issn p- 0973-5666 issn e- 0973-5674 april 2019.pdf · volume 12 number 1 jan-march 2018 issn p-...

Volume 12 Number 1 Jan-March 2018

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

Volume 13 Number 2 April-June 2019

Indian Journal of Physiotherapy and Occupational TherapyEditor-in-Chief

Dr. Archna SharmaHead, Dept. of Physiotherapy, G. M. Modi Hospital, Saket, New Delhi-110 017

Email : [email protected]

Executive EditorDr. R.K. Sharma

Formerly, All-India Institute of Medical Sciences, New Delhi

Sub EditorDr. Kavita Behal

MPT (Ortho)

INTERNATIONAL EDITORIAL ADVISORY BOARD 1. Vikram Mohan, (Lecturer) Universiti Teknologi MARA, Malaysia

2. Angusamy Ramadurai, (Principal) Nyangabgwe Referral Hospital, Botswana

3. Faizan Zaffar Kashoo, (Lecturer), College Applied Medical Sciences, Al-Majma'ah University, Kingdom of Saudi Arabia

4. Amr Almaz Abdel-aziem, (Assistant Professor of Biomechanics) Faculty of Physical Therapy, Cairo University, Egypt

5. Abhilash Babu Surabhi, (Physiotherapist) Long Sault, Ontario, Canada

6. Avanianban Chakkarapani, (Senior Lecturer) Quest International University Perak, IPOH, Malaysia

7. Manobhiram Nellutla, (Safety Advisor) Fiosa-Miosa Safety Alliance of BC, Chilliwack, BC

8. Jaya Shanker Tedla, (Assistant Professor), College of Applied Medical Sciences, Saudi Arabia

9. Stanley John Winser, (PhD candidate) at University of Otago, New Zealand

10. Salwa El-Sobkey, (Associate Professor), King Saud University, Saudi Arabia

11. Saleh Aloraibi, (Associate Professor) College of Applied Medical Sciences, Saudi Arabia

12. Rashij M, (Faculty-PT Neuro Sciences) College of Allied Health Sciences, UAE

13. Mohmad Waseem, (Exercise Therapist) Alberta-CANADA

14. Muhammad Naveed Babur, (Principle & Associate Professor) Isra University, Islamabad, Pakistan

15. Zbigniew Sliwinski, (Professor) Jan Kochanowski University in Kielce

16. Mohammed Taher Ahmed Omar, (Assistant Professor) Cairo University, Giza, Egypt

17. Ganesan Kathiresan, (DBC Senior Physiotherapist) Kuching, Sarawak, Malaysia

18. Kartik Shah, (Registered Physiotherapist) Vancouver, Canada

19. Shweta Gore, (Senior Physical Therapist) Narayan Rehabilitation, Bad Axe

20. Ashokan Arumugam, MPT (Ortho & Manual Therapy), PhD, Department of Physical Therapy, College of Applied Medical Sciences, Majmaah University, Kingdom of Saudi Arabia

21. Veena Raigangar, (Lecturer) Dept. of Physiotherapy, University of Sharjah, U.A.E.

22. Dave Bhargav, (Senior Physical Therapist) Houston, Texas

23. Dr. Jagatheesan A, (Assistant Professor) Gulf Medical University, Ajman, U.A.E.

24. Dr. C. B. Senthilkumar, (Assistant Professor-Physical Therapy), Jazan University, Kingdom of Saudi Arabia

SCIENTIFIC COMMITTEE 1. Gaurav Shori, (Assistant Professor) I.T.S College of

Physiotherapy

2. Baskaran Chandrasekaran, (Senior Physiotherapist) PSG Hospitals, Coimbatore

3. Dharam Pandey, (Sr. Consultant & Head of Department) BLK Super Speciality Hospital, New Delhi

4. Jeba Chitra, (Associate Professor) KLEU Institute of Physiotherapy, Belgaum, Karnataka

5. Deepak B. Anap, (Associate Professor) PDVPPF's, College of Physiotherapy, Ahmednagar, Maharashtra

6. Shalini Grover, (Assistant Professor) HOD-FAS,MRIU

7. Vijay Batra, (Lecturer) ISIC Institute of Rehab. Sciences

8. Ravinder Narwal, (Lecturer) Himalayan Hospital, HIHIT Medical University, Dehradun-UK

9. Abraham Samuel Babu, (Assistant Professor) Manipal College of Allied Health Sciences, Manipal

10. Anu Bansal, (Assistant Professor and Clinical Coordinator) AIPT, Amity university, Noida

11. Bindya Sharma, (Assistant Professor) Dr. D. Y .Patil College Of Physiotherapy, Pune

12. Dheeraj Lamba, (Associate Professor & Research Coordinator) School of Physiotherapy, Lovely Professional University, Phagwara (India)

13. Soumya G, (Assistant Professor) MSRMC

14. Nalina Gupta Singh, (Assistant Professor) Physiotherapy, Amar Jyoti Institute of Physiotherapy, University of Delhi, Delhi

15. Gayatri Jadav Upadhyay, (Academic Head) Academic Physiotherapist & Consultant PT, RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore

16. Nusrat Hamdani, (Asst. Professor and Consultant- Neurophysiotherapy) Rehabilitation Center, Jamia Hamdard, New Delhi

17. Ramesh Debur Visweswara, (Assistant Professor) M.S. Ramaiah Medical College & Hospital, Bangalore

18. Nishat Quddus, (Assistant Professor) Jamia Hamdard, New Delhi

19. Anand Kumar Singh, (Assistant Professor) RP Indraprast Institute of Medical Sciences Karnal, Haryana

20. Pardeep Pahwa, (Lecturer) Composite Regional Rehabilitation Centre, Sunder-Nagar under NIVH (Ministry of social justice & Empowerment), New Delhi

Indian Journal of Physiotherapy and Occupational Therapy

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

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

Website: www.ijpot.com© All Rights reserved The views and opinions expressed are ofthe authors and not of the Indian Journal of Physiotherapy andOccupational Therapy. The Indian Journal of Physiotherapy and Occupational Therapy does not guarantee directly or indirectly the quality or efficacy of any products or service featured in the advertisement in the journal, which are purely commercial.

EditorArchna Sharma

Institute of Medico-legal PublicationsLogix Office Tower, Unit No. 1704, Logix City Centre Mall

Sector-32, Noida-201 301 (Uttar Pradesh) Printed, published and owned by

Archna SharmaInstitute of Medico-legal Publications

Logix Office Tower, Unit No. 1704, Logix City Centre MallSector-32, Noida-201 301 (Uttar Pradesh)

Published atInstitute of Medico-legal Publications

Logix Office Tower, Unit No. 1704, Logix City Centre MallSector-32, Noida-201 301 (Uttar Pradesh)

NATIONAL EDITORIAL ADVISORY BOARD 1. Charu Garg, (Incharge PT) Sikanderpur Hospital (MJSMRS),Sirsa

Haryana, India 2. Vaibhav Madhukar Kapre, (Associate Professor) MGM Institute

of Physiotherapy, Aurangabad, Maharashtra 3. Amit Vinayak Nagrale, (Associate Professor), Maharashtra

Institute of Physiotherapy Latur, Maharashtra 4. Manu Goyal, (Principal) M. M. University Mullana, Ambala,

Haryana, India 5. P. Shanmuga Raju, (Asst.Professor & I/C Head) Chalmeda

AnandRao Institute of Medical Sciences, Karimnagar, Andhra Pradesh

6. Sudhanshu Pandey, (Consultant Physical Therapy and Rehabilitation Department) Base Hospital, Delhi

7. Aparna Sarkar, (Associate Professor) AIPT, Amity University, Noida

8. Jasobanta Sethi, (Professor & Head) Lovely Professional University, Phagwara, Punjab

9. Patitapaban Mohanty, (Assoc. Professor & H.O.D.) SVNIRTAR, Cuttack , Odisha

10. Suraj Kumar, (Asso. Prof. & Head) Department of Physiotherapy, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, UP

11. U. Ganapathy Sankar, (Vice Principal) SRM College of Occupational Therapy, Kattankulathur, Tamil Nadu

12. Hemant Juneja, (Head of Department & Associate Professor) Amar Jyoti Institute of Physiotherapy, Delhi

13. Sanjiv Kumar, (I/C Principal & Professor) KLEU Institute of physiotherapy, Belgaum, Karnataka

14. Narasimman Swaminathan, (Professor, Course Coordinator and Head) Father Muller Medical College, Mangalore

15. Pooja Sharma, (Assistant Professor) AIPT, Amity University, Noida

16. Nilima Bedekar, (Professor, HOD Musculoskeletal Sciences) Sancheti Institute College of Physiotherapy, Pune

17. N. Venkatesh, (Principal and Professor) Sri Ramachandra University, Chennai

18. Meenakshi Batra, (Senior Occupational Therapist) Pandit Deen Dayal Upadhyaya Institute for The Physically Handicapped , New Delhi

19. Shovan Saha, T, (Associate Professor & Head, Occupational Therapy) School of Allied Health Sciences, Manipal University, Manipal, Karnataka

20. Akshat Pandey, (Sports Physiotherapist) Indian Weightlifting Federation/Senior Men and Woman/SAI NSNIS Patiala

21. Maneesh Arora, (Professor and as Head of Dept.) Sardar Bhagwan (P.G.) Institute of Biomemical Sciences, Balawala, Dehradun, UK

22. Jayaprakash Jayavelu, (Chief Physiotherapist) Medanta The Medicity, Gurgaon Haryana

23. Deepak Sharan, (Medical Director and Sole Proprietor) RECOUP Neuromusculoskeletal Rehabilitation Centre, New Delhi

24. Vaibhav Agarwal, (Incharge) Dept. of physiotherapy, HIHT, Dehradun

25. Shipra Bhatia, (Assistant Professor) AIPT, Amity University, Noida

26. Jaskirat Kaur, (Assistant Professor) Indian Spinal Injuries Center, New Delhi

27. Prashant Mukkanavar, (Assistant Professor) S.D.M. College of Physiotherapy, Dharwad, Karnataka

28. Chandan Kumar, (Associate professor & HOD Neuro-Physiotherapy) Mahatma Gandhi Mission's Institute of Physiotherapy, Aurangabad, Maharashtra

29. Satish Sharma, (Assistant Professor) I.T.S. Paramedical College, Murad Nagar, Ghaziabad

30. Richa, (Assistant Professor) I.T.S. Paramedical College Murad Nagar Ghaziabad

31. Manisha Uttam, (Research Scholar) Punjabi University, Patiala 32. Dr. Ashfaque Khan (PT), (HOD Physiotherapy), Integral

University Lucknow U.P. 33. Dr. Dibyendunarayan Bid(PT), (Senior Lecturer) The Sarvajanik

College of Physiotherapy Rampura, Surat 34. Vijayan Gopalakrishna Kurup, (Chief Physiotherapist) Rajagiri

Hospital, Aluva, Ernakulam, Kerala 35. Charu Chadha, (Assistant Professor) Banarsidas Chandiwala

Institute of Physiotherapy Kalka Ji, New Delhi 36. Neeraj Kumar, (Programme Chair & Asst. Professor) Galgotias

University, Greater Noida

I

Volume 12 Number 1 Jan-March 2018

Indian Journal of Physiotherapy and Occupational Therapy

www.ijpot.com

CONTENTS

Volume 13, Number 2 April-June 2019

1. A Comparative Study on Deep Cervical Flexors Training and Neck Stabilization Exercises in Subjects with Chronic Neck Pain .................................................................................................................. 1

Addala Suvarna Raju, Patchava Apparao, Ganapathi Swamy, P. Chaturvadi, R. Geetha Mounika

2. To Check 10% Rule of Dominance in Hand Grip Strength of Physiotherapy Students ............................... 6Ajay Malshikare, Akhil Samson, Akansha Singh, Tushar J Palekar

3.AcuteEffectsofMatrixRhythmTherapyVersusPassiveStretchingonHamstringFlexibilityinFemales11Namrata Rawtani, Akhil Samson, Tushar J Palekar

4.EffectofCoreStabilisationExercisesinPostnatalWomenwithLumbo-PelvicInstability.......................17Ashwini A Kale, Nawaj M Pathan

5.AComparativeStudyonMirrorTherapyandMotorImageryonImprovingGaitinPostStrokeSubjects23Choppala Mary Margrett, P. R. Sri Thulasi, P. Kiran Prakash, Patchava Apparao, Ganapathi Swamy Chintada, Brundha Tanavarapu

6.EffectsofAerobicExerciseontheGestationalWeigthGainofHealthyPregnantWomen– A Systematic Review ................................................................................................................................... 29

Ezeukwu Antoninus Obinna, Nweke Ugochukwu Noel Martins, Nebo Ifeanyichukwu, Nwafulume Chidubem, Ojukwu Chidiebele Petronilla, Ezugwu Uchechukwu, Uduonu Ekezie M.

7.AssessmentofBalanceandRiskforFallsinaSampleofCommunity-DwellingAdultsAged60andOlder33Harshita Chojar, Gurpreet Kaur

8.TestRetestReliabilityofModifiedTardieuScaletoQuantifytheSpasticityinElbowFlexorsin PatientswithCerebroVascularAccident....................................................................................................38

Indrani Sonvane, Suresh Kumar T

9. Correlation between BMI Categories and Hand Grip Strength among School Children between 11 and 14 Years of Age: A Cross Sectional Study ....................................................................................... 43

J Andrews Milton, A Turin Martina

10.AStudytoFindOutImmediateEffectofMuscleEnergyTechniqueonPectoralisMinorTightnessin HealthyCollegiateIndividuals-AnInterventionalStudy............................................................................48

Jalpa K. Patel, Parinda R. Kansagara

11.EffectofScapularDownwardRotatorStretchExercisesonScapularUpwardRotatorActivityDuring Arm Elevation in Subjects with Scapular Downward Rotation Syndrome ................................................. 53

Na-Yeon Jeon, Jong-hyuck Weon, Kwon-ho Lee, Do-young Jung, In-cheol Jeon

12. CorrelationofIronSaturationIndexwithAerobicCapacityinYoungIndianFemales.............................59Nidhi Mehta, Bhamini Krishna Rao, Kalyana Chakravarthy B, Animesh Hazari, Karthik Rao

II

13.EffectofActiveCranioCervicalFlexionExerciseofUpperCervicalSpineonPain,Cervical RangeofMotionandCraniocervicalFlexionTest(CCFT)inPatientswithAgeGroup20-40Yearsof Chronic Neck Pain ....................................................................................................................................... 64

Ganesh MSP, Komal Mali

14. FallPreventionbyShort-FootExerciseinDiabeticPatients......................................................................69Kukiat Tudpor, Wallapa Traithip

15.TheEffectofRhythmicAuditoryCueingonFunctionalGaitPerformanceinParkinson’sDiseasePatients 75Manali Akre, Jui Dave

16.EffectofCryoflow(IRGuided)andMoistHotPackonPainandFunctioninFrozenShoulder: AComparativeStudy(PilotStudy).............................................................................................................82

Manmitkaur A. Gill, Neela C. Soni

17.EffectivenessofFartlekTrainingonCardiorespiratoryFitnessandMuscularEnduranceinYoungAdults: A Randomized Control Trial ....................................................................................................................... 86

Mansi Shingala, Yagna Shukla

18.PhysiotherapyApproachinImprovingKneeFunctionFollowingTotalKneeReplacement:ACaseReport 90Maria Justine, Alia Ibrahim

19.EffectivenessofGazeStabilityandConventionalExercisesonBalanceinVestibular Hypofunction Patients ................................................................................................................................. 95

Mariyamath Arifa, Chinnakalai Thangadurai, Sajjad Abdul Rahiman Ebrahim

20.TheeffectsofHomeBasedProgressiveResistanceExercisesonDepressionofElderlyAdults.............100Mohammed Aslam Ahmed

21.EffectofMyofascialReleaseinAxillaryWebSyndromeinCarcinomaofBreast...................................105Nirmiti. A. Datar, Vaishali. Jagtap

22.IncreasedScapularAnteriorTiltingandDecreasedHumeralInternalRotationintheMouse ShoulderinComputerWorkerswithShoulderPain.................................................................................111

In-cheol Jeon, Oh-yun Kwon, Ui-jae Hwang, Sung-hoon Jung, Jong-hyuck Weon

23.ToComparetheEffectivenessofMyofascialRelease(MFR) with Strengthening and Stretching with StrengtheningtoImprovetheRoundedShoulderPosture........................................................................116

Paramdeep Kaur, Jayaraman G

24.MuscleEnergyTechniqueforSacroiliacJointDysfunction–AnEvidenceBasedPractice......................122Parinda R. Kansagara, Jalpa K. Patel

25.ToComparetheActivityofScapularUpwardRotatorsduringIsometricShoulderFlexionwithForward VsNeutralHeadPostureinNormalHealthyIndividuals.........................................................................126

Parul A. Rakholiya, Priyanka P. Makwana, AshishD. Kakkad

26.EmergingNeuro-rehabilitationTechniqueinSports:TheTranscranialDirectCurrentStimulation (AReviewArticle).....................................................................................................................................131

Parul Sharma, Shilpa Jain

27.CurrentScenarioofDiabetesinAhmednagarCityPopulation.................................................................136Poonam R. Pandey, Suvarna Ganvir

III

28.EffectofSportsActivityDependentAntagonistMusclesStrengthening(Sadams)onPerformance Parameters in Competitive Roller Skaters: An Experimental Study ......................................................... 144

Prasannajeet P Nikam, Basavraj Motimath, Dhaval Chivate

29.NormativePerformanceofIndianAdultsAged20-80YearsonModifiedJebsenTestofHandFunction 150Prerna Lal, Sebestina Anita Dsouza, Timsy Jain

30.TheEffectivenessofAerobicExerciseProgramforImprovingFunctionalPerformanceandQualityof LifeinChronicLowBackPain.................................................................................................................155

Priyanka Gupta, P. P. Mohanty, Monalisa Pattnaik

31.EffectofVestibularRehabilitationonCognitionandEyeHandCoordinationinElderly........................161Rajneet Kaur Sahni, Harpreet Singh, Gurpreet Kaur

32.AgeandGenderRelatedDifferencesinPushUpTestinAthletesofBelagavi–ACrossSectionalStudy166Basavaraj Motimath, Sadhvi Koyande, Dhaval Chivate

33.EffectofEarlyInterventionwithSpinalIsometricExercisesinAcuteLumbarIntervertabralDiscProlapse 170Shraddha Anandrao Mohite, Sandeep Babasaheb Shinde

34.PrevalenceofLowerCrossedSyndromeinSchoolGoingChildrenofAge11To15Years....................176Shrikrushna Shripad Kale, Sayali Gijare

35.EffectofCryokineticsonTalofibularLigamentofImprovingProprioceptionoftheAnkle JointamongSportsPersonHavingAnkleSprain.....................................................................................180

Bably Kaur, Kavita Kaushal, Simratjeet Kaur

36. EffectsofNDTTreatmentBasedTrunkProtocolonGrossMotorFunctionofSpasticCP Children ..... 186Sonia Sharma, Rashida Begum

37.FunctionalUpperLimbRehabilitationinBrainInjuryduetoStrokethroughMotorSynergy Rehabilitation–ACaseStudy....................................................................................................................191

V. Siddharth

38.DocumentationofElectrotherapyTreatmentinClinicalPractice-IsItHappening?.................................195Prashanth V Mangalvedhe, Vijay Samuel Raj V

39.TheEffectivenessofVideoAssistedTeachingProgramonReproductiveHygieneamong Students at Selected College ..................................................................................................................... 200

Vishal A, Ajay Kumar, Sundari, Lakshmi

40.GenderDifferenceintheRelationshipbetweenWorkStressandQualityofLife: TheCaseofPhysicalandOccupationalTherapistsinTaiwan..................................................................204

Yi-Ching Lin, Yu-Li Lan, Yu-Hua Yan, Yu-ping Tang

41.EffectofPlayingBadmintononCervicalSpinePostureinYoungCollegiateStudents...........................210Tanya Gujral, Zuheb Ahmed Siddiqui

42.ComparisonoftheTwoMinuteStepTestwithSixMinuteWalkTestinChronicObstructive Pulmonary Disease Patients ..................................................................................................................... 215

P. Shanmuga Priya, Anwar K. Nazar, S. Azarudheen, N. Saranya, A. Thenmozhi, V. Vaishnavi

IV

43.EffectofTwoProprioceptiveTrainingProgramsonCervicalRepositioningSenseonSubjectswith ChronicNonSpecificNeckPain...............................................................................................................220

Prakash Kumar Mahto, Sapna Malla

44.Cross-CulturalAdaptationofEnglishVersion(1.0)ofBarthelIndexinPunjabi.....................................226Rajneet Kaur Sahni, Shanu

45.ToEvaluatetheEfficacyof780nmLowLevelLaserTherapyfortheTreatmentofPlantarFasciitisin SouthWesternEthiopia.............................................................................................................................231

Dheeraj Lamba

46.ToKnowtheEffectivenessofRockerBoardTrainingProgrameonTrunkBalanceandGaitin Subjects with Stroke .................................................................................................................................. 236

N. Lakshmi Tirupatamma, G. Kameshwari, V. Sri Kumari, K. Madhavi

DOI Number: 10.5958/0973-5674.2019.00035.2

A Comparative Study on Deep Cervical Flexors Training and Neck Stabilization Exercises in Subjects with Chronic Neck Pain

Addala Suvarna Raju1, Patchava Apparao2, Ganapathi Swamy3, P. Chaturvadi4, R. Geetha Mounika5

1Post Graduate Student, 2Principle of College, Department of Physiotherapy, Swatantra Institute of Physiotherapy and Rehabilitation, GSL Medical College, Rajahmundry, NTR University of Health

Sciences, Andhra Pradesh, India; 3Asst Professor of Statistics, Department of Community Medicine, GSL Medical College, Rajahmundry; 4Vice Principle of College, 5Asst Professor Physiotherapy, Department of

Physiotherapy, Swatantra Institute of Physiotherapy And Rehabilitation, GSL Medical College, Rajahmundry

ABSTRACT

Neckpainisacommonproblem.Ithasmanycausessomeofthemmaybeduetotightnessofmusclesofbothneckandupperback,orpinchingsensationofthenervesoriginatingfromthecervicalvertebraeandalso caused by other numerous spinal problems

Purpose: Thepurposeofthisstudyistocomparetheeffectivenessofdeepcervicalflexorstrainingandneckstabilization exercises in chronic Neck Pain.

Method: 100subjectswereassessedwithchronicneckpainandoutofthatonly70wererecruitedwhoarewillingtobeinthestudyandtheywererandomlyallocatedintotwogroups.InGroupA(n=35)subjectsweretreatedwithDeepcervicalflexorstraining,wheretheinterventionwasdonethriceaweekfor4weeks,whereasinGroupB(n=35)subjectsweretreatedwithneckstabilizationexercises.TheoutcomeofthisinterventionwasVisualanalogscale(VAS),Neckdisabilityindexscale(NDI)ANDmanualmuscletesting(MMT)whichwererecordedbeforeandafterpostsessionofthe4weeksintervention.

Results: Statistical analysis of the data revealed that in within group comparison both group showed significantimprovementforallparameterswhereasinbetweengroupcomparisonshowedthereissignificantimprovement at 3rdweekitselfandhighlysignificantat4th week in between groups.

Conclusion: Both interventions are effective.When compared with Neck stabilization, Deep Cervicalflexorstrainingshowedbetterreductioninpainintensity,functionaldisabilityandimprovemusclestrengthin participants with chronic neck pain.

Keywords: Neck pain, deep cervical flexors training, Neck Stabilization exercises, VAS, NDI and MMT.

Corresponding Author:Dr. Addala Suvarna RajuPostGraduateStudent,SwatantraInstituteofPhysiotherapyandRehabilitation,GSLMedicalCollege,Rajahmundry,NTRUniversityofHealthSciences,AndhraPradesh,IndiaEmail: [email protected]

INTRODUCTION

Neckpainisacommonproblem.Ithasmanycausessome of them may be due to tightness of muscles of both neckandupperback,orpinchingsensationofthenerves

originating from the cervical vertebrae and also caused by other numerous spinal problems. Joint disruptioncreatespain in theneck.Lower joints in theneckandthose of the upper back create a supportive structure for the head to sit on. The muscles in the area will become tightened,leadingtoNeckPainwhenthissupportsystemis affected adversely1.It is estimated that about 22%to 70% populationwill experienceNeck Pain in theirlives.Incidenceofthispainisincreasingatanalarmingrate.Atanygiventime,10%to20%ofthepopulationreportbeingsufferingfromthispainanditsproblems2. Neck pain and its associated disorders are describing neck pain as pain located in the anatomical region of the neckwithorwithout radiation to thehead, trunk, and

2 Indian Journal of Physiotherapy and Occupational Therapy, April-June 2019, Vol.13, No. 2

upper limbsand thepain isclassifiedaschronicwhenit has duration of 12 weeks or more3.Chronic Neck pain often presents as widespread hyperalgesia on palpation on both passive and active movements of the neck and shoulder region. Considerable research has shown that psychosocial factors are an important prognostic indicator of prolonged disability in individuals with neck pain. It iswell known that chronic pain is oftenassociated with anatomical, psychological, social, andprofessional factors3.Although the natural history of neckpain appears tobe favourable, rateof recurrenceis high in 30% of patients with this pain will develop chronic symptoms, with Neck pain of greater than 6months in duration affecting 14% of all individualswhoexperienceanepisodeofneckpain.Additionally,arecentsurveydemonstratedthat37%ofindividualswhoexperience neck pain will report persistent problems for at least 12 months. Chronic Neck pain is seen in middle aged females majorly, of those affected haveco-existinglowbackpain,alonghistoryofneckpain,cycling as a regular activity, loss of strength in thehands,worrisomeattitude,poorqualityoflife,andlessvirility as predisposing factors for the development of chronic neck pain4.Etiological factors of chronic neck pain are poorly understood and is usually multi factorial includingpoorposture,anxiety,depression,neckstrainand sporting or occupational activities. The symptoms usually have postural or mechanical basis which are found to be predictably caused by limited range of Motion(ROM), stiffness, shortening, lengthening ofmuscles, tenderness, cervical pain aggravated by neckmovements.Itisbecomingacommonproblem,probablydue tomore frequent and prolonged use of electronicgadgetsdailybasisofworkcommunication,particularlyamong the younger age groups. It is an unpleasantsensory experience in the neck which may be manifested asfatigue,tensionorpainthatradiatestotheshoulders,upper extremities or head. Neck pain appears to be acommonailmentofallover theworld. It isapublichealth problem associated with significant disability5. In the central line the head moves towards. Furtherweight could be loaded on the neck thereby exacerbating projection of the acromion or cervical lordosis and resulting in serious changes in the joints between the neck and head6.The Neck Pain have been described and included in osteoarthritis, discogenic disorders,trauma, tumours, infection,myofascialpainsyndrome,torticollis and whiplash7.The Neck stabilisation exercise training is designed to restore cervical muscle endurance

andco-ordination8. DCF exercise applied in the present study has been reported to be an exercise/ examination method that is characterised by low loading and induced properposture,activationofdeepinsteadofsuperficialmuscles. This method bends the head instead of neck so that the deep longus colli muscles are activated as opposite to activation of the superficial musclesincluding the sternocleidomastoid and anterior scalene muscles.Hence,normalneckpostureandarrangementare recovered. In clinical practise, patients with NeckPain are common however relaxation or strengthening of superficialmusclesonlyhasachievedshorttermeffectsandlimitedtomaintaineffectiveposturecorrectionandmitigation of symptoms8.

METHOD AND MATERIAL

Inclusion Criteria: SubjectswithChronicNeckpain,SubjectswithaNeckdisabilityindex(NDI)scoreof<15points whose symptoms could not be exacerbated by muscularstrengthexercise,Agebetween18-65years,. who were not involved in any other form of exercises training.

Exclusion Criteria: Subjects who had not experiencing neck pain more than 3 months, Neck surgeries. Uncooperative patients. Disc prolapsed Spinal canal stenosis Sever trauma Psychiatric illness

Deep Cervical Flexor Training Group: In thisgroup Subjects follow the training 15 repetitions per section3daysaweek4weekduration.Thesuperficialsternocleidomastoid and anterior scalene muscles were kept relaxed while performing deep flexor muscletraining for the neck and head. The pressure biofeedback device ispositionedon thebacksideofhead,and thenflattened cervical lordosiswas confirmedbyusing thevisual feedback obtained via the dials of the device. First,theairbagundertheneckisinflatedto20mmHg,and then the subject presses the bag slightly with slight increments of pressure through the sensor dial (i.e., 2mmHg;upto30mmHg),contractionwasmaintainedfor about 10–15 seconds. This was repeated 10 timeswith3–5restperiodspersession.

Neck Stabilization Exercises Group: The Neck Stabilization Exercise training is designed to restore cervical muscle endurance and coordination. All the subjects in this group performed the following exercises,3daysaweekfor4weeksduration

Indian Journal of Physiotherapy and Occupational Therapy, April-June 2019, Vol.13, No. 2 3

Chin Tuck: Instandingposition,subjectpullsbackthechin(asiftryingtomakeadoublechin)whilekeepingthe eyes level. This was done for 15 repetitions.

Cervical Extension: Instandingposition,subjectgraspsthebaseoftheneck,withbothhandswhileextendingtheneck as far as possible. This was done for 15 repetitions

Shoulder Shrugs: Instandingposition,subjectshrugsthe shoulders, bringing them up towards the ears anddropping them back. This is done for 15 repetitions

Shoulder rolls: In standing position, subject rolls theshoulders forward and backward in a circle respectively. Thentheparticipantrelaxesandrepeatsthesequencefor15 times.

Scapular retraction: Instandingposition,subjectbringsthe shoulder blades together in the back; participant then relaxes and repeats the procedure for 15 times.

FINDINGS

A total of 100 participants were screened for eligibilityamong70subjectswereincludedinthisstudy.All the 70 participantswhomet inclusion criteria haveundergone baseline assessment and included participants wererandomizedintotwogroups,35participantseachinDeep Cervical Flexors Training and Neck Stabilization Exercises Groups. In this study 30 subjects completedtraining in Deep Cervical Flexors Training Group and 29 subjects completed in Neck Stabilization Exercises Group

Table 1: Comparison of Mean scores in VAS, NDI, MMT between the DCF Group & NSE Group

Group Mean Std. Deviation P-Value Inference

VASPre-test

DCF 7.70 0.7940.065 Insignificant

NSE 7.27 0.980

Post-testDCF 1.37 0.490

0.000** SignificantNSE 4.17 3.270

NDIPre-test

DCF 12.60 0.968 0.083 Insignificant

NSE 13.07 1.081



Neck FlexorsPre-test

DCF 3.00 0.6951.000 Insiginificant

NSE 3.00 0.743



Neck Extensor

Pre-testDCF 2.90 0.481

0.017 InsignificantNSE 3.23 0.568



SideflexorsPre-test


NSE 3.20 0.610



RotatorsPre-test


NSE 3.07 0.640




DISCUSSION

In this study the patientswithChronicNeckPainunderwenteitherDeepCervicalFlexors(DCF)activationexercise or Neck Stabilization Exercises for 4 weeks; and then, relevant parameters were assessed before,4 weeks after exercise in order to assess for pain and disability and muscle strength in subjects with Chronic Neck pain. The following outcomes measures named as Visual analog scale (VAS), Neck disability index(NDI)andManualmusclestrength(MMT)wereusedtomonitortheeffectsoftheseexercisesonChronicNeckPain,functionalstatus,viaprospectivecomparison.

InthisstudytheDeepCervicalFlexorexercisehasbeen reported to be an exercise/examination method that is characterized by low loading and induces proper postures and activation of deep, instead of superficial,muscles. This method bends the head instead of the Neck so that the deep longus colli and longus copitis muscles areactivatedasopposedtoactivationofthesuperficialmuscles,includingthesternocleidomastoidandanteriorscalene muscles. Hence, normal Neck postures andarrangement are recovered.

CONCLUSION

Both interventions are effective. When comparedwithNeckstabilizationExercises,DeepCervicalFlexorsTraining showed better reduction in pain intensity,functional disability and improve muscle strength in subjects with Chronic Neck Pain.

Conflict of Interest: Nil

Source of Funding: Self

Ethical Clearance: The ethical clearance of this study protocolwasapprovedbytheEthicalCommitteeofGSLMedical College; The participants were requested toprovide their consent to participation in the study.

REFERENCES

1.Hoy D,March L, Brooks P, Blyth F,WoolfA,BainC,WilliamsG,SmithE,VosT,BarendregtJ,MurrayC.Theglobalburdenoflowbackpain:estimatesfromtheGlobalBurdenofDisease2010study.Annalsoftherheumaticdiseases.2014Jun1;73(6):968-74.

2.Childs JD, Cleland JA, Elliott JM, Teyhen DS,Wainner RS, Whitman JM, Sopky BJ, GodgesJJ, Flynn TW, Delitto A, Dyriw GM. Neckpain: clinical practice guidelines linked to the International Classification of Functioning,Disability, and Health from the OrthopaedicSection of the American Physical Therapy Association. Journal of Orthopaedic & SportsPhysicalTherapy.2008Sep;38(9):A1-34.

3.HoyDG, ProtaniM,DeR, Buchbinder R.Theepidemiology of neck pain. Best Practice &Research Clinical Rheumatology. 2010 Dec 1;24(6):783-92.ChildsJD,ClelandJA,ElliottJM,Teyhen DS, Wainner RS, Whitman JM, SopkyBJ,GodgesJJ,FlynnTW,DelittoA,DyriwGM.Neck pain: clinical practice guidelines linked to the International Classification of Functioning,Disability, and Health from the OrthopaedicSection of the American Physical Therapy Association. Journal of Orthopaedic & SportsPhysicalTherapy.2008Sep;38(9):A1-34..

4.Kaka B, Ogwumike OO. Effect of neckstabilization and dynamic exercises on pain,disability and fear avoidance beliefs in patients withnon-specificneckpain.Physiotherapy.2015May1;101:e704.

5.KimJY,KwagKI.Clinicaleffectsofdeepcervicalflexormuscleactivation inpatientswithchronicneck pain. Journal of physical therapy science.2016;28(1):269-73..

6.Childs JD, Cleland JA, Elliott JM, Teyhen DS,Wainner RS, Whitman JM, Sopky BJ, GodgesJJ, Flynn TW, Delitto A, Dyriw GM. Neckpain: clinical practice guidelines linked to the International Classification of Functioning,Disability, and Health from the OrthopaedicSection of the American Physical Therapy Association. Journal of Orthopaedic & SportsPhysicalTherapy.2008Sep;38(9):A1-34.

7.KimJY,KwagKI.Clinicaleffectsofdeepcervicalflexormuscleactivation inpatientswithchronicneck pain. Journal of physical therapy science.2016;28(1):269-73.

8.ChungSH,HerJG,KoT,YouYY,LeeJS.Effectsof exercise on deep cervical flexors in patientswith chronic neck pain. Journal of PhysicalTherapyScience.2012;24(7):629-32..


9.Abdel-aziem AA, Draz AH. Efficacy of deepneckflexorexerciseforneckpain:arandomizedcontrolled study. Turkish Journal of PhysicalMedicine & Rehabilitation/Turkiye Fiziksel TipveRehabilitasyonDergisi.2016Jun1;62(2).

10.Beer A, Treleaven J, Jull G. Can a functionalpostural exercise improve performance in the cranio-cervicalflexiontest?–Apreliminarystudy.Manualtherapy.2012Jun1;17(3):219-24.

11.Noh HJ, Shim JH, Jeon YJ. Effects of neckstabilization exercises on neck and shoulder muscle activation in adults with forward head posture. International JournalofDigitalContentTechnology and its Applications. 2013 Aug 1;7(12):492.

12.Dusunceli Y, Ozturk C, Atamaz F, HepgulerS, Durmaz B. Efficacy of neck stabilizationexercises for neck pain: a randomized controlled study.Journalofrehabilitationmedicine.2009Jul5;41(8):626-31.

13.Griffiths C, Dziedzic K, Waterfield J, Sim J.Effectiveness of specific neck stabilizationexercises or a general neck exercise program for chronic neck disorders: a randomized controlled trial. The Journal of rheumatology. 2009 Feb1;36(2):390-7..

14.Vijaykage,nishitay.patel,tocomparetheeffectsof deep neck flexors strenghtning exerciseand mckenzie neck exercise in subjects with forward neck posture: a randomised res 2016, vol 4(2):1451-58. issn 2321-1822doi: http://dx.doi.org/10.16965/ijpr.2016.117

15.Asgariasthianiahmadreza “investing the effectof stabilisation exercises and proprioceptive neuromuscular facilitation exercises on cross-sectionareaofdeepcervicalflexormuscleswithchronic neck pain subjects. int j med res health sci.2016,5(11):502-508

16. Smaeilebrahimi et.al conducted a clinical controlled trail on “the effects of stabilisation

exercises and maximum isometric exercises on fearavoidancebeliefinpatientswithchronicnon-specificneckpain”.

17.NezamuddinM,KhanSA,HameedUA,AnwerS,EquebalA.Efficacy of PressureBiofeedbackGuided Deep Cervical Flexor Training on ForwardHeadPostureinVisualDisplayTerminalOperators. Indian Journal of Physiotherapy andOccupationalTherapy.2013Oct1;7(4):141.

18.JullGA,FallaD,VicenzinoB,HodgesPW.Theeffect of therapeutic exercise on activation ofthe deep cervical flexormuscles in peoplewithchronic neck pain. Manual therapy. 2009 Dec1;14(6):696-701.

19.AriensGA,BongersPM,DouwesM,MiedemaMC,HoogendoornWE, van derWalG, BouterLM, van Mechelen W. Are neck flexion, neckrotation,andsittingatworkriskfactorsforneckpain? Results of a prospective cohort study.Occupationalandenvironmentalmedicine.2001Mar1;58(3):200-7.

20.AckelmanBH,LindgrenU.Validityandreliabilityofamodifiedversionoftheneckdisabilityindex.Journal of rehabilitation medicine. 2002 Nov1;34(6):284-7.

21.Cuthbert SC, Goodheart GJ. On the reliabilityand validity of manual muscle testing: a literature review. Chiropractic & osteopathy. 2007Dec;15(1):4.

22.DeBoerAG,VanLanschotJJ,StalmeierPF,VanSandickJW,HulscherJB,DeHaesJC,SprangersMA. Is a single-item visual analogue scale asvalid,reliableandresponsiveasmulti-itemscalesin measuring quality of life?. Quality of LifeResearch.2004Mar1;13(2):311-20.”

23.Litcher-KellyL,MartinoSA,BroderickJE,StoneAA. A systematic review of measures used to assess chronic musculoskeletal pain in clinical and randomized controlled clinical trials. The JournalofPain.2007Dec1;8(12):906-13.

To Check 10% Rule of Dominance in Hand Grip Strength of Physiotherapy Students

Ajay Malshikare1, Akhil Samson1, Akansha Singh2, Tushar J Palekar3

1Assistant Professor, 2Graduate, 3Principal, Dr D Y Patil College of Physiotherapy, Pune

ABSTRACT

The objective of this study was to check whether the dominant hand has 10% more grip strength than the non-dominanthandandprovidenormativedataofhandgripstrengthinphysiotherapystudents.100studentsbetween18-25yearsparticipatedinthissurvey.Afterobtainingwrittenconsentfromthestudentstheywereaskedtositonthechairwithstraightback,witharmrestwiththefeetflatonthefloor,shoulderadductedandneutrallyrotated,elbowflexedat90°,forearmrestingonthearmrestinmidpronepositionandwristwithout support between 0o –10o of ulnar deviation. Then the handle of dynamometer was set at setting of 3.8cmapartandkeptconstantforall.Subjectswereaskedtoholdthedynamometerfirstinthedominanthand in above saidpositionandwere instructed to squeeze for3 secondsor less to initiate theoptimalhandgripstrength.Threeattempts foreachsubjectwereconducted,alternatingrightand lefthandswith30secondsrestbetweentwoattemptstoovercomethefatigue.100students(72females&28males)wereprovidedwiththeirnormativedataofhandgripstrength.Weconcludedafterobtainingresultsthatthereisan overall 9.10% differencebetweenthedominantandthenon-dominanthandwhichisapproximately10%.Thus our study supports the 10% rule of hand dominance of physiotherapy students.

Keywords: 10% rule of hand dominance, Physiotherapy students, Jamar dynamometer

Corresponding Author:Dr Akhil SamsonAssistant ProfessorDrDYPatilCollegeofPhysiotherapy,DYPatilVidyapeeth,SantTukaramNagar,PlotNoBGP/190Pimpri,Pune-411028Phone:+918921567915Email: [email protected] [email protected]

INTRODUCTION

Human beings have been unable to construct a machine which can be more perfectly balance and coordinated thanhumanhand.Thehand isacomplex,multiple organ. The hand is irreplaceable when it comes toperforminganykindofmovement,may itbegrossor skilled. Human hand is a complex instrument that has many aims. Only the hand is capable of makingdistinctions about external characteristics because it combines strength and accuracy. The hand has a central roleinmanyactivitiesofdailylifelikeeating,writing,typing etc. the list is endless. Loss of optimal hand

function does not merely hamper practical tasks such as personalhygieneitaffectsotherareasoflife.1

Figure 1

Many daily activities involve interaction withobjects that are grasped in the hand. The manipulative ability of thehumanhand requires effective force anddexterity.2

Metacarpo Phalangeal flexors, abductors andadductors i.e. introssei helps in strong grip as same as

DOI Number: 10.5958/0973-5674.2019.00036.4


extrinsicflexors.ExtensorDigitorumincreasesthejointcompression and enhances the joint stability.Musclesof the hypothenar eminence that are Abductor digiti minimi,Opponens digitiminimi, Flexor digitiminimiare responsible in an active in cylindrical grip.1

Manydailyfunctionalactivitiesofprofessionalsintheirprofessionaleventsrequirehighactivitylevelsoftheflexormusclesoftheforearmsandhands.Thesearethe muscles involved in gripping strength varies from one profession to another profession like Physiotherapy. Physiotherapist need to do patients manipulation and ambulation. Some degree of grip strength is necessary to be successful in their profession in their activities of daily living. The purpose of this literature review is to dissect importance of grip strength and how it correlates to their physical performance.2

The 10% dominance rule states that the dominant hand has a 10% greater grip strength than the non-dominant hand.3 Thus to assist the therapist in setting strength goals for patientswith injured hands, rule of10% hand dominance is majorly used.

TheJamarHandgripDynamometerisaninstrumentfor measuring the maximum isometric strength of the hand and forearm muscles. The Jamar dynamometerwasintroducedin1954(Bechtol,1954).Itconsistsofasealedhydraulicsystemwithadjustablehandspacing’sthatmeasureshandgripforceinpoundspersquareinch(PSI)Asimilardeviceisalsomarketedunderthename‘Baseline’. The dynamometer is used for testing yourhand grip strength and tracking improvements with strength training and during rehabilitation.4

Figure 2: Jamar Handgrip Dynamometer

MATERIALS AND METHOD

Physiotherapystudentsbetweenagegroupof18-25yrs of both the sex were included in the study. Itwasa cross sectional survey, in which 100 physiotherapystudents from Dr. D. Y. Patil College of Physiotherapy participated in the survey. Approval was taken from research and ethical committee of the institute for participation of students in the survey. Convenient sampling method was used to carry out the study. Normal healthy students were included in the study and those having any musculoskeletal or neurological injury orsurgery,preexistingjointarthritisandinflammatorydisease in upper limb were excluded from the study.

METHOD

All Subjects were given Edinburgh Handedness Inventoryquestionnairetofill,afterobtainingtheresultof the questionnaire; subjectswere divided in to rightor left hand dominant. Afterwards subjects were asked tositonthechairwithstraightback,witharmrestwiththefeetflatonthefloor,shoulderadductedandneutrallyrotated,elbowflexedat90°,forearmrestingonthearmrest in mid prone position and wrist without support between 0o –10o of ulnar deviation.

Then the handle of dynamometer was set at setting of 3.8 cm apart and kept constant for all. Subjects were asked to hold the dynamometer first in the dominanthand in above said position and were instructed to squeeze for 3 seconds or less to initiate the optimalhandgrip strength. Three attempts for each subject were conducted, alternating right and left hands with30 seconds rest between two attempts to overcome the fatigue. The dynamometer was reset to zero prior to each reading of grip strength. Subjects were asked to give maximumeffort3

The investigator used the same instrument to record the data and did the calculation with the formula:

X=V V

V V

1 2

2

1 2

�� × 100

X–PERCENTAGEDIFFERENCE

V1–MEANOFTHEDOMINANTHAND

V2–MEANOFTHENON-DOMINANTHAND


DATA ANALYSIS

1. Gender DistributionTable 1

Gender No. of Students ParticipatedMale 28

Female 72Total: 100

2. Left Hand Dominance and Rigth Hand Dominance Distribution

Table 2

Hand Dominance No. of Students Participated

Right hand dominance 94Lefthanddominance 6

3. Comparison of Hand Grip Strength in Dominant and Non-Dominant Hand

Table 3

Hand N Mean Standard Deviation

Dominant 100 57.74 19.91

Non-dominant 100 52.55 19.84

Interpretation: There is a significant difference of9.10% betweenthedominantandnon-dominanthandinthe sample population

4. Comparison of Hand Grip Strength to Check the 10% Rule of Hand Dominance

Scatter Plot graph showing distribution of percentage difference of the entire population

Interpretation: Number of students with 10% more grip strengthintheirdominanthandthanthenon-dominanthand–32

Number of students with dominant hand grip strengthmore than 10% of that of the non- dominanthand-39

Number of students with dominant hand grip strength less than 10% of that of the non- dominanthand-20

Numberofstudentswithequalgripstrengthofboththehands-2

Number of students with more grip strength in their non-dominanthandascomparedtothedominanthand-7

DISCUSSION

Physiotherapists let it be students or therapists practicemainlyhandsontechniquesinwhichalongwiththe upper extremity strength hand grip strength also play an important role. They come across a variety of patients likeoverweight,obese,etc.inwhichthestrengthofthephysiotherapistisrequired.Alsoinpatientswithstrokegross motor function is hampered in which assessment of hand grip strength is essential. Hand grip strength helps indeterminingthefitnessquotientofanindividual.

The power grip of a hand results from a forceful flexionofalljointsofthehandalongwiththemaximalvoluntary contraction of all the muscles of the hand. “Whilenotyetwidelyusedinthemedicalcommunity,


a grip strength test can be an important screening tool in assessing a person’s overall health, grip strengthgives you an overall sense of someone’s vitality. It isreflective of muscle mass and can be used to predictthings in the future like post-operative complications”says Bohannon, a professor of physical therapy intheDepartment of Kinesiology at theNear School ofEducation.5

This study has investigated the comparison between the grip strength of dominant and non-dominant handof healthy young adults and its relation with their hand dominance. In our study 100 healthy physiotherapystudentsbothmaleandfemaleof theagegroup18-25years with hand dominance of both right hand and left handwereevaluatedforhandgripstrengthusingJamardynamometer.We found anoverall handgrip strengthdifference of 9.10% between dominant and non-dominant hand.

When calculated individually only 32% of the population followed the 10% dominance rule (9.1%-10.9%). 39% of the population hand a hand grip strength difference of more than 10% ranging from11.11% to 31.2%. 20% of the population had a hand grip strength less than 10% which was ranging from 0.91% to7.9%.2% ofthepopulationhadequalstrengthinbothdominantandthenon-dominanthandwhile7% of the population had less strength in the dominant hand as comparedtothenon-dominantonewhichwasrangingfrom-1.0%to-9.2%.

The population that shows their dominant hand strength10%more than thenon-dominanthandcheckswith the 10% rule of dominance in hand grip strength that has been used since 19943 for hand rehabilitation program.

The possible reason for the dominant hand grip strength to be more than 10% from that of the non-dominant hand could be due to the population being of physiotherapists, as the use of dominant hand grip ismore in them.Physiotherapistsuse techniques suchasmanipulation, mobilization, stabilization, traction, etc.in which mainly the grip strength along with the upper extremity strength is used. Thus the grip strength with time and continuous practice tends to increase.

The concept of ‘handedness’ could be a possiblereason for the grip strength of the dominant hand to be less than 10% from that of the non-dominant one.Handedness refers to the tendency of humans to be more dexterous or skilled with one hand over the other

irrespective of the hand dominance6. Some people have developed a good gross motor function in their non-dominant hand due to this handedness leading to less percentage difference between the dominant and thenon-dominanthand.

Averysmallamountofpopulationthatis7%showedmorestrengthintheirnon-dominanthandascomparedtothedominanthand,thiscouldbepossibleduetotheextra-curricular activities they could be involved in. These extra-curricularactivitiesmayincludesports,gymingetc.inwhich theirnon-dominanthandplaysavital role toowhich may lead to increasing its strength. Also previously mentioned concept of handedness can also lead to the increase in non-dominant hand grip strength.BMI alsoplays a vital role it has been observed that people with lowBMIhave lessgripstrength that thatofhighBMI.Accordingtothestudytherangeofpercentagedifferenceisnotthatsignificantintheseindividuals.

Thus,whentherapistsplanarehabilitationprogramfor a post upper extremity injury case of dominant hand they must not limit the training to only 10% more strength than the non-dominant hand and musttake under consideration other parameters like the patient’s occupation, lifestyle, need of the hand etc.The rehabilitation must be continued till the patient has completely or nearly achieved the hand grip strength that is necessary for theirwork (i.e. occupation) and dailyactivities.

CONCLUSION

Hand grip strength is an important physiological component in physiotherapy students given their nature ofwork,which involvesmobilizations,manipulations,resistanceexercisetraining,thatneedsgoodamountofstrength in forearm and hand. This study was conducted on 100 physiotherapy students both male and female to measure the hand grip strength of their dominant and non-dominant hand and compare their values tocheck 10% rule of dominance. According to this study we found out that there is an overall 9.10% differencebetweenthedominantandthenon-dominanthandwhichisapproximately10%.Thus,ourstudysupportsthe10%rule of hand dominance of physiotherapy students.

Conflict of Interest:Thereisnoconflictofinterest.


Ethical Clearance: Dr D Y Patil Ethics Committee


REFERENCES

1.MalshikareA,PalekarT.J,NarayankarP.Assessinghand grip strength and screening of performance relatedupperlimbinjuriesexperiencedbyIndianmusicians.IJRTSAT.2014;12(2):285-291

2.LuchauT.ThumbPainandtheTherapist:AdvancedMyofascial Techniques [Internet]. MASSAGEMagazine. 2019 [cited 6th September 2018].Available from: https://www.massagemag.com/thumb-advanced-myofascial-techniques-90175/

3.NitishBansal:Handgripstrengthnormativedataforyoungadults.IJPOT.2008;2(2):4-6.

4.Bechtol C.O. The use of a dynamometer withadjustablehandlespacings.JBone Joint SurgAm.1954;36-A(4):820-824

5.Hamilton G, McDonald C, Chenier T.C.Measurement of grip strength: validity andreliability of the sphygmomanometer and jamar grip dynamometer. J Orthop Sports Phys Ther.1992;16(5):215-219

6.ChaurasiaB,GargK,MittalP,ChandrupatlaM.BD Chaurasia’s human anatomy. 5th ed. NewDelhi: CBS Publishers & Distributors Pvt Ltd;2017

Acute Effects of Matrix Rhythm Therapy Versus Passive Stretching on Hamstring Flexibility in Females

Namrata Rawtani1, Akhil Samson2, Tushar J Palekar3

1Graduate, 2Assistant Professor, 3Principal, Dr D Y Patil College of Physiotherapy, Pune

ABSTRACT

Purpose:Hamstringextensibilityisoffunctionalsignificanceinpreventionoflocomotionrelatedinjuries.Passivestretchingisatypicalcomponentofitsrehabilitationprograms.Recentlyevolved,matrixtherapypromotes extracellular matrix clearance on a cellular level thereby normalizing tension of the musculature.Hence,thisstudywasdonetocomparetheacuteeffectsofpassivestretchingversusmatrixrhythmtherapyon hamstring flexibility in normal healthy females. In this experimental study 30 female subjects agedbetween18-25wererecruited.Aftertheirpriorconsent,selectioncriteriaincludedscreeningandassessmentofhamstringtightnessbyactivekneeextensiontest(p>0.05).Subjectsfittingthestudydesignweredividedinto2groupsof15eachwhoreceivedeithermatrixtherapy(GroupA)orpassivestretching(GroupB)for3timeseachwithin3weeks.Oneachlegmatrixwasgivenfor30minuteswhereaspassivestretchingwasrepeated 6 times each with 30 secs hold. Pre and Post interventional ranges of both knee extension were measuredaftereachsession.Paired‘t’testwasusedtoanalyzewithingroupdifferencewhileindependent‘t’testwasusedforbetweengroupdifferences.

Results: Significant improvement in hamstring flexibilitywas found post intervention compared to preinterventioninboththegroups(p<0.001).HowevergreaterimprovementinflexibilitywasseeningroupA(Matrixrhythm)whencomparedtogroupB(passivestretching).

Conclusion: Basedon the results,matrix therapyhadanupperhand in improvinghamstringflexibilitythan passive stretching. matrix rhythm therapy can be used in the early rehabilitation of individuals with hamstring tightness.

Keywords: Matrix rhythm therapy, passive stretching, Extracellular Matrix (ECM), active knee extension test, ROM.

Corresponding Author:Dr Akhil SamsonAssistant ProfessorDrDYPatilCollegeofPhysiotherapy,DYPatilVidyapeeth,SantTukaramNagar,PlotNoBGP/190Pimpri,Pune-411028Phone:+919511919208;+918921567915Email: [email protected] [email protected] [email protected]

INTRODUCTION

Flexibility training is an integral component in the prevention and rehabilitation of injuries as well as a method of improving performance in daily activities and sports.1

Evidence suggests that hamstring and fascia tightness is common in asymptomatic healthy individuals. The incidence of hamstring tightness is reported to be 27.50% in males and 45% in females.2Hamstring is one of the most common muscles prone to tightness especially in females. It is “the inability to extend theknee to less than 20 degrees of knee flexionwith thefemurheldat90degreeofhipflexionwhilethepersonis positioned in supine”.3Various causes have beenestablished for hamstring tightness. Some studies say that development of hamstring tightness can be due to genetic predisposition, injury tomuscle or adaptiveshortening due to some chronic condition. Pathological reasons leading to muscle tightness can be neural tension (tautnessofthesciaticnervesupplyingthemuscle),faultyposture or overuse syndromes and hamstring trigger points.Mostcommonlymodernsedentarystyleofliving

DOI Number: 10.5958/0973-5674.2019.00037.6


is one of the main reason for postural abnormalities evidentinsociety.Theprolongedsittinghoursrequiredin most of the jobs and educational setups can affectflexibilityofsofttissues,especiallytwojointmuscles.4

According to isometric length-tension relationship,whenamusclefiberislengthenedorshortenedbeyondoptimal length, itsability togenerateamountofactivetension reduces.3Due to attachment of back extensor musclesonthepelvis,theposteriorpelvictiltputsthesemuscles into a lengthened position and makes them work harder. Constant pulling of the pelvis by the shortened hamstrings foraprolonged time,weakens themusclesin the lowbackcausingsooner fatigue.Backextensormuscles with reduced endurance may over load the soft tissueandpassivestructuresofspineleadingtoLBP.

Tight hamstrings increase knee flexion,whichinduces prolonged forefoot loading and engages the windlass mechanism which in turn produces greater stressovertheplantarfasciacausingitsinflammation.5

When hamstring tightness surpasses borderlinevalues,ankledorsiflexionandlumbarlordosisdecreasesleading to postural deformities, there is a bending-forward deficit, discomfort when sitting(especiallycrosssitting),andashamblinggait.Inolderadultstighthamstrings can lead to reduced stride length and walking speed,which in turncancauseproblemswithdynamicbalance.6Many treatment techniques are availablefor muscle tightness. To name a few are relaxation training, pilates, stretching,sub occipital inhibitionand other medical interventions. A new dimension in the management of pain and restricted mobility is matrix rhythm therapy. Studies have shown that it has an effective role in significant reduction of shoulderpain andROM in non-traumatic restrictedmovementsof the shoulder. On the other hand, commonly usedstretching techniques have also known to be effectiveinimprovingmusclelength.However,veryfewstudieshaveexploredtheeffectsofmatrixrhythmtherapyasanewclinicalmodalityonflexibility.Toseetheresponseof tight musculature to matrix therapy is a current need. Therefore,tofulfillthisdemandthepresentstudyaimedtocompare theeffectofmatrix rhythm therapyversuspassivestretchingonhamstringflexibility.


This study was conducted among females aged between 18 to 25 years with a sample size of 30.Prior

to participation, all participants were explained aboutthe study and an informed consent was received from them. Ethical approval was obtained from the committee incharges. Participants were screened based on the inclusion and exclusion criteria. Inclusioncriteria were:Normal healthy female individuals aged between 18 to 25 years,knee extension loss of morethan 20 degrees due to hamstring tightness in bi lateral extremities,healthy female individuals with goodquadriceps strength(MMT grade 4 or 5). Exclusioncriteria were: Any previous trauma within the last 6 months,anysurgeryaroundthehiporknee,anyhistoryofLBPsincethelast2months,professionalsportplayers.Included participants were screened using a validatedself-designed questionnaire. Eligible participants werethen randomized by lottery method.

METHOD

Pre and post measurements were taken by active knee extension test after each session of treatment and under the same testing procedures and environmental conditions. Both the groups received an interventionwithinadurationof3weeks. Ineachweek3sessionsof matrix therapy or passive stretching were given in the respective groups on alternate days. Before eachmaneuver inboth thegroups,moistheatwasgiven for10 minutes over the hamstrings to relax the area. Ingroup A matrix therapy was given for a total of nine sessions. Each session of matrix therapy was given for a duration of 30 minutes on alternate days.7Here the patient was in a prone position and any dry substance like powder which reduces friction was applied to the area before treatment. The head of the machine was moved in all directions rhythmically from proximal to distal covering the main areas of tightness or spasm with the vibrations directed from the tail towards the base of the head.Scooping action of the head from the tail towards the base was maintained with every stroke. Pressurewasappliedaccordingtopatient’stolerance,italsodependedupontheamountoffatpresent.Similarly,ingroupBpassive stretchingwasgiven for totalninesessions. Here the patient was in a supine position with hands over the abdomen. The extremity to be stretched was supported on the therapist’s armor shoulder.Theopposite extremity was extended and stabilized at the distal aspect of the thigh.With hip-kneeflexion at 90degrees, the knee was passively extended as far aspossible. The terminal position of knee extension was


defined as the point at which the subject complainedof a feeling of discomfort or tightness in the hamstring muscles or the therapist perceived resistance to stretch. This was done with a duration of 30 second hold. For everysessiontwosetsofthreerepetitions(total6)wasgiven in each leg.3

STATISTICAL ANALYSIS

Data was analyzed using WINPEPI software forwindowsversion4:2001.ShapiroWilktestwasusedtoanalyzenormalityofbaselinevalues.(NormalityvalueforGroupAwas0.36andforGroupBwas0.32).

Pre values of both the groups was analyzed by Independent T-test which showed that groups werecomparable i.e. there was no significant statisticaldifference.PvalueforrightextremityofGroupA&Bwas0.067andpvalueforleftextremityofGroupA&Bwas0.875.Pairedt-testwasusedtoanalyzewithingroupdifference (Pre&Post)whereas the independent t-testwasusedtoanalyzebetweengroupdifference(GroupA&GroupB).ThelevelofsignificancewassetatP<0.05(-level at power of 80%).

RESULTS

Results showed an increase in the post mean in all the subjects for bi lateral extremities within Group A and this differencewas found to be statistically significant(p<0.001)(refertable3).IncreaseinthepostmeanwasalsoseenwithinGroupBinallthesubjectsforbilateralextremities and this difference was also found to be

statistically significant (p<0.001) (refer table 4). Post-interventionalmean values betweenGroupA (matrix)and Group B (passive stretching) showed significantimprovement in ROM,which was more in the matrixgroup as compared to the stretching group.(p<0.001)(refer tables1and2).TheMeanageforGroupAwas21.8yrsandforGroupBwas22.8yrs.

Figure 1: Matrix Therapy

Table 1: Between Group A and B comparison of knee extension ranges for right extremity pre and post intervention (Independent t-test)

Group A Group B N Std Dev t value/p valueRight Extremity (ROMindegrees)

Pre Mean Post Mean Pre Mean Post Mean 15 6.681(GroupA)3(GroupB)

t=3.209p=0.00336.46° 58.2° 31.06° 46.4°

Table 2: Between Group A and B comparison for left extremity pre and post intervention (Independent t-test)

Group A Group B N Std Dev t value/p valueLeftExtremity

(ROMindegrees)Pre Mean Post Mean Pre Mean Post Mean 15 8.518(GroupA)

3.739(GroupB)t=4.032p<0.00135.73° 58.4° 36.13° 49.66°

Table 3: Mean difference of pre to post active knee extension ranges of right and left extremities within Group A (Paired t test)

Right (Degree) Left( Degree) N Std Dev t value/p valueGroup A

(Meandifferenceof pre to post)

21.73° 22.46° 15RIGHT LEFT RIGHT LEFT

6.681 8.958 t=-12.361p<0.001

t=-9.204p<0.001


Table 4: Mean difference of pre to post active knee extension ranges of right and left extremities within Group B (Paired t test)

Right (Degree) Left (Degree) N Std Dev t value/p valueGroupB

(Meandifferenceofpretopost)

15° 13.53° 15RIGHT LEFT RIGHT LEFT

3.266 5.11 t=-21.349p<0.001

t=-12.386p<0.001

DISCUSSION

This study was conducted with an aim to compare the effect of matrix rhythm therapy versus passivestretching on hamstring flexibility in normal healthyfemale individuals. Thirty females were recruited in the study who received either matrix rhythm therapy or passive stretching over nine sessions for a period of three weeks.

Group A showed significant result in improvinghamstringflexibility.Postinterventionanalysisshoweda mean difference of 21.73 and 22.46 degrees onthe right and left extremities respectively(p<0.001).Physiologicallystating,thesechangescanbeattributedto the re-synchronization of cells into their normaloscillatory rhythm.7According to the Principle of Matrix,ahealthymusculaturealwayssynchronizesitselfbetweenafrequencyof8-12Hzwhichhasbeenfoundwith the help of piezo electric sensors. This internal rhythm of cells concerns the partial pressure of oxygen in cell medium which is decisive for ATP regeneration andenergybalanceofthecell.Itisimportanttoachievea correct acid- base ratio for the proper functioningof cells which depends upon the metabolism of the cell(supply of oxygen) and upon the ion gradients ofthe semi permeable membrane.7 Degradation of cell logistics causes theECMfluid tobecomemoreacidicleadingtodeficiencyofATPcausingdifficultyinmusclere-polarization which is the actual energy consumingprocess. Thereby, hindering ability of the muscle tostretch.AstudybyDhamanePetalshowedsignificantimprovements in pain and ROM in degenerative posttraumatic conditionsof theknee. In the samecontext,Dr.Randoll, the inventor ofmatrix has stated that themodel of energy crisis is the most plausible physiological explanation for myofascial and myotendinous pain syndromes.8 Mechanically,the Matrix Mobil is a rodwith a spiral shaped vibration head and an oscillating electromagnetic field induced by permanent magnetsmounted in it. Therapeutic application of matrix generates a rhythmic microstretching of the tissues along

thepropagationofwavesinthecells.Thishasaneffecton the acceleration or stretch sensitive muscle spindle apparatus and pressure sensitive Golgi tendon apparatus.

Passive stretching on the other hand also showed a significant improvement on hamstring flexibility. Inthe analysis,mean difference showed an improvementof 15 and 13.3 degree on the right and left extremities respectively(p<0.001).9Here the muscle’s response totensile force is rate and time dependent.3The changes due to stretching can be attributed to this viscoelastic property that occurs with creep in the elastic region. Passive stretch exerts both longitudinal and lateral force transduction,wherein there is tissue re-modelling andplasticdeformationofthefibresallowingthefilamentstoslideapartandthesarcomerestorelaxandlengthen.Ifamuscle is held in a lengthened position for a long period oftime,itadaptsbyincreasingthenumberofsarcomeresin series causing greater functional overlap of actin and myosin leading to a permanent /plastic form of the muscle provided newly gained length is maintained on a regular basis.3ProskeandMorganstudiedviscoelasticpropertiesofmusclesandsaidthatthegaininROMmayalsobeduetoadecreasein inter-filamentspacingandincreasedmyofilamentcalciumsensitivityleadingtotheformationofnewerandstrongercross-bridges.10

Holding stretches for 20 to 30 seconds is a good standard because most of the stress relaxation in a passive stretchoccursinthefirst20seconds.11Thestretchreflexismorelikelytobeactivatedduringaquickstretchtothe muscle.3

Knudson D studied the biomechanical effects ofstretching and stated that according to sensory theory ROMimprovementsmayalsobeduetoanincreaseinstretch and pain tolerance found with static stretching rather than actual mechanical increase in the muscle length11. However, Duong et al stated that viscousdeformation is only transient and dissipates shortly after the removal of the stretch12.So passive stretching is one of the techniques tomaintain flexibility and length of


themuscletissue.Withingroupcomparisonshowedthatboththetreatmentmethodsweresignificantinimprovinghamstringflexibilitybutmatrixtherapyshowedhighlyappreciable results both statistically and clinically. To explainthesame,elasticityandplasticityofmusclearedirectly connected with oscillations of the individual cell. Energy transmission at 8-12 Hz allows ECMclearance. Release of cross links between myosin and actin depends on the physiochemical quality ofECM.Matrix therapy releases tightness by normalization oftension of the musculature and target relaxation of the local muscular spasm.7

Similarly, this experimental study showed betterresultswithmatrixtherapyonhamstringflexibilitywhencompared with passive stretching. This electrotherapeutic modality will help in early rehabilitation of athletes and in individuals having hamstring tightness stating that it canbeefficientlyaddressedinourtreatmentprotocols.Passive stretching being a manual technique requiresgoodamountofstabilizationandexternalforce,itthusdemandsmore therapist effort andmaynot be able toservethepurposeofimprovingflexibilityincaseslikeLBPorlowerextremityinjuries/traumawherestretchingmay aggravate the acute condition13.Matrixontheotherhandistherapistfriendlyandrequireslessmanualeffortwhich adds more to its benefit. Matrix therapy hasnegligible contraindications,whereas passive stretchinghas many limitations when it comes to certain medical conditions. Passive stretching works on muscle tendon unitandreflexzonestoobtainflexibilityofthemusclefibers,whereasmatrixrhythmtherapyworksontheentirebelly of the muscle across its whole cross sectional area. Hence,toobtaincredibleeffectsitisclearlyessentialtoexploit the natural vibrations of the body which can be donebyMatrixRhythmTherapy.

Howeverlongtermeffectisamatterofconcernandneeds to be evaluated. Small sample size and follow up is crucial and needs to be considered.

LIMITATION

There was no follow up done for this study. Hence thelongtermeffectsofROMgainswithmatrixrhythmtherapy or passive stretching is not clear. Future double blinded studies can be conducted with a larger computer generated sample size.

CONCLUSION

The present study accepts the alternate hypothesis. Matrixrhythmtherapyhasanupperhandinimprovinghamstring flexibility when compared to passivestretching.

Clinical Significance: This study is therefore useful for the faster rehabilitation of muscle tightness and musculoskeletal imbalances.

Conflict of Interest:Thereisnoconflictofinterest.


Ethical Clearance: Dr D Y Patil Ethics Committee

REFERENCES

1.Abbas DM, Sultana B. Efficacy of ActiveStretchinginimprovingHamstringFlexibility.IntJofPhysiotherRes.2014;2(5):725-32

2.Minarro LA, Muyor J M, Belmonte F et al.Acute effects of Hamstring Stretching onSagittalSpinalcurvaturesandPelvicTilt.JHumKinet.2012;31(10):69-78

3.Kisner C, Colby LA. Therapeutic Exercise. 6thedition. New Delhi: Jaypee Brothers MedicalPublishers(P)Ltd;2013.76-81

4.Thakur D,Rose S.A study to find correlationbetween the right and left hamstring length in both genderstofindprevalenceofhamstringtightnessamongcollegestudents.NitteUniversityJournalofHealthSciences.2016December;6(4):46-47

5.JonathanM,Labovitz,JennyYu,ChulKim.Roleof Hamstring Tightness in Plantar Fascitis. SAGE Journals.2011March2;4(3):141-142

6.Jozwiak M, Peitrzak S, Franciszek, Tobjasz.The Epidemiology and Clinical Manifestaionsof Hamstring Muscle and Plantar Foot FlexorShortening.JDevMedChildNeurol.1997.39:481-483

7.Ulrich G. Randoll. The Matrix Concept-Fundamentals of Matrix Rhythm Therapy.2014;1:141-173

8.Ulrich G. Randoll. Matrix RhythmTherapy.2014;1:2


9.Ulrich G. Randoll, Friedrich F. Hennig. Cellbiologicalbasis,TheoryandPractice2009;1:2

10.Rani B, Mohanty PP. A Comparison BetweenTwoActiveStretchingTechniquesonHamstringsFlexibility in Asymptomatic Individuals.Journal Of Dental and Medical Sciences.2015April;14(4):12-16

11.Knudson D. The Biomechanics of Stretching.JESP.2006;2:3-12

12.HolzmannC,Weppler,MagnussonP. IncreasingMuscle Extensibility- A Matter of IncreasingLengthorModifyingSensation.JAmPhysTher Assoc.2010;90:438-449

13.Mutungi G, Ranatunga KW. Do Cross-BridgesContribute to the Tension During Stretch of PassiveMuscle-AResponse. JMuscleRes Cell Motil.2000February:21:301-302

Effect of Core Stabilisation Exercises in Postnatal Women with Lumbo-Pelvic Instability

Ashwini A Kale1, Nawaj M Pathan2

1PhD Scholar & Associate Prof., 2Assistant Prof., MGM’s Institute of Physiotherapy,Aurangabad

ABSTRACT

Background: The postnatal period has been described as the most critical; yet neglected phase in the motherhood.Lumbo-pelvic instabilityhasbeenattributedasoneofmajorcauseforpost-partumlumbarpainresultingduetocoremuscleweakness,beingtheusualprobleminpostnatalperiod.Hence,thisstudywasaimedtodiagnosethelumbopelvicinstability,andtofindouttheeffectofcoremusclesstabilizationexercisesonpostpartumlowbackpainduetolumbo-pelvicinstability.

Method: 30postpartum females with vaginal deliveryin the age group of 20-40 years, suffering fromlumbo-pelvicinstabilitywithlowbackpainwererecruited.Initially,thelumbo-pelvicinstabilitywasruledoutbyseriesofclinicaltest.Later,thesubjectswereprovidedcorestabilizationexerciseswithweekwiseprogressiontill4weeks.Theoutcomeofinterestincludednumericalpainratingscale(NPRS),andcoremusclestrengthviapressurebiofeedbackunit,whichwererecordedatweek1andweek4.

Results: Attheendof4weeks,therewassignificantimprovementnotedinpostpartumlumbopelvicpainand core muscle strength after the application of core stabilization exercises to postpartum female individuals atp<0.05,onpairedt-test

Conclusion: Core stabilization exercises have a profound effect in restoring lumbopelvic instability, asitreduceslumbopelvicpain,andimprovesthecoremusclestrengthinpostpartumfemaleindividuals.

Keywords: Core stability, Lumbopelvic instability, Postpartum low back pain, Pressure Biofeedback

Corresponding Author:AshwiniAKaleAssoProf.,MGM’sInstituteofPhysiotherapy,N-6Cidco,AurangabadEmail: [email protected]

INTRODUCTION

Postnatal period has been defined as the periodbeginning immediately after the birth of child and extendingfor about six to sixteen weeks.1The WorldHealth Organization (WHO) describes the postnatalperiod as the most critical yet neglected phase in the lives of the mothers and babies.2

Post partum pain occurs due to lumbo-pelvicinstability, isdefinedas the inabilityof the supportingstructures of the trunk to maintain the optimum position of the spine and the pelvic girdle.3

The Core stability of the trunk is provided by a combination of active, passive and neutral control.Instabilityariseswhenoneormoreofthesecomponentsare not functioning appropriately.3

The mechanisms of the deep muscles and stability are controversial but transverse abdominis may act like a canisterwiththediaphragmandpelvicfloormuscles.Thisco-contraction increases the intra abdominal pressure,which creates an extension movement at the spine and has beenhypothesizedasincreasingstiffnessinparticularviaconnectionswiththethoraco–lumbarfascia.4

Out of 70 % of Postpartum LBP, approximately10%ofthesewomencontinuetoexperiencesignificantlumbo-pelvic pain and dysfunction a year and a halfafterdelivery,whichcanbecomechronic.5

The release of oestrogen, relaxin and progesteronehormones cause global relaxation of the muscles and the ligaments. Postpartum women have lax tissues and hyper mobilespinalsegments,increasingsusceptibilitytopain.6

DOI Number: 10.5958/0973-5674.2019.00038.8


Core muscles are primarily responsible for the posture and stability and providing strength during dynamic movements..7Since the deep muscles system in the lumbar spine and pelvic region is directly responsible forstabilizingthevertebralsegmentsandsacroiliacjoint,strengthening of these muscles may help in restoring the lumbo pelvic instability of postpartum females.8.

Hence, the purpose of this study was to find outthe effect of core muscles stabilization exercises onpostpartumlowbackpainduetolumbo-pelvicinstability.

METHOD

AQuasiexperimentalstudywasconductedbetweenAugust2017andAugust2018inDepartmentofOBGY,MGM Hospital, Aurangabad, Maharashtra, India.Subjects were referred by their healthcare providers as well as recruited via advertisements in local newspapers and health magazines. Individuals were included iftheywerepostnatalwomenwithlowbackpain,havingabnormal posture, undergone vaginal delivery, withinagegroup20to40years,andwomenafterdeliverytill3 months.Exclusion criteria included any spinal surgery within 6 months, women having any musculoskeletalproblems like spondylitis, PIVD, etc, Traumatichistoryofspinalfractures,Spinalfracturesresultinginneurologicaldefects,Pregnantwomen,Belowageof20,andSIjointinvolvement.

Followingscreening for inclusion,writtenconsentwas taken from women participated in the study and surveywasproceededfirstofallbyaclearexplanationabout,questions,data,assessmentandinstrumentsused.Sample was chosen according to inclusion exclusion criteria and also answers were given by the women and scoring was done which were showing any prevalence of instability and low back pain.

To assess the lumbo-pelvic instability, proneinstabilitytestwasdone.ToisolateSIjointApproximationtest,Gappingtest,SacroiliacrockingtestandFABERStest were performed.

1. Prone instability test: The examiner applies posterior to anterior pressure over the spinous process of lumbar spine. Then the prone lying patient lifts the leg off the floor and posterioranterior pressure is applied again on the lumbar spine while the trunk musculature is contracted. The test is considered positive if pain is present

in the resting position but subsides in second position suggesting lumbo pelvic instability.18

2. Approximation(Transverse Posterior Stress)test:Withpatientsidelying,theexaminershandisplacedovertheupperpartoftheiliaccrest,pressingtowards thefloor.Themovement causes forwardpressure on the sacrum. An increased feeling of pressureintheSIjointindicateapossibleSIlesionand/orposteriorSIligament.15,16

3. Gapping (Transverse Anterior Stress or Distraction Provocation) test: The examiner applies crossed arm pressure to ASIS. Theexaminer pushes down and out with the arms with patient in side lying. The test is positive only if unilateralglutealorposteriorlegpainisproduced,indicatingasprainofanteriorSIligaments.15,16

4. Sacroiliac rocking (Knee to Shoulder) test: With patient in supine, the examiner flexes thepatient knee and hip fully and then adducts the hip. TheSIjointisrockedbyflexionandadductionofthepatient’ship.Pain in theSI joint indicatesapositive test.15,17

5. FABER (Patricks test): The examiner places the supine patients test leg so that foot of the test leg is on the top of the knee of opposite leg. The examiner then slowly lowers the knee of the test leg towards the examining table. A positive test is indicatedbythetest leg’skneeremainingabovethe opposite straight leg.18

Outcome Measures: Outcomemeasuresofcoremusclestrength via pressure biofeedback unit and pain status using Numerical pain rating scale was recorded at week 1 and week 4.

A. Biofeedback: Pressure biofeedback is a tool designed to facilitate muscle re-educationby detecting movement of the lumbar spine associated with a deep abdominal contraction in relationtoanair-filledreservoir.

Subjects were positioned in a prone lying for all measurements and practice trials. Subjects were givenstandardinstructions(“Takeabreathinand,asyouexhale,gentlydrawyournavelintowardyourspine”)toperformtheADIM.9,12,14. The cue todrawin“gently”isusedtolimitoveraggressiveforce generation or any need to modify pelvic or


spinal position, as theTrA contraction does notrequirepelvicorspinalpositionchange.9,10,13.

Inthisstudy,subjectswereaskedtomaintaintheADIM contraction for 10 seconds. Participantswere allowed 5 practice repetitions with verbal and tactile feedback from the examiner to correct errors such as breath holding, pelvic tilt, orbracing.11,14.

The subjects were not allowed to see the pressure gauge.Following5practicetrials,subjectsrestedfor 2 minutes. This allowed the participant to contract and exhale. And all readings were recorded during normal breathing at the end of expiration.

Fig. 1: Pressure Biofeedback Unit

B. NPRS: The NPRS is a segmented numeric version of the visual analog scale (VAS) inwhich a respondent selects a whole number (0–10 integers) thatbest reflects the intensityof his/her pain. The 11-point numeric scaleranges from‘0’ representingonepainextreme(e.g. “no pain”) to ‘10’ representing the otherpain extreme (e.g. “pain as bad as you canimagine”or“worstpainimaginable”).

Treatment: After the assessment of patient the core stabilizing exercises were prescribed. Week wiseprogressionwassetintheexerciseprotocolfromWeek1-Week4.Theexercisesareasfollows.

Week 1:

1. Static back: A roll of towel was pressed against the back and the position was held for 10 secs and then released.

2. Static gluteus:Theglutswerepressedinside,andhold for 10 secs and then released.

3. Abdominal bracing: Brace your abdomen bycontracting your entire abdomen. From here perform different exercises such as raising yourarms and then raising your legs.

Week 2:

1. Pelvic bridging: In crook lying, engage yourgluts and core lift your hips towards the ceiling. Hold the position for 10 secs and then release.

2. Yoga boat position:Sitonthefloorwiththekneesbent.Bracetheabdomen,slightlyleanyourtorsobackwhileliftingyourfeetoffthefloor.Liftuntilyourshinsareparalleltothefloor,backisstraightandhipsareflexedto90degrees.Extendyourarmsforward to a comfortable position to help maintain your balance. Hold the position for 10 secs.

3. Crunches: In crook lying, with hands behindhead,askthepatienttolift thetorso.Repeattheprocedure for 10 times.

Week 3:

1. Single leg pelvic bridging:Incrooklying,engageyour gluts and core lift the hips towards celling keeping one leg straight. Hold the position for 10 secs and then release.

2. Planks:Withelbowbelowshoulders,extendthelegsbehindpressingintotheheels.Keepthecoretight,pullinginyourabs,whilemakingsurethebody stays in straight line from head to heel. Hold for 30 secs and then release.

3. SLR with hold at 30 and 45 degrees: Ask the supine patient to raise the leg upto 45 degrees and hold for 10 secs. Then raise the leg upto 30 degrees then hold for 10 secs.

Week 4:

1. Side planks:Beginonyoursidewithyourweightonrightelbowundertherightshoulder.Withtheknees slightly bent lift the hips off the ground.Hold for 30 secs and then release.

2. Bird dog:Beginonyourhandsandknees,withyour spine in straight line from head to toe and core engaged.Now, lift your left arm and rightlegoffthegroundsimultaneously,extendingyourright leg behind you and left arm in front of you. Holdfor5sec,returntoyourstartingpositionandrepeatfor10to15reps,alternatingsides.


DATA ANALYSIS

Data analysis was performedwith SPSS version 22.0. Themean differences with SD for outcomemeasuresoftemporalanddistancevariableswerecalculatedfortimeperiodsofweek1–4week.Studentt-testwasusedtodetermineifsignificantdifferences(p<0.05)existedwithingroupsforeachoutcomemeasureateachfollowupperiod.

Table 1: Pain and Core muscle strength changes at Week-1 and Week-4

Outcome Measure

Wk-1 Wk-4 t-value t-value 95 % CI p-value p-valueInferenceMean

± SDMean ±

SD Wk-1 Wk- 4 Wk-1 Wk-4 Wk-1 Wk-4

Pain intensity

6.333 ± 0.660

3.0666 ± 0.6396 52.488 26.258

(U)96.5801 (U)3.3055 0.003 0.001Significant

(L)6.0866 (L)2.8278 0.003 0.001BiofeedBack

70.733± 0.944

63.96 ± 1.188 410.212 298.663

(U)71.086 (U)64.3711 0.003 0.001Significance

(L)70.3807 (L)963.4955 0.003 0.001

Graph 1: Effect of Core stabilization excercises pain and biofeedback in 1st and 4 th week

RESULTS

Themeanageofthefemaleswas26.9±3.77.Themean postpartum duration after vaginal delivery of the subjectwas3.46±1.67.

There was significant reduction in postpartumlow back pain after application of core stabilization exercisefor4weeks.Atweek1,themeanNPRSscorewas6.33±0.66,whichreducedsignificantlyto3.06±0.63.There was also significant improvement in coremuscle strength on pressure biofeedback for 4 weeks at

p<0.001.Atweek1,themeanscorewas70.73±0.94,which improved to 63.96 ± 1.18.

WithingroupsignificancedifferenceswasnotedforNPRSandPressureBiofeedbackScoreatp<0.001,onpairedt-testatWeek-1andWeek-4,asshownintable1,and Graph 1

DISCUSSION

In the present study, 30 postpartum women werescreened with a mean age of 20 to 40 years were


randomlyallocatedshowinghigherincidenceofLPP.Inthis study marked improvement in clinical parameters were found in both pressure biofeedback reading and NPRS score. After 4 weeks it was observed that core stability exercises were effective in reducing lumbopelvic pain.

Also positive correlation was found between age,BMI, postpartum duration and core muscle strengthwith NPRS score that suggested LPP associated withpostpartumperiodwas also affected by age,BMI andpostpartum duration. A study conducted by Annelie Gutke, Mary Lundberg and Birgitta oberg which isbased on impact of postpartumLPP on pain intensityalso found similar results.

In the present study there was significantimprovement regarding core muscle strength assessed by biofeedback reading and manual muscle testing when compared to pre therapy values in patients receiving 4weeks of therapy. The finding was supported by arandomisedcontrolledtrialbyPeiChingTseng,ShubyPuthussery and Meei Ling Gau on effectiveness ofexerciseprogramonLPPamongpostnatalwomen.Theyconcluded that physical therapy including postnatal exercises tend to be one of the treatment approach used toreduceLPPinpostnatalwomen.

In our study transversus abdominis recruitmentwas done through core muscle stabilizing exercises to increase the strength of TrA and thereby reducing the postpartumLPP.SimilarstudywasconductedbyMonicaUnsgaardTendel,OttarVasseljenonexerciseforwomenwithpelvicandLBPafterpregnancy,inwhichtailoredexercise therapy for activation of TrA by activation of deep muscle strengthening and stretching exercise was performed.

The present study concludes that postpartum women when treated with core muscle stabilizing exercises resultedwithsignificantimprovementinstrengthofcoremuscle aswell as reduction in LPP.The finding goesin favor of result obtained by recently conducted study in 2014 in which Siv Morkvedconcludedthat womenwithLPPafterdeliveryreportedreducedpainafteranyindividually adjusted exercise intervention.

The present study has several limitations. The study wasconductedonsmallnumberofsubjects,whichlimitsthe generalized ability of the findings to postpartum

population. Only females with vaginal delivery wererecruited,hence,theimplementationoftheseresultsoncaesariansectioninducedlowbackpainisquestionable.Core muscle recruitment patterns were not investigated byus,whichmaybe reason formissoutofanyothercauseoflumbo-pelvicinstability.

CONCLUSION

Core stabilization exercises appear a effectivemeans of intervention in reducing postpartum low back pain and increasing the strength in postnatal women with lumbo-pelvic instability. Further research shouldbe conducted on core muscle recruitment patterns in postpartumfemaleswithcaesariansection,usingEMGbiofeedback.

Conflict of Interest: None

Ethical Clearance: Ethical clearance was obtained from institutional ethic committee ofMGM’s InstituteofPhysiotherapy,Aurangabad,Maharashtra,India


REFERENCES

1.Core stability exercise principles.AkuthotaVenu,ferreiro Andrea, Moore Tamora. Current sportsmedicinereportsJanuary/February2008,volume7

2.Corrigan, Catherine P et al. “Social Support,Postpartum Depression, and ProfessionalAssistance: A Survey of Mothers in theMidwestern United States” Journal of perinataleducation vol. 24,1(2015):48-60.

3.Massimo Allegri, Silvana Montella, FabianaSalici, Adriana Valente, Maurizio Marchesini,ChristianCompagnone,MarcoBaciarello,MariaElenaManferdini,GuidoFanelli.Mechanismsoflow back pain: a guide for diagnosis andtherapy. F1000Research2016,5(F1000FacultyRev):1530Lastupdated:11OCT2016

4.DelittoA,ErhandRE,BowlingRW,Atreatmentbased classification approach to low backsyndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995 Jun;75(6):470-85

5.Physiotherapy Torentto, Rehab science blog.LindsayDavey,May24,2017


6.CrysRtalES,SamanthaMB,RubinowDR.TheRole of Reproductive Hormones in Postpartum Depression.CNSSpectr.2015February ;20(1):48–59.

7.Fitzgerald C M, Segal N A. MusculoskeletalHealth in Pregnancy and Postpartum. Springer InternationalPublishingSwitzerland2015.

8.VleemingA,M.DSchuenke,MasiA.T,CarreiroJ.E,DanneelsLandWillardF.H.The sacroiliacjoint: an overview of its anatomy, function andpotential clinical implications. J. Anat. (2012)221,pp537—567

9.Hides J, Wilson S, Stanton W, et al. AnMRI investigation into the function ofthe transversus abdominis muscle during “drawing-in” of the abdominal wall. Spine (PhilaPa1976).2006;31:E175E178.http://dx.doi.org/10.1097/01.brs.0000202740.86338.df.

10.Hodges PW. Is there a role for transversesabdominis in lumbo-pelvic stability? Man Ther. 1999;4:74-86. http://dx.doi.org/10.1054/math.1999.0169.

11.KieselKB,UnderwoodFB,MattacolaCG,NitzAJ, Malone TR. A comparison of select trunkmuscle thickness change between subjects with lowbackpain classified in the treatment- basedclassificationsystemandasymptomaticcontrols.JOrthopSportsPhysTher.2007:37:596607. http://dx.doi.org/10.2519/jospt.2007.2574.

12.Koppenhaver SL, Hebert JJ, Parent EC, FritzJM.Rehabilitativeultrasound imaging isavalidmeasure of trunk muscle size and activation duringmostisometricsub-maximalcontractions:a systematic review. Aust J Physiother. 2009;55:153-169.

13.Richardson C, Hodges P, Hides J. Therapeutic Exercise for Lumbopelvic Stabilization: A Motor Control Approach for the Treatment and Prevention of Low Back Pain.2nded.Edinburgh,UK:ChurchillLivingstone;2004..

14.Teyhen DS, Rieger JL, Westrick RB, MillerAC, Molloy JM, Childs JD. Changes in deepabdominal muscle thickness during common trunk-strengthening exercises using ultrasoundimaging. J Orthop Sports PhysTher.2008;38:596-605.http://dx.doi.org/10.2519/jospt.2008.2897.

15.Lee D:The pelvic girdle, ed 2, Edinburg, 1999,ChurchillLivingstone.

16.Laslett M, Aprill CN, Macdonald B, et al:DiagnosisofSIjointpain:Validityofindividualprovocationtestsandcompositesoftests.ManualTherapy10:207-218,2005.

17.Portelfield JA, Derosa C, Mechanical lowback pain, perspectives in functional anatomy,Philadelphia1991,WBSaunders.

18.Evans RC, Illustrated essentials in orthopedicphysicalassessment,St.Louis,1994,CVMosby.

A Comparative Study on Mirror Therapy and Motor Imagery on Improving Gait in Post Stroke Subjects

Choppala Mary Margrett1, P. R. Sri Thulasi2, P. Kiran Prakash2, Patchava Apparao3, Ganapathi Swamy Chintada4, Brundha Tanavarapu1

1Post Graduate Student, 2Asst Professor Physiotherapy, 3Principle, Department of Physiotherapy, Swatantra Institute of Physiotherapy and Rehabilitation, 4Assistant Professor of statistics, Department of Community

Medicine, GSL Medical College, Rajanagaram, NTR University of Health Sciences, Andhra Pradesh, India

ABSTRACT

Objective:Tocompare theeffectsofMirror therapyandMotor imageryand todeterminewhich is theeffectiveapproachonimprovinggaitperformanceinpost-strokesubjects

Method:A totalof71 subjectswere taken,where9patientsdosenotmet inclusioncriteria.A total62patientswere includedwith31 ineach into twogroupsGROUP-A(Mirror therapy),GROUP-B(Motorimagery).57subjectscompletedtheintervention,Boththegroupsreceived45minutesoftreatmentwhichinclude15+30minutes,wheretheGROUP-A,performstheexercisesinfrontoftheMirrorandconventionaltherapyGROUP-Bwhich include the mental representation of movement without any body movement. Theseinterventionsareheldfor6weeks,5daysaweekfor45minutes.theassessmentwastakenatbaselinei.e.priortheintervention(pre-test)andattheendofprotocoli.e.theposttestmeasuresweretakenusinggaitparameters for gait function. 10meters walk test for walking velocity as the outcome measures.

Results:Statisticalanalysisofthedatarevealedthatinbetweenthegroupcomparisonshowednosignificantdifference,boththegroupshasshownimprovementingaitinpoststrokesubjects.

Conclusion: This study concluded that there is no difference in Mirror Therapy and Motor Imageryimprovinggaitinpoststrokesubjects,andtheyareequallyeffective.

Keywords: Stroke, Mirror Therapy, Motor Imagery, Gait Parameters-(Step Length, Stride Length, Cadence), 10 Meter Walk Test.

Corresponding Author:ChoppalaMaryMargrettPostGraduateStudent,SwatantraInstituteofPhysiotherapyandRehabilitation,GSLMedicalCollege,Rajanagaram,NTRUniversityofHealthSciences,AndhraPradesh,IndiaEmail: [email protected]

INTRODUCTION

Stroke or cerebral vascular accident is a clinical syndrome consisting of rapidly developing clinical signs of focal disturbance function lasting more than 24hrs or leading to death with no apparent cause other than vascular origin. Stroke is the second leading cause of death

world wide1-4,whichmayincreaseinfuture,asaresultdemographic transitions in population. The formation of ischemic cascade around the area effected in brainleads to neuronal death along with an irreversible loss of neural function 5.InIndia1.2%oftotaldeathsoccurdueto stroke.6TheIncidenceofstrokerangedfrom105to152/100,000personsperyear,andaprevalenceofstrokeranged from44.29 to559/100,000persons indifferentparts of the country during the past decade and by 2030 it is expected to increase up to 98/10000 7,8.After stroke Motorimpairmentfrequentlyoccurs.Nearly80%ofthestrokesurvivorswilldevelopdifficultyinwalkingwhichwill regain with rehabilitaton9.Lowerextremitymotorfunction after stroke is often impaired causing restriction in functional mobility10,11. Walking ability is the mostcommon reported limitation of stroke. Proprioceptive inputs can adjust the timing and degree of activity of

DOI Number: 10.5958/0973-5674.2019.00039.X


the muscle to the speed of locomotion. Gait is complex behavior involving coordinated muscle activation and balance control as activation and balance controls as well as adaptation of the movement accordingly to the environment.Itisincreasinglyrecognizedthatgaitalsorequireshigherlevelcognitivecontrolsuchasattentionand executive functions.Visual attentionwas vital forsuccessful completion of the combined motor and walking risk for stroke surviours12.The ankle is reported to exhibit irregular movements into dorsiflexion instance, reduced dorsiflexion in mid-stance and push-off in stance.13 The swing phase patterns of hip, kneeand ankle motions on the hemiplegic side have been characterizedbylimitedorreducedhipflexion,andanupwardtiltofthehip,alackoforreducedkneeflexionandreduceddorsiflexionorcontinuousankleplantarflexion.Voluntary ankle dorsiflexion in the lower extremity isa standpoint indicating the achievement of selective motor control in stroke patients. Therefore, the mostimportant goal of rehabilitation for hemiplegic patients istoachieveafastandefficientgaitandtorestoretheirnormal gait pattern so that they can smoothly perform activities of daily life.14

Mirror therapy is a relatively new therapeuticintervention which is simple15, inexpensive and mostimportantly patient directed treatment that focuses on moving the unimpaired limb. It was first introducedby Ramachandran and Roger Ramachandran16 to treat phantom limb pain after amputation. This techniqueinvolves performing movements of unimpaired limb whilewatchingitsmirrorreflectionsuperimposedovertheimpairedlimb,thuscreatingavisualillusionofenhancedmovement capability of the impaired limb17. Multipleareas of brain such as occipital lobe frontal dorsal area and corpus collsum are involved during the intervention. Mirrortherapymainlyfocusedonvisualinput18,16.

Differentrehabilitationapproachesareusedforpoststroketreatment.Oneofthemismotorimagery.Motorimagery is initially developed to improve the performance of the athelets19-21 and has been adapted in rehabilitation programme22 for a person with stroke. To support motor recovery23,24Mental practice is the voluntary rehearsalof imagery scenes or tasks 27,28. White and Hardyproposed that imagery is an experience that mimics real experience.Wecanbeawareofseeinganimage,feelingmovements as an image or experiencing an image of smell,tastesorsoundswithoutexperiencingtherealthing29. Recent research demonstrates that motor imagery and

similar processes such as observing a demonstration or watchingavideo,producea selectiveenhancementofneural activity in motor pathways concerned with the simulated action 30..Hypothesis of the study is that the mirror therapywouldbemorebeneficial in improvingthe gait in post stroke subjects.

METHODOLOGY

This was a Prospective Cohort Study, Includingsixty-eightpatients,ofagebetween30-80yearssufferingwith motor impairment of lower limbs with stroke. Subjects who are willing to participate in the study were recruitedaccordingtoInclusioncriteriafromdepartmentofphysiotherapy,neurologydepartment,GSLMedicalCollege and General Hospital, Rajanagaram., AndhraPradesh,India.

All the participants signed the informed consent and the rights of the included participants have been secured. With treatmentdurationof45minutesaday,5daysaweek,for6weeksStudywasheldfor1Year2months.(may -2017 to june - 2018).62 subjectsmet the studycriteria,InclusionCriteria:A scoreof>25pointsintheMini-Mental Scale examination. No musculoskeletaldisordersandoperationsoflowerextremity,Nounilateralneglect or apraxia. Ability to walk >10 meters withsupport,Patientswhohadexperiencedfirsteverstroke.Exclusion Criteria: Recurrentstroke. Hemianopsia,Contractures of lower limb and limited range of motion of lower limb,,Psychological or emotional problems,Auditory and visual problems,.A total of 71 subjectsweretaken,Thesubjectsinthestudywereallocatedintogroupsbysystemicrandomsampling,

Group A(mirror therapy): The subjects in the mirror therapy group received treatment for 45min. Mirror therapy for 15 minutes and 30 minutes forconventional physiotherapy for 5 days a week for 6 weeks.Amirrorboard[40x70cm]wasplacedbetweenthelegsperpendiculartothesubject’smidline,withthenonpareticlegfacingthereflectivesurface.Amirrorwasmounted on a stand tilted towards non paretic side of the body which is to prevent the subject to viewing the paretic limb.Mirrorwasplaced inbetween the limbs.exercises were performed in semi seated position and make the patient to do the following exercises;(1) hipknee and ankle flexion (2) knee extension with ankledorsiflexion(3)kneeextensionwithankledorsiflexioncare should be taken. Conventional physiotherapy


include neurodevelopmental facilitation techniqueswere done with 10 minutes resting period for 30 minutes. Exercise includeFunctional tasks such as sit to stand,step-ups,obstaclecoursewalking,standingbalance,andstrengthening.

Group B(motor imagery): During motor imagery practice participants were seated in a chair with eyes closed.Videos of normal gait movements whichincludeankletoemovements,hipandkneeflexionandextensionwereshown,thensubjectsshouldimaginethenormal gait movements based on visuals showed and the researcher ask the subjects to explain the movement they were imagining. The practice was performed from an internal perspective with both a visual and kinesthetic mode.With 15 minutes session 5 days a week for 6weeks and each session involved initial relaxation1-2minute, a description of the surrounding environmentandforupcomingtask(1-2)minutes,imaginedwalkingfrom external perspective(3-8)minutes, and refocusinginto the room(1minute) exercises were focused onspecific gait improvement and improving speed andsymmetry and completing of certain walking tasks.

Every session started with 2min of relaxation preceding the imaging session. This is followed by a thirty minute of conventional therapy.

FINDINGS

Statistical analysis has done by using SPSS software version20.0andMSExcel–2007datawastabulatedandsubjected to statistical analysis. Descriptive statistical data was presented in the form of mean ± standard deviation and percentages also graphically represented. Student t-testwasperformed tocompare themeansofvariousgroupsofgaitparametersi,e.,steplength,stridelength and cadence and 10 meters walk test.

Boththecomponentsgaitparametersand10meterswalk test for gait has showndifferences in the pre andposttest values. But on comparing the means of bothgroupstherewasnodifference,asthebothinterventionshas improved gait in post stroke subjects. Paired student T testisusedtocheckthemeandifferencewithinthegroups,Andthebetweenthegroupdifferencesarecheckedusingindependent student T test. For all statistical analysis,p<0.05wasconsideredasstaticallysignificant.

Table 1: analysis of Pre-Test and Post-Test means of Step length, Stride length, Cadence and 10-meter walk test between Group-A and Group-B

PAREMETERS GROUP SCORING N MEAN STD.DEVIATION

STD.ERROR P-VALUE

STEPLENGTH

APre-Test

28 8.214 1.833 0.3460.678*

B 29 8.034 1.4011 0.206A

Post-Test28 9.143 2.304 0.435

0.441*B 29 9.517 1.18 0.219

STRIDELENGTH

APre-Test

28 16.06 3.1765 0.60030.463*

B 29 9.517 2.6717 0.4961A

Post-Test28 18.5 2.925 0.5528

0.538*B 29 18.93 2.298 0.4267

CADENCE

APre-Test

28 49.03 8.5872 1.62280..300*

B 29 0.418 0.0881 0.01636A

Post-Test28 54.57 7.269 1.373

0.916*B 29 0.352 9.935 1.844

10METERWALKTEST

APre-Test

28 0.085 0.01621 0.016210.056**

B 29 0.418 0.0881 0.01636A

Post-Test28 0.446 0.10278 0.01942

0.314*B 29 2.352 9.93359 1.84462


DISCUSSION

Aimof the studywas to compare the effectivenessof mirror therapy and motor imagery on improving gait in post stroke subjects. Till date very less studies were conducted on mirror therapy and motor imagery on improving gait. After the results my study accepted null hypothesisastherewasnosignificantdifferencebetweenthe groups. The cortical mechanism of stroke recovery wassameforbothmirrortherapyandmotorimagery,

Toourknowledge,thisisthefirststudytocomparethe mirror therapy and motor imagery. A total of 71subjects were included in the study with 5 dropouts. we have taken gait parameterswhich include step length,stride length and cadence. And walking speed was assessed with 10meter walk test as outcomes.

Altuschuler et al in his study hypothesized that mirror therapy will provide visual input of a normal movementoftheeffectedarminthestrokepatientswhichis thought to compensate the decrease proprioceptive inputs.During theactionobservation, imaginationandaction execution the bimodal visuomotor neurons will be active. During the therapy sessions all the subjects performedvoluntarilyankledorsiflexion,hipandkneeflexion and extension movements on nonparetic side.Repeated ankle movements are known to facilitate he brain reorganization as they are the key points to deal with gait abnormality.

Mirrorneuronsarepresentinthefrontalandparietallobes which are important for motor commands and the scientist believed that these neurons fires to guidea sequence of muscle twitch to produce any skilledmovement. Mirror neurons are bimodal visuomotorneurons that are active during action observation mental status and action execution. Subset of these mirror neurons also become active when the person nearly watches another individual performed the same movement. Holden et all reported that the amount of physical assistance needed for functional ambulation was significantly related to measures of step lengthstride length and cadence.

Confaloliera et al stated that the sensory motor and premotorareaarestimulatedduringmotorimagery,evenin the stroke subjects with poor imagination capacity 23.Manypreviousstudiesonmotor imageryforstrokepopulationhavereportedpositiveeffectongaitinchronicstroke subjects on using motor imagery training program

for gait rehabilitation. Both the persons walking andimagining the walking patterns are functionally similar inbrainimaginingstudies.Inthefurtherliteratureitwasstated that therewill be increase inmotor excitability,motor imagery stimulates, cortical circuitry with thepreparation and execution of a task32.Motorimageryre-educates by reinforcement at the cortical level any by initiating neuromotor pathways necessary for walking performance.

CONCLUSION

This study concluded that both mirror therapy and motorimageryareequallyeffective.Somirrortherapyisnot superior to motor imagery on improving gait in post stroke subjects.

Conflict of Interest: Nill.

Source of Funding: Self.

Ethical Clearance: Ethical clearance taken from-InstitutionalEthicsCommitteeGSLMedicalCollege&generalhospital,Rajahmundry,AndhraPradesh,India.

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2.ZandiehA,KahakiZZ,SadeghianH,FakhriM,PourashrafM,ParvizS,GhaffarpourM,GhabaeeM.Asimpleriskscoreforearlyischemicstrokemortality derived from National Institutes ofHealth Stroke Scale: a discriminant analysis. Clinical neurology and neurosurgery. 2013 Jul1;115(7):1036-9.

3.Kanyal N. The science of ischemic stroke:pathophysiology & pharmacological treatment.International Journal of Pharma Research &Review.2015;4:65-84.

4.StollG,KleinschnitzC,NieswandtB.Molecularmechanisms of thrombus formation in ischemic stroke: novel insights and targets for treatment. Blood.2008Nov1;112(9):3555-62

5.McEwen BS. Plasticity of the hippocampus:adaptation to chronic stress and allostatic load.


Annals of the New York Academy of Sciences. 2001Mar1;933(1):265-77..

6.Kamalakannan S, GudlavalletiAS, GudlavalletiVS,GoenkaS,KuperH.Incidence&prevalenceofstrokeinIndia:Asystematicreview.TheIndianjournalofmedicalresearch.2017Aug;146(2):175.

7.Dutta A, Khattar B, Banerjee A. Immediateimprovementinankleflexor-extensorcoordinationfollowing electromyogram-triggered functionalelectrical stimulation therapy. stroke. 2012;3:6.

8.Barker WH, Mullooly JP. Stroke in a definedelderly population, 1967-1985: a less lethal anddisabling but no less common disease. Stroke. 1997Feb1;28(2):284-90.

9.OlneySJ,RichardsC.Hemipareticgaitfollowingstroke. Part I: Characteristics. Gait & posture.1996Apr1;4(2):136-48.

10.Perry J, Garrett M, Gronley JK, Mulroy SJ.Classification ofwalking handicap in the strokepopulation.Stroke.1995Jun1;26(6):982-9.

11.LordSR,MenzHB,TiedemannA.Aphysiologicalprofile approach to falls risk assessmentand prevention. Physical therapy. 2003 Mar1;83(3):237-52.

12.Latham NK, Jette DU, Slavin M, RichardsLG, Procino A, Smout RJ, Horn SD. Physicaltherapy during stroke rehabilitation for people with different walking abilities. Archives ofphysical medicine and rehabilitation. 2005 Dec 1;86(12):41-50.

13.WoolleySM.Characteristicsofgaitinhemiplegia.Topicsinstrokerehabilitation.2001Jan1;7(4):1-8.

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15.Michielsen ME, Selles RW, van der Geest JN,Eckhardt M, Yavuzer G, Stam HJ, Smits M,RibbersGM,BussmannJB.Motorrecoveryandcortical reorganization after mirror therapy in chronic stroke patients: a phase II randomizedcontrolled trial. Neurorehabilitation and neural repair.2011Mar;25(3):223-33.

16.Ramachandran VS, Rogers-RamachandranD. Synaesthesia in phantom limbs induced with mirrors. Proc. R. Soc. Lond. B. 1996Apr22;263(1369):377-86.

17.LafleurMF, JacksonPL,Malouin F,RichardsCL,EvansAC,DoyonJ.Motorlearningproducesparalleldynamic functional changes during the execution and imagination of sequential foot movements.Neuroimage.2002May1;16(1):142-57.

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Effects of Aerobic Exercise on the Gestational Weigth Gain of Healthy Pregnant Women–A Systematic Review

Ezeukwu Antoninus Obinna1, Nweke Ugochukwu Noel Martins1, Nebo Ifeanyichukwu1, Nwafulume Chidubem1, Ojukwu Chidiebele Petronilla1, Ezugwu Uchechukwu1, Uduonu Ekezie M.1

1Department of Medical Rehabilitation, University of Nigeria, Enugu Campus

ABSTRACT

Excessivegestationalweightgainhasbeenshowntoberelatedtohigh-postpartumweightretentionandthedevelopmentofoverweightandobesitywiththeirco-morbiditiessuchasatherosclerosis,diabetes,strokeetc later in life.StudieshavereportedconflictingfindingsontheeffectsofaerobicexerciseonGWGofhealthy pregnant women. This study therefore systematical reviewed such studies.

ThePICOmethodwasusedtodefinethefourmajorcomponentsofthesystematicreviewquestion.ElectronicdatabasessuchasCochraneLibrary,MEDLINE,CumulativeIndextoNursingandAlliedHealthLiterature(CINAHL), Excerpta Medica database (EMBASE), Science Direct, PubMed, Physiotherapy EvidenceDatabase(PEDro)weresearchedonlinetofindpapers.ThemethodologicalqualitiesoftheprimarystudieswereassessedusingtheirPEDroscore(9–10=excellent;6–8=good;4–5=fair;4=poor).

Atotalof868articlesweregeneratedfromthesearchstrategy;5articlesfulfilledallthecriteriaandwereselected for this review.Majorityof thestudiesdidnot report theparityof theirparticipants (60%)andrecruitedpregnantwomenatanystageoftheirpregnancy(40%).mostofthestudieswereeitherofgoodmethodologicalquality (40%)orofpoormethologicalquality (40%).Majorityof thestudiesprescribedwalkingastheirmodeofaerobicexercisetraining(60%),thatlastedbetween26minutesand50mintes(80%)at a frequencyof3 to5 sessionsperweek (80%) for8 - 16weeks (60%)at light tomoderate intensity(100%).Theoverallcombinedeffectsofthestudieswassignificantlyinfavourofaerobicexercise(SMD=-0.03,95%CI=-0.51,-0.09).

Aerobicexercisesuchasbriskwalkingfor25-50minutesperday,3-5timesperweekatlighttomoderateintensityforupto8-16weekscanbeusedtoreduceexcessiveweightgainduringpregnancy.

Keywords: Aerobic Exercise, Gestational Weight Gain, Systematic Review, Meta-analysis

Corresponding Author:UduonuEkezieMDepartmentofMedicalRehabilitation,UniversityofNigeria,EnuguCampusEmail: [email protected]

INTRODUCTION

“Eatingfortwo”hasbeenthemostcommonreasonfor increased weight again among pregnant women. This weight a woman gains during pregnancy is known as gestationalweightgain (GWG). Ithas importanthealthimplications for both the mother and the child [1]. The Institute ofMedicine providesGWG recommendationsthat promote optimal health by balancing risks associated

withtoomuchortoolittleGWG[2,3]. Excessive gestational weightgainhasbeenshowntorelatetohigh-postpartumweight retention and the development of overweight and obesitywiththeirco-morbiditiessuchasdiabetes,strokeetc later in life [4].Itisthereforepertinentthatexpectantmothers engage in exercises especially during pregnancy to dissipate the exercise positive energy balance that culminates in weight gain.

Literature appears unsettled as to the effects ofaerobic exercise on the gestational weight gains of healthypregnantwomen.Whilestudiesby[5,6] reported that aerobic exercise is effective in significantlyreducingexcessivegestationalweightgain,thestudyby[7] reported otherwise.A systematic reviewwithmeta-analysis that will combine these different randomized

DOI Number: 10.5958/0973-5674.2019.00040.6


clinical trials with the aim of reporting their combined overalleffectandreportinghigherevidenceisthereforewarranted. It isagainst thisbackground that thisstudysystematically reviewed randomized clinical trials on theeffectofaerobicexerciseonthegestationalweightgain of healthy pregnant women.

METHOD

ThePICOmethodwasusedtodefinethefourmajorcomponentsofthesystematicreviewquestion:P(patient)=Healthypregnantwomen;I(intervention)=exerciseprogrammes that include a substantial aerobic exercise component,withaerobicexercise;C(comparison)=nointervention or other activities not designed to improve aerobic fitness; O (outcome) = Gestational weightgain. Only randomized controlled trials (RCT) thatinvestigated the effects of aerobic exercise on healthypregnant women; that the aerobic training protocol was clearly described (e.g. mode, frequency, intensity andtime), and published in English were included. Thefollowing electronic databases were searched online: Cochrane Library, MEDLINE, Cumulative Indexto Nursing and Allied Health Literature (CINAHL),ExcerptaMedicadatabase(EMBASE),ScienceDirect,PubMed, Physiotherapy Evidence Database (PEDro).Google search and a hand search of the reference list of existingarticleswerealsoconducted tofindpapersthat did not appear in the main databases. The search coveredliteraturefrom1997-2017withthelastsearchperformedinApril,2018.

ThemethodologicalqualitiesoftheprimarystudieswereassessedusingtheirPEDroscore(9–10=excellent;6–8=good;4–5=fair;4=poor)andtheleveloferrorassessedusingtheRiskofBias(RoB)table.

RESULT

A total of 868 articles were generated from the search strategy; 5 articles fulfilled all the criteria andwere selected for this review.Majority of the studiesdid not report the parity of their participants (60%)and recruited pregnant women at any stage of their pregnancy(40%).Withtheexceptionofastudythatdidnot report inclusion or exclusion based on the type of pregnancy(singleormultiplepregnancy),therestofthestudies(80%)excludedpregnantwomenwithmultiplepregnancies.

Whileallthestudies(100%)ofthestudiesrandomlyallocated their participants into groups, assessedbetween group difference, as well as reported pointestimates and variability; none of the studies (0%)blinded their participants or their therapist with only a study [5].Also,very fewstudies (40%)had less than15%attrition,concealedtheirallocationandusedanon-completer analysis (intention to treat analysis). Noneof the studieshad an excellentmethodologicalqualitybased on the PEDro rating while most of the studies wereeitherofgoodmethodologicalquality(40%)orofpoormethologicalquality(40%).

Walkingwasthemostcommonlyprescribedmodeof exercise (60%), although few studies prescribeddance (20%) and acquatic (20%) exercises as theiraerobic exercise training modalities. Virtually all thestudies prescribed aerobic exercise that lasted between 26minutesand50mintes(80%)atafrequencyof3to5sessionsperweek(80%)andinmostofthestudies(60%),the entire aerobic exercise training programme spanned between 8weeks and 16weeks. All the studies included in this review had their aerobic exercise prescribed using lighttomoderateintensity.Thefiverandomizedclinicaltrial included yielded a total of 538 participants. The risk ofbiasasreportedintheROBtableisaverage(50%).The degree of heterogeneity among the studies is low (I2=30%).Whilemostofthestudies[8,5,6,7]werenon-significant though in favorofaerobicexercise,only [8] wassignificantlyinfavorofaerobicexerciseasagainstthe control. However, the overall combined effects ofthestudieswassignificantlyinfavorofaerobicexercise(SMD=-0.03,95%CI=-0.51,-0.09)

DISCUSSION

Excessive weight gain during pregnancy is a major determinant of high postpartum weight retention and long-termobesityinwomen[10].Itisthereforenecessaryto device effect exercise programme for controllingexcessive weight gain during this important period of lifeasdoneinthetrialsincludedinthisreview.Majorityof the studies in this review did not report the parity of their participants who were recruited irrespective of their stagesofpregnancy(trimester).ParityhasbeenshowntobestronglyrelatedtoBodyMassIndex(BMI)[11]and BMI is a direct predictor of exercise adherence [12]. Itis therefore possible that parity may have influencedthe adherence of these participants to their exercise


programmes. Majority of the studies in the reviewrecruited pregnant women irrespective of their stages. Sinceweightgainandperceivedfatiguedifferacrossthedifferent stages in pregnancy [13], a woman’s trimestermayinfluenceheradherencetoanexerciseprogramme.

The mode of exercise can influence pregnancyoutcomes [14]. Majority of the studies in this reviewprescribed walking as their mode for exercising their participants. It is recommended that pregnant womenshould not engage in strenuous unaccustomed exercise programme prior to becoming pregnant [8]. Ithasbeenrecommended that exercises involving high risk of contact(e.g.basketball,hockey,baseball),highriskoffall(e.g.offroadcycling,gymnastic),scubadive,supinelying (e.g. curl up), prolonged standing etc should beavoided during pregnancy [15] [16] especially as they progresses to term. The American College of Sports Medicine and American Congress of Obstetrics andGynecology recommendedwalking (Brisk), stationarycycling,swimmingetcforpeopleduringpregnancy[17].

Also, most of the studies had their participantstrainedbetween26and50minutespersession,3 to5sessions per week using light to moderate intensity for a trainingdurationof8–16weeks.Thisexercisetrainingfrequency, intensity and duration is in line with boththe exercise recommendation by the American College of Sports Medicine for adults [18] and the American CongressofObstetricsandGynecology[19].Itisadvisedthat pregnant women should aim to be physically active on most, preferably all days of the week. However,for previously sedentary women and those that are overweight or obese, exercisemay be prescribed at areducedfrequencyatthecommencementoftheprograme.g.3daysperweekonnon-consecutivedaystoprovidea day for recovery between sessions [20].

Aerobic exercise was significantly effective inreducing gestational weight gain. This implies that aerobic exercise can be used to prevent excessive weight gained during pregnancy. The major causes of excessive weight gain during pregnancy includes increasedadiposity,weightof the fetus,hemodynamicchanges as well also decreased physical activity [20].OneofthemajorrecommendationsofInstituteofMedicineon gestational weight gain is that women with normal BMI (18.5-24.9 kg/m2) should gain between11 to 16kilograms, overweight women (BMI 25-29.9 kg/m2)shouldaimtogain7to11kilogramswhileobesewomen

(BMI>30kg/m2)shouldaimtogain5to9kilograms(ACOG,2013).Aerobicexerciseisthereforeaveritablemodality for achieving this recommendation.

CONCLUSION

Evidence has been established that aerobic exercise especiallybriskwalkingfor25-50minutesperday,3-5timesperweekatlighttomoderateintensityforupto8-16weeks reduces excessive weight gain during pregnancy and can therefore be used to meet the recommendations of the institute of medicine.



Ethical Approval: Sought and obtained from the ethicalcommitteeoftheUniversityofNigeriaTeachingHospital,Enugu,Nigeria

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19.American College of Sports Medicine. ACSM’s Exercise Testing and Prescription. N Lippincottwilliams&wilkins,2017.

20.Hesketh KR, Evenson KR, Prevalence of USpregnantwomenmeeting,ACOGphysicalactivityguidelines. American journal of preventive medicine; 2016.51(3),pp.e87-e89.

21. Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG).Exercise During Pregnancy. A statement developedandreviewedbytheWomen’sHealthCommittee and approved by the RANZCOGBoard and Council. https://www.ranzcog.edu.au/RANZCOG/RANZCO./Women’sHealth/Statement;2016.

22.American College of Obstetricians andGynecologists. ACOG Committee opinion no.548: weight gain during pregnancy. Obstetrics and gynecology; 2013. 121(1),p.210.

Assessment of Balance and Risk for Falls in a Sample of Community-Dwelling Adults Aged 60 and Older

Harshita Chojar1, Gurpreet Kaur2

1BPT Student, 2Asst. Professor, College of Applied Education and Health Sciences, A-122 Gangotri Colony, Roorkee Road, Meerut , UP, India

ABSTRACT

Purpose of Study: The purpose of this study was to investigate the fall risk in 60 and older and prevalence of predictive properties of FullertonAdvanced Balance Scale in a group of independently-functioningcommunity-dwellingolderadults.

Methodology:Onehundredcommunity-dwellingolderadults(male=50,female=50)whowerecapableofwalking independently on assessment was included in this study. A binary logistic regression analysis of FullertonAdvancedBalanceScalescorewasusedtoinvestigateapredictivemodelforfallrisk.

Result and Conclusion: ThisstudyshowedthatFullertonAdvancedBalance(FAB)Scaleisapromisingscreening and assessment instruments,whichmight have utility in future investigations of the possibleeffectsofchiropracticcareonbalance.

Keywords: Proprioception, postural control, motor skill, Fullerton advanced balance scale.

INTRODUCTION

Balanceistheabilityofanindividualtosuccessfullymaintain the position of their body or restore the center of mass over time. Balance impairments are oftenassociatedwithimpairedvision,poorhearing,vestibulardysfunction, polyneuropathy, diabetic neuropathyand many chronic diseases and disorders i.e. cerebral and cerebellar disorders, cerebrovascular disease,spinal cord disorders, intervertebral disc disorders,psychological factors, dementia, high blood pressure,postural hypotension, diabetes mellitus, heart disease,arrhythmias, proprioception, joint problems, arthritisand muscular weakness1.Among the several factors affectingthehealthoftheelderly,afallisamajoreventresulting inanumberof functional,psychologicalandsocial impairments2.

Human aging causes physiological changes such as decreasedpostural balance, thus increasing the risk offalls. Postural control is considered to be a complex motor skill derived from interaction of multiple sensorimotor processes. Age-related changes in the peripheral andcentral components of the visual, somatosensory andvestibularsystemscanbeexpectedtoaffectbalanceandmobility.One-thirdofpeopleaged65yearsandoverfall

oneormoretimesayear.Amongcommunity-dwellingolder people, the cumulative incidence of falls rangesfrom 25 to 40%3.

Asmany as one-third of older adults fall at leastonce over the course of a year. Falls and fear of falling contribute to restricted activity as a strategy to reduce perceivedriskofsubsequentfalls.Resultantsecondarydeconditioning may actually increase risk of falling. Fall-related injuries (eg,hip fracturesandhead injury)contribute to increasing care costs for older adults4.

Fallsmayresultinheadtrauma,fractures,andevendeath.Immobilityresultingfromfallsinolderpeoplecanlead to severe depression, malnutrition, and increasedchance of infection and can have more deleterious effectsonphysiologicalstructuresandfunctionsinolderpeople than in younger people. The ability to maintain balanceandtopreventfallsisdifferentbetweenwomenand men. Studies have shown that women have worse balance than men and that their balance is less likely to improvewithexerciseinterventions.Oneofthereasonsfor this difference could be thatmen are stronger andhavemorepracticewithrisktaking.Ithasbeenshownthat people with decreased physical function or general health are more likely to have poor balance and increased risksoffallsandfall-relatedinjuries5.

DOI Number: 10.5958/0973-5674.2019.00041.8


A fall can be defined as a sudden, unintentionalchange in position causing an individual to land at a lowerlevel,onanobject,thefloor,ortheground,otherthan as a consequence of sudden onset of paralysis,epilepticseizure,oroverwhelmingexternalforce6.

Themostimportantmodifiableriskfactorsforfallincommunity-dwellingolderadultsareuseofpsychotropicdrugs, polypharmacy, environmental hazards, poorvision, lower extremity impairments, and impairmentsinbalance,gaitandactivitiesofdailyliving7.

It has been reported that balance is multifactorialandmaybeeffectedbyavarietyoffactors.Apartfrommedicalandpsychologicalfactors,agingprocessplaysasignificantrole inmaintainingbalanceof thebody.Fallsin older people are a common and important problem that can have devastating consequences for individuals andtheir support networks. Falls are also important for health systems due to the burden they place on health services. Physiotherapists can play a crucial role in the prevention offallsinolderpeople.Thereishigh-levelevidencethatappropriately prescribed interventions can prevent falls8.

People may begin to limit their activities after a fall or as they become weaker and less agile with increasing age. This leads to a more sedentary lifestyle andphysicalatrophy,whichfurtherpredisposesthemtofalls. Successful encouragement to maintain or increase physical activity may promote the ability to avoid falling or to catch oneself before a fall9.Ontheotherhand,whenseniorsunderestimatetheirriskoffalling,theymaytakerisksbeyondtheirphysicalability,andplacethemselvesat greater risk of falling10.

Postural control may have different goals underdifferent circumstances. The functionally importantcomponents of balance are maintenance of posture,posturaladjustmentsinanticipationofandduringaself-initiated movement and adjustments in response to an external perturbation11.

Clinical balance scales are useful tools to assess postural control, as they are able to reflect variousdimensions of postural control (eg, static/dynamicpostural control, sensory reception and integration,feedforward/feedback postural control). Recently, theFullertonAdvancedBalance(FAB)scalewasvalidatedandcomparedwiththeMini-BESTestandBBStoassesspostural control in people with PD12.

AIMS AND OBJECTIVE OF STUDY

AIM: This cross-sectional study explores thepsychometric properties and dimensionality of the

FullertonAdvancedBalance(FAB)Scale,amulti-itembalancetestforhigher-functioningolderadults.

Objective: To determine the frequency of balanceproblems in elderly population.

SIGNIFICANCE OF STUDY

z The youth in present scenario is facing enough problems and health related issues to make them physically unfit,weak leading to poor balance co-ordination,posturalcontrolandfunctionalcapacity.There is a need to aware people about exercise protocol to control these above mentioned problems.

z Poor balance co-ordination, postural control andfunctional capacity in professional and social front mayaltertheoverallperformanceandmayaffecttheprofessionalandsociallifetoo.So,abetterwaytocombat these problems along with improvement of responsivenesstoenvironmentalstimuliisrequired.

z To have better functioning and standard of life and to react in a better way to problem solving situations.

HYPOTHESIS

Null Hypothesis: Therewillbenosignificantdifferencebetween that there is a higher risk of fall in female elderly population as compared to the male population.

Alternative Hypothesis: There will be significantdifference between that there is a higher risk of fallin female elderly population as compared to the male population.

MATERIALS AND METHODOLOGY

Design of Study: Survey

Sample Size: 100 subjects

Source of Data:CAEHSRehabilitationCentre,Meerut;MilitaryHospital,Meerut;L.L.R.M.Hospital,Meerut;TheUrbanPopulation,MeerutCantt

Duration of Study: 2 months

Criteria of SamplingInclusion Criteria:

z Malesandfemales

z Age group above 60 years


z Volunteerswhorequiredanassistivedevice(caneor walker) to walk are eligible

z Informedconsent

z Individualswhocanunderstandcommands

Exclusion Criteria: Potential participants are excluded if they are:

z Non-cooperativesubjects

z Wheelchair-bound

z Unabletostandunassistedforaminimumof1minute

PROCEDURE

“The research work has been approved by the research committeeofCAEHS,Meerut.”ThesubjectsweretakenfromvariousplacesfromCAEHSRehabilitationCentre,Meerut;MilitaryHospital,Meerut;L.L.R.M.Hospital,Meerut;andTheUrbanPopulation,MeerutCantt.

A door-to-door survey was performed in which asampleofcommunity-dwellingadultsaged60andolderare taken.

Total 100 subjects were included in the study. The informedconsentwasfilledbythesubjects.Personswhowere normal and fulfilled the inclusion criteria wererandomly selected into the study. Complete evaluation was taken by the therapist after accomplishment of the evaluation, subjects were randomly selected for thecontrol group.

Eachparticipantcompletedasequenceofphysicalbalance challenges representing the 10 items of the FullertonAdvancedBalance(FAB)Scale.

DATA ANALYSIS AND RESULT

Graph 1: The figure reveals that 17 women out of 50 were at below borderline ; i.e., those who were

having high risk of fall. At borderline there was only 1 out of 50 found and 31 out of 50 were at above

borderline; those who did not have any risk of fall.

Graph 2: The figure reveals that 9 men out of 50 were at below borderline ; i.e., those who were

having high risk of fall. At borderline there was no significant value found and 41 out of 50 were at above borderline; those who did not have any risk

of fall.

DISCUSSION

TheaimofthestudywastoassesstheBalanceandriskforfallsinasampleofcommunity-dwellingadultsaged60andolderbyusingFullertonAdvancedBalance(FAB)Scale.

The scale comprised of several tasks that helps to measure balance in older adults.A total of 100 subjects participated in the study and they performed the tasks accordingtothescale,onthebasisofwhichtheirbalancewas measured.

The present study showed that the Fullerton Advanced Balance (FAB) Scale appears to be animportant tool in assessing the balance in the older adults and the risk of falls is higher in the females in comparison with the male population.

FromthebeginningofFABScaletestdevelopment,it was theorized that individual test items and possible subgroupingsofitemswithintheFABScalemightinvolvedifferentbalance-controlsystemstovaryingdegrees.

ResultsofRaschmodellingfortheFABScalefoundthat 9 of the 10 test items were related within a single domainofbalance,whichsuggeststhatscoresforitems1–9maybesummedintoatotalscoreforameaningfulmeasure of balance ability.

Item 10 (reactive postural control) was found tomeasure a balance-control mechanism different fromthatmeasuredbytheothernineFABscaleitems.Item10 is intended to measure an individual’s ability to


respondquicklytoanunexpectedlossofbalanceusingaprotective and involuntarily controlled righting response.

Further exploration of the diagnostic value of the FAB Scale should be addressed in future research byreferencing individual person patterns that do not match Rasch generated expected patterns.

Future research should also explore diagnostic and prescriptive test applications, aswell as the test’ssensitivity to change over time.

Infavourwehave,CarynPearson,JulieSt-ArnaudandLeslieGerancocludedthatin2008–2009,morethanthree-quartersofseniors(78%)hadalowriskoffalling,and22%hadahighriskoffalling.Morewomenthanmen perceived a risk of a fall, and the proportion ofseniors who perceived a risk tended to increase with age. About 34% of seniors reported perceiving a risk of a fall.

Yong-Jin Jeon and Gyoung-Mo Kimconcludedthat the FullertonAdvanced Balance scale is a moreappropriate tool to assess balance ability than the PediatricBalanceScaleinagroupofhigherfunctioningchildren with cerebral palsy.

Christian Schlenstedt, Stephanie Brombacher,GesaHartwigsen, BurkhardWeisser, Bettina Möller,GuntherDeuschlconcludedthatTheFABscale,Mini-BESTest, and BBS provide moderate capacity topredict “fallers” (peoplewith one ormore falls) from“nonfallers.”Onlysomeitemsofthe3scalescontributeto the detection of future falls.

Debra J. Rose, Nicole Lucchese and Lenny D.WiersmaconcludedthatpreliminaryresultssuggestthattheFABscaleisavalidandreliableassessmenttoolthatis suitable for use with functionally independent older adults residing in the community.

Penelope J. Klein, Roger C. Fiedler, Debra J.Rose concluded that The FAB Scale appears to be areliable and valid tool to assess balance function in higher-functioning older adults.The testwas found todiscriminate among participants of varying balance abilities. Further exploration of concurrent validity of Rasch-generatedexpecteditemscoringpatternsshouldbe undertaken to determine the test’s diagnostic andprescriptive utility.

IncontrastwehaveSchlenstedtC,BrombacherS,Hartwigsen G concluded that lower sensitivity (67%)

and specificity (58%) values obtained using the FABscale on Parkinson patients.

CONCLUSION

ThisstudyshowedthatFullertonAdvancedBalance(FAB) Scale is a promising screening and assessmentinstruments, which might have utility in futureinvestigationsofthepossibleeffectsofchiropracticcareon balance.

Balanceimpairmentisoneofthechiefriskfactorsforfallsintheolderadults.Although,theresultshowedthat there is a higher risk of fall in female elderly population as compared to the male population.

Limitation of the Study:

z Small sample size

z Treatment options were not taken into consideration

Future Scope of the Study:

z Largesamplesize

z Morereliablesurvey

z Considering the treatment options also

Conflict of Interest:NIL


Ethical Clearance: Taken from College of Applied Education and Health Sciences

REFERENCES

1.Momena Shahzad1, Haider Darain2, AyeshaShaukat3, Shakirullah4. Balance Problems inGeriatricPopulation:APopulationBasedSurvey.Journalof IslamabadMedical&DentalCollege(JIMDC);2016:5(4):195-197

2.MatheusMGomes*,JuliaG.Reis,ThamiresM.Neves,Marina Petrella,DanielaC.C. deAbreu.Impactofagingonbalanceandpatternofmuscleactivation in elderly women from different agegroups. International Journal of Gerontology 7(2013)106-111

3.Helen BenincasaNakagawaI, JulianaRizzattoFerraresiII, Melina GalettiPrataIII,Marcos Eduardo ScheicherIV. Postural balance


and functional independence of elderly people according to gender and age: cross-sectionalstudy.SaoPauloMedJ.2017;135(3):260-5

4.Michelle M. Lusardi, Stacy Fritz, AddieMiddleton, Leslie Allison, Mariana Wingood,Emma Phillips, Michelle Criss, SangitaVerma,JackieOsborne,KevinK.Chui.DeterminingRiskof Falls in Community Dwelling OlderAdults:A Systematic Review and Meta-analysis UsingPosttest Probability. Journal of GERIATRICPhysicalTherapy.Copyright©2017AcademyofGeriatricPhysicalTherapy,APTA.Unauthorizedreproduction of this article is prohibited.

5.GeWu.EvaluationoftheEffectivenessofTaiChiforImprovingBalanceandPreventingFallsintheOlderPopulation—AReview.JAGS50:746–754,2002 © 2002 by the American Geriatrics Society.

6.Waleed Al-Faisal. Falls Prevention for OlderPersons.EasternMediterraneanRegionalReviewOctober2006

7.Cheryl Hawk, John K Hyland, Ronald Rupert,MakashaColonvega and Stephanie Hall.Assessment of balance and risk for falls in a sample of community-dwelling adults aged 65andolder.Chiropractic&Osteopathy2006,14:3

8.Catherine Sherrington, Anne Tiedemann.Physiotherapy in prevention of falls in older people.JournalofPhysiotherapy61(2015)54-60

9.Aimee Lee, Kuo-Wei Lee, Peter Khang.Preventing Falls in the Geriatric Population. The PermanenteJournal/Fall2013/Volume17No.4

10.CarynPearson,JulieSt-ArnaudandLeslieGeran.Understanding seniors’ risk of falling and theirperception of risk. Statistics Canada, Catalogueno.82-624-X•HealthataGlance,October2014

11.DigantaBorah,SanjayWadhwa,UpinderpalSingh,ShivLalYadav,ManasiBhattacharjeeandSindhu.AGE RELATED CHANGES IN POSTURALSTABILITY.IndianJPhysiolPharmacol2007;51(4):395–404

12.Christian Schlenstedt, Stephanie Brombacher,GesaHartwigsen, BurkhardWeisser, BettinaMöller, Gu¨ntherDeuschl. Comparison of theFullerton Advanced Balance Scale, Mini-BESTest, and Berg Balance Scale to PredictFalls in Parkinson Disease. Phys Ther. 2016 Apr;96(4):494-501. doi: 10.2522/ptj.20150249.Epub2015Sep17.

Test Retest Reliability of Modified Tardieu Scale to Quantify the Spasticity in Elbow Flexors in Patients with Cerebro

Vascular Accident

Indrani Sonvane1, Suresh Kumar T2

1Intern, 2Associate Professor, Maharashtra Institute of Physiotherapy, Latur

ABSTRACT

Background: Spasticity is best described as ‘a motor disorder characterized by a velocity dependent increase intonicstretchreflexeswithexaggeratedtendonjerks,resultingfromhyperexcitabilityofthestretchreflex.TheMTSdeterminesthepassiverangeofmovement(PROM)atdifferentmovementvelocities,withtherelativedifferencebetweenaslowandafastvelocitypassivestretchdeterminingthedynamiccomponentofthemusclecontracture.ThereareverylimitedstudiesonreliabilityonMTS.

Methodology: 60 Patients with age group of 40 to 65 year will be selected for the study. The patient will be explained about the study and procedure. All subjects were tested by two examiners. Subjects were at restatleasttenminutesbeforethetest.Standardizedrestinglimbpositionsarefollowedforelbowflexormeasurements.

Results:CorrelationcoeffientR1valueis0.973,R2valueis0.913,R2-R1valueis0.924andMTSvalueis0.937.thesevaluessuggestthereisstrongcorrelationfromrater1andRater2

Conclusion:Inter-raterreliabilityforelbowflexorswereverygoodforR1,R2,R2-R1,ANDMTSscore.

Keywords: Spasticity, Modified tardieu scale, stroke, hemiplegia, upper limb function.

Corresponding Author:Ms.IndraniSonvane,Intern,MIPCollegeofPhysiotherapy,Latur.Maharastra,IndiaEmail: [email protected]

INTRODUCTION

Stroke is one of the major conditions which cause spasticity. Prevalence of spasticity after stroke has been reported in 50% of subjects with stroke1. Spasticity is reported to develop within one month of an acute stroke2.

Spasticity is best described as ‘a motor disorder characterized by a velocity dependent increase in tonic stretch reflexes with exaggerated tendon jerks,resulting fromhyper excitability of the stretch reflex3. Thisdefinitionsuggeststhattheabnormalityunderlyingspasticityishyperexcitabilityofthestretchreflex,bothtonic and phasic components, which can result in anincreased resistance to passive movement4.

Measurementofspasticitycanbedonebyclinicaland laboratory methods. The currently used clinical measurement tools for spasticity are the Ashworth and Modified Ashworth scales (MAS)5. but their validity has been questioned as they do notmeasure velocity-dependent aspect of spasticity6.Vattanasilpet al. also described Ashworth scale as a grading of muscle stiffness,which is unable to differentiate’ between‘theneural and peripheral contributions7.

In 1954,Tardieu et al. developed a clinical scale,knownasTardieuScale,tomeasurethespasticity8 which wasfurthermodifiedbyHeldandPeierrot-Deseilligny,andwaslatermodifiedbyBoydandGraham,presentlyknownasModifiedTardieuScale(MTS) 9.

TheMTSdeterminesthepassiverangeofmovement(PROM) at different movement velocities, with therelative difference between a slow and a fast velocitypassive stretch determining the dynamic component of the muscle contracture10.With theMTS, two resulting jointangles are measured by goniometer which include the R1

DOI Number: 10.5958/0973-5674.2019.00042.X


anglewhich is the ‘angle of catch’ after a fast velocitystretchandtheR2angledefinedasthepassivejointrangeof movement following a slow velocity stretch11.

The R2–R1 value indicates the level of dynamiccomponentofspasticityinthemuscle.AlargerdifferencebetweenR1 andR2means large dynamic component,whereasa smalldifferencebetweenR1andR2meansstatic contracture in the muscle12.

The inter-rater reliabilityofMTSforelbowflexorwas moderately high in a study done by Ansari et al. in adult subjects with hemiplegia13. There is less published literatureregardingreliabilityofMTSinadultsubjectswith stroke which prevents recommendation of this tool in this population. The purpose of this study was toinvestigateintra-raterreliabilityoftheMTSinelbowflexorsandankleplantarflexors in largepopulationofadult subjects with stroke.

METHODOLOGY

60 Patients with age group of 40 to 65 year will be selected for the study and screened through inclusion and exclusion criteria. The inclusion criteria are medically stableacutestrokesubjectsatleastonemonthofonset,agegroupbetween45to85years,bothmaleandfemalesareincludedandMMSCmorethan24.TheexclusioncriteriawereUnco-operativepatients,Historyofpainorsurgeryintheelbowjoint,PrevioushistoryofTIApatientsontonemodifyingdrugs(baclofen,Diazepametc)andAnyotherorthopedic, Neurologic, Cardio respiratory conditionsthataffectstheoutcomeofthestudy.Thepatientwillbeexplained about the study and procedure. Consent of the patient will be taken. The study passed through ethical committee before starting of the study

All subjects will be tested in the same position for both the tests. Subjects will be at rest at least ten minutes before the test. Standardized resting limb positions are followed for elbow flexor measurements. Goniometerisusedtomeasurerangeofmotionandtheequipmentwas rounded to 1 degree for accuracy. Placement of goniometer for measurement of angle of muscle reaction R1and R2 was adapted.

The subjects were made to sit on a chair with shoulder inadductionforelbowflexors.Auniversalgoniometerwas used for the test procedure. The lateral epicondyle of humerus was marked with a marker pen and a point was marked on the acromion process for reference. A linewasdrawnjoiningthesetwopoints(firstline).

The second line was drawn from the radial head to the radial styloidprocess, afterpositioningof the axisover the lateral epicondyle of humerus with stabilizing arm along the first line and movable arm along thesecondline.ThegoniometerwasfixedbytwoVelcro(2inch width) around the arm and forearm.

The joint will be moved first with a very slow-stretchingvelocity(V1)fromelbowflexiontoextensiontomeasurethePROMbycountingas1001,1002,1003……onwards. During this maneuver, the catch was notedby the rater and R2 is documented. Quality ofmusclereaction(MTSscores)rangingfrom0to4gradeswillberatedbytherateratthestretchingvelocityofV2.Atlast,the angle of muscle reaction is measured at the point of resistancetothefasteststretchingvelocityV2bycounting1,2,3…..onwards.Theangleofcatch(R1)isnotedbytheobserver.Throughouttheprocedure,theraterwillbeblindedbycoveringthegoniometerwithopaquetapeandobserver documented all values. The test procedure will berepeatedbyrateraftertwodaysintervaltore-measuretheR1,R2,andMTSscoresparameters.


Table I: Correlation of R1:

r-value p-value Result

0.973 <0.0001 P<0.0001Strong correlation

Intra-rater Reliability of R1 Value 0.973 showsstrongco-relationbetweenRaterIandRater2

Table II: Corelation of R2:



Intra-rater Reliability of R2 Value 0.913 showsstrongco-relationbetweenRaterIandRater2

Table III: Corelation of R2-R1:



Intra-raterReliability ofR2-R1Value 0.924showsstrongco-relationbetweenRaterIandRater2


Table IV: Corelation of MTS Score:

t-value p-value Result

R=0.937 <0.0001 <0.0001Strong correlation

Intra-raterReliabilityofMTSscorevalueR=0.937showsstrongco-relationbetweenRaterIandRater2.

Table V: Correlation:

Session Mean S. D. R-value P-value

R11 64.30 20.70 0.19 0.842 65.33 19.74 0.19 0.84

R21 115.00 17.37 0.61 0.532 117.83 18.08 0.61 0.53

R2-R11 51.7 19.00 0 12 51.6 19.00 0 1

MTS1 1.87 0.57 0.4 0.662 1.80 0.61 0.4 0.66

RESULTS

Intra-rater Reliability of R1 Value 0.973 showsstrongco-relationbetweenpreandposttest.

Intra-rater Reliability of R2 Value 0.913 showsstrongco-relationbetweenpreandposttest.

Intra-raterReliabilityofR2-R1Value0.924showsstrongco-relationbetweenpreandposttest.

Intra-raterReliabilityofMTSscorevalueR=0.909showsstrongco-relationbetweenpreandposttest.

DISCUSSION

ToolssuchastheAshworthScaleandtheModifiedAshworth Scale have been used in clinical trials under the assumption that theymeasure spasticity.However,it is now established that these instruments evaluate a combination of soft tissue contracture and spastic dystonia, in addition to spasticity itself14.Based on hisdetailed observations of muscle response to stretch in CP, Tardieu created a clinical method to specificallymeasure spasticity, which was based on comparingthe threshold angles of muscle reaction to stretches at severalpredefinedvelocities15.

Most studies of clinical spasticity measurementand treatment of spastic paresis have consistently used theAshworth Scale, an instrument measuring tone or

stiffness,thatbecameadefactocriterionstandardbeforeconceptual or methodological validation occurred.

ThisarticleprovidesthefirstfulldescriptionoftheTardieu Scale, which we have developed and namedfrom Tardieu’s clinical method,working after Heldand Pierrot- Deseilligny’s initial modifications16.A simpleclinicaltoolforspecificspasticitymeasurementmay have practical and theoretical importance, as thetherapies administered to patients withspastic paresis require reliable instruments to evaluate outcome. Apositive correlation appears to exist between the degree of spasticity and other forms of stretch-sensitive overactivity,suchasspasticco-contraction,aswellaswithfunctional impairment17.

Thus, a clinical marker of stretch sensitivity likespasticitymay be useful to predict the severity of co-contraction during movement in spastic paresis. Inpractice,theTardieuScalemakesspasticitytheonlytypeofmuscleoveractivityeasilyquantifiableatthebedside,incontrasttospasticco-contractionandspasticdystonia.Thistoolhasbeensuccessfullyusedtoquantifyclinicaleffectsofantispastictreatments18.

Patrick and Adashow strong construct validity of the Tardieu Scale as compared with an electromyographic measureofmusclereactiontofaststretch.Otherstudies

have tested the validity of theModifiedTardieuScaleversus functional assessments19.


The key strength of the Tardieu Scale is that, incontrast to theAshworthscale, it includesassessmentsat two different velocities to discriminate betweencontracture and spasticity. It is this feature alone thatmakes the Tardieu Scale the most clinically relevant assessment of spasticity. The Tardieu Scale has many limitations.Perhapsthemostsignificantlimitationisthatinterpretation of the scale relies on a good understanding of thedifferencebetweencontractureandspasticity.Asecond limitation is that some new users may consider the widely available instructions accompanying the scale to be inadequate. Various authors have subsequentlyexplained the scale, and new users will find thisadditional detail useful20

The TS compares the angle of appearance of the increased muscle tone at three different movementvelocities. A measure derived from the TS, used inthe literature40asaclinicalmeasureofspasticity, is the‘dynamic component’. This can be calculated as thedifferencebetweenthejointangleofthepassiverangeof jointmovementat avery slowpassive stretch (R2)and the joint angle of the catch at a fast velocity stretch (R1).However, thecalculateddifferenceadds togetherthevariancesofbothjointangles,resultinginverywideinter-sessionalvariations,ashasbeendemonstratedinarecent study.

Therefore, to evaluate the treatment of spasticity,it is probably better to compare themaximalROMata very slow passive stretch before and after treatment and the joint angle of the catch at a fast velocity passive stretch before and after treatment.

Subjectsincludedinourstudywereinrangeof45-65daysafteronsetofstroke,whereaspreviousstudieshave large range of duration of stroke subjects. There are few limitations of this study. The interval between two sessions was two days and this can be one of the reasons toachievehigherintra-raterreliabilityinthisstudy.Onelimitation can be the achievement of relaxed state in the subjects across the sessions by raters.

Goniometerwasattachedineachsession,althoughthis was tried to overcome by use of standard landmark. One of the major limitation of this study can be theinterval between assessment, which was two days.Astudy can be conducted with larger interval of one to two weeks.

CONCLUSION

InthisstudywearereportingtestretestreliabilityofMTSinapopulationof30strokesubjects.

Inter-rater agreement for elbow flexors were verygoodforR1,R2,R2-R1,ANDMTSscore.

Inthisstudyweuseduniversalgoniometerinstudyasthiseasytouse,costeffectiveandwidelyavailableinallkindsofsetting.WerecommendtheModifiedTardieuscale can be used for future research purposes.

Conflict of Interest: There is no conflict of interestbetween the authors

Source of Funding: Nil

Ethical Clearance: This research study is given clearanceunderEthicalcommitteeheadedbyPrincipal,MaharashtraInstituteofPhysiotherapy,Latur.

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10.LeeHM,HuangYZ,ChenJJ,HwangIS.(2002)Quantitativeanalysis of the velocity relatedpathophysiology of spasticity andrigidity in the elbowflexors.J NeurolNeurosurg Psychiatry72:621–629.

11.BleckEE,editor.(1987)Orthopeadic Management in CerebralPalsy.Clinics in Developmental Medicine No. 100.London:MacKeithPress.

12.GrahamHK,AokiKR,Autti-RamoI,BoydRN,Delgado MR, Gaebler-Spira DJ, Gormley ME,Guyer BM, Heinen F, Holton AF, MatthewsD,MolenaersG,MottaF,GarciaRuizPJ,WisselJ.(2000)Recommendationsfortheuseofbotulinumtoxin type A in themanagement of cerebral palsy. Gait Posture 11:67–79.

13.FosangAL,GaleaMP,McCoyAT,ReddihoughDS,StoryI.Measuresofmuscleandjointperformancein the lower limb of childrenwith cerebral palsy. DevMedChildNeurol2003;45:664-70.

14.AshworthB.Preliminarytrialofcarisoprodol inmultiplesclerosis.Practitioner1964;192:540-2.

15.BohannonRW,SmithMB.InterraterreliabilityofaModifiedAshworthScaleofmusclespasticity.PhysTher1987;67:206.

16.PatrickE,AdaL.TheTardieuScaledifferentiatescontracture from spasticity whereas the Ashworth Scale is confounded by it.ClinRehabil 2006;20:173-82.

17.TardieuG.Evaluation etcaractèresdistinctifs desdiversesraideursd’originecérébrale. ChapitreVB1bLesfeuilletsdel’infirmitémotricecérébrale.Paris:AssociationNationaledesIMCEd;1966.p1-28.

18.TardieuG, Lacert P. Le tonus etses troubles enclinique. Encyclopédiemédico-chirurgicale.Neurologie.Paris:1977.p17007A20.

19.GraciesJM,MarosszekyJE,RentonR,SandanamJ,Gandevia SC,BurkeD. Short-term effects ofdynamicLycrasplintsonupperlimbinhemiplegicpatients.ArchPhysMedRehabil2000;81:1547-55. 1.

20.Peacock WJ, Staudt LA. (1990) Spasticityin cerebral palsy and the selective posterior rhizotomyprocedure.JChildNeurol5:179–185.

Correlation between BMI Categories and Hand Grip Strength among School Children between 11 and 14 Years of Age:

A Cross Sectional Study

J Andrews Milton1, A Turin Martina2

1Professor, Bethany Navajeevan College of Physiotherapy, Thiruvananthapuram; 2Associate Professor, PG & Research Department of Rehabilitation Science, Holy Cross College, Tiruchirappalli

ABSTRACT

Background: Childhood obesity leads to major disabilities in the adulthood. Hand grip strength testing is suggestedasacomponentofthephysicalfitnesstest,becausehandgripstrengthcanbeusedtoassessthegeneral muscle strength

Objective: TheobjectiveofthestudyistofindouttheassociationbetweenBMIcategoriesandhandgripstrength among the school going children between 11 and 14 years of age

Materials and Method: 100 school children between 11 and 14 years from the schools in thiruvananthapuram citywereincludedinthestudyusingsimplerandomsamplingmethod.BMIpercentilehasbeencalculatedfor all the students.Theyweredivided into threeBMIcategories. i.e.,Normalweight,Overweight andObese.HandgripstrengthwasmeasuredusingaJamarAnalogueHandDynamometerwithparticipantsseated,theirelbowbytheirsideandflexedtorightangles,andaneutralwristposition.Maximumofthreetrialsofgripstrengthforbothrightandlefthand,hasbeendocumented.

Result: The result was analyzed using SPSS software version 24. The statistical tool used was pearson correlation.

ThepearsoncorrelationfortheLeftandRighthandgripwas-.847,Pvaluewas.000whichshowsthatthereisasignificantcorrelationat0.01levelbetweenBMIpercentileandhandgrip.Alsothevalueshowsthatthecorrelationisnegative,i.e.,astheBMIpercentileincreasesthehandgripdecreasesandviceversa.

Conclusion:ThestudyconcludesthatthereisanegativecorrelationbetweenBMIpercentileandhandgripi.e.,astheBMIpercentileincreasesthehandgripdecreasesandviceversainchildrenagedbetween11and14 years old.

Keywords: Hand grip, Childhood Obesity, Body Mass Index percentile

INTRODUCTION

The urbanization and digitalization of the world decrease the opportunities for the children to indulge in outdoor physical activities. Obesity is defined as‘’abnormal or excessive fat accumulation that presentsa risk to health’’. Obesity is the main source of noncommunicable diseases such as cardiovascular diseases and diabetes, musculoskeletal disorders etc. Musclestrength is the utmost importance for the locomotion and thereby the social interaction of a child. Nowadays the children are havng a passive lifestyle where there is less physical activity and more of indoor activity

withmobile, computer etc1. Thus a decreased physical activities outdoor and in indoor activities are the main source of childhood obesity. Hence it is essential to give more importance on physical activity and muscle strength in children. Studies show that decreased muscle strength correlateswithdecreasedphysicalfitness and increasedcardiometabolic risk and mortality 1,3,4. Elevated blood pressure,diminishedphysicalactivitylevel,lowaerobicendurance,increasedwaistcircumference(WC)andhighlevelsofbodymassindex(BMI),serumcholesterolandpercent body fat have all been proposed as important factors in predicting cardiometabolic diseases 2,5,6,. Researcheshavedocumentedadecreaseinphysicalfitness

DOI Number: 10.5958/0973-5674.2019.00043.1


and increased cardiometabolic risk in obese children with less physical activity. 5,6,7,8. Hand grip strength testing is suggestedasacomponentof thephysicalfitness test9, because handgrip strength canbe used to assess thegeneral muscle strength 10. Also handgrip strength is associated with various medical conditions at differentagegroups,weakhandgripisassociatedwithincreasedmetabolic risk profile in children 11, has been linked todiabetes and other cardiometabolic risk factors in older adults 12,andhasbeenconnectedwithotherparametersofphysicalfitness13. The purpose of the present study is todeterminetheassociationbetweenBMIpercentileandhand grip strength among school children aged between 11 and 14 years.


100 school children between 11 and 14 years from the schools in thiruvananthapuram city were included in the study using simple random sampling method. BMIpercentilehasbeencalculated forall the students.They were divided into three BMI categories. i.e.,Normal weight, Overweight and Obese.. Hand gripstrength was measured using a JamarAnalogue HandDynamometer. The testing position recommended by the ASHT(AmericanSocietyforHandTherapists)wasused.The subjects were instructed to be seated with shoulder adductedandneutrallyrotated,elbowflexed90o,forearminmid-proneandwristinneutralto30o extension(wristin slightly extended position), with neutral radioulnardeviation for optimal performance in power grip 14. Before testing, the examiner demonstratedhow to holdthe handle of the dynamometer. The same instructions were given for each trial. After the subject was positioned with the dynamometer, the examiner instructed thesubject to squeeze thehandlemaximallyand to sustainthisfor3–5secondswitharestof15–20secondsbetweenmeasurements 15.Theexaminertoldthesubjecttosqueezethe dynamometer as hard as possible and gave verbal encouragementstosqueezeharderduringthetest16. Three successive measurements were taken and the maximum of the three grips recorded 17,18. The maximum value was taken instead of the average value for many reasons; to avoid problem could arise due to fatigue of the muscle 19. The result was analysed statistically.


The result was analyzed using SPSS software version 24. The statistical tool used was pearson correlation.

RESULTS

Figure 1: Agewise distribution of boys in different BMI categories

Figure 2: Agewise distribution of girls in different BMI categories

Figure 1 and 2 shows the Age and Gender wise distributionofthesubjectsinBMIpercentilecategoriesUnder 11 years of age 2 boys and 2 girls were undernormalweight category, 6boys and4girlswereunderover weight category and 3 boys and 2 girls were under obesecategory.Under12yearsofage2boysand2girlswereundernormalweight category, 7boys and4girlswere under over weight category and 3 boys and 3 girls wereunderobesecategory.Under13yearsofage3boysand3girlswereundernormalweightcategory,7boysand5 girls were under over weight category and 4 boys and 7girlswereunderobesecategory.Under14yearsofage3boysand3girlswereundernormalweightcategory,7boysand7girlswereunderoverweightcategoryand3boys and 8 girls were under obese category

Table 1: Hand grip score for BMI categories

BMI Categories Hand Grip Right

Hand Grip Left

Normal weight

Mean 18.9000 18.3000N 20 20

Std. Deviation 1.07115 1.08094Minimum 17.00 16.00Maximum 20.00 20.00

over weight

Mean 10.3404 9.7234N 47 47

Std. Deviation .86669 .77184Minimum 8.00 7.00Maximum 12.00 11.00


Conted…

obesity

Mean 9.3939 8.8485N 33 33

Std. Deviation 1.05887 .97215Minimum 7.00 7.00Maximum 11.00 10.00

Total

Mean 11.7400 11.1500N 100 100

Std. Deviation 3.74872 3.72373Minimum 7.00 7.00Maximum 20.00 20.00

Table 1 shows the hand grip score for BMIcategories. In normalweight category, themean right

handgripscorewas18.8,standarddeviationwas1.07,minimumvaluewas17andthemaximumvaluewas20.Themeanvalueoflefthandgripscorewas18.3,standarddeviation was 1.08, minimum value was 16 and themaximumvaluewas20.Intheoverweightcategory,themeanrighthandgripscorewas10.3,standarddeviationwas.86,minimumvaluewas8andthemaximumvaluewas12.Themeanvalueoflefthandgripscorewas9.7,standard deviation. 77,minimumvaluewas 7 and themaximumvaluewas11.Intheobesecategorythemeanvalueofrighthandgripwas9.3,standarddeviationwas1.0,minimumvaluewas7andthemaximumvaluewas11.Themeanvalueoflefthandgripwas6.6,standarddeviation was. 97, minimum value was 7 and themaximum value was 10.

Table 2: Correlation between BMI percentile and hand grip

CorrelationsBMI Percentile Hand Grip Left Hand Grip Right

BMIPercentilePearson Correlation 1 -.847** -.847**

Sig.(2-tailed) .000 .000N 100 100 100

HandGripLeftPearson Correlation -.847** 1 .991**

Sig.(2-tailed) .000 .000N 100 100 100

Hand Grip RightPearson Correlation -.847** .991** 1

Sig.(2-tailed) .000 .000N 100 100 100

**.Correlationissignificantatthe0.01level(2-tailed).

Table 2 shows the correlation between BMIpercentile and handgrip in school children between 11 year and 14 years old age. The pearson correlation for the Left andRight hand gripwas -.847, P valuewas.000whichshowsthatthereisasignificantcorrelationat0.01levelbetweenBMIpercentileandhandgrip.Alsothevalueshowsthatthecorrelationisnegative,i.e.,astheBMIpercentileincreasesthehandgripdecreasesandvice versa.

DISCUSSION

100 school children between 11 and 14 years from the schools in thiruvananthapuram city were included in the study using simple random samplingmethod.BMIpercentile has been calculated for all the students. They were divided into three BMI categories. i.e., Normalweight,OverweightandObese.Handgripstrengthwas

measured using a JamarAnalogueHandDynamometerforall thesubjects.ThepearsoncorrelationfortheLeftandRighthandgripwas-.847,Pvaluewas.000whichshows that there is a significant negative correlation at0.01 level between BMI percentile and hand grip i.e.,as theBMIpercentile increasesthehandgripdecreasesandviceversa.Majorityof theactivitiesofdaily livingsuchaswriting,turningadoorknobetc.utilizesthehandgrip strength. Hand grip strength can be used to assess the general muscle strength. Lack of physical activityleads to obesity. Accumulation of fat reduces the muscle strengthinobesity.ObesesubjectshavefewertypeIandmoretypeIIbfiberswhencomparingtotheleansubjects.Fat mass is inversely correlated with type I fibers andis positively correlated with type II fibers. The resultof the study conductedbyHulens et al, shows that thehandgripstrengthwas10-60%lowerinobesewomen.20 The result of the study conducted by Sari Stenholm 21


suggest that a long-lasting obesity may predispose todecreasedmusclestrength, thuspotentiallyendangeringto an imbalance between fat and muscle mass or strength. The result of the study conducted by Duangporn Thong et al, showed that subjects with higher BMI tended tohave less muscular strength 22. Thus passive lifestyle and obesity have a negative impact on the physical performance because of decreased muscle strength. This seriously affect themobility of the personwhich leadsto functional limitation. In obesity, it is mainly due toimpairment of muscle strength by accumulation of fat; also,obeseparticipantshavefewertypeIandmoretypeIIbmusclefibers than their lean counterparts.FatmassisinverselycorrelatedwithtypeIfibersandispositivelycorrelatedwithtypeIIfibers23,24. Shetty et al. found that significant negative correlation betweenHGS andBMIinoverweightmalesand significantpositivecorrelationbetween HGE and BMI only in underweight males 25. The result of the present study concludes that there is a negativecorrelationbetweenBMIpercentileandthehandgrip in school children aged between 11 and 14 years.

CONCLUSION

TheresultofthestudyshowsthatthereisasignificantnegativecorrelationbetweentheBMIpercentileandthehand grip in school children aged between 11 years and 14 years. Hence the study concludes that as the BMIpercentile increases the handgrip strength decreases and vice versa in school children. Therefore specificstrategies to prevent or to reduce childhood obesity and itsconsequenceshastobeestablished.

Ethical Clearance: Ethical clearance has been obtained from the Institutional Ethical Committee of BethanyNavajeevan College of Physiotherapy



REFERENCES

1.Silverman,IW.Theseculartrendforgripstrengthin Canada and the United States. J Sports Sci2011;29:599–606.

2.Ekelund, U, Steene-Johannessen, J, Brown,WJ. Does physical activity attenuate, or eveneliminate, the detrimental association of sittingtimewithmortality?Aharmonisedmeta-analysis

of data from more than 1 million men and women. LancetLondEngl2016;388:1302–10.

3.Steene-Johannessen, J, Anderssen, SA, Kolle, E.Lowmusclefitnessisassociatedwithmetabolicriskinyouth.MedSciSportsExerc2009;41:1361–7.

4.Venckunas, T, Emeljanovas, A, Mieziene, B.Secular trends in physical fitness and body sizein Lithuanian children and adolescents between1992and2012. JEpidemiolCommunityHealth2017;71:181–7.

5.WHO.Commissiononendingchildhoodobesity.Report of the Commission on Ending Childhood Obesity. Geneva: World Health Organization,2016.

6.GBD2015ObesityCollaborators.Healtheffectsof overweight and obesity in 195 countries over 25years.NEnglJMed.Epubaheadofprint12June2017.DOI:10.1056/NEJMoa1614362.

7.Ekelund, U, Andersen, S, Froberg, K.Independent associations of physical activityandcardiorespiratoryfitnesswithmetabolic riskfactors in children: the European youth heart study.Diabetologia2007;50:1821–40.

8.Dobbins,M,DeCorby,K,Robeson, P. School-based physical activity programs for promoting physical activity and fitness in children andadolescents aged 6–18. Cochrane Databse SystRev2009;21:CD007651.

9.BiancoA, Jemni M, Thomas E, Patti A, PaoliA,RamosRoqueJ,etal.Asystematicreviewtodetermine reliability andusefulnessof thefield-based test batteries for the assessment of physical fitness in adolescents—TheASSOProject. Int JOccupMedEnvironHealth.2015;28:445–478.doi: 10.13075/ijomeh.1896.00393

10.Wind AE, Takken T, Helders PJM, EngelbertRHH.Isgripstrengthapredictorfortotalmusclestrength in healthy children, adolescents, andyoungadults?EurJPediatr.2010;169:281–287.doi:10.1007/s00431-009-1010-4

11.Cohen DD, Gomez-Arbelaez D, Camacho PA,PinzonS,HormigaC,Trejos-SuarezJ,etal.Lowmuscle strength is associated with metabolic risk factorsinColombianchildren:theACFIESstudy.PLoSONE.2014;9:e93150doi:10.1371/journal.pone.0093150


12.Peterson MD, McGrath R, Zhang P, MarkidesKS, Al Snih S, Wong R. Muscle weakness isassociated with diabetes in olderMexicans: theMexican health and aging stud Matsudo VKR,Matsudo SM, Rezende LF, Raso V. Handgripstrength as a predictor of physical fitness inchildrenandadolescents.RevBrasCineantropomDesempenhoHum.2015;17:1–10.y.JAmMedDir Assoc. 2016; 17: 933–938. doi: 10.1016/j.jamda.2016.06.007

13.MatsudoVKR,MatsudoSM,RezendeLF,RasoV. Handgrip strength as a predictor of physicalfitness in children and adolescents. Rev BrasCineantropom Desempenho Hum. 2015; 17:1–10.

14.Fess,E.E.(1992).Gripstrength.InJ.S.Casanova(Ed.), Clinical Assessment Recommendations(pp. 41–5). 2nd edition. American Society ofHandTherapists,Chicago

15.Tsang, R.C.C. (2005). Reference values for6-minute walk test and hand-grip strength inHealthyhongKongChineseadults.HKPJ,23(1),6–12.

16.Richards, L.G. (1997). Posture effects on gripstrength.ArchPhysMedRehabil,78(10),1154–6

17.Roy, J.S., MacDermid, J.C., Orton, B., Tran,T., Faber,K.J.,Drosdowech,D.& et al (2009).The concurrent validity of a hand-held versusa stationary dynamometer in testing isometric shoulderstrength.JHandTher,22(4),320–6.

18.Roberts,H.C.,Denison,H.J.,Martin,H.J.,Patel,H.P., Syddall, H., Cooper, C.& et al (2011).Areview of the measurement of grip strength in clinical and epidemiological studies: towards a standardisedapproach.AgeAgeing,40(4),423–9

19.Haidar,S.G.,Kumar,D.,Bassi,R.S.,&Deshmukh,S.C. (2004). Average Versus Maximum GripStrength:WhichisMoreConsistent?JHandSurgBr,29(1),82–84.

20.MHulens1,GVansant,RLysens,ALClaessens,EMulsandSBrumagne:Studyofdifferences inperipheral muscle strength of lean versus obese women: an allometric approach: InternationalJournalofObesity(2001)25,676-681.

21.SariStenholm,JanneSallinen,AnnemarieKoster,TainaRantanen,PäiviSainio,MarkkuHeliövaara,and Seppo Koskinen. Association betweenObesityHistoryandHandGripStrengthinOlderAdults—Exploring the Roles of Inflammationand Insulin Resistance as Mediating Factors.J Gerontol A Biol Sci Med Sci. 2011 March;66A(3):341–348.

22.Duangporn Thong-Ngam, ManeeratChayanupatkul, Vikit Kittisupamongkon. Bodymass index and percentage of body fat determined physical performance in healthy personnel. Asian BiomedicineVol.6No.2April2012;313-318

23.Tanner CJ, Barakat HA, Dohm GL, PoriesWJ, MacDonald KG, Cunningham PR, et al. Musclefiber type isassociatedwithobesityandweight loss. Am J Physiol Endocrinol Metab.2002;282(6):E1191-6.

24.Kriketos AD, Pan DA, Lillioja S, Cooney GJ,Baur LA, Milner MR, et al. Interrelationshipsbetweenmusclemorphology, insulinaction,andadiposity.AmJPhysiol.1996;270:R1332-9

25.ShettyCS,ParakandySG,NagarajaS.Influenceof various anthropometric parameters on handgrip strength and endurance in young males and females.IntJBiolMedRes.2012;3(3):2153-7.

A Study to Find Out Immediate Effect of Muscle Energy Technique on Pectoralis Minor Tightness in Healthy Collegiate

Individuals-An Interventional Study

Jalpa K. Patel1, Parinda R. Kansagara2

1M.PT. Student, PT in Musculoskeletal (Orthopedic) Science, 2M.PT. Student, PT in Orthopedic Conditions, Shri K. K. Sheth Physiotherapy College, Rajkot, Gujarat

ABSTRACT

Background: Pectoralis minor shortening can lead to scapular anterior tilting and internal rotation and a decrease in scapular upward rotation. Pectoralis minor adaptive shortening has been implicated as a mechanismforforwardshoulderpostureandforshoulder impingement.Muscleenergytechniquesareaclassofsoft tissueosteopathic (originally)manipulationmethods that incorporatepreciselydirectedandcontrolled,patient initiated, isometricand/or isotoniccontractions,designed to improvemusculoskeletalfunctionandreducepain.Theaimofstudywastoexaminetheimmediateeffectofmuscleenergytechniqueon pectoralis minor tightness in healthy collegiate individuals.

Method:An interventional studywas conducted on 50 subjects (25males, 25 females)with pectoralisminortightnessofage18-25yearswereselectedasperinclusionandexclusioncriteria.Pectoralisminortightnesswasmeasuredbeforeandaftertreatment.AllthesubjectsreceivedMuscleenergytechniqueforpectoralisminormuscle(3repetitionsin1session).Statisticalanalysiswasdoneusingparied‘t’testfromSPSS version 20.0.

Outcome: Pectoralis minor length test was used to measure pectoralis minor tightness

Result:Staticallysignificant(p<0.05)differencebetweenpre-andpost-treatmentvalueofpectoralisminorlength test was found in healthy collegiate individuals.

Conclusion: This study concludes that muscle energy technique is helpful to reduce pectoralis minortightness in healthy collegiate individuals.

Keywords: Pectoralis minor tightness, Muscle energy technique, collegiate individuals, Pectoralis minor length test.

INTRODUCTION

In the absence of a specific or identifiable causeof symptoms, poor upper body posture, colloquiallyreferred to as a ‘forward head posture’, ‘slouchedposture’, ‘poking chin posture’, or ‘rounded shoulderposture’hasbeencitedasapotentialetiologicalfactorin the pathogenesis and perpetuation of many clinical syndromes involving the shoulder.1AstudybyVishwaM.(2016)showedthatthereisprevalenceofpectoralisminor tightness in healthy collegiate individuals.2

Thepectoralisminor(PM)originatesoutersurfaceof 3rd to 5th ribs and adjoining intercoastal fascia and inserts on medial inferior border of the coracoid process.3

Becauseofthisanatomicalpositionofpectoralisminor,shortening can lead to an scapular anterior tilting and internal rotation and a decrease in scapular upward rotation, which can be a predisposed condition forshoulder impingement syndrome.4

It is the only scapula-thoracic muscle with ananterior thoracic attachment.5 The fiber orientation ofthe PMmuscle favors scapular internal rotation (IR),downward rotation, and anterior tilt (AT), and for thisreason, it is considered an antagonist to the necessaryscapular motions during arm elevation. Repetitive use of the upper extremity for activities that protract and downwardly rotate the scapula may also contribute to adaptive shortening. PM’s adaptive shortening leads

DOI Number: 10.5958/0973-5674.2019.00044.3


to changes in the resting position of the scapula and altered scapular kinematics and these changes can cause imbalance between agonist and antagonist muscle strength of shoulder joint.6

Changes inmuscle lengths, joint congruency, andsofttissueflexibilitymayoccurasaresultofprolongedpostural deviation. These adaptations may lead to abnormal movement or force distribution about a joint whichmaymanifestaspain,decreasedrangeofmotion,or impairment of muscle performance or motor function.7

Healthy subjects with a relatively short pectoralis minor have demonstrated limitations in scapular posterior tippingandexternalrotationduringarmelevation,whichmayminimizethesubacromialspace,impingethesofttissues,andcontributetoshoulderinjury.8

Dr. Fred Mitchell has been titled the father ofMuscle Energy Technique (MET).9 Muscle energytechniqueisamanualtherapyinterventioninwhichthepatient actively contracts a targeted muscle(s) againsta precise, clinician-controlled counterforce, followedby relaxation and a passive stretch. This technique iscommonly used to strengthen and lengthen muscles,reduce edema, improve circulation, and mobilizerestricted articulations. MET has been demonstratedto bemore effective in improving the extensibility ofshortened muscles than static stretching.10

METmay be used to decrease pain, stretch tightmuscles and fascia, reduce muscle tonus, improvelocal circulation, strengthen weak musculature, andmobilize joint restrictions. This method employs muscle contraction by the patient followed by relaxation and stretch of an antagonist or agonist. It is essentially amobilization techniqueusingmuscular facilitation andinhibition. METworksontwobasicprinciplesi.e.postisometric relaxation and reciprocal inhibition.11

KevinG.etal. (2015) states thatMETmayassistin preventing and treating various shoulder injuries associated with forward shoulder posture and pectoralis minor tightness among swimmers.9

Pectoralis minor tightness can be examined using pectoralis minor length test. Pectoralis minor length test measurement demonstrated acceptable clinical intra-rater reliability. Pectoralis minor length test is a reliable method measuring the distance from the treatment table to the posterior aspect of the acromion. However the recommended ‘gold standard’ reference of a normaldistance is 2.6cm.12

Despite research supporting the use of MET fora large number of conditions and large muscles, noinvestigators have determined the immediate effect ofMETforsmallmuscle.ExaminingtheefficacyofMETfor reducing pectoralis minor tightness in asymptomatic healthy collegiate individuals may assist clinicians in preventing and treating shoulder injuries in this group. Therefore,thepurposeofthisstudywastodeterminetheimmediateeffectsofMETonpectoralisminortightnessin healthy collegiate individuals.

This study hypothesized that there is immediate effectofMETonpectoralisminor tightness inhealthycollegiateindividuals,nullhypothesizedthatthereisnoimmediateeffectofMETonpectoralisminortightnessin healthy collegiate individuals.

METHODOLOGY

Study Design: An interventional study.

Sample Size: 50 subjects.

Study Duration:Onetimestudy.

Study Setting:ShriK.K.ShethPhysiotherapyCollege,Rajkot.

Criteria for Selection:

Inclusion criteria:

z Age:18-25year.

z Gender:Maleandfemale.

z Subjectswithpectoralisminortightness(>2.6cm).

Exclusion criteria:

z Any musculoskeletal impairment.

z Any surgical history.

z Anydeformity(eg.Spasmodictorticollis,scoliosis).

z Any neurological impairment.

z Fracture of upper limb.

MATERIALS USED

z Pen

z Paper

z Plinth


z Protractor

z Consent form

z Measurementform

Figure 1: Materials used in the study

PROCEDURE

z The proposed title and procedure had been approved by ethical committee. 50 subjects (25 males, 25females) with age group of 18-25 years wereselected for the study that fulfilled the inclusionand exclusion criteria. The details and purpose of the study were explained to all patients and written consent was taken from them.

Measurement procedure:

z Pectoralis minor length test:12 Subject in supine position. The linear distance from the treatment table to the posterior aspect of the acromion was measured by protractor. A distance greater than 2.6 cm would suggest the muscle had shortened. (Figure2)

Pectoralis minor length test was measured before and after the treatment session.

Figure 2: Measurement Procedure

Clinical Intervention:

z MET for pectoralis minor muscle:13 The subject is sidelying,armsarelightlyfoldedacrossthelowerthorax,withthesidetobetreateduppermost,andthepractitionerstandingbehindthepatient,closetothe edge of the table.

The therapist threads his caudad arm anterior to the subject elbow so that his caudad hand rests on pectoralisminor,withhisotherhandonthescapula. Posteriorly directed pressure is gradually applied to the shoulder to induce retraction, coupledwith aguidingeffortfromthehandonthescapula.

The subject was asked to lightly push the shoulder anteriorly,againstrestraininghandofthetherapist,for7to10seconds.

After this slack is taken out of the muscle and a small degree of stretch is induced for between 5 and 30 seconds repeat 3 times in 1 session.

Figure 3: MET for Pectoralis minor muscle


Statistical analysis was done by SPSS statistics version 20.00 for windows software. Normality of the data was checked by Shapiro-wilk test. Pre treatmentand post treatment data of pectoralis minor length test wasanalyzedusingpaired‘t’test.Levelofsignificance(pvalue) was set to 0.05.

REUSLT

An interventional study consisting of 50 subjects with age group of 18-25 yearswas conducted. In thisstudy 25 males and 25 females were included suggesting equalmale–femaleratio.


Table 1 shows the intra group comparison of pectoralisminor length testwith pre treatment 7.704+ 1.726(SD)andposttreatment5.538+1.911(SD)values.Onstatisticallycomparingthedata,asignificantdifferencewithp<0.05was foundbetweenpreandpost treatmentvaluesofpectoralisminorlengthtest.(Table1)

Table 1: Intra group comparison of pectoralis minor length test

Pectoralis minor

length testMean SD T p Result

Pre treatment 7.704 ± 1.726

25.1

09

<0.05

Significant

Post treatment 5.538 ± 1.911

DISCUSSION

The intention of the study was to find out theimmediateeffectmuscleenergytechniqueonpectoralisminor tightness in healthy collegiate individuals. Results showed that there is statistically significant (p<0.05)reduction in pectoralis minor tightness in healthy collegiate individuals after applying muscle energy techniqueforpectoralisminormuscle.

Thus,theresultsofthepresentstudyrejectsthenullhypothesis and supports the experimental hypothesis i.e. ImmediateeffectofMETonpectoralisminortightnessin healthy collegiate individuals.

Postural and muscle imbalance theory suggests that a short pectoralis minor is associated with a number of syndromeseffectingtheshoulderandupperquadrant.14 The pectoralis minor length test is one method that has been recommended to determine if this muscle is of normal length or is short and the 2.6 cm distance has been proposed as the length that separates a muscle of normal length to one that is short and may be associated with symptoms.

An adaptively shorter pectoralis minor may,therefore,notallowthescapulatofullyupwardlyrotate,externally rotate,posteriorly tip,orelevate. In supportofthis,JohnD.andsPaulaM.(2005)havedescribethatshorter resting length of the pectoralis minor would demonstrate altered scapular kinematics during arm elevation when compared to individuals with a longer muscle resting length.5

Inprevious studydonebyKevinG. et al., (2015)explained that tightness of the anterior musculature,suchas thepectoralisminor, hasbeenassociatedwiththe development of shoulder pain among competitive female swimmers and can lead to forward shoulder posture, which has been described as forward headand rounded shoulders. Routine applications of METmay assist in preventing and treating various shoulder injuries associated with forward shoulder posture and pectoralisminortightnessamongswimmers.METmayassist in decreasing the prevalence of shoulder pain among competitive female swimmers.9

MET employs muscle contraction by the patientfollowed by relaxation and stretch of an antagonist or agonist.10ItisessentiallyamobilizationtechniqueusingAutogenic inhibition. Autogenic inhibition occur when certain muscles are inhibited from contracting due to the activation of the Golgi tendon organ (GTO),which respond to changes in muscle tension and length.Post-IsometricRelaxation(PIR)worksontheconcept of autogenic inhibition.

Post-Isometric Relaxation (PIR) refers to the subsequent reduction in tone of the agonist muscleafter isometric contraction. This occurs due to stretch receptors called Golgi tendon organs that are located in the tendon of the agonist muscle.15

A strong muscle contraction against equalcounterforcetriggerstheGolgitendonorganduringPIR.TheafferentnerveimpulsefromtheGolgitendonorganenters the dorsal root of the spinal cord and meets with an inhibitory motor neurone. This stops the discharge of the efferentmotorneurone’simpulseandthereforepreventsfurthercontraction,themuscletonedecreases,whichinturn results in the agonist relaxing and lengthening.15

Thus, applying muscle energy technique usingautogenic inhibition helps reducing tightness of small muscle like pectoralis minor.

Clinical implication: Withthebasesofthisexperiment,METcanbeincludedinlengtheningtheshortedpectoralisminor in collegiate individuals to prevent forward shoulder posture and shoulder impingement syndrome.

Limitation:

z Onlysubjectswithage18-25yearswererecruited.

z Onlycollegestudentswereincluded.


Further recommendation:

z Study can be done on subjects with shoulder pain.

z Study could be done with large sample size.

z StudycanbedoneonProfessionlikebankofficersor computer users.

CONCLUSION

According to this study it can be concluded that muscle energy technique has been found to haveimmediate effective in reducing the pectoralis minortightness among healthy collegiate individuals.

ACKNOWLEDGMENT

Iwouldliketothankmyparents&friendsfortheirsupport&guidance.

Conflict of Interest: There was no personal or institutionalconflictofinterestforthisstudy.

Source of Funding: No fund was needed.

Ethical Clearance: Taken from Shri K. K. ShethPhysiotherapyCollege,Rajkot.

REFERENCE

1.Filip S.,MitraM., Erik F., Nathalie R., Nick J.,StevenT.,JoN.Interraterandintraraterreliabilityof the pectoralis minor muscle length measurement in subjects with and without shoulder impingement symptoms.ManualTherapy.2014;19(4):294-298.

2.Vishwa Mankad, Bhavesh Jagad. A study tofindoutprevalenceofpectoralisminortightnessin healthy collegiate individuals. IJPOT. 2016;10(4):149-152.

3.B.D.Chaurasia: Anatomy of upper limb andthorax: 4th edition

4.MurakiT.,AokiM.,IzumiT.,FujiiM.,HidakaE.,MiyamotoS.Lengtheningofthepectoralisminormuscle during passive shoulder motions and stretchingtechniques:acadavericbiomechanicalstudy.PhysicalTherapy.2009;89:333-341.

5.Borstad JD., Ludewig PM. The effect of longversus short pectoralis minor resting length on

scapularkinematicsinhealthyindividuals.JournalofOrthopedicandSportsPhysicalTherapy.2005;35:227-238.

6.Hebert LJ., Moffet H., McFadyen BJ., DionneCE. Scapular behavior in shoulder impingement syndrome. Archive of Physical MedicineRehabilitation.2002;83:60-69.

7.John D. Borstad. Measurement of pectoralisminor muscle length: validation and clinical application. Journal of Orthopaedic & Sports PhysicalTherapy.2008;38(4):169-174.

8.PoppenNK.,Walker PS. Normal and abnormalmotionoftheshoulder.AmericanJournalofBoneandJointSurgery.1976;58(2):195-201.

9.Kevin G. Laudner, Melissa Wenig, Noelle M.,Jeffrey Williams, Eric Post. Forward shoulderposture in collegiate swimmers: a comparative analysisofmuscle-energytechniques.JournalofAthleticTraining.2015;50(11):1133–1139.

10.HertlingD,KesslerRM.Managementofcommonmusculo skeletal disorders, physical therapy:principles and practice. Third edition. Philadelphia: LippincottWillams&Wilkins;1996.

11.Stephanie D. Moore, Kevin G. Laudner, ToddA.Mcloda,MichaelA. Shaffer. The immediateeffects ofmuscle energy technique on posteriorshoulder tightness. Journal of Orthopaedic & SportsPhysicalTherapy.2011;41(6):400-407.

12.JeremyL.,RachelV.,Thepectoralisminorlengthtest: a study of the intra-rater reliability anddiagnostic accuracy in subjects with and without shoulder symptoms. BMC MusculoskeletalDisorders.2007;64(8):1-10.

13.Leon Chaitow : Muscle energy techniques. 4th edition;2013;5:139-140.

14.KiblerWB.Theroleofscapulainathleticshoulderfunction.American Journal of SportsMedicine.1998;26:325-337.

15.Webster G. The physiology and application ofmuscleenergytechniques,2001

Effect of Scapular Downward Rotator Stretch Exercises on Scapular Upward Rotator Activity During Arm Elevation in

Subjects with Scapular Downward Rotation Syndrome

Na-Yeon Jeon1, Jong-hyuck Weon2, Kwon-ho Lee2, Do-young Jung2, In-cheol Jeon3

1B.H.Sc, PT, Master Student, Department of KEMA Therapy, Graduate School of Humanities Industry; 2PT, Ph.D, Professor, Department of Physical Therapy, College of Tourism & Health Science,

Joongbu University, Geumsan, South Korea; 3PT, PhD, Professor, Department of Physical Therapy, College of Life & Health Sciences, Hoseo University, Asan, South Korea

ABSTRACT

Thepurposeofthisstudywastoinvestigatetheeffectsofscapulardownwardrotatorstretchexercisesonmuscle activity of the scapular upward rotators during arm elevation in subjects with scapular downward rotation syndrome. Sixteen people with scapular downward rotation syndrome were participated. To investigatetheeffectivenessofthesestretchingexercises,thesurfaceelectromyography(EMG)activityoflevatorscapula,uppertrapezius,lowertrapezius,andserratusanteriorwasmeasuredatshoulderflexionsof90°,120°,and150°pre-andpost-exercise.Two-wayrepeated-measuresanalysisofvariancewasusedtodeterminethechangesinmuscleactivities.ABonferronicorrectionwasperformedontheposthoctest(α=0.017).Theactivityofthelevatorscapular,uppertrapezius,andserratusanteriormusclewasincreased(p<0.017)asshoulderflexionanglechanged.Acomparisonofmuscleactivitypre-andpost-exerciseandatdifferentshoulderflexionanglesshowedthatlevatorscapularanduppertrapeziusmuscleactivitywasdecreased at a shoulder flexion of 150° (p< 0.017). Serratus anteriormuscle activitywas decreased atshoulderflexionof120°and150°(p<0.017).Thisstudysuggeststhatscapulardownwardrotatormusclestretching exercises should be performed before strengthening exercises to improve mobility in people with scapular downward rotation syndrome.

Keywords: Scapular downward rotator; stretching exercises; scapular downward rotation syndrome

Corresponding Author:Jong-hyuckWeon(JHWeon)PT,Ph.D,Professor,DepartmentofPhysicalTherapy,CollegeofTourism&HealthScience,JoongbuUniversity,Geumsan,SouthKoreaEmail: [email protected]

INTRODUCTION

Normal scapular alignment plays an important role in postural control of scapulohumeral motion and the glenohumeral joint (Kibler et al. 2010; Sahrmann2002)1,2. The scapular medial border for normal alignment isapproximately7–8cmawayfromthespinousprocessof the thoracic vertebrae and parallel with the superior and inferior scapular angles located between the second and seventh thoracic vertebra. The scapula is tilted by 30°onthefrontalplane(Bunchetal.1993)3.

Abnormal scapular alignment can occur with scapular downward rotation, depression, elevation,adduction,abduction, tilting,andwinging; itmaycausemuscle imbalance and pain in the neck and shoulder muscles and alter scapulohumeral rhythm and the stabilityoftheglenohumeraljoint(Azevedoetal.2008)4. Scapular downward rotation syndrome is characterized by impairment of the shoulder joint such that the inferior scapular angle is closer to the spine than the superior angle; the distance between the medial border of the scapula and spineislessthan7–8cm(Caldwelletal.2007)5.

Scapular downward rotation syndrome causes abnormal changes in the length and tension of cervicoscapular muscles; these changes may result in malalignment and abnormal posture of the glenohumeral joint (Lee et al. 2016;)6. Changes in muscle length exhibited in scapular downward rotation syndrome

DOI Number: 10.5958/0973-5674.2019.00045.5


occurinshortenedscapulardownwardrotators,suchasthelevatorscapular(LS),rhomboid(RHOM),latissimusdorsi(LD),andpectoralisminor(PM),andlengthenedscapular upward rotators, such as the upper trapezius(UT), serratus anterior (SA), and lower trapezius (LT)(Choietal.2015;Haetal.2016;Haetal.2011)7,8,9.

To compensate for insufficient upward scapularrotation, scapulardownward rotation syndromecausesshoulder elevation and adduction,with pain to theLSandUT(Leeetal.2015)6.Inapreviousstudy,shortenedscapular elevator and lengthened scapular upward rotator were found to cause neck pain due to shear forces in the cervical vertebrae such that arm weight was unbearable (Johnson et al. 1994)10. These types of overload can contributetolimitedneckrotationandpain,aswellasmicrotrauma in the neck region with repeated occurrence (VanDillenetal.2007)11.

Ha et al. (2011)9 reported that neck rotation, pain,and proprioception sense were improved with scapular re-alignmentinsubjectswithscapulardownwardrotationsyndrome. The shrug exercises of the scapular abductor in patients with scapular downward rotation syndrome can increasemuscleactivityofthescapularupwardrotators,suchastheUT,SA,andLT,andthattheseincreasesweregreaterthanintheLS(Leeetal.2016)12.

Scapular upward rotator strengthening must be combined with scapular downward rotator stretching for effective shoulder joint treatment (Caldwell etal. 2007)5. Since the scapular downward rotator and scapular upward rotator motion can act in opposition in shoulder function, scapular upward rotation is limitedby the length of the scapular downward rotator; this

is termed passive insufficiency (Kisner et al. 2017)13. Muscleactivationofthescapularupwardrotatorsmustbe sufficient to work against the passive insufficiencyoftheshortenedscapulardownwardrotators;therefore,muscle activation in the scapular upward rotators may decrease with increased length of the scapular downward rotators during shoulder flexion.The effectof scapular downward rotators stretching has not been studied,althoughnumerouspreviousstudiesofscapularalignment and strengthening of the scapular upward rotator have been conducted. The purpose of this study was therefore to investigate the effect of stretchingscapulardownwardrotators,suchastheLS,RHOMandPM,onmuscleactivitiesofthescapularupwardrotators,suchastheUT,LTandSA,duringshoulderflexionat90°,120°,and150°.Themuscleactivityofthescapularupward rotator was expected to decrease after stretching.

METHOD

Participants: Sixteenhealthymalesubjects(Age:23.6 ± 2.7; Height: 176.2 ± 5.0;Weight: 70.7 ± 4.1) wererecruitedforthisstudy;21sampleshoulders(10right;6left) met our inclusion criteria and were used in testing.

Instrumentation:TheNoraxonTeleMyo2400system(Noraxon, Inc., Scottsdale, AZ, USA) was usedto measure electromyography (EMG) signals, andNoraxonMyoResearchXP1.06softwarewasusedfordata collection.A digital band-pass filter (10–450Hz;LancoshFIR)wasusedtoeliminatemovementartifacts.Thesampleratewassetat1,000Hz.Twoelectrodeswereplacedparalleltothetargetmusclefiber,approximately2cmapart,ontheLS,UT,LT,andSA.

Figure 1: Arm elevation at three shoulder flexion angles (a: 90°, b: 120°, c: 150°)

Figure 2: Scapular downward rotator stretch exercises (a: LS stretching, b: quadruped backward rocking, c: pectoralis muscle stretching)


Procedures: Each subject was asked to perform scapular downward rotator stretching (Figure 2a: LSstretching,b:quadrupedbackwardrocking,c:pectoralismusclestretching),andtheUT,LT,LS,andSAmuscleswere measured before and after stretching exercises in shoulderflexionat90°,120°,and150°towardthetargetbar.Thesubjectswereaskedtomaintainshoulderflexionat90°,120°,and150°whiletouchingthetargetbar;atthistime,EMGsignalswererecorded.Thisexercisewasperformedthreetimes(Figure1).Therewasa1-minrestperiod between measurements, and shoulder flexionangles were selected in random order.

Stretching intervention: Each stretching intervention was performed for 20 s and repeated 40 times for a total of20minutesperstretch(Figure2).Tensecondsofrestwas provided between stretching.

Levator scapula stretching: Each subject was asked toperformshoulderabductiontowardthesame-sideearin prone position with head rotation to the contralateral side and slight neck flexion. The examiner appliedpressurebyhandduringscapulardepression,abduction,and upward rotation until the subject was comfortable. ThethumbwasplacedonthemuscleregionoftheLS,andtheotherfingerswereplacedonthemuscleregionoftheRHOM.Theappliedpressurewasmaintainedfor20 sec and then relaxed for 10 sec. The same procedure wasperformedseveraltimes(Figure2a).

Quadruped backward rocking: Each subject was askedtoperformshoulderflexiontouchingeachlowerarmwith90°flexioninquadrupedpositionfortheLD.The subject was asked to tuck his chin and simulate a push-up posture. The subject passively performedshoulderadductionandflexion.Theexaminersupervisedthesubject’sposture,includingtheshoulder,lowerarm,and head position. The subject was asked to perform backward rocking for 20 sec and relax for 10 sec. The sameprocedurewasrepeatedseveraltimes(Figure2b).

Pectoralis muscle stretching: Each subject was asked to perform shoulder abduction to 155° by external

rotation of the glenohumeral joint in a supine position for pectoralis muscles. The examiner applied pressure with massage by hand to stretch the pectoralis muscle group until the subject was comfortable. The applied pressure wastransmittedalongthemusclefiber(Figure2c).

2.3.2 Surface EMG protocol: Two electrodes were placedparalleltothetargetmusclefiberapproximately20mmapartontheLS,UT,LT,andSA.Tonormalizethe measurements, the absolute root-mean-square(RMS)wasdividedbythemaximalvoluntaryisometriccontraction (MVIC).Manualmuscle test positions forMVIC were performed following the guidelines ofKendalletal.(2005)4.

Testing protocol:ThemuscleactivitiesoftheUT,LT,LS,andSAbeforeandafterthestretchingexercisesweremeasured by an examiner and an experimental assistant. The examiner performed the stretching exercise for the subjects. The applied pressure for stretching was maintained for 20 s and then relaxed for 10 s. Subjects performed three stretching exercises for 20 minutes each to stretch the scapular downward rotators. The examiner askedsubjectstoperformshoulderflexionat90°,120°,and150°witha1kgdumbbelltowardthetargetbar,andtomaintaineachshoulderflexionangleatthetargetbarfor5stomeasureEMGsignalsduringshoulderflexionat90°,120°,and150°(Figure1).


The SPSS for Windows statistical package (ver.18.0; SPSS, Inc., Chicago, IL, USA) was used. Theone-sampleKolmogorov–Smirnov test was employed.SignificantdifferencesinEMGmuscleactivitiesamongthe threeconditions (shoulderflexion90°vs.120°vs.150°)beforeandafterstretchingexerciseswereassessedusing two-way repeated-measures analysis of variance(ANOVA) with a significance level of 0.05. When asignificantdifferencewasfound,Bonferroni’sadjustmentwasperformedatasignificancelevelof0.017(a=a/thenumberofpairwisecomparisons=0.05/3).

Table 1. Muscle activity at 90°, 120°, and 150° shoulder flexion before and after exercise (21 shoulders)

Angle MuscleLS UT LT SA

Beforeexercise

90° 7.94±0.66a 19.11 ± 2.12 28.76±3.87 27.69±2.39120° 16.24 ± 2.08 35.16 ± 3.98 29.76±2.92 48.19 ± 3.54150° 27.78±3.06 57.33±5.87 40.31 ± 3.95 62.64 ± 4.32

Afterexercise

90° 8.07±0.91 19.97±2.54 28.47±3.16 26.34 ± 2.38120° 14.21 ± 1.59 33.25 ± 3.52 28.39±2.78 41.90±2.70150° 19.16±2.07 43.50 ± 3.98 38.61 ± 4.23 54.87±3.97

aMean±standarddeviation


Table 2: Significance of the electromyography (EMG) activity of the levator scapula and scapular upward rotators before and after stretching exercises (21 shoulders)

Muscle Effect F-value p-value

LSExercise 28.93 0.00*

Angle 27.67 0.00*

Exercise × angle 17.98 0.00*

UTExercise 9.48 0.00*

Angle 40.39 0.00*


LTExercise 0.71 0.00*

Angle 5.74 0.00*


SAExercise 19.17 0.00*

Angle 33.83 0.00*


*p<0.05

Abbreviations:LS,levatorscapula;UT,uppertrapezius;LT,lowertrapezius;SA,serratusanterior

Figure 3: EMG activity of the LS and scapular upward rotators before and after stretching exercises

FINDINGS

The LS, UT, LT, and SAmuscle activities beforeand after stretching exercises are provided in Tables 1 and2andFigure3.Therewasasignificantinteractioneffectbetweenanglesofshoulderflexionandstretching

exercises(p<0.05).LS,UT,andSAmuscleactivitiessignificantly increased as the angle of shoulderflexion increased (p< 0.017). SAmuscle activitywassignificantlyloweratshoulderflexionanglesof120°and150°aftercomparedtobeforethestretchingexercises(p<0.017).


DISCUSSION

The purpose of this study was to investigate the effect of stretching for scapular downward rotatorsyndrome on scapular upward rotator muscle activity duringarmflexion.OurresultsshowedthattheactivitiesofallmusclesexceptfortheLTincreasedastheshoulderflexion angle increased (p < 0.017). This result canbe explained by the length–tension relationship. Thescapular upward rotator may be activated by shortened muscle length as the angle of arm flexion increases(Ludewig et al. 1996)14. The LS, UT, and SAmuscleactivities were significantly lower after the stretchingexercises thanbefore at150°armflexion (p<0.017),whichmaybeduetoadecreaseinpassiveinsufficiencyof the scapular downward rotator during the exercise. Thesignificantdifferenceinmuscleactivitiesobservedonlyat150°shoulderflexionmaythereforeexplainwhypassive insufficiency during scapular upward rotationcan occur at the end of the range of motion during arm flexion,i.e.,muscleshortnessofthescapulardownwardrotator. Therefore, sufficient length of the downwardrotator can be important for minimizing excessive muscle activities of the scapular upward rotators during shoulder flexion in subjects with scapular downwardrotationsyndrome(Sahrmann2002)2,.

The scapular upward rotation was possible at lower SAandUTactivitiesbecausethepassiveinsufficiencylimiting scapularupward rotation in thefinalphaseofshoulderflexionwasimprovedbythemusclestretchingexercise. Unlike the SA and UT, LT muscle activitybefore was not significantly different from that afterstretching exercises at each shoulder angle. However,as thearmangle increased to90°,120°,and150°,LTmuscleactivityincreased,becausethefunctionoftheLTwasmainlyperformedduringthefinalphaseofshoulderflexionandshoulderabduction.

The previous study have investigated scapular re-alignmentforpainandsymptoms(Kimetal.2016)15 in subjects with scapular downward syndrome. Abnormal scapular alignment can indicate potential changes in joint position and muscle length, because muscleshortnessmayresultinadifferentpositionofthescapulaormovement(Sahrmann2002)2.Scapularre-alignmentcan be achieved using muscle stretching exercises or passivescapularpositioningbyhand,becauseanormalmuscle length in the scapular region produces normal scapularpositionandmovement(Sahrmann2002)2.

However, muscle stretching may contribute todifferencesinthemuscleactivitiesofthescapulabecauseinthelength-tensionrelationship,thelengthenedmusclescannot generate sufficient tension to perform upwardrotation of the scapula (Ludewig et al. 1996)14. In thisstudy,weappliedmusclestretchingexercisestoachieveanappropriate counterbalancing force between the scapular upward and downward rotators. The counterbalanced upward rotator is accompanied with a sufficient lengthof downward rotators. These stretching interventions for scapular downward rotator muscles can be effective forimproving scapular mobility in subjects with scapular downwardrotationsyndrome,andforefficientlyperformingupwardrotationduringshoulderflexion.

LIMITATIONS

Thisstudyhadseverallimitations.First,themusclestretching exercise used herein may not be able to yield normal-length shortened muscles during exercises.Further study is required to determine changes inkinematic data and neural input, which will allowgreater upward rotation after stretching. Second, thesurfaceEMGwasperformedbeforeandafterstretchingexercises.Therefore, the regionoccupiedby theEMGpatch may have changed slightly between measurements.

REFERENCES

1.Kibler, W. Ben, & Aaron Sciascia. Currentconcepts: scapular dyskinesis.British journal ofsportsmedicine44(5)2010;300-5.

2.Sahrmann, Shirley. Diagnosis and treatmentof movement impairment syndromes. Elsevier HealthSciences,2002.

3.Bunch, Wilton H., & Irwin M. Siegel.“Scapulothoracic arthrodesis in facioscapulohumeral muscular dystrophy. Review ofseventeenprocedureswiththreetotwenty-one-yearfollow-up.”JBJS75(3)1993;372-6.

4.Azevedo.,DanielCamara.,T.L.,etal.“Influenceof scapular position on the pressure pain threshold oftheuppertrapeziusmuscleregion.”EuropeanJournalofpain12(2)2008;226-32.

5.Caldwell,Cheryl,ShirleySahrmann,&LindaVanDillen. “Useof amovement system impairmentdiagnosis for physical therapy in the management


of a patient with shoulder pain.” journal oforthopaedic&sportsphysicaltherapy37(9)2007;551-63.

4.Kendall., Florence Peterson., McCreary., et al.Muscles:TestingandFunction,withPostureandPain(Kendall,Muscles).Philadelphia:LippincottWilliams&Wilkins,2005.

5.Sobush, D. C., Simoneau, G. G., Dietz, K. E.,Levene,J.A.,etal.“Thelennietestformeasuringscapular position in healthy young adult females: a reliability and validity study.” Journal ofOrthopaedic & Sports Physical Therapy 23(1)1996;39-50.

6.Lee,Ji-Hyun,etal.“Reliabilityoflevatorscapulaeindex in subjects with and without scapular downwardrotationsyndrome.”PhysicalTherapyinSport192016:1-6.

7.Choi,W.J.,Cynn,H.S.,Lee,C.H.,etal.“Shrugexercises combined with shoulder abduction improve scapular upward rotator activity and scapular alignment in subjects with scapular downward rotationimpairment.”Journalofelectromyographyandkinesiology25(2)2015;363-70.

8.Ha,S.M.,Kwon,O.Y.,Yi,C.H.,etal.“Effectsof scapular upward rotation exercises on alignment of scapula and clavicle and strength of scapular upward rotators in subjects with scapular downward rotationsyndrome.”JournalofElectromyographyandKinesiology262016;130-6.

9.Ha, Sung-min, Kwon, O. Y., Yi, C. H., et al.“Effectsofpassivecorrectionofscapularposition

on pain, proprioception, and range of motionin neck-pain patients with bilateral scapulardownward-rotation syndrome.” Manual therapy16(6)2011;585-9.

10.Johnson, G., Bogduk, N., Nowitzke, A., et al.“Anatomyandactionsof the trapeziusmuscle.”Clinicalbiomechanics9(1)1994;44-50.

11.Van Dillen, Linda R., McDonnell, M. K., etal. “The immediate effect of passive scapularelevation on symptoms with active neck rotation inpatientswithneckpain.”TheClinicaljournalofpain23(8)2007;641-7.

12.Lee, Ji-Hyun, et al. “Various shrug exercisescan change scapular kinematics and scapular rotator muscle activities in subjects with scapular downwardrotationsyndrome.”Humanmovementscience452016:119-129.

13.Kisner, Carolyn, Lynn Allen Colby, & JohnBorstad. Therapeutic exercise: foundations andtechniques.FaDavis,2017.

14.Ludewig, Paula M., Thomas M. Cook., &Deborah A. Nawoczenski. “Three-dimensionalscapular orientation and muscle activity at selectedpositionsofhumeralelevation.”JournalofOrthopaedic&SportsPhysicalTherapy24(2)1996;57-65.

15.Kim,Tae-Ho,& Jin-Yong Lim. “The effects ofwall slide and sling slide exercises on scapular alignment and pain in subjects with scapular downwardrotation.”Journalofphysical therapyscience28(9)2016;2666-9.

Correlation of Iron Saturation Index with Aerobic Capacity in Young Indian Females

Nidhi Mehta1, Bhamini Krishna Rao2, Kalyana Chakravarthy B3, Animesh Hazari4, Karthik Rao5

1Physiotherapist, Gujarat, India,; 2Professor, 3Associate Professor, 4PhD Scholar, Department of Physiotherapy, School of Allied Health Sciences, Manipal Academy of Higher Education (MAHE),

Manipal; 5Associate Professor, Kasturba Medical College, MAHE, Manipal, India

ABSTRACT

Introduction:Irondeficiencyanemiaisverycommoninyoungwomenindevelopingcountries.Theaerobiccapacityisphysiologicallyinfluencedbyironandhemoglobinlevelsalthoughthereareothercontributingfactors for reduced aerobic capacity in adolescents.

Aim: TostudythecorrelationbetweentheironsaturationindexandaerobiccapacityinyoungIndianfemalepopulation.

Materials and Method: The cross-sectional study included forty-one youngwomenwho underwent ablood testanda treadmill test tomeasureaerobiccapacity.Bruce treadmill testingprotocolwasused toestimateVO2max.Descriptive statisticswereused to present hemoglobin, iron, ferritin, iron saturationindexandaerobiccapacity(expressedinVO2peak).Theironsaturationindex,hemoglobin,ironandferritinlevelswerecorrelatedwiththeV02peakusingSpearman’sRhocorrelationcoefficienttest.Thelevelofsignificancewassetat<0.05andthestrengthofcorrelationwasinterpretedasweak,moderateorstrongwiththeˊrˋvalue.

Results:ThemedianandIQRvaluesofhemoglobininmg/dlwas12.6(11.9,13.05),ironinmg/dlwas79(65,95),ferritininmg/dlwas20(13.9,37),ironsaturationindexwas21(16,24)andVO2 peak in ml/kg/min was37.45(35.17,38.7).TheVO2peakvaluesdidnotshowsignificantcorrelationwithhemoglobin(r=0.07,p=0.65),ferritin(r=-0.28,p=0.07),iron(r=0.03,p=0.56)andironsaturationindex(r=0.01,p=0.9).

Conclusion:Theaerobiccapacitydidnotshowsignificantcorrelationwithhemoglobin,iron,ferritinandiron saturation index.

Keywords: Anemia, iron, aerobic capacity, young women

Corresponding Author:KalyanaChakravarthy.B,MPT,PhDAssociateProfessor,Physiotherapy,SchoolofAlliedHealthSciences,ManipalAcademyofHigherEducation,Manipal,IndiaMobile:+919986249740Email: [email protected]

INTRODUCTION

Irondeficiencyisthemostcommoncauseofanemiain females. The prevalence of iron deficiency anemiain women is found to be very high. 1Inclinicalterms,anemiacanbedefinedasadecreaseinoxygendelivery

tothetissuesduetoaninsufficientmassof(Redbloodcells)RBC’scirculatingintheblood. 2 Irondeficiencyanemia is an indicator of poor health and poor nutrition and thus is the most crucial factor contributing to the global burden of disease. 3

The most common cause of iron deficiency isnutritional deficiency affecting almost 45% of theadult females.4 Iron deficiency is classified into threestagesnamelypre-latentstage,latentstageandanemicstage.5 In anemic state, clinical symptoms manifestwith exertion and increased physical activity. 6,7 Tissue oxidative capacity is affected across all levels of irondeficiency, whereas the oxygen carrying capacityis affected only at the most severe stages of iron

DOI Number: 10.5958/0973-5674.2019.00046.7


deficiencywhenhemoglobin concentration is reduced.8,9Potentialrelationshipexistsbetweenirondeficiencyandvariousactivitiesrelatedtowork,leisureandfamilyresponsibility. 10TheaerobiccapacitymeasuredasVO2 maxorVO2peakisdefinedphysiologicallyasthehighestrate of oxygen transport and utilization of oxygen that can be achieved at physical exertion.11 VO2 max values are comparatively low in females compared to males due to several factors including the tissue oxygen carrying capacityandhemoglobinlevels.Irondeficiencywithoutanemiawaspreviouslyfoundtoaffecttheadaptationdueto aerobic training in previously untrained women. 12 Thereisscarcityofliteratureontheassociationofiron,hemoglobin and ferritin levels on aerobic capacity in females.Therefore,theaimofthepresentstudywastodetermineaerobiccapacityinyoungIndianfemalesandcorrelate it with indicators of anemia

METHODOLOGY

Thecross-sectionalstudyincludedforty-oneyoungfemales (age=22 ± 5 years, height=156 ± 5.9 cm andweight=48±6.6kg).Thestudywasconductedinexercisephysiology laboratory of Physiotherapy department associated with a tertiary care hospital (KasturbaHospital, Manipal, Karnataka, India). The approvalwas obtained from Institutional research committeebefore the commencement of the study. The screening oftheparticipantswasdone,andtheparticipantswereincluded based on the selection criteria. A written informed consent was obtained from all the participants included in the study. The participants included were college going female students of age between 18-29.The participants height and weight were recorded and those includedwere of normalweight category (bodymassindexof18.5to24.9asperWHOguidelines).13 Thefactorswhichcouldaffectthebloodtestresultsandthe exercise performance were noted. Dietary habits,

details of menstrual cycle, exercise habits as well asthe involvement in sports were duly taken. Exercise testingandthebloodinvestigationswereconductedfivedays after the follicular phase. The circadian changes were taken in to consideration before testing. Febrile participants,presenthistoryofcardiopulmonarydisease,musculoskeletal problems were excluded from the study.

Theinstrumentsusedforthestudyincludedradio-telemeter device to measure the heart rate (POLAR),treadmill for exercise testing (TandurustwithConceptIntegrationSoftware)andautoanalyzer(IntegraROCHEDiagnostic). An electronic weighing machine was used (Model DS-215 series Essae- Teraoka limited -2003).The participants were asked to stand on the weighing machine without shoes. The height was measured using a wall stuck inch tape. The body mass index was calculated using the formula weight in kg divided by height in m2. Hemoglobin estimation was performed by colorimetermethodandImmunoassaymethodwasusedforestimationofIron,Ferritin,andironsaturationindex.

After familiarizing the participants, incrementalmulti stage treadmill test was conducted to the point of participant’svolitionalfatigue(17-20onrateofperceivedexertion scale). Bruce treadmill testing protocol wasusedandtheVO2 max values were estimated to measure aerobic capacity. 14 The heart rate was measured using radio telemeter. The heart rate and the MET levelachieved were recorded at every stage. The participants wererefrainedfromintakeofmealsandcaffeinebeforean hour of treadmill testing.

Thestatisticalanalysiswasconducted,anddescriptivestatistics was used. The data was not normally distributed andwaspresentedinmedianandinterquartilerange.Thecorrelation of aerobic capacity and iron saturation index wasobtainedbySpearman’scorrelationcoefficient.Thesignificancewas set at p<0.05.Data analysiswas doneusing SPSS version 16.0.

RESULTS

Table 1: The results of blood test in all the participants (n = 41) in median (interquartile range)

Iron saturation index

Hemoglobin (Hb in mg/dl) Iron (in µg/dL) Ferritin

(Fe in ng/mL)VO2 max

(ml/kg/min)21(16,24) 12.6(11.9,13.05) 79(65,95) 20(13.9,37) 37.45(35.17,38.7)

The blood test results show that young female participants in the study had median iron levels of 79(below50isconsideredasdeficiency),Ferritinlevelsof

20(lessthan12isconsideredasdeficiency,ironsaturationindexof21(lessthan30isconsiderednotnormal)andV02maxvaluesof37.45(lessthan40isconsideredless)


Table 2: Correlation of VO2 max with ISI, Hb, Ferritin and Iron using Spearman correlation

coefficient test

Variables Spearman’s rho (r) p valueISI 0.017 0.9Hb 0.072 0.65

Ferritin -0.286 0.07Iron 0.093 0.56

The VO2valuesshowedsignificantcorrelationwithferritin values. There was no significant correlationbetween VO2 max and hemoglobin, iron and ironsaturation index

Table 3: Correlation of distinct phases of iron deficiency with aerobic capacity

Variables Spearman’s rho (r) p value

Pre-latentphaseFe 0.27 0.3LatentphaseFeISI -0.4 0.6LatentphaseISI 0.0 1.0

Anemic phase Ferritin -0.31 0.6AnemicphaseISI -0.2 0.8Anemic phase Hb 0.2 0.8

There was maximum distribution of subjects in the ferritinrange4-20mg/dlandtheaerobiccapacitywasatthehighestin15-20mg/dl.Mostofthesampleswereinthe rangeof 12-14mg/dl and the aerobic capacitywashighestattherange12-13mg/dl

Table 4: The median VO2p across distinct phases of IDA

Phases of IDA VO2max (ml/kg/m2)Prelatent(20) 38.15(35.4,40.6)Latent(4) 36.5(27.5,38.2)Anemic(4) 34.4(28.2,37.5)Normal(13) 38.4

The findings from the present study clearlydemonstrated that therewas no statistically significantcorrelation of iron saturation index (ISI) with aerobiccapacityacrossnormalbodymassindex(table2).Fromtable 1, the sample population had median ISI of 21(IQRis16,24).Theferritinlevelswerelowinmostofthesamplepopulationandnosignificantcorrelationwasseenwithaerobiccapacity.Also,therewasnocorrelation

of iron with aerobic capacity and even the correlation of hemoglobin (Hb) with aerobic capacity was notsignificant.Thesefindingssuggestthataerobiccapacityis influencedby factorsother than irondeficiencyandlowHb. However, the low blood iron profiles clearlyindicate the burden of nutritional deficiencies that areprevalent in our studied population.

DISCUSSION

Inthepresentstudy,wefailedtoestablishastatisticalsignificantcorrelationofaerobiccapacitywithallphasesofirondeficiencyamongstindividualswithnormalBMI.Majorityoftheparticipants48.78%(n=20)amongtheentire study population (n=41) were in the pre-latentphase of iron deficiency anemia. Nevertheless, fromtable 3we found no significant correlation (p=0.3) ofaerobiccapacitywithferritinvaluesinthisphase(rho=-0.27).Thelowferritinleveldidnotaffecttheoxidativeenzymes and hence the aerobic metabolism is in turn not affected.OurresultsarecongruouswiththestudydonebyZhuYiet.al,whereitwasshownthatirondepletionwithout anemia did not affect the endurance capacity.15Moreover, therewerenoother studiesperformed inthe pre-latent phase of iron deficiency in the humanpopulation.

In the latent phase of iron deficiency, the studiedpopulation consisted of 9.75 % (n=4) of all subjects(Fig.1). Again there was no correlation of aerobiccapacitywithserumferritinlevels(rho=-0.4,p=0.6)andISI (rho=0.0,p=1.0) in combination, hence stating thesetwo factorsdidnot affect aerobic capacity inour studypopulation (Table3).To the best of our knowledge andsearch, we did not find any studies reporting aerobiccapacity in the latent phase. In the anemic stage, therewereonlyafewparticipants(n=4)withapercentageof9.75%.Theresultsfromtable3showsthattherewasnocorrelation of aerobic capacity with ferritin (rho= -0.3,p=0.6), ISI(rho=-0.2,p=0.8)andHb(rho=0.2,p=0.8).Our results are in consistent with the previous studieswhich revealed that aerobic capacity is affectedonly atvery low levels of Hb.16 However,inourstudywehadmostofsubjectswithHblevelsof12-14mg/dl,withexceptionoffourparticipants.Intriguingly,thoughtheparticipantsin the study belonged to higher socio-economic status,theirondeficiencywasprevalent in67.5%of thestudypopulation. This emphasizes the need for correction of nutritionaldeficienciesinyoungfemales.


Fromtable4,themeanVO2peak of the subjects was 37.45(35.17, 38.7),whichwas lower compared to agematched western standards. 17,18 Six subjects in our study completed 2nd stage of Bruce protocol, 16 subjectscompleted 3rd stage and 19 subjects completed 4th stage. Muscular fatigue of the lower limb was the commoncause for termination of the test. In the present study,we were not able to compare the aerobic capacity across different levels of irondeficiencydue to inappropriatedistributionofsamplesineachgroup.ThevaluesofVO2 peakwerehigherat thepre-latentphaseanddecreasesfrom latent to anemicphase (Table4).Although therewasnoinfluenceofirondeficiencyonaerobiccapacityfoundinthepresentstudy,theearlierstudiesindicatedthat the iron supplementation or iron therapy can improve the exercise capacity in young females. 19,20The major limitation of the study is that the study was conducted on a small sample and there were very few participants inthestudywithsevereirondeficiency.Alargersamplestudy in future focusing on the influence of iron,ferritin and iron saturation index on aerobic capacity is recommended. The influence of iron deficiency onexercisecapacity in femalepopulationacrossdifferentagegroupsandbasedonthephysicalfitnesslevelsmayhelp in identifying the exact causes for low exercise capacitiesinyoungIndianfemalepopulation.

CONCLUSION

There is no correlation of iron saturation index with aerobiccapacityinyoungIndianfemalesacrossnormalBMI.Similarly,nocorrelationofHb, ironand ferritinwith aerobic capacity was noticed in young Indianfemales across normal BMI. Thus, the present studysuggests that aerobic capacity is influenced by factorsotherthanirondeficiencyandlowHb.

ACKNOWLEDGEMENTS

The authors acknowledge all the participants of the study.

Research project approval and ethical clearance: TheclearancewasobtainedfromInstitutionalresearchcommittee and Institutional Ethics committee, SchoolofAlliedHealthSciences,ManipalAcademyofHigherEducation.

Declarations: The authors declare that the study did not receive any external funding and there are no potential conflictsofinterest.

REFERENCES

1.Alvarez-Uria G, Naik PK,MiddeM,Yalla PS,Pakam R. Prevalence and severity of anaemia stratifiedbyageandgenderinruralIndia.Anemia.2014;2014:1–6.

2.BentleyME,GriffithsPL.Theburdenofanemiaamong women in India. European journal ofclinicalnutrition.2003Jan;57(1):52.

3.WoldieH,KebedeY,TarikuA.FactorsAssociatedwithAnemiaamongChildrenAged6-23MonthsAttendingGrowthMonitoringatTsitsikaHealthCenter,Wag-Himra Zone, Northeast Ethiopia. JNutrMetab.2015;2015.

4.Benoist BD, McLean E, Egll I, Cogswell M.Worldwide prevalence of anaemia 1993-2005:WHO global database on anaemia. Worldwideprevalenceof anaemia1993-2005:WHOglobaldatabase on anaemia.. 2008.

5.McLean E, Egli I, Cogswell M, Benoist BD,Wojdyla D. Worldwide prevalence of anemiain preschool aged children, pregnant womenand non-pregnant women of reproductive age.InNutritional anemia2007 (pp.1-12).Sight andlife Press.

6.KetleyN.Wintrobe’sclinicalhematology.Journalofclinicalpathology.1993Dec;46(12):1142.

7.HaasJD,BrownlieT.Irondeficiencyandreducedwork capacity: a critical review of the research to determine a causal relationship. The Journal ofnutrition.2001Feb1;131(2):676S-90S.

8.Nazli H, Hamid S. Concerns of food security,role of gender, and intrahousehold dynamics inPakistan. Working Papers & Research Reports.1999Aug31:RR-No.

9.McArdle WD, Katch FI, Katch VL. Exercisephysiology: nutrition, energy, and humanperformance.LippincottWilliams&Wilkins;2010.

10.ZhuYI,HaasJD.Alteredmetabolicresponseofiron-depletednonanemicwomenduringa15-kmtimetrial.JApplPhysiol.1998;84(5):1768–75.

11.BrownlieT,UtermohlenV,HintonPS,HaasJD.Tissue iron deficiency without anemia impairs


adaptation in endurance capacity after aerobic training in previously untrained women. The Americanjournalofclinicalnutrition.2004Mar1;79(3):437-43.

12.WHO.Physicalstatus:theuseandinterpretationof anthropometry. Report of a WHO ExpertCommittee.WHOTechnical Report Series 854.Geneva:WorldHealthOrganization,1995.

13.Wessel HU, Strasburger JF,Mitchell BM. Newstandards for the Bruce treadmill protocol inchildren and adolescents. Pediatric Exercise Science.2001Nov;13(4):392-401.

14.James G. ACSM’s Guidelines For ExerciseTesting And Prescription (8th edition). SportExercSci.2011;(28):24.

15.ZhuYI,HaasJD.Irondepletionwithoutanemiaand physical performance in young women. The Americanjournalofclinicalnutrition.1997Aug1;66(2):334-41.

16.Haas JD, Brownlie T. Iron deficiency andreduced work capacity: a critical review of the

research to determine a causal relationship. JNutr. 2001;131(2S–2):676S–688S; discussion688S–690S.

17.BandyopadhyayA.Queen’scollegesteptestasanalternative ofHarvard step test in young Indianwomen.InternationalJournalofSportandHealthScience.2008;6:15-20.

18.ShvartzE,ReiboldRC.Aerobicfitnessnormsformalesandfemalesaged6to75years:areview.Aviation, space, and environmental medicine.1990Jan;61(1):3-11.

19.RowlandTW,DeisrothMB,GreenGM,KelleherJF. The effect of iron therapy on the exercisecapacity of nonanemic iron-deficient adolescentrunners. American Journal of Diseases ofChildren.1988Feb1;142(2):165-9.

20.MagazanikA,WeinsteinY,AbarbanelJ,LewinskiU, ShapiroY, Inbar O, Epstein S. Effect of aniron supplement on body iron status and aerobic capacity of young training women. European journal of applied physiology and occupational physiology.1991Sep1;62(5):317-23.

Effect of Active Cranio Cervical Flexion Exercise of Upper Cervical Spine on Pain, Cervical Range of Motion and

Craniocervical Flexion Test (CCFT) in Patients with Age Group 20-40 Years of Chronic Neck Pain

Ganesh MSP1, Komal Mali2

1Professor, HOD, 2M.P.T, NDMVP College of Physiotherapy, Nashik

ABSTRACT

Background: Cervical spine is surrounded by a complex arrangement of muscles that controls head and neck,protectsthespinalcordandfacilitatesbloodflowtothebrainthroughvertebralopeningswhichareonlypresentincervicalspine.Painisonlyasingle,non-recurrenteventin6.3%ofpatientsexperiencingneckpain.Betweenhalfandthreequartersofpeoplewithneckpainexperiencerecurrencewithin1-5years.Thedeepcervicalflexormuscleisanimportantstabilizerofheadandneckposturelocatedonanteriorandlateral surface of cervical spine. Neck pain is chronic if it lasts for more than 3 months.

Purpose of Study: To findwhether active cranio-cervical flexion exercise could reduce pain, improvecervicalROMandCCFTinpatientswithchronicneckpain.

Aim: Toobservetheeffectofactivecranio-cervicalflexionexerciseofuppercervicalspineonpain,cervicalROMandCCFTinpatientswithchronicneckpain.

Objective: Tofindouttheeffectofactivecranio-cervicalflexionexerciseonpain,cervicalROMandCCFTin patients with chronic neck pain.

Method: Experimental studywas conducted on 35 chronic neck patients between age 20-40 years andaccordingtoinclusioncriteriawererecruitedinstudy.Pain,cervicalROMandCCFTwasassessed.

Results:Pvalue:lessthan0.05forNPRS,cervicalROMandCCFT.

Conclusion:activecranio-cervicalflexionexerciseofuppercervicalspine iseffective in reducingpain,improvecervicalROMandCCFTinpatientswithchronicneckpain.

Keywords: Neck pain, Exercise, CCFT.

INTRODUCTION

Neck pain (NP) is a common problem in thecommunityaffectingapproximately70%ofpopulation.Inoneyear,30%ofadultswill reportNeckpain.Thecervical vertebral column includes seven cervical vertebrae. The cervical column is divided into two regions i.e the upper cervical or craniovertebral region and the lower cervical spine. The craniovertebral region includesoccipitalcondylesandthefirsttwovertebrae;C1and C2 i.e atlas and axis. The lower cervical includes C3 toC7vertebrae.Vertebraes fromC3 toC6are typicalcervicalvertebrae.Theatlas,axisandC7vertebraesareconsidered to be atypical vertebraes1

Thedeepcervicalflexormusclegroup(longuscolli,longus capitis, rectus capitis anterior and lateralis) areconsider to be an important stabilizer of head and neck posture2,3.Therapeutic exercise is one method for curing chronic neck pain. It focuses on solving the dynamicproblems,thatarereportedtobethemaincauseofchronicneckpain,andemphasizesthevalueandimportanceofremediation4.Oneofthesetherapeuticexercises,cranio-cervical flexion, is effective for reducing cervicogenicheadachethatminimizestheactivityofsurfacemuscles,suchasSCM,andtrainstheDCF5

The Deep Cervical Flexor muscles (DCF) areconsidered to be an important stabilizer of the head-

DOI Number: 10.5958/0973-5674.2019.00047.9


on-neck posture. It has been theorized that whenmuscle performance is impaired,the balance betweenthe stabilizers on the posterior aspect of the neck and theDCFswillbedisrupted, resulting in lossofproperalignmentandposture,whichisthenlikelytocontributeto cervical impairment6,7. Therefore DCF training is recommended for increasing the endurance of these postural muscles, leading to improvement in NP.Research recommends that training that emphasizes the correctuseofDCF,beforeintroducingstrengtheningoftheglobalcervicalspinemusculature,ismoreeffectiveintherehabilitationofthecervicalspinethannonspecificstrengthening of neck muscles.

Acraniocervicalflexiontest(CCFT)isatreatmentfor activating DCFs and to reduce activity of SCMmuscle. Treatment of DCF helps in reducing neck pain andcervicogenicheadache.Hence,DCFmuscletrainingis recommended for the clinical management of neck pain8.Julletal.endorseaspecificcraniocervicalflexionexercise(CCFEx)protocolinthesupineposition.Thisprogram initially involves retraining a static holding contraction of the target muscles at a submaximal level to improve their tonic postural function. The type of training employed is based on the nature of the dysfunction presenting in these muscles9,10, aswell astheir normal functional role7.

AIM

Tostudytheeffectofactivecranio-cervicalflexionexerciseofuppercervicalspineonpain,cervicalROMand CCFT in patients with age group 20-40 years ofchronic neck pain.

OBJECTIVES

To see the effect of active cranio-cervical flexiononpain,cervicalROMandCCFT inpatientswithagegroup20-40yearsofchronicneckpain.

MATERIAL AND METHOD

It was an experimental study conducted on 35patients with chronic neck pain between age group 20-40yearswastakenfromMVP’shospitalandresearchcentre Physiotherapy OPD. Convenient samplingmethod was used in the study.

Materials used were:

1. Pen

2. Consent form

3. Assessment form

4. NPRS scale

5. Sphygmomanometer

6.Mobilizationtable

7.Goniometer

Inclusion Criteria:

z Subjects with informed consent.

z Agegroupof20-40years.

z Bothsexi.emaleandfemale.

z Historyofchronic,nonsevereneckpainmorethan3 months.

z Patients who have mild neck pain and disability scoring 5 to 15 from 50 on neck disability index.

z Poor performance on clinical cranio-cervicalflexiontest(unabletoachieve24mmHg)

z Pain intensity more than 3 on numerical pain rating scale(NPRS).

Exclusion Criteria:

z People with severe neck pain.(disability scoringmorethan15onNeckDisabilityIndex)

z History of fracture or trauma around cervical spine.

z History of surgery around cervical spine.

z Patientsufferingfromvertigoordizziness.

z Patients having congenital cervical disorders i.e cervicalrib,torticollis,thoracicoutletsyndrome.

z Majorcirculatoryorrespiratorydisorder.

z Pregnant women or postnatal since 3 months.

PROCEDURE

Permission from The Head of Institution andapproval from Institutional Ethical Committee wasobtained. Subjects who were clinically diagnosed with chronic neck pain were screened according to the inclusion and exclusion criteria and informed consent wastaken.Interventionwasgivenforthriceaweekfor


5weeks.BaselinemeasurementNPRS,CervicalROMand CCFT were assessed before intervention and at the end of last day of intervention. The patients received activecraniocervicalflexionexercise.

Patient positioned in supine, crook lying withcervical spine in neutral position and instructed to performrepeatedmovementsofcranio-cervicalflexionattherhythmof3setsof10repetitions.Duringthefirstset, the therapistassisted theactionofcranio-cervicalflexioncradlingtheheadofthepatientandguidingthecorrectmovement.Forfollowingnexttwosets,patientperformed the movement independently for 5 weeks with a frequency 3days/week. Such as 3 sets of 10repetitions in one day. Figure 1: Patient Performing Active Cranio Cervical

Flexion Exercise

RESULT

Table 1: Intra group comparison of Pain (NPRS), CCFT and Cervical ROM

Outcome measure Pre Rx Post Rx T value P value NPRS 5.57±0.85 4.17±0.82 16.66 <0.0001CCFT 21.03±0.79 22.74±0.82 22.12 <0.0001

Cx Flexion 70.80±5.17 76.37±4.18 11.59 <0.0001Cx Extension 61.43 ± 2.58 66.71±2.43 22.94 <0.0001CxRtlatflx 31.51±2.47 36.20±2.72 19.96 <0.0001CxLftlatflx 33.34 ± 2.40 37.89±2.58 13.81 <0.0001

Cx Rt rotation 73.94±5.18 78.54±4.56 14.22 <0.0001CxLftrotation 74.49±6.40 79.54±6.02 13.22 <0.0001

Result:ThePain(NPRS),CCFTandCxROMimprovedsignificantlyaftertreatment.

DISCUSSION

Active Cranio Cervical Flexion Exercise on Pain: The result found in our study is accordance with study donebyEnriqueLluch JochenSchomacher,LeonardoGizzi, Frank Petzke,Dagmar Seegar,Deborah Falla11. On Immediate effects of active cranio-cervical flexionexercise versus passive mobilisation of the upper cervical spineonpainandperformanceon thecranio-cervical flexion test concluded that Both an exerciseand mobilisation intervention induced immediate pain relief and reduced pressure pain sensitivity over the cervicalspineinpatientswithchronicneckpain.Bothinterventionsresultedinareductioninpain,morechangeswere observed for the exercise group. The reduction in pain was greater than 1 point on the NRS in the exercise group,whichisrecognisedasclinicallyrelevantchange

(Briggs and Closs, 1999)12, and above 0.5 points inboth groups, which is considered clinically relevantif the patients entry level pain is low (Rowbotham,2001)13.Further, the percentage of pain reduction aftertheinterventionwasabove33%fortheexercisegroup,which represents a clinically relevant pain reduction (Farraretal.,2000,2001)14,15. The observation that the active exercise resulted in immediate pain relief has beenobservedpreviously(O‟Learyetal.,2007)16.

Active Cranio Cervical Flexion Exercise on Cervical Rom: The result found in our study is accordance with study done by Enrique Lluch, Jochen Schomacher,LeonardoGizzi,FrankPetzke,DagmarSeegar,DeborahFalla11. On Immediate effects of active cranio-cervicalflexionexerciseversuspassivemobilisationoftheuppercervical spine on pain and performance on the cranio-


cervical flexion test concluded that Both an exerciseand mobilisation intervention induced immediate pain relief and reduced pressure pain sensitivity over the cervical spine in patientswith chronic neck pain.Bothinterventionsresultedinareductioninpain,morechangeswere observed for the exercise group the active group did display a significant reduction in pain during the rangeofmotiontests,whichsupportsthenotionofagenerallygreaterpainrelievingeffectfortheexercisecomparedtothe sustained mobilisation tested in this study.

ZaheenAhmedIqbal,ReenaRajan,SohrabAhmedKhan,AhmadH.Alghadir17DidthestudyonEffectofDeepCervicalFlexorMusclesTrainingUsingPressureBiofeedbackonPainandDisabilityofSchoolTeacherswithNeckPain concluded that therewas a significantchange in both pain and disability in both the groups after the intervention.

Active Cranio Cervical Flexion Exercise on CCFT: Enrique Lluch, Jochen Schomacher, Leonardo Gizzi,FrankPetzke,DeborahFalla11didthestudyonImmediateeffects of active cranio-cervical flexion exercise versuspassive mobilisation of the upper cervical spine on pain and performanceonthecranio-cervicalflexiontest.concludedthat The exercise group displayed an improvement in performanceof themotor task,whichwas reflected inareduction of sternocleidomastoid and anterior scalene. some studies have reported positive effects of passivemobilisation on performance of the CCFT.

ThomasTaiWingChiu, EllisYukHungLaw,MSc2TonyHiuFaiChiu,MSc18. Did the study on Performance oftheCraniocervicalFlexionTestinSubjectsWithandWithoutChronicNeckPainconcludedthatCraniocervicalflexion represents the action of the longus capitis insynergywiththelonguscolli,whichcausesareductionof the cervical lordosis19,20 The pressure biofeedback unit,whichwasplacedbehindtheneck,monitoredtheflatteningofthecervicalspineasthedeepneckflexorswere activated. The results of our study revealed that the highest pressure level successfully achieved during the CCFT was less on average in the subjects with chronic neck pain compared to the asymptomatic group.

CONCLUSION

Active cranio cervical flexion exercise is effectivein reducing pain, CCFT and cervical ROM in subjectsbetweentheagegroup20-40yearswithchronicneckpain.

Limitation of Study:

1. No follow up was done after said duration of study hence,longtermoutcomeoftreatmenttechniquewere not evaluated.

2.Improvementinstrengthwerenotmeasured.

3. Home exercise program were not taught to the patients.


Ethical Clearance: Yes

Disclaimers: None


REFERENCES

1.Dr. amrit kaur, komal mali, Dr. mahesh mitra:To compare the immediate effects of activecranio cervical flexion exercise versus passivemobilization of upper cervical spine on pain,rangeofmotionandcraniocervicalflexiontestinpatientswithchronicneckpain : July:2018:Vol12,number3,22-27

2.Williams P & Warwick R: Grays AnatomyEdinburgh Churchill livingstone.:36th ed:1980

3. JandsV.Muscleandcervicogenicpainsyndromes.ingrantRE(Ed),Nweyork:Churchilllivingstone,physicaltherapy.1988;17:153-166.

4.FallaDL,JullGA,HodgesPW:Patientswithneckpain demonstrate reduced electromyographic activityofthedeepcervicalflexormusclesduringperformance of the craniocervical flexion test.Spine,2004,29:2108–2114.

5.Jull G, Trott P, Potter H, et al.: A randomizedcontrolled trial of exercise and manipulative therapy for cervicogenicheadache.Spine,2002,27:1835–1843.

6.JandaV:Musclesandmotorcontrolincervicogenicdisorders: assessment and Management. In:Physical therapy of the cervical and thoracic spine.2nded.NewYork:ChurchillLivingstone,1994pp195–216.

7.Conley MS, Meyer RA, Bloomberg JJ, et al.:Noninvasive analysis of human neck muscle function.Spine,1995,20:2505–2512


8.FallaD, JullG,RusselT, et al.: Effect of neckexercise on sitting posture in patients with chronic neckpain.PhysTher,2007,87:408–417.

9.JullG,FallaD,TreleavanJ,etal.:Atherapeuticexercise approach for cervical disorders. In:Grieve‟sModernManualTherapy–TheVertebralColumn.Edinburgh:ChurchillLivingstone;2004pp451–469.

10.Enrique Lluch, Jochen Schomacher, LeonardoGizzi, Frank Petzke, Dagmar Seegar, DeborahFalla Immediateeffectsofactivecranio-cervicalflexion exercise versus passive mobilisation ofthe upper cervical spine on pain and performance on the cranio-cervical flexion test. ManualTherapy(2013)17

11.BriggsM, Closs JS.A descriptive study of theuse of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedicpatients.JournalofPainandSymptomManagement1999;18(6):438e46.

12.RowbothamMC.Whatisa‟clinicalmeaningful‟reduction in pain Pain 2001;94: 131e2.

13.Farrar JT,PortenoyRK,Berlin JA,Kinman JL,Storom BL. Defining the clinically importantdifference in pain outcome measures. Pain2000;88:287e94.

14.FarrarJT,YoungJrJP,LaMoreauxL,WerthJL,Poole RM. Clinical importance of changes inchronic pain intensity measured on an 11-pointnumerical pain rating scale. Pain 2001;94:149e58.

15.O‟LearyS,FallaD,HodgesPW,JullG,VicenzinoB. Specific therapeutic exercise of the neckinducesimmediatelocalhypoalgesia.TheJournalofPain2007;8(11):832e9.

16.ZaheenAhmedIqbal1)*,ReenaRajan2),SohrabAhmed Khan3),Ahmad H. Alghadir Effect ofDeep Cervical Flexor Muscles Training UsingPressure Biofeedback onPain and Disability ofSchool Teachers with Neck Pain J. Phys. Ther.Sci.25:657–661,2013

17.Thomas TaiWing Chiu, PhD1 Ellis Yuk HungLaw, MSc2 Performance of the CraniocervicalFlexion Test in Subjects With and WithoutChronic Neck Pain J Orthop Sports Phys Ther2005.35:567-571

18.Mayoux-Benhamou MA, Revel M, Vallee C.Selectiv electromyography of dorsal neck muscles inhumans.ExpBrainRes.1997;113:353-360.

19.Mayoux-Benhamou MA, Revel M, Vallee C,RoudierR,Barbet JP,BargyF.Longuscollihasa postural function on cervical curvature. Surg RadiolAnat.1994;16:367-371.

Fall Prevention by Short-Foot Exercise in Diabetic Patients

Kukiat Tudpor1, Wallapa Traithip2

1Faculty of Public Health, 2Physical Therapy Unit, Suddhavej Hospital, Faculty of Medicine, Mahasarakham University, Maha Sarakham, Thailand

ABSTRACT

A fall during walking is a common problem in diabetic patients due to neuromuscular complications of the foot,especially intrinsic footmuscles(IFMs).Short-footexercise(SFE)hasbeenreported tostrengthenIFMs in healthy individuals. This present study was aimed to investigate effects of SFE on mediallongitudinalarchintegrity(naviculardroptest,NDT)anddynamicposturalcontrol(starexcursionbalancetest,SEBT).TheSEBTvaluesweremeasuredonsingle-legstandingin8directions(anterior,anteromedial,medial,posteromedial,posterior,posterolateral, lateral, andanterolateral)atbaseline,week4,8, and12(followup)in15diabeticpatients:controlgroup(n=7)andSFEgroup(n=8).ResultsshowedthatNDTwasreducedinSFEgroupcomparedtocontrolatweek8andfollowup.ThenormalizedSEBTvaluesinSFEgroupwassignificantlyhigherthanbaselineonlyinmedialdirectionandincreasedfrombaselinesinanteromedial,medial,andposteromedialdirectionsatweek4and8,respectively.Atthefollow-uppoint,onlyposteromedialdirectionshowedanimprovementofnormalizedSEBTinSFEgroup.Inconclusion,8-weekSFEreducedfootpronationandimproveddynamicposturalcontrolinasingle-legstandingphaseofdiabeticfoot.TheSFEshouldbecontinuouslyappliedtodiabeticfootsincethebenefitswerenotwellpersistentinthefollow-upphase.

Keywords: short-foot exercise, intrinsic foot muscles, diabetes mellitus, dynamic postural control, fall prevention

Corresponding Author:KukiatTudpor,PT,PhDFacultyofPublicHealth,MahasarakhamUniversity,Khamrieng,Kantarawichai,MahaSarakham,Thailand-44150Phone:+66-95-8983096Email: [email protected]

INTRODUCTION

Walking consists of stance (weight-bearing)and swing (non-weight-bearing) phases.1 The foot is an exquisite structure primarily devised for forcetransduction and propulsion in stance phase.2 These functionslargelyrelyonmediallongitudinalarch(MLA)integrity.3 The stance phase can be divided into early and latephases.Intheearlystancephase,theMLAmustbeappropriately compliant to allow downward movement of the navicular bone and foot pronation. These temporarily absorb the ground reaction force which increases up to 1.5-time body weight during this phase.4 The subtalar jointhyperpronationisasignofMLAweakness,whichcan be determined by the NDT values.5Inthelatestance

phase,theMLAbecomesrigidtogeneratesubtalarjointsupination and transmit the propulsive force from the foot to the other parts of the body.6

TheMLA integrity ismaintainedbyplantar fascia,ligaments,andplantarextrinsic(EFMs)andintrinsicfootmuscles (IFMs).7 However, only the EFMs and IFMscan be trained with the active exercise programs. The concentric exercises such as heel raises, toe curls, feetpointed up-and-down, toe spreads, toes up-and-downarecommonlyusedtostrengthenEFMsandIFMs.8IFMactivities can prevent foot hyperpronation and provide the MLAstability,whichisimportantforasingle-legdynamicpostural control during walking.9Therefore,IFMwastingand imbalance in some chronic diseases such as chronic kidney diseases and diabetes mellitus might impair walkingability;however,theIFMstrengtheninghasnotbeen applied to patients with these diseases.10,11

Diabetic peripheral neuropathy (DPN) is definedas the presence of symptoms and/or signs of peripheral nerve dysfunction in diabetic patients.12 A cause of DPN is microvascular impairment surrounding peripheral nerves.13 DPN onset is insidious taking several weeks to

DOI Number: 10.5958/0973-5674.2019.00048.0


years after diagnosis of diabetes.14DPNcanbeclassifiedinto 4 stages: 0-1, no clinical neuropathy; 2, clinicalneuropathy (painful, sensory loss, ormuscle atrophy);and 3, late complications of clinical neuropathy (footlesions or neuropathic deformity).12DPN-inducedIFMatrophycausespoordynamicposturalcontrol,increasingin a risk of fall during walking.10, 15 Early prevention should be implemented beforehand. However, mostclinicians start to tackle this problem only after the patients manifest clinical signs of sensory DPN. The purposeofthispresentstudywastoexaminetheeffectsofSFEonMLAintegrityand dynamic postural control as the fall preventive intervention in diabetic patients.


Human Subjects: Fortydiabeticpatientsfromtheout-patient department, SudthavejHospital were allocatedtocontrolexercisegroup(n=20)andSFEgroup(n=20)afterbeingassessedforeligibility.Inclusioncriteriawere diabetes mellitus by WHO criteria16, ability towriteandspeakThai,andinformedconsent.Exclusioncriteriawere cognitive impairment, sensoryDPN and/ordiabeticfootulceration,symptomatic jointdiseases,and uncontrolled heart diseases. All procedures have been approved by the Ethical Review Committee for HumanResearch,MahasarakhamUniversity(038/2559)and registerd to the Thai Clinical Trials Registry (TCTR20180916001).

Baseline Assessments: The out-patient subjects wereevaluated for fasting plasma glucose (FPG), HbA1c,and other demographic data. The data of the completed subjects are shown in Table 1. The subjects were re-confirmed for the absence of foot ulceration andsensory footDPN using SemmesWeinstein 5.07/10-gmonofilament(SWM).

Exercise Procedures: The control subjects were instructed to perform 30 repetitions of 5 standard foot exercisesinsitting:1)plantarflexionwithadduction;2)toe curls; 3) feet pointed up and; 4) toe spreads; and 5) toes upanddown.Inadditiontothe5standardfootexercises,the SFE subjects were guided to perform SFE exercise by shifting the metatarsal heads toward the calcaneus without flexingthetoesandsustainingfor5secondsduringeachrepetition in sitting for 30 min/day.17

Navicular Drop Test: The NDT is a procedure conducted tomeasureadegreeoffootpronationandIFMfatigue.18 Eachsubjectwasrequestedtositonachairwithsubtalarjointneutralpositioninsitting–thekneejointflexedto90°andplacethesecondtoeandthepatellainastraightline. Then the distance from the navicular tuberosity to the ground was measured. Subsequently, the distancewas measured again in a standing position. Details are described elsewhere.9

Figure 1: Directional mapping of the star excursion balance test (SEBT) for both left and right limb standing. 1, anterior; 2, anteromedial; 3, medial;

4, posteromedial; 5, posterior; 6, posterolateral; 7, lateral; 8, anterolateral

Star excursion balance test: While the subjectswerestandingonasingle limb, theywereasked toreachtheother limb as far as possible along each reaching line without shifting body weight toward the reaching limb; and then returns the reaching limb to the beginning positioninthecenterof thegrid,reassumingabilateralstance.19DirectionalmappingoftheSEBTisdepictedinFig.1.SEBTvaluesweremeasuredand normalized with respective leg lengths.19


Ifnotspecifiedotherwise,thedataareexpressedasmean±SEM.NormalityofsampledatawastestedbyKolmogorov-Smirnov test.Multiple sets of data werecomparedbytheFriedmantest.Meansoftwodependentand independent groups were compared byWilcoxonsigned-ranktestandMann-WhitneyUtest,respectively.ThelevelofstatisticalsignificancewasP<0.05.AlldatawereanalyzedbyGraphPadPrism(version4.0cforMacOSX;GraphPadSoftware,USA).


Table 1: Basic characteristics of subjects at baseline

Variable Control SFEAge(years) 67.4±0.5 62.6 ± 0.4YearsofDM 3.7±0.9 10.0 ± 2.3

GenderMale 3 4

Female 4 4Height(cm) 156.2 ± 0.4 163.6 ± 0.4Weight(Kg) 65.3 ± 0.5 70.4±0.4BMI(Kg/m2) 26.8 ± 0.3 26.6 ± 0.3

HbA1c 7.6±0.3 8.4 ± 0.5

Conted…

HDL 44.0±1.7 45.4 ± 3.3LDL 106.9±8.7 105.2 ± 10.8

BUN/Creatinineratio 16.2 ± 2.8 15.7±1.6

RESULTS

Baseline Assessments: 15 patients completed the program (control, n=7 andSFE,n=8).All subjectshadnofootsensoryDPNassessedwithSWM,nofootulceration or wound. All basic demographic data are shown in Table 1.

Figure 2: Mean navicular drop test values (mm) at baseline (0 week) compared to 4, 8, and 12 weeks post-exercise training interventions in control (A) and SFE (B) groups. *P<0.05 compared to respective baseline. Comparison of mean navicular drop (mm) between control (white bar) and SFE (black bar) groups at 0, 4,

8, and 12 weeks post-exercise training interventions (C).

Short-foot exercise improves NDT: Atbaselines,NDTvalueswerenotdifferentbetweencontrolandSFEgroups(7.0±1.8and8.3±1.0mm,respectively).Afterinterventions,NDTwasnotchangedthroughoutthestudyincontrolgroup(Fig.2A).Incontrast,NDTofSFEgroupsignificantlydecreasedfrom8.3±1.0to4.5±0.5mmatweek8.ThisreductioninNDTstillpersisteduntilweek12(3.8±0.6mm)inSFEgroup(Fig.2B).However,thereisnodifferenceinNDTbetweencontrolandSFEgroupatanypointsofmeasures(Fig.2C).

Table 2: Normalized star excursion balance test

Normailized SEBT Baseline Post-intervention Follow-upPoint of measures (0 week) (4 week) (8 week) (12 week)

Group Control SFE Control SFE Control SFE Control SFEAnterior reach 62.0 ± 3.1 67.5±3.8 67.9±3.2 70.8±2.2* 64.4 ± 2.1 71.1±4.6* 63.8 ± 3.1 71.7±2.3*

Anteromedial reach 61.1 ± 1.9 61.7±3.0 64.2 ± 3.3 68.3 ± 4.0 63.8 ± 3.2 67.9±3.2#* 75.4±3.3 71.6±3.2Medialreach 63.0 ± 2.3 63.6 ± 3.0 64.9 ± 3.6 75.2±2.4# 68.2 ± 2.5 77.0±3.1# 68.0 ± 2.8 74.0±2.5

Posteromedial reach 58.2 ± 2.5 59.5 ± 3.1 65.3 ± 3.8 69.1 ± 4.1 65.1±3.7 75.6±3.4#* 66.3 ± 3.2 71.4±3.3#

Posterior reach 54.9 ± 3.3 58.2 ± 4.0 59.9 ± 3.8 60.7±2.9 55.4±3.7 62.6 ± 3.1 56.9 ± 2.6 61.5 ± 4.3Posterolateral reach 61.2 ± 3.1 53.2±4.7 62.9 ± 5.1 59.4 ± 2.0 57.3±3.7 60.7±3.7 57.7±3.1 57.0±3.7

Lateralreach 59.0 ± 3.6 54.8 ± 1.9 64.2 ± 5.8 52.3 ± 2.6 55.6 ± 2.6 53.6 ± 3.4 54.8 ± 3.8 48.7±2.1Anterolateral reach 55.9 ± 3.9 57.0±1.9 62.5 ± 4.5 59.8 ± 3.3 57.0±2.7 65.6 ± 3.6 55.7±3.4 60.3±2.7


Star excursion balance test (SEBT) values werenormalized with length of respective lower limb. Data arepresentedasmeans±SEM.*p<0.05versusrespectivecontrol, #p<0.05versusrespectivebaseline.

Short-foot exercise improves dynamic postural control in standing: Normalized SEBTs werecalculated and shown in Table 2.After 4 weeks, thenormalizedSEBTsinalldirectionsofthecontrolgroupwerenotchanged.MeanwhiletheSFEgrouphadhigher

anterior reach compared control and higher medial reach compared to baseline. Effects of the SFE were moreprominent after 8 weeks–the anterior, anteromedial,and posteromedial reaches were higher than control. Moreover,theanteromedial,medial,andposteromedialreaches were also higher than their respective baselines. Then all of the subjects stopped the exercise program for 4weeks.Atweek12,theincreasednormalizedSEBTsstill persisted only in the anterior and posteromedial directions.

Figure 3: Levels of fasting plasma glucose at baseline, 4, 8, and 12 weeks post-exercise training interventions in control (A) and SFE (B) groups

Effects of SFE on MLA stability and dynamic postural control were independent of plasma glucose levels: Controlling blood glucose levels is one of the key practices to prevent the progress of diabetic complications.20 Results showed that FPG levels were in therangeofdiabetes(≥126mg/dL) throughout theexperimentsinbothgroups(Fig.3AandB).

DISCUSSION

ThispresentstudyshowsthatSFEimprovesMLAintegrity and dynamic postural control independently of FPG levels.Our conclusion is based on the followingfindings: (1) SFE reduces NDT, signifying improvedMLA functions. (2) SFE improves dynamic postural control as indicated by increased normalized SEBTvalues. (3) The FPG levels were in the range of diabetes throughout the experiments.

The finding NDT reduction after 8-week SFEtraining is in accordance with the previous report of positive correlation between decreased NDT with the IFMactivitiesandMLAfunctions.21Therefore,theeffectof SFE on reducing NDT could be mainly attributed to

increasedstrengthofIFMs.Jungandcolleaguesreportedthat the EMG activity of the abductor hallucis in thesingle-legstancepositionwassignificantlyhigherthanthat while sitting.22Additionally,previousstudyshoweda significant rise in IFM activities during single-legstance.23Altogether,thepositiveeffectofSFEonMLAis potentially due to strengthening of IFMs. FurtherstudywithquantitativeEMGindiabeticpateintswouldpointspecificIFMs.

WealsofoundtheimprovementsofthenormalizedSEBTvalues.Toourknowledge,thispresentstudywasfirsttomeasureSEBTindiabeticpatients.SensoryDPNimpairs cutaneous protective sensations whereas motor DPNcausesIFMatrophy.10ThemonofilamentassessestheintegrityofMerkeldiscsandMeissner’scorpusclesandassociatedsensoryfibers.24However,the10-gSWMhasbeen reported tohave afluctuative sensitivity andlackaspecificitytodetectanearlyDPN.25UsingsmallerSWM or other more sensitive instruments might beneededforearlydetection.Besides,motorDPNmightalso occur in motor cortex depicted by the reduction in the size of the motor area of the brain.26 Clarifying whether theeffectsofSFEareassociatedwithcorticalmotorareaadaptationswouldbebeneficial.


Lastly,theeffectsofSFEonNDTandnormalizedSEBTvalueswerenotdependentonthelevelsofFPGandHbA1c.Musclewasting,acommoncomplicationindiabetesmellitus,isenhancedbyhyperglycemiathroughatranscriptionfactornuclearfactorkappa-B(NF-κB).27 Exercise training attenuated diabetes-induced musclewasting through NF-κB.28 Whether the effect of SFEis related to NF-κB inhibition still requires furtherinvestigation.Insummary,SFEimprovesMLAintegrity and dynamic postural control independently of plasma glucose levels. The exercise should be continued in the longtermastheeffectsarenotpreservedaftera4-weekuntrained period.

ACKNOWLEDGMENT

This work was supported by Faculty of Public Health and Faculty of Medicine, Mahasarakham University,Thailand.

Conflict of Interest: The authors declare that they have noconflictofinterest.

Informed Consent: Informed consent was obtainedfrom all individual participants included in the study.

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3.Robbins SE and Hanna AM. Running-relatedinjury prevention through barefoot adaptations. Med Sci Sports Exerc1987;19:148-156.

4.Keller TS, Weisberger AM, Ray JL, et al.Relationship between vertical ground reaction force and speed during walking, slow jogging,and running. Clinical biomechanics 1996; 11: 253-259.

5.RazeghiMandBattME.Foottypeclassification:a critical review of current methods. Gait Posture 2002;15:282-291.

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7.FiolkowskiP,BruntD,BishopM,etal.Intrinsicpedal musculature support of the medial longitudinal arch: an electromyography study. J Foot Ankle Surg2003;42:327-333.

8.KuligK,PomrantzAB,BurnfieldJM,etal.Non-operative management of posterior tibialis tendon dysfunction: design of a randomized clinical trial [NCT00279630]. BMC Musculoskelet Disord 2006;7:49.

9.Mulligan EP and Cook PG. Effect of plantarintrinsic muscle training on medial longitudinal arch morphology and dynamic function. Manual therapy2013;18:425-430.

10.Bus SA, Yang QX, Wang JH, et al. Intrinsicmuscle atrophy and toe deformity in the diabetic neuropathic foot: a magnetic resonance imaging study. Diabetes care2002;25:1444-1450.

11.ArnoldR,IssarT,KrishnanAV,etal.Neurologicalcomplications in chronic kidney disease. JRSM Cardiovasc Dis2016;5:2048004016677687.

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13.Singh R, Kishore L and Kaur N. Diabeticperipheral neuropathy: current perspective and future directions. Pharmacol Res2014;80:21-35.

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The Effect of Rhythmic Auditory Cueing on Functional Gait Performance in Parkinson’s Disease Patients

Manali Akre1, Jui Dave2, Medha Deo3

1MPTh Student, 2Professor, 3Principal, Terna physiotherapy college, Nerul

ABSTRACT

Purpose: Parkinson’s disease is a progressive neurological movement disorder. Gait and its relateddysfunctions cause a lot of disability to the patient. The common objective for all therapeutic intervention aimstopreserveapatient’sindependenceandqualityoflife.Thereareestablishedbenefitsofexercisestomaintainfunctionalindependenceincludinggait,preventfallsanddecreasediseaseprogression.Externalcueing such as rhythmic auditory cueing is a strategy that can be used in adjunct with traditional gait training intervention to facilitatemovement, gait initiation and continuation. The external auditory cue trainingreroutedthemovementthroughanon-automaticpathway,removingitfromautomaticbasalgangliapathway.TherehasbeensomeevidencewhichsuggeststhepositiveeffectofapplicationofrhythmicauditorycueingongaitandbalanceperformanceofParkinson’spatient,butitstillremainsambiguous,hence,thisstudyisplannedtogathermoreevidence,ontheeffectofexternalauditorycuesongaitperformanceinParkinson’sdisease patients.

Aim: To study the effects of rhythmic auditory cueing on functional gait performance in individualsdiagnosedwithParkinson’sdisease.

Objectives:Toassessandcomparetheeffectofconventionalrehabilitationexercisescombinedwithrhythmicauditory cueing and conventional rehabilitation exercises on functional gait performance using freezing of gaitquestionnaire(FOGQ),modifiedgaitefficacyscale(MGES)andfigureofeightwalktest(FO8WT)inParkinson’sdiseasepatients.METHOD-Prospectiverandomizedcontrolledtrial.

Results:ThestudyresultsshowthatthereisasignificantimprovementinfunctionalgaitperformanceinParkinson’sdiseasepatientsafterauditorycueingreflectedbythesignificantpvaluesofrespectivetests.

Conclusion:Theabovestudyconcludesthatapplicationofrhythmicauditorycueinghasbeneficialeffectsonthefunctionalgaitperformanceprimarilyonfreezingofgait,MGESandthetimecomponentofFO8WTinParkinson’sdiseasepatients.

Keywords: Functional gait performance, Parkinson’s disease, Rhythmic auditory cueing, freezing of gait.

Corresponding Author:Dr.JuiDaveProfessor,TernaPhysiotherapyCollege,Sector12NerulRoadnearSarsoleDepot,Nerul,NaviMumbai-400706

INTRODUCTION

Parkinson’s disease is a chronic, progressivedisease of the nervous system characterised by the cardinal features of rigidity, bradykinesia, restingtremors and postural instability1. It is a very common

neurodegenerative disease that affects more than 2percent of the population older than 65 years of age. Average age of onset is approximately 50 to 60 years1. ThecauseofParkinson’sdiseaseremainsunknownandthe consensus is that it is multifactorial. Parkinson’sdiseaseorIdiopathicparkinsonism,isthemostcommonform, affecting approximately 78 percent of patients.Parkinsonian signs and symptoms are the results of dysfunctional basal ganglia activity, with specificinvolvement of the substantia nigra and its effects onmotor pathway inhibition and excitation, ultimatelyleading to a reduced supply of internally generated

DOI Number: 10.5958/0973-5674.2019.00049.2


movement cues. As the disease progresses there is an increased death rate of dopminergic cell bodies leading to the classic presentation of Parkinson disease motor dysfunction. The clinical presentation of Parkinson diseaseincludesrestingtremor,bradykinesia,muscularrigidity,impairedposturalreflexesandbalance,lossofautonomicmovements, and speech changes2. External cueing with temporal or spatial stimuli is a strategy that can be used in adjunct with traditional gait training intervention to facilitatemovement, gait initiation andcontinuation Perhaps one explanation is that the external auditory cue training rerouted the movement through a non‐automaticpathway,removingitfromtheautomaticbasal ganglia pathway3.

Whenwalking,peopleoftenneedtovisuallysearchtheir intendedpath.Therefore,visual cueing strategiesinevitably impose various impracticalities for use in daily life4. While auditory cueing largely bypassesthis problem, attempts to develop acoustic cues forParkinson’smayhave been discouragedby a reporteddetrimentalinfluenceoflisteningtomusicwhilstwalking.Recentevidencesuggeststhat,whenwalkingtoauditorycues, improvements to gait inParkinson’s patients aredirectly influenced by the specific nature of auditoryinformation presented4. Use of external cues promptconscious thought about the desired movement via the frontal cortex, thereby circumventing dysfunctionalinternal movement mechanism of basal ganglia and actively engaging the cerebral cortex into movement control3. The external auditory cue training rerouted the movement through a non-automatic pathway,removing it from automatic basal ganglia pathway5. However, positive observational results in the clinicalsetting have limited quantitative validation.There hasbeensomeevidencewhichsuggests thepositiveeffectof application of rhythmic auditory cueing on gait and balanceperformanceofParkinson’spatient,but it stillremains ambiguous, hence, this study is planned togathermoreevidence,ontheeffectofexternalauditorycuesongaitperformanceinParkinson’sdiseasepatients.

MATERIAL AND METHOD

Study Type:Prospective,Experimental

Study Design: Prospective randomized controlled trial

Sample Size:84Parkinson’diseasedpatients.

Samplesizewasdeterminedusingtheformula,N=(Z1-a/2)

2 (S)2/d2.

Z1-a/2=normallevelofdeviation,

S=standarddeviation,d=minimumallowableerror.

With90%statisticalpowerat0.05significancelevelusing SAS 9.1.3

Sampling Technique: Simple random Sampling.

Duration: 18 months.

Sampling Frame: Research was conducted in the Parkinson’s disease and Movement Disorder Society,Mumbai(PDMDS).

Computed N Per Group

Index Nominal Power

Actual Power

N Per Group

1. 0.80 0.804 312. 0.85 0.851 353. 0.90 0.902 41

Require sample size for this study: 42 × 2 = 84: 84 Parkinson’s disease patients (42 experimental group,42 control group) of age group (64.23+5.04) involved voluntarily. Participants with Grade 2 and Grade 3 of Parkinson’s disease onHoehn andYahr classification,which all were having score >24onmini-mentalstateexamination and ambulated independently indoors without aid were included in a study. Subjects with the presence of any other neurological or cardiopulmonary disease which interferes with the mobility of participants andsubjectswithcognitive,auditoryorvisualproblemswere excluded from the study.

Materials Used:MetronomeApp,penandpaper,cones,chock,measuringtape,stopwatch,headphones.

Fig. 1: Materials used-Metronome App, pen and paper, cones, chock, measuring tape, stopwatch,

headphones


Initially functional gait performancewas assessedusing the outcome measures. Rehabilitation was carried out during ‘ON’ phase of medication. Conventionalprotocol of rehabilitation for gait training, whichincluded,

z Stretching

z Strengthening.

z PNFtechniques

z Active assisted movements

z Fine motor activities

z Gait training

z Functional movements

Then for experimental group subjects were additionally received the treatment with rhythmic auditory cueing that is sound generated by an “Auditory Application” which was downloaded from a Google playstore.Itgeneratesasoundatparticularfrequencyof80-100BPMandsubjectswereaskedtowalkfor20mins.

Inparticular,20minofeachsessionwerededicatedtocontinuouslevelwalking,whileparticipantsequippedwith a portable speaker and headphones listened to the auditory cues. During this period, participants werealsoinstructedtoperformattheirhomes(atleastthreetimes a week) a subset of the same exercises as used at thehospital, including20minofgaitwith rhythmicauditory cueing. The exercise program was continued for5weeksdurationwithtwosessionsaweek,45minper session. Patients were provided with a diary in which theyself-reportedboththedurationandtypeofactivitiesperformed at home6. The diary was monitored by the physical therapists once a week.

The exercise program was continued for 5 weeks durationwithtwosessionsaweek,45minpersession.

Eachsessionwillbedividedinto5warm-upminutes—30min for the main part and 10 min for the cool down. The rhythmic auditory cueing made available to patients and patients were educated to do the same exercises as a part of home program.

Reassessment of functional gait performance with theoutcomemeasures (MGES,FO8WT,FOGQ)weredone after 5 weeks. These pre-and post-scores werecalculated and assessed.

Fig. 2: Parkinson’s patient while gait training with auditory cueing generated by metronome

FINDINGS

Statistical calculations and analysis of data was performedusingasoftwarepackageSPSSforwindows,version 19.0 and results were calculated at 0.005 level of significance.NormaldistributionofdatawastestedforallbaselineparametersusingShapiroWilktest.

Table 1: Age group of Patients in Experiment and Control Group

Age Group Experiment Percentage Control Percentage Total Percentage50–59 8 20.5 9 21.4 17 21.060–69 25 64.1 24 57.1 49 60.570–79 5 12.8 8 19.0 13 16.080+ 1 2.6 1 2.4 2 2.5Total 39 100.0 42 100.0 81 100.0

TheabovetableshowstheagegroupofParkinson’sdiseasepatientsinexperimentandcontrolgroups.Overallinthisstudy81patientsareincludedand39inexperimentgroupand42incontrolgrouprespectively.Maximum60


to69yearsofpatientsareincludedinboththegroups25(64.1%)and24(57.1%)inexperimentgroupandcontrolgrouprespectively.Veryleastthatisoneeachjustmorethan80inbothgroups.

Table 2: Measures of Parameters in Control group (Pre test Vs Post test)

ParametersControl group

Test N Mean SD Wilcoxon Signed rank test P-value Significance

FOGPre 42 15.90 2.32

3.112 0.002 YesPost 42 14.79 2.38

MGESPre 42 60.93 7.94

0.000 1.000 NoPost 42 60.93 6.25

Figure of 8 Walk Test Test N Mean SD Wilcoxon Signed

rank test P-value Significance

TimesPre 42 19.24 3.57

0.768 0.447 NoPost 42 18.95 2.60

No. of StepsPre 42 20.90 3.15

2.689 0.101 NoPost 42 21.88 3.35

MarkersPre 42 2.81 0.51

0.628 0.534 NoPost 42 2.86 0.35

Theabove tableshows thatpreandpost testdata incontrolgroup.ThescoreofFOGis statisticallyhighlysignificantinpreandpoststudybutnotinMGESscore.SimilarlyFigureof8walktestalltheparametersliketime,numberofstepsandmarkersarenotstatisticallysignificant.

Table 3: Measures of Parameters in Experiment group (Pre test Vs Post test)

ParametersExperiment group

Test N Mean SD Wilcoxon Signed rank test P-value Significance

FOGPre 39 16.59 2.46

3.773 <0.001 YesPost 39 14.51 2.63Test N Mean SD Paired T test P-value Significance

MGESPre 39 61.69 7.46

4.059 <0.001 YesPost 39 65.95 5.12

Figure of 8 Walk Test Test N Mean SD Wilcoxon Signed


TimesPre 39 17.13 3.57

4.857 <0.001 YesPost 39 15.33 2.94

No. of StepsPre 39 19.72 3.53

1.561 0.127 NoPost 39 19.15 3.86

MarkersPre 39 2.62 .63

1.525 0.135 NoPost 39 2.77 .48

Theabovetableshowsthatpreandposttestinexperimentgroup.ThescoreofFOGandMGESarestatisticallyhighlysignificantinpreandpoststudy.SimilarlyFigureof8walktestonly‘time’parameterisstatisticallyhighlysignificantinpreandpoststudybutotherfactorsnumberofstepsandmarkersarestatisticallynotsignificantinpreand post study.


Table 4: Measures of Parameters of Experiment group Vs Control group

ParametersExperiment group Vs Control group

Group N Mean SD Wilcoxon sum rank test P-value Significance

FogExperiment 39 14.5128 2.6345

0.847 0.397 NoControl 42 14.7857 2.3843Group N Mean SD Independent T test P-value Significance

MGESExperiment 39 65.9487 5.1245

3.936* <0.001 YesControl 42 60.9286 6.2485

Figure of 8 Walk Test Group N Mean SD Wilcoxon sum


TimesExperiment 39 15.3333 2.9409

5.873* <0.001 YesControl 42 18.9524 2.6035

No. of StepsExperiment 39 19.1538 3.8562

3.404* 0.001 YesControl 42 21.8810 3.3510

MarkersExperiment 39 2.7692 0.4846

0.937 0.352 NoControl 42 2.8571 0.3542

The above table shows that there is a statistical significant difference found in MGES and twocomponents of FO8WT, those components are timeand number of steps while no statistical significantdifference found in FOG questionnaire and markercomponent of FO8WT on comparison of post studybetweenexperimentgroupVscontrolgroup.

DISCUSSION

The study results show that there is a significantimprovement in functional gait performance in Parkinson’s disease patients after auditory cueingreflected by the significant p values of respectivetests. Improvement infunctionalgaitperformancewasseen after 5 weeks, assessed using Freezing of gaitquestionnaire,Modifiedgaitefficacyscaleandfigureofeight walk test.

There are two fundamental modes of timing:

1.Explicit timing which is required to makedeliberate estimates of duration and relies on internal sense of time7.

2.Implicit timingwhich utilizes external cues andrelies less on conscious time-based judgments,engaging automatic timing systems8.

An example of an implicit timing task is the serial prediction task, which requires the subject to use a

regularly timed stimulus to make temporal predictions about future stimuli9.

Patients with Parkinson’s disease have greaterdifficultywithexplicittimingthanwithimplicittiming.More specifically, Parkinson’s disease patients haveproblems with explicit temporal discrimination tasks involving tactile, visual and auditory stimuli whileexplicit timing performance decreases as disease severity increases10,11.

The underlying neural networks of implicit and explicittimingaredistinct.WhileimplicittimingmainlyrecruitsthecerebellumandislessdependentontheBasalGanglia and theSupplementaryMotor, explicit timingrecruits the Basal Ganglia, the Supplementary MotorArea,thePrimaryMotorCortex,andthecerebellum12.

Parkinson’s disease patients have impairmentswithexternaltimingduetointernalpacingdysfunction,patients still have the ability to make temporal predictions through implicit timing. In other words, Parkinson’sdisease patients can still use external rhythmic cues to inform temporal-based decisions, such aswhen thenext footstep should occur13. Since implicit timing is stillmostly intact inParkinson’sdiseasepatients, theycompensate for the disruption in the Basal Ganglia–Supplementary Motor Area–Primary Motor Cortex(explicittiming)byrecruitingthecerebellum(essentialfor implicit timing)14.


The basic neural pathways involved in gait training thatisintheabsenceofexternalcueing,internalcueingsignalsgeneratedbytheBasalGanglia–SupplementaryMotorArea–PrimaryMotorCortexcircuitfeedintothemotor programs, which are carried out in the medialmotor areas comprised of the Supplementary MotorArea and the cingulate motor area15.

The results also showed improvement in pre and post values of time component of FO8WT in experimentalgroup,butno improvement isseen innumberofstepscomponentandmarkercomponentofFO8WTinpreandpost values of experimental group. As time component is dependent upon reaction time which can be trained with repeated auditory cueing, sowe can conditionedsomebody by giving them rhythmic auditory cues so it is possible to improve upon the reaction time and there by thetimecomponentofFO8WTimproves.WhereaswhenweconsiderthenumberofstepscomponentofFO8WT,itdependuponpersons’physical characteristicswhichincludesstiffness,lengthofmuscle,rigiditybutnoneofthatcanbemodifiedbyusingametronome.Asauditorycueing has not going to have any effect on physicalcharacteristics which decides number of steps that person is going to take. A rigidity is not being change by auditory cueing hence we cannot see a change in the physicaldimensionsofFO8WT.

CONCLUSION

Fromtheresultsobtaineditcanbeconcludedthat-Applicationofrhythmicauditorycueinghasbeneficialeffectsonthefunctionalgaitperformanceprimarilyonfreezingofgait,modifiedgaitefficacyscaleandthetimecomponent of figure of eightwalk test in Parkinson’sdisease patients.


Source of Funding: Self funded.

Ethical Clearance:Approval was taken for scientificand ethical committee of institute as well as from Parkinson’s disease and movement disorder society(PDMDS)

REFERENCES

1.SusanB.O’Sullivanetal.“PhysicalRehabilitation”Fifthedition.PublishedbyJaypeeBrothers.2007.

2.Morris M, Iansek R, Matyas T, Summers J.et al. Stride length regulation in Parkinson’sDisease: Normalization Strategies and underlying Mechanisms.Brain. 1996.Volume119.Pageno.551-568.

3.TamineTeixeiradaCostaCapato,JulianaTornaietal. Randomized controlled trial protocol: balance training with rhythmical cues to improve and maintain balance control inParkinson’s disease.MCNeurol.2015Publishedonline2015Sep7.

4.Butterfield PG, Valanis BG, Spencer PS, etal. Environmental antecedents of young-onsetParkinson disease. Neurology 1993 volume 43. Pageno.1150–1158.

5.Susan E. Halbig, Ron Andrews et al. Effectsof External Cueing on Gait Parameters in Parkinson’s disease Patients.University ofNewMexicoSchoolofMedicineDivisionofPhysicalTherapy 2014.

6.MassimilianoPau,FedericaCoronaetal.EffectsofPhysicalRehabilitationIntegratedwithRhythmicAuditory Stimulation on Spatio-Temporal andKinematic Parameters of Gait in Parkinson’sDisease,FrontinerNeurology.Publishedon2016;Volume7:Pageno.126-132.

7.Coull J, Nobre A, et al. Dissociating explicittiming from temporal expectation with fMRI.CurrOpinNeurobiol(2008)18(2):137–44.

8.PirasF,CoullJT,etal.Implicit,predictivetimingdraws upon the same scalar representation of time asexplicittiming.PLoSOne(2011)6(3)

9.Aidin Ashoori, David M. Eagleman et al.Effects ofAuditoryRhythm andMusic onGaitDisturbancesinParkinson’sDisease,frontiersinneurology, Published online 2015 Nov 11.

10.Artieda J, Pastor MA, Lacruz F, Obeso JA,et al. Temporal discrimination is abnormal in Parkinson’s disease. Brain 1992. Volume115(1):199–210.

11.Smith JG,HarperDN,GittingsD,AbernethyDet al. The effect of Parkinson’s disease on timeestimation as a function of stimulus duration range and modality. Brain Cogn 2007. Volume64(2):130–43.


12.Coull JT, Cheng RK, Meck WH et al.Neuroanatomical and neurochemical substrates of timing. Neuropsychopharmacology 2011. Volume36(1):3–25.

13.SenS,KawaguchiA,TruongY,LewisMM,HuangXet al.Dynamic changes in cerebello-thalamo-cortical motor circuitry during progression of

Parkinson’sdisease.Neuroscience2010.Volume166(2):712–719.

14.MiriumR.Rafferty, Janeyprodoehletal.Effectsof 2 years of exercise on gait impairment in people with Parkinson’s disease: The PRED-PDRandomizedtrial.JournalofNeurologicalphysicaltherapy.January2017;Volume40:pageno.21-30.

Effect of Cryoflow (IR Guided) and Moist Hot Pack on Pain and Function in Frozen Shoulder: A Comparative Study (Pilot Study)

Manmitkaur A. Gill1, Neela C. Soni2

1MPT, Senior Lecturer, Government Physiotherapy College and Government Spine Institute, Civil Hospital Campus, Ahmedabad, Gujarat, India; 2MPT, PhD, Academic Director, SKUM College of Physiotherapy,

Ahmedabad

ABSTRACT

Background: Frozen shoulder is a painful and debilitating condition with an incidence of 3% to 5% in the generalpopulationandupto20%inthosewithdiabetes.Physiotherapyhasbeenfoundtobeveryeffectiveintreatmentoffrozenshoulder.CryoflowIRisanewadvancedmodality,whichisthefirstcryotherapydevicetocooldownfreesurroundingairwithabiofeedbacksystem,therebyensuringaconstanttemperatureonatreatedspot.HencethisstudywasconductedtocomparetheeffectofmoisthotpackandCryoflow(IRGuided).

Aims and Objectives: TostudyandcomparetheeffectofCryoflow(IRguided)andmoisthotpackonpainand function in frozen shoulder.

Methodology: 15 patients of frozen shoulder were included by simple random sampling after taking ethical approval for the present study. The patients were then divided in two groups. Along with the conventional physiotherapy,patientsinGroupAweregivenmoisthotpack;whileinGroupBCryoflow(IRGuided)wasgivenfor6days/weekfor4weeks.PreandpostinterventionaloutcomemeasuresintermsofVASscoreatrest,ROMandSPADIscorewereevaluated.

Results: Bothgroupsshowedsignificantimprovementwhenpreandpostdatawereanalyzedforalloutcomemeasures(p<0.05).Whereasbetweengroupcomparisonshowednosignificantdifference.

Conclusion: ItcanbeconcludedthatConventionalphysiotherapyalongwithmoisthotpackandconventionalphysiotherapyalongwithCryoflow(IRguided),bothareindividuallyeffectiveinrelievingpain,improvingrange of motion and functional ability in patients with frozen shoulder.

Keywords: Frozen shoulder, moist hot pack, Cryoflow (IR guided)

INTRODUCTION

Frozen shoulder is a painful and debilitating condition with an incidence of 3% to 5% in the general population and up to 20% in those with diabetes.1 The term“frozenshoulder”wasfirstintroducedbyCodmanin 1934. Long before Codman, in 1872, the samecondition had already been labelled “peri-arthritis”byDuplay. In1945,Nevasier coined the term“frozenshoulder”.1Frozen shoulder involves 3 phases. These include the ‘freezing phase’ or the ‘painful phase’lasting2to9months,the‘frozenphase’orthe‘adhesivephase’lasting4to12monthsandthe‘thawingphase’or‘resolution/recoveryphase’,whichlastsanywherefrom12 months to 24 months and is characterized by a steady

return of shoulder mobility and function.2 Physiotherapy has been found to be very effective in treatment offrozen shoulder. Treatment is generally given by using electrotherapeuticmodalitiessuchasUltrasound,Moisthot packs, TENS and Short Wave Diathermy. Apartfrom electrotherapeuticmodalities, activemovements,active assistedmovement, stretching andmobilizationexercises are also given.3Cold application is one of the mostextensivelyusedtreatment.CryoflowIRisanewadvancedmodality,whichisthefirstcryotherapydeviceto cool down free surrounding air with a biofeedback system, thereby ensuring a constant temperature on atreated spot. The unique IR sensor monitors the skintemperature and auto regulates the airflow in order tokeep the perfect and selected temperature constant.

DOI Number: 10.5958/0973-5674.2019.00050.9


4 Several studies have proved the effect of variouselectrotherapeutic modalities on frozen shoulder. Studies have also been done on effects of different manualtechniques,butthereareveryfewstudiesdoneoneffectofCryoflow(IRguided)infrozenshoulder.

Aim:Tostudy theeffectofCryoflow(IRguided)andmoist hot pack on pain and function in frozen shoulder.

OBJECTIVES

z TostudytheeffectofCryoflow(IRguided)onpainand function in frozen shoulder.

z Tostudytheeffectofmoisthotpackonpainandfunction in frozen shoulder.

z To compare the effect of Cryoflow (IR guided)and moist hot pack on pain and function in frozen shoulder.

METHODOLOGY

The Patients of frozen shoulder referred to physiotherapy department fromOrthopaedicOPD andcomingtophysiotherapydepartmentonOPDbasiswereselected according to inclusion and exclusion criteria. All the patients were informed about the nature and purpose ofthestudy.Writteninformedconsentwastakenfromallthepatientsintheirunderstandablelanguage.Inclusioncriteria for the present study were- Patients whowerediagnosedwithfrozenshoulder,Agegroup:40-60years,bothmaleandfemale,LimitationofpassiveROMin glenohumeral joint compared with unaffected side,more than 30 degree for atleast 2 of these 3 movements: flexion,abductionorexternalrotationandPatientswhoare willing to participate in the study. Exclusion criteria were kept as - Recent injury in and around shoulder,anyneurologicaldisorder,cervicalspondylosis,cervicalradiculopathy and Contraindication to Cryoflow (IRguided)andMoisthotpackapplication.Afterapprovalofethicalcommittee,15patientswithunilateralfrozenshoulderwere selected (mean age = 52.08 ± 5.62) asper inclusion and exclusion criteria by using simple random sampling technique for the comparative studyof 3 months duration. Then they were divided into two groups:GroupA(n=8)andGroupB(n=7).AssessmentintermsofVisualanalogscaleratingsofpainseverity(VAS score)at rest, shoulder active Range OfMotion(ROM)andshoulderpainanddisabilityindex(SPADI)score,weretakenatfirstdayandatlastdayof4th week in

both groups. Patient in both group received conventional treatment which included Codman’s exercise, fingerladder exercises, wand exercises, active exercises andcapsular stretching, and Strengthening exercises forscapularretractors,shoulderflexors,abductors.Patientsin GroupA were treated with Moist hot pack for 10minutes,whilepatientsinGroupBreceivedcryoflow(IRguided) along with the conventional therapy. Treatment protocolforCryoflow(IRguided)was14degreeCelsiustemperature–10minutes.SizeofNozzlewas15mmaccording to cryoflow IRguidedmanual.Bothgroupswere received respective treatment for 6 days/week for total of 4 weeks.

Photograph 1: Treatment with Moist pack

Photograph 2: Treatment with Cryoflow

Photograph 3: Finger ladder exercise


Photograph 4: Stretching exercise

RESULT

Data of 15 patients were analysed with SPSS SOFTWAREVERSION16.0.Levelof significancewaskeptat5%andconfidenceintervalof95%.Baselinedatawas analyzed and no significant difference was foundbetweentwogroups.WithingroupanalysiswasdoneusingWILCOXON SIGNED RANKED TEST and betweengroupanalysiswasdoneusingMANN–WITHNEYUTESTforVASscoreandSPADIscore.Toanalysewithinandbetweengroupdifferences forROM,STUDENT’SPAIREDANDUNPAIREDTTESTwereused.

Table 1: Within Group Analysis of VAS Score at Rest

VAS Score Pre Score Mean ± S.D. Post Score Mean ± S.D. Z Value P Value SignificanceGroup A 5.6 ± 0.89 1.02 ± 0..95 -2.023 0.042 SignificantGroupB 3.8 ± 1.92 0.80 ± 0.40 -2.024 0.043 Significant

Table 2: Within group analysis of SPADI score

Spadi Score Pre Score Mean ± S.D. Post Score Mean ± S.D. Z Value P Value SignificanceGroup A 78±13.65 38.60±17.95 -2.023 0.042 SignificantGroupB 64.60 ± 8.26 31.20 ± 15.31 -2.024 0.043 Significant

Table 3: Analysis of difference between groups for VAS and SPADI score

Difference of Score Group A Mean ± S.D. Group B Mean ± S.D. U Value P Value SignificanceVasScore(AtRest) 4.6 ± 1.14 3 ± 1.58 -3.36 0.151 NotSignificant

Spadi Score 39.40 ± 12.62 33.40 ± 10.11 -7.36 0.462 NotSignificant

Table 4: Within group analysis of ROM of group A

Rom Pre Rom (º) Mean ± S.D. Post Rom (º) Mean ± S.D. T Value P Value SignificanceFlexion 113±20.79 138.60 ± 10.55 -3.822 0.019 Significant

Abduction 79±0.65 122 ± 14.40 -4.072 0.015 SignificantInternalRotation 34 ± 4.18 50±11.17 -4.355 0.012 SignificantExternal Rotation 34.60 ± 10.45 47±19.55 -11.047 0.047 Significant

Table 5: Within group analysis of ROM of group B

Rom Pre Rom (º) Mean ± S.D. Post Rom (º) Mean ± S.D. T Value P Value SignificanceFlexion 135 ± 25.49 170.80±5.54 -3.207 0.033 Significant

Abduction 97±25.39 151 ± 21.03 -6.095 0.004 SignificantInternalRotation 43.6 ± 10.35 71.60±5.94 -4.802 0.009 SignificantExternal Rotation 51 ± 6.51 76±12.94 -4.385 0.043 Significant

Table 6: Analysis of difference between groups for ROM

Mean Difference of Rom

Group A (º) Mean ± S.D.

Group B (º) Mean ± S.D. T Value P Value Significance

Flexion 25.60±14.97 35.80 ± 24.96 -0.783 0.456 NotSignificantAbduction 43 ± 23.61 54 ± 19.81 -0.798 0.448 NotSignificant

InternalRotation 16 ± 8.21 28 ± 13.03 -1.741 0.12 NotSignificantExternal Rotation 12.40 ± 2.50 25±12.74 -2.169 0.062 NotSignificant


DISCUSSION

Thepurposeofthisstudywastocomparetheeffectof Cryoflow (IR guided) and moist hot pack on painandfunction infrozenshoulder. Inpresentstudy thereisimprovementinpain,functionandROMinboththegroups individually although there are no significantdifferencesfoundinpostinterventionoutcomemeasuresbetween groups. Ranjan R et al (2013) did study onthirtypatientsontheeffectofCryoflow(IRguided)asacomponent of comprehensive treatment in shoulder pain. Thetreatmentwasgivenforfivedaysperweekfortwoweeks.TheyfoundthatCryoflow(IRguided)alongwithsupervisedexerciseprogramismoreeffectiveshort-termtreatment for shoulder impingement syndrome. Salah EldinBetal (2016)alsoconcluded in theirstudy thatCryoflow(IRGuided) therapyiseffectivethanregularcryo gel packs in minimizing symptoms associated with DOMS.The improvement in range ofmotionmay beduetomanyfactors,suchasneurophysiologicreductionin pain and associated muscle guarding, mechanicalreductioninedema,improvedrotatorcuffandshouldergirdlestrength,orimprovedextensibilityoftheshouldermusculotendinous and capsuloligamentous structures. Robertson VJ et al (2005) found that application ofmoist heat in conjunction with stretching has been shown to improve muscle extensibility. This may occur byareductionofmuscleviscosityandneuromuscular-mediated relaxation.

CONCLUSION

Conventional physiotherapy along with moist hot pack and conventional physiotherapy along with Cryoflow(IRguided),bothareindividuallyeffectiveinrelievingpain,improvingrangeofmotionandfunctionalability in patients with frozen shoulder. Also it concludes that neither of the treatment is superior to the other.

Conflict of Interest: None declared.

Source of Funding: Nil.

Ethical Clearance: Ethical committee approval was taken prior to the study.

REFERENCES

1.Philpage,AndreLabbe.Frozenshoulder:Use theevidence to integrate your interventions. North AmericanJournalofSportsPhysicalTherapy,2010.

2.Reeves B; The natural history of the frozenshoulder syndrome. Scand J Rheumatol.1975;4(4):193–6.

3.RobertsonVJ et al.The effect of heat on tissueextensibility:acomparisonofdeepandsuperficialheating.ArchPhysMedRehab2005;86:819-25.

4.RanjanRetal.Theeffectofcryoflow(irguided)as a component of comprehensive treatment in shoulderpain.JODMSE2013.

5.Polly E Bijur et al. Reliability of visual analogscaleforacute,AcademicEmergencyMedicine-pain,2001;8(12):1153-7.

6.MichaelJMullaneyetal.Reliabilityofshoulderrange of motion comparing a goniometer to a digitallevel,2010;26(5):327–333.

7.Susan L et al. Measuring shoulder functionwith the shoulder pain And Disability Index JRheumatol1995;22(4):727-732.

8.MartinJKellyetal.FrozenShoulder:Evidenceand a Proposed Model Guiding Rehabilitation.JOSPT,2009;Volume39,No.2

9.Val.Robertson,AlexWard,JohnLow,AnnReed.Electrotherapy explained principles & practice2011; 4th edition.

10.Bierman W. Therapeutic use of cold. JAMA, 1955;157(14):1189-2.

Effectiveness of Fartlek Training on Cardiorespiratory Fitness and Muscular Endurance in Young Adults: A Randomized

Control Trial

Mansi Shingala1, Yagna Shukla2

1MPT (Sports), Tutor cum Physiotherapist, Govt. Physiotherapy College- Jamnagar 2MPT, PhD (Physiotherapy), Senior Lecturer, Govt. Physiotherapy College - Ahmedabad, India

ABSTRACT

Background: FartlekisaSwedishwordmeaning“speedplay”.Itisatrainingmethodthatblendscontinuoustrainingwithintervaltraining.Fartlekisaformofroadrunningorcrosscountryrunninginwhichtherunner,variesthepacesignificantlyduringtherun.Physicalinactivityisanimportantpublichealthissueandisthe seventh most prevalent risk factor for cardiovascular disease globally. Fartlek training is majorly used for athletic population.Evidences are still lacking for the role ofFartlek training in non-athletic youngpopulation.So,thisstudywasconductedtofindtheeffectoftheFartlektrainingamongyoungadults.

Aim: Tostudytheeffectivenessoffartlektrainingoncardiorespiratoryfitnessandmuscularenduranceinyoung adults.

Methodology: 32 participants were included after taking ethics approval and written informed consent. Thepatientswerethenequallydividedintwogroups.Thepatientswerethenequallydividedintwogroupsby randomsampling.GroupA(StudyGroup)wasgiven fartlek trainingwhileGroupB (controlgroup)performedaerobicexercise.12min.Coopertest,CurlupsandSquats(Performedin1min.)wereevaluatedbefore and after completion of 6 weeks of training.

Results: Dataof32participantswereanalysedbySPSS16andMicrosoftExcel2007.Ttestwasappliedforevaluation.Resultsshowedsignificantimprovementinboththegroupsforcardiorespiratoryfitnessandcurlupsperformedin1min.Butno.ofsquatsperformedwereimprovedonlyinstudygroup.Betweengroupanalysisshowedstatisticallysignificantimprovementinfartlektraininggroup(p<0.05).

Conclusion: Resultsshowedsignificantimprovementinboththegroups.Buttherewasstatisticallysignificantdifferencefoundbetweentheeffectoffartlekandaerobictraininggroups.Thus,Fartlektrainingisstatisticallysignifanctlyeffectiveinimprovingcardiorespiratoryfitnessandmuscularenduranceinyoungadults.

Keywords: Fartlek Training, Cardiorespiratory fitness, Muscular Endurance.

INTRODUCTION

Fartlek is a Swedishwordmeaning “speed play”.It is a trainingmethod that blends continuous trainingwith interval training. Swedish coach Gosta Holmer developedfartlekin1937,sincethenmanyphysiologistshaveadoptedit.Itdiffersfromtraditionalintervaltraininginthatitisunstructuredintensityand/orspeedvaries,asthepersonwishes.Itisgenerallyassociatedwithrunning,but can include almost any kind of exercises. Fartlek is a form of road running or cross country running in which therunner,variesthepacesignificantlyduringtherun.Itisusuallyregardedasanadvancedtrainingtechnique,

for the experienced runner who has been using interval training to develop speed and to raise the anaerobic threshold.However,theaveragerunnercanalsobenefitfromasimplifiedformofFartlek trainingto introducevariety into the training program.1,2 Physical inactivity is an important public health issue and is the seventh most prevalent risk factor for cardiovascular disease globally. Inadditiontocardiovasculardisease,physicalinactivityis a leading risk factor for premature mortality, type2 diabetes, osteoporosis, and certain types of cancer.AccordingtotheWorldHealthOrganization(WHO),indevelopingcountries,almosthalfoftheadultpopulation

DOI Number: 10.5958/0973-5674.2019.00051.0


does not accumulate enough physical activity for health benefits. Because of its importance to chronic diseaseprevention, physical activity is a key behavioral riskfactor that is measured in most general health surveys.3 Because of busy pace of modern life; one can’t getsufficienttimeforregularexercises.Inthatcase,Fartlektrainingprotocolisveryhelpfulasitrequireslesstimeandisveryflexibleinnaturetoperformtheexercisesasone wish. Fartlek training is majorly used for athletic population. Evidences are still lacking for the role of Fartlektraininginnon-athleticpopulation.So,thisstudywasconductedtofindtheeffectoftheFartlektrainingamong young adults.


This interventional study was conducted at physiotherapy department and at college premises. Nature and purpose of the study was explained to the participants after taking the ethics approval. Young adults were recruited according to the inclusion and exclusion criteria.Writteninformedconsentsweretakenfromalltheparticipants.Inclusioncriteriaforthepresentstudywere,Youngadultswiththeagegroupof20-30yrs.,bothmaleandfemale,whowerewillingtoparticipate,readyaccording to Get active questionnaire and those whowere not on any medication. Exclusion criteria were kept asanycardiorespiratory,musculoskeletal,neurologicaland/or medical conditions, Having any medications,Not co-operative, Mentally ill or psychologicallydisturbed,IlliterateandnotabletounderstandGetactivequestionnaireandBorgscale.Total32participantswererecruited for the study and were divided randomly by block randomization into two groups. Demographic data and pre outcome measures were taken from all the participantsbeforethetraining.GroupA(Studygroup)was given Fartlek training for 20 mins. and exercise intensity was decided with borg’s perceived rate ofexertionscore,WhileGroupB(Controlgroup)receivedAerobicexerciseinformofwalkingfor20mins.Warmup and cool down remained same for both the groups. Duringwarmup,selfstretches(hamstring,quadriceps,calf, piriformis), backmovements, jumping jacks andhigh knees exercises were performed by both the groups for5-7mins.Whilecooldownexercisesweregiveninformofslowwalking,selfstretchesofabovemuscles,ankle pump movements and breathing exercise for 5 mins.Toassesscardiorespiratoryfitness12min.Cooper

testwastakenasanoutcomemeasure,whilemuscularendurancewasassessedwithcurlups(fig.1a&b)andsquats performed in 1 min. Training was given for 6weeks(3days/weekforfirst2weeks,4days/weekfornext two weeks and 5 days/week for last two weeks) in both the groups and all the outcomes7,9 were again analysed after completion of 6 weeks.

Figure 1a: Start position

Figure 1b : End positionFigure 1 a & b: Curl ups performed in 1 min.

Figure 2 : Fartlek training in Group A

RESULTS

Data of 32 participants (Group A-16, Male: 6,Female:10andGroupB-16,Male:4,Female:12)wereanalysed by using statistical package for social sciences version16(SPSS16)andMicrosoftExcel2007.Meanage for group A was 22.31 ± 3.34 years while for Group Bwas22.06±1.73years.Paired t testwasapplied toevaluate the pre and post outcome measures within group while unpaired t test was applied for between group analyses.


Table 1: Within Group Comparison of Outcome measures in Group A

Outcome Measure Pre (Mean ± SD) Post (Mean ± SD) p value12min.Walkdistanceinmeters 1353.97±197.35 1489.69 ± 209.22 <0.05

Vo2maxmlO2/kg/min. 18.98 ± 4.41 22.02 ± 4.68 <0.05Curl ups performed in 1 min. 26.75±4.75 33.88 ± 3.95 <0.05Squatsperformedin1min. 34.75±6.62 43.06±7.68 <0.05

Table 2: Within Group Comparison of Outcome measures in Group B

Outcome Measure Pre (Mean ± SD) Post (Mean ± SD) p value12min.Walkdistanceinmeters 1289.00 ± 129.36 1346.87±137.63 <0.05

Vo2maxmlO2/kg/min. 17.53±2.89 18.82 ± 3.08 <0.05Curl ups performed in 1 min. 27.19±5.87 29.81±5.27 <0.05Squatsperformedin1min. 39.44±7.13 40.62±6.87 >0.05c

Table 3: Between Group Comparison of differnce of Outcome measures

Outcome Measure Group A (Mean ± SD) Group B (Mean ± SD) p value12min.Walkdistanceinmeters 135.72±38.58 57.88±33.52 <0.05

Vo2maxmlO2/kg/min. 3.03 ± 0.64 1.29±0.75 <0.05Curl ups performed in 1 min. 7.12±2.85 2.63 ± 1.46 <0.05Squatsperformedin1min. 8.31 ± 5.23 1.19 ± 3.21 <0.05

Aboveresultshowedsignificantimprovementinalltheoutcomemeasuresinwithingroupanalysis(p<0.05)exceptforno.ofsquatsperformedin1min.inGroupB(p>0.05).TherewassignificantimprovementfoundinGroupAwhencomparedwithgroupB(p<0.05)forallthe outcome measures.

DISCUSSION

The purpose of the present study was to find theeffectofFartlektrainingoncardiorespiratoryfitnessandmuscular endurance in young adults. Total 32 participants weregiven trainingeither in formof fartlek (GroupA=16)oraerobicexercises (GroupB=16) for6weeks.All 32 participants completed the intervention and there was no adverse events found during study duration. All outcome measures were taken before and after completion of the training of 6 weeks. Fartlek training hasprovenusefulinimprovingcardiorespiratoryfitnessand muscular endurance in young adults. Intensityof an exercise should be to stimulate an increase in stroke volume and cardiac output and to enhance local circulation and aerobic metabolism in the appropriate muscle groups. The exercise period must be within the person’s tolerance above the threshold level for

adaptation to occur. Exercises have effects on almostall the systems of the body and these adaptations are reflected on improvement in VO2 max. During the activerecoveryphaseoffartlektraining,aportionofthemuscular stores of ATP and the oxygen associated with myoglobin that were depleted during the work period are replenished by the aerobic system and increase in VO2 max occurs.11 Improvement inaerobicfitnesshaslead to improvement in muscular endurance in both the groups.8However no. of Squats has not improvedsignificantly in control group.Thismaybe due to theeffect of legmuscles loadwhich improvesmorewiththerunningcomparedtowalking.Thus,boththegroupswere improved but fartlek training group had shown statistically significant difference compared to controlgroup in all outcome measures. The variable intensity and continuous nature of the fartlek exercise places stress on both the aerobic and anaerobic systems. This kind of exercises gives results in shorter periods of time because calories are even consumed after the completion of exercises.1 The advantages of the fartlek training is that thereisnospecializedequipmentisneededandisveryflexible innatureasonecanperformitasonewishes.Also it can be performed at any place by individuals themselves.Limitationofthepresentstudywasthatdiet


andlifestylewasnottakenintoconsideration,howeverthe participants were told not to change their routine during the training period.

CONCLUSION

Resultsshowedsignificantimprovementinboththegroups.Buttherewasstatisticallysignificantdifferencefoundbetweentheeffectoffartlekandaerobictraininggroups.Thus,Fartlektrainingisstatisticallysignifanctlyeffective in improving cardiorespiratory fitness andmuscular endurance in young adults.


Source of Funding: Nil.

Ethical Clearance: Ethical committee approval was taken prior to the study.

REFERENCES

1.McArdle W., Katch F & Katch V. Exercisephysiology. Wolters Kluwar and Lippincottwillims&Wilkins.7thedition,ch.21,pg.483.

2.Varalakshmy S. Effect of Fartlek training onselected bio chemical variables among women football players. International journal of recentresearchandappliedstudies,2016;3(3):10-12.

3.Medina C, Barquera S, Janssen I. Validity andreliability of the International PhysicalActivity

Questionnaire among adults in Mexico. RevPanamSaludPublica,2013;34(1):21–8.

4.ZakariaA.&MohamedD.Effectofusingfartlekexercises on some physical and physiological Varieblesoffootballandvolleyballplayers.WorldjournalofSportssciences,2011;5(4):225-231.

5.Babu S. & Kumar P. Effect of continuousrunning fartlek and interval training on speed and coordinationamongmalesoccerplayers.Journalof physical education and sports management,2014;1(1):33-41.

6.Kothari C. ResearchmethodologyMethods andtechniques,2ndrevisededition,2013.

7.ACSM’s Guidelines for exercise testing andprescription. Wolters Kluwar and Lippincottwillims&Wilkins.8th edition.

8.Andrew M jones and Halen Carte. Effect ofendurance training on parameter of aerobic fitness.SportsMed2000,June29(6):373-386.

9.ACSM’shealthrelatedphysicalfitnessassessmentmannual.WoltersKluwarandLippincottwillims&Wilkins.2nd edition.

10.Australiancollegeofsportsfitness,2013.

11.Kisner C., Colby L. Therapeutic exerciseFoundationandTechniques.MargaretBiblis. 5th edition.

Physiotherapy Approach in Improving Knee Function Following Total Knee Replacement: A Case Report

Maria Justine1, Alia Ibrahim1

1Centre for Physiotherapy, Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam Campus, 42300 Puncak Alam, Selangor MALAYSIA

ABSTRACT

Totalkneereplacement(TKR)isthemostcommonlyperformedjointreplacementsurgeryforosteoarthritis.FollowingTKR,patient is recommended toundergo an intensive rehabilitation to restoreknee function(strengthandmobility)andregainnormaldailyroutines.ThiscasereportpresentedaphysiotherapyapproachintheearlyphaseofrehabilitationfollowingTKR.Thepatientpresentedwithkneepain,swelling,muscleweakness and limited range ofmotion.Her interventions included pain relief, exercise therapy, patienteducation and home exercise program. The outcome measures used to evaluate her progression included painvisualanaloguescale,goniometry,manualmuscletestingandthetimeupandgotest.Thepatientbeganto show positive improvement at the third physiotherapy.

Keywords: Muscle strength, osteoarthritis, range of motion, rehabilitation.

Corresponding Author:MariaJustine,CentreforPhysiotherapy,FacultyofHealthSciences,Universiti Teknologi MARA, Puncak Alam Campus,42300PuncakAlam,SelangorMALAYSIAPhone:+60332584365,+60176573248Email: [email protected]

INTRODUCTION

Totalkneereplacement(TKR)isasafeprocedure,most commonly performed joint replacement surgery for kneeosteoarthritis(OA)whenallnonsurgicaltreatmentsarenolongerhelpfulandifthediseasesymptoms(painand stiffness) greatly limit daily activities. TKR isperformed to relieve pain, correct leg deformity, andhelp patients resume normal activities. Nowadays,TKR has developed into one of the most successfulprocedures in the modern medicine.2More individualsarenowoptedforaTKRtomaintainanactivelifestylethatmayenhancetheirqualityoflife.3

Following TKR, patient normally will undergointensive rehabilitation to restore muscle strength and joint mobility. The acute-phase postoperativerehabilitationconsistsofachievingakneeflexionof90°-120°,initiatingambulationinpartialweight-bearingon

the operated limb with walking aides and without wearing kneeimmobilizer,however,a10°-15°extensorlagisnotunusual.Atdischargefromtheorthopaedicdepartment,thepost-acutephaseof rehabilitationusuallywill startonthe7th to 10th postoperative day.4ItwassuggestedthataTKRshouldachieveapostoperativerangeofmotion(ROM)of0–120°,whileaflexionof65°isrequiredtowalkonaflatground,of70° to get up from a chair and of 90°todescendstairs,whilekneelingrequires125°.5

Stiffness, a painful ROM limitation is the mostprevalent local complication after TKR.6 It is verycomplex, both in terms of pathogenesis and treatmentas it represents a frustrating problem for surgeon,physiotherapist and patient.5 Various definitions forknee stiffness were gathered by Panni et al. such asa flexion contracture >15° and a maximum flexion<75°; a postoperative ROM smaller than 10–90°; a flexioncontracture≥20°andamaximumflexion≤45°; amaximumflexion ≤85° or amaximumROM≤70°.5 Limited knee flexion ROM may alter gait patternaffecting the ankle and hip, limit functional squatting,and cause difficulty in stair climbing and sitting.Therefore,regainingfullfunctionofkneeisimportant7to ensure patient can perform their daily routines.

Case Description: This report presents physiotherapy (PT)approachforapatientwhohadundergoneaTKR,

DOI Number: 10.5958/0973-5674.2019.00052.2


targeting to restore patient’smuscle strength,mobilityand a gradual return to daily activities.8

Patient history: Mrs. L, a 62-year-old Chinese ladywasdiagnosedwithrightkneeOAsince2012.Shewasdischarged from the hospital a week after her operation andreferredtothePTdepartmentonherpost-operativeday14.Duringherfirstvisit, shecomplaint: i)painonthe right knee and feeling tight, ii) limited right kneemovement,whenbending,iii)rightkneeweakness.Sheclaimed thepain tobe4/10whenaggravated,basedonthepainscale(VAS)giventoher.Toeasethepain,shewouldrestthekneebysittingdown.Ifthepainwassevereenough to disturb her daily routines, she would takepainkiller prescribed by the physician and the pain would lessen till 1/10 in less than 15-minute. Fortunately, thepaindidnotaffecthersleepasitwouldusuallyprovokedmostly during day time after house chores.

Mrs.Lhadhistoryofhypertensionsince≥10-yearago,onmedicationandaregulardoctor’sfollow-up.HerX-rayontherightTKRindicatedasuccessfuloperation.MrsL,awidowerwithnochildren(husbanddied10-yearago)alsohadhistoryofleftkneeOAandwasmanagedwithTKRin2013.Mrs.Lisaretired(4-yearago)governmentofficer.HeroldersisterwholivesinCanadawillvisitheronce a year.Mrs.L spentmost of her time indoor andcarriedoutherdailyroutinese.g.,buyinggroceriesanddoinghousechores,independently.Priortotheoperation,shewas able to drive independently.At present, she isdependent on her sister to drive her to places she needed togo.Mrs.Llivesinadouble-storeyhouse,herbedroomwaslocatedupstairs,andhertoiletsweresitting-type.Sheclaimednodifficultiesinclimbingupanddownstairsonherownasshesleepsontheupperfloor.

Physical examination: Mrs. L presented with amoderate-sized body built. She walked into the PTdepartment using a quadripod with a limping gait,accompaniedbyhersister.Sheappearedwell,talkative,obeying commands and speaks good English. The operated site was covered with white dressing. The rightkneeappearedslightlyswollenandreddened.Onpalpation, thesitefeltwarm,butnotendernessandnoother structural deformity was noted around the knee.

For theROM, a goniometerwas used tomeasurethekneemovement.Thefindings(Table1)showedthatMrs.Lhadlimitedmovementinbothheractiveflexionandextensionof the rightkneeROM.Meanwhile, theleftkneewasnormal,activelyandpassively.

Table 1: Mrs L’s goniometry measurements for right and left knee

MovementActive Passive

Right Left Right LeftKneeFlexion 15-75° FROM 10-90° FROMKneeExtension lag15° FROM lag10° FROM

FROM=fullrangeofmotion.

TheManual Muscle Testing (MMT) was used toassess muscle strength. Following TKR, the affectedleg is immobilized for a certain duration for recovery tooccurbuttheaffectedmuscleswillundergoatrophydueto inactivity, thus leadingtomuscleweaknessandlimitationinROM.TheMMTmayconfirmwhethertheweakness could be the reason for the extension lag. The MMTconfirmedthatMrs.Lhadweaknessofherrightkneemuscles(flexors=3/5;extensors=2/5).Bothflexorsand extensors of the left knee scored 3/5. The ROMand muscle strength of the hip and ankle joints were also assessed to clear the joints from any limitations. Generally,Mrs.LhadactivefullROMforbilateralhipsandankles,withallinvolvedmusclesscored3/5.

Treatment methods: Based on the findings,Mrs. L’streatmentwasdesignedaccordingly,namely,painrelief,exercise therapy, patient education and home exerciseprogram (HEP).Table 2 summarizes the interventionsfor Mrs L. She was evaluated after each treatment.Generally,shewasabletofollowinstructionswellandvery cooperative throughout the session. She claimed herrightkneepainhadlessenedfromVAS4/10to2/10after the application of cryocuff. However, the ROMand muscle strength had no changes after completing all treatmentinherfirstsession.AsforpatienteducationandHEP,shewasabletounderstandtheinformationgivenand demonstrate all exercises taught to her correctly.

Onthe2ndvisit(thefollowingday),MrsLwalkedintothedepartmentstillusingaquadripodwithalimpinggait. She reported that the knee pain was still the same as yesterday,butfeelingmorecomfortableduringwalking,after performing several sets of HEP and ice compression at home.When examined, Mrs. L’s ROM and musclestrength were still the same as the previous day. This time, theTimedUpandGO(TUG) testwasconductedtoassessherfunctionaloutcomeandrisksoffalls.Mrs.Lscoredanaverageof13.86-sec(withquadripod)whichindicated a moderate risk of falls.9 The exercises taught


toherduringthefirstvisitwerereviewedandshehadnoproblem remembering them. The prone leg hang exercise was taught toMrs.L.This exercise requiredher togetinto prone lyingwith the right knee hanging off at theedgeofthebed.Asandbagoftolerableweight(1lb)was

strappedonthepatient’saffectedlegattheankle,tocreateasustainedforce thatmay increase theextensionROMpassively,combinedwithgravity-assistedpositionfor10-to45-minhold.7 The second visit was ended up with a painrelieftechniqueusingcryocufftotherightknee.

Table 2: Summary of intervention procedures and its clinical reasoning for Mrs L

Intervention Procedure Rationale

Pain relief (Cryocuff)

Position: Supinelying,rightkneeelevated45°ona wedge.

Area: Right knee.Duration:15-min.

Cryocuffslowsdownpainsignaltransmission,localeffectontissuemetabolism via decreasing enzyme function,andlocalvasoconstriction.10 Othersfounddecreaseinswellingand

decrease in blood loss.11

Mobilizingexercise

Wall leg slidePosition: Supine lying with both legs placed

parallel on the wall.Technique:Instructpatienttostraightenrightknee

as much as possible and sliding the leg down as much as possible.

Frequency (Freq): Repeat 10x; 3 sets.

KneeROMisimportantinearlyphasesof therapy for enhancing functional performance;however,thereislittle

evidence that function is related to knee ROM.12

Strengthening exercise

Modified SQEPosition:Longsitting,arolloftowelunderthe

right ankle.Technique: Press right knee downward.

Duration:Hold10-sec;repeat10x;3sets.Inner Range Quad (IRQ)

Position:Longsitting,bolsterplacedbelowrightknee.

Technique: Press right knee against bolster to extend right leg.

Duration:Hold10-sec;repeat10x;3sets.

Theassociationbetweenquadricepsstrength and disability emphasizes the importanceofeffectivequadriceps

exercisesfollowingTKR.2Quadricepsexercisescanenhance

functional abilities.12

Circulatory exercise

Ankle PumpingPosition:Supinelying,rightkneeelevated45°on

a wedge.Technique:Rightanklemovement(up&down).

Duration:10-min

This exercise prevent circulatory complications,promotestaticandactivestrengthening,ROM,andgaittraining.13

Patient education

Educatepatientregardingherimpairment,importanceofexercisesandconsequencesofnon-

compliance. Teach patient about pain relief e.g. icecompression,correctuseofwalkingaids.

Education has been shown to improve the healthstatusofpatients,especiallywithrespecttopain,functionalcapacityand

otherqualityoflifevariables.14

Home Exercise Program(HEP)

Review all exercises taught earlier to ensure patient can perform it correctly. Encourage patient

toperformexercisesregularly(≥3x/day).

A regular and continuous exercise enhance recovery.

On the 3rd visit, Mrs L still walked into thedepartment using her quadripod, with slight limpinggait. She reported that her knee pain had reduced to VAS 2/10 and able towalkwith a better pattern. Shealso claimed to be walking independently at home. The rightkneewasstillabitwarmwhenpalpated,thiscould

be due to the knee movement while walking after some distances.ShealsoshowedimprovementinROMwith10-90° foractive rightkneeflexion, lag10° for active kneeextension,5-100°forpassivekneeflexion,lag5° forpassivekneeextension.Meanwhile,musclestrengthmeasurement indicated no progression yet.


As usual, the exercises taught to Mrs L werereviewed. This time, Mrs L was prescribed a staticcycler as part of the lower limb closed kinetic chain (CKC)mobilizing exercises for 15-minute per session(withoutanyresistance).Cyclingisusuallyclassifiedasalow-demandactivityforthekneejointandisthereforerecommended for persons with OA and rehabilitationprograms following TKR.15 The treatment session was ended with cryocuff to alleviate knee pain andtemperature after performing exercises.

DISCUSSION

Rehabilitation following TKR should focusedon reducing pain and swelling, improving ROMand functional mobility. Progressive, high-intensityexercises may be applied to regain muscle function. Hence,alowerextremitystrengthtrainingfor1to3setsof10 to20 repetitions,mayovercome the recalcitrantmuscle impairments which may persist for a long time. Using a neuromuscular electrical stimulation (NMES)duringearlyrehabilitationmayhelpresolvequadricepsactivation failure and alleviate quadriceps muscleweakness.12

Immediately after discharge, the goals that TKRpatient like Mrs. L has already achieved are usuallyan articular excursion in flexion of around 90°, and apossible coexistence of an extensor lag of 5-10°.4 The least condition for resumption of the common daily activities represented by the attainment of 90° kneeflexion, and the combined flexion of hip and kneeshouldbegreater than190°.4 Therefore, it is importantto achieve the targeted knee ROM to have a betterfunctional status and quality of life prior to dischargefrom PT rehabilitation.

VAS as ameasure of painwas designed only forshort term purposes as it is asked during assessment and on that time only,with a high reliability (96.5%)andvalidity (88.7%).16 A goniometer that was used to measure ROM can inform progression directly to thepatient,besideaidingPTtoemphasizeonmovementthatneedattention.ThemusclegrademeasuredbytheMMTis used todeterminemuscle strengthduring a specificmovement and each grade has its own descriptions,for instance, a grade 4, full ROM is achieved againstgravity with minimal resistance and grade 5 is when full ROM is achieved against gravity with maximalresistance.However,itisimpossibletogiveastandard

measurementofresistance,aseachtherapisthashisorher own minimal and maximal resistance that the body canapply to thepatient. Inaddition, theTUGtestcanbeusedforlong-termpurposesasitalsoassessesbasicmobilityskills,strength,balance,andagility.17TheTUGhasexcellenttest-retestreliability(ICC=0.97).18

OtheroutcomemeasuresthatcanbeusedforMrs.L,included a measure of knee extensor mechanism function usingeitherthechairrisetest(CRT)orthestairclimbingtest(SCT).CRTismorefocusedonextensormechanismfunction and is one of the activities used in functional indexes and in test of physical functioning.2 SCT measures thetimetoascendanddescendaflightofstairs,especiallywhenpatient’sdailyroutineinvolvedclimbingstairs.ThistestisconsideredmorechallengingthantheTUG,anditreducesthepossibilityofaceilingeffect.19

CONCLUSION

Themainaim forPT followingTKR is to restorestrength and mobility so that patient can return to his or her daily routine as early as possible without enduring painandmovementdiscomfort.ForMrsL,withinthreevisits to the PT, she had shown a good progressionespeciallyintermsofherlevelofpain,kneeROM,andfunctional movement. In the long term, interventionstrategies forMrsLshouldbe targetedatencouragingher to re-establish and maintain a physically activelifestyle. Remaining physically active allows patients to maintain their general health after joint replacement and toenhancethequalityoftheinterfacebetweentheboneand prosthesis.

REFERENCES

1.American Academy of Orthopaedic Surgeons,AAOS. Total Knee Replacement. 2011. http://orthoinfo.aaos.org/topic.cfm?topic=a00389 (accessedon2ndJune,2014)

2.UnverB,KaratosunV,BakirhanS.(2005).Abilitytoriseindependentlyfromachairduring6-monthfollow-upafterunilateralandbilateraltotalkneereplacement.JournalofRehabilitationMedicine.2005;3:385-387.

3.Vogel LA,CarotenutoG,Basti JJ, LevineWN.Physical activity after total joint arthroplasty. SportsHealth.2011;3:441–450.


4.CademartiriC,SonciniG.Totalkneereplacement.Postacute phase in rehabilitation: objectives and strategies in postacute treatment.Acta Bio-Medica:AteneiParmensis.2004;75:56-62.

5.Panni SA, Cerciello S, Vasso M, Tartarone M.Stiffness in total knee arthroplasty. Journalof Orthopaedics and Traumatology: OfficialJournaloftheItalianSocietyofOrthopaedicsandTraumatology.2009;10:111-118.

6.Della Valle GA, Leali A, Haas S. Etiologyand Surgical Interventions for Stiff Total KneeReplacements.HSSJournal.2007;3:182-189.

7.ShahN. Increasing knee range ofmotion usinga unique sustained method Correspondence.2008;3:110-113.

8.American Academy of Orthopaedic Surgeons,AAOS(2018).TotalKneeReplacementExerciseGuide.2018; https://orthoinfo.aaos.org/en/recovery/total-knee-replacement-exercise-guide/ (accessed on3rd August 2018)

9.Shumway-Cook A, Brauer S, Woollacott M.Predictingtheprobabilityforfallsincommunity-dwellingolderadultsusingthe timedup&gotest.PhysicalTherapy.2002;80:896-903.

10.Gibbons CER, Solan MC, Ricketts DM,PattersonM.CryotherapycomparedwithRobertJones bandage after total knee replacement:A prospective randomized trial. InternationalOrthopaedics(SICOT).2001;25:250-252.

11.MarkertSE.Theuseofcryotherapyafteratotalkneereplacement:aliteraturereview.OrthopaedicNursing.2001;30:29-36

12.Meier W, Mizner RL, Marcus RL, Dibble LE,Peters C, Lastayo PC. Total knee arthroplasty:muscle impairments, functional limitations,and recommended rehabilitation approaches. The JournalofOrthopaedicandSportsPhysicalTherapy.2008;38:246–256.

13.Rahmann AE, Brauer SG, Nitz JC. A specificinpatientaquaticphysiotherapyprogramimprovesstrength after total hip or knee replacement surgery: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation.2009;90:745–755.

14.NunezM,NunezE,SegurJM,MaculeF,QuintoL,HernandezMV,etal.Theeffectofaneducationprogramtoimprovehealth-relatedqualityoflifein patients with osteoarthritis on waiting list for total knee replacement: A randomized study. OsteoarthritisandCartilage.2006;14:279-285.

15.KutznerI,HeinleinB,GraichenF,RohlmannA,HalderAM,BeierA,etal.Loadingof theKneeJoint During Ergometer Cycling: TelemetricInVivo Data. Journal of Orthopaedic& SportsPhysicalTherapy.2012;42:1032-1038.

16.Bijur PE, SilverW,Gallasher EJ. Reliability oftheVisualAnalogue Scale forMeasuringAcutePain.AlbertEinsteinCollegeofMedicine,USA;2011.

17.BennellKL,DobsonF,HinmanRS.Measuresofphysicalperformance.ArthritisCare&Research.2011;63:S350-S370.

18.Mizner RL, Petterson SC, Clements KE, ZeniJA, Irrgang JJ, Snyder-Mackler L. Measuringfunctional improvement after total knee arthroplasty requires both performance-basedand patient-report assessments: a longitudinalanalysisofoutcomes.TheJournalofArthroplasty.2011;26:728–737.

19.Bade MJ, Kohrt WM, Stevens-Lapsley JE.Outcomes Before and After Total KneeArthroplasty Compared to Healthy Adults. The Journal of Orthopaedic and Sports PhysicalTherapy.2001;40:559–567.

Effectiveness of Gaze Stability and Conventional Exercises on Balance in Vestibular Hypofunction Patients

Mariyamath Arifa1, Chinnakalai Thangadurai2, Sajjad Abdul Rahiman Ebrahim1

1Assistant Professor, 2Associate Professor, Yenepoya Physiotherapy College, Yenepoya (Deemed to be University)

ABSTRACT

Objective: To determine the effectiveness between gaze stability with conventional exercises andconventional exercises alone on balance in patients with vestibular hypofunction.

Method: Twenty four patients clinically diagnosed with vestibular hypofunction who met the criteria for selectionwereequallyallocated into2groups.Thegroup Iwas taughtgaze stability exerciseswithconventionalexercisesandgroupIIwastaughtconventionalexercisesonly.Allthepatientswereinstructedtoperformtheexercisesasahomeprogramfor6weekswithaweeklyfollowup.BergBalanceScaleandDizzinessHandicapInventorywereusedasoutcomemeasurestomeasurepreandposttestvalues.

Result:Datawas analysed to determine the effect of exercises on balance scoreswithin the group andbetweengroupsbyWilcoxonSignedRanktestandMannWhitneyUtestrespectively.Theresultsshowedthat therewasastatisticallysignificantchangeinbalancescoresandperceivedqualityof lifewithinthegroups(p<0.003),whereastherewasnostatisticallysignificantdifferenceinbalancescoresandperceivedqualityoflifebetweengroups.

Conclusion: The result of the study showed that there was an improvement in balance in both the groups but addition of gaze stability exercises to conventional exercises had a little impact in improving balance. Furtherstudiesrequiredtoruleouttheroleofgazestabilityexercises.

Keywords: Vestibular hypofunction, Gaze stability exercises, BBS, DHI.

Corresponding Author:MariyamathArifaAssistantProfessor,YenepoyaPhysiotherapyCollege,Deralakkatte,Mangalore,India,575018.Email: [email protected]

INTRODUCTION

Balanceistheabilitytomaintainthebody’scenterofmassoveritsbaseofsupport.Itisoneoftheordinarybodyfunctionswedonotthinkof,untilitisdisrupted.The upright posture imposes particular demands on the vestibular apparatus as a human balance his/her large body mass on very small areas of support.1Vestibularsystem is the sensory system that provides the dominant input about themovement and equilibrioception. It isimportantforthedevelopmentofbalance,coordination,

eye control and attention.1 The human vestibular system is made up of three components: a peripheral sensory apparatus, a central processor and a mechanism formotor output. The peripheral apparatus consists of a set of motion sensors that send information to the central nervous system. The central nervous system processes these signals and combines them with other sensory information to estimate head and body orientation. The output of the central vestibular system goes to the ocular muscles and spinal cord to serve three reflexes, thevestibulo-ocularreflex(VOR),thevestibulocolicreflex(VCR)andthevestibulospinalreflex(VSR).2

Adeficiency in the vestibular system implies thatthelabyrinthineinputshavebeenreducedorabolished,resulting in gaze instability.1 In the case of vestibularhypofunction,eyerotationalvelocityislessthanheadrotational velocity, and gaze stability is reduced.3 A prevalenceof7.4%vestibularvertigo isseen inadults

DOI Number: 10.5958/0973-5674.2019.00053.4


and the vestibular vertigo is 3 times more common in elderly.4 Vestibular hypo function is caused bydysfunction of the vestibular system of the inner ear. It can be of unilateral or bilateral involvement.5 The primary symptoms of vestibular hypo function are vertigo,imbalance,blurredvisionanddisequilibrium.6

Vestibularrehabilitationincludesanexercisebasedapproachtowardsvestibulardysfunction,whichaimstomaximize the central nervous system compensation. The gaze stability exercises are based on the demonstrated ability of the vestibular system to modify the magnitude oftheVORinresponsetoagiveninput.7 These exercises are aimed at improving vision, which in turn has aninfluence onbalance.Thebest stimulus for increasingthe gain of the vestibular response is the error signal inducedby retinal slip,which is the imagemotiononthe retina during head motion. The repeated response to this stimulus would induce vestibular adaptation.8 These exercises, both static and dynamic, require subjectsto focus on visual targets during head motion3. The conventional exercises like single leg stance, tandemwalking etc. have been used to rehabilitate balance since many years. These exercises are designed to maintain body’s center of mass within the limits of base ofsupport in response to an unexpected perturbation or stimulus.9 A simple and easy scale to assess functional balanceperformance is theBergBalanceScale (BBS)based on 14 items common to daily life.10 The Dizziness Handicap Inventory (DHI) was developed to evaluatethe self-perceived handicapping effects imposed byvestibular system disease. 11

Although studies have been done to evaluate the effects of vestibular rehabilitation on balance, there isa little research evidence regarding the effect of gazestability exercises alone with conventional exercises for balance in rehabilitating patients with vestibular hypofunction. Hence aim of this study is to find theeffectiveness between gaze stability exercises andconventional exercises.

MATERIAL AND METHOD

This study was conducted in 24 patients with vestibular hypofunction ranging referred from ENT department of a private medical college hospital in Mangaluru. Prior to the participation, the patientswere explained about the study and informed consent was taken from them. The subjects were assessed for

inclusionandexclusioncriteriaandthosewhofulfilledthe criteria were included in the study. Approval was taken fromUniversity Ethical Committee prior to thecommencement of the study.

The inclusion criteria kept in this study were male andfemalepatientswithvestibularhypofunction,aged40years and above and who have the ability to comprehend theinstructions.Patientswhowerenon-cooperative,hadcentralvestibulardisorders,imbalanceduetoconditionslike diabetic neuropathy etc., hypertensive patients,and any condition that compromises rehabilitation (ambulatory problems, visual, cognitive or neurologicdisorders) were excluded from the study.

Allthepatientsweredividedintotwogroups,with12eachinboththegroups.Pre-testwascarriedoutforassessing balance using BBS and DHI questionnaire.Subjects in Group I were advised to perform GazeStability exercises7 and Conventional exercises12-15 for 20 minutes per session twice a day for 6 weeks. Subjects in Group II were advised to perform ConventionalExercises only for 15 minutes per session twice a day for 6 weeks. The exercises to both the groups were demonstrated by the researcher on the day one in the department of Physiotherapy. The subjects of both the groups were advised for follow up once a week for 6 weeks. They were given a follow up card to mark when they do the exercises daily and they were advised to bring it when they come for follow up. The researcher administeredthepost-testontheendofthesixthweekusing the same scalesused forpre-test and the resultswerecomparedbetweenGroupIandGroupII.

The collected data was analysed to determine the effect of exercises on balance scores within the groupandbetweengroupsbyWilcoxonSignedRanktestandMannWhitneyU test respectively using SPSS version22. Descriptive statistics was produced for age and gender distribution.LevelofsignificancewassetatP<0.05.

RESULTS

A total of 24 patients were recruited and all data were included in the analysis. Group I consisted of 4males and 8 females with a mean age of 48.8 ± 10.74andgroupIIconsistedof8malesand4femaleswithamean age of 51.5 ± 9.77(Table1and2).

A comparison was done within the groups for both groups(Table3).IngroupI,thepre-testmedianforBBSscorewas34.5andpost-testmedianforBBSscorewas


49whichshowssignificantdifference.Thesubjectspre-testmedianDHIscorewas44andpost-testmedianDHIscorewas14whichshowedasignificantdifference.

IngroupII,thepre-testmedianforBBSscorewas36.5andthepost-testmedianBBSscorewas44,whichshowedasignificantdifference.Thepre-testmedianforDHIscorewas35andthepost-testmedianDHIscorewas28whichshowedasignificantdifference.

ForbothBBSscoreandDHIvaluesthesignificantdifferencewas based onWilcoxon’s SignedRank testwith a p value of 0.003 (<0.05). This result showedthat the balance improved significantly in both gazestability exercises with conventional exercises group and conventional exercises alone group.

Table 4 shows the details of comparison between 2 groups.TheaverageBBSscorewas49ingroupIand

44ingroupII.TheaverageDHIscorewas14ingroupIand28ingroupII.ItshowedthatgroupIimprovedmorewhencomparedtogroupII,but itwasnotstatisticallysignificant. The significance was based on the MannWhitneyUtestwiththepvalueof1.000and0.193forBBSandDHIrespectively.Thisresultshowedthattherewas no statistically significant difference in balancebetween the gaze stability exercises with conventional exercises group and conventional exercises alone group.

Table 1: Age Distribution

N Mean ± SDGroupI 12 48.8 ± 10.74GroupII 12 51.5 ± 9.77

Total 24 50.2 ± 9.82SD-StandardDeviation

Table 2: Gender Distribution

GroupFrequency Percent

Male Female Total Male Female TotalGroupI 4 8 12 33.3 66.7

100GroupII 8 4 12 66.7 33.3

Table 3: Within Group Comparison of Group I and II

GroupBBS DHI

Median (IQR)P Value

Median (IQR)P Value

Pre Post Pre PostGroupI 34.5(24.0-37.5) 49(42-50) 0.003 44(36.5-47) 14(12-24) 0.003GroupII 36.5(29.7-40.5) 44(34-49) 0.003 35(30.0-42) 28(10-34) 0.003

IQR-InterQuartileRange,DHI-DizzinessHandicapInventory,BBS-BergBalanceScale

Table 4 : Between Group Comparison of Group I and II

Outcome MeasuresMedian (IQR)

P ValueGroup I Group II

BBS 49(42-50) 44(34-49) 1.000(>0.05)DHI 14(12-24) 28(10-34) .193(>0.05)

IQR-InterQuartileRange,DHI-DizzinessHandicapInventory,BBS-BergBalanceScale

DISCUSSION

Several studies have been done in the past in order to develop treatment protocols to rehabilitate patients with vestibular hypofunction presenting with balance impairments.Substitutionexercises,adaptationexercises,

habituation exercises etc. were some of the techniquesused for rehabilitation.However, this study focused onthe use of gaze stability exercises along with conventional exercises. The main aim of the study was to compare the effectivenessofgazestabilityexercisesgivenalongwithconventional exercises and conventional exercises alone.


The age and gender were similar at the baseline in both the groups. The study results showed that when gaze stability exercises were given along with conventional exercisesthebalanceimprovedsignificantly,asassessedby the BBS. These findings are consistent with thestudy done by Murat Giray et. al, which concludedthat customized vestibular rehabilitation includes gaze stabilityexercisewaseffectiveinimprovingbalanceandreducing the symptoms in vestibular dysfunction.16 This resultalsogoesinlinewiththefindingsofBadkeMBet. al,whichprovedvestibular rehabilitation improvedfunctional balance and gait stability.17

The resultsalsoshowed that theperceivedqualityof life in thepatients improved significantlywhen thecomparison was done within the group as per DHIscores. This was consistent to a study done by Patatas OHG et. al, where they used several rehabilitationexercises including gaze stability exercises in patients with peripheral vestibular dysfunction.18 Similar studies byBrownKEet.al,andBayatAetalshowedthattherewasasignificantimprovementinallthesub-groupsofDHIinalltheparticipantsaftervestibularrehabilitationincluding gaze stability exercises.19,20

Conventional exercises were also given for both the groups to improve balance. The study result showed an improvement in balance after administering conventional exercises including single leg stance, tandem walkingetc.inboththegroupsassessedbyBBS.Also,theresultsshowed that there was a significant improvement inperceivedqualityoflifeassessedbyDHIafterrehabilitatingwith conventional exercises. An improvement in balance correspondswith the findings of the study byWolf et.al, in which the balance improved significantly withindividualized balance exercise programme.21But thesefindingsarecontradictorytotheresultsofstudybyKimJY et al which showed no significant improvement inbalance after exercise program.22

The study result showed a non-significantimprovement in DHI and BBS when gaze stabilityexercise along with conventional exercises was compared with conventional exercises alone. This resultcorrespondswiththeresultsofastudybyKrebsDE et. al, which showed that the improvements werestatisticallynotsignificantaftervestibularrehabilitationin all the patients with vestibular hypofunction.23 The results of a study by Cowand JL et. al, showed thatnot all participants improved statistically inDHI aftervestibular rehabilitation.24

InthisstudyitwasfoundthatbalancewasimprovedmoreingroupIwhencomparedtogroupII,butitwasnotstatisticallysignificant.Thepossiblereasoncouldbethatgaze stability exercises were done under no supervision; rather it was given as a home exercise program. The patients may not have performed well as these exercises requireproperattention.Andonlyadaptationexercisesweregiventothepatients,notallthecomponentsofthevestibular rehabilitation were given. Since within group comparison has shown significant improvements inboth thegroupandno significant improvementswhencompared between groups, it was observed that theaddition of gaze stability exercise to the conventional exercise had a little importance in improving the balance in patients with vestibular hypofunction. This leads to an assumption that the improvements in balance and perceived quality of life is brought outmainly by theconventional exercises. This study, in other words,say that further investigation is required to check forthe effectiveness of gaze stability exercises in therehabilitation of vestibular hypofunction.

CONCLUSION

ThestudyshowssignificantimprovementinbalanceandperceivedqualityoflifeinbothgroupsinpatientswithvestibularhypofunctionassessedbyBBSandDHIscores.Butwhencomparingthetwogroups,therewasnosignificantchangeinbalance.Hence,itisconcludedthat the conventional exercises has a major role in improving balance in vestibular hypofunction. The gaze stability exercises has got a little role in improving balance,furtherstudiesrequiredtoruleout.

Conflict of Interest: None.


Ethical Clearance: Ethical clearance was obtained fromtheUniversityEthicalCommittee.

REFERENCES

1.Writer HS,Arora RD. Vestibular rehabilitation-an overview. Otolaryngology Clinics. AnInternationalJournal.2012;4(1):54-69.

2.HainTC,HelminskiJO.VestibularRehabilitation.FADavis.2007;2-18.

3.Schubert MC, Migliaccio AA, ClendanielRA, Allak ABS, Carey JP. Mechanism of


dynamic visual acuity recovery with vestibular rehabilitation.ArchivesofPhysicalMedicineandRehabilitation.2008;89(3):500-507.

4.Agrawal Y, Ward BK, Minor LB. Vestibulardysfunction:Prevalence,impactandneedfortargetedtreatment.JVestibRes.2013;23(3):113-117.

5.Schubert MC, Minor LB. Vestibulo-ocularphysiology underlying vestibular hypofunction. PhysTher.2004;84(4):373-385.

6.Shah PS, Kale JS. A study of the effects of avestibular rehabilitation program on patients with peripheral vestibular dysfunctions. The Indian Journal of Occupational Therapy. 2004July;36(1):11-16.

7.Clendaniel RA. The effects of habituation andgaze stability exercises in the treatment of unilateral vestibular hypofunction preliminary results.NeurolPhysTher.2010;34(2):111-6.

8.HanBI,SongHS,KimJS.Vestibularrehabilitationtherapy: reviewof indications,mechanisms,andkeyexercises.JClinNeurol.2011;7:184-196.

9.HoweTE,RochesterL,JacksonA,BanksPMH,Blair VA. Exercise for improving balance inolder people. Cochrane Database of Systematic Reviews.2007;(4):CD004963.

10.Miyamoto ST, Junior IL, Berg KO, Ramos LR,Natour J. Brazilian version of the berg balancescale.BrazJMedBiolRes.2004;37(9):1411-1421.

11.JacobsonGP,NewmanCW.ThedevelopmentoftheDizziness Handicap Inventory.Arch OtolaryngolHeadNeckSurg.1990;116(4):424-427.

12.McGarryST,McGuireSK,MageeTM,BethardHK,Flom-MelandCK.Theeffectsof“TheGetOffYourRocker”exerciseclassonbalance.JournalofGeriatricPhysicalTherapy.2001;24(3):21–5.

13.Smania N, Corato E, Tinazzi M, Stanzani C,Fiaschi A, Girardi P, Marialuisa Gandolfi M.Effectsofbalancetrainingonposturalinstabilityin patients with Parkinsons disease. Neurorehabil NeuralRepair.2010;24(9):826-834.

14.Campbell AJ, Robertson MC, Gardner MM,Norton RN, Tilyard MW, Buchner DM.Randomised controlled trial of a general practice programme of home based exercise to prevent

fallsinelderlywomen.BMJ.1997;315:1065–9.

15.Gill-Body KM, Popat RA, Parker SW, KrebsDE. Rehabilitation of balance in two Patients with cerebellar dysfunction. Phys Ther. 1997;77(5):534-552.

16.GirayM, KirazliY, Karapolat H, Celebisoy N,BilgenC,KirazliT.Short-termeffectsofvestibularrehabilitation in patients with chronic unilateral vestibular dysfunction: a randomized controlled study.ArchPhysMedRehabil.2009;90(8):1325-1331.

17.BadkeMB, SheaTA,Miedaner JA,GroveCR.Outcomes after rehabilitation for adults withbalance dysfunction. Arch Phys Med Rehabil.2004;85:227-33.

18.PatatasOHG,GanançaCF,GanançaFF.Qualityof life of individuals submitted to vestibular rehabilitation. Braz J Otorhinolaryngol.2009;75(3):387-94.

19.BrownKE,WhitneySL,MarchettiGF,WrisleyDM, Furman JM. Physical therapy for centralvestibulardysfunction.ArchPhysMedRehabil.2006;87:76-81.

20.Bayat A, Pourbakht A, Saki N, Zainun Z,Nikakhlagh S, Mirmomeni G. Vestibularrehabilitation outcomes in the elderly with chronic vestibular dysfunction. Iran Red Cres Med J.2012;14(11):705-8.

21.WolfB,FeysH,DeW,VanderMeerJ,NoomM,AufdemkampeG.Effectofaphysicaltherapeuticintervention for balance problems in the elderly: asingle-blind,randomized,controlledmulticentretrial.ClinicalRehabilitation.2001;15(6):624–36.

22.Kim JY, Park SD, Song HS. The Effects of aComplex Exercise Program with the visual block on the walking and balance abilities of elderly people.J.PhysTher.Sci.2014;26(12):2007-09.

23.Krebs DE, Gill-bodyKM, Parker SW, RamirezJV, Robinson MW. Vestibular rehabilitation:useful but not universally so.OtolaryngolHeadNeckSurg.2003;128(2):240-50.

24.CowandJL,WrisleyDM,WalkerM,StrasnickB,JacobsonJT.Efficacyofvestibularrehabilitation.OtolaryngolHeadNeckSurg.1998;118(1):49-54.

The effects of Home Based Progressive Resistance Exercises on Depression of Elderly Adults

Mohammed Aslam Ahmed

H.O.D, Associate Professer, Uttaranchal (PG) College of Biomedical Scs And Hospital, Sewla Khurd, Near Transport Nagar Sharanpur Road, Dehradun

ABSTRACT

Atotalof33subjectswereselectedsufferedwithDepressionbyGeriatricDepressionScaleandmettheinclusion criteria were included in the study. An informed consent of subjects was taken and 33 subjects were then divided randomly toGroupA (Experimental group) andGroupB (Control group) through alotterysystem,forafourweekstudy.TheprogressiveresistanceexercisewasgiventoGroupAandAllthesubjectsofgroupBperform45-60minutesofonlyactiverangeofmotionexercisesofmajorjointsofboththelowerandupperlimbs.Experimentalgroup:n=17,Control:n=16.Pre-test,Post-testExperimental.OutcomemeasuresbyPainMeasuredonGeriatricDepressionScale.AndWithinGroupAnalysisbypaired“t” Test and Between GroupAnalysis by unpaired “t” test. The test revealed a statistically significantreduction(p<0.001)ofdepressioninexperimentalgroup.

Keywords: Geriatric Depression Scale, Progressive Resistance Exercise

INTRODUCTION

Depression is potentially life threatening disorders thataffectshundredsofmillionsofpeopleallovertheworld. Itcanoccursatanyagefromchildhood to latelife and is a tremendous cost of society as this disorders causesseveredistressanddisruptionoflifeand,ifleftuntreated, can be fatal.1 The etiology of depression in the elderly is poorly understood.2It is not a homogenous disorder,butacomplexphenomenon,whichhasmanysubtypes and probably more than one etiology. Physical disability may induce depression because of loss of independence and social function.1

Ontheotherhand,depressionmayinducephysicaldisability by reducing motivation for physical activity and subsequent deconditioning in older persons.3

Moreover, individualswhohad been physically activein the past but who became inactive were 1.5 times more likely to become depressed than those who consistently maintained a high level of physical activity.4 Doctors view depression and old age as going hand in hand. Chronicailments,lossesindifferentspheresoflifeandthedeathsoffriendsinone’sownpeergroupareseenassufficientreasonstojustifysuchaview.5

Depression in older people can be conceptualized as being either early onset, with the initial episode

occurringbefore65yearsofage,orlateonset,beginningafter 65 years of age. Early-onset depression is moreoften associated with a family history of mood disorders suggesting that genetic vulnerability is less relevant in thelate-onsetgroup.6

Depression is a widespread and often chronic condition. Women are twice as likely as men to bediagnosedwithdepression,withlifetimeprevalenceratesof 10% to 25% in women versus 5% to 12% in men.7

There are many causes of depression; however,in the elderly, one factor that is frequently associatedwith depression is loss of health.8 In addition, thehippocampal formation is only one of two brain regions whererobustneurogenesiscontinuesintoadulthood,andnerve cells in the hippocampal formation are among the mostsensitivetothedeleteriouseffectsofstress.Thus,itseemsreasonabletohypothesizethatastress-induceddecrease in neurogenesis may be an important factor in precipitatingepisodesofdepression.Ontheotherhand,increases in serotonergic neurotransmission have been shown to augment hippocampal neurogenesis.10

Since increases in brain serotonergic neurotransmission are themost effective treatment fordepression,itisalsoreasonabletoproposematserotonin-

DOI Number: 10.5958/0973-5674.2019.00054.6


induced increases in neurogenesis may be an important factor in promoting the recovery from depression.10

Therefore,wesuggestthatthewaningandwaxingofneurogenesis in the hippocampal formation are important causalfactors,respectively, intheprecipitationof,andrecoveryfrom,episodesofclinicaldepression.10 Elderly depressed patients were found to have smaller caudate nuclei, smaller putaminal complexes and in increasedfrequency of subcortical hyper intensities comparedwithnormal,healthycontrols.Thesefindingsweremorepronounced in patients with late onset depression.2

DiagnosticGuidelines ofMildDepressive Episodearedepressedmood,lossofinterestandenjoyment,andincreased fatigability are usually regarded as the most typicalsymptomsofdepression,andatleasttwoofthese,plus at least two of the other symptoms described above shouldusuallybepresentforadefinitediagnosis.Noneof the symptoms should be present to an intense degree.

Diagnostic Guidelines of Moderate DepressiveEpisode are the presents of at least two of the three most typical symptoms noted for mild depressive episode should be present, plus at least three (and preferablyfour) of the other symptoms.

Diagnostic Guidelines of Severe Depressive Episode with Psychotic Symptoms are a severe depressive episode which meets the criteria given for severe depressive episode without psychotic symptoms and in which delusions, hallucinations, or depressive stupor arepresent.12

The mechanisms responsible for the reduction in depressive symptoms are unknown. Several observational studies have shown an association between enhancedphysicalfitnessandimprovedmentalhealth.13 Treatment of depression by pharmacological means is likely to leave residual symptoms in most patients. Such symptoms produce impairment and are important risk factors for relapse.5

Physical therapy seems to determinate improvement in depressive aspects not frequently responsive to thedrug treatment.10 Physical activity might be one of the most important behavioral interventions for preventing depression amongolder adults. Indeed, evidence frompopulation-based epidemiological studies using eithercross-sectionalorprospectiveresearchdesignssupportsan association between physical activity participation and a reduction in depression among older adults.6

Moreover, the comparison of aerobic and non-aerobic forms of activity for reducing depression would provide further evidence that vigorous physical activity might not be necessary for the accrual of psychological benefits.7The use of prolonged static exercise should be avoided.However,short,intermittentstaticcontractionsmay be useful for increasing muscle strength.17

Response to various treatment modalities within the spectrum of depressive symptoms observed is not well definedinolderindividuals.9

Strengthtrainingsignificantlyreducedalldepressionmeasures.9

No study has shown standard treatment to be superior to exercise for the relief of depression of the elderly persons.

MATERIAL AND METHOD

Sample: Total 30 subjects consisting of both male and female meeting the inclusion criteria were recruited for studyfromcommunitydwellinghomesofUttarahand.

Study Design: An Experimental study.

Inclusion criteria:

1. Subjects are not taking any physiotherapy treatment during the study.

2.Age65-85years

3. Scores between 11 and 19 on GDS.

4.BothGenders

5.Mini-MentalStateExaminationscalescore>22

Exclusion criteria:

1. Neurological problems other than depression

2. GDS score less than 11 and more than 19

3.Musculoskeletal disorders i.e. acute soft tissueinjuries,Fracturesetc.

4. Cardiovascular problems as diagnosed by the physician

5.Currentanti-depressantmedicationuse

6.CognitiveimpairmentasevidencedbyaMMSE<_22.

7.Anysuicidaltendenciesinpast


Instrumentation and Outcome Measures:

1. Dumbbells

2.Weightcuffs.

3.Mini-MentalStateExaminationScale

Outcome Measures:

1. Geriatric Depression Scale.

Protocol of Experimental Group: The progressive resistance exercise was used to strengthen the major muscles of both the lower limb and upper limb for the exercise duration of 45 to 60 minutes per sessions. The resistance exercise program was performed one time in aday,2daysaweekand48hrs.Restwasgivenduring4 weeks in a groups of 15 participants with a proper instruction.11

1RMwasusedforresistanceexerciseasbaselinemeasurement of a subject’s maximum effort. Theexercises given in 4 weeks for Intervention groupconsists of 12

1.Bicepscurlwithdumbbell.

2. Triceps extension with dumbbell.

3. Side shoulder raise with dumbbell.

4.Kneeextensionwithweightcuff.

5.Straight-leggedraisewithweightcuff.

6.Hamstringcurlcuff.

WeekwiseProgressiveResistanceExerciseTrainingProtocol10

1. During Week 1: Participants performed one set of10repetitionsatintensities40-50%of1RM.

2. During Week 2: Participants performed one sets of12-14repetitionsatintensities50-55%of1RM.

3. During week 3: The number of repetitions was reduced to 10 while set of exercise is remained oneandintensities55to60%of1RM.

4. During 4 week: The participants performed one set of 12 repetitions at intensities 60 to 65% of 1 RM.

Protocol of Control Group: All the subjects of group B performed 45-60 minutes of only active range ofmotion exercises of major joints of both the lower and upper limbs. The lower limb exercises were consists of

Flexion/Extension,Abduction/Adduction of Hip joint,Knee joint exercises of Flexion/Extension, andActiveanklemovementsofDorsiflexion/Plantarflexionofeachlimb.Whereas the upper limb exerciseswere consistsof Active Shoulder movements of Flexion/Extension,Abduction/Adduction, Elbow joint movements ofFlexion/Extension,andActivewristjointmovementsofwrist Flexion/Extension.

PROCEDURE

A total of 33 subjects were selected suffered with Depression by Geriatric Depression Scale and met the inclusion criteria were included. An informed consent of subjects was taken and 33 subjects were then divided randomlytoGroupA(Experimentalgroup)andGroupB (Controlgroup) througha lotterysystem, fora fourweek study. The blood pressure was measured before the treatment session for each subject.

GroupA got 17 subjects with mean age = 72.53years,S.D.=3.62.

Group B got 16 subjects with mean age = 74.93years,S.D.=4.84.

None of the subjects was taken physiotherapy during study. None of the subjects was taken physiotherapy during study. Study duration for both the groups was 4 weeks with 2 treatment sessions per week.11,12 Each treatment session was consists of 45-60 minutes per day and 5 minutes warm up and cool down periods added to it. Rest has been permitted to all the subjects during exercise session. The blood pressure was measured before the treatment session for each subject. Group A (Experimental group) was given Progressive Resistance Exercise training protocol to strengthen the majormusclesofthelowerandupperlimb.1RMwasused for resistance exercise as baseline measurement ofasubject’smaximumeffort.Theexercisegivenin4weeksforInterventiongroupsconsistsof 12

Bicepscurlwithdumbbell,Tricepsextensionwithdumbbell, side shoulder raise with dumbbell, Kneeextensionwith weight cuff, Straight-legged raise withweightcuff,Hamstringcurlwithweightcuff.

The position of the subjects to do resisted biceps curl; triceps extension, side shoulder raise and kneeextension were well supported sitting position, andsupineforstraightlegged-raise,whereaspronepositionwas used for hamstring.


Trial Session: Visual demonstration of both theprogressive resistance exercise and active range of motion exercises was given to subjects of both the groups.

Actual Exercise Session:After the trial sessions, theprogressive resistance exercise protocol was given to all the subjects of the experimental group was consist of free-weight dumbbells for upper limb exercises,and weighted ankle cuffs for lower limb exercises.Dumbbell loads ranged from 1 to 10 kg. and loading of theweightedanklecuffsrangedfrom1to8kgwasused.All the Active range of motion exercises were given to the subjects of Group B to improve depression and sleep. The data was collected at the end of fourth weeks of both groups by using Geriatric Depression Scale

FINDING

Resistanceexerciseswillbebeneficialforreducingsigns and symptoms of depression of those older adults who are facing depression at their age.

CONCLUSION

From the study we conclude that both the Progressive Resistance Exercise and Free Active Range ofMotionexercisesareeffective inreducing thesignsand symptoms of the depression of the older adults. Thefindings arehighly significant inboth thegroups.Unpairedt–testwasusedtocomparetheGDSvaluesofGroupAandGroupBforboththeinterventionsandtofindtheireffectiveness,whereaswithinthegroupsweappliedPairedt–testtocomparethevaluesofPreandPostGDS.Thet–valuesforPre–GDS,Post-GDSforGroupAandgroupBare9.53and7.246respectively.

The results of the study suggest that t value is highly significantineachPairofbothGroupAandGroupB.This reveals that the treatment given to both the Groups areeffectiveasthepvaluesinboththegroupsare<0.000.Whereas the mean difference between the Post GDSScore of both the group clearly shows that the Group A (Experimentalgroup)isquitesignificanttoGroupB.Themean ± s.d.valuesforPre-GDS,Post-GDSforGroupAare14.4±.0.73and12.6±0.72respectively.Themean±s.dvaluesfortheGroupBare14.7±1.29and13.79± 1.05 respectively. This result shows that the treatment giventothePatientsinGroupA(ExperimentalGroup)ismoreeffectivethanthatofGroupB(ControlGroup).

Therefore,dependsonthefindingsaftercomparingthe mean post GDS values of both the Groups, theProgressiveResistanceExercisearemuchmoreeffectivethantheFreeActiveRangeofMotionExercise.

Conflict of Interest: The results of this study is limited infewfactors,whichisgivenasfollows

1.Major Depressive Disorders were not includedin thisstudy,so that thisstudyisnotfeasible tochecktheeffectivenessofProgressiveResistanceExercise program on those elderly adults who are clinically depressed as Major DepressiveDisorders.

2.The sample size included in this study is small,so it could not be generalized to conclude that Progressive Resistance Exercise is effective inreducing depression of elderly adults.

3. The age is a factor that the subjects aged only 65-85 were included in this study, so this studycouldnotcheckedtheeffectivenessofhomebasedProgressive Resistance Exercise program on depression of elderly aged below 65 and over 85.

4. The follow up of outcome measurement were not taken,sothisstudyisnotgeneralizedtoconcludethat the long effectiveness of ProgressiveResistance Exercise program on depression.

Therefore, the future study shouldbedonedue tothe above given facts of limitations.

Source of Funding: FromUttranchal (Pg)College ofBiomedicalScsandHospitalDehradun

Ethical Clearance:ItisaabonafideworkdonebymeandIhavenottakenanypartofthethesisfromanywhere.

REFERENCES

1.Bondy B: Athophysiology of depression andmechanisms of treatment. State of the art: Dialogues in Clinical Neuroscience 2002; 4(1):311-4.

2.Ranga K, Krishnan R, William M, DonaldMc, Murali Doraiswamy P: Neuroanatomicalsubstrates of depression in the elderly. Eur Arch Psychiatry Clin Neurosci (1993); 243 : 41-46

3.Mock P, Norman T, Olver J: ContemporaryTherapiesforDepressioninOlderPeople:Journal of Pharmacy Practice and Research 2001; 40 (1), 210-3.


4.KnapenJ,VancampfortD,SchoubsB,ProbstM,SienaertP,HaakePetal:ExercisefortheTreatmentof Depression ; The Open Complementary Medicine Journal 2009 ; Volume 1.

5.Williams A : Depression and Function in theElderly ; [p 154], Geriatric Physical Therapy journal

6.YanagitaM,BradleyJ,KamalH,ChenR,BeatrizL : Disability and Depression: Investigating aComplex Relation Using Physical PerformanceMeasures ;Geriatric Psychiatry journal 2006 ; 14(2), 213-2.

7.BabyakM ,Blumenthal J,HermanS,Khatri P,DoraiswamyM : Exercise Treatment forMajorDepression:MaintenanceofTherapeuticBenefitat10Months ;Psychosomatic Medicine journal 2000: 62:633–638

8.Roos JL:Depression later in life - an approachfor the family practitioner: Journal of Pharmacy Practice and Research 2008 ; 50 ( 4): 210-3.

9.Mock P, Norman T, Olver j: ContemporaryTherapiesforDepressioninOlderPeople:Journal of Pharmacy Practice and Research 2010; 40(1): 230-2.

10.Knapen J, Vancampfort D, Schoubs B, ProbstM, Sienaert P, Haake P et al : Exercise for

the Treatment of Depression: The Open Complementary Medicine Journal 2009 : 30( 1): 310-3

11.Jacobs B: 2002, Adult brain neurogenesis anddepression: Brain, Behavior, and Immunity journal 2002:16 (2): 602– 4

12.Depression Criteria, 1992, The ICD-10ClassificationofMentalandBehavioralDisorders,World Health Organization, Geneva, 1992

13.BlumenthalB,BabyakM,MooreK,CraigheadE, Herman S, Khatri P, et al :1999, Effects ofExerciseTrainingonOlderPatientsWithMajorDepression. Arch Intern med journal(1999) :14(3): 341-2

14.Fava GA, Ruini C: Long-term treatment ofdepression: there is more than drugs: Recenti Prog Med journal 2002: 93(6):343-5.

15.Carta M, Hardoy M, Pilu A, Sorba M, FlorisA, Mannu F, et al. 2008: Improving physicalqualityoflifewithgroupphysicalactivityintheadjunctive treatment of major depressive disorder. Clinical Practice and Epidemiology in Mental Health journal 2008: 4:1

Effect of Myofascial Release in Axillary Web Syndrome in Carcinoma of Breast

Nirmiti. A. Datar1, Vaishali. Jagtap2

1Faculty of Physiotherapy, 2Assistant Professor, Faculty of Physiotherapy, Krishna Institute of Medical Sciences Deemed To Be University, Karad, Maharashtra, India

ABSTRACT

Background: Axillary web syndrome causes painful scar tissue formation and contractures that extend from axilladownwardstothemedialaspectofarm.Itispainfulandcanbeinitiatingfactorforpostoperativecomplications suchas lymphedema,numbness in thearmand limited shoulder andarmmobility in theaffectedarm.

Objective:TofindtheeffectofmyofascialreleaseandstretchingonAxillarywebsyndrome.

Method: A randomized controlled trial consisting of 10 females was done who underwent axillary dissection procedures forbreastcarcinoma,withvisibleandpalpablecordsonaxillaorarmwith restricteduseofipsilateral upper extremity. 2 groups were made and were treated with mfr and stretching respectively for 4weeksandpreandpostassessmentwasdonewithVAS,DASHandGoniometry.

Results:ThestatisticalanalysisforMFR-VAS(p=0.0026),DASH(p=0.0013),Shoulderflexionandmedial rotation (p=0.005), extension (p=0.0005), abduction (p=0.003) and lateral rotation (p=0.0002)showedsignificantimprovement.Thestatisticalanalysisforstretching-VAS(p=0.0086),DASH(p=0.0008),shoulderflexion(p=0.0009),extension(p=0.0019),abductionandmedialrotation(p=0.001),lateralrotation(p=0.009)showedsignificantimprovement.AnditwasfoundthatMFRshowedmorebettereffectcomparedto stretching.

Conclusion:ThisstudyfoundoutthatMFRhadbetterresultsinallthe3outcomemeasureswhichweretaken.HenceMFRcanbeusedmorefrequentlyinmanagementofAWS.

Keywords: Axillary web syndrome, MFR, Stretching, DASH, carcinoma of breast.

Corresponding Author:VaishalijaptapAssistantProfessor,FacultyofPhysiotherapy,KrishnaInstituteofMedicalSciencesDeemedToBeUniversity,Karad-415110Maharashtra,IndiaEmail: [email protected]

INTRODUCTION

Cancer is abnormal growth of cells in an uncontrolled mannerthatinfiltratenormalbodytissues.1 All cancers occur from single cell, this differentiates betweenneoplasia and hyperplasia. Changes in tissue occur to a single brief exposure to carcinogen which causes initiation. Multi-cellular organisms are susceptible to

clonal acquired genetic disorder. Common cancers inIndiainmalesarelung,oralcavity,stomach,colorectal,pharynxandinfemalesbreast,cervix,colorectal,ovary,oral cavity.2Breast cancer is themost common cancerin women accounting 25.1% of all the cancers.3 Due to lackofestrogeninpostmenopausalwomen,itismorecommonly seen in them.4 Mostbreastcancersstartintheduct cells and only some in cells of lobules and other tissues.5Breast cancer can be invasive carcinoma ornon-invasive carcinoma. Invasive carcinoma is furtherdividedintoinvasiveductalcarcinoma,invasivelobularcarcinoma, tubular carcinoma, medullary carcinoma.Non-invasivecarcinomaincludesductalcarcinomaandlobular carcinoma.2

Diagnosis: Detailed history and examination coupled with Fine Needle Aspiration Cytology(FNAC),

DOI Number: 10.5958/0973-5674.2019.00055.8


Mammography, Ultrasonography, MRI (MagneticResonanceImaging)areusedfordiagnosis.2

Treatment of breast carcinoma is classified intotwo types- Local therapy (surgery and radiotherapy)or Systemic treatment (chemo, hormone and targetedtherapy).Surgicaltreatmentofbreastcancerisclassifiedintotwocategories:-Mastectomyandbreastconservingsurgery.2Mastectomy includes removal of entirebreast.Lumpectomyinvolvesexcisionofthemassandpreserving a portion of the breast.2

Axillary complications after surgery for breast carcinoma areWound infections, Lymphedema of thearm, Limitation of armmovement, Reducedmobility,Axillary web syndrome, Seroma, Tissue necrosis,Lymphangitis,Incisionalpain.6,7

Axillary web syndrome(AWS) is a conditioncharacterised by painful scar tissue formation and contractures that extend from axilla downwards to the medial aspect of arm.8 It can be visually described asa web of skin covering cords which are more visible with abduction of the shoulder. It can be painful andresults in limited shoulder and arm mobility in the affected arm. It usually develops in 2-4 weeks aftersurgery.9 It most commonly occurs because of breastcancer surgery-Mastectomy (removal of the breast),Lumpectomy (removal of lump within the breast),Lymphadenectomy.2,6SignsandsymptomsofAWSareasfollows:Scartissue,Cordformation,Pain,Decreasedrangeofmotion,Numbnessinarm.10

Diagnosis: Diagnosis can be done by palpating in the axillary area for presence of thick bands of scar tissue andMRI,USimagingcanbeusedfordiagnosis.10,11

Treatment of AWS:AWScanbetreatedbyStretching,Massage, moist heat, Home exercises andMyofascialrelease. Stretching is done to relieve tightness and reduce hypomobility and stretches may vary depending on the scar tissue extent. Patients are advised to perform the stretchestheylearned,gentlearmflexionandhorizontalabduction with hand supported on wall and move to the point of tension and holding position for few seconds before releasing.12

Myofascial release (MFR) therapy is a techniqueused to release the restrictions in soft tissues of the body. As there is shortening of muscles and adhesions between layersoffascia,thistechniqueactstoelongateorstretch

themuscularandfascialstructures.Myofascialtherapycausesreliefofpaininpatientswithrestrictedmobility,thus allowing patients to return to normal function.13


Typeofstudy-experimentalstudy,Studydesign-preandposttest,Placeofstudy-Krishnainstituteofmedicalsciences deemed to be university, sample size- 20,Samplingmethod-simplerandomsampling,Durationofstudy-3months.

Inclusion Criteria:

1. Females

2. Subjects who underwent axillary dissection procedures for breast carcinoma.

3. Subjects with visible and palpable cords on axilla or arm with restricted use of ipsilateral upper extremity

Exclusion Criteria:

1.Infectioninaxillaryarea

2. Eczema

3.Openwounds.

4. Hypersensitive skin

Materials:

1. Hot moist pack

2. Examination couch

3. Goniometer

Procedure: This study was conducted to find theEffectofmyofascialreleaseinAxillarywebsyndrome.Protocol clearance was done. Ethical consent from the university was taken.

The subjects were divided into 2 groups based on the inclusion and exclusion criteria using simple random sampling.Informedconsentwastakenfromthesubjects.Subjects were assessed for pain status, disabilities ofshoulderfunction,mobilityofshoulderpriorinterveningwith the treatment. Subjects were explained about the procedure of the study.

GroupAwasexperimentalgroupandgroupBwasconventional group.


Group A was given myofascial release and moist heat for alternate days per week for 4 weeks.

GroupBwasgiven conventional treatment that isstretching and moist heat for alternate days per week for 4 weeks.

After 4 weeks the post treatment assessment for pain status, disabilities of shoulder function, mobilityof shoulder was taken with the help of assessment tools (visual analogue scale,DASHQuestionnaire, shouldergoniometry).

Pre and post treatment scores of pain status,disabilities of shoulder function with help of VAS,DASHQuestionnaire,ShoulderGoniometryofboththegroups was taken for statistical analysis.

The interpretation of the study was done on the basis ofcomparingpretestandposttestassessmentofVAS,DASHQuestionnaireandShoulderGoniometry.

The study was concluded by statistical analysis of all the outcome measures.

MFR:Itisatechniqueusedtoreleasetherestrictionsinsofttissuesofthebodyasthistechniqueactstoelongatethemuscularandfascialstructures.MFRwasgivenfor90-120seconds,alternatedaysperweekfor1month.[14]

Stretching to relieve tightness and reduce hypomobility was given for 3-5min, alternate daysper week for 1 month.[13] Subjects were asked perform gentlearmflexionandhorizontalabductionwithhandsupported on wall and move to the point of tension and holding position for few seconds before releasing.

Hot Moist Pack: 10 min per session was applied prior the treatment to decrease discomfort.

Outcome Measures:

Visual Analogue Scale (VAS): Pain measurement by means of a visual analogue scale on which the patient can indicate their pain status along a 10cm line ranging from0(Nopainatall)to10(mostseverepain).

DASH (Disabilities of Arm, Shoulder and Hand): Itisa30itemselfreportquestionnaireusedtoassesstheability of a patient to perform certain upper extremity activitiesandratedifficultyandinterferencewithdailylife on a 5 point scale.

Shoulder Goniometry: It is used to assess range ofmotion by measuring in all planes of movement.

Statistics: Statistical analysis was done manually and by usingInstatsoftwaretoverifythederivedresults.Withingroup analysis was done using paired t test and between group analysis was done using unpaired t test.

FINDINGS

I. Within the group comparison 1. Shoulder Goniometry

Table 1: Shoulder Goniometry

Group Parameter Pre Post Mean Diff T Value P Value RemarkA SHDFL 120 ± 22.36 168 ± 8.36 -48 5.58 0.005 Significant SHD EX 24.6±7.47 54 ± 6.51 -29.4 10.48 0.0005 Significant SHDABD 107±28.63 166 ± 9.61 -59 6.45 0.003 Significant SHDMR 41.8 ± 15.2 71±12.45 -29.2 5.4 0.005 Significant SHDLR 24 ± 11.93 76±7.41 -52 12.8 0.0002 SignificantB SHDFL 112 ± 22.52 138 ± 19.23 -26 8.91 0.0009 Significant SHD EX 32.4 ± 3.36 46 ± 4.18 -13.6 7.311 0.0019 Significant SHDABD 112 ± 26.59 139 ± 23.02 -27 7.96 0.001 Significant SHDMR 29 ± 8.94 49±5.47 -20 7.3 0.001 Significant SHDLR 38 ± 14.38 61±7.41 -23 4.69 0.009 Significant

Interpretation: The above table and graph shows pre and post comparison within the group. Post treatment there wassignificantimprovementnotedingroupAandgroupBaccordingtothepvalues.


2.VAS

Table 2: VAS

Parameter Pre Post Mean diff t value p value RemarksGroup A 5.0±1.732 2.0 ± 1.22 3 6.708 0.0026 SignificantGroupB 5.20 ± 1.304 3.40±0.547 1.8 4.811 0.0086 Significant

Interpretation: The above table and graph shows pre and post comparison within the group. Post treatment there wassignificantimprovementnotedinpainstatusinboththegroupsaccordingtothepvalues. 3. DASH

Table 3: DASH

Parameter Pre Post Mean diff t value p value RemarksGroup A 53.03 ± 9.84 21.72±5.10 31.3 8.083 0.0013 SignificantGroupB 55.31 ± 8.82 30.16 ± 6.13 25.14 9.207 0.0008 Significant

Interpretation: The above table and graph shows pre and post comparison within the group. Post treatment there wassignificantimprovementnotedinshoulderandarmmobilityinboththegroupsaccordingtothepvalues.

II. Between the group comparison 1.VAS

Table 4: VAS

Parameter Group A Group B t value p value RemarksPRE(VAS) 5.0±1.732 5.20 ± 1.304 0.206 0.841 NotsignificantPOST(VAS) 2.0 ± 1.22 3.40±0.547 2.33 0.047 Significant

Interpretation:Theabovetableshowspreandpostcomparisonbetweenthegroup.Thegraphshowsdifferencein the post treatment values between the group. Statistically the pre treatment mean between the groups was not significantwhileposttreatmenttherewassignificantimprovementnotedinonegroupascomparedtotheothergroupaccording to the p values. 2. DASH

Table 5: DASH

Parameter Group A Group B t value p value RemarksPRE(DASH) 53.03 ± 9.84 55.31 ± 8.82 0.386 0.709 NotsignificantPOST(DASH) 21.72±5.10 30.16 ± 6.13 2.36 0.045 Significant

Interpretation:Theabovetableshowspreandpostcomparisonbetweenthegroup.Thegraphshowsdifferencein the post treatment values between the group. Statistically the pre treatment mean between the groups was not significantwhileposttreatmenttherewassignificantimprovementnotedinonegroupascomparedtotheothergroupaccording to the p values. 3. Shoulder goniometry

Table 6: Shoulder goniometry

Parameter (Pre) Group A Group B t value p value RemarksSHDFL 120 ± 22.36 112 ± 22.52 0.563 0.588 NotsignificantSHD EX 24.6±7.47 32.4 ± 3.36 2.129 0.065 NotsignificantSHDABD 107±28.63 112 ± 26.59 0.286 0.782 NotsignificantSHDMR 41.8 ± 15.2 29 ± 8.94 1.622 0.143 NotsignificantSHDLR 24 ± 11.93 38 ± 14.38 1.644 0.138 Notsignificant


Conted…

Parameter (Post) Group A Group B t value p value RemarksSHDFL 168 ± 8.36 138 ± 19.23 3.19 0.012 SignificantSHD EX 54 ± 6.51 46 ± 4.18 2.3 0.049 SignificantSHDABD 166 ± 9.61 139 ± 23.02 2.420 0.041 SignificantSHDMR 71±12.45 49±5.47 3.61 0.006 SignificantSHDLR 76±7.41 61±7.41 3.19 0.012 Significant

Interpretation:Theabove tableshowspreandpostcomparisonbetween thegroup.Thegraphshowsdifferencein the post treatment values between the group. Statistically the pre treatment mean between the groups was not significantwhileposttreatmenttherewassignificantimprovementnotedinonegroupascomparedtotheothergroupaccording to the p values.

DISCUSSION

This study “To Find Effect ofMyofascial releaseon Axillary web syndrome in carcinoma of breast”was conducted to compare the two treatments that is stretchingandMFRandfindoutwhichbest improvesfunctional mobility of shoulder and arm and reduces pain. The study was conducted with 10 subjects. The subjects were divided into two groups. Prior consent was taken from them.The subjects in first group receivedmoist heat and myofascial release and in second group received moist heat and stretching. The interventions were carried out for alternate days per week for 4 weeks. TheoutcomemeasuresforthisstudywereVAS,DASHQuestionnaire, ShoulderGoniometry. 4 participants inMFR group and 3 in control group did not completefollow up assessments and 1 participant from MFRgroup and 2 from control group dropped out due to recurrence of cancer.

Studies conducted previously byRebeccaMarshallMckennastatedthatmyofascialreleasewaseffective intreatment of axillary web syndrome and the use of DASH questionnaire showed good reliability and validity,butstretchingastreatmentforAWSwasn’tused.Theresultsof this study indicate that myofascial release and stretching bothareeffectiveintreatmentofaxillarywebsyndromeand DASH questionnaire was reliable to producesatisfactory results. This study shows that myofascial release and stretching show significant improvementin the outcome variables concluding that it improves shoulder and arm mobility. Previous studies conducted by Weietal,usedmassageandshoulderabductionexercisesonly to increase range but tightness and numbness was still present. From this study, it was concluded thatstretching is effective in relieving symptoms ofAWS.

StudyconductedbyLindaKoehlerstatedthatassessingpainbyVASandrangesbyshouldergoniometryreportedtoprovidequantifiableandreliableresults.

Studies conducted by John Crawford usedmyofascial release to provide symptomatic relief for chest wall tenderness following lumpectomy and radiation in breast cancer patients. This study was conductedtofindeffectofmyofascialreleaseinaxillarywebsyndrome,whichledtotheconclusionthatMFRiseffectiveinprovidingpainreliefbyreleasingrestrictionsand also improvement in range of motion.

Within the group comparison: Myofascialrelease(MFR):-Post training there was significantimprovement noted with MFR in VAS (p = 0.0026)and DASH (p = 0.0013). Post training there wassignificantimprovementinShoulderflexionandmedialrotation(p=0.005)andextension(p=0.0005),abduction(p=0.003)andlateralrotation(p=0.0002),followingarethe p values which led to analysis of improvement.

Stretching: Post training there was significantimprovement notedwith stretching inVAS(p=0.0086)and DASH (p=0.0008). Post training there wassignificantimprovementinshoulderflexion(p=0.0009),extension (p=0.0019), abduction and medial rotation(p=0.001),lateral rotation (p=0.009), following are thep values which led to analysis of improvement. Post treatment improvement in range of motion was seen as treatment elongated or stretched the muscular and fascial structures.

Between the group comparison:

1. Pre test:Pretesttherewasnosignificantdifferencebetween outcome variables in VAS (p= 0.841),


DASH (p=0.709), Shoulder flexion (p=0.588),extension (p=0.065),abduction(p=0.782),medialrotation(p=0.143) and lateral rotation(p=0.138),following p values showed that there was no significantdifferencebetweenoutcomevariables.

2 Post test:Posttesttherewassignificantdifferencebetween outcome variables in VAS(p= 0.047),DASH (p=0.045). Following are the p valueswhich led toanalysisof improvement inflexionandlateralrotation(p=0.012),extension(p=0.049),abduction(p=0.041),medialrotation(p=0.006).

CONCLUSION

This study shows that myofascial release showed significant improvement in the outcome variablesconcluding that it improves shoulder and arm mobility andshowsmorebettereffectcomparedtostretching

Conflict of Interest: The authors declare that there are no conflicts of interest concerning the content of thepresent study.

Source of Funding: This study was self funded.

Ethical Clearance: The study was approved by the InstitutionalEthicsCommitteeofKIMSDU.

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14.CrawfordJS,SimpsonJ,CrawfordP.Myofascialrelease provides symptomatic relief from chest wall tenderness occasionally seen following lumpectomy and radiation in breast cancer patients. International journal of radiationoncology,biology,physics.1996;34(5):1188-9.

Increased Scapular Anterior Tilting and Decreased Humeral Internal Rotation in the Mouse Shoulder in Computer

Workers with Shoulder Pain

In-cheol Jeon1, Oh-yun Kwon2, Ui-jae Hwang3, Sung-hoon Jung3, Jong-hyuck Weon4

1Department of Physical Therapy, College of Life & Health Sciences, Hoseo University, Republic of Korea; 2Department of Physical Therapy College of Health Science, Yonsei University, South Korea;

3Department of Physical Therapy, Graduate School, Yonsei University, Wonju, South Korea; 4Department of Physical Therapy, College of Tourism & Health Science, Joongbu University, South Korea

ABSTRACT

The purpose of this study was to investigate whether the pectoralis minor on the mouse shoulder side and thatonthenon-mouseshouldersideweresignificantlydifferentinlength,resultinginadifferentangleofshoulder internal rotation. This study included 33 computer workers employed in an electronics company who engagedinheavymouseuse(>6.1h/day).Thedistancebetweenthechairbackrestandtheposterioraspectofthelateralacromionprocessinthetransverseplaneduringworkingwasmeasuredbytwo-dimensionalphotographicanalysis(acromiondistance).Thelengthofthepectoralisminorwasdeterminedusingarulerto measure the distance between the examining table and the posterior aspect of the lateral acromion process inasupineposition.Internalandexternalrotationofthemouseandnon-mouseshoulderswasmeasuredusingauniversalgoniometer.Inthemouseshoulder,theacromionwasina53.7%moreanteriorpositioninthetransverseplanecomparedwiththenon-mouseshoulderduringworking.Thedistanceofpectoralisminordifferedby39.7%between themouseandnon-mouse shoulder (p <0.001).Themouse shouldershowedmorelimitedpassiveinternalrotation(69.2%ofthenormalrange)withpain(VAS5.2)comparedwith the non-mouse shoulder (79.0% of normal range) without pain. This suggests that excessive andfrequentanteriortiltingofthescapulainthemouseshouldermaycompensateforshoulderinternalrotation,leadingtoinhibitionofshoulderinternalrotationduringworkingcomparedwiththenon-mouseshoulder.

Keywords: Computer workers; Humeral internal rotation; Mouse shoulder; Scapular anterior tilting.

Corresponding Author:Oh-yunKwonDepartmentofPhysicalTherapy,CollegeofHealthScience,YonseiUniversity,SouthKoreaEmail: [email protected]

INTRODUCTION

The diagnosis of mouse shoulder is increasingly common in family medicine clinics. The associated discomfort and pain in muscles and tendons of the shoulderandforearmcanbecausedbyfrequentmouseusewithoutergonomicconsiderations(ChenandLeung2007)1.Approximately75%ofjobsrequirethatworkersuseacomputerandamouse(Tiric-Camparaetal.2014)2. Heavy computerwork can cause tendon inflammationandabnormalitiesoftheshoulderjointandrotatorcuff,

resulting in even torn muscles and tendons in severe cases.Severeinflammationinthecapsuleandligamentsofshoulderjointcancausestiffnessintheshoulderjointand limited mobility. Forward reaching posture as an inappropriate positioning of the computer and mouse may evoke abnormal postures in computer workers,resultinginjointimpairments(BauerandWittig1998)3. Therefore, those who engage in heavy computer useshould employ an ergonomic computer mouse position that promotes upper armnext to trunk atwork (Tiric-Campara et al. 2014)2.

Aprevious study defined “technological diseases”as impairments caused by injurious factors in work places associated with overuse of the keyboard and mouse(Tiric-Camparaetal.2014)2.Becauseoveruseofthemouse is associatedwith non-ergonomic positions

DOI Number: 10.5958/0973-5674.2019.00056.X


ofthehand,elbow,andshoulder,ergonomicmouseusewas recommended to prevent technological diseases associatedwithprolongedseatedcomputerwork,suchas cervical syndrome, carpal tunnel syndrome, andmouseshoulder(Tiric-Camparaetal.2014)2.

The mouse can be considered indispensable for modern software and graphicwork, and heavymouseusersfrequentlysufferfrommusculoskeletalsymptomsin theupperextremities(Cook,Burgess-Limerick,andChang 2000)4. Atkinson et al. (2004)5 reported that nearly 50% of those who worked with a mouse for an average of 6 h per day reported musculoskeletal pain and discomfort, especially in theupper extremities. Jensenetal. (2002)6 also observed that workers who engaged in intensive mouse use had more severe symptoms in their upper extremities than did those who worked with computerswithoutusingamouse.Onesourceofthesedifferencescouldbethatduringmouseuse,theshouldermaybefixedinaforwardreachingpositionovertime,which can result in shortening of the pectoralis minor muscle (Knudsen1988)7.Mountingevidence in recentyears has linked prolonged poor posture with increased muscle loading and subsequently increased symptomsintheshoulder(WinkelandWestgaard1992)8. Postural impairment of the shoulder may be caused by shortness of the pectoralis minor (Sahrman 2002)9. However,no study has investigated whether computer workers with intensive mouse use exhibit differences betweenthemouseandnon-mouseshouldersinpainandinthelength of the pectoralis minor.

The purpose was to assess whether the mouse shoulderandnon-mouseshoulderincomputerworkersshowed different pectoralis minor lengths and wereassociated with differential shoulder internal/externalrotation. In thepresent study, itwashypothesized thatcomputer workers would have shorter pectoralis minor muscles and less internal rotation with pain on the mouse comparedwiththenon-mouseside.

Table 1: Subject profiles

Information Subjects (20 females, 13 males)

Age(years) 23.4 ± 2.2Bodyheight(cm) 176.7±3.8Bodymass(kg) 69.1±7.1

Hand dominancy 15Left;18Right

Conted…

Workexperience 8.4 ± 1.2Workinghoursperweek 8.1 ± 2.0

Computer usage at work in h/day 6.2 ± 1.2Keyboarduseinh/day 3.8 ± 1.1Mouseuseinh/day 6.1 ± 1.6

Visualanalogscale,paininpast 12 mo 5.2 ± 1.2

Bodymassindex 20.2 ± 1.8

METHOD

Participants: Forthisstudy,33computerworkerswererecruited. The subjects worked on computers a minimum of6hdaily,performingmainlymouseusingtasks.Theexclusion criteria included previous traumatic injuries and surgical interventions to the neck or upper limb regions. All subjects had shoulder pain related to computer and mouseuseofmorethan3-monthdurationduringthepastyear (Table 1). The subjects were informed about thepurpose and procedures of the study. The experimental protocolswereexplainedindetail toallof thesubjects,and all subjects signed an informed consent form.

Study Design: Toassessdifferencesbetweenthemouseand non-mouse shoulder duringworking, the distanceof the acromion from the seat back in a seated position (after 30 min computer work) were measured. In thestartingpositionduringcomputerwork,eachworkersatcomfortablyerectwithbothkneesflexed90ºandthefeetshoulder width apart. All workers were instructed to keep their heads looking forward and to use a single monitor. Then,theywereaskedtouseakeyboardandmousefora computerwork simulation,which entailed typing ata comfortable speed and using the mouse naturally for 30 min. During this time, the acromion distance wasrecorded in the transverse plane.

Figure 1: Measurement of acromion distance on both sides


Acromion Distance: Rounded shoulder posture during working by measuring the distance between the chairbackrest (65cmheight fromchairplate)and theposterior aspect of the lateral acromion process in the transverse plane using two-dimensional photographicanalysis(Figure1).Theexaminertookpicturesofeachworker’s head and shoulders.A camerawas placed ataconsistentheightandinthesametransverseplane,1m from the head to measure the distance between the posterior aspect of the acromion and the chair backrest inthetransverseplaneforbothshoulders(Figure1).Themeasurements were performed three times by taking pictures for photographic analysis (National InstitutesofHealth,USA)(Abràmoffetal.2004)10. The distance valueswererecordedincentimeters.TheICCvaluewas0.85 for photographic analysis of the study.

The distance of the pectoralis minor: The distance of the pectoralis minor was assessed by measuring the distance between the examining table and the posterior aspect of the lateral acromion process in a supine position (Kendall et al. 1993)11. An examiner palpated the posterior aspect of the lateral acromion process and marked it using a black pen while the subject was supine,withelbowsinflexionandbotharmsplacedonthechest(Sahrman2002)9.Then,usingaruler(JohnsonLevel&ToolMfg.Co,Inc.,Mequon,WI),theexaminermeasured the distance from the examining table to the mark indicating the posterior aspect of the lateral acromion process. The distance values were recorded in centimeters.Anintra-classcorrelationcoefficient(ICC)value of 0.95 was obtained.

Passive internal and external rotation: The range of motion (ROM) was measured using a universalgoniometer(Jamar,Jackson,MI,USA),whichisa14-inchstainlesssteelgoniometerwith360°range.Passiveinternal and external rotations were measured with the armin90ºshoulderabductioninsupineposition.Apilotstudy showed high intra-rater reliability (ICC rangingfrom0.92to0.97)inbothinternalandexternalrotation.


Apairedt-testwasusedtodeterminethestatisticalsignificanceofdifferencesintheacromiondistance,thedistance of the pectoralis minor, and passive internalandexternalrotationbetweenthemouseandnon-mousesidesinalltheworkers.Significancewassetatα =.05.TheStatisticalPackagefortheSocialSciences(SPSS)was used for all analyses.

Figure 2: Differences in acromion distances of the two shoulders according to mouse placement

Figure 3: Mouse versus Non-mouse shoulder: Acromion (acromion distance) and Length (length

of pectoralis minor)

Figure 4: Mouse versus Non-mouse shoulder: IR (internal rotation) and ER (external rotation)

RESULTS

1. Acromion distance:Asignificantdifferencewasobserved between the mouse and non-mouseshoulder (11.06± 2.49 cmand7.21± 1.83 cm,respectively;[t =8.10,p <0.001](Figure3).

2. The distance of the pectoralis minor: A significant differencewas observed between themouseandnon-mouseshoulder(7.11± 1.49 cm and 5.09 ± 1.40cm, respectively; [t =6.10,p <0.001](Figure3).


3. Passive internal rotation:Asignificantdifferencewas observed between the mouse and non-mouseshoulder(62.30± 9.74ºand71.09± 9.35º,respectively;[t =–3.91,p <0.001](Figure4).

4. Passive external rotation: No significantdifferencewas observed between themouse andnon-mouse shoulder (84.33± 4.42º and 86.09 ± 3.21º,respectively;[t =–1.91,p <0.07](Figure4).

DISCUSSION

Thepresentstudyreportedthatforallworkers,themouseshoulder,whichwasthedominantside,showeda greater distance between the posterior aspect of acromionand theexamining table,and thenon-mouseshoulder, the non-dominant side, showed a relativelyshorter distance. Sahrman (2002)9 reported that with normalpectoralisminor length, thedistancemeasuredhereshouldnotexceed1inch(2.54cm).Inthepresentstudy, even though the average distances of both themouse(7.11cm)andthenon-mouse(5.09cm)shouldersexceeded the normal length of 1 inch, there was asignificant difference (39.7%) between these distances(p <0.001). Somepossible reasons for this differencewill now be discussed.

First, this result suggested that different taskingstrategies were used for the mouse shoulder compared with the non-mouse shoulder. All of these computerworkers with heavy mouse use showed acromion positions that were more anterior in the mouse shoulder (by53.7%)thaninthenon-mouseshoulderasmeasuredin the transverse plane during working. This result implied that most of these workers tended to reach their dominant hand forward to control the mouse overalongperiodofwork.Incontrast,comparedwiththemouse shoulder, the other shoulder was held in arelatively posterior position to use the keyboard. This difference in shoulder reaching patterns highlights therole of the pectoralis minor muscle in postural control of theshoulder joint.Thisfindingsupportsotherworkshowing that altered movement patterns associated withstaticpostureswithdifferentjointpositionsacttolimittherangeofmotion(Sahrman2002)9. A shortened pectoralis minor is related to increased anterior scapular tilting(Lukasiewiczetal.1999)12 because the insertion of the pectoralis minor is at the coracoids process of the scapula(Kendalletal.1993)11.

Theshortenedpectoralisminormaycausefrequentscapular anterior tilting instead of shoulder internal rotation during work and during activities of daily living.Thedifferences in internal rotationbetween themouseandnon-mouse shouldersmaybeexplainedbythe altered movement patterns resulting from a static posture.Theresultshowedthat thedifferencebetweensides in the angle of passive internal rotation became even moreapparentintermsofinternalrotation,withgreaterlimitation of passive internal rotation (69.2% of thenormal range) in the mouse shoulder compared with the non-mouseshoulder(79.0%ofthenormalrange).Thisresult implied that these computer workers frequentlyreached forward during mouse use, maintaining astaticroundedshoulderposture. Incontrast,useof thekeyboard alone allowed the workers to employ a less rounded shoulder posture in the non-mouse shoulder.Thefindings regardingdifferences in the limitationoninternal rotation indicated that greater scapular anterior tilting associated with mouse use contributed to reduced internalrotationinthemouseshoulder.Thus,excessiveand frequent anterior tilting of the scapula associatedwith movement of the mouse shoulder may compensate for shoulder internal rotation, leading to inhibition ofinternal rotation in the mouse shoulder compared with non-mouseshoulderduringwork.

Anotherfindingofthisstudywasthatpainwasinthe mouse shoulder. The shortened pectoralis minor may resultinimpairedmovementoftheglenohumeraljoint,leading to shoulder pain (Sahrman 2002)9. Excessive rounded shoulder altered the scapular kinematics affecting shoulder ROM (Kanlayanaphotporn 2014)13. Ashortenedpectoralisminorcontributestoinsufficientscapular upward rotation and posterior tilting during shoulder flexion and abduction (Lukasiewicz et al.1999)12. Scapular upward rotation and posterior tilting are important during glenohumeral motion to minimize compression of the subacromial tissues, which canevokeshoulderpain(Flatowetal.1994)14. The elderly workers with rounded shoulder at rest tended to have narrower acromiohumeral distance (subacromialspace) compared with those without rounded shoulder (Gumina et al. 2008)15. The acromiohumeral distance tends tobe significantlydifferent inhealthy comparedwith impinged shoulders during shoulder flexion andabductionofmorethan80º(Kanlayanaphotporn2014)13. Inthepresentstudy,mostparticipantsworkedwithmoreprotraction and anterior tilting of the mouse shoulder compared with the non-mouse shoulder. This posturemaycontribute todecreasedacromiohumeraldistance,


whichisrelatedtoshoulderpain.Thesedifferenttasksstrategies between the two sides can affect scapularalignment,leadingtoshorteningofthepectoralisminorand causing limitations in scapular upward rotation andposterior tilting, accompaniedby shoulderpain inthemouseshoulder.Therefore, it isrecommendedthatworkers who use a mouse intensively place the mouse with ergonomic considerations in mind so as to reduce shoulder protraction and anterior tilting by controlling the scapular alignments and avoiding a forward reaching posturewhileusingthemouse.Furthermore,stretchingof the pectoralis minor and recovery of shoulder internal rotation are needed to support normal scapular kinematics during shoulder movements.

Thisstudyhasseveral limitations.First, thisstudydid not assess the angle of the thoracic and lumbar spine during computer work. Correct shoulder evaluations must consider variations in sitting posture such as thoracickyphosis and lumbarflexion.Further study isneededtoconsidersubtledifferencesinsittingposition.Second,our results,whichwereobtained fromyoung,symptomatic,long-timeworkers,cannotbegeneralizedto healthy adolescent and elderly populations. Third,we did not use electromyography to evaluate shoulder muscle activity in this study.

Source of Funding: This work was supported by the National Research Foundation of Korea (NRF)grant funded by the Korea government (MSIT) (No.2017R1C1B5076172)

Ethical Statement: YONSEI UNIVERSITY WonjuCampusInstitutionalReviewBoard(1041849-201507-BM-055-01)


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effectonforearmandshouldermuscleactivityinusing different slanted computermice.”ClinicalBiomechanics22(5)2007:518-523.

2.Tiric-Campara,Merita,etal.“Occupationaloverusesyndrome (technological diseases): carpal tunnelsyndrome,amouseshoulder,cervicalpainsyndrome.”ActaInformaticaMedica22(5)2014:333.

3.Bauer,Wilhelm,andThomasWittig.“Influenceofscreenandcopyholderpositionsonheadposture,muscle activity and user judgement.” AppliedErgonomics29(3)1998:185-192.

4.Cook, Catherine, Robin Burgess-Limerick, andSungwon Chang. “The prevalence of neck and upper extremity musculoskeletal symptoms in computermouseusers.” International JournalofIndustrialErgonomics26(3)2000:347-356.

5.Atkinson, S., et al. “Using non-keyboard inputdevices:interviewswithusersintheworkplace.”International Journal of Industrial Ergonomics33(6)2004:571-579.

6.Jensen,B.,MariannePilegaard,andA.Momsen.“Vibrotactile sense and mechanical functionalstate of the arm and hand among computer users compared with a control group.” Internationalarchives of occupational and environmental health75(5)2002:332-340.

7.Knudsen, K. A. “Posture.” In posture: Sitting,standing,chairdesignandexercise1988:314-25.

8.Winkel,Jørgen,andRolfWestgaard.“Occupationaland individual risk factors for shoulder-neckcomplaints:PartIIThescientificbasis(literaturereview) for the guide.” International Journal ofIndustrialErgonomics10(1-2)1992:85-104.

9.Sahrmann, Shirley. Diagnosis and treatmentof movement impairment syndromes. Elsevier HealthSciences,2002.

10.Abràmoff,MichaelD., Paulo J.Magalhães, andSunandaJ.Ram.“ImageprocessingwithImageJ.”Biophotonicsinternational11(7)2004:36-42.

11.Kendall,F.P.,E.K.McCreary,andP.G.Provance.“Testsforlengthofhipflexormuscles.”Muscles:Testing and Function. 4th ed. Baltimore, Md:Williams&Wilkins1993:27-68.

12.Lukasiewicz,Amy Cole, et al. “Comparison of3-dimensional scapular position and orientationbetween subjects with and without shoulder impingement.” JournalofOrthopaedic&SportsPhysicalTherapy29(10)1999:574-586.

13.Kanlayanaphotporn,Rotsalai.“Changesinsittingpostureaffectshoulderrangeofmotion.”Journalofbodyworkandmovementtherapies18(2)2014:239-243.

14.Flatow,EvanL.,etal.“Excursionof the rotatorcuffundertheacromion:patternsofsubacromialcontact.”TheAmericanjournalofsportsmedicine22(6)1994:779-788.

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To Compare the Effectiveness of Myofascial Release (MFR) with Strengthening and Stretching with Strengthening to

Improve the Rounded Shoulder Posture

Paramdeep Kaur1, Jayaraman G2

1M.P.T. (Musculoskeletal Conditions), Department of Physiotherapy, 2Assistant Professor, Department of Physiotherapy, Punjabi university Patiala, India

ABSTRACT

Introduction: Rounded shoulder posture is the protrusion of the acromion of the shoulder joint in relation to the centerline of gravity of the body, causing stooped posture alongwith elevation, protraction, anddownward rotation of the scapula due to muscular imbalance between a shortened pectoral muscle and lengthened retractors. Out of the various musculoskeletal problems between ages 20-35 year roundedshoulderpostureconstitutes73%.

Objectives:To investigate and compare the effectiveness ofmyofascial releasewith strengthening andstretchingwithstrengtheningon“roundedshoulderposture”.

Methodology: Aminimumof30subjectsweretakenforthestudy.Convenientsamplingtechniquewasused;with2equalgroupsof15subjectseach,i.e.GroupAreceivedMyofascialreleasewithStrengtheningandGroupBreceivedStretchingwithStrengthening.Treatmentwasgivenfor10daysin2weeks.

Results: Theresultsshowedsignificantimprovementinmusclelengthandroundedshoulderanglewithiningroups.IntergroupanalysisshowedthattherewasalsoasignificantdifferencebetweentheeffectivenessofMFRwithstrengtheningandstretchingwithstrengtheninginimprovingroundedshoulderposture.

Conclusion:MFRwith strengthening ismore effective than stretchingwith strengthening in improvingrounded shoulder posture.

Keywords: Rounded shoulder posture, Myofascial release, Stretching, Strengthening, rounded shoulder Angle, Muscle length.

INTRODUCTION

Postureisdefinedasalignmentofbodysegmentsataparticulartimethatcorrespondstoaspecificbodypositionin space that minimizes antigravity stresses on muscles and body tissues1,2. Regular maintaining of bad posture for longer durations can lead to various musculoskeletal problems3,4.Outofthevariousmusculoskeletalproblemsbetween ages 20-35 year, rounded shoulder postureconstitutes 73%5. Rounded shoulders is the protrusion of the acromion of the shoulder joint in relation to the centerlineofgravityofthebody,causingstoopedposturealongwithelevation,protraction,anddownwardrotationof the scapula, due to muscular imbalance between ashortened pectoral muscle and lengthened retractors6,7,8. Head, neck, shoulder pains and various upper quarter

dysfunctions like bicipital tendinitis, thoracic outletsyndrome,painfultriggerareasandneuropathiesaretheconsequencesofmuscleimbalance9.Toconfirmroundedshoulders, forwardshoulderangle ismeasured. It is theanglebetweenverticallinethatcrossesC7spinousprocessandthelinethatpassesthroughtheC7spinousprocessandacromion.Theangleequaltoorgreaterthan52degreesconsidered as RSP10. This could be the result of excessive exercise, sedentary habits, and inadequately equippedworksites,repetitivemovementsofhands,lackofposturalawareness,strengtheningorshorteningofanteriormusclesof scapula or weakening/ elongation of the muscles that pull the shoulder toward the front of the spine11. Due to the high prevalence of rounded shoulder posture especially in modern society, proper treatment of this problem isnecessary for prevention of further complications12. There

DOI Number: 10.5958/0973-5674.2019.00057.1


aredifferenttreatmentsapproachesforroundedshoulderposture like strengthening of lengthenedmuscles, suchas scapular stabilizers, stretching of shortened musclesespecially pectoral muscles and soft tissue mobilization13. Stretchingenhanceselasticityofthesofttissues,increasestheflexibilitythuslengtheningthestructureswhichhavebeen shortened due to decreased mobility14.Myofascialrelease (MFR) is hands on soft tissue technique inwhich sustained pressure is applied into the restricted tissuebarrier.It isuseful inalleviatingmusclestiffness,reducing pain, and improving range of motion15. Till date there is lack of evidence that can conclude about the effectivenessoftreatmentemployedforimprovementofroundedshoulderpostureandcomparetheeffectsofMFRwith strengthening and Stretching with strengthening on rounded shoulder posture.

PURPOSE OF THE STUDY

Thepurposeofthestudyistoinvestigatetheeffectsof myofascial release-strengthening and stretching-strengthening and to compare the effectiveness ofmyofascial release-strengthening with stretching-strengtheningon“roundedshoulderposture”.

MATERIAL AND METHOD

The study was experimental in nature, wherecomparison between two therapeutic interventions (myofascial release combined with strengtheningand stretching combined with strengthening) for their efficacy on rounded shoulder was carried out.Convenient sampling method was used for recruiting the participants. 30 rounded shoulder females were taken from Punjabi University; Patiala aged between20 to 30 years. They were allocated randomly into two groups,GroupA(MFRwithStrengthening)andGroupB(stretchingwithstrengthening).

Inclusion criteria: Female subjects were taken;Subjects having Age group- 20-30 years and havingrounded shoulder posture were included in the study.

Exclusion criteria: Shoulder instability, Fracturesrelated to shoulder, Nerve lesions in upper quadrant,recentinjuriesintheshoulder,anytypeoftreatmentorsurgery in upper limbs.

Method of Collection of Data: Subjects from Punjabi University Patiala were assessed for their suitability tobe included in the study and 30 subjects were recruited

in the study using convenient sampling. Participants were explained in detail the purpose and procedure of the study and their informed consent was obtained. Participants were assigned to two groups: Group A (MFR with Strengthening) and Group B (StretchingwithStrengthening).Prior to the intervention,Roundedshoulder angle, muscle length of pectoralis major andminorwasmeasured.MFRcombinedwithStrengtheningwasadministeredtoGroup-AsubjectsandStretchingwithStrengthening was administered for 10 days in 2 weeks. At 10thdayofintervention,roundedshoulderangle,musclelength of pectoralis major and minor was measured.

Interventions

Myofascial muscle release15, 16

Pectoralis Major: Subjects position was supine lying with shoulder flexed to 90 to 120 degrees. Theinvestigator was standing by the side of the patient at the angle of 45 degree frommidline of the patient,investigator’s thumbs slide underneath the pectoralismajorandthehandsgraspedthemusclefirmlybetweenthe thumbs and fingers, is gently lifted or bent awayfrom the thorax.

Pectoralis Minor: With one hand maintaining thesame position as described above, the thumbs movedposteriorly until in contact with the pectoralis minor. The muscleisdifficulttopalpate,butiftheribsarepalpable,the muscle is being palpated. The thumbs pressed onto thepectoralisminor,andagentle“cross-friction type”techniqueperformed.

Stretching exercises given passively for the following muscles. Duration was 3 repetitions in a set with 30 second hold17.

Pectoralis minor stretching: Position of the subject was supine lying. Retracts the subject’s shoulder anddepresses the shoulders. Hand cupped around shoulder toallowfirm,uniformpressurethathelpedtorotatetheshoulder girdle back.

Pectoralis major stretching: Position of the subject was sitting.Abductedthesubject’sarmto90degreeandlacehis/herfingersbehindthehead,thentheinvestigatorbehindthe subject’s scapulae, lacing his or her fingers together,aswell.Investigatorpullsupandbackfromthesubject’strunk until restricted by the subject. The stretch was held for 30 seconds and repeated thrice per training session.

Strengthening exercises were given by Theraband. Duration was 3 sets/10 repetitions 18.


Shoulder retractors strengthening: The position of subject was standing. Shoulder abducted to 90 degree in the scapular plane, the elbowsflexed to 90 degree,andtheforearmshorizontal,thesubjectholdanexerciseband between the right and left hands and retracted the scapulae by stretching the band. The subject maintained the original 90 degree position of the shoulders and elbows and then executed a controlled return to the starting position.

Shoulder external rotators strengthening: Position of the subject was standing; the upper arm was positioned at 90 degree of shoulder abduction and 90 degree of elbow flexion.The forearmmoved in ahorizontalpositionandexternally rotates into a vertical position. The subject then executed a controlled return to the starting position. The exercise band was fixed in front of the subject atapproximately waist height at the beginning of the exercise.

FINDING

Data Analysis: Statistics were performed by using SPSSsoftware20version.Independentt-testandPairedt-testwereused.Statisticalsignificancewasacceptedatp<0.05level.

Within group analysis: GroupAandGroupBshowsstatisticallysignificantimprovementinroundedshoulderangle and muscle length of pectoralis major and minor muscles after 10 days of treatment.

The results of paired-sample t-test for MFRgroup, shows significant difference in the scores forpretreatmentpectoralismajormusclelength(M=8.53,

SD=0.44) and post treatment pectoralis major musclelength (M=4.5, SD=0.65); t(14)= 25.55, p=0.000; pretreatment pectoralis minor muscle length (M=5.83,SD=0.64) and post treatment pectoralis minor musclelength(M=2.16,SD=0..30);t(14)=27.139,p=0.000;pretreatmentroundedshoulderangle(M=54.40,SD=0.91)and post treatment rounded shoulder angle (M=49.93,SD=0.88);t(27.03),p=0.000.

The results of paired-sample t-test for Stretchinggroup,alsoshowssignificantdifferenceinthescoresforpretreatmentpectoralismajormusclelength(M=8.76,SD=0.65) and post treatment pectoralis major musclelength(M=7.56,SD=0.84); t(14)=12.61,p=0.000;pretreatment pectoralis minor muscle length (M=5.63,SD=0.97) and post treatment pectoralis minor musclelength(M=3.43, SD=0.59); t(14)= 10.68, p=0.000; pretreatmentroundedshoulderangle(M=54.00,SD=0.84)and post treatment rounded shoulder angle (M=52.40,SD=0.73);t(12.22),p=0.000.

Between group analysis: Theresultsofanindependent-samplest-testforpectoralismajorbetweenMFRgroupand stretching group shows significant difference inpost treatment values of pectoralis major between MFR (M=4.5, SD=0.65) and stretching (M=7.56,SD=0.84) groups; t (29) =11.13, p= 0.000.Therewasa significant difference in post treatment values ofpectoralis minor between MFR (M=2.16, SD=0.30)andstretching(M=3.43,SD=0.59)groups;t(29)=7.33,p= 0.000. There was a significant difference in posttreatment values of rounded shoulder angle between MFR (M=49.93, SD=0.884) and stretching (M=52.40,SD=0.737)groups;t(29)=8.30,p=0.000.

Table 1: Pre and post treatment scores of Group A

Muscle length testing Pectoralis Major (in cm)

Muscle length testing Pectoralis Minor (in cm)

Rounded shoulder Angle (in degrees)

MFR Group Mean ± SD Mean ± SD Mean ± SDPre treatment 8.53 ± 0.44 5.83 ± 0.64 54.40 ± 0.91Post treatment 4.50 ± 0.65 2.16 ± 0.30 49.93 ± 0.88

t-value 25.55 27.13 27.03p-value 0.000 0.000 0.000

Table 2: Pre and post treatment scores of Group B




Stretching Group Mean ± SD Mean ± SD Mean ± SDPre treatment 8.76±0.65 5.63±0.97 54.00 ± 0.84Post treatment 7.56±0.84 3.43 ± 0.59 52.40±0.73

t-value 12.61 10.68 12.22p-value 0.000 0.000 0.000


Table 3: Independent Samples test (Between Groups)




t-value 11.13 7.33 8.30p-value 0.000 0.000 0.000

Figure 1: Comparison of mean muscle length testing of Pectoralis Major between groups

Figure 2: Comparison of mean muscle length testing of Pectoralis minor between groups

Figure 3: Comparison of mean Rounded shoulder angle between groups

DISCUSSION

The current study was carried out to conclude the efficacyoftwointerventionalapproachesforimprovingthe rounded shoulder posture. In exiting literature,

researcher could not locate even a single study that is directly related the result of present study showing efficacy of myofascial release with strengtheningexercise to improve rounded shoulder posture but a few studies demonstrate the effect of self myofascialrelease in improving flexibility and ROM of variousmuscles and optimize muscular function. The factors that can be attributed to the mechanisms bringing about the improvement in rounded shoulder posture include thixotropic property of fascia encasing the muscle.Myofascial release is thought toenhancesoft-tissue pliability,which allows increased joint rangeofmotion and flexibility of muscles19, 20. However, thereare many studies available that have examined the efficacy of stretching and strengthening on roundedshoulder posture. Stretching and strengthening exercises are efficient in improving the muscular imbalance,correcting scapular alignment and correcting the forward shoulder posture. Strengthening of weakened muscles leads to biomechanical movement and obtaining appropriate direction of abnormal parts. Indeed,stretchingthehypertrophiedmuscle(shortened)mutually with strengthening the weakened muscles has considerable influence on improving the roundedshoulder abnormality10,18,21.Inliteraturethereisdearthofstudiesthathavecomparedtheefficacyofmyofascialrelease with strengthening over effect of stretchingwith strengthening on rounded shoulder posture. Findings of present study help us to deduce that each intervention exerts unique effects and combined useof these interventions bring about more positive and desirableeffectsdependinguponcondition,populationgroup, these interventionsareadministered.StretchinghaslongbeenappliedasamethodforimprovingROMandflexibilitymeasuresbutitcanalsohavesignificantnegative effects on neuromuscular performance.Stretching places strain on the origin and insertion of the muscle and may cause damage to the sarcomeres. From this evidence, it can be hypothesized that since therewere no deficits in muscular performance withMFR,myofascial release with strengthening showed better results as compared to stretching with strengthening to improveflexibilityandROM.


CONCLUSION

Results of present study are convincing enough to suggest thatMFRwithstrengtheningexercisesaswellasstretchingwithstrengtheningexercisesareeffectiveinimproving rounded shoulder posture in female students and each intervention could be treatment of choice for preventive and rehabilitative management of rounded shoulder posture.

Findings of present study establish the efficacyofone intervention over other. Results showed inclination towards MFR with strengthening exercises forbeing better intervention option than stretching with strengthening exercises in treating rounded shoulder posture as it improved muscle length and rounded shoulder angle in female students.We believe that inpresentstudy10daysofinterventionwasnotsufficienttocomeatdefiniteconclusion,furthermorethesamplesizewas also small. This demand better designed controlled studiesinthisdirectiontoreachatdefiniteconclusion.



Ethical Clearance: Ethically approved

REFERENCES

1.GrimmerK,DansieB,MilaneseS,PirunsanU,Trott P. Adolescent standing postural response to backpack loads: a randomised controlled experimental study. BMC MusculoskeletalDisorders.2002Dec;3(1):10.

2.Gangnet N, Pomero V, Dumas R, Skalli W,Vital JM. Variability of the spine and pelvislocationwithrespecttothegravityline:athree-dimensional stereoradiographic study using a force platform. Surgical and radiologic anatomy. 2003Dec1;25(5-6):424-33.

3.HajibashiA,AmiriA,SarrafzadehJ,MaroufiN,Jalae S. Effect of kinesiotaping and stretchingexercise on forward shoulder angle in females with rounded shoulder posture. Journal ofRehabilitationSciencesandResearch.2015May31;1(4):78-83.

4.SzetoGP,StrakerL,RaineS.Afieldcomparisonof neck and shoulder postures in symptomatic and asymptomatic office workers. Appliedergonomics.2002Jan1;33(1):75-84.

5.Griegel-Morris P, Larson K, Mueller-KlausK, Oatis CA. Incidence of common posturalabnormalities in the cervical, shoulder, andthoracic regions and their association with pain in two age groups of healthy subjects. Physical therapy.1992Jun1;72(6):425-31.

6. Sahrmann S. Diagnosis and treatment of movement impairment syndromes. Elsevier Health Sciences; 2002.

7.LukasiewiczAC,McClureP,MichenerL,PrattN,SennettB.Comparisonof3-dimensionalscapularposition and orientation between subjects with and without shoulder impingement. Journal ofOrthopaedic & Sports Physical Therapy. 1999Oct;29(10):574-86.

8.LynchSS,ThigpenCA,MihalikJP,PrenticeWE,PaduaD.Theeffectsofanexercise interventionon forward head and rounded shoulder postures in eliteswimmers.Britishjournalofsportsmedicine.2010Apr1;44(5):376-81.

9.Dewan N, Raja K, Balthillaya Miyaru G,MacDermidJC.Effectofboxtapingasanadjunctto stretching-strengthening exercise program incorrection of scapular alignment in people with forward shoulder posture: A Randomised trial. ISRNRehabilitation.2014Jan20;2014.

10.Hajihosseini E, Norasteh A, Shamsi A,Daneshmandi H. The effects of strengthening,stretching and comprehensive exercises on forward shoulder posture correction. Physical Treatments-Specific Physical Therapy Journal.2014Oct15;4(3):123-32.

11.SavadattiR,GaudeGS.Effectofforwardshoulderposture on forced vital capacity-ACo-relationalStudy. Indian Journal of Physical Therapy andOccupationalTherapy.2011Apr1;5(2):119-23.

12.Thigpen CA, Padua DA, Michener LA,GuskiewiczK,GiulianiC,Keener JD, StergiouN. Head and shoulder posture affect scapularmechanics and muscle activity in overhead tasks. Journal of Electromyography and kinesiology.2010Aug1;20(4):701-9.

13.KendallFP,McCrearyEK,ProvancePG,RodgersMM,RomaniWA.Muscles,testingandfunction:withpostureandpain.Baltimore,MD:williams&wilkins;1993.


14.Kisner C, Colby LA. Therapeutic exercise:foundations and techniques. 2007. Philadelphia:FADavis&Co.

15.Barnes MF. The basic science of myofascialrelease: morphologic change in connective tissue. Journal ofBodywork andMovementTherapies.1997Jul1;1(4):231-8.

16.Stanborough M. The upper extremities. Directreleasemyofascialtechnique:anillustratedguidefor practitioners. UK: Churchill Livingstone.2004Sep:p172-175.

17.KotteeswaranK,RekhaK,AnandhV.Effect ofstretching and strengthening shoulder muscles in protracted shoulder in healthy individuals. International journal of computer application.2012;2(2):111-8.

18.Kluemper M, Uhl T, Hazelrigg H. Effect ofstretching and strengthening shoulder muscles on forward shoulder posture in competitive

swimmers. Journal of sport rehabilitation. 2006Feb;15(1):58-70.

19.MacDonald GZ, Penney MD, Mullaley ME,CuconatoAL,DrakeCD,BehmDG,ButtonDC.Anacuteboutofself-myofascialreleaseincreasesrange of motion without a subsequent decreasein muscle activation or force. The Journal ofStrength&ConditioningResearch.2013Mar1;27(3):812-21.

20.SullivanKM,SilveyDB,ButtonDC,BehmDG.Roller‐massager application to the hamstringsincreasessit‐and‐reachrangeofmotionwithinfiveto ten seconds without performance impairments. International journal of sports physical therapy.2013Jun;8(3):228.

21.Sharma M, Jeba C, Khatri S. Double crossedsyndromeincricketer’sshoulder:RCT.JournalofExercise Science and Physiotherapy. 2008 Dec; 4(2):119.

Muscle Energy Technique for Sacroiliac Joint Dysfunction– An Evidence Based Practice

Parinda R. Kansagara1, Jalpa K. Patel1

1M.PT. Student, PT in Orthopedic Conditions, Shri K. K. Sheth Physiotherapy College, Rajkot, Gujarat

ABSTRACT

MostcommonsourceoflowbackpainisSacroiliacjointdysfunction.Dysfunctionischaracterizedbypaininthegluteal,posteriorthighandgroinregionwithsomefunctionaldisability.PhysicaltherapystrategiesemphasizemanualcorrectionofSIJasymmetry,useofphysicalmodalitieslumbopelvicstabilizationandcorrectionofmuscleimbalance.Formanyyears,METhasbeenadvocatedtotreatmuscleimbalancesofthelumbopelvicregionsuchaspelvisasymmetry.MuscleEnergyTechnique(MET)whichisaformofactivestretchisusedinmanualtherapytoincreaserangeofmotion.Ittargetsthesofttissueprimarily,althoughitalso makes a major contribution towards joint mobilization.

Keywords: Muscle energy technique, Sacroiliac joint dysfunction.

INTRODUCTION

Low Back Pain (LBP) affects 70-85% of adultsatleast once in their lifetime. Prevalence of Sacroiliac (SI) joint dysfunction is 13% to 30% with low backpain.1Thesacroiliac joint is a frequentorigin forpainin pelvic girdle and lower back with referred pain to the lower extremity.2

ThebiomechanicsoftheSIjointarecomplex.SIjointmotionisaffectedbymotionofthespine,ilium,pubicsymphysis,andhip.3 The sacrum becomes dysfunctional between the two iliac bones either unilaterally or bilaterally. The bone does not twist or change its shape; thefindingsaretheresultoftheunilateralrestrictionofboth the overturning and translatory movement on one side relative to its ilia.4

One sided dysfunction is easily explained by thecommon asymmetry of the two sacroiliac joints. Oneappears to continue to function normally and the other becomes restricted, either anteriorly or posteriorly

nutated. The torsional restrictions include both joints and involve the oblique axes. The diagnostic findingthat identifies the torsional dysfunctions is the sacralbaseandILAbeingposterioronthesameside.4 These presentations are:5

1.Rotational malalignment (80-85%) – anteriorrotatedinnominate,posteriorrotatedinnominate

2.Pelvic flare - innominate out flare/inflare (40-50%),and

3.Upslip(15-20%)ordownslipisrare.

Thefirst twocanbecorrectedwithmuscleenergytechniquewhile the thirdmay require a high velocitythrust.6 Pain is usually unilateral or paramidline as opposed to midline LBP 3 and is usually relieved with rest and/or by unweighting the joint.6 History of trauma or pregnancy or even lumbar fusion should be identified,asSIjointpaintendstobemorecommonlyassociated with this history.3Unresolved inflammationoratraumaticetiologymayyieldahypomobileSIjoint.6

Dr.FredMitchellhasbeentitledthefatherofMuscleEnergy Technique (MET). METs are a class of softtissue osteopathic (originally) manipulation methodsthat incorporate precisely directed and controlled,patientinitiated,isometricand/orisotoniccontractions,designed to improve musculoskeletal function and reduce pain.7

Corresponding Author:Dr.ParindaR.KansagaraPostgraduate(OrthopedicConditions)Student,ShriK.K.ShethPhysiotherapyCollege,Rajkot,Gujarat,IndiaEmail: [email protected]

DOI Number: 10.5958/0973-5674.2019.00058.3


It is used to help mobilize restricted joints bystretchinghypertonicmuscles,capsules,ligaments,andfascia. This leads to improved postural alignment and the restoration of proper joint biomechanics and functional movement.METworksontwobasicprinciplesi.e.postisometric relaxation and reciprocal inhibition.8

Greenman, (1996) has stated that function ofany articulation of the body which can be moved by voluntarymuscleaction,eitherdirectlyorindirectlycanbe influenced byMETprocedure, so this can be usedtolengthenacontractured,hypertrophicortightmuscleor strengthen a physiologically weak muscle, relievepassive congestion and oedema. All of these factors contribute to chronic musculoskeletal pain which can be reducedsuccessfullyusingMET.9

The reduction in pain due to MET can beextrapolated on the basis of its neurophysiology, postisometric relaxation refers to the subsequent reductionin tone of the agonist muscle after isometric contraction. This occurs due to stretch receptors called golgi tendon organ that are located in the tendon of the agonist muscle. These receptors react to over stretching of the muscle by inhibiting the further muscle contraction. METcanadjustasymmetricalpositionsofthepelvisbyfocusing on contracting hip extensors and hip flexorsintheaffectedlowerbackregionandputtingthepelvicbones in the right position.7

METHODOLOGY

Electronicliteraturesearchfrom2008-2018,wasdoneusing the search termsMuscleenergy technique,Sacroiliac JointDysfunction,Lowback pain of sacralorigin,Pelvicflair,Upslipordownslip,SIjointrotationaldysfunction. This yielded a total of 11 articles.

REUSLT

Outof11articles,9articleswere includedhavingPEDROscore7 for6articles and6 for3articles.Allthearticlesincludedwerehavinglevelofevidence-2a.2articleswereexcludedduetofairqualityofPEDROscore. (“high quality” = PEDRO score 6 – 10; “fairquality”=PEDROscore4–5;“poorquality”=PEDROscore <3).7outof9articlesweresupporting,whereas2outof9articleswerenon-supporting.

DISCUSSION

In 2018, Shivangi Sachdeva et al. conducted astudy on effects of Muscle energy technique versusMobilization on pain and disability in post-partumfemaleswithSIjointdysfunction.30subjectswithagegroup of 20 – 40 yrs were randomly allocated into 2groups(Mobilization)(MET).ReadingsweretakenforNPRSandMODIonbaselineandattheendof4thweek.ItconcludedthatMuscleEnergyTechniquewasfoundto bemore effective in femaleswith post partum lowback pain due to Sacroiliac Dysfunction.10

In 2017, Reema Joshi et al. conducted anexperimentalstudyoneffectofmuscleenergytechniqueonpainandfunctioninpatientswithSIdysfunction.20male and 20 female participants with age group of 20 -60yrsreceivedMETtreatmentfor3timesperweekfor2weeks.NPRSandODIwereusedtomeasureoutcome.It concluded that MET can be use effectively in themanagement of sacroiliac dysfunction.11

In 2017, Sabah Mohammed Easa Alkady et al.conductedastudyonefficacyofmulliganmobilizationversusMuscle energy technique in chronic Sacroiliacjoint dysfunction. 45 patients with age group of 30 -50 years were divided into 2 groups (Mulliganmobilization with movement + conventional treatment) (Muscle energy technique + conventional treatment)(conventional treatmentonly)for12sessions.Dopplerimaging of vibration, palpation meter, and VAS wasutilizedpreandpost-treatmentforevaluatingpatients.ItconcludedthatMulliganmobilizationismoreeffectivethanmuscleenergytechniqueinthetreatmentofchronicsacroiliac joint dysfunction.12

In 2015, Rajesh Sewani et al. conducted a studyto determine the effect of hot moist pack andmuscleenergytechniqueinsubjectswithSIjointdysfunction.34subjectswithagegroupof20–45yrsweredividedin2groups(HMP+coremusclestrengthening)(HMP+MET)for10days.VAS,MODIandspinalROMwereusedasanoutcomemeasure.ItconcludedthatHMPandMET in combination are effective in management ofsacroiliac joint dysfunction.1

In 2015, Prakash Patel et al. conducted a studyon effectiveness of manipulation and muscle energytechniques in subjects with SI joint dysfunction. 30subjectswith theagegroupof20-55yrsweredivided


in 2 groups (Manipulation + SWD) (MET + SWD).VisualAnalogue scale and Oswestry Disability Indexweretakenbefore,attheendof1stweek,2nd week and follow up measurement at 6th week. Itwas concludedthat manipulation showed significant improvementwhencomparedtoMETinreducingVAS&dysfunctionat1st,2ndweekandfollow-upat6thweekinpatientswith innominate dysfunction.2

In2014,DeepaliSharmaetal.conductedastudyonEffectofMuscleEnergyTechniqueonpainanddisabilityin subjects with SI joint dysfunction. 20 men andwomenweredividedin2groups(MET+Mobilization)(Mobilizationonly)for2weeks.VASandMODIwereused as outcome measure before and at 1 and 2 week of treatment. ItconcludedthatMETandmobilisationarebotheffectiveintreatingchroniclowbackpainduetosacroiliac joint dysfunction.13

In2013,SupreetBindraconducteda studyon theEfficacy of Muscle Energy Technique as comparedto Conventional Therapy on Lumbar Spine Range ofMotioninChronicLowBackPainofSacroiliacOrigin.30patientswithagegroupof30–50yrsweredividedin2groups(MET)(Conventionaltherapy)for6days.VASand revised Oswestry disability index, Lumbar spineROMwereusedasoutcomemeasurebeforeandafter6daysoftreatment.ItconcludedthatSIJDisasignificantcontributor to chronic LBP and successfullymanagedusingMETalongwithConventionalTherapy.9

In 2011, Mullai Dhinkaran et al. conducted acomparative analysis ofMuscle energy technique andconventional physiotherapy in treatment of Sacroiliac Joint Dysfunction. In this study 30 subjects with ageof 18-35 yr complaining of low back pain due to SIjoint dysfunction were participated and divided in 2 groups(MET+correctiveexercise)(TENS+correctiveexercise).OswestryDisabilityindexandNumericpainrating scale reading were taken before and at the end of 6 treatment sessions. This study concluded that along with correctiveexercises,METismoderatelysignificantoverconventional physiotherapy in improving functional ability and decreasing pain.14

In 2009, Kanchan Rana conducted a comparativeanalysison theefficacyofG.D.Maitland’sconceptofmobilization and muscle energy technique in treatingsacroiliac joint dysfunction. 45 subjects were recruited with mean age of 22.82 and were divided in 3 groups

(MET+exercise)(G.D.Maitland+exercise)(control).Pain(thermometerpainratingscale),disability(Oswestrydisabilityindex)andhiprangeofmotion(Goniometry)were evaluated at baseline and after 6 sessions. This studyconcludedthatalongwithactiveexercisesMuscleenergy technique (MET) is moderately significantover theG.D.Maitland’s technique ofmobilization inimproving functional ability and increasing the medial rotation of hip joint in mechanical chronic low back pain caused due to sacroiliac joint dysfunction.15

CONCLUSION FROM EVIDENCES

METalongwithconventionalorotherphysiotherapytreatment can be helpful in reducing pain and improving function in patients with sacroiliac joint dysfunction. However, effectiveness of MET in Sacroiliac jointdysfunction is still need to be identified with higherqualityofresearch.



Ethical Clearance: Ethical clearance does not normally requiredforthistypeofresearch.

REFERENCE

1.Rajesh Sewani, Sandeep Shinde. Effect of HotMoist Pack and Muscle Energy Technique inSubjects with Sacroiliac Joint Dysfunction.International Journal of Science and Research. 2017;6(2):669-672.

2.Prakash Patel, Namarta Patel, Vandana Rathod.Effectivenessofmanipulationandmuscleenergytechniques insubjectswithSI jointdysfunction. International Journal of Pharmaceutical Science and Health Care.2015;4(5):16-29.

3.James F. Wyss, Amrish D. Patel. TheraputicProgramsforMusculoskeletalDisorders.

4.Philip E. Greenman. Principles of ManualMedicine.3rd edition.

5.Mahesh Shinde, Dr. Vaishali Jagtap. Effectof Muscle Energy Technique and MulliganMobilization in Sacroiliac Joint Dysfunction.Global Journal for Research Analysis.2018;7(3):79-81.


6.Carolyn Kisner, Lynn Allen Colby. TheraputicExerciseFoundationsandTechniques.6th edition. 2012.

7.Leon Chaitow. Muscle Energy Techniques.AdvancedSofttissueTechnique.3rd edition. 2006.

8.Dr.KerryDAmbrogio:MuscleEnergyTechnique.Revised edition. 2012; 11.

9.SupreetBindra.AstudyontheEfficacyofMuscleEnergyTechnique as compared toConventionalTherapy on Lumbar Spine Range ofMotion inChronic Low Back Pain of Sacroiliac Origin.Human Biology Journal.2013;2(4):336-349.

10.Shivangi Sachdeva, Sheetal Kalra Sonia Pawaria.

Effects of Muscle Energy Technique versusMobilizationonPainandDisabilityinPost-PartumFemaleswithSacroiliacJointDysfunction.Indian Journal of Health Sciences and Care.2018;5(1):11-17.

11.Reema Joshi, Manisha Rathi, Shilpa Khandare,Tushar J Palekar. Effect of Muscle EnergyTechniqueonPainAndFunctioninPatientsWithSacroiliac Dysfunction—Experimental Study. International Journal of Scientific Research and Education.2017;5(6):6502-6506.

12.Sabah Mohammed Easa Alkady, RagiaMohammed Kamel, Enas AbuTaleb., YasserLasheen., Fatma Anas Alshaarawy. Efficacy ofMulligan Mobilization Versus Muscle EnergyTechniqueInChronicSacroiliacJointDysfunction. International Journal of Physiotherpy.2017;4(5):311-318.

13.Deepali Sharma, Siddhartha Sen. Effects ofMuscleenergytechniqueonPainandDisabilityinSubjectswithSIjointDysfunction. International Journal of Physiotherapy and Research. 2014; 2(1):305-11.

14.Mullai Dhinkaran, Aarti Sareen, Tanu Arora.Comparative Analysis of Muscle EnergyTechnique and Conventional Physiotherapy inTreatmentofSacroiliacJointDysfunction.Indian Journal of Physiotherapy and Occupational Therapy.2011;5(4):127-130.

15.Kanchan Rana1, Nitesh BansaF, Savita3.Comparative analysis on the efficacy of G.D.Maitland’s concept of mobilization & muscleenergy technique in treating sacroiliac jointdysfunction. Indian Journal of Physiotherapy and Occupational Therapy.2009;3(2):18-21.

To Compare the Activity of Scapular Upward Rotators during Isometric Shoulder Flexion with Forward Vs Neutral Head

Posture in Normal Healthy Individuals

Parul A. Rakholiya1, Priyanka P. Makwana2, AshishD. Kakkad3

1Assistant Professor at Shri Bhartimaiya College of physiotherapy, Surat; 2Assistant Professor at Harivandna College of physiotherapy, Rajkot; 3Assistant Professor at SPB College of physiotherapy, Surat

ABSTRACT

Background: Work-relatedneckandshoulderpainarefrequentlyreportedintheworkplace.Forwardheadposture(FHP)isassociatedwithneckandshoulderpain.FHPisbelievedtoalterthescapularkinematicsandmuscleactivitywhichincreasesstressontheshoulder,leadingtoshoulderpainanddysfunction.

Aim and Objectives: To compare the electromyography (EMG) activity of scapular upward rotatorsduringisometricshoulderflexionwithforwardheadpostureversusneutralheadpostureinnormalhealthyindividuals.

Method: 40normalhealthy individualswithageof18-24yearswhohavenohistoryofpathologywillparticipateinthestudyandinstructedtoperformisometricshoulderflexionwiththeupperextremityinboththeforwardheadposture(FHP)andneutralheadposture(NHP).Surfaceelectromyography(EMG)willberecordedfromtheupperandlowertrapezius,andserratusanteriormuscles.

Result: CollecteddataareanalyzedstatisticallybyPairedt-testtest.

Conclusion: ThereisincreaseinEMGactivityofuppertrapeziusandlowertrapeziusanddecreaseinEMGactivity of serratus anterior while forward head compare to neutral head posture.

Keywords: Forward head posture, Neutral head posture, Scapular upward rotators, EMG activity and Isometrics shoulder flexion

INTRODUCTION

Posture is a “position or attitude of the body, therelativearrangementofbodypartsforaspecificactivity,or a characteristic manner of bearing one’s body.”It is describedby the positions of the joints andbodysegments and also in terms of the balance between the muscles crossing the joints. Impairments in the joints,muscles, or connective tissues may lead to faultypostures; or, conversely, faulty postures may lead toimpairments in the joints, muscles, and connectivetissues as well as symptoms of discomfort and pain. Manymusculoskeletal complaints can be attributed tostresses that occur from repetitive or sustained activities when in a habitually faulty postural alignment.1

Proper posture is believed to be the state of musculoskeletal balance that involves a minimal amount of stress and strain on the body. Although correct posture

isdesired,manypeopledonotexhibitgoodposture.Anideal posture is considered to exist when the external auditory meatus is aligned with the vertical postural line. Theverticalpostureline,asseeninasideview,passesslightly in front of the ankle joint and the centre of the knee joint, slightly behind the centre of the hip jointand through the shoulder joint and the external auditory meatus. Forward head posture is one of the common types of poor head posture seen in patients with neck disorders.2 A forward head posture is one in which the head is positioned anteriorly and the normal anterior cervical convexity is increased with the apex of the lordotic cervical curve at a considerable distance from theLineofGravityincomparisonwithoptimalposture.3

Due to forward head posture 60% of individuals are havingneckandshoulderpain.Work-relatedneckandshoulderpainarefrequentlyreportedintheworkplace.4 Several risk factors for development of shoulder and

DOI Number: 10.5958/0973-5674.2019.00059.5


neck pain, including extrinsic risk factors such asrepetitive overhead use (>60 of shoulder elevation),sustainedoverheadwork,andhigherloadsraisedaboveshoulder height. While these may be noticeable thatthey are difficult tomodify asmany occupational andathletic activities require repetitive overhead activity.Intrinsicriskfactorssuchasforwardheadandroundedshoulderposture(FHRSP),alteredscapularkinematicsand altered muscular activity are reported in patients with shoulder pain.5

Forward head and rounded shoulder posture [FHRSP] is believed to alter scapular kinematics andmuscleactivityplacingincreasedstressontheshoulder,leadingtoshoulderpainanddysfunction.Itisimportantto understand the effects of FHRSP on scapularkinematics and muscle activity because FHRSP has been showntobemodifiableandmayprovideapathwaytoimprove shoulder mechanics and decrease the risk to develop shoulder pain.5

Poorpostureasdefinedbyincreasedforwardhead,greater thoracic kyphosis and a more anterior shoulder position have been demonstrated to be associated with altered scapular position, kinematics, andmuscleactivity. Alterations in scapular kinematics and muscle activity have also been reported in patients with shoulder impingementsyndromeandrotatorcuffdisease.5

Forward head posture involved lengthening of posterior neck extensor muscles and tightening of anteriorneckmuscles.Theseshouldermusclesaffectingshoulder position and kinematics. Forward head posture is also considered to be an etiological factor in the pathogenesis of subacromial impingement syndrome. Because forward head posture involved a dowardrotated,anteriorlytiltedandprotractedscapulaleadingto increase compression in subacromial space during arm elevation.4

Considering muscular imbalance of shoulder girdle impairs neuromuscular control and cause abnormal movement pattern for elevation of upper extremity,which suggests the relationship between forward head and stabilizer muscles of scapula. Serratus anterior and trapezius muscles play a major role in creating and controlling the movements of scapula and leads to upward rotation, external rotation and posterior tiltof scapula as a paired force. Thigpen et al. compared combination of scapular motion and activity of serratus

anterior,upperand lower trapeziusmuscles inhealthysubjects and patients with forward head posture and rounded shoulder.6

To prevent shoulder pain associated with abnormal neck posture, many researchers have stressedmaintenance of a neutral head posture (NHP) duringarm movement and functional activity. Many studieshavebeenperformed todetermine theeffectsofhead,thorax,andshoulderpositiononshoulderandscapularkinematics and the strength of the shoulders and hands.4 Ludewig and Cook (1996) investigated the effects ofhead position on scapular orientation and muscle activity during shoulder elevation in the scapular plane without an applied load.7

However, there has been less number of previousstudies which shows the effects of head position onmuscle activity of the scapular upward rotators during loadedshoulderflexioninthesagittalplane.Itisgenerallybelieved that FHP is a contributor to development of chronic neck and shoulder pain. The need of the study is to prevent shoulder pain by maintenance of neutral head posture during arm movement and functional activity.


Study Setting: ShriK.K.Shethphysiotherapycollege,Rajkot

Sample Size: 40 subjects were selected who fulfilledinclusion criteria

Sampling Technique: Convenient sampling

Study Design: ACross-sectionalcomparativestudy

Study Population: Normal healthy individuals

Inclusion Criteria:

z Age group:18-25years

z Gender: male and female

z Selected muscles strength: 5 [according tomodifiedMRC]

Exclusion Criteria:

z Cervical pathology

z Shoulder pathology

z Any postural deviation related to neck and shoulder.

z Unwillingnessofindividualtoparticipate


Procedure: A sequential series of 40 individuals, asample composed of 6 male and 34 female ranging in agefrom18–25yearsofagewereparticipatedaccordingto inclusion and exclusion criteria. All individuals provided informed consent and agreed to participate in the study. Procedure, potential risks and benefitswere explained. The dominant hand of subjects was determined by Edinburg handedness scale for electrode placement. Electromyographic data were collected using RMSEMGPKM-IIsystemfromuppertrapezius,lowertrapezius and serratus anterior of dominant hand.

Each subject was requires to assume an uprightposition. While sitting in chair subject ask to raisedominant upper extremity in sagittal plane [60o, 90o,120o] in both neutral and forward head posture inrandom order. A plumb line hanging from ceiling was used to determine the neutral and forward head posture ofsubjects.Universalgoniometerwasusedtodeterminewhen the shoulder was at 60o,90o,120o flexion.

Electrodes Placement:

Upper trapezius: 2cmlateraltomid-pointoflinedrawnbetweenC7andposterolateralacromion.8

Lower trapezius: placed on 5 cm inferomedial from route of spine of scapulae.8

Serratus anterior: placed vertically along the mid axillarylineat6-8rib.8

Statistics: Collected data are analyzed statistically by Pairedt-testtest.DatawereanalyzedinSPSSversion14.

RESULTS

Therewere comparisonofEMGactivityof uppertrapezius, lower trapezius andSerratus anterior at 60o,90o,and120o with neutral head and with forward head. Therewassignificantdifferencefoundduringactivityofupper trapezius at 60o(t- value3.207, p<0.05) but lesssignificant difference at 90o and 120o (t-value 1.749,p>0.05 and t-value 1.518, p>0.05respectively). Therewassignificantdifferencefoundduringlowertrapeziusat60o,90o(t-value3.548,p<0.05andt-value4.331,p<0.05respectively)butlesssignificantdifferencefoundduringlower trapezius at 120o(t-value1.968andp>0.05).TherewassignificantdifferencefoundduringSerratusanteriorat 60o,90o,120o (t-value5.283,p<0.05, t-value4.138,p<0.05andt-value4.323,p<0.05respectively).

Table 1: results of muscles activity muscles at different angle

60o 90o 120o

T p-value R T p-value R T p-value RUppertrapezius 3.207 <0.05 S 1.749 >0.05 LS 1.518 >0.05 LSLowertrapezius 3.548 <0.05 S 4.331 <0.05 S 1.969 >0.05 LSSerratus anterior 5.283 <0.05 S 4.138 <0.05 S 4.323 <0.05 S

Figure 1: Upper trapezius activity at different angle with neutral and forward head posture

Figure 2: Lower trapezius activity at different angle with neutral and forward head posture


Figure 3: Serratus anterior activity at different angle with neutral and forward head posture

DISCUSSION

Themajorfindingofpresentstudywastocompareelectromyographic (emg) activity of scapular upwardrotatorsduringisometricshoulderflexionwithforwardhead posture vs neutral head posture in normal healthy individuals.Theresultofpresentstudyshowssignificantdifference during activity of upper trapezius at 60o (t-value 3.207, p<0.05) but less significant difference at90o and 120o (t-value1.749,p>0.05andt-value1.518,p>0.05respectively). There was significant differencefound during lower trapezius at 60o,90o(t-value3.548,p<0.05andt-value4.331,p<0.05respectively)butlesssignificant difference found during lower trapezius at120o (t-value1.968andp>0.05).Therewassignificantdifference found during Serratus anterior at 60o, 90o,120o (t-value5.283,p<0.05, t-value4.138,p<0.05andt-value4.323,p<0.05respectively).

FHP may alter the length and tension of the levator scapulae muscle during scapular upward rotation. Significantly increased levator scapulae activity wasreportedpreviouslyinFHPvs.NHP.McLean,L.,(2005)suggestedthatduringFHP,thereisincreasedactivityofupper and lower trapezius due to alteration in length and tension of leavator scapulae. The upper trapezius is an agonistmuscleforupwardrotationofthescapulae,andthe levator scapula is an antagonist for scapular upward rotation.Thus,increasedtensionofthelevatorscapulaewill prevent scapular upward rotation. To overcome this increased levator scapulae tension, it is believed thatthe upper and lower trapezius should be activated to a greater extent in FHP than in NHP.4

The upper trapezius muscle has higher recruitment with maximal activity level compared to other muscles. Also, because of quick response and increased muscletension,itcanbesaidinadditiontoitsroleasascapularrotator, it tends to have short length as a posturalmuscle with high level of activity. It is also possible

that biomechanical changes of cervical spines due to forward head posture cause changes in muscle EMGactivity.Torque of cervical flexors increases in patientswithforwardheadposture.Therefore,tocounteractthisimbalance,cervicalextensormusclesshowmoreactivity.6

Scapular or thoracoscapular position could be changed during the FHP condition. Clinicians have postulated that abnormal cervical spine alignment alters the resting position of the scapula. Previous studies have shown that sitting posture and thoracic spine position affect scapular kinematics. Ludewig and Cook (1996)reported that the scapular upward rotation and posterior tiltingweresignificantlydecreasedinthe20o flexedheadposition during humeral elevation without load.4

It is also due to increase in flexion moment ofcervical spine to counterbalance greater activity of neck extensor muscles in FHP.

Ludewig, P.M. et al, (1996) suggested that FHPaffectsposteriortiltingofscapulasoactivityofSerratusanterior is decrease.7

LimitationofthestudyistomeasureupwardrotatormuscleactivitysurfaceEMGwasusedandassumedthattherecordedEMGsignalindicatedtheactivityofeachmuscle. However, signal alterations could potentiallybe caused by muscle movements below the surface electrode or cross-talk from adjacent muscles. It isdifficulttoconcludethatincreaseduppertrapeziusandlower trapezius and decreased serratus anterior activity caused reduced scapular upward rotation during shoulder flexion in FHP without kinematic data for scapularupward rotation during isometric shoulder flexion. Inthis study subjects were young and healthy individuals with no other cervical and shoulder pathology. Sample size was too small.

Further studies involving the collection of kinematic data were to verify that scapular upward rotation occurs


duringshoulderflexioninForwardheadposture.Italsocan involve comparison between activity of dominant andnon-dominantupperextremityforthesamestudy.

CONCLUSION

In this study, there is increase inEMGactivityofupper trapezius and lower trapezius and decrease in EMGactivity of Serratus anteriorwhile forward headcompare to neutral head posture.

ACKNOWLEDGMENTS

We would like to thank god and our parents forblessing and encouragement.We also acknowledge toour friends and students who were participated in study for their support and encouragement.



Ethical Clearance: Nill

REFERENCES

1.Carolyn Kisner, LynnAllen Colby. TherapeuticExercise Foundations and Techniques. Fifthedition.F.A.DavisCompan2007:383.

2.Chris Ho Ting Yip, Thomas Tai Wing Chiu,Anthony Tung Kuen Poon. The relationshipbetween head posture and severity and disability ofpatientswithneckpain.ManualTherapy2006.

3.Pamela K. Levangie, Cynthia C. Norkin, Jointstructure and function: A comprehensive analysis. Fourthedition.F.A.DavisCompany2005:497.

4.Jong-Hyuck Weon, Jae-Seop Oh, Heon-SeockCynn,Yong-WookKim,Oh-YunKwon,Chung-Hwi Yi. Influence of forward head postureon scapular upward rotators during isometric shoulder flexion. Journal of Bodywork &MovementTherapies.2009June;20:1-8.

5.Charles A. Thigpen, Darin A. Padua, Lori A.Michener, Kevin Guskiewicz, Carol Giuliani,Jay D. Keener, Nicholas Stergiou. Head andshoulder posture affect scapular mechanics andmuscle activity in overhead tasks. Journal ofElectromyographyandKinesiology.2010;30.

6.AydinValizadeh,RezaRajabi,FarhadRezazadeh,Azam Mahmoudpour, Shirin Aali.Comparisonof the forward head posture on scapular muscle contributions during shoulder flexion ofpredominant arm in women with forward head posture.ZahedanJournalofResearchinMedicalSciences.2014June;16(6):68-72.

7.Ludewig,P.M.,Cook,T.M.,1996.Theeffectofhead position on scapular orientation and muscle activity during shoulder elevation. Journal ofOccupationalRehabilitation.1996;6(3):147-158.

8.UK Misra, J Kalita. Clinical Neurophysiology.2nd ed. Elsevier.2012.

Emerging Neuro-rehabilitation Technique in Sports: The Transcranial Direct Current Stimulation (A Review Article)

Parul Sharma1, Shilpa Jain1

1Assistant Professor, Delhi Pharmaceutical Science & Research University, New Delhi

ABSTRACT

Introduction: The Transcranial direct current stimulation method has attested the usefulness of their applicationinsports.Itisapprovedasanon-pharmacologicalwaytotreatdepression,anxiety,andinsomnia.Nowadays,AthletesuseCranialnervestimulationto improvetheircoordinationability, to increase theirconcentration ability and even to improve the indicators of the body functional condition before sport competitions as well.

Method:StudiesweretakenfromPubmed,springerlink,sciencedirect,databaseetcandthereisclearlypotential for use of transcranial direct current stimulation in affecting motor skills related to sportingperformanceeitherbyaidingmotororperceptuallearningand/ortheeffectivenessoftraininginsports.

Result & Discussion:Itisclearthatthetrans-cranialdirectcurrentstimulationcanmodulatebrainactivity,andisconsideredsafewithinacceptedboundaries,itremainstobeconclusivelydeterminedwhetheritcanimprovesportsperformanceatanelitelevelinrespectofmusclecontrolandmaximizespeed,powerordurationiscrucialtomanysports,asistrainingandmotivation

Conclusion:Frompreviousstudies,itcanbeclearlyseenthatthereispotentialforuseoftranscranialdirectcurrent stimulation improve motor skills in sports.

Keywords: Transcranial direct current stimulation, sporting performance, motor skills, Non-pharmacological.

Corresponding Author:Dr.ParulSharma(PT)Assistant ProfessorPharmaceuticalScience&ResearchUniversityNew DelhiEmail: [email protected]

INTRODUCTION

Citius, altius, forties—faster, higher, stronger—these adjectives define the spirit of competitive sportfor professional as well as for amateur athletes. A lot of pressure exerted by trainers on athletes to enhance performance and to get top positions all the time ultimately it turns into raising the interest to enhance the performance using new methods and materials. In the ultracompetitive world of professional sports,professional athletes take great interest in ergogenic aids include multivitamin supplements and hypoxic training,whichrefertoanytechniqueorsubstanceusedto enhance performance.

Recently,theabilityofbrainstimulationtoenhancesports performance has become focused. Non invasive techniqueslikeBrainstimulationandneuralentrainmenttechniquesappliedtosportsenhanceactivityofbraininhealthy athletes to improve their physical performance. According toprevious studies related toneuro-sciencefield,thistechniquecouldhelpincreaseattentionspan,enhance memory, improve cognitive ability, improvesports performance through the change in aspects of mental performance such as motor learning and enhanced muscularstrengthorreducedfatigue(Davis,2013).

Davis (2013) coined the term “neurodoping” toindicate the use of these emerging neurorehabilitation techniquestoenhancephysicalandmentalperformancein sports such as motor learning, enhanced muscularstrength or reduced fatigue, or even improve specificmotor skills.1

The purpose of this study is to provide an overview of the emerging neuro-technology technique i.e.Transverse Direct Current Stimulation and its ability to enhance athletic performance.

DOI Number: 10.5958/0973-5674.2019.00060.1


Transcranial Direct Current Stimulation (tDCS): tDCSdeliversalow-intensityconstantcurrent,usuallybetween1and2mA,viaelectrodesthatareappliedontheparticipant’sscalpabovebrainregionsofinterestforavariableamountof time(usuallyfor5to20min).Aportion of the applied current penetrates the brain and is effective in altering spontaneousneural activity andexcitability.2

Neurophysiological Effects: Weak transcranial directcurrent stimulation cause excitability changes in the human cortex3. Regulation of the physiological activity of severaldeep-brainnucleicanbedonebyTransmissionofpulsed electrical currents across the skin to peripheral or cranial nerves like the trigeminal nerve and vagus. Some of these nuclei make up the ascending reticular activating system (RAS), which releases neuromodulators likenorepinephrine (NE) from the locus coeruleus (LC),acetylcholine (ACh) from pedunculopontine nuclei(PPN),andserotonin(5-HT)fromraphenuclei(RN)tocortical and subcortical regions of the brain to regulate arousal,sleep/wakecycles,emotions,andhighercognitivefunctions.Afferent fibres of the trigeminal, vagal, andcervical nerves pass information to the trigeminal nuclear sensorycomplex(TNSC)andthenucleusofthesolitarytract(NTS)locatedinthemedullaoblongataandponsofthe brain stem and make direct synaptic connections in turn with reticular activating system to modulate functions of brain.4

ThetDCS-inducedchangesintherestingmembranepotential are for the most part regulated by the polarity of

the stimulation. Depolarization of the resting membrane potential induced by anodal stimulation, specially atthesomaandaxonofthetargetedneurons,whichmaycauseneuralfiringandcorticalexcitability.Incontrast,cathodal stimulation causes a slight hyperpolarization of the resting membrane potential of and thereby reduces thechancesofneuralfiringandexcitability.5

During the stimulation period as well as after the stimulation period, shifting of neural activity takesplace.. If the current is delivered for at least 9–10min, Such neural shifts can last for longer than 1 hafter the stimulation has ended. This much of current through tDCS is not sufficiently strong to generateactionpotentials.Indeed,tDCSinducesasub-thresholdmodulation of the resting membrane potential of cortical neurons, changing thefiring and influence thespontaneous cortical activity.6

METHODOLOGY

In previous studies, Nitsche and Paulus (2000)explained cerebral excitability was diminished by cathodal stimulation, which hyperpolarizes neurons,andanodalstimulationcausedneuronaldepolarization,leading to an increase in excitability. Initial studiesemploying tDCSmodulated motor cortex excitability,showing that the modulated cortical excitability can persist after the cessation of the stimulation and that this effectcanbemodulatedbybothintensityanddurationof delivery.7

Cogiamanianetal.(2007)investigatedcapabilityofmodulating the activity of the motor cortex by delievery of tDCS in several studies (e.g., Nitsche and Paulus,2000), will have an effect on fatigue level in normalvolunteers. They concluded that anodal stimulation elevatescorticalexcitability,hadpositiveeffectswithareduction in fatigue in comparison to both no stimulation and cathodal stimulation with endurance time over 15% longer in the anodal stimulation condition. Anodal stimulation of the primary motor cortex had positive effect on sports performance,while stimulation of theremainingcorticeshadnoeffect.8

Staggetal.(2011)foundthatforhealthysubjects,tDCS during learning of an explicit motor sequenceresulted in modulation of performance in a polarity specific manner. Anodal stimulation improvedperformance and cathodal stimulation reduced learning


speed.SimilartothefindingsofStaggetal.(2011),Kuoet al. (2008) found disruption to motor learning withanodal tDCS applied before task performance whereas stimulation after training has been reported to result in enhancement.9

Improvements in Muscular Strength, Motion Perception, Motor Learning, and Muscle Fatigue Through Brain Stimulation: Cogiamanian et al. (2007)examinedtheeffectsoftDCSonneuromuscularfatigue in submaximal isometric contractions of the left elbow in 24 healthy participants (who did notparticipate in competitive sports). The authors found when anodal tDCS was applied over the motor areas of thescalp, therewasasignificant15%decrease in theneuromuscular fatigue. This study cocluded that anodal tDCS can improve muscle performance and decrease muscle fatigue.10

Previous studies shows that improvement of muscle endurance in which sustained submaximal contractions of the elbow flexion were examined in 18 healthyparticipants(Williamsetal.2013).Duringfatiguetaskperformance, either anodal or sham stimulation wasgiven to the motor cortex for up to 20 min. 11

Okano et al. studied the effects of 20 minutes oftDCS with the anode over the left temporal cortex (T3) on trained cyclists (Okano et al., 2013) duringan incremental cycling test, and found improved peakpower, reduced heart rate and perception of effort atsubmaximal workloads.

Okano et al. studied the effects of 20 minutes oftDCS with the anode over the left temporal cortex (T3) on trained cyclists (Okano et al., 2013) duringan incremental cycling test, and found significantlyimprovedpeakpower,aswellasreducedheartrateandperceptionofeffortatsubmaximalworkloads.12

Clarkeetal.evaluatedtheeffectsofstimulationbytDCSonaperceptuallearningparadigm(objectdetectionin a simulated combat environment) and cocluded that enhancement of threat-detection accuracy with tDCSwith the anode over the right inferior frontal cortex. 13

Angiusetal.(2016)notedthatAnodalstimulationof the motor cortex reduced perception of effort andincreased endurance in 9 cyclists when the cathode was placed on the contralateral shoulder but not when placed over the prefrontal region. 14

Studies have also investigated the effects of tDCSon motor strength. For example, Tanaka et al. (2009)found that anodal tDCS resulted in a transient increase in maximumlegpinchforceinhealthyvolunteers,similartoeffectspreviouslyreportedforthehand(e.g.,Fregnietal.,2005;Hummeletal.,bothinpatientgroups;Boggioetal.,2006inhealthyvolunteers),withadurationofaround30min.Vitor-Costaetal.(2015)investigatedtheenhancingeffectoftDCSovertheprimarymotorcortexonmusclefatigue and exercise tolerance in 11 cyclists. Anodal tDCS increased the time of fatigue at 80 % of peak power output. However, no significant effects were found onperceivedexertionandheartrate, indicatingthatanodaltDCSselectivelyenhancedperformancewithoutaffectingphysiological and perceptual variables 15

Asidefromthebeneficialeffectonmusclefatigue,arecentstudyhasshownanenhancingeffectoftDCSonmotor learning through a stimulation procedure over the leftdorsal-lateralprefrontalcortex.16

In an October 2017 article titled “Bilateralextracephalic transcranial direct current stimulation improves endurance performance in healthy individuals. The Halo Sport, a wearable neurostimulation device,which looks like a pair of headphones and leverages tDCS technology, is becoming popular among NFLathletes,MLBathletes,Olympicathletes,andmore.Thedevicepromisesimprovementsinstrength,skill,speed,and endurance.17

According to Reardon (2016), the US Ski andSnowboard Association (USSA), and a companythat makes a product for improving athletic capacity using neuro-technology alongwith testing whetherelectronic stimulus to the brain could upgrade national ski-jumpers’ capabilities during performance througha new device worn as a headset. This test concluded that tDCS improves the players high jumping force and their coordination when compared to the force and coordination of the control group.18

RESULT & DISCUSSION

Although more research is needed to fully understand theeffectsofnoninvasivebrainstimulation techniqueson athletic performance, We conclude that thesetechniques enhance sports performance such asmotorlearning,muscular strength, increased learning rate ofspecificmotor skills, sleep, and fatigue.Regulationof


Pharmacological methods such as neurochemicals like norepinephrine and serotonin to treat diseases or enhance humanperformance.Incontrasttogrosspharmacologicalmethodsthatgenerallyimposeunnecessaryside-effects,we are developing modern digital devices and electronic methods of regulating these endogenous neurochemicals using targeted neuro-modulation approaches. ToFigure out the efficacy of tDCS in real-world sportsperformance, and assess its safety in the context ofrepeated use is the biggest and primemost challenge for researchers. The other Challenge for sports authorities is todeterminewheretDCSsupplementationfits intotheregulatory framework at the elite level.

CONCLUSION

The transcranial direct current stimulation is the effectiveneurorehabilitationtechniqueinsportsfieldtoenhance sports performance.


Ethical Clearance: None


REFERENCES

1.Davis N.J., Neurodoping: brain stimulationas a performance enhancing measure. Sports Medicine,2013,43(8),649–653

2.NitscheMA,CohenLG,WassermannEM,PrioriA,LangN,AntalA,PaulusW,HummelF,BoggioPS, Fregni F, Pascual-Leone A., Transcranialdirect current stimulation:Stateof the art 2008,BrainStimul.2008Jul;1(3):206-23

3.Nitsche MA1, Liebetanz D, Antal A, Lang N,Tergau F, Paulus W, Modulation of corticalexcitability by weak direct current stimulation--technical, safety and functional aspects, SupplClinNeurophysiol.2003;(56):255-276

4. Transdermal Electrical Neuromodulation for PerformanceEnhancement,science&technology,tylerlab,2017

5.Nitsche MA1, Paulus W, Excitability changesinduced in the human motor cortex by weak transcranialdirectcurrentstimulation,JPhysiol.2000Sep15;527(3):633-639.

6.Nitsche MA1, Paulus W, Transcranial directcurrent stimulation--update 2011, RestorNeurolNeurosci.2011;29(6):463-92.

7.NitscheMA,SchauenburgA,LangN,LiebetanzD,ExnerC,PaulusW,TergauF,Facilitationofimplicit motor learning by weak transcranial direct current stimulation of the primary motor cortexinthehuman,JCognNeurosci.2003May15;13(4):619-626

8.Tecchio F, Zappasodi F, Assenza G, TombiniM, Vollaro S, Barbati G, Rossini PM, Anodaltranscranial direct current stimulation enhances procedural consolidation, J Neurophysiol. 2010Aug;104(2):1134-1140.

9.CogiamanianF,MarcegliaS,ArdolinoG,BarbieriS,PrioriA, Improved isometricforceenduranceafter transcranial direct current stimulation over thehumanmotorcorticalareas,Eur JNeurosci.2007Jul;26(1):242-249.

10.WilliamsPS,HoffmanRL,ClarkBC,Preliminaryevidence that anodal transcranial direct current stimulation enhances time to task failure of a sustained submaximal contraction, PLoS One.2013Dec9;8(12):e81418

11.Alexandre Hideki Okano, Eduardo BodnariucFontes,RafaelAyresMontenegro,PaulodeTarsoVeras Farinatti, Edilson Serpeloni Cyrino, LiMinLi,MaromBikson,TimothyDavidNoakes,Brain stimulation modulates the autonomicnervoussystem,ratingofperceivedexertionandperformanceduringmaximalexercise,BrJSportsMed2013;1–7

12.Clark VP, Coffman BA, Mayer AR, WeisendMP, Lane TD, Calhoun VD, Raybourn EM,Garcia CM, Wassermann EM, TDCS guidedusing fMRI significantly accelerates learning toidentifyconcealedobjects,Neuroimage.2012Jan2;59(1):117-28

13.Angius L, Pageaux B, Hopker J, MarcoraSM, Mauger AR, Transcranial direct currentstimulation improves isometric time to exhaustion of the knee extensors, Neuroscience. 2016 Dec17;(339):363-375

14.Vitor-CostaM,OkunoNM,BortolottiH,BertolloM,BoggioPS,FregniF,AltimariLR,Improving


Cycling Performance: Transcranial Direct Current Stimulation Increases Time to Exhaustion inCycling,PLoSOne,2015Dec16;10(12)

15.ZhuFF,YeungAY,PooltonJM,LeeTM,LeungGK, Masters RS, Cathodal Transcranial DirectCurrent Stimulation Over Left DorsolateralPrefrontalCortexAreaPromotes ImplicitMotor

Learning in a Golf Putting Task, Brain Stimul.2015Jul-Aug;8(4):784-6

16.NaveedS,EnhancingAthleticPerformanceWithBrainStimulation,Oct13,2017

17.KwanghoP,Neuro-Doping (tDCS):TheRiseofa Loophole to Get aroundAnti-Doping Policy,Park,CogentSocialSciences(2017),3:1360462

Current Scenario of Diabetes in Ahmednagar City Population

Poonam R. Pandey1, Suvarna Ganvir2

1IVth BPTh., DVVPF’s College of Physiotherapy, Ahmednagar, 2Professor, Dept of Neurophysiotherapy, Ahmednagar

ABSTRACT

Aim: Todeterminetheprevalenceofdiabetesandtoexplorevariousmodifiableandnonmodifiablefactorsassociated with diabetes in Ahmednagar city.

Method: The data was then collected using convenient sampling method. The subjects were selected from VPMHhospital,variouscampsanddoortodoorsurvey.ThesubjectswereassessedbasedontheassessmentformincludingDemographicdata,Socio-economicdata,Familyhistory,Medicalhistory,Surgicalhistory,Personal history, B.M.I., Waist Hip ratio, Diabetes history, Drug history and human activity profilequestionnaire.

Result: 38.6% of adult diagnosed with diabetes in Ahmednagar city population the prevalence came out to be46.6%amongmalesand30.5%infemales.Themeanageformaleandfemaleare57.3yearsand57.2yearsrespectively.About47.8%diabeticsamplesbelongstouppermiddleclassand4.3%belongstolowerclass. 58.6% have a positive family history and 41.3% have a negative family history. 50% have no medical historyand30.4%havepositivehistoryofHTNand3.5%havepositivehistoryofCVDandHTN&CVD.

Conclusion: Themeanagefordiabetesinmaleis57.3%andforfemaleis57.2%.Themeandurationofdiabetesinmalesis13.1yearinmalesand9.8yearinfemales.Thisismostlythefirststudytoincludeuseof sugar in beverage by diabetic population i.e. 56.5% out total diabetic population.

Keywords: Diabetes, hypertension, stroke

Corresponding Author:MissPoonam.R.Pandey,IVthBPTh.,DVVPF’sCollegeofPhysiotherapy,AhmednagarEmail:[email protected]

INTRODUCTION

There is increasing prevalence of diabetes over the globeatanextensiverate.AccordingtoWHOreportof2014,outof7billiontotalpopulation422millionadultsintheworldaresufferingfromdiabetes5,7

InIndiathereare69.2milliondiabeticpatientsoutof 1.2 billion of total population which is highest in the world.Outofthesediabeticpatients36millioncasesareundiagnosed.InIndiamalearemorecommonlyaffectedascomparetofemalei.e.11.7%maleand8.6%female2. Urban population (9.8%) is more affected than ruralpopulation(5.7%)withdiabetes5.

The risk factors such as urbanization, unhealthyeatinghabitsandphysicalinactivity,geneticinheritanceand body composition contributes to the increase incidence of diabetes.

The life expectancy have been decrease to approximately50-60yearsduethebehaviouralchangeslike unhealthy lifestyles as these promote the risk of diseases like cardiovascular disease and hypertension9.

If thesecontinuesof a longperiodof time then itcan seriously compromise the major organ system in the body which then leads to causes of diseases like heart attack, stroke, nerve damage or neuropathy, kidneyfailure,blindness,impotenceandseriousinfectionsthatcan lead to amputation.

Hence, to improve the quality of life and lifeexpectancy it is important to reduce the risk factors contributing to the diabetes.Maintaining normal body

DOI Number: 10.5958/0973-5674.2019.00061.3


weight,engaginginregularphysicalactivityandeatinga healthy diet can reduce the risk to some levels.

Against this background it has been important to findtheprevalence,spreadawarenessaboutthediabetes,keep a eye on the changing epidemiology and identify the of high risk group.

Thereiscurrentlyinsufficientinformationavailableon the overall status of diabetes in Ahmednagar city population.Usingacross-sectionaldataofAhmednagarcity population drawn from the convenient sampling method, this studyassesses theprevalenceandoverallscenario of diabetes in Ahmednagar city.

METHODOLOGY

Study Design:cross-sectionalstudy

Sampling Method: convenient sampling method.

Study Setting: Ahmednagar city.

Study Duration: 1 year

Sample Size: 119

Outcome Measure: Human activity profilequestionnaire.

Kuppuswamy’sscale.

PROCEDURE

After the approval of institutional ethical committee subjectwererecruitedfromthosesufferingfromdiabetesin Ahmednagar city population. Subjects were then explainedabouttheproposedbenefitsandprocedureofstudy,inalanguagebestunderstoodbythem.

Subjects willing to participate in the study were enrolled in the study and the written informed consent wasthenobtainedbyalltheparticipants.Variouscampswearconductedindifferentcommunities,schools,clinicand localities. Door to door survey was done in some localities and the subjects wear selected.

The subjects wear assessed based on the assessment form including Demographic data, Socio-economicdata,Familyhistory,Medicalhistory,Surgicalhistory,Personal history, B.M.I., Waist Hip ratio, Diabetes

history, Drug history and human activity profilequestionnaire.

The measurement of height wear taken using a overhead measuring tape. The subjects wear ask to remove the footwear, socks and any other headaccessories. The subjects wear then made to stand against thewallwithaoverheadtapemeasurementequipmentwith the heel of the foot touching the wall. The subjects wear then instructed to look straight with the hand by their side and shoulder relaxed and measurement was taken and was noted.

The measurement of weight was done by using the weighing machine. The subjects wear instructed to remove footwear, socks, wallet, and any otheraccessories. The weighting machine was then calibrated and the subject was ask to stand on the machine. The subject was instructed to stand straight without stooping downwards. Then reading was then noted.

The measurement of the waist circumference was taken using a measuring tape. The measurement was taken at the narrowest part between the lower rib and the ASIS.Thereadingwasthennoted.

The measurement of the hip circumference was taken using a measuring tape. The measurement was taken on the largest circumference around hip. The reading then was noted.

The components then wear selected and analysed for further result and conclusion.

RESULT

Table 1: sample size

Male FemaleTotal 60 59

Diabetic 27 18Normal 33 41F:MRatioinDM=9:14

z Out of the total samples maximum participantsbelongs to male gender.

z Out of the total diabetic samples maximumparticipants belongs to male gender.

z Out of the total normal samples maximumparticipants belongs to female gender.


Table 2: Age range

Male Mean Female MeanTotal 13-90 53.5 15-87 46.4

Diabetic 13-86 57.3 15-87 57.2Normal 22-90 50.3 15-78 41.6

Table 3: Body Mass Index

Non-diabetic Total % Male % Female %Underweight 7 9.5 4 12.5 3 7.3

Normal weight 38 52 12 37.5 26 63.4Overweight 18 24.6 10 31.2 8 19.5

ClassIobesity 10 13.6 6 18.7 4 9.7ClassIIobesity 0 0 0 0 0 0ClassIIIobesity 0 0 0 0 0 0

DiabeticUnderweight 3 6.5 1 3.5 2 11.1

Normal weight 23 50 15 53.5 8 44.4Overweight 11 23.9 6 21.4 5 27.7

ClassIobesity 6 13.0 3 10.7 3 16.6ClassIIobesity 3 6.5 3 10.7 0 0ClassIIIobesity 0 0 0 0 0 0

z Outofthetotalnon-diabeticpopulationmaximumparticipantsareundernormalweightcriteriaandminimumare under underweight criteria.

z Outofthetotaldiabeticpopulationmaximumparticipantsareundernormalweightcriteriaandminimumareunderunderweight&classIIobesitycriteria.

Table 4: Human activity profile

Non-diabetic Total % Male % Female %Active 6 8.2 5 15.6 3 7.3

Moderatelyactive 50 68.4 17 53.1 33 80.4Impaired 17 23.2 12 37.5 5 12.1

DiabeticActive 6 13.0 4 14.2 2 11.1

Moderatelyactive 21 45.6 13 46.4 8 44.4Impaired 19 41.3 11 39.2 8 44.4

z Outofthetotalnon-diabeticpopulationmaximumparticipantsareundermoderatelyactivecriteriaandminimumare under active criteria.

z Outofthetotaldiabeticpopulationmaximumparticipantsareundermoderatelyactivecriteriaandminimumare under active criteria.

Table 5: Glucose level in diabetics

Total % Male % Female %Known 31 67.3 24 85.7 17 94.4Unknown 5 10.8 4 14.2 1 5.5


z Itrepresentsweatherthepersonwithdiabeteshavearegulartrackornotbyknowingtheglucoselevel.

z Outofthetotaldiabeticpopulationmaximumparticipantsknowstheirglucoselevel.

z Outofthetotalmaleandfemalepopulationmaximumparticipantknowstheirglucoselevel.

Table 6: Route of drug administration in diabetics

Total % Male % Female %Nil 4 8.6 4 14.2 0 0Oral 35 76 21 75 14 77.7

Injection 6 13 3 10.7 3 16.6Both 1 2.1 0 0 1 5.5

z Out of the diabetic population maximumparticipants use oral route and minimum use both oral and injectable route.

z 63% of population out of the total non-diabeticpopulation belongs to upper middle class and 8.2% belongs to lower class.

z 47.8%out of total diabetic populationbelongs toupper middle class and 4.3% belongs to lower class.

z 23.2% of the total non-diabetic population havea positive family history out of which 31.2% are maleand17%arefemalepopulation.

z 26% of the total diabetic population have positive family history, out ofwhich 31.2% aremale and50% are female.

z 16.4% and 1.3% out of the total normal population have positive history ofHTN andCVD,HTN&CVD,HTN&Strokeresp.

z Outof thetotaldiabeticpopulation30.4%haveapositivehistoryofHTNand2.1%PCODandHTN&Stroke.

z 65.7%outofthetotalnormalpopulationbelongstomix diet group.

z 54.3% out of the total diabetic population belongs to a mix diet group.

z 56.5% out the total diabetic population have beverage with sugar.

z 53.5% and 61.1% out of the total male and female resp. have beverage with sugar.

z Out of the total non-diabetic population 24.6%have reduced sleep and 1.3% have increased sleep.

z 28.1% male and 21.9% female population have reduced sleep.

z Out of the total diabetic population 41.3% havereduced sleep and 2.1% have increased sleep.

z 35.7% male and 50% female population havereduced sleep.

z 65.7% out of the total non-diabetics have noaddiction and 1.3% have both tobacco and smoking addiction.

z 78.2%outofthetotaldiabeticpopulationhavenoaddiction and 4.3% have smoking addiction.

WHR:

z 36.9%outofthetotalnon-diabeticpopulationareunder at risk criteria and 15% are under excellent criteria.

z 43.4% out of the total diabetic population are under atriskcriteriaand8.6%areunderexcellent&goodcriteria.

z Out of total diabetic population 2 months is theminimum limit of duration and 25 years is the maximum limit of duration.

DISCUSSION

BasedonthenationallevelsurveysdoneinINDIA,thepreviousstudyestimates7%adultsdiagnosedwithdiabetes5 whereas the present study reports estimates 38.6% of adult diagnosed with diabetes in Ahmednagar city population which is higher than the previous study.

Globalage-standardizedadultdiabetesprevalencewas 9.8% among male and 9.2% among female in 20086,but the in our study the prevalence came out to be 46.6% among males and 30.5% in females which is higher than the previous study.


Astudyconducted in theUnitedStates found thatthe mean age has decreased from 52 years, reportedin theyears1988 to1994, to46years, reported in theyears 1999 to 200021but,ourstudyshowsthatthemeanage male and female are 57.3 years and 57.2 yearsrespectively.

A study conducted Canada states that low income is associated with a higher prevalence of diabetes and a higher population rate25. Inourstudywefoundabout47.8%diabetic samplesbelongs touppermiddle classand 4.3% belongs to lower class. Among the males 57.1%belongstouppermiddleclassand7.1%belongsto lower middle class. Among the females 33.3% belongs to upper middle class and 11.1% belongs to upper and lower class.

AstudyconductedinEUROPEfoundthatthefamilyhistory is a independent risk factor for type 2 diabetes20.Inourstudywefoundthatoutofdiabeticsamples,58.6%havea positive family history and 41.3% have a negative family history. In males 64.2% have a negative family historyand35.7%haveapositivefamilyhistory.Infemales,50%have a positive family history and 50% a negative family history which is similar to the previous study.

Under theheading,co-existing factorsaffecting theMedicalRisksofHypertensionthepreviousstudystatesthat the Diabetic individuals with coexisting hypertension have a much greater prevalence of stroke and peripheral vascular disease19.Inourstudywefoundthatoutofthetotal diabetic population 50% have no medical history and 30.4% have positive history of HTN and 3.5% have positivehistoryofCVDandHTN&CVD. In females33.3%have positive history of HTN and 5.5% have positivehistoryofPCODandHTN&CVD.

A study conducted in INDIA have found that thepopulation on vegetarian diet have low risk of diabetes18. Inour studywe found the same result,45.6%of totaldiabetic population have a veg diet while 54.3% have a mixdiet.Inmales60.7%haveamixdietand39.2haveavegdiet.Infemales55.5%haveavegdietand44.4%have a mix diet.

About 56.5% of diabetic population consumes beverage with sugar and 32.6% without sugar. Inmales about 53.5% consume beverage with sugar and 32.1%withoutsugar.Infemalesabout61.1%consumebeverage with sugar and 33.3 % without sugar these component is not included in any other study.

A pervious study done in Taiwan found the correlation between sleep duration and diabetes suggesting that short sleep duration could be a serious risk factor23. In our studywe found the similar resultthat out of the total diabetic sample 41.3% have reduced sleepand2.1%have increased sleep. Inmales around35.7%havereducedsleep.Infemalesaround50%havereduced sleep and 5.5% have increased sleep.

A previous study conducted in Australia found no relation between diabetes and hyperglycaemia24but,inourstudy we found out of the total diabetic sample 26% have reduced appetite. Inmales around 21.4%have reducedappetite.Infemalesaround33.3%havereducedappetite.

In previous study, Tobacco (smoking and/orsmokeless) consumptionwasprevalent among48.7 % of men and 30.6 % of women14,inourstudyoutofthetotaldiabeticpopulation78.2%havenoaddictionand17.3% have positive tobacco history and 4.3% havepositivesmokinghistory.Inmales21.4%havepositivetobaccohistoryand7.1%havepositivesmokinghistory.Infemales11.1%havepositivetobaccohistorywhichislower than the previous study.

The susceptibility of the urban Indians to centraladiposity was highlighted in the previous study shows that larger proportion of the subjects having higher BMI 30.8%12, in our study majority of populationbelongs to normal weight criteria i.e. out of the total diabeticpopulation50%havenormalweight,23.9%areoverweightand6.5%areunderweightandunderclassIIobese.Inmales53.5%havenormalweight,21.4%areoverweightand3.5%areunderweight.Infemales44.4%areundernormalweight,27.7%areoverweightand11.1are underweight.

The susceptibility of the urban Indians to centraladiposity was highlighted in the previous study that the larger proportion of the subjects having higherWHR50.3%12, inourstudytheresultcameout tobesimilari.e. out of the total diabetic population 43.4% are at risk. Inmales46.4%areatrisk.Infemales38.8%areatrisk.

A study conducted in Cameroon, used the Sub-Saharan Africa Activity Questionnaire (SSAAQ)found that therewas a significant negative correlationbetween physical activity and diabetes17. In our studybyusingHMPwe found the similar result.Outof thetotal diabetic population 45.6%aremoderately active,41.3%areimpairedactivityleveland13%areactive.In


males46.4%aremoderatelyactive,39.2%areimpairedactivityleveland14.2%areactive.Infemales44.4%aremoderately active and impaired activity level and 11.1% are active.

The CARDIA study found that the average (SD)durationofdiabeteswas10.7(10.7)years22.Inourstudywe found the mean duration of diabetes in males is 13.1 years and in females is 9.8 years. The mean duration of total diabetic population came out to be 11.5% which is higher than the pervious study.

AstudyinIndiaindicatesthatmorethan50%ofpeoplewith diabetes have poor glucose control5,inourstudyoutof the total population majority of population have a good controlontheirglucoselevelabout67.3%havearegulartrack on the glucose level whereas 10.8% lack to have a tract on glucose level which less than the previous study. Inmales about 85.7% have attract on the glucose levelwhereas14.2%don’tknowtheirglucoselevel.Infemalesabout 94.4% have a regular track on the glucose level whereas5.5%don’tknowtheirglucoselevel.

Outof the total diabeticpopulation8.6%havenodrugtocontroltheirglucoselevel,76%haveoralrouteof drug administration, 13% have injectable drug and2.1%use both route. Inmales population14.2%haveno drug to control their glucose level, 75% have oralroute of drug administration, 10.7% have injectabledrug. In females population 77.7% have oral route ofdrug administration, 16.6% have injectable drug and5.5% use both route. These components is not included in other study.

CONCLUSION

Themeanagefordiabetesinmaleis57.3%andforfemaleis57.2%.Themeandurationofdiabetesinmalesis 13.1 year in males and 9.8 year in females. This is mostlythefirststudytoincludeuseofsugarinbeverageby diabetic population i.e. 56.5% out total diabetic population. This is mostly the first study to includeprevalence of route of drug administration in diabetic populationi.e.76%usesoralroute,13%usesinjectableroute and 2% uses both route of drug administration. This ismostly thefirst study tofind theprevalenceofglucose level control i.e. 8.6% in diabetic population by using the drug history.


Ethical Clearance: Obtained from the DVVPF’SCollegeofPhysiotherapy,Ahmednagar,Maharashtra.


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13.Anjana RM1, Pradeepa R, Deepa M, Datta M,SudhaV,UnnikrishnanR,BhansaliA,JoshiSR,JoshiPP,YajnikCS,DhandhaniaVK,NathLM,DasAK,RaoPV,MadhuSV,ShuklaDK,KaurT, Priya M, Nirmal E, Parvathi SJ, SubhashiniS, Subashini R,Ali MK, Mohan V, Prevalenceof diabetes and prediabetes (impaired fastingglucose and/or impaired glucose tolerance) in urbanandruralIndia:phaseIresultsoftheIndianCouncil of Medical Research-INdia DIABetes(ICMR-INDIAB) study. Diabetologia. 2011Dec;54(12):3022-7. doi: 10.1007/s00125-011-2291-5.Epub2011Sep30.

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Effect of Sports Activity Dependent Antagonist Muscles Strengthening (Sadams) on Performance Parameters in

Competitive Roller Skaters: An Experimental Study

Prasannajeet P Nikam1, Basavraj Motimath2, Dhaval Chivate3

1Post Graduate Student, 2Associate Professor, HOD, 3Lecturer, Sports Physiotherapy, KLE University’s Institute of Physiotherapy, Belgaum, Karnataka, India

ABSTRACT

Background: There has been literature supporting the fact that athletes involved in high-speed sportsrequiretailor-madetrainingtominimizetheriskoffallsandtoenhancebetterperformance.SportActivityDependentAntagonistMusclesStrengthening (SADAMS) is a newconceptwhich is designedwith theultimate goal of focusing on the resistance strengthening of only those isolated muscles which are known to develop muscle strength imbalance mostcommonly in skaters. Targeting mobility exercises especially in hip,groin,quadricepsandhamstringsmayhelpskatingtechnique,improvefootworkandreducetheriskof injuries.

Objective: The ultimate goal of this study is to provide a Precise Resistance training protocol for roller skaters which will target those muscles which are known to be most vulnerable for developing strength imbalance.

Method:100roller-skaters(n=100)wererecruitedanddividedrandomlyintocontrolgroupandSADAMSgroupandchangesinvariousperformanceparameterslikestrength,flexibilityandagilitywereseen.

Results:SADAMSgroupshowedimprovedmusclestrengthandagilityascomparedtothecontrolgroupwhich showed improvementonly in theagilitycomponent.Bothgroupsdidnot showedany significantimprovementinflexibilitycomponent.

Conclusion:SADAMSprotocolprovedtobeeffectiveinimprovingstrengthandthusultimatelycorrectingmuscle imbalance in competitive roller skaters.

Keywords: Skating, Muscle imbalance, Roller skaters, SADAMS.

Corresponding Author:Prasannajeet P NikamPostGraduateStudent,SportsPhysiotherapy,KLEUniversity’sInstituteofPhysiotherapy,Belgaum,Karnataka,India

INTRODUCTION

Skatingisanextremelydifficultsportthatrequiresa combination of grace, artistry, flexibility, speed, andpower.1Speedskatingisatypicalphysical-abilityleadingitem-groupevent,andtheathlete’sphysicalabilityandskills are the main elements that decide their sporting ability.2 Itisoneofthepopulargameswhichnowadaysis gaining more of a professional rather than recreational

importance.In1991,Knapiketal.reportedthatstrengthandflexibility imbalances in femalecollegiateathleteswereassociatedwithlowerextremityinjuriesingeneral,butnotspecificallywiththemusclegroupinwhichtheimbalance was found.9

Asperonestudy,inUSAalone,approximately35millionchildrenandyoungadultsbetweentheages6-20yearsparticipateinsports,including6to8millioninschool sports programs.10Becausetraininghasbecomemore sport-specific and nearly continuous, overuseinjuries are now common among young athletes. Recent data indicate that 30% to 50% of all pediatric sports injuries are due to overuse.11,12,13 In a 2-year study of453 young elite athletes, 60% of swimmers’ injurieswereduetooveruse,comparedto15%ofsoccerplayers

DOI Number: 10.5958/0973-5674.2019.00062.5


injuries.14,15 Athletes who had overuse injuries lost 54% more time from training and competition than those who had acute injuries.

Thesport-specificmovementscancauseskaterstodevelopasymmetriesinmusclestrengthandflexibility.21 Asymmetries have been thought to reflect limbdominance.22 Moreover, it is possible that a muscularimbalance could be created through prolonged unilateral use of the dominant side. Studies also suggest that about 50% of injuries are traumatic and remaining 50% are due to overuse injuries. Skating can cause strength and flexibility imbalance between the quadriceps andhamstrings,hipflexorsandextensors,andhipabductorsand adductors.25

The aerodynamic requirements for optimalperformance in speed skating impose physiological as well as biochemical constraints.23 Controlled laboratory andon-iceexperimentsofspeedskatinghaveshownthatskating in the ‘low sitting’ position leads to a numberof biochemical changes like reduced sub maximal VO2,increasedbloodlactateconcentrationandreducedblood volume change coupled with increased muscle deoxygenationinthequadricepsmuscle.24

Sport Activity Dependent Antagonist MusclesStrengthening (SADAMS) is a new concept whichis designed with the ultimate goal of focusing on the resistance strengthening of only those isolated muscles which are known to develop muscle strength imbalance most commonly in skaters. Targeting mobility exercises especially in hip, groin, quadriceps and hamstringsmay help skating technique, improve foot work andreduce the risk of injuries.34 So the ultimate purpose of thisstudyis tofindoutwhether theproposedSportActivity Dependent Antagonist Muscle Strengthening(SADAMS) protocol has any role in correcting themuscle strength imbalance commonly seen in roller skaters and also whether it has any secondary positive or negativeeffectonvariousperformanceparameterslikeagilityandflexibility.

METHODOLOGY

Participants were randomly allocated to either GroupAorGroupBusingEnvelopmethod.100rollerskaters were recruited from various roller skating clubs from Belagavi, Karnataka. Inclusion criteria’s wererollerskatersbetweenagegroupof13-18yearsofage,

skaters who were skating since 1 year but not more than 2 years.Bothmale and female skaterswere included.Exclusion criteria’swere any recent injuries, fracturesand subjects who had underwent any recent surgeries. OutcomemeasuresusedwereHandhelddynamometer,Goniometer&T-testforAgility.

PROCEDURE

Each exercise was performed in 3 sets with 30 seconds hold for each set with 15 second rest after exercises.Inaddition,thesubjectsweregivenstretchingexercises to match the control group. Assessment of Musclestrength,FlexibilityandAgilitywasdonepriortothecommencementofthestudyandafter7weeksofintervention and the results were compared.

The details of the protocol which was administered to both groups is as enlisted below:

Group A : The subjects allocated to this group were asked to perform general stretching followed by Conventional exercises once a day.

Group B: The subjects allocated to this group were givenSADAM’sprotocolwhichconsistedofasetof7resisted exercises. The subjects were asked to perform these 7 exercises once a day. Resistance band wasused to add on the additional resistance. The exercises included inSADAMSprotocolweregivenasfollows:Neck Extensor, Shoulder Retractors, Back extensors,Hipextensors,Kneeextensors,Wristextensors&AnkleDorsiflexors.


Statistical analysis for the present study was done using Statistical Package of Social Sciences (SPSS)version21.Variablesofalltheoutcomeswerecomparedafter eight weeks with the baseline values. Probability valuesofp≤0.05wereconsideredstatisticallysignificant.

STRENGTH

Neck Extensors: Animprovementof22.17%wasseenin neck-extensors strength in SADAMS group post-interventionascomparedtothepre-interventionvalues.(3.06±1.04) (p=0.0001*).Nochange in strengthwasseen in the control group.


Shoulder Retractors: SADAMS group showed adifferenceof2.38±1.19fortheleftside&2.48±1.01fortheright-sidepostintervention.16.95%(p=0.0001*) increment in muscle strength of shoulder retractors was seen in left side & 17.74% (p=0.0001*) improvement was seen in right side. 0.79% more improvement instrength was seen in the right side than the left side.

Shoulder Extensors: The flow of uneven muscle-strength improvement was also evident in case of shoulder extensors with the right side exhibiting 2.24% more strength improvement than the left side.

Forearm Extensors: Right side showed improved forearm extensorstrengththanleftsideintheSADAMSgroup.

Back Extensors: Thepercentageincreasewas21.17%(p=0.0001*)intheSADAMSgroup.

Hip Extensors:A difference of 2.36± 1.08was seenbetweenpre-test&post-testscoresinrightside(16.81%)(p=0.0001*)and2.56±1.45wasseeninleftsidewhichaccounted for a total percentage improvement of 18.58% (p=0.0001*).

Knee Extensors: No increase or decrease was seen in control group as the strength scores were maintained throughoutthestudy.Leftsideimprovedby7.98%overthe right side.

Flexibility: NoimprovementintermsofflexibilitywasseeninboththecontrolgroupaswellastheSADAMSgroup.

Agility: The SADAMS group showed significantreduction in agility T-test scores post-intervention(p=0.0179*)(Differencepretopostmean±sd=-1.34±12.46).7.63%(p=0.0001*)improvementwasseenincontrol group whereas the agility parameter improved by10.7.

DISCUSSION

Strength: The results of this study showed significantimprovementinmusclestrengthoftheSADAMSgroupthan the control group. This is in accordance with the study done by Simen Thorrud which states that there exists a bias between preferring dominant side in G2 skaters.

Flexibility: As the sustained active contraction of agonist leads to stretching of the antagonist, this theprolonged hold period of 30 seconds for each exercise.

This is in accordance with a study conducted by Saari &Lumioetalwhichsaysthatastaticstretchshouldbemaintained for at least 20 to 30 seconds in order to gain improvementintermsofflexibility.5

Agility: The results of this particular study also demonstrated improvement in the agility parameter for both groups. Comparatively higher improvement was seenintheSADAMSgroupwhichwas10.75%thantheControlgroupwhichwas7.63%.(p=0.0001*). Previous studies have shown correlation between strength and agility.

Relationship between strength, flexibility & agility: Itisclearlyevidentthatstrength,flexibilityandagilityareinter-related.Thiscouldbethepossibleexplanationof obtaining improved agility score in the SADAMSgroup wherein no intervention was given as such that would possibly target the improvisation of the agility parameter.

Sport Activity Dependent Antagonist Muscle Strengthening (SADAMS): Simons and Andel assessed theeffectsofresistancetrainingandwalkingexerciseonfunctionalfitness.6 Participants were randomly assigned to walking, resistance training or control group. Bothexercisegroupshowedsignificantimprovementsrelativeto control group in upper and lower body strength,shoulderflexibility,agilityandbalanceexercises.

CONCLUSION

The present study concluded that muscular imbalance was efficiently corrected by SADAMSprotocol in competitive roller-skaters. In addition toimprovement in strength, reduced T-test completiontime,i.e.improvedagilitywasseeninboththecontrolaswellastheinterventiongroup.Nosignificantchangeswere seen in theflexibilitycomponent ineitherof thetwo groups.



Ethical Clearance: Taken

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Normative Performance of Indian Adults Aged 20-80Years on Modified Jebsen Test of Hand Function

Prerna Lal1, Sebestina Anita Dsouza2, Timsy Jain3

1Professor and Head of Department, 2Assistant Professor, Department of Occupational Therapy, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India; 3Consultant Occupational

Therapist, Health Factor Multi-Speciality Centre, WZ-78, Beriwala Bagh, Harinagar, New Delhi

ABSTRACT

Objective: Toestablishtest-retestreliabilityandnormativevaluesforIndianadultsonModifiedJebsenTestofHandfunction(MJT)agedbetween20-80yearsofage.

Method:Fivehundredfifty-fiveadults(Twohundredeighty-fivemenandTwohundredseventywomen)ofthreeagegroups;20-50,51-65,66-80yearsperformedtheMJT.Sixtyparticipantsrepeatedthetestafter48hours.Intra-classCorrelationCoefficientwascalculatedusingTest-retest.TheinfluenceofageandgenderwasanalyzedwithTwo-wayANOVA.

Result:Test-retestreliabilityofMJTwasfoundedtobehigh(0.93).Therewasnosignificantinfluenceofgender,butsignificantinfluenceofageonMJT(p<0.05).Therewasnosignificantinteractionofagewithgender(p>0.05).

Conclusion:TheMJTisaquickandreliabletest toassessthegrosshandfunction.Thisstudyprovidesreferencenormsbasedonageandgenderforyoung,middleagedandolderIndianadults.

Keywords: Gross Hand Function; Modified Jebsen Test of Hand Function; Dexterity

Corresponding Author:Dr.SebestinaAnitaDsouza,MOT,PhDProfessor and Head of Department DepartmentofOccupationalTherapySchool of Allied Health SciencesManipalUniversity,Manipal–576104,Karnataka,IndiaMob:+919448152143,Tel:+918202922188Email:[email protected] [email protected]

INTRODUCTION

Dexterity is a very important component to consider during the assessment of upper extremity function1.

Jebsen Hand Function Test (JHFT) is a widely usedstandardized assessment of dexterity. It consists ofseven subtests to assess gross and fine dexterity, and reflects activity limitation2. In the initial acute phaseof rehabilitation, interventiongoals focuson regaininggrosshandfunction.ThefinemotortestsofJHFTmaybe challenging and disappointing for clients with limited hand functions and increase assessment time3.

Bovend’Eerdt modified the JHFT for quickassessment of gross hand functions. The modifiedversionofJebsenTestofHandFunctionincludesthreesubtests: flipping over cards, stacking four cones, andspooning five kidney beans into a bowl. The test has goodconcurrentvalidityandhigh test-retest reliabilityon patients with neurological disorder3.

Hand injuries in the working population are a prevalentprobleminIndia4.TheIndianolderpopulationis also expected to increase dramatically5.Olderadultsare at risk for age-related or degenerative orthopaedicandneurologicalproblemssuchasarthritis,strokeetc.,whichaffectstheirhandfunctionsandleadstodifficultyin performing functional tasks. Retraining gross hand functions is usually a priority in rehabilitation of older adults. TheMJT could thus be a valuable assessmenttool in varied clinical settings for a broad range of ages and clinical disorders. However, normative scores areessentialforitseffectiveuse.ThisstudyaimstoestablishnormsforhealthyIndianadultsonMJT,determinethe

DOI Number: 10.5958/0973-5674.2019.00063.7


influence of age and gender on MJT among Indianpopulationandestablishitstest-retestreliability.

METHOD

The studyfindings presented in this paper are theresult of compiled data from two research projects. The first project was conducted between 2011-2012 andinvolved participants aged 20-59 years. The secondprojectwasconductedbetween2013-2014andinvolvedparticipants aged 60-80 years. Both the projects wereapproved by the institutional ethical committee, andinvolved a convenience sample of participants from New DelhiandUdupi,Karnataka.Toensureaheterogenoussample,thestudyparticipantsweredrawnfromdifferenteducational background, socio-economic status, andoccupation.Toparticipateinthestudy,participantshadto have good comprehension abilities and able to follow instructions. Adults having cognitive and psychiatric conditions, traumatic or non-traumatic neurological ormusculoskeletal impairments of the upper limb were excluded. Interested participants were explained thestudy aim and procedure and provided written informed consent. Participants were then performed the MJT.Participants volunteering for test-retest reliability (TRgroup)performedtheMJTagainafter48hours.

As specific dimensions for test material wereunavailable, commercially available playing cards,

cones, teaspoon and steel bowl were used in MJT.Participantssatonacomfortablechairinfrontofatable,with a horizontal wooden board (85×32cm with 9mridge) placed in front of the participant on the table. The wooden board had marking that indicates the position ofcards,cones,andbeans3. Participants performed the test first with non-dominant hand and then dominanthand. The hand with which a participant performed most activities; especially feeding and writing was considered as the dominant hand. Participants performed one practice trial and then performed each subtest three times,alternatingbetweendominantandnon-dominanthand.The time for each subtest ofMJTwas recordedwith a stopwatch and the maximal time limit was set at 150seconds3.Thefinalscorewastheaveragetimeoverthree trials for each subtest with dominant and non-dominant hand.


Descriptive statistics was computed. Test-retestreliability was calculated using Intra-class correlationcoefficient (ICC). Two-way ANOVA with Tukeypost-hocmethod was used to analyze themain effectof the independent variables of age and gender and the interaction between the independent variables. Normative data was expressed in terms of 50th, 84th,97.5th percentiles.

Table 1: Participant’s characteristics: Participants in the total study and in the test-retest group

Age Group (years)Total (N = 555) Test-Retest Group (N = 60)

Mean year (S.D.)Men Women Men Women

20-50 147 146 15 17 34.14(9.31)

51-65 79 77 8 8 58.86(4.26)

66-80 59 47 7 5 72.21(4.69)

Total 285 270 30 30 48.36(17.37)

Note:N=numberofparticipants;S.D=StandardDeviation

RESULTS

The study included 555 participants aged from 20 and80years(mean48.36yearsandSD17.37).Table1summarizes the participant characteristics. Three age

groups were established: 1) 20-50yrs; 2) 51-65yrs; 3)66-80yrs. The TR group composed of 60 participants(30menand30women).


Table 2: Performance of Indian Adult population on MJT

MJT (Subtest) Hand Age Group (years) Men (N = 285) Women (N = 270) Total

Flipping cards

Dominant20-50

MeanSeconds(SD)4.61(0.81) 4.71(0.76) 4.66(0.81)

51-65 4.82(1.22) 4.89(1.04) 4.86(1.14)66-80 5.11(0.98) 5.41(1.36) 5.24(1.17) a,b

Non-Dominant

20-50 5.02(0.86) 5.16(0.85) 5.09(0.86)51-65 5.20(1.26) 5.19(1.11) 5.20(1.19)66-80 5.36(0.95) 5.56(1.23) 5.45(1.08) a

Stacking Cones

Dominant20-50 4.49(0.71) 4.59(0.66) 4.54(0.69)51-65 4.72(0.99) 4.60(1.09) 4.66(1.04)66-80 5.16(1.07) 4.91(1.15) 5.05(1.11) a,b

Non-Dominant

20-50 4.84(0.73) 4.86(0.68) 4.85(0.71)51-65 5.08(1.11) 4.87(1.10) 4.98(1.11)66-80 5.17(0.99) 5.05(1.15) 5.12(1.06) a

SpooningBeans

Dominant20-50 9.49(1.19) 9.51(1.14) 9.51(1.17)51-65 10.19(1.62) 10.05(10.05) 10.12(1.89)a

66-80 10.89(2.15) 11.45(2.71) 11.14(2.41)a,b

Non-Dominant

20-50 10.82(1.37) 10.84(1.37) 10.83(1.37)51-65 11.32(2.24) 11.08(2.97) 11.20(2.62)66-80 11.75(2.61) 11.93(3.05) 11.83(2.80)a,b

Note:SD=Standarddeviation;a=significantdifferencefrom20-50yearsagegroup,b=significantdifferencefrom51-65yearsagegroup.

Table2summarizestheresultsofanalysiswithtwo-wayANOVA.Resultsdemonstrateasignificantmaineffectfortheindependentvariableofage(p<0.05)inallMJTsubtests.PosthocanalysiswithTukeyindicatedsignificantdifference(p<0.05)between51-65and66-80yearsagegroupsformostsubtestsofMJTassummarizedinTable3, exceptflippingcardsandstackingconeswith thenon-dominanthand.NosignificantgenderdifferenceswereobservedinallMJTsubtests.TherewasnosignificantinteractionofageandgenderinallsubtestsofMJT.

Table 3: Reference norms for MJT scores, shown in 50th-97.5th percentile

Subtest (MJT) Age group (Years) Gender

Dominant Non-Dominant50th 84th 97.5th 50th 84th 97.5th

Flipping Cards

20-50Men 4.61 5.42 6.23 5.02 5.88 6.74

Women 4.71 5.47 6.23 5.16 6.01 6.86

51-65Men 4.82 6.04 7.26 5.20 6.46 7.72

Women 4.89 5.93 6.97 5.19 6.3 7.41

66-80Men 5.11 6.09 7.07 5.36 6.31 7.26

Women 5.41 6.77 8.13 5.56 6.79 8.02

Stacking Cones

20-50Men 4.48 5.19 5.9 4.84 5.57 6.3

Women 4.59 5.25 5.91 4.86 5.54 6.22

51-65Men 4.72 5.71 6.7 5.08 6.19 7.3

Women 4.59 5.67 6.75 4.86 5.95 7.04

66-80Men 5.16 6.23 7.3 5.17 6.16 7.15

Women 4.91 6.06 7.21 5.05 6.2 7.35


Conted…

SpooningBeans

20-50Men 9.50 10.7 11.9 10.82 12.19 13.56

Women 9.51 10.65 11.79 10.84 12.21 13.58

51-65Men 10.19 11.81 13.43 11.32 13.56 15.8

Women 10.05 12.2 14.35 11.08 14.05 17.02

66-80Men 10.89 13.04 15.19 11.75 14.36 16.97

Women 11.45 14.16 16.87 11.93 14.98 18.03Note:MJT=ModifiedJebsenTestofHandFunction

Table3summarizestheperformanceofIndianmenandwomenaccordingtothehanddominanceforthreeagegroups.ThistabledepictsthenormativedataforIndianadultscorrespondingtomedian,+1SDand+2SDrespectively.The values of +1SD and +2SD allow comparison of a patient with the average values of adult population.

Table 4: ICC value illustrating test-retest reliability of the MJT

Variable Cronbach-α ICC CI (95%)

MJT(Test)× MJT(Retest) 0.930.86(SM) (0.77-0.92)0.93(AM) (0.87-0.96)

Note:SMindicatesinglemeasure,AMindicatestheaveragemeasure

Table 4 summarizes the value of Cronbach-α fortest-retest reliability. The ICC value was higher than0.90, that indicates excellent reliability.

DISCUSSION

The study aimed to establish normative values for MJT on large sample of healthy Indian adults agedbetween 20 to 80 years. The mean values represent the 50th percentile.The values of +2SD (97.5th percentile) and+1SD(84th percentile) are used based on the need for accuracy in clinical practice. The threshold of +1SDmaybesuitableforsituationsrequiringstringentscreening for at-risk individuals. The +2SD thresholdmay be suitable for identifying adultswith significantdecline in hand functions. The reference norms provided in this study will facilitate application of theMJT inclinical practice.

The study demonstrates good test-retest reliabilityonalargesampleofhealthyIndianadults.ThisfindingfurthersupportsthereliabilityofMJTinIndianadults3.

The results indicate that gross dexterity decreases with increasingage,especially inolderadultsafter65years.Also,men andwomen have similar gross handdexterity. Similarfindings are reported in studieswithother tests of gross hand dexterity6

CONCLUSION

Thestudyestablishesexcellenttest-retestreliabilityof MJT in healthy Indian population that adds to itspsychometric properties. The present study provides normsforIndianadultsbetween20to80yearsofageonlargeheterogeneousIndianpopulation.Thegenderandage based values provided in percentiles will support application of MJT in clinical practice and research.It may also facilitate in establishing age appropriateintervention goals.

LIMITATION

The study results are not applicable for older adults beyond80yearsofage.ThemodifiedJebsentestusefulinassessingspeedratherthanqualityofthemovement.



REFERENCES

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3.Bovend’EerdtTJH,DawesH,Johansen-BergH,WadeDT.EvaluationoftheModifiedJebsenTestofHandFunctionandtheUniversityofMarylandArm Questionnaire for Stroke. Clin Rehabil.2004;18(2):195-202.

4.Mathur N, Sharma KKR. Medico-economicimplications of industrial hand injuries in India.J Hand Surg Am. 1988; 13(3): 325-327. DOI:10.1016/0266-7681(88)90101-5.

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6.HackelME,WolfeGA,Bang SM,Canfield JS.Changes in hand function in the aging adult as determinedbytheJebsenTestofHandFunction.PhysTher.1992;72(5):373-377.

7.JebsenRH,TaylorN,TrieschmannRB,TrotterMJ,HowardLA.Anobjectiveandstandardizedtestofhandfunction.ArchivesofPhysicalMedicineandRehabilitation.1969;50(6),311-319.

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The Effectiveness of Aerobic Exercise Program for Improving Functional Performance and Quality of Life in Chronic Low

Back Pain

Priyanka Gupta1, P. P. Mohanty2, Monalisa Pattnaik3

1Physiotherapy Department, Nehru Hospital, Cobalt Block, pgimer, Chandigarh, MPT [Musculoskeletal], 2HOD, 3Assistant professor, Department of Physiotherapy, Svami Vivekanand National Institute Of

Training And Research [SVNIRTAR], Olatpur, Cuttack ; affiliated by Utkal University.

ABSTRACT

Background: Thepresenceofpersistentlowbackpaincausespatientstoavoiddailyactivities,whichmayleadtophysicaldeconditioning,bothgenerallyandspecifically.Suchsignsofphysicaldeconditioningmayresultinevenmorepainanddisabilityandsocontributetothechronicity..Fromthepatient’sperspective,chronicLBPhasadailyimpactonfunctionalabilityandqualityoflife(QoL).Enduranceexercisereversesthecycleofdeconditioning,weakness,andfunctionallossassociatedwithmanychronicdisorders.

Purpose:Thepurposeof this randomisedcontrolled trialwas to investigate theeffectivenessofaerobicexerciseprogramforimprovingfunctionalperformanceandqualityoflifeinchroniclowbackpain.

Method: 30patientsofchroniclowbackpainwithmeanage(48.6±5.32)havingchroniclowbackpaingreater than 3 months completed the trial. Subjects were randomly placed into two groups receiving the Aerobic exercises and conventional treatment (n = 15) or the conventional treatment alone ( n = 15).Conventionaltreatmentconsistofmobilization,stretchingandexercisesforlowbackpatients.Eachgroupreceivestheirrespectivetherapy5daysaweekfor8weeks.Oswestrydisabilityindex,heartrateandRAND-36weretheoutcomemeasuresassessedatbaselineandagainafterthe8weekintervention.

Results: TheaerobicexercisesgroupshowssignificantimprovementinOswestrydisabilityindex(5.73±2.64,p=0.001)theRAND-36Physicalfunctioning(Zscore=-4.706,p=0.00)andEnergyandfatiguescores(Zscore=-4.715,p=0.00)thancontrols.

Conclusion: The study demonstrates that conventional low back pain treatment combined with aerobic exercise program is superior to conventional low back pain treatment alone in improving functional performanceandqualityoflifeinpatientswithchroniclowbackpain.

Keywords: Chronic low back pain, physical deconditioning, aerobic exercise program, oswestry disability index, RAND-36.

Abbreviation: LBP: Low back pain; CLBP: Chronic low back pain; ODI: Oswestry disability index; RAND: RAND short form -36; FAB: Fear avoidance belief

INTRODUCTION

Chronic low back pain is defined as persistent& disabling low back pain lasting more than threemonths.1QuebecTaskForceonspinaldisorderssuggestthat symptoms leading to greater than twelve weeks can be labelled as chronic.2Lowbackpainisamongthemostprevalent musculoskeletal disorders affecting a largeproportion of the population during their lifetime which

hasalifetimeprevalenceof60%-85%. An incidence of recurrentorchroniclowbackpainat3months,6months,and12monthsrangesfrom35%to79%.3Itisfifthmostcommon reason for physician visit and is a major health problem throughout the world.4

Chronic low back pain (CLBP) and its associateddisabilityareasignificanthealthandeconomicburdentosociety.5Peoplewithlowbackpainfrequentlylimittheir

DOI Number: 10.5958/0973-5674.2019.00064.9


work and leisure time activity. There is circumstantial evidence that the social and personal context of the person influencesatleastthemedicalpresentationwithbackpainand also the nature and extent of activity limitation.6

Itisalsopostulatedthatthepresenceofpersistentlowbackpaincausespatientstoavoiddailyactivities,whichmay lead to physical deconditioning, both generally(e.g., loss of cardiovascular capacity) and specifically(e.g., loss of strength and endurance of paraspinalmuscles). Such signs of physical deconditioning may result in even more pain and disability and so contribute to the chronicity of low back pain. 7This pattern of signs andsymptomsiscalledthe‘deconditioningsyndrome’as a factor contributing to the intolerance to physical activities and subsequent further loss of function anddisability in patients with chronic low back pain.8Also fromthepatient’sperspective,chronicLBPhasadailyimpactonfunctionalabilityandqualityoflife(QOL).9,10

Endurance exercises reverses the cycle of deconditioning,weakness,andfunctionallossassociatedwith many chronic disorders.11,12Inadditiontopositivephysiologiceffectsofexercisetraining,aerobicexerciseshave been shown to improve quality of life in otherchronic disorders.13,14

Aerobic exercises in the form of bicycle exercise program have been shown to improve functional status and endurance in low back patients also stationary cycling provides support for the rationale that psychological factors,suchascatastrophizingandFAB,maybeoneofthemechanismsaccountingforthepotentialinfluenceofstationary cycling on pain and disability.15Catastrophizing maybedefinedasanexaggeratednegativeinterpretationof pain that might occur during an actual or anticipated painexperience.Fearavoidancebeliefsrefersactivity–avoidance behaviour based on pain related fear.16Manystudies suggest that catastrophizing and FAB areimportant factors in predicting pain and disability in patientswithLBP.17

Studies has shown patients of chronic low back pain were treatedwith lowimpactaerobics(swimmingandcycling) and found improvement in aerobic capacity than in comparison to control subjects.18but no studies have investigated the improvement in disability and quality of life in patients with chronic low back painwith aerobic exercises. Thus the purpose of the study wastoinvestigatetheeffectofaerobicexercisesintheformofstaticbicycleondisabilityandqualityoflifeinpatients with chronic low back pain

MATERIAL AND METHOD

Subjects: This was a randomized experimental design toevaluatetheeffectivenessofaerobicexerciseprogramforimprovingfunctionalperformanceandqualityoflifein chronic low back pain. The study was approved by Institutionalethicalcommitteewherethestudywasdone.

The criteria for inclusion were :Chronic low back paingreaterthan3months;ageshouldbebetween30-65years;painonVASscoreshouldbelessthanorequalto5; pain should not aggravate in sitting since the patients arerequiredtoperformaerobicexercisesoverstationarybicycle. Subjects were excluded if they had history of any respiratory, cardiac disease, grossmusculoskeletaldeformities, any listing, any injury or disease at oraroundspine,pelvis,hip,kneeandankle.Patientshouldnot be pregnant and any habit of smoking.

A total of 40 subjects were assessed for eligibility. Seven subjects did not satisfy the inclusion criteria and three refused to participate. The subjects were then allocated randomly to either aerobic exercises group and conventional group by computer generated number.

Procedure: After fulfilment of all the inclusion andexclusion criteria, all subjects were asked to fill theconsent form. After completion of all inclusion and exclusion criteria assessment was done on all the demographical parameters in the chronic low back pain patient.15 patients were given only conventional therapy including piriformis, hamstring and rectus femorisstretching (3-5 times each lasting 1 minute) maitlandlumbar mobilization(slow smooth oscillations 5repetitionseachsegmentlastingfor30seconds),sustainedlumbartractionfor10minutes,corestrengtheningandflexibility(spinal flexion and extension 10 repetitions)exercises forchronic lowbackpain.Other15patientswere given conventional as well as stationary bicycle exercise program.

Prior to and after completion of conventional therapy ODIandRAND-36weremeasuredin30patients.Outof 30 patients 15 patients were given stationary bicycle exercise program and conventional treatment for 8 weeks since studies shows that a training response occurs with exercise performed at least three times weekly for at least 6 weeks.19After completion of programODI andRAND-36wasmeasured.

Protocol for stationary bicycle program was followedbypatientsfor8weeks,asfollows:


Week1&2-20minutes5minute–Warmup-easypedallingatacomfortable

pace10minutes-Training-higherintensity(60rpm)5 minutes – cool down- easy pedalling at a

comfortable paceWeek3&4-25minutes5minutes–Warmup-easypedallingatacomfortable

pace15minutes-Training-higherintensity(60rpm)5 minutes – cool down- easy pedalling at a


pace.20minutes-Training-higherintensity(60rpm)5 minutes – cool down- easy pedalling at a


pace.25minutes-Training-higherintensity(60rpm)5 minutes – cool down- easy pedalling at a

comfortable pace.

All the testing procedure was described and taught to the patient of aerobic exercise group.

Outcome measurement: Oswestry Disability Index.,RAND(Physical functioningandenergy/ fatigue)wereusedas theoutcomemeasuresof thisstudy.ODIis themost reliable and ‘gold standard’ tool for evaluatingdisability of patients with chronic low back pain.20SF-36is a sensitive measure of treatment success and measuring qualityoflifeinpatientswithlowbackpain21since there issomealgorithmdifficultywithSF-36,RAND-36waschosenasoutcomemeasurement.Baselinereadingwastakenattheendoffirstweekandattheendof8weeks.


An intention to treat analysis was done using SPSS15.0Software(SPSSInc,Chicago,USA).

ODIwas assessed by 2×2ANOVA.All pairwisepost – hoc comparisons were analysed using a 0.05levelofsignificance.RAND(PhysicalfunctioningandEnergy/Fatigue) were analysed using Mann- whitneytest.Pwassetat0.05forlevelofsignificance.

RESULTS

Subject information: A total number of 30 subjects with mean age (48.6 ± 5.32)were taken and dividedintotwogroupswith15subjectsineachgroup,namelyExperimental Group (mean age 48.06 ± 4.97 ) andControlGroup(meanage49.2±5.528).60%ofsubjectsweremales&40%werefemales.

Table 1: Mean, standard deviation (SD) & standard error of mean (SEM) values of ODI at 0 week & 8th week

Group 0 Week 4TH WeekMean ± SD SEM Mean ± SD SEM

Experimental 26.53 ± 1.35 0.35 5.73±2.64 0.68Control 26.46 ± 1.66 0.43 21.73±1.69 0.44

ODI:Oswestrydisabilityindex

Oswestry disability index (ODI): TherewasanimprovementintotalODI(OswestryDisabilityIndex)scoreinboththegroupsafter8weeks(StationaryCyclingtrainingtoexperimentalgroupandconventional treatmenttocontrolgroup).But,theextentofimprovementincontrolgroupwaslessascomparedtoexperimentalgroup.(ReferTable–1)Therewasamaineffectfortime(F=996.916,df=1p=0.000).Therewasamaineffectalsoforgroup(F=394.725,df=1,p=0.000).Themaineffectalsoqualifiedtointeractionoftime×group(F=952.017,df=1,p=0.000).

Table 2: ANOVA Table for ODI: Test of between subject & within subject effect

BetweenSubjectEffect

Source Sum of sq Df Mean Square F SignificanceGroup 952.017 1 952.017 4.573 .00Error 148.667 28 5.310 179.304

WithinSubjectEfffect

Time 2444.817 1 2444.817 996.916 .00Time x Group 968.017 1 968.017 394.725 .00

Error 68.667 28 2.452


PostHocanalysisrevealedstatisticallysignificantdifferenceandimprovementinpostinterventionODIscoresofboth thegroupsafter8weeks.However, improvementofexperimentalgroupwassignificantlymore than thecontrolgroup.(ReferTable–2)

Table 3: RAND (Physical functioning) Mann Whitney Test for RAND(Physical functioning)

RanksGroup N Mean Rank Sum of Ranks

1 15 23.00 345.002 15 8.00 120.00

Total 30Mann Whitney U Wilcoxon W Z score Significance

0.00 120 -4.706 . 00

Table 4: RAND (Energy/Fatigue)Mann Whitney Test for RAND (Energy/Fatigue)

RanksGroups N Mean Rank Sum of Ranks

1 15 23.00 345.002 15 8.00 120.00

Total 30

Mann Whitney U Wilcoxon W Z score Significance0.00 120 -4.715 0.00

Quality of life: RAND-36 (Physical functioning & Energy and Fatigue): There was improvement in both the experimental (Stationary cycling & conventionaltreatment)&control(conventionaltreatment)groupsafter8weeks.Buttheextentofreductioninexperimentalgroupismorethanthecontrolgroup(ReferTable–5&6)

DISCUSSION

RAND (Physical functioning and energy/fatigue) & Oswestry Disability Index (ODI): The results indicate that the intervention given in the study proved to be effective in improvingphysical functioning inpatientswith chronic low back pain.

As supported by studies done by Iversen et al (2003)18,intheirstudytheyalsofoundimprovementingeneralphysicalfunctioning(SF-36)andglobalphysicalfunction after cycling intervention was significantlyassociatedwithbaselineSF-36Physicalfunction.

Maura D iversen et al in their study of endurance and aerobic training to chronic non specific low backpain where stationary bicycle exercise program was

given to patients and found improvements in energy and fatiguelevelsandstatisticallyimprovementintheSF-36score in experimental group.

TheODIwasused toquantifydisability inCLBPpatients in both the groups and it was found that there was statistically significant reduction in disability inbothexperimentalgroup(i.e.76.10%)aswellascontrolgroup (i.e. 52.10%). However the extent of disabilityreductioninexperimentalgroupwassignificantlymorethan the control group at the end of 8 weeks.

To the experimental group stationary bicycle exercise program was given in addition to the conventional treatmentandtheadditionaleffectseenmaybeattributedtothesignificantimprovementindisability.

Theauthorhavenoconflictsofinterestrelevanttothe article.

CONCLUSION

The study demonstrates that conventional low back pain treatment combined with aerobic exercise program is superior to conventional low back pain treatment alone


inimprovingfunctionalperformanceandqualityoflifeas well as reducing the extent of disability in patients with chronic low back pain.

Source of Funding: There is self funding in the research project.

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1.Bogduk N. Management of chronic low backpain. Medical journal of Australia. 2004 Jan19;180(2):79.

2.SpitzerWO.Scientificapproachtotheassessmentand management of activity-related spinaldisorders: a monograph for clinicians. Spine. 1987;(12):1-59.

3.ManchikantiL.Epidemiologyof lowbackpain.Painphysician.2000Apr;3(2):167-92.

4.PetrofskyJS,BattJ,BrownJ,BS’LonnaStaceyBS, Bartelink T, Le Moine M, Charbonnet M,Lohman EB, Aiyar S, BE’Ashley ChristensenBS.Improvingtheoutcomesafterbackinjurybyacoremusclestrengtheningprogram..2008Mar1;(41):13-6.

5.Andersson GB. Epidemiological features ofchronic low-back pain. The lancet. 1999 Aug14;354(9178):581-5.

6.Cassidy JD, Côté P, Carroll LJ, Kristman V.Incidenceandcourseof lowbackpainepisodesin the general population. Spine. 2005 Dec 15;30(24):2817-23.

7.AbenhaimL,RossignolM,Valat JP,NordinM,Avouac B, Blotman F, Charlot J, Dreiser RL,LegrandE,RozenbergS,VautraversP.The roleof activity in the therapeutic management of back pain:ReportoftheInternationalParisTaskForceonBackPain.Spine.2000Feb15;25(4S):1S-33S.

8.JetteDU,JetteAM.Physical therapyandhealthoutcomes in patients with spinal impairments. PhysicalTherapy.1996Sep1;76(9):930-41.

9.Smeets RJ,Wade D, HiddingA, Van LeeuwenPJ,VlaeyenJW,KnottnerusJA.Theassociationof physical deconditioning and chronic low back pain: a hypothesis-oriented systematicreview. Disability and rehabilitation. 2006 Jan1;28(11):673-93.

10.MarshallPW,KennedyS,BrooksC,LonsdaleC.Pilates exercise or stationary cycling for chronic nonspecific low back pain: does it matter? arandomizedcontrolledtrialwith6-monthfollow-up.Spine.2013Jul1;38(15):E952-9.

11.HicksonRC.Interferenceofstrengthdevelopmentby simultaneously training for strength and endurance. European journal of applied physiology and occupational physiology. 1980 Dec1;45(2-3):255-63.

12.PuaYH,CaiCC,LimKC.Treadmillwalkingwithbody weight support is no more effective thancycling when added to an exercise program for lumbar spinal stenosis: a randomised controlled trial. Australian journal of physiotherapy. 2007Jan1;53(2):83-9.

13.vanderVeldeG,MierauD.Theeffectofexerciseonpercentilerankaerobiccapacity,pain,andself-rateddisabilityinpatientswithchroniclow-backpain: a retrospective chart review. Archives of PhysicalMedicineandRehabilitation.2000Nov1;81(11):1457-63.

14.SealsDR,Hagberg JM,HurleyBF,EhsaniAA,Holloszy JO. Endurance training in older menand women. I. Cardiovascular responses toexercise.Journalofappliedphysiology.1984Oct1;57(4):1024-9.

15.IzquierdoM,HäkkinenK,IbanezJ,KraemerWJ,Gorostiaga EM. Effects of combined resistanceand cardiovascular training on strength, power,muscle cross-sectional area, and endurancemarkersinmiddle-agedmen.Europeanjournalofappliedphysiology.2005May1;94(1-2):70-5.

16.WobySR,WatsonPJ,RoachNK,UrmstonM.Arechangesinfear‐avoidancebeliefs,catastrophizing,andappraisalsofcontrol,predictiveofchangesinchronic lowbackpainanddisability?.EuropeanJournalofPain.2004Jun1;8(3):201-10.

17.SchmidtA.Cognitivefactorsintheperformancelevel of chronic low back pain patients. JPsychosomRes1985;29:183–9.

18.Iversen MD, Fossel AH, Katz JN. Enhancingfunction in older adults with chronic low back pain: a pilot study of endurance training1. Archives of physical medicine and rehabilitation. 2003Sep1;84(9):1324-31.


19.AiraksinenO,BroxJI,CedraschiC,HildebrandtJ, Klaber-Moffett J, Kovacs F, Mannion AF,Reis S, Staal JB,UrsinH, ZanoliG.Chapter 4European guidelines for the management of chronic nonspecific low back pain. Europeanspinejournal.2006Mar11;15:s192-300.

20.VanMiddelkoopM,RubinsteinSM,KuijpersT,Verhagen AP, Ostelo R, Koes BW, van TulderMW. A systematic review on the effectiveness

of physical and rehabilitation interventions for chronic non-specific low back pain. EuropeanSpineJournal.2011Jan1;20(1):19-39.

21.Unsgaard-Tøndel M, Fladmark AM, SalvesenØ, Vasseljen O. Motor control exercises, slingexercises,andgeneralexercisesforpatientswithchronic low back pain: a randomized controlled trial with 1-year follow-up. Physical therapy.2010Oct1;90(10):1426-40.

Effect of Vestibular Rehabilitation on Cognition and Eye Hand Coordination in Elderly

Rajneet Kaur Sahni1, Harpreet Singh2, Gurpreet Kaur3

1Associate Professor, 2MPT (Neurology), 3MPT 2nd Year (Neurology), All Saints Institute of Medical Sciences and Research

ABSTRACT

Introduction: People’s lives are growing longer and in elderly people there is need to develop andimplement effective exercise program to help alleviate some of the problems associated with aging.VestibularRehabilitation refers to interventionssuchasadaptationexercise, repositioning techniqueandexercise. Cognitive decline is among the most feared aspect of growing old. There is now growing line of research showing that the vestibular system which is intrinsically highly convergent with other sensory and motor signals interacts with various cognitive processes.

Objectives: The main objective of this study is to evaluate the effect of Vestibular Rehabilitation onCognition and Eye Hand Coordination in Elderly.

Method: BasedontheInclusionandExclusioncriteria60subjectswillbeenrolledforthestudybyrandomsampling.Thesubjectswillbedividedinto2groupsAandBof30each.GroupAwillbegivenconventionaltreatmentofflexibilityandstrengtheningexercises.GroupBwillbegivenconventional treatmentalongwithitVestibularRehabilitationexercisesprotocolwillbeaddedwhichincludeCawthorneandCookseyexercises for head movements. The exercise protocol will be given for twice a week for 12 weeks. Pre andPosttestevaluationwillbedoneforCognitionusingMiniMentalStateExaminationandEyeHandCoordination will be assessed by measuring reaction time using Ruler Drop test.

Statistical Analysis:DescriptiveStatistics,Paired’t’andUnpaired’t’test.

Keywords: Vestibular Rehabilitation; Cognition; Eye Hand Coordination

INTRODUCTION

According to Patel et al.1,people’slivesaregrowinglongerandelderlypeopleconstituteanever-increasingshare of the population, there is a growing need todevelop and implement effective exercise programsto help alleviate some of the problems associated with aging. Aging brings about a lowered integrity of many physiologicalsystems,leadingtomobilityandstabilityproblems.

As Schubert et al.2 mentioned, VestibularRehabilitation (VR) refers to interventions such asadaptation exercises, repositioning techniques, andexercises to improve muscle force, gait, or balance.There is effect of aVestibular Rehabilitation exerciseprogramonbalance, strength, speedandagility,upperlimb coordination in elderly population. Hansson3 stated,VR as a therapeutic tool used in patients with

body balance disorders of vestibular origin. The proposedactionofVRisbasedoncentralmechanismsofneuroplasticity,knownasadaptation,habituationandsubstitution,aimingavestibularcompensation.Asstatedby Ricci et al.4,theaimofVRexercisesistoimprovethevestibule-visual interaction during cephalicmovementand to increase static and dynamic postural stability in conditionsthatproduceconflictingsensoryinformation.

As mentioned by Bekkering et al.5, Eye HandCoordination and Cognition are essential for humans and there is age related decline in both of them. Eye HandCoordinationreferstotheintegrateduseofvision,arms, hands and fingers to accomplish goal-directedhand movements. As discussed by Hedden et al.6,thereislittleage-associateddeclineinsomementalfunctionssuch as verbal ability, some numerical abilities andgeneral knowledge but other mental capabilities decline frommiddleageonwards,orevenearlier.

DOI Number: 10.5958/0973-5674.2019.00065.0


As stated by Spirduso et al.7,EyeHandCoordinationinvolves sensory input from the tactile kinesthetic and proprioceptive systems as well as vision, as theyprovide the initial information needed for formulating motor plans and regulating the initiation and execution ofmovements.Afteramovementisinitiated,feedbackfrom the sensory and motor systems will modify other movements such as postural control that are to be incorporated into the Eye-Hand Coordination activity.As discussed by Carrey8,goal-directedarmmovementssuch as reaching or pointing to a visual target are typically accompanied by saccadic eye movements. Several studies have examined the relative timing of eye and hand movements as a way of assessing the potential coupling of the oculomotor and limb motor systems. According toBrayne9,Cognitivedecline is among themostfearedaspectsofgrowingold.It isalsothemostcostly, in terms of the financial, personal and societalburdens. It is important, because Cognitive declineheraldsdementia,illnessanddeath.

There is now an exciting and rapidly growing line of research showing that the vestibular system-whichis intrinsically highly convergent with other sensory and motor signals inter acts with various Cognitive processes suchas spatialnavigation, spaceperception,bodyrepresentation,mentalimagery,attention,memory,risk perception and even social cognition as mentioned by Palla et al.10

MATERIAL AND METHOD

Study Design: This study is of Experimental Design

Sampling Technique: The subjects will be selected by RandomSamplingtechnique

Source of Data: Subjects will be taken from in and around ludhiana and rupnagar.

Eligibility

Inclusion Criteria

z Subjectswithagegroupof60-75years

z Subject who are independent according to FunctionalIndependenceMeasure(FIM)

z Abletocommunicate&followinstructions

Exclusion Criteria

z Who are regular players of sports involvingsignificantamountofEyeHandCoordination.e.g.-golf,tennis,badminton,etc

z Those with severe visual problems or any eye pathology.eg-glaucoma,cataract.

z Upper limb problem & lack enough functionalrange of arm movement.

z Lowerlimbproblemandlackofenoughfunctionalrange of movement.

z Whohavemedicalcontraindication?

z Thosewhohaveneurological&movementrelateddisorders.

z Pathological cognitive decline.

PROCEDURE

z Based on the Inclusion andExclusion criteria 60Elderly subjects will be enrolled for the study by random sampling. Informed consent will beobtained from all the subjects. The subjects will be dividedinto2groupsAandBof30each.

z Pretest evaluation will be done for Cognition using MiniMentalStateExamination(MMSE)andEyeHand Coordination will be assessed by measuring Reaction time using Ruler Drop Test.

Group A including 30 subjects will be given conventional treatment offlexibility and strengtheningexercises. Protocol will be of 2 sessions per week for 12 weeks.. Traditional training exercises are performed in high body positions. These exercises included, forinstance:Performing a squat, and then returning to astandingposition,combinedwithvariousmovementsofthe upper limbs

Group B will be given conventional treatment offlexibility and strengthening exercises and VestibularExercises protocol will be given as prescribed by Cawthorne and Cooksey. Protocol will be of 2 sessions per week for 12 weeks.

z Post test evaluation will be done for Cognition using MMSEandEyeHandCoordinationwillbeassessedby measuring Reaction Time using Ruler Drop test. Thedatawillbecollected,compiled&analyzed.

FINDINGS

Shows comparison of Pre intervention values of Coding test between group A and B as well ascomparison of Post intervention values of Coding test


betweengroupAandB.WherePre-interventionMean±SDofCodingtestofGroupAwas3.55±1.317andthatofGroupBwas3.10±1.317.TheunpairedTtestvalueforpreinterventionforGroupAandGroupBwas1.208,whichwasstatisticallynonsignificant,atp>0.05.

Post-intervention Mean ± SD of Coding test ofGroupAwas4.05±1.317andthatofGroupBwas5.05±1.701..TheunpairedTtestvalueforpostinterventionfor Group A and Group B was 2.079, which wasstatisticallysignificant,atp<0.05.

Comparison of Pre intervention values and Post intervention values of Colour name test between group AandB.WherePre-interventionMean±SDofColourname test of Group A was 80.35 ± 22.368 and that of GroupBwas82.65±20.121.TheunpairedTTestvalueforpreinterventionforGroupAandGroupBwas0.342,whichwasstatisticallynon-significant,atP>0.05.

Post-interventionMean±SDofColourname testofGroupAwas 72.95 ± 15.073 and that ofGroupBwas65.95±17.231.TheunpairedTTestvalueforpostinterventionsforGroupAandGroupBwas1.367,whichwasstatisticallynon-significant,atP>0.05.

Comparison of Pre intervention values and Post intervention values of Colour patches test between group AandB.WherePre-interventionMean±SDofColourpatches test of Group A was 201.25 ± 48.363 and that ofGroupBwas206.50±44.704.TheUnpairedTTestvalueforpreinterventionforGroupAandGroupBwas0.356,whichwasstatisticallynonsignificant,atP>0.05.

Post-interventionMean±SDofColourpatchestestofGroupAwas188.70±44.426and thatofGroupBwas167.25±44.377.TheunpairedTTestvalueforpostinterventionforGroupAandGroupBwas1.528,whichwasstatisticallynonsignificant,atP>0.05.

Comparison of Pre intervention values and Post interventionvaluesofColournamewithdiffcolourtestbetweengroupAandB.WherePre-interventionMean±SDofColournamewithdiffcolourtestofGroupAwas230.85±42.812andthatofGroupBwas240.40±51.691. The unpaired T Test value for pre intervention for GroupAandGroupBwas0.636,whichwasstatisticallynonsignificant,atP>0.05.

Post-interventionMean±SDofColournamewithdiffcolourtestofGroupAwas217.65±37.785andthat

ofGroupBwas193.60±43.364.TheunpairedTTestvalue forpost interventions forGroupAandGroupBwas 1.870, which was statistically non significant, atP>0.05.

comparison of Pre intervention values and Post intervention values of Reaction time between group A andB.WherePre-interventionMean±SDofReactiontime of Group A was 2.05 ± 0.431 and that of Group Bwas2.16±0.399.TheunpairedTTestvalueforpreinterventionforGroupAandGroupBwas0.830,whichwasstatisticallynonsignificant,atP>0.05.

Post-interventionMean ± SD ofReaction time ofGroupAwas1.98±0.410andthatofGroupBwas1.74±0.379.TheunpairedTTestvalueforpostinterventionfor Group A and Group B was 1.929, which wasstatisticallynonsignificant,atP>0.05.

DISCUSSION

The reason behind the improvement by vestibular stimulation is the mechanics and physiology of vestibular system. The experiment described in this paper involves a simple exercise program that actuates the vestibular organ by means of movements of the head and body in allplanes.Thissetofexercisedoesnotrequirealotofenergyortime;instead,itfocusesonrelaxingtechniquesthat also stimulate cognitive function. As discussed by Horowitz et al.11,onanlowerlevelthemedialvestibularnucleus located in the medulla oblongatta is connected tothedifferentbrainareasassociatedwithnociception,sleep,arousalandhemostasisandeyemovements.Onasmallerscale,vestibularstimulationinfluences neuro‐trasmitter release. As found in a study by Samoudi et al.12,galvanicvestibularstimulationincreasesGABAreleaseinratsandthusthealterationofspecificneurotransmitterssuchasdopamine,serotoninandGABAarecrucialforunderstandingtheinfluenceofvestibularstimulationoncognition. According to Archana13,Vestibularstimulationmodulates spatial processing and place cell firing andfacilitates long term potentiation in the hippocampus by increasing acetylcholine release in hippocampus. Furthermore, thevestibularsystemishavingextensiveconnections with hippocampus, raphe nucleus, locuscoeruleus, thalamus,amygdale, insularcortex,anteriorcingulatecortex,cerebellum,occipitalcortex,putamen,parietal lobe,andotherareasof thebrainwhichplaysakeyroleincognitiveprocess.InastudybyGiocomoet al14,evidencewasfoundthatactivationofvestibular


system can modulate memory. The cognitive effectsof vestibular loss was found to be due to mainly the important contribution that the vestibular system makes toneurons involvedinspatialnavigationandmemory,such as head direction cells and place cells. In theirstudiesBalabanetal.15 showed that parabrachial nucleus and the hippocampus are the two anatomical regions that provide links between the vestibular system and neural networks involved in Cognitive and emotional processing. Colcombe et al.16 concluded in their study that physical exercise improves cognition in cognitively normal older adults andOkankwoo at al17also shown that physical exercise reduces age related hippocampal atrophy and general brain tissue loss and interacts withgenetic risk factor forAD.Thepotential benefitsof physical exercise on cognitive function have been supported by study done by Dik et al.18&studyshowingthat physically active subjects during adulthood have a decreased risk of cognitive impairment during later life done by Colcombe et al.19

Gurvich et al.20 discussed about the cortical connections to the vestibular system. The anterior cingulatecortex(ACC)hasbeenconsideredpartofthevestibularcortex,henceitmayprovideabridgebetweenthevestibularsensorimotorareasandtheaffectdivisionsof the prefrontal regions that entail motivational states. The prefrontal cortex regions indirectly by way of motor associationcorticesandanteriorcingulatecortex,exertregulatoryinfluenceoverthevestibularsensoryareasforattenuationofsensorystimulation.Theparietalcortex,particular the parietal opercular area has been implicated as a core cortical region for vestibular processing.

The reason behind effect of vestibular stimulationon cognition is thus the connections of vestibular system withthecorticalareas.Itisknownthatthefunctionofparietaloperculumismathematicalthinking,visuospatialcognitionandimageryofmovement.Similarly,Anteriorcingulate cortex has connections both to ‘emotional’limbicsystemand‘cognitive’prefrontalcortex.ACCisalsoinvolvedindecisionmaking.InastudybyEpsteinand Kanwisher22, the role of hippocampus in spatialmemory has been well documented.

Most importantly, patients with chronic bilateralvestibular deficits demonstrate bilateral hippocampalatrophyandspatialmemoryimpairement,asmentionedbyBrandtetal.23.

CONCLUSION

The present study concludes that 12 weeks of vestibular stimulation with conventional treatment which includes Flexibility & Strengthening exerciseshad statistically significant effect on improvingCognition and Eye Hand Coordination in elderly. However,VestibularRehabilitationprovedtobeaboonin case of improving Cognition where the result was significant.IncaseofEyeHandCoordination,theresultshowednosignificantdifferencewhenbothgroupswerecompared but when evaluated within the groups it was found to be significant. So, on the basis of this studythat in order to delay the problems of cognitive decline and functional disability, easy to perform exercisesspecificallytargetingthevestibularsystemshouldbeapartofalleffortstoimprovefitnessinolderpeople,andmoreover,thatitwillbeeasiertomotivateolderpeopletoengageinsuchspecificallytargetedexercisethanintraditional programs of general physical exercise.

ThedatawasanalysedthroughUnpaired‘t’testforcomparison between the vestibular rehabilitation group andconventionalgroupwhichgave‘t’valueforcodingtestas2.079,whichwasstatisticallysignificant,‘t’valuefor Picture word Learning test as 4.627, which wasstatistically significant. Coding Test and Picture wordLearningTest thus showedsignificant improvement investibular rehabilitation group for Cognition and Stroop test was having values which were statistically non significant.IncaseofEyeHandCoordination,‘t’valuefor Reaction Time as 1.929 which was statistically non significant.



Ethical Clearance: Ethical clearance has been taken from All Saints Institute of Medical Sciences andResearch,Ludhiana,Punjab

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4.RicciNA, Aratani MC, Dona F, Caovilla HH,GanancaFF.Asystematicreviewabouttheeffectsofthevestibularrehabilitationinmiddle-ageandolderadults.BrazilianJournalofPhysicaltherapy.2010;14(5):361-71.

5.BekkeringH,SailerU.Commentary:Coordinationof eye and hand in time and space. Progress in BrainResearch.2002;140:365-373.

6.HeddenT,GabrieliJDE.Insightsintotheageingmind: a view from cognitive neuro science. Nature ReviewsNeuroscience.2004;5:87-96.

7.SpirdusoWW, FrancisKL,MacRae PG.Motorcoordination and control in: Physical Dimensions ofAging.2nded.Champaign:HumanKinetics;2005.

8. Carrey DP. Eye Hand Coordination: eye to hand orhand to eye?CurrentBiology. 2000; 10:416-419.

9.BrayneC.Theelephantintheroom:healthybrainsin later life, epidemiology and public health.NatureReviewsNeuroscience.2007;8:233-239.

10.Palla A, Lenggenhager B. Ways to investigatevestibular contributions to cognitive processes. Frontiersinintegrativeneuroscience.2014:8(40).

11.Horowitz SS, Blanchard J, Morin LP. Medial vestibular connections with the hypocretin system. Journal of Comparitive Neurology. 2005;487:127–146.

12.SamoudiG,NissbrandtH,DutiaMB,BergquistF.NoisyGalvanicVestibularStimulationPromotesGABA Release in the Substantia Nigra andImprovesLocomotioninHemiparkinsonian Rats. PLoSONE.2012;7(1):1-10.

13.Archana R, Sailesh KS, Abraham J, et al.Prevention/delay of Alzheimer’s Disease by

VestibularStimulation:AHypothesis.JournalofMedicalSciencesandHealth.2016;2(3):30-33.

14.Giocomo LM, Moser MB, Moser EI.ComputationalModelsofGridCells.Neuron71.2011:589-603.

15.Balaban CD. Projections from the parabrachialnucleus to the vestibular nuclei: potential substrates forautonomicandlimbicinfluencesonvestibularresponses.BrainResearch.2004;996:126-137.

16.ColcombeSJ,KramerAF.Fitnesseffectson thecognitivefunctionofolderadults:ameta-analyticstudy.PsychologyScience.2003;14(2):125-130.

17.Okonkwo OC, Schultz SA, Oh JM. Physicalactivity attenuates age related biomarker alterations in preclinical AD. Neurology. 2014;83(19):1753-1760.

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20.Balaban CD. Projections from the parabrachialnucleus to the vestibular nuclei: potential substrates forautonomicandlimbicinfluencesonvestibularresponses.BrainResearch.2004;996:126-137.

21.GurvichC,MallerJJ,LithgowB,HaghgooieS,KulkarniJ.Vestibularinsightsintocognitionandpsychiatry.BrainResearch.2013;1537:244-259.

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23.Brandt T, Strupp M, Dieterich M. Towardsa concept of disorders of “higher vestibular function”.Frontiers in IntegrativeNeuroscience.2014;8(47):1-8.

Age and Gender Related Differences in Push Up Test in Athletes of Belagavi–A Cross Sectional Study

Basavaraj Motimath1, Sadhvi Koyande2, Dhaval Chivate3

1Associate Professor, Head of Department, 2Post Graduate Student, Sports Physiotherapy, 3Lecturer, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

ABSTRACT

Background: Endurance training is a type of exercise which helps to determine the physical capabilities of anathletetoperformanykindofsport.Standardpush-uptestisthemostwidelyusedandeasytoperform,minimumequipmentrequired,inexpensiveandcanbeperformedinagroupofathletesatatime.Henceitiswidelyusedtoknowthefitnesslevelandenduranceinathletes.

Aim/Objectives:Toknowtheendurancerelatedtoperformanceintheagegroupsof18-29yearsforPushUptest inathleticpopulationofBelagavi.ToknowthegenderbaseddifferencesduringPushUptest inathleticpopulationofBelagavi.

Method:Bothmaleandfemaleathletesbetweentheagegroups18-29yearsfromvarioussportsinstitutionsofBelagavi,Karnatakawererecruitedinthestudy.A5minutewarmupsessionwasperformedbeforetheactualtest.Theathletehadtocompleteasmanypush-upsaspossiblein1minuteandthemaximumnumberofpush-upswererecorded.

Results:Thecomparisonbetweenmalesandfemalesforthebaselinedatawasdonebyt-testwiththelevelofsignificanceatp<0.05.Mostmaleathletesperformedpush-upsbetween40-50seconds.

Conclusion:Thisstudyconcludedthatthevaluesofpush-uptestrangedbetween10.00-102.00forbothgenders and male athletes showed better performance than female athletes.

Keywords: Muscular endurance, push-up test, athletes, fitness.

Corresponding Author:SadhviKoyandePostGraduateStudent,SportsPhysiotherapy,KAHERInstituteofPhysiotherapy,Belagavi,Karnataka,IndiaPhone:08088979260/09158616810Email: [email protected]

INTRODUCTION

Physicalfitnessisasetofattributesthatpeoplehaveor achieve that relates to the ability to perform physical activity.1 Hence,beingphysicallyfitmeans“theabilitytocarryoutdailytaskswithvigorandalertness,withoutundue fatigueandwithampleenergy toenjoy leisure-timepursuits and tomeet unforeseen emergencies”. Itincludescomponentslikemuscularstrength,flexibility,cardiovascular endurance, muscular endurance and

bodycomposition,andanathletemustpossessallthesecomponents tobephysicallyfit.2 Oneof the importantcomponentsofanathlete’sphysicalfitnessisenduranceand it is defined as the ability to voluntarily produceforceortorquerepeatedlyagainstsubmaximalexternalresistances,ortosustainarequiredlevelofsubmaximalforce in a specific posture for as long as possible3. Ithelps supply oxygen to the mitochondria from the atmospheric air which helps in the metabolism inside the muscle cells. This further helps improve the muscular endurance while performing any activity4.

Endurance tests are done to determine the physical capabilities of an athlete to perform any kind of sport.6 Push-up test is a method to determine the muscularendurance of an athlete, mostly in those who playsports involving the upper body and the core. Push up test can be executed in various ways according to the handplacements,thedipofthepushup,durationofthe

DOI Number: 10.5958/0973-5674.2019.00066.2


test.7The primary muscles activated during a standard push-up are triceps brachii, upper trapezius, anteriordeltoid,pectoralis,rectusabdominis.8 To make it easier forchildrenandfemales,ModifiedPushuptestisdoneas the upper body strength is weaker in this population. This test is easy to learn, quick to perform,minimumequipmentareused,inexpensiveandcanbedoneonagroup of athletes at a time. Hence Push up test is widely usedtoknowthefitnesslevelandenduranceinathletes.7

This study will determine the age and gender differencesintheathletesduringthePushuptest.Theresults of which will provide us with better understanding offitnessleveloftheathletesinBelagaviinrespecttotheir muscular endurance. This further will give us the normalvalueforPushuptestintheathletesofBelagavi.Tothebestofknowledge,therearenostudiesdoneinathleticpopulationofBelagavitomeasurethecommonvalue of push up test to assess endurance. Hence the present study aims to evaluate the common data for push up test in athletic population inBelagavi between theagegroupof18-29years.


EthicalclearancewasobtainedfromtheInstitutionalEthicalCommitteeofKAHERInstituteofPhysiotherapy,Belagavi.Awritteninformedconsentwasobtainedfromall the participants before the commencement of the study.Bothmale and female athletes between the agegroupof18-29yearfromvarioussportsinstitutionsandclubsinBelagavi,Karnatakawereincluded.Thestudyincluded 103 athletes out of which 84 were males and 19 were females.

Inclusion Criteria Exclusion Criteria

Athletes of various sports disciplinesAge18-29years

Subjects willing to participate

AnyneurologicaldeficitsAny surgery to the upper or lower limb in past 6 monthsHistoryoftraumatoshoulder,

anklePainintheshoulder,elbow,

wrist or ankleAthletes with mental issues

Intervention: Brief demographic data was obtainedfromtheathletesthatincludedtheirname,age,gender,height,weight,BMI,sportshistory.

A warm up session of 5 minutes was given to the athletes before performing the test. After which the test was performed. The push up test position begins in prone position on the mat with the hands and the toes in contact withthefloor.Thebodyisheldupstraight,paralleltothefloorwhilethefeetareslightlyapart.Thearmsarekeptatshoulder width apart. The elbows are extended. Holding thesameposition,theathletehastolowerdownhisbodyuntilhiselbowsmakeanangleof90°andthenreturntothe starting position. The athlete has to complete as many push-ups as possible in one minute and the maximumnumberofpush-upsare recorded. If the athletedidnotlowerhisbody,thepushupwasnotcounted.7


The data was analyzed by SPSS version 21. The comparison between males and females for the baseline data was done by t-test with the level of significanceat p< 0.05.The correlation between number of push-upswith timewas done byKarl Pearson’s correlationcoefficientmethodwith the levelof significancesetatp<0.05.

RESULTS

Table no. 1 presents the baseline variables like age,height,weightandBMIforalltheathletes.Thesevariableswereanalyzedbythet-test.Thepushuptestwasadministered on 84 males and 19 females and the scores were used to develop normative values for the same. The mean ages of men and women were 20.83 and 20.53 respectively.Theresultsshowedstatisticalsignificancein height and weight in both males and females with the p<0.05TherewasnostatisticalsignificancewithrespecttotheageandBMIinmalesandfemales.

Table1: Comparison between male and female with mean age and BMI by t test

Variable Gender Mean SD SE t-value p-value

AgeMale 20.83 2.34 0.26

0.5451 0.5869Female 20.53 1.54 0.35

HeightMale 1.71 0.07 0.01

6.3264 0.0001*Female 1.60 0.06 0.01


Conted…

WeightMale 64.37 10.29 1.12

4.6715 0.0001*Female 52.63 7.76 1.78

BMIMale 21.76 2.98 0.32

1.4778 0.1426Female 20.63 3.06 0.70

*p<0.05

Table 2: Correlation between No. of PUSH Ups with time (sec) taken in males and females by Karl Pearson’s correlation coefficient method

VariablesCorrelation between No. of PUSH Ups with

Males Femalesr-value t-value p-value r-value t-value p-value

Time(sec)taken 0.6617 7.9919 0.0001* 0.6525 3.5505 0.0025*P<0.05

Tableno.2showsapositivecorrelationbetweenthenumberofpush-upsandthetime(sec)takentocompletemaximumnumberofpush-upsbybothmaleandfemaleathletes.

Table 3: Normality of No. of PUSH Ups in the study by gender

Best timeTotal Male Female

Range No Range No Range NoPoor 10.00-21.87 12 10.00-22.81 13 14.00-17.44 2Good 21.87-59.93 57 22.82-60.31 58 17.45-58.43 13

Excellent 59.94-102.00 34 60.32-102.00 13 58.44-83.00 4Total 10.00-102.00 103 10.00-102.00 84 14.00-83.00 19Mean 40.90 41.57 37.95SD 19.03 18.75 20.50

Note:Excellent:<mean-SD,Good:Betweenmean-SDto<mean+SDandPoor:>mean+SD

Accordingtotableno.3,theresultsofthepush-uptesthavebeencategorizedintopoor,goodandexcellentaccording to the number of push-ups performed bymales and females. For males, number of push-upsbetween 10.00- 22.81 and for females, range between14.00-17.00fellinthepoorcategory.Push-upsrangingfrom22.82-60.31formalesand17.45-58.43forfemalesfell into good category. Males performing push-upsbetween60.32to102.00andfemalesperformingpush-ups between 58.44 to 83.00 fell under excellent category.

DISCUSSION

The primary objective of this study was to determine the age and gender differences for push uptest in athletes. This would give the baseline data for the pushuptestinIndianathleticpopulation.AccordingtoastudydonebyBaumgartenetal,thepushuptestscores

explains the strength of an athlete’s arm and shouldergirdlemuscles,aswellastheendurancetomoveabodyweight.9Inthepresentstudy,only34athletesoutof103couldsustaintilltheendofoneminute.Whenanathleteperformsmaximumnumberofpush-ups,thefatiguesetiniscausedmaybeduetoinsufficientanaerobiccapacityratherthanmuscularstrength-endurance.10

Ludwigetal(2004)proposedthatthereismaximalactivation of serratus anterior muscle while performing apush-up.Whilethepush-upisperformed,alowuppertrapezius to serratus anterior ratio is seen. This indicates that serratus anterior muscle is highly activated while uppertrapeziusisminimallyactivatedinproportion.Inthepresentstudy,notmanyathletescouldperformpush-ups till the end of one minute.11 The possible reason might be not enough muscular endurance in the primary musclesthatworkduringastandardpush-up.


AstudyconductedbyDeanetal,includedfemaleswhocouldatleastcomplete10standardpush-upssincefemales have lesser strength abilities as compared to men. Inthepresentstudy,19femaleathletesparticipatedandtheminimumnumberofpush-upstheycouldcompletewas 14 whereas maximum push-ups were 83.12 A 4 weekwhole-body,shortduration,highintensityintervaltraining which was initially designed to improve aerobic fitness,alsoresultedinincreaseinmuscularendurancebyexhibiting135%higherperformancein60secpush-ups in females.13

Out of the total number of participants, 34participantsfellintheexcellentcategory,57participantsfell into good category and 12 participants fell into poor categoryfornumberofpush-upsinoneminute.

CONCLUSION

Based on the clinical observations and analysispresented,thisstudyconcludedthatthevaluesofpush-up test rangedbetween10.00-102.00 forbothgendersand, male athletes showed better performance thanfemale athletes.

Limitations & scope: The major limitation of the study was a less sample size. The study would have given better results for a normative data if the sample size would be larger. Another limitation was that the male andfemaleratiowasnotequal.

Practical applications: The results of the present study canbeusedasareferenceforpush-uptestaswellasforfitness evaluation.Hence anupperbody strengtheningprogram should be included in all training programs irrespective of the type of sport.



REFERENCES 1.BaranowskiT,BouchardC,Bar-OrOD,Bricker

T, Heath G, Kimm SY, Malina R, ObarzanekE, Pate R, StrongWB, Truman B.Assessment,prevalence, and cardiovascular benefits ofphysical activity and fitness in youth. Med SciSportsExerc.1992Jun1;24(6):S237-47.

2.Caspersen CJ, Powell KE, Christenson GM.Physical activity, exercise, and physicalfitness: definitions and distinctions for health-related research. Public health reports. 1985 Mar;100(2):126.

3.MoirGL.Muscularendurance.NationalStrengthandConditioningAssociation:NSCA’sguidetotestsandassessments,HumanKinetics.2012:193-217.

4.Jones AM, Carter H. The effect of endurancetrainingonparametersof aerobicfitness.Sportsmedicine.2000Jun1;29(6):373-86.

5.Hickson RC, Dvorak BA, Gorostiaga EM,Kurowski TT, Foster C. Potential for strengthand endurance training to amplify endurance performance.Journalofappliedphysiology.1988Nov1;65(5):2285-90.

6.Bangsbo J, Lindquist F. Comparison of variousexercise tests with endurance performance during soccerinprofessionalplayers.InternationalJournalofSportsMedicine.1992Feb;13(02):125-32.

7.Push-Up Test/Press Up Test [Internet].Topendsports.com.2018[cited29August2018].Available from: https://www.topendsports.com/testing/tests/push-up.htm

8.Calatayud J,Borreani S,Colado JC,MartínFF,Rogers ME, Behm DG, Andersen LL. Muscleactivation during push-ups with differentsuspension training systems. Journal of sportsscience&medicine.2014Sep;13(3):502.

9.BaumgartnerTA,OhS.,Chung,H.andHalesD.Objectivity, reliability,andvalidity fora revisedpush-up test protocol.Measurement in PhysicalEducation and Exercise Science. 2002 Dec 1;6(4):225-42.

10.LaChancePF,HortobagyiT.InflueceofCandenceon Muscular Performance During Push-up andPull-up Exercise. The Journal of Strength &ConditionngResearch.1994May1;8(2):76-9.

11.Ludewig PM, HoffMS, Osowski EE,MeschkeSA, Rundquist PJ. Relative balance of serratusanterior and upper trapezius muscle activity duringpush-up exercises.TheAmerican journalofsportsmedicine.2004Mar;32(2):484-93.

12.Mayhew JL, Ball TE,Arnold MD, Bowen JC.Push-ups as a measure of upper body strength.TheJournalofStrength&ConditioningResearch.1991Feb1;5(1):16-21.

13.McRaeG,PayneA,ZeltJG,ScribbansTD,JungME,Little JP,GurdBJ.Extremely lowvolume,whole-bodyaerobic–resistancetrainingimprovesaerobicfitnessandmuscularenduranceinfemales.Applied Physiology,Nutrition, andMetabolism.2012Sep20;37(6):1124-31.

Effect of Early Intervention with Spinal Isometric Exercises in Acute Lumbar Intervertabral Disc Prolapse

Shraddha Anandrao Mohite1, Sandeep Babasaheb Shinde2

1Department of Musculoskeletal Sciences, Faculty of Physiotherapy; 2Associate Professor, Department of Musculoskeletal Sciences, Krishna College of Physiotherapy, KIMS “Deemed to be” University, Karad,

Maharashtra, India

ABSTRACT

Background: Generally bed rest is recommended in acute phase of lumbar intervertebral disc prolapse. Deleteriouseffectsofbedrestarereportedinlargenumbersandtheseeffectshavenegativeimpactonspinalfunction after disc lumbar disc prolpse.

Objective: The objective was tocomparetheeffectearlyinterventionwithspinalisometricexercisewithbed rest in acute lumbar intervertebral disc prolapse.

Method: This studywas carried out to determine the effect of early interventionwith spinal isometricexercise in acute lumbar intervertebral disc prolapse. A total of 60 subjects were randomly allocated into 2 groups(GroupAandGroupB).GroupA(Controlgroup)includedonlybedrestGroupB(Interventionalgroup)includedhotmoistpack,Interferentialtherapyandspinalisometricexercise.

Result: Statisticalanalysiswasdonebypairedt-testandunpairedt-test.Duringpreintervention,itshowednosignificantdifferenceforVAS,lumbarrangeofmotion,manualmuscletestingandODI,whileduringpostintervention,itshowedextremelysignificantdifferenceforVAS,lumbarflexors(MMT),ODI,lumbarflexion(ROM)andlumbarextensors(MMT)andlumbarextension(ROM).

Conclusion: Itisconcludedthatearlyinterventionwithspinalisometricexercisehassignificanteffectonpain,improvingspinalmusclestrengthandfunctionalmobilityoflumbarspineinacutelumbarintervertebraldisc prolapse.

Keywords: Prolapse intervertabral disc, Interferential Therapy, Discogenic pain, Spinal dysfunction, spinal isometric exercises.

INTRODUCTION

Prolapsed intervertabral disc is an orthopedic conditionaffectingthespineinwhichatearintheouterfibrousringofanintervertabraldiscallowsthesoft,centralportion to bulge out beyond the damaged outer ring1. The highest prevalence is among people aged 30-50 years,withamaletofemaleratioof2:1.Lumbardiscprolapseisestimated toaccountforapproximately37%ofcasesof low back pain2. Prolapsed intervertabral disc disease and disc herniation are most prominent on in otherwise healthy people in third and fourth decades of life.3,4

There are different types of etiological factorslike age, gender, race, type of transportation, tightmusculature,excessiveheight,sittingforlongduration,

child labor and body mass index.5,6There are various risk factors responsible for low back pain like increase lumbarlordosis,decreaseinabdominalmusclestrengthandreductioninabdominalmuscle length,decrease inbackmuscleendurance,flexibility,lengthofiliosoasandincrease tightness of hamstring muscle.7

Interferential therapyismediumfrequencycurrentproducing low skin impedance and allowing deeper tissue penetration, this being considered effective toimmediately decrease pain. Two medium frequencycurrents passed through the skin to produce a low frequency current where they intersect8,9Non specificlow back pain or mechanical low back pain is termed as thepainwhichisnotduetoanypathologyi.e.fracture,discpathology,tumor,spinalinjuries10

DOI Number: 10.5958/0973-5674.2019.00067.4


Spinal exercises in both the group included front plank, side plank, bridges, superman, quadruped, catandcamelexercises,wallsquat,extensorregime,flexorregime,Spinalextensionexercise, thestrengthandthepower of the spinal extensor muscle is increased leading to decrease in pain and increased stability of the spinal column.11,12

Exercise therapy for pain control has not widely been used clinically. Lumbar rehabilitation exerciseprogram increase erector spine muscle strength and reduce pain and disability. so this study was carried out toassesstheeffectofspinalisometricexercisesinacutelumbarinter-vertebraldiscprolapsed.

Lumbarregionallowsforforwardflexion,extension,lateralflexionandlateralrotation.Flexionandextensionoccursatsaggitalplane.Lumbarflexionandextensionoccurs with combination of lumbar and pelvic motion whichistermedasLumbar-pelvicrhythm.Inthis,thereiscoordinatedmovementoflumbarflexionandanteriortiltingofpelvisinsaggitalplaneduringforwardflexionand posterior tilting of pelvis with lumbar extension. Core,speciallyinvolvesthemusclesmainlyabdominalsin front,Para spinalsonposterior aspect, thoracic andhip muscles. Core muscles involves deep muscles which are Transverses abdominis,Multifidus, Internaloblique and Quadratus lumborum while superficialmuscleswhichRectusabdominis,InternalandExternalOblique,ErectorSpine,Quadratus lumborum, andhipmuscles13,14,15 Core muscles functions in maintaining the stability of spine and reducing stress on spine16

METHOD

This experimental study was carried out in KrishnacollegeofPhysiotherapy,KIMSDeemedtobe

University,KaradafterobtainingtheEthicalpermissionfromInstitutionalEthicalCommittee,KIMSDeemedtobeUniversity,Karad.Thestudyincluded60individualsdiagnosed with acute lumbar inter-vertebral discprolapsed. Subjects were selected as per the inclusion and exclusion criteria. An inclusion criterion was: Subjects between 1.age group 25-40Years2.Durationbetween7days-3weeks3.Bothmale&female4.Patientwilling to participate 5.Confirmation of acute lumbarintervertabral disc prolapsed with MRI investigation.Exclusion criteria was 1. History of spine surgery 2. Historyoffracturedislocation3.Historyofinflammatoryconditions4.HistoryofMalignancy5.HistoryofSpinalInstability. Subjects were briefed about the study andinformed consent was taken from the subjects.

Study participants fulfilling the inclusion criteriawere divided into two groups with random allocation (Group A and B). The duration for the study was 3months. The individuals were assessed before giving the treatment. ForGroupA, the participantswere advisedonly bed rest and NSAIDs prescribed by orthopedicsurgeon; while for Group B, the participants weregivenhotmoistpack, interferential therapyand spinalisometric exercise.Bothgroup subjectswere admittedin hospital for 10 days.

Group A:BedrestandNSAIDsprescribedbyorthopedicsurgeon for 10 days

Group B: Early intervention with spinal isometric exercise(day1to10)

z Hot moist pack

z Spinal isometric exercise

z Interferentialtherapyfor15min

z NSAIDsprescribedbyorthopedicsurgeonfor10dayTable 1: Visual analogue scale (VAS)

Pre-interventionalMean ± SD

Post-interventionalMean ± SD

Paired t-testP value

Group(A) 7.8±0.92 3.23 ± 0.93 <0.0001Group(B) 7.93±0.82 6.9±0.75 <0.0001

Unpaired t-test P value 0.5585 <0.0001

VAS: During pre-intervention, the score was7.8 ±0.92in group A while7.93 ± 0.82in group B. Duringpost-intervention, the score was3.23 ± 0.93 in groupA while6.9 ± 0.75in group B. It showed statisticallyextremelysignificantdifferencewithpvalues<0.0001inboththegroupsbyusingpairedt-testwhereasduring

pre-intervention, the score between both the groupswasstatisticallynotsignificantdifferencewithpvalues0.5585whileduringpost-intervention,thescorebetweenboth the groupswas statistically extremely significantdifferencewithpvalues0.0001usingunpairedt-test.


Table 2: Range of motion (Lumbar flexion)

Groups Pre-interventionMean ± SD

Post-interventionMean ± SD


A 3.80±0.47 4.97±0.44 <0.0001B 3.77±0.509 4.59 ± 0.56 <0.0001

Unpaired t-test P value 0.7950 0.0049

ROM (Lumbar flexion):Duringpre-intervention,thescorewas3.80±0.47ingroupAwhile3.77±0.50ingroupB.Duringpost-intervention,thescorewas4.97±0.44ingroupAwhile4.59±0.56ingroupB.Itshowedstatisticallyextremelysignificantdifferencewithpvalues<0.0001inboththegroupsbyusingwhereasduringpre-intervention,thescorebetweenboththegroupswasstatisticallynotsignificantdifferencewithpvalues0.7950whileduringpostintervention,thescorebetweenboththegroupswasstatisticallypairedt-testverysignificantdifferencewithpvalues0.0049usingunpairedt-test.

Table 3: Range of motion (Lumbar extension)




A 1.073±0.17 1.313 ± 0.11 <0.0001B 1.086 ± 0.13 1.28 ± 0.12 <0.0001


ROM (Lumbar extension):Duringpre-intervention,thescorewas1.07±0.17ingroupAwhile1.08±0.13ingroupB.Duringpost-intervention,thescorewas1.31±0.11ingroupAwhile1.28±0.12ingroupB.Itshowedstatisticallyextremelysignificantdifferencewithpvalues<0.0001inboththegroupsbyusingpairedt-testwhereasduringpre-intervention,thescorebetweenboththegroupswasstatisticallynotsignificantdifferencewithpvalues0.7437whileduringpost-intervention,thescorebetweenboththegroupswasstatisticallynotsignificantdifferencewithpvalues0.3050usingunpairedt-test.

Table 4: Manual muscle testing (Lumbar flexors)



Paired t- testP value

A 2.6 ± 0.49 4.13±0.57 <0.0001B 2.53 ± 0.50 3.16 ± 0.59 <0.0001


MMT (Lumbar flexors):Duringpre-intervention,thescorewas2.6±0.49ingroupAwhile2.53±0.50ingroupB.Duringpost-intervention,thescorewas4.13±0.57ingroupAwhile3.16±0.59ingroupB.Itshowedstatisticallyextremelysignificantdifferencewithpvalues<0.0001inboththegroupsbyusingpairedt-testwhereasduringpre-intervention,thescorebetweenboththegroupswasstatisticallynotsignificantdifferencewithpvalues0.6096whileduringpost-intervention,thescorebetweenboththegroupswasstatisticallyextremelysignificantdifferencewithpvalues<0.0001usingunpairedt-test.

Table 5: Manual muscle testing (Lumbar extensors)




A 3.16±0.79 4.4±0.67 <0.0001B 3.13±0.157 3.8 ± 0.168 <0.0001



MMT (Lumbar extensors):Duringpre-intervention,thescorewas3.16±0.79ingroupAwhile3.13±0.15ingroupB.Duringpost-intervention, thescorewas4.4±0.67 ingroupAwhile3.8±0.16 ingroupB. It showedstatisticallyextremelysignificantdifferencewithpvalues<0.0001inboththegroupsbyusingpairedt-testwhereasduringpre-intervention,thescorebetweenboththegroupswasstatisticallynotsignificantdifferencewithpvalues0.8764whileduringpost-intervention,thescorebetweenboththegroupswasstatisticallyverysignificantdifferencewithpvalues0.0057usingunpairedt-test.

Table 6: Oswestry Disability Index (ODI)

Groups Pre-interventionalMean ± SD

Post-interventionalMean ± SD


Group(A) 74.51±14.70 20.82±2.79 <0.0001Group(B) 78.46±9.83 41.65 ± 10.03 <0.0001


ODI (Oswestry Disability Index)19:Duringpre-intervention,thescorewas74.51±14.70ingroupAwhile78.46±9.83ingroupB.Duringpost-intervention,thescorewas20.82±2.79ingroupAwhile41.65±10.03ingroupB.It showedstatisticallyextremelysignificantdifferencewithpvalues<0.0001 inboth thegroupsbyusingpairedt-testwhereasduringpre-intervention,thescorebetweenboththegroupswasstatisticallynotsignificantdifferencewithpvalues0.2272whileduringpost-intervention,thescorebetweenboththegroupswasstatisticallyextremelysignificantdifferencewithpvalues0.0001usingunpairedt-test.

DISCUSSION

Thestudywascarriedout tofindout theeffectofearly intervention with spinal isometric exercises in acute lumbar intervertebral disc prolapse individuals. ThisstudyshowsthatIFT,hotmoistpackwithSpinalisometricexercisesshowssignificanteffectonpainandfunctional mobility. This study was done after reviewing theotherstudiesand theaimof thisstudywas tofindouttheeffectofearlyinterventionwithspinalisometricexercise inprolapsed intervertebraldisc. Inapreviousstudy conducted by Topp R, et al Prolonged bed restcanadverselyaffect thespinalfunctionas itcancausemuscle weakness, impaired physical functioning andreduce mobility. The anti gravity muscles such as leg extensors and trunk musculature are preferentially affected by loss of mechanical loading compared tohand and upper limb musculature17There is also atrophy seen in the antigravity muscle groups such as soleus,back extensors and quadriceps musculature.17 Due to prolonged bed rest, skeletal muscles respond rapidlyleading to bony desorption than formation which leads to reduction in bone integrity and bone demineralization whichusuallyaffectsthetrabecularbone.18Inapreviousstudy conducted by Meryl D, Anne M, Andrew L,StephenH(1996),theeffectivenessoftreatmentforthelumbar intervertebral disc prolapsed was studied and this

studyconcludedthatconservativetreatmentiseffectivein the lumbar intervertebral disc prolapsed.

Within the group was analyzed statistically usingpairedttestforVAS,ODI,MMTrangeofmotionscoresand between the group was analyzed statistically using unpairedttestforVAS,ODI.MMTandrangeofmotionscores. Within the group was analyzed statisticallyusing paired t test forVAS,ODI.MMT and range ofmotionchart.Itshowsthatthereisextremelysignificantdifference ofGroupAVAS,ODI,MMTand range ofmotionwithPvalue<0.0001andextremelysignificantdifferenceofGroupBVAS,ODI,MMTand rangeofmotionwithPvalue<0.0001.

Between the group was analyzed statisticallyusingunpairedttestforVAS,ODI,MMTandrangeofmotion. It shows thatpre interventional scorewasnotstatisticallysignificantwithPvaluesforVASas0.5585,ODIas0.2272.Aftercomparingthepostinterventionalscorebetweenthetwogroups,thePvaluesforbothVASandODIwere<0.0001respectivelywhichisstatisticallysignificant while, ROM of lumbar flexion as 0.7950,lumbarextensionas0.7437andMMTforlumbarflexorsas0.6096andlumbarextensorsas0.8764.

Thisstudywasdone toanalyze theeffectofearlyintervention with spinal isometric exercise in prolapsed


intervertebral disc for reducing pain and increasing mobility and its post treatment assessment was also taken using outcome measures. The study showed that therewassignificantimprovementinPIVDsubjectsinboththegroupsbutgroupBshowedmoreimprovementthan group A. According to research done by Faccil LM and Cheing GL9Interferential therapy is mediumfrequency current producing low skin impedance andallowingdeepertissuepenetration,thisbeingconsideredeffective to immediately decrease pain. Two mediumfrequencycurrentspassedthroughtheskintoproducealowfrequencycurrentwheretheyintersect18-19.

Hot moist pack relaxes the tight muscles causing tissue to relax it also helps decrease pain caused by muscle tension and spasm. Hot moist pack causes vasodilatation of blood vessels which increases circulation to the area. Increase circulation to injured body part helps to bringnutrients,oxygen,andcellsthatpromotehealing.Spinalexercisesininterventiongroupincludedfrontplank,sideplank,bridges,quadruped,catandcamelexercises.Spinalisometric exercises can maintain the strength of the spinal muscles leading to decrease in pain and increased stability of the spinal column.12 The risk factors for lumbar disc proplapse such as the Sacroiliac dysfunction commonly seeninpost-natalcasesrequiresdetailedposturalanalysisto find out the actual type of dysfunction such as out-flare, posterior rotational dysfunction, upslip & downslip[20]. For post natal low back hydrotherapy based spinalexercisesarebeneficial[21]. Early intervention with spinal isometric exercise in acute lumbar disc prolapse isrequiredtopreventfuturecomplicationsuchasspinalinstability,spinalcanalstenosis,spinalmuscleimbalance,postural alternations etc.

CONCLUSION

It isproved thathotmoistpackwith interferentialtherapy and lumbar isometric exercises has significanteffect on pain, improving spinal muscle strength andfunctional mobility of lumbar spine in acute lumbar intervertebral disc prolapse.

Ethics Committee Permission:TakenfromInstitutionalEthicsCommitteeofKrishnaInstituteofMedicalSciencedeemedtobeUniversity,Karad,Maharashtra,India

Source of Funding:KIMSDTU,Karad.


REFERENCES

1.JordenJ,KonstantionouK,ODowdJ.Herniatedlumbardisc.BMJEvid,UK,2009;2009.455-58.

2.SolomonL,WarwickD,NayagamS.Apleysystemoforthopaedicsandfractures,NinthEdition.CRCPress;2010,249-250.

3.Schultz A, Andersson G, Ortengren R,Haderspeck K, NachemsonA.Loads on thelumbar spine. Validation of a biomedicalanalysis bymeasurements ofintradiscal pressureand myoelectricsignal.J Bone Joint SurgAm.1982;(5):713-720

4.CarrollL J,Cassidy JD,CoteTheSaskatchewanHealth and Back Pain Survey:the prevalenceand factors associated with depressive symptommatologyinSaskatchewanadults.CanJPublic Health.2000Nov-Dec;91(6):459-64.

5. Philadelphia panel Philadelphia panel evidence –Based Clinical practice guidelines on selectedRehabilitation Interventations for lowback painPhyTher(2001)81(10):1641-1674

6.Watson KD, Papageorgiou AC, Jones GT,Taylor S,Symmons DP, Silman AJ, et al.Low back pain in schoolchildren: the roleof mechanical and psychosocialfactors.ArchDisChild.2003;88(1):127

7.DrautErnaniAiresCavalcanteFilho,LowBackPainInAdolescents:ASchoolScreeningJournalofHumanGrowthandDevelopment,2014;24(3):347-353.

8.Risch SV,NorvellNK, PollockML,Risch ED,Langer H, Fulton M, Graves JE, Leggett SHLumbar strengthening in chronic low backpatients.Physiologicandpsychologicalbenefits.Spine(PhilaPa1976).1993Feb;18(2):232-8.

9.Faccil LM NowotnyJP, Tormem F, TrevisaniVF, Effects of transcutaneous electrical nervestimulation and interferential currents in patients with nonspecific chronic low backpain :randomized clinical trial. Sao Paulo MedJ.2011;129(4):206-16

10.Borden. S.The use of radiographic imaging studies in the evaluation of patients who have degenerative disorders of the lumbar spine.JBonejointsurgAm1996;78:114-116


11.AiraksinenO,Brox JI, CedraschiC, etal.COSTB13WorkingGroup onGuidelines for Chroniclow back pain: chapter 4.European guidelines for themanagementofchronicnonspecificlowbackpain.EurSpineJ,2006,15:S192-S300.

12.Andersson GB. Epidemiological features ofchronic lowbackpain.Lancet.1999;354(1978):581-5.

13.Koley S, Sandhu NK. An association of bodycomposition components with the menopausal statusofpatientswithlowbackpaininTarnTaran,Punjab,India.JLifeSci2009;1:129-132.

14.Peng HY, Lin TB: Spinal pelvic- urethra reflexpotentiation.Biomedicine,2012,2:64-67.

15.HuangJT,ChenHY,HongCZ,etal:Lumbarfacetinjection for the treatment of chronic piriformis myofascial pain syndrome: 52 case studies. PatientPreferAdherence,2014,8:1105-1111.

16.HuxelBliven KC, Anderson BE: Core stabilitytraining for injury prevention. Sports Health,2013,5:514-522.

17.ToppR,etal.Theeffectofbedrestandpotentialof prehabilitation on patients in the intensive care unit,AACNClinIssues.2002;13(2):14

18.CheingGL, So EM,ChaoCY. Effectiveness ofelectrocupuncture and interferential electrotherapy in the management of frozen houlder.JRehabilMed.2008;40(3):166-70.

19.Fairbank J.C., Pynsent P.B. The OswestryDisabilityIndex.Spine.2000;25(22):2940-2952.

20.Rajesh Sewani, Sandeep Shinde, Effect of HotMoist Pack and Muscle Energy Technique inSubjects with Sacro-Iliac Joint Dysfunction,International Journal of Science and Research,Vol.6(2)February2017,pg.no.669-672.

21.Rakhi Sadanand Sawant, Sandeep BabasahebShinde,EffectofHydrotherapyBasedExercisesforChronicNonspecificLowBackPain, IndianJournal of Physiotherapy and OccupationalTherapy, January-March 2019, Vol.13, No. 1,pg.no.149-153.

Prevalence of Lower Crossed Syndrome in School Going Children of Age 11 To 15 Years

Shrikrushna Shripad Kale1, Sayali Gijare2

1Intern, 2Assistant Professor, Faculty of Physiotherapy, Krishna Institute of Medical Sciences Deemed To Be University, Karad, Maharashtra, India

ABSTRACT

Introduction: Schoolgoingchildrenintheagegroup11to15yearsareseatedforprolongedduration,whichcausestightnessofhipflexormusclesandlengtheningofglutealmuscles.Thisprogressedtoweaknessofabdominal muscles and tightness of back muscles which is known as lower crossed syndrome.

Method: A total 369 subjects between age group 11 to 15 years were taken with parents consents. Each subject underwent for assessment of strength of abdominal muscles and gluteal muscles with the use of ManualMuscleTechniqueandmeasurementoftightnessofhipflexormuscleswiththeuseofThomastest.

Results:21%ofthetotalpopulationhavelowercrossedsyndromei.e.76subjectsoutof369totalsubjectshave lower crossed syndrome.

Conclusion:Outofthetotalsubjects21%ofsubjectswerefoundtobeprevalentforlowercrossedsyndrome.29% of the total subjects are at risk of developing lower crossed syndrome in future.22% of the total male subjectshavelowercrossedsyndromes,18%ofthetotalfemalesubjectshavelowercrossedsyndrome.

Keywords: Lower crossed syndrome, School going Children, Sedentary lifestyle, muscular imbalance, Low back pain in school children.

Corresponding Author:ShrikrushnaSKaleIntern,FacultyofPhysiotherapy,KrishnaInstituteofMedicalSciencesDeemedToBeUniversity,Karad–415110Maharashtra,IndiaEmail: [email protected]

INTRODUCTION

Withtherecentdevelopment,lowbackpainishighlyprevalent,which is the 2nd leadingmedical conditionwhich results in lost productivity than any other medical condition.1

TheLowerCrossedSyndrome is characterised bytight hip flexors and lower back muscles paired withweak abdominals and gluteus muscle.2 The tightness of thethoraco-lumbarextensorsonthedorsalsidecrosseswith tightness of the illiopsoas and rectus femoris. Weakness of the deep abdominals ventrally crosseswith weakness of the gluteus maximus and medius.

This pattern of imbalance creates joint dysfunction,commonly at theL4-L5 andL5-S1 segments, SI jointand hip joint.2

Ithasbeenbelievedthatlowbackpainisgenerallyuncommon among children and adolescents before the age of 20.3Accordingtoastudy,theannualincidenceoflow back pain in children of age between 11 to 15 gets increasing from 11.8% to 21.5% over a period of 5 years. The lifetime prevalence of low back pain increased from 11.6% at age 11 to 50.4% at age 15 years.4

There are mainly two types of muscle present in ourbody,whichareposturalmusclessuchasilliopsoas,quadrates lumborum and phasic muscles such asabdominals, hip extensors etc. Postural muscles havetendency to tighten and phasic muscle commonly develops weakness.2, 5 Lower crossed syndrome isone of the threatening combinations of biomechanical muscle imbalance due to excessive stress it places on the structures of lower back. This postural imbalances develops a chronic pain condition of lower back that becomesmoredifficulttocorrectinlaterstages.6

DOI Number: 10.5958/0973-5674.2019.00068.6


Nowadays, children spend more time in a seatedposition,bothatschoolduringclassandathomeinfrontof television.7 Children become more sedentary with age &alsoaccumulatestheirsedentarytimeinincreasinglyprolonged periods.8 Objective data show that childrenaged4-15yearsaresedentaryforanaverage7-8hoursaday.7Nurseryschoolchildrenwereseatedfor37.2%oftheirtimeintheclassroomthroughto78.7%forseniorschool pupils aged 13 to 16 years.9 Children under 11 years averaged approximately 1.3 hours less daily sedentarytimethanthoseaged11to14yearsofage&roughly 2 hours less than those 15 to 19 years of age.8

Prolongedsittingposturescausesthehipflexorstoshorten or tighten. Hence the brain will automatically starts to inhibit the activity of glutei muscles. This imbalance pattern promotes increased lumbar lordosis because of the anterior pelvic tilt and over activity of the hip flexors which compensates for the weakabdominals.10

The ergonomically designed sitting arrangement,resulted in more preferable postural alignment &decreased activity of muscles of the lower & middleback.Ifthisismaintainedforaprolongedperiodoftimesuch as during school hours, it may reduce muscularfatigue.11Musclesarenotactivelyusedwhilesittingifcomparedtowalkingandrunning.Muscularfunctionisreplaced by the seat.Weakening of the correspondingmuscle occurs due to muscular inactivation over long period of time.7

Children adopt different postures during classesregardless of postural variations created by ergonomically designed sitting arrangement.12 Prevalence of low back pain did not reduced even if children preferred ergonomically designed furniture.13


Research Design: survey.

Place of study:CBSEschoolsinKarad.

Inclusion Criteria:

z Both boys and girls willing to participate in thestudy between the age group of 11 to 15 years.

z Both boys and girls diagnosed with LowerCrossedSyndromebyaCertifiedPhysiotherapist/Orthopedician.

Exclusion Criteria:

z Historyofspinaltrauma,Jointdysfunctioninpast3 months or congenital deformities at hip or lumbar region.

z Recent fracture to related joints in past 6 months.

z History of abdominal, hip or lumbar surgeries inpast 3 months.

z Not willing to participate in the study.

METHODOLOGY

After getting ethical clearance from the institutional ethics committee informed consent were obtained from the parents of the 369 children. Boys and girls wereassessedintwodifferentrooms.Manualmuscletestingof the abdominal muscles and gluteal muscles is done. AndThomastestisdonefortightnessofhipflexors.

Outcome Measures: Manual Muscle Testing ofAbdominalmusclesandglutealmuscles&ThomasTest. 1. Muscle Strength Test14

Abdominal muscles:Isometricabdominaltestis used to assess the strength of the abdominal muscles.

Position: Patient is in supine with the hips at 45 degree and knees at 90 degree.

Test: The patient is asked to assume the end position and hold it. The gradings of this test are:

Normal5=Handsbehindneck,untilscapulaecleartable20-30sechold.

Good 4= Arms crossed over chest, untilscapulaecleartable15-20sechold.

Fair3=Armsstraight,untilscapulaecleartable10-15secheld.

Poor2=Armsextended, towardsknees,untiltopofscapulaeliftfromtable1-10sechold.

Trace 1=Unable to raisemore than head offtable.

Gluteal muscles: Position: The subject is placed in prone with the hips straight and the kneeflexedto90degree.

Test: The patient is asked to extend the hip,keepingthekneeflexed.

z Anterior force is applied to the posterior thigh.


z The pelvis is stabilized during the movement.

z Bothlegsaretested. The gradings of this test are: Normal5=Completehipextensionandholds

endflexionagainstmaximumresistance. Good4=Hipextensionispossibleandcanbe

held against heavy to moderate resistance. Fair3=Competesfullhipextensionandholds

end position but takes no resistance. Poor2=Completesfullrangeofhipextension

in side lying position. Trace 1= Palpable contractions of gluteus

maximus will be sees as narrowing of the gluteal crease. No visible joint movement.

2. Thomas Test14

Illiopsoas Tightness: The Thomas test is used toassessthehipflexioncontracture.

Position: The patient lies supine while the examiner checks for excessive lordosis.

Test:Theexaminerflexesoneofthepatient’ships, bringing theknee to the chest toflattenout the lumbar spine and to stabilize the pelvis.

z Thepatient holds theflexedhip against thechest.

z If a contracture is present, the patient’sstraight leg rises off the table and amusclestretch end feel will be felt.

z Now the angle of contracture is measured using a goniometer.

z The test is done on both sides.

RESULT AND STATISTICAL ANALYSIS

1. Total Prevalence of lower crossed syndrome:

Table 1: Total Prevalence

Normal At Risk Present47% 32% 21%

21% of the total population have lower crossed syndromei.e.76subjectsoutof369totalsubjectshave lower crossed syndrome. And 32% of the population are at risk of having it in near future i.e. 119 subjects out of 369 are at risk of having lower crossed syndrome.

2. Prevalence of male population:

Table 2: Male Prevalence


22% of total male population are having lower crossed syndrome i.e. 45 students out of 201 male students are having lower crossed syndrome. And 30% of total male population i.e. 60 students out of 201 students are at risk of having lower crossed syndrome in near future.

3. Prevalence of female population:

Table 3: Female Prevalence


18% of total female population i.e. 31 students out of 168 female students are having lower crossed syndrome. And 35% of total female population i.e. 59 students out of 168 students are at risk of having lower crossed syndrome in future.

DISCUSSION

The time children spend in a seated position is average 7-8 hours a day, which consists of 6-7 hoursin school, 1-2 hours in tuitions, 1 hours in front oftelevision. This time reaches its peak in between 11 to 15 years. 7

Prolongedsittingcauseshipflexortightnesswhichcauses anterior pelvic tilt which promotes lumbar lordosis. This causes weakness of gluteal muscles and abdominal muscles. This pattern of muscular weakness give rise to low back pain. 10

Accordingtoastudy,theincidenceoflowbackpainin children of age between 11 to 15 years gets increasing from 11.8% to 21.5% over a period of 5 years. 4

This study was focused on prevalence of lower crossed syndrome in school going children of age 11 to 15years.ThestudywasconductedinKrishnaCharitableTrust’sKrishnaEnglishMediumSchool,Karad.

After getting ethical clearance from the institutional ethics committee, the consent formswere given to all


the parents of children of age between 11 to 15 years. Consents of the parents and assents of 369 children were obtained.

Aftergettingtheconsent,manualmuscletestingforcheckingtheweaknessofabdominalandglutealmuscle,and Thomas test was performed for checking the hip flexortightness.TheDatawascollected.

After analysing the data, it is found that out ofthe total 369 students, 32% students have abdominalweakness,46%studentshaveglutealmuscleweakness&81%studentshavetighthipflexors.

Out of the 201male students, 45% students haveabdominalmuscleweakness,40%haveglutealmuscleweakness&87%havetighthipflexormuscles.

Out of 168 female students, 24% students haveabdominalmuscleweakness,53%studentshaveglutealmuscleweakness&75%havetighthipflexormuscles.

Overall, 21% children showed the pattern ofmuscular imbalance. In this, 59% of male populationfoundtohavelowercrossedsyndrome&41%offemalepopulation found to have lower crossed syndrome.

32% of total population is at risk for developing lower crossed syndrome in future in which 50% of male population&50%offemalepopulationisinvolved.

Thus, itcanbesaid that, theprevalenceofhavinglower crossed syndrome in school going children in age 11 to 15 years is 21%.

CONCLUSION

The study concludes that there is 21% of school going students of age 11 to 15 years have incidence of lower cross syndrome and 32% are at risk of having lower crossed syndrome in near future.

Conflict of Interest: Do not have any conflicts ofinterest to declare.

Source of Funding: This study is funded by Krishna Institute Of Medical Sciences Deemed to beUniversity(KIMSDU),Karad.

REFERENCES

1.David G Borstein, Sam W Wiesel, Scott DBoden. Low back pain: medical diagnosis andcomprehension. management: -2nd ed. 1989 pg. 22,23,59.

2.JandaV.Musclesandmotorcontrolinlowbackpain:Assessment and management. In Physicaltherapy of the low back. New York: Churchill Livingstone;1987.253-78

3.Kelsey JL, Golden AL, Mundt DJ. Low backpain: prolapsed intervertebral disc. Rheum Dis ClinNorthAm.1990;16:699-716

4.BurtonAK,ClarkeRD,McCluneTD,TillotsonKM. The natural history of low back pain inadolescents.Spine21.1996:2323-2328

5.ParasharP,RArunmozhi,KapoorC.Prevalenceof low back pain due to abdominal weakness in collegiateyoungfemales.IJPT.2014;2(1):86-88

6.DasS,SarkarB,SharmaR,MondalM,KumarP,Sahay P. Prevalence of lower crossed syndrome inyoungadults:Acrosssectionalstudy.Int.J.Adv.Res.2017Jun;5(6):2217-2228

7.Justyna Drzal-Grabiec, Slawomir Snela,Justyna Rykala, Justyna Podgorska, MaciejRachwal. Effect of the sitting position on thebody posture of children aged 11 to 13 years. Work.2015;51(4):855-862

8.Saunders.T.J, Chaput.J.P, Tremblay.M.S.Sedentary behaviour as an emerging risk factor for cardiometabolic diseases in children and youth.CanJDiabetes.2014;38:53-61.

9.Dillon.J. School furniture: standing and sittingpostures.BuildingBulletin.1976.

10.Dhanani S, Dr. Tarpan Shah. A survey onprevalence of lower crossed syndrome in young females.IJPSH.2014;1:2249-5738

11.Marscall.M,Harington.A.C,Stelle.J.R.Effectofwork station design on sitting posture in young children.Ergonomics.1995;38(9):1932-1940

12.Murphy.S, Buckle.P, Stubbs.D. Classroomposture and self-reported back andneck pain in schoolchildren. Applied Ergonomics.2004;35:113-120

13.Troussier.B, Tesniere.C, Fauconnier.J, Grison.J,Juvin.R, Phelip.X. Comparative study of twodifferentkindsofschoolfurnitureamongchildren.Ergonomics.1999;42(3):516-526

14.Magee D. Orthopaedic physical assessment.Saunders. 6thEd.2016;pg.578,724,725,729

Effect of Cryokinetics on Talofibular Ligament of Improving Proprioception of the Ankle Joint among Sports Person

Having Ankle Sprain

Bably Kaur1, Kavita Kaushal2, Simratjeet Kaur3

1Intern, 2Principal, 3Assistant Professor, College of Physiotherapy, Adesh University, Bathinda, Punjab, India

ABSTRACT

Anklesprainisthestretchingofligaments,wherebythefibersorcollagenoftheanklefibersarepartiallyorcompletely disrupted. The incidence of the ankle sprain is high among sports population. The loss of ankle joint position sense as a clinical symptom is one of the factor leads to instability and gets overlooked by the physiotherapy practitioners many times.

Thepurposeofthestudywastochecktheeffectivenessofcryokineticsontalofibularligamenttoimprovejoint proprioception among sports person.

Materials and Method:Total30subjects(havinganklesprain)wereselectedfromAdeshHospitalandUniversity,byRandomsampling.Thesubjectswerescreenedaccordingtocriteria:ofage18-30years,bothmale& female,State: acute, sub-acuteandchronic,Unilateral&bilateral,Sportsperson,NPRS rangesbetween3to8,restrictedR.O.Mofdorsiflexion,inversionandeversionwereincludedinthisstudy.Afterthe data collection a written consent was obtained from participants and in the intervention cold therapy and open chain kinematic exercises were given in combination term as Cryokinetics to improve the ankle joint proprioception.

Pain intensity with the help of NPRS and proprioception with the help of Goniometer were considered asoutcomemeasures&assessedon1stdaypriortothetreatment&re-assessedafter4weeksposttothetreatment

Result:Thestatisticalanalysiswasdonewithpairedt-test.Thecalculatedp-valuesforNPRS&GoniometerScoreswerelessthanthetablevalueswhencomparedat5%significancelevelwithdf-29.

Conclusion:Thefindingsof studyconcluded thatcryokineticsweresignificantlyeffective in talofibularligament of improving proprioception of the ankle joint among sports person having ankle sprain.

Keywords: Ankle sprain, Cryokinetics,Proprioception, Open chain exercise.

Corresponding Author:SimratjeetKaurAssistantProfessor,CollegeofPhysiotherapy,AdeshUniversity,Bathinda-151001,Punjab,IndiaEmail: [email protected]

INTRODUCTION

Anklesprainisthestretchingofligaments,wherebythe fibers or of the collagen of the ankle fibers arepartially or completely disrupted.1Most ankle sprainsresult from damage to the lateral ligament structures (Anterior, talofibular, calcaneofibular and posterior

talofibular ligaments) after a stressonan invertedandplantar-flexed foot.2 The incidence of ankle sprain is high in the sportspopulation,posinga significant riskfor participants of a wide range of activity types and sport.3 These incidence rates of ankle injury and sprain are highest in field hockey, followed by volleyball,football,basketball,cheerleading, icehockey, lacrosse,soccer,rugby,trackandfield,gymnastics,andsoftball.2

Reduced active ankle-joint dorsiflexion range ofmotion after acute ankle sprain has a major impact on walking, aswell as other functional activities. Lateralankle sprain is an extremely common athletic injury.

DOI Number: 10.5958/0973-5674.2019.00069.8


The clinical signs and symptoms of functional ankle instabilityincludejointposition-sensedeficits,muscle-strength deficits, delayed peroneal muscle-reactiontime, balance deficits, altered common peroneal nervefunction, and decreased dorsiflexion range of motion.Ankle injury may disrupt joint afferents located inthe supporting ligaments. After injury to the nervous and musculotendinous tissue, proprioceptive deficitsare likely to occur and may manifest as reduced joint position sense. The ability to detect motion in the foot and to make postural adjustments in response to these detected motions is thought to be crucial in the prevention ofankleinjury.Improperpositioningmaybeduetotheloss of proprioceptive input from mechanoreceptors. 4

Proprioception is defined as perception of jointposition, kinesthesia and sense of force which istransmittedbyafferent informationfrominternalareasof the body (i.e. Muscles, tendons, joint capsulesand ligaments) and contributes in postural control (postural equilibrium) and joint stability (segmentalpostural) and several conscious sensations (musclesense). Proprioception also plays an important role in neuromuscular control and is regarded as one of the input components of somatosensory system.5

Clinicians on a daily bases utilize many differentcryotherapy modalities for ankle sprain injuries.6Early management includes RICE (rest, ice, compression and elevation). And there are number of exercises performed to improve functioning of the ankle joint. But combination of exercises and cryotherapy werenot applied or mentioned in previous studies. In thisstudy combination of cold therapy and open chain exercises has been given and this approach is known as Cryokinetic.ThetermCryokineticscanbedefinedasarehabilitation procedure that combines cold and exercise following acute joint injury.7 Cold can be combined with rehabilitative exercise to decrease pain during the exercise using a technique called cryokinetics.Cryokinetics allows the patient to perform exercises soonerandmoreeffectively.Usingthistechnique,coldisappliedtotheaffectedbodypartforamaximumof20minutes, oruntil the area is numbed.Thepatient thenperforms exercises. This process can be repeated for 5minutes to re-numb the area if necessary.6In clinicalpractice,itisusedinsportinjuriesoftheknee,ankleandfoot and in injuries of physically active individual during physical therapy.8

An Open chain exercises involve motions in which the distal segment is free to move in space, withoutnecessarily causing simultaneous motion at adjacent joint.Limbmovementonlyoccursdistaltothemovingjoint,andmuscleactivationoccurs in themuscles thatcross the joint. Open chain exercise also is typicallyperformedinnonweight-bearingpositions.9

The study provides athletic trainers and other sports health care professionals with guidelines and criteria to deliver the best health care possible for the prevention and management of ankle sprains.

AIM OF THE STUDY

To study the effect of Cryokinetics on talofibularligament of improving the proprioception of ankle joint among sports person having ankle sprain.

Hypothesis

Null Hypothesis (H0): Therewillbenosignificanteffectof cryokinetics on talofibular ligament of improvingthe proprioception of ankle joint among sports person having ankle sprain.

Alternate Hypothesis (HA): Therewillbeasignificanteffect of cryokinetics on talofibular ligament ofimproving the proprioception of ankle joint among sports person having ankle sprain.

METHODOLOGY

Study design: ObservationalStudy

Sample design: 30 subjects

Sampling method: Random sampling

Duration: 4 weeks

Inclusion criteria:

z Age:18-30years

z Gender:male&female

z State:acute,sub-acuteandchronicanklesprain

z Unilateral&bilateralanklesprain

z Sportsperson(Athletes)

z NPRS scale between 3 to 8

z Rangeofmotionofdorsiflexion<150andinversion<250andeversion<200.


Exclusion criteria:

z Age above 30 years

z Bonyankleinjury

z Any contraindication of cryotherapy.

z Any open wound.

z Tightness of gastrocnemius and soleus muscle.

z Historyofback,hip,knee injury, any lower limbsurgery or pathology within last one year.

Tools and instrumentation: Goniometer, Couch,Pillow, Towel, Footrest, Straps, Col pack, ElasticTheraband,,Watch,Penandpaperfordocumentation.

Procedure: After getting approval of InstitutionalresearchcommitteeandInstitutionalEthicalcommitteeofCollegeofPhysiotherapyofAdeshUniversity,noticewas displayed on the notice boards of all colleges regarding the study title. The voluntary subjects were screened according to the inclusion and exclusion criteria andwho fulfill thecriteriawas included for the study.The verbal as well as written consent were taken from the subjects after explaining the treatment procedure. The Pain with the help of NPRS and propr ioception with the help of Goniometer was assessed on 1st day prior to the treatment. Cryokinetics that includes Cryotherapy and theraband exercises (dorsiflexion, inversion, eversion)in open chain pattern were applied for 3 alternative daysfor4weeks.Thepainandproprioceptionwasre-assessed at the end of 4th week.

34 subjects had been screened for the study and 4 subjects did not meet the selection criteria and get excluded. Total 30 subjects were included in the study procedure.

The procedure of the study was implemented in the OPDofCollegeofPhysiotherapy.

Intervention: Cryotherapy was applied around the ankle joint in supine position for 10 minutes in the form of cold pack. Then patient was instructed to do the theraband

exercise in open kinetics chain pattern. Theraband exercise (resistance exercises) was performed withelastic theraband. Inversion, eversion and dorsiflexionmovements of ankle with ten second hold and fiverepetitions each.These exerciseswill require durationoffiveminutes.

Measurement technique for proprioception: To measuretheproprioceptionwithgoniometer,goniometeris fixed to the ankle joint. Therapist then flexes thepatientanklefixedwithgoniometertoparticulardegreeand holds it for 5 seconds and then it is brought back to neutral. Then the patient is asked to achieve same range ofankledorsiflexion,eversion,inversionwitheyesopenand eyes closed. Active ankle ranges were assessed before treatment on 1st day and after treatment at the end of 4th week.

Response:While the ankle joint was held in a staticposition by the therapist, the patient was asked todescribe the position verbally or duplicate the position of ankle joint with the contralateral joint.

Position of patient: High sitting (for dorsiflexion,inversion,eversion)

Data analysis: To assess the outcome measure of NPRS forpainandGoniometerforankleproprioception,pairedt-testwasusedtocomparethepreandpostvalueNPRSscores and proprioception values. Using statisticalformulae, the values were expressed as a mean, S.Dand t-value. As all the variables followed a normaldistribution a p value less than 0.05% was considered to behighlysignificant.

RESULT

Thecalculatedp-value forNPRSandGoniometer(R.O.M)waslessthanthetablevaluewhencomparedat0.05%levelofsignificance(withdf-29).Sothismeansthedifferenceobservedwassignificant,soanAlternativeHypothesis(H1) had been accepted and Null Hypothesis (H0) was rejected.

Table 1: Presenting the calculated pre and post values for R.O.M (for Dorsiflexion, Inversion, Eversion proprioception) with eyes opened

R.O.M Group Mean SD p-value

DorsiflexionPre-ROM 13.07 3.58

0.0001Post-ROM 18.17 2.78


Conted…

InversionPre-ROM 20.67 5.68

0.0001Post-ROM 14.83 5.94

EversionPre-ROM 12.33 5.21

0.0001Post-ROM 17.17 3.13

Table 2: Presenting the calculated pre and post values for R.O.M (for Dorsiflexion, Inversion, Eversion proprioception) with eyes closed

R.O.M Group Mean SD p-valueDorsiflexion Pre-ROM 8.97 3.76 0.0001

Post-ROM 13.00 3.85Inversion Pre-ROM 9.50 6.26 0.0001

Post-ROM 15.00 5.87Eversion Pre-ROM 8.87 5.88 0.0001

Post-ROM 13.33 4.97

Table 3: Presenting the calculated values for NPRS Score (both Pre and post)

Group Mean SD p-valuePre 5.07 1.36 0.0001Post 1.83 1.49

DISCUSSION

The current study was conducted to evaluate the effectofcryokineticsontalofibularligamentofimprovingthe proprioception of ankle joint among sports person havinganklesprain.Inthisstudytotal30subjectsweretakenfromcollegeofAdeshUniversity,Bathindawithcertainselectioncriteria,withmean±SDofageof22.3±1.64975.Thisstudyexploredthatsubjectshavinganklesprain had improved proprioception by cryotherapy and theraband exercise. In present study reading ofNPRSand proprioception were taken and compared and the correspondingpreandpostmean±SDwereNPRS-5.07± 1.36, 1.83± 1.49,R.O.M (proprioceptionwith eyesopen)Dorsiflexion-13.03±3.58,18.17±2.78,Inversion20.67±5.68,14.83±5.94,Eversion12.33±5.21,17.17± 3.13 and R.O.M (proprioception with eyes close)Dorsiflexion8.97±3.76,13.00±3.85,Inversion9.50±6.26,15.00±5.87,Eversion8.87±5.88,13.33±4.97.

The results of current study are in accordance with the study performed by Subin Chungath; the results showseffect of cryokinetics in quadriceps muscle ofhemophilic patients in improving proprioception of

the knee joint. The data was analysed by using paired t-test.The results concluded that therewas significantimprovement in the proprioception of the knee joint by giving multi angle isometric exercises in closed kinematics chain pattern with cryotherapy. This improve proprioception at 150 angle compared to 300 and 600 degreepositionwitht-value8.01,6.06,3.20respectivelywith5%levelofsignificance(p<0.05).12

The mechanism behind these results explained that Cryotherapy is a form of electromagnetic energy that utilizesthetherapeuticeffectsofcold.Thecryotherapyis themosteffective treatment foracuteandsub-acutecare of musculoskeletal injuries. Cryotherapy decreases secondary metabolic injury by slowing down metabolism and reducing oxygen demands in the affected area.A greater cooling effect leads to greater decrease inmetabolism. Cryotherapy has other beneficial effectsas well. The term cryotherapy refers to the lowering of tissue temperature by the withdrawal of heat from the body to achieve a therapeutic objective12

In addition to it, the results of present study aresupported by one another study of Yuji Uchio et al in which author concluded that the total laxity and anterior knee laxity decreased by 1.0 and 1.2mm after 15 minutes of cooling (p=.003, p=.017), respectively. Anteriorterminalstiffness(ATS)andinaccuracyofpositionsenseincreased byN/mm and 1.70 (p=.003), respectively.Allparameters had normalized at 15 minutes post cooling. The result of study shows that the cooling for 15 minutes


makesthekneejointstifferandlessensthesensitivityofthepositionsense.Thesefindingmaybesignificantandshould be taken into account for therapeutic programs that involve exercise immediately after a period of cooling.

Inthisstudy,theneurologicaleffectsofcryotherapy,maybecausedbyreductionofNCVorbyblockingnerveconduction. Abramson et al. observed a reversed linear relationbetweenNCVand tissuecooling temperature.Although the reduction ofNCV is regarded as one oftheadvantagesofcooling,itcanhaveeffectsonathletesbefore therapeutic exercise and training11.

Ontheotherhandthereisonemorestudyperformedby Heather A et al: subjects were tested under two conditions:a20-minuteapplicationof iceandcontrol.Proprioceptive accuracy and timing were measured by passively moving the knee, then comparing thesubject’sactivereproductionofthepassivemovement.Subjectswereblindfolded, then tested in three sectorsof theknee’srangeofmotion:90-60°,60-30°and30°tofullextension.Iceapplicationhadnoapparenteffecton the subject’s ability toperformaccuratemovementreproductions in thesectors tested.However,accuracyofthesubject’sfinalanglereproductionvariedbetweenthesectorsasdidthetotaltimeofthemovement.Onepossibleexplanationforthedifferencebetweensectorsis that different receptors are active at different pointsintheknee’srangeofmotion.Theresultconcludedthatcooling the knee joint for 20 minutes does not have an adverseeffectonproprioception.Apparently,thenervewasnotcooledenoughduringthe20-minuteapplicationof two ice packs to alter proprioceptive transmission. We tested proprioception with the knee isolated (i.e,in open kinetic chain). During closed chain activities,which are used during functional rehabilitation such as cryokinetics, many more joints and receptors areinvolved in proprioception. Thus the minimal effectswe observed during open chain testing would be even lesspronouncedduringfunctionalactivities.Therefore,cooling can be safely used to facilitate exercise during rehabilitation without fear of reinjury due to decreased proprioception.10

CONCLUSION

Thefindingofcurrentstudyshowedthatcryokineticswere effective in talofibular ligament of improvingproprioception of the ankle joint among sports person having ankle sprain. The pains score prior treatment

andafter4weekstreatmentweresignificantlyreducedpainfromthepreandposttest(p<0.0001)andimproveproprioception after 4 weeks treatment (cryotherapywithresistanceexercise)weresignificantlypreandposttest(p<0.0001).

Thus an author accepts the altrernative hypothesis (H1)&rejectsthenullhypothesis(H0).

Limitations of the Study:

z The sample size of study was small.

z Only open chain exercises were performed. Noother exercises had been considered.

z Samples were chosen from only one area by using random sampling method.

z The study does not show the result beyond the limit ofage18-30years.

Future Scope of Study:

z Inthefutureofsimilarstudycanbeperformedonlarge sample size.

z Study can be conducted on different age grouphaving pathological condition.

z Inthefuturestudycanbeappliedtoawarenessofphysiotherapy treatment.

z This study would be widely applied in clinics as wellasinsportfield.

z For better results more scales and tools can be used for outcome measures.

Conflict of Interest: Author declares no conflict ofinterest.

Source of Funding: College of Physiotherapy.

REFERENCES

1.Yeung MS, Chan KM, So CH, Yuan WY. Anepidemiological survey on ankle sprain. Britishjournalofsportsmedicine.1994Jun1;28(2):112-6.

2.KaminskiTW,Hertel J,AmendolaN,DochertyCL, Dolan MG, Hopkins JT, Nussbaum E,PoppyW, Richie D. NationalAthletic Trainers’Association position statement: conservative management and prevention of ankle sprains in athletes. Journal of athletic training. 2013Jul;48(4):528-45.


3.Doherty C, Bleakley C, Delahunt E, Holden S.Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J SportsMed. 2017 Jan1;51(2):113-25.

4.WillemsT,WitvrouwE,Verstuyft J,VaesP,DeClercq D. Proprioception and muscle strengthin subjects with a history of ankle sprains and chronic instability. Journal of athletic training.2002Oct;37(4):487.

5.Eftekhari F, Sadeghi H, Rajabi H, Memar R,Leili AK. The effect of local cooling on kneejoint position sense in healthy trained young females. International Journal of Sport Studies.2015;5(6):700-7.

6.IfftN,SpauldingJ.ExaminingRewarmingTrendsFollowingCryokineticsUsingDifferentCoolingModalitiesonAnkleSkinSurfaceTemperature.

7.HopkinsJT,StencilR.Anklecryotherapyfacilitatessoleus function. JournalofOrthopaedic&SportsPhysicalTherapy.2002Dec;32(12):622-7.

8.Macedo CS,Alonso CS, Liporaci RF,Vieira F,Guirro RR. Cold water immersion of the ankle decreases neuromuscular response of lower limb after inversion movement. Brazilian journal ofphysicaltherapy.2014Feb;18(1):93-7.

9.Kisner C, Lynn Allen Colby. TherapeuticExercise Foundations And Techniques.JAYPEE.2012;6:188.

10.Ozmun JC, Thieme HA, Ingersoll CD, KnightKL.Coolingdoesnotaffectkneeproprioception.JournalofAthleticTraining.1996Jan;31(1):8.

11.UchioY,OchiM,FujiharaA,AdachiN,IwasaJ,SakaiY.Cryotherapy influences joint laxity andposition sense of the healthy knee joint. Archives ofphysicalmedicineandrehabilitation.2003Jan1;84(1):131-5.

12.ChungathS.EffectofCryokineticsinQuadricepsMuscle of Hemophilic Patients in ImprovingProprioceptionoftheKneeJoint-AnExperimentalStudy. Indian Journal of Physiotherapy andOccupational Therapy-An International Journal.2016;10(2):181-6.

Effects of NDT Treatment Based Trunk Protocol on Gross Motor Function of Spastic CP Children

Sonia Sharma1, Rashida Begum2

1Paediatrics, 2Assistant Professor Jamia Hamdard

ABSTRACT

Background:TostudytheeffectsofNDTtreatmentbasedtrunkprotocolongrossmotorfunctionofspasticCP children

z TostudytheeffectsofNDTtreatmentbasedtrunkprotocolongrossmotorfunctionofspasticCPchildren.

z TocomparetheeffectsofNDTtreatmentbasedtrunkprotocolwithconventionaltherapyforspasticCP children.

Materials and Method: Pre and post test experimental design was used. The study was conducted with 25 spasticCPchildrenagedbetween1to6yearshavingoneormoremilestonedelayedandhavingGMFCS>/=IIgrade. Permission was taken from Amarjyoti institute Delhi for sample collection.25 Children were taken according to inclusion criteria with the consent from their parents. Children were divided in control and experimentalgroup.GrossmotorfunctionsofallchildrenwereassessedusingGMFM-88scalepriortotheprotocol(NDT/Conventional)andreevaluatedaftertreatment.

Result:ThestudyprovedNDTbasedtrunkprotocoltobeeffectiveongrossmotorfunctionofspasticCPChildren.

Conclusion:LongdurationNDTtreatmentbasedtrunkprotocolfocusedondynamicco-activationoftrunkflexorsandextensorssignificantlyimprovedgrossmotorfunctioninchildrenwithspasticCP(1-6Years).Alsoitwasmoreeffectivethanconventionaltherapy.henceitissuggestedthattrunkshouldbefocusedandit should not be overlooked while working for gross motor function of CP children.

Keywords: Gross motor function, Neuro development technique,Spastic Cerebral Palsy.

Corresponding Author:Ms.RashidaBegumAssistantProfessor-OccupationalTherapyDept.of Rehabilitation SciencesHIMSR,JamiaHamdard,NewDelhi-110062Phone: 9891442506Email:[email protected]

INTRODUCTION

Cerebral palsy is a common disorder occurring in 2to2.5per1000livesbirth(StanleyFBlairE,2000;MGladstone) 1Spastic CP is characterized by muscle that are stiff in which velocity dependent resistanceto passive movement produces increase muscle tone,selective control is limited, producing abnormal andlimitedmovementsynergies,excessiveco-activationof

muscular activity leads to limitation in range of motion and timing of muscle activation and postural responses is abnormal (Campbell,1991;Koella, 1980)2 and so it causes limitation in gross motor function. The primary probleminCPisgrossmotordysfunction(ScherzerandTscharnuter 1982).3

Though there are many approaches being practiced today to deal with the limitation in gross motor function in spastic CP but NDT is an problem solving approach commonlyusedbypediatric therapist. It isbasedonaconceptualmodeldevisedbytheBobathin1940(Bobath1980;BobathandBobath1972,1984)4 and has achieved popular acceptance through its empirical appropriateness.

Studiesof theeffectivenessofNDThavereportedinconclusive evidence and have not resulted in any

DOI Number: 10.5958/0973-5674.2019.00070.4


empirical consensus (Ottenbacher et al. 1986,Royeenand Degangi1992,Butler and Darrah 2001)5.Some of the studies have found NDT approach effective inimproving measures of motor performance in children with CP, especially in gross motor ability, posturalcontrol and stability (Carlsen 1975,Campbell 1990,Barry1996,ketelaaretal.2001)6.Ontheotherhand,otherinvestigatorshavefoundlittleornodifferenceinmotorfunction(Herendonetal1987,ButlerandDarrah2001)7.

Despite of the inconclusive evidence it is widely used approach in pediatric therapy.

There were studies in the past which gave the evidence that trunk control is impaired in spastic CP children(Heyrman et al 2013)8 and some studies supportedtheimprovementinGMFofCPchildrenwheninvestigation was trunk targeted(Butler,1998;MarianneUnger,2013)9 hence these studies clearly showed the link betweentrunkandgrossmotorfunction.Buttherewerevery few studieswhichhad targeted specifically trunkusingNDTandseenitseffectongrossmotorfunctions.

Arndt et al 10conducted the RCT that included an operationally definedNDT -protocolwhichwas trunktargeted.Sequencedtrunkactivationprotocolwasgivento posture and movement disordered infants for 10 one hour intervention session over a period of 3 weeks by NDT associationinstructor. The researchers studied 19 infants aged 4 months to 1 year. To assess gross motorfunctiontheyusedGMFM-88.Evenwithasmallsamplesizeandshortinterventionduration,infantswhoreceived trunkprotocol improved significantly.Butnosuch well focused protocol which had targeted trunk using NDT had been investigated for the CP children above 1 year of age. The purpose of this study was to seetheeffectofNDTbasedtrunkprotocolonGMFofspastic CP children above 1 year of age and to compare it with conventional therapy.

Experimental Hypothesis: It was hypothesized thatspastic children (above 1 year) of age receiving anNDT trunk protocol would make greater gains in gross motor function compared to children who received conventional therapy.

Null Hypothesis: There is no relationship between type oftreatmentandeffectongrossmotorfunctionofspasticCP children above 1 year of age.

METHODOLOGY

Research Design:

z Control trial

z Pre-postexperimentalstudy

Place of Data Collection: Amarjyoti Research and rehabilitation centre

Sampling: Sample of convenience

Sample Size: 25

Material Used: Therapy ball,mat,bolster,stool,smallbenches

Variables:

z Independent Variables: Type of treatment

z Dependent Variables: Effect on gross motorfunction

Inclusion Criteria:

z SpasticCPwithagegroup1-6years

z SpasticCPwithGMFCS>/=IIgrade

z Delayed one or more motor milestones

Exclusion Criteria:

z Congenital anomalies

z Chromosomal disorders

z Orthopedicremedialsurgery

Outcome Measures:

z GMFM-88

z GMFCS

Procedure: Consent from institution and parents of children were taken to conduct study.Subjects were selected on the basis of inclusion and exclusion criteria.participants were divided into 2 groups 13 in experimental group(Group1)and12incontrolgroup(group2).Grossmotor function of both the groups were assessed using GMFM-88.Experimental groupwas givenNDT basedtreatmentfor50minutes,3daysaweekfor8weeks.

Focus points for protocol given to experimental group were:

z Facilitation of dynamic co-activation of trunkflexorsandextensors

z Facilitation of active weight shifting


z Facilitation of active trunk rotation while maintainingdynamicco-activationoftrunkflexorsand extensors.

z Functional trunk rotation

z Emphasis on transitional activities

z Treatment in control group was given for same duration.

Focus points of Control group were as follows:

z Stretching exercises

z Strengthening exercises

z Passive movements of limbs

z Weightbearingindifferentpositions

Statistical Interpretation: This study used pre post experimental design. Statistical difference was testedwith the parametric paired sample t-test to determineanysignificantdifference inparametricvariable (grossmotor function).The level of significancewas p<0.05.Data were analyzed with SPSS for windows.

RESULT

Control Group: Apairedsamplet-testwasconductedto compare the pre and post value of total score; pre (M=34.66;SD=19.36) andpost (M=38.00;SD=20.24)in the control group.

Therewas significant difference in total score forpreandpostGMFM;t=6.325,p=0.00.

Apairedsamplet-testwasconductedtocomparethepre and post value of goal total score; pre (M=14.41;SD=7.63)andpost(M=17.91,SD=8.71)inthecontrolgroup.

TherewassignificantdifferenceingoaltotalscoreforpreandpostGMFM;t=4.841,p=0.00.

Experimental Group: A paired sample t-test wasconducted to compare the pre and post value of total score;pre(M=16.84;SD=15.01)andpost(M=21.2308;SD=16.361) in the experimental group. There wassignificant difference in total score for pre and postGMFM;t=7.98,p=0.00.

Apairedsamplet-testwasconductedtocomparethepre and post value of goal total score; pre (M=17.92;

SD=8.34) and post (M=24.69; SD=9.91) in theexperimental group.

TherewassignificantdifferenceingoaltotalscoreforpreandpostGMFM;t=7.708,p=0.00.

Hence,resultssupportexperimentalhypothesis.

Graph I

Interpretation: It classifies data according to gender.There were 7 male and 6 female with mean age 2.9,SD=1.5 inExperimentalgroupwhereas9maleand3femalewithmeanage2.97,SD=1.6WereinCONTROLgroup.

Graph II

Interpretation: Shows sample distribution on the basis ofgrossmotorfunctionclassification.

Graph III

Interpretation: Shows the pre and post value of mean total score and mean goal total score for experimental group.


Graph IV

Interpretation: Shows the pre and post value of mean total score and mean goal total score for control group.

Graph V

Shows the increment in goal score for experimental group

Graph VI

Shows the increment in goal score for control group

DISCUSSION

NDT trunk targeted intervention, which wasadministered for 8 weeks in children with spastic CP with physical disability (more than level 1onGMFCS) andadistributionofhemiplegia,diplegiaandquadriplegiaimproved their gross motor function as measured with GMFM-88.This improvementwas significant for bothgroup (EXPERIMENTAL, CONTROL).Furthermore,trunktargetedNDTinterventionhadagreatereffectonchildren’s motor function than reference conventional

intervention. This conclusion justifies the notion formorespecificfocusontrunkinCP.

The result supported the efficacy of NDT basedtrunk protocol and control group. Of the 25 childrenwho participated, none remained static; all showed animprovement.

As the improvement was found in both the groups itsignifiesthepossibleroleofextraneousfactorbehindthesignificantresult.

These other factors are:

z Time -There is always a possibility of naturalphenomenonofrecoveryinCPchildren(studybyE beckung; 2007).There could be possibility thatwhatever improvement in gross motor scores were coming it was because of the natural recovery with time. As the duration of study was 8 weeks which itself was long duration.

z Parallel line of treatment-Improvement might bea result of medication; few of the children in both the groups were on muscle relaxants. Study by Frencesco et al, 2011 suggested that intrathecalbeclofen therapy is an effective treatment formanagingspasticityanddystonia,andforimprovingmotor function in children with CP.

z Motivation-Cristopheretalin2014supportedtherole of motivation in performance.

z Sofactorsstatedabovemighthaveinfluencedtheresultbuttheywereequallyresponsibleforboththegroups.

Though the improvement was significant in boththe groups but it cannot be overlooked that mean total score and goal total score of experimental group were higherthancontrolgroup.ThisjustifiesthehypothesisofNDTapproachthatcorrectionoftrunkanomaly(Co-activation,sustenance,recruitmentofmuscles,alignmentdifficulties)willhelpoverallalignmentofbodyandwillresult in better posture which facilitates the usage of theavailabletoneforthedesiredfunction(Grossmotorfunction),JStyler1999.ItisalsoindicatedfromRCTbywinter(1994),inthisstudy3roupsweremadeforinfantsborn prematurely and at high risk for developmental stability.Outofthe3groups,onereceivedNDT,Secondreceived no specific handling, and third received notreatment. Results suggested that neuro development treatmentwas effective in improving postural control,motor control in comparison to others which showed insignificantresult.


CONCLUSION

LongdurationNDTtreatmentbasedtrunkprotocolfocusedondynamiccoactivationof trunkflexorsandextensorsandspecificallysequenced trunkmovementssignificantlyimprovedgrossmotorfunctioninchildrenwithspasticCP(1-6Years)NDTtreatmentbasedtrunkprotocol1wasmoreeffectivethanconventionaltherapywhichindirectlyaddressedthetrunk.Itissuggestedthattrunk should be focused and it should not be overlooked while working for gross motor function of CP children.




REFERENCES 1.M.Gladstone,A review of incidence and

prevalence, types and aetiology of childhoodcerebral palsy in resource-poor settings, journalofpediatricandinternationalchildhealth,2013.

2.Campbell et al, Efficacy of physical therapy inimproving postural control in children with CP. Pediatricphysicaltherapy2:135-140.

3.Scherzer AL, TscharnuterI.Early diagnosis andtherapy in Cerebral palsy: a primer on infant development problems. New York: MarchelDekker,1982.

4.Bobathk,BobathB.Cerebralpalsy.In:PearsonPH,Williams CE, editors.Physical Therapy Servicesin thedevelopmentaldisabilities.Springfield, IL:Thomas.p37-185,1972.

5.Royeen CB, DeGAngi GA. Use ofneurodevelopment treatment as an intervention: annotated listing of studies 1980-1990.PerceptMotorskills75:175-194,1992

6.Butler C, Darrah J.Effects of NDT for cerebralpalsy: anAACPDM evidence report. DevMedChildNeurol43:778-779,2001.

7.Campbell SK, Efficacy of physical therapy inimproving postural control in children with cerebralpalsy.PediatricPhysicalTherapy2:135-140.Carlsen PN. (1975)Comparison of twooccupational therapy approaches for treating the young cerebral palsied child. Am JoccupTherapy29:267-272,1990.

8.Butler C, Darrah J.Effects of NDT for CP: anAACPDM evidence report. Dev Med ChildNeurol43:778-790,2001.

9.Herndon WA, Troup p,Yngve DA,SullivanJA(Effects of NDT treatment on movementpatterns of Children with Cerebral Palsy.JPediatricOrthopedic7:395-400,1987

10. 12. Heyman et al Clinical characteristics of impaired trunk control in children with spastic CP, research in developmental disabilities: Vol-34,issue-1,pg327-334.(2013).

11.13.PB.Butler.A Preliminary report on theeffectiveness of trunk targeting in achievingindependentsittingbalanceinchildrenwithC.P,journalofclinicalrehabilitation,1998.

12.Arndtetal,EffectsofNDTbasedtrunkprotocolforinfantswithpostureandmovementdysfunction,2008.

13.DoreenJBartlettetal,Determinantsofgrossmotorfunction of young children with CP: a prospective cohortstudy, journalofdevelopmentalmedicineandchildneurology,2014

14.MariarineUngeretal,Effectofa trunktargetedintervention using vibration on posture and gait in children with spastic CP:ARCT, Journal ofdevelopmentalneurorehabilitation,2013

15.Brownetal,TheefficacyofNDTinpediatrics:asystematicreview,BJOT,2001

16.LiKangetal,EffectsofearlyNDTonmotorandcognitive development of critically ill premature infants,journalofmedicalsciences,2013.

17.DaniCowanetal,NDTisnotmoreeffective inimproving gross motor function of spastic Cp children when compare to no therapy or alternative therapy,OTS,UWLAX.edu.com,2010.

18.Nikosetal,effectofintensiveNDTtreatmentongross motorfunction, developmental medicineandchildneurology,2004.

19.Girolami,EfficacyofaNDTProgramtoimprovemotorcontrolininfantsbornprematurely,journalofpediatricphysicaltherapy,1994.

20.Degangietal,towardamethodologyoftheshort-termeffectsofNDTtreatment,AJOT,1983.

21.Keneth et al, Quantitative analysis of theeffectiveness of pediatric therapy, journal ofAmericanphysicaltherapy,1985.

Functional Upper Limb Rehabilitation in Brain Injury due to Stroke through Motor Synergy Rehabilitation–A Case Study

V. Siddharth

Chief Neuro Rehabilitation Expert, Occupational Therapist, NewRo, Unit of PRS Neurosciences and Mechatronics Research Centre, Bengaluru

ABSTRACT

Background: This study aims to determine motor synergy rehabilitation for upper limb functional recovery in stroke patients.

Methodology:A 48year oldmale, apparently normal till June, 2016, had an acute onset of right sidedhemiparesisandslurredspeech.2yearslaterhereportedwithinabilitytousetheupperlimbanddifficultyin walking independently. He was a diagnosed case of left capsule-ganglionic bleed with acceleratedhypertension.Hisparticipationlimitationswereinabilitytofingerfeed,drinkhiscoffee,dressandgroomselfand discontinuation of his job as an automobile salesman. He received motor synergy rehabilitation for 6 weeks.

Result: At 6 weeks patient was able to perform scapular elevation and shoulder scaption up to 100 o with isolatedelbowandforearmmovements.Here-learnttoreleaseobjectswithwristinneutralpositionwithverbalcues.Hisabilitytofeelroughtexturesimprovedby50%andsilkytextureby40%(self-reported)throughoutthelimbexcepthand.Heretrainedtoeathardcutfruit,sipwaterfromaglasswithstrawandcombhairwith20–25%assistanceandrejoinedhisjobonceaweek.

Conclusion:Musclesynergyrehabilitationcanhelptoimprovethefunctionaluseofupperlimbinstroke.

Keyword: stroke, hand rehabilitation, motor synergy pattern correction, deep relaxation, multisensory stimulation, motor synergy rehabilitation

INTRODUCTION

Human upper limb and hand is the most versatile organ whichhasevolvedwithtime.Itsusesareunfathomablewhich makes upper limb rehabilitation one of the most challenging areas in brain injury rehabilitation. All the skilled movements which we perform in our day to day life are a result of muscle synergies.

Asabiologicalphenomenon,acommonlyacceptedgeneraldefinitionofmusclesynergyissimplyastablespatiotemporal pattern of activity across muscles simultaneously involved in the performance of a movement.Musclesynergy isdescribedas theco–andreciprocalactivationthatoccurduringmovement.BraininjurieslikestrokeandTBIresultindisturbanceinthemotor pathways resulting in alteration of the muscle synergies. The time course of abnormal synergy pattern seems to lag spontaneous recovery that occurs in initial weekafterstroke.Inhealthyindividuals,motorcortical

activity, driving down through the corticospinal tractis thepredominantdriverofvoluntarybehavior.Whenthe CST is damaged, other descending pathwaysmaybe up-regulated to compensate which re-emerges asnew synergies and takes shape in chronic stage of brain injury due to stroke.(1)

In clinical use, abnormal muscle synergies areidentified in form of abnormally patterned voluntaryaction of the limb. These synergy patterns also depend on the spatio-temporal capabilities especially whenbimanual task are considered.

These muscle synergies can be divided into hard muscle synergies which have dedicated interneurons and softmusclesynergieswhichareflexibleandcorrespondto thespecifictasks.Unlikehardmusclesynergies,softmuscle synergies do not have dedicated centers in the brain. Studies have suggested that that these synergies are coded either at the level of brainstem of spinal cord. (1)

DOI Number: 10.5958/0973-5674.2019.00071.6


The most common impairment after stroke is hemiparesis. (2)Upperlimbimpairmentoccursin75%ofpatients,andupperlimbparesisisakeyindicatorastowhether or not patients will engage in activities of daily living 6months after stroke. (3) Prediction of upper limb recovery at six months from stroke is determined by shoulderabductionandactivefingerextension.Patient’sability to shrug his shoulder is also associated with better upper limb recovery. (4)

However, if the two main synergies of the upperlimb identified after stroke which are the flexor andextensor synergy, inwhich shoulder, elbow, andwristflexion are obligatorily linked, are considered as thegoldenrule,shoulderabductionisassociatedwithwristandfingerflexion.

The challenge still lies in how to correct the synergy pattern in upper limb while maintaining the improvement achieved through use of other contemporary neurorehabilitation therapies and accelerate the limb rehabilitation process; the ultimate goal of the process being to achieve a functional hand.

METHODOLOGY

Mr.BYP, 48year oldmale presentedwith inabilityto use the right upper limb and difficulty in walkingindependently.HewasapparentlynormaltillJune,2016when he had an episode of acute onset of right sided hemiparesisandslurredspeech.BasedonhisCTscanreports, he was diagnosed as a case of left capsule-ganglionic bleed with accelerated hypertension. He was diagnosedtohaveDiabetesMellitus(RBS=150)atthetime of stroke. His echocardiogram showed concentric LVH with normal LOV (EF-62%). He received earlyphysiotherapy as a part of rehabilitation.

He reported for further neurorehabilitation in September, 2018. In the initial occupational therapyevaluation,hisrightupperlimbwasinStage3Brunstrom.Hisshoulderadductorshadagradeof2MAS,shoulderflexorshadgrade1+MAS,forearmpronatorshadgrade1+MAS,wristflexors(FCU)hadgrade2MAS,longfingerflexorshadgrade2MASandFPBhadgrade2MAS. The right shoulder was subluxated (1 and halffingerspace)withwastingoftheDeltoid,Supraspinatus,Infraspinatusandpainonmovementbeyond100degreesofpassiveflexionand90degreesofpassiveabduction.There was additional tightness in the long finger

flexors and thumb IP flexorswhich could be palpatedas a tight band. Sensory examination revealed that the patient could not feel superficial, deep and combinedcortical senses. His parietal lobe related functions were impaired (Proprioception,Kinesthesia,Graphaesthesia,andBarognosis).He had a dominant flexor pattern ofmovement and active shoulder abduction but no active fingerextension.Hehas intactcognitive(MMSE=29)andperceptualabilities(interpretedbasedondailylifeskill performance and informal assessment).He wanted tofingerfeed,drinkhiscoffee,dressandgroomselfandreturn to his job as a automobile salesman.

Intervention:ThepatientwasadvisedtouseaBobathsling for preventing shoulder subluxation during the therapy session. His upper extremity rehabilitation started withdeeprelaxationtechnique,amethodtoreducestressfollowedbyRood’stoneinhibitorytechniques.SensoryRe-educationwasusedincombinationwithmultisensorystimulation(combinationofolfactorysensewithtactile,proprioceptive and barognosis) to improve awareness towards the limb.

Motor relearningprogram (MRP)wasusedas thebasis of synergy pattern correction. The synergy pattern correctionprogramstartedwith combinequick stretchwith the shoulder abducted to 90 degree and externally rotated with forearm pronated and wrist and fingerextended.Attheendofthequickstretched,thepatientwasaskedtopullthehanddownagainstresistance.Oncethe patient was able to pull the limb down against the resistance,hewasretrainedforshoulderexternalrotation.This was followed by forearm supinator- pronatorretraining and combined elbow and wrist extension with assistedfingerextension. Itwasalsonotedduring thattraining that scapular elevation and elbow extension wasassociatedwithfistingofthehandi.e.flexionofthefingersandthumb.Scapulardepression,extensionoftheshoulder helped to improve release ability provided the patienthaselbowflexionandminimalabilitytoextendthewrist.Assistedshoulderexternalrotationandflexionwith scapular retraction was used to improve the ability to reach forwards and sideways.

He was also retrained to perform his targeted daily lifeactivitiesoffeedingwithfingers,combinghishair,drinking from a steel glass. He was provided assistance at the proximal segment i.e. at the shoulder and the hand to support the forearm and hand. He was subjected to visual feedback and practice with closed eyes to redirect his focus towards his proprioceptive sense.


RESULT

At the end of 6 weeks patient was able to perform scapular elevation and shoulder scaption up to 100 degrees from the resting adducted position. He learnt isolated elbow flexion and extension and forearmsupination and pronation. He was able to learn forearm supination and perform elbow extension at a near normal velocity. His forearm and wrist control improved. He was able to release objects with wrist in neutral position with verbal cues. His ability to extend his wrist significantlyimproved.Hewasabletoholdthewristinneutralposition.Asaresult,hisabilitytoreleaseobjectsimproved. Ability to supinate the forearm also helped to relax the long finger flexors and open the thumbfollowing repeated practice.

At end of 2 weeks he started feeling rough textures on the dorsal and volar aspects of the arm and forearm. Bytheendof4weekshestartedfeelingroughtexturesthroughout the limb and 50 percent of smooth texture ontheaffectedlimbascomparedtotheintactlimb(self–reported).Attheendof6weeks,hereportedcompletesense of rough and smooth texture and 40 percent of the silky textures. In spite of retraining, he did not reportanyimprovementintheBarognosis,GraphaesthesiaandKinesthesia.

He was able to finger feed on hard food i.e. cutfruits like apple or guava with 25 percent assistance as compared to complete dependence before the training. He also regained ability to comb his hair if the comb in placed in the hand with 25 percent assistance. His dependence decreased from being complete dependent to minimal assistance. He was able to hold a glass half filledwithwaterandtaketothemouthanddrinkwithastraw with 20 percent assistance. He was still learning how to maintain the wrist in neutral position while drinking from the glass.

DISCUSSION

Upper extremity recovery in stroke has beenrecordedtobebestinthefirst6monthspoststroke.Astudy done to record the recovery of stroke patients over aperiodof6monthsshowedthattherewassignificantimprovementinupperlimb,trunkandlowerlimbmotoruntil first four months. The rate of recovery reducedby the 5 month and ably the lower limb recovery was observed after the 6thmonth.However,thiscasedidnot

follow this principle and continued to show improvement in motor recovery even after 2 years of stroke. (5)Inourcase,thepatientpresentedwithastage3Brunstromafter2 years from the day of onset of stroke and still showed significantchangeintheupperlimbcontrol.

Usuallyasingledeepseatedintracranialhemorrhageinganglionicregionwithoutanyinjurytoscalp,skullandbrain is due to natural disease. Hypertension is the most common cause of spontaneous intracranial hemorrhage.(6) Patientswithbleedintheganglionic-capsularregionare capable of recovering isolated movements in the upper limb. (7) These researches support the possibility of upper limb recovery in this case.

Deep relaxation technique and Multisensorystimulation were used to facilitate recovery in addition to traditional neurorehabilitation for upper limb. The highlight of the rehabilitation protocol for upper limb was the application of specific synergy correctionpatterns which improved the functional outcomes.

Multisensory stimulation imitates the naturalbehavior of the brain to process multiple sensory inputs at a time and give sensible motor outputs. In animalmodels stimulation of the olfactory pathways resulted in long lasting potentiation of synaptic transmission in dentate areas.(8) The stimulation of the olfactory system also activates the RAS which in turn increases the awareness level towards the second sense stimulated along with the olfactory sense. Olfactory stimulationalso results in lowering of the blood pressure and lowers downstressbyre-establishesthedopamineandserotoninbalance, hence lowering the chances of further injuryto thebrainandpotentiatingplasticity.Although,deeprelaxation can reduce stress associated to post- strokerecovery,doesitplayaroleinneurologicalrecoverybymodulating muscle tone or improve the functionality of the motor pathway needs further introspection.

The motor synergy correction patterns identifiedinthisstudyhavescientificsupportinbits.Thegravityassisted manual resisted movements have been well used in Muscle Energy Techniques to activate thecore which directly improve the ability of the patient to recruit his scapular muscles. This is supported by another study which concluded that upper extremity task exerciseswithsymmetricabdominalmusclecontraction,conducted as part of adult hemiplegic patients’ trunkstabilizationexercises,canbeappliedtoadiverserangeof hemiplegic patients and implemented as an exercise program after discharge from hospital.(9)


In another study which investigated the effect ofactive scapular protraction and grip strength, it wasfound that the surrounding muscles of the scapula,such as the serratus anterior, upper trapezius, flexorcarpiulnaris,flexorcarpiradialisandpalmaris longus,showed significant changes in muscle activation afteractive scapular protraction. The muscles of the upper extremity also showed significant changes after activescapular protraction. (10) This study supports the use of combinedexternalrotationandassistedshoulderflexiontoimproveforwardandsidewaysreach.Inversely,itcanbeunderstoodscapularretraction,releaseabilityshouldbe improved which was seen in this particular case.

Inarecentstudyanalyzingthetorqueappliedduringsupinationandpronationinstrokehand,theable-bodiedsubjects provoked less forearm pronation/supination torque during similar movements as compared toparalyzedindividuals.Itwasindicatedthatbrachioradialisandbicepsbrachiicontraction,producingelbowflexionduringcircularmovements,werealsoresponsiblefortheaccompanied forearm supination. (11) This supports the use of isolated supination and pronation retraining and combined supination and pronation with elbow extension and external rotation as a means of modulating the stability oftheforearm–wrist–handstabilityandhenceimprovesability to grasp and prehend.

This case study also showed that repeated wrist extension had influence on the active finger extensionbut the changes were not clinically significant. Weneed more cases and longer rehabilitation duration to establish this relationship to use it on regular basis as a part of synergy correction and relearn the natural attitude to reach for objectswith adequate finger opening andthumb-first finger span.A future study to confirm theapplicability of thesemethods in different agegroups,differenttypesofstrokeandscoringtheimprovementona standardized assessment scale can further strengthen the importance of correcting the synergy patterns in upper limb stroke rehabilitation.

CONCLUSION

Musclesynergyrehabilitationcanhelptoimprovethefunctional use of the hand in conjunction to sensory motor retraining, relaxation and techniques and conventionaloccupational therapy program. It improves the abilityto use the hand provided the site of neurological insult allows for recovery and the patient has intact cognition andenoughmotivationtorelearnthenecessarytechniquestaught to modulate the muscle tone.


Ethical Clearance: Ethical clearance was taken from theinstitute’sethicalcommittee.


REFERENCES 1.McmorlandAJC,RunnallsKD,ByblowWD.A

Neuroanatomical Framework for Upper LimbSynergies after Stroke. Frontiers in Human Neuroscience. 2015;9.

2.Wolfe, C. D. The impact of stroke. Br.Med.Bull.2000 56,275–286

3.Veerbeek, J. M., Kwakkel, G., van Wegen, E.E. H., Ket, J.C.F., and Heymans, M.W.. Earlyprediction of out come of activities of daily living after stroke: a systematic review. 2011 Stroke 42,1482–1488.

4.Lamolaetal.,IntJNeurorehabilitationEng2015,2:3

5.LeeKB, LimSH,KimKH,KimKJ,KimYR,ChangWN,etal.Six-monthfunctionalrecoveryof stroke patients. International Journal ofRehabilitationResearch.2015;38(2):173–80.

6.Dr.R.KP.Capsulo-ganglionicBleed:MurderorPathology?Capsulo-ganglionicBleed:MurderorPathology?32(3):257–8

7.FatimaDeN.A.P.Shelton,RedingMJ.EffectofLesionLocationonUpperLimbMotorRecoveryAfterStroke.Stroke.2001;32(1):107–12.

8. Bliss TVP, Lømo T. Long-lasting potentiationof synaptic transmission in the dentate area of the anaesthetized rabbit following stimulation of the perforant path. The Journal of Physiology.1973Jan;232(2):331–56.

9.LeeJ-H,ChoiJ-D.Theeffectsofupperextremitytask training with symmetric abdominal muscle contraction on trunk stability and balance in chronic stroke patients. Journal of PhysicalTherapyScience.2017;29(3):495–7.

10. Yang J, Lee J, Lee B, Jeon S, Han B, Han D.The Effects of Active Scapular Protraction ontheMuscleActivationandFunctionoftheUpperExtremity. JournalofPhysicalTherapyScience.2014;26(4):599–603.

11. Kung B-C, Ju M-S. Clinical Assessment ofForearm Pronation/Supination Torque in StrokePatients. Journal of Medical and BiologicalEngineering.2004Dec16;25(1):39–43.

Documentation of Electrotherapy Treatment in Clinical Practice-Is It Happening?

Prashanth V Mangalvedhe1, Vijay Samuel Raj V2

1Lecturer, 2Assistant Professor, JSS College of Physiotherapy, Mysuru, Karnataka, India

ABSTRACT

Documentation is a very important component for the delivery of health care; it provides a continuity of care andservesascommunicationtool.Itcreatespermanentrecordandfacilitatesrecordandresearchprocess.DocumentationinPhysiotherapyplaysanimportantroleasaprofessionalrequirement.Aholisticpatientcareisbestensuredthroughaccuratedocumentation,whichcanfacilitateinformationtoallthehealthcareteam.Electrotherapy as a part of intervention must be well planned and executed which must be guided through evidence. An evidence based practice has to be widely practiced while incorporating the electrotherapy modalities.Thiswillhelpinprovidingthebestcarewithcosteffectivenessandpreventionofcomplications.Documentationindeliveringtheelectrotherapyparametersisconsideredanimportanttool,whichguidesuniformity in treatment. Clinical decision making in the selection of modalities and to use best available evidence depends on the skill the practitioner which are guided by documentation. This observational study elaboratestheimportanceofdocumentationwithanaimtofindoutwhetherdocumentationisbeingdoneeffectivelywhileusingelectrotherapymodalitiesbyphysiotherapistsinMysuru.Seventytwoparticipantswereincludedinthestudy;theywereevaluatedaboutthedocumentationthroughquestionnairemethod.Theresultsyieldedthat17%documented,47%hadincompletedocumentation,36%didnotdocumentatall.ThisstudyconcludesthatdocumentationofelectrotherapytreatmentinclinicalpracticeinMysuruispoor(17%).

Keywords: Documentation, Physiotherapy, Electrotherapy, Patient records

Corresponding Author:VijaySamuelRajVAssistantProfessor,JSSCollegeofPhysiotherapyMGRoad,JSSHospitalCampusMysore–570004,KarnatakaPhone:+91-8123732414Email:[email protected]

INTRODUCTION

Document is any material that provides officialinformation or evidence or that serves as a record. Documentation is the process of classifying the official information and annotating texts,photographsand materials1. Documentation is a set of documents providedonpaper,online,orondigital,analogmedia.Some forms of documents include user guides, onlinehelp,quickreferenceguides.Typesofdocumentsusedare - requests for proposal, requirements/statement ofwork,scopeofworkandsoon.

Proper maintenance of source of documentation is a key but often an overlooked factor to ensure proper and accurate transactions are posted to the accounting system. Each time an organization makes a financialtransaction, a paper trail is generated. The presenceof documentation helps keep track of all aspects of an application and improves the quality. It focuses ondevelopment, maintenance and knowledge transfer toother developers2. It isquitecommoninmedicalfield,especially during critical care/ high risk management thatdocumentationdidn’thappenprecisely, accuratelyandcompletely.Itisindeedimportanttorecordthefactsand findings regarding patient care so that the recordreadslikeabook.Thepatient’schartisaboutcontinuumofcare.Ifarecordiswelldocumentedtofacilitatecare,then there is no worry that the record will be a liability if there is a claim. Hence, documenting is a criticalcomponent to the delivery of health care.

DOI Number: 10.5958/0973-5674.2019.00072.8


Itisatoolto:

z Ensure continuity of care as it serves as a communication tool among health care providers.

z Planandevaluateapatient’streatment.

z Create a permanent record or a database to evaluate effectivenessoftreatment

z Facilitate research

z Recollect memory and/ or justify/defend care provided.

Tips to maintain a document intelligently and clearly are-

z Mentiondate,timeandsigneveryentry

z Makeentriesimmediately/soonaftercareisgiven

z Writelegibly

z Bethorough,accurateandobjective

z Useapprovedabbreviations3.

Documentation in Physiotherapy: As per WorldConfederationofPhysicalTherapy(WCPT)guidelines,physiotherapist is required to document all aspectsof patient care including results of initial evaluation,diagnosis, plan of care, intervention, response totreatment, and soon.Thephysiotherapistmust ensurethat the document is accurate, complete, legible andfinalizedinatimelymanner,Isdatedandappropriatelyauthenticated, which includes status of patient andrationale of treatment

Physiotherapist must also make sure that documentation is used properly by ensuring that it is

z Stored securely at all times in accordance with legal requirements forprivacyandconfidentialofperson’shealthinformation.

z Only released, when appropriate with patient’spermission.

z Consistentwithreportingrequirements

z Consistent with intellectual and rational data standards where possible4.

Evidence to support the use of electrotherapy modalitiesisextensive.Itisusedasapartofaprotocol(planorpackage)ofcareintreatment,andisstrongandsupportive.Modernelectrotherapyneedstobeevidence

basedandusedappropriatelytobeeffective;otherwiseitcouldbeofnouseorcouldmakemattersworse,aslikeany other form of therapy. Skill of the practitioner in use of electrotherapy modalities to make appropriate clinical decisionastowhichmodalitytouseandwhen,andtouse best available evidence when making decision is required.Andwhateverdecisionistakeninadministeringelectrotherapy has to be documented so that the same treatment is carried out throughout the entire course of treatment for that particular patient. This enables any physiotherapistwhoisthereatthatmoment,tocarryouttheexacttreatmentthatwasdonepreviously.Similarly,anychangesintreatmentalsomustbedocumented,withjustification5.

Despite being aware of the importance of documentation, still not many physiotherapists followdocumentation while administering electrotherapy modalities, making uniformity in carrying out thetreatment difficult. There is a need to understand theutility of documentation practiced by the physiotherapist inthefieldofelectrotherapy

AIM AND OBJECTIVE

Find out whether documentation is being done effectivelywhileusingelectrotherapymodalitiesbyallthephysiotherapistsinvolvedinpatientcareinMysuru.The objective is to find out if documentation is beingdone while using electrotherapy as treatment in clinical practice and the reasons for lack of documentation while using electrotherapy modalities.

METHODOLOGY

This Observational study was limited to Mysurucity. All physiotherapists engaged in patient care in hospitals and using electrotherapy as one of their intervention in their patient care were included for the study. Physiotherapists working only in clinics and domiciliary care were excluded from this study. The physiotherapists were selected through exploring the directory of hospitals and contacted through phone for their consent to participate in this study. The data was collected by interview method using questionnaire,which was framed and validated by the experts with more than10yearsofexperienceinthefieldofphysiotherapy.

Procedure: AllthephysiotherapistsofMysuruworkingin hospitals were approached. The objective of the study


was explained and the consent for sharing information related to patient care documentation was obtained. A totalof72physiotherapistswereincludedinthisstudy,and no one refused to participate. A simple questionconsisting of whether the participants were documenting while administering electrotherapy modalities was asked. Those who said yes, were further deliveredvalidated questionnaire to know if the documentationwas effective or not, and the reasons for documentingwas further asked in the second level. For those who said no,oriftheysaidthatitwasincomplete,theywereaskedto justify the reasons for not doing/ completing and the answers they gave were noted. The answers given by all those who said no were summarized to obtain the results.

FINDINGS/RESULTS

A total of 72 physiotherapists, working in 6hospitals,andfrequentlyusingelectrotherapymodalities,participated in this study. The gender distributions are as shown in the table 1

Table 1: demographic data of participants

Gender Number PercentageMales 25 35%

Females 47 65%Total 72 100%

A total of 12 participants said that they regularly document treatment parameters while administering electrotherapy to patients. Thirty eight participants responded that they did not document the treatment given to patients using electrotherapy modalities. The remaining 26 participants said that they were documenting, but itwas not complete.The results arerepresented in Table 2 and Fig 1.

Table 2: Description of documentation by Physiotherapist

Description of documentation Participants* Percentage

Documented completely 12 17%

Did not document completely 34 47%

Did not document at all 26 36%*Quantityinnumbers

Fig. 1: Description of documentation by Physiotherapist

DISCUSSION

As evident from the results of the study,majorityof the participants did not do effective documentationwhileusingelectrotherapymodalities(47%didnotdoat all and 36% were incomplete). The reason for not doingatallwasthattherewaslackoftime,whichwassaid by most of the participants who did not document atall.Someofthemsaidthattheywerenotconfidentonwhether what they would document was right or not. The other reason given by a few of the participants for not doing documentation or not completing it was that they used to forget to do it later. The participants who said that they were doing complete documentation (17%)justified that this would be beneficial in carrying outthe same treatment by anyphysiotherapist, apart fromadhering to the hospital policy of documentation. These participants,onbeingaskedwhattheydocumented,saidthat all treatment parameters of that particular modality werenoted.Theysaidthatbydocumenting,uniformityin carrying out the same treatment to the patient was possible, and thereby, it also enabled adherence tothe policy of the hospital. The study indicates that for optimal continuity of care and to identify the patients,thereisaneedforimprovementinpromotingphysiotherapy documentation. One of the suggestionswas implementation of the electronically organised documentation6.

Hence, it is alarming to note that, despite beingaware of how important it is to document treatment parameters,aswithothertreatments,whileadministeringelectrotherapymodalities,mostof thephysiotherapistswere not documenting the details of treatment.

CONCLUSION

The present study concludes that documentation of electrotherapy treatment inclinicalpractice inMysuruis poor.


RECOMMENDATIONS

z The present study can be carried out among all the practicing physiotherapists of the country, toget a national scenario of documentation while administering electrotherapy modalities.

z Methods to improve the percentage ofdocumentation among practicing physiotherapists to be found out, as, majority of them do notdocument,despitebeingawareofhowimportantitis to document treatment of patients.

z Training on documentation and its importance can be incorporated and a longitudinal study can be carried out.

Conflict of Interest:Theauthorsdeclarenoconflictofinterest

Source of Funding: Self funded

Ethical Clearance:Taken from InstitutionalResearchCommittee (IRC),JSS College of Physiotherapy,Mysuru.

REFERENCES

1.Oxford Dictionaries | English. (2018).documentation | Definition of documentation inEnglishbyOxfordDictionaries.[online]Availableat: https://en.oxforddictionaries.com/definition/documentation[Accessed25Aug.2018].

2.SusanMHealthfield.Importanceofdocumentationin human resources [Internet] 2017[cited25 July 2018]. Available from https://www.thebalancecareers.com/documentation-1918096

3.Documentation-How important is it? [Internet].Crozer Keystone.2009 [cited June 2018].Available from: http://www.crozerkeystone.org/healthcare-professionals/medical-staff/physician-info/cme/articles/documentation/.

4.World Confederation for Physical Therapy.Policy statement: Description of physical therapy. London,UK:WCPT;2017.www.wcpt.org/policy/ps-descriptionPT(Accessdate9August2018)

5.ProfTimWatson.KeyconceptsinElectrotherapy.2017[cited 5 June 2018].Available from http://www.electrotherapy.org/assets/Downloads/Key%20Concepts%20in%20Electrotherapy%20March%202017.pdf(accessdate,9August2018)

6.World Confederation for Physical Therapy.Strategic Plan 2017-2021. https://members.physio-pedia.com/wp-content/uploads/2017/01/Strategic-Plan-Final-070716.pdf(Access date 8August 2018)

7.OlawaleOA,AkoduAK,TabesonEA.Analysisofphysiotherapydocumentationofpatients’recordsanddischargeplans ina tertiaryhospital. JClinSci2015;12:85-9.

The Effectiveness of Video Assisted Teaching Program on Reproductive Hygiene among Students at Selected College

Vishal A1, Ajay Kumar1, Sundari1, Lakshmi2

1B.Sc (Nursing) Student, 2Principal, Chettinad College of Nursing, Chettinad Academy of Research and Education, Kanchipuram district, Tamilnadu, India

ABSTRACT

ReproductiveHygieneshouldbelookedatthroughalifecycleapproachasitaffectsbothmenandwomenfrominfancytooldage.AccordingtoUNFPA,ReproductiveHygieneatanyageprofoundlyaffectshealthlaterinlife.Thelifecycleapproachincorporatesthechallengespeoplefaceatdifferenttimesintheirlivessuchasfamilyplanning,servicestopreventsexuallytransmitteddiseasesandearlydiagnosisandtreatmentofreproductivehealthillness.ReproductiveHygieneisdefinedasthestateofphysical,mentalandsocialwellbeinginallmattersrelatingtothereproductivesystem,atallstagesoflife.Itisnotmerelytheabsenceofdisease,dysfunctionorinfirmity.

ReproductiveHygieneimpliesthatpeopleareabletohavearesponsible,satisfyingandsafersexlifeandthat they have the capability to reproduce and that they have the capability to reproduce and freedom to decideif,whenandhowoftentodoso.Oneinterpretationofthisimpliesthatmenandwomenoughttobeinformedofandtohaveaccesstosafe,effective,affordableandacceptablemethodsofbirthcontrol.

AstudytoassesstheeffectivenessofvideoassistedteachingonReproductiveHygieneamongfemalecollegestudentsinDhanalakshmiEngineeringCollege,Poonchery,KanchipuramDistrict,TamilNadu,India.Thestudy was conducted with the aim to improve the knowledge on Reproductive Hygiene among the college students.AQusaiExperimentalstudywasconductedandthesamplewasconsistedofatotalof100femalecollegestudents.Thetoolusedforthisstudywasstructuredquestionnaire.

The data of the study was collected after conducting video assisted teaching on Reproductive Hygiene. TherewasasignificantincreaseintheknowledgelevelofcollegestudentsonReproductiveHygiene.

Keywords: knowledge, Reproductive Hygiene, female students of an Engineering college, effectives, video assisted teaching programme.

Corresponding Author:Mr.VishalA.B.Sc(Nursing)Student,ChettinadCollegeofNursing,ChettinadAcademyofResearchandEducation,Kanchipuramdistrict,Tamilnadu,IndiaEmail: [email protected]

INTRODUCTIONHygiene is Two Thirds of Health

−Lebanese

According toWHO,Reproductivehygiene shouldbe looked at through a lifecycle approach as it affectsboth men and women from infancy to old age. According toUNFPA,ReproductiveHygieneatanyageprofoundlyaffects health later in life. The life cycle approach

incorporates the challenges people face at differenttimes in their lives such as family planning, servicesto prevent sexually transmitted diseases and early diagnosis and treatment of reproductive health illness. ReproductiveHygieneisdefinedasthestateofphysical,mental and social well being in all matters relating to the reproductive system, at all stages of life. It is notmerelytheabsenceofdisease,dysfunctionorinfirmity.Reproductive Hygiene implies that people are able to have a responsible, satisfying and safer sex life andthat they have the capability to reproduce and that they have the capability to reproduce and freedom to decide if,whenandhowoftentodoso.Oneinterpretationofthis implies that men and women ought to be informed ofand tohaveaccess tosafe,effective,affordableandacceptable methods of birth control.[1]

DOI Number: 10.5958/0973-5674.2019.00073.X


Reproductive hygiene must be carried out by every individual in order to prevent reproductive disorders and diseases.We can get many types of diseases withoutproper care of our reproductive system. The worst part is that some of them can cause infertility.[2]

To protect us from these types of diseases there areways toprevent itbyscreening forHIVandothersexually transmitted disease. We should not ignoreaboutourprostate.Beawareofworkplacehazards.Weshould take care of our testicles; Stay away from toxins; Increasecalciumandmagnesiumintakeinourdiet.[3]

Take proper hygiene when menstruating; get a check up with a female doctor every 6 months. Eat withaproperdietlowinfatandhighinfiber.Maintaina healthy weight. Consume proper amounts of good quality drinking water. Get adequate rest. Exerciseregularly. Do not smoke and take illegal drugs. Reduce stress levels.[4]

TITLE

A quasi Experimental study to assess theeffectiveness of video assisted teaching program onReproductive Hygiene among students in a selected college,KanchipuramDistrict,TamilNadu,India.

OBJECTIVES OF THE STUDY

To assess the pre test and post test knowledge level on Reproductive Hygiene among the female students in a selected college.

To determine the effectiveness of video assistedteaching on Reproductive Hygiene among college students.

To associate between post test knowledge score and selected demographic variables like educational status and their family income

Hypothesis:

H1: There will be a significant difference betweenpre and post test knowledge scores on Reproductive Hygiene.

H2: There will be a significant association betweenpost test knowledge scores of female students regarding Reproductive Hygiene and selected demographic variables such as educational status and their family income

RESEARCH METHODOLOGY

This chapter deals with the description of research methodology adopted by the investigators to study and analyze the outcome of structured questionnairemethodology is the most important part of any research which enables the researcher to form a blue print of the study.

Sampling Criteria:

Inclusion Criteria:

z The female students who are available at the time of study.

z The students who can write and speak English and Tamil.

Exclusion Criteria:

z The college students who are not willing to participate in the study.

z The college students who are having any physical illness.

Section A: Description of Demographic Characteristics

Table 1: Frequency and percentage distribution of samples with reference to gender, educational qualification of the family, occupation of the family members and their family income

(N = 100)

Characteristics Categories Frequency Percentage

1. GenderMale 0 0

Female 0 0

2.Educationalqualificationof the family.

No formal education 19 19Primary education 10 10

High school education 10 10


Conted…

Higher secondary education 26 26Graduation 30 30

Post graduation and above 05 05

3.Occupation

Private employee 27 27Government employee 11 11

Self employed 21 21Others 41 41

4.Monthlyincome

LessthanRs.5000 16 16Rs.5000 to Rs.10000 31 31RS.10001to Rs.15000 12 12Rs.15001to Rs. 20000 23 23Rs. 20001 and above 18 18

Plan For Data Collection Procedure: The main study wasconductedinDhanalakshmiCollegeofEngineering,Poonchery,KanchipuramDistrict in themonthofApril2018. The data collection period was for one week. The investigators obtained written permission from the Dean, Chettinad Hospital and Research Instituteand the Principal of Chettinad College of Nursing and written consent from the each student prior to the study. The investigators introduced them to the respondents to ascertain their cooperation for the study. Later, theinvestigator collect data from the samples after obtaining their consent. Data were collected from 100 female collegestudentswhofulfilled thecriteria.Demographicdata was collected and the structured questionnairewas given to assess the knowledge on Reproductive Hygieneamongfemalecollegestudents.Theytook10-15minutestoanswerthequestionnaire.Afteranalyzing,theinvestigators provided video assisted teaching program on Reproductive Hygiene for about 20 minutes. After 6 days theinvestigatorsadministeredthesamequestionnairetothe same female college students to assess how much knowledge they gained. The college students took 10 minutes to answer the questionnaire. The investigatorsthanked the college students and the authorities for their cooperation and support for the study.

Section B: Assessment of Pre Test Level of Knowledge on Reproductive Hygiene:

Table 2: Frequency and percentage distribution of pre test level of knowledge on reproductive hygiene

Level of Knowledge Frequency PercentageInadequate 62 62Moderate 36 36Adequate 02 02

Table 2 shows the students knowledge in pre test were having (62%) having low knowledge, (36%)havingmoderateknowledgeand(2%)arehavinghighknowledge.

Section C: Effectiveness of Video Assisted Teaching Level of Knowledge on Reproductive Hygiene Among College Students.

Table 3: Frequency and percentage distribution of post test level of knowledge on reproductive hygiene

Level of Knowledge Frequency PercentageInadequate 8 8Moderate 52 52Adequate 40 40

Table 3 shows the students knowledge in post test were having (8%) are having low knowledge, (52%)arehavingmoderateknowledge,(40%)arehavinghighknowledge regarding reproductive hygiene.

Section D: Comparison of Pre and Post Test Level of Knowledge on Reproductive Hygiene among College Students.

Table 4: Comparison of pre test and post test level of knowledge on reproductive hygiene among college

students.(N = 100)

Test Mean SD Paired T Test

PRE TEST 9 3.86T=40.7

POSTTEST 15 2.53*p<0.05significant


Table 4: The analysis reveals that with respect to knowledge the mean value 9 with SD 3.86 of pre test and themeanvalueof15withSD2.53ofposttestprojects’’valueas40.7isstatisticallysignificantatp<0.05level.

RESULT

The research finding reveal that Assess the pre test level of knowledge on Reproductive Hygiene among female students: The study result shows that the level of knowledge of students regarding Reproductive Hygiene wasassessedbystructuredquestionnaireandanalyzedusing descriptive statistics that indicates the mean pre test knowledge scorewithmean (XI=9) and StandardDeviation(3.86).

Evaluate effectiveness of video assisted teaching on knowledge on Reproductive Hygiene among female students: The study result shows the there is a difference in knowledge of subjects regardingthe aspects after the administration of video assisted teaching on Reproductive Hygiene. Data depicts that theMeanposttestknowledgescorewashigherthantheMeanpretestknowledgescore.Thecalculatedtvalueisgreater than the table value. The computed t value shows thattherewasasignificancedifferencebetweenthetwomean knowledge score on hypothesis and the research hypothesis was accepted.

This indicates that video assisted teaching is effective in increasing theknowledgeonReproductiveHygiene score of the female students.

Comparison of the pre test and post test knowledge scores on Reproductive Hygiene among female students: The study results shows that there is a difference in the knowledge onReproductiveHygieneamong female students after the administration of video assisted teaching. The accepted t value is greater than thatofthetablevalue(t<pvalue)

Association of the post test knowledge on Reproductive Hygiene with related demographic variables: As therewasnosignificanceassociationofpost test knowledge score with the selected demographic variablessuchasgender,educationalqualificationofthefamily,occupationofthefamily,monthlyincomeofthefamily of the female students.

Inconclusion, thediscussionof thestudyfindingsobtained by the researchers shows that there was a

significant difference in the level of knowledge onReproductive Hygiene after administration of video assisted teaching among female students.

CONCLUSION

The result from this study shows that level of knowledge on Reproductive Hygiene among female studentswas inadequate andmoderate.This has to betaken into consideration. There may be reason for early studentinadequacy,whichcanbeimprovedupon.

Video assisted teaching is one of the effectivemethods in increasing the knowledge regarding Reproductive Hygiene among female students. The findingofthestudyshowsasignificantlyincreasedinthepost test level of knowledge score after administration of video assisted teaching.

Ethical Clearance: Chettinad Academy of Research andEducationInstitutionalHumanEthicsCommittee.



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2.JoyceMBlack,JaneHokinsonHawks.TextbookofMedicalSurgicalnursing.8th edition. Elsevier publisher.Indiapage2017pageno;524-531.

3.Park K. Text book of preventive and socialmedicine. 23th edition. Banarsidas BhanotPublisher.India.Pageno:461-465.

4.Bornman M, Delport R, Farías P, Aneck-HahnN,PatrickS,MillarRP,DeJagerC.Alterationsin male reproductive hormones in relation to environmental DDT exposure. Environment international.2018Apr1;113:281-9.

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Adolescents in Slemanregency, Yogyakarta,Indonesia. Journal of family & reproductivehealth.2017Jun;11(2):104.

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Gender Difference in the Relationship between Work Stress and Quality of Life: The Case of Physical and Occupational

Therapists in Taiwan

Yi-Ching Lin1, Yu-Li Lan2, Yu-Hua Yan3, Yu-ping Tang1

1Department of Rehabilitation, Taiwan Adventist Hospital; 424, Sec. 2, Bade Rd., Songshan District, Taipei City, Taiwan (R.O.C.); 2Department of Health Administration, Tzu Chi University of Science and

Technology; 880, Sec.2, Chien-kuo Rd. Hualien City 970, Taiwan (R.O.C.); 3Superintendent office, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation); 670, Chongde Rd., East Dist.,

Tainan City 701, Taiwan (R.O.C.)

ABSTRACT

Background:This study investigated the influenceofgenderdifferenceon the effectofwork stressonqualityoflife(QoL).

Method:Thisstudywasacross-sectionalstudycombinedwithaquestionnaireinvestigation.Participantswerephysicalandoccupationaltherapistsat10hospitalsinTaiwan.Of162copiesofthequestionnairethatweredistributed,132werevalid,yieldingavalidreturnrateof81.4%.

Results:WorkstressandworkloadwerenotsignificantlycorrelatedwithQoLformen(F=0.931,R2=0.390,p>0.1),butweresignificantlyandpositivelycorrelatedwithQoLforwomen(F=2.405,R2 =0.495,p<0.05).

Conclusion:Provideaclean,safe,andcomfortableworkingenvironmentandopportunitiesforlearningandgrowth,andcompetitivepayandbenefits.Theseeffortswouldhelptoreducetheworkstressandworkloadofmedical professionals,which could lower the staff turnover rate, thereby lowering the labor costs ofmedicalinstitutions,andenhancethequalityofmedicalcareprovided.

Keywords: gender difference, work stress, workload, quality of life

Corresponding Author:Yu-HuaYanTainanMunicipalHospital(ManagedbyShowChwanMedicalCareCorporation);670,ChongdeRd.,EastDist.,TainanCity701,Taiwan(R.O.C.);Email: [email protected]

INTRODUCTION

InTaiwan,theuniversalNationalHealthInsurancehas made seeking medical support affordable. Inaddition,theincreasedprevalenceofchronicdiseasesinan aging population has resulted in patients presenting with more severe diseases and a growing demand for health care services. Resulting in high levels of work stress.Workstresshasaconsiderableinfluenceonhealth

care professionals; specifically, excessive work stresscan lead to unbalanced physical functions and affectthe professionals’ thoughts, emotions, and behaviors,increasing the likelihood of errors or accidents [1]and affectingtheirsafetybehavior[2].

Quality of life (QoL) is defined as satisfactionwithlife,especiallywithrespecttoafeelingofdignity,physical andmentalhealth,happiness, andadjustment [3-6]. The World Health Organization defined QoLas individuals’ perceptions and cognitions of “theirpositioninlife…inrelationtotheirgoals,expectations,standards,andconcerns”[7];itissubjecttotheinfluencesof “physical health, psychological state, level ofindependence, social relationships, personal beliefs,and…theirenvironment.”AltafandAwan[8] determined that in a situation characterized by limited resources or time, the following can all be considered instances of

DOI Number: 10.5958/0973-5674.2019.00074.1


excessiveworkload:beingrequiredtoworkovertimeorperformmore tasks than they can reasonablymanage,beingdeprivedofanadequateamountoftimeforrest,and being demanded to achieve improbable or impossible expectations [9-10].Lin,Chou,andTsai[11] demonstrated thatthedegreeofworkstressofemployeesaffectedtheirlikelihood of experiencing occupational burnout.

HartandWickens[12] posited that workload refers to the costs employees pay when executing assigned tasks; costs includeattention,physical fatigue, andemotionalstress such as anxiety [13-14]. The symptoms associated with stress induced by such a working environment can degradehealthprofessionals’physicalandmentalhealthas well as their service quality [15]. Therefore, hospitaladministrators should regularly conduct surveys to identifyhealthprofessionalswithahigh self-perceivedlevel of work stress[16]. The relevant foreign literature has incorporated gender as a factor in empirical analyses of health,but littleresearchhasbeenconductedregardingthegenderdifferenceofemployeesindiverseprofessionalfields.Withrespecttogenderdifference,botheasternandwestern cultures tend to adopt a dichotomous framework in which men are generally viewed as rational and masculine and women are generally viewed as sensitive and feminine[17-20].Thus,thepresentstudyhypothesizedthatgenderdifferencealsoexertedaninfluenceonworkstressandQoL.

The average life expectancy of human beings has been extended along with progress and technological advancements. However, human beings have alsobecome subject to a growing number of stresses and health threats that affect people’s modes of living.

Nevertheless,thepursuitofafavorableQoLhasbecomea key life goal for people in the contemporary world[21]. This study investigated the effect of gender differenceon the relationshipbetweenworkstressandQoL.Thephysical and occupational therapists in Taiwan were recruited as research participants. The results can serve as a reference for administrators and managers for developing employee safety policies to alleviate work stress and improve workplace safety for therapists employed in rehabilitation departments, therebyenhancingthetherapists’intentiontostay.


This study employed convenience sampling to select eligible physical and occupational therapists from rehabilitation departments.A cross-sectional study wasthen conductedwith a questionnaire.The questionnairewas distributed at 10 medical institutions; 162 copies were distributed. The researcher compiled and reviewed thereturnedcopiestoeliminateinvalidones,whichwereeitherblank,incomplete,orfilledoutbypeopleotherthanthe research participants. Eventually, 132 valid copieswereobtained,yieldingavalidreturnrateof81.4%.

With respect to the data collected using thequestionnaire, the dimensions and their respectiveCronbach’s α were as follows: work stress had 10items and a Cronbach’s α of 0.863, workload had 6items and a Cronbach’s α of 0.79, QoL had 10 itemsandaCronbach’sαof0.869,andtheoverallreliabilityanalysisofempiricaldatahadaCronbach’sαof0.857.Therefore, the empirical data collected in this studyexhibitedadequatereliability(Table1).

Table 1: Pearson Correlation Analysis

Construct Mean SD Cronbach’s α Work stress Workload Quality of lifeWorkstress 3.289 0.653 0.863 1Workload 3.693 0.483 0.791 -.116 1

Qualityoflife 3.243 0.534 0.869 -.209* .176* 1Note:*p<.05

Table 2: Baseline characteristics (N = 132)

Measure Male % Female % Sum % X2

Age≦34Years 35 26.5 46 34.8 81 61.4

0.476≧35Years 20 15.2 31 23.5 51 38.6


Conted…

Civil statusSingle 34 25.8 46 34.8 80 60.6

0.477Married 21 15.9 31 23.5 52 39.4

Presence of childrenNo 15 11.4 21 15.9 36 27.3

0.580Yes 40 30.3 56 42.4 96 72.7

Educational levelJuniorcollege 1 0.8 9 6.8 10 7.6

0.017University 45 34.1 64 48.5 109 82.6Graduate school 9 6.8 4 3.0 13 9.8

J Public HealthMedicalcenter 14 10.6 22 16.7 36 27.3

0.565Regional hospital 11 8.3 20 15.2 31 23.5District hospital 30 22.7 35 26.5 65 49.2

Type of profession licenseOccupationaltherapist 40 30.3 55 41.7 95 72.0

0.236Speech-languagepathologist 15 11.4 22 16.7 37 28.0Length of service (year)

≦10Years 45 34.1 54 40.9 99 75.00.092

≧11Years 10 7.6 23 17.4 33 25.0Average leisure time per week (hour)

<10 18 13.6 28 21.2 46 34.8

0.89211–20 17 12.9 26 19.7 43 32.621–30 12 9.1 14 10.6 26 19.7>30 8 6.1 9 6.8 17 12.9

Average expense on leisure per week (NT$)<2,000 18 13.6 30 22.7 48 36.4

0.8952,001–4,000 15 11.4 21 15.9 36 27.34,001–6,000 12 9.1 13 9.8 25 18.96,001–8,000 5 3.8 5 3.8 10 7.6>8,000 5 3.8 8 6.1 13 9.8

Table 3: Regression model

Measure Quality of lifeControl variable Male Female

Age (Referencegroup:≦34Years)

0.274 1.720*

Civil status (Referencegroup:Married)

1.067 1.056

Presence of children (Referencegroup:Yes)

-.581 2.370**

Educational level (Reference group: college)Juniorcollege .141 -1.606

Graduate school -.953 -.340

Conted…

Medical institution level(Reference group: Regional hospital)

Medicalcenter -1.460 -1.606District hospital -1.037 -.340

Type of professional license(Reference group: Occupational therapist)

Physical therapist -2.070** .457Lengthofservice(Reference

group: ≦10Years)-1.362 .566

Average leisure time per week(Reference group: < 10 hours)


Conted…

11–20hours -1.119 -1.788*21–30hours -.597 1.575>30hours -.696 1.579

Average cost on leisure per week (Reference group: < NT$2,000)

NT$2,001–4,000 -.318 .307NT$4,001–6,000 1.184 -1.221NT$6,001–8,000 .539 -1.857*>NT$8,000 .227 -.718

Independent variableWorkstress -1.759* 1.853*Workload .148 2.981**

R2 .390 .495Adj. R2 -.029 .289F values 0.931 2.405P values 0.562 0.005**

Note:**p<.05,*p<.1

RESULT

Atotalof132questionnairecopieswere returned.The demographic characteristics and work characteristics wereasfollows.Morewomen(n=77;58.3%)thanmen(n=55;41.7%)weresurveyed,mostofthemwereaged34yearsorless(n=80;60.6%).Mostoftherespondentswere single (n = 80; 60.6%) but some of them weremarried(n=52;39.4%),36of themhadhadchildren(27.3%). Most of the respondents were universitygraduates (n = 109; 82.6%).With respect to the levelof the medical institutions at which they worked, thegreatest proportion of the respondents worked at district hospitals(n=65;49.2%),followedbymedicalcenters(n=35;26.5%)andregionalhospitals(n=32;24.2%).Most of the respondents had fewer than 10 years ofservice (n = 99; 75%). The respondents generallyarranged fewer than 10 hours of leisure time per week (n=46;36.2%)andspentlessthanNT$2000forleisureactivitieseachmonth(n=48;36.4%)(Table2).

The results indicated that work stress and workload didnotexertasignificantinfluenceontheQoLofmen(F=0.931,R2=0.390).Comparedwithworkingasanoccupational therapist,working as a physical therapisthadasignificantlynegativeinfluenceontherespondents’QoL(p <0.05,β=−.378,andT=−2.070);moreover,

the effect of work stress on QoL exhibited negativestatisticalsignificance(p <0.01,β=−.298,T=−1.759).Forwomen,workstressandworkloadhadsignificantlypositiveinfluencesontheirQoL(F=2.405,R2=0.495),andbeingolderthan35yearshadasignificantlynegativeinfluence on theirQoL (p < 0.1, β = .87,T = 1.720).Having children had a significantly negative influenceontheirQoL(p <0.5,β=.481,T=2.370),andhavingmore than 11 years of service also had a significantlynegative influenceon theirQoL (p <0.01,β=−.653,T=−3.540).Significantlynegative influencesonQoLwerealsoobservedamongwomenwhoarranged11–20hoursofleisuretimeperweekandspendNT$8,000permonthforleisureactivities(p <0.1).TheirworkloadhadasignificantlypositiveinfluenceontheirQoL(p <0.05,β=.350,T=2.981)(Table3).

DISCUSSION

InTaiwan,mostrehabilitationtherapistsareemployedin the rehabilitation department of medical institutions of various levels. More male participants than femaleones were recruited in this study. Although no gender restrictionsareimposedonrehabilitationtherapists, thisstudy inferred that the specialty of the medical institution with which the rehabilitation department is generally affiliated(e.g.,anorthopedicclinic)couldhaveaffectedthe gender proportion of therapists, thus leading to ahigher proportion of male therapists.

ThisstudyrevealedthattheeffectofworkstressonQoLwassignificantlypositiveinwomenbutnotmen.Thisfindingwaspossiblybecausemenaregenerallylessattentive to details, aremore prone to thinkpositivelyand communicate when encountering difficulties, andarelesssusceptibletotheinfluenceofinterruptionsfromtheir personal liveswhen they are atwork.Therefore,compared with women, men may be more easilysatisfied in terms ofwork-relatedQoL.However, thisresultdiffersfromthatofothercareertypes.Harrison[22] determined that medical teams generally had relatively highexpectationsofmen,resultingintheexperienceofrelatively high levels of stress by male nurses working inanenvironmentdominatedbyfemalecoworkers.Lin,Liang, and Chen [23] explored the gender difference inthe relationship between religious beliefs and health-related QoL and discovered that women were morelikely than men to seek religious assistance or engage in religiousactivitieswhentheyencountereddifficultiesorexperienced health deterioration.


However, this study also determined that thedemographic characteristics (e.g., sex and number ofchildren)andworkconditionsoftheworkers(primarilythe arrangement of leisure activities per week) were the key factors influencingworkload andQoL.The resultsalso differed from those of other studies. Wang andHung[24] contended that in addition to payment and work content,work-relatedQoLformedicalstaffshouldincludea comfortable work environment, reasonable payment,and an opportunity for learning and personal growth.

CONCLUSION

Most Taiwanese studies on the QoL of hospitalemployeeshavefocusedonnurses.Onthebasisoftheresults obtained in this study,we suggest thatmedicalinstitutionsadoptappropriateleadershipstyles,maintainsatisfactory communication channels, and provideexcellent working environments and opportunities for learning and growth, as well as reasonable paymentandbenefits,toreducetheworkstressandworkloadofmedicalprofessionals,decreasetheirturnoverrate,lowerthelaborcostsofmedicalinstitutions,andenhancethequalityofmedicalcareprovided.

Because of various accreditation projectsimplementedinrecentyears,anemphasisonteamworkhas prevailed in medical institutions. The continual pursuit of high-quality medical services has imposedintangible stress on physical and occupational therapists inrehabilitationdepartments,influencingtheirintentionto continue to work at their current post. Therefore,administrators should endeavor to mitigate work stress and reduce the occupational hazards of health professionals,therebyensuringthesafetyoftheirworkenvironment.

Onthebasisoftheresearchresults,threesuggestionsare proposed: (1) Flexible staffing can be introducedto lower the workload of physical and occupational therapists; specifically, a mentoring system can beestablished whereby the care of patients with severe disease conditions or difficulties in treatment can beavailable on a flexible basis. (2) For employees whohaveexperiencedwork-relatedaccidents,theirworkloadshouldbereduced,andappropriatecounseling,care,andassistanceshouldbeprovided.(3)Administratorsshouldinterview health professionals regularly to determine the factorscausingworkstress,andproposecorrespondingmeasures for work stress relief.


Ethical Clearance: The research design was approved bytheInstitutionalReviewBoardofTaiwanAdventistHospital(105-E-21).

Source of Funding: Taiwan Adventist Hospital for research funding

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7.World Health Organization. Measuring ofQuality ofLife.TheDevelopment of theWorldHealth Organization Quality of Life Instrument(WHOQOL); Geneva: WHO (MNH/PSF/93.1),1993.

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9.Kahn RL, Wolfe DM, Quinn RP, Snoek J D.OrganizationStress:StudiesinRoleConflictandAmbiguity,JohnWiley&Sons,Inc,1980.

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Effect of Playing Badminton on Cervical Spine Posture in Young Collegiate Students

Tanya Gujral1, Zuheb Ahmed Siddiqui2

1Bachelor of Physiotherapy (BPT), 2Assistant Professor, Department of Rehabilitation Sciences, School of Nursing Sciences and Allied Health, Jamia Hamdard

ABSTRACT

Objectives: To evaluate and compare the cervical spine posture of young collegiate badminton players and non-trainingcollegiatestudents.

Method: Atotalof80malesubjectsallagedbetween18–25yearswererecruitedbasedontheinclusioncriteria and divided into two groups. GroupA had 40 collegiate badminton players and Group B had40 untrained collegiate students.The subjects underwent a baseline evaluation procedurewhere height,bodyweightandBMIweredetermined.Cervicalspineposturewasmeasuredusingsagittalheadtiltandcraniovertebral angle.

Result: Theresultswererevealedusingunpairedt-testwithalphabeingsetat0.05level(p<0.05).Absolutevaluesoftforsagittalheadtiltcameouttobe0.124(p=0.534)andforcraniovertebralangleitwas0.156(p=0.729).Nosignificantdifferenceswerefoundbetweenthetwogroupsforanyoftheanglesofcervicalspine.

Conclusion: Itcanbeconcluded that throughpostureanalysis,playingbadmintondoesnot imposeanyimpactoncervicalspineposture.Thusnosignificantdifferenceswerefoundin thepostureofcollegiatebadminton players as compared to untrained peers.

Keywords: neck posture, badminton, evaluation, sagittal head tilt

Corresponding Author:Dr.ZuhebAhmedSiddiqui(PT)AssistantProfessor,DepartmentofRehabilitationSciences,SchoolofNursingSciencesandAlliedHealth,JamiaHamdard,NewDelhi–110062Mobile:+919810744297Email:[email protected]

INTRODUCTION

Badminton is the fastest non-contact racket sportwhich involves immediate jumps, lunging combinedwith the movement of the upper extremity and rapid turnings from a variety of postural positions 1. An estimated 150 million people play the sport throughout the world and around 2000 players participating in international competitions 2.Peopleofdifferentgender,age and skill level participate in badminton as a form of physical exercise or athletic competitions 3.

BadmintonisapopularandsecondmostplayedsportinIndia.Sportingactivitiesareanimportantstimulatorfor both motor and physical development of young individuals 4. Regular participation in sporting activities moulds the character of a young person, improvesmotor function and coordination and affects physicaldevelopmentandbodyposturesignificantly5.However,special care should be given to young individuals when they take part in strenuous physical training in order to ensure their proper physical development 6.

Correct body posture requires symmetry in bothtransverse and frontal plane, proper sagittal planealignment of the spine and proper arrangement of various body parts 6. Previous studies have evaluated the influence of sports training and physical activityon posture concluding with both positive and negative impact depending on the exercises performed 5, 6. Posture alterations and disorders of gross joint mobility are common in athletes and the general population as well 7.Manysportingactivitiesinvolvetheuseofeitherrighthandor lefthandduringplay.Kendalletalhave

DOI Number: 10.5958/0973-5674.2019.00075.3


demonstrated that one hand dominance results in muscle imbalance and leads to postural asymmetries 8.

Evidence based on clinical experiences has demonstrated that playing an appropriate sport supports and helps to build a good posture 7.However,sportsthatinvolve overhead activities such as tennis, volleyball,basketball etc. lead to intensive overloading mainly asymmetric causing undesirable changes in posture 5-9. During the game and practice, repetition of specificmovementsandtheadoptionofspecificposturesbytheplayers results in unilateral overloading 9. According to VařekaandDvorak,anoptimalposture is required forperforming a targeted motion10.Manyresearchershavedescribedposturalasymmetriesinsportslikevolleyball,basketball etc. but studies involving badminton are scarce11,12,13,14.

Our study aims to assess the effect of playingbadminton on cervical spine posture. With our study,students at risk of injury and musculoskeletal pain can be identified.Itwillalsohelptodemonstratethatinvolvingin physical activities like badminton either act as a good medium for building and supporting a good posture or else it places additional stress on musculoskeletal structures andleadstoposturalimbalance.Moreover,itwillsupportthe fact that training of upper extremities on both sides to be incorporated into the daily regimes of sportspersons.

MATERIALS & METHOD

This study was a correlational study design. A total of 80 subjects were recruited based on the inclusion and exclusion criteria. Group A had 40 subjects that were engaged in at least 6 months of regular badminton training while Group - B subjects were 40 collegiate students.Informedconsentwasobtainedfromthesubjectsbeforethey underwent a baseline evaluation procedure.

Inclusion Criteria:

z Allmalesubjectsagedbetween18–25yearswereincluded.

z Recreational collegiate badminton players who were engaged in at least 6 months of regular badminton training

Exclusion Criteria:

z Subjects who have neck and shoulder surgery.

z Subjectswithanyhistoryofback,neck,orshoulderpain in the last 6 months.

z Subjects with a history of a tumour or injury to an anatomical structure.

z Subjects diagnosed with a cardiovascular and neurovascular disease.

z Veryseverepainpreventingparticipation

z Systemicinflammatorydisorders

z Scoliosis

Outcome Measures:

z Sagittal Head Tilt

z Craniovertebral Angle

PROCEDURE

The cervical spine posture was assessed by measuringSagittalHeadTilt(SHT)andCraniovertebralangle (CVA)usingsagittalplanephotographs.SagittalHeadTilt isdefinedas theanglebetweenahorizontalline passing through tragus of the ear and a line passing through canthus of the eye 15. Craniovertebral Angle is definedas theanglebetweenahorizontal linepassingthrough C7 vertebrae and a line extending from thetragusoftheeartoC716.

The images for measuring SHT and CVA werecaptured using a digital camera (Sony Cyber-shotDSC-W530 14.1megapixels) placed on an adjustabletripod 0.3m from the subject. The subjects were asked to remove their shoes and wear sportswear so that their neck and upper thoracic spine could be exposed. The spinous process of seventh cervical vertebrae was palpated and a marker was placed on the most prominent midpoint. Another marker was placed on tragus of the right ear. The subjects were instructed to stand with the lateral side of the trunk facing the camera and to lookata targetfixed in front.Theywere instructed tostand relaxed placing their weight evenly on both feet. Subjects were asked to walk 10 steps and then stand still.Theresearcheraskedthesubjecttoflexandextendthe neck for a few times after assuming the standing restingposture.Then, three sagittalplanephotosweretakenontherightsideofthesubjects’bodyandsavedto a personal computer for further analysis. Repeated photographs aimed at reducing bias due to subject’stension during photography capturing as well as to overcomethedifferencebetweenmeasurementsbecauseof postural swaying. Analysis of photographs was done


usingtheUTHSCSAImageToolProgram(UniversityofTexasHealthScienceCenter,SanAntonio,Texas).

Figure 1: Craniovertebral Angle

Figure 2: Sagittal Head Tilt


Data was computed and analyzed using SPSS 20.0 version and find out the t-value unpaired t-test (two-tailed)wasused.Thesignificancelevelwassetatp<0.05.

RESULTS

Demographic Data: A total of 80 male subjects volunteered in the study. Their demographic data was analyzed by comparing the means of descriptive analysis. Theirage,height,weight,andBMIwererecorded.Themeanage(inyears)inGroupAandGroupBwere19.97±1.57,21.00±1.56respectively.Meanheight(incms)inGroupAandGroupBwas167.92±9.8and159.71±23.17respectively.Meanweight(Kgs)GroupAandGroupBwas64.21±9.62and62.19±19.52respectively.

ThemeanBMIinGroupAandGroupBwere22.75±2.83 and 24.09 ± 10.1 respectively. Table 1 gives details of the mean and standard deviation of these data. These variables had no significant differences between thegroups.

Table 1: Demographic details of the subjects

Group A Group BNumber of Subjects 40 40

Age 19.97±1.57 21.00 ± 1.56Height 167.92±9.8 159.71±23.17Weight 64.21 ± 9.62 62.19 ± 19.52BMI 22.75±2.83 24.09 ± 10.1

Cervical Angles: Craniovertebral angle was measured three times and sagittal head tilt was measured three times.Betweengroupsanalysisofcraniovertebralangleand sagittal head tilt was conducted using an unpaired t –testwithlevelofsignificancesetatp<0.05.Themeanof craniovertebral angle came out to be 131.4 ± 6.39 ofgroupAand128.87 ± 4.94ofgroupB.Themeanofsagittal head tilt came out to be 166.22±4.77 of group A and 165.18±5.47ofgroupB.AbsolutevaluesoftforCVAandSHTcameouttobe0.156(p=0.729)and0.124(0.534)respectively.Thereadingsofboththegroupsforcraniovertebral angle and sagittal head tilt angle were statisticallynon-significant.

Table 2: Mean and standard deviation of Cervical Angles

Group AMean ± SD

Group BMean ± SD p-value

SHT 166.22±4.77 165.18±5.47 0.534CVA 131.4 ± 6.39 128.87 ± 4.94 0.729

DISCUSSION

Sagittal head tilt:According to clinicians, a forwardhead posture implicates an extended upper cervical spine anda relativelyflexed lowercervical spine 17. Sagittal head tilt describes an inclination of the head from the horizontalandreflectsthepostureoftheuppercervicalspine 15.Thefindingsofourstudydemonstratedanon-significantdifferencebetweenthetwogroupswithmeanvaluesforGroupAandGroupBas166.22º ±4.77and165.18 º±5.47 respectively.Ourfindingsare incloseproximity to the findings of Harrison and colleagues


reportingasagittalheadtiltof161.2ºinasymptomaticsubjects 18. Niekerk et al reported a mean sagittal head tiltof159.95ºamonghighschoolstudentsmeasuredinsitting position 19. Szeto et al have also reported mean values164.91ºinasymptomaticofficeworkers20.

As forward head posture causes shortening of sub-occipitalmuscles thereby lengthening the anteriorneck flexors and producing hyperextension of theupper cervical spine 21.Theflexormomentcreateddueto forward head posture is balanced by the extensor moment created by cervical erector spinae muscle 27. As a result no static cervical posture is adopted while playing badminton;henceitdoesnotimposeasignificantloadon neck muscles.

Craniovertebral angle: The present study demonstrated a statistically non-significant difference for thecraniovertebral angle between the two groups with mean values forGroupA andGroupB as 131.4º and128.87ºrespectively.InastudybyRaineandTwomeyon asymptomatic subjects a mean craniovertebral angle 127.8º (aged 17 to 29 years)was reported15, which isslightly less than the value reported for students in our study.ThefindingsofourstudyareincloseproximitywiththefindingsofHarrisonetal18 that reported mean CVAvalueof130.7º.

A non-significant difference between the meanvalues of the two groups is that head and neck do not contribute to the coordinated sequence of actionsrequiredforplayingastrokeorsmashduringthegameof badminton 5, 22. During forehand and backhand strokes, the large proximalmuscles initiate the actionwhile the distally located smaller muscles follow up through contact with the shuttle in a coordinated sequence 22. All the body segments are required tofunction in a coordinated manner for generation of forces required for the propulsion of the shuttle. Thiscoordinated sequencing of the segments in a distal toproximalmanner is termed as the “kinetic chain” andmaybereferredtoasawhip-likeaction23. The legs and trunk provide a stable base so that the motion of the arm can take place and the scapula acts as a link between distal and proximal segments of the kinetic chain24. The forcesaregeneratedbythegroundreactionforces,kneeextension,hipextension,andextensionofthetrunkfromflexiontoneutralwhichwouldbeguided,directedandincreased by doing shoulder rotations 25. The shoulder is thought to act as a funnel through which the generated forces are passed on to the forearm and hand, where

after the shuttle is hit with concentric actions of elbow flexorsandforearmsupinators22. 26.Itisevidentfromtheabovefacts;theheadisrequiredtomaintainanuprightpositionforplayingastroke.Whileplayingasmashorclearstroke, theforce transmission to thearmorhandorgenerationofforcesdoesnotrequiremuscleactivityaround head and neck.

CONCLUSION

The photogrammametric quantification of cervicalspine posture did not reveal any significant differencebetweenthetwogroups.Itcanbeconcludedthatplayingbadminton does not place significant impact on thecervical spine.

Future Research: Ourpresentworkexaminedcervicalspineposturewhilemeasuringonlytwoangles.Infutureresearches,moreanglescanbeexaminedtodeterminethe cervical spine posture with a large sample size. Moreover, subjects above25years of age can also beincluded in the study.


Conflict of Interest: There is no conflict of interestrelated to this manuscript

Ethical Clearance: All the procedures followed were in accordance with the ethical standards of the responsible committeeonhumanexperimentation(institutionalandnational)andwiththeHelsinkiDeclarationof1975,asrevised in2000 (5). Informedconsentwas taken fromthe subjects prior to the study.

REFERENCES

1.Hensley LD, Paup DC.A survey of badmintoninjuries.BritishJournalofSportsMedicine.1979Dec1;13(4):156-60.

2.AAR.MusculoskeletalinjuriesamongMalaysianbadminton players. Singapore medical journal. 2009Jan1;50(11):1095-7.

3.Kwan M, Cheng CL, Tang WT, Rasmussen J.Measurement of badminton racket deflectionduringastroke.Sportsengineering.2010May1;12(3):143-53.

4.ZengN,AyyubM,SunH,WenX,XiangP,GaoZ. Effects of physical activity on motor skills


and cognitive development in early childhood: A systematicreview.BioMedresearchinternational.2017;2017.

5.Grabara M. Body posture of young femalebasketball players.BiomedicalHumanKinetics.2012Jan1;4:76-81.

6.Grabara M. Analysis of body posture betweenyoung football players and their untrained peers. HumanMovement.2012Jun1;13(2):120-6.

7.VařekovaR,VařekaI,JanuraM,SvobodaZ,ElfmarkM.Evaluationofposturalasymmetryandgrossjointmobilityinelitefemalevolleyballathletes.Journalofhumankinetics.2011Sep1;29:5-13.

8.SinglaD,VeqarZ.Effectofplayingbasketballonthe posture of cervical spine in healthy collegiate students.IntJBiomedAdvRes.2015;6(2):133-6.

9.Barczyk-Pawelec K, Bańkosz Z, Derlich M.Body Postures and Asymmetries in Frontal andTransverse Planes in the Trunk Area in Table Tennis Players.BiologyofSport.2012Jun1;29(2).

10.Vařeka I, Dvorak R. Posturalní model řetězeníporuch funkce pohybového systému [Posturalmodel of chain reactions of functional disorders of the locomotorsystem].RehabfyzLek.2001;8(1):33-7.

11.BurkhartSS,MorganCD,KiblerWB.Thedisabledthrowing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, thekinetic chain, and rehabilitation. Arthroscopy:The JournalofArthroscopic&RelatedSurgery.2003Jul1;19(6):641-61.

12.Henne, S. Volleyball and physiotherapy. Part I:Thoracicvertebralcolumn.Coach,1999;1:28-31.

13.WangHK,JuangLG,LinJJ,WangTG,JanMH.Isokinetic performance and shoulder mobilityin Taiwanese elite junior volleyball players. Isokinetics and Exercise science. 2004 Jan 1;12(2):135-41.

14.YooJC,SuhSW,JungBJ,HurCY,ChaeIJ,KangCS,WangJH,MoonWN,CheonEM.Asymmetricexercise and scoliosis: A study of volleyball athletes. Journal of the Korean OrthopaedicAssociation.2001Oct1;36(5):455-60.

15.RaineS,TwomeyLT.Headandshoulderposturevariations in 160 asymptomatic women and men. Archives of physical medicine and rehabilitation. 1997Nov1;78(11):1215-23.

16.LeeMY, Lee HY,YongMS. Characteristics ofcervical position sense in subjects with forward headposture.Journalofphysicaltherapyscience.2014;26(11):1741-3.

17.Gugliotti M. Contribution ofAberrant Posturesto Neck Pain and Headaches in e Sport Athletes. 2018;ResInvesSportsMed3(1).

18.Harrison AL, Barry-Greb T, Wojtowicz G.Clinical measurement of head and shoulder posture variables. Journal of Orthopaedic &SportsPhysicalTherapy.1996Jun;23(6):353-61.

19.VanNiekerkSM,LouwQ,VaughanC,Grimmer-SomersK,SchreveK.Photographicmeasurementof upper-body sitting posture of high schoolstudents: a reliability and validity study. BMCmusculoskeletaldisorders.2008Dec;9(1):113.

20.Szeto GP, Straker LM, O’Sullivan PB. Acomparison of symptomatic and asymptomatic officeworkersperformingmonotonouskeyboardwork—2:neckandshoulderkinematics.Manualtherapy.2005Nov1;10(4):281-91.

21.Lau MC, Chiu TT, Lam TH. Measurementof craniovertebral angle with electronic head posture instrument: criterion validity. Journal ofrehabilitation research and development. 2010.

22.Waddell DB, Gowitzke BA. Biomechanicalprinciples applied to badminton power strokes. InISBS-Conference Proceedings Archive 2000(Vol.1,No.1).

23.ReidM.Loading andvelocitygeneration in thehigh performance tennis serve. University ofWesternAustralia;2006.

24.ForthommeB,CrielaardJM,CroisierJL.Scapularpositioninginathlete’sshoulder.SportsMedicine.2008May1;38(5):369-86.

25.BenKiblerW.Theroleofthescapulainathleticshoulder function. The American journal of sports medicine.1998Mar;26(2):325-37.

26.LintnerD,NoonanTJ,KiblerWB.Injurypatternsandbiomechanicsoftheathlete’sshoulder.Clinicsinsportsmedicine.2008Oct1;27(4):527-51.

27.ChansirinukorW,WilsonD,GrimmerK,DansieB.Effectsofbackpacksonstudents:measurementofcervicalandshoulderposture.AustralianJournalofphysiotherapy.2001Jan1;47(2):110-6.

Comparison of the Two Minute Step Test with Six Minute Walk Test in Chronic Obstructive Pulmonary Disease Patients

P. Shanmuga Priya1, Anwar K. Nazar2, S. Azarudheen2, N. Saranya2, A. Thenmozhi2, V. Vaishnavi2

1Associate Professor, PSG College of Physiotherapy, 2PSG College of Physiotherapy

ABSTRACT

Background: ThepatientswhohaveCOPDfacedifficultyintheirfunctionalactivitiesespeciallyduringclimbingstairs,walkinguphill.Inviewofassessingthemaximalfunctionalcapacity,weneedashorttermfunctionalstresstestoverthegoldstandard6MWT.SothiswasdonetofindouttheapplicabilityofTwominutesteptestwhichisfulfillingthecriteriaofthefunctionalwalktest.

Specific objective: TofindouttheapplicabilityofTwominutesteptestbycomparingtheSixminutewalktest with the Two minute step test.

Methodology: Crossover Study Design was adopted for the study.

Results: There is a moderate correlation exists among distance walked in six minute walk test and number of stepstakenintwominutesteptestinmildtomoderateCOPDpatients(r=0.690).ThereisahighcorrelationexistsbetweenthemeanvaluesofHeartrate(r=0.752),Respiratoryrate(r=0.754),Dyspnoea(r=0.701)andFatigue (r=0.729) insixminutewalk testand twominutestep test.There ismoderatecorrelationexistsbetweenthemeanvaluesofOxygensaturation(r=0.475),Systolicbloodpressure(r=0.472)andDiastolicbloodpressure(r=0.563).

Conclusion: The study results show that a correlation exists between Two minute step test and Six minute walk test

Keywords: Chronic obstructive pulmonary disease, Six minute walk test, Two minute step test

INTRODUCTION

ChronicObstructive PulmonaryDisease is a lungdisease characterised by airflow limitation that is notfullyreversible,isusuallyprogressiveandisassociatedwithan inflammatory responseof the lungs to inhalednoxious particles or gases.–The Global initiative for Chronic Obstructive Lung Disease (GOLD).

Chronic bronchitis is defined as presence ofproductive cough for three months in each of two consecutive years. It is a condition associated withchronic swelling and inflammation of the bronchi andbronchioles with the symptoms of chronic cough and sputum production. Patients with COPD experienceacute exacerbations or periods of worsening symptoms.

Emphysema isdefinedas theabnormalpermanentenlargement of air spaces from distal to the terminal bronchioles accompanied by destruction of their walls.

TherewillbereductioninairflowwhichisquantifiedbyusingresultsofPulmonaryFunctionTest(PFT),withFEV1 being one of the standard used to assess disease severity and monitor disease history. The FEV1, FVC,FEV1/FVC and single breath diffusing capacities areprimaryPFTrecommendedtoaidindiagnosisofCOPD.12

Most of the patients with COPD have a reducedexercise capacity in the face of an increased ventilatory demand,becauseexerciseplacesan increaseddemandon respiratory system. Exercise testing provides an objective evaluation of the functional capacity of the COPDpatient.

Exercise testing is an integral component in evaluationofpatientswithCOPD.InpatientswithmildtomoderateCOPD,symptomsgenerallydonotpresentuntilincreaseddemandisplacedonrespiratorysystem,such as with exercise. In severe cases, even simpleactivities may cause symptoms9.

DOI Number: 10.5958/0973-5674.2019.00076.5


Assessment of exercise tolerance is an important componentof the comprehensiveevaluationofCOPDpatients8. Time limited walk test and step test occupy the important position among many instruments used for monitoring of functional status.

The six minute level walk test has been a gold standard in the assessment of functional capacity. The six minute walk test has close similarities to daily life activities and can be carried out even by elderly and severely limited patients who are not able to perform symptom-limitedexercisetests(bicycle/treadmill)11.

The 2 minute step test evaluate exercise tolerance and doesnotneedexpensiveequipments,withtheadvantagethat it can be used in limited amount of space and time.

AIMS & OBJECTIVES

To show the validity of two minute step test and to prove that it can be used as an alternative for six minute walktestinCOPDpatients.

TofindouttheapplicabilityofTwominutesteptestby comparing the Six minute walk test with the Two minute step test.

METHODOLOGY

Study Design: Cross over study was adopted for the study.Inthecurrentstudy,theparticipantsareassignedfor six minute walk test and two minute step test with interval time of 30 minutes between the tests.

Population and Sampling: Patients with mild to moderateCOPDwhowerereferredfromthedepartmentof pulmonarymedicine in PSG hospitals, Coimbatorewere chosen as population for this study. A total of 30 patients were selected by purposive sampling method. Thenature,risksandbenefitsofthestudywereexplainedto the patients. The patients were allocated after obtained the informed consent form.

Criteria for Sample Selection:

Inclusion Criteria z Individualswithage20–75years z Mildtomoderate(FEV1 >80%or50-79%)COPDpatients(accordingtoGOLDcriteria)

z Bergbalancescalescore41–56(lowfallrisk) z Patients with stable vitals

z Able to follow up commands in English and Tamil. z BMI<30

Exclusion Criteria z Concomitant heart failure z Unstableangina z RecentMyocardialInfarction z Uncontrolledhypertension z SevereCOPD,AsthmaticusandILD z Patients with mobility impairment

Study Setting: Department of Pulmonary Medicine,PSGHospitals,Coimbatore.

Study Duration: Six months

Treatment Duration: z 30 participants were received six minute walk test

with duration of 20 minutes. z Intervalperiodof30minutes. z 30 participants were received two minute step test

with duration of 10 minutes.

Instrument and Tool for Data Collection

Six minute walk test z 30 meter hallway z Twosmalltrafficconestomarkturnaroundpoints z Stop watch z Pulse oximeter z Sphygmomanometer z Inchtape z Assessment chart z Chair z Oxygencylinder

Two minute step test z Steps z Stop watch z Pulse oximeter z Sphygmomanometer z Inchtape z Assessment chart z Chair z Oxygencylinder


Technique of Data Collection: Patients with COPDwere screened by surgeon/physician in the mild to moderateCOPDfor risksandclearance forfieldwalktest.Baselineassessmentwastakenbeforethefirsttestfor all the 30 participants who met the inclusion criteria. Mild tomoderate COPD patients are assigned for sixminute walk test. After 30 minutes of washout time the two minute step test will be administered. Distance walkedinSixminutewalktest,numberofstepsinTwominutesteptest,Heartrate,Respiratoryrate,SpO2,Pulserate,Bloodpressure,Fatigue,DyspnoeawithMBRPEscale was the parameters assessed during the test. The dataarecollectedbefore,duringandimmediatelyafterthefirstminuteofcompletionofeachtest.

Both pre-test and post-test measurement of sixminute walk test and two minute step test were noted and analyzed.

The data collected in each tests are z Distance covered in 6 minute walk test z Number of steps in 2 minute step test z Heart rate z Bloodpressure z Respiratory rate z SpO2

z DyspnoeawithMBRPEscale z Legfatigue

Table 1: Summarised Vital Parameters Correlation

S. No. Variables

Pearson Correlation

(r Value)1. Correlation of Distance and Steps 0.6902. Correlation of HR between

6MWTand2MST 0.752

3. Correlation of RR between 6MWTand2MST 0.754

4. CorrelationofSpO2 between 6MWTand2MST 0.475

5. CorrelationofSYSTOLICBPbetween6MWTand2MST 0.472

6. CorrelationofDIASTOLICBPbetween6MWTand2MST 0.563

7. Correlation of DYSPNEA between6MWTand2MST 0.709

8. CorrelationofFATIGUEbetween6MWTand2MST 0.729

Table 2: Summarized Vital Parameters Difference

S. No.

Paired t Test Variables (Vitals)

t Value p Value

1. MeanHRdifferenceof2MSTvs6MWT 2.481 p<0.05

2. MeanRRdifferenceof2MSTvs6MWT 1.748 p>0.05

3. MeanSpO2 differenceof2MSTvs6MWT 0.576 p>0.05

4. MeanSYSTOLICBPdifferenceof2MSTvs

6MWT2.362 p<0.05

5. MeanDIASTOLICBPdifferenceof2MSTvs

6MWT1.095 p>0.05

6. MeanDYSPNEAdifferenceof2MSTvs6MWT 0.828 p>0.05

7. MeanFATIGUEdifferenceof2MSTvs6MWT 2.055 p<0.05

Graph 1: Correlation of Number of Steps and Distance Covered

DISCUSSION

Theaimofthisstudyis tofindoutthecorrelationbetween the six minute walk test and two minute step test in patients with mild to moderate chronic obstructive pulmonary disease.

Atotalof30patientswithmildtomoderateCOPDin stable condition were included in the study. Bothmales and females were included in both the tests

All the 30 patients completed the six minute walk test and two minute step test. The selected outcome


measures were numbers of steps taken in two minute steptest,distancecoveredinsixminutewalktest,heartrate, respiratory rate, oxygen saturation, systolic anddiastolic blood pressure, dyspnoea and fatigue. Datawere collected before and after each test.

None of the patients are experienced angina pain,arrhythmia or deterioration of general cardiac and physical status during the testing.

The obtained data were analysed by using Pearson correlation and paired ‘t’ test. Paired ‘t’ test wasperformedbetweenthemeandifferenceoftheparametersof two minute step test and six minute walk test. Pearson correlation was performed between the number of steps and distance walked. Pearson correlation was also performedbetweenthemeandifferenceoftheparametersof two minute step test and six minute walk test.

There is a moderate correlation exists among distance walked in six minute walk test and number of steps taken in two minute step test in mild to moderate COPD patients (r = 0.690) (graph 1).There is a highcorrelation exists between the mean values of Heart rate(r=0.752), Respiratory rate (r=0.754), Dyspnoea(r=0.701)andFatigue(r=0.729)insixminutewalktestand two minute step test. There is moderate correlation existsbetweenthemeanvaluesofOxygensaturation(r=0.475),Systolicbloodpressure(r=0.472)andDiastolicbloodpressure(r=0.563)(table1).Themeandifferencebetween vital parameters of each test were analyzed through paired ‘t’ test. The parameters heart rate,systolicbloodpressureandfatigue(p<0.05)showshighsignificance. The parameters respiratory rate, oxygensaturation, diastolic blood pressure and dyspnoea (p>0.05)showsminimalsignificance(table2).

This indicates that there is a correlation exists between the two minute step test and six minute walk test.

CONCLUSION

Atotalof30patientswithmildtomoderateCOPDpatients were included in the study. All the patients had completed six minute walk test and two minute step test.

The study result shows that there exists a similar response between two minute step test and six minute walktestinpatientswithCOPD.

Thus, the twominute step test can be used as analternative for six minute walk test by comparing the two minute step test and six minute walk test.

Therefore,itisprovedthat,“ComparisonoftheTwoMinuteStepTestwithSixMinuteWalkTestinChronicObstructivePulmonaryDiseasePatients”.



Ethical Clearance:InstitutionalReviewCommitteeofResearch,CollegeofPhysiotherapyandHumanEthicsCommittee of PSG Institute of Medical Science andResearch

REFERENCE

1.Wegrzynowska- Teodoczyk. Could the two-minutesteptestbeanalternativetothesix-minutewalk test for patients with systolic heart failure. EurJprev.cardiol.2016;Aug;23(12):1307-13

2.Copper KH. A means of assessing maximaloxygen uptake: correlation between field andtreadmilltesting.JAMA1968;203:201-204

3.BittnerV,WeinerDH,YusufS,etal.Predictionofmortalityandmorbiditywitha6-minutewalktest in patients with left ventricular dysfunction. JAMA1993;270:1702-1707

4.Fiorina C, Vizzardi E, Lorusso R etal.The6-minutewalkingtestearlyaftercardiacsurgery.Referencesvaluesandtheeffectsofrehabilitationprogramme. Eur J Cardiothoracic surg 2007;32:724-729

5.JonesCJ,RikliRE.Developmentandvalidationofafunctionalfitnesstestforcommunity-residingolderadults.JAgingPhysAct.1999;7:129-61

6.Jonathan K. Ehrman, Paul M. Gordan, Paul S.Visich, Steven J. Keteyian. A book of ClinicalExercise Physiology

7.Solway S, Brooks D, Lacasse Y, Thomas S. Aqualitative systemicoverviewof themeasurementpropertiesoffunctionalwalktestsusedinthecardio-respiratorydomain.Chest2001;119:256-270

8.Wasserman K, Hanson JE, Sue DY, et al.Principles of exercise testing and interpretation,third edition. Philadelphia: Lippincott,WilliamsandWilkins;1999

9.WeismanIM,ZeballosRJ.Anintegratedapproachtotheinterpretationofcardio-pulmonaryexercisetesting.ClinChestMed1994;15:421-445.


10.VagagginiB,TaccolaM,SeverinoSetal.Shuttlewalking test and six minute walking test induce a similar cardio-pulmonary response in patientsrecovering from an Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Respiration2003;70-579-584

11.Ozalevli S, Ozden A, Itil O, Akkoclu A.Comparison of the sit to stand test with six minute walk test in patients with chronic obstructive pulmonary disease. Pulmonary Medicine 2007;101:286-293

12.Frownfelter D, Dean E. Cardiovascular andpulmonary Physical Therapy2006:4th edition

13.Irwin S, Tecklin JS. Cardiopulmonary physicaltherapy-Aguidetopractice2004:4th edition

14.Cho BL, Scarpace D, Alexander NB. Tests ofstepping as indicators of mobility, balance andfallofriskinbalance-impairedolderadults.JAmGeriatrSoc.2004;52:1168-73

15.SusanOSullaivan.Thomas JSchmitz.PhysicalRehabilitation114-1165thedition;2007

16.BeutnerF,UbrichR,ZachariaeS,etal.Validationof a brief step test protocol for estimation of peak oxygenuptake.2014;22:503-512

17.PedrosaR andHolandaG.Correlation betweenthe walk, two minute step and tug test amonghypertensive older women. Rev Bras Fisioter2009;13:252-256

18.Meyer K, Hajric R, Samek L, et al. Cardio-pulmonary exercise capacity in healthy normals ofdifferentage.Cardiology1994;85:341-51

19.RobertsMM,ChoJG,SandozJS,WheatleyJR.Oxygendesaturationandadverseeventsduring6minutewalktest inCOPDpatients.Respirology2015Apr;20(3):419-25.Epub2015Jan20

20.Guyatt, G.H., Townsend,M., Keller, J., Singer,J.andNogradi,S.Measuringfunctionalstatusinchroniclungdisease:RespiratoryMedicine1991;85,17-2

Effect of Two Proprioceptive Training Programs on Cervical Repositioning Sense on Subjects with Chronic Non Specific

Neck Pain

Prakash Kumar Mahto1, Sapna Malla2

1Physiotherapist, Kathmandu Medical College, Kathmandu, Nepal; 2Asst. Professor, Chanakya college of Physiotherapy, Kutchh, Bhuj Gujrat

ABSTRACT

Study Objective:comparisonbetweentheeffectsofDeepCervicalStrengtheningExerciseusingPressureBiofeedbackandPNFexerciseonNonSpecificneckpain.Study Design: Comparative study.

Setting: All subjects were included from forest research institute at Dehradun.

Method: A total of 20 subjects were recruited for the study on the basis of inclusion and exclusion criteria aftersigningtheinformedconsentform.Thesubjectsweredividedintotwogroups(PNFexercisesprogram&DeepNeckflexorStrengthening).

Outcome Measures: VisualAnalogScale(VAS),CervicalRepositionsense&Jointpositioningerror.

Results: Showedsignificantimprovementintheoutcomemeasuresinboththetechniques.However,bothmethodswere found tobesimilarlyeffective indecreasingpainand improvingJPE the results forVAS(p=1.000) and JPE (p=0.529)were taken after intervention in both groups, therewas a non-significantdifference.

Conclusion:Bothmethodsproved tobe similarlyeffectiveandcanbeequallyused tocorrect the jointposition error and reduce pain irrespective of the other.

Keywords: Joint Positioning Error, Deep Cervical flexors, Cervical repositioning sense, PNF.

INTRODUCTION

Chronic neck pain can be defined as a conditionwith episodes of persistent or recurrent and disabling pain,withsymptomslastinglongerthanthreemonths.3

Chronic cervical pain is a common source of disability in society, andevidencesuggests that individualswithneckpainhaveimpairmentofthedeepcervicalflexors(DCF)muscles.10 Chronic neck pain may be linked to reduced cervicocephalic kinesthetic sensibility and postural balance.

Kinesthesia generally refers to the perception ofchanges in the angles of joints, a function dependentupon mechanoreceptor input; it is a critical component in the proprioceptive system12. Altered kinesthetic sensitivity has been implicated in functional instability of joints and their predisposition to re-injury, chronicpain and even degenerative joint disease12.Itisnowwell

accepted that these late complications of joint injury are rarely caused by mechanical instability or adhesion formation,butinvolveadisturbanceinthecomplicatedfeedback system between muscles and joints and the central nervous system12.

Joint Posiotining Error: A widely used measure of cervicalproprioceptionisthejointpositionerror(JPE)test, inwhich impairedability to relocateneutralheadposition has been demonstrated in acute and chronic whiplash and in non-traumatic neck pain patients13. Head repositioning accuracy measures the ability of neuromuscular system to reposition the head to a neutral posture after movement in different planes.Cervical joint positioning error is considered to mainly reflectdisturbedafferentinputfromarticulationofneckand muscle receptors. The test assesses the ability to perceive both movement and position of the head related tothetrunk.Jointpositioningerrorresultsinanangular

DOI Number: 10.5958/0973-5674.2019.00077.7


differencebetweenthestartingpositionandtheresumedneutral head posture. Over the last decade, functionalimpairment of suboccipital and deep cervical flexormuscle and cervical mechanoreceptors dysfunction have beenthoughttoaffectproprioceptioninneckofpatientswith chronic cervical neck pain6.

Deep Cervical Flexors: Individualswithchronicneckpain seem to have less activity of the deep cervical flexors (DCF), longus capitis and longus colli, theprimary muscles involved in the support and control of thecervicalcurve,comparedtoasymptomaticsubjects.Deepcervicalflexormuscle(DCF)activationisimpairedwith neck pain3.

Whileneckpainmayalterproprioceptivefunction,there is no clear consensus in the literature. Ability to reposition the head to a previous position is dependent on cervicocephalic kinesthetic sensibility7. The test of targeting the neutral head position indicates that relocation inaccuracy exists in neck pain7. Crisco and Panjabi2 suggested that muscles that have direct attachments to the vertebrae are responsible for the segmental stability through the control of the neutral zone8. The deep musclesoftheneck,whichactlikedynamicligaments,play an important role in maintaining the stability of the cervical spine. Several studies demonstrated that neck muscle is strongly correlated with neck pain5

PNF: ProprioceptiveNeuromuscularFacilitation(PNF)exercises are designed to promote the neuromuscular response of the proprioceptors. Neuromuscular Facilitation Exercises is based on some movement patterns to facilitate and correct sensory motor function. It has been suggested that these exercises corrects theimpaired impulses emerging from the proprioceptive receptors in the muscles. Therefore pain may be decreased and strength of the muscles may be improved12.

METHODOLOGY

Twenty adultswithNon SpecificNeck Painwerechosen by convenient sampling and included in this study. The subjects were chosen from Forest Research Institute, Dehradun. Pre-test post-test interventioncomparative design was chosen for this research.

Samples were chosen on the basis of inclusion and exclusion criteria that included subjects within the age group of 25-40 years with neck pain in the cervical

region, possiblywith referred or radiating pain in theocciput, nuchal muscles, shoulders and upper limbswithoutprovenstructuraldisordersinthecervicalspine,nerve roots or spinal cord.

Subjects excluded for the study were made on the basis of following features

z Having signs and symptoms of neurological disorders.

z Headache

z Infection,malignancy.

z whiplash

z polyarthritis,Musculardisease

Instruments used for data collection were Couch,pencil,ruler,PressureBiofeedback(ChattanoogaGroupInc.,Chattanooga,TN),LaserPointerDevice,VASforpain,andChairwithbackrest

Outcomemeasures taken in the studywereVisualAnalog Scale for Pain and Joint Positioning Error bylaser pointer Device

Method: Subjects were assigned into two groups namely, GroupA- PNF and Group B- Deep cervicalFlexor strengthening on the basis of inclusion and exclusion criteria. Then Subjects were assessed for pre-interventionpainbyVASandJPEbylaserpointerdevice. After 6 weeks post intervention measurement of painandJPEwastaken.

Procedure: Cervicocephalic relocation test was recorded after whole procedure was explained. The subjects were seated in a chair with support for lower back at a distance of 3 meters from the wall. 1 cm grid graph paper was attached to the wall in front of the subject. The thigh of subject was kept horizontal and knee joint flexed at 900. Then the Laser pointer was placed andscrewed on subjects head upon a helmet and adjusted for thefit.Eyeswerekeptoccludedduringentireprocedure,once the target neutral position is obtained. Subjects then locate the head in comfortable position and laser spot was marked as the neutral head position. Subject was asked to memorize their neutral head; position after aslowphasespecificheadmovementsthatareleftandrightrotationinhorizontalplaneandflexioninsagittalplane for 10 times totalling 40 movements consecutively. Again the subject relocated the head and the laser spot which was marked as a new target point or neutral head


position. Then the distance was measured for the error with linear metric scale. Then the same procedure was repeated for post reading.

Group A: PNF Neck Patterns

Two diagonal patterns for neck were practiced alternately for five repetitions each totalling 10repetitions.

z Flexion/Left Lateral Flexion/Left Rotation: The patient was sitting. The therapist was standing behind the patient to the right of center.

Grip: The fingertips of the therapist’s right handwasunderpatient’s chin.The topof thepatient’sheadwas holdwith left hand, just left of center.Resistancewasgivenwiththefingersandpalmofthat hand.

Elongated Position: The chin was elevated and the neck elongated. The head was rotated and tilted to the right.

Traction: Gentle traction was applied by elongating the entire pattern.

Command: “Tuck your chin in. Bend your headdown.Lookatyourlefthip.”

Movement: The patient’s mandible depressed asthe chin tucked with rotation toward the left. The neck flexed, following the line of the mandible,bringingthepatient’sheaddowntowardsthechest.

Resistance: Therapist’srighthandonpatient’schinresisted rotation to the left. The left hand on the patient’s head gave a rotational force to the headback towards the starting position.

End Position: Thepatient’sheadneckandupperthoracicspinewerefullyflexed.Thepatient’snosepointed towards the left hip.

z Extension/Right Lateral Flexion/Right Rotation: The starting and ending positions were reversed for this pattern and movements were carried out from the ending position of previous pattern to the startingpositionofthepreviouspattern.Thegrip,command and resistance were adjusted accordingly.

Group B: Deep Cervical Flexor Strengthening.

Position: Supine

Equipment:Airfilledpressure sensor.This studyusedStabilizerTM,ChattanoogaGroupInc.,Chattanooga,TN

Procedure: The pressure sensor was placed sub-occiptally,underneath theneck.The target level for theexercise was the level that the subject can hold steadily for 5 seconds while moving smoothly into the range and withoutretractingorusingsuperficialneckflexormuscles.

Target Movement: Gently and slowly nod the head asifsaying“yes”sothatthepressuresensormeasures2 mmHg above baseline (20 mmHg), then 4mmHg,followed by 6mmHg, 8mmHg, and 10mmHg withoutrests in between (the pressure sensor should read30mmHgat theendof themovementsequence).Holdeach increment for 5 seconds.

Dosage:Holdattheidentifiedtargetlevelfor10secondsfor 10 repetitions with 3 to 5 second rest periods in between. Progress to train at the next target level up with thefinaltargetof10mmHgabovebaseline(30mmHg).

DATA ANALYSIS

z SPSS version 12 was used for data analysis. The statistical significance was set at 0.05 at95% confidence interval and p value < 0.05wasconsideredsignificant.

z Wilcoxon Signed Ranks Test was used for theanalysis of data comparisons between variables,within group pre and post data.

z Mann Whitney Test was used for the analysisof data comparisons between variables between groups pre and post data.

RESULTSMeanageforthewholepopulationwas34.45±4.57

WilcoxonsignedranktestwasdonetocomparethedataforVASwithinthegroups.AsignificantdifferenceofVASpreandpostwithinGroupA(p=0.04)andVASpreandpostGroupB(p=0.04)wasseen.

Table 1: Comparision of Within Group Analysis of VAS

VariableMean SD

Z PPre Post Pre Post

Group A 5.1 2.7 1.37032 1.25167 -2.871 0.004GroupB 4.9 2.7 1.44914 1.25167 -2.844 0.004

Again, Wilcoxon signed rank test was used tocompare JPE within the groups. The mean valuedecreased for JPE and showed a significant differencein both GroupsA and B pre and post within groups,(p=0.05)and(p=0.05)respectively.


Table 2: Comparisions of Within Group Analysis For JPE

VariableMean SD

Z PPre Post Pre Post

Group A 6.25 2.05 1.62019 1.0395 -2.823 0.005GroupB 5.3 1.8 1.97484 0.97753 -2.807 0.005

Mann-Whitney testwasdone tocomparepreandpostdataofVASandJPEbetweengroupAandgroupB.Resultsshowednon-significantdifferenceofpre-interventiondatabetweenthegroupsandpost-interventiondatabetween the groups.

Table 3: Between Group Analysis for VAS

VariableMean SD

Z PGroup A Group B Group A Group B

Pre 5.1 4.9 1.37032 1.44914 -0.309 0.796Post 2.7 2.7 1.25167 1.25167 0.000 1.000

Table 4: Between Group Analysis for JPE

VariableMean SD

Z PGroup A Group B Group A Group B

Pre 6.25 5.3 1.62019 1.97484 -1.367 0.190Post 2.05 1.8 1.0395 0.97753 -.698 0.529

DISCUSSION

Theaimofthepresentstudywastofindoutwhetherthere will be any significant difference between thetwomethodsofproprioceptive trainingviz,PNFneckpatternsexerciseanddeepcervicalflexorstrengtheningusing pressure biofeedback on pain and cervical joint position sense. Visual analog scale (VAS) was usedto measure pain and laser pointer device was used to measure the joint position sense by changes in joint positionerror(JPE).TheresultsprovedthatPNFneckpatternexercisesanddeepcervicalflexorstrengtheningboth were similarly effective in correcting jointpositioning error as well as pain in subjects with chronic non-specificneckpain.

ThepatientsinGroupA(PNFneckpatterns)showedimprovementinVAS(p=0.004)andJPE(p=0.005)attheend of six weeks of intervention period. The mean age of the patients in group A was 36.2 ± 3.42 years. The PNF neck pattern exercise included two different patternsof movements and provided proper neuromuscular function via the stimulation of proprioceptive system. Thepatternsofmovementwere rotational,multi-axialand multidirectional. These movements were more

effective than single axial movements11. According to theresults,itwasobservedthattherewasastatisticallysignificant difference in PNF neck patterns group forreducing JPE and pain; the evidence forwhich is notvery much prominent. In spite of the proven effectsof PNF for reducing pain and improving strength of muscles, itsusefor improving jointpositionsensehasrarely been documented.

In group B (deep cervical Flexor strengthening)there was a significant improvement in pre and postinterventionofVAS(p=0.004)andJPE(p=0.005).Themeanage for thepatients ingroupBwas32.7±5.05years.When the patients with neck pain were treatedwith six weeks of deep cervical strengthening there was increase in joint position sense in cervical spine and decrease in pain.

The second part of the hypothesis was to compare between the effects ofPNFneckpatterns training anddeep cervical strengthening. After the six weeks of intervention of deep cervical training and PNF neck pattern both groups showed significant difference inreducingpainandJPE.However,therewasnosignificantdifference between the groups which shows that both


groups are similarly effective in decreasing pain andJPE.Head repositioning task are not solelydependenton proprioceptive input from muscle but also depend on visual and vestibular input6.

The measurements for VAS (p=0.796) and JPE(p=0.190)pre-treatment inbothgroupAandgroupB,showed no statistically significant difference whichsuggests that the groups were similarly matched and had similarmeasures for the variables being compared. Inother words both groups were homogeneous in terms of outcome measures being compared. Pain might be the reason for joint position error (Revel et al)10. Authors have shown that patients with neck pain exhibit increased EMG amplitude of superficial sternocleidomastoidand anterior scalene muscles and reduced activation of the deep cervical flexors3.Owens et alwas able toelicit a repositioning error in asymptomatic subjects6. This suggests that there is existence of some advanced neurologic control mechanism. Proprioceptors are situated in joints, tendons and muscles of neck andshoulder, and vestibular apparatus. Patients with neckpain show altered proprioceptive response4.

Again,whentheresultsforVAS(p=1.000)andJPE(p=0.529)weretakenafterinterventioninbothgroups,therewasanon-significantdifference.Thisindicatesthatboththegroupswereequallyeffectiveinimprovingjointposition sense and decreasing pain. The proprioceptors locatedelsewhereother thandeepcervicalflexors likesuperficialflexors, capsuleof joints, scapularmuscles,vestibular apparatus could be stimulated by the PNF neck pattern training. Also proprioceptors might be furtherstimulatedbyvisualfeedback.ButaccordingtothestudydonebyPinsaultNetal,thevestibularsystemis not involved in the performance of the cervicocephalic relocation test to neutral head position9. The deep cervical flexor training results in improved proprioceptiveresponse and joint position sense as already suggested by previous evidence.

CONCLUSION

WeconcludethatthesixweekinterventionofPNFtraining and deep cervical strengthening training is both effectiveindecreasingthejointpositionerrorandpain.Bothmethods canbe equally used to correct the jointposition error and reduce pain irrespective of the other.

Conflict of Interest: We declare that there were noconflictsofinterestintheentirejourneyofthestudy.

Ethical Clearance: Research Ethics Committee.


REFERENCES

1.AdlerS.,DominiqueB.etal,PNFinPractice3rd edition,Springer pg. 2,158

2.CrisoJJIII,PanjabiMM.Posturalbiomechanicalstability and gross muscular architecture in the spine. In:Winters JM,Woo SLY, eds.Multiple MuscleSystem. New York: Springer-Verlag,1990:438–50.

3.Jull GA, Falla D.,Vicenzino B.et al. The effectof Therapeutic exercise on activation of Deep CervicalFlexorMuscleonpatientswithchronicneck pain. Man Ther14(2009):696-671

4.Kofotollis N, Kellis E. Effects of two 4 weekProprioceptive Neuromuscular Facilitation Programs onMuscle endurance, Flexibility andfunctional performance in women with chronic low back pain. PhysTher.2006;86:1001–1012.

5.Mayoux MA et al. Longuscolli has apostural function on cervical curvature.SurgRadiolAnat1994;16:367-71 (abstract)

6.Owens EF et al. Head repositioning errors innormal student volunteers: A possible tool to assesstheneck’sneuromuscularsystem.Chiro& Osteopathy 2006March06:1-7

7.Palmgren PJ et al. Cervicocephalic kinestheticsensibility and postural balance in patient with non-traumatic chronic neck pain-A pilot Study.Chiropractice and osteopathy 2009June30:1-10

8.Panjabi MM. The Stabilizing system of thespine: II. Function dysfunction, adaptation andenhancement. J Spinal Disord1992;5:390–7.

9. Pinsault N et al. Cervicocephalic relocation test to the neutral head position: Assessment in bilateral labyrinthine-defectiveandchronicnontraumaticneck pain patients. Arch Phys Med Rehabil2008 Dec;89:2375-78.

10.Revel M et al. Changes in cervicocephalickinesthesia after a proprioceptive rehabilitation


program in patients with neck pain: a randomized control study. Arch Phys Med and Rehabil 1994;75:80-85

11.RezasoltaniA.etal.Theeffectofaproprioceptiveneuromuscular facilitation program to increase neckmusclestrengthinpatientswithchronicnon-specific neck pain. World J. of Sports Sci.3 (1):59-63,2010

12.RogersRG,1997.Effectsofspinalmanipulationon cervical kinesthesia in patients with chronic

neck pain: A pilot study. J. of Manipul and Physiol Therapeutics. (20)2:80-85.

13.SwaitG,RushtonABetal.Evaluationofcervicalproprioceptive function. Optimizing protocolsand comparison between tests in normal subjects. SpineVol.32,No24,ppE692-E701.

14.Mahato PK, Malla S. Cervical Repositioningsense in subjects with non specific neck pain.Lambert Academic Publishing

Cross-Cultural Adaptation of English Version (1.0) of Barthel Index in Punjabi

Rajneet Kaur Sahni1, Shanu2

1Associate Professor, 2MPT (Neurology), All Saints Institute of Medical Sciences and Research, Ludhiana, Punjab

ABSTRACT

Introduction: BarthelIndexservesasameasureofdailylivingactivitiesinrelationtopersonalcareandmobilityof thepatient.Barthel Indexiswidelyused tomeasure thefunctionaldisability.AsavalidatedandculturallyadaptedPunjabiversionofBarthelIndexhasnotbeenproducedyet,thisstudywilldescribethetranslationoftheoriginal10-itemversionofBarthelIndexintoPunjabilanguageanditsPsychometricanalysis in individuals with stroke. The Cross-Cultural adaptation of a health status self-administeredquestionnaireforuseinanewcountry,cultureorlanguagerequiresauniquemethodologyinordertoreachequivalencebetweentheoriginalsourceandtargetlanguages.

Objectives:TotranslatetheEnglishversion(1.0)ofBarthelIndexintoPunjabilanguageandit’sPsychometricAnalysis in individuals with stroke.

Method: Thisstudywillbedividedintotwophases.TheEnglishversionofBarthelIndexwillbetranslatedintoPunjabilanguagefollowingguidelinesgivenbyoftheMapiResearchTrust.InthesecondphasethetranslatedBarthelindexwillbethentestedforitsvalidityandreliabilityinindividualswithstroke.

Statistical Analysis:DescriptivestatisticswillbeappliedandIntraclassCorrelationCoefficient(ICC)willbe calculated.

Keywords: Cross-Cultural adaptation; Translation; Barthel Index; Psychometric analysis.

INTRODUCTION

Independence in self–care activities is a commonoutcome measure to assess disability. Barthel Indexhas been regarded as the best in terms of sensitivity,simplicity,communicabilityandeaseofscoring,amongall other instruments that measures activities of daily living.1

Amongallotherinstruments,BarthelIndexhasbeenregardedas thebest in termsof sensitivity, simplicity,communicability and ease of scoring.2TheBarthelIndexwasfirstdevelopedbyMahoneyandBarthel(1965)andlatermodifiedbyCollinetal.3

As rehabilitation was integrated in the processes of caretodisablingpeople,theneedofobjectivemeasuresof both disability and recovery will be satisfied bydevelopingPunjabiversionsoftheBarthelIndexamongPunjabi speaking population. A validated and reliable PunjabiversionofBarthelIndexwillfacilitateassessing

the activities of daily living in Punjabi speaking patients whohavebeensufferingfromstroke.

Theterm“culturaladaptation”isusedtoencompassaprocesswhichlooksatbothlanguage(translation)andcultural adaptation issues in the process of preparing a questionnaire for use in another setting. The cross-cultural adaptationof a health status self-administeredquestionnaire for use in a new country, culture andlanguage requires a unique methodology in order toreachequivalencebetweentheoriginalsourceandtargetlanguages.4

The adaptation of psychological instruments is a complex task that requires careful planning regardingits content maintenance, psychometric properties, andgeneral validity for the intended population.5

Theprocessofadaptinganexistinginstrument,ratherthandevelopinganewonethatisspecificallyforthetargetpopulation, has considerable advantages. By adapting

DOI Number: 10.5958/0973-5674.2019.00078.9


an instrument, the researcher is able to compare datafromdifferentsamplesandfromdifferentbackgrounds,which enables greater fairness in the evaluation because the same instrument assesses the construct based on the same theoretical and methodological perspectives. The use of adapted instruments naturally enables a greater ability to generalize and also enables one to investigate differenceswithinanincreasinglydiversepopulation.6

AvalidatedandreliablePunjabiversionofBarthelIndex will facilitate assessing the activities of dailyliving in Punjabi speaking patients with stroke. The purposeofthisstudyistoincreasetheusageofBarthelIndex among Punjabi speaking patients as it will beeasy for them to understand and rate themselves on theBarthel Index.ThePunjabiBarthel Indexwill notbe limited only to the particular geographical area but will be able to use anywhere, where the Punjabispeakingpopulationwillbepresent.Itwillalsofacilitateexchangeofinformationininternationalstudies&alsoforcomparisonofdifferentresearchfindingsworldwide.Itwillhelpinassessingpreandposttreatmentefficacyin Punjabi speaking population and will serve as a guide for therapist.

PROCEDURE

The study was divided into two stages i.e. translation of English version 1.0 of Barthel index into PunjabilanguageandpsychometricanalysisofPunjabiBarthelIndex in population suffering from stroke. Firstly,permissionwas taken from theMapi research test forusing and translating English version 1.0 of BarthelIndex into Punjabi language and after taking theirpermission the translation phase was started. InthisphasetheEnglishversionofthe10-itemBarthelIndexversion1.0wastranslatedintoPunjabilanguageaccording to guidelines given by the Mapi ResearchTrust.7InthesecondphasethetranslatedBarthelIndexwas then tested for its validity and reliability properties in individuals with stroke.

Phase1: Translation of English version 1.0 of Barthel Index in Punjabi language

Stage I: Initial Translation: The first stage was theforward translation of English version 1.0 of BarthelIndex in Punjabi language. Two forward translationswere made of the instrument from the English language

(source language) to the Punjabi language (targetlanguage). Poorer wording choices was identified andresolvedinadiscussionbetweenthetranslators.Bilingualtranslators whose mother tongue was the Punjabi language produced the two independent translations. Thetwotranslatorswereofdifferentbackgrounds.

Translator 1: This translator was aware of the concepts beingexaminedinthequestionnairebeingtranslatedandwas from medical background. Appendix of informed consent of the translator was taken. This translator gave thefirstPunjabitranslation(T1)oftheEnglishversion1.0ofBarthelIndex.

Translator 2: The second translator was not be aware or informed of the concepts and was having no medical or clinical background. This type of translator was called a naive translator. This translator gave the second translation (T2)oftheEnglishversion1.0ofBarthelIndex.

Stage II: Synthesis of the Translations: Workingfrom theoriginalEnglishversion1.0ofBarthel Indexquestionnaire aswell as the first translator’s (T1) andthe second translator’s (T2) versions, a synthesis ofthesetranslationswasfirstconductedthatproducedonecommontranslationT-12.

Stage III: Back Translation (BT): Working from theT-12 version of the questionnaire and totally blind tothe original version, another translator then translatedthequestionnaireback into theEnglish language.Thiswas a process of validity checking to make sure that the translated version reflected the same item contentastheEnglishversions.Backtranslationwasonlyonetype of validity check. These back-translations BT1andBT2(AppendixKandAppendixM)weredonebypersonswiththeEnglishastheirfirstlanguage.Thetwotranslators were not be aware or informed of the concepts explored,andwerewithoutmedicalbackground.

Stage IV: Expert Committee: According to guidelines given by Beaton et al.4 the composition of expert committee comprised of methodologist,health professionals, language professionals and theforward and back translators. The original developers of the questionnaire were in close contact with theexpert committee during this part of the process. The expert committee consolidated all the versions of the questionnaire and developed the pre final version ofthe questionnaire for field testing. The committeereviewed all the translations and reached a consensus


on certain discrepancy. The material at the disposal of thecommittee included theoriginalquestionnaire,andeachtranslation(T1,T2,T12,BT1,andBT2)togetherwith corresponding written reports. Decisions were madebythiscommitteetoachieveequivalencebetweenthe English and Punjabi version in four areas that are Semantic Equivalence, Idiomatic Equivalence, and ExperientialEquivalenceaConceptualEquivalence.

Stage V: Test of the Prefinal Version: Thefinalstageofadaptationprocesswasthepretest.Thisfieldtestofthenewquestionnairewasdonewiththeprefinalversionin individuals from the Punjabi setting. 10 individuals with stroke were tested. Each individual completed the questionnaire,andinterviewedtoprobeaboutwhatheorshethoughtweremeantbyeachquestionnaireitemandthechosenresponse.Boththemeaningoftheitemsandresponses were explored.

Phase 2: Psychometric Analysis of Punjabi version of Barthel Index.

The data was assorted for psychometric analysis. Subjects suffering from stroke were assessed usingthe Punjabi Barthel Index. According to inclusionand exclusion criteria, 100 subjectswere selected andrandomly divided into two groups i.e. Group A and Group Bwith50subjectsineachgrouptocheckreliabilityandvalidity. All the subjects were informed about the study and their consent was taken.

InGroupA test retest reliabilitywasmeasuredbyintraratercorrelationcoefficientandcronbach’salpha,Split-Half(odd-even)correlationandSpearman-BrownProphecy were calculated to check internal consistency. To calculate test retest reliabilty readings with Punjabi BarthelIndexwerescoredandcalculatedtwicewithgapof6daysbysametherapistasdescribedbyWeir.8

Concurrent validity was assessed in Group B bytakingreadingsonbothPunjabiandEnglishBarthelindexon the same day. The scores of both Punjabi and English BarthelindexwerecalculatedandPearson’scorrelationcoefficientwasmeasuredtofindthecorrelationbetweenthe readings of both Punjabi and English version 1.0 of BarthelIndex.

FINDINGS

Translation: After forward and backward translation and afteraconsensusmeeting,thetranslatedscalewasformed.

Psychometric Analysis: Test retest reliability and internal consistency was calculated in Group A

InordertoevaluateinternalconsistencyCronbach’salpha,Split-Half(odd-even)correlationandSpearman-BrownProphecywerecalculatedfromthereadingtakenonPunjabiBarthelIndextwiceafterthegapofsixdays.CalculatedreadingsofCronbach’salphaare0.937and0.923,Split-Half(odd-even)correlationare0.938and0.905 and Spearman- Brown Prophecy are 0.968 and0.950 from both test and retest values shown to have excellent internal consistency. Test retest intra-raterreliabilitycalculatedforPunjabiBarthelIndexingroupAresultedequalto0.999(95%IC:0.998–0.999).

Concurrent validity was checked in group Bby calculating Pearson’s correlation. The value ofPearson’scorrelationCoefficienti.e.r=0.997,thisshowsstatisticallysignificantresultforvalidity.

DISCUSSION

Test-retestintra-raterreliabilityhasbeencalculatedforPunjabiBarthelIndexandresultedequalsto0.999.The test and retest values for internal consistency of PunjabiBIwereequalto0.937and0.923andthevalueofPearson’scorrelationCoefficientwasequalto0.997,the results showed the excellent reliability and validity ofPunjabiBarthelIndex.

Wade firstly developed Barthel Index as a simpleindex of independence, useful to evaluate functionaldisability in any disabled patient and in calculation of scoring improvement in rehabilitation. The original versionofBarthelIndexitselffoundtobevalidasADLindicator and the examples of its validity are available inliterature.TheoriginalBIhasbeenshowntohaveaCronbach’salphaof0.87.ThisshowsthatBarthelIndexshows good internal consistency and therefore the use of barthel index plays an important role in measurement of activities of daily living in various neurological disorders.TheexamplesofvalidationofBarthelIndexare present in literature.9

Morleyetal.confirmsthevalidationofself-reportBarthel Index in people with Parkinson’s disease. ACronbach’s alpha coefficient of 0.69 was calculated,indicating adequate internal consistency and alsoconfirm the role of Barthel Index in neurologicalconditionslikeParkinson’s.10Pietraetal.confirmedthe


validityandreliabilityoftheBarthelindexadministeredby telephone. So Barthel Index can be used throughcommunication sources like telephone also this also confirmedtheeaseofuseofBarthelIndex.11

BecauseofthesimplicityandeaseofusingEnglishversion1.0ofBarthelindexformeasuringactivitiesofdailyliving,therequirementofBarthelIndexwassensedinthelanguagesotherthanEnglish,sothatitcanalsobeusedinvariousnon-Englishspeakingpopulation.AlongwiththeEnglishversion1.0ofBarthelIndexitwasalsotranslatedandvalidatedinmanyotherlanguages,suchasTurkish,German,Persian,Chinese,Brazilian,Dutchand Japanese. Study done by Ohura et al. confirmsvalidityandinternalconsistencyoftheJapaneseversionof themodifiedbarthel index forelderlypeople livingathomeandreportedaCronbach’salphaequalto0.93,thisstudyalsoshowedthattheuseofBarthelIndexisnot age limited and can be used in all age groups.12 The Dutch translated version of the BI has been reportedto have a Cronbach’s alpha of 0.87.13 The Turkish have validatedBI for rehabilitation patients, reportingan internal consistency of 0.88.14 and the cronbach’salphaofChineseversionwasequalto0.92.15 Inastudydone by Cincura et al. the National Institute NationalInstituteofHealthStrokeScale(NIHSS),BarthelIndexand modified Rankin Scale show good validity whentranslated and culturally adapted in Brazil language.The cronbach’s alpha in Brazilian Barthel Index was0.967.16InMiddle-Eastcountry,nodisabilityscalewastranslatedandvalidatedforuseinstrokeclinicaltrials,thestudywasdesignedtotranslatetheBarthelIndexintoPersion language and its validation was proved in stroke patients with cronbach’s alpha equals to 0.994.17All these examples shows the greater reliability and validity of Barthel Index in different languages and differentgeographical areas.As the Punjabi version of BarthelIndexalsoshowedthegoodreliabilityandvalidity.Thetest and retest values for internal consistency of Punjabi BIwereequalto0.937and0.923.ThehighreliabilityofPunjabiBIindicatesthatscoresofpatientsremainstableafter repeated measurements.

As the Barthel Index is a widely used measureof functional disability. The index was developed for use in rehabilitation patients with stroke and other neuromuscular disorders. In a pilot study done byPandian et al. found the crude annual incidence rate to be 140/100,000 person-years. Therefore, with such

a burden, it is of great importance to apply reliable,validated and adapted instruments to determine the duration of stay of patient in hospital, the burden ofcare, the efficiency and effectiveness of rehabilitationintervention.18Unfortunately, nodata on translationofthe scale and adaptation processes to Punjabi culture are available in literature.

Cross-culturaladaptationofaquestionnaireforuseinanewsettingistimeconsumingandcostly.However,to date the authors believe it is the best way to get an equivalent metric for whatever self-report attribute isbeing considered. It allows data collection efforts tobe the same in cross national studies or to avoid the selection bias that may be associated with studies that must exclude all patients who were unable to complete a form in English.

CONCLUSION

ThePunjabi culturally adaptedBartheI Index as awholehasdemonstratedtobevalid,reliable,acceptable,easy to understand and rapidly administrable. This work provides a new tool for professionals to measure functional impairment when appraising Punjabi speaking disable patients in health and social care settings along the continuum of care.

Ethical Clearance: All Saints Institute of MedicalSciencesandResearches,Ludhiana,Punjab.


Conflict of Interest: Nil.

REFERENCES

1.Shah S, Cooper B. Commentary on ‘A CriticalEvaluation of the Barthel 1Index’. The BritishJournalofOccupationalTherapy.1993;56(2):70-72

2.Galeoto G, LautaA, PalumboA, Castiglia SF,MollicaR,SantilliV,SacchettiML.TheBarthelIndex: Italian Translation, Adaptation andValidation. International Journal of Neurologyand Neurotherapy. 2015; 2(2):1-7.

3.Collin C, Wade DT, Davies S, Horne V.The Barthel ADL Index: a reliability study.International Disability Studies Journal. 1988; 10(2):61-63.


4.BeatonDE, Bombardier C,Guillemin F, FerrazMB, Marcos B. Guidelines for the Processof Cross-Cultural Adaptation of Self-ReportMeasures.Spine. 2000; 25(24):3186–3191

5.Borsa JC, Damasio B, Bandeira DR. Cross-Cultural Adaptation and Validation ofPsychologicalInstruments:SomeConsiderations.Paideial.2012;22(53):423-432.

6.Hambleton RK, Merendra PF, Spielbergen CD.Adapting educational and psychological tests for cross-cultural assessment. Psychometrika. 2007;72(4):649-651.

7.MAPI Institute. Linguistic Validation Manualfor Health OutcomeAssessments. Lyon: MAPIResearch Trust; 2012.

8.Weir JP. Quantifying test-retest reliability usingthe intraclass correlation coefficient and theSEM. Journal of Strength and ConditioningResearch.2005;19:231-240.

9.Wade DT, Skilbeck CE, Hewer RL. PredictingBarthel ADL score at 6 months after an acutestroke. Archives of Physical Medicine andRehabilitation.1983;64:24-28.

10.MorleyD,SelaiC,ThompsonA.Theself-reportBarthel Index: preliminary validation in peoplewith Parkinson’s disease. European Journal ofNeurology.2012;19:927-929.

11.DellaPietraGL,SavioK,OddoneE,etal.ValidityandReliabilityoftheBarthelIndexAdministeredbyTelephone.Stroke.2011;42:2077-2079.

12.Ohura T, Higashi T, Ishizaki T, Nakayama T.Assessment of the validity and internal consistency

of a performance evaluation tool based on the Japaneseversionofthemodifiedbarthelindexforelderlypeoplelivingathome.JournalofPhysicalTherapyScience.2014;26:1971-1974.

13.PostMW,VanAsbeckFW,VanDijkAJ,SchrijversAJ.DutchinterviewversionoftheBarthelIndexevaluated in patients with spinal cord injuries. NederlandsTijdschriftVoorGeneeskundejournal.1995;139:1376-1380.

14.Kucukdeveci AA, Yavuzer G, TennantA et al.AdaptationofthemodifiedBarthelIndexforusein physical medicine and rehabilitation in Turkey. ScandinavianJournal ofRehabilitationMedicine.2000;32:87-92.

15.LeungSO,ChanCC,ShahS.DevelopmentofaChineseversionof theModifiedBarthel Index--validity and reliability. Clinical Rehabilitation. 2007;21:912-922.

16.Cincura C, Pontes-Neto OM, Neville IS, et al.Validation of the National Institutes of HealthStrokeScale,modifiedRankinScaleandBarthelIndex in Brazil: the role of cultural adaptationand structured interviewing. Cerebrovascular Diseases.2009;27:119-122.

17.Oveisgharan S, Shirani S, Ghorbani A, et al.BarthelindexinaMiddle-Eastcountry:translation,validity and reliability. Cerebrovascular Diseases. 2006;22:350-354.

18.PandianJD,KalraG,Jaison,etal.Aknowledgeof stroke among stroke patients and their relatives in Northwest India. Neurology India. 2006;54(2):152-156.

To Evaluate the Efficacy of 780 nm Low Level Laser Therapy for the Treatment of Plantar Fasciitis in South Western

Ethiopia

Dheeraj Lamba

Associate Professor, Faculty of Physiotherapy, Institute of Health, Jimma University, Jimma, Ethiopia

ABSTRACT

Objective: Bydefinitionplantarfasciitis(PF)isaninflammationoftheplantarfascia.Presentstudyevaluatestheeffectsof780nmLowLevelLaserTherapy(LLLT)inthetreatmentofplantarfasciitis&establishesthestatusofLLLTasacosteffectivemodalityforthetreatmentofplantarfasciitis.

Method: 80 subjects were selected on the basis of the inclusion and exclusion criteria andwere recruited randomlytoeither780nmLLLT(experimentalgroup)orshamirradiation(placebocontrolgroup).

Result: OverallresultsshowedsignificantdifferenceinVisualAnalogueScale(VAS),FootFunctionIndex(FFI)andDorsiflexion(DF)from0weekto4thweekinGroupAindicatingthattherateofimprovementinGroupAwasmorethanGroupB.Henceconcludingthepositivecontributionoftherapeuticmodalityforpainrelief,increasingfunctionalabilityandincreasingdorsiflexionRangeofMotion(ROM)

Conclusion: ThepresentstudyfindsthatLLLTattheparametersshownisasafe,potentandcosteffectiveconservative treatment method for the patients having plantar fasciitis.

Keywords: (PF) Plantar fasciitis, LLLT (Low Level Laser Therapy), (FFI) Foot Function Index, (VAS) Visual Analogue Scale, ROM (Range of Motion), DF (Dorsiflexion)

INTRODUCTION

Pain and difficulty performing activities of dailyliving is the most common patient complaints associated with musculoskeletal disorders of the foot. Plantar fasciitis (PF) is a common pathological conditionaffectingthehindfootandwasfirstdescribedbyWoodin 1812 [1,2]BydefinitionPFisaninflammationoftheplantarfascia.Itisacommoncauseofheelpaininadults.The pain is usually caused by collagen degeneration at the origin of the PF at the medial tubercle of the calcaneus. PF is found at almost every age in both sexes and in many occupations [3,4].The peak age of incidence in general population is between 40 and 60 years.[1,3]The perpetuatingfactorsforPFcanbedividedunderIntrinsicand Extrinsic factors. Intrinsic factors includeObesity,Pesplanus, Pescavus, diabetes mellitus, increasedbody mass index (BMI) and decreased dorsiflexion.Extrinsicfactorsincludepoorfootwear/shoe,typeandintensityofdailyactivity,incidenceofrepetitivetrauma,occupations involving long period of standing or weight

bearing, undulatingor uneven surface and waking forlong periods of time.

Geographically Jimma Region of South WestEthiopia has hilly areas andplain area, this differencein geography plays a vital role in the biological traits. Several morpho-physiological and demographicstudieshavebeencarriedout indifferenthighaltitudepopulations worldwide to study the pattern of growth and development, sexual maturation, structural,compositional and physiological variations. Hiroyuki Tanaka et al[5]in their study on the bone metabolism in high mountaineering found that low barometric pressure andlowoxygentension,isprobablyresponsibleforthebone atrophy at high altitude.

Need of the Study:

1.Toinvestigatetheeffectivenessof780nmLLLTin the treatment of plantar fasciitis.

2.ToestablishthestatusofLLLTasapopular,potentand cost effectivemodality for the conservativetreatment of plantar fasciitis.

DOI Number: 10.5958/0973-5674.2019.00079.0


MATERIAL & METHOD

Sample Size: 40 subjects per group will provide 80% powertodetectaminimaldifferenceof3Pointsonthepainscale(SD2,α=0.05,5%losstofollow-up).

Study Design: Randomized, single-blinded, placebo-controlled trial

Study Setup: The subjects were recruited from OutpatientdepartmentofphysiotherapyandoutpatientdepartmentofOrthopaedics,JimmaUniversity,Jimma,Ethiopia. After briefing the protocol their informedconsent was taken.

Ethical clearance for the same has been taken by the institutional ethical committee.

Study Population: 80 subjects were selected, on thebasis of the inclusion and exclusion criteria and were recruitedrandomlytoeither780nmLLLT(ExperimentalGroup) or ShamLaser(PlaceboControlledGroup). 76subjects completed the study with 4 dropouts

Inclusion Criteria:

1.Age:40-50years

2.Bothmalesandfemales

3. Subjects with symptoms of plantar fasciitis for 6 weeks.

4.Painthatisworseinthemorningduringinitialsteps,but decreases gradually after continued walking.

Exclusion Criteria:

1. Pescavus

2. Excessive foot pronation

3. Pesplanus

4. Tight Achilles tendon

5. Previous Surgery on foot

6.Reiter’sSyndrome

7.AnkylosingSpondylitis

8. Gout

9. Rheumatoid Arthritis.

10. Neurological disorders e.g. Tumors or epilepsy

11. Calcaneal Stress fracture and fractures around the ankle joint

12.Anyknownradiatingpain(lowerLimb)e.g.Discpathology

13. Subjects who received corticosteroid injections in last 6 months

14.Paget’sDisease

Instrumentation:780nmClass3B,Ga-Al-AsLLLT

Outcome Measures:

1.VisualAnalogScale(VAS)

2.FootFunctionIndex(FFI)

3.ROM(Dorsiflexion)

Procedure: Each subject underwent a physical,radiological, blood examination and assessmentby the Orthopaedic Surgeon to rule out any othermusculoskeletal or neurological causes for their pain. Therapy was performed in a standard manner with the subjects washing their symptomatic foot in soap and water and the therapist lightly scrubbing the painful area withaspiritswab.ThepatientsfilledtheVAS,FFIandDorsiflexionROMbeforefirsttherapy(zeroday),endofFirst,second,thirdandfourthweekrespectivelytocheckthe level of improvement. The approach to develop optimal parameters and dosage has been adopted by the WorldAssociation of Laser Therapy (WALT) in theirrecommendations for treating musculoskeletal disorders withLLLTwww.walt.nu[17].

Group A: Patients in this group received 780nm lowlevel laser therapy followed by stretching exercises of the plantar fascia. The patient is positioned prone lying to obscure viewing of laser with probe in contact with the skin at right angle. The foot was irradiated with a continuouswave780nmlaser.Therapyconsistedof90seconds with of irradiation over the origin of the plantar fascia on the anterior inferior calcaneus and then twice 90 seconds continuous sweeps of the laser along the prominent medial border of the plantar fascia. Therapy will begiven three times aweek for 4weeks.100mWcontinuouswave 780 nm IR diodedevicewith energydensityof10J/cm2.Toperformtheplantarfasciastretch,thepatientwasinstructedtofirstcrosstheaffectedlegover the contra lateral leg while seated. The patient then applied force distal to the metatarsophalangeal joint on the affected side, pulling the toes upward towardsthe shin until a stretch was felt in the sole of the foot. Tension in the plantar fascia was palpated with the contra


lateralhandwhileperforming thestretch.Bothgroupswereinstructedtoholdtheassignedstretchforten(10)seconds and repeat ten (10) times. The patient wereinstructed to follow the assigned protocol three times per day,withthefirststretchdonebeforethefirststeptakenin the morning and prior to any weight bearing activity.

Group B: Patient in this group received sham laser radiation (no laser beam), followed by plantar fasciastretching exercises as explained above.


Statistical analysis was done using SPSS software version 21.0.

T- Test was used to analyze the variable of agebetweenGroupAandB.

SplitplotANOVAwasusedtodeterminetheVAS,FFI,andDFat0week,1stweek,2ndweek,3rd week and 4thweekbetweenGroupAandB.SplitANOVAisusedtotestthedifferencesbetweentwoormoreindependent

groups while subjecting participants to repeated measures.Inpresentstudytwoindependentgroupsi.e.(GroupA&B),bothgroupswererepeatedlymeasuredallparticipantson0,1st,2nd,3rd,and4th week.

Validity of repeated measure analysis was doneusingMauchly’sSphericitytest.Itreferstotheconditionwhere the variances of the differences between allpossiblepairsofthegroupi.e.(leveloftheindependentvariables)areequal.

Thelevelofsignificanceisaforeassumedprobabilityofrejectingnullhypothesissoweassume0.05(5%levelofsignificance)thereforeLevelofsignificancewassetas 0.05 for the present study.

RESULTS

OverallresultsshowedsignificantdifferenceinVAS,FFIandDFfrom0weekto4th week in Group A as compared to Group B indicating that the rate of improvement inGroupAwasmorethanGroupB.(Table1-4)

Table 1: Comparison of Age between Group A and B

Variable Group AMean ( + SD)

Group BMean ( ± SD) P Value

Age 45.88(±10.38) 45.42(±9.65) *0.931

Table 2: Comparison of Pain on VAS from 0 to 4th week between Group A and B

VariableVAS

Group AMean (± SD)

Group BMean (± SD)

F Value P Value

0Week 6.75(±)1.08 7.20(±)0.75

(3.07,249.8)=109.0 *0.0041stWeek 6.40(±)1.08 7.10(±)0.772ndWeek 5.63(±)1.05 6.98(±)0.693rdWeek 4.60(±)1.00 6.68(±)0.884thWeek 3.55(±)0.87 6.37(±)0.86

Table 3: Comparison of Functional Ability on FFI from 0 to 4th week between Group A and B

VariableFFI

Group AMean ( ± SD)

Group BMean ( ± SD) F Value P Value

0Week 72.68(±)10.53 77.28(±)7.16

(2.34,172.8)=202.7 *0.0001stWeek 68.38(±)10.56 75.81(±)7.182ndWeek 60.92(±)11.02 74.10(±)7.143rdWeek 50.55(±)9.08 71.30(±)7.634thWeek 39.81(±8.10 68.31(±)8.15


Table 4: Comparison of Range of motion (DF) from 0 to 4th week between Group A and B

VariableDF

Group AMean ( ± SD)

Group BMean ( ± SD) F Value P Value

0Week 14.32(±) 2.25 13.35(±) 2.28

(2.30,193.4)=26.8 *0.0051stWeek 14.83(±) 2.14 13.57(±) 2.212ndWeek 15.95(±) 2.12 14.10(±) 1.983rdWeek 17.68(±) 1.52 14.92(±) 2.204thWeek 19.45(±) 1.41 15.83(±)1.97

DISCUSSION

Plantar fasciitis is one of the most common disorders. [1]It isestimated toaccount for11 to15percentofallfootsymptomsrequiringprofessionalcareamongadults

[6].Approximately10% of such individuals go to have chronic pain [7]. The major goal of therapy is to relieve pain and increase functional ability. Common therapy consist of drugs, non-steroidal anti-inflammatorydrugs(NSAID)[3-5]Variousphysicalmodalitiesincludeintermittent cold [9] stretching, soft tissue therapy,massage, heat, SWD, Extra corporeal shock wavetherapy, patient education, shoe modification, nightsplints,activitymodification, iontophoresis,ultrasoundand Low level laser therapy (LLLT) [1,5,7,8]Hana Hronkovaet al [10]andDhiaAKJaddueetal[11] reported functional recovery and decrease of spontaneous pain withLLLTonPlantarfasciitis.ImplicationofthepresentstudyshowssignificantdifferenceinVAS,FFIandDFfrom 0 to 4th week between the two groups i.e. Group A (Ga-Al-AsLaser+PFstretching)andGroupB(Placebo+ PF stretching).

Onanalyzingtheresults,GroupAwasfoundmoreeffective thanGroupB,concludingthecontributionoftherapeuticmodality(LowLevelLaserTherapy)inpainrelief,increasingfunctionalabilityandrangeofmotion.significantimprovementseenfrom0to4th week could beduetodecreaseinpain,increaseinATPproductionandotherpossiblemechanismspredictedareeffectsonendomorphin[12,13] level gate control of pain given by MelzackandWall.[14]ErnestoCesarPintoLealJunioretal [15]advocatedthatinfraredLLLTcanpreventischemicmuscle injuries by reducing the releaseof reactive oxygen species (ROS) and creatine phosphokinase activity,while increasing levels of antioxidants and heat shock protein insupport to thisThiagoDeMarchietal [16]in their study suggested that LLLT application decreasesoxidative stress leading to a delay in the development the skeletal muscle fatigue, improvement of skeletalmuscleperformance,andpreventionofmuscledamage.

Ontheotherhand,onanalyzingtheresultsforGroupB(Placebo+PFstretching)veryslightimprovementwasseen from 0 to 4thweekinVAS,FFIandDFasstretchingexercises relieves stress on the plantar fascia[1],theyformsthe basis of conservative treatment in plantar fasciitis [3,7-8.]F. DiGiovanni[7]etalreportedthatlongterm(8weeks)plantarfasciastretchingexercisescouldprovebeneficialin decreasing pain and functional limitation in patients withchronicplantarfasciitis.InthestudybyTurliketaltheuseofdifferent interventionsalongwithstretchingprogramsmakesitimpossibletodeterminetheeffectsofthe stretching itself on the result of the studies[1].

CONCLUSION

Result of the present study shows significantdifferenceintheeffectsofGa-Al-Aslaserwithstretchingwhen compared to placebo with stretching alone on pain relief,functionalabilityandDFrangeofmotionwhichconcludes that using 780 nm LLLT at the parametersshownisasafe,potentandcosteffectiveconservativetreatment method for the patients having plantar fasciitis.

ACKNOWLEDGMENT

I am thankful to my patients, department ofphysiotherapy,departmentoforthopaedics,mycolleagueandthestaffforhelpingincarryingoutthisresearchtoits fruitful outcome.



REFERENCES

1.ChakrabortyMK,OntaPR,SathianB.EfficacyofStretching Exercises in the treatment of Chronic Plantar Fasciitis- A Prospective study. AsianJournalofMedicalSciences.2011;2:97-101.


2.SimonJ.Bartold.ThePlantarFasciaasasourceofpain- biomechanics, presentation and treatment.Journal ofBodywork andMovementTherapies.2004;8:214-226.

3.MarioRoxas,ND.PlantarFasciitis:DiagnosisandTherapeuticConsiderations.AlternativeMedicineReview.2005;10:83-93.

4.MarkW. Cornwall, ThomasG.McPoil. PlantarFasciitis: Etiology and Treatment. Journal ofOrthopaedicandSportsPhysicalTherapy.1999;29(12):756-760.

5.Hiroyuki Tanaka, KeijiMinowa, Tetsuya Satoh.Bone Atrophy at High Altitude. JRMM. 1992;(10):31-32.

6.Tae Im Yi, GaEun Lee, In SeokSeo. Clinicalcharacteristics of the causes of Plantar Heel Pain. Annals of Rehabilitation Medicine. 2011; 35:507-513.

7.Benedict Digiovanni, Deborah A., Daniel P.Plantar Fascia- Specific Stretching ExerciseImproves Outcomes in patients with chronicPlantarFasciitis.The Journal ofBone and JointSurgery.2006;88A(8):1176-1781.

8.Craig C. Young, Darin Rutherford, Mark W.Treatment of Plantar Fasciitis. American Family Physician.2001;63(3):467-474.

9.Edmund M., Herbert E. Painful Plantar Heel,Plantar Fasciitis, and Calcaneal Spur: EtiologyandTreatment.The Journal ofOrthopaedic andsportsPhysicalTherapy.(1987);9(1):17-24.

10.Lucie Brosseau, Vivian Welch, George Wells.Low level laser therapy for Osteoarthritis andRheumatoidArthritis:AMetanalysis. Journal ofRheumatology.2000;27:1961-1969.

11.DhiaAK,AliSulaiman.UsingofLaserTherapyin the treatment of patients with plantar Fasciitis. Al-KindyColMedJ.2008;4(1):72-76.

12.Nina Palmgren,Grethe F. Jensen,KammaKaae,MarianneWindelin,HansC.Colov.Lowpowerlaser therapy inRheumatoidArthritis. Lasers inMedicalScience.1989;4:193-196.

13.E. LiisaLaakso, Tess Cramond, CarolynRichardson, John P. Galligan. PlasmaActh andß-Endomorphin levels in response to low levellaser therapy (LLLT) for myofascial triggerpoints.LaserTherapy.1994;6:133-142.

14.SimunovicZ.Lowlevellasertherapywithtriggerpointstechnique:Aclinicalstudyon243patients.JournalofClinicalLaserMedicalSurgery.1996;14(4):163-167.

15.ErnestoCesarPintoLealJunior,RodrigoAlvaro.Effect of 830 nm Low level laser therapy inexercise induced skeletal muscle fatigue in humans.LasersMedSci.2008;592-599.

16.Thiago De Marchi, Ernesto Caesar Pinto.Low level laser therapy (LLLT) in humanprogressiveintensityrunning:effectsonexercisesperformance,skeletalmusclestatusandoxidativestress.LasersMedSci.2011;955-960.

17.WALT. Recommended treatment doses of LowLevelLaserTherapy;2010.

To Know the Effectiveness of Rocker Board Training Programe on Trunk Balance and Gait in Subjects with Stroke

N. Lakshmi Tirupatamma1, G. Kameshwari2, V. Sri Kumari3, K. Madhavi4

1PG–Masters of Physiotherapy (Neurology), 2Lecturer, 3Assistant Professor, 4Principal, College of Physiotherapy, SVIMS, Tirupathi, Andhra Pradesh

ABSTRACT

Stroke is a clinical syndrome with signs of focal or global disturbance of cerebral functions with apparent causesofvascularorigin.StrokeisoneoftheleadingcausesofdeathanddisabilityinIndia.Asperavailableliterature,inIndia104.39deathsper1’00’000populations.Theincidenceratewas99.54per1,00,000inmenand149.49per1,00,00inwomen.80percentofstrokepatentsdidn’tsurviveafter10years.Moreoverstroke patients face balance problems which limit lower limb functional activities which demand rapid and optimal improvementofpostural control for their independence, socialparticipationandgeneralhealth.Balancetraining,onRockerBoardinsittingpositionhasprovedtobeeffectiveinimprovingbalanceinstrokepatients,butthereisnoavailablestudyevaluatedeffectivenessofbalancetrainingprogramonRockerBoardinstandingpositionwhichisanurgentneedforstrokepatientswithdifficultyinstandingbalance.Tofillthisgap,thepresentresearchworkstudiedtheeffectivenessofRockerBoardtrainingprogramonbalanceandgaitinstrokepatientswiththehelpof‘Bergbalancescale’(BBS),‘Functionalreachtest’(FRT)and ‘Timedwalking test’(TWT).Values obtainedwere compared by using a paired t-test.According toobtainedvaluesthepreandposttestvaluesofBBS,FRT,TWThadshownasignificanteffecton‘p’values<0.05inexperimentalgroupandafter6weeksofinterventionprotocol,thepresentstudyconcludesthatthetrunkbalanceandgaithavesignificantimprovementinexperimentalgroupthanthecontrolgroup.

Keywords: stroke, trunk balance gait, Rocker Board, training program

INTRODUCTION

Stroke is a clinical syndrome characterized by rapidly developing signs of focal or global disturbance of cerebral functions, lasting for more than 24 hoursorleadingtodeath,withnoapparentcausesotherthanvascular origin. Stroke is one of the leading causes of deathanddisabilityinIndia.AsperWHOstudiesin2014,the estimated adjusted prevalence rate of stroke ranges 84-262per100,000inruraland333-424per1,00,000inurbanareas.Theincidencerateis119-145per1,00,000.In India 104.39 deaths per 1’00’000 populations1.The incidenceratewas99.54per1,00,000inmenand149.49per1,00,00inwomen.30to40percentcaseswerewithlong term disability and 0.45 to 0.6 million were left with short term disability2.Strokeaccountsfornearly5.7milliondeathsglobally,and87percentofthesedeathsoccurinlowandmiddleincomenations.Mortalityonemonthafterstrokeis25percent,sixmonthsafterstrokeis 33 percent and after one year is 50 percent3,80percentofstrokepatientsdidn’tsurviveafter10years4,Strokeis

one of the major causes of permanent disability with an incidenceofapproximately1.75percentperyear5.

Moreover stroke patients face balance problemswhich limit lower limb functional activities. Hence; rapid and optimal improvement of postural control in stroke patients is essential for their independence,socialparticipationandgeneralhealth.Balancetrainingon Rocker Board in sitting position has proved to beeffective in improving balance in stroke patients16 but thereisnoavailablestudyevaluatedtheeffectivenessofbalancetrainingprogramonRockerBoardinstandingposition which is an urgent need for stroke patients with difficultyinstandingbalance.

Therefore, thepresent study is aimed toknow theeffectiveness of Rocker Board training program onbalance and gait in stroke patients. To achieve this the followingobjectiveswereconsideredtostudyviz.,

1.TodeterminetheefficacyofRockerBoardtrainingin standing on balance by

DOI Number: 10.5958/0973-5674.2019.00080.7


i.‘BergBalanceScale’(BBS). ii.‘FunctionalReachTest’(FRT).

2.To determine the efficacy of Rocker Boardtraining in standing on gait by ‘TimedWalkingTest’(TWT).


Materials

1. Rocker Board:TheRockerBoardcantiltintwodirectionsoneisanteriorandposterior,otheroneis in side to side direction.

2. Yard stick

3. Inch tape

4. Stop watch

Methodology: A randomized control study was undertaken for the present research work where the patients were randomly selected by using simple random method from the Department of Neurology and the DepartmentofPhysiotherapy,SVIMSandalsofromSVAyurvedicHospital,Tirupathi.30Patientswere selectedasperthecriteriaofthestudymentionedintable-1andtheselected patients were randomly divided into two groups Viz., Experimental Group and Control Group. Bothgroups were administered with trunk exercises according to their treatmentprotocolsmentioned in table-2, in45minsessions,6daysaweekfor6weeksduringAugust2016 to June 2017.A schematic representation of studyplanismentionedinfigure-1asstudyalgorithm.

Table 1: The criteria considered for the study

S. No. Inclusive Criteria Exclusive Criteria

1. 40-60yearsofage P.C.A Stroke2. Unilateralhemiplegic Anycognitivedeficits3. Firsttimeaffected Anyotherneurologicaldeficitsasmultiplesclerosis,Parkinson’s

disease etc4. ACAandMCAlessonsonly AnymusculoskeletaldisorderslikeOA,ligamentinjuryetc5. Bothmaleandfemale Patients undergoing any other balance training protocol simultaneously6. Novisualandsensorydeficits7. Scoring at least 24 out of 30 on

mini mental state examination

Table 2: Treatment Protocols

S. No. Experimental Group Control Group1. Stretching exercises Strengthening exercises2. Strengthening exercises Stretching exercises3. Pelvicbridgingexercises,unilateralandbilateral Pelvicbridgingexercises,unilateralandbilateral4. TrunkcontrolexercisesonRockerBoardin

standing position for 20 min with breaks in between.

Trunkbalanceexercise(Flexion,extensionoflower,uppertrunk,Rotationofloweranduppertrunk,

Forward and lateral reach) on plain surface

The intensity of the exercises was increased by introducing one or several of the following changes:

z Reducing the base of support

z Increasingtheleverarm

z Advancing the balance limits

z Increasingtheholdtime

Outcome Measures

Berg Balance Scale (BBS): BalancewasevaluatedwiththeBergbalancescale(BBS),aclinicaltestthatassesses14 common tasks6. Scoring is based on the patient’sabilitytomeetspecifictimeanddistancerequirements.The test is easily administered and has been shown to have strong internal consistency and high interrater and intrarater reliability in patients with acute stroke6,7.


Functional Reach Test9 : The patient is instructed to standnext to,butnot touchingawallandposition thearm that is closer to the wall at 90 degrees of shoulder flexion with a closed fist. The assessor records thestarting position at the 3rd metacarpal head on the yardstick. Instruct the patient to “Reach as far as youcan forward without taking a step.” The location ofthe 3rd metacarpal is recorded. Scores are determined by assessing the difference between the start and endposition is the reach distance, usually measured ininches. Three trials are done and the average of the last two is noted.

Timed Walking Test: Timing of walking can be carried out in several ways. These either test speed over a short distanceorendurance.Shortdistancespeed testhas5,10,20miterswalk tests; andendurance tests are2,6,12-minutewalk tests.New this study takes endurancetest of 2-Minute Walk Test (2MWT). The 2MWT ispractical, simple,quick,andeasy toadminister. In thepresent prospective study,we found evidence of goodinter-and intrarater reliability of the 2MWT in for thepopulation of persons with unilateral below-kneeamputation 10. Figure 1: Study Algorithm

DATA ANALYSIS

Thedatacollectedasperthestudyplanrepresentedschematicallyinfigure-1wasstatisticallyanalysedbyusingSPSS20.0software.TheVariableswithinagroupwerecomparedbyusingpairedt-testandbetweenthegroupsbytwo-samplet-test.Thedifferencebetweenthepretestandposttestscoresaswellas95%confidenceintervalsforeachoutcome variable was reported.

Table 3: Comparison of pretest and posttest values within Experimental Group

Experimental N Mean SD t-value p-value RemarksBergBalance

ScorePre 15 31.93 4.818

20.627 0.000 Asp<0.05,thereissignificantdifferencebetween the pretest and posttest values.Post 15 51.53 2.326

Functional Reach Test(Inches)

Pre 15 5.60 1.40415.663 0.000 Asp<0.05,thereissignificantdifference

between the pretest and posttest values.Post 15 12.17 1.345TimedWalkingTest(Meters)


between the pretest and posttest values.Post 15 13.76 2.438

Table 4: Comparison of pretest and posttest values within Control Group

Control N Mean SD t-value p-value RemarksBergBalance

ScorePre 15 34.73 4.731

13.758 0.000 Asp<0.05,thereissignificantdifferencebetween the pretest and posttest values.Post 15 45.00 4.359





Conted…

TimedWalkingTest(Meters)



Table 5: Comparison of pretest and posttest values between Experimental Group and Control Group

Group N Mean SD t-value p-value RemarksBergBalance

ScoreExperimental 15 19.60 3.680

7.725 0.000 Asp<0.05,thereissignificantdifferencebetweenthetwogroups.Control 15 10.27 2.890


Experimental 15 6.57 1.6249.311 0.000 Asp<0.05,thereissignificant

differencebetweenthetwogroups.Control 15 2.30 0.716TimedWalkingTest(Meters

Experimental 15 6.78 1.9506.491 0.000 Asp<0.05,thereissignificant

differencebetweenthetwogroups.Control 15 3.03 1.093

RESULTS

The results show that, there is a statisticallysignificantimprovementofbothgroupswithp-valueis0.000.Butaspermeanvaluesthereismoreimprovementin the experimental group than in the control group.

DISCUSSIONS

Aim of this study is to know the effectiveness ofRockerBoardtrainingprograminstandingpositionontrunkbalance andgait in strokepatients.After stroke,patients have trunk imbalance and gait problems which lead to functional impairment. They cannot even control/balance their body due to sensory impairment and decreased power in trunk and leg muscles.

In this study, trunk balance exercises wereadministered to Control Group on plain surface and to Experimental Group on Rocker Board in standingposition apart from strengthening and stretching exercises incommon.Both thegroupswere treatedaspertheirtreatmentprotocolmentionedintable-2.Aftercompletionof the treatment, thestudyresults revealedthat the post test values of both Control Group and Experimental Group were statically significant withp-value0.000butoncomparingthemeandifferencesinboththegroups,theExperimentalGroupshowedbetterimprovement than Control Group.

The better improvement in experimental group is may be due to perturbations felt by patients and consequenttrailstocompensatewhiledoingexercisesonthetiltedRockerBoard.Thesecompensatoryreactionscan activate the motor system of the patients. Neural

plasticity may be enhanced by regular and repeated administration of this training which is confirmed bythe authors in a study where the trunk balance improved mainly by the development of a compensatory posture strategy and neural plasticity11. That the balancing ability improved after training on an uneven surface is due to the training might increase neurotransfer through the descending cortico spinal pathway to the trunk muscles12. The balancing exercises on an unstable surface sensitize the muscle spindle through gamma motorneurons, therebyimprovingmotoroutputwhichinfluencesthestabilityofjoint13.

The patients exercising on Rocker Board showeda significant improvement in Berg balance scale thanthose exercising on a plain surface. This study supports that balancing exercises on the unstable surface had a greater effect on sensory motor function and posturalreactions were faster on a moving surface20. Shumway Cook andWollacott21 suggested that the exercises on an unstable surface increases the external swing which more effectively encourages postural orientation byforcing faster modifications of the sensory andmotorsystemsandalsoassistsintheposturalstrategyofself-postural control.

BydoingtrunkbalanceexercisesonRockerBoardin standing position can improve not only trunk balance but also improves the gait. The gait was mainly improved by doing Rocker Board training as it increases ROMof ankle joint and strength of the ankle and lower limb musculature. The wobble board training can improve the symmetrical weight distribution on lower limbs14.


The present study is supported by following previous studies; The wobble board exercise program can significantly increase the strength of lower limbmuscles and balance performance15. The trunk exercises performed on the physio ball more effective thanthose performed on the plinth in improving both trunk control and functional balance in acute stroke patients17. Wobbleboard training improvesbalance inbothstaticand dynamic conditions in stroke patients18 and also enhancesproprioceptionandbalancecontrol,especiallyamong young adults and teenagers19.

The improvement in functional reach test may be due to the fact that the Rocker Board training helpedin strengthening of trunk muscles and also increased awareness of trunk position and anticipatory postural adjustments which also helped in achieving good trunk control20. The improvement was due to improvement in postural orientation by forcing faster modification ofsensory and motor system. The improvement was due to improved proprioception and muscle strength. The trunk stabilization in stroke patients in an important prognosticator of the recovery of balance ability and functional ambulation22.

The gait and balance improvement was because the motor cortex precedes from proximal to distal,the improved level of proximal trunk control leads to improvement in distal lower limb control which helped in altering better balance and gait22. The improved gait speed due to improved trunk control with trunk rehabilitation. Therefore, if an improved level ofproximal trunkcontrolwasattained,abetter thedistallower extremity mobility might be anticipated such as that involved in walking. The proximal muscle stability promotes distal muscle activity21.

CONCLUSIONS

Theresultsshowthat,thereisstatisticalsignificancein improvement of both groupswith p-value is 0.000.But the mean values show more improvement inExperimental Group than in Control Group. Hence; it is provedthattheTrunkBalanceandGaitofstrokepatientswillbeimprovedbybalancetrainingon‘RockerBoard’in standing position.

LIMITATIONS AND RECOMMENDATIONS

Limitations

1. Small sample size.

2.Thereisnosidespecificationofpatient.

Recommendations

1.Comparebetweenrightandleftaffectedpatients.

2. Further study can implement the protocol for other diseased patients.

Conflict of Interest: Nill



REFERENCES

1.WHO studystroke incidence and prevalence in2014.

2.Shyam kumar Das, MD, DM; Tapas KumarBanerjee,MD,StrokeIndianScenarioAmericanHeartAssociation,Circulation.2008;27,19-24.

3.DonnanGA,FisherM,MacleodM,DavisSM:Stroke.Lancet.2007;370:1-12.

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