Quadriceps Femoris Strength Training Eff

DOI Number: 10.5958/0973-5674.2014.00001.
X
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2015, Vol. 9, No. 3 129
Quadriceps Femoris Strength Training: effect of

Neuromuscular Electrical Stimulation Vs Isometric
Exercise in Osteoarthritis of Knee
Shahnaz Hasan
Associate Professor, Department of Physiotherapy, College of Applied Medical Sciences, Umm Al-Qura
University,Makkah, K.S.A
ABSTRACT
Objective: To evaluate the effectiveness of the Neuromuscular Electrical stimulation as an add-on

therapy with maximum voluntary isometric contraction exercise on the quantitative changes of the
quadriceps strength, pain and functional outcomes in patients with osteoarthritis of knee.
Method: Fifty patientswith Osteoarthritis of Knee (22 women and 28 men) were randomly divided
into experimental and control group (25 subjects in each group).
Experimental Group received the NMES guided isometric exercise for 5 days a week for 3 week,
whereas the control group received an isometric exercise along with sham NMES, without any
instruction regarding muscle recruitment. Maximum isometric quadriceps strength was assessed
with the electronic strain gauge. Pain and the functional status of the patients were measured
throughvisual analogue scale (VAS) and the reduced WOMAC scale.
Results: Maximum isometric quadriceps strength improved significantly at the end of 3 week,
compared with the pretreatment values in both the groups. On between group comparisons, the
maximum isometric quadriceps strength in NMES group, at the end of 3 week and after 2 week
follow-up i.e. on 5th week were significantly higher than those of control group (p<0.05). Significant
improvements were shown for both the VAS and reduced WOMAC in both groups (p<0.05).
Conclusion: The addition of Neuromuscular Electrical stimulation in maximum voluntary isometric

contraction exercise has been shown to produce greater gains in isometric quadriceps strength, thereby
reduce pain and improved function.
Keywords: Neuromuscular Electrical Stimulation, Isometric Exercise, Osteoarthritis Of Knee
INTRODUCTION is the most common symptom of OA and contributes

to significant declines in functional ability, including
Osteoarthritis (OA) is the most common
getting up off the floor and going up and down stairs 4.
rheumatological disease that causes physical
disability1. When symptoms of disease affect the knee, Risk factors for knee OA include age, female sex,
as in 10% of all adults, it results in a limited ability to obesity, trauma, and quadriceps weakness. Among
use stairs, arise from a chair, stand comfortably, walk, these quadriceps weakness may be the most amenable
and complete activities of daily living (ADLs)2.Ettinger to treatment for the prevention of knee OA 5, 6, 7. In the
et al3 reported that 50% to 71% of their sample with Bristol OA knee study, quadriceps weakness was
knee OA had difficulty in ambulation and 44% to 67% found to be the greatest single predictor of lower limb
had difficulty in transferring. Pain in the affected joint functional limitation, exceeding that of knee pain5.
26. Shahnaz Hasan--129--.pmd 129 5/10/2015, 5:14 PM

130 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2015, Vol. 9, No. 3
It has been well established in cross-sectional Study design

studies that individuals with symptomatic knee OA
Pretest-posttest experimental group design was
have weaker quadriceps than do age-matched subjects
selected for testing the hypothesis, where a baseline
without knee OA8, 9. Treatment guidelines for OA of
reading was taken prior to the intervention, rest
the knee have considered exercise as an important non-
measurements were taken at the end of 2nd week, 3rd
pharmacological approach 10. A growing body of
week and after two week follow-up i.e. at the end of
evidence shows that exercise improves knee joint
5th week. The outcome measure, selected for this study
function and decreases symptoms 11, 12, 13. were pain, knee function and quadriceps strength.
Neuromuscular Electrical stimulation is another These variables were measured using VAS scale,
current method that has a place in the strengthening reduced WOMAC index and electronic strain gauge.
of weak muscles14. A good number of studies advocate Procedure
the use of electrical muscle stimulation as an adjunct
to muscle strengthening exercises 15, 16, 17. The subjects were screened first according to
the inclusion and exclusion criteria. The Patients were
The results of this training intensity of maximum randomized to experimental (Group A) and control
voluntary isometric contraction during neuromuscular (Group B) groups. An informed consent was obtained
electrical stimulation on the strength response of from the patients.
quadriceps femoris muscle will guide the therapist
who design the treatment plan for strengthening and Measurement of pain intensity
improve their functional outcome. Pain intensity was assessed using a horizontal
visual analog scale. The subject was asked to mark
The aim of this study was intended to evaluate the
along the line to denote his level of pain. The distance
effectiveness of the Neuromuscular Electrical
from mark 0 was calculated in cm and was recorded.
stimulation as an add-on therapy with maximum
The readings were taken at baseline (before the
voluntary isometric contraction standard exercise on
treatment) and marked as V0, at the end of 2nd week
the quantitative changes of the quadriceps strength,
marked as V2, at the end of 3rd week marked as V3 and
functional outcomes of the knee osteoarthritis and at the end of 5th week as V5.
pain.
Measurement of functional index
METHODS AND MATERIALS
The functional status was assessed using reduced
Subjects WOMAC scale. The readings were taken at baseline
(before the treatment), at the end of 2nd week, at the
Fifty patients with OA knee(22 women and
end of 3rd week and at the end of 5th week designated
28 men) were included in the study. The criteria for
as WOM0, WOM2, WOM3 and WOM5 respectively.
inclusion were: radiological evidence of primary
osteoarthritis with grade 2 on the Kellgren Lawrence Measurement of isometric strength
scale; both male and female patients; age between 40-
65 years; unilateral or bilateral involvement, in case of The isometric strength of quadriceps femoris was
bilateral involvement more symptomatic knee was measured using an electronic strain gauge at baseline
recorded as STN0, at the end of 2nd week recorded as
included. Subjects were excluded if they had any
STN2, at the end of 3rd week recorded as STN3 and at
deformity of knee, hip or back, soft tissue injury, any
the end of 5th week recorded as STN5.
central or peripheral nervous system involvement,
received steroids or intra articular injection within During the testing subject was made to sit on the
previous three months, systemic inflammatory disease, quadriceps table with the knee joint in 60 degrees of
uncooperative patients and those who received flexion. Thigh was stabilized with a belt; the shin pad
physiotherapy treatment in the past 6 months. was adjusted at 5.1cm superior to the medial malleolus.

The fulcrum of the lever arm was aligned with the most Terminal knee extension exercise: The knee extension
inferior aspect of the lateral epicondyle of the femur. exercise was performed with the patient in a sitting
Strain gauge was attached to the distal end of the position with the knee flexed from 30 to 0 degrees.
quadriceps table arm. Subject was given verbal The patient was instructed to maximally activate their
encouragement in order to motivate the subject to thigh muscles in order to straighten their knee. This
attain maximum effort during the 5-second exercise was of 3 sets of 10 repetitions each.
contraction. Each test includes 3 consecutive 5-second
Group B: Same set of exercise were given to Group B
trials with 30-second rest between trials. The mean of
also but the electrodes was placed away from the VMO
readings was used for the purpose of analysis.
and Rectus femoris, and reference electrode was placed
Intervention below the tibial tuberosity. Here the patients did
exercises without any instruction to recruit VMO and
Experimental group received the NMES guided Rectus femoris muscle.
isometric exercise. The other group received the
isometric exercise along with sham NMES, without Statistical Analysis
any instruction regarding muscle recruitment. Both the
group received paraffin wax bath (temperature 520 C) Statistical analysis was done using STATA 11.0
for 20-minute prior to exercise. Statistical Software. A paired t-test was used to
compare the changes in isometric quadriceps strength,
NMES Training: NMES training was performed with VAS and WOMAC in both the groups at baseline, 2nd
anEndomed 982, a two-channel neuromuscular week, 3rd week and after two week follow up i.e. at 5th
electrical stimulator provided for muscle stimulation. week. A two sample t-test with equal variances used
The stimulator produced a frequency of 2500 Hz to compare the changes in isometric quadriceps
delivered with AMF 50 HZ with 5 sec, time interval strength, VAS and WOMAC in both between the
and holding time 8 sec, ramp up and down 2 sec and groups at baseline, 2nd week, 3rd week and after two
intensity will set according to the subject’s tolerance week follow up i.e. at 5th week.
and it will be given for 25 minutes.
A statically significant difference was defined as p less
Electrode placement: Pair of standard carbon rubber than 0.05.
electrodes in moistened sponge pads will be positioned
over the femoral nerve in the femoral triangle and
RESULTS
transversely over the quadriceps muscle motor point.
Motor points were identified as the area that produced Isometric strength
greatest visible muscle contraction when electrical
stimulation intensity will be applied. The electrodes The baseline reading STN0 for both the groups was
will securely fastened using Velcro straps. statistically significant (p=0.004). On comparing the
STN2 between two groups a significant difference was
Exercise procedure obtained (p<0.001).On comparing at the end of
treatment session STN 3 between two groups a
Isometric quadriceps exercise: Patient was positioned
significant difference was obtained (p<0.001) again
in supine lying. A roll of towel was put beneath the
when comparing after two-week follow-up i.e. on 5th
knee. The patient was instructed to maximally activate
week (STN 5 ) between two groups a significant
their thigh muscles in order to straighten their knee.
This exercise was of 3 sets of 10 repetitions each. difference was obtained (p<0.001).
Table: 1.1Comparison of isometric quadriceps strength between the groups
Group A Group B Two sample t-test

(Mean±SD) (Mean±SD) with equal variances
T P
STN0 9.23±1.66 7.90±1.50 2.96 0.004
STN2 11.68±1.85 8.87±1.73 5.53 0.000
STN3 12.66±1.90 9.47±1.91 5.90 0.000

Pain Intensity session i.e. on 3rd week (V3) found to be statistically

significant between two groups (p<0.001). The final
For both the groups the baseline value V0 was readings after two-week follow-up i.e. at 5th week (V5)
statistically insignificant (p=0.209). The reading at 2nd were also found to be statistically significant between
week (V2) found to be statistically insignificant between two groups (p=0.014).
groups (p=0.158). The reading at the end of treatment
Table 1.2: Comparisonof VAS score between the groups

T P
V0 6.18±0.82 6.78±1.05 2.241 0.029
V2 3.92±0.98 4.28±0.77 1.43 0.158
V3 2.26±1.00 3.3±0.75 4.15 .000
V5 1.64±0.94 2.28±0.84 2.53 .014
Functional index of treatment session i.e. on 3rd week (WOM3) also found
to be statistically significant between two groups
For both the groups the baseline value WOM0 was (p<0.001). The final reading after 2-week follow-up i.e.
statistically insignificant (p=0.58). The readings at 2nd at 5th week (WOM5) was also found to be statistically
week (WOM2) found to be statistically significant significant between two groups (p<0.001).
between the groups (p<0.001). The reading at the end
Table 1.3: Comparison of Reduced WOMAC score between the groups

T P
WOM0 24.56±3.797 25.04±2.11 0.552 0.583
WOM2 15.88±4.10 20.04±3.67 3.77 0.000
WOM3 8.96±3.56 16.36±4.72 6.25 0.000
WOM5 6.32±3.15 14.36±5.13 6.66 0.000
DISCUSSION period. Gained improvement was also maintained

over a period of 2-week follow-up i.e. at the end of 5th
The study was designed to determine the week.
efficacy of Neuromuscular Electrical stimulation with
maximum voluntary isometric contraction training on Isometric quadriceps strength
In support of the application of NMES to the
functional outcomes of the knee osteoarthritis and
quadriceps femoris muscle, cabric et al. found
pain. The purpose of study was to assess the
increased muscle fiber size and nuclear volume plus
effectiveness of NMES as an adjunct to strength
type-II muscle heterochromatin and mitochondrial
training of quadriceps muscle in order to increase
fractions which might be expected to improve the
strength of quadriceps muscle and thereby reducing
mitochondrial oxidative capacity and fatigue
pain and improving function.
resistance of the stimulated muscle as well as its force
The results of the study demonstrated that a generating capacity.18
combination of Neuromuscular Electrical stimulation Reduction in pain intensity and functional
with maximum voluntary isometric contraction disability
exercises brought greater gains in all outcome
measures, including isometric quadriceps strength, The findings are consistent with previous
pain intensity and functional disability. These effects investigators who have reported that exercise can
were largely gained during the 3 weeks of treatment reduce pain and increase the functional abilities of OA

patients. The Fitness Arthritis and Seniors Trial11 Conflict of Interest: I declare no conflict of interest.
reported a modest 8% to 10% improvement in pain This manuscript has not been published or considered
and functioning scores as a result of 18 months of for publication by any other journal or elsewhere.
aerobic or resistance exercise among their sample of
knee OA patients. Source of Funding: Self.
Further Deyleet al12. Falconer et al97 and Fisher et Ethical Clearance: I am undertaking that subject
al98 found same positive effects of exercise program studies were taken after the prior approval of
on pain and function. It is well documented in institutional ethical committee. The procedures
literature that the impaired quadriceps strength found followed were in the accordance with the ethical
to be the greatest single predictor of lower limb standards of the responsible committee on human
functional limitation.6 experimentation and it’s fulfilled the Helsinki
Declaration of 1975, as revised in 2000(5).
So, it may be hypothesized that improvement on
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Contents
Volume 09 Number 03 July-September 2015
1. A Study to Compare the effect of Scapular Taping Along with Stretching and ............................................................... 01
Stretching Alone in Patients with Postural Neck Pain- Randomised Control Trial
Chatla Jyoti Ramanand
2. The effectiveness of Stress Management Technics on Alcoholic Patients ........................................................................... 07

M Ramakrishnan M O T
3. Influence of Different Movements on Blood Pressure in Hypertensive Subacute Stroke Patients ................................. 13
Pritika Lalwani, Purti Haral, SujataYardi
4. Comparison of Balance in Elderly with and without Diabetes using .................................................................................. 17

Balance Evaluation Systems Test Test (BESTest)
Riddhi Desai, Ramesh Debur
5. Isokinetic Measurement of Functional Hamstrring: Quadriceps Strength ......................................................................... 22

Ratio in Various Age Groups of Asymtomatic Females
Ahmad Zahid, Beigh Zafarullah, Khan Sohrab
6. Hindi Translation, Cross-Cultural Adaptation and Validation of the "Self-Efficacy ......................................................... 27

in Wheeled Mobility" (SEWM) Scale in Wheelchair Users with Spinal Cord Injury
Swati Dash, Ruby Aikat, Neha Khanna
7. Prevalence of Airflow Limitation in Women Exposed to Biomass Fuel in Rural ............................................................... 32

Parts of Belgaum District- a Cross Sectional Study
Vinay Mahishale, Arati Mahishale
8. Intra and Inter Rater Reliability of a Modified CROM Device for Measuring Cervical Rotation AROM ...................... 37
Kiran Satpute, Richa Bisen, Rebecca Pinto, Swati S Raje
9. Effects of Neuromuscular Electrical Stimulation (Nmes) on Hand Function in Stroke Patients ..................................... 48
Pawan Sharma, Jayshree M Sutaria, Prajakta Zambare
10. Relationship of 6 Minute Walk Distance, Bmi and Waist to Height Ratio .......................................................................... 49
in South Indian Men and Women with Coronary Artery Disease- a Tertiary
Care Hospital Based Study
Runella D'souza, Renu Pattanshetty
11. Effect of Cawthorne and Cooksey Exercise Program on ....................................................................................................... 55

Balance and Likelihood of fall in Older Women
Prajakta D Zambare, Neela Soni, Pawan Shrama
Content Final.pmd 1 5/10/2015, 7:19 PM

II
12. To Screen Coronary Artery Disease using Rose Angina Questionnaire .............................................................................. 61
in Young Adults- an Observational Study
Arpita Gopinath Rao, Ganesh B R
13. The Study of Improving Prewriting Skills Through Simplified ........................................................................................... 63

Teaching Techniques for Mild Mental Retardation
14. Reliability and Sensitivity of Shuttle Walk Test in Chronic Mechanical Low Back Pain Patients ................................... 67
Priyadarshini Mishra, J Ayyapan
15. Effect of Active Stretching Exercises on Primary Dysmenorrhea in .................................................................................... 72

College Going Female Students
Neha S Patel, Tanvi Tanna, Sweta Bhatt
16. To Evaluate the effects of Physiotherapy (a Home Based Exercise Program) .................................................................... 77
in Improving Functional Capacities and Quality of Life in Patients with
Chronic Kidney Disease
Supriya Khanna, Paramjot Kaur, Sanjeev Kumar Khanna
17. Effectiveness of Acu-Transcutaneous Electrical Nerve Stimulation in Middle .................................................................. 82

Aged Borderline Hypertensive Patients - a Randomised Controlled Trial
Dishita Kadam, Ganesh B R
18. Effect of Incorporation of Regular Rhythm in Exercises on .................................................................................................. 87

Motor Function of Children with Cerebral Palsy
Amruta Nerurkar, Sujata Yardi
19. A Study to Evaluate Influence of Attentional Cognitive Tasks on Postural Sway ............................................................ 92
in School Going Children in Standing Posture Using Force Platform
Jadeja Urvashiba Narendrasinh, T Joseley Sunderraj Pandian
20. The Immediate effect of Chest Mobilization Technique on Oxygen Saturation ................................................................ 98
in Patients of Copd with Restrictive Impairment
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21. Efficacy of Muscle Energy Technique and PNF Stretching Compared to Conventional ................................................ 103
Physiotherapy in Program of Hamstring Flexibility in Chronic Nonspecific Low Back Pain
Praveen Kumar, Monika Moitra
22. A Study to Investigate Test-Retest Reliability of Two Minute Walk .................................................................................. 108
Test to assess Fuctional Capacity in Elderly Population
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23. An Experimental Study to Compare the effectiveness of Nmes Vs Emg .......................................................................... 114
Biofeedback in the Early Phases of Rehabilitation Following Acl Reconstruction
Alpa J Dhanani
24. Assessing Internal Consistency of "Antenatal Care Knowledge Questionnaire" ............................................................ 120
Abha Dhupkar, Manasi Ketkar

III
25. A Comparative Study to Determine the effectiveness of Carpal Bone .............................................................................. 123
Mobilization vs. Neural Mobilization for Carpal Tunnel Syndrome
Hiral R Solanki, Leena R Samuel
26. Quadriceps Femoris Strength Training: effect of Neuromuscular Electrical .................................................................... 129
Stimulation Vs Isometric Exercise in Osteoarthritis of Knee
Shahnaz Hasan
27. Comparison of the effect of Spinal Accessory Nerve Mobilization, Integrated ............................................................... 135
Neuromuscular Inhibition Technique and Conventional Therapy on in
Upper Trapezius Trigger Point
Pajnee K, Choteliya K, Raghav D, Verma M
28. Effect of Physiotherapy Rehabilitation in Acute Burn Injury Around Shoulder Joint .................................................... 139
Thakrar Gira N, Patel Dilip A, Sejpal Jaykumar J
29. Balance Affection in Elderly People with Osteoarthritis of Knee and Low Back Pain .................................................... 143
Anu Arora, Akshata Teli
30. To Compare the effect of Wobble Board as Bilateral Proprioceptive Exercise to ............................................................. 148
Unilateral Leg Standing Exercise in Knee Osteoarthritis Patients: a Randomized Controlled Trial
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31. Effect of Retro Walking on Pain, Balance and Functional Performance in Osteoarthritis of Knee ............................... 154
Nayyar Manisha, Yadav Joginder, Rishi Priyanka
32. A Study to Find Association of 6mwd with Resting Cardiovascular Parameters in Obese Subjects ............................ 160
Archana Dave
33. Effect of Proprioceptive Training on Knee Joint Position Sense and its Co-Relation ...................................................... 164
with Jump Motion Control Ability in Normal Healthy Untrained Individuals
Kaustubh W Lasunte, Vishakha Shinde, Rajashree Naik
34. Awareness of Physiotherapy as Career Option Amongst HSC Students in Urban Area ............................................... 170
Rutika S Potdar, Atiya A Shaikh
35. Relationship of Depression, Anxiety, Stress and Kinesiobhobia with Balance ................................................................ 174
Function in Individuals with Different Chronic Pain Conditions
Amruta Nerurkar, Hemangi Thali
36. A Comparative Study on Role of Different Electrotherapy Modalities to ........................................................................ 180

Control Knee Osteoarthritis Pain
Bibek Adhya, Salil Saha
37. Benefits of Early Mobilization of Icu Patients ........................................................................................................................ 186

Mayur Patel, Swati M Sanghvi
38. Effectiveness of Fall Prevention Training Programme for Patients with Hemiplegia ..................................................... 191
K Kalaichandran

IV
39. Correlation between Performance Oriented Mobility Assessment Scale .......................................................................... 197
and Activity Specific Balance Confidence Scale in Elderly Individual
Chetana A Kunde, Suvarna Shyam Ganvir
40. A Study to Compare the effectiveness of Met and Joint Mobilization Along with ......................................................... 203
Conventional Physiotherapy in the Management of Si Joint Dysfunction in Young Adults
Rachel Mathew, Namrata Srivastava, Sneha Joshi
41. An Experimental Study to Findout the effect of Visual- Vestibular Habituation ........................................................... 209
and Balance Training Exercises in Patients with Motion Sickness
Chiranjeevi Jannu
42. Comparative effectiveness of Static Stretch and Proprioceptive Neuromuscular ........................................................... 216
Facilitation (PNF) Stretch on Hamstring Flexibility in Young Adult Females
Manasi Joshi, Ambarish Akre
43. Myofascial Pain Syndrome ....................................................................................................................................................... 221

Anudeep Saxena, Mayank Chansoria
44. The effectiveness of Progressive Resisted Exercises and Kinesiotaping of Lower ......................................................... 227
Trapezius in Reducing Pain and Disability in Subjects Presenting with Unilateral
Neck Pain: a Comparative Study
Warikoo D, Roy R R, Agnihotri S, Kaul Bhumika
45. A Study on the Role of Proprioceptive Training in non Operative ACL Injury Rehabilitation .................................... 232
Salil Saha, Bibek Adhya, M S Dhillon, Ashish Saini
46. Efficacy of Moderate Intensity Aerobic Exercises on Quality of Life in HIV Positive Individuals ............................... 238
Rima N Musale, G Varadharajulu
47. Effect of HIP Abductors and Lateral Rotators Strengthening Exercises on Knee ............................................................ 242
Valgus Alignment among Adolescents: a Prospective Study
A Nagaraj, P Krishnan
48. Efficacy of Conventional Treatment and Eccentric Exercise with and Without ............................................................... 249
Deep Transverse Friction Massage in Supraspinatus Tendinitis
Patients a Randomized Clinical Trail
Kusum Lata Jindal, Monika Moitra
49. Neck Pain and Role of Scapular Position in Dentists ........................................................................................................... 254
Kritika Joshi, Jyoti Dahiya, Priyanka Chugh
50. Co-activation Index of Muscles Across Knee and Ankle During Sit to Stand in ............................................................. 261
Normal Young Individuals: a Pilot Study
Priyadharshini G Ravichandran, Kavitha Raja, Saumen Gupta
51. "Trunk Dissociation Retrainer" for Improving Balance and Gait in Hemiplegia ............................................................. 265
ArunachalamRamachandrana, AnandhVaiyapuri, Jagatheesan Alagesan, Rajkumar Krishnan Vasanthi

DOI Number: 10.5958/0973-5674.2014.00001.X
A Study to Compare the effect of Scapular Taping Along

with Stretching and Stretching Alone in Patients with
Postural Neck Pain- Randomised Control Trial

Assistant Professor, MGM School of Physiotherapy, Kamothe
ABSTRACT
This study aimed to compare the effect of scapular taping along with stretching of pectoralis minor,
upper trapezius and levator scapula muscle with stretching alone in patients with postural neck
pain. Pain on VAS, resting position of scapula by lennie test, pectoralis minor and upper trapezius
tightness were recorded on 32 patients (18-30years) with postural neck pain before, 1week and 2weeks
after intervention. The patients in the experimental group received scapular taping and stretching of
pectoralis minor, upper trapezius and levator scapula muscles, whereas the control group received
only stretching for two weeks. Statistically significant improvement was seen in both the groups for
all dependent variables by repeated measures ANOVA. Intergroup comparison by independent
sample t-test showed statistically significant reduction in pain, pectoralis minor and upper trapezius
tightness in experimental group at the end of 1week as compared to control group. However, at the
end of 2weeks both groups showed statistically non-significant results. Thus, scapular taping
combined with stretching does not have beneficial effects over stretching alone in patients with
postural neck pain.
Keywords: Scapular Taping, Postural Neck Pain, Lennie Test, Flexibility
INTRODUCTION minor muscles goes into tightness whereas, the deep

neck flexors, middle trapezius and lower trapezius
Neck pain is common among individuals involved
muscles develop weakness.4
in occupations that need assumption of prolonged
static postures. 1,2 It has been demonstrated that, Biomechanical reasoning indicates that decreased
patients with neck pain tend to drift away from the extensibility of these axioscapular muscles i.e., upper
normal posture while involved in work across the trapezius and levator scapulae , by virtue of its
duration of the task.3 In addition these patients develop attachment to cervical motion segments, can produce
forward head and rounded shoulder posture over a abnormal compressive, rotational and shear forces
period of time. This deviation in posture from the which can predispose a person to neck pain. 5 In
normal is considered to be a contributing factor in these addition, pectoral muscle tightness results in rounded
patients and is characterised by an upper crossed shoulder posture which in turn can cause forward
syndrome. In this syndrome, the axioscapular muscles head posture.
i.e., upper trapezius, levator scapulae and pectoralis
The presence of pain in the neck area has also been
associated with altered activity in the scapular muscles.
Corresponding author:
It has been demonstrated that office workers with neck
pain tended to drift in and out of scapular protraction
Assistant Professor
MGM School of Physiotherapy, Kamothe more than asymptomatic office workers. 3 These
24, Progressive Pearl CHS, Plot-18, Sector-4A, changes were associated with altered behaviour in
Koparkhairane, Navi Mumbai upper trapezius and were linked to the severity of neck
E-mail: jyoti_bimanpalli@yahoo.co.in pain experienced. 6
1. Jyoti--1-6.pmd 1 5/10/2015, 5:13 PM

Currently, it is recommended that analysis and operationally defined as when the following applied:
correction of function of the axioscapular muscles
should be included for the treatment of patients with • pain on sustained loading;
postural neck pain. Consequently, improving the • abolition of pain, if present, on posture correction;
flexibility of the tight muscles and strengthening of
the weak deep neck flexors and scapular muscles and • no restriction of range of movement;
scapular posture correction exercises have been
advocated as part of intervention for these patients.7 • no pain on repeated movements.10
According to the current clinical practice Participants were excluded if they were more than
30 years of age, had changes of cervical spondylosis
guidelines, addressing specific impairments of muscle
length for an individual patient may be a beneficial on x-ray, complained of radicular pain in upper
extremity, had associated shoulder dysfunction,
addition to a comprehensive treatment program.7
vertigo, and any dermatology problems.
Role of scapular taping has been established for
Randomisation
correction of resting position of the scapula and
altering the activity of the axioscapular muscles.1 There Participants were randomly assigned to the groups
are a number of studies that have demonstrated via sealed envelope. The process of randomisation was
positive effects of scapular taping in patients with undertaken by a staff member within the college who
shoulder dysfunction. 8,9 However, to the knowledge was not aware of the group allocation indicated in
of author, no studies have investigated the role of sealed envelope and was not part of any of the follow-
scapular taping in patients with postural neck pain. up testing or intervention procedures. Participants
It can be hypothesized that, flexibility exercise assigned to the control group received therapist
supervised self stretching of upper trapezius, levator
targeting tight axio-scapular muscles will help in
reducing the biomechanical stresses on the cervical scapula and pectoral muscles. Whereas, those in the
experimental group received stretching program along
motion segments. Scapular taping can have additional
effect on pain that may occur due to aberrant activity with scapular taping. Scapula was taped by the same
of the muscles. staff who supervised the stretching intervention. This
staff, was blinded to the assessment results.
Therefore, purpose of this study was to compare
the effect of scapular taping along with stretching and PROCEDURE
stretching alone in patients with postural neck pain
Baseline readings of the outcome measures were
METHOD recorded on 1st day before the start of program and
after 1st and 2nd week of intervention. The outcome
Study design: Prospective, single-blinded measure were pain on Visual Analogue scale (VAS),
randomized controlled trial. resting position of scapula by lennie test, upper
trapezius and pectoralis minor muscle length.
Setting and Participants
Intervention
Participants (18-30yrs) who presented with
complains of neck pain on assumption of prolonged Scapular taping8
static postures, most commonly sitting, and relief of
pain with the resumption of an upright posture or Micropore tape was used to protect patient’s skin,
change of posture where examined using a standard and the taping was done using Leukopore tape. Taping
cervical-McKenzie assessment sheet. 10 Participants was initiated with two 4-in-wide micropore strips
were asked a series of standard history questions and applied from upper trapezius muscle belly region to
five main components were assessed: posture, effect 2-3inch below the inferior angle of scapula. Another
of static loading, effect of posture correction, range of strip was then applied from posterior-lateral acromion
movement, and effect of repeated movements. Positive diagonally across the back lateral to thoracic spinous
static loading was operationally defined as when processes (Figure-1). Several 1.5-in-wide Leukopore
sustained positioning in the participant’s aggravating strips of tape were then applied, with the first two
posture provoked symptoms. Postural syndrome was strips of tape starting at mid-muscle belly region of
1. Jyoti--1-6.pmd 2 5/10/2015, 5:13 PM

right upper trapezius muscle and pulling downward with each piece from mid-muscle belly region of the
and in toward the spinous processes attaching the tape upper trapezius muscle and continuing outward to the
just medial and inferior to inferior angle of the scapula. posterior-lateral acromion process (Figure-2).
Additional strips of tape were then applied by starting
Self-Stretching: Patients in both the groups were corresponding marks were made over the spinal
given therapist supervised self-stretching exercises to midline. Measurements were then taken to the nearest
upper trapezius, levator scapula and pectoralis minor millimetre from each scapular landmark to their
muscle. Stretch was maintained for 30 seconds and corresponding midline landmark using a tape.
three repetitions were given.
Pectoralis minor muscle length: 12 Patients were
Outcome measures requested to lie supine with their arms by sides and
fingers pointing to the ceiling. Without exerting any
Primary outcome measures downward pressure into the table, the distance
Pain on VAS: Participants were explained visual between the treatment table and posterior aspect of
analogue scale. Participants were asked to mark on a acromion was measured using rigid plastic scale in
scale based on the worst pain they experienced centimeters.. The muscle was considered tight if the
throughout the day. distance measured was more on one side as compared
to the contralateral side. Three readings were taken
and mean was recorded.
Upper trapezius muscle length:13 Cervical spine was

taken into contra-lateral flexion till the onset of pain
The secondary outcome measures
with chin pointing forwards. Linear distance between
Lennie test:11 The resting position of scapula was mastoid process and acromion process was measured
assessed by measuring the spino-scapular distance. with tape in centimeters. The muscle was considered
Patients were asked to stand in relaxed manner facing tight if the distance measured on one side was less as
the wall. Spinal midline was marked as a straight line compared to the contralateral side. Three readings
drawn from the spinous process of C7 cranially to the were taken and mean was noted.
midpoint between posterior superior iliac spines
caudally. Markings were made on the skin overlying DATA ANALYSIS
the right and left scapulae for the following landmarks:
superior angle, root of spine of scapula and inferior Summary statistics are presented as Means ±
angle. For each of these three marks over each scapula, Standard Deviation (SD). The demographic
1. Jyoti--1-6.pmd 3 5/10/2015, 5:13 PM

characteristics ( age, duration of symptoms, height,

weight & Body mass index) between the groups were
compared by independent sample t-test. The
categorical variables (gender) was analysed by chi-
square test. To study the effect of respective
intervention in each group over the period of two
weeks repeated measures ANOVA was used. In
presence of significance, data was further analyzed by
post-hoc-Bonferroni test. For intergroup comparison
independent sample t-test was applied on all the days
of assessment. Statistical Package for Social Sciences
(SPSS) software package (version 16) was used and
the alpha level was set at 0.05. All outcome analyses
were conducted according to intention-to-treat (ITT)
principle.
RESULTS
Fifty participants were enrolled in the study. Table-2 provides the mean outcome scores for each
Eighteen participants were not randomized to group at each time point . Repeated measures Anova
treatment group, as they did not meet the study showed statistically significant improvement in both
inclusion criteria during screening procedures groups at both the time points. Intergroup comparison
(Figure.3). Therefore, 32 participants were randomized showed statistically significant difference in both
to a treatment group ( Experimental group n=16; groups from baseline, with the experimental group
control group n=16). Characteristics of these exhibiting more improvement than the control group
participants, by group, are shown in Table-1. There in pain on VAS, lennie test, pectoralis minor and upper
were no statistically significant differences between trapezius tightness at the end of 1 week (p>0.05).
groups for any of the baseline characteristics of However, these differences disappeared by the 2week
participants (p<0.05). There were no adverse events endpoint for all the outcome measures except for
resulting from participation in study. lennie test.
Table 1: Baseline characteristics by treatment groups
Characteristic Experimental Control group P

group Mean (SD) Mean (SD)
Age 28.69(5.13) 27(5.80) 0.39
Gender F=13; M=3 F=12; M=4 0.67
Duration 3.88(2.70) 3.88(3.07) 1.00
Pain(VAS) 5.75(1.07) 5.31(0.95) 0.30
Upper Trapezius tightness 7.03(0.16) 7.19(0.68) 0.50
Pectoralis minor tightness 10.90(0.38) 10.50(1.22) 0.21
Lennie Test SA* 7.98(0.49) 7.63(0.72) >0.05
Lennie Test RS† 7.68(0.49) 7.83(0.47) >0.05
Lennie Test IA‡ 8.76(0.58) 9.03(0.60) >0.05
*SA=superior angle, †RS=root of spine, ‡IA=Inferior angle
Table 2: Mean and standard deviations of Outcome Measures by Treatment Group
Characteristic 1week follow-up 2week follow-up

Exp group Control group P Exp group Control group P
Pain(VAS) 0.81(0.83) 3.44 (0.95) 0 0.31(0.48) 0.75(0.58) 0.06
Upper Trapezius Tightness 8.75(0.10) 7.78(0.77) 0 9.63(0.19) 9.59(0.76) 0.91
Pectoral Tightness (1.19) 10.59(0.58) 0.04 9.28(1.02) 9.94(1.29) 1.20
Lennie Test at SA* 7.25(0.45) 7.69(0.70) <0.05 6.88(0.34) 7.69(0.60) <0.05
Lennie Test at RS† 7.25(0.45) 7.60(0.40) <0.05 6.69(0.48) 7.40(0.47) <0.05
Lennie Test at IA ‡ 7.93(0.44) 8.99(0.65) <0.05 7.56(0.63) 8.22(0.52) <0.05
* SA=superior angle, †RS=root of spine, ‡IA=Inferior angle
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DISCUSSION Limitations
The principal aim of this study was to compare the One of the key limitations of this study is the small
effect of scapular taping along with stretching and sample size. A convenient sample size of 32 was used.
stretching alone in patients with postural neck pain. This may have contributed to a potential type II error
This study showed that patients who received scapular in statistics and also insufficient power to detect a
taping in addition to stretching showed faster difference between the two groups. The data will
improvement in pain and flexibility in a period of however be useful to help develop future studies with
1week as compared to the group who received larger sample sizes.
stretching alone. However, at the end of 2nd week,
both the groups showed no statistically significant CONCLUSION
difference in both the groups in pain and flexibility.
Scapular taping along with stretching had no
Patients with postural neck pain develop muscle additional benefit over stretching alone in patients with
imbalances in which the upper trapezius, levator postural neck pain. Low-cost stretching exercises used
scapula and pectoralis minor becomes overactive and in common healthcare are still recommended as an
tight while the middle and lower trapezius become appropriate therapy intervention to relieve pain, at
weak. It has been implicated that tightness in these least in the short-term and can be introduced in
axioscapular muscle place compressive stresses on the practice. Subsequent investigations examining the
cervical motion segments. 5 Thus stretching of these effect of scapular taping for longer duration and on a
muscles may have led to normalization of the length larger sample size may be of interest in this patient
of the muscles thereby, reducing the stresses on the population.
cervical spine. The positive effect of stretching seen in
this study is supported by several studies in the Acknowledgement: We express our deep sense of
literature.7 gratitude to Head of Department, staff members and
patients who rendered their help during the period of
In this study, scapular tape was applied to inhibit our research work.
the upper trapezius and to activate middle and lower
trapezius. However, addition of tape did not have any Conflict of Interest: There was no conflict of interest.
beneficial effects over stretching alone. To the author’s
Source of Funding: Self
knowledge, the effect of scapular taping has been
studied in the patients with impingement syndrome Ethical Clearance: The study was cleared by the
8,9
or in healthy population 14,15 This is the first study, Departmental ethics committee of the institute.
that has evaluated the effect of scapular taping along
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DOI Number: 10.5958/0973-5674.2014.00001.X
The Effectiveness of Stress Management Technics on

Alcoholic Patients
Occupational Therapist, Department of Psychiatry, Jipmer Hospital, Puducherry
ABSTRACT
Background study: Current science is more informative about the relationship between drinking
and stress than about the relationship between stress and alcohol dependence. Studies indicate that
people drink as a means of coping with economic stress, job stress, and marital problems, often in the
absence of social support, that the more severe and chronic the stressor, the greater the alcohol
consumption. Stress management techniques are integral part of alcoholism treatment programs.
Aims and Objectives: To determine the effectiveness of stress management program among alcoholics
in the rehabilitation setup.
To identify the level of stress.
To test the effect of stress management among alcoholics in the rehabilitation setup.
Methodology: Clients should be addict for alcohol in more than one year. Chronic alcoholic addicts
where selected for the present study based on the following inclusion criteria
a) Clients who are habituated of having alcohol three times a week or more
b) Regular customs of arrack shop/bar/toddy
c) Clients who were complained of being chronic alcoholics by the family members
Sample: 121 alcoholic patients, age group of 18 -59 years studies are conducted at various de addiction
centers.
Duration is 15 years patient at rehabilitation setup Exclusion criteria: alcoholics not having any
associated psychiatric complications alcohol dependent only
Stress questionnaire are used in this study.
Results: The results showed that there was a significant difference between the pre and post test of
stress questionnaire. (75.386 If P=0.000)
Conclusion: The influence of stress among the alcoholic groups is embedded. Although many studies
stated that the stress influence and reduced among the various conditions. This study concluded
that various relaxation techniques should be established for reducing the level of stress on the alcoholic
groups.
Keywords: Alcoholism, Stress Management Techniques
INTRODUCTION in nature (Kathleen T.Brady and C.Sone, Pharm.D

1999)7. The degree to which perceived controllability
The term stress generally refers to the reactions of
alters the way a stressor is experienced varies greatly
the body to certain events or stimuli that the organism
among individuals (Tim.V. Salomons 2007) 7 .
perceives as potentially harmful or distressful. Such
Occupational stress is a term used to define on going
stress inducing events or stimuli, which are referred
stress that is related to the workplace. The stress may
to as stressors, can be either physical or psychological
have to do with the responsibilities associated with
2. Ramakrishnan --7--.pmd 7 5/10/2015, 5:13 PM

the work itself, or be caused by conditions that are - To test the effect of stress management among
based in the corporate culture or personality conflicts. alcoholics in the rehabilitation setup.
As with other forms of tension, occupational stress can
eventually affect both physical and emotional well HYPOTHESIS
being if not managed effectively (Malcolm Tatum - Alternative hypothesis:
2010)1.
- There is a significant difference between the pre
Alcoholism is defined as “a diseased condition due and post test of stress questionnaire.
to the excessive use of alcoholic beverages” Alcoholism
is also known as a family disease (Tatyana Parsons
REVIEW OF LITERATURE
2003)13. Parental alcoholism also has severe effects on
normal children of alcoholics. Many of these children Fanous S(2010)15 conducted a study on social defeat
have common symptoms such as low self-esteem, stress is an ethologically salient stressor which
loneliness, guilt, feelings of helplessness, fears of activates dopaminergic areas and when experienced
abandonment, and chronic depression (Berger,1993)11. repeatedly, has long term effects on dopaminergic
Alcoholism is a chronic, often progressive disease in function and related behaviour. These effects is brain
which a person craves alcohol and drinks despite derived neurotrophic factor, a neurotrophin involved
repeated alcohol related problems (like losing a job or in synaptic plasticity and displaying alterations in
a relationship). Alcoholism involves a physical dopaminergic reactions in response to various types
dependence on alcohol, but other factors include of stress. The dynamic nature of brain derived
genetic, psychological, and cultural influences (Steven neurotrophic factor expression in dopaminergic brain
D. Ehrlich 2009)10. regions in response to repeated social stress may
therefore have implications for lasting
The effectiveness of brief group training in
neurochemically and behavioral changes related to
meditation or Progressive Muscular Relaxation
dopaminergic function.
reduces state anxiety after exposure to a transitory
stressor (Rausch, et al. 2006)9. Psychological stress may Muzaffer Kasar (2010)1 conducted a study on a
lead to increased rates of anxiety and depression. study of people who had relapsed to Driving under
Aerobic exercise is frequently described as having the influence of alcohol found subtle deficits in their
positive effects on psychological well-being by decision-making abilities that tend to go undetected
enhancing mood and reducing anxiety (Johansson, through conventional neuropsychological testing.
Mattias, Peter;Jouper,John 2008)3. The schizophrenic
patient’s improved on 7 of 20 items of the State-Trait Pohorecky, L.A. (1991)8 In a review investigating
Anxiety Inventory demonstrated the effectiveness of the connection between alcohol consumption and
even a short-term stress management program stress, he notes several studies in which researchers
(Franklin Stein 1989)5. sampled individuals from areas affected by natural
disaster. Studies indicate that people drink as a means
Stress management techniques are integral part of of coping with economic stress, job stress, and marital
alcoholism treatment programs, although it is difficult problems, often in the absence of social support, that
to specifically ascertain the value of these techniques the more severe and chronic the stressor, the greater
(Kathleen T.Brady and C.Sone, Pharm.D 1999)3. the alcohol consumption
AIM AND OBJECTIVES Ann Turner (2002) 7 stress management

programmes offer a practical way to change
Aim maladaptive responses, using cognitive and
physiological components. The occupational therapist
To determine the effectiveness of stress and the individual need to establish a set number of
management program among alcoholics in the sessions during which they will explore issues and
rehabilitation setup. practice dealing with this. Identifying negative
thoughts, understanding the meaning of them and
OBJECTIVES changing and modifying thoughts can help stressful
situations become manageable. By incorporating
- To identify the level of stress.
relaxation techniques and breathing control into daily

living, individuals can counteract stressful responses DATA COLLECTION PROCEDURES

and replace these with relaxed posture and controlled
breathing. Techniques should be selected on an The study was explained to the head of the
individual basis to suit specific needs. Progressive rehabilitative institution. Institutional consent form
muscular relaxation may not be suitable for individuals was obtained from the Dean of the college. Pre test
with bone or muscle pain; people with limited was done by using the stress questionnaires. After the
concentration and extreme fatigue may need shorter intervention post test was done by using the stress
techniques. questionnaires.
Norman (2002)6 conducted study on schizophrenic Intervention starts with the progressive muscular
patients who received the stress management program relaxation techniques (Jacobson) to the verbalization
did have fewer hospital admissions and but it did not for the patients. Its include coping skills strategies,
reduce schizophrenia symptom level. The author’s aerobic exercises, autogenic training, communication
hypotheses that stress management training may skills, deep breathing, laughter, meditation, time
provide people with coping skills that reduce the management and verbalization. This could be done at
likelihood of acute exacerbation of symptoms reducing least from 8 to 12 weeks after admission.
hospitalization. Jacobson Techniques
METHODOLOGY Jacobson was a renowned behavior therapist who

evolved this procedure.
Research Design
Tightly clench your right fist. Feel the tension. Feel
Quantitative and experimental study how uncomfortable it is when you are tensed. Now
slowly relax your fingers. Relax them completely and
Sample
feel the difference. Feel how comfortable it is when
This study was conducted on 121 Alcoholic patients you are relaxed. Enjoy the feeling of being relaxed.
with the age group of 18 – 60 years from the various
Repeat the same procedure with the left fist.
institutions.
Do the same with both fists.
Screening Criteria
Clench both fists. Touch your shoulders with your
A. Inclusion criteria
fist without raising your arms from the floor.
- Alcoholic patient
Press the sides of your body with your open palms
- Age group 18 – 60 years (fingers open).
- Patient at rehabilitation setup Touch the sides of your body with your open palms
and push your shoulders downwards.
B. Exclusion criteria:
Touch the sides of your body with your open palms
Patients with severe mental illness and push your shoulders upwards (towards your
ears).
Drug dependent patient
Raise your eyebrows with your eyes closed
Questionnaires used
gently….
Stress questionnaire - Test retest reliability of 0.87,
Knit your eyebrows…..
Good concurrent validity
Press your eyelids harder (do not contract them)….
Score interpretation
Press the upper part (roof) of the mouth with your
0 -17 low stress tongue (the whole tongue and not just the tip of the
tongue)…
18 – 35 moderate stress
Clench your teeth as hard as possible (press your
36 – 52 high stress upper teeth to your lower teeth)…

Press your upper lip to your lower lip…. involves repetitive, rhythmic contractions of the large
muscles of the legs and arms. Aerobic exercise appears
Raise your head off the ground and touch your to be an effective mood regulating behavior (Thayer,
chest with your chin. In the same raised posture, slowly Newman and McClain, 1994)16.
turn your head to the right (as much as possible) then
to the left, then slowly to the centre and then slowly Autogenic training
relax….
It uses self-hypnosis and mental imagery to achieve
Raise your chin upwards as much as possible. In relaxation. It typically involves imagining sensations
the raised posture slowly turn to your right, then of physical heaviness and warmth to achieve muscle
slowly to the left and then bring it to the centre and relaxation and vasodilatation.
then slowly relax….
Imagining oneself in settings where one would feel
Try to bring your shoulders as close as possible, by warm, comfortable, and heavy can facilitate these
keeping your arms on the ground (you can feel the autosuggestions.
tension at the nape of your neck)…
Autogenic training is an effective adjunctive
Press your shoulders to the ground, so that your treatment for stress-related conditions (Ehlers et al,
chest expands…. 1995).
Push your stomach as far inward as possible… It is not recommended for people who are agitated
or actively psychotic (Courtney and Escobedo, 1990)16.
Push your stomach as far inward as possible…
Communication skills
Keep your head, arms, waist, legs and feet on the
ground and raise just your back off the ground…. Clarifying expectations, defining needs honestly
and providing tactful and constructive feedback, can
Tighten your thigh muscles…. decrease the number of stressful understandings.
Bring your feet closer and push them as far inward Social skills training and assertive training
as possible… programs are an important part of stress management
Bring your feet closer and push them as far outward for certain client populations (Willard and Spackman’s
as possible…. 1993)16
Now slowly take a deep breath and hold it (for a Deep breathing
few seconds) then slowly breathe out…
Deep breathing involves slowly inhaling and
Start breathing normally. exhaling to reduce tension in the shoulders, trunk and
abdomen. The process begins with focusing on normal
Now right from head to toe, each part of your body breathing in a quiet and comfortable place. This is
is relaxed and is as light as a feather. Likewise your followed by a period of deep inhalation and slow
mind is also calm and comfortable. Enjoy the comfort exhalation. During inhalation, the abdominal muscles
of being relaxed. should be relaxed. During exhalation, the abdominal
RELAX….RELAX…. muscles should be contracted. It is often helpful to rest
a hand lightly on the abdomen during this process.
Be in that relaxed state for about five minutes, each
minute enjoying the feeling of being relaxed. Then Deep abdominal breathing has been demonstrated
slowly count 5, 4,3,2,1 and slowly turn your right and to reduce physiological responsiveness (Forbes and
tie down and then slowly get up and sit down feeling Pekala, 1993)16 15 minutes with 2 – 3 minutes interval.
light and relaxed, both in mind and body ( Edmund
Laughter
Jacobsen, 1920 )16.
Laughter’s may stimulate the release of endorphins,
Aerobic exercise
the brain’s endogenous opiates, thereby helping to
Early morning it is done for 20 – 30 minutes. It alleviate pain and stress (Cousins, 1979)16.

Meditation: at a time in one set up per day. This has to continue

minimum eight to twelve weeks sessions.
Meditation involves focusing attention on a
rhythmic, repetitive word, phrase or sensation (e.g Data Analysis Procedure
breathing, heart rate) to achieve relaxation. Benon
Data analysis carried out uses SPSS (version 15).
(1975)16 has suggested that this mental process blocks
the stress response of the sympathetic nervous system
RESULTS AND INTERPRETATION
by activating the anterior hypothalamus which
controls the parasympathetic nervous system. Each In this study one hundred and twenty one subjects
one has to teach the patient for more than twenty between the age group of eighteen to sixty were
minutes up to forty five minutes for twenty patients selected. All are selected from different institutions.
Table 1: The demographic distribution of variable
Gender Sample size

Male 121
Table 2: Pre and Post test values in low range
Range 0 - 17 Pre-Test Post-Test Total

26 92 118
The number of patients at low stress level was more at post test.
Table 3: Pre and Post test values in moderate range

95 28 123
The number of patients at moderate stress level was less at post test.
Table 4: Pre and Post test values in severe range

2 0 2
There is none of the patients at severe stress level was at post test.
Table 5: Pre and Post test values of all ranges
S. No Scoring Range Pre-TestNo Post-TestNo. Total Chi-squareValue PValue

of patients of patients
1. Range 0-17 26 92 118 75.386 0.000 S
2, Range 18-35 95 28 123
3. Range 36-52 2 0 2
(p = 0.000)
Chi-square test was used to find whether, a alcoholic patients. The results concluded that stress
significant difference was seen between the pre and has an influence on alcoholic life events and that
post test. The results showed that there was a various relaxation techniques should be established
significant difference (75.386 if p value is 0.000) for reducing the level of stress on the alcoholic groups.
between the both tests.
RECOMMENDATIONS
CONCLUSION
1) Follow up studies can be extended up to one year.
This study has been done to determine the
effectiveness of stress management program for 2) Women should be included in the future studies

Acknowledgement: I take this opportunity to thank journal of the Schizophrenia International

our Dean Mr. D. Suresh Kumar, M.O.T, SRM college Research Society.
of Occupational Therapy for his encouragement, 6. Norman R, Malla A, Mclean T et al (2002) “Stress
support and guidance. I also wish to thank Mr. management programme may reduce hospital
Christopher Amalraj, Bio-statistician for his help in admissions among people with schizophrenia
Schizophrenia Research.
statistical analysis work.
7. Ann Turner, Margaret Foster, Sybil E. Johnson
I am very grateful to all Managing Directors who (2002) Occupational therapy and physical
helped my thesis data collection in the De-addition dysfunction: principles, skills, and practice.
8. Pohorecky, L.A. (1991) Stress and alcohol
centers.
interaction: An update of human research.
Conflict of Interest: The author declares no conflict of Alcoholism: Clinical and Experimental Research
interest. 15(3):438-459.
9. Raush, Sarah M.; Gramling, Sandra E.; Auerbach,
Source of Funding: The study was not funded by any Stephen M (2006). “Effects of a single session of
source. large-group meditation and progressive muscle
relaxation training on stress reduction, reactivity,
Ethical Clearance: There is no violation of human and and recovery” International Journal of stress
animals in this study. The study was conducted at de- management.
addiction center under the supervision of SRM college 10. Richard M.Grinnell, Yvonne A, Unraue (2007)
of OT. In this study ethical clearance was not obtained. Social work research and evaluation: Foundation
of evidence based practice by -Google book
results.
REFERENCES
11. Sara Graefe (1999). Parenting Children Affected
1. Muzaffer Kasar, Ezequiel Gleichgerrcht, (2010, by Fetal Alcohol Syndrome: A Guide for Daily
september 9) Alcoholism: Clinical & Living. Ministry for Children and Families
Experimental Research Decision-making deficits edition (British Columbia) retrived from http/
related to driving under the influence are often google.com.
undetected. ScienceDaily(2010, September 9). 12. Sadava, S.W., &Pak A.W (1993). Stress-related
2. Victor R. Preedy(2005), Alcohol related pathology problem drinking and alcohol problems: A
Book review: 403 -404. longitudinal study and extension of Marlatt’s
3. Johansson, Mattias; Hassmen, Peter; Jouper, John model. Canadian Journal of Behavioral Science.
(2008) “Acute effects of qigong exercise on mood 13. Tetyana Parsons (2003) All Psych Journal:
and anxiety” International Journal of Stress Alcoholism and its Effects on the Family 363-376.
management,. 14. Volpicelli, J.R (1987). Uncontrollable events and
4. McIlvane JM; Baker TA; Mingo C A (2008) Racial alcohol drinking. British Journal of Addiction.
differences in arthritis-related stress, chronic life 15. Fanous; Hammer RP; Nikulina EM (2010) short
stress, and depressive symptoms among women and long term effect of intermittent social defeat
with arthritis: a contextual perspective J Gerontol stress on brain-derived neurophic factor
B Psychol Sci Soc Sci. expression in mesocorticolimbic brain regions.
5. Norman R, Malla A, Mclean T et al, (2000) “An Neuroscience167 (3): 598-607.
evaluation of a stress management program for 16. Willard and Spackman’s (1993) Occupational
individuals with schizophrenia” An official Therapy 8th edtion 461 – 463.

DOI Number: 10.5958/0973-5674.2014.00001.X
Influence of Different Movements on Blood Pressure in

Hypertensive Subacute Stroke Patients
Pritika Lalwani1, Purti Haral2, SujataYardi3

Internship,Bachelor of Physiotherapy, 2Assistant Professor, 3Professor and Director, Deprtment of Physiotherapy,
1
Dr.DYPatilUniversity,Nerul,Navi Mumbai
ABSTRACT
Blood pressure is the pressure exerted by the blood against the walls of the blood vessels, especially
the arteries, and is one of the vital signs. Acute stroke patients with hypertension require rehabilitation,
but exercise seems to be linked to transient increase in blood pressure. Thus, it is necessary to examine
the effects of different types of active movements on blood pressure in hypertensive stroke patients.
Objectives: 1. To assess the variation of Blood pressure following different active movements in
normal healthy individuals and subacute stroke patients. 2. To compare the variation of Blood pressure
following different active movements in normal healthy individuals and hypertensive subacute stroke
patients.
Method: 15 normal and 15 hypertensive subacute stroke patients between the ages of 40-60 years
were selected.Resting parameters such as heart rate and Blood pressure were recorded in both the
groups. The following movements were shown to the patient and then repeated 15 times each
unilaterally. Shoulder flexion,hip flexion, Bridging, Standing,Walking Blood pressure was taken post
every movement being repeated 15 times.
Result: In normal the maximum rise in systolic blood pressure was seen while walking, followed by
standing and bridging and the least in shoulder and hip flexion. Maximum influence on diastolic
blood pressure in normal was caused by walking followed by standing. No significant change was
brought about by shoulder and hip flexion and bridging.
In hypertensive subacute stroke patients the maximum rise in systolic blood pressure was seen while
walking. Standing was more significant than bridging which was more significant than shoulder
and hip flexion. Maximum influence on diastolic blood pressure in stroke patients was caused while
walking followed by standing. No significant change is brought about by shoulder and hip flexion
and bridging.
Conclusion: Systolic blood pressure was found to be increased in hypertensive subacute stroke
patients specially while walking, compared to shoulder and hip flexion. There was minimal change
seen in the diastolic blood pressure while performing these activities.
Keywords: Stroke, Blood Pressure, Hypertension
INTRODUCTION pressure. The normal blood pressure is 120/80 mm

Hg.
Blood pressure is the pressure exerted by the blood
against the walls of the blood vessels, especially the While exercising, the body’s need for oxygen
arteries, and is one of the vital signs. During each increases. To meet the growing demands of the body
heartbeat the blood pressure varies between a the heart pumps faster. Since the pulse is a direct
maximum (systolic) and a minimum (diastolic) measure of heartbeat per minute it increases during
3. Pritika--13--.pmd 13 5/10/2015, 5:14 PM

exercise. As a result the heart beats faster and pumps Sample Size: 30
blood through the arteries faster resulting in increase
internal pressure and thus blood pressure also rises Inclusion Criteria
during exercise. 1. Normotensive, healthy individuals.
Blood pressure is frequently elevated in patients 2. Hypertensivesubacute stroke patients with stable
following acute stroke and has been associated with vital signs, stable neurological condition,
an increased risk of recurrent stroke and other vascular determined by a physician and being alert ( able
events. Acute stroke patients with hypertension to participate actively in study-related physical
require rehabilitation, but exercise seems to be linked therapy).
to transient increase in blood pressure. Thus, to
maintain acceptable blood pressure and optimize Exclusion Criteria
motor ability restoration in stroke patients, appropriate
types and amounts of active movements during • Unstable cardiac disease.
physical therapy must be selected. • Hypertension (blood pressure greater than or
Little is known about the association between blood equal to 180/110 mmHg) after antihypertensive
pressure and different active movements during treatment.
rehabilitation sessions. Thus, it is necessary to examine • Any other disorder potentially associated with
the effects of different types of active movements on medical instability.
blood pressure in hypertensive stroke patients.
Plan of study: Resting parameters such as heart rate
AIMS AND OBJECTIVES and Blood pressure were recorded in both the groups.
The following movements were shown to the patient
Aims and then repeated 15 times each unilaterally. Blood
pressure was taken post every movement being
To assess the variation of Blood pressure following
repeated 15 times. The recovery was noted and further
different active movements in hypertensive subacute
movements were conducted:
stroke patients.
1. Lifting the shoulder (shoulder flexion)
OBJECTIVES
In supine flex the shoulder close to 90 degrees and
1. To assess the variation of Blood pressure following extend the elbow as much as possible.
different active movements in normal healthy
individuals. 2. Flexing the hip and knee
2. To assess the variation of Blood pressure following In supine position, flex the hip and raise the knee from
different active movements in hypertensive the bed as much as possible.
subacute stroke patients.
3. Bridging
3. To compare the variation of Blood pressure
In supine, lifting the pelvis off the plinth, without
following different active movements in normal
holding the breath.
healthy individuals and hypertensive subacute
stroke patients. 4. Standing
MATERIALS AND METHOD Two extremity standing without support.
Study Design: Cross-sectional study 5. Walking
Duration of study: 6 Months. 10 Meter walk test.
Study Subjects: 15 normal ,healthy subjects between FINDINGS

the age of 40-60 years.
This study evaluated variation in blood pressure
15 hypertensive subacute stroke patients,healthy in hypertensive sub acute stroke patients performing
subjects between the age of 40-60 years. five different types of active movements. The greatest
3. Pritika--13--.pmd 14 5/10/2015, 5:14 PM

effect of the different active movements in stroke muscles. Thus, the bridging activity may have been
patients was on mean systolic blood pressure easier for stroke patients to perform and might explain
variability. There was a significant difference in why blood pressure was not significantly increased
systolic and diastolic blood pressure variation between during bridging8,9.
stroke patients on different movements and in normal.
Environmental and psychological factors can also
During exercise, in order for the working muscles contribute to an elevation in systolic blood pressure.
to be receiving adequate amounts of nutrients and An unfamiliar environment may have contributed to
oxygen, the heart rate needs to be increased such that increase blood pressure. Patients may have been
waste products which include the lactic and carbon nervous owing to a new therapist and additionally the
dioxide are being removed. Anticipatory rise in heart patients were faced with the challenge of
rate occurs before even starting to exercise due to the participitating in new training activities10.
release of adrenaline in the sympathetic nervous
system1. Many patients may have had concerns about falling
while sitting, standing or walking, particularly if it was
Once exercise has begun, there is an increase in their first attempt at performing these activities post
carbon dioxide and lactic acid in the body which is stroke. Patients may also have had concerns about
detected by chemoreceptors. The chemoreceptors completing the movements correctly according to the
trigger the sympathetic nervous system so as to therapists instructions, and those patients unable to
increase the release of adrenaline, which will further
complete the movements fully may have been
increase heart rate. As exercise continues, the body core
concerned about having disabilities as a result of the
temperature rises, which will also help to increase the
stroke. This could potentially lead to some patients
heart rate since it increases the speed of the conduction
experiencing psychological reactions to stress, such as
of nerve impulse across the heart2.
anxiety or fear, resulting in increased blood pressure11.
The intensity of the movement may contribute
In normal the maximum rise in systolic blood
because the energy used during high intensity
pressure was seen while walking, followed by
movements is greater than that used during low-
standing and bridging and the least in shoulder and
intensity movements3,4. Shoulder flexion is a low-
hip flexion (P value<0.05). Maximum influence on
intensity activity that did not particularly increase post-
diastolic blood pressure in normal was caused by
test systolic blood pressure compared with pretest
walking followed by standing. No significant change
values, in contrast walking, which involves more
motor activity than the other movements showed the was brought about by shoulder and hip flexion and
greatest systolic blood pressure variation5. bridging. (P value >0.05).
Difficulty of the movements may also contribute In hypertensive subacute stroke patients the
to elevation of systolic blood pressure. The effort and maximum rise in systolic blood pressure was seen
strength required to perform more difficult while walking. Standing was more significant than
movements of similar intensity is larger than for easier bridging which was more significant than shoulder
movements and might explain why systolic blood and hip flexion.( P value< 0.05). Maximum influence
pressure variation during more difficult movement on diastolic blood pressure in stroke patients was
was higher than those during easier movements6,7.For caused while walking followed by standing. No
example, bridging activity uses the body’s long significant change is brought about by shoulder and
muscles which are relatively stronger than short hip flexion and bridging.(P>0.05)
Table 1: Systolic Blood Pressure Variability
SYSTOLIC Shoulder flexion Hip flexion Bridging Standing Walking

NORMALS 119.73 ± 6.307 120.27 ± 6.871 121.53 ± 6.875 123.13 ± 6.791 126.00 ± 6.698
STROKE 132.27 ± 8.689 133.73 ± 9.308 136.13 ± 9.054 137.93 ± 9.475 140.73 ± 9.543
3. Pritika--13--.pmd 15 5/10/2015, 5:14 PM

Table 2: Diastolic Blood Pressure Variability
DIASTOLIC Shoulder flexion Hip flexion Bridging Standing Walking

NORMALS 79.533 ± 5.383 79.533 ± 5.383 81.067 ± 5.161 82.200 ± 5.060 84.533 ± 5.167
STROKE 89.333 ± 6.779 90.067 ± 7.304 92.333 ± 7.188 94.600 ± 7.169 96.867 ± 7.405
CONCLUSION 2. Cardiopulmonary exercise testing for evaluation

of chronic cardiac failure (1985) http://
Systolic blood pressure was found to be increased www.ncbi.nlm.nih.gov/pubmed (29th Apr
in hypertensive subacute stroke patients specially 2008).
while walking, compared to shoulder and hip flexion. 3. BrittonM,CarlssonA,de Faire U: Blood pressure
Therefore therapists should be careful in giving graded in patients with acute stroke and matched
exercises to these patients to prevent excessive rise in controls.Stroke 1986; 17:861-864.
blood pressure resulting in its recurrence. There was 4. Thrombly CA: Motor control therapy. In:
minimal change seen in the diastolic blood pressure Occupational Therapy for Physical
while performing these activities. dysfunction,2 nd edition(Thrombly CA ed).
Baltimore: Williams and Wilkins, 1983;pp 316.
Acknowledgement: I would like to express my 5. MackoRF,KatzelLI,YatacoA,et al: al Low velocity
gratitude towards my parents & members of graded readmill stress testing in hemiparetic
Padmashree Dr.D.Y.Patil University Department of stroke patients. Stroke 1997;28: 988-992.
Physiotherapy for providing me with an opportunity 6. AmundenLr,TakahashiM,Carter CL, et al:
to do my project on “Influence of different movements Exercise response during wall-pulley versus
on Blood pressure in hypertensive subacute stroke bicycle ergometer work. PhysTher 1980;60: 173-
178.
patients and for their kind co-operation and
7. SpitzerSB,LlahreMM,IronsonGH,et al: The
encouragement which helped me in completion of this
influence of socialSituations on ambulatory blood
project. pressure.Psychosom Med 1992;54:79-86.
8. SegaR,CesanaG,MilesiC,etal:Ambulatory and
Conflict of Interest: NIL
home blood pressure normality in the
Source of Funding: NIL elderly:data from the PAMELA
population.Hypertension 1997;30:1-6.
An Ethical Committee: Approval was taken prior to 9. JacobRg,ThayerJF,ManuckSB,etal:Ambulatory
starting of the study. blood pressure responses and the circumplex
Med 1999;61:319-333.
Limitations of the present study are 10. HarperG,FotherbayMD,PanayiotouBJ,etal:The
changes in blood pressure after acute stroke:
• Small sample size. abolishing the ‘white coat effect’ with 24-h
ambulatory monitioring.J Intern Med
• Psychological factors.
1994;235:343-346.
• Onetime assessment. 11.
PaternitiS,AlperovitchA,DucimetiereP,etal:Anxiety
but not depression is associated with elevated
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blood pressure in a communitygroup of French
1. Baechle,T.R. and R.W.Earle, (2000) Essentials of elderly.Psychosom Med 1999;61:77-83
Strength training Conditioning/National
Strength and Conditioning (2 nd Ed) Human
Kimectics.
3. Pritika--13--.pmd 16 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Comparison of Balance in Elderly with and without

Diabetes using Balance Evaluation Systems Test Test
(BESTest)
Riddhi Desai1, Ramesh Debur2

1
Assistant Professor, Shree Swaminarayan Physiotherapy College, Kadodara Char Rasta, Surat, Gujarat,
2
Assistant Professor, M.S. Ramaiah Medical College, MSRIT, Bangalore
ABSTRACT
Purpose of the study: Changes in postural alignment and other mechanisms are commonly noticed
with ageing. These changes results in loss of balance in elderly. Diabetes is also associated with
imbalance. Very few studies examine various sources of impairment that causes loss of balance in
elderly with and without diabetes. There seems to be a lack of evidence about the sources of
impairment. Balance evaluation systems test (BESTest) is an evaluation tool to assess variety of balance
impairment sources. Hence, the following study is undertaken to compare balance in elderly with
and without diabetes using BESTest.
Method: A comparative study was undertaken. 94 subjects were selected based on the screening for
inclusion and exclusion criteria. Group 1 consisted of 47 subjects with diabetes and group 2 consisted
of 47 non diabetic subjects. Next, the balance was assessed using BESTest.
Results: Independent T-Test was used to compare the Difference in balance between elderly subjects
with and without diabetes and showed a significant difference in the balance on the total score of
BESTest(<0.001) and in 4 domains i.e. biomechanical constraints, reactive postural reactions, sensory
orientation(<0.001) and dynamic stability in gait(<0.005). There was no significant difference in stability
limits and transitions/anticipatory postural reactions sections of BESTest between 2 groups.
Conclusion: The study concluded that diabetic individuals perform differently on BESTest compared
to non-diabetic and their balance is more affected compared to non-diabetics. It was found that out
of the six domains of BESTest, four domains which includes biomechanical constraints, reactive
postural responses, sensory orientation and stability in gait were affected which could result in a risk
of falls.
Keywords: Balance, Elderly, Balance Evaluation Systems Test (BESTest), Diabetes
INTRODUCTION adaptation occur and thereby eliminate some of the

stages of postural control leading to an increased
“Ageing in humans refers to a multidimensional
instability.2
process of physical, psychological, and social
change.” 1Ageing is a physiological and dynamic The population of older adults is increasing and
process, where changes in ability of homeostatic awareness of the impact of falls and falls related
injuries is also increasing. In elderly, as a part of ageing
Corresponding author: process there will be degenerative changes in various
Riddhi Desai systems including the neuromuscular system which
Assistant Professor is majorly involved in maintaining balance.3
Shree Swaminarayan Physiotherapy College,
Kadodara Char Rasta, Surat, Gujarat Balance control is not considered as an isolated
Phone: 8469120494 system. The ability to maintain balance is complex
E-mail: Desairiddhi13@gmail.com motor task which involves different systems such as
4. Riddhi--17--.pmd 17 5/10/2015, 5:14 PM

biomechanical, reactive postural responses, disorder that is characterized by high blood

anticipatory postural adjustment, sensory integration glucose resulting from insulin resistance leading to
and constraints on dynamic balance during gait and development of associated diseases or complications
any of these systems can impair balance.4 such as retinopathy, nephropathy, peripheral
neuropathy, loss of joint mobility and muscle
The biomechanical constraints are one of the most
strength.” These complications may cause damage to
important aspects responsible for postural control.
balance maintenance systems resulting in functional
These constraints are quality and size of base of
limitations, poor lower limb functions and falls.2
support (BOS). The limitations in the feet such as ankle
Ageing associated with diabetes mellitus progressively
muscle weakness, limited range, pain or poor motor
leads to further risk of falls.6
control of feet and postural malalignment can impair
the ability of elderly persons to use compensatory steps Various studies have compared balance in elderly
or ankle strategy to maintain balance.4 with and without diabetes using scales like berg
balance scale(BBS), timed up and go test(TUG), balance
Constraints of anticipatory postural reactions prior
screening tool (BST)and concluded that balance is more
to voluntary movements require an active movement
affected in elderly with diabetics and diabetes mellitus
of body’s centre of mass (COM) in anticipation of
is an independent fall risk factor among elderly.2
transitions from one body posture to another. Any
lesion or degeneration of basal ganglia and brainstem Despite the conclusion that elderly with diabetes
areas result in imbalance while standing.4 has more balance impairment compared to non-
Reactive postural responses are also one of the most diabetics, studies have not explored the sources of
important constraints to maintain balance. impairment that contribute to balance impairment.
Compensatory and in place stepping responses are the Various studies concluded that TUG, BST and BBS
reactive postural responses to an external perturbation. provide screening of balance in elderly, but they do
Constraints on short, medium and long proprioceptive not offer details regarding source of impairment and
feedback loops are responsible for reactive postural recommended that there remains a need of a valid and
responses to slips, trips and pushes include late reliable functional balance test that appropriately
responses in conditions such as sensory neuropathy.5
measures balance and help in finding source of
Another important aspect of postural control is impairment in community dwelling older individuals.7
sensory orientation which involves Somatosensory,
Rose D. et al concluded that BBS has limited
visual and vestibular inputs. Individuals need to re-
dynamic balance assessment that do not provide a
weight relative dependence on each to sense as they
great enough challenge to older adults who live
change sensory environment. Somatosensory system
independently.8Newton R. et al reported that despite
among all three systems is the most important
of good reliability and validity, the presence of ceiling
contributor of feedback for postural control. Healthy
effect limits the use of scale to detect balance
individuals rely 70% on somatosensory information
to maintain balance. Individuals with somatosensory impairments in community dwelling older adults.9
loss have limited ability to re-weight postural sensory TUG is also limited balance measurement scale and
dependence and have increased risk of falling.4 addresses dynamic balance and yields a narrower
assessment of balance in older adults.10
The dynamic balance during gait and transition
requires complex control of a moving COM. Forward Since there are no scales that determine sources of
dynamic balance comes from placing the swing limb impairment and cannot assess both static and dynamic
under the falling COM. Older people are prone to have balance in individual BESTest was developed by Fay
imbalance due to impaired coordination between Horak to help physical therapist identify the
spinal locomotor and brainstem postural sensorimotor underlying sources of impairment responsible for poor
programs when COM must be caught by moving BOS. balance in individuals.5
In elderly individual gait speed is considered affected
The BESTest aims at 6 various balance control
due to balance impairment. Thus, in elderly dynamic
balance can be impaired despite of good static balance.4 systems like “biomechanical constraints, stability
limits, transitions and anticipatory postural, reactive
“Type 2 Diabetes also known as Non-Insulin- postural responses, sensory constraints, dynamic
dependent Diabetes Mellitus(NIDDM) is a metabolic stability during gait” so that specific physiotherapeutic
4. Riddhi--17--.pmd 18 5/10/2015, 5:14 PM

approaches can be designed for different balance ulcer/ visual impairment, any injury to foot or fracture
deficits. The BESTest is easy to learn, administer and a of lower limb, prior ankle surgery and other
cost effective scale.5 BESTest can help in identifying neurological problems like Stroke, Parkinsonism were
the various sources of balance impairments in elderly excluded from study. Study was explained to each
with and without diabetes. Specific physiotherapeutic subject and an informed consent was obtained from
treatment strategies can be designed based on source the subjects. BESTest was explained to each individual
of impairment involved for imbalance in elderly with prior to administration. Materials Used were ABC
and without diabetes. scale, BESTest, Stop watch, Measuring tool for
Hence, the following study is undertaken to functional reach test,60cm × 60cm block of medium
compare balance in elderly with and without diabetes density foam, 10Úincline ramp ( 2×2 ft), Stair step,
using BESTest and to understand the possible sources Obstacles, 2.5kg weight for rapid arm raise, Firm chair
of impairment that affects balance. with arms, Measuring tape. Next, the balance was
assessed using BESTest in all subjects. Subjects were
MATERIALS & METHOD asked to perform 36 items divided into 6 subsections
of BESTest. The readings were taken by the researcher
In this comparative study, after taking ethical on a 0-2 point scale based on their performance for
clearance, convenient sample of 94 subjects (47 in each both groups and scores had been calculated using the
group) between the age group of 55-75 years with and formula given in the scale. Rest was given to all subjects
without diabetes group based on their history and for 5 minutes during the test in order to prevent fatigue.
recent reports were taken from different old age homes Time taken for administration of scale on each subject
and from the community in the city of Bangalore.
was 20 minutes.
Diabetics were asked for duration of onset in years.
Elderly males and females (aged 55-75 years) without Statistical Analysis
diabetes and with diabetes who had type-2 diabetes
and self ambulatory without walking aids and Activity For the parametric data, Independent T-Test (two-
specific balance confidence scale score d” 67.11 were tailed) was used to compare the Difference in balance
included in the study. Subjects who were Wheel chair between elderly subjects with and without diabetes
or bedridden and subjects with amputation, diabetic by using statistical software SPSS 16.0.
FINDINGS
Table 1: Results of independent t test of bestest values between both groups
Independent T test for equality

of means
t value P value -
Sig (2 – tailed)
Age .725 .470
Biomechanical constraints(BC) -5.066 .001
Stability Limits(SL) -.438 .663
Transitions -.822 .413
Reactive Postural Responses(RPR) -7.595 .001
Sensory Orientation(SO) -6.645 .001
Stability in Gait -2.869 .005
Total -5.179 .001
With the current study, the results showed orientation and dynamic stability in gait sections
of BESTest in diabetic subjects compared to non
• There was a significant difference in the balance diabetics.
on the total score (<0.001), biomechanical
constraints, reactive postural reactions, sensory
4. Riddhi--17--.pmd 19 5/10/2015, 5:14 PM

• There was no significant difference in stability COP information are important for correct reactive
limits and transitions/anticipatory postural postural adjustments.13
reactions sections of BESTest in diabetic group
compared to non diabetic group. The significant change in section of sensory
orientation in diabetic elderly compared to non-
diabetics can be explained by mechanism of
DISCUSSION
neuropathic process that impairs integrity of
Reduced mobility in old age due to various reasons mechanoreceptors and joint propioceptors resulting
leads to muscle weakness, joint stiffness and thereby in decreased sensation. This decreased sensation can
causes disability, pain, falls, loss of independence and be attributed to sensory loss and instability.14 Ducic et
frailty etc. Ageing process leads to changes in al found that impairment in ankle sensation has a
alignment of posture. strong relation with imbalance.15
The results of the current study showed that there Another finding in the current study indicated that
was a significant difference (<0.01) in scores of BESTest there was a significant change in dynamic stability
between elderly with and without diabetes. Balance during gait in diabetic individuals compared to non-
in diabetic elderly is more affected compared to non- diabetic. This can occur as a result of decreased ankle
diabetic elderly. In the current study it was assumed mobility, lack of ankle muscle strength reduced ankle
that diabetes can be independent factor that can cause moments and inability to use ankle strategy for
increased postural imbalance and increased risk of falls maintenance of balance. Individuals with diabetes may
in elderly compared to age matched elderly without have limited stride length and velocity during
diabetes. This could indicate that diabetes can be walking.16Diabetic individuals use hip strategy to
considered as an independent risk factor leading to compensate for limited ankle strategy which results
imbalance. This finding is supported by Muerer et al in altered walking pattern.17
who concluded that there is a strong association
The study further observed no significant difference
between diabetes mellitus and increased risk of falls
in the scores of the two groups including stability limits
and mentioned that diabetes mellitus is an
(SL) and transitions/anticipatory postural reactions.
independent risk factor resulting in loss of balance and
Both the groups performed equally in these two
falls in elderly.6
sections of BESTest.
Significant change in section of biomechanical
Diabetic elderly did not show difference in SL
constraints on BESTest can be attributed to the fact that
compared to non-diabetic elderly. A study done by
ankle movements are impaired more in diabetic
Elizabeth et al reported that distal muscle groups i.e.
individuals resulting due to reduction in distal muscle
ankle dorsi flexors and plantar flexors are involved
strength, foot abnormalities such as hammer and claw
mainly than the proximal musculature i.e. trunk and
toes and intrinsic foot muscle atrophy. These changes
hip muscles to maintain SL and balance.18The results
results in limited joint mobility leading to
in the current study in the SL can be attributed to the
malalignment of joint and resultant loss of balance.
components of the BESTest which involves the
This result was supported by a study done by Carine
assessment of both distal and proximal muscles.
et al (2004) who had been examined relationship
between foot deformities and muscle weakness in The transitions and anticipatory postural responses
diabetic and non-diabetic men and concluded that did not show significant change between both groups.
there was increased muscle weakness and atrophy of Anticipatory reactions are of central origin and occur
intrinsic foot muscle causing imbalance between as a result of interaction of basal ganglia, brainstem
extensors and flexors of toes and foot leading to and supplementary motor areas of brain. Peripheral
deformities such as hammer toes and claw toes that mechanisms may not be involved in generating these
results in loss of balance.12 reactions. These reactions do not alter in presence of
diabetes and loss of sensation .Robert F.et al mentioned
Another finding of significant reactive postural that these reactions can be generated in absence of
responses could be due to somatosensory feedback and peripheral inputs and cuteneous and proprioceptive
ankle muscle strength as they are necessary to maintain feedbacks are not necessary to generate this reactions.19
these reactions. In diabetics, due to muscle weakness
and progressive diabetic neuropathy, individual’s This study was limited by Small sample size,
centre of pressure (COP) information is lost causing Diabetic individuals were included based on the
altered reactive reactions. Somatosensory inputs and history and recent reports, and diagnostic procedure
4. Riddhi--17--.pmd 20 5/10/2015, 5:14 PM

was not administered. In future scope, BESTest can be 7. Shylie F.H. mackintosh. Functional balance
used as falls predictor and to correlate with different assessment of older community dwelling adults:
physiological measures in diabetes. a systematic review of literature. The internet
journal of allied sciences and practice.2007;
CONCLUSION 5(4):1540-1580.
8. Rose D et al. Development of multidirectional
Tthe study concluded that diabetic individuals balance scale for use with functionally
perform differently on BESTest compared to non- independent older adults. Archives of physical
diabetic and their balance is more affected. It was medicine & rehabilitation. 2006; 87:1478-85.
found that out of the six domains of BESTest, four 9. Newton R. Balance screening of an inner city
domains which includes biomechanical constraints, older adult population. Archives of physical
reactive postural responses, sensory orientation and medicine and rehabilitation. 1997; 78:587-91.
stability in gait were affected which could result in a 10. Whitney SL et al. A review of balance instruments
risk of falls. for older adults. Am J Occup Ther.1998; 52:
666-671.
Acknowledgement: We present our sincere gratitude
11. Lajoie Y. Predicting falls within the elderly
to Dr. Savita Ravindra, HOD of M.S. RAMAIAH community: comparison of postural sway,
PHYSIOTHERAPY COLLEGE, BANGALORE for her reaction time, the berg balance scale and ABC
guidance and support throughout the study. scale for comparing fallers and non-fallers.
Conflict of Interest: Archives of Gerontology and Geriatrics. 2004;
38:11-26.
Authors agree that there was no source of Conflict of 12. Carine H et al. Carrington, Andrew boulton.
Interest. Muscle weakness and foot deformities in
diabetes. Diabetes care. 2004; 27(7):1668-1673.
Source Of Funding: There was no source of funding 13. Ruth Dickstein, Fay horak. Diabetic neuropathy
from anyone for the present study. and surface sway-referencing disrupt
somatosensory information for postural stability
REFERENCES in stance. Somatosensory and motor research.
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14. G. G. Simoneu et al. Foot and ankle sensory
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Global advanced research journal of medicine &
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medical sciences. 2012; 1(6):139-144.
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2. Patricia P. Alvarenga et al. functional mobility
15. Ducic I et al. Relationship between loss of pedal
and executive function in elderly diabetics and
sensibility, balance, and falls in patients with
non-diabetics. Brazilian Journal of physiotherapy.
peripheral neuropathy. Annals of plastic surgery.
2010; 14(6):491-496.
2004; 52(6):535-540.
3. Anne Shumway-cook, Marjorie woollacott.
16. Mueller MJ et al. Differences in the gait
Motor control: Translating research into practice,
characteristics of patients with diabetes and
postural control, Lippincott Williams and
peripheral neuropathy compared with age
Wilkins, United States of America, 2007pp 157-
matched control. Journal of physical therapy.
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4. Fay horak et al. Postural orientation and
17. Angela Hohne et al. Effects of reduced plantar
equilibrium: what do we need to know about
cuteneous afferent feedback on locomotor
neural control of balance to prevent falls. Oxford
adjustments in dynamic stability during
journals, age and aging.2007; 35(2):7-11.
perturbed walking. Journal of biomechanics.
5. Fay horak et al. the balance evaluation systems
2011; 44(12):2194-2200.
test (BESTest) to differentiate balance deficits.
18. Marguerite Elizabeth. Lower extremity muscle
Journal of the American physical therapy
force and balance performance in adults aged 65
association.2009; 89(5): 484-498.
years and older. Physical therapy. 1999; 79: 1177-
6. Maurer MS et al. diabetes mellitus is associated
1185.
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residents of a long term care facility. Journal of
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4. Riddhi--17--.pmd 21 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Isokinetic Measurement of Functional Hamstrring:

Quadriceps Strength Ratio in Various Age Groups of
Asymtomatic Females
Ahmad Zahid1, Beigh Zafarullah2, Khan Sohrab3

1
Post Graduate Student MPTh, 2Senior Resident Department of ENT, 3Assistant Professor, Jamia Hamdard University
ABSTRACT
Objective: The purpose of this study was to provide clinicians with descriptive data on the isokinetic
strength of knee extensor and flexor muscles in asymptomatic females of various age groups i.e.,
measurement of functional H: Q strength ratio during knee extension representing peak eccentric
hamstring to peak concentric quadriceps torque ratio (Hecc: Qcon), functional H: Q strength ratio
during knee flexion representing peak concentric hamstring to peak eccentric quadriceps torque
ratio (Hcon: Qecc) and also to check whether age has a significant effect on H: Q strength ratio or not.
Design and Setting: A normative research design was incorporated to measure the functional H: Q
strength ratio at slow angular velocity of 60deg/sec during knee flexion and extension. The
measurement was carried out on Biodex isokinetic dynamometer (Biodex multi-joint system 4 pro).
Subjects: A total of 120 asymptomatic female subjects participated in the study. Subjects were assigned
to the four groups on the basis of their age. The mean age and weight of subjects in group1 (21-30
years) was 23.23±1.22 and 55.36±6.10, in group2 (31-40 years) was 34.90±3.22 and 58.96±8.87, in
group3 (41-50 years) was 45.40±2.60 and 65.53±8.83, and in group4 (51-60 years) was 55.13±3.32 and
65.05±8.11 respectively.
Measurement of functional H: Q ratio: The testing was carried out at slow angular velocity of 60deg/
sec in sitting position. Subjects performed 3 maximal contractions for both knee flexion and extension
movement. Peak torque values recorded and functional H: Q ratio obtained [Both H (con): Q (ecc) &
H(ecc):Q(con)].
Results: The statistical analysis of the data showed that the mean functional H: Q strength ratios
during knee extension and flexion in group1 were 1.26±0.71 and 0.81±0.18, in group2 were 2.02±1.30
and 0.71±0.25, in group3 were 1.81±1.56 and 0.81±0.22, and in group4 were 2.10±1.32 and 0.82±0.22
respectively. The results also showed a p-value of 0.052 and 0.37 between groups during extension
and flexion respectively.
Conclusion: The information provided by the study is useful to the clinicians who have a considerable
contact with the female patients of different age groups. The study provided a normative data of
functional H: Q strength ratio in females during knee flexion and extension at a speed of 60deg/sec.
The study also concluded that there is no significant age effect on functional H: Q strength ratio in
females.
Keywords: Functional H: Q ratio [Hecc: Qcon(knee extension) & Hcon: Qecc(knee flexion)]
INTRODUCTION used in the rehabilitation and assessment of

musculoskeletal injuries. Although an isokinetic
Over the last 15 years, the use of isokinetic exercise
assessment can be made for any major muscle group
devices has steadily increased. Such devices have been
in the body, the knee is probably the most commonly
Corresponding author: tested joint. 1
Zahid Ahmad
Isokinetic strength ratios of the hamstrings (H) and
Parbagh Rawalpora Srinagar Kashmir (J & K)- 190001
quadriceps (Q) muscle groups, and their implication
E-Mail: zahidphysio13@gmail.com
Mobile: 09971445692 in muscle imbalance, have been investigated for more
5. ZAHID--22--.pmd 22 5/10/2015, 5:14 PM

than three decades. The conventional concentric H/Q extensively used for the assessment and, evaluation
ratio with its normative value of 0.6 has been at the of muscle function rehabilitation, training and
forefront of the discussion. The most frequently assessments of muscle strength and injury.6
reported strength ratio of the muscles of the knee has
been the concentric hamstring-quadriceps ratio For our study we decided to use the functional H:
(Hcon/Qcon). Steindler (1955) advanced the Q ratios since they are more effective in identifying
generalisation that absolute knee extension muscle where strength discrepancies exist.7When assessing the
force should exceed knee flexion force by a magnitude results of an isokinetic test, the involved knee is
of 3:2 i.e. Hcon/Qcon of 0.66. Values ranging from 0.43- compared with the uninvolved knee. Therefore,
0.90 for this knee flexor-extensor ratio have been normative isokinetic strength data on knee
reported. musculature are needed. The purpose of this study was
to provide clinicians with descriptive data on the
During leg extension the quadriceps contract isokinetic strength of knee extensor and flexor muscles
concentrically (Qcon) and the hamstrings contract in females of various age groups.1, 8
eccentrically (Hecc). Conversely, the hamstrings
contract concentrically (Hcon) and the quadriceps MATERIALS AND METHOD
eccentrically (Qecc) during leg flexion. Therefore, in
order to accurately assess the balancing nature of the A total of 120 asymptomatic female subjects
hamstrings about the knee joint the hamstring- participated in the study. Subjects were assigned to
quadriceps ratio should be described either as a Hecc/ the four groups on the basis of their age. The mean
Qcon ratio representing knee extension, or an Hcon/ age and weight of subjects in group1 (21-30 years) was
Qecc ratio representing knee flexion.2 23.23±1.22 and 55.36±6.10, in group2 (31-40 years) was
34.90±3.22 and 58.96±8.87, in group3 (41-50 years) was
Isokinetic testing can be used to evaluate 45.40±2.60 and 65.53±8.83, and in group4 (51-60 years)
quadriceps and hamstrings muscle strength, providing was 55.13±3.32 and 65.05±8.11 respectively. . The limb
a determination of the magnitude of torque generated, dominance was obtained by asking the subject about
and subsequently, the hamstrings to quadriceps (H: the preferred kicking leg. A complete musculoskeletal
Q) strength ratio. The H: Q ratio has been used to examination of the subjects was performed. Testing
examine the similarity between hamstrings and was carried out on Biodex isokinetic dynamometer
quadriceps moment-velocity patterns and to assess multi-joint system4 pro at an angular velocity of
knee functional ability and muscle balance. It has been 60deg/sec.
suggested that a highly developed quadriceps muscle
contributes to decreased antagonist hamstrings co The subjects were tested in the seated position and
activation, thereby increasing susceptibility to anterior subjects were properly stabilised on the dynamometer
cruciate ligament (ACL) injury.3 seat. Mode, speed, number of contractions was selected
in Biodex isokinetic dynamometer.
Hamstring muscle activation aids in stabilization
of the knee joint. A muscular strength imbalance- Suitable period of time was provided to the subjects
whether caused by weak hamstrings or by strong to familiarize themselves with the machine. The testing
quadriceps—thereby hinders stabilization of the knee sequence was three repetitions at 60°/ sec for each
joint, requiring the ACL to play a larger role in knee flexion and extension movement, separated by a 30-
stabilization. Female athletes are 2 to 8 times more second or 1 minute rest interval. The order of muscle
likely to tear the ACL than male athletes.4 testing (Hams or Quads) was randomized to eliminate
any learning effect. The verbal encouragement is given
The muscular torque exerted during isokinetic throughout the testing procedure to facilitate a
testing decreases with increasing angular velocity of maximum performance by each subject.
movement. This decline in torque output has been
Subjects were instructed to apply maximum force
attributed to different neurological activation patterns
during flexion and extension movement, and
of motor units at different velocities. 5
performed 3 maximal contractions in each mode. The
Assessment of muscle strength is a vital component peak torque of both concentric and eccentric
of diagnosing and treating patients in which muscle contractions during knee flexions and extension were
weakness is present. Isokinetic devices have been recorded. The functional H: Q ratio during knee
5. ZAHID--22--.pmd 23 5/10/2015, 5:14 PM

extension was obtained by dividing the peak eccentric RESULTS

hamstring torque to peak concentric quadriceps
The statistical analysis of the data showed that the
torque. Likewise functional H: Q ratio in flexion is
mean functional H: Q strength ratios during knee
obtained by dividing the peak concentric hamstring
extension and flexion in group1 were 1.26±0.71 and
torque to peak eccentric quadriceps torque.
0.81±0.18, in group2 were 2.02±1.30 and 0.71±0.25, in
Statistics group3 were 1.81±1.56 and 0.81±0.22, and in group4
were 2.10±1.32 and 0.82±0.22 respectively. The results
One way ANOVA was used to obtain the mean also showed a p-value of 0.052 and 0.37 between
values of age, weight, and functional H: Q strength groups during extension and flexion respectively.
ratio during knee flexion and extension in various
The results also showed that there is no significant
female age groups. The data analysis was also done to
difference of H: Q strength ratio both during knee
check whether age has an impact on the H: Q strength
extension and flexion statistically. Normative values
ratio. Between group comparisons were made by Post
of functional Hecc: Qcon strength ratios during knee
Hoc tests (Bonferroni).
extension are described in table no. 1.
Table 1:
Group N Mean± SD One way ANOVA Post Hoc

1 30 1.26±0.71 F value- 2.65 P value- 0.052 1vs2 p- 0.13
2 30 2.02±1.30 1vs3 p-0.59
3 30 1.81±1.56 1vs4 p-0.07
4 30 2.10±1.32 2vs3 p-1.00
Total 120 1.80±1.29 2vs4 p-1.00
3vs4 p-1.00
The normative values of functional Hcon: Qecc strength ratios during knee flexion are described in table no. 2.
Table 2:
Group N Mean± SD One way ANOVA Post Hoc

1 30 0.81±0.18 F value- 1.05 P value- 0.37 1vs2 p- 1.00
2 30 0.71±0.25 1vs3 p-1.00
3 30 0.81±0.22 1vs4 p-1.00
4 30 0.82±0.22 2vs3 p-0.91
Total 120 0.79±0.22 2vs4 p-0.75
3vs4 p-1.00
DISCUSSION Hamstring: Quadriceps Strength ratio in males and

females: Implication of ACL injury” showed that in
The results of the study are contradictory to many females with mean age of 21.7±1.2, the mean H: Q
previous studies in the literature as the study showed strength ratio was 0.80 and 0.77 during knee extension
slightly higher mean values of functional H: Q ratios and flexion respectively at angular velocity of 60deg/
during knee extension in all age groups. Hamstring: sec.10 Donne and Luckwill (1996) reported an average
Quadriceps ratio was studied by Hannah Mich in Hecc: Qcon strength ratio equal to 0.63±0.07
may15, 2011 who described that the normal hamstring throughout the ROM of knee extension.11
to quadriceps strength ratio is between 50 and 80
percent (i.e., 0.5-0.8), according to a 2001 “Journal of The possible reason of why various female age
Athletic Training” article. This means the hamstrings groups showed higher values of functional H: Q
are usually weaker than quadriceps. The strength strength ratio during knee extension could be due to
imbalance between hamstrings and quadriceps is the presence of quadriceps dominant muscle weakness
partly due to quads being larger and used more in female population which altered the functional H:
frequently during daily activities.9 An another study Q ratio to higher values. Age-associated losses of
by Lyons, Meghan Eileen (2006) titled as “isokinetic skeletal muscle mass and strength have received
5. ZAHID--22--.pmd 24 5/10/2015, 5:14 PM

considerable attention in the literature over the past movement at the joint. Weakness may also reduce
two decades. This decline in skeletal muscle mass, or shock absorption, leading to abnormal loading of the
sarcopenia, is considered a major contributing factor knee joint. Evidence from the medical literature
to the loss of functional independence and frailty suggests that quadriceps weakness may be a
present in many older individuals. potentially modifiable risk factor for incident
symptomatic and progressive knee osteoarthritis;
Overall, strength appears to peak between 25 and although it’s relative significance seems to be a function
35 years of age, is maintained or slightly lower between of patient gender and mal alignment.15
40 and 59 years of age and then declines by 12-14%
per decade after 50 years of age. Aging is associated The results also showed that there is no significant
with significant decreases in strength in men and effect of age on H: Q strength ratio between various
women and, while women may show somewhat groups of asymptomatic females during knee
earlier losses in strength, the overall reductions are extension and flexion, with a P-value of 0.05 and 0.37
reasonably similar. Decline in the quantity and perhaps respectively. The reason for this could be that the
quality of muscle mass is the most important individual muscle strength values (concentric or
contributing factor to age-related reductions in eccentric) of hamstring or quadriceps were not taken
strength.12 into consideration. Therefore whatever might have
been the strength disparities between the reciprocal
The female population with higher values of muscle groups, these differences in strength are highly
functional H: Q strength ratios during knee extension minimized when “strength ratios” were taken into
are rather benefited in way because the risk of ACL consideration. Hannah Mich (May 15, 2011) described
injury will be highly minimised in such population. that age does not appear to impact the hamstring to
William R. Holcomb et al in their study “effect of quadriceps ratio; instead strength decreases equally
hamstring-emphasized resistance training on in both muscle groups with aging.16 The result of the
hamstring: quadriceps strength ratio concluded that study statistically reveals that there is no significant
the mean functional ratio increased from 0.96±0.09 in difference in H: Q strength ratio either in knee flexion
pre-test to 1.08 ±0.11 in post-test. These results suggest or extension in various age groups of asymptomatic
that 6 weeks of strength training that emphasizes females. These values are in line with those reported
hamstrings is sufficient to significantly increase the in the literature. A another study carried out by
functional ratio. The functional ratio after training Jaiyesimi et al (2005) to investigate how age and gender
exceeded 1.0, which is specifically recommended for influence hamstring-quadriceps (knee flexor-extensor)
prevention of ACL injuries.13 In another study by muscle strength ratio in a Nigerian urban population.
Rosalind Coombs and Gerard Garbutt (2002) on It was concluded that age has no effect on hamstring/
“development in the use of the hamstring/quadriceps quadriceps strength ratio, whether in female or male
ratio for the assessment of muscle balance described individuals.17
that Hecc/Qcon ratio e”1.0, which is labelled the point
of equality, indicate that the eccentrically acting
CONCLUSION
hamstrings have the ability to fully brake the action of
the concentrically contracting quadriceps during knee The study demonstrated the following results
extension. This would help to reduce anterior tibial
translation on the femur and prevent hyperextension 1. Normative values of functional H: Q strength ratio
of knee, therefore minimizing the risk of ACL injury.14 in various age groups of asymptomatic females
during knee flexion and extension at a speed of
However, on the other hand, higher values of H: 60deg/sec.
Q strength ratios suggest a quadriceps dominant
muscle weakness making the knee more predisposed 2. No significant age effect on Hecc: Qcon strength
to the OA. Neil A. Segal et al in their study “Quadriceps ratio in various female age groups during knee
strength and risk of knee OA” described that among extension.
lower limb muscles, the quadriceps muscle is a
3. No significant age effect on Hcon: Qecc strength
primary contributor to knee joint stability. Weak
ratio in various female age groups during knee
quadriceps muscles may fatigue easily, leading to poor
flexion.
neuromuscular control that could allow pathological
5. ZAHID--22--.pmd 25 5/10/2015, 5:14 PM

Conflict of Interest: None High School Students. Phys Ther. 1984; 64:
914-918
Source of Funding: Self 9. Hannah Mich (May 15, 2001), John M.
Acknowledgement: To my family especially Rosene, Tracey D. Fogarty, and Brian L.
grandparents and younger brother for their love and Mahaffey: Isokinetic Hamstrings: Quadriceps
support. Ratios in Intercollegiate Athletes. Journal of
Athletic Training 2001; 36 (4):378–383.
Ethical Clearance: Taken from Jamia Hamdard ethical 10. Lyons, Meghan Eileen: “Isokinetic Hamstring:
committe. Quadriceps Strength Ratio in Males and
Females: Implications for ACL Injury”. 2006. All
REFERENCES Volumes (2001-2008). Paper 64.
11. Rosalind Coombs and Gerard Garbutt:
1. James R Holmes and Gordon J Development in the use of the Hamstring/
Alderink).Isokinetic Strength Characteristics of Quadriceps ratio for the assessment of muscle
the Quadriceps Femoris and Hamstring Muscles balance. Journal of sport science and medicine.
in High School Student. Phys Ther. 1984; 64:914- 2002; 1:56-62.
918. 12. LaDora V Thompson: Effects of Age and Training
2. Rosalind Coombs and Gerard Garbutt. on Skeletal Muscle Physiology and Performance.
Development in the use of the Hamstring/ PHYS THER.. 1994; 74:71-81.
Quadriceps ratio for the assessment of muscle 13. William R. Holcomb, Mack D. Rubley, Heather
balance. Journal of sport science and medicine. J. Lee, and Mark A. Guadagnoli. Effect of
2002; 1:56-62. hamstring-emphasized resistance training on
3. John M. Rosene, Tracey D. Fogarty, and Brian L. hamstring: quadriceps strength ratios. Journal of
Mahaffey: Isokinetic Hamstrings: Quadriceps Strength and Conditioning Research. 2007; 21(1):
Ratios in Intercollegiate Athletes. Journal of 41–47.
Athletic Training 2001; 36 (4):378–383. 14. Rosalind Coombs and Gerard Garbutt.
4. Lyons, Meghan Eileen. “Isokinetic Hamstring: Development in the use of the Hamstring/
Quadriceps Strength Ratio in Males and Females: Quadriceps ratio for the assessment of muscle
Implications for ACL Injury” 2006. All Volumes balance. Journal of sport science and medicine.
(2001-2008). Paper 64. 2002; 1:56-62.
5. V. Baltzopoulos and D.A Brodie (1989). Isokinetic 15. Neil A. Segal and Natalie A. Glass: Quadriceps
Dynamometry Applications and Limitations. strength and risk of knee OA. The Physician and
Sports Medicine. 1989; 8 (2): 101-116. Sports medicine. November 2011; Volume 39,
6. Khaled Takey, Olfat A. Kandil, and, Shimaa N. Issue 4.
Abo Elazm: Isokinetic Quadriceps peak torque, 16. Hannah Mich (May 15, 2011). John M.
average power and total work at different angular Rosene, Tracey D. Fogarty, and Brian L.
knee velocities. Mahaffey: Isokinetic Hamstrings: Quadriceps
7. Lyons, Meghan Eileen.”Isokinetic Hamstring: Ratios in Intercollegiate Athletes. Journal of
Quadriceps Strength Ratio in Males and Females: Athletic Training 2001; 36 (4):378–383.
Implications for ACL Injury” 2006. All Volumes 17. Jaiyesimi Ao and Jegedeja. Hamstring and
(2001-2008). Paper 64. Quadriceps strength ratio: Effect of age and
8. James R Holmes and Gordon J Alderink. gender. Journal of the Nigeria Society of
Isokinetic Strength Characteristics of the Physiotherapy. 2005; Vol. 15 No.2
Quadriceps Femoris and Hamstring Muscles in
5. ZAHID--22--.pmd 26 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Hindi Translation, Cross-Cultural Adaptation and

Validation of the "Self-Efficacy in Wheeled Mobility"
(SEWM) Scale in Wheelchair Users with Spinal Cord
Injury
Swati Dash1, Ruby Aikat2, Neha Khanna3

1
Masters of Occupational Therapy (Neurology), 2Assistant Professor, Masters of Occupational Therapy (Neurology),
3
Occupational Therapist, Masters of Occupational Therapy (Orthopedics), ISIC Institute of Rehabilitation
Sciences, New Delhi
ABSTRACT
Study Design: Methodological design.
Objectives: To translate and cross-culturally adapt and validate the Hindi version of "Self-Efficacy
in Wheeled Mobility (SEWM)" scale in wheelchair users with Spinal Cord Injury.
Method: The study was carried out in two phases: the first was translation into Hindi and cultural
adaptation of the questionnaire using standardized guidelines of Beaton et al (2000), the second was
estimation of content validity of translated Hindi version of SEWM using both qualitative and
quantitative methods.
Results: The Hindi translated version of the scale was approved by all the translators, expert panel
members, wheelchair users with Spinal Cord Injury and by the developer of the Original English
version of SEWM. Content validation estimation resulted with retention of all the items of the
questionnaire.
Conclusion: The results of this study indicate that the Hindi version of SEWM is a valid tool for
assessing self-efficacy in Hindi speaking wheelchair users with Spinal cord injury.
Keywords: Self-Efficacy, Wheelchair, Mobility, Spinal Cord Injury, Translation and Cross-Cultural
Adaptation, Content Validity
INTRODUCTION wheelchair skills and manual wheeled mobility (WM)

can make the difference between dependence and
Spinal cord injury (SCI) is an interruption of the independence in daily life for people with SCI,
neural pathways in the spinal canal that disrupts acquiring these skills has to be considered as an
nervous transmission throughout the body, affecting important part of SCI rehabilitation.(3)
a person’s motor movement and sensory abilities.(1)
Wheelchair Mobility is a physical activity that may
Rehabilitation interventions following SCI require possibly affect participation, and perceived self-
major adaptations in physical capacity, and the efficacy is a meaningful personal factor” that
development of skills and functional behaviour. An determines physical activity behaviour. (3-5)
important change that many subjects with SCI (80%)
encounter in early rehabilitation is the state of mobility, Perceived Self-efficacy refers to ‘‘beliefs in one’s
which is transition from being a walking individual capabilities to organize and execute the courses of
to a manual wheelchair user. They remain dependent action required to produce given attainments’’.(6)
on a wheelchair for the rest of their lives. (2) As Increased self-efficacy in wheelchair skill performance
6. Swati Dash--27--.pmd 27 5/10/2015, 5:14 PM

may encourage wheelchair users with SCI to approach, tongue was Hindi. Two independent forward
persist, and persevere at executing wheelchair-related translations were produced with a written report of
tasks that were previously avoided. In contrast, the translations.
wheelchair users with low perceived self-efficacy in
wheelchair skill performance may become inactive Step two: Synthesis of the translations.
when facing daily physical challenges; evidently, Both the translators and the record observers
perceived self-efficacy ultimately may affect changes (researchers) synthesised the results of the translations,
in wheelchair skill performance over time.(6) working from the original questionnaire and the two
To encourage or to promote more physical forward translations (T1, T2). A synthesis of these
participation in the wheelchair users, the concept of translations was conducted producing one common
self-efficacy is needed to assess.(7) translation T12.
“Self-Efficacy in Wheeled Mobility Scale” (SEWM), Step three: Back translations

a clinimetrically reliable and valid scale was developed During this step, the final synthesised version T12
for assessing perceived self-efficacy in manual wheeled was back translated into the original language. The
mobility by Osnat fliess- Douer et al in 2011.(3) This two back-translations had to be done by two persons
scale measures self-efficacy perception in wheelchair with the source language English as their mother
skills performance of individuals with SCI, and thus tongue. The two back translations were compared with
may be a predictor for actual wheelchair mobility the original scale by the researchers of the study. The
performance, and may be used comprehensibly to inconsistencies and discrepancies in the words and
actual performance-based wheelchair mobility concepts across both the back translations were
evaluation. (6) analysed.
To increase the applicability and the usability of Step four: Expert committee review:
SEWM, it is needed to be cross-culturally adapted and
validated. As Hindi is the national language and also The committee was formed as per the guidelines
the majority of people, particularly in Delhi (the capital to achieve the cross-cultural equivalence which
of the country) speak Hindi, a Hindi version of SEWM consisted of all the four translators involved in this
is needed to be translated and validated. (8-9) study (two forward translators-T1, T2 and two back
translators- BT1, BT2), a health professional, a language
Therefore, the purpose of this study is to translate professional and a methodologist. Expert committee’s
and cross-culturally adapt the existing self-efficacy role was to consolidate all the versions of the
measure, i.e., (SEWM) to Hindi language and to questionnaire and develop a pre-final version of the
determine its content validity so as to make it available questionnaire for field testing. Decision was needed
to Hindi speaking subjects with spinal cord injury. to be made to achieve equivalence between the source
(English) and the target version (Hindi) in the
METHOD following four areas (10) : Semantic Equivalence,
Idiomatic Equivalence, Experiential Equivalence, and
The study was carried out in two phases: the first
Conceptual Equivalence. By considering all the
phase was translation into Hindi and cultural
recommendations suggested by the panel members, a
adaptation of the questionnaire: second phase was
final consensus was reached, which helped in
estimation of the content validity of the Hindi version
formulation of the pre-final version.
of SEWM.
Step five: Test of the pre-final version
Phase one: Translation and Cultural Adaptation
The final stage of adaptation process was the pre-
For the translation the researchers used the
test comprising field testing of the new questionnaire
guidelines of the American Association of Orthopedic
(the pre-final version of the questionnaire Field testing
Surgeons (AAOS)(10) that is Cross-Cultural Adaptation
was done in 30 persons fulfilling the inclusion criteria.
of Self-Report Measures by Beaton et.al.
i.e. SCI (traumatic), paraplegics (T4 level or
Step one: Forward translation
below), (3) SCI categorized as A, B, C or D on the
In this step, the original English version of SEWM American Spinal Injury Association impairment scale
was translated into the target language that is Hindi (ASIA), must be medically stable, 18-75 years,(3) have
by two bilingual translators (T1, T2) whose mother their own wheelchair, Using manual wheelchair for
6. Swati Dash--27--.pmd 28 5/10/2015, 5:14 PM

at least 2 years, able to read and understand Hindi, given by C. H. Lawshe for the quantitative
Both genders: Male and Female. Spinal cord injury approach to content validity.(13) All the members
subjects in spinal shock state, Subjects diagnosed with of the expert panel were asked to rate the
any psychiatric or cognitive impairment, and subjects appropriateness of each item of 10 itemed
using a power wheelchair as their main means of questionnaire by stating on the coding, if each item
mobility were excluded.
was:
The subjects were explained about the study
• Essential – 1
objective and their consent for participation was
obtained, demographic details of each subject were • Useful but not essential – 2
taken. Each subject was asked to complete the
questionnaire, was interviewed to probe what he or • Not necessary – 3
she thought was meant by each item of the
questionnaire, regarding the understanding of all the After receiving each expert’s ratings, the Content
words and the overall opinion about the Validity Ratio was calculated by applying the formula
questionnaire.(11) This ensured the adapted version developed by C.H.Lawshe(13) and then compared to the
retained its equivalence in an applied situation. levels required for statistical significance. A minimum
CVR value of 0.62 was necessary for statistical
Step six: Submission of documentation to the
significance at p d” 0.05 based on 10 panelists.(13)
developers or coordinating committee for appraisal of
adaptation process
RESULT
This step was carried out as a means for the original
developers to verify that the recommended stages were The result of the translation procedure provided
followed, and the reports seem to be reflecting this us with the finalized version of the translation
process well. At the end, acceptance letter was taken procedure provided us with the Hindi version of the
from the author of the original scale. SEWM i.e. “wheelchair chalane main swa-khsamata
ka mandand” (Self-Efficacy in Wheeled Mobility
Phase two: Estimation of Content Validity of the
Scale). This was approved by all the translators, expert
translated Hindi version.
panel members, wheelchair users with spinal cord
The content validation was done as per the injury and by the developer of the original version of
guidelines given by McKenzie and Lawshe.(12,13) The SEWM scale. The result of content validity suggested
selection of panel of experts is the initial step in to modify the title of the scale into “wheelchair chalane
establishing the content validity. During this step, 10 main swa-khsamata ka mapak” (Self-Efficacy in
experts were selected, of which six were professionals Wheeled Mobility Scale) with few other modifications
including two psychologists, three occupational in the scale like removing “Team/club”, adding a
therapists, one wheelchair skill trainer, and four were
column of remarks and a few grammatical errors in
wheelchair users with spinal cord injury.
some items. In the quantitative phase, at 95%
1. Qualitative reviews on questionnaire confidence interval, all items had minimum CVR value
components of 0.62, thus all items were retained.(13)
The process was begun by providing the experts a S.NO. Item number CVR Value
copy of translated Hindi questionnaire and a set 1 1 1
of questions which the experts had to answer in 2 2 1
order to provide feedback on the overall 3 3 1
questionnaire including the title, directions, 4 4 0.8
content areas, and items of the questionnaire, need 5 5 1
for revision of items, addition and/or deletion of 6 6 1
items and any additional suggestions.(12) 7 7 1
8 8 0.8
2. Quantitative reviews on questionnaire
9 9 1
components
10 10 0.8
This step was carried out as per the guidelines
6. Swati Dash--27--.pmd 29 5/10/2015, 5:14 PM

DISCUSSION Thus, this Hindi version of SEWM showed similar

content as in the English version.
Perceived self-efficacy is defined as “beliefs in one’s
capabilities to organize and execute the courses of Limitations of the study
action required for producing given attainments”.(6)
Research has shown a high correlation between self- In current study, no screening was done to exclude
efficacy and behaviour and it has also provided cognitive decline, if present in the subjects i.e. in the
evidence that self-efficacy is a more consistent pre-testing phase, but those who were diagnosed with
predictor of behavior than other motivational cognitive impairment were excluded from the study.
constructs.(14) Increased self-efficacy in Wheelchair The Guidelines for the Process of Cross-Cultural
Mobility (WM) may encourage wheelchair users with Adaptation of Self-Report Measures given by Beaton
Spinal Cord Injury to approach, persist, and persevere states that the translated version of outcome measures
at WM related tasks that were previously avoided.(6) should be understood by the equivalent of a 12-year-
“Self-efficacy in Wheeled Mobility” scale measures old (roughly a Grade 6 level of reading), as is the
how much a person feels self-efficacious about general recommendation for questionnaires, but the
propelling his/her wheelchair by his own. translated version of SEWM has not been tested with
12-year-old (roughly a Grade 6 level of reading)
The Objective of the presented study was to subjects. In other words, the understandability of the
translate and cross-culturally adapt the “Self-efficacy scale for a 12-year-old (roughly a Grade 6 level of
in Wheeled Mobility” scale into Hindi language and reading) has not been determined.
to estimate the content validity in Hindi speaking
wheelchair users with spinal cord injury. Since “Self- Future recommendations
Efficacy in wheeled mobility” scale is in English Future study is needed to determine the scale’s
language, so its usability in Hindi speaking wheelchair reliability and other psychometric properties. The
users within spinal cord injury is limited. Hence, the applicability of the scale in wheelchair users with
translation and cross cultural adaptation of the English traumatic quadriplegics, non-traumatic SCI or any
scale into a Hindi version would enhance its other diagnostic cause can also be determined. A
application with wider range of wheelchair users with survey can be done to make sure that the final Hindi
spinal cord injury. Modifications to the title of the version of the questionnaire would be understood by
questionnaire, wording of the items were required to the equivalent of a 12-year-old (roughly a Grade 6 level
ensure that the Hindi version of SEWM would be of reading), so that the translated version can be used
applicable with Hindi speaking population. With for such educational level (according the translation
retention of all the 10 items, it had been ensured that guidelines by Beaton).
the Hindi version is content wise valid to assess self-
efficacy in Hindi speaking wheelchair users. Conclusion
Like, the original SEWM scale, the Hindi version The Hindi version of “Self-Efficacy in Wheeled
“wheelchair chalane main swa-khsamata ka mapak” Mobility” scale, i.e. “wheelchair chalane main swa-
(Self-Efficacy in Wheeled Mobility Scale) instructs khsamata ka mapak” was found to be cross-culturally
respondents to rate how confident they are with regard adapted and content wise valid.
to the performance of WM skills on a 4-point Likert
Acknowledgement: We are highly indebted to Mrs.
scale i.e 1 = bilkul bhi satya nahi (Not at all true), 2 =
kabhi-kabhi satya (Rarely True), 3 = lagbhag satya Osnat Douer for her continuous support throughout.
(Moderately True), 4 = sadaiv satya (Always True). Lastly, we offer our regards and blessings to all those
who were part of the study.
Consisting of only 10 items, the SEWM is easy to
administer and interpret which is a major strength of Conflict of Interest: None
the tool.(3) The remarks, given in remarks column for
each item by the repertoire will be subjectively Source of Funding: None
analyzed, which can give additional information about
Ethical Clearance: We certify that all applicable
any individual’s aspects which can influence wheeled
institutional regulations concerning the ethical use of
mobility skills. The higher the score (maximum score
human volunteers were followed during the course
of 40), more is the self-efficacy of a wheelchair user
of research.
and vice versa.
6. Swati Dash--27--.pmd 30 5/10/2015, 5:14 PM

REFERENCES non tennis participants. Adap Phys Act Quart.

1990; 7(1): 12-21.
1. Eng JJ. Miller WC. Rehabilitation: from bedside 8. Constitution of India. [Internet]; 2008. Available
to community following spinal cord injury. from: Constitution of India-lawmin.nic.in/coi/
Spinal Cord Injury Rehabilitation Evidence. 2008; coiason29july08.pdf.
2:1.1-1.11. 9. Census india gov. [Internet]; 2001. Available
2. Post M, Asbeck van FW, Dijk van AJ, Schrijvers from: http://www.censusindia.gov.in/
AJ. Services for spinal cord injured: availability Census_Data_2001/Cesus_Data_Online/
and satisfaction. Spinal Cord. 1997; 35: 109–115. Language/data_on_language.aspx.
3. Osnat fliess-douer, Lucas H. V. Van Der Woude, 10. Beaton, Dorcas E. Guidelines for the Process of
Yves C. Vanlandewijck. Development of a new Cross-Cultural Adaptation of Self-Report
scale for perceived self-efficacy in manual Measures. Spine. 2000; 25(24): 3186–3191.
wheeled mobility: a pilot study. J rehabilitation 11. Martinez, SM, Ainsworth, BE, Elder, JP.
med. 2011; 43: 602-608. Guidelines for Culturally Appropriate Measures.
4. Van der Ploeg. Successfully improving physical The San Diego Prevention Research Center.
activity behavior after rehabilitation. Am J Health [Internet]. Available from: http://
Promot. 2007; 21: 153-159. www.sdprc.net/lhn-cam.php.
5. Van der Ploeg HP, van der Beek AJ, van der 12. McKenzie, Wood LM, Kotecki EJ, Clark KJ, Brey
Woude LH. Physical activity for people with a AR F. Establishing content validity: using
disability: a conceptual model. Sports Med. 2004; qualitative and quantitative steps. American
34(10): 639-49. Journal of Health Behaviour. 1999; 23(4): 311-318.
6. Osnat fliess-douer, Lucas H. V. Van Der Woude, 13. CH Lawshe. A Quantitative Approach to Content
Yves C. Vanlandewijck. Reliability and validity Validity. Personnel Psychology. 1975; 28: 563-575.
of perceived self-efficacy in wheeled mobility 14. Fernando Juárez, Francoise Contreras.
scale among elite wheelchair-dependent athletes Psychometrics Properties of the General Self-
with a spinal cord injury. Disability & Efficacy Scale In a Colombian Sample.
Rehabilitation. 2012; 1-9. International Journal of Psychological Research.
7. Greenwood CM, Dzewaltowski DA, French R. 2008; 1(2): 6-12.
Self-efficacy and psychological well-being of
wheelchair tennis participants and wheelchair
6. Swati Dash--27--.pmd 31 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Prevalence of Airflow Limitation in Women Exposed to

Biomass Fuel in Rural Parts of Belgaum District- a Cross
Sectional Study
Vinay Mahishale1, Arati Mahishale2

1
Associate Prof, Dept Pulmonary Medicine, JNMC, KLE University Belgaum, 2Assistant Professor, Institute of
Physiotherapy, KLE University, Belgaum
ABSTRACT
Background: Approximately 2/3rd of women in rural India are exposed to biomass fuel in various
forms. They are at risk of airflow limitation, however literature on prevalence of which in Indian
rural women is limited.
Objective: The present cross sectional study aimed to find the prevalence of airflow limitation in
women exposed to biomass fuel in rural areas of Belgaum district.
Materials and method: A total of 538 women exposed to biomass fuel in six rural areas of Belgaum
district were subjected to handheld spirometry testing for airflow limitation which was defined as a
ratio of forced expiratory volume in one second (FEV1) to forced expiratory volume in six second
(FEV6) less than 0.75.
Results: Of 538 women, 79 women were detected with airflow limitation which accounted to 14.6%.
Out of 79 women, 53 women were chest symptomatic (67.09%) and 26 women were asymptomatic
(32.91%).
Conclusion: Prevalence of airflow limitation in women exposed to biomass fuel in rural areas of
Belgaum district is as high as 14.6%, detected by handheld spirometer. However significant number
of women were asymptomatic at the time of screening, which provides a window of opportunity for
early intervention and prevention of deterioration of airflow limitation in Indian rural women.
Keywords: Airflow limitation, Biomass fuel, Handheld spirometer, Rural women
INTRODUCTION increases the impact of the smoking chulha (cooking

stove). This has a significant impact on the respiratory
India largely depends on solid fuels for cooking
health of women as they are at increased risk of
energy needs. About 80% of rural homes in India
developing airflow limitation and subsequently
continue to use biomass fuel like firewood, crop
chronic obstructive pulmonary disease (COPD)1.
residue or cow dung as their primary cooking fuel.
This resource is available at almost free of cost, a factor COPD is characterized by poorly reversible airflow
that explains its high usage rate. Inspite of the health obstruction secondary to an abnormal host response
hazards of the resultant smoke pollution produced by to noxious environmental stimuli like biomass fuel.
biomass fuels, the ‘free’ factor appears to override all Biomass fuel is one of the most important risk factor
other considerations. Many women in rural homes use for women in rural India. Airflow limitation is a
closed kitchen for cooking without exhausts that hallmark of this condition which is currently an
7. Vinay Mahashale--32--.pmd 32 5/10/2015, 5:14 PM

important cause of mortality in India, and the world. PROCEDURE

It is an independent predictor of mortality from
respiratory and cardiovascular causes.2,3 However, Ethical clearance was obtained from the
airflow limitation in rural women largely remains Institutional ethical review committee prior to
undiagnosed due to lack of availability of diagnostic commencement of the study. A total of 680 women
tool like spirometer and lack of awareness of the from six rural areas of Belgaum district were screened
condition.4 Early detection of airflow limitation is for their suitability for the study. 538 women fulfilled
essential to prevent the continuous deterioration of the inclusion criteria and informed consent was
lung function.5 As diagnosis of airflow limitation is a obtained from all the participants. 142 women were
daunting task in rural women, by the time the disease excluded due to various reasons namely history of past
is brought to clinical attention it is usually in advanced or present pulmonary tuberculosis, bronchiectasis,
stage. Many of the patients are misdiagnosed having interstitial lung disease, chest wall deformities, history
bronchial asthma, cardiac illness, allergic illnesses etc. of smoking and cardiac illnesses. The information of
In recent years handheld spirometers have contributed the same was obtained from detailed history, clinical
enormously in early detection of airflow limitation. examination, chest radiography and medications used
These devices can be portably used as a screening tool by the women currently or previously. Baseline data
for airflow limitation as they have good sensitivity and was recorded which included level of education, age,
specificity. 6,7,8,9 Hence the present study was years of exposure to biomass fuel, BMI and respiratory
undertaken to find the prevalence of airflow limitation symptoms. All women were subjected to spirometry
in rural women exposed to biomass fuel using testing for airflow limitation using handheld
handheld spirometer at poor resource setting. spirometry device (Model 4002, vitalograph, Ennis,
Ireland). Handheld spirometry test was conducted by
two trained residents. A measurement was deemed
METHODOLOGY
to be satisfactory when a beep sound was heard,
Research setting: Six rural areas of Belgaum district indicating that expiration of at least 6 s had been
with population less than 5000. achieved. Any attempt that did not produce a beep
sound was rejected as unacceptable. At least three
Population: Women aged 30 and above, exposed to acceptable measurements were recorded for each
biomass fuel for >10 years subject. Any patient with ratio of FEV1/FEV6 <0.75 was
Study design: A cross sectional study considered to have possible airflow limitation. 6,7
Study period: Data was collected from November 2013 Outcome Measures: Forced expiratory volume in one
to March 2014. second (FEV1), forced expiratory volume in six second
(FEV6) and ratio of FEV1/FEV6.
Sampling design: Rural areas were selected using
simple random sampling. RESULTS
Sample size: Total of 538 women were assessed for Data was computed and analyzed using SPSS
airflow obstruction. (Statistical package for social sciences) software version
16. For different quantitative parameters mean and SD
Inclusion criteria: 1) Women exposed to biomass fuel
were calculated. Results were interpreted in terms of
for >10 years, 2) Age of women >30years, 3) Body mass
percentage values. A total of 538 women were assessed
index (BMI) < 27 kgs/m2 4) Willingness to participate
for airflow limitation using FEV1/ FEV6 manoeuvre.
in the study.
Of these 79 women were detected with airflow
Exclusion criteria: 1) H/o Bronchial Asthma, 2) Other limitation which accounted to 14.6%. Out of 79 women,
Obstructive / Restrictive chronic pulmonary diseases, 53 women were chest symptomatic (67.09%) and 26
3) H/o Tuberculosis, 4) H/o Cardiac diseases. women were asymptomatic (32.91%). The values of

mean age, duration of exposure, age at which the cough, expectoration, dyspnoea, wheezing and chest
women were exposed, BMI, mean FEV1, FEV1/FEV6 pain.
are shown in Table 1. The chest symptoms included
Table 01: (Demographic profile & Spirometry outcomes)
Women Without Women With Women With Airflow

Airflow Limitation Airflow Limitation Limitation And
N-459 and Chest Symptomatic Asymptomatic
N-53 N-26
Mean Age 44+/- 8.24 39+/- 7.29 43+/-6.45
BMI 23+/-3.44 19+/-4.24 19+/-3.63
Duration of exposure 17+/-6.23 20+/-4.12 18+/-3.22
Age at exposure 26+/-8.23 21+/- 6.34 23+/-4.56
% Predicted FEV1 94.24+/- 11 48.35+/-12.24 59.15+/- 6.43
FEV1/FEV6 0.96 +/- 0.14 0.48+/- 0.19 0.58+/-0.16
DISCUSSION spirometer. In poor resource settings of rural areas

where spirometers are not available, these devices
The results of the present study shows that the could be used as case finding tool for airflow limitation
prevalence of airflow limitation based on hand held . Hand held spirometer has good specificity and
spirometer in rural women exposed to biomass fuel sensitivity,6-8 hence the present study used the same
was 14.6%. This is the first kind of study that used as a screening tool for detecting airflow limitation.
handheld spirometer in India. When airflow limitation
was confirmed with conventional spirometry, the The high prevalence of airflow limitation in the
prevalence of airflow limitation in Chinese rural present study was could also be due to extensive use
women was estimated to be 12%. This study was done of biomass fuel with non ventilated small kitchens
in south China comparing prevalence of COPD in which are common in the remote parts of Indian
rural and urban non smoking women.10 A significant villages. Other factors that could contribute to the early
association between biomass fuel exposure and development of airflow limitation and enhanced
development of COPD in Indian rural women using prevalence could be age at which the exposure to
conventional spirometry was demonstrated by biomass fuel occurred and duration of exposure.14 In
Johnson P et al. The prevalence of airflow limitation the present study women with airflow limitation who
was low compared to the present study,11 where they were chest symptomatic had prolonged exposure of
used a conventional spirometer to detect airflow more than 15 years and exposure started early in life
limitation in contrast to handheld spirometer used in as cooking is main household work for these rural
the present study. This suggests that handheld women. One more attention-grabbing observation in
spirometer tends to overestimate the airflow limitation. our study was that about 32.91% of women diagnosed
This overestimation could be due to higher cut-off were asymptomatic when screened for airflow
point for FEV1/FEV6 less than 0.75 as compared to limitation. These susceptible women who remain
FEV1/FVC less than 0.70 by conventional spirometry. asymptomatic for long time, do not seek health care
attention are therefore at greater risk of developing
The handheld spirometer measures FEV1 and FEV6 COPD over a period of time.
and is essentially unable to measure forced vital
capacity (FVC). However, FEV6 was taken as surrogate Exposure to biomass fuel remains an important risk
for FVC as many studies have demonstrated that FEV6 factor for the development of airflow limitation in
in handheld spirometer is able to reflect quite Indian rural women, as tobacco smoking among
accurately the actual value of FVC. 12,13 It is also women is regarded socially unacceptable in our
interesting to note that performing FEV6 maneuver is country and the number of women smokers is
simple as all subjects will not be able to expire forcibly negligible compared to Nepal and other Western
for more than six seconds in conventional spirometer. countries.15,16 Hence the present study draws attention
The hand held spirometer is inexpensive, ultra portable to one of the most important unavoidable occupational
and easy to use as compared to conventional hazards in Indian rural women. Therefore it is

imperative to detect the airflow limitation at the 5. Price D. Spirometry and questionnaire use for
earliest and prevent development of COPD . Handheld early diagnosis of chronic obstructive pulmonary
spirometer is an excellent device to screen such disease. Hot Top. Respir. Med. 2010; 14: 13–18.
hazards at low cost and should be placed at all primary 6. Nishimura K, Nakayasu K, Kobayashi A,
care centers. Further comprehensive studies are Mitsuma S. Case identification of subjects with
recommended at different geographical areas of rural airflow limitations using the handheld spirometer
India which can suggest suitable and cost effective ‘Hi-Checker TM’: comparison against an
alternative to biomass fuel and to prevent this work electronic desktop spirometer. COPD 2011; 8:
related consequence in Indian rural women. 450–5.
7. Frith P, Crockettb A, Beilbyc J, Marshall D,
CONCLUSION Attewell R, Ratnanesan A, Gavagna G. Simplified
COPD screening: validation of the PiKo-6® in
Prevalence of airflow limitation in women exposed primary care. Prim.Care Respir. J. 2011; 20:
to biomass fuel in rural areas of Belgaum district is as 190–8.
high as 14.6%, detected by handheld spirometer. 8. Thorn J, Tilling B, Lisspers K, Jorgensen L,
However significant number of women were Stenling A, Stratelis G. Improved prediction of
asymptomatic at the time of screening, which provides COPD in at-risk patients using lung function pre-
a window of opportunity for early intervention and screening in primary care: a real-life study and
prevention of deterioration of airflow limitation in costeffectiveness analysis. Prim. Care Respir. J.
Indian rural women. 2012; 21: 159–66.
9. Swanney MP, Jensen RL, Crichton DA, Beckert
Acknowledgement: None
LE, Cardno LA, Crapo RO. FEV6 is an acceptable
Source of Funding: Self funded surrogate for FVC in the spirometric diagnosis
of airway obstruction and restriction. Am.J.
Conflict of Interest: None declared Respir. Crit. Care Med. 2000; 162: 917–19.
10. Liu S1, Zhou Y, Wang X, Wang D, Lu J, Zheng J,
REFERENCES Zhong N, Ran P. Biomass fuels are the probable
risk factor for chronic obstructive pulmonary
1. Smith KR, Mehta S, Maeusezahl-Feuz M. Indoor
disease in rural South China. Thorax. 2007
air pollution from household solid fuel use. In:
Oct;62(10):889-97. Epub 2007 May 4.
Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds.
11. Johnson P, Balakrishnan K, Ramaswamy P,
Comparative quantification of health risks: global
Ghosh S, Sadhasivam M, Abirami O,
and regional burden of disease attributable to
Sathiasekaran BW, Smith KR, Thanasekaraan V,
selected major risk factors. Geneva: World Health
Subhashini AS. Prevalence of chronic obstructive
Organization; 2004 pp. 1435_93.
pulmonary disease in rural women of Tamilnadu:
2. World Health Organization. Chronic respiratory
implications for refining disease burden
diseases. COPD: definition, 2013. [Accessed 15
assessments attributable to household biomass
Apri 2014.] Available from URL: http://
combustion. Glob Health Action. 2011;4:7226. doi:
www.who.int/respiratory/copd/en/ .
10.3402/gha.v4i0.7226. Epub 2011 Nov 3.
3. World Health Organization 2005. Updated
12. Surya P. Bhatt, Young-il Kim, James M. Well1,
projections of global mortality and burden of
William C. Bailey, Joe W. Ramsdell, Marilyn G.
disease, 2002–2030: data sources, methods and
Foreman,Robert L et al; FEV1/FEV6 to Diagnose
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4. Roche N, Perez T, Neukirch F, Carré P, Terrioux
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P, Pouchain D, Ostinelli J, Suret C, Meleze S,
Kartounian J, Vincke W. FEV1/FEV6 and FEV6
Huchon G. High prevalence of COPD symptoms
as an alternative for FEV1/FVC and FVC in the
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14. Balakrishnan K1, Sankar S, Parikh J, Padmavathi Demographic and Health Survey2011.Ministry of
R, Srividya K, Venugopal V, Prasad S, Pandey Health and Population, New ERA and ICF
VL. Daily average exposures to respirable International Calverton Maryland, Kathmandu,
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fuels in rural households of southern India. 16. Bhandari R, Sharma R. Epidemiology of chronic
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[Nepal], New ERA,ICF International Inc. Nepal

DOI Number: 10.5958/0973-5674.2014.00001.X
Intra and Inter Rater Reliability of a Modified CROM

Device for Measuring Cervical Rotation AROM
Kiran Satpute1, Richa Bisen2, Rebecca Pinto3, Swati S Raje4

Assistant Professor, Department of Kinesiothreapy and Physical Diagnosis, 2Assistant Professor, Department of
1
Electrotherapy, 3Intern, Smt. Kashibai Navale College of Physiotherapy, Pune, Maharashtra, India,
4
Asst.Prof. Statistician, MIMER Medical College Pune, Maharashtra, India
ABSTRACT
Objective assessment of musculoskeletal dysfunction of patients helps to justify the intervention.

Documentation the effectiveness of these interventions further enables the physiotherapist to choose
the appropriate intervention. The measurements of cervical spine ROM can be obtained with various
measuring instruments. Reliability of the measurements by these instruments helps the clinician in
selecting them. The present study aims to measure an intra and inter-rater reliability for measuring
the AROM of cervical rotations with the Modified CROM device.
Results of this repeated measure reliability done on sixty asymptomatic participants, using modified
CROM, indicate that with intraclass correlation coefficient (ICC) for right rotation ranged between
0.870 to 0.925 and 0.954 to 0.960 for left rotation. For right rotation the SEM values ranged between
2.61and 4.51 with MDC values ranged 6.06° to 10.5° For left rotation the SEM values ranged between
1.37 and 1.69, along with MDC values ranged 3.19° to 3.94°
Thus the modified CROM device can be used to measure AROM of cervical rotations, while facilitating
normal weight bearing sitting position. This method is relatively less expensive, and has its potential
for use in clinical practice as well as in research.
Keywords: Modified Cervical Range of Motion Device, Cervical Goniometry, Active Range of Motion
INTRODUCTION
the axis of rotation of a particular movement at that
The physiotherapy assessment of musculoskeletal joint. This land mark should be easily and repeatedly
dysfunction of patients incorporates various objective located on which fulcrum of the goniometer should
assessment methods to quantify the disability. This coincide.
objective assessment helps to justify the intervention
The biomechanical complexity of the cervical spine
and to document the effectiveness of these
makes it difficult to assess the available ROM.3 The
interventions while treating musculoskeletal
measurements of cervical spine ROM can be obtained
dysfunctions.9 Physiotherapist must use standardized
with various measuring instruments, like universal
methods for objective assessment to quantify
goniometer, electro goniometer, bubble goniometer,
musculoskeletal dysfunctions. 20 One of the
gravity goniometer, hydro goniometer, magnetic
standardized methods for objective assessments to
compasses, radiographs and computerized
quantify the limitations of Range of Motion (ROM) in
tomography.8,19,20 Each device has its own advantages
musculoskeletal dysfunction is measurement of ROM
and disadvantages and utilizes supine or sitting as a
available at various joints with reliable measuring
starting position. 6,15,18 The CROM device used to
instruments like goniometer.1,13
measure the ROM of cervical spine in all planes while
For measuring ROM at particular joint fixed land patient is in sitting position had shown good intra rater
marks are marked on body which will coincide with and inter rater reliability with an intra-class correlation
coefficient (ICC) greater than 0.80. This device utilizes
magnetic compass to measure cervical rotation
8. Kiran--37--.pmd 37 5/10/2015, 5:14 PM

ROM.7,11 This device is easy to apply on seated patient’s

head without considering specific anatomical
landmarks and does not require special training. This
device though is easy to implement into clinical
practice but it is an expensive device.4 The gravity-
dependent goniometer with one degree inclination can
be used to measure cervical ROM. This type of
goniometer is financially accessible, having excellent
intra rater and inter rater reliability. This type of
goniometer measures all movements of cervical spine
with patient in sitting position except rotations, which
are measured in supine position.10, 21
The modified CROM (MCROM) device is a

relatively less expensive as compared to CROM device
and mainly used for measuring the upper cervical
rotational ROM.22 This device can be used to measure
ROM of cervical rotations with patient in sitting
position.
The reliability of goniometry is influenced by

various factors like methods of application of
goniometer, relative position of other joints, precise
localization of axis of rotation of joint, stabilization of
proximal joints, and variations among different patient
Fig. 1. Position of MCROM on vertex
types.20
In clinical practice or in research the measurements

used must be reliable both within and between
clinicians to confidently interpret meaningful changes
in patient’s symptoms when measured on different
occasions. Thus purpose of the study was to find intra
and inter rater reliability of MCROM device for cervical
spine rotation measurement.
MATERIALS AND METHODS
This study was designed to measure cervical spine

AROM of rotation with MCROM device. Sixty (30
male; 30 female) asymptomatic participants between
the age group 20 - 30yrs were included after obtaining
their informed consent. Inclusion of subjects with
different body types and flexibility levels was ensured.
MCROM consists of one ring Velcro was strapped

around the head. The compass was fixed on the Velcro
straps which were placed perpendicular to each other.
Side straps were placed exactly on the ear and the
centre strap was placed at the centre of the forehead
so that position of compass was exactly on the vertex Fig. 2. Measurement of right cervical rotation AROM with
of subject.22 MCROM device
8. Kiran--37--.pmd 38 5/10/2015, 5:14 PM

Fig. 3. Scatter plot showing the Correlation of Cervical rotation AROM by both Raters.
Patients were sitting on chair with a high back rest for Social Sciences (SPSS 19) software was used for
with the thoracic and lumbar spine well supported. statistical analysis. Intra-class correlations (ICCs) were
The cervical spine was in neutral position. Thoracic calculated in order to establish inter- rater and intra-
spine and shoulder girdle was stabilized to the back rater reliability with the help of Shrout and Fleiss
of the chair with the help of a belt to prevent rotation methodology (1979).
of the thoracic and lumbar spine.
The Cut off values for acceptable reliability at 95%
Fulcrum was over the vertex of the cranial aspect confidence were ICC > 0.8 indicating high reliability;
of the head. ICC > 0.6 to d” 0 .8 moderate reliability; ICC > 0.4 to
d” 0 .6 fair reliability; and ICC d”.0.4 poor reliability.
Subjects were initially asked to perform five cervical
rotations to right and left as much as possible; any Correlation between the readings of both the raters
deviations from normal were corrected so that it was also shown with the help of scatter plots. Figure 3
simulated the actual test procedure. Next they were
asked to actively rotate cervical spine to any one side Results of the reliability analysis were used to
and starting and end position on MCROM was noted. calculate the standard error of measurement (SEM) and
Manual and verbal cues were provided to prevent the MDC. Standard error of measurement SEM was
tipping of head. The procedure was repeated for calculated to find out quantification of the test–retest
rotation on other side. reproducibility of results and it differentiates actual
clinical changes from irrelevant fluctuations.12 The
Two experienced and qualified physiotherapists in
minimum detectable change (MDC) or Smallest Real
musculoskeletal physiotherapy worked as raters
Difference (SRD) in measurements was proposed as a
(Rater A and Rater B). A standardised procedure for
measure of sensitivity to change.17 It is expressed as a
measuring AROM of cervical was followed by them.
Figure 2 measure in degrees and as a percentage of the
measurement and calculated as 1.96 “2 SEM. 2
Subjects were allotted randomly to the raters using
random number tables. Both the raters recorded 3 RESULTS
readings of each participant. After rest period the
participants were asked to change the rooms where Cervical rotation AROM of sixty asymptomatic
the same measurement procedure was repeated by participants (30 male, 30 female) with mean age 25.03,
other rater. The same procedure was repeated after SD ± 3.24 years is measured in degrees with the
15 days. Each rater was blinded for their previous MCROM device by two raters. Descriptive and intra
readings and that of other rater. The Statistical Package rater reliability statistics is depicted in Table 1.
8. Kiran--37--.pmd 39 5/10/2015, 5:14 PM

Table shows average cervical rotation AROMs as reliable. For right rotation the SEM value was 4.51
observed by both the raters, did not differ significantly. with MDC of 10.5° for rater A and for rater B, SEM
Thus observations of both the raters are in agreement. value was 2.61 with MDC of 6.06°.
It can be seen that all the values of ICC are more For left rotation the SEM value was1.69 with MDC
than 0.8, indicating high reliability. Thus this method of 3.94° for rater A and for rater B, SEM value was
of measuring cervical AROM is found to be highly 1.37, with MDC of 3.19°.
Table 1: Cervical rotation AROM of Both sides
Variable BeforeMean ± SD AfterMean ± SD ICC 95% CF SEM MDC

Right Rotation AROM Rater A 68.66 ± 6.22 68.46 ± 5.52 0.870 0.79 - 0.92 4.51 10.5
Right Rotation AROM Rater B 69.39 ± 6.17 68.83 ± 5.65 0.925 0.88 - 0.96 2.61 6.06
Left RotationAROM Rater A 71.79 ± 6.2 71.16 ± 5.98 0.954 0.93 - 0.97 1.69 3.94
Left Rotation AROM Rater B 72.16 ± 5.95 71.59 ± 5.89 0.960 0.94 - 0.98 1.37 3.19
Abbreviations: AROM - active range of motion; CF- confidence interval; ICC - intraclass correlation coefficient; MDC- minimal detectable
change; SD- standard deviation; SEM- standard error of the measurement.
DISCUSSIONS Florencio conducted study on 20 normal females,

to verify the correla-tions between cervical ROM
The ICC confidence interval of inter-rater reliability measurements measured with the CROM and with the
indicates the consistency of the measurements when Fleximeter, showed excellent inter rater reliability for
taken in same situation by different raters and the rotations but showed moderate intra rater reliability
extent to which the different raters are interchangeable. for right rotations measured with CROM instrument.
The ICC of intra rater reliability indicates the The inter-rater reliability was moderate for the right
consistency and reproducibility of the measurements and left rotations when measured with fleximeter.10
which are taken on various time points. The ICC can
be influenced by variation within individuals, The analysis with the help SEM, and MDC in
measurement error and number of trials.12 degrees is done to express measurement error. SEM
explains the variability within the raters’ own
The results for the current study are similar to a measurements. The SEM and MDC values are
previous investigations with consistently same ICC unaffected by subject variability. The largest values of
values across both groups and higher values for ICC SEM, and MDC for right rotation were 4.51° and 10.5°
>0.8. This value denotes excellent intra rater and intra respectively. These values were approximating to the
rater reliability for the measurement of cervical rotation study conducted by Flecher where the largest SEM and
AROM using the MCROM. MDC values across both samples were about 4.0° and
A study conducted by Youdas et al to determine 9.5° respectively.5 The largest values of SEM for left
normal values for cervical active range of motion rotation were 1.69° and 3.94° indicating good precision.
(AROM) measured with a CROM instrument on The fleximeter is cost effective device compared to
normal subjects showed excellent intra rater reliability CROM device, but fleximeter cannot measure rotation
left rotation (ICC= 0.84) and for right rotation (ICC = ROM with patient in sitting position like CROM.10 To
0.80). In this study, sample size was 337 subjects out avoid change in patient position while measuring
of which 42 subjects (20 Male 22 Female) were between ROM of cervical spine in weight bearing position,
age group 20 to 29 years of age.7 another cost effective device like MCROM can be used
A study done by Fletcher to determine the intra in conjunction with fleximeter. The magnetic compass
rater reliability of cervical active range of motion used in MCROM device a similar that is used in CROM
(AROM) measurement of subjects with and without device to measure cervical rotation ROM. The
neck pain using the CROM device indicated that ICC MCROM device can be useful as an objective
values were 0.92 for right rotation and 0.96 for left assessment tool to measure cervical rotations
rotation in asymptomatic subjects.5 especially when manual therapy techniques in which
8. Kiran--37--.pmd 40 5/10/2015, 5:14 PM

mobilization is given in weight bearing position of 2. Beckerman H, Roebroeck M, Lankhorst G, Becher

spine like Mobilization with movement (MWMs).14 J, Bezemer P, Verbeek A. Smallest real difference,
a link between reproducibility and
Though the rater has provided manual and verbal responsiveness. Quality of Life Research 2001; 10:
clues to conform the starting position of head, the 571–578.Bland JM, Altman DG. Statistical
starting point readings were read prior to each methods for assessing agreement between two
movement of rotation. Thus before active rotations the methods of clinical measurement. The Lancet
consistency of achieving neutral head position is a 1986; 1: 307- 310.
relevant to consider, which could be the substantial 3. Bogduk N, Mercer S. Biomechanics of the cervical
source of error. spine. I: Normal kinematics. Clinical
However, based on the results of this observational Biomechanics (Bristol, Avon) 2000;15(9): 633–48
study, the MCROM device is suitable for clinical use 4. Ioannis D. Gelalis, De Frate LE, Stafilas KS, Pakos
and adequate enough to control substantial EE, Kang JD, Gilbertson LG. Three-dimensional
measurement error. analysis of cervical spine motion: reliability of a
computer assisted magnetic tracking device
compared to inclinometer. Eur Spine J. 2009;
CONCLUSIONS
18(2):276-81.
The result of our study demonstrates that the 5. James P. Fletcher, william D Bandy, Intrarater
MCROM device has an excellent intra-rater and inters Reliability of CROM Measurement of Cervical
rater reliability for measuring AROM of cervical spine Spine Active Range of Motion in Persons With
rotations in normal subjects. This method of measuring and Without Neck Pain; J Orthop Sports Phys
rotation ROM of cervical spine is relatively less Ther 2008; 38 (10):640-645.
expensive and has potential for use in clinical practice 6. James W Youdas, Carey JR, Garret TR. Reliability
as well as in research. of measurements of cervical spine range of
motion: comparison of three methods. Phys Ther.
Another device like fleximeter can be used to 1991; 71(2):98-104.
measure ROM of cervical spine in frontal and sagittal 7. James W Youdas, Garret TR, Suman VJ, Borgard
plane without changing the patient position. CL, Hallman HO, Carey JR. Normal range of
Limitations motion of the cervical spine: an initial goniometric
study. Phys Ther. 1992; 72(11):770-80.
The MCROM devices can not measure the frontal 8. Jan Lucas Hoving, Pool JJ, van Mameren H,
and sagittal plane ROM of cervical spine. The intra Devillé WJ, Assendelft WJ, de Vet HC, et al.
and inter-rater correlations would be better Reproducibility of cervical range of motion in
understood if study is conducted with multiple patients with neck pain. BMC Musculoskelet
assessors with varying degrees of experience. Further Disord. 2005; 6:59.
research for the validation of this instrument can be 9. Jeremy Reynolds, D. Marsh, Heiko Koller, Juliane
carried out. Zenenr, and G. Bannister, Cervical range of
movement in relation to neck dimension; Eur
Conflict of Interest: Nil Spine J. 2009 June; 18(6): 863–868.
Source of Funding: Self 10. Lidiane L. Florencio, Patrícia A. Pereira, Elaine
R. T. Silva, Kátia S. Pegoretti, Maria C. Gonçalves,
Acknowledgement: The authors gratefully Débora Bevilaqua-Grossi , Agreement and
acknowledge all the subjects participated in the study. reliability of two non-invasive methods for
We also acknowledge the principal prof. Ashok Patil assessing cervical range of motion; Rev Bras
for their valuable suggestions. Fisioter. 2010; 14(2):175-81.
11. Mark A. Williams • Esther Williamson, Simon
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1. A. F. Mannion, G. N. Klein, J. Dvorak, C. Lanz, individuals with sub-acute whiplash associated
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intraindividual reliability and the influence of 12. Michael Eliasziw, Young SL, Woodbury MG,
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reliability: using goniometric measurements as Reproducibility and validity of digital
an example. Phys Ther. 1994; 74:777-788. inclinometry for measuring cervical range of
13. Michele Petherick, Wendy Rheault, Sharon motion in normal subjects; Physiother Res
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1988; 68:966-969 20. Richard L Gajdosik and Richard W Bohannon,
14. Mulligan BR 2004 Manual Therapy ‘Nags’, Clinical Measurement of Range of Motion:
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Knoester, Jan C. Winters, Pieter U. Dijkstra, David A. Browder, Inter-tester reliability of
Assessment of the cervical range of motion over passive intervertebral and active movements of
time, differences between results of the Flock of the cervical spine; Manual Therapy 11 (2006)
Birds and the EDI-320: A comparison between 321–330
an electromagnetic tracking system and an 22. Toby Hall, Kathy Briffa, Diana Hopper, The
electronic inclinometer; Manual Therapy 13 influence of lower cervical joint pain on range of
(2008) 450–455 motion and interpretation of the flexion–rotation
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8. Kiran--37--.pmd 42 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Effects of Neuromuscular Electrical Stimulation (NMES)

on Hand Function in Stroke Patients
Pawan Sharma1, Jayshree M Sutaria2, Prajakta Zambare3

1
Assistant Professor, Shri U.S.B. College of Physiotherapy, Abu-Road, 2Lecturer, Government Physiotherapy College,
Government Spine Institute, Ahmedabad, Gujarat, 3Assistant Professor, Padmashree Dr. D.Y. Patil College of
Physiotherapy, Pune
ABSTRACT
Background: Motor dysfunction after stroke is a major reason which disables a person in performing
activities of daily living (ADL). During the process of natural recovery affected upper limb and
lower limb recovers but recovery of the hand function often remains incomplete and can lead to a
major disability for a person. A lot of treatment options are available to solve this problem and
NMES appears to be a promising and easily available among them.
Objective- To assess the effectiveness of NMES along with Conventional Physiotherapy on Hand
Function rehabilitation in Stroke Patients.
Methodology: 30 (thirty) patients were divided in a consecutive manner into two groups for the
study; one group received conventional treatment (Control Group) and other for conventional
treatment as well as NMES to wrist and finger extensors (Experimental group). An assessment was
done prior to starting of treatment and after 4 weeks of treatment.
Results: At the end of 4 weeks experimental group showed significant improvement in Block to Box
Test (p<0.05), Fugl Meyer Assessment Tool for Wrist and Hand (p<0.05) and Grip Strength (p<0.05)
as compared to the control group except Action Research Arm Test(p>0.05).
Conclusion: Conventional exercise therapy and NMES to wrist and finger extensors is more effective
than Conventional exercise therapy alone in improving hand function in stroke patients.
Keywords: Stroke, Hand Function, Neuromuscular Electrical Stimulation (NMES)
INTRODUCTION perception and cognition defects and bladder and

Stroke or Brain Attack or Cerebro-Vascular bowel dysfunctions.2
Accident (CVA) is defined as an acute onset of Grasping, holding, and manipulating objects are
neurological dysfunctions due to an abnormality in daily functions that remain deficient in 55% to 75% of
cerebral circulation with resultant signs and symptoms
patients 3 to 6 months post stroke. Close to complete
that corresponds to involvement of focal areas of the
functional recovery has been documented in only 5%
brain. Further, the symptoms should last for 24 hours
to 20% of stroke survivors.3 While restoring voluntary
or more.1
control of skilled reaching and grasping movements,
The primary impairments commonly seen after 60% of stroke survivors continue to have significant
stroke are impaired sensations, pain, visual changes, upper extremity (UE) disability after 6 months.4, 5
motor dysfunctions, postural control and balance Approximately half of the stroke survivors are left with
dysfunctions, speech and language dysfunctions, major functional problems in their hand and arm.6
9. PAWAN SHARMA--43--.pmd 43 5/10/2015, 5:14 PM

Loss of functional control results from decrease in MATERIALS AND METHODOLGY

strength, range of motion, abnormal muscle tone,
sensations, and awareness of the affected side. 7 An interventional study was conducted in the
Intervention strategies for rehabilitation of hand Department of Physical Medicine and Rehabilitation,
include exercise therapy, neurodevolopmental Civil Hospital, Ahmedabad. Ethical clearance was
Therapy (NDT), functional task training, constraint taken from the Institutional Ethics Committee,
induced movement therapy (CIMT), motor relearning Government (CL & SC) Spine Institute, Civil Hospital,
program (MRP), positioning strategies, range of Ahmedabad. Convenient purposive Sampling was
motion exercises, tone reduction strategies, strategies used. Sample size was 30. All the subjects were treated
to improve postural control & functional mobility, for 4 weeks, 5 days a week, once a day.
electrotherapeutic modalities such as bio-feedback, Inclusion Criteria- 10, 11
NMES & functional electrical stimulation (FES), patient
& family education etc.8 Male or female with age > 18 years, Unilateral
stroke leading to hemiplegia with hand dysfunction,
NMES refers to the electrical stimulation of an intact Duration of stroke more than six months, Mini-Mental
lower motor neuron (LMN) to activate paralyzed or Status Score of e” 24, 10° of active wrist extension, 90%
paretic muscles. Clinical applications of NMES provide of passive extension of the fingers and thumb with the
either a functional or therapeutic benefit. NMES may wrist in a neutral position, Voluntary shoulder flexion
lead to a specific effect that enhances function but does to at least 30°, Voluntary elbow extension of ~10° when
not directly provide function.9 the initial position of the elbow was 90° flexed.
Marcio Santos, Laura H. Zahner (2006) stated that Exclusion Criteria-10, 11
short bouts of NMES can produce significant changes
in wrist and hand function for the chronic stroke Impaired sensations over the affected forearm and
survivor. Also, using NMES to assist during task hand, Cardiac pacemakers, Cochlear implant,
practice appears more beneficial than activating the Uncontrolled cardiac arrhythmias, Pregnancy,
wrist flexors and extensors in a passive mode.10 Seizures within the past 12 months or other systemic
illness, Previous Wrist problem such as arthritis,
AIMS AND OBJECTIVES Central/peripheral neurological diseases other than
stroke, Open wound on the involved upper limb,
1. To study the effectiveness of Conventional Presence of shoulder instability based on a positive
Physiotherapy on Hand Function in Stroke sulcus test, anterior or posterior apprehension tests,
Patients. Subjects participating in the other upper extremity
program, Subject had received a Botox injection within
2. To study the effectiveness of Conventional
the past three months, Have undergone brain surgery
Physiotherapy plus NMES on Hand Function in
after stroke, Visual impairment, Unilateral Neglect(
Stroke Patients.
Lateral Cancellation Test)
3. To compare the effectiveness of Conventional
Physiotherapy alone versus Conventional MATERIALS
Physiotherapy plus NMES on Hand Function in
Stroke Patients. Written Informed Consent Form, Assessment
Form, Mini-Mental State Questionnaire, Fugl Meyer
Hypothesis Assessment (FMA) Tool, Wrist and Hand component,
Action Research Arm Test (ARAT), Blocks to Box Kit
Null Hypothesis (BTB), Hand Dynamometer, Two Channel Electrical
There is no significant effect of NMES on Hand Stimulator, Action Research Arm test Kit, Digital
Function in Stroke Patients. Camera, Stop Watch, Hammer, Chair.
Alternate Hypothesis METHODOLOGY

There is significant effect of NMES on Hand OUTCOME MEASURES: The following outcome
Function in Stroke Patients. measures were used with high reliability and Interclass

Correlation [ICC] to predict the hand function- Block the half-hour period of NMES of the day without
to Box Test (BTB), Fugl Meyer Assessment (FMA) Tool fatigue of the stimulated muscle groups for 3
(Wrist and Hand), Action Research Arm Test (ARAT) consecutive days, the off-time was decreased by 2
and Grip Strength. seconds. The stimulation period was maintained
throughout as 5 seconds.
PROCEDURE
The patient is instructed to add full wrist and
Subjects referred from the Neuro-medicine fingers extension with abduction and extension of the
Outpatient Department those who fulfilled the thumb as much as feasible during the perception of
inclusion criteria were taken up for the study. A written stimulation on time. If the patient is unable to move
informed consent of all subjects was taken. A total of volitionally, the movement is produced by the non
30 subjects were divided in two groups after initial paretic hand and patient is asked to observe it. The
assessment- subjects were made aware about the ES related adverse
Group A- Conventional Therapy (Control Group, effects. The duration of the stimulation was kept 30
n=15) minutes per session.
Group B- Conventional Therapy and Neuromuscular Conventional Physiotherapy Protocol- 13, 14

Electrical
The conventional physiotherapy interventions
Stimulation (NMES) to wrist and finger (Experimental for both the groups were aimed at improving hand
Group, n=15) function. Both groups received the conventional
intervention techniques for approximately 60 minutes
Nmes to Wrist And Finger Extensors-9, 11, 12 sessions daily for 5 days in a week with the following
Wrist and finger extensors were stimulated with a aims-Improving ROM and Flexibility, Normalization
pair of surface electrodes (4X3cm). One electrode was of Tone, Improving Muscle Force Production,
placed proximally over the forearm below the elbow, Proprioceptive Neuromuscular Stimulation (PNF) for
and the other was placed distally on the forearm functional improvement, Improving Trunk, Scapula
(positioned for optimally balanced joint movement). and Glenohumeral Stability, Improving Scapular
NMES had a pulse width of 1000 ms and a frequency Mobility, Improving Task Related Performance.
of 60 Hz, with the amplitude set at a minimum level
required to produce full joint extension. The muscle RESULTS
contraction/relaxation time ratio was progressively
increased by shortening the relaxation period (from All 30 subjects completed the 4 weeks of treatment
5/10 seconds on/off time to 5/8, then to 5/6, and then sessions and 2 assessment sessions and there were no
to 5/4 seconds); when a subject was able to complete reports of study-related adverse events.
Table 1. Baseline charecterisritcs of the patients
Age in Years Gender Affected Duration Level of

Mean±SD Extremity of Stroke Spasticity
in Months Mean±SD
Mean±SD (On Modified
Ashworth Scale)
Male Female Right Left
Group A 48.7±10.99 9 6 6 9 17.26±7.35 1.33±0.81
Group B 50.2±9.24 8 7 5 10 15.86±5.66 1.26±0.79
All the patients were similar at the baseline within the group, Wilcoxon Signed Rank Test was used
characteristics. To analyze the effects on outcome and for between group comparisons Mann-Whitney
measures (i.e. Block to Box, FMA Hand and Wrist, test was used.
ARAT and Grip Strength) before and after intervention

Table 2, Changes in Outcome Measures after 4 Week Intervention within group
Block to Box Fugl Meyer Assessment, Action Research Grip Strength (Kg)
Test (BTB) Hand and Wrist (FMA) Arm Test (ARAT)
Group A Group B Group A Group B Group A Group B Group A Group B
Mean Median Mean Median Mean Median Mean Median Mean Median Mean Median Mean Median Mean Median
±SD ±SD ±SD ±SD ±SD ±SD ±SD ±SD
Pre- 19.4±6.64 18 19.73±7.17 18 15±2.87 16 14.6±2.79 15 28.73±7.60 28 28±7.30 27 3.06±1.83 3 3.28±2.41 3
treatment
Post- 26.8±6.28 25 34.66±7.23 34 18.2±2.51 18 20.2±2.36 20 31.4±8.13 30 32.73±7.86 31 4.73±1.75 4 6.46±2.61 7
treatment
W- value 120 120 120 120 120 120 78 120
P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.002 0.001
In within group comparison using Wilcoxon Signed improvement in terms of all the outcome measures
Rank test both the groups yielded significant (P<0.05).
Table 3. Changes in Outcome Measures after 4 Week Intervention between Groups
Groups Mean of Post p Value Mean of Post p value Mean of Post p value Mean of Post p value
treatment treatment treatment treatment
BTB Score FMA score ARAT score Grip Strength%
Group A 26.8±6.28 0.007 18.2±2.51 0.03 31.4±8.13 0.771 4.73±1.75 0.045
Group B 34.66±7.23 20.2±2.36 32.73±7.86 6.46±2.61
In between group comparison, significant groups yielded statistically significant results but none
improvement was noted in the experimental group as of the study group exceeded the Minimally Clinically
compared to the control group in terms of BTB, FMA Importance difference (MCID).
and Grip Strength (p<0.05). No significant
improvement was noted in ARAT in experimental The MCID has been defined as “the smallest
group as compared to control group (p>0.05). difference in score in the domain of interest which
patients perceive as beneficial and which would
DISCUSSION AND CONCLUSION mandate, in the absence of troublesome side effects
and excessive cost, a change in the patient’s
In the present study significant improvement was management”. MCID values for grip strength are 5.0
noted in the experimental groups as compared to the and 6.2kg for the affected dominant and nondominant
control group in terms of BTB, FMA and Grip Strength sides, respectively. MCID values for the ARAT are 12
(p<0.05). The findings of the present study are similar and 17 points for the affected dominant and non-
to the one found by Joanna Powell, A. David Pandyan dominant side.16
(1999) suggesting that cyclic ES of the wrist extensors
enhances motor recovery and reduces upper-limb As like present study showing low clinical
disability. This treatment should be considered for improvement, J. R. de Kroon, M. J. IJzerman et al. (2004)
highly motivated patients with moderate motor deficit in his study to compare the effectiveness of stimulation
persisting beyond 2 weeks.12 Pomeroy et al. (2009) of extensor of the hand vs. alternate stimulation of
recently used the Cochrane paradigm of systematic flexors and extensors concluded that for duration of 6
review and meta-analysis to assess the merits of the weeks the success rate (i.e., percentage of patients with
study comparing electrical stimulation and the a clinically relevant improvement of <5.7 points on the
conventional treatment group. Statistically significant ARAT) was 27% in group B (four patients) and 8% in
difference was only found for motor impairment and group A (one patient). The reason for low functional
this was in favour of electrostimulation compared with gain can be due to short duration of the study.17
conventional therapy, SMD 1.06 (95% CI 0.25 to 1.88).15
Apart from this a 12 week study conducted by the
Apart from statistical significance, clinical relevance Joanna Powell, A. David Pandyan (1999) to improve
also keeps importance while deciding the prognosis hand function by NMES to wrist extensors got an
of the intervention. In the present study both the average change of 21.1 in the scoring of ARAT at the

end of the training session.12 Similarly a 12 week study REFERENCES

conducted by Gad Alon, Alan Lewitt et al. (2007) to
improve hand function by Functional Electrical 1. World Health Organization: Recommendation on
Stimulation reported an average increase of 31 in the stroke prevention, diagnosis & therapy: Report
scores of Block to Box test in FES group.11 The clinical of the WHO task force on stroke & other
improvement in the above stated two studies can be cerbrovascular disorders, Stroke 1989; 20: 1407-
due to the longer duration of the study or may be due 1431
to more sophisticated equipments like Functional 2. Susan B O’Sullivan, Thomas J Schmitz: Physical
Electrical Stimulation (FES) and Electromyography Rehabilitation, 5th edit; Chapter 18- Stroke. pp
Triggered NMES. 705-776. Jaypee Publication.
3. Nakayama H, Jorgensen HS, Raaschou HO,
The result concluded by the present study do Olsen TS. Compensation in recovery of upper
conflict some of the previously conducted studies. John extremity function after stroke: the Copenhagen
Chae, Francois Bethoux (1998) stated that surface Stroke Study. Arch Phys Med Rehabil. 1994; 75 (8):
NMES is effective in reducing motor impairment but 852-857.
the improvements are not significant. The probable 4. Broeks JG, Lankhorst GJ, Rumping K, Prevo AJ.
cause for such conclusion can be the outcome measure The longterm outcome of arm function after
i.e. FIM. The self-care component of the FIM measures stroke: results of a followup study. Disabil Rehabil.
general disability and is not arm disability specific and 1999; 21: 357-364.
the stroke survivor can score well at FIM if he manages 5. Duncan PW, Goldstein LB, Horner RD,
to do the activity in a required manner with the non Landsman PB, Samsa GP, Matchar DB. Similar
affected limb.9 motor recovery of upper and lower extremities
after stroke. Stroke. 1994; 25: 1181-1188.
In the present study there was no statistical 6. Wade DT. Measuring arm impairment and
significant difference between groups in terms of the disability after stroke. Int Disabil Stud. 1989; 11:
score of ARAT. The cause behind such outcome can 89-92.
be very diverse and different types of activities of the 7. Terri Sterlish. Electrical Stimulation as a
hand included in the outcome of the ARAT and Sensorimotor Intervention to Facilitate Recovery
subjects might not have been able to achieve significant of Upper Extremity. Dissertation submitted to
improvement in a period of four weeks. Texas Women University 2009.
The mechanisms which support the improvement 8. Physical Rehabilitation, Assessment & treatment. 4th
in the hand function after NMES are increased wrist edition, Susan B O’ Sullivan & Thomas J Schmitz:
and fingers extensors power, sensorimotor integration, pp 545-562.
neural plasticity, motor relearning, increased attention 9. John Chae, Lynne Sheffler, and Jayme Knutson.
to the arm and sensorimotor integration.18 Neuromuscular Electrical Stimulation for Motor
Restoration in Hemiplegia. Top Stroke Rehabil.
The whole of the study concludes that the novel 2008; 15(5): 412–426
application of NMES along with the conventional 10. Marcio Santos, Laura H. Zahner, Brian J.
physiotherapy can render more beneficial results as McKiernan, Jonathan D. Mahnken, Barbara
compared to the conventional physiotherapy alone. Quaney. Neuromuscular Electrical Stimulation
The results can be more promising with the use of more Improves Severe Hand Dysfunction for
sophisticated and improved equipments like FES and Individuals With Chronic Stroke: A Pilot Study.
EMG NMES and with longer duration of the Journal of Neurologic Physical Therapy 2006; 30 (4).
interventions such as for 12 weeks or 16 weeks.10, 11 11. Gad Alon, Alan F. Levitt et al. Functional
Electrical Stimulation Enhancement of Upper
Acknowledgment: Sincere thanks to all the subjects
Extremity Functional Recovery During Stroke
for their active participation in the study without Rehabilitation: A Pilot Study. Neurorehabil Neural
whom the study would have been impossible. Repair 2007; 21:207–215.
Conflicts of Interest: Nil 12. Joanna Powell, A. David Pandyan et al. Electrical
Stimulation of Wrist Extensors in Poststroke
Source of Funding: Self Hemiplegia. Stroke 1999; 30: 1384-1389.

13. Susan B O’Sullivan, Thomas J Schmitz: Physical Differences of Upper-Extremity Measures Early
Rehabilitation, 5th edit; Chapter 18- Stroke. pp 497. After Stroke. Arch Phys Med Rehabil. 2008; 49.
Jaypee Publication. 17. J. R. de Kroon, M. J. IJzerman, G. J. Lankhorst, G.
14. Carolyn Kisner, Lynn Allen Colby. Therapeutic Zilvold. Electrical Stimulation of the Upper Limb
exercise, 5th edition; Chapter 17- The Shoulder and in Stroke. Am. J. Phys. Med. Rehabil 2004; Vol. 83,
Shoulder Girdle. pp 505-6. Jaypee Publication. No. 8.
15. Pomeroy VM, King LM et al. Electro stimulation 18. Ghez C, Gordon J, Ghilardi M, Sainburg R.
for promoting recovery of movement or Contributions of vision and proprioception to
functional ability after stroke (Review). Cochrane accuracy in limb movements. The Cognitive
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14651858.CD003241.pub2
16. Catherine E. Lang, PT, PhD, Dorothy F. Edwards.
Estimating Minimal Clinically Important

DOI Number: 10.5958/0973-5674.2014.00001.X
Relationship of 6 Minute Walk Distance, BMI and Waist

to Height Ratio in South Indian Men and Women with
Coronary Artery Disease- a Tertiary Care Hospital Based
Study
Runella D'souza1, Renu Pattanshetty2

1
Post Graduate Student, Assistant Professor, KLEU Institute of Physiotherapy, Belgaum, Karnataka, India
2
ABSTRACT
Background: Coronary artery disease is a major cause of death worldwide. There are various factors
associated with coronary artery diseases
Aim: The present study was undertaken to evaluate the relationship of 6minute walk distance, BMI
and waist to height ratio in south Indian men and women with coronary artery disease.
Settings and design: It was an observational stady carried out in an Indian tertiary care set up.
Material and Method: 20 subjects with coronary artery disease were included in the study. All the
subjects anthropometric measures were recorded after which the subjects were asked to perform 6
minute walk test. The subjects were also asked to answer the DASI (Duke Activity Scale Index)
questionnaire which was administered to them..
Statistical analysis: The co-relation between anthropometric variables,6 MWD and DASI score was
done using Karl Pearsons correlation coefficient method, using SPSS software (version 16).The level
of significance was considered at (p?0.05)
Results: A negative correlation was seen between BMI and DASI score, Mets and 6 minute walk
distance which was statistically significant. The correlation of BMI with DASI score was statistically
significant(p=0.0053).There was a negative correlation between BMI and mets which was statistically
significant(p=0.0040)Similarly correlation of BMI and 6 minute walk distance was statistically
significant(p=0.0336).No statistical significance was seen between waist to height ratio with DASI
score, mets and 6 MWD. There was a statistical significant difference between DASI score,mets and
6 minute walk distance(p=0.0033)(p=0.00259)
Conclusions: There is a positive correlation seen between 6 MWD and BMI along with DASI score
and BMI. Higher self-reported physical fitness scores were independently associated with less CAD
risk factors and lower risk for adverse cardiovascular events
Keywords: 6 Minute Walk Distance, Anthropometric Measurements, Waist To Height Ratio, Coronary Artery
Disease
Corresponding author: INTRODUCTION

Renu B Pattanshetty
Coronary heart disease (CHD) is the single largest
Assistant Professor
cause of death in the developed countries and is one
Kleu Institute of Physiotherapy, Belgaum-590010,
Karnataka, India of the leading causes of disease burden in developing
E-mail id: renu_kori@rediffmail.com countries as well. In 2001, there were 7.3 million deaths
Contact no.:+919448482564 and 58 million disability adjusted life years (DALYs)
10. Runella--49--.pmd 49 5/10/2015, 5:14 PM

lost due to CHD worldwide 1. Three-fourths of global 11% in the urban population and 7% in the rural
deaths and 82% of the total DALYs due to CHD population across India.5-15
occurred in the low and middle-income countries.
A study by Kutty et al in 1993 in a Southern rural
Previously thought to affect primarily high-income area of Kerala reported a CAD prevalence rate of
countries, CHD now leads to more death and disability 7.4%.16.
in low- and middle-income countries, such as India,
with rates that are increasing disproportionately Obesity increasingly recognized as a public health
compared to high-income countries. CHD affects epidemic and modifiable risk factor for coronary artery
people at younger ages in low- and middle-income disease .Numerous studies have shown that
countries, compared to high-income countries, thereby anthropometric indices including including body mass
having a greater economic impact on low- and middle- index (BMI),waist circumference, waist hip ratio and
income countries. Effective screening, evaluation, and waist height ratio are associated with coronary heart
management strategies for CHD are well established disease risk factors or adverse events . Previous reports
in high-income countries, but these strategies have not have documented that increased cardiovascular (CV)
been fully implemented in India2. risk associated with being overweight is partially
explained by its association with numerous risk
In 2004, CHD was the leading cause of death in mediators, including traditional atherosclerotic risk
India, leading to 1.46 million deaths (14% out of a total factors, insulin resistance, inflammation and
of 10.3 million deaths). Leeder et al. (2004) estimate endothelial dysfunction.3
total years of life lost due to total cardiovascular disease
(CVD) among the Indian men and women aged 35- 64 6 Minute walk test is commonly used to assess the
to be higher than comparable countries such as Brazil functional status of a patients with severe
and China, These estimates are predicted to increase cardiopulmonary disease. The six-minute walk test
from 2000 to 2030, when the differences may become (6MWT) is a simple, easy-to-perform, commonly used
more marked3 test of functional exercise capacity. Its ability to predict
outcomes has been established in patients with heart
In the Prospective Cardiovascular Münster Heart failure, pulmonary hypertension, and pulmonary
Study (PROCAM), a large prospective study in men disease.17
aged 35–65 years, eight variables that made an
independent contribution to risk of CAD were age, Since there is a lack of literature to see the
systolic blood pressure, LDL-C, HDL-C, triglycerides, relationship of 6MWT on coronary artery disease in
diabetes mellitus, smoking, and family history of MI. Indians population the present study was taken up to
The lower HDL-C and higher triglyceride levels in both see the relationship of 6 minute walk distance, BMI,
younger and older cases appear to be a hallmark of and wasit to height ratio in south indian men and
the Indian population, which indicate that women with coronary artery disease.
abnormalities in lipid metabolism play an important
role in development of CAD in young Indians. METHODOLOGY
Smoking and low physical activity in Indians have
been found to be prevalent in 20–39-year-old urban Participants
adults (Gupta et al 2002). Furthermore, the prevalence All adult male and female subjects with coronary
of smoking in South Indian males (44.6%) and passive artery disease visiting the cardiology OPD were
smoking in South Indian females (45.3%) has been included in the study. The data was collected from an
reported to be significantly higher than in North
Indian tertiary care set up . Subjects were excluded if
Indians (Begom and Singh 1995).
they had any cardiac impairment / Hemodynamic
Interestingly, smoking has not been found to be a instability, recent history of surgery on thoracic region
significant risk factor in acute MI patients from rural or were undergoing psychiatric treatment Ethical
parts of India. The patients from rural India, however, approval for the study was granted by the Institutional
have elevated blood glucose and abnormal waist/hip Ethical Committee and the procedures were conducted
ratio (Patil et al 2004).4 according to the declaration of Helsinki.
Various studies from India have shown high Study design: The study was an observational study
prevalence of the disease, approaching approximately design with random selection of coronary artery
10. Runella--49--.pmd 50 5/10/2015, 5:14 PM

disease subjects using anon probability sampling RESULTS

method. Sample size was calculated with á error of 80
A negative correlation was seen between BMI and
and level of significance of p d” 0.05 and assuming
DASI score, Mets and 6 minute walk distance which
fall out rate of 10% of subjects in both the groups. was statistically significant. The correlation of BMI
with DASI score was statistically
PROCEDURE significant(p=0.0053).There was a negative correlation
between BMI and mets which was statistically
After screening patients for inclusion and exclusion
significant(p=0.0040)Similarly correlation of BMI and
criteria standing height, BMI, Waist to height ratio and 6 minute walk distance was statistically
Duke Activity scale index (DASI) was measured. significant(p=0.0336).No statistical significance was
Patients were asked to perform 6 minute walk test seen between waist to height ratio with DASI score,
(according to ATS guidelines). mets and 6 MWD. There was a statistical significant
difference between DASI score,mets and 6 minute
Standing height was measure with a metric tape walk distance(p=0.0033)(p=0.00259)
positioned securely and vertically against the wall. The
participant (without footwear) was asked to stand erect Statistical Analysis
, arms hanging at the side of the body, feet together
Statistical analysis was done manually as well as
the heels and back in contact with the wall. The using the statistic software SPSS 16.0 version so as to
participant was then instructed to look straight ahead verify the results obtained. The data was entered in
, stand as tall as possible and take a deep breath while an excel spread sheet, tabulated and subjected to
the measurement was taken. The distance from the statistical analysis. Various statistical measures such
floor to the pencil mark was recorded to the nearest as mean, standard deviation and test of significance
0.5cms.18 such as student Mann-whitey U test and
Wilcoxonmatched paired test was utilized for all the
Body weight was measured on a weighing scale available scores. The co-relation between
with the participant standing on it without footwear anthropometric variables,6 MWD and DASI score was
and with loose clothing. Weight was recorded in done using Karl Pearsons correlation coefficient
kilograms to the nearest 0.1kg18 method.The level of significance was considered at
(pd”0.05)
Girth measurements were taken of the waist and
hip were taken to the nearest 0.1cm with a measuring Table 1 : Demographic data of the study subjects in
both the groups.
tape.
AGE(years) 45-65
Waist(abdomen) girth :The participant was asked GENDER
to stand erect. The therapist used the cross hand Male 17(85%)
technique to position the measuring tape horizontally female 3(15%)
at the level of the noticeable waist narrowing. The tape OCCUPATION
was then positioned at the narrowest part of the torso Govt servant -3
(above umbilicus and below the xiphoid process) Farmer -3
Housewife -2
Hip(gluteal) girth: The participant was asked to Engineer -2
stand erect with feet together. The tape was positioned Businessman -2
around the hips at the level of the symphysis pubis at retired -8
the greatest gluteal protuberance.19.20 SMOKING
Smokers 3
Since(year) 6.66±2.5
MEASUREMENTS OF OUTCOME VARIABLES
RISK
1. Body mass index Low risk 11(55%)
Moderate risk 8(40%)
2. Waist to height ratio High risk 1(5%)
BMI
3. 6 minute walk distance as per ATS guidelines 18.5-24.9 11(55%)
25-29.9 9(45%)
4. 4.duke activity status index(DASI)
10. Runella--49--.pmd 51 5/10/2015, 5:14 PM

Table2: Correlation between BMI with Waist to height ratio, Dasi score, Mets, 6 min walk distance by Karl
Pearson’s correlation coefficient method
Variables Correlation between BMI with

r-value t-value p-value
Waist to height ratio 0.1730 0.7454 0.4656
Dasi score -0.5987 -3.1716 0.0053*
Mets -0.6132 -3.2931 0.0040*
6 min walk distance -0.4766 -2.3003 0.0336*
*p<0.05
Table3: Correlation between waist to height ratio with, DASI score, Mets, 6 min walk distance by Karl Pearson’s
correlation coefficient method
Variables Correlation between Waist to height ratio with

r-value t-value p-value
Dasi score -0.1424 -0.6104 0.5492
Mets -0.1513 -0.6496 0.5242
6 min walk distance 0.2060 0.8932 0.3836
Table 4: Correlation between Dasi score with Mets, 6 min walk distance by Karl Pearson’s correlation coefficient
method
Variables Correlation between Dasi score with

r- value t-value p-value
Mets 0.6240 3.3875 0.0033*
6 min walk distance 0.4968 2.4285 0.0259*
*p<0.05
Table5: Correlation between Mets score with 6 min walk distance by Karl Pearson’s correlation coefficient method
Variables Correlation between Mets score with

r- value t-value p-value
6 min walk distance 0.3624 1.6498 0.1163
DISCUSSION
The present study suggests that there is a

correlation between DASI score, BMI and 6 minute
walk distance. Most of the the studies of BMI and other
measures of obesity have not adequately accounted
for physical fitness ,a known modifier of weight status
and a very potential mediator of the effects of obesity
on the coronary artery disease and the adverse effects
of cardiovascular outcomes. Therefore the
independent contributions of BMI and fitness to
cardiovascular health or disease have been unclear21.
The present study indicates that there is a negative
correlation between 6MWD and BMI which can be
explained as more the BMI less will be the functional
capacity. Individuals with more body weight and
sedentary lifestyle will have less physical activity and
hence less functional capacity. Venkatramanea et al
Fig. 1. Consort Study Flow Chart
suggested that BMI and waist circumference are better
10. Runella--49--.pmd 52 5/10/2015, 5:14 PM

indicators of CAD risk factors ,which is partially Conflict of Interest: There are no competing interests
comparable with the present study.22
Acknowledgement: Nil
Similary a negative correlation is seen between BMI
and DASI score, which shows that more the body mass Source of Funding: Self
index less is the physical acticity. Rosmond et al. in a
selected population study ,reported that obesity (BMI) REFERENCES
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The AUROC analysis indicate that waist to height 8. Gupta R, Prakash H, Majumdar S, Sharma SC,
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tool than waist circumference, with a weighted mean and coronary risk factors in an urban population
boundary value of 0.5 23 .The findings cannot be of Rajasthan. Indian Heart J. 1995;47:331e338.
gerenalized due to a small sample size however more 9. Gupta R, Gupta VP, Sarna M, et al. Prevalence of
number of trials need to be conducted in a large sample coronary heart disease and risk factors in an
population. urban Indian population: Jaipur Heart Watch-2.
Indian Heart J. 2002;54:59e66.
CLINICAL MESSAGE 10. Gupta SP, Malhotra KC. Urban-rural trends in
epidemiology of coronary heart disease. J Assoc
There is a positive correlation seen between 6 MWD Physcians India. 1975;23:885e892.
and BMI along with DASI score and BMI. Higher self- 11. Dewan BD, Malhotra KC, Gupta SP.
reported physical fitness scores were independently Epidemiological study of coronary heart disease
associated with less CAD risk factors and lower risk in rural community of Haryana. Indian Heart J.
for adverse cardiovascular events. Evaluation of 1974;26:68e78.
physical activity using simple questionnaire and 12. Jajoo UN, Kalalntri SP, Gupta OP, Jain AP, Gupta
anthropometric measure may help in identification, K. The prevalence of coronary heart disease in
risk stratification and intervention aiming at increasing the rural population from central India. J Assoc
physical fitness Physcians Ind. 1988;36:689e693.
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13. Chadha SL, Gopinath N, Radhakrishnan S, 18. David C Reid .Sports medicine .Churchill
Ramachandran K, Kaul U, Tandon R. Prevalence Levingston
of coronary heart disease and its risk factors in a 19. ACSM’s Resource Manual for guidelines for
rural community in Haryana. Indian J Comm exercise testing and prescription.3rd edition.1998.
Med. 1989;14:141e147. 20. ACSM’s Certificate Review 3rd edition Lippincott
14. Wander GS, Khurana SB, Gulati R, et al. Williams and Wilkins.
Epidemiology of coronary heart disease in a rural 21. Mohebi R etal .effects of obesity on the impacts
Punjab population: prevalence and correlation of short term changes in anthropometric
with various risk factors. Indian Heart J. measurements o coronary arery disease in
1994;46:319e323. women.Mayo clinic 2013 may;88(5):487-94
15. Gupta R, Gupta VP, Ahluwalia NS. Educational 22. Patil Virendra et al.relationship if anthropometric
status, coronary heart disease and coronary risk variables to coronary artery disease risk
factor prevalence in a rural population of India. factors.indian J endocrinol metab 2011 jan-
BMJ. 1994;309:1332e1336 mar;15(1):31-37
16. Kutty VR, Balakrishnan KG, Jayasree AK, 23. Browning LM, Hsieh Shiun, Ashwell Margaret.
Thomas J. Prevalence of coronary heart disease A systematic review of waist to height ratio as a
in the rural population of Thiruvananthapuram screening tool for the prediction of cardiovascular
district, Kerala, India. Int J Cardiol. 1993;39:59e70. disease and diabetes:0.5 could be a suitable global
17. Alexis L. Beatty, MDa,*, Nelson B. Schiller, MDa, boundary value.Nutrition research review. 2010,
and Mary A. Whooley, MDa,b, Six minute walk 23:247-26
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Intern Med 2012 July 23; 172(14): 1096-1102
10. Runella--49--.pmd 54 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Effect of Cawthorne and Cooksey Exercise Program on

Balance and Likelihood of fall in Older Women
Prajakta D Zambare1, Neela Soni2, Pawan Shrama3

1
Assistant Professor, Padmashree Dr. D.Y Patil Physiotherapy College, Pune, 2Senior Lecturer, Govt. Physiotherapy
College, Ahmedabad, 3Assistant Professor, Shri U.S.B Physiotherapy College, Abu-Road
ABSTRACT
Background: Falls are common and a complex geriatric syndrome that cause considerable mortality,
morbidity & reduced functioning. There are several causes of falls in elderly such as muscle weakness,
dizziness, postural hypotension etc. & about 17% of falls are due to loss of balance. Cawthorne &
Cooksey exercise (CCE) is part of Vestibular Rehabilitation program which helps in improving balance
by enhancing gaze stability, postural stability, daily living activities and by restoring self confidence
in elderly.
Objectives: To study the effectiveness of Cawthorne-Cooksey exercise (CCE) on balance, likelihood

of fall and fear of fall in older women.
Method: 60 older women who fulfilled the inclusion criteria were taken up for the study. Control
group received conventional physiotherapy to improve balance and experimental group received
conventional physiotherapy and CCE. All subjects were evaluated with BBS (Berg Balance Scale),
DGI (Dynamic Gait Index), PQ (Likelihood of Fall) and VAS-FOF (Visual analogue scale for fear of
fall) score before & after 9 weeks of intervention.
Results: The result of within group analysis yielded significant improvement in BBS, DGI, VAS-FOF
and Likelihood of Fall (p=0.0001) for both the groups. Between group analysis showed significant
improvements in DGI (p=0.013), VAS-FOF (p=0.030) in Group-B but no significant difference in BBS
score (p=0.390) and Likelihood of Fall (p=0.459) between two Groups.
Keywords: Cawthorne and Cooksey Exercise, Balance, Likelihood of Fall, Elderly, Fear of Fall
INTRODUCTION admission (32%), disability, dependence and death. It

can also result into a Post Fall Syndrome that includes
Elderly people in the society face lots of physical
dependence (32%), loss of autonomy (14%), confusion
and medical problems which make them more prone
(22%) and immobilization (4%), depression (2%) and
to deconditioning and confined to their home and
restriction of daily activities.2, 3, 4
some of them are impaired mobility, falls, impaired
cognition, urinary incontinence etc.1 Out of this, falls There are several causes of falls in elderly and about
are common and complex geriatric syndrome which 17% of falls in elderly are due to loss of balance.5 It has
can result in a range of adverse outcomes, like minor been found that about 28-35% of community dwelling
bruises to factures (64%), fear of fall (44%), hospital older people above 64 years of age fall each year and
also the falling rates are higher in older women (40%)
than in older men 28%).6 Considering the significant
Prajakta Zambare increase in life expectancy of the population in general,
Assistant Professor therapeutic interventions directed to the elderly and
Padmashree Dr. D.Y Patil Collge of Physiotherapy, especially those that provide prevention of falls will
Sant Tukaram Nagar, Pimpri, Pune eventually lead to improvement in quality of life of
E-mail: prajakta.zambare8189@gmail.com this part of the population.
11. Prajakta--55--.pmd 55 5/10/2015, 5:14 PM

The major culprit behind the falls in geriatric PROCEDURE

population is balance impairment. Maintaining
balance require co-ordination of inputs from multiple The elderly women those who fulfilled the
sensory systems which includes Vestibular, inclusion criteria were taken up for the study. The
Somatosensory and Visual system. 7. Age related procedure was explained to all the subjects and written
decline in the ability of the above systems to receive informed consent was taken. A pre-participation
and integrate sensory information contributes to poor evaluation was carried out to find the descriptive
balance in elderly leading to more falls in them.8 As demographic data, history of fall or instability, medical
the age advances the ability of the brain to reorganize history and all were evaluated for the baseline data of
or Neuroplasticity declines but not depleted, therefore BBS score, DGI score, VAS- FOF and Likelihood of Fall
the creation of an ideal environment for motor learning (PQ) prior to starting of intervention & after the 9
may determine a significant improvement of the weeks of intervention.
function and it serves as the base for all the vestibular After thorough evaluation the patients were divided
rehabilitation program. in 2 groups
CCE is Vestibular Rehabilitation Therapy. They are Group A- Conventional therapy (n=30)
the exercises designed to gradually retrain the eye and
body musculature to use vision and proprioceptive Group B- CCE program along with Conventional
signals to compensate for the lost or disrupted therapy (n=30)
vestibular signals (which cause poor balance and co-
LIKELIHOOD OF FALL (PQ)- 10, 11
ordination). These are the exercises developed by
physician Terrance. In CCE, patients are encouraged Absolute scores obtained in BBS were applied to
to move into positions that provoke symptoms. The reach the rate of Likelihood of Fall (PQ) using the
central nervous system then attempts to reduce this following equation:-
error signal by modifying the gain of the vestibular
system, that is, through adaptation of the vestibular PQ = 100% x exp (10.46 – 0.25 x BBS score + 2.32 x
system.9 history of instability) / [1 + exp (10.46 – 0.25 x BBS
score + 2.32 x history of instability)]
METHODOLOGY
[BBS score is the score obtained by the subject in
An Interventional study was carried out after the the BBS. History of instability receives value 0 if there
ethical clearance at Jeevan Sandhya Old Age Home is no report of instability and value 1, if there is report
and Department of Physical Medicine and of instability].
Rehabilitation, Civil Hospital, Ahmedabad. Purpose
TREATMENT PROTOCOL
sampling method was used to recruit 60 subjects. The
duration of the study was 9 weeks and subjects were Cawthorne and cooksey exercise programme- 10
treated 3 days/week for 60 minutes. Subjects were
treated on every alternate day (Except Sunday). This exercise program includes-12
Inclusion Criterias 1. Adaptation exercises with the goal of improving

the gain of Vestibulo-Ocular Reflex (VOR),
Age- 60- 69 years, Gender- Female, BBS score- reducing the slippage of visual images on the retina
Below 54, History of fall/ having fear of fall, Ability to with head movements,
understand & follow instructions.
2. Habituation exercises, the use of repeated head
Exclusion Criterias and visual movement activities to facilitate a
reduction in the symptoms provoked by a specific
Neurological conditions like Traumatic Head
movement,
Injury, stroke and impaired cognitive function,
Diabetes, Severe disability/ deformity, severe 3. Balance and gait exercises targeted to improve in
musculoskeletal degeneration, any disorder related to both static and dynamic balance abilities together
Ear Nose Throat (ENT). with overall improvement in gait under a variety
of environmental conditions,
11. Prajakta--55--.pmd 56 5/10/2015, 5:14 PM

4. General conditioning exercises to maintain the b) Walking while looking to the right and to the left
accomplishment of the active therapy program and (as if to read labels in the market.
continue to challenge the patient’s maintenance of
the compensation process. c) Practicing standing on one foot, with open eyes,
then with closed eyes.
1. Eye and Head Movement (in Sitting): first slowly,
then faster. d) Standing up, on a soft surface;
a) Looking up and down; - Walking on it to get used to it.
b) Right and to the left; - Walking on it, with open eyes and then with closed
eyes,
c) Focusing on object (Pen) moving from 3 feet to 1
foot away from face. - Ascend and descend the slope with eyes open and
then with eyes closed.
d) Moving head to right and left, with open eyes;
- Walk around the room with closed eyes.
e) Moving head up and down, with open eyes;
(Adapted from Dix and Hood, 1984 and Herdman,
f) Repeat (d) and (e) with closed eyes.
1994; 2000)
2. Head and Body Movement (in Sitting)
Conventional Therapy- 13, 14
a) Placing object on the floor. Picking and bringing it
1. Flexibility Exercise: It included Hamstring,
above the head and place it on the floor again (look
at the object the whole time); Gluteus Maximus, Hip Flexors, Gastrocnemius,
Soleus and Paraspinal stretch.
b) Shrugging the shoulders and making circular
movements; 2. Strenghtening Exercise: For upper limb, lower
limb & abdominal muscles (curl ups).
c) Bending forward and taking an object through the
back and front of your knees. (Resistance and number of repetitions were added
as per the comfort and compatibility of the subject)
3. Standing up Exercises
3. Endurance Walking: Starting with 5 minute and
a) Circling shoulder, and turning head to right and increased by 2 min every week.
then left along with it.
b) Circling shoulder, and bending head forward and RESULTS

backward along with it.
All the subjects included in the study completed
c) Sitting down and standing up with open eyes and the 9 weeks of intervention and so study related
with closed eyes. adverse effects were reported.
d) Sit to stand, but turning to the right while standing. Table 1: Baseline characteristics of the subjects
Age in years BBS Score

e) Sit to stand, but turning to the left while standing. mean±sd mean±sd
f) Throwing a small ball from one hand to the other Group a 65.53±2.95 39.90±8.26
(above the eye level). Group b 65.03±2.55 39.07±8.96
g) Throwing a small ball from one hand to the other All the subjects were similar at the baseline
under your knees and alternatively. characteristics. Statistical analysis was done using SPSS
16.0 trial Version. Within group comparison of
4. Other Activities to Improve Balance outcome measures (i.e. BBS, DGI, VAS-FOF and PQ)
was done using Wilcoxon Signed Rank Test and
a) Climbing up and down the stairs (using handrail,
between group comparison was done using Mann
if necessary); with eyes open and then with eyes
Whitney U Test.
close.
11. Prajakta--55--.pmd 57 5/10/2015, 5:14 PM

Table 2. Changes in Outcome Measures after 9 Weeks Intervention within group
BBS Score DGI Score VAS-FOF Score % of PQ
A B A B A B A B
Mean Median Mean Median Mean Median Mean Median Mean Median Mean Median Mean Median Mean Median
±SD ±SD ±SD ±SD ±SD ±SD ±SD ±SD
Pre- 39.90±8.26 42 39.07± 8.96 41 18.8± 1.82 19.5 18.6 ± 1.83 19 3.1± 2.09 2.5 3.7 ± 2.18 4 74.37± 34.86 90.72 73.12± 36.41 92.62
treatment
Post 44.50± 7.16 48 45.73± 7.67 48.5 20.13± 1.99 20.5 21.43± 1.94 22 1.73± 1.53 1 0.96± 1.21 0 64.8 ± 34.90 68.56 59.33± 36.92 65.75
treatment
W- value 465 465 406 465 300 351 465 465
P-value 0.0001* 0.0001* 0.0001* 0.0001* 0.0001* 0.0001* 0.0001* 0.0001*
The result of within group analysis of the study FOF and Likelihood of Fall (p=0.0001) for both the
yielded significant improvement in BBS, DGI, VAS- groups.
Table 3. Changes in Outcome Measures after 9 Weeks Intervention between Groups
Groups Mean of Post p Value Mean of Post p value Mean of Post p value Mean of Post p value
treatment treatment treatment treatment
BTB Score DGI score VAS score PQ %
Group A 44.5 ± 7.16 0.390 20.13 ±1.99 0.013 1.73 ± 1.53 0.030 64.79 ± 34.90 % 0.459
Group B 45.7 ± 7.67 21.43 ± 1.94 0.96 ± 1.21 59.33 ± 36.92 %
Results of between the group analysis showed more Rehabilitation. The DGI score improved in 95% of the
improvements in DGI (p=0.013), VAS-FOF (p=0.030) patients. Scores increased from 1 to 9 points.
in Group-B than Group-A. There was no significant
difference in BBS score (p=0.390) and Likelihood of Natalia A. Ricci et al16 conducted a systemic review
Fall (p=0.459) between Group A and Group B. to assess the therapeutic effects of CCE in improving
balance and fear of fall in elderly population and
concluded that despite the shortage in numbers, the
DISCUSSION
studies included showed positive results in favor of
In the present study the subject’s undergone CCE VR regarding the outcomes postural control, functional
program gained significantly greater improvement in capacity and quality of life in elderly and middle-aged
the balance especially in terms of dynamic component adults with complaints or diagnosis of vestibular
(DGI)(p=0.013), and Fear of Fall (VAS- FOF) (p=0.030) syndrome.
as compared to the subject’s undergone conventional
Rasteh H, Olyaei et al.17 suggested that CCE for
Physiotherapy program alone. There was no
three months, three times a week, for sixty minutes
significant difference in BBS score (p=0.390) and
can improve balance status on BBS and also stated that
Likelihood of Fall (p=0.459). There are few pieces of
exercise for 2 months were enough to improve balance
literature concentrating over the effect of CCE in
in elderly (p< 0.05).
improving balance and likelihood of fall in healthy
elderly individuals without any symptoms of dizziness The result conclude by the present study do conflict
or vertigo. CCE is mostly targeted in the population some of the previously conducted study. Angela dos
with vestibular symptoms but it can lead tremendous Santos et al (2005)10 suggests that CCE for 3 months,
beneficial in the subjects without vestibular symptoms. 3times/week for 60 minute improves balance in terms
The mechanism of the CCE is similar to the one of BBS score and also reduces the likelihood of fall (p<
imposed by vestibular rehabilitation as both of them 0.05). The probable cause of such a conclusion of the
is about reintegrating visual, vestibular and study may be because of no conventional
somatosensory pathways. physiotherapy training to the control group.
The findings of the present study are similar as Several mechanisms like Neural Plasticity,
found by Mary Beth Badke, Terry A. Shea (2004)15 Vestibular Adaptation, Vestibular Habituation, Gaze
suggesting the improvement in DGI score in elderly Stabilization, Formation of Internal Models, Learning
subjects with the complaint of balance disorder of of Limits, Sensory Re-weighing, cognitive behavioral
vestibular origin after undergoing the Vestibular learning and improved postural stability are been
11. Prajakta--55--.pmd 58 5/10/2015, 5:14 PM

proposed as an reason for improvement in the balance 5. Dr. Nabil Kronfol, President of the Lebanese
and likelihood of fall among elder population after Health Care Management Association in
undergoing CCE. Lebanon. Biological, Medical and Behavioural
Risk Factors on Falls, Page no.4.
Curthoys IS, Halmagyi GM18 proposed that, motor 6. Stephen R Lord, Catherine Sherrington, Hylton
learning of new postural strategies or alteration of the Menz. Falls in olderly people: Risk factors and
relative weight of inputs to the posture control system strategies for preventions. 2001. Cambridge, Press
could play a major role in improvement after CCE. Syndicate of the University of Cambridge. Page
Lucinda Simoceli, Roseli Saraiva et al. (2008) 19 no.13.
proposed that CCE for elderly patients consist of global 7. Gribble, Hertel. “Effect of Lower-Extremity
stimulation of the balance which is based on exercises Fatigue on Postural Control”. Archives of Physical
of substitution, adaptation and habituation. The Medicine and Rehabilitation.2004; (85): 589–592.
intensive training of Vestibulo-Ocular Reflex, together 8. Schmitz, T. J. Examination of Sensory Function,In:
with other stimuli, has been efficient for both balance S. B. O’Sullivan & T.J. Schmitz Physical
recovery and fall prevention. Rehabilitation.5th edition. Philadelphia, F.A.
Shepard NT, Telian SA et al.20 stated that in CCE, Davis Company. Jaypee Brothers Medical
patients are encouraged to move into positions that Publisher.pp. 121–157.
provoke symptoms. It is believed that reduction of 9. Stefano Corna, Antonio Nardone, Alessandro
symptoms is then obtained through habituation of the Prestinari, Massimo Galante, Margherita Grasso,
vestibular system. Marco Schieppati. Comparison of Cawthorne-
Cooksey Exercises and Sinusoidal Support
Surface Translations to Improve Balance in
CONCLUSION
Patients With Unilateral Vestibular Deficit. Arch
CCE which are easy to apply and affordable can Phys Med Rehabil.2003 August; 84: 1173-1184.
play an important role in prevention and cure of 10. Angela dos Santos Bersot Ribeiro, Joao Santos
balance problems and can help in reducing risk of falls Pereira, Balance improvement and reduction of
in elderly population. likelihood of falls in older women after
Cawthorne and Cooksey exercises. Brazilian
Acknowledgement: Thanks to all the subjects for their Journal of Otorhinolaryngology. 2005 Jan-Feb;
active participation in the study. 71(1):38-46.
Conflict of Interest: Nil 11. Anne Shumway-Cook, Margaret Baldwin,
Nayak L Polissar and William Gruber.
Source of Funding: Self Predicting the Probability for Falls in
Community-Dwelling Older Adults. Journal of the
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812-819.
1. Prudham D, Evans JG. Factors associated with 12. Anna Eleftheriadou, Nikoleta Skalidi and
falls in the elderly: a community study. Age Georgios A. Velegrakis. Vestibular rehabilitation
Ageing. 1981; 10:141–6. strategies and factors that affect the outcome.
2. Suraj Kumar, G Venu Vendham, Sachin Awasthi, European Archives of Oto-Rhino-Laryngologyand
Madhusudhan Tiwari, V P Sharma. Relationship Head & Neck.2012.
between Fear of Falling. Balance Impairment and 13. Anne D. Kloos, Heiss D G. Exercise for Impaired
Functional Mobility in Community Dwelling Balance,In: Kisner C and Colby L.A.Therapeutic
Elderly. IJPMR. 2008 October; 19 (2): 48-52 exercise. 5th edition. Jaypee Brothers Medical
3. Sachiyo Yoshida. A Global Report on Falls Publication.pp.267.
Prevention- Epidemiology of Falls, Page no.5. 14. Means KM, Rod E, O’Sullivan PS. Balance,
4. Seematter-Bagnoud, Vincent Wierlisbach, mobility and falls among community dwelling
Bertrand Yersin, C.J.Bula. Healthcare Utilization elderly persons: effects of a rehabilitation exercise
of Elderly Persons Hospitalized After a program. Am J Phys Med Rehabil. 2005; 84:238-250.
Noninjurious Fall in a Swiss Academic Medical 15. Mary Beth Badke, Terry A. Shea, James A.
Center.Journal of the American Geriatrics Society. Miedaner, Colin R. Grove. Outcomes After
2006 June; 54 ( 6): 891-897. Rehabilitation for Adults With Balance
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Dysfunction .Arch Phys Med Rehabil. 2004 18. Curthoys IS, Halmagyi GM. Vestibular
February; 85:227-233. compensation: a review of the oculomotor,
16. Natalia A Ricci, Marya C. Aratani .”A systemic neural, and clinical consequences of unilateral
review about the effects of the vestibular vestibular loss. J Vestib Res. 1995;5:67-107.
rehabilitation in middle-age and older adults”. 19. Lucinda Simoceli, Roseli Saraiva Moreira Bittar,
Rev Bras Fisioter. 2010;14(5):361-71. Juliana Sznifer. Adaptation Exercises of
17. Rasteh H, Olyaei GR, Abdolvahab M, Jalili M, Vestibulo-ocular Reflex on Balance in the Elderly.
Jalaei SH.”Efficacy of Cawthorne and Cooksey Intl. Arch. Otorhinolaryngol. 2008; 12 (2): 183-188.
exercise on balance improvement in elderly 20. Shepard NT, Telian SA, Smith-Wheelock M.
persons in Mashhad”. TUMS Habituation and balance retraining therapy: a
Journals.2009;3(1,2):9-9. retrospective review. Neurol Clin.1990;8:459-75.
11. Prajakta--55--.pmd 60 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
To Screen Coronary Artery Disease using Rose Angina

Questionnaire in Young Adults- an Observational Study
Arpita Gopinath Rao1, Ganesh B R2

1
2nd year MPT, Cardiopulmonary, 2Associate Professor, KLE University's Institute of Physiotherapy
ABSTRACT
Introduction: Large epidemiological studies have shown that a family history of coronary heart
disease (CHD) is an independent risk factor for cardiovascular disease. While a positive family history
is not modifiable, it can be used to identify individuals in whom a more intensified strategy of
preventions by intervening on modifiable risk factors such as hypertension, hypercholesterolemia or
smoking should be developed.CHD is forecast to be the most common cause of death globally,
including India by 2020. Hence this study is done to screen CAD in young adult population so that
early intervention can be started.
Aims and objectives: To find the relative risk of coronary artery disease in young adults.
Method: After obtaining the approval for the study from institutional ethical committee, all the subjects
who are willing to participate in the study were asked to sign an informed consent. Rose angina
questionnaire was administered in young adults. The score taken was analyzed for prevalence and
relative risk of coronary artery disease among the young adults. Higher the score the more the risk of
having CAD. Results will analyzed using SPSS 14.
Results: Study was conducted to screen the normal individuals for the risk of CAD, this study showed
the out of 100 individuals 82 were at low risk, 18 were at high risk of CAD among 100 individuals for
intermittent 67 were at low risk and 33 showed signs of intermittent claudication. There was no
difference between male female ratio and no correlation between BMI.
Conclusion: Findings of this study suggested that early identification of coronary artery disease can
be screened through rose angina questionnaire so that early intervention can be administered along
with life style modification.
Keywords: Rose Angina Questionnaire, Coronary Artery Disease, Intermittent Cloudication, Young Adults
INTRODUCTION cardiovascular disease.(5,6) While a positive family

history is not modifiable, it can be used to identify
Coronary artery disease incidences in India are
individuals in whom a more intensified strategy of
increasing. Coronary heart disease is forecast to be the
preventions by intervening on modifiable risk factors
most common cause of death globally, including India
by 2020. (1) Interaction between genetic and such as hypertension, hypercholesterolemia or
environmental factors determines susceptibility of an smoking should be developed. There are evidences of
individual to develop coronary artery disease.(2) Large increasing prevalence mainly in women but it is based
epidemiological studies have shown that a family on few studies. Using rose angina questionnaire a
history of coronary heart disease (CHD) is an postal questionnaire which is already been used to
independent risk factor for cardiovascular disease.(3,4) screen CHD.(7) Hence this study is done to screen CAD
A parental history of CHD is considered to reflect in young adult population so that early intervention
genetic biochemical and behavioural components that can be started.
may predispose an individual to be at higher risk of
12. arpita g rao--61--.pmd 61 5/10/2015, 5:14 PM

METHODOLGY screening, so this questionnaire can be used to screen

the individuals for risk factor CAD.
After obtaining the approval for the study from
institutional ethical committee, all the subjects who are Limitation
willing to participate between the age group of 20-30
years were enrolled in the study and asked to sign on The sample size was less in the study. Thus the
informed consent. Rose angina questionnaire will be results cannot be generalised to the entire population.
administered in young adults. The score taken will Equal number of males and females should have taken
analyzed for prevalence and relative risk of coronary to find out the prevalence in both the sex.
artery disease among the young adults. Higher the
score the more is the risk of having CAD. Results were CONCLUSION
analyzed using SPSS 14. Findings of this study suggested that early
identification of coronary artery disease can be
RESULTS screened through rose angina questionnaire so that
early intervention can be administered along with life
As the above study was conducted to screen the
style modification.
normal individuals for the risk of CAD, this study
showed the out of 100 individuals 82 were at low risk, Acknowledgement: Nil
18 were at high risk of CAD Among 100 individuals
for intermittent 67 were at low risk and 33 showed Source of Funding: Self
signs of intermittent claudication. There was no
Conflict of Interest: Nil
difference between male female ratio and no
correlation between BMI. Ethical Clearance: Ethical clearance obtained from
KLE University’s ethical committee.
Table1: BMI distribution in the study.
BMI No. of individuals REFERENCES

<18 16
18-24.9 70 1. Bhargava SK, SachdevHS et al: Relation of Serial
25-29.9 12 Changes in body-mass index to impaired glucose
>30 3 tolerance in young adulthood.
2. Lakshmy Ramakrishnan, Harshpal S Sachdev et
Table2: Sex Distribution and the risk of individuals. al: Relationship of APOA5, PPARã and HL gene
Sex Low Risk High Risk Total varients with serial changes in childhood body
Females 67 14 81 mass index and coronary artery disease risk
Males 16 3 19 factors in young adulthood.
3. J.De Sutter, D. De Bacquer et al: Screening of
DISCUSSION family members of patients with premature
coronary heart disease Results from the
This simple chest pain score can predict coronary EUROASPIRE II family survey.
atomy with similar sensitivity to exercise testing. In 4. N Ahmad, R Bhopal: Is coronary heart disease
routine clinical practice patients with chest pain are rising in India? A systematic review based on
assessed in terms of their chest pain characteristics, ECG defined coronary heart disease.
coronary risk profile, and the results of non-invasive 5. S.Ugurlu, E.Seyahi et al: Prevalence of angina,
investigation, usually a treadmill exercise test. Chest myocardial infarction and intermittent
pain has traditionally been classified as ‘typical’ and claudication assessed by rose angina
‘atypical’ of cardiac origin, which are subjective terms questionnaire among patients with Behcet’s
open to wide interpretation, even with the use of syndrome.
standardized questionnaires. There was no difference 6. E.B. WU, F. Hodson et al : A simple score for
between the males and females may be because there predicting coronary artery disease in patients
were no equal number of males and females taken in with chest pain
the study. This study concluded that after screening 7. Hopkins PN, Williams RR et al: Family history as
100 individuals, this questionnaire has more amount an independent risk factor for incident coronary
of justification for intermittent claudication and angina artery disease in high-risk cohort in Utah.
12. arpita g rao--61--.pmd 62 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
The Study of Improving Prewriting Skills Through

Simplified Teaching Techniques for Mild Mental
Retardation
Occupational Therapist, Psychiatry Department, JIPMER, Gorimedu Post, Pondicherry. India (South)
ABSTRACT
Background study: The prewriting skills are important to be assessed because writing as the
predominant task for the elementary school children. Intervention in prewriting skills is useful as it
can help in the production of legible handwriting. Previous studies are done in normal kinder garden
children. However no studies are in mental retardation. This study was planned because of the value
of prewriting skills training has not been special explored in children with mental retardation.
Aims and objectives: To evaluate the present level of prewriting skills.

To set realistic goals to improve the next prewriting skill.
To facilitate the get through simplified teaching technique.
To re-evaluate his prewriting skills.
To reinforce his newly learnt prewriting skills.
Methodology: A prewriting skill assessment form was made. Bala Vihar, where the study was done.
The inclusion criteria were
1. The entire subject should have only mild Mentally Retardation.
2. The entire subject should be institutionalized at Bala Vihar.
3. The entire subject should not receive any other interventions for drawing in the same institution.
The exclusion criteria are
Visual impairment and auditory loss was ruled out.
The researcher taught and helped the subjects to attain these goals, through simplification.
Repetition was encouraged for to enhance learning skill. This method of prewriting was too
implemented for the involving twenty minutes per days per student. After a week, the subjects were
re-assessed with the same from which showed improvement in these prewriting skills.
Results: Pre intervention mean value is 5.3 N. Post intervention mean value is 10.25 N. it shows that
there is significant improvement.
Conclusion: The difference between pre and post intervention score is 4.95 N. This different has
proved that the prewriting skills were improved through simplified technique.
Keywords: Mild Mental Retardation, Prewriting Skills
INTRODUCTION This scribbles of children are drawings as truly as are

the sketches of the masters. Children make marks on
Drawing uses a kind of universal language. The surface long before they lean to write. It is easy to
world “draw” means to drag a pointed instrument understand, therefore, that drawing is the most
such as pen, pencil, or brush over a smooth surface. fundamental of the arts and is closely related to all the
13. Ramakrishnan--63--.pmd 63 5/10/2015, 5:14 PM

others. Although drawing differs in quality, they have Review of Literature

a common purpose.
Prewriting skills usually develops in a specific
Mental Retardation is defined as impairment in sequence and are acquired at certain developmental
intelligence from early life and inadequate mental ages. Though these skills usually, develop and similar
development leading to impaired learning ability7. ages in most children it is not abnormal for there to be
some variation in the age at which they are acquired,
Although cognitive and academic skills are not In addition, the ability to draw specific shapes and
specific objectives of occupational therapy for sensory representations of objects does not only really on motor
integrative disorders, improvement in these domains skills and motor planning, but also on the visual
has been detected in some intervention studies perception and understanding of them. A child’s
involving the provision of classical sensory integration prewriting skills usually develop as follows3.
treatment7. Occupational therapy aimed at developing
15 months – Initiates scribble or may scribble
compensatory skills such as improved drawing also
spontaneously when appropriate materials of familiar
may free the child to facts on the conceptual aspects of
and available.
academic tasks, rather than the perceptual motor
details of how to draw8. In such compensatory 18 months – scribbles spontaneously and initiates
programs, effects on outcome skills tend to be limits a demonstrated crayon stroke.
to the specific task of concern7. Similarly, consultation
programs may enhance cognitive or academic skills 2 years – imitates a vertical stroke and round
by providing strategies for reducing the effect of scribble. The Denver Developmental Screening Test
states that to be acceptable the vertical stroke must be
sensory integrative disorders on these functions, for
within 30 degree of the vertical.
instance helping a teacher understand how best to seat
a child in class(such as in a bean bag chair versus a 2 and a half years – initiates a horizontal strokes.
firm wooden chair on the front corner of the room near
the teachers task) may assist in reducing the effects of 3 years – copies a circle: (It should be note that
a sensory integrative disorder by making it easier for “copy” is different from “initial”. “Copy” indicates that
the child to attend to instruction in the class room. the shape is drawn after seeing the conceptual shape
which has not been seen in the process of being drawn,
Since their developmental milestone (especially where as “initiate” indicates that the shape has been
cognition) would be less with respect to the observed during the process of being drawn as well
chronological age, their drawing skills would be as when it was complete. Therefore copying a circle
affected. Therefore they require special attention to requires the child to understand the shape and devise
improve their drawing skills. Since drawing is a a motor plan for reproducing it. Initiating a circle
complex process and demands high cognitive and requires only the imitation of the movement, which
sensory motor functioning interrelated with each was perceived during its construction)
other. Drawing was simplified to them when they were 3 years – initiates a cross which is composed of a
taught. vertical and a horizontal line not one which is
composed of 2 diagonal lines.
AIMS AND OBJECTIVES
Some children may attempt to draw a
To evaluate the present level of prewriting skills. representation of head with some indication of features
and perhaps less. The Denver Developmental
To set realistic goals to improve the next prewriting
Screening Test indicates that 25 percentages of children
skill. are able to represent a human figure with 3 parts of 3
To facilitate the get through simplified teaching and a quarter years and all are able to do so at the
technique. developmental age of 5 years.
4 years – copies a cross: representations of a human

To re-evaluate his prewriting skills.
figure usually contain move parts heads, features, legs
To reinforce his newly learnt prewriting skills. thinks and often arms.

4 and a half — copies a square: some children will learning and developmental interest. These technique
initiate a square which they have watched will initiate or method of drawing was too implemented for the
a square which they have watched being drawn from involving twenty minutes per days per student. After
about 3 and half years. a week, the subjects were re-assessed with the same
from which showed improvement in these prewriting
5 years—copies a triangle: this is usually the Ist skills. These improvements are shown in the graph
shape children are able to draw which contains and the results were analyzed.
diagonal lines.
Data Analysis
6 years—copies a diamond (Illing worth, 1983)
some authorities suggest that the average age when a Pre intervention
diamond may be drawn in 7 years and that 50 percent
Table I:
of 7 years old find imitation of the diagonal in
configuration difficult to execute. X x f fx
0-5 2.5 8 16.0
METHODOLOGY 5-10 7.5 12 90.0
10-15 12.5 - -
The researcher spent sufficient time to review 15-20 17.5 - -
various literatures throughout the entire period of Σf=20 Σfx=106.0
study. Then set the objectives for the study. A
X – Limits, x – midpoints, f – frequency, Σf –total number of
prewriting skill assessment form was prepared. A
persons, X – mean? X =Σfx =106 -
sample of assessment is enclosed. Priority permission Σf 20
was taken from the authorities of Bala Vihar
(government), which was the proposed school to carry Post intervention
out the study. Table II
The inclusion criteria were X x f fx

0-5 2.5 - -
1. The entire subject should have only mild Mentally 5-10 7.5 9 67.5
Retardation. 10-15 12.5 11 137.5
2. The entire subject should be institutionalized at 15-20 17.5 - -
Bala Vihar. “f=20 “fx=206.0
X - Limits, x – midpoint, f – frequency, Σf – total number of

3. The entire subject should not receive any other persons, X - mean? X = Σfx = 206
interventions for drawing in the same institution. Σf 20
The exclusion criteria are RESULTS

Visual impairment and auditory loss was ruled out. Pre intervention mean value is 5.3 N
A pilot study was conducted with two subjects, so Post intervention mean value is 10.25 N
the researcher would be familiar with the assessment
form. A quiet room was preferred and care was taken From these two results, it is showed that there is
to remove the destructible stimuli. And each subject significant improvement.
was seen individually at a time. A blank white sheet
was given and was asked to draw free hand with no CONCLUSION
specific theme given to them for fifteen minutes. Then
these drawing were estimates with to developmental The difference between pre and post intervention
age was identified, realistic goals were set. score is 4.95 N. This different has proved that the
prewriting skills were improved through simplified
The researcher taught and helped the subjects to technique.
attain these goals, through simplification.
Limitations
Repetition was encouraged for to enhance learning
skill. Primary towards to encourage and motivate Since psychologist was not analysis at that

institution, mild group of Mental Retardation were Additionally I thanks to my teachers who are the staffs
selected based on these academic performance, given of Santhosh College of occupational therapy.
by the teacher of that institution. Home program was
not given as there were no adequate cares taken. Conflict of Interest: NIL
Source of Funding: NIL

DISCUSSION
Ethical Clearance: NIL
These subjects are selected based on the IQ test.
All are mild level. All the subjects are well in draw a REFERENCES
line both horizontal and vertical and also the circle by
copying the given pictures. Most of the subjects are 1 Modified from Bayley, N. (1993), Bayley scales
finding difficult in copy a cross and they are not go for on infant development (rev.ed.), San Antonio, TX:
the further item which are shown in the table. Staff or Psychological Corporation, Hartcourt Brace;
the therapist introduces the simplified teaching 2. Beery, K.E. (1982), the Development Test of
technique of learning the copy a cross with completion. Visual-Motor Integration. Cleveland: Modern
The intervention period of each child is approximately Curriculum Press;
around 15 to 20 minutes. The cross item is performed 3. Tan-Lin, A.S. (1981), an investigation into the
in many times by using the pencil or wax crayon after developmental course of preschool/kinder
the intervention. This practice took for each child is garden aged children’s handwriting behavior.
around two to three months. All the subjects are Dissertation Abstracts International, 42, 428
encouraged through giving positive reinforcement 4. Amunson, S.J. (1992). Handwriting: evaluation
immediately after successful completion of the given and intervention in school setting. In J. Case-
the item. Here the subjects are doing the same of smith & C.Pehorski (Eds.). Development of hand
copying the cross in many times. After completion of skills in the child (pp.63-78). Rockville, MD:
the study the therapist suggest this technique to the American Occupational Therapy Association.
institutional staff to teach the same to the children. 5. Anderson, P.L. (1983). Denver handwriting
Finally the study find that the pre test means value is analysis, Novato, CA: Academic Therapy
5.3 N and the post test mean value is 10.25 N. Hence, Publications.
this can be seemed that there is definitely significant 6. Willard and Spackman’s (1993) Occupational
improvement. Therapy 8th edition.
7. Jane Case Smith (1996) occupational therapy for
Acknowledgement: I sincere thanks to the Director of children 3rd edition
Bala Vihar institute for helping my project study and
the staffs who also help me to complete my study.

DOI Number: 10.5958/0973-5674.2014.00001.X
Reliability and Sensitivity of Shuttle Walk Test in

Chronic Mechanical Low Back Pain Patients
Priyadarshini Mishra1, J Ayyapan2

1
Asst Professor, Neelachal Institute of Medical Sciences, Bhubaneswar, Orissa, 2Asst Professor, SRM College of
Physiotherapy, Kattankulathur, Chennai
ABSTRACT
Purpose: The purpose of the study is to test reliability and sensitivity of shuttle walk test in chronic
mechanical low back pain patient.
Objective: This study is to test the reliability and sensitivity of shuttle walk test in patients with
chronic mechanical LBP to assess their functional disability.
Method: It is a non experimental design type of study with a sample size of 30.
Results: Karl Pearson's correlation coefficients were used to analyze the relationship SWT and
functional disability .Reliability of the test was found to be very significant but sensitivity didn't
have much significance .
Discussion: In this study a sample of patients of chronic low back pain were taken without any
particular work aspect in consideration. Three times walking was administered with specific
recordings by pulse oximeter and the therapist.
FROST et al (1995) extended the use of shuttle walk test to measure functional capacity in patients
with chronic low back pain.
This study shows that shuttle walk test has a reliability as a measure of functional capacity in patients
with chronic low back pain where as it didn't find much on aspect of sensitivity of the test. Thus
shuttle walk test fulfils the basic norms as a measure of functional capacity in patients with chronic
low back pain.
Analytical values of the physiological baseline measurement showed no significance difference

between the two days of test.
Conclusion: The study conducted showed good reliability and low sensitivity of shuttle walk test as
a measure of functional capacity in patients with chronic low back pain
Keywords: SWT- Shuttle Walk Test, LBP -Low Back Pain
INTRODUCTION broadly divided into acute, sub acute and chronic

according to the duration it persists. Low back pain
Low back pain is a common musculoskeletal
which remains consistent for more than 3 months with
disorder affecting 80% of population at some point of
relapsing symptom is well said as “Chronic low back
time.1 Low back pain is a persistent and commonest
pain”. Low back pain whereas is not a clinical entity
form of job related disability of this era. Every year
but a symptom which is often neglected, in turn having
one in five adults will have low back pain. Back is the
different stages as it worsen i.e. impairment, disability
second most common site of pain. Low back pain can
14. Priyadarshani--67--.pmd 67 5/10/2015, 5:14 PM

and chronicity. Low back pain is a major health Walking tests have been around since the 1960’s,
problem within Western industrialised populations. when the 12min walk was popularised by aerobic
It is simple yet a complex phenomenon which is one fitness enthusiast, “Kenneth H.Cooper, as a quick find
of the greatest health problems within western easy fitness test. 25Walking is a part of everyday
industrialised population. The greater the duration of activity, and patients with chronic low back pain often
low back pain, greater the probability of permanent complain difficulty in walking. So shuttle walk test
disability 6. The disability caused by chronic low back represents a logical choice as an objective major of
pain is a growing problem that has escalated functional disability in this patient.25
dramatically over recent years. Many studies by eminent researcher have been
One of the main aims of rehabilitation is to reduce conducted on shuttle walk test as a endurance
indicator of healthy as well as cardiovascular diseased
this low back pain related disability, however the
patients .Where as there are fewer studies on shuttle
fundamental questions remain about the identification
walk test as a prognostic yet evaluative factor for
and selection of an appropriate functional outcome
patients with chronic low back pain before and after a
measures to asses and record the progress of patient
treatment protocol. The studies had some lacunas such
with low back pain 9
as no practice walk test; sample size being small, result
Traditionally clinicians use visual analogue scale, being influenced may be by treatment. These entire
range of motion, muscle strength and straight leg raise loop holes were taken into consideration in this study,
as a measure of wellbeing of patient’s symptoms. further which may enable us to make use of shuttle
walk test in departments as an assessment tool.
Wherever, a simplified form of measure yet reliable
and valid test should be established to help as a better
prognostic indicator. METHODOLOGY
Study design: Non Experimental design

Walking is an attractive exercise mode for testing
because of its simplicity, relation with daily life Study type: Co relational study
activities, low risk of injuries and health and fitness
Sample size: 30 subjects
benefits. In clinical practice, walking tests have been
developed to assess exercise performance, functional Sampling method: Convenient sampling
capacity or functional disability of patients with
Study duration: one week
respiratory diseases, chronic heart failure, cystic
fibrosis and low back pain. There are two types of Study setting: Department of physiotherapy, SRM
clinical walking tests: a self paced walking test in which College of Physiotherapy
patients have to walk as far as possible in a certain
Inclusion Criteria
time period – for instance, 2, 6 or 12 mins - and an
externally paced walking test and in which patients • patients with at least 6 months duration of low
have to walk at increasing speeds. back pain
The shuttle walk test is an incremental externally • Age –20-40 years

paced walking test .This is a simple and feasible test.
• No previous history of cardiovascular problems.
The test involves a walking on flat platform between
two markers 10m apart and at the end of each minute • 6 min walk test endurance
the speed increase .This is more profoundly used for
Exclusion Criteria
testing cardiovascular fitness of chronic obstructive
pulmonary disease 10and in cardiac patients12.The • Radiculopathy
distance is measured in meters, longer the distance • Any other form of disability
signifies better performance. Further it is a
performance based test that measures exercise • Osteoarthritis
performance level. Being a incremental test, it stresses • Traumatic injury to lower limb
the patient to a symptom limited maximal
performance. • Impaired hearing or comprehension.

MATERIAL AND METHOD disability index and distance travelled on both day 2
and day 7 showed low correlation .There by showing
Materials Used good reliability and low sensitivity of shuttle walk test
• Shuttle walk test tape to show the functional capacity of chronic low back
pain patients.
• 2 marker cones
Peak heart rate values did not show significant
• Pulse oximeter (p<0.005) in patients . By comparing peak heart rate
and distance travelled on both day 2 and day 7 showed
• meter tape low correlation,there by showing good reliability and
• Non – slippery, flat walking surface at least 10m low sensitivity of shuttle walk test to show the
length. functional capacity of chronic low back pain patients.
Number of shuttles completed showed significant

PROCEDURE increase (p<0.005) in patients. By comparing number
Patients first were selected basing on the criteria of shuttles completed on day 2 and day 7 showed high
fixed. Then patient were given oswestry questionnaire correlations .There by showing good reliability of
to be filled by them, they were clearly explained about shuttle walk test to show the functional capacity of
the procedure and the dos and dont’s of it. On day 1 chronic low back pain patients.
the patient were given a practice walk test for them to Borg rate of perceived exertion values decreased
be used to the procedure and cardiovascular significantly (p<0.005).spO2 values increased
endurance was checked by 6MWT .The patient were significantly (p<0.005).By comparing Borg and spO2
then asked to come on day 2. On day 2 patients were on day 2 and day 7 showed low correlation. There by
asked to walk in a 10 m shuttle in accordance to showing low sensitivity of shuttle walk test to show
increasing speed with the verbal clues given by the the functional capacity of chronic low back pain
therapist 12 levels of the test in mind. In this walking patients.
at first VAS, BORG, resting oxygen saturation, resting
heart rate were jotted down. Again after 15 sec spo2 Peak heart rate and Borg rate of perceived exertion
and heart rate was noted down. Patients were asked when comparing did not so statistically significant
to stop the walk if they suffered from leg pain, felt there by denoting that shuttle walk test is not sensitive
palpitation or fatigue. End of the session the no of enough to detect functional capacity of chronic low
shuttle completed, vo2 max, and rate of perceived back pain patients.
exertion, spo2, heart rate, peak heart rate, peak spo2,
peak Borg and time were kept track of. Then on day 7 DISCUSSION
patient were again asked to come after treatment, again
the data’s were recorded down and patient were again In this study a sample of patients of chronic low
asked to fill in the owswestry questionnaire. back pain were taken without any particular work
aspect in consideration. Three times walking was
administered with specific recordings by pulse
oximeter and the therapist.
RESULT
FROST et al (1995) extended the use of shuttle walk
Visual analogue scale values decreased
test to measure functional capacity in patients with
significantly (p<0.005) in patients in table 2, showing
chronic low back pain9.
decreasing pain. Comparing visual analogue scale and
the distance travelled on both day 2 and day 7 showed This study shows that shuttle walk test has a
low correlations. There by showing good reliability reliability as a measure of functional capacity in
and low sensitivity of shuttle walk test to show the patients with chronic low back pain where as it didn’t
functional capacity of chronic low back pain patients. find much on aspect of sensitivity of the test. Thus
Oswestry disability index values decreased shuttle walk test fulfils the basic norms as a measure
significantly (p<0.005) in patients in table 3, showing of functional capacity in patients with chronic low back
decrease in functional disability. Comparing oswestry pain.

Analytical values of the physiological baseline In physiological means, this inactivity is closely
measurement showed no significance difference related with a loss of oxygen consumption and aerobic
between the two days of test. fitness. There by keeping this in mind 6 min walk test
was performed to check the cardiovascular endurance
M AMSTRONG et al (2005) showed the
before the test. Further the physiological responses
reproducibility of shuttle walk test in chronic low back
were recorded in this test to ensure that the patients
pain1.
were clinically stable throughout the study and to give
ARNOTT et al (1997) showed that shuttle walk test guarantied safety.
is a measure of functional capacity in cardiac patients12.
The most common reason for stopping the test was
BRADLEY et al (2002) showed the reliability, leg pain and fatigue whereas in some cases there was
repeatability and sensitivity of modified shuttle walk inability in maintaining the pace. These all factors may
test in cystic fibrosis adult patient. According to the be in relation to the muscle weakness and a decrease
earlier studies on shuttle walk test practice walk test in general fitness experienced by the patient due to
was an important aspect to be looked upon while prolonged period of low back pain.
conducting the test, where as in this study this glaring
In practical means shuttle walk test require very
fact was taken into account5.
little space and inexpensive equipments to be used in.
LYNN K. THOMAS (1980) et al showed that All the patients were at ease while performing the test.
decrease in pain the patients tend to walk more37. Maintenance of increased pace helped in denoting the
degree of chronic low back pain, the lesser the pain
TAYLOR et al (2001) showed that fitness the more the speed they were able to catch up with.
programme significantly improved shuttle walk test
results28.
CONCLUSION
When a comparison was done between visual
The study conducted showed good reliability and
analogue scale and shuttle walk test it showed high
low sensitivity of shuttle walk test as a measure of
coefficency. This implies that with decrease in pain the
functional capacity in patients with chronic low back
patient walked more with a greater speed and lesser
pain
time period.
Acknowledgement: I would like to pay my hearty
The results of this study are in agreement with the
gratitude and benevolence to the Almighty, who
later findings. There was a significant high correlation
showered his blessings to make my paper a successful
between the distances travelled on the two days,
one and my parents for their support throughout.
whereas low correlation was found between the
physiological measures and distance walked between Ethical Clearance:Taken from SRM Universities
the two days. Summing up these, result suggests that ethical committee
shuttle walk test produce a reliable but less sensitive
result. Source of Funding: Self
Being the main concern of this study on the Conflict of Interest: NIL
reliability and sensitivity of shuttle walk test in terms
of the distance travelled when compared with the REFERENCES
result of oswestry disability index score. In oswestry
1. M Armstrong, 5 McDonough. D Baxter( 2005)
disability index it takes into consideration all aspects
Reliability and repeatability of the shuttle walk
of variation in a patient with chronic low back pain
test in patients with chronic low back pain :Int J
where as shuttle walk just takes into account a single
Ther Rehabil 12(10)
aspect i.e. physical inactivity. Patient with chronic low
2. Huskisson EC (1983) Visual analogue scales. In:
back pain tend to be inactive as a result of severe pain.
Melzack R, ed
Further as a result of inactivity, cardiac and skeletal
3. Biand JM, Altman OJ (1986) Statistical methods
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for assessing agreement between two methods
WITTINK et al (2000) showed this decreased of clinical measurement.
efficiency results in a loss of muscle endurance and 4. Frost H, Klaber Moffett JA. Moscr JS. Fairbank
cardiac output20. JCT (1995) Randomised controlled trial for

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DOI Number: 10.5958/0973-5674.2014.00001.X
Effect of Active Stretching Exercises on Primary

Dysmenorrhea in College Going Female Students
Neha S Patel1, Tanvi Tanna2, Sweta Bhatt2

1
Associated Professor, Internee, Shree B. G. Patel College of Physiotherapy, Opp. General Post Office, J.P.Road,
2
Anand, Gujarat
ABSTRACT
Introduction: Dysmenorrhea is most common disorder among menstruating young adult girls. Active
stretching exercises has been promoted as a preventive regimen for dysmenorrhea hence the purpose
of this research project is to investigate the effect of active stretching exercises on symptoms of primary
dysmenorrhea.
Material and method: 120 girls aged between 17- 25 years with moderate-to-severe primary
dysmenorrhea were selected from Shree B. G Patel College of physiotherapy, Anand and Shree
Jalaramgirls hostel, V. V Nagar. The students were non-athletes and volunteered for the study. The
participants were randomly divided into 2 groups: an experimental group (n = 60) and a control
group (n = 60). In the intervention group, the subjects were requested to complete six active stretching
exercises for 8 weeks (3 days per week, 2 times a day) at home. In the pre-test, all the subjects were
examined for pain intensity (10-point scale, visual analogue scale), pain duration and other signs
and symptoms of primary dysmenorrhea using Moos Menstrual Distress Questionnaire.
Results: After 8 weeks, pain intensity in experimental group was reduced from 7.1 to 3.0(p<0.0001)
MMDQ score was reduced from 99.15 to 65.92 (p<0.0001). In the control group there was no significant
decline in pain intensity or other sign and symptoms of dysmenorrhea.
Conclusion: Active stretching exercises decrease pain and other signs and symptoms of primary
dysmenorrhea.
Keywords: Dysmenorrhea, Primary Dysmenorrhea, Active Stretching Exercises, Visual Analogue Scale,
Moos Menstrual Distress Questionnaire
INTRODUCTION muscle activities (primary dysmenorrhea).4 Primary

dysmenorrhea is more common in early menstrual
Dysmenorrhea is defined as painful menstruation
stages. The pain is felt over the lower abdomen and
that prevents a woman from performing normal
sacral region in the first hours of periods and it may
activities, often accompanied by other symptoms
be colicky. In such patients the uterine isthmus is
including diarrhoea, nausea, vomiting, headache and
hypertonic and that results in menstrual flow debris
dizziness. Dysmenorrhea may be caused by clinically
being temporarily retained causing pressure on this
identifiable cause (secondary dysmenorrheaassociated
highly innervated zone. Others postulate that the pain
with some structural abnormality or pathology)or by
may be due to ischemia of vigorously contracting
excessive prostaglandins leading to painful uterine
uterine muscles16.
As per study conducted in Andhra Pradesh in 2013,
Sweta Bhatt
the overall prevalence of Primary dysmenorrhea in
17, Amul colony, Amul Dairy, Anand- 388001, Gujarat
Email: tweetyksia@yahoo.com, India was 54% out of which 52.5% belong to urban
jaswepa@yahoo.com areas and 55.7% belonged to rural areas14.
15. Sweta Bhat--72--.pmd 72 5/10/2015, 5:14 PM

Primary Dysmenorrhea is associated with 1. The subject was asked to stand behind a chair, bend
restriction of activities and absence from school, college trunk forward from the hip joint so that the
or work. Physical exercise has been suggested as a non- shoulders and back were positioned in a straight
medical approach for the management of the line and the upper body was placed parallel to the
symptoms despite of the widespread belief that floor. Duration of holding time was 5 seconds;
exercise can reduce dysmenorrhea evidence based Repetition was 10 times.
studies are limited.11
2. The subject was requested to stand 20 cm behind
And hence, with this increasing prevalence of a chair, then raise one heel off the floor, then repeat
primary dysmenorrhea in women we felt it necessary the exercise with the other heel alternatively. The
to investigate the effect of active stretching in primary exercise was performed 20 Times.
dysmenorrhea on adolescents and young adults and
have an approach from our side towards the 3. The subject was asked to spread their feet shoulder
conservative treatment of primary dysmenorrhea. width, place trunk and hands in forward stretching
mode, then completely bend her knees and
We included active stretching exercises in our maintain a semi squatting position. Duration of this
protocol so as the person is able to perform by position was 5 seconds; the subject then raised her
themselves independently without any assistance or body and repeated the same movement 10 times.
external force. Thus it would be convenient for the
subjects and help them build more confidence in 4. The subject was asked to spread her feet wider than
performing exercises. shoulder width and was asked to bend and touch
left ankle with her right hand while putting her
left hand in a stretched position above her head,
METHODOLOGY
so that the head was in the middle and her head
Subjects from Shree B.G. Patel College of was turned and looked for her left hand. This was
Physiotherapy, Anand and Shree Jalaram Girls Hostel repeated for the opposite foot.. The exercise was
V.V.nagar who volunteered to participate were repeated alternatively 10 times for each side of the
randomly allotted in two groups: Experimental group body.
(Group A n=60 subjects) and Control group ( B n=60
5. The subject was asked to lie down in the supine
subjects).Eventually 120 subjects met with inclusion
position so that the shoulders, back, and feet were
criteria of age group between 17 to 25 (mean age 21)
kept on the floor. In this position the knees were
and with regular menstrual cycle. All participants
bent with the help of her hands and reached to her
experiencing moderate to severe primary
chin. The repetition frequency was 10 times.
dysmenorrhea. The selection process of subjects was
done by history taking. History of specific disease 6. The subject was asked to stand against a wall and
,compulsory use of special drug, having symptoms put her hands behind her head and elbows
such as tingling, itching, discharge, irregular touching the wall, then without bending the
menstruation cycle or subjects with regular exercise vertebral column, the abdominal muscle wall was
history were excluded from the study. Informed contracted for 10 seconds.
consent of participants was taken. Experimental group
performed active stretching exercise till 8 weeks and Outcome measures
control group did not perform any type of exercise
Visual analogue scale (Cronbach’s á 0.99)23 and
Moos menstrual Distress (Cronbach’s á 0.946)9 were
PROCEDURE
taken before initiating program, after 4 weeks and after
In experimental Group six type of active stretching 8 weeks of active stretching exercises for the both
exercise were performed. All exercises were done for groups.
three days a week and two times a day, for 8 weeks.
Visual analogue scale: pain score of the subjects
The participants were instructed to inform about any
involved was recorded by visual analogue scale, which
kind of discomfort caused during exercise program
is 10cm straight line drawn and it starts with no pain
and not to perform these active stretching exercises
and ends with worst thinkable pain. The participants
during the 4 days of menstruation.
were asked to mark a point on this line as per severity
of their pain which indicated present pain level12.
15. Sweta Bhat--72--.pmd 73 5/10/2015, 5:14 PM

Moos’ Menstrual Distress Questionnaire: consists ranging from “no experience of symptoms” to “acute
of 48 symptoms which women may experience during disabling”17. The total is obtained by adding rating of
menstruation. According to the severity the subjects all symptoms out of the grand total of 264.
were asked to rate those symptoms on a 6 point scale
RESULTS
Unpaired t test was used to compare the outcome measures between the two groups.
Baseline Data
Table no.1: Mean Value Comparison of Baseline Data between the Group
Mean Value Comparison of Baseline Data Between the Group

Groups Age in Years Height in cm Weight in kg AOM in Years
Experimental Group 21.35 159.5 49.88 6.3
Control Group 21.28 158.3 47.88 6.7
Table no.2: Comparison of Pre VAS Values between the Groups
Comparison of Pre VAS Values Between the Groups

Group Mean SD t test p value Significant
Experimental 7.133 1.467 2.113 0.0367 NO
Control 7.417 1.418
Table no.3: Comparison of pre MMDQ Values between the Groups
Comparison of pre MMDQ Values Between the Groups

Experimental 99.15 23.74 0.08745 0.9305 No
Control 99.55 26.3
Table no.4: Comparison of VAS Values after 8 Weeks between the Groups
Comparison of VAS Values after 8 Weeks Between the Groups

Experimental 3.017 0.9654 18.53 <0.0001 Yes
Control 7.2 1.436
Table no.5: Comparison of MMDQValues after 8 weeks Between the Groups
Comparison of MMDQ Values after 8 weeks Between the Groups

Experimental 65.92 12.53 8.916 <0.0001 Yes
Control 99.08 25.95
DISCUSSION be prostaglandins which is present in high quantity in

menstrual fluid. They are potent vasoconstrictors and
The present clinical trial was conducted to study thus cause ischemia of the uterus. Exercise act on the
the effectiveness of active stretching on primary linings of uterus and increase the level of Endorphin
dysmenorrhea for 8 weeks in terms of reduction of pain which acts as non-specific analgesics for short term
using Visual Analogue Scale (VAS) and improvement
relief of pain. Similar results were obtained by Shahnaz
in other sign and symptom of dysmenorrhea using
et al who had conducted the study on ‘Effects of
Moos Menstrual Distress Questionnaire22.
stretching exercises on primary dysmenorrhea in
The average VAS score showed significant adolescent girls’ on 179 high school girls4. In this
reduction after intervention in experimental group, protocol of 8 weeks, active stretching exercise had
from 7.133 to 3.017 after 8 weeks of protocol (p<0.0001). significantly reduced pain implying the same
During menstruation pain causing factor are said to mechanism as above.
15. Sweta Bhat--72--.pmd 74 5/10/2015, 5:14 PM

A study by Abbaspur et al in his study also was presence of stress. Numbers of studies have shown
suggested that stretching exercise reduces the a correlation between stress and dysmenorrhea. A
incidence of dysmenorrhea and is due to exercise study by Noorbaksh et al suggested that stress
related hormonal effects on the lining of the uterus, or increases sympathetic activity which enhances
increased level of circulating endorphins1. intensity of uterine contraction. Therefore reducing the
intensity of pain by stretching exercises indirectly
Another study by Committee of Physical Therapy, reduces stress19.
in New Zealand in their study of pelvic stretching
exercises also supported the reduction in pain intensity A number of studies have shown a comparison
by concluding that pain in dysmenorrhea is spasmodic between aerobic exercises verses stretching exercises
in character hence stretching exercises helps to increase and had concluded that aerobic exercises had better
the endorphin level and reduce uterus muscle spasm13. results in reducing pain intensity than stretching
exercise10. However stretching exercises being less time
Kristina S Gamit et al with her evaluation on effect consuming and convenient seems to impact more
of active stretching exercises, a 12 week protocol, confidence in subjects. Therefore I emphasized on
proved that the increase in the blood flow and active stretching exercises.
metabolism of the uterus during stretching exercise
was effective in the reduction of dysmenorrhea
CONCLUSION
symptoms 11.
According to the results obtained after performing
In our study we also noted that the Moos Menstrual
8 weeks of active stretching exercises, reduced pain
distress questionnaire score had reduced from 99.15
intensity, diminished pain duration, reduction in stress
to 65.92 in experimental group (p <0.0001). This is
level were observed. Hence, Active stretching exercises
supported by Golub et al who had conducted study
indeed alleviate pain and symptoms of primary
on effect of Golub’s stretching exercises on primary
dysmenorrhea. And because of high potential benefits
dysmenorrhea 7.
of active stretching exercises girls are recommended
A hypothesis suggesting this was, dysfunction of to perform these exercises on regular basis to help the
lumbosacral vertebra reduces the mobility of spine. decrease the negative impact of these symptoms.
There by affecting the sympathetic nerve and hence
Acknowledgement: A sincere gratitude to the esteem
affecting the supply of blood vessels to pelvic viscera.
principal Dr.Manoj Kumar for his valuable suggestion
This leads to dysmenorrhea as a result of
and views on the topic. A special word of thanks to
vasoconstriction. Stretching exercises increase spinal
Dr. Pratik Vakhariya whose endeavor and guidance
mobility and improve pelvic blood supply through an
were constant source of motivation and strength.
influence on autonomic nerve supply to blood vessels7.
Ethical Clearance: Nil
A community in Belgaum, KLE University had
performed a comparative study on aerobic training Conflict of Interest: Nil
verses stretching exercises using MMDQ score and
they concluded that dysmenorrhea is a referred pain Source of Funding: Nil
from musculoskeletal structures that share the same
pelvic nerve pathway. Referred pain from lumbar REFERENCES
spine, pelvis and hip may be responsible for pelvic
pain and other signs and symptoms associated with 1. Abbaspour Z. MSc et al The Effect of Exercise on
primary dysmenorrhea. Hence stretching the Primary Dysmenorrhea, Dept. of Nursing &
surrounding muscles as well as suprapubic region over Midwifery, Ahwaz Jondishapoor University of
comes the referred pain10. Medical Sciences, Iran.
2. Ali A. Thabet et al Effect of Low Level laser
LuanaMacêdoet al suggested that improving the Therapy and Pelvic Rocking Exercise in the Relief
flexibility of spine and pelvic structures minimises the of Primary Dysmenorrhoea, Department of
referred muscular pain and suppresses the signs and Obstetrics and Gynaecology, Faculty of Physical
symptoms of dysmenorrhea13.
Therapy, Cairo University.
There was an interesting element of relationship 3. Amber Keefer, Merck Manuals: dysmenorrhea,
between stretching exercise and dysmenorrhea, which 2010.
15. Sweta Bhat--72--.pmd 75 5/10/2015, 5:14 PM

4. Charles R. B. Beckmann et al orbs, and gynaecology Controlled Trial OBG Physiotherapy, Institute of
6th ed.; 277 Physiotherapy, KLE University, Belgaum.
5. ElhamKarampour et al the influence of stretch 16. Margaret Polden et al physiotherapy in obstratics
training on primary dysmenorrhea, Department and gynaecology; JP brothers; 306
of Obstetrics &Gynaecology, Jahrom Medicine 17. Mary Brown Parlee. Stereotypic beliefs about
university, Iran. menstruation: A methodological note on Moos
6. Ganon L. The potential of exercise in the Menstrual Distress Questionnaire and some new
alleviation of menstrual disorders and data. Psychosomatic Medicine. May-June 1974.
menopausal system. Women health 1986. Vol. 36. 229-240
7. Golub et al primary dysmenorrhea and physical 18. NateghehDehghanzadeh et al The effect of 8 weeks
activity; Medical science exercises 1998. of aerobic training on primary dysmenorrhea
8. Kavitha.C et al a study of menstrual distress Department of Physical Education, Jahrom
questionnaire in first year medical students, Branch, Islamic Azad University, Jahrom, Iran.
International Journal of Biological & Medical 19. NoorbakhshMahvash et al The Effect of Physical
Research. Activity on Primary Dysmenorrhea of Female
9. Kim, Hae-Won, validity and reliability of the University Students, College of Physical
MMDQ Korean parent-child health journal; ISSN: Education and Sport Sciences, Islamic Azad
1229-263x @; VOL.7; NO.2; PAGE.111-120; (2004). University - Karaj Branch, Iran.
10. KLE University Belgaum, 8 week comparative 20. OzlemOnur et al, Impact of home based exercises
study of Golub’s exercises verses Aerobic on quality of life of women with primary
exercises in primary dysmenorrhea in high school dysmenorrhea, department of Physical Medicine
girls in Belgaum city: a randomized clinical trial: and Rehabilitation, Fatih University, Turkey.
1-7, 41-51. 21. RUDOLF H. MOOS, PH.D. The Development of
11. Krishna S. Gamit et althe effect of stretching a Menstrual Distress Questionnaire, Department
exercises on primary dysmenorrhea in adult girls. of Psychiatry Stanford University School of
12. Linancre J. M. Rasch. Visual Analogue Scale. Medicine Palo Alto, Calif.
Measurement Transactions: 1998: 12(2): 639 22. ShahnazShahr-jerdy et al Effects of stretching
13. LuanaMacêdo de Araújoet alPain improvement in exercises on primary dysmenorrhea in adolescent
women with primary dysmenorrhea treated with girls, Department of Physical Education and
Pilates. Sport Sciences, University of Arak, Iran.
14. Maitri shah et al A study of prevalence of primary 23. Thomas R. Knapp Assessing Validity and
dysmenorrhea in young students - A cross- Reliability of Likert and Visual Analogue Scales.
sectional study. 24. Wanda Marie Thibodeaux, Australian Journal of
15. Mahishale Arati et al Effect of Knee Chest Position Physical Therapy, primary dysmenorrhea, 2010.
in Primary Dysmenorrhea- a Randomized
15. Sweta Bhat--72--.pmd 76 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
To Evaluate the effects of Physiotherapy (a Home Based

Exercise Program) in Improving Functional Capacities and
Quality of Life in Patients with Chronic Kidney Disease
Supriya Khanna1, Paramjot Kaur1, Sanjeev Kumar Khanna2

1
Assistant Professor, 2Associate Professor , College of Physiotherapy, Christian Medical College and Hospital,
Brown Road, Ludhiana
ABSTRACT
Objective: Design: Experimental.
Setting: Nephrology unit, CMC&H, Ludhiana.
Participants: Twenty patients with Chronic Kidney Disease of any stage between the age group 35-
70 years were selected by random convenient sampling technique.
Intervention: Patients were selected and baseline assessment is taken on the questionnaire. Home
based exercises are taught to the patient. Patient is re-assessed after 4 weeks.
Main Outcome Measures: Patient's status is recorded on SF-12 Health Status Questionnaire for
Baseline and after four week protocol assessment. Then the comparison between the scores before
and after intervention was done.
Results: The paired t-test value for scores on SF- 12 Health Status Questionnaire pre- and post-
therapy is calculated to be 6.176(PCS), 4.189(MCS) which is statistically significant p=0.0107(PCS)
and 0.0674(MCS). So we have better results after the intervention given to chronic kidney disease
patients as compared to the scores before intervention.
Conclusions: There is significant improvement in quality of life and functional capacities of patients
with chronic kidney disease.
Keywords: Physiotherapy, Renal Insufficiency, Kidney Disease, Quality of Life, PCS, MCS
INTRODUCTION patients to perform activities in everyday life and

occupational tasks. Physical functioning in patients
The physical fitness and physical functioning ( the
with CKD is affected by several factors like
ability and capacity to perform activities of daily living)
consequences of CKD in it-self, the original disease
is severely reduced in adults with CKD7.It is declining
process that brought about the patient’s kidney disease
from 70% of the expected norm in a pre-uremic phase
and the treatment of CKD which may have further
to 50% of the expected norm when starting dialysis
detrimental effects8 .
therapy11,7,2 . Patients with a renal transplant have a
lower physical fitness of approximately 70-80% of the The main factors causing reduced physical fitness
age-matched controls11. Here, the corticosteroids, still are anaemia3,9 and muscular weakness1,6. This results
a basic immunosuppressive treatment, contribute to in fatigue and increasing inactivity, which in turn
muscular atrophy. Thus, the physical fitness in adults reduces physical fitness even further and increases
with CKD is reduced and affects the capacity of the impairments in physical functioning1,10,6 .It is important
16. Supriya--77--.pmd 77 5/10/2015, 5:14 PM

that the consultant renal physiotherapist, renal nurse, Adults with CKD are subjected to multiple
renal dietician and renal physician have an physiological and psychological stressors. Welch et al
understanding of limitations in physical fitness and 13
have for instance showed that the most common
physical functioning that adults with CKD are treatment-related stressors in patients with
expected to face and how various unique issues may haemodialysis are fluid limitations, the length of
alter the treatment approach. All training methods dialysis and vacation limitations. When adults with
have to start with cautions and feed-back to the CKD rank the stressors that they are subjected to, it is
patients. limitation of physical activity which is the number one
stressor .Therefore, when meeting a patient with CKD
Many adults with CKD experience difficulties in and evaluating his or her coping and adaptation, the
walking if the ground is not level, as in the case of health-care provider must take into account diverse
stairs or steps, uphill slopes, etc. In such conditions, levels of analysis (physiological, psychological,
they experience physical resistance very quickly. Many sociological), short versus long-term consequences and
elderly with CKD also have difficulties in performing the specific nature of the situation in question.
everyday chores, such as managing their personal
hygiene, making their bed, hanging up laundry, RESEARCH DESIGN & METHODOLOGY
vacuum-cleaning, lifting things, rising from a squatting
Study Design: Experimental
position, cleaning, etc. They also experience difficulty
in performing a physical activity over a prolonged Research Setting: Nephrology unit, CMC& H,
period of time, for instance, hanging up laundry, Ludhiana and; Physiotherapy unit, College of
without having to pause several times, which they Physiotherapy, CMC&H, Ludhiana.
have not had to do prior to the disease. Most of the
patients also have difficulties in performing physical Sample Size: 20 patients with CKD of any stage
activities at the same pace as they did prior to the CKD. Sampling Technique: Random convenient sampling
Adults with CKD may also experience temporal stress technique
since they cannot do as much as they would have liked
to. They need more time to perform various activities, Sampling Criteria
partly due to “internal demands”, like the need for
Inclusion Criteria
physical rest and partly due to their experiences of
external demands as a result of all the medical • Age group 35-70 years
appointments and other appointments. All these
factors may have a negative impact on the patients’ • Both Male/Female
level of activity and participation as well as their social • To receive medical prescription for practice of
life 4. It seems urgent to do something for these patients. physical activity.
Rehabilitation has a positive effect on physical fatigue
and improves both ‘endurance’ and physical • Patients willing to participate in the study
‘performance’, which, in turn, could reduce the need
Exclusion Criteria
for more time to be able to perform everyday chores
or other physical activities. It would then be possible • Patients with carcinomas
for the patients to find more time for their own
activities, increasing their physical activity level. It is • Pregnancy
important to make clear to patients that just by putting • Patients with unstable angina, recent MI ,
time and effort into physical exercise or activity they uncontrolled arrhythmias
can improve several aspects of their experience of
fatigue, reduced physical fitness and temporal stress. • Uncontrolled hypertension
It is, though, important that appointments for physical
• Severe diabetes
exercise training are co-ordinated, as far as possible,
with the patients’ other medical appointments. This • Presence of neurological or motor dysfunction that
would give the patients more time to perform their is impeding for implementation of the exercise
own physical activities. protocol
16. Supriya--77--.pmd 78 5/10/2015, 5:14 PM

Outcome Measures RESULTS
Assessment done on 0th( Baseline ) day & last day The paired t-test value for scores on SF- 12 Health
of 4th week on SF-12 Health Status Questionnaire Status Questionnaire pre- and post- therapy is
calculated to be 6.176(PCS) and 4.189(MCS) which is
PROCEDURE statistically significant as the p-value for PCS is 0.0107
and P-value for MCS is 0.0674. So there come better
In this study, patients with any stage of CKD results after the intervention given to chronic kidney
(Chronic Kidney Disease) were selected. The patients disease patients as compared to the scores before
were taken from Nephrology Unit, Christian Medical intervention.
College , Ludhiana. 20 patients were participated in
this research. Hence, alternate hypothesis is accepted i.e. there is
significant psychotherapeutic effect of physiotherapy
The patients were selected based on the sampling on quality of life and functional capacities of patients
criteria. The exercises were demonstrated to each with CKD after intervention of exercise program.
patient and they were told to perform the exercises
Table 1:
daily at home for four weeks.
Component Mean Standard Standard
The Exercise program includes breathing exercises, deviation Error
free range of motion exercise, aerobic exercises of low Pre-PCS 24.155 6.063 1.355
intensity progressing gradually according to the Post-PCS 31.07 9.808 2.193
patient’s tolerance. Pre-MCS 39.725 13.316 2.977
Post-MCS 47.035 11.142 2.49
Exercise Protocol
P value and statistical significance
Physical exercise done once a day for 30 minutes The two-tailed P value is less than 0.0001
and vitals should be checked before the exercise By conventional criteria, this difference is considered to be
protocol. The exercise protocol starts with warm up extremely statistically significant.
Confidence interval
session of 5 minutes which includes deep breathing
The mean of Group One minus Group Two equals -6.915
and stretching exercises followed by range of motion
95% confidence interval of this difference: From -9.258 to -4.572
(ROM) exercises for upper limb (shoulder,elbow,wrist
Intermediate values used in calculations
and hand) and lower limb (hip,knee and ankle) on both
t = 6.1761
sides except on the side bearing fistula.10 repetitions
df = 19
were to be done on each joint in rhythmic and
controlled fashion.It was followed by isometrics of standard error of difference = 1.120
quadriceps and hamstrings muscles(10 repetitions Table 2

with 10 seconds hold).Further, walking (upto 100
Physical Mental
meters) with or without support was to be done. Component Component
Finally cooling down session of 5 minutes of deep (PCS) (MCS)
breathing while sitting was followed. The time for the t value 6.1761 4.1896
aerobic and strengthening exercise varied according P value 0.0107 0.0674
to the tolerance of the patient.
P value and statistical significance
After patients enrolled in the study and provided The two-tailed P value equals 0.0005
consent, the nature of the research was explained in By conventional criteria, this difference is considered to be
extremely statistically significant.
detail to the patient.Then, baseline assessment was
Confidence interval
done for all the participants.Then, Home exercise
The mean of Group One minus Group Two equals -7.310
protocol was taught to them and they were re-assessed
95% confidence interval of this difference: From -10.962 to -3.658
on last day of 4th week using SF-12 health status
Intermediate values used in calculations
questionnaire tool.
t = 4.1896
Scores of tool before and after the therapy sessions df = 19
were compared and data was analyzed. standard error of difference = 1.745
16. Supriya--77--.pmd 79 5/10/2015, 5:14 PM

DISCUSSION CONCLUSION
The aim of the study was to find out the Effects of The result of the study concludes that there is
Physiotherapy to improve Quality Of Life and significant psychotherapeutic effect of physiotherapy
on Quality of Life and Functional Capacities of patients
Functional Capacities of Patients with CKD. The study
with CKD (Chronic Kidney Disease).
was carried out on 20 patients. Treatment protocol was
set for the patients. Data analysis of 20 subjects was Limitations of the Study
done by comparing baseline and 4th week assessment
• Sample size taken was small.
using SF-12 Health Status Questionnaire (includes
questions based on physical, mental, social, emotional • Age related factors were not included.
well-being) which revealed the significant results of
• Treatment protocol is of short duration.
exercise on patients Quality of life. The t-test value
comes out to be 6.176(PCS) and 4.189(MCS) which is • Male and female ratio was disproportionate.
statistically significant as the p-value for PCS is 0.0107
Future Scope of the Study
and p-value for MCS is 0.0674. Thus, results are better
after the intervention.There are many studies showing • Can be done on larger number of subjects.
scientific evidence that if adults with CKD do not
• Comparative study can be done on male and
exercise and only do a certain level of physical activity
female patients.
in their daily living then the muscle mass and physical
fitness will continue to decrease. Also, other studies • Considering a particular stage of CKD study can
says that absence of exercise in daily routine of the be done.
patients with CKD leads to difficulty in maintaining
• Therapy for six months can be given and
him or her which thus reduces their social life and assessment can be taken every month to check the
finally end up in reduced Quality Of Life(QoL).In the results.
study conducted by Parson et al lower intensity
intradialytic exercise program resulted in a significant • A study on effects of resisted exercise on CKD
improvement in urea clearance perhaps due to acute patients can also be done.
increase in blood flow to working muscle12. Acknowledgement: The authors would like to thank
Dr Timothy Rajamanickan ,HOD, Associate Professor
Similar studies conducted by Johansen suggests and Dept. Of Nephrology , Christian Medical College
that exercise can improve many indicators of physical and Hospital, Ludhiana for his immense help.
functioning such as fitness, muscle mass, physical
performance and self reported physical functioning5. Ethical Clearance: Taken from ethical committee
Also, in another work exercise reduces immune system Source of Funding: Self
chemicals that can worsen depression and increases
body temperature which may have calming effects. Conflict of Interest: The authors have no conflict of
Physical activity and Mental Health Current concepts, interest with each other.
explain three basic theories involved with connection
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16. Supriya--77--.pmd 81 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Effectiveness of Acu-Transcutaneous Electrical Nerve

Stimulation in Middle Aged Borderline Hypertensive
Patients - a Randomised Controlled Trial
Dishita Kadam1, Ganesh B R2

1
Post graduate Student, 2Associate Professor, HOD of Cardio- Respiratory Physiotherapy Department, KLEU Institute
of Physiotherapy, Belgaum
ABSTRACT
Background: This trial was carried out to see the effect of Acu- Transcutaneous Electrical Nerve
Stimulation in patients with middle aged borderline hypertension.
Subjects: twenty subjects with borderline hypertension
Method: All subjects were randomly assigned to either group A- Acu- Transcutaneous Electrical
Nerve Stimulation or group B- conventional therapy (relaxation technique - jacobson's progressive
muscular relaxation). Both groups were assessed for blood pressure, heart rate and mean arterial
pressure at the baseline and after four weeks of stimulation as an outcome measure.
Results: Intra group comparison showed a statistically significant difference in blood pressure, mean
arterial pressure and heart rate before and after an intervention in both the groups. Acu-
Transcutaneous Electrical Nerve Stimulation group as compared to conventional group (relaxation
technique - jacobson's progressive muscular relaxation) showed statistically significant reduction in
blood pressure and mean arterial pressure. However the heart rate showed equal improvements in
both the groups.
Conclusion: The present study suggests that stimulation of acupuncture points lowers the blood
pressure in middle aged borderline hypertensive patients.
Keywords: Transcutaneous Electrical Nerve Stimulation, Borderline Hypertension, Acupuncture, Blood

Pressure
INTRODUCTION increasing in other countries, and an estimated 972

million people in the world are suffering from this
Hypertension is the leading cause of cardiovascular
problem. Incidence rates of hypertension range
disease worldwide. Prior to 1990, population data
between 3%
suggest that hypertension prevalence was decreasing;
however, recent data suggest that it is again on the and 18%, depending on the age, gender, ethnicity,
rise. In 1999-2002, 28.6% of the U.S. population had and body size of the population studied. Despite
hypertension. Hypertension prevalence has also been advances in hypertension treatment, control rates
continue to be suboptimal. Programs that improve
Corresponding author: hypertension control rates and prevent hypertension
Dishita A Kadam are urgently needed. 1
Post Graduate Student
KLE University Institute of Physiotherapy, Belgaum - 590010 Hypertension is defined as, systolic blood pressure
E-mail: kdishita@yahoo.co.in (SBP) of 140 mmHg or greater and/or diastolic blood
17. Dishita--82--.pmd 82 5/10/2015, 5:14 PM

pressure (DBP) of 90 mmHg or greater. Borderline Sample size

hypertension is a condition in which the arterial blood
pressure is sometimes within the normotensive range 20 patients with borderline hypertension of either
and sometimes within the hypertensive range.2 gender satisfied the inclusion criteria were selected.
The use of needle acupuncture as a method of Group A- Acu- TENS

treatment for hypertension has been explored in both Group B- Conventional therapy
western and Chinese literature. Tim Williams and
Karen Mueller found that using a clinical modality as Procedure/Study design: The study was a
stimulation produces a quick, but short acting, randomised controlled study. Baseline blood pressure,
therapeutic effect with significant reduction in diastolic pulse rate and mean arterial pressure was recorded
blood pressure in hypertensive patients.3, 4 for both the groups. All monitoring were carried out
on working days and instructions were given to
Hence purpose of this study was to determine the patients to avoid physical exercise and remain calm
long term effect of stimulation of acupuncture points during monitoring.
on blood pressure and heart rate.
Transcutaneous Electrical Nerve Stimulation –The
METHOD stimulation was given at the cardiopulmonary
physiotherapy set up under supervision of the
The study was carried out at Cardiopulmonary investigator. Burst mode of TENS was used. Two
Physiotherapy department of a multispeciality tertiary electrodes were used to give stimulation. In supine
care hospital for a period of 8 months starting from position, electrodes were placed over 2 acupuncture
August 2012 to March 2013. The study was approved points on the body 5-
by the (ethical committee for research on human
subjects of the institute. Written informed consent was 1) 3.8 cm distal to lower border of patella and 1.3 cm
taken from patients. 20 patients were randomly left to the anterior tibial ridge
distributed into two groups using envelope method.
2) The dorsal surface of the foot between the first and
Group A received an intervention in the form of Acu-
second metatarsals at the meta- tarsophalangeal
Transcutaneous Electrical Nerve Stimulation and
joints
Group B received conventional treatment in the form
of relaxation. Both the groups were assessed before Stimulator was set at the frequency of 2Hz and
and after 4 weeks of training. The outcome measures pulse width 200μs, intensity at the level that patient
being blood pressure, heart rate and mean arterial could tolerate. Stimulation was given for 30 minutes.
pressure. Patients were given treatment for 4 weeks, frequency
being 2 times per week.
Inclusion Criteria
Conventional therapy: Conventional therapy was
Diagnosed cases of borderline hypertension of
given in the form of jacobson’s progressive muscular
either gender between 40 – 60 years of age and patients
relaxation. Relaxation was given in supine position by
those who are willing to participate.
giving commands. Relaxation was given for 4 weeks,
Exclusion Criteria 3 times per week.
Patients having either cardiovascular instability like Data Analysis

arrthymia, uncontrolled diabetes mellitus, any
The test for differences in blood pressure and heart
respiratory condition like bronchial asthma, ILD, cystic
rate before and after treatment was performed using
fibrosis, pleural disease and any neurological depletion
paired t test.
like stroke or musculoskeletal dysfunction like recent
fracture, orthopaedic surgery excluded from study. P < 0.001 was considered as statistically significant.
17. Dishita--82--.pmd 83 5/10/2015, 5:14 PM

Table 1: Baseline Characteristics
Parameters ACU- TENS CONTROL

No. of patients 10 10
Age(years) 50.7±4.99 54.4±5.40
BMI 22.99±2.12 23.60±1.75
Male: female 7:3 7:3
Table 2: Intra and Inter group comparison (SBP)
EG CG Difference P value
(Betn Grps)
Pre 134.6±4.90 137.2±3.55 2.6±1.35 .191
Post 129.4±4.72 135.6±2.46 6.2±2.26 .003+
Reduction 5.2±1.03 1.6±2.63 3.6±1.6 0.001+
P value 0.001 .087
Table 3: Intra and Inter group comparison (DBP)
(Betn Grps)
Pre 85.4±6.46 86.8±3.42 1.4±3.04 .553
Post 82.8±6.05 86±3.26 3.2±2.79 .158
Reduction 2.6±2.67 0.8±2.41 1.8±0.27 .115
Table 3: Intra and Inter group comparison (DBP)
(Betn Grps)
Pre 85.4±6.46 86.8±3.42 1.4±3.04 .553
Post 82.8±6.05 86±3.26 3.2±2.79 .158
Reduction 2.6±2.67 0.8±2.41 1.8±0.27 .115
P value 0.013+ 0.269
Table 4: Inter and Intra group comparison (MAP)
(Betn Grps)
Pre 102.2±5.01 103.2±3.39 1±1.62 0.607
Post 98.5±5.19 102.5±2.71 4±2.48 0.045+
Reduction 3.7±1.70 0.7±2 3±0.3 0.002+
P value .001+ 0.298
Table 5: Inter and Intra group comparison (HR)
(Betn Grps)
Pre 80.8±3.79 83.6±9.51 2.8±5.72 0.399
Post 83.7±4.05 87.5±6.02 3.8±1.97 0.155
Improvement 2.9±2.23 3.9±5.13 1±2.9 0.582
P value 0.003+ 0.040+
DISCUSSION Table 2 shows, that there was significant reduction

in systolic blood pressure by 3.86% in experimental
The demographic data in table 1 shows that the group and 1.16% in control group from baseline.
subjects in the both the groups had comparable
characteristics in terms of sample size, age, BMI and Current study shows significant decrease in systolic
male female ratio. As seen in table 2, baseline systolic blood pressure in the patients with borderline
blood pressure was comparable as there was non- hypertension after Acu- transcutaneous electrical
significant difference between the two groups. nerve stimulation on two acupuncture points.
17. Dishita--82--.pmd 84 5/10/2015, 5:14 PM

Comparison of experimental and control group finding that TENS increased coronary blood flow at
suggests that there is statistically and clinically rest in patients with coronary artery disease and
significant reduction in systolic blood pressure in syndrome X.
experimental group than the control group. Our
Current study concluded that Acu: TENS can be
finding shows similar finding as that of John Zhang
used as an alternative method to reduce blood pressure
MD et al on 27 subjects with normal to mild
in middle aged borderline hypertensive patients.
hypertension treated by Hans electrical stimulation on
two acupuncture points for 30 minutes. They found Conclusion: Acu- transcutaneous electrical nerve
that electrical stimulation of acupuncture points can stimulation causes clinically and statistically significant
reduce systolic blood pressure not the diastolic blood reduction in systolic BP, diastolic BP and mean arterial
pressure in the subjects with normal to elevated blood pressure in patients with borderline hypertensive
pressure6. patients. Conventional therapy group also shows
clinically significant but statistically non- significant
Table 3 shows that the diastolic blood pressure has
reduction in these parameters but to lesser extent than
shown statistically significant reduction in
that caused by Acu- TENS group.
experimental group by 3.04% than control group
(0.92%) Limitation
Our study suggests low frequency electrical 1. Sample size was less.
stimulation of two acupuncture points results in
significant reduction of diastolic blood pressure. Tim 2. Only borderline hypertensive patients were taken.
Williams et al have demonstrated that the stimulation
Conflict of interest- We, the authors declare that
of four selected acupuncture points with current of
there are no conflicts of interest and the study
medium frequency sinusoidal signal of 10,000 Hz gives
presented here is original work of authors.
significant reduction in diastolic blood pressure in
hypertensive patients and also showed an efficacy of Acknowledgement: Nil
electrical stimulation in lowering blood pressure.4
Another study by Kaada B et al suggested that Funding: This project is self funded
significant reduction in blood pressure may be
achieved by low- TENS by central inhibition of REFERENCES
sympathetic activity.7
1. American Heart Association Public Education
Current study shows significant reduction in mean Program Pamphlet: How You Can Help Your
arterial pressure (table 4) in experimental group Doctor Treat Your High Blood Pressure. Dallas,
(3.62%) than the control group(0.67%). F. Jacobsson et Tex: American Hean Association; 1986.
al have demonstrated the effect of transcutaneous 2. API Textbook of Medicine. 8th edition. Page no –
electrical nerve stimulation in patients with therapy 531-537
resistant hypertension and suggested that 4 weeks of 3. Omura Y. Patho- physiology of acupuncture
TENS application may have an additional blood treatment: effects of acupuncture on
pressure lowering properties in hypertensive patients cardiovascular and nervous systems. Acupunct
who did not respond to the pharmacological Electrother Res 1975; 1: 51- 140
treatment.8 4. Tim Williams, Karen Mueller and Mark W
Cornwall. Effect of Acupuncture - Point
Our study showed that there is no significant
difference in heart rate in experimental group (3.58%) Stimulation on Diastolic Blood Pressure in
with comparison of control group (4.66%). Kaada et Hypertensive Subjects: A Preliminary Study -
al7 and Chauhan et al9 have demonstrated similar PHYS THER. 1991; 71:523-529.
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5. Brown ML, Ulry GA, Stern JA . Acupuncture loci 8. Jacobsson F et al. The effect of transcutaneous
techniques for location. Am J Chin Med 1974; 2, electrical nerve stimulation in patients with
67- 74 therapy resistant hypertension. Journal of human
6. John Zhang MD, Derek Ng, Amy Sau. Effects of hypertension 2000 ISSN 0950- 9240; vol 14,
electrical stimulation of acupuncture points on 837-856
blood pressure. Journal of Chiropractic Medicine 1) A Chauhan; P A Mullins; S I Thuraisingham; G
(2009) 8, 9–14 Taylor; M C Petch; P M Schofield. Effect of
7. Kaada B, E. Flatheim, L. Woie. Low-frequency transcutaneous electrical nerve stimulation on
transcutaneous nerve stimulation in mild/ coronary blood flow. Circulation.1994; 89:
moderate hypertension. Clinical Physiology 694-702
March 1991;11, 161–168,
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DOI Number: 10.5958/0973-5674.2014.00001.X
Effect of Incorporation of Regular Rhythm in Exercises on

Motor Function of Children with Cerebral Palsy
Amruta Nerurkar1, Sujata Yardi2

Associate Professor, Professor and Director, Department of Physiotherapy, Pad. Dr. D. Y. Patil University
1 2
ABSTRACT
Motor learning in a child demands orientation and integration of various cognitive, emotional, sensory
motor and musculoskeletal systems. Therapy has focused on allowing optimal arousability, sensitivity
and alignment of these systems to create internal and external environments conducive to motor
learning in children with cerebral palsy. Music and especially rhythmic musical cues have been used
in individuals with Parkinson's disease, stroke and autism with relatively less research being
performed in children with Cerebral Palsy. In the current study, 12 children with cerebral palsy ( age
group of 6 to 12 years ) Age Group of 6 to 12 years with Intelligence Quotient of 80 or above (
Wechsler scale), without any auditory dysfunction and with severity of disability on GMFMCS graded
as II, III and IV were divided into 2 groups of 6 each. The experimental group received 6 weeks of
training in activities performed in synchronization with regular beats played by a Digital Metronome.
This was done in addition to conventional Physiotherapy which was received by both Groups. Motor
function was assessed on Gross Motor Function Scale 66 and Jebson Taylor Hand Function Measure.
Results: Between Group analysis was performed for Differences in GMFM scores using Man Whitney
U test which showed significantly greater change in % of Gross Motor Function (p value 0.038).
Between Group analysis revealed a statistically significant difference in changes observed on Jebson
Taylor hand function Measure in all areas in terms of time taken.
This suggests that children with cerebral palsy without mental retardation can be trained with
rhythmic musical or non musical cues to improve their feedforward planning strategies which may
reflect on their ambulatory skills as well as their speed of activity.
Keywords: Regular rhythm, Cerebral Palsy, Motor Function
INTRODUCTION present state of being in time and space. This is called

volition which requires sensing the demand to move
Cerebral Palsy is an umbrella term covering a and a belief that movement can be performed.
group of non progressive, but often changing motor Performing a motor activity is further actuated by
impairment syndromes secondary to lesions or being able to activate the necessary motor units with
anomalies of the brain arising in the early stages of reasonable precision which means disengaging from
development. all other possible activations in favour of the
appropriate motor program.
Children diagnosed with cerebral palsy face
constraints to their motor development as a result of a Rhythmic musical stimuli have been used in
spectrum of structural and functional impairments. rehabilitation of motor function in the past. Studies
Any aspect of development if considered is a result of done to train upper extremity function in adults with
integrated activity of various bodily systems. Learning hemipaeresis have used rhythmic musical cues in the
a new motor skill demands the desire to change the form of playing of musical instruments and have
18. Amruta--87--.pmd 87 5/10/2015, 5:14 PM

shown a more specific lateralization of Motor areas as Motion Experience’. If results of behavioral,
opposed to only activation of temporal cortex prior to neuroimaging and primate physiology studies are
the course of therapy.1 integrated, it has been hypothesized that rules about
the internal emotional states of the musician , motor
Rhythm has been defined as a pattern of events in plan of the musician and the end results get encoded.
time or/and space. Rhythm is said to be regular when These are then revised based on the current experience
every two events within this pattern are equally and thus the perceptual space gets updated. 4
spaced. A research project on Human perception of
Rhythm by John Simpson described rhythm as being Mirror neuron system has also been purported as
inherent to human nature. The human tendency to being the basis of social communication and empathy
move in tandem with rhythmic beats is hypothesized and research on children with Autism has highlighted
as being associated with reminiscence of intrauterine activation of mirror neurons in correlation with
experience when the baby receives auditory stimulus improved social cognition.1-5
and vestibular- somatosensensory stimulus
simultaneously or in close succession in the form of In the present study, regular rhythmic beats were
mother’s heart beats. It has also been hypothesized that presented using a metronome and subjects were made
every time the brain receives a vestibular input, there to perform activities in tandem with the beats. Musical
will be an alteration in posture or balance unless some patterns were not used to avoid the influence of music
motor activity counteracts the stimulus. Sound or its preference on the results.
variations get transmitted by way of compressions and
rarefactions set in the air. These stimulate the METHODOLOGY:
semicircular canals and hence the brain initiates some
Study Design: Experimental
motor activity to avoid a sensory chaos6,8.
12 children diagnosed with cerebral palsy with an
Studies have been done first on maquaque
IQ score of > 80 on Weschler’s scale were included in
monkeys and then on humans which have identified
the study. These children were selected from the
a group og neurons in the human brain which have
Physiotherapy OPD of Pad. Dr. D. Y. Patil Hospital
been titled the ‘Human Mirror Neuron System’. These
and Research Center and NASSEOH (Chembur,
neurons are said to form the basis of perceptual
Mumbai). Children with auditory deficits were
learning which means they get activated when an
excluded from the study. A written informed consent
activity is observed as well as performed. These
was taken from the parents of the children. The type
neurons are present in the posterior parietal and
of sampling used was stratified random ie they were
inferior frontal cortex.4. These are also found to be the
divided into 2 groups of 6 each with respect to the
basis of auditory motor coupling. It has been observed
severity of motor impairment and type of Cerebral
that the frontoparietal mirror neurons get activated
Palsy. Both groups were assessed for their Gross Motor
when a certain piece of music is heard along with the
function using Gross Motor Function Measure 66 and
temporal i.e. the primary auditory area, the limbic lobe
for their fine motor function using Jebsens Taylor Hand
and the insular cortex. By way of the Mirror neurons
function scale.
there is activation of motor areas that are
commensurate with the kind of music or beats played. Both groups were given conventional training
Thus the loudness or pitch variations will change the making use of the principles of Neurodevelopmental
activations. Just the way an observed activity creates techniques, Motor learning, Roods and Proprioceptive
within the observer a certain prediction of the future neuromuscular Fascilitation with respect to their
events, listening to a piece of music is suppose to make impairments. Additionally the experimental group
the listener aware of a plan of action in terms of was given training of certain movements and activities
intention, result, short term objectives, kinematics and which were supposed to be performed in
muscle work. When the performer actually performs synchronization with the rhythmic beats played on a
the activity in tandem with the music or actually tries metronome. The activities differed in range and
to create the same music, similar motor areas in the amplitude with respect to the specific level of function
brain get activated although at variable levels of available but did not differ largely from the
precision. This experience of sharing the motor plan conventional exercises. Thus the independent variable
of the music creator is called as ‘Shared Affective was incorporation of regular rhythm in exercise. Scores
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on GMFM 66 and Jebsens Taylor hand function t test for Jebsen Taylor hand function measure. For
measure were done after 6 weeks of therapy for both comparing the differences between the 2 groups over
groups. 6 weeks, Mann Whitney U test was used for Scores on
GMFM 66 and unpaired t test was used for Jebsen
RESULTS Taylor hand function measure.
2 children, 1 in each group had hemiplegia, hence There was a significant improvement in GMFM66
could not perform 2 of the tasks : checkers, turning scores ( Fig 1) and significant decrease in time taken
cards with the affected hand. Their readings on the for each task in Jebsen Taylor Hand Function Measure
affected side for the 2 activities have not been for both groups . Experimental Group ( treated using
considered. Metronome) showed significantly greater
improvement on GMFM66 (Fig 2) and significantly
Data Analysis was done using Graph Pad Instat. greater decrease in time taken for all 7 activities of
Statistical tests used for within Group comparison Jebsen Taylor hand function (Table 1) measure as
were: Wilcoxon matched test for GMFM66 and paired compared to the control group.
Fig 1: Comparison of GMFM scores between 2 groups. Fig. 2: Comparison of % change in GMFM between the 2 groups.
Control: p value= 0.025 P value= 0.038
Exp Gr: p value= 0.0156
Table 1: Comparison of change in Jebson Taylor timings in seconds between the 2 groups
Groups writing feeding Light cans Heavy cans Small objects checkers cards
Control 26 7 10 11 8 8 9
Exp 62 10 20 20 18 16 26
P value 0.0251 0.0146 0.0004 0.0031 0.0015 0.0001 0.0021
DISCUSSION Considering the results of the previous studies

associated with use of rhythmic musical cues, one can
The results show a significantly better explain the results of the present studies. The theory
improvement in Gross Motor Function as measured of Shared Affective Motion Experience1,2,3,4 if integrated
on GMFM 66 and Fine motor function as measured with the results presently achieved, tells that the
by Jebsen Taylors hand function measure in the group rhythmic auditory cues used for training get perceived
trained with exercises done on Regular rhythmic cues as a structure of events i.e. a group of 3,4 or 5 beats.
in addition to conventional training as compared to The commencement of the next set of beats of the
the conventionally trained group. metronome was signalled by a change in pitch. This
18. Amruta--87--.pmd 89 5/10/2015, 5:14 PM

coupled with the regularity of rhythm, over a period suggested that the arousability of these children got
of time created a model of predictability in the modulated with rhythmic musical cues, thus allowing
hierarchy of motor control. This happens via the activation of the mirror neurons essential for social
Human Mirror Neuron System4, 10-14, that is known to empathy and perceptual learning. This data can be
get activated while observing an action being extrapolated to our study theoretically with the
performed as well as while listening to a piece of music. hypothesis that rhythmic cues could have modulated
This means that while listening to a set of auditory the arousability of children with Cerebral Palsy
musical cues, the listener starts recognising the allowing better attention in the task being trained. This
intentions of the person creating the music. The motor can also prevent emergence of abnormal motor
action performed in order to create the music is patterns that are known to get exaggerated in moments
vaguely perceived by a novice (individual not trained of mental stress and emotional excitement.
on music) and this allows the listener to reconstruct
various elements of the cues in his or her mind. This is In a thesis by John Simpson6,8 it was explained that
called echoic memory of the cues. This is coupled with Human beings have an innate tendency to move in
the motor plan visually or kinaesthetically imagined tandem with regular rhythmic auditory cues because
by the listener. This enables prediction of the this brings back memory of the intrauterine experience
movement most appropriate to the auditory cues in of mother’s heart beats being perceived along with the
terms of its Intention (end point), Short term goals vibrations generated by the myocardial contraction.
(parts of the activities), Kinematic attributes (amount Thus auditory motor coupling comes naturally to the
of movement) and the muscle work. Thus the human brain. This also makes such training more
movement gets planned via the Mirror neuron system attractive for most children as well as adults.
in anticipation of the next beat. The performance then These theories can help explain the results of the
updates this framework with every subsequent present studies. However, further research can help
repetition. The top down perceptual framework of decipher the precise role of Mirror neuron system
movement or activity gets updated with the ongoing activations (assessed by neuro-imaging) in children
or Bottom up perception of the performance17. with cerebral palsy.
In the individuals trained in our study, the basic
biomechanical considerations, visual orientation and CONCLUSION
sensorimotor challenges remained largely the same for
Incorporation of Regular rhythmic auditory cues
both groups19. The experimental group however was
in exercise helps improve gross motor function as well
additionally trained for activities performed in
as time taken to perform fine motor tasks in children
synchronisation with rhythmic auditory cues, thus
with Cerebral Palsy without Mental retardation.
sensitising them to the demand of prediction, planning,
Research can be extended by studying such effects in
execution and error correction in a more structured
children with deficient cognitive control. This will
manner and more intensively as compared to the
reveal the efficacy of musical or non-musical cues in
control group. This slight addition was shown to result
getting the child organised in terms of arousal and
on better gross motor function and less time in
attention and the subsequent planning and error
performing activities on Jebsen Taylor hand function
correction. Studies need to be conducted on a bigger
measure. The theory explained above also means that
sample which will improve the external validity of the
the individuals in the experimental group relied on
results.
their feed forward strategies in addition to feed back,
i.e. made better use of their recall and recognition Conflict of Interests: Nil
schema in acts of simultaneous and successive
processing18. Source of Funding: Self
In an earlier study, children with autism7,11 were Acknowledgement

shown to have better activation of the mirror neuron 1) Staff of Department of Physiotherapy, Pad. Dr. D.
system with simultaneous improvement observed in Y. Patil University, Nerul, Navi Mumbai.
social cognition. Lack of activation of the MNS was
purported to be the basis of social handicaps in 2) Staff of National Society of Equal Opportunities
children with autism. But the results of this study for Handicaps Chembur, Mumbai.
18. Amruta--87--.pmd 90 5/10/2015, 5:14 PM

Ethical Clearance: Taken from the Ethical Committee, 8. The Beat Alignment Test (BAT): 2007, Surveying
Pad. Dr. D. Y. Patil Hospital and Research Center. beat processing abilities in the general
population, John R. Iversen and Aniruddh D.
Patel, The Neurosciences Institute, CA, San
Diego, USA
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1. P.Janata, B. Tilmann & J.J Barucha.S, LBengstonn
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F. Ullen, H.H. Ehrson et al.Listening to Music
Laboratories, New Haven, Connecticut.
Activates Motor& Pre-Motor Cortices; Cortex
10. Journal of Cognitive Neuroscience 2008, 20:2, pp.
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2. MichealH.Thaut( (Colorado State University),
Auditory–Motor Synchronization is Modulated
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Sebastian Kirschner *, Michael Tomasello
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Sciences1169.1(2009):395-405.
Thaut, M.H. (1999).
4. Overy, Katie &Istvan Molnar-Szakacs,”Being
13. Brain Networks for Integrative Rhythm
Together in Time :Musical Experience and the
Formation. PLoSONE 3(5): e2312. doi:10.1371/
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Danes, J. N. (2008).
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Componenets of the Perception of Musical
Thaut, M.H. (2006). In. Miell, D., MacDonald, R.,
Sequences- A Cognitive Neuroscience Analysis
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503. Cognitive and brain mechanisms in sensory
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Physiological and Psychophysical Research into
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DOI Number: 10.5958/0973-5674.2014.00001.X
A Study to Evaluate Influence of Attentional Cognitive

Tasks on Postural Sway in School Going Children in
Standing Posture Using Force Platform
Jadeja Urvashiba Narendrasinh1, T Joseley Sunderraj Pandian2

1
Lecturer and Guide Pediatric, Ahmedabad Physiotherapy College, Ahmedabad, 2Associate Professor and Guide,
Srinivas College of Physiotherapy, Mangalore
ABSTRACT
Background: Cognitive processing plays important role in motor performance. Children at preschool
need to perform motor or cognitive tasks concurrently. This study is intended to measure postural
sway while performing attentional cognitive tasks.
Methodology: This study includes 60 normal children between the ages of 8- 10 years. Postural sway
was measured by force plate.
Results: Influence of attentional cognitive tasks on balance in school going children was calculated
using one way ANOVA repeated measures.
Interpretation & Conclusion: There is influence of attentional cognitive tasks on postural sway in
children age group between 8-10 years.
Keywords: Cognitive Tasks, Force Plate
INTRODUCTION relation to the base of support (BOS) to prevent falls

and complete desired movements.3, 4, 5
Postural control during normal upright stance in
humans is a well-learned task. Hence, it has been Various system contributor to postural control
argued that it requires very less attention.1 However, which are_3
many studies have recently shown that postural
1) Musculoskeletal
control is modified when cognitive task is executed
simultaneously.2 This study examined postural control 2) Internal representation
modification when a cognitive task of varying
difficulty levels is added. 3) Adaptive mechanisms
Balance is a dynamic process involving establishing 4) Anticipatory mechanism

equilibrium between destabilizing and stabilizing 5) Sensory strategies
forces.3 it is the process by which postural stability is
maintained. Postural stability is defined as the ability 6) Individual sensory system
to maintain or control the center of mass (COM) in
7) Neuromuscular synergies
Peripheral inputs from visual, somatosensory and

vestibular system are available to detect the body’s
Urvashiba Narendrasinh Jadeja
position and movement in space with respect to
Lecturer and Guide Pediatric
Ahmedabad Physiotherapy College gravity and environment.3 Nashner first suggested that
Bopal Ghuma Road, Bopal, Ahmedabad, Gujarat posture during quite standing is controlled by sensory
E-mail: urvashi_sweet2007@yahoo.com feedback using a closed loop (Feedback) system
Mobile number : 09099636906 dependent on visual and proprioceptive information.6
19. Urvashi Jhala--92--.pmd 92 5/10/2015, 5:14 PM

This feedback system appears at a very early age, different from that obtained from simple upright
as continued by evidence showing that sensory standing..25
perturbation can generate postural response synergies
in children as young as 15 to 30 months of age.7 A dual task procedure was developed to estimate
the level of automaticity of a quite upright standing
An open loop (Feed forward) system appears to be task.26 Dual task paradigms typically are used for two
used during dynamic tasks. Disturbances in postures different purposes, one is a motor task and other is to
are predicted and the body makes appropriate examine the effect of concurrent cognitive or motor
adjustments through anticipatory postural performance. Type of focal task could influence the
adjustments to maintain stability.8 proficiency of dual task performances.23
The overall function of the balance system is The limits of mobilization potential of the cognitive
stability and function, achieved through the integrative processes constrain the individual to share attentional
CNS system of control. The reactive control occurs in resources when carrying out several tasks
response to external forces displacing the COM of simultaneously. 27 The cognitive tasks involved
movement of BOS; and the proactive control that identifications processing of visual and verbal stimuli
occurs in anticipation of internally generated similar to those children encountered during their
destabilizing forces imposed on the body’s own daily activity.15
movement.13,14
A child’s daily routine in the school environment
Postural adjustment requires cognitive processing will often require performing motor and cognitive
and more attention and Cognitive processes broadly tasks simultaneously.7 Children with many types of
include, attention, motivation and emotional aspects disabilities ranging from learning disabilities with mild
of motor control that under lie the establishment of motor problems to CP with more severe motor
goal. Attention described as the capacity or resources problems have been shown to have dysfunction of
for processing information.15 postural control.28 So, development of postural control
under concurrent conditions in the child that is
The cognitive processes, via executive processes, typically developing will lead to improved
controls the mechanisms of attention, activation, and rehabilitative strategies for children with neurological
inhibition, the aim being to focus on relevant dysfunction who have altered sensory, motor and
information and to manage attention sharing between perceptual system.15
the different tasks.
An understanding of the effect of different cognitive
Using a dual task methodology, the investigator
task may assist with development of guidelines for the
showed that postural sway increased with increasing
progression of motor learning activities.15 Increased
attentional demands of concurrent cognitive tasks,
understanding of the effect of divided attention on
with most difficult task having the greatest influence
motor performance may assist physical therapists in
on sway.20
incorporating attentional factors in to their
This study includes mainly 5 tasks which are examination and intervention techniques.23
standing still, reading task, counting backwards,
Cognitive load can lead to an improvement in
visual-verbal task and auditory-verbal task. Counting
task was used as mental task and reading task visual- balance performance, that during disruptive postural
verbal task and auditory-verbal task which requires situations, this improvement can be linked to a
external sensory information. All the tasks require reduction in exploratory movement behavior. The
attention as well as sensory information during quite processing involved in performing a cognitive task
standing. while walking may influence walking patterns in
children who are developing typically.24
The modified stroop test is used because the test
demands a considerable amount of focused attention, AIM OF THE STUDY
few instructions and shows relatively learning effects.
Simultaneous performances of modified stroop test To find the influence of attentional cognitive tasks
and balance task would provide information that is on postural sway in Normal school going Children.

METHODOLOGY Reading
Material and Method Subjects standing still while reading 2nd grade level
sentences projected on the wall facing the child at the
Normal healthy school going children from rate of 5 seconds for each sentence.
Government school, Saint Rita, Joy land and
Ganapathy School Mangalore. A Visual-Verbal (Stroop Test)
The cognitive exertion was based on naming in a

METHOD OF COLLECTION OF DATA
clear, the color of the writing of the word, itself
60 children from various schools participated in the meaning another color.
study, both boys and girls in the age group between
An Auditory Verbal
8-10 years. In each age group, there were 10 boys and
10 girls. To compare a listening word meaning a listening
side and the identical the subject will say “right”
Inclusion Criteria
otherwise the subject will say “wrong”. These 5 tasks
1. AGE: 8-10 years. (Normal healthy children.) were analyzed on force plate to measure postural
sway.
2. Children those who walk independently.
Table 1: Descriptive statistics for ap and ml postural
Exclusion Criteria sway (cms) of cognitive tasks
1. Any orthopaedic or neurological impairment. Tasks Mean SD N

1. S S 1.9453 .61020 60
2. Any congenital and structural abnormalities. 2. R T 3.6065 1.62190 60
3. C B 3.0507 1.37795 60
3. Acute illness (fever, cough)
4. V V 3.4787 1.47278 60
4. Postural deviations. 5. A V 3.2648 1.18003 60
Table 2: Descriptive statistics for max standard

Sampling: purposive sampling.
stability in % of cognitive tasks
MEASUREMENT PROCEDURE Tasks Mean SD N

1. Standing Still 15.5602 4.06747 60
Subjects were instructed to remove their shoes but 2. Reading Task 33.8367 19.34759 60
not socks.15 seconds practice trail were administered 3. Counting Backwards 28.6900 16.92161 60
for each task. After practicing the trails, the subject was 4. Visual-Verbal 32.6000 17.53248 60
asked to stand on the force plate form. Subjects were 5. Auditory-Verbal 28.5950 12.09679 60
performed three, 30 secs trails of each task.
Table 3: Descriptive statistics for stability score in %
Measurement of each task was taken by force platform
of different cognitive tasks
with readings of AP-ML postural sway, Maximum
standard stability and stability score. Tasks Mean SD N
1. Standing Still 84.3267 4.61834 60
Subject’s Position: Standing. 2. Reading Task 66.1550 19.20263 60
3. Counting Backwards 71.3100 16.92161 60
TASKS
4. Visual-Verbal 67.3900 17.52371 60
Standing Still 5. Auditory-Verbal 71.2500 12.36066 60
Subjects were asked to stand with their feet together DISCUSSION

and arm alongside the trunk while looking at an
image projected on a wall seven feet away. This study was conducted to investigate the
influence of attentional cognitive tasks in school-going
Counting Backwards children and study utilized dual-task methodology to
Subjects were instructed to stand still while determine the interaction of cognitive tasks and
counting backwards out loud. postural stability, as indexed by COP excursion.

The performance on the focal tasks was measured children adapt their postural stability under conditions
to determine postural sway in children by using force of increased attentional demands by reducing sway
platform. The application of dual-task methodology range and sway variability.6
in children frequently has involved investigation of
the tasks, attentional demands of various cognitive Using a dual tasks methodology, the investigator
tasks. showed that postural sway increased with increasing
attentional demands of concurrent cognitive task, with
This is important for physical therapists to the most difficult cognitive task having the greatest
understand how age-related differences in the influence on the sway. 6
cognitive abilities may influence a child’s ability to
combine cognitive and motor tasks. Dual-task Similarly Huang et al reported that children in their
methodology is often used to examine the role of study demonstrated slower gait speeds with decreased
cognition in motor performance from two cadence and step length during simultaneous
perspectives: one is to assess the attentional demands performances of three different cognitive tasks (visual
of motor skills; the other is to investigate the effects of identification, auditory identification and
divided attention on motor skills.23 memorization) than during a single task walking
condition.15
In our study, standing still task, shows stability
score of 84.33% with AP-ML postural sway of 1.95cms It appears from this suggestion and our findings
and maximum standard stability of 15.56%.In standing that therapists should incorporate more opportunities
still task adding cognitive component like standing still to practice dual-tasks in the clinical setting to better
with reading task showed increased postural sway and prepare children to adequately respond and adapt to
decreased stability score. their everyday environment.
Counting backward task showed AP-ML postural It is postulated that, with practice and maturation,
sway of 3.05cms with stability score of 71.31% but children develop different strategies for postural
compared to other task it has got better postural stability to accommodate the changing level of
stability. Reading task showed increased AP-ML attentional demands in a given task.6
postural sway of 3.61cms with increased maximum
Our findings therefore suggest that children may
standard stability of 33.84% with decreased stability
be doing a different strategy than adults to adjust their
score of 66.16%.
postural sway during cognitive tasks.
In visual-verbal task, showed postural sway of
These findings may be understood in terms of
3.48cms with stability score of 67.39%, which is lesser
as compared to reading task. In auditory verbal task, controlling “degrees of freedom”. When faced with
deterioration observed, there is decrease in stability performing a new task, children may have responded
score of 71.25% and increase in AP-ML postural sway initially by “freezing” degrees of freedom, making the
of 3.26cms with increase in maximum standard task easier to perform and due to that there is increase
stability of 28.60% . in postural sway by constricting the movements. With
practice through repeated trails, children may then
Therefore, while performing visual-verbal and release additional degrees of freedom as they become
auditory-verbal tasks, the visual or auditory working more familiar with the task and there is improvement
information constitutes additional external landmarks in balance.6
for task performance and this attentional division
between postural control and tasks which requires CONCLUSION
sensory stimuli like vision and audition results in
deterioration in postural performance.35 There is influence of atentional cognitive tasks on
balance in school going children
Results of Yvette Blanchard et al suggests that there
is influence of concurrent cognitive task on postural Acknowledgement: First I’d like to thank the
sway in children and they reported that there is Almighty Lord for his blessing throughout my study.
increase in sway range and sway variability while I’d like to take this opportunity to thank my Parents
performing tasks and with practice, children’s sway and my husband for their constant support,
range and sway variability decreased. It appears that encouragement and guidance.

Conflicts of Interest: Nil 15. Huang,Hsiang –ju. Effects of different concurrent

cognitive tasks on Temporal-distance gait
Fundings: By the Institute.
variables in children.Pediatric Physical
Ethical Clearance: It was Given by commitee therapy.vol.15(2) ;2003 :105-113.
16. Smith EE. Storage and executive processes in the
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17. Gurfinkel. Perceptual and automatic aspects of
1. kingNashner LM, fixed patterns of rapid postural postural body scheme. Oxford university
responses among leg muscles during stance. Exp press;1991:147-62.
Brain Res.1977;30:13-24. 18. Allport A. Visual attention. Posner MI,
2. Myelene C. Dault. Postural control and cognitive Foundation of cognitive science;1989:632-682.
task performance while balancing on different 19. Neumann O. Beyond capacity: a functional view
support surface, Gait and Posture. 2001;14:248- of attention. Heuer H Sanders AF, perspective
255. on perception and action.1987:361-394.
3. Shumway-cook A. Motor Control Theory and 20. Geraldine L.Pellecchia. Postural sway increases
Practical Applications: Williams and with attentional demands of concurrent cognitive
Wilkins;1995. task. Gait and posture 2003;18:29-34.
4. Horak FB. Clinical measurement of postural 21. T.Mulder.A process oriented model of human
control in adults. Physical therapy 1987; 67: 1881- motor behavior: towards a theory based
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5. Shumway cook A, Assessment and treatment of therapy.1991;71:157-164.
balance deficits. Motor control and physical 22. Schmidt RA.Motor control and learning: A
therapy : theoretical framework and practical Behavioral emphasis, 2nd ed. Champaign, I II:
applications. 1991 :123-137. Human kinetics publishers; 1988.
6. Yvette Blanchard. The influence of concurrent 23. Huang HJ, Mercer. Dual-task
cognitive tasks on postural sway in methodolody.Application in studies of cognitive
children.Pediatric physical therapy, 2005(17):189- and motor performance in adults and
193. children.pediatric physical therapy 2001;13 :133-
7. Shumway-cook A. The growth of stability:
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postural control from the developmental
24. D.L.Weeks. Interaction between attention
perspective. J Mot. Behav.1985;17:131-147.
demanding motor and cognitive tasks and
8. Massion J. Movement, Posture and equilibrium:
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coordination.prog.Neurobiol.1992;38:35-56.
25. I.Melzer.Age related changes of postural control:
9. Donna Cech, Functional Movement
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10. Nashner LM. Adapting reflexes controlling the
26. Neumann O, Sanders AF. Cognition and motor
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11. Staply P Pozzo.The role of anticipatory postural
adjustments during whole body reaching 27. Kerr B. Condon. Cognitive spatial processing and
movements. Neuroreport 1998;9:395-401. the regulation of posture.J Exp Psychol Hum
12. Suzane Tink Martin. Neurological Intervention Percept Perform.1985;11:617-22.
For Physical Therapist, 2000. 28. Sarah L. Westcott. Evaluation of postural stability
13. Patricia C. Montagomery. Clinical application for in children: current Theories and assessment
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14. Susan B O’Sullivan et al. physical rehabilitation 29. J.F. Stins. Effects of expertise, vision, cognition.
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30. Hyeong-Dong Kim. The effect of dual task on with and without DCD, Gait and
centre of pressure trajectory during obstacle Posture.2008;27:347-351.
crossing. J.Phys.Ther.Sci.2009;21:99-104. 34. Yvette Blanchard. The influence of ambient
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executive function of attention.2008;40:90-102. 35. Mallaury jamet. Age related part taken by
32. Dinah S. Reilly.Attention and postural control in attentional cognitive processes in standing
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33. Youcheved Laufer. Effects of a concurrent
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DOI Number: 10.5958/0973-5674.2014.00001.X
The Immediate effect of Chest Mobilization Technique on

Oxygen Saturation in Patients of COPD with Restrictive
Impairment
Dharmesh Parmar1, Anjali Bhise2

1
1Lecturer, Ahmedabad Physiotherapy College, Gujarat, 2Principal, Govt. Physiotherapy College, Civil Hospital,
Ahmedabad, Gujarat
ABSTRACT
Objective of Study: To improve the Oxygen Saturation in patients of COPD with restrictive
impairment by chest mobilization tech..
Background: Chronic Obstructive Pulmonary Disease is a primary lung disease but as it advances,
there is restriction in chest wall mobility which decreases pulmonary functions and Oxygen saturation
of lung. So purpose of this study is to assess the immediate effect of Chest Mobilization on improving
the Oxygen Saturation.
Materials and Method: An Experimental study was conducted on 30 COPD patients having vital
capacity <80%, to assess the pre and post differences in SpO2 by applying chest mobilization technique:
Rib rotation, Chest wall rotation, Lateral flexion of chest wall, Chest wall extension and Pectoralis
major muscle stretching.
Result: For within group analysis, comparison of data for SpO2 values were done using paired t test
and for between groups analysis, comparison of data for SpO2 values were done using unpaired t
test. Statistical analysis showed that there was significant improvement in SpO2 after application of
chest mobilization technique.
Conclusion: It can be concluded from the present study that Chest Wall mobilization has significant
effect on Oxygen saturation in COPD patient who is having restrictive impairment of chest wall in
later stage of disease.
Keywords: Chest Mobilization, COPD, Oxygen Saturation (SpO2)
INTRODUCTION pulmonary component is characterized by airflow

limitation that is not fully reversible. The airflow
The term Chronic Obstructive Pulmonary Disease
limitation is usually progressive and associated with
(COPD) refers to chronic disorder that disturbs airflow.
an abnormal inflammatory response of the lung to
COPD is a major cause of morbidity and mortality in
noxious particles or gases.2
INDIA1. COPD is a preventable and treatable disease
with some significant extrapulmonary effects that may The common task force statement of The American
contribute to the severity in individual patients. Its Thoracic Society (ATS) and The European Respiratory
Society (ERS) adds to this definition that: “COPD
is…..primarily caused by cigarette smoking.” 3 Both
Urvashiba Narendrasinh Jadeja
GOLD and ATS/ERS agree that COPD is to be
Lecturer and Guide Pediatric
Ahmedabad Physiotherapy College suspected when there is a history of exposure to risk
Bopal Ghuma Road, Bopal, Ahmedabad, Gujarat factors for the disease, chronic cough, sputum
E-mail: urvashi_sweet2007@yahoo.com production and/or dyspnoea and that diagnosis must
Mobile number : 09099636906 be confirmed by spirometry. When forced expiratory
20. Dharmesh--98--.pmd 98 5/10/2015, 5:14 PM

volume in one second (FEV1) divided by forced pressure/effort relationship, leading to fatigue and
ventilator capacity (FVC) is < 70%, even after increased dyspnoea.10 To avoid the distressing feeling
administration of a bronchodilator, the diagnosis is of dyspnoea, the patients with COPD tend to avoid
confirmed1. In patients older than 70 years a somewhat physical exertion and adapt a more sedated lifestyle
lower ratio (< 65%) has been suggested. 4 Some than healthy elderly subjects.11 This, in turn, leads to a
guidelines claim that besides FEV1/FVC < 70%, the vicious cycle of reduced exercise capacity inducing
FEV1 should be < 80% of predicted value for diagnosis increased dyspnoea during exercise which leads to a
of COPD.5 further avoidance of exercise and so on.
Normally, people take deep breaths or sigh Exercise capacity is impaired in COPD, both peak
regularly. These actions stretch the respiratory exercise capacity and functional exercise capacity.
structures. Patients of COPD with chronic respiratory Besides lung hyperinflation and physical inactivity,
muscle weakness have reductions in lung volumes and ventilation-perfusion mismatch, hypoxemia, cardio-
vital capacity (VC) and they may have decreases in vascular problems and muscular changes contribute
lung distensibility with lung volume restriction.6 As to the reduced exercise capacity. Functional exercise
shown by Mizuri et al, failure to fully expand the lungs capacity is one of the key prognostic factors of
causes increases in lung tissue and chest wall elastance morbidity and mortality in COPD.12 and correlates
and decreases in compliance. strongly with physical activities in daily life.11
The total mechanical work of breathing (WOB) is Mobilization of rib cage joints appears as a specific
the sum of the work of overcoming both the elastic aim for physiotherapy, as rib cage mobility seems to
and frictional forces opposing inflation. In healthy be reduced with obstructive lung disease. Chest wall
adults, about two thirds of the WOB can be attributed mobilization improves mobility of chest wall, reduces
to elastic forces opposing ventilation. The remaining respiratory rate, increases tidal volume, improves
third is due to frictional resistance to gas and tissue ventilation gas exchange, reduces dyspnea, decreases
movement. In diseased states, the WOB can work of breathing and facilitate
dramatically increase. In patients with restrictive lung relaxation.13,14,15,16,17,18,19,20,21
disease, work is the integration of the volume-pressure
breathing curve. The increase in the WOB is a function MATERIALS AND METHOD
of tissue elastance and an inverse function of
pulmonary compliance.7 Study Design
Failure to take periodic deep breaths can change Experimental study (Before and after with control), one
alveolar surface forces and increase the tendency for time study
alveolar collapse. Gross muscle weakness alters the
Dependent Variable: Oxygen Saturation,
passive recoil of the thoracic cage, modifying the
neutral position at which lung and cage recoil Independent Variable: Chest Mobilization tech.
pressures are balanced. 8 This result in altered
inspiratory muscle length-tension relationships. The Sample Design: Random sampling
lungs and chest walls are susceptible to the effects of Sample Size: 30 Patients
incomplete regular mobilization. The tendons and
ligaments of the rib cage and the costovertebral and Study Setting: General Hospital, Ahmedabad
costosternal articulations stiffen, and the latter
ankylose, as the intercostal and other respiratory Selection Criteria
muscles become fibrotic and contracted.8 Inclusion Criteria
Expiratory airflow is limited because of the • Patients diagnosed as having COPD by the
obstruction, leading to air trapping and hyperinflation. physician. The diagnosis was confirmed by COPD
This accentuates when the minute ventilation or questionnaire.
respiration rate is increased, for example during
exercise.9 The hyperinflation induces increased strain • Patients with COPD with restrictive impairment
on the respiratory muscles, which are forced to work (VC<80%)
in a limited range of movement with negative
• Age: >40yrs
20. Dharmesh--98--.pmd 99 5/10/2015, 5:14 PM

• Sex: male COPD Questionnaire and PFT of all these patients

were done. These patients were divided randomly into
• Patients who are able to comprehend commands
two groups (15 in each group), one group was
• Patients who are willing to participate experimental and other was control group. Chest
mobilization techniques and Breathing exercises are
Exclusion Criteria
given to experimental group an only breathing
• Patients with unstable vital parameters exercises were given to control group. Oxygen
saturation values were measured before and after
• Those who have active lung infection
giving chest mobilization technique. 3 Repetitions of
• Patients with congenital heart disease, ischemic each maneuver was done.
heart disease, rheumatic heart disease
Chest Mobilization tech. are13:
• Patients who have recently taken bronchodilator
drugs. • Rib rotation
• Patients with continuous Oxygen therapy • Chest wall rotation
• Patients with artificial ventilation • Lateral flexion of chest wall
• Sex: Female Patients
• Chest wall extension
Materials: Assessment format, COPD Questionnaire,
Reliable Ambulatory Pulse Oxi meter, Stethoscope, • Pectoralis major muscle stretching
Pencil, Pulmonary Function Test
RESULT
Outcome Measure
30 patients, 15 in each group, were taken in study
• Pulse Oximetry (SpO2)22,23: Pulse oximetry is a non-
invasive method allowing the monitoring of the Group A: Chest mobilization and Breathing exercise
oxygenation of a patient’s hemoglobin. A sensor
is placed on a thin part of the patient’s anatomy, Group B: Breathing exercise only
usually a fingertip or earlobe, and a light
containing both red and infrared wavelengths is For within group analysis, comparison of data for
passed from one side to the other. Changing SpO2 values was done using paired t test. For between
absorbance of each of the two wavelengths is groups analysis, comparison of data for SpO2 values
measured, allowing determination of the was done using unpaired t test.
absorbances due to the pulsing arterial blood
Table 1: Difference in means of AGE
alone, excluding venous blood, skin, bone, muscle,
fat, and (in most cases) fingernail polish. Based Group A 55.47+5.06
upon the ratio of changing absorbance of the red Group B 57.47+8.22
and infrared light caused by the difference in color
Table 2: Difference in means of SpO2:
between oxygen-bound (bright red) and oxygen
unbound (dark red or blue, in severe cases) blood Before After t-value p value
hemoglobin, a measure of oxygenation (the per Group A 90.60+2.20 92.67+1.79 7.75 <0.0001
cent of hemoglobin molecules bound with oxygen Group B 90.33+1.34 91.00+1.69 2.87 0.0124
molecules) can be made.
Table 3: The mean of differences of outcome measures
PM-60 Ambulatory pulse Oximeter was used for between the groups
measuring saturation of oxygen. SpO2
Group A 2.07+1.03
PROCEDURE Group B 0.60+0.75
30 patients were randomly selected according to The SpO2 mean of differences shows no significant
inclusion criteria. Their diagnosis was confirmed by difference between the groups. (t=4.48, P<0.0001)
20. Dharmesh--98--.pmd 100 5/10/2015, 5:14 PM

DISCUSSION The major limiting factor in present study was

smaller sample size. So future study can be done by
Though COPD is obstructive type of pulmonary taking a larger sample.
disease, as disease progresses, there is stiffening of
chest wall which gives restrictive pattern to the This was a one time study and no further follow
diseased lung. If this little but important thing is up was taken so could not assess the long term effect
missed in the rehabilitation of COPD patient then it of chest mobilization on COPD.
can hamper the progress of rehabilitation as this
restriction alters other physiology of lungs and chest CONCLUSION
wall and it doesn’t allow other rehabilitation protocols
to work in improving the condition of the patient. It can be concluded from the present study that
Chest Wall mobilization has significant effect on
Minoguchi H, Shibuya M, et al. in 2002, in their Oxygen saturation in COPD patient who is having
study “Cross over comparision between Respiratory restrictive impairment of chest wall in later stage of
muscle stretch Gymnastics and inspiratory training” disease.
had concluded that RMSG may have clinically
Chest Mobilization is the definite tool for the
significant benefits, which may be somewhat different
improving condition of the patient of COPD with
from the benefits of IMT, in patients with COPD.24
restrictive impairment of chest wall. So it should be
Kriel, Achmat. An investigation into the immediate included as a part of management in the patient of
effect of rib mobilization and sham laser application COPD with other exercise treatment program.
on chest wall expansion and lung function in healthy
Acknowledgement: I am thankful to the Principal of
asymptomatic males: a pilot study. Dept. of
the Govt. Physiotherapy College, Civil Hospital,
Chiropractic, Durban Institute of Technology.2005.25
Ahmedabad for support and guidance during the
Leelarungrayub D, Pothongsunun P, et al. Acute study. Sincere thanks to patients who participated in
clinical benefits of chest wall-stretching exercise on the study.
expired tidal volume, oxygen saturation, dyspnea and
Ethical Clearance: Taken by committee of institute
chest expansion in a patient with chronic obstructive
pulmonary disease: a single case study. J Body w Mov Source of Funding: By Institute
Ther. 2009 Oct;13(4):338-43.26
Conflict of Interest: There is no conflict of interest
So, in this study, stretching of chest wall muscles
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11. Pitta F, Troosters T, Spruit MA, Probst VS, rehabilitation improves pulmonary function in
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Care Med 2005;171(9):972-7. 22. Schermer T, et al. Pulse oximetry in family
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2005;99(12):1546-54. Oximetry during Exercise in Pulmonary Patients.
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14. Kakizaki F. Shibuya M. et. al.: Preliminary report 25. Kriel, Achmat. An investigation into the
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20. Dharmesh--98--.pmd 102 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Efficacy of Muscle Energy Technique and PNF Stretching

Compared to Conventional Physiotherapy in Program of
Hamstring Flexibility in Chronic Nonspecific Low Back
Pain
Praveen Kumar1, Monika Moitra1

1
Associate Professor, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Mullana, Ambala
ABSTRACT
Objective: The effect of muscle energy technique and PNF stretching in comparison of conventional
physiotherapy on hamstring flexibility.
Background: Hamstring tightness or decrease flexibility is a predisposing cause for hamstring strain,
lumber spine disorders and low back pain. This study aimed to evaluate the effects of Muscle energy
technique (MET) and PNF stretching in improving pain intensity (PI) hamstring flexibility (HF) in
chronic nonspecific low back pain (CNSLBP).
Study design: Randomized Clinical Trial
Setting: MMIPR, Mullana (Ambala)
Method: SUBJECTS; 30 subjects male and female in age group of 20-40 years with hamstring tightness
in chronic nonspecific low back pain were recruited for study. The pre-post outcome measures
included range of motion (ROM) of active knee extension test as measured using Goniometer, and
Pain intensity measurement using Numerical pain rating scale (NPRS). The treatments were given
for five consecutive days a week for total of four weeks.
Results: Results showed that there is significant improvement by MET and PNF stretching in
comparison of conventional group static stretching used in hamstring flexibility in significantly
decrease pain in low back and increase active knee extension range of motion in hamstring flexibility
in three groups.
Conclusion: The result of this study indicates that muscle energy technique , PNF stretching and
static stretching produce a significant improvement in hamstring flexibility. Therefore it is concluded
the MET, PNF and static stretching can be use as an effective therapeutic maneuver for decrease
pain, improving ROM and increase flexibility of tight hamstring in chronic low back patient.
Keywords: Chronic Nonspecific Low Back Pain, Muscle Energy Technique, PNF Stretching and Static
Stretching, Hamstring Flexibility, Active Knee Extension ROM, RCT- Randomized Clinical Trial
INTRODUCTION ankylosing spondylitis, fracture, inflammatory

process, Radicular syndrome or caudal equine
Non-specific low back pain(LBP)is defined as LBP
which is not attributed to recognizable, known specific syndrome (Burton et al 2004).1 Acute LBP refers to pain
pathology, e.g. Infection, tumor, osteoporosis, present for upto 6 weeks. Disorders of the low back
21. praveen kumar--103--.pmd 103 5/10/2015, 5:14 PM

are the leading cause of disability in people younger length of post contraction and length of post
than 45 years of age.2 80% of LBP has been mentioned contraction stretch.11 Several study have investigated
nonspecific.3 It has been estimated that mechanical various flexibility treatment on joint range motion.
disorders of the spine, represent at least 98% of These study have established that PNF stretching and
LBP.4low back pain occurs in people with a wide MET are both effective in improving joint flexibility in
variety of professions, including those involving heavy comparison to control group however ,there is still
labor, repetitive work activities, and extended some conjecture about which is most effective method
sedentary postures.5Ischemia, Trigger Points, Nerve to be used by practitioner.12
Compression and Nerve Entrapment, Structural
Imbalance, Postural Distortion & Dysfunctional Reduced hamstring muscle flexibility has been
Biomechanics are the 5 primary problems that causes implicated in lumbar spine dysfunction, with a
non-specific low back pain.6 number of studies showing a strong positive
correlation between decreased hamstring flexibility
Approximately 90% of adults will suffer from an and low back pain.13
episode of LBP at some time in their lives, 50% will
have a recurrent episode and 5–10% will develop METHOD
chronic and potentially disabling LBP(Andersson GBJ).
Mechanical LBP is one of the common causes of LBP; Participants:
however, there is no clear consensus on the best
The sample consisted of 30 volunteers, male and
treatment for this condition. Conservative treatment
female, with no history of musculoskeletal disease.
may include manipulation, myofascial release,
Their ages ranged from 20 to 40 years. Each volunteer
exercise, modalities, and a number of other treatment
was randomly assigned to one of three independent
options. Conservative treatment often includes
groups: a Muscle energy technique (PIR), PNF
flexibility exercises, especially of the hamstrings.7
stretching (Contract Relax) and control group Static
In patients with NSLBP, it is difficult to assess with stretching in hamstring flexibility in chronic
a clinically performed manual test whether the limited nonspecific low back pain.
ROM can be attributed to increased muscle stiffness
Variables
or decreased extensibility of the hip or the back
muscles. It is also not known whether these muscles The Independent variables were muscle energy
are active or passive during manual testing. Patients technique and PNF stretching and conventional
with NSLBP show similar ROM and fingertoe- ground physiotherapy for hamstring flexibility in chronic
distance as subjects with short hamstrings. In subjects nonspecific low back pain and the dependent variables
with short hamstrings, stretching exercises result in were pain and ROM.
increased ROM and no changes in muscle stiffness.-
Stretching exercises are also applied in patients with Outcome measures
NSLBP.8 Primary outcome measures were pain (measured
Many clinicians support this practice based on the using numeric pain rating scale) and hamstring
theory that normal hamstring length will prevent flexibility measured by universal goniometer.
excessive lumbar flexion during postures that place Study Protocol
the hamstrings in a lengthened position such as
forward bending.9 McGill has shown that increased 30 subjects of chronic nonspecific low back pain
lumbar flexion during forward bending tasks increases were selected according to inclusion criteria and
anterior shearing forces on the spine and increases risk allocated into group A, group B and group C. All the
of injury. Thus, if decreased hamstring flexibility leads patients in both the groups were pre-tested for pain
to increased lumbar flexion during forward bending and hamstring flexibility. After pre-testing subjects in
tasks it may increase the risk of injury to the spine from group A were given muscle energy technique and
mechanical stresses.10 group B were given PNF stretching. Post-test
measurements were done after 4 weeks. The
Various authors have suggested different way of treatments were given for five consecutive days a week
applying MET, by altering the force, duration of for total of four weeks.
contraction, direction of isometrics contraction and

RESULTS
Group A is muscle energy technique, Group B is

PNF stretching and Group C is conventional
physiotherapy in static stretching. The analysis
revealed that there was statistically significant
difference between pre and post scores of NPRS and
goniometer in all groups. Group B is showing more
improvement than group A and C at p value < 0.05.
Fig. 2. Mean, standard deviation of Pre-Post ROM within Group
A, B and C.
PAIN: The mean and standard deviation value of
pre NPRS of Group A was 5.1±0.875, Group B was
5.1.±0.875, and Group C was 5.1±0.875 respectively. The above graph shows pre test and post test scores
No significant difference was found among 3 groups of Knee extension range of motion within group-A, B
in terms of Pre NPRS. The mean and standard & group C. Though there is significant improvement
deviation value of post NPRS of Group A was of Active knee extension ROM in three groups. in the
2.1±0.737, Group B was 1.3±0.483, and Group C was between group comparison, there was significant
2.5±0.527 respectively. Here, significant difference was improvement of group A,B & group C. but significant
found among 3 groups in terms of post NPRS after 4 improvement was more in group B as compare to
weeks of intervention. group A and group C.
ROM: The mean and standard deviation value of DISCUSSION

pre ROM of Group A was 121.6±4.467, Group B was
121±1.886, and Group C was 122.1±1.524 respectively. In the present study the three groups had equal
No significant difference was found among 3 groups number of subjects and show no significant difference
in terms of Pre NPRS. The mean and standard with respect to their age and gender distribution,
deviation value of post ROM of Group A was which could have altered the result of the study. There
131.5±2.415, Group B was 134.4±2.366, and Group C is statistically significant improvement in three groups
was 130.9±2.961 respectively. Here, significant but the group B has shown more significant
difference was found among 3 groups in terms of post improvement in reducing pain and improving
ROM after 4 weeks of intervention. flexibility as compared to the group A and group C
and the result of group A is more significant than group
C. Therefore after the data analysis the result of present
study did not support the null hypothesis and thus
alternate hypothesis was accepted.
The present study suggest that the gains achieved

by MET and PNF stretching might be explained by
autogenic inhibition defined by Ruch and Pattonis
inhibition mediated by afferent fibers from a stretched
muscle and acting motor neurons supplying the
Fig. 1. Mean, standard deviation of Pre-Post NPRS within Group
stretched muscle. Houkand Henneman found that
A, B and C. golgi tendon organs(GTOs) are very sensitive to active
contraction of muscle. During the isometric contraction
with muscles in their lengthened range, a great amount
The above graph shows pre test and post test scores of tension is produced which may stimulate the GTOs
of NPRS within group-A, B & group C. Though there in the hamstring muscle, causing the muscle to reflexly
is significant improvement of Pain in three groups. in relax.
the between group comparison, there was significant
improvement of group A,B & group C. but significant Muscle tightness is one of the limiting factors for
improvement was more in group B as compare to restricted range of motion and reduce flexibility of
group A and group C. joint. Hamstring muscles are more prone for tightness

cause for musculoskeletal problems. This study was In the present study the basis for PNF stretching is
designed to compare the effect of muscle energy theorized to be through neural inhibition of the muscle
technique and PNF stretching on hamstring flexibility group being stretched. The proposed neural inhibition
in chronic nonspecific low back pain patient . reduces reflex activity, which then promotes greater
relaxation and decreased resistance to stretch, and
Nourbakhsh and Arab decrease hamstring hence greater range of movement (Hutton). However,
flexibility is a common finding in low back patient, if Magnusson et al. noted that paradoxically, some
hamstring flexibility is reduce with low back pain. studies have shown PNF techniques to be associated
Improving hamstring flexibility in low back pain with greater electromyography activity in the muscle
patient may allow increase motion of the pelvis around being stretched when compared to a static stretch. Still,
the hip during forward bending, reducing the stresses other research has found PNF techniques to promote
on the posterior structures of the legs and spine and greater relaxation.20
decrease pain.14
This finding is indicating that it is possible to
Li et al,14 found a four weeks program of daily significantly increase range of motion in people with
hamstring stretching lead to an increase hamstring CLBP by use of a 4-week intensive PNF exercise
flexibility. This present study that used to Muscle program. The positive effects of the present training
Energy Technique , PNF and Static stretching to see programs could be attributed to the nature of PNF
the effect of hamstring flexibility in chronic low back exercises, which are designed primarily to maximize
pain pateint and this study will significantly improvements in flexibility. Such exercises take
improvement in flexibility in all group. But PNF advantage of the body’s inhibitory reflexes to improve
stretching technique are more effective than the MET muscle relaxation. This muscle relaxation allows a
and Static stretching. greater stretch magnitude during stretch training,
MET and PNF stretching methods have been clearly which should result in superior gains in flexibility.
shown to bring about greater improvement in joint These results provided further support of previous
ROM and muscle extensibility than passive, static findings on the positive effects of PNF techniques on
stretching, Both in short and long term conducted by hamstring flexibility7, Also supported my study the
study by Sady et al, Wallin et15,16,17,18. The present study effects of sustained stretch and proprioceptive
also suggest that the muscle energy technique neuromuscular facilitation (PNF) stretch techniques on
emphasized on the relaxation of the contractile hamstring muscle activation and knee extension range
component of the muscle while static stretching of motion (ROM) in different athletic populations11.
focused on the non-contractile viscoelastic component. Based on the results of this study, the muscle energy
Thus, our study demonstrated that the MET are the technique, PNF stretching and static stretching are
more effective than the static stretching to improving effective methods in increase hamstring flexibility and
the flexibility of the muscle. decrease pain in chronic nonspecific low back patient.
A comparison of the pre-test and post -test values PNF stretching are more effective than the MET and
of the ROM by active knee extension test and NPRS static stretching in increasing hamstring flexibility.
for the group shown that there was a significant Limitations
improvement of all the group after 4 week. Another
important observation is that there was a significant A large sample size required to make the study
improvement in pain and ROM of group B(PNF more reliable. Our study is limited to two outcome
stretching) as compare to the group A (MET) and measures other outcome measures can also be used.
group C(static stretching). Only pain and knee extension range of motion was
measured and analyzed. The another limiting factor
The finding of our study suggested that there was is that no functional scale is used in this study.
significant difference between muscle energy
technique and static stretching which concurs with
CONCLUSION
other study that have similar result. Gribble et al19
compare the effect of static and hold relax stretching The result of this study indicates that muscle energy
on hamstring muscle, drawing the influence that both technique, PNF stretching and static stretching
were equally effective in improving hamstring range produce a significant improvement in pain and
of motion in low back pain patient. hamstring flexibility. After a 4 week, The group are

performing the MET, PNF and static stretching in Stretching. Arch Phys Med Rehabil. 2006; 36(11):
increase hamstring flexibility significantly. Therefore 929-39.
it is concluded the MET, PNF and static stretching can 9. Erica N. Johnson, BS and James S. Thomas Effect
be use as an effective therapeutic maneuver for of Hamstring Flexibility on Hip and Lumbar
decrease pain, improving ROM and increase flexibility Spine Joint Excursions During Forward Reaching
of tight hamstring in chronic low back patient. Tasks in Individuals With and Without Low Back
Pain. Arch Phys Med Rehabil. 2010; 91(7):
Acknowledgement: It is a pleasure to acknowledge 1140–42.
the gratitude I thanks to my teachers who immensely 10. Halbertsma JP, GoekenLN, Hof AL, Groothoff
helped me by giving valuable advice and relevant JW, EismaWH. Extensibility and stiffness of the
information regarding the collection of material. And hamstrings in patients with nonspecific low back
I thank God for best owing me with knowledge and pain. Arch Phys Med Rehabil. 2001;82:232–8.
giving me the encouragement. 11. Sahrmann, SA. Diagnosis and Treatment of
Conflict of Interest: None declared Movement Impairment Syndromes. Saint Louis:
Mosby; 2002.
Source of Funding: Self 12. McGill, S. Low Back Disorders: Evidence based
Prevention and Rehabilitation. 2. Champaign:
Ethical Clearance: The study is approved by
Human Kinetics Publishers; 2007.
Departmental Research Committee. 13. Amir Massoud Arab, Mohammad Reza
Nourbakhsh et al The relationship between
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DOI Number: 10.5958/0973-5674.2014.00001.X
A Study to Investigate Test-Retest Reliability of Two

Minute Walk Test to assess Fuctional Capacity in Elderly
Population
Mulla Ayesha Sikandar1, Varghese John2

1
Lecturer, Ahmedabad Physiotherapy College, Ahmedabad, 2Associate Professor Srinivas College of Physiotherapy,
Mangalore
ABSTRACT
Objective: This study aims to establish test retest reliability of two minute walk test in elderly
population to assess functional capacity and secondary aim is to find out correlation between two
minute walk test and six minute walk test in elderly population.
Method: 50 healthy subjects aged 58-85 years were included in the study. The baseline cardiovascular
parameters were taken and the subjects were asked to perform the two minute walk test three times
with one week period between them done at a same time 1+ hour of 1st occasion. Post cardiovascular
parameters were measured immediately after completion of the test. The two minute walk distance
was recorded. Six minute walk test was performed once to correlate two minute walk test with six
minute walk test.
Results: 50 subjects of mean age 67.68±6.4(SD) completed study.ICC of the repeated two minute
walk tests was high (ICC=.942, p<0.05) Significant Correlation have been found between two minute
walk distance and six minute walk distance(r=.760,p<.05), heart rate, respiratory rate and rate of
perceived exertion were,(r=.693,p<.05), (r=.814,p<.05) and (r=.663,p<.05) respectively.
Conclusion: The two minute walk test has good test retest reliability in elderly population and two
minute walk test has shown significant correlation between two minute walk test and six minute
walk test.
Keywords: 2MWT; Test Retest Reliability; Elderly
INTRODUCTION functions. The ageing process is of course a biological

reality which has its own dynamic, and largely beyond
Walk tests have gained important in clinical
the human control.2All the physiological changes that
practice and research since past few years. Walk tests
occur during the aging process, the most important
are useful for measuring functional capacity,
with regard to quality of life and functional
monitoring effectiveness of treatment and establishing
independence are decline in muscle strength and in
prognosis.1
aerobic capacity, indexed as peak oxygen
Aging involves gradual progressive and consumption.3
spontaneous deterioration of most physiological
Functional capacity refers to the capacity to respond
to an exercise stimulus, maintain the physiological
Ayesha Sikandar Mulla adjustment necessary to sustain aerobic exercise from
Lecturer a period of time, and then recover appropriately from
Ahmedabad Physiotherapy College, Bopal Ghuma that stimulus on cessation of exercise. 4 Although
Road, Bopal, Ahmedabad, Gujarat. Progressive incremental tests are gold standard for
E-mail : ayesha_011@yahoo.com the measurement of exercise capacity, which is
Mobile number : 09913620400 outcome measurement for treatment and
22. Ayesh Mulla--108--.pmd 108 5/10/2015, 5:14 PM

rehabilitation. But these technically intense and is to correlate two minute walk test with six minute
relatively expensive measures are questionable benefit walk test.14
when predicting physical functioning for daily living
in frail elderly, with severe cardiac or pulmonary So, purpose of the study is to investigate the test-
disease, as they become exhausted after only a few retest reliability of two minute walk test in elderly
minutes of conventional maximum exercise testing and population to assess functional capacity in Indian
exercise capacity may be underestimated.5 population
Although maximal testing provide a more accurate METHODOLOGY

assessment of aerobic capacity, sub maximal testing
may be desirable in several situations. These include Study design: Correlational study.
pre-discharge testing after myocardial infarction,
Source of data: Healthy individuals of age group
assessment of frail elderly subjects unaccustomed to
vigorous exercise and field testing of large number of 58-85 years were taken from the societies and old age
subjects.6 homes of Gujarat population.
Walk Test is significant tool in screening, Sample size: Total 50 healthy subjects took part in
management and prognostication of Pulmonary and study.
Cardiovascular diseases.1 Walking tests are considered Sampling procedure: Healthy subjects between age
more reliable than other performance based measure
group of 58-85 years were purposively selected.
in elderly such as timed chair stand and weight lifting.7
Criteria for selection: Subjects were included in the
Butland et al proposed two minute walk test in
study based on following criteria.
1982.8 Two minute walk test is based on same concept
as six minute walk test and is less time consuming than Inclusion criteria
six minute walk test.9 Walk test is simple, practical,
quick and easy to administer.5 1. BMI < 30
Reliability is the stability of the measuring 2. Age between 58 to 85 years, both male and females
instrument that is, a reliable instrument will obtain the included.
same results with repeated administration of the rest.
Exclusion criteria
Test retest reliability is used to establish that an
instrument is capable of measuring a variable with 1. Cardiovascular insufficiency.
consistency. In a test retest study, one sample of
individuals is subjected to the identical test on two [unstable angina, myocardial infarction,
separate occasions, keeping all testing condition as uncontrolled hypertension]
constant as possible.10
2. Recent illness including Upper respiratory tract
Studies have been done with two minute walk test infection.
with older adults to examine function and with other
3. Presence of any factor that limit the walk test.
population like asthma, chronic obstructive pulmonary
disease, amputation and cystic fibrosis.5,11,12,13 No study [Impaired cognition function, neuromuscular
have been done to establish Test retest reliability of disease, claudication, severe musculo-skeletal
two minute walk test in elderly population. So this problems affecting lower extremity or spine]
study is an attempt to establish the reliability of two
minute walk test in elderly population. Outcome measure
Study done by Kervio et al of reliability and 1. Two minute walk distance

intensity of six minute walk test in healthy elderly
subjects, it states that the intensity of the 6-MWT 2. Heart rate
corresponded to 79.6 +/- 4.5% of the VO2max, 85.8 +/
3. Respiratory rate
- 2.5% of the HRmax of maximal exercise testing.
Therefore considering this, secondary aim of the study 4. Borg scale of exertion.

Location: The two minute walk test (2MWT) and • The subjects were positioned at the starting line.
six minute walk test were performed indoors, along a As soon as the subjects started to walk, the timer
long, flat, straight corridor with a hard surface. The and lap counter were started.
walking course was kept 30 m in length. The length of
the corridor was marked every 3 m. • After completion of two minutes, the subjects were
asked to stop and the spot where the subject
Procedure stopped was marked by placing a bright tape on
the floor.
• Subjects were informed to avoid caffeine, alcohol
and consumption of heavy meal for at least 2 hrs • Post-test: the cardiovascular and respiratory
prior to testing and strenuous physical exercise in responses (Heart Rate, and respiratory rate) were
the previous 24 hrs. measured immediately after the completion and
after of the test.
• Anthropometric and demographic data was
collected. • The numbers of laps from the counter (or tick
marks on the worksheet) were recorded.
[gender, age, height, weight, BMI]
• The distance covered was recorded. The total
• Borg scale of perceived exertion was explained to distance walked was calculated, and recorded on
the subject before the walk test and asked to rate the worksheet.
the perceived exertion after walk test.
• All the readings were taken and cumulated for
• Two minute walk test was repeated three times, analyses of data.
each session with one week apart in order to assess
reliability
RESULTS
• As administration of two minute walk test is
Baseline characteristics of the subjects like age,
similar as six minute walk test, the subjects
height, weight and BMI are presented in the Table-1
underwent the two minute walk test in accordance
as mean, minimum, maximum, and standard
to American Thoracic Society (ATS) guidelines.
deviation values.
Instructions to the subjects: (as per ATS guidelines)
The mean distance of first, second repeatation of
“The objective of this test is to walk as far as possible two minute walk test ( 1st 2MWT,2nd 2MWT) and third
for two minutes. You will probably get out of breath repitation of Two minute walk test (3rd2MWT ) shown
or become exhausted. You are permitted to slow down, in Table- 2.
stop, and rest as necessary. You may lean against the
The intraclass correlation coefficient for repeated
wall while resting, but resume walking as soon as you
measurements of the 2 MWTs are shown in Table -3.
are able to. You will be walking back and forth around
It shows good test retest reliability of 2 MWT.
the cones. You should pivot briskly around the cones
and continue back the other way without hesitation. I Correlation between the two minute walk test and
am going to use this counter to keep track of the different measures of six minute walk test (heart rate,
number of laps you complete. I will click it each time respiratory rate and rate of perceived exertion) are
you turn around at this starting line. shown in Table- 4. It shows significant correlation
found between the 2 MWD and 6MWD, heart rate,
Remember that the aim is to walk AS FAR AS
respiratory rate and rate of perceived exertion
POSSIBLE for two minutes, but don’t run or jog.”
respectively.(p<0.05).
Table 1: Normative data of baseline characteristics:
Number Minimum Maximum Mean Std. Deviation

Age (yrs) 50 58.00 85.00 67.68 6.41
Height (cm) 50 152.00 182.88 165.81 8.38
Weight 50 43.00 87.00 65.17 9.88
BMI (kg/cm2) 50 15.30 28.90 23.72 3.22

Table 2: Mean distance of three trials of two minute walk test
N Minimum Maximum Mean Std. Deviation

FIRST 2 MWD 50 62.90 180.00 100.9920 30.15480
SECOND 2 MWD 50 69.23 210.45 106.0900 35.41991
THIRD 2MWD 50 69.23 210.45 106.2438 34.59263
Table 3: The intraclass correlation of the Two minute walk tests
MEASURE ICC VALUE 95% CI F-VALUE SIG.

Lower Bound Upper Bound
SINGLE RATER .942 .9096 .9646 49.74 .000
AVERAGE OF RATERS* .979 .9679 .9878 49.74 .000
Table 4: Correlation between different measures of 2 MWT and 6 MWT :
Variables Correlation coefficient (r) Significance(p)

2MWD-6MWD .769 .000
Heart Rate (2MWT- 6MWT) .693 .000
Respiratory Rate(2MWT-6MWT) 814 .000
Rate Perceived Exertion.(2MWT-6MWT) .663 .000
DISCUSSION to assess functional capacity. So, this study examined

the test retest reliability of the 2 MWT to assess
Aging involves gradual progressive and functional capacity in elder people.
spontaneous deterioration of most physiological
functions.2 A decline in physical activity contributes In this study 2 MWT was repeated on the subjects
to age related decline in aerobic power.15 Fucntional thrice with one week gap between each tests. Rater
decline in older adults is related to physiological, to was blinded from results of the previous studies. Retest
both aging and lifestyle related risk factors.16 was done at a same time +1 hour of 1st occasion by the
same rater. Both the test and retest were done mostly
Submaximal exercise tests are used in older people in evening time. To find the co-relation between 1st test,
as they provide information regarding an individual’s 2nd test and 3rd test score of 2 MWTs, Intra class
functional capacity and endurance.4 Timed walk tests Correlation Coefficient (ICC) was used in this study.
are widely used to evaluate functional exercise The results of the present study showed that test retest
performance, as it is one of the most natural human scores of 2 MWTs are closely related with each other.
activities and does not require complex tests The high test-retest reliability (ICC= 0.942) was found
equipments.16 in this study. The mean distance for first 2 MWT is
Two minute walk test measures the distance that a 100.99 ±30.15m and 106.09± 35.41, 106.24± 34.59 for
patient can quickly walk on a flat, hard surface in a second and third 2 MWT respectively.
period of 2 minutes (the 2MWD). Two minute walk Study done by Amy S Y Leung et al, in which there
test is important tool for screening, responsiveness of is high correlation between three trials of two minute
treatment and assess prognosis of pulmonary and walk test, (r =.99) for 2 MWD were in chronic
cardiac diasease.5 Submaximal exercise testing can obstructive pulmonary disease patients.5.
provide a basis for prescribing activity and exercise
that is both therapeutic and safe for older people.4 Dina Brooks et al found ICC value (r=.90-.96) for
reliability of two minute walk test in people with
Studies have been done of 2 MWT diseased transtibial amputation, each subject has performed 2
population like asthma, chronic obstructive pulmonary MWTs. The results of this study shows high
disease, amputation and cystic fibrosis.5,11,12,13 Test- correlation.11
retest reliability of two minute walk test is not done
in geriatric population. 2 MWT is administrated easily Apart from the reliability the secondary objective
in very older people as they may find difficulty in was to know correlation between two minute walk test
performing 6 MWT. So, this study attempts to establish and six minute walk test. Significant correlation was
test retest reliability of 2 MWT in elderly population found between the 2 MWTs and 6 MWT, heart rate,

respiratory rate and rate of perceived exertion. The Acknwoledgement: I wish my special thanks to
strong correlation was found between the 2 MWD and
6 MWD (r=.760) and p <.05.Correlation between heart 1. Prof Ramprasad M., Principal Srinivas college of
rate of 2MWT and 6 MWT is moderate (r=.693) and physiotherapy and research centre, Mangalore for
p<.05 and high Correlation between respiratory rate showing keen interest in my dissertation work
and moderate correlation for rate of perceived exertion 2. Associate professor T Joseley Sunderraj Pandian,
as (r=.814) and (r=.663) with significance of p<.05 are co-guide, for help and guidance through out my
obtain respectively for 2MWTs and 6 MWT. study.
Study done by Butland et al who has compared Conflict of Interest: Nil
two, six and twelve minute walk test and found high
correlation between these three tests. High correlation Source of Funding: Self
are found between two minute walk and twelve
minute walk test (r=0.864) and six minute walk test Ethical Clearance: Ethical committee has given
(r=0.892), suggesting that two minute walk test is permission to do this study as study was done on
elderly subjects and prior permission was taken for
comparable to more established walk test for
measuring exercise tolerance in patients with the same from old age home.
respiratory disease.8 Study done by Amy S Y lung et
al to evaluate reliability, validity and responsiveness REFERENCES
of two minute walk test to assess exercise capacity in 1. Sherra S, Dina B, Yves L,et al. A qualitative
patients with chronic obstructive pulmonary disease. systemic overview of the measurement
High correlation was found between the 2MWT and properties of functional walk tests used in the
the 6MWT (r = 0.70; p < 0.05).5 cardiorespiratory. domain, Chest, 2001; 119;256-
The Ratings of Perceived Exertion scale is a measure 270.
of the perceived exertion during exercise and other 2. Definition of an older people or elderly people-
functional tasks. An RPE scale can be used to measure world health organization
exercise intensity with the Six Minute Walk Test. The 3. Jerome LF, Christopher HM, et al. Accelerated
ratings correspond to measures of heart rate maximum Longitudinal Decline of Aerobic Capacity in
and VO2 maximum -values which allows the therapist Healthy Older Adults. Circulation 2005;112;674-
to evaluate the intensity of the -program established 682
for the -patient.19 Results of our study shows that there 4. Bette RB, Marilyn BW. Functional performance
is high correlation between rate of perceived exertion in older adults, 1994.
of 2MWT and 6 MWT (r=.814). 5. Amy SY, Leung C, et al. Reliability, validity and
responsiveness of two minute walk to to assess
Hence we can conclude that two minute walk test exercise capacity of COPD patient. Chest 2006;
is reliable measure in geriatric and the results of this 130;119-125.
study will help us to know the effectiveness of 6. Jerome LF, Ileana LP, et al.Assessment of
measurement properties of 2 MWT used to measure functional capacity in clinical and research
functional capacity with great use to the application. Circulation 2000;102;1591-1597.
physiotherapist in clinical practice. 7. Pual LE, Mary AM, et al. Six minute walk test, a
quick measure of functional status in elderly
CONCLUSION adults. Chest 2003;123;387-398
8. Butland RJA, Pang J, et al. Two-, six-, and 12-
Our study leads to the following conclusion minute walking tests in respiratory disease. BMJ
• Two minute walk test has good Test retest 1982; 284:1607–1608.
reliability in elderly population. 9. Carole L, Keiba S. Benefits of the 2-Minute Walk
Test. Geriatric Function 16; 16:6.
There is significant correlation between two minute 10. Leslie gross portney and Mary p. Watkins.
walk test and six minute walk test in elderly Foundation of clinical research, 2nded. Julie
population. Alexander.2000:61-77.

11. Brooks D, et al. Reliability of the Two-minute 16. Wong CH, et al. The effect of later-life health
walk test in individuals with transtibial promotion on functional performance and body
amputation. Arch Phys Med Rehab 2002; composition. Aging Clin Exp Res. 2008
83:1562–1565 Oct;20(5):454-60.
12. Mancuso CA, Choi TN, et al. Measuring physical 17. Chan, L.H. et al Validation of 2-Minute Walk Test
activity in asthma patients: two-minute walk test, as a Measure of Exercise Tolerance and Physical
repeated chair rise test, and self-reported energy Performance in Patients With Chronic Graft
expenditure. Jour Asthma 2007; 44 (4), 333-40. Versus Host Disease. Arch phy medi
13. Upton CJ,et al. Two minute walking distance in rehab.2008.89,e28.
cystic fibrosis. Arch Dis Child 1988; 63:1444–1448. 18. Mark K, et al. Comparison of the 2-, 6-, and 12-
14. Kervio, et al. Reliability and Intensity of the Six- minute walk tests in patients with stroke. Jour of
Minute Walk Test in Healthy Elderly rehab and research dev.; 42; 1, 103–108
Subjects.Med.Sci.SportsExerc.2003,35;(1),169-174. 19. Bob Thomas Endurance Testing and Training in
15. Jerome LF, et al. Accelerated Longitudinal the Frail Elderly Endurance Testing and Training
Decline of Aerobic Capacity in Healthy Older in the Frail Elderly :12; 23; 41
Adults 2005;112;674-682.

DOI Number: 10.5958/0973-5674.2014.00001.X
An Experimental Study to Compare the effectiveness of

Nmes Vs Emg Biofeedback in the Early Phases of
Rehabilitation Following ACL Reconstruction
Alpa j Dhanani
Assistant Professor, Shree Swaminarayan Physiotherapy College, Kadodara Char Rasta, Surat, Gujarat
ABSTRACT
Objective: To compare the effectiveness of NMES Vs EMG biofeedback along with conventional
physical therapy in the recovery of quadriceps femoris muscle strength and knee range of motion in
the early phases of rehabilitation following ACL reconstruction.
Design: A Quasi Experimental study.
Method: In a 6-week intervention study, 30 patients following ACL reconstruction were studied.
They were divided in two Groups by convenient sampling for Group A (n = 15) NMES along with
conventional physical therapy was given; for Group B (n= 15) EMG biofeedback along with
conventional physical therapy was applied. The treatment protocol consisted of 2 session / day /5
days/week for 6 weeks. Data was collected and analysed using SPSS16.0 by Wilcoxon Signed Rank
Test, Mann-Whitney-U test and T-test.
Results: A significant improvement in the strength of quadriceps femoris muscle strength (p< 0.05),
and increase in the active knee extension ROM (p <0.05) between pre & post treatment stages in both
groups were found.
Conclusion: Using NMES along with conventional physical therapy and EMG biofeedback along
with conventional physical therapy evidenced a significantly greater improvement in isometric
quadriceps femoris muscle strength and active knee extension ROM in both the groups in early
phases of rehabilitation following ACL reconstruction, with no statistically significant difference
between the two experimental groups.
Keywords: ACL Reconstruction, Quadriceps Strength, Knee ROM, NMES, EMG Biofeedback
INTRODUCTION Acute ACL injuries can be classified by the degree

of damage to the ACL (partial or complete
The ACL (Anterior cruciate ligament) is one of the
disruption). 2 Anterior cruciate ligament (ACL)
most commonly injured ligaments of the knee. The
reconstruction is a common procedure to allow
incidence of ACL injuries is currently estimated at
patients to return to their for-mer active lifestyle.3
approximately 200,000 annually, with 100,000 ACL
reconstructions performed each year.1 In the 1980s, arthroscopic techniques led to intra-
articular reconstructions which allowed the use of
“accelerated” rehabilitation protocols that focused on
Corresponding author: early motion.4 The quadriceps femoris muscles suffer
Alpa J Dhanani the greatest functional loss after ACL reconstruction
Assistant Professor and are the focus of rehabilitation protocol.5
Shree Swaminarayan Physiotherapy College,
Kadodara Char Rasta, Surat, Gujarat Two exercises commonly used by therapists to
Phone: 8866320545 strengthen this muscle group are the quadriceps
E-mail: dr.alpajdhanani@yahoo.com femoris muscle setting (QS) exercise and the straight-
23. Alpa--114--.pmd 114 5/10/2015, 5:14 PM

leg raising (SLR) exercise. Both of these exercises are Several authors have suggested that the
designed to facilitate quadriceps femoris muscle biofeedback may be a valuable augmentor of receptor
performance without imposing damaging stress on the feedback from the knee musculature during
graft site and suture line.5 quadriceps femoris muscle exercises.15
As several clinicians have noted, however, patients In 2008, The Association for Applied
often have considerable difficulty executing an Psychophysiology and Biofeedback (AAPB), defined
effective QS exercise contraction following knee “Biofeedback is a process that enables an individual
surgery, contracting primarily the hip musculature to learn how to change physiological activity for the
and neglecting to contract the knee extensors.6 purposes of improving health and performance.
Precise instruments measure physiological activity
In an effort to maximize a patient’s effort to contract such as brainwaves, heart function, breathing, muscle
the quadriceps femoris muscle and enhance the rate activity, and skin temperature. These instruments
of force production, clinicians may choose to augment rapidly and accurately ‘feedback’ information to the
the exercise with a training modality that facilitates user. The presentation of this information - often in
higher levels of motor unit activity and more complete conjunction with changes in thinking, emotions, and
contractions during exercise. Because force behavior - supports desired physiological changes.
development is a result of both neural and muscular Over time, these changes can endure without
elements, the training method should facilitate both.7 continued use of an instrument.16"
Neuromuscular electrical stimulation (NMES) has The principle of EMG (electromyography)
been recommended as an adjunct treatment for Biofeedback is based on converting myoelectrical
strengthening the quadriceps femoris muscle signals sensed from muscles by surface electrodes to
following anterior cruciate ligament reconstruction auditory and/or visual signals.17
(ACLR).8
Several studies have compared biofeedback-
NMES is the application of electrical current to elicit facilitated quadriceps femoris muscle exercise with
muscle contraction 9, also known as exercise alone in healthy individuals and in patients
electromyostimulation,10 is widely used to delay or following knee surgery and have demonstrated greater
prevent the atrophy associated with disuse of the peak torque, greater EMG output, an increased rate of
quadriceps femoris muscles, 11 and also targeted knee extension recovery, and an increased rate of peak
directly at improving strength and minimizing torque recovery with the use of biofeedback.7
at-rophy.12
Muzafir et al, in their study shows each treatment
Wigerstad Lossing I et al in a study, compared the modality may be effective in strengthening quadriceps
effect of electrical muscle stimulation combined with femoris muscles contraction force, but EMG
voluntary muscle contractions with a program only biofeedback may be superior to the traditional
with voluntary muscle contractions after anterior treatment modalities in enhancing muscle electricity
cruciate ligament reconstruction, had concluded that activity.18
a significantly larger improvement in the knee
extension isometric muscle strength.13 This effort of mine is to compare NMES and EMG
biofeedback along with conventional physical therapy
Anthony Delito et al, in their study, shows in patients following ACL reconstruction and
statistically significant results when simultaneous determine the better of these to yield best results and
contraction of thigh muscles is prescribed during an greater benefits for the population.
early phase of postoperative rehabilitation following
ACL reconstruction.14
MATERIALS AND METHODOLOGY
Postoperatively, although pain and oedema are
Study duration: 1 year (During the period -
certainly factors, may result in diminished control and
December 2010 to November 2011)
use of the quadriceps femoris muscles during
rehabilitative exercises and, consequently, a limited Study setting: Out Patient Department of C.U.Shah
rate of return to normal muscle function.5 Physiotherapy College Surendranagar, Gujarat.
23. Alpa--114--.pmd 115 5/10/2015, 5:14 PM

Study population: Subjects following ACL Tools

Reconstruction who fulfills the selection criteria.
• EMG biofeedback unit and its accessories.(Intellect
Sample size: A Total Number of 30 Patients with a Advanced - Chattanooga group).
maximum of 15 patients allotted to each Group (Group
A: 15 Patients, Group B: 15 Patients). • NMES unit and its accessories. (Intellect Advanced
- Chattanooga group).
Sample design: Convenience sampling.
• Baseline hydraulic Hand- held dynamometer.
Selection Criteria
• Universal goniometer.
Inclusion Criteria
Outcome Measures
• Age: 16-36 year5
• Isometric strength of quadriceps femoris muscle.
• Unilalateral involvement.
• Active knee extension ROM.
• ACL that required arthroscopic reconstruction
Sampling Procedure
using a bone patellar tendon bone autograft
procedure.7 All patients following ACL reconstruction were
identified by convenience sampling technique. The
• Patients willing to take part in the study by signing
procedure was clearly explained to all the patients and
a written informed consent.
their consent was obtained.
Exclusion Criteria
Randomization into groups was achieved through
• ACL that required arthroscopic reconstruction odd/even assignment: the first patient was assigned
using hamstring tendon autograft or Quadriceps to Group A, the second patient was assigned to Group
tendon autograft or allograft. B, the third patient was assigned to Group A, the fourth
patient was assigned to Group B, and so forth through
• ACL that required arthroscopic reconstruction the 29th being assigned to Group A and the 30th patient
along with menisci or collateral ligament repair. being assigned to Group B.
• Patients who have received preoperative
DATA COLLECTION
conventional physical therapy.
All the subjects completed a detailed Orthopaedic
• Patients who come 48 hours after surgery.
assessment. The assessment obtained information
• Dermatological conditions (e.g. eczema, about demographic details, medical history, surgical
dermatitis).9 history, investigation reports and range of motion and
muscle strength of the patients. Subjects who fulfilled
• Allergy to the electrode or contact material the selection criteria were informed about the study
(tape / gel)9 and requested to sign written informed consent forms.
• Patients with insufficient audition and reception Experiments were conducted on 15 patients in
to hear and comprehend simple directions or are Group A and 15 patients in Group B. Group A and
unable to respond to the instructions of the Group B patients were treated with NMES along with
therapist.9 conventional physical therapy and EMG biofeedback
along with conventional physical therapy respectively.
• Patients with Impaired sensations, cold
intolerance/hypersensitivity.19 Each patient was evaluated prior to the first session,
after every week of treatment and after the last session,
• Patients with neurological disorders.9
concerning the following aspects:
• patients with any associated fractures, dislocations
Muscle Strength
of the ipsilateral lower limb and/or the presence
of metal implants.9 Isometric quadriceps femoris muscle strength testing
23. Alpa--114--.pmd 116 5/10/2015, 5:14 PM

Isometric quadriceps strength was measured • Waveform: Symmetrical biphasic

bilaterally, using a baseline hydraulic hand-held
dynamometer. Subjects sat upright on the examination • Frequency: 50 pulse per second
table with the hips flexed at 90 degrees and knees • Intensity: MTL (maximum tolerated level)
flexed at approximately 60 degrees. 20, 21
• Duty cycle: 10 second on/10 second off
ROM
• Ramp: 2 second
Active knee extension ROM
• Phase duration: 300 microseconds
The active knee extension range of motion of the
affected knee was measured with a universal double- • Treatment time: 10 minutes
armed goniometer with the patients in high sitting
GROUP B
position with hip and knee in approximately 90 degree
flexion. The supine lying position was not used, to Group B was treated with EMG biofeedback along
avoid knee flexion beyond 90 degrees.22 with QS and SLR exercises.
Treatment Protocol Electrode placement: In preparation for the
During the first postoperative session, patients in electrode placement, the skin just proximal to the
patella was scrubbed with a spirit pad.9
both groups were reviewed and subjectively evaluated
on QS and SLR performance and then they were Two dura-stick 6 cm round self adhesive electrodes
instructed to perform of these exercises in conjunction were used over the belly of quadriceps femoris muscle
with the device they had been assigned. and ground electrode was placed in between the active
GROUP A and reference electrodes.9
Group A was treated with NMES along with QS After electrodes were affixed and a baseline activity
and SLR exercises. level was determined. The initial selection of threshold
value was different for each patient (because of
Electrode placement: In preparation for the individual differences in amount of subcutaneous
electrode placement, the skin just proximal to the tissue, edema, and ability to contract the quadriceps
patella was scrubbed with a spirit pad.9 femoris muscle) and was set so that the patient has to
contract primarily the knee extensors and exert
Two dura-stick 6 cm round self adhesive electrodes maximally to reach the threshold. The patients were
were used over the belly of quadriceps femoris instructed to contract the quadriceps femoris muscle
muscle.9, 23 to their EMG threshold level, to maintain the audible
NMES parameters were set: 24 signal for 10 seconds on, and to rest for 10 seconds
off.
• Type of stimulator: constant voltage
Statistical Evaluation
Table 1: Inter group comparison of post test scores.
Group A Group B t value p values

Mean SD Mean SD
Isometric quadriceps 27.83 ±2.160 27.77 ±2.412 .080 .937
femoris muscle strength
Group A Group B Mann z value p values
Whitney U
Mean SD Mean SD
Active knee ex 2 ±1.927 2.40 ±2.028 99.500 -.558 .577
tension ROM
23. Alpa--114--.pmd 117 5/10/2015, 5:14 PM

RESULTS treatment stage in comparison to the pretreatment

stage.
The analysis of demographic data did not evidence
statistically significant difference between groups. Though both NMES and EMG biofeedback along
with conventional physical therapy improved the
The inter group comparison of pre test scores shows quadriceps femoris muscle strength and active knee
The p value is > 0.05 indicates there is statistically no extension ROM, by comparing the post treatment
significant difference between the pre test scores. variables in both experimental groups. There was no
Hence it proves that the groups are homogenous. statistically significant difference in improvement in
The intra group comparison of pre and post test the active knee extension ROM (p=0.577), or in
scores of isometric quadriceps femoris muscle strength quadriceps femoris muscle strength (p=0.937) between
and active knee extension ROM within Group A, the Groups A and B.
where the p value is < 0.05. A statistically significant
difference was found after treatment. CONCLUSION
The intra group comparison of pre and post test In the experimental conditions used in this study,
scores of isometric quadriceps femoris muscle strength using NMES along with conventional physical therapy
and active knee extension ROM within Group B, where and EMG biofeedback along with conventional
the p value is < 0.05. A statistically significant physical therapy evidenced a significantly greater
difference was found after treatment. improvement in isometric quadriceps femoris muscle
strength and active knee extension ROM in both the
The inter group comparison of post test scores of groups in early phases of rehabilitation following ACL
quadriceps femoris muscle strength and active knee reconstruction, with no statistically significant
extension ROM between group A and group B. The P difference between the two experimental groups.
value being >0.05, a statistically significant difference
was not found for the quadriceps femoris muscle Acknowledgement: I am very much grateful to my
strength and active knee extension ROM between loving family members for their interest in my
group A and group B. Thus, it shows that both the academic excellence and also for their love,
interventions are equally effective in the early phases encouragement & support which made this work
of rehabilitation after ACL reconstruction in improving possible.
quadriceps femoris muscle strength and active knee
Conflict of Interest: Authors agree that there was no
extension ROM.
source of Conflict of Interest.
DISCUSSION Source of Funding: There was no source of funding

from anyone for the present study.
The results found in this study disclosed that after
a six week treatment programme, both the groups Ethical Clearance: Ethical clearance for my study was
attained a significant improvement in the strength of given by “Saurashtra University”, Rajkot, Gujarat.
quadriceps femoris muscles and active knee extension
ROM. REFERENCES
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effect of early implementation of electrical muscle Orthopaedic Surgeons (AAOS) March 5, 2008-
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and study by Christanell F et al, 2006, on the influence 2. Evans N.A.; Chew H.F.; and Stanish W.D.: The
of EMG-Biofeedback-Therapy on knee extension Natural History and Tailored Treatment of ACL
following ACL reconstruction. Injury. Phys Sports med. 2001; 29 (9): 19-34.
This study was conducted on thirty patients with 3. Rick W. Wright et al, A Systematic Review of
the mean age of 25.23 ± 6.43(mean ± SD) following Anterior Cruciate Ligament Reconstruction
ACL reconstruction showed a significant improvement Rehabilitation .J knee Surg. 2008;21:225-234.
in quadriceps femoris muscle strength (p < 0.05) and 4. S.Brent Brodtzman Kevin E.Wilk. 2003;Clinical
in active knee extension ROM (p < 0.05) in the post Orthopaedic rehabilitation , Second edition,
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Mosby An Affiliate of Elsevier Science. West 14. Anthony Delitto, Steven j. Rose, Joseph m.
Philadelphia, Pennsylvania . Mckowen, Richard c. Lehman, James a. Thomas,
5. Draper V. Electromyographic biofeedback and and Robert a. Shively :Electrical Stimulation
recovery of quadriceps femoris muscle function Versus Voluntary Exercise in Strengthening
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6. Soderberg GL, Minor SD, Arnold K, et 1988,Volume 68 / Number 5.660-663.
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Physical Therapy-2003;33:492-501. 19. Christanell F, Hoser C, Huber R, Fink C,
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DOI Number: 10.5958/0973-5674.2014.00001.X
Assessing Internal Consistency of "Antenatal Care

Knowledge Questionnaire"
Abha Dhupkar1, Manasi Ketkar2

1
MPT, B.P.Th., D.E.Society's Brijlal JIndal College of Physiotherapy
2
ABSTRACT
Aim: To assess internal consistency of questionnaire titled "Knowledge of Antenatal Care

Questionnaire."
Method: A questionnaire to assess knowledge of pregnant women about the antenatal period was
developed. It was administered to 30 women as a pilot to elicit answers in order to assess the internal
consistency of the questions. The questionnaire was divided into two sections and Cronbach's alpha
was calculated for the same.
Results: The internal consistency of the two sections was 0.557 and 0.5918 respectively, which denotes
a fair internal consistency.
Conclusion: Further revision to improve the questionnaire is required.
Clinical Implication: The questionnaire aims to find out how much information a pregnant woman
has about her pregnant state and about the perceptions a woman has about the care which she is
supposed to take in this period. Educating the woman and her family about the care which needs to
be taken in the antenatal period can potentially reduce maternal and infant mortality.
Keywords: Antenatal Care Knowledge, Questionnaire, Internal Consistency
INTRODUCTION which she might need to take for a safe delivery and
also the need to be educated about the complications
One of the important stages of a woman’s life is
or potential problems that she might face in her
pregnancy, which asserts her ability to reproduce and
pregnancy or in her delivery. In an absence of the
carry new life inside her. As a woman progresses
ability to identify and recognize potential danger signs,
through pregnancy, each month and trimester present
preventable and treatable conditions, like gestational
with a variety of changes, which need to be assessed,
diabetes, hypertension, can have severe repercussions
evaluated and documented at that particular point in
on the to-be-mother’s health(5).
time(1). Each trimester is characterized by its own set
of changes, complaints and disorders(1). Furthermore, The need for imparting health education to women
each woman presents with a different and unique set of reproductive age has been identified in different
of demands and requirements. In the nine months of regions of India as well as the world(6,7,8,9,10). Though,
pregnancy, the changes a woman undergoes can many research has been directed more towards assessing
a times overwhelm her, causing stress and fatigue to utilization of antenatal care in these studiess(8,9,10), the
her (2,3,4). With physical and physiological changes undercurrent running throughout is the need to
dominating this period, the woman can face potentially disseminate information about the antenatal period,
life threatening disorders. These are scenarios where the changes occurring in it and the importance of
it becomes necessary to educate the woman about the understanding these changes in order to improve and
changes she is undergoing, the different measures increase the antenatal care utilization.
24. Abha--120--.pmd 120 5/10/2015, 5:14 PM

Indian authors like Manju Sharma (6) , Prabin score of 1 was given; the other options received a score
Kumar(7) have emphatically documented the need for of 0. The scores were added up and these were used
imparting health care education to the pregnant or for analysis. For the second group of questions, if the
reproductive age woman. However, in the absence of option “Agree” was chosen, a score of 1 was given
an adequate knowledge of how much information while the other options received a score of 0. Again
these women already have about antenatal care, it the scores were added up for data analysis.
becomes difficult for the primary contact health care
deliverers to impart any education on this subject. Microsoft Excel was used to calculate the
Cronbach’s Alpha value of the questions asked. For
This study was hence undertaken to identify questions discussing importance, the alpha value of
questions which need to be asked to a pregnant woman the combined score of the 9 questions was 0.557
in order to find her knowledge of antenatal care and denoting a fair internal consistency. For the 6 questions
assess their internal consistency in order to revise the discussing agreement, the alpha value of the combined
questions further. scores was 0.5918, again denoting a fair internal
consistency.
METHOD
The reasons for the responses were documented
Focus topics about antenatal care were identified. but were not considered in the present study.
These were transformed into questions, with sub-
questions for each topic, attempting to find the DISCUSSION
knowledge, awareness and practices of the pregnant
woman. This questionnaire was revised when a peer The alpha values describe the internal consistency
review felt that it was too long (approximately 45 of a questionnaire, that is, how each question is relating
questions had been formed). The second edition of the to the other in the questionnaire and points out
questionnaire was administered to 5 women to assess redundancies if required. Having a very high alpha
if the appropriate responses were being received. On value, though good, can also mean that there are
receiving answers to these questions, it was felt that redundant questions being asked. Conversely a very
the questions were being misunderstood and were not low alpha value shows that the questions do not have
able to elicit the awareness or knowledge aspects of any relation to each other and are eliciting answers
the questions. Thus, a third revision was performed. which might not be of any help to the surveyor. Thus,
This was administered to 30 women and included having alpha values in either range requires a drastic
separate columns for the woman to enlist reasons for revision of the questionnaire. Having an alpha between
her response to the questions. As the questionnaire 0.6 and 0.8 is considered a good value as it denotes a
had been developed in English, pregnant women who good chance that questions being asked are eliciting
understood and could respond in English were asked answers appropriately and that questions are not being
to answer it. repeated (11) . This study showed a fair internal
consistency with alpha values being 0.557 and 0.5918
Most of the questions were based upon a Likert- respectively for two different question groups. This
like response, with a few requiring “Yes/No” answers. denotes that the questionnaire needs to be analysed to
3 open ended questions were incorporated into the identify lacunae in language to avoid possible
questionnaire, which dealt with the woman’s misinterpretations of the questions and also to identify
perception of who should deliver her baby and where redundant questions if any. Also, it was felt that a few
she would prefer to deliver. Also, she was asked if she topics like breast feeding, foetal movements need to
wished to know more about the pregnant state. be added to the questionnaire.
Though the preparation of such a questionnaire

RESULTS AND ANALYSIS
may in itself seem redundant, in a busy outpatient
For analysis purposes, the questionnaire was department, many a times, the health care professional
divided into two parts, questions 2 through 10 and may not be able to correctly identify a woman’s
questions 11 through 16 were clubbed together. knowledge and hence, will find it difficult to provide
Scoring for these questions was based on which option appropriate answers to the woman or her family.
was chosen by the woman. For the first group of Having a baseline awareness of the knowledge which
questions, if the option “Important” was chosen, a the woman has might help the health care professional
24. Abha--120--.pmd 121 5/10/2015, 5:14 PM

to customize answers in order to explain the different 2 nd edition,2005, Butterworth-Heinemann,

stages of pregnancy and concomitant changes, Edinburgh.
problems and complications adequately to her. 5. http://www.who.int/mediacentre/factsheets/
Though age of marriage in India is 18, the girl might fs348/en/
not have had appropriate access to health care 6. Sharma M, Sharma S. Knowledge, attitude and
information or might not understand the material she belief of pregnant women towards safe
has at hand. Such a lack of information can be motherhood in rural Indian setting. Social
potentially harmful to her, more so if she is not able to Sciences Directory, Sept 2012;Vol. 1(1), 13-18
identify warning signs like elevated blood pressure, 7. Manna P.K., De D., Ghosh D. Knowledge
oedema or elevated blood sugar levels especially in Attitude and Practices for antenatal care and
the latter stages of pregnancy. Knowledge of these delivery of the mothers of tea garden in Jalpaiguri
conditions can help reduce maternal and infant and Darjeeling districts, West Bengal. National
mortality further(12,13), along with helping the health Journal of Community Medicine, 2011, Vol 2 (1):
care delivery system in providing better and more 4-8.
effective care. 8. Tura G. Antenatal care service utilization and
associated factors in Metekel zone, Northwest
CONCLUSION Ethiopia. Ethiop J Health Sci. 2009 July; 19(2): 111-
119.Raaof A.M., Al-Hadithi T.S. Antenatal care
Further revisions of the questionnaire need to be in Erbil city - Iraq: assessment of information,
done prior to reassessing it for validity and internal education and communication strategy. Duhok
consistency. Med J, 2011; 5(1): 31-40.
9. Guilford WH, Downs KE, Royce TJ. Knowledge
Clinical Implication: This questionnaire can be used
of prenatal health care among Costa Rican and
to assess the baseline knowledge available to a
Panamanian women. Rev Panam Salud Publica.
pregnant woman with a view to improve or add upon
2008;23(6):369–76.
it as required by the woman.
10. Abdel Azem A. Ali, Mohammed M Osman,
Ethical Clearance: Taken from institutional committee. Ameer O Abbaker, Ishag Adam. Use of antenatal
care services in Kassala, Eastern Sudan. BMC
Source of Funding: Self Pregnancy and Childbirth, 2010, 10:67
Conflict of Interest: Nil. 11. Foundations of Clinical Research Applications to
Practice. Leslie Gross Portney, Mary P. Watkins.
3 rd Edition, Appleton and Lange, Norwalk,
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Connecticut.
1. Textbook of Obstetrics. D.C. Dutta. 6th ed., 2004, 12. www.unfpa.org/monitoring/toolkit/
New Central Book Agency(p) Ltd. Tool6_2.docý
2. Women’s Health: A Textbook for 13. Ekabua J, Ekabua K, Njoku C. Proposed
Physiotherapists. Ruth Sapsford. 1st edition, 1997, framework for making focused antenatal care
Bailliere Tindall. services accessible: a review of Nigerian setting.
3. Physiotherapy in Obstetrics and Gynaecology. ISRN Obstetrics and Gynecology, Volume 2011,
Margaret Polden and Jill Mantle. 1 st Indian Article ID 253964,5pages; doi:10.5402/2011/
edition, 1994, Jaypee Brothers Medical Publishers 253964.
(P) Ltd., New Delhi.
4. Physiotherapy in Obstetrics and Gynaecology.
Jill Mantle, Jeanette Haslam, Sue Barton.
24. Abha--120--.pmd 122 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
A Comparative Study to Determine the effectiveness of

Carpal Bone Mobilization vs. Neural Mobilization for
Carpal Tunnel Syndrome
Hiral R Solanki1, Leena R Samuel2

1
Lecturare, Ahemdabad Physiotherapy College, Ahemdabad, 2Sr. Lecturare and Guide C. U. Shah Physiotherapy
College, Surendranagar
ABSTRACT
Purpose: To find out the comparison in pain and range of motion in CTS with CBM and NTM.
Methodology: 30 subjects with CTS were recruited and conveniently allocated to NTM group (n=15)
and CBM group (n=15). Subjects in A group received NTM and B group received CBM technique.The
treatment period was 6 weeks for both groups. The outcome measure was Wrist Extension ROM and
NPRS.
Results: According to need of study test were applied and seen clinical improvement in pain and
ROM in CTS patients receiving NTM in comparison to NTM.
Conclusion: Greater improvement is seen in CTS patients who received NTM than CBM.
Keywords: CTS, NCV,NTM,CBM
INTRODUCTION paresthesia in the median nerve distribution are the

hallmark neuropathic symptoms of CTS.The Etiology
Carpal Tunnel Syndrome (CTS) is an idiopathic
of CTS is unknown cause.CTS can be associated with
median neuropathy at the carpal tunnel.CTS is the
any condition that causes pressure on the median
most common peripheral neuropathy.Patients with
nerve at the wrist.
CTS experience numbness, tingling, or burning
sensations in the thumb and fingers, in particular the Clinical assessment by history taking and physical
index, middle fingers, and radials half of the ring examination can support a diagnosis of CTS. Special
fingers, which are innervated by the median Tests such as Phalen’s maneuver 2,3 ,Electro
nerve1.Compression of the median nerve as it runs Physiological Testing4,Reverse Phalen’s test3 ,Carpal
deep to the transverse carpal ligament causes atrophy compression test, Prayer Test are done to confirm
of the thenar eminence, weakness of the flexor pollicis CTS6,7.
brevis, opponens pollicis, abductor pollicis brevis, as
well as sensory loss in the distribution of the median If history and physical examination suggest CTS,
nerve distal to the transverse carpal ligament.Less- patients will sometimes be tested electro diagnostically
specific symptoms may include pain in the hands or with nerve conduction studies and
wrists and loss of grip strength.Numbness and electromyography.When the median nerve is
compressed, as in CTS, it will conduct more slowly
Corresponding author: than normal and more slowly than other nerves.Nerve
Hiral R Solanki conduction studies are a sensitive measure of detecting
L-101, Orchid,parshwanath Atlantis Park, compression of the median nerve.
Ahmedabad-382424, Gujarat
Mobile number: 9662516448 Generally accepted treatments, as described below,
E-mail: Parmarhiral87@yahoo.in may include Carpal bone mobilization8-10,Ultrasound11-
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13
,splinting or bracing14,15,steroid injection16-18,activity Gujarat.Group A (n=15) subjects were given NTM and
modification19-29,Neural tissue mobilization30-35,Yoga36- Group B (n= 15) given CBM.
39
,medications40-43 and surgical release of the transverse
carpal ligament44-45. Sampleing Criteria
Neural Tissue Mobilization Inclusion Criteria
Mechanism of Recovery Through Neural • CTS patients older than 18-65 years.
Mobilisation,1)Circulation and nutrition occur
• Patients with Unilateral acute CTS.
optimally through movement 2)Musculoskeletal tissue
changes ,dimension and exert mechanical forces on • Males and Females.
neural structures 3)Minimize forces on adjacent neural
structures 4)Increase nerve tension and intraneural • Clinical diagnosis consistent with neurodynamic
pressure 5)Facilitate venous return 6)Disperse edema dysfunction.
7)Reduce pressure inside the perineurium 8)Limit
• Positive clinical tests (Phalen /Tinel’s test).
fibroblastic activity and minimize scar formation.
• Positive upper limb tension test with median nerve
Carpal Bone mobilization
bias ULTT.
Joint mobilization is a type of passive movement
of a skeletal joint47-48.It is usually aimed at a ‘target’ • Positive electro diagnostic test
synovial joint with the aim of achieving a therapeutic
Exclusion Criteria
effect.CBM is effective for CTS.1)Restore structures
within a joint to their normal position or pain-free • Patients having known psycho-social problems.
status so as to recover a full range painless movement
.2)Relieves pain Restoring neurodynamic to their ideal • Diabetes mellitus, herpes zoster, rheumatoid
state to provide an ideal environment of mobility arthritis.
within which the nervous system can function
• Pregnancy, hyperthyroidism, known congenital
optimally.CBM (Maitland mobilization) may result in
abnormality of the nervous system.
alteration of the pressure in the nervous system and
subsequently to a dispersion of any existing intra • Cervical or thoracic spine origin of symptoms on
neural odema49.The aim of CBM is to loosen possible assessment.
post-traumatic adhesions between the scaphoid,
Trapezoid and Hamate joints and the median nerve, • Patients under medications for CTS.
which overlies these carpal bones.CBM restore
Tools and Parameters 3
structures within a joint to their normal position or
pain-free status so as to recover a full range painless • Numerical Rating Pain scale,3,25
movement, relieves pain, restoring neuro dynamics to
their ideal state to provide an ideal environment of • Measurement of active range of movement –wrist
mobility within which the nervous system can function extension 3,26,27,42
optimally.According to Walsh (2005), joint
mobilizations can restore mobility and decrease Protocol 39,15,,47
interfacing tissue adherence with the nerve. Mobilization in above manner CBM in
Posterioanterior or anteroposterior direction Grade
MATERIALS AND METHODOLOGY II( A large amplitude movement performed with in a
30 subjects of CTS were selected and divided into resistance free part of the available range)3 repetation
2 group.A Quasi Experiment study with Convenient 15 ossiltion per day one session and Median nerve
sampling Subjects with acute CTS done in C.U.Shah neurodynamic test repeted 10 times in 3 sets with 3
Physiotherapy College OPD, Surendranagar. seconds hold and 5 times a week.
25. Hiral--123--.pmd 124 5/10/2015, 5:14 PM

DATA ANALYSIS
Comparison of pre and post intervention of Neural Tissue Mobilization for wrist extension values by Non Parametric
Wilcoxon Signed Ranks Test in Group A .
GROUP A MEAN S.D MIN MAX Z VALUE P VALUE

PRE 10.80 1.971 8 14 3.423 0.00
POST 63.87 4.984 55 69
Comparison of pre and post intervention of Maitland Mobilization for wrist extension values by Non Parametric
Wilcoxon Signed Ranks Test in Group B.
GROUP B MEAN S.D MIN MAX Z VALUE P VALUE

PRE 10.93 2.120 8 15 2.449 0.009
POST 11.33 2.193 8 16
Comparison of pre and post intervention of Neural Tissue Mobilization for NPRS values by Non Parametric Wilcoxon
Signed Ranks Test in Group A
GROUP A MEAN SD MIN MAX Z VALUE P VALUE

PRE 8.53 1.506 5 10 3.431 0.00
POST 1.80 0.941 0 3
Comparison of pre and post intervention of Maitland Mobilization for NPRS values by Non Parametric Wilcoxon
Signed Ranks Test in Group B.
GROUP B MEAN SD MIN MAX Z VALUE P VALUE

PRE 8.53 1.506 5 10 1.633 0.104
POST 8.27 1.223 6 10
Comparison of post values of Range Of motion and NPRS of Group A and B byMann-WhitneyU test.
Z value P value
Wrist Extension 4.682 0.000
NPRS 4.717 0.000
Table shows comparison of post values of Range DISCUSSION

of motion and NPRS scale of Group A and B by Mann-
Whitney U test. The z value was for Wrist Extension The nerve tissue can be injured or irritated by
4.682 with p value =0.000, which was<0.001. The z elevated hydrostatic pressure, mechanical contact or
value was for NPRS scale 4.717 with p value =0.000, stretch. The action of elevated hydrostatic pressure and
which was<0.001.which suggests rejecting null mechanical contacted stress is occuring.
hypothesis and proved that there was statistically The use of electro-diagnostic testing taken as
significant increase in the improvement of Range of inclusion criteria to strengthen the diagnosis of CTS.
Motion and NPRS in Group A (Neural tissue Myer’s et al stated that, compression injury of a nerve
Mobilization) as compared to Group B (Maitland can lead to an increase of the intraneural fluid and
Mobilization). subsequent impairment of nutritional transport to the
nerve1(58). Lundborg and Ryedick (1989) stated that the
RESULTS mechanical effect on nerve compression is depends up
on the magnitude of pressure and duration.
Mean and SDwere found out to assess the
parameters. The Comparison of pre and post intervention
values of range of motion in Group A (Neural Tissue
All above tables which suggests rejecting null
Mobilization) showed the result in such a way that
hypothesis and proved that there was statistically
the mean ± SD values before and after intervention of
significant increase in the improvement of Range of
Neural tissue Mobilization and measured by Range
Motion and NPRS in Group A (NTM) as compared to
Of Motion in Group A were 10.80 ±1.971 and
Group B (CBM).
63.87±4.98 respectively. The “z value” was 3.432 with
25. Hiral--123--.pmd 125 5/10/2015, 5:14 PM

p value <0.001. This statistical data proved that following carpal tunnel has effectiveness and no
treatment with Neural Mobilization significantly conclusion can be drawn regarding the longer term
improve in Range Of Motion. effects of Maitland Mobilization.
The Comparison of pre and post intervention There are no set rules for how long or how many
values of range of motion in Group A (NTM) showed times a technique should be performed. This should
the result in such a way that the mean ± SD values be dictated by the effects that the technique is having
before and after intervention of NTM and measured on the patient’s symptoms both during and after its
by NPRS in Group A were 8.53 ±1.506 and performance.Duration of Treatment depends upon
1.80±0.941respectively. The “z value” was 3.431 with patient’s response. The treatment protocol is purely
p value <0.001. This statistical data proved that depend upon signs and symptoms based on severity,
treatment with NTM significantly reduction in NPRS irritability, and nature of disorder. For CTS posterior
score. anterior and anterioposter mobilization at intercarpal
is highly applicable. Although some statistically
The reason behind improving in Wrist Range of significant results were obtained from this Quasi
Motion and reduction in NPRS score patients with experimental study but there is significant difference
NTM was due to improve axonal transport and by this in results of Neural Tissue Mobilization and CBM.
mechanism to improve nerve conduction (Butler & NTM having more benefit for CTS patients Rather
Gifford 1989). By NTM the nerve may reduce the Than CBM When analyzing the results of ROM
pressure existing within the nerve and could therefore between conditions visually it can be seen that for
result in an improvement of blood flow to the nerve. ROM extension groups A & B. Both demonstrated
Consequently, regeneration and healing of an injured improvement but better improvement in Group A
nerve may also occur (Butler 1991). Rozmaryn et al. Compare to Group B.
(1998) treated patients experiencing CTS with nerve
gliding exercises and report in 70.2% of patients good When analyzing the results of Range of motion and
or excellent results. The beneficial effects of these NPRS in GROUP A and GROUP B, there is Marked
exercises may include direct mobilization of the nerve, improvement in Range of motion and reduction in
facilitation of venous return, edema dispersal, decrease NPRS score in GROUP A compared to GROUP B. The
of pressure inside the perineurium, and decrease of Maitland mobilization not effective means of treatment
carpal tunnel pressure.16–18 for CTS the reason behind that could be CTS is purely
the condtion which is inflammation of nerve and to
Review on Non-surgical treatment for CTS for relive the condition Neural Mobilzation can directly
neurodynamic mobilization VS control group and targeting on nerve where as the Carpal Bone
concluded neuro dynamic mobilization is more Mobilization is Mobilization of Bone so it do not
effective than control with Secondary outcome directly affect the nerve.so more reduction in
measures included. 1)Improvement in functional symptoms is due to Neural tissue mobilization.
status and/or health-related quality of life parameters
2) Improvement in objective physical examination These treatment techniques should not be
measures, such as grip, pinch strength, and sensory considered as a tool for resolving all
perception.Improvement in neurophysiologic neuromusculoskeletal conditions. They have though
parameters after three months after treatment. 4) a prominent place amongst the various manual
Clinical improvement at of follow-up.5) clinical therapy techniques and they could be part of
improvement at one year after treatment and no need comprehensive and evidence-based manual therapy
for surgical release of the flexor retinaculum during program.
followup.
O’Conner et al. concluded there were no significant
Maitland (1991) suggested mobilizing of carpal benefits to neural gliding, whereas Muller et al.
bone. Literature concerning the effects of joint recommended neural gliding for the benefit of reduced
mobilization as applied by manual therapists is pain.Goodyear- Smith and Arroll concluded that there
however lacking and at present there is no specific was possible benefit in reduced rates of surgical
literature exploring the treatment of CTS.Other intervention with the use of neural gliding. In
prospective randomized study with 50 consecutive evaluation of these three systematic reviews, we
patients and concluded that early mobilization identified that there were additional research studies
25. Hiral--123--.pmd 126 5/10/2015, 5:14 PM

that examined the efficacy of nerve gliding exercises with CTS. Hence, NTM was proved to be a better
in the treatment of CTS that were not included in these treatment option for the patients with CTS than CBM.
previous reviews.
Acknowledgement: First I’d like to thank the Almighty
Limitations Lord for his blessing throughout my study. I’d like to
take this opportunity to thank my Parents and my
• Small sample size. husband for their constant support, encouragement
• Home programe was not given and guidance.
• Long Term Follow Up was not taken. Conflicts of Interest:Nil
• No Blinding Fundings: By The Institute.
• No Randomization Ethical Clearance: It was Given by Commitee
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DOI Number: 10.5958/0973-5674.2014.00001.X
Quadriceps Femoris Strength Training: effect of

Neuromuscular Electrical Stimulation Vs Isometric
Exercise in Osteoarthritis of Knee
Shahnaz Hasan
Associate Professor, Department of Physiotherapy, College of Applied Medical Sciences, Umm Al-Qura
University,Makkah, K.S.A
ABSTRACT
Objective: To evaluate the effectiveness of the Neuromuscular Electrical stimulation as an add-on

therapy with maximum voluntary isometric contraction exercise on the quantitative changes of the
quadriceps strength, pain and functional outcomes in patients with osteoarthritis of knee.
Method: Fifty patientswith Osteoarthritis of Knee (22 women and 28 men) were randomly divided
into experimental and control group (25 subjects in each group).
Experimental Group received the NMES guided isometric exercise for 5 days a week for 3 week,
whereas the control group received an isometric exercise along with sham NMES, without any
instruction regarding muscle recruitment. Maximum isometric quadriceps strength was assessed
with the electronic strain gauge. Pain and the functional status of the patients were measured
throughvisual analogue scale (VAS) and the reduced WOMAC scale.
Results: Maximum isometric quadriceps strength improved significantly at the end of 3 week,
compared with the pretreatment values in both the groups. On between group comparisons, the
maximum isometric quadriceps strength in NMES group, at the end of 3 week and after 2 week
follow-up i.e. on 5th week were significantly higher than those of control group (p<0.05). Significant
improvements were shown for both the VAS and reduced WOMAC in both groups (p<0.05).
Conclusion: The addition of Neuromuscular Electrical stimulation in maximum voluntary isometric

contraction exercise has been shown to produce greater gains in isometric quadriceps strength, thereby
reduce pain and improved function.
Keywords: Neuromuscular Electrical Stimulation, Isometric Exercise, Osteoarthritis Of Knee
INTRODUCTION is the most common symptom of OA and contributes

to significant declines in functional ability, including
Osteoarthritis (OA) is the most common
getting up off the floor and going up and down stairs 4.
rheumatological disease that causes physical
disability1. When symptoms of disease affect the knee, Risk factors for knee OA include age, female sex,
as in 10% of all adults, it results in a limited ability to obesity, trauma, and quadriceps weakness. Among
use stairs, arise from a chair, stand comfortably, walk, these quadriceps weakness may be the most amenable
and complete activities of daily living (ADLs)2.Ettinger to treatment for the prevention of knee OA 5, 6, 7. In the
et al3 reported that 50% to 71% of their sample with Bristol OA knee study, quadriceps weakness was
knee OA had difficulty in ambulation and 44% to 67% found to be the greatest single predictor of lower limb
had difficulty in transferring. Pain in the affected joint functional limitation, exceeding that of knee pain5.

It has been well established in cross-sectional Study design

studies that individuals with symptomatic knee OA
Pretest-posttest experimental group design was
have weaker quadriceps than do age-matched subjects
selected for testing the hypothesis, where a baseline
without knee OA8, 9. Treatment guidelines for OA of
reading was taken prior to the intervention, rest
the knee have considered exercise as an important non-
measurements were taken at the end of 2nd week, 3rd
pharmacological approach 10. A growing body of
week and after two week follow-up i.e. at the end of
evidence shows that exercise improves knee joint
5th week. The outcome measure, selected for this study
function and decreases symptoms 11, 12, 13. were pain, knee function and quadriceps strength.
Neuromuscular Electrical stimulation is another These variables were measured using VAS scale,
current method that has a place in the strengthening reduced WOMAC index and electronic strain gauge.
of weak muscles14. A good number of studies advocate Procedure
the use of electrical muscle stimulation as an adjunct
to muscle strengthening exercises 15, 16, 17. The subjects were screened first according to
the inclusion and exclusion criteria. The Patients were
The results of this training intensity of maximum randomized to experimental (Group A) and control
voluntary isometric contraction during neuromuscular (Group B) groups. An informed consent was obtained
electrical stimulation on the strength response of from the patients.
quadriceps femoris muscle will guide the therapist
who design the treatment plan for strengthening and Measurement of pain intensity
improve their functional outcome. Pain intensity was assessed using a horizontal
visual analog scale. The subject was asked to mark
The aim of this study was intended to evaluate the
along the line to denote his level of pain. The distance
effectiveness of the Neuromuscular Electrical
from mark 0 was calculated in cm and was recorded.
stimulation as an add-on therapy with maximum
The readings were taken at baseline (before the
voluntary isometric contraction standard exercise on
treatment) and marked as V0, at the end of 2nd week
marked as V2, at the end of 3rd week marked as V3 and
functional outcomes of the knee osteoarthritis and at the end of 5th week as V5.
pain.
Measurement of functional index
METHODS AND MATERIALS
The functional status was assessed using reduced
Subjects WOMAC scale. The readings were taken at baseline
(before the treatment), at the end of 2nd week, at the
Fifty patients with OA knee(22 women and
end of 3rd week and at the end of 5th week designated
28 men) were included in the study. The criteria for
as WOM0, WOM2, WOM3 and WOM5 respectively.
inclusion were: radiological evidence of primary
osteoarthritis with grade 2 on the Kellgren Lawrence Measurement of isometric strength
scale; both male and female patients; age between 40-
65 years; unilateral or bilateral involvement, in case of The isometric strength of quadriceps femoris was
bilateral involvement more symptomatic knee was measured using an electronic strain gauge at baseline
recorded as STN0, at the end of 2nd week recorded as
included. Subjects were excluded if they had any
STN2, at the end of 3rd week recorded as STN3 and at
deformity of knee, hip or back, soft tissue injury, any
the end of 5th week recorded as STN5.
central or peripheral nervous system involvement,
received steroids or intra articular injection within During the testing subject was made to sit on the
previous three months, systemic inflammatory disease, quadriceps table with the knee joint in 60 degrees of
uncooperative patients and those who received flexion. Thigh was stabilized with a belt; the shin pad
physiotherapy treatment in the past 6 months. was adjusted at 5.1cm superior to the medial malleolus.

The fulcrum of the lever arm was aligned with the most Terminal knee extension exercise: The knee extension
inferior aspect of the lateral epicondyle of the femur. exercise was performed with the patient in a sitting
Strain gauge was attached to the distal end of the position with the knee flexed from 30 to 0 degrees.
quadriceps table arm. Subject was given verbal The patient was instructed to maximally activate their
encouragement in order to motivate the subject to thigh muscles in order to straighten their knee. This
attain maximum effort during the 5-second exercise was of 3 sets of 10 repetitions each.
contraction. Each test includes 3 consecutive 5-second
Group B: Same set of exercise were given to Group B
trials with 30-second rest between trials. The mean of
also but the electrodes was placed away from the VMO
readings was used for the purpose of analysis.
and Rectus femoris, and reference electrode was placed
Intervention below the tibial tuberosity. Here the patients did
exercises without any instruction to recruit VMO and
Experimental group received the NMES guided Rectus femoris muscle.
isometric exercise. The other group received the
isometric exercise along with sham NMES, without Statistical Analysis
any instruction regarding muscle recruitment. Both the
group received paraffin wax bath (temperature 520 C) Statistical analysis was done using STATA 11.0
for 20-minute prior to exercise. Statistical Software. A paired t-test was used to
compare the changes in isometric quadriceps strength,
NMES Training: NMES training was performed with VAS and WOMAC in both the groups at baseline, 2nd
anEndomed 982, a two-channel neuromuscular week, 3rd week and after two week follow up i.e. at 5th
electrical stimulator provided for muscle stimulation. week. A two sample t-test with equal variances used
The stimulator produced a frequency of 2500 Hz to compare the changes in isometric quadriceps
delivered with AMF 50 HZ with 5 sec, time interval strength, VAS and WOMAC in both between the
and holding time 8 sec, ramp up and down 2 sec and groups at baseline, 2nd week, 3rd week and after two
intensity will set according to the subject’s tolerance week follow up i.e. at 5th week.
and it will be given for 25 minutes.
A statically significant difference was defined as p less
Electrode placement: Pair of standard carbon rubber than 0.05.
electrodes in moistened sponge pads will be positioned
over the femoral nerve in the femoral triangle and
RESULTS
transversely over the quadriceps muscle motor point.
Motor points were identified as the area that produced Isometric strength
greatest visible muscle contraction when electrical
stimulation intensity will be applied. The electrodes The baseline reading STN0 for both the groups was
will securely fastened using Velcro straps. statistically significant (p=0.004). On comparing the
STN2 between two groups a significant difference was
Exercise procedure obtained (p<0.001).On comparing at the end of
treatment session STN 3 between two groups a
Isometric quadriceps exercise: Patient was positioned
significant difference was obtained (p<0.001) again
in supine lying. A roll of towel was put beneath the
when comparing after two-week follow-up i.e. on 5th
knee. The patient was instructed to maximally activate
week (STN 5 ) between two groups a significant
their thigh muscles in order to straighten their knee.
This exercise was of 3 sets of 10 repetitions each. difference was obtained (p<0.001).
Table: 1.1Comparison of isometric quadriceps strength between the groups

T P
STN0 9.23±1.66 7.90±1.50 2.96 0.004
STN2 11.68±1.85 8.87±1.73 5.53 0.000
STN3 12.66±1.90 9.47±1.91 5.90 0.000

Pain Intensity session i.e. on 3rd week (V3) found to be statistically

significant between two groups (p<0.001). The final
For both the groups the baseline value V0 was readings after two-week follow-up i.e. at 5th week (V5)
statistically insignificant (p=0.209). The reading at 2nd were also found to be statistically significant between
week (V2) found to be statistically insignificant between two groups (p=0.014).
groups (p=0.158). The reading at the end of treatment
Table 1.2: Comparisonof VAS score between the groups

T P
V0 6.18±0.82 6.78±1.05 2.241 0.029
V2 3.92±0.98 4.28±0.77 1.43 0.158
V3 2.26±1.00 3.3±0.75 4.15 .000
V5 1.64±0.94 2.28±0.84 2.53 .014
Functional index of treatment session i.e. on 3rd week (WOM3) also found
to be statistically significant between two groups
For both the groups the baseline value WOM0 was (p<0.001). The final reading after 2-week follow-up i.e.
statistically insignificant (p=0.58). The readings at 2nd at 5th week (WOM5) was also found to be statistically
week (WOM2) found to be statistically significant significant between two groups (p<0.001).
between the groups (p<0.001). The reading at the end
Table 1.3: Comparison of Reduced WOMAC score between the groups

T P
WOM0 24.56±3.797 25.04±2.11 0.552 0.583
WOM2 15.88±4.10 20.04±3.67 3.77 0.000
WOM3 8.96±3.56 16.36±4.72 6.25 0.000
WOM5 6.32±3.15 14.36±5.13 6.66 0.000
DISCUSSION period. Gained improvement was also maintained

over a period of 2-week follow-up i.e. at the end of 5th
The study was designed to determine the week.
efficacy of Neuromuscular Electrical stimulation with
maximum voluntary isometric contraction training on Isometric quadriceps strength
In support of the application of NMES to the
functional outcomes of the knee osteoarthritis and
quadriceps femoris muscle, cabric et al. found
pain. The purpose of study was to assess the
increased muscle fiber size and nuclear volume plus
effectiveness of NMES as an adjunct to strength
type-II muscle heterochromatin and mitochondrial
training of quadriceps muscle in order to increase
fractions which might be expected to improve the
strength of quadriceps muscle and thereby reducing
mitochondrial oxidative capacity and fatigue
pain and improving function.
resistance of the stimulated muscle as well as its force
The results of the study demonstrated that a generating capacity.18
combination of Neuromuscular Electrical stimulation Reduction in pain intensity and functional
with maximum voluntary isometric contraction disability
exercises brought greater gains in all outcome
measures, including isometric quadriceps strength, The findings are consistent with previous
pain intensity and functional disability. These effects investigators who have reported that exercise can
were largely gained during the 3 weeks of treatment reduce pain and increase the functional abilities of OA

patients. The Fitness Arthritis and Seniors Trial11 Conflict of Interest: I declare no conflict of interest.
reported a modest 8% to 10% improvement in pain This manuscript has not been published or considered
and functioning scores as a result of 18 months of for publication by any other journal or elsewhere.
aerobic or resistance exercise among their sample of
knee OA patients. Source of Funding: Self.
Further Deyleet al12. Falconer et al97 and Fisher et Ethical Clearance: I am undertaking that subject
al98 found same positive effects of exercise program studies were taken after the prior approval of
on pain and function. It is well documented in institutional ethical committee. The procedures
literature that the impaired quadriceps strength found followed were in the accordance with the ethical
to be the greatest single predictor of lower limb standards of the responsible committee on human
functional limitation.6 experimentation and it’s fulfilled the Helsinki
Declaration of 1975, as revised in 2000(5).
So, it may be hypothesized that improvement on
muscle strength is one of the main cause of reducing REFERENCES
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1. Altman RD, Lozada CJ. Clinical features.In:
In present study, the reduction of pain and Rheumatology.3 rd Ed. Vol. 2. Eds:
disability in both groups may be attributed to increased Hochberg,Silman AJ, Smolen JS, Weinblatt ME,
quadriceps muscle strength and thereby improve Weismann MH: Mosby,2003,pp.1793-800.
stability which leads to reduction of pain and 2. Focht BC, Ewing V, Gauvin L, Rejeski WJ. The
disability. unique and transient impact of acute exercise on
pain perception in older, overweight, or obese
The results of this study indicate that the adjunctive
adults with knee osteoarthritis. Ann Behav Med
therapy of NMES was an effective means for reducing
2002; 24:201-10.
pain and disability. The analysis of difference between
3. Jadelis K, Miller ME, Ettinger WH Jr, Messier
two groups, showed statistical significant
SP.Strength, balance, and the modifying effects
improvement at 2nd, 3rd and after 2 week follow-up
of obesity and knee pain: results from the
i.e. at 5 th week. Since pain and disability are
Observational Arthritis Study in Seniors (oasis).
interdependent, a reduction in one will cause a
J Am GeriatrSoc 2001;49:884-91.
reduction in other.
4. WolheimFA.Pathogenesis of osteoarthritis. In:
Thus these results show the effectiveness of NMES Rheumatology. 3rd ED. Vol. Eds: Hochberg MC,
in the reduction of pain and improvement of function, Silman JS, Weinblatt ME, Weismann MH: Mosby,
possibly provided by its positive effect on quadriceps 2003, pp.1801-15.
muscle strength. Our results are consistent with other 5. Lawrence JS, Bremner JM, Bier F. Osteo-arthrosis:
results in the literature, in that NMES was a very prevalence in the population and relationship
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Rheum Dis1966; 25:1-24.
CONCLUSION 6. Felson DT, Anderson JJ, Naimark A, Walker AM,
Meenan RF. Obesity and knee osteoarthritis: the
In conclusion the addition of Neuromuscular Framingham study. Ann Intern Med 1988; 109:
Electrical stimulation in maximum voluntary isometric 18-24.
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rationale for the clinical use of Neuromuscular Arthritis Rheum 1998; 41:1951-9.
Electrical stimulation. 8. O’Reilly SC, Jones A, Muir KR, Doherty M.
Acknowledgement: I express my gratitude to Prof. R. Quadriceps weakness in knee osteoarthritis: the
M. Panday, HOD, Dept. of Biostatistics, AIIMS, effect on pain and disability. Ann Rheum Dis
NewDelhi for devising the study design and making 1998; 57:588-94.
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appropriately organized. SA, Braunstein EM, Katz BP. Quadriceps

weakness and osteoarthritis of the knee. Ann 14. Curries, D.P and Ralph Mann (1983) Muscular
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Rejeski WJ, Morgan T. A randomized trial 15. Mackler L.S. Delitto, A (1994) Use of electrical
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DOI Number: 10.5958/0973-5674.2014.00001.X
Comparison of the effect of Spinal Accessory Nerve

Mobilization, Integrated Neuromuscular Inhibition
Technique and Conventional Therapy on in Upper
Trapezius Trigger Point
Pajnee K1, Choteliya K2, Raghav D3, Verma M4

1
Assistant Professor, Sports, MPT (Orthopedics), Physiotherapist, 3Principal, 4Assistant Professor, Santosh Medical
2
College and Hospital, Ghaziabad, Uttar Prades
ABSTRACT
Aim: To compare the effects of Spinal Accessory nerve mobilization; Integrated Neuromuscular
Inhibition Technique and conventional treatment in treatment of Upper Trapezius Trigger Point.
Subjects: Forty five subjects between 19 and 25 years of age with nonspecific neck pain of minimum
4 on VAS scale , an upper trapezius trigger point (TrP) and decreased cervical lateral flexion to
opposite side of the upper trapezius Trigger Point were selected from the college.
Method: The subjects were randomly assigned to one of the three treatment groups: Accessory nerve
mobilization, Integrated Neuromuscular Inhibition technique or conventional treatment. Pain level
was determined by using a Visual Analog Scale, Degree of lateral flexion was determined by using a
cervical range of motion Goniometer. All subjects attended one treatment session and outcome
measures were repeated after treatment.
Results: There was no statistically significant difference between the groups before the treatment
application in pain level, lateral cervical flexion (p>0.05). The outcome measure of pain reduction
with Integrated neuromuscular inhibition technique(64%) was greater than the patients treated with
spinal accessory nerve mobilization or conventional therapy while the improvement in cervical lateral
flexion was higher with spinal accessory nerve mobilization(15%) than INIT or conventional therapy.
Conclusion: Spinal accessory nerve mobilization appears to be more effective than INIT or
conventional treatment in treating patients with non specific neck pain in upper trapezius trigger
points.
Keywords: Myofascial trigger points, Stretching, INIT, Nerve Mobilization, VAS scale, Range of motion
INTRODUCTION with hyperalgesia, psychological disturbance, and

significant restriction of daily functioning.1 A Trigger
Trigger points are most often discussed in the
Point is a hyperirritable spot within a palpable taut
setting of Myofascial pain syndromes, in which
band of a skeletal muscle that is painful on
widespread or regional muscular pain is associated
compression, stretch or overload of the affected tissues
and that can give rise to a typical referred pain pattern.2
Travell defined a Trigger Points as “a hyperirritable
Kopal Pajnee
Assistant Professor spot in skeletal muscle that is associated with a
Santosh Medical College and Hospital, Ghaziabad, hypersensitive palpable nodule in a taut band. The spot
Uttar Pradesh. is tender when pressed and can give rise to
Address : 47/25, Ground Floor, East Patel Nagar, New characteristic referred pain, motor dysfunction, and
Delhi-110008 autonomic phenomena.” 3 Recent studies have
Mobile number: 09810787863 hypothesized that the pathophysiology of Myofascial
E-mail id: kopalsportsphysio@yahoo.com Pain Syndrome and the formation of Trigger points
27. Kopal ---135--.pmd 135 5/10/2015, 5:14 PM

result from injured or overloaded muscle fibres, enrolling in the study. Forty five subjects from Santosh
leading to involuntary shorting and loss of oxygen and college of physiotherapy were conveniently selected
nutrient supply, with increased metabolic demand on and randomly assigned to the three groups by the
local tissues. Furthermore, adaptive lengthening and
lottery method, each group having 15 subjects. The
eccentric strain of the muscle may represent other
subjects in group A received Spinal Accessory nerve
mechanisms for activation of Myofascial Trigger
Points.4 mobilization. First the affected trapezius muscle is
applied with hot pack for 20 minutes in supine. Then
The various treatment techniques that are utilized the patient is placed in sidelying position on the
for treating trigger points are LASER, trigger point opposite side. The Mobilisation is started by flexing
injection, spray and stretch method, dry needling, the neck laterally and protracting the neck. The next
ultrasound, TENS, trigger point pressure release
step is to retract the shoulder and increase the neck
(TrPPR)/ischemic compression (direct inhibitory
pressure), muscle energy technique (MET), Myofascial flexion further and give oscillations (67). Then in the
release therapy (MRT), positional release therapy end of the session isolated stretching to upper
(PRT) i.e. strain counter strain technique and integrated trapezius on affected side is given held for 30 second17.
neuromuscular inhibitory technique (INIT). 5 An GROUP B receives the INIT technique. At first the
integrated neuromuscular inhibition technique (INIT) patient is applied a hot pack for the affected upper
consisting of muscle energy techniques, ischemic trapezius muscle for 20 minutes. Then the patient is
compression, and strain–counterstrain (SCS).6 The given Ischemic compression on the upper trapezius
effectiveness of INIT was reported in two case series, trigger point. Therapist places the thumb over the
which showed rapid results with decreased pain and
trigger point; slow increasing levels of pressure were
stiffness. The individual components (TrPPR, Post
applied until the tissue resistance barrier was
Isometric Relaxation , Stretching) of INIT has been
proved effective for treating Myofascial pain identified. Pressure is maintained until a release of the
syndrome5. Certain studies also explains that nerve tissue barrier was identified, that is for approximately
tissues can contribute to the origin or perpetuation of for 30 seconds for three times.(17) then was followed by
Trigger Points. Decreased extensibility of the upper application of Post isometric relaxation to the trapezius
quadrant neural structures may be associated with muscle and at the end of the session isolated isometric
shortening of upper trapezius muscle.8 contraction of upper trapezius was given for three
times with 30 second hold.(17)GROUP C receives the
METHOD conventional therapy that is hot pack for 20 minutes
The study was conducted at Santosh College of followed by stretching of the upper trapezius held for
Physiotherapy. Forty five subjects were selected for 30 seconds (17).
the study from the population of 2000 students
studying in Santosh medical college. The subjects were RESULTS
ramdomly divided into three groups of 15 subjects
each. The inclusion criteria was : A taut band or nodule The data were summarized as Mean ± SD. The age
in upper trapezius muscle, Tender nodule, Painful and pre and post (Periods) outcome measures (VAS,
restriction of neck ROM, Twitch response, male or AROM and PROM) of three groups were compared
female of age 19-25 yrs7. Subjects with any of the together by repeated measures two factor ANOVA
following were excluded: medication for pain, and the significance of mean difference within and
underlying neuromuscular pathology , Diagnosis of
between the groups was done by Tukey’ post hoc test.
fibromyalgia syndrome, History of whiplash injury,
. A two-sided (á=2) p<0.05 was considered statistically
History of cervical spine surgery, Fractures/tumours
in cervical region, Autoimmune disorder, Peripheral significant. All analyses were performed on
vascular diseases, Visual disturbance.2,7. STATISTICA (version 6.0) software.
Table 1: Age (Mean ± SD) of three groups

PROCEDURE
Group A Group B Group C
Each subject read and signed an informed consent 22.00 ± 2.00 21.00 ± 1.51 21.47 ± 1.25
form and a voluntary participation form before
27. Kopal ---135--.pmd 136 5/10/2015, 5:14 PM

Table 2: Pre and post treatments VAS scores (Mean ± DISCUSSION

SD) within the three groups
The aim of the study was to compare the effect of
Groups Pre treatment Post treatment %mean
change Accessory Nerve Mobilization, Integrated
Group A 5.53 ± 1.73 3.07 ± 1.28 44.6% Neuromuscular Inhibition Technique and
Group B 4.93 ± 1.58 1.73 ± 1.28 64.9% Conventional therapy on Upper Trapezius trigger
Group C 4.00 ± 2.07 2.33 ± 1.80 41.7% points. It was found that both the techniques Accessory
Nerve Mobilization and Integrated Neuromuscular
The mean VAS scores in all three groups decreased Inhibition Technique were found to be effective in
(improved) after the treatments and the decrease improving pain and range of motion (cervical lateral
(improvement) was evident highest in Group B (64.9%) flexion to opposite side) as compared to the
followed by Group A (44.6%) and Group C, the least conventional therapy. The decrease in VAS was
(41.7%). significant in group receiving Integrated
Table 3: Comparison (p value) of mean VAS scores
Neuromuscular Inhibition Technique than in other two
between the groups groups. The Active range of motion improved in all
the groups, and the improvement was evidently
Comparisons Pre treatment Post treatment
highest in group receiving Spinal Accessory Nerve
Group A vs. Group B 0.916 0.249
mobilization. Cesar Fernandez (2007), explained that
Group A vs. Group C 0.130 0.825
trigger points in upper trapezius muscle might
Group B vs. Group C 0.633 0.916
indirectly have a relationship with neural impairment
Comparing the mean VAS score between the in upper quadrant tissues (8). It was found in our study
groups the comparison concluded that for improving that spinal accessory nerve mobilization could also
pain in trigger point in upper trapezius, Group A and dramatically help in improving the range of motion
Group B were significantly better than Group C with as well as reducing tenderness-pain in trigger points.
Group B being the best (Group C < Group A < Group The possible reason for this improvement could be the
B). increase in the neural extensibility by the mobilization
which in turn helped in relieving the spontaneous
Table 4: Pre and post treatments AROM scores stimulation of the trigger point in trapezius muscle (9).
(Mean ± SD) within the three groups
The hypothesized benefits from neural mobilization
Groups Pre treatment Post treatment include facilitation of nerve gliding, reduction of nerve
Group A 35.49 ± 4.44 41.82 ± 4.07 adherence, dispersion of noxious fluids, increased
Group B 36.33 ± 5.73 41.89 ± 6.26 neural vascularity, and improvement of axoplasmic
Group C 33.02 ± 6.19 38.38 ± 5.21 flow (10). Effectivity of neural mobilization is thought
to be due to neural “flossing” effect, that is, its ability
The mean AROM scores in all three groups
to restore normal mobility and length relationship, and
increased (improved) after the treatments and the
consequently, blood flow and axonal transport
increase (improvement) was evident highest in Group
dynamics in compromised neural tissue (11).
A (15.1%) followed by Group C (14.0%) and Group B,
the least (13.3%). The group with the subjects receiving Integrated
Table 5 : Comparison (p value) of mean AROM scores Neuromuscular Inhibition Technique were found to
between the groups show improvement in pain after its application.
According to Travell, ischemic compression decreases
Comparisons Pre treatment Post treatment
the sensitivity of painful nodules in muscle. By
Group A vs. Group B 0.998 1.000
applying digital pressure the sarcomeres become
Group A vs. Group C 0.807 0.504
longer, tending to normalize the length of all
Group B vs. Group C 0.547 0.483
sarcomeres in that muscle fiber. Pain relief from
The comparison concluded that for improving ischemic compression treatment may result from
AROM trigger point in upper trapezius, all three reactive hyperemia in the Myofascial Trigger Point
treatments are equally effective but in the following region, counter-irritant effects, or a spinal reflex
order: Group C < Group B < Group A mechanism for the relief of muscle spasm(12). Then
27. Kopal ---135--.pmd 137 5/10/2015, 5:14 PM

followed by Post Isometric Relaxation, allows the Neuromuscular Inhibitory Technique and
lengthened sarcomeres to exert an effective elongation LASER with Stretching In the Treatment of Upper
force on the shortened sarcomeres of the contraction Trapezius Trigger Points, Journal of Exercise
knot. Immediate elongation of the muscle encourages Science and Physiotherapy, Vol. 5, No. 2: 115-
equalization of sarcomere lengths throughout the 121, 2009.
length of affected muscle fibers, and when done slowly 6. César Fernández-de-las-Peñas.”Interaction
helps to reset the new sarcomere lengths so they tend between Trigger Points and Joint Hypomobility:
to stay that way. This elongation is done by stretching A Clinical Perspective”. J Man Manip Ther, 2009;
immediately after the technique (13). The passive 17(2):74-77.
stretching directs at lengthening of the over shortened 7. Amit V Nagrale, Paul Glynn, Aakanksha Joshi,
muscle fibbers (8). The efficacy of an integrated neuromuscular
inhibition technique on upper trapezius trigger
The limitations of the study were the small sample points in subjects with non-specific neck pain: a
size, less number of trials, stretch sensation during randomized controlled trial, J Man Manip Ther.
Nerve Mobilization was subjective so research had to 2010 March; 18(1): 37–43.
depend on patient feedback which may be a wrong 8. Cesar Fernendes, De las Penas. Neural and joint
interpretation of stretch sensation and Instrumental afferences as etiologic or perpetuating factors of
error could not be ruled out. Myofascial trigger points,Barcelona,November
Acknowledgements: Nil 2007.
9. Shapour Jaberzadeh, Sheila Scutter, Homer
Conflict of Interest: Nil Nazeran, Mechanosensitivity of the median nerve
and mechanically produced motor responses
during Upper Limb Neurodynamic Test 1.
Ethical Clearance: Nil Physiotherapy 91 (2005) 94–100
10. Richard F. Ellis, B. Phty, Post Grad Dip Wayne
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Miangolarra Page. Manual therapies in 13. Simons D (2002) Understanding Effective
Myofascial trigger point treatment: a systematic Treatments of Myofasical Trigger Points. Journal
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5. Sibby, George Mathew, Narasimman, Kavitha
Vishal. Effectiveness of Integrated
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DOI Number: 10.5958/0973-5674.2014.00001.X
Effect of Physiotherapy Rehabilitation in Acute Burn

Injury Around Shoulder Joint
Thakrar Gira N1, Patel Dilip A2, Sejpal Jaykumar J3

Senior lecturer, Ahmedabad Physiotherapy College, Bopal-Ghuma Road, Ghuma, Ahmedabad, Gujarat,
1
2
Former Principal, Government Physiotherapy College, Ahmedabad, 3Medical Advisor, Intas Pharmaceuticals Ltd.,
Ahmedabad
ABSTRACT
Introduction: Joint contractures are the most common sequel of burn injury. Post burn axillary
contracture interferes with and limits the shoulder joint movement mainly. The extent of the
contracture can be controlled to some degree if an intensive and vigorous physical therapy program
is initiated during the first few days of the acute phase and continued daily throughout all phases of
burn care program. Functional impairment is a major threat during this period.
Method: We selected 22 patients with acute shoulder burn injuries for our study. We conducted this
longitudinal study at Civil Hospital, Ahmedabad. We gave physiotherapy treatment to each patient
for 6 weeks; one session of 20 minutes every day for 6 days in a week. We analyzed range of motion
of shoulder joint with goniometer, before starting treatment and after 6 weeks of physiotherapy. We
applied paired t-test for all variables; i.e., shoulder flexion, abduction and external rotation.
Results: Improvements in all variables were statistically significant (p < 0.001) which meant
physiotherapy treatment given during acute stage led to improvement in range of motion of shoulder.
Conclusion: Loss of function and deformity are avoidable outcome of burn injury in most instances,
provided there is an intervention in the early acute stage. This can preserve function and prevent or
minimize deformities.
Keywords: Post Burn Axillary Contracture, Stretching Exercise
INTRODUCTION medical attention and approximately 5000 deaths are

related to burn injury3,4.
Burn injury is necrosis and damage of tissue
secondary to exposure to an external agent such as Although these data report the extent of the health
flame, radiation or other agent of extreme temperature. care problem caused by burn injury, recent medical
Burn injuries result from thermal, electrical, frostbite, advances have significantly reduced the number of
chemical and radiation1. Burn injuries are a major deaths from burn injuries and have improved the
problem of the industrial World2. Survey data have prognosis functional abilities of surviving patients5.
indicated that more than two million persons are The survival rate has improved annually owing to
burned each year. One fourth number of these require improved resuscitation techniques, the actual medical
and surgical cares that are now available, and
continued research into the management and care in
Corresponding author: patient with burns. Because of improvement in care,
Gira N Thakrar treatment, and survival of burned patient, more
Senior Lecturer physical therapist will become responsible for treating
D2-506, Shree Darshan Apartment, these patients for a significant portion of their
Opp. Vishwakarma Temple, Chandlodia, rehabilitation in settings other than a hospital burn
Ahmedabad- 382481 unit 6-8. Burn injuries cause complex local and systemic
Email: girathakrar25@yahoo.in
28. Gira Thakrar--139--.pmd 139 5/10/2015, 5:14 PM

response involving the cardiovascular and pulmonary (ADLs). This was a prospective study of children with
system, microcirculation, metabolism, nutrition, axillary contractures scheduled for surgical release.
endocrinology, and immunology. Deep or widespread Three-dimensional upper extremity kinematic analysis
burns can lead to many complications, including was used to assess shoulder, elbow, and trunk motion
infections, hypovolemia, hypothermia, scars and during two ADLs: high reach and hand to back pocket.
keloids and long-term sequel of bone and joint During high reach, significant decreases in shoulder
problems like limiting joint movement and flexion, shoulder internal rotation, arm pronation, and
contractures. Burn injuries, regardless of the etiology, trunk extension occurred & elbow flexion increased
rarely involve a joint itself. However, the joint function significantly. In the hand to back pocket task, shoulder
is often impaired because of burns. The joint problems extension and elbow flexion decreased and shoulder
and joint deformities noted in burn patients are mostly abduction increased. Axillary contractures result in
due to physical inactivity combined with limitation of quantifiable movement changes during ADLs.
joint movement because of scar contracture3. Post burn Aggressive rehabilitation is required to prevent
axillary contracture almost interferes with and limits contracture formation.
the shoulder joint movement mainly. These are mainly
According to study by Schneider et al.10 more than
due to soft tissue deficiency from thermal or chemical
one third of the patients with a major burn injury
injury. In burn patient most frequently soft and dense
developed a contracture at hospital discharge, which
tissue contracture seen because loss of skin,
highlights the importance of therapeutic positioning
subcutaneous and loose connective tissue around joint.
and intensive therapy intervention during acute
The process of healing in burn wounds is conductive
hospitalization. This kind of finding challenges the
to the formation of hypertrophic scars and contracture
burn care community to find new and better ways of
as it is characterized by a marked increase in
preventing contractures after burn injury.
vascularity, fibroblast, myofibroblast , collagen
deposition and interstitial material. Thus, there is need to initiate physiotherapy
treatment during the first few days of the acute phase
Shoulder joint is a ball and socket type of synovial
and continued daily throughout all phases of burn care
joint. Movements mainly take place at glenohumoral
program. The acute phase generally refers to the time
joint. Thus this joint is usually having three rotational
after emergent care through wound coverage when
degree of freedom; Flexion – Extension, Abduction –
the foundations of scarring are just beginning to form.
Adduction, Medial – Lateral rotation. The articular
Functional impairment is a major threat during this
structures of the shoulder complex are designed
period. Planned exercise program, therefore are
primarily for mobility, allowing us to move and
needed to prevent undesirable burn wound healing
position the hand through a wide range of space. The
sequel. Therefore, this study was undertaken to
glenohumoral joint linking the humerus and scapula,
evaluate benefit of physiotherapy rehabilitation
has greater mobility than any other joint in the body.
initiated in acute phase of burn injury around shoulder
These characteristic advantages of the shoulder joint
joint
become source of major morbidity limiting most useful
movement of upper limbs in case if contracture
MATERIAL AND METHOD
develops after burn injury. This greatly affects daily
routine (activities of daily living-ADL) of patients and This interventional study aimed to evaluate effect
may cause major handicap3. of physiotherapy rehabilitation to improve shoulder
joint range of motions in acute stage of burn patient.
Patients with axillary burns often develop scar
We conducted this study at Government College of
contractures that restrict shoulder movement. Palmieri
Physiotherapy, Civil Hospital, Ahmedabad. Twenty–
et al. 9 evaluated how axillary contractures affect
two patients of acute burn injury (less than 10 days of
shoulder movement during activities of daily living

injury) involving shoulder joints were included in the • Passive range of motion(ROM) exercise: The goal
study. Patients in age group of 20-50 years, who had of these exercises is to gently increase range of
partial thickness and full thickness burn injury motion while decreasing pain, swelling, and
involving d” 60% body surface area were included in stiffness. We moved the shoulder joint in three
the study. Patients who had any orthopedic condition directions flexion, abduction and external rotation
that affect the shoulder joint, more than 60% of total with no effort from the patient. Therefore, it helps
body surface area burn or patient treated with skin to keep a person’s joints flexible, even if he cannot
grafting were excluded from this study. move by himself.
Fig. 2. Active ROM exercise

Physiotherapy treatment was started as soon as
possible after inclusion of patient in the study. Active range of motion (ROM) exercise: Active
Physiotherapy treatment was given to each patient for exercises were encouraged by patient from acute
6 weeks; one session of 20 minutes every day for 6 phase. Patients were carefully guided for active
days in a week. Following modes of physiotherapy 11- exercises of shoulder joint through appropriate planes
13
were given: of motion attempting completion of motion through
the entire range permitted by joint. Active range of
• Positioning: Anti-contracture positioning for motion exercises were applied on shoulder joint
shoulder joint i.e. 90 degree of abduction and flexion, abduction and external rotation movements.
external rotation was given using commercial
positioning stands, over – bed tables padded with We analyzed effect of physiotherapy treatment on
bed pillows, simple shoulder board or foam range of motion of shoulder joint with the help of
wedge. Patients were encouraged to include goniometer, before starting treatment and after 6 weeks
external rotation of the shoulder in the positioning of physiotherapy. Inter class correlation coefficient for
schedule. inter tester is 0.90 and intra tester 0.92, which suggest
goniometry is reliable for measure for outcome
• Splint: Aeroplane splint was used to immobilize evaluation14.
the axilla in 90 degree of abduction.
Statistical analysis was done using paired t-test for
Stretching exercise: Stretching exercises maintains all variables; i.e., shoulder flexion, abduction and
joint mobility and tissue pliability as well as external rotation.
minimize loss of strength and thus improve
flexibility and increase range of motion. Stretching RESULTS
was given to the limit of maximum achievable
We measured range of motion (ROM) for shoulder
range segment and was held for a slow count of flexion, abduction and external rotation initially i.e.,
10. Stretching was applied on shoulder joint before starting of treatment and after giving six week
flexion, abduction and external rotation of physiotherapy treatment. To evaluate effect of
movements. physiotherapy treatment we applied paired t-test on
values of initial ROM and after 6-weeks ROM. There
was significant improvement (p<0.001) in all ROM
after 6 weeks of physiotherapy treatment started in
acute stage of burn injury. Table-1 shows the mean
values of initial ROM and after 6-weeks ROM.
Table 1: Mean values of initial ROM and after 6-weeks

ROM
Movement Initial After 6

ROM weeks - ROM
Flexion 98.33 159.5
Abduction 94.66 160.5
External rotation 81.1 86
Fig. 1. Stretching exercise

DISCUSSION REFERENCES
The objective of the study was to determine the 1. Wolf A, Ray P. The Rehabilitation Handbook.
effect of physiotherapy rehabilitation in acute stage of 1998.
second and third degree of burn to prevent contracture 2. Demling RH. Burns. The New England Journal
and to maintain range of motion of the shoulder joint. of Medicine. 1985;313:1389–98.
3. Herndon DN. Total Burn Care: Expert Consult -
Previous study showed that incidence and severity Online. Elsevier Health Sciences; 2012.
of large joint contracture after burn injury and 4. Baker SP, O’Neill B, Ginsburg MJ, Li G. The Injury
determined predictor of contracture development Fact Book. 2 edition. New York: Oxford
therefore we selected the axilla which is one of the most University Press; 1991.
frequently affected areas by burn injury with 5. Saffle JR, Davis B, Williams P. Recent outcomes
associated cosmetic and functional problem. in the treatment of burn injury in the United
Stastical analysis showed that there is marked States: a report from the American Burn
increase in range of motion of shoulder joint. Association Patient Registry. J Burn Care Rehabil.
1995;16:219–232; discussion 288–289.
Limitations 6. Richard RL, Staley MJ. Burn Care and
Rehabilitation: Principles and Practice.
In our study we were selected limited age group Philadelphia: F.A. Davis Company; 1993.
as well as treatment duration was also very short so 7. Ward RS. Physical Rehabilitation.In: Carrougher
we did not evaluated any parameter for patient’s
GJ. Burn Care and Therapy. 1 edition. St. Louis,
functional outcome. Mosby; 1998. p. 293.
8. Moore M. The Burn Unit. In: Campbell et al.
CONCLUSION Physical Therapy for Children, St. Louis, Mo.:
This findings suggest that physiotherapy Saunders; 2011.
rehabilitation treatment, if initiated in timely manner 9. Palmieri TL, Petuskey K, Bagley A, Takashiba S,
can mitigate severity of contracting scar and make Greenhalgh DG, Rab GT. Alterations in
sequel less incapacitating, reduce need of invasive of functional movement after axillary burn scar
surgical operation in late stage, and favors early return contracture: a motion analysis study. J Burn Care
to normal life and leads to more independence in Rehabil. 2003;24:104–8.
activity of daily living. As with any aspect of the 10. Schneider JC, Holavanahalli R, Helm P, Goldstein
rehabilitation plan, all personnel- patients, their family R, Kowalske K. Contractures in burn injury:
and care takers must cooperate in ensuring compliance defining the problem. J Burn Care Res.
with the physiotherapy rehabilitation for successful 2006;27:508–14.
functional and cosmetic outcome. Further studies can 11. Fisher SV, Helm PA. Comprehensive
be done with extended duration of follow-up to Rehabilitation in Burn. March 1984. Williams &
evaluate functional parameters which can reflect long Wilkins. Philadelphia, USA. P. 96-134.
term impact of early intervention. 12. Staley MJ, Richard RL. Burns. In: O’sullivan SB,
Schmitz TJ, Physical Rehabilitation: Assessment
Acknowledgement: I am immensely grateful to the and treatment. 4th edition, 2001, Jaypee Brothers.
patients who agreed to participate in this study, New Delhi, India. P. 861
without whom this study would not have been 13. Stretching for Impaired Mobility. In: Kisner C,
possible. I am also thankful to my seniors, colleagues Colby LA. Therapeutic Exercise: Foundations and
and nursing staff who helped me in conducting this Techniques. 5 th edition, 2007. F. A. Davis
study. Company. Philadelphia, USA. p. 65-108
14. Norkin CC, White DJ. Measurement of Joint
Conflict of Interest: None Motion: A Guide to Goniometry. 2nd edition, 1995.
Source of Support: None F. A. Davis Company. Philadelphia, USA.
Ethical Clearance: Institutional ethics committee had

approved this study

DOI Number: 10.5958/0973-5674.2014.00001.X
Balance Affection in Elderly People with

Osteoarthritis of Knee and Low Back Pain
Anu Arora1, Akshata Teli2

1
Associate Professor, Physiotherapy Intern Department of Physiotherapy, Pad Dr DY Patil University, Nerul
2
ABSTRACT
Age related decline in balance is a common problem seen in geriatric age group which is further
compounded by the presence of degenerative conditions like Osteoarthritis of knee and low back
pain. Hence the aim of this research was is to study and compare affection of balance in elderly
population with Osteoarthritis of the Knee and Low back pain.
Static balance was assessed by unilateral stance on firm surface ,limit of stability (LOS) tests(Balance
Master System) and dynamic balance were assessed by time get up and go test.
Result: Assessment of static balance in patients with knee OA(8.835)and low back pain (8.7) showed
that subjects with osteoarthritis knee had statically significant greater sway as compare low back
pain subject and control group(2.185). However these differences were not statistically significant.(p-
>0.05). similar findings were seen in directional control, movement velocity, end point excursion,
Maximum excursion and reaction time.
Assessment of dynamic balance in subjects with osteoarthritis knee showed TGUP of 15.1 sec as
compared to 13.7 seconds in subjects with low back pain (13.700sec) with level of significance lesser
than 0.05 (p<0.05).
Conclusion: Statistical analysis of the data collected in the study implies that there is reduction in
static as well as dynamic balance in elderly subjects with OA Knees as well as those with LBP as
compared to normals. However, on comparing elderly subjects with OA Knees with those with LBP,
we found that there was, no statistically significant difference in the two groups with respect to Static
Balance but the elderly subjects with OA knees had lesser dynamic stability as compared to those
with LBP.
Keywords: Balance, Elderly, Low Back Pain, Osteoarthritis Knee
INTRODUCTION dependent on a sensory input from the vestibular,

visual, and somatosensory system. The central
Balance is defined as the ability to maintain
processing of this information results in coordinated
postural equilibrium while performing functional
movement either at rest (static) or in a steady state of neuromuscular responses that ensure the centre of
motion (dynamic) or to maintain the centre of mass mass remaining within the base of support in a
within the limit of base of support. Balance is the ability situation where balance is disturbed. The effective
to control COG over base of support in a given sensory control of balance relies not only on accurate sensory
environment. inputs but also on timely responses of strong muscles.
Balance is an integral component of daily functional Static balance can be defined as the ability to
activities; however, balance control is very complex maintain a base of support with minimal movement.
and multifactorial. Balancing is a complex function In other words static balance is an attempt to maintain
involving numerous neuromuscular processes. It is a position with little or no movement. Dynamic balance
29. Akshata--143--.pmd 143 5/10/2015, 5:14 PM

involves the completion of a functional task without level from disuse muscle atrophy Patient having grade
compromising one’s base of support. It is thus, the 1and 2 Osteoarthritis (according to Kellgren and
ability to perform a task while maintaining a stable Lawrence classification) Non-specific Low back pain
position (Winter et al.1990). Dynamic control is not attribute to a recognisable known specific
important in many functional tasks as it requires pathology such as infection, tumours, osteoporosis,
integration of appropriate level of proprioception, fractures, structural deformity, inflammatory disorder,
range of motion and strength4. This ability to balance radicular or cauda -equina syndrome. All participants
dynamically is very important in the prevention and were independent in activities of daily living. Able to
rehabilitation of injury. walk 10ft (3m) without shortness of breath, chest pain
or joint pain. Not depended on assistance of another
Osteoarthritis of knee and low back pain are very person or device (cane, crutch, walker). Exclusion
common musculoskeletal problem which are seen in criteria included Subject with uncompensated
elderly population. The main functional impairment cardiovascular, neurological or psychiatric diseases,
in the affection of feet forward mechanism would Amputation of Lower limb, Unable to stand up alone
further affect balance in elderly population. without another person or device aid, Severe visual
With advancing age, a chronic degenerative or hearing impairment uncorrected, Any recent
disease, the Osteoarthritis (OA), usually is detected1. surgical procedure, Bed ridden patients, Any
The knees are the joints most often affected and for addiction, Inability to understand informed consent.
their relevance in corporal biomechanics it may trigger Instruments
a negative impact on functionality. Like presence of
knee pain, characteristic of OA, back pain is also Functional impairment (postural sway as measured
usually common and these symptoms can reflect on by unilateral stance), motor impairment (dynamic
quality of life of elderly people. The manifestation of standing as measured by limit of stability (LOS) test).
low back pain is characterized by painful sensations Were evaluated using Balance Master System
and discomfort among the inferior gluteal line and (Neurocom System, Neurocom International Inc.,
costal border that can irradiated to the lower limbs Clackamas, OR.USA). The equipment provides
(LL). Low back pain is also associated with restrictions quantitative and objective data through balance that
of many activities, decrease in functional capacity and reproduces the activity of daily living (ADLS) 1,
can lead to falls. In this way, it is necessary to identify 3.
Dynamic balance was assessed through time get up
the relationship between falls and conditions like OA and go test using standardised procedures2.
and low back pain to guide elderly people which are
affected by them. In addition, the risk of falls may be Procedure
minimized with such information. All the measurements were done while patient
Purpose of study: The purpose of our present research barefoot to eliminate the effects of shoe use17. Before
is to study and compare affection of balance in elderly performing the balance tests, the patient’s age and
population with Osteoarthritis of the Knee and Low basic .anthropometric data were registered. The
back pain. balance tests took place in a discrete room free from
external distractions. Following the assessment, the
researcher positioned the patient’s feet following the
MATERIAL AND METHODOLOGY
appropriate alignments on the force platform for the
Subjects this was cross-sectional study of a sample medial malleolus and the outside border of the heel.
composed of 30 geriatric subjects; 10 patients with knee For Dynamic balance test ie Timed Get Up & Go Test,
OA and 10 low back pain subjects and 10 control one training trial was allowed before data collection.
groups. All volunteers were recruited from Unilateral Stance
orthopaedic clinic .The inclusion criteria were: age >
60 years clinical and radiological diagnosis of This test measures center of pressure (COP) sway
unilateral or bilateral knee based on the criteria of the velocity for 4 progressively more difficult functional
American Association of Rheumatism12. Participants ability including three consecutive trials lasting
with OA were included if they had knee pain, duration of 10 s: (1) standing with eyes open on a firm
Clinically and radiological diagnosed cases of patella- surface, (2) standing with eyes closed on a firm surface.
femoral and/or tibio-femoral Osteoarthritic knee, The test sequence of the conditions was identical for
Quadriceps weakness, Knee extensor strength loss, all patients. Participants were instructed to look
Loss of skeletal muscle mass leading to significant directly ahead at a screen placed approximately 2
decreases strength can be distinguished on cellular meters from the force plate formed at eye height.
29. Akshata--143--.pmd 144 5/10/2015, 5:14 PM

Patients were instructed to stand upright as steady as by contacting and receiving approval from the
possible with the arms by their sides. Research committee, Pad Dr D.Y. Patil University.
Limit Of Stability: This test quantified several Written Informed Consent was taken from all study
movement characteristics associated with the subject’s subjects.
ability to voluntary sway towards various locations
in space, and briefly maintain stability at those OBSERVATION & RESULTS
positions. Individual were asked to stand on the force
platform of the Nerocomm balance master and are A total of 30 subjects were enrolled in the The data
given verbal instruction to move multidirectional as was processed using two aspects, which were as
stated. This test checks the individual’s stability in all follows:-
8 directions (forward, right lateral, right backward,
backward, left backward, left lateral and left Descriptive statistics - for demographic data (age &
forward).The determinants of the test are reaction time, BMI)
movement velocity, directional control, end-point
excursion and maximum end-point excursion. Analytical Statistics - for outcome measures (Static &
Dynamic Balance)
Reaction Time (RT) is the time in seconds between
the command to move and the patient’s first Descriptive Statistics: Results of descriptive analysis
movement. at baseline are reported as means and standard
deviations.
Movement Velocity (MVL) is the average speed of
COG movement in degrees per second. Analytical Stastistics
Endpoint Excursion (EPE) is the distance of the first
Data was analysed using GraphPad Instat
movement toward the designated target, expressed as
Version3.10, 32 for Windows. Tables were made using
a percentage of maximum LOS distance. The endpoint
is considered to be the point at which the initial Microsoft word and figures were plotted using
movement toward the target ceases. Microsoft Office Excel 2007. Associations denoted as
statistically significant were those that yielded a p
Maximum Excursion (MXE) is the maximum distance value< 0.05, assuming a 2-sided alternative hypothesis.
achieved during the trial.
Demographics
Directional Control (DCL) is a comparison of the
amount of movement in the intended direction The mean age of the group A (OA knee) was
(towards the target) to the amount of extraneous (65.9±4.508) years. Group B (LBP) was (67.1±5.405)
movement (away from the target).
years, and Group C (control) was (66.8±6.015) years.
Ethical approval Gender based analysed was shown that 57% subject
of male & 43% of female. Graph 3 shows no statically
Permission for the study was obtained by making difference in the mean BMI of the subjects of three
a petition prior to collecting data. This was achieved group existed.(p>0.05).
Table 1. Comparison of Static & Dynamic Balance between subjects with OA Knees and Low Back Pain
Measurement mean±SD p value

OA LBP
TGUGT 15.100 13.700 0.0009
Unilateral stance Eyes open 4.75±0.9475 3.215±0.3465 0.1643
Eyes close 8.835±0.8000 8.7±0.7000 0.9990
LOS RT 0.91025±0.1867 0.87425±0.3306 0.7932
MV 2.73125±0.4549 2.83125±0.9345 0.7895
EPE 54.9±11.042 55.175±5.679 0.9509
ME 72.4375±7.646 78.2875±5.689 0.1045
DCL 59.825±12.363 68.2±10.450 0.2800
29. Akshata--143--.pmd 145 5/10/2015, 5:14 PM

Inference: No statistically significant difference was that there is a high prevalence of falls in those with
found between osteoarthritis of knee and low back knee osteoarthritis (OA) compared to healthy older
pain for static balance (unilateral stance and limit of adults. The subjects with symptomatic knee OA have
stability). However dynamic balance(TGUGT) was quadriceps weakness, reduced knee proprioception,
more affected in subjects with OA knees as compared altered pattern of muscle recruitment and increased
to LBP postural sway 6 . Pain and muscle strength may
particularly influence postural sway. The interaction
DISCUSSION between physiological, structural, and functional
abnormalities in knee OA
Static Balance
In low back pain subjects the quantum of increase
Static balance was found to be decreased in subjects in the activity of hip flexors and biceps femoris was
with osteoarthritis of knee as well as those with low much greater than the paraspinal muscle which could
back pain .The age related decline in balance occur in be the possible reason for the pathologies of lower limb
both the groups but over and above the same, there is like OA to have a more severe detrimental effect on
further decline in balance associated with balance as compared to LBP7.
biomechanical changes and presence of pain seen with
osteoarthritis of knee and low back pain. However on Clinical Significance
comparing the two no significantly significant
As Physiotherapists, we frequently come across
difference was found in Static Balance affection
elderly subjects with OA Knees and Low Back
between the two groups.
Pain.These elderly patients are known to have a age
In addition to the age related changes patient with related decline in their visual, somatosensory,
Osteoarthritis of knee have, alteration in the normal vestibular system and central processing mechanism,
knee alignment causing a biomechanical changes, thus leading a decreased in static as well in dynamic
decreased quadriceps muscle strength and altered balance. These balance affliction are further
pattern of muscle recruitment5. Pain associated with aggravated with the presence of back and knee
knee OA may play a role in balance impairment and problems. Hence, when these subjects come for
sway increase generating a reflex inhibition of knee management of their musculoskeletal complaints
muscles which yields an ineffective and imprecise appropriate attention needs to be paid to their balance
response related to postural control furthermore, knee issues and suitable strategies to enhance balance must
pain could result in lower weight bearing by affected be part of their comprehensive treatment protocol
joint, preventing the ability of a person with knee OA thereby reducing the risk of fall.
to maintain the centre of mass inside the base of
Acknowldegement: We wish to acknowledge our
support. In low back pain hip abductor increased
gratitude to Padmashree Dr.D.Y.Patil Hospital And
greatly while standing with one foot on the irregular
Research Centre, Nerul, for their kind support to this
surface, compared to standing with two feet on the
flat surface. study.
It has also been shown that visual feedback could Conflict of Interest: To the best of my knowledge,
reduce postural sway by 30-60%6. Therefore where there were no known conflicts of interest encountered
proprioception is not fully preserved, such as may in the present research.
occur in low back pain, the role of the visual apparatus Source of Support: No financial support was obtained
could be even more critical. This could account for the from any external agency for this research.
more severely affected balance with eyes closed in both
the groups.
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DOI Number: 10.5958/0973-5674.2014.00001.X
To Compare the effect of Wobble Board as Bilateral

Proprioceptive Exercise to Unilateral Leg Standing
Exercise in Knee Osteoarthritis Patients: a Randomized
Controlled Trial
Raj Laxmi Chaturvedi1, Joginder Yadav2 Sheetal Kalra3

1
MPT Student, Principal&Prof., 3Associate Prof., Dashmesh College of Physiotherapy, SGT Group of Institutions,
2
Gurgaon
ABSTRACT
Study Design: Experimental study design
Background: To our knowledge there are no prospective, randomized studies in the literature
investigating the effectiveness of two different proprioceptive techniques i.e. wobble board and
unilateral leg standing exercise in knee osteoarthritis.
Purpose of the study: To compare the effectiveness of wobble board as bilateral proprioceptive exercise
to unilateral leg standing exercise in knee Osteoarthritis patients.
Method: 20subjectswith bilateral knee osteoarthritis were randomly assigned to either wobble board
exercise group or unilateral leg standing exercise group. Readings were taken for joint reposition
error, Berg balance scale and VAS on the 1st day, 2nd week and last day of protocol i.e. 4th week.
Results: The results of the study showed that there was no significant difference in JRE, BBS, and
VAS scores between group A and B from baseline to 2nd week (p>0.05), 2nd week to 4th week
(p>0.05) and baseline to 4th week(p>0.05)
Conclusion: The null hypothesis of the study has been accepted that there is no significant difference
between the wobble board proprioceptive exercises and the unilateral propriceptive exercises for
improvement of balance and joint reposition error in patients with knee osteoarthritis.
Keywords: Arthritis, Balance, Joint position error, Proprioception
INTRODUCTION present with pain, swelling and restricted movements

leading to functional disability1. In osteoarthritis,
Osteoarthritis is a slowly evolving articular disease, earliest change seen in radiological examination is
which appears to originate in the cartilage and affects asymmetrical narrowing of joint space and
the underlying bone, soft tissues and synovial fluid1. subchondral sclerosis in medial compartment of joint
It is a non inflammatory degenerative disorder of joints mostly. Later osteophytes are seen in periphery of
characterized by progressive deterioration of articular articular surfaces of femur, tibia and patella.
cartilages and formation of new bone (osteophytes). It Symptomatic knee osteoarthritis progresses with a
is most common joint disorder, a prevalence that pattern of disease related impairements such as joint
increases with age and sex specifications, among adults pain, decreased muscle strength of the joint, decreased
45-74 years of age or older1, 2. The patients are usually ability to balance during motion, gait disability and
males above 50 years and middle aged obese female, reduced aerobic fitness and these all leads to functional
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disability and can be easily seen in grade 2 and 3 Steroid injection in past two months; 4) Inflammatory
according to kellgren-Lawrence grading scale3. So arthritis; 5) Metal implants in the knee joint
treatment of knee osteoarthritis includes both osteoporosis; 6) Acute knee ligament/meniscal injury.
strengthening exercises with conventional therapy Those who fulfilled the inclusion criteria were divided
such as short wave diathermy and proprioceptive into two different groups A and B by Convenient
exercises1. Proprioception is defined as the afferent random sampling with 10 subjects in each group.
information arising from the internal peripheral areas Before starting exercise, patients were given treatment
of the body that contribute to postural control and for pain reduction by short wave diathermy and
several conscious sensations and is closely linked to strengthening exercises. Patients in each group
balance. Having good proprioception helps to reduce received twenty minutes short wave diathermy by
the risk of injury, located with the muscles, tendons, contra planer method, thrice a week for four weeks.
ligaments and other soft tissues of body which relay The intensity of SWD was based on each subject’s
information about joint position pressure and muscle tolerance but all the subjects were advised that they
stretch to brain5. It has been reported in the literature should feel just comfortable warmth1.
that age, muscular fatigue and articular disease such
as osteoarthritis can all have negative effects on Strengthening Exercises: Static quadriceps in knee
proprioception. extension, Closed chain exercises, Seated leg press.
Quadriceps muscle weakness in knee osteoarthritis Interventions

can easily lead to strength loss. Strength loss can limit Wobble board exercises were given to group A
the activities of daily living and mobility, increase the subjects. The unilateral proprioceptive exercises were
chance of falling and possibly even cause a loss of given to group B subjects.
mechanoreceptors that can further decrease
proprioception and lead to poorer dynamic balance Group A
in knee osteoarthritis patients5,6,7.
Wobble board exercise:
Proprioception can be improved through certain
exercises known as proprioceptive exercises and with 1. Stand with feet parallel on the board, rock the
some devices such as wobble board-which are quite board forward and back.
simple and can be gradually progressed. Wobble 2. Stand with feet parallel on the board, rock the
boards are effective for improving sense of board from side to side.
proprioception and most commonly used in
rehabilitation in knee and ankle injuries7, 8. 3. Stand with feet wide apart on the board, rock the
front of the board from side to side in a circulating
METHOD movement.
Design 4. Repeat exercises 1-3 but with your knees slightly

bent and your hands on your buttocks Continue
A Pre-test/Post-test study design was used for this exercises 1–4 for 30 seconds, rest for 10 seconds
study. The independent variables were bilateral and repeat 9, 10.
proprioceptive training and unilateral proprioceptive
training. The dependent variables were joint position Group B
sense, balance and pain.
One leg balance- involved standing on affected foot
Subjects with relaxed upright posture and other leg flexed at
knee, hip and ankle for 1 minute followed by rest for
A total of 30 subjects were included in the study 10 to 20 seconds1. Blind advanced one leg balance- was
same as like one leg balance but in this the patient was
Inclusion Criteria: age group of 45-60 years, having asked to keep his or her eyes completely closed while
bilateral knee osteoarthritis with grade 2 and 3 and performing it1.
berg balance scale measurement should range between
21-40. Outcome Measures
Exclusion Criteria: were subjects with 1) recent trauma Joint position sensation was measured using
(as road traffic accidents); 2) Neurological disorder; 3) Inclinometer by reposition error test in which all the
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procedure for reposition error test was explained and properties consistent with a linear scale, at least for
demonstrated and adequate practice was done 1, 11. patients with mild-to moderate pain and thus VAS
Inclinometer was attached to the distal thigh of scores can be treated as ratio data13.
dominant extremity (approx) 1 inch above knee joint
line. Patient was standing with back against wall and RESULT
was blind folded to eliminate visual cues. Patient
performed squatting to 30 degree of knee flexion and Analysis of the data collected was done by using
maintained this position for fifteen seconds then SPSS software 15 version. The results were considered
returned to starting position of 0 degree extension; statistically significant if the p-value <0.05. Repeated
following fifteen seconds rest period then patients measures analysis of variance (ANOVA) was used to
attempted to them at the predetermined angle. These analyze the intra group difference of the knee joint
target angles were recorded and average over three reposition error, VAS and berg balance scale (BBS) at
trials was used for data analysis. Balance was baseline, 2nd week and 4th week for both groups
measured by using Berg Balance Scale. It is a valid and separately. Paired ‘t’test was performed to analyze the
reliable 14-item scale designed to measure balance in inter group difference in the knee osteoarthritis
adults in a clinical setting12. Pain was measured using patients for joint reposition error, VAS and BBS at
the visual analogue scale (VAS). The VAS has baseline, 2nd week and 4th week.
Table 1: Between group comparison of JRE in group A and B
Variable (JRE) Group AMean ± SD Group BMean ± SD t P

JRE 1 st
2.0300±1.7632 2.0600±1.13353 -.056 .956NS
JRE 2 nd
1.7500± 1.10980 1.8300 ±1.03177 -.167 .869NS
JRE 3rd 1.1800±.91748 1.5100± .94687 -.791 .439NS
NS- Not significant
Table 2: Between group comparison of BBS in group A and B
Variable (BBS) Group AMean ± SD Group BMean ± SD t P

BBS 1st 32.6000±4.85798 31.8000±4.46716 -.383 .706NS
BBS 2nd 36.4000±5.23238 34.8000±4.61399 -.725 .478NS
BBS 3 rd
40.6000±5.98517 39.8000±4.18463 -.346 .733NS
NS-not significant
Table 3: Between group comparison of VAS in group A and B
Variable (VAS) Group AMean ± SD Group BMean ± SD t P

VAS 1st 7.2000 ±1.31656 7.3000± 1.05935 -.187 .956NS
VAS 2nd 4.7000 ±1.41814 5.7000 ±1.63639 -1.460 .161NS
VAS 3 rd
2.9000± .56765 3.7000± 1.33749 -1.741 .099NS
NS- not significant
Change in JRE for Group A and B Between Group Analysis
Within Group Analysis There was no significant difference in JRE scores

between group A and B from baseline to 2nd week
There was a highly significant improvement in JRE (p>0.05), 2nd week to 4th week (p>0.05) and baseline to
score in Group B from baseline to 2nd week (p<0.001) 4th week (p>0.05). Between group comparison of JRE
from 2nd week to 4th week (p<0.001) and from baseline in group A and B *Table 1
to 4th week (p<0.001). Paired sample t-test revealed that
there was a significant increase in JRE after 4 weeks in Change in BBS Score for Group A and B
both the groups (p< .001).
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Within Group Analysis In our study Berg Balance Scale was used to note
the changes in the balance and function due to knee
There was a significant improvement in BBS score osteoarthritis. There was a significant difference within
in group A and B from baseline to 2nd week (p<0.001), both the groups in the BBS scores. Study by Felson et
from 2nd week to 4th week (p<0.001) and from baseline al. (2009) states that proprioceptive acuity as assessed
to 4th week (p<0.001). by the accuracy of reproduction of the angle of knee
Between Group Analysis flexion has modest effects on pain and physical
function limitation in knee osteoarthritis. This could
There was no significant difference in BBS scores be due to pain relief, reduction in stiffness, increased
between group A and B from baseline to 2nd week lubrication of joints, gain in strength of weak muscles,
(p>0.05), 2nd week to 4th week (p>0.05) and baseline to correct mechanical loading, improved joint stability
4th week (p>0.05). *Table 2 and thus increased quality of movement and improved
proprioception which in turn provides participants
Change in VAS Score for Group A and Group B with an opportunity to adapt to potentially
Within Group Analysis destabilizing load on knee during the study7.
There was a highly significant reduction in VAS A multi-station proprioceptive exercise program in
score in group A and B from baseline to 2nd week patients with bilateral knee OA, 6 week study was
(p<0.001), from 2nd week to 4th week (p<0.001) and from done by Sekir et al. (2005) in which balance training
baseline to 4th week (p<0.001). was given to treatment group while the control group
did not receive any exercise concluded that there was
Between Group Analysis no significant difference by the end of training in
weight bearing joint position sense. Therefore it may
There was no significant difference in VAS scores
be concluded that proprioceptive acuity takes longer
between group A and B from baseline to 2nd week
duration to show significant improvement.
(p>0.05), 2nd week to 4th week (p>0.05) and baseline to
4th week (p>0.05). *Table 3 The study done by Da-Hon Lin et al. (2009)
concluded that proprioceptive information alone
DISCUSSION (without visual feedback) can correct up to 95% of
velocity and timing errors associated with sudden
The finding of the present study suggest that perturbation in resistance during a multi-joint
addition of either bilateral and unilateral movement sequence15.
proprioceptive exercises to the conventional treatment
in both the groups has resulted in improvement of Laskowski ER et al, (1997) in his study found that
balance, pain and joint reposition error in both groups. proprioceptive based rehabilitation programs in knee
However results also revealed that there was no osteoarthritis improved objectives measurements of
significant difference between both the groups in functional status independent of changes in joint laxity
improving JRE, balance and VAS indicating that both and proprioception can be improved through
types of proprioceptive exercises are equally effective proprioceptive training16.
in patients of knee osteoarthritis.
Sachdeva Abha et al. (2010) in their comparative
Astha maggo et al. (2011) in their study showed study concluded that proprioceptive exercise and
that proprioceptive training activities provide patient conventional therapy both the two interventions
with an opportunity to adapt to potentially produced significant improvement in range of motion
destabilizing loads on the knee during rehabilitation, and reduction in VAS score. Hence the combined use
gives additional exposure to pivoting, quick starting of conventional therapy with proprioceptive exercises
and stopping and quick changes in direction and could be better choice of conservative treatment in the
challenge their balance capabilities. In their study joint management of knee osteoarthritis17.
position sense was measured by reposition error test
(RET) which showed significant improvement in Knee instability is a common complaint of patients
group C and improved joint stability and with knee OA and perturbation training (which
proprioception as compared to group A and B1. enhances proprioceptor signals to muscles) has been
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shown to reduce reported symptoms of knee so as to verify the long term effects of the treatment
instability in people with anterior cruciate ligament program which may be beneficial for the individuals
injury. The researchers reasoned that agility and suffering from knee osteoarthritis. Future research is
perturbation training techniques—which require also needed to see whether the bilateral (wobble board)
changes in direction, challenges to balance and exercises or the unilateral leg standing proprioceptive
negotiating obstacles—might help enhance function exercises if continued for a longer period of time can
in patients with knee OA18, 19. improve the balance and functional disability and
increase or restore knee joint motion.
According to the study done by Diracoglu D et al.
(2005) there is positive effect of balance exercise on CONCLUSIONS
knee osteoarthritis patients9. So this study showed that
for the conservative treatment of knee osteoarthritis Results of the study showed that addition of either
patients, if conventional therapy is given in the unilateral proprioceptive exercises or bilateral leg
combination with the proprioceptive exercises it brings standing exercises when added to conventional
better relief to the subjects in reducing pain and treatment are effective in improving joint reposition
functional disability and provides improvement in error, balance and pain. Hence our null hypothesis is
proprioception as compared to patients performing accepted that there will not be any significant
difference between the wobble board proprioceptive
Strengthening exercise only exercises and the unilateral propriceptive exercises for
improvement of balance and joint reposition error in
Limitations of Study
patients with knee osteoarthritis.
1. The sample size was small.
Acknowledgement: We are grateful to all the
2. There was no long term follow up. participants and the hospital staff who assisted in the
study.
Relevance to Clinical Practice
Conflict of Interest: We certify that there is no conflict
This study will provide useful information about of interest and the study presented is the original work
the effect of wobble board exercise and the unilateral of the authors.
leg standing exercise in improving joint reposition
error and balance in knee osteoarthritis patients thus Ethical Clearance and Funding: We certify that this
providing a better approach for individuals suffering study has been duly approved by the relevant ethical
from knee osteoarthritis leading to impaired balance. committee and is not funded by any organization.
So both types of proprioceptive exercises that is
unilateral as well as bilateral leg standing exercises REFERENCES
when added to conventional therapy can help in
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reduce potential for injury and to enhance the rheumatoid Research Centre, Univercity of
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The merits associated with the long term effects of Arch phys med. Rehabilitation: 346-50.
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examined in this study due to time constraints. So, J. Indian Assoc. Physiotherapists, 3: 2. Demirhan
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9. Dinesha AS, Arun Prasad B et al (2011). Indian J. 12. Laskowski ER, Kareen Aney et al (Year). The
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DOI Number: 10.5958/0973-5674.2014.00001.X
Effect of Retro Walking on Pain, Balance and Functional

Performance in Osteoarthritis of Knee
Nayyar Manisha1, Yadav Joginder2, Rishi Priyanka3

MPT Student, Principal & Prof., 3Assisstant Prof, Dashmesh College of Physiotherapy, Gurgaon
1 2
ABSTRACT
Background: There is a lack of clinical research regarding effectiveness of retro walking for
improvement in pain, balance and functional performance. To our knowledge there are no prospective,
randomized studies in the literature investigating the effectiveness of retro walking for improvement
in pain, balance and functional performance.
Purpose of the study: To determine which rehabilitation program either Conventional treatment or
Conventional treatment with retro walking is more effective in reducing pain and increasing balance
and functional performance in Osteoarthritis of knee.
Method: 30 subjects having osteoarthritis with grade 3 were randomly assigned to either control
group or experimental group. Readings were taken for Western Ontario and McMaster Universities
Osteoarthritis Index scale (WOMAC) and Dynamic balance through Step Test on 1st day and 4th day
of4th week.
Results: The results of the study revealed that Group B treatment protocol is better than group Ain
reducing pain and increasing balance and functional performance. There was a significant
improvement in WOMAC score in group B in 4thweek (p<0.05) compared to that in group A. There
was a significantly improvement in step test score in group B 4th week (p<0.05) as compared to
group A.
Conclusion: The results of the study revealed that retro walking is more effective in decreasing pain,
improving balance and functional performance in knee osteoarthritis patients.
Keywords: Osteoarthritis(OA), Retro walking, Pain, Balance, Functional performance, WOMAC index, Step
test
INTRODUCTION The major symptoms seen in OA knee are; Pain,

stiffness of knee joint swelling, balance deficits, loss of
Osteoarthritis (OA) is the most common form of
function and deformity. Knee pain is a major symptom
arthritis and is a major cause of, morbidity, limitation
of knee osteoarthritis (OA), and the presence and
of activity and health care utilization. Osteoarthritis is
severity of knee pain are important determinants of
a progressive disorder of the knee joints caused by
disability. Factors such as: Age, family history, obesity,
gradual loss of cartilage result in development of bony
and hyper mobility increase susceptibility to OA2. In
spurs and cysts at the margin of the joints. It is also
addition to these, local biomechanical factor like,
known as osteoarthritis or degenerative joint disease
congenital anomalies, trauma and occupational
Osteoarthritis (OA) of knee is steadily becoming the
injuries affect the occurrence and localization of OA.
most common cause of disability among the age of
The origin of pain in OA remains unclear, therefore
65years and above1.
the relationship of pain with other important
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physiological variables is worthy of exploration. METHOD

Cartilage is aneural, but other joint tissues possess pain
receptors and are potential sites for pain sensation2,1. Design
Kellgren proposed at least three clinical pain An Experimental study design was used for this
patterns that may be associated with different study. Patients were randomly allocated to 2 groups
anatomical origins in OA knee that is ligamentous and either control or experimental with 15 subjects in each
muscular pain, synovial pain, and pain resulting from group. The independent variables were Group A-
a disordered joint. Histological studies of periarticular conventional treatment and Group B-Retro waking.
tissues confirm the presence of a diffuse network of Subjects
nociceptors scattered throughout the fibrous capsule,
ligaments, tendons, articular fat pads, synovium, Subjects ranging in age from 40-60 years were
periosteum, and muscle.The great increase in the recruited from Physiotherapy OPD of Dashmesh
elderly population worldwide is the most important College of Physiotherapy.
change in the ûeld of public health in the 21st century.
Inclusion criteria included age group of 40-60 years,
It is being estimated that the number of people over
the age of 65 will be doubled in the next 20 years. male/female both subjects, subject having
osteoarthritis with grade 3, subject having WOMAC
Consequently, osteoarthritis (OA) and similar diseases
that are more frequently encountered in advanced score between 45-905.
years will become much more important from both Exclusion criteria were subjects having cardio
medical and economic aspects3. vascular disease, subjects suffering from grade 4 or 5
The sensation of proprioception can be deûned as osteoarthritis, subjects having avascular necrosis of
hip joint; subjects underwent total knee replacement,
the conscious or unconscious perception of the position
of extremities in space and being aware of the subject who injected corticosteroid within the previous
movement and position of the joints. 3 months6.
In patients with knee OA, there is a prominent loss Intervention

in proprioception compared with control subjects of Conventional treatment (Group A)
the same age and gender. It has been demonstrated
that impaired proprioception adds to functional Group A underwent treatment with hot
insufûciency by generating impairment in walking fermentation with 5 min fixed bike exercise without
rhythm, shortening step distance, and a decrease in resistance, Range-of-motion and active stretching
walking speed and total walking time3,2. exercises applied to hamstring and quadriceps
muscles, quadriceps isometric strengthening exercise.
Another benefit of retro motion includes practice In week 2: hamstring muscles isometric exercise and
and training of skills used in specific sports. Many Short-arc terminal extension exercise for the knee joint.
court and field sports, such as basketball, American In week 3: isometric exercise for the abductor and
football and soccer all incorporate backward running adductor muscles of the hip joint and short-arc
during competition. Performing the activity during terminal extension exercise with resistance for the knee
training may allow one to improve performance and/ joint. In week 4: isometric strengthening exercises with
or reduce potential for injury. resistance for the hamstring muscle and strengthening
exercise of knee and ankle7.
Back ward walking (B.W) increases stride rate,
decreases stride length and increases support time. Retro walking(Group B)
B.W. reduces overall range of motion of knee thereby
increase active functional range. Muscular structure Group B patients were treated with Conventional
supporting ankle and knee reversed their role during treatment (as in Group A) which was added upon by
B.W. In B.W. knee provides the primary power retro walking12. They were instructed to hold the Rails
producer and ankle plantar flexors shock absorber. of Tread mill for support while doing retro walking.
Direction of knee joint shear force directed forward After taking rest for 20 min and being familiarized with
initially during retro walking whereas backward in Retro Walking. Step backward and slightly to one side
forward walking4. with leading foot, bring trailing foot together with
31. Priyanka--154--.pmd 155 5/10/2015, 5:14 PM

leading foot; alternate leading foot for 10 minutes on suitable statistical analysis tests by using Graph
Tread mill. Subjects underwent retro walking on PadPrism 5 version (Graph Pad Software, Inc.7825 Fay
motorized treadmill with (self-tolerated) minimal pace Avenue, Suite 230La Jolla, CA 92037 USA).
and gradually increased depending on the patients
comfort up to 10 minutes8. The results were considered statistically significant
if the p-value < 0.05.
Outcome Measures
The characteristics of the data were presented
Pain and functional performance were measured
through tables and graphs.T-test was used to analyze
by Western Ontario and McMaster Universities
inter-group differences in pain and function. Paired
Osteoarthritis Index scale (WOMAC) and pain was
sample t-test was used to compare the intra-group
measured by step test.1st reading was taken on1st day
before treatment and 2nd reading was taken on 4th day differences in pain, balanceand functionalscale
of 4thweek after treatment. readings before and after performing the retro walking.
Within group analysis revealed that there was a

RESULTS
significant improvement in WOMAC score and step
Analysis of the data collected of pain, balance and test in group A and group B from baseline from1stday
functional performance for of 30 subjects was done by to4th day of 4thweek (p<0.001).
Table 1: With in group analysis of WOMAC-Group A
Variables Group AMean ± SD MeanDifference t p

Mean Pre WOMAC 83.866 ± 3.356 -5.73 0.006 .05*
Mean Post WOMAC 78.133 ±4.673
Pair 1- Difference of mean WOMACbetween day 1 and 4th day of 4th week
*p -Significant at p < 0.05
Table 2: With in group analysis of step test-Group A
Variables Group AMean ± SD MeanDifference t p

Mean Pre STEP TEST 61.2 ± 4.988 -0.93 0.589 .05*
Mean Post STEP TEST 60.266 ± 4.366
Table 3: Within group analysis of WOMAC Group B
Variables Group BMean ± SD MeanDifference t p

Mean Pre WOMAC 83.2 ± 6.383 -18.06 1.244 .001*
Mean Post WOMAC 65.133 ±4.273
Between group analysis revealed that there was no significant difference in WOMACand step test scores between group A and B on
baseline (p>0.05).There was a significant improvement in WOMACand step test scores in group B in 1 and 4th day of 4th week (p<0.001)
as compared to that in group A.
Table 4: Within group analysis of step test Group B
Variables Group BMean ± SD MeanDifference t p

Mean Pre STEP TEST 61.466 ± 4.485 -5.20 0.003 .001*
Mean Post STEP TEST 56.266 ± 4.366
Pair 1- Difference of mean WOMAC and step test between day 1 and 4th day of 4th week
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Table 5: Comparison of WOMAC between Group A and Group B
Pre WOMACDay 1 Group Mean ± S.D t value p Value

Pre WOMAC Day 1 A 83.866 ± 3.356 0.7230 .0012*
B 83.2 ± 6.383
Post WOMACDay 4 of 4th week A 78.133 ± 4.673 0.0193 .0009*
B 65.133 ± 4.273
*p - Highly significant
Table 5: Comparison of Step test between Group A and Group B
Day 1 STEP TEST Group Mean± S.D t Value p Value

Day 1 STEP TEST A 61.2 ± 4.988 0.878 .001*
B 61.466 ± 4.485
4th day of 4th week STEP TEST A 60.266 ± 4.366 0.018 .001*
B 56.266 ± 4.366
Pair 1- Difference of mean Step test between day 1 and 4th day of 4th week
*p - Highly significant
DISCUSSION value ± standard deviation of STEP TEST scores for

subjects in group A was 61.2 ± 4.988 on day 1 and on
The study compared the effectiveness of the two 4th day of 4th week was 60.26 ± 4.366. The mean value
methods that is conventional treatment and ± standard deviation of step test scores for subjects in
retrowalking in improving pain, balance and group B was 61.466 ± 4.485on day 1 and on 4th day of
functional performance. The subjects in this study have 4th week was 56.266 ± 4.366.
similar base values of all the dependent variables
suggesting that all group had homogenous group of In this study, we have investigated the effects of
patients. 38 Knee O.A. is a prevalent condition Pain, Balance and Functional performance exercises
contributing significantly to functional limitation and on knee OA. According to Arata statistically,
disability. Numerous studies show secondary gait significant improvement in function is seen in both the
change pattern of O.A. is due to pain, decreased muscle groups and between the groups. However, the
strength, instability and stiffness9. improvement in Group B is greater than that of Group
A12. Improvement in function may be attributed to the
The result of the study reveals that the reduction of pain, reduction in abnormal joint kinetics
Retrowalking is more effective in improving pain, and kinematics during functional movements and
balance and functional performance than the improved muscle activation pattern. Studies have
conventional treatment. The Retro walking group shown that compared to forward walking; backward
(group B) showed a significant improvement in walking creates more muscle activity in proportion to
WOMAC scores of 27.73% than the Conventional efforts. As advantages of Retro-walking include
treatment group (Group A) who showed an increase improvement in muscle activation pattern, reduction
of 7.33%.The mean value ± standard deviation of in adductor moment at knee during stance phase of
WOMAC scores for subjects in group A was 83.866 ± gait and augmented stretch of hamstring muscle
3.356 on day 1 and on 4th day of 4th week was 78.133 groups during the stride; all of these may have helped
± 4.673. The mean value ± standard deviation of in reducing disability thus leading to improved
WOMAC scores for subjects in group B was 83.2 ± function13.
6.383 on day 1 and on 4th day of 4th week was 65.133
± 4.27310,11. Backward walking, as opposed to forward walking,
reduces the compression forces at the patella femoral
The Retro walking group (Group B) also showed a joint and decreases the force absorption at the knee.
significant improvement in the step test of 9.24% than This is mainly because of the reduced eccentric
the Conventional treatment group (Group A) who function of the quadriceps muscle Both Vilensky et al
showed an increase of 1.54%. The mean and Kramer and Reid, 1993 concluded that backward
31. Priyanka--154--.pmd 157 5/10/2015, 5:14 PM

walking was different from forward walking. They REFERNCES

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Sample size was small replaced knees. J Bone Joint Surg Br. 1991;73:53–
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3. Marks R, Quinney HA, Wessel J. Proprioceptive
Follow up was not done . 15 sensibility in women with normal and
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Clinical Relevance joints. ClinRheumatol. 1993;12:170–175.
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A (1993) Determinants of disability in
improvement of pain, function and balance in both
osteoarthritis of the knee. Ann Rheum
control and experimental groups but the result of retro Dis 52:258–262.
walking is more significant than conventional 5. Badley E, Rasooly I, Webster G(1994) Relative
treatment group. Hence, the result of this study importance of musculoskeletal disorders as a
provide the evidence that Retro walking may be the cause of chronic health problems, disability, and
valuable and useful tool in clinical practice and is health care utilization: Findings from the 1990
consistence with the current use by clinical Ontario Health Survey. J Rheumatol 21:505–514.
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Estimates of the prevalence of arthritis and
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In future studies, research can be done on the wider States. Arthritis Rheum. 1998; 41:778799.
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Louis:Mosby; 1998:8 –11.
CONCLUSION 9. Martel-Pelletier J. Pathophysiology of
osteoarthritis. Osteoarthritis Cartilage. 1998; 6:
The results of the study revealed that retro walking 374–376.
is more effective in decreasing pain, improving balance 10. Davies GM, Watson DJ, Bellamy N. Comparison
and functional performance in knee osteoarthritis of the responsiveness and relative effect size of
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Osteoarthritis Index and the short-form Medical
Acknowledgement: We are grateful to all the Outcomes Study Survey in a randomized, clinical
participants and the hospital staff who assisted in the trial of osteoarthritis patients. Arthritis Care Res.
study. 1999;12:172–179.
Conflict of Interest: We certify that there is no conflict 11. Beynnon BD, Renstro¨m PA, Konradsen L, et al.
Validation of techniques to measure knee
of interest with any financial organization regarding
proprioception. In: Lephard SM, Fu FH, eds.
the material discussed in the manuscript.
Proprioception and Neuromuscular Control in
Ethical Clearance and Funding: We certify that this Joint Stability. Human Kinetics. 2000:127–142.
study has been duly approved by the relevant ethical 12. Hassan BS, Mockett S, Doherty M. Static postural
committee and is not funded by any organization. sway, proprioception, and maximal voluntary
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quadriceps contraction in patients with knee with chronic knee pain: a 30-month longitudinal,
osteoarthritis and normal control subjects. Ann observational study. Arthritis Rheum.
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13. AL-ZAHRANI KS, BAKHEIT AM. A study of the 16. Hassan BS, Doherty SA, Mockett S, et al. Effect
gait characteristics of patients with chronic of pain reduction on postural sway,
osteoarthritis of the proprioception, and quadriceps strength in
knee. DisabilRehabil. 2002;24:275–80. subjects with knee osteoarthritis. Ann Rheum
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Joan M Walker; Antoine Helewa – Text book of 17. Sharma L, Cahue S, Song J, et al. Physical
physical therapy in arthritis. functioning over three years in knee
BuckwalterJA.articular cartilage injuries. osteoarthritis: role of psychosocial, local
Climorthop 2002;21-37. mechanical, and neuromuscular factors. Arthritis
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Declines in strength and balance in older adults
31. Priyanka--154--.pmd 159 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
A Study to Find Association of 6MWD with Resting

Cardiovascular Parameters in Obese Subjects
Archana Dave
M.P.T In Cardio-Pulmonary, S.B.B College of Physiotherapy, V.S General Hospital, Ahemedabad, Gujarat
ABSTRACT
Objective: To determine if aerobic fitness assessed by 6MWD is able to predict resting
Cardiovascular function and cardiovascular disease risk factors in obese subjects.
Study Design: Observational study
Method: 30 obese females with age group between 20-30 years were selected according to inclusion
criteria. Resting SBP, DBP, HR and RPP were measured in sitting position. Aerobic fitness was assessed
using the 6MWD-test according to ATS guidelines. Correlation of measured value of 6MWD with
SBP, DBP, RPP, and HR was done.
Outcome Measures: 6MWD, SBP, DBP, HR, RPP
Results: Inverse association were observed between 6MWD and SBP (r=-0.699, p<0.01), 6MWD and
DBP(r=-0.485, p<0.01), 6MWD and HR(r=-0.694, p<0.01), 6MWD and RPP(r=-0.699, p<0.01).
Conclusion: There was a significant negative correlation of 6MWD with resting SBP.DBP, HR and
RPP in obese female subjects. It suggests that there is significant effect of aerobic fitness on resting
cardiovascular function in obese subjects.
Keywords: Obesity, Aerobic Fitness, Cardiovascular Risk Factors
INTRODUCTION The 6MWT can be used as a one-time measure of

functional status of patients, as well as a predictor of
Obesity is a major health problem affecting young
morbidity and mortality. (6)
and old throughout the world. (1)Obesity has been
increasing in epidemic proportions in Adults. (2) Normal 6MWD in healthy adults aged 20 to 50
years is 638±44 in males and 594±67 in females. (12).
Obesity is defined as abnormal or excessive fat
Obese individuals commonly present reduced lean
accumulation that presents a risk to health. It is
body mass and, consequently, a shorter 6MWD. (13)
associated with numerous co morbidities, like glucose
intolerance, insulin resistance including hypertension Poor fitness in young adults is associated with
(HTN) and major cardiovascular (CV) Risk factors. (3) obesity and the development of cardiovascular disease
risk factors. These risk factors can be modified by
General obesity which is usually described in terms
improving fitness. (5)
of body mass index (BMI) is calculated by dividing
the subject’s weight in kilograms by height in meters The 6MWD-test was firstly used in clinical settings
squared (kg/m2). (1) According to WHO classification to evaluate cardiopulmonary capacity and function,
of Asian Indians, BMI of obese people is ≥ 25 kg\ previous studies (Miyamoto et al., 2000; Rostagno et
m2. (4) al., 2003; Pinto-Plata et al., 2004) consistently
32. Archana Dave--160--.pmd 160 5/10/2015, 5:14 PM

demonstrated that 6MWD is a useful prognostic PROCEDURE

marker of mortality in CVD patients.
This Study was conducted on 30 females aged
Gradually, due to be considered a simple, safe, between 20 to 30 years. Subjects, who fulfil the
inexpensive (Rostagno et al., 2003) and valid test, inclusion criteria were selected purposefully, were
6MWD-test became popular in other settings. (7) informed about the nature of study, procedure and
usefulness of the study.
Obesity has many adverse effects on hemodynamic
and CV structure and function. In obesity due to The subjects are evaluated with a detailed history,
increased sympathetic activation, heart rate is typically physical examination. Informed written consent is
mildly increased. Weight gain is also typically obtained. All subjects are requested to abstain from
associated with increases in arterial Pressure. (2) beverages including caffeine for 12 h before the
experiment.
In this study we are using the 6MWD-test to decide
physical fitness in obese people and the aim of this After 5 min of rest in supine position, in
study is to find if there is any correlation between this temperature-controlled room, Resting BP and HR are
6MWD and the resting cardiovascular parameters in measured after taking the subject in sitting position
obese people. with the arm comfortably placed at heart level.
Average of two measures for Systolic blood pressure
MATERIALS AND METHOD (SBP), Diastolic blood pressure (DBP), Rate Pressure
Product (RPP) and Heart rate (HR) entered as data.
Materials: Sphygmomanometer
Aerobic fitness is assessed using the 6MWD-test
Stethoscope according to ATS guidelines which is a commonly used
physical performance measure in research.
Stopwatch
It was taken as follows, (6)
Two small cones to mark the turnaround points
The 6MWT was performed indoors, along a long,
Chair
flat, straight, enclosed corridor with a hard surface that
Worksheet is seldom travelled. The walking course was 30.16 m
in length. The turnaround points were marked with a
Inclusion Criteria cone. A starting line, which marks the beginning and
end of each 60.32-m lap, was marked properly.
• Gender: Females
Subjects were prepared by wearing Comfortable
• Age group: 20-30 Years clothing and appropriate shoes for walking.
• BMI ≥ 25 kg/m2 A light meal was acceptable before early morning
Exclusion Criteria or early afternoon tests. Patients should not have
exercised vigorously within 2 hours of beginning the
• Uncontrolled hypertension or diabetes test.
• Symptomatic cardio respiratory disease The patient should sit at rest in a chair, located near
the starting position, for at least 10 minutes before the
• Uncontrolled epilepsy test starts. After taking the patient to the starting point
• Chronic disabling arthritis timer was set to 6 minutes.
Instructions were given to the subjects as follows;

• Smoker
“The object of this test is to walk as far as possible
• Having any difficulty in walking
for 6 Minutes. You will walk back and forth in this
• Under treatment with drugs that can affect muscle hallway. If u get out of breathe or become exhausted.
function You are permitted to slow down, to stop, and to rest

as necessary. You may lean against the wall while GRAPH: 1 CORRELATION OF 6MWD WITH
resting, but resume walking as soon as you are able.
You will be walking back and forth around the cones.”
Then one demonstration of how to walk was given

to the subject. Proper instructions were given about
not to run and about don’t talk to anyone during walk.
At the end of 6 minutes subject was asked to stop

immediately and then marking of the spot where he
stopped was done. The number of laps covering and
the additional distance covered were recorded and
Finally the total distance walked by the subject was
calculated.
Then correlation of this value of 6MWD with above

measured resting SBP, DBP, RPP, and HR were done
independently to find out whether they are correlating r= -0.699
or not.
GRAPH: 2 Correlation of 6MWD with resting DBP
FINDINGS
Results were analysed using SPSS 16.0 version.
There was a non parametric relation of the

collecting data. So spearman rank correlation
coefficient test was used to know whether the 6MWD
was significantly correlated with resting
cardiovascular parameters or not.
Table: 1.1 Descriptive characteristics of Study sample
Parameters(N=30) Mean ± Standard SEM (Standard

Deviation Error of
Measurement)
Age(years) 23.33±2.022 0.3693
Height(m) 1.60±0.083 0.01520 r= -0.485
Weight(kg) 70.00±9.34 1.705
BMI(kg/m2) 27.29±2.55 0.4668 GRAPH: 3 Correlation of 6MWD with resting HR
SBP(mmHg) 119.97±7.854 1.4339
DBP(mmHg) 82.33±5.920 1.081
HR(bpm) 88.23±5.852 1.068
RPP 10,579.53±1317.8 2.405
6MWD(m) 538.17±34.38 6.277
Obese individuals showed reduced performance

in 6MWD comparing normal individual values. (13)
Aerobic fitness was significantly and inversely

related with resting cardiovascular parameters.
Inverse association were observed between 6MWD

and SBP (r=-0.699, p<0.01), 6MWD and DBP(r=-0.485,
p<0.01), 6MWD and HR(r=-0.694, p<0.01), 6MWD and
RPP(r=-0.699, p<0.01). r= -0.694

GRAPH: 4 Correlation of 6MWD with resting 2. Lavie CJ et al. Obesity and Cardiovascular
Disease. Journal of the American College of
Cardiology Vol. 53, No. 21, 2009
3. McArdle WD, Text book of Exercise physiology,
seventh edition-2010.
4. India reworks obesity guidelines, Makes fitness
norms tighter, The Hindu, 25 November2008
5. Carnethon MR et al. Cardio respiratory fitness
in young adulthood and the development of
cardiovascular disease risk factors. JAMA. 2003
Dec 17; 290(23):3092-100.
6. ATS Statement: Guidelines for the Six-Minute
Walk Test. March 2002
7. Fla´ via Accioly Canuto Wanderley. Six-minute
walk distance (6MWD) is associated with body
fat, systolic blood pressure, and rate-pressure
RPP r= -0.699
product in community dwelling elderly subjects.
Archives of Gerontology and Geriatrics 52 (2011)
206–210.
RESTING SBP 8. Alpert MA, Obesity cardiomyopathy:
CONCLUSION pathophysiology and evolution of the clinical
There was a significant negative correlation of syndrome. Am J Med Sci; 321:225–36, 2001.
6MWD with resting SBP.DBP, HR and RPP in obese 9. Alpert MA, Hashimi WW. Obesity and the heart,
female subjects. Am J Med Sci; 306: 117-123, MEDLINE, 1993.
10. Girotti AW et al, Lipid hydroperoxide generation,
It Suggest that there is effects of aerobic fitness on turnover, and effectors action in biological
resting cardiovascular function in obese subjects. systems. J Lipid Res; 39: 1529?1542, MEDLINE,
1998.
It reinforces the idea that a worse cardiovascular
11. Vincent HK et al. Mechanism for obesity-induced
profile, with elevated SBP, DBP, HR and RPP is related
increase in myocardial lipid peroxidation,
with lower aerobic fitness in obese subjects.
internal journals of obesity, Volume 25, March
Acknowledgement: I would like to express my 2001.
wholehearted thanks to my respected guide Dr. 12. Chetta A, Zanini A, Pisi G, Aiello M, Tzani P, Neri
Sweety Shah, my subjects for their co-operation in my M et al. Reference values for the 6-min walk test
study, my family and my friends. in healthy subjects 20-50 years old. Respire Med.
2006; 100 (9): 1573-8.
Conflict of Interest: There is no conflict of interest 13. Dourado VZ, Reference equations for the 6-
minute walk test, Arq Bras Cardiol, Feb 25, 2011.
14. Tuomo Rankinen et al, Cardio respiratory Fitness,
Ethical Clearance: Ethical approval is taken. BMI, and Risk of Hypertension: The HYPGENE
Study, Med. Sci. Sports Exer., Vol. 39, 2007.
REFERENCES 15. Carnethon MR et al, Joint Associations of Physical
Activity and Aerobic Fitness on the Development
1. Dr. Talay Yar, Department of Physiology, of Incident Hypertension: Coronary Artery Risk
University of Dammam. Resting Heart Rate And Development in Young Adults (CARDIA),
its Relationship with General and Abdominal Hypertension; 56(1): 49-55, July 2010.
Obesity in young male Saudi University
Students. Pak J Physiology 2010; 6(1)

DOI Number: 10.5958/0973-5674.2014.00001.X
Effect of Proprioceptive Training on Knee Joint Position

Sense and its Co-Relation with Jump Motion Control
Ability in Normal Healthy Untrained Individuals
Kaustubh W Lasunte1, Vishakha Shinde2, Rajashree Naik3

1
Physiotherapist, BGWH, Gondia, Maharashtra, 2Assistant Professor, 3Professor & Head of the Department, PT
Teaching & Treatment Centre, LTMMC, Sion, Mumbai, Maharashtra
ABSTRACT
Objective: To examine the correlation between knee joint position sense and jump motion control
ability in normal healthy untrained individuals pre and post proprioceptive training.
Method: Pre and post proprioceptive training, forty subjects jumped 3 times with blindfold to each
of what they thought was 25%, 50% and 75% of their maximum jump distance; also they reproduced
150, 450 and 600 of knee angles.
Measurements: Each subject was pre tested and post tested for 25%, 50% and 75% of their maximum
jump distance and 150, 450 and 600 of knee angles.
Results: Statistical tests show a relationship between jump distance and knee joint flexion angles
after the proprioceptive training which was not present before the training.
Conclusion: Proprioceptive training improved knee joint position sense and its correlation with jump
motion control ability.
Keywords: Proprioception, Joint Position Sense, Motion Control, Knee Joint, Jump, Proprioceptive Training
INTRODUCTION control point of view, because there exists a unique

set of control signals yielding maximal performance.
Various motion controls are needed so that a
human being can move in daily life. It is important to Providing control signals for submaximal
discover factors related to motion control ability in performance of a jump motion is more difficult because
order to carry out physical therapy necessary for there exists, in principle, different sets of control signals
maintaining it4. If the factor is amenable to physical which yield the same submaximal performance. Also,
therapy, then motion control ability can derive there are many levels of submaximal performances
beneficial effects from it. possible, each of which requires an appropriate set of
control signals.
Humans can execute most jump motions at
different levels of performance. Performing a jump Abilities of Joint Position Sense (JPS) are related to
motion maximally might be relatively easy from a motion control ability.1, 7 JPS is defined as the ability to
assess a limb’s position without the assistance of
vision2
Kaustubh W Lasunte The purpose of this study was to examine the
Vasundhara', Plot No. 9 & 10, Siddheshwar nagar, control mechanism that centers on the intrinsic
Saikheda road, Jail Road, Nashik Road, 422101 feedback mechanism between motion control ability,
Mobile: 9890785488 JPS ability and to investigate the abilities in healthy
E-mail id: dr.kaustubhlasunte@rediffmail.com subjects.
33. Kaustabh--164--.pmd 164 5/10/2015, 5:14 PM

MATERIALS AND METHOD
Location: Public Sector Hospital, Mumbai.
Duration of study: 4 week.
Sample size: 40
Study Design: Prospective comparative and

correlation open study.
Inclusion Criteria
1. Normal healthy untrained males (age 18-25).
Exclusion Criteria
1. Presence or history of musculoskeletal and / or

Fig .1: Measurement of maximum jump
neurological dysfunction.
2. Individuals undergoing structured training

program.
Materials used were
1. Measuring tape
2. Goniometer
3. Marker pens
4. Foam surface.
Study Description
After approval of institutional ethics committee, an

informed written consent was taken from all the
subjects. Fig .2: Measurement of 50% of maximum jump
At the beginning, Knee Joint Position Sense (KJPS)

and Jump Motion Control Ability (JMCA) were tested,
Measurement of KJPS (Knee Joint Position Sense)
followed by a 4 week proprioceptive training. Again,
KJPS and JMCA were re-tested at the end. Goniometer was placed at the lateral knee joint line
of dominant knee joint in one leg standing position.
Measurement of JMCA (Jump Motion Control
Ability) The investigator verbally guided the subjects to the
desired position in 150 of knee flexion and held for 5
In standing long jump, the subject stood behind a seconds, the subject was asked to concentrate on this
line and attempted to jump as far as possible. The position. The subjects were then asked to return the
measurement is taken from the line to the nearest point knee to neutral position. The subjects were then asked
of contact at the landing spot. to voluntarily place the knee in 150. The subjects then
verbally notified the investigator when they believed
Three attempts were given to note the maximum
the position was obtained saying “stop”. The
jump. Each subject jumped thrice each to what he
reproduction angle was recorded. The recording was
thought was 75%, 50% and 25% of his maximum jump
and mean was recorded, for a total of 9 jumps with performed for total of three times and mean was
blindfold. True 25, 50 and 75% of were calculated from recorded. This difference between actual 150, 450 and
the maximum jump values. Difference between mean 600 angle and mean of reproduction angle was the
and calculated value was the “error”. “error”.
33. Kaustabh--164--.pmd 165 5/10/2015, 5:14 PM

14. One leg stance with 150 knee flexion
Fig. 3: Testing of knee joint position sense (KJPS)
The Training Program: 4 week, 5 days/week (each

session 20 mins)
On floor with eyes open
1. One leg stance

Fig. 5: Exercise no. 10
On floor with blindfold
5. One leg stance
On foam surface with eyes open
9. One leg stance
On foam surface with blindfold
13. One leg stance Fig. 4: Exercise no. 2
33. Kaustabh--164--.pmd 166 5/10/2015, 5:14 PM

Training program started with the first exercise and successfully. This was done till the subjects completed
if they performed it successfully without a loss of all exercises. If any subject completed the last exercise
balance (touching the other leg to the surface) and before 4 weeks then, last and the most challenging
completed 10 repetitions, they progressed to the next exercise was performed for the remaining duration. If
exercise. If they failed to perform any exercise, then, any subject could not complete the exercises by 4
they repeated the same exercise until it was performed weeks, still then, at the end the parameters were tested.
FINDINGS
Table 1: Difference of means for pre and post proprioceptive training of 150 KJPS
KJPS15° pre training post training

Mean 18.72 15.76
Observations 40 40
P Value 5.19489E-08
Paired t-test p = 5.19489E-08, p < 0.05 statistically significant
Table 2: Difference of means for pre and post proprioceptive training analysis on 75% of maximum Jump of JMCA
JMCA ( 75% of Maximum Jump) pre training post training

Obtained Calculated Obtained Calculated
Mean 134.85 141.10 143.51 143.20
Error 6.3 0.3
Percentage Error 4.67 0.20
P Value 6.90115E-05
By paired T-test p =6.90115E-05, p < 0.05 statistically significant
Table 3: Difference of means for pre and post proprioceptive training analysis on 50% of maximum jump of JMCA
JMCA ( 50% of Maximum Jump) Pre Training Post Training

Obtained Calculated Obtained Calculated
Mean 92.52 91.8 94.53 95.4
Error 0.7 0.9
Percentage Error 0.75 0.95
P Value 0.1969
By paired T-test p =0.1969. p > 0.05 not statistically significant
Table 4: Pre-training co-relation of 15°, 45° and 60° KJPS with 75% of maximum jump
KJPS 75% of Max

Jump (cm)
15° 45° 60°
Mean 18.72 48.99 65.26 133.62
r value 0.0404 0.0454 -0.0761
P Value 9.985E-33 4.774E-27 1.189E-16
By Pearson test p<0.05 significant
75% of JMCA is not co-related with all the parameters of KJPS (r=0.0404, 0.0454 and -0.0761 with 150, 450 and 600 respectively).
Table 5: Post-training co-relation of 15°, 45° and 60° KJPS with 75% of maximum jump
KJPS 75% of Max

Jump (cm)
15° 45° 60°
Mean 17.24 45.68 63.81 143.51
r value -0.3572 -0.3506 -0.2138
P Value 3.628E-36 3.424E-33 3.076E-22
By Pearson test p<0.05 significant
75% of JMCA has moderate negative co-relation with all parameters of KJPS (r= -0.3572, -0.3506 and -0.2138 with 150, 450 and 600
respectively).
33. Kaustabh--164--.pmd 167 5/10/2015, 5:14 PM

DISCUSSION the mid range9; we assume that the subjects of this age
group may be using this range of jumping more
Proprioceptive training improved KJPS and JMCA frequently. This probably might have resulted in a
apparently because subjects were better able to cross training effect9 leading to minimal errors.
reproduce angles and control jumps post training
possibly because, firstly, joint mechanoreceptors which From table and chart no. 7, co-relation of 75% of
respond specifically to end range of motion and local maximum jump with KJPS of 15° (r value = 0.0404),
compression8 were stimulated by the motion of the 45° (r value = 0.0454) and 60° (r value = -0.0761), when
exercise resulting in increased sensitivity. Secondly, statistically analyzed by Pearsons’ test, indicate that
local compression effect during Closed Kinematic there is no co-relation. This no co-relation in pre
Chain (CKC) exercises produced axial loading effect training parameters between KJPS and JMCA can be
on the joint mechanoreceptors. attributed to overshooting of target distances, which
were seen in all standing long jump and all
The increase in strength of leg extensor muscles reproduction of knee angles. This observation is
along with inhibition of stretch reflex3 and the co- consistent with the finding reported in a previous
contraction mechanism possibly resulted in studies5,6.
improvement in standing long jump. In the
literature10,11 exercise regimes which increase muscle Table and chart no. 10, shows post training co-
strength may also facilitate the neural pathways relation of 75% of maximum jump with KJPS (15°, 45°
involved in proprioception, central processing and the and 60°). For 15° (r value = -0.3588), 45° (r value = -
acquisition of motor skills. This may also account for 0.3333) and 60° (r value = -0.2420) indicate that there
the improvements in KJPS and JMCA. is a moderate negative co-relation in the post training
parameters between 75% of maximum jump with KJPS
In table and chart no.1 showing assessment of 150, (15°, 45° and 60°). This could be probably because post
450 and 600 of KJPS respectively, the mean “error” in training we obtained reduction in the errors of both
post training had reduced. In table and chart 1, for 150 KJPS and JMCA.
KJPS, the mean changed from 18.72 to 15.76. Applying
paired T test, p = 5.19E-08(statistically significant). The According to literature4, Jump distance depends on
improvements in accuracy of jumps can be probably angle of the knee joint and that the jump distance was
because the jump distance is controlled by initial angle adjusted by changing the angle of the knee joint.
of knee flexion4. The subjects who had a high ability to Changing the knee joint angle allows for control of sub-
reproduce knee joint angles were able to control jump maximal jump distances4. The subjects who had a high
distance more precisely, we obtained improved ability to reproduce knee joint angles were able to
reproducibility of KJPS. Thus, improvement in KJPS control jump distance more precisely, because the
might have resulted in the improvement of JMCA in jump distance is controlled by the knee joint angle4.
all the parameters. The control ability of sub-maximal distance was
increased by training the adjustment of the knee joint
Assessment of KJPS was done for 150, 450 and 600 flexion angle
and training program also comprised of maintenance
of knee joint position at same angles. Thus, we also
CONCLUSION
attribute the improvement of accuracy of KJPS post
training to the principle of specificity. 4 weeks of proprioceptive training resulted in
improvements in KJPS and JMCA which can be
Table and chart no. 4 shows 75% of maximum jump,
attributed to the proprioceptive training program
error had reduced to 0.28cm from 6.25cm. Applying
which stimulated the joint mechanoceptors, muscle
paired T test p value = 6.901E-05(statistically
spindles and Golgi tendon organ.
significant)
The improvements were not statistically significant
Table and chart no. 5 shows 50% of maximum jump,
in 50% of maximum jump possibly because mid range
error had reduced to 0.95cm from 0.63cm. Applying
activities are performed most frequently which might
paired T test p value = 0.1969(statistically non
have resulted in cross training effect and the subjects
significant). Our subjects comprise of males of age
were better able to reproduce angles even in pre
group 18 to 25 for whom jumping can be a day to day
training.
activity. Since, much day to day activities are done in
33. Kaustabh--164--.pmd 168 5/10/2015, 5:14 PM

We found no statistical significant co-relation with respect to the shoulder. Journal of sport
between KJPS and JMCA in pre training, probably rehabilitation. 1994;3:(228-238)
because there were more errors in jumping. We found 4. Fitzpatrick R, McCloskey D. Proprioceptive,
a moderate negative co-relation between them post visual and vestibular thresholds for the
training. The control ability of sub-maximal distance perception of sway during standing in humans.
was increased by training the adjustment of the knee J Physiol.1994; 478(173-86)
joint flexion angle, because the accuracy sub-maximal 5. Gandevia SC, McCloskey DI. Joint sense, muscle
jump distance depends on knee joint flexion angle. sense, and their combination as position sense,
measured at the distal interphalengeal joint of the
Acknowledgement: I am thankful to ‘The Almighty’ middle finger. J Physiol.1976; 260(387-407)
for giving me the energy to take up the study and 6. Grigg P. Mechanical factors influencing response
complete it. of joint afferent neurons from the cat knee. J
I am thankful to my mum and dad, for their Neurophysiol 1975; 39(1473-1484)
unconditional love and support. I am thankful to my 7. Huang MH, Lin YS, Yang RC, Lee CL. A
guide and to the Head of Department, who has comparison of various therapeutic exercises on
sacrificed considerable time to provide assistance and the functional status of patients with knee
support in my moments of need. osteoarthritis. Semin Arthritis Rheum.
2003;32(398-406)
Conflict of Interest: There is no interest of conflict 8. Kawahara Y: adjustment of jump motion, Jpn J
among the authors and all of us agree to publish the Phys Fit Sports Med, 1972, 22: 101-110
article in your journal. 9. Kisner C, Colby L. Therapeutic Exercise
foundations and Techniques.5th ed. 2007.P.178
10. Mattacola CG, Lloyd JW. Effect of a 6 week
strength and proprioceptive training program on
REFERENCES measure of dynamic balance: A single case
1. Barrack RL, Skinner HB, Cook SD, et al. Effect of design. Journal of athletic training.2; June
articular disease and total knee-position sense. 1997(127-135)
Journal of Neurophysiology.1983;12(684-687) 11. Zandwijk JPV, Bobbert MF et al. Control of
2. Bouet V, Gahery Y. Muscular exercise improves maximal and submaximal vertical jumps.
knee position sense in humans. Neuroscience Medicine & science in sports & exercise.
Letters.2000;268(143-6) December 1998(477- 485)
3. CJ Dillman, TA Murray et al. Biomechanical
differences of open and closed chain exercises
33. Kaustabh--164--.pmd 169 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Awareness of Physiotherapy as Career Option Amongst

HSC Students in Urban Area
Rutika S Potdar1, Atiya A Shaikh2

1
Intern, Lecturer, D.E. Society's Brijlal Jindal College of College of Physiotherapy
2
ABSTRACT
Aim: To find awareness of HSC students about Physiotherapy as a career option.
Objective: A] To find awareness of HSC students about Physiotherapy with reference to,
• General awareness about profession.
• Career option & Future scope.
• Earning & Remuneration.
B] To find common source of information about physiotherapy.
Material & Method: This was a survey were 300 HSC students of private classes & colleges in Mumbai
& Pune were interviewed. They had biology as an elective subject. The data was analyzed using
descriptive analysis.
Results: 40% students think, Physiotherapy is a part of medical course, ,59% students think therapist
can be 1st contact practitioner,36% think, gross earning of Physiotherapist for month is about 15000-
20000,only 54% would likes to pursue this field as career option, 49% students received information
of this course through mass media.
Conclusion: There is moderate awareness of Physiotherapy as a career option in HSC students in

urban areas.
Keywords: Awareness, Physiotherapy, Students, Career
INTRODUCTION Physiotherapist. If they already know the job demands

& scope of Physiotherapy, they can cope up with
The earliest documental origin of physiotherapy as
patients needs effectively. Thus giving their maximum
professional group dated back to 1894 when nurses in
for patient & community care. More & more students
England formed the chartered society of
will pursue Physiotherapy as career option, if they
physiotherapy.[1] Since then physiotherapy profession
already aware about the field & scope of
has flourished worldwide. In India, Physiotherapy
Physiotherapy.[2]
school opened in year 1947 in Mumbai. Physiotherapy
has been serving in society for last 60 years. No statistical or detailed studies have been
documented about awareness of students about this
As the need of Physiotherapy is increasing in major
field or their wiliness to pursue this field as their career.
medical sectors, so is the need of number of good
HSC students being the target population to pursue
Physiotherapy & other medical fields, we tried to find
Kaustubh W Lasunte
awareness of Physiotherapy in these students. The
Vasundhara', Plot No. 9 & 10, Siddheshwar nagar,
Saikheda road, Jail Road, Nashik Road, 422101 information will help us to improve awareness in this
Mobile: 9890785488 population and community if required, and take
E-mail id: dr.kaustubhlasunte@rediffmail.com appropriate measures to enhance the number of
34. Rutika--170--.pmd 170 5/10/2015, 5:14 PM

Physiotherapist in India. Thus improving patient & Table 3: Physiotherapist can work in following fields
community care.[4]
Option No. of Students Percentage
Pediatrics 24 7%
MATERIAL & METHOD
Women’s Health 47 14%
Type of study: Survey. Neurological condition 69 20%
Orthopedic problems 161 47%
Study population: HSC students. Cardiac/Respiratory
problems 42 12%
Study settings: College & Private Classes in Mumbai
and Pune. Table 4: Information about this course ?
Sample size: 300 participants. Option No. of Students Percentage

Mass media 141 49%
Inclusion: HSC student with biology as elective Relatives 78 27%
subject, both genders Professionals 56 19%
Exclusion: Those who have already cleared HSC or Other 15 5%

yet have to attain HSC. Table 5: Gross earning of physiotherapist for month?
Material: Questionnaire. Option No. of Students Percentage
5K-10K 15 5%
Data Analysis & Interprétation: Descriptive analysis.
10K-15K 62 22%
Method: Ethics clearance from college ethical 15K-20K 105 36%
committee was taken. More than 20K 107 37%
Permission to conduct study was taken from respective

college authorities & students. Graph 1
Verbal consent from students was taken.
Participants were made to fill questionnaire.
Gathered data was analysed using descriptive

statistics.
OBSERVATION & RESULTS
Demographic data
Out of 300 participants, 196 (65%) had PCMB as

their elective group and 207(69%) students were
females.
Table 1: Physiotherapy is part of

Graph 1
Nursing 10 3%
Paramedical 115 39%
Medical 120 40%
Allied health 54 18%
Table 2: Physiotherapy treatment includes

Massage 52 15%
Exercises 156 46%
Pain management 91 27%
Hot or Cold Therapy 14 4%
Machine treatment 27 8%
34. Rutika--170--.pmd 171 5/10/2015, 5:14 PM

Graph 1 physiotherapy from other medical counterparts also

should be increased which will serve as a effective
source of information for community.
Although 36% participants thought average income

of therapist is Rs.15,000-20,000 which is seen in Table
5 but we have observed that, a competent therapist
earns more than 20,000-30,000 . The remuneration
depends on the hours and practice setting and field of
practice.
49% participants thought physiotherapists can

prescribe medicines as shown 1 in graph. Although
Physiotherapy students learn Biochemistry &
DISCUSSION Pharmacology in their curriculum, the main
functioning is on learning the body functioning &
This was a survey were students were asked
questions related to physiotherapy with respect to its physiological relationship between different body
affiliation ,treatment options included ,ability to components, effect of pharmacological agents of
prescribe medicines or be first contact practitioner , functioning of body. They know the mode of action of
branches , gross remuneration ,source of information drugs, their effect of systems & their side-effects on
and students preference as a career option. body. Thus they prescribe exercises more effectively
as compared to prescribing medicines.
Table 1 shows, 37% participants thought
Physiotherapy as a medical field, although it is an 59%participants thought therapist can be first
allied health. contact practitioner is shown in Graph 2. Many
Physiotherapist work in hospitals, but the no. of
46% participants thought Physiotherapy treatment independent clinics is increasing day by day as the
includes only exercises is shown in Table 2 but referral practice is blooming in community. Many of
physiotherapists have been using pain management them also have been working independently as
techniques, hot & cold therapy, machine treatment like qualified 1st contact practioner. They take home visit
IFT, US, Laser, Matrix, Mentamove, Electrical for patients who are not able to come to their clinics.[5]
stimulation, Paraffin wax bath, Whirlpool etc. Adjuncts
to exercise, options like mobilization, myofacial As represented in graph 3, 54% participants
release, craniosacral therapy, neural tissue tension, etc expressed the interest to pursue this field as career
have been widely used.[3] options. As the awareness about self care & quality of
life is improving, there is increase in students pursuing
47% participants thought Physiotherapist work in
physiotherapy as career option.
orthopaedic field is shown in Table 3, but also they
effectively work in neurological conditions, cardio-
CONCLUSION
respiratory & paediatrics conditions as well as in
women’s health problems. [4] Although need of • From the survey, we conclude that there is
qualified therapists is increasing in society, lack of moderate awareness of Physiotherapy in HSC
awareness of physiotherapy in many hospitals & students in urban areas.
private clinics pay less to the therapists.
• 54% would like to pursue Physiotherapy as a
49% participants said they received information career option.
about Physiotherapy through Mass-media is shown
in Table 4. Thus it shows mass-media as a main Future Scope
contributor to spread information about this field. To
• Large sample size can be taken.
increase awareness of Physiotherapy in society for
rehabilitation, number of physiotherapist should • Students from rural areas can be included.
increase which will work effectively in patient &
community care. The awareness and promotion of Clinical Implication
34. Rutika--170--.pmd 172 5/10/2015, 5:14 PM

• This information will helps to improve the REFERENCES

awareness of Physiotherapy amongst students &
their parents with the reference of: 1. Chartered Society Of Physiotherapy “History of
Chartered Society Of Physiotherapy” retrieved
- Awareness about profession. 2008;5;29.
2. Yashaswi Agarwal, Nalina Gupta, Manish
- Career option & Future scope.
Agarwal, Awareness about physiotherapy
- Earning & Remuneration. among higher secondary students &
perseverance among physiotherapy students &
- Main source of information. professionals in Meerut. Indian Journal Of
Physiotherapy & Occupational Therapy- An
• Thus for spreading awareness, mass media may
International Journal 2012;176.
be used as main contributor.
3. Clinical electrophysiology & wound
Acknowledgement: We would like to thank students, management curriculum content guidelines for
and principals of all schools visited. Dr.Apara electrophysiological evaluation in section of
Sadhale(PT), D.E Society’s Brijlal Jindal College of American Physical Therapy Association-2005.
Physiotherapy, Pune for their support and 4. American Physical Therapy Association
encouragement. We are grateful to authors ,editors and background 2008.
publishers of all those articles, journals and books from 5. Physical therapist assistant (PTA) Education
where the literature of this article has been reviewed Overview” American Physical Therapy
and discussed. We are also grateful to IJPOT editorial Association 2011.
board members and team of reviewers who have
helped to bring quality to this manuscript.
Sponsorship/ Financial Assistance: Nil.
Conflict of Interest: Nil.
34. Rutika--170--.pmd 173 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Relationship of Depression, Anxiety, Stress and

Kinesiobhobia with Balance Function in Individuals with
Different Chronic Pain Conditions
Amruta Nerurkar1, Hemangi Thali2

1
Associate Profesor Dep of Physiotherapy, 2Physiotherapist, Pad. Dr. D. Y. Patil University. Nerul Navi Mumbai
ABSTRACT
Chronic pain is defined as pain that has lasted longer than three-six month where perception,
interpretation and evaluation of pain depends on increased peripheral and central nervous system
responsiveness to peripheral noxious and non noxious stimuli. Several studies in the past say that
chronic pain is accompanied with depression, anxiety, stress and kinesiophobia. The fear avoidance
model explains changes in motor behavior resulting from pain that progress from acute to chronic.
From the literature thus reviewed, one indentifies a possible relationship between motor function in
chronic pain conditions and cognitive functioning with respect to the depressive thoughts that
accompany chronic pain. The present study aims to study the relationship between these psychological
domains and balance function in individuals with chronic pain.120 individuals with chronic pain
conditions participated as subjects in the study. Balance function was assessed using bergs balance
scale. DAS scale was used to determine the presence and severity of depression, stress and anxiety
and TAMPA score was used to assess kinesiophobia. When 120 subjects were studied for the
correlation between balance the psychological dysfunction, no significant correlation was found.
However when the subjects with balance score of 56 (full score of berg balance scale) were excluded
from the analysis, the relationship between balance & kinesiophobia (Spearman r = -0.08465, The
two-tailed P value is 0.6035), anxiety (Spearman r = -0.2127, The two-tailed P value is 0.1877), stress
(Spearman r = -0.03286, The two-tailed P value is 0.8405) was found to be consistently negative
though not statistically significant. The relationship between balance & depression (Spearman r = -
0.4811, the two-tailed P value is 0.0017) was negative with high degree of statistical significance.
Thus in this study all the subjects with chronic pain were not found to have balance issues.
Conclusion: In chronic pain conditions there seems to be a relationship between psychological

functions i.e. the cognitive& affective features of a person's profile and balance function only in cases
when balance appears to deviate from normal.
Keywords: Depression, Balance, fear avoidance
INTRODUCTION which can be either noxious or non-noxious. Local

tissue injury is coupled with presence of local chemical
Pain is an unpleasant sensory or emotional mediators that cause peripheral sensitization of pain.
experience associated with acute or potential tissue Four components’ of chronic pain: the physical
damage or described in term of such damage .Chronic sensation, automatic thoughts, uncomfortable
pain is defined as pain that has lasted longer than three- emotional reactions, Self defeating behavior that often
six month. In chronic pain conditions perception and result from the thinking and feeling. As pts learn to
interpretation and evaluation of pain is influenced by separate the physical sensations from their psycho
pain depends on increased peripheral and central emotional response, stress level associated with pain
nervous system, responsiveness to peripheral stimuli symptoms are reduced 1, 2 ,3, 4. Central sensitization, an
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aspect of chronic pain is a condition of the nervouse sensory environment, they need to re-weight their
system that is associated with the development and relative dependence on each of the senses.
maintenance of chronic pain. This persistent, or
regulate state of reactivity subsequently comes to Many cognitive resources are required in postural
maintain pain even after the initial injury might be control.
healed. Central sensitization also corresponds with
Because the control of posture and other cognitive
increase level of emotional distress, particularly
processing share cognitive resources, performance of
anxiety. When the nervous system is stuck in a
postural tasks is also found to be impaired by a
persistent state of reactivity pts are going to be anxious
secondary cognitive task. Falls can result from
/nervous. Modulation of pain perception in terms of
insufficient cognitive processing to control posture
its severity as well as its interpretation happens at
while occupied with a secondary cognitive task. This
various levels, like the thalamus, the primary and
leads us to the conclusion that cognitive processing
secondary somatosensory cortex (the perception of
forms an integral aspect of balance performance.
pain), the limbic lobe comprising of areas like the
hippocampus (the memory of pain) and the amygdale The coordination of postural control may be
(emotions that is associated with pain), the forebrain affected in subjects with chronic low back pain (CLBP).
(interpretation and evaluation of pain in terms of its The cause of this disturbance is not known. Specifically,
origin and consequences) , The degeneration of the it is not clear whether changes in postural control are
proprioceptive system due to changes that happen in
related to pain itself and to its stressful nature, so-called
the peripheral receptors as well as the sensory
‘‘pain interference’’. In humans, discharge from high-
neurological system may contribute to the changes in
threshold nociceptive afferents interacts with spinal
modulation of pain and there by its interpretation and
motor pathways as well as with primary
evaluation. Several studies in the past say that chronic
somatosensory and motor cortex. These complex
pain leads to depression, anxiety, stress and
actions are likely to contribute to adaptive changes in
kinesiophobia. A depressive disorder is not a passing
postural control.
blue mood but rather persistent feelings of sadness &
worthlessness & a lack of desire to engage in formerly Studies done in patients with CLBP have been
pleasurable activities. Anxiety is the subjectively found to have abnormalities of the soleus H-reflex17
unpleasant feeling of dread over something unlikely which depends on the activation of large-diameter
to happen, such as the feeling of imminent death. It is mechano-receptive afferents (group Ia fibers) in the
often accompanied by muscular tension restlessness, muscle. It is known that changes in Ia input may result
fatigue & problems in concentration. Stress: is a in altered proprioception and distortion of sensory
psychological & physical response of the body that maps. In addition, altered processing of non-noxious
occurs whenever we must adapt to changing afferent information from large-diameter afferent
conditions, whether those conditions be real or fibers has been suspected to contribute to some aspects
perceived, positive or negative. of pain.
Three main types of movement strategies in balance Depression and kinesiophobia are also recognized
control are the ankle strategy, the hip strategy and the as feature of chronic pain.
stepping strategy can be used to return the body to
equilibrium in a stance position. Individuals can Neuroendocrine studies done in individuals with
influence which strategy is selected and the magnitude depression have reported deviation of the
of their responses based on intention, experience and Hypothalamo-pituitary-thyroid, hypothalamo-
expectations. Anticipatory postural strategies, before pituitary-adrenal, nor epinephrine and dopamine
voluntary movement, also help maintain stability by secretions from normal.
compensating for anticipated destabilization
From the literature thus reviewed, one indentifies
associated with moving a limb.
a possible relationship between motor function in
Sensory information from somatosensory, visual chronic pain conditions and cognitive functioning in
and vestibular systems must be integrated to interpret general and specially the depressive thoughts that
complex sensory environments. As subjects change the accompany chronic pain.
35. Amruta--174--.pmd 175 5/10/2015, 5:14 PM

The present study aims to study the relationship

between these psychological domains and balance
function in individuals with chronic pain.
MATERIALS AND METHODOLOGY
120 Individuals suffering from chronic pain

conditions participated in the study and they are
classified into 4 categories( 30 each) based on the area
of involvement i.e. back pain, knee pain, cervical pain
Spearman r = -0.2127, the two-tailed P value is 0.1877, considered
& shoulder pain. Individuals suffering from any not significant.
known psychological conditions; acute pain conditions
Fig 2. Relationship b/w BBS and Anxiety in subjects with score <
& any known neurological illness & inability to
56 on BBS
understand written material were excluded from the
study. Study design: cross sectional correlational.
Subjects were assessed for their balance using berg

balance scale. They were then administered following
questionnaires: 1) TAMPA scale of kinesiophobia 2)
DASS scale
DASS (Depression, Anxiety and Stress scale), is a

self report inventory where each of the three scales
contains 14 items, divided into subscales of 2-5 items.
Kinesiobhobia was measured using the TAMPA

scale.
Spearman r = -0.4811, the two-tailed P value is 0.0017, considered
very significant.
The TSK questionnaire comprises 17 items
assessing the subjective rating of kinesiobhobia. Fig 3. Relationship b/w Depression and BBS in subjects with
scores< 56 on BBS.
DASS: I.e. levels of depression, anxiety & stress
were tested for their individual correlations with scores RESULTS AND DISCUSSION
on BBS.
In the present study when the entire sample of 120
Scores of kinesiobhobia were tested for its subjects was studied for the correlation between
correlation with scores on BBS balance as assessed on berg balance scale & the
psychological dysfunction like kinesiophobia,
The statistical analysis was done using graph pad
depression, anxiety, stress as reported on the respected
instat. The test of correlation used was spearman’s rho.
questionnaire, no significant correlation was found.(
fig 1) When the individual groups of subjects suffering
from knee pain, low back pain, cervical pain, shoulder
pain were analyzed no such correlation was seen.
However when the subjects with balance score of 56
(full score of berg balance scale) were excluded from
the analysis, the relationship between balance &
kinesiophobia, anxiety, stress was found to be
consistently negative though not statistically
significant.( fig2). Further the relationship between
balance & depression was found to be negative with
high degree of statistical significance (fig 3). Thus in
Spearman r = 0.1361, the two-tailed P value is 0.1384, considered this study all the subjects with chronic pain were not
not significant.
found to have balance issues. It can be seen that in
Fig. 1. Relationship b/w BBS and Anxiety on DASS (120 subjects) chronic pain conditions there seems to be a relationship
35. Amruta--174--.pmd 176 5/10/2015, 5:14 PM

between psychological functions i.e. the cognitive& affects the fight-or-flight response, activating the
affective features of a person’s profile and balance sympathetic nervous system to directly increase heart
function only in cases when balance appears to deviate rate, release energy from fat, and increase muscle
from normal. readiness. The previous study has reported a sub
sensitivity of the alpha 2 adrenergic receptors in
Depression has been associated with decreased individuals with depressions which leads to
pain thresholds and tolerance levels, reduced ability, inadequate negative feedback to the sources of nor
general withdrawal and mood disturbance such as adrenaline in the body which include the presynaptic
irritability, anhedonia (loss of enjoyment of good sympathetic nerve endings and the adrenal medulla
things in life), frustration and reduced cognitive leading to excessive release of nor adrenalin.
capacity. Persistance and pain beyond the expected Considering the above mentioned effects of nor
healing time is associated with physical deconditioning adrenalin / epinephrine, this should lead to hyper
such as loss of mobility, muscle strength and lowered responsiveness to any stress situations (mental or
pain thresholds (allodynia). Consequently, the physical). So this can be hypothesized as being one of
performance of daily physical activities may lead more the factors affecting planning and execution of the
easily to pain and physical discomfort. As a result, the motor plans demanded in balance. Further research
avoidance of activity becomes increasing likely, as does
needs to be perform to determine the specific effects
the risk of chronicity.11
of nor adrenalin dysregulation on balance
Dopamine was first implicated in the etiology and

treatment of depression. Evidence from clinical
investigations support the finding that depressed
patients have reduced cerebrospinal levels of
homovanillic acid (HVA), the major metabolite of
dopamine in the central nervous system.
Neuroimaging studies of medication-free depressed
patients have found decreased ligand binding to the
dopamine transporter and increased dopamine
binding potential in the caudate and putamen, a
finding consistent with the interpretation that
depressed subjects have a functional deficiency of
synaptic dopamine. The type of depressive-feeling
There are neural substrates of depression explained caused by a lack of dopamine in the brain is a very
in previous studies. Hypothalamic-pituitary-adrenal low energy depression, with lack of motivation.21, 22
(HPA) axis activity is governed by the secretion of Motor Control Perspective: In the present study,
adrenocorticotrophic hormone releasing factor (CRF)
balance function was assessed using the Berg’s Balance
and vasopressin (AVP) from the hypothalamus, which
scale which includes items that demand feed forward
activate the secretion of adrenocorticotrophic hormone
strategies of balance and motor control. Pre-orientation
(ACTH) from the pituitary, which stimulates the
into the task requires integration of all sensory
secretion of the glucocorticoids (cortisol in humans and
receptions that form the primary body scheme which
corticosterone in rodents) from the adrenal cortex. The
depends largely on functioning of the prefrontal cortex.
CRF release is found to be increased in depression with
Prefrontal cortex coordinates with the parieto-
higher levels of cortisol in circulation.8, 10
temporal-occipital lobe and is influenced by the limbic
Hypothalamo pituitary Thyroid axis is also found lobe for the formation of the basic frame of reference.
to be deviant in function with excessive secretion of
Since the prefrontal cortex requires activation from
Thyrotropin releasing factor and resultant increase in
the basal ganglia, dopamine turns out to be an
serum thyroid levels.
important mediator of balance function. Dopamine
As a stress hormone, Nor adrenaline affects parts levels have been purported as being reduced in
of the human brain where attention and impulsivity depressive states which offers insight into the possible
are controlled. Along with epinephrine, this compound inadequate functioning of the prefrontal cortex. One
35. Amruta--174--.pmd 177 5/10/2015, 5:14 PM

caveat needs to be mentioned that the dopamine 2. Gamsa A: The role of psychological factors in
reduction has not been specifically attributed to any chronic pain. 2 A critical appraisal. Pain 1994,
particular source. 3. Melzack R, Wall PD: Pain mechanisms: a new
theory. Science 1965, 150:971-979.
Altered activity of the limbic which has
interactions with prefrontal cortex can affect the 4. Flor H, Turk DC: Psychophysiology of chronic
disengagement and precise activations demanded of pain: do chronic pain patients exhibit symptom-
any sensory-motor function. These can be the possible specific psychophysiological responses? Psychol
reasons for the significant negative relationship Bull 1989,
observed between scores on depression and on BBS. 5. Turner JA, Franklin G, Fulton-Kehoe D, Egan K,
As anxiety and stress are psychological states not as Wickizer TM, Lymp JF, Sheppard L, Laufman JD:
rigidly established as depression, one understands the Prediction of chronic disability in work-related
relationship between these and balance being negative musculoskeletal disorders: a prospective,
yet not significant. population-based study. BMC Musculoskeletal
Disorders 2004
As a result of the above mentioned changes in the
6. Pincus T, Vlaeyen JWS, Kendall NAS, Von Korff
neurological functions as well as the overt motor
MR, Kalaukalani DA, Reiss S: Cognitive-
behavior there are certain secondary biomechanical
Behavioral therapy and psychosocial factors and
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low back pain. Spine 2002
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chronic pain who show deficiency in balance consequences in chronic musculto-skeletal pain,
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new review of chronic pain behaviour. Pain
Ethical Clearance: Taken from Ethics committee, Pad. Management
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the coping with chronic pain? Clinical Journal of
Conflict of Interest: Nil.
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in patients with physically unexplained low back
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Physiotherapy, Pad. Dr. D. Y. Patil University
14. Eccleston C, Crombez G: Pain demands
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DOI Number: 10.5958/0973-5674.2014.00001.X
A Comparative Study on Role of Different Electrotherapy

Modalities to Control Knee Osteoarthritis Pain
Bibek Adhya1, Salil Saha2

Research Scholar, Singhania University, Pacheri Bari, Jhunjhunu, Rajasthan. India, 2Assistant Professor of
1
Orthopedic ,Tripura Medical College, Hapania, Agartala & Consultant Orthopedic and Spine Surgery , Saha Spine
Centre, Chandigarh
ABSTRACT
200 Knee Osteoartritis(KOA) patients with pain randomly divided in 4 groups of 50 each. Group A
was treated with Pulsed electromagnetic energy (PEME),Group B was treated with Ultrasonic
therapy(US), Group C was treated with Interferential therapy(IFT) & Group D received no
electrotherapy for 8 weeks. All four groups received Exercise therapy. Statistical analysis revealed
no electro treatment is superior than other.
Keywords: Osteoarthritis, Pulsed Electromagnetic Energy, Ultrasonic Therapy, Interferential Therapy
INTRODUCTION rupture and the erosions, the classic characteristic of

OA (Huang et al ,2005). 3
Knee osteoarthritis is one of the common cause of
pain & disability. Osteoarthritis (OA) occurs most OA knee is characterized by presence of muscle
frequently in the knee joint, one of the most common atrophy surrounding the joint involved. Quadriceps
sites of major health problems in older subjects (Felson muscle being the commonest affected causes reduced
et al,1990). Intractable pain is the commonest symptom dynamic joint stability & decreased loading strength.
of KOA. Quality of life (QOL) patients with KOA The gradual decline in quadriceps strength seen in
significantly deteriorates due to pain and loss of knee OA has been attributed in part to arthrogenic
mobility leading to dependence and disability. 1,2 muscle inhibition.4
OA is characterized by non inflammatory Physiotherapeutic Modalities e.g. applications of

deterioration of the articular cartilage with reactive heat ,electricity , cold, US , have widely been employed
new bone formation at the joint’s surface and margins. for short-term pain relief in many musculoskeletal
The primary lesion of OA is in the articular cartilage, conditions, including KOA. But literatures on efficacy
in which the earliest change is diminution of of these application is scarce or not available.
mucopolysaccharide and chondroitin sulphate in
proportion relative to the collagen matrix, thereby Aktas et al. (2007) worked on PEME for pain. In a
unmasking the collagen. Normally, the matrix double-blinded, randomized, and controlled study,
dissipates stresses hydrostatically, but when the these researchers examined if PEME provided
collagen is unmasked, its fibers are subjected to additional benefit when used with other conservative
excessive flexural and torsional stresses, leading to treatment modalities in acute phase rehabilitation
program for pain. Results were assessed before and
after treatment. When compared with the baseline
values, significant improvements in all variables were
Corresponding author: observed at the end of the treatment in all groups (p <
Bibek Adhya
0.05). No significant difference between treatments
Sr. Physiotherapist
was observed for any of these variables (p > 0.05). The
Department of PRM, (Physiotherapy), .G.I.M.E.R.,
Chandigarh, India authors concluded that there is no convincing evidence
Email: bibek.adhya@gmail.com that PEME therapy is of additional benefit in acute
Ph.: +919876044966 phase rehabilitation program to control pain.5
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Gundog et al.(2012) demonstrated the superiority Dosage: Treatment dosages as suggested by previous
of the IFT with some advantages on pain and disability research, 11 m waves at 27.12 MHz and 150 watts for
outcomes when compared with sham IFT for the 15 minutes with condenser electrodes (Lankhorst et
management of knee osteoarthritis. However, the al., 1983); 19
effectiveness of different amplitude-modulated
Group B: Exercise, postural care & precautions, plus
frequencies of IFT was not demonstrated.6
Ultrasonic therapy.
Fuentes et al. (2010) stated that IFT as a supplement
The locations of sonication (US treatment): The regions
to another intervention seems to be more effective for
for application of therapeutic ultrasonic therapy were
reducing pain than a control treatment at discharge
selected according to locations of tender points, the
and more effective than a placebo treatment at the 3-
knee divided in four quadrants noted on orthopedic
month follow-up. However, it is unknown whether
clinical examination.
the analgesic effect of IFT is superior to that of the
concomitant interventions.7 Dosage: Therapeutic Ultrasound therapy set at a
frequency of 1.1 MHz, duty cycle 100%, ERA 4.0cm2,
Ozgönenel et al. (2009) suggested that therapeutic
intensity 1.00 w/cm2, treatment time 7.30 minutes,
US is safe and effective treatment modality in pain
applied to each treatment (the default program for
relief and improvement of functions in patients with
Arthrosis with Gymna, Pulson 200,Belgium).
knee OA.8
Sonication performed 3 times a week for 8 weeks .
Yang et al. (2011) also documented that Ultrasound
Group C: Exercise, postural care & precautions, plus
treatment significantly alleviates joint symptoms, Interferential therapy.
relieving joint swelling, increasing joint mobility and
reducing inflammation, in osteoarthritis patients.9 Patients were told what they could expect to feel and
that the sensation should be mild. The treatment
Köybasi et al.(2010) documented that addition of protocol recommended by Taylor et al. (1987) 20 was
therapeutic ultrasound to the traditional physical adopted. The intensity of the stimulus was gradually
therapy showed a longitudinal positive effect on pain, increased until the patients felt an appreciable
functional status, in patients with hip osteoarthritis. 10 sensation (moderate pins & needles). The treatment
group received interferential current stimulation at a
AIMS & OBJECTIVES frequency of 100 Hz and pulse length of one-thirtieth
of a second for the first 15 minutes of their treatment
The aim was to find out the efficacy of different
session. The stimulus was then reduced to 80 Hz for
electro-physiotherapeutic modalities, i)Pulsed
the next five minutes while other parameters remained
electromagnetic energy ii) Ultrasound & iii)
unchanged.
Interferential Therapy used in conjunction with
exercise for knee pain in osteoarthritis. Group D: Exercise ,postural care & precautions.
MATERIALS & METHOD Electrotherapy treatment given for group A,B,C 3

times weekly for 8 weeks. Group D patients was called
Sampling: 200 osteoarthritis patients,( with 3 times weekly, 8 weeks for monitoring & inspection
radiological grading) between the age group of 45 - of exercises.
65 years from the Physiotherapy department of
The exercise was carried out daily at home by all four
PGIMER, Chandigarh randomly selected for this
groups (A,B,C,D).
study. Male-32 , Female-168.
Exercise: Isometric Exercises for Hamstrings,
Study design: Experimental, a pre & post treatment
Quadriceps (10 seconds hold, 20 repetitions, 3sets
study design.
each), Hip Abductors dynamic strengthening exercises
Grouping: Randomization into 4 equal groups. (20 repititions,3 sets for each leg, with 1kg.wt.), Free
ROM exercises 10 repetitions. The patients wore knee
Group A: Exercise , postural care & precautions, plus caps while in weight bearing position for a longer time
Pulsed electromagnetic energy (Pulsed shortwave as advised (standing & walking), as exercise protocol
diathermy). is used in PGIMER Chandigarh.
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Home Program of Exercise Illiterate (nor have any literate caregivers),Unable to

comply with exercise protocol excluded.
Patients (All groups) was given the exercise
program to follow at home as per the exercise protocol Apparatus
used in PGIMER, Chandigarh. Curapuls 670, Enraf Nonius, The Netherlands;
Sonopuls 692 VS(Combo), Enraf Nonius, The
All Patients were sent to clinical psychologists
Netherlands; Sonopuls 434, Enraf Nonius, The
for routine counseling. Netherlands & Gymna Pulson 200, Belgium.
Inclusion Criteria Measuring Tape. Weighing Machine.
Measures
Confirmed OA knee by radiologic investigation,
No history of any knee surgery, Pain of duration was The severity of knee pain was evaluated by the
3 months or more. Visual Analogue Scale (VAS) after patients had
remained in a weight-bearing position (walking or
Exclusion Criteria standing) for 5 minutes in the parallel bars. The
WOMAC (Western Ontario and McMaster
Reported bleeding disorders, local malignancy, Universities) Index of Osteoarthritis for disability
Fever, Tumors, Pregnant women, scoring.
Excessive obesity (BMI>40)or any co-morbidity not Statistical Analysis & Results
allowing proper exercise protocol, People wearing
cardiac pacemakers or with any metallic implants, SPSS-20 was applied to find out the inter group
differences.
Abnormal skin sensation, Obvious deformity, History
of knee surgery or knee trauma,Hip or ankle instability,
RESULT
excessive weakness, Hip or knee replacement, Intra-
articular joint injection within 4 weeks of the study, The result of effect of various modalities are being
Inadequate communication skills in Hindi /Punjabi, presented in tabulated form.
Table 1, Intra group analysis (pre-post) for group A,B,C,D
PEME US IFT EXCS

Mean t-value Mean t-value Mean t-value Mean t-value
VAS 2.060 14.303 2.900 11.330 4.820 22.606 1.940 18.542
WOMAC 8.300 11.664 16.900 7.330 23.180 12.611 9.180 10.157
p-value <0.05 in all the groups.
Table 2: Comparison of different experimental groups(A,B,C) with group D with VAS scores.
Sum of Squares df Mean Square F Sig.

VAS Post PEME
Between Groups 39.424 7 5.632 1.483 .199
Within Groups 159.456 42 3.797
Total 198.880 49
VAS Pos tUS
Between Groups 22.575 7 3.225 .655 .709
Total 229.520 49
VAS Post IFT
Between Groups 4.817 7 .688 .504 .826
Total 62.180 49
The result is non-significant,p<0.05
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Table-3: Comparison of different experimental groups(A,B,C) with group D with WOMAC score.
Sum of Squares df Mean Square F Sig.

WOMAC Post IFT
Between Groups 2735.667 23 118.942 1.468 .172
Within Groups 2106.333 26 81.013
Total 4842.000 49
WOMAC Post PEME
Between Groups 2315.387 23 100.669 2.200 .027
Within Groups 1189.833 26 45.763
Total 3505.220 49
WOMAC Post US
Between Groups 1255.000 23 54.565 .602 .889
Within Groups 2357.500 26 90.673
Total 3612.500 49
The result is non-significant, p<0.05
Results show there is no statistically significant intergroup difference in outcome measures .
DISCUSSION significant differences in total of the scale between two

groups (p > 0.05). Applying between-group analysis,
The results shows a non significant result for both the authors were unable to demonstrate a beneficial
VAS & WOMAC scores (p>0.05) (Table-2 & 3) for symptomatic effect of PEME in the treatment of knee
intergroup though a significant result(p<0.05) found osteoarthritis in all patients.16 In our study we have
in case of intragroup (pre-post) (Table-1). It proves that observed an improvement in all the groups in OA of
none of the above electrotherapy modality is superior knee.
to other as per these findings.
Aktas et al. (2007) found no significant difference
McCarthy et al. (2006) noted that the rehabilitation between treatments for any of the variables (p > 0.05)
of knee osteoarthritis often includes electrotherapeutic in their study. The authors concluded that there is no
modalities as well as advice and exercise. One convincing evidence that PEME therapy is of
commonly used modality is PEME. Its equivocal additional benefit in acute phase rehabilitation
benefit over placebo treatment has been previously program to control pain.5 We however could not find
suggested. However the authors concluded that their any significant difference in pain & functional
systematic review provides further evidence that outcomes as measured by VAS & WOMAC scales.
PEME has little value in the management of knee When we compared & tested within the groups further
osteoarthritis. There appears to be clear evidence that could not find any significant difference (irrespective
PEME does not significantly reduce the pain of knee of male & females). We also could not find any result
osteoarthritis.15 difference based primary anatomical pain distribution
In a randomized, placebo-controlled study, Ay and site I, II, III, IV. We could not find any literature for
Evcik (2009) examined the effects of PEME on pain comparison. So the efficacy of PEME based on primary
relief and functional capacity of patients with knee pain location making the study is an unique one.
osteoarthritis. A total of 55 patients were included. Laufer et al.(2005) documented that their findings
At the end of treatment, there was statistically do not demonstrate pulsed short-wave diathermy, as
significant improvement in pain scores in both groups it is utilized in clinical settings, to be effective in the
(p < 0.05). On the other hand, no significant difference treatment of osteoarthritis of the knee.17 The present
was observed within the groups (p > 0.05). These study also supports this finding.
investigators observed statistically significant
improvement in some of the subgroups of Lequesne Fukuda et al.(2011) suggest that PSW therapy is
index (e.g., morning stiffness and activities of daily effective for the treatment of knee OA when compared
living) compared to the placebo group. However, to the active groups (17 and 33 KJ), and the control
these researchers could not observe statistically and placebo groups. 18 However our study contradicts
36. Bibek--180--.pmd 183 5/10/2015, 5:14 PM

such findings. Welch et al (2010) documented that Ultrasound

therapy appears to have no benefit over placebo or
Gundog et al (2012) in their study aimed to compare short wave diathermy for patients with knee
the effectiveness of different amplitude-modulated osteoarthritis. This study contradicts the above
frequencies of interferential current (IFT) and sham findings 12
IFT on knee osteoarthritis. They demonstrated the
superiority of the IFT with some advantages on pain
CONCLUSION
and disability outcomes. However, the effectiveness
of different amplitude-modulated frequencies of IFT This prospective randomized study on multiple
was not superior when compared with each other.6 electro modalities on osteoarthritis induced pain , were
In our study we found a comparable outcome. compared & focused the effectiveness but supremacy
However while analyzing further we did not find any over each other has failed to be established.
difference on sex difference or anatomically localized
areas. There had no difference in result in respect to
different age & sex group. Anatomical localization of
Fuentes et al.(2010) documented that Interferential tender spots did not have any influence on the outcome
current as a supplement to another intervention seems of the electro modalities.
to be more effective for reducing pain than a control
treatment at discharge and more effective than a Acknowledgement: Prof. MS Dhillon, HOD of
placebo treatment at the 3-month follow-up. However, Physiotherapy, PGIMER for providing facilities.
it is unknown whether the analgesic effect of IFT is
Conflict of Interest: None.
superior to that of the concomitant interventions.
Interferential current alone was not significantly better Source of Funding: None.
than placebo or other therapy at discharge or follow-
up .Their study is limited by the low number of cases Ethical Clearance: Cleared by Ethics committee of
& modalities like only IFT was used. There had been Singhania University, Pacheri Bari, Jhunjhunu,
fallacy in methodology, unlike our study where we Rajasthan. India.
have used exclusion & inclusion criteria & multiple
modalities has been compared. This study has further REFERENCES
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osteoarthritis: results from the Framingham
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2. Gupta SJ. Osteoarthritis and Obesity.
Yang et al. (2011), investigated the effect of Orthopaedics today. 2001; 3:137-41.5.
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alleviates joint symptoms, relieving joint swelling, Ultrasound to Increase Effectiveness of Isokinetic
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8. Ozgönenel L, Aytekin E, Durmuºoglu G. electromagnetic energy treatment offers no
Ultrasound Med Biol. 2009 Jan;35(1):44-9. clinical benefit in reducing the pain of knee
9. Yang PF, Li D, Zhang SM, Wu Q, Tang J, Huang osteoarthritis: a systematic review . BMC
LK, Liu W, Xu XD, Chen SR. Efficacy of Musculoskeletal Disorders . 2006, 7:51.
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the knee. Orthop Surg. 2011 Aug;3(3):181-7. electromagnetic fields in the treatment of knee
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DOI Number: 10.5958/0973-5674.2014.00001.X
Benefits of Early Mobilization of ICU Patients
Mayur Patel1, Swati M Sanghvi2

1
M.D, F.C.C.P,Head of Department, Critical Care Medicine, Sir H.N Reliance Foundation Hospital, Mumbai
2
MPT,Head of Department, Department of Advanced Physiotherapy, Saifee Hospital, Mumbai
ABSTRACT
With advances in the management of critically ill patients there is overall reduction in the mortality,
but the ICU survivors are facing greater morbidity. The focus has now shifted to long-term outcomes
of ICU survivors.
Neuromuscular weakness is a common sequela of critical illness which is persistent, and often severe.
Prolonged immobility and bed rest may play an important role in the development of ICU-acquired
weakness. Early mobilization therapy has been suggested as an intervention to prevent or ameliorate
ICU-acquired weakness. Early mobilization is safe, feasible, and associated with improved ICU
outcomes, but requires a significant change in ICU practice.
Keywords: Early Mobilization, CINM- Critical illness neuromyopathy, CIP- critical illness polyneuropathy,
Safety Concerns
INTRODUCTION
In this review we highlight the potential risks,
Physicians working in ICUs focus their attention benefits, and challenges of early mobilization of
on normalizing the cardiopulmonary & hemodynamic critically ill patients to reduce ICU-acquired weakness
derangements that put their patients’ lives at risk. and improve patient outcomes.
Although, the survival from critical illness has
Risk Factors for ICU-Acquired Weakness
improved, focus has shifted in preventing the sequela
of critical illness, including neuromuscular weakness. The disease severity (for instance, APACHE II
Neuromuscular weakness occurs in approximately 25– score), the presence of the systemic inflammatory
50% of critically ill patients1. It persists for years after response syndrome, and organ failure are associated
ICU discharge, such that only half of survivors return with neuromuscular abnormalities on
to work within a year2. electromyography/nerve conduction studies . Other
6
risk factors include the duration of mechanical

Bed rest has been recommended for acute medical
ventilation7, ICU length of stay8, as well as serum
illnesses to postoperative convalescence, and
glucose levels 8 , hyper osmolality 6 , and use of
especially in ICU patients3. Immobility from prolonged
parenteral nutrition6. Drugs which are potentially
bed rest is associated with many complications,
myotoxic or neurotoxic, such as corticosteroids7 and
including muscle atrophy, pressure ulcers, atelectasis,
non-depolarizing neuromuscular blocking agents6, has
and bone demineralization4.
been associated with neuromuscular abnormalities.
The etiology of this weakness is multifactorial.
The Physiologic Sequela of Immobility
Early mobilization helps to reduce the muscle atrophy,
weakness, and deconditioning associated with bed In recent years, there is increased awareness of the
rest. Exercise has been found to be effective in reducing adverse effects of physical inactivity, bed rest, and
inflammation and all-cause mortality in healthy immobility, amongst medical fraternity. Various inter-
individuals and patients with chronic disease5. related complex processes are involved leading to
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muscle weakness in critical illness (Figure 1). Apart How to Prevent?

from immobility, the muscle loss in the critically ill
patient is promoted due to synergism between local The incidence of CIP/CIM has been estimated at
and systemic inflammation. The mechanical 50% in general ICU patients1, reaching 100% in patients
unloading of muscles during prolonged bedrest, with both SIRS/sepsis and multiple organ failure12. But
triggers a cascade of responses – decreased protein currently, there are few options for the prevention of
synthesis, accelerated proteolysis, and increased ICU-acquired weakness.
apoptosis – that alters skeletal muscle morphology, the Attempts to identify interventions to prevent CINM
proportion of slow and fast twitch muscle fibers, have been disappointing. A recent Cochrane review
contractility, and aerobic capacity, ultimately resulting on the topic identified only one possible preventive
in catabolism, atrophy, and weakness9. measure—intensive insulin therapy13; however it is
Critically ill patients rapidly develop protein- known to increase mortality in critically ill patients14.
energy malnutrition during their ICU stay. This, in Early mobility therapy has emerged as a potential
association with the hyper metabolic stresses of critical preventative strategy to prevent or at least ameliorate
illness, results in significant protein loss in the form of CINM15.
amino acids derived primarily from muscle10. Benefits of Early Mobilization
Critical illness neuromyopathy (CINM) is a Early mobilization in the ICU setting is an emerging
spectrum of neuromuscular disorders associated with therapeutic option to reduce ICU-acquired weakness.
critical illness, including critical illness polyneuropathy It is associated with improved muscle strength,
(CIP), critical illness myopathy (CIM), and disorders physical function and quality of life 16,17 . Early
of the neuromuscular junction1. CIP primarily affects mobilization was associated with a greater likelihood
motor and sensory axons, whereas muscles are the of achieving independent functional status, less ICU-
primary target in CIM. Electrophysiology and/or acquired weakness, and a greater unassisted walking
direct muscle stimulation is often required to distance at hospital discharge16.
differentiate between CIP and CIM. Since CIP and CIM
frequently coexist, it is treated as one entity: CINM. It is also associated with cost reduction through
ICU-acquired weakness is the clinical manifestation decreased hospital and/or ICU length of stay (LOS),
of CINM. It often presents with flaccid quadriparesis hospital readmissions and duration of mechanical
and hyporeflexia or areflexia, with sparing of the ventilation16,17.
cranial nerves. This acquired weakness is associated
with respiratory muscle weakness, difficulty weaning Based on the mounting evidence in favor of early
mobilization, the European Respiratory Society and
from the ventilator, and prolonged ICU length of stay
(LOS)11. European Society of Intensive Care Medicine Task
Force on Physiotherapy for Critically Ill Patients now
clearly states that “active or passive mobilization and
muscle training should be instituted early.”19.
Safety Concerns
Concerns about the safety and feasibility of

mobilizing critically ill patients is but obvious, because
they may have severely deranged physiologic
parameters, limited cardiopulmonary reserve, and
decreased exercise tolerance. Moreover, they are often
connected to various lines and tubes, some of which
are integral to their survival20. Early mobilization
therapy was successfully administered despite
perceived barriers, including mechanical ventilation,
vasopressor administration, neuromuscular blocker
infusion, renal replacement therapy, and delirium with
Fig. 1 low adverse events21.
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The contraindications to early mobilization are as were reported. These studies enforce that early
follows mobility in the ICU is feasible in ICUs with a
supportive culture.
Mean arterial pressure <60 mm Hg or <20% of
patient’s baseline, or increasing vasopressor Other Complimentary Changes to Facilitate Early
requirement Mobilization
1. Heart rate <40 or >130 beats per minute Some other barriers which also needs attention in
are over use of sedatives, incomplete knowledge, and
2. Respiratory rate <5 or >40 breaths per minute lack of resources in some ICUs. Continuous sedation
3. Pulse oximetry <88% infusions used are frequently associated with increased
duration of mechanical ventilation, preventing patients
4. Fio2 > 80% and/or PEEP > 12, or acutely from participating in mobility activities. Daily
worsening respiratory failure interruption of sedation infusions can result in
decreased duration of mechanical ventilation (4.9 days
5. Elevated intracranial pressure
versus 7.9 days; P = 0.004) and ICU length of stay (6.4
6. Active gastrointestinal bleed days versus 9.9 days; P = 0.02) (24). There may be
synergistic benefits of combining early mobility and
7. Active myocardial ischemia decreased sedation.
8. Unstable spine fracture To prioritize early mobilization will require

transforming ICU culture. This change must be
9. Open abdomen
assisted by clinician education in regards the long term
10. Femoral dialysis catheter sequela of critical illness, as well as the safety,
feasibility, and potential benefits of early mobilization.
11. Unresponsive to verbal stimuli Targets for these changes include institutional
leadership, as well as bedside clinicians, nurses, and
12. Unsecured airway
physical therapists, who play a crucial role in
Barriers to Early Mobilization transforming routine care25.
The perceived barriers to mobilization and the level A clinical leader must establish the necessary
of activity achieved differs between nurses and coordination and cooperation among the
physical therapists22. SOPs for automatic physical multidisciplinary team. However, with teamwork,
therapist assessment and initiation of therapy will training, and restructuring, it is possible to provide a
benefit an early mobilization program. This approach higher level of physical activity in the ICU without
showed more patients received physical therapy requiring additional resources25.
during their ICU stay (73% in the protocol versus 6%
Way Forward
in the usual care group), with a trend toward decreased
hospital mortality (12.1% versus 18.2%; P = 0.125)16. A variety of technological advances can facilitate
early mobilization in the ICU. To facilitate patient
A multifaceted approach on early mobilization
ambulation, “Moving Our patients for Very Early
should be a part of daily clinical routines in the ICU. It
Rehabilitation,” (MOVER aid) was created. It includes
must start immediately after physiologic stabilization.
a walker with a built-in emergency seat and an
The clinicians fear that mobilization is not feasible
equipment tower that holds monitoring equipment,
because of the presence of various devices attached to
intravenous fluids, medications, infusion pumps, a
the patient. In one prospective cohort study patients
portable ventilator, and two oxygen cylinders26. Use
with an endotracheal tube participated in 593 activity
of this aid decreases the number of personnel required
events ranging from sitting on the edge of the bed to
to administer ambulation therapy to a patient.
ambulation. Despite 42% of these events involving
ambulation, there were no accidental extubations23. A The use of bedside cycle ergometry has been found
further study, reinforced by a controlled trial of a to be safe, feasible, and effective in the critically ill16.
mobility protocol on 145 intubated ICU patients16, in Neuromuscular electrical stimulation (NMES) which
which no incidents of accidental removal of devices elicits muscle contraction via low-voltage electrical
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impulses delivered by skin electrodes, reduces disuse 5. Pedersen BK, Saltin B: Evidence for prescribing
atrophy in healthy adults and chronically ill patients26. exercise as therapy in chronic disease. Scand J
The European Respiratory Society and European Med Sci Sports 2006, 16(suppl 1):3-63.
Society of Intensive Care Medicine Task Force on 6. Garnacho-Montero J, Madrazo-Osuna J, García-
Physiotherapy for Critically Ill Patients recommends Garmendia JL, Ortiz-Leyba C, Jiménez-Jiménez
NMES “in patients who are unable to move FJ, Barrero-Almodóvar A, Garnacho-Montero
spontaneously and at high risk of musculoskeletal MC, Moyano-Del-Estad MR: Critical illness
dysfunction”19 polyneuropathy: risk factors and clinical
consequences. A cohort study in septic patients.
CONCLUSIONS Intensive Care Med 2001, 27:1288-1296.
7. De Jonghe B, Sharshar T, Lefaucheur JP, Authier
Although survival from critical illness has FJ, Durand-Zaleski I, Boussarsar M, Cerf C,
improved, neuromuscular weakness due to prolonged Renaud E, Mesrati F, et al.: Paresis acquired in
stay in the intensive care is common and often persists the intensive care unit: a prospective multicenter
for years. Bedrest has been found to be associated with study. JAMA 2002, 288:2859-2867.
catabolism, atrophy, and ICU-acquired weakness. 8. Witt NJ, Zochodne DW, Bolton CF,
Early mobilization is a safe and feasible intervention Grand’Maison F, Wells G, Young GB, Sibbald WJ:
in ICU patients, and is associated with improved Peripheral nerve function in sepsis and multiple
outcomes. A structured approach and a change in ICU organ failure. Chest 1991, 99:176-184.
culture along with new technology helps in increasing 9. Chambers MA, Moylan JS, Reid MB: Physical
compliance and in implementation of an early inactivity and muscle weakness in the critically
mobilization program. ill. Crit Care Med 2009;37:S337–46.
10. Pingleton SK: Nutrition in chronic critical illness.
Ethical Clearance: Approval from ethical committee
Clin Chest Med 2001, 22:149-163.
of Saifee Hospital was taken for reporting the above.
11. Puthucheary Z, Harridge S, Hart N: Skeletal
Acknowledgement: Nil muscle dysfunction in critical care: Wasting,
weakness, and rehabilitation strategies. Crit Care
Conflict of Interest: None Med 2010; 38:S676–82.
Source of Funding: None 12. Tennila A, Salmi T, Pettila V, Roine RO, Varpula
T, Takkunen O. Early signs of critical illness
polyneuropathy in ICU patients with systemic
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DOI Number: 10.5958/0973-5674.2014.00001.X
Effectiveness of Fall Prevention Training Programme for

Patients with Hemiplegia
K Kalaichandran
Sr.OTist, RMMCH, Annamalai University (Former, Professor & Head, school of OT, Faculty of Health Science, Kuala
Lumpur Metropolitan University (KLMU), Kuala Lumpur, Malaysia)
ABSTRACT
Aim: The aim of the study was to find out the effectiveness of fall prevention training programme for
patients with hemiplegia
Objectives
• To find out the fall risk in hemiplegic patients
• To educate and train the hemiplegic patients who are prone to fall
Method: Twelve subjects with hemiplegic patients who are prone to fall were selected for this study.
FRT Functional Reach Test was used for the objective measurement of patients fall risk. The pre and
post therapy values were statistically analyzed on the effect of (Taichi) fall prevention training
programme for patient with hemiplegia.
Result: The statistical analysis of functional reach test scores between pre-treatment mean value is
5.33, S.D is 0.72 and post-treatment mean value is 9.45, S.D 1.47, paired t-test value is 10.50 and P
value is P(<0.001).
The statistical analysis shows that, there is significant difference between early stages than later
stages. The rate of falls was comparatively reduced better with early stages of hemiplegia than the
later stages.
Conclusion: Fall prevention training programme (Taichi) can be used effectively as one of the
interventions for preventing falls in patients with hemiplegia.
Keywords: Hemiplegia, Taichi, Functional Reach Test
INTRODUCTION survivors of stroke are ambulatory, there is an

increased risk of falling mainly on paretic side,
Stroke is an acute onset neurological dysfunction
difficulty in walking on uneven terrain etc., it is
due to abnormality in cerebral circulation with
associated with considerable morbidity, reduced
resultant signs and symptoms that correspond to
functioning and prolonged hospital stays.
involvement of focal areas of the brain. Stroke is one
of the most neurological disorders leading to chronic
disability. Hemiplegia resulting from stroke has motor,
sensory, balance, speech and percepteuo-cognitive Hemiplegics have decreased trunk control, poor
deficits. bilateral integration and impaired automatic postural
control resulting in balance dysfunction. Postural
Falls are among the most common and serious instability has been suggested as one of the main causes
problems facing persons in hemiplegia. Even if leading to falls in this population. The incidence of falls
38. Kalaichandra--191--.pmd 191 5/10/2015, 5:14 PM

ranging from 25% to 75% among stroke patients occupational therapy, in group programs or as
residing in different settings, with greater incidence individual programs at home. ”Tai Chi to be
of falls occurring after discharge to home. recommended as a best senior fall prevention exercise,
and balance training for stroke victims and to be
The functional reach test was developed by Duncan routinely prescribed for older patients at risk for falling
– et al as a screening tool to assess fall in hemiplegic after appropriate screening.” Occupational Therapists
patients score of less than 7 inches are indicative of a need to embrace this method for falls prevention.
frail that may have limited mobility activities of daily
living (ADL) skills and demonstrates increased risk of Alice M. Wong Yin – Chow et al – 2011
fall.
Taichi is strongly recommended as a regimen of
The recovery of the ability to maintain balance balance exercise to prevent from falling in stroke
during activities of daily living is essential functional patients. Regular practice of taichi show better postural
independence and safety of these patients. stability in the more challenging conditions than those
who do not have balance. Falling is a major
Literatures suggest that balance training helps to complication seen in stroke patients
prevent falls in hemiplegic patients, only a few studies
have mentioned about the fall prevention training Tai Chi and fall prevention for stroke: 2011
programme and patients education for hemiplegic
patients. Stroke is one of the leading causes of chronic
disability in the world. Falls are one of the primary
Therefore, in this study, evaluation done on the complications after stroke. The incidence of falls ranges
effectiveness of fall prevention training programme for from 25% to 75% among stroke patients residing in
patients with hemiplegia different settings, with greater incidence of falls
occurring after discharge home. Postural instability has
AIM AND OBJECTIVES been suggested as one of the main causes leading to
falls in this population. The recovery of the ability to
The aim of the study was to find out the maintain balance during activities of daily living,
effectiveness of fall prevention training programme for therefore, is essential for functional independence and
patients with hemiplegia safety of these patients.
OBJECTIVES RELATED LITERATURE

To find out the fall risk in hemiplegic patients The Benefits of Tai Chi For Stroke Victims
To educate and train the hemiplegic patients who Tai Chi is a 600-year-old Chinese martial art that
are prone to fall seeks to integrate the body, mind and soul through
slow, flowing movements and postures. In theory
NEED FOR THE STUDY these slow, fluid moves, in addition to working
To avoid fall in hemiplegic patients, fall risk muscles, help to focus concentration, resulting in a
assessment and fall prevention training programme greater flow of “chi” energy. “Chi,” which is also
is essential to avoid certain complications such as spelled “qi,” is thought to be the vital life energy that
Fracture, Head injury, Laceration promotes calmness of mind and body as well as good
health.
REVIEW OF LITERATURE
Benefits of Tai Chi
Fall Prevention Exercise and balance training for
Tai Chi is well known for helping people maintain
stroke victims: Tai Chi
balance as they grow older. However, avid tai chi
Tai Chi Moving for Better Balance as senior fall practitioners cite a whole host of other benefits. Those
prevention exercise, Recommendations in the 2010 include better breathing, better organ function,
guidelines specify programs that include balance, gait, increased stamina, lower blood pressure and greater
and strength training, such as tai chi or physical and bone density.

Pouwels, Lalmohamed, Boer, Cooper and Vries, Functional Reach Test - Score Sheet / Record Sheet
2009. Falls can have dive stating consequences
NAME :
physically, psychologically and socially.
AGE :
There is a decrease in the mineral bone density in
the patient on the side affected by the stroke causing GENDER :
significant bone loss. This occurs quickly after the
DATE OF ASSESSMENT :
stroke. In addition, when falls occur stroke patients
have a tendency to fall on their hips. Other patients Number of Date Functional Signature
will brace their fall with their wrist; stroke patients trial Reach Test scores
Trial I
fall directly on their hips.
Trial II
Functional Reach Test and Instructions Trial III
Total (average
General Information: The Functional Reach test can of trial 2
be administered while the patient is standing and 3 only)
(Functional Reach) Instructions

Functional Reach (standing instructions): Instruct the patient to “Reach as far as you can
forward without taking a step”
The patient is instructed to next to, but not touching,
a wall and position the arm that is closer to the wall at
METHODOLOGY
90 degrees of shoulder flexion with a closed fist.
METHOD
The assessor records the starting position at the 3rd
metacarpal head on the yardstick. This study includes 12 hemiplegic patients with fall
risk. These patients were identified from a list obtained
Instruct the patient to “Reach as far as you can from medical record division of the hospital in and
forward without taking a step.” The location of the around Chidambaram.
3rd metacarpal is recorded.
The sample was selected on the following criteria:
Scores are determined by assessing the difference
between the start and end position is the reach distance, Inclusion criteria
usually measured in inches. Three trials are done and • Patients with an informed consent
the average of the last two is noted.
• Age group between 35-65 years of only hemiplegic
Instructions should include leaning as far as patients
possible in each direction without rotation and without
touching the wall. Record the distance in centimeters • Both male and female subjects
covered in each direction. • No side limitation
If the patient is unable to raise the affected arm, • Able to communicate
the distance covered by the acromion during leaning
is recorded. First trial in each direction is a practice Exclusion criteria
trial and should not included in the final result A 15 • Neurological diseases other then hemiplegia
second rest break should be allowed between trials
• Altered visual and sensory dysfunction
Set-up
• Functional reach test scores of more than 7 inches
A yardstick and duck tap will be needed for the
Settings
assessment. The yardstick should be affixed to the wall
at the level of the patient’s acromion process Patients home setup.

Evaluation procedure Protocols
All the 12 patients were screened by using Frequency: Thrice weekly for 6 weeks.
functional reach test (FRT) as a tool. A leveled
Yardstick is mounted on the wall and positioned at Duration: 45 minutes
the patients shoulder height (acromion).The patient At the end of every two week, functional reach test
stands next to the wall with the shoulder flexed to 90 will be taken and recorded in the given record sheet.
and elbow extended. The hand is fisted. An initial This is continued for 6 consecutive weeks and finally
measurement is made of the position of the 3 rd the scores of functional reach test will be statistically
metacarpal along the yardstick. The patient is then analyzed on the effect of taichi’s fall prevention
instructed to lean as much as forward as possible training programme and patient education will be
without losing balance or taking a step. A derived.
measurement is then subtracted from the initial
measurement. The three trials of functional reach test
MATERIALS
where performed and the average of all three trials
were recorded. The materials used for the study are
Training procedure • Functional reach test
After screening, patient identified for fall risk will • A record sheet for recording functional reach test
be trained by taichi programme, it will be detailed in score and treatment sessions.
the appendix and additionally patients are educated
by providing a brochure on fall prevention measure, • Resources such as inch tape, marker etc.
record sheet which in turn were used to check the • Information brochure on fall prevention training
regularity in patients training programme. programme and patient education.
DATA ANALYSIS AND RESULTS
Table 1: Functional reach test scores before and after treatment (in inches)
Sl no Gender with age Pre-test Post – test values

scores
Trial I Trial II Trial III Total
(average of
trial 2 and
3 only)
1 M / 41 6 6 9 11 10
2 M / 51 5.5 6.5 8.5 11.0 9.75
3 M / 49 5 5 6 7 6.5
4 F / 53 4.5 6 7.5 8.5 8
5 M / 61 6.5 7 9.5 10 9.75
6 M / 49 6 6 7.5 10.5 9.0
7 M / 63 5.5 6.5 9.5 12.5 11
8 M / 54 5 6 8 10 9
9 M / 44 5 5 7 10 8.5
10 F / 49 6 7 10 14 12
11 M / 52 4 5 7 10 8.5
12 M / 61 5 7 9 11 10
With a view to find the effect of fall prevention before and after treatment (in every two week for 6
training programme in increasing the functional reach consecutive weeks) indicated by pre and post therapy
test score of the responding, the measurements had values. To examine whether the treatment has
been obtained. On the functional reach test scores produced significant results, paired‘t’ test has been

applied for the data given in table – 1A. The null significantly before and after treatment. The results of
hypothesis to be tested is H0: M1=M2, Which implies paired `t’ test are given in table 1A
that the functional reach test scores do not differ
Table 1A: Comparison of Functional Reach Test Scores between Pre and Post treatment in Trial I, II & III
Functional reach test scores (inches) Mean S.D Paired t-test (t-value) P-value
Pre- test 5.33 0.72
Post-test1st Trial 6.08 0.76 3.95 P<0.001 (S.S)
Post-test2nd Trial 8.20 1.23 10.41 P<0.001 (S.S)
Post-test3rd Trial 10.71 1.72 11.59 P<0.001 (S.S)
Post-test(Average of trial 2 and 3 only) 9.45 1.47 10.50 P<0.001 (S.S)
The above table reveals that the mean, S.D, paired The functional reach test scores has shown an
t-test and p-value of the functional reach test scores increase in the mean values between pre-treatment and
between pre-treatment and post-treatment in Trial I, post-treatment in Trail I, II & III (Graph - 1).
II & III.
Table 2: Comparison of Functional Reach Test Scores between Pre and Post treatment
Functional reach test scores (inches) Mean S.D Paired t-test (t-value) P-value
Pre- test 5.33 0.72
Post-test(Average of trial 2 and 3 only) 9.45 1.47 10.50 P<0.001 (S.S)
The functional reach test scores have shown an falls, contributing factors (or) associated risk factors
increase in the mean values of pre-treatment and post- should be considered.
treatment (Graph - 2). The table shows statistically
Wancy Lundebjery stated that, intrinsic factors such
significant result between pre-treatment and post
as balance disorder, lower extremity weakness,
treatment in IV weeks at P<0.001 level.
functional impairment or external factors such as poor
It is observed that, the t value is grater then the lighting, loose carpets and lack of bathroom safety
table value, the null hypothesis is getting rejected. It equipment etc., may increase the risk of falls. Many of
implies that there is significant difference in the mean these factors are controllable. There are no studies that
values prior to and after treatment. Hence, it is address with control of these contributing factors.
concluded that, the treatment significantly improve Mary E.Tinetti et al stated that education is an
functional reach test scores. important component of strategies to manage the risk
of falling. The patient at risk of his or her family
DISCUSSION members should be educated.
Aim of the study was focused on the effect of fall The statistical analysis of functional reach test
prevention training programme for patient with scores between pre-treatment mean value is 5.33, S.D
hemiplegic. is 0.72 and post-treatment (IV Week) mean value is
9.45, S.D 1.47, paired t-test value is 10.50 and P value
In this study, out of 12 patients, 10 male and 2 is P(<0.001). The statistical analysis shows that
female patients were selected and treated. 8 patients according to functional reach test, there is significant
were right sided and 4 patients were left sided. The difference between early stages than later stages. The
duration ranging from 3 months to one year, all of them rate of falls was comparatively reduced better with
were ambulant. early stages of hemiplegia than the later stages.
In this study, evaluation done on the effectiveness Wolf SL suggested that in early stages of hemiplegia
of fall prevention training programme in reducing falls. fall prevention training programme shows an
However it is widely argued that in order to prevent improved prognosis.

Cahitugur et al stated that at 3 months 60% of 2. Study of balance training in ambulatory

patients had effective results, but at 2 years, this has hemiplegics. Snehal bhupendra sha, smita
reduced to 30%. According to Wolf SL and Cahitugur jayavant: the Indian journal of Occupational
et al, this results also shown that, the patients with Therapy (IJOT): Vol, XXXVII: Vo:1 April – July
early stage got good prognosis. So, with all forms of 2006: 9-15.
therapy were available, this study was done to justify 3. TSR SK, Bailey DM: Taichi and postural control
fall prevention training programme and patient in the well elderly. American Journal of
education has an effect on hemiplegic patients. Occupational Therapy (AJOT)
4. Diane M. Wrisley, Kathryn E. Brown Therapeutic
LIMITATION AND RECOMMENDATIONS exercise: treatment planning for progression
Balance: 160 – 162.
Limitation 5. Susan B.O’ Sullivan: Physical rehabilitation –
Assessment and treatment: 4 th Edition 2001:
• One serious limitation of the functional reach test
Assessment of Motor Function: 196.
is that it measures sway in only one direction
6. Liao W: Taichi classics: New translations of three
(forward)
essential texts of Taichi chan, Boston Shambhala,
1990.
RECOMMENDATIONS
7. Debra K. Weiner, Dennis R. Bongiorni et al: Does
• Fall prevention training programme and patient functional reach improve rehabilitation? Arch
education can be compared with other balance phys med rehab vol 74, Aug 1993.
training programme 8. Duncan PW, Welner DK, et al functional reach: a
new clinical measure of balance. J gerotol 1990;
• Study can be done on the factors associated with 45: M 192-7
fall risk and its prevention 9. Duncan PW, student SK.S, et al functional reach
predictive validity in a sample of elderly male
• Further studies are warranted increasing the
veterans. J Gerontol 1992: 47: M 93-8.
sample size.
10. Jannet Cart: Roberta shepherd: stroke
CONCLUSION rehabilitation guidelines for exercise and training
optimize motor skill balance
Fall prevention training programme (Taichi) can 11. Washer and Macullam – 1995 the balance scale;
be used effectively as one of the interventions for treatment and investigation. Arch Phy Med
preventing falls in patients with hemiplegia. Rehab: 1995 Vol 84.
12. Kazn H. Taichi – 197 Fal risk – screening test; a
ACKNOWLEDGEMENTS
prosp predictors for falls in community dwelling
I would like to place on record a deep sense of elderly. J clin Epidemiol 1974: 54: 837-844.
gratitude to my most loving parents and my wife 13. Wancy Lundebjeru, 2001, guideline for
Mrs.K.Sunithapriya B.Sc(CS) for being a source of prevention of falls in older persons: American
inspiration and encouragement in doing this project. Geriatric Society JAGS 49: 664-72.
REFERENCES
1. Catherine A. Trombly - Occupational Therapy for

physical dysfunction - 5th Edition. William and
Wilkins.

DOI Number: 10.5958/0973-5674.2014.00001.X
Correlation between Performance Oriented Mobility

Assessment Scale and Activity Specific Balance
Confidence Scale in Elderly Individual
Chetana A Kunde1, Suvarna Shyam Ganvir2

1
MPT, Department* of Neurosciences: Ravi Nair Physiotherapy College, Sawangi, Meghe, Wardha, 2MPTh,
Department of Neurosciences: PDVVPF's college of Physiotherapy, Ahmednagar
ABSTRACT
Objective: To find out correlation between Performance Oriented Mobility Assessment Scale and
Activity Specific Balance Confidence Scale in elderly individual.
Study design: Correlation study.
Study setting: OPD and IPD Patients of Ravi Nair Physiotherapy college and A.V.B.R.H, Sawangi
Meghe, Wardha.
Participants: 60 elderly individual, with the age group between 60 - 80 yrs, those who are able to
walk without human assistant.
Main outcome measures: Performance Oriented Mobility Assessment Scale (POMA) and Activity
Specific Balance Confidence Scale (ABC).
Result: Significant correlation was found between Performance Oriented Mobility Assessment Scale
and Activity Specific Balance Confidence Scale i.e. (r = 0.57, p<0.05) using Pearson co-efficient of
correlation test. Correlation was found to be significant between Performance Oriented Mobility
Assessment Scale and Activity Specific Balance Confidence Scale in individual with diabetes (r -
0.81, p <0.05) and normal elderly (r - 0.40, p <0.05). But non significant correlation was found in
individual with hypertension (r - 0.35, p >0.05).
Conclusion: The results of this study shows positive correlation between Performance Oriented
Mobility Assessment Scale and Activity Specific Balance Confidence Scale, which suggest that balance
impairments are present in people with diminished confidence. This relationship has important
implications for the development of rehabilitation programs.
Keywords: Balance, Gait, Fall, Performance Oriented Mobility Assessment Scale, Activity Specific Balance
Confidence Scale
INTRODUCTION activity, functional ability, and Consequently may lead

to reduced quality of life and adverse health
Falling is a common problem associated with
consequences.3
aging.1studies have shown that more than half of
community-dwelling elderly people over the age of Falls are the leading cause of accidents and death
62 years report a fear of falling.2 The fear of falling, on due to injury in those persons 65 and older.4 According
the other hand, results in restrictions of physical to a 1987 study done by the National Safety council,
39. Chetna kunde--197-.pmd 197 5/10/2015, 5:14 PM

individuals who are 65 and over accounted for 74% of The gait portion of the Tinetti test include:
deaths caused by falls (Zylke, 1990). Initiation of gait, Path, Missed step, Turning, Steps over
obstacle
Numerous factors, both biological and
environmental, work together to produce falls. These Falls also have psychological consequences. fear of
factors include visual and musculoskeletal falling, defined as concern about falling that leads to
abnormalities, ill-fitting shoes, poor lighting activity avoidance or reduction (Tinetti & Powell, 1993)
conditions, medication, judgment and low levels of Fear of fall and lack of balance confidence, 2 closely
physical fitness (Zylke, 1990), age, number of chronic related concepts,10,11may exist among older people with
diseases, body composition, muscle strength, or without a history of falls.12 In an effort to measure
functional mobility and performance measures related fear of falling based on the concept of self-efficacy, 2
to balance function.5 measurement tools have been developed: the Falls
Efficacy Scale (FES)13 and Activity Specific Balance
Balance is an important issue in aging, since it is Confidence Scale (ABC)11. Activity Specific Balance
undoubtedly linked with motor performance affecting, Confidence Scale was more discriminative and
thus, activities of daily living and consecutively the yielding a wider range of response. Greater item
quality of life in the elderly. Maintenance of good responsiveness of Activity specific balance confidence
balance ability reduces the chance of a fall which, scale (ABC) make it more suitable to detect loss of
especially in the elderly. Factor responsible for balance confidence.( L E Powell) in elderly people aged
maintaining balance are visual, vestibular CNS 65 to 95 years.14
integration, sensory system, (proprioception &
kinesthetic) and motor system. Hence assessment of Balance confidence is task-specific. The Activities-
balance is focus on each of these components because Specific Balance Confidence (ABC) scale assesses a
all these systems are affected with ageing.6 Lack of person’s confidence to perform different tasks without
balance confidence may cause deterioration of function losing balance or falling. Assessing the ABC scale takes
through avoidance of activities in which a person only a few minutes and may thus be feasible in clinical
observes an increased fall risk.7 practice as well. 11, 12 The ABC Scale is a 16-item
questionnaire that asks respondents to score their level
There are numerous clinical tests that have been of confidence in performing situation-specific
used to assess balance .Each clinical test may provide activities 11
a unique contribution to the complete description of
an individual’s balance capabilities.e.g. Berg balance Balance confidence and balance performance have
scale, functional reach test, performabnce oriented been found to be significant predictors of fall status .15
mobility assessment scale, time up and go test.6 Hence the purpose is to investigate if there exist any
correlation using between person confidence using
Tinetti, Williams & Mayewski (1986) discussed nine Activity Specific Balance Confidence Scale (ABC) and
risk factors in a fall risk index. One of these factors Performance Oriented Mobility Assessment Scale.
was the mobility score. This score was derived from
the Performance-Oriented Assessment of Mobility. MATERIAL AND METHOD
This assessment was noted as “the best single predictor
of recurrent falling” because it is simple, recreates fall 60 elderly individual of 60 to 80 years were selected
situations and provides integrated assessment of on voluntary basis for the study with or without the
mobility.8,9 history of fall . Sample were collected from the OPD
and IPD of Ravi Nair physiotherapy college and A. V.
Tinetti Gait Scale (Tinetti, et al., 1986). There are B. R. H. Sawangi Meghe , Wardha.
two sections to the test: balance and gait. The balance
section was administered first. All participants were community dwelling subject
who were able to walk without human assistance and
Balance test include Sitting balance, Arise from a were able to follow the instructions given to them,
chair, Immediate standing balance, Side-by-side Exclusion criteria are listed below. Eligible participants
standing balance, Pull test , Turn 369, one leg standing, were included for the study. Before the collection of
Tandem stand, Reach up , Bending over , Sit down. the data, informed consent was obtained.

Criteria for Excluding Individuals from Study walk back. This test was administered in the hallway.
Participation Subjects were to complete the task two times. During
the first trial, the researcher observed the following
• Unstable or limiting cardiac disease (e.g., angina)
items. Higher score indicating better balance. The
• History of myocardial infarction, coronary artery mean time to administer the gait and balance subscales
bypass or other cardiac surgery within the is 15 minutes.17
previous 6 months.
The ABC Scale is a 16-item questionnaire that asks
• Respiratory conditions requiring oxygen respondents to score their level of confidence in
supplementation or frequent use of inhalers.
performing situation-specific activities such as
• History of neurological disease (e.g., Stroke, “reaching at eye level,” “reaching on tiptoes,” “picking
Parkinson disease) with residual impairment. up slipper from floor,” and “walking in crowded mall”
“without losing balance or becoming unsteady.”14 Each
• History of fracture within the previous 6 months
item is scored from 0% to 100%, with 0% being no
(especially spinal or hip fracture)
confidence and 100% being full confidence in the
• Severely limiting arthritis, joint instability, or back ability to perform the activity without losing balance.
pain.
At the end total score of Performance Oriented
• Total joint replacement within the previous 6 Mobility Assessment Scale (POMA) and Activity
months. Specific Balance Confidence Scale (ABC) was
correlated using Pearson co-efficient of correlation
• Abdominal surgery/ any surgery within the
previous 6 months. test.
• Documented dementia or significant clinical FINDINGS

depression.
Table 1: Age wise and sex wise distribution of patient
The subjects were interviewed and the information
Age group(yrs) Male Female Total
gathered about their demographic data, living
60-70 19 23 42
situation, living condition health related information
71-80 12 6 18
like past medical history, use of assistive device, and
Total 31 29 60
use of medication, and fall-related information- fear
of falling [yes/no], fall history and frequency, the need According to table 1: 60 elderly individual were
for medical attention due to falls. Activity Specific assessed between age group of 60- 80 years out of that
Balance Confidence Scale (ABC) Questionnaire was 70% subjects were of age group 60- 70 years and 30%
administered through interview. Following the were between 71- 80 years. In age group 60-71 years
interview, Performance Oriented Mobility Assessment 45.23% were male and 54.76% were female. In age
Scale (POMA) was introduces as physical performance group 71- 80 year 66.66% were male and 33.33% were
measures to assess balance performance and gait. female.
Balance section was administered first. Balance test Table 2: Distribution of subjects according to the
include Sitting balance, Arise from a chair, Immediate history of secondary diagnosis.
standing balance (first five seconds), Side-by-side
Secondary diagnosis No. of subject Percentage
standing balance, Pull test (subject at maximum
Diabetes 15 25
position, examiner stands behind and exerts mild pull
Hypertension 18 30
back at wrist), Turn 369, Able to stand on one leg for 5
seconds, Tandem stand, Reach up (examiner holds 5 None 27 45
lb weight at height of subject’s fully extended reach), Total 60 100
Bending over (place 5 lb weight on floor and ask subject According to table 2: Subjects were distributed
to pick it up), Sit down. according to the history of secondary diagnosis. In this
The gait portion of the Tinetti test required the 25% of individual have diabetes and 30% have
subjects to walk a distance of 15 ft, turn around and hypertension and 45% were normal elderly individual.

Table 3: Correlation between Performance Oriented Mobility Assessment Scale and Activity Specific Balance
Confidence Scale.
Scale Mean Std. No. of Correlation ‘r’ p-value

deviation subject ‘n’
Performance Oriented Mobility Assessment 13.85 3.95 60 0.57 0.000p<0.05
Activity Specific Balance Confidence Scale 52.29 16.96 60
According to table 3: When the total score report reduced balance confidence not only have
Performance Oriented Mobility Assessment Scale impaired balance, but are fearful that they are likely
(POMA) and Activity Specific Balance Confidence to fall due to these balance limitations. A finding which
Scale was correlated it shows significant correlation supports the notion that balance performance alone is
i.e. (r- 0.57, p< 0.05). The mean and standard deviation a strong determinant of balance confidence in
of total Performance Oriented Mobility Assessment community-dwelling elderly (Janine Hatch 2003). This
Scale (POMA) score was 13.85 + 3.95 and Activity relation between the fear of falling and the balance was
Specific Balance Confidence Scale (ABC) score was in agreement with Maki et al. (1991)19
52.29 +16.96. This relation indicates that people who
Table 3: Correlation between Performance oriented mobility assessment scale and Activity specific balance
confidence scale in diabetes, hypertension and general patients.
Scale Mean SD N Correlation r p- value

Diabetes
Performance oriented mobility assessment 14.26 5.17 15 0.81 0.000p<0.05
Activity specific balance confidence scale 49.15 19.62 15
Hypertension
Performance oriented mobility assessment 14.61 3.68 18 0.35 0.15p>0.05
General
Performance oriented mobility assessment 13.11 3.34 27 0.40 0.03p<0.05
According to table 4: Significant correlation was balance confidence. 14 Diabetes leads to glucose
found between Performance Oriented Mobility fluctuations in metabolically active structures of the
Assessment Scale and Activity Specific Balance inner ear that interferes with the sodium potassium
Confidence Scale in elderly individual with diabetes pump activity which creates electrical potentials of the
(r – 0.81, p <0.05) and general (normal elderly) cochlear and vestibular neuroepithelial cells that, when
individual (r – 0.40, p <0.05). The balance control altered, produce loss of balance and also the reduced
apparatus is very complex it includes many number of mechanoreceptors located in the feet affect
physiological subsystem i.e. somatosensory, visual, balance performance and balance confidence which
vestibular systems, musculoskeletal system, CNS and are commonly seen in diabetes.20
PNS. In elderly, the predictive central set for balance
control i.e., the higher level predictive processing of But study shows non- significant correlation
the central nervous system that sends out descending between Performance oriented mobility assessment
commands to the peripheral sensory and motor scale and Activity specific balance confidence scale in
systems to prepare for an anticipated stimulus or elderly individual with hypertension (r – 0.35, p >0.05)
voluntary task is impaired and the attention-related i.e. Finding of our study is that hypertensive’s did not
abilities, which are required for more challenging show worse balance scores, compared with non-
balance tasks, are reduced (Brown et al., 2002). All hypertensive elderly subjects. This finding may be
these physiologic modifications may worsen explained by the fact that, in the sample studied;
performance in balance tests observed in the elderly.16It hypertension was uncomplicated, well tolerated and
is possible to the understanding that balance well controlled. So, the effect of hypertension could
limitations leads to the development of diminished be minimal in comparison to the effects of the

numerous age-related changes on the complex 6. Holbein Jenny, Mary Ann, Billek Sawhney,
balance–control system. But the low confidence level Barbara, Beckman, Elizabeth, Smith, Trin. Balance
in hypertensive subject was because of previous in personal care home residents: a comparison
experiences of dizziness, vertigo and unsteadiness of the Berg Balance Scale, the Multi directional
which is possibly associated with hypertension. Reach Test, and the Activities Specific Balance
Confidence Scale. Journal of Geriatric Physical
CONCLUSION Therapy: August 2005 - Volume 28 - Issue 2 - p
48–53.
The results of this study suggest that balance 7. Hadjistavropoulos, T., Delbaere, K., and
impairments are present in people with diminished Fitzgerald, T.D. Reconceptualizing the role of fear
balance confidence. Balance ability plays an important of falling and balance onfidence in fall risk. J
role in determining balance confidence. This Aging Health. 2011; 23: 3–23.
relationship has important implications for the 8. Tinetti, M. E. Performance-oriented assessment
development of rehabilitation programs that aim to of mobility problems in elderly patients. Journal
improve balance confidence and diminish its impact of the American Geriatrics society. 1986;34,
on function in elderly people. Prediction of balance 119-126.
confidence is necessary to indentify and effectively 9. Tinetti, M. E., Williams, T. F., & Mayewski, R.
manage those people at risk for declining balance Fall risk index for elderly patients based on
confidence, and prevent decline of function that is number of chronic disabilities. The American
common problem associated with ageing. Journal of Medicine.1986; 80, 429-434.
10. Bandura, A. Self-efficacy: toward a unifying
Source of Funding: None
theory of behavioral change. Psychol
Ethical Clearance: Institution Ethical committee Rev. 1977; 84: 191–215.
approval was obtained prior to beginning of the study. 11. Powell, L.E. and Myers, A.M. The Activities-
Specific Balance Confidence (ABC) scale. J
Conflict of Intrest: Nil Gerontol A Biol Sci Med Sci.1995; 50A: M28–M34.
12. Erja Portegijs, Johanna Edgren, Anu Salpakoski,
Acknowledgement: I am deeply grateful to the god Mauri Kallinen, Taina Rantanen, Markku Alen,
almighty and my parents for being the guiding star in Ilkka Kiviranta, Sanna Sihvonen, Sarianna Sipila.
my life. I express my sincere thanks to all the subjects Balance Confidence Was Associated With
who participated and gave their full co-operation for Mobility and Balance Performance in Older
the study. People With Fall- Related Hip Fracture: A Cross-
Sectional Study. June 12. J.APMR. 2012.05.022.
REFERENCES 13. Tinetti ME, Richman D, Powell LE. Falls efficacy
as a measure of fear of falling. J Gerontol. 1990;
1. Prudham D, Evans JG. Factors associated with 45:P239–P243.
falls in the elderly: a community study. Age 14. Janine Hatch, Kathleen M Gill-Body and Leslie
Ageing. 1981; 10:141–146. G Portney Determinants Of Balance Confidence
2. Howland J, Lachman ME, Peterson EW, et al. In Community-Dwelling Elderly People. PHYS
Covariates of fear of falling and associated THER. 2003; 83:1072-1079.
activity curtailment. Gerontologist. 1998; 38: 15. Lajoie Y., Girard A, Guay M., Comparison of the
549–555. reaction time, the Berg Scale and the ABC in non-
3. Li F, Fisher K.J, Harmer P, McAuley E, Wilson fallers and fallers, Arch Gerontol Geriatr. 2002,
N.L. Fear of falling in elderly persons: Association 35: 215-225.
with falls, functional ability, and quality of life, J 16. Michele Abate , Angelo Di Iorio, Barbara Pini ,
Gerontol.2003, 58B: P283-P290. Corrado Battaglini , Isabella Di Nicola Nunzia
4. Urton M. M. A community home inspection Foschini, Marianna Guglielmi, Marianna
approach to preventing falls among the elderly. Marinelli, Pierluigi Tocco, Raoul Saggini,
Public Health Reports. 106(2), 192-195. Giuseppe Abate. Effects of hypertension on
5. Tseng SZ, Wang RH: Quality of life and related balance assessed by computerized
factors among elderly nursing home residents in posturography in the elderly. Archives of
Southern Taiwan. Public Health Nurs 2001, Gerontology and Geriatrics.10.1016/j.archger.
18:304-11. Feb 2008.05.008.

17. Nancy Elisabeth Gray. The relationship between Community Dwelling Elderly. IJPMR 2008
the Scores on the UP AND GO Test and the October; 19 (2): 48-52.
TinettI gait Groups of elderly. September 29, 19. Maki BE, Holliday PJ, Topper AK. Fear of falling
1994.(Unpublished article, Master thesis, and postural performance in the elderly. J
Emporia State University). Gerontol 1991; 46:M123-31.
18. Suraj Kumar, G Venu Vendhan, Dr Sachin 20. Onivald O Bretan, Faculdade de Medicina de
Awasthi Madhusudan Tiwari, V P Sharma. Botucatu. Plantar cutaneous sensitivity as a risk
Relationship between fear of falling, Balance for falls in the elderly. Otorhinolaryngology. Rev
Impairment and Functional Mobility in Assoc Med Bras 2012; 58(2):132.

DOI Number: 10.5958/0973-5674.2014.00001.X
A Study to Compare the effectiveness of MET and Joint

Mobilization Along with Conventional Physiotherapy in
the Management of SI Joint Dysfunction in Young Adults
Rachel Mathew1, Namrata Srivastava2, Sneha Joshi3

1
Physiotherapist, 2Assistant Proffesor, 3Assistant Proffesor, Career Institute of Medical Science,Department of
Physiotherapy, Bhopal
ABSTRACT
Objective: To compare the effectiveness of MET and Joint Mobilization over conventional
physiotherapy, in the management of SI joint dysfunction in young adults.
Subjects: 30 patients between the age group of 18-30 years with SI joint dysfunction were selected as
per the inclusion criteria.
Procedure: Using random sampling method the thirty subjects were divided into 2 equal groups
with 15 patients each. Both the groups were given conventional physiotherapy which included
Ultrasound and corrective exercises as a baseline treatment. Along with conventional physiotherapy
the experimental group received MET and Joint Mobilization to correct the anterior innominate,
whereas the control group received only the conventional physical therapy. The study duration was
for 4 weeks. Evaluation was done before starting the treatment and then after 4 weeks.
Outcome Measures: Outcomes were evaluated using Modified Oswestry Disability Questionnaire
and Visual Analogue Scale.
Result: The data were analyzed using paired and independent 't'test at 5% level of significance. The
group receiving MET and Joint Mobilization along with conventional physiotherapy (Group A)
showed significant improvement t = -10.121454(MODI); t = 12.8557(VAS) when compared to
conventional physiotherapy alone (Group B) t = -8.935035(MODI); t = 11.0000(VAS). p values between
the groups for MODI scores were 0.9407 (Pre test ) and 0.0488 (Post test) and for VAS were 0.8515(Pre
test ) and0.0159 (Post test).
Conclusion: Even though there was significant reduction of pain and improvement in activities of
daily living in both the groups the results supported the efficacy of MET and Joint Mobilization in
the management of SI joint dysfunction more than conventional physiotherapy alone.
Keywords: Sacroiliac joint dysfunction, Muscle Energy technique, Joint Mobilization, Therapeutic Ultrasound,
Stabilizing Exercises
INTRODUCTION An incidence of 26.5% was found for low back pain,

Sacroiliac joint (SIJ) pain is pain arising from SIJ while an incidence of 19.3% was found for sacroiliac
structures and SIJ dysfunction generally refers to joint dysfunction in a sample of physically fit college
aberrant position or movement of SIJ structures.1 students2 and between 8 and 16% in asymptomatic
individuals.3
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In its normal functioning state, the sacroiliac joint static and dynamic posture.10 Sarah Armstrong et al
is a non-weight bearing joint. It would seem that the (2011) performed two muscle energy techniques 3-5
sacrum is well protected from sinking into the pelvis times on four separate occasions over a 2-week period,
and the ilia from rotating posteriorly on the sacrum. resulted in long-term (7-months) symptom
Unfortunately, the relatively thin sheath of anterior improvement in a patient with chronic unilateral pain
sacroiliac ligaments does not offer the same protection in the area of the SIJ that was presumed to be caused
from movement and injury in the opposite direction. by posterior innominate rotation.11
Anterior rotation of the innominate bones on the
sacrum not only tends to loosen the fibers of the strong Richard L DonTigny (1985) reported that physical
posterior sacroiliac ligaments, but spreads the ilia on therapists can correct the dysfunction by manually
the sacrum causing them to wedge or bind. rotating the innominates posteriorly on the sacrum.12
Dysfunction occurs when the patient leans forward Backward Torsion Joint mobilization serves the
or stands with lordotic posture. This causes the line of purpose to increase joint play in SI joint, to increase
gravity to be displaced anterior to the center of the ROM into sacroiliac backward torsion and to reduce a
acetabula creating a rotational force in extension forward torsion positional fault of the ilium on the
around the acetabula. If support from the abdominal sacrum. 13 Correction is simply the restoration of the
muscles is not adequate, the anterior pelvis rotates position of ligamentous balance by manually rotating
downwards around the acetabulae. This anterior each innominate bone so as to cause it to move
rotational force tends to rotate the innominate bones inferiorly and medially on the sacrum. This can be
anteriorly on the sacrum, but because the sacrum is done by grasping the innominate and rotating it
placed within the innominates and is wider anteriorly posteriorly so as to cause the posterior aspect of the
than posteriorly, the innominate bones tend to spread innominate to move caudad on the sacrum. The patient
on the sacrum. On reaching the limit of their motion, can be taught to self-correct either with a direct self-
they wedge and lock.4 corrective stretch; or with a strong isometric
contraction.14 Manipulations always are performed in
Common pain patterns include medial buttock conjunction with other treatment techniques. 15
pain, groin pain, anterior thigh pain, posterior thigh
pain, and pain in the superior lateral thigh. Long term Continuous ultrasound is found to be effective for
sitting present a classic sign of pain from the SIJs. A reducing pain. The treatment parameters found to be
complaint of unilateral pain (on one side only) rather effective for this application are 1 or 3 MHz frequency,-
than bilateral pain is also considered more likely to be depending on the tissue depth, and 0.5 to 3.0 Wcm2
coming from an SIJ.5,6 Laslett et al (2005) reported intensity, for 3 to 10 minutes.16 Proper exercise is
highest sensitivity (93.8%) and specificity (78.1%) for essential to relieve pain, to prevent recurrence of joint
SI joint pain provocation tests when a combination of dysfunction. 4 Treatment with stabilizing exercises was
at least three tests was used.7 superior to standard treatment.17
The changes in visual analogue scores correlated METHODOLOGY

well with changes in simple descriptive pain scores.
The visual analogue and graphic rating scales were a) Study Design: Experimental Study Design
more sensitive than the traditional simple descriptive
b) Sampling: Simple Random sampling
pain scale.8 The modified Oswestry Low Back
Pain Disability Questionnaire (OSW) demonstrated c) Study Center: Career Institute of Medical Sciences
superior measurement properties compared with the
Quebec Back Pain Disability Scale (QUE). The d) Sample Size: 30 SI joint dysfunction subjects
measurement characteristics of the Oswestry Disability between 18-30 years participated in the study. They
Index are good to excellent. Test-Retest ICC 0.83 - 0.94 were randomly divided into 2 groups; Group A(
(1-14 days) and 0.90 over 4 weeks in a group of patients Experimental) and Group B(Control) with each
judged stable. The minimal clinically important group having 15 subjects.
difference for the Oswestry is 8 – 12 percentage points.9 e) Source of Data: Department of physiotherapy,
Muscle Energy Technique (MET) is low amplitude Career College
muscle contractions against resistance, to improve f) Sampling Criteria
vascular circulation and have positive influence on
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Inclusion criteria Group A: Experimental Group and Group B: Control

group
• Age group: 18-30 years
Experimental Group
• Pain and tenderness at SI joint
Subjects received MET: four contractions were
• SI joint dysfunction on examination
resisted by 30% force against therapist force and held
• Minimum 3 clinical SI joint provocation test for 7-10seconds, relaxing for 5seconds followed by
positive which includes Distraction Test, Sacral Joint Mobilization two to three oscillations per second
Thrust test, for about 1 minute and Conventional Physiotherapy
which included US with a frequency of 1 MHz and
Compression Test, Gaenslen’s Test, Thigh Thrust intensity of 0.8 Wcm2 for 5 minutes followed by
Test Corrective exercises.
Exclusion criteria Control Group
• Abdominal or back pain referred due to organic Subjects received conventional Physiotherapy
cause which included US and Corrective exercises. MET and
joint mobilization was not administered.
• Neurological disorder, Psychosomatic disorders
Methods of Application of Treatment
• Infectious condition
MET
• Pregnancy
Patient position was supine lying with both thighs
• Tumour
at the edge of the table. The leg of the anterior
• Recent hip or pelvis fractures or dislocations innominate was placed over the examiner’s shoulder
and the leg of the posterior innominate was placed
• Radiating pain upto toes
under the examiner’s hand. During the MET, the
• Any recent surgeries subject was asked to push their leg into the examiner’s
shoulder and push up with the opposite leg into
g) Materials & Apparatus Required examiner’s hand. A total of four contractions were
resisted by 30% force against therapist force and held
• Assessment sheet
for 7-10seconds, relaxing for 5seconds, performed on
• Outcome scales MODI, VAS four separate occasions over a 2-week period.
• Consent form Backward Torsion Joint mobilization
• Measuring Tape The patient lied on the unaffected side, with the
side to be manipulated positioned with the hip flexed
• Couch to the end of the available range and the unaffected
• Chair side positioned with the hip extended and the knee
flexed. The sacroiliac joint approximated the restricted
• Ultrasound Machine range into backward torsion. The clinician stood at the
patient’s side facing the pelvis. The manipulating hand
h) Procedure
was on the patient’s ischium. The guiding hand was
The aim of the study and procedure were explained on the patient’s anterior superior iliac spine and the
to all the patients and informed consent was taken. ventral surface of the iliac crest. The manipulating
The subjects were selected on the basis of inclusion hand glided the ischium ventrally, thus rotating the
criteria and the selected subjects were randomly pelvis into backward torsion. The guiding hand glided
divided into two groups: the anterior superior iliac spine and the ventral surface
40. rachel--203--.pmd 205 5/10/2015, 5:14 PM

of the iliac crest in a dorsal and cranial direction. i) Treatment Duration

Oscillations were performed at a rate of about two to
The treatment was given 5 days a week for 4 weeks
three per second for about 1 minute, followed by a
rest period of several seconds. j) Outcome measures
Ultrasound Modified Oswestry Disability Questionnaire
Ultrasound was administered in continuous mode at VAS
PSIS with patient in prone lying position, with a
frequency of 1 MHz and intensity of 0.8 Wcm2 for 5 k) Variables
minutes every alternating day.
Independent Variables
Corrective Exercises
1. Joint Mobilization
The following low back corrective exercises were
2. MET
given:
3. Ultrasound
a) To stretch the tight lower back muscles- Seated
Forward Bend- held for 5 sec and repeated for 3 Dependent Variables
times, once a day
1. VAS
b) To stretch the tight lower back muscles- Full Squat-
held for 5 sec and repeated for 3 times, once a day 2. Modified Oswestry Disability Questionnaire
c) To strengthen the weak lower abdomen- Draw in- DATA COLLECTION:

holding for 3 seconds, repeating 5 times , once a
day Data was collected under similar conditions for
each subject. Data was collected in data collection form
d) To strengthen the weak lower abdomen- Reverse along with other details of the patient. 2 readings were
Crunch- holding for 2 sec, repeating 5 times, twice taken as pre and post scores at 4 weeks.
a day.
Statistical Analysis
e) To stretch the tight hip flexors: Standing Hip Flexor
Stretch- holding for 10-15 seconds repeating 5 Suitable statistical analysis test was used in order
times on both legs, once a day. to verify the investigation of the study. Statistics was
performed using the software package Graph Pad. The
f) To strengthen the weak gluteus: Toed in Glutei characteristics of the data are presided through tables.
Squeeze- holding for 3 sec, repeating 10 times, once Pre and post test scores of MODI and VAS were
a day. analyzed using paired t test within the group.
Independent t- test was used to find out any significant
g) To strengthen the weak gluteus: Bridge both single
difference between Groups A and B. Significant level
and double leg- holding for 3 seconds, repeating
was defined at p< 0.05
10 times, once a day
h) To stretch the tight quadriceps: Standing RESULT

Quadriceps Stretch- holding for 3 seconds,
A sample of 30 patients using random sampling
repeating 5 times on each side, once a day.
method was divided into 2 equal groups with 15
i) To strengthen weak hamstrings: Kick Butts - patients each. Both the groups were given conventional
holding for 2 sec, repeating 8 times, once a day, physiotherapy as a baseline treatment. Along with
progressing 2 times per day. conventional physiotherapy the experimental group
received MET and joint mobilization to correct anterior
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innominate, whereas the control group received only starting the treatment and then after 4 weeks.
the conventional physical therapy. The study was Outcomes were evaluated using MODI and VAS
performed for 4 weeks. Evaluation was done before Scores.
Table No 1: Comparison between the Pre test and Post test scores between the groups using MODI scores
Sample Size Mean S.D. t value p value

Pre 15 Experimental Group 41.73 8.53 0.0750 0.9407not
statistically
significant
Control Group 41.93 5.81
Post 15 Experimental Group 22.47 7.61 2.0600 0.0488
statistically
significant
Table No 2: Comparison between the Pre test and Post test scores between the groups using VAS scores
Sample Size Mean S.D. t value p value

Pre 15 Experimental Group 7.13 7.20 0.1890 0.8515P> 0.05
not statistically
significant.
Post 15 Experimental Group 4.20 5.00 2.5668 0.0159p<0.05
statistically
significant.
CONCLUSIONS on improvement in pain and disability. The reasons

postulated for this improvement are: MET decreases
1. The data were analyzed using paired and
neuro-physiological pain. Manual contact with the
independent ‘t’test at 5% level of significance.The
patient may have resulted in alleviation of pain,
group receiving MET and Joint Mobilization along
through the neuro-physiological mechanisms of
with conventional physiotherapy (Group A) t = -
applied movement. Small-amplitude oscillatory and
10.121454(MODI); t = 12.8557(VAS) showed
marked improvement when compared to distraction movements may have stimulated the
conventional physiotherapy alone (Group B) t = - mechano-receptors that may inhibit the transmission
8.935035(MODI); t = 11.0000(VAS). p values of nociceptive stimuli at the spinal cord or brain stem
between the groups for MODI scores were 0.9407 levels. Gentle joint-play techniques help maintain
(Pre test ) and 0.0488 (Post test) and for VAS were nutrient exchange and thus prevent the painful and
0.8515(Pre test ) and0.0159 (Post test). degenerating effects of stasis when a joint is swollen
or painful and cannot move through the ROM. The
2. Even though there was significant reduction of results obtained suggested that both group
pain and improvement in activities of daily living demonstrated significant improvements in all subsets
in both the groups the results supported the
of MODI and VAS scores, subjects in Experimental
efficacy of MET and Joint Mobilization in the
group showed better improvement than control group
management of SI joint dysfunction more than
who received only conventional physiotherapy.
conventional physiotherapy alone.
Acknowledgement: We are thankful to all our subjects
DISCUSSIONS who participated with full cooperation
The changes observed in this study are noteworthy, Conflict of Interest/ Source of Funding: Nil
within group showed significant changes in the
improvement of pain and disability in both groups. Ethical Clearence: We certify that this study involving
Inter group analysis revealed significant difference that human subjects is in accordance with the regulations
shows group A (Experimental) is better than the other stated by ethical committee
40. rachel--203--.pmd 207 5/10/2015, 5:14 PM

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DOI Number: 10.5958/0973-5674.2014.00001.X
An Experimental Study to Findout the effect of Visual-

Vestibular Habituation and Balance Training Exercises in
Patients with Motion Sickness
Chiranjeevi Jannu
Assistant Professor, Vaagdevi College of Physiotherapy, Ramnagar, Hanamkonda, Warangal, Telangana
ABSTRACT
Objective: To find out the effectiveness of visual-vestibular habituation exercises and balance training
exercises in treating patients with motion sickness.
Method: Initially 54 subjects suffering with Motion sickness and various manifestations were
approached; from this 30 subjects who met all the inclusion criteria were selected. From this the
subjects were divided randomly in to two groups (Control group=15 & experimental group=15).
Therapy was advocated for 8weeks. Outcome measures were compared pre and post therapy by
using motion sickness questionnaire and VAS scale.
Results: Paired t test was used to evaluate the difference in both the groups. The data was analyzed
and there was a significant difference in each parameter before and after treatment. The scores on
VAS scale for each parameter are less in experimental group after treatment when compared to
control group.
Conclusion: The results conclude that visual-vestibular habituation exercises and balance training
exercises following the prescribed protocol, for treating motion sickness is effective.
Keywords: Motion Sickness, Physiotherapy, Visual -Vestibular Habituation and Balance Training Exercises
INTRODUCTION Manifestations of motion sickness may include

visual and postural instability, pallor, diaphoresis,
Motion sickness is common. Nearly anyone can be excess salivation, headaches, anxiety, nausea and
made motion sick by an appropriate stimulus, In a vomiting 4, 6, 7, 11, 14 . Precipitating environmental
large study done in India, the prevalence of motion conditions include vertical (up-down) or frontal axis
sickness was about 28%, and females were more movements (roll movements), movement in the
susceptible (27%) were more susceptible than males anterior-posterior direction (pitch movements),
(16.8%). In medical transport personnel, 46% of rotational (yaw) movements and optokinetic stimuli4,
personnel reported nausea and 65%, the sopite 6- 8, 10, 15
. Most investigators agree that movement,
syndrome (sleepiness caused by motion). (Wright, movement stimulus as well as a conflict in movement
1995) information detected by different sensory modalities
result in motion sickness.
Little information exists about evaluation and
effective treatment to ameliorate the symptoms of Motion sickness is a normal protective response
motion sickness, except as it relates to astronauts and that alerts an individual to impending trouble with
pilots3, 6,9,10, May be due to lack of evidence of vestibular equilibrium 7. Individuals who experience motion
deficit in people with motion sickness, as well as a sickness typically have vestibular and visual system
limited operational definition of motion sickness. function. Thus, to address the condition is not to
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provide intervention for dysfunction, but to improve 2. An index card with letters of 0.5 inch size printed
functional and adaptive responses. on it in color
OBJECTIVES 3. An 8 x 11 inch white sheet with a horizontal line

drawn on it from edge to edge
To find out the effectiveness of visual-vestibular
habituation exercises and balance training in treating 4. A daily log paper
patients with motion sickness.
5. A chair of sufficient height such that the person
METHOD sits on it with 900 flexion at both hip and knee with
his/her feet resting on the floor.
Source Of Data
6. A stable table or a kitchen platform to hold against
Patients of Vaagdevi Physiotherapy and
for support while performing exercises initially.
Rehabilitation Clinic, Warangal, Telangana.
Sampling Method METHODOLOGY
Then the 30 participants were randomly divided Initially 54 participants approached. Finally 30
into two groups on lottery basis. One group is named subjects were included in the study. The procedure
as experimental group and the other as control group.
was explained and informed consent form is taken.
Inclusion Criteria
Motion sickness questionnaire forms were
1. Subjects are diagnosed to have Motion sickness by provided. The questionnaire consisted information
Neurophysician. regarding demographic data like name, age, sex, and
2. Subjects of age group between 18 to 26 years. contact address, information about the mode of
transport, symptoms of motion sickness and their
3. Both males & Females are included. duration. The participants were asked to mark on VAS
4. Subjects suffering from motion sickness from the scale to quantify the intensity of these symptoms.
past 6 months to 1 year are included.
Procedure
5. Subjects suffering from motion sickness while
Participants of control group were told to follow
traveling by Bus, Train and Car.
remedies like taking mint chocolates, smelling lemon,
6. Subjects presenting with Giddiness, Nausea and munching citrus fruits, listening to music and
Headache due to motion sickness, with their concentrating on distant objects while traveling.
intensities documented on Visual Analog Scale
(VAS) between 4–6 for Giddiness, Nausea, Participants of experimental group were told to
Headache are included. follow remedial treatment, additionally they were
Exclusion Criteria provided each with an index card, a white paper with
a horizontal line drawn on it and a daily log paper to
1. Any other non specific neurological cause tick on after every session of exercise. In the first step
2. People with mental illness who cannot understand visual-vestibular habituation exercises were taught to
and/or execute the commands 5 participants at one time to ensure that the technique
of exercise is well understood and executed correctly.
3. People with physical disabilities that prevent them
Later they were asked to demonstrate the exercises and
from doing the exercises in a correct manner.
were corrected for any mistakes. All their queries were
Duration of Treatment: Two months answered and doubts ruled out.
MATERIALS USED Protocol
1. Motion sickness questionnaire including Visual Exercise should be carried out daily and as per the
Analog Scale (VAS) instructions.
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1. Visual-Vestibular Exercises: you are counting to 50. Try to use the hand minimally.
Gradually lift it off in an attempt not to use it at all.
A. Stage 1
If you are able to march without the use of the counter
A1. Sit in a chair; hold an index card with letters at
arm’s distance in front of you at eye level. Move the for support, advance to completing this activity with
card from left to right repeatedly as you maintain arms at your side.
fixation on the letters. First move the card slowly,
A2. Place a thick sofa or cushion on floor 5 inches from
counting in seconds, (one to thousand) as the card is
counter used. Place the sheet of paper with horizontal
moved from left to right repeatedly. Continue for ten
line on the wall at eye level. 10 to 15 feet away from
seconds. If you experience no motion sickness and can
maintain a clear image of the letters at this speed, move the place where you are standing.
the card more rapidly for ten seconds. In this way keep
March in the place on the cushion, as you look at the
on increasing the speed. Continue at maximum speed
horizontal line, using the counter for support, as
for 30 seconds. When all the symptoms stop, repeat at
needed. Count 50.
the maximum speed for 30 seconds 4 times.
A2. Repeat the same activities, but move the card in DATA ANALYSIS
up & down directions, centered in front of you
(approximately 8 inches from the center.) The parameters of giddiness, nausea, and headache
were measured individually on VAS scale and
A3. Sit in a chair, repeat step A1, keep your arm and documented accordingly.
card steady and centered in front of you. Turn your
head from left to right looking at the card and focusing Average change in the parameters on VAS scale
to keep a clear image of the letters. Establish a was measured and recorded in the master chart. The
maximum speed as above efficiency of the treatment protocol was tested for the
parameters on computer based data analysis system.
A4. Repeat step A3, but move your head in up – down
direction. The mean difference between the scores before and
A5. Repeat step A4 but tilt your head side to side (bring after treatment for motion sickness was calculated. The
right ear towards right shoulder and then left ear significance of mean difference for each parameter was
towards left shoulder) tested with paired t test using SPSS 15.0 software
(Statistical Package for Social Sciences) at 5% level of
2. Balance Training
significance to draw the inference on effectiveness of
A1. Stand with hands on kitchen counter or other firm the treatment.
support object with eyes closed. March in place where
Giddiness
Mean and standard deviation values,
Table 1
Sl:no. Parameter Experimental group Control Group

Before After Before After
Treatment Treatment Treatment Treatment
1. Giddiness 5.7 (1.5) 3.5 (1.8) 5.9 (1.5) 5.4 (1.4)
Table 2 Paired sample statistics
The correlation coefficient for before and after treatment:
Pairs Group N Correlation

1 Control group before & after treatment 15 0.866
1 Experimental group Before & After treatment 15 0.892
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There exists high correlation between the variables significant value for experimental group is 0.000 and
in both the groups. Further analysis was conducted to 0.029 for control group.
know the level of significance. It was found that the
Table 3: Paired samples tests
Mean Standard Std Error 95% t df Sig.

deviation Mean confidence (2-tailed)
interval of
the difference
Lower Upper
Control group before and after treatment 0.467 0.743 0.192 0.055 0.878 2.432 14 0.029
Experimental group before and after treatment 2.267 0.799 0.206 1.824 2.709 10.990 14 0.000
We observe that changes in both the groups are (0.000) is more significant when compared to control
significant as of both of them are less than level of group (0.029), which states that the treatment is
significance at 5% (0.05), but the experimental group effective.
HEADACHE
Table 4 Mean and standard deviation values
Parameter Experimental group Control Group

Headache 6.1 (1.7) 4 (1.7) 6.1 (1.7) 5.8 (1.7)
Table 5 The correlation coefficient

1 Control group before treatment & after treatment 15 0.993
1 Experimental group Before treatment & After treatment 15 0.878
There exists high correlation between the variables. experimental group is 0.000 and 0.055 for control
Further analysis was conducted to know the level of group.
significance. It was found that the significant value for
Table 6

interval of
the difference
Lower Upper
Control group before and after treatment .333 .617 .159 -.008 0.675 2.092 14 0.055
Both groups are significant as the values of both of compared to control group (0.055), which states
them are less than level of significance at 5% (0.05), treatment is effective.
but the experimental group (0.000) is more significant
NAUSEA
Table 7 Mean and standard deviation values
Sl.no. Parameter Experimental group Control Group

1. Nausea 4.7 (1.6) 2.7 (1.6) 4.9 (1.5) 4.5 (1.5)
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Table 8: The correlation coefficient

1 Control group before treatment & after treatment 15 0.880
1 Experimental group Before treatment & After treatment 15 0.877
There exists high correlation between the variables. experimental group is 0.000 and 0.054 for control
Further analysis was conducted to know the level of group.
significance. It was found that the significant value for
Table 9

interval of
the difference
Lower Upper
Control group before and after treatment 0.400 0.737 0.190 -0.008 0.808 2.103 14 0.054
Both groups are significant as the values of both of sample in control group is 22 years with a standard
them are less than level of significance at 5% (0.05), deviation of 2.3 years.
but the experimental group (0.000) is more significant
compared to control group (0.054), which states Paired t-test was done for each parameter before
treatment is effective. and after treatment. The calculated value for each
parameter is compared with the tabulated value at 5%
level of significance.
RESULTS
The values of mean and standard deviation for all
The mean and standard deviation for each
the three parameters before and after the treatment
parameter was measured to see the average and
for both groups are given in Table 6.1.
variations in both the groups. The mean age of the
sample in experimental group is 22.2 years with a Mean and standard values of Giddiness, Headache
standard deviation of 2.7 years where the mean age of and Nausea
Table 6.1
Sl.no. Parameter Experimental group Control Group

1. Giddiness 5.7 (1.5) 3.5 (1.8) 5.9 (1.5) 5.4 (1.4)
2. Headache 6.1 (1.7) 2 (1.7 6.1 (1.7) 5.8 (1.7)
3. Nausea 4.7 (1.6) 2.7 (1.6) 4.9 (1.5) 4.5 (1.5)
The data was analyzed to show the differences in These exercises do not require any machinery or
each parameter before and after treatment. The scores equipment, or regular visit to the physical therapist
on VAS scale for each parameter are less in except proper training of the procedure and technique,
experimental group after treatment when compared which is very easy to learn.
to control group.
Establishment of maximum speed to perform
exercises, which is a key factor, is subjective. As a result
CONCLUSION
the patients are at an ease to perform these exercises
Visual-vestibular habituation exercises and balance at greater comfort. The number of female patients is
training are very easy to perform by patients. When more than the male patients in the sample showing
properly trained, these exercises can be performed at the more prevalence of motion sickness in females than
home without the need of supervision by a therapist. in males.
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The overall results conclude that visual-vestibular 8. Eyeson-Annan M, Peterken C, Brown B, Atchison
habituation exercises and balance training following D. Visual and vestibular components of motion
the prescribed protocol, for treating motion sickness sickness. Aviat Space Environ Med.1996; 67:955–
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Conflict of Interest: Nil
12. Lawther A, Griffin MJ. A survey of the occurrence
of motion sickness amongst passengers at sea.
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DOI Number: 10.5958/0973-5674.2014.00001.X
Comparative effectiveness of Static Stretch and

Proprioceptive Neuromuscular Facilitation (PNF) Stretch
on Hamstring Flexibility in Young Adult Females
Manasi Joshi1, Ambarish Akre2

1
Intern, 2Associate Professor, DES Brijlal Jindal College of Physiotherapy, Pune, India
ABSTRACT
Objective: To compare the effect of static stretch and PNF stretch on hamstrings flexibility in young
adult females.
Methodology: This was a pilot study done amongst students at DES Brijlal Jindal College of
Physiotherapy, Pune between October 2013 to February 2014. Total 30 females of the age group of
18-30 years were selected by convenient sampling. The subjects were required to have tight hamstring
as defined by a 20 degree knee extension angle (KEA) with the hip in 90 degree of hip flexion. The pre
intervention flexibility of hamstrings was measured by a universal goniometer. Subjects in one group
received a passive static stretch to the hamstrings for 30 seconds. Subjects in the other group got a
Proprioceptive neuromuscular facilitation (PNF) stretch for 30 seconds. The range of motion after
the respective stretches was again measured.
Results: Paired and Unpaired t test was done to compare the hamstrings flexibility pre and post the
static and proprioceptive neuromuscular facilitation stretches and between the two stretching
techniques. The difference in the pre and post hamstrings flexibility was found to be extremely
significant (p < 0.0001) in both the groups. However there was no significant difference in the post
stretching measurements between the two stretching techniques.
Conclusion: A single session of static stretching and proprioceptive neuromuscular (PNF) stretching
both significantly increase the hamstrings flexibility. When compared between the two, no intervention
is significantly better than the other.
Keywords: Hamstring flexibility, Static stretch, Proprioceptive Neuromuscular (PNF) stretch
INTRODUCTION effective movement. More efficiency and effectiveness

in movement as a result of enhanced muscle flexibility
Flexibility of a muscle is the ability of a muscle to
will assist in preventing or minimizing injuries and
lengthen allowing one joint or more than one joint in a
may enhance performance.1
series to move through a range of motion. Good muscle
flexibility will allow muscle tissue to accommodate to Maintaining a normal muscle length requires
imposed stress more easily and allow efficient and regular stretching .A variety of stretching activities
have been presented in the literature in order to regain
or maintain muscle flexibility and avoid a decrease in
range of motion (ROM) that can impair functional
Ambarish Akre
Associate Professor activities in an individual. Some techniques used to
DES Brijlal Jindal College of Physiotherapy, Fergusson increase flexibility in muscle include the ballistic
College Campus, Pune- 411 004 stretch, static stretch, active self stretch and
E-mail: physioambarishakre1412@gmail.com proprioceptive neuromuscular facilitation (PNF)
Tel: +91-9970577204 stretch2.
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Static stretching is a common technique used by with the ultimate goal being to optimize motor
strength and conditioning specialists and athletes to performance and rehabilitation5.
increase muscle length. It has been defined as
elongating the muscle to tolerance and sustaining the The literature regarding PNF has made the
position for a length of time. One of the advantages of technique the optimal stretching method when the aim
static stretching may be facilitation of the Golgi tendon is to increase range of motion, especially in short-term
organ (GTO). Static tension placed on the muscle changes. Generally an active PNF stretch involves a
tendon unit has been shown to activate the GTO, which shortening contraction of the opposing muscle to place
may produce autogenic inhibition of the muscle that the target muscle on stretch. This is followed by an
is stretched3. isometric contraction of the target muscle. PNF can be
used to supplement daily stretching and is employed
Duration, frequency, number of repetitions, daily
to make quick gains in range of motion to help athletes
dose, and length of program are important parameters
improve performance. Aside from being safe and time
for static stretching. Limited research is available
efficient, the dramatic gains in range of motion seen
examining the optimal time a stretch should be
in a short period of time may also promote compliance
sustained. Suggested effective durations range from 5
with the exercise and rehabilitation program6.
to 60 seconds. The optimal time a stretch should be
held is 30 seconds one time per day. Benefits of this PNF stretching technique achieves the greatest
slower stretching technique include that the stretch gains in ROM, e.g. utilising a shortening contraction
prevents the tissue from having to absorb great of the opposing muscle to place the target muscle on
amounts of energy per unit time, the slow stretch will stretch, followed by a static contraction of the target
not elicit a forceful reflex contraction, and this
muscle. The inclusion of a shortening contraction of
technique alleviates muscle soreness4.
the opposing muscle appears to have the greatest
Static stretching has the least associated injury risk impact on enhancing. The superior changes in ROM
and is believed to be the safest and most frequent that PNF stretching often produces compared with
method of stretching. When performed correctly and other stretching techniques has traditionally been
at the right time, static stretches help you lengthen tight attributed to autogenic and/or reciprocal
muscles and improve your balance and overall fitness. inhibition.1, 6
A good stretch session also helps relieve stress and
tension. The stretch is held in a challenging but A number of studies have investigated the efficacy
comfortable position for a period of time, usually of several repetitions of proprioceptive neuromuscular
somewhere between 10 to 30 seconds. Researchers facilitation stretching (PNF) and static stretching.
have proposed frequencies ranging from 1 to 3 times However, there is limited research comparing the
per day and up to 5 days per week4. effects of a single bout of these stretching manoeuvres.
That is why the study was to done compare the
To perform a static stretch properly, you should effectiveness of a single bout of a therapist-applied 30-
get far enough into the stretch that you feel a slight second static stretch versus a single bout of therapist-
pull but no pain. It helps to exhale as you get into a applied 30-second PNF stretch.7
stretch. When you’re holding a stretch, breathe
normally and avoid the tendency to hold your
OBJECTIVES
breath.1, 4
1. To study the effect of static stretch on hamstrings
Introduced by Knott and Voss, proprioceptive
flexibility
neuromuscular facilitation involves techniques that
use a brief isometric contraction of the muscle to be 2. To study the effect of proprioceptive
stretched prior to a static stretch. These techniques seek neuromuscular facilitation (PNF) stretch on
to facilitate the Golgi tendon organ to inhibit the muscle hamstrings flexibility.
in which it lies and to use the principle of reciprocal
inhibition.PNF stretching is a set of stretching 3. To compare the difference in hamstrings flexibility
techniques commonly used in clinical environments following static stretching and PNF stretching on
to enhance both active and passive range of motion hamstrings flexibility

METHODOLOGY
Study design: A Pilot Study.
Study area: DES Brijlal Jindal college of Physiotherapy,

Pune.
Duration: 6months
Sampling: Convenient Sampling.
Sample Size: 30 females.
Materials Used: Universal Goniometer.
30 females of the age group of 18-30 years were

included in the study. To be included in the study, the
subjects were required to have tight hamstring as
defined by a 20 degree knee extension angle (KEA)
with the hip in 90 degree of hip flexion. Subjects were
excluded from the study if they had a previous history
of lower extremity pathology (fractures or soft tissue
injuries) which may adversely affect hamstring
flexibility length2. The subjects signed a consent form
and ethical clearance from the institutional ethical
committee was obtained for the study.
PROCEDURE Fig. 1. Measurement of hamstring flexibility
Measurements were taken with the subjects in the

supine position on a treatment plinth. The hip and knee Method for static stretching: The therapist gives a
of the dominant leg were flexed up to 90 degrees with passive static stretch to the hamstrings for 30 seconds.
The range of motion after the stretch is recorded10.
the contra lateral extremity placed flat on the plinth.
The knee was passively extended by the therapist to Method for giving PNF stretch: For the first 15 seconds
the point of a strong but tolerable stretch was reported the subject is asked to do the hold-relax technique
by the subject. The fulcrum was kept on the lateral where the subject is asked to do isometric contraction
knee joint line. The movable arm was kept along the of the hamstrings and then relax. The next 15 seconds
lateral shaft of fibula and the stationary arm is kept the subject is asked to do contract-relax technique
perpendicular to the floor. The range of motion is where the knee is flexed by the therapist against
recorded with the help of goniometer. The angle that moving resistance isotonically and then relaxed. The
was used for statistical analysis was 180 - u, where u hip held at 90 degrees, the knee is moved into its fully
is the acute knee angle from terminal extension2.The extended position so as to apply a stretch to the
hamstring. Thus the PNF stretch too is applied for
knee extension test has been shown to be a reliable
duration of 30 seconds. The range of motion after the
measure of hamstring flexibility. Sullivan and
stretch is recorded.
colleagues found the intratester reliability of the knee
extension test to be 0.99 by using the inclinometer Statistical Analysis
method8. Webright and colleagues also found high
Paired and Unpaired t tests were used to compare
intratester (0.98) and intertester (0.98) reliability with
the knee extension test by using a universal • Pre and post effects of static stretch on hamstrings
goniometer9. flexibility.

• Pre and post effects of PNF stretch on hamstrings In the second group the mean range of motion pre
flexibility. PNF stretch is 30.067 degrees and post PNF stretch is
24.6 degrees (Table 2). This is considered extremely
• Difference post stretch between static and PNF statistically significant (p value < 0.0001) indicating
stretch on hamstrings flexibility. significant difference in the pre PNF stretch and post
PNF stretch knee extension range of motion indicating
RESULTS that hamstring flexibility does improve after a single
Table 1: Comparison of Pre and Post Static Stretch on session of PNF stretching.
hamstring flexibility
Table 3 showed that the mean difference of the
U Knee extension angle Mean SD p value range of motion post static stretch is 28.133 and post
Pre ROM (degrees) 28.133 10.453 <0.0001 PNF is stretch is 24.6. Here the p value is 0.3130 which
Post ROM (degrees) 21.067 8.259 is not considered statistically significant. This indicates
that both the interventions resulted in a significantly
There is a high statistical significant difference in
greater increase in knee extension and there was no
the hamstrings flexibility following a single session of
intervention of the two was significantly effective than
static stretch (p value < 0.0001).
the other in comparison.
Table 2: Comparison of Pre and Post Proprioceptive
neuromuscular facilitation (PNF) stretch on hamstring One of the limitations of the study was a small
flexibility sample size. Despite the small sample size, the
response to stretching was statistically significant by
U Knee extension angle Mean SD p value
both the static stretch and the PNF stretch. The
Pre ROM (degrees) 30.067 11.177 <0.0001
intervention was only a single session which can be
Post ROM (degrees) 24.600 10.425
increased too. Also since the hamstrings group was
There is a high statistical significant difference in only tested, the results cannot be generalised to the
the hamstrings flexibility following a single session of other muscle groups.
Proprioceptive neuromuscular facilitation stretch (p
value < 0.0001). CONCLUSSION
Table 3: Comparison of difference in static stretch and The study concluded that a single session of static
PNF stretch on hamstrings flexibility
stretching and proprioceptive neuromuscular (PNF)
U Knee extension angle Mean SD p value stretching both significantly increase hamstring
(degrees) (degrees) flexibility. When compared, no intervention of the two
Post Static stretch ROM 21.067 8.259 0.3130 is found significantly more effective than the other.
Post PNF stretch ROM 24.600 10.425
Clinical Implication
There is no significant difference in static stretch
and PNF stretch on hamstrings flexibility. (p value is A single session of static stretch and PNF stretch
not <0.0001) can increase hamstring flexibility and can be used on
field to give a significant result. Strength and
DISCUSSION conditioning experts should recognise that the type,
intensity, dose, frequency and programme duration
The results of this study showed that the mean are important with muscle stretching as with strength
range of motion pre static stretch is 28.133 degrees and training.
post static stretch is 21.067 degrees (Table 1). This was
extremely statistically significant (p value < 0.0001) in Acknowledgment: We would like to thank our
the pre and post static stretch knee extension range of principal Dr. Aparna Sadhale (PT) and the DES college
motion indicating that hamstring flexibility does management for allowing us to conduct and guiding
improve after a single session of static stretching. This us during and after completion of the study. We extend
was in accordance with the study done by Bandy and our gratitude to all the subjects for their cooperation
colleagues who had concluded that one 30- second and support.
static stretch was just as effective as a 60-second stretch
Conflict of Interest: I, Ambarish A Akre, am taking
performed 3 times a day10.
full responsibility for the data, the analyses and

Interpretation, and the conduct of the research and that 4. Bandy WD, Irion JM. The effect of time on static
I have full access to all of the data; and have the right stretch on the flexibility of the hamstring muscles.
to publish any and all data separate. I declare no Phys Ther. 74:845- 850, 1994
conflict of interest from the co-author for the same. 5. Kisner C, Colby L. Therapeutic exercise:
Foundations and techniques. Philadelphia: FA
Source of Funding: No major funding required for the Davis Co.2002.
research study, conducted as a part of internship 6. Osternig LR, Robertson RN, Troxel RK, Hansen
Programme. P. Differential response to proprioceptive
Ethical Clearance: Ethical clearance by DES Brijlal neuromuscular facilitation(PNF) stretching
Jindal College of Physiotherapy institutional review techniques. Med. Sci. Sports Exerc. 1990;
board. 22(1):106-11.
7. O’Hora J, Cartwright A, Wade CD, Hough AD,
Shum GL.J Strength Cond Res 2011.
REFERENCES
8. Sullivan MK, Dejujlia JJ, Worrell TW. Effect of
1. Bandy WD, Irion JM, Briggler M. The effect of pelvic position and stretching method on
static stretch and dynamic range of motion hamstring muscle flexibility. Me. Sci. Sports
training on the flexibility of the Hamstring Exerc.1992; 24 :1383-1992.
Muscles. J. Ortho. Sports Phys. Ther, 1998 ; 27: 9. Webright WG, Randoph BJ, Perrin DH.
295-300. Comparison of non ballistic active knee extension
2. Davis DS, Ashby PE, McCale KL, McQuain JA, in neural slump position and static stretch
Wine JM. The effectiveness of 3 stretching techniques on hamstrings flexibility. J. Orthop.
techniques on hamstring flexibility using Sports Phys. Ther, 1997; 26: 7-13.
consistent stretching parameters. Journal of 10. Bandy WD, Irion JM, Briggler M: The effect of
Strength and Conditioning research, 2005; time and frequency of static stretch on flexibility
19(1):27-32. of the hamstring muscles. Phys. Ther. 1997; 77:
3. Bandy WD, Sanders B. Therapeutic Exercise. 1090-1096.
Techniques for intervention. Philadelphia:
Lippincott Williams& Wilkins, 2001.

DOI Number: 10.5958/0973-5674.2014.00001.X
Myofascial Pain Syndrome
Anudeep Saxena1, Mayank Chansoria2

1
Senior Resident, Department of Anesthesiology, JPN Apex Trauma Center AIIMS, New Delhi, 2Assistant Professor
and Head of Pain Clinic, Department of Anaesthesiology and Critical Care NSCB Medical College, Jabalpur, M.P.
ABSTRACT
Over the last few decades, advances have been made in the understanding of myofascial pain
syndromes. In spite of its high prevalence in the society, it is not a commonly established diagnosis.
MPS is said to be the great imitator. This article puts some light on the various clinical presentations
of the syndrome, on the various tools to reach to a diagnosis for commencing the treatment and on
the treatment modalities that have been used so far.
Keywords: Myofascial Pain Syndrome, Trigger Points
INTRODUCTION hyperirritable palpable nodules in the skeletal muscle

fibers, which are termed MTrPs (Myofascial trigger
Myofascial Pain Syndrome is a largely
points)4. MTrPs are the cardinal feature of MPS and
underdiagnosed and undertreated entity. The clinical
hence differentiate it from other painful, inflammatory
picture of MPS is one of musculoskeletal pain, limited
myositis and fibromyalgias.
mobility, weakness and referred pain. There may be
clumsiness and in-coordination as well. Myofascial
ETIOLOGY
trigger points have been described as a ‘common cause
of pain in clinical practice’ and an ‘extremely common, The trigger point is responsible for the clinical
yet commonly overlooked’ source of musculoskeletal symptoms of MPS.
disorders1. Prevalence varies from 30% to 93% among
the persons with musculoskeletal pain2. The estimated Myofascial trigger point (MTrP) has been described
overall prevalence of active myofascial trigger points as a tender point in a taut band (TB) of muscles,
is 46.1 ± 27.4%3. This large variation is due to the fact although it is not always tender. Traumatic events,
that there is still no consensus on the criteria for the muscular overloads, psychological stress and systemic
definition of MPS, although it is treatable. pathology may lead to development of one or more
palpable bands in which a latent MTrP (without
DEFINITION spontaneous symptomatology) could appear. Such
latent MTrP, if subjected to mechanical stress or to
MPS is a noninflammatory disorder of other harmful factors could become active MTrP
musculoskeletal origin, associated with pain and (spontaneously symptomatic). An active MTrP could
muscle stiffness, characterized by the presence of spontaneously recover, regress to the latent stage or
persist as isolated clinical entity without progression.
Corresponding author: This MTrP remains in a dynamic state, which means
Anudeep Saxena that it can undergo transitions between a nontender
Senior Resident taut band to a latent trigger point to an active trigger
Department of Anesthesiology, JPN Apex Trauma point and back again5. Sometimes, in the presence of
Center AIIMS, New Delhi perpetuating and aggravating factors, a worsening
Address - 165-Double Story, New Rajinder Nagar, progression starts with an increase in the number of
New Delhi MTrPs (satellite MTrP) and the development of
Email- dranudeepsaxena@yahoo.in myofascial chronic syndromes6.
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Various perpetuating factors7 have been identified
Ergonomic factors- hypermobility forward neck

posture, forward shoulder posture, work related
activities, prolonged static postures, repetitive
activities, activity related stresses, telephone use,
computer use, recreational activities, frozen shoulder,
impingement syndrome
Structural factors- scoliosis, structural or functional

leg-length inequality, pelvic height asymmetry, pelvic
torsion, sacroiliac joint dysfunction, joint arthritis,
osteoarthritis of spine or hip
Medical factors: Hormonal (hypothyroidism,

testosterone deficiency, estrogen deficiency), Myofascial Pain Syndrome includes number of
Nutritional (vitamin d deficiency, iron deficiency), clinical presentations. We have considered some of the
Infectious disease (Lyme disease, Babesiosis, studies that have reliably established a correlation
Candidiasis). between the MTrPs and the pain syndromes6,8,9.
Examples of pathologies in which it is possible to find one or more MTrPs that contribute to painful condition
Pathology Muscles involved Source

Headaches Neck and shoulder muscles Davidoff 1998
Herpes zoster infection of Muscles innervated by the intercostals
the intercostal nerve nerve involved Chen et al. 1998
Cervical disc bulding Levator scapulae, rhomboid minor, splenium Hsueh et al. 1998
capitis, deltoid, latissimus dorsi
Noctural calf cramps Gastrocnemius Prateepavanich et al. 1999
Shoulder impingement Subscapularis muscle Ingber 2000
Postthoracotomy pain syndrome Muscles in the scapular region Hamada et al. 2000
Subacute Low Back Pain Quadratus lumborum, Gluteus maximus, Hsieh et al.2002
Gluteus minimus, Gluteus medius, Piriformis
Tennis Elbow Triceps and other Extensors Davies J 2003
Temporomandibular pain Masseter and Temporalis Laat et al.2003
Referred Knee Pain Iliopsaos Cummings 2003
Post trans-axillary surgery pain Pectoralis major Cummings 2003
Nonodontogenic toothache Masseter Mascia 2003
Abdominal–pelvic pain syndrome Pelvic floor muscles Fitzgerald 2003
Chronic abdominal pain Thoracic paraspinal muscle Cimen 2004
Thoracic outlet syndrome Biceps, triceps, trapezius, scalene, pectoralis Crotti et al.2005
Rotator cuff tendinitis Teres minor, infraspinatus, subscapularis Al-Shanqiti 2005
Post Whiplash injury pain Trapezius, suboccipaital scalene, Fernandez-de-las-penas 2005
sternocleidomastoid
Posterior upper thoracic pain Pectoralis major, serratus posterior Fruth 2006
superior, serratus anterior, lower trapezius
Chronic migrane Frontalis, temporalis, trapezius, suboccipitalis Calandre 2006
Clinical Features and Diagnosis because pain may be felt elsewhere than where the
pain originates. MPS may persist long after the
MPS presents both as acute and chronic muscle initiating cause of pain has resolved, as in late MPS
pain. In both cases, muscle pain is like other somatic persisting months or years after whiplash injury. It
and visceral pains, dull, aching, and poorly localized. may be further complicated by nerve entrapments
It may be accompanied by a sensory component of caused by constricting myofascial taut bands. Thus,
paresthesias or dysesthesias. MPSs can be enigmatic,
43. Anudeep--221--.pmd 222 5/10/2015, 5:14 PM

MPS can be complex, with the underlying cause not of the referred pain is crucial since MPS characterized
obvious. It may be more straightforward, especially by MTrPs often reproduce symptomatologies of more
when it is acute or subacute 7. Trigger points are serious pathologies such as angina pectoris, headache,
detectable only if superficially located in the muscle, shoulder bursitis, lumbar herniated disc with
or if associated with areas of localized spasm4, their radiculopathy and appendicitis.
average size varying between 2 and 10mm10, 11. The
reliability of MTrP diagnosis has long been a debatable Restricted range of motion (RROM): The complete
point in the medical literature, because there had been elongation of the muscle affected by MTrP is
no laboratory or imaging technique that was capable compromised because of the pain. The reduction of
of confirming the clinical diagnosis. Diagnosis had joint ROM will normalize as the contracted fibers
been possible only by clinical history and examination. loosen following the deactivation of the MTrP. The
restored ROM of a joint and the increased elongation
The physical assessment is mainly based on muscle of a muscle are not specific positive signs. They
palpation. The most important clinical signs6,7 are constitute a diagnostic criteria valid only for some
muscles whose impairment clearly affects a joint
Tender Point (TP): A very tender spot located function. When movement is markedly restricted,
within the contracted fibers of the palpable band measurement of increase in range of motion becomes
affected by the MTrP. The sensitivity of the spot is a useful objective measure of progress.
increased by increasing the tension of the palpable
band while it is decreased as the band is released with Weakness: Muscles harboring a trigger point are
a progressive and passive elongation of the fibers. A often weak. Weakness in affected muscles occurs
pressure on the spot would elicit a local and referred without atrophy, and is not neuropathic or myopathic
pain. Recent studies showed the usefulness of in the sense that weakness is not caused by either a
analyzing the relation between pressure and pain with neuropathy or a myopathy or myositis. It is usually
the intent of determining the degree of sensitivity of rapidly reversible immediately on inactivation of the
the MTrP. The analysis can be efficiently performed trigger point, suggesting that it is caused by inhibition
using a pressure algometry. of muscle action.
Jump Sign (JS): Pressure on the spot can cause the Recruitment: The trigger point causes a disordered
patient to react to the pain with a spontaneous recruitment of muscles that work together to produce
exclamation or movement an action. For example, the orderly activation of
muscles that produces abduction of the upper
Pain reproduction (RepP): Digital pressure or
extremity is disrupted by a latent trigger point, and is
needle injection on a tender spot within the palpable
restored by inactivation of the latent trigger point.
band may elicit local pain or distal pain that is similar
Likewise, the ability to rapidly activate painful and
to the patient’s usual complaint, or may aggravate the
pain-free synergistic muscles is more severely
existing pain. This finding by definition identifies an
impaired in women with chronic trapezius myalgia
active MTrP.
(TM), in which there are active and latent trigger
Local twitch response (LTR): When MTrP is points, than is the ability to produce maximal muscle
stimulated by vigorous snapping palpation or by activation.
needle penetration, the TB contracts producing a local
twitch response (LTR) which is unique to MTrP and Associated phenomena: MTrPs can cause
not seen in normal muscle. According to recent studies autonomic nervous system (ANS) changes like
this type of reflex contraction is primarily sustained at localized hypothermia, referred cutaneous
the spinal cord level, without an involvement of the hypothermia and persistent lacrimation. Some authors
upper structures of the central nervous system17-20. also make reference to proprioceptive changes, such
as balance problems or tinnitus in patients with MTrPs.
Referred Pain: Mechanical stimulation of the MTrP
also produces the phenomenon of referred pain (RefP). There is still no consensus on the criteria for the
The pattern of pain distribution does not follow any definition of MTrP syndrome, although The 4 most
dermatomal or myotomal pattern. A correct evaluation commonly applied criteria12 are
43. Anudeep--221--.pmd 223 5/10/2015, 5:14 PM

“Tender spot in a taut band” of skeletal muscle, treatments had been more efficacious than control
intervention.
“Patient pain recognition,”
Non-invasive, non-manual therapies: Treatments
“Predicted pain referral pattern,” and in this category include all forms of electrical
“Local twitch response.” stimulation (TENS, EMS, HVGS, IFC, and FREMS),
ultrasound, laser, and magnet therapies7.
Another study reported that reliability estimates
were generally higher for subjective signs such as A review of literature by Howard Vernon et al15,
tenderness and pain reproduction, and lower for reported that there is moderate evidence of manual
objective signs such as the taut band and local twitch therapies (manipulation and ischemic compression)
response13. being useful in short-term relief of MTrP pain. There
is strong evidence of laser and moderate evidence of
Electrophysiology of MTrP: A characteristic TENS, magnet or acupuncture in the short- and long-
electromyographic discharge termed Endplate noise term relief of MPS.
is associated with the taut band. Low amplitude (10-
50ìV) discharges are present in the taut band, whether Invasive therapies: MTrPs can also be inactivated
painful or not. Intermittent high amplitude (up to by inserting a needle into the trigger zone or point.
500ìV) discharges are seen in painful trigger points. This can be done with or without the injection of local
Endplate noise intensity is directly correlated with the anaesthetic16. Properly done, a local twitch response
degree of trigger point irritability as measured by the will occur, often with a momentary reproduction of
pain intensity and the pressure pain threshold7. referred pain, and then the taut band will relax and
tenderness will diminish or disappear. In either case,
Management of Myofascial Pain Syndrome inactivation by needling or injection, or by manual
(physical) therapy, must be followed by correction of
Treatment of myofascial pain requires the mechanical or structural stresses such as forward
inactivation of MTrPs, the restoration of normal muscle
displaced shoulders and a forward head position, or
length, and the elimination or correction of the factors by pelvic rotation or sacroiliac joint dysfunction. There
that created or perpetuated the trigger points in the is no evidence to support the injection of other
first place. materials such as steroids or ketorolac. In fact,
Manual therapies: Manual therapy to inactive a intramuscular stimulation, a term coined by Gunn17,
MTrP includes trigger point compression, often or dry needling, works well, and may work as well as
the injection of local anaesthetic, but adequate studies
accompanied by a short excursion of the appropriate
to support one position or the other are lacking.
body part actively to slightly lengthen and shorten the
Superficial dry needling, a technique in which the
muscle. MTrP pain will usually subside within 20-30
needle is inserted into subcutaneous tissues about
seconds, the referred pain will disappear, and finally
4mm overlying the trigger point, is another means
the taut band will relax, if not go away, within about a
whereby the myofascial trigger point can be
minute. The taut band of muscle is stretched locally
inactivated18,19. Acupuncture has also been used to treat
along its long axis for a distance of a few inches. This
myofascial pain syndrome. There are few controlled
local stretch is not across a joint. A myofascial release
or blinded studies to rely upon. However, there is some
technique is applied to the muscle to stretch the fascia,
indication that acupuncture may be effective in treating
moving over the skin away from the trigger point. A some myofascial pain syndromes20.
larger range therapeutic stretch is applied, to stretch
the muscle across the joint or joints associated with Once trigger point pain is reduced, it is the need to
the muscle, e.g. the hip and knee for the rectus femoris identify the underlying cause(s) of persistent or chronic
muscle. These stretches must be muscle specific to be muscle pain in order to develop a specific treatment
most effective. Manual therapies described by various plan. Chronic myalgia may not improve until the
authors are ischemic compression, spray and stretch, underlying precipitating or perpetuating factor(s) are
strain and counterstrain, muscle energy techniques, themselves managed. Precipitating or perpetuating
trigger point pressure, transverse friction massage. A causes of chronic myalgia include structural or
review literature 14 reported that none of these mechanical causes like scoliosis, localised joint
43. Anudeep--221--.pmd 224 5/10/2015, 5:14 PM

hypomobility, or generalised or local joint laxity; and 5. Chen SM, Chen JT, Kuan TS et al. Decrease in
metabolic factors like depleted tissue iron stores, pressure pain thresholds of latent myofascial
hypothyroidism or Vitamin D deficiency. Sometimes, trigger points in the middle finger extensors
correction of an underlying cause of myalgia is all that immediately after continuous piano practice. J
is needed to resolve the condition Musculoskelet Pain 2000;8(3):83–92
6. Testa M, Barbero M, Gherlone E. Trigger points:
After trigger point pain is reduced and Update of the clinical aspects. Eur Med Phys
perpetuating factors are addressed, a physical 2003;39:37-43
conditioning programme can strengthen muscle, 7. S. Mense and R.D. Gerwin. Muscle Pain:
increase endurance, and perhaps reduce the possibility Diagnosis and Treatment, Chapter 2- Myofascial
of reactivating the trigger points. Pain Syndrome
Johannes Fleckenstein et al21 presented a research 8. Simons DG, Dommerholt J. Myofascial Trigger
article on the discrepancy between prevalence and Points and Myofascial Pain Syndrome: A critical
perceived effectiveness of treatment methods in review of recent literature The Journal of Manual
myofascial pain syndrome. Frequently prescribed & Manipulative Therapy 2006; 14: E124 - E171
treatments are analgesics, mainly metamizol/ 9. Simons DG, Dommerholt J. Myofascial Pain
paracetamol (91.6%), non-steroidal anti inflammatory Syndromes- Trigger Points. . J Musculoskelet
drugs/coxibs (87.0%) or weak opioids (81.8%), and Pain 2004;12(1):51-59
physical therapies, mainly manual therapy (81.1%), 10. Cummings TM, White AR. Needling therapies
TENS (72.9%) or acupuncture (60.2%). Overall in the management of myofascial trigger point
effectiveness ratings for analgesics and physical pain: a systematic review. Arch Phys Med
therapies were moderate. Effectiveness ratings of the Rehabil. 2001;82:986-92
various treatment options between specialities showed 11. Kruse RA Jr, Christiansen JA. Thermographic
wide variation. 54.3% of all physicians characterized imaging of myofascial trigger points: a follow-
the available treatment options as insufficient. up study. Arch Phys Med Rehabil.1992;73:819-
23
Acknowledgement: Nil 12. Tough EA, White AR, Richards S et al. (2007)
Variability of criteria used to diagnosis
Ethical Clearance: From the Ethics Committee NSCB myofascial trigger point pain syndrome—
medical college, Jabalpur, M.P.
evidence from a review of the literature
Source of Funding: Self 13. Lucas M, Macaskill P, Irwig L et al. (2009)
Reliability of physical examination for diagnosis
Conflict of Interest: Nil of myofascial trigger points. Clin J Pain 25:80–89
14. Cesar Fernandez de las Penas, Monica Sohrbeck
REFERENCES Campo, Josue Fernandez Carnero, Juan Carlos
Miangolarra Page. Manual therapies in
1. Simons DG: Understanding effective treatments
myofascial trigger point treatment: a systematic
of myofascial trigger points. J Bodywork
review. Journal of Bodywork and Movement
Movement Therap 2002, 6:81-88.
Therapies 2005; 9: 27–34
2. Simons DG: Clinical and Etiological Update of
15. Howard V, Michael S. Chiropractic management
Myofascial Pain from Trigger Points. Journal of
of myofascial trigger points and myofascial pain
Musculoskeletal Pain 1996, 4:93-122
syndrome: a systematic review of the literature.
3. Fleckenstein J et al : Discrepancy between
prevalence and perceived effectiveness of J Manipulative Physiol Ther 2009;32:14-24
treatment methods in myofascial pain syndrome: 16. Cummings TM, White A. Needling therapies in
Results of a cross-sectional, nationwide survey. the management of myofascial trigger point pain:
BMC Musculoskeletal Disorders 2010, 11:32 a systematic review. Arch Phys Med Rehabil
4. Simons DG, Travell JG, Simons LS, Travell JG. 2001;82(7):986-92.
Travell & Simons’ myofascial pain and 17. Gunn CC. The Gunn approach to the treatment
dysfunction the trigger point manual. 2th ed. of chronic pain. 2nd ed. New York: Churchill
Baltimore: Williams & Wilkins; 1999 Livingstone; 1996.
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18. Baldry PE. Myofascial pain and fibromyalgia 21. Johannes Fleckenstein, Daniela Zaps, Linda J
syndromes. Edinburgh: Churchill Livingstone; Rüger, Lukas Lehmeyer, Florentina Freiberg,
2001. Philip M Lang, Dominik Irnich. Discrepancy
19. Edwards J, Knowles N. Superficial dry needling between prevalence and perceived effectiveness
and active stretching in the treatment of of treatment methods in myofascial pain
myofascial pain-a randomized controlled trial. syndrome: Results of a cross-sectional,
Acupunct Med 2003;21(3):80-6. nationwide survey. BMC Musculoskeletal
20. Itoh K, Katsumi Y, Kitakoji H. Trigger point Disorders 2010, 11:32.
acupuncture treatment of chronic low back pain
in elderly patients-a blinded RCT. Acupunct Med
2004;22(4):170-7.
43. Anudeep--221--.pmd 226 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
The effectiveness of Progressive Resisted Exercises and

Kinesiotaping of Lower Trapezius in Reducing Pain and
Disability in Subjects Presenting with Unilateral Neck
Pain: a Comparative Study
Warikoo D1, Roy R R2, Agnihotri S3, Kaul Bhumika2

Assistant Professor, Student Researcher-Department of Physiotherapy Dolphin(PG) Institute of Biomedical &
1 2
Natural Sciences, Manduwala, Dehradun, 3Assistant Professor, Department of Physiotherapy,SRMS College, Barielly,
ABSTRACT
Study Objective: To compare the effectiveness of progressive resisted exercises and kinesiotaping
of lower trapezius in reducing pain and disability in subjects presenting with unilateral neck pain.
Design: Comparative study.
Setting: All the subjects were included from various clinics and hospitals and community in Dehradun.
Method: A total of 30 subjects were recruited for the study on the basis of inclusion and exclusion
criteria after signing the informed consent form. The subjects were divided into two Groups (A=
Delorme and Watkins PRE along with MET & B= Kinesiotaping).
Outcome Measures: Neck Disability Index and Visual Analog Scale.
Results: Result of the study showed that although progressive resistive exercises and kinesiotaping
were significantly effective but PRE was found to be more effective than kinesiotaping in reducing
pain and disability in patients with unilateral neck pain.
Conclusion: The present study demonstrates that both techniques in improving the pain and disability
in subjects with unilateral neck pain. However it is concluded that progressive resistive exercises is
a better choice of treatment in improving pain and disability in subjects with unilateral neck pain.
Keywords: PRE (Progressive Resistive Exercises), MET ( Muscle Energy Technique)
INTRODUCTION activity of upper trapezius can lead to middle and

lower trapezius muscle weakness, resulting in postural
Neck pain is a frequent and disabling complaint in
adaptations and pain.5 This tightness of the upper
the general population.3 Patients with neck pain often
trapezius can be addressed by MET according to
have subjective complaints of muscle stiffness, tension
Janda.1
or tightness in addition to their pain.6,5 Characteristics
of scapulothoracic muscle imbalances are found not Peterson et al. 5 in their study concluded that
only in patients with shoulder pathologies but also in participants with unilateral neck pain exhibited
individuals with neck pain.5 Janda2 described muscle significantly less lower trapezius strength on the side
imbalances as impaired relationships between muscles of neck pain as compared to the contralateral side. In
prone to tightness that lose extensibility, and those addition Travel and Simon 7 stated in their book about
prone to inhibition and weakness.Various authors myofacial pain that lower part of the trapezius is often
have also proposed that prolonged tightness or over the key to successful treatment of upper trapezius.
44. Bhumika--227--.pmd 227 5/10/2015, 5:14 PM

Razmjou S, Rajabi H et al. (2010)10,8 established that • Head turned to the affected side, towel roll was
the Delorme resistance training method is an efficient placed under the subject’s head to maintain the
protocol in developing muscle strength. Therefore, cervical spine in a neutral position.
lower trapezius muscle strength in this population can
be addressed by using de Lorme & Watkins PRE • For 10RM test, each subject began by lifting a load
scheme. in the above position with an interval of 2 minutes.
Kinesio Tape is a relatively unique tape that is • Patients performed three sets of 10 repetitions the
capable of stretching up to 130 percent to140 percent next day in the same test position: 10 with half of
of its resting state, may either be used as a compressive 10 RM, 10 with three fourths of 10 RM, and 10 with
or non compressive external adjunct to rehabilitation, full 10 RM. The 10RM was progressed once
is approximately the same weight and thickness of weekly. The intervention was given 5 times a week
skin, and has no medicinal qualities.12 And it has been for 6 weeks.
found that compared to placebo taping , the strength In MET to upper trapezius, the patient lie supine,
of the lower trapezius has a tendency to increase after arm on the side to be treated lying alongside the trunk,
kinesiotaping application (P=0.5).9 Improvement of head/neck side bent away from the side being treated
muscle strength usually takes place after a period of to just short of restriction barrier, while the therapist
4-6 weeks of training. As to the reason why the stabilized the shoulder with one hand and cupped the
application of kinesio taping could lead to the marginal ear /mastoid area of the same side of the head with
increase of the lower trapezius muscle strength other:
immediately has been explained by the results of the
facilitated muscle activity & the improved scapular • With the neck fully side bent and fully rotated
alignment.9 contra laterally, the posterior fibers of upper
trapezius are involved in the contraction. This
The purpose of this study was to compare the effect would facilitate stretching of this aspect of the
of both these strengthening techniques over lower muscle.
trapezius muscle in individuals with unilateral neck
pain, as an initial step in determining which of these • With the neck fully side bent and half rotated, the
strengthening exercises included with MET of upper middle fibers of upper trapezius were involved in
trapezius can be effective in reducing pain and the contraction.
disability in individuals with unilateral neck pain.
• With the neck fully side bent and slightly rotated
towards the side being treated the anterior fibers
METHOD
of the upper trapezius were being treated.
30 subjects who were included in a comparative
The patient introduced a light resisted effort (20%
study from various hospitals in Dehradun based on
of available strength) to take the stabilized shoulder
the inclusion and exclusion criteria and they were
towards the ear (a shrug movement) and the ear
divided into two groups after an informed consent
towards the shoulder. The double movement was
form was obtained. Pre intervention reading of NDI
important in order to introduce a contraction of the
and VAS were taken for each patient.
muscle from both ends simultaneously. The
15 patients in group A received de Lorme & contraction was sustained for 10 seconds and the
Watkin’s PRE to the lower trapezius along with MET therapist gently eased the head/neck into an increased
stretch to the upper trapezius, for 6 weeks. degree of side bending and rotation, where it was
stabilized, as the shoulder was stretched caudally.
• Each subject performed a standard warm-up for
10 minutes before 10RM testing. 10RM was Once the muscle was being stretched, the patient
determined in standard position as described by relaxed and the stretch was held for 10-30 seconds.
Kendall et al. Subjects were positioned in prone, The intervention was given 3 times per session, 5 times
with the upper extremity diagonally overhead, in a week for a total of 6 weeks.
line with the fibers of lower trapezius muscle.
Kinesiotaping of lower trapezius was introduced
Forearm was in mid prone with the thumb
in group B. The elastic tape was a 5 cm X 28 cm piece
pointing towards the ceiling.
of Kinesio tape (Kinesio Tex, KT-X-050,Tokyo, Japan),
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cut into an Y shape, and applied to envelope the lower DISCUSSION

trapezius muscle with minimal tension according to
the recommendation of Kase (Kase and Wallis, 2002). The study conducted by Choudhari R et al.13(2012)
demonstrated that individuals with unilateral neck
The taping was started by placing the base of the pain exhibit significantly less lower trapezius strength
Kinesio Y strip at a 45-degree angle towards the inferior than middle trapezius than upper trapezius on the side
angle of the scapula, at approximately the level of the of neck pain compared to the contralateral side. This
TlO-12 spinous processes. Then the patient moved into was also supported by Petersen and Wyatt5 that lower
shoulder abduction and horizontal flexion, and light trapezius strength is decreased in individuals with
tension (25 % of available) was applied surrounding unilateral neck pain. Results of the present study
the lower trapezius muscle. The tails were then laid depicted that there is a significant reduction of pain
down with no tension. and disability in group A after 6 weeks of intervention.
MET led to subsequent reduction in tone of the
• The kinesiology tape was changed every 4th day. overactive upper trapezius as the neurophysiological
The intervention was given 3 times per session, 5 principle of post isometric relaxation states that after
times a week for a total of 6 weeks. a muscle is contracted, it is automatically in a relaxed
state for a brief, latent period.1PRE, on the other hand,
RESULTS increased the lower trapezius strength thereby altering
the scapulothoracic muscle imbalance. Strength gain
Data analysis was done using SPSS software
by PRE occurred due to neural adaptations (e.g.
(version 14.0). Paired t-test was applied to compare
increased motor unit recruitment, increased rate and
the pre and post intervention readings of VAS and NDI
synchronization of firing) and adaptation of skeletal
within the groups. Data was analyzed for 28 subjects.
muscle structure (e.g. Hypertrophy of type II muscle
The subjects were categorized into 2 groups – Group
fibers). 4 Previous research demonstrated that
A and Group B.
individuals with unilateral neck pain exhibit mild
amount of disability due to pain.
Kinesiotaping of lower trapezius along with MET of
upper trapezius in Group B showed a significant
reduction of pain and disability after 6 weeks of
intervention. Kinesiotaping leads to a marginal
increase of the lower trapezius muscle strength
immediately by the results of the facilitated muscle
activity and the improved scapular alignment.11
Kinesiotape produces a concentric pull on the

fascia, stimulating increased muscle contraction
(Hammer 2006). 15 It had been suggested that
Kinesiotape applied under tension in the direction of
Fig. 1.1: Comparison of pre and post VAS score for group A and B muscle ûbres facilitates the strength of the underlying
muscle. 17 Thus,kinesiotaping elevated the lower
trapezius activity whereas MET reduced the upper
trapezius.
According to Williams et al. (2012) kinesiotaping

might have a small beneficial effect on strength.
Additional hypotheses suggested that facilitated
muscle activity and improved muscle alignment
obtained by kinesiotaping may contribute to only a
marginal increases in muscle strength. 14 Studies
showed that the effects of kinesiotape on strength,
movement, range of motion and pain are very small
Fig. 1.2: Comparison of pre and post NDI score for group A and B and, for the most part, short lived.16In a study by Fu T
44. Bhumika--227--.pmd 229 5/10/2015, 5:14 PM

et al. (2008), kinesiotaping applied to skin apparently REFERENCES

provided tactile input which has been reported to
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of the central neuron system but the negative result of efficacy of kinaesthetic taping for musculoskeletal
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kinesiotaping not altering the muscle performance
Journal of Physiotherapy 2010.
observed in that study was explained by the fact that
2. Choudhari R, Anap D et al. Comparison of upper,
the tactile input generated by Kinesiotaping was not
middle and lower trapezius strength in
strong enough to modulate muscle power of healthy
individuals with unilateral neck pain. J Spine
athletes. 18
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In the study conducted by Wong et al. (2012), the 3. Cleland JA, Whitman JM, Fritz JM, Palmer JA.
kinesiotaping was suggested to provide tactile input Manual physical therapy, cervical traction, and
and stimulate the cutaneous mechanoreceptors and it strengthening exercises in patients with cervical
was concluded that such stimulation might alter the radiculopathy: A case series. Journal of
ûring time of the motor neurons, but not be strong Orthopaedics and Sports Physical Therapy 2005
enough to enhance muscle strength. They also December; 35(12):805.
suggested that the superficial effect of the tape alone 4. Cools AM, Witvroum EE et al. Scapular muscle
is not enough to increase muscle force output, but recruitment pattern: electromypgrapinhic
enough to improve activation.21 It had been suggested response of the trapezius muscle to sudden
shoulder movement before and after a fatiguing
earlier that kinesiotaping may have a small but not
exercise. Journal of Orthopaedics and Sports
statistically signiûcant eûect on muscle activation.19 It
Physical Therapy 2002; 32:221-229.
is not also known if the increased muscle contraction
5. Gardiner MD. The principles of exercise therapy.
observed immediately after the positioning of
Fourth edition. New Delhi: CBS publishers and
kinesiotape last for a long duration.20 According to
distributors; 2004.
Jones, Rutherford, & Parker (1989), in order to enhance
6. Hains F, Waalen J et al. Psychometric properties
the muscle strength, a period of speciûc overload
of neck disability index. Journal of Manipulative
training would be required to promote neural
and Physiological Therapeutics 1998; 21(2):75-80.
activation and muscle ûber regeneration which can be 7. Hsu YH, Chen WY et al. The effects of taping on
well provided by progressive resisted exercise. Thus scapular kinematics and muscle performance in
the above literatures suggested that the strength gains baseball players with shoulder impingement
resulting from kinesiotaping were very marginal and syndrome. Journal of Electromyography and
PRE caused a more increase in lower trapezius muscle Kinesiology 2009; 19:1092-1099.
strength as compared to kinesiotaping and thereby was 8. Ingemann-Hansen T, Halkjaer-Kristensen J.
more effective in reducing the pain in unilateral neck Progressive resistance exercise training of the
pain patients hypotrophic quadriceps muscle in man. The
effect on morphology, size and function as well
Small sample size was the main Limitation of study.
as the influence of duration of effort. Scand J
Rehabil Med 1983; 15(1):29-35.
CONCLUSION
9. Janda V. Muscles and motor control in
The present study concludes that progressive cervicogenic disorders: assessment and
resisted exercise and kinesiotaping of lower trapezius management. Physical Therapy of the Cervical
are both significantly effective in reducing the pain and and Thoracic Spine. New York, NY: Churchill
disability of patients with unilateral neck pain. Livingstone; 2002:182-199.
10. Jull GA. Management of cervical headache.
Acknowledment: All our best wishes to those valuable Manual Therapy 1997;2(4):182-190.
subjects & supporter of this study. 11. Lee JH, Yoo WG et al. Effects of head-neck
rotation and kinesiotaping of the flexor muscles
Conflict of Interest: We declare that there were no on dominant hand grip strength. J Phys Ther Sci
conflicts of interest in the entire journey of the study. 2010; 22:285-289.
12. Murray M. Effects of kinesio taping on muscle
Ethical Clearance: Research Ethics Committee
strength after ACL repair. [cited 2004 Dec 12,
Source of Funding: Self about 3p].
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13. Razmjou S, Rajabi H et al. The effects of Delorme using hand held dynamometry. Journal of Sports
and Oxford techniques on serum cell injury Rehabilitation 2009; 18:502-520.
indices and growth factor in untrained women. 18. Vernon H, Mior S. The neck disability index: a
World Journal of Sport Sciences 2010;3(1):44-52. study of reliability and validity. J Manipulative
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Delorme exercises on quadriceps muscle. Eastern 19. Vithoulk I, Beneka A et al. The effects of
Journal of Medicine 1999; 3(2):51-53. kinesiotaping on quadriceps strength during
15. Thorm S, Forsman M et al. Motor unit firing isokinetis exercise in healthy non-athlete women.
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16. Travel and Simon. Myofacial pain and taping on quadriceps strength. Kinesio Taping
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DOI Number: 10.5958/0973-5674.2014.00001.X
A Study On The Role Of Proprioceptive Training In Non

Operative ACL Injury Rehabilitation
Salil Saha1, Bibek Adhya2, M.S.Dhillon3, Ashish Saini4

1
Assistant Professor of Orthopedic ,Tripura Medical College, Hapania, Agartala & Consultant Orthopedic and Spine
Surgery , Saha Spine Centre, Chandigarh, 2Sr. Physiotherapist, Deptt. of PRM, PGIMER, Chandigarh & Research
Scholar, Singhania University, Pacheri Bari, Jhunjhunu, Rajasthan. India, 3Prof. & HOD, 4Intern, Deptt. of PRM,
PGIMER, Chandigarh
ABSTRACT
Total 45 subjects with anterior cruciate ligament (ACL) injury were divided randomly in 3 groups,
Group A & B received proprioception exercise training & balance exercises along with conventional
strengthening exercises, Group C received only conventional strengthening exercises. After three
weeks it is found that exercises such as calf/toe raises, squatting, steps, lunges, figure of '8' walking,
wobble board exercises, single leg standing along with strength training program is effective in the
overall outcome of the patients with the ACL injury who are conservatively managed.
Keywords: Anterior Cruciate Ligament (ACL), Proprioception, Balance Exercise
INTRODUCTION three components: a static awareness of joint position,

awareness and detection of movement and
The ACL fibres receive their innervations from the
acceleration, and a closed loop efferent activity which
tibial nerve, which infiltrates the capsule posteriorly,
starts reflex response and regulates muscles.
investing Golgi receptors and nerves; the nerves
Proprioception is receptor and neural arc mediated; it
transmit pain and the Golgi receptors are
has been demonstrated that a significant number of
Proprioception mechanoreceptors that sense ACL
mechanoreceptors exist in the fibres of the ACL. These
stretch. A normal ACL provides knee stability in the
receptors play an important role in the complicated
AP plane and, secondarily, rotational stability in
neural network of proprioception. Mechanical stability
extension. It also allows for proper articulation of the
of the knee, although the principal factor for a
tibia on the femoral condyles. The importance of ACL
successful outcome, may not be sufficient in itself for
function has been emphasized in active persons who
a good outcome after ACL reconstruction; the
require knee stability in various activities, such as
evolution of our knowledge has now shown that
jumping, cutting, deceleration, and changing direction.
proprioception recovery also plays a significant role
In the normal ACL, the proprioceptive sensory
in the overall success of this reconstructive procedure 3
function provides positional feedback to central motor
control in the cerebellum to protect the knee during Post injury proprioception loss is perhaps indirectly
use .1,2 demonstrated by the altered gait patterns of the ACL-
deficient knee; studies have demonstrated that these
Proprioception refers to the specialized variation
are probably altered due to changes in proprioception,
of the sensory modality of touch that encompasses the
and not principally due to the mechanical instability
sensation of joint movement and joint position. It has
that ensues. Altered gait patterns plus proprioceptive
deficits significantly add to the mechanical instability
Bibek Adhya in ACL-deficient knees, and can predispose to
Sr. Physiotherapist, secondary injuries. It thus becomes relevant to
Department of PRM, (Physiotherapy), P.G.I.M.E.R., understand the importance of proprioception in
Chandigarh, India stabilizing the knee joint, and also the fact that
Email: bibek.adhya@gmail.com anatomic issues alone may not suffice to get back good
Ph.: +919876044966 function .3
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Proprioceptive deficits after ACL injury may be a Exclusion criteria : Injuries other than above
factor related to both giving-way and higher incidence mentioned. An MCL injury Grade II or III where
of subsequent injuries, which in turn may contribute surgery is indicated. Meniscal Lesion requiring
to the development of osteoarthritis. Proprioceptive fixation. Previous knee injury , inflammatory arthritis.
deficits are claimed to adversely affect activity Presence of associated PCL injury. History of
level,balance, re-establishment of quadriceps strength significant knee injury or fracture.
and increase the risk of further injury. 4,5
Groups: The 45 selected subjects were randomly
Physiotherapy should commence immediately allocated into three groups of 15 patients each.
after injury. Research has demonstrated that
physiotherapy provided, is effective in increasing Group A: strength training , Proprioceptive
strength and balance which may limit the number the training (calf raises, steps, lunges, figure of ‘8’ walking),
episodes of ‘giving way’ and decrease the incidence postural care and precautions.
of re-injury in the ACL deficient knee 18. Ideally Group B : Strength training , Proprioceptive training
Proprioception should be initiated immediately after using rocker board, postural care and precautions.
injury, as it is known that proprioceptive input and
neuromuscular control are altered after ACL injury. Group C: (Control Group): strength training ,
By challenging the proprioceptive system though postural care and precautions.
specific exercises, other knee joint mechanoreceptors
are activated that produce compensatory muscle Intervention Protocol
activation patterns in the neuromuscular system that Group A was given a rehabilitation programme
may assist with joint stability 19. A dynamically stable that aimed to challenge the Proprioception of the
joint is the result of an optimally functioning participant. The exercises and activities were based on
proprioceptive and neuromuscular system and and adapted from previous ACL Proprioceptive
functional outcome has been proven to be highly studies.5,9
correlated with balance in the rehabilitation of the
injured ACL.20 These included: Quadriceps , hamstring and calf
muscles strengthening exercises
Study Design and Methodology: The patients with
ACL deficient knees were selected for this study. All Stretching of Quadriceps , hamstring and calf
the patients underwent a three week rehabilitation muscles,Gluteal Muscles’ exercises.
program and were assessed with the scales mentioned
ROM exercises for Knee joint (in range as
below at 1st and 21st days of intervention.
tolerated),Stationary cycle,Steps, calf raises, lunges,
For outcome two scales were used: 1.International Figure of ‘8’ walking.
Knee Documenting Committee Rating Score.
Group B was given a rehabilitation programme that
2.Cincinnati Knee Rating System
aimed to challenge the balance of the participant. The
Subjects: 45 subjects were taken for this study.They exercises and activities were based on and adapted
were taken from the Physiotherapy Department, from previous studies 9,10.
PGIMER , Chandigarh after a referral from the
These included : Quadriceps , hamstring and calf
Orthopaedics Department.
muscles strengthening exercises
The clinical criteria for confirming an ACL tear
Stretching of Quadriceps , hamstring and calf
was on the basis of the History, Physical examination,
muscles, Gluteal Muscles’ exercises.
Radiological confirmation ( MRI ).
Stationary cycle, Rocker board exercises, Squats,
Inclusion criteria : Age between 18 and 45 years of
one leg stance.
age. Symptom free contra lateral knee. Patients with
medial or lateral meniscus tear and/or a medial Group C was given a traditional strength training
collateral ligament injury Grade I , where surgical programme that excluded exercises that aimed to
repair is not indicated. improve balance and Proprioception. This was
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adapted from the modified protocol of Brukner and that aimed to improve strength and endurance of
Khan (2001)11. lower limbs. This was common for all three groups.12.
These included: Quadriceps , hamstring and calf For Groups A & B the Proprioception and balance
muscles strengthening exercises exercises , the emphasis was on maintenance of stable
and balanced position for 15 to 20 seconds or more
Stretching of Quadriceps, hamstring and calf with 10-15 repetitions 12.
muscles, Gluteal Muscles’ exercises
Appliances used: Rocker Board, Stationary Cycle,
Stationary cycle. Foot Stool, Universal Goniometer, Measuring Tape.
Most exercises used a set-repetition type structure, Statistical measures: SPSS Version 20.
such as 2 to 3 sets of 20 repetitions for all those exercises
RSULTS
Table: 1 shows the comparison of the means of the IKDC score before-after the treatment and CKRS score before-
after the treatment in Group-A.
Table 1: Paired Differences t df Sig.

(2-tailed)
Mean Standard Std Error 95% confidence interval
deviation Mean of the difference
Lower Upper
Pair 1
Pre IKDC GrpA – postIKDC GrpA -14.033 5.71 1.47 -17.2 -10.8 -9.503 14 .000
Pair 2
preCKRS GrpA- postCKRS GrpA -4.266 3.283 .847 -6.0 -2.4 -5.033 14 .000
p-value <0.05, significant.
Table: 2 shows the comparison of the means of the IKDC score before-after the treatment and CKRS score before-
after the treatment in Group-B.

(2-tailed)
Lower Upper
Pair 1
preIKDC GrpB – postIKDC GrpB -13.26 4.55 1.171 -15.77 -10.74 -11.32 14 .000
Pair 2
preCKRS GrpB – postCKRS GrpB -4.40 3.13 .8097 -6.13 -2.66 -5.43 14 .000
p-value <0.05, significant.
Table 3. Shows the comparison of the means of the IKDC score before-after the treatment and CKRS score before-
after the treatment in Group-C.

(2-tailed)
Lower Upper
Pair 1
pre IKDC Control – postIKDC Control -11.83 4.635 1.19 -14.46 -9.326 -9.938 14 .000
Pair 2
preCKRS Control – postCKRS Control -6.133 3.739 .965 -8.20 -4.062 -6.353 14 .000
p-value <0.05, significant
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Table 4: Shows the IKDC pre-post scores and CKRS pre-post scores, ANOVA.
Table 4(a) Sum of Squares Df Mean Square F Sig.

IKDC GrpA
Between Groups 1521.983 10 152.198 1.261 .444
Within Groups 482.890 4 120.723
Total 2004.873 14
IKDC GrpB
Between Groups 910.441 10 91.044 1.240 .451
Total 1204.036 14
Table 4 (b) Sum of Squares Df Mean Square F Sig.
CKRS GrpA
Between Groups 208.233 5 41.647 3.035 .071
Total 331.733 14
CKRS GrpB
Between Groups 31.733 5 6.347 .840 .554
Total 99.733 14
p-value >0.05, non-significant
DISCUSSION Table 2 shows comparison of International Knee

Documenting Committee (IKDC) scores and pre and
This study was undertaken to find the role of post intervention scores and Cincinnati Knee Rating
different Proprioception training in non operative System (CKRS) pre and post intervention scores in the
ACL rehabilitation. Group B shows significant results as the p-value < 0.05.
In table1, the analysis of comparison of Hence it is clear that exercises with the wobble board
International Knee Documenting Committee (IKDC) along with other forms of routine exercises is effective
scores and pre and post intervention scores and in the overall recovery in the non operative ACL
Cincinnati Knee Rating System (CKRS) pre and post rehabilitation. The exercises using the wobble board
intervention scores in the Group A shows significant are a variety of the Proprioceptive training program
results as the p-value < 0.05. Thus with this it is clear that focuses on the balance activities of the patient.
that Proprioceptive exercise training,( with exercises Balance is defined as when postural equilibrium
such as Steps, Lunges, Calf Raises and Figure of ‘8’ during all motor activities is achieved. Lee et al. (2009)
walking) is beneficial in the overall outcome in the non had found out a moderate correlation between knee
Operative ACL rehabilitation along with other routine function and balance training program in ACL
exercises. Proprioception is described as the deficient knees. They had stated that balance deficits,
acquisition of stimuli by peripheral receptors in if they persist, decrease the overall function of the knee.
addition to the conversion of mechanical stimuli to a Caraffa et al. (1996) implemented a balance training
neural signal that is transmitted along afferent program using wobble board with soccer players and
pathways of the sensorimotor system. Zetterstroem et had found out a success of 87% in recovery from ACL
al. (1992) had also emphasised on the fact that injury in the trained group compared to the control
Proprioception training is effective and it benefits the group. However Pasanen et al. (2008) had found that
patients and they had suggested that it should become balance training had a parallel result to the control
standard in ACL rehabilitation. Heidt et al. (2000) had group in the overall outcome .6,7,8
found out that the groups trained with Proprioception In Table3,the analysis of comparison of
exercises reported better knee status and a reduced International Knee Documenting Committee (IKDC)
recurrence of ACL injuries. However Cooper et al. scores and pre and post intervention scores and
(2005) had not found out any additional benefits of Cincinnati Knee Rating System (CKRS) pre and post
Proprioception exercises in their study and had intervention scores in group C shows significant
suggested longer follow up periods.13,14,15 results as the p-value is < 0.05 because exercises help
45. Bibek--232--.pmd 235 5/10/2015, 5:14 PM

in the muscle strengthening which in turn provide Acknowledgement: Department of Orthopedics,

stability to the joint. Many studies have shown that an PGIMER, Chandigarh.
increase in the isometric strength of the ACL deficient
knees improves the overall knee function. Vickers and Conflict of Interest: None.
Altman(2001), had suggested that strength training is Source of Funding: None.
one of the best type of training in the ACL deficient
knees, especially in the early phases of rehabilitation. Ethical Clearance: Cleared by Departmental Ethics
Gokeler et al. (2011) had, however, stated that though committee of PRM, PGIMER, Chandigarh.
strength training is important in alleviating the knee
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Phys Ther. 2001;632-644.
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6. Borsa PA, Lephart SM, Irrgang JJ, Safran MR, Fu
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improvement of the knee in patients with ACL injury American Journal of Sports
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10. Beard DJ, Dodd CA, Trundle HR, Simpson AH. dynamic standing balance in patients with
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DOI Number: 10.5958/0973-5674.2014.00001.X
Efficacy of Moderate Intensity Aerobic Exercises on

Quality of Life in HIV Positive Individuals
Rima N Musale1, G Varadharajulu2

1
Lecturer, DES'S Brijlal Jindal College of Physiotherapy, Pune, 2Principal, Krishna College of Physiotherapy, Karad
ABSTRACT
Background: The increased chronocity of HIV infection has been mirrored by increased prevalence
of disablement in HIV infected population because of immunocompression. Thus the needs of these
individuals have increasingly included the management of impairment, activity limitations, and
participation restriction .The Quality of life of HIV infected individuals gets hampered. Aerobic
Exercise is an effective mean of maintaining and improving quality of life of HIV positive individuals.
Objective: To find efficacy of moderate intensity aerobic exercises on quality of life in HIV positive
individuals.
Materials and Method: A total of 30 clinically diagnosed HIV positive individuals under regular
anti-retro viral therapy of both genders and between 20-40 years of age suffering from stage 2 (CD4
cell count between 201-500 cells/mm3) of HIV, were selected by random sampling. Moderate Intensity
aerobic exercises in the form of stair climbing were given for period of 12 weeks. Quality of life is
measured before giving exercises and at the end of 12 weeks by SF 36 v2.
Results: Study shows that there is significant difference between pre and post exercise score with
mean rise of 10.600 (31.80%) in post exercise value with t value 9.199 and p<0.01.
Conclusion: Moderate intensity aerobic exercise given in the form of stair climbing is effective in
improving Quality of life in HIV positive individuals.
Keywords: HIV, Moderate Intensity Aerobic Exercises, Stair climbing, S F 36(v2)
INTRODUCTION lymphadenopathy, pneumonia, hampers the physical

domain of quality of life 4. There are changes in
India is one of the largest and most populated
appraisals and coping skills4.
countries in the world. With over one billion
inhabitants, of this number, it is estimated that around The American college of sports medicine (ACSM)
2 million people are currently living with HIV.1 HIV defined exercise intensity by % of maximum Heart
is a fourth leading cause of disability2,3. The increased Rate, Rate of Perceived Exertion and Metabolic
chronocity of HIV infection has been mirrored by Equivalent (MET) 5,6. Moderate intensity aerobic
increased prevalence of disablement in HIV infected exercise has been defined as 55%-69% of maximum
population. Thus the needs of these individuals have Heart Rate5,6. Stair climbing is an effective mode to
increasingly included management of impairment, squeeze a great aerobic workout in a short period of
activity limitation and participation restriction4. In HIV time which fulfills the criteria of moderate intensity
infection the Quality of life of a person gets changed. aerobic exercise 7. As HIV positive individuals gets
The physical changes like immunocompression, fatigued easily and susceptible to injury; it is always
reduction in weight, loss of appetite, fever, better to prescribe moderate intensity exercise rather
46. Rima Musale--238--.pmd 238 5/10/2015, 5:14 PM

than high intensity exercise 7. As low intensity exercise 4. At the end of session a cool down exercise program
training will help HIV positive individuals to improve for 5 minutes was given which also included
Quality of life in combination with progressive resisted generalized stretching.
exercise and it needs lengthy follow-up, it is better to
prescribe moderate intensity exercise7. Quality of life 5. There after subjects were followed for 12 weeks
is a broad and multi-dimensional concept related to and subjects were asked to perform this exercise
personnel satisfaction or happiness with life8. In HIV for 3 times per week.
infection the QOL of a person gets changed. 6. Post-test evaluation was carried out at the end of
The SF-36 v2is a multi-purpose, short-form health 12 weeks, using same questionnaire Student’s
survey with only 36 questions. It is one of the most paired t test was used for evaluation of pre and
widely used generic questionnaires to measure quality post result obtained by means of SF 36 health
of life. It has two major health summary measures: related quality of life scale.
physical and mental with 8 multi-item scales having Tips for stair climbing10
36 questions9.
1. Proper climbing posture- Leaning forward slightly
MATERIALS AND METHOD from the hips, with back straight. Look forward
keeping eye on the stairs from time to time without
Ethical approval was taken from the institutional looking down with bent head the whole time.
ethics committee. Individuals in second stage of HIV
(CD4 cell count between 201-501cells/mm3) those who 2. Climb up with right or left foot.
were on regular antiretroviral therapy were included
3. While climbing up place entire foot on each step.
in study. Terminally ill patients, patients with
opportunistic infections, and patients with AIDS were 4. Advised to take support if necessary.
excluded from study
5. While climbing down; climb down safely and use
After taking written consent from30 clinically the same foot used for climbing up.
diagnosed HIV positive individuals general
information was documented. Subjects recruited 6. Stair climbing was done on actual stairs at
randomly. Pre-test evaluation was done by assessing snehalaya-sports ground.
their quality of life by SF 36 V2 health survey
7. Selected stair height was 20 inches.
questionnaire. Maximum score is 125 for entire
questionnaire, which carries 36 questions. After 8. Repetition of activity depends on ability of
answering all 36 questions, a particular score was subjects.
obtained. At the first session, exercise protocol was
given to the subjects in the form of aerobic exercise. Statistical Analysis
1. Exercise was started with warm up exercise for 10 Statistical analysis was done by using Students
minutes; that included quadriceps stretching, paired t-test. Student’s paired t test was used for
hamstring stretching and calf stretching. evaluation of pre and post results obtained by means
of SF 36 health related quality of life scale.
2. After warm up exercise, Continuous Aerobic
exercise program started; which had following RESULTS
components-
The results obtained show that there is significant
Mode: Stair Climbing difference in Quality Of Life after 12 weeks of moderate
intensity aerobic exercise program in the form of stair
Intensity: Moderate Intensity
climbing.
Frequency: 3 times per week for 12 weeks
Table 1 shows the descriptive statistics of pre test
Duration: 20 minutes and post test. The study shows a significant difference
between pre and post values with mean increase of
3. Moderate intensity was determined by THR 10.600 and standard deviation of 6.311 in which the t
(Targeted heart rate formula) i.e220-Age. value= 9.199 and p value < 0.01. Thus it is rejecting

null hypothesis(Table-2) The pre and post value co- of HIV can be defined as the stage in which CD-4 cell
relation is .951 with p value<0.01 indicates that the count is between 201-500 cells/mm3.4. This is an early
study is significant.(Table-3).The study gives the symptomatic stage in which Quality Of Life issues
interpretation that the obtained t value is 9.199 which have a devastating effect. A total of 30 subjects, who
is greater than the table value for t i.e. 2.261. fit the inclusion criteria were taken for study. The mean
age of study subjects, was 31 and it has no any
DISCUSSION significance in the study. The moderate intensity
aerobic exercise was given to the subjects for 12 weeks;
India being a developing country there are about stair climbing as a mode for a period of 20 minutes
2.4 million victims of HIV infection. HIV infection is that includes 10 minutes of warm up exercise, 5
progressive condition in which total cure of the minutes of Stair Climbing and 5 minutes of cool down
patients is not possible. HIV infection causes exercise12. All instructions regarding climbing posture,
immunocompression that primarily targets CD4 cells climbing up and down, duration for climbing stairs
which plays important role in immune function4. This was given to each subject. The Quality Of Life is
immune suppression makes HIV positive individuals assessed by solving SF-36 v2 questionnaire; which has
to land up with physical problems and disturbed 36 questions. The total score of SF-36 v2 is 12513. After
emotional, mental and social functioning4. Even though follow up period of 12 weeks the Quality Of Life is
lots of medical interventions such as Antiretroviral and reassessed by solving the same questionnaire by the
Highly active antiretroviral are consumed but still the same subjects. This study shows the significant
issues of quality of life of HIV positive individuals difference between the pre and post values in both
remains unanswered 11. Exercise is effective mean of physical and mental summary measure of SF-36 v2.
maintaining and improving quality of life of HIV
positive individuals. There are studies done so far CONCLUSION
emphasizing on the effects of exercises on particularly
aerobic exercise and progressive resisted training on Moderate intensity aerobic exercise given in the
HIV positive patients. Not much has been talked of form of stair climbing is effective in improving Quality
the effect of moderate intensity aerobic exercise on of life in HIV positive individuals.
quality of life particularly in stage II of HIV. Stage II
Table 1: Standard deviations of Pretest and Posttest Values
N Min. Max. Mean StdDeviation

Pretest 30 7 93 71.3 19.769
Pretest % 30 5.60 74.40 57.04 15.808
Posttest 30 25 115 81.9 20.568
Posttest % 30 20 92.00 65.52 16.448
Table 2: Paired Differences
Paired differences T Df Sig.2-tailed

Mean StdDeviation
10.600 6.311 -9.199 29 P<0.01
Table 3: Corelation between Pre-test and Post-test Values
N Correlation Sig.
Pair 1 Pre and Post Value 30 .951 .000
Pair 2 Pre value % and post value % 30 .951 .000
Acknowledgement: I would like to thank Dr. Rafi REFERENCES

Mohammad for his support throughout the study.
1. Jim Shahir, Delate Ron Days.HIV Population
Conflict of Interest: None Rate-AIDS &HIV information-first edition. Los
Angeles: 2003.
Source of Funding: None 2. Gemma Spink, Glice, et al.HIV & statistics
manual, first edition.canada:2003.

3. WHO(2004) World health Report 2004: changing 9. Jenkinson C, Wright L editors. SF 36-An
history:WHO Geneva Upgrading Manual, 2ed.U.S 1991.
4. Darcy A Umphred, Chronic Illness (HIV). 10. Stringer et al, Thonie et al, Penna et al, Chages
Textbook of Neurological Rehabilitation, fourth of Aerobic Functions with exercise
edition, vol.1, 553-572. training.second edition.553-555
5. ACSM guidelines,volume-3. 11. NACO(2000):Country Scenario.NatioanalAIDS
6. Alice j editors. Go Ask Lice-An Alice As Client, control Organization, Dept.of Health & Family
twenty eight edition, Canada 2004. Welfare,1998-1999, New Delhi.
7. William D Mcardle,Frank I Katch,Victor I Katch- 12. Kisner c, Colbey L.Therapeutic exercise
Exercise Physiology-Energy, Nutrition and Foundations and techniques.4th edition, New
human performance-sixth edition,2007 Delhi:Jaypee Brothers;2002
8. Dr Ashok Sahani, Dr Sudha Xirsagar-HIV and 13. Ware Snow Kosinski and Gander, SF 36 Users
AIDS in India-An upgrade for Action. manual-1991.

DOI Number: 10.5958/0973-5674.2014.00001.X
Effect of HIP Abductors and Lateral Rotators

Strengthening Exercises on Knee Valgus Alignment
among Adolescents: a Prospective Study
A.Nagaraj1, P Krishnan1
1
Department of Physiotherapy, Faculty of Therapeutic Sciences, Asia Metropolitan University, Taman Kemacahaya
43200 Batu 9, Cheras Selangor, Malaysia
ABSTRACT
Objective: The objective is to study the effect of hip abductors and lateral rotators strengthening
exercises on improving the knee valgus alignment among adolescents.
Background: In accordance to the well known fact that knee dysfunction condition among growing
adolescents contributes to a wider segment of entire orthopedic practice, it is therefore essential to
aware of the effect of strengthening the hip muscles on correcting functional knee valgus problem.
So, we conducted this study to find out the effect of strengthening hip abductors and lateral rotators
exercises on functional knee valgus among healthy adolescents.
Subjects: 30 subjects (25 females and 5 males) aged between 18 to 20 years old.
Method: The subjects were assigned to hip abductor and lateral rotator strengthening exercises 3
times per week for 6 weeks. Knee valgus alignment was assessed at baseline and post-intervention.
Result: Paired t-test and Microsoft Excel 2010 were used for data analysis. The mean difference for
the pretest group is 161.071±5.106 while the posttest group is 166.867±5.106. There is a difference in
variance between pre and post intervention with a difference of 5.6977. Paired sample test value
shows a t value of -29.446119 and a p value of p<0.00001. The result is significant at p ? 0.01.
Conclusion and discussion: The hip abductors and lateral rotators strengthening exercises are effective
in reducing the dynamic knee valgus alignment among the adolescents.
Keywords: Knee Valgus, Hip Muscles, Strengthening Exercises, Knee Alignment
INTRODUCTION involving in sports and games over the last few

decades. Recent study shows that 40% of all paediatric
Of all other joints in the human body, the knee joint
injuries are caused by sports activities which contribute
sustains the most frequent number of orthopaedic
to about 4.4 million numbers of injuries every year.3
injuries. 1,2 Adolescents are noted to be actively
A retrospective study done by Sariff, Ramlan A. in
Corresponding author: 2009 found that about 58.8% of all musculoskeletal
A Nagaraj1 injuries reported in Malaysia were sustained by
Department of Physiotherapy, Faculty of Therapeutic
adolescent children aged less than 20 years and lower
Sciences, Asia Metropolitan University, Taman
Kemacahaya 43200 Batu 9, Cheras Selangor, Malaysia extremities are mostly affected (63.1%), primarily the
Tel: +603-9080 5888 ext 453 knee joint (37.1%) and the major incidence occurs
Fax: +603-9080 1995 during practice and game sessions.4
E-mail: anaphysioforyou@gmail.com
47. Ananth--242--.pmd 242 5/10/2015, 5:14 PM

In a previous retrospective study, an individual’s pathological implications are becoming more evident.
recollection of having had “childhood knock-knees or Knee valgus is associated with muscle weakness in
bow-knees” was related with a 5-fold rise in the risk adolescents and is an early risk factor of knee disease
of knee osteoarthritis development in future.5 The development in future. Hence, study discussing the
continuous involvement of the adolescent children in effect of strengthening hip muscles turn out to be very
recreational or amateur sports with presenting knee helpful on correcting knee valgus alignment.
mal-alignment will further increase the risk of various
knee pathologies in future. HYPOTHESES
Awareness of the structural and muscular Null hypothesis: Hip abductors and lateral rotators
consequences of postural faults re-inforces the belief strengthening exercises may not have a significant
that beginning in childhood, all individuals should be difference on knee valgus alignment among
monitored on a yearly basis to assess acquired skeletal adolescents.
mal-alignment and monitor structural deviations.
According to the outcome of examination, therapist Alternate hypothesis: Hip abductors and lateral
can suggest exercise programs and postural training.6 rotators strengthening exercises may have a significant
difference on knee valgus alignment among
BACKGROUND OF STUDY adolescents.
There are many longitudinal studies provide ample Review Of Literature

amount of evidence that knee injury is as-sociated with
According to John H. Hollman et al1, during step-
hip muscle weakness.7,8 Willson et al9, studying single-
down tasks, lateral rotation strength might have lesser
leg squats in athletes, reported that reduced hip
association with decreased knee valgus in females than
external-rotation strength was correlated with
does gluteus maximus. Increased knee valgus might
increased knee valgus. Ireland et al10 reported that
be related with gluteus medius.
women with patellofemoral pain had reduced hip-
abduction and external-rotation strength. Niemuth et Christopher M. Powers et al2, stated that even
al11 reported that runners with overuse injuries had though excessive tibia and femur movement in the
reduced hip-abduction strength compared with transverse and frontal planes can influence
uninjured limbs and with healthy subjects. The authors
patellofemoral joint mechanics and PFP, existing
postulated that inadequate hip strength might have
research suggests that such abnormalities are not a
results to lower extremity injury and mal-
universal finding in this population. Hence, treatments
alignment.6,10,11
aimed at controlling lower limb motion may be
In accordance to the well known fact that knee warranted in a subpopulation of persons with PFP.
dysfunction condition among growing adolescents
Khalil Khayambashi et al16, concluded that isolated
contributes to a wider segment of entire orthopaedic
strengthening programme of hip external rotator and
practice, it is therefore essential to aware of the effect
of strengthening the hip muscles on correcting abductor muscles were efficient in improving health
functional knee valgus problem. However, there is no and pain status in women with patellofemoral pain
such related study has been done to date. So, I would compared to a non exercise control group. Whenever
like to conduct this study to find out the effect of designing a rehabilitation program for females
strengthening hip abductors and lateral rotators suffering from patellofemoaral pain, consider
exercises on functional knee valgus among healthy incorporate hip strengthening exercises.
adolescents.
According to Kyung Mi Park et al17, the rating of
movement quality during the forward step-down test
STATEMENT OF THE PROBLEM
in asymptomatic women received good agreement
As the prevalence of knee valgus deformity among researcher in predicting musculoskeletal
increases, its anatomical, physiological and conditions.
47. Ananth--242--.pmd 243 5/10/2015, 5:14 PM

Last but not the least, Balsalobre-Fernández C et criteria. 30 eligible subjects were recruited on the basis
al18 in his study of reliability and validity of HSC- of random sampling for the study.
Kinovea video motion analysis method for calculating
Three dimensional (3D) frontal plane projection of
the jump height and flight time concluded that the
knee valgus alignment was measured during a single-
results showed a ideal correlation agreement (ICC=1,
leg step-down test performed from a 15cm step using
p<0.0001). This clearly shows that the HSC-Kinovea
Kinovea 0.8.15 Video Motion Analysis Software on the
technology does not only require known experience
selected subjects prior to intervention. Average frontal
of application but also can be used to provide highly
knee plane angles during the stance phase of step
reliable and valid flight time and vertical jump height
descent were analyzed for data analysis. A digital
measurements as similar to a costly equipment.
video camera was placed 3m anterior to the subject, at
the subject’s knee height and aligned perpendicular
to the frontal plane projection angle of knee.
METHODS AND PROCEDURES
The frontal-plane projection angle of knee valgus/
Study design: One group pretest, posttest design varus was defined by the angle formed from a linear
line that joins the ASIS with the midpoint of the
Sampling method: Simple random sampling tibiofemoral joint and a second line connecting the
midpoint of the tibiofemoral joint and the talocrural
Study location: This study was conducted in
joint. 2cm diameter markers were placed on subjects’
physiotherapy lab, Asia Metropolitan University at
ASISs bilaterally in order to facilitate digitization of
Jalan Kemacahaya, Batu 9, Cheras.
bony landmarks with the motion-analysis software.
Sample size: 30 subjects (25 females & 5 males)
We analyzed joint alignments at 2 distinct points
Study sample: Adolescents aged 18 to 20 during the task. First, we measured static alignment
in double-limb stance to provide an estimate of
Duration of study: 4 Months baseline knee alignments (figure 1). Next, when the
frontal-plane knee angle was maximally departed from
Inclusion Criteria
the baseline position, we measured knee valgus during
• Individuals with normal BMI the eccentric phase of the step-down (figure 2).
• Both genders (females & males) The subjects were assigned to hip abductor and
lateral rotator strengthening exercises 3 times per week
• Aged between 18-20 years for 6 weeks. Knee valgus alignment was assessed at
baseline and post-intervention. Prior to participation,
• Has functional knee valgus
all the subjects were provided written informed
• Capable to climb up & down a flight of stairs consent. The subjects were educated regarding their
without assistive devices condition and the intended treatment approach and
realistic goal setting were discussed.
Exclusion Criteria
Each session con-sisted of warm-up segment for 5
• Has any orthopedic, neurology, or any other minutes (brisk walking), 20 minutes of hip-
pathology that impaired motor function. strengthening exer-cises, and cool-down segment for
• Has antalgic gait. 5 minutes (brisk walking). All strengthening exercises
were completed unilaterally. Strengthening exercises
were progressed according to FITT principle at 2-week
DATA SELECTION AND STUDY
intervals (table 1). Subjects were given strengthening
METHODOLOGY
exercises according to the muscle group and type of
A single-leg step-down was performed on exercises (table 2). After successful completion of 6
randomly picked students aged 18-20 years from a weeks intervention, three dimensional frontal plane
college to assess for eligibility. Potential participants projection of knee valgus alignment was calculated
were evaluated for specific inclusion/inclusion again for post-test analysis.
47. Ananth--242--.pmd 244 5/10/2015, 5:14 PM

Method of measuring the 3-D frontal plane projection of knee valgus alignment
Fig. 1. Static phase Fig. 2. Eccentric phase
Table 1: Strength training protocol according to FITT principle
FREQUENCY 3 days/week for(1-2weeks) 3 days/week for(3-4weeks) 3 days/week for(5-6weeks)

INTENSITY 50% of 1 RM 75% of 1 RM 100% of 1 RM
TIME 3 sets of 10 repetitions each set 3 sets of 10 repetitions each set 3 sets of 10 repetitions each set
TYPE Isometric Concentric-using theraband Eccentric-using theraband
Table 2: Strengthening exercise procedures for hip abductors and lateral rotators
Muscles Isometric Exercise Concenctric Exercise Eccentric Exercise

(1-2 Weeks) (3-4weeks) (5-6 Weeks)
Hip abductors Stand against wall and try Abduct the leg away in Using theraband, maintain
to abduct leg against wall. standing using theraband. the abducted leg in position.
Hip external rotators Stand against wall and try to Externally rotate the leg in Using theraband, maintain the
rotate leg externally. sitting using theraband. externally rotated leg in position.
Analysis of Data Interpretation
Statistical analysis
Paired t-test was used to compare the results of pre

and post intervention of the hip abductors and lateral
rotators strengthening exercises on knee valgus
alignment using Microsoft Excel 2010.
Data analysis for pretest intervention

Graph 1: Pretest
47. Ananth--242--.pmd 245 5/10/2015, 5:14 PM

Graph 1 shows the data analysis for pretest group. hypothesis is accepted. This shows a high significant
The graph shows a normal distribution. The mean difference between pre and post intervention group.
value is 161.071with the standard deviation of 5.106. Thus, we conclude that hip abductors and lateral
rotators strengthening exercises are effective in
Data analysis for posttest intervention reducing the dynamic knee valgus alignment among
the adolescents.
DISCUSSION AND CONCLUSION
Discussion
The primary finding was to study the effectiveness

of strengthening hip abductors and lateral rotators in
improving the knee valgus alignment among
adolescents. Alternate hypothesis was accepted which
shows that there is a significant result in this study
with a P< 0.01(0.00). Results showed the subjects had
noteworthy improvement in knee valgus range of
Graph 2: Posttest
motion in pre and post intervention.
Interpretation According to many related studies done before,

researchers found that increased knee valgus
Graph 2 shows the data analysis for posttest group. alignment was associated with reduced hip lateral
The graph shows a normal distribution. The mean rotation and abduction strength. Willson et al9 in his
value is 166.667 with the standard deviation of 5.106. study of single-leg squats among athletes, reported that
Data analysis for pre and post intervention decreased strength of hip lateral rotation was related
with elevated knee valgus. On the other hand, Ireland
PRE-TEST POST-TEST
et al10 found that women with patellofemoral pain
Mean 161.071 166.867
syndrome had shared common medical history of
Variance 18.64482759 12.94712644
reduced hip abduction and lateral rotation strength
Standard deviation 5.106 5.106
compared with age matched healthy subjects. Besides
Observations 30 30
that, Niemuth et al11 concluded that runners with
Pearson Correlation 0.979644378
overuse injuries had reduced hip-abduction strength.
Hypothesized Mean Difference 0
In spite of several limitations of the aforementioned
Df 29
studies, these researchers collectively agreed that
t Stat -29.44611903
lower extremity mal-alignments, especially the knee
P(T<=t) two-tail 0.00
valgus was correlated with hip muscle weakness.
t Critical two-tail 2.045229642
According to Power et.al2, the kinematics of the

Table 3: Data analysis of pre and post intervention
entire lower extremity has the potential to get affected
group
by excessive hip medial rotation and adduction during
Interpretation weight bearing. Dynamic knock-knee happens because
of knee’s inferior rotational movement which makes
Table 3 shows the data analysis for pre and post the shin bone to abduct from midline and the ankle to
intervention group. The mean difference for the pretest pronate.
group is 161.071±5.106 while the posttest group is
166.867±5.106. There is a difference in variance of Till today, only researcher Mascal et al 13 have
5.6977 between pre and post intervention. On the other studied the link between strength of hip musculature
hand, the Pearson correlation shows the value of and lower limb joint motion. According to his case
0.979644378 (close to the value of 1). Paired sample report, the subject who had been assessed in terms of
test value shows a t value of -29.446119 and a p value showed increased hip strength and kinematics (eg, less
<0.00001. The result is significant at p d” 0.01. Hence, hip adduction and medial rotation) which ranged from
the null hypothesis is rejected and the alternate 32% to 56% during a step-down task following 14
47. Ananth--242--.pmd 246 5/10/2015, 5:14 PM

weeks of core muscles strengthening programmes. 4. Sariff A, George J., Ramlan A. Musculoskeletal
Succeeding studies by Earl and Hoch, Boling et al, and injuries among Malaysian badminton players.
Tyler et al 19 collectively suggested that hip Singapore Medicine (2009).
strengthening exercise programs resulted in pain 5. Schouten JSAG, van den Ouweland FA,
reduction and improved functional outcomes among Valkenburg HA. A 12 year follow up study in
women with patellofemoral pain syndrome. These the general population on prognostic factors of
valuable data supported the speculation concerning cartilage loss in osteoarthritis of the knee. Ann
hip muscles weakness and altered kinematics of lower Rheum Dis (1992):51:932–7.
extremity. 6. Shirley Sharmann. Movement system
impairment syndromes of the extremities,
CONCLUSION cervical and thoracic spines. Elsevier Publications
(2001).
In conclusion, we found that hip abductors and 7. Willson JD, Ireland ML, Davis IM. Core strength
lateral rotators strengthening exercises proved to be and lower extremity alignment during single leg
effective in improving knee valgus alignment among squats. Med Sci Sports Exerc (2006):38:945–952.
adolescents aged between 18 to 20 years. 8. Sharma L, Song J, Felson DT, Cahue S, Shamiyeh
E, Dunlop DD. The role of alignment on knee
Limitation of study
osteoarthritis progression according to baseline
This study had several draw backs. Foremost stage of disease. JAMA (2002): 2636-2632.
limitation was neither the therapist nor subjects was 9. Willson JD, Ireland ML, Davis IM. Core strength
not blinded. Secondly, only two types of hip muscle and lower extremity alignment during single leg
groups were tested. Besides that, we had a relatively squats. Med Sci Sports Exerc. (2006): 38:945–952.
small number of subjects in this study and the 10. Ireland ML, Willson JD, Ballantyne BT, Davis IM.
intervention session was only for 6 six weeks. Hip strength in females with and without
patellofemoral pain. Journal of Orthopaedic &
Acknowledgement: Nil Sports Physical Therapy. (2002): 33:671–676.
Ethical Clearance: Yet to receive the copy as soon I 11. Niemuth PE, Johnson RJ, Myers MJ, Thieman TJ.
get will submit Hip muscle weakness and overuse injuries in
recreational runners. Clinical Journal of Sport
Source of Funding: Self Medicine (2005):15:14-21.
12. Danial F. MCWilliams, Sally Doherty, Rose A.
Conflict of Interest: Nil Maciewicz, Kenneth R. Muir, Weiya Zhang,
Michael Doherty. Self-Reported Knee and Foot
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Osteoarthritis. JAMA (2010).
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13. Mascal CL, Landel R, Powers C. Management of
Kozuchowski, Amanda S. Vaughn, David A.
patellofemoral pain targeting hip, pelvis, and
Krause, James W. Youdas. Relationship between
trunk muscle function: 2 case reports. Journal of
knee valgus, hip muscle strengrh and hip muscle
Orthopaedic & Sports Physical Therapy
recruitment during a single limb step down.
(2003):33:647-660.
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14. Joseph et al. Hip muscle activity during 3-Side
Therapy (2009).
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2. Christopher M. Powers. The influence of
runners. Journal of Athletic Training (2012).
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15. Strengthening exercise. http://
biomechanical perspective. Journal of
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3. Williams. Adolescent sports injuries among
16. Khalil Khayambashi et al. The Effects of Isolated
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Hip Abductor and External Rotator Muscle
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Randomized Controlled Trial. Journal of camera based method for measuring the flight
Orthopaedic & Sports Physical Therapy (January time of vertical jumps. PubMed (May 2013).
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17. Kyung Mi Park et al. Musculoskeletal Predictors Concentric and eccentric torque of the hip
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Orthopaedic & Sports Physical Therapy (2013):43: (2009):44:7-13.
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DOI Number: 10.5958/0973-5674.2014.00001.X
Efficacy of Conventional Treatment and Eccentric Exercise

with and Without Deep Transverse Friction Massage in
Supraspinatus Tendinitis Patients a Randomized Clinical
Trail
Kusum Lata Jindal1, Monika Moitra2

1
Student, Associate Professor, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Mullana,
2
Ambala
ABSTRACT
Background: Supraspinatus tendinitis is the most common soft tissue injury of the shoulder which is
associated with long term consequences of stiffness impaired function of the shoulder. Early
appropriate management of supraspinatus tendinitis is necessary to prevent frozen shoulder or
impingement syndrome.
Purpose: The aim of the study is to evaluate the efficacy of Deep transvers friction massage as an
adjunct to conventional physiotherapy and eccentric exercise in supraspinatus tendinitis patients.
Method: Thirty patients (group1,n=15;group2,n=15) with the diagnosis of an supraspinatus tendinitis

of the shoulder were treated. Group 1 was instructed with MHP, ultrasound with eccentric exercise
at least 5 days a week for 15-20 min and group 2 received a prescription for 12 session of DTFM and
patient education in clinic for three times per week.
Result: Between groups pain score were reduced more in the intervention group(4.1 ±1.1)than
conventional group (1.9 ±0.9). Ranges of motion (flexion, abduction and internal rotation) improved
more in the intervention group (flexion 18±3.2; abduction 25.3±6.2; internal rotation 13.2±2.2) than
conventional group (flexion 8.2±1.5; abduction7.2±1.2; internal rotation 4.2±1.7). Functional disability
was reduced more in the intervention (32± 7.5) than conventional group (8.9±5.8).
Conclusion: Subjects in both groups experienced significant decrease in pain and increases in shoulder
function & ROM but there was significantly more improvement in the intervention group compared
to the conventional group.
Implications: The study findings provided beneficial evidence for DTFM in improving functional
and range of motion in supraspinatus tendinitis patients, so that future studies could compare DTFM
with other treatment methods for effective evidence-informed clinical decision making in management
of Supraspinatus tendinitis.
Keywords: Cyriax Physiotherapy, Manual Therapy, Physical Therapy, Exercise Therapy, Strengthening
Exercise, Tendinopathy,Soft Tissue Mobilization
often seen in the general population and a

INTRODUCTION
predisposing factor is resistive overuse 1,2 .
Supraspinatus tendinitis is an inflammation of the Supraspinatus is the most frequently involved
tendon of the supraspinatus muscle. This problem is tendon2,3.
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The tendon of the supraspinatus commonly Variables

impinges under the acromion as it passes between the
acromion and the humeral head. Supraspinatus is a The three Independent variables were deep
muscle stabilizes the shoulder, excoriates and helps transverse friction massage, eccentric exercise and
abduct (lift up sideways) the arm. Any friction between conventional treatment for supraspinatus tendinitis
the tendon and the acromion is normally reduced by and the dependent variables were functional disability,
the subacromial bursa4. ranges of motion and pain.
Pain and dysfunction of the shoulder is common Outcome measures

causes of impaired quality of life in the general Primary outcome measures were functional
population. Two per cent of the age group 42-46 years disability (measured by shoulder pain and disability
report shoulder pain. Studies from primary care show index) and secondary outcome measure were pain and
that 16% of the general population suffers with range of motion (measured by numeric pain rating
shoulder pain. This rises to 21% in elderly hospital and scale and Goniometer).
community populations. Supraspinatus tendinitis was
the most common cause of shoulder pain found in the Study Protocol
various studies5.
30 subjects of supraspinatus tendinitis were
Long term shoulder problems are more likely when selected according to inclusion criteria and allocated
pain develops gradually or discomfort is recurrent into group A and group B. Group A were given
over a period of time. Chronic pain is often triggered conventional physiotherapy and eccentric exercise and
by prior injuries, especially if original injury was severe group B were given conventional physiotherapy and
or was not allowed to heal completely. Condition eccentric exercise with deep transverse friction
involves in shoulder pain-poor posture, frozen massage. Deep transverse friction massage were given
shoulder, rotator cuff disorder, shoulder instability, with the patient in sitting position with hand behind
acromioclavicular joint disorder and osteoarthritis5. back for 20 minutes 3 times per weeks for 4 weeks.
Index finger of the ipsilatral hand placed on the
The supraspinatus is effective stabilizer of the tenoperiosteum junction reinforced by the middle
Gleno-humeral joint, because its rotatory component finger. Eccentric strengthening were given with the
is proportionally larger than that of the other rotator patients sitting. In order to put high load on the deltoid
cuff muscles. The supraspinatus has a large enough and supraspinatus muscles the patients performed the
moment arm (MA) that it is capable of independently eccentric exercise with the shoulder in 30 degrees of
producing a full or nearly full range of Gleno-humeral horizontal abduction, with the thumb pointing
joint abduction while simultaneously stabilizing the towards the ground (the ’empty can’ position) .The
joint. Weakness of the supraspinatus muscle is rather patients were instructed to do the Exercise in three sets
common and with age it is well documented. It can of10 repetition per day for 5 times per weeks for 4
result from denervation secondary to an entrapment weeks was performed during each treatment with a 1
of the suprascapular nerve and inhibition of muscle minute rest interval between each set. The ultrasound
contraction caused by pain secondary to such disorders mode (frequency_1 MHz, spatial-average intensity_1
as tendinitis6. W/cm2 , gel coupling).
METHOD RESULTS
Participants Group A is the conventional treatment and
The sample consisted of 30 volunteers, both male eccentric exercises and Group B is the conventional
and female, with no history of musculoskeletal disease. treatment and eccentric exercises with deep transverse
Their ages ranged from 45 to 60 years. Each volunteer friction massage. The analysis revealed that there was
was randomly assigned in two independent groups: a statistically significant difference between pre and post
conventional treatment and eccentric exercise, scores of AROM and functional disability and pain
conventional treatment and eccentric exercise with score in all groups. Group B is showing more
deep transverse friction massage. improvement than group A at p value < 0.05.
48. kusum--249--.pmd 250 5/10/2015, 5:14 PM

The above graph shows pre test and post test scores
within and between group-A and B. Though there is
significant decreased of NPRS score in both the groups
.In the between group comparison, the NPRS score was
decreased significantly in group B compared to
group A.
DISCUSSION
This result of the study has shown that DTFM with

conventional physiotherapy & eccentric exercise is
statistically more significant than conventional
Fig. 1. Comparison of active rom within and between groups
physiotherapy & eccentric exercise alone in reducing
pain and disability and improving range of motion.
The above graph shows pre test and post test scores Thereby my study is not supported the null hypothesis
within and between group-A and B. Though there is & accepting the alternate hypothesis.
significant increase of active ROM in both the groups
.In the between group comparison, there was In the present study combined effect of deep
significant improvement of active flexion, abduction, transverse friction massage & conventional
physiotherapy has shown a significant important on
internal rotation of group B. Improvement of active
pain in patient of supraspinatus tendinitis. The results
range of motion was more in group B compared to
are in accordance with previous study done by Bang
group A.
et al, in which conventional physiotherapy and DTFM
was given to the patient and he concluded that manual
therapy group is better than the conventional
physiotherapy alone. They said that DTFM might
reduce pain by stimulating joint mechanoreceptor
activity, which in turn is thought to block aberrant
afferent pain signal and reduce the awareness of pain.
It also hypothesized that deep transverse friction
massage shortened collagenous tissue and improve
interstitial fluid content resulting in restoration of
movement7.
In this study the effect of eccentric exercises with

Fig. 2. Comparison of spadi within and between group a and g
roup b DTFM has been seen on pain and disability and there
was a significant improvement after 4 weeks of
treatment. The results are supported by study done
The above graph shows pre test and post test scores by Aimie et al who conducted a randomized pilot
within and between group-A and B. Though there was clinical trial to compare the effectiveness of four
significant decreased of total SPADI score in both the physical therapy intervention and he concluded that
groups .In the between group comparison, the SPADI DTFM in combination with an eccentric exercises
score were decreased more significantly in group B program may result in a greater decease in pain and
compared to group A. improved function8.
In the study DTFM resulted in pain reduction

through the pain gate control mechanism.The
physiological reasoning supports by a case study
conducted by Kachingwe et al, who apply DTFM to
the patients of supraspinatus tendinopathy and
concluded that DTFM resulted in pain reduction
through activation of mechanoreceptors inhibiting
nociceptive stimuli through the gate control
mechanism or through the facilitation of synovial fluid
Fig: 3. Comparisons of nprs within and between group a and
group b nutrition8.
48. kusum--249--.pmd 251 5/10/2015, 5:14 PM

Efficacy of the ultrasound has been done for range of motion. But there was more significant
reducing the pain and there was a significant difference in pain and disability reduction and
improvement of pain after treatment. The results are improvement in range of motion in intervention group.
supports with previous study done by Young et al, It can be concluded that intervention group is more
studied the physiological effects of ultrasound. They effective than conventional group in reducing pain and
concluded that ultrasound therapy accelerate the disability and improvement in range of motion in
normal resolution of inflammation provided the patients with supraspinatus tendinitis.
inflammatory stimulus is removed9.
Acknowledgement: It is a pleasure to acknowledge
The effect of deep friction massage has been done the gratitude I thanks to my teachers who immensely
for pain and inflammation there is significant helped me by giving valuable advice and relevant
improvement after treatment. The findings supports information regarding the collection of material. And
the previous study done by Hammer et al, have I thank God for best owing me with knowledge and
reported that deep friction massage is beneficial in giving me the encouragement.
management of shoulder and hip condition like
tendinitis; he said that there is clinical evidence for the Conflict of interest: None declared
positive effects of deep friction massage10. Source of Funding: Self
The present study DTFM enhances visco-elastic Ethical Clearance: The study is approved by
property of the muscle which shows a significant Departmental Research Committee.
improvement on patients of supraspinatus tendinitis.
The results are supports with previous study done by
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Gibbon et al, a concept of visco-elastic property in the
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in turn improve function and reduce pain. Thus can 2001; 40: 155-63.
be used in the conditions like tendinitis11. 2. Green E. Systematic review of randomized
controlled trials of interventions for painful
The combined effect of deep transverse friction
shoulder: selection criteria, outcome assessment,
massage & eccentric exercise improve the ROM at
and efficacy. BMJ.1998; 316: 167-73.
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3. Erbenbichler H. Ultrasound therapy for calcific
tendinitis. The results are supports with previous
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5. Hasvold T, Johnsen R. Headache and neck or
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transverse friction massage on supraspinatus ultrasound. J Int Med Res. 2010; 32: 124-28.
tendinitis –A randomized pilot trial study. IJCRR. 18. Stanish WD, Rubinovich M, Curwin S: Eccentric
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48. kusum--249--.pmd 253 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Neck Pain and Role of Scapular Position in Dentists
Kritika Joshi1, Jyoti Dahiya2, Priyanka Chugh2

1
Student of Bachelors of Physiotherapy, 2Assistant professor Banarsidas Chandiwala Institute of Physiotherapy
Kalkaji, New Delhi
ABSTRACT
Background: The position of scapula is the key contributor to normal and abnormal scapular motion
and control. Scapular protraction will become abnormal when there is increased distance between
the inferior angle of scapula and the Spinous process of vertebra. Individuals with neck pain may
display altered postural behavior when treating a patient in OPD or Dental clinic.
Aim: To determine whether neck pain is associated with scapular position in dentists or not.
Methodology: A case control study with convenience sample was done with 30 subjects.
Subjects fulfilling the inclusion criteria were chosen for study. Each subject's Scapular protraction
measurements were taken with the participant standing with normal, relaxed posture. The
measurements were performed at 3 different positions (Resting, Hands on Hip , and 90o Gleno-
humeral Abduction with maximum internal rotation) . First the inferior angle of scapula was palpated
and marked then the lateral arm of vernier calliper was positioned at the corresponding spinous
process , and the measurement was recorded. All measurements were taken bilaterally. This procedure
was repeated three times and the average of the measurement was used for analysis.
Results: The results showed that there is a significant difference in scapular position in
Dentists with neck pain in all three position that is at rest , hands on hip, and 90o glenohumeral
abduction.
Conclusion: In the present study it was concluded that scapular position is altered in dentists
Who suffered from neck pain in all three positions that is at rest, hands on hips, and 90 degree
glenohumeral abduction.
Keywords: Neck Pain, Scapula Position, Altered Scapular Position, Dentists
INTRODUCTION away or toward the vertebral coloumn, repectively 2.

Alterations that have been identified in dentists include
The position of scapula is the key contributor to increased protraction3.Scapular protraction is an
normal and abnormal scapular motion and control1. abnormal position which has been defined as an
Protraction and retraction of scapula on the thorax are increased distance between the inferior angle of
often described as translatory motions of the scapula scapula and the spinous process of corresponding
vertebra 4 .
Priyanka Chugh Work related to musculoskeletal disorders
Assistant professor (WRMSDs) are an important health problem in many
Chandiwala Estate, Banarsidas Chandiwala Institute industrialized countries 5. Poor postural habits and
of Physiotherapy, Maa Anandmayi Marg, Kalkaji, New neck pain are increasingly common among individuals
Delhi- 110019. who work with wrong posture (forward head posture
Mobile No. 9871202074 and arm abducted), this is very common especially in
E-mail: drpriyankachugh2@gmail.com dentists 6.
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Neck pain from poor posture can be explained in 30 Dentists both male and female of age group
an upright position as the head is supported by the between 20 - 35 years took part in the study were
spinal vertebra 7. allotted in two groups:
There is a significant positive association between • Group A (study subjects = 15) consists of Dentists
prolonged static posture at work and neck pain , with neck pain.
implying that there is an increased risk of neck pain
for people who are working almost all day in a static • Group B (control subjects= 15) consists of Dentists
awkward posture8. without neck pain.
Variables
METHODOLOGY
Dependent variable
Type of study : case control study
Protraction of scapula.
Independent variable
Sampling size : 30 participants
VAS
INSTRUMENTATION
Sampling technique : convenience sampling
Instruments and tools used
1. Vernier calliper
Source of data : Dentists working in Krishna
Dental College OPD/ 2. Marker
Private Clinics
3. Goniometer
Inclusion Criteria
PROCEDURE
Study group
The ethical clearance was obtained from the ethical
1. Dentists with neck pain. committee of Banarsidas Chandiwala
2. Dentists working more than 8 hours. Institute of Physiotherapy. Subjects who fulfilled
the inclusion criteria were taken up for the study. An
3. Age group- 20-35 years informed consent was obtained from the subjects prior
to the study.
Inclusion Criteria
Initially before measuring the scapular position, a
Control group
brief physical assessment was done which included
1. Dentists without neck pain. demographic data and assessment of neck pain by
using VAS. The no of hours each individual works in
2. Dentists working more than 8 hours. a day will also be taken into consideration. Two groups
included in the study :
3. Age group 20 – 35 years.
Study Group: Neck pain
Exclusion crieteria for both study and control group
Control Group: Without Neck pain
1. Any recent surgery of back and neck.
Measurement 0f Sacpular Protraction
2. Any neurological dysfunction.
Scapular protraction measurements were taken
3. Any pain or muscular disorder.
with the participant standing with normal relaxed
4. Any psychological dysfunctionMethod of selecting posture. The measurements were performed at three
and assigning to groups: different positions:
49. kritika-254--.pmd 255 5/10/2015, 5:14 PM

1. At rest. After using descriptive statistics mean value,

standard deviation, confidence interval, t value and p
2. Hands on hip. value was obtained.
3. 90 o Glenohumeral abduction with internal Statistical Test
rotation.
Independent t test was used to compare the mean
First the inferior angle of scapula was palpated and in terms of distance of right and left side in study and
marked then the subject was asked to stand in relaxed control group, also test was used to compare the mean
manner with arms by the side of the body. This was difference of scapular position at three different
considered as position of rest. The distance from the position between study group and control group.
inferior angle of corresponding spinous process was
taken. Right and left side measurements were RESULT
recorded. The measurements were done three times. The total number of subjects who were included in
Average of the three readings was considered as final the study was 30 of which 15 subjects in study group
reading. The same procedure was repeated for second and 15 in control group.
position hands on hip and third position 90o
The minimum age was 20 and maximum was 35
abduction.
with mean of 24.66(0.61). Also minimum working
Data Analysis hours was 8 and maximum was 10 with mean of
9.53(0.51). And mean of working experience was
Statistical Method 4.66(0.48).
Descriptive statistical analysis has been carried out Also minimum working hours was 8 and
in the present study. Measurement of scapular position maximum was 10 with mean of 9.53(0.51). And mean
was taken at three different positions that is at rest, of working experience was 4.66(0.48).
hands on hip, and 90 degree glenohumeral abduction Table1: Gives details of gender distribution of the
with maximal internal rotation. Mean of right and left study population including both study and control
side were compared within the study and control group.Which shows there are 8 females and 7 males
group,and after that mean difference of the study and who were having neck pain and 7 females and 8 males
control group was compared. who were not having neck pain.
Table1: Gender distribution between study population:
Group Females Males Total

Cases 8(53.3%) 7(46.6%) 15
Control 7(46.6%) 8(53.3%) 15
Total 15(50%) 15(50%) 30
Table2: Gives details of homogeneity between study group and control group.
Table 2: Homogeneity between study group and control group:
N Mean Age Work Hour Work Experience p - val u e

Study Group 15 2 4 .3 3 9 .4 4 .9 <0.001
Control Group 15 2 4 .6 6 9 .5 4 .6 <0.001
Table3: Gives details of scapular position in individuals side and 12.34(2.02) for left side and finally for 900
without neck pain, At rest mean values of distance abduction the mean shows 13.36(1.98) for right side
between inferior angle of scapula and corresponding and 13.22(1.96) for left side. Results showed that there
spinous process shows 11.58(1.95) for right side and was no significant difference between right and left
11.48(1.89) for left side, similarly for second position side in all three positions.
hands on hip mean value shows 12.41(2.07) for right
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Table 3: Scapular position in individuals without neck pain
Position Right Mean(SD) Left Mean(SD) t- value p - val u e

At rest(cm) 11.5(1.95) 11.48(1.8) 2 .9 8 0 .0 0 0 1
Mean difference 0 .1 8
Handson hip(cm) 12.41(2.07) 12.34(2.02) 2 .9 8 0 .0 0 0 1
Mean difference .1 4
900abduction (cm) 13.26(1.98) 13.22(1.96) 2 .9 8 0 .0 0 0 1
Mean difference .1 4
The result shows there is no significant difference second position hands on hip mean value shows
between right and left side in all three positions. 12.38(1.31) for right side and 12.54(1.50) for left side
and finally for 900 abduction the mean shows
Table4: Gives details of scapular position in 13.11(1.40) for right side and 12.57(1.55) for left side.
individuals with neck pain, At rest mean values of the Results showed there is a significant difference
distance between the inferior angle of scapula and between right and left side in all three positions.
corresponding spinous process shows 11.79(1.33) for
right side and 11.16(1.6) for left side, similarly for
Table 4: Scapular position in individuals with neck pain.

Position Right Mean(SD) Left Mean(SD) t- value p-value
At rest(cm) 11.79(1.33) 11.16(1.62) 2 .9 8 0 .0 1 0 3
Hands on hip(cm) 12.78(1.31) 12.54(1.50) 2 .9 8 0 .0 0 4 7
900 abduction(cm) 13.11(1.40) 12.57(1.55) 2 .9 8 0 .0 0 6 8
The result shows there is a significant difference significant difference of scapular position among
between the right side and left side in all the three study and control group that is Dentists with neck
positions. pain have altered scapular movement.
Table5: gives details of scapular position of study

and control group the results shows there is a
Table 5:Comparison between study and control group:
Position Cases Control t- value

Mean(SD) Mean(SD)
At rest(cm) 1 .4 6 .1 8 2 .9 9
Hands on hip(cm) 1 .3 0 .1 4 2 .9 9
900 abduction(cm) 1.47 .1 4 2 .9 9
The result shows that there is a significant difference of scapular position among study and control group.
49. kritika-254--.pmd 257 5/10/2015, 5:14 PM

Graph 1: Comparison Between Study Group and decreased blood flow and oxygen to the soft tissues,
Control Group ultimately causing pain.
The altered scapular position could have probably

occurred due to working posture of dentists, as they
are used to work for long hours in static awkward
posture which include, forward head posture, and
protracted shoulder. Poor working posture may
further lead to imbalance of scapular muscle activity
especially excessive loading of scapular muscles.This
probably have then caused neck pain in dentists who
works in poor posture. This can be supported by a
systematic review done by Green B.N et al, who
observed that neck pain is associated with prolonged
static posture maintained by dentists while treating a
patient.
Impaired alignment of scapula may be classified

as scapular downward rotation, depressed, elevated,
adducted, abducted, tilted, or winged scapula.
Scapular downward rotation is defined as the
downwardly rotated scapula with inferior border
being more medial than superior border; the shoulder
DISCUSSION is lower and slopes downward at the acromial end.
Scapular downward rotation can contribute to
The present study assessed the scapular position
prolonged compressive loading of neck as a result of
in dentists with and without neck pain in three
the transfer of the weight of the upper extremities to
different positions. The vernier calliper was used to
the cervical region through the attachments of the
assess the scapular position in dentists.
cervicoscapular muscle (upper trapezius and levator
The result of the study showed that there is scapulae).Increased upper trapezius muscle length in
significant difference of scapular position in computer scapula downward rotation does not effectively
professionals in all three positions that is at rest , hands transfer the weight of an upper extremity load to the
on hip and 90 degree gleno humeral abduction with sternoclavicular joint , and increased levator scapulae
internal rotation in dentists with neck pain as seen muscle stiffness may contribute increased compressive
.Which infers that the scapular kinematics is altered load and shear force on the cervical spine during active
in all three positions in dentists who works in abnormal neck movement. Repetitive and excessive stress in the
posture for long hours which causes neck pain. neck structures has the potential to cause cumulative
micro trauma to tissue in the cervical region which
The possible reason for this change can be explained lead to neck pain, and limited neck rotation range of
by the fact that neck pain from poor posture can be motion. Also it has been found that prolonged
explained as in an upright position the head is exposure to stress can impair proprioception related
supported by the spinal vertebrae. Once the head is muscle function, which can further damage muscle
flexed forward, For instance while treating a patient spindles. In this way, cervical compressive stress might
in clinic / OPD. The vertebrae do not support the inhibit the proprioceptive muscular feedback system.
weight of the head as much. Muscles, tendons and This increased joint position error has been in patients
ligaments work harder to hold up the head. Over the with neck pain.
time the muscles and other soft tissues tighten due to
the excessive workload required to hold the head in Our results showed a significant difference that is
position. The anterior neck muscle become weak from more than 1.5 cm indicating change in scapular
being stretched and neural structures are kept in less position in dentists with neck pain this is similar to
than optimal positions. This chronic overload and observation made by Alexopoulos E. C, Tanagra D Et
tightening of soft tissues may eventually result in al who observed that altered scapular alignment is
49. kritika-254--.pmd 258 5/10/2015, 5:14 PM

proposed to be related to neck dysfunction and pain. especially excessive loading of scapular muscles.This
Aberrant activity within the three portions of the probably have then caused neck pain in dentists who
trapezius muscles and associated changes in scapular works in poor posture. This can be supported by a
posture have been identified as potential contributing systematic review done by Green B.N et al, who
factors. observed that neck pain is associated with prolonged
static posture maintained by dentists while treating a
However the limitation of the study was that hand patient.
dominance was not included in the study.On the basis
of these findings it is shown that the scapular position Impaired alignment of scapula may be classified
is altered in dentists with neck pain as compared to as scapular downward rotation, depressed, elevated,
those who are not having neck pain. However it has adducted, abducted, tilted, or winged scapula.
not been established that whether neck pain leads to Scapular downward rotation is defined as the
altered scapular position or its altered scapular downwardly rotated scapula with inferior border
position which is responsible for neck pain in dentists being more medial than superior border; the shoulder
is lower and slopes downward at the acromial end.
CONTROL Scapular downward rotation can contribute to
prolonged compressive loading of neck as a result of
The present study assessed the scapular position the transfer of the weight of the upper extremities to
in dentists with and without neck pain in three the cervical region through the attachments of the
different positions. The vernier calliper was used to cervicoscapular muscle (upper trapezius and levator
assess the scapular position in dentists. scapulae).Increased upper trapezius muscle length in
The result of the study showed that there is scapula downward rotation does not effectively
significant difference of scapular position in computer transfer the weight of an upper extremity load to the
professionals in all three positions that is at rest , hands sternoclavicular joint , and increased levator scapulae
on hip and 90 degree gleno humeral abduction with muscle stiffness may contribute increased compressive
internal rotation in dentists with neck pain as seen load and shear force on the cervical spine during active
.Which infers that the scapular kinematics is altered neck movement. Repetitive and excessive stress in the
in all three positions in dentists who works in abnormal neck structures has the potential to cause cumulative
posture for long hours which causes neck pain. micro trauma to tissue in the cervical region which
lead to neck pain, and limited neck rotation range of
The possible reason for this change can be explained motion. Also it has been found that prolonged
by the fact that neck pain from poor posture can be exposure to stress can impair proprioception related
explained as in an upright position the head is muscle function, which can further damage muscle
supported by the spinal vertebrae. Once the head is spindles. In this way, cervical compressive stress might
flexed forward, For instance while treating a patient inhibit the proprioceptive muscular feedback system.
in clinic / OPD. The vertebrae do not support the This increased joint position error has been in patients
weight of the head as much. Muscles, tendons and with neck pain.
ligaments work harder to hold up the head. Over the
time the muscles and other soft tissues tighten due to Our results showed a significant difference that is
the excessive workload required to hold the head in more than 1.5 cm indicating change in scapular
position. The anterior neck muscle become weak from position in dentists with neck pain this is similar to
being stretched and neural structures are kept in less observation made by Alexopoulos E. C, Tanagra D Et
than optimal positions. This chronic overload and al who observed that altered scapular alignment is
tightening of soft tissues may eventually result in proposed to be related to neck dysfunction and pain.
decreased blood flow and oxygen to the soft tissues, Aberrant activity within the three portions of the
ultimately causing pain. trapezius muscles and associated changes in scapular
posture have been identified as potential contributing
The altered scapular position could have probably factors.
occurred due to working posture of dentists, as they
are used to work for long hours in static awkward However the limitation of the study was that hand
posture which include, forward head posture, and dominance was not included in the study.On the basis
protracted shoulder. Poor working posture may of these findings it is shown that the scapular position
further lead to imbalance of scapular muscle activity is altered in dentists with neck pain as compared to
49. kritika-254--.pmd 259 5/10/2015, 5:14 PM

those who are not having neck pain. However it has Conflict of Interest: I did not have any personal
not been established that whether neck pain leads to relationships that might had inappropriately
altered scapular position or its altered scapular influenced my actions, such as dual commitments,
position which is responsible for neck pain in dentists competing interests, or competing loyalties.
Source of Funding: The study was self financed.

CONCLUSION
Ethical Clearance: All the procedures followed were
In the present study, it was seen that scapular
in accordance with the ethical standards of the
position is altered in dentists who are suffering from
responsible committee on human experimentation
neck pain in all three position that is at rest, hands on
(institutional and national) and with the Helsinki
hip, and 9o degree abduction.
Declaration of 1975, as revised in 2000 (5).Informed
Clinical relevance consent was taken from the subjects prior to the study.
1. It helped to derive the correlation between neck REFERENCES

pain and scapular movement.
1. Cynthia.C.Norkin and Pamela K. Levangie, Joint
2. It helped to provide ergonomic advice for structure and function: A comprehensive
correction of posture. analysis, fourth edition.
Limitations of study 2. A critical review of epidemiologic evidence for
work related musculoskeletal disorders of the
1. Small sample size. neck,upper extremity, low back, chapter 2,
NIOSH Publication no. 97-141, july 1997.
2. Hand dominance was not included in the study.
3. DiVeta.J, M.L Walker and B. Skibinski,
3. Manual muscle testing was not included to note Relationship between performance of selected
whether weak muscles could also be a cause of scapular muscles and abduction in standing
increased protraction. subjects,World Journal of sport sciences,vol ,470-
4 7 6 ,2 0 0 9 .
Scope for Future research 4. Ludewig,P.M and T.M Cook, Alterations in
shoulder kinematics and associated muscle
1. Diagnostic muscle evaluation to measure altered
activity in people with symptoms of shoulder
scapular position.
impingement, World Journal of sport science,
2. Study done till now on Dentists and can be done vol3,276-291,2000.
on other population of the same ergonomic 5. A critical review of epidemiologic evidence for
posture. work related musculoskeletal disorders of the
neck,upper extremity, low back, chapter 2,
3. To compare male and female subjects of same NIOSH Publication no. 97-141, july 1997.
population. 6. Mostamand J, Lotti H, Sati N. Evaluating the head
posture & neck pain. Journal of Bodywork &
4. And to add hand dominance as one more factor
movement. 2013 oct 17(4):430-3
for drawing a relation between neck pain and
7. Gupta BD1, Aggarwal S, Gupta B, Gupta M,
scapular position.
Gupta N Effect of Deep Cervical Flexor Training
5. Manual muscle testing can also be used, to check vs. Conventional Isometric Training on Forward
the role of weak muscles in developing protraction. Head Posture, Pain, Neck Disability Index In
Dentists Suffering from Chronic Neck Pain.
Acknowledgement: I would like to thank Dr Sanjeev 8. Morse T, Bruneau H, Dussetschleger J.
Gupta, Director, Banarsidas Chandiwala Institute of Musculoskeletal disorder of the neck and
Physiotherapy for his Guidance & support & all the shoulder in the dental professions. Work.
subjects who voluntarily agreed to participate in the 2010;35(4):419-29. doi: 10.3233/WOR-2010-0979
present study.
49. kritika-254--.pmd 260 5/10/2015, 5:14 PM

DOI Number: 10.5958/0973-5674.2014.00001.X
Co-activation Index of Muscles Across Knee and Ankle

During Sit to Stand in Normal Young Individuals: a Pilot
Study
Priyadharshini G Ravichandran1, Kavitha Raja2, Saumen Gupta3

1
Assistant Professor, Padmashree Dr. D.Y. Patil College Of Physiotherapy, Dr.D.Y.Patil Vidyapeeth, Pune, 2Principal,
3
Lecturer, J.S.S College of Physiotherapy, Mysore
ABSTRACT
Background: Loss of selective motor output is a major component for impaired mobility, which has
been attributed to increased co-activation among individuals with supraspinal lesions. Increased co-
activation of antagonist muscle contributes to the pathomechanics in the joint by weakening the
agonist muscle function. Transitional movements like sit to stand is a prerequisite for many functional
activity of daily living. Our main aim is to study and quantify co-activation across knee and ankle
during sit to stand which can be used as an outcome for therapeutic purposes.
Methodology: Six healthy young adults (age: 22.6 ± 2.4yrs) participated in the study. Participants
performed Sit to stand movement. Muscle activity from quadriceps, hamstring, tibialis anterior and
gastrocnemius were recorded by using EMG and simultaneous video was recorded to analyse the
quality of movement. The best three trials were taken to calculate co-activation index across knee
and ankle.
Results and observation: Co-activation index across knee was found to be 58.07±21.81% and that of
ankle was 29.24±2.85%. Constant firing was observed in tibialis anterior throughout the movement.
Maximum activity was seen in quadriceps during the descent phase of sit to stand.
Keywords: Electromyogram, Rehabilitation, Strategy for Achieving Movement, Transition Movement
INTRODUCTION contributing factor of disordered gait in individuals

with supraspinal lesions including stroke and cerebral
Impaired mobility is a critical determinant of
palsy. Researchers have hypothesized several possible
independence and is a major contributor to disability.
reasons for the presence of increased co activation like
Skeletal muscle on the other hand is an actuator that
the pathologically disorganized central programs and
drives natural limb movements1. One of the common
compensatory programming. This increased co
and important strategy to control these voluntary
activation of the antagonistic muscles leads the
movement is by muscle co activation, which has been
agonistic muscle to attains a disadvantage state
studied under diverse condition like isometric
resulting in weakness of the muscle contributing to
activities 2, standing 3, locomotion 4 etc. Muscle co
the pathomechanics in the joint 6 Co activation of
activation is explained as the simultaneous activation
antagonist muscles is frequently observed under
of agonist and antagonist muscle groups around a
normal physiological conditions as their actions
joint5. In view of controlling a movement, it has been
oppose one another1.
suggested that muscle co activation modulates the
impedance of a joint, by stabilizing the joint1. Increased Most recent literature has focused studying the
co activation is the ensuing response to the loss of effect of co activation during gait or posture among
selectivity of motor output which is a major individuals with or without neuromuscular deficits.
50. priyadharshini G R--261--.pmd 261 5/10/2015, 5:14 PM

Functional activities like sit to stand is a prerequisite for three trials as a part of familiarization. The side of
for participation in many activities of daily living7. Sit the leg for electrode placement was selected randomly.
to stand training is one of the key focus of neurological For the electrode placement the participants were
rehabilitation for integration into the community. asked to perform isometric contraction of quadriceps,
Under the assumption that increased metabolic energy hamstrings, tibialis anterior, gastrocnemius muscles.
is warred without profit during increased co activation. Pair of surface electrodes were placed were the
This increased co activation if quantified will serve as maximal muscle bulk was observed. The area of
an objective measurement which will aid in planning electrode placement was exposed and placed in situ
of rehabilitation protocols and can be used as outcome with the help of adhesive tapes. Active and inactive
measure to check the selectivity of the muscle during electrode was placed approximately at a distance of
a functional activity like sit to stand. In experimental one centimeter as explained by delsys. Ground
conditions, co activation is most often estimated by electrode was placed at a different site over the Upper
comparing the amplitude of the myoelectric activity Limb. The electrodes were connected to the EMG
of muscles that generate opposite torques during a apparatus (RMS An ISO 9001:2000 company, Model:
task. Coactivation index based on amplitude of EMG RMS EMG EP MARK II). The EMG signals were
signals is been employed in the literature5.There is recorded as the participants performed sit to stand for
dearth in literature on, co activation indices used for ten trials. Simultaneous video recording was
measuring co activation during functional activity like performed to obtain the sagittal plane movement
sit to stand and thus leading to the objective of our which was considered for performing the activity
study which is to quantify co-activation index during analysis.
sit to stand activity across knee and ankle muscles in
normal young individuals. The quantification of co DATA ANALYSIS
activation of muscles during sit to stand in normal
individuals will aid in comparison of co activation Activity analysis
above normal value in adults with neurologically Sit to stand to sit was divided into phases as
impairment. Hence can be used as an outcome for explained by Schenkman M et al8. The video was
therapeutic purposes analyzed by two independent rater by using adobe
premiere pro software. Best three trails of the subjects
METHODOLOGY were taken into consideration. The phase of descent
Institutional ethical committee clearance was was extracted from the video. The time of initiation of
descent which is explained as the time at which the
obtained as a part of a larger study. Informed consent
was obtained from all the participants. Six normal knee begins to flex was taken into consideration for
healthy individuals with mean age of 22.6 ± 2.4yrs the calculation of co activation indices for knee and
participated in the study. Participants with skin ankle during the phase of descent. Figure 1 describes
the study of phase of descent.
infection, hypersensitivity of the skin, musculoskeletal
injury and/or neurological deficits were excluded
from the study.
Experimental set up
The study was conducted at the EMG unit, Dept of

Physiotherapy, SOAHS, Manipal University, Manipal,
Karnataka. Participants were asked to sit in the
standard wooden chair with hand across the shoulder
and knee maintained at 90 degree of flexion. A foot
platform was used for the adjustment of the knee to
90 degrees of flexion and the inter feet distance was
maintained at one foot. All participants were instructed
to maintain the foot placement and perform sit to stand Fig. 1

The above Figure describes the initiation of the EMG of the antagonistic muscle activity are the
phase of descent. The EMG signals obtained were used lower electromyographic signal between two muscles
for further analysis. that generate opposite joint torques and The EMG of
agonitics muscle activity are the higher
EMG analysis
electromyographic signal between two muscles that
The surface electrode was attached to the RMS generate opposite joint torques as stated in Ervilha UF
EMG EP MARK II. All EMG signals were passed et al5.
through preset filter settings. Noise was eliminated.
The EMG parameters were set with sensitivity: 100 μV, RESULTS AND OBSERVATION
Low pass filter setting: 200 Hz, Sweep speed: 50ms/
div, Gain: 500 μV. The phase of descent was identified Table 1 depicts the co activation index of knee
in the EMG using the time parameter which was during the phase of descent of sit to stand to sit. The
matched with the simultaneous video recording. mean signifies the amount of antagonist contraction
in percent in relation with the agonist. There is about
Calculation Co activation index 58.07 ± 21.81% of muscle activity of hamstrings muscle
The peak to peak amplitude was frozen during the during the phase of initiation of the descent. Table 2
phase of descent and the co activation index (CI) was depicts the co activation index of ankle during the
calculated for knee and ankle joint using the following phase of descent of sit to stand to sit. The mean signifies
formula: the amount of antagonist contraction in percent in
relation with the agonist. There is about 29.24±2.85%
CI= [ EMG (Antagonist) / EMG (Agonist) ] × 100 activity of gastrocnemius muscle during the phase of
initiation of the descent.
Where,
Table 1: Peak to peak amplitude of EMG signals in microvolts of quadriceps and hamstrings. Co activation index
of knee during the descent phase
Age(years) Gender Amp Quadriceps Amp Hamstrings CI (Knee) % Mean ± SD

(μV) (μV)
23 Female 980 570 58.16 58.07±21.81
20 Female 970 460 47.42
23 Male 420 156 37.14
22 Male 390 290 74.35
21 Male 540 500 92.59
27 Male 670 260 38.8
Table 2: Peak to peak amplitude of EMG signals in microvolts of tibialis anterior and gastrocnemius. Co activation
index of ankle during the descent phase
Age(years) Gender Amp Tibialis Amp Gastrocnemius CI (Ankle) % Mean ± SD

Anterior (μV) (μV)
23 Female 2450 710 28.97 29.24±2.85
20 Female 1910 490 25.65
23 Male 1560 490 31.41
22 Male 1300 420 32.3
21 Male 1350 420 31.11
27 Male 1190 310 26.05
It was observed that there was constant firing of Limitations

tibialis anterior throughout the activity. Maximum
recruitment occurs in the quadriceps during the phase The study was conducted in normal individuals
of control descent and further investigation is required to be conducted

on patients for definite conclusion. Sample in the 2. Busse ME, Wiles CM, van Deursen RW. Co-
current study is small to be conclusive of the normative activation: its association with weakness and
value. The current study observed the phase of specific neurological pathology. J Neuroeng
initiation of descent of sit to stand activity. The Rehabil2006; 3: 26.
available EMG apparatus was not dynamic. Raw data 3. Benjuya N, Melzer I, Kaplanski J. Aging-induced
was used for analysis. shifts from a reliance on sensory input to muscle
cocontraction during balanced standing. J
Future scope Gerontol A Biol Sci Med Sci2004; 59: 166-171.
A larger sample size is required for the estimation 4. Collins JJ. The redundant nature of locomotor
of normative values of co activation during various optimization laws. J Biomech1995; 28: 251-267.
functional activities.. The need arises to study the entire 5. Ervilha UF, Graven-Nielsen T, Duarte M. A
transitional activity of sit to stand. Use of dynamic simple test of muscle coactivation estimation
EMG apparatus for analyzing functional activities. Use using electromyography. Braz J Med Biol Res.
of normalized EMG signals to eliminate inter 2012 Oct;45(10):977-81.
participant differences .Other joints and muscle can 6. Anne Shumway-Cook , Marjorie H. Woollacott.
be studied for more conclusive results Motor Control: Theory and practical application.
Baltimore,Md: William and Wilkins
Acknowledgement: Nil Inc ;1995.p.371-373.
7. Vander Linden DW, Brunt D, McCulloch MU.
Variant and invariant characteristics of the sit-
Conflict of Interest: Nil to-stand task in healthy elderly adults. Arch Phys
Med Rehabil. 1994.
REFERENCES 8. Schenkman M, Berger RA, Riley PO, Mann RW,
Hodge WA. Whole-body movements during
1. Hogan N. Adaptive control of mechanical rising to standing from sitting. Phys Ther. 1990.
impedance by coactivation of antagonist
muscles. IEEE Transactions on Automatic
Control 1984; 29: 681-690.

DOI Number: 10.5958/0973-5674.2014.00001.X
"Trunk Dissociation Retrainer" for Improving Balance and

Gait in Hemiplegia
ArunachalamRamachandrana1, AnandhVaiyapuri2, Jagatheesan Alagesan3, Rajkumar Krishnan Vasanthi4

1
Physiotherapist, Sri Jayendra Saraswathy Medical college& Hospital, 2Professor and Principal, 3Professor, Saveetha
College of Physiotherapy, Chennai, 4Head, School of Physiotherapy, Kuala Lumpur Metropolitan University
College, Malaysia
ABSTRACT
Introduction: Devisingequipment for postural rehabilitation where the subjects can rehearse the
movements withminimal physiotherapist guidance is must.
Objectives: Determine the effectof "Trunk Dissociation Retrainer" (TDR) in improving balance and
gait in hemiplegia.
Method: In this single blinded randomised control trial,56subjects were equally allotted by Simple
random sampling into TDRGroup and Control group(CG). Berg balance scale(BBS) and Gait
velocity(GV) were usedas outcome measure.
Results: Both groups were homogeneous at baseline. TDR group showed statistically significant
improvement in the within group analysis for bothBBSand GV with p<0.001.CG showed statistically
significant improvement in the within group analysis for both BBS and GV p< 0.0001. TDR group
showed statistically significant improvement than the CG in GV withp<0.001 andBBS with p<0.007.
Conclusion: TDR is a betteralternative tool in improving balance and gait in hemiplegia as compared
to manual techniques.
Keywords: Trunk Dissociation Retrainer, Trunk Training,Gait, Balance, Hemiplegia
INTRODUCTION sensorimotorconsequences of stroke, impaired

postural controlprobably has the greatest impact on
Most literature concerning rehabilitationafter ADL independence and quality of gait.4,5 Postural
stroke focuses on the motor recovery of upper and control includes both static posture and dynamic
lowerextremity.1The consequences of stroke have a postural responses like trunk-limb coordination,
wide spectrum. Out of that, a majority of the survivors anticipatory trunk muscle recruitment before limb
from stroke have a combination ofsensory, motor, movement, reciprocal inhibition, trunk dissociation
cognitive and emotional impairmentsleading to etc. That’s why among many biological andfunctional
restrictions in their capacity to perform basicactivities characteristics, postural control is the bestpredictor of
of daily living.2Most of the ADL are performed either achieving independent 6 and showsthe highest
in sitting or standing. Sitting and standing involves correlation with person-perceiveddisability after
not only the ability to maintain a static posture, but discharge from rehabilitation.7 Loss ofpostural control
also the ability to move around and reach for a variety has been recognised as a major healthproblem in
of objectslocated both within and beyond arm’s individuals with stroke resulting in a highincidence
length.3For such functions to occur smoothly, both of falls both during rehabilitation and
trunk and limbs have to move in specific thereafter,particularly in those patients with both
pattern,compensating each other. Of all possible motor and sensorydeficits.8 There was a significant

correlation between abnormal movement patterns of Table 1: Demographic detail of the subjects
trunk in stroke patients and the level of upper limb TDR Group Control Group
motor impairment. As specificity of exercise plays a (mean ± SD) (mean ± SD)
vital role in the prognosis of the stroke Age (years) 56.5±4.53 54.87± 5.2
patients,9adaptation of body or posture which precedes Time since stroke (months) 3.8± 1.2 3.5± 1.7
movement which allows for smooth, economical Gender (N)MaleFemale 208 1810
movement should be trained.10 These postural set are Hemiplegic side (N)RightLeft 1414 1612
position or posture of symmetry or alignment of key-

Interventions
points from which a normal person evolves a
movement or sequences of selective movements. Berta Trunk Dissociation retrainer Group
Bobath proposed the manual training for trunk
dissociation in 1990, which concentrates mainly on The subjects in TDR Group received conventional
specific trunk patterns along with limb movements. stoke rehabilitation programme and additional TDR
Manual trunk training is provided by therapist training programme. TDR consists of two units namely
positioned either to control the trunk or to control the the wheel unit and the patient unit. The wheel unit
distal limb movement. The major flaws of this consists of a metal upright rod fixed to a central pivot
procedure are that, it is a time consuming process and axis with equal halvesabove and below. On upper end
involves constant manual effort by the physiotherapist. of the upright rod there is a curved rod simulating a
So, there is a strong need for devising new equipments steering, for the upper limb to hold. Straps were
usedwhenever there was difficulty in gripping with
which can reduce the human effort involved in trunk
affected hand. The lower end of the upright rod
training following hemiplegia. To our knowledge there
consists of horizontal rests, on either side of the rod
is no equipment for training trunk dissociation so
for incorporation the feet which is held in place by
effectively like manual training.”Trunk Dissociation
buckled footwear. The patient unit consists of an
Retrainer” isequipment designed by us, for training
adjustable seat in front of the wheel unit for the patient
the trunk movements following hemiplegia. In this
to sit. The seat’s height can be adjusted depending on
study an earnest effort has been taken to find out the
the patient’s height and it does not have a back rest.
effectiveness of “Trunk Dissociation Retrainer” in
The distance between the patient unit and the wheel
improving balance and gait in hemiplegic subjects.
unit can be adjusted depending upon the patient’s
height and comfort. The central pivot axis of the wheel
METHODOLOGY unit was fixed so that it corresponds to the umbilical
Subjects level of the subject. After making sure that the patient
is comfortably seated, the therapist explained the
56 hemiplegic subjects from two different concept of the TDR and then the subjects perform the
rehabilitation centres from Chennai were randomised movement with the physiotherapist’s guidance. Two
into two groups, namely TDR group and Control different movements were trained. The first set was
Group with 28 subjects in each group, using Simple donetowards the affected as well as the unaffected side,
random sampling. All the subjects signed an informed parallel to the frontal plane. When the upper end of
consent form before participation. Study was approved the upright rod moved to affected side the lower limb
by the institutional ethical committee.The subjects moves to the opposite side simulating in normal
were included in the study if they fulfil the following postural adjustment pattern. The second set was done
criterias. Both Male and female subjects with history moving to front and back parallel to the sagittal plane.
of stroke before 15 days, in age group of 40 to 75 with When the upper end of the upright rod moved
demographic details as shown in table 1. anteriorly the lower limb moves posteriorly. The
subjects trained in TDR for 30 minutes with 5 minutes
Subjects who scored minimum 6 in static sitting of exercises and 5 minutes of rest for three sets. The
balance rating using Trunk impairment scale were subjects also received conventional exercises in the
selected. Subjects who had impaired comprehension, form of Voluntary control training for the affected
perceptual deficits that may interfere with the study extremities 11 and strengthening exercises 12for 15
and previous history of stroke, double hemiplegia or minutes, Static and dynamic balance training13 for 10
any other coexisting neurological and orthopaedic minutes, Hand function training with task oriented
disorders were excluded from the study. approach for 15 minutes, Gait training14 for 10 minutes,

trunk activities like reaching to anterior aspect and RESULTS

lateral direction clasping the hands from a seated
posture15 for 10 minutes. Total duration of exercises There were no dropouts in the study as shown in
for TDR group was 90 minutes a day, 3 days in a week fig.1. The mean performance of the groups at the
for 4 weeks. baseline in BBS was 22.07±2.36 and 21.35±2.30 for TDR
and control group respectively.Between group
Control Group: analysis of the pre-test value was done using Mann-
Whitney Test. The groups were homogenous at the
The subjects in this group received conventional base line value with p value = 0.307. Both groups
exercises as mentioned in the TRD group for 60 showed statistically significant improvement in the
minutes and received manual trunk dissociation within group analysis done using Wilcoxon Signed
training for 30 minutes. Total duration of exercises for Rank Test with p value <0.001 for both the groups.
Control Group was90 minutes, 3 days in a week for 4 The mean performance of the groups, at the end of
weeks. four weeks of intervention for BBS was34.78±2.26for
Outcome measures: TDR group and 30.5±3.715 for control group. Between
group analyses of the post-test value revealed that TDR
All the subjects underwent baseline analysis before group showed a statistically significant improvement
the subjects were assigned to the groups and Post than the control group with p value < 0.007. The mean
analysis was done at the end of last treatment session. performance of the groups at the baseline in GV was
Berg balance scale was used to assess the outcome of 0.277±0.037and 0.262±0.035 for TDR and control group
balance16 andgait velocity over a distance of 10 meters respectively. Between group analysis of the pre-test
out of given 14 meters was measured to gauge the gait value was done using independent t test. The groups
performance17. A physiotherapist, who was blinded were homogenous at the base line value with p value
about the study, was used to evaluate the outcome = 0.307. Both groups showed statistically significant
measures before and after the intervention. improvement in the within group analysis done using
paired t test with p value <0.001 for both the groups.
The mean performance of the groups, at the end of
four weeks of intervention for GV was 0.410±0.049for
TDR group and 0.328±0.0413 for control group.
Between group analysis of the post-test value revealed
that TDR group showed a statistically significant
improvement than the control group with p value <
0.001.
DISCUSSION
The trunk dissociation is very important

component for most of the functional activities.Trunk
dissociation is the act of upper and lower half of the
bodies compensating equally with each other, there
by bringing the line of gravity as close to the body as
possible and also keeping the centre of gravity as low
as possible. In 1984, Friedli WGstudied postural
adjustments associated with rapid voluntary limb
movements and concluded thattrunk muscles activity
began much prior to activity in the limb muscles and
demonstrated a distal to proximal order of activation.17
He also considered muscles of lower limb as part of
postural muscles and are recruited prior to upper
extremity movement in an anticipatory
fashion.ChariVR,in 1986, studied the lower limb
Fig. 1. Study flow chart
influence on trunk control on sitting while reaching

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Quadriceps Femoris Strength Training Eff

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DOI Number: 10.5958/0973-5674.2014.00001.

Quadriceps Femoris Strength Training: effect of

Objective: To evaluate the effectiveness of the Neuromuscular Electrical stimulation as an add-on

Conclusion: The addition of Neuromuscular Electrical stimulation in maximum voluntary isometric

INTRODUCTION is the most common symptom of OA and contributes

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It has been well established in cross-sectional Study design

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Table: 1.1Comparison of isometric quadriceps strength between the groups

Group A Group B Two sample t-test

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Pain Intensity session i.e. on 3rd week (V3) found to be statistically

Table 1.2: Comparisonof VAS score between the groups

Group A Group B Two sample t-test

Table 1.3: Comparison of Reduced WOMAC score between the groups

Group A Group B Two sample t-test

DISCUSSION period. Gained improvement was also maintained

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INTERNATIONAL EDITORIAL ADVISORY BOARD NATIONAL EDITORIAL ADVISORY BOARD

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

EDITORIAL PAGES.pmd 3 6/26/2014, 4:24 PM

Indian Journal of Physiotherapy and

2. The effectiveness of Stress Management Technics on Alcoholic Patients ........................................................................... 07

4. Comparison of Balance in Elderly with and without Diabetes using .................................................................................. 17

5. Isokinetic Measurement of Functional Hamstrring: Quadriceps Strength ......................................................................... 22

6. Hindi Translation, Cross-Cultural Adaptation and Validation of the "Self-Efficacy ......................................................... 27

7. Prevalence of Airflow Limitation in Women Exposed to Biomass Fuel in Rural ............................................................... 32

11. Effect of Cawthorne and Cooksey Exercise Program on ....................................................................................................... 55

Content Final.pmd 1 5/10/2015, 7:19 PM

13. The Study of Improving Prewriting Skills Through Simplified ........................................................................................... 63

15. Effect of Active Stretching Exercises on Primary Dysmenorrhea in .................................................................................... 72

17. Effectiveness of Acu-Transcutaneous Electrical Nerve Stimulation in Middle .................................................................. 82

18. Effect of Incorporation of Regular Rhythm in Exercises on .................................................................................................. 87

Content Final.pmd 2 5/10/2015, 7:19 PM

36. A Comparative Study on Role of Different Electrotherapy Modalities to ........................................................................ 180

37. Benefits of Early Mobilization of Icu Patients ........................................................................................................................ 186

Content Final.pmd 3 5/10/2015, 7:19 PM

43. Myofascial Pain Syndrome ....................................................................................................................................................... 221

Content Final.pmd 4 5/10/2015, 7:19 PM

A Study to Compare the effect of Scapular Taping Along

Chatla Jyoti Ramanand

INTRODUCTION minor muscles goes into tightness whereas, the deep

1. Jyoti--1-6.pmd 1 5/10/2015, 5:13 PM

1. Jyoti--1-6.pmd 2 5/10/2015, 5:13 PM

Upper trapezius muscle length:13 Cervical spine was

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characteristics ( age, duration of symptoms, height,

Table 1: Baseline characteristics by treatment groups

Characteristic Experimental Control group P

*SA=superior angle, †RS=root of spine, ‡IA=Inferior angle

Table 2: Mean and standard deviations of Outcome Measures by Treatment Group

Characteristic 1week follow-up 2week follow-up

* SA=superior angle, †RS=root of spine, ‡IA=Inferior angle

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1. Jyoti--1-6.pmd 5 5/10/2015, 5:13 PM

1. Jyoti--1-6.pmd 6 5/10/2015, 5:13 PM

The Effectiveness of Stress Management Technics on

INTRODUCTION in nature (Kathleen T.Brady and C.Sone, Pharm.D

2. Ramakrishnan --7--.pmd 7 5/10/2015, 5:13 PM

AIM AND OBJECTIVES Ann Turner (2002) 7 stress management

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living, individuals can counteract stressful responses DATA COLLECTION PROCEDURES