Volume 8 Number 4 October-December 2014

Published, Printed and Owned : Dr. R.K. Sharma

Designed and Printed : M/s Vineeta Graphics, B-188, Subash Colony, Ballabgarh, Faridabad
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 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)

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1. Vikram Mohan (Lecturer) Universiti Teknologi MARA,
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2. Angusamy Ramadurai (Principal) Nyangabgwe Referral
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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,
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12. Rashij M, Faculty-PT Neuro Sciences College of Allied Health
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14. Muhammad Naveed Babur (Principle & Associate Professor)
Isra University, Islamabad, Pakistan
15. Zbigniew Sliwinski (Professor) Jan Kochanowski University
in Kielce
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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
21. Dr. Abdel Hameed Nabil Deghidi (Lecturer) Dept. of Physical
Therapy & Health Rehabilitation, College of Applied Medical
Sciences, Majmaah University Majmaah, KSA
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.
19. N.Venkatesh (Principal and Professor) Sri Ramachandra
university, Chennai
20. Meenakshi Batra (Senior Occupational Therapist), Pandit
Deen Dayal Upadhyaya Institute for The Physically
Handicapped, New Delhi
21. Shovan Saha, T (Associate Professor & Head) Occupational
therapy School of allied health sciences,Manipal
university,Manipal,, karnataka,

EDITORIAL PAGES.pmd 2 6/26/2014, 4:24 PM

 Indian Journal of Physiotherapy and Occupational Therapy
NATIONAL EDITORIAL ADVISORY BOARD SCIENTIFIC COMMITTEE
21. Akshat Pandey (Sports Physiotherapist) Indian Weightlifting 1. Gaurav Shori (Assistant Professor) I.T.S College of
Federation/ Senior Men and Woman / SAI NSNIS Patiala Physiotherapy
23. Dr. Jagatheesan A (HOD-Paediatric Physiotherapy & 2. Baskaran Chandrasekaran (Senior Physiotherapist) PSG
Associate Professor) Saveetha College of Physiotherapy, Hospitals, Coimbatore
Thandalam, Chennai 3. Dharam Pandey (Sr. Consultant & Head of Department) BLK
24. Maneesh Arora (Professor and as Head of Dept) Sardar Super Speciality Hospital, New Delhi
Bhagwan (P.G.) Institute of Biomemical Sciences, Balawala, 4. Jeba Chitra (Associate Professor) KLEU Institute of
Dehradun, UK Physiotherapy Belgaum, Karnataka
25. Jayaprakash Jayavelu (Chief Physiotherapist) Medanta The 5. Deepak B.Anap (Associate Professor) PDVPPF's, College
Medicity, Gurgaon Haryana of Physiotherapy, Ahmednagar. ( Maharashtra)
26. Deepak Sharan (Medical Director and Sole Proprietor) 6. Shalini Grover (Assistant Professor) HOD-FAS,MRIU
RECOUP Neuromusculoskeletal Rehabilitation Centre, New 7. Vijay Batra (Lecturer) ISIC Institute of Rehab. Sciences
Delhi
8. Ravinder Narwal (Lecturer) Himalayan Hospital, HIHIT
27. Vaibhav Agarwal (Incharge, Dept of Physiotherapy) HIHT, Medical University, Dehradun-UK.
Dehradun
9. Abraham Samuel Babu (Assistant Professor) Manipal
28. Shipra Bhatia (Assistant Professor) AIPT, Amity university, College of Allied Health Sciences, Manipal
Noida
10. Anu Bansal (Assistant Professor and Clinical Coordinator)
29. Jaskirat Kaur (Assistant Professor) Indian Spinal Injuries AIPT , Amity university, Noida
Center, New Delhi 11. Bindya Sharma (Assistant Professor) Dr. D. Y. Patil College
30. Prashant Mukkanavar (Assistant Professor) S.D.M College Of Physiotherapy, Pune
of Physiotherapy, Dharwad, Karnataka 12. Dheeraj Lamba (Lecturer) Institute of Allied Health
31. Chandan Kumar (Associate Professor & HOD) Neuro- (Paramedical) Services, Education & Training (IAHSET) Govt. Medical
physiotherapy, Mahatma Gandhi Mission's Institute of 13. Soumya G (Assistant Professor) (MSRMC)
Physiotherapy, Aurangabad, Maharashtra
14. Nalina Gupta Singh (Assistant Professor) Physiotherapy,
32. Dr. Kshitija Bansal (Assistant Professor) Amar Jyoti Institute of Physiotherapy, University of Delhi
Amar Jyoti Institute of Physiotherapy University of Delhi
15. Gayatri Jadav Upadhyay (Academic Head) Academic
33. U Albert Anand (Professor), Physical Therapy Education and Physiotherapist & Consultant PT, RECOUP Neuromusculoskeletal
Research, Senior Physiotherapist, KG Hospital and K.G Rehabilitation Centre, Bangalore
College of Physiotherapy, Coimbatore, Tamilnadu, India 16. Nusrat Hamdani ( Asst.Professor and Consultant)
34. Dr. M G Mokashi (Professor Emeritus), Physiotherapy, Neurophysiotherapy (Rehabilitation Center, Jamia Hamdard) New Delhi
Dr. D Y Patil University, Pimpri, Pune 17. Ramesh Debur Visweswara (Assistant Professor) M.S.
35. Dr. Balaji.G (Professor and Research Coordinator), Ramaiah Medical College & Hospital, Bangalore
Krupanidhi College Of Physiotherapy, 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
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EDITORIAL PAGES.pmd 3 6/26/2014, 4:24 PM

 I

Indian Journal of Physiotherapy and

Occupational Therapy
www.ijpot.com
Contents
Volume 08 Number 04 October-December 2014

1. Modifications in Homes of the Geriatric Population to Improve Quality of Life .............................................................. 01

Ashutosh Kurtkoti

2. Comparative Study of Short Term Response between Maitland Mobilization and ......................................................... 06
Mulligan's Mobilization with Movement of Hip Joint in Osteoarthritis of Knee Patients
Identified as Per Clinical Prediction Rule
Ajit Dabholkar, Sneha Kumari, SujataYardi

3. Correlation of Balance Performance and Fear of Fall in Parkinson's Disease ..................................................................... 11

Avani Desai, Vivek Kulkarni, Nimisha Mishra, SavitaRairikar, AshokShyam, ParagSancheti

4. A Study on Co-Relationship between Static Back Extensor Endurance in Patients .......................................................... 16

with Non-Specific Chronic Low Back Pain and Healthy Individual
Paras Bhura, Camy Bhagat

5. To Compare the effect of Task Oriented Intervention and Treadmill Training to ............................................................. 21
Improve Gait in Chronic Ambulatory Hemiparetic Stroke Patients
Monika Sharma, Dharam Pani Pandey

6. Effect of Muscle Energy Technique to Improve Flexibility of Gastro-Soleus Complex in ................................................ 26

Plantar Fasciitis: A Randomised Clinical, Prospective Study Design
Rahul Tanwar, Monika Moitra, Manu Goyal

7. Effect of Muscle Energy Technique to Improve Flexibility of Gastro-Soleus Complex in ................................................ 31

Plantar Fasciitis: A Randomised Clinical, Prospective Study Design
Sharma S, Saini S, Kaprail M, Dhillon PK, Benjamin KE, Saini P

8. A Comparative Study of Static Stretch and Proprioceptive Neuromuscular Facilitation ................................................. 37

(PNF) Stretch on Pectoral Muscle Flexibility
Vohra Ramneesh, Kalra Sheetal, Yadav Joginder

9. Effect of Muscle Energy Technique and Deep Neck Flexors Exercise on Pain, Disability and ........................................ 43
Forward Head Posture in Patients with Chronic Neck Pain
Narang Sakshi, Mehra Suman, Sikka Geetanjali

10. Application of TENS on Acupoints as an Important Adjunctive Tool with Task-Related ............................................... 49
Training in Stroke Rehabilitation Program- A Case Study
Manoj Kumar Deshmukh, Manu Goyal, Yogita Verma

11. Effect of Progressive Resisted Exercise on Strength, Endurance and Balance on .............................................................. 54
Older Adults above 60 Years
Hetal Jain

Content Final.pmd 1 11/1/2014, 8:00 AM

 II

12. Lumbar Stabilization Exercises on Pain, Disability and Endurance in Patients with and ................................................ 60
Without Lumbosacral Belt in Mechanical Low Back Pain
Neha Gulati, Monika Moitra, Manu Goyal

13. Effectiveness of Physiological Cost Index and Gait Parameters in Conventional ............................................................. 66
Versus Ultramodern Prosthesis in Unilateral Transtibial Amputees -A Comparitive Study
Shivananda V, Syed Yakub, Nidhin Jose, Sasidhar

14. Nerve Conduction Studies of Upper Extremity in Badminton Players ............................................................................... 72

Manish Dhabliya, Twinkle Y Dabholkar, Sujata Yardi

15. Correlation of Transverses Abdomonis Strength and Endurance with .............................................................................. 77

Pulmonary Functions in Healthy Adults
Gotmare Neha, Nagarwala Raziya, Ghodke Aditi, Rairikar Savita, Shyam Ashok, Sancheti Parag

16. A Study on the effectiveness of Plyometric -Weight Training on Anaerobic Powerand .................................................. 82
Muscular Strength in Athletes
Sathish Gopaladhas, Elanchezhian Chinnavan, Dhayanidhi Rajaram

17. Effect of Complete Decongestive Therapy (Cdt) in Upper Limb Lymphedema ................................................................ 87
in Breast Cancer Patients
Mullai Dhinakaran, Kunal Jain, K E Benjamin, ParamdeepKaur, Dhinakaran

18. Effects of Early Mobilization Combined with Conventional Physiotherapy Treatment .................................................. 92
After 4 Hrs of Lobectomy on Haemodynamics, Abg and Pft
Mohammad Qasim, Jyoti Jalwan, R K Dewan

19. Comparison of Active Cycle of Breathing and High-Frequency .......................................................................................... 97

Oscillation Jacket in Bronchiectasis Patient
Manish P Shukla, Vaibhav M Kapre

20. Injury Management and Return-To-Play: Practices in India ............................................................................................... 102

Nandakumar T R MPT, Jaspal Singh Sandhu MS

21. Effect of Music Intervention on Immediate Post Operative Coronary Artery .................................................................. 106
Bypass Graft Surgery (CABG) Patients
ShwetaS DevarePhadke, HadiyaParkar, SujataYardi

22. Compare the effectiveness of Massage Versus Cryotherapy in Treating .......................................................................... 112
Delayed Onset Muscle Soreness
Sai Deepthi Yarlagadda, M Seshagiri Rao

23. A Study of Common Impairements Following Modified Radical Mastectomy ............................................................... 117
Kinjal D Raja, U S Damke, S Bhave, M M Kulsange

24. Effects of A Six-Weeks Balance Training on Balance Performance and ............................................................................ 123
Functional Independence in Hemiparetic Stroke Srvivors
Caleb Ademola Gbiri, Aishat Shittu

25. Effect of Swiss Ball Training on Balance in Hemiplegic Patient ......................................................................................... 128
Preeti Gazbare, Tushar Palekar

26. Role of Physiotherapy in Public Health Domain: India Perspective .................................................................................. 134
Kirti Sundar Sahu, Bhavna Bharati

Content Final.pmd 2 11/1/2014, 8:00 AM

 III

27. Effect of Joint Approximation through Weights Around Waist on ................................................................................... 138
Postural Sway and Balance in Elderly
Neetu Rani Dhiman, Sunil Bhatt, Vyom Gyanpuri, Girdhari Lal Shah

28. Effectiveness of Tailor Made Exercise Intervention for Low Back Pain and ..................................................................... 143
Pelvic Pain during Pregnancy - A Randomized Controlled Trial
Arati Mahishale, Shobhana Patted

29. A Study to Correlate Various Anthropometric Measures on Excursion Distances while .............................................. 149
Performing on the Star Excursion Balance Test among Amateur Sports Person - A Cross
Sectional Observational Study
Krishna D Desai, Hardik Trivedi

30. Return to Run: Lateral Ankle Sprain with Sural Nerve Involvement - A Case Study .................................................... 156
Jacob Praveen Jayamoorthy

31. Prevalence of Neck or/and Low Back Pain and Associated Risk Factors in Sidcul ........................................................ 162
Industrial Area, Rudrapur, Uttrakhan
Sunil Bhatt, Prabhjot Kaur

32. A Study to Compare the effectiveness of Different Dosage of Therapeutic Ultrasound on ........................................... 168
Pain and Grip Strength in Patients with Lateral Epicondylitis
Mittal Hareshbhai Shanishwara, Ashish Kakkad

33. Effect of Slump Stretching with Static Spinal Exercise for the Management of Non ...................................................... 175
Radicular Low Back Pain among Non Active Sports Persons
Karthikeyan, Jaihind jothikaran, Pradeep Kiran

34. A Cor-Relational Study Between Carpal Tunnel Syndrome Questionnaire and Nerve ................................................. 180
Conduction Study in Computer Operators
Hemal Paneri, Sarla Bhatt

35. Effect of Body Weight Squatting on Functional Independence in the Individuals with ................................................. 186
Incomplete Spinal Cord Injury
Disha Solanki

36. Effecacy of Backwardwalking on Patient with Osteoarthritis of Knee on Quadriceps ................................................... 192
Strength, Pain and Physical Functions
Manisha Rathi, Tushar Palekar, Anjumol Varghese

37. A Comparative Study to Find out the Calcaneal Eversion in Overweight and Normal Individuals ........................... 197
Hemal Paneri, Sheshna Rathod, Disha Solanki

38. Effect of Cryotherapy on the Intrinsic Muscle Strength of the Hand ................................................................................ 202
Himanshu Mohan Pathak

39. A Comparative Study between Taping and Medial Arch Support on EMG Activity ..................................................... 207
of Selected Foot Muscles in Individuals with Flexible Flat Foot
Dabie Wu, Navin Daniel Raj

40. Comparison of Flow and Volume Oriented Incentive Spirometry on Lung Function and ............................................ 214
Diaphragm Movement After Laparoscopic Abdominal Surgery. A Randomized Clinical Pilot Trial
Gopala Krishna Alaparthi, Alfred Joseph Augustine, Anand R, Ajith Mahale

Content Final.pmd 3 11/1/2014, 8:00 AM

 IV

41. Effect of Treadmill Training on Gait and Balance Impairments in Patients with Parkinson's Disease ........................ 219
Nimisha Mishra, Vivek Kulkarni, Savita Rairikar, Ashok Shyam, Parag Sancheti

42. A Study to Compare efficacy of Taping Technique Versus Calcaneum Glide ................................................................. 224
Mobilization for the Treatment of Planter Fasciitis
Mayur Solanki

43. Comparison of Sit and Reach Test, Back Saver Sit and Reach Test and Chair Sit and Reach ........................................ 230
Test for Measurement of Hamstring Flexibility in Female Graduate and Undergraduate
Physiotherapy Students
Garima Wadhwa, Chaya Garg

44. Prevalence of Post Polio Syndrome in Gujarat and the Correlation of Pain and ............................................................. 235
Fatigue with Functioning in Subjects with Post Polio Syndrome
Megha Sandeep Sheth, Srishti Sanat Sharma, Rajesh Jadav, Bhaskar Ghoghari, Neeta Jayprakash Vyas

45. A Study of Neck Pain and Role of Scapular Position in Computer Professionals .......................................................... 241
Jyoti Dahiya, Savita Ravindra

46. Efficacy of Maitland's Spinal Mobilizations Versus Mckenzie Press-Up Exercises on ................................................... 247
Pain, Range of Motion and Functional Disability in Subjects with non Radiating Acute Low Back Pain
Arpit Sheth, Anu Arora, Sujata Yardi

47. Effect of Breathing Exercises on Lung Functions in Postpartum Mothers with Normal Vaginal Delivery ................. 253
Amrita L Tomar, Manisha A Rathi

48. Impact of Simultaneous Feedback Augmentation and Real Time Treadmill ................................................................... 258
Training on Gait in Diplegic Childre
Ragab Kamal Elnaggar

49. Relative & Cumulative efficacy of Auditory & Visual Imagery on Upper Limb ............................................................... 64
Functional Activity among Chronic Stroke Patients
Fuzail Ahmad, Sami Al-Abdulwahab, Nasser Al-Jarallah, Raidah Al-Baradie,
Mohammad Z Al-Qawi, Faizan Z Kashoo, Harpreet S Sachdeva

50. Effect of Dexamethasone Iontophoresis Combined with Strong Surged Faradic ............................................................ 270
Current on Piriformis Syndrome -A Simple Randomized Control Clinical Trail
FGowrishankar Potturi, A N Sundaresan, J Mahendran, P D Karthikeyan, V KrishnaReddy

51. Effect of Ageing on Lumbar Curvature, Lumbar Mobility, Back Extensor Strength and ............................................... 276
Their Relationship with Postural Stability and Clinically Relevant Low Back Pain
Mohammad Rehan Asad, Khwaja Mohammad Amir, Fahim Haider Jafari, Mohamed Taha, Waqas Sami

52. A Study to Identify Responses to Sensory Events in Daily Life in Children with ........................................................... 282
ADHD & Typical Developing Children among Indian Population
U Ganapathy Sankar, Kotharu Akhila

53. Comparison of Incentive Spirometry V/S Peak Flow Meter by Measuring the .............................................................. 288
Peak Flow Rate in Post Operative Abdominal Surgery Patients
Apeksha O Yadav

54. Effect of Passive Vibration on Skin Blood Flow in Persons with Good Glycemic ........................................................... 293
Control and Poor Glycemic Control Type 2 Diabetes
Kanikkai Steni Balan Sackiriyas, Everett B Lohman, Noha S Daher, Lee S Berk, Rafael Canizales, Ernie Schwab

Content Final.pmd 4 11/1/2014, 8:00 AM

 DOI Number: 10.5958/0973-5674.2014.00344.X

Modifications in Homes of the Geriatric Population to

Improve Quality of Life

Ashutosh Kurtkoti
Asst. Professor, CMF's College of Physiotherapy, Nigdi, Pune
1

ABSTRACT
Introduction & Purpose: Older people are often not aware about healthcare and lack scientific
knowledge about the home modifications, rehabilitation and the place of living. So in order to study
the basis geriatric problems with respect to their living place and the mentality of care givers for
acceptance of home modifications, a specially designed study was needed.
Aim: To assess the homes to find out environmental barriers and to check the readiness of the people
to modify them.
Objectives: To assess the homes of geriatrics for potential environmental barriers, to suggest the
home modifications and check readiness of the people for home modifications and check which area
is of home people are keener to modify to prevent falls.
Methodology: Study design is descriptive study and sample population taken was geriatric people
in PCMC area with sample size of 100 (50 first visit, 50 second visit). Simple random sampling method
was used. Healthy elders living in homes with family were included in the study. Survey was done
in living room, bed room, kitchen, bathroom, and stairs of house, then questionnaire based assessment
was done & required modifications were suggested, in the second visit it was checked whether the
people have done the modifications or not & which is the most common area of the house for barriers,
and people are keener to modify. Pre & post questionnaire survey was used as an outcome measure.
Result: The data was analyzed using descriptive statistics at Level of significance (? ) 5 % ( p value
0.05) & Degree of freedom 1. Out of 50, 40 homes have done suggested home modifications i.e. 80%
and 10 homes have not done home modifications i.e. 20 %, Maximum people have done modifications
in toilet/bathroom (24%) followed by living room (21%), stairs (20%), kitchen (19%) and bedroom
(16%).
Conclusion: People have willingness to do home modifications. Bathroom/toilet is found to be the
most concerned area of home where maximum home barriers are found and modifications are done.
Clinical Significance: we can check the home hazards & suggest appropriate modification so that
rehabilitation will have a clinical along with an added community level approach.
Keywords: Geriatrics, Home Modifications, Home Hazards/Barriers

INTRODUCTION in the bathroom. Approximately 75 percent of these

Approximately 20-55 percent of all unintentional
falls and fall-related injuries in adults over the age of
60 years occur inside the home. Most falls (44 percent)
occur on a level surface (e.g. ground level), 16 percent
occur on the stairs or from a height, and 4 percent occur
falls happen during the performance of routine daily
activities, 44 percent occur in the presence of one or
more environmental hazards and 2 to 5 percent during
the performance of hazardous activities, such as
climbing onto ladders.(1) Only 20 percent of older adults

1. ashutosh--1-5.pmd 1 11/1/2014, 12:17 AM

 2 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
who fall seek medical attention therefore, the full extent
of falls and injuries is unknown. The result of
unintentional falls can have a negative effect on quality
of life, including loss in days of work, increased
healthcare expenditures, dependency, and early
admission to an assisted living or long-term care
facility. (4)
Preventing falls and disability and maintaining
older adults as valuable members of their communities
is rapidly becoming a national priority. This major
public healthcare concern not only encompasses the
physical and psychological squeal associated with the
fall itself, but also the social and economic impact on
the individual, family/caregivers, and the healthcare
industry. (2) Recently published guidelines include
home hazard and safety assessment and home
modification as part of fall prevention for adults over
the age of 65 years. The purposes of this study is to
highlight findings from selected research studies and
identify components of a home hazard and safety
modifications and level of acceptance for home
modifications as part of a geriatric assessment for older
adults living at home. (5)
Home modifications include five basic services that
directly support independent living (Steinfeld.
1981) (9) (17)
• Security improvements such as improving locks,
outdoor lighting, securing windows,
• Fire safety improvements such as eliminating
overloaded electrical circuits and installing smoke
detectors,
• Accident prevention measures, including repairing
stairways, improved lighting, and repair of floor
surfaces,
• Accessibility and usability modifications including
construction of entry ramps, installation of grab
bars and adapting round door knobs with levers,
• Construction related services such as emergency
repairs, weatherization, maintenance and general
rehabilitation.
Home modifications help you to improve the
quality of life of elderly people that provide
independence and dignity of life for the elderly.
Accessible housing doesn’t simply mean a house with
a ramp or lift anymore. Today, the concept of universal
design extends to all—old, young, tall, short, disabled.
Today’s contemporary values require personal
1. ashutosh--1-5.pmd 2 11/1/2014, 12:17 AM
comfort at the least—not just for people with
disabilities! Words like “barrier free” and “ergonomic”
are now part of the common vocabulary. (3) (9)
Older people are often neglected in research (in
INDIA) also in the health care and in scientific
knowledge about medical treatment and the place of
living.
Aim & objectives of the study is to assess the homes
to find out environmental barriers and to check the
readiness of the people to modify them and to check
which area of home people are keener to modify to
prevent falls and to improve the quality of life of their
elderly.
MATERIALS AND METHOD
Consent to carry out the study was granted by the
institutional ethical clearance committee. All subjects
signed the required consent before beginning the
study. 50 subjects aged above Geriatric people above
60 years of age with No diagnosed health problems,
Males and females randomly selected. Any fracture,
Geriatric people with vascular disease, stroke,
neuromuscular disease etc, Visual impairment
problems, Sensory impairment, congenital
abnormalities were excluded.
Data is taken from the corporation (Pimpri-
Chinchwad, Maharashtra, India) about the Age, Sex,
Address of the community living elderly, a formal
permission is taken from the Chair person of the
Society & Residential House owner to do the survey
and assessment. A formal Consent form was given to
Geriatric people in home. Survey is conducted mainly
in five areas like living room, bed room, kitchen,
bathroom, and stairs of house. In this we have focused
mainly as per table and further intervention for home
modification programs was explained and
emphasized.
A second visit was done to the same house after
fifteen days to check whether the people have done
the modifications or not. And what is the most
common area of the house for barriers, what is the most
common problem and people are keener to modify
which part of the home to prevent falls and improve
independence of geriatrics in home.
DATA ANALYSIS
The Chi-Square test is known as the test of goodness
of fit and Chi-Square test of Independence. In the Chi-
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 3
Square test of Independence, goodness of fit frequency
of one nominal variable is compared with the
theoretical expected frequency. In the Chi-Square test
of Independence, the frequency of one nominal
variable is compared with different values of the
second nominal variable.
RESULTS
Out of 50, 40 homes have done suggested home
modifications i.e. 80% and 10 homes have not done
home modifications i.e. 20 %. Maximum people have
done modifications in toilet/bathroom (24%) followed
by living room (21%), stairs (20%), kitchen (19%) and
bedroom (16%).
Obstacles in the pathway (26 homes) is the most
common home barrier found in the living room
followed by curled carpet edges (13 homes),
improperly marked light switched (10 homes) and dim
lighting (7 homes). Improper placement of frequently
used items is the most common barrier found in
kitchen (17 homes) followed by improperly marked
light switched (16 homes) and dim lighting (15 homes)
and obstacles in the pathway (9 homes). Light switches
were not clearly marked in majority of the bedrooms
(14 homes) followed by wrong placement of frequently
used items needing frequently reaching or bending (9
homes), non sturdy furniture (8 homes) and obstacles
in the pathway (8). Slippery area is the most common
home barrier found in bathroom/toilet (28 homes)
with equal prevalence of dim light (20 homes) and low
toilet seat (20 homes) and absence of grab bars (17
homes). Most common home barrier found in stairs is
the damaged or unequal steps (23 homes) followed
by dim light (20 homes), absence of hand rails
(13homes), and not clearly marked light switches (2
homes).
Graph 1: Analysis of overall modification
Interpretation: 80% people have done home
modifications and 20% have not done.
1. ashutosh--1-5.pmd 3 11/1/2014, 12:17 AM
Graph 2: Modifications done by number of families
in different areas of the home
Interpretation: Maximum people have done
modifications in toilet/bathroom followed by living
room, stairs, kitchen and bedroom.
DISCUSSION
In this study we have evaluated the homes of
geriatric people in the form of observation method and
then interviewed the elderly and the care giver
together to ask them whether the home barriers we
have found are troublesome for them or not. If yes then
what do they think about home modifications? A
thorough survey is done of all the areas of home mainly
living room, bedroom, kitchen, toilet/bathroom and
stairs to find the potential home hazards. Also to check
that which the area of home is where the geriatric
people face maximum difficulty to perform their
activities of daily lining (ADL’S).
The various home modifications suggested by
therapist in different areas of home are as follows:
KITCHEN: The doorway must be a minimum of
36 inches wide - measure the width of your chair so
you’ll know what you have. Rather than paying for a
new doorway to be cut and rebuilt, remove the door
and its hinges, molding or threshold. If the only way
into the kitchen is up or down stairs, it may be possible
to ramp it if it’s not too steep. Electrical
outlets and light switches can be easily relocated by
an electrician and lighting can be enhanced by marking
it clearly, adding track or overhead fixtures, or a
portable desk lamp on the counter. Since cabinets are
expensive to replace, removing a cabinet door below
the sink or counter will provide knee space so you can
work from a seated position. Just remember to insulate
the pipes below the sink to prevent scalding legs. Store
 4 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
cabinet doors in a safe place with their hardware taped
to them. (18) It may be necessary to replace the
cabinets with lower ones. Although costly, this may
be all you need to make the kitchen useable. Vertically
adjustable models can be raised and lowered; roll-out
shelves are much more useful within any cabinet.
Cabinets may also be reinstalled higher to
accommodate someone tall or unable to bend down.
A platform is the most versatile option, especially
when the space below is kept free for leg space, rather
than putting a cabinet there to store pots and pans.
The floor must be kept dry and free of obstacles in the
pathway. Adequate illumination. Frequently used
items should be kept in easy reach. (6) (20)
BATHROOM & TOILET: Frequently used items
like soap, towel, scrubber, etc can be raised for their
height if someone is having difficulty bending over or
lowered to accommodate a seated person. If one has
several people living in the home, decide on a
compromised height. Toilet height is also important.
If the toilet seat is too low, it’s difficult for many people
to lower themselves down up to the seat or to get up
back from the seat. This can be remedied with portable
toilet seats. (9) (11) Many different styles and types of
toilets are available, along with safety straps and other
aids. A hand-held shower will bring the water down
to a comfortable level. It’s also possible to install a stand
or adjustable pole to free up the bather’s hands. When
skin has decreased sensitivity, an anti-scald
device should also be installed in both the shower and
bathroom sink. (8)
Entrance Exit & Doorways: A doorway must be at
least 36 inches wide. Doorstops can be removed, as
well as thick thresholds that are difficult to roll over.
If bathroom doors are the narrowest; a curtain or
decorative screen will provide privacy, as well as
access to the room. Locks on doors can be lowered for
a person in a wheelchair to comfortably reach it. Avoid
thick doormats, like the contemporary bristly-style
mats. Older people may trip over them and they’re
hazardous to persons with walking difficulties, and
persons with visual impairment. A thin, rubber mat is
safer and still traps some dirt and moisture. (7) (12)
Living Room: The height of the furniture should
custom made means it should be made according to
the alderfly’s convenience so that they should not have
trouble in sitting & getting up. Floor should be kept
dry. Preferably antiskid mat should be used. Carpet
edges should not be curled up. Adequate lighting
should be done. (11)
1. ashutosh--1-5.pmd 4 11/1/2014, 12:17 AM
Stairs: All steps should have equal height, Proper
illumination is also a must, Hand railing throughout
the length of the staircase should be present, No
obstacles in the pathway. (10)
CONCLUSION
People have willingness to do home modifications.
Bathroom/toilet is found to be the most concerned area
of home where maximum home barriers are found and
modifications are done followed by living room, stairs,
kitchen and bedroom.
ACKNOWLEDGMENTS:
I am thankful to my Guide Dr. Tushar Palekar, for
his valuable guidance.
I am also thankful to all my subjects, who were
essential part of the project.
Conflicts of Interest: None
Source of Funding: None
Ethical Clearance: Ethical clearance was obtained from
Ethical committee, Padmashree Dr. D.Y. Patil College
of Physiotherapy, Pimpri, Pune 411018.
REFERENCES
1. Garson LW, Cameron CA Jar, Wilber ST. Home
modification to prevent falls by older ED patients.
Am J Emerge Med 2005; 23:295-298.
2. Stevens M, Holman CD, Bennett N. Preventing
falls in older people: Impact of an intervention to
reduce environmental hazards in the home. J Am
Geriatric Soc 2001; 49:1442-1447
3. Northridge ME, Levitt MC, Kelsey JL, Link B.
Home hazards and falls in the elderly: The role
of health and functional status. Is J Public Health
1995; 85:509-515?
4. Gill TM, Williams CS, Tinette ME. Assessing risk
for the onset of functional dependence among
older adults: the role of physical performance.
JAm Geriatric Soc. 1995; 43:603-609.
5. Gill TM, Richardson ED, Tinetti ME. Evaluating
the risk of dependence in activities of daily living
among community-living older adults with mild
to moderate cognitive impairment. J Gerontology
Med Sci. 1995; 50:M235-M241.
6. Gill TM, Williams CS, Richardson ED, Tinetti ME.
Impairments in physical performance and
cognitive status as predisposing factors for
functional dependence among nondisabled older
persons. J Gerontology Med Sci. 1996; 51:M283-
M288.
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 5
7. Cumming RG, Thomas M, Szonyi G, et al.
Adherence to occupational therapist
recommendations for home modifications for
falls prevention. Am J Occup Ther 2001; 55(6):
641-648.
8. Ostroff, E., 1989. A Consumer’s Guide to Home
Adaptation. (Available from the Adaptive
Environments Center, 374 Congress St., Suite 301,
Boston, MA 02210.
9. Pynoos, J., 1988. Home Modification for Frail
Older Persons: Policy Barriers and New
Directions. Paper presented at the meeting of the
National Conference on Low-Income Older
Homeowners, sponsored by the American
Association of Retired Persons.
10. Pynoos, J., in press. “Home Modification and
Repair.” In A. Monk, ed., Columbia Handbook
on Retirement. New York: Columbia University
Press.
11. Pynoos, J. and Cohen, E., 1990. Home Safety
Guide for Older People: Check It Out / Fix It Up.
Washington, D.C.: Serif Press.
12. Pynoos, J., Cohen, E. and Lucas, C., 1988. The
Caring Home Booklet: Environmental Coping
Strategies for Alzheimer’s Caregivers. Los
Angeles: Long Term Care National Resource
Center at UCLA/USC.
13. Pynoos, J. et al., 1987. “Home Modification:
Improvements That Extend Independence.” In V.
Regnier and J. Pynoos, eds., Housing the Aged:
Design and Directives and Policy Considerations.
1. ashutosh--1-5.pmd 5 11/1/2014, 12:17 AM
New York: Elsevier Science Publishing Co., pp.
277-303.
14. Pynoos, J. et al., in press. Home Modification
Guidebook. Los Angeles: Long Term Care
NAtional Resource Center at USC/UCLA.
15. Shekelle P, Maglione M, Chang J, et al. Evidence
report and evidence-based recommendations:
Falls prevention interventions in the Medicare
population. Baltimore, MD: U.S. Department of
Health and Human Services, Centers for
Medicare and Medicaid Services and RAND;
2003.
16. Gillespie LD, Gillespie WJ, Robertson MC, et al.
Interventions for preventing falls in elderly
people. Cochrane Database Sys Rev 2003;
4:CD000340.
17. Physical & Occupational Therapy in Geriatrics
2000, Vol. 16, No. 3-4, Pages 79-99 , DOI 10.1080/
J148v16n03_05
18. Carter SE, Campbell EM, Sanson-Fisher RW,
Redman S, Gillespie WJ. Environmental hazards
in the homes of older People. Age Ageing 1997;
26: 195–202.
19. Connell BR, Wolf SL. Environmental and
behavioral circumstances associated with falls at
home among healthy individuals. Arch Phys Med
Rehabil 1997; 78: 179–86.
20. Josephson KR, Fabacher DA, Rubenstein LZ.
Home safety and fall prevention. Clin Geriatric
Med 1991; 7: 707–31.
 DOI Number: 10.5958/0973-5674.2014.00344.X
6 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Comparative Study of Short Term Response between

Maitland Mobilization and Mulligan's Mobilization with
Movement of Hip Joint in Osteoarthritis of Knee Patients
Identified as Per Clinical Prediction Rule

Ajit Dabholkar1, Sneha Kumari2, SujataYardi3

1
Associate Professor, MPT, Professor and Director, Department of Physiotherapy, Pad. Dr. D.Y. Patil University,
2 3

Nerul, Navi Mumbai

ABSTRACT
Background and Purpose: Research suggests that many patients with knee osteoarthritis (OA) have
hip impairments. A study demonstrated that subjects with knee OA had favourable outcome following
a single intervention of hip mobilizations. With a Clinical Prediction Rule (CPR) various components
are combined to determine the diagnosis, prognosis, or likely response to treatment of that individual.
Thus the purpose of this study is to compare the short term response between Maitland mobilization
and Mulligan's Mobilization with Movement (MWM) of hip in osteoarthritis of knee patients identified
as per Clinical Prediction Rule.
Methodology: An experimental study was done with 60 subjects with OA knee who completed self-
report questionnaires -Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC),
Patient Specific Functional Scale (PSFS), Numerical Pain Rating Scale (NPRS), underwent clinical
examination of the hip and knee, and functional tests. These 60 subjects were divided into 2 groups
-Group I received Maitland Mobilization and Group II received Mulligan mobilization. Follow-up
testing was completed 2 days later. The reference criterion for determining a favourable response
was either (1) a decrease of at least 30% on composite NPRS score obtained during functional tests or
(2) a Global Rating of Change Scale (GRCS) score of at least 3.
Results: At 48 hour follow-up, 48 subjects (80%) out of 60 - 21(35%) from Maitland group and 27(45%)
from Mulligan group were considered to have a favourable short-term response to the treatment.
The mean difference in WOMAC, PSFS and NPRS were not statistically significant, whereas GRCS
was statistically significant in Mulligan group.
Conclusion: Mulligan mobilization of hip was found to be extremely significant than Maitland
mobilization in patients with OA knee identified as per CPR.
Keywords: Osteoarthritis, Maitland, Mulligan, Clinical Prediction Rule

INTRODUCTION improved range of motion (ROM), and fewer positive

provocative hip test findings following a single
Worldwide estimates are that 9.6% of men and
18.0% of women aged e”60 years have osteoarthritis34. intervention of hip mobilizations.

Altered knee function as a result of OA knee may
affect the hip and result in painful impairments7.Many
patients with knee OA have hip impairments,
indicating the need to examine the hip in these
patients12.Cliborne et al also demonstrated that subjects
with knee OA experienced an average decrease in pain,
30% to 40% of people with knee OA also have hip
OA, and it is well known that hip structures can refer
pain to the knee1, 23, 35. A CPR consisting of 5 variables
was developed by Currier et al 13 for identifying
patients with knee pain and clinical evidence of knee
OA who will demonstrate a favourable short-term

2. SNEHA--6--10.pmd 6 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 7
response to hip mobilizations. These variables are hip
or groin pain or paresthesia, anterior thigh pain,
passive hip medial rotation less than 17 degrees,
passive knee flexion less than 122 degrees and pain
with hip distraction, The number of subjects who
benefited from hip mobilizations was substantially
larger (68%).Based on the pre-test probability of
success (68%), the presence of one variable increased
the probability of a successful response to 92% at 48-
hour follow-up. If 2 variables were present then the
probability of success increased to 97%.
Clinical prediction rules (CPRs) are tools designed
to improve decision making in clinical practice by
assisting practitioners in making a particular diagnosis,
establishing a prognosis, or matching patients to
optimal interventions based on a parsimonious subset
of predictor variables from the history and physical
examination24,29.
Manual therapy techniques like Maitland and
Mulligan mobilization are widely used in
physiotherapy practice.
The responsiveness of this CPR has not been
studied on Maitland Mobilization and Mulligan’s
MWM .Thus the purpose of this study was to compare
the short term response between Maitland
Mobilization and Mulligan’s MWM of hip joint in
patients with OA knee identified as per CPR.
MATERIALS AND METHOD
Institutional Ethics Committee approval was taken
before the start of the study. 60 subjects with OA knee
participated in the study and were divided into two
groups : Group I - Maitland mobilization, Group II -
Mulligan’s MWM The inclusion criteria was based on
Altman and colleagues’ criteria2 for diagnosis of OA
knee. Subjects were included if they were 50 to 80 years
of age, had a primary complaint of knee pain, and met
at least 3 of the Altman’s criteria. The exclusion criteria
were : Primary complaint of low back pain (LBP);
secondary complaint of LBP with pain radiating below
the knee; history of cancer; history of hip or knee
arthroplasty; Cortisone or synthetic fluid injection to
the hip or knee within 30 days of their initial
examination; A history of prior treatment with hip
mobilization to the involved limb within 6 months of
their initial examination; Or any current condition
precluding physical therapy intervention (e.g., deep
vein thrombosis).For a favourable response to hip
mobilization either of the two outcome measures
2. SNEHA--6--10.pmd 7 11/1/2014, 12:17 AM
should be positive - a decrease of at least 30% on
Composite NPRS score obtained during functional
tests or a GRCS score of at least 3.Other outcome
measures were WOMAC and PSFS. Patients were
selected according to the CPR -Hip or groin pain or
paresthesia; Anterior thigh pain; Passive knee flexion
< 122°; Passive hip medial rotation < 17°;Pain with hip
distraction. The procedure involved selecting the
patients according to CPR and dividing them into two
groups. After the subjects signed an informed consent
document, they completed the WOMAC and PSFS, a
brief history was taken and physical examination and
functional tests were done.
The procedure was
Physical examination was done for both the limbs.
It included : ROM measurements using Universal
Goniometer31 for Hip abduction, adduction, extension
and Knee flexion ,extension and Universal
Inclinometer12,14 for Hip flexion, medial rotation, lateral
rotation; Mobility assessment27 of lumbar and lower
thoracic spine ;Manual Muscle Testing22 of hip and
knee; Hip distraction, Hip Scour, Thomas test, FABERS
test. For each of these procedures, subjects were asked
to rate their pain from 0 to 10 on the NPRS and
describe the pain location. Assessments regarding joint
mobility17 .Subjects in Group I was given Maitland
Mobilization and Group II subjects were given MWM.
3 sets of 30 seconds with 30 second rest period between
the sets of Grade IV of Maitland mobilization was
given to Group I. Each subject received 4 hip
mobilization procedures: Lateral glide; Caudal glide;
Anteroposterior glide (AP); Posteroanterior glide (PA).
3 sets of 10 repetitions with 30 second rest period
between the sets of MWM was given to group II. The
following instructions were given to be followed at
home: Maintain normal daily activities within pain
tolerance levels; avoid activities that will exacerbate
the symptoms; pain-free hip flexion ROM - 2 sets of 30
seconds in supine position. All subjects were instructed
to continue their routine exercises. Follow up was done
48 hours later. At the time of follow up all the subjects
completed a final WOMAC, final PSFS and GRCS
scales. The same physical examination and functional
tests were repeated and associated pain ratings were
recorded. The data thus obtained was statistically
analysed for the level of significance. Comparison
within the groups was done using non parametric test
–Wilcoxon test and between groups comparison was
done using Mann-Whitney test.
 8 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

RESULTS & OBSERVATIONS both the manual therapy interventions had equally
GROUP MEAN SD P VALUE
favourable outcome.
Pre WOMAC(Maitland) 116.6 36.43 0.002*
But there was a significant difference in GRCS
Post WOMAC(Maitland) 110.6 34.33
scores between both the groups. This significant
Pre PSFS(Maitland) 14.73 4.78 0.03*
difference can be attributed to the fact that the GRCS
Post PSFS(Maitland) 15.6 4.85
scale allows the patients themselves to decide what
Pre Composite NPRS(Maitland) 9.83 4.37 0.01*
they consider important 21.As Mulligan technique
Post Composite NPRS(Maitland) 7.76 4.28
involves active participation of the patient , more
Pre WOMAC(Mulligan) 99.6 36.50 <0.0001*
number of patients had a positive outcome
Post WOMAC(Mulligan) 90.46 37.07
(score e” 3) and higher scores as compared to Maitland
Pre PSFS(Mulligan) 16.73 3.140 <0.0001*
technique.
Post PSFS(Mulligan) 18.6 3.255
Pre Composite NPRS(Mulligan) 9.4 3.25 <0.0001* 9 subjects from Maitland group and 3 subjects from
Post composite NPRS(Mulligan) 5.23 3.32 Mulligan group had more pain during functional
Mean WOMAC (Maitland) 5.9 8.22 0.22 % tasks at the time of follow up and also had a worsened
Mean WOMAC (Mulligan) 9.13 6.83
GRCS score. However, none of the subjects reported a
Mean PSFS (Maitland) -0.93 2.21 0.35 %
rating of lower than somewhat worse (-3) on the GRCS
Mean PSFS (Mulligan) -1.86 1.50
or an increase of more than 4 points on the composite
Mean COMP NPRS (Maitland) 2.06 4.12 0.052 %
NPRS. This aggravation can be attributed to increased
Mean COMP NPRS (Mulligan) 4.16 3.34
and prolonged soreness from the hip mobilizations or
GRCS (Maitland) 1.46 2.47 0.01*
some other intervening factor. Small amplitude grade
GRCS (Mulligan) 3.03 2.58
IV mobilizations, as applied in this study, are thought
* - Significant to produce more local soreness compared with large-
% – Not significant amplitude grade III mobilizations28.

15% of subjects were positive for CPR variable hip

DISCUSSION
At 48 hour follow-up, 48 subjects(80%) out of 60 -
21(35%) from Maitland group and 27(45%) from
Mulligan group were considered to have a favourable
short-term response to the treatment.9 subjects from
Maitland group and 3 subjects from Mulligan group
had more pain with the functional tests at the time of
follow up than they did at baseline. These subjects also
reported on GRCS scale that their condition had
worsened. The majority of subjects (60%) in this study
met all 6 of Altman and colleague’s criteria for clinical
diagnosis of osteoarthritis, 25% met 5 of the criteria
and the remaining 15% met 4 of the criteria. Based on
the subject’s pain and ROM findings, the severity of
the knee OA symptoms experienced by the subjects in
this study varied from mild to moderate. Duration of
symptoms was greater than one year for 41(68%) of
the subjects.
Statistical analysis showed significant
improvement in WOMAC, PSFS, composite NPRS
scores in both the groups. However the level of
significance was higher in Mulligan group than in
Maitland group. The difference between pre and post
scores for WOMAC, PSFS, composite NPRS between
both the groups was not significant. This shows that
or groin pain or paraesthesia, 28% for anterior thigh
pain passive, 35% for knee flexion less than 122
degrees,31% for passive hip medial rotation less than
17 degrees, 13% for pain with hip distraction.
The variables contained within the CPR are not
surprising given the prevalence of concomitant hip OA
in people with knee OA and the sensory innervations
of the hip and knee1, 23, 35. According to Almans1 and
colleagues criteria for clinical diagnosis of hip
osteoarthritis have two variables, “hip or groin
pain”and limited “hip medial rotation” similar to CPR
identified in OA knee. The CPR variable “limited knee
flexion” may be indicative of more severe joint
involvement in general and, therefore, of more
potential for response to intervention. The only
provocative test in the CPR, “pain with hip
distraction”, was highly specific but present in only 8
subjects. All 8 subjects had a successful response to
hip mobilizations. Although hip distraction might be
expected to be an easing factor when applied to a hip
contributing to a patient’s symptoms, it may have the
opposite effect if the distensibility of periarticular soft-
tissue structures is impaired. The combination of any
2 CPR variables is the best predictor of which patients
with knee OA will respond to hip mobilizations.

2. SNEHA--6--10.pmd 8 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 9
The plausible mechanisms for favourable outcomes 2.
gained by manual therapy are
The regular physical loading and unloading of joint
cartilage that occurs with movement during manual
therapy facilitates the movement of synovial fluid.26,
37, 15, 36
. 29: 1039–1049.
3.
Reduction of pain could be due to “Sensory gating” 30,
6,32,8
. 4.
Inhibition of reflex muscle spasm20, 25, 38
Stretching of periarticular soft tissues18
Conduction block effect11, 19
5.
Mulligan originally postulated a “positional fault”
to explain the results gained through his techniques.
The combination of joint mobilization with active
movement may be responsible for the rapid return of 6.
pain free movement3.
Thus, MWM enables the therapist to perform
treatment in more dynamic, weight bearing, functional 7.
positions. As the aggravating movement is used,
treatment is specific and the results are often dramatic
8.
(Mulligan1995). This explains greater improvement in
subjects treated with Mulligan technique as compared
to the subjects treated with Maitland technique. 9.
The mean difference between WOMAC, PSFS,
composite NPRS was not significant leading to the
conclusion that both the techniques are effective .But
10.
there was a significant difference in GRCS scores
between the two groups suggesting that the patients
perception of improvement was more with Mulligan 11.
technique rather than Maitland technique.
CONCLUSION 12.
This study gives an insight into the effect of hip
mobilization as a treatment for patients with OA knee
identified as per CPR.
Acknowledgement: Nil 13.
Conflicts of Interest: Nil
Funding: Nil
REFERENCES
14.
1. Altman R, Alarcon G, Appelrouth D, et al. The
American College of Rheumatology criteria for
the classification and reporting of osteoarthritis
of the hip. Arthritis Rheum. 1991; 34:505–514.
2. SNEHA--6--10.pmd 9 11/1/2014, 12:17 AM
Altman R, Asch E, Bloch D, et al, for the
Diagnostic and Therapeutic Criteria Committee
of the American Rheumatism Association.
Development of criteria for the classification and
reporting of osteoarthritis: classification of
osteoarthritis of the knee. Arthritis Rheum. 1986;
Beeton KS, Moore AP, Jull Ga, Manual therapy
Master class The Peripheral Joints, Elsevier 2003
Bellamy N, Buchanan WW, Goldsmith CH, et al.
Validation study of WOMAC: a health status
instrument for measuring clinically important
patient relevant outcomes to antirheumatic drug
therapy in patients with osteoarthritis of the hip
or knee. J Rheumatol. 1988; 15:1833–1840.
Breivik EK, Bjornsson GA, Skovlund E. A
comparison of pain rating scales by sampling
from clinical trial data. Clin J Pain. 2000; 16:
22–28.
Casey K 1978,Neural mechanisms of
pain.In:Carterette EC,Friedman MP,Handbook of
perception:feeling and huring .Academic press
London,ch 6,p 183-219
Chang WS, Zuckerman JD. Geriatric knee
disorders, part II: differential diagnosis and
treatment. Geriatrics. 1988; 43:39–42, 44, 46.
Chapman CE 1987 Sensory perception during
movement in man. Experimental Brain research
68;516-524
Chatman AB, Hyams SP, Neel JM, et al. The
Patient-Specific Functional Scale: measurement
properties in patients with knee dysfunction. Phys
Ther. 1997; 77:820–829.
Childs JD, Piva SR, Fritz JM. Responsiveness of
the numeric pain rating scale in patients with low
back pain. Spine. 2005; 30:1331–1334.
Clark FJ 1975, information signaled by sensory
fibres in medial articular nerve.Journal of
Neurophysiology; 38;1464-1472
Cliborne AV, Wainner RS, Rhon DI, et al. Clinical
hip tests and a functional squat test in patients
with knee osteoarthritis: reliability, prevalence of
positive test findings, and short-term response
to hip mobilization. J Orthop Sports Phys Ther.
2004; 34:676–685.
Currier L, Froehlich P, Carow S, et al.
Development of a clinical prediction rule to
identify patients with knee pain and clinical
evidence of knee osteoarthritis who demonstrate
a favorable short-term response to hip
mobilization. Phys Ther. 2007; 87:1106–1119.
Flynn T, Fritz J, Whitman J, et al. A clinical
prediction rule for classifying patients with low
back pain who demonstrate short-term
improvement with spinal manipulation. Spine.
2002; 27:2835–2843
 10 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
15. Frank C,Akesow WH,Woo SL-Y,et al .Physiology
and therapeutic value of passive joint motion.Clin
Orthop.1984;185;113-125
16. Fritz JM, Delitto A, Erhard RE, Roman M. An
examination of the selective tissue tension
scheme, with evidence for the concept of a
capsular pattern of the knee. Phys Ther. 1998;
78:1046–56; discussion 1057–1061.
17. Fritz JM, Irrgang JJ. A comparison of a modified
Oswestry Low Back Pain Disability
Questionnaire and the Quebec Back Pain
Disability Scale. Phys Ther. 2001; 81:776–788.
18. Grigg P, Greenspan BJ1977, Response of primate
joint afferent neurons to mechanical stimulation
of the knee joint. Journal of neurophysiology40;1-
18
19. Guilbaud G, Iggo A, Sensory receptors in ankle
joint capsules of normal and arthritic rats.
Experimental Brain Research58; 29-40
20. Jull GA, Bogduk NM, 1985, Manual examination.
An objective test of cervical joint dysfunction,
conference of Manipulative therapists association
of Australia, 159-170
21. Kamper SJ, Maher CJ, Global Rating of Change
Scales: A Review of Strengths and Weaknesses
and Considerations for Design, J Man Manip
Ther. 2009; 17(3): 163-170
22. Kendall FP, Kendall EM, Provance PP, Muscles
Testing and Function with posture and pain, 5th
edn, 2005
23. Lanyon P, Muir K, Doherty S Doherty M.
Assessment of a genetic contribution to
osteoarthritis of the hip: sibling study. BMJ. 2000;
321:1179–1183.
24. Laupacis A, Sekar N, Stiell IG. Clinical prediction
rules: a review and suggested modifications of
methodological standards. JAMA. 1997; 277:
488–494.
25. Lewit K1985The muscular and articular factor in
movement restriction.Manual medicine, 1, 83-85
26. Lowther D. The effect of compression and tension
on the behaviour of connective tissues in aspects
2. SNEHA--6--10.pmd 10
of manipulative therapy .Melbourne, Victoria,
Australia:Longman Cheshoire Pty Ltd,1985
27. Magee DJ, Orthopedic Physical Assessment, 4th
edn,Elsevier
28. Maitland G, Hengeveld E, Banks K, English K.
Maitland’s Peripheral Manipulation. Oxford,
United Kingdom: Butterworth- Heinemann; 2000
29. McGinn TG, Guyatt GH, Wyer PC, et al;
Evidence-Based Medicine Working Group.
Users’ guides to the medical literature, XXII: how
to use articles about clinical decision rules. JAMA.
2000;284:79–84.
30. Melzack R, Wall Pd 1965, Pain mechanisms-a new
theory; Science 1850; 971-979
31. Meyerson N, Milano R. Goniometric
measurement reliability in physical medicine.
Arch Phys Med Rehabil. 1984; 65:92–94
32. Milne RJ, Aniss AM, Kay NEReduction in
perceived intensity of cutaneous stimuli during
movement: a quantitative study. Experimental
Brain Research 60:569-576
33. Mulligan B R, Manual therapy, 6th edition, 2010
34. Murray CJL, Lopez AD, editors. The global
burden of disease. A comprehensive assessment
of mortality and disability from diseases, injuries,
and risk factors in 1990 and projected to 2020.
Cambridge (MA): Harvard School of Public
Health on behalf of the World Health
Organization and The World Bank; 1996
35. O’Reilly SC, Muir KR, Doherty M. Occupation
and knee pain: a community study. Osteoarthritis
Cartilage. 2000; 8:78–81.
36. Saler RB.The biologic concept of continuous
passive motion of synovial joints.Clin
Orthoo.1989; 242; 12-25
37. Twomey LT, Taylor JR.Age related changes of the
lumbar spine and spine rehabilitation. Critical
reviews in Physical and Rehabilitation
Medicine.1991;2;153-169
38. Wyke BD 1976, Neurological aspects of lowback
pain. The lumbar spine and back pain.189-256
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 11

Correlation of Balance Performance and Fear of Fall in

Parkinson's Disease

Avani Desai1, Vivek Kulkarni2, Nimisha Mishra1, SavitaRairikar3, AshokShyam4, ParagSancheti4

1
Clinical Physiotherapist, 2Associate Professor, Department of Neurophysiotherapy, 3Principal, 4M.S.Orth, Sancheti
Healthcare Academy, 12, Thube Park, Shivajinagar, Pune, Maharashtra

ABSTRACT
Parkinson's disease(PD) is characterized by abnormalities in postural control and balance along with
psychological issues like fear/anxiety, both affecting the fall rates.Thus,understanding whether
balance issues remains same with increased fear of fall or vice a versa is essential for planning our
treatment goals for PD patients. This study aimed at assessing correlation between balance
performance and fear of falls in Parkinson's patients. 30 subjects of Parkinson disease were included
in the study. Balance performance was assessedusing following outcome measures: Unified Parkinson
Disease rating scale (UPDRSIIIsubscale items 27, 28, 29, 30), Berg Balance Scale (BBS), Timed Up and
GO (TUG), Multidirectional Reach Test (MDRT) and fear of falls using Activity Specific Balance
Confidence Scale (ABC) and Modified Fall Efficacy Scale (MFES).Out of the balance measures TUG
shows significant moderate correlation with both ABC and MFES (p=0.01). UPDRS III shows poor
but significant correlation only with MFE (p=0.04). MDRT BR shows moderate significant correlation
with MFES (p=0.02). The other outcome measures showed no significant correlation. Thus,
improvement in balance performance does not mean that the fear of fall or confidence level will also
improve and should be considered as a different construct.
Keywords: Postural instability, Fear of fall, Parkinson's disease

INTRODUCTION Thus, there is reduced strength followed by balance

Parkinson disease(PD) is defined as a chronic
neurodegenerative condition characterized by rigidity,
bradykinesia, tremors and postural instability affecting
activities of daily living.1Several hypothesis for causes
of balance abnormalities exist like ineffective sensory
processing, some found deficits in proprioceptive and
kinaesthetic processing. Martin found delayed
labyrinthine equilibrium reactions. 2 Glatt et al 3
demonstrated lack of anticipatory postural reactions
whereas Horak4 found defects in strategy selection as
well. Parkinson disease occurs in middle age where
changes due to ageing process have already begun.
Corresponding author:
Nimisha Mishra
Sancheti Institute College of Physiotherapy,
Sancheti Healthcare Academy, 12, Thube Park,
Shivajinagar, Pune - 411 005, Maharashtra (INDIA).
Telephone: 020 - 25539393
Fax No: 020 - 25539494
Email: nimisha.s.mishra@gmail.com
problems, now superimposed by parkinsonian
features which furthermore affect the postural control
of PD patients making this special population more
liable for balance abnormalities. This loss of balance
can lead to further slips, trips and falls in Parkinson
patients. Falls are significant problems with fall rates
ranging from 40- 68% in PD population dwelling older
people have more than one fall in a year.1
PD patients have cognitive issues as in learning
and perceptual deficits because of the disease. Hauck6,
Scheffer7 and Boyd 8 in their studies mention fear of
falls in community dwelling elderly individuals.
Similarly Mak and Pang 9 in their study assess self
perceived balance confidence which tells us about fear
of falls in Parkinson disease.They concluded that lower
self perceived balance confidence levels were
associated with increased risk of falling in
PD.Therefore it is important to understand the
relationship between fear of fall in this special
population with their balance performance. Silburn 10,
Ashburn 11 found that PD fallers had an increased fear

3. Nimisha Mishra--11--15.pmd 11 11/1/2014, 12:17 AM

 12 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

of falling compared to PD non-fallers and reported
more falls during the previous 12 months than PD non-
fallers. The prevalence of fear of falling is estimated to
be between 12% and 65% in PD people who have not
previously fallen and between 29-92% in those who
have fallen.12 Activities of daily living are restricted as
multitasking and loss of anticipatory postural reaction
leads to avoidance of the activity. This causes disuse
and further balance problems, low confidence which
are associated with falling.12Thus, it is seen that there
is fear of fall as well as balance issues in PD. But
understanding whether balance issues remains same
with increased fear of fall or vice a versa is essential
for planning our treatment goals for PD patients.
Various studies have assessed these components in
‘on’ phase of PD patient’s medication
cycle.13,14,15Therefore there is need for more exploration
to find out relationship between the two i.e. balance
performance and fear of falls in Parkinson’s disease
especially in the ‘off’ phase.
MATERIAL AND METHOD
A correlation observational study designwas
performed between 2009 and 2010. Subjects included
in the study were those diagnosed as idiopathic
Parkinson’s patients falling in grade I, II, III scale of
Hoehn & Yahr 16 were included in the study. Grade III
were ambulatory. Subjects with other neurological,
cardiovascular, orthopaedic, psychological disorder,
poor hearing or vision and those who have underwent
any replacement or recent cardiac surgeries were
excluded. Forty-five subjects of Parkinson disease from
Parkinson Support Group were screened and 30
subjects were selected according to inclusion
criteria.The permission to carry out the study was
obtained from the ethical committee. A prior written
consent was taken from each subject. History was
noted with specified drug history and fall history. A
detailed examination of all the subjects was performed.
All outcome measures were performed in the OFF
phase of the parkinsonianmedications. The outcome
measures were carried out as follows: for assessing
balance performance: Unified Parkinson Disease rating
scale (UPDRSIII-subscale items 27, 28, 29, 30), 17 Berg
Balance Scale (BBS), 18 Timed Up and GO (TUG), 19
Multidirectional Reach Test (MDRT) 20 were used. Fear
of fall was assessed by Activity Specific Balance
Confidence Scale (ABC), 21 Modified Fall Efficacy Scale
(MFES).22 Initially ABC questionnaire and MFES were
questioned to the subjects. In case the subjects haven’t
performed the given task, the patient was requested
to judge the score imagining the task.UPDRS scores
were measured followed by TUG, MDRT, and BBS
were administered at the same time. Rest periods were
given to the patients to avoid fatigue. All the above
mentioned tests were correlated statistically with each
other using Spearman’s correlation equation and ‘r’
values were obtained.SPSS version was used for
statistical analysis.
RESULTS
The results of the correlation analysis are shown in
the Table 1. Of the five balance scales, TUG showed
moderate significant correlation with both ABC and
MFES (p=0.01) .UPDRS III showed poor but significant
correlation only with MFES (p=0.04) but not with
ABC.MDRT BR showed moderate significant
correlation with MFES (p=0.02), not with ABC.Of
MDRT the RL, LL and FR components showed no
correlation with either ABC or MFES. In addition, there
was no significant relationship between BBS with
either ABC or MFES.

Table 1: Summarizing means and r values : r= significant correlation (p<0.05)

Tests BBS TUG UPDRS III MDRT RL MDRT LL MDRT FR MDRT BR
‘r’ VALUES ABC r= 0.120 r= -0.28 r=-0.27 r= 0.21 r=0.23 r=0.07 r= 0.28
p= 0.5 p= 0.01* p= 0.14 p= 0.24 p=0.23 p=0.71 p= 0.12
Mean 64.89 ±21.33 42.17 ± 6.28 16.64 ± 7.30 4.93 ±2.71 5.44 ± 2.95 5.05 ± 2.67 7.59 ± 3.07 5.24 ±2.99
Values±
Standard
Deviation
RANGE 25-98 8 –55 9-39 0-11 2-13 1-10 2-15 0-10
MFES r= 0.23 r= -0.43 r= 0.36 r=0.13 r=0.23 r=0.15 r=0.40
p= 0.11 p= 0.01* p=0.04* p=0.49 p= 0.22 p=0.41 p=0.02*
7.77±1.82
4-10

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 13
ABC-Activity Specific Balance Scale,MFES-
Modified Fall Efficacy Scale,BBS-Berg Balance Scale,
TUG-Timed Up & Go, UPDRS III-Unified Parkinson’s
Disease Rating Scale(27,28,29,30),MDRT RL-
Multidirectional Reach Test Right lateral reach,MDRT
LL-Multidirectional Reach test Left lateral
reach,MDRT FR-Multidirectional Reach Test Forward
Reach,MDRT BR-Multidirectional Backward reach.
DISCUSSION
This study was undertaken to assess the correlation
between balance performance and fear of falls in a
Parkinson’s patients. Thirty subjects were included in
this study who were assessed for balance performance
and fear of fall.TUG showed moderate significant
correlation with both ABC and MFES (p=0.01), UPDRS
III showed poor but significant correlation only with
MFES (p=0.04) and MDRT BR showed moderate
significant correlation with MFES (p=0.02). Thus,
improvement in balance performance does not mean
that the fear of fall or confidence level will also improve
and should be considered as a different construct.
Kuo and Zajac; 23Kuo 24 state that the stiffening
response at the hip inhibits postural response in PD
patients because movements at hip provide fast and
efficient counterbalance to a perturbation to a COM.In
our study, ABCshowed insignificant and weak
correlation with MDRT for all direction reaches.
Similarly MFES and MDRT, showed insignificant
weak correlation except for backward reach showed
moderate significant correlation. In PD, there are
abnormal anticipatory responses in association with
stooped posture; there might be reduced backward
excursion of movement. While reaching backward it
is possible that their COG may fall way backward. As
they are adjusted to their usual reaches they may fail
to correct their posture automatically. Due to rigidity
and inability to correct automatically and
apprehension and fear of falls these patients fail to
show larger displacements in backward direction.
However the values are not significant to prove that
MDRT BR is one the factors contributing for fear of
fall.
Hatch 25 et al in their study of finding the
determinants of balance confidence carried out
stepwise regression on ABC, BBS and TUG and found
that balance confidence revealed 57% of BBS score.
After adding fear of fall score to the model it increased
to 0.62 suggesting that BBS which measures risk of falls
based on physical performance explained that 60%
3. Nimisha Mishra--11--15.pmd 13
variance in ABC score. Mak and Pang 9 concluded that
a lower self-perceived balance confidence level and
prolonged time to complete TUG were associated with
increased risk of falling in PD. In our study, BBS
showed weak insignificant correlation with both ABC
and MFES suggesting that even though BBS score is
good it is not necessary that patient will not have fear
of falls whereas TUG showed significant moderate
inverse correlation with both ABC and MFES. Berg
balance scale is a geriatric balance measurement tool
assessing both dynamic and static balance. ABC and
MFES are balance confidence and self efficacy scale
which are self report measures of fear of fall. These
scales are based on patient’s perception of his /her
own confidence level irrespective of the task. Patients
with Parkinson disease are known to have
psychological features like depression 26 and dementia
27
along with perceptual deficits. 28 It is very likely
possibility that their perception of confidence might
not match with their physical performance. Along with
the above reasons with the ceiling effects of BBS and
subjectivity of ABC and MFES in a small sample like
in this study, there might be weak insignificant
correlation. TUG is a mobility scale, an objective
measurement for risk of falls and not for fear i.e.
perception of falls.It is a possibility that patient is
anxious and is being careful by walking slowly so he
is taking longer to finish the test. Therefore a good
score of balance does not imply that fear of fall would
be less.
Adkin and Frank 14 in their study found there was
a significant relationship observed between mean ABC
scale score and UPDRS posture and gait score. They
concluded that, PD patients with a greater degree of
balance and gait impairment reported less confidence
in their ability to avoid falling during ADLs. In our
study, UPDRS III (27-30 items) showed weak
insignificant inverse correlation with ABC whereas
with MFES and UPDRS III it showed significant
inverse relationship suggesting that there might be
some small contribution of posture and gait
component in fear of fall. Adkin and Frank 14 mention
as the limitation that their data was notable to
distinguish whether FOF results from postural
instability related to the disease process or whether
FOF exaggerates postural instability related to the
disease process. Also in their study the sample
population for PD was less than that in our study. And
they conducted their study in the ‘on’ phase of the
medication cycle where in our study all measurements
even fear of fall were administered in ‘off’ phase of
11/1/2014, 12:17 AM
 14 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
their medication cycle. Therefore even though there is
relation present but it is not that significant to put forth
that UPDRS III posture and gait component may be
one of the contributing factors.
A commonly overlooked, yet incapacitating
consequence of falls is a fear of future falls, which was
common among patients. This fear of fall forced
patients to restrict their physical activities and
sometimes led to social isolation. There is mixed
understanding regarding fear of fall and its relation
with balance performance. FOF is an ongoing concern
about falling that ultimately limits the performance of
daily activities. 29 In chronic diseases like PD
psychological aspects like depression, perceptual
deficits may have a contribution to induce a
psychological reaction characterized by fear of fall.25
Parkinson patients’ age related changes also contribute
to the fear of fall as mentioned by Boyd. 8 As Parkinson
patients are in older ages, the above mentioned causes
along with loss of anticipatory control strategies to
maintain balance together might increase the fear of
fall.
Our study had a limitation. Sample size was small.
In conclusion, good balance performance does not
mean that the fear of fall or confidence level is also
good. Further studies can be done along with
comparison with age matched individuals, large
sample size and in ’on’ phase of the medication cycle
of Parkinson patient for better understanding of the
relationship between the two.i.e.balance and fear of
fall.
ACKNOWLEDGEMENT
The authors are thankful to the participants of this
study, without whom this study would not have been
possible.
Conflict of Interest: None
Source of Funding: No funding obtained
REFERENCES
1. Dibble LE, Lange M. Predicting falls in
individuals with Parkinson disease: a
reconsideration of clinical balance measures.
JNeurolPhysTher. 2006 Jun; 30(2):60-7.
2. Martin, J. P. (1967) The Basal Ganglia and Posture.
Pitman: London.
3. Koller WC, Glatt S, Vetere-Overfield B, Hassanein
R. Falls and Parkinson’sdisease.
ClinNeuropharmacol. 1989 Apr; 12(2):98-105.
3. Nimisha Mishra--11--15.pmd 14
4. Horak FB, Nutt JG, Nashner LM. Postural
inflexibility in parkinsoniansubjects. J Neurol Sci.
1992 Aug; 111(1):46-58.
5. Ann- Shumway –Cook, Marjorie Wollacott,
Motor Control 3rdedition Chapter 10 Pd 234-240
6. Laura Jane Hauck: Understanding The Influence
Of Fear Of Falling On Clinical Balance Control –
Efforts In Fall Prediction And Prevention: Thesis:
2011.
7. Alice C.Scheffer, Marieke J. Schuurmans, Nynke
Van Dijk, Truus Van Der Hooft And Sofia
Ederooiji: Fear Of Falling: Measurement Strategy,
Prevalence, Risk Factors And Consequences
Among Older Persons: Age And Ageing 2008:1;
19-24.
8. Rebecca Boyd, Judy A. Stevens: Fall Ad Fear of
Falling: Burdens, BeliefsandBehaviours: Age And
Aging 2009; 38; 423-428.
9. Mak Mk, Pang My: Balance Confidence And
Functional Mobility Are Independently
Associated With Falls In People With Parkinson’s
Disease: J Neurol 2009 May, 256; 5; 742-9
10. Cole, Michael H Silburn,Peter A Wood, Joanne
M Worringham, Charles J Kerr, Graham K: Falls
In Parkinson Disease : Kinematic Evidence For
Impaired Head And Trunk Control: Movement
Disorders 25(14) 2369-2378.
11. Ashburn A,.Stack E, Ballinger C, Fazakarley L,
Fitton C: The Circumstances Of Falls Among
People With Parkinson Disease And Use Of Falls
Diaries To Facilitate Reporting. DisabilRehabil
2008; 30(16) ; 1205-1212.
12. EllenJorstad, K Hauer, C Becker and S Lamb:
Systematic Review On Falls Related
Psychological Outcome Measures: JAGS 2005 53:
501-510.
13. Cole, Michael H Silburn,Peter A Wood, Joanne
M Worringham, Charles J Kerr, Graham K: Falls
In Parkinson Disease : Kinematic Evidence For
Impaired Head And Trunk Control: Movement
Disorders 25(14) 2369-2378.
14. Allan L Adkin, James S Frank,Mandar S Jog: Fear
Of Falling And Postural Control In Parkinson
Disease: Movement Disorders Vol18, No 5 2003,
496-502.
15. Leland E Dibble, Jesse Christensen, D James
Ballard, K Bo Foreman: Diagnosis Of Fall Risk In
Parkinson Disease: An Analysis of Individual and
Collective Clinical Balance Test Interpretation.
PhysTher . 2008; 88; 323-332
16. J.Jankovic: Parkinson Disease: Clinical Features
And Diagnosis, J. Neurol. Neurosurg. Psychiatry
2008; 79; 368-376.
17. J.Jacobs, F.B.Horak, V.K.Tran et al: Multiple
Balance Test Improve The Assessment Of
Postural Stability In Subjects With Parkinson
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 15
Disease: J NeurolNeurosurg Psychiatry 2006 77:
322-326.
18. Abu A Qutubuddin, Philip O Pegg, David X
Clofu , Rashelle Brown, Shane Mcnamee , William
Carne:Validating The Berg Balance Scale For
Patients With Parkinson Disease : A Key To
Rehabilitation Evaluation. Arch Phys Med
Rehabil Vol86, 2005.
19. Susan Morris, Meg E Morris and Robert Iansek:
Reliability of Measurements Obtained With the
Timed “Up And Go” Test in People Parkinson
Disease:PhysTherVol 81, No.2 February 2001, Pp
810- 818.
20. Newton RA. Validity of the multi-directional
reach test: a practical measurefor limits of stability
in older adults. J Gerontol A BiolSci Med Sci.
2001Apr; 56(4):M248-52.
21. KristineMc Talley, Jean F Wyman And Cynthia
Gross: Psychometric Properties Of The Activity
Specific Balance Confidence Scale And The
Survey Of Activities And Fear Of Falling In Older
Women. JAGS 2008 56: 328-333.
22. Edwards N, Lockett D. Development and
validation of a modified falls-efficacy scale.
DisabilRehabil Assist Technol. 2008 Jul; 3(4):
193-200.
23. Kuo AD, Zajac FE. Human standing posture:
multi-joint movement strategiesbased on
biomechanical constraints. Prog Brain Res. 1993;
97:349-58.
3. Nimisha Mishra--11--15.pmd 15
24. Kuo AD. An optimal control model for analyzing
human postural balance. IEEETrans Biomed Eng.
1995 Jan; 42(1):87-101.
25. Janine Hatch, Kathleen M Gill- Body, Leslie G
Portney: Determinants Of Balance Confidence In
Community Dwelling Elderly People: PhysTher
2003; 83: 1072-1079.
26. PaulaScalzo, ArthurKummer, Pransico Cardoso,
AntonicLucioTeixeiro: Depressive Symptoms
And Perception Of Quality Of Life In Parkinson
Disease: ArqNeuropsiquiatr 2009; 67(2-A):
203-208.
27. Florid Stella, Cjaudio Eduardo, Muller Banzato,
Elizabeth Maria, Aparecida Barasnevicius
Quagliato, MauraAparecidaViana, Crustauo
Christofoletti: Dementia And Functional Decline
In Patients With Parkinson’s Disease: Dementia
And Neuropsychologia 2008 June; 2(2): 96-101.
28. Yaakov Steen, Richard Maysux, Jeffery Rosen,
Joyce Ilson:Perceptual Motor Dysfunction In
Parkinson Disease: A Deficit In Sequential And
Predictive Voluntary Movement: Journal Of
Neurology, Neurosurgery And Psychiatry 1983;
46: 145-151.
29. KristineLegters: Fear Of Falling: PhysTher 2002;
82 (3): 264-272.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
16 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

A Study on Co-Relationship between Static Back Extensor

Endurance in Patients with Non-Specific Chronic Low
Back Pain and Healthy Individual

Paras Bhura1, Camy Bhagat2

1
M.P.T (Musculoskeletal Conditions), Clinical Therapist, Care Physiotherapy Center, Vadodara, 2M.P.T
(Musculoskeletal Conditions with Sports) Lecturer, Parul Institute of Physiotherapy, Vadodara

ABSTRACT
Background:Non-specific low back pain is defined as low back pain not attributable to a recognizable,
known specific pathology. Low back pain became one of the biggest problems for public health
systems in the western world during the second half of the 20th century, and now seems to be
extending worldwide. The endurance of the back extensor muscles have been reported to be related
to low back. Hamstrings tightness is one of the most common findings in patients with LBP.
Controversy exists regarding the degree of association between these physical characteristics and
LBP.
Objective: To study the static back extensor endurance in chronic low back pain patients and in
normal subjects by using Biering Sorenson test.
Method and Methodolgy: 50 subjects with low back pain and 50 subjects without low back pain
were included in the study. Demographic data (age, Gender, BMI) were collected. Then static back
extensor endurance was measured with Biering Sorenson test was measured in these subjects.
Result: There was significant difference in static back extensor endurance in both the groups with
higher endurance in subjects without low back pain.
Conclusion: It can be concluded from this study that static back extensor endurance is decreased in
subjects with low back pain and normal individual.
Keywords: Postural instability, Fear of fall, Parkinson's disease

INTRODUCTION
Non-specific low back pain is defined as low back
pain not attributable to a recognizable, known specific
pathology (eg, infection, tumour, osteoporosis,
fracture, structural deformity, inflammatory disorder,
radicular syndrome, or cauda equine syndrome). Low
back pain became one of the biggest problems for
public health systems in the western world during the
second half of the 20th century, and now seems to be
extending worldwide.4 Waddell suggested common
lower back pain (LBP) was an epidemic in the 20th
century. The World Health Organization (WHO) has
included “low back pain” as a priority in the Bone and
Joint Decade 2000–2010.10
Most people will experience back pain at some
point in their life. All age groups are affected by low
back pain. For decades it was suggested that children
and adolescents did not experience low back pain
unless they had a serious and sometimes life-
threatening disorder. The effect of low back pain on
wellbeing or health related quality of life and
functioning in any age-group is substantial, even in
those reporting low pain intensity and disability;
nonetheless, fewer than half of elderly people with low
back pain seek care.4Non-specific lower-back pain
includes common diagnoses, such as lumbago,
myofascial syndromes, muscle spasms, mechanical
LBP, back sprain, and back strain. Each of these vague

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 17
conditions includes pain in the lumbar region that may
radiate to one or both thighs, but not below the knee.
Nonspecific lower-back pain is not a well-defined
diagnosis and may lead to failed expectations to
provide reassurance, assigning improper treatment,
and uncertainty of prognosis and outcomes for
clinician and patient.10Previous studies have shown
that especially the back extensor muscles are weak in
patients with chronic LBP. Inadequate trunk muscle
performance could be a causal factor. Biering-Sørensen
found that poor static endurance of back muscles was
predictive of first-time experience of LBP in men. The
endurance of the back extensor muscles have been
reported to be related to low back.
AIMS OF THE STUDY
To determine the co-relation between static back
extensor endurance in subjects with non-specific
chronic low back pain and normal healthy individuals.
PROPOSED HYPOTHESIS
Null Hypothesis
There is no significant co-relation of static back
extensor endurance in non-specific chronic low back
pain and normal healthy individuals.
Alternate Hypothesis
There is significant co-relation of static back
extensor endurance in non-specific chronic low back
pain and normal healthy individuals.
MATERIALS AND METHODOLOGY
Study Design: Cross- Sectional Study.
Sampling Technique: Convenient Sampling
Study Setting: Physiotherapy Center
Sample Size: 100
Sample Population: 50 subjects diagnosed with
chronic low back pain and referred to physiotherapy
OPD and 50 other asymptomatic healthy individuals.
Inclusion Criteria
• Chronic LBP of at least 4 months in duration.
• Age between 20 and 60 years old.
• Visual Analogue Scale (VAS) of 5 or less than 5.
(GILLIAN A. HAWKER et al, 2011)
4. PARAS BHURA--16--.pmd 17
• Thorough clinical examination by an X-ray or MRI
and referred from physician or orthopedic.
• Both genders were included.
Exclusion Criteria
• Red flags indicative of serious spinal pathology
with signs and symptoms of nerve root
compression.
• Individuals with any obvious spinal deformity or
neurological disease (fracture, metastatic,
inflammatory or infective diseases of the spine,
cauda equina syndrome/widespread neurological
disorder).
• Pregnancy
• Previous spinal surgery
• Co-morbid health conditions that would prevent
active participation in the program.
Outcome Measures:Biering Sorenson Test: to measure
static back extensor endurance.
MATERIALS
• Plinth
• Non-elastic straps
• Stop watch
• Towel
Procedure: 50 subjects diagnosed with chronic low
back pain and referred by orthopaedician, and 50
asymptomatic healthy individuals were recruited for
the study. Subjects were selected on the basis of
inclusion and exclusion criteria. All subjects were
provided written informed consent. Then baseline data
were taken.
Measuring Static Back Endurance: The Biering-
Sorensen test of static muscular Endurance (BSME)
otherwise known as the Sorensen test was used in the
assessment of back extensor muscles endurance.9 It
measures how long the participant can keep the
unsupported trunk (from the anterior iliac crests level
up) horizontal while lying prone on a plinth (standard
treatment table) with their hands held by their sides.2
During the test, two non-elastic straps were lightly
fastened around the participants’ gluteus maximus
and ankles (just superior to the medial and lateral
malleoli) for stability on the plinth, a towel was
positioned beneath the ankle straps to reduce the strain
11/1/2014, 12:17 AM
 18 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
on the distal aspect of the tendo calcaneus (Achilles
tendon) and thereby ensure comfort of the
participants.2
The participants will be asked to maintain the
horizontal position until they can no longer control
the posture or tolerate the procedure. The total time
from the onset of the test to trunk flexion and loss of
the static neutral position is recorded as the endurance
time or the isometric holding time (in seconds) with
the stop watch. The test will be conducted only once
and thereafter the participants will be discharged.
RESULTS
There were two groups
Group A: 50 subjects with low back pain
Group B: 50 subjects without low back pain
Table 2: Comparison of Static Back Extensor Endurance Holding Time in Both the Groups
Mean(secs) SD±(secs)
G group A (LBP) 4747.06 9. 9.79
Group B(no LBP) 10102.64 37 37.11
The above graph shows that the mean static
extensor endurance times in subjects with low back
pain (Group A) was 47.06 secs and in the subjects
without low back pain (Group B) was 102.64 secs. Also
their standard deviation of Group A was 9.79 secs and
Group B was 37.11 secs. Here the unpaired t-test was
used. t value was 10.24 and p< 0.0001. So the difference
was extremely significant at confidence interval.
DISCUSSION
The results of this study suggested that static back
extensor endurance is decreased in subjects with low
back pain as compared to the subjects without low back
pain This result is in accordance with other studies.
Trunk extensors are classified as postural muscles.
Because these muscles are rich in larger diameter type
I muscle fibers, they are suited to support low levels
of activity for long periods of time. 13
Electromyographic (EMG) studies, however, indicate
that the paraspinal muscles in patients with LBP have
a faster fatigue rate compared with those in
asymptomatic subjects. Investigators have attributed
the decreased muscle endurance found in patients with
LBP to various factors, such as higher muscle
4. PARAS BHURA--16--.pmd 18
To analyze the difference of endurance between
subjects with low back pain and those without low
back pain, unpaired t-test was used.
Table 1: Demographic data of Subjects with Low Back
Pain (LBP) and without Low Back Pain
LBP No LBP
Age (years) 3333.04 ± 6.19 3131.74 ± 7.46
H height (cms) 16161.2 ± 4.66 16162.16 ± 6.14
W weight (kg) 6161.24 ± 5.43 5858.5 ± 5.24
BMI (kg/m2) 2323.56 ± 1.75 2222.50 ± 1.55
The mean age of the subjects with low back pain
(Group A) was 33.04 years and standard deviation was
6.19 years. And the mean age of the subjects without
low back pain (Group B) was 31.74 years and standard
deviation was 7.46 years. It suggests that there were
no significant Age difference seen across two Groups.
T Test used T +-value Value significance
Unpaired test t= 10.24 P < 0.0001 E Extremely
significant
metabolite level resulting from prolonged muscle
tension and spasm, higher proportion of type II muscle
fibers in paraspinal muscles, muscle deconditioning,
impaired muscle coordination and unequal
distribution of back extensor muscle force, and
inhibition and atrophy of the paraspinal muscles,
especially the lumbar multifidus muscles, in response
to pain and de-creased activity.11
Hides et al showed a 31% decreased cross-sectional
area in lumbar multifidus muscles in patients with
LBP, which did not resolve automatically after
remission of painful symptoms. According to Roy et
al, these muscles consistently demonstrate a higher
fatigue rate in patients with LBP. Wilder and Aleksiev
showed that fatigued erector spinae muscles have a
longer response time and decreased ability to tolerate
sudden loads. Excessive uncontrolled loads may
induce strain on the facet joints and the passive
structure of the lumbar spine, resulting in LBP.14
In a bio-mechanical modelling study by Goel et al.,
(1993), it was proposed that lumbar spinal muscles
impart stability to the ligamentous segment and also
lead to a decrease in stresses in the vertebral body and
the intervertebral disc. On the other hand, back muscle
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 19
fatigue has been shown to be associated with reduced
spinal proprioception in both healthy and LBP subjects.
It is considered that these factors in turn may lead to
increased passive system loading and resultant tissue
strain. Possible causes of reduced back muscle
endurance might include disuse through inactivity,
altered motor control patterns, or prolonged passive
system loading associated with reduced activity of
spinal stabilising muscles.12
Hypotheses differ about the mechanism by which
adolescent physical activity in boys prevents adult low
back pain. Although extreme sport related loading may
cause injury to an adolescent’s back, physical activity
during growth may improve the development of some
of the low back structures enabling them to withstand
more robustly physical loading in adulthood. Also,
physical activity increases trunk muscle strength,
endurance, and motor abilities, which may help the
back to function better. On the other hand, high
physical performance is also related to sports with
increased risk of low back pain, and this may dilute
the beneficial effects of physical activity. Interestingly,
hyperalgesia resulting from differences in
experiencing pain stimuli at the level of the central
nervous system occurs more often in patients with
chronic low back pain than in controls. Physical activity
during adolescence may modify the sensory
perception of peripheral pain at the level of the central
nervous system, which is one possible explanation for
fewer pain symptoms in subjects who have been
physically active during adolescence.8
The back extensor muscles, predominantly the
erector spinae group, provide posterior stability for
vertebral column. Previous studies have found that
erector spinae endurance and strength play a
significant role in CLBP. Calliet found that subjects
with a high degree of erector spinae endurance
experience back pain less often than those with poor
muscular endurance, the erector spinae works against
the forces of gravity to maintain erect posture and to
control forward flexion. Weakness in the erector spinae
muscles can lead to vertebral malalignment, ultimately
resulting in abdominal loading on the spine. There is
some debate whether this weakness can be attributed
to muscle fatigue or to absolute force production (i.e
strength).
Plowman attributed this to greater proportion of
Type-2 (fast twitch) muscle fibres, whereas the
demands for postural control are better managed by
Type-1 (slow twitch) fibers. This scenario would result
4. PARAS BHURA--16--.pmd 19
in the accumulation of metabolites in the fatiguing
muscles. In fact, Delitto and Rose theorized that high
precontraction metabolite levels from persistent
muscle spasm and prolonged muscle tension are
associated with excessive back fatigue.7
Investigators have attributed the decreased muscle
endurance found in patients with LBP to higher muscle
metabolite level resulting from prolonged muscle
tension and spasm, muscle deconditioning and
inhibition of the paraspinal muscles in response to pain
and decreased activity.6
Previous investigations have used the BSME as a
predictor of low-back health, based on endurance
time.1 Poor static back endurance has been found to
be linked to an increased risk of LBP during a follow
up of 1- year. Subjects with less than 58 seconds’
endurance have been reported to have a 3.4 times
greater likehood of developing LBP when comparing
those with poor static back endurance performance to
those with good performance.1
Low-back endurance in this study was determined
by monitoring the time to exhaustion during sustained
isometric back extension. This result was consistent
with previous observations in that subjects with CLBP
had less endurance capacity than control subjects.
The participants were categorized into three groups
based on their endurance pattern according to Alaranta
et al as (1) Good performance (2) Medium performance
and (3) Poor performance categories. Participants with
endurance time of less than 58 seconds were classified
as having poor performance, an endurance time of
between 58 – 104 seconds was considered medium
performance while an endurance time ranging
between 104 – 240 seconds was classified as good
performance.2
Luoto et al15 in a longitudinal study among 126 pain
free subjects, separated the participants into three
groups (good, medium and poor performers) based
on PHT. It was reported that a time less than 58 s was
associated with a threefold increase in the risk of LBP,
as compared to a time greater than 104 s. It is believed
that quantifying endurance capacity of the back
extensor muscles can be used to predict the risk of
future LBP.3
Hultman et al. studied 3 groups of middle-aged
men: 36 with nonimpaired low backs, 91 with
intermittent LBP and 21 with CLBP.5 The nonimpaired
group had longer trunk muscle endurance times, yet
11/1/2014, 12:17 AM
 20 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
in all 3 groups the ratio of trunk extensor endurance
to trunk flexor endurance approximated 3 :1.
Endurance of both trunk flexors and extensors is also
decreased in 15-year-olds with back pain histories
compared to those free of back pain.5
CONCLUSION
It can be concluded from this study that static back
extensor endurance is decreased in the subjects with
low back pain as compared to those subjects without
low back pain. It can be assumed that decreased back
extensor muscle endurance is an important factor in
chronic LBP. It can be agreed that endurance exercises
should be incorporated in order to reduce the
occurrence of LBP.
Acknowlegements: we are very thankful to our
parents and patients who had given us support
throughout our study.
Conflict of Interest: Nil
Source of Funding: self
Ethical Clearence: ethically approved
REFERENCES
1. Biering-Sørensen F. “Physical measurements as
risk indicators for low-back trouble over a one-
year period”, Spine (Phila Pa 1976). 1984
Mar;9(2):106-19
2. Chidozie Emmanuel Mbada, Olusola Ayanniyi,
“Static back endurance in apparently healthy
Nigerian adults”, Fizyoterapi Rehabilitasyon.
2008; 19(1):30-36.
3. Chidozie Emmanuel, Olusola Ayanniyi,
“Relations between Back Muscles’ Endurance
Capacity and Risk of Low-Back Pain”, TAF
Preventive Medicine Bulletin, 2010: 9(5).
4. Federico Balagué, Anne F, Ferran Pellisé,
Christine Cedraschi, “ Non-specific low back
pain” 2012; volume: 379
5. Hultman G, Nordin M, Saraste H, Ohlsen H,
“Body composition, endurance, strength, cross-
sectional area, and density of MM erector spinae
in men with and without low back pain”, J Spinal
Disord. 1993 Apr;6(2):114-23.
6. Ismaeil Ebrahimi PT. Ph.D, Gholam Reza Shah
Hosseini, M.D, Mahyar Salavati, PT., Ph.D.,
Hossein Farahini, M.d., and Amir Massoud Arab,
4. PARAS BHURA--16--.pmd 20
PT., M.Sc. “ Clinical Trunk Muscle Endurance
Tests in Subjects With and Without Low Back
Pain”, MJIRI, Vol.19, No.2, 95-101, 2005.
7. Kathleen J.Ashmen, C. Buz Swanik, and Scott. M.
Lephart, “Strength and Flexibility Characteristics
of Athletes With Chronic Low Back Pain”, Journal
of Sports Rehabilitation.1996. 5. 275-286
8. L O Mikkelsson, H Nupponen, J Kaprio, H
Kautiainen, M Mikkelsson, U M Kujala,
“Adolescent flexibility, endurance strength, and
physical activity as predictors of adult tension
neck, low back pain,and knee injury: a 25 year
follow up study”, Br J Sports Med 2006;40:107–
113.
9. Latimer J, Maher CG, Refshauge K, Colaco I.,
“The reliability and validity of the Latimer
J, Maher CG, Refshauge K, Colaco I., “The
reliability and validity of the Biering-Sorensen
test in asymptomatic subjects and subjects
reporting current or previous nonspecific low
back pain”, Spine (Phila Pa 1976). 1999 Oct
15;24(20):2085-9.
10. Margereta Nordin, Federico Balague, Christine
Cedraschi, “Non-Specific Low-Back Pain-
Surgical versus Non-surgical Treatment “,
Clinical Orthopaedics and Related Research,
LippincottWilliams and Wilkins, 2006, Number
443.
11. Markku Kankaanpaa, BM, Simo Taimela, MD,
Olavi Airaksinen, MD,and Osmo Hanninen, MD,
PhD, “ The Efficacy of Active Rehabilitation in
Chronic LowBack Pain”, 1999, Lippincott
Williams & Wilkins, SPINE Volume 24, Number
10, pp 1034–1042.
12. Mary Moffroid, PhD, PT, Sheila Reid, BS, PT,
Sharon M. Henry, PhD, PT larry D. Haugh, PhD
Anthony Ricamato, MS, “Some Endurance
Measures in Persons With Chronic Low Back
Pain”, JOSPT Volume 20 Number 2 August 1994.
13. Mary T. Moffroid, PhD, PT, “Endurance of trunk
muscles in persons with chronic low back pain :
Assessment, performance, training”, Journal of
Rehabilitation Research and Development Vol.
34 No . 4, October 1997, Pages 440-447.
14. Mohammad Reza Nourbakhsh, PT, PhD, Amir
Massoud Arab, PT, MSc, “Relationship between
Mechanical Factors and Incidence of Low Back
Pain”, J Orthop Sports Phys Ther ,Volume 32
Number 9 ,September 2002.
15. S Luoto; “Static back endurance and the risk of
low-back pain”. Volume 10, Issue 6, September
1995.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 21

To Compare the effect of Task Oriented Intervention and

Treadmill Training to Improve Gait in Chronic
Ambulatory Hemiparetic Stroke Patients

Monika Sharma1, Dharam Pani Pandey2

1
Assistant Professor in Santosh College of Physiotherapy, Ghaziabad, 2Head Department of Physiotherapy and
Rehabilitation Sciences, B L Kapoor Hospital, New Delhi

ABSTRACT
Objective: The main objective of this study was to compare the effects of task-oriented intervention
with treadmill training to improve gait in chronic ambulatory hemiparetic stroke patients.
Design of study: A comparative study randomized controlled trial design consisted of two groups
and two measurements, pre and post intervention.
Participants: 30 subjects (male & female), age groups of (40-70 years) with hemiplegia secondary to
CVA were taken. All the subjects were received physiotherapy previously and none were allowed
to attend physiotherapy other than intervention protocol.
Main outcome Measures: Balance was assessed by Berg Balance Scale , gait was assessed by
Rivermead Mobility Index.
Results: The between groups comparison shows that there is significant effect of task oriented
intervention on BBS which was 28.33 ± 11.91 at 0 week, 38.53 ±10.66 at 4th week. And for treadmill
training group on BBS which was 31.66±7.35 at 0 week, 41.0±7.11 at 4th week.
The between group comparison shows that there is significant effect of task oriented intervention on
RMI which was 7.2 ± 1.66 at 0 week, 10.93 ± 2.22 at 4th week, and for treadmill training group on RMI
which was 8.26 ± 1.44 at o week , 11.6 ± 1.55 at 4th Week.
The analysis revealed that both types of training influence balance and walking ability of hemiparetic
stroke patients during the study period. This analysis showed that both groups improved with training
over time i.e. from pre to post.
Conclusion: The result of present clinical study support the view that task oriented intervention and
treadmill training both helps to improve balance and walking ability for chronic ambulatory
hemiparetic stroke patients. Result of this study provides the ground for future research with specific
gender, large sample size, longer duration and with the use of other tools like force platform.
Keywords: Task-Oriented Intervention, Stroke, Treadmill, Rivermead Mobility Index, Berg Balance Scale

INTRODUCTION that resolve completely within 24 hours. Disability

(2)

affects 75% of stroke survivors enough to decrease

The traditional definition of stroke, devised by the
World Health Organization is a “neurological deficit
of cerebrovascular cause that persists beyond 24 hours
or is interrupted by death within 24 hours”. (1) The 24
hours limit divide stroke from transient ischemic attack
employability. (3) Walking is the activity which is
mostly affected by stroke. (4) Before individuals can
walk they must be able to balance HAT in the erect
standing posture, transfer HAT from one extremity to

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 22 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
other .These activities require coordination, balance,
and intact kinesthetic and proprioceptive senses and
integrity of the joints and muscles. (6)
Stroke often results in impaired balance. Balance is
essential for optimal functioning of the locomotor
system. (7)
According to Carr and Shepherd (8)
, major
requirement for successful walking are
1) Production of basic locomotor rhythm.
2) Support and propulsion of body in intended
direction.
3) Dynamic balance control of moving body.
Previous studies illustrated the beneficial transfer
effects of task-oriented strength training in disabled
older adults and traumatic brain injured patients. (9)
Current approaches to stroke rehabilitation put
emphasis on task oriented training, advocates task
oriented training utilize a training program that
focuses on specific functional task to engage the
systems (musculoskeletal, neuromuscular, etc). (10)
Traditionally, the physical rehabilitation of
individuals typically ended within several months
after stroke because it was believed that most if not all
recovery of motor function occurred during this
interval. Nevertheless, recent studies have shown that
aggressive rehabilitation beyond this time period,
including treadmill exercise with or without
bodyweight support, increases aerobic capacity &
sensorimotor function. (11, 12)
Some researchers oppose speed-oriented treadmill
training for patients with hemiparesis. It is feared by
some that gait symmetry might worsen and that “un
physiological” walking patterns might be established,
which would persist & be difficult to correct later. (13)
In contrast, other investigators report that treadmill
training can improve selected components of gait
biomechanics and reduce the energycost .(14)
MATERIAL AND METHOD
Subjects:-A total of 30 subjects (male and female)
with hemiplegia secondary to CVA were included in
the study.
5. Monika Sharma--21--.pmd 22
Inclusion criteria
Hemiparetic from a single stroke occurring at least
one year earlier, age between 40-70 years, medically
stable enough to allow participation, and able to
understand instructions, MMSE score 26-30, time
required to walk 10-meter should be between 5 and
60 seconds.
Exclusion criteria
Previous treadmill training , cognitive disorders.,
severe or active renal disease, cardiac, pulmonary or
hematological illness, movement disorders. and other
gait influencing diseases.
All the subjects were randomly assigned following
lottery method to group A and group B.
The study was a randomized controlled trial design
consisting of two groups and two measurements, both
the groups had half an hour intervention sessions for
3 days a week for 4 weeks.
Outcome measures
Balance was tested by Berg balance scale, and the
walking ability measured by Rivermead mobility
index.
Intervention
Patients found suitable on the basis of inclusion and
exclusion criteria were requested to sign the written
informed consent forms.
GROUP A
Subjects in task oriented group participated in 30
minutes of training 3 times a week for 4 weeks. The
program was designed as a circuit class with
completing practice at a series of work stations. Each
work station was 5 minutes in duration for each
exercise class. Progressions included increasing the
number of repetitions, completed within 5 minutes at
a work station and increasing complexity of the
exercise performed at each work station. The six
workstations incorporated into the circuit were:-
1. Warm up: - Marching on the spot.
2. Heels raise and lower while maintaining in
standing posture.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 23

3. Standing and reaching in different direction for
objects located beyond arms length.
4. Kicking a ball against a wall, progressing to
increasing the distance from the wall and to
kicking to a target.
phase (Vo max -10%, Vt 1 -10%, Vt 2 – 10%..........). At
the next treadmill session the treadmill would be set
(after a short warm up) to the last achieved maximum
speed from the previous session. The treadmill was
run at 0% incline.

5. Five minutes of continuous walking carrying a DATA ANALYSIS

grocery bag, progressing to carrying a bag in each The data was managed on excel spread sheet and
hand, and to increasing the weight of the bag. was analyzed using SPSS (Statistical Package for social
6. Five minutes of continuously walking backward. sciences for windows) software, version 12.

GROUP B Paired t-test was used to analyze the difference of

Patients participated in 12 speed dependent
treadmill training sessions three times a week for four
weeks for 30 minutes of duration.
The maximum over ground walking speed (Vo
max) was determined before the first training session.
This speed was then halved and used for a five minutes
warm up on the treadmill. After the warm up, the first
speed dependent training phase (Vt 1) began. During
a period of 1-2 minutes the belt speed was increased,
in communication with the patient, to the highest
speed at which the patient could walk safely and
without stumbling. The maximum achieved speed (Vt
1) was held for 10 second followed by rest period. If
the patient maintained the speed and felt safe during
the 10 seconds at Vt 1, the speed would then be
increased by 10% during the next attempt. This speed
(Vt 2) was again held for 10 seconds, followed by
another rest period. If the patient during any phase,
was unable to maintain the speed, felt unsafe, or
stumbled, the speed was reduced to 10% in the next
the variables of the two tests (i.e. BBS and RMI) and to
assess recovery within the two groups. Independent
t-test was used to determine whether there was a
significant difference between the mean of the
variables of the two tests in between the two groups.
The significance level for this study was set at .01.
RESULTS
The analysis revealed that both types of training
influence balance and walking ability of stroke patients
during the study period. There was a significant effect
for within group comparison in both the groups. This
analysis showed that both groups improved with
training over time i.e. from pre to post.
The between groups comparison shows that there
is significant effect of task oriented intervention on BBS
which was 28.33 ± 11.91 at 0 week, 38.53 ±10.66 at 4th
week. And for treadmill training group on BBS which
was 31.66±7.35 at 0 week, 41.0±7.11 at 4th week.

Table 1 Comparison of BBS between group A & group

BBS Group-A Group-B t-Value

Mean S.D Mean S.D
BBS (0) 28.33 11.91 31.66 7.35 0.92 NS
BBS (4) 38.53 10.66 41.0 7.11 0.75 NS

The between group comparison shows that there and for treadmill training group on RMI which was
is significant effect of task oriented intervention on RMI 8.26 ± 1.44 at o week , 11.6 ± 1.55 at 4th Week.
which was 7.2 ± 1.66 at 0 week, 10.93 ± 2.22 at 4th week,

Table 2 Comparison of RMI between group A & group B

RMI Group-A Group-B t-Value

Mean S.D Mean S.D
RMI (0) 7.2 1.66 8.26 1.44 1.88 NS
RMI (4) 10.93 2.22 11.6 1.55 0.95 NS

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 24 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

The between group comparison for BBS scale comparison to Group B which are 9.33 ± 5.2 from (0-4
shows that there is no significant difference of BBS for weeks), with value 0.43.
Group A which are 10.2 ± 5.72 from (0-4 weeks), in

Table 3 Difference of BBS between group A & group B

Diff b/w post and pre score of BBS. Group-A Group-B t-Value
Mean S.D Mean S.D
BBS 0–BBS4 10.20 5.72 9.33 5.20 0.43 NS

The between group comparison for RMI shows that to Groups B which are 3.33 ± 1.68 from (0-4 week),
there is no significant difference of RMI for Groups A with to value 0.68.
which are 3.73 ± 1.53 from (0-4 weeks) in comparison

Table 4 Difference of RMI between group A & group B

Diff b/w post & pre score of RMI Group-A Group-B t-Value
Mean S.D Mean S.D
RMI 0- RMI 4 3.73 1.53 3.33 1.68 0.68 NS

DISCUSSION 1. By using different work stations, circuit class

training allows patients to practice intensively in
Individuals with hemiparesis often have difficulty
a meaningful and progressive way that suit to their
bearing weight or “loading” the paretic limb and
individual needs.
transferring weight from one leg to the other. As a
result these individuals commonly exhibits asymmetry 2. Circuit class training is an efficient use of therapist
during sitting and standing activities and during time in which patients actively engaged in task
walking, with greater proportion of body weight practice when compared with individual therapy.
distributed on the non paretic lower extremity than
on the paretic lower extremity.(15, 16) Rehabilitation of 3. A circuit training approach that does not allow rest
balance and mobility has been identified as an periods, may lead to greater improvement.
important goal of stroke rehabilitation. (17) Thus the The results suggest that there is significant
current study was designed to evaluate which is a
improvement in balance and walking ability of
better method among task oriented intervention and hemiparetic patients by task oriented intervention and
treadmill training to improve walking ability in chronic treadmill training .This means to achieve the better and
stroke patients. The highest quality of movement is
faster outcome therapists should give either task
achieved by use of techniques that foster normal oriented intervention or treadmill training to the
postural reactions and patterns of movement; increase
chronic hemiparetic patients.
awareness and integration of activity in the involved
extremities; demand weight-bearing and postural
CONCLUSION
reactions on the more involved side. (18)
The present study compare the task oriented
In present study gait-specific repetitive training
intervention and treadmill training to improve walking
was a key feature. The previous studies also had the
ability in chronic ambulatory stroke patients and result
findings that a skill will improve if it is practiced. (19, 14)
suggests that both the interventions showed significant
Sullivan and colleagues shows that programs that improvement on BBS and RMI scale.
combined muscle strength training , balance training,
Limitations
and aerobic conditioning have demonstrated
significant improvements in walking function. (20) Study was not gender specific. resources like Force
platform biofeedback for measuring balance etc was
Task-oriented circuit class training satisfies the
not utilized in this study.small sample size.
following key features of an effective and efficient
physical training program. (21)

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 25

Acknowledgement: The author acknowledges 11. Potempa K, lopez M, , et al physiological

support of Mr. Abhishek Tyagi. outcomes of aerobic exercise training in
hemiparetic stroke patients. Stroke 1995; 20:101-
Conflict of Interest: There is no conflict of interest 105.
12. Hesses S. Bertelt C, et al treadmill training with
Source of Funding: Self partial body weight support compared with
physiotherapy in nonambulatory hemiparetic
Ethical Clearance: Ethical Clearance Taken
patients. Stroke. 1995; 26:976-981.
13. Davis Pm, Weight- supported treadmill training.
REFERENCES Neuro rehabil neural repair. 1991; 13:167-169.
14. Speed dependent treadmill training in
1. World health organization Cerebrovascular
ambulatory hemiparetic stroke patients, Marcus
disorders. Geneva: World health
pohl, MD; Jan Mehrhal et al.
organization(1978). ISBN 9241700432.occc
15. Vicki stemmans Mercer, purser et al,
4757533.
measurement of paretic lower extremity loading
2. Dannan GA, Fisher M, Davis SM “Stroke”.
and weight transfer after stroke. Phys Ther :
Lancet(May 2008) 371(9624).
Vol.89, No. 7, July 2009, PP. 653-664.
3. Coffey C. Edward, et al Stroke-the American
16. Sullivan, fourth edition: - Physical rehabilitation
psychiatric press textbook of geriatric
(Assessment and treatment).
neuropsychiatry (2000) (second ed).PP.601-607.
17. Marie nanly, Sarah F Tyson, Balance Disability
4. NM salbach,NE mayo, et al. a task oriented
after stroke. Phys ther, Vol. 86, No. 1, Jan 2006,
intervention enhances walking distance and
PP. 30-38.
speed in the first year post stroke : clin rehabil
18. Stroke rehabilitation, the recovery of motor
2004;18;509.
control. By pamelaw and ducan, PP 223-251.
5. Joint structure and function, Third edition: -
19. Nakamura R, Nanda T et al, The relationship
Pamela K. Levangie, Cynthia C. Norkin
between walking speed and muscle strength for
6. Professional staff association, Rancho-LOS
knee extension in hemi paretic Stroke patients: a
Amigos Medical center: observational gait
follow-up study. Tohoku Jerip Med 1988; 154:111-
analysis Hand-book. Downey, Calif.1989.
13.
7. Sackley CM, Bagulay BI, et al. The use of a
20. Katherine J Sullivan et al, effects of task-specific
balance performance monitor in the treatment of
loco motor and strength training in adults who
weight bearing weight transference problems
were ambulatory after stroke: (PT clin Res Net)
after stroke. Physiotherapy 1992; 78:907-913.
Jul 19, 2007.
8. Carr and shepard: IInd edition, MRPfor Stroke.
21. Stroke rehabilitation, the recovery of motor
9. Canning CG, Shepherd RB et al. A randomized
control. By pamelaw and ducan, PP 223-251.
controlled trial of the effect of intensive sit to
stand training after recent Traumatic brain injury.
Clin rehabil 2003, 17: 355-62.
10. Carr JH, Shepherd RB. Stroke Rehabilitation
guidelines for exercise and training to optimize
motor skill. Butterward- Heinemann, 2003.

5. Monika Sharma--21--.pmd 25 11/1/2014, 12:17 AM

 DOI Number: 10.5958/0973-5674.2014.00344.X
26 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effect of Muscle Energy Technique to Improve Flexibility

of Gastro-Soleus Complex in Plantar Fasciitis: A
Randomised Clinical, Prospective Study Design

Rahul Tanwar1, Monika Moitra1, Manu Goyal2

1
MPT Ortho, 2MSc Musculoskeletal, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation,
Mullana, Ambala

ABSTRACT
Background: Plantar fasciitis is considered to be an overuse syndrome as it develops over time and
is a result of repeated stress that exceeds the body's inherent capacity to repair and adapt which
eventually leads to the failure of the ligaments, bones and muscles. Functional risk factors include
tightness in gastronemius, soleus and weakness of intrinsic foot muscles because limited dorsiflexion
due to tight Achilles tendon strains the plantar fascia. short-term treatments such as muscle stretches
are regularly used to alleviate symptoms during this interim period. An increase in ankle range of
motion may reduce the symptoms of plantar heel pain by reducing the strain in the plantar fascia.
Objective: To study the effectiveness of muscle energy technique to improve flexibility of gastro-
soleus complex in plantar fasciitis.
Study Design: Randomized Clinical Trial
Setting: MMIPR Mullana Ambala
Materials & Method: SUBJECTS; 30 subjects both male and female in age group of 25-65 years with
Plantar fasciitis were recruited for study. ROM, Pain and FFI were analyzed in MET and SS groups.
Outcome measures were NPRS, GONIOMETER and FFI.
Results: Results showed that there is significant improvement in MET Group than SS group.
Conclusion: Muscle energy technique were proved to be more effective in reducing pain, improving
range of motion and foot functional index in Plantar fasciitis patients.

Keywords: Plantar Fasciitis, Muscle Energy Technique (MET), Static Stretching (SS), Conventional Exercises

INTRODUCTION occurrence of plantar fasciitis in cases with a body mass

Plantar fasciitis (PF) is a degenerative syndrome of
the plantar fascia resulting from repeated trauma at
its origin on the calcaneus.1,2 Pain is generally caused
by collagen degeneration at the origin of the plantar
fascia at the medial tubercle of the calcaneus.4,6,8 It
affects up to 10% of the general population.5,6,7
Functional risk factors include tightness in
Gastrocnemius, soleus and weakness of intrinsic foot
muscles because limited dorsiflexion due to tight
Achilles tendon strains the plantar fascia.3,4,9 The
index (BMI) more than 25 kg/m2 or above 30 kg/m2 is
approximately double, at least triple in cases with
passive ankle dorsiflexion of less than 10°, and
increases to 3.6 times in those with a history of standing
for long periods.1,9,10,11,12
Muscle energy technique was developed by
osteopathic physician, Fred Mitchell, Sr. 15,16 It is
claimed to be effective for a variety of purposes,
including lengthening a shortened or contractured
muscle, strengthening muscles, as a lymphatic or

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 27
venous pump to aid the drainage of fluid or blood,
and increasing the range of motion of a restricted
joint.217,18,19,20
Applications of MET to stretch and increase
myofascial tissue extensibility seem to affect
viscoelastic and plastic tissue property, autonomic-
mediated change in extracellular fluid dynamics, and
fibroblast mechanotransduction.17
METHOD
Participants
Subjects were drawn from MMIPR institute, a
sample of 30 symptomatic subjects were selected by
means of simple random sampling with aged group
of 25 to 65 years who fulfill the inclusion and exclusion
criteria.
Inclusion criteria: Age 25 to 65 years old, Both
genders will be included, Unilateral plantar fasciitis,
A history of plantar fasciitis more than one month,
Passive ankle DFROM less than 10 0 and Clinical
diagnosis of plantar fasciitis based on patient history
and physical examination. Subjects with the following
criteria were excluded: Presence of coagulation
disease, Presence of other musculoskeletal disorders
in the lower limbs, Any central or peripheral
neuropathy, Any systemic inflammatory disease,
Associated metabolic and endocrine diseases, Any
psychiatric disorders, Surgery for Plantar fasciitis
within the previous six months and Any corticosteroid
injection treatment.
Variables
Independent variables are Muscle energy technique
and Static stretching and Dependent variables are
Flexibility and Pain.
Outcome measures:
Goniometer, pain intensity (estimated using a
numeric pain rating scale), Foot function index.
Study Protocol
30 subjects will be taken including both males and
females and randomly allocated in two groups. Two
groups are i.e. Group A (n=15)=conventional treatment
with MET. Group B (n=15)=conventional treatment
with Static stretching.
6. Rahul Tanwar--26--.pmd 27
Procedure
Pre test readings were taken for ankle dorsiflexion
range of motion, pain and foot functional scale.
Conventional treatment-Therapeutic Ultrasound
(1MHz) with the output of 1.5W/cm2 for 7 minutes
with patient in prone lying position for 3 days per week
for 6 weeks.
Plantar fascia stretching-Supine lying. The
Therapist will grasp the patient’s heel with one hand
and maintain the subtalar joint in neutral position, with
other hand grasp the metatarsal region, Next Gently
applying pressure back toward the shin until he or
she felt a stretch in the arch or plantar fascia. Hold the
position for atleast 15 to 30 seconds. Repeat 3 times. 3
days per week for 6 weeks.
Intrinsic muscle exercises-Place a tennis ball under
the feet and roll it in forward, backward and sideways
directions (done for 5 minutes).
Towel gripping (curls) exercises with the toes
strengthen the intrinsic musculature of the foot. The
patient sits with the foot flat on the end of a towel
placed on a smooth surface. Keeping the heel on the
floor, the towel is pulled toward the body by curling
the towel with the toes. 3 days per week for 6 weeks.
Group A (Experimental group)-Subjects received
conventional treatment with MET for 8-10 minutes.
MET- The subject will be in supine, with the knee
flexed over a rolled towel for soleus and the knee
straight for Gastrocnemius. Starting from the
restriction barrier or just short of it, the subject will be
asked to exert a small effort (no more than 20% of
available strength) towards plantar flexion, with
appropriate breathing. This contraction is held for 7-
10 seconds. On slow release, on an exhalation, the ankle
will be dorsiflexed to slightly and painlessly beyond
the new barrier, with the subject’s assistance, Stretch
for up to 30 seconds. Single session will last for 30
minutes including 5 minutes each of warm up and cool
down exercises and rest period of 1 minute in between
each cycle of muscle energy technique. Steps are
repeated for 3 times and 3 days per week for 6 weeks.
Group B (Control group)-Subjects received
conventional treatment as group A with static
stretching of gastro-soleus muscles for 6 weeks.
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 28 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Gastro-soleus stretching- The subject stood There were significant difference found between
approximately 91.44 to 137.16 cm (3–4 ft) from the wall pre-intervention and post-interventions measures in
with his or her hands placed flat against the wall at both groups but, the group receiving MET (Group A)
shoulder level and with elbows extended. The subject displayed the greatest improvement than the static
stepped forward, flexing the one knee (unaffected stretching (group B) (P<.05).
foot), and then shifted their body weight forward onto
the same leg. The affected heel remained flat on the DISCUSSION
floor with the knee extended. The subject continued
to shift weight forward until the affected heel began Although improvements were seen in both the
to rise off the floor. The stretching exercise was treatment groups to improve flexibility of Gastro-
performed gently and slowly until tightness, not pain, Soleus complex to increase ankle dorsiflexion range
was felt. This position was maintained for 20 seconds. of motion and relieve pain in plantar fasciitis patients.
Repeated for 3 times and 3 days per week for 6 weeks. When statistical analysis was done after intervention
it was found that when MET was given along with
RESULTS conventional treatments, statistical significance
improvement was noted after 6 week of intervention
The ‘Paired t-test’ was used to compare the scores
in all the clinical parameters. Hence, the MET program
for passive DFROM, NPRS and FFI before and after
significantly outperformed the static stretching
intervention. Independent t-test was used to ascertain
program in all outcome measures.
any significance difference between Group A and
Group B. The level of significance was set at p< 0.05. The mechanisms by which MET may produce
In each group, mean age of 40.8±8.06 and 43.5±8.3 increased joint ROM remain speculative. Many authors
in group A and group B respectively. No significant of MET claim that segmental muscle contraction
differences present with respect to age before the restricts joint motion and the efficacy of MET to
intervention (p< .05). produce relaxation of the affected muscles due to
inhibition of motor activity through the Golgi tendon
Table 1 Mean and S.D scores for passive DFROM, FFI organs.27 Viscoelastic and plastic changes in myofascial
and NPRS of Group A.
connective tissue elements following isometric
Variables Pre TestMean(SD) Post TestMean(SD) t-value contraction and repetitive muscle contraction is a likely
DFROM 6.73±1.16 14.53±1.76 -19.278 explanation for increased muscle length.16,17
FFI 43.91±5.318 24.513±2.99 12.317
NPRS 6.46±0.915 2.2±0.861 17.122 The study by kent et al5 found that Achilles tendon
stretching group had a greater improvement in pain
Table 2 Mean and S.D scores for passive DFROM, FFI
and NPRS of Group B. scale and foot functional index in plantar fasciitis
which is in consistent with the findings of the present
Variables Pre TestMean(SD) Post TestMean(SD) t-value
study.
DFROM 6.4±0.985 10.46±1.125 -13.52
FFI 43.659±4.702 29.82±2.355 10.185 DiGiovanni et al21 determines with their study that
NPRS 6.33±0.975 3.33±0.816 13.748 plantar fascia and Achilles tendon stretching exercises
Graph 1 Mean values of post-intervention for passive showed high rate of improvement, is supporting the
DFROM, NPRS and FFI between Group A and results obtained in the present study and mentioned
Group B. that 77% patients reported no limitation in recreational
activities and 94% patients reported a decrease in pain.

The average NPRS on 1st day was 6.4±0.985 and on

last were 2.133±0.743. The statistical analysis showed
a significant improvement in experimental group.

The result of the study suggests that MET along

with conventional treatment for plantar fasciitis
provides effects in improving ankle range of motion
and foot functional index and also reduction in pain
in patients with plantar fasciitis.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 29
Limitation of the study
First limitation of study is that it was done on small
sample size. Second is lack of long term follow-up to
measure the lasting effects of the technique.
Future research
This study can be carried out on large sample size.
Future research can be done with long term follow
up to see the substantiate effects.
CONCLUSION
This sutdy concluded that after 6 week intervention
to group A (MET with conventional), the outcomes
are significantly improved with regard to ankle range
of motion, foot functional index and NPRS, an overall
improvement was seen as compared to the other
group, i.e. Group B (static stretching with
conventional).
ACKNOWLEDGEMENT
With extreme gratitude and indebtness, I wish to
express my regards, sincere thanks and express my
deep sense of gratitude to my parents and my teachers.
They immensely helped and rendered their valuable
guidance, advice, precious knowledge, timely
assistance & invaluable suggestions. Last but not least,
I thank God for bestowing me with knowledge and
giving me the encouragement.
Conflict of Interest: None declared
Source of Funding: Self
Ethical Clearance: The study is approved by
Departmental Research Committee.
REFERENCES
1. Roxas M. Plantar Fasciitis:Diagnosis and
Therapeutic Considerations. Alternative Med Rev.
2005;10(2):83-93.
2. Cornwall MW, McPoil TG. Plantar fasciitis:
etiology and treatment. J Orthop Sports Phys Ther.
1999;29:756-760.
3. Singh D, Angel J, Bentley G, Trevino SG.
Fortnightly review. Plantar fasciitis. BMJ.
1997;315:172-175.
4. Young CC, Rutherford DS, Niedfeldt MW.
Treatment of plantar fasciitis. Am Fam Phys.
2001;63:467-474.
6. Rahul Tanwar--26--.pmd 29
5. Kent Stuber, Kevyn Kristmanson. Conservative
therapy for plantar fasciitis: a narrative review
of randomized controlled trials. J Can Chiropr
Assoc. 2006; 50(2):118–133.
6. Martin JE. Mechanical treatment of plantar
fasciitis: a prospective study. J Am Pod Med Assoc
2001;91(2):55–62.
7. Buchbinder R. Plantar fasciitis. N Engl J Med 2004;
350(32):2159–2166.
8. DiGiovanni BF. Tissue-specific plantar fascia
stretching exercise enhances outcomes in patients
with chronic heel pain: a prospective,
randomized study. J Bone Joint Surg 2003;
85A(7):1270–1277.
9. Nemegyei JA, Canoso JJ. Heel pain: Diagnosis
and treatment, step by step. Clevelend Clinic
Journal of Medicine. 2006 May;73(5):465-471.
10. Namik SAHIN, Alpaslan ÖZTÜRK, Teoman
ATICI. Foot mobility and plantar fascia elasticity
in patients with plantar fasciitis. Acta Orthop
Traumatol Turc 2010;44(5):385-391.
11. Kwong, PK, Kay D, Voner, RT, White MW.
Painful heel syndrome. Mechanics and
pathomechanics of treatment. Ciin. Sports Med
1988;7(1):119-126.
12. Yolanda AB, Pedro VM, Juan PP. Relation
between tightness of the posterior muscles of the
lower limb and plantar fasciitis. American
Orthopaedic Foot & Ankle Society 2013;34:42-48.
13. Sweeting D, Parish B. The effectiveness of manual
stretching in the treatment of plantar heel pain: a
systemic review. Journal of foot and ankle research
2011;4:1-19.
14. Benedict F.Digiovanni, Deborah A. Nawoczenski.
Plantar Fascia-Specific Stretching Exercise
Improves Outcomes in Patients with Chronic
Plantar Fasciitis: a prospective clinical trial with
two-year follow-up. The Journal of Bone & Joint
Surgery 2006;88:1775-1781.
15. Burns DK, Wells MR. Gross range of motion in
the cervical spine: the effects of osteopathic
muscle energy technique in asymptomatic
subjects. JAOA 2006 March;106(3):137-142.
16. Fryer G. Muscle energy concepts: a need for
change. J osteopathic medicine. 2000;3:54-59.
17. Fryer G. Muscle energy technique: An evidence-
informed approach. Int J Osteopath Med.
2011;14(1):3-9.
18. Ballantyne F, Fryer G, McLaughlin P. The effect
of muscle energy technique on hamstring
extensibility: the mechanism of altered flexibility.
Journal of Osteopathic Medicine. 2003;6(2):59-63.
19. Greenman P. Principles of Manual Medicine.
Baltimore: Williams &Wilkins; 1996;2:93-98.
11/1/2014, 12:17 AM
 30 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
20. Waseem M, Nuhman S, Ram CS. Efficacy of
muscle energy technique on hamstring muscles
flexibility in normal Indian collegiate males.
Calicut medical Journal 2009;7:1-5.
21. DiGiovanni BF, Nawoczenski DA, Lintal ME,
Moore EA, Murray JC, Wilding GE, Baumhauer
JF. Tissue-specific plantar fascia-stretching
exercise enhances outcomes in patients with
chronic heel pain. A prospective, randomized
study. J Bone Joint Surg Am. 2003;85:1270-7.
22. Joel A Radford, Karl B Landorf, Rachelle
Buchbinder, Catherine Cook. Effectiveness of calf
muscle stretching for the short-term treatment of
plantar heel pain: a randomised trial. BMC
Musculoskeletal Disorders 2007;8:1-8.
23. Knight CA, Rutledge CR, Cox ME. Effect of
superficial heat, deep heat, and active exercise
warm-up on the extensibility of the plantar
flexors. Phys Ther 2001;81:1206–13.
24. Fryer G & Ruszkowski W. The influence of
contraction duration in muscle energy technique
applied to the atlanto-axial joint. Journal of
osteopathic medicine 2204;7(2):79-84.
25. Chaitow L. Muscle Energy Technique. 2nd ed.
2006. Churchill Livingstone.
26. Shadmehr A, Hadian MR, Naeimi SS, Jalaie S,
Mokhtari A. The effect of muscle energy
techniques on flexibility of the hamstring muscles
2007;1(2-3):60-65.
27. Lenehan KL, Fryer G, McLaughlin P. The effect
of muscle energy technique on gross trunk range
of motion. Journal of Osteopathic Medicine.
2003;6(1):13-18.
28. Leslie J. Jennings. A Study into the comparison
of counterstrain and muscle energy techniques
on the gastro-soleus complex and their
subsequent effects on passive dorsiflexion of the
talo-crural joint. British School of Osteopathy. 2000.
29. Schenk R, Adelman K, Rousselle J, (1994). The
Effects of Muscle Energy Technique on Cervical
6. Rahul Tanwar--26--.pmd 30
Range of Motion. Journal of Manual and
Manipulative Therapy. 1994; 2(4): 149 – 155.
30. Moore SD, Laudner KG, McLoda TA, Shaffer
MA. The immediate effects of muscle energy
technique on posterior shoulder tightness: a
randomized controlled trial. JOSPT
2011;41(6):400-407.
31. Ibrahim Ayshe. The effects of MET and STT on
calf muscle strength and flexibility. British college
of osteopathic medicine 2010.
32. Bergold MS, Franke H. The effectiveness of
muscle energy technique. A systemic review.
Academy for osteopathy, Deutschland 2005.
33. Baggett BD, Young G. Ankle joint dorsiflexion:
established of a normal range. Doxey-hatch medical
center 1993;83(5):251-254.
34. Roaas A & Anderson GBJ. Normal range of
motion of the hip, knee and ankle joints in male
subjects, 30-40 years of age. Acta orthop scand
1982;53:205-208.
35. SooHoo NF, Samimi DB, Vyas RM, Botzler T.
Evaluation of the validity of the Foot Function
Index in measuring outcomes in patients with
foot and ankle disorders. Foot ankle int, 2006
Jan;27(1):38-42
36. Wu SH, Liang HW, Hou WH. Reliability and
validity of the Foot Function Index, J Formos Med
Assoc. 2008 Feb;107(2):111-8.
37. Downie WW, Leatham PA, Rhind VM. Studies
with pain rating scales. Ann Rheum Dis
1978;37:378-381.
38. Konor MM, Mortom S. Reliability of three
measures of ankle dorsiflexion range of motion.
IJSPT 2012;7(3):279-287.
39. Norkin CC, White DJ. Measurement of joint
motion: A guide to goniometry. Philadelphia: FA
Davis Company; 1995.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 31

Effect of Muscle Energy Technique to Improve Flexibility

of Gastro-Soleus Complex in Plantar Fasciitis: A
Randomised Clinical, Prospective Study Design

Sharma S1, Saini S2, Kaprail M3, Dhillon PK4, Benjamin KE5, Saini P6
1
Hysiotherapist, 2Assoc Prof., 3Physiotherapist, 4Asst Prof., 5HOD Physiotherapy, College of Physiotherapy Christian
Medical College & Hospital, Ludhiana, 6Assoc Prof., College of Nursing, Dayanand Medical College & Hospital,
Ludhiana, Both Affiliated to Baba Farid University of Health Sciences, Faridkot, Punjab

ABSTRACT
Objective: Functional outcome before and after total hip arthroplasty
Introduction: In osteoarthritis of the hip joint, there is a softening and fibrillation of the articular
cartilage. Cyst formation and sclerosis occurs in the underlying bone. Joint stiffness may be a result
of synovial hypertrophy and capsular fibrosis. Arthroplasty is an operation to restore pain free motion
to a joint and function of muscles, ligaments and others soft tissue structures that control the joint.
Design: Experimental Design.
Methodology: Research was conducted in Christian Medical College & Hospital, Ludhiana .20 patients
aged above 55 were recruited by personal invitation or voluntary consent. WOMAC Score was used
as diagnostic tool. For analysis WOMAC Score was taken pre op and every week post op for 4 weeks.
Result: From the data analysis we find that WOMAC score which included pain, stiffness and difficulty
with physical functions. Increased from 18.6% on pre op day when strengthening exercises were
taught to 93.1% at week 4 when the patient came for follow up after doing regular strengthening
exercises at home. WOMAC score pre op. We conclude that there was severe pain, stiffness and
difficulty in performing daily activities.
Conclusion: There were significant improvements in physical function, Pain and stiffness after the
targeted exercise program.

Keywords: Hip, Pain, Stiffness, Strengthening Exercises, WOMAC Score

INTRODUCTION education, weight reduction), with surgical

Arthritis means “joint inflammation.” It causes pain
and swelling in the body’s joints, such as the knees or
hips. There are many types of arthritis, but
osteoarthritis is the most common. Also known as
degenerative joint disease or age-related arthritis,
osteoarthritis is more likely to develop as people get
older. Symptomatic hip osteoarthritis occurs in 3% of
the elderly5 and is associated with poor general health
status2. Treatment strategies for hip pain have usually
involved conservative measures (analgesia, exercise,
intervention (total hip replacement; THR) being the
most effective treatment for end stage disease 3.
The most common preoperative complaints by
patients who elect to have THR are pain and loss of
mobility 5,12 . It therefore follows that the most
commonly reported outcomes of THR in the literature
relate to pain relief and restoration of mobility5. It is
clear that a major predictor of outcome after THR is
the preoperative status - worse preoperative status is
followed by a poorer absolute outcome as defined by

7. Sandeep singh--31--.pmd 31 11/1/2014, 12:17 AM

 32 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
several outcome measures7. Outcome studies of pain
reduction and range of motion restoration, usually
conducted 3 to 6 months after THR, indicate an overall
satisfaction by patients and physicians1. However,
outcome studies performed at least 1 year after THR
reveal that limitations in physical function remain even
in the absence of pain. These persisting impairments
include decrements of 10-21% in muscle strength and
postural stability of the involved hip relative to the
non-operated hip at 1 year post-THR surgery13,11, with
these deficits still evident 2 years after surgery2,11. Prior
to surgery, there is a general deficit in muscular
strength along the affected limb as compared to the
contra-lateral (healthy) side in patients with unilateral
hip osteoarthritis (OA)9, and muscles such as the
abductors, vastii, rectus femoris and psoas show
marked atrophy. This muscular dysfunction is likely
to contribute to the reduced ambulatory capacity of
OA patients, as loss of lower-limb muscle strength has
been shown to predict the onset of activities of daily
living dependence in the elderly10. Consistent with the
persisting functional deficits following surgery, these
atrophic changes about the hip are still evident up to 2
years following THR surgery9. Earlier operation may
prevent the development of persistent atrophic
changes that occur after THR and there is a suggestion
by Rasch et al.9.There have been considerable technical
efforts towards optimising surgical treatment of
patients with arthritis of the hip, for example with over
100 varieties of hip prostheses being available, multiple
types of bearing couples and several surgical
approaches. As technology and surgical techniques for
total hip replacement (THR) improve, patient
expectations, including for an early return to normal
physical function and activities, have In the past, a
prolonged hospital stay after THR surgery
incorporated a period of supervised rehabilitation to
try to achieve restoration of physical function.
However, due to the introduction of initiatives such
as integrated care pathways and considerations of cost
and increasing patient satisfaction, the length of
hospital stay following joint replacement has been
substantially reduced6. Mean length of stay after THR
over the past decade has declined from 3 weeks to 4
days 4 . Rehabilitation is therefore increasingly
important following total hip replacement. The aim of
this review is to systematically investigate the
literature with regards to the highest-level evidence
(randomised controlled trials) for studies of
rehabilitation programmes that have tried to improve
function after this common surgical intervention.
7. Sandeep singh--31--.pmd 32
Review of Literature
• George H Smith (2008) stated that it was the young
and those less disabled from their arthritis that
excelled at three years. When making a decision
about the timing of hip arthroplasty surgery it is
important to take into account the age and pre-
operative function of the patient. Whether these
patients continue to excel however will be the basis
of future research
• Röder C(2007) stated that Patients with poor
preoperative walking capacity and hip flexion are
less likely to achieve an optimal outcome with
regard to walking and motion. In contrast, there is
no correlation between the preoperative pain level
and pain alleviation, which is generally good and
long-lasting after total hip arthroplasty
• Mette Krintel Petersen (2008) stated that Total hip
replacement (THR) has evolved into a reliable and
suitable surgical procedure to relieve pain and
restore function among patients with damaged or
degenerated hip joints and chronic pain. The
longevity of currently available implants is often
considered as the main outcome after THR.
However, outcome after THR depends not merely
on a successful surgical procedure, but also on
adequate postoperative rehabilitation. Multimodal
rehabilitation, which evolved as a coordinated
multimodal effort combining modern concepts of
patient care with multimodal anesthetic and
analgesic methods, has been introduced to
improve rehabilitation after surgery.
• Garellick G (1998) stated that In a prospective
study of 410 cemented hip replacements in 372
patients with a mean age of 71 years, mortality after
8 years was 33%. Mortality for patients with
osteoarthritis was lower than in an age matched
control population, probably because of a
preoperative selection of patients. An estimate of
costs and adjusted quality of life has shown that
total hip replacement has a good cost utility even
in the elderly patient. The conclusion of this study
is that the indications for hip replacement in the
elderly patient can be expanded. Such patients
should undergo surgery earlier in the course of
their disease.
• Galea MP stated the targeted strengthening
program was effective for both the home- and
center-based groups. No group differences were
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 33
found in the majority of the outcome measures.
This finding is important because it shows that
THR patients can achieve significant
improvements through a targeted strengthening
program delivered at a center or at home.
AIM AND OBJECTIVES
AIM: To assess functional outcome after total hip
replacement
Objective: To find the effectiveness of total hip
replacement.
HYPOTHESIS
Null Hypothesis: There is no functional outcome and
improvement after total hip replacement.
Alternative Hypothesis: There is improvement and
functional outcome after total hip replacement.
MATERIAL AND METHODOLOGY
• Source of Data
• Research Design :- Experimental
• Research Setting:-Department Of Orthopedic
surgery and Department Of Physiotherapy
Chritian Medical College & Hospital Ludhiana.
• TARGET POPULATION: “ Patient aged above
55 years”
• SAMPLING TECHNIQUE : “Simple random”
• SAMPLE SIZE : ” Total of 20 patients”
Research Variables
• Independent Variable: Strengthening exercises
(Supervised Ex’s)
• Dependent Variable : OA hip
Inclusion Criteria
• Patients previously in good health
• Osteoarthritis of hip with grade 2 and 3
• Patients above age of 55 years
• Both male and female are taken as subject
Exclusion Criteria
• Fracture neck and shaft of femur
7. Sandeep singh--31--.pmd 33
• Infected injuries around hip
• Deformities of hip
• Avascular necrosis
PROCEDURE
20 Patients who were planned for total hip
arthroplasty were assessed pre operatively and per
week post operatively till 4 weeks. All had undergone
total hip arthroplasty for primary diagnosis of
osteoarthritis of hip. Strengthening exercises were
taught pre operatively and were supervised post
operatively. Strengthening exercises include:-
• Ankle Pumps
• Ankle Rotations
• Bed-Supported Knee Bends
• Buttock Contractions
• Abduction Exercise
• Quadriceps Set
• Straight Leg Raises
After surgery when patient is able to stand
independently
• Standing Knee Raises
• Standing Hip Abduction
• Standing Hip Extensions
Follow up was done per week for every 4 weeks.
We use WOMAC score to investigate the effect of
training on patient’s symptoms on affected hip. The
index consists of 24 questions divided into 3 sections:
pain, stiffness and difficulty with physical functions.
The items were scored where 0 represents no pain,
stiffness or difficulty with physical function. Higher
scores on the WOMAC indicate worse pain, stiffness,
and functional limitations.
DATA COLLECTION
Tool consist of two parts
• Part 1 : Socio demographic profile
• Part 2 : Data collection sheet on the assessment of
OA hip by radiograph and WOMAC Scale
11/1/2014, 12:17 AM
 34 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

• Assessment: WOMAC SCORE was used to assess

pain, stiffness and functional activities before and
after THR.

• REVISIT PROTOCOL: After every 1week for 4

weeks.

Interpretation of Scores

Higher scores on the WOMAC indicate worse pain,

stiffness, and functional limitations.

Method of Scoring
Fig. 3. Shows WOMAC score post op on week 2 .We conclude
that there was moderate decrease in pain and stiffness and
The WOMAC is typically scored by hand, using moderate increase in performing daily activities after surgery
the conventions described above.

Time to Score

5-10 minutes

Statistics And Data Analysis

Data Analysis was done using t-test

Womac Score

Fig. 4. Shows WOMAC score post op on week 3.We conclude that

there was significant decrease in pain and stiffness and significant
increase in performing daily activities after surgery

Fig. 1. Shows WOMAC score pre op. We conclude that there was
severe pain, stiffness and difficulty in performing daily activities.

Fig. 5. Shows WOMAC score post op on week 4.We conclude that

there was no pain and stiffness and near normal performance of
daily activities after surgery

RESULT

From the data analysis we find that WOMAC score

Fig. 2. Shows WOMAC score post op on week 1 .We conclude
that there was mild decrease in pain and stiffness and mild
increase in performing daily activities after surgery.
which included pain, stiffness and difficulty with
physical functions, increased from 18.6% on pre op day
when strengthening exercises were taught to 93.1% at
week 4 when the patient came for follow up after doing
regular strengthening exercises at home.

7. Sandeep singh--31--.pmd 34 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 35
WOMAC score pre op. We conclude that there was
severe pain, stiffness and difficulty in performing daily
activities.
Pre op: Pre op WOMAC score was 18.6%. Thus
illustrating that there was severe pain, stiffness and
decrease in performing daily activities.
Post op week 1: Post op week 1 WOMAC score was
32.7%. Thus illustrating that there was mild decrease
in pain , stiffness and mild increase in performing daily
activities.
Post op week 2: Post op week 2 WOMAC score was
55.9%. Thus illustrating that there was moderate
decrease in pain , stiffness and moderate increase in
performing daily activities.
Post op week 3: Post op week 3 WOMAC score was
75.1%. Thus illustrating that there was significant
decrease in pain , stiffness and significant increase in
performing daily activities.
Post op week 4: Post op week 4 WOMAC score was
93.1%. Thus illustrating that there was no pain ,
stiffness and near normal in performing daily activities.
DISCUSSION
According to Mette Krintel Petersen (2008) Total
hip replacement (THR) has evolved into a reliable and
suitable surgical procedure to relieve pain and restore
function among patients with damaged or degenerated
hip joints and chronic pain. However, outcome after
THR depends not merely on a successful surgical
procedure, but also on adequate postoperative
rehabilitation. Regular exercises help to restore normal
hip motion and strength and a gradual return to
everyday activities are important for full recovery. The
strengthening program was effective for both the
home- and center-based groups. No group differences
were found in the majority of the outcome measures.
It shows that THR patients can achieve significant
improvements through a strengthening program
delivered at a center or at home. The targeted exercise
program was effective for the THR patients in this
study. All outcome measures improved with the
majority showing significant improvement by the end
of the 4-week program. Total hip replacement (THR)
has evolved into a reliable and suitable surgical
procedure to relieve pain and restore function among
patients with damaged or degenerated hip joints and
chronic pain. The longevity of currently available
implants is often considered as the main outcome after
7. Sandeep singh--31--.pmd 35
THR. However, outcome after THR depends not
merely on a successful surgical procedure, but also on
adequate postoperative rehabilitation. Rehabilitation,
which evolved as a coordinated effort combining
modern concepts of patient care with anesthetic and
analgesic methods, has been introduced to improve
rehabilitation after surgery.
CONCLUSIONS
There were significant improvements in physical
function, pain and stiffness after the targeted exercise
program. The findings suggest the exercise program
might be used successfully by THR patients to improve
functional outcome. There is improvement and
functional outcome after total hip replacement hence
null hypothesis is rejected.
Scope of Study
• Further research with adequate sample size and
comparable sex distribution may be taken of over
sufficient duration to arrive at quality better
results.
• Same researches can be carried out having more
variables than WOMAC.
LIMITATIONS OF THE STUDY
• Sample size was small
• The study was defined to a limited area only.
• Only few variables were included in the study.
• The data collected from WOMAC is very subjective
in nature.
Conflict of Interest: Nil
Source of Funding: Nil
Ethical Clearance: Approval has been taken
Acknowledgement: We would like to thank
Department of Orthopedics and Department of
Physiotherapy, CMCH, LDH for their immense help
REFRENCES
1. Barber TC, Roger DJ, Goodman SB, Schurman
DJ.1996. Early outcome of total hip arthroplasty
using the direct lateral vs the posterior surgical
approach. Orthopedics , 19(10):873-875.
2. Dawson J, Linsell L, Zondervan K, Rose P,
Randall T, Carr A, et al.2004 Epidemiology of hip
11/1/2014, 12:17 AM
 36 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
and knee pain and its impact on overall health
status in older adults. Rheumatology (Oxford) ,
43(4):497-504.
3. Di Domenica F, Sarzi-Puttini P, Cazzola M,
Atzeni F, Cappadonia C, Caserta A, et al.2005.
Physical and rehabilitative approaches in
osteoarthritis. Semin Arthritis Rheum 2, 34(6
Suppl 2):62-69.
4. Epstein AM, Read JL, Hoefer M.1998.The relation
of body weight to length of stay and charges for
hospital services for patients undergoing elective
surgery: a study of two procedures. Am J Public
Health , 77(8):993-997
5. Felson DT, Lawrence RC, Dieppe PA, Hirsch R,
Helmick CG, Jordan JM, et al.2000.:
Osteoarthritis: new insights. Part 1: the disease
and its risk factors. Ann Intern Med , 133(8):
635-646.
6. Husted H, Holm G, Jacobsen S.2008. Predictors
of length of stay and patient satisfaction after hip
and knee replacement surgery: fast-track
experience in 712 patients. Acta Orthop,
79(2):168-173.
7. Kennedy DM, Hanna SE, Stratford PW, Wessel
J, Gollish JD.2006. Preoperative function and
gender predict pattern of functional recovery
after hip and knee arthroplasty. J Arthroplasty ,
21(4):559-566
7. Sandeep singh--31--.pmd 36
8. Long WT, Dorr LD, Healy B, Perry J.1993.
Functional recovery of non cemented total hip
arthroplasty. Clin Orthop Relat Res, 288:73-77.
9. Rasch A, Bystrom AH, Dalen N, Martinez-
Carranza N, Berg HE: Persisting muscle atrophy
two years after replacement of the hip. 2009.J
Bone Joint Surg Br, 91(5):583-588.
10. Rantanen T, Avlund K, Suominen H, Schroll M,
Frandin K, Pertti E.2002. Muscle strength as a
predictor of onset of ADL dependence in people
aged 75 years. Aging Clin Exp Res 2002, 14(3
Suppl):10-15.
11. Shih CH, Du YK, Lin YH, Wu CC.1994. Muscular
recovery around the hip joint after total hip
arthroplasty. 1994.Clin Orthop Relat Res ,
302:115-120.
12. Trudelle-Jackson E, Smith SS.2004. Effects of a
late-phase exercise program after total hip
arthroplasty: a randomized controlled trial. Arch
Phys Med Rehabil , 85(7):1056-1062.
13. Trudelle-Jackson E, Emerson R, Smith.2002.
Outcomes of total hip arthroplasty: a study of
patients one year postsurgery. 2002.J Orthop
Sports Phys Ther, 32(6):260-267.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 37

A Comparative Study of Static Stretch and Proprioceptive

Neuromuscular Facilitation (PNF) Stretch on Pectoral
Muscle Flexibility

Vohra Ramneesh1, Kalra Sheetal2, Yadav Joginder3

1
MPT Student, 2Assistant Professor, Department of Physiotherapy, Dashmesh College of physiotherapy, SGT group of
institutions, Gurgaon, 3Principal, Dashmesh College of Physiotherapy, SGT Group of Institutions, Gurgaon

ABSTRACT
Study Design: Experimental study design
Background: There is a lack of clinical research regarding effectiveness of various stretching techniques
for pectoral muscle flexibility. To our knowledge there are no prospective, randomized studies in the
literature investigating the effectiveness of different stretching techniques for pectoral muscle
flexibility.
Purpose of the study: To compare the effectiveness of Static stretching and Proprioceptive
Neuromuscular facilitation stretching for improving pectoral muscle flexibility.
Method: 30 subjects having forward shoulder posture and pectoral muscle tightness were randomly
assigned to either static stretching group or PNF stretching group. Readings were taken for shoulder
external rotation ROM and decrease in distance from C7 to anterior tip of acromion process on 1st
day, 3rd week and last day of protocol i.e. 6th week.
Results: The results of the study revealed that Group B treatment protocol is better than group A in
improving flexibility of pectoral muscle in terms of shoulder external rotation ROM and forward
shoulder posture. There was a significant improvement in ROM score in group B in 3rd week (p<0.05)
and in 6th week (p<0.05) as compared to that in group A. There was a significantly higher reduction
in distance score in group B on 6th week (p<0.05) as compared to group A.
Conclusion: The results of the study indicated that PNF stretching will be more effective than static
stretching for improving pectoral muscle flexibility in terms of shoulder external rotation range of
motion and forward shoulder posture.

Keywords: Static Stretching, Proprioceptive Neuromuscular Facilitation Stretching, Pectoral Flexibility, Baylor
Square

INTRODUCTION practitionar annualy because of pain and dysfunction

Posture is the mechanical relationship of the parts
of the body to each others and posture is influenced
by many factors including general health, sex, body
built, personal habits, environment. Any deviation in
this parameter is stated as faulty posture, and this
faulty posture is becoming very common which needs
to be corrected in right manner for betterment of life1.
Shoulder pathology is the third most common
musculoskeletal condition treated in primary care and
upto 2% of the population consult with their general
in this region2.
Poor shoulder posture and muscle imbalance are
believed to be important factors that contribute to
shoulder dysfunction2. Abnormal postural alignment
can be detrimental to muscle function, is aesthetically
unpleasing, and might contribute to joint pain. It has
been postulated that short and tight scapular abductor
muscles or weak and lengthened scapular retractor
muscles or a combination cause an abducted scapulae
posture and that exercise can correct this condition3.

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 38 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Pectoral muscle plays an important role in
maintenance of erect posture. Pectoralis major is a
powerful shoulder muscle as shoulder adductor,
internal rotator, and flexor of the humerus4. It has been
assumed that rounded shoulder posture causes a
decrease in flexibility of the pectoralis major/minor
complex5,6. An intricate relationship between the
dynamic stabilizers and static stabilizers is required
to simultaneously supply the range of motion, force,
and stability of the glenohumeral joint7. Tightness of
the pectoralis major creates an anterior force on the
glenohumeral joint with a consequent decrease in
stability. A tight pectoralis minor limits scapular
upward rotation, posterior tilt, and shoulder external
rotation thereby reducing subacromial space6,7.
Tightness of pectoral muscles leads to poor posture
which identifies as forward shoulder or rounded
shoulder posture with weak posterior scapular
stabilizers8. Stretching of tight pectoral muscles in
proper manner results in correction of the faulty
posture, as stretching results in elongation of tight
pectoral muscle which improves the flexibility of
pectoral muscle therefore improving the range of
motions of shoulder joint which ultimately helps in
improvement of posture and balance at the shoulder
level9. Persons who remain in slouch posture i.e. head
and shoulder forward for prolong period, the
elongated muscles (posterior scapular stabilizers) may
become weaker and shortened muscles (pectorals) may
become stronger. As a result force imbalance develops
between those two muscle groups which in time may
result in resting scapular position and in forward
shoulder posture8,10.
Proprioceptive neuromuscular facilitation and
static stretching are commonly advocated techniques
to enhance flexibility and ROM11. The static stretch
takes advantage of the inverse myotatic reflex, which
promotes muscle relaxation and hence further stretch
and range of motion. The slow, controlled movement
allows the stretch to be performed safely, with reduced
risk of injury as compared to the other forms of
stretching12,13.PNF stretching is a popular method of
stretching that utilizes inhibition techniques 14; of these,
contract-relax , hold-relax and contract-relax
antagonist-contract appear to be most commonly
used15.
8. ramneesh vohra--37--.pmd 38
METHOD
Design
An Experimental study design was used for this
study. Patients were randomly allocated to 2 groups
either static stretching or PNF stretching with 15
subjects in each group. The independent variables
were Group A-Static stretching and Group B-
Proprioceptive neuromuscular facilitation stretching
(PNF).
Subjects
Subjects ranging in age from 18-35 years were
recruited from Physiotherapy OPD of Dashmesh
College of Physiotherapy.
Inclusion criteria included age group of 18-35 years,
male subjects, subject having tightness of pectoral
muscles, subject having round or forward shoulder
posture.
Exclusion criteria were Subject taking treatment
for shoulder dysfunction, subject having overt
shoulder trauma or shoulder injury, acute pain around
shoulder area, subject experiencing signs and
symptoms of DOMS.
INTERVENTION
Static stretching
The subject assumed a sitting position in front of
the therapist and laced his or her fingers behind the
head. The therapist then reached in front of the subject
arms and back behind the subject scapulae, lacing his
or her fingers together, as well. The therapist pulls in
a diagonal direction, both up and back from the subject
trunk, until instructed to stop and hold by the subject.
The stretch was held for 30 seconds9. Posture was again
measured with the help of Baylor square and shoulder
external rotation was measured with the help of
goniometer. The stretching exercises were done for five
days per week for six weeks12.
PNF stretching
The subject assumed a sitting position in front of
therapist and laced his or her fingers behind the head.
The therapist then reaches in front of the subject arms
and back behind the subject scapulae, lacing his or her
fingers together, as well. The therapist pulls in a
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 39

diagonal direction both up and back from the subject
trunk. Subject is then asked to perform maximum
voluntary contraction of shoulder adduction for 6sec,
the arm will further bring backward to maintain “mild
discomfort” the subject was relaxed at this point for
10 sec, followed by another 6sec contraction and 10
more sec of rest at the point of “mild discomfort”16,17.
Posture was again measured with the help of Baylor
square and shoulder external rotation was measured
with the help of goniometer. The stretching exercises
were done for five days per week for six weeks12.
OUTCOME MEASURES
Shoulder external Rotation ROM was measured
with a standard goniometer and forward shoulder
posture was measured with Baylor square by
measuring distance from C7scpinous process to
anterior tip of acromion process20. All the readings
were taken on baseline, 3rd week and 6th week of
protocol.
RESULTS
Data analysis was performed using SPSS software
12 version. The results were considered statistically
significant at (p<0.05).Repeated measures analysis of
variance (ANOVA) was used to analyze the intra
group difference of the shoulder ROM and distance
scores at baseline, 3rd week and 6th week for both group
separately. Paired‘t’ test was performed to analyze the
inter group differences at baseline, 3rd week and 6th
week.
Within group analysis revealed that there was a
highly significant improvement in ROM score in group
A and group B from baseline to 3rd week from 3rd week
to 6th week and from baseline to 6th week (p<0.001).

Table 1-With in group analysis-Group A

Variable (ROM) Group A Mean t p

Mean ± SD Difference
ROM1 53.6±8.12 -5.6 -8.5 .000**
ROM2 59.3±7.28
ROM2 59.3±7.28 -6.3 -10.7 0.000**
ROM3 65.6±6.51
ROM1 53.6±8.12 -12 -11.2 0.000**

ROM 1- ROM 2 = Difference of ROM score between baseline and 3rd week

ROM 2- ROM 3 = Difference of ROM score between 3rd week and 6th week

ROM 1- ROM 3 = Difference of ROM score between baseline and 6th week

** Highly Significant at p < 0.05

Table 2-Within group analysis Group B

Variable (ROM) Group A Mean t p

Mean ± SD Difference
ROM1 56±8.06 -9.6 -9.37 0.000**
ROM2 65.6±5.30
ROM2 65.6±5.30 -13.3 -11.4 0.000**
ROM3 79±4.30
ROM1 56±8.06 -23 -13.7 0.000**
ROM3 79±4.30

ROM 1- ROM 2 = Difference of ROM score between baseline and 3rd week.

ROM 2- ROM 3 = Difference of ROM score between 3rd week and 6th week.

ROM 1- ROM 3 = Difference of ROM score between baseline and 6th week.

** Highly significant at pd”0.001

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 40 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Between group analysis revealed that there was improvement in ROM score in group B in 3rd week
no significant difference in ROM scores between group and in 6th week (p<0.05) as compared to that in
A and B on baseline (p>0.05).There was a significant group A

Table 3: Comparison of ROM between Group A and Group B

(ROM) Group A Group B t p

Mean ± SD Mean ± SD
Day 1 53.6±8.12 56±8.06 -0.7 0.4NS
Week 3 59.3±7.28 65.6±5.30 -2.7 0.01*
Week 6 65.6±6.51 79±4.30 -6.6 0.001**

There was a highly significant reduction in distance score in group A and group B from baseline to 3rd week,
from 3rd week to 6th week and from baseline to 6th week (p<0.001)

Table 4: Within group analysis of Distance score Gp A

Variables (D) Group A Mean t p

Mean ± SD Difference Value Value
D1 21.1±0.83 0.4 3.5 0.000**
D2 20.6±0.81
D2 20.6±0.81 0.8 9.5 0.000**
D3 19.8±0.77
D1 21.1±0.83 1.3 10.5 0.000**
D3 19.8±0.77

D 1- D 2 = Difference of distance score between baseline and 3rd week.

D 2- D 3 = Difference of distance score between 3rd week and 6th week.

D 1- D 3 = Difference of distance score between baseline and 6th weeks.

** Highly significant at pd”0.001

Table 5: Within group comparison of Distance score – Gp B

Variables (D) Group A Mean t p

Mean ± SD Difference Value Value
D1 21.3±0.72 1.06 16 0.000**
D2 20.2±0.79
D 20.2±0.79 1.6 8.9 0.000**
D3 18.6±0.63
D1 21.3±0.72 2.7 15 0.000**
D3 18.6±0.63

D 1- D 2 = Difference of distance score between baseline and 3rd week.

D 2- D 3 = Difference of distance score between 3rd week and 6th weeks.

D 1- D 3 = Difference of distance score between baseline and 6th weeks.

** Highly significant at pd”0.001

Between group analysis revealed that there was no However there was a significantly higher reduction
significant difference in distance score between group in distance score in group B on 6th week (p<0.05) as
A and group B on baseline and on 3rd week (p>0.05). compared to group A.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 41
Table 6: Comparison of distance score between Group A and Group B
Distance
Day 1
Week 3
Week 6
DISCUSSION
The study compared the effects of static stretching
and PNF stretching on pectoral muscle flexibility. The
results of the study showed that although both the
groups showed improvement, the contract relax- PNF
stretching appears to be more effective than static
stretching for improving flexibility of pectoral muscles
in terms of increased shoulder external rotation range
of motion and posture correction.
There was a significant improvement in range of
motion scores on 3rd week and 6th week in both groups
(p<0.05). However the range of motion score of group
B showed improvement better than group A at 3rd
week and 6th week (p<0.001).
The distance score (distance from c7 spinous
process to anterior tip of acromion process) showed
statistically significant improvement in both groups
(p<0.05). However there was a statistically significant
reduction in the distance score in group B as compared
to that of group A (p<0.001).
The basis for PNF stretching is theorized to be
through neural inhibition of the muscle group being
stretched. The proposed neural inhibition reduces
reflex activity, which then promotes greater relaxation
and decreased resistance to stretch, and hence greater
range of movement (Hutton 1993) 18,19 . However,
Magnusson et al. (1996) noted that paradoxically, some
studies have shown PNF techniques to be associated
with greater EMG activity in the muscle being
stretched when compared to a static stretch. Still, other
research has found PNF techniques to promote greater
relaxation 18.
Moore & Hutton, (1980) reported that the static
stretch appears to be more desirable technique for
compliance if comfort and limited training time are
major factors 19.
J. Brent Feland, et al (2001) investigated acute
changes in hamstring flexibility by comparing static
stretch and contract relax-Proprioceptive
Neuromuscular Facilitation (CRPNF). They were
assigned to either a control group (no stretching), or
8. ramneesh vohra--37--.pmd 41
Group A Group B t p
Mean ± SD Mean ± SD
21.1±0.83 21.3±0.72 - 0.7 0.4NS
20.6±0.81 20.2±0.79 1.3 0.1*
19.8±0.77 18.6±0.63 4.6 0.001**
one of two treatment groups contract-relax
Proprioceptive neuromuscular facilitation stretch, or
a static stretch. They concluded that CRPNF stretch is
more beneficial than static stretch18.
Wang C.H, et al (1999) stated that the stretching
exercises for the pectoral muscles and restricted
strengthening exercises for the scapular retractors and
elevators and the glenohumeral abductors and external
rotators for three times per week for six weeks
Improves muscle strength, produced a more erect
upper trunk posture, increased scapular stability10.
Mark Kluemper, et al (2006) concluded in his study
that stretching (static) anterior shoulder soft tissue,
primarily the internal rotator and adductor muscle
groups, and strengthening posterior shoulder muscles,
including the external rotator and abductor groups can
reduce forward shoulder posture in competitive
swimmers9.
LIMITATIONS
Sample size was small
No female subjects were taken.
Follow up was not done.
CLINICAL RELEVANCE
This results of the study provided useful
information about the effect of Static stretching and
PNF stretching in improving pectoral muscle flexibility
thus providing a better approach for forward shoulder
posture correction. It can be successfully included in
conditioning and skill training program to improve
performance and reduce potential for injury.
FUTURE RESEARCH
In future studies, research can be done with a large
group of samples including subject with different age
groups. The merits associated with the long term
effects of static stretching and PNF stretching for
pectorals flexibility with the same treatment period can
be studied which may include a follow up of 2-4
months.
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 42 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
CONCLUSION
The results of the study revealed that PNF
stretching is found to be more effective than static
stretching for improving pectoral muscle flexibility in
terms of shoulder external rotation range of motion
and forward shoulder posture.
Acknowledgement: We are grateful to all the
participants and the hospital staff who assisted in the
study.
Conflict of Interest: We certify that there is no conflict
of interest with any financial organization regarding
the material discussed in the manuscript.
Ethical Clearance and Funding:
We certify that this study has been duly approved
by the relevant ethical committee and is not funded
by any organization.
REFERNCES
1. Tattersall R, Walshaw M.J: Posture and cystic
fibrosis. J R Soc Med, 2003; 96(43):18-22.
2. Morris P.G, Larson K: Incidence of Common
Postural Abnormalities in the cervical, shoulder,
and thoracic region and their association with
pain in two age groups of healthy subject. Phys
Ther 1992;72:425-431.
3. Hrysomallis, Con: Effectiveness of strengthening
and stretching exercises for the postural corr.
4. Robert C. Manske, Dan Prohaska. Pectoralis
major tendon repair: post surgical rehabilitation.
Amj sports med.2007;2:22-31.
5. Clark, M.A., Chapter III: Postural Considerations,
in NASM OPT Optimum Performance Training
for the Performance Enhancement Specialist
Course Manual, R.T. Wittkop, Editor. 2001 and
Lewis, J.S., A. Green.
6. C. Wright, Subacromial impingement syndrome:
the role of posture and muscle imbalance. J
Shoulder Elbow Surg, 2005. 14(4):385-92.
7. Borstad, J.D., Resting position variables at the
shoulder: evidence to support a posture-
impairment association. Phys Ther,2006;86(4):
549-57.
8. Kendall FP. McCreary EK. Muscle testing and
function. 3 rd ed Baltimore: Williams and
Wilkins:1983.
9. Mark Kluemper, Tim Uhl, and Heath Hazelrigg:
Effect of stretching and strengthening shoulder
8. ramneesh vohra--37--.pmd 42
muscles on forward shoulder posture in
competitive swimmers. J Sports Rehabilitation.
2006; 15: 58-70.
10. Wang CH, Nobilini: Stretching and strethning
exercises: their effect on three dimensional
scapular kinematics. Arch Phys Med
Rehabilitation 1999;80:923-929.
11. Feland J.B,Marin H.N Effect of submaximal
contraction intensity in contract relax PNF
stretching: Brj Sports Med 2004;38:18
12. William D. Bandy, Jean M. Irion, Michelle
Briggler: the effect of time and frequency of static
stretching on flexibility of hamstring muscles.
phys ther.1997;77(10):1090-1096
13. Smith C A 1994. The warm-up procedure: to
stretch or not to stretch. A brief review Journal of
Orthopaedic and Sports Phy Ther; 19:12-17.
14. Kisner, C, and L.A. Colby: therapeutic exercise:
Foundations and Techniques. Philadelphia, F.A
Davis Co., 2003, ed4.
15. Hutton, R S 1993 Neuromuscular basis of
stretching exercises. In: Komi, PV Strength and
power in sports, 1st Ed, vol1. Blackwell Scientific
Publications, Oxford, pp 29-38.
16. American college of sports medicine, (2000)
ACSM’s guidelines for exercise testing and
prescription, 6; 158. Robert C. Manske, PT,
DPT,Matt Meschke, DO,† Andrew Porter, DO,
Barbara Smith, PhD, PT,‡ and Michael Reiman.
17. Puentedura EJ, Huijbregts PA, Celeste S,
Edwards D, In A, Landers MR, Fernandez-de-
Las-Penas C. Immediate effects of quantified
hamstring stretching: hold-relax Proprioceptive
neuromuscular facilitation versus static
stretching; Phys Ther Sport. 2011 Aug;12(3):
122-6.
18. Feland J.B., Myer J.W, Merill R.M. Acute changes
in hamstring flexibility: PNF versus static stretch
in senior athletes. Phys Ther In Sports 2001, 2:
186-193.
19. Davis DS, Ashby PE, McCale KL, McQuain JA,
Wine JM: the effectiveness of 3 stretching
techniques on hamstring flexibility using
consistent stretching parameters. J strength-cond
res.2005;19(1):27-32
20. Dan L. Riddle, Jules M. Rothstein and Robert L.
Lamb: goniometric reliability in clinical setting:
shoulder measurements. Phys
ther.1987;67(5):668-673.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 43

Effect of Muscle Energy Technique and Deep Neck

Flexors Exercise on Pain, Disability and Forward Head
Posture in Patients with Chronic Neck Pain

Narang Sakshi1, Mehra Suman2, Sikka Geetanjali2

1
Assistant Professor, Faculty of Physiotherapy, SGT University, Budhera, Gurgoan, 2Assistant Professor
Department of Physiotherapy, Pt B D Sharma University of Health Sciences, Rohtak

ABSTRACT
Study Design: Pre test Post test Study Design
Objectives: To evaluate the effectiveness of Muscle energy technique combined with Deep neck
flexors exercise in reducing pain, disability and correcting Forward head posture in patients with
chronic neck pain.
Background: Previous trials have investigated the effect of MET on pain, disability in low back pain
and Range of Motion in Cervical region. No clinical trial examining the effect of this treatment on
pain, disability and Forward head posture in patients with chronic neck pain has been reported in
the literature.
Method: 30 patients having chronic neck pain were assigned to one of two groups. The group A
received MET combined with deep neck flexors exercises while group B received deep neck flexors
exercises alone. Both groups received the selected treatment over a 4 week period. All outcome
measures were evaluated at baseline, day 14 and day 28.
Results: The results revealed a significant difference between group A and B at the end of the study
depicting that Muscle Energy Technique combined with Deep neck flexors exercise was more effective
than Deep neck flexors exercise alone in improving pain, decreasing disability and correcting forward
head posture.
Conclusion: The research hypothesis which states that there will be more reduction in pain, disability
and forward head posture in subjects treated with MET and Deep neck flexors exercises than Deep
neck flexors alone in patients with chronic neck pain has been accepted.

Keywords: Forward Head Posture, MET, Deep Neck Flexors Exercise

INTRODUCTION The origin of neck pain is multifactorial. Excessive

physical strain may cause microtrauma in connective
Neck pain is among the most common pain
tissues and physiological stress may lead to increased
problems with a reported prevalence ranging from 22-
muscular tension2. Researches have shown that neck
30%1.
musculature contributes 80 % to the mechanical
stability of the cervical spine while the
osseoligamentous system contributes the remaining
Corresponding author:
20%3.
Sakshi Narang
M.P.Th. (Musculoskeletal Disorders) Forward head posture (FHP) is one of the common
Assistant Professor types of poor head posture seen in patients with neck
Faculty of Physiotherapy, SGT University, Budhera
disorders4. In FHP, weakness of deep neck flexors
Gurgoan
(DNF) and tightness of posterior neck muscles and
E mail: sakshinarang.mpt@gmail.com

9. Sakhshi Narang--43--.pmd 43 11/1/2014, 12:17 AM

 44 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
anterior thorax develops5. Impaired activation of the
deep cervical flexor muscles in people with neck pain
is identified6. Rather than responding in a normal feed
forward manner as observed in pain free individuals,
the onsets of the cervical flexors and to the greatest
extent, the deep cervical flexors is found to be delayed.
Researchers have found that specific training of the
craniocervical flexors muscles is effective in increasing
the activation of the DNF muscles and improving the
ability to maintain an upright posture of the cervical
spine during prolonged sitting7.
Physical therapist attempt to manage patients with
FHP by utilizing a wide variety of interventions
including stretching and strengthening exercises,
Spinal manipulation and anterior head weighing8,9.
Greenman described muscle energy technique
(MET) as a manual medicine treatment procedure that
involves the voluntary contraction of patient muscle
in a precisely controlled direction at varying levels of
intensity, against a distinctly executed counter force
applied by the operater10. Researchers have found MET
to be effective in producing a significant increase in
overall regional cervical range of motion in the
treatment group when compared with control
subjects3.
Paralleling our increased understanding of FHP
with chronic neck pain, refinement must be made in
our ability to adequately lengthen the tight muscle and
strengthen the weak muscles and thus decreasing pain,
disability and FHP in patients with chronic neck pain.
But there is no scientific data till date that has studied
the effect of MET and DNF Exercise in patients with
FHP. Therefore, the main aim of the study is to
determine the effectiveness of MET on pain, disability
and FHP in patients with chronic neck pain.
METHOD
Study Design
Pretest Posttest study design.
The independent variables were MET and DNF
exercise. The dependent variables were Pain, Disability
and FHP.
Subjects
30 Subjects were recruited from various hospitals
of Hisar, India.
9. Sakhshi Narang--43--.pmd 44
Inclusion criteria included age group of 30-50 years
,neck pain for atleast 3 months and having RHPSIT more
than 43% (in males) and 47% (in females).
Exclusion criteria included subjects with a history
of cervical spine surgery, trauma to neck and with
fractures of cervical spine, having neck pain secondary
to following conditions (including neoplasm, vascular
disease, spasmodic torticolis),with radiculopathy,
with presenting neurological deficit, with infection or
inflammatory arthritis in cervical spine, with shoulder
disease(tendinitis, bursitis, capsulitis).
The FHP was measured by measuring RHPsit. for
measurement16.
Following base line measurements (NRS, NDI,
RHPsit), the subjects (n=30) were randomized into one
of 2 exercise groups: Group A (N=15): Hot packs +
MET + DNF exercises6,8,14 and Group B (N=15): Hot
packs + DNF exercises6,14.
Intervention
Both groups received the selected treatment over a
4 week period.
MET Intervention
MET for 3 muscles were given in supine position
(3Repetitions/ 2 times/ week for 4 weeks)10. For
suboccipitalis, therapist had to move neck in to flexion
just short of cranioflexion barrier and Subject was
asked to gently push back into craniocervical extension
with mild effort for 7-10 seconds. Then, neck was
moved in to new barrier11.
For upper trapezius, therapist moved subject neck
in to flexion, side flexion, and then rotation of the neck.
And then depress the shoulder just short of resistance
barrier. Subject was asked to gently push the shoulder
back for 7-10 seconds. Then, neck was moved in to
new barrier12.
For pectoralis major, Subject arm was abducted to
450 (for clavicular fibres) and 1400 (for coastal and
sternal fibres) and externally rotated. Grasp the subject
arm above the elbow and subject was asked to gently
push the arm towards the ceiling for 7-10 seconds and
arm was moved in to new barrier13.
DNF exercise intervention
DNF exercises was progressed in the following
manner (Each exercise was performed for 1 week
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 45

progressing to next exercise). Subject performed 10
repetitions twice daily for 4 weeks12. Exercise in 1st
week was in supine position with a small rolled towel
placed under the mid scervical spine and head nod
was performed with no lifting of head off the surface
with progressing to head nodding exercise in sitting
in 2nd week. Then progression was made to exercise in
standing with wall support. And in 4 th week,
progression was made by adding resisted upper
extremity motions (flexion and abduction) 5 repetitions
with each movement /twice daily for 4 weeks14.
Statistical analysis
was done using unpaired t test. Comparison of effect
of treatment within the group for all the variables was
done using one way ANOVA .The significance level
was kept at 95% (p d” 0.05).
RESULTS
The results revealed a significant difference
between group A and B at the end of the study
depicting that MET combined with DNF exercises was
more effective than DNF exercises alone in improving
pain, decreasing disability and correcting forward
head posture.

Data analysis was performed with the software Change in NRS

package SPSS 16 for window version. Mean and
standard deviation of all the variables were calculated. With in group analysis revealed that there was a
Comparison between the groups for all the variables highly significant improvement in pain in group A and
(NRS, NDI Score and RHPSIT) on Day 0, 14 and 28th in group B also (P d” 0.01) on day 14th and 28th.

Table 1: Change in NRS in between Group A and Group B

Day Group A Group B T - value p - value

(Mean ± S.D.) (Mean ± S.D.)
Day 0 6.4± 1.055 6.73 ± 1.032 0.8742 0.3895NS
Day 14 3.73 ± 1.032 5.40 ± 1.121 4.2344 0.0002**
Day 28 1.60± 0.910 3.93 ± 1.222 5.9282 0.0001**

* Significant at p d” 0.05

** Highly significant at p < 0.01

NS – Non significant

Change in NDI Score

With in group analysis revealed that there was a highly significant improvement in disability in group A and
in group B also (P d” 0.01) on day 14th and 28th.

Table 2: Change in NDI Score in between Group A and Group B

Day Group A Group B T - value p - value

(Mean ± S.D.) (Mean ± S.D.)
Day 0 34.95 ± 9.74 34.50± 5.92 0.1519 0.8806NS
Day 14 24.59 ± 7.72 29.022±7.09 1.6372 0.1129NS
Day 28 11.99 ± 4.42 22.80 ± 6.79 5.1644 0.0001**

* Significant at p d” 0.05

** Highly significant at p < 0.01

NS – Non significant

Change in RHPSIT Score

Within group analysis revealed that there was a highly significant correction of FHP in group A (P d” 0.01).

9. Sakhshi Narang--43--.pmd 45 11/1/2014, 12:17 AM

 46 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Table 3: Change in RHPSIT Score in between Group A and Group B
Day
(Mean ± S.D.)
Day 0
Day 14
Day 28
* Significant at p d” 0.05
** Highly significant at p < 0.01
NS – Non significant
Thus , the results reveal that both MET combined
with deep neck flexors exercise and deep neck flexors
exercise alone were effective in reducing pain and
disability. While only MET combined with Deep neck
flexors exercise was effective in correcting forward
head posture.
DISCUSSION
The data obtained from this study suggest that
Muscle energy technique combined with Deep Neck
Flexor exercises is more effective than Deep neck
flexors exercise alone for decreasing pain, disability
and correcting Forward head posture. In this study,
two groups were taken, group A was given Muscle
energy technique combined with Deep neck flexors
exercise and group B was given Deep neck flexors
exercise alone. The effects of exercises were seen on
pain, disability and resting head posture.
Muscle energy technique is considered a gentle
manual therapy technique for restricted motion of the
spine and the extremities and its short term effects
include to decrease pain, muscle tension and spasm,
increase range of motion and strength15. Wilson et al 10
found that muscle energy technique twice in a week
for 4/52 significantly decreases disability in patients
with acute low back pain. So in current study, 2
sessions of Muscle energy technique in a week for 4/
52 was included.
According to Jull and Janda, in upper crossed
syndrome, there occur tightness of suboccipital
muscles, Levator scapulae , upper trapezius,
sternocleidomastoid, Pectoralis major and minor and
weakness of Deep neck flexors, Lower and middle
trapezius, Serratus anterior and rhomboids also13. So,
Muscle energy technique for stretching suboccipital
9. Sakhshi Narang--43--.pmd 46
Group A Group B T - value p - value
(Mean ± S.D.)
51.70 ± 1.70 52.96± 3.70 1.20 0.2442NS
49.37 ± 1.66 51.83±3.81 2.297 0.333*
47.18 ± 1.63 50.74 ± 3.91 3.25 0.004**
muscles, upper trapezius, pectoralis major and
strengthening exercise of Deep neck flexors were
included.
EMG analysis of Deep neck flexors in subjects with
chronic neck pain has revealed that there was
decreased Deep neck flexors activity during each stage
of craniocervical flexion test7. Falla et al (2007) 6 in their
study on VDT workers with chronic neck pain found
that subjects were not able to maintain neutral cervical
posture during prolonged sitting. However, subjects
were able to maintain the neutral cervical posture for
longer duration after a 6/ 52 Deep neck flexors
strengthening exercise program. The pain and
disability also found to decrease significantly. Carrie
M. Hall14 has described a 4 week exercise program for
Deep neck flexors strengthening. In it, the progression
from week one to week four was made by changing
the position of patient and adding resisted upper
extremity movements.
This is the only clinical trial that has compared the
effect of MET and deep neck flexors exercise on pain,
disability and RHPSIT in chronic neck pain patients.
Comparing pre intervention mean NRS scores with
post intervention mean scores revealed that there was
significant decrease in pain and between groups
comparison revealed that there was significant
improvement in Group A when compared with Group
B (p d” 0.01). Thus the results suggest that both MET
combined with Deep neck flexors exercise and Deep
neck flexors exercise alone were effective in
significantly reducing pain and thus indicating that
even 14th day exercise intervention results in significant
improvement supported by Selkow et al , reported that
subjects with lumbo pelvic pain receiving MET
demonstrated a decrease in VAS score15.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 47
Comparing pre intervention mean scores of NDI
and RHPSIT in between Group A and B with post
intervention mean scores revealed that there was
significant improvement in Group A. These findings
were consistent with the findings reported by Wilson
et al (2003) 10 who found MET to be effective in
decreasing disability in chronic low back pain.
However, with in group analysis in Group B, no
significant difference was found in mean RHPSIT score.
Falla et al6 demonstrated that 6 week exercise targeted
at training the craniocervical flexor muscles improved
the ability to maintain an upright cervical posture in
VDT workers when distracted while in this study only
4/52 exercise program was used. Probably 4 week
Deep neck flexors training protocol is not sufficient
time period for correcting Forward head posture.
These findings were similar with the findings
reported by Harmen et al done on Forward head
posture patients and found stretching exercise for neck
extensor and Pectoralis major and strengthening
exercise for Deep neck flexors and shoulder muscles
for 10 weeks and reported improvement in FHP8.
So the trend of mean score in this study give
insights that Muscle energy technique combined with
Deep neck flexors exercise is an effective intervention
than Deep neck flexors exercise alone in decreasing
pain ,disability and correcting FHP. This is also
consistent with findings reported by Denise et al3 who
found that MET produced a significant increase in
overall regional cervical ROM.
Clinical Relevance
Although it is agreed that exercise should be part
of the management of FHP, there is significant
variation in the type of exercise and the proposed
mechanisms of effect for each exercise. The findings
in the study suggest that MET combined with DNF
exercises is more effective intervention for correcting
FHP in patients with chronic neck pain. MET is easy
to apply and has many advantages and may help in
providing basis for designing exercise programme for
correcting FHP, thus reduces the risk and further
consequences.
This study has several limitations. Firstly, sample
size was small. Secondly, this study has not focused
other muscles involved in FHP like Scaleni, Levator
scapulae, Sternocleidomastoid which can be addressed
in future studies. As another limitation, No follow up
9. Sakhshi Narang--43--.pmd 47
was there to see the time duration for which these
effects lasts.
In future studies, effect of more than 4/52
intervention of MET and DNF can be studied to see
that whether it enhances the improvement or not and
relatively small sample sizes must be addressed by
larger studies examining outcomes that have the
potential for detectable changes. Future studies should
compare MET with other manual therapy techniques
like spinal mobilisation, PNF.
CONCLUSION
The research hypothesis which states that there will
be more reduction in pain, disability and forward head
posture in subjects treated with Muscle energy
technique and Deep neck flexors exercises than Deep
neck flexors alone in patients with chronic neck pain
has been accepted.
Acknowledgement: We are thankful to all our subjects
and to Dr Manju and Dr Deepa for their invaluable
support.
Conflict of Interest: There is no conflict with any
organization and this research is not funded by any
organization.
Ethical Clearance: We certify that this study has been
approved by the relevant ethical committee.
REFERENCES
1. Yesim Dusunceli, Cihat Ozturk: Efficacy of neck
stabilization exercises for neck pain- a
randomized controlled study. J Rehab Med 2009:
00:00-00
2. Rodriquez AA, Burns SP: Assessment of chronic
neck pain and a brief trial of cervical
strengthening. Am J Phys Med Rehab 2008: 87:
903- 909
3. Denise K. burns, Michael R. Wells: Gross ROM
in the cervical spine, the effect of osteopathic MET
in asymptomatic subjects. JAOA 2006: Vol. 106:
No.3:137-142
4. Chris Ho Ting Yip, Thomas Tai Wing Chiu et al:
The relationship between head posture and
severity and disability of patients with neck pain.
Manual therapy 2008:13:148-154
5. Chukuka S. Enwemeka, Ivette M. Bonet: Postural
correction in persons with neck pain. JOSPT 1986:
Vol. 8: No.5: 235-39
11/1/2014, 12:17 AM
 48 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
6. Deborah Falla, Gwendolen Jull: Effect of neck
exercise on sitting posture in patients with
chronic neck pain.Physical therapy: 2007: Vol. 87:
No.4: 408-417
7. Gwendolen Jull, Shaun P. O’Leary. Clinical
assessment of the deep cervical flexors muscle:
The craniocervical flexion test. J Manipulative
Physio Therap 2008: 31: 525-533
8. Katherine Harmen, Cheryl L. Hubley-Kozey:
Effect of an exercise program to improve FHP in
normal adults: A randomized clinical 10 week
trial. JMMT 2005: Vol 13: No. 3:163-176
9. Mark W.Morningstar : Spinal manipulation and
anterior head weighting for the correction of
Forward head posture and cervical hypolordosis
– A pilot study. Journal of Chiropractic Med 2003:
2 :51-54
10. Eric Wilson, Otto Payton: MET in patients with
acute LBP – a pilot clinical trial. JOSPT 2003: 33:
502-514
9. Sakhshi Narang--43--.pmd 48
11. Chaitow Leon: Cranial manipulation theory and
practice (pp 243-245): Churchill Livingstone:
London: 1999
12. Liebenson Craig: Rehabilitation of the spine - A
Practitioner’s Manual (pp 273-275) Lippincott
Williams & Wilkins: Newyork : 1986
13. Chaitow Leon: Muscle energy techniques (pp 51-
52): Churchill Livingstone: London: 2003
14. Hall Carrie M.: Therapeutic exercise (pp 587-598):
Lippincott Williams & Wilkins: Newyork: 2005:
2nd ed
15. Noelle M. Selkow, Terry L. Grindstaff : Short term
effect of muscle energy technique on pain in
individuals with non specific lumbopelvic pain-
A pilot study. Journal of manual and
manipulative therapy: Vol 17: No.1: 14-18
16. William P. Hanten, Roberta M. Lucio: Assessment
of total head excursion and resting head posture.
Arch Phys Med Rehab 1991: 72:877-880
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 49

Application of TENS on Acupoints as an Important

Adjunctive Tool with Task-Related Training in Stroke
Rehabilitation Program- A Case Study

Manoj Kumar Deshmukh1, Manu Goyal2, Yogita Verma3

1
M.P.T. Neurology Student, 2Principal, 3M.P.T. Ortho Student, M.M. Institute of Physiotherapy and Rehabilitation,
M.M. University, Mullana, Ambala, Haryana

ABSTRACT
Stroke is an important cause of disability and there is no generally accepted method for rehabilitation
of stroke survivors. Repeated practice of motor activity will enhance the sensory-motor cortex activity
and the TENS is the one way to maximize that sensory input in stroke patients. A 53 year old female
was the subject of this case study, who had walking impairment and spasticity in right lower limb.
The treatment included 6 weeks of intervention in which TENS was applied over 4 acupoints followed
by TRT exercise protocol. Before and after intervention, spasticity was measured by MAS; functional
mobility was measured by TUG test and DGI. The findings of this case study showed that there was
reduction in spasticity by application of TENS along with TRT and relative improvement in functional
mobility up to follow-up.

Keywords: Transcutaneous Electrical Stimulation (TENS), Acupoints, Task-related Training (TRT), Stroke

INTRODUCTION involving repetitive practice of meaningful daily

Stroke or a cerebral vascular accident, is the sudden
death of brain of brain cells due to inadequate blood
flow. The WHO clinically defines the stroke as the
rapid onset of clinical signs and symptoms of a focal
neurological disturbances lasting more than 24 hours
or leading to death with no apparent cause other than
vascular origin.[1] Recent studies showed that the age-
adjusted annual incidence rate was 105/100,000 in the
urban community of Kolkata and 262/100,000 in a
rural community of Bengal.[2,3]
The most important part of daily physical activity
is an ambulation. After stroke 65% of survivors have
reduced ambulatory capacity and after 6 months 50%
still have impaired muscle function because damage
in motor and sensory pathways leads to altered motor
function and, over time intramuscular changes.[4-7]
activities can lead to increased activation of the affected
motor cortex, to help patients derive optimal control
strategies for alleviating movement disorder.[9,10] There
is strong evidence that task-specific gait training
improves lower limb function and gait after stroke.[11,12]
Cortical representation areas can be increased by
training that is specific, requires attention and is
repeated over the time.[13] Neuromuscular stimulation
can be used to enable such practice and is the one of
the way to maximize the amount of sensory input via
sensory amplitude electrical stimulation (SES) like
transcutaneous electrical stimulation (TENS). Wong
and co-workers demonstrated that 2 weeks of TENS
over 4 acupuncture points each in the affected upper
and lower limbs produced a shorter hospital stay and
better functional outcomes than standard
rehabilitation alone.[14]

Neuro-rehabilitation is the methods for relearning CASE DESCRIPTION

a previously learned task in different way, either by
compensatory strategies or by adaptively recruiting A 53 year old female admitted to the medicine unit
alternative pathways.[8] Task-specific physiotherapy 3 months after stroke and referred for rehabilitation

10. Manoj Deshmukh--49--.pmd 49 11/1/2014, 12:17 AM

 50 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
in physiotherapy unit of MMIMSR hospital Mullana,
Ambala. She was house-wife and right handed. As a
consequence of stroke she had Rt. spastic hemiplegia.
During that time she was able to ambulate with help
of cane. She was partially dependent on her ADLs. She
was alert and scored 24/30 in Mini Mental State
Examination. The spasticity score in Modified
Ashworth scale (MAS) was grade 3. She had history
of hypertension since 6 years. The female has
supportive family. Radiological investigation revealed
that there was a moderate sized infarction in left MCA
territory and the area supplied by it. She was medically
stable and completed the neurological investigation.
She was co-operative during the treatment procedure
and signed the consent form prior the intervention.
BASELINE MEASUREMENTS
Patient completed the following baseline
investigation prior to intervention.
Modified Ashworth Scale (MAS)
The objective measurement of spasticity of plantar
flexor was done by using MAS scale. The test has
recently been validated and shown to be reliable
measurement of spasticity on lower limb in subjects
with stroke.[15,16] The patient was examined on a couch
in relaxed position in supine lying. The affected limb
was moved passively and resistance encountered by
the single therapist to passive movement of ankle was
then recorded by the MAS scale.
Timed up and GO test (TUG)
The timed up and go test is a simple, quick and
reliable functional mobility test that is used to examine
the functional mobility and balance in community
dwelling, frail older adults and individual wit
stroke.[17,18] A recent study demonstrated the reliability
and validity of TUG test in stroke population.[19,20] The
patient was asked to stand up from chair, walks 3
meter, turn around, return to chair and sit down. The
time taken to complete the task was recorded in
seconds with help of stopwatch.
Dynamic Gait Index (DGI)
The DGI was developed to evaluate the functional
stability during gait activities in older people and to
evaluate their risk of falling.[21] The DGI is an 8-item
10. Manoj Deshmukh--49--.pmd 50
tool with which the examiner rates an individual’s gait
performance on an ordinal scale that ranges from 0 to
3. It takes approximately 10 minutes or less to complete
and score the DGI. Reliability and validity of DGI for
people with stroke has been established.[22,23] Test was
performed on distance of 20 foot. The patients were
instructed to walk on marked surface with different
task.
INTERVENTION METHOD
The patient received 60 minutes of TENS on
acupoints followed by Task-related training and
conventional physiotherapy for upper limb for 6
weeks. Stimulator applied with 0.2 ms pulses, at 100
Hz in the constant mode within the subject’s tolerance
level, via (5 × 3.5 cm) electrodes attached to the
following acupuncture points on the affected lower
extremity: St 36, Lv 3, GB 34, and Bl 60 (Fig. 1). The
selection of acupuncture points and parameters for
application of TENS were adapted by previous
studies.[24-26]
Task-related training program was adapted by
previous study [25] which was modified from that
recommended by Carr and Shepherd (Apendix-1). The
program was conducted for 60 minutes per session. It
included 40 minutes of 4 lower limb task specific
exercises with wooden blocks of 10-15 cm in height.
The wooden blocks was used for loading, stepping and
heel-lift exercise.
Total duration of intervention was 6 weeks in which
the TENS was applied in initial and last two weeks,
while the TRT was given for 6 weeks. TENS was not
applied at week 3 and 4.
Fig. 1. Acupuncture points used in this study.[25,26]
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 51
OUTCOME MEASUREMENTS AND RESULT
Measurements were assessed following 2, 4, and 6
weeks. The follow-up measurements were assessed 3
weeks after the intervention stopped (Table 1). The
spasticity score in MAS was decreased at week 2 and
Table 1: Outcome measurement and result
Outcome Baseline 2 wk(TENS+TRT)
MAS 3 2
TUG 28 27
DGI 10 14
(MAS= Modified Ashworth Scale, TUG= Timed up and GO test, DGI= Dynamic Gait Index)
DISCUSSION
The result of the study shows that the TENS on
acupoints is an important adjunctive tool with TRT
intervention strategies to reduce plantar flexor
spasticity and relative improvement in functional
abilities.
In present study, it was found that spasticity was
decreased after application of TENS at week 2 and 6.
In week 4 when TENS was not applied the spasticity
again increased in MAS but in follow-up after 3 weeks
of treatment session the spasticity was maintained.
The finding of present study is similar to study
done by Wong and co-worker which found that
application of TENS on acupoints by surface electrode
5 times a week is effective therapy for better
neurological and functional outcomes.[14] When TENS
is applied over acupoints by surface electrode the area
stimulated were much larger than those of
acupuncture needles. Study by Gladys and co-workers
states that application of TENS on acupoints at 4 Hz;
and 0.2ms pulse duration at the tolerable intensity
increases negative peak latency (NPL) which indicates
that the conduction velocity of nerve had decreased.[27]
The mechanism underlying the improvement in motor
function and reduction in spasticity could be
enhancement of pre-synaptic inhibition of hyperactive
stretch reflex in spastic muscle and disinhibition of
descending voluntary commands to motor neuron of
paretic muscle and decrease in co-contraction of spastic
plantar flexor following application of TENS.[24,28]
Gladys investigated that similar effect were found
during stimulation by TENS on peripheral and
acupoints. However the effect was somewhat greater
in acupoints. The effects may be due to specific
10. Manoj Deshmukh--49--.pmd 51
6 from the baseline measurement. Spasticity again
increased and it was 3 at week 4. The time taken to
complete task in TUG test was decreased from baseline
to week 6. The score in DGI was also improved from
baseline and it was 16 of 24 at week 6.
4 wk(TRT) 6 wk(TENS +TRT) Follow-up
3 1+ 1+
22 20 16
14 16 16
characteristic that occur at acupuncture points
included large peripheral nerve, cutaneous nerves,
blood vessels, and motor points. The acupoints are the
loci of type II and type III afferents fibres which can be
stimulated by TENS.[27]
In present study the functional abilities was also
improved up to the 3 weeks after intervention. The
study by Catherinel et al stated that 4 weeks of TRT
intervention improves sit to stand performance and
reduced time to complete the TUG task.[11] The possible
mechanism behind this as suggested by Sung et al may
be that brain plasticity occurs after physical
intervention which involves repetition of task. The
study demonstrated that the 4 week TRT program can
induce functional recovery and sensory cortical
reorganization in chronic hemiplegic population.[29]
It was found that electrically stimulated sensory
inputs could enhance brain plasticity. The sensory
motor cortices are intimately involved with receiving
and transmitting sensory information to other cortical
area including premotor and motor cortices.[30] In
present study the subjects were asked to practice the
task specific exercise after sensory stimulation for 60
minutes. The above mechanism might be involved in
improvement of lower extremity functions in relation
to spasticity, TUG and walking function.
CONCLUSION
In conclusion the present case study reveals that
TENS on acupoints can be used as an adjunctive tool
with task related training and other rehabilitation
program. The clinical improvement was observed after
the 6 week intervention. Therefore, TENS on acupoints
can be incorporated with task-related training for
effective reduction of spasticity and associated
11/1/2014, 12:17 AM
 52 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
functional improvement in subjects after stroke.
However the above result of present study shows
improvement which cannot be generalized in stroke
population because it is a study of single subject.
Ethical Clearance: The study was ethically approved
by institutional review board, MMIPR, Mullana.
Aknowledgement: I would like to extend my gratitude
towards the subject who willingly participated in the
study. I am also thankful to all the authors of those
articles from where the literature has been reviewed
for this study.
Conflict of Interest: Not declared
Source of Funding: Not funded.
REFERENCES
1. World Health Organisation. Preventing Chronic
Diseases: A vital investment. Geneva,
Switzerland. 2005.
2. Tapas Kumar Banerjee, Shyamal Kumar DAS,
Epidemiology of stroke in India, Neurology Asia
2006; 11 : 1 – 4.
3. Banerjee TK, Mukherjee CS, Sarkhel A. Stroke in
the urban population of Calcutta- an
epidemiological study. Neuroepidemiology 2001;
20: 201-7
4. H. S. Jorgensen, H. Nakayama, H. O. Raaschou,
and T. S. Olsen, “Recovery of walking function
in stroke patients:the Copenhagen stroke study,”
Archives of Physical Medicine and
Rehabilitation, vol. 76, no. 1, pp. 27–32, 1995.
5. M. Kelly-Hayes, A. Beiser, C. S. Kase, A.
Scaramucci, R. B. D’Agostino, and P. A. Wolf,
“The influence of gender and age on disability
following ischemic stroke: the Framingham
study,” Journal of Stroke and Cerebrovascular
Diseases, vol. 12, no. 3, pp. 119–126, 2003.
6. K. S. Sunnerhagen, U. Svantesson, L. L¨onn, M.
Krotkiewski, and G. Grimby, “Upper motor
neuron lesions: their effect on muscle
performance and appearance in stroke patients
with minor motor impairment,” Archives of
Physical Medicine and Rehabilitation, vol. 80, no.
2, pp. 155–161, 1999.
7. F. M. Ivey, R. F. Macko, A. S. Ryan, and C. E.
Hafer-Macko, “Cardiovascular health and fitness
after stroke,” Topics in Stroke Rehabilitation, vol.
12, no. 1, pp. 1–16, 2005.
10. Manoj Deshmukh--49--.pmd 52
8. Matthews P.M., Johansen-Berg H. & Reddy H.
(2004) Non-invasive mapping of brain functions
and brain recovery: applying lessons from
cognitive neuroscience to neurorehabilitation.
Restorative Neurology and Neuroscience 22(3–
5), 245–260.
9. Jang SH, Kim YH, Cho SH, et al. Cortical
reorganization induced by task-oriented training
in chronic hemiplegic stroke patients.
Neuroreport. 2003;14:137-141.
10. Gentile AM. Skill acquisition: action, movement
and neuromotor processes. In: Carr JH, Shepherd
RB, eds. Movement Sciences: Foundation for
Physical Therapy in Rehabilitation. 2nd ed.
Gaithersburg: Aspen; 2000:111–187.
11. Dean CM, Richards CL, Malouin F. Task-related
circuit training improves performance of
locomotor tasks in chronic stroke: a randomized,
controlled pilot trial. Arch Phys Med Rehabil
2000;81:409-417.
12. Salbach NM, Mayo NE, Wood-Dauphinee S,
Hanley JA, Richards CL, Cote R. A task-
orientated intervention enhances walking
distance and speed in the first year post stroke: a
randomized controlled trial. Clinical
Rehabilitation 2004;18:509-519.
13. Byl N, Roderick J, Mohamed O, et al.
Effectiveness of sensory and motor rehabilitation
of the upper limb following the principles of
neuroplasticity: patients stable poststroke.
Neurorehabil Neural Repair.2003 ;17:176–191.
14. Wong AMK, Su TY, Tang FT, Cheng PT, Liaw
MY. Clinical trials of electrical acupuncture on
hemiplegic stroke patients. Am J Phys Med
Rehabil 1999; 78: 117–122.
15. Gregson JM, Leathley M, Moore AP. Reliability
of the tone assessment scale and the modified
ashworth scale as clinical tools for assessing
poststroke spasticity. Arch phys med rehabil. 1999
sep;80(9):1013-6.
16. Blackbum M van Vliet P, Mockett Sp. Reliability
of measurements obtained with the modified
ashworth scale in the lower extremities of people
with stroke. Phys therapy. 2002 jan;82(1):25-34.
17. Podsiadlo D, Richaedson S. The time “up & go”:A
Test Of Basic Functional Mobility For Frail
Elderly Person. Journal of the American Geriatrics
Society. 1991; 39(2):142-148.
18. Shumway Cook A, Brauser S. Woollacott M.
Predicting the Probability for falls in community
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 53
dwelling older adults using the timed “up & go”
test. The physical therapy. 2000;80:896-903.
19. Ng SS, Hui-chan CW. The timed up & go test: its
reliability and association with lower-limb
impairments and locomotor capacities in people
with chronic stroke. Arch phys med rehabil. 2005
aug;86(8):1641-7.
20. Flansbjer UM, Holmbäck AM, Downham D.
Reliability of gait performance tests in men and
women with hemiparesis after stroke. J rehabil
med. 2005 mar;37(2):75-82.
21. Shumway-Cook A, Woollacott M. Motor control:
theory and practical applications. Baltimore:
Williams & Wilkins; 1995.
22. Jonsson IR, kristensen MT. Intra- and interrater
reliability and agreement of the danish version
of the dynamic gait index in older people with
balance impairments. Arch phys med rehabil. 2011
oct;92(10):1630-5.
23. Jonsdottir J, Cattaneo D. Reliability and validity
of the dynamic gait index in persons with chronic
stroke. Arch phys med rehabil. 2007
nov;88(11):1410-5.
24. Levin MF, Hui-chan CWY. Conventional and
acupuncture-like transcutaneous electrical nerve
stimulation excites similar afferent fibers. Arch
phys med rehabil. 1993; 74: 54–60.
10. Manoj Deshmukh--49--.pmd 53
25. Tiebin Yan,and Christina W. Y. Transcutaneous
electrical stimulation on acupuncture points
improves muscle function in subjects after acute
stroke: a randomized controlled trial. J rehabil med
2009; 41: 312–316.
26. Shamay S.M. Ng and Christina. Transcutaneous
electrical stimulation combined with TRT
improves lower limb function in subjects with
chronic stroke. Stroke. 2007, 38:2953-2959.
27. Gladys L. Y. Cheing, and Winnie W. Y. Chan.
Influence of choice of electrical stimulation site
on peripheral neurophysiological and
hypoalgesic effects; J Rehabil Med. 2009; 41:
412–417.
28. Fabio L. Martins,Luis C. Carvalho, Immediate
effects of TENS and cryotherapy in the reflex and
voluntary activity in hemiparetic subjects: a
randomized control trial;Rev Bras
Fisioter.2012;16(4):337-44.
29. Sung Ho Jang, Yun-Hee Kim. Cortical
reorganization induced by task-oriented training
in chronic hemiparetic stroke patients.Lippincott
Williams and Williams. 2003;14(1):137-141.
30. Barbro B. Johansson. Acupuncture and
transcutaneous nerve stimulation in stroke
rehabilitation:a randomized controlled trial.
Stroke 2001; 32: 707-713.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
54 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effect of Progressive Resisted Exercise on Strength,

Endurance and Balance on Older Adults above 60 Years

Hetal Jain
Lecturer, Charotar institute of Physiotherapy ,Changa,Anand

ABSTRACT
Introduction: Older people can experience large improvements in muscle strength, if their muscles
are overloaded during training. Progressive resistance exercise (PRE) is system of dynamic resistance
training where constant external load is applied to contracting muscle by mechanical means (usually
free weight or weight machine) and incrementally increased. The repetition maximum (RM) is used
as basis for determining and progressing resistance.
Aim of Study: To study the effect of Progressive Resistance Training on Strength, Endurance and
Balance in Older Adults > 60 years of Age.
Methodology: A Clinical trial consisting of 30 persons, as per Inclusion & Exclusion Criteria were
recruited from Government spine institute Civil Hospital, Ahmedabad. Persons were divided into
two, one group (B) was given PRE for 3days per week and other was control group. A written informed
consent of all subjects was taken prior to study. Outcome measures like 1 RM, Performance oriented
mobility assessment scale and 6 min walk test were taken at 1st day and after 2 month.
Results: As per paired t test PRE group showed significant improvement in 1 RM, 6MWD but not in
POMA score.
Discussion: There is a significant increase(100%) in strength in 1 RM values taken after 2 month
training period, even 6 Minute walk test Distance showed improvement depicting carry over effects
of improved strength of lower limb muscles due to training in more distance covered at end of
training period with little effect on Balance score ie POMA Scale .
Conclusion: Progressive Resisted Exercise are Beneficial adjunct to other exercise interventions in
case of the elderly above 60 years.

Keywords: 1RM,6MWT,POMA

INTRODUCTION Muscle strength declines with age such that, on

Elderly are defined as being 65 years of age or
older.1 In early old age (65-75 years), there may be a
modest increase of physical activity, in an attempt to
fill free time resulting from retirement 2. By middle
old age (75-85 years), many people have developed
some physical disability, and in the final stage (very
old age, over 85 years) they become totally dependent.
A typical expectation is of 8-10 years of partial
disability, and a year of total dependency 3.
average, the strength of people in their 80’s is about 40
per cent less than that of people in their 20’s (Doherty
1993). Muscle weakness, particularly of the lower
limbs, is associated with reduced walking speed
(Buchner 1996), increased risk of disability (Guralnik
1995) and falls in older people (Tinetti 1986).
A well-rounded exercise program that includes
aerobic exercise, strength training using weights, and
flexibility exercises - even when performed regularly

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 55

in small increments - is key, according to the • Study Duration: 3 days per week , for 8 weeks
ACSM(American College of Sports Medicine)
report.Given adequate training stimulus older adults Inclusion Criteria
can make significant gain in strength, even 1) People above 60 yrs of age
institutionalized frail 80 to 90 year olds can be benefited
from strength training.4 2) Both male and female persons.

The three elements of muscle performance 3) Persons able to comprehend commands.

Strength, Endurance, and Power can be enhanced by
some form of resistance exercise.5The most common 4) Persons ready to participate and continue exercise
adaptation to heavy resistance exercise is an increase training.
in the maximum force producing capacity of muscle
5) Elderly adults free of cardiorespiratory and
and is a result of neural adaptations and an increase
neurological diseases.
in muscle fiber size. 6 If muscle performance is to
improve, load that exceeds the metabolic capacity of Exclusion Criteria
the muscle must be applied; that is, the muscle must
be challenged to perform at a level greater than that to 1) People with active cardiovascular, pulmonary,
which it is accustomed. 7When body systems are vestibular, bone disease. Major psychiatric illness,
exposed to a greater than usual but appropriate level active metabolic disease, chronic anaemia,
of resistance in an exercise program, they initially react amputation , chronic neurological or muscular
with a number of acute physiological responses8 and disease.
then later adapt. That is, body systems accommodate
2) People unable to walk dependent in eating,
over time to newly imposed physical demands.9
dressing, transfers, bathing .
A repetition maximum (RM) is defined as greatest
3) Taking medications like neuroleptics, oral steroids,
amount of weight (load) a muscle can move through
testosterone, growth hormone.
the available range of motion (ROM) a specific number
of times. DeLorme reported use of a 1 RM (the greatest 4) Patients with spinal tumors
amount of weight a subject can lift through the
available ROM just one time) as baseline measurement 5) Patients with spinal infection
of subject’s maximum effort but used a 10 RM (the
6) Previous spinal surgery
amount of weight that could be lifted and lowered
exactly 10 times) during training.10 7) Recent motor vehicle accident involving cervical
spine and myelopathies.
Despite criticism that establishing a 1 RM involves
some trial and error, it is frequently used method for 8) Severe Osteoporosis
measuring muscle strength in research studies and has
been shown to be a safe and reliable measurement tool MATERIALS
with healthy young adults and athletes11, as well as
active older adults prior to beginning conditioning • Examination table, Plinth
programs.12
• Consent form and assessment chart
MATERIALS AND METHOD • Performance oriented mobility assessment scale
• Study Design: Clinical Trial Study • Pencil, Papers and recording sheets ,stop watch
• Study Setting: This study was conducted in • Electronic Weighing machine.
Government Spine Institute, Civil Hospital,
Ahmedabad. • Quadriceps table

• Sample Selection: 30 persons. Group A: 15 persons. • Dumbbells and plates of various poundage

Group B: 15 persons. • Chair without armrest

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 56 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Outcome measures • Cool-down. 5 minutes of light exercises (using

some of the same flexibility exercises employed in
1) 1 RM : the warm-up phase). The purpose of cool-down is
2) POMA SCALE: to return respiration levels back to normal levels
and to stretch muscles worked in the exercise
3) 6 Minute walk test session.

METHOD Activities Resisted exercise phase: Arm flexors,

Arm Abductors, Biceps, Triceps, Trunk Curlups,
30 elderly persons were recruited from Hip Extensors, Hip Abductors, Quadriceps ,
Government Spine institute who could be relatives or Plantar Flexors. [30 – 40 min]
friends of patients visiting the dept. They were divided
into 2 groups, one of the group (B) was given exercise
training while other group A, was asked to continue
their ADL. All subjects were informed in detail about
the type and nature of study and were randomly
selected and assigned in to each group. Group B was
treated for 3 days a week for 2 months and both groups
were followed up after a period of 2 months.

Group B

The following Progressive Resistance Training

(PRT) intervention program describes activities that
should begin on a two-month, three workouts per
week basis.

The following activities should be performed as

part of the PRT program. During each 40-minute Fig. 1. Quadriceps Strengthening on Quadriceps Table
session, participants should complete the following
activities:

Warm-up. 5 minutes of light exercises like self paced

walking for 3 minutes and self stretches to the muscles
like Biceps, Pectoralis Major, Triceps, Wrist Flexor,
Hamstring,Quadriceps and Tendoachilles designed
to prepare the participant for muscle conditioning and
to improve overall flexibility

• Muscular conditioning. 30 minutes of exercises

designed to improve muscular strength and
endurance. Most of the exercises use light weights
(hand-held dumbbells with typical resistance of 1
to 10 pounds for most exercises) and are
progressive in nature (i.e., participant advances to
higher demand levels at their own pace, according
to personal ability to tolerate the exercises and
accommodate the increases in demand). Generally,
these exercises are performed for three sets of 8 to
10 repetitions each, progressing to three sets of 15
repetitions each.
Fig. 2. Hip Abductors Strengthening

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 57

Freq Time Intensity Progression

1) One set of 10 – 15 rep of low intensity wt Low:- 40% of 1 RM Up to 15 repetitions
2) One set of 8 – 10 rep of Mod intensity wt Mod : 41 – 60% of 1 RM Increase wt in next session
3) One set of 6 – 8 rep of High intensity wt High : > 60% of 1 RM Gradually 15 rep of new wt

Cool Down Phase: Repeat the stretches and the warm Graph: 1
up activities at a slow rate.

Graph: 2

Fig. 3. Self Pectoralis major stretch

RESULTS

Paired t test was applied in Group A and B for with- Graph: 3

in group analysis and it is as follows:

In Group B, results showed significant

improvement on 1 RM score, at p < 0.05 with t value
for Biceps 3.24, Quadriceps 3.42, Hip abductors 2.46 ,
Shoulder abductor 2.5 and for 6MWD t value = 3.19 at
p < 0.05 .

In Group B, results showed insignificant

improvement on POMA score as t value =1.47.

In Group A, results showed no significant change Graph: 4

in value of 1 RM test, 6 MWD and POMA score

The‘t’ values (corresponding to ‘p’) are highly

significant which suggest that progressive resisted
exercises are effective in improving strength and
endurance of geriatric persons. But the t value for
POMA score does not show significance which proves
that strength training has minimum carry over effects
on balance score

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 58 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
DISCUSSION
Muscle strength declines with age such that, on
average, the strength of people in their 80’s is about 40
per cent less than that of people in their 20’s (Doherty
1993). Muscle weakness, particularly of the lower
limbs, is associated with reduced walking speed
(Buchner 1996), increased risk of disability (Guralnik
1995) and falls in older people (Tinetti 1986).
PRT has large positive effect on strength, the most
proximal impairment measure, and small to modest
positive effect on some other measures of impairment
and functional limitations. PRT also appears to have a
positive effect on aerobic capacity and most measures
of functional limitations, including gait speed and time
to stand up from a chair. Some of these effects, such as
improvements in gait speed and distance walked in
Six-Minute Walk Test, could be considered clinically
as well as statistically significant. Despite these
improvements in functional limitations, no effect of
PRT was found on measures of functional abilities.
In Group B we see that there is a significant increase
in strength as per 1 RM values taken after completion
of 2 month training period. The increase in strength
was 100% in the muscles and even 6 Minute walk test
Distance showed considerable improvement which
depicts the carry over effects of improved strength of
the lower limb muscles due to training in more
distance covered at end of training period.
We also note that gained strength had little effect
on Balance score ie POMA Scale .
Limitations
1. The study consisted of only a small quantity of
subjects; which should be revised to a large
number of subjects and for a longer duration of
period.
2. This was a short term study of 8 (six) weeks and
no further follow up of subjects were carried out.
3. Control group was not given any intervention.
4. There are no exercises to improve proprioception,
balance and endurance in the form of
5. Aerobics, hydrotherapy and conventional
electrotherapy modalities have been used in the
elderly.
6. Home programme was not taught to elderly
11. Hetal Jain--54--.pmd 58
7. Fall risk was not assessed.
8. Incidents of adverse events were not reported
CONCLUSION
Progressive resistance exercise appears to be a safe
and efficacious intervention for many patients with
muscle force deficits contributing to their motor
disability in physical therapy. Despite being able to
improve ability to increase muscle force production
,more evidence is needed to determine whether PRE
can make substantial or sustained improvements in
daily activity or have an effect on societal participation.
Progressive resistance exercise for people in more
acute phases of recovery or for those with degenerative
diseases requires more careful consideration and study
but may have positive effects. It is suggested here that
term “progressive resistance exercise” be used in place
of term “strengthening” or as an added modifier to
describe exercise programs that are designed to
increase muscle force production and that follow the
principles of (1)performing a small number of
repetitions (8–12) until fatigue, (2) allowing sufficient
rest between exercises for recovery, and (3) increasing
the resistance as the ability to generate muscle force
develops.
Thus we can conclude that Progressive Resisted
Exercise are a Beneficial adjunct to other exercise
interventions in case of the elderly above 60 years of
age.
Acknowledgement: I would like to thank Dr Anjali
Bhise (Senior Physiotherapist),Principal of
Government Physiotherapy College, my teachers and
I am grateful to all persons for their kind cooperation
and willingness to participate in this study, without
whom this study would not have materialized.
Conflict of Interest: It has been assured while doing
the study that no financial help has been maintained
with any one of the person involved in the study and
the author did not have any kind of relationship with
them
Source of Support: Self
Ethical Clearance: Ethical clearance was obtained from
the Ethical
Clearance Committee of Government Physiotherapy
College, Civil Hospital, Ahmedabad prior to the study.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 59

REFERENCES 8. Kraemer, WJ, Bush, JA: Factors affecting the acute

neuromuscular responses to resistance exercise.
1. Landefeld CS, Palmer RM, Johnson CB and Lyons
In Rotman, JL (ed) ACSM’s Resource Manual for
LW. Current geriatric diagnosis and treatment.
Guidelines for Exercise Testing and Prescription,
International edition, McGraw Hill, 2004, 4-6.
ed 4. Lippincott Williams & Wilkins,
2. Shephard, R.J. Physical Activity and Aging. 2nd
Philadelphia, 2001, p 167.
Ed. London: Croom Helm Publishing, 1987.
9. American College of Sports Medicine: ACSM’s
3. Health & Welfare Canada. Health Promotion
Guidelines for Exercise Testing and Prescription,
Survey: Ottawa: Health & Welfare, Canada
ed 6, Lippincott Williams & Wilkins,
4. Fiatrone MA, et al High intensity strength
Philadelphia, 2000.
training in nonagenarians, JAMA, 1990263:
10. DeLorme, TL, Watkins, A: Progressive Resistance
30293034
Exercise. Appleton-Century, New York, 1951.
5. American Physical Therapy Association: Guide
11. Fleck, SJ, Kraemer, WJ: Designing Resistance
to Physical Therapist Practice, ed 2. Phys Ther
Training Programs, ed 2. Human Kinetics,
81:9–744, 2001
Champaign, IL, 1997.
6. American College of Sports Medicine: Position
12. Nichols, JF, et al: Efficacy of heavy-resistance
stand: progression models in resistance training
training for active women over sixty: muscular
for healthy adults. Med Sci Sports Exerc
strength, body composition and program
34:364–380, 2002.
adherence. J Am Geriatr Soc 41:205, 1993.
7. Hellebrandt, FA, Houtz, SJ: Mechanisms of
muscle training in man: experimental
demonstration of the overload principle. Phys
Ther Rev 36:371, 1956.

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 DOI Number: 10.5958/0973-5674.2014.00344.X
60 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Lumbar Stabilization Exercises on Pain, Disability and

Endurance in Patients with and Without Lumbosacral Belt
in Mechanical Low Back Pain

Neha Gulati1, Monika Moitra1, Manu Goyal2

1
MPT Orthopaedics, 2MSc Applied Musculoskeletal Physiotherapy, Maharishi Markandeshwar Institute of
Physiotherapy and Rehabilitation, Mullana, Ambala

ABSTRACT
Objective: To find out the effectiveness of Lumbar Stabilisation exercises on pain, disability and
endurance in patients with and without Lumbosacral Belt in Mechanical low back pain.
Background: As there is a trend towards an increase in the number of low back pain patients with
growing stress in life globally there is need of appropriate physical therapy management. Lumbosacral
Belt is used worldwide to support the lower back and rehabilitate to get back well to work soon.
Study Design: Randomized Clinical Trial
Setting: MMIPR Mullana Ambala
Method: 30 LBP subjects of both gender in age group of 20-50 yrs were selected by randomization
method and randomly allocated in 2 groups. Group A patients were provided with LS Belt for 4
weeks and Lumbar Stabilisation Exercises performed whereas Group B were non-LS Belt patients
with same exercise protocol.
Main Outcome Measure: Patients were assessed before commencement and after the completion at
12th session on the basis of pain, disability and endurance by NPRS, MODI and Curl Up test &
Sorensen Test in both the groups.
Results: A Significant difference was found post treatment in pain and disability in LS Belt user
(Mean±SD 3.80 ± 0.775 and 34.53 ± 3.739) while Abdominal and Back Endurance proved statistically
non significant (Mean±SD 16.67 ± 2.920 and 152.00 ± 29.442).
Conclusion: Lumbar Stabilisation Exercises were proved to be more effective tool on reducing pain,
disability and improving endurance in LS Belt patients.

Keywords: Lumbosacral Belt, Pain, Disability, Endurance

INTRODUCTION strain on the muscles of lower back may be caused by

The most common work-related health problem is
back pain affecting 30% of workers1.It is the most
important work-related physical problem from
maintaining the same posture and carrying out
repetitive tasks. Low back pain (LBP) is one of the main
causes of disability, and despite its high prevalence,
the source of pain is not established in the majority of
cases.2 Mechanical Low Back Pain is defined as chronic
obesity, pregnancy, job related stooping, bending or
other stressful postures.3
Around 60–80% of the population will at some time
exhibit low back pain4 and of these 70 to 80% will have
at least one recurrence5 despite the enormous amount
of resources directed to the treatment of chronic low
back pain worldwide, treatment for this health
condition continues to have a low success rate.6-8

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 61
Mechanical Back Pain is the name given to any type of
back pain, which is caused by putting abnormal stress
and strain on the muscles which support the vertebral
column. For the most part, this type of pain is as a
result of bad habit which can be corrected, such as bad
posture, poorly-designed seating, incorrect methods
of bending and lifting etc. Mechanical means that
source of the pain may be in the spinal joints, vertebrae
or soft tissues. However, in the vast majority of cases
of mechanical back pain it is not possible to identify a
pathologically definable problem. That is, no structural
abnormality of the back can be found on examination
or x-ray to account for the symptoms.9
The lifetime prevalence has been estimated at
anything between 59% to 90%. Prevalence of chronic
low backache in the state is increased from 3.9 percent
in 1992 to 12.2 percent in 2009.Increases are seen in
both Men and Women and across all ages and racial
and ethnic groups.10 Exercise is widely used to treat
LBP, but again, research findings without
methodological flaws to support this therapeutic
approach are limited. Dynamic stabilization exercises
are widely accepted as being effective. This technique
begins with the spine placed in a neutral position,
which is defined as the posture of least pain,
biomechanical stress, and potential risk for injury. Role
of muscle such as Multifidus, TrA, diaphragm and
pelvic floor, as well as those working across pelvic
region, play an integral role in dynamic stability of
Lumbar and Lumbopelvic region11
Belt effect to the change of lumbar sagittal angles
in posture which involve knee flexing and/or trunk
flexing seems not as the same as in standing posture.12
Low back pain affects men and women equally; with
onset most often between the ages of 30 and 50 years.
It is the most common cause of work-related disability
in people under 45 years of age and the most expensive
cause of work-related disability, in terms of workers’
compensation and medical expenses.13Children as
young as preteens have been diagnosed with LBP.14-16
“Balanced, healthy functioning of the
musculoskeletal system requires that muscles be able
to exert force or torque (measured as strength), resist
fatigue (measured as muscular endurance), and move
freely through a full range of motion (measured as
flexibility). Because of this, strength, endurance and
flexibility are viewed as important dimensions of
health related fitness”17
12. NEHA GULATI--60--.pmd 61
MATERIAL AND METHOD
Participant
A sample of 30 subjects were assessed and selected
by means of simple random sampling on the basis of
inclusion and exclusion criteria. Subjects were
randomly allocated in two groups.All the subjects met
the following inclusion criteria:- Age group:20-50 years
with both gender,Patients referred from orthopedics
and rheumatology clinics if they had recurrent low
back pain for past 3-8 months which can be postural
or occupation related low back pain,Identify low back
as a primary site of pain,NPRS scoring from 5-7 on a
10 point scale,Initial Disability 30%-60% as measured
on MODI.Subjects with following criteria were
excluded from the study:-History of any recent
fracture of spine at that level or malignancy of
spine,Structural, inflammatory, degenerative
abnormalities of spine and thorax like scoliosis,
kyphosis, pectus exacavatum, carinatum, Ankylosing
spondylitis ,Red flags for serious spinal disorders ,any
neurological deficit of spine and surgery,Pregnancy.
Variables
Primary outcome measures were pain intensity
(estimated using a numeric pain rating scale[NPRS]),
disability (evaluated using the Modified Oswestry
Disability Questionnaire[MODI]) and endurance
(abdominal and back endurance using Curl up and
Sorensen Test)
Study Protocol
The procedure of the study was explained to the
subjects and written consent was taken. Then subjects
will be randomly divided into two groups - Group A
(n=15) M=8,F=7 and Group B (n=15) M=7,F=8
Group A- Modified Watkins-Randall Lumbar
Stabilisation exercise protocol (30 mins) along with
Moist Hot Pack(10 minutes) followed by LS Belt and
Group B-Modified Watkins-Randall Lumbar
Stabilisation exercise protocol (30 mins) along with
Moist Hot Pack (10 mins) in Non LS Belt user
Group A
1. Partial Sit Ups (forward and diagonal):-Lie on your
back with both knees bent and your feet flat on
the floor.Slowly raise your head and shoulders off
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 62 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
the floor, keeping your hands across your
chest.Return to the starting position.Work up to
30 repetitions.
2. Dying Bug:-Begin on your back and feet on the
floor. Bias your spine into your position of comfort
with a towel roll. Tighten the lower abdominals
and alternately lift one arm over your head and
then the other. Do not let the low back arch up as
you lift your arms over head. Lift one arm and the
opposite knee at the same time. Repeat with the
other pair.
3. Bridge:-Lying flat on back, find neutral spine and
draw lower stomach in. Slowly push down
through feet and lift right up so your trunk is
straight (shoulder, hip, knee in a line) Hold the lift
for 5-10 seconds and thinking of squeezing
buttocks as to lift.Repeat 10-15 times
4. Superman (prone extension):-Lie flat on stomach
on the floor and extend your arms straight down
along body.Slowly raise trunk and legs from the
floor simultaneously as far as possible, alternative
arm and opposite leg.Try to hold the position for
a slow count of 10 and return to original position
5. Quadruped:-Kneel with both knees and both
hands flat on the floor (Starting Position) and
simultaneously raise one arm and the opposing
leg to the horizontally outstretched position and
hold for the desired time period (Finishing
Position). Return back to the starting position and
repeat with the opposing arm and leg.
6. Wall Squats:-Standing with back to wall and take
one step away from the wall, still leaning against
the wall.Toes should be in line and slightly turned
out.Holding this position, slowly perform a ½
squat (bottom should stay in contact with the
wall).Hold the squat for 5 sec and return to start.
Repeat 12 times complete 3 sets
7. Lunges:-Stand with left leg in front of the right leg
and bend knees slowly, sinking into a lunge. Keep
back straight and left knee directly above left foot.
Vice versa with 3 times on each side15 sec holds.
8. Prone Plank:-Elbows and shoulder width apart
and directly under the shoulders and feet are either
12. NEHA GULATI--60--.pmd 62
together or slightly apart. Maintain head in
alignment with the spine (do not look ahead or to
the side).Hold this position while breathing
normally. Perform holds of 10-60 seconds using a
1:1 work: rest ratio.
For Group B same treatment for same time duration
along with Moist Hot Pack and without LS Belt
providence. (3/week x 4 weeks, duration 40 mins)18,19
RESULTS
Group A showed better results in pain and
disability than Group B while endurance in both the
groups proved clinically significant and statistically
non-significant.
Pain Intensity: Postintervention, the av-erage NPRS
score for Group A was (mean ± SD) 3.80 ± 0.775 (p =
.01) lower than the preintervention score. The
reduction in NPRS score was 4.60 ± 0.98 for the Group
B. Decrease in pain intensity was significantly different
between the 2 groups. (Figure 1)
Disability Score: Improvement in disability is
indicated by a lower score on MODI. The MODI score,
from preintervention to postintervention, decreased
by an aver-age ± SD of 34.53 ± 3.73 (p = .04) for Group
A and 38.40 ± 6.197 for Group B. The improvement in
MODI score was signifi-cantly greater for Group A.
(Figure 2)
Abdominal Endurance: Improvement in abdominal
endurance is indicated by increase in curl up counts
per minute. Abdominal Endurance is reported
improved in Group B (non LS Belt) by an average ±
SD of 17.73 ± 2.658 and in Group A by 16.67 ± 2.920.
Abdominal endurance proved statistically non-
significant in both the groups. (Figure 3)
Back Endurance: Improvement in Back Endurance
is indicated by increase in Sorensen test duration (hold
position per sec). Back Endurance is reported
improved in Group A (LS Belt) by an average ± SD of
152 ± 29.44 whereas in Group B 151.13 ± 29.84. Back
Endurance proved statistically non-significant in both
the groups. (Figure 4)
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 63

DISCUSSION

Overall the present study provides some evidence

that Lumbosacral Belt along with Lumbar Stabilisation
Exercises is more effective in reducing pain and
disability in comparison to non LS Belt user. However
the Abdominal and Back Endurance showed no
statistically significant results in both the groups. Thus,
there is a rejection of null hypothesis and acceptance
of alternate hypothesis.

Fig. 1. Baseline and Post Treatment (4th week) Comparison of
NPRS in group A and B
There is statistically significant improvement in
pain and disability scores within and between the
groups however group A i.e. With LS Belt has
predominance over Without LS belt patients in group
B. In this study back pain was a significant cause of
disability particularly affecting the productive middle
years of adult life. There was a significant disruption
of daily activities including sleep as observed by
Modified Oswestry Disability Questionnaire. This has
social economic implications, economic loss to the
worker, employer and society.

The present study showed an advantage in terms

Fig. 2. Baseline and Post Treatment Comparison of MODI in group
A and group B
Fig. 3. Baseline and Post Treatment Comparison of Abdominal
Endurance in group A and group B
of pain and disability in the Low Back Pain patients
using LS Belt with the possible mechanism illustrated
in a systemic review by Van Poppel which
demonstrates that the support belts might relieve stress
due to: spine intersegmental motion restriction, gross
body motion restriction, direct transmission of loads
through the support belt, and/or indirect transmission
of loads via increased inner abdominal pressure. The
support may either physically obstruct extreme
postures, or it may improve body postures through
tactile feedback.20 The results of present study are
consistent with findings obtained in the study
conducted by Calmels which states that Lumbar belt
wearing is consequent in subacute low back pain to
improve significantly the functional status, pain level,
and the pharmacologic consumption.21
Similarly, According to Ngoc Huynh LumboSacral
Belt support has a tendency to reduce vertebral
mobility and discal deformations mainly at the upper
segments (L1-L3), while it seems to increase vertebral
displacements and discal deformations at the lower
levels (L4-S1) by observing the spinal geometry and
geometrical deformations of discs with a three-
dimensional (3-D) reconstruction technique of the
lumbar spine22

In accordance with the result findings the subjects

Fig. 4. Baseline and Post Treatment Comparison of Back with previous serious LBP had significantly lower
Endurance in group A and group B endurance capacity than normal subjects. 23 The

12. NEHA GULATI--60--.pmd 63 11/1/2014, 12:17 AM

 64 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Sorensen test can detect low isometric extension
endurance and might be useful for identifying subjects
who are at risk for developing LBP in the future.
Specific Stabilisation Exercise was not more effective
in reducing pain or disability for acute low back pain.
However, it is effective in reducing recurrence after
an acute episode of low back pain.24
The mechanism by which Lumbar Stabilisation
Exercises affects LBP patients has been described by
Morey J. Kolber as the spinal conditioning exercises
specifically designed to challenge and activate the local
stabilizers through passive structures and the neural/
muscular systems. The passive structures are often
insufficient for stabilization during dynamic activities
that challenge the spines neutral zone, particularly
among individuals with LBP.25
Limitations
There was no long term follow up to study the
sustained effect of Lumbar Stabilisation Exercises in
mechanical low back pain.Qualitative tool for
assessment of Abdominal and Back Endurance.
The study sample was small and thus it is difficult
to generalize the result. Lack of blinding in the study
to minimise the error. Body Mass Index (BMI)
Future Research
Further studies can be done with large sample size
including different subjects with different age groups.
Quantitative method of Abdominal and Back
Endurance assessment.
Further studies should be performed on utilization
of Lumbosacral Belts in improving functional
performance and quality of life in LBP patients.
CONCLUSION
The results of the study lead us to conclude that
Lumbar Stabilisation Exercises has a greater effect in
reducing pain and disability in patients with LS Belt
in Mechanical Low Back Pain whereas Back and
Abdominal Endurance remains same in both the
groups. There was significant decrease in pain and
disability in both the groups but the addition of LS
Belt showed better results.
Acknowledgment: My sincere thanks to my Parents
and Teachers. They immensely helped and rendered
their valuable guidance, advice, precious knowledge,
timely assistance & invaluable suggestions. Lastly, I
12. NEHA GULATI--60--.pmd 64
thank God for bestowing me with knowledge and
giving me the encouragement.
Conflict of Interest: None declared
Source of Funding: Self
Ethical Clearance: The study is approved by
Departmental Research Committee.
REFERENCES
1. European Foundation for the Improvement of
Living and Working Conditions, Best Pract Res
Clin Rheumatol. 2005 Aug;19(4):541-555.
2. WHO, World Health Organization definition of
LBP, 2006
3. Hellman, David B. Arthritis and Musculoskeletal
Disorder. In current medical diagnosis and
treatment 1998
4. Hicks GE, Fritz JM, Dellito. A Preliminary
development of clinical prediction rule for
determining with patients with LBP will respond
to a stabilization exercise program. Archi Physic
Med Rehab Sept 2005;86(9):1753-1762
5. FreBurger JK, Carey TS, Holmes GM.
Effectiveness of physical therapy in management
of chronic spinal disorder. Physical Therapy March
2006;86(6):381-394
6. Goldby LJ, Lucy Jane, Moore, Ann P., Doust,
Trew. A Randomized clinical trial investigating
efficiency of musculoskeletal physical therapy on
chronic Low Back disorder, Spine 2006
May1;31(10)pp1083-1093
7. Hayden JA, Van Tulder MW, Malmivaara A, Koel
W. Exercise therapy for treatment of Non Specific
Low Back Pain Cochrane Data Base system Review
2005,July 20(3);CD000335
8. Waddel G. The Clinical course of LBP in living
stone C Back Pain Dynamic Chiropractic June 16,
2003;Vol.21,Issue 13
9. Dr. Veerle Hermans. Research on work-related
low back disorders, Institute for Occupational
Safety and Health, Brussels in 2000 pp71
10. Dr. Veerle Hermans. Research on work-related
low back disorders, Institute for Occupational
Safety and Health, Brussels in 2000 pp71
11. Hides P, Richardson C. Inefficient muscle
stabilisation of lumbar spine associated with
LBP.A motor control evaluation of TrA. Spine Nov
15,1996;21(22):2640-2650
12. Lee YH, Chen CY. Belt effects on lumbar sagittal
angles. Spine Feb 2000;15(2):79-82
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 65
13. Andersson GBJ. Epidemiologic features of
chronic low-back pain. Lancet Aug
14,1999;354(9178):581-585.
14. Balagué F, Damidot P, Nordin M, Parnianpour
M, Waldburger M. Cross-sectional study of the
isokinetic muscle trunk strength among school
children. Spine. July 18,1993;18(9):1199-1205.
15. Brattberg G, Wickman V. Prevalence of back pain
and headache in Swedish school children: A
questionnaire survey. The Pain Clinic 1992; 5:211-
220.
16. Burton AK, Clarke RD, McClune TD, and
Tillotson KM. The natural history of low back
pain in adolescents. Spine. Oct 15
1996;21(20):2323-2328.
17. Plowman SA. Muscular strength, endurance, and
flexibility. http://www. cooperinst.org/ftgrefi
ntro.asp, 2001
18. Paulo H Ferreira, Manuela L Ferreira,
Christopher G Maher, Robert D, Kathryn: Specific
Stabilisation Exercise for spinal and pelvic pain
Australian Journal of Physiotherapy 2006;52 79-88.
19. UCSF Sports Medicine. Lumbar Stabilisation
Protocol (Modified Watkins Randall) and Test
11/14/05
12. NEHA GULATI--60--.pmd 65
20. Van Poppel, Mireille N. M Mechanism of Action
of Lumbar Supports: Spine 15 August 2000;25 -
Issue 16 - pg 2103-2113
21. Calmels P, Queneau P; Effectiveness of a lumbar
belt in subacute low back pain: an open,
multicentric, and randomized clinical study.
Spine Feb 1, 2009;34(3):215-220
22. Ngoc Huynh Tuong, Jean Dansereau. Three-
dimensional evaluation of lumbar orthosis effects
on spinal behaviour Journal of Rehabilitation
Research and Development 1998;35 No.1,
Pages34–42
23. Salminen JJ, Maki P. Spinal mobility and trunk
muscle strength in 15-year-old school children
with and without low-back pain. Spine
1992;17(4):405-11.
24. Maurits Van Tulder, Malmivaalra A, Esmail R,
Koel B. Therapy for Low Back Pain: A Systematic
Review within the Framework of the Cochrane
Collaboration Back Review Group Spine Nov 1
2000;25(21)2784–2796
25. Morey J. Kolber and Kristina. Lumbar
Stabilization: An evidence based approach for the
athletes with Low Back Pain. April 2007 Strength
and Conditioning journal 29:2, pg 26-37
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 DOI Number: 10.5958/0973-5674.2014.00344.X
66 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effectiveness of Physiological Cost Index and Gait

Parameters in Conventional Versus Ultramodern
Prosthesis in Unilateral Transtibial Amputees -A
Comparitive Study

Shivananda V1, Syed Yakub2, Nidhin Jose3, Sasidhar4

Chief Physiotherapist, Bangalore Baptist Hospital, Hebbal, Bangalore, 2Physiotherapist, Gold Finch
1

Hospital, Bangalore, 3Physiotherapist, Bangalore Baptist Hospital, Bangalore, 4Assistant Professor. KTG College Of
Physiotherapy, Bangalore

ABSTRACT
Objectives: To determine the effects of two different prosthetic types on physiological cost index(PCI)
and gait parameters in persons with transtibial amputation during ambulation and to determine the
effect of 8 weeks of exercise program for transtibial amputees on PCI and gait parameters.
Intervention: All the subjects were given standardized exercise program, which include Balance
activities, Ambulation activities, Functional activities, Resisted isotonic exercises and endurance
training.
Methodology: Forty transtibial amputees using either conventional or ultramodern prosthesis with
independent community walking were allocated into two groups Group A and Group B. Group A
was using ultramodern prosthesis and Group B was using Conventional prosthesis. Both the groups
received similar exercise program thrice a week on alternate days for 8 weeks.
Outcome Measures: The spatio-temporal parameters of gait like step length, stride length and cadence
were measured using foot print method of gait analysis and energy expenditure of transtibial amputees
was measured using Physiological cost index. All the parameters were measured pre and post
treatment and compared statistically.
Results: The paired t test showed significant improvements in all the outcome measures, PCI, Step
Length, Stride Length, and cadence between the pre and post intervention in both the groups, but
the changes in group A were more significant when compared with group B.
Conclusion: Exercise program for 8 weeks significantly decreased the energy expenditure of the
below knee amputees walking with a prosthesis in terms of PCI and also improved the gait symmetry
ultimately improving their functional capability. These exercises should be considered while
rehabilitating a below knee amputee.

Keywords: Below Knee Amputee, Conventional Prosthesis, Ultramodern Prosthesis, PCI, Linear Gait
Parameters

INTRODUCTION body.1 Lower limb amputations are performed more

often below the knee than any other level.
Amputation is defined as the surgical removal of a
part or all of a limb or some other outgrowth of the There are more than 110000 lower limb
amputations performed annually in USA that is
Corresponding author: approximately 30000 of these being transtibial
Shivananda V amputees.2 According to data collected by national
Chief Physiotherapist hospital discharge survey among lower
Bangalore Baptist Hospital, Hebbal, Bangalore extremity amputations 23 percent were transtibial
E-mail: vshivananda@gmail.com. amputees.3
Phone- 09945335590

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 67

It is well documented that transtibial amputees
spend more energy for walking compared with non
amputees. Studies indicate that transtibial amputees
spend 55% more energy for walking when compared
with subjects with nonpathologic gait at self selected
walking velocity.4 Thus physiologic assessment is an
important aspect in evaluating efficacy of a below knee
prosthesis. Various methods used for measuring
physiologic variables include energy expenditure, gait
efficiency, Rate of perceived exertion. Usually the
metabolic energy cost assessment requires
measurement of the rate of oxygen uptake from
inspired air and calculating the energy expenditure,
this method requires expensive equipment and trained
personnel which are not always available.
Physiological cost index (PCI) is a new method to
assess energy expenditure it works on the principle
that heart rate and walking speed are linearly related
to oxygen consumption (vo2) at sub maximal levels of
exercise.5
PCI is defined as the difference between working and
resting heart rate divided by walking speed.6
been undertaken on them using energy expenditure
and gait analysis as outcome measures. There is lack
of evidence comparing conventional prosthesis and
ultramodern prosthesis using physiological cost index
and linear parameters of gait as a measure hence this
study is undertaken
OBJECTIVES OF THE STUDY
To determine the effects of two different
prosthetic types on physiological cost index and gait
parameters in persons with transtibial amputation
during ambulation
To determine the effect of 8 weeks of exercise
program for transtibial amputees on PCI and gait
parameters.
Inclusion Criteria
1. Patients with unilateral below knee amputation.
2. Independent community walking with prosthesis.
3. Age group between 40-60 yrs.

PCI = walking heart rate – resting heart rate (beats/min) 4. Ideal stump length.
Walking speed (m/min)
5. Without any musculoskeletal abnormality of the
One of the main factors for increased energy stump.
expenditure in transtibial amputees is asymmetrical
gait. People with unilateral transtibial amputees often Exclusion Criteria
demonstrated significant asymmetrical gait pattern
1. Any associated disability.
specifically the prosthetic limb has a smaller push off
force longer swing time, longer step length and a 2. Amputee using walking aids.
shorter stance time than the intact limb7. The factors
influencing this asymmetrical gait pattern are 3. Difficulty in treadmill walking.
generally believed to be the socket fit, prosthetic
4. Balance disorders.
alignment, and the prosthetic components including
its parts and weight can all influence the gait of 5. Stump neuromas.
amputees.8
6. Cylindrical stump.
Temporal-spatial parameters are particularly useful
measurements for prosthetic evaluation because they 7. Phantom pain.
provide fundamental timing and position information
8. Stump oedema.
about a person’s gait, and they can be made relatively
easily in a clinical setting with simple measurement 9. Skin abrasions of the stump.
tools. The most common temporal- spatial parameters
used are walking speed, stride length, step length and 10. Short stump/long stump.
cadence.
11. Chronic Obstructive Pulmonary Diseases.
Even though different types of prosthesis have been
12. Cardiac pathology.
developed in recent years and abundant studies have

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 68 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
MATERIALS AND METHOD
1. Inch tape.
2. Heart rate monitor. (Lloydspharmacy K901B)
3. Stop watch.
4. Blot paper.
5. Ink pad
6. Marker.
7. Conventional PTB prosthesis.
8. Ultramodern PTB prosthesis.
The patients with Transtibial amputation fitted
with a definitive prosthesis coming to Goldfinch
Hospital were screened for inclusion/ exclusion
criteria. The purpose of the study was explained to all
the patients those who volunteered to take part in the
study.
An informed consent was taken from them. The
total number of subjects in the study were 40. All
subjects were assessed using a specific proforma and
were allocated to two groups through Purposive
Sampling method. Patients who were using
ultramodern prosthesis were allocated to Group A and
the TTA using conventional prosthesis were allocated
to Group B.
All the four parameters were measured prior to the
commencement of the intervention on the first day. A
standardized exercise program was given to the
patients of both groups, thrice a week on alternate days
for 8 weeks. At the end of 8 weeks of intervention all
the parameters were measured again under similar
conditions. Then the values of pre and post
intervention were compared statistically.
Interventions
Balancing Activities
Ambulation Activities
Functional Activities
Resisted Exercises
Upper extremity strengthening
Endurance training.
13. Shivananda--66--.pmd 68
Parameters Measured
STRIDE LENGTH
STEP LENGTH
CADENCE
physiological cost index
Procedure For Foot Print Gait Analysis
Footprint data were obtained using 8m lengths of
whitepaper 52 cm wide. The paper was laid out over a
level corridor on the floor. A chair was positioned at
either end of the paper then subjects shoes were soaked
with ink The subject was instructed to rise from the
chair and walk normally to the other end, looking
straight ahead, commencing with the right foot and to
sit down upon reaching the other end. Following this
the patients name prosthetic side and the trial number
was recorded on the paper. Once dry, prosthetic and
normal side step length were measured, then the stride
length also measured and recorded the 8m length of
paper was rolled-up. All trials were laminated to
facilitate repeated measurements. To exclude phases
of acceleration and deceleration, footprints 3–6 (two
left and two right) were identified on each trial, and
used to calculate step length and stride length. This
process was undertaken under identical conditions,
both pre and post exercise.
Procedure For Measuring PCI
Participants were included in the study if they had
no lesion on the residual limb or any problems with
their knee joint and walked with their prosthesis
acceptably without the need of assistive devices at the
time of this study. Participants were asked not to drink
alcohol 24 hours before testing and not to smoke.
Subjects were also instructed to avoid eating for at least
2 hours prior to the test, and to wear comfortable shoes
to the testing session. All measurements took place in
a warm and well ventilated room. Heart rate was
measured with a heart rate monitor (Lloydspharmacy
k901B) device. It consists of a chest transmitter and a
wrist unit. The chest transmitter was fastened around
the chest and the Heart rate monitor watch on the wrist.
Then the subject was made to sit for 5 min after which
the resting heart rate was recorded from the watch.
After which subjects were asked to walk on a 20m
walkway marked on the floor at their normal,
comfortable walking pace Subjects walked for at least
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 69

6 minutes. The distance walked was recorded and the
heart rate after walking for 6 min was recorded then
subject returned to sitting. Values of speed (in m/min),
and PCI (in beats/m) were calculated after each walk
by using the formula for PCI.9
Stastical Analysis
Student t test (Two tailed, Independent) was
employed to test the significance of study parameters
between the two groups of subjects.

Student t test (paired) was used to find the

significance of study parameters between pre and post
intervention in each group.

Table 1: Comparison of PCI in two groups Results are

presented in Mean + SD (Min- Max)

PCI Group A Group B

Pre- Intervention 0.8272 + 0.3117 1.3017 + 0.4885
Post-Intervention 0.6525 + 0.2563 1.13113 + 0.4221
Significance of ‘t’ test 8.974 6.008
P Value <0.0001 <0.0001
% Change 21 14

In the above table PCI score at pre- Intervention in

group A is 0.8272 (SD: 0.3117) which significantly
reduced to 0.6525 (SD: 0.2563) with 21% change. In
group B Pre-Intervention PCI score is 1.3017(SD:
0.4885) which decreased to 1.13113 (SD: 0.4221) with
14% change. Overall group A had better improvements
in PCI when compared with group B.
Fig. 1: Foot print method for gait evaluation Table 2: Comparison of Cadence in two groups

Cadence Group A Group B

Pre- Intervention 89.95 + 7.5357 84.35 + 8.9341
Post-Intervention 94.7 + 7.928 87.85 + 9.6697
Significance of ‘t’ test -8.462 -7.985
P Value <0.0001 <0.0001
% Change 5.28 4.14

The above table shows almost similar changes in

both the groups in terms of percentage change with
5.28% change in group A and 4.14% change in group
B with a P value < 0.0001.subjects in group a Using
Ultramodern prosthesis had better improvements in
cadence than the group B who were using
Conventional type of prosthesis.

Table 3: Comparison of Step Length (PL) in two

groups.

Step Length (PL) Group A Group B

Pre- Intervention 52.03 + 6.2696 45.93 + 7.7771
Post-Intervention 58.86 + 5.3513 49.765 + 6.8102
Significance of ‘t’ test -10.961 -5.793
P Value <0.0001 <0.0001
% Change 13.1 8.34

Above Table shows Result of comparison of step

length of the prosthetic limb. It reveals that the Step
Fig. 2: PCI Evaluation Length at Pre-Intervention in Group A was 52.03 (SD:

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 70 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

6.2696) was significantly increased to 58.56 (SD: 5.3513) The comparison of cadence shows almost similar
Post-Intervention with 13.1% change of step length changes in both the groups in terms of percentage
score. In Group B the pre-Intervention step length score change with 5.28% change in group A and 4.14%
was 45.93 (SD: 7.7771) significantly increased to 49.765 change in group B with a P value < 0.0001 from pre to
(SD: 6.8102) with 8.34% change from baseline. Overall post. Subjects in group A had better improvements in
Group A had better outcome in terms of step length cadence than the group B.
when compared to Group B.
Result of comparison of step length of the prosthetic
Table 4: Comparison of step length (NL) in two groups limb reveals that the Step Length at Pre-Intervention
Step Length (NL) Group A Group B
in Group A was 52.03 (SD: 6.2696) was significantly
Pre- Intervention 48.87 + 6.4319 43.655 + 6.9545
increased to 58.56 (SD: 5.3513) Post-Intervention with
Post-Intervention 53.795 + 5.9191 46.325 + 6.323
13.1% change of step length score. In Group B the pre-
Significance of ‘t’ test -7.535 -10.311
Intervention step length score was 45.93 (SD: 7.7771)
P Value <0.0001 <0.0001
significantly increased to 49.765 (SD: 6.8102) with
% Change 10.07 6.11
8.34% change from baseline.

In above Table step length of the unaffected limb
has been compared pre and post in two groups. It
shows That Pre-Intervention in Group A was 48.87
(SD: 6.4319) was significantly increased to 53.795 (SD:
5.919) Post-Intervention with 10.07% change of step
length score. In Group B the Pre-Intervention step
length score was 43.655 (SD: 6.9545) significantly
increased to 46.325 (SD: 6.323) with 6.11% change from
baseline. Overall Group A had Better outcome in terms
of step length on the unaffected side when compared
to Group B.
Table 5: Comparison of stride length in two groups
Stride Length Group A Group B
Pre- Intervention 100.905 + 12.645 89.085 + 13.941
Post-Intervention 112.155 + 10.971 96.09 + 13.06
Significance of ‘t’ test -8.214 -5.258
P Value <0.0001 <0.0001
% Change 11.14 7.86
The data in table shows that the Pre-Intervention
Stride length in Group A increased from 100.905 (SD:
12.645) to 112.155 (SD: 10.971) Post-Intervention. In
Group B Also showed improvements in stride length
from Pre-Intervention score of 89.085 (SD: 13.94) to
96.09 (SD: 13.06). Overall the Group A had significant
changes with 11.14% of improvement compared to
Group B with a Change of 7.86%.
FINDINGS
The results of PCI score at pre- intervention in
group A significantly reduced to by 21% post-
intervention change. In group B Pre-Intervention PCI
score decreased to by 14%. Overall group A had better
improvements in PCI when compared with group B.
Comparison of step length on the unaffected limb
shows that the Pre-Intervention score in Group A was
48.87 (SD: 6.4319) was significantly increased to 53.795
(SD: 5.919) Post-Intervention with 10.07% change of
step length score.
In Group B the Pre-Intervention step length score
was 43.655 (SD: 6.9545) significantly increased to 46.325
(SD: 6.323) with 6.11% change from baseline.
The Pre-Intervention Stride length in Group A
increased from 100.905 (SD: 12.645) to 112.155 (SD:
10.971) Post-Intervention. In Group B Also showed
improvements in stride length from Pre-Intervention
score of 89.085 (SD: 13.94) to 96.09 (SD: 13.06). Overall
the Group A had significant changes with 11.14% of
improvement compared to Group B with a Change of
7.86%.
Thus, the results suggests that Subjects in Group
A using ultramodern prosthesis has added effects in
terms of PCI, Length, Stride Length and Cadence as
compared to Group-B who were using conventional
prosthesis.
A possible explanation for this could be the material
and method used in fabrication of ultramodern
prosthesis. Subjects using ultramodern prosthesis had
better suspension of prosthesis than the conventional
prosthesis. Even the weight of prosthesis would have
played a part in reducing energy expenditure of
Subjects with ultramodern prosthesis
The exercise program of 8 weeks duration proved
to be an effective method to reduce the energy cost
and improve the gait efficiency and Ultramodern
prosthesis is effective in reducing the energy

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 71
expenditure and improving gait efficiency in
transtibial amputees than Conventional prosthesis.
CONCLUSION
Unilateral below knee amputates treated with
exercises showed significant improvement in PCI and
linear gait parameters when pre exercise PCI and gait
parameters were compared statistically with post PCI
and gait parameters.
Subjects using ultramodern prosthesis showed a
greater improvements in PCI than the group which
was using conventional prosthesis, Suggesting
ultramodern prosthesis is better than conventional
prosthesis as they help in reducing the energy
consumption to some extent. This also suggests that
the type of the prosthesis is one of the major factors
determining the energy expenditure and gait
asymmetry in below knee amputees (BKA).
Even the gait parameters like step length, stride
length and cadence improved significantly in group
A who were using ultra modern prosthesis than the
group B.
Limitations
• Previous levels of physical fitness of individuals
were not taken into account
• Duration of prosthetic use prior to the study was
not standardized.
Acknowledgement: We would like to thank our
friends and above all would like to express our deep
sense of gratitude towards all the Subjects who
participated in the study, which would not have been
possible without them.
Conflict of Intrest Statement: We hereby declare no
conflict of interest in the manuscript
13. Shivananda--66--.pmd 71
Source of Funding: Nil
Ethical Clearance Letter: Taken from The ethical
clearance committee of Goldfinch Hospital
REFERNCES
1. Beasley RW. General considerations in managing
upper limb amputations. Orthop clin North Am.
1981;12:743-749.
2. Bodily KC, Burgess EM. Contralateral limb and
patient survival after leg amputation. Am J Surg
1983;146:280-282
3. Detailed diagnosis and procedure, National
Hospital survey: Vital and health statistics series.
1997;13, 45.
4. Fisher SV, Gullickson G. Energy cost of
ambulation in health and disability: A literature
review. Arch Phys Med Rehabil 1978;59:124-133.
5. Astrand P & Rodahl K Text book of work
Physiology 3 rd ed. London, England : MC
GrawHill, 1986.PP-372.
6. Kaven CP, Angela DW, Hargot AS. PCI in elderly
subjects during treadmill and floor walking.
Physiotherapy 1986;31(1):11-16.
7. Mattes SJ.Martin PG. Royer TD.Walking
symmetry and enrgy cost in persons with
unilateral transtibial amputations: matching
prosthetic and intact limb inertial properties.
Arch Phys Med Rehabil 2000:81:561-8.
8. Perry J. Pathologic gait. In: Atlas of Orthotics.
American Academy of Orthopaedic Surgeons, St.
Louis: Mosby; 1975:144-168.
9. Graham RC, Smith NM, White CM. The
reliability and validity of the Physiological cost
index in healthy subjects walking on 2 different
tracks. Arch Phys Med Rehabil 2005;86:2041-6
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
72 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Nerve Conduction Studies of Upper Extremity in

Badminton Players

Manish Dhabliya1, Twinkle Y Dabholkar2, Sujata Yardi3

1
MPT- Sports, Assoc. Prof., 3Professor & Director, Department of Physiotherapy, Pad. Dr. D.Y. Patil University,
2

Nerul, Navi Mumbai

ABSTRACT
Aim: The purpose of this study was to compare the conduction studies of the median nerve and the
ulnar nerve in the dominant extremity with the non-dominant extremity of badminton players.
Methodology: The study included 20 male badminton players [mean (sd) age of 23 years (3.68)]
playing at state or district level, training for about 2 hours/day for 4 days/week since last 5 years.
Standard nerve conduction technique was applied to evaluate the median and ulnar nerves in the
dominant and non-dominant upper extremity of each player.
Results: Statistical significance was accepted at p<0.05. Unpaired t-test or Mann Whitney test for
between extremity data analyses. There were no statistical differences in the latencies, conduction
velocities, or amplitudes of the median & ulnar motor and sensory nerves between the dominant
and non-dominant upper extremity in badminton players.
Conclusion: There were no differences in nerve conduction of Median & Ulnar nerves in dominant
& non dominant extremity of badminton players.

Keywords: Badminton Players, Nerve Conduction Studies, Median & Ulnar Nerve

INTRODUCTION various skillful maneuvers like services -long service,

Badminton is one of the most popular racquet
sports in the world. Badminton is based on fast
movements, with a great demand on the alactic
anaerobic system and, to a lesser degree, on the lactic
anaerobic metabolism. The high frequency and
intensity of play throughout a match, together with
the high maximum and minimum average heart rates,
indicate that badminton is a sport that, at competition
level, demands a high percentage of individual aerobic
power and that high levels of aerobic power allow
players to maintain this type of effort during a total
time of about 30 minutes11. At an elite level, players
are often required to perform at their limits of speed,
agility, flexibility, endurance and strength.
It is an individual non-contact sport including lots
of twisting, reaching for shots, sudden stopping,
jumps, rapid arm movement and also rapid and
repetitive wrist movements. Badminton encompasses
short service; strokes i.e. overhead stroke, forehead
stroke, back-hand stroke etc. and shots i.e. drop shots,
smash & clear3. The forehand overhead stroke is one
of the most typical and powerful badminton technique.
Wrist contributes the most of the racquet-head velocity
when compared to elbow and shoulder joint. Wrist
acted to increase the speed of racquet at impact7 and
exerted the greatest velocity and power in all kind of
strokes8. Being a dominant arm sport there is repetitive
movement in the dominant upper extremity2.
Within the body, the musculoskeletal system is the
mechanical interface (MI) to the nervous system. With
movement, the musculoskeletal system exerts non-
uniform stresses and movement in neural tissues,
depending on the local anatomical and mechanical
characteristics and the pattern of body movement. As
the body moves, the MI changes its dimensions which
in turn impose forces on neural structures (Goddard

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 73
and Reid, 1965; Millesi, 1986). e.g. the position of
shoulder abducted and externally rotated, elbow
extended, forearm supinated and wrist extended
(MNT1 end position) put stretches on median nerve.
This position is also encountered while reaching for
book shelf or hitting an overhead badminton stroke6.
Movement activates an array of mechanical
responses like - neural sliding, pressurization,
elongation, tension and physiological responses in
neural tissue like - changes in intraneural
microcirculation, axonal transport and impulse traffic.
The nerve can be stressed due to joint position;
neighboring bone, muscle; pressure due to passive
stretch; repetitive movements; fascial thickening. Un-
physiological movement, body postures and repetitive
muscle contraction may be contributing factors to a
nerve injury6.
Participants in racquet sports are prone to a host of
soft-tissue injuries to their hands and wrists owing to
the direct impact of the handle as well as the repetitive
stretching that occurs as the wrist is forcefully whipped
into extremes of position. Tendinitis can occur in all
tendons but is most common in the first dorsal
compartment, flexor carpi ulnaris, flexor carpi radialis,
and extensor carpi ulnaris. Ligamentous tears can
produce instability patterns that, if unrecognized, can
become chronic disabilities10. Safran1 suggests that
elbow injuries are becoming more common as more
people participate in throwing and racquet sports. The
type of injury that is encountered depends, to some
extent, on the type of athletic pursuit, but the injuries
can be roughly grouped into the enthesopathies (lateral
and medial epicondylitis and other rarer similar
conditions), valgus stress injuries as the result of
altered function of the primary constraint to valgus
stress, and the MCL, posterior impingement, and nerve
compression syndromes. Many neurological injuries
remain subclinical and are not recognized before
neurological damage is permanent. In a study done
by T Colak et al latencies of the ulnar sensory nerve
potential were considerably greater and conduction
velocities were smaller in the tennis players’ dominant
arms compared with the controls.
In a prospective study done by Jorgensen U. &
Winge S. in 375 randomly chosen elite and recreational
badminton players, they found 257 injuries: an
incidence of 2.9 injuries/player/1000 badminton
hours. Men were more frequently injured than women.
The prevalence was 0.3 injury per player. It was highest
in men, and there was no difference between elite and
14. Manish Dhabliya--72--.pmd 73
recreational badminton players; 92% of the injured
were playing with their injury. The pathophysiology
was overuse in 74% (169/229), strains in 12% (28/229),
sprains in 11% (26/229), and fractures in 1.5% (3/229).
Possibilities for reducing the number of injuries and
their severity are increased injury information to
players and trainers and the introduction of stretching
all involved muscle groups4.
The influence of regular and intense practice of an
asymmetric sport such as badminton on nerves in the
elbow & wrist region needs to be examined. So the
purpose of the study was to find if there is any
difference existing in the conduction study of median
and ulnar nerve in the dominant upper extremity of
badminton players when was compared with the non-
dominant upper extremity of same badminton players.
METHODOLOGY
The group of tennis players consisted of 20 male
between the age of 18 and 32 years [mean (SD) age 23
yrs (3.68) years] subjects who have played for district
or state level, training for about 2 hours/day for 4
days/week since last 5 years. Each individual was
initially screened for any history, signs, or symptoms
of either peripheral neuropathy or compression
syndrome of the upper extremities. The
neurophysiological study consisted of motor and
sensory nerve conduction studies of the median and
ulnar nerves. All studies were performed with the
subject in a sitting position in a warm room with the
temperature maintained at 26–28ÚC. Both the
dominant and non-dominant extremities of all subjects
were tested. Nerve conduction studies were
performed using standard techniques of
supramaximal percutaneus stimulation with a
constant current stimulator and surface electrode
recording on both extremities of each subject. Sensory
responses were obtained by orthodromically
stimulating at the index finger (median nerve) and little
finger (ulnar nerve) and recording from the wrist with
surface electrodes. The median motor nerve was
examined by stimulating the median nerve at the wrist
(between the tendons of the Flexor Carpi Radialis and
Palmaris Longus), the elbow (next to the brachial
artery). The nerve was stimulated with bipolar surface
electrodes and the recording was carried out over the
Abductor Pollicis Brevis muscle with surface
electrodes. The ulnar motor nerve was examined by
stimulating the ulnar nerve at the wrist and above the
elbow (1–6 cm above the tip of the medial epicondyle)
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 74 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

with bipolar surface electrodes. The motor response
was recorded from the Abductor Digiti Minimi muscle
with surface electrodes.
In the present study, the following median and
radial nerve conduction measures were used for
analysis:
(i) Baseline to peak amplitude of the sensory nerve
action potential (Amp-S); (ii) Conduction Velocity of
the sensory nerve fibres (CV-S); (iii) Baseline to peak
amplitude of the compound muscle action potential
(Amp-M); (iv) Distal onset latency of the compound
muscle action potential (DL-M); and (v) Conduction
Velocity of the motor nerve fibres (CV-M). The mean
nerve conduction of dominant side was compared to
non-dominant side.
When performing nerve conduction studies, the
observers were not blinded to the subjects’ tennis
playing habits.
The results are presented as Mean values. The
Graphpad Instat(version 3.0) was used for the
statistical analyses. A p value of 0.05 or lower was
considered significant. Differences between the groups
were calculated using a parametric test (unpaired t-
test) when the data passed normality or non-
parametric test for independent samples (Mann-
Whitney U test) when the data did not pass normality.

RESULTS

Table 1: Nerve conduction results of median nerve

Parameters(mean) Dominant Non-dominant p-value t-value U-value Significant

Amp-M (mV) 14.55 13.61 0.21* 0.78 - Non Significant
PL-M(ms) 7.80 7.73 0.38* 0.29 - Non Significant
DL-M (ms) 3.32 3.19 0.11* 1.23 - Non Significant
CV-M (m/s) 61.38 59.83 0.21* 0.78 - Non Significant
AMP-S (μV) 15.66 17.71 0.15* 1.10 - Non Significant
CV-S (m/s) 55.09 58.74 0.07** - 130.50 Non Significant

*unpaired t test **Mann-Whitney Test

Interpretation

The above data shows that there was no significant change in the median nerve conduction when dominant
extremity was compared with non-dominant extremity.

Table 2:-Nerve conduction results of ulnar nerve

Parameters(mean) Dominant Non-dominant p-value t-value U-value Significant

Amp-M (mV) 12.31 12.68 0.36* 0.35 - Non Significant
PL-M(ms) 6.80 6.83 0.44* 0.12 - Non Significant
DL-M (ms) 2.46 2.39 0.22** - 154 Non Significant
CV-M (m/s) 61.15 59.94 0.31** - 163.50 Non Significant
AMP-S (μV) 10.3 9.11 0.33** - 165.50 Non Significant
CV-S (m/s) 58.54 58.53 0.49* 0.00 - Non Significant

*unpaired t test **Mann-Whitney Test

Interpretation DISCUSSION

The above data shows that there was no significant The purpose of this study was to compare the
difference in the ulnar nerve conduction when conduction studies of the median nerve and the ulnar
dominant extremity was compared with non- nerve in the dominant extremity with the non-
dominant extremity. dominant extremity of badminton players. The data

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 75
in this study indicates that the parameters of Nerve
conduction for the Median & Ulnar nerves (i.e.
amplitudes, latencies & conduction velocity) were
within normal limits. There was no statistical
significant difference in the nerve conductions of either
median nerve or the ulnar nerve between the dominant
and non-dominant extremity of badminton players.
The probable reasons for these findings could be
• Workload: The total workload can be estimated
by the intensity, frequency and duration of play
practice. The time spent during training/playing
can influence the occurrence of injury. Our study
subjects were training for duration of 20 minutes
followed by rest of 15 minutes with an average
total of 2 hours per session and 4 days per week.
The playing duration was well spaced with
adequate breaks which by itself is a good
ergonomic consideration in injury prevention.
Hence, in view of the findings of our study, we
assume that tennis players with this workload of
training are not prone to affection of the neural
tissue of the median & ulnar nerve at the wrist or
the elbow.
• Magnitude & generation of forces: Another reason
could be related to the magnitude of forces across
the elbow & wrist. The forces across the elbow
during tennis strokes can produce tremendous
valgus and extension overload in players9,12 which
may be more when compared to badminton
strokes, hence the changes in nerve conduction
were observed in study done on tennis players12.
Applying the three-dimensional kinematic model
by Sprigings et. al. (1994), they calculated the
contributions of each segmental rotation of the arm
to the final speed of the racket head. The results
showed that the main contributors were the
glenohumeral internal rotation (66%), the elbow
pronation (17%) and the hand flexion (11%). For
the player and serve analyzed, the greatest
contribution to racquet-head speed at impact was
produced by internal rotation of the upper arm (8
m s-1). Forearm pronation, although exhibiting the
fastest rotation at impact (24 rad s-1), ranked only
fourth in terms of its contribution (4 m s-1) to
racquet-head speed5. Hence we observe that the
greatest force is generated from the shoulder
rotation which could be a reason that there is no
neural tissue affection at the wrist or elbow in
badminton players.
14. Manish Dhabliya--72--.pmd 75
• Competitive category of player: There may even
be influence of the competitive category of the
player in injury profile. This study aimed to
determine the risk of nerve entrapments in
Intermediate level players i.e District & State level.
Since there is no affection in these players we
assume that the reason for which could be that they
are neither undertrained like recreational players
who play occasionally without much practice nor
over trained like the elite category both of which
may be at more risk than the intermediate level
players. These differences lead to difference in
injury risk & profile in different player levels. So,
although there are no changes in intermediate level
players, further studies should be conducted to
determine the risk of neural tissue involvement in
the elite group as they may be at a higher risk of
involvement.
CONCLUSION
There seems to be no evidence of subclinical nerve
entrapment of median or ulnar nerve at the wrist &
elbow in badminton players who were practicing or
playing at an average of 8 hours per week & playing
at least for 5 years. The effect of higher play workload
than this duration needs to be determined.
Acknowledgement: Nil
Conflict of Interest: None
Source of Funding: None
Ethical Committee Clearance: Number PDDYPU /
1851 / 2011 / 7
REFERENCES
1. Safran MR. Elbow injuries in athletes.A review.
Clin Orthop Relat Res. 1995 Jan;(310):257-77.
2. M. Azarbal, D. Adybeik, H. Ettehad & M.A. KIA.
A Survey of Elbow Injuries in Badminton Players.
The Internet Journal of Orthopedic Surgery. 2004;
2 (1).
3. Ikram Hussain and Saleem Ahmed. Analysis of
Arm Movement in Badminton of Forehand Long
and Short Service. Innovative Systems Design
and Engineering. 2011. HYPERLINK “http://
www.iiste.org/Journals/index.php/ISDE/
issue/view/30”2(3).
11/1/2014, 12:17 AM
 76 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
4. Jørgensen U, Winge S. Epidemiology of
Badminton injuries. Int. J. Sports Med. 1987
Dec;8(6):379-82.
5. Sprigings, E., Marshall, R. Elliott, B. & Jennings,
L. (1994). A three-dimensional kinematic method
for determining the effectiveness of arm rotations
producing racquet-head speed. Journal of
Biomechanics, 27: 245-254.
6. Michael Shacklock. Neurodynamics.
Physiotherapy. 1995, January; 81(1):9-16.
7. Abu Bakar Wan Abas Wan and A. S. Rambely.
Research on Badminton Games: Past and Present.
4th Kuala Lumpur International Conference on
Biomedical Engineering 2008 IFMBE
Proceedings, Springer Berlin Heidelberg;
BIOMED 2008 June 25–28; Kuala Lumpur,
Malaysia; 21(2): 22-26.
8. Chien-Lu Tsai, Chenfu Huang, Der-Chia Lin and
Shaw-Shiun Chang. Biomechanical Analysis Of
14. Manish Dhabliya--72--.pmd 76
The Upper Extremity In Three Different
Badminton Overhead Strokes. 18 International
Symposiums on Biomechanics in Sports ; 2000
June 25 – 30; China.
9. Denise Eygendaal, F T G Rahussen, R L Diercks.
Biomechanics of the elbow joint in tennis players
and relation to pathology. Br J Sports Med 2007;
41:820–823.
10. Osterman AL, Moskow L, Low DW. Soft-tissue
injuries of the hand and wrist in racquet sports.
Clin Sports Med. 1988 Apr; 7(2):329-48.
11. D Cabello Manrique, J J González-Badillo.
Analysis of the characteristics of competitive
badminton. Br J Sports Med 2003; 37:62–66
12. T Colak, B Bamac¸, A Ozbek, F Budak, Y S Bamac.
Nerve conduction studies of upper extremities
in tennis Players. Br J Sports Med 2004; 38:
632–635
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 77

Correlation of Transverses Abdomonis Strength and

Endurance with Pulmonary Functions in Healthy Adults

Gotmare Neha1, Nagarwala Raziya2, Ghodke Aditi3, Rairikar Savita4, Shyam Ashok5, Sancheti Parag6
1
M.P.Th, Working as Clinical Therapist, 2Associate Professor, 3Post Graduate Student, 4Principle,
5
Research Co-coordinator, 6Chairman of Sancheti Institute of Orthopedics and Rehabilitation, 12, Thube Park,
Shivajinagar, Pune, Maharashtra, India

ABSTRACT
Purpose: Increase in demand on the respiratory system leads to recruitment of abdominal muscles
[transverses abdominals] as accessory respiratory muscle. This correlation between the muscle strength
and the pulmonary function test is studied in this research.
Method: 80 healthy subjects were included in the study. Lumbar core strength, breath holding time
(BHT) and components of pulmonary function tests such as Peak Expiratory Flow Rate (PEFR), Tidal
Volume (TV) and Maximum voluntary Ventilation (MVV) were assessed using pressure biofeedback
unit, stopwatch and RMS-respirator® respectively.
Result: Data analysis revealed a significantly good correlation between PEFR and TA strength(r=
0.51) and fair correlation with endurance(r=0.42). TV showed no correlation with both TA strength
(r= 0.0031) and endurance (r= 0.081). MVV showed fair correlation with both TA strength(r=0.41)
and endurance(r=0.33) which was statistically significantly. BHT showed a good correlation with
TA strength(r= 0.51) and endurance (r=0.65).
Conclusion: Thus the study supports that there is a correlation of TA strength and pulmonary
functions in healthy adults except with tidal volume.

Keywords: Lumbar Core Muscle Strength and Endurance, Pulmonary Function Test, Breath Holding Time

INTRODUCTION occurs during strenuous activities that require rapid

Ventilation is the mechanical process by which air
is inhaled and exhaled through lungs and airways [1].
The relative intensity of ventilation can be described
as quiet or forced. In healthy individuals quiet
ventilation occurs during relatively sedentary activities
that have low metabolic demands. Forced ventilation
and voluminous exchange of air such as exercising,
coughing, sneezing etc. [2]
Quiet (tidal) expirations are normally passive
process by elastic recoil of the thorax, lung and relaxing
diaphragm which reduces the dimensions of the
thorax.

During forced expiration active muscles

Corresponding author:
contractions is required to rapidly reduce intrathoracic
Aditi Ghodke
(B.P.Th.) volume which includes four abdominal muscles rectus
Sancheti Institute College of Physiotherapy, abdominis, external oblique, internal oblique and
Sancheti Healthcare Academy, 12, Thube Park, Transverses Abdomonis(TA) that forms the ventro-
Shivajinagar, Pune - 411 005, Maharashtra, India lateral wall of the abdomen.[3] They have a wide variety
Telephone: 020 - 25539393 of functions, including participation in postural,
Fax No: 020 - 25539494 ventilatory, and airway defensive reflexes. These
Email: ghodke.aditi@gmail.com muscles exhibit specific characteristic activity during

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 78 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
different behaviors. For example, the rectus abdominis
is considered to be primarily a postural muscle,
whereas the Transversus abdominis has both postural
and ventilatory functions.[4]
TA is primary core muscle. EMG recordings from
individual abdominal muscles using needle or fine
wire electrodes have shown that during breathing in
humans, Transversus abdominis (TA) and internal
oblique (IO) are recruited in preference to the
superficial muscle layers.[5]It was found that TA is the
active throughout the respiratory cycle and was
modulated during respiration, but the amplitude of
TA EMG was higher during expiration.[6]TA has close
relationship in modulating Intra Abdominal
Pressure.[7]Different tools can be used to check TA and
needle electromyography and real time ultrasound is
the gold standard method. These tools have limitation
as it is an invasive method and costlier so TA
recruitment can be assessed using pressure
biofeedback unit.[8]
Breath holding generate intra-abdominal pressure
which is produced with co-ordination of diaphragm
and TA.[9]
Thus the interrelationship between changes in
vertical and transverse dimensions of the thorax
depends on the activity of the abdominal muscles.
Peak Expiratory Flow Rate (PEFR), Maximum
Voluntary Ventilation (MVV), TV(Tidal Volume) and
Breath Holding Time(BHT) are the parameters of
pulmonary function are dependent on inspiratory and
expiratory muscle strength.
When the ventilatory capacities of the lung are
compromised, the respiratory functions are affected;
the individual utilizes the abdominal muscles for
effective forced expiration, thus giving room to
improve inspiratory muscle action. The abdominal
muscles could be strengthened in order to assist the
ventilatory processes, especially in patients with
obstructive disorders, and so that the strength can
assist prolonged and forced expiration.[10]
Breath holding is required during lifting, sprinting,
weight lifting, swimming etc activities.
So, the purpose of the study is to correlate lumbar
core muscle strength and pulmonary function changes
in healthy adults.
15. aditi--77---.pmd 78
MATERIALS AND METHOD
The research protocol was approved by ethical
commity of Sancheti Institute of Orthopedics and
Rehabilitation. A Cross-sectional study design was
performed at our institute between 2009 and 2010.
Healthy adults between 20-40 yrs were included in this
study. Within this age group people who were
suffering from Cardiovascular /Respiratory/
Neuromuscular or Musculoskeletal condition affecting
respiratory system, mentally challenged, Recent
URTI/LRTI, Recent cataract removal surgery, recent
thorax or abdomen surgery OR Pregnant women were
excluded. Based on convenient sampling 80 subjects
were included. A prior written consent was taken from
each subject and the rights of the subjects were
protected. Subjects’ age, height and weight were
recorded. Lumbar core strength was then measured
in prone position with pressure biofeedback
unit(Picture:1). [8,11] Breath holding time was then
assessed with Subjects in relaxed sitting position on
chair and asking them to take deep inspiration and
pinch nose with the thumb and forefingers and to hold
the breath. RMS-respirator® was used for pulmonary
function testing.[12,13]
Tidal volume (TV), force vital capacity and MVV
were asked to perform with the spirometry. PEFR
value was recorded from the flow-volume curve of
FVC. For all three outcome measures Maximum three
readings were taken and the highest value was
recorded.
Microsoft Excel 2007 analysis tool pack was used
for the analysis of the data. Pearson’s correlation was
calculated using regression. Level of significance was
set at 0.05.
RESULT
Data analysis revealed a significantly good
correlation between PEFR and TA strength (p=0.0001)
and statistically non-significant correlation of PEFR
with endurance (p= 0.07). TV showed no correlation
with both TA strength (p=0.0001) and endurance
(p=0.0001). MVV showed fair correlation with both TA
strength (p=0.0001) and endurance which was
statistically significant. BHT showed a good correlation
with TA strength and endurance.
The results of the analysis are shown in the table.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 79

Table 1: showing the descriptive characteristics of the subjects the mean and standard deviations of parameters

Parameters Mean Standard deviation

Tidal Volume (L/min) 0.94 ±0.37
% predicted PEFR (L/min) 85.25 ±16.09
%predicted MVV (L/min) 70.45 ±14.82
BHT (seconds) 41.46 ±17.85
core muscle strength (mmHg) 5.1 ±2.05
core muscle endurance (seconds) 37.16 ±29.68

Table 2: Showing correlation of core muscle strength(mmHg) and endurance(Time)with Tidal volume(TV), Peak
Expiratory Flow Rate(PEFR), Maximum Voluntary Ventilation (MVV) and Breath Holding Time (BHT)

Correlation ‘r’ Value ‘p’ Value

Strength Time Strength Time
(mmHg) (Seconds) (mmHg (Seconds)
TV 0.0031 o.o81 0.0001 o.ooo1
%Predicted PEFR 0.51 0.42 0.0001 0.07
MVV 0.41 0.33 0.000 0.000
BHT 0.51 0.65 0.0001 0.004

DISCUSSION abdominal circumference, this increases the IAP and

The abdominal muscles serve as a vital component
of the core. Transversus abdominis (TA) is of chief
importance amongst them. Due to the anatomic
arrangements and extensive insertion of its fibers on
thoracolumbar fascia, it has major influence at all
lumbar level. TA is a major contributor in generating
intra-abdominal pressure (IAP) with the co-activation
of diaphragm and pelvic floor‘ and helps in
stabilization of spine. The isolated action of TA is
“hollowing in” of the abdomen which develops
tension on thoracolumbar fascia and increases the
IAP.[14]
A study provided evidence that individual TA
motor unit is recruited differently in respiratory and
postural tasks. TA is also considered main expiratory
muscle and found to activate earlier with sub-maximal
and maximal expulsive effort.[15] Missuri et al, in their
study found that anterolateral abdominal muscles do
not operate as a unit during respiratory maneuvers
and TA was found to be the major contributor in
generating IAP during forceful maneuvers which
supported the present study.[5]
The result of the present study demonstrated a
good correlation between PEFR and TA strength (r =
51, p= 0.0001), but PEFR did not significantly
correlated with the endurance of TA (r = 0.46, p = 0.07).
ERS states PEF is the maximum flow during expiration
delivered with maximal force starting from the
maximal lung inflation.[16] During forceful exhalation
there is posterior pull of abdomen which reduces the
pushes the diaphragm upward into the thoracic
cavity.[17]This may attribute the dependence of PEFR
on the force-length relationship of TA and force-
velocity property of TA muscle. This maneuver
requires the strength of muscle, as the activity is not
sustained for longer duration of time.
A fair correlation of MVV with TA strength (r =
0.41, p = 0.0001) and endurance (r = 0.31, p = 0.002)
was found in the present study. TA act as synergistic
during deep inspiration by resisting diaphragm with
increase in IAP and elevates the lower ribs. During
forceful exhalation TA is a most active muscle in
increasing the IAP and pushing the diaphragm into
the thoracic cavity. Maximum voluntary ventilation
is sustained for 12-15 seconds and requires rapid deep
inhalation and exhalation, therefore MVV depends on
the force-velocity property of TA muscle as well as
the force-length relationship of TA muscle.[3,13]
In the present study no correlation of TV with TA
strength and endurance was found. Normal tidal
breathing is automatically generated by neurons
located in the brainstem. Diaphragm and/or external
intercostals contract; intra pleural pressure becomes
more negative and increases the tidal volume.
Diaphragm descends 1-2 centimeters into abdominal
cavity during quiet/tidal breathing.[18] Ambrigo et al.,
from the study indicated that diaphragm is the main
inspiratory muscle at all level of inspiratory capacity
and tidal breathing. Diaphragm was found to
contribute 75% than other inspiratory muscles.[19] In the

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 80 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
present study, it is found that there is no relation of
TA which is an expiratory muscle with tidal volume
which infers that normal breathing may not get
affected because of TA strength and endurance. Shirley
et al, in the study found positive correlation between
changes in spinal stiffness with both Trans-
diaphragmatic and abdominal pressure. It was found
that there is no change in stiffness during tidal
breathing but increased spinal stiffness with increased
lung volume below and above FRC.[20] This finding
supported the present study; intra-abdominal pressure
is not generated during tidal breathing but is required
during forceful maneuvers.
Goldman et al, in his studied found no EMG activity
of abdominal muscles during tidal breathing which is
also found in the present study.[21] However they also
found increase in activity of abdominal muscles with
forceful maneuvers. In the present study a good
correlation of TA strength with PEFR is found and TA
showed fair correlation with MVV, this infers that TA
has an effect on forceful maneuver.
The present study found a good correlation
between breath holding time with Transversus
abdominis strength as well as endurance. This can be
possibly because when diaphragm descends for
inhalation, it is resisted by the contraction of
Transversus abdominis muscle. Diaphragm and
Transversus abdominis co-contract to increases the
intra-abdominal pressure. If one of the both fails to
co-contract then intra-abdominal pressure cannot
increase appreciably.[17] Mitrouska et al., study found
no effect of time on breath holding with and without
respiratory effort.[22] The present study found that the
BHT has correlation with TA strength as well as
endurance which indicates that TA activity play a role
in BHT.
Another study suggested significant effect of an
inhalation-hold breathing pattern on intra-abdominal
pressure magnitude when compared with exhalation-
hold and inhalation–exhalation during lifting tasks.[23]
The study by Marshall et al., suggested that IAP
increases with breath holding.[24] The present study
found a correlation of BHT with TA strength and
endurance, so it indicates that TA activity may
influence IAP and contribute in increasing the BHT
with the diaphragm co-contraction.
Thus, the present study supports the hypothesis
that there is a correlation of TA strength and
pulmonary functions in healthy adults except with
15. aditi--77---.pmd 80
tidal volume. The study also found correlation of TA
endurance with MVV and BHT. Thus clinically it can
be applied as TA strength should be considered as a
part of assessment and should be strengthened to
improve endurance and strength of ventilatory
muscles and for better functioning of the diaphragm.
Our study had a limitation. Sample size was small
and the study is not applicable to all age groups also
the Subjects were not correlated according to body
mass index (BMI). So, further studies can be done in
different age groups and larger sample size.
Effect of TA strengthening can be seen on PEFR,
MVV and BHT also BHT and TA strength and
endurance can be correlated in sports persons.
Acknowlegement: The authors are thankful to the
participants for this study, without whom this study
would not have been possible.
Conflict of Interest: None observed
Source of Funding: Funds not required.
Ethical Clearance: obtained from institutional ethical
committee
REFERENCES
1. Michael G. Levitzky: Function and structure of
the respiratory system: Pulmonary Physiology,
Sixth Edition: page no.3, McGraw-Hill.
2. Donald Neumann: Kinesiology of Mastication
and ventilation, Kinesiology of musculoskeletal
system; second edition: 439-448, Mosby Elsevier.
3. Robert L. Wilkins, James K. Stroller, Robert M.
Kacmaerk: Fundamentals of respiratory care,
Ninth edition 2003; Mosby Elsevier, 8:162-165.
4. De Troyer, M. Estenne, V. Ninane, D. Van
Gansbeke and M. Gorini: Transversus abdominis
muscle function in humans. Journal of Applied
Physiology1990; 68: 1010-1016.
5. G. Misuri, S. Colagrande, et al: In vivo ultrasound
assessment of respiratory function of abdominal
muscles in normal subjects. European
Respiratory Journal 1997; 10:2861–2867.
6. Hodges, Paul W., and Simon C. Gandevia:
Changes in intra-abdominal pressure during
postural and respiratory activation of the human
diaphragm. Journal Applied Physiology 2000;
89:967–976.
7. Carolyn Richardson, Paul Hodges: Abdominal
mechanism and support of the lumbar spine and
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 81
pelvis, Therapeutic Exercise for Lumbopelvic
Stabilization, Second Edition :31-57.
8. Leonardo Do Oliveira Pena Costa: Intra-tester
reliability of two clinical tests of transverses
abdominis muscle recruitment”. Physiotherapy
Research International Physiother. Res. Int. 2006:
11(1) 48-50.
9. Andry Vleeming, Carl DeRosa and James A
Portfield : Function control of the spine,
Movement, Stability &Lumbopelvic Pain, Second
edition : 499-501
10. Sanya AO, Famuyide AO: Abdominal muscle
strength and some respiratory function indices
in subjects of varying parity status. Journal of the
nigeria society of physiotherapy, 2002 ; 14 (2)
11. Carolyn Richardson, Paul Hodges and Julie
Hides: Local segmental control, Therapeutic
Exercise for Lumbopelvic Stabilization, Second
Edition: page no.185-219.
12. Miller MR, Crapo R, Hankinson J, et al : ATS/
ERS task force: Standardization of lung function
testing. European respiratory journal 2005;
26(2):153–161
13. Robert L. Wilkins, Richard L. Sheldon:
Pulmonary Function Testing, Clinical assessment
in respiratory care, Mosby Elsevier Fourth
edition: 141-157.
14. Akuthota V, Nadler SF. Core strengthening.
Archives Physical Medicine and Rehabilitation
2004; 85:S86-92.
15. P.W. Hodges: Is there a role for transverses
abdominis in lumbo-pelvic stability. Manual
Therapy1999; 4(2): 74-86
16. P.H. Quanjer, M.D. Lebowitz, I. Gregg, M.R.
Miller, O.F. Pedersen: Peak expiratory flow:
15. aditi--77---.pmd 81
conclusions and recommendations of a Working
Party of the European Respiratory Society.
European Respiratory Journal 1997; 10: Suppl. 24,
2s–8s.
17. AndryVleeming, Carl DeRosa and James A
Portfield: Anatomical linkages and muscle slings
of the lumbopelvic region, Movement, Stability
&Lumbopelvic Pain, Second edition: 48-60.
18. Michael G. Levitzky: Mechanics of breathing:
Pulmonary Physiology, Sixth Edition, McGraw-
Hill: page no.12-18.
19. SantAmbrigo and E. Camporesi: Contribution of
various inspiratory muscles to ventilation and the
immediate and distant effect of diaphragmatic
paralysis. ActaNeurobiologiaeExpirementalis
1971: page no. 402-409.
20. D. Shirley et al: Spinal stiffness changes
throughout the respiratory cycle. Journal of
Applied Physiology 2002.
21. J M Goldman et al, An Electromyography study
of the abdominal muscles during postural and
respiratory maneuvers. Journal of neurology,
Neurosurery, and Psychiatry 1987:50:866-869.
22. Mitrouska et al, Effect of voluntary respiratory
effect on breath-holding time. Respiratory
Physiology and Neurobiology 2007; 157: 290-294.
23. Marshall Hagins et al, The effect of breath control
on IAP during lifting task. Spine 2005 volume 29:
page no. 464-469.
24. Marshall Hagins et al: The effect of breath control
on maximum force and IAP during a maximum
isometric lifting task. Clinical Biomechanics 2006:
page no. 775-780
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
82 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

A Study on the effectiveness of Plyometric -Weight

Training on Anaerobic Powerand Muscular Strength in
Athletes

Sathish Gopaladhas1, Elanchezhian Chinnavan2, Dhayanidhi Rajaram3

1
Principal,White Memorial College of Physiotherapy, Tamil Nadu, India, 2Lecturer, School of Physiotherapy, AIMST
University, Malaysia, 3Consultant Sports Physiotherapist, Physio Care Clinic, Chennai, Tamilnadu, India

ABSTRACT

Purpose:In events like jumping, throwing, track and field and other activities, the athlete must be
able to use strength as quickly and forcefully as possible. This study is aimed to prove the effectiveness
of plyometric-weight training on anaerobic power and muscular strength in young male athletes.

Outcome measures: Tools used are vertical jump height, 50 yard dashand 1 RM squat.

Methodology: 40 athletes are divided into two groups using simple random sampling technique
namely the plyometric-weight training group (Experimental group, n=20) and plyometric group
(Control group, n=20). Both groups are trained for six weeks, 2 days per week.Experimental group
performs plyometric drills and weight training protocol.Control group performs only plyometric
drills. All training sessions are supervised.

Statistical analysis: The data are analyzed using unpaired t-test.

Results: The results showed that the experimental group who underwent plyometric-weight training
reported a higher level of improvement on anaerobic power and muscular strength than control
group. (p value < 0.05).

Keywords: Weight Training, Plyometrics, Vertical Jump, 1 RM Squat

INTRODUCTION strength training increases muscle fiber size. The

In sports, success depends heavily upon the
athlete’s explosive leg power and muscle strength. For
centuries, weight training is used by the athletic
trainers to build up muscular strength which uses the
gravitational force to oppose the force generated by
muscle through concentric or eccentric contraction.
Weight training uses a variety of specialized
equipment to target specific muscle groups and types
of movement. When done sufficiently and consistently,
Corresponding author:
Sathish Gopaladhas
Principal
White Memorial College of Physiotherapy, Tamil
Nadu, India
Mobile: +919443431403
E-mail address: gdssathish@rediffmail.com
maximum force a muscle can generate is determined
by cross-sectional area of the muscle as well as the
complex integration of the biochemical composition
and the neural input to the muscle9. For strength
adaptations to occur within muscle tissue, the overload
principle must be applied to the specific strength
training program9.
Weight training has shown to improve muscular
strength for sports performance particularly for
sprinters, jumpers and throwers but it is not beneficial
in developing rate of force. Therefore, for speed,
strength events like sprinting, football etc., it is the rate
of force development that becomes more important
than absolute strength. An increase in power gives the
athlete, the possibility of improved performance in
sports 16.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 83
Strength and conditioning professionals have long
relied on plyometrics as one of the primary tools for
developing athletic power and speed. Plyometrics is a
type of training involving an active muscle switching
from a rapid eccentric muscle action to a rapid
concentric muscle action or from a rapid deceleration
to a rapid acceleration 17, 21that can increase power
output and explosiveness 1,2,13 . This action of
deceleration to acceleration is known as the stretch-
shortening cycle 15.
Muscles that start in static position cannot generate
as much force as those using stretch-shortening cycle
since the eccentric to concentric muscle action uses
elastic energy stored in the muscle 5. A greater power
output can be found when the stretch-shortening cycle
is used because of the efficiency gained by releasing
elastic energy stored in the muscles 14. The muscles
react to the sudden stretch by sending a signal to the
central nervous system to resist the sudden stretch.
The muscle rebounds rapidly from sudden stretch8.
So plyometric training has the potential to develop
quicker reaction times that lead to an increase in an
athlete’s speed and power 5. This type of training can
improve performance in explosive sports that rely on
moving speed and power such as hockey, basketball,
track and field, football, and volleyball 20.In a recent
survey of training preferences, strength and
conditioning coaching reported plyometric training for
athletes10.
Need and significance
Jumping is a complex multi-joint action that
demands not only force production but also high
power output. Numerous investigators have
underlined the significance of maximal rate of force
development in the improvement of explosive
jumping 4.
METHODOLOGY
Study design: Quasi experimental design.
Study setting: Department of physical education,
Pachaiyappa Arts and Science College and
Department of sports, Integral Coach Factory (ICF).
Inclusion criteria:( 5, 12, 16, 19)Only male off-season
athletes, foot ball and hockey playerswho are not
trained earlier in plyometricsin the age group between
20 to 25 years.
16. Satish Gopaldas--82--.pmd 83
Exclusion criteria: (3, 6, 11, 19) Athletes with any recent
injuries, fractures, acute inflammation, weight above
100 kg (220 lb) andhyper mobility of joints.
Procedure: Athletes volunteered to participate in
the training program were selected based on the
selection criteria. 40 athletes were selected and divided
into two groups, plyometric- weight training group
and plyometric training group by a simple random
sampling technique. Each group consists of 20
subjects.All subjects finished training program without
injury. All athletes were instructed to do general warm-
up before training sessions and cool down exercise
after training sessions. The initial demographical data
were measured for both groups one week before
starting the training period.
Vertical jump height (cm): Vertical jump height
was measured by using stand and reach test and was
completed from a 2-foot standing position without a
step into the jump. The subjects were allowed to use
their hands as they desired. The best of the three test
jumps was recorded. This test was chosen because of
its high validity (0.80) and reliability (0.93) coefficients
and also it allows arm movement and squat motion
before the jump similar to sports activities.
50 yard dash (sec): The 50-yard dash is one of the
short-term tests for muscular power. This test was
chosen because of its high correlation coefficient
(0.974). In this protocol the subjects starts 15 yards
before the start line and time is measured from
thestarting distance of 50 yards.
1 RM squat (kg): To assess leg strength isotonically,
One Repetition Maximum (1RM) squat test was
performed. In this test, subjects executed the traditional
back squat exercise and a manual goniometer was used
at the knee to standardize the range of motion. The
subjects started the squat exercise at a 30° knee flexion,
descended to 90°, and then forcefully returned to the
starting position by extending knees, hips and plantar
flexing at ankles. Subjects were alerted at starting and
finishing positions.
Pre-testing was conducted in four sessions. The first
session included an introduction of the testing
protocols to the subjects. The second session included
the measurement of vertical jumping performance. In
the third session, leg strength was determined by 1RM
Squat. During fourth session, the 50- yard run was
measured. There was 24-hour pause between the
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 84 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

testing sessions. The two groups were trained for six supervised. After 6 weeks of the exercise protocol post-
weeks, 2 days per week. All training sessions were test outcome scores were recorded in four sessions.

Training protocol18

Increase in Set, repetition (reps) and box height are presented in the table

Table.1 Plyometric training group

S.No Training program Week 1 Week 2 Week 3 Week 4
1. Depth jump 3 set X 6 reps with 3 set X 8 reps with 4 set X 7 reps with 4 set X 8 reps with bo
box height 40 cm box height 50 cm box height 60 cm x height 75cm
2. Split squat jump 3 set X 6 reps 3 set X 8 reps 4 set X 7 reps 4 set X 8 reps
3. Rim jump 3 set X 6 reps 3 set X 8 reps 4 set X 7 reps 4 set X 8 reps
4. Box to Box depth jump 2 set X 6 reps with 3 set X 5 reps with box 4 set X 5 reps with box 4 set X 6 reps with box
box height of 40 cm height of 50 cm height of 60 cm height of 75 cm

(Rest time of 30 sec between each set)

Table.2 Plyometric-weight training group

S.No Training program Week 1 Week 2 Week 3 Week 4
1. Depth jump 3 set X 4 reps with 3 set X 6 reps with 3 set X 7 reps with 3 set X 7 reps with
box height 30 cm box height 40 cm box height 45 cm box height 45 cm
2. Split squat jump 3 set X 4 reps 3 set X 6 reps 3 set X 7 reps 4 set X 6 reps
3. Rim jump 3 set X 4 reps 3 set X 6 reps 3 set X 7 reps 4 set X 6 reps
4. Box to Box depth jump 3 set X 4 reps with 3 set X 4 reps with box 3 set X 5 reps with box 3 set X 6 reps with box
box height of 30 cm, height of 30 cm, 4 boxes height of 45 cm, 3 boxes height of 55 cm, 6 boxes
3 boxes
5. Squat 4 set X 8 reps, with 4 set X 8 reps, with 4 set X 6 reps, with 3 set X 6 reps, with
30% of 1 RM 45% of 1 RM 60% of 1 RM 75% of 1 RM
6. Leg press 4 set X 8 reps, with 4 set X 8 reps, with 4 set X 6 reps, with 3 set X 6 reps, with
30% of 1 RM 45% of 1 RM 60% of 1 RM 75% of 1 RM
7. Leg extension 4 set X 8 reps, 4 set X 8 reps, with 4 set X 6 reps, with 3 set X 6 reps, with
with 30% of 1 RM 45% of 1 RM 60% of 1 RM 75% of 1 RM
8. Leg flexion 4 set X 8 reps, with 4 set X 8 reps, with 4 set X 6 reps, with 3 set X 6 reps, with
30% of 1 RM 45% of 1 RM 60% of 1 RM 75% of 1 RM

(Test No. 1-4: rest time of 30 sec between set; Test No. 5-8: rest time of 60 sec between set)

Table.3 Plyometric-weight training techniques

Techniques used in the study

Depth jump7
Equipment A box of varying
heights
Starting Stand on the box
Position with toes being close
to the front edge
Action Step from the box and
drop to land on both
feet. Try to anticipate
the landing and spring
up quickly.
Split squat jump7
None
Spread the feet far apart,
front to back, and bend the
front leg 90 degrees at the
hip and 90 degrees
at the knee
Jump up; using arms to
help lift, hold the split-
squat position. Land
in the same position,
immediately repeat
the jump
Rim jump7
A high object such as a
basketball goal or
crossbar on a football
goal post.
Stand under the high
object with feet shoulder-
width apart
Jump continuously,
reaching with alternating
hands and trying to reach
the object on every jump.
Time on the ground should
be minimal, with each jump
being at least as high as the
one before
Box-to-box depth jump7
A row of same heighted
boxes (increase box
height according to
progression).
Stand with feet shoulder-
width apart at the end of
boxes
Jump onto the first box, then
off on the other side, on to
the second box, then off,
and so on down the row.
After jumping off the last
box, walk back to the start
for recovery

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 85

Statistical Analysis

Table 4. Comparisonof plyometric-weight training group and plyometric group

Tools Used Plyometric -weight Plyometric group t-test significance

training group
Mean SD Mean SD
Vertical jump height Pre test 41.505 2.530 41.145 2.494 0.453 0.653
Post test 49.470 2.482 46.560 2.655 3.580 0.001
50 yard dash Pre test 7.897 0.449 7.828 0.571 0.425 0.673
Post test 6.713 0.366 7.036 0.548 2.190 0.035
1RM Squat Pre test 80.250 8.346 81.750 9.072 0.544 0.590
Post test 111.00 8.207 88.000 9.233 8.326 0.000

Statistical analysis was performed using SPSS
software package, values were presented as means +/
-standard deviation, unpaired t-test were used to
analyze the effect of plyometric-weight training using
vertical jump height, 50 yard dash and1 RM squat.
Statistical significance was accepted at p<0.05.
DISCUSSION
The plyometric-weight training had a significant
effect on plyometric training alone for increasing hip
and thigh power as measured by 50-yard dash test.
This allows the excellent transfer of power to other
biomechanically similar movements (running) that
require a powerful thrust from hips and thighs.
Training programs that utilized plyometric exercises
are proved to positively affect performance in power
related movements (jumping) and speed.
In this study, the maximal strength measured by
1RM squat was improved by plyometric - weight
training than plyometric training. This finding is
related to the nature of muscular strength, which is
increased in low movement phase of eccentric
contraction than the fast movement phase. Therefore,
a weight training program increases strength than the
plyometric training. Weight and plyometric training
programs involve eccentric and concentric
contractions.In weight training programs the velocity
of the contraction is lesser than the plyometric training.
The results indicate that all trainings produce
improvement in vertical jumping, explosive
performance and muscular strength. However, the
combination training treatment evoked the most
significant changes in these variables. Subjects in the
study were novices in plyometric training in contrast
to the subjects in previous investigations. However,
they were strength trained enough to sustain
plyometric training loads. One needs to be weight
trained to enjoy positive adaptations to plyometric
training.
The study clearly illustrates the close working
relationship between neuromuscular efficiency and
dynamic strength performance. With reasonable
confidence, it can be said that weight training
programs are conducive to the development of hip and
thigh strength, while the simultaneous application of
plyometrics permits effective use of this strength to
produce explosiveness in sports or events demanding
speed and quickness. In other words, the role of
plyometrics is to facilitate the neuromuscular system
into making a more rapid transition from eccentric to
concentric contractions, whereby maximal ballistic
force is generated. This tends to support that
plyometric training is the link between speed and
strength.
CONCLUSION
The above results show that combined plyometric-
weight training improves anaerobic power and muscle
strength by a six week training protocol in athletes than
the plyometric training. Hence combined plyometric-
weight training protocol can successfully be
incorporated in fitness training and conditioning
programs to improve anaerobic power and muscle
strength in athletes.
Acknowledgement: The authors extend their gratitude
to Department of Physical Education, Pachaiyappa
Arts &Science College, Department of Sports, ICF and
the participants.
Conflict of Interest: No conflicts of interest between
the authors during the elaboration of this paper.
Source of Funding: No author or related institution
has received any financial benefit fromthis study.

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 86 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Ethical Clearance: The study was approved by
Meenakshi College of Physiotherapy review board and
complies with the principle laid down in the
declaration of Helsinki in 2005.
REFERENCES
1. Adams K, O’Shea JP, O’Shea KL &Climstein M.
The effect of six weeks of squat, plyometrics and
squat-plyometric training on power production.
Journal of Applied Sports Science Research. 1992;
6(1): 36-41.
2. Adams TM, Worley D &Throgmartin D. An
investigation of selected plyometric training
exercises on muscular leg strength and power.
Track and Field Quarterly Review. 1984; 84(1):
36-40.
3. Allerheiligen B and Rogers R. Plyometrics
Program Design. NSCA Journal, Colorado
Springs. 1995; 17: 4.
4. Bauer T, Thayer, RE &Baras G. Comparison of
training modalities for power development in the
lower extremity. Journal of Applied Sports
Science Research. 1990; 4: 115–121.
5. Brown ME, Mayhew, JL, &Boleachl. The Effect
of plyometric training on the vertical jump of high
school boys basketball players. Journal of Sports
Medicine and Physical Fitness. Quarterly Review.
1986; 26: 1-4.
6. Carter C and J Wilkinson. Persistent joint laxity
and congenital dislocation of the hip. Journal of
Bone Joint Surg. (Br.), 1969; 46:40-45.
7. Cavagna G. Storage and utilization of elastic
energy in skeletal muscle. Exercise Sports Science
Review. 1977; 5: 89-129.
8. Cavagna G. Positive work force by a previously
stretched muscle. Journal of Applied Physiology.
1968; 24: 21-32.
9. Chu DA. Plyometrics in Sports Injury
Rehabilitation and Training: Human Kinetics
Athletic therapy today. 1999; 4: 7-11.
10. Clutch D, Wilton M, Mcgown C & Bryce GR. The
effect of depth jumps and weight training on leg
strength and vertical jump. Res. Q., 1983; 54:
5–10.
16. Satish Gopaldas--82--.pmd 86
11. David J Magee. Orthopedic Physical Assessment.
Fourth edition, Saunders, imprint of Elsevier,
2002; 977-979.
12. Ford JR., Puckett JR, Drummond JP, Sawyer K,
Knatt K &Fussel C. Effects of three combinations
of plyometric and weight training programs on
selected physical fitness test items. Percept. Mot.
Skills, 1983; 56: 59–61.
13. Hakkinen K &Komi PV. Changes in electrical and
mechanical behavior of leg extensor muscles
during heavy resistance strength training. Scand.
Journal of Sports Science. 1985; 7: 55–64.
14. Ioannis G Fatouros, Athanasios Z Jamurtas, D
Leontsini, KyriakosTaxildaris et al. Valuation of
Plyometric Exercise Training, Weight Training,
and Their Combination on Vertical Jumping
Performance and Leg Strength. Journal of
Strength and Conditioning Research. 2000; 14(4),
470–476.
15. KomiP&Bosco C. Utilization of stored elastic
energy in leg extensor muscles by men and
women. Medicine and Science in Sports and
Exercise. 1987; 10(4): 261-265.
16. Michael G Miller, Jeremy J Herniman, Mark D
Ricard, Christopher C Cheatham and Timothy J
Michael. The effects of a 6 week plyometric
training program on agility. Journal of Sports
Science and Medicine. 2006; 5: 459-465.
17. O’Shea, J P. Throwing speed. Sports Fitness, 1985;
66-70, 89-90.
18. O’Shea, J P. The parallel squat. NSCA Journal,
1985; 7(l): l-6.
19. Peggy A Houglum, Therapeutic Exercise for
Musculoskeletal Injuries, second edition, Human
Kinetics, 2005; 283-295.
20. RahmanRahimi, NaserBehpur et al. Evaluation
of plyometrics, weight training and their
combination on angular velocity. Physical
education and sport. 2006; 4:1-8.
21. Safrit MJ. Introduction to Measurement in
Physical Education and Exercise Science, 2nd
edition. St Louis: C.V Mosby Company, 1990.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 87

Effect of Complete Decongestive Therapy (CDT) in Upper

Limb Lymphedema in Breast Cancer Patients

Mullai Dhinakaran1, Kunal Jain2, K E Benjamin3, ParamdeepKaur4, Dhinakaran5

1
Associate Professor, Department of Physiotherapy, 2Assistant Professor and Head, Medical Oncology Unit, 3Head,
Department of Physiotherapy, 4Department of Community Medicine, CMC & H, Ludhiana, 5Text YTC

ABSTRACT

Objective: To find long term effectiveness of complete decongestive therapy to reduce lymphedema
and improvement of quality of life in the patients of unilateral upper limb lymphedema of post
radical mastectomy.

Materials and method: Patients were recruited from January 2011 to December 2012. Each patient
received an intensive phase of complete decongestive therapy for 10 days from out patients unit,
Department of Physiotherapy, CMC&H Ludhiana. Self care and self management techniques were
taught to the patients and relatives .The patients were followed up every month for up to 3months.The
base line assessment of oedematous limb were assessed with modified truncated cone method and
their quality of life was assessed with European organization for research and treatment of cancer
quality of life questionnaires - core 30 questions (EORTC- LYMQLQ ARM- C 30).

Result: Forty five female patients with lymphedema developed after mastectomy was analyzed in
this study.The mean age of subjects was 48.44 years. Volume was reduced by 80.22 (95% CI: -96.71
to -63.73) from baseline to 3rd month (p<0.0001). There was significant mean change in QOL at 2nd
month as compared to baseline [69.95 (95% CI: 66.49 to 73.42); p<0.0001]. Volume of affected limb
was similar to the normal limb at 3rd month (normal limb: 312.38±82.20 vs. affected limb: 324.44±82.19;
p=0.48).

Conclusion: Complete decongestive therapy is effective in lymphedema and improves the quality
of life and required to assess the effectiveness of self management under supervision.

Keywords: Lymphedema, Lymphedema Quality of Life Tool, Complete Decongestive Therapy

INTRODUCTION Incidence rates ranging from 5 to 56% with in 2 years

One of the complications of breast cancer is
lymphoedema of ipsilateral arm.1 Even if the patient
undergone extensive axillary surgery and improved
radiotherapy techniques the literature reported
incident of secondary lymphoedema is diverse
Corresponding author:
Sathish Gopaladhas
Principal
White Memorial College of Physiotherapy, Tamil
Nadu, India
Mobile: +919443431403
E-mail address: gdssathish@rediffmail.com
of surgery.2
The breast cancer related lymphoedemaposses
multiple challenges for patients who experience this
condition as well as for the patient who are fearful of
developing this difficult side effect of treatment.3,4
Because, It causes disfigurement, physical discomfort
and functional impairments. This can affect social
relationship and remaining body images and the self
esteem. This condition may also precipitated cellulitis,
erysipelas, lymphangitis and occasionally
lymphangiosarcoma.5So the treatment of this condition
posses a great challenges to physicians. The available
treatment of this condition is pharmacotherapy and
surgery, physical therapy rehabilitation. The previous

17. Mullai Dinakaran--87--.pmd 87 11/1/2014, 12:17 AM

 88 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
two treatments give disappointing result to the
physicians.6A novel form of physical therapy called
comprehensive decongestive therapy which combines
various physiotherapeutic modalities like massage,
compression bandaging and exercises, is the standard
therapy in some western countries.7
Complex lymphedema Therapy, as practiced
today in the US, was principally introduced, applied,
and refined in Germany by the Foldis in the 1980’s.
This technique also called Combined Decongestive
Physiotherapy (CDP) was modified and supplemented
with Specific physical therapy exercise by the casley-
smith in Australia.8The lymphedema that develops
may lead to impairments in mobility and function. A
program of CDP consisting of instruction in skin care,
manual lymph techniques, compression and exercise
may decrease edema and subsequently improve
function. Several studies related to lymphedema with
CDP have shown that the greatest reduction in volume
occurred during the first 2 weeks of the therapy.9Only
one study was conducted that to find effectiveness of
complete decongestive therapy in post mastectomy
lymphoedema in India. But it is not quantified
improvement of quality of life of patients after CDT.
But using multilayer bandaging in CDT is discomfort
like repeated episode of cellulites, blistering and
exacerbation of fungal infection faced by patients in a
tropical country like India.10
Lymphedema can be viewed as a QOL issue, due
to the difficulties in functioning at work or at home,
altered body image, low self-esteem, difficulty in
dressing, and a loss of interest in social activities. Some
studies were examine whether the QOL at long-term
follow –up was improved in breast cancer patients
with lymphedema following CDT, and whether limb
volume changes were associated with any detected
changes in the QOL by using SF-36 Health Survey
Manual and Interpretationquestionnaires.11-12 Morgan
et al in their review study were concluded that general
health quality measures may not be as accurate or
informative as condition – specific tools.13 There was a
special tool of lymphedema - European organization
for research and treatment of quality of life for
lymphedema questionnaires – Core 30 questions
(EORTC QLQ – C30) were valid and reliable, used to
measure upper limb lymphedema patients.14 Our aim
of study to find out effectiveness of Complete
Decongestive Therapy and how it improves the patient
quality of life using specific scale. Till date, no studies
17. Mullai Dinakaran--87--.pmd 88
were conducted to find effectiveness and increase the
quality of life in India.
METHOD
The prospective randomized study was conducted
on female patients with post mastectomy
lymphoedema in Outpatients Department of
Physiotherapy from January 2011 to December 2012.
Out of 60 subjects 45 female patients were analyzed in
this study with duly signed consent form.
Inclusions of criteria were patients who have
history of unilateral post mastectomy lymphedema
with more than 2 cm circumference than normal side,
more than 19 years old, no known neurological
disorder that would interfere with completion of the
measures, ability to complete a questionnaire, no
known untreated or unstable medical conditions, no
edema in lower limbs. Women with evidence bilateral
breast cancer, primary lymphedema and loco regional
recurrence cancer, recently underwent breast cancer
surgery on ipsilateral side (increase in arm
circumference immediately after surgery is common
and it resolve within weeks) were excluded in this
study.
The subjects were underwent base line assessments
of edematous limb were assessed with modified
truncated cone method of circumference
measurements on bilateral upper limb. It was taken
from wrist (base of ulnar styloid process) and every
4cm to the top of the arm (axillary fold) as well as two
measurements of hands that were not included in the
volume measurements by using standard inch tapes.
If maximum difference between two adjacent points
was greater than 2cm was taken as reference point for
calculating. Each of volume was calculated from
circumferences values by an approximation to a
modified truncated cone with formula of V=C12+C22+
(C 1 2 C 2 2 ) /12ð. V means volume of limb,C 1 and
C 2circumference of two adjust location, Dis the
distance between C1 and C2.
In secondary Lymphoedema, upper limb of quality
of life was measured using EORTC or ca-30 questions.
Their quality of life was assessed with European
organization for research and treatment of cancer
quality of life questionnaires – core 30 questions
(EORTC- LYMQLQ ARM- C 30). These questions were
covered four domains symptoms, Body image/
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 89

Appearance, Function and Mood. This is a reliable
questions to assess the quality of life (p- value <0.001).
A total score for each domain was calculated by adding
all scores together and dividing by the total number
of questions answered. The overall ULLQOL (upper
limb lymphedema quality of life) item scored 0-10 (0
poor- 10 excellent).
PROCEDURE
After baseline assessments, patient were
underwent intensive phase of CDT which included
skin care, manual decongestive therapy or manual
lymph drainage(MLD) of Vodder’s method for 45
minutes, The ComprezonTM low elastic compression
stocking lymphoedema arm sleeve with hand ,
shoulder cap and belt with the pressure of 23 to 32
mm Hg was applied. It should be instructed to wear
the garment 23hrs / daily. Exercise of warm up of
active movement of glenohumeral joint for 5 minutes
up .Deep abdominal breathing exercise 3 -5 times,
Isometrics exercise were given for the arm and
shoulder, elbow and wrist for 10 repetition of each with
compression garments , Deep abdominal breathing
exercise 3 -5 times in between each isometric exercise.
Instruct subjects to be done these exercisestwice in a
day upto10 days. Meanwhile patients and their relative
were trained for self –drainage and exercises. Subjects
were followed same protocol in home, every month
they turned back for follow up. After a month
(maintenance phase)along with CDP isotonic exercise
of shoulder , elbow and wrist muscles for 50 – 60 % of
10RM 8-10 times / twice in a day and stretching
exercise of pectoralis major and minor, latissimusdorsi
.Afterwards patients had come for follow up every
month, up to 3 month to assess circumference
measurements and QOL.
Statistical analysis
Statistical analysis was done with SPSS version 16
(SPSS Inc., Chicago, IL, USA). The means of continuous
variables were compared between the normal and
abnormal limb using independent t-test. The effect of
treatment at different time period was tested by
applying within abnormal limb design in repeated
measures ANOVA. A P value of 0.05 was considered
significant.
RESULTS
During the study period,45 female patients with
lymphedema developed after mastectomy was
included in this study. The mean of patients was 48.44±
6.5 years. At baseline, the mean volume of normal and
affected limb was 312±82.20 and 404.66±98.18
respectively. The mean QOL score was 18.33±6.58. At
the time of follow up, there was reduction in volume
of the affected limb after this treatment and QOL was
improved (Figure 1 and 2)
In the baseline to follow up time, there was
significant mean change in volume was seen. Volume
was reduced by 80.22 (95% CI: -96.71 to -63.73) from
baseline to 3rd month (p<0.0001) (Table 1). There was
significant mean change in QOL at 2 nd month as
compared to baseline (Table 2).

Table 1: Mean Change in outcome volume measures at different time periods

Volume of affected limb Mean change (95% CI¶) P Value§

Baseline to 10 day
th
-60.76 (-73.08 to -48.44) <0.0001
Baseline to 1st month -73.92 (-89.37 to -58.48) <0.0001
Baseline to 2nd month -70.71 (-86.65 to -54.77) <0.0001
Baseline to 3rd month -80.22 (-96.71 to -63.73) <0.0001

CI- confidence interval, §p<0.05 significant.

Table 2: Mean Change in outcome measures at different time periods

QOL‡ Mean change (95% CI¶) P Value§

Mean change
Baseline to 10th day 30.95 (26.97 to 34.94) <0.0001
Baseline to 1st month 54.88 (51.75 to 58.02) <0.0001
Baseline to 2nd month 69.95 (66.49 to 73.42) <0.0001

CI-confidence interval, §p<0.05 significant, ‡QOL-qualityof life

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 90 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
DISCUSSION
Lymphoedema is a chronic progressive, long term
adverse effect of breast cancer treatment resulting in
affected upper limb swelling, pain, heaviness and
discomfort. Although the incident of this condition is
decreased due to various approaches in surgery like
breast conservation surgery and sentinel lymph node
biopsy. So, no treatment can cure this condition but
we can control. In our study shows that reduction of
volume in the intensive phase is 65.85%. At the end of
3rd month was 86.94%.And Also the quality of life
improved gradually from 1st day to 2nd month (20.64%
to 84.78%).
Joachim zuthar states that if lymphoedma is
presents, the application of traditional massage
therapy is contraindicated in the affected extremity and
trunk area bordering the extremities and may trigger
the onset of lymphoedema or worsen the existing
lymphedema. So, Manual lymph drainage (MLD)
which is a gentle, manual treatment techniques used
in combination with compression therapy, skin care
and decongestive exercises is effective to treat primary
and secondary lymphoedema.15
Johansson et al compared the effect of multilayer
bandage and the combination of multilayer bandage
and MLD and he found that combination method was
more effective.16 Robert Harris & Neil Piller et al, in
pilot study, using MLD massage only 8.7% of
reduction of lymphedema at 20 minutes of post
treatment. This perhaps provides evidence for need
to provide some form external support (compression
bandage or Garments) after MLD massage.17 Badger
et al.found that the multilayer bandaging is very
effective volume reduction of lymphedema after 18
days of bandaging versus compression garment. But
both the groups were underwent same procedure of
Complete decongestive therapy. This study was not
clear to confirm that only whether MLB(multilayer
bandaging) alone reducing the volume.18In our study
we have proved that compression garment following
MLD in the initial stage significantly reduced the
volume (p<.001).
Rashmikoul et al, found that complete decongestive
therapy was more effective than MLD at the end of 1
year (p<0.0001) and they have not assessed “quality
of life” changes before and after treatment.10 But in our
study we have measured quality of life to assess the
functional health status also. Ajay P Gautam et al were
used progressive resisted exercises program to
17. Mullai Dinakaran--87--.pmd 90
increase muscle strength and endurance in home based
protocol. It was helped to reduce the lymphedema after
8 weeks and increased the Quality of life.12This study
also followed same isotonic exercise in the
maintenance phase to increase the muscle power and
endurance.
Almir José Sarri et al physiotherapeutic
interventions on patients who have undergone axillary
lymph node manipulation can be implemented at any
postoperative stage. However, it is increasingly certain
that early intervention significantly minimizes the
emergence of lymphedema.19
However consensus has been reached regarding a
standard treatment of lymphedema still the limitation
of this study results must be interpreted cautiously.
This limitation includes the absence of non treatment
of control group which meant that effects of complete
decongestive therapy on the quality of life could not
be distinguished from the effects of simply
participating in a clinical research studies.
It required further studies on more number of
subjects and longer duration of follow up. And also
Quality of life should be assessed in the improvement
of various domains, needed to compare the effects of
different modalities of treatment on the quality of life
of patients with various characteristics and clinical
symptoms
CONCLUSION
All the components of CDT to the patients with
secondary lymphedema were associated with
significant reduction in mean volume. So, early
physiotherapy with an educational strategy should be
added to reduce the incidence rate of lymphedema
after treatment of breast cancer.
Acknowledgement: Study concept, design and
Acquisition of data: Mullai.D
Drafting of Manuscript: Mullai.D,Kunal Jain.
Critical Revision of Manuscript for Important
Intellectual Content: Dhinakaran
Statistical Analysis: Paramdeep Kaur.
Administrative Support: K E .Benjamin.
Conflict of Interest: None
Source of Funding:This Material was unfunded at the
time of manuscript preparation.
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 91
Ethical Clearance: Patients were recruited in this study
with duly signed consent form.
REFERENCES
1. Rashmi koul,MD.,TarekDufan,MD., catherine
Russell, BPT., Wanda Guelther,R.M.T.,Efficacy of
complete decongestive therapy and manual
lymphatic drainage on treatment related
lymphedema in breast cancer. Internal journal of
radiation oncology. biology physics. 2007 ; 67 (
3):841-846.
2. Effectiveness of early physiotherapy to prevent
lymphoedema after surgery for breast cancer.
BMJ 2010; 340 doi: 10.1136/bmj.b5396 (Published
12 January 2010).
3. Lee TS ,KilbreathSL,Sullivan G. The development
of an arm activity survey for breast cancer
survivors using the protection motivation
theory.BMC Cancer. 2007;7:75
4. Hayes SC ,Reul-Hirche H, Turner J. exercise and
secondary lymphedema:safty,potential benefits,
and research issuesMEDSci sports
exercise.2009;41:483-489.
5. OcanaA.Delgaco C. Case 3.upper limb
lymphangiosarcoma following breast cancer
therapy. Journal of clinical oncology .2006; 24:
1477- 1478.
6. Soran A, d Angelo G, BegovicMrdic F, Harlak A,
Wieand HS, Breast cancer- related lymphedema
– what are the significant predictors and how they
affect the severity of lymphedgema. Breast J 2006;
12: 536 - 43.
7. Gary DE.Lymphedema diagnosis and
managements.journal of American Academy
nurse practice.2007; 19:72-78.
8. Bonnie B. Lasinski, MA,Comprehensive
Lymphedema Management; Result of a 5 - year
follow – up.Lymphology.2002;35(Suppl):301- 304.
9. Karen M Holtgrefe .Twice –weekly complete
Decongestive Physical Therapy in the
management of secondary lymphedema of the
lower extremities. Physical therapy
.2006;86(8):1128-1136.
10. Randheer S, kadambari D, Srinivasan K,
Bhuvaneswari V, Bhanumathy M, Salaja R.
Comprehensive decongestive therapy in post
mastectomy lymphedema: An Indian
17. Mullai Dinakaran--87--.pmd 91
perspective. Indian journal of cancer 2011;
48(4):397-402.
11. S-J Kim, C-H. Yi, O. - Y. Kwon. Effect of complex
decongestive therapy and Quality of life in breast
cancer patients with unilateral
lymphedema.Lymphology.2008; 40:143-151.
12. Ajay P. Gautam MPT. Arun G. Maiya, Phd,
Mamidipudi S, Vidyasagar MD. Effect of home
based exercise program on lymphedema and
quality of life in female post mastectomy
patients:Pre- post intervention study. Journal of
rehabilitation research and development.
2011;48(10):1261-1268.
13. Morgan PA, Franks PJ, Moffatt CJ. Health-related
quality of life with lymphoedema: a review of
the literature. Internal Wound Journal.2005; 2:
47–62
14. Keeley Vaughan, Sue Crooks, Jane
Locke,Debbie.v.A Quality of life measure for limb
lymphoedema (LYMQOL). Journal of
Lymphoedema, 5(1), pp. 26–37.
15. Joachim E.Zuther, Traditional Massage Vs
.Manual lymph drainage in the treatment of
lymphedemaMassage Today.June, 2002, Vol. 02,
Issue 06.
16. Johansson K. Albertsson M, Ingvar C,
EkdalC.Effect of compression banding with or
without manual lmph drainage treatment in
patients with postoperative arm
lymphedema.Lymphology.1999;32:103-110.
17. Robert Harris, Neil Pillar. Three case studies
indicating the effectiveness of manual lymph
drainage on patients with primary and secondary
lymphedema using objective measuring tools.
Journal of body And Movement Therapies.2003.
7(4), 213-221.
18. Badger CMA, Peacock JL and Mortimer PS. A
randomized, controlled, parallel-group clinical
trial comparing multilayer bandaging followed
by hosiery versus hosiery alone in the treatment
of patients with lymphedema of the upper
limb.Cancer.2000;88(12):2832-2837.
19. Almir José Sarri and Sonia Marta
Moriguchi.Evidence-Based Usefulness of
Physiotherapy Techniques in Breast Cancer
Patients - Novel beyond Conventional
Approaches.2011:751-766.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
92 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effects of Early Mobilization Combined with

Conventional Physiotherapy Treatment After 4 Hrs of
Lobectomy on Haemodynamics, ABG and PFT

Mohammad Qasim1, Jyoti Jalwan2, R K Dewan3

1
Research Student, 2Asstt. Proff, Faculty Allied Health Science, Jamia Hamdard, Hamdard Nagar, New Delhi, 3HOD,
CTS Department, L.R.S Hospital, Mehrauli, New Delhi

ABSTRACT

Objectives: The aim of the present study is to evaluate the effect of early mobilization along with
conventional physiotherapy ( CPT) on haemodynamic, ABG and PFT in the patient undergoing
lobectomy.

Method: The present study is a pre-test post-test control group design. Inclusion criteria consisted of
patient undergoing lobectomy. In experimental group15 patients completed 10 sessions of
physiotherapy intervention programme (early mobilization at 4 hours combined with CPT). ABG,
haemodynamics were taken at day 0 and after completion of 10 sessions PFT was taken preoperatively
at 10th post operative day. In control group15 patients were mobilized with CPT at day 1 and variables
were taken after intervention and after completion of 10 sessions .

Results: On completion of the physiotherapy intervention program there is no significant difference

found between both groups in haemodynamics, ABG and PFT values .

Conclusions: Early mobilization combined with CPT does not improves haemodynamics, ABG and
PFT values of patients undergone lobectomy but we can say that it is a safe approach to start early
rehabilitation after 4 hours of surgery.

Keywords: Early Mobilization, Conventional Physiotherapy(CPT), Arterial Blood Gases(ABG), Pulmonary

Function Test (PFT),Haemodynamics

INTRODUCTION effects on postoperative pulmonary function.

Anesthesia and tissue dissection contribute to major
Lobectomy is the removal of a lobe or section of a
changes in lung volumes, mechanics of gas exchange,
lung1. The most common indications for Lobectomy
cough reflex and expansion of the lungs, they
are post tubercular haemoptysis, post tubercular
eventually cause delayed recovery of pulmonary
empyema, lung cancer and bronchiectasis2. Lobectomy
function1. Patient may restrict chest wall motion to
is done under general anesthesia via posterolateral
avoid pain when moving and deep breathing1. Patient
thoracotomy incision2. In early post operative phase
also may resist maximal inspiratory effort when
,anesthesia, pain and stress of surgery have adverse
coughing. Patients after thoracic surgery go through
higher risk of pulmonary complications1 in immediate
Corresponding author: postoperative period, which is the most vulnerable
Mohammad Qasim period. Prolonged recumbency and immobilization
Physiotherapist
foster unfavorable drainage condition in dependent
Northern Area Armed forces Hospital
lung segment and set alveolar collapse3, 4.
KKMC, Hafer Al Baten - 31991
KSA Early mobilization can reduce the incidence of post
E-mail: mohd_qasim786@yahoo.com operative pulmonary complications 1 which are
mob- 00966532934820

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 93

developed in patients after surgery. Physiotherapy had were matched according to the Inclusion and Exclusion
been advocated as an important component in the criteria and then randomly Assigned on the basis of
prevention of postoperative pulmonary complications alternate patient into Group A and Group B, each
(postoperative hypoxia, atelectasis, pneumonia, acute consisting of 15 subjects.
pneumonitis) 4 following surgery. Conventional
postoperative physiotherapy5 consists of bronchial Inclusion criteria
hygiene techniques breathing exercises and 1. Patients have undergone elective Lobectomy1.
ambulation/mobilization practice. Positioning also has
beneficial effect in critically ill and post surgical 2. Age group: 18 to 45.
patients. Attainment of erect position reduces ill effects
of supine position after surgery and enhances oxygen 3. Stable haemodynamic
transport by enhancing the ventilation and perfusion 4. Patient should be extubated after 2 hrs of surgery
and by regulating body fluid 6.
Exclusion criteria
Mobilization possibly increases depth of inspiration
causing alveolar inflation thus resolving micro 1. Drowsy or not fully conscious1
atelectasis. There are few studies that support standing
2. Any orthopedic, neurological or musculoskeletal
posture and they found that FRC was greatest in
problem.
standing position which offsets hazards of early airway
closure and result in substantial improvement in V/Q 3. Uncooperative patient.
matching9 and reduces the incidence of postoperative
pulmonary complication. After the surgery, retention Withdrawal criteria
of secretions lead to hypoxemia and V/Q mismatching
1. Development of any of the exclusion criteria.
and can cause variation in ABG values of the patient7,8.
Various studies have been documented with cardiac 2. Haemodynamic instability.
Surgery, where the patients had been successfully
mobilized as early as 24-36 hours after surgery 10,11,12,13 3. Need for intubation
and this was found to offset the ill effects of
4. Change in heart rate more than 20 beats/min
immobilization. The effects of early mobilization on
during the intervention.
postoperative recovery are being increasingly
investigated in other surgical groups but remain under
STUDY DESIGN
investigation in patients following thoracic surgery15,16.
Literature is available in support of the benefits of early This study was designed as prospective
mobilization as a therapy and is considered an randomized controlled study to test the hypothesis that
important aspect in postoperative care protocol17,18,19,20. the early mobilization combined with the CPT after 4
Haemodynamic variables can be used as the predictor hours of Lobectomy is safe approach and will have
for safety of the patient for early mobilization which an effect on ABG , PFT and haemodynamic than after
helps to prevent the patient from the detrimental effect 24 hours of lobectomy.
of immobilization after the surgery1.
Variables
MATERIAL AND METHOD
Dependent variables
Sample
ABG, PFT. Haemodynamic (HR, SBP,)
A total number of 30 samples were selected for the
Independent variables
study on the basis of inclusion and exclusion Criteria.
All the patients had undergone Lobectomy. Timing of Mobilization and conventional
physiotherapy treatment
Space and location
Procedure
All the patients were recruited from DEPTT. OF
THORACIC SURGERY, L.R.S. INSTT. OF T.B. and All the patients were selected on the basis of
RESPIRATORY DISEASE New Delhi. The patients inclusion criteria. The patients were informed in details

18. Mohd Qasim--92--.pmd 93 11/1/2014, 12:17 AM

 94 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
about the type and nature of study. Patients were
requested to sign the consent form as per the hospital
requirement. A complete assessment was done for each
patient according to Performa, patients selected for the
study were assigned into two groups (Group A and
B). Group A consisted of early mobilization combined
with CPT after 4 hours of lobectomy and group B
consisted of mobilization combined with CPT after 24
hrs of lobectomy.
Group A
Heart rate, blood pressure, respiratory rate, ABG
values were noted before intervention Then the
intervention to group A was given after 4 hours of
surgery .the patient made to sit with Propped Up bed
at around 60 degree for 20 minutes. Then patient is
made to sit in high sitting position on the bed , HR
and BP is observed during this position for any
abnormal fall or increase , then patient is made to stand
on the side of the bed for two minutes and at the end
of two minute post intervention measurement of HR
and BP is taken. Again patient comes in sitting position
(semi fowler position) on bed and the conventional
physiotherapy treatment was given. The
physiotherapy treatment include, Incentive spirometry
10 times 2 sets with1 min break in between two sets,
Chest expansion exercise 10 times 2 sets with arm
elevation up to pain limits with 1 min gap in between,
Diaphragmatic breathing 5 times after rest period of
every set of chest expansion exercise. and then 2-3
huffs for clearance of secretions. The value of PFT was
taken before surgery and at 10th session after the
lobectomy.
Group B
Heart rate, blood pressure, respiratory rate, ABG
values were noted before intervention Then the
intervention given to group B after 24 hours of surgery
.The protocol was same as mentioned above for the
group A. The PFT values were taken before surgery
and at the 11th day after surg
RESULTS
There were thirty patients included in this study
meeting the inclusion criteria. there were two groups
(A and B) containing fifteen subjects in each of them.
The effects of the intervention were seen on PH, PaO2,
PaCO2, SaO2, FEV1, FVC, FEV1/FVC, HR and SBP.
18. Mohd Qasim--92--.pmd 94
Table .1: demographic data of both the groups
Group Mean age Mean weight Mean height Mean BMI
Group A 30.67 52.67 1.63 19.71
Group B 35.53 53.87 1.65 19.56
ABG
There were no statistical significant changes seen
between the two groups in pH( p=0.191) PaO2 (p=0.906
), PaCO2(p=0.420 ) and SaO2(p=0.554) after the
intervention. The probable reason for this could be
increased amount accumulated secretions and
incisional pain. Although it was not a variable in
present study but Incision and anesthesia affects the
normal mechanics of inspiration and may deter the
patient from taking deep breaths. Secretions cause
decrease in V/Q matching there fore between group
significant changes are not seen.
PFT
There were no statistical significant changes seen
in FEV1 (p=0.288), FVC(p=0.406 ) and FEV1/FVC(
p=0.677 ) between the groups. The probable reason of
this could be because the patients had undergone the
similar surgical procedure (for all the patients only a
single lobe was resected), equal amount of reduction
in the lung volume, incisional pain or inability to blow
air forces fully. This can lead to decrease in PFT values
for both the groups and the difference not being
significant.
HR
There were no significant changes seen in HR
(p=0.851) between the groups. The probable reason of
this could be, equal amount of work load was applied
for all the patients in both the groups. Changes in heart
rate were within the safe limits (20 beats/min)
although these changes were not statistical significant
but clinically significant and no matter rehabilitation
started at 4th hour or 24th hour there are not much
changes in heart rate and it is safe for the patients to
be mobilize 4 hours after surgery.
SBP
There were no statistical significant changes seen
in SBP (p= 0.376) between the groups, though the SBP
was raised in both groups probably it may be because
of change in position and mobilization after surgery
and the demand imposed on heart, therefore blood
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 95
pressure may rise in both the groups. The extent of
mobilization and conventional physiotherapy
treatment were same in both groups but the time after
surgery when they were started differed, therefore
changes were seen in groups with insignificant
difference between groups. Although these changes
are not statistical significant but clinically significant
and no matter rehabilitation started after 4th hour or
24th hour there are not much changes seen in SBP.
In present study we did not find any significant
changes in haemodynamics, ABG and PFT values, but
the patients in group A had better recovery. The
patients of group A developed more confidence and
had better recovery than patients of group B it may be
assumed that the changes could be seen on other
variables which were not included in this study.
Clinical Relevance
The result of this study will help therapists working
in the Intensive Care Unit to render safer and evidence
based early mobilization with conventional
physiotherapy following thoracic surgeries. It may be
able to help therapists in establishing effects of early
mobilization and help for better recovery and
confidence level in patients.
Limitation of Study
1. The sample size was small.
2. The study was not confined to the surgery of
particular lobe.
3. Patients were included only on the basis of
lobectomy irrespective of the primary cause of it.
CONCLUSION
The results of the present study show that when
the hemodynamics, ABG and PFT variables of the post
lobectomy patients are compared after 4 hours and
after 24 hours of mobilization after surgery , the
changes are not significant. So we conclude that there
are no effects of early mobilization, but it is a safe
approach to start early rehabilitation after 4 hours of
lobectomy
ACKNOWLEDGEMENT
I mohammad qasim declare that the manuscript is
being offered to the IJP alone, and
18. Mohd Qasim--92--.pmd 95
Does not duplicate work that has been or will be
published elsewhere.
I also acknowledge that my work is truly genuine
under the guidance of two prestigious guides, who
were guiding me throughout my research, and there
is no any part taken or copied from elsewhere.
Conflict of Interest: I declare no conflict of interest in
my study “Effects of Early Mobilization Combined
with Conventional Physiotherapy Treatment After
4 Hrs of Lobectomy on Haemodynamics, ABG and
PFT”.
Source of Fundings: All the research is funded by the
research student , but the test like arterial blood gas
analysis, Pulmonary function tests are done in the
hospital after permission from the research committee
without any cost.
REFERNCES
1. Hiroyuki Kenada,Yukihito Saito, Early Post
Operative Mobilization With Walking At 4 Hours
After Lobectomy Gen Thorc Cardiovasc surg .
2007(55);493-98.
2. Robert M Janes the CMA journal , june 1938 ;
538-44
3. T.J. Locke, T.L.Griffith . Rib cage mechanics after
median sternotomy.thorax.1990;45:465-68
4. Sheldon R, Marvin L.B. pre and post operative
pulmonary function amnormalities in coronary
artery revascularization surgery. Chest
1978;3:316-20.
5. Sandra Howell .Chest operative physical therapy
procedure in open heart surgery. Physical
therapy. 1978; 58(10):1205-14
6. Donna F, Elizabeth D. Principles and practice of
cardio pulmonary physicl therapy 1993;third
edition:302-03
7. David C.Waritier. Pulmonary atelectasis.
Anesthesiology.2005;102:838-54
8. Bondixen H.H , Hedley W, impaired oxygenation
in surgical patients during general Anesthesia
with controlled ventilation. N. Engl. J.Med.
1963;269-96
9. K.G. Ninsen, K. Holte and K.Kehlet, Effects of
posture on postoperative Pulmonary function,
ACTA Anesthesial Scand 2003,47;1270-75.
10. Joanne L, Martina M. Rapid recovery
management; the effects on patient who Has
11/1/2014, 12:17 AM
 96 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

undergone heart surgery, heart and 16. Alexendra Hough. Physiological basis of Clinical
lung(1997)26;289-98. Practice. In. Alexendra Hough(ed).
11. Eivind Ovrum, Geir T, Rapid recovery protocol Physiotherapy in Respiratory Care: An Evidence
applied to 5,658 consecutive “ON PUMP” CBP. based Approach to Respiratory and Cardiac
Ann. Thorac. Surg(2000)70;2008-12. Management (3rd edn). Nelson Thornes Ltd, U.K.;
12. Waliji S Peterson R.J Ultra fast track hospital 2001
discharge using conventional Cardiac surgical 17. Jo Ann Brooks. Postoperative atelectasis and
technique. Ann. Thorac.Surg.(1999)67;363-71. pneumonia . Heart Lung.1995;24:94-175.
13. A Richard, Dan EG Rapid recovery after bypass 18. O’Donohve . Postoprative pulmonary
grafting in elderly patient Eligible ? Ann. complications when are preventive and
Thorac.Surg(1997)63;634-39. therapeutic measures necessary.Post
14. Tom J. Ocerend, Catherne M. Anderson, S. grad.Med.1992;91:167-75
Debora Lucy. Bhatia, Birgitta I.Jonsson and 19. Pierson D.J ,Bramon .R.D. Professor round in
Catherne Timmermans. The Effect of Incentive respiratory care. prevention of post operative
Spirometery on Post Operative Pulmonary atelectasis and pneumonia. Resp.Care1992
Complications. A Systemic Review. Chest.2001; nov;17:122-34
120:971-978 20. Mzrtin L.F, Asher E.F.Post operative pneumonia
15. Susan C Jenkins, S.A.Soutar, J.M. Loukota, L.C. determinants of mortality.
Johnson, and John Moxham. A Comparison of Ach.Surg.1984;119:379-83
Breathing exercises , Incentive Spirometry and
Mobilization After Coronary Artery Surgery.
Physiotherapy Theory and Practice. 1990;
6:117-126

18. Mohd Qasim--92--.pmd 96 11/1/2014, 12:17 AM

 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 97

Comparison of Active Cycle of Breathing and High-

Frequency Oscillation Jacket in Bronchiectasis Patient

Manish P Shukla1, Vaibhav M Kapre2

Assistant Professor, MPT, 2Associate Proferror, MGM Institute of Physiotherapy, Aurangabad
1

ABSTRACT

Background: The efficacy of a new airway clearance device (High-Frequency Oscillation jacket) has
not been previously investigated. Active cycle of breathing techniques (ACBT) is the standard airway
clearance technique used in patients with bronchiectasis.

Objective: The objective of this study was to compare the efficacy of ACBT with High-Frequency
Oscillation as methods of airway clearance in adults with stable, productive bronchiectasis

Method: All thirty patients (17 males), age 46 ± 10 years (mean ± SD) completed the study. The
signi?cant differences were found between baseline measures of lung function- FVC (3.10 ± 0.391) &
after the treatment (3.19 ± 0.400), FEV1 (2.94 ± 0.489) & after the treatment (3.00 ± 0.484), FEV1/FVC
(94.5 ± 3.21) & after the treatment (96.1 ±3.10) in ACBT group. But in High-Frequency Oscillation
jacket the signi?cant differences were found between baseline measures of lung function- FVC (3.15
± 0.276) & after the treatment (2.92 ± 0.462), FEV1 (2.95 ± 0.455) But there is no significant difference
was found between SPO2 or breathlessness score between study days indicating that patients were
stable.

Results: Signi?cant differences were found between weight of sputum expectorated with ACBT
treatment and weight of sputum expectorated with High-Frequency Oscillation jacket treatment -
mean difference 2.16 g (95% CI -2.94 to 5.46). The extremely signi?cant differences were found between
baseline measures of lung function (FVC, FEV1, FEV1/FVC) between the group.

Conclusion: ACBT is as effective a method of airway clearance as High-Frequency Oscillation jacket.

It was found to be the preferred method of airway clearance and provides a technique that can be
administered independently.

Keywords: Bronchiectasis, Airway Clearance Technique, Active Cycle of Breathing Techniques,

High-Frequency Oscillation Jacket

INTRODUCTION bronchiectasis. A number of other adjuncts are also

Bronchiectasis is characterized by repeated
pulmonary infections requiring antibiotics, disabling
productive cough, shortness of breath and occasional
haemoptysis. 1 Impaired clearance of sputum results
in a vicious cycle of colonization and infection of
bronchi with pathogenic organisms, dilation of bronchi
and further production of sputum. 1, 2 Airway
clearance techniques (ACTs) are an important
component of the management of patients with
available for airway clearance (for example, positive
expiratory pressure and Flutter, high-frequency
external chest compression); however, there is limited
evidence of their effectiveness in bronchiectasis.
Hayek External High-Frequency Oscillator is a
device for administering negative pressure ventilation
across the chest wall, which has been shown to be an
advantageous mode of Ventilatory support during
anesthesia, 3 acute respiratory failures in adults on

19. Manish Shukla--97--.pmd 97 11/1/2014, 12:17 AM

 98 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
intensive care, 4 and in severe chronic obstructive
pulmonary disease. 5 An increase in pulmonary blood
ûow, coronary blood ûow, and cardiac output were
also reported. 6,7 Therefore, the purpose of this study
was to compare the efficacy of Hayek External High-
Frequency Oscillator jacket with ACBT in adults with
stable, productive bronchiectasis and to determine
patient preference between the two techniques.
MATERIALS AND METHOD
Study Subjects
Twenty adult patients with stable (change of not
greater than FEV1 10% predicted), productive
(history of expectoration of half an egg cup sputum/
day) bronchiectasis (diagnosis by CT scan) were
recruited from a specialist respiratory clinic at the
MGM Hospital Aurangabad. Written informed
consent was obtained from all participants. The study
was approved by the local ethics committee. The Ethics
Committee of the MGM, Medical Research Council
Institute, Aurangabad approved the study, and full
informed written consent was obtained. Subjects were
familiarized with the functioning of the Hayek
Oscillator and the HFCC.
ACBT
ACBT was performed in the two predetermined
postural drainage positions. The components of ACBT
included breathing control, thoracic expansion
exercises (percussion and/or vibration was added) and
forced expiration (huff) in a set cycle. 8
Hayek Oscillator 1000
The Hayek Oscillator 1000 Cuirass TM (Flexico
Medical InstrumentsAG,Zu ¨rich, Switzerland) is a
ûexible, lightweight, clear plastic shell, which covers
the anterior chest wall and upper abdomen. A
diaphragmatic pump inside the unit operates over a
wide range of frequencies to generate an oscillating
pressure, which is transmitted to the chamber between
the chest wall and shell, enabling ventilation. Both the
inspiratory and expiratory phases are active, with set
modes and operator-set with automatic adjustments.
The chest is oscillated around a mean negative-
pressure baseline. One of the preset modes is called
‘‘secretion mode,’’ which delivers a period of high
frequency/low-amplitude chest wall oscillation (T1),
followed by a period of high-span oscillation at low
frequency with a shortened expiratory ratio (T2). T1
lasts or 3 min, inspiratory : expiratory ratio (I:E) 1:1,
19. Manish Shukla--97--.pmd 98
operating 600 cycles per minute (CPM), with
inspiratory values of -12 cmH2O to expiratory values
of +6cmH2O. T2, with I:E - 5:1, has a frequency of 60
CPM ranging inspiratory pressures of-24 cmH2Oto
expiratory pressure of +12 cm H2O. T2 is set at 3 min;
however, in piloting the secretion mode, 3 min was
not tolerated, and we reduced this phase to 2 min
MEASUREMENTS
An independent, blinded observer measured the
weight of wet sputum produced during each
treatment, including 15 min immediately following
treatment, and sputum produced over a 24-hr period,
excluding treatment times. Recordings of forced vital
capacity (FVC) and forced expiratory volume in 1 sec
(FEV1) were taken immediately before, immediately
following, and at 10 min after the end of treatment
(MicroLoop II Spirometer, Micro Medical Ltd., UK).
The spirometer was calibrated with a 1-liter syringe
before each study, and measurements were made in
accordance with American Thoracic Society standards.
9
During all treatment sessions, arterial oxygen
saturation and heart rate were continuously recorded
(Nellcor Oximeter). Blood pressure measurements
were taken immediately before, every 10 min during,
and immediately following treatments (Dynamap). All
subjects completed a ûve point, ûve item questionnaire
for each treatment mode. They were asked to rate the
treatment mode for 1) ease of technique; 2) comfort; 3)
secretion clearance; 4) Breathlessness
Statistical Analysis
Statistical analyses were performed using the
Statistical Package for the Social Sciences (SPSS version
16.0). The students paired t test was used to compare
pre- and post-treatment outcome measures within
each group & unpaired paired t test was used to
compare the outcome measure between each group.
A p value of <0.05 was considered statistically
signiûcant.
RESULTS
All thirty patients (17 males), age 46 ± 10 years
(mean ± SD) completed the study. The signiûcant
differences were found between baseline measures of
lung function (FVC, FEV1, FEV1/FVC). But there is no
significant difference was found between SPO2 or
breathlessness score between study days indicating
that patients were stable.
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 99
The signiûcant differences were found between
weight of sputum expectorated in ACBT treatment or
High-Frequency Oscillation jacket treatment – mean
difference 2.16 g (95% CI –2.94 to 5.46)
There were signiûcant differences between pre- and
post-treatment measures of lung function (FVC, FEV1,
FEV1/FVC) in ACBT group & in High-Frequency
Oscillation jacket (FVC, FEV1). There was signiûcant
change in pulmonary function at any time following
ACBT when compared with the High-Frequency
Oscillation jacket.
DISCUSSION
The present study aimed to compare the ACBT &
High-Frequency Oscillation jacket in bronchiectasis
patient. This study demonstrates that the ACBT is as
effective a method of airway clearance as High-
Frequency Oscillation jacket in patients with
bronchiectasis during single treatment sessions. The
efûcacy of High-Frequency Oscillation jacket has not
been previously investigated, and therefore, this study
was conducted in the form of a single-session crossover
trial.
ACBT is the standard ACT used in patients with
bronchiectasis. A single intervention study
demonstrated ACBT to be more effective than an
inspiratory muscle training technique advocated as an
ACT in patients with bronchiectasis.10 A randomized
controlled trial compared the efûcacy of ACBT with
Flutter in 17 patients, for 4 weeks of each technique in
a crossover design. No signiûcant differences were
found in daily sputum weight produced between
treatment.11
This study showed that patients at the start of
treatment for a pulmonary exacerbation in
bronchiectasis were able acutely to clear more sputum
Table-1: Group Comparison Pre and post training for FVC
Group FVC N Mean
ACBT Pre 15 3.10
Post 15 3.19
HFCC Pre 15 3.15
Post 15 3.22
Table-2: Group Comparison between ACBT & High-Frequency Oscillation jacket for FVC
Group (Change in FVC) N Mean
ACBT 15 -9.00
HFCC 15 -4.033
19. Manish Shukla--97--.pmd 99
with ACBT than with HFCC by Hayek Cuirass. On
each study day, baseline measurements of pulmonary
function were comparable. Following chest
physiotherapy using ACBT, a signiûcant improvement
in pulmonary function was seen, whereas there was
no change in pulmonary function following HFCC
treatment by Hayek Cuirass. Furthermore, the weight
of expecto-rated sputum was greater with sessions of
ACBT than with HFCC. It is unsurprising that 24-hr
sputum weights were similar on both days because
those patients, in whom it was clinically indicated,
underwent an additional evening ACBT treatment
session on HFCC treatment days. Following chest
physiotherapy using ACBT, a signiûcant improvement
in pulmonary function (FVC, FEV1, FEV1/FVC) was
seen, whereas there was a significant improvement in
pulmonary function (FVC, FEV1) following High-
Frequency Oscillation jacket treatment but there is no
change in FEV1/FVC following HFCC. Furthermore,
the weight of expectorated sputum was greater with
sessions of ACBT than with High-Frequency
Oscillation jacket.
Although we have speculated on why sputum may
be cleared less efûciently with the Hayek for HFCC in
bronchiectasis patient, whatever the true mechanism,
it is clear that the Hayek is not as effective a method of
acute secretion clearance as ACBT in patients with
bronchiectasis during an infective exacerbation. Our
study ûndings conûict with previous reports
comparing HFCC and secretion clearance, But direct
comparisons are difûcult to make.
In conclusion, this single intervention study
indicates that ACBT is as effective a method of airway
clearance as High-Frequency Oscillation jacket. It was
found to be the preferred method of airway clearance
and provides a technique that can be administered
independently.
SD t-value p-value
0.391 -11.0 0.0001 (Extremely Statistically sign.)
0.400
0.276 -5.80 0.0001 (Extremely Statistically sign.)
0.296
SD t-value p-value 95% CI
3.162 3.618 0.012 (Statistically Very Sign.) -7.77846 to -2.15554
4.273
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 100 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Table-3: Group Comparison Pre and post training for FEV1

Group FEV1 N Mean SD t-value p-value

ACBT Pre 15 2.94 0.489 -8.14 0.0001 (Extremely Statistically sign.)
Post 15 3.00 0.484
HFCC Pre 15 2.92 0.462 -7.00 0.0001 (Extremely Statistically sign.)
Post 15 2.95 0.455

Table-4: Group Comparison between ACBT & High-Frequency Oscillation jacket for FEV1

Group (Change in FEV1) N Mean SD t-value p-value 95% CI

ACBT 15 -6.00 2.854 2.945 0.0064 (Statistically Very Sign.) -4.40812 to -0.79188
HFCC 15 -3.400 1.882

Table-5: Group Comparison Pre and post training for FEV1/FVC

Group FEV1/FVC N Mean SD t-value p-value

ACBT Pre 15 94.5 3.21 -9.19 0.0001 (Extremely Statistically sign.)
Post 15 96.1 3.10
HFCC Pre 15 94.5 3.21 -0.217 0.8313 (Not statistically sign)
Post 15 94.5 2.95

Table-6: Group Comparison between ACBT & High-Frequency Oscillation jacket for FEV1/FVC

Group (Change in FEV1/FVC) N Mean SD t-value p-value 95% CI

ACBT 15 -1.58 0.666 14.4474 0.0001 (Extremely 4.36575 to 5.80825
Statistically sign.)
HFCC 15 -6.667 1.19

Acknowledgment: We thank our patients for their REFERENCES

continued support in our research endeavors.
Source of Funding: self
Conflict of Interest Statement: A recent consensus
statement describes airway clearance techniques as a
cornerstone of management for adults with
Bronchiectasis. A large proportion of time as a
respiratory physiotherapist is spent teaching,
assessing, encouraging and physically administering
various airway clearance techniques. Unfortunately,
airway clearance is generally the component of
treatment least favoured by those with Bronchiectasis
and the most likely to be neglected. The purpose of
this study was to compare the efficacy of Hayek
External High-Frequency Oscillator jacket with ACBT
in adults with stable, productive bronchiectasis and
to determine patient preference between the two
techniques.
Ethical Clearance: The study was approved by the
local ethics committee. The Ethics Committee of the
MGM, Medical Research Council Institute,
Aurangabad approved the study.
1. Barker A: Medical progress bronchiectasis. N
Engl J Med 2002; 346: 1383–1393.
2. Cole PJ: Inû ammation: A two-edged sword. The
model of bronchiectasis. Eur J Respir Dis. Suppl
1986;147:6–14.
3. Monkes PS, Broomhead CJ, Dilkes MG, Mckelvie
P. The use of the Hayek oscillator during
microlaryngeal surgery. Anaesthesia
1995;50:865–869.
4. Al-Saady NM, Fernando SSD, Singer M, Bennett
ED. External high frequency oscillation can
replace intermittent positive pressure ventilation
in patients with acute respiratory failure.
Intensive Care Med [Suppl] 1992;18:54.
5. Biox JH, Tejeda M, Alvarez F, Bataller A.
Comparison of nasal positive pressure ventilation
to external high frequency oscillatory ventilation
in COPD. Respir Care 1996;41:187–190.
6. Penny DJ, Hayek Z, Rawle ML, Rigby ML,
Redington AN. Ventilation with external high
frequency oscillation around a negative pressure
baseline increases pulmonary blood ûow after

19. Manish Shukla--97--.pmd 100 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 101
Fontan operation. Cardiol Young 1992;2:
277–280.
7. Smithline HA, Rivers EP, Rady MY, Blake HC,
Nowak RM. Biphasic extrathoracic pressure CPR.
A human pilot study. Chest 1994;105:842.
8. Pryor J, Webber B, Hodson M, Batten J:
Evaluation of the forced expiration technique as
an adjunct to postural drainage in treatment of
cystic ûbrosis. Br Med J 1979;2: 417–418.
9. American Thoracic Society. Standardization of
spirometry, 1994 update. Am J Respir Crit Care
Med 1995;152:1107–1113.
19. Manish Shukla--97--.pmd 101
10. Patterson JE, Bradley JM, Elborn JS: Airway
clearance in bronchiectasis: A randomised
crossover trial of active cycle of breathing
techniques [incorporating postural drainage (PD)
and vibration] versus test of incremental
respiratory endurance (TIRE). Chronic Resp Dis
2004;1:127–130.
11. Thompson C, Harrison S, Ashley J, Day K, Smith
D: Randomised crossover study of the Flutter
device and the active cycle of breathing in non-
cystic ûbrosis bronchiectasis. Thorax 2002;57:
446–448.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
102 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Injury Management and Return-To-Play: Practices in

India

Nandakumar T R MPT1, Jaspal Singh Sandhu MS2

1
Ph.D scholar, Dean, Faculty of Sports Medicine and Physiotherapy, Guru Nanak Dev University, Amritsar, India
2

ABSTRACT

Objective: To examine the injury management and return to play practices in India.

Methods: A sample consisted of 420 athletes and 110 coaches participated in the study. Information
was obtained from athletes and coaches through survey method. Two different questionnaires were
prepared for the athletes and coaches.

Results: A total of 420 athletes with mean age of 20.4±3.84 years and 110 coaches with the mean age
of 45.5±5.8 years participated in the study. The results showed that the athletes and coaches were
concerned more about the major injuries rather than the minor injuries. The minor injuries are managed
by the athletes themselves on the advice of the coaches, teammates and senior players. Also, there is
no standard procedure followed for return to play of players in India.

Conclusions: The study showed that there is no standardized and well established practice for injury
management and return to play practices in India.

Keywords: Awareness, Sports Physiotherapist, Indian Sport System, Relative Importance

INTRODUCTION on the other hand, refers to each athlete’s choice to

The development of elite athletes capable of
winning medals in international competitions is of high
national concern in many countries. Governments,
international federations, and national federations
have long been concerned about formulating policies
that will promote the development of sport 4. The
concern to enhance sport participation has been
supported by three key legitimations: (a) health
promotion (b) economic benefits of enhanced fitness
and (c) enlargement of the nation’s pool of athletes
who can be developed into international competitors.7
The concerns about the rate of sport participation are
linked by the endeavor to create a deep pool of athletes
from which elite competitors can develop.3 Sport
development is more closely related to at least three
key matters: athlete entrance, athlete retention, and
athlete advancement. Entrance refers to the ways in
which athletes are first introduced to sports. Retention,
continue to participate. An athletes retention in sport
is based on the motivation to continue in the sport.
Sport psychologists have identified a number of
significant motives for sport participation, including
exhilaration, social interaction, skill development, team
affiliation, and fitness 5. Conspicuously less significant
are such extrinsic rewards as winning and prizes.
Fitness of an athlete is mainly related to his injuries.
As sporting and physical activity participation
increase, the incidence of related injuries and illnesses
is likely to increase as a result. Although most sport
injuries are not life threatening, the occurrence of sport
injury can result in pain, disability, and/or dysfunction
in the short and long term. Injuries are a leading reason
people stop participating in physical activity.6 Players
who have been injured and return to competitive play
prematurely, face a heightened risk of further damage
and injury. The prospect of injury or incomplete

20. Nandakumar--102--.pmd 102 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 103
recovery from injury affects the ability to participate
in sport and recreational activities that would be
beneficial to health. The prevalence of injury could be
significantly reduced by means of scientific
management and through ensuring that players do not
resume participation prematurely. Injury reduction,
control, and prevention are important goals for
clinicians, athletes, and the active population.
In India, we often see that most of our players
frequently suffer from injuries and many promising
players suffer decreased performance. Most of the
young players at the grass root level do not reach the
elite level as they drop out of the sport completely due
to injuries, which affect the prospects of the country
in sports. The reason may range from inappropriate
management of injuries to premature return to sport.
Hence a need arises to analyse the pattern of injury
management and Return to Play practices in India.
METHODOLOGY
Ethical approval for this study was granted by the
Research Degree Committee, Guru Nanak Dev
University, Amritsar. A retrospective survey design
was used to examine the injury management and
Return to play (RTP) practices in Indian sports. This
study obtained information from the athletes and
Table 1 Demographic characteristics of athletes and coaches
Athletes (n=421) coaches (n=110)
Number
MaleFemale
Athletes: Initially, the athletes were asked to furnish
the history of injuries during their sporting career.
Among the 420 athletes, 126 suffered from major
injuries and 296 from minor injuries in their sporting
career. According this study, the criteria of major injury
is any injury which made the athlete to discontinue
the sport for one month and above. The athletes were
asked about the first line management of their injuries.
Among the 126 athletes who suffered major injuries, 4
athletes consult the coach initially, 56 athletes consult
the doctor or physiotherapist on the advice of the
coach, 62 athletes consult the doctor or physiotherapist
directly and 4 athletes consult their parents. Among
the 126 athletes, 42 had undergone surgery and 84 had
conservative management. The athletes were asked to
furnish the details of post operative rehabilitation of
20. Nandakumar--102--.pmd 103
coaches . The sample consisted of 420 athletes of
International and national level 110 coaches (table 1).
The athletes and coaches interviewed were from the
following sports disciplines: athletics, badminton,
boxing, basketball, football, hockey, judo, squash,
swimming, table tennis, volleyball, wrestling and
weight lifting. These sports disciplines falls under
‘priority’ category, a dynamic criteria for
categorization of sports disciplines which was based
on the performance of India in recognized international
events like Olympic, Asian, Commonwealth Games
etc.8
Information was obtained from athletes and
coaches through survey method. Two different
questionnaires were prepared for the athletes and
coaches. Questionnaire development included
examination of content validity. The questionnaires
were reviewed by six content experts including a
sports physiotherapist, orthopedic surgeon,
biostatistician, market research specialist, psychologist
and coach. A pilot study was conducted to determine
the reliability and validity of the questionnaires.
RESULTS
A total of 420 athletes with mean age of 20.4±3.84
years and 110 coaches with the mean age of 45.5±5.8
years participated in the study (table 1).
Mean±SD Number Mean±SD
32398 20.5±4.1320.2±2.97 1028 41±4.545.8±5.7
their injuries. Among the 42 athletes who had the
surgery, 6 athletes had simple exercises taught by the
surgeon and 36 athletes followed the rehabilitation
protocols given by physiotherapist. Among the
athletes who had conservative treatment, 9 athletes
had treatment as suggested by friends or others and
73athletes had treatment given by the by the
physiotherapist.
Incomplete recovery and a premature return to play
remains a major contributor to injury in this sport. On
examining the return to sport issue, 2 athletes return
to sport based on the advice of their teammates, 2
athletes based on the suggestions of their parents, 21
athletes by coaches, 25 athletes started playing based
on the fitness test of the physiotherapist, 69 athletes
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 104 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
took their own decision independently. Injury
recurrence is the main concern after the athlete returns
to sport. It was found that 42 athletes consult or took
advice against the recurrence of their injuries. Among
the 42 athletes, 3 athletes consulted their teammates,
18 athletes to the coaches, 9 athletes to the doctor or
physiotherapist.
On the management of minor injuries, 202 athletes
leave the injuries as such without any treatment, 95
athletes took painkillers by themselves, 95 athletes
consult the doctor or physiotherapist and 55 athletes
does the management as suggested by the coach.
Coaches: The coaches were asked about the criteria
that they followed to allow the players to play the
sports again after the injury. 2 coaches allowed the
players based on their feedback, 22 coaches on their
own discretion, 44 coaches based on the opinion of
the surgeon who operated the athlete, 12 coaches based
on the fitness test done by the physiotherapist and 22
coaches said their players do not suffer from any injury.
On the management of minor injury of their athletes,
49 coaches advice their athletes to take rest, 28 coaches
advice them to apply pain killer ointments/ sprays
and 32 coaches advice them to consult the doctor or
physiotherapist.
DISCUSSION
This evaluation of injury management practices in
India found that the athletes and coaches were
concerned more about the major injuries rather than
the minor injuries. The minor injuries are managed by
the athletes themselves on the advice of the coaches,
teammates and senior players. They approach the
doctor or physiotherapist only when their
management does not provide any relief or the injury
aggravates. It was found during the course of research
that majority of the athletes consult the doctor or
physiotherapist recommended by their coaches
without paying much importance to their
specialization and expertise in the field. The coaches
exert their influence over the athletes to the extent that
they decide the severity of any injury that require
medical attention or even decide the fitness of the
athletes to return to play after the injury. Thus the
coach in India doubles as a physiotherapist, trainer,
nutritionist and psychologist for the athlete.
In addition, the non availability of services of sports
physiotherapist is a major reason for the low utilization
of sports physiotherapy. The sports medicine centres
20. Nandakumar--102--.pmd 104
of SAI are located in the regional and sub centres
provide treatment to the athletes. The athletes of these
cities and nearby places utilize the facilities in these
centres and undergo free treatment for their injuries.
The players of other places do not have access to such
facilities and had to visit private clinics for specialized
care and bear the expenses or visit the nearby
government hospitals which do not have a specialized
sports medicine centre. Even the SAI centre in Chennai
do not have Sports medicine centre. The athletes had
to undergo treatment either in the nearby government
hospital or in private physiotherapy clinics. Treatment
under a specialist physiotherapist in private clinics is
perceived expensive and only few players could afford
it. Also, it was found that the players give priority to
nutrition and purchase of sports equipments rather
than the treatment under a specialist. Taking the
financial background of the athlete into consideration,
the coaches refer them to the nearby government
hospitals for the treatment, overlooking the importance
of specialized care.
Another important finding of this study is that there
is no standard procedure followed for Return to play
of players in India. Incomplete recovery and a
premature return to play remains a major contributor
to injury in this sport. Ideally, an athlete’s return to
play is contingent on the athlete passing a ‘fitness test’.
These tests of course have less to do with an athlete’s
physiological status, and more to do with their ability
to participate following illness or injury, but they do
imply some form of pass/fail assessment. An expert
panel of ACSM, 2002, states that, the goal of return-to-
play (RTP) deliberations is to return an injured or ill
athlete to practice or competition without putting the
individual or others at undue risk for injury or illness.
Evaluations for RTP should seek to confirm anatomical
and functional healing, recovery from acute illness and
its sequelae, or the status of chronic injury or illness.
There is a need to establish that there is no risk to the
safety of other participants that the athlete’s sport
specific skills are restored, and that the athlete is
psychosocially ready to return. A medical care team
may also need to establish that the athlete is able to
perform with equipment modification, braces, or
strapping, and that these comply with the laws and
regulations of the sport 1. Macauley8 has recently
suggested that the increasing commercialisation of
sport may result in increasing pressure on doctors to
treat or rehabilitate players in a manner that they find
unacceptable, or to allow a player to return to play
sooner than the doctor may wish
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 105
Beardmore et al2 in their research on RTP practices
in New Zealand found that most subjects considered
the opinions of the physiotherapists and medical
personnel, ranked first and second, respectively, to be
the most important criteria for deciding readiness for
a return to play. In India, there is no standardized and
well established procedure followed for Return to play.
Most of the subjects report that athletes themselves or
coaches determine the readiness of the player to return
to play. Full recovery was not always considered
necessary before a player was cleared to
return to training or competition. This practice
aggravates the injury and frequently results from
discontinuing the sport by the athlete.
The results of the study shows a serious lacunae in
the sports sciences set up in the country. The Ministry
of sports had set up expert committee in 2011 to look
at the gaps in the existing Sports Science set up in SAI
as well as the requirements in the sports sector as a
whole, to enhance performance of our sportspersons
and support excellence in sports (as part of National
Sports Policy) along with suggestion of measures to
address them. The committee proposed to set up a
National Institute of Sports Science and Medicine
(NISSM) at the Jawahar Lal Nehru Stadium Complex,
New Delhi11. The setting up of the institute along with
qualified sports scientists might become a significant
milestone in the development of sports sciences in
India.
CONCLUSION
The success of a nation depends on creation of a
deep pool of athletes and then to develop a percentage
of them into high caliber performers. The poor injury
management and return to play practices in India
produce an atmosphere of increased drop outs from
sport.
Acknowledgement: We gratefully acknowledge all the
players and coaches who enthusiastically participated
in the research.
Ethical Clearance: Ethical approval for this study was
granted by the Research Degree Committee, Guru
Nanak Dev University, Amritsar.
20. Nandakumar--102--.pmd 105
Source of Funding : Nil
Conflict of Interest: Nil
REFERENCES
1. ACSM. ,(2002) The team physician and return-
to-play issues: a consensus statement. Medicine
and Science in Sports and Exercise, 34(7),
1212–1214.
2. Beardmore et al. (2005) Return-to-play after
injury: practices in New Zealand rugby union.
Physical Therapy in Sport ; 24–30
3. Broom, E.F. (1991) Lifestyles of aspiring high
performance athletes. Journal of Comparative
Physical Education and Sport, 13(2), 24-54.
4. Chalip, L. (1995) Policy analysis in sport
management. Journal of Sport Management, 9,
1-13.
5. Cox, R.H. (2002). Sport psychology: Concepts and
applications (5th ed.). Boston: McGraw- Hill.
6. Emery C A et al (2007).A Prevention Strategy to
Reduce the Incidence of Injury in High School
Basketball: A Cluster Randomized Controlled
Trial Clin J Sport Med 2007;17:17–24
7. Green, M., & Oakley, B. (2001). Elite sport
development systems and playing to win:
Uniformity and diversity in international
approaches. Leisure Studies, 20, 247-267.
8. Macauley D. (1997) Will money corrupt sports
medicine? Br J Sports Med;32:1
9. Ministry of Youth Affairs and Sports, Govt of
India National Sports Development Code of India
2011. Available from: http://yas.nic.in [Accessed
on March 2011]
10. Waddington et al (2001). Methods of
appointment and qualifications of club doctors
and physiotherapists in English professional
football: some problems and issues. Br J Sports
Med 2001 35: 48-53
11. Ministry of Youth Affairs and Sports, Govt of
India National Sports Development Code of India
2011. Available from: http://yas.nic.in [Accessed
on November 2012]
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
106 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effect of Music Intervention on Immediate Post Operative

Coronary Artery Bypass Graft Surgery (CABG) Patients

ShwetaS DevarePhadke1, HadiyaParkar2, SujataYardi3

1
Asst.Professor, M.P.T, 3Prof.&Director, Dept. of Physiotherapy,Pad Dr. D.Y. Patil University, 6th Floor,
2

Pad Dr. D.Y. Patil Medical College Bldg., Sector 5, Nerul, Navi Mumbai

ABSTRACT

Introduction: The Gold standard treatment for Coronary Artery Disease is Coronary Artery Bypass
Graft [CABG] surgery .Cardiac surgery can be considered a major stress.8The therapeutic effects of
music have been known . The most beneficial music for the health of a patient is classical music,
which holds an important role in music therapy.

Purpose: Of this study is to find out effect of instrumental music on post operative CABG patients in
phase 1 of cardiac rehabilitation .

Aim &Objectives: To study the effect of music on Vital parameters, RPE, incision pain using VAS
scale &DAS scale .

Method: 60 post operative CABG subjects (n=60) were randomly selected .After explaining about
the aims and objectives of the study, consent taken. Subjects were randomly divided into 2 groups;
comprising of 30 subjects each. Intervention group underwent the music sessions and regular
rehabilitation schedule, control group underwent just regular rehabilitation schedule. Outcome
measures like vital parameters, the score on VAS scale, the score on DAS scale, RPE on Modified
.Borg's scale. Were assessed before and after. 35 minutes of music was played via headphones for the
intervention group for 7 days. After 1 week of intervention, they were reassessed. The data was
analyzed using GraphPadInstat Version3.10, 32 for Windows. Within the group non parametric
Wilcoxon matched pairs test was used. Between the group non parametric Mann-Whitney test was
used.

Result: 1-week of regular music resulted in extreme statistically significant reduction in Pain, RPE
score, Respiratory rate. For DAS scale, anxiety and stress reduction were extremely significant. In
clinical practice, Music intervention can be incorporated as cost effective method. Further studies are
needed, to clarify dosage of music, and long term effects.

Keywords: CABG, Music therapy, Cardiac Rehabilitation

INTRODUCTION factors for developing atherosclerosis are smoking,

The modern lifestyle, adapted by all, has its both
pros and cons. All round the world modernization has
affected health in all possible ways, be it our eating
habits, long working hours or social life. The heart, a
mechanical pump has been affected by Coronary
Artery Disease, caused by atherosclerosis. 29 Risk
obesity, imbalanced diet (much fast food), stress,
depression and lack of exercise.4The Gold standard
treatment for Coronary Artery Disease is Coronary
Artery Bypass Graft [CABG] surgery.18Cardiac surgery
can be considered a major stress.8There is a basic fear
inherent in cardiac surgery.8 Cardiac rehabilitation is
done post CABG by multidisciplinary team .

21. Shwata phadke--106--.pmd 106 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 107
The therapeutic effects of music have been known
since the beginning of time. Music plays an important
role in our everyday lives. It can be exciting or calming,
joyful or poignant, can stir memories and powerfully
resonate with our feelings, helping us to express them
and to communicate with others.5 Sacks believed that
the power of music goes to the heart of being human.28
In 1990, Thaut proposed that music stimuli have
biological effects on human behaviour by engaging
specific brain functions involved in memory, learning,
and multiple motivational and emotional states. The
effects of music are seen in the right hemisphere of the
brain; however, the left hemisphere may play a major
role in the analytical aspects of cerebral interpretation
of the music. Auditory perception of music occurs in
the auditory centre of the temporal lobe of the brain,
which then signals the thalamus, midbrain, pons,
amygdala, medulla, and hypothalamus.33Music has
been used since ancient times to influence human
health.27 The most beneficial music for the health of a
patient is classical music, which holds an important
role in music therapy.11It is well known that soft
sounds have beneficial effects on patients while treated
in intensive care medicine and will reduce pain and
stress significantly.30 The tempo of the music is the
most important factor, slow and flowing music having
positive outcomes on relaxation and pain relief.31post
surgery patients need to be relaxed for faster and better
recovery.
METHODOLOGY
Research design: Randomized controlled trial
Sample size: 60(Immediate post operative CABG
patients)
Group 1 (intervention group) – 30
Group 2 (Control group) – 30
Materials used: Head phones, mobile phone,
instrumental music audio.
Inclusion criteria
• Immediate post operative stable CABG patients,
• Patients with no hearing problem/aids
21. Shwata phadke--106--.pmd 107
Exclusion criteria
1. Patients on ventilator for prolong period of time.
2. Patients with complications.
3. Patients with psychiatric disorder.
4. Patients with cognitive problems.
PROCEDURE
60 post operative CABG subjects (n=60) were
randomly selected for the study. Each subject was
explained about the aims and objectives of the study.
After taking the consent, the subjects were accordingly
allotted into 2 groups; comprising of 30 subjects each
(n=30 each) Group1 i.e. the intervention group
underwent the music sessions and exercise program
while the other group was the control group which
underwent just exercise program.
Following outcome measures were assessed before
each treatment sessions for both the groups.
• Heart rate
• Respiratory rate
• Blood pressure
• The score on VAS scale
• The score on DAS scale.
• RPE score on Modified .Borg’s scale.
35 minutes of music was played via headphones
for the intervention group for 7 days. After 1 week
of intervention, they were reassessed for the above
parameters.
Statistical analysis
The data was processed using two aspects
Descriptive statistics: For demographic data age,
the mean was considered.
Analytical statistics: For outcome measures data
were collected on standardised forms and encoded for
computerised analysis using GraphPadInstat
Version3.10, 32 for Windows. Within the group
Wilcoxon matched pairs test was used. Between the
group Mann-Whitney test was used.
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 108 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

RESULTS

Table 1. Nearly equal mean showing two samples homogeneous with respect to age & gender distribution.

Age Intervention Group Control Group

Mean 58.46 59.6
Standard Deviation 7.89 6.32
Male 24 20

Table 2. Comparison of vital parameters

Variables Interventiongroup Controlgroup

Pre Post Pre Post
Heart Rate Mean 78.66 68.46 79.06 72.13
Standard Deviation 7.14 4.41 6.77 5.35
Lower 95% Conf.limit 75.99 66.81 76.53 70.13
Upper 95% Conf. Limit 81.33 70.11 81.59 74.13
Respiratory Rate Mean 29.4 18.73 30.16 20.96
Standard Deviation 4.16 1.04 4.06 2.18
Lower 95% Conf.limit 27.84 18.34 28.64 20.14
Upper 95% Conf. Limit 30.95 19.12 31.68 21.78
Systolic Blood Pressure Mean 119.4 106.26 118.2 111
Standard Deviation 10.68 7.60 10.80 8.06
Lower 95% Conf.limit 115.41 103.43 114.17 107.99
Upper 95% Conf. Limit 123.39 109.11 122.23 114.01
Diastolic Blood Pressure Mean 75.46 66.33 74.8 70.2
Standard Deviation 10.85 6.60 10.35 7.43
Lower 95% Conf.limit 71.41 63.86 70.93 67.42
Upper 95% Conf.limit 79.51 68.79 78.66 72.97

Table 3. Comparison of VAS & RPE scores.

Interventiongroup Controlgroup
Pre Post Pre Post
Vas Score Mean 7.66 1.23 7.66 7.19
Standard Deviation 0.92 0.50 0.85 0.40
Lower 95% Conf.limit 7.28 1.04 7.31 1.75
Upper 95% Conf. Limit 7.98 1.42 7.95 2.05
Rpe Score Mean 12.46 7.06 12.33 7.86
Standard Deviation 1.38 0.36 1.32 1
Lower 95% Conf.limit 11.95 6.93 11.84 7.49
Upper 95% Conf. Limit 12.98 7.20 12.82 8.24

DISCUSSION The four central hypotheses explaining music’s

facilitation of exercise performance include
In the present randomized study, we found that 1-
week of regular music plus conventional treatment a. Reduction in the feeling of fatigue
resulted in extreme statistically significant reduction
in Pain ,RPE score, Respiratory rate whereas , there is b. Increase in levels of psychological arousal
significant change in heart rate and blood pressure
c. Physiological relaxation response
when compared with the conventional group. For
DAS scale, the depression score was not significant d. Improvement in motor coordination16
whereas anxiety and stress are extremely significant.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 109
Music effectively reduces anxiety and improves
mood in postoperative patients. The theoretical basis
for using music as an intervention for anxiety has to
do with its ability to promote relaxation through its
effect on the autonomic nervous system.6,18
Music reduces stress by
α. Physical relaxation Music can promote relaxation
of tense muscles, enabling you to easily release
some of the tension you carry from a stressful day.
β. Aids in stress relief activities Music can help you
get “into the zone” when practicing yoga, self
hypnosis or guided imagery, can help you feel
energized when exercising and recover after
exercising, help dissolve the stress when you’re
soaking in the tub.
χ. Reduces negative emotions Music especially
upbeat tunes, can take your mind off what stresses
you, and help you feel more optimistic and
positive. This helps release stress and can even help
you keep from getting as stressed over life’s little
frustrations in the future. Researchers discovered
that music can decrease the amount of the cortisol,
a stress-related hormone produced by the body in
response to stress16.
Thus listening to music during the postoperative
recovery gives
a) Comfort from a discomforting condition
b) Providing familiarity in a strange environment
c) Distraction from fear, pain, and anxiety.18
It also has been suggested that
• Music intervention is easy to implement and cost
effective,
• Patients enjoy it, and
• Patients can use music as a self-management
technique for distraction or escapism.
These results suggest that listening to music,
especially while being treated with medicine could
greatly enhance the recovery speed. It is also
suggestive that music is a good tool for relieving stress
either mentally or physically. 1
The music intervention has multiple, desirable
clinical effects, primarily in the reduction of pain,
anxiety, and stress.
21. Shwata phadke--106--.pmd 109
During postoperative care, soothing and relaxing
music can be used as audioanalgesia, audioanxiolytic,
or audio - relaxation as an integral part of the
multimodal regimen administered to patients.
Providing music to patients is an inexpensive
technique that does not require extra staff members
or expensive equipment.
Music intervention can help maximize efforts to
promote patient comfort and relaxation as well as
reduce or control postoperative patient distress.
Listening to music, as is true for many nondrug
therapies such as hypnosis or distraction, offers
potential advantages of low cost, ease of provision, and
safety.
Acknowledgement: We are heartily thankful to the
staff of Dept. Of Physiotherapy, Pad.Dr.D.Y.Patil
University, who supported us from the preliminary
stages of the project.
Conflict of Interest: We, Phadke S,Parkar H, Yardi S
state that there is no conflict of interests with other
people or organizations about our work.
Source of Funding: Study was self funded.
Ethical Clearnce: Study have ethical clearance by
ethics committee of Padmashree Dr.D.Y.Patil
University, letter no. PDDYPU/ 0276 / 2011 , 17.
REFERENCES
1. Aidan Smith, 2012.Soothing the Stress:
Physiological responses to Tensile release in
Music.
2. American Society of Hypertension meeting in
New Orleans.
3. Beck SL. The therapeutic use of music for
cancerrelated pain. Oncol Nurs Forum. 1991;
18(8):1327-1337.
4. Benson, H. (1975/2000). The Relaxation
Response. New York: HarperCollins. p. 27 -30.
5. British Society of Music Therapy.
6. Cooke, M., Chaboyer, W., & Hiratos, M.A. (2005).
Music and its effect on anxiety in short waiting
periods: a critical appraisal. Journal of Critical
Nursing, 14, 145-155.
7. Dawn Kent .The Effect of Music on the Human
Body and Mind Liberty University Spring 2006
8. Denber, H. (1995). Cardiac Surgery: Biological
and psychological implications. Armonk, New
York: Futura Publishing.
11/1/2014, 12:17 AM
 110 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
9. Erkkila¨ J, Punkanen M, Fachner J, Ala-Ruona E,
Po¨ntio¨ I, Tervaniemi M,et al. Individual music
therapy for depression: randomised controlled
trial.Br J Psychiatry 2011; 199: 132–9.
10. Evans, D. (2002). The effectiveness of music as
an intervention for hospital patients: a systematic
review. Journal of Advanced Nursing, 37(1),
8-18.
11. Gess A. Birds like music, too. Science 2007; 317:
1864
12. Good, M., Stanton-Hicks, M., Grass, J.A.,
Cranston, A.G., Choi, C., Schoolmeesters L.J., &
Salmon, A. (1999). Relief of postoperative pain
with jaw relaxation, music and their combination.
Pain. 81(1-2), 163-72.
13. Hans-Joachim Trappe 2012 The effects of music on
the human being Applied Cardiopulmonary
Pathophysiology 16: 133-142.
14. How Music Affects Us and Promotes Health?
eMedExpert.
15. http://www.apollolife.com/HealthTopics/
Cancer/TamingtheCrab/Music Therapy fo
rCardiacRehab
16. http://www.eMedExpert.com
17. Ie Roux FH, Bouic PJ, Bester MM. The effect of
Bach’s magnificat on emotions, immune, and
endocrine parameters during physiotherapy
treatment of patients with infectious lung
conditions. J Music Ther. 2007 Summer;44(2):156-
68. PubMed
18. KARIN SCHOU, September 2008.MUSIC
THERAPY FOR POST OPERATIVE CARDIAC
PATIENTS.Aalborg University.
19. Kelly D. Allred, MSN, RN,The Use of Music for
Postoperative Pain and Anxiety ,CCRN
University of Central Florida,Orlando, FL.
20. Kreutz G, Bongard S, Rohrmann S, Hodapp V,
Grebe D. Effects of choir singing or listening on
secretory immunoglobulin A, cortisol, and
emotional state. J Behav Med. 2004 Dec;27(6):623-
35. PubMed
21. Kuhn D. The effects of active and passive
participation in musical activity on the immune
system as measured by salivary immunoglobulin
A (SIgA). J Music Ther. 2002 Spring;39(1):30-
9. PubMed
22. Labbe’ E, Schmidt N, Babin J, Pharr M. Coping
with stress: the effectiveness of different types of
music. Appl Psychophysiol Biofeedback. 2007
Dec;32(3-4):163-8. PubMed
21. Shwata phadke--106--.pmd 110
23. L Bernardi, C Porta, and P Sleight Cardiovascular,
cerebrovascular, and respiratory changes
induced by different types of music in musicians
and non musicians: the importance of silence.
24. Maratos AS, Gold C, Wang X, Crawford MJ.
Music therapy for depression. Cochrane Database
Syst Rev. 2008 Jan 23;(1):CD004517.
Review. PubMed
25. Mockel M, Rocker L, Stork T. et al Immediate
physiological responses of healthy volunteers to
different types of music: cardiovascular,
hormonal and mental changes. Eur J Appl
Physiol Occup Physiol1994. 68451–
459.459. [PubMed]
26. Music therapy association of British Columbia.
27. Nilsson U. The Effect of Music and Music in
Combination With Therapeutic Suggestions on
Postoperative Recovery [doctoral thesis].
Linköping, Sweden: Linköping University; 2003.
28. Sacks O. The power of music. Brain. 2006;129
(Pt10):2528-2532
29. Schmidt, T. A. (2005). Hjertekirurgi. In Kirurgi –
Sygdomslære og sygepleje.
Copenhagen,Denmark: Nyt Nordisk Forlag
Arnold Busck.
30. Schwabe C. Music therapy in geriatric
rehabilitation. Zeitschrift für die gesamte
Hygiene und ihre Grenzgebiete 1981; 27: 937-941
31. Staum MJ, Brotons M. The effect of music
amplitude on the relaxation response. J Music
Ther.2000;37(1):22-39.
32. Terry Richards,Jennifer Johnson, Amy Sparks
.The Effect of Music Therapy on Patients’
Perception and Manifestation of Pain, Anxiety,
And Patient Satisfaction,West Virginia University
Hospitals, Morgantown, WV.
33. Thaut MH. Neurophysical processes in music
perception and their relevance in music therapy.
In: Unkefer RF. Music Therapy in the Treatment of
Adults With Mental Disorders: Theoretical Bases and
Clinical Interventions. New York, NY: Schirmer
Books; 1990:3-32.
34. Thorgaard P, Ertmann E, Hansen V, Noerregaard
A, Hansen V, Spanggaard L. Designed sound and
music environment in postanaesthesia care
units—a multicentre study of patients and staff.
Intensive Crit Care Nurs. 2005;21(4):220-225.
35. Trappe HJ. Music and health – what kind of
music is helpful for whom? What music not?
Dtsch Med WSchr 2009; 134: 2601-2606
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 111

36. Ulrica Nilson. The anxiety & pain reducing effects
of music interventions: A systematic review.
AORN Journal volume 87,issue 4, April
2008,780,782,785-794,797-807.
37. What music does for stress? Syncrat.com
38. White JM. Music as intervention: a notable
endeavour to improve patient outcomes.
NursClin North Am. 2001;36(1):83-92.
39. White JM. State of the science of music
interventions. Critical care and perioperative
practice. Crit Care Nurs Clin North Am.
2000;12(2):219-225.
40. Zachariae, B. (1997). Hjerne og immunitet. Psyke
& Logos, 18, 342-356

21. Shwata phadke--106--.pmd 111 11/1/2014, 12:17 AM

 DOI Number: 10.5958/0973-5674.2014.00344.X
112 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Compare the effectiveness of Massage Versus

Cryotherapy in Treating Delayed Onset Muscle Soreness

Sai Deepthi Yarlagadda1, M Seshagiri Rao2

1
B.P.T, M.P.T (Sports), Department of Physiotherapy and Rehabilitation, Southern Institute of Medical Sciences,
2

College of Physiotherapy, Mangaldas Nagar, Guntur

ABSTRACT

Back Ground and Purpose of the Study: Delayed-onset muscle soreness (DOMS) is a common muscle
problem among athletes and individuals beginning an exercise program. Initially, damage caused
by DOMS leads to an inflammatory response followed by regeneration2. However, these inflammatory
changes are not correlated with perceived soreness ratings, leaving the reasons for DOMS
unanswered8. Furthermore, current treatment protocols for DOMS have yielded inadequate results.
It is the goal of this study to further our understanding of DOMS and the healing process over 7-days
by using the non-invasive techniques of EMG and MMG to determine muscle function in the presence
of DOMS. Should we determine changes in MMG as hypothesized, future research can utilize MMG
as a non-invasive technique to monitor treatment protocols for DOMS10. Purpose of this study is to
compare the effectiveness of massage versus cryotherapy in delayed onset muscle soreness.

Keywords: Massage, Ice Cubes, Doms, Biceps

INTRODUCTION DOMS is known to result in a reduction in contractile

Every active person at some time has experienced
general muscle soreness resulting from unaccustomed
physical activity. Exercised-induce muscle soreness
can either be classified as acute or delayed onset. Acute
onset occurs during exercise and may last four to six
hours post-exercise before subsiding2.
Delayed onset muscle soreness (DOMS) typically
appears approximately 12 hours after activity and may
last for several days following exercise It is perhaps
one of the most common and recurrent forms of sports
injury person experiencing DOMS will notice soreness
and aching within the affected muscles beginning 12-
24 hours after exercise (and peaking at 48-72 hours),
tenderness with palpation throughout the involved
muscle belly or at the myotendinous junction,
increased muscle tension, decreased range of motion,
decreased muscle strength, local edema and warmth,
stiffness and resistance to stretching9. The severity is
variable, ranging from a mild discomfort to severe
debilitating pain that limits the use of muscles10. Since
function and cause muscle soreness that may last for
several days post-exercise, it is likely to have an
unfavourable effect on athletic performance. It takes
up to three or four days before the symptoms gradually
subside.
Despite the considerable evidence of muscle
damage produced with repeated eccentric
contractions, the cause of delayed onset muscle pain
is still currently questioned. The cause of DOMS
appears to be linked to a form of contraction-induced,
micro trauma of muscle fibers and/or connective tissue
in and around muscle which results in degeneration
of the tissue13.
This structural damage to muscle and connective
tissue results in alterations of muscle function, joint
mechanics and produces a less than optimal training
intensity; therefore, an individual experiencing DOMS
ha an increased risk of further injury if premature
return to sport is attempted. Reasonable evidence
supports the concept that high intensity eccentric

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 113
muscle contractions stress the muscle enough to elicit
severe symptoms of DOMS at a greater frequency and
severity than other types of muscle actions 15 .
Minimizing the effects of DOMS should be a concern
to coaches, athletes, athletic trainers, physical
therapists and other medical personnel due to the
presence of pain and potential risk for debilitating
performance of athletes14. Nevertheless, little research
exists on the prevention and treatment of DOMS, and
treatment strategies are still unclear despite the high
incidence in novice and elite athletes. Effective
treatment is continually being sought, because
currently the efficacy of DOMS treatment strategies
has Produced mixed results.
MATERIALS
• Collection tray.
• Draping cloth.
• Lubricant oil or powder.
• Ice cubes.
• Towels.
• Pillows.
• Treatment couch.
METHODOLOGY
PROCEDURE
30 subjects sample size divided into 15 each,
GROUP A selected for massage (15) and GROUP B
selected for cryotherapy(15).group A experimental and
group B control group.
Group A subjects were given massage as
physiotherapy treatment were as group B subjects
were given cryotherapy treatment for 10 days .
Pain parameter measured with VISUAL
ANOLOGUE SCALE in both before and after the
treatment another parameter creatinekinase levels
measurement was taken before and after the treatment
for biceps muscle in both groups.
22. Deepthi --112--.pmd 113
Both parameters were measured on first day and
after 10 days of treatment procedure.
Experimental Group
• Figure kneading is given with effleurage for biceps
muscle following 10 times per session daily once
for 10 days.
Control Grou
• Ice cube application on the biceps muscle for one
to two minutes with repetition of 5-8 times per
session daily once for 10 days.
RESULTS
The result showed there is significant change in
pain and muscular tension By applying massage and
cryotherapy but according to this study both are
Having significant effects, but massage is more
effective than cryotherapy.
CONCLUSION
This study reveals that group A(massage) shows
significant change in relation to decreasing pain and
CK levels in biceps muscle soreness than group
B(cryotherapy).
Limitations
• Sample size is not large.
• Study duration is short.
• Treatment session of both massage and
cryotherapy is short.
Recommendations
• Sample size should be large.
• Study duration should be more.
• Treatment duration should be increased.
Data Analysis:
Both pre-treatment and post-treatment measures
are analysed with visual analogue scale and creatine
kinase levels.
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 114 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

PRE and POST COMPRISION by VAS in group A Unpaired t test

MEAN and STANDERD deviation P value

The two-tailed P value is < 0.0001, considered

extremely significant.

t = 17.727 with 28 degrees of freedom.

95% confidence interval

Mean difference = -4.467 (Mean of POST minus mean

of PRE)

The 95% confidence interval of the difference: -4.983

to -3.951

Mean 8.2 3.7333333333

Standard deviation (SD) 0.6761 0.7037

Sample size (N) 15 15

Unpaired t test, Pre and Post Comprsion of CK Levels in Group A
Do the means of PRE and POST differ significantly?P
Mean and Standerd Deviation
value
The two-tailed P value is < 0.0001, considered
extremely significant.
t = 21.689 with 28 degrees of freedom.
Mean difference = -5.600 (Mean of POST minus mean
of PRE)
The 95% confidence interval of the difference:
-6.129 to -5.071
Mean 8.2 2.6
Standard deviation (SD) 0.6761 0.7368
Sample size (N) 15 15

Pre and Post Comparision by vas in Group B

Mean and Standerd Deviation

Unpaired t test

P value

The two-tailed P value is < 0.0001, considered

extremely significant.

t = 79.851 with 28 degrees of freedom.

95% confidence interval

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 115

Mean difference = -1650.0 (Mean of POST minus mean ACKNOWLEDGEMENT

of PRE)
I am very much thankful to My Subjects, my friends
The 95% confidence interval of the difference: -1692.3 and well-wishers. I also thank Indian journal
to -1607.7 publishing author’s and editor’s for giving me this
opportunity and guiding me in publishing my article.
Mean 1903.333333333 253.3333333333
Conflict of Interest: Nil
Standard deviation (SD) 61.140 51.640
Source of Support: Self
Sample size (N) 15 15
Ethical Clearance: While doing this project I have
Pre and Post Comparision of CK Levels in Group B maintained the privacy of my subject’s. I did not
Mean and Standerd Deviation mention their names, initials, addresses and
photographs or hospital numbers, and written
descriptions because the information about the subject
is not essential in my project.

REFERENCES

1. Churasia-skeletal muscle anatomy.

2. Karim khan-physiotherapy management of
delayed onset muscle soreness.
3. Shambulingam-skeletal muscle structure.
4. Cynthia.C.knorkin-bio-mechanics of muscle
5. Deena gardiner-bio-mechanics of muscle.
6. Human Anatomy & Physiology- Asha latha.
7. Isabell, W.E., E.Durrant, W.Myrer, and
S.Anderson. 1992. The effects of ice massage, ice
massage with exercise, and exercise on the
prevention and treatment of delayed onset
muscle soreness. J Athl Train. 27(3):208-217.
8. Kuligowski, L.A., S.M. Lephart, F.P.
Giannantonio, and R.O. Blanc. 1998. Effect of
whirlpool therapy on the signs and symptoms of
delayed-onset muscle soreness. J Athl Train.
Unpaired t test 33(3):222-228.
9. Francis, K.T. 1983. Delayed muscle soreness: A
P value t
review. The Journal of Orthopaedic and Sports
The two-tailed P value is < 0.0001, considered Physical Therapy. 10-13.
extremely significant. 10. Newham, D.J. 1988. The consequences of
t = 58.217 with 28 degrees of freedom. eccentric contractions and their relationship to
delayed onset muscle pain. Eur J Appl Physiol.
95% confidence interval 57:353-359.
Mean difference = -1483.3 (Mean of POST minus mean 11. Nadler, S.F., K.Weingand, and R.Kruse. 2004. The
of PRE) physiologic basis and clinical applications of
cryotherapy and thermotherapy for the pain
The 95% confidence interval of the difference: -1535.5 practitioner. Pain Physician. 7:395-399.
to -1431.1 12. Marieb, E.N. 2004. Human Anatomy &
Mean 1903.333333333 420 Physiology. 6th ed. Pearson Education, Inc., San
Francisco. 298-303pp.
Standard deviation (SD) 61.140 77.460
13. Abraham WJ. Factors in delayed onset
Sample size (N) 15 15 musclesoreness. Med Sci Sports 1977;9:11-20.

22. Deepthi --112--.pmd 115 11/1/2014, 12:17 AM

 116 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

14. Callaghan MJ. The role of massage in the
management of the athlete: a review. Br J Sports
Med. 1993 Mar;27(1):28–33.
15. Kowal M. A review of physiologicaleffects of
cryotherapy. J Orthop Sports Phys Ther 1983: 5:
66–73.
16. Cryotherapy in sports medicine. Scand,J Med Sci
Sports 1996: 6: 193–200.
17. Gulick DT, Kimura IF, Sitler M, Paolon M,
Paolone A, Kelly JD. Various treatment
techniques on signs andsymptoms of delayed
onset muscle soreness. J Athletic Training
1996,145–152.
18. Knight KL. Cryotherapy in sport
injurymanagement. Champaign, IL: Human
Kinetics, 1995.
20. Kowal M. A review of physiological effects of
cryotherapy. J Orthop Sports Phys Ther 1983: 5:
66–73.
21. Meeusen R, Lievens P. The use ofcryotherapy in
sports injuries. Sports Med 1986: 3: 398–414.
22. Tiidus PM. Massage and ultrasound as
therapeutic modalities in exercise-induced
muscle damage. Can J Appl Physiol. 1999
Jun;24(3):267–278.
23. Yackzan L, Adams C, Francis KT. The effects of
ice massage on delayed muscle soreness. Am J
Sports Med. 1984 Mar-Apr;12(2):159–165.
24. Abraham WM. Factors in delayed muscle
soreness. Med Sci Sports. 1977 Spring;9(1):11–20.
25. MacDonald G. Massage as a respite intervention
for primary caregivers. Am J Hosp Palliat
Care.1998;15:43–47.
27. Callaghan MJ. The role of massage in the
management of the athlete: a review. Br J Sports
Med.1993;27:28–33.
28. Tiidus PM. Manual massage and recovery of
muscle function following exercise: a literature
review. J Orthop Sports Phys Ther. 1997;25:
107–112.
29. Hilbert, J. E., Sforzo, G. A., & Swensen, T. (2003).
The effects of massage
30. On delayed onset muscle soreness. British Journal
of Sports Medicine 37,72-75
31. Weerapong, P., Hume, P. A., & Kolt, G. S. (2005).
The mechanisms of massage and effects on
performance, muscle recovery and injury
prevention. Sports Medicine, 35(3), 235-256.
32. Weerapong, P., Hume, P. A., & Kolt, G. S. (2005).
The mechanisms of massage and effects on
performance, muscle recovery and injury
prevention. Sports Medicine, 35(3), 235-256.
33. Tiidus, P. M., & Shoemaker, J. K. (1995).
Effleurage massage, muscle blood flow and long-
term post-exercise strength recovery.
International Journal of Sports Medicine, 16,
478483.
34. Mortimer, P. S., Simmons, R., Rexvani, M.,
Robbins, M., & Hopewell, J. W. (1990). The
measurement of skin lymph flow by isotope
clearance-reliability, reproducibility, injection
dynamics and the effects of massage. Joltma1 of
Investigative Dermatology, 95, 677-682.
35. Meussen R, Lievens I. The use of cryotherapy in
sports injuries Sports Med 1986; 3: 398-414.
36. Smith LL, Keating MN, Holbert D. The effects of
athletic massage on delayed onset muscle
soreness, creatine kinase, and neutrophil count:
a preliminary report. J Orthop Sports Phys
Ther. 1994;19:93–99. et al.
37. Callaghan MJ. The role of massage in the
management of the athlete: a review. Br J Sports
Med. 1993;27:28–33.

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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 117

A Study of Common Impairements Following Modified

Radical Mastectomy

Kinjal D Raja1, U S Damke2, S Bhave3, M M Kulsange4

1
Physiotherapist, Projectee, Principal/Professor, 3Professor, Guide, 4Physiotherapist, Co-Guide, Physiotherapy School
2

& Centre, Govt. Medical, College, Nagpur

ABSTRACT

Objective: To determine the pattern of impairments following MRM with axillary clearance for
established cases of early carcinoma of breast.

Material and Method: This descriptive study was carried out in the P.T. School and Center, in
G.M.C.H. Oncology Dept. & Surgery Dept., RSTCH, Gupte Cancer Hsp., Columbia Cancer Hsp.,
Baraskar Cancer Hsp. & Care Hsp., Nagpur from Dec. 2011- April 2012, Maharashtra. The study
included female patients with the established diagnosis of early carcinoma of breast (stage I, stage II)
and had undergone MRM with axillary clearance within pass six months. These patients, even if
undergone chemotherapy or radiotherapy were assessed for postoperative complications on
outpatient basis.

Results: During the study period, 30 patients underwent MRM with axillary clearance as per inclusion
criteria, were assessed. Average age of the patients was 43+12.3 SD. Characteristics of impairments
seen after MRM on all thirty patients implies that the most common impairment observed grossly
was pain which was 19%, which was followed by postural deviations i.e. 17%. The next most dreadful
impairment documented was lymphedema of arm, which was 16% also reduced flexibility of muscles
observed, was the same. Restricted ROM at shoulder seen was (11) 7% out of 30 patients, reduced
strength (19) 12% & impairments due to scar like adherence, infection documented was (8) 5%.

Conclusion: Pain at various sites, postural deviations, lymphedema, tightness of anterior chest wall,
restricted shoulder range of motion, scar related complications like adherence, infection & reduced
chest expansion for established cases of early carcinoma of breast are impairments of MRM with
axillary dissection that may be detected and treated well through proper postoperative physiotherapy
care.

Keywords: Cancer Hospital (CH), ** Modified Radical Mastectomy (MRM)

INTRODUCTION in incidence rates. The overall rate is now estimated at

Breast cancer is the 2nd most common cause of
death from cancer among females. Studies indicate that
as India becomes westernized, the incidence rate of
breast cancer increases. A 2005 study conducted by
the International Association of Cancer Research,
based in Lyon, France, projected that there would be
2,50 000 cases in India by 2015, a 3% increase per year.
Currently, India reports roughly 100,000 new cases
annually. There are also significant regional variations
80 new cases per 100 000 population per year. But in
Delhi, that rate is pegged at 146 per 100 000. By contrast,
the national rate was 23.5 in 1990 (Current Science 2001;
81:465-74).
The term “breast cancer” refers to a malignant
tumor that has developed from cells in the breast.
Usually it either begins in the cells of the lobules, which
are the milk-producing glands, or the ducts, the
passages that drain milk from the lobules to the nipple.

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 118 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Less commonly, breast cancer can begin in the stromal
tissues, which include the fatty and fibrous connective
tissues of the breast.7
Fig. 1: Before MRM
Fig. 2: After MRM
Success in its management depends on the
development of new diagnostic methods, surgical
treatments, histopathological compliance and, of
course, new treatment options. The modern approach
to breast cancer management surgery is
multidisciplinary. It includes surgery, with a
radiotherapy, hormonal therapy & chemotherapy. The
type of surgery depends on its stage at the time of
initial presentation, patient’s preference and surgeon’s
choice. The different surgical treatment options
available include simple mastectomy, MRM and breast
conservation surgery.2
Historically, radical mastectomy, first described in
1894 by William Stewart Halsted was the primary
method of. As the treatment evolved, MRM & currently
chemotherapy, hormone therapy & radiation therapy
for breast cancer have nearly eliminated the need of
Halsted Radical & has become more widely used.
Patey and Dyson described MRM in 1948.
MRM is a procedure in which the entire breast is
removed, including the skin, areola, nipple, and most
axillary lymph nodes; the pectoralis major muscle is
spared.
METHODOLOGY
SAMPLE SIZE – 30.
Inclusion Criteria
1) Patients who underwent MRM in past six months
i.e. November 2011- May 2012.
2) Histopathological confirmation of the diagnosis
and stage I or II of breast cancer
3) Patients who received adjuvant chemotherapy,
hormone therapy & radiotherapy.
Exclusion Criteria
1) Lumpectomy
2) Simple mastectomy
3) Pre-existing physical deformities
23. kinjal --117--.pmd 118
4) Pathological conditions of Shoulder joint
5) Concomitant secondary malignancies
6) Patients with Psychiatric or Psychological
abnormalities
Procedure
After taking informed consent of thirty patients
each & explaining the study in their language, a
complete history was obtained and thorough physical
examination was performed. It included a general
physical examination along with examination of neck,
chest wall, mastectomy scar, axilla, supra clavicular
fossa and both upper extremities in comparison to each
other & were recorded in a specially designed
proforma also comprising of identification code & basic
clinical parameters of disease.
Histopathologic details and other necessary
information were obtained from the medical record
of the patients. Patients with lymphedema were
instructed to use tight bandages, perform regular
exercises, and to elevate their limbs while resting. They
were also explained the precautions to be followed to
prevent any infections or injuries to operated side.
• A lymphedema grading system, devised by Foldi
et al, the most frequently used grading system was
used to record the severity.
• Obesity was also recorded using Quetelet’s index
(Body Mass Index) to determine the contribution
in predisposing the disease.
Statistical Analysis
Total No. of patients analyzed – 30
Graph No. 1: Analysis of overall impairments of
Modified Radical Mastectomy
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 119

Table 2: Incidence of pain after MRM in 30 Patients • Incidence of pain at various sites shown in table 2
PAIN No. Percentage reveals, 25% pain at shoulder & incision site, 24 %
Incisional 19 25 (15) axilla, 14% (11) in upper thoracic & 12% (9) in
Axillary 18 24 cervical region respectively.
Shoulder 19 25
• Table 3 documented the incidence of reduced
Upper Thoracic 11 14
strength, presenting with 66% (19) of patients
Cervical 9 12
having reduced shoulder strength & 34% (10) with
Table 3: Incidence of Reduced Strength reduced strength of grips & pinches respectively.
Reduced Strength Found No. Percentage %
• Various postural deviations as shown in Table 4
Shoulder 19 66
describes (16) 37% of patients have protracted
Grips & Pinches 10 34
shoulders, 16% (7) had postural scoliosis, 12% (5)
Table 4: Incidence of various postural deviations: with thoracic kyphosis & elevation of shoulder on
operated side was seen in 35% (15) of patients.
Postural Deviations No. Percentage
Scapula Protrated 16 37 • Table 5 shows the incidence of tightness in MRM
Postural Scoliosis 7 16 patients which reveals 36% (14) of trapezius
Thoracic Kyphosis 5 12 tightness & 64% (25) of pectoralis major tightness
ElevatedShoulder(ES) 15 35
respectively.
Table No.5: Incidence of tightness in MRM patients
• Incidence of lymphedema listed in Table 6 reveals
Tightness No. Percentage 47% (17) patient presented with lymphedema of
Trapezius 25 36 arm & 53% (19) patients showed that of forearm.
Pectoralis Major 14 64
• Scar related impairments observed in 10 patients
Table 6: Incidence of Lymphedema:
i.e. 37%, tenderness in 41% (11) patients &
Sr. No. Lymphoedema No Percentage unhealed wound in 22% (6) of patients is
1 Arm 17 47 documented in Table 7.
2 Forearm 19 53

Table 7: Incidence of Scar Complications DISCUSSION

Scar No. Percentage % This study was conducted on patients who

Adherence 10 37
Tenderness 11 41
Unhealed 6 22
RESULTS
Mean age of these patients was 46 years with a
range of 30-65 years & mean BMI was 23.2 i.e. within
normal range.
• Characteristics of impairments seen after MRM on
all thirty patients are given in Table-1 which
implies that the most common impairment
observed grossly was Pain as 19%, followed by
postural Deviation i.e. 17%. The next most dreadful
impairment documented was lymphedema, which
was 16% also reduced flexibility of muscles
observed was the same. Restricted ROM at
shoulder seen was (11) 7% out of 30 patients,
reduced strength (19) 12% & scar impairments
documented was (8) 5%.
underwent MRM and thus the succeeding
complications were documented. Pain was the most
common complication observed among all i.e. grossly
19%, being more specific as shown in table 2, shoulder
pain & incisional pain was most prevalent among
these patients, which was 25% of all other sites.
Axillary pain as per our study was 24%.
According to Kisner Colby, incisional pain may be
because the sutured skin over the breast & axilla may
feel tight due to increased adhesions in the series elastic
along the incision & hence the movement of the arm
pulls on the incision and is uncomfortable. Delayed
healing, in turn, prolongs pain in the area of the
incision. Cervical, Upper Thoracic pain may be due to
muscle spasm occur in the neck and shoul der region
as a result of muscle guarding, also that the levator
scapulae, teres major and minor, and infraspinatus
often are tender to palpation due to inadequate
healing.4

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 120 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Postural deviations, the next common complication
in our study, contributing to 17% grossly, comprising
various deviations like protraction of shoulder 37%,
elevated shoulder on operated side was 35%, also
thoracic kyphosis presenting 12% & postural scoliosis
25%. As referenced to Kisner the patient may sit or
stand with rounded shoulders and kyphosis because
of pain, skin tightness, or psychological reasons. An
increase in thoracic kyphosis associated with aging is
commonly seen in the older patient.4
Asymmetry of the trunk and abnormal scapular
alignment may occur as the result of a subtle lateral
weight shift, particularly in a large-breasted woman
contributes to postural scoliosis. Restrictive scarring
of underlying tissues on the chest wall can develop as
the result of surgery, radiation fibrosis, or wound
infection. Chest wall adhesions can lead to increased
risk of postural asymmetry and discomfort in the neck,
shoulder girdle, and upper back.4
Major impairment post MRM, incidence of
lymphedema is seen grossly 17% among all
complications, listed in Table 1. Table 6 reveals its
incidence as 53% (19) of arm & 47% (17) that of forearm.
As per Bhatty I et. al. approximately 15-20% of breast
cancer patients develop lymphedema after treatment.1
Development of lymphedema has been variously
attributed to the number of risk factors which
principally include the extent of axillary surgery and
post operative axillary radiotherapy. MRM entails
removal of the breast tissue and surgical clearance of
the axilla. Therefore the need for post mastectomy
axillary radiation is obviated in these patients. Majority
of surgeons perform level 1 and 2 axillary clearances.
Ozaslan states that Lymphatic obstruction is not the
only responsible mechanism in the pathophysiology
of lymphedema, total arm blood flow and vascular bed
size also appear to be increased in lymphedema. It has
been reported that body weight or BMI are the
important factors that increase lymphedema.
However, body weight was not found to influence the
lymphedema in the series reported by Larson et al.
As stated previously in the study, tightness of
pectoralis major muscle is equally prevalent i.e. 66%
Some degree of subjective tightness around the scar
area and the anterior chest was the most frequent
complication and was seen in 56% of patients. This
can be attributed to be the sequel of radiation to chest
23. kinjal --117--.pmd 120
wall which leads to some degree of subcutaneous
fibrosis.4 Adherence between muscles, subcutaneous
tissue and skin in the axillary and pectoral regions
mechanically inhibits the flexibility of muscles and RT
and chemotherapy increase the strong fibrotic
connections between these structures.5 Trapezius
tightness observed in 34% patients may be due to
overuse & guarding.
Reduced strength of shoulder joint prevalent in 66%
of patients may be contributed by faulty shoulder
mechanics and use of substitute motions with the
upper trapezius and levator scapulae during overhead
reaching can cause subacromial impingement and
shoulder pain. Shoulder impingement, in turn, can be
a precursor to a reduced use of the extremity due to
pain & thus leading to weakness. Decreased grips &
pinches strength seen in 34% of patients is often
diminished as the result of lymphedema and
secondary stiffness or may be due to pain & unhealed
wound.
Scar adhesion in 10 patients i.e. 37% of total
complications grossly 8% related to scar, tenderness
in 41% (11) patients & unhealed wound in 22% (6) of
patients as documented in Table 7 found it the study.
Restrictive scarring of underlying tissues on the chest
wall can develop as the result of surgery, radiation
fibrosis, or wound infection, the inflammatory process
following surgery or infection if any leads to
tenderness at the site.4
Restricted shoulder ROM in our study was 7%, seen
in 11 patients. Oliveira MMF1 states that, shoulder
morbidity resulting from surgery and subcutaneous
fibrosis (which is a biological effect from RT) results
in limited shoulder range of motion (ROM). Blomqvist
et al. found that, radiation was the greatest cause of
impaired ROM. Adherence between muscles,
subcutaneous tissue and skin in the axillary and
pectoral regions mechanically inhibits shoulder
movement, and RT and chemotherapy increase the
strong fibrotic connections between these structures.5
which has also contributed to 5% of reduced chest
expansion in our study. According to Kisner Colby,
factors contributing to reduced shoulder mobility are
incisional pain immediately after surgery, muscle
guarding and tenderness of the shoulder and posterior
cervical musculature, need for protected shoulder
ROM until the surgical drain is removed, Adherence
of scar tissue to the chest wall, causing adhesions.5
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 121
CONCLUSION
Pain at various sites & postural deviations is most
common complication following MRM.
Lymphedema & anterior chest wall tightness rank
second most common complication.
Reduced strength of shoulder & grips & pinches
were next most observed complications.
Succeedingly, rarest complications seen due to
MRM, is the mastectomy scar & these patients also
presented with restricted shoulder ROM.
ROLE OF PHYSIOTHERAPY
Pre–Operative Physiotherapy
1) Prepare for postoperative self-management:
• Interdisciplinary patient education involving all
aspects of potential impairments and functional
limitations.
• Self-management activities and preparation for
participation in a home program on the first
postoperative day.
2) Prevent postoperative pulmonary complications
and thrombo-emboli
3) Prevent restricted mobility of the upper extremity:
4) Prevent muscle tension and guarding in cervical
musculature:
Post-operative Physiotherapy
Ø Initially involves direct interventions by a therapist
and an emphasis on patient education
• Later lifelong prevention and self-management by
the patient.
Exercise Precautions and Treatment
• Exercise only at a moderate level and never to the
point that the affected arm aches during or after
exercise, even if there is no evidence of
lymphedema.
• Monitor upper extremity girth measurements
closely.
• Adjust the timing of exercise during cycles of
radiation therapy or chemotherapy. With some
23. kinjal --117--.pmd 121
chemotherapy medications, a patient can develop
cardiac arrhythmia and therefore should not
perform aerobic exercises, such as stationary
cycling, for 24 to 48 hours after a chemotherapy
session.
• Return to more physically demanding work and
recreational activities gradually after completion
of chemotherapy or radiation therapy.
During Exercises
a) Wear Non-elastic or low-stretch bandages or
custom-fitted garments compression bandages.
Also Intermittent, sequential pneumatic
compression pump
b) Proceed with total body relaxation activities & then
lymphatic drainage exercises with elevation of the
involved limb above the heart during distal
pumping exercises. Incorporate self-massage into
the exercise sequence to further enhance lymph
drainage.
c) Combine deep breathing exercises with active
repetitive movements & holds of the head, neck,
trunk, and limbs for about 1 to 2 seconds per
repetition.
d) Posture awareness training: Encourage the patient
to assume an erect posture when sitting or standing
to minimize a rounded shoulder posture.
e) Strengthening exercises are added to the lymph
drainage sequence, use light resistance and avoid
excessive muscle fatigue.
f) Flexibility exercises
g) Cardiovascular conditioning:
Activities such as upper extremity ergometry,
swimming, cycling, and walking increase circulation
and stimulate lymphatic flow.4 Thirty minutes of
aerobic endurance exercises complement lymph
drainage exercises. Conditioning exercises are done
at low intensity (at 40% to 50% of the target heart rate)
when lymphedema is present and at higher intensities
(up to an 80% level) when the lymphedema has been
reduced and exercise is otherwise safe.4
Ergonomic Advice
• Keep the skin clean and supple with advised
moisturizers.
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 122 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
• Pay immediate attention and caution to a skin
abrasion or cut, an insect bite, a blister, or a burn
to avoid infections
• Protect hands; wear rubber gloves, oven mitts, etc.
• Avoid contact with harsh chemicals.
• Avoid hot baths, whirlpools, and saunas that
elevate the body’s core temperature.
• Avoid carrying heavy loads
• Perform regular exercises as explained. Carry
maintenance by inculcating in all activities of daily
living by awareness of faulty postures &
correction.
• Avoid wearing objects that restricts circulation,
such as tight jewelleries, sleeves with elastic bands,
taking blood pressures on affected arm.
• Monitor diet to maintain an ideal weight and
minimize sodium intake
• Support the arm in a sling during extended periods
of standing or walking, sleeping.
• Psychological counseling:
Promote more optimistic attitude towards the real
life situations.
Acknowledgement: First of all I would like to thank
Goddess, who blessed me with everything I have
today, Her faith is my strength. We extend our thanks
to G.M.C.H. Oncology Dept. & Surgery Dept., RSTCH,
Gupte C.H.* & Columbia C.H.* at Nagpur.
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance: Taken
23. kinjal --117--.pmd 122
REFERENCES
1. Bhatty I1, Shaharyar2, Ibrahim M3 & Chaudhry
ML4 complications after MRM in early breast
cancer.
2. WaqarAlam Jan, Mian Iftikhar Ul Haq, Mian
Ayaz Ul Haq, Abdus Samad Khan, Department
of Surgery Postgraduate Medical Institute, Lady
Reading Hospital, Peshawar. Early complications
of MRM.
3. Carien HG Beurskens1*, Caro JT van Uden1,2, Luc
JA Strobbe3, Rob AB Oostendorp4,5 and Theo
Wobbes6 The efficacy of physiotherapy upon
shoulder function following axillary dissection
in breast cancer, a randomized controlled study
4. Therapeutic Exercise Foundations and
Techniques, Fifth Edition. Carolyn Kisner, PT,
MS. & Lynn Allen Colby, PT, MS.
5. Oliveira MMF1, Gurgel MSC1, Miranda MS2,
Okubo MA2, Feijó LFA3, Souza GA1Efficacy of
shoulder exercises on locoregional complications
in women undergoing radiotherapy for breast
cancer: clinical trial
6. Carien HG Beurskens1*, Caro JT van Uden1,2, Luc
JA Strobbe3, Rob AB Oostendorp4,5 and Theo
Wobbes6 , Published 30 Aug. 2007, The efficacy
of physiotherapy upon shoulder function
following axillary dissection in breast cancer, a
randomized controlled study.
7. http://en.wikipedia.org/wiki/Breast_cancer
8. Cihangir Ozaslan, M.D., Bekir Kuru, M.D.*
Manuscript received August 13, 2002; revised
manuscript December 12, 2002X Lymphedema
after treatment of breast cancer.
9. O’Sullivan CMAJ. 2008 July 1; 179(1): 27.
doi: 10.1503/cmaj.080763
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 123

Effects of A Six-Weeks Balance Training on Balance

Performance and Functional Independence in Hemiparetic
Stroke Srvivors

Caleb Ademola Gbiri1, Aishat Shittu2

1
Department of Physiotherapy, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria, 2Department of
Physiotherapy, Murtala Muhammed Specialists Hospital, Kano, Nigeria

ABSTRACT

Objective: To investigate the effects a 6-week balance training on balance performance and functional
independence.

Method: Forty-six stroke survivors whose informed consents were obtained participated in this study.
They were purposively recruited from the Murtala Muhammed Specialists Hospitals, Kano, Nigeria
and randomly assigned to two groups. They were included if they scored ?45 in the Berg balance
scale and have had stroke for not more than six months. The intervention group received conventional
stroke treatment and balance training exercise, while the control group received the conventional
stroke treatment only. Balance performance was assessed using the Berg balance scale while functional
independence was assessed using the Barthel Index. Participants received treatment every other day
for six weeks and were re-assessed at 6-week. The balance training used was the sit-to-stand training
exercise and was conducted according to standard protocol. Data was analysed using the independent
and paired t-tests at 0.05 significance.

Results: The mean age of the participants was 43.69±6.05 years for the intervention group and
47.40±7.50 years for the control group. The groups were homogeneous at the baseline. The mean
score of the intervention group (51.22±5.47) was significantly better (p<0.05) in balance performance
at the end of the 6-week period than the control (45.26±3.03). The intervention group (61.13±5.68)
performed significantly better in functional performance at the end of the 6-week period than the
control (53.39±6.11 ).

Conclusion: The sit-to-stand exercise is effective in improving balance performance and functional
independence in a stroke patient.

Keywords: Stroke Survivors, Balance, Functional Independence, Physiotherapy

INTRODUCTION after a stroke has been the focus of researchers in recent

time. It is the largest single cause of neurological
Stroke and its sequels remain a major challenge to
disability and individuals with stroke are the largest
healthcare professionals worldwide and effort to
consumers of rehabilitation services1. Most individuals
improve the quality of life and functional performance
after a stroke will recover a degree of functional
performance. However more than 50% will remain
Corresponding author: with residual motor deficits2. Functional ambulation
Caleb Ademola Gbiri is often the primary goal for many individuals after
Department of Physiotherapy, stroke3. However, many never regain this ability, and
College of Medicine, University of Lagos,
those who do walk after a stroke, have slow gait, poor
Idi-Araba, Lagos, Nigeria
endurance and balance with associated changes in the
+2348033598072
E-mail: calebgbiri@yahoo.com quality and adaptability of their walking pattern3.
cgbiri@unilag.edu.ng; agbiri@cml.edu,ng Approximately 90% of patients with chronic stroke

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 124 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
ambulate with impaired coordination, and continue
to ambulate with a degraded pattern of coordination
which predisposes them to greater risk of falling, thus
developing a fear of falling, and losing independence
and function2. Hemiparetic stroke patients frequently
present with balance abnormalities and increased fall
risk, resulting in high economic costs and social
problems4,5. The components of balance are disturbed
following stroke resulting in greater amount of
postural sway during static stance, asymmetry with
greater weight on the non-paretic leg, decreased ability
to move within a weight-bearing posture and difficulty
with transitional movements6.
Functional independence in individuals with stroke
is defined as the improvement of mobility and
activities of daily living and has long been known to
be influenced by rehabilitation 7. Balance training
programme is the intervention designed to help an
individual attain stability over the center of gravity
during a shift in body weight in either static or dynamic
equilibrium. Re-establishment of balance in patients
following stroke has been advocated as an essential
component in the rehabilitation of patients. This is
because the maintenance of adequate balance is a
prerequisite for functional activities 2 . Different
methods have been designed to train balance in
individuals with balance challenges ranging from
sophisticated methods like force platform feedback,
postural rehabilitation, integrative approach and use
of functional tasks based on movement analysis
principles to less sophisticated approach such stair
climbing, sit-to-stand and deprivation of visual cues.
The Sit-to-Stand (STS) movement can be described
as the change in body posture
from a sitting to standing position. In more
biomechanical terms, it can be defined as a transitional
movement to the upright posture requiring movement
of the center of mass from a stable to a less stable
position over extended lower extremities8. The STS
movement is an important skill because it is related to
functioning and mobility, and is a prerequisite for
walking9. It consists of flexion and extension of the
trunk combined with extension of the legs, is a
prerequisite for standing and walking, and critical for
daily activities8. Loss or decline of this function leads
to functional limitations in self-care, walking, and
independent functioning 10,11 . However, balance
improvement as a result of exercise would support the
value of developing and implementing long-term
programmes for functional performance after stroke.
24. Caleb--123--.pmd 124
Therefore, this study investigated the effects of sit-to-
stand balance training on balance performance and
functional independence.
METHODOLOGY
The protocol for this study was approved by the
Ahmadu Bello University Teaching Hospitals’ Human
Ethics and Research Committee, Kano, Nigeria. A total
number of 46 ambulatory stroke survivors whose
informed consent was obtained and volunteered to
participate were purposively selected from the Murtala
Muhammed Specialists Hospitals and randomly
assigned to two groups using allocation concealment.
This was done by writing even and odd numbers on a
piece of paper, wrapped and placed an envelope.
Participants were asked to pick one envelop, even
number represented intervention group and odd
number represented the control group. The
intervention group participated in a 6-week balance
training exercise. The participants were recruited if
they had a score of 45 in the Berg Balance Score,
ambulatory with stroke duration not more than six
months
DATA COLLECTION PROCEDURE
The intervention group received conventional
stroke treatment which include passive movement,
assisted active movement, active movement and
functional re-education, and additional balance
training exercise, while the control group received
conventional stroke treatment only. The baseline
balance performance was assessed using the Berg
balance scale while functional independence was
assessed using the Barthel Index. The participants were
treated every other day for six weeks and were re-
assessed using the same scales at the end of the
programme.
Weight and Height Measurement: The
participants’ weights were measured using a
standiometer. With the participants’ minimally
dressed, they were asked to stand erect on the
standiometer while their weights are height were read
off.
Balance Assessment: Berg balance scale was used
to score balance performance. At the initial
commencement of the treatment, participants were
assessed using the Berg balance scale for the baseline
balance performance and repeated weekly six weeks.
The scale consists of 14 items requiring subjects to
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 125
maintain positions or complete movement tasks of
varying levels of difficulty13. All items are common to
everyday life. It has a scale of 0-4 for each item, with 0
score being the least and score of 4 being the highest13.
The subjects were assessed and scored appropriately
based on their performance. The scale has a maximum
score of 5612.
Functional Independence Assessment: The
Barthel Index was used to assess functional
independence; it was used to determine the baseline
level and the outcome of the functional independence
at the end of every week for six weeks. The participants
were scored based on whether they have received help
while doing the task or not. The scores for each of the
items were then summed to create a total score. The
minimum score is 0 and maximum 10013.
Balance Training Exercise: The balance training
exercise was sit-to-stand training exercise. The balance
training was conducted according to standard
protocol14.
Step 1: Participant was asked to sit on the chair,
well supported by the back of the chair. Sit upright
with the feet flat on the floor and the knees at right
angle to the ankles.
Step 2: Shift forward to the edge of the chair by
placing hands on the sides of the chair to assist, in so
doing keep the back and head straight.
Step 3: Place hands, palms down, on the thighs.
Push down with the hands as one stands up.
Step 4: Participant continues pressing down on the
thighs with the hands as one stands all the way up,
making sure the weight gradually shifts forward from
the heels to the entire foot. Keep a small bend in the
knees at all times without buckling towards each other.
Step 5: Gently sit back down into the chair and
repeat 10 times
Step 6: Placing the hands on the back of a second
chair in front, if needed. Breathe normally throughout
Table 1: Physical Characteristics of the Participants
VARIABLES Intervention Group
Mean
Age (Years) 43.69
Weight (Kilogram) 74.35
Height (Meters) 1.63
Body Mass Index (Kilogram/Meters) 27.98
24. Caleb--123--.pmd 125
the exercise.
Balance Training Exercise Progression: The
participant performed 10 repetitions in the first two
weeks; it was increased after the second week to 15
repetitions and finally 20 repetitions at the last two
week, making a total of 6 weeks.
Data analysis
Descriptive statistics of mean and standard
deviation were used to summarize and describe the
anthropometric values. The paired t-tests was used to
compare the pre-training and post-training
performances within each of the groups while the
independent t-tests was used to compare variables
between the two groups. All the statistical analysis was
performed using Statistical Package for Social Science
-SPSS (Windows Version 16) at alpha level set at
probability level of 0.05.
RESULTS
This study investigated the effects of 6 weeks
balance training exercise on balance performance and
functional independence in hemiparetic stroke
patients. There were 27 females and 19 males given
male to female ratio of 1:1.4. The mean age of the
participants was 43.69±6.05 years for the intervention
group and 47.40±7.50 years for the control group
(Table 1). Their mean weight was 74.35±7.29 kilogram
and 74.96±9.09 kilogram for the intervention and
control group respectively (Table 1). The height for the
intervention group was 1.63±.0.052 meters and control
group was 1.60±.0.050 meters (Table 1). The two
groups were homogeneous at the baseline (Table 2).
The mean score of the intervention group (51.22±5.469)
was significantly better (p<0.05) in balance
performance at the end of the 6-week period than the
control group (45.26±3.033) (Table 2). The intervention
group (61.13±5.675) performed significantly better in
functional performance of self-care at the end of the
6-week period than the control group (53.39±6.111 )
(Table 2).
Control Group p-Value
SD Mean SD
6.05 47.40 7.50 0.562
7.29 74.96 9.09 0.897
0.052 1.60 0.050 0.768
2.69 29.28 3.63 0.776
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 126 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Table 2: Comparison of Balance and Functional Performances between the Intervention and Control Groups.

VARIABLES Intervention Group Control Group p-Value

Period Mean SD Mean SD t-Value
Balance Performances Pre-Training 46.04 0.429 45.06 0.433 0.828 0.591
Post-Training 51.22 5.469 45.26 3.033 4.568* 0.000
Functional Performances Pre-Training 51.13 6.686 50.37 6.231 0.521 0.761
Post-Training 61.13 5.675 53.39 6.111 4.451* 0.001

t (44) = 1.684; (*pÂ0.05)

DISCUSSION protocol shows that balance training can be used to

The study investigated the effects of a 6-week
balance training exercise on balance performance and
functional independence in hemiparetic stroke
survivors. The female preponderance in this study may
not mean that stroke affects more females than males
but it may show gender differences in the health
seeking behaviours of the residence of Kano. The fact
that those who received balance training had a better
balance and functional performances of self-care shows
that balance training is very essential in stroke
rehabilitation. It also shows that achievement of good
balance will translate to a better functional
performance. This may be due to the fact that if an
individual is able to maintain good balance, he/she
may be able to perform independent function without
fear of losing balance of fall. He/she will be able to
function with adequate confidence. This result
corroborates that of Alexander et al15 that balance
training translates to better performance of activity of
daily living after stroke. This study also agrees with a
previous among stroke survivors in a tertiary health
institution in southwestern Nigeria who observed a
significant improvement in balance and functional
independence using a stair bench training for stroke
patients16. However, the improvement in functional
performance in response to balance training is in
contrast with report of a previous study who
concluded that a 6-week balance training only resulted
in balance performance and not improvement in
functional independence15. The improvement observed
in balance performance in response to balance training
have also been previously observed in previous studies
who assessed the balance response of a group of stroke
survivors to balance training but they did not measure
functional independence6,17,18. Similarly, Laura19 in a
work on an intensive massed practice approach for
retraining balance found a significant improvement
in balance using task based oriented approach.
The fact that functional independence increases
with balance performance in a balance training
compliment functional training and functional
performance in an individual with functional
deficiency. This result disagrees with the those of Karl
et al18 and Catharine et al20 who reported only a change
in balance performance and not in functional
independence following balance training. The findings
of this study suggests that sit-to-stand balance training
is equally effective as other balance training techniques
and is useful in less sophisticated environment for
balance training and functional performance.
CONCLUSION
The sit-to-stand exercise is effective in improving
balance performance and functional independence
in a stroke patient.
Conflict of Interest: There is no conflict of interest on
this article.
Source of Funding: Self-funded
Acknowledgement: We appreciate all the stroke
survivors who participated in this study. We also
appreciate the authority of Murtala Muhammed
Specialists Hospital for allowing us to carry out this
study in their hospital.
REFERENCES
1. Wolfe CA. The impact of stroke. Br Med Bull.
2000; 56(2):275–286.
2. Dickson BA and Abulla F. Sex differences in the
clinical presentation, resource use, and 3-month
outcome of acute stroke in Europe: data from a
multicenter multinational hospital-base
registry. Stroke. 2000; 34:1114–1119.
3. Fritz SL, Pittman AL, Robinson AC, Orton SC
and Rivers ED. An Intense Intervention for
Improving Gait, Balance, and Mobility for
Individuals With Chronic Stroke: A Pilot Study.
Journal of Neurologic Physical Therapy .2007;
1(2):71-76.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 127
4. Berg KO, Maki BE, Williams JI, Holliday P and
Wood-Dauphinee SL. Clinical laboratory
measures of postural balance in an elderly
population. Arch Phys Med Rehabil. 1995;
73(11):1073-80.
5. Mao HF, Hsueh IP and Tang PF. Analysis and
comparison of the psychometric properties of
three balance measures for stroke patients. Stroke
2002; 33(4):1022-1027.
6. Susan LW, Diane MW, Gregory FM, Michael AG,
Mark SR, Joseph MF and James GS (2005). Clinical
Measurement of Sit-to-Stand Performance in
Balance Disorders: Validity of Data for the Five-
Times-Sit-to-Stand Test. Physical Therapy . 2005;
85:10.
7. Teasell N and McClure L (2012). An intensive
massed practice approach to retraining balance
post-stroke. Gait & Posture 2012; 22:154–163.
8. Vander DW, Brunt D, McCulloch MU and Linden
S. Variant and invariant characteristics of the sit-
to-stand task in healthy elderly adults. Arch Phys
Med Rehabil, 1994; 75: 653-60.
9. Tiedemann A, Shimada H, Sherrington C,
Murray S and Lord S. The comparative ability
of eight functional mobility tests for predicting
falls in community-dwelling older people. Age
Ageing. 2008; 37: 430-5.
10. Cheng PT, Wu SH, Liaw MY, Wong AM and
Tang FT. Symmetrical body-weight distribution
training in stroke patients and its effect on fall
prevention. Arch Phys Med Rehabil. 2001; 82:
1650-4.
11. Geiger RA, Allen JB, O’Keefe J and Hicks RR.
Balance and mobility following stroke: effects of
physical therapy interventions with and without
biofeedback/forceplate training. Phys Ther. 2001;
81: 995-1005.
24. Caleb--123--.pmd 127
12. Sahin F, Yilmaz F, Ozimaden A, Ketovoli N and
Sahen I. Reliability and validity of the Turkish
version of Berg balance scale. J Geriatric Physical
Therapy, 2008; 31 (1): 32-37.
13. Mahony FI and Barthel D. Functional evaluation:
the Barthel Index. Maryland State Medical Journal
1965; 14:56-61.
14. Johnson PH. Physical therapy clinical companion.
Springhouse corporation. USA. 2000.
15. Alexander CH, Mirjam H, Ilse JW and Jaak D. A
review of standing balance from stroke. Gait &
Posture 2005; 22:267–281.
16. Hamzat TK and Fashoyin OF. Balance retraining
in post stroke patients using a simple, effective
and affordable technique. Afican Journal of
Neurological sciences 2007; 23(4):85-89.
17. Tung N, Yang M, Lee S and Wang S.
Predominance of postural imbalance in left
Hemiparetic patient. Scand journal of Rehab
Medicine. 2010; 29: 11-6.
18. Karl N, Sandin A, Barry H and Smith B. Effects
of Phys exercise training programs on walking
competency after stroke: a systematic review. Am
J Med Rehabil. 2007; 86(11):935–951.S
19. Laura S. The association of balance capacity and
falls self-efficacy with history of falling in
community-dwelling people with chronic stroke.
Arch Phys Med Rehabil. 2010; 87(4):554–561.
20. Catharine S, Elizabeth N, Julian H and Hall G.
Sitting training early after stroke improves sitting
ability quality carried over to standing up but not
walking:a randomized controlled trial. Adv
Physiotherapy; 2007; 10(4):163–172.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
128 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effect of Swiss Ball Training on Balance in Hemiplegic

Patient

Preeti Gazbare1, Tushar Palekar2

1
Assistant Professor, Principal, Padmashree Dr D Y Patil physiotherapy college, Dr D Y Patil Vidyapeeth,
2

Pimpri, Pune

ABSTRACT

Background: Stroke is sudden loss of neurological function caused by interruption of blood flow to
the brain. Loss of muscle strength, spasticity and imbalance play a role in functional disability in
stroke. Balance status is one of the predictors of outcome of stroke rehabilitation. Exercises on dynamic
surface like Swiss ball is becoming common mean of treatment in stroke patients.

Objective: To analyze the difference in the balance of hemiplegic patients pre & post Swiss ball
training.

Materials and Method: Experimental study with 30 hemiplegic patients of 35-60 year of age with
one time stroke were randomly assigned in two groups, group A (n=15) Swiss ball training along
with conventional therapy and group B (n=15) only conventional therapy. Treatment was given for
60 minute per session, 3 days a week for 4 weeks. The outcome was measured by Berg Balance Score
before and after training.

Result: paired and unpaired t test was applied. Both the groups showed improvement (p<0.001)
with experimental group showing more gain (p<0.002).

Conclusion: Swiss ball training has an additional effect in improving balance in hemiplegic patients.

Keywords: Hemiplegic, Balance, Swiss Ball

INTRODUCTION control, passive mobility, sensation, tone and

Stroke is an acute onset of neurological dysfunction
due to an abnormality in cerebral circulation with
resultant sign and symptoms that correspond to
involvement of focal areas of the brain. Stroke is the
third leading cause of death in industrialized countries
and the leading cause of adult disability. Half of all
stroke survivors are left with major functional
problems in hand, gait, balance, cognition. Residual
impairment persisting longer than 3 week leads to
permanent disability 1 For many people, these
impairments are the major obstacles preventing their
return to independence and quality of life2. Hemiplegia
constitutes the main somato- neurological disorder in
about 90% of the patients3. Stroke patients exhibit
varying deficits in balance, muscle strength, motor
perception. Balance status is one of the predictors of
outcome of stroke rehabilitation4.
Balance is define as the ability to maintain the
body’s centre of gravity over its base of support with
minimal sway or maximal steadiness.5 Every activity
we carry out requires us to react to gravity & our body
to adjust accordingly in order to maintain balance6. In
stroke, one’s ability to balance may be impaired
because of deficits of strength, range of movements,
proprioception, vision, vestibular function and
endurance7.Studies have showed that balance and
perceptual disturbance are found as risk factors for
falls in stroke patients8. Basic components of balance
include center of gravity, posture alignment, limit of
stability (LOS), rhythmic weight shift9. Asymmetry of

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 129
weight bearing is seen in stroke, with patient bearing
as much as 61-80% of their body weight through non
paretic lower extremity10. Task of maintaining balance
in-place is static balance where the base of support
(BOS) remains stationary and only the body center of
mass (COM) moves. The activity of the ankle muscles
is sufficient to maintain static balance during quiet
standing. In dynamic balance, however, both the BOS
and COM are moving, and the COM is never kept
within the BOS during the single-limb support
periods11.
Sensory processes in balance control involve
interaction among orientation inputs from
somatosensory, visual and vestibular systems. Most
common cause of balance dysfunction following stroke
is muscle weakness in the leg as a results of inability
of CNS to control muscle activity. Also decreased
trunk control, poor bilateral integration and impaired
automatic postural control contributes to it. Bobath
described, “Walking as a constant losing and regaining
of balance”12.The adjustment to maintain balance is
anticipatory, in that the postural muscles are activated
in advance of a skilled movement or task or before
expected perturbation 6. Three automatic reaction
namely righting reaction, equilibrium reaction and
postural adaptation to gravity play a important role
in postural reflex mechanism. A change in the COG
necessitates continous postural adjustments during
movement and has to counter by change in the tone
throughout the body musculature. In hemiplegic
patient, spasticity prevents these automatic reactions
from functioning on the affected side. Therefore these
patients are reluctant to put weight on affected side13.
To maintain balance, it is necessary to have a functional
awareness of the base of support to better
accommodate the changing centre of gravity. The goal
of balance training is to improve balance through
perturbation of the musculoskeletal system that will
facilitate neuromuscular capability, readiness, and
reaction14.
SWISS BALL
Dr Klein-Vogelbach was first to describe and
analyze ball exercises. Swiss ball can be used in
evaluating and train balance, co-ordination, strength
and skill. The Swiss ball reduces the amount of body
weight a patient has to lift when weak or partially
paralyzed because the effect of gravity is less. The
convex surface of the ball creates constant demand for
equilibrium reaction as it has minimal contact with
floor. This improves postural awareness, symmetry,
25. Preeti--128--.pmd 129
alignment, alertness, balance of patient and makes
them active participant15.
A Swiss ball movement requires a greater degree
of coordination and permits the execution of both static
stretches as well as more demanding dynamic
stretches. Swiss ball permits a range of exercises that
are based on the user’s ability to move with the motion
of the ball while performing the exercise, using the
ball to both support the body during the movement
as well as to provide a measure of resistance to the
muscles employed in the movement16.With Swiss ball,
muscles activities are stimulated in three different
ways: the patient moves the ball in specific direction.
Patient maintains a certain position and prevents ball
movement. Ball is moved or moves and patient reacts6.
Swiss ball is frequently use as a tool to treatment
neurologically affected patient. However no studies
have quantified the effect of balance training on Swiss
ball in hemiplegia.The purpose of this study is to test
the effect of Swiss ball exercises on balance training
with hemiplegic patients as study population
objectively.
AIM AND OBJECTIVE
The aim is to quantify the effect of Swiss ball
training on balance in hemiplegic patients.
The objective is to analyze the difference in the
balance score pre & post Swiss ball training in
hemiplegic patients
MATERIALS AND METHOD
Study design : Experimental study
Sampling technique: Simple Random method.
Study setting: Padmashree Dr. D.Y. Patil Medical
Hospital & Physiotherapy OPD, Pimpri, Pune and
Sasoon hospital, Pune.
Sample size: 30
Inclusion criteria
• Diagnosed patient of hemiplegia secondary to
vascular stroke by doctors with stable
cardiovascular condition
• Patient in age group of 35 to 60 year, both gender.
• First time stroke patients, Middle cerebral artery
involvement.
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 130 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
• Brunnstrom’s recovery stage grading 2-4.
• Mini-Mental State Examination score greater than
24/30.
Exclusion criteria
• People with any orthopedic problems, any recent
medical or surgical history.
• Any other associated neurological condition.
• Chronic alcoholism, Postural hypotension.
• Vestibular dysfunctions, Sensory impairments,
Vision impairments.
Material used
• Stopwatch. Stool. Ruler, Chair with arm rest and
without armrest.
• Swiss ball 65 & 75 cm, Treatment mat- firm non
slippery.
Outcome measure: Berg’s balance scale (BBS)
Procedure
Patients who fulfill the inclusion criteria were
included. Purpose of the study and procedure was
explained to the patients. Ethical approval from the
institutional ethical committee and written consent
from patients was taken. Patient was randomly
divided into two groups by chit method.
Group A: Experimental group = Conventional
treatment + Swiss ball
Group B: Control group = Only Conventional
treatment
Pre-training BBS score was recorded on day 1.For
group A, therapy was initiated with conventional
therapy followed by Swiss ball. All exercises were
assisted initially by therapist & later it was carried out
actively by patients.
Swiss ball exercises
1. Sitting on the ball
• Pelvic tilt exercises, weight shift exercises.
25. Preeti--128--.pmd 130
• Limb movements: alone then with alternate upper
limb & lower limb.
• Reach out in all direction with both hands clasped
or with the normal hand.
2. Supine on mat with lower limb on ball:
• Bridging with lower limbs on ball.
• Abduction-Adduction of legs.
3. Standing, hemiplegic leg on ball – produce
movement by affected and normal limb.
4. Bouncing on ball.
Conventional therapy includes
• Slow sustained stretches to spastic muscles.
• Passive movements of all joints on affected side.
• Mat exercises: rolling, quadruped, kneeling, half
kneeling.
• Strengthening of affected side.
• Functional activities such as bed mobility, scooting
in a sitting position, standing, reaching,
transfers.Stair climbing, and gait training on
different surfaces.
• Balance exercise like Tilt board exercise, one leg
standing, tandem –standing and walking,
braiding, reach outs within and out of base of
support.
Conventional treatment was tailor-made according
to muscle affected. Duration of training – 4 weeks, 3
times per week. An exercise was terminated on
patients demand if they feel tired or fatigue or any
complains. Appropriate rest pause between each
exercise was given. Total treatment duration 60
minutes. After 4week, patients balance was reassessed
on BBS and score was documented.
Statistical Analysis
Statistical analysis was done using SPSS 15.0
Software. An independent t-test was used to compare
the changes in BBS score in both the groups at baseline
and after the end of treatment protocol i.e. at week 4.
A statistically significant difference was defined as p
less than 0.05.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 131

RESULTS

Table 1: Demographic characteristic of the patients

Variables Group A Group B

(experimental group) (control group)
Females 04 (26.6%) 05 (73.3%)
Males 11 (33.3%) 10 (66.6%)
Mean Age (yrs) 48+_9.47 48.2+_8.33
Right Hemiplegic (%) 08 (53.3%) 07 (46.6%)
Left Hemiplegic (%) 07 (46.6%) 08 (53.3%)
Duration of affection (yrs) 2.34+_1.8 2.43+_1.75

Table 2: Comparison of pre and post treatment berg balance scale score of Experimental group(A) and Control
group(B)

GROUP A GROUP B
(experimental group) (Control group)
Mean Std Dev Mean Std Dev
Pre-treatment 34.47 5.69 32.53 6.312
Post treatment(4 weeks) 47.2 4.769 41.87 6.567
Difference 12.73 9.33
T value & p value t = -16.126, p=0.00 t = -15.583, p=0.00

The mean of berg balance score pre and post
training is 34.47±5.69 and 47.2 ± 4.76 for group A
respectively and for group B is 32.53±6.31and
41.87±6.56 respectively. Both the groups individually
showed significant improvement in balance with
p=0.001. However, between group comparison shows
greater improvement in group A than group B with t
value 3.43 and p=0.002.
differential components such as postural sway and
symmetry of weight distribution. Improving
symmetry of weight distribution while bilateral
standing, is one of the main treatment goals in the
rehabilitation, acknowledging that the degree of
asymmetric weight distribution during quiet standing
is negatively associated with motor function and
independence.

Training on Swiss ball provides the patient with

DISCUSSION
This study investigated the relative effectiveness
of the combination of Swiss ball with conventional
physical therapy compared with conventional therapy
alone on balance in hemiplegics. The potential of Swiss
ball training as the method of acquiring and improving
the motor skills and balance has been recognized in
the studies. The study finding showed that patients
treated with Swiss ball combined with conventional
physical therapy and those treated with only
conventional therapy, both clinically and statistically
showed significant improvement, but the
improvement was greater in experimental group i.e.
with Swiss ball. Therefore we can say Swiss ball
training enhance the effects of conventional physical
therapy on balance in hemiplegia secondary to stroke.
In particular, recovery of postural control is found
to be a prerequisite for regaining independence in
activities of daily living. Current research concerning
balance deficits in hemiplegic patients focuses on
proprioceptive, visual and somatosensory feedback at
each challenge level. This is supported by the study
on Relationship of Sensory Organization to Balance
Function in Patients with Hemiplegia by Richard
Fabio, Mary Badke who found that balance behaviour
can be influenced by somatosensory, visual and
vestibular system. Studies says in stroke,
proprioception is often compromised which may lead
to increased risk of falling. Results are also in
agreement with the study by Anne Cook, Fay Horak
on Assessing the Influence of Sensory Interaction on
Balance which says that standing, walking, swaying
and functional movements on foam may be practiced
by patients as a therapeutic treatment approach to
improve flexible use of all senses for postural control.12
Swiss ball training for postural control, postural
adaptation, trunk alignment has increasing order of
destabilizing effect. So there is probably a transfer of
learning, which refers to a person’s ability to carry out
the same task in a different environment. Most subjects
in the study had reduced social activity, were restricted

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 132 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
to home due to fear of fall, could not use public
transport, and could not walk in crowded places. After
training, patients were more confident about their
upright postures and its control thereby became more
social.
Paul Goodman in his study stated that training on
a ball elicits greater neuromuscular stimulation than
performing similar movements on a stable surface i.e.
floor. Swiss ball enhance performance by forcing the
exerciser to use additional muscles in order to maintain
balance. A developed core leads to more
neuromuscular efficiency, which then lends to
coordinated functional movement.14In hemiplegics the
core muscle especially the abdominals are weak and
so strengthening of core can help improve limb
functions. Jerrold Petrofskg in 2007 stated to reduce
the risk of fall good core muscle strength is required.
Total work done was greater in any condition for the
Swiss ball. This is probably because of the increase in
muscle use of the core muscles to stabilize the body to
balance on the Swiss ball.15
Most of the patient in the study has onset of stroke
above 3 – 4 month. Most spontaneous recovery takes
place in the first 3 months, and then reaches a plateau.
Later ongoing improvement in neurologic function
occurs by a neuroplasticity that allow structural and
functional reorganization within the brain and may
continue for many months. The two most plausible
forms of plasticity are collateral sprouting of new
synaptic connections and unmasking of previously
latent functional pathways. Restitution of partially
damaged pathways and expansion of representational
brain maps occur, implying recruitment of neurons
that are not ordinarily involved in an activity. Key
aspect of neuroplasticity for rehabilitation is the
modifications in neuronal networks which are use-
dependent and hence contributes to improved
function.10
In this study while performing exercises, patients
had to maintain position for few seconds with good
postural control and alignment which is the deficit area
in hemiplegics, supported by Ikai Kanni in the study
Dynamic Postural Control in patients with hemiparesis
says trunk control allows the body to remain upright,
to adjust to weight shifts, to control movement against
the constant pull of gravity. The training protocol
which provides increased postural & trunk control
thus may have improved balance.11 During the training
sessions, patients were given feedback about their
posture, trunk alignment. The most promising
25. Preeti--128--.pmd 132
application of the study would be to implement
balance training on Swiss ball in the early phase of
rehabilitation to provide a reduced risk of falling.
Limitations of the study was that sample size was
small therefore the results of the study cannot be
generalized for balance training in hemiplegics.
Further studies can be carried out on various type of
stroke, varying frequency and duration of balance
training on Swiss ball and by checking training effect
on other outcomes measure like gait, spasticity, trunk
alignment, functional ability.
CONCLUSION
Both the groups showed significant improvement
in balance but there was additional effect found in
experimental group. Therefore Swiss ball training can
be combined with conventional physical therapy for
improving balance in hemiplegics.
Acknowledgment: I thanks all the patients for their
cooperation throughout the study and my sincere
thanks to my guide and colleagues for all their help.
REFERENCES
1. Susan B. O’Sullivan, Thomas J. Schmitz, Physical
Rehabilitation: Assessment and treatment,
5thEdition: Jaypee Brothers, 2001:pp519-581.
2. Polly Laidler. Stroke Rehabilitation-structure and
stratergy, 1st Edition, 1994:pp99-114.
3. Darcy A Umphred. Neurological Rehabilitation
5th edition. USA.2001 Mosby Elsevier: pp857-891.
4. Chun Chen, MD et al. Effect of balance training
on hemplegics stroke patient. Med J 2002;25:
583-90.
5. Shumway cook, Woollacott. Motor control:
theory & practical application. 4th edition, 2000.
6. Patricia M. Davies. Steps to follow: The
comprehensive treatment of patients with
hemiplegia, Chapter No.2, Second Edition, New
Delhi, Jaypee Brothers Medical Publishers (P)
Ltd., 2003, pp235-276.
7. Nashler L. Evaluation of postural stability,
movement and control. In Hasson(ed): Clinical
exercise physiology, Philadelphia, CV Mosby,
1994
8. Lars Nyberg, Yngve Gustafson. Patient Falls in
Stroke Rehabilitation: A Challenge to
Rehabilitation Strategies. Stroke, 1995;26:838-42.
9. Ruthgeiger, Hicks, Allen, Keefe. Balance and
mobility following stroke: effect of physiotherapy
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 133
intervention with and without biofeedback
training. Physical therapy 2001; 81:995 -1005.
10. Marjm’e H Woollacott, Pei-Fang Tang. Balance
Control During Walking in the Older
Adult:Research and Its Implications. Physical
Therapy 1997;77(6).
11. Snehal Shah, Smita Jayavant. Study of balance
training in ambulatory hemiplegics. The Indian
Journal of Occupational Therapy : Vol. XXXVIII :
No. 1 (April - July 2006)
12. Berta Bobath. Adult hemiplegia assessment and
treatment, 3 rd edition, 1990, butterworth-
heinemann, Delhi, India
25. Preeti--128--.pmd 133
13. Yaggie, JA, Campbell BM. Effects of balance
training on selected skills. J. Strength Cond.
Res.2006;20(2):422-428.
14. Paul J, Goodman P. NCSA’S performance
training journal 2003; 2(6):9-25.
15. Jerrold S. Petrofsky et al. Core Muscle Activity
During Exercise on a Mini Stability Ball
Compared With Abdominal Crunches on the
Floor and on a Swiss Ball. the journal of applied
research 2007;7:3.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
134 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Role of Physiotherapy in Public Health Domain: India

Perspective

Kirti Sundar Sahu1, Bhavna Bharati2

1
Founder, Bhubaneswar Advanced Rehabilitation Center, Bhubaneswar, Odisha, 2Consultant, J-PAL, Bhubaneswar
and, Co-founder Bhubaneswar Advanced Rehabilitation Center, Bhubaneswar, Odisha

ABSTRACT

Physiotherapy professionals restore healthy lifestyle, reduce pain and maintain optimum function
of the body. In the other hand public health try to prevent diseases, promote healthy life and work
towards making a disease free world. In this article it is explained how both the profession can
coincides and merges. Present burden of diseases within India and lack of sufficient human resource
making the situation difficult. Addition of physiotherapist in the team for prevention, treatment and
rehabilitation of Cardio vascular diseases, diabetes, cancer, respiratory conditions, hypertension and
other chronic conditions can be more cost effective and better prognostic way. In present day situation
if those bio-medically trained professional assessed, trained appropriately then utilization can be
possible in a verity of direction and symbiotic relationship can be created between both the professions.

Keywords: Physiotherapy, Public Health, Human Resource, Burden Of Disease

INTRODUCTION profession is multifaceted, which includes direct or

Physiotherapy, a profession fully dedicated for the
service of humanity is still enjoying its adolescent stage
in India. Though historically it is very old profession,
in India it is celebrating its 60th year of formal existence.
According to World Confederation of Physical
Therapy it provides services to individual at micro
level and the whole population at macro level to
develop maintenance and restoration of optimum
movement and functional capabilities all through the
lifetime. The domain of Physiotherapy includes
restoring bodily movement which is commonly
affected by pain, age, injury, stress, disorders, various
pathological conditions or even environmental factors.
The term healthy can be grossly understood by a
common man is moving healthy. The scope of this
indirect patient or client care, public health strategies,
advocacy for the society towards healthy, supervising
and delegating to others, leading, managing, teaching
and participate in research and development. Role of
Physiotherapist also includes help in formulation of
local, national and international policy.1
The steps of a ground level Physiotherapist consist
of assessment, planning and implementation of a
program which improves or restore movements,
maximize movement abilities, reduction of pain, treat
or prevent physical challenges resulted due to injuries,
diseases or multiple causes of impairments.
Multimodal treatment protocol of Physiotherapy
intervention contains some exercise, some manual
therapy and electrotherapy procedures.2

As per World Health Organisation the field of

Corresponding author:
Kirti Sundar Sahu Public health includes all organized activities whether
MPT (Musculoskeletal) or public or private to prevent disease, promotion of
MPH Scholar at Achuta Menon Center for health and increase life expectancy of the population
Health Science Studies, Sree Chitra Tirunal as a whole. The aim of Public health is to create the
Institute for Medical Sciences and Technology, environment where people can be healthy and focus
Thiruvananthapuram - 11, Kerala on whole population not individual patient or disease.
Employee Code- 6455 The main functions of the profession are, assessment
Mobile No: 8281658158 and monitoring of the health of communities and
Email id: kirtisundar@gmail.com populations at risk to get the information about various

26. Kirti Sunder Sahu--134--.pmd 134 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 135
health problems and the order, formulation of policies
to answer those problems at local or national level,
assure accessibility to appropriate and cost effective
care including disease prevention and health
promotion facilities.3
India in a period of epidemiological transition with
double burden of communicable and non
communicable diseases needs a critical and well
planned strategy for its future. The major causes of
death are Communicable diseases, maternal, peri-natal
and nutritional disorders (38 % of deaths), non-
communicable diseases (42 %), Injuries and ill-defined
causes constitute 10 per cent of deaths each. However,
majority of ill-defined causes are at older ages (above
70 years) and likely to be from non-communicable
diseases.4
According to WHO the four leading chronic
diseases in India are cardiovascular diseases (CVD),
diabetes Mellitus (diabetes), chronic obstructive
pulmonary disease (COPD) and cancer. The six leading
risks factors associated with non-communicable
diseases are tobacco Use, physical inactivity,
overweight/obesity, high blood Pressure, high
cholesterol levels, and high blood glucose levels.5, 6, 7
Role of Physiotherapy in Public health
Cardiovascular diseases (CVD) are conditions such
as stroke, myocardial infarction or angina pectoris.
These diseases are caused by gradual deposition of
fatty materials in the coronary arteries resulting into
narrowing and angina. If a broken piece of those
accumulation or clot will travel in the blood stream
and block then it stopped the blood supply to the heart
or brain leading to stroke. Within the group of CVD
patients, 30% are suffering back pain, arthritis, 21%
diabetes and 16% respiratory associated diseases.
Physiotherapy based cardio rehabilitation
programme are not only clinically effective in reducing
mortality but also improves health and quality of life.
It also reduces length of hospital stay and number of
hospital readmission by preventing recurrence. They
also learn self management of the problem which leads
them to early return to work. Experience of
Physiotherapy session discover the other associated
problem which are need to be identified and proper
intervention adapted to make them more mobile and
active. Within the team of multi-professional team for
cardiac rehabilitation they are the key member for
physical rehabilitation, modification of lifestyle with
26. Kirti Sunder Sahu--134--.pmd 135
individual tailor made exercise program. This is cost
effective and the prognosis is better.
Regarding cost benefit it is second to aspirin and
beta blockers to reduce the risk of cardiac mortality
by 26% over five years but unfortunately this facility
is not available for many of the community. Even with
comparison to traditional care five studies found
cardiac rehabilitation is cost effective. The result
showed the incremental cost of each additional Quality
adjusted life years (QALY) is about 8000 pounds,
which is much less comparison to standardized cost.
In UK it is estimated that reduction of CVD risk by 1%
would generate discounted savings of nearly 260
million pounds per year. So if cardiac rehabilitation
program will be equally accessible and relevant then
it can save many quality life years. Physiotherapist can
prove those exercised centered rehabilitation programs
are much better and cost effective than other ways of
interventions. Almost 25 % of improvement in fitness
levels will be there for exercise group. Even in abroad
the health department recognizes the benefit of
Physiotherapy and has produced an evidence based
service specification for implementation. It is an
inexpensive method, which saves lives and retains
patients on their own mobility, physically and
emotionally fit through exercise, awareness and
support. Clinical experience of Physiotherapist helps
them lead cardiac rehabilitation program in an
effective way by making tailor made exercise protocols,
deliver public health messages and support
individually to change their lifestyle ,indirectly
reducing economic burden on healthcare system.8,9,10
Diabetes mellitus is the big share of the non
communicable disease where the roles of
physiotherapist are multidimensional. Starting from
prevention to handle end stage complications like
amputation and application of orthosis, wheelchair
planning are the components. Thirty minutes of
moderate physical activity on most days of the week
can prevent initiation of diabetes and its complications.
The economical burden of the diseases also can be
reduced which is direct and indirect. For type I diabetes
the importance of exercises to allow safe participation
in physical activity consistent with individual’s goal
and desire.11.12.13.14
In case of chronic non infectious respiratory
conditions exercise training is very effective in
increasing physical capacity, strengthening muscles
(respiratory and accessory) improvement of quality of
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 136 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
life, reduction of symptoms. Conditions like COPD or
Asthma these are proven to be beneficial even in
bronchiectasis some degree of benefit in all above
parameters observed. Non exercise based treatments
such as bronchial hygiene techniques; inspiratory
muscle training techniques also creates improvements
in all types of respiratory conditions.15
Cancer the killer disease also comes up with high
level of pain, muscle weakness, joint stiffness and other
associated problems where role of Physiotherapy is
multifold. Recent studies shown reduction of cancer
pain can be possible by mechanism based
Physiotherapy interventions.10, 16, 17, 18
Hypertension also can be prevented by
Physiotherapeutic maneuvers like aerobics, exercise
interventions, yoga and others. Other chronic
conditions where physiotherapy can help are
musculoskeletal problems including low backache,
neck pain, chronic disabling arthritis, post surgical
conditions, antenatal, post natal complications, obesity
and so on. These conditions are not only handled
individually but also through community intervention
strategies.
DISCUSSION
The current of number of registered
Physiotherapists are approximately more than 50000
within India. Some of them working in public, private,
corporate and other sectors, sometimes after studying
for a period of four and half year or more they are
opting to work in non health sectors like probationary
officers in banks, administrative jobs in different areas
as lack of government employment and negligence.
Where very high deficiency of human resource of
health in India if this process can modified and
provided appropriate training, they can be engaged
in various health related positions. It can be useful
not only for the country but for the profession.
At present community based Physiotherapy
rehabilitation are the main areas where specially
trained candidates of physiotherapists intervening
disabled conditions and rehabilitating them. If that
manpower can be utilized for a bigger intervention
then it can solve many Public health problems with a
different perspective. India the “Birthplace of Yoga”
is now facing burden of physical inactivity and
sedentary occupations. It is the Physiotherapy
professional who can aware the community about the
26. Kirti Sunder Sahu--134--.pmd 136
ground level benefits of exercise and prevent these
burden of non communicable diseases.
CONCLUSION
It is the high time to think about the proper
management of human resource of Physiotherapy
profession towards high value laden Public health.
Utilization of biomedical professional in the health
field will definitely helpful for the future generation
of Public health.
Acknowledgement: Authors are highly thankful to
faculties of NIRTAR and SCTIMST for their knowledge
sharing.
Conflict of Interest: No conflict of interest.
Source of Support: No support
Ethical Clearance: No
REFERENCES
1. World Confederation of Physical Therapy. Policy
statement.WCPT,London,2013
2. World Health Organisation. Classification of
heath worker statistics, Geneva, WHO
3. http://www.who.int/trade/glossary/story076/
en/(accessed on 18th August 2013)
4. Ministry of health and family welfare. Annual
report to the people on health. New Delhi 2010
5. D Wayne Taylor. The burden of non
communicable disease in India. Hamilton ON,
Cameron institute 2010.
6. Aaron J Kohen, Global burden of disease 2010,
Institute of Health Metrics and Evaluation, 2013.
7. National commission on macroeconomics and
health. Burden of disease in India 2005, New
Delhi.
8. Artero EG, Lee D, Lavie CJ, España-Romero V,
Sui X, Church TS, et al. Effects of muscular
strength on cardiovascular risk factors and
prognosis. J Cardiopulm Rehabil Prev. 2012 Dec;
32(6):351–8.
9. Blohm D, Ploch T, Apelt S. Efficacy of exercise
therapy to reduce cardiometabolic risk factors in
overweight and obese children and adolescents:
a systematic review. Dtsch Med Wochenschr 2012
Dec; 137(50):2631–6.
10. Scott JM, Koelwyn GJ, Hornsby WE, Khouri M,
Peppercorn J, Douglas PS, et al. Exercise therapy
as treatment for cardiovascular and oncologic
disease after a diagnosis of early-stage cancer.
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 137
Semin Oncol. 2013 Apr; 40(2):218–28.
11. Santeusanio F, Di Loreto C, Lucidi P, Murdolo
G, De Cicco A, Parlanti N, et al. Diabetes and
exercise. J Endocrinol Invest. 2003 Sep;26(9):
937–40.
12. Cano-De La Cuerda R, Aguila-Maturana AM,
Miangolarra-Page JC. [Effectiveness of physical
exercise programs in patients with diabetes
mellitus]. Med Clínica. 2009 Feb 14;132(5):
188–94.
13. Apor P. Physical activity in prevention and
treatment of diabetes. Orv Hetil. 2009 Mar 29;
150(13):579–87.
14. Zinman B, Ruderman N, Campaigne BN, Devlin
JT, Schneider SH, American Diabetes Association.
Physical activity/exercise and diabetes mellitus.
Diabetes Care. 2003 Jan;26 Suppl 1:S73–77.
26. Kirti Sunder Sahu--134--.pmd 137
15. Divo M, Pinto-Plata V. Role of exercise in testing
and in therapy of COPD. Med Clin North Am.
2012 Jul; 96(4):753–66.
16. Kumar S, Prasad K, Kumar V, Shenoy K, Sisodia
V. Mechanism-based classification and physical
therapy management of persons with cancer
pain: A prospective case series. Indian J Palliat
Care. 2013;19(1):27.
17. Lihua P, Su M, Zejun Z, Ke W, Bennett MI. Spinal
cord stimulation for cancer-related pain in adults.
Cochrane Database Syst Rev. 2013;2:CD009389.
18. Hurlow A, Bennett MI, Robb KA, Johnson MI,
Simpson KH, Oxberry SG. Transcutaneous
electric nerve stimulation (TENS) for cancer pain
in adults. Cochrane Database Syst Rev.
2012;3:CD006276.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
138 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effect of Joint Approximation Through Weights Around

Waist on Postural Sway and Balance in Elderly

Neetu Rani Dhiman1, Sunil Bhatt2, Vyom Gyanpuri3, Girdhari Lal Shah4
1
Department of Anatomy, Institute of Medical Sciences, Banaras Hindu University, 2Assistant Professor, Department
of Physiotherapy, Dolphin (PG) Institute Of Bio-Medical and Natural Sciences, Dehradun, Uttarakhand, 3Kings
Physiotherapy Clinic, Varanasi, Uttar Pradesh, 4Department of Anatomy, Institute of Medical Sciences, Banaras
Hindu University

ABSTRACT

Background and Purpose: The use of external body weights has been employed to improve balance
in patients. The aim of this study was to determine the effect of joint approximation through weights
around waist on postural sway and balance in elderly.

Method: Thirty elderly subjects with Berg Balance Scale (BBS) Score<45 between the ages of 65 to 95
years were recruited from the community in and around Dehradun. The BBS score and postural
sway were assessed three times; without weights, with weights and after removing weights from the
pelvic belt. All three readings were compared to see the effect of approximation on reduction of
sway and improvement in balance. The amount of weight taken was 10% of body weight of each
subject. The immediate after effect of approximation was also determined. The reliability of sway
meter used in study was quantified using Intraclass Correlation Coefficients (ICC) before starting
the study procedure (Antero-Posterior sway, ICC= 0.83).

Results: The results suggested that there was a significant (p=0.000) reduction in Antero-Posterior
postural sway (A-P Sway) and significant (p=0.000) improvement in balance with the application of
weights. The immediate improvement in balance and reduction in sway was also seen after removing
weights. There was no significant improvement in Medio-Lateral sway (M-L Sway).

Conclusion: The present study concluded that joint approximation through weights around the waist
is beneficial for reducing postural sway and improving balance in elderly.

Keywords: Approximation, Postural Sway, Balance

INTRODUCTION life in 500 adults aged 40 to 80 years, who were free of

Balance or postural stability is the ability to
maintain the body in equilibrium which means that
all the forces acting on a body should be balanced.1
Postural sway is a state of dynamic equilibrium
which results in small oscillations of the body.2 Postural
sway was found to be increased with each decade of
Corresponding author:
Neetu Rani Dhiman
Department of Anatomy, Institute of Medical Sciences,
Banaras Hindu University, Varanasi, India
Ph.: +91 8765759806
Email: gyanpurineetu@gmail.com
pathology. 1 Sophisticated equipment such as
computerized force platforms and motion analysis
machines, eventually allow therapists to be quite
accurate in their descriptions of centre-of-body mass
position and in kinematic descriptions of movement
strategies for equilibrium. 3 More sophisticated
measurements of sway include posturography using
force-plates, used to measure ground reaction forces.4
Several studies have used postural sway as a measure
of standing balance. 5-7 Both sway amplitude and
velocity in a population of institutionalized elderly
have been examined and it has been determined that
sway velocity was significantly greater for those who
fell one or more times in a year than those who had

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 139
not fallen.8 The musculature of legs, feet and trunk,
using this feedback circuit, allows the individual to
stand erect against the forces of gravity.9
Approximation is defined as “compressing the joint
surfaces” either manually or through the application
of weights. 3 to 5 kg of weight around the ankles, knees
and waists of patients with balance impairment caused
by Friedreick’s ataxia, multiple sclerosis or cerebellar
degeneration and cerebro-vascular accidents produced
functional improvement in gait in 11 out of 14
patients.2,4
Recently an innovative idea for therapy has
emerged from the observation that holding heavy
objects appears to improve muscle control and lead to
improvements in balance and functional ability.10 In
many studies, weights have been used for joint
compression.11,12 Elderly people show changes in the
motor and sensory systems affecting postural control
and these changes can contribute significantly to an
inability to maintain balance.13 Maintenance of upright
posture is a fundamental homeostatic mechanism
governed by visual, proprioceptive, exteroceptive and
vestibular sensory input, by central processing and
coordination and by muscular tone and voluntary
muscular activity.14 The vestibular system registers the
positions and movements of our bodies relative to
gravity.15 A decline in vestibular function with age
causes this internal absolute reference system to be less
reliable and thus the nervous system has difficulty
dealing with coming information from visual and
somato-sensory systems.1
MATERIAL AND METHOD
This study was performed on 30 elderly adults (22
Male and 8 Female) selected with convenient sampling
after signing the informed consent form. Table 1
represents the demographic data for all subjects.
Subjects were recruited from the community in and
around Dehradun. In order to participate in the study,
subjects needed to be able to stand without support
and having a Berg Balance Scale (BBS) score of less
than 45. We excluded volunteers from the study if they
had history of clinical depression or progressive
neurological disorder, have had lower extremity
fracture, surgery, or joint replacement within the past
year, subjects taking any drugs currently causing
dizziness and subjects having any known vestibular
dysfunction were excluded. We also excluded those
subjects who had Mini mental status examination
(MMSE) less than 23.
27. Neetu Rani Dhiman--138--.pmd 139
Instruments
Pelvic belt to hold the weights, and was placed
around the subjects’ waist (Figure 1).
Sway Meter (Figure 2) was designed to measure
the displacement of the body at waist level. 16 It
consisted of a rod with a vertically mounted pencil at
its end. The rod was attached to the subject by the
pelvic belt and extends posteriorly. The pencil
recorded the subjects’ sway on a sheet of millimeter
graph paper fastened at the top of a sway table which
could be adjusted according to patient’s height (Figure
3). We measured both inter-rater and intra-rater
reliability of sway meter. Table 2 displays the
Reliability data of sway meter.
Berg Balance Scale (BBS) is a 14 item scale
developed to measure balance among older people
with impairment in balance. It is a valid and reliable
instrument (ICC=0.97-0.99; IRR=0.99).
Procedure
Whole procedure was explained to the participants
and then the informed consent was signed by each
subject. The BBS score and the sway meter reading
were taken without the weights in belt and then with
weights. Balance and sway were also assessed after
removing the weights from the belt to see the
immediate after effect of approximation (Figure 4). 10%
of subjects’ body weight was taken as the amount of
weight attached to the belt.11 The belt was wrapped
securely around the participants’ waist. The belt was
adjusted according to comfort level of each subject.
Participants were made to stand for thirty seconds and
then, step off the sway meter. After measuring the
amount of sway, the BBS score of each subject was
measured. Finally, sway meter reading and BBS score
were analyzed in all three conditions: Without weights,
with weights and after weights.
RESULTS
The data was analyzed by using Statistical Package
of Social Science-SPSS software (version 11.5) for
windows. Within group analysis revealed that mean
for A-P sway in before weights condition is much
greater than with weights condition and this difference
is statistically significant but there is no statistically
significant difference in the mean for M-L postural
sway (Table 3). Mean for BBS is also significantly less
in before weights condition than with weights
condition. There is also significant difference between
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 140 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
before weights and after weights condition in means
of both A-P sway and BBS scoring (Table 4). This
indicates that weights have some after effect also, on
sway and balance.
Pairwise comparison showed that the mean
difference between with weights and after weights
condition for both sway and balance was not
significant (Table 5&6).
DISCUSSION
These results might be due to the stimulation of
afferent impulses from deep pressure receptors from
joint compression of lower limbs by loading, exceeding
than the normal body weight and reflexively
facilitating co-contraction of the stabilizing muscles
around the compressed joints. Weighted vests or berets
were recommended to facilitate co-contraction around
the joint and thereby increase the patient’s stability.11
Pomeroy10 et al did a study to determine the effect
of weighted garments on balance and gait patients with
stroke and residual disability. They found no evidence
to support the clinical use of those weighted garments
for stroke survivors. The reason might be unilateral
application of weights. This asymmetrical distribution
of weights would not have much effect on the stability
of joints and muscles of lower limb. While, we used
weights symmetrically over the waist of the subjects.
A case report was done to see the effect of balance-
based Torso-weighting on balance in a single patient
of ataxia and Multiple Sclerosis (MS). Good success in
the patient was reported.12 The results of our study
are in support with the results of these studies. But
these studies were performed on the patients with
cerebellar ataxia and MS and in less number of patients
while our study was performed on a large group of
elder subjects.
Clopton et al studied the effects on gait
characteristics of placing weight on the shoulders or
around the waist of 5 subjects with cerebellar ataxia.
He found improvement in gait by axial loading in three
out of five patients.11,12 These studies were inconclusive
in finding the effect of weighting on balance. They
applied weight over the shoulders which would have
less effect on the joints of lower limb and hence less
joint approximation.
Using motor control theories, it has been suggested
that adding mass in the appropriate amounts and at
the appropriate locations might increase the stability
27. Neetu Rani Dhiman--138--.pmd 140
of the body or body parts biomechanically by changing
the moment of inertia.11,12 The sense of touch can
facilitate increased body orientation. Previous studies
showed that the use of light touch contact of a fingertip
can provide sensory information as a balance aid to
decrease body sway.19 Our findings demonstrate that
there is influence of contact of the weighted belt on
the subjects’ body which provided additional
kinesthetic sense information to improve stability as;
in elderly the kinesthetic cues from lower limbs are
inaccurate. Increasing sensory input via the application
of additional weight may increase afferent input from
deep pressure receptors, thus facilitating co-
contraction of the muscles and increasing stability.12
If ageing compromises sensorimotor functions of
muscle, the ability of older subjects to detect and
correct postural sway may be impeded, resulting in
impairment of functional performance.20 Most of the
previous studies done on weighting by a number of
researchers were performed on patients with ataxia
and MS21, 22.
It has been seen that with weighting, the centre of
pressure becomes more centered from the baseline to
the weighted condition.22 Therefore, it can be said that
with application of weights, our subjects’ centre of
pressure would have shifted more centrally, which
made them much more stable in standing still and in
performing the various components of BBS. Weighting
improved both static and dynamic balance of the
subjects.
Subjects also showed improved stability after
removing the weights from the belt. This indicates that
weighting has immediate after effect on improvement
of balance but this effect is less than the improvement
shown in with weighted condition. This improvement
may be due to the same mechanisms explained above.
These changes would be present after removing the
weights but may be only for a short period of time.
As it has been expressed in literature that there is
more Antero-Posterior sway than Medio-Lateral sway
in normal subjects, so it can be said that changes in A-
P sway are more detectable and visible than M-L sway.
In our study, this could be one of the reasons for no
change in M-L sway of the subjects. Moreover, the
instrument we used for the measurement of sway that
is the Sway Meter is not much sensitive for sway
measurement at least not in comparison with force
platform which is most valid and reliable method for
quantitatively assessing functional balance through
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 141
analysis of postural sway and is used by most of the
researchers. Many studies11,12 have used the force
platform to detect sway changes and they reported
improvement in Medio-Lateral stability with
weighting in paients with ataxia. But, in our study,
we could not found significant reduction in M-L sway
and that might be due to the instrument.
In our study, we saw that the baseline sway of
female subjects was much greater than the male
subjects especially the Medio-Lateral sway. So, a future
study can be recommended to compare the amount of
sway between male and female elder subjects. Aother
research can be done in which this intervention is
extended for longer duration of time. This study can
be done on a large number of patients with
neurological disorder.
From the above explanation and discussion of
results, we can say that joint approximation through
weights around waist may be a beneficial technique
for decreasing postural sway and improving balance
in elderly people.
CONCLUSION
Joint approximation through weights around the
waist is beneficial for reducing postural sway and
improving balance in elderly. Therefore, joint
approximation can be used as a beneficial technique
for functional improvement of balance in the treatment
of elders and patients who has balance disturbances.
Acknowledgement: The authors thank all the senior
candidates for their active participation in the study.
Conflict of Interest: There is no conflict of interest in
this study.
Source of Funding: No source of funding.
Ethical Clearance: Consent form was signed from each
and every subject participated in this study.
REFERENCES
1. Cook AS, Woollacott MH. Motor Control: Theory
and Practical Applications. 2nd ed. Philadelphia,
USA: Lippincott Williams & Wilkins; 2001:164-
167,229,236.
2. Ratliffe KT, Alba BM, Hallum A, Jewell MJ. Effect
of approximation on postural sway in healthy
subjects. Phys Ther. 1987;67(4):502-506.
27. Neetu Rani Dhiman--138--.pmd 141
3. Horak FB. Clinical measurement of postural
control in adults. Phys Ther. 1887;67(12):
1881-1885.
4. O’Sullivan SB, Schmitz TJ. Physical Rehabilitation:
Assessment and Treatment. 4th ed. New Delhi,
India: F.A. Davis Company; 2001:192,403.
5. Dornan J, Fernie GR, Holiday PJ. Visual input:
its importance in the control of postural sway.
Arch Phys Med Rehabil. 1978;59(12):586-591.
6. Hasselkus BR, Shambes GM. Aging and postural
sway in women. J Gerontol. 1975;30(6):661-667.
7. Black FO, Wall C, Rockette HE, Kitch R. Normal
subject postural sway during the Romberg test.
Am J Otolaryngol. 1982;3(5):309-318.
8. Fernie GR, Gryfe CI, Holiday PJ, Llewellyn A.
The relationship of postural sway in standing
incidence of falls in geriatric subjects. Age Ageing.
1982;11(1):11-16.
9. Guskiewicz, KM, & Perrin DH. Research and
clinical applications of assessing balance. J Sport
Rehabil. 1996;5(1):45-63.
10. Pomroy VM, Evans B, Falconer M, Jones D, Hill
E, Giakas G. An exploration of the effects of
weighted garments on balance and gait of stroke
patients with residual disability. Clin Rehabil.
2001;15(4):390-397.
11. Clopton N, Schultz D, Boren C, Porter J, Brillbart
T et al. Effects of axial loading on gait for subjects
with cerebellar ataxia: preliminary findings. J
Neurol Phys Ther. 2003;27(1):15–21.
12. Gibson-Horn C. Balance-Based Torso-Weighting
in a Patient with Ataxia and Multiple Sclerosis. J
Neurol Phys Ther. 2008;32(3):139–146.
13. Flores AM. Objective measurement of standing
balance. J Neurol Phys Ther. 1992;16(1):17-22.
14. Swift CG. Postural instability as a measure of
sedative drug response. Br J Clin Pharmacol.
1984;18(Suppl 1):87S-90S.
15. Barnes MR, Crutchfield CA, Herzia CB, et al.
Reflex and Vestibular Aspects of Motor Control,
Motor Development and Motor Learning. Atlanta,
GA: Stokesville Publishing Company; 1990:
250-253.
16. Lord SR, Menz HB, Tiedemann A. A
Physiological Profile Approach to Falls Risk
Assessment and Prevention. Phys Ther.
2003;83(3):237–252.
17. Lusardi MM, Pellecchia GL, Schulman M.
Functional performance in Community living
older adults. J Geriatr Phys Ther. 2003;26(3):14-22.
11/1/2014, 12:17 AM
 142 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
18. Conradsson M, Lundin OL, Lindelof N, et al. Berg
Balance Scale: Intrarater Test-Retest Reliability
Among Older People Dependent in Activities of
Daily Living and Living in Residential Care
Facilities. Phys Ther. 2007;87(9):1155-1163.
19. Baccini M, Rinaldi LA, Federighi G, Vannucchi
L, Paci M, Masotti G. Effectiveness of fingertip
light contact in reducing postural sway in older
people. Age Ageing. 2007;36(1):30-35.
20. Hurley MV, Rees J, Newham DJ. Quadriceps
function, proprioceptive acuity and functional
performance in healthy young. Age Ageing.
1998;27(1):55-62.
27. Neetu Rani Dhiman--138--.pmd 142
21. Widener GL, Allen DD, Gibson-Horn C.
Randomized Clinical Trial of Balance-Based
Torso Weighting for Improving Upright Mobility
in People with Multiple Sclerosis. Neurorehabil
Neural Repair. 2009;23(8):784-791.
22. Widener GL, Allen DD, Gibson-Horn C. Balance-
Based Torso-Weighting May Enhance Balance in
Persons With Multiple Sclerosis: Preliminary
Evidence. Arch Phys Med Rehabil. 2009;90(4):
602-609.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 143

Effectiveness of Tailor Made Exercise Intervention for

Low Back Pain and Pelvic Pain during Pregnancy - A
Randomized Controlled Trial

Arati Mahishale1, Shobhana Patted2

1
Assistant Professor, Institute of Physiotherapy, 2Professor, Dept of OBG, KLE University, Belgaum

ABSTRACT

Background and objectives: The incidence of low back pain & pelvic pain during pregnancy is
about 55% and can occur at any time during the gestational period. Several biomechanical and
physiologic changes during pregnancy contribute to pain which can manifest as lumbopelvic pain.
The present study aimed to evaluate the effect of a tailor made physiotherapy intervention for lumbar
pain & pelvic pain during pregnancy.

Method: 210 pregnant women with complaint of low back pain and pelvic pain were recruited after
obtaining an informed consent and clearance from the institutional ethical committee. Various clinical
tests were used to diagnose and classify subjects into both lumbar pain group, sacroiliac pain group
and symphysis pain group respectively. The subjects were then randomly allocated to control (C1,
C2 & C3) and study groups (S1, S2 & S3). Physiotherapy intervention included education and postural
correction and routine antenatal exercises in control group whereas exercises specific to particular
joint dysfunction which was tailor made was given for each study group for 5 days consecutively.
Outcome measures were documented using visual analog scale (VAS) and Modified Oswestry
Disability Questionnaire (MODQ) on 1st day pre intervention and 5th day post intervention
respectively.

Results: There was statistically significant reduction in VAS and MODQ scores in all study and
control groups postintervention. However when study and control were compared in each subgroups
the study group, lumbar pain group and symphysis pubis pain group showed significant reduction
in VAS & MODQ than sacroiliac pain group.

Conclusion: Tailor made Physiotherapy intervention has shown to be effective in declining pain and
improving functional outcome in lumbar pain & symphysis pubis pain during pregnancy.

Keywords: Pregnancy, Lumbar Pain, Sacroiliac Pain, Symphysis Pubis Pain, Vas, MODQ

INTRODUCTION shearing forces 3 . Several biomechanical and

During pregnancy, maternal anatomic changes
present mechanical challenges to the musculoskeletal
system 1,2. During pregnancy, production of the
hormone relaxin increases ten-fold which creates joint
laxity. It not only allows the pelvis to accommodate
the enlarging uterus, but also weakens the ability of
static supports in the lumbar spine to withstand
physiologic changes during pregnancy contribute to
back pain. As the woman’s abdominal muscles are
stretched and tone is diminished, they lose their ability
to contribute to neutral posture4,5. Till 1970 pelvic girdle
pain during pregnancy was not investigated. The
National Board of Health in Denmark made the first
report of estimated incidence of pelvic pain during

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 144 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
pregnancy in 1977 which accounted to be 48%. A high
percentage of women suffer from low back and pelvic
girdle pain (lumbopelvic pain) during pregnancy and
after delivery6. The average prevalence from different
studies of lumbopelvic pain in pregnancy is 45%, and
of all women postpartum 25%. Lumbopelvic pain is
the most common reason for sick leave during
pregnancy. Pelvic girdle pain can present as anterior
or posterior pelvic pain7. Low back pain can present
as vertical back pain i.e., lumbar region or horizontal
back pain i.e. sacroiliac pain also referred as posterior
pelvic pain. Pubic symphysis pain refers to anterior
pelvic pain that also appears to be increasing. Various
treatment options are available which include rest,
medications and conservative treatment like
education, exercises, mobilizations and supportive
devices8. Exercises are proved to correct and prevent
muscle imbalance and help in alignment of the pelvic
girdle 9. Antenatal exercises are a part of routine
antenatal care which is accepted & practiced globally.
Studies are conducted for classifying pelvic girdle pain
during pregnancy & postpartum period
recommending specific tests for diagnosis with high
reliability10,11,12,13. Follow-up studies have shown that
75% of the women have persisting pelvic pain 3-6
months after delivery 14 . Although specific joint
exercises are recommended in postpartum period,
scientific evaluation of treatment programs for pelvic
pain & lumbar pain during pregnancy lacks evidence.
Also comparison of tailor designed exercises with
routine antenatal exercises which are generalized have
not been studied. Hence the present study was
undertaken to evaluate the effectiveness of tailor made
exercise intervention for lumbar pain and pelvic pain
during pregnancy.
METHODOLOGY
Population: Pregnant women with complaint of
lumbo-pelvic pain
Study Design: Prospective Randomized
Controlled trial
Study Period: Data was collected at a tertiary care
centre, Karnataka from March 2008 – November 2011
Sampling Design: (Non probability sampling)
convenience sampling
Allocation: Random allocation to control and
study groups using envelope method
28. Arti Mahashale--143--.pmd 144
Sample Size: Total- 210 subjects (Control group (C)
– 105 & Study group (S) - 105)
(C1) Lumbar pain- 40, (C2) Sacroiliac pain- 40, (C3)
Symphysis pain- 25
(S1) Lumbar pain- 40, (S2) Sacroiliac pain- 40, (S3)
Symphysis pain- 25
Inclusion criteria: Pregnant women referred with
c/o of lumbar pain or pelvic girdle pain, Age: 18 – 35
years, Gestational age: 16 to 34 weeks, Willingness to
participate in study.
Exclusion criteria: Neurological pathology
(asymmetric Achilles tendon reflex, hyperesthesia in
a radicular pattern), Organic pathology (nerve root
pathology, rheumatoid disorders, TB spine),
Orthopedic deformities of spine & lower limb,
Obstetric complications (Incompetent cervix, multiple
gestation), Antepartum hemorrhage, High risk factors-
preeclampsia, heart disease. (ACOG 2002).15
Procedure: Study was approved by University
Ethical Review Committee. Pregnant women with
complaints of lumbar pain or pelvic pain were
screened for inclusion & exclusion criteria. Written
Informed consent was taken from all the study
participants. After enrollment they were subjected to
clinical tests namely straight leg raise test, Specific
provocation test, Femoral compression test/ Thigh
thrust test, Ventral gapping test, Dorsal gapping test,
Modified Trendelenburg test, Patrick test, Leg
abduction test and Fortin finger test to classify them
into Lumbar pain group, Sacroiliac pain group and
Symphysis pubis pain group respectively. Each group
was then randomized into study group (S1, S2, and
S3) & control group (C1, C2, and C3) using envelope
method. Base line data was collected and interventions
were given accordingly (control group- antenatal
exercises/ Study group- tailor made exercises).
Preintervention & postintervention outcome measures
were recorded using visual analogue scale (VAS) and
Modified Oswestry Disability Questionnaire (MODQ).
(Figure -1)
Control group- C1 (LJP) , C2 (SIJP) & C3 (SPP) :
Education & postural correction, deep breathing
exercises, stretching exercises, pelvic tilting, core
stability exercises (bridging, pelvic floor contraction,
abdominal muscle contraction). Therapy duration was
for 30 minutes/session (5 mins warm up + 20 mins
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 145
antenatal exercises + 5 mins cool down) for 5
consecutive days16.
Lumbar joint pain group (LJP) (S1): Education &
postural correction, deep breathing exercises,
stretching exercises, core stability exercises, spine
stretch, bobath ball exercises in sitting with therapist
assisted. For lumbar joint mobility linear translatory,
lumbar twisting movements and pelvic tilts in antero-
postero direction were given
Sacroiliac joint pain group (SIJP) (S2): Education
& postural correction, deep breathing exercises,
stretching exercises, core stability exercises, bobath ball
exercises assisted by the investigator. Sacroiliac joint
mobility in supine, sitting & all four positions
(Quadruped) and pelvic rotation in sitting- clockwise
& anticlockwise were given.
Symphysis pubis pain group (SPP) (S3): Education
& Postural correction, Deep breathing exercises,
Stretching exercises, Core stability exercises. Kegel’s
exercises in supine and sitting on Bobath ball &
standing and pelvic stabilization exercises were given.
Therapy duration for all study groups was 30 minutes/
session (5 mins warm up + 20 mins tailor made
exercises + 5 mins cool down) for 5 consecutive days.
Outcome measures: Pain was measured by Visual
Analog Scale (VAS) on 1st day pre intervention and 5th
day post intervention and functional outcome was
assessed using Modified Oswestry Disability
Questionnaire (MODQ) on 1st day pre intervention and
5th day post intervention respectively.
Statistical analysis: For comparison of pre and
post- intervention VAS & MODQ scores in subgroups,
Wilcoxon matched pairs test was used. Mann-Whitney
U Test was applied to compare VAS & MODQ scores
between control and study groups at pre and post
intervention.
RESULTS
A total of 187 subjects completed the study of 210
enrolled. 23 dropped out due to inconvenience in
transport, residing out of city & discontinued therapy.
Age and gestational age in all the groups were well
matched.
VAS: Pretest and posttest VAS scores in subgroups
i.e. S1, S2 and S3 of study group showed significant
difference with p=0.0001. Comparison of pretest and
posttest VAS scores in subgroups i.e. C1, C2 and C3 of
28. Arti Mahashale--143--.pmd 145
control group also showed significant difference with
p=0.0001. There was no statistically significant
difference between VAS scores of C1 and S1 on 1st day
preintervention (p= 0.069) but significant difference
was noted between VAS scores of C1 and S1 on day 5
post intervention (p-value is 0.000) which suggested
that pain in S1 was significantly lower than pain in
C1. There was no significant difference between VAS
scores of C2 and S2 preintervention (p= 0.808). Also
no significant difference was seen between VAS scores
of C2 and S2 postintervention (p=0.285) which meant
equal reduction of pain was noted in both the groups.
There was no significant difference between VAS
scores of C3 and S3 preintervention (p=0.502) but
significant difference between VAS scores of C3 and
S3 postintervention was noted which suggested pain
in S3 was significantly lower than pain in C3 (p= 0.000)
(Table-1).
MODQ: Pretest and posttest MODQ scores in
subgroups i.e. S1, S2 and S3 of study group showed
significant difference with p=0.0001.Comparison of
pretest and posttest MODQ scores in subgroups i.e.
C1, C2 and C3 of control group showed significant
difference with p=0.0001. There was no significant
difference between MODQ scores of C1 & S1
preintervention (p= 0.929) but results showed
significant difference between MODQ scores
postintervention (p= 0.000). No significant difference
was seen between MODQ scores of C2 & S2
preintervention (p= 0.556) and postintervention (p=
0.974). There was no significant difference noted
between MODQ scores of C3 & S3 preintervention
(p=0.075) but there was significant difference between
MODQ scores postintervention (p=0.000) (Table-2).
DISCUSSION
In our study, women with pregnancy related
lumbo- pelvic pain were benefited more from a tailor-
made exercise program than antenatal exercises. Two
studies showed that 70% of all working pregnant
women in Sweden took sick leave for some reason at
some time during their pregnancy for a period of
average 7 weeks17,18. Other studies from Scandinavia
have also shown the same trend, indicating that back
pain in pregnancy is also a large socioeconomic
problem19. The job places cannot be planned around
the capacity of a pregnant woman who are working
and take care of other household chores. Earlier studies
have shown that it is important to define pain during
pregnancy that is pain from the lumbar area and pain
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 146 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

from the pelvis. The various types of pain should be syndromes together without classifying them into
treated differently. European Guidelines are specific groups 24. The mechanics of each joint is
recommended for diagnosis of pelvic girdle pain. The different, hence only certain movements are painful
posterior pelvic pain provocation test and Patrick’s and restricted which are well diagnosed by special
Faber test have superior sensitivity if pain is evident clinical tests25. The therapy should be tailor made
in the SI-joints11,12,13,14. Modified Trendelenburg’s test accordingly when pregnant women complains of low
and palpation of the symphysis are superior with back pain and pelvic pain which can then be carried
regard to sensitivity if the pain is evident in the out as a group therapy which can be helpful to reduce
symphysis. The tests have high intertester reliability, pregnancy discomfort.
straight leg test or lasegue test can be used to exclude
nerve root syndrome20. Garshasbi in 2005 investigated CONCLUSION
the effect of exercises during pregnancy low back pain
and kinematics of spine & concluded significant For lumbar pain and symphysis pubis pain during
reduction in the intensity of low back pain after pregnancy, tailor made exercises were more effective
exercise (p<0.0001)21. The results of the present study than routine antenatal exercises. For sacroiliac joint
also showed a decline in pain intensity in both control pain tailor made exercises showed a higher trend than
and experimental groups who were subjected to routine antenatal exercises though it was not
exercises. The present study also found that tailor statistically significant.
made therapy for specific joint dysfunction was more
Acknowledgement & Funding: Nil
effective than routine antenatal exercises in reducing
pain and improving function. Effect of the sitting pelvic COI: No Conflict of Interests.
tilt exercise during the third trimester in primigravida
on back pain was studied by Suputtitada A, Chaisayan
P et al (2002) and concluded that sitting exercises are
more beneficial. The present results also showed
improvement in all study groups where sitting pelvic
tilting exercises were administered 22 . Antenatal
exercises given in group may not address individual
needs and usually include exercises targeting pelvic
girdle as a whole and not specific joint segment in
particular23. This could be the probable reason for
better reduction of pain intensity in experimental
group where subjects were given specific protocol
designed for a particular dysfunction. Sacroiliac pain
(SI) group did not show much change in experimental
as compared to control which could be due to the
exercises included in routine antenatal classes are
effective in mobilizing the SI joint. Effectiveness of a
tailor made intervention for pregnancy-related pelvic
girdle and/or low back pain after delivery was studied
in 2006 but it included exercises designed for all pain Fig. 1. Methodology Flowchart

Table 1: Mann-Whitney Test to compare VAS scores between control and study groups at pre and post
intervention

Groups VAS VAS

Preintervention Postintervention
Control (C1) and LJP (S1) Mann-Whitney U 678.500 224.000
P-value 0.069 0.0001
Control (C2) and SIJP (S2) Mann-Whitney U 959.500 859.000
P-value 0.808 0.285
Control (C3) and SPP (S3) Mann-Whitney U 645.500 247.000
P-value 0.502 0.0001

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 147

Table 2: Mann-Whitney Test to compare VAS scores between control and study groups at pre and
post intervention

Groups MODQ MODQ

Preintervention Postintervention
Control (C1) and LJP (S1) Mann-Whitney U 871.500 331.500
P-value 0.929 0.0001
Control (C2) and SIJP (S2) Mann-Whitney U 917.500 985.000
P-value 0.556 0.974
Control (C3) and SPP (S3) Mann-Whitney U 540.000 343.000
P-value 0.075 0.0001

REFERENCES system for pregnancy-related lumbopelvic pain.

1. M. J. Mantle et al, Backache in Pregnancy,
Rheumatology and Rehabilitation, 1977, 16, 95.
2. Mary Lloyd Ireland et al, The Effect of Pregnancy
on the Musculoskeletal System, Clinical
Orthopedics and Related Research, No. 372 pp
169-179, March 2000.
3. Stendal H, Robinson A, Eskild A, Heiberg E,
Eberhard-Gran M. pelvic girdle pain in
pregnancy: The impact on function. Acta Obstet
Gyn Scand 2006;85(2):160-164.
4. Albert HB, Godskesen M, Korsholm L,
Westergaard JG: Risk factors in developing
pregnancy-related pelvic girdle pain. Acta Obstet
Gynecol Scand 2006, 85:539-544.
5. John Smithline : Low back pain, Occupational
Therapy – Practice skills for physical disfunction
(IV edition) Lorraine Williams Pedetti page 720,
678.
6. Pitts MK, Ferris JA, Smith AM, Shelley JM,
Richters J: Prevalence and correlates of three
types of pelvic pain in a nationally representative
sample of Australian women. Med J Aust 2008,
189:138-143.
7. Gutke A, Östgaard HC, Oberg B: Pelvic girdle
pain and lumbar pain in pregnancy: a cohort
study of the consequences in terms of health and
functioning. Spine (Phila Pa 1976) 2006, 31:E149-
E155.
8. Margaret Polden et al, 1994, The Antenatal
Period, Physiotherapy in Obstetrics and
Gynecology, Jaypee Brothers, Pb No. 7193, New
Delhi, 96, 106, 134, 132, 12, 135, 133.
9. HC Osgaard, Gunilla Zetherstrom et al Reduction
of back & post pelvic pain in pregnancy spine,
Vol. 19, Number 8, pp984-900, 1994, J. B.
Lippincott company.
10. Gutke A, Kjellby-Wendt G, Oberg B: The inter-
rater reliability of a standardized classification
Man Ther 2009, 15:13-18.
11. Mens JMA, Vleeming A, Snijders CJ, et al. The
active straight leg raising test and mobility of the
pelvic joints. Eur Spine J 1999; 8: 468-73.
12. Östgaard HC, Zetherström GBJ, Roos-Hansson
E. The posterior pelvic pain provocation test in
pregnant women. Eur Spine J 1994; 3: 258-60.
13. Cook C, Massa L, Harm-Ernandes I, Segneri R,
Adcock J, Kennedy C, Figuers C: Interrater
reliability and diagnostic accuracy of pelvic girdle
pain classification. J Manipulative Physiol Ther
2007, 30:252-258.
14. Gutke A, Östgaard HC, Oberg B: Predicting
persistent pregnancy-related ow back pain. Spine
(Phila Pa 1976) 2008, 33:E386-E393.
15. ACOG Committee. Opinion no. 267: exercise
during pregnancy and the postpartum period.
Obstet Gynecol 2002; 99:171–3.
16. ACSM. Guidelines for exercise testing and
prescription. 6th ed. Philadelphia: Lippincott
Williams & Wilkins, 2000.
17. Sydsjo A, Sydsjo G, Wijma B. Increase in sick
leave rates caused by back pain among pregnant
Swedish women after amelioration of social
benefits. A paradox. Spine. 1998;23:1986–1990.
18. Noren L, Ostgaard S, Nielsen TF, Ostgaard HC.
Reduction of sick leave for lumbar back and
posterior pelvic pain in pregnancy. Spine.
1997;22:2157–2160.
19. Olsson C, Nilsson-Wikmar L. Health-related
quality of life and physical ability among
pregnant women with and without back pain in
late pregnancy. Acta Obstet Gynecol Scand.
2004;83:351–357.
20. Vleeming A, Albert HB, Östgaard HC, Sturesson
B, Stuge B: European guidelines for the diagnosis
and treatment of pelvic girdle pain. Eur Spine J
2008, 17:794-819.

28. Arti Mahashale--143--.pmd 147 11/1/2014, 12:17 AM

 148 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
21. A.Garshasbi, S. Faghih Zadeh: The effect of
exercise on the intensity of low back pain in
pregnant women. International Journal of
Gynecology & Obstetrics 88 (3), 271-275, 2005.
22. Arrerat Suputtitada et al, Effect of the Sitting
Pelvic Tilt Exercise During the Third Trimester
in Primigravidas on Back Pain, J. Med. Assoc.
Thai, June 2002, Vol. 85:170-178.
23. Haugland KS, Rasmussen S, Daltveit AK: Group
intervention for women with pelvic girdle pain
in pregnancy: a randomized controlled trial. Acta
Obstet Gynecol Scand 2006, 85:1320-1326.
24. Bastiaenen CH, de Bie RA, Wolters PM, Vlaeyen
JW, Leffers P, Stelma F,Bastiaanssen JM, Essed
28. Arti Mahashale--143--.pmd 148
GG, van den Brandt PA: Effectiveness of a
tailormade intervention for pregnancy-related
pelvic girdle and/or low back pain after delivery:
short-term results of a randomized clinical trial
[ISRCTN08477490]. BMC Musculoskelet Disord
2006, 7:19.
25. Ramannavar A, Patted S: Symphysis Pubis
Dysfunction During Pregnancy- A multimodality
physiotherapeutic approach. Indian Journal of
Physiotherapy and Occupational Therapy. Jan-
Mar., 2012, Vol.6, No.1: 1-4.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 149

A Study to Correlate Various Anthropometric Measures

on Excursion Distances while Performing on the Star
Excursion Balance Test among Amateur Sports Person - A
Cross Sectional Observational Study

Krishna D Desai1, Hardik Trivedi2

1
B.P.T, M.P.T, Senior Lecturer, Shri K.K.Sheth Physiotherapy College, Rajkot, Gujarat
2

ABSTRACT

Objective: To examine the role of various predictive factors on dynamic postural control through
the Star Excursion balance test.

Method: This cross sectional observational study included 120 amateurs sports person of both gender
with mean age of 19.48+2.86 years. Their height, leg length, waist hip ratio, body mass index and
ankle dorsiflexion range of motion were measured. The participants were asked to perform on the
star excursion balance test (SEBT) with the dominant limb. The distances were recorded at the point
of maximum excursion.

Results: Pearson correlation test revealed that there was a significant correlation of height, leg length,
waist hip ratio on excursion distance. While Regression analysis showed the highest variation on leg
length

(R2= 0.518) followed by height (R2=0.337) on excursion distance. Ankle dorsiflexion range of motion
(R2= 0.134) showed the least variance.

Conclusion: The most significant correlated predictive factors were leg length followed by height
with excursion distance.

Keywords: Star Excursion Balance Test, Ankle Injury, Anthropometric Measures

INTRODUCTION be the most common injury amongst recreational

Participation in athletics by adolescents is ever
increasing with over 7 millions high school students
participating in interscholastic athletics. It has been
estimated that over 70,000 sports and recreation related
injuries occur in the secondary school setting annually.1
At high school level it has been found that over 6000
athletes sustain a sport related injury at least once per
year, and over 25% of these injuries result in loss of
more than 7 days of participation.2
The frequency of ankle and knee injuries has
become a paramount. Ankle sprains are reported to
sports and competitive athletes, particularly in contact
sports like basket ball and soccer.3 A systematic review
of 227 epidemiological studies regarding the frequency
and occurrence of ankle sprains in sports was
performed (Yung & Chan, 2007). It is found that out
of 70 sports, the ankle ranked the most injured in 24 to
34 % of the observed sports, followed by frequency of
knee injuries.
After sustaining an injury when athletes return to
an activity with sub-optimal ankle function they are
often reduced to playing at a sub-optimal level and

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 150 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

are at a greater risk of sustaining chronic ankle used to evaluate and quantify the dynamic balance in
instability. These injuries are mostly prevalent in multiple directions.
cutting and jumping sports such as volleyball, football,
soccer and basketball where as in non contact sports MATERIALS AND METHOD
mechanisms such as landing from a jump, frequently
lead to joint or ligament injuries that are probably This cross-sectional observational study consisted
result of impaired balance.4 of 120 athletes between ages of 15- 25 years of both
gender. The study was performed at Shree K.K Sheth
Balance is an indispensible motor skill mainly based Physiotherapy College, Rajkot, Gujarat.
on the muscular synergies, which minimize the
displacement of the Center Of Pressure while Inclusion criteria: The participants who were
maintaining upright stance, proper orientation and involved in track and field sports, involving more of
adequate locomotion. It can be quantified either lower extremity and playing for more than 6 months
statically or dynamically. Dynamic balance is required
Exclusion criteria: Any complaints of vestibular
for the normal activites of daily living like walking,
disorders, diagnosed of any recent concussion within
running etc. It is commonly linked to sports specific
1 month of the test, any ear infection, upper respiratory
activity that causes the body’s Center Of Gravity to
tract infection or participant with any lower limb
change in response to muscle activity. This ability is
impairment.
influenced by a complexity of factors that are sensory
information, ROM, strength and it is responsible for Prior to the participation in the study, subjects were
the correct execution of complex sports movements explained about the procedure and written consent
as well as for protection against sports injuries.5 was taken for their voluntary participation. A
questionnaire was given for their pre- test physical
Due to high rate of injury a large numbers of
assessment.
extensive researches have been conducted to
determine the intrinsic and extrinsic factors associated
with ankle and knee injury. Some of the most common
intrinsic factors include previous history, sex, height,
weight, limb dominance, foot type, foot size, and joint
laxity, range of motion, strength, proprioception, and
muscle reaction time. While extrinsic factors include
ankle bracing and taping, shoe type, playing surface,
duration and intensity of competition. Most of these
proposed factors are considered as predictive factors
for ankle injury.6

Many different measurement tools have been

utilized to assess dynamic balance which can be
objectively measured and evaluated also the
effectiveness of the interventions can be applied.
During past years instrumented measures like
Stabiliometry, NeuroCom, New Balance System,
Single leg stance on a force plate, etc.7,8 While non
instrumented measures included the use of assessing
dynamic balance through single leg stance. Although
these give valid and reliable measures, they are
impractical for most high school sports setting and
require high cost, time and staff.
Therefore the Star Excursion Balance Test was
introduced as a reliable and valid measurement tool
for assessing dynamic balance. It is a challenging test
Fig. 1. Materials used in the study
Measurement of anthropometric measures
Subject’s height was measured with a standard
height chart. Squaring of pelvis was checked prior to
the measurement of leg length. It was measured with
the participants lying supine from the anterior
superior iliac spine to the distal aspect of the medial
malleolus.9
The measurement of Waist to hip ratio was carried
out with the participant in standing position with the

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 151

arms at the side, feet positioned close together and

weight evenly distributed across the feet. The waist
circumference was measured at a midpoint between
the lower margin of last palpable rib and top of the
iliac crest at the end of normal expiration. The hip
circumference measurement was taken around the
widest portion of the buttocks. Waist hip ratio, height
and leg length were measured in centimetres. 10

SEBT Procedure

The SEBT was performed with the participants

standing in the middle of a grid formed by 8 lines
extending out at 45 degrees from each other. The
participants reached as far as possible along each of
the 8 lines, make a light touch and return to the centre
while maintaining a single leg stance with the other
leg in the centre. The terminology of excursion distance
is based on the directions of reach in relation to the
stance leg. When reaching in lateral and posterolateral
directions, participants must reach behind the stance
leg to complete the task. Participants were allowed to
practice 6 times prior to testing to minimize the
learning effects. Following 5 minute rest period,
participants performed 3 trials. Each reach distance
was recorded with a mark on the tape as the distance
from the centre of the grid to the point of maximum
excursion with a standard tape measure.
Fig. 3. Posteromedial Reach direction

Fig. 2. Posterolateral Reach direction Fig. 4. Medial Reach direction

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 152 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Criteria for termination any time, removed his or her foot from the centre or
was unable to maintain the balance on the support leg
The test was terminated if the participant used the throughout the trail.
reaching leg for the substantial amount of support at

RESULTS

Table 1- Analysis of descriptive data

Mean Standard deviation

Age (years) 19.48 +2.86
Height (cms) 167.73 +11.03
Weight (kgs) 61.95 +10.95
Body Mass Index (kg/m2) 22.18 +3.85

Table 2- Data analysis for Gender distribution

Gender No. of participants

Male 98
Female 22
Total number of subjects 120

Pearson correlation test were used to determine the
degree of association between height, leg length, waist
hip ratio, and body mass index with excursion
distances. Linear regression was used between height,
leg length, waist hip ratio and body mass index as
independent variables and excursion distance as
dependent variables, to find out the highest correlation
amongst each of them. In order to assess the relative
importance of each excursion distance with
independent variables beta coefficients were used:
higher the value, more important is each direction with
that variable. The data analysis was carried out using
SPSS 18.0 version.

Table 3. Pearson correlation between height, leg length, waist hip ratio and excursion distances.

Excursion distance (cms) Height (cms) Leg length (cms) Waist hip ratio (cms)
r- value p-value r-value p-value r-value p-value
Anterior 0.550 0.000 0.474 0.000 0.063 0.495
Anteromedial 0.546 0.000 0.599 0.000 0.055 0.549
Medial 0.313 0.001 0.510 0.000 0.072 0.433
Posteromedial 0.235 0.010 0.390 0.000 0.384 0.000
Posterior 0.353 0.000 0.440 0.000 0.051 0.584
Posterolateral 0.385 0.000 0.459 0.000 0.026 0.782
Lateral 0.211 0.021 0.284 0.002 -0.266 0.003
Anterolateral 0.327 0.000 0.461 0.000 -0.021 0.821

Table 4. Pearson correlation between body mass index and excursion distances.
Over weight BMI Normal BMI Under weight
(> 24.9 kg/m2) (18.5-24.9 kg/m2) BMI(<18.5 kg/m2)
r-value p-value r-value p-value r-value p-value
Anterior -0.390 0.022 -0.218 0.027 0.633 0.018
Anteromedial -0.699 0.000 -0.213 0.030 0.563 0.036
Medial -0.530 0.002 -0.012 0.458 0.653 0.015
Posteromedial -0.242 0.112 0.243 0.458 0.675 0.011
Posterior -0.111 0.291 0.115 0.156 0.316 0.172
Posterolateral -0.188 0.173 0.159 0.081 0.562 0.036
Lateral -0.037 0.427 -0.195 0.042 0.047 0.446
Anterolateral -0.174 0.193 -0.108 0.172 0.299 0.186

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 153

Table 5. Linear regression statistics for various anthropometric measures

Excursion distances Height (cms) Body Mass Index (kg/m2) Waist hip ratio (cms) Leg length (cms)
r R 2
B r R2 B r R2 B r R2 B
0.614 0.337 0.538 0.290 0.544 0.296 0.720 0.518
Anterior 0.105 0.058 0.001 -0.161
Anteromedial 0.508 -0.168 - 0.304
Medial -0.092 -0.083 -0.002 0.130
Posteromedial -0.114 0.241 0.003 0.016
Posterior 0.196 -0.058 -0.002 0.169
Posterolateral 0.147 -0.025 - 0.009
Lateral -0.002 0.002 -0.002 0.153
Anterolateral -0.094 0.070 0.001 -0.081

Results demonstrate that height and leg length
showed a moderately positive correlation in all
directions. While waist hip ratio showed positive
correlation in Anterior, Antero-medial, Medial,
Postero-medial, and Posterior & Postero-lateral. The
results from linear regression analysis shows that leg
length was the most highly correlated with excursion
distance (R2 = 0.518), following height (R2=0.337)
The Pearson Product Correlation of BMI on
excursion distance was categorized according to
underweight, normal and overweight. The group with
normal and overweight BMI showed negative
correlation while there was a moderately positive
correlation between underweight BMI and excursion
distances. Also the results from linear regression
analysis showed the R2=0.290, which indicates that the
BMI may be an important predictor while performing
SEBT.
DISCUSSION
The SEBT appears to be a promising test of postural
control and sensitive in detecting functional reach
deficits as well as serves as predictor of lower extremity
injury amongst athletes.9 Reliability and sensitivity of
the same was established previously.11
Thus, from the above results it is seen that leg length
will correlate significantly with excursion distances,
as longer limb would give subject an advantage in
reaching that limb further. In addition because height
and leg length strongly correlate with each other, it is
inherent that height and excursion distances would
also correlate significantly. This indicates that when
leg length is significant predictor on the SEBT, other
factors also account for majority of variance with the
excursion distances.
Considering the leg length as the most significant
predictive factor from the results of the linear
regression analysis, the value of beta coefficient for
Anteromedial (b=0.304), Posterior (b=0.169) and
Lateral (b=0.153) directions were showing the higher
significant association rather than other directions. This
contradicts the results by some other studies.
Braham, Hale et al., (2006) reported that
posteromedial direction was the most representative
of the task as a whole and there was a great
redundancy amongst the different reaching directions.
They also found that reaches in Medial, Anteromedial
and Posteromedial reach directions is indicative of
overall performance in both groups. Therefore
performance in all the directions will be
inconsequential and could be narrowed down
depending upon the purpose of the study.12
It has been postulated that in multi directional sport
activities proprioception, strength, and dynamic
balance plays an important role for efficient
performance. Therefore in order to examine the
dynamic balance of athletes, the present study is
concentrated on various sports like basketball, football,
cricket, volleyball etc.
Another predictive factor that was incorporated in
the present study was Body Mass Index. Mc. Hugh et
al., conducted a study among overweight football
players and he concluded that they were 19 times more
likely to sustain an ankle sprain than a healthy athlete
with no previous injury of ankle sprain14 In a study by
Tokmakidis S. et al., it has been found that definite
correlation exist between overweight category of BMI
group and reduced flexibility. It is quite apparent that
as the level of BMI increases the flexibility decreases.
Therefore it implies that overweight and obesity are
the limiting factors for fitness and performance.14

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 154 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
According to Olmsted et al., dynamic balance tests
provide a more accurate reflection of lower extremity
function and motor control deficits post injury
particular in an athletic population.16
Hertel et al., found that while performing the SEBT
there was co-contractions of quadriceps and hamstring
in all directions. Quadriceps was more active during
Anterior, Anteromedial & Anterolateral directions,
where as vastus lateralis was more recruited during
medial and posteromedial directions. The
improvement in the dynamic balance due to balance
training can be attributed to increase in muscle
strength, neuromuscular control and range of motion
and imposing an overload over the information
transferring through three sensory systems of Central
nervous system mechanism i.e. visual, vestibular and
somatosensory. It has been reported that change in the
strength, neural control of movement or range of
motion affects the overall dynamic balance that is
required in various sporting activities. Improvement
of the above factors can cause the displacement of
centre of gravity to shift to the ankle joint, thus
improving dynamic balance.14
Thus this study has both clinical as well as practical
implications. The ability to predict and identify the risk
for individuals before any pre-season match that is
needed due to the high amount of lower extremity
injuries sustained in various sports. By utilizing the
star excursion balance test as a screening tool, by taking
into considerations some of the above factors, clinicians
can identify at risk individuals and recommend proper
interventions for the same.
The limitations of the present study were lack of
warm up exercises before the performance of the SEBT.
Also the study being carried out among the amateurs
may have given more generalized results. In future
the study can be further explored by finding out the
other physical factors like strength, neuromuscular
control and range of motion at various joints of lower
extremity. The study can also be carried out amongst
the injured athletes that can give a better idea about
the performance of SEBT.
CONCLUSION
The most significantly correlated predictive factors
were leg length followed by height.While waist hip
ratio and body mass index were moderately correlated
with the excursion distance.
29. hardik trivedi--149--.pmd 154
ACKNOWLEDGEMENTS
We wish to express sincere thanks to parents,
lecturers of Shri K.K.Sheth Physiotherapy College &
Dr.D.K.Ghosh Phd, HOD Statistics department
Saurashtra university for their valuable guidance.
Conflict of interest: There is no conflict of interest
Source of Funding: No funding is provided by any
organisation
Ethical Clearance: The proposed study was approved
by ethical committee members.
REFERENCES
1. Ingram JG, Fields SK, et al., Epidemiology of knee
injuries among male and female in high school athletics
Am J Sports Med 2009; 36(6): 1116-1122.
2. Rechel JA, Yard EE, et al., An Epidemologic
comparision of high school sports injuries sustained
in practice and competition. J Athl Train 2008; 43(2):
197-204.
3. Tropp H. Pronator muscle weakness influence
instability of ankle joint. International Journal of
Sports Medicine 1986; 25(1): 1-14.
4. Mckay GD, Goldie PA, Payne WR, et al., Ankle
injury in basketball: injury rate and risk factors. Br. J
Sports Med 2001; 35: 103-108.
5. Palmeiri RM, Ingersoll CD, Stone MB, et al. The
center of pressure parameters used in the assessment
of postural control. Journal of sports and
rehabilitation 2002; 11:51-66.
6. Beynnon B, Murphy, DF, Alosa, DM. Predictive
Factors for lateral ankle sprains: A literature review
.Journal of athletic training 2002; 37(4): 376-380.
7. Mc.Guine, TA, Grene. J.J, Best. T et al., Balance as
a predictor of ankle injuries in high school basketball
players. Clinical journal of sports medicine 2000;
10: 239-244.
8. Newell K, Mayer-Kress,G, Lill,YT et al., Time
scales in motor learning and development. Psycho
Rev. 2001; 108: 57-82.
9. Phillip A. Gribble and Jay Hertel Considerations
for the normalizing measures of the star excursion
balance test. Measurement in physical education
and exercise science. 2003; 7(2): 89-100.
10. Waist circumference and Waist-Hip ratio: Report of
WHO Expert consultation. Geneva, 8-11
December 2008.
11. Kinzey Stiphen, Armstrong CW. The reliability of
the star excursion balance test in assessing dynamic
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 155
balance. J ortho Sports Phys Ther. 1998; 27(5):
356-360.
12. Olmsted Kramer, LC et al., Simplifying the star
excursion balance test: analyses of subjects with and
without chronic ankle instability. J Ortho & Sport
Phys ther. 2006; 36: 131-137.
13. Timothy, Mirabella, Micheal R, et al. The
effectiveness of balance training intervention in
reducing the incidence of noncontact ankle sprains in
high school football players. The American Journal
of Sports Medicine 2007; 35(8): 1280-1293.
14. Jabbar Bashiri, Hamdollah Hadi et al., Effect of
resistance balance training on dynamic balance in
29. hardik trivedi--149--.pmd 155
active elderly males. Annals of Biological Research
2011; 2(5): 689-695.
15. Kim Bannell et al. Intra rater and inter rater
reliability of weight bearing lunge measure on ankle
dorsiflexion. Australian physiotherapy 1998; 44(3):
175-180.
16. Olmsted, L., Carcia, C., et al. Efficacy of the star
excursion balance tests in detecting reach deficits in
subjects with chronic ankle instability. Journal of
athletic training. 2002; 37: 501-506.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
156 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Return to Run: Lateral Ankle Sprain with Sural Nerve

Involvement - A Case Study

Jacob Praveen Jayamoorthy

Senior Physiotherapist, Changi General Hospital, 2 Simei Street 3, Singapore

ABSTRACT

Lateral ankle sprains are the most common injuries sustained by athletes. The sprains not only cause
ligamentous damage, but also affects the musculotendinous and nervous tissue around the lateral
ankle complex. In order to render appropriate rehabilitation, a proper evaluation is required. Injury
to the sural nerve in association with lateral ankle sprain is rarely mentioned in the literatures.
However, sural nerve injury can occur more frequently than commonly expected, leading to
misdiagnosis and mistreated component of ankle sprains. There is a lack of literature relating the
whole scenario of lateral ankle injury involving ligament sprain, joint dysfunction, peroneal muscle
strains, sural nerve involvement and physiotherapy management. Thus, the present study is
conducted to highlight the outcomes of a patient with lateral ankle sprain involving sural nerve
pathology as well as describes the physiotherapy management including mobilisation of the joint,
neural mobilisation and balance exercise training. This case study demonstrates an ankle inversion
injury of 22 year old male while playing football. Detailed examination and physiotherapy
management were carried out for 5 visits over 4-weeks period. Outcome measures were compared
between the baseline and final visit. The patient exhibited significant improvement and back to run.
Thus, suggesting the need of neural tissue examination on patients with lateral ankle sprains.

Keywords: Lateral Ankle Sprains, Sural Nerve, Physiotherapy, Management

INTRODUCTION lateral aspect of the ankle and foot. Ligament ruptures

are commonly encountered with this injury.7,8,9 Sixty
Lateral ankle sprains (LAS) are common
six per cent of LAS occurs in anterior talofibular
musculoskeletal injuries experienced in clinical setting
ligament (ATFL), twenty percent in combination with
especially in sports arena. Fifty per cent of LAS are
calcaneo-fibular ligament (CFL) and least affecting the
sports related and highly seen in athletic population.1,2
posterior talofibular ligament (PTFL). 7,8 Fallat 10
High incidence of LAS occurs in basketball, volleyball,
reported classifications of ligament injuries into I, II,
soccer, and cross-country training.3,4,5 Returning to
and III grades depending on the severity of injury.
sports after LAS imposes a greater challenge to sports
Grade I sprains have been reported to account for
doctors and sports physiotherapist.
71.3% of total injuries, grade II and III sprains
The mechanism of injury in lateral ankle sprains is accounting for 9.5% and 2.9% of the injuries.10
identified as excessive supination and adduction of the
Lateral ligament sprains are the striking structure
plantar flexed foot.6 The excessive inversion of ankle
that comes to clinician’s attention whenever there is
increases the tensile stress of lateral ligament complex,
inversion sprain of the ankle. However, the other
peroneus muscles and neurovascular structures on the
structures should be carefully examined on the lateral
ankle. The other lateral structures include peroneal
Corresponding author: longus and brevis tendon, fifth metatarsal, lateral
Jacob Praveen Jayamoorthy
malleolus, sinus tarsi, lateral joint capsule,
Senior Physiotherapist,
neurovascular structures like peroneal nerve, posterior
Changi General Hospital, 2 Simei Street 3
Singapore 529889 tibial nerve, sural nerve, dorsalis pedis artery and
Email : Jayamoorthy_Jacob_Praveen@cgh.com.sg posterior tibial artery.11,12,13,14

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 157
The relationship between ligament, joint, muscle
and nerve involvement should be clinically reasoned
and managed appropriately for early return to sports.
During the inversion sprain, the high tensile tension
on the ATFL pulls the distal fibula inferiorly and
anteriorly resulting in distal tibiofibular joint
dysfunction and causes narrowing of the mortise
which restricts the antero-posterior glide of talus
during dorsiflexion.15,16 Hence, restricting the ankle
dorsiflexion during functional activities like walking,
running, stair climbing and sports activities.17,18 The
higher tensile force also affects the peroneal longus
and brevis tendon to cause peroneal tendinitis.19,20 The
high impact causes traction of the nerve leading to
bleeding and hematoma in the epineural sheath
affecting the neural conduction and neural glide
causing severe nerve pain on its distribution.21
The common nerves involved in LAS are peroneal,
posterior tibial and sural nerve.21,22 Peroneal nerve
injury is reported in 8% of severe ankle sprain. Sural
nerve is rarely affected in inversion injuries. 23
Nonetheless, a study by Jotwani 12 has reported
incidence of cutaneous sural neuropathy after ankle
injury. A nerve conduction study is done to confirm
the nerve injuries associated with the ankle sprains.12,21
There is lack of literatures to relate the whole
scenario of LAS involving ligament sprain, joint
dysfunction, peroneal muscle strains, sural nerve
involvement and physiotherapy management. Hence,
the purpose of this case report is to describe assessment
and physiotherapy management of a patient with
lateral ankle joint pain, paraesthesia over lateral border
of the foot and return to run after successful
physiotherapy management including mobilisation of
the joint, neural mobilisation and balance exercise
training.
CASE PRESENTATION
A 22 year old physically active man was referred
to the physiotherapy clinic by General Physician for
his left lateral ankle pain injured while playing football
4 weeks ago. The patient complaint of left ankle
twisting inward and down associated with sudden
sharp pain with swelling in spite of 30 min rest after
the injury. He pointed the loci of pain just inferior to
the left lateral malleolus followed with pins and
needles and numbness on the lateral border of foot.
He also noticed worsening of pain with weight bearing
activities such as walking, standing, climbing up and
down stairs. Patient self-treated with ice and reported
30. J Jacob Praveen--156--.pmd 157
considerable relief of pain and decrease in swelling
however, paresthesia remained the same.
Objective examinations were carried out and there
was no obvious changes noted in the arches of foot
and no anatomical abnormalities identified.
Examination of his shoes noted to have wearing of
lateral sole which is prone to get inversion injuries.
Functional test such as walking, climbing up and down
stairs, squatting, hopping and toe standing were
reported painful on left ankle. On movement
examination, affected ankle showed dorsiflexion of 5
degrees. Tenderness over the lateral malleoli, lateral
ankle joint line and anterior talofibular ligament was
reproduced on palpation. Passive accessory of inferior
tibiofibular joint was painful and hypomobile on
antero-posterior glide, decreased antero-posterior
glide of talus on talocrural joint was noted whereas
subtalar joint glides felt normal with no pain. Isometric
to the evertors reproduced pain on the lateral aspect
of the ankle. Positive results obtained on anterior
drawer test for anterior talofibular ligament and
proprioception test with eyes closed on the injured
ankle.
Finally, Neurological examinations were
performed to examine the mobility of sural and
peroneal nerve. SLR with sural nerve component
reproduced pins and needles, and numbness on the
lateral border of the foot. Peroneal nerve and posterior
tibial nerve component did not reproduce any
symptoms.23
Clinical Impression
Clinically reasoning the scenario, the patient was
provisionally diagnosed with inversion ankle sprain
with sural nerve pathology. Sprain involving ATFL,
distal tibiofibular and talocrural joint dysfunction,
peroneal muscle strain and sural nerve involvement.
Intervention
The long term physiotherapy management mainly
focused on restoring the functional ability and return
to run. The short term goals were to reduce pain and
swelling and restoring joint mobility. Manual therapy
such as non-thrust mobilization of the distal
tibiofibular and talocrural joint, sural nerve
mobilisation technique and balance exercises were
chosen as treatment options.
On Day 1, Grade III anterior posterior mobilisation
to the distal tibiofibular joint was applied in supine
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 158 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

position (Fig I). After treatment, patient reported

decrease in pain from 7/10 to 3/10 in NRPS,
dorsiflexion range improved from 5 degrees to 15
degrees. Home based plan to carry out isometric
exercises were given to peroneus group muscles for
10 repetitions with 10 seconds hold.

Fig. 2. Antero-posterior glide at talocrural joint

Fig. I. Antero-posterior glide at distal tibiofibular joint

On Day 2, scores shifted to 2/10 with no pain while

walking however, pain persisted while climbing up
and downstairs. Treatment was progressed to grade
III+ at distal tibiofibular (Fig I) and grade III to
talocrural joint gliding talus anteroposteriorly for 30
seconds (Fig II). On reassessment, patient reported
reduced pain 1/10 and improved dorsiflexion range
Fig. 3. Evertors strengthening with theratube
to 20 degrees.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 159
On Day 3, patient complained of same intensity of
pain with normal dorsiflexion range. After attaining
dorsiflexion, straight leg raise with sural nerve
component produced paresthesia on the lateral aspect
of the foot. Patient was taught sural nerve mobilisation
with straight leg raise position with foot in dorsiflexion
and inversion for 15 times with 10 seconds hold.
Resisted exercise was given for the lateral
compartment muscles with theratube and sural nerve
mobilisation was taught to be done at home.
On Day 4, no pain in the ankle and full range of
dorsiflexion was identified. Patient was given
proprioceptive exercise such as standing on affected
leg with eyes open and closed. Patient is asked to run
and check of his pain.
Table 1: Shows the scores on NRS, ROM, PSFS obtained during the baseline and final therapy day measurements.
Criteria
Pain intensity in lateral ankle (NRS)
Range of motion (ROM)
Dorsiflexion
Patient Specific Functional Scale (PSFS)
• Running
• Walking
• Stair climbing
The treatment has produced drastic improvement
in the reduction of pain, improvement in range of
motion and return to run in 5 physiotherapy sessions.
DISCUSSION
Our present case demonstrated LAS affecting
various structures on the lateral ankle and foot. Sprain
of anterior talofibular ligament, strain of lateral
musculature, distal tibiofibular and talocrural
dysfunction and sural nerve involvement as a result
of LAS. Sural nerve on the lateral border of foot
produced paresthesia on the lateral border of foot.
Mostly, sports athletes who sustain acute LAS
during the play or training self-manage their injury
with rest, icing, compression and elevation (RICE
therapy). The subject in this study self-managed with
RICE therapy to reduce his swelling and pain as
described by Van Den Beckerom6 on acute lateral
ligament injuries reported RICE therapy as treatment
of choice for first 4-5 days to reduce the pain and
swelling.
30. J Jacob Praveen--156--.pmd 159
On final visit, patient reported no pain, no
restriction in dorsiflexion range of ankle joint, no
paresthesia felt on the lateral border of foot. Patient
reported that he could run with no difficulty. He was
checked for hoping, squatting, tip toe and reported to
be completely restored. Running shoe modification
was advised.
Outcome Measures
Outcome measures were recorded using Numerical
Rating Pain Scale (NPRS), Patient Specific Functional
Scale (PSFS), active range of motion measurements
(AROM). Scores were obtained during the initial
examination and on the day of discharge as shown in
the table 1.
Baseline (Day 1) Final (Day 5)
7/10 0/10
Restricted to 5 degrees Full range
of dorsiflexion
(20 degrees)
10-Mar 10-Oct
10-Apr 10-Oct
10-Apr 10-Oct
Several studies have hypothesised the reasons for
decreased dorsiflexion following lateral ankle sprains.
However, Our study participant correlates with two
different dysfunctional hypothesis. A study by
Vicenzino25 showed lack of posterior glide of talus on
tibia is associated with a positional fault of talus being
anteriorly positioned restraining anterior talus
translation. Another study by Kavanagh17 reported
that pull of ATFL on inferior tibiofibular joint
repositions the fibula anteriorly and inferiorly causing
narrowing of mortise restricting dorsiflexion at
talocrural joint. However, these two hypothesis fits
into our subject, treated with anterior posterior
mobilisation at inferior tibiofibular joint to widen the
mortise for the talus to glide posteriorly during ankle
dorsiflexion17 and posterior talar glide was performed
to enhance the complete arthrokinetic movement at
talocrural joint.25,26
To our knowledge, this is the first study to present
physiotherapy management of sural nerve
involvement in LAS. Injury to sural nerve in
association with LAS is rarely mentioned in the
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 160 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
literatures. However, clinically straight leg raise with
sural nerve component should be tested to identify
the integrity of the sural nerve. Neural mobilisation is
the treatment of choice for nerve involvement.
Shacklock 24 and Hunt 27 reported the movement
patterns that attempt to move and challenge the
nervous system to affect the gliding and elongation of
nerve trunks in challenge to affect the physiological
function of the nerve. Hence, causing paresthesia
throughout the nerve distribution. In our subject,
paresthesia was on the sural nerve dermatomal
distribution which found positive on neural
examination and responded well with sural nerve
mobilisation technique and the patient reported nil
paresthesia.
The muscle strains are commonly seen in LAS
especially in peroneal groups. Strengthening of these
muscles is very important in the recovery and to
prevent the recurrence of LAS. 28,29 The ankle
compromises proprioceptive capabilities and motor
pattern after initial injury resulting in loss of
proprioception.30 Positive proprioception test would
indicate the instability of the ankle. Balance exercise
was prescribed to stimulate the neuromuscular control
on the ankle joint enhancing the stability of ankle.
Exercise like single leg standing with eyes open
initially, progressing to eyes closed on firm or moving
platform will improve the proprioceptive impulse
resulting in restoration of ankle stability.30,31
CONCLUSION
There is little scientific background for sural nerve
involvement in relation to lateral ankle sprains and
physiotherapy management. This case report describes
the observation of anterior talofibular ligament sprain
with hypomobile distal tibiofibular joint and talocrural
joint with sural nerve pathology responded well with
mobilisation technique, neural mobilisation and
exercise therapy resulting in return to run. Hence,
examination of neurovascular structures should be
considered in lateral ankle sprain patients with
paresthesia on lateral side of foot and ankle.
Conflict of Interest: As this is single author, there is
no conflict of interest.
Source of Funding: The author did not receive any
source of fund or grant to manuscript the case
study.
30. J Jacob Praveen--156--.pmd 160
Acknowledgment: The author would like to
acknowledge the patient for his consent to write this
case report.
REFERENCES
1. Ferran NA, Maffulli N. Epidemiology of sprains
of the lateral ankle ligament complex. Foot Ankle
Clin. 2006;11(3):659–662.
2. Fong DT, Hong Y, Chan LK, Yung PS, Chan KM.
A systematic review on ankle injury and ankle
sprain in sports. Sports Med.2007;37(1):73–94.
3. Purcell SB, Schuckman BE, Docherty CL,
Schrader J, Poppy W. Difference in ankle range
of motion before and after exercise in 2 tape
conditions. Am J Sports Med 2009;37(2):383-389.
4. Borowski LA, Yard EE, Fields SK, Comstock RD.
The epidemiology of US high school basketball
injuries, 2005- 2007. Am J Sports Med
2008;36(12):2328-2335.
5. Halasi T, Kynsburg A, Tallay A, Berkes I.
Development of a new activity score for the
evaluation of ankle instability. Am J Sports Med
2004;32(4):899-908.
6. Van Den Bekerom MPJ, Kerkhoffs GMMJ,
McCollum GA, Calder JDF, Dijk CN.
Management of acute lateral ankle ligament
injury in the athlete. Knee Surg Sports Traumatol
Arthrosc 2012;28 (7):985-992
7. Brostrom L. Sprained ankles. Anatomic lesions
on recent sprains. Acta Chirurgica Scandinavica
1964;128:483–495
8. Holmer P, Sondergaard L, Konradsen L, Nielsen
PT, Jorgensen LN. Epidemiology of sprains in the
lateral ankle and foot. Foot & Ankle International
1994;15(2):72–74.
9. Brukner P, Khan K. Clinical sports medicine.
Sydney: McGraw-Hill; 1993, p 438-453.
10. Fallat L, Grimm DJ, Saracco JA. Sprained ankle
syndrome: Prevalence and analysis of 639 acute
injuries. Journal of Foot Ankle Surgery
1998;37(4):280–285.
11. Young CC, Sherwin. Ankle sprain differential
diagnoses [Internet]. 2011 [Cited 2011 Sep 22].
Available from :http://
emedicine.medscape.com/article/1907229-
differential.
12. Jotwani, Weber K, Lee S. Cutaneous sural nerve
injury after lateral ankle sprain: A case report. J
of Musculoskeletal Med. 2008;126-128.
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 161
13. Hertel J, Denegar C, Monroe MM, Stokes WL.
Talocrural and subtalar joint instability after
lateral ankle sprain. Med Sci Sports
1999;31(11):1501-1508.
14. Konradsen L, Olesen S, Hansen HM. Ankle
sensorimotor control and eversion strength after
acute ankle inversion injuries. Am J Sports Med
1998;26(1):72-77.
15. Leo AW, Fred CR, James C. Ellsasser tibiofibular
synostosis and recurrent ankle sprains in high
performance athletes Am. J. Sports
Med.1978;6;204
16. Jend R. Ney, M. Heller. Evaluation of tibiofibular
motion under load conditions by computed
tomography. Journal of Orthopadic Research
3:418-423
17. Kavanagh J. Is there a positional fault at the
inferior tibiofibular joint in patients with acute
or chronic ankle sprains compared to normals?
Manual Therapy 1999;4(1):19–24
18. Denegar CR, Hertel J, Fonseca J. The effect of
lateral ankle sprain on dorsiflexion range of
motion, posterior talar glide, and joint laxity.
Journal of Orthopaedic & Sports Physical
Therapy 2002;32(4):166–173.
19. Sobel M, DiCarlo EF, Bohne WHO, Collins L
(1991). Longitudinal splitting of the peroneus
brevis tendon: An anatomic and histologic study
of cadaveric material. Foot and Ankle 1991.12(3):
165–170
20. Bassett FH, Speer K P. Longitudinal rupture of
the peroneal tendons. The American Journal of
Sports Medicine 1993: 21(3): 354–357
21. Matt. Importance of neurologic exam in ankle
sprains. Posted April 10th http://
www.eorthopod.com/public/patient_
education/9028/importance_ of_ neurologic_
exam_in_ankle_sprains.html
22. Nitz J, Dobner J, Kersey D. Nerve injury and
grades II and III ankle sprains. Am. J. Sports Med
1985; 13:177.
30. J Jacob Praveen--156--.pmd 161
23. Pringle RM , Protheroe K. Mukherjee KS.
Entrapment neuropathy of the sural nerve. The
orthopaedic and accident division 1974;56b:3.
Glasgow, Scotland.
24. Shacklock. Clinical neurodynamics: A new
system of musculoskeletal treatment. 2005;
Edinburgh :Butterworth-Heinemann.
25. Vicenzino B, Branjerdporn M, Teys P, Jordan K.
Initial changes in posterior talar glide and
dorsiflexion of the ankle after mobilization with
movement in individuals with recurrent ankle
sprain. J Orthop Sports Phys Ther 2006;36(7):
464–71.
26. Maitland GD. Vertebral manipulation.5th edition.
1986. Butterworths, London.
27. Hunt GC. Injuries of peripheral nerves of the leg,
foot and ankle: an often unrecognised
consequence of ankle sprains. The Foot:
2003;13(1);14-18.
28. Thacker SB, Stroup DF, Branche CM, Gilchrist J,
Goodman RA, Weitman EA. The prevention of
ankle sprains in sports. A systematic review of
the literature. Am J Sports Med; 1999;27:753-760
29. Hartsell HD, Spaulding SJ. Eccentric/concentric
ratios at selected velocities for the invertor and
evertor muscles of the chronically unstable ankle.
Br J Sports Med: 1999;33:255-258
30. Freeman MA, Dean MR, Hanham IW. The
etiology and prevention of functional instability
of the foot. J Bone Joint Surg Br. 1965;47:678-685.
31. Mattacola CG, Lloyd JW. Effects of a 6-week
strength and proprioception training program on
measures of dynamic balance: a single-case
design. J Athl Train: 1997;32:127-135.
Prevelance of ankle sprain. [Internet] 2008. [cited
on 2008 Oct 10]. Available from: http://
www.wrongdiagnosis.com/a/ankle_sprain/
prevalence.htm.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
162 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Prevalence of Neck or/and Low Back Pain and Associated

Risk Factors in Sidcul Industrial Area, Rudrapur,
Uttrakhan

Sunil Bhatt1, Prabhjot Kaur2

1
Assistant Professor, 2PT, Dolphin (P.G) Institute of Biomedical & Natural Sciences, Dehradun

ABSTRACT

Purpose: To study the prevalence of neck or/ and low back pain, their associated risk factors and
whether the quality of life is associated with neck pain /or and low back pain in Sidcul industrial
area, Rudrapur, India.

Subjects: 500 workers, aged 20-60 years.

Method: Each subject was administered an assessment form and then on the basis of the category of
either neck or/and low back pain had completed the modified OSW (modified Oswestry Low Back
Pain), NPDI (Neck Pain Disability Index) and QOL (Quality of Life Scale) questionnaires.

Results: Prevalence of neck pain was found to be 3%, low back pain 27%, low back & neck pain 11%.

Conclusion: Computing time of more than 6 hours and continuous standing for 2 hours were found
to be major risk factors. Smoking was a major risk factor for neck pain.

Keywords: Prevalence, Neck Pain, Low Back Pain, Risk Factors, Quality Of Life

INTRODUCTION The various occupational factors were found to be

Low back pain is a common health condition in
working populations throughout the world and is a
major cause of disability among the workforce.11,15 It is
ranked first as a cause of disability and inability to
work, and expected to affect up to 90% of the world’s
population at some point in their lifetime.2 It remains
the leading cause of disability in persons younger than
45 years old and comprises approximately 40% of all
compensation claims in the United States.6
Low back pain does not only signify poor quality
of individuals’ life, but also showed decreased in labor
productivity due to off-work, absenteeism and early
retirement. It had been observed that individuals who
suffered from low back pain problems might develop
major physical, social and mental disruptions, which
could affect their occupations (Tavafian et al., 2007).
associated with low back pain e.g. manual handling,
heavy lifting, flexion and lateral bending of the trunk,
awkward postures for prolonged period of time,
prolonged sitting and standing, whole body vibration;
which causes fatigue of para-spinal muscles and
ligaments, lumbar disc flattening, disc fiber strain,
increase in intradiscal pressure and microfractures in
the vertebral end plates. 3,12,18 Poor workstation
ergonomics has been shown to significantly contribute
to the development of low back pain. Various
psychosocial problems, such as high stress, low job
satisfaction, low social support and effort reward
imbalance also contributed to an increased occurrence
of low back pain.6
Neck pain is common in the adult general
population, typical 12 month prevalence estimates
from 30% to 50%.5 In the general population, neck pain

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 163

and dysfunction are common, affecting up to 67% of
the general population at some time during their life
Postulated factors for neck pain include: individual
factors (e.g. gender) work environment factors (e.g.
repetitive work, exposure level) and psychosocial
factors (e.g. stress, high job demands, low decision
latitude). Physical risk factors such as prolonged sitting
and neck flexion have been reported as predictors of
neck pain in a mixed population of workers from
various industry, health and professional settings.4
The National Institute for Occupational Health
(NIOSH) in the United States concluded that there was
“strong evidence” for an association between neck
complaints and static loading of the neck-shoulder
musculature at work, as well as “suggestive evidence”
for risks from continuous arm and hand movements
and forceful work involving the same muscle
groups.13Activities such as physical exertion at work,
frequent bending, twisting, lifting heavy weights and
handling tasks, all play an important role in
contributing to the occurrence of low back pain and
neck pain.11,13
in work conditions in Indian workers compared to
others it is needed to see the prevalence, the quality of
life and risk factors that are associated with work-
related neck and low back pain in the Indian industrial
workers.
METHOD
Subjects: 500 workers
Inclusion criteria
1) Subjects working in different areas in Sidcul
industrial area, Rudrapur, Uttrakhand.
2) Age group: 20 to 60 years of age.
3) Gender: Male and female.
Exclusion criteria
The subjects should not have any previous history
of diagnosed
1) Spinal fracture

Gangopadhyay et al also stated that working in an 2) Caudal equinal syndrome

awkward posture for prolonged period of time may
3) Ankylosing spondylitis
lead to severe musculoskeletal disorder including neck
pain.1,4 4) Osteomyelitis.
Ergonomic hazards are directly linked to 5) Cervical rib
musculoskeletal complains among office workers. Van
Vuuren showed significant adjusted odds ratio for 6) Adhesive capusilitis.
bending and twisting and in findings of Ghaffari et al.
the common risk factors were awkward positions.15 7) Systemic illness.
For the most part, all jobs contain these factors to some 8) Pregnancy.
degree depending upon the physical tasks involved
in the job, the characteristics of the workers and the 9) Tumor back and neck conditions.
individual’s personal work style (Feuerstein, 1996).17
It has been seen that work related risk factors, working 10) Those having any history of psychiatric illness.
with awkward postures, poor ergonomics has been 11) Spinal surgery
shown to significantly contribute to the development
of low back and neck pain.4,6 12) Leg length discrepancy

It has been seen that the Indian professionals are at
more risk of developing the work related
musculoskeletal disorders as compared to those of the
USA professionals. Prevalence of physical discomfort
was higher among those who used computers for more
than 8 hours/day.16
13) Congenital anomalies of spine.
Instrumentation
1. Modified Oswestry Low Back Pain questioonaire
2. Neck Pain Disability Index

Although many studies have been done to see the 3. Quality of Life Scale.
prevalence and risk factors of neck and low back pain
in various population, but considering the difference 4. VAS

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 164 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Procedure OSW and QOL. After the questionnaires were

500 subjects based on the inclusion and exclusion
criteria were included in the study , the informed
consent was taken and were given an assessment form
including the individual characteristics: name, age,
gender, occupation, information about type of work,
history of any surgery, vascular disorder, metabolic
disorder, any fracture or recent injury, history of low
back pain and neck pain along with the duration, daily
sitting time, smoking habits, years of employment,
continuous standing for >2 hours, frequent waist
rotation and bending activities, chair having lumbar
support, daily computing time, average workday
weight lifted, number of days absent because of low
back pain and neck pain, pain intensity on VAS. On
the basis of the assessment the subjects were
categorized of having neck / and low back pain and
no pain. They were administered NPDI, modified
Table 1: Correlation between QOL, NPDI and OSW for the subjects included in the study
completed they were recollected by the human
resources head person.
Data analysis
Statistics were performed by using SPSS 13 Results
were calculated by using 0.05 level of significance.
Pearson correlation (2 tailed) was used to calculate
correlation between QOL, modified OSW and NPDI.
Chi- square was used to find out relation between the
modified OSW, NPDI and the various risk factors.
RESULTS
The total sample size of our study was 500 subjects
from industrial area Sidcul, Rudrapur, out of which
27% complained of low back pain, 3% had neck pain,
11% had both low back pain and neck pain and 59%
had no pain complain.

Correlation r value p value

QOL Vs NPDI -0.212 0.079
QOL Vs OSW -0.380 0.000

Table 2: Association between modified OSW with various risk factors:

Chi square p value

1 OSW vs sitting time 47.121 0.346 (NS)
2 OSW vs experience 35.414 0.035 (S)
3 OSW vs computing time 62.142 0.037 (S)
4 OSW vs average workday weight 21.616 0.483 (NS)
5 OSW vs smoking 16.769 0.776 (NS)
6 OSW vs continuous standing for 2 hours 36.318 0.028 (S)
7 OSW vs bending and twisting activities 23.909 0.352 (NS)
8 OSW vs lumbar support 22.102 0.454 (NS)

Table 4: Association between NPDI and various risk factors:

Chi square p value

1 NPDI vs sitting time 31.491 0.392 (NS)
2 NPDI vs experience 15.897 0.389(NS)
3 NPDI vs computing time 26.068 0.672(NS)
4 NPDI vs average workday weight 25.939 0.039 (S)
5 NPDI vs smoking 25.886 0.039 (S)
6 NPDI vs continuous standing for 2 hours 19.387 0.197 (NS)
7 NPDI vs bending& twisting activities 24.365 0.059 (NS)
8 NPDI vs lumbar support 11.640 0.706 (NS)

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 165

Table 5.3: Percentage distribution of various subjects according to the various risk factors:

Low Back Neck Pain No Pain

Pain (In %) (in %) (In %)
Sitting <4 19 4 23
Time 4-8 40 56 49
>8 41 40 28
Experience <10 60 61 82
>10 40 39 18
Computing <3 30 27 39
Time 3-6 32 31 31
>6 38 42 30
Average <10 72 76 77
Workday Weight >10 28 24 23
Smoking Yes 50 61 32
No 50 39 68
Continuous Yes 53 56 50
Standing For 2 Hrs No 47 44 50
Bending And Twisting Yes 55 60 28
Activities No 45 40 72
Lumbar Yes 45 56 68
Support No 55 44 32

DISCUSSION pain has a positive association with increased like hood

We had found no association between QOL and
NPDI (Neck Pain Disability Index), this could be
because may be the workers have adjusted themselves
according to the workplace environment. Also it could
be because we had a mixed population; involving
workers with different types of works such as some
workers might had less of computing activities and
they must have breaks during their working hours
which do not place them at a risk of having neck pain.
Also it could be that the workers might have adapted
themselves with the workplace environment. But there
was a weak negative association seen between
Modified OSW and QOL. This states that with a
decrease in the disability there is an improved quality
of life.
In our study we found the prevalence of low back
pain was 27%, neck pain 3% and 11% of the workers
had low back pain and neck pain for a period of more
than 3 months and 59% of them complained of no pain
in the industrial workers in Sidcul,Rudrapur.
Maryam Rezaee et al., (2011) in among office
workers found that one year and point prevalence was
37.3% and 13.7% respectively and also revealed that
increased age of up to 40 years, increased weight, daily
sitting work style more than 4 hours, daily computer
use more than 5 hours also past history of low back
of low back pain.15
Our study showed sitting for more than 8 hours
and using of computer for more than 6 hours increased
the risk of low back pain. This could be because
prolonged sitting and computer use leads to static
loading of the muscles & soft tissues & causes
discomfort leading to accumulation of metabolites,
acceleration of disc degeneration and leading to disc
herniation.17 Bending and twisting activities and no
lumbar support were found to be minor risk factors
for low back pain.
Bending in forward flexion, lateral flexion, or
extension of the spine results in a tensile stress on the
convex side of the annulus and a compressive stress,
caused by the body weight, on the concave side. The
side of the annulus under tension stretches, while the
side under compression bulges. During twisting and
rotation the motion of one vertebra on another
produces both tensile and shear stresses in the annulus.
The peripheral surface structures e.g the ligaments and
muscles are subjected to the largest stresses and
subsequently develop the greatest strains. Thus,
combinations of movements such as twisting, bending,
and bending with rotation will result in increased
stresses and strains on the disk, especially with a
superimposed load. These stresses alone can account

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 166 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
for disk injury; in the presence of any disk
degeneration.7
Korhoren et al found an incidence of local neck pain
to be 13.3% and radiating pain to be 14.4% in office
employees in visual display units. Poor physical
environment and poor placement of keyboard
increased the risk of neck pain. Smoking showed a
tendency for increased risk of neck pain. They had seen
that the current smokers and ex- smokers had twice
the risk of having neck pain as compared to those who
never smoked.9
Our study also showed a positive association
between smoking and neck pain. This could be because
smoking leads to decreased blood supply and
degeneration of the discs and leading to discomfort
and pain.3Sitting for more than 4 hours, computing of
more than 6 hours, continuous standing for 2 hours,
bending and twisting activities and having no lumbar
were found to be minor risk factors for neck pain.
Continuous standing requires static loading of the
neck muscles and also to maintain the neck in neutral
position the extensors of the neck acts against gravity.8
This increases the work of the muscles and leads to
fatigue, decreased blood supply, increased metabolite
formation and causes neck pain.14 Also while standing
there is neck flexion, during which the major load is
carried by C7-T1 joint. There is a considerable stress
of the ligaments; joint capsule during extreme flexed
position.10
CONCLUSION
The prevalence of neck or/and low back pain in
industrial workers, Sidcul, Rudrapur, India was 3%,
27% respectively. The prevalence both neck and low
back pain among the workers was 11%.
Computing time of more than 6 hours and
continuous standing for 2 hours were found to be
major risk factors. Sitting for more than 8 hour, having
bending and twisting activities and no lumbar support
were found to be minor risk factors for low back pain
Smoking was a major risk factor for neck pain.
Sitting for more than 4 hours, computing of more than
6 hours, continuous standing for 2 hours, bending and
twisting activities and having no lumbar were found
to be minor risk factors for neck pain.
31. Mani Kaur--162--.pmd 166
ACKNOWLEDGEMENT
It is my privilege to express my deep sense of
gratitude to the Almighty for showering his blessings
and who has always been my source of strength and
inspiration and who guides me throughout. I am very
much grateful to my loving parents for their love, care,
support and their keen interest in my academic
excellence.
Conflict of Interest: informed consent was taken from
each subject.
Source of Funding: Self
Ethical Clearance: from the departmental ethical
committee, physiotherapy department, dolphin (pg)
institute of biomedical and natural sciences, dehradun.
REFERENCE
1. Banibrata Das et al., Assessment of ergonomical
and occupational health related problems among
visual display terminal workers of West Bengal;
India. Asian journal of Medical Sciences 2010;
1:26-31.
2. Brennan et al., Lower back pain in physically
demanding college academic programs: a
questionnaire based study. BMC Musculoskeletal
Disorders. 2007; 8:67.
3. Ghaffari M et al., Low back pain among industrial
workers. Occup Med London. 2006; 56(7):455-60.
4. Hush JM et al., Risk factors for neck pain in office
workers: a prospective study. BMC
Musculoskeletal Disorders. 2006; 7:81.
5. Hogg Johnson S et al., The burden and
determinants of neck pain in general population.
Spine 2008; 33 (45): 539-551.
6. Jawantankul P et al., Development of risk score
for low back pain in office workers- A cross
sectional study. BMC Musculoskeletal Disorders.
2011; 12:23.
7. Jensen GM et al., Biomechanics of the lumbar
intervertebral dick: A review. Physical Therapy.
1980; 60: 765-773.
8. Kapandgi I.A. The physiology of the joints. Vol
3: the trunk and the vertebral column, 2nd edition.
Edinburg London and New York, Churchill
Livingstone, 1974, pg.112, 216.
9. Korhonen T et al., work related and individual
predictors for incident neck pain among office
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 167
employees working with video display units.
Occup Environ Med 2003; 60: 475-82.
10. Magnusson ML and M.H Pope. A review of the
biomechanics and epidemiology of working
postures. Journal of Sound and Vibration. 1998;
21.5(4): 965-76.
11. Murtezani A et al., Low back pain among Kosovo
power plant workers: Survey study. Italian Journal
of Public Health. 20122;9(4):
12. Nieuwenhuyse AV et al., The role of physical
workload and pain related fear in the
development of low back pain in young workers:
Evidence from the BelCokBack study; results
after one year of follow up. Occup Environ Med.
2006; 63:45-52.
13. Palmer KT et al., Prevalence and occupational
association of neck pain in British population.
Scand J W ork Environ Health.2001; 27 (1): 49-56.
31. Mani Kaur--162--.pmd 167
14. Pope MH et al., Spine ergonomics. Annu REV
Biomed Eng. 2002; 4: 49-68.
15. Rezaee M et al., Low back pain and related factors
among Iranian office workers. International
Journal of Occupational Hygiene. 2011; 3(1): 23-28.
16. Rupali Das. Occupational health concerns and
software professionals and their coping
stratergies. International Journal of Research
Business Strategy. 2012; 1(1).
17. Shrawan Kumar. Perspectives in Rehabilitation
Ergonomics. 2005. U.S.A. Taylor & Francis.
Pg.142.
18. Tomita S et al., Prevalence and risk factors of low
back pain among Thai and Myanmar migrant
seafood processing factory workers in Samut
Sakorn Province, Thailand. Industrial Health. 2010;
48: 283-291.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
168 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

A Study to Compare the effectiveness of Different Dosage

of Therapeutic Ultrasound on Pain and Grip Strength in
Patients with Lateral Epicondylitis

Mittal Hareshbhai Shanishwara1, Ashish Kakkad2

1
2nd year MPT, 2Lecturer, Shree K.K. Sheth Physiotherapy College, Rajkot

ABSTRACT

Purpose of study: To compare the effectiveness of different dosage of therapeutic ultrasound on

pain using Numeric Pain Rating Scale (NPRS) and grip strength using jamar hand dynamometer
(kg) in patients with lateral epicondylitis (LE).

Materials and Method: A comparative study was conducted on 45 patients with LE (age- 30 to 55
years, male and female) who complained of pain from 1 week to 4 months were selected by convenient
sampling method from civil hospital and K.K Sheth physiotherapy college in Rajkot.Patients were
assigned randomly into three groups. Measurements of pain and Grip strength were taken prior to
the test. Ultrasound (US) was given with Frequency- 1 MHz, duration 7 min, for 7 days for three
groups with variable mode and intensity as explained. Group A: Mode- Continuous, Intensity- 1.5
W/Cm2, Group B: Mode- Pulsed 1:4, Intensity- 1.0 W/Cm2, Group C: Mode- Pulsed 1:1, Intensity-
0.8 W/cm2. Post treatment measurement of pain and Grip strength were taken.

Results: The obtained data were calculated using Wilcoxon matched-pairs signed-ranks test and
Kruskal-Wallis Test which suggested that there is a significant decrease in NPRS. Student's paired t
test and Analysis of variance (ANOVA) test suggested there is a significant increase in grip strength
after the application of different dosages of ultrasound for all the Groups (A, B, C). Statistical analysis
was performed with SPSS version 14.0.

Conclusion: The study concluded that all three dosages of therapeutic ultrasound are effective to
reduce the pain and improve the grip strength in patients with LE. However continuous mode showed
a better effect as compared to other dosages in patients with LE.

Keywords: Ultrasound (US), Lateral Epicondylitis, Grip Strength, NPRS

INTRODUCTION in age group between 30 and 55 years.4 Males are more

Lateral epicondylitis (LE) is the condition
characterized by pain and tenderness at the lateral
epicondyle of the humerus due to non specific
inflammation at the origin of the extensor muscle of
forearm.1 Madras called the tennis elbow.2 There is an
annual incidence of 4-7 cases per 1000 patients in
general practice and 1-3% with in general population.
It is a common condition that significantly impacts on
the individual and society.3 Most patients with LE are
common than females. LE is more common in the
dominated arm however both arms can be affected. 2.
The tendon most commonly involved in LE is called
the Extensor Carpi Radialis Brevis (ECRB). It results
in weakness of wrist extension and radial deviation.
Weakness of wrist extension produces difficulty in
forceful grasp and pinch because of necessary
interaction between wrist extension and
finger flexion.5

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 169
It is more common in non- tennis players (95%).
Causes can be throwing, swimming, carpentry,
plumbing, textile workers and housewives.
Pathophysiology is divided in three stages. Stage I is
acute inflammation but no angioblastic invasion. Stage
II is stage of chronic inflammation with some
angioblastic invasion. Stage III is chronic inflammation
with extensive angioblastic invasion.2
The symptom of LE develops gradually. In most
cases, the mild pain begins and slowly worsens over
weeks and months. Other symptoms are point
tenderness on the lateral epicondyle, pain during
different activities (wrist extension, lifting objects,
shaking hands and turning a doorknob), morning
stiffness and burning on the outer part of elbow. The
symptoms are often worsened with forearm activity.6
it is generally a work related or sport related pain
disorder usually caused by excessive quick,
monotonous, repetitive eccentric contractions and
gripping activities of the wrist.7
Grip strength measurement can be taken with use
of jamar hand dynamometer. Most of the recent studies
of grip strength measurement have reported the Jamar
dynamometer to be the most reliable (test-retest
ICC=0.96-0.99), valid (p=0.21-0.004) and accurate
device for measurement of hand grip strength.8
NPRS measures the subjective intensity of pain. The
NPRS is an 11-point scale from 0-10. “0” = no pain,
“10” = the most intense pain imaginable. Patients
verbally select a value that is most in line with the
intensity of pain that they have experienced. The NPRS
has good sensitivity while producing data that can be
statistically analyzed.9
Non-surgical treatment includes Rest, Non-
steroidal anti-inflammatory medicines, Steroid
injections, Brace and Physical therapy. It includes
specific exercises those are helpful for strengthening
the muscles of the forearm and also modalities like
ultrasound, ice massage, or muscle-stimulating
techniques.6
US is one of the most common clinical modalities
used in physical therapy. Parameter selection for
ultrasound application should be based on the type of
pathology, location and tissue depth. There are studies
reporting the use of ultrasound to treat soft tissue
damage and consequently to reduce pain by
promoting healing and resolving inflammation. The
therapeutic effects of US are generally divided into
thermal & non thermal. In thermal mode, US is most
32. Mittal Shaniwara--168--.pmd 169
effective in heating the dense collagen tissues and is
requiring a relatively high intensity, preferably in
continuous mode to achieve this effect. The non
thermal effects of us are now attributed primarily to a
combination of cavitations, acoustic streaming and
micromassage.10
OBJECTIVES
1. To find the effect of continuous mode of
therapeutic ultrasound on pain and grip strength
in patients with LE.
2. To find the effect of different pulse modes of
therapeutic ultrasound on pain and grip strength
in patients with LE.
3. To compare the effectiveness of different dosages
of US on pain and grip strength in patients with
LE.
HYPOTHESIS
Null Hypothesis: There is no significant difference
among different dosages of therapeutic ultrasound on
pain and grip strength in patients with LE.
Experimental Hypothesis: There is a significant
difference among different dosages of therapeutic
ultrasound on pain and grip strength in patients with
LE.
MATERIALS AND METHODOLOGY
MATERIALS: Therapeutic ultrasound (Electrogenic
709), Jamar hand dynamometer (5030J1), pen, paper,
chair, pillow, cotton, conducting gel, universal
goniometer, NPRS scale.
SAMPLE SIZE: 45 patients
SAMPLE POPULATION: Patients with LE
SAMPLE DESIGN: Convenient sampling for
selection of patients and randomly allocation to three
groups
STUDY DESIGN: A comparative study.
STUDY SETTING: Civil hospital and Shree K K Sheth
Physiotherapy College, Rajkot.
STUDY DURATION: 7 days
Inclusion Criteria
· Age – 30- 55 years
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 170 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
• Gender – Male and Female
• Patient with LE diagnosed clinically
• Patients with LE affecting dominant or non
dominants hand
Exclusion Criteria
• Dysfunction at shoulder, neck, thoracic region
• Neuromuscular disorders
• Trauma or surgery of the elbow region
• Peripheral nerve entrapment
• Corticosteroid injection within 6 months
• Radiculopathy (C5-C6)
• Wrist and figure pathology
• Skin condition or open wound
• Local arthritis or poly arthritis
• Uncooperative patients
• Previous and/or continuous any another therapy
for LE
The diagnostic criteria’s used were: 8
1. Tenderness on lateral epicondyle 2.Cozen’s test
3. Mill’s test 4. Resistes finger extension tests (Modified
Mill’s maneuver).8
The patients of the LE were explained about the
study and written informed consent was taken from
them. Subject’s age, gender, dominancy, occupation,
history of symptoms and medication history was
taken. Prior to the test NPRS and grip strength with
jammer hand dynamometer (Kg) were taken.
Patients verbally selected a value of NPRS that was
most in line with the intensity of pain that they have
experienced in the last 24 hours10.
The American Society of Hand Therapists’
standardized arm position for grip strength testing was
utilized. Subject was positioned in a straight back chair
with both feet flat on the floor. For the tested arm
shoulder adducted and neutrally rotate, the elbow was
flexed to 90o. The forearm mid prone position and wrist
15 0 of extension with neutral Radioulnar deviation,
and the fingers were flexed as needed for a maximal
contraction. Each subject was instructed to breathe in
32. Mittal Shaniwara--168--.pmd 170
through her nose and blow out through pursed lips as
a maximum grip effort was made. At this time, a verbal
command of “Squeeze! Harder! Harder! Relax!” was
given by the examiner. The mean score among three
trials of each instrument was recorded for data
calculations.11
45 patient of LE were consecutively assigned
randomly in to three groups: Group A (Mean age- 41.7
Years), Group B (Mean age- 41 Years) and Group C
(Mean age- 40.2 Years). US was given after the use of
gel to the skin surface and overlapping circles patterns
of movement of the ultrasonic transducer on the skin
was used, Frequency- 1 MHz, duration 7 min, for 7
days for three groups with variable mode and intensity
as explained. Group A: mode- continuous, intensity-
1.5 W/cm2.12 Group B: mode- pulsed 1:4 (20% of duty
cycle), intensity- 1.0 W/cm2, 13 Group C: mode- pulsed
1:1 (50% of duty cycle), intensity- 0.8 W/cm2.10 After
the treatment NPRS and grip strength were taken.
RESULTS
The obtained data was calculated by using
Wilcoxon matched-pairs signed-ranks test for
comparison of pre and post values of NPRS and
Student’s paired t test for pre and post values Grip
strength for all Groups (A, B, C). Kruskal-Wallis Test
for comparisons of NPRS among three groups and
ANOVA test for comparison of grip strength among
three groups. Statistical analysis was performed with
SPSS version 14.0.
The results for NPRS were analyzed by using the
Wilcoxon matched-pairs signed-ranks test. In Group
A the mean Difference for NPRS was 4.13, the value
of Sum of all signed ranks (W) = 120.00, P<0.0001 (two-
tailed). In Group B the mean difference was 0.4667, W
= 35.000 at 0.0391 P value. In Group C the mean
difference was 1.267, W = 78.000, at 0.0005 P value.
These results suggest that there is a significant decrease
in NPRS after the application of different dosages of
ultrasound in all the Groups. (Graph -1)
Kruskal-Wallis Test for comparisons among three
groups of NPRS and the result was considered
extremely significant, The P value is < 0.0001 (Kruskal-
Wallis Statistic KW= 28.211). (Table-1)
The results for grip strength were analyzed by
using the Student’s paired t test. In Group A the mean
difference for the grip strength (in kg) was 6.26 kg, the
results were analyzed using the related t test and were
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 171
found to be significant (t= -7.11, df= 14), P<0.000 (two-
tailed). In Group B the mean difference was 2.00 kg, t
test were found to be significant (t= -2.67, df= 14), P<
0.018. In Group C the mean difference was 2.8 kg it
was found to be significant (t = -3.58, df= 14), P< 0.003.
These results suggest that there is significant increase
in grip strength after the application of different
dosages of ultrasound. (Graph - 2)
Graph-1: Age Distribution in Years
32. Mittal Shaniwara--168--.pmd 171
ANOVA test for comparison among three groups
of grip strength. The results of an ANOVA, at df 44,
for Grip strength is significant at p< 0.0011 (F =8.036).
(Table-2) A result of Post hoc analysis honestly
significant difference (HSD) value of grip strength in
continuous mode of therapeutic ultrasound is
significant at level of 7.36 (at df, 44).
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 172 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Graph-2: Gender Distribution

Graph-3: Mean Pre and Post NPRS Values of Diffrent Dosages of Theraputic Ultrasound.

Graph-4: Mean Pre and Post Grip Strength (Kg) Values of Diffrent Dosages of Theraputic Ultrasound.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 173

Table 1: Kruskal-wallis for NPRS of Diffrent Dosages of Theraputic Ultrasound

Group Number of Sum of Mean of Kruskal-wallis

Ranks Ranks Ranks Statistic KW
Column A 15 548.50 36.567
Column B 15 185.00 12.333 28.211
Column C 15 301.50 20.100

Table 2: Anova Analysis for Grip Strength of Diffrent Dosages of Theraputic Ultrasound

Source of Variation Sum of Squares D.F Mean Squares F

Between 131.7 2 65.87
Error 344.3 42 8.197 8.036
Total 476.0 44

DISCUSSION given placebo, and in 24% of those recommended rest.

The present study showed improvement on pain
and grip strength with different dosages (continuous,
1:4 and 1:1) of therapeutic ultrasound in patients with
LE. The result showed significant improvement in
NPRS and Grip strength with all dosage of therapeutic
ultrasound in patients suffering from LE but
continuous mode US showed significantly more
improvement than pulsed mode of ultrasound 1:1 and
than 1:4. So, different dosage of therapeutic ultrasound
can be used in LE for the reduction in pain level and
improvement in Grip strength.
Valma J Robertson et al., (2001) conducted a
systemic review on Effectiveness of Therapeutic
Ultrasound and concluded that active therapeutic
ultrasound is more effective than placebo ultrasound
for treating people with pain or a range of
musculoskeletal injuries or for promoting soft tissue
healing.14
A study was done on Pulsed ultrasound for LE.
Forty-five patients were consecutively assigned at
random to two groups for pulsed ultrasound or
placebo. The parameters for ultrasound were 1 MHz;
1:4; 1 W/cm2 for 10 min, ten treatments and the
statistical analysis showed no significant differences
in relation to the groups after the treatment period or
at the follow-ups.15 The study did not support the use
of pulsed ultrasound treatment with the chosen
parameters in lateral epicondylalgia.
A comparative study was done with 99 patients
(33 continuous ultrasound, 33 placebo ultrasound and
33 only rest) on pain alleviating effects of continuous
ultrasound treatment in epicondylalgia has been
compared to placebo ultrasound and to rest. The
condition was significantly improved in the group
treated with continuous ultrasound in 36%, in 30%
A significant improvement was noted when the effect
of continuous ultrasound was compared with rest, but
continuous ultrasound treatment was not significantly
better than placebo ultrasound.16
Demir H et al., (2004) conducted a study to
Compare the effects of laser, ultrasound, and combined
both treatments in experimental tendon healing.
Although US, laser, and combined US and laser
treatments increased tendon healing biochemically
and biomechanically more than the control groups, no
statistically significant difference was found between
them. Also the study did not find significantly more
cumulative positive effects of combined treatment. As
a result, both of these physical modalities can be used
successfully in the treatment of tendon healing.17
US enhance protein synthesis in fibroblast. US has
also been reported to reduce the inflammation by
directly including mast cell to release histamine which
in turn cause vasodilatation and increased vascular
permeability and it enhances tissue healing and
reduced the pain and ultimately improve the grip
strength.18,10
Limitation
• Sample size was small.
• Study was not conducted on uniform occupation.
• Study duration was limited to 7 days only; Long
term follow-up is not taken.
• Study was not conducted with specific chronicity
of the disease.
• Study is not conducted separately for dominant
and non-dominant upper extremities.

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 174 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Future research recommendations
• Further study can be done with larger sample size.
• Study can be conducted on uniform occupation.
• Study can be done with Long term follow-up.
• Study can be done separately for dominant or non-
dominant upper extremities.
• Electromyography Study can be done.
CONCLUSION
The study concluded that all three given dosages
of therapeutic ultrasound are effective to reduce the
pain and improve the grip strength in patients with
lateral epicondylitis. However continuous mode
showed a better effect as compared to pulsed dosages.
Clinical Implication
Continuous mode of ultrasound can be chosen as
a first treatment choice in a patient with lateral
epicondylitis for reducing pain and improving grip
strength.
Conflict of Interest: There was no personal or
institutional conflict.
Funding: All apparatus and materials were used from
institutes where study was conducted.
Ethical Clearance: Permission for study was taken
from head of department of institute.
Aknowlegment: We gratefully acknowledge our
Principal and teachers (Shree K.K Sheth Physiotherapy
College, Rajkot.) and Dr. Paras Joshi and Dr. Nishant
Nar (Physiotherapist in Civil hospital, Rajkot.) all
patients with LE, my colleagues for their kind support
and help for this study.
REFERENCE
1. J. Maheshwari , Essential orthopedics, 3rd edition,
Mehta Publishers 2003, p257
2. Ebenezer, essential of orthopedics for
physiotherapy, 1 st edition, Jaypee brothers
Medical publishers 2005, p 315
3. Bisset L, Vicenzino B, Coombes BK. A new
integrative model of lateral epicondylalgia.Br J
Sports Med 2009; 43(4):252-8.
4. Brent Brodzmen ,Kevin E Wilk , clinical
orthopedic rehabilitation, Mosby An Affiliate of
Elsevier Science 2003, p 104.
32. Mittal Shaniwara--168--.pmd 174
5. Carol A. Otis, kinesiology: the mechanics and
pathomechanics of human movement, first
edition, Lippincott Williams and wilkins 2004 p
351-367
6. Griffen L: Essentials of Musculoskeletal Care,
Third Edition, American Academy of
Orthopaedic Surgeons, 2009
7. D Stasinopoulos, M I Johnson (2004): Cyriax
physiotherapy for tennis elbow/lateral
epicondylitis Br J Sports Med; 38: 675-677.
8. David J Magee, orthopedic physical assessment,
Fifth edition, Reed Elsevier Indian Private
Limited, 2008, p 379-469
9. Williamson and Hoggart (2013), “Pain: a review
of three commonly used pain rating scales.” J
Clin Nurs ; 14 (7): 798-804.
10. Baker, K. G., et al. (2001). “A review of therapeutic
ultrasound: biophysical effects.” Phys Ther 81(7):
1351-8.
11. George F. Hamilton, Measurement of Grip
Strength: Validity and Reliability of the
Sphygmomanometer and Jamar Grip
Dynamometer, JOSPT Volume 16 Number 5
November 1992.
12. Kristina M Calder and Daniel W Stashuk, Motor
unit potential morphology differences in
individuals with non-specific arm pain and
lateral epicondylitis Journal of Neuro
Engineering and Rehabilitation December 2008,
5: 34 p 4.
13. Angela Forster, Nigel Palastanga. Clayton’s
Electropherapy. AITBS publishers.2006; 6:
165-179.
14. Valma J Robertson (2001). A Review of
Therapeutic Ultrasound: Effectiveness Studies;
Physical Therapy, vol. 81 no. 7 1339-1350
15. Haker E and Lundeberg T (1991), Pulsed
ultrasound treatment in lateral epicondylalgia,
Scand J Rehabil Med.; 23(3):115-8.
16. Lundeberg T and Abrahamsson P (1988);
comparative study of continuous ultrasound,
placebo ultrasound and rest in epicondylalgia.
Scand J Rehabil Med.; 20(3):99-101.
17. Demir H and Menku P (2004); Comparison of the
effects of laser, ultrasound, combined laser and
ultrasound treatments in experimental tendon
healing. Lasers Surg Med.; 35(1):84-9.
18. Brain D and Chad M (2003); A compression of
continuous and pulsed ultrasound on soft tissue
injury; J Phy.ther Sci, 15(2), 65-70.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 175

Effect of Slump Stretching with Static Spinal Exercise for

the Management of Non Radicular Low Back Pain among
Non Active Sports Persons

Karthikeyan1, Jaihind jothikaran2, Pradeep kiran3

1
Physiotherapist, Department of Neuro Rehabilitation, NIMHANS (A Govt of India Deemed University, Institute of
National Importance) Bangalore, 2Former Prof ., Faculty of General Adapted Physical Education and Yoga,
RamakrishnaMission Vivekananda University, Coimbatore, 3Direcor, Rhea Health CARE, T. Dasharahalli, Bangalore

ABSTRACT

Abstract Text YTChe effectiveness of different dosage of therapeutic ultrasound on pain using
Numeric Pain Rating Scale (NPRS) and grip strength using jamar hand dynamometer (kg) in patients
with lateral epicondylitis (LE).

Materials and Method: A comparative study was conducted on 45 patients with LE (age- 30 to 55
years, male and female) who complained of pain from 1 week to 4 months were selected by convenient
sampling method from civil hospital and K.K Sheth physiotherapy college in Rajkot.Patients were
assigned randomly into three groups. Measurements of pain and Grip strength were taken prior to
the test. Ultrasound (US) was given with Frequency- 1 MHz, duration 7 min, for 7 days for three
groups with variable mode and intensity as explained. Group A: Mode- Continuous, Intensity- 1.5
W/Cm2, Group B: Mode- Pulsed 1:4, Intensity- 1.0 W/Cm2, Group C: Mode- Pulsed 1:1, Intensity-
0.8 W/cm2. Post treatment measurement of pain and Grip strength were taken.

Results: The obtained data were calculated using Wilcoxon matched-pairs signed-ranks test and
Kruskal-Wallis Test which suggested that there is a significant decrease in NPRS. Student's paired t
test and Analysis of variance (ANOVA) test suggested there is a significant increase in grip strength
after the application of different dosages of ultrasound for all the Groups (A, B, C). Statistical analysis
was performed with SPSS version 14.0.

Conclusion: The study concluded that all three dosages of therapeutic ultrasound are effective to
reduce the pain and improve the grip strength in patients with LE. However continuous mode showed
a better effect as compared to other dosages in patients with LE.

Keywords: NPRS, FABQW, FABQPA, FABQT, and ODI, Slump Test, Neural Tissue, Slump stretching,
lumbar mobilization

INTRODUCTION primary care most commonly classify these patients

The problem and its settings
Low back pain (LBP) is the common reason for
seeing a physiotherapist in primary care. The goal for
the therapist managing these patients is to select the
appropriate treatment for each patient. The clinical
reasoning process required to achieve this goal starts
with a diagnostic classification that place the patient
into a recognizable group with a particular pattern of
signs and symptoms. The medical professionals in
with patho-anatomically labeled categories. However,
there appear to be a wide diversity in the opinion as
to the patterns of signs and symptoms that constitute
a category (Kenna C7. (1997).
Non-radicular low back pain (Spondylogenic
referred pain)
Spondylogenic referred pain is that which
originates from any of the components of the vertebrae
(spondyles) including joints, the intervertebral disc and

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 176 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
ligaments, muscle attachments. An important example
of spondylogenic pain is referred pain in an area distal
to or removed from the actual source of pain, such as
Table 1: Common cause of non radicular low back pain
Spondylogenic pain Origin
Non-radicular low back pain Ligaments
Muscles
Apophyseal joint
Intervetebral disc
Dura mater
Slump test
This is a provocation test for lumbosacral pain, a
screening test for a disc lesion. They basically sit on
the couch and then slump forward, placing their chin
on the chest. This causes stretching of the lumbar nerve
root on the effected leg. Get them to straighten the
unaffected leg, then the affected. It’s positive if the
back or leg pain is reproduced on the affected leg,
suggesting disc disruption.
Inclusion Criteria
1. Subjects must have symptoms in the lumbo-pelvic
region.
2. Subjects with a chief complaint of LBP having age
between 20 -45 years among non active sports
persons.
3. Subjects were required having symptoms that
referred distal to the buttocks, reproduction of
patient symptoms with slump testing.
4. Subjects with positive slump test with absence of
radicular symptoms.
5. Subjects with no change in symptoms with lumbar
flexion or extension mobility testing.
6. Oswestry disability score greater than 10%.
7. Straight leg raise (SLR) test at 45º or greater.
8. The onset of pain was between 7days and 3weeks
before the study begun.
9. Subjects had no history of back pain for a period
of 6months prior to the current episode.
10. Subjects were able to understand the English
language.
11. Both Genders were included.
33. Karthikeyan--175--.pmd 176
pain experienced in the buttocks from a disorder of an
apophyseal joint. (Butler. D2 (2000)).
Causes Clinical features
Inflammation Deep, dull, aching
Mechanical Relieved by rest
(Compression& strain) No localizing features
No dermatome reference
No neurological signs
Exclusion Criteria
1. Subjects having pregnancy, have history of spinal
surgery, positive neurological sign or symptoms
suggestive of nerve root involvement (diminished
upper or lower extremity reflexes, sensation to
sharp and dull, or strength),
2. Subjects with “red flags” serious spinal conditions
like infections, tumours, osteoporosis and spinal
Fracture, spinal surgery, etc.
3. Reflexes, sensation to sharp and dull, or strength.
4. Subjects with signs of nerve root involvement were
excluded.
5. Subjects exhibited a straight leg raise (SLR) test of
less than 45 degree.
6. If they had any contraindications to exercise
therapy such as Uncontrolled hypertension,
Previous Myocardial infarction, Cerebro vascular
disease, Peripheral vascular disease, Respiratory
disorders.
7. If they were receiving medications other than
analgesics and non-steroidal anti Inflammatory
drugs.
8. Subjects with obese persons.
Statistical tools adopted in this study
The performance of Control group and Intervention
group was compared using Repeated measure
ANOVA followed by Bonferrani test. The Student t
test was used to test association between the measured
scales and demographic variables. Sample selection
1. Population – subjects with non radicular low back
pain.
2. Sample size – 40 non active sports subjects (20
subjects in intervention group, 20 subjects in
control group).
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 177

Treatment procedure

Table 2: Control group treatment protocols (Mobilization with static spinal exercise) (Shacklock16(1995a))
Control group (Total duration -30 Minutes)
Day Warm up Rest Mobilization with static spinal exc Warm down
Mon/Wed/Fri Static bicycle- Duration-5 Min Mobilization Grade III,IV followed 5 Minutes of‘Basic Run’
(Under supervision (Duration-5 Min) by Static spinal exercise(15Min) Activity.
of physiotherapist)
Tue/Thu/Sat Pelvic tilt Duration-5 Min Mobilization Grade III,IV followed by 5 Minutes of
(Home programme) (Duration-5 Min) by Static spinal exercise(15Min) 'Basic Run' Activity.

Table 3: Intervention group treatment protocols (Slump stretching)

Intervention group (Total duration -30 Minutes)
Day Warm up Rest Slump stretching, mobilization Warm down
with static spinal exec
Tue/Thu/Sat(Under Static bicycle- Duration-5 Min Slump stretching (2 Min/1 Min Rest. 5 Minutes of‘Basic Run’
supervision of (Duration-5 Min) Repeated 5 –Times/Day) followed by Activity.
physiotherapist) Mobilization by Static
spinal exercise (15Min)
Mon/Wed/Fri Pelvic tilt Duration-5 Min Self slumps stretching 5 Minutes of‘Basic Run’
(Home program) (Duration-5 Min) followed by static spinal Activity.
exercise (15Min)

Treatment procedure
Slump stretching was performed with the patient
in the long sitting position with the patient’s feet
against the wall to assure the ankle remained at 0
degrees of dorsiflexion. The therapist applied over
pressure into cervical spine flexion to the point where
the patient’s symptoms were reproduced. The position
was held for 30 seconds. A total of 5 repetitions was
completed. Patients in the slump stretching group
completed a similar self-slump stretching home
exercise program, except patients actively flexed their
neck and applied overpressure using their upper
extremities until symptoms were reproduced. Patients
completed 5 repetitions, maintaining this position for
30 seconds. The time spent performing on the slump
stretching added only 3–4 minutes to the total
treatment time.
the time entry into the study and the reassessment
was carried out at the end of the first and second
week.
FINDINGS
NPRS scale
The total percentage of pain reduction from
baseline to first post intervention was 37.37%. So the
overall percentage of pain reduction from baseline in
the second post intervention was 57.17%.
The total percentage of pain reduction from
baseline to first post intervention was 61.6% while the
overall percentage of pain reduction from baseline in
the second post intervention was 90.4%.
FABQW Subscale

Clinical utility of outcome measures
1. Numeric pain rating scale (NPRS) at the time of
entry into the study and the reassessment was
carried out at the end of the first and second week.
2. Fear Avoidance Belief Questionnaire (FABQ) used
to assess patient beliefs performed at the time entry
into the study and the reassessment was carried
out at the end of the first and second week.
3. Oswestry Disability Questionnaire (ODI) used for
asses’ functional ability evaluation performed at
The total percentage of pain reduction from
baseline to first post intervention was 40.21%. So the
overall percentage pain reduction pain from baseline
to second post intervention was 85.12 %.
The total percentage of pain reduction from base
line in the first post intervention was 39.17% while the
overall percentage of pain reduction from base line to
second post intervention was 92.6%.
This result highlights that total percentage of pain
reduction in the intervention group is more than the
control group.

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 178 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

FABQPA subscale
The percentage of pain reduction from baseline to
first post intervention was 33.49%. The overall
percentage of pain reduction from baseline in the
second post intervention was 84.03%.
The percentage of pain reduction from baseline to
first post intervention was 39.19% while the overall
percentage of pain reduction from baseline in the
second post intervention was 93.0%.
This result highlights that the total percentage of
pain reduction in the intervention group is more than
the control group.
FABQT
The total percentage of pain reduction from
baseline to first post intervention was 37.76%. While
the overall percentage of pain reduction from baseline
in the second post intervention was 84.73%.
The total percentage of pain reduction from
baseline to first post intervention was 39.18%. While
the overall percentage of pain reduction from base line
to second post intervention was 92.8%.
This result highlights that the total percentage of
pain reduction in the intervention group is more than
the control group.
ODI
The total percentage of pain reduction from base
line to first post intervention was 46.17%.So the overall
percentage of pain reduction from base line to second
post intervention was 83.16%.
The total percentage of pain reduction from base
line to first post intervention was 44.6%. So the overall
percentage of pain reduction from base line in the
second post intervention was 92.46%.
This result highlights that total percentage of pain
reduction in the intervention group is more than the
control group.

Table 4: Mean comparisons between J.A. Cleland et al 2006 and Present study

Control group Intervention group

Baseline Post intervention Baseline Post intervention
NPRS J.A. Cleland et al. 3.80 2.70 4.00 1.70
Present study 9.10 3.75 8.85 0.85
ODI J.A. Cleland et al. 24.40 17.60 26.20 7.90
Present study 46.90 7.90 46.00 3.45

CONCLUSION of Neuro-Rehabilitation), NIMHANS, for providing

A present study on the Slump was done using the
Slump stretch for clients with mechanical back pain.
After 2 weeks of a Physiotherapy program +/- slump
stretching, the slumping group had 47.86 % greater
improvements over those that did not slump, as
measured on the Oswestry Disability Index. It can be
assumed that Slump stretching is beneficial for
improving short term disability, decreasing pain, and
centralization of symptoms compared to treatment
without slump stretching in a subgroup of patients
hypothesized to benefit from this form of treatment.
me all the facilities for this study.
I am thankful to Dr. Anupam Gupta (Additional
Prof/Department of Neuro-Rehabilitation),
NIMHANS, for providing me all the facilities for this
study. T.KARTHIKEYAN
Conflict of Interest Statement
I have read the above information and understand
the request for disclosure. The details are accurate to
the best of my knowledge.

The author giving assurance the treatment strategy

ACKNOWLEDGEMENT
non radicular low back pain purely on a clinical
I am thankful to Dr. P.Satish Chandra (Director & application not intension any other purpose.This study
Vice-chancellor), and Dr. A.P.Taly, HOD (Department purely clinical oriented approach.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 179

Source of Funding: This study utilized by the scholar 13. McCaffery and Beebe.(1993). Clinical Manual for
self source of money Nursing Practice.Baltimore: V.V.Mosby Company.
14. Maigne R. (1986). Manipulation of the spine. In:
Ethical Clearance: As this study involved human Basmajian JV ed. Manipulation, Traction
subjects, the ethics clearance had been obtained from and Massage. Paris: RML: 71–96.
the ethics committee of Ramakrishna Mission 15. Mashford. (2006). Therapeutic Guidelines:
Vivekananda University, Faculty of General & Rheumatology (Version 1). Melbourne:
Adapted Physical Education and Yoga Coimbatore- Therapeutic Guidelines Ltd: 85–100.
20, as per ethical guidelines, research from bio-medical 16. Shacklock. (1995a). In: Moving in on pain.
research on human subjects, 2000, ICMR New Delhi. Chastwood: Buttersworth-Heinemann.
17. Sharma R. (1999). A Study on Prevalence of Low
REFERENCES Back Pain in General Population. Guru Nanak Dev
University. Amritsar, Punjab, India.
1. Braggins. (2000). Back care,clinical approach.
18. Waddell G. (1998). The back pain revolution;
london,United kingdom: Churchill
Churchill Livingstone, Edinburg.
Livingstone.
19. Walsh M. (2005). Upper limb neural tension
2. Butler. D. (2000). The sensitive nervous system.
testing and mobilization fact, fiction and a
Adelaide: Noigroup Publications.
practical approach. J Hand Ther; 18: 241-258.
3. Cormack J et al. (1980): A Handbook of Primary
20. Adams CBT. (1971). Studies in cervical
Health Care.London: Kluwer-Harrap
spondylitic myelopathy:movement of the cervical
Handbooks; 3(68): 1–10.
roots, dura and cord, and their relation tothe
4. Clive Kenna and John murtagh. (1989): Back pain
course of the extrathecal roots. Brain; 94: 557–568.
and Spinal manipulation Butterworth; 4- 5.
21. American Physical Therapy Association (APTA).
5. Gatterman . (1995). Foundations of chiropractic
(2001). What is Physical Therapy? (A guide to
subluxation. Boston, NewYork: Mosby. pp.
Physical Therapists Practice). Physical Therapy; 81
11 – 12. Boston, New York.
(1): 21.
6. Gibson JNA. (2002). Surgery for lumbar disc
22. Anderson. (1998). Position of the American
prolapse. Cochrane Database of Systematic
Dietetic Association: The Role of Nutrition in
Reviews Issue 2.
Health Promotion and Disease Prevention
7. Kenna C. (1997). Back Pain and Spinal Manipulation
Programs. J Am Diet Assoc; 98(2): 205-208.
(2nd edn).Oxford:Butterworth
23. Aure O and Vasseljen O. (2003). Manual therapy
Heinemann; 70–164.
and exercise therapy in patients with
8. Kornberg C (1987). Positive slump test in Australian
chronic low back pain: A randomized, controlled
Rules football players with grade one
trial with 1-year follow-up. Spine ; 28: 525–531.
hamstring strain. In: Proceedings of the 10th
24. Aina A and Clare H. (2004). The centralization
International Congress, World
phenomenon of spinal symptoms—A
Confederation for Physical Therapy, Sydney,
systematic review. Manual Therapy; 9: 134–143.
Australia, Sydney, New South Wales,
25. Alessandro Aina and Helen Clare. (2004). the
Australia: World Confederation for Physical
centralization phenomenon of spinal
Therapy, Book 11, pp 1060-1064.
symptoms—A systematic review. Manual
9. Maitland GD. (1986). Vertebral Manipulation. 6th
Therapy; 9: 134–143.
ed. London, UK: Butterworths.
26. Axel Scha¨ fer and Kathy Briffa. (2007).
10. Maitland G and English K.(2001). Maitland’
Classification of low back-related leg pain—A
svertebralmanipulation: Oxford
proposed patho-mechanism-based approach
11. Vol. [chapter 12]. Oxford (Ed).
Manual Therapy, j.math; 10(003):1-9.
12. Murtagh C. (1989). Back Pain And Spinal
Manipulation. Sydney: Butterworths.

33. Karthikeyan--175--.pmd 179 11/1/2014, 12:17 AM

 DOI Number: 10.5958/0973-5674.2014.00344.X
180 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

A Cor-Relational Study Between Carpal Tunnel

Syndrome Questionnaire and Nerve Conduction Study in
Computer Operators

Hemal Paneri1, Sarla Bhatt2

1
Tutor cum Physiotherapist, Government Physiotherapy College, Jamnagar, 2Principal, Shri K. K. Sheth College of
Physiotherapy, Rajkot

ABSTRACT

Background: Prevalence of Carpal Tunnel Syndrome (CTS) is increased because of increased use of
computers. Repetitive stress injuries and sustained abnormal posture thought to be mechanisms for
CTS in key board users. Nerve Conduction Velocity (NCV) is gold standard electro-diagnostic
investigation which also measures severity of CTS. Carpal Tunnel Questionnaire Score (CTQS), a
symptom severity based questionnaire is cost effective, less time consuming and easily administrable
tool which is commonly used in clinical setup.

Objective: To assess the severity of CTS in long term key board users using CTQS and NCS. To
correlate the CTQS severity score with NCS findings (sensory and motor latency; sensory and motor
velocity).

Methodology: The cross sectional study was done on 35 healthy long term key board users (>32 hr/
wk) with mean age of 32.86±9.28 with no any musculo-skeletal disorders. The sensory and motor
NCS of median nerve in dominant extremities of subjects were tested and the values obtained were
correlated with CTQS.

Result: A significant positive correlation was seen between the Carpal Tunnel Questionnaire Score
(CTQS) and the sensory and motor latency (r=0.817; r=0.659) respectively and significant negative
correlation was seen between CTQS and sensory and motor velocity (r= -0.749; r = -0.493) respectively.
Conclusion: From the above result, it can be said that Carpal Tunnel Questionnaire Score (CTQS)
can be replaced in place of NCS and thereby the severity of the CTS can be assessed.

Keywords: Carpal Tunnel Syndrome, Nerve Conduction Velocity Studies, Carpal Tunnel Questionnaire
Score (CTQS)

INTRODUCTION upper extremity Musculo Skeletal Disorders (MSD)2,3

The use of computer is increasing in the working
population 1, So the concern exist about possible
adverse effect as an occupational risk factor for distal
Corresponding author:
Hemal Paneri
Tutor cum Physiotherapist
Government Physiotherapy College, Jamnagar. Block-
16, Shilpan kunj Society, Sadhu Vasvani Road, Rajkot
E mail : hemalpaneri@rocketmail.com
Mobile No : 9725995697
such as, Carpal Tunnel Syndrome (CTS) which has
biggest impact in the professional computer users4, due
to repetitive typing or keyboard data entry.
Keyboard use for 20h/week or more was slightly
associated with tingling/numbness. High rates of
repetitive movement of the wrists, working with flexed
or extended wrist, forceful hand motions and improper
rests of the hands and wrists may result in compression
neuropathy such as carpal tunnel syndrome which is
also described as occupational hazard, particularly in
computer operators5 .

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 181
CTS is an entrapment neuropathy of median nerve
at the wrist caused by compression of median nerve
in the carpal tunnel as it passes from forearm to the
hand beneath transverse carpal ligament. The clinical
features of CTS include pain and paresthesia in hands,
which aggravate at night. The clearest indications of
median nerve entrapment are: sensory symptoms in
1st, 2nd and radial half of 3rd digits and over the carpal
tunnel, sometimes awakening the patient at night.6 In
the clinical examination, Passive flexion or extension
of hand at wrist for 1 min or more may result in
aggravation of sensory symptoms (Phalen’s sign;
Phalen 1970)7.
Nerve Conduction Studies (NCS) is a gold standard
technique used to diagnose the CTS.8 Nerve conduction
studies (NCS) assess peripheral nerve function by
recording evoked stimulation response to confirm a
clinical diagnosis of CTS in patients with a high degree
of sensitivity and specificity.9 Abnormal findings
include conduction slowing, conduction blockage, lack
of responses, and/or low amplitude responses.
The suggested severity grade for CTS is as follows
(Herrmann and Logigian, 2002)10:
1) Mild – Slowing of median distal motor and sensory
latency only.
2) Mild to moderate – Latency prolongation with
mild reduction of SNAP.
3) Moderate – latency prolongation with moderate
reduction of SNAP or CMAP.
4) Severe – unrecordable median SNAP or severe
reduction of CMAP with active denervation or
severe chronic denervation/reinnervation
Another tool to assess the severity of CTS is Carpal
Tunnel Syndrome Questionnaire (CTQS). CTQS is a
standardized, patient-based outcome measure of
symptom severity and functional status in patients
with carpal tunnel syndrome. The questionnaire
comprises of symptom severity scale with 11 questions
scored from 1 to 5 point and for evaluation of
functional status 8 questions with same point scale.
The scale has criterion validity with reliability (0.91).11
Keeping this in view this study aims to know
whether there is any correlation between NCS and
CTQS to assess the severity of CTS in long term key
board users.
34. Hemal Paneri--180--.pmd 181
HYPOTHESIS
Experimental hypothesis
There will be significant correlation between CTQS
and NCS findings (sensory and motor latency; sensory
and motor velocity).
Null hypothesis
There will be no correlation between CTQS and
NCS findings (sensory and motor latency; sensory and
motor velocity).
MATERIALS AND METHOD
Study Design:- Cross Sectional Study
Sampling Technique:- Purposive sampling
Sample Collection:- 35 subjects were selected in the
age group between 20 and 60.With mean age 32.86 ±
9.28. The data were collected from Bank and corporate
offices in Rajkot. Before taking NCS study subjects
filled the CTQS and scores were obtained.
Inclusion Criteria: Both male and female patients
diagnosed with unilateral or bilateral CTS were asked
to participate in this study if they met the following
criteria:
(1) Pain, weakness, numbness or tingling in one or
both extremities.
(2) Should be using keyboard > 30 hours/week since
2 years and with the age group between 20 to 60
years.
(3) No surgery for the CTS should be done for the
involved limb.
Exclusion Criteria
Subjects with cervical radiculopathy and cervical
spondylosis
(1) Subjects with diabetic history
(2) Pregnant and lactating females
(3) Subjects with reflex sympathetic dystrophy
(4) Subjects with distal forearm bone fracture
(5) Family history of neuropathy
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 182 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

(6) Subject taking medication causing neuropathy like
AKT, ART, Vincristine
(7) Alcohol addicted
Materials to be used
Electromyography machine (RMS EMG EPMK-2),
Electrodes (surface, ground, ring), conducting gel,
spirit, adhesive tape, cotton, inch tape, CTQS, kidney
tray, chair, pillow, scissor, pen, pencil.
carried out by placing the recording ring electrodes
with coupling gel at the 2nd digit. Cathode is placed at
1st interphalangeal joint and anode is 3 cm distal to it.16
• Sub maximal stimulation was given at 3 cm
proximal to the distal wrist crease by stimulating
electrode.
• Distal Sensory Latency (DSL) and SNCV were
recorded.

Measurement procedure SNCV = D/L17

D – Distance (mm)
Written consent was taken from subjects who
fulfilled the inclusion criteria. L - Latency (ms)

CTQS12,13,14 was given to subjects. The subjects were Motor component

asked to fill the Symptom Severity Scale form (11
• Recording surface electrode with coupling gel was
questions) to know the severity of the CTS and score
were obtained. Both sensory and motor NCS for the placed exactly on motor point of abductor pollicis
median nerve of involved extremity was recorded for brevis muscle, reference electrode was placed 3 cm
the selected subjects to assess the severity of the distal at the 1st Metacarpo Phalangeal Joint.16
condition.
• Supramaximal stimulation was given for median
Equipment setting: nerve at two sites:

The bandwidth of the filter setting for Motor
conduction studies was 5 Hz- 10 kHz, and for Sensory
conduction studies was 10-2 kHz and sweep speed was
kept at 2-5 ms/division.15
Subject position - Sitting on back rest chair with
pillow in lap to support the forearm and hand of the
subject .The hair present on the assessed extremity
were shaved and cleaned with spirit to reduce the skin
resistance.
Recording procedure
Median nerve
NCS for the sensory component of median was
- At wrist – 3 cm proximal to distal wrist crease
- At elbow – medial to brachial artery15
MNCV = D/PL – DL16
D - Distance
PL – Proximal latency, DL – Distal latency
DATA ANALYSIS
Comparison of Carpal Tunnel Questionnaire Score
with Nerve Conduction Studies (sensory and motor
latency; sensory and motor velocity) on the affected
side was analyzed by using Spearman’s Correlation
test. 18 It is denoted by “ñ” (rho).

RESULTS

Table 1: Mean and standard deviation of age

N Mean Std. Deviation Minimum Maximum

AGE 35 32.8571 9.28675 24.00 59.00

Table 2 : Correlation between CTQS and DML:

CTQS DML
Spearman’s rho CTQS Correlation Coefficient 1.000 .659
Sig. (2-tailed) . .000
N 35 35
DML Correlation Coefficient .659 1.000
Sig. (2-tailed) .000 .
N 35 35

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 183

The above table shows the positive correlation between CTQS and DML (ñ = 0.659). The correlation is significant at the 0.01 level.

Table 3: Correlation between CTQS and MNCV:

CTQS MNCV
Spearman’s rho CTQS Correlation Coefficient 1.000 -.493
Sig. (2-tailed) . .003
N 35 35
MNCV Correlation Coefficient -.493 1.000
Sig. (2-tailed) .003 .
N 35 35

The above table shows the negative correlation between CTQS and MNCV (ñ = - 0.493). The correlation is significant at 0.01 level.

Table 4: Correlation between CTQS and SNCV :

CTQS SNCV
Spearman’s rho CTQS Correlation Coefficient 1.000 -.749
Sig. (2-tailed) . .000
N 35 35
SNCV Correlation Coefficient -.749 1.000
Sig. (2-tailed) .000 .
N 35 35

Above table shows the negative correlation between CTQS and SNCV (ñ = - 0.749). The correlation is significant at the 0.01 level.

Table 5: Correlations between CTQS and DSL:

CTQS DSL
Spearman’s rho CTQS Correlation Coefficient 1.000 .817
Sig. (2-tailed) . .000
N 35 35
DSL Correlation Coefficient .817 1.000
Sig. (2-tailed) .000 .
N 35 35

Above table shows the positive correlation between CTQS and DSL (ñ = 0.817). The correlation is significant at 0.01 level.

DISCUSSION Heecheon Y et al. (1999) examined severity of

NCS play an important role in clinical practice and
research, by establishing the diagnosis more
adequately for these conditions. Severity of the CTS
can be measured with CTQS which can replace nerve
conduction studies in assessment for clinical decision
making for treatment of choice. The objective of the
study was to know whether the CTQS severity score
is related with NCS findings (Sensory and motor
latency; sensory and motor velocity).
This study was done on 35 healthy individuals with
a mean age of 32.85 ± 9.286 who is working on
computer keyboard on a daily basis for at least 32hrs/
wk. Sensory and Motor nerve conduction studies of
median nerve in affected upper extremities was
evaluated. The values obtained from the NCS (NCV,
latency) and CTQS were correlated using the
Spearman’s Correlation.
symptoms in CTS in relation to NCS of median sensory
nerve and found that clinical scales are significant and
reflect median nerve injury. He found the negative
correlation between the CTQS and SNCV (ñ = -0.49).
The present study also shows the similar results with
significant negative correlation between CTQS and
SNCV (ñ = - 0.749).10 Also Heecheon Y et al. found the
positive correlation between the CTQS and the distal
sensory and motor latency (ñ = 0.53 ; ñ = 0.46)
respectively. In the present study also, significant
positive correlation was found between the CTQS and
DSL and DML (ñ = 0.817; ñ = 0.659) respectively. Thus
it supports their potential utility for evaluating the
outcome of CTS treatment and developing a model
for exposure of severity relationship.19 Also, there is a
significant negative correlation between CTQS and
MNCV(ñ = - 0.493) which could be due to the subjects
included were very heavy users of the keyboard.

34. Hemal Paneri--180--.pmd 183 11/1/2014, 12:17 AM

 184 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
In another study conducted by V. Kamath et al.
(2003) who compared the sensitivity of scored
questionnaire and electrophysiological examination in
diagnosis of CTS and found 85% and 92% of sensitivity
respectively and recommended that questionnaire can
replace nerve conduction studies.20
On the contrary N. Heybeli et al.(2002) studied the
relation between Boston Questionnaire and nerve
conduction studies pre and post operatively and
found no correlation exist in NCS and questionnaire
score. The difference may be due to variability between
symptoms and nerve conduction threshold required
for symptom production varies from person to
person.14
The present study indicates that the symptom
severity scale is more closely related to the nerve
conduction measures. The significant relationship
between the clinical scales and the nerve conduction
measures indicates that these clinical scales probably
have biological significance and reflect median nerve
injury. The symptom severity scales are painless and
easy to administer in virtually every place including
industrial work sites. It is pertinent to note, however,
that the incidence of primary symptoms in subjects
with normal nerve conduction studies is unknown.
Nevertheless, such scales may be useful as a screening
procedure for CTS in the work place, to help determine
which patients should be sent for more specific testing,
such as nerve conduction studies. They also may be
useful in the study of exposure severity relationships
for CTS and in the evaluation of outcomes of CTS
treatment.
Clinical Implication: CTQS can be replaced with
Nerve Conduction Studies.
CONCLUSION
The conclusion of the study
- There is positive correlation between CTQS and
Latency (motor and sensory).
- There is negative correlation between CTQS and
conduction velocity (motor and sensory).
Limitations of the Study
• Small sample size.
• Type of keyboard used by the subject was not
specified.
34. Hemal Paneri--180--.pmd 184
• Room temperature was not controlled.
• Work done on computer was not specific. Example:
typing or surfing.
Acknowledgement: I wish to express my gratitude to
my respected Dr. Karishma Jagad for her valuable
guidance and keen interest shown in this dissertation
and without whom this work would not have taken
shape.
Conflict of Interest: There is no Conflict of Interest.
Source of Funding: There was no funding taken for
this study from any agency or institution.
Ethical Clearance: The study was been approved by
relevant ethical committee.
REFERENCES
1. Johan Hviid Anderson, Jane Froelund Thomsen,
Erik Overgaard, Christina Funch Lassen, Lars
Peter Andreas Brandt and Imogen Vilstrup et al.
Computer use and CTS: A 1 Year follow- up study.
Journal of American medical association 2003;
289(22): 2963-69.
2. Hart DL. Occupational Injury. Physical Therapy
1999; 79:1084-88.
3. Marklin R.W., SimoneauG.G.and Monroe J.F.
Wrist and forearm posture from typing on split and
vertically inclined computer keyboard. Human Factor
1999; 41:559-69.
4. Mircea F and Sharwan Kumar. Work related carpal
tunnel syndrome: Current concept. J Musculoskeletal
Research 2003; 7: 2:87-89.
5. Kao SY. Carpal Tunnel Syndromes an occupational
disease. J Am Board Fam Med 2003; 16:533-542.
6. Stevens J.C., Smith B.E., Weaver A.L., Bosch E.P.,
Deen H.G. Jr and Wilkens J.A. Symptoms of 100
patients with electromyographically verified carpal
tunnel syndrome. Muscle Nerve.1999; 22:10:1448-56.
7. U K Misra, J Kalita. Clinical Neurophysiology.
2nded. New Delhi: Elsevier; 2006. p. 34
8. www.aetna.com/cpb/medical/data/500 599/
0502.html
9. Martha J Sanders. Ergonomics and management of
musculoskeletal disorders. 2nded Butterworth
Heinemann; 2004: 505.
10. U K Misra, J Kalita. Clinical Neurophysiology.
2nded. New Delhi: Elsevier; 2006. p. 36
11. Levine, David W.; Simmons, Barry P.; Koris,
Mark J.; Daltroy, Lawren H.; Hohl, Gerri G.;
Fossel Anne H. and Katz, Jeffrey N. A Self-
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 185
Administered Questionnaire for the Assessment of
Severity of Symptoms and Functional Status in Carpal
Tunnel Syndrome. Journal of Bone and Joint
Surgery.1993; 75A(11): 1585-92.
12. Atroshi I, Gummesson, C, Johnsson, R. Ornstein,
E., Ranstam, J.and Rosen, I. Revalence of Carpal
Tunnel Syndrome in a General Population. JAMA
1999; 282 No 2:153-8.
13. Senthil Nathan S, P. Priyanka, ArifG. and
BalkrishnanIlango. Critical analysis of outcome
measures used in the assessment of carpal tunnel
syndrome. International Orthopaedics 2007.
14. N. Heybeli, S. Kutluhan, S. Demeric, M. Kerman
and F. Mumcu. Assessment of outcome of carpal
tunnel syndrome: A comparison of electrophysiological
findings and a self-administered Boston
Questionnaire.J hand surgery (Bri and Euro) 2002;
27B:3:250-64.
15. U K Misra, J Kalita. Clinical Neurophysiology.
2nded. New Delhi: Elsevier; 2006. p. 25
34. Hemal Paneri--180--.pmd 185
16. U K Misra, J Kalita.Clinical Neurophysiology.
2nded. New Delhi: Elsevier; 2006. p. 35.
17. Jun Kimura. Electrodiagnosis in Diseases of
Nerve & Muscle: Principles & practice. 2nded.
New York Oxford: Oxford University Press;
1989.p.104.
18. T Ogura, N Akiyo, T Kubo, Y Kira, S Aramaki, F
Nakanishi. The relationship between NCS and
clinical grading of carpal tunnel syndrome. Journal
of Orthopedic surgery 2003; 11(2):190-93.
19. Jeremy D.P.A Neurophysiological grading scale for
carpal tunnel syndrome. Muscle and Nerve
2000;23:1280-3.
20. Roberta Bonfiglioli, Stefano Mattioli, Maria Rosa
Spagnolo and Francesco Saverio Violante. Course
of symptoms and median nerve conduction
values in performing repetitive jobs at risk for
carpal tunnel syndrome. Occupational Medicine
2006; 56: 115-21.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
186 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effect of Body Weight Squatting on Functional

Independence in the Individuals with Incomplete Spinal
Cord Injury

Disha Solanki
Physiotherapist, Guru Govind Singh Government Hospital, Jamnagar

ABSTRACT

Background: Spinal cord injury may result in incomplete or complete paralysis of the lower limbs
making activities of daily living difficult or impossible. Persons with a spinal cord injury (SCI)
demonstrate strength deficits that can limit their functional ability to perform activities of daily living
(ADL). Thus, recovery of motor activity and enhancement of residual muscle strength are determinant
factors of a high level of functional independence. One activity that paraplegics in American Spinal
Injury Association's (ASIA) impairment category D and some in impairment category C can perform
is the Arm assisted body weight squat (BWS). It is hypothesized that the lower body strength gained
from BWS would not only facilitate chair transfers but could also improve ambulation with a walker
and several other active daily living (ADL) tasks requiring balance.

Aim: To study the effectiveness of body weight squatting on functional independence in the
individuals with incomplete spinal cord injury.

Materials & Method: An interventional study was conducted Total 30 subjects were randomly divided
into 2 groups: Group A (Experimental group) & Group B (Control group). Both the groups were
given conventional physiotherapy treatment and Group A was additionally given body weight
squatting. All the patients were treated for the period of 6 weeks, 3 days a week for one year.

Before and after intervention assessment was done. Berg Balance Scale, Motor-functional
independence measure, sit to stand test with dynamometer taken in each group of patients.

Results: Both the groups showed significant improvement in BBS, FIM, Sit to stand test with
dynamometer after 6 week's intervention period. There were greater improvements in Motor FIM
(U= 54 and P= 0.0157), BBS (U= 56 and P= 0.0199) and Sit to stand test (Ascending phase P-
value=0.0001, Descending phase P-value=0.0129) scores in the experimental group that received both
conventional treatment and body weight squatting which was statistically significant.

Conclusion: Body weight squatting showed overall significant improvement in lower extremity
muscle strength, balance and functional independence and is effective adjunct to rehabilitation in
the patients with thoracic incomplete spinal cord injury.

Keywords: Spinal Cord Injury, Body Weight Squatting, Functional Independence

Corresponding author: INTRODUCTION

Disha Solanki
Spinal cord injury (SCI) is a devastating injury
Physiotherapist
resulting in the loss of somatic and autonomic nervous
Guru Govind Singh Government Hospital, Jamnagar.
Address :- Ambaji Krupa, block no.-4, Taxasila society, system function. 1 The term ‘incomplete lesion’
Timbavadi, Junagadh-362015 encompasses all patients with some sparing of neural
E-mail ID - sdisha50@yahoo.com. activity below the level of lesion.2 Persons with a spinal
Mobile No. - 9898174424 cord injury (SCI) demonstrate strength deficits that can

35. Disha Solanki--186--.pmd 186 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 187
limit their functional ability to perform activities of
daily living (ADL). Limitations in motor activities are
among the most severe perturbations in individuals
with SCI. Thus, recovery of motor activity and
enhancement of residual muscle strength are
determinant factors of a high level of functional
independence.3
The health and performance benefits of resistance
training are particularly important for populations
with limited mobility, including those with spinal cord
injury (SCI).4 One such activity that paraplegics in
American Spinal Injury Association’s (ASIA)
impairment category D (and some in impairment
category C) can perform is the Arm assisted body
weight squat (BWS).4 Due to the high biomechanical
and neuromuscular similarity to sportive movements,
such as running and jumping, and to daily living tasks,
such as walking, getting up from a chair or step up or
down stairs (Flanagan et al., 2003), squats are
commonly used as exercise in general fitness training
and in rehabilitation programs (Escamilla et al., 1998;
Gullet et al., 2008). It is a prerequisite for upright
mobility and is an important factor for independent
living.4This type of weight-bearing or closed-chain
exercise is ideal at the early stages of recovery because
it mimics the functional use of a patient’s legs during
routine sit-to-stand activity. Closed-chain exercise
facilitates co-contractions of several muscles (both
prime movers and stabilizers), elicits eccentric muscle
contractions, and stimulates joint proprioceptors in the
weight-bearing position.6
Therefore, the purpose of this study is to examine
the effectiveness of Arm assisted BWS among those
with SCI in improving performance in rising out of a
chair, ambulating using a walker, and maintaining
balance in selected ADL activities.
Hypothesis
Hypothesis: BWS has effect in improving lower
extremity strength, balance and functional
independence in the patients with incomplete spinal
cord injury.
Null Hypothesis: BWS has no effect in improving
lower extremity strength, balance and functional
independence in the patients with incomplete spinal
cord injury.
MATERIALS AND METHOD
Study design: An interventional study.
35. Disha Solanki--186--.pmd 187
Sampling Technique:- Random sampling.
SampleCollection :- 30 patients were selected divided
into two groups viz. Group A and Group B. Both the
groups were given conventional physiotherapy
treatment and Group A was additionally given body
weight squatting.
Inclusion criteria
• Patients with traumatic spinal cord injury in
thoracic level.
• Age : 20 to 50 years
• Sex: both male and female
• ASIA impairment scale C and D
• No history of long bone fractures secondary to
osteoporosis
• No history of knee pain
• Sufficient range of motion in hip, knee and ankle
joints to allow deep squat.
• Able to rise out of wheelchair to walker with
assistance.
Exclusion criteria
• Pressure sore which can be disturbed by deep
squatting.
• Severe spasticity in lower limb muscles (Modified
Ashworth Score equal to or more than 2)
• Severe autonomic disturbances (autonomous
dysreflexia or postural hypotension)
• History of traumatic brain injury, cerebro-vascular
accident or other brain pathology
• Spinal tumors or any other space occupying lesion
in the spine
• Cauda equina syndrome
• Lower extremity joint instability
MATERIALS USED
• Manual muscle testing sheet
• Functional independence measurement sheet
• Berg balance score sheet
• Mounted Dynamometer
11/1/2014, 12:17 AM
 188 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
• Stool
• Chair
• Stepping stool
• Crutches
• Cane
• Walker
• Weight cuffs, sand bags
• Medicine ball
Procedure:-Participants were requested to sign
Consent Form. The participants were randomly
divided in two groups i.e., Group A was given Arm
assisted body weight squats training along with
conventional physical therapy intervention; Each
patient was treated for 3 days/weekly for 6 weeks
using 3 sets of 10 repetitions of BWS with rest in
between of 4-5 mins on non-consecutive days and
Group B was given only conventional physical therapy
intervention for period of 6 weeks. Outcome measures
were taken to assess effectiveness of the intervention:
1. Functional independence measure (FIM) – Motor
items
2. Berg Balance Scale (BBS)
3. Sit to Stand Test with mounted Dynamometer
In Sit to stand test subjects are asked to sit on stool
in front of mounted dynamometer, height of stool is
adjusted so that hip and knee joint of subjects remains
at an angle of 900 flexion, feet flat on ground. Subjects
are asked to hold dynamometer while performing Sit
to stand test and use of upper limbs are measured in
dynamometer in Kg. Instructions regarding minimal
use of arms and more emphasis on legs.
Conventional Physical Therapy Intervention
Progressive resisted exercises in open chain for the
weak lower extremity muscles as tolerated by the
patient; along with strengthening of upper extremity
and trunk muscles to maintain their strength1, 2, 7
• Trunk balancing in sitting as well as standing
positions- static balance with manual
perturbations as well as reach outs in different
directions
35. Disha Solanki--186--.pmd 188
• Gait training with walker, crutches or canes as
required by the patient; with or without orthotic
support.
• The subjects in both the groups received this
conventional therapy 3 days a week for 6 weeks.
Body Weight Squatting Training
In beginning session squats performed from the
stool in front of horizontal bar as subjects gain
confidence as well as dynamometer shows
improvement, height of stool was decreased and
subjects are asked to perform full squat. Subjects are
advised to standwith feet shoulder-width apart in front
of horizontal bar with head, neck and back should
remain straight at all the times. Participants are
instructed to gently grasp horizontal bar, descend and
ascend relying mostly on the legs and as little as
possible use of upper limbs. Verbal feedback and
Dynamometer is used to provide feedback regarding
less use of hands (upper limb) and constant
commanding regarding less use of hands (upper limb)
was given.
Descending phase: The knees first move directly
forward as far as possible. After the knee initiates the
movement, the hips lower down as low as flexibility
allows. The body is lowered under control until the
hamstrings make contact with the calves. The heel
should remain flat on the floor throughout the squat.
Ascending phase: The hips and knees extend
together to bring the body back to the starting position.
Data Analysis: In this study, to analyze the
difference of FIM and BBS before and after intervention
in each group, non-parametric Wilcoxon Matched-
pairs Test was used. To analyze the difference of use
of upper limb (in Kg) in sit to stand test with
dynamometer before and after intervention in each
group, parametric Paired t-test was used. To compare
Group A and Group B for the difference in scores of
BBS and FIM Mann Whitney U test was used. To
compare Group A and Group B for the difference in
scores of Sit to Stand test both Ascending and
Descending Phase Unpaired t –test was used. SPSS
version was used for analysis.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 189

RESULTS The mean of differences of MOTOR-FIM score shows

significant difference between the groups at U= 56
Table 1: The mean Fim-Motor Scores before and after
Interventions
and P= 0.0199

Pre (mean ± SD) Post (mean ± SD) Table 6: Summary of BBS differences between the
groups
GROUP A 66.53±5.78 82.33±5.87
Group A Group B
Both Group A and Group B results showed
No. of subjects 15 15
significant difference in improvement in the FIM-
Mean 20.47 13.73
motor scores after the intervention at W value 120
SD 8.331 6.829
and P< 0.032
Sum of ranks 291 174
Table 2: The Mean BBS Scores before and after
Interventions
The mean of differences of BBS score shows
significant difference between the groups at U= 54
Pre (mean ± SD) Post (mean ± SD) and P= 0.0157
GROUP A 23.27±10.81 43.73±9.61
GROUP B 20.07±7.43 35.53±11.04 Table 7: Summary of sit to stand test differences
between the groups
Both Group A and Group B results showed highly
Ascending Phase Descending Phase
significant difference in improvement in the BBS
t-value 4.58 2.65
scores after the intervention at W value 120 and P<
Df 28 28
0.001
P-value 0.0001 0.0129
Table 3: The Mean Sit to Stand Test (in Ascending
Phase) Scores Before and After Interventions DISCUSSION
Pre (mean ± SD) Post (mean ± SD)
Kg Kg
The results of the study suggest that body weight
GROUP A 17.20±5.24 8.93±5.91 squatting showed significant improvements in lower
GROUP B 16.40±5.76 13.07±6.02 body strength during rehabilitation for individuals
with incomplete SCI which in turn can improve their
Both Group A and Group B results showed highly balance and functional independence. These responses
significant difference in improvement in the SIT TO
to training are explained by Neural adaptation which
STAND(ASCENDING PHASE)scores after the
involves changes in the ability of the nervous system
intervention at P< 0.0001
to recruit the appropriate muscles to obtains a desired
Table 4: The Mean Sit to Stand Test (in Descending results.8Initially, resorption of edema and hemorrhage
Phase) Scores Before and After Interventions at the lesion site might explain short-term recovery.
Pre (mean ± SD) Post (mean ± SD) Improvement of motor function observed 6 months
Kg Kg after injury may partially be explained by collateral
GROUP A 13.33 ± 4.46 7.60 ± 5.19 sprouting within the spinal cord.9 Peripheral nerve
GROUP B 13.27 ± 5.32 10.20 ± 4.28
sprouting and muscle fiber hypertrophy are other
Both Group A and Group B results showed highly hypotheses that explain muscle strength
significant difference in improvement in the SIT TO improvement between 2 to 8 months after partial
STAND (DESCENDING PHASE)scores after the denervation.9’8
intervention at P< 0.0001
Combined with the natural process of muscle
Table 5: Summary of Fim-Motor Differences Between strength recovery, functional rehabilitation aims at
the Groups
improving residual muscle strength. Muscle
Group A Group B strengthening exercises and the intensive practice of
No. of subjects 15 15 functional activities 10,11,12,13 are likely to enhance muscle
Mean 14.73 10.13 strength to an optimal level during the rehabilitation
SD 4.OO 5.37 period. It is attributed to two different adaptations:
Sum of ranks 289 176 Neural adaptation and muscle fiber hypertrophy.

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 190 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
While short-term gains (up to 4 weeks) are
attributed to an improved capacity to recruit motor
units, long-term gains (after 4 weeks) have been related
to morphologic changes within the contractile tissues.8
Body weight squatting facilitates simultaneous
coordinated co-contractions of several muscles (prime
movers and stabilizers) of hip, knee and ankle,14
stimulates joint proprioceptors in the weight bearing
positions and in addition elicits eccentric muscle
contractions during descending phase of squatting
while concentric contractions during ascending
phase.15
Continued practice of patterned motion required
less cognitive awareness, until it eventually becomes
automatic or habitual and can be performed with
ease.16,17Using functional Close Kinetic Chain activities
enhances the nervous system’s ability to recruit groups
of muscles work together. Neural pathways were
created that closely replicate functional demand.
Proponents of motor learning describe the process of
learning a new movement as beginning on a conscious
cognitive level, with repetitions moving to more
subconscious level.18
In the study by Danial Estape et al. (2006) on effects
of BWS on balance and upright mobility in persons
with incomplete SCI reported lower body strength
gained by BWS facilitates chair transfers, improve
ambulation and several selected ADL tasks requiring
balance. Despite this immediate substantial loss in
neuromuscular control, the ability to regain much of
this control is present in many cases.
Similar results were given by Jacobs PL et al. (2003)
in study on the effects of resistance training on
participants with SCI. revealed that persons with SCI
can achieve significant improvements in strength in
lower body resistance training program on strength
and ambulatory performance.
Clinical Implication:- Squatting exercises are non-
invasive and inexpensive type of treatment. Squatting
can be used as a functional resistance training and is
effective adjunct to rehabilitation in the patients with
thoracic incomplete spinal cord injury.
Conclusion:-Body weight squatting, along with
conventional physical therapy, led to improvements
in functional independence of the patients with
incomplete spinal cord injury, as shown by the results
of FIM-Motor items, BBS and sit to stand test with
mounted dynamometer after the intervention.
35. Disha Solanki--186--.pmd 190
Limitations
Small sample size, variations in the age and weight
of the participants, differences in their levels of injury
and duration of injury which can alter recovery as well
as progression of intervention itself.
Acknowledgement: I have been privileged to have the
direction and guidance from my P.G. Guide Mrs.
Anjali Bhise, Sr. Lecturer and Principal of Government
Physiotherapy College, Ahmedabad, who has
remained generous with her time and guided me with
her resourceful knowledge.
Conflict of Interest: There is no Conflict of Interest.
Source of Funding: There was no funding taken for
this study from any agency or institution.
Ethical Clearance: The study was been approved by
relevant ethical committee.
REFERENCES
1. Thomas W.J. et al Normative values and
determinants of physical capacity in individuals
with spinal cord injury journal of Rehabilitation
and development;2002;39:29-39
2. Ida Bromley. Tetraplegia and paraplegia. A guide
for physiotherapist. 6 th edition, Churchill
Livingstone, 2006.
3. Malanie Drolet et al. Muscle strength changes as
measured by Dynamometry following functional
rehabilitation in individuals with spinal cord
injury Arch Phys Med Rehabil 1999;80:791-800
4. Daniel Estape, Patrick L Jacobs, Rechard Lopez
Effects of Body Weight Squats on Balance and
Upright Mobility in Participants with Incomplete
Spinal Cord Injury Florida International
University, Miami, FL. The American College of
Sports Medicine 2006;1:12-1
5. Berger RA, Riley PO, Mann RW, Hodge WA.
Total body dynamics in ascending stairs and
rising from a chair following total knee
arthroplasty. Trans Orthop Res Soc 1988;13:542
6. Gerda Strutzenberger et al. Joint loading at
different variations of squats. Institute of
Engineering Mechanics, Karlsruhe Institute of
Technology (KIT), Germany 2002
7. Somnath Datta, Douglus J. Lorenz, Sarah
Morrison, Elizabeth Ardolino, Susan J. Harkema
A Multivarient Examination of Temporal changes
in Berg balance scale items for patients with ASIA
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 191
impairment scale C and D spinal cord injury.
Arch Phys Med Rehabil 2009; 901.
8. Sale DG. Neurological adaptation to resistance
training. Med Sci Sports Exerc 1988;20 Supply:S
135-45
9. Benjamin W. Meyer Comparison ofhip & knee
extensor torques in conventional & split squat
exercises Journal of Strength and Conditioning
Research 2005;16:1238-44.
10. Biss S, Grundy D, Russell J. ABC of spinal cord
injury. Physiotherapy.Br Med J Clin Res 1986;
292:388-91.
11. Perry J. Rehabilitation of the neurologicallv
disabled patient: principles, practice, and
scientific basis. J –Neurosurg 1983;38:799-816.
12. Frost FS. Role of rehabilitation after spinal cord
injury. Urol Clin North Am 1993; 20:549-59.
13. Ragnarsson KT, Gordon WA. Rehabilitation after
spinal cord injury. The team approach. Phys Med
Rehabil Clin North Am 1992; 3:853-78
35. Disha Solanki--186--.pmd 191
14. Flanagan S. et al. Exercises in Older Adults:
Kinematic and Kinetic Comparisons. Ameriacn
college of sports medicine: 2002
15. Snyder-Mackler L. Scientific rationale and
physiological basis for the use of closed kinetic
chain exercise in the lower extremity. J of Sports
Rehab 1996;5:2-12
16. Sullivan PE, Markos PD An integrated approach
to therapeutic exercise theory and clinical
application. Reston publishing company;1982
17. Borsa PA, Lephart SM, Mininder SK, Lephart SP
Functional assessment and rehabilitation of
shoulder proprioceptors for glenohumeral
stability. J of Sports Rehabil.1994;3:84-104
18. Hall CM, Brody LT, Therapeutic Exercise:
Moving Toward Function eds. Philadelphia, PA,
Lippincott-Williams & Williams, 1999, hardback;
707 p
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 DOI Number: 10.5958/0973-5674.2014.00344.X
192 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effecacy of Backwardwalking on Patient with

Osteoarthritis of Knee on Quadriceps Strength, Pain and
Physical Functions

Manisha Rathi1, Tushar Palekar2, Anjumol Varghese3

1
Professor, 2Principal, 3Intern, Padmashree Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth,
Pimpri, Pune

ABSTRACT

Background: Osteoarthritis of knee joint is a very common cause of locomotor disability in the elderly.
Reduction of pain and disability with maintaining strength and mobility is a challenge in such patients.
Hence the purpose of the study is to find the effect of backward walking in OA knee patients.

Method: 20 diagnosed cases of OA knee were divided randomly into two groups of 10 each. Group
A received backward walking training with Conventional physiotherapy treatment whereas Group
B received only conventional treatment for 2 weeks. Pain on NPRS, Quadriceps strength and Reduced
WOMAC scale for disability was assessed before the treatment and after 2 weeks. Statistical Analysis
was done by using t-test and Statistical significance was accepted at the confidence interval of 95%.

Result: Pain intensity on NPRS was significantly reduced in group A from 7+1.25 to 2.7 + 1.05
(p<0.00) and in Group B from 6.3+ 0.95 to 4 + 1.15 (P = 0.00). Quadriceps strength in Group A was 6.6
+ 3.77 which significantly increased to 9.8 + 3.7 (p=0.00) whereas Group B showed non-significant
improvement from 4.8+ 1.93 to 5.4 + 1.35 ( P= 0.08). Pain on Reduced WOMAC Scale in Group A
showed significant reduction from 8.7 + 3.23 to 2.9+ 1.79 (P< 0.00) as well as in group B from 8.8 +
3.04 to 4.9 + 2.13 ( P<0.00) But inter group Comparison showed non- significant reduction (p=0.05).
Physical Function in Group A showed significant improvement from 13.7+ 4.08 to 5.5 + 1.65 (P< 0.00)
as well as in group B from 10.8 + 2.93 to 8.6 + 2.13 ( P<0.00).

Conclusion: Backward walking along with conventional Physiotherapy treatment is effective in

treatment of OA Knee in reducing pain & disability and improving quadriceps strength.

Keywords: Osteoarthritis, Backward Walking, WOMAC Scale

INTRODUCTION synovial joints, more common in the weight bearing

Osteoarthritis (OA) is defined as a degenerative,
non-inflammatory joint disease characterized by
destruction of articular cartilage and formation of new
bone at the joint surface and margins. It affects the
Corresponding author:
Manisha Rathi
Professor
Padmashree Dr. D. Y. Patil College of Physiotherapy,
Sant Tukaram Nagar, Pimpri, Pune - 411018
Maharashtra, India
Email: manisharathi_24@rediffmail.com
manisha.rathi@dpu.edu.in
joints like the hip, knee and spine.1 OA is the second
most common rheumatological problem and is most
frequent joint disease with prevalence of 22% to 39 %
in India.2-4 This is the most common cause of locomotor
disability in the elderly.5 The factors suspected to play
an important role in the causation of OA knee are
obesity, genetics, hereditary, occupation involving
prolonged standing, multiple endocrinal disorders,
sports , multiple metabolic disorders, poor posture,
and previous joint injuries. Typical symptoms of
osteoarthritis are pain, early morning stiffness,
restricted range of joint movements, swelling of the
joints.1

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 193
Backward walking is an activity that results in joint
kinematic patterns different from those experienced
during forward walking.6 Backward walking is also
known as retro walking, is said to have originated in
ancient china, where it was practiced for good health.
When walking backward, the leg not only reverses its
direction of movement but it travels in the opposite
direction along virtually the same path as in walking
forward.7 Backward walking, as opposed to forward
walking, reduces the compressive forces at the
patellofemoral joint and decreases the force absorption
at the knee.8 This observation supports the conjecture
that knee pain may decrease when walking backward.
In order to built quadriceps strength and improves
fitness without putting excessive stress on already
painful knees, we can consider adding some backward
travel to training program.
From physiological and biomechanical
perspectives, walking backward and forward are quite
different.9 Backward locomotion produces higher
cardiopulmonary demand than forward locomotion
at the same speed as compared to forward motion. It
also suggests that walking backward increases energy
expenditure to a level high enough to maintain cardio
respiratory fitness. 10, 11 There are many article reported
the benefits of backward walking. In order to build
quadriceps strength and improves fitness without
putting excessive stress on already painful knees,
backward walking can be added in exercise program
to start early rehabilitation program. Till date very few
researches are available stating the effect of backward
walking in OA knee. So purpose of our study is to find
out the effect of backward walking on quadriceps
strength, pain and function in patient with
osteoarthritis of knee.
MATERIALS AND METHOD
In this Pre test-post test experimental study, 20
subjects were selected randomly and divided into two
groups of 10 each. Subjects were recruited from
Physiotherapy OPD of Padmashree Dr. D.Y. Patil
College of Physiotherapy, Pimpri Pune. Subjects
fulfilling the inclusion and exclusion criteria were
included in the study. Subjects diagnosed with
Osteoarthritis of Knee, falls in the age group of 40 – 60
years, Grade I to grade III of OA Knee as per Kellgren
and Lawrence scale and Unilateral involvement of
knee were included in the study. In case of bilateral
involvement more severely involved joint was
considered. Subjects with Inflammatory joint diseases
36. Manisha Rathi--192--.pmd 193
of Lower extremity, Received physical therapy and
an intra-articular injection for the knee since last 6
months, Neurological disease which affects backward
walking, H/o recent surgery to the hip, knee or ankle
joint involving ligament, meniscus; participating in any
exercise regularly and patients with cardiac or
metabolic condition were excluded from the study.
The study was approved by the ethical committee of
the Padmashree Dr. D. Y. Patil College of
Physiotherapy, Pimpri, Pune. All the subjects were
informed about the procedures and potential risks and
gave their written informed consent to participate in
the study.
Pre test measurement included weight, height,
Quadriceps strength, Pain intensity by Numerical pain
rating scale (NRPS) and Functional disability by
Reduced WOMAC Scale (RWS).
Reduced WOMAC Scale is the reduced version of
the WOMAC function scale which provides a practical,
valid, reliable and responsive alternative to the full
function scale for use.12
Measurement of Quadriceps Strength:-13,14
Subjects were seated on a chair to measure
quadriceps strength. A restraining belt strapped
around waist to minimize substitution. A non
Extensible strap was placed around their affected
lower leg just above the malleoli and the other end
was attached to a dynamometer which was attached
to the frame of the chair. Then the subjects were
instructed to attain maximum extension. Reading from
the dynamometer was recorded in Kgmf.
Measurement of Pain
The pain was measured using Numerical pain
rating scale. Subjects were instructed to mark the
number on NPRS which resembles the maximum
intensity of pain.
Measurement of functional disability
Reduced WOMAC scale was used to measure
functional disability. This Scale was given to all the
participants and told them to tick the appropriate mark
on the activities where they feel their maximum pain.
It has 5 components of pain and 7 components of
Physical activity. Maximum score for each component
is 4 ( 0- None, 1- Slight, 2- moderate, 3- very, 4-
extreme) and total score for pain is 20 and for physical
activity is 28.
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 194 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Procedure ( P<0.00) But when inter group Comparison was done

Group A received Backward walking training along
with Conventional physiotherapy treatment which
includes Pulsed shortwave for 20 min. 15 , Unilateral
Straight leg raise, Hamstring stretching and static
Quadriceps exercises. Group B received only
conventional physiotherapy treatment. Both groups
received treatment for 2 weeks.
it showed non- significant reduction ( p=0.05). Physical
Function in Group A also showed significant
improvement from 13.7+ 4.08 to 5.5 + 1.65 (P< 0.00) as
well as in group B from 10.8 + 2.93 to 8.6 + 2.13 (
P<0.00). And when inter group Comparison was done
it showed significant reduction (p=0.00).

Backward Walking Training Protocol- Initially the

patient was made to walk 10 steps forward and 9 steps
backward and was observed for any discomfort. If no
discomfort then, Patient is made to walk backward for
10 minutes per session. This training programme was
carried out for 3 days/week for 2 weeks with the total
of 6 sessions.

Quadriceps strength, Pain intensity by Numerical

pain rating scale (NRPS) and Functional disability by
Reduced WOMAC Scale were measured as Post test
parameters at the end of 2 weeks.

Statistical analysis Graph 1: Pain on NPRS in both groups, Gr. A showed more
reduction of pain than Gr. B
Descriptive statistics were calculated as the means
and standard deviation ( Mean+ SD). Statistical
Analysis was done by using Primer software. Paired t
test was used to compare intra group parameters
whereas unpaired t test was used to compare both
groups. Statistical significance was accepted at the
confidence interval of 95% and p < 0.05 level.

FINDINGS

This study was carried out on 20 subjects with

osteoarthritis of Knee. Mean age of group A 53.9 + 5.7
was whereas group B was 53.2 + 8.24. Graph 1 showed
Pain intensity on NPRS in group A before the treatment
Graph 2: Quadriceps Strength in Both groups, Gr. A showed more
was 7+1.25 and it was significantly reduced after 2 improvement in Quadriceps Strength than Gr. B
weeks to 2.7 + 1.05 (p<0.00). Group B also showed
significant reduction in Pain from 6.3+ 0.95 to 4 + 1.15
(P = 0.00). In inter-group comparison group A showed
significant improvement than group B as p < 0.00.
Graph 2 showed initial Quadriceps strength in Group
A was 6.6 + 3.77 which significantly increased to 9.8 +
3.7 (p=0.00) after 2 weeks whereas Group B showed
non-significant improvement in quadriceps strength
from 4.8+ 1.93 to 5.4 + 1.35 ( P= 0.08). Functional
disability was assessed by using Reduced WOMAC
Scale (RWS) (Pain and Physical function) as shown in
graph 3. Pain on RWS in Group A also showed
significant reduction from 8.7 + 3.23 to 2.9+ 1.79 (P<
Graph 3: Scores of Reduced WOMAC Scale – Pain and Physical
0.00) as well as in group B from 8.8 + 3.04 to 4.9 + 2.13
Function in both Groups.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 195
DISCUSSION
The purpose of this study was to investigate the
effectiveness of a backward walking exercise program
in Osteoarthritis patient. There were two group made,
Group A : patients were given backward walking
exercise for 10 minutes along with conventional
therapy. Group B : In this , patient were given only
conventional therapy. The result of the study indicate
that there is significant decrease in the pain when
measured by NPRS scale. Pain was reduced in group
A due to less joint reaction force in backward walking.
As concluded by Nutthapon et al ( 2012)16, backward
walking produces higher peak of Tibio-Femoral Joint
Reaction Force during the stance phase than forward
walking in every speed. But it produced lower average
of Tibio-Femoral Joint Reaction Force than forward
walking with the same exercise intensity.
The study reported significant increase in
quadriceps strength in Group A as compared to
Group B . It was measured with the help of
dynamometer. The result of this study was supported
by the study done by Swati K. et al (2012)17 where she
reported that backward walking improved quadriceps
strength significantly. According to Flynn TW et al
(1993), backward walking reduces the compression
forces at the patellofemoral joint and decreases the
force absorption at the knee. This is mainly because of
the reduced eccentric function of the quadriceps
strength. Several reasons have been postulated for the
improvement seen in quadriceps strength. Novel tasks
required a larger number of motor units to be recruited,
which resulted in increased energy utilization because
backward walking was a novel task for most of the
individuals, increased motor unit recruitment would
result in greater amount of skeletal muscle activation
compared with equivalent familiar task.11
It was also stated that peripheral muscle
requirement were different during backward walking
than forward walking. During Backward walking, the
quadriceps group worked isometrically as a knee
stabilizer and concentrically as a accelerator. 8,18,19
Flynn TW et al (1993, 1995) also concluded that
backward training might be useful in clinical
conditions that require an increase in knee extensor
strength. 8, 20
This study also states that pain and physical
function of the OA knee has significantly improved in
Group A subjects than group B when used Reduced
36. Manisha Rathi--192--.pmd 195
WOMAC scale for measuring functional disability.
When walk backwards , it puts less strain and requires
less range of motion to knee joints, making it ideal for
people who have knee problems or injuries. Backward
walking is an activity that results in joint kinematic
patterns different from those experienced during
forward walking. One of the unique aspects of
backward walking is the toe heel versus the heel toe
foot contact pattern in forward locomotion by landing
on the toe, there is less shock transferred to the knee
joint during rehabilitation. The pain and functional
discomfort has been reduced and patient can perform
those activity without any pain. As the quadriceps
muscle strength increased and pain reduced there was
improvement in the functional ability in patient.
Further studies can be done on larger sample size,
severely affected knee joints, acute knee injuries.
CONCLUSIONS
This study concludes that backward walking has
significant effect on OA knee patient in improving
pain, quadriceps strength and functional ability. So we
can incorporate backward walking training in the
treatment protocol of OA knee.
Conflict of Interest: Authors declares no conflict of
interest
Acknowledgement: The authors would like to
acknowledge all the subjects for their voluntary
involvement in the present study, thereby making the
project a success. Special thanks to Dr. Shahnawaz
Anwar(PT) for his contribution in the study.
Source of Funding: It was Self Funding Research.
REFERENCES
1. Textbook of orthopaedics; 4th edition; Jaypee
publication; John Ebenezer. Chapter no: 47, page
no – 674, 675, 678.
2. Chopra A, Patil J, Bilampelly V, Relwane J, Tandle
HS. “Prevalence of rheumatic disease in rural
population in Western India: A WHO-ILAR-
COPCORD study.” J Assoc Physicians India
2001;49:240-46.
3. A Mahajan, S Verma, V Tandon; “Osteoarthritis”,
JAPI; volume 53, July 2005. Page no. 634-641
4. Mahajan A, Jasrotia DS, Manhas AS, Jamwal SS.
Prevalence of major rheumatic disorders in
Jammu. JK Science 2003;5:63-66.
11/1/2014, 12:17 AM
 196 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
5 Martin JA, Buckwalter JA. Aging, articular
cartilage chondrocyte senescence and
osteoarthritis. Biogerontology 2002;3:257-64.
6. Vilensky J A Gankiewicz E and Gehlsen G “ A
kinematic comparison of backward and forward
walking in Humans. “ J Human Movement
Studies 13: 29 -50, 1987
7. Thorsten son A: How is the normal locomotors
program modified to produce backward
walking? Exp Brain Res 61:664- 668, 1986.
8. Flynn TW, et al Mechanical power and muscle
action during forward and backward running. J
Orthop Sports Phys Ther. 1993;17:108-112.
9. Winter D A , Pluck N, Yang J F (1989) “Backward
walking : Simple reversal of forward walking? J
Mot Behav 21:291-305
10. Fynn TW,et al Comparison of cardiopulmonary
responses to forward and backward walking and
running. Med Sci Sports Exerc. 1994; 26:89-94.
11. Myatt G, Baxter R, et al. The cardiopulmonary
cost of backward walking at selected speeds. J
Orthop Sports Phys Ther. 1995: 21:132-138.
12. Whitehouse SL, Lingard EA, Katz JN, Learmonth
ID, “Development and testing of a reduced
WOMAC function scale.” J Bone Joint Surg Br.
2003 Jul;85(5):706-11.
13 JA Oldham: Reliability of Isometric Quadriceps
Muscle Strength Testing in Young Subjects and
Elderly Osteo-arthritic Subjects. Physiotherapy
Volume 81, Issue 7, 1995, Pages 399- 404
14 Michael V.Hurley: Quadriceps function,
proprioceptive acuity and functional
36. Manisha Rathi--192--.pmd 196
performance in healthy young, middleaged and
elderly subjects. Age and Ageing 1998; 27: 55-62
15 Thiago Yukio fukuda, Ronaldo alves da
cunha,Vanessa ovanessian fukuda, Favio
Albanez Rienzo,Claudio Cazarrini Jr, Nilza de
Amedia Aparecida Carvaldho and Aline
Almeida Centini.; “Pulsed shortwave treatment
in women with knee osteoarthritis: A multicenter,
Randomized, placebo-controlled clinical Trial”
Physical therapy; July 2011, vol.91; no.7,
1009-1017
16. Nuttapon Zonthichaia, Chatchadaporn
Pitaksathienkulb, pasakorn watanatada
“Tibiofemoral joint reaction force during the
stance phase of backward walking and forward
walking at variable speeds”; , Asian Biomedicine
Vol.6 N0.1 february2012;117-122.
17. Swati K , Ashima c,and Saurab.S .Efficacy of
backward training on agility and quadriceps
strenth; ;5th december 2012.
18. Vilensky A, et al A Kinematic comparison of
Backward and forward walking in Humans. J
Orthop Sports Phys Ther 1993; 17: 108-112
19. Kramer J F : Backward walking : a
cinematographic and electromyographic pilot
study.Physiother Can 33:77-86, 1981.
20. Flynn TW, Soutas-Little RW. Patellofemoral joint
compression forces in forward and backward
running. J Orthop Sports Phys Ther. 1995; 21:
277-82.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 197

A Comparative Study to Find out the Calcaneal Eversion

in Overweight and Normal Individuals

Hemal Paneri1, Sheshna Rathod1, Disha Solanki2

1
Tutor cum Physiotherapist, Government Physiotherapy College, Jamnagar, 2Physiotherapist, Guru Govind Singh
Government Hospital, Jamnagar

ABSTRACT

Background: Obesity is a major health problem worldwide. An increase in body weight is considered
to cause overload of the foot, which represents the interface between the body and ground. This can
induce various stress and strains during walking that can predispose to overuse injuries of the lower
limb.

Objective: To compare and correlate the effect of weight on calcaneal eversion.

Methodology: Forty subjects with a mean age of 29.3 years were divided into 2 groups according to
their body mass index (BMI). Group A (n = 20), Normal individuals (18.5 - 24.9 kg/m2) and Group B
(n = 20) overweight individuals (25 - 29.9 kg/m2). Measurements for Calcaneal eversion were obtained
in double limb stance.

Results: The result of the present study has shown a significant difference of Calcaneal eversion
between Normal individuals and Overweight individuals with t value 4.68 and p value is < 0.001.

Conclusion: The angle of Calcaneal eversion is greater in overweight individuals compared to normal
individuals. Overweight person may have structural changes in their foot anatomy. These structural
changes adversely affect the functional capacity of the medial longitudinal arch if excess weight
bearing continues throughout the adulthood.

Keywords: Calcaneal Eversion, Body Mass Index

INTRODUCTION “single most important factor in achieving the

The foot has been recognized as one of the most
dynamic, reactive and adaptive organs of the body.
Directly or indirectly feet balances the individual in
the static or dynamic status of standing, walking,
running, swimming, diving and other allied
maneuvers. Foot is composed of 26 bones and 30 major
synovial joints. Close and Inman points out the
importance of the foot in gait, they stated that the
Corresponding author:
Hemal Paneri
Tutor cum Physiotherapist
Government Physiotherapy College, Jamnagar.
Address: Block- 16, Shilpan Kunj Society, Sadhu
Vasvani Road, Rajkot-360005
E mail: hemalpaneri@rocketmail.com
Mobile No: 9725995697
conversion of the centre of mass from a series of
intersecting arcs to a smooth curve in the presence of
a foot attached to the distal end of the limb”. The foot
serves as a to absorb shock, to act as a rigid lever of
propulsion and to help transfer the body weight
forward. Their function are achieved mainly through
subtalar joint and transverse tarsal joint motion.1
The foot acts as a base of support that provides the
necessary stability for upright posture with minimal
muscle effort. It provides flexibility to adopt to uneven
terrain and for the absorption of shock. It also provides
a mechanism for rotation of the tibia and fibula during
stance phase of gait and act as a rigid lever during
push-off.2
The subtalar or talocalcaneal joint is a gliding joint
with three articulating facets, posterior, middle and

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 198 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
anterior facet. Function of the weight bearing subtalar
is critical for dampening the rotational forces imposed
by the body weight while maintaining contact of foot
with the supporting surface. Subtalar joint is composed
of three articulations; the result of it is a triplanar
motion of talus around a single oblique joint axis. The
subtalar joint is therefore a uniaxial joint with 1 degree
freedom: supination and pronation. The axis of motion
is oblique and passes through the calcaneum and talus
from posterior, inferior and lateral to anterior, superior
and medial.
The subtalar axis has been subject of many
investigations. Manter framed the axis inclined 42°
upward and anteriorly from the transverse plane (with
a broad inter-individual range of 29°-47°), inclined
medially 16° from sagittal plane (with again broad
inter-individual range of 8°-24°). In Non-weight
bearing position, Supination is Calcaneal inversion,
adduction and plantarflexion whereas Pronation is
Calcaneal eversion, abduction and dorsiflexion. In
Weight bearing position, Supination is Calcaneal
inversion, Talar abduction and dorsiflexion whereas
Pronation is Calcaneal eversion, Talar adduction and
plantarflexion. The definition of subtalar neutral is
used to assess the position of the hind foot to assess its
potential role in dysfunction of more proximal and
distal joints and is similarly used as reference point
for assessing position on the forefoot. Subtalar neutral
is found by Root and Colleagues as point from which
the calcaneum will invert twice as many degrees as it
will evert.3
Obesity can be defined as a condition of abnormal
or excessive fat accumulation in adipose tissue to the
extent that health may be impaired. However, it is
difficult to measure body fat directly and so surrogate
measures such as the body mass index (BMI) are
commonly used to indicate overweight and obesity in
adults. Additional tools are available for identification
of individuals with increased health risks due to
‘central’ fat distribution.4
MEASURING GENERAL OBESITY
1. BMI (BODY MASS INDEX) : The body mass index
provides the most useful and practical population
level indicator of overweight and obesity in adults.
It is calculated by dividing body weight in
kilograms by height in meters squared.4
BMI = weight/(height2)
37. Hemal Paneri--197--.pmd 198
Classification of overweight and obesity in adults
according to BMI
CLASSIFICATION BMI (KG/M2)
Underweight <18.5
Normal range 18.5 – 24.9
Overweight 25 – 29.9
Obese class 1 30.0 – 34.9
Obese class 2 35 – 39.9
Obese class 3 >40
2. WAIST CIRCUMFERENCE RATIO: It is a
common measure used to assess abdominal fat
content. The waist circumference of men > 102
cm and women > 88 cm is responsible for various
health consequences.4
3. WAIST – HIP CIRCUMFERENCE RATIO: Waist
to hip ratio is the measures of persons Waist
Circumference (WC) to Hip Circumference (HC)
mathematically calculate as WC/HC. WC/HC >2
is not considered to be safe.4
EFFECT OF OBESITY ON FOOT:
Obesity is a major worldwide health problem
where the body weight is more than 20% of the ideal.
Foot problems in obese adult are most important. This
may be due to the increased stress placed on the feet
through the need to bear excessive mass. Foot
problems are frequent because the interface between
body and ground is subjected to high stresses and load.
The foot provides a stable support for the body,
attenuates impact and rotational forces, provides
sensory information and combines flexibility and
stability for propulsion of body. However, excessive
Calcaneal eversion has been linked due to muscle
imbalance which disrupts normal lower limb
alignment. This misalignment is thought to place
undue stress and strain on the joints, ligaments and
muscles.5, 6
Obesity may be considering an extrinsic anatomic
impairment because it is a structural fault. The
difference between obesity and other anatomic
impairments is that obesity can be altered with
individualized exercise prescription and with
nutritional and behavioral modification. The body’s
center of mass falls between the feet and with obesity,
has an excessive pronatory effect on the foot. The most
common cause of Calcaneal eversion is heredity. This
biomechanical defect is inherited. The second most
common cause is due to the way feet were positioned
in the uterus during development; this is called a
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 199
congenital defect. In either instance, the following
occurs in the feet during development: The muscles,
ligaments, and other soft tissue structures which hold
bones together at the joints become looser than normal.
When the bones are not held tightly in place, the joints
are not aligned properly, and the foot gradually turns
outward at the ankle. The foot moves in this direction
because it is the path of least resistance. It is more
difficult for the foot to move in the opposite direction.
As development occurs, the muscles and ligaments
accommodate to this abnormal alignment. By the time
growth is complete, the foot is: abnormally flexible,
flat, and its outer border appears raised so that while
stepping down, weight do not come down equally
across the entire foot; instead, weight comes down
mostly on the inner border of the foot. Normal aging
will produce further laxity of muscles which causes
the Calcaneal eversion to become gradually worse.5, 6
RESULTS OF CALCANEAL EVERSION
Due to the laxity of the soft tissue structures of the
foot, and the fact that the joints are not held together
properly, the bones of the feet shift. When this occurs,
the muscles which attach to these bones must also shift
or twist in order to attach to these bones. The strongest
and most important muscles which attach to foot bones
come from lower leg. So, as these muscles course down
the leg and across the ankle, they must twist to
maintain their proper attachments in the foot. The
twisting of these muscles will cause: Reducing walking
and running speed and endurance.6
HYPOTHESIS
Hypothesis: In overweight individuals, there is
increase in angle of Calcaneal eversion.
Null Hypothesis: In overweight individuals, there
is no increase in angle of Calcaneal eversion.
MATERIALS AND METHODOLOGY
Study Design: Hospital based cross sectional study
Sampling: Purposive Sampling Method
Sample Selection: Subjects with age group
between 20 to 45 years. Mean age 29.3.
Sample Size: 40 Subjects was taken and divided
into two groups. Group A (n = 20), Normal individuals
(18.5 – 24.9 kg/m2) and Group B (n = 20) overweight
individuals (25 – 29.9 kg/m2).
37. Hemal Paneri--197--.pmd 199
Inclusion Criteria
• Subjects with a BMI between 18.5 to 29.9 kg/m2.
• Age between 20 to 45 years.
• Both male and female subjects were included for
the study
Exclusion Criteria
• Subjects with musculoskeletal disorder
• Subjects with neurological disorder
• Subjects with any fracture of spine, pelvis and
lower limbs.
• Pregnant ladies.
• Subjects with foot deformity.
Materials Used
• Universal Goniometer
• Measure tape.
• Pen.
• Weighing scale.
Outcome Measures:- Calcaneal eversion angle
METHODOLOGY
Forty participants fulfilling the inclusion criteria
were considered for the study. They were divided into
the 2 groups according to the BMI classification. In
group 1 subjects with BMI between 18.5 to 24.9 kg/m2
and in group 2 subjects with BMI between 25 to 29.9
kg/m2 were taken. Then subject’s Calcaneal eversion
angle was measured and comparison between these
two groups was done.7
BMI Procedure
Subject’s height and weight was determined for
calculating BMI as per Quetelet’s Index.
BMI= weight/height2. The formula of weight in
kilograms divided by the height in meters squared was
used to calculate BMI. Participant weight was
measured by using a digital set of scales and height
was measured by using a wall measure tape from a
point on the wall perpendicular to the vertex of the
skull.8, 9
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 200 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Calcaneal eversion Angle
Calcaneal eversion angle was measured as the acute
angle between the distal midline of the leg and the
midline of the calcaneum. Range of eversion was
measured using a goniometer.7, 10, 11
Statistical Analysis: Here, mean and standard
deviation of both the groups were calculated.
Unrelated t-test was performed for comparison of
calcaneal eversion angle between group 1 and
group 2.
RESULTS
Table 1: This table shows the Mean and Standard
Deviation of Calcaneal eversion angle of group 1
(Overweight individuals) and group 2 (Normal
individuals).
Mean Value Standard
Deviation
Group 1 180.4 2.14
Group 2 190.9 3.42
Table 2: This table shows comparison of the Calcaneal
eversion between group 1 (Overweight individuals)
and group 2 (Normal individuals).
Mean Value t Value P Value
Group 1 180.4 4.68 <0.001
Group 2 190.9
Here, unrelated t - test was performed for statistical
analysis which shows result to be significant. Level of
significance was kept at 0.01.
DISCUSSION
The result of the present study has shown a
significant difference of Calcaneal eversion between
Normal individuals and overweight individuals with
t value 4.68 and p value is < 0.001. The hypothesis
proves that increased weight has an effect on calcaneal
eversion. This is because extra weight puts stress on
the foot causing flattening of the arches. Similar results
were also found by Dr. P. Dhakshinamoorthy et al,
(2006) which concluded that Calcaneal eversion was
increased in overweight females. Results of these
studies denotes that beyond the physiological state of
the body there are some other external factors such as
gastrocnemius extensibility and angle of toe-out
influences the hind foot. 7 J R Steele, et al (2010)
concluded that Obese adults had significantly more
pronated foot compared to normal weight adults.12
Hall and Brody (1999) also concluded that obesity has
an excessive pronatory effect.5
37. Hemal Paneri--197--.pmd 200
Messier SP, et al (1994) concluded that severe
obesity effects on foot mechanics during walking.13
Overweight/Obese person may have structural
changes in their foot anatomy. It is postulated that
these structural changes adversely affect the functional
capacity of the medial longitudinal arch and it might
be exacerbated if excess weight bearing continues
throughout the adulthood. Thus, these structural
changes will eventually lead to increase in the angle
of calcaneal eversion.14
Raymond C. Browning, et al (2010) concluded that
obesity greatly increases Ground Reaction Force
during walking, without changes in lower-extremity
sagittal-plane kinematics. As a result, sagittal-plane net
muscle moments at the hip, knee and ankle are also
greater for obese versus normal-weight adults. At
slower walking speeds, Ground Reaction Force and
net muscle moments are all significantly smaller. These
results suggest that slower walking may reduce the
risk of musculoskeletal pathology in obese adults.15
CONCLUSION
The angle of Calcaneal eversion are greater in
overweight individuals as compared to normal
individuals.
Clinical Implication
Increase in Calcaneal eversion in overweight
individuals leads to alterations in foot biomechanics
resulting in heel pain. So correction of increased
Calcaneal eversion may help in alleviating heel pain.
Thus, obese people with heel pain can be advised for
slow walking.
Limitations
• Small sample size.
• Limited age group.
Acknowledgement: - I am grateful to subjects who
participated in the study.
Conflict of Interest: There is no Conflict of Interest.
Source of Funding: There was no funding taken for
this study from any agency or institution.
Ethical Clearance: The study was been approved by
relevant ethical committee.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 201
REFERENCES
1 B. D. Chaurasia, Human anatomy, regional and
applied, Vol. 2, edition 3rd 135- 138.
2 Richard. Snell, Clinical anatomy, edition: 6th 2000;
591- 607.
3 Cynthia C. Norkin, Joint structure and function,
edition: 3rd 2001; 327-328, 549, 553.
4 John Wiley , International textbook of obesity,
edition : 1st 2001; 1-2.
5 Carrie M. Hall Therapeutic exercise, Moving
toward function, edition : 1st 1999; 478- 480.
6 Karen P Cote, Michael E Brunet “Effects of
Pronated and Supinated Foot Postures on Static
and Dynamic Postural Stability” J Athl Train.
2005 Jan–Mar; 40(1): 41–46.
7 Shannon M. Mahar et al “Bilateral Measurement
of Resting Calcaneal Stance Position and Tibial
Varum Using Digital Photography and
Standardized Positioning Protocols” J Am
Podiatr Med Assoc 99(3): 198–205, 2009.
8 Megha Masaun, P. Dhakshinamoorthy
“Comparison of Calcaneal Eversion,
Gastrocnemius Extensibility and Angle of Toe-
Out between Normal and Overweight Females”:
The Foot and Ankle Online Journal
(www.faoj.org).
9 Eknoyan, Garabed (2007). “Adolphe Quetelet
(1796–1874)—the average man and indices of
37. Hemal Paneri--197--.pmd 201
obesity”. Nephrology Dialysis Transplantation 23
(1): 47–51. doi:10.1093/ndt/gfm517.
PMID 17890752.
10 Robert A Elveru, et al Goniometric Reliability in
a Clinical Setting Subtalar and Ankle Joint
Measurements Physical Therapy May 1988 vol.
68 no. 5 672-677
11 Jean Masse Genova et al Effect of Foot Orthotics
on Calcaneal Eversion During Standing and
Treadmill Walking for Subjects With Abnormal
pronation; Journal of Orthopaedic & Sports
Physical Therapy 2OOO;3O (1 1) :664-675
12 Riddifort , Harland DL, et al “Does obesity
influence foot structure in adult” International J
Obesity 24 (5): 541 – 544, 2000.
13 Trzciñska, DorotaTabor, et al “Effects of static
loads on selected features of foot structure”
Physical Education and Sport Volume 51,
Volume 51 / 2008.
14 Sibel Cubukcu, M. Kemal Alimoglu et al “Effects
of three different posting methods on controlling
abnormal subtalar pronation.” Physical Therapy
79 (2): 149 – 158, 2005.
15. Dr. Jonathan Deland “Validity of 3 clinical
techniques for the measurement of static foot
posture in older people.”J Orthop Sports Phys
Ther 2010 , 35:479-486.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
202 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effect of Cryotherapy on the Intrinsic Muscle Strength of

the Hand

Himanshu Mohan Pathak

Asso. Professor, CMF College of Physiotherapy, Sector No 27-A, Opposite Ruston Colony, PCNTDA, Pradhikaran,
Nigdi, Pune, Maharashtra

ABSTRACT

Purpose of the study: Therapeutic use of cold has clinical applications both in rehabilitation and
other areas of medicine. Cryotherapy has been shown to decrease, increase and not impact torque
production. Grasping is a functional activity which requires isometric strength of intrinsic and extrinsic
muscles of hand. Till date few studies have been conducted to see the carry over effect of cryotherapy
on isometric strength of muscles. Thus, purpose of the present study is to find out the immediate and
carry over effect of cryotherapy on isometric intrinsic muscle strength of hand.

Material and Methodology: Materials used were, hand held dynamometer, thermometer, ice water,
first aid tray.

Design: Single group prospective experimental study design.

Variables: Cryotherapy, Intrinsic muscle strength.

Procedure: A group of 20 students in college of physiotherapy, loni, Dist. Ahmednagar were selected,
ruling out contradictions to cryotherapy. After explaining the whole procedure, subjects' hands were
immersed in water of 10º-15ºc till 15 minutes. Intrinsic muscle strength was checked before the
treatment of cryotherapy and immediately after, after 15 min, 30 min, and 45 min of cryotherapy
treatment with the help of hand held dynamometer. Position of patients was high sitting, elbow
supported; wrist slight extended according to the recommendations of the American Hand Society
of Hand Therapists. The dynamometer was set at the second handle position.

Result: Paired t-test was applied. There is significant decrease in Intrinsic muscle strength immediately
after the cryotherapy (t -18.835; D.F. =19, p<0.0001). There is significant increase in Intrinsic muscle
strength after 30 min of cryotherapy (t-9.484; D.F. =19, p<0.0001).Intrinsic muscle strength reaches to
its pre immersion value after 45 min of cryotherapy application (t-0.5684; d.f=19, p-0.5764).

Conclusion: The study concludes that muscle strength is diminished by cooling the limb in water at
10 -15 C. Intrinsic muscle strength increases over the original value, after cooling ceased (15-30 minutes)
and reaches to its pre immersion value after 45 min of cryotherapy application.

Keywords: Cryotherapy, Hand Held Dynamometer, Intrinsic Muscle Strength

INTRODUCTION a substance to the body for purpose of removing heat

and decrease tissue temperature has been around since
Since the time of Hippocrates, cold therapy has beginning of medicine. Due to the depressive effects
been documented as beneficial treatment for acute cold has on many physiological systems, such as the
injuries24. Cryotherapy, the therapeutic application of myotatic reflex, nerve conduction velocity, and force

38. Himanshu Pathak--202---.pmd 202 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 203
production, the practice of applying a cold modality
to an injury site before rehabilitative exercises or
athletic competition has been questioned.19, 22, 23 Much
has been written about the effects of cryotherapy on
individual physiological systems, such as the nervous
system and the muscular system. 12, 16, 19, 21-23, 31.
Cryotherapy can affect the ability of muscle to
generate tension. Depending on the duration of the
treatment and timing of measurement, cryotherapy
has been associated with both increase and decrease
in the muscle strength. There are 35 muscles involved
in movement of the forearm and hand, with many of
these involved in gripping activities. During gripping
activities, the muscles of the flexor mechanism in the
hand and forearm create grip strength while the
extensors of the forearm stabilize the wrist. There are
extrinsic muscles that cross the wrist and intrinsic
muscles with both of their attachments distal to the
wrist .The Extrinsic muscles include the pronator
teres, flexor carpi radialis, flexor Carpi ulnaris, flexor
Digitorum Superficialis, and Palmaris longus on the
extrinsic layer and the flexor profundus digitorum,
flexor policus longus, pronator quadratus, on the
intrinsic layer. Intrinsic muscles include four each;
Thenar, Hypothenar, lumbricals, Palmer
Interossei, Dorsal Interossei2. Each of these muscles
is active during gripping activities.
Thus, the purpose of this study is to investigate the
effects of various cold immersions durations on
maximal isometric intrinsic muscle strength of hand
and to see the carry over effect on muscle strength
following cryotherapy.
RESEARCH DESIGN
This is a prospective study with same subject
design.
Research is conducted at college of physiotherapy,
Loni.
Selection Criteria
The total 20 subjects with normal sensation in hands
were selected. The subjects were between 18 and 23 yr
old. Subjects with any open wound, recent fracture,
and acute injury were excluded from the study.
Subjects with previous history of cold hypersensitivity
were also excluded. Samples were taken from
population of students of college of physiotherapy,
Loni. Method of selection was convenient random
38. Himanshu Pathak--202---.pmd 203
sampling. Total duration of study was 2 months. Each
subject signed an informed consent after a complete
explanation of the testing procedure.
Ethical Approval
Ethical clearance for the study was taken from the
ethical committee of college of physiotherapy, loni.
METHODOLOGY
Subjects were asked to perform warm up activities
consisting of free exercises of wrist and hand. It was
followed by passive stretching of intrinsic and extrinsic
muscles of hand.
Study was done on dominant hand of each
individual. Study was done during the same time of
day to avoid diurnal fluctuations. Grip strength was
measured using a factory-calibrated Jammer
dynamometer (Baseline Hydraulic Hand
Dynamometer Unit, U.S.A.). For this study, the
dynamometer was set at the second handle position.
The upper extremity was positioned according to the
recommendations of the American Hand Society of
Hand Therapists: shoulder adducted and neutrally
rotated, forearm in neutral position, and wrist slightly
extended (0-30°).Grip strength was measured with the
elbow in 90°.
The subjects made a total of three attempts in this
position, and the highest of these readings was
recorded .To control for fatigue, the subjects took a
rest period of 30 sec between each attempt and subjects
were not allowed to maintain their maximum effort
for prolonged period of time .Fatigue resistance was
defined as the point when the maximum grip strength
of the subjects was dropped to 50% of its maximum
value.
The subject’s hand was immersed in water of 10°-
15C till 15 minutes. Temperature was maintained by
continuous immersion of ice in water. Temperature
was measured by calibrated mercury thermometer
(corning) ranged,-100 C-1100 C. Maximal isometric grip
strength was measured before, immediately after, and,
15, 30, 45 minutes after cold immersion.
Data analysis
Grip strength was determined for dominant hand
in pounds; Data were analyzed using Paired t-test.
Mean and standard deviation was also calculated.
Statistical significance was accepted at P < 0.0001.
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 204 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

RESULT

Table 1. Mean and Standard Deviation of Intrinsic Muscle strength (pounds), before and after ice immersion

Groups Mean/SD
Before Immersion 43.6/0.7760
Immediately after immersion 35.95/1.536
15 Minutes after immersion 44.75/0.8507
30 Minutes after immersion 46.4/1.061
45 Minutes after immersion 43.75/0.8622

Table 2. Comparison of Intrinsic Muscle Strength before and after ice immersion using paired t -test

Comparative Groups T P Mean Diff SD Diff.

Before and immediately after 18.835 <0.0001 7.680 1.816
Before and after 15 min 7.435 <0.0001 -1.15 0.691
Before and after 30 min. 9.484 <0.0001 -2.80 1.32
Before and after 45 min. 0.5684 0.5764 -.1500 1.180

significant increase in muscle strength. After 45

minutes of immersion less significant difference is
observed in muscle strength. Value of t is 0.5684 (p-
0.5764). It suggests that muscle strength is again
regaining its pre immersion value.

DISCUSSION

Results of the present study show variable effect

Fig. Measurement of isometric grip.
on Isometric muscle strength of intrinsic muscle after
immersion in cryotherapy. Immediately after
immersion in cold bath, muscle strength decreases
significantly. It increases after 15-30 min and regains
its pre immersion value after 45 min. Cold’s effect on
the muscle spindle and the myotatic reflex is of great
importance when considering the muscle’s physiology.

When reductions in intramuscular tissue

Results were analyzed using paired t-test.
Table 1 shows the arithmetic mean and standard
deviation of muscle strength before immersion in cold
bath and subsequently after, after 15 minutes, after 30
minutes, after 45 minutes.
Table 2 shows result of paired t-test.
There is highly significant difference in muscle
strength before and immediately after immersion in
cold water, t -18.835 (p<0.0001).Muscle strength
decreases significantly. There is a significant difference
in intrinsic muscle strength before and after 15 minutes
of immersion in cold bath. Value of t – 7.435
(p<0.0001).Muscle strength is higher than its pre
immersion value. After 30 minutes of immersion in
cold bath, highly significant difference observed in
muscle strength. Value of t-9.484 (p<0.0001).There is
temperature occur, the neuronal discharge and
sensitivity of the muscle spindles are impeded. 12, 19, 21-
23, 25
Additionally, even if stimulation from the muscle
spindle activates the reflex arc, the neuronal message
for increased muscle excitability may be inhibited due
to a significant decrease in the motor end plate’s
potential. 23 .Mecomber and Herman 21 clinically
validated these findings by noting a decrease in the
amplitude of action potentials, twitch contraction, and
nerve conduction time following maximal tendon taps
of pre cooled Achilles tendons. Consequently, the
resultant force development within the muscle and the
myotatic reflex’s protective mechanism may be
negatively influenced.
The positive dependence of the velocity of
adenosine triphosphate (ATP) splitting on muscle
temperature may also be a factor in the decreased
maximal muscle activity.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 205
John Low & Ann Read (2000)14states that, muscle
strength is diminished by cooling the limb in water at
10°-15°c .Muscle strength also decreases due to
decrease in blood supply.
Clarke et.al.3 noted decrease in tension when water
temperature was less than 18.4 0 celcius.They
concluded that decrease in blood flow in superficial
fibers of the muscle inhibited contractions. Another
study examined a cooling temperature spectrum from
0-460 celcius.As the temperature to which the subjects
were exposed decreased, there was a steady decline
in force production and maximum voluntary
contractions of triceps surae.10.Edwards et al and
Davies et al concluded that the decrease was a result
of decreased nerve conduction velocity and decrease
speed of contractions.10,11
Depending on the duration of the treatment and
timing of measurement, cryotherapy has been
associated with both increase and decrease in muscle
strength. In our study, isometric muscle strength
increases after 15 minutes of immersion, reaches
maximum after 30 minutes.
It happens due to the increase in blood supply,
increase nerve excitability and increase in synaptic
nerve activity. In addition, ice would have
psychologically motivated the subjects to perform
better post-test. Increase in blood supply lead to
increase in temperature.
The increase in total work following cryotherapy
could be attributed to decreased pain during exercise
bout, decreased rate of torque decline 4, 13, Increase
muscle viscosity and decrease metabolic by products
4, 5
and a more gradual increase in muscle temperature
during exercise bout. Muscles fiber recruitment order
may also have been influenced.28
Therefore, it is recommended that, application of
cold on muscle should be employed while
rehabilitating an individual with muscle-pathology
particularly while training for muscle strength.
CONCLUSION
Cryotherapy drags the attention towards the
treatment of muscle strength and rehabilitation.
Present study is an experimental based study which
highlights the effect of cryotherapy on intrinsic muscle
strength. When referring to this study, readers should
note the limitations of the subject sample size; duration
38. Himanshu Pathak--202---.pmd 205
of the study as well as the study was done on normal,
young adults.
The study concludes that muscle strength increases
when measured after 15-30 minutes of cryotherapy
cessation. Future research should attempt to define the
effects of more common cold applications on functional
performance.
ACKNOWLEDGEMENT
I am grateful to all the students and staff of college
of physiotherapy, loni for their support and co
operation during my study.
Conflict of Interest: None
Source of Funding: The present study is funded by
College of physiotherapy, Pravara Institute of medical
Sciences, loni, Maharashtra.
REFERENCE
1. 1. Albert F. Bennett. Temperature and Muscle
J. exp. Biol. US, 333-344 (1985) 333
2. BD Chaurasia, s Human Anatomy, Volume one,
Third Edition, p.no.94-98 &108-114.
3. Clarke RSJ, Hellon RF, Lind AR.The duration of
sustained contractions of the human forearm at
different muscle temperature. J-Phyiol (Lond)
1958; 143:454-473.
4. Clarke DH, stelmach GE, Muscular fatigue and
recovery curve parameters at various
temperatures .Res Q 1966; 37:468-479.
5. Clarke DH, Wojciechowicz RA.The effect of low
environmental temperatures on local muscular
fatigue parameters. Am Corr. Ther. J.1978; 32:
35-40.
6. Chester L Ray. Muscle cooling delays activation
of the muscle metabolism reflex in
humans.Am.J.Physiol.1997.273:H2436-2441.
7. Clayton, Clayton’s electrotherapy, 10th edition,
2001,p-179
8. Coppin EG. Effect of handgrip strength due to
arm immersion in a 100 C water bath. Aviat Space
Environ Med.1978 Nov;49(11):1332-6
9. Davis TM, Young K: Effect of temp on contractile
properties &muscle power of triceps surae in
humans, J Appl Phy, 1983,55:191-195
10. Davies CTM.Mecrow IK, White MJ.Contractile
properties of the human triceps surae with some
observations on the effects of temperature and
exercise. Eur J.Appl.Physiol.1982; 49:255-269.
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 206 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
11. Edwards RHT, Harris RF,Hultman E,Kaijsar
L,Koh D,Nordesjo LO,Effect of temperature on
muscle energy metabolism and endurance during
successive isometric contractions sustained to
fatigue of the quadriceps muscle in man J.Physiol.
(Lond) 1972; 220:335-352.
12. Halvorson GA. Therapeutic heat and cold for
athletic injuries. Phys Sportsmed. May 1990; 18:
87-94.
13. Haymes EM, Rider RA.Effect of leg cooling on
peak isokinetic torque and endurance.Am,
Corr.Ther.J.1983; 37:109-115.
14. John Low &Ann read, electrotherapy explained
principle &practice, 3rd edition, 2000, p-259.
15. Johnson J, Leider FE, influence of cold bath on
max handgrip strength, Percept Motor skills, 1977,
44:323-325.
16. Johnson EW, Olsen KJ. Clinical value of motor
nerve conduction velocity determination. J. Am.
Med. Assoc. 1960; 172:2030-2035
17. Kevin M. Cross, Functional Performance
Following an Ice Immersion to the Lower
Extremity. Journal of athletic training.June1996,
31:113-116.Vol.2.
18. Knuttsson, E & Mattson, E: effect of cooling on
monosynaptic reflexes in man, scand J. Rehab Med,
1969, 1:126.
19. Kowal MA. Review of physiological effects of
cryotherapy. J. Orthop. Sports Phys. Ther. 1983;
5:66-73.
20. Lippincott, Wilkins &Williams, Springer Verlag
& Butterworth Heinemann, sports medicine, 1987,
1983, p-229.
38. Himanshu Pathak--202---.pmd 206
21. Me comber SA, Hermnan RM. Effects of local
hypothermia on reflex and voluntary activity.
Phys Ther. 1971; 51:271-282.
22. McMaster WC. Cryotherapy. Phys Sportsmed.
Nov 1982;10: 112-119
23. McMaster WC. A literary review on ice therapy
in injury. Am. J. Sport Med. 1977; 2: 124-126.
24. McGowin H. Effects of cold application on
maximal isometric
contraction.Phys.Ther.Rev.1967; 47:185-192.
25. Newton MJ, Lehmkuhl D. Muscle spindle
response to body heating and Localized muscle
cooling: implications for relief of spasticity. J. Am.
Phys. Ther. Assoc.1965; 45:91-105.
26. Oliver RA, Johnson DJ, and wheelhouse et al,
isometric contraction response during recovery
from reduced intramuscular temp Arch Phys Med
Rehab. 1979, 60:126-129.
27. Peter Douris. Recovery of Maximal Isometric
Grip Strength following cold immersion. Journal
of strength and conditioning research: Vol.17, No.3,
pp.509-513.
28. Petrofsky JS, The influence of recruitment order
and temperature on the muscle contraction with
special reference to motor neuron
fatigue.Eur.J.Appl.Physiol.1981; 47:17-25.
29. Susan L. Micholovitz, thermal agents in
rehabilitation, 3rd edition, 1986, p-87.
30. Salter harrins, hand therapy, 2000, p-278.
31. Zankel HT. Effect of physical agents on motor
conduction velocity of the ulnar nerve. Arch. Phys.
Med. Rehab. 1966; 47:787-792.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 207

A Comparative Study between Taping and Medial Arch

Support on EMG Activity of Selected Foot Muscles in
Individuals with Flexible Flat Foot

Dabie Wu1, Navin Daniel Raj2

1
Physiotherapist, Srinivas College of physiotherapy, Pandeshwar, Mangalore, India, 2Physical Therapist, Wilmington,
North Carolina, USA

ABSTRACT

Background & Objective: Loss of medial longitudinal arch or excessive pronation of the subtalar
and midtarsal joints is associated with abnormal biomechanics and leads to overuse injuries of the
lower limb. These injuries tend to occur gradually over a period of time as a result of soft tissue creep
and hysterisis from repeated loading. The intrinsic and extrinsic foot muscles work out of phase and
prolong their activity in order to stabilize the foot. Physiotherapy treatment involves the application
of anti-pronation taping and temporary orthotics in order to alleviate patient's symptoms. Low Dye
taping generates a supinating force and is designed to support the medial longitudinal arch.
Temporary foot orthosis also has an anti-pronation effect and has been extensively used. Thus this
study aimed to compare and analyze the EMG activity of Tibialis Anterior and Peroneus Longus
with modified Low Dye taping as opposed to with medial arch support.

Method: This study included 30 individuals with flexible flat feet with a navicular drop of more than
10mm, selected randomly, of age group between 18 to 26 years. EMG activity of Tibialis Anterior and
Peroneus Longus was recorded and analysed, first with the application of modified Low Dye taping
and then with medial arch support, in single limb stance position.

Results: The recorded data was then subjected to statistical analysis. ANOVA of the mean amplitude
of the muscles with modified Low Dye taping and medial arch support revealed a p-value of 0.000,
which is a highly significant relationship. Pairwise comparison of the mean amplitude of muscles by
the Bonferroni test, between taping and medial arch support showed a highly significant difference,
with a p-value of 0.000.

Interpretation and Conclusion: this study revealed that the mean amplitude of the muscles was
significantly reduced with both forms of intervention. However when comparing modified Low
Dye taping procedure to medial arch support, the mean amplitude was significantly lower with the
former than the latter. Thus we can conclude that modified Low Dye taping is more effective in
controlling the muscle activity associated with excessive pronation than medial arch support.

Keywords: Medial Longitudinal Arch, Pronation, Modified Low Dye Taping, Medial Arch Support

INTRODUCTION flattening of the plantar vault.1 The appearance of flat

or pronated feet is often present at birth due to the
The absence or collapse of arches leads to flat feet
presence of fatty tissue in the arch, this is often called
or pes planus or pronated feet. It is a diverse condition
physiological flat feet. The arch gradually develops to
with many causative factors characterized by the
its mature form by age 4 to 7 years. 2, 3, 4 the prevalence
of flat feet is 10% to 23% in adults.5.6

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 208 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Pes planus is divided into two types. First is the
rigid pes planus foot, which shows an abnormally low
medial longitudinal arch in weight bearing and non
weight bearing positions, tarsal coalition and
congenital vertical talus are examples of this type.7 The
second type is the flexible flat foot, which shows a
normal appearing arch in non weight bearing position
but an abnormally low arch in weight bearing position,
these are correctable and can be demonstrated by the
restoration of the arch when the patient sits or stands
on tip toes.
Various anatomical structures are responsible for
the formation and support of the arches. The head of
the talus forms the key stone of the summit and is
situated in the deep socket formed by the anterior end
of calcaneum and navicular and is supported by the
plantar calcaneo navicular ligament called the spring
ligament.8
The tendon of Tibialis anterior and peroneus longus
together forms a sling (or stirrup), which keeps the
middle of the foot pulled upwards, thus supporting
the longitudinal arches. The intrinsic muscles of the
foot also play a major role in maintaining the arches.
The plantar aponeurosis joins the two ends of the arch
and acts as a tie beam.8
In people with flat foot, the ligaments are more lax
and muscle activity now becomes proportionately
more important in maintaining posture9, the intrinsic
muscles are reported to demonstrate increased periods
of activity in order to control the subtalar and
transverse tarsal joints and resist further flattening of
arch and pronation of foot. Stabilization of the
midtarsal articulations begins at 35% of gait cycle in
normal foot, whereas in the pronated foot this
stabilization occurs at 0 to 26% implying greater
intrinsic muscle activity. Similarly there is increased
eccentric activity of Tibialis anterior from heel strike
to 25% of stance phase as well as Tibialis posterior, as
it eccentrically contracts to stabilize the medial arch
during pronation. The peroneus longus muscle loses
its mechanical efficiency as a stabilizer of the first ray,
when the ray approaches the transverse plane of the
cuboid bone during abnormally late midstance
pronation. The muscle unit may react eccentrically an
attempt to stabilize the medial plantar aspect of the
forefoot during abnormal pronation. This unbalanced
condition may further destabilize the cuboid resulting
in hypermobility of the fifth ray. This out of phase
muscular activity may lead to osseous subluxations
39. Dabie Wu--207--.pmd 208
will alter the proper function of the musculotendinous
unit, causing a variety of pathologies.10
Conservative interventions for excessive pronation
aim to support the medial longitudinal arch, reduce
medial stress, provide proproceptive input and
enhance muscular activity around the foot and ankle.11
Taping is a common intervention strategy by which
functional mechanical support can be provided to the
joints of the foot.12 Low dye taping technique, designed
by Ralph Dye and modified later, has been used
effectively in controlling excessive pronation. 10.11
Studies using static measurements of foot posture such
as vertical navicular height and resting calcaneal stance
angle, revealed that low dye taping improved static
foot position immediately after taping.11,13
Orthotic devices are designed to maximize function
in two ways; firstly by correcting a biomechanical
problem so that there is no energy wastage to
compensate for a problem, and secondly it is used to
reduce discomfort by changing the weight bearing
profile of the foot.14 Arch support helps to elevate the
arch in flexible flat foot, and materials such as
polyurethane, ethyl vinyl acetate (EVA), microcellular
rubber and cork has been widely used for making
inserts as it is light weight, durable flexible and can
absorb shock well. Many varieties of pre-
manufactured inserts are available in the market
today.15, 16 Imhauzer et al (2002) evaluated the efficacy
of in shoe orthosis and ankle braces in stabilizing the
hindfoot and medial longitudinal arch in a cadaveric
model of acquired flexible flat foot. In shoe orthosis
was found to stabilize both the hindfoot and the medial
longitudinal arch, while ankle braces did not.17
There have been very few studies that have
compared the efficacy of low dye taping and medial
arch support by analyzing the extrinsic muscle activity.
Thus, the primary objective of this study is to compare
the effectiveness of the same by studying the activity
of the peroneus Longus and the Tibialis Anterior
muscle, in order to devise an efficient and most
appropriate intervention.
MATERIAL AND METHOD
Subjects with flexible flat feet were taken from
various educational institutes in Mangalore.
All subjects were explained about the procedure
and a written consent form (approved by the
institution) was obtained.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 209

STUDY DESIGN Emg Preparation

Experimental study The EMG machine was set with the following
parameters
Inclusion Criteria
Sensitivity: 100μv/div
1) Males and females between the age of 18 to 26
years. Filter setting: 200 Hz–2 kHz
2) Individuals with flexible flat foot. Sweep speed: 10ms/div
3) Individuals with a navicular drop of more than 10 Duration: 0.10ms
mm.
It was tested before using on subjects of the study.
Exclusion Criteria
Minimum baseline value was kept 2-3μv for all subjects
1) Individuals with history of surgery, trauma or of the study.
fractures to the lower extremity.
Subject Preparation
2) Individuals with mental impairments.
The area for placement of electrodes was exposed,
3) Individuals wearing lower limb orthosis. shaved and cleaned with spirit. All readings were
taken in between 10am and 2pm, in order to minimize
4) Individuals having known reactions to rigid tape the temporal variation
such as redness, rash, or discomfort.
Electrode Positioning
Tools and Materials Used
• Peroneus Longus: electrodes were placed 3 cm
• Electromyographic (EMG) equipment, (neurocare
below the head of Fibula.21
TM
-2000, computerized EMG with NCV and
evoked potentials. Manufacturer: Bio-Tech TM, • Tibialis Anterior: electrodes were placed in the
India middle of the muscle belly.21
• Surface electrodes: Recording, reference and • Inter electrode distance was kept as 2cm.21
ground electrode (5mm in diameter)
Exercise Position and Task
• Non stretch adhesive tape: For the application of
low dye taping procedure. EMG readings were taken in four positions

• Medial arch support: Over the counter arch
support made of Microcellular rubber.
PROCEDURE
Thirty subjects with flexible flat feet were selected
using random sampling procedure, from a pool of sixty
subjects. An orthopaedic assessment was performed
and all Subjects were informed about the task to be
performed. The dominant leg was found out by asking
subjects to kick a football, whichever leg the patient
used was the dominant leg.20
Navicular Drop measurement: Was the difference
in measurement of the distance from the navicular
tuberosity to the floor in subtalar joint neutral position
and in relaxed stance position11, 19
1) Relaxed bilateral stance
2) Single leg stance
3) Single leg stance after the application of modified
Low Dye tape
4) Single leg stance after the insertion of medial arch
support
Single leg stance was performed on the dominant
leg with eyes open and hip and knee of opposite leg
flexed to a comfortable position. Once the subject
assumes a balanced position, he/she has to indicate it
verbally. He/she will then be asked to hold the
position for 3 seconds, during which EMG readings
was taken.20

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 210 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

The EMG recordings for the above positions was TAPING

taken three (3) times and the mean was calculated. A
rest period of two (2) minutes was given between each The Low dye taping technique11 involved the use
trial. The data was tabulated for all the four (4) of rigid adhesive tape (Leuko sports tape.
positions, for the muscles- Peroneus Longus and
Tibialis Anterior.

RESULTS

Table No.1: Mean and standard deviation of age, weight and height.

Table No. 2: Distribution of navicular drop measurements.

Table No. 3: anova analysis of amplitude of emg activity of peroneus longus muscle.

B/L ST: bilateral stance; SING ST: single leg stance; WITH TAPE: Single leg stance with tape on; WITH ARCH: single leg stance with
arch support; HS: highly significant

Table No. 4: anova analysis of amplitude of emg activity of tibialis anterior muscle.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 211

Table No. 5: Bonferroni test for the pair wise comparison of emg activity (amplitude) of peroneus longus and
tibialis anterior muscle in different situations.

Table No. 6: Independent t-test used to compare the activity of tibialis anterior muscle and peroneus longus muscle
in different situation

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 212 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
DISCUSSION
In this study, the ANOVA analysis of mean EMG
amplitude of Tibialis Anterior and Peroneus Longus
revealed that the greatest amplitude was during single
limb stance only condition, followed by single limb
stance with medial arch support, then with single limb
stance with modified Low Dye taping, and finally the
minimum amplitude was in bilateral stance position,
which was expected since body weight is distributed
and equilibrium is maintained, thus minimizing the
required muscle activity.
In the pair wise comparison between test positions
of single leg stance with tape and single leg stance with
arch support (using the Bonferroni test), it was found
that there was a highly significant difference in the
EMG activity of Tibialis Anterior and Peroneus Longus
muscle, favouring taping over arch support. Hence we
can infer that even though both modified Low Dye
taping procedure and medial arch support
significantly reduces the EMG amplitude of both
muscles compared to no intervention, Low Dye taping
is more effective in reducing the negative work done
by the muscles for controlling the excessive pronation
associated with flexible flat feet, than a medial arch
support.
The results of the data analysis were consistent with
the work of Vicenzino B, Griffiths SR et al (2000). They
investigated the effect of anti-pronation taping and
temporary soft orthotics in subjects with navicular
drop of 10mm and more, on the navicular height
immediately post application and after 10mins and
20mins of jogging. Both tape and orthoses significantly
increased the navicular height, but the increase was
greater with tape as compared to with orthoses,
implying that the tape was more effective in controlling
vertical navicular height immediately following
application. Though, after exercise the navicular height
reduced with both forms of interventions (greater with
tape). However, both remained superior to the control
group.18
Hyperpronation leads to abnormal lower limb
biomechanics, which is associated with overuse
injuries. Ator et al (1991) suggested that it maybe the
extremes of pronation range that leads to injury of the
soft tissue structures that control pronation. They
proposed that anti-pronation taping may prevent
excursion into the extremes of range and thus prevent
injury. Based on the tissue stress model of McPoil and
hunt, the anti-pronation techniques may thus prevent
39. Dabie Wu--207--.pmd 212
deformation of the soft tissue beyond the elastic region
of the load deformation curve, and thus provide a
means to rest over stressed tissues.22
This study provides background information for
further research required to determine the extent to
which pronation needs to be controlled in order to
prevent excessive soft tissue deformation and to
ameliorate symptoms in subjects who have overuse
injuries that are associated with flexible flat feet.
CONCLUSION
We can conclude that both the forms of
intervention, i.e. modified Low Dye taping and medial
arch support significantly reduce muscular activity
and have an anti-pronation effect. Since the reduction
is greater with modified Low Dye taping procedure,
as compared to medial arch support, it is much more
effective in controlling the muscular activity during
excessive pronation.
Limitation of the study
1. The study only evaluated the immediate effect of
tape and arch support on muscle activity.
2. The study evaluated the EMG activity of muscles
only in static posture of single limb stance.
3. Only two muscles, i.e. Tibialis Anterior and
Peroneus Longus activity were investigated.
Acknowledgement: None
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance: Informed consent was obtained
from all subjects in the research and code of ethics was
adhered to.
REFERENCES
1. Louis Solomon, David J. Warwick and Selvadurai
Nayagam. Apley’s system of orthopaedics and
fractures. 8th edition. Arnold publishing; 2001.
2. Sullivan J A. Pediatric flat foot- evaluation and
management. Journal of American academy of
orthopedic surgeons. 1999; 7:43-44.
3. Staheli LT, Chew DE and Corbett M. the
longitudinal arch- a survey of eight hundred and
eighty two feet in normal children and adults.
Journal of bone joint surgery. 1987; 69-A: 426-428.
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 213
4. Stuart L. Weinstein and Joseph A. Buckwalter.
Turek’s Orthopedics- principles and their
applications. 5 th edition. J. B. Lippincott
Company; 1994.
5. Gould N, Moreland M and Alverez R.
Developmant of the child’s arch. Foot and ankle.
1989; 9: 241-245.
6. Raw UB and Joseph B. The influence of footwear
on prevalence of flat foot- a survey of two
thousand three hundred children. Journal of bone
joint surjery 1992; 74B: 525-527.
7. John Ebnezer. Textbook of Orthopedics. 2 nd
edition. Jaypee publishers; 2000.
8. B. D Chaurasia. Human anatomy regional and
applied dissection and clinical, volume2. 4th
edition. CBS publishers and distributors; 2004.
9. David C Reid. Sports injury assessment and
rehabilitation. Churchill Livingstone; 1992.
10. Hunt CL and McPoil T G. physical therapy of foot
and ankle. 2nd edition. Churchill Livingstone;
1995.
11. Belinda Lange, Lucy Chipchase and Angela
Evans. The effect of Low Dye taping on plantar
pressures during gait in subjects with navicular
drop exceeding 10mm. Journal of Orthopaedic
and Sports Physical Therapy. 2004; 34(4): 201-202.
12. Maria Zuluga, Christopher Briggs and John
Carlisle. Sports physiotherapy applied science
and practice. Churchill Livingstone; 1995.
13. Clayton F Holmes, Donald Wilcox and James P
Fletcher. Effect of modified Low Dye taping
procedure on the subtalar joint neutral position
before and after light exercise. Journal of
Orthopaedic and Sports Physical Therapy 2002;
32(5).
14. Freddie H Fu and David Ashton. Sports injuries-
mechanisms, prevention and treatment. Williams
and Wilkins publishers; 1994.
39. Dabie Wu--207--.pmd 213
15. Rene Calliet. Foot and ankle pain. 2nd edition.
Jaypee Brothers publishers; 1983.
16. Brian McCludy. Study sheds new light on
therapeutic footwear for patients with diabetes.
Podiatry today 2004; 17: 6-16.
17. Imhauser CW, Abidi NA, Frankel DZ, Gavin K
and Siegler S. Biomechanical evaluation of the
efficacy of external stabilizers in the conservative
management of acquired flat foot deformity. Foot
and ankle international 2002; 23(8); 727-737.
18. Vicenzino B, Griffiths, Griffiths SR, Griffiths LA
and Hadley A. Effect of anti-pronation tape and
temporary orthotic on vertical navicular height
before and after exercise. Journal of Orthopaedic
and Sports Physical Therapy 2000; 30(6): 333-339.
19. Kecia E Sell, Todd M Verity, Teddy W Worrel,
Brian J Pease and Janet Wigglesorth. Two
measurement techniques for assessing subtalar
joint position- A reliability study. Journal of
Orthopaedic and Sports Physical Therapy 1994;
19(3): 162-167.
20. J Troy Blackburn, Christopher J Hirth and Keviin
M Guskiewicz. Exercise sandals increase lower
extremity Electomyographic activity during
functional activities. Journal of Athletic Training
2003; 38(3): 198-203.
21. P M Palmieri, C D Ingersoll, M A Hoffman, M L
Cordova, D A Porter, J E Edwards et al.
Arthrogenic muscle responses to a stimulated
ankle joint effusion. British Journal of Sports
Medicine 2006; 38:26-30.
22. Ator R, Gunn K, McPoil T and Knecht H. The
effect of adhesive strapping on medial
longitudinal arch support before and after
exercise. Journal of Orthopaedic and Sports
Physical Therapy 1991; 14:18-23.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
214 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Comparison of Flow and Volume Oriented Incentive

Spirometry on Lung Function and Diaphragm Movement
After Laparoscopic Abdominal Surgery. A Randomized
Clinical Pilot Trial

Gopala Krishna Alaparthi1, Alfred Joseph Augustine2, Anand R3,Ajith Mahale4

1
Asst. Professor- Selection Grade, Department of Physiotherapy, 2Professor, Department of Surgery, 3Professor,
Department of Pulmonary Medicine, 4Professor, Department of Radiodiagonsis, Kasturba Medical College, A
Constituent Institute of Manipal University, Mangalore

ABSTRACT

Objective: This study was designed to evaluate the efficacy of two types of incentive spirometer
(flow and volume) on pulmonary function and diaphragm excursion in patients who underwent
laparoscopic surgery

Materials and Method: Twenty sample sizes with eleven men and nine women who underwent
laparoscopic surgery were randomly divided as follows: 10 subjects performed flow oriented incentive
spirometer group, and other 10 subjects performed volume oriented incentive spirometer group.
(Other therapies like bronchial hygiene therapy, Thoracic mobility exercise and mobilization
performed both group). All of them underwent evaluations of pulmonary function test with
measurement of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1),
FEV1/FVC ratio, peak expiratory flow (PEF) and diaphragm movement by ultra songraphy before
the operation and first, second postoperative day(POD)
Results: pulmonary function and diaphragm movement values between preoperative and
postoperative (first, second) days were found to be higher in the volume oriented incentive spirometer
group when compared to flow oriented incentive spirometer group.
Conclusions: volume oriented incentive spirometry contributed towards early recovery of pulmonary
function and diaphragm movement among patients who had undergone laparoscopic abdominal
surgery

Keywords: Incentive Spirometry, Laparoscopic Abdominal Surgery, Flow Incentive Spirometry, Pulmonary
Function, Diaphragm Movement, Volume Incentive Spirometry

INTRODUCTION pneumonia, respiratory dysfunction and pleural

The associations between thoracic and abdominal
surgeries and the high incidence of respiratory
complications are already well documented in the
literature and its main characteristics are: atelectasis,
Corresponding author:
Joseph Augustine
Head & Professor
Department of Surgery, Kasturba Medical College,
A Constituent Institute of Manipal University,
Mangalore-575004
E mail: alfred.augustine@manipal.edu
Mobile: +91-98450047
effusion1. Now a day’s many abdominal surgeries are
performed by the laparoscopic technique 2 . The
advantages of the laparoscopic technique include les
patient discomfort, shorter hospitalization, and short
interval to return to full activities after operation.
Pulmonary function is commonly altered after surgery,
particularly in patients who have had chest or
abdominal surgery3.
The physiological changes are directly related to
anaesthesia (general or regional) and to the type of
incision and surgical technique employed and are
reflected by decreases in total pulmonary capacities

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 215
and volumes. Impairment of Pulmonary function is
one of the most significant postoperative pulmonary
complications of upper abdominal surgery4. It has been
postulated that due to the minimal incisional
discomfort, postoperative pulmonary function
following laparoscopic surgery would be improved
as compared to open abdominal surgery3.
Chest physiotherapy techniques of lung re-
expansion have been recommended as strategies to
prevent and/or to treat the postoperative
complications, as well as to recover the ventilation
function in the postoperative period. Techniques such
as diaphragmatic breathing exercise, incentive
spirometry and positive airway pressure exercises
stimulate the generation of a large and sustained
increase in the transpulmonary pressure, with
consequent expansion of collapsed alveolar units5.
Incentive spirometer is activated by a inspiratory
effort, that is, breathing is visualized by an uplifted
ball in a transparent cylinder during sustained
inspiration .on a calibrated scale on the cylinder, the
uplifted ball on the spirometer displays either the
inspired volume ( a volume –oriented incentive
spirometer ) or the generated flow ( a flow- oriented
incentive spirometer ) .The incentive spirometer has
been widely used in clinical practice, especially in the
management of patients in the pre and post-operative
period of major abdominal and cardio-thoracic
surgeries6.
Though chest physiotherapy is not specifically
recommended for laparoscopic abdominal surgery, it
stills a common practice in many treatment centres
around the world. Study also shows that chest physical
therapy contributed towards early recovery of
pulmonary function and muscle strength among
patients who had undergone laparoscopic
cholecystectomy7.
Recently a randomized control trail studies shows
that diaphragmatic breathing exercise contributed
towards early recovery of pulmonary function and
diaphragm excursion among patients who had
undergone laparoscopic surgery8. The most recent
study conclude that aerobic exercise to incentive
spirometry helped in controlling postoperative
pulmonary complications after laparoscopic
cholecystectomy4.
However, there are no studies showing the effect
of flow and volume oriented incentive spirometer on
lung function and diaphragm movement after
40. Gopala --214--.pmd 215
laparoscopic surgery. The present study aims to
compare the effect of flow and volume oriented
incentive spirometer on lung function and diaphragm
movement following laparoscopic abdominal surgery,
which has not been investigated previously.
METHOD
The study was approved by the Department of
Physiotherapy Scientific Committee and the
Institutional Ethics Committee of Kasturba Medical
College Mangalore. The study included 20 patients
aged 20-70 years undergoing laparoscopic abdominal
surgery. Exclusion criteria was patients who were
uncooperative, unstable cardiovascular system,
Presence of any acute infection, and patients who
underwent open abdominal surgery
The purpose of the study was explained to the
participant and an informed consent was obtained.
Patients were divided in two groups; (1) flow oriented
incentive spirometry group (2) volume oriented
incentive spirometry group. Each group contained 10
patients. Patients were selected through convenient
sampling. Allocation of the group was done by block
randomization.
Each subject was allocated a unique study number
which corresponded to that on a sealed opaque
envelope containing information about subjects’
allocated flow (IS) or volume (IS) group. Once the
allocation of the groups was done, the patient in the
both exercise group was seen one day prior to the
surgery and was given preoperative information and
flow or volume (IS) Exercise were taught to the patient.
Other therapies like bronchial hygiene therapy,
Thoracic mobility exercise and mobilization were
taught to every patient in both groups.
Pulmonary function test procedures were
performed ensuring technical acceptability and
reproducibility criteria recommended by the American
Thoracic Society 9. The following variables were
recorded; Forced Vital Capacity (FVC), Forced
Expiratory Volume in the first second (FEV1), FEV1/
FVC ratio,) these were taken in the preoperative period
and it was measured again first and second day after
surgery. The Ultra sonography for diaphragm
movement was taken in the preoperative period in
both groups and it was measured again on 1 st
postoperative day and at the time of the discharge.
These measurements were taken by an experienced
radiologist.
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 216 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Method of performing flow oriented and volume
oriented incentive spirometer
Incentive spirometer was given with the patient
positioned in half lying (450) with a pillow under the
knees. The patient was instructed to take a deep
sustained breath with a breath holding for 5-10
seconds. Then the patient will be instructed to breathe
out slowly and passively and to avoid any forceful
expiratory maneuver. After the process is
demonstrated to the patient, he/she will be asked to
perform it to make sure that he/she had understood
the process. Initially the therapist will hold the
spirometer in front of the patient and give him ideas
about the Inspiratory flow. But later the patient will
hold the spirometer by himself/herself and practice
the maneuver. For incentive spirometer, the patient
was instructed to perform it for 5-10 breaths every hour
while awake. The treatment was given by the therapist
four times in a day and the patient had to perform the
same maneuver unsupervised thereafter, which was
recorded in a log book10.
Method of performing diaphragm movement
The probe was placed between the midclavicular
and anterior axillary lines, in the sub-costal area, and
directed medially, cranially and dorsally, so that the
ultrasound beam reached perpendicularly the
posterior third of the right hemi diaphragm.
Diaphragm movements were recorded in M-mode.
This maneuver begins at the end of normal expiration,
and the patients were asked to inhale in as deeply as
they possibly could do.
DATA ANALYSIS
All statistical analysis was performed using the
Table 1: Demographic data of the study participants
Characteristics
N 10 ( male 6, female 4)
Age
Height
Weight
Laparoscopic cholecystectomy
Laparoscopic appendectomy
Laparoscopic hernioplasty
laparoscopic varicocelectomy
40. Gopala --214--.pmd 216
Statistical Package for Social Science (SPSS) version
13.0 software. P-value of < 0.05 with confidence
interval of 95% was considered statistically significant.
An analysis of variance (ANOVA) was used to
compare the results of each group obtained pulmonary
function (FEV1,FVC, FEV1/FVC) and diaphragm
excursion in the pre-operative as well as for first and
second post-operative (OP) days.
RESULTS
The characteristics of the 20 patients included in
the data analysis were shown in (Table-1). The baseline
analysis characteristics demographic data, including
age, sex, height, weight,,10 patients took part in the
flow oriented incentive spirometry group, in which 6
were females and 4 males, age 44.0 ±17.9 years old,
and 10 engaged in the volume incentive spirometry
group, 3 females and 7 males, age 40.4 ±18.3 years
old.
The mean values for pulmonary function (FVC,
FEV1, FEV1/FVC, PEF) and diaphragm movement in
the preoperative period and on the first and second
day after the surgery in both groups are shown in
(Table-2, 3, 4, 5) one can observe a meaningful
pulmonary function and diaphragm excursion
reduction in the first postoperative in relation to the
preoperative phase for all variables analyzed (p<0.05)
for both groups, except in the relation FEV1/FVC,
which did not show any significant differences. By
comparing preoperative and second postoperative in
both groups, the value found in the volume oriented
incentive spirometry group were greater than those
in the flow oriented incentive spirometry group.
Flow oriented incentive Volume oriented
spirometry group incentive spirometry
group
10 (male 7, female, 3)
44.2±15.5 40.6 ±14.8
157.1± 10.8 162.5 ±9.46
60.0± 13.6 57.0±12.0
5 5
2 1
2 4
1 0
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 217

Table 2: Comparison of pulmonary function in flow oriented incentive spirometry group

Preop Postop 1day Postop 2day Difference p value Difference P value

(preminuspost1) (preminuspost2)
FVC 2.45±.90 1.78±1.10 2.07±.85 0.67±.56 .005 0.38±.51 .028
FEV1 2.07±.78 1.37±.70 1.64±.61 0.70±.51 .005 0.43±.49 .028
FEV1/FVC 83.9±8.0 80.2.4±8.0 83.2±7.0 0.30±.11 .202 0.0±.09 .610
PEF 4.24±1.90 2.72±1.60 3.57±1.24 1.52±1.35 .007 .66±1.09 .169

Table 3: Comparison of pulmonary function in volume oriented incentive spirometry group

Preop Postop 1day Postop 2day Difference p value Difference P value

(preminuspost1) (preminuspost2)
FVC 2.81±.78 2.22±.66 2.53±.75 0.58±.55 .017 0.28±.33 .037
FEV1 2.34±.64 1.73±.52 1.94±.58 0.60±.38 .005 0.40±.28 .007
FEV1/FVC 83.5±6.0 77.1±6.0 77.3±7.0 0.64±.06 .019 0.62±.06 .028
PEF 4.86±1.16 3.30±1.26 3.65±1.30 1.56±1.08 .007 1.21±1.17 .074

Table 4: Comparison of diaphragm movement in flow oriented incentive spirometry (FOIS) group

FOIS Preop Postop 1day Postop 2day Difference p value Difference P value
(preminuspost1) (preminusdischarge)
Diaphragm movement 3.58±.99 2.60±1.23 3.49±.84 0.98±.55 .008 0.09±.39 .440

Table 5: Comparison of diaphragm movement in volume oriented incentive spirometry (VOIS) group

VOIS Preop Postop 1day Postop 2day Difference p value Difference P value
(preminuspost1) (preminusdischarge)
Diaphragm movement 3.76±.92 2.57±.66 3.82±.60 1.56±1.08 .007 1.21±1.17 .017

DISCUSSION position for prolonged periods promote decreased

This study was conducted to determine the efficacy
of flow oriented incentive spirometer versus volume
oriented incentive spirometer on pulmonary function
and diaphragm excursion of patients who underwent
laparoscopic abdominal surgery. It is necessary to
point out that in the literature no such references were
found for any works that linked the chest
physiotherapy or laparoscopic surgery, which attests
to the importance and pioneering nature of this pilot
study.
The results of this study pointed out that
pulmonary function (FVC, FEV1, FEV1/FVC and PEF)
and diaphragm excursion between preoperative, first
and second postoperative day were lesser in the flow
oriented incentive spirometer group compare to
volume oriented incentive spirometer group.
During normal respiration, large intermittent
breaths, three times the normal tidal volume, are
inspired approximately ten times each hour. During
post-operative, such sighing is absent. Shallow,
monotonous breathing may decrease ventilation to the
dependent lung regions and may contribute to the
development of atelectasis. Incisional pain, residual
anesthetic effects, and assuming the recumbent
resting lung volume12.
In addition, when patients remain recumbent for
long periods, especially during the first 24 hours
postoperatively, their abdominal content limits
diaphragmatic movement. Both the recumbent
position and a change in breathing pattern may
decrease FRC. Diminished expiratory lung volumes
are associated with decreased lung compliance, which
increases the elastic work of breathing. to minimize
this work patients take shallow, frequent breaths
which may further decrease lung volume12.
Incentive spirometry is widely used clinically as
an adjunct to chest physiotherapy; the theoretic basis
on which the incentive spirometer was proposed was
that it encourages patients to maximally inflate their
lungs and to sustain that inflation. Maximal lung
inflation is thought to open collapsed alveoli, and
thereby, prevent and resolve atelectasis. Maximal lung
inflations increase transpulmonary pressure during
inspiration. If the re-expanded alveoli remain inflated
during expiration, FRC will be increases13.
Volume oriented incentive spirometer achieved a
larger lung volume than did patients using flow
oriented incentive spirometer. To attain this goal, a

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 218 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
sustained and prolonged inspiratory phase is needed
to meet the increased demand of the time constant in
collapsed alveoli. The inspiratory volume indicated in
flow oriented incentive spirometer is determined by
peak inspiratory flow rate to attain the maximal
possible inspiratory volume13.
In addition, patients might not sustain a sufficient
inspiratory phase to counteract the increased time
constant to expand the alveoli. In contrast, the
inspiratory volume indicated on volume oriented
incentive spirometer is determined by the volume
inspired. Patients may adjust their inspiratory flow rate
and inspiratory time to inflate their high time- constant
alveolar units. Therefore volume oriented incentive
spirometer may be more suitable for lung expansion
therapy13.
One of the limitations of study is small sample size.
Further research is needed studies with large sample
size and comparing diaphragmatic breathing exercise
and different breathing exercise devices (flow IS and
volume IS) in laparoscopic surgery.
In conclusion, Volume oriented incentive
spirometry contributed to the early recovery of both
the pulmonary function and diaphragm movement of
the patients who underwent laparoscopic abdominal
surgery.
Source of Support: Nil
Conflict of Interest: None declared
Acknowledgments: we would like to thank all the
subjects who has been actively involved in the study.
REFERENCES
1. Dias CM, Plácido TR, Ferreira MFB, Guimarães
FS, Menezes SLS. Incentive spirometry and
breath stacking: effects on the inspiratory capacity
of individuals submitted to abdominal surgery.
Rev. bras. fisioter. 2008;12(2):94-9.
2. M. Fagevik Olsen, K.Josefson, H.Lonroth. Chest
physiotherapy does not improve the outcome in
laparoscopic fundoplication and vertical-banded
gastroplasty. Surg Endosc 1999; 13: 260–263
3. Ravimohan SM, Kaman L,Jindal R, Singh R,
Jindal SK. Postoperative pulmonary function
in laparoscopic versus open cholecystectomy:
40. Gopala --214--.pmd 218
prospective, comparative study. Ann Surg. 2005;
241(2):219-26.
4. Ashraf A. El-Marakby, Ashraf D, Ehab A, Ahmed
M , Salwa R. E , Riziq Al etal Aerobic Exercise
Training and Incentive Spirometry Can Control
Postoperative Pulmonary Complications after
Laparoscopic Cholecystectomy
5. Carvalho Celso R. F., Paisani Denise M., Lunardi
Adriana C.. Incentive spirometry in major
surgeries: a systematic review. Rev. bras. Fisioter
2011;15(5):343-50.
6. Weindler J, Kiefer RT. The efficacy of
postoperative incentive spirometry is influenced
by the device-specific imposed work of breathing
Chest. 2001 Jun;119(6):1858-64.
7. Gastaldi AC, Magalhaes C. Benefits of
postoperative respiratory kinesiotherapy
following laparoscopic cholecystectomy. Rev
Bras Fisioter. 2008;12(2);100-106.
8. Alaparthi G K, Augustine A J, R Anand, Mahale
A. Chest physiotherapy during immediate
postoperative period among patients undergoing
laparoscopic surgery- A Randomized Controlled
Pilot Trail. IJBAR: 2013;04(02);118-122.
9. M.R Miller, J Hankinson, V.Brusasco, F. Burgos
R. Casaburi et al, Standardisation of spirometry.
European respiratory journal 2005; 26; 319-338.
10. AARC (American Association for Respiratory
Care) clinical practice guideline. Incentive
spirometry. Respir Care. 1991;36(12):1402-5.
11. Boussuges A, YoannGole. Diaphragmatic Motion
studied by M-Mode Ultrasonography: methods,
reproducibility, and normal values. Chest 2009;
135:391-400.
12. Celli BR, Rodriguez KS, Snider GL. A controlled
trial of intermittent positive pressure breathing,
incentive spirometry, and deep breathing
exercises in preventing pulmonary complications
after abdominal surgery. Am Rev Respir Dis.
1984;130(1):12-5.
13. Ho SC, Chiang LL, Cheng HF, Lin HC, Sheng DF,
Kuo HP, Lin HC. The effect of incentive
spirometry on chest expansion and breathing
work in patients with chronic obstructive airway
diseases: comparison of two methods. Chang
Gung Med J. 2000 Feb;23(2):73-9.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 219

Effect of Treadmill Training on Gait and Balance

Impairments in Patients with Parkinson's Disease

Nimisha Mishra1, Vivek Kulkarni2, Savita Rairikar3, Ashok Shyam4, Parag Sancheti5
1
Clinical Physiotherapist, 2Associate Professor, 3Principal, Sancheti Institute College of Physiotherapy, 4MS-Orth,
5
Chairman, Sancheti Institute for Orthopaedics and Rehabilitation

ABSTRACT

Background: Postural instability and gait impairments are the most disabling aspect of Parkinson's
disease. Rehabilitation training on a treadmill is an acceptable approach for the treatment of gait
dysfunction in the early stages of Parkinson's disease. However studies till now have focused only
on gait and not on assessment of balance. We performed this study to assess the effect of treadmill
training on both gait and balance.

Aim: To study the effect of Treadmill training on gait and balance in Parkinson's patients.

Methodology: 10 patients of Parkinson's disease who met the inclusion criteria were included in the
study. Treadmill training was given for 30 minutes, 3 days per week, for 6 weeks. All subjects were
evaluated before treadmill training at baseline and reevaluated at the end of 6 weeks. Main outcome
measures used were Tinneti Balance and Gait Assessment, Dynamic Gait Index, Gait speed and
Stride length.

Results: Post treadmill training there was significant improvement seen in the outcome measures:
Tinneti balance and gait score (P=0.005), dynamic gait index (P=0.005) ,gait speed (P=0.002)and stride
length of right (P=0.002) and left (P= 0.002) leg.

Conclusion: Treadmill training is effective in improving the gait and balance impairments in patients
with Parkinson's disease.

Keywords: Treadmill Training, Gait, Balance, Parkinson's Disease

INTRODUCTION interventions for posture, balance, and gait disorders

Parkinson’s disease is a progressive, idiopathic,
neurodegenerative characterized by rigidity,
bradykinesia, tremors, postural instability and gait
impairments.1 Postural instability and gait impairment
are the most disabling aspect of Parkinson’s disease.2,
3, 4
Current physical therapy and rehabilitation
Corresponding author:
Nimisha Mishra
Clinical Physiotherapist
Department of Neurophysiotherapy, Sancheti Institute
College of Physiotherapy, Sancheti Healthcare
Academy, Thube Park 11-12, 16, Shivaji Nagar, Pune
Maharashtra, India
Telephone: 020 - 25539393, Fax No: 020 - 25539494,
email id: nimisha.s.mishra@gmail.com
in Parkinson’s disease mainly focus on separate aspects
of the problems such as posture and balance training
5, 6
or gait training. 7,8,9,10,11
From a physical therapy standpoint, treadmill
training promises to become an acceptable approach
for the treatment of gait dysfunction in the early stages
of Parkinson’s disease. Recent studies suggest that
treadmill training is more effective than conventional
approaches to improve gait characteristics (speed,
stride length, stride variability) associated with
Parkinson’s disease.1,7,12,13,14 There is a dearth of studies
15
done to find the effect of treadmill training on balance
in patients with Parkinson’s disease. Also, most of the
studies have used full or partial body weight support
treadmill training for Parkinson’s patients. Thus, the
purpose of this study was to find the effect of treadmill

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 220 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

training on balance and gait impairments seen in Statistical analysis

patients with Parkinson’s disease, using a safety
harness. Wilcoxon Signed Rank test was used for within
group comparison between pre and post training of
all the Outcome Measures –Tinetti Gait and Balance
MATERIAL AND METHOD
Assessment and Dynamic Gait Index and right and
This was an experimental study performed in 2011- left stride length. All statistical analyses were
2012. The permission to carry out the study was performed using SPSS Version 17.A p-value of 0.05 or
obtained from the ethical committee. The study less was considered statistically significant.
enrolled 10 subjects (6 men, 4 women, mean age-66±7)
with Hoehn &Yahr 16 stage 3 Parkinson’s disease who RESULTS
were on a steady drug regime. Demographic details
of the patients at the baseline are summarized in Table Table 2 compares pre training values with those
1. Five patients with other neurological, measured post 6 weeks of treadmill training. There
cardiovascular, lower limb orthopaedic, psychological was significant change in all the outcome measures.
disorder, poor hearing or vision and those who have Scores on Tinneti gait (P=0.005) and balance (P=0.005),
underwent any replacement or recent cardiac surgeries Dynamic gait index (P=0.005) and Gait speed (P=0.02)
were excluded. Written informed consent was significantly improved. Stride length (left leg, p=0.002
obtained from all patients. All outcome measures were and right leg, P=0.002) also improved significantly post
assessed and the pre training data was recorded. The training.
Tinneti balance and gait assessment 17 and dynamic Table 2: Measures of Pre and Post Treadmill Training
gait index 18 were used to assess balance and gait. The
Measures Pre-treadmill Post treadmill P
Tinneti balance subscore and Dynamic gait index were training training
used to assess static and dynamic balance while Tinetti Tinetti Balance score 8±2.52 13.1±2.18 0.005*
gait subscore score, gait speed and stride length were Tinneti Gait score 5.2±1.93 10.1±2.51 0.005*
used to assess the gait. To measure stride length, DGI 14.4±3.53 19.4±3.37 0.005*
footprint analysis method was used, in which the Gait Speed (in m/s) 0.46±0.155 0.736±0.205 0.002*
patients were made to walk at their comfortable Stride length (in cm) 74.81±18.37 86.09±21.04 0.002*
walking speed with inked feet on 25 inches wide and Right
Left 73.37±19.11 84.99±23.24 0.002*
30 feet white paper sheet. Patients walked on a
motorized treadmill under the close supervision of a * = P value is significant (P<0.05)
physical therapist. The patients walked in all sessions DGI: Dynamic Gait Index
while wearing a safety harness to prevent falls. The
training program consisted of sessions of 30 minutes DISCUSSION
each in which the patient walked for 20 minutes with
two rest intervals, each of 5 minutes duration. Training Postural instability and gait impairments are the
was given for 3 sessions a week, for 6 weeks, treadmill most disabling aspect of Parkinson’s disease. This
speed – 80% of patient’s overground walking speed, study examined the possibility that treadmill training
12
0% incline. Pre training patients overground speed may be used in treatment for balance and gait
was evaluated over a distance of 10 meters. Once a impairments in patients with Parkinson’s disease.
week overground walking speed was re-evaluated and
the treadmill speed was adjusted accordingly. Patients’ Treadmill training showed improvement in both
vital parameters were noted in the beginning and at static and dynamic balance and in gait including speed,
the end of every session. Post 6 weeks the patients were stride length, rhythmicity and postural stability during
again assessed with the outcome measures and post gait was observed. Several hypotheses have been
treatment data was recorded. Pre and post treadmill postulated to explain the improvements of gait over
evaluation was done at same time of the day. the treadmill. The first possible set of explanations is
related to the proprioceptive information provided by
Table 1: Demographic details the treadmill. The treadmill belt displacement gives
Sex (male/female) 6/4 an external proprioceptive cue due to loading of the
Age (yrs) 66±7 limb which enhances the postural control and also
increases step length in patients with Parkinson’s

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 221
disease.18 In Parkinson’s disease, external sensory cues
help to switch from one movement component to next
in a movement sequence. Thus, it bypasses defective
internal pallido-cortical projections.19 Proprioceptive
cues have not been investigated extensively in
Parkinson’s disease, but if they share the same
mechanism of other sensory cues, it is possible that
they may also be involved in the balance and gait
improvement in Parkinson’s disease patients.19 Thus,
while on the treadmill the subjects may use
appropriate sensory inputs such as hip extension and
correct loading of the limbs.20 This proprioceptive cue
may help in overcoming the co-contraction of the
agonist-antagonist muscle seen in Parkinson’s disease
patients, leading to better intersegmental co-
ordination. So, there may be an enhanced motor
control and better force output generation. It may also
help in orderly recruitment of strategies in a distal to
proximal manner contrary to the proximal to distal
strategy seen in Parkinson’s disease patients 21 and it
also leads to better compensatory stepping mechanism
which will prevent the patient from falling. Also
treadmill itself is a moving platform which further
challenges the balance of the patients. 22 Another
explanation could be that the treadmill belt forces
stepping, probably through stretch facilitation of hip
ûexors and ankle plantarûexors at the end of the stance
phase.23 Thus, the treadmill training could rely on the
adequate afferent activation of the central pattern
generator in Parkinson’s disease patients.7,24 As this
stimulus is repetitive, it will lead to better hip-knee
flexion and thus induce a reciprocal pattern, like in
normal gait. The improved stepping pattern which is
induced leads to better foot clearance which will help
the patient to overcome obstacles preventing a fall and
also improving the stride length. The reciprocal pattern
will lead to reduction in double stance duration in gait
.The reduction in double stance duration and increase
in stride length leads to improvement in gait speed.7
Thus, treadmill training may improve the rhythmicity
and speed of gait and balance strategies by providing
an external rhythm that compensates for the defective
internal rhythm.
Also an important observation is that, in the present
study neither partial nor full body weight support has
been used as used in most of the studies stated above.
Only a safety harness has been used in the study. It is
seen that even without body weight support significant
improvement was seen in the balance and gait
impairments in Parkinson’s patient. There is almost
full weight bearing during treadmill training with a
41. Nimisha--219--.pmd 221
safety harness. So it may be hypothesized that as the
body is not suspended the proprioceptive cue would
be more than that provided by body weight support
treadmill training. Also, treadmill training with safety
harness is feasible and less expensive compared to
body weight support treadmill training.
Second, it has been proposed that treadmill training
probably imposes external pace and focuses attention
on gait 25 and reduces gait variability in Parkinson’s
disease. The fixed gait speed reduces the degrees of
freedom improving locomotor rhythmicity and
promoting a more stable walking pattern in patients
with Parkinson’s disease.
Third treadmill training can also work as a form of
task-specific training. Animal models of Parkinson’s
disease have also supported activity-dependent
neuroplasticity after intensive treadmill training as
measured through changes in dopamine handling and
neurotransmission. 26, 27, 28 Treadmill training is
intensive, repetitive, and involves on-going feedback
and may restore the normal motor processing.
This study had few limitations. The long term
effects of treadmill training were not observed to
evaluate the carry over effects of treadmill training.
In conclusion, treadmill training seems to be an
innovative, feasible, safe, task –specific, promising,
patient-directed treatment, which can prove to be an
important adjunct in the treatment of balance and gait
impairments in patients with Parkinson’s disease.
Acknowledgement: The authors are thankful to the
participants of this study without whom this study
would not have been possible.
Conflict of Interest: The authors have no conflict of
interest to report.
Source of Funding: None
Ethical Clearance: The permission to carry out the
study was obtained from the ethical committee.
REFERENCES
1. Mehrholz J, Friis R, Kugler J, Twork S, Storch A,
Pohl M.Treadmill training for patients with
Parkinson’s disease (Review).The Cochrane
Library, 2010, Issue 1, http://
www.thecochranelibrary.com
2. Boonstra TA, van der Kooij H, Munneke M,
Bloem BR. Gait disorders and balance
11/1/2014, 12:17 AM
 222 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
disturbances in Parkinson’s disease: clinical
update and pathophysiology. Curr
Opin Neurol. 2008 Aug;21(4):461-71. doi:
10.1097/WCO.0b013e328305bdaf. Review.
PubMed PMID: 18607208.
3. Carr J, Shepherd R. Neurological Rehabilitation:
Optimizing Motor Performance.1st ed.
Butterworth- Heinmann; 1998.Chapter 13, p.461
4. Umphred D. Neurological Rehabilitation.5th
ed.Mosby Elsevier;2007.Chapter 24, p.785
5. M.Schenkman, T.M.Cutson, M.Kuchibhatla et al,
Exercise to improve spinal ûexibility and function
for people with Parkinson’s disease: a
randomized, controlled trial, Journal of the
American Geriatrics Society, 1998, vol.46, no.10,
pp.1207–1216
6. M.A. Hirsch, T.Toole, C.G. Maitland, and
R.A.Rider, The eûects of balance training and
high- intensity resistance training on persons
with idiopathic Parkinson’s disease, Archives of
Physical Medicine and Rehabilitation, 2003,
vol.84, no.8, pp.1109–1117
7. Pohl M; Rockstroh G; Rückriem S; Mrass G;
Mehrholz J. Immediate effects of speed-
dependent treadmill training on gait parameters
in early Parkinson’s Disease. Archives of Physical
Medicine and Rehabilitation - 01-Dec-2003;
84(12): 1760-6
8. T.C.Rubinstein,N.Giladi,andJ.M.Hausdorû,The
power of cueing to circumvent dopamine deûcits:
a review of physical therapy treatment of gait
disturbances in Parkinson’s disease, Movement
Disorders, 2002,vol.17,no.6,pp.1148–1160
9. S.H.J.Keus, B.R.Bloem, D.Verbaan et al,
Physiotherapy in Parkinson’s disease: utilization
and patient satisfaction, Journal of Neurology,
2004, vol.251, no.6, pp.680–687
10. L.E.Dibble,D.E.Nicholson, B.Shultz, B.A.Mac
Williams, R.L.Marcus,and C.Moncur, Sensory
cueing eûects on maximal speed gait initiation
in persons with Parkinson’s disease and healthy
elders,” Gait and Posture,2004 vol.19, no.3,
pp.215–225
11. Y. Jiang and K.E. Norman, Eûects of visual and
auditory cues on gait initiation in people with
Parkinson’s disease, Clinical Rehabilitation, 2006,
vol.20, no.1, pp.36–45
12. Herman T, Giladi N, Gruendlinger L, Hausdorff
JM. Six weeks of intensive treadmill training
improves gait and quality of life in patients with
Parkinson’s disease: a pilot study. Archives of
Physical Medicine and Rehabilitation, 2007 Sep;
41. Nimisha--219--.pmd 222
88(9):1154-8
13. Miyai I, Fujimoto Y, Ueda Y, Yamamoto H,
Nozaki S, Saito T, Kang J. Long term effect of body
weight supported Treadmill training in
Parkinson’s disease. Archives of Physical
Medicine and Rehabilitation, 2002 Oct; 83:1370-3
14. Frenkel-Toledo S, Giladi N, Peretz C, Herman T,
Gruendlinger L, Hausdorff JM. Treadmill
walking as an external pacemaker to improve gait
rhythm and stability in Parkinson’s disease. Mov
Disord 2005; 20:1109-14
15. Cakit B, Saracoglu M, Genc H, Erdem H, Inan L.
The effects of incremental speed-dependent
training on postural instability and fear of falling
in Parkinson’s disease. Clinical Rehabilitation
2007; 21: 698–705
16. J.Jankovic: Parkinson Disease: Clinical Features
And Diagnosis, J. Neurol. Neurosurg. Psychiatry
2008; 79; 368-376.
17. Kegelmeyer DA, Kloos AD, Thomas KM, Kostyk
SK. Reliability and validity of the Tinetti mobility
test for Individuals With Parkinson Disease, Phys
Ther, 2007; 87:1369-1378
18. Chiu Y, Fritz S, Light Kl, Velozo CA. Use of item
response analysis to investigate measurement
properties and clinical validity of data for the
Dynamic gait index. Phys Ther. 2006; 86:778-787
19. Bello O, Marquez G, Camblor M, Fernandez-Del-
Olmo M, Mechanisms involved in treadmill
walking improvements in Parkinson’s disease,
Gait & Posture 32, (2010), 118–123
20. Cunnington R, Iansek R, Bradshaw JL, Phillips
JG. Movement related potentials in Parkinson’s
disease: Presence and predictability of temporal
and spatial cues. Brain.1995; 118:935–950
21. Barbeau H, Locomotor training in neuro
rehabilitation: emerging rehabilitation concepts,
Neuro rehabil Neural Repair 2003; 17:3–11
19. Ann- Shumway –Cook, Marjorie Wollacott.
Motor Control, 3rd edition Chapter 10 Pd 237-
246,250-251,255-256,379,385-387
22. Mansfield A, Peters A, Liu B, Maki B. A
perturbation-based balance training program for
older adults: study protocol for a randomised
controlled trial, BMC Geriatrics 2007, 7:12.
23. Shepherd R, Carr J, Treadmill walking in neuro
rehabilitation. Neuro rehabil Neural Repair 1999;
13:171–173
24. Lepers R, Breniere Y, Maton B. Changes to the
gait initiation programme following a running
exercise in human subjects. Neurosci Lett.1999;
260:69–73
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 223
25. VanHedel HJ, Waldvogel D, Dietz V. Learning a
high-precision locomotor task in patients with
Parkinson’s disease. Mov Disord 2006; 21:406-11
26. Fisher BE, Petzinger GM, Nixon K, et al. Exercise-
induced behavioral recovery and neuroplasticity
in the 1-methyl-4-phenyl-1,2,3, 6-
tetrahydropyridine-lesioned mouse basal
ganglia. J Neurosci Res. 2004; 77:378–90
27. Fisher B, Wu AD, Salem GJ, Song JS, Lin CH, Yip
J, Cen S, Gordon J, Jakowec M, Petzinger G. The
41. Nimisha--219--.pmd 223
Effect of Exercise Training in Improving Motor
Performance and Corticomotor Excitability in
Persons With Early Parkinson’s Disease. Arch
Phys Med Rehabil. 2008 July; 89(7): 1221–1229
28. Petzinger GM, Walsh JP, Akopian G, et al, Effects
of treadmill exercise on dopaminergic
transmission in the 1-methyl-4-phenyl-1,2,3,6-
tetrahydropyridine-lesioned mouse model of
basal ganglia injury, J Neurosci 2007;27:5291–300
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 DOI Number: 10.5958/0973-5674.2014.00344.X
224 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

A Study to Compare efficacy of Taping Technique Versus

Calcaneum Glide Mobilization for the Treatment of
Planter Fasciitis

Mayur Solanki
Master of Physiotherapy (Ortho), Lecturer, Ahmadabad Physiotherapy College, Bopal-Ghuma,Ahmedabad

ABSTRACT

Introduction: Planter fasciitis is a common foot disorder involving inflammation of planter fascia.
The goal of individualized program requires critical analysis of potential benefits of taping technique
versus calcaneal glides. Taping helps to increase joint stability by preventing the motion and providing
proprioceptive signals to joint. Calcaneal glides are given to improve calcaneum mobility in attempt
to compensate for paucity of planter fascia.

Aim of Study: To study the effects of taping technique and calcaneal glide mobilization for the
treatment of Planter Fasciitis

Methodology: A Clinical trial consisted of 30 patients, diagnosed with Planter Fasciitis , as per the
Inclusion & Exclusion Criteria were recruited from orthopedic Out-patient Department to
Physiotherapy Department, Civil Hospital, Ahmedabad. Patients were divided into two, one group
was given Mac Donald taping and other group calcaneal glide mobilization. The functional outcome
were pain measured on visual analogue scale (VAS) & Function by Ankle & Foot Function
Index(FFI)for objective assessment taken on the 1st day & after 15 days.

Results: There is significant difference as per Student t -test between the Mac Donald Taping and
Calcaneum glide mobilization. Taping produces greater comfort and better functional outcome in
patients with Planter Fasciitis as compared to gliding

Discussion: Planter fascia, because of its non-elastic nature can begin to separate from calcaneum
where excessive loads are applied. Calcaneum glide helps to improve mobility of calcaneum and
corrects pathomechanics. Taping increases mechanical joint stability ,improve proprioceptions, thus
helps in regulation of the tone of muscles.

Conclusion: Taping techniques are significantly effective than calcaneal glide mobilizations for
improving pain and functional outcomes in Planter Fasciitis.

Keywords: VAS,FFI,Planter Fasciitis

INTRODUCTION resolve. Planter fasciitis represent the fourth most

Planter fascia is a thick fibrous band that runs the
length of the sole of the foot. The planter fascia helps
to maintain complex arch system of the foot and plays
role in one’s balance and the various phases of gait.
Injury to the tissue ,called planter fasciitis is one of the
most disabling running injuries and also difficult to
common injury to the lower limb and represent 8-10%
of all presenting injuries to the sports clinic.1
Planter fasciitis is an inflammation of the planter
fascia-which is band of dense fibrous tissue located
along the bottom of the foot extending from heel bone
to the ball of the foot. It is most important structure in

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 225

maintaining the longitudinal arch of the foot. Unlike MATERIALS AND METHOD
tendon, planter fascia is not elastic and therefore cannot
stretch when forces on the foot to flatten the arch • Study Design: Clinical Trial Study
become too great. Because of its inelasticity, the planter • Study Setting: This study was conducted in
fascia begins to separate from its weakest point of Orthopedic Out-patient Department,
attachment, often the heel bone, resulting in pain and
inflammation that is distinct and treatable.2 Civil Hospital, Ahmadabad to
B1ward,Physiotherapy Department, Civil
The four recognized types of planter fasciitis are Hospital, Ahmedabad
systemic, traumatic, degenerative and mechanical.
systemic planter fasciitis is often seen in collagen tissue • Sample Selection: 30 patients. Group A: 15 patients.
disorders, like rheumatoid arthritis. The traumatic type
Group B: 15 patients.
of planter fasciitis is usually a partial tear/complete
rupture of planter apponeurosis secondary to the • Study Duration: total 15 days, 6 days per week
application of high forces such as in athlete activity.
The degenerative type of planter fasciitis is usually the Inclusion Criteria
result of continual trauma over many years.
1. Age greater than 25 years, both sexes
Mechanical type of planter fasciitis is caused by
excessive pronation ,results in micro tears of the planter 2. Symptoms greater than 3 months duration
fascia.3
3. Patients with specific diagnosis of planter fasciitis
Planter fascia among its three portions-medial, having pain around heel without calcaneal spur
lateral and lateral bands-the largest is the central
portion. The central portion of the fascia originates Exclusion Criteria
from the medial process of the calcaneal tuberocity
1. Planter fasciitis with calcaneal spur
superficial to the origin of the flexor digitorum brevis,
quadrates plantae and abductor hallucis muscle. The 2. Previous surgery for planter fasciitis
fascia extends through medial longitudinal arch into
individual bundle and inserts into each proximal 3. History of documented autoimmune or systemic
phalanx. During the third phase of the ground contact, inflammatory disorders
called toe-off, the planter fascia is tractioned tight over
4. Coagulation disorders
the planter surface of the base of the toes. Due to
limited elastic qualities of the planter fascia, the arch 5. Peripheral vascular disorders
is slightly raised, creating the rigid lever to apply the
results of the forceful gastronomies contraction. This 6. Diabetes
is called as “Windlass Effect”.4
7. Calcaneal stress fracture
Non-operative treatments for planter fasciitis vary
8. Infection
widely and include shoe modifications, use of
prefabricated and custom inserts, stretching exercises, 9. Pregnancy
physical therapy, non steroidal anti-inflammatory
medications, cortisone injections, night splints, 10. Peripheral neuropathies
application of casts5-9
MATERIALS USED IN THE STUDY
The basic idea of the tape use in sports and
rehabilitation of planter fascist is to support weakened 1. Consent Form.
part of the body by means of preventing motion in the
2. Assessment Form.
body part that can cause further insult to the weakened
body part. Taping a joint increases mechanical joint 3. Examination Table
stability directly but also increases proprioceptive
signals. 4. Scissors

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 226 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

5. Water

6. Cotton

7. Adhesive tape (Dynaplast)

8. Towel

Outcome Measures

1. Visual analogue scale for subjective

assessment(VAS)12

2. Ankle and Foot Function Index for objective

assessment(FFI)13

METHOD Fig. 1. MacDonald Tapping Technique

All the subjects were informed in detail about the

type and nature of the study. The subjects were divided
in to two groups; Group A and Group B, 15 patients
in each group. All the subjects were randomly selected
and assigned in to each group.

Group A:

The subjects in Group A were given MacDonald

Taping.

Group B:

The subjects in Group B were given Calcaneal

glides
Fig. 2. Calcaneal Glide Mobilization
Mac Donald Taping:10

Position of patient: Prone with both the foot in
neutral position over the end of the couch.
Application
1. With the ankle placed in a slightly planter flexed
the adhesive tape is applied at the posterior aspect
of the heel and will be pulled firmly towards the
metatarsal pads
2. Adhesive ankle strips from medial aspect of the
first metatarsal, around heel, to lateral aspect of
the 5th metatarsal head is applied
3. A stretch tape around the mid foot area will be
applied. circular strips beginning from dorsal
aspect to the medial portion of the foot. crossing
the tape to finish on the lateral dorsum of the foot.
Calcaneal Glide Mobilization12
Anterior: posterior calcaneal glide
Position of patient: prone with the foot extended out
of the plinth
Method: with the patient lying prone, foot extended
out of the plinth the therapist will stabilize the foot
with one hand & by using the web space of other hand
on the posterior calcaneum, posterior to anterior force
will be applied to produce glide.
Medial-Lateral Calcaneal Glide
Position of patient: supine, with the hip slightly
abducted, knee slightly flexed and placed on the lower
third of tibia of the other leg.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 227
Method: Therapist will stand on the side of the
plinth. one hand will stabilize the foot. The other hand
on the medial calcaneum. Using the palm of the hand,
pressure is applied from medial to lateral direction to
produce the glide
RESULTS
Statistical Analysis: As per the objective of the study
the data was collected for Group A and Group B to
compare efficacy on planter fasciitis.
- VAS- Visual Analogue Score
- FFI- Foot Function Index
Paired “t” Test was applied to Group A and in
Group B for with-in group analysis and it is as follows:
In Group A, results showed significant improvement
on VAS score
(t value27.15 =at p<0.05)
In Group A, results showed significant
improvement on FFI score(t value42.50 =at p<0.05).In
Group B, results showed significant improvement on
VAS score(t value=20.57 at p<0.05). In Group B, results
showed significant improvement on FFI score(t
value=18.61 at p<0.05)
Graph No-1
Un-paired “t” test was applied for between-group
comparison of Group A and Group B, and it is as
follows: For VAS t value=1.821 at p<0.05, On
comparing Group A and Group B for post-treatment
VAS score, results showed significant difference in
improvement in terms of VAS. For FFI t
value=1.830,p<0.05. On comparing Group A and
Group B for post-treatment FFI score, results showed
significant difference in improvement in terms of FFI.
42. Mayur Solanki --224--.pmd 227
From the above findings, which suggest that there
is statistically significant difference between the groups
A and B. Based on the un-paired “t” values calculated
for the improvements between the groups it can be
seen that Group A(taping) patients have undergone
greater improvement in both parameters at
p<0.05.Based on this outcome, it can be said that taping
produces greater comfort and better functional
outcome in patients with planter fasciitis as compared
to gliding.
Graph No-2
DISCUSSION
In a series of 15 subjects with planter fasciitis in
Group A, an improvement in physical function was
observed with Mac Donald taping. There was also a
significant improvement in pain regarding as per the
VAS score on an average in all the subjects in Group
A.
In a series of 15 subjects with planter fasciitis in
Group B, there is significant improvement in physical
function with calcaneal glide mobilization. There was
significant improvement in pain grading as per the
VAS score.
Both treatments groups obtained successful
outcomes, as measured by considerable changes in
VAS , FFI scores.
Planter fascia , because of its non elastic nature can
begin to separate from the calcaneum whenever
excessive loads are applied. Based on this
pathomechanical consideration calcaneal glides are
given to improve the modality of calcaneum in an
attempt to compensate for paucity of movement of
planter fascia.
Several studies have been done to analyze the
effects of mobilization for injuries of ankle. Collins
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 228 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
N,Teys P & Vicenzino B (2004) in their study utilized
mulligan mobilization & found that it was effective in
the treatment of ankle injuries with p= 0.002. Denegar
CR, Hertel J & Fonseca J (2002) have assessed tarsal
glides in patients with ankle injuries & found that it
was reduced.
In this study patients were administered medial –
lateral glides & anterior – posterior glides and they
showed significant improvements from their
pretreatment status (p =0.01).
Taping seems to give more support to any joint
when applied appropriately. In a study on taping by
Arnold BL & Docherty CL (2004) it was noted that
taping can be used as a relatively inexpensive & easy
treatment alternative both for preventive injury &
reducing recurrences in athlete. Wilkerson GB (1991),
Verbrugge JD (1996) showed that taping could be used
specifically to stabilize ankle.
It has been shown that taping can be used as
stabilizer of joint helpful in subjects in whom taping
was done specially to ankle region. This was supported
by two separate studies by Leanderson J & associates
(1996) & Robins S and colleagues (1995).
In this study, Taping was used to patients who were
considered to be obese & cause of planter fasciitis is
because of overuse. These patients improved much
better with stabilizing effects of taping (p=0.05) than
patients for whom gliding was given.
Limitations
1. The study is primarily limited in its finding
because only one group of patients having planter
fasciitis were evaluated & treated. The effects of
these modalities on other causes of planter fasciitis
can not be generalized based on these outcomes.
2. There were no standardization of age group &
duration of condition in subjects selected for the
study & hence the effects of application of these
modalities should be more research in to.
3. The study consisted of only a small quantity of
subjects; which should be revised to a large
number of subjects and for a longer duration of
period.
42. Mayur Solanki --224--.pmd 228
CONCLUSION
Our study suggests that There are significant
improvements in patients with planter fasciitis when
effects of taping & gliding are compared. But taping
produces greater comfort & better functional outcome
as compare to gliding.
Acknowledgement: I would like to thank Dr Chandni
Shah ( senior Physiotherapist), Principal of
Government Physiotherapy College, my teachers and
I am grateful to all my patients for their kind
cooperation and willingness to participate in this
study, without whom this study would not have
materialized.
Conflict of Interest: The authors perceive conflict of
interest in this study about no standardization of age
group & duration of condition in the subjects selected
for this study.
Ethical Clearance: Ethical clearance was obtained from
Ethical Committee of Government Physiotherapy
College, Civil Hospital, Ahmadabad prior to the study.
Source of Support: Self
REFERRENCES
1. Ambrosuis.H and M.P.Kondracki. Planter
Fasciitis: European journal of chiropractic 40:
29-40
2. Huang CK et al: Biomechanical evaluation of
longitudinal arch stability. Foot and ankle
International, 1993, 14(6): 353-357
3. Kwong PK et al: Planter fasciitis. Clinical sports
med 1988,7:119
4. Noyes FE, Demaion, Mangne RE : orthopedics ;
1993
5. Gill LH, Kiebzak GM. Outcome of nonsurgical
treatment of planter fasciitis. Foot and ankle
international. 1996; 17:527-32.
6. Martin RL, Irrgang JJ, Conti SF. Outcome study
of subjects with insertional planter fasciitis. Foot
and ankle international. 1998. 19:803-11
7. Powel M, Post WR, Keener J, Wearden S. Effective
treatment of chronic planter fasciitis with
dorsiflexion night splint: A crossover prospective
randomized outcome study. Foot and ankle
international; 1998. 19:10-8.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 229
8. Wolgin M, Cook C, Graham C, Mauldin D,
conservative treatment of planter heel pain: long
term follow- up. Foot and ankle international;
1994; 15:97-102.
9. Pfeffer G, Bacchetti P, Deland J, Lewis A,
Anderson R, Davis W, Ross S, Smith R, Herrick
R, Comparison of custom and prefabricated
orthosis in the initial treatment of proximal
planter fasciitis. Foot and ankle international;
1999, 20:214-21.
42. Mayur Solanki --224--.pmd 229
10. Rose MacDonald. Taping techniques- principles
and practice.1994.
11. Steven I Subotnick; Sports medicine of lower
extremity; Churchill Livingstone; edition 2; 1999.
12. David J Magee. Orthopaedic Physical
Assessment; Saunders: Edition 4; 2002
13. Budiman-mak, E., Conrad. K.J. , Roach. The Foot
Function Index: a measure of foot pain and
disability. Journal of clinical Epidemiology, 44,
561-570. 1991.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
230 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Comparison of SIT and Reach Test, Back Saver SIT and

Reach Test and Chair SIT and Reach Test for
Measurement of Hamstring Flexibility in Female
Graduate and Undergraduate Physiotherapy Students

Garima Wadhwa1, Chaya Garg2

1
BPT student, Banarsidas Chandiwala Institute of Physiotherapy, 2Head and Associate Professor, Department of
Physiotherapy, Galgotias University, Gautam Buddh Nagar

ABSTRACT

Background: Sit and reach and its modifications and passive straight leg raise test are most commonly
used in various physical and health related fitness test programs.

Method: 100 healthy female students between the age group of 18-25 years were made to perform
traditional sit and reach test, chair sit and reach, back saver sit and reach and passive straight leg
raise test on same day.

Results and Conclusion: This study shows that the traditional sit and reach( r=0.61), the chair sit and
reach test(r=0.58) and the back saver sit and reach test(r=0.54) are moderately related to passive
straight leg raise test and hence are moderately effective in measuring hamstring flexibility in female
graduate and undergraduate physiotherapy students.

Keywords: Sit and Reach Test, Back Saver Sit and Reach Test, Chair Sit and Reach Test, Passive Straight Leg
Raise Test

INTRODUCTION for Health, Physical education, Recreation and Dance,

Flexibility has been defined as the ability of the
muscle to lengthen and allow one joint or more than
one joint in series to move through a range of motion.
Flexibility is related to the extensibility of the
musculotendenious unit that cross a joint based on
their ability to relax or deform and yield to a stretch
force1. In the human body, flexibility of the muscle is
important to maintain coordinated and rhythmic
movements in precision. 2
Loss of flexibility is defined as decrease in the ability
of muscle to deform. Lack of hamstring flexibility has
been associated with low back pain, postural deviation,
gait limitation, risk of falling and susceptibility to
musculoskeletal injuries.3
Due to importance of hamstring flexibility, its
measurement is included in most of the fitness test
programs including AAHPERD (American Alliance
1988), Prudential FITNESS- GRAM (Cooper institute
for aerobics research, 1994) etc.4, 5
The most common method of assessing hamstring
flexibility in the field setting has been the floor SIT
AND REACH TEST.
The Sit and Reach Test: was first described by
WELLS AND DILLON (1952).
The test involves the whole body motion, it is
simple, quick and easy to administer. However a
special constructed box is required and the score and
validity may be influenced by many anthropometric
and joint flexibility factors e.g. hamstring muscle
length6 .Some authors have questioned the validity of
sit and reach test, suggesting that there is an advantage
for an individual with long trunk, long arm and short
leg.7

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 231
There are several modifications of sit and reach test.
Each possesses unique advantage and disadvantage
as compared to other protocol. 8
The Back Saver Sit and Reach Test: is modified one
leg version of sit and reach test. It is based on stretching
one leg at a time as it is intended to be safer on spine
by restricting intervertebral flexion. It can also be used
to determine symmetry in hamstring flexibility. 9, 10
The Chair Sit and Reach Test: is a modification of
back saver sit and reach test. It adopts the notion of
single leg stretch which eliminates the excessive
posterior disc compression on vertebra and is also
beneficial for those who found it difficult to get down
and up from floor (e.g. obese). 3, 11
The number of studies on validity and reliability
of sit and reach test protocol have been reported and a
number have been proposed. Controversy still exists
as to whether the sit and reach test is a measure of
flexibility in both the hamstring and the low back
muscles. However, the Sit and reach , the back saver
sit and reach and the chair sit and reach are generally
considered acceptable field test measures of hamstring
flexibility for most age groups , there are no studies of
which is best technique. Therefore, the purpose of this
study was to relate the three tests) as a measure of
hamstring flexibility.
METHODOLOGY
100 Normal healthy female subjects with age 18-25
years were included in the study. The group had mean
Age of 21.25 ± 1.76 years, mean Height of 159.98 ±
6.77cms and mean Weight of 54.66 ± 9.96 Kgs. Subjects
were excluded if they had any neurological and
musculoskeletal disorder of spine and lower limb, any
hip, knee, ankle joint pathology, any history of surgery,
any metal implant in lower limb, any unhealed scar or
wound, any history of low back pain.
Potential subjects were apprised of the procedure
and its potential risks and benefits and evaluation was
done. Subjects who gave their informed consent were
included in the study. All subjects performed all the
flexibility tests on the same day with the rest interval
of 5 min between the tests. The tests included the Chair
Sit and Reach test(CSR), the Sit and Reach test (SR),
the Back Saver Sit and Reach test (BSSR), the Passive
Straight Leg Raise test (PSLR). All subjects underwent
a familiarization session on the day prior to testing.
They performed warm up followed by the flexibility
43. Chaya Garg--230--.pmd 231
tests in sequence: CSR, SR, BSSR, and the goniometric
measurement of hamstring flexibility that is the PSLR.
Flexibility tests
All participants performed three types of flexibility
tests followed by PSLR test. Each type was performed
to the terminal range, defined as a point where subject
felt a mild discomfort or tightness in the back of thigh.
Participants were reminded to exhale as they were
bending forward to avoid bouncing or rapid forceful
movement and never to stretch to the point of pain.
Chair Sit and Reach flexibility test
The participants sat on the chair which was placed
against the wall to make it stable and instructed to slide
forward in chair until they reach front edge of chair.
The participants were then asked to extend one leg in
front of their hip with heel on floor and dorsiflex to 90
degrees. The contralateral non - testing leg was flexed
at knee such that the sole of the leg resting on the floor.
Participants then reach down to extended leg in an
attempt to touch the toes, keeping spine as straight as
possible and head in normal alignment with spine till
they felt mild discomfort or tightness in back of thigh.
The position was maintained for 5 sec while the
distance reached was recorded using an 18 inch ruler
positioned parallel to the lower leg. The middle toe
represents “zero”, reach short of toe recorded “minus”
and beyond recorded “plus”. Then the rested leg was
tested in same way.
Traditional Sit and Reach flexibility test
The participants sat on the floor with legs out
straight ahead. Feet (shoes off) were placed flat against
box, shoulder width apart. Both the knees were held
flat against the floor by the tester. With hands on top
of each other and palm facing down, participant reach
forward along measuring scale on sit and reach box
till they felt mild discomfort or tightness in back of
thigh. This position was maintained for 5 sec while
the distance in inches was recorded.
Back Saver Sit and Reach flexibility test
Participants sat on the floor with one leg fully
extended so as the sole of feet as flat against box and
knee held flat against the floor. The contralateral non
- testing leg was kept to side of straight knee so that
sole as flat against floor. With hands on top of each
other and palm facing down, participant reach forward
along measuring scale on sit and reach box till they
felt mild discomfort or tightness in back of thigh. This
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 232 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

position is maintained for 5 sec while the distance in
inches was recorded. Then the rested leg was tested in
same way.
Passive Straight Leg Raise test
Participants lied in supine position on plinth. The
contralateral or non – testing leg was kept extended
by tester. During testing participants were told not to
lift upper body and arms. Marking was made to
specific bony prominence (greater trochanter of femur)
where fulcrum of universal goniometer was placed
with stationary arm positioned in lined with trunk and
movable arm positioned in lined with femur. With
knee extended the examiner then moved leg passively
into hip flexion till participant felt mild discomfort or
tightness in back of thigh. The angle in degrees of
motion was recorded followed by testing the rested
leg.
DATA ANALYSIS
The Pearson correlation coefficient was used to find
the correlation between the goniometric measurement
and chair sit and reach test, traditional sit and reach
test and back saver sit and reach test.
RESULT
A positive correlation was found between sit and
reach test and passive straight leg raise, back saver sit
and reach test and passive straight leg raise and chair
sit and reach test and passive straight leg raise. (as
summarized in table 4.2)
Analysis revealed that:
• The traditional sit and reach test is moderately
related to passive straight leg raise (r=0.61) in
female graduate and undergraduate
physiotherapy students.
• The chair sit and reach test is moderately related
to passive straight leg raise (r=0.58) in female
graduate and undergraduate physiotherapy
students
• The back saver sit and reach test is moderately
related to straight leg raise (r=0.54) in female
graduate and undergraduate physiotherapy
students
• Sit and reach test is better correlated to passive
straight leg raise as compared to back saver sit and
reach test and chair sit and reach test .

Flexibility scores of participants found from chair Table 1 Flexibility scores of participants
sit and reach test, traditional sit and reach test, back Variable Mean ±Standard deviation
saver sit and reach test and passive straight leg raise
SR SCORE B/L 7.2±3.09
test are shown in table 4.1.
CSR SCORE RIGHT -0.7±3.62
The correlation between hamstring flexibility LEFT -0.9±3.61
values for right and left leg was found to be quite high, BSSR SCORE RIGHT 7.3±2.62
0.90 for passive straight leg raise, 0.97 for chair sit and LEFT 7.1±2.57
reach test and 0.96 for back saver sit and reach test. PSLR SCORE RIGHT 71.7±13.5
Therefore only values of right leg for all the flexibility LEFT 71.0±13.07
tests were used for statistical analysis.

Table 2 Pearson correlation coefficient of traditional sit and reach test, back saver sit and reach test and chair sit
and reach test with passive straight leg raise.

SR CSR (RT) CSR (LT) BSSR(RT) BSSR(LT) PSLR(RT) PSLR(LT)

SR 0.76 0.75 0.89 0.87 0.61 0.52
CSR (RT) 0.97 0.74 0.73 0.58 0.53
CSR (LT) 0.72 0.71 0.56 0.51
BSSR(RT) 0.96 0.54 0.46
BSSR(LT) 0.56 0.49
PSLR(RT) 0.90

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 233
DISCUSSION
The study shows that the traditional sit and reach
test, the back saver sit and reach and the chair sit and
reach were moderately effective in measuring
hamstring flexibility in female graduate and
undergraduate physiotherapy students. Similar result
was shown as our study by Jackson and Baker12.
According to their study the traditional sit and reach
test yield moderate validity for hamstring flexibility
and poor validity for low back flexibility in girls of 13
– 15 years.
However, in our study the sit and reach test, the
back saver sit and reach test and the chair sit and reach
test failed to achieve high correlation with passive
straight leg raise, though some of the previous studies
by G.Baltaci and S. Gerceka 11 .Ayala F, Sainz D
Baranda13 reported a high correlation of sit and reach
and back saver sit and reach with passive straight leg
raise. Study by G.Baltaci and S. Gercekar, revealed
that the sit and reach and back saver sit and reach were
highly related to hamstring flexibility. In contrast,
chair sit and reach test was not related to hamstring
flexibility. The study by Ayala F, Sainz D Baranda
showed high correlation of sit and reach test, toe touch
test and back saver sit and reach test with passive
straight leg raise in adolescence.
Since our study is limited to young female subjects,
there are various studies that showed the comparison
of sit and reach test and its modifications in men and
women like recent study by Miller CM14 revealed that
the validity of sit and reach test for hamstring flexibility
was found to be moderate in women and low in men.
CONCLUSION
This study showed that the traditional sit and reach,
the back saver sit and reach test and the chair sit and
reach test are moderately effective in measuring
hamstring flexibility in female graduate and
undergraduate physiotherapy students.
Acknowledgments: Authors are thankful to all the
participants and the collegues for extending their
support.
Conflict of Interest: None
Source of Funding: Self funded
43. Chaya Garg--230--.pmd 233
Ethical Clearance: From the Ethical Committee of the
Institute
REFERENCES
1. Carolyn kisner and lynn allen Colby , foundations
and technique therapeutic exercise, 5 th
edition,chapter 4 , stretching for impaired
mobility,pg66
2. David O Draper, Lisa Miner. Carry over effects
of diathermy and stretching in developing
hamstring flexibility. J athl train.2001:33:141-147.
3. Jones CJ, Rikli RE, Max J. The reliability and
validity of a chair sit-and-reach test as a measure
of hamstring flexibility in older adults. Res Exerc
Sport 1998; 69:338–43.
4. A.A.H.P.E.R.D. (1984). Technical manual for the
health related physical fitness test.
Washington,DC: Author.
5. Cooper Institute for Aerobics Research. The
Prudential FITNESSGRAM test administration
manual. Dallas, TX: Cooper Institute for Aerobics
Research, 1994.
6. Taher Afsharnezhad, Navi Nategi and Morteza
Razaee Soufi. Normalizing scores of back saver
sit and reach test in middle school boys.
International Journal of Sports Science and
Engineering.2010: vol 4(2):99-105.
7. Hoeger WW, Hopkins DR. A comparison of the
sit and reach and the modified sit and reach in
the measurement of flexibility in women. Res Q
Exerc Sport 1992;63:191–5.
8. Hui SS, Yuen PY. Validity of the modified back-
saver sit-and-reach test: a Comparison with other
protocols. Med Sci Sports Exerc. 2000; 32(9):
1655-9.
9. Cailliet, R (1988). Low back pain syndrome.
Philadelphia: F. A.Davis.
10. Castro Pinero, Chillon P, Ortega FB. Criterion
related validity of sit and reach test and modified
sit and reach test for estimating hamstring
flexibility in children an adolescence. Int J Sports
Med 2009 Sep; 30(9):658-62.
11. Baltaci, G., Tunay, Besler & Gerceker, S.
Comparison of three different sit-and-reach tests
for measurement of hamstring flexibility in
female University students. British Journal of
Sports Medicine. 2002: 37: 59-61
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 234 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

12. Jackson AW, Morrow JR, Brill PA, et al. The
relationship of the sit and reach test to criterion
measures of hamstring and back flexibility in
young females. ResQ Exerc Sport 1986; 57:183–6.
13. Ayala F, Sainz de Baranda P, De Ste Croix M.
Reproducibility and criterion-related validity of
the sit and reach test and toe touch test for
estimating hamstring flexibility in recreationally
active young adults. Phys Ther Sport. 2012 Nov;
13(4):219-26..
14. Miler CM. Reliability of passive straight leg raise
and validity of sit and reach test among adults.
Research quarterly for exercise. 2011:82(4):617-
623.

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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 235

Prevalence of Post Polio Syndrome in Gujarat and the

Correlation of Pain and Fatigue with Functioning in
Subjects with Post Polio Syndrome

Megha Sandeep Sheth1, Srishti Sanat Sharma2, Rajesh Jadav2, Bhaskar Ghoghari2, Neeta Jayprakash Vyas3
1
Lecturer, 2Post graduate Student, 3Principal, SBB College of Physiotherapy, VS General Hospital Campus, Ellisbridge,
Ahmedabad

ABSTRACT

Background: Post-polio syndrome (PPS) refers to a clinical disorder affecting polio survivors with
sequel years after the initial polio attack. They report new musculoskeletal symptoms like fatigue,
pain and muscle weakness. The aim of this study was to determine prevalence of PPS in subjects
with poliomyelitis in Gujarat state and to co-relate pain and fatigue with function in these subjects.

Method: 100 subjects with polio were recruited through tertiary care hospitals in this cross sectional
survey. Those fulfilling the diagnostic criteria of PPS (Halstead 1991) were included who filled a self
administered questionnaire. A convenience sample of 50 subjects having pain was analyzed for pain
and fatigue intensity measure using Numerical Rating Scale. Physical and psychological functioning
were examined using Patient Reported Outcomes Measurement Information System and Patient
Health Questionnaire-9 questionnaires respectively.

Findings: Muscle weakness was reported by 66 and pain by 78 subjects. 70 subjects complained of
joint pain and fatigue was present in 44 subjects. 68 polio survivors complained of difficulty in walking
and 22 subjects had no complaints in activities of daily living. Pearson's test for co-relation was
applied for 50 subjects with pain. A moderate co-relation between pain and physical functioning (r=-
0.794; p=0.01) and between pain and psychological function(r=0.564; p=0.01) was found. Fatigue had
a weak co-relation with physical (r=-0.135, p=0.351) and psychological functioning (r= 0.072; p=0.620)

Conclusion: The prevalence of PPS among polio survivors can be estimated to be 66% in Gujarat,
commonest symptoms being difficulty in walking, joint and muscle pain and muscle weakness and
fatigue. Pain affects the physical and psychological function of subjects with PPS whereas fatigue
did not.

Keywords: Fatigue, Pain, Polio Survivors, Physical Function, Psychological Function

INTRODUCTION The existence of PPS has been questioned, but the

In the past few years, many polio survivors have
experienced late-onset neuromuscular symptoms and
decreased functional abilities1. After many years of
stable functioning, these patients report new
musculoskeletal symptoms like fatigue, pain, new and
unusual muscular deficits, in healthy muscles as well
as deficient muscles initially affected by the poliovirus.
These symptoms have been termed Post Poliomyelitis
Syndrome (PPS) 2.
late effect of poliomyelitis, or PPS, is generally accepted
as a defined clinical entity. The term post-polio
syndrome was introduced by Halstead in 1985 to cover
problems possibly or indirectly related to the long-term
disability occurring many years after the acute
episode3.
Interest in PPS has increased over the past two to
three decades worldwide, with research varying in
focus from molecular to clinical aspects, and health-

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 236 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
related quality of life. The prevalence of PPS has been
reported to be between 20% and 85% in people who
have had poliomyelitis. 4 India has been considered
one of the toughest places in the world to eradicate
polio. Considering the large number of polio survivors
in our country, it is important to determine the number
of polio survivors suffering from PPS.
Looking at the prevalence of pain and fatigue in
polio survivors, it becomes important to identify the
problems faced by PPS subjects from a rehabilitative
perspective. Measures of pain and fatigue have been
shown to be associated with dysfunction in PPS
population. The purpose of the current study was to
determine prevalence of PPS in subjects with
poliomyelitis in Gujarat state and to find the correlation
between pain and fatigue intensity; using Numeric
Rating Scale with physical and psychological
functioning using PROMIS and PHQ-9 questionnaires
respectively.
METHOD
A cross sectional survey was conducted amongst
polio survivors in the community of Gujarat. Subjects
were recruited through various tertiary care hospitals.
PPS is an exclusion diagnosis. Those fulfilling the
diagnostic criteria of PPS3 as below were included.
1. Confirmed history of polio.
2. Partial or fairly complete neurological and
functional recovery after the acute episode.
3. Period of at least 15 years with neurological and
functional stability.
4. Two or more of the following health problems
occurring after the stable period: extensive fatigue,
muscle and/or joint pain, new weakness in
muscles previously affected or unaffected, new
muscle atrophy, functional loss, cold intolerance.
5. No other medical explanation found.
Halstead revised these criteria in 1991 and added
gradual or abrupt onset of new neurogenic weakness
as a necessary criterion for PPS, with or without other
co-existing symptoms5.
Those having medical, orthopedic and neurological
conditions that may be causing the new health
problems, subjects having cognitive impairments and
44. Megha seth--235--.pmd 236
those unwilling to participate were excluded. All
subjects provided informed consent for participation
in the study.
A self administered questionnaire, concerning the
demographics, paralysis, new symptoms, and
limitations in daily living, in local language with close
ended questions was filled by 100 subjects with history
of poliomyelitis. Data of a convenience sample of 50
subjects having pain was then analyzed for pain and
fatigue intensity measure using Numerical Rating
Scale (NRS).6 Physical and psychological functioning
were examined using Patient Reported Outcomes
Measurement Information System (PROMIS) and
Patient Health Questionnaire-9(PHQ-9) questionnaires
respectively7.
FINDINGS
Data of 100 polio survivors was analyzed using tally
marking that gave a brief idea of prevalence of post-
polio syndrome. 80 males and 20 females participated
in the study. The age group of subjects was between
20 and 70 years.
Table 1 shows the prevalence of new symptoms.
86 subjects complained of new symptoms, whereas 14
subjects did not have any new symptoms. Of these
66% subjects had a complaint of new weakness in
affected or previously unaffected muscles. 47 subjects
had new weakness in affected muscles and 26 had
weakness in unaffected muscles. Muscle pain was
reported by 78 polio survivors and 70 polio survivors
complained of joint pain. 44 survivors complained of
fatigue. 68 polio survivors complained of difficulty in
walking. Difficulty in bathing, toileting, grooming and
dressing was reported by 53, 50, 36 and 32 patients
respectively while only 22 subjects had no complaints
regarding activities of daily living (ADL).
Table 1: Prevalence of PPS symptoms
Common symptoms(n=100) Number (%)
Muscle pain 78
ADL problem 78
Joint pain 70
Fatigue 44
Weakness affected muscles 47
Weakness unaffected muscles 26
Cold intolerance 23
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 237

Table 2: Pain and Fatigue scores

Variable Mean +SD

Age(years), n=50 32.58+7.65
P-NRS 6.82 +1.48
F-NRS 6.54 +1.34
PROMIS 19.99 +2.13
PHQ-9 24.10 +2.39

Pain and fatigue scores of a sample of 50 subjects

with pain were then co-related with their functioning
using Pearson’s test of co-relation, as shown in Table
2. Statistical analysis was done using SPSS 16.0 for co-
relation analysis. Variables were evaluated to see if
they were normally distributed using one sample
Kolmogorov- Smirnov test. Pain intensity had a strong
linear co-relation with physical functioning (r=-0.794;
p=0.01) which was statistically significant. Pain had a Fig 2. Co-relation of Pain NRS with PHQ9
moderate linear co-relation with psychological
functioning (r=0.564, p=0.01). Fatigue intensity had a
weak linear co-relation with physical functioning (r=-
0.135, p=0.351) and psychological functioning
(r=0.072, p=0.620) which was statistically insignificant.

Figures 1-4 show the graphs of co-relation between

the outcome measures. Components most affected on
the physical function scale were “being unable to bend
down and pick up clothing from floor”, “being unable
to push a heavy door”, “unable to do eight hours of
physical labor” and “unable to reach and get down an
object from above the head”. On psychological
function scale, the components most affected were
“feeling tired or having less energy”, “Moving or
speaking so slowly that other people could have
noticed- or the opposite, being so fidgety or restless
that you have been moving around a lot more than Fig 3. Co-relation of fatigue NRS with PROMIS
usual”.

Fig 1. Co-relation of Pain NRS with PROMIS Fig 4. Co-relation of Fatigue NRS with

44. Megha seth--235--.pmd 237 11/1/2014, 12:17 AM

 238 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
DISCUSSION
This survey which included 100 polio survivors in
Gujarat confirmed a high level of impairment and
disability in people who had suffered from
poliomyelitis earlier. A prevalence of new symptoms
of 86% and new weakness in 66% found in this study
shows that subjects with previous polio attacks
complain of new symptoms some years after polio
infection and experience increasing symptoms and
new loss of function, particularly functions associated
with ADL.
A study by Farbu E8 et al, where 85 patients were
examined prospectively to identify their symptoms
and loss of function, found that the most common
complaints were pain (44%), muscular weakness
(27%), and fatigue (16%). Walking on stairs was
impaired in 72% and outdoor walking in 65%. 17(19%)
subjects reported no loss of function. Our study has
showed that most common complaints in polio
survivors were muscle and joint pain, muscle
weakness and fatigue and 78% polio survivors
complained of problems in ADL.
Another study by Takemura J9 concluded that 85%
polio survivors complained of new health problems
such as difficulty in climbing stairs, muscle weakness,
difficulty in walking, or fatigue. A survey done by
Pentland B10 et al involving 221 post polio subjects
found that common symptoms were cold intolerance
(70%); fatigue (66%); increased weakness in previously
affected muscles (67%); new weakness in unaffected
muscles (60%); muscle pain (64%); joint pain (61%);
and joint stiffness (64%). These symptoms were often
of recent onset. In terms of disability 78% had difficulty
with stairs; 72% with walking and 70% with bending.
Both study finding are similar to present study.
Bruno R et al 11 did a survey to find out the
prevalence of post polio syndrome in North America
and found that 76% of the 1.8 million North American
polio survivors had Post-Polio Sequel (PPS), and
reported unexpected and often disabling symptoms
that included overwhelming fatigue, muscle weakness,
pain and dysphagia. Fatigue was the most commonly
reported and most debilitating symptom. In the
National Post-Polio Survey, 91% of respondents
reported new or increased fatigue, 41% reported
fatigue interfering with performing or completing their
work and 25% reported fatigue interfering with self-
care activities.
44. Megha seth--235--.pmd 238
The findings from this study also suggest a
statistically significant negative co-relation between
the severity of pain and physical functioning and
positive co-relation with depression in individuals
with PPS whereas severity of fatigue did not have a
statistically significant co-relation. Also, the severity
of pain showed a stronger co-relation with physical
functioning than with psychological functioning.
These findings have important implications in
understanding the role of pain on functioning in PPS
subjects.
Jenson MP7 et al studied the independent effect of
pain and fatigue on function in subjects with PPS and
concluded that pain and fatigue both made
independent contributions to the prediction of
functioning. They found that relationship between
pain and fatigue and both physical and psychological
functioning was similar across all age cohorts
suggesting that complaints of pain or fatigue in
patients with PPS who are older or elderly should not
be attributed merely to the process of aging. In contrast,
the present study did not show a co-relation with
psychological function. The reason could be the
recruitment of younger participants in the present
study.
Lygren H et al12 studied the perceived disability,
fatigue, pain and measured isometric muscle strength
in patients with post-polio symptoms. They found
significant correlation of self-reported general muscle
strength, pain intensity and pain distribution with
patients’ perceived fatigue and function at the activity
level. This is much in line with the results of our study.
In a similar study by Trojan DA13 et al, different
variables were found to be associated with general,
physical, and mental fatigue. Correlates of general
fatigue included disease-related and psychosocial
factors whereas correlates of physical fatigue were
disease-related and behavioral factors, and correlate
for mental fatigue was a psychosocial factor. In the
present study fatigue did not have a significant effect
on function, indicating that affection in function was
mainly due to pain and not fatigue. This could be
because the number of subjects with complain of
fatigue were less. However the components most
affected on physical and psychological function scales
in our study are similar to the findings of this study.
Consistent with previous findings, participants in
the present study reported pain problems that were
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 239
significantly affecting their functioning. The flowchart
below explains the cycle of overuse and disuse leading
to pain and hence reduced function14.
Fi. 5. Flow chart of overuse and disuse leading to pain and reduced
function
A co-relation between pain and reduced function
is believed to be either a measure of overuse or disuse
that falls into a vicious cycle. Motor unit dysfunction
leads to atrophy and cramping muscle pain, both of
which lead to a combination of overuse and disuse in
muscles. When musculoskeletal overuse occurs, pain
develops. Rest and immobilization can relieve this
pain, but this leads to decreased use of certain muscles,
with development of disuse atrophy and further
weakness. After this, relatively normal use of the
muscle leads to pain and further disuse.
Musculoskeletal dysfunction resulting in pain occurs
as a consequence. And this pain restricts an
individual’s level of physical function and as a result
to some extent, psychological function as well.
In the present study fatigue did not have a
significant effect on function, indicating that affection
in function was mainly due to pain and not fatigue.
Limitations
This study, although population based, was not
designed to provide an accurate figure for the size of
the post-polio population in Gujarat. The sample size
was small. Use of a self administered questionnaire,
which may be less sensitive than a direct interview,
could exert certain amount of bias.
Clinical Application
Acute polio is no longer a constant threat to people
in the polio-free areas of the world but there are still
44. Megha seth--235--.pmd 239
thousands of polio survivors who are at risk of
developing late manifestations of the disease. These
findings highlight the importance of carefully
screening patients with PPS for the presence of new
symptoms, so that a variety of interventional strategies
to reduce their problems can be implemented
promptly.
Future Recommendations
This survey has provided the basis for further
epidemiological studies in Gujarat in order to
understand the extent of problems of PPS and
measures to curb it. A study to assess potential
predictors of these outcomes may be valuable. The
current study also highlights the need of helpful and
accessible treatment options for pain relief. The use of
assistive devices play an important role in health
related problems. Hence, an elaborated study with
effects of these biomechanical devices and the role of
exercises on pain and fatigue can be done.
CONCLUSION
The prevalence of Post Polio Syndrome in Gujarat
can be estimated to be 66% according to this survey.
The commonest symptoms were muscle weakness,
difficulty in walking, muscle and joint pain and muscle
fatigue. This study also suggests that pain intensity
significantly affects the physical and psychological
function highlighting the need for effective and
accessible treatment options.
Acknowledgement: We are thankful to Dr. Sagun
Desai for providing vision and great support for this
study. We also appreciate the help of Dr. Hemant
Tiwari (AP, PSM department NHLMMC).
Conflict of Interest: None
Source of Funding: Self
Ethics Committee Approval: This study has been
approved by SBBIEC of SBB College Of Physiotherapy
letter number PTC/IEC/19/2012-2013.
REFERENCES
1. Nollet F, Beelen A, Twisk JW, Lankhorst GJ, de
Visser M. Perceived health and physical
functioning in post-poliomyelitis syndrome: a 6-
year prospective follow-up study. Arch Phys
Med Rehabil 2003; 84: 1048-56.
2. Halstead LS, Rossi CD. Post-polio syndrome:
clinical experience with 132 consecutive
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 240 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
outpatients. Birth Defects Original Article Ser
1987; 23: 13-26.
3. Halstead LS, Rossi CD. New problems in old
polio patients: results of a survey of 539 polio
survivors. Orthopedics 1985; 8: 845-850
4. Nollet F, Beelen A, Prins MH, et al. Disability and
functional assessment in former polio patients
with and without postpolio syndrome. Arch Phys
med Rehabil 1999; 80: 136-43
5. Halstead LS. Assessment and differential
diagnosis for post-polio syndrome. Orthopedics
1991; 14: 1209-1217
6. Farrara JT, James P. Young, Moreaux LL, Werth
JL, Pool RM. Clinical importance of changes in
chronic pain intensity measured on an 11 point
numeric rating pain scale. International
Association for the Study of Pain. 2001.
Pg: 149-158.
7. Jenson MP, Alschuler KN, Smith A, Molton IR.
Pain and fatigue in persons with post-polio
syndrome: Independent effect on functioning.
Archives of Phys Med and Rehab Volume 92,
Issue 11 , Pages 1796-1801, November 2011
8. Farbu E, Rekand T, Gilhus NE. Post-polio
syndrome and total health status in a prospective
hospital study. European Journal of Neurology
2003, 10: 407-413
44. Megha seth--235--.pmd 240
9. Takemura J, Saeki S, Hachisuka K, Aritome K.
Factors associated with QoL in Japan. Japan J
Rehabil Med 2004; 36: 1-3
10. Pentland B, Hellawell DJ, Benjamin J, Prasad R.
Survey of late effects of polio in Lothian.
Lincolnshire post-polio library. January 1999.
11. Bruno R, Miles M, Huberman M. Qualitative Data
Analylsis; an expanded sourcebook; 2nd ed.,
Thousand Oaks, California. Sage Publications
1990.
12. Lygren H, Jones K, Grenstad T, Dreyer V, Farbu
E, Rekand T. Perceived disability, fatigue, pain
and measured isometric muscle strength in
patients with post-polio symptoms. Physiother
Res Int 2007; 12:39-49.
13. Trojan DA, Arnold DL, Shapiro S, Barr A,
Robinson A. Fatigue in Post-poliomyelitis
Syndrome: Association with Disease-Related,
Behavioral, and Psychosocial Factors. American
Academy of Physical Medicine and
Rehabilitation Vol. 1, 442-449, May 2009.
14. Silver JK, Gawne AC. Postpolio syndrome.
Hanley and Belfus publications. 2004. Chapter 5:
Joint and muscle pain. Pgs: 61-71.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 241

A Study of Neck Pain and Role of Scapular Position in

Computer Professionals

Jyoti Dahiya1, Savita Ravindra2

1
Assistant Professor in Banarasidas Chandiwala institute of physiotherapy, IP University New Delhi,2Head of
Physiotherapy Department, M.S.Ramaiah Medical College Bangalore

ABSTRACT

The position of scapula is the key contributor to normal and abnormal scapular motion and control.
Normally scapula rests at a position on the posterior thorax approximately two inches from the
midline, between the second and seventh ribs. The scapula also is internally rotated from vertical,
and is upwardly rotated 10 to 20 degrees from vertical1.

Scapular protraction will become abnormal when there is increased distance between the inferior
angle of scapula and the Spinous process of vertebra2. Some authors reported that imbalanced force
produce superior translation of the scapula with less efficient downward rotation and increased
posterior tipping3.

Abnormal scapular position is defined as an observable alteration in the position and motion of the
scapula relative to the thoracic cage .alterations that have been identified in computer professionals
include increased protraction4.

Neck joints may be kept in abnormal positions which may eventually cause joint pain and muscle
weakness. Due to which one may feel that just holding up the head is difficult, that is the head feels
so heavy because of this heavy feeling, the person may maintain a slouched posture, which continues
the vicious cycle5.

Individuals with neck pain may display altered postural behavior when performing prolonged sitting
tasks such as during computer use, hence aim of the study is to find out whether neck pain is associated
with scapular position in computer professionals.

Methodology: An case control study with convenience sampling was done with 100 subjects(50
study group and 50 in control group). Each subject's Scapular protraction measurements were taken
with the participant standing with normal, relaxed posture. The measurements were performed at 3
different positions ( at rest, hands on hip, and 900 glenohumeral abduction with internal rotation).
First the inferior angle of scapula was palpated and marked, then the lateral arm of the vernier
caliper was then positioned at the corresponding spinous process, and the measurement was recorded.
All measurements were taken bilaterally.

Data analysis: Independent t test was used to compare the mean in terms of distance of right and left
side in study and control group, also test was used to compare the mean difference of scapular
position at three different positions between study and control group.

Results: The results showed that there is a significant difference in scapular position in computer
professionals with neck pain in all three position that is at rest, hands on hip, and 900glenohumeral
abduction.

Conclusion: In the present study it was concluded that scapular position is altered in computer
professionals who are suffering from neck pain in all three positions that is at rest, hands on hip, and
90 degree glenohumeral abduction.

Keywords: Neck Pain, Scapula Position, Altered Scapular Position, Computer Professionals

45. Jyoti Dahiya--241.pmd 241 11/1/2014, 12:17 AM

 242 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
INTRODUCTION
Normally scapula rests at a position on the posterior
thorax approximately two inches from the midline,
between the second and seventh ribs1.Upward rotation
is the predominant scapulothoracic motion2. Most
epidemiological studies reviewed, have defined
repetitive work for the neck as work activities which
involve continuous arm and hand movements which
affect the neck/shoulder musculature and generate
loads on the neck/shoulder area resulting in altered
scapular position3.
Alterations that have been identified in computer
professionals include increased protraction4. Scapular
protraction is an abnormal position which has been
defined as an increased distance between the inferior
angle of scapula and the spinous process of
corresponding vertebra5.
Work related musculoskeletal disorders
(WRMSDs) are an important health problem in many
industrialized countries7,6. This term is not a diagnosis,
but an umbrella term for disorders that develop as a
result of repetitive movements, awkward postures,
and impact of force8. many epidemiological studies
have demonstrated that specific work – related risk
factors may cause musculoskeletal complaints9.
Computer professionals who work for long hours
used to adapt poor work posture most commonly
altered scapular postures which cause various
musculoskeletal disorders10.
Neck flexion, forward head posture , scapular
retraction, forward stoop posture are some of the faulty
postural alignment, resulting in neck pain due to
increased cervical muscle activity to support head in
forward position and results in increase in fatigue11 .
Neck joints that is cervical spine may be kept in
abnormal positions which may eventually cause joint
pain and muscle weakness Due to which one may
feel that just holding up the head is difficult, that is
the head feels so heavy because of this heavy feeling,
the person may maintain a slouched posture, which
continues the vicious cycle12.
Increase of computer work coincided with a
prevalence increase of work related musculoskeletal
45. Jyoti Dahiya--241.pmd 242
disorders of the upper extremities (WRMSDs),
employees affected by WRMSDs often experience
substantial pain and functional impairment13.
Marcus et al found that postural factors were
associated with upper quarter musculoskeletal
symptoms in computer operators. The number of
hours spent performing keyboard operation appears
to be a risk factor for work related musculoskeletal
disorders14.
It has been shown that visual discomfort and
musculoskeletal strain, particularly in the neck and
shoulders, are associated with computer screen
height15.
Office work is often associated with prolonged
sitting, particularly with poor workstation ergonomics,
which may cause prolonged static contraction of
muscles, increased pressure on the intervertebral discs
and tension on ligaments and muscles, decreased
tissue flexibility, altered spinal curvature and
weakened paravertebral muscles , and such changes
may lead to the risk of musculoskeletal injury in the
spine and finally cause altered and abnormal scapular
posture which lead to neck pain.16.
There is positive association between neck pain and
neck flexion at work, although not significant ,
suggesting that there is an increased risk of neck pain
for people who are working with the neck flexed more
than 20o for major part of their working day17.
Individuals with neck pain display altered
postural behavior when performing prolonged sitting
tasks such as during computer use abnormal scapular
posture and any associated changes in axioscapular
muscle activity may contribute to, or exacerbate
painful neck disorders by adversely affecting
mechanical stresses on pain sensitive cervicobrachial
structures18.
MATERIAL OR METHOD
In the study 100 participants were included who
were further divided in to two groups.
Study group- with neck pain.
Control group- without neck pain.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 243

Inclusion criteria for study include age group of

35-40 years, with working hours of 8 or more per day.
All professionals who were undergone recent surgery
and have any kind of neurological deficit were
excluded from the study. A brief physical assessment
was taken which Included Demographic data and
assessment of mechanical neck pain by using VAS.
Participants who were having VAS score of 7 or more
were included in the study. The scapular protraction
measurements were performed at 3 different positions

1. At rest.

2. Hands on hip.

3. 900 glenohumeral abduction with internal rotation.

Fig. 2. Measurement of scapular position at hands on hip

Fig. 1. Measurement of scapular position at rest. Fig. 3. Measurement of scapular position at 90 degree abduction

45. Jyoti Dahiya--241.pmd 243 11/1/2014, 12:17 AM

 244 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

FINDINGS statistical software namely SPSS 15.0 was used for

Descriptive statistical analysis was done in the
present study. mean value, standard deviation,
confidence interval, t value and p value was
obtained.Independent t test was used to compare the
mean in terms of distance of right and left side in study
and control group, also t test was used to compare the
mean difference of scapular position at three different
position between study and control group. The
analysis of the data.
Table 1 gives details of the sample size, working
hours per day, and work experience of study group ,
which shows minimum age was 30 and maximum was
36 with mean of 31.71(1.87). Also minimum working
hours was 8 and maximum was 12 with mean of
9.48(0.76).and mean of working experience was
6.14(0.98).

Table 1. Demographic characteristics of study group

N MIN MAX MEAN SD

Age( in years) 50 30 36 31.71 1.87
Working hour(per day) 50 8 12 9.48 0.76
Work experience(in years) 50 5 9 6.14 0.98

Table 2: gives details of the sample size, working working hours was 8 and maximum was 12 with mean
hours per day, and work experience of control group of 10.38(1.38).And mean of working experience was
, which shows minimum age was 30 and maximum 6.4(0.99).
was 36 with mean of 31.78(1.28). Also minimum

Table 2- Demographic characteristics of control group

N MIN MAX MEAN SD

Age(in years) 50 30 36 31.78 1.28
Working hour(per day) 50 8 12 10.38 1.38
Work experience(in years) 50 5 9 6.4 0.99

Table 3: gives details of gender distribution of the Table 4 Scapular position in individuals without Neck
study population including both study and control pain
group.Which shows there are 12 females and 38 males Position Right Left t- value p-value
who were having neck pain and 10 females and 40 Mean (SD) Mean(SD)
males who were not having neck pain. At rest(cm) 11.68(1.65) 11.68(1.49) 1.98 0.884
Mean difference 0.49
Table 3- Gender distribution of the study population
Hands on hip(cm) 13.32(1.61) 13.35(1.47) 1.98 0.995
Group Females Males Total Mean difference 0.43
Cases 12(24%) 38(76%) 50(50%) 900abduction(cm) 13.32(1.61) 13.35(1.47) 1.98 0.93
Control 10(10%) 40(80%) 50(50%) Mean difference 0.43
Total 22(22%) 78(78%) 100
Results shows there is no significant difference
Table 4: gives details of scapular position in between right and left side in all three positions.
individuals without neck pain, At rest mean values of
Table 5: gives details of scapular position in
distance between inferior angle of scapula and
individuals with neck pain, At rest mean values of
corresponding spinous process shows 11.68(1.65) for
distance between inferior angle of scapula and
right side and 11.68(1.49) for left side, similarly for
corresponding spinous process shows 12.04(1.57) for
hands on hip mean value shows 13.32(1.61) for right
right side and 11.07(1.22) for left side, similarly for
side and 13.35(1.47) for left side and for 900 abduction
second position hands on hip mean value shows
the mean shows 13.32(1.61) for right side and
12.67(1.56) for right side and 111.74(1.24) for left side
13.35(1.47) for left side.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 245

and finally for 90 0 abduction the mean shows anterior neck muscles become weak from being in
13.51(1.63) for right side and 12.52(1.24) for left side. shortened position and neural structures are kept in
Results shows there is significant difference between less than optimal positions. This chronic overload and
right and left side in all three positions. Table 7: gives tightening of soft tissues may eventually result in
details of scapular position of study and control group decreased blood flow and oxygen to the soft tissues,
the results shows there is significant difference of ultimately causing pain.
scapular position among study and control group that
is computer professionals with neck pain have altered The altered scapular position could have probably
scapular occurred due to working posture of computer
professionals, as they used to work for long hours in
Table 5 Scapular position in individual with Neck poor postures which include, forward head posture,
pain and protracted shoulder. Poor working posture will
Position Right Left t- value p-value further lead to imbalance of scapular muscle activity
Mean (SD) Mean(SD) especially exessesive loading of scapular muscles. This
At rest(cm) 12.04(1.57) 11.07(1.22) 1.98 0.0004 will then causes neck pain in computer professionals
Mean difference 1.36 who works in poor posture. This can be supported by
Hands on hip(cm) 12.67(1.56) 11.74(1.24) 1.98 0.0007 a systematic review done by Green B.N et al, who
Mean difference 1.30 observed that neck pain is associated with prolonged
900abduction(cm) 13.51(1.63) 12.52(1.24) 1.98 0.0005 computer use in poor working posture.
Mean difference 1.37
Our results showed a significant difference that is
Table 6 The result shows there is significant more than 1.5 cm indicating change in scapular
difference of scapular position among study and position in computer professionals with neck pain
control group in all three positions.
Acknowledgement: My sincere thanks to
Table 6 Comparison between study and control group Mrs.Bandana kumari IT professional IBM Bangalore
Position Cases Control t-value p-value for helping me during the study. I would like to thank
Mean (SD) Mean(SD) all my subjects for their kind cooperation and
At rest(cm) 1.36 0.49 1.99 0.0007 participation in my study.
Hands on hip(cm) 1.3 0.43 1.99 0.0009
Conflict of interest: None
900abduction(cm) 1.37 0.43 1.99 0.0006

Source of funding: Self

CONCLUSION
The result of the study showed that there is
significant difference of scapular position in computer
professionals in all three positions in computer
professionals with neck pain as seen in Table 7. Which
infers that the scapular kinematics is altered in all three
positions in computer professionals who works in
abnormal posture for long hours which cause neck
pain.
The possible reason for this change can be explained
by the fact that Neck pain from poor posture can be
explained as in an upright position the head is
supported by the spinal vertebrae. Once the head is
flexed forward, For instance while working on
computer, the vertebrae do not support the weight of
the head as much. Muscles, tendons, and ligaments
work harder to hold up the head. Overtime the muscles
and other soft tissues tighten up due to the excessive
workload required to hold the head in position. The
Ethical clearance: Ethical clearance was taken from the
institute
REFERENCES
1. Cynthia.C.Norkin and Pamela K. Levangie, Joint
structure and function: A comprehensive
analysis, fourth edition.
2. Paula M. Ludewig, PT, PhD, et al , Clinical
commentary, Journal of orthopaedic and sports
physical therapy, vol 39, no.2, 2009.
3. A critical review of epidemiologic evidence for
work related musculoskeletal disorders of the
neck,upper extremity, low back, chapter 2,
NIOSH Publication no. 97-141, july 1997.
4. DiVeta.J, M.L Walker and B. Skibinski,
Relationship between performance of selected
scapular muscles and abduction in standing
subjects,World Journal of sport sciences,vol 3,470-
476,2009.

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 246 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
5. Ludewig,P.M and T.M Cook, Alterations in
shoulder kinematics and associated muscle
activity in people with symptoms of shoulder
impingement, World Journal of sport science,
vol3,276-291,2000.
6. Sally Wegner et al, The effect of a scapular
postural correction strategy on trapezius activity
in patients with neck pain, Journal of manual
therapy,2010.
7. A critical review of epidemiologic evidence for
work related musculoskeletal disorders of the
neck,upper extremity, low back, chapter 2,
NIOSH Publication no. 97-141, july 1997.
8. Ostergren P, Hanson BS, Balogh I, et al, Incidence
of shoulder and neck pain in a working
population: effect modification between
mechanical and psychosocial exposures at work?
Results from a one year follow up of the malmo
shoulder and neck study cohort. J . epidemiol.
Community health 2005; 59:721-8.
9. Verhagen AP, et al , ergonomics and
physiotherapeutic interventions for treating
work – related complaints of the arm, neck or
shoulder in adults (review) . Cochrane database
of systematic reviews 2006, issue 3, Art No.
CD003471.
10. Alexopoulos EC,Tanagra D, et al,
Musculoskeletal disorders in shipyard industry:
prevalence, health care use, and absenteeism.
BMJ Musculoskeletal Disorders 2006;7:88.
11. Shilpi Chhabra, et al, The effectiveness of self
snags over conventional physiotherapy
management in chronic neck pain among
computer professionals, Indian journal of
physiotherapy and occupational therapy, vol.2,
No.3, 2008.
12. Green B.N, A literature review of neck pain
associated with computer use:Public health
implications, Journal of the Canadian chiropractic
association 52.3,161-167,2008.
13. J Heinrich, B M Blatter, occupational.
Environment med 2004;61:1027-1031,doi:
10.1136/ oem. July, 2004.
14. Exercises at work for computer operators, neck
pain postures, 67-75, 2007.
15. T Korhonen, R Ketola, et al, Work related and
individual predictors for incident neck pain
among office employees working with video
display units, occup Environ Med 2003; 60; 475-
482,doi:10.1136/oem.60.7.475.
16. Prawit Janwantanakull, Praneet Pensril, et al,
Prevalence of self reported musculoskeletal
symptoms among office workers, occupational
medicine, vol 58, issue 6,p- 436-438,2008.
45. Jyoti Dahiya--241.pmd 246
17. G A M Ariens, P M Bongers, et al ,Are neck flexion
, neck rotation, and sitting at work risk factors
for neck pain? Results of a prospective cohort
study, occupational and environmental medicine,
vol 58, issue 3, 2001.
18. Dinesh Bhanderi, SK Choudhary, et al, A Study
of occurrence of musculoskeletal discomfort in
computer operators, Indian journal of community
medicine, vol 33, 33(1), 65-66, march 2007.
19. Bart N.Green et al, A literature review of neck
pain associated with computer use: a public
health implications, The Journal of te Canadian
chiropractic association,Vol 3, 161-167,2008.
20. Philip Fabrizio, Ergonomic interventions in the
treatment of a patient with upper extremity and
neck pain, The American Journal of sports
medicine,2009.
21. Weon J.H et al ,Influence of forward head posture
on scapular upward rotators during isometric
shoulder flexion, Vol 4, 365-74.
22. Mats.Hagberg et al , ABC of work related
disorders, British Medical Journal, Vol 313, no.
7045, 313-419,1996.
23. Kristine.L.Turville et al, The effects of video
display terminal height on the operator: a
comparison of the 15 degrees and 40 degrees
recommendations, Vol 29, 239-246,1998.
24. L.Strakera et al, The impact of computer display
height and desk design on 3D posture during
information technology work by young adults,
Vol 18,336-349,2008.
25. Morten Wersted , Therese N Hanvold et al ,
Computer work and musculoskeletal disorders
of the neck and upper extremity :A Systematic
review, BMC musculoskeletal disorders , 2010.
26. Leon M Straker, Peter B. O. Sullivan et al,
Computer use and habitual spinal posture in
Australian adolescents , 122(5), 0ct 2007.
27. Mary. F. Barbe and Ann E. Barr, Inflammation
and the pathophysiology of work – related
musculoskeletal disorders, vol 5, 423-429, sep
2006.
28. Stefen I Jmker, Maaike A Huysmans et al ,
Software- recorded and self – reported duration
of computer use in relation to the onset of severe
arm-wrist-hand pain and neck-shoulder pain,
occupation and environmental medicine,2010.
29. B.M Blatter , P. M Bongers et al, Should office
workers spent fewer hours at their computer? A
systematic review of the literature, vol 64 ,211-
222,occupational and environment medicine,
2006.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 247

Efficacy of Maitland's Spinal Mobilizations Versus

Mckenzie Press-Up Exercises on Pain, Range of Motion
and Functional Disability in Subjects with non Radiating
Acute Low Back Pain

Arpit Sheth1, Anu Arora2, Sujata Yardi3

1
Physiotherapist, Associate Professor, 3Professor and Dean, Padmashree Dr.D.Y.Patil University, Department of
2

Physiotherapy

ABSTRACT

Aim and Objectives: To assess and compare efficacy of Maitland's Spinal mobilizations versus
McKenzie press-up exercises on pain, range of motion and functional disability in subjects with non
radiating acute low back pain

Materials and Method: 30 patients in the age group 20-40 yrs. experiencing non radiating low back
pain with duration less than 3 months were randomly assigned to either of the two groups- Group I
- Maitland & Group II - McKenzie. Kinematic & functional assessment of the patients was done and
level of pain measured on Numerical Rating Scale (NRS). Group I (15 subjects) received Posterior to
Anterior (PA) mobilization and Group II (15 subjects) received McKenzie press-up exercises for five
days continuously and post intervention assessments were recorded.

Result: Both groups showed statistically significant decline in pain (NRS), improvement in range of
motion (ROM) and reduction in disability associated with LBP post five days of intervention. However,
no statistically significant difference was found on comparing the two groups on the above mentioned
outcome measures.

Conclusion: Maitland's PA mobilization and McKenzie press-up exercise resulted in a significant

reduction in pain, increase in lumbar flexion range and an improvement in the function.

Keywords: Low Back Ache, Maitland, McKenzie, Oswestry LBP Disability Index

INTRODUCTION and range-of-motion exercises often are prescribed by

Low back pain is a common musculoskeletal
disorder with approximately 12% to 13% of the adult
workforce being affected by it.1-3 Future trends predict
that 70% to 95% of adults will have low back pain at
some time during their lives.4-6 As much as 80% of the
industrial population and 60% of the general
population experience acute musculoskeletal low back
pain at some point of time in their life.7 People who
report low back pain often have reduced spinal motion,
with spinal extension frequently more restricted than
flexion8-11 Reduced spinal extension can be the result
of pain or stiffness and can be classified as being either
general (i.e., total spine) or segmental (i.e., one
vertebral level).8-10,12,13 Spinal mobilization techniques
physical therapists as an attempt to improve lumbar
extension and ultimately reduce low back pain.14-16
Most low back pain is triggered by some
combination of overuse, muscle strain, and injury to
the muscles, ligaments, and discs that support the
spine. Many experts believe that over time this muscle
strain can lead to an overall imbalance in the spinal
structure. This leads to a constant tension on the
muscles, ligaments, bones, and discs, making the back
more prone to injury or reinjury. For example, after
straining muscles, you are likely to walk or move in
different ways to avoid pain or to use muscles that
aren’t sore. That can cause you to strain other muscles
that don’t usually move that way.

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 248 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
Backache thus caused can be a cause of functional
disability, pain, decreased range of motion and thereby
reduced productivity of the affected patients in their
respective activities.17-18
Various modalities and techniques like ultrasound,
cryotherapy, TENS, IFT, Spinal traction, lumbar
support have been used as an adjunct to Spinal
Exercises & Specialized techniques like McKenzie and
Maitland’s mobilization.
Maitland’s PA mobilization and McKenzie press
up exercises are common physical therapy
interventions used by physiotherapist to treat low back
pain.17,18
The purpose of this study was to examine the effects
of PA mobilization and a press-up exercise on pain
and range of motion with lumbar flexion in people
with non radiating acute low back pain.
AIM
To compare the effects of Maitland’s PA
mobilizations versus McKenzie press-up exercises on
pain and range of motion (with lumbar flexion) and
functional disability in subjects with non radiating
acute low back pain.
OBJECTIVES
• To study the effects of PA mobilization &
McKenzie press-up exercise on pain, range of
motion of flexion and functional disability
• To compare the effects of PA mobilization versus
McKenzie press-up exercises on pain, range of
motion of flexion and functional disability
METHODOLOGY:
Ethical approval: Permission for the study was
obtained by making a petition prior to collecting data.
This was achieved by contacting and receiving
approval from the Research committee, Pad Dr D.Y.
Patil University.
Procedure: The study was carried out on 30 patients
with low back pain in the age group 20-40 yrs at Pad.
Dr. D. Y. Patil Hospital, Nerul, Navi Mumbai.
Informed consent was obtained from subjects prior to
participation in the research. Subjects were randomly
divided into two groups so that Group I (15 subjects)
received PA mobilization and Group II (15 subjects)
46. Arpit Seth--247.pmd 248
received McKenzie press-up exercises. Study subjects
were chosen who fulfilled the following inclusion
criteria (non radiating low back pain, duration of pain
less than 3 months, Centralized symmetrical localized
low back pain at or above waist level, subjects who
gave an informed consent.) The subjects were excluded
if they matched any of the following criteria (Radiating
pain, Neurological signs and symptoms, Chronic low
back pain (more than 3 months), Known Spondylosis/
listhesis, Bowel-bladder dysfunction.) Materials used
were a measuring tape, a numerical rating scale and
an Oswestry disability index.
Group I (Maitland’s PA Mobilization)
• Patient prone with pillow under the abdomen.
• PA glide starting with Grade 1 on all joint
segments.
• At painful joint level, the grading was increased
with 3-4 sets of oscillations of 40 counts in each
set.
• Below and above the affected joint level, 2 sets of
oscillations were given.
• Total time duration: 10 minutes.
• Treatment continued for 5 days continuously.
Group II (McKenzie press-up exercise)
• Patient prone with arms at side.
• Press on hand and forearm and come up with
pelvis on the treatment table. Reach to maximum
pain free lumbar extension over the course of 5
seconds.
• Hold the end range position for 5 seconds and then
come to starting position.
• A total of 10 repetitions to be done.
• If pain free, do more 2 sets of 10 repetitions each.
• Total time duration: 10 minutes.
• Treatment continued for 5 days continuously.
Assessment: The patients were assessed on the
following outcome measures pre and post
intervention.
Pain: Numerical Rating Scale (NRS). The subjects
were asked to mark the number on the scale which
reflected the intensity of their pain.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 249

Kinematic assessment: Forward flexion range. OBSERVATIONS & DATA ANALYSIS

Forward flexion was measured as the distance from
Descriptive statistics: Results of descriptive
the tip of the index finger to the floor at maximal
analysis of demographic features at baseline are
comfortable forward flexion.
reported as means and standard deviations in Table I.
Functional assessment: Oswestry low back pain Table I: Age and BMI of the subjects of both groups
disability scale was used to identify functional (Experiment & Control)
disability.
Domains Group I Group II p Value
Age (years) (Mean+SD) 27.33+4.85 28.46+5.22 >0.05
(not significant)
BMI 24.52+2.74 24.97+2.36 >0.05
(not significant)

Analytical statistics: Data were collected on

standardized forms and encoded for computerized
analysis using GraphPad Instat Version3.10, 32 for
Windows. Tables were made using Microsoft word
and figures were plotted using Microsoft Office Excel
2007. Continuous variables were summarized by mean
(range) or number (percent).Associations denoted as
statistically significant were those that yielded a p
value< 0.05, assuming a 2-sided alternative hypothesis.

Table II: Effects of Maitland’s PA Mobilization On

Group I
Domains PRE POST p Value*
(Mean + S.D.) (Mean + S.D.)
NRS 5.46+0.915 1.2+0.77 <0.05( significant)
ROM 28.46+6.75 16.8+9.53 <0.05( significant)
SCALE 16.6+1.55 4.13+0.99 <0.05( significant)

* Wilcoxon matched pair test showed a statistically significance

decline in the pain, ROM and functional disability in Group I
(Maitland).

Table III: Effects of McKenzie Press-Up Exercises on

Group II
Domains PRE POST p Value*
(Mean + S.D.) (Mean + S.D.)
NRS 5.2+0.86 0.67+0.723 <0.05( significant)
ROM 25.8+7.48 14.67+4.67 <0.05( significant)
SCALE 15.6+1.404 3.73+0.703 <0.05( significant)

*Wilcoxon matched pair test showed a statistically significance

decline in the pain, ROM and functional disability in Group II
(McKenzie).

Table IV: Comparing Group I (Maitland) and Group

II (McKenzie) subjects for NRS, ROM and Disability
Scale
Domains Group I Group II p Value*
(Mean + S.D.) (Mean + S.D.)
NRS(POST) 1.2+0.77 0.67+0.723 0.0667(Not quite
significant)
ROM(POST) 16.8+9.53 14.67+4.67 >0.9999(Not
significant)
SCALE(POST) 4.13+0.99 3.73+0.703 0.1756 (Not
significant)

Flow diagram summarizing study design. *The above statistics were derived by using the Mann-Whitney
U test

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 250 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
DISCUSSION
Maitland’s PA glide and McKenzie press up
exercise are both effective in bringing statistically
significant reduction in pain and improvement in the
lumbar range of motion & disability in patients with
LBP.
Effects of Maitland’s PA Mobilization On Group I
Subjects
Effect on Pain: Maitland’s PA mobilizing
movements stimulate the type I postural and type II
dynamic mechanoreceptors in the joint capsules
causing reflexogenic and pain suppression effects19.
Also, since the articular mechano-receptors afferent
nerve fibres give off collateral branches that distributed
intersegmentally as well as segmentally throughtout
the neuraxis, PA mobilization of an individual joint
not only affects the motor activity in the muscle
operating over the joint being mobilized but also in
more remote muscles20.
Effect on ROM: Prolonged immobilization of joints
due to any cause results in an increase in the synthesis
of collagen and a random laying down of additional
cross-linkage between the collagen fibrils of soft
connective tissues21,22. There is also a decrease in the
concentration of glycosaminoglyans and water which
form the ground substance, and this reduces collagen’s
lubrication efficiency in interfibril movement21. The
overall effect of these changes are a decrease in the
extensibility of the periarticular tissues leading to joint
hypomobility.
Repetitive PA mobilization might cause breakage
of the cross linkage that cause hypomobility 21 .
Furthermore, if sufficient force of PA has been applied,
some of the excess collagen fibres laid down randomly
during repair might also be loaded to failure, resulting
in an improvement in the joint flexibility21.
Effect on functional disability: According to the
Oswestry scale, majority of the subjects complained
of pain while lifting heavy weights, difficulty in
sleeping continuously during the night and inability
to sit or stand for prolonged hours. On giving the
treatment to Group I subjects, there was a reduction
in all of these complaints with an improvement in
sitting or standing for longer time and ability to carry
out daily activities effectively.
Effects of McKenzie Press-Up Exercises on Group
II Subjects:
46. Arpit Seth--247.pmd 250
McKenzie press-up exercises on Group II subjects
resulted in a significant reduction in pain, an
improvement in the range of forward flexion and
functional ability of the subjects.
McKenzie suggested press-up exercises as one of
the low back exercises to accentuate the lordosis and,
thus, correct the derangement syndrome23,24. McKenzie
emphasizes the maintenance of both the lumbar
lordosis and a full range of
lumbar spine extension to maintain the nucleus
pulposus anteriorly.
McKenzie25 suggests that all spinal pain can be
attributed to alteration of the position of the disc’s
nucleus pulposus, in relationship to the surrounding
annulus; mechanical deformation of the soft tissue
about the spine which has undergone adaptive
shortening; or mechanical deformation of soft tissue
caused by postural stress
Cyriax postulated that the lumbar lordosis serves
to protect the posterior longitudinal ligament from
excessive strain and exerts anteriorly directed pressure
on the intervertebral disk.26 Posteriorly directed disks
may exert pressure on pain-sensitive structures
resulting in low back pain, whereas passive
hyperextension exercises and maintenance of lordosis
could move the disk away from these structures.
Nachemson, in his study of the lumbar disk, found
high tangential strains in the posterior part of the
annulus fibrosus of lumbar disks in subjects who sit
unsupported or lean forward during sitting and
standing and less disk pressure the more the lumbar
spine was moved toward lordosis27. The results of a
recent study documented the effects of the McKenzie
protocol in decreasing low back pain and increasing
lumbar flexion and lateral flexion ROM.28
Because of the reasons described above, there was
a reduction in pain, improvement in the range of
lumbar flexion and improvement in the functional
disability in the subjects receiving McKenzie press-up
exercises.
Comparing PA Mobilization versus McKenzie
Press-Up Exercises
Pain Relief: Though both the techniques were
individually effective in reduction of pain, none was
found to be superior to the other (p>0.05).
Improvement in Range of Flexion: None of the
treatment procedures is superior to the other; however,
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 251
subjects in both the treatment groups have
individually shown statistically significant
improvement in the range of lumbar flexion. (p>0.05).
Improvement in Functional Disability (Oswestry
Low Back Pain Scale):
Both the study groups individually showed
significant improvement in the functional ability of the
subject to carry out the daily activities more efficiently,
however when the intervention results were compared
with each other no statistically significant difference
was found between the two groups.(p>0.05)
CONCLUSION:
Maitland’s PA mobilization and McKenzie press-
up exercise resulted in a significant reduction in pain,
increase in lumbar flexion range and an improvement
in the function. However, when the two groups were
compared, none of the groups proved to be superior
to the other, hence either can be effectively used in
treating non radiating acute low back pain.
Acknowledgment: We wish to extend our thanks to
Department of Orthopedics at Pad Dr. D Y Patil
Hospital for their support to the study and referral of
subjects.
Conflict of Interest: To the best of my knowledge,
there were no known conflicts of interest encountered
in the present research.
Source of Support: No financial support was obtained
from any external agency for this research.
REFERENCES
1. Frank C, Akeson WH, Woo SL, et al. Physiology
and therapeutic value of passive joint motion.
Clin Orthop. 1984;185: 113–115.
2. Frank JW, Brooker AS, DeMaio SE, et al.
Disability resulting from occupational low back
pain, part II: what do we know about secondary
prevention? A review of the scientific evidence
on prevention after disability begins. Spine.
1996;21:2918–2929.
3. Frank JW, Kerr MS, Brooker AS, et al. Disability
resulting from occupational low back pain, part
I: what do we know about primary prevention?
A review of the scientific evidence on prevention
before disability begins. Spine. 1996;21:2908–2917.
4. Scientific approach to the assessment and
management of activity-related spinal disorders:
46. Arpit Seth--247.pmd 251
a monograph for clinicians. Report of the Quebec
Task Force on Spinal Disorders. Spine. 1987;12(7
suppl):S1–S59.
5. Volinn E. The epidemiology of low back pain in
the rest of the world. Spine. 1997; 22:1798.
6. Walker B. The prevalence of low back pain: a
systematic review of the literature from 1966 to
1998. J Spinal Disord. 2000;13:205–217.
7. Kelsey, J.L. and White,A.(1980) : Epidemiology
and impact of low back pain. Spine 5(2):133
8. McGregor A, Anderton L, Gedroyc W. The
assessment of intersegmental motion and pelvic
tilt in elite oarsmen. Med Sci SportsExerc.
2002;34:1143–1149.
9. Burton AK, Battie´ MC, Gibbons L, et al. Lumbar
disc degeneration and sagittal flexibility. J Spinal
Disord. 1996;9:418–424.
10. Latimer J, Lee M, Adams R, Moran CM. An
investigation of the relationship between low
back pain and lumbar posteroanterior stiffness. J
Manipulative Physiol Ther. 1996;19:587–591.
11. Troup JD, Foreman TK, Baxter CE, Brown D. 1987
Volvo award in clinical sciences: the perception
of back pain and the role of psychophysical tests
of lifting capacity. Spine. 1987;12:645–657.
12. Mellin G. Decreased joint and spinal mobility
associated with low back pain in young adults. J
Spinal Disord. 1990;3: 238–243.
13. Pearcy M, Portek I, Shepherd J. The effect of low-
back pain on lumbar spinal movements
measured by three-dimensional X-ray analysis.
Spine. 1985;10:150153.
14. Koes BW, Bouter LM, Beckerman H, et al.
Physiotherapy exercises and back pain: a blinded
review. BMJ. 1991;302:1572–1576.
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 oneyear follow-up. BMJ.
1992;304:601–605.
16. Koes BW, Bouter LM, van der Heijden GJ.
Methodological quality of randomized clinical
trials on treatment efficacy in low back pain.
Spine. 1995;20:228–235.
17. Maitland GD, Hengeveld E, Banks K, English K.
Maitland’s Vertebral Manipulation. Oxford, United
Kingdom: Butterworth-Heinemann; 2001.
18. McKenzie R, May S. The Lumbar Spine: Mechanical
Diagnosis & Therapy. Waikanae,New Zealand:
Spinal PublicationsNew Zealand Ltd; 2003.
19. Wyke B.D. (1985) Articular Neurology and
Manipulative Therapy In. Glasgow E.F.Twomey
11/1/2014, 12:17 AM
 252 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
L.T., Scull E.R. and Kleynhans A.M.(eds.) Aspects
of Manipulative Therapy. 2nd edition. Churchill
Living-stone, Melbourne, pp 72-80.
20. Melzack R and Wall P.D. (1965) Pain Gate
Mechanism. (Low and Reed)
21. Grover M. (1982) Proposed Mechanical Effects of
manipulative Therapy In: Proceedings of the
Manipulative Therapists association of Australia
Symposium: Towards a Better Understanding of
Spinal Pain. Brisbane,pp 158-169.
22. Zusman M.(1986) Spinal Manipulative Therapy:
Review of Some Proposed Mechanism, and a
New Hypothesis< Aust. J. Physiotherapy 32(2):
89-99.
23. McKenzie RA: The Lumbar Spine:
MechanicalDiagnosis and Therapy. Waikanae,
New Zealand,Spinal Publications Ltd, 1981, pp
25, 57,103
46. Arpit Seth--247.pmd 252
24. McKenzie RA: Prophylaxis in recurrent lowback
pain. NZ Med J 89:22-23, 1979.
25. McKenzie R: The Lumbar Spine, Ed 1. Upper
Hutt, NZ: Wright andCarmen Ltd, 1981
26. Cyriax J: Textbook of Orthopaedic
Medicine:Diagnosis of Soft Tissue Lesions, ed 7.
London,England, Baillière Tindall, vol 1, 1978,
pp345, 407-413, 473-482, 535
27. Nachemson A: Towards a better understandingof
low-back pain: A review of the mechanicsof the
lumbar disc. Rheumatol Rehabil 14:129-149, 1975
28. Ponte DJ, Jensen GJ, Kent BE: A
preliminaryreport on the use of the McKenzie
protocolversus Williams protocol in the treatment
oflow back pain. Journal of Orthopaedic
andSports Physical Therapy 6:130-139, 1984
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 253

Effect of Breathing Exercises on Lung Functions in

Postpartum Mothers with Normal Vaginal Delivery

Amrita L Tomar1, Manisha A Rathi2

1
**********, Professor, PadmashreeDr.D.Y.PatilCollege of Physiotherapy, Pimpri, Pune
2

ABSTRACT

Aim: To compare the effect of breathing exercises on lung functions in post partum mothers with
normal vaginal delivery.

Objective: To evaluate the effect of breathing exercises on lung function in postpartum mothers with
normal vaginal delivery & to compare the effect of breathing exercises with control group in
postpartum mothers with normal vaginal delivery.

Methodology: In this experimental study 30 females with normal vaginal delivery were screened for
inclusion and exclusion criteria & explained the procedure in detail then consent was obtained from
all the subjects. After this all the subjects, were randomly divided into two equal groups. Group A, as
control group, had 15 subjects and Group B; the experimental group had 15 subjects. Common
exercises given to both the groups A & B were: Kegel's exercises, back and abdominal exercises with
progression, ergonomic advice which included postural correction and baby care. Whereas group B
in addition was undergone various breathing exercises for total 8 weeks out of which 1st week exercise
training was under supervision and rest of the 7 weeks, a home exercise program was followed.
Participants of each group undergone 3 PFT. 1st on 1st day of 1st week, 2nd on last day of 4th week,
3rd on last day of 8th week. The readings were noted and compared with the previous readings.

Result: Significant improvement is seen in group B than group A. FVC showed 14.86% improvement
(p=0.001), FEV1 showed 17.2% improvement (p=0.000), PEFR showed 17.73% improvement (p=0.001).
FEF25-75% showed more improvement in group A than group B (p=0.542).

Conclusion: As per the results and discussion we can conclude that there is significant change in the
lung functions (FVC, FEV1, PEFR, FEF25-75%, FEV1/FVC) in postpartum mothers after breathing
exercises.

Keywords: Pulmonary Function Test, Post Partum Period, Breathing Exercises

INTRODUCTION 3. The growth of the fetus resulting in consequent

Pregnancy initiates an extraordinary array of
alterations to all body systems i.e. cardiovascular,
respiratory, reproductive, metabolic, thermoregulatory,
which may take many weeks to resolve after
delivery.1,2,3,4 The changes of pregnancy are chiefly the
direct result of the interaction of four factors:
1. The hormonally mediated changes in collagen and
involuntary muscle,
2. The increased total blood volume with increased
blood flow to the uterus and the kidneys,
enlargement and displacement of the uterus, and
finally
4. The increase in body weight and adaptive changes
in the centre of gravity and posture.
The demands that these changes must make upon
a woman should never be underestimated.5
During pregnancy as a result of uterine
enlargement & abdominal distention, diaphragmatic
mid position is elevated by 4-5 cm & circumference of
thorax increased by 5 to 7 cm. Also ribcage undergoes

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 254 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
structural changes in response to hormonal changes.
Progressive relaxation of the ligamentous attachments
of the ribs cause the subcostal angle of the rib cage to
increase from 68 degree to 103 degree early in
pregnancy before the uterus is substantially enlarged.
Resulting in increase in antero-posterior diameter of
chest.5
Postural changes that take place during pregnancy
are: The center of gravity shifts upward and forward
because of the enlargement of the uterus and breasts.
This requires postural compensations to maintain
balance and stability. The lumbar and cervical lordosis
increase to compensate for the shift in the center of
gravity, and the knees hyperextend, probably because
of the change in the center of gravity. The shoulder
girdle and upper back become rounded with scapular
protraction and upper extremity internal rotation
because of breast enlargement.
These postural tendencies persist with postpartum
positioning for infant care. Tightness of the pectoralis
muscles and weakness of the scapular stabilizers may
be preexisting to or perpetuated by the pregnancy
postural change. The sub occipital muscles respond
in an effort to maintain appropriate eye level (optical
righting reflex), and to moderate forward head posture
along with the change in shoulder alignment. Weight
shifts toward the heels to bring the center of gravity to
a more posterior position. This contributes to the
“waddling” gait that is typically seen in pregnancy.
Changes in posture do not automatically correct
after childbirth, and the pregnant posture may become
habitual. In addition, many child-care activities
contribute to persistent postural faults and
asymmetry.6,7,8
The altered pulmonary functions during pregnancy
which persists in postpartum period needs to get back
towards normal for meeting the demands of functional
capability. This can be achieved by practicing different
breathing techniques, which emphasises controlled
breathing; segmental breathing associated with
thoracic mobility exercises. General exercises for e.g.
postural correction exercises, pelvic floor muscle
exercises, back and baby care techniques should also
be practiced by the mother after normal vaginal
delivery.
Antenatal changes occurred during pregnancy
comes back to normal after 6-8 weeks of postpartum
in all systems of body. According to the literature, the
effect of postpartum exercises on restoring pelvic floor
47. AMRITA TOMA--253--.pmd 254
and cardiac function after child birth has been well
documented but very limited literature and lack of
quantitative data available on its effect on restoration
of pulmonary function. Hence this study was
undertaken to ascertain the effect of postpartum
breathing exercises on pulmonary functions.
MATERIAL AND METHOD
In this experimental study after ethical approval
30 females with normal vaginal delivery from places
approved by guide and college were screened for
inclusion and exclusion criteria & explained the
procedure in detail then consent was obtained from
all the subjects. Procedure of pulmonary function test
was explained and done in participants and readings
were noted. After this all the subjects, were randomly
divided into two equal groups. Group A, as control
group, had 15 subjects and Group B; the experimental
group had 15 subjects. Common exercises given to both
the groups A & B were: Kegel’s exercises, back and
abdominal exercises with progression, ergonomic
advice which included postural correction and baby
care. Whereas group B in addition was undergone
various breathing exercises for total 8 weeks out of
which 1st week exercise training was under supervision
and rest of the 7 weeks, a home exercise program [HEP]
was followed. Participants of each group had
undergone 3 PFTs 1st on 1st day of 1st week, 2nd on last
day of 4th week and 3rd on last day of 8th week. The
readings were noted and compared with the previous
readings.
Pulmonary function test (PFT) procedure was done
by using spirometer. Best of 3 readings was taken. The
reading of FVC, FEV1, FEF25-75%, PEFR, & FEV1/
FVC ratio was noted from the graph plotted on the
screen.
Breathing exercises given are Diphragmatic
Breathing, Segmental Breathing, Lateral Costal
Expansion, Posterior Basal Expansion, Pursed Lip
Breathing & Thoracic Mobility Exercises. All exercises
repeated for 5 times, twice a day.
FINDINGS
Table shows significant difference in predicted FVC
values between pre (immediate postpartum), post 1
(after 4 week) & post 2 (after 8 week) of GROUP A (F=
10.847, P=0.000) by repeated measure ANOVA. It also
shows significant difference in FVC values between
pre (immediate postpartum), post 1 (after 4 week) &
post 2 (after 8 week) of GROUP B (F= 42.774, P=0.000)
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 255

by repeated measure ANOVA. When both the groups
compared by unpaired T-test (of pre & post 2) it shows
significant difference in improvement of lung functions
(t=-3.572, P=0.001). This shows that significant change
in the lung functions in postpartum mothers after
breathing exercises.
Table shows significant difference in predicted
FEV1 values between pre (immediate postpartum),
post 1 (after 4 week) & post 2 (after 8 week) of GROUP
A (F= 21.263, P=0.000) by repeated measure ANOVA.
It also shows significant difference in FEV1 values
between pre (immediate postpartum), post 1 (after 4
week) & post 2 (after 8 week) of GROUP B (F= 59.096,
P=0.000) by repeated measure ANOVA. When both
the groups compared by unpaired T-test (of pre & post
2) it shows significant difference in improvement of
lung functions (t=-3.680, P=0.000). This shows that
significant change in the lung functions in postpartum
mothers after breathing exercises.
Table shows significant difference in predicted
PEFR values between pre (immediate postpartum),
post 1 (after 4 week) & post 2 (after 8 week) of GROUP
A (F= 15.892, P=0.000) by repeated measure ANOVA.
It also shows significant difference in PEFR values
between pre (immediate postpartum), post 1 (after 4
week) & post 2 (after 8 week) of GROUP B (F= 27.495,
P=0.000) by repeated measure ANOVA. When both
the groups compared by unpaired T-test (of pre & post
2) it shows significant difference in improvement of
lung functions (t=-3.552, P=0.001). This shows that
significant change in the lung functions in postpartum
mothers after breathing exercises.
Table shows significant difference in predicted FEF
25-75% values between pre (immediate postpartum),
post 1 (after 4 week) & post 2 (after 8 week) of GROUP
A (F= 7.134, P=0.003) by repeated measure ANOVA.
It also shows significant difference in FEF 25-75%
values between pre (immediate postpartum), post 1
(after 4 week) & post 2 (after 8 week) of GROUP B (F=
23.966, P=0.000) by repeated measure ANOVA. When
both the groups.
Compared by unpaired T-test (of pre & post 2) it
shows significant difference in improvement of lung
functions (t=-3.242, P=0.003). This shows that
significant change in the lung functions in postpartum
mothers after breathing exercises.
Table shows significant difference in FVC/FEV1
values between pre (immediate postpartum), post 1
(after 4 week) & post 2 (after 8 week) of GROUP A (F=
4.864, P=0.016) by repeated measure ANOVA. It also
shows significant difference in FVC/FEV1 values
between pre (immediate postpartum), post 1 (after 4
week) & post 2 (after 8 week) of GROUP B (F= 3.861,
P=0.033) by repeated measure ANOVA. When both
the groups compared by unpaired T-test (of pre & post
2) it shows significant difference in improvement of
lung functions (t=0.604, P=0.0551). This shows that
significant change in the lung functions in postpartum
mothers after breathing exercises.
Table 1 shows significant difference in comparing
predicted FVC, FEV1, PEFR, FEF 25-75% and FEV1/
FVC values in GROUP A and GROUP B. This shows
that significant change in the lung functions in
postpartum mothers after breathing exercises. Thus,
this study rejects the null hypothesis.

Table 1: Comparison of Pulmonary Function Test Values in Pre Treatment, Post Treatment (1), Post Treatment (2)
in Group A & B

PFT VALUES Group PRE POST 1 POST 2 ANOVA unpaired T-TEST

(of pre & post2)
FVC A 63.2±13.8 69.47±11.01 74.47±11.48 F=10.847P=0.000 t = -3.572P = 0.001
B 59.27±17.33 71.87±11.72 85.4±13.56 F=42.774P=0.000
FEV1 A 69.67±14.5 81.87±11.64 87.13±14.26 F=21.263P=0.000 t = -3.680P = 0.000
B 68.47±18.83 85.73±14.59 103.1±17.24 F=59.096P=0.000
PEFR A 35.67±11.54 46.53±9.07 50.67±8.64 F=15.892P=0.000 t = -3.552P = 0.001
B 37±11.77 52±15.87 69.73±14.77 F=27.495P=0.000
FEF25-75% A 59.13±17.9 74.47±6.69 75.93±16.47 F=7.134P=0.003 t = -3.242P = 0.003
B 64.53±22.08 82.6±19.18 112.3±30.74 F=23.966P=0.000
FVC/FEV1 A 91.38±9.79 97.75±3.30 96.55±4.48 F=4.927P=0.015 t = 0.617P = 0.542
B 96.1±5.67 98.64±2.39 99.45±1.20 F=4.118P=0.027

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 256 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
CONCLUSION
As per the results and discussion we can conclude
that there is significant change in the lung functions
(FVC, FEV1, PEFR, FEF25-75%, FEV1/FVC) in
postpartum mothers after breathing exercises
Acknowledgement: At the completion of this
dissertation I would like to express my gratitude to
the people who gave me guidance, inspiration, and
suggestions all through the dissertation, without
whom this study could not have been a success.
Conflict of Interest: none
Source of Funding: none
Ethical Clearance: Obtained from parent institute.
CONSENT FORM
REFERENCES
1. Joanna C. Girling; 2004; Physiology Of
Pregnancy; Obstetrics; Anesthesia And Intensive
Care Medicine; The Medicine Publishing
Company Ltd.; Page No. 215-218
2. Robson S.C.; 1991; Serial Changes In Pulmonary
Haemodynamics During Human Pregnancy: A
Non-Invasive Study Using Doppler
Echocardiography.; Clin Sci 80; Page No.113–117
3. Girling J C.; 2000; Re-Evaluation Of Creatinine
In Pregnancy.;Journal Of Obstet Gynaecol; 20;
Page No.128–31
4. Girling J C, Dow E;1997 Liver Function Tests In
Pre-Eclampsia: The Importance Of Comparison
With A Reference Range Derived For Normal
Pregnancy. Br J Obstet Gynaecol; 104: Page No.
246–50
5. Jill Mantle, Jeanette Haslam, Sue Barton; 2004;
Physiotherapy In Obstetrics And Gynecology;
Second Edition; Elsevier Publication; Page
No.31-38
6. Physiotherapy In Obstetrics & Gynecology;
Margret Polden; Chapter 2; Physiology Of
Pregnancy; Pg.No.34
7. S.Sunder; Textbook Of Rehabilitation; Third
Edition; Chapter 25; Cardiac & Pulmonary
Rehabilitation; Pg.No.464
47. AMRITA TOMA--253--.pmd 256
8. Therapeutic Exercise Foundation And
Techniques; Fifth Edition; Carolyn Kisner And
Allen Colby; Chapter 23; Women’s Health:
Obstetrics And Pelvic Floor; Pg.No.800-821,
852-880
9. El-Batanouny Mm,2009, Effect Of Exercise On
Ventilatory Function In Welders, Egyptian Journal
Of Bronchology, Vol 3, No 1,Page No. 69-73
10. Guyton A And Hall Je. Text Book Of Medical
Physiology 9th Ed Pulmonary Ventilation And
Pulmonary Circulation), Ch 5 Philadelphia, W.B.
Saunders Company; Pp. 1996;300-18.
11. Brannon, Fj, Et Al: Cardiopulmonary
Rehabilitation: Basic Theory And Application, Ed
2. Fa Davis, Philadelphia, 1993.
12. Frownfelter, D, Massey, M: Facilitating
Ventilation Patterns And Breathing Strategies. In
Frownfelter, D, Dean, E (Eds) Cardiovascular
And Pulmonary Physical Therapy: Evidence And
Practice, Ed 4. Mosby, St. Louis, 2006,
Pp 377–403
13. Fishburne Ji. Physiology And Disease Of The
Respiratory System In Pregnancy. A Review. J
Reprod Med 1979;22: Page No. 177–89.
14. Delket K, David A And Kervy R. The Effect Of
Biofeed Back Assisted Breathing Retraining In
Lung Function In Patient With Cystic Fibrosis.
Chest. 1994;100:23-28
15. Barr, Rn: Pulmonary Rehabilitation. In Hillegass,
Ea, Sadowsky, Hs (Eds) Essentials Of
Cardiopulmonary Physical Therapy, Ed 2. Wb
Saunders, Philadelphia, 2001, P 727.
16. Bianchi, R, Gigliotti, F, Romagnoli, L, Et Al: Chest
And Wall Kinematics And Breathlessness During
Pursed Lip Breathing In Patients With Copd.
Chest 125:459–465, 2004.
17. Jones, Aym, Dean, E, Chow, Ccs: Comparison Of
The Oxygen Cost Of Breathing Exercises And
Spontaneous Breathing In Patients With Stable
Chronic Obstructive Pulmonary Disease. Phys
Ther 83(5):424–431, 2003.
18. Amawy Aa, Emara Am And Ibrahim A. Effect
Of Physical Therapy On Workers With Chronic
Obstructive Lung Disease In Jute And Hemf
Industry. A Master Thesis, Faculty Of Physical
Therapy, Cairo University. 198:140.
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 257
19. Casiari, Rj, Et Al: Effects Of Breathing Retraining
In Patients With Chronic Obstructive Pulmonary
Disease. Chest 79:393, 1981
20. Dr. Suresh.R; A Study Of Efficiency Of Breathing
Exercises To Improve Pulmonary Function In
Tetraplegic And High Paraplegic Subjects; Ijpmr
15, April 2004; 17-22
21. Gross D, Ladd Hw, Riley Ej, Macklem Pt,
Grassino A. The Effect Of Training On Strength
47. AMRITA TOMA--253--.pmd 257
And Endurance Of The Diaphragm In
Quadriplegic. Am J Med 1980; 68:27-35.
22. Janice Derrickson, Nancy Clesia, Nancy Simpson,
P Cristina Imle. A Comparison Of Two
Breathings Exercises Programs For Patients With
Quadriplegia. Phys Ther 1992;72:763-9.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
258 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Impact of Simultaneous Feedback Augmentation and Real

Time Treadmill Training on Gait in Diplegic Childre

Ragab Kamal Elnaggar

Lecturer of Physical Therapy, Department of Physical Therapy for Disturbances of Growth and Development in
Children and its Surgery, Faculty of Physical therapy, Cairo University, Egypt

ABSTRACT

Background: Gait training is the basic component of rehabilitation of diplegic children. Gait
abnormalities often persist throughout their life and negatively affect their functional performance.
This study aimed to investigate the effectiveness of simultaneous feedback augmentation and real
time gait training on gait in diplegic children.

Method: participants were thirty ambulant diplegic children, aged from 6 to 10 years, randomly
assigned into two groups. Control group; received the treadmill training without provision of sensory
cues and study group; received treadmill training with augmented visual and verbal feedback.
Treatment was for 30 minutes treadmill training, three times weekly for three successive months.
Step length, step width, velocity, hip, knee, and ankle joints angular displacement at mid stance
were evaluated by 3D gait analysis using Vicon Clinical Manager software before and after the
intervention.

Results: No significant difference between groups pre-treatment (P> 0.05). There was a significant
improvement in all the measuring variables within both groups and significant differences between
groups in favor of the study group in all outcomes post treatment (p < 0.05).

Conclusion: implementation of augmented feedback in gait training program may be effective in

improving gait performance in diplegic children.

Keywords: Spastic Diplegia, Feedback Augmentation, Gait Parameters

INTRODUCTION Throughout the rehabilitation, physical therapist

may impose a walking rhythm upon the child that is
Cerebral palsy (CP) is a group of persistent
not the child own and not self driven by the child so
movements and postural disorders caused by
that inadequate motor learning occurs4. So that creating
unprogressive lesion in the developing immature
a tangible intuitive interface by using feedback system
brain1. Large number of children with CP may have
help to improve the children capabilities and walking
impaired lower Limb (LL) function during standing
practice in cerebral palsied children through the
and walking2.
provision of additional support5.
spastic diplegic children are usually independent
Feedback augmentation technologies provide a
ambulant but most have an identified gait deviations
safe, controlled environment to teach children proper
such as toe walking, semi flexed hips and knees,
functional motor skills. It provides consistent feedback
interiorly tilted pelvis with compensated lumbar hyper
for motivation and wide ranges of practice6. It creates
lordosis, low walking speed and impaired functional
a virtual context and objects that allow for interactions
capacity 3.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 259
with users7, 8. This technology provides an alternative
intervention program for helping to manage functional
limitations in children with CP9. Also it provides an
exercise environment in which the intensity of practice
and positive visual and auditory feedback can be
precisely and systematically selected in various nearly
natural environments to allow for individualized
training in motor learning9, 10.
Feedback augmentation is often used as an adjunct
to a well established traditional rehabilitation
programs to reinforce performance rather than being
used as a primary intervention for rehabilitation. The
child has to gain in the real time settings to get benefits
from the feedback training11.
MATERIALS AND METHOD
Study Design: This study was a randomized
controlled trial. The procedure followed was in
accordance with the ethical standards and after the
attainment of informed consent from children’s
parents or their legal guardian.
Subjects: 30 spastic diplegic children were
recruited for this study from King Khalid hospital, Al-
Kharj, Saudi Arabia based on the following inclusion
criteria. 1) Diplegic children has the ability to self
ambulate independently, 2) Their ages ranged from 6-
10 years, 3) Emotional and cognitive state enable the
child understanding and cooperation during
evaluation and treatment, 4) Free of fixed
musculoskeletal deformities in their lower limbs, 5)
Informed consents were obtained from the parents or
the legal guardian of all children. All participants were
assigned to randomly into two groups; control and
study group. Both had basically received the same gait
training program but the experimental group had
additional feedback augmentation using both visual
and verbal cues during the training program.
Instrumentation: For evaluation, motion analysis
system with Vicon Clinical Manager software which
consists of: a camera system with twelve cameras for
three dimensional gait analyses, a wand kit is used for
calibration of system, six meters long walkway with
embedded force platform, a computer with installed
Vicon Manager Software.
For treatment: The system used for training was
Zebris Rhawalk Platform System; the system includes
an instrumented treadmill with a pressure sensor
matrix, a unit for projecting the step pattern within
48. Ragab Cairo --258--.pmd 259
the platform, a large screen for projecting the
individual virtual feedback training and a processing
unit.
PROCEDURES
For evaluation: Kinematic gait analysis by 3D
motion analysis system: step length (cm), step width
(cm), velocity (m/min) and angular displacement of
hip, knee and ankle during mid stance phase were
measured for both groups before and after treatment.
Preparing the system includes the following steps: a-
Setup for the cameras and volume. b- Calibration of
the 3D before capture was performed. c- Capture or
measurement phase starts, including marker setup and
entering subject data (name, age, weight and height)
on computer software. The child asked to walk along
the walk path on freely chosen speed for a minimum
5-10 walking trials before data collection. d- Export or
transfer of the selected gait cycle of the evaluated
patient for analysis and obtaining the desired data.
When the calculations are completed, the results were
displayed showing the calculated global gait
parameters.
For treatment: The control group received treadmill
gait training program with full body weight support
conducted for 30 minutes (2 blocks each block is 15
minutes with rest in between) without provision of
any external cues in addition to a physical therapy
program including, strengthening exercises, standing
and walking balance exercise, postural reactions
exercises, stretching exercises for 30 minutes The
program conducted 3 times per week for three
successive months.
The study group received the same physical
therapy program with augmented visual and verbal
feedback during treadmill gait training; each session
after familiarization the actual gait parameters
recorded by the pressure sensors and 2D cameras
connected to the treadmill, the target training
parameters on a self selected speed were defined then
the training started. The training environment the
patient had to follow consisted of a straight walking
path through a forest with minimal visual distraction
displayed on the screen on the face of the child. The
feedback consisted of real time representation of the
target parameters by foot projections displayed on both
the treadmill and the screen in front of the child and
verbal cues from the therapist were used to guide the
patient feedback. The treadmill training also was 30
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 260 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

minutes divided into 2 bouts each one for 15 minutes
with time for rest and instruction between bouts in
addition to 30 minutes for the other exercise program.
Statistical analysis: T-test was conducted to
compare the mean differences between both groups
pre and post treatment. Paired t test was conducted to
compare pre and post treatment mean differences of
the outcome measures within each group and
unpaired T-test conducted to compare the differences
between groups. The level of significance for all
Table 1:Age, weight and height of both groups at the baseline.
statistical tests was set at p < 0.05. All statistical
measures were performed through the statistical
package for social studies (SPSS) version 20 for
windows.
RESULTS
The mean ± SD age, weight, and height of control
and study groups as shown in table 1 indicates no
significant difference between both groups in the mean
age, weight, and height (p > 0.05) at the baseline.

Item Χ ±SD p-value

Control Study
Age 8.050±1.214 7.786±1.168 0.556
Weight 33.867±3.852 34.643±3.835 0.591
Height 134.067±6.363 130.929±7.966 0.250

Measurement data were expressed as mean ± SD. Age (years); Weight (kg) and Height (cm).

Results of the control group: the mean changes in
the all outcome measures for the control group pre
and post treatment is summarized in Table 2. Results
of the outcome measures of spatiotemporal gait
assessment and hip, knee and ankle joint displacement
showed that there was a significant difference pre and
post-treatment in control group (P<0.05).
Results of the study group: also comparison of the
pre and post treatment mean values of the outcome
measures of the study group indicates a significant
differences in mean changes for all outcome measures
(P<0.05) as represented in table 2.

Table 2: pre and post treatment mean differences of spatiotemporal gait parameters and hip, knee and ankle joints
displacement of right and left sides within both control and study group.

Control group Study group

Χ ±SD Χ ±SD
Pre Post p-value Pre Post p-value
Step length(cm) 32.883±4.748 34.368±3.289 0.005 32.451±5.044 38.146±3.847 0.001
Step width(cm) 20.564±2.167 19.914±2.248 0.001 20.480±2.811 18.347±1.625 0.001
Velocity(m/min) 45.377±4.812 47.107±3.987 0.003 44.457±4.912 50.692±5.167 0.001
RT hip displacement 34.467±2.295 31.933±2.492 0.001 33.933±1.944 27.667±2.469 0.001
LT hip displacement 34.533±2.669 31.467±3.021 0.001 33.267±2.251 25.467±2.264 0.001
RT knee displacement 35.133±3.979 33.400±3.757 0.001 35.333±3.599 29.733±3.788 0.001
LT knee displacement 36.067±3.283 33.533±3.399 0.001 35.267±3.127 28.733±3.327 0.001
RT ankle displacement 31.667±2.319 27.867±2.031 0.001 32.200±3.342 25.667±2.380 0.001
LT ankle displacement 32.400±1.919 29.267±2.086 0.001 31.733±2.789 26.267±2.219 0.001

Comparison between groups: The baseline
characteristics of the spatiotemporal gait parameters
(step length, stride length and velocity) and hip, knee
and ankle joint displacement of both right and left side
at mid stance for both control and study groups are
represented in table 3. Comparison revealed that there
were no significant differences in mean changes for
all outcome measures between the two groups pre-
treatment (P> 0.05).
In table 3: Comparison of the post treatment mean
values for both groups indicates significant increase
in the step length (P= 0.007), significant decrease in
the step width (P= 0.037), significant increase of gait

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 261

velocity (P= 0.042), significant decrease of both right decrease of ankle joint displacement for both right
and left hip joint displacement (P=0.001), significant (P=0.011) and left (P=0.001) sides in favor of the study
decrease of knee joint displacement for both right group.
(P=0.013) and left (P=0.013) sides and finally significant

Table 3: pre and post treatment mean differences of spatiotemporal gait parameters and hip, knee and ankle joints
displacement of right and left sides between both control and study group.

Pre treatment Post treatment

Χ ±SD Χ ±SD
control study p-value control study p-value
Step length(cm) 32.883±4.748 32.451±5.044 0.811 34.368±3.289 38.146±3.847 0.007
Step width(cm) 20.564±2.167 20.480±2.811 0.927 19.914±2.248 18.347±1.625 0.037
Velocity(m/min) 45.377±4.812 44.457±4.912 0.608 47.107±3.987 50.692±5.167 0.042
RT hip displacement 34.467±2.295 33.933±1.944 0.498 31.933±2.492 27.667±2.469 0.001
LT hip displacement 34.533±2.669 33.267±2.251 0.171 31.467±3.021 25.467±2.264 0.001
RT knee displacement 35.133±3.979 35.333±3.599 0.886 33.400±3.757 29.733±3.788 0.013
LT knee displacement 36.067±3.283 35.267±3.127 0.500 33.533±3.399 28.733±3.327 0.001
RT ankle displacement 31.667±2.319 32.200±3.342 0.616 27.867±2.031 25.667±2.380 0.011
LT ankle displacement 32.400±1.919 31.733±2.789 0.452 29.267±2.086 26.267±2.219 0.001

DISCUSSION engagement and compliance to the rehabilitation

The gait of spastic diplegic cerebral palsied children
is often characterized by abnormal temporal and
spatial parameters of walking when compared with
those who are typically developing children during
the early stages of walking12. It adversely affect walking
stability by altering the base of support, stance time,
step length, swing time, double support time and stride
length13.
Because the gait pattern is a highly adapting pattern
the primary deficits together with the secondary
compensations may results in weakness, tightness or
contractures, in coordination, muscle imbalance and
altered forces acting on the lower limb joints and
abnormal motor control which causes these possible
gait abnormalities, the primary focus of most of motor
training program for those population should be to
improve or maintain their motor abilities14.
However the mechanisms supporting the
biofeedback augmentation induced motor recovery is
limited, so the aim of this study is to investigate the
effect of simultaneous visual and verbal feedback
augmentation and real time treadmill gait training
spatiotemporal gait parameters and lower limb’s joint
displacement.
The augmented feedback is an interesting and
interactive treatment method that has recently
identified to improve motor function with greater
program15.
Results of this study demonstrated significant
improvements in all outcomes measures in both
groups when comparing pre and post treatment mean
values within each group. There was significant
improvement in the step length increases, step width
become narrower, the velocity showed significant
increment and the hip, knee and ankle joint
displacement are significantly decreased.
The improvement of the measuring variable in the
control group may be attributed to the treadmill
training and the assigned physical therapy program.
This may have been because the leg movement
imposed by treadmill enforcing the patient to move
the lower extremities and progressively enhance the
lower limb extensibility, increased muscle strength
after training and help to optimize gait kinematics16.
These results agreed with Provost et al. 2007 who
reported that full weight support treadmill training
may be an effective intervention to improve the gait
function for some children with CP who are
ambulatory17.
Also the results supported by Mattern-Baxter et
al.2009 who found that treadmill training helps
cerebral palsied children to improve their ambulation
skills18.

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 262 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
The results of the study group demonstrated a
significant differences pre and post treatment. There
were also significant differences when the post
treatment results of the control and study groups are
compared in favor for the study group. This could be
attributed to the effect of the augmented feedback
during treadmill gait training during which repetitive
practice using visual and verbal feedback may help
generate effective synaptic potentiation and increase
the practice-induced neural plasticity and the
subsequent motor improvement.
Similarly previous studies mentioned the
neuroimaging findings after virtual and augmented
feedback training suggest that training could induce
cortical reorganization of the neural locomotor
pathways. This cortical reorganization was
accompanied with remarkable gain in locomotor
function19.
In the same context it has been shown that during
the visuomotor training vision exerts a detectable effect
on cortical excitability and spinal circuit excitability
after 120 ms of the engagement in training that includes
visual sensory inputs20, 21. Thus, augmented feedback
constitutes an effective intervention that helps to
improve motor performance and motor learning.
CONCLUSION
A 3-months augmented feedback during the gait
training program showed the potential to improve gait
performance in children with spastic diplegic cerebral
palsy who are compliant to the program and had
normal cognition. So it is recommended as adjunctive
method of the rehabilitation programs.
Acknowledgement: I’m grateful for all children
participated in this study and their families. Special
thanks to the motion analysis and therapeutic exercises
laboratory team at Salman bin Abdul-Aziz University,
Saudi Arabia.
Conflict of Interest: none
Source of Funding: none
Ethical Clearance: The procedure followed was in
accordance with the ethical standards and after the
attainment of informed consent from children’s
parents or their legal guardian.
48. Ragab Cairo --258--.pmd 262
REFERENCES
1. Bax M, Goldstein M, Rosenbaum P, et al.
Proposed definition and classification of cerebral
palsy. Dev Med Child Neurol. 2005; 47:571–576.
2. Aicardi J. Disease of the Nervous System in
Childhood. London, United Kingdom: MacKeith
Press; 1992.
3. Novacheck TF, Stout JL, Tervo R. Reliability and
validity of the Gillette Functional Assessment
Questionnaire as an outcome measure in children
with walking disabilities. J Pediatric Orthop
2000;20:75-81.
4. Valvano J. (2005) Neuromuscular system:the plan
of care. In S.Effgen (Ed.) Meeting the physical
therapy needs of children. 2005; 258-
266.Philadelphia: FA Davis.
5. Kott K, Lesher K, Deleo G. virtual reality gaming:
improving functional ambulation in children
with cerebral palsy. Annual review of
cypertherapy and telemedicine. 2008; 6: 105-110.
6. Pantelidis, V. Reasons to use virtual reality in
education. VR in the Schools. 1995; 1:9.
7. Wilson P, Foreman N, Stanton D. Virtual reality,
disability and rehabilitation. Disabil Rehabil.
1997; 19:213–220.
8. Merians AS, Jack D, Boian R, et al. Virtual reality-
augmented rehabilitation for patients following
stroke. Phys Ther. 2002; 82:898–915.
9. Sveistrup H, Thornton M, Brvanton C, et al.
Outcomes of intervention programs using
flatscreen virtual reality. Conf Proc IEEE Eng Med
Biol Soc. 2004; 7:4856–4858.
10. Carr J, Shepherd R. Movement Science:
Foundations for Physical Therapy in
Rehabilitation. 2nd ed. Austin, Tex: Pro-Ed
Publisher; 2000.
11. Wang M, Reid D. Virtual Reality in Pediatric
Neurorehabilitation: Attention Deficit
Hyperactivity Disorder, Autism and Cerebral
Palsy. Neuroepidemiology 2011; 36:2–18.
12. Boyd R, Pliatsios V, Starr R, Wolfe R, Kerr
Graham H. Biomechanical transformation of the
gastroch-soleus muscle with botulinum toxin A
in children with cerebral palsy. Dev Med Child
Neurol 2000;42:32–41.
13. Norlin R, Per Odenrick M. Development of gait
in spastic children with cerebral palsy. J Pediatr
Orthop 1986;6:674–80.
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 263
14. Deivendran K, and Jeganathan A. Gait training
On Spastic Diplegic children-A physiotherapy
approach. Nursing and Health Science.2012;1:
01-05.
15. Merians AS, Jack D, Boian R, Tremaine M, Burdea
GC, Adamovich SV, Recce M, Poizner H. Virtual
reality-augmented rehabilitation for patients
following stroke. Phys Ther. 2002; 82:898 –915.
16. Bottos M, Gericke C: Ambulatory capacity in
cerebral palsy: prognostic criteria and
consequences for intervention. Dev Med Child
Neurol 2003; 45:786-90.
17. Provost B, Dieruf K, Burtner P, Phillips J,
Bernitsky A, Sullivan K, , Bowen C, and Toser L.
Endurance and Gait in Children With Cerebral
Palsy After Intensive Body Weight-Supported
TreadmillTraining. Pediatr Phys Ther 2007; 19:
2- 10.
18. Mattern-Baxter K, Bellamy S and Mansoor J.
Effects of intensive locomotor treadmill training
48. Ragab Cairo --258--.pmd 263
on young children with cerebral palsy. Pediatr
Phys Ther 2009;21:308 –319.
19. You S, Jang S, Kim YH, Hallett M, Ahn S, Kwon
YH, Kim J and Lee M.Virtual Reality Induced
Cortical Reorganization and Associated
Locomotor Recovery in Chronic Stroke: An
Experimenter-Blind Randomized Study. Stroke.
2005; 36:1166-1171.
20. Franca M, Turella L, Canto R, Brunelli N, Allione
L, Andreasi NG, Desantis M, Marzoli D, Fadiga
L: Corticospinal facilitation during observation
of graspable objects: a transcranial magnetic
stimulation study. PLoS One 2012, 7(11): e49025.
21. Roche N, Bussel B, Maier MA, Katz R, Lindberg
P: Impact of precision grip tasks on cervical spinal
network excitability in humans. J Physiol
(Lond) 2011,589(14): 3545-3558.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
264 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Relative & Cumulative efficacy of Auditory & Visual

Imagery on Upper Limb Functional Activity among
Chronic Stroke Patients

Fuzail Ahmad1, Sami Al-Abdulwahab2, Nasser Al-Jarallah3, Raidah Al-Baradie4, Mohammad Z Al-Qawi5,
Faizan Z Kashoo6, Harpreet S Sachdeva7
1
Head, Department of Physical Therapy, College of Applied Medical Sciences, Majmaah University, Kingdom of
Saudi Arabia, 2Professor, Department Rehabilitation Sciences, College of Applied Medical Sciences, King Saud
University, Riyadh, Kingdom of Saudi Arabia, 3Dean, College of Applied Medical Sciences, Majmaah University,
Kingdom of Saudi Arabia, 4Consultant Neurologist, Neuroscience Center, King Fahd Specialist Hospital, Department
of Pediatrics, Dammam University, Dammam, Saudi Arabia, 5Head Stroke Unit, King Faisal Specialist Hospital and
Research Center, Riyadh. Kingdom of Saudi Arabia,6Department of Physical Therapy, College of Applied Medical
Sciences, Majmaah University, Kingdom of Saudi Arabia, 7Physical Therapist, Department of Neurology &
Neurosurgery, CN Centre, All India Institute of Medical Sciences, New Delhi, India

ABSTRACT

Introduction: Stroke is a very limiting disease for the patient and a major health problem in most
parts of the world. Activity limitations of the upper extremity are a common finding for individuals
living with the effects of stroke, with its prevalence reported between 33% and 95% of this population.
This study aims to explore whether imagery involves the activation of primary sensory cortices and
to determine the therapeutic effectiveness and benefits of mental imagery training for arm function
in chronic stroke patients.

Material & Method: The study was conducted as a randomized, pre-post pilot project with four
patient groups. Patients underwent imagery ability screening using the mental chronometry,
autonomic monitoring before group allocation and randomization. We also assessed the patients on
Motor Activity Log (MAL) to assess motor impairment in the affected Upper extremity. F-wave, f
MRI along with MAL was administered.

Result Recovery between baseline and outcome assessment was evident on all outcome variables.
However, no differences between the three groups were found on the primary outcome measure.

Conclusion: The results support the efficacy of programs incorporating mental practice for
rehabilitating affected arm function in patients with chronic stroke. Mental imagery is a clinically
feasible, cost-effective complement to the therapy that may improve outcomes more than participation
in therapy only. This concept in the clinical settings can provide an additional benefit in improving
the upper limb function in stroke patients.

Keywords: Stroke, Hemiplegia, Mental Imagery, Stroke Rehabilitation

INTRODUCTION problem in most parts of the world. People who

experience a stroke may undergo sudden and intense
Stroke is a sudden loss of brain function caused by
changes in perception, cognition, mood, speech,
the interruption of flow of blood to the brain or the
health-related quality of life, and function2.
rupture of blood vessels in the brain1. Stroke is a very
limiting disease for the patient and a major health

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 265
Activity limitations of the upper extremity are a
common finding for individuals living with the effects
of stroke, with its prevalence reported between 33%
and 95% of this population. These activity limitations
may occur because of deficits in body structures and
functions caused by the stroke, such as in motor ability,
somatosensation and perceptual ability3.
Traditional stroke rehabilitation therapies address
this incompatibility by using behavior repetition. The
hope is that repeated physical practice will improve
motor activity, allowing for smooth and controlled
movements to occur, acting as examples for the brain
to use in reestablishing the circuitry that mediates
voluntary movement4-5.
This has led to a variety of interventions that
rehabilitation professionals, may use to maximize the
upper extremity function of the individuals, they treat6.
Recently, mental imagery; a technique through
which an individual repeatedly mentally rehearses an
action or task without actually physically performing
the action or task have become additional therapy
interventions7.
As the current approaches to stroke rehabilitation
is characterized by multiple and unsubstantiated
philosophies and a tendency to invest efforts in those
with severe stroke and in goals limited to self-care it is
posited that mental practice could be a non-invasive,
useful tool in rehabilitating patients with strokes.
This study aims to explore whether imagery
involves the activation of primary sensory cortices and
to determine the therapeutic effectiveness and benefits
of mental imagery training for arm function in chronic
stroke patients.
METHODOLOGY
The study was conducted as a randomized
controlled trial with four groups; auditory imagery
group (EA); visual imagery group (EV); cumulative
imagery group (EC) & control group (CG). Subjects
aged having first episode of unilateral stroke within
1-6 months with not more than grade 3 spasticity on
Motor Assessment Scale (MAS) in the affected upper
extremity, without any severe cognitive deficits,
aphasia, rheumatologic or musculoskeletal damage in
the affected upper extremity, were selected for this
study. The patients were excluded from the study if
they did not perceive upper extremity motor
49. Fuzail Ahmad-264--.pmd 265
weakness. Patients were excluded from the study if
they were discharged from hospital within 1 week and
did not present with an upper limb motor weakness
All the patients signed an informed consent then
underwent imagery ability screening using the mental
chronometry before group allocation and
randomization.
Outcome Measures
Action Research Arm Test (ARAT) was used for
assessing the functional limitations of the upper limb
(UL) on the affected side. It includes 19 items divided
into four subscales: grasp, grip, pinch, and gross
movement. Reliability (interrater = 0.99, test-retest =
0.98), construct validity, and predictive validity of the
ARAT have been well-established8.
Motor Activity Log (MAL)9, is a focal measure of
self-perceived disability on tasks requiring UL use. It
is used for assessing how much and how well patients
use their affected arm for activities of daily living
(ADL). Thirty specific ADL tasks are evaluated with
the use of a 6-poin amount of use (AOU) scale and a 6-
point quality of movement (QOM) scale.
Levels of independence and functional limitations
were evaluated with regards to Activities of Daily
Living using the Barthel Index (BI)10 covering items of
ambulation, body care, mobility, alertness and
communication.
Intervention Protocol
All the four groups received single task training
during the physiotherapy sessions in the intervention
program. The selected task in the study experiment
consisted of four discrete stages; sit upright with hand
supported on the lap, reach for and grasp the cup, lift
the cup and drink a sip of water, extend your arm and
keep the cup back to starting point, grasp release, hand
back to lap. The task was selected since it was
considered familiar and not complex for single session
training; moreover, the task involves unilateral
extremity activity.
Fig. 1. Discrete stages of the selected task.
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 266 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

The experimental groups received training with
auditory, visual or both auditory and visual imagery
techniques. A blinded examiner performed the
screening assessments and recorded outcome
measures at baseline (BA), and immediately after the
training session (TS) on the same day. In total the
treatment time was about 45 – 50 minutes.
RESULTS
Randomization, using a statistical minimizing
procedure, was successful and no group differences
at baseline were found on all the outcome measure or
on any of the other demographic or clinical
characteristics.
At baseline MAL-QOM score for EA, EV, EAV
group patients were 3.4+0.5, 3.8+0.5 & 3.3+1, which
have been changed post training to 3.8+0.6, 4+0.9 and
3.7+0.6 respectively. Median MAL-QOM score for
control patients before the intervention was 3.4 + 0.6;
and the post-intervention score was 3.5 + 0.4.

Table 1: Comparison between baseline and post-training scores of motor activity log.

EA M+SD EV M+SD EC M+SD CG M+SD Kruskal–Wallis test

N=3 N=3 N=3 N=3
X2 P
QOM BA 3.4+0.5 3.8+0.5 3.3+1 3.4+0.6 0.423 0.672
QOM TS 3.8+0. 6 4+0.9 3.7+0.6 3.5+0.4 1.311 0.921
AOU BA 3.8+0.9 3.5+0.8 3.7+0.5 3.9+0.7 0.08 0.934
AOU TS 3.6+0. 6 3.9+0.7 3.2+0.8 3.4+0.5 1.35 0.177

Keys: EA-Auditory Imagery Group EV-Visual Imagery Group EC-Cumulative Imagery Group CG-Control Group, QOM-Quality of
Movement, AOU-Amount of Use

Similarly, at baseline MAL-AOU score for EA, EV,
EAV group patients were which have been changed
3.8+0.9, 3.5+0.8, 3.7+0.5 post training to 3.6+0.6, 3.9+0.7,
3.2+0.8 respectively. Median MAL-AOU score for
control patients before the intervention was 3.9+0.7
and 3.4+0.5 post-intervention.
There were no differences in motor imagery ability
between the treatment groups (Table 2). Control data
collected with age-matched neurologically intact
healthy volunteers on the same measure with the right
hand, suggests no difference in motor imagery ability
between participants.
No differences between the three groups were
found on the primary outcome measure, the ARAT
(Table 3). Neither were there differences between the
groups on measures of functional impairment.
Improvement on the primary outcome measure, the
ARAT score, correlated with improvement on the
secondary outcome measures of activities of daily
living level, (r = 0.23, P < 0.05), QOM-AOU
(r = -0.60, P <  0.001), and BI (r = -0.25,
P<0.01), but not with MAL-QOM(r=0.12, n.s).
Mental status questionnaire score at baseline showed
a significant relationship with improvement on
activities of daily living level (r=-0.26, P<0.01)
but not with improvement on any of the other outcome
measures (P>0.12).

Table 2: Between Group mean performance and ANCOVA analysis group differences on primary and secondary
outcome measures.

Group n Baseline Post-training Between group

assessment assessment difference
Mean (SD) Mean (SD) P-value

Action Reach Arm Test (ARAT)

Mental Imagery Training- Auditory 10 21.22 (14.20) 26.33 (19.24) 0.77 0.35
Mental Imagery Training-Visual 10 25.64 (18.10) 31.51 (20.68)
Mental Imagery Training-Cumulative 10 26.23 (17.92) 32.87 (20.76)
Control-Group 10 23.06 (17.66) 30.38 (20.53)

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 267

Table 2: Between Group mean performance and ANCOVA analysis group differences on primary and secondary
outcome measures. (Contd.)

Group n Baseline Post-training Between group

assessment assessment difference
Mean (SD) Mean (SD) P-value

Motor Assessment Log (QOM)

Mental Imagery Training- Auditory 10 3.4 (.52) 3.8 (.63) 0.98 0.14
Mental Imagery Training-Visual 10 3.8 (.52) 4 (.93)
Mental Imagery Training-Cumulative 10 3.3 (.97) 3.7 (.59)
Normal Care Control 10 3.4 (.62) 3.5 (.42)
Motor Assessment Log (AOU)
Mental Imagery Training- Auditory 10 3.8 (.87) 3.6 (.63) 0.38 0.19
Mental Imagery Training-Visual 10 3.5 (.81) 3.9 (.73)
Mental Imagery Training-Cumulative 10 3.7 (.53) 3.2 (.79)
Normal Care Control 10 3.9 (.74) 3.4 (.53)
Barthel Index
Mental Imagery Training- Auditory 10 55.20 (11.02) 47.28 (15.16) 0.98 0.54
Mental Imagery Training-Visual 10 58.40 (15.02) 50.28 (18.78)
Mental Imagery Training-Cumulative 10 64.16 (14.04) 55.42 (15.81)
Normal Care Control 10 62.50 (14.26) 53.49 (18.68)

There were no differences in motor imagery ability

between the treatment groups [F(2,97) = 0.65,
P=0.52). Control data collected with age-matched
neurologically intact healthy volunteers on the same
measure with the right hand, suggests no difference
in motor imagery ability between participants in the
trial and healthy controls [F(1,142) = 1.56,
P=0.21, Graphic=0.01]. Motor imagery ability
of the participants in the trial correlated with change
between baseline and outcome assessments on the
primary outcome measure, the ARAT difference score
(r=0.28, P=0.002). However, within the ‘Motor
Imagery Training’ group, motor imagery ability was
not correlated with ARAT change scores (r=0.12,
P=0.23).

Fig. 1. Difference in various outcomes selected for this study.

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 268 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
DISCUSSION
The aim of this study was to evaluate the
therapeutic benefit of mental practice in sub-acute
stroke patients with a moderate motor weakness. The
rationale for the efficacy of mental practice in stroke is
that activation of motor brain areas through imagery
will enhance brain plasticity. If the neural principle of
‘firing is rewiring’ applies to mental practice in stroke,
than we would expect to find a clinical benefit in
patients’ early post-stroke. Processes of functional
redistribution have been demonstrated in early
recovery and have been linked to physical practice. If
the underlying mechanisms of mental practice can be
attributed to brain plasticity rather than motivational
or cognitive factors, then we should see enhanced
recovery in stroke patients participating in mental
practice independent of physical practice of
movements11. In the design of this study a number of
factors were carefully considered in order to provide
a more direct evaluation of this plasticity account.
Mental practice was not embedded in physical therapy,
which was instead offered to all participants as part of
normal care, in order to provide a more direct
evaluation of the plasticity account12.
This relates to the issue of combined physical and
mental practice. An important part of the rationale of
the current trial was to exclude the possibility that
mental practice merely provides prolonged
opportunity to consolidate particular movement
patterns, and find a more direct indication that mental
practice works through processes of brain plasticity
independent of the effects of physical movement. Since
we previously found that combined mental and
physical practice gave improvement on the trained
task only13, We felt it was necessary to evaluate the
benefit of mental practice when not combined with
physical practice of the movements. The prudence of
evaluating motor imagery training independent of
motor performance was also pointed out by Sharma
and colleagues14. Previous studies combined mental
practice with physical practice. In their mental practice
evaluations Page and colleagues15 reported a clinical
benefit for mental practice in a series of small studies
and one randomized controlled trial. The placebo
condition was always audiotape-led relaxation. This
means that patients in the treatment group had an
opportunity during mental practice to consolidate
movement patterns that they earlier had been
practicing physically, while the control group did not
49. Fuzail Ahmad-264--.pmd 268
have this advantage. The benefit of combined physical
and mental practice can therefore be attributed to any
of the following mechanisms. The mental practice
extended engagement with motor processes, which
may give rise to enhanced cognitive models of
performed movements, or may even have a
motivational effect. Alternatively, it is possible that an
indirect effect of neuroplasticity accounts for the
findings, where mental practice reactivates recently
used motor representations allowing for an increased
effect of the physical practice itself. However, all these
explanations would imply that the benefit of mental
practice is not independent of physical practice, and
does not provide a ‘backdoor to the motor systems
after stroke’ or form an alternative if physical practice
is not possible16.
Furthermore, as patients performed well on the
objective motor imagery ability measure, it is also
unlikely that patients were unable to benefit from
mental practice due to impaired motor imagery. It is
possible that spontaneous recovery in these sub-acute
patients masked the subtle benefit of mental practice,
but again the reported small effect sizes of the
treatment effects in this study do not suggest this.
As such, the finding of the current carefully
controlled powered trial, representative of the stroke
population, is important in the evaluation of the
therapeutic benefit of mental practice. Future research
will need to investigate the role of both chronic patient
status and prolonged mental practice in clarifying the
therapeutic benefit of cumulative mental practice in
stroke.
CONCLUSION
The results support the efficacy of programs
incorporating mental practice for rehabilitating
affected arm function in patients with chronic stroke.
Mental imagery is a clinically feasible, cost-effective
complement to the therapy that may improve
outcomes more than participation in therapy only. This
concept in the clinical settings can provide an
additional benefit in improving the upper limb
function in stroke patients.
Acknowledgment: I would like to express my
gratitude towards Sheikh Abdullah bin Abdul Mohsen
Al-Tuwaijri, Dr. Raid Al-Baradie and Majmaah University
for providing the necessary support for completing this
piece of work.
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 269
Source of Funding: This research was funded by
Sheikh Abdullah bin Abdul Mohsen Al-Tuwaijri Chair
for Applied Research in Stroke at Majmaah University,
Al-Majmaah, Saudi Arabia.
Ethical Clearance was taken from the Institutional
Review Board, Centre for Basic and Applied Medical
Sciences at Majmaah University.
Conflict of Interest: Nil
REFERENCES
1. Heart and Stroke Foundation of Canada. What
is a stroke? http://www.heartandstroke.com/
site/c.ikIQLcMWJtE/b.3483935/k.A279/
WhatÿisÿStroke.html
2. Mayo N, Wood-Dauphinee S, Ahmed S, Gordon
C, Higgins J, McEwen S, et al. Disablement
following stroke. Disability and Rehabilitation
1999; 21(5/6):258–68.
3. Andrews AW, Bohannon RW. Short-term
recovery of limb muscle strength after acute
stroke. Archives of Physical Medicine and
Rehabilitation 2003; 84:125–30.
4. Kosslyn, S.M., Ball, T.M., & Reiser, B.J. Visual
images preserve metric spatial information:
Evidence from Studies of image Scanning.
Journal of Experimental Psychology: Human,
Perception and Performance, 1978:Vol.4, No.1,
47-60
5. Jackson PL, Doyon J, Richards CL, Malouin F.
Potential role of mental imagery using motor
imagery in neurological rehabilitation. Arch Phys
Med Rehabil 2001; 82:1133-41.
6. Baddeley, A.D. & Logie, R. Auditory imagery and
working memory. In Auditory Imagery, D.
Reisberg, (Ed.), 179-197, Lawrence Erlbaum
Associates, Inc. Publishers, ISBN 0-8058-2292-5,
New Jersey, USA
7. Dijkerman HC1, Ietswaart M, Johnston M,
MacWalter RS. Does motor imagery training
improve hand function in chronic stroke patients?
49. Fuzail Ahmad-264--.pmd 269
A pilot study. Clin Rehabil. 2004 Aug; 18(5):
538-49.
8. Leeuwen van R, Inglis J. Mental imagery and
imagery: a potential role in stroke rehabilitation.
Phys Ther Rev 1998; 3:47-52.
9. Taub E, Morris D, Bowman M, Delgado A,
Uswatte G. Upper-Extremity Motor Activity Log
[Manual].(Available from Edward Taub,
Psychology Department, UAB, CH415,
Birmingham, Ala); 1996.
10. Mahony FL, Barthel DW. Functional evaluation.
The Barthel Index. Maryland State Med J
1965;14:61-5.
11. Pylyshyn, Z.W. Mental imagery: In search of a
theory. Behavioral & Brain Sciences,2002; Vol25,
No.2, 157-238
12. Watson, J., Myers, R., Frackowiak, R., Hajnal, J.,
Woods, R., Mazziotta, J., Shipp, S., & Zeki, S. Area
V5 of the human brain: Evidence from a
combined study using positron emission
tomography and magnetic resonance imaging.
Cerebral Cortex, 1993: Vol.3, No.2, 79–94
13. Sharma N1, Pomeroy VM, Baron JC. Motor
imagery: a backdoor to the motor system after
stroke? Stroke. 2006 Jul; 37(7):1941-52.
14. Page SJ, Levine P, Leonard A (2007) Mental
practice in chronic stroke: results of a
randomized, placebo-controlled trial. Stroke
38(4):1293–1297.
15. Page SJ, Levine P, Leonard AC (2005) Effects of
mental practice on affected limb use and function
in chronic stroke. Arch Phys Med Rehabil
86(3):399–402.
16. Page SJ, Levine P, Sisto S, Johnston MV (2001) A
randomized efficacy and feasibility study of
imagery in acute stroke. Clin Rehabil 15(3):
233–240
17. Johnson MR1, Mitchell KJ, Raye CL, D’Esposito
M, Johnson MK. A brief thought can modulate
activity in extrastriate visual areas: Top-down
effects of refreshing just-seen visual stimuli.
Neuroimage. 2007 Aug 1; 37(1):290-9.
11/1/2014, 12:17 AM
 DOI Number: 10.5958/0973-5674.2014.00344.X
270 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effect of Dexamethasone Iontophoresis Combined with

Strong Surged Faradic Current on Piriformis Syndrome -A
Simple Randomized Control Clinical Trail

Gowrishankar Potturi1, A N Sundaresan2, J Mahendran1, P D Karthikeyan1, V KrishnaReddy3

1
Lecturer, 2Senior Lecturer, School of Physiotherapy, Allianze University College of Medical Sciences, Kepalabatas,
Penang, Malaysia, 3Consultant Physiotherapist, Anisha Multispeciality Hospital, Opp. Rama Buidings, Guntur,
Andhra Pradesh, India

ABSTRACT

Piriformis syndrome has been a potential source of pain and dysfunction due to entrapment of sciatic
nerve in the piriformis muscle due to spasm and inflammation of the muscle. Ultrasound and deep
tissue frictional massage are the techniques of choice usually given to the patients with piriformis
syndrome. In this study Dexamethasone Iontophoresis along with Strong surged faradic currents
were tested and compared for alleviating pain and improving functional abilities with ultrasound
and deep tissue frictional massage. 30 patients with confirmed diagnosis of Piriformis syndrome
who satisfy the inclusion criteria were selected and are divided randomly into two, by coin flip
method. Group A, experimental group (n=15) was given Dexamethasone iontophoresis and strong
surged faradic currents. Group B, control group (n=15) was given Ultrasound and deep tissue
transverse frictional massage. Pain Visual Analog Scale (VAS) and Modified Oswestry Pain disability
questionnaire were used to measure the Outcomes. All values were tabulated and statistically analyzed
by means of paired and independent't' test .Data analysis revealed significant difference between the
two groups. Dexamethasone iontophoresis along with strong surged faradic currents is found effective
than ultrasound with deep tissue transverse frictional massage in alleviating pain and improving
functional abilities.

Keywords: Piriformis, Dexamethasone, Strong Surged Faradic Currents, Ultrasound, MOPD Questionnaire,
Deep Transverse Frictional Massage

INTRODUCTION The Piriformis is a triangular muscle that enters the

Piriformis syndrome is an entrapment neuropathy
that presents as pain, numbness, paresthesias, and
associated muscle weakness in the distribution of the
sciatic nerve1.The age of incidence for Piriformis
syndrome is usually in the fourth and fifth decades of
life 2,3,4,5
The incidence of Piriformis syndrome among the
patients with low back pain vary from 5% to 36 % and
it is estimated that a minimum of 6% patients were
wrongly diagnosed for low back pain who were
actually suffering from piriformis syndrome 4,5,13. It is
more common in women than men, possibly because
of wider ‘Q’ angle in women. 6,13
gluteal region from the pelvis through the greater
sciatic foramen. In the gluteal region, it crosses laterally
to insert onto the greater trochanter of the femur. 7The
sciatic nerve, forming a continuation of the sacral
plexus, it enters the buttock by passing through the
greater sciatic foramen, in the interval between the
piriformis and superior gemellus 8 . In 96% of
population, the sciatic nerve exits the greater sciatic
foramen deep along the inferior surface of the
piriformis muscle2, 9, 10,13. Around 22% of population,
the sciatic either pierces or splits the piriformis muscle
or both making them vulnerable for piriformis
syndrome2, 10-13.

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 271

Delay in the diagnosis of piriformis syndrome can Inclusion criteria

lead to chronic somatic dysfunction.13. The piriformis
syndrome is mainly due to the direct trauma to the 1. Patients with age 30-60
sacroiliac and gluteal region and occasionally as a 2. Both females and males
result of repetitive pressure on the piriformis muscle
leading to spasm and inflammation of the muscle 3. Patients with confirmed diagnosis of Piriformis
resulting in increase pressure over the underlying syndrome
sciatic nerve.1, 13
4. Unilateral involvement of piriformis muscle
There are many treatment options available
5. Willing to participate
conservatively by Physiotherapy which includes rest,
cryotherapy, thermotherapy, gentle pain-free 6. Conscious and coherent
stretching exercises, and Deep tissue friction massage.
All these techniques are beneficial in the form of Exclusion criteria
relieving pain and symptomatic relief and most of
1. Herniated discs
them are time consuming and effects are dictated by
various contraindications. Dexamethasone 2. Decreased skin sensations
Iontophoresis is proved for its anti-inflammatory
effects on various musculoskeletal disorders and 3. Patients with cardiac pacemakers
Strong surged faradic currents has been more
4. Known allergies to Dexamethasone
beneficial on the Muscle spasms16-20
5. Hip or pelvic pathologies
AIMS AND OBJECTIVES
6. Compromised vascular competency like in
Aim Peripheral vascular diseases

To study the effectiveness of Dexamethasone 7. Diabetic Patients

iontophoresis along with strong surged faradic
currents on the piriformis syndrome in alleviating pain Materials
and improving the functional abilities.
1. Consent forms

OBJECTIVES 2. Evaluation format

1. To study the effect of Dexamethasone 3. Ultrasound machine and conduction gel

iontophoresis along with strong surged faradic
currents in alleviating the pain and improving 4. A muscle stimulator with surged faradic and
functional abilities in patients with piriformis iontophoresis facility
syndrome. 5. Dexamethasone vials (4mg/ml) I.P
2. To compare the effects of Dexamethasone 6. Disposable syringes and needles
iontophoresis along with strong surged faradic
currents with Ultrasound with deep tissue 7. Talcum powder
transverse frictional massage in patients with
8. Towels and tissues
piriformis syndrome.
9. Electrodes, Sterile gauze,Velcrow straps
MATERIALS AND METHOD
10. Plastic cover.
The study was conducted at Anisha Multispecialty
Hospital ,Guntur (India), SIMER college of 11. Skin resistance tray
Physiotherapy OPD,Guntur(India),Anisha Polyclinic,
12. Distilled water
Tadikonda (India),Satya Hospitals Guntur(India).The
study was conducted for a period of one year .The Treatment and assessment technique
treatment for each subject was for a period of two
weeks with 3 sessions a week. 30 patients with confirmed diagnosis of Piriformis

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 272 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
syndrome who satisfied the inclusion criteria by
clinical evaluation and investigations were selected
and are divided into two, 15 in each group. The
randomization was done by coin flip method.
The patients were explained the treatment
procedure and were taken their consent before
randomization.
Group A was given Dexamethasone iontophoresis
and strong surged faradic currents each alternative day
for a total of 3 sessions per week for a period of two
weeks.
PROCEDURE
Initial assessment for the pain was done by Pain
Visual analog scale (VAS) and functional abilities were
assessed by Modified Oswestry Pain disability
questionnaire.
The iontophoresis was given by using
Dexamethasone sodium phosphate vials. A 1ml of
drug (4mg/ml injectable) was drawn into a syringe
and was mixed with 1ml of distilled water to make a
solution of 2ml. A 8 folded gauge lint was prepared
for appropriate size of electrode with 1 cm larger on
all sides. The Gauge was saturated with the solution
and was placed over the site of tenderness over the
piriformis muscle after cleaning the area to reduce the
skin resistance .A metal electrode large enough that
the current density doesn’t exceed 0.5mA/cm2 was
used for this purpose and was attached to the negative
terminal of the machine. The dispersive electrode was
placed 5 inches away from the treatment site. The
amplitude of the current was determined by patient’s
comfortable levels between 1.0 to 4.0 mA. The duration
of the treatment is adjusted to current amplitude to
produce a total treatment dose of 40mA-min.20
After the Iontophoresis treatment, the patient were
given 3-5 min strong surged faradic currents over the
piriformis muscle making the muscle to contract for
10-15 contractions with an intensity quite high to get a
maximum contraction and on-off time with a ratio of
1:3.
Group B was given Ultrasound and deep tissue
transverse frictional massage each alternative day for
a total of 3 sessions per week, for a period of two weeks.
The initial assessment and follow up was same as in
group A. The patients were given continuous
ultrasound at 2.0 W/cm2 intensity and a frequency of
50. Gowrishanker--270--.pmd 272
1MHz for duration of 10 min. The patients were given
later Deep tissue frictional massage over the piriformis
muscle. The transverse friction is applied transversely
across the longitudinal fiber orientation of the
structure. Along with transverse friction, effleurage is
given to the muscle draining into the inguinal lymph
nodes. The massage was done for 15 min.
The patients in both groups were trained for self
stretching of piriformis muscle as a part of home
programme
Outcome measures
The outcome was measured by Modified Oswestry
Pain disability questionnaire and Pain visual analog
scale and was compared to the initial readings. The
Modified Oswestry pain disability questionnaire is an
extremely important tool designed to give the therapist
information as to how the back pain has affected
patient’s ability to manage in everyday life. It consists
of 10 sections, each section with a minimum score 0
and a maximum score 5, thus the total score is 50, and
the patient is asked to tick one box that best describes
his condition. The scoring is calculated in percentage
by the following formula:
% of disability= where is the
calculated MOPD score from the patient.
The Pain visual analog scale (VAS) was used to
assess the pain. It is a simple assessment tool consisting
of a 10 cm line with 0 on one end representing no pain
and 10 at the other representing the worst pain ever
experienced. The patient is asked to indicate where
the pain is present in that range.
Results and data analysis
In this study to analyze the effects on the outcome
measures before and after Dexamethasone
iontophoresis and strong surged faradic currents in
Group A (experimental group) and Ultrasound with
Deep transverse friction massage in Group B (control
group), all data was expressed as mean+/-, standard
deviation and was statistically analyzed using paired‘t’
test and independent‘t’ test to determine the statistical
difference among the parameters at 0.5% level of
significance.
Paired‘t’ test was used to examine the changes in
dependent variables from base-line to after completion
of intervention in each group. The pre test mean value
of Modified Oswestry pain disability questionnaire in
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 273
Group A is 81.73 (S.D=5.39) and the post test mean
value is 31.33(S.D=4.70) with t value 37.2 and P value
< 0.05.(Table 1)
The pretest mean value of MOPD questionnaire in
Group B is 82.4 (SD=4.22) and the post test is
43.6(S.D=3.31) t=31.1 and P value < 0.05. (Table 1)
The independent‘t’ test is done to calculate the
significance of difference in MOPD questionnaire
results between Group A and Group B. The mean of
differences of MOPD questionnaire scores between
pretest and post test in Group A is 50.4(S.D=5.11) and
in Group B is 38.8(S.D=4.73) with t-value 6.89.
(p<0.05)(Table 2)
The pretest mean value of Pain Visual Analog Scale
(VAS), in Group A is 8.33 (S.D=0.816) and the post test
mean value of VAS is 1.93(S.D=0.704) t=22.1 and
p<0.05 (Table 3 )
The pretest mean of VAS in Group B is
7.53(S.D=0.64) and the post test mean value of VAS is
4.80(S.D=0.414), t=13.3 and p<0.05 (Table 3)
The independent t test is done to calculate the
significance of difference in VAS scores between Group
A and B. The mean of differences in VAS scores
between pretest and post test in Group A is
6.4(S.D=1.12) and in Group B is 2.73(S.D=0.79) t value
=10.3154 (p<0.05) (Table 4)
Thus from above statistical data of MOPD and VAS,
Group A is significantly different from Group B with
p<0.05, i.e. 95% of significance, hence we reject the null
hypothesis.
DISCUSSION
This randomized single blinded controlled clinical
trial evaluated the efficiency of Dexamethasone
iontophoresis along with strong surged faradic
currents over pain and functional abilities in the
patients diagnosed with Piriformis syndrome over a
two weeks trail has found significant differences
favoring the experimental group in the form of
reduction of pain and improving the functional
abilities.
There are many researches proving the effect of
iontophoresis in inflammatory conditions like bursitis
and tendinitis.16-19
50. Gowrishanker--270--.pmd 273
Stephenson, R. ed (2009), in his study Iontophoresis
protocol calcaneal Bursities, demonstrated that
Dexamethasone is an anti-inflammatory drug which
gives best results in iontophoresis.
Taskaynatan,M;OzgulA, et.al(2007) in their study
Effect of steroid Iontophoresis and Electrotherapy on
bicipital tendonisits,(Journal of Musculoskeletal pain
) demonstrated that Dexamethasone iontophoresis has
a anti-inflammatory effect in bicipital tendinitis.
Andrew T. Doyle, et.al (2011) in their study Effects
of Dexamethasone Iontophoresis: Acute Muscle Injury
of the Biceps Brachii (Athletic Training and Sports
Health Care.) proved Dexamethasone iontophoresis
has speedy effects in acute muscle injuries.
Iontophoresis is the easiest and safe method of
introduction of the drug without having the
disadvantages of systemic or parenteral administration
such as pain, risk of cross infections from needles,
systemic ill effects. The benefits of using transdermal
drug delivery include improved systemic
bioavailability resulting from by passing first
metabolism.19 Thus the drug acts faster than the oral
administration or parenteral administration.
Strong surged faradic currents are believed that it
breaks the spasm cycle by deblocking the muscle
spasm in which the over activity of the muscle spindle
cycle is broken down.17,18 It also helps in increased
circulation and venous return, thus reducing the ill
effects of inflammation and spasm.
CONCLUSION
The following conclusions are drawn from the present
study
Dexamethasone iontophoresis along with strong
surged Faradic currents have a beneficial effect in
alleviating pain and improving functional abilities in
patients diagnosed with Piriformis syndrome.
Dexamethasone iontophoresis along with strong
surged Faradic currents are faster ,safer, and effective
in alleviating pain and improving functional abilities
in patients diagnosed with Piriformis syndrome over
Ultrasound with Deep tissue frictional massage.
Acknowledgements: I would like to extend my
gratitude to Dr. SrinivasaNaidu, Director, SIMER and
Satya Hospitals, Guntur and Dr.I Ramesh Babu,
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 274 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Director and Medical Superintendent Anisha least; I would like to thank all the subjects who actively
Multispecialty Hospitals Guntur for allowing us to participate in this study.
take up the study in their hospital. Last but not the

Table 1: Comparison of Pre and Post test values of MOPD questionnaire scores in Group A and Group B

MOPD questionnaire score Group A Group B

Mean SD P value Mean SD P value
Pre test 81.73 5.39 <0.05 82.4 4.22 <0.05
Post test 31.33 4.70 43.6 3.31
T value 37.2 31.1

Table 2: Comparison of Pre test and Post test differences in MOPD scores in Group A and Group B

Mean of differences in MOPD scores Pre test and Post test Mean SD T value P value
Group A 50.4 5.11 6.89 <0.05
Group B 38.8 4.73

Table 3: Comparison of Pre and Post test values of Pain VAS scores in Group A and Group B

Pain VAS scores Group A Group B

Mean SD P value Mean SD P value
Pre test 8.33 0.816 <0.05 7.53 0.64 <0.05
Post test 1.93 0.704 4.80 0.414
T value 22.1 13.3

Table 4: Comparison of Pre test and Post test differences in Pain VAS scores in Group A and Group B

Mean of differences in Pain VAS scores Pre test and Post test Mean SD T value P value
Group A 6.4 1.12 10.3154 <0.05
Group B 2.73 0.79

procedures were in accordance to the protocol and

followed ethical and humane principles of research.
A written consent for participation has been obtained
for this study.

REFERENCES

1. Steven D Waldman (2002) Atlas of common Pain

2.
Conflict of Interest: We do not have anything to
declare.
3.
Source of funding: This research received no specific
grant from any funding agency in the public,
commercial, Or not-for-profit sectors.
4.
Ethical Approval: I here with certify that the research
has been approved by the SIMER research ethics
committee, and all investigations and treatment
syndromes Elsevier’s Health sciences
Philadelphia P.A, USA. Page 220.
Beaton LE,Anson BJ.The Sciatic nerve and the
Piriformis Muscle: their relation a possible cause
of coccygodynia Journal of Bone joint surgery
AM.1938;20:686-688
Benson ER,Schutzer SF.Post traumatic Piriformis
Syndrome:diagnosis and results of Operative
treatment.Journa of Bone joint surgery
AM.1999;81:947-949
Papadopoul OSEC, Khan SN.Piriformis
syndrome and Low back pain: A new
classification and review of the literature.
Orhtopclin North America.2004; 35:65-71.

50. Gowrishanker--270--.pmd 274 11/1/2014, 12:17 AM

 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 275
5. Papadopoul OSEC, Korres DS,Papachristou G,
Efstathopoulosn.Orthopaedics.2004 Aug;27(8):
797,799
6. Pace Jb, Nagle D.Piriformis syndrome west
journal of medicine 1976; 124:435-439.
7. Carmine D clement (2010), Clemente’s Anatomy
Dissector (3rd ed) Lippincott Williams & Wilkins,
Page 214
8. Daniel John Cunningham, Arthur Robinson.
Cunningham’s textbook of Anatomy, W.Wood,
1818 Page 728.
9. Pecina M. contribution to the etiological
explanation of the piriformis syndrome. Acta
Anat(Basel) 1979;105:181-187.
10. Williams PL ,Warwick R.Gray’s Anatomy ,36th
ed:Philadelphia PA:WB saunders co:1980
11. Lori A.Boyajian-ONeill;Rance L.Mc
Clain;MicheleK.Coleman,Pamela P.Thomas
Diagnosis and Management of Piriformis
syndrome: An Osteopathic approach.The journal
of American Osteopathic Association, Nov 1, 2008
Vol.108 no 11 657-664.
12. Nwuge VCB, Ultrasound treatment of back Pain
resulting from Prolapsed disc,Arch Phys.Med
Rehabil 64:88-89,1983.
13. Stephenson ,R. ed(2009),Iontophoresis
protocol:calcaneal Bursities,IOMED online
references.
14. Taskaynatan,M;OzgulA, Ozdenir A, Tan A &
Kalyon T(207) Effect of steroid Iontophoresis and
Electrotherapy on bicipital tendonisits,Journal of
Musculoskeletal pain,14(4),47-54.
50. Gowrishanker--270--.pmd 275
15. Anderson CR,Morris RL,BoehSD,Panus
PC,Sembrowich WL, Effects of Iontophoresis
current magnitude and duration on
Dexamethasone deposition and localized drug
retension,Physther.2003Feb;83(2):161-70
16. Andrew T. Doyle, MA, LAT, ATC, CSCS;
Christopher C. Cheatham, PhD; Michael G.
Miller, EdD, ATC, CSCS; Timothy J. Michael,
PhD, FACSM, ACSM-CES; Robert J. Baker, MD,
PhD, ATC; John M. Spitsbergen, PhD Effects of
DexamethasoneIontophoresis: Acute Muscle
Injury of the BicepsBrachii Athletic Training and
Sports Health CareNovember/December 2011 -
Volume 3 · Issue 6: 260-270.
17. Srinivasan N,(2011) Srimathi’s Electrotherapeutic
Agents Manual, Jaypee Brothers Medical
Publishers(p)Ltd, New Delhi, India Page 54,75
18. Monica Kesson,(2005) Elaine Atkins. Textbook of
Orthopaedic Medicine. 2nd Edition. Elsevier:
Butterworth Heinemann; page: 71-82.
19. Nagappagari Madhuri, E Bhrgav, AnandManne,
V Ravi, K Ramesh: Transdermal Drug delivery
system-A review(2013) ,WJPPS, Volume 3,Issue
1,170-186
20. MichelleH.Cameron (2009) ,Physical Agents in
Rehabilitation From research to practice 3 rd
ed,Saunders Elsevier Missouri(Page 223-225)
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 DOI Number: 10.5958/0973-5674.2014.00344.X
276 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Effect of Ageing on Lumbar Curvature, Lumbar Mobility,

Back Extensor Strength and Their Relationship with
Postural Stability and Clinically Relevant Low Back Pain

Mohammad Rehan Asad1, Khwaja Mohammad Amir2, Fahim Haider Jafari3,

Mohamed Taha 4, Waqas Sami5
1
Assistant Professor, Department of Anatomy, 2Assistant Professor, Department of Physiology, 3Associate Professor
and Head, 4Assistant Professor, Department of Basic Medical Sciences, College of Medicine, Majmaah University,
Kingdom of Saudi Arabia, 5Lecturer, Biostatics, Department of Public Health and Epidemiology, College of Medicine,
Majmaah University, Kingdom of Saudi Arabia

ABSTRACT

Introduction: CLBP is one of the most disabling and therapeutically challenging pain conditions
afflicting older adults, till now very limited research has conducted to define its impact on function.
Mainly in older individuals, CLBP is at least partially related to degenerative changes associated
with aging.

Objectives: To investigate the differences in spinal kyphotic angle, spinal mobility, muscle power,
and postural imbalance in people of different age. To elaborate the important spinal factors
contributing postural instability in clinically relevant low back pain.

Materials and Method: It was cross sectional correlational study. The total sixty patients, age ranging
from 17 -70 (yrs.) having complaint of back pain from minimum three months were included from in
the study. Cognitive impairment, Severe visual or hearing impairment, Acute illness or pain
Neurological or Metabolic disorders were considered as the criterion of exclusion. The twenty six
healthy subjects were included in an age matched control group. The shape and mobility of the
spinal column was recorded by using spinal mouse for both normal and back pain subjects. They
were also asked to fill the Oswestiry questionnaire for evaluating disability index.

Results: A positive correlation between the Oswestry disability index (ODI) with age (r = .505,
p = .000) and negative correlation with lumbar lordosis (r = -.581, p = .002) and lumbar extension
range of motion (r = -.542, p = .004) was found.

Conclusion: The findings of our study establishes the fact the in patients suffering from chronic low
back pain, the back extension range of motion and lumbar curvature is affected across the age group.

Keywords: Low Back Ache, Lumbar Lordosis, Spinal Mouse, Lumbar Extension

INTRODUCTION older adults, yet there is a limited body of research

Low back pain is a major health problem affecting
the adult population. Recurrent or chronic Low back
pain (CLBP) is estimated to occur in 35–79% of patients
[1, 2]
.
CLBP is one of the most disabling and
therapeutically challenging pain conditions afflicting
dedicated to defining its impact on function [3]. Mainly
in older individuals, CLBP is at least partially related
to degenerative changes associated with aging [4]. The
degenerative process (Spondylosis) involves the
intervertebral discs, facet joints, vertebral bodies, and
spinal ligaments. Although these studies have begun

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 277
to shed light on the functional consequences and
disability related to low back pain, the
multidimensional consequences of CLBP in older
adults remain unknown.
As the aging process can lead to the decreased
spinal mobility, clinician must be able to distinguish
between age-related decreases in spinal mobility and
pathological limitations in spinal mobility [5] .
Distinguishing between age-related and pathological
limitations on spinal mobility is difficult because
within the same age group, values of spinal mobility
may vary widely [6].
The degree of spinal mobility indicates the extent
of the limitation in CLBP patients. The role of postural
differences and spinal mobility in CLBP disability are
uncertain. A plausible contributing factor to CLBP is
poor control of trunk muscles to the exigencies of day-
to-day activities. [7] The postural instability in patients
with LBP was hypothesized to stem from, among other
things, injury and/or damage to proprioceptive tissues
in the lumbar spine.
Any knowledge of the associations between spinal
morphology and mobility in CLBP will help in
preventing disability, in determining diagnosis and the
therapy program.
Evidence of both a relationship and no relationship
between posture and CLBP has been reported in
previous in-vivo posture studies [8, 9]. These conflicting
findings may be due to posture being relevant to CLBP
in some populations but not others. However, no
reports have described the relationships between
ageing, spinal curvature, spinal mobility, back extensor
strength and their association with postural
imbalances in clinically relevant low back pain
patients. The purpose of this study was therefore to
investigate the differences in spinal kyphotic angle,
spinal mobility, muscle power, and postural imbalance
in people of different age group, and to elucidate the
significant contributing spinal factors for postural
instability in clinically relevant low back pain patients.
Material & Method: This study was designed as
cross-sectional correlation study and data collection
was done at King Khalid Hospital, Majmaah and
Majmaah University, Al-Majmaah, KSA. The span of
the study was one year. The Community dwelling
adults aged between 17 to 70 years with chronic low
back pain, defined as pain of at least moderate intensity
for at least past 3 months and age matched normal
were included in this study.
51. Dr. Rehan soudi arabia--276--.pmd 277
Spinal Mouse: The Spinal Mouse is a computer-
assisted medical device that can be used to determine
the shape and mobility of the spinal column by simply
gliding the device manually down the back. From the
superficial shape, an intelligent recursive algorithm
computes information concerning the relative position
of the vertebral bodies of the thoracic and lumbar
spine, while taking into account the local curvature.
PROTOCOL
Before the test, the valuator explained the test
procedures and the subjects were instructed to take
off their shirts and stand in front of the valuator with
their normal posture. Then the valuator marked the
neck of the subject with a felt-tip pen, placed the wheel
of the Spinal Mouse on the seventh cervical vertebrae
and moved down to the natal cleft of the subject. The
data were transferred from the Spinal Mouse to the
computer through blue tooth and the kyphotic angle
of the backbones was identified.
RESULTS
The data were analyzed using IBM SPSS (version
20.0), and the significance level was set at p < 0.05. A
total 60 subjects participated in this study with a mean
age of 34.9+15 years. To find out the effect on aging on
lumbar curvature and lumbar mobility the subjects
were categorized into three groups, group I (below 30
years), group II (31 – 60 years) and group III (above 60
years). Majority of the patients fall in the age group of
17 – 35 years (n=26, 43.3%), twenty-one (35%) patients
belonged to the age group of 36 – 50 years. However,
13 (21.7%) patients belonged to the age group of 51 –
70 years.
The mean Oswestry Disability Index score was
15.1+4.3, with the normal population showing a score
13.7+4.2 and the CLBP population showed a score of
17.2+4.3. The mean Sacral-Hip joint angle was 9.2+6.9
and the normal and CLBP 9+8 and 9.5+5 respectively.
The thoracic Kyphosis angle (50.7+15.2) did not
showed much variation between the normal and CLBP
population. Similarly mean Lumbar lordosis was -
20.7+15.2 that showed very little deviation in normal
& CLBP population. (Table 1)
It was found that thoracic spine angles were
significantly greater in group II (58.64°) as compared
to group III (58.03°), and smaller in group I (39.24°).
Range of Flexion was significantly greater in group III
(8.36°) as compared to group I (6.90°) and group II
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 278 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

(8.30°). In addition, Range of Flexion and Extension
was significantly greater in group III (14.16°) as
compared to group II (13.42°).
Lumbar spine angles in standing position, were
significantly greater in group III (-31.61°) as compared
to group II (-21.49°) and group I (-22.58°). Range of
Flexion was significantly greater in group III (43.35°)
as compared to group II (37.60°). However, angles of
range of extension and range of flexion and extension
does not significantly differ in age groups (p>0.05). In
the standing position, whole trunk angles were
significantly greater in group II (6.10°) as compared to
group III (2.99°).

Table 1: Descriptive statistics

Group AGE ODI U_SHJ_A U_TC U_LC U_Inc U_LOS

Age Matched N 39 39 39 39 39 39 39
Control Group
Mean 32.38 13.72 9.00 50.59 -20.56 3.54 491.87
SD 14.041 4.249 7.967 16.752 9.528 5.744 72.575
Experimental Group N 26 26 26 26 26 26 26
Mean 38.58 17.23 9.46 50.92 -19.77 4.96 511.69
SD 12.602 3.581 4.958 12.964 9.953 4.771 40.774
Total N 60 60 60 60 60 60 60
Mean 34.86 15.12 9.18 50.72 -20.25 4.11 499.80
SD 13.727 4.328 6.880 15.241 9.631 5.383 62.230

ODI- Oswestry disability indexscores; SHJ_A- Sacral hip joint angle; TK- Thoracic kyphosis; LL- Lumbar lordosis; AOI- Angle of inclination;
LOS- Length of spine.

Range of Flexion was significantly greater in group
III (85.92°) as compared to group II (75.28°). In
addition, range of flexion and extension was
significantly greater in group III (102.51°) as compared
to group II (91.73°). However, no significant difference
was observed in range of extension and age groups.
Sac / hip angles in standing position, were significantly
greater in group III (13.96°) as compared to group II
(8.16°). However, angles of range of flexion, range of
extension and range of flexion and extension does not
significantly differ in age groups (p>0.05) respectively.
To find out the correlation between the outcome
variables Pearson correlation coefficient was calculated
which a showed a positive correlation between the
Oswestry disability index (ODI) with age (r = .505, p =
.000) and negative correlation with lumbar lordosis (r
= -.581, p = .002) and lumbar extension range of motion
(r = -.542, p = .004). Lumbar lordosis also showed
negative correlation with Sacral-Hip joint angle (r = -
.647, p = .000) and lumbar extension range of motion
(r = -.277, p = .026) and positive correlation with angle
of inclination (r = .297, p = .016). (Table: 3)

Table 2. Group wise description of the outcome variables

Sub_Group AGE ODI SHJ_A TK LL AOI LOS

Age Matched Normal N 19 19 19 19 19 19 19
Subjects <30 Years
Mean 20.11 11.63 9.63 45.42 -19.84 2.74 465.58
SD 2.601 2.773 9.299 19.577 11.147 7.194 84.239
Young Subjects N 10 10 10 10 10 10 10
with LBP <30 Years
Mean 26.80 15.90 8.80 45.80 -20.60 2.90 495.80
SD 7.131 3.695 4.849 12.497 10.543 3.957 44.542
Age Matched Normal N 15 15 15 15 15 15 15
Subjects 31-50 Years
Mean 38.87 14.27 8.27 53.07 -20.20 4.33 520.67
SD 2.774 3.127 7.611 13.030 7.729 3.559 55.344

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 279

Table 2. Group wise description of the outcome variables

Sub_Group AGE ODI SHJ_A TK LL AOI LOS

Middle Aged LBP N 11 11 11 11 11 11 11
Subjects b/n 31-50 Years
Mean 40.36 19.00 9.91 57.00 -22.73 5.55 519.82
SD 3.557 3.578 5.718 10.602 8.878 5.047 35.919
Age Matched Normal N 5 5 5 5 5 5 5
Subjects >50 Years
Mean 59.60 20.00 8.80 62.80 -24.40 4.20 505.40
SD 3.975 5.612 2.683 3.271 8.532 5.495 27.628
Older Population N 5 5 5 5 5 5 5
with LBP >50 Years
Mean 58.20 16.00 9.80 47.80 -11.60 7.80 525.60
SD 3.114 1.581 4.147 15.450 7.925 4.658 40.581
Total N 65 65 65 65 65 65 65
Mean 34.86 15.12 9.18 50.72 -20.25 4.11 499.80
SD 13.727 4.328 6.880 15.241 9.631 5.383 62.230

ODI- Oswestry disability indexscores; SHJ_A- Sacral hip joint angle; TK- Thoracic kyphosis; LL- Lumbar lordosis; AOI- Angle of inclination;
LOS- Length of spine.

Table 3: Correlation between the outcome measures.

AGE ODI SHJ_A LL AOI LR-Flx LR_Ext

AGE Pearson Correlation 1 .505** -.059 .085 .252* -.213 -.068
Sig. (2-tailed) .000 .639 .502 .043 .088 .589
ODI Pearson Correlation .505 **
1 -.043 -.581** .199 -.061 -.542**
Sig. (2-tailed) .000 .732 .002 .113 .630 .004
SHJ_A Pearson Correlation -.059 -.043 1 -.647** .164 .302* .117
Sig. (2-tailed) .639 .732 .000 .192 .014 .354
LL Pearson Correlation .085 -.581** -.647** 1 .297* .040 -.277*
Sig. (2-tailed) .502 .002 .000 .016 .754 .026
AOI Pearson Correlation .252* .199 .164 .297* 1 -.378** .087
Sig. (2-tailed) .043 .113 .192 .016 .002 .491
LR_Flx Pearson Correlation -.213 -.061 .302* .040 -.378** 1 .290*
Sig. (2-tailed) .088 .630 .014 .754 .002 .019
LR_Ext Pearson Correlation -.068 -.542** .117 -.277* .087 .290* 1
Sig. (2-tailed) .589 .004 .354 .026 .491 .019

**. Correlation is significant at the 0.01 level (2-tailed).

*. Correlation is significant at the 0.05 level (2-tailed).

a. Group = Age Matched Control Group

Fig. 1. Between group comparison of Oswestry Disability index

scores Fig. 2. Between group comparison of Lumbar Lordosis

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 280 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
DISCUSSION
Abnormal posture and spinal mobility of the
sagittal plane has been demonstrated to cause
significant impairments in the elderly [10]. Prior studies
have proven an existing, although conflicting, evidence
linking different spinal postures to low back pain [11,
12]
. Notably, most of the literature studies focus on
either thoracic kyphosis or lumbar lordosis, but not
on the change of the entire spinal alignment [13, 14, 15].
Also, there are still some controversies regarding
whether the curvature and mobility of the lumbar
region better relate to spinal function and balance
compared to the thoracic spine, in both cases without
fully understanding their progression [16, 17, 18]. Thus, it
is meaningful to focus more attention on the global
change of the spine and the relationship between the
different spinal postural types [10] Roussouly et al.
classified patients into four types mainly according to
the reciprocal relationships between the sacral slope
and the characteristics of the lumbar curvature [19].
Similarly, Lee et al. grouped 86 volunteers into three
types based on the horizontal lumbar level [20]. Smith
et al. established four subgroups by cluster analysis of
three angular measurements of thoraco-lumbopelvic
alignment [21].
CONCLUSION
The findings of our study establishes the fact the in
patients suffering from chronic low back pain, the back
extension range of motion and lumbar curvature is
affected across the age group.
Acknowledgement: This project was funded by Basic
& Health Sciences Research Centre, Deanship of
Research, Majmaah University, Saudi Arabia.
Ethical Clearance: The scanned copy the ethical
clearance by Majmaah Research Institutional Ethical
Committee is pasted here.
Funding: This project was funded by Basic & Health
Sciences Research Centre, Deanship of Research,
Majmaah University, Saudi Arabia.
Conflict of Interest: Nil
REFERENCES
1. P. R. Croft, G. J. Macfarlane, A. C. Papageorgiou,
E. Thomas, and A. J. Silman, “Outcome of low
back pain in general practice: a prospective
study,” British Medical Journal, vol. 316, no. 7141,
pp. 1356–1359, 1998.
51. Dr. Rehan soudi arabia--276--.pmd 280
2. H. J. M. Van Den Hoogen, B. W. Koes, W. Devillé,
J. T. M. Van Eijk, and L. M. Bouter, “The prognosis
of low back pain in general practice,” Spine, vol.
22, no. 13, pp. 1515–1521, 1997.
3. Hartvigsen J, Christensen K, Frederiksen H.
(2003). Back pain remains a common symptom
in old age; a population-based study of 4486
Danish twins aged 70-102. European Spine
Journal 12(5):528-34.
4. R. A. Deyo and J. E. Bass, “Lifestyle and low-back
pain. The influence of smoking and
obesity,” Spine, vol. 14, no. 5, pp. 501–506, 1989.
5. Fitzgerald GK, Wynveen KJ, Rheault W, et al:
Objective assessment with establishment of
normal values for lumbar spinal range of motion.
Phys Ther 63:1776-1781, 1983.
6. Einkauf, D.K., Gohdes, ML, Jensen, GM, Jewell,
M.J.1987. Changes in spinal mobility with
increasing age in women. Physical Therapy,
67 (3), 370–75.
7. Muthukrishnan R, Shenoy SD, Jaspal
SS, Nellikunja S, Fernandes S. The differential
effects of core stabilization exercise regime and
conventional physiotherapy regime on postural
control parameters during perturbation in
patients with movement and control impairment
chronic low back pain. Sports Med Arthrosc
Rehabil Ther Technol. 2010; 2-13.
8. Tuzun C, Yorulmaz I, Cindas A, Vatan S: Low
back pain and posture. Clin
Rheumatol 1999, 18:308-312
9. Widhe T: Spine: posture, mobility and pain. A
longitudinal study from childhood to
adolescence. Eur Spine J 2001, 10:118-123.
10. Hua-Jun Wang et al. A Modified Sagittal Spine
Postural Classification and Its Relationship to
Deformities and Spinal Mobility in a Chinese
Osteoporotic Population. PLoS ONE, 2012; 7(6),
1-8.
11. Satoh K, Kasama F, Itoi E, et al. (1988) Clinical
features of spinal osteoporosis: spinal deformity
and pertinent back pain. Contemp Orthop 16: 23–
30
12. Takemitsu Y, Harada Y, Iwahara T, Miyamoto
M, Miyatake Y (1988) Lumbar degenerative
kyphosis. Clinical, radiological and
epidemiological studies. Spine 13: 1317–1326.
13. Nevitt MC, Ettinger B, Black DM, Stone K, Jamal
SA, et al. (1998) The association of
radiographically detected vertebral fractures with
back pain and function: a prospective study.
Annals of Internal Medicine 128: 793–800.
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 281
14. Martin AR, Sornay-Rendu E, Chandler JM,
Duboeuf F, Girman CJ, et al. (2002) The impact
of osteoporosis on quality-of-life: the OFELY
cohort. Bone 31: 32–36.
15. Miyakoshi N, Itoi E, Kobayashi M, Kodama H
(2003) Impact of postural deformities and spinal
mobility on quality of life in postmenopausal
osteoporosis. Osteoporosis International
16. Imagama S, Matsuyama Y, Hasegawa Y, Sakai
Y, Ito Z, et al. (2011) Back muscle strength and
spinal mobility are predictors of quality of life in
middle-aged and elderly males. European Spine
Journal 20: 954–961.
17. Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa
Y, Noguchi H, et al. (2010) Relationships between
falls, spinal curvature, spinal mobility and back
extensor strength in elderly people. Journal of
Bone & Mineral Metabolism 28: 82–87.
18. Sinaki M, Brey RH, Hughes CA, Larson DR,
Kaufman KR (2005) Balance disorder and
51. Dr. Rehan soudi arabia--276--.pmd 281
increased risk of falls in osteoporosis and
kyphosis: significance of kyphotic posture and
muscle strength. Osteoporosis International 16:
1004–1010.
19. Roussouly P, Gollogly S, Berthonnaud E, Dimnet
J (2005) Classification of the normal variation in
the sagittal alignment of the human lumbar spine
and pelvis in the standing position. Spine 30: 346–
353.
20. Lee CS, Chung SS, Kang KC, Park SJ, Shin SK
(2011) Normal patterns of Sagittal Alignment of
the Spine in Young Adults Radiological analysis
in a Korean population. Spine (Phila Pa 1976):
0.1097/BRS.0b013e318216b0fd.
21. Smith A, O’Sullivan P, Straker L (2008)
Classification of sagittal thoraco-lumbo-pelvic
alignment of the adolescent spine in standing and
its relationship to low back pain. Spine 33: 2101–
2107.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
282 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

A Study to Identify Responses to Sensory Events in Daily

Life in Children with ADHD & Typical Developing
Children among Indian Population

U Ganapathy Sankar1, Kotharu Akhila2

1
Vice Principal, 2BOT, Occupational Therapist, SRM College of Occupational Therapy,
SRM University, Kattankulathur

ABSTRACT

Objective: The purpose of this study was to compare parents' perceptions of the responses of their
children, with ADHD and typically developing children, to sensory events in daily life in India.

Method: Forty four children with ADHD and matched typically developing children parents were
recruited for the study. Sensory Profile(SP) was used to identify differences in sensory abilities of the
children.

Results: MANOVA was used to compute the results. The result shows that there is statistically
significant difference demonstrating a group effect on the SP section scores(F (13, 74) = 6.97; p<
0.011) and factor scores (F (8, 79) = 10.88, p<0.01). The comparison between groups on the individual
scores revealed that there is a significant difference on 6 out of 14 subsections and 6 out of 9 factor
scores in sensory profile.

Conclusion: The findings of the present study suggest that young children with ADHD seem to be at
increased risk of deficits in a variety of sensory processing abilities, over and above the core symptoms
of ADHD as reported by the mother's.

Keywords: Sensory Profile, ADHD, Typically Developing Children

INTRODUCTION information through our senses, organize, and

The term sensory integration dysfunction was first
used by Ayres in 19631.She theorized that impaired
sensory processing might result in various functional
problems, which she labeled Sensory Integration
Dysfunction 2. According to the new nosology a
classification was proposed based on previous work
by many theorists and researchers3,4,5. It proposes that
the diagnosis of Sensory Processing Disorder (SPD)
rather than Sensory Integration Dysfunction6.Sensory
Processing is the term that refers to the way in which
the central and the peripheral nervous system manage
incoming sensory information including the reception,
modulation, integration and organization of sensory
stimuli7. It refers to our ability to take in sensory
interpret that sensory information and make a
meaningful response. The neurological
disorganization resulting in SPD occurs in three
different ways: the brain does not receive messages
due to a disconnection in the neuron cells; sensory
messages are received inconsistently; or sensory
messages are received consistently, but do not connect
properly with other sensory messages. When the brain
poorly processes sensory messages, it results in
inefficient motor, language, or emotional output.
According to Sensory Integration International
concerned with the impact of sensory integrative
problems on people’s lives, the following are some
signs of sensory processing disorder:

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 283
• Oversensitivity to touch, movement, sights, or
sounds, underreactivity to touch, movement,
sights, or sounds
• Tendency to be easily distracted,social or
emotional problems
• Activity level that is unusually high or
low,physical clumsiness or apparent carelessness
• Impulsive, lacking in self-control
• Inability to unwind or calm self
• Delays in speech, language, or motor skills
• Delay in academic achievement
Need For The Study
Researchers have attempted to describe the unique
patterns of sensory responsivity typical of children
with ADHD, using both physiological and behavioral
measures. Testing children with ADHD on
physiological measures, such as the Somatosensory
Evoked Potential (SEP) 8 , and Electro Dermal
Reactivity (EDR) 9 , has shown that a signiûcant
percentage of ADHD children display differences in
sensory reactivity compared to typical developing
children. Various behavioural measures, such as
parent questionnaires and examiner checklists, have
indicated an increased sensitivity to sensory stimuli
such as tactile10,11,12, visual, auditory, and taste13. In
addition, research has indicated that children with
ADHD may have deûcits in vestibular and
somatosensory functions, such as balance, postrotary
nystagmus,14 and tactile discrimination. Additional
deûcits, believed to result largely from inefûcient
sensory processing, have also been described, such as
problems in motor coordination and
planning.Recently, two studies incorporating the use
of the Sensory Proûle (SP) Questionnaire on children
with and without ADHD 15 have been performed,
inorder to understand parents’ perceptions of their
children’s responses to sensory events in daily life
across all sensory domains. Dunn and Bennett 16
compared parents’ perceptions of sensory behaviors
of 70 children ages 3 to 15 years with ADHD to those
of parents of 70 typical children matched for age and
gender. Results revealed that parents’ perceptions of
children with ADHD differed signiûcantly from those
52. A Ganapathy--282--287.pmd 283
of children without disabilities in their sensory
responsiveness on all 14 sections of the SP. Mangeot
et al. (2001) compared the occurrence of sensory
modulation dysfunction (SMD) of 26 children with
ADHD and a control group of 30 typically developing
children (ages 5 to 13 years). The children were tested
on various measures, including the Short Sensory
Proûle Questionnaire (SSP; McIntosh, Miller, Shyu, &
Dunn,1999). Their results indicated that children with
ADHD displayed greater abnormalities in sensory
modulation on both physiological and parent report
measures. The children with ADHD showed
signiûcantly lower scores on six of the seven subscales
of the SSP, particularly in sensory seeking, auditory
ûltering, and in sensitivity to tactile, auditory, visual,
taste, and olfactory stimuli. In addition, on all subscales
of the SSP except auditory ûltering, greater variability
was found in parents’ perceptions of sensory responses
among the children with ADHD. Literature revealed
that there may be sensory processing deûcits among
children with ADHD, most studies investigated
isolated sensory systems only. Of the only two studies
that did explore the sensory processing of children
with ADHD across all sensory domains9,16, the age
range of the participants was wide. Research has
indicated the existence of a developmental trend for
sensory processing within some of the systems17.
Therefore, it seems appropriate to conduct a thorough
investigation of these abilities within each distinct age
group18. In addition, since poor sensory processing
abilities in young children may affect their social,
cognitive, and sensory-motor development4 , early
identiûcation and intervention may contribute to their
overall well being.
Therefore, current study was carried out to
compare the Sensory Profile scores of 4-8 years childen
in India with ADHD and typically developing.
Research Question
Is there significant difference in response to sensory
events in ADHD & typical developing children?
AIM& OBJECTIVES
To compare the section scores and factor scores of
sensory profile between ADHD & typical developing
children.
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 284 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

MATERIALS & METHOD Instrument used

Research Design Sensory Profile

Group comparison design was used to identify Description

possible differences in sensory processing between
children with ADHD and typically developing
children.
SAMPLE
Forty four children (32 males and 12 females) with
ADHD and 44 typically developing children (32 males
and 12 females), matched by age, gender, recruited in
this study. Ages ranged from 4–8 years (mean age =
5.8 years, SD = 0.92). Participants were included from
various special school, occupational therapy center and
normal school by using convenience sampling
procedure.
The sensory profile is a standardized sensory
questionnaire15 with 125 items, in which parents rate
their children’s responses to sensory events that occur
in daily life. The 14 subsections are divided into three
overall sections: Sensory Processing, Sensory
Modulation, and Behavioral & Emotional responses.
The 9 factors includes sensory seeking, emotionally
reactive, low endurance- tone, oral sensory sensitivity,
poor registration, inattention-distractibility, sensory
sensitivity, sedentary, and motor- perceptual. It is a 5
point rating scale.
Reliability

Screening Criteria Reliability includes internal consistency estimates

of 4.0 to 0.91.Content validity, construct19, Convergent
Inclusion Criteria and discriminant validity has been reported. Research
- DSM IV criteria for ADHD. has also demonstrated that the sensory profile can
discriminate between children with and without
- Age group 4- 8 years. various disabilities19, 20.

- Both genders. Data Collection Procedure & Analysis

The typically developing children group was
matched to the research group (ADHD) by age, and
gender.
Exclusion Criteria for both groups
- Children with physical handicapped.
- Children with pervasive developmental disorder.
- Children with motor problems like cerebral palsy,
infantile hemiplegia etc.
The purpose of this study was explained to the head
of the institutions of schools and therapy center.
Consent forms were obtained from parents of those
children. Sensory Profile was distributed to parents
and filled questionnaire was collected for data analysis.
Multivariate Analyses Of Variance (MANOVA) was
used to compare the 14 section scores and 9 factor
scores of sensory profile between ADHD and typically
developing children.

RESULTS

Table 1: Comparison of section scores of sensory profile between children with ADHD & typical developing
children.

S.No Section ADHD Typical F(13,74) Level of

developing =6.79 significance
chilren (p<0.01)
Mean SD Mean SD
A Sensory processing
1 Auditory Processing 31.250 5.257 30.770 4.528 0.208 0.649
2 Visual Processing 37.980 5.276 37.360 5.503 0.289 0.595
3 Vestibular Processing 45.840 6.731 47.300 6.579 1.051 0.308
4 Touch Processing 68.730 10.566 73.410 7.543 5.722 0.019
5 Multi sensory Processing 25.730 14.083 28.070 4.245 1.114 0.294
6 Oral Processing 38.750 8.851 42.730 10.480 3.699 0.058

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 285

Table 1: Comparison of section scores of sensory profile between children with ADHD & typical developing
children. (Contd.)

S.No Section ADHD Typical F(13,74) Level of

developing =6.79 significance
chilren (p<0.01)
Mean SD Mean SD
B Sensory Modulation:
7 Endurance – Tone 39.570 5.386 37.910 4.997 2.254 0.137
8 Body Position & Movement 38.230 5.477 42.680 6.287 12.559 0.001
9 Activity Level 26.680 6.924 30.840 4.052 11.826 0.001
10 Emotional Response 14.590 2.806 14.930 2.555 0.355 0.533
11 Visual- Emotional- Activity 13.750 9.839 16.500 1.772 3.33 0.072
C Behavior& Emotional Responses:
12 Social- Emotional 63.000 13.316 66.480 10.197 1.909 0.171
13 Behavior 25.980 9.559 26.730 4.877 0.215 0.644
14 Thresholds For Responses 10.750 3.013 12.950 2.901 12.225 0.001

MANOVA was used to compute the results. The between groups on the individual scores revealed that
result shows that there is statistically significant there is a significant difference on 6 out of 14
difference (F (13, 74) = 6.97; p< 0.011) demonstrating a subsections with in sensory profile.
group effect on the SP section scores. The comparison

Table 2: Comparison of factor scores of sensory profile between children with ADHD / typical developing
children.

S.No Factor ADHD Typical F(8,79) Level of

developing =10.881 significance
chilren (p<0.01)
Mean SD Mean SD
1 Sedentary Seeking 52.55 12.576 63.59 10.56 19.907 0.000
2 Emotionally Reactive 58.16 10.954 62.52 10.101 3.774 0.055
3 Low Endurance-Tone 39.09 5.387 39.39 5.226 0.068 0.795
4 Oral Sensory Sensitivity 34.75 7.892 31.7 7.645 3.38 1.069
5 Inattention/ Distractibility 24.34 5.969 29.07 4.887 16.524 0.000
6 Poor Registration 32.02 6.432 32.02 6.26 0 1.000
7 Sedentary Sensitivity 17.89 3.164 18.8 1.773 2.765 0.100
8 Sedentary 16.14 4.859 18.05 2.44 5.435 0.022
9 Fine Motor- Perceptual 11.41 3.294 13.2 1.936 9.715 0.002

MANOVA was used to compute the results. The . Sensory processing ability is one of the many factors
22

result shows that there is statistically significant
difference (F (8, 79) = 10.88, p<0.01) between groups.
The comparison between groups on the individual
scores revealed that there is a significant difference on
6 out of 9 factor scores in sensory profile.
DISCUSSION
Children with ADHD confirmed signiûcant
impairment of occupational performance 21. In addition
to impairment caused by the core indication of ADHD,
these children are at increased risk of associated deûcit
in various areas, one of these being sensory processing
that needs to be considered in assessing the reasons
why a child with ADHD may be experiencing
difficulties participating in occupations essential for
adequate performance in the home, at school,and
during play. The purpose of this study was to describe
the sensory processing proûle of Indian children with
ADHD as perceived by their mothers. The result of
study indicating that children with ADHD were
reported to have significantly lower scores on 6 out of
14 subsection (Table 1 & Table 2) and 6 out of 9 factor
scores in Sensory Profile. These results suggest that
children with ADHD have different pattern of sensory
modulation and sensory processing abilities compared

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 286 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
to typical developing children. Yochman et al 23 found
that there is a statistical significant difference in 6 out
of 9 factor scores & 11 out of 14 section scores. These
results are consistent with those of other studies that
have used both subjective behavioral and objective
physiological measures 8,9,10,11. The current study
ûndings are also in row with Dunn and Bennett’s
16
study, currently the only other study in which the
long version of the SP was used with this population.
Dunn and Bennett’s comparison of section scores
revealed statistically signiûcant differences between
the groups on all 14 sections, while in our study
signiûcant differences were found in 11 out of the 14.
In our analysis of the factor scores, signiûcant
differences were also found between the study groups
on 6 out of 9 factors. Since Dunn and Bennett did not
report on the factor scores in their study, no
comparison could be made on this component. The
differences, albeit minor, between the results of Dunn
and Bennett’s16 study and the current one, could
possibly be explained by differences in the nature of
the study samples used.
The present study findings and literature indicate
that section and factor scores provide different
perspectives, in that the sections reflected group
differences with respect to sensory processing deficits.
The factor scores differences were more reflective of
symptoms that characterize ADHD in general. This
highlights the importance of including both section
and factor scores in the investigation of specific study
samples. Limitation of the study is parent
questionnaire. This is one of the profiles to know the
information from parent’s to child response to sensory
event. We can’t rely on parent questionnaire because
perception of the parents may be different.
Convenience sampling procedure and small sample
size were other limitations.
CONCLUSION
This study has been taken to identify the responses
of sensory events in children with ADHD and typical
developing children. The results of this study showed
statistically significant difference on 6 out of 14 section
scores and 6 out of 9 factor scores of sensory profile.
The findings of the present study suggest that young
children with ADHD seem to be at increased risk of
deficits in a variety of sensory processing abilities, over
and above the core symptoms of ADHD as reported
by the mother’s.
52. A Ganapathy--282--287.pmd 286
Acknowledgement: We pay sincere thanks to the
chairman of SRM group of institutions and SRM
University. We owe our sincere thanks to
Mr.Christoper for their assistance with the statistical
analysis. We also immensely thank all the participants
and their family for their participation and co-
operation without whom this study would not have
been possible.
Ethical Clearance: We got consent from SRM ethical
clearance committee to carry out this study
Source of Fund: None
Conflict of Interest: None
REFERNCES
1. Ayres, A. J. (1963). Eleanor Clarke Slagle
Lecture—The development of perceptual–motor
abilities: A theoretical basis for treatment of
dysfunction. American Journal of Occupational
Therapy, 27, 221–225.
2. Ayres, A. J. (1972b). Southern California Sensory
Integration Tests. Los Angeles: Western
Psychological Services.
3. DeGangi, G. A. (2000). Pediatric disorders of
regulation in affect and behavior: A therapist’s
guide to assessment and treatment. San Diego,
CA: Academic Press.
4. Dunn, W. (2001). 2001 Eleanor Clarke Slagle
Lecture—The sensations of everyday life:
Empirical, theoretical, and pragmatic
considerations. American Journal of
Occupational Therapy, 55, 608–620.
5. Mulligan, S. (1998). Patterns of sensory
integration dysfunction: A conûrmatory factor
analysis. American Journal of Occupational
Therapy, 52, 819–828.
6. Miller, Cermak,Lane, Anzalone, & Koomar, 2007.
Concept Evolution in Sensory Integration:A
Proposed Nosology for Diagnosis,American
Journal of occupational therapy,2007, 61,(2),
135-140.
7. Miller, L. J., & Lane, S. J. (2000, March).Toward a
consensus in terminology in sensory integration
theory and practice: Part 1: Taxonomy
of neurophysiological processes.Sensory
Integration Special Interest Section Quarterly, 23,
1–4.
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 287
8. Parush, S., Sohmer, H., Steinberg, A., & Kaitz, M.
(1997).Somatosensory functioning in children
with attention deûcit hyperactivity disorder.
Developmental Medicine & Child Neurology, 39,
464–468.
9. Mangeot, S. D., Miller, L. J., McIntosh, D. N.,
McGrath-Clarke,J., Simon, J., Hagerman, R. J., et
al. (2001). Sensory modulation dysfunction in
children with attention deûcit hyperactivity
disorder. Developmental Medicine & Child
Neurology,43, 399–406.
10. Ayres, A. J. (1964). Tactile functions: Their relation
to hyperactive and perceptual motor behavior.
American Journal of Occupational Therapy, 18,
6–11.
11. Bauer, B. A. (1977). Tactile sensitive behavior in
hyperactive and non-hyperactive children.
American Journal of Occupational Therapy, 31,
447–453.
12. Lightsey, R. (1993). Tactile defensiveness in
attention deûcit/hyperactive disorder children.
Sensory Integration Special Interest Section
Newsletter, 21, 6.
13. Papadopoulos, R. J. B., & Staley, D. (1997).
Occupational therapy assessment of
neurodevelopmentally disorded children and
adolescents. Occupational Therapy in Mental
Health, 13, 23–36.
14. Mulligan, S. (1996). An analysis of score patterns
of children with attention disorders on the
Sensory Integration and Praxis Tests. American
Journal of Occupational Therapy, 50, 647–654
15. Dunn, W. (1999). Sensory Proûle: Examiner’s
manual. San Antonio, TX: Psychological
Corporation.
52. A Ganapathy--282--287.pmd 287
16. Dunn, W., & Bennett, D. (2002). Patterns of
sensory processing in children with attention
deûcit hyperactivity disorder. Occupational
Therapy Journal of Research, 22, 4–15.
17. Dunn, W., & Daniels, D. (2001). Initial
development of the Infant Toddler Sensory
Proûle. Manuscript submitted for publication.
18. Watling, R. L., Deitz, J., & White, O. (2001).
Comparison of Sensory Proûle scores of young
children with and without autism spectrum
disorders. American Journal of Occupational
Therapy, 55, 416–423.
19. Kientz, M., & Dunn, W. (1997). A comparison of
children with autism and typical children on the
Sensory Proûle. American Journal of
Occupational Therapy, 51, 530–537.
20. Ermer, J., & Dunn, W. (1998). The Sensory Proûle:
A discriminant analysis of children with and
without disabilities American Journal of
Occupational Therapy, 52, 283–290.
21. Barkley, R. A. (1990). Attention deûcit
hyperactivity disorder: Ahandbook for diagnosis
and treatment. New York: Guilford.
22. Cermak, S. A. (1988). The relationship between
attention deûcit and sensory integration
disorders (part 1). Sensory Integration Special
Interest Section Newsletter, 11, 1–4.
23. Yochman, A., Parush, S., & Ornoy, A. (2004).
Responses of preschool children with and
without ADHD to sensory events in daily life.
American Journal of Occupational Therapy, 58,
294–302.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
288 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Comparison of Incentive Spirometry V/S Peak Flow Meter

by Measuring the Peak Flow Rate in Post Operative
Abdominal Surgery Patients

Apeksha O Yadav
1
Asst. Professor, Ravi Nair Physiotherapy College, Datta Meghe Institute Medical Sciences
(DU) Sawangi (M). Wardha

ABSTRACT

Objective:

1) To find the effectiveness of inspiratory exercises in post operative abdominal surgery patients.

2) To find the effectiveness of expiratory exercises in post operative abdominal surgery patients.

3) To compare the effectiveness of inspiratory exercises v/s expiratory exercises in post operative
abdominal surgery patients.

Design: Prospective Comparative study.

Participants & outcome measure: 20 patients who underwent abdominal surgery were alternately
allocated into two equal groups. Group A subjects were given inspiratory exercises & Group B subjects
were given expiratory exercises post operatively. Outcome measures were recorded on first & seventh
day with the help of Peak flow meter.

Result: Data was collected and statistically analyzed using Student's paired t test, day one inspiratory
and expiratory volumes were measured and was found significant, whereas on seventh day both
groups showed statistically non significant result.

Conclusion: It can be concluded that both inspiratory and expiratory exercises are effective in
improving the peak flow rate in post operative abdominal surgery patients.

Keywords: Incentive Spirometry, Peak Flow Meter, Post Operative Abdominal Surgery

INTRODUCTION pressure and in oxygen-haemoglobin saturation.1, 4

Surgery and general anaesthesia directly affect the
respiratory system.1-3 Upper abdominal surgery alters
postoperative pulmonary function, as observed by
impairment of lung volumes such as total lung
capacity,1 vital capacity and tidal volume. It also
reduces the efficiency of efforts to cough for as long as
one week. There are also falls in oxygen arterial
Corresponding author:
Apeksha O Yadav
D/o Omprakash L Yadav
New State Bank Colony, Nagpur Road, Nalwadi,
Wardha - 442001
Postoperative pulmonary complications (PPC) occur
after upper abdominal surgery at a rate ranging from
6 to 70% of patients, depending on the criteria for
defining them. 1, 5-7 They may include atelectasis,
pneumonia or hypoxemia, among others.3, 7, 8 The
incidence rate depends on the surgical site, the
presence of risk factors, and the criteria used to define
a PPC.1–5 Reported incidence rates for upper abdominal
surgery ranges from 17 to 88%. 2,6,7 The basic
mechanism of PPCs is a lack of lung inflation that
occurs because of a change in breathing to a shallow,
monotonous breathing pattern without periodic
sighs, 8,9 prolonged recumbent positioning, 10 and

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 289
temporary diaphragmatic dysfunction.11,12 Mucociliary
clearance also is impaired postoperatively,13,14 which,
along with the decreased cough effectiveness, increases
risks associated with retained pulmonary secretions.
Ward et al15 showed that postoperative atelectasis is
better reduced by taking a deep breath and holding it
for 3secs than by taking multiple deep breaths or not
holding a deep breath. The first report16 on the use of
such sustained maximal inspiration for the treatment
of postsurgical patients originated in Great Britain. The
first major study showing the benefits of postoperative
maximal inspiration was carried out by Thoren17 in
343 patients who were undergoing cholecystectomy.
Thoren documented an incidence of atelectasis
(detected via radiograph) of 42% in control subjects
v/s 27% in patients treated postoperatively with
physical therapy including deep-breathing (DB)
exercises. The incidence rate declined further, to 12%,
in patients who received additional preoperative
instruction in the breathing exercises. An incentive
spirometer is a device that encourages, through visual
and/or audio feedback, the performance of
reproducible, sustained maximal inspiration. 18,19
Incentive spirometry (IS) is the treatment technique
utilizing incentive spirometer. Bartlett et al18 developed
an incentive spirometer that both provided visual
feedback to the patient and recorded the number of
successful breathing maneuvers. This unit, the Bartlett-
Edwards incentive spirometer, remained the standard
for many years, although it has since been replaced by
less expensive, single-use units. The first specific report
of IS as a treatment technique appears to be that of
Van de Water et al,20 who compared IS to intermittent
positive-pressure breathing (IPPB) in 30 patients after
they had undergone abdominal bilateral
adrenalectomy. No statistical difference was reported
in the incidence of pulmonary complications between
treatment groups. IS remains a widely used technique
for the prophylaxis and treatment of respiratory
complications in postsurgical patients. O’Donohue21
surveyed its use in the United States and reported that
95% of hospitals in which cardiothoracic and
abdominal surgery was performed used IS in
postoperative care.
The diaphragm is the main inspiratory muscle and
the abdominal muscles are the accessory expiratory
muscles of great strength, which can produce forced
expiration. Though apparently antagonistic, these
muscles are also synergistic. In fact the diaphragm
would be less effective in the absence of the abdominal
muscles.
53. Dr._Apeksha_Yadav--288-.pmd 289
Both sets of muscles are always in active contraction
but their activity varies reciprocally thus, during
inspiration the tone of the diaphragm increases while
that of the abdominal muscle decreases, and vice versa
during expiration. Hence there exists a floating
equilibrium constantly shifting in both directions; this
is the basis of antagonism – synergism of this muscles.
Respiratory complications are among the most
common of surgery and most lethal, responsible for 5
– 35% of post operative death. Upper abdominal and
thoracic incisions result in significant decrease in vital
capacity, most prominently in first 24 hrs of operation.
After upper abdominal surgery, vital capacity may
be reduced to as much as 50 – 60% while forced
respiratory capacity reduced by 30%, the cause of these
changes is multifactorial. Post operative pain alters the
mechanics of respiration; upper abdominal and
thoracic incisions have great impact. Narcotic analgesia
carries its own inherent risk because it eliminates
sighing and promotes atelectasis.
Even if pain is eliminated, there remains a
demonstrable decrease in respiratory volume, an
observation that had leaded some to suggest
diaphragmatic and abdominal muscles dysfunction.
The decrease in respiratory volumes is multifactorial.
Post operative pain alters the mechanics of respiration.
Analgesics carry its own inherent risk because it
eliminates a proper breathing pattern. Diaphragmatic
inhibition can result from inhibitory reflexes arising
from asympathetic, vagal or abdominal receptors.
Another factor is that any operation affecting the
abdominal receptors. Another factor is that any
operation affecting the abdominal muscles, the patients
tends to avoid using them because of pain or fear of
pain and thus hampers respiratory movements.
In addition to alter the mechanics and decreased
closing lung volume, other physiologic causes that
contributes to respiratory insufficiency include
diffusion defects, abnormalities in ventilation –
perfusion ratio, decrease in cardiac output with con-
committing persistent shunt, alteration in haemoglobin
level.
Incentive Spirometry
Incentive spirometers are mechanical devices
introduced in an attempt to reduce post operative
pulmonary complications.
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 290 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

Diaphragmatic movement is thought to be an Patient’s history of chronic COPD, previous abdominal

important factor in the prevention of post operative
pulmonary complications. Post operatively an increase
in lung volumes while using the patients of breathing
control without the resistive loading of an incentive
spirometer. This may help to reduce complications by
increasing ventilation to the dependent parts of the
lungs.
operations and presence of any thoracic deformities
were excluded from the study. The study was
explained to them in the language they understand
and a written consent was taken from all the
participants to undergo treatment for a week.
Observations were recorded on first & seventh day
with the help of Peak flow meter.

Peak Expiratory Flow Rates Subjects in Group A received inspiratory exercises

Peak expiratory flow rate is sustained over a 10
msec period at the beginning of forced expiratory
manoeuvre. The subject places the peak expiratory
flow meter horizontally i.e. parallel to the ground and
places the mouth piece inside the mouth, thus ensuring
that the lips curl around the mouth piece. Patient
inspires fully and forcefully expires through their
mouth. The displacement of the valve or piston is
proportional to maximum flow rate.
The best result of two or three attempts is taken,
allowing a pause of atleast 30 seconds between each
attempt. Baseline readings are repeated at 5 minute
intervals until the maximum pre treatment level is
known.
using peak flow meter and PEFR reading were taken
on first and seventh post op day.
Subjects in Group B received expiratory exercises
using peak flow meter and PEFR reading were taken
on first and seventh post op day.
Statistical analysis
Data was assessed as follows - For between group
comparisons of age distribution Chi-square test was
used. For intergroup comparison of group A and
group B Paired t-test was used, whereas for intragroup
comparison students unpaired t-test was used.
RESULT:

Table 1: Demographic data:

The purpose of this study was to compare Incentive
Spirometry v/s Peak flow meter by measuring the Age (yrs) Group A Group B
peak flow rate in post operative abdominal surgery 40 - 50 yrs 4 (40%) 4 (40%)
patients. 51 - 60 yrs 4 (40%) 2 (20%)
>60 yrs 2 (20%) 4 (40%)
MATERIAL & METHODOLOGY Total 10 (100%) 10 (100%)
Mean Age 52.10 55.20
This Prospective comparative study was carried out SD 9.72 10.43
in Tertiary Care Hospital. Materials used were
incentive spirometer and peak flow meter. 20 patients Above table reveals that age of the subjects were
who underwent abdominal surgery were alternately ranging from 40 - 60 years with average age of 52.10
allocated into two equal groups. Group A subjects years amongst Group A and 55.20 years amongst
were given inspiratory exercises & Group B subjects Group B which were comparable and difference was
were given expiratory exercises post operatively. statistically non significant.

Table 2: Comparison of inspiratory volume and expiratory volume pre and post treatment.

Group N Mean Std. Deviation Std. Error Mean

Pre T/t Inspiratory Exes 10 133.46 27.13 8.57
Expiratory Exes 10 143.96 18.51 5.85
Post T/t Inspiratory Exes 10 186.60 9.94 3.14
Expiratory Exes 10 193.30 5.01 1.58

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 291

Students unpaired t test

t Df p-value Mean Std. Error 95% Confidence
Difference Difference Interval of
the Difference
Lower Upper
Pre t/t 1.011 18 0.325 NS 10.50 10.38 -11.32 32.32
Post t/t 1.902 18 0.073 S 6.70 3.52 -0.69 14.09

Above table shows that mean score of pre treatment
for group A was 133.46 and for group B 143.96. (Lower
limit CI -11.32 - Upper limit CI 32.32) which were same
and difference was statistically non significant
(p=0.325). Post treatment score i.e. on seventh day
showed that mean score for group A was 186.60 and
for group B was 193.30. (Lower limit CI -0.69 - Upper
limit CI 14.09). Both the groups showed statistically
significant increase in peak expiratory flow rate but
Intergroup analysis showed that there is no difference
in between both the methods i.e. both are equally
effective.
CONCLUSION
It can be concluded from the study that both the
groups are equally effective in increasing the peak
expiratory flow rate.
I wish to acknowledge my parents and my sister
Dr. Abhilasha for their tremendous contribution and
support both morally and financially towards the
completion of this project.
Conflict of interest - None.
No funding was taken and ethical clearance was
taken from the institutional ethical committee (EC/
54/10).
REFERENCES
1. Siafakas NM, Mitrouska I, Bourus D,
Georgopoulos D. Surgery and the respiratory
muscles. Thorax. 1999; 54(5):458-65.
2. Brooks D, Parsons J, Newton J, et al. Discharge
criteria from preoperative physical therapy.
Chest 2002; 121(2):488-94.
3. Warner DO. Preventing postoperative
pulmonary com-plications: the role of the
anesthesiologist. Anesthesiology. 2000;
92(5):1467-72.
4. Saad IA, De Capitani EM, Toro IF, Zambon L.
Clinical vari-ables of preoperative risk in thoracic
surgery. Sao Paulo Med J. 2003; 121(3):107-10.
5. Ferguson MK. Preoperative assessment of
pulmonary risk. Chest. 1999; 115(5 Suppl): 58S-
63S.
6. Overend TJ, Anderson CM, Lucy SD, Bhatia C,
Jonsson BI, Timmermans C. The effect of
incentive spirometry on postop-erative
pulmonary complications: a systematic review.
Chest. 2001; 120(3):971-8.
7. Doyle RL. Assessing and modifying the risk of
postoperative pulmonary complications. Chest.
1999; 115(5 Suppl):77S-81S.
8. Ephgrave KS, Kleiman-Wexler R, Pfaller M,
Booth B, Werk-meister L, Young S. Postoperative
pneumonia: a prospective study of risk factors
and morbidity. Surgery. 1993; 114(4):815-9;
discussion 819-21.
9. O’Donohue WJ Jr. Postoperative pulmonary
complications: when are preventive and
therapeutic measures necessary? Postgrad Med
1992; 91:167–170, 173–175.
10. Wightman JAK. A prospective survey of the
incidence of postoperative pulmonary
complications. Br J Surg 1968; 55:85–91.
11. Hallbook T, Lindblad B, Lindroth B, et al.
Prophylaxis against pulmonary complications in
patients undergoing gall-bladder surgery. Ann
Chir Gynaecol 1984; 73:55–58.
12. Mohr DN, Lavender RC. Preoperative
pulmonary evaluation. Postgrad Med 1996;
100:241–256.
13. Kips JC. Preoperative pulmonary function. Acta
Clin Belg 1997; 52:301–305.
14. Garibaldi RA, Britt MR, Coleman ML, et al. Risk
factors for post-operative pneumonia. Am J Med
1981; 70:677–680.
15. Ferguson MK. Preoperative assessment of
pulmonary risk. Chest 1999; 115:58S–63S

53. Dr._Apeksha_Yadav--288-.pmd 291 11/1/2014, 12:17 AM

 292 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
16. Bendixen HH, Smith GM, Mead J. The pattern of
ventilation in young adults. J Appl Physiol 1964;
19:195–198.
17. Zikria BA, Spencer JL, Kinney JM, et al.
Alterations in ventilatory function and breathing
patterns following surgical trauma. Ann Surg
1974; 179:1–7.
18. Alexander JI, Spence AA, Parika RK, et al. The
role of airway closure in postoperative
hypoxaemia. Br J Anaesth 1973; 45:34–40.
19. Ford GT, Rosenal TW, Clergue FC, et al.
53. Dr._Apeksha_Yadav--288-.pmd 292
Respiratory physiology in upper abdominal
surgery. Clin Chest Med 1993; 14:237–252.
20. Chuter TAM, Weissman C, Mathews DM, et al.
Diaphragmatic breathing maneuvers and
movement of the diaphragm after
cholecystectomy. Chest 1990; 97:1110–1114.
21. O’Donohue WJ Jr. National survey of the usage
of lung expansion modalities for the prevention
and treatment of post-operative atelectasis
following abdominal and thoracic surgery. Chest
1985; 87:76–80.
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 DOI Number: 10.5958/0973-5674.2014.00344.X
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 293

Effect of Passive Vibration on Skin Blood Flow in Persons

with Good Glycemic Control and Poor Glycemic Control
Type 2 Diabetes

Kanikkai Steni Balan Sackiriyas1, Everett B Lohman2, Noha S Daher3, Lee S Berk3, Rafael Canizales4,
Ernie Schwab3
1
Doctor of Science Candidate, 2Professor, 3Associate Professor, 4Assistant Professor, Dept. of Physical Therapy, School
of Allied Health Professions, Loma Linda University, Loma Linda, California, USA

ABSTRACT

Aim: Assess the effect of passive vibration (PV) on skin blood flow (SBF) in persons with good glycemic
control (GGC) and poor glycemic control (PGC) type 2 diabetes.

Method: Fifteen GGC (HbA1c < 7.5%) and twelve PGC (HbA1c > 9%) individuals with type 2 diabetes
received PV using Power Plate® to their calf and plantar area of foot. The SBF was measured using
a MOOR full-field Laser perfusion imager before, immediately after vibration and 10 minutes post
the PV application.

Results: There was a significant difference in the mean SBF for the calf area from baseline to
immediately after vibration in both groups. The mean calf SBF was almost doubled in GGC group
from baseline (38.9 flux) to immediately after vibration (69.5 flux) (p=.03). The mean calf area SBF
was more than doubled in PGC group from baseline (32.9 flux) to immediately after vibration (77.9
flux) (p=.02). However, there was no significant change in mean SBF over time for the foot area in
both groups (p<.05). Baseline resting SBF was higher in foot than calf for both groups. The percent
change from baseline to immediately after vibration in the calf area SBF was higher in PGC (132.6%)
than the GGC group (76%). The SBF in the foot area showed a higher percent increase in the GGC
(72.3%) than the PGC group (32.1%).

Conclusion: Passive vibration may be an effective therapy for increasing lower extremity circulation
in persons with GGC and PGC diabetes.

Keywords: Vibration, Circulation, Hemodynamic hypothesis, Vasomotion, Glycemic control

INTRODUCTION times higher in persons with diabetes than persons

Diabetes Mellitus (DM) is a major health care
problem and can lead to stroke and heart disease (1).
Millions of Americans are affected by DM. The
associated medical expenses and death rate is two
Corresponding author:
Kanikkai Steni Balan Sackiriyas
Professions
24951 North Circle Drive, Room no A620, Nichol Hall
Loma Linda University-School of Allied Health
Loma Linda, CA 92350
Cell (909) 991-5445
E-mail: stenidsc@yahoo.com
with no diabetes (1), (2). Type 2 diabetes is the commonest
(90% to 95%) of all diabetes. This typically results from
the inadequate use of insulin by target cells even
though circulating insulin level maybe normal or
elevated (1), (2), (3). According to the Center for Disease
Control and Prevention (CDC), DM is classified into
good glycemic (HbA1c <7.5%), fair glycemic (HbA1c
e”7.5% to d”9%) and poor glycemic control (HbA1c
>9%) based on the Hemoglobin A1c (HbA1c)
level (4), (5).
Circulation
Tissue healing is an intricate process and primarily

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 294 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4

depends on blood circulation (6). Skin circulation is
under the control of central nervous system and
tissue’s metabolic state (7). Resting SBF is dependent
on factors such as skin moisture, tissue pressure, age,
vitamins, race, diabetes, and exposure to free
radicals (8).
Subjects were assigned into one of two groups: Good
glycemic control group and Poor glycemic control
group. Both groups received passive vibration to their
calf area and the opposite foot area on the same day.
Instrumentation

Aging, body mass index (BMI) and diabetes affect
endothelial cells and autonomic function, hence
decreases microcirculation (6), (9), (10) . Complex
architecture of skin is responsible for differential
circulation rate. Glabrous skin (palms, soles) has thick
walled arteriovenous anastomoses (AVA). Numerous
larger arteries and venules in these areas allow low
resistance and high SBF rate. Whereas, non-glabrous
skin (forearm, calf, dorsal hand) has more nutritive
(NUTR) perfusion and is served by capillaries with
fewer AVA (11), (12), (13).
A Physio Plate® (Domino S.R.L, San Vendemiano,
Italy) was used to deliver passive vibration at a
frequency of 50 Hz for a total number of ten cycles
(one cycle= 60s working time: 2 s rest time) for a total
of approximately ten minutes (Figure 1). A MOOR full-
filed Laser perfusion Imager (FLPI) (MOOR FLPI V
2.1, Oxford, England) was pre-warmed for about 30
minutes to stabilize measurements and was used to
measure SBF non-invasively. The FLPI uses a red light
laser beam applied perpendicularly to capture SBF and
blood flow was measured in “Flux” unit.

In research, vibration is being used to increase skin

circulation. Research supports the use of passive
vibration (PV) to improve SBF without increasing the
risk of burns. Lohman et al., (2012) showed that PV
significantly improved SBF in hairy and non-hairy skin
in persons with good to fair glycemic control diabetes
and persons with no diabetes (14), (15), (16). The purpose of
this study was to examine the effect of PV on SBF in
good glycemic control versus poor glycemic control
individuals with type 2 diabetes. We hypothesized that
passive vibration induced increase in SBF in calf area
and foot area were higher in good glycemic control
group than the poor glycemic control diabetes group.
The secondary hypothesis was that passive vibration
induced increase in SBF was higher in calf (non-
glabrous) area than the foot area (glabrous) in both
GGC and PGC groups with type 2 diabetes.

MATERIAL AND METHOD

Study Population

Subjects with type 2 diabetes between the age

ranges of 18-75 years invited to participate in this
study. Subjects with neurological disorders,
Fig. 1. Physio Plate® vibration platform.
orthopedic disorders, bleeding disorders, leg ulcer,
chronically exposed to vibration, cardiovascular
diseases, deep vein thrombosis (DVT), or pregnant PROCEDURE
were excluded. Thirty two subjects were recruited
Screening
from the Diabetes Support Group and from the
Diabetes Treatment Center at Loma Linda University The testing room temperature was maintained at
(LLU) Medical Center. Five subjects were excluded 71.6°F-75.2°F (22°-24° C) for about 30 minutes before
because they did not meet the inclusion criteria. the subject enters. A 30 minutes rest period in supine

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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 295

position was given to subjects to stabilize their blood DATA ANALYSIS

flow before intervention. Subjects were screened for
exclusion and demographic data was collected
(Appendix A). Subjects were screened for possible
DVT using the Well’s criteria (17). Subjects with a score
of e”2 (high risk) were excluded.
Cutaneous sensation was checked using a Semmes-
Weinstein Monofilament (North Coast Medical, Inc,
Morgan Hill, CA, USA) and the response, color of the
handle and notations were noted on the sensory foot
mapping form (Appendix B). Vibration sense was
checked with a 128 Hz tuning fork and subjects with a
score of 2 (absent sensation) were excluded.
Testing
Subjects were asked to lie prone on a plinth. A
square shaped 3 cm x 3 cm area was marked on the
posterior aspect of the calf (muscle belly) and on the
plantar aspect of the first three (1-3) metatarsal heads
to capture SBF. Baseline SBF was measured in the calf
area using the FLPI. Then, subjects received passive
vibration to their calf area for ten minutes. The second
reading was taken immediately after vibration.
Subjects were given a ten minutes rest before the third
reading was taken. The same procedures were
repeated for foot on the opposite leg.
Data was analyzed using SPSS version 20.0 (18). One
sample Kolmogorov Smirnov test was used to examine
the distribution of the continuous variables. Chi-square
test of independence was used to compare the
proportions of males & females, ethnicity and levels
of physical activity by group. We compared mean age
and body mass index (BMI) by group using
independent t-test. Mixed factorial analysis of variance
was used to compare the effect of passive vibration on
SBF from baseline to immediately after vibration and
10 minutes post rest in good glycemic control and poor
glycemic control type 2 diabetes subjects’ calf and foot.
Significant differences were further examined with
Bonferroni test. The level of significance was set at
p<.05.
FINDINGS
Fifteen GGC and twelve PGC persons with type 2
diabetes participated in the study. The results of the
Kolmogorov Smirnov test showed the distribution of
age, BMI and SBF were approximately normal. There
were no significant differences between the good
glycemic and poor glycemic control diabetes groups
in terms of gender, race, physical activity, age and BMI
(p>.05) (Table 1).

Table 1. Distribution of demographic data by group (N=28).

Variables Good (n=16) Poor (n=12) p-value

Gender† Male 9 (56.2%) 6 (50%) .74
Female 7 (43.8%) 6 (50%)
Ethnicity† White 7 (70%) 3 (30%) .49
Hispanic 4 (66.79%) 2 (33.3%)
Others¶ 2 (33.3%) 6 (66.7%)
African American 2 (66.7%) 1 (33.3%)
Physical activity† Very light 3 (37.5%) 5 (62.5%) .43
Light 5 (71.4%) 2 (28.6%)
Moderate & Heavy 8 (61.5%) 5 (38.5%)
Age (Mean±SD)* 62.3±11.4 56.9±7.7 .17
BMI (Mean±SD)* 31.1±5.6 32.0±6.8 .71

†: Chi-square test

*: Independent t test

¶: Others: Asians, Middle eastern

Good Glycemic Control
There was a significant change in mean calf area
SBF over time in good glycemic control diabetes group
(F2, 30=6.71, p=.02) (Table 2). A significant change was
seen between baseline and immediately after vibration
(p=.03) and between baseline and 10 minutes post rest
(p=.03). However, there was no significant change in
mean foot area SBF over time in good glycemic control
diabetes group (F2, 30=2.6, p=.11). The mean SBF in the

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 296 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
good glycemic control was significantly higher in foot
area than in calf area at baseline (137.5±22.4 vs 38.9±2.3;
p<.001), immediately after vibration (187.0±29.2 vs
Table 2. Mean (SE†) skin blood flow over time by group and site.
Site Group
Calf Good
Poor
Foot Good
Poor
*Analysis of variance
†SE: Standard error
Poor Glycemic Control
There was a significant change in mean calf area
SBF over time in poor glycemic control group (F2, 22=9.8,
p=.01) (Table 2). A significant change was detected
between baseline and immediately after vibration
(p=.02), between baseline and 10 minutes post rest
(p=.01). There was no significant change in mean foot
area SBF over time in poor glycemic control group (F2,
=.04, p=.91). The mean SBF in the poor glycemic
30
control was significantly higher in foot area than in
the calf area at baseline (157.6±33.4 vs 32.9±2.6; p<.01),
immediately after vibration (163.8±32.3vs 77.9±15.5;
p=.03) and 10 minutes post rest (160.1±37.0 vs
70.9±12.5; p=.04) (Table 2).
Good Glycemic Control vs. Poor Glycemic Control
There was a significant difference in mean calf SBF
over time in both good glycemic control and poor
glycemic control groups (F2, 52=16.6, p=.001). However,
there was no significant difference between groups (F2,
30
=.03, p=.90). Based on the Bonferroni test, there was
a significant difference in calf SBF between baseline
and immediately after vibration (p=.001) and between
baseline and 10 minutes post rest (p=.001) in both good
glycemic control and poor glycemic control groups.
There was no significant difference in mean calf SBF
between immediately after vibration and 10 minutes
post rest (p=.40). There was no significant difference
in foot SBF over time in both good glycemic control
and poor glycemic control groups (F2, 52=1.57, p=.22).
DISCUSSION
The diabetic foot ulcer (DFU) is the leading cause
of amputation in persons with diabetes and
54. Steni Balan--293--.pmd 296
69.5±12.5; p<.001) and 10 minutes post rest (142.1±21.8
vs 66.8±11.6; p<.01) (Table 2).
Baseline Immediately 10 min post p-value*
after rest
vibration
38.9(2.3) 69.5(12.5) 66.8(11.6) .02
32.9(2.6) 77.9(15.5) 70.9(12.5) .01
137.5(22.4) 187.0(29.2) 142.1(21.8) .11
157.6(33.4) 163.8(32.3) 160.1(37.0) .91
approximately 8% of diabetics tend to have peripheral
vascular disease (PVD) at the time of initial diagnosis
(19)
. Peripheral vascular disease rapidly rises with age
and duration of diabetes. The associated lower
extremity amputation rate is 15 times higher in diabetic
individuals than non-diabetic individuals. In most
cases, the lesion starts from a painless trauma in an
insensate neuropathic foot. Healing of these lesions is
thwarted by the presence of PVD. Lack of sufficient
blood flow and decreased delivery of leukocytes
impairs the function of some of tissue growth factors
and antibiotics that are oxygen dependent, and
increases the growth of highly destructive anaerobes
in the infected tissues (19). Therefore, modalities that
can increase even a small amount of circulation may
play a clinically important role in the healing process.
Studies from the department of physical therapy in
Loma Linda University and others have shown that
vibration can be effective in increasing SBF in persons
with diabetes as well as with no diabetes (14), (15), (16), (20),
(21), (22), (23), (24), (25)
. We believe that the increase in SBF may
help in accelerating the healing process and the
prevention of DFU.
Contrary to our expectation, the study results did
not meet our first hypothesis; there was no significant
increase in SBF in the calf area and foot area in good
glycemic control than in poor glycemic control group.
On the other hand, the results from this study
supported our second hypothesis; SBF in the calf area
was significantly increased more than the foot area in
both the good glycemic control and the poor glycemic
control groups as a result of passive vibration.
In this study, mean foot SBF was higher than the
calf at baseline, immediately after vibration and 10
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 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 297
minutes post rest in both good glycemic control and
poor glycemic control groups. One possible
explanation could be that the arteriolar myogenic
response, vasoarteriolar reflex and precapillary
arteriolar vasomotion in the microcirculation are
impaired. Normally, all these mechanisms regulate the
blood flow during daily physiological stimuli such as
local tissue metabolic needs and positional changes
(upright position). Upright position increases
hydrostatic pressure in the leg that triggers sensors in
the vein to signal the arterioles to constrict. This
phenomenon prevents excessive perfusion in the
capillaries and the subsequent hypertension. This very
important mechanism is deficient in persons with both
type 1 and type 2 diabetes (hemodynamic hypothesis)
(26)
. This could be the reason why we observed higher
mean SBF, over time, in foot than calf in both good
glycemic control and poor glycemic control group.
This could also possibly explain why there was no
significant change in foot SBF overtime due to passive
vibration in both good glycemic control and poor
glycemic control groups.
Precapillary arteriolar vasomotion is a
phenomenon in which tissues show a rhythmic, slow-
wave and high amplitude changes in the arteriolar
diameter. This maintains the distribution of blood
flowing through capillaries. Failure of this mechanism
may fill capillaries permanently and allows no further
reserve when the demand is increased. This function
is impaired in many pathological conditions such as
hyperinsulinaemia (diabetes) (26). In this study, the
percent change in calf SBF from baseline to post
vibration was significantly higher in poor glycemic
control (132.6%) than good glycemic control (76%)
group. There could be two possible explanations for
this finding. The possible explanation could be the
absence of vasomotion due to hyperinsulinaemia
might be higher in poor glycemic control than good
glycemic control persons with type 2 diabetes. This
could be the reason why we observed higher percent
change in the calf area in poor glycemic control than
in good glycemic control group. On the other hand,
the absence of vasomotion is more common in foot
than calf. This suggests that calf SBF in poor glycemic
control might have responded well with the passive
vibration. Further studies have to be done to analyze
this phenomenon.
The mean SBF in calf was almost doubled from
baseline (38.9 flux) to immediately after vibration (69.5
flux) in good control and was more than doubled from
54. Steni Balan--293--.pmd 297
baseline (32.9 flux) to immediately after vibration (77.9
flux) in poor glycemic control group. This implies that
passive vibration was effective in increasing SBF in
calf in both good glycemic control and poor glycemic
control groups. However, no considerable change in
the calf SBF was observed from immediately after
vibration to 10 minutes post rest in both good glycemic
control and poor glycemic control groups. This finding
suggests that effect of passive vibration was
maintained more than ten minutes after the
intervention.
Although significant SBF changes have been
documented in the calf, PV for 10 minutes did not
significantly increase skin blood flow in the foot; a
common site of diabetic ulcers. The percent change of
foot SBF from baseline to immediately after vibration
was significantly higher in the good glycemic control
(72.3%) as compared to the poor glycemic control
(32.1%) group. Hyperinsulinaemia and associated
impaired vasomotion could be a possible reason why
good glycemic control group showed higher calf SBF
than the poor glycemic control group. However, from
a clinical perspective, distribution of blood in the whole
foot is an important factor although the quantity of
blood flow is less in micro-vascular bed (26). Therefore,
a 72.3% increase in the good glycemic control foot SBF
and 32.1% increase in the poor glycemic control foot
SBF imply that passive vibration to the foot in both
good glycemic control and poor glycemic control
diabetes groups can be a good “head start” in
maintaining healthy circulation in foot.
In our study, we tried to minimize all the external
factors that could mask the effect of passive vibration.
However, we did not stop the subjects from taking
their blood pressure and glucose control medications
such as diuretics and metformin from a clinical
perspective. These medications could lower blood
pressure (27) and might have masked the effect of
passive vibration. High fat meal also decreases blood
flow (28) and may have masked the vibration’s effect if
subjects had high fat meal before vibration. Future
studies should focus on comparing the effect of
vibration with and without high fat meal prior to
vibration. We did not record the subject’s physical
activity just prior to the vibration application although
we recorded their general physical activity. Exercising
before vibration can increase or decrease the skin blood
flow based on the training activity (29) and thus may
mask the effect of passive vibration. All of these factors
could have masked the real effect of passive vibration
and can be avoided in the future studies. Future studies
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 298 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4
can also examine whether assessing blood flow in the
whole foot rather than a single point for at least one
minute. This would be helpful in understanding the
blood distribution in the micro-vascular bed.
CONCLUSION
Findings of higher mean calf SBF overtime in both
poor glycemic control and good glycemic control,
higher percent change of calf SBF from baseline to
immediately after vibration in poor glycemic control
than good glycemic control and higher percent change
of foot SBF from baseline to immediately after vibration
in good glycemic control than poor glycemic control
suggest that passive vibration can be safely applied to
maintain good circulation in the lower extremities.
Although the observed increase in foot was less in poor
glycemic control, the distribution not the quantity
plays a vital part in the micro-vascular bed.
Acknowledgement: Gurinder S. Bains, Kulbhushan
H. Dhamane, Kinjal J. Solani for their immense help
in collecting data.
Conflict of Interest: Authors express no conflict of
interest
Source of Support: Nil
Ethical Clearance: The Loma Linda University’s
institutional review board approved all procedures
and subjects signed statements of informed consent.
REFERENCES
1. Centers for Disease Control and Prevention.
National diabetes fact sheet: national estimates
and general information on diabetes and
prediabetes in the United States, 2011. Atlanta,
GA: U.S. Department of Health and Human
Services, Centers for Disease Control and
Prevention, 2011.
2. Ziegler D. Diabetic cardiovascular autonomic
neuropathy: prognosis, diagnosis and treatment.
Diabetes Metab Rev. 1994 Dec;10(4):339-83.
PubMed PMID: 7796704. Epub 1994/12/01. eng.
3. Sumpio BE. Foot ulcers. New Engl J Med. 2000
Sep 14;343(11):787-93. PubMed PMID:
ISI:000089221300007. English.
4. Hartemann-Heurtier A, Sultan S, Sachon C,
Bosquet F, Grimaldi A. How type 1 diabetic
patients with good or poor glycemic control cope
54. Steni Balan--293--.pmd 298
with diabetes-related stress. Diabetes Metab. 2001
Nov;27(5):553-9. PubMed PMID:
ISI:000172065400003. English.
5. Juarez DT, Sentell T, Tokumaru S, Goo R, Dawis
JW, Mau MM. Factors asscoiated with poor
glycemic control or wide glycemic variability
among diabetes patients in Hawaii, 2006-2009; 6.
Available from: http://dx.doi.org/10.5888/
pcd9.120065.
6. Petrofsky J, Lee S. The effects of type 2 diabetes
and aging on vascular endothelial and autonomic
function. Med Sci Monit. 2005 Jun;11(6):CR247-
54. PubMed PMID: 15917714. Epub 2005/05/27.
eng.
7. Berne RM, Levy MN. Principles of Physiology. 4
ed. St. Louis, MO: Mosby; 2005.
8. Petrofsky JS. Resting blood flow in the skin: does
it exist, and what is the influence of temperature,
aging, and diabetes? J Diabetes Sci Technol. 2012
May;6(3):674-85. PubMed PMID: 22768900.
Pubmed Central PMCID: 3440047. Epub 2012/
07/10. eng.
9. Ray CA, Monahan KD. Aging attenuates the
vestibulosympathetic reflex in humans.
Circulation. 2002 Feb 26;105(8):956-61. PubMed
PMID: 11864925. Epub 2002/02/28. eng.
10. Petrofsky JS, Alshammari F, Bains G, Khowailed
IA, Lee H, Kuderu YN, et al. What is More
Damaging to Vascular Endothelial Function:
Diabetes, Age, High BMI, or all of the above? (in
press). 2013. English.
11. Rendell MS, Milliken BK, Finnegan MF, Finney
DA, Healy JC. The skin blood flow response in
wound healing. Microvasc Res. 1997
May;53(3):222-34. PubMed PMID: 9211400. Epub
1997/05/01. eng.
12. Zweifach BW, Lipowsky HH. Pressure-flow
relations in blood and lymph microcirculation.
In: Renkin EM, Michel CC, Geiger SR, editors.
Handbook of Physiology The Cardiovascualr
System. 4. Oxford: Oxford Univ; 1987. p. 251-308.
13. Johnson JM, Brengelmann GL, Hales JR,
Vanhoutte PM, Wenger CB. Regulation of the
cutaneous circulation. Fed Proc. 1986
Dec;45(13):2841-50. PubMed PMID: 3780992.
Epub 1986/12/01. eng.
14. Lohman EB, 3rd, Bains GS, Lohman T, DeLeon
M, Petrofsky JS. A comparison of the effect of a
variety of thermal and vibratory modalities on
skin temperature and blood flow in healthy
11/1/2014, 12:17 AM
 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2014, Vol. 8, No. 4 299
volunteers. Med Sci Monit. 2011 Sep;17(9):MT72-
81. PubMed PMID: 21873956. Epub 2011/08/30.
eng.
15. Lohman EB, Sackiriyas KSB, Bains G, Calandra
G, Lobo C, Nakhro D, et al. A comparison of
whole body vibration and moist heat on lower
extremity skin temperature and skin blood flow
in healthy older individuals. Med Sci Monit.
2012;18(7):CR415-24. English.
16. Lohman EB, 3rd, Petrofsky JS, Maloney-Hinds C,
Betts-Schwab H, Thorpe D. The effect of whole
body vibration on lower extremity skin blood
flow in normal subjects. Med Sci Monit. 2007
Feb;13(2):CR71-6. PubMed PMID: 17261985.
Epub 2007/01/31. eng.
17. Wells PS, Owen C, Doucette S, Fergusson D, Tran
HY. Does this patient have deep vein thrombosis?
Jama-J Am Med Assoc. 2006 Jan 11;295(2):199-207.
PubMed PMID: ISI:000234544300027. English.
18. SPSS 20.0 for Windows Manual. Chicago, I11:
SPSS, Inc; 2013.
19. Donayre CE. Diagnosis and Management of
Vascular Ulcers. In: Sussman C, Jensen BM,
editors. Wound Care: A colloborative Practice
Manual for Physical Therapists and Nurses.
Gaithersburg: Aspen publishers, Inc; 1998. p. 301-
13.
20. Maloney-Hinds C, Petrofsky JS, Zimmerman G.
The effect of 30 Hz vs. 50 Hz passive vibration
and duration of vibration on skin blood flow in
the arm. Med Sci Monit. 2008 Mar;14(3):CR112-
6. PubMed PMID: 18301353. Epub 2008/02/28.
eng.
21. Maloney-Hinds C, Petrofsky JS, Zimmerman G,
Hessinger DA. The role of nitric oxide in skin
blood flow increases due to vibration in healthy
adults and adults with type 2 diabetes. Diabetes
Technol Ther. 2009 Jan;11(1):39-43. PubMed
PMID: 19132854. Epub 2009/01/10. eng.
22. Maikala RV, Bhambhani YN. In vivo lumbar
erector spinae oxygenation and blood volume
measurements in healthy men during seated
54. Steni Balan--293--.pmd 299
whole-body vibration. Exp Physiol. 2006
Sep;91(5):853-66. PubMed PMID: 16740640. Epub
2006/06/03. eng.
23. Bovenzi M, Lindsell CJ, Griffin MJ. Response of
finger circulation to energy equivalent
combinations of magnitude and duration of
vibration. Occup Environ Med. 2001
Mar;58(3):185-93. PubMed PMID: 11171932.
Pubmed Central PMCID: 1740111. Epub 2001/
02/15. eng.
24. Stewart JM, Karman C, Montgomery LD, McLeod
KJ. Plantar vibration improves leg fluid flow in
perimenopausal women. Am J Physiol Regul
Integr Comp Physiol. 2005 Mar;288(3):R623-9.
PubMed PMID: 15472009. Epub 2004/10/09. eng.
25. Skoglund CR. Vasodilatation in human skin
induced by low-amplitude high-frequency
vibration. Clin Physiol. 1989 Aug;9(4):361-72.
PubMed PMID: 2766680. Epub 1989/08/01. eng.
26. Wiernsperger NF, Bouskela E. Microcirculation
in insulin resistance and diabetes: more than just
a complication. Diabetes Metab. 2003 Sep;29(4 Pt
2):6S77-87. PubMed PMID: 14502104. Epub 2003/
09/23. eng.
27. Giugliano D, De Rosa N, Di Maro G, Marfella R,
Acampora R, Buoninconti R, et al. Metformin
improves glucose, lipid metabolism, and reduces
blood pressure in hypertensive, obese women.
Diabetes Care. 1993 Oct;16(10):1387-90. PubMed
PMID: 8269798. Epub 1993/10/01. eng.
28. Bui C, Petrofsky J, Berk L, Shavlik D, Remigio W,
Montgomery S. Acute effect of a single high-fat
meal on forearm blood flow, blood pressure and
heart rate in healthy male Asians and Caucasians:
a pilot study. Southeast Asian J Trop Med Public
Health. 2010 Mar;41(2):490-500. PubMed PMID:
20578534. Pubmed Central PMCID: 3170142.
Epub 2010/06/29. eng.
29. Johnson JM. Physical training and the control of
skin blood flow. Med Sci Sports Exerc. 1998
Mar;30(3):382-6. PubMed PMID: 9526883. Epub
1998/04/04. eng.
11/1/2014, 12:17 AM