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 279

A Study on efficacy of different Therapeutic Modalities to

Alleviate Pain due to Knee Osteoarthritis

Bibek Adhya1, Anu Gupta2, Mandeep Singh Dhillon3, Upendra Goswami4, Vijay Kumar5
1
Senior Physiotherapist, Deptt. of PRM (Physiotherapy), PGIMER, Chandigarh & Research scholar ,Singhania University,
Pacheri Bari, Jhunjhunu, Rajasthan, 2Intern,Physiotherapy, Deptt. of PRM (Physiotherapy) 3Prof. & Head, Deptt. of
PRM(Physiotherapy) & Orthopedics, 4Physiotherapist, Deptt.of PRM(Physiotherapy) 5Research Associate, Deptt. of PRM
(Physiotherapy), PGIMER, Chandigarh

ABSTRACT
Introduction: Physiotherapy is one of the recommended non pharmacological management options
in patients with osteoarthritis.Ultrasound & Pulsed electromagnetic energy(PEME) & Exercises are
widely used in to treat pain due to osteoarthritis.
Aims& Objectives: The purpose of the study was an effort to find out the role of different modalities
(Therapeutic ultrasound, PEME , Exercises) to control the pain in osteoarthritis of knee.
Study design & Methodology: The study was experimental, pre & post design. 60 female
osteoarthritis patients including those suffering from bilateral osteoarthritis between age group 40-
65 years from the Department of Physiotherapy and Department of Orthopedics, PGIMER,
Chandigarh were chosen for the study & randomly distributed in 3 groups. Electrotherapy modalities
were administered for Group A (PEME) and Group B (Ultrasound) three times weekly for 6 weeks.
The exercises & hot water fomentation were carried daily for all the three groups (Group A, Group B
& Group C). The severity of knee pain was evaluated by Visual Analog Scale (VAS) in a weight
bearing position (walking or standing) in parallel bars. Western Ontario McMaster universities
(WOMAC) index of osteoarthritis was used to assess pain, stiffness, and physical function. SPSS-
Version17 was used for statistical analysis.
Conclusion: It is concluded that all the therapies administered (pulsed electromagnetic energy,
therapeutic ultrasound, exercises) help to reduce pain in knee osteoarthritis but none of the modality
proved more effective than others.
Keywords: Knee, Osteoarthritis, Pain, Pulsed Electromagnetic Energy, Ultrasound, Exercise

INTRODUCTION this condition, there is also remodeling of subchondral

Knee osteoarthritis marked by pain, degeneration,
muscle atrophy, inflammation, stiffness, deformity, and
progressive loss of independence.1,2
Although the precise cause of pain accompanying
this destructive process is not clear, possible causes
may include bone loss and exposure of bone nerves
due to loss of protective cover of articular cartilage. In
Corresponding author:
Bibek Adhya
Sr. Physiotherapist
Department of PRM (Physiotherapy), P.G.I.M.E.R.,
Chandigarh, India.
Email: bibek.adhya@gmail.com
Ph. +919876044966
bone occurs along with the varying degree of
degenerative changes occurs in the joint capsule,
ligaments, muscle and tendon. Due to the neural
adaptations in the central nervous system and
peripheral nervous system in the presence of
unremitting pain, one can also expect behavioral
changes such as anxiety and depression to contribute
to the osteoarthritis pain production and its
detrimental effects on function. Although there is no
successful cure for knee osteoarthritis, the therapeutic
approach is mainly directed at symptoms and many
treatment options including non pharmacological and
pharmacological measures are recommended in the
management of osteoarthritis. Non steroidal anti
inflammatory drugs (NSAIDS) and other drug
therapies involve potential hazards including

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 280 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
gastrointestinal side-effects, particularly in the elderly.
Physiotherapy (including PEME, Ultrasound, Hot
packs, Exercise etc.) is one of the recommended non
pharmacological management options in patients with
osteoarthritis. 3,4,5,6
Physical agents are devices using physical
modalities to produce beneficial therapeutic effects (e.g
therapeutic ultrasound, pulsed electromagnetic
energy, hot packs etc.). Heat therapy is applied to
obtain analgesia, decrease muscle spasm, increase
collagen extensibility and accelerate the metabolic
processes.
Therapeutic ultrasound is constituted by high
frequency sound waves of 0.75 MHz,1MHz and
3MHz. Ultrasound has been widely used for many
years in the treatment of osteoarthritis. Ultrasound
converts electrical energy into an acoustic waveform
which is then converted into heat as it passes through
tissues of varying resistance .Ultrasound, reduces
muscle spasm through thermal effect, it also causes
cavitation, microstreaming and acoustic streaming.
Cavitational effects result from the vibration of the
tissue causing microscopic air bubbles to form, which
transmit the vibrations in a way that directly stimulates
cell membranes. This physical stimulation appears to
enhance the cell-repair effects of the inflammatory
response including pain.7
Pulsed electromagnetic energy is a popular variant
of short wave diathermy. This consists of bursts of the
same alternating high frequency current, interspersed
with a cut off phase, during which heat can be
dissipated in the tissues. It is used for the treatment of
soft tissue injuries and also for more chronic conditions
including osteoarthritis pain. In addition, the use of
low frequency pulsed electromagnetic field may
produce a potentiated anti-inflammatory effect and
reduces pain without the unfavorable effects of the
excessive heat production. Pulsed EME uses electrical
energy to direct a series of magnetic pulses through
injured tissues whereby each magnetic pulse induces
a tiny electrical signal that stimulates cellular
repair.8,9,10,11.
Exercises in case of osteoarthritis should be focused
on pain, muscle weakness and loss of motion in and
around the involved joint, strengthening helps to
overcome pain.3
Here an effort is executed to find out the role of
different electro modalities (Therapeutic ultrasound,
55. BIBEK--279--284.pmd 280
Pulsed EME, Hot packs) to control the pain in
osteoarthritis particularly in females in Indian scenario.
Aims and objectives
The aims & objectives were to evaluate the
effectiveness of pulsed electromagnetic energy
(PEME), to evaluate the effectiveness of ultrasound,
to evaluate the effectiveness of exercises & to compare
the effect of pulsed electromagnetic energy(PEME)
,therapeutic ultrasound & exercise in osteoarthritis
knee pain & function.
STUDY DESIGN & METHODOLOGY
Sampling
60 female osteoarthritis patients including those
suffering with bilateral osteoarthritis between age
group 40-65 years were chosen for the study.
Inclusion criteria
Radiological changes in the knee reported as
degenerative or osteoarthritic. Pain emanating from
the joint.
Exclusion criteria
History of previous Surgery of the effected joint.
Apparatus
Curapuls 670, Enraf Nonius, The Netherlands.
Gymna Pulson 200, Belgium.
STUDY DESIGN
Experimental, a pre and post study design.
Patients were randomly divided into 3 equal
groups of 20 patients each.
Group A: Exercises, Postural and ergonomic care,
Knee cap, Precautions, Hot water fomentation &
Pulsed electromagnetic energy. Dosage: Treatment
dosage was as suggested by previous research 11m
waves at 27.12MHz and 150watts for 15 minutes with
condenser electrode. Treatment was admininistered
for 3 days for 6 weeks.
Group B: Exercises, Postural and ergonomic care,
Knee cap, Precautions, Hot water fomentation &
Therapeutic ultrasonic therapy. Locations of ultrasonic
treatment: The regions for application of therapeutic
ultrasonic therapy are selected according to locations
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 281

of tender points noted on orthopedic clinical
examination. Dosage: Therapeutic Ultrasound therapy
set at a frequency of 1.1MHz,duty cycle 100%, ERA
4.0cm2, intensity 1.00 w/cm2 , treatment time 7.30
minutes, applied to each treatment (the default
program for Arthrosis with Gymna, Pulson
200,Belgium). Sonication was performed for 3 days for
6 weeks.
Group C: Exercises, Postural and ergonomic care,
Knee cap, Precautions, Hot water fomentation.
The exercises were carried daily for all the three
groups.
Exercise protocol
All patients were advised to wear knee caps while
in weight bearing positions such as standing and
walking.
Patients were advised to avoid crossed leg sitting,
squatting, restrictions in use of steps as the postural &
ergonomic care (Precautions).
Measures
The severity of knee pain was evaluated by Visual
Analog Scale (VAS) after patients had remained in a
weight bearing position (walking or standing) in
parallel bars. The VAS instrument consisted of
horizontal line which is 10 cm long with anchor points
of 0(no pain) and 10(maximum pain).

Isometric exercises for quadriceps and hamstrings
with 10 seconds hold,20 repetitions(=1set), 3 sets each.
Hip abductor dynamic strengthening exercises : 3
sets(1 set=20 repetitions) for each leg with 1 kg weight.
Dynamic strengthening exercises for the knee joint :
20 repetitions , 3 times a day.
Hot water fomentation once per day for 15 minutes.
Western Ontario McMaster universities(WOMAC)
index of osteoarthritis used to assess pain, stiffness,
and physical function.
Statistical analysis
SPSS-Version 17 was used for statistical analysis.

RESULTS
Table 1: Shows the comparison of the means of the VAS score before-after the treatment and WOMAC score before
& after the treatment in Group-A.

Paired Differences t Df Sig.

(2-tailed)
95% Confidence
Interval of the
Difference
Mean Std. Std. Error Lower Upper
Deviation Mean
Pair -1 VAS Pre Post 1.250 .786 .176 .882 1.618 7.109 19 .000
Pair-2 WOMAC Pre Post 3.250 2.447 .547 2.105 4.395 5.940 19 .000

p-value <0.05, significant

Table 2: Shows the comparison of the means of the VAS score before-after the treatment and WOMAC score
before-after the treatment in Group-B.

Paired Differences t Df Sig.

(2-tailed)
95% Confidence
Interval of the
Difference
Mean Std. Std. Error Lower Upper
Deviation Mean
Pair 1 VAS Pre Post 1.450 .945 .211 1.008 1.892 6.866 19 .000
Pair 2 WOMAC Pre Post 4.850 3.543 .792 3.192 6.508 6.121 19 .000

p-value <0.05, significant.

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 282 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 3: Shows the comparison of the means of the VAS score before-after the treatment and WOMAC score before-
after the treatment in Group-C.

Paired Differences t Df Sig.

(2-tailed)
95% Confidence
Interval of the
Difference
Mean Std. Std. Error Lower Upper
Deviation Mean
Pair 1 VAS Pre Post 1.350 .671 .150 1.036 1.664 9.000 19 .000
Pair 2 WOMAC Pre Post 4.450 2.874 .643 3.105 5.795 6.924 19 .000

p-value <0.05, significant

Table 4: Shows the VAS pre-post scores and WOMAC pre-post scores.

Sum of Df Mean F Sig.

Squares Square
VAS Score_pre Between Groups 7.3 2 3.65 1.301
(GroupA, GroupB & Within Groups 159.95 57 2.806
Group C) Total 167.25 59
VAS Score_Post Between Groups 9.1 2 4.55 1.188
(GroupA, Group B & Within Groups 218.3 57 3.83
Group C)) Total 227.4 59
WOMAC Score_Pre Between Groups 18.433 2 9.217 0.294
(GroupA, GroupB & Within Groups 1786.15 57 31.336
Group C)) Total 1804.583 59
WOMAC Score_Post Between Groups 90.433 2 45.217 1.038
(GroupA, GroupB & Within Groups 2483.3 57 43.567
Group C)) Total 2573.733 59

p>0.05,non significant

DISCUSSION P-value < 0.05 with therapeutic ultrasound treatment.

The analysis of comparison of VAS scores and
WOMAC scores in the group A shows (Table 1)
significant results as the P-value <0.05.Hence it is clear
that pulsed electromagnetic energy is effective to
reduce pain in patients suffering with knee
osteoarthritis along with other interventions. Pulsed
electromagnetic energy is a popular variant of short
wave diathermy. This consists of bursts of the same
alternating high frequency current, interspersed with
a cut off phase, during which heat can be dissipated
in the tissues. It increases oxygenation of tissues and
accelerating the elimination of debris in the affected
area. It accelerates the regeneration of nerve tissue and
eliminates excessive scar formation. It suppresses
inflammatory responses at the cell membrane level to
alleviate pain. Also exercises focus on pain, muscle
weakness and loss of motion in and around the
involved joint. 9 Documented study on pulsed
electromagnetic field too suggests that this therapy
may be useful to reduce pain associated with knee
osteoarthritis.11
The comparison of VAS scores and WOMAC scores
in the group B show significant results (Table 2) as the
Ultrasound sends sound waves into the desired tissue
causing vibration of the tissues. This vibration of
tissues has numerous effects in improving healing. As
the tissue cells vibrate, heat is created. This heat is deep
in the tissue and much more advantageous as
compared to superficial heat on the skin. This heat
loosens muscle or ligamentous tissue to increase joint
range of motion, decreases muscle spasm, increases
blood circulation to bring new healing cells to the area,
increases cell membrane permeability to allow each
cell to take in the appropriate fluids and nutrients and
rid the area of excess swelling, and stimulates the
release of encephalins, the body’s natural painkillers.
Cavitational effects result from the vibration of the
tissue causing microscopic air bubbles to form, which
transmit the vibrations in a way that directly stimulates
cell membranes. This physical stimulation appears to
enhance the cell-repair effects of the inflammatory
response. Thus decreases pain in osteoarthritis patients
along with other interventions. Exercises on a regular
basis helps to reduce osteoarthritis symptoms, improve
range of motion in the affected joint, improve joint
function.7

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 283
The study conducted by A. Loyala Sanchez, et al.
(2010) supports the effectiveness of therapeutic
ultrasound. It suggests that 10-24 sessions of
ultrasound may improve physical function in patients
suffering from osteoarthritis knee.13
The analysis of comparison of VAS and WOMAC
scores in group C shows significant results as the P-
value is < 0.05(Table3). Exercises help in the muscle
strengthening as appropriate strengthened muscles
help to minimize the adverse effects of weight bearing
on the joints by reducing the amount of force that is
transmitted across the affected joints. Some studies
have shown that when these patients strengthen their
quadriceps muscles significant improvements in pain
and function are seen when compared with those who
did not strengthen these muscles. Exercise program
also helps in increasing flexibility and range of motion
of the affected joints. Heat such as hot packs helps to
reduce pain by improving circulation and relaxing
muscles. Hot fomentation is the method of choice for
heating superficial tissues such as with the application
of heat in the form of moist hot packs. Ergonomic &
postural care also help by preventing the further
damage of the joint. Studies performed over the
exercise protocol shows that the patients assigned to
exercise groups had greater pain reduction and
improved function12,14,15
The analysis of comparison of VAS pre treatment-
scores, VAS post treatment-scores, WOMAC pre
treatment-scores and WOMAC post treatment-scores
for all the 60 patients and found that there is no
significant result in one way anova (Table 4). Thus it
is clear that there is not much difference in result in all
the three types of treatment. It has been found that
improvement is noticed in every individual patient but
no significant value found on comparison of different
groups. Definitely there is scope for study with large
number of samples.
Study conducted by Y Laufer ,et al.(2005) shows
that ,a difference across time was observed for the pain
and stiffness categories of the WOMAC Osteoarthritis
Index (p < 0.033 and p < 0.008, respectively), with no
differences between groups as treatment is effective
for individual patient. No other significant differences
across time or between groups were observed in any
of the other measures16.
Another study was performed by J.A.Klaber
Moffett,et al.(1996) in support that when analysis of
55. BIBEK--279--284.pmd 283
variance (anova) with repeated measures over time
was used to compare the mean scores of each of the
three groups such as active, placebo and control group
of pulsed electromagnetic energy at pre-treatment and
post-treatment at 1month and 3months follow up and
stated that there were not any significant differences
found on the baseline data17.
CONCLUSION
This study shows a mixed result in reduction of
pain in the patients suffering from knee osteoarthritis
as there is significant results found in paired t-test in
all the three groups when their pre treatment and post
treatment VAS and WOMAC scale scores were
compared but when one way ANOVA was applied
within and between the groups no significant result
was found. Findings show that when individual
patient was considered there was significant
improvement. Finally it is concluded that all the
therapies such as pulsed electromagnetic energy,
therapeutic ultrasound, exercises, hot packs and
precautions help to reduce pain in knee osteoarthritis
but none of the modality proved more effective than
others.
ACKNOWLEDGEMENTS
The authors are thankful to Dr. Sharad Prabhakar,
Asst. Prof., Deptt. Orthopedics, PGIMER, Chandigarh,
Dr.Devender Chouhan, Asst. Prof., Deptt. of
Orthopedics, PGIMER, Chandigarh & Dr. Sarvdeep
Dhatt, Asst. Prof., Deptt. of Orthopedics, PGIMER,
Chandigarh for their support by referring patients for
the study.
Conflict of Interest
Authors declare that there was no financial and
personal relationships (employment, consultancies,
stock ownership, honoraria, paid expert testimony,
patent applications/registrations, and grants or other
funding) with other people or organizations that could
inappropriately influence (bias) the work.
Funding Source: None
Ethical clearance
The study has been approved by ethical committee
constituted for Physiotherapy research by PGIMER,
Chandigarh.
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 284 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

REFERENCES M (Eds). Pain Therapy. Elsevier Biomedical

Press.1983; p. 229-238.
1. Davis M A . Epidermiology of osteoarthritis.
11. Nadasdi M. Inhibition of experimental arthritis
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by athermic pulsating shortwaves in rats.
2. Threlkeld AJ, Currier.DP. Osteoarthritis.Effect on
Orthopedics.1960; 2:105-107.
synovial joint tissues. Physical therapy. 1988;68:
12. Kovar PA, Allegrante JP, Mackenzie CR, Peterson
364-370.
MG, Gutin B, Charison ME. Supervised fitness
3. Hochberg MC: Osteoarthritis: pathophysiology,
walking in patients with osteoarthritis of the
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knee-a randomized control trial. Ann Intern
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4. Marks R. Peripheral mechanisms of pain
13. Loyola-Sanchez A, Richardson J, MacIntyre NJ.
production in osteoarthritis. Australian journal
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osteoarthritis. A systematic review and meta-
5. Altman.RD. Osteoarthritis:Aggravating factors
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medicine.1986;80:150-163
14. Chamberlain MA, Care G, Harfield B.
6. Hough AJ. Pathology of
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osteoarthritis.In:Koopnian WJ.edition.Arthritis
Rehablitation Medicine.1982;4:101-106.
and allied conditions.13th ed. Baltimore.Williams
15. Marks R, Cantin D. Symptomatic OA of The
and Wilkins.1997; p.1945-1968.
Knee. Physiotherapy 1997 June ; 83 ( 6). 61.
7. American College of Rheumatology
16. Laufer Y , Zilberman R, PoratR , Nahir AM
Subcommittee on Osteoarthritis Guidelines.
.Effect of pulsed short-wave diathermy on pain
Arthritis & Rheumatism.2000;43(9):1905-15.
and function of subjects with osteoarthritis of the
8. George E, Creamer P, Dieppe PA.Clinical Susets
knee:a placebo-controlled double-blind clinical
of osteoarthritis of the hip joint.
trial. Clinical Rehabilitation.2005.19; 3:255-263.
Physiotherapy.1994;77:737-740.
17. Klaber Moffett JA, Richardson PH, Frost H,
9. Fabbri F,Lucchese V .Non thermal effects of
Osborn A. A placebo controlled double blind trial
pulsed magnetic fields.An experimental study of
to evaluate the effectiveness of pulsed shortwave
22 laboratory parameters. Minerva
therapy for osteoarthritic hip and knee
Orthopedica.1980; 31: 251-256.
pain.Pain.1996;67:121-127.
10. Warnke U.The possible role of pulsating magnetic
fields in the reduction of pain. In: Rizzi R, Visentin

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 DOI Number: 10.5958/j.0973-5674.7.3.109
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 285

A Comparative Study of effectiveness of Balance Training

with and without Visual Cues on Activities of Daily
Living in Stroke Patients

Dhoriyani Narendra B1, Patel Fagun B2, Smitha D3, Kagathra Shailesh4, Bhatt Kaushal5
1
Tutor Cum Physiotherapist, Government Physiotherapy College, Jamangar, 2Lecturer, Ahmedabad Institute of Medical
Sciences, Ahmedabad, 3Assistant Professor, Shree Devi College of Physiotherapy, Mangalore, 4Physiotherapist & Director,
Prayas Multispeciality Physiotherapy Center, Rajkot, 5Physiotherapist & CEO, KIDS Paediatric Physiotherapy Clinic,
Bhavnagar

ABSTRACT
Background: In stroke balance can be affected by deficits of strength, range of motion, proprioception,
vision, vestibular function. Patients are trained to rely more on visual input to maintain balance but
rarely are trained for the vestibular and other sensory system. Balance is also a predictor of functional
rehabilitation. Hence aim of this study is to find out the difference between training somatosensory,
vestibular and tactile system with and without visual cues, with emphasis on balance and its effect
on ADL and mobility in stroke patients.
Materials and Method: Thirty post stroke subjects with balance problem were assigned into two
groups: GroupA (Control) and GroupB (Experimental). Both the groups received similar balance
training program for six weeks. Subjects of group A were allowed to use free vision and group B
were deprived of visual cues during balance training. After six weeks both groups were re-evaluated
for balance, ADL and mobility.
Results: There was significant improvement in balance(p<0.001), ADL(p<0.001) and mobility(p<0.001)
in both the groups but between the groups there was significant improvement in balance(p<0.01) but
not in ADL(p>0.05)and mobility(p>0.05).
Discussion and Conclusion: Balance is the basic need for doing all ADL activities but training for
balance will not necessarily improve quality of ADL. This study suggests that patients improved
their integration of somatosensory and vestibular input and enables them to use the pertinent input
to become less reliant on visual input. From this result it was concluded that balance training without
vision is more effective in balance recovery in stroke patients.
Keywords: Balance, Activities of Daily Living, Vision, Stroke

INTRODUCTION
After coronary heart disease (CHD) and cancer of
all types, stroke is the third leading cause of death
worldwide. However, Asians have a lower rate of
coronary heart disease and higher prevalence of
stroke.1 Each year approximately 600,000 people suffer
Corresponding author:
Dhoriyani Naredra B
Tutor Cum Physiotherapist
Mahendranagar, Ta: Morbi , Di: Rajkot, Gujarat, India
Ph: +91-987-971-8851
E-mail: Narendra41067@yahoo,com
from stroke and nearly 400,000 survive with some level
of neurological impairment and disability.2 The WHO
defined stroke as ‘ rapidly developed clinical signs of
focal disturbance of cerebral function; lasting more
than 24 hours or leading to death, with no apparent
cause other than vascular origin.3 In India during
ninety’s the prevalence rate of stroke was between
250-350/100,000.4
In stroke the physical impairments includes motor,
sensory, balance, perceptual problems etc. Balance
impairment is the most common in any type of stroke
because balance can be affected by more than one

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 286 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
component. Balance has been defined as the ability to
maintain an upright posture.5,6 Traditionally balance
has been divided into either static or dynamic as if
they have separate physiological mechanisms. 7
Balance is a very complex task that involves sensory
input, and the execution of the appropriate
neuromuscular response.5
In stroke, one’s ability to balance may be impaired
because of deficits of strength, range of motion,
proprioception, vision, vestibular function or
endurance.5,11 In this condition balance impairment
may be much more complex because of impaired use
of individual sensory system along with impaired
central processing of the sensory organization
mechanisms.12,13Studies shows the disorders of the
sensory information organization underlie distorted
representation of the body in space due to vestibular
or somatosensory system insufficiency. They are more
dependent on visual system while maintaining balance
and doing ADL. Again balance control will be more
difficult in patients with visuo-vestibular conflict.14,
Balance is also an important predictor of functional
rehabilitation in post-stroke patients. Functional
improvement may be due to the true physiological
recovery derived from normal balance responses.
During rehabilitation stroke patients are knowingly or
unknowingly trained to rely more on visual input but
are rarely trained for the vestibular and other sensory
system. Generally the patient is trained in such a way
that the patient always uses vision as compensation
to loss of other sensory system to repair themselves to
their fullest extent.
Whether there is a statistically significant difference
between training somatosensory, vestibular and tactile
system with and without vision on balance and
therefore on Activities of Daily Living and mobility in
stroke patients?
MATERIALS AND METHODOLOGY
A randomized control double blinded study was
conducted at Yenepoya Hospital, Govt. Wenlock
hospital and Shree Devi College of physiotherapy,
mangalore with sample size of 30 patients in 2008.
Subjects were included based on criteria that patients
is having hemiplegia by stroke, could assume
independent standing for minimum of 10 seconds and
have balance problem with minimum 20 scores on BBS.
56. Narendra--285--290.pmd 286
Subjects were excluded if having orthopedic disorders
in one or both lower limbs, any neurological diseases
such as vertigo, vestibular dysfunction, subjects with
peripheral neuropathy or cognitive/perceptual
disorders, peripheral or central visual problem, stroke
due to PCA syndrome and not older than 65 years.
Pre-intervention outcome measures were evaluated
and recorded for the 30 subjects. Berg Balance Scale
for balance impairments, Stroke Specific-Quality of
Life Scale (Family Roles, Mobility, Self Care, Upper
Extremity Functions and Work/Productivity) for ADL,
Rivermead Mobility Index for mobility function.
The subjects were randomly allocated to either
control group (Group A) or experimental group (Group
B) by using sealed envelopes. The subjects of group B
were blindfolded during balance training sessions with
a soft and dark colored cloth material, taking adequate
care to ensure a safe environment. Subjects of group A
were allowed to use free vision during balance
training. A set of training exercises as described below
were given to the both the groups for a period of six
weeks. Five sessions of exercises per week was given
and each session lasted for 45 to 60 minutes. Post-
intervention outcome measures were reassessed at the
end of six weeks exercise protocol. Pre to post
comparison of each outcome measure was done by
students paired‘t’ test. Comparison between the two
groups i.e. group A and group B was done using
students unpaired‘t’ test. Mean and standard deviation
were calculated and data were subjected to statistical
analysis using SPSS software. One-way analysis of
variance was done to determine any significant
differences between the experimental and control
groups before and after intervention.
Exercise protocol is described below
Exercises in supine lying
In supine position with both the knees flexed to 900
and asked to do pelvic bridging. Knees were stabilized.
Progressed to single leg bridging, therapist supports
extremity at knee joint and perturbation was added.
Exercises in prone lying
In forearm support prone lying, with the therapist
stabilizing the shoulder and trunk on the affected side.
Progressed in prone kneeling, with the therapist on
the affected side stabilizing elbow and shoulder to
prevent buckling of elbow.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 287

Therapist stood behind. Progressed to without upper

limb support. Then progressively decreasing BOS from
lower limb. Then standing on foam surface without
external support to alter somatosensory input.
Marching on foam surface. Then standing balance on
wobble board. Then walking forward and side to side.

Role of funding source: The study was partly

Fig. 1. Indicates patients is in prone kneeling position and
therapist stabilizes elbow and the perturbation is given.
sponsored by Shree Devi College, however it does not
had any role in study design, in collection, analysis or
interpretation of the data; or in writing the manuscript
or the decision to publish the results.

Exercises in sitting
In long sitting position on low plinth with both the
upper limb placed behind trunk on plinth. Care was
taken to prevent fall then progressed to cross-leg sitting
and then to high sitting with same position of upper
limbs. In high sitting progressed with decreasing BOS
of upper limbs. Then buttocks lifting and moving in
side to side and front back.
Exercises in standing
Standing in a parallel bar with wide base of support,
upper limbs were supported on horizontal bar.
RESULTS
From the below Table 1.1, it is understood that a
very highly significant increase is found in the scores
of Berg Balance Scale (P<0.001) in both groups. When
measured with SS-QOL , the mobility, self care, upper
extremity functions shows a very highly significant
improvement after the treatment in both the groups.
Therefore a very highly significant increase in total SS-
QOL scores. However, no significant increase is found
in family roles(P<0.001) in either groups. It is also
understood that a very highly significant increase is
found in scores of Rivermead Mobility Index (P<0.001)
in both the groups.

Table 1.1: Comparison of pre & post measures (Mean & SD) with paired students‘t’ test within Group
and within Group B.

Group Paired Differences t p

Mean Std. Deviation
EXERCISES WITH VISION – A BBS 3.9333 1.53375 9.932 0.001 vhs
Family Roles 0.2000 0.41404 1.871 0.082 ns
Mobility 2.2000 1.01419 8.401 0.001 vhs
Self Care 1.5333 0.83381 7.122 0.001 vhs
UEF 1.3333 0.72375 7.135 0.001 vhs
Total SS-QOL 5.4667 1.72654 12.26 0.001 vhs
RMI 1.7333 0.79881 8.404 0.001 vhs
EXERCISES WITHOUT VISION – B BBS 6.4000 2.61315 9.486 0.001 vhs
Family Roles 0.2000 0.41404 1.871 0.082 ns
Mobility 2.9333 1.33452 8.513 0.001 vhs
Self Care 2.2000 1.32017 6.454 0.001 vhs
UEF 1.6667 0.72375 8.919 0.001 vhs
Total SS-QOL 7.0667 2.78944 9.812 0.001 vhs
RMI 1.9333 0.96115 7.79 0.001 vhs

(p<0.05 significant, p<0.01 highly significant, p<0.001 very highly significant

From the below Table 1.2 it is understood that a vision) compared to group A(with vision). When
highly significant improvement is found in scores of changes in components of SS-QOL like family roles,
Berg Balance Scale (P<0.001) of group B(without mobility, self care and upper extremity functions are

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 288 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

compared between the groups, there is no significant scores of Rivermead Mobility Index (p>0.005) when
difference therefore no significant difference in SS- the two groups are compared.
QOL. It is understood that no significant change in

Table 1.2 Comparison of measures (Mean & SD) with unpaired students ‘t’ test between Group A and Group B.

Exercises Exercises t p
Withvision- A Withoutvisionb-b
Mean Std. Deviation Mean Std. Deviation
BBS 3.9333 1.53375 6.4000 2.61315 3.079 0.004 hs
Family Roles 0.2000 0.41404 0.2000 0.41404 3.00E-07 1 ns
Mobility 2.2000 1.01419 2.9333 1.33452 1.6884 0.102 ns
Self Care 1.5333 0.83381 2.2000 1.32017 1.6418 0.111 ns
Upper Extri. Fun 1.3333 0.72375 1.6667 0.72375 1.2603 0.217 ns
Total SSQOL 5.4667 1.72654 7.0667 2.78944 1.8716 0.074 ns
RMI 1.7333 0.79881 1.9333 0.96115 0.6193 0.540 ns

(p<0.05 significant, p<0.01 highly significant, p<0.001 very highly significant)

DISCUSSION AND CONCLUSION
The purpose of this study was to assess the
effectiveness of balance training with and without
vision on activities of daily living and mobility in stroke
patients. At the start of study the groups were uniform
in their characteristics. At the end of study the results
of balance training program were compared between
the subjects with and without vision. Balance, ADL
and mobility improved significantly in both groups
but the visually deprived group had significantly better
balance scores but not ADL and mobility
improvement. While comparing the individual
components of SSQOL like family roles, mobility, self
care, upper extremity functions between groups, there
was no significant improvement was noticed.
Thus, from the results we can infer that balance will
improve significantly better with visual cue
deprivation but not ADL & mobility. Balance is the
basic need for doing all ADL activities but training only
for balance will not necessarily improve the quality of
ADL activities. ADL can be improved by giving
exercises similar to the ADL activities combined with
balance training program. Similarly mobility can be
improved by training for mobility combined with
balance training program.
Subjects were homogenous for age and level of
recovery: all could assume independent standing for
10 seconds without any assistance and screened for
positive balance problem. The same balance training
program was given to both groups. The only difference
being the visual cues. This ensured that any differences
between the group differences in the results were
caused by visual cues and not by the balance training
program. In this study balance training was more
precisely concentrated with longer duration & sessions
and with more repetition of exercises which could be
the possible reason of this study’s findings.
The findings of this study suggest that the patients
improved their integration of somatosensory and
vestibular inputs and that the program enabled them
to use the pertinent input and to become less reliant
on visual inputs.
The predominant influence of visual input
constitutes a natural compensatory strategy for coping
with initial imbalance and that traditional
rehabilitation reinforces this excessive visual reliance
by focusing on visual compensation rather than
restoring the normal use of all sensory inputs. It is
suggested that excessive reliance on vision is an
attempt to compensate for defective balance is
supported by result of this study that this reliance is
reversible after a vision-deprived balance
rehabilitation program.
The subjects were treated for balance with vision
and without vision for six weeks. Five sessions of
exercises per week and each lasted for 45 to 60 minutes.
The subjects in experimental group, who received
balance training without vision showed better
improvement in balance than control group, who
received similar balance training with free vision. In
conclusion the balance training without vision is more
effective in balance recovery in stroke patients.
The limitations of study were as it was done on
smaller sample size and treatment protocol was of

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 289
smaller duration. There may be different result if with
longer duration of neuro-rehabilitation protocol. This
study can be further extended with modifying sensory
input and sensory conflict with very precise
instruments such as Smart Balance Master, forceplate
etc.
ACKNOWLEDGEMENTS
The authors are thankful to Mr.S.Jayasrikanth for
guiding throughout the study and thankful to
Principal, Shree Devi College for providing laboratory
facility and funding for study. The study was approved
by Research and Development and Ethical committee
of Shree Devi college of Physiotherapy.
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 DOI Number: 10.5958/j.0973-5674.7.3.110
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 291

Correlation among Cervical Pain, Neck Disability Index

and Health Related Quality of Life for Subjects Suffering
from Cervical Pain of Age Group 20 to 75 Years

Shubha Arora1, Taruna Mathur2

1
Assistant Professor (Occupational Therapy), Department of Rehabilitation sciences, Jamia Hamdard Delhi, Formerly H.O.D
(Department of Occupational Therapy) of D.I.R.D, Under Guru Gobind Singh I.P. University, 2Occupational Therapist,
G.B. Pant Hospital, Delhi, India

ABSTRACT
Objectives:
1. To evaluate neck pain, neck disability and quality of life of patients with cervical pain
2. To find correlation between pain, disability and quality of life
Outcome measures:
1. Visual analogue scale (VAS) for pain
2. Neck disability index for evaluating disability
3. Rand shortform-36 for health related Quality of life
Methodology:
Approx. 50 patients of age group 20-75 years with cervical pain were included in the study. This
study is based on observation. Data was collected from G.B..Pant Hospital , Delhi, various clinics
and from general population on the basis of inclusion criteria. After rapport building, subjects were
evaluated for pain, disability and quality of life for functional outcomes.
After data collection, correlation between the three scales was established and data was analyzed
statistically by using correlation Regression.
Results:
1. Increase in cervical pain will lead to decrease in quality of life in all different domains
2. Disability is directly correlated to quality of life
Keywords: Disability, Quality of life

INTRODUCTION substantial effect on daily life that results in extensive

Neck pain is the most chronic pain problems with
reported 90% of men older than 50 years and 90% of
women older than 60 years have evidence of
degenerative changes in the cervical spine. (1)
Mechanism of disability caused by neck pain has yet
been elucidated, but it is usually accomplished by
use of health care resources.(2,3,4). Neck-pain is frequent
source of disability causing human suffering and
affecting the well-being of an individual. The outcome
measures ought to be multidimensional and include
the subjective experience of the patient. This can be
achieved by measuring the health related qualities of
life (5).

Corresponding author: Neck-pain has been shown to be associated with

Ms Shubha Arora decrease in health related quality of life in several
Assistant Professor studies (6,7-12). While no gold standards exist for
120-B, Deep Enclave, Pocket –D, Phase-3, assessing health related quality of life among patients
Ashok Vihar, Delhi-110052 with neck-pain. Several different measurement tools
Mob No: 9810195029 have been used such as Rand short form–36 health
Email: arora.shubha@yahoo.co.in related survey (13).

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 292 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
To improve functional status and quality of life
measuring neck pain is an important component of
clinical practice, and required validated instruments
in order to gather information about impact of disease,
which is not offered by clinical data.
In recent decades, several questionnaires have been
designed and developed for the purpose, viz, Neck
disability Index (NDI); Visual analogue scale (VAS);
Rand SF36.(14-17)
These three scales were applied to the patient
population and compared with regard to their
psychometric properties and usefulness in order to
determine how pain is correlated with neck disability
index and neck disability index to Medical outcome
study, Rand SF-36 used for Quality of life (QOL). The
rationale behind this study is keeping in mind the
correlation between neck pain and Quality of life; we
can set better goals for individual subjects suffering
from neck pain.
MATERIAL AND METHOD
Fifty patients of age group “20-75 years” with
cervical pain were included in the study. This study
was mainly based on observations. Sample Data was
collected from G.B..Pant Hospital, Delhi ; various
clinics and from general population on the basis of
inclusion criteria.
Inclusion criteria
- Male or female of age group 20-75 years, having
constant or frequent neck pain for more than 6
months.
- Mostly office employed.
- Motivated to continue working.
- Motivated to continue rehabilitation programme.
Exclusion Criteria
Several disorders of cervical spine such as disc
prolapse, spinal stenosis, post operative conditions in
the neck and shoulder area, history of severe trauma,
instability, spasmodic torticollis, frequent migraine,
fibromyalgia, shoulder diseases (tendonitis, bursitis,
capsulitis), inflammatory Rheumatic diseases.(18)
PROCEDURE
All the participants provided written informed
Consents before entry in the study. After rapport
building, each subject was evaluated for neck pain,
neck- disability and quality of life for functional
57. Shubha Arora--291--298.pmd 292
outcomes.
All measurements were performed blind by the
same occupational therapist.All patients completed the
assessment in all 3 scales with in 1-3 days interval.
In administration of scales, the following clinical
parameters were used to assess neck pain, neck-
disability and quality of life by the same therapist. :
• Neck- Pain on Visual Analogue Scale.
• The Therapist global Assessment
• Muscle Spasm
• Neck - sensitivity
• Active range of motion (ROM) of the cervical spine.
In addition, baseline socio-cultural characteristics
including age, gender, education level, occupation,
disease duration in months and morning stiffness were
assessed
Outcome measures
1. Visual analogue scale (VAS) for Neck- pain
2. Neck disability index for evaluating disability
3. The Medical Outcome study Rand Short Form-36
was used to examine health related quality of life
(QOL)
VAS was presented as 100-mm vertical line
containing word anchors at extreme with no pain on
the bottom and worse possible pain on the top with
ten markings.(19)
Neck disability index is a functional pain
assessment scale, used as functional outcome tool for
cervical related disabilities. NDI have been shown to
be valid and reliable tool in evaluation of patients with
neck pain. NDI manifested adequate test/retest
reliability (ICC=0.68).(14,20). This scale has 10 sections
each having 5 questions, having equal scores. Good
scores was given highest marks and poor was marked
lowest scores, so neck pain score was registered
through a scale of 0-50.
Whereas, Medical outcome study “Rand short form
–36”is a likert scale used to assess quality of life and
has 8 health concepts i.e. physical functioning, bodily
pain, role limitations due to physical health problems,
role functioning due to personal and emotional
problems, emotional well-being, social functioning,
energy/fatigue-ness and general health perception.
For each concepts, summery score ranges from 0 to
100.(21)
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 293

From the data collected, correlation between the
three scales was established through data analyzed
statistically by using correlation Regression technique.
Statistical Analysis
subjects (Table-2).Their means and standard deviations
are also calculated as given in Table- 3.
Table2: Categories of Neck Disability Index with
frequency of subjects in each category.

Neck disability index Frequency

Data collected from 50 subjects was tabulated.
Mild Disability 12
Mean and standard deviation was calculated for all
Moderate Disability 21
the 10 variables (e.g..VAS scores, Neck disability index
Severe Disability 17
and eight variables of Rand SF- 36) as given below in
Table-1 Data Sample was subjected to” One way analysis
to variance (Anova) for unrelated subject design test”
Table-1: Mean and Standard Deviation of all ten
variables for finding out “f” value and “t” test for finding
regression coefficient to establish the significance of
Variable Observations Mean Standard the Results
Deviation
Neck pain 50 6.7 1.5 Table3: Mean and standard deviation of different
Neck disability index 50 20.1 9.1 categories of neck disability Index
Physical function 50 62.9 19.3
Categories Frequency Mean Standard
Physical Health 50 37.2 24.0 of Neck Disability Deviation
Emotional problem 50 68.1 33.1 Index
Energy/Fatigue-ness 50 49 20.9 Mild 12 71.6 13.7
Emotional Well-being 50 77.1 19.4 Moderate 21 65.86 19.2
Social Functioning 50 65.8 22.7 Severe 17 52.9 19.45

Bodily pain 50 57.7 24.0 Total/Combined 50 62.86 19.32

General health 50 66.2 18.5 On the basis of Anova test, coefficient “f” was
Correlation coefficient was found between neck calculated among the neck disability variable and all
eight variables of Rand SF-36.one by one to establish
pain and neck disability by conducting Pearson co-
significance of the results. Calculation was performed
rrelation test(22) on the data and was calculated as 0.71
by calculating the variance from mean and standard
(Graph-I). It reflects the positive relationship i.e. if deviation parameters of each group to establish the
neck-pain increases neck disability also enhances. coefficient “f” and probability was read from the table
against the calculated ‘f”. Results of the tests are given
Correlation between two variables is minimum if
in Table-4.
correlation coefficient is equal to zero and is maximum
if it is +1, i.e. closer the co-rrelation coefficient is to Table 4: Variables along with F value and P value
zero, weaker the relationship between the variables.
Variable F Value P Value
Taking the neck disability as principal variable, Physical function 4.23 0.0204
correlation between eight variables as per SF-36, was Physical Health 2.37 0.0104
established one by one (Graph II) Emotional problem 10.07 0.0002
Energy/Fatigue-ness 9.07 0.005
In order to check the chance/Random error, Emotional Well-being 9.01 0.005
subjects were divided into three categories for neck Social Functioning 7.60 .0014
disability index as per severity of neck disability: Bodily pain 5.58 0.0067
General health 4.83 0.0124
1. Mild disability: includes no or mild disability
Data was also subjected to regression analysis to
2. Moderate disability: includes moderate disability
find out regression coefficient “t” for neck disability
3. Severe disability: includes “severely or completely and Rand SF-36 variables one by one through variance
disability” and standard error parameters.This was done to be
doubly sure about test results and correlation among
It was found that for first category of disability there various variables. Result of the test are given below
are 12 subjects, for second 21 subjects and for third 17 (Table5).

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 294 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 5: Rand SF36 Variables along with regression

coefficient and T value and p value.

RandSF36 Regression
Variables coefficient. T value P value
Physical function -0.56 -1.75 0.045
Physical Health -0.24 -0.62 0.268
Emotional problem -1.31 -2.68 0.015
Energy/Fatigue-ness -0.82 -2.85 .006
Emotional Well-being -0.54 -1.83 .035
Social Functioning -0.83 -2.44 .009
Bodily pain -0.76 -2.09 0.022
General health -0.53 -1.85 0.035

RESULTS
4. All Rand SF-36 variables, reduces as the neck
1. Correlation between Neck- pain and Neck
disability was found to be in the ratio of 1:0.71. As
it is positive relation, which shows that if neck pain
increases, neck disability also increases ( Graph I )
disability increases. This is being denoted by “t”
negative value for all variables. As neck disability
increases, physical functioning, bodily pain, role
limitations due to physical health problems, role
functioning due to personal and emotional
problems, emotional well-being, social
functioning, energy/fatigue-ness and general
health perception. Same is also reflected in Graph-
II.as all correlation coefficients are negative, with
respect to Neck disability.

DISCUSSION AND CONCLUSION

Fifty subjects suffering from neck pain were

analyzed on the basis of pain (VAS), neck disability
index and quality of life (Rand SF36)

Graph-I: Neck-Pain scores Vs Neck disability
Index in relation to Pearson correlation coefficient
2. It is clear from Graph-II that there is Negative
correlation of Rand –36 variables with neck
disability index, which in turn is positively co-
related to neck pain. Correlation is maximum in
energy/ fatigue-ness variable, followed by
emotional problems, social functioning, body pain,
emotional well-being, general health, and is
minimum for physical health variable.
GRAPH-II: Ray diagram showing Pearson corr.
between neck disability and eight variables of
Rand SF36
3. From Table5 it is clear from the results that but for
the physical health variable correlation with neck
disability, all other results are significant because
p<5%or 0.05.For Physical health relation, random
error or chance error has spoiled the results
showing high rate of error probability.
First of all pain was correlated with neck disability
index on the basis of Pearson Correlation Coefficient.It
was found to having a ratio of 1:0.71 which signifies
that it has a positive correlation. It shows that if pain
increases neck disability also increases. It was
supported by KoseG (22).who compared the four
disability scales on Turkish patients with neck pain.
Secondly correlation between neck disability index
and eight variables of QOL (Rand SF-36) was done
which showed that Pearson correlation is more in
energy/fatigue-ness and least in physical health.
All Rand SF-36 variables reduce as the neck
disability increases. This is being denoted by negative
values of correlation coefficients between neck
disability and Rand SF-36 all variables and was
supported by Wanch in 2005(23),Lingin2003(24)and Li Nx
in 2001(25) who analyzed that SF36 dimensions were
remarkably impaired in chronic diseases. People with
Chronic diseases had worse quality of life that those
without.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 295
Ignoring the Physical health analysis (which is one
of the variables of Rand SF- 36). Probability error due
to chance is minimum for emotional functioning and
maximum for physical functioning so our results are
significant because “p” value is <5%
For physical health random/chance error has
spoiled the results showing high rate of error
probability.
The limitation of above study is that the scale used
was likert one that does not define that person who
scores- 4 feels twice strongly pain than the one who
scores- 2.But questionnaire was made to collect the
data, however human intelligence limit may mislead
and misinform in defining the health quality
parameters. This may have serious implications in
concluding the result.
For future recommendation the sample size should
be increased for best results and more standardized
tools with higher reliability can be used for different
variables to arrive at best results.
ACKNOWLEMENT
I would like to give a vote of thanks to Dr
R.N.Pandey, a Biostatician at AIIMS, Delhi who helped
me in analyzing the sample..
Conflict of Interest: Nil
Source of Funding: Self
Ethical Clearance: As it is observational study, ethical
clearance not required.
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Physiology Thera. 1991; 14:409-415.
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AO.The Northwick Park Neck Pain
Questionnaire devised to measure neck Pain and
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Copenhangen Neck Functional Disability scale:
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16. Wheeler A H Goolkasian P Baird AC, Darden BV
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17. Petricksalo, and Jari J yunen:Effect of neck
strength training on health related quality of life
in females with chronic neck pain: A randomized
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Quality of life Outcome 2010 ;8: 42-48
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Scale. A practical Guide to their development and
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discussion of MOS Measures.Measuring function
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and wellbeing:The Medical Outcome
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22. KoseG,Hepguler, Ataman et al :A comparison of
four disability scales for Turkish population with
neck pain.:2007,May39(5):358-62
23. Wanch Fang et al :the effect of evaluation on
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24. Liang Xy et al : evaluation of health related quality
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 DOI Number: 10.5958/j.0973-5674.7.3.111
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 297

Profile of Older Adults in Memory Outpatients' Clinic

Setting and effectiveness of Novel Occupational Therapy
Intervention in Patients with Mild to Moderate Dementia

Prakash Kumar1, SC Tiwari2, V Sreenivas3, Nand Kumar4, R K Tripathi5, Dey AB6

1
PhD Scholar, KGMU Lucknow, SRF (ICMR), Occupational Therapist, AIIMS, New Delhi, 2Professor and Head,
Department of Geriatric Mental Health, KGMU, Lucknow, 3Associate Professor, Department of Biostatistics,
AIIMS, New Delhi, 4Associate Professor, Department of Psychiatry, AIIMS, New Delhi, 5Assistant Professor, Department of
Geriatric Mental Health, KGMU, Lucknow, 6Professor and Head, Department of Geriatric Medicine, AIIMS, New Delhi

ABSTRACT
Background: Researchers and clinicians are working hard for prevention and management of dementia
and its complications, no definite remedy is available now. Our aim is to investigate effects of
occupational therapy in maintaining quality of life of patients having mild to moderate dementia.
Methodology: 263 older subjects (new-182, old-81) were included between November 2010 and April
2013. After screening of all patients by a geriatrician, 192 were excluded having [Cognitive impairment
with no dementia (CIND)]. Rest 71 patients were included after satisfying DSM IV criteria and were
randomly assigned to experimental and control groups. Experimental group received newly developed
occupational therapy intervention along with the drug, and control group received only drug for a
period of 5 weeks. Both groups were evaluated using the six outcome measures a) Folstein Mini
Mental status examination, b) Geriatric Depression scale Hindi Version c)Bristol Activity of daily
Living, d) Modified Physical Performance test, e) BEHAV-AD, f)WHO QOL [Hindi Version] obtained
baseline and reassessment after 5 weeks.
Result: Included subjects with mean age 69.39 having 33.80% of primary education, 32.39 % up to
class 12, 47.88% of living with spouse, 47.88% of living with spouse and family, 78.87% married,
16.9% widowed, 22.53% unemployed, 43.66% retired. After application of novel occupational therapy
on experimental group there is statistically improvement in the domain of Depression, ADL, Physical
performance, and quality of life, out of all six domains.
Conclusion: The study reveals that the newly developed occupational therapy program can improve
behavioral status, functionality, physical performance, mood and quality of life in elderly dementia
patient at short term. A follow up study is required to ascertain the long term effect of treatment.
Keywords: Novel Occupational Therapy Intervention Programme and Dementia

INTRODUCTION Dementia can impact daily living as initiating and

Dementia is a condition that affects one in eight
people over the age of 65 and one in three over the age
of 85; it is one of the three major diseases with regard
to health care consumption1, 2 and is a major cause of
disability and care burden in the elderly. Dementia can
be caused by one or more pathologies, such as
Alzheimer’s disease, stroke, vascular dementia and
Parkinson’s disease and comprises of a collection of
symptoms, including a decline in memory, impaired
judgment and reasoning, difficulty in learning, as well
as changes in behavior, mood and ability to
communicate and a gradual loss of skills needed to
carry out daily activities.3, 4
completing tasks becomes increasingly difficult with
declines in cognition.5, 6 There usually comes a time
when losses in abilities necessitate a caregiver to help
complete first instrumental activities of daily living
(IADLs; such as grocery shopping and paying bills)
followed by basic activities of daily living (BADLs;
such as bathing, toileting and dressing.7, 8
The American Geriatric Society 9 recognizes four
stages in the progression of AD. These stages are
identified through the use of standardized screening
tools such as the Mini Mental Status Exam (MMSE),
The initial, or preclinical, stage is classified as MCI with
MMSE scores between 26 and 30, with complaints of

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 298 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3
memory loss, no functional impairment. Progression
to the early stage of AD is classified as Mild
Impairment with MMSE score between 21 and 25.
Moderate Impairment is characterized by further
decline in screening scores from 11 to 20 and it is
marked by the onset of aphasia, deterioration in ADLs,
IADLs, and the onset or increase in neuropsychiatric
symptoms. Late stage AD is accompanied by severe
impairments in memory, cognition, speech, and motor
function. Patients are usually incontinent, unable to
care for themselves, and may exhibit motor or verbal
agitation.
It has been projected that two out of every three
patients with dementia will soon be in developing
countries and the urgent need to prepare to face it10
and there is a need for developing comprehensive
management strategy. In such a strategy, concepts and
interventions of occupational therapy need to be
included as a complement to standard drug therapy.11
Occupation is the purposeful activity which is
performed in daily life, require a balance between
self-care, productivity and leisure and assists people
in developing the “skills for the job of living”.12
Occupational therapy applicable in old age adults
with Dementia
Principles of occupational therapy includes
preventive, accommodative and restorative
approachs. 13 and for maximizing the remaining
capabilities, use compensatory strategies.14 Therapists
use client centered methods to determine their own
needs and goals.15 The method of assessment is based
on two patient centric models: the model of human
occupation 16 and the Canadian model of occupational
performance, 17 whereas for interventions use
biomechanical18 and cognitive disability framework of
reference.19
METHODOLOGY
The aim of the research is to see the effect of a novel
occupational therapy intervention programme on
cognition, activity of daily living, physical
performance, depression, psychological and
behavioral symptom and quality of life of patients with
mild to moderate dementia. Experimental Pre and
Posttest control group design was chosen for the study.
Subjects coming at memory clinic, department of
Geriatric Medicine, AIIMS, New Delhi, and
department of Geriatric Mental Health, KGMU,
58. Dementia--297--304.pmd 298
Lucknow, who met the inclusion criteria, were
recruited in the study which one is diagnosed by
geriatrician/clinician after satisfying DSM IV criteria.
Severity of dementia was determined with the use of
MMSE and written consent was obtained from each
subject /subject’s caregiver. Subjects randomly
assigned into control and experimental group.
Inclusion criteria were as follows: older adults aged
60 years and above , Mini Mental State Examination
MMSE ranging from 11 to 23, educational level of
subject is at least 5th standard, who can read and
understand simple sentences. Exclusion criteria were
as follow: severe Dementia patients, depression
(Patients having GDS Score is more than 24), subjects
having severe behavioral or psychological symptoms
in dementia, subjects require nursing care due to severe
medical illness.
A pilot study was conducted on 13 subjects at
Memory Clinic, AIIMS in 2011, to find out the
feasibility of the study, gather information for framing
a suitable sampling design, and develop a novel
occupational therapy programme. This data suggests
that the newly developed occupational therapy
intervention programme can possibly improve some
of the parameters include physical performance,
mood, and functionality and quality of life. Paper
based on pilot study was awarded as a NIMS best
paper award (3rd prize) IAG congress Vellore, 2011.20
INTERVENTION
The study intervention was developed in a
consensus process, during pilot study and in delivering
treatment according to this client-centered
occupational therapy guideline for patients with
dementia.21 Detailed development and content of novel
occupational therapy intervention programme was
published in Journal of Indian academy of Geriatrics22,
which include 10 session with duration of one hour
ten minutes completed within 5 weeks. Each session
consist of a. Relaxation for 10 minutes23, b. Physical
Exercises for 10 minutes24, c. Personal activities for 15
minutes, d. Cognitive exercise for 20 minutes25, and e.
Recreational activity for 15 minutes26.
Outcome Assessment
Each group was assessed at baseline before
intervention by using the general Occupational
Therapy assessment Performa performa and further
evaluation were done using 6 standardized scale.
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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 299

standardized scale. MMSE 27 , Hindi Geriatric PROCEDURE

Depression Scale 28 (GDS), Modified Physical
performance test29, Bristol ADL Scale30 BEHAV-AD31
for and Hindi version of WHOQOL-BREF32.MMSE,
MPPT and WHO-QOL have higher scores have better
performance, whereas BADL, BEHAV-AD and GSD
have lower scores have better performance.
263 older subjects (new-182, old-81) were included
between November 2010-April 2013. After screening,
192 were excluded and rest 71 patients were included.
The experimental group received newly developed
occupational therapy programme along with the drug,
and control group were only received drug for a period
of 5 weeks.

RESULT

Statistics were performed using STATA 11 software.

Level of significance taken was < 0.05.Two sample t-
test was using for analysis between groups and paired
t-test for within groups. The mean age of control group
is 69.85 years and 68.93 years in experimental group.
Sample size is male dominant with right handedness.
Details of demographic data are shown in table 1.

Table 1. The descriptive statistics of subjects

Control Experimental p-Value

group (%) group (%)
Gender Male 32(78.0) 27 (90.0) 0.218
Female 9 (21.9) 3 (10.0)
Handedness Right 35 (85.4) 27 (90.0) 0.724
Left 6(14.6) 3(10.0)
Occupation Unemployed 12(29.2) 4(13.3) 0.113
Employed 1(2.4) 4(13.3)
Retired 18(43.9) 13(43.3)
Business 7(17.0) 3(10.0)
Farming 3(7.3) 6(20.0)
Education Primary 15(36.5) 9(30.0) 0.455
Class 12 11(26.8) 12(40.0)
Graduate 10(24.3) 8(26.7)
Postgraduate 5(12.2) 1(3.3)
Marital Single 2(4.9) 1(3.3) 0.456
status
Married 34(82.9) 22(73.3)
Widow/ 5(12.2) 7(23.3)
widower
Living Living 2(4.9) 1(3.3) 0.542
arrangement alone
With spouse 22(53.7) 12(40.0)
family with 17(41.5) 17(56.7)
spouse
Dementia Mild 32(78.0) 18(60.0) 0.100
Moderate 9(21.9) 12(40.0)

Graph 1. Showing means value of MMSE, GDS, BADL, PPT,

BEHA-AD, and WHO-QOL pre-post.

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 300 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table -2 Comparison of MMSE, GDS-Hindi, BADL, PPT, BEHAV-AD, and HWHO-QOL-Hindi, within the group,
and between groups.

Variables Group PreMean ±SD PostMean ±SD p-value

MMSE Control 21.12±2.62 20.95±2.52 0.164
Experimental 20.6±2.54 20.76±2.50 0.057
p-value 0.404 0.761
GDS (H) Control 14.31±3.22 15.58±3.94 0.000**
Experimental 15.36±4.26 13.06±3.91 0.000**
*
p-value 0.241 0.009
BADL Control 21.95±5.89 23.56±6.32 0.000**
Experimental 23.1±6.47 15.7±2.93 0.000**
p-value 0.439 0.000*
MPPT Control 17.19±2.56 16.80±2.54 0.040
Experimental 17.06±3.25 20.6±3.72 0.000**
p-value 0.853 0.000*
BEHAV-AD Control 15.60±5.93 15.36±5.80 0.375
Experimental 18.23±8.13 17.2±7.09 0.010**
p-value 0.120 0.235
WHO-QOL (H) Control 68.14±3.26 67.65±3.49 0.010**
Experimental 66.46±3.58 71.33±4.70 0.000**
* *
p-value 0.043 0.003

*p-value between group **p-value between group

DISCUSSION The physical performance (MPPT) of the subject in

The cognition (MMSE) in the control group has
decreased (21.2-20.95) and increased in experimental
post intervention, as in shown by their means, (20.6-
20.76) though the change in the experimental group
was slightly higher than in the control group. Further
analysis on the scores revealed that these changes are
statistically not significant both in the control (p=0.164)
and the experimental group (p=0.057). Though it has
not reached up to the level of statistical significant, but
there is visible improvement in experimental group.
Moreover we can conclude better once our study will
be completed with sample size of 100.
The depression score in the control group has
increased significant (14.31-15.58; p=0.000), whereas
it has decreased in experimental group (15.36-13.06;
p=0.000) suggest that occupational therapy has define
role in prevention of progression of depression.
The activity of daily living (BADL) in the control
group has increased (21.95-23.56; p=0.000) means that
subjects in this group have increased their dependency
in their activity of daily living in the absence of
occupational therapy intervention. In experimental
group their independency is increased significantly
(23.1-15.7; p=0.000).
control group is decreased (17.19-16.80; p=0.040),
which is statistically significant, means that without
novel programme the physical performance of subject
is decreased. Whereas in experimental group it is
increased significantly (17.06-20.6; p=0.000).
Behavior and psychological issue (BEHAV-AD), of
the subject in control group has no changes seen post
intervention, whereas in the experimental group a
slight improvement is noted which is significantly
improved. (18.23-17.20; p=0.010).
The quality of life of subject in control groups is
decline significantly (68.46-71.33; p=0.010), and after
application of novel occupational therapy in subject
in experimental groups, there quality of life were
increased which is statistically significant. (66.46-71.33;
p=0.000). Though authors accept that there is
significant difference between the two study groups
during index visit, so concluding improvement in
WHO-QOL is difficult at this juncture may be we will
be in better position once all sample size will be taken
into consideration.
When all six variables are compared between the
groups then we found that GDS, BADL, MPPT, and
WHO-QOL is statistically significant results in post
intervention (15.58-13.06; p=0.009), (23.56-15.7;

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 301
p=0.000), (16.80-20.6; p=0.000), (67.65-71.33; p=0.003)
respectively.
Previous studies have shown that community
based occupational therapy, helps to improve the
functional independence and autonomy of the patients
with dementia and to decrease their caregiver
burden. 33 Another study results shows that
occupational therapy improved patients’ daily
functioning and reduced the burden on the care giver,
despite the patients’ limited learning ability. Effects
were still present at 12 weeks, which justifies
implementation of this intervention.34
CONCLUSION
This novel occupational therapy programme
proved to be effective in increasing the mood,
functionality, physical performance and overall quality
of life of the cognitive impaired elderly. Better outcome
may be seen by combining the physical, cognitive,
personal, and recreational activities and doing some
relaxation tasks. We strongly advocate the inclusion
of such intervention in dementia management
programme. Clinicians need to apply these techniques
to improve quality of life dementia patients and their
care givers.
ACKNOWLEDGMENTS
This work was funded by a grant from Indian
Council of Medical Research, New Delhi, under the
Senior Research Fellowship program.
Ethical Clearance: Taken
Conflict of Interest: Nil
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