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Volume 12 Number 1 Jan-March 2018

Indian Journal of Physiotherapy and Occupational TherapyEditor-in-ChiefArchna Sharma

Ex-Head Dept. of Physiotherapy, G. M. Modi Hospital, Saket, New Delhi - 110 017 Email : [email protected]

Sub-Editor

Kavita BehalMPT (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, British Columbia

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

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

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

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

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

13. Mohmad Waseem, (Exercise Therapist) Alberta- CANADA14. Muhammad Naveed Babur (Principle & Associate Professor)

Isra University, Islamabad, Pakistan15. Zbigniew Sliwinski (Professor) Jan Kochanowski University in

Kielce16. Mohammed Taher Ahmed Omar (Assistant Professor) Cairo

University, Giza, Egypt17. Ganesan Kathiresan (DBC Senior Physiotherapist) Kuching,

Sarawak, Malaysia18. Kartik Shah (Health Consultant) for the Yoga Expo, Canada19. Shweta Gore (Senior Physical Therapist) Narayan Rehabilitation,

Bad Axe, Michigan, USA20. 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, Texas23. Dr. Jagatheesan A

Assistant Professor, Gulf Medical University, Ajman, UAE.

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 (HOD and Lecturer) Physiotherapy Rural Institute of Medical Sciences & Research, Paramedical Vigyan Mahavidhyalaya 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. Shaji John Kachanathu (Associate Professor) Jaipur Physiotherapy College, Rajasthan, India

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

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

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

18. N.Venkatesh (Principal and Professor) Sri Ramachandra university, Chennai

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

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

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

Indian Journal of Physiotherapy and Occupational Therapy

NATIONAL EDITORIAL ADVISORY BOARD

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

24. Deepak Sharan, Medical Director and Sole Proprietor, RECOUP Neuromusculoskeletal Rehabilitation Centre, New Delhi

25. Jayaprakash Jayavelu, Chief Physiotherapist –Medanta The Medicity, Gurgaon Haryana

26. Vaibhav Agarwal, Incharge, Dept of physiotherapy, HIHT, Dehradun,

27. Shipra Bhatia, Assistant Professor, AIPT, Amity university, Noida28. Jaskirat Kaur, Assistant Professor, Indian Spinal Injuries Center,

New Delhi29. Prashant Mukkanavar, Assistant Professor, S.D.M College of

Physiotherapy, Dharwad, Karnataka30. Chandan Kumar, Associate Professor & HOD,

Neuro-physiotherapy, Mahatma Gandhi Mission’s Institute of Physiotherapy, Aurangabad, Maharashtra

31. Satish Sharma, Assistant Professor, I.T.S. Paramedical College Murad Nagar Ghaziabad

32. Richa, Assistant Professor, I.T.S. Paramedical College Murad Nagar Ghaziabad

33. Manisha Uttam, Research Scholar, Punjabi University, Patiala34. Dr. Ashfaque Khan (PT), HOD Physiotherapy, Integral University

Lucknow U.P, 35. Dr. Dibyendunarayan Bid (PT) Senior Lecturer

The Sarvajanik College of Physiotherapy Rampura, Surat36. Vijayan Gopalakrishna Kurup, Senior Physiotherapist,

Rajagiri Healthcare & Education Trust, Aluva, Kerala

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

SCIENTIFIC COMMITTEE

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,MRIU7. Vijay Batra (Lecturer) ISIC Institute of Rehab. Sciences8. Ravinder Narwal (Lecturer) Himalayan Hospital, HIHIT Medical

University, Dehradun-UK.9. Abraham Samuel Babu (Assistant Professor) Manipal College of

Allied Health Sciences, Manipal10. Anu Bansal (Assistant Professor and Clinical Coordinator) AIPT,

Amity University, Noida11. Bindya Sharma (Assistant Professor) Dr. D. Y. Patil College of

Physiotherapy, Pune12. 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 Delhi15. 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 Delhi19. Anand Kumar Singh, Assistant Professor, RP Indraprast Institute

of Medical Sciences Karnal, Haryana20. 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” 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 Publications501, Manisha Building, 75-76, Nehru Place,

New Delhi-110019 Printed, published and owned by

Archna SharmaInstitute of Medico-legal Publications501, Manisha Building, 75-76, Nehru Place,

New Delhi-110019 Published at

Institute of Medico-legal Publications501, Manisha Building, 75-76, Nehru Place,

New Delhi-110019

Contents

Indian Journal of Physiotherapy and Occupational Therapy

www.ijpot.com

Volume 12, number 1 January-March 2018

I

1. EffectsofExerciseIntensityonCardiovascularVariablesDuringConcentricandEccentricResistiveKneeExtensorsExercisesinAdultsunderIsotonicCondition..................................................................................01 Akriti Gupta, Jyoti Ganai, Deepak Malhotra

2. EffectofTask-orientedTrainingwithandwithoutTrunkRestraintonReachingActivityinAdultHemiparetics.....................................................................................................................................................07 Ibtisam Sani Sulaiman, Anwesh Pradhan, Gargi Ray Chaudhuri, Shabnam Agarwal, Tirthadeep Das

3. AStudyofHighFatigueandLowFatigueResistanceTrainingonQuadricepsMuscleStrengthandHypertrophyinNormalIndividuals..................................................................................................................12 Sandhya Kashyapketan Singal, Manmit Gill, Mumtajben Payla, Nikita Shah

4. ToFindOuttheCorrelationbetweenPainDisabilityandQualityofLifewithLowBackPaininHousewivesofAgeGroup40-50Years................................................................................................................................ 18 Ankita Sharma, Saqueba Shahi, Rashida Begum, Nirupma Singh

5. AComparisonoftheImmediateandLastingEffectsbetweenPassiveStretchandMuscleEnergy TechniqueonHamstringMuscleExtensibility.................................................................................................24Mumtajben Payla, Manmit Gill, Sandhya Kashyapketan Singal, Nikita Shah

6. InfluenceofEarlyPhysiotherapyInterventiononPain,JointRangeofMotionandQualityofLifeinUnilateralHipJointReplacementSurgery.......................................................................................................30 Anupriya Sahu, K Senthil Kumar, S Raghava Krishna, K Madhavi

7. GenderDifferenceinPhysicalPerformanceTestswithintheIndividualwithNormalBodyMassIndex.....35 K Kalaiselvi, Mahendran P, Biswajit Debnath

8. EffectofAsymptomaticArmNeuralMobilizationinPatientswithCervicobrachialPainSyndrome............41 Poonam Gupta, Ganesh Balthillaya, Ramakrishnan Mani, Ravi S Reddy

9. CorrelationbetweenBalanceandFunctionalAbilityinElderly:APilotStudy..............................................47 Samuel SE, Shaji E P, Suresh B V

10. ImmediateEffectsofUnilateralThoracicPostero-AnteriorPressureVersusTransversePressure inChronicMechanicalNeckPain:AComparativeStudy................................................................................52Rishav Shukla, Pallavi Sahay, Rachana Sharma, Bibhuti Sarkar, Abhishek Biswas

11. AComparativeStudyonAlterationofBloodPressureDuringMechanicalIntermittentandContinuousCervicalTraction...............................................................................................................................................58Mudasir Rashid Baba, Muhammad Arafath km, Niyaz Abdullah Ponneth, Ramlath Haseena, Hafis Al Hassan

12. EffectofStrengtheningofInspiratoryMusclesusingInspiratoryMuscleTraineronPulmonary FunctionamongPatientswithSpinalCordInjury-AQuasi-experimentalStudy............................................64 Shanmuga Priya M, Kalpana A P

13. InvasivevsNonInvasiveTreatmentinStenosingTenosynovitis...................................................................70 Amit Kumar, Piyush Mittal

14. ComparisonofCardioRespiratoryResponsesandLevelofExertionFollowingTwoCommonTestsforArmExerciseCapacityinPatientswithCOPD........................................................................................................76 Sumana Baidya, Michel W Coppieters, Subin Solomen, Pravin Aaron

15. PrevalenceofAnteriorKneePaininMarathonRunners..................................................................................82 Devashree S Mistry, Leena Chilgar, Ajay Kumar

16. ToComparetheEffectivenessofTendo-achillesandPlantarFasciaStretchingwithUltrasoundwithPlantaFasciaStretchingandUltrasoundinPlantarFasciitis.......................................................................................88Shweta Kulkarni, Sunil K M, Prashant Mukkannavar

17. FootPostureandFrontalPlaneKneeAlignmentinObeseIndividualswithandwithout OsteoarthritisKnee............................................................................................................................................94Bharati Asgaonkar, Ankita Prakash Matondkar

18. EffectofScapulaStabilizingMusclesStrengtheningtoImproveThrow-inDistanceamong CollegeLevelMaleSoccerPlayers................................................................................................................101Danishpaul P.D, Veena Pais

19. StigmatizingAttitudesinCommunitytowardsPeopleLivingwithHIV/AIDS:ACross-SectionalStudy...107Rajiv D Limbasiya, M M Prabhakar, Rajendra Gadhavi

20. LevelofStressamongDoctorofPhysicalTherapyStudentsinKarachi,Pakistan.......................................112 Tooba Kafeel, Rafia Shoaib, Fatima Sohail, Faisal Yamin, Imran Ahmed, Hafsa Paracha

21. ImmediateEffectofVirtualRealityonBalance,GaitandPostureinStrokePatients- AnExperimentalStudy...................................................................................................................................118Anjali Parab Akshaya Patil

22. EffectofClusterTrainingVersusTraditionalTrainingonMuscularStrengthamongRecreationally ActiveMales-AComparativeStudy.............................................................................................................. 122 Akhil Samson, Padmakumar Somashekharan Pillai

23. EffectivenessofKleinert’sControlledMotionProtocolonTendonGlidingFollowingZone5 FlexorTendonRepair..................................................................................................................................... 128 Uday Raj J, Praveen D, Mukunda Reddy D, Srikanth R

24. ComparisonbetweenImmediateEffectLandbasedandWaterbasedSquattingActivityonPainin OsteoarthritisKneePatients............................................................................................................................ 134 Parag Kulkarni, Arti Tank, Ajay Kumar, Satish Pimpale, Suchit Shetty

25. Co-relationbetweenVC&6MinuteWalkTestinPatientswithImpairedLungFunctions.........................138Ayesha Shaikh, Poonam Parulekar

II

26. IntraandInter-RaterReliabilityofBriefBalanceEvaluationSystemTestinPatientswith TotalKneeArthroplasty..................................................................................................................................144Shah Mital B, Thangamani Ramalingam A, Bid Dibyendunarayan D, Patel KeniK, Patel Krishna S, Patel Kaushal A

27. EfficacyofRetro-treadmillWalkingVersusForward-treadmillWalkingonHamstringFlexibility,StrengthandBalanceinYoungCollegiateStudents.....................................................................................................151Shilpy Jetly, Dhawani Sharma

III

Effects of Exercise Intensity on Cardiovascular Variables During Concentric and Eccentric Resistive Knee Extensors

Exercises in Adults under Isotonic Condition

Akriti Gupta1, Jyoti Ganai2, Deepak Malhotra2

1MPT (Cardiopulmonary), Department of Physiotherapy, Max Super Specialty, Hospital, New Delhi, India, 2Assistant Professor, Department of Rehabilitation Sciences, HIMSR, Jamia, Hamdard, Deemed University,

New Delhi, India

AbstRACt

Background and Objectives: Resistance training in the form of concentric and eccentric exercise is ahighly recommended formof exercise for athletesandalsoforindividualswithor at riskofdevelopingcardiovascular disease. The purpose of this study was to compare the effect of exercise intensity oncardiovascularchangesduringconcentric and eccentric resistive kneeextensionexerciseinadultsunderisotoniccondition.Methods: A sample of 60 healthy subjects between the agegroup(20-30years)wasselectedfor the study. Each subject performed concentric resistive kneeextensionexerciseat85%of1RMand75%of1RMandeccentricresistive kneeextensionexerciseat85%of1RMofconcentric+30%of1RMand75%of1RMofconcentric+30%of1RMonBiodexmultijointexercisesystem4pro.Samenumbersofrepetitionswereperformedforconcentricandeccentriccontractions.SBP,DBP,HR,MAPwere measured beforeandaftereachexercise.Results: Statisticalanalysiswasdone using singlesamplet-test.Theresultsofthestudyindicatethatthereisdifferenceincardiovascularresponseatdifferentintensitiesofconcentricandeccentricactivity.Morevariationsareseenincardiovascularvariablesafterconcentricactivityatrespectiveintensitiesascomparedtoeccentricactivity.Conclusion: Theresultofthestudysuggeststhateccentricexerciseproducelowercardiovascularresponsethanconcentricexercise.

Keywords: cardiovascular variables; concentric; eccentric; exercise intensity resistance exercise;

INtRODUCtION

Isotonicexercisetrainingischaracterizedbyvariablejoint speed against a constant resistance. Exercisingto develop and maintain muscular strength, muscularendurance and muscle mass is called as resistancetraining.Thereareseveral typesofresistanceexerciseslikeisometric,isotonici.e.concentricandeccentricwithconstant resistance and variable resistance, isokinetic/hydraulics/pneumatics resistance exercises1. Dynamicmuscleactioncanbeperformedwithtwotypesofaction

Corresponding author:Deepak MalhotraAssistantProfessor,DepartmentofRehabilitationSciences,HamdardInstituteofMedicalSciencesandResearch,JamiaHamdard,DeemedUniversity,NewDelhi-110062,India,Ph.+91-9871-666-669Email–[email protected]

(1)concentric(shorteningcontraction)and(2)eccentric(lengtheningcontraction)

There are many physical and physiologicaladaptationsthatoccurasaresultofconsistentresistancetraining2. Resistance exercise has a positive effect onhumanmusculature, connective tissue,bone formationand metabolism3,4. One of the many cardiovascularadaptationstoresistancetrainingistheabilitytotoleratehigherbloodpressure(BP)responsesduringexercise2. During resistance exercise several cardiovascularchanges occur including increased systolic bloodpressure (SBP), diastolic blood pressure (DBP), heartrate (HR), mean arterial pressure (MAP) and ratepressure product (RPP)4,5. The BP increases duringresistance training possibly due to mechanicalcompression, pressure reflex, and/ or increase ofintrathoracic pressure reflex, and/ or increase ofintrathoracicpressurecausedbyValsalvamaneuver6,7.

DOI Number: 10.5958/0973-5674.2018.00001.1

Indian Journal of Physiotherapy and Occupational Therapy. January-March 2018, Vol. 12, No. 1 2

In recent years, the use of resistance training hasbeenpromotedasaphysicalactivityfor thepreventionand treatment of lifestyle related diseases as well asfor theprevention of disabilities becauseof instabilityandfallsinelderlyadults5,8.Itisstronglyrecommendedfor implementation in primary and secondarycardiovascular disease-prevention programs8. Intenseresistancetrainingatloadinglevelsgreaterthan60%ofIRMhasattainedpositiveresultswithrespecttogeneralhealth9,10.

As compared to concentric, eccentrictrainingleadstopreferentialrecruitmentoftypeIImusclefibersleading to their selective hypertrophy. The muscleperformanceatgreatervelocitiesofmovementdependsprimarilyonfast-twitchmotorunitsandthefunctionof these neuromuscular units is also affected bytemperature showing a positive relationship11,12.SmithRCandRutherfordOM.havedemonstratedthat,thechangesindynamic force tend tobegreater followingeccentric trainingandgreatermechanical efficiencyandenergydissipationcanbeachievedwitheccentriccontractions.

As the acute elevation in BP during exercise isknown tobecomeaccentuatedwithaging13,itwouldbedangeroustoprescriberesistanceloadsnearer tothevoluntarymaximum in theelderly5.Therefore,thisstudyisimportanttoclarifythecardiovascularresponseto concentric and eccentric muscle contraction inyoungersubjects. Sothatfindingsmaybeextrapolatedtomiddleageandelderlyindividualsinordertobetterprescribe resistance training for thepreventionof fallsduringinstability.

MetHoDs

Participants

Atotalof60subjectswereselected for this studyfromtheUniversitycampus.Alltheparticipantswererecruitedbasedonpredefinedselectioncriteriaaftertakinganinformed consent.Bothmales and femalesin theagegroupof20-30years,havinganormalBMIandrestingheartratebetween60–100beats/min.wereselected.Subjectswith anymedical condition, presentor past, which may have affected the results of thestudy,wereexcluded.

Modalities used

Biodexmultijointexercisesystem4pro (also

knownasisokineticdynamometer),treadmill,weighingscale,heightscale,andBPapparatus.

Procedure

The study was conducted in the RehabilitationCenterofJamiaHamdard.Firstofall,thelegdominancywas tested by ball kicking test. A maximum of twosubjects were tested in a single given day.On day 1,thesubjectwasfamiliarizedwiththemulti jointbiodexsystem4pro.

On day 2, he/she took rest for 15 minutes insupine lying position and then baseline BP and HRmeasurements were taken. After that the subject didwarmupfor5minutesontreadmillatspeedof3.2kph14,15 followingwhichHRandBPmeasurementsweretaken.Afterwarmup, thestandardpositioningguidelinesforknee exercises on the Isokinetic Dynamometer werefollowed. Any discomfort or subjects reporting 9 oraboveon theRPE scalewouldhave led to immediateterminationofthesession.

Each subject was asked to perform themaximumnumberofrepetitionswhichhe/shecanperformtill thefatigue level with 35 Kgs of resistance on isokineticmachineandaccording to that,1RMwascalculatedbyusing equation {RepWt/(1-0.02RTF)}16 and accordingto the 1RM, 75% of 1RM and 85% of 1RM werecalculatedforeachsubject.Afterthisa15minrestwasgiventothesubject.

The pre- exercise BP and HR measurementswere recorded. The subject was asked to performthe concentric resistive knee extension on isokineticdynamometer at 85% of 1RM intensity. They didrepetitions till the voluntary failure to docontractionswasachieved.Thenthepost-exerciseBPandHRwererecorded, and the maximum number of repetitionsperformed were recorded. After this 5 min rest wasgiven tosubject.

Then again the pre-exercise BP and HRmeasurements were recorded. The subject was askedto perform concentric resistive knee extensionexerciseonisokineticdynamometerat75%of1RMintensity.Theydidtherepetitions till the voluntaryfailure to do the contractions was achieved.The post-exercise BP and HR measurementswere recorded along with the maximum number ofrepetitions.

3 Indian Journal of Physiotherapy and Occupational Therapy, January-March 2018, Vol. 12, No. 1

On day 3, subjects took rest for 15 minutesin supine lying position then baseline BP and HRmeasurements were taken. Then subject didwarmupexercise for 5minutes on treadmill at a speed of 3.2kph14,15andHRandBPmeasurementsweretakenafterthe warm up. After that the subject was askedto perform eccentric resistive knee extension onisokinetic dynamometer at 85% + 30% of concentricRMintensity17.Subjectperformedthesamenumberofrepetitionsasin85%of1RMofconcentriccontraction.Then post-exercise BP and HR measurements weretaken.Afterthis5minrestwasgiventosubject.

Again the pre-exerciseBP andHRmeasurementswere taken. Subjectswere asked to perform eccentricresistive knee extension exercise on dynamometerat 75% +30% of concentric RM intensity17. Subjectperformedthesamenumberofrepetitionsasin75%of

1RMofconcentriccontraction.Thenpost-exerciseBPandHRmeasurementsweretaken.

REsULts

StatisticalanalysiswasdonewiththehelpofIBMSPSSsoftware.Cardiovascularvariableswerecomparedbetweentwointensitiesusingthepairedt-test.Ap-valueless then equal to 0.05was considered as statisticallysignificant.

bEtWEEN tHE GROUPs COMPARIsONs

Comparisons between the concentric and eccentric resistive knee extension

bLOOD PREssURE

DIAstOLIC bLOOD PREssURE:

table 1: Comparison of mean values, standard deviation (sD) and t- value and significance Level (P) of DbP obtained in both groups i.e. concentric and eccentric at different intensities.

DIASTOLICBLOODPRESSURE:

IntensItIesDIAstOLIC bLOOD PREssURE

CONCENtRIC ECCENtRIC sIGNIFICANCE (p) t-VAL UE

MEAN sD MEAN sD

85% DBPpre 77.05 8.089 75.40 8.916 0.1361.510NS

85% DBPpost 78.43 9.464 77.35 9.940 0.3860.874NS

75% DBPpre 77.25 7.213 76.32 9.912 0.4270.801NS

75% DBPpost 80.40 9.788 76.55 9.258 0.010* 2.655**

*significantatpvalue<0.05

tAbLE 2: Compassion of mean values, standard deviation (sD) and t- value and significance level (P) of sbP obtained in both groups i.e. concentric and eccentric at different intensities.

IntensItIessYstOLIC bLOOD PREssURE

CONCENtRIC ECCENtRIC sIGNIFICANCE (p) t-VALU E

MEAN sD MEAN sD

85% SBPpre 119.05 15.263 116.82 11.803 0.209 1.270NS

85% SBPpost 127.97 16.590 124.23 13.254 0.017* 2.454**

75% SBPpre 121.47 15.161 119.42 12.830 0.256 1.146NS

75% SBPpost 130.82 17.242 123.27 15.121 0.001* 3.567**



HEARt RAtE:

tAbLE 3: Comparison of mean values, standard deviation (sD) and t- value and significance level (P) of HR obtained in both groups i.e. concentric and eccentric at different intensities.

IntensItIes HEARt RAtE

CONCENtRIC ECCENtRIC sIGNIFICANCE t-VAL

UEMEAN sD MEAN sD

85% HRpre 86.02 11.084 86.82 13.230 0.6260.491NS

85% HRpost 99.45 13.618 96.10 11.750 0.0771.800NS

75% HRpre 90.28 11.504 87.27 12.025 0.0901.724NS

75% HRpost 101.98 13.534 96.32 13.213 0.001* 3.362**


MEAN ARtERIAL PREssURE:

tAbLE 4: Compassion of mean values, standard deviation (sD) and t- value and significance level (P) of MAP obtained in both groups i.e. concentric and eccentric at different intensities.

IntensItIesMEAN ARtRIAL PREssURE

CONCENtRIC ECCENtRIC

sIGNIFICANCE t-VALU EMEAN sD MEAN sD

85% MAPpre 91.21 9.209 89.17 9.265 0.048* 2.015**

85% MAPpost 95.02 9.856 92.44 9.996 0.010* 2.658**

75% MAPpre 92.08 8.641 90.87 9.408 0.242 1.181NS

75% MAPpost 97.66 10.353 92.20 9.345 0.000* 3.774**

*significant at p value < 0.05

The results shows that there is statically significantdifferencebetweenposttest readingsof DBPat75%ofintensity,SBPat85%and75%ofintensities,HRat75%ofintensity,MAPat75%ofintensity.

DIsCUssION

systolic blood Pressure

InthepresentstudytheSBPatboth85%and75%of 1RM intensities increased more after concentricresistive knee extension exercises than after eccentricresistivekneeextensionexercises.Thepossiblereasonfor this difference may be due to the fact that thereis increase in peripheral resistance during concentriccontractionascomparedduringeccentriccontraction18.

Diastolic blood Pressure

Alsowhencomparisonwasdonebetweenconcentricandeccentricexercisesatanintensityof75%of1RM,the posttest value of DBP after concentric exerciseswasmore than after eccentric exercises. SimilarresultwasfoundbytomJ.Overendin2000whoconcludedthatduringeccentriccontractioncardiacoutputandstroke volume increase and also there is decrease inperipheralvascularresistancewhencomparedtochangesduring concentric contraction.Decrease inperipheralresistanceduringeccentriccontractionisassociatedwith


lesserincreaseindiastolicbloodpressure.

The smaller cardiovascular response duringeccentric contraction as compared to concentriccontractionin thisstudymaybeattributabletothedifference in activemuscle mass utilized in thesetwomodes of muscle contraction i.e. concentric andeccentriccontractionastheskeletalmusclerecruitmentis less during eccentric contraction than concentriccontraction as stated by fiatarone et.al, brigand etal9,19,20,21.

Thereareseveralpossiblereasonsforthedifferencein energy demands and cardiovascular stress betweenconcentric and eccentric exercise. More motor unitsare recruited in concentric exercise as compared toeccentric as stated by komie et. al andOkamoto et.al5,19,21 because eccentric movements require lessmuscle activation,theintramuscularforcesarereduced,resultinginadecreaseinBP.

Heart Rate and Mean Arterial Pressure

InpresentstudywhenposttestvalueofHRat75%of1RMafterconcentricexercises was comparedwiththataftereccentricexercisesitwasfoundoutthattheHRafterconcentricexercisesincreasedmorethanafterthe eccentric resistive knee extension exercise. Thepressor response to exercise includesallof thereflex-induced cardiovascular changes that serve to increasearterial blood pressure during a muscle contraction22. Exercise mode, intensity, and duration, and size ofthe active muscle mass are all factors related to themagnitudeofincreaseinHRandBP23,24,25.Anincreasein the excitation of muscle afferent receptors willcausegreaterincreasesinHRandBPduringresistanceexercise, utilizing either a largermusclemass25,26 or ahigher relative exercise intensity27 .There have beenstudies which show that even when concentric andeccentric exercise are done against same amountof resistance the RPE rating given by the subjectswere higher for concentric contraction as comparedto eccentric contraction18. The greater increase incardiovascular stress with greater active muscle massmay explain the increasedHR,MAP, associatedwithconcentricexerciseinpresentstudy.

CONCLUsION

Theresultofpresentstudyconcludesthatdifferentintensities of concentric and eccentric activity have

different effects on cardiovascular variables. Alsoeccentricactivity imposes lessstressoncardiovascularvariablesascomparedtoconcentricactivity.

Conflict-of-Interest statement : The authorsdeclarethatthereisnoconflictofinterest

statement of Informed consent: An informedconsentwastakenfromallthesubjects.

statement of Human and Animal Rights

Ethical Clearance: was taken from InstitutionalEthicsCommittee,JamiaHamdard

source of Funding - Self

REFERENCEs

1. SasranMR.Manual of sportsmedicine- chapter8:buildingstrength.1steditionpages:77-83.

2. Wilborn C t al. the effect of exerciseintensity and body position oncardiovascularvariables during resistance exercise journalof exercisephysiologyonline,vol-7,no.4,Aug2004.

3. McArdle WD, katch FI and katch VL.Exercise physiology. 5th edition,LippincottWilliamsandWilkins.Pages:305-324.

4. Wilmore JH and Costill DL. Physiology andsports andexercise.2nd edition,humankinetics,pages:222-235.

5. Okamoto T, Masuhara M and Ikuta kcardiovascular responses induced during highintensity eccentric and concentric isokineticmusclecontraction inhealthyyoungadults.Clinphysiolfunetimaging(2006)26.pg39-44.

6. Graves JE and franklin BA. Resistance trainingfor health and rehabilitation. 1stedition, humankinetics.Pages:45-46.

7. McDougalletal.Arterialbloodpressureresponsetoheavyresistancetraining.Jaaplphysio.1985,58(3):785-790.

8. PollockML et al. resistance exerciseinindividual with and without cardiovasculardiseasecirculation2000;101:828.

9. Fiatarone MA et al. High intensity strengthtraining in nonagenarians. Effects on skeletalmuscle.JAmmedassoc(1990);263:3029-3034.

10. Hagermana FC et al. Effects of high intensityresistance training on untrained older menstrength,cardiovascularandmetabolicresponses.The journals ofgerontologyseriesA:biologicalsciences and medical science 55:B336-B346(2000).

11. HortobagyiT,Hill JP,Houmaed JA,FraserDD,LambertNJ,IsraelRG.Adaptive responsestomusclelengtheningandshorteninginhumans.JApplphysiol.1996Mar:80(3):765-72.

12. Komi, P.V. relationship between muscletension, EMG and velocity of contractionunder eccentric and concentric work.Electromyography, 1:1- 10,1971.

13. LakattaEGcardiovascularregulatorymechanismin advanced age. Physiol Rev (1993); 73:413-467.

14. Comparison of vo2 peak during treadmill andcycleergometer in severelyoverweightyouth.Jsportsscimed2004Dec1:3(4):554-60.

15. Alicia D’Souza, Annalisa Bauchi, Anne Berit,Johnsen, Sunil Jilt R.J. Logantha, OliverMonfredi,ElizabethCartwright,UlrikWisloff,HalimaDobryznski,DarioDiFrancesco,GwilymM.Morris,andMarkR.Boyett.Exercisetrainingreduces resting heart rate via downregulation ofthefunnychannelHCN4.

16. Accuracy of prediction equations fordetermining one repetition maximum benchpress in women before and after resistancetrainingJerryI.Mayhew,1,2BlairD.Johnson,3Michaelj.Lamonte,4dirklauber,andWolfgangKemmler journal of strength and conditioningresearch2008Nationalstrengthandconditioningassociation.

17. Wayne S. doss and peter V. karpovich:compassionofconcentric,eccentricandisometricstrengthofelbowflexors.Physiological researchlab, SpringfieldCollege,Massachusetts.Vol 20:issue2:1965:350-353.

18. TomJOverendetal(2000)Cardiovascularstressassociatedwithconcentricandeccentricisokineticexercise in young and older adults. Journal

of gerontology: BIOLOGICAL SCIENCEScopyright 2000 by the gerontological society ofAmerica2000,VOL.55A,no.4,B177-B182

19. KomiPVet al.ForceandEMGpowerspectrumduringeccentric andconcentric actions.Med scisportsexercise(2000);32:1757-1762.

20. Linnamoetal.EMGpowerspectrumandmaximalMwaveduringeccentricandconcentricactionatdifferenceforcelevel.Actaphysiolpharmacologybulg(2001);26;32-36.

21. Madeleine P et al. Mechanomyography andelectromyographyforce relationrelationshipduring concentric, isometric and eccentriccontractions. JelectromyographyKinesiol2001;11;113-121.

22. MitchellJH,KaufmanMP,IwamotoGA.Theexercisepressorreflex;itscardiovasculareffects,afferent mechanisms, andcentralpathways.Annrevphysiol.1983;45;229-242.

23. Buck JA,Amundsen LR,Nielson, DM. systolicbloodpressureduringisometriccontractions ofsmallandlargemusclegroups.Medscisports. 1980;12:145-147.

24. Seals DR. Washburn RA, Hanson PG,painter PL,NagleFJ. Increasedcardiovascularresponsetostaticcontractionoflargemusclegroups.J applphysiol.1983;54;434-437.

25. LewisSF,SnellPG,TaylorWF,etal.Roleof muscle mass and node of contraction incirculatory responses to exercise. J applphysiol.1985;58;146-151.

26. MacDougall JD,McKelvieRS,MorozDE,SaleDG, McCartney N, Buick F.Factors affectingbloodpressureduringheavy weight liftingand staticcontractions.Japplphysiol.1992;73:1590-1597.

27. Haennel RG, Snydmiller GD, Teo KK,GreenwoodPV,Quinney HA,KappagodaCT.Changes in blood pressure and cardiac outputduring maximal isokinetic exercise. Arch Physmedrehab.1992



Effect of task-oriented training with and without trunk Restraint on Reaching Activity in Adult Hemiparetics

Ibtisam sani sulaiman1, Anwesh Pradhan2, Gargi Ray Chaudhuri3, shabnam Agarwal4, tirthadeep Das5

1Senior Physiotherapist, Nizamiye Hospital Abuja, Nigeria, 2Associate Professor, 3Professor, 4Associate Professor, Director, Nopany Institute of Healthcare Studies, Kolkata, India,

5Senior Physiotherapist, Institute of Neurosciences Kolkata, India

AbstRACt

The normal pattern for reaching to a target is not seen in hemiparesis, as patients are seen to usecompensatory trunkmovements to accomplish the same task.Asmuch as this compensatory behaviorallows themtoaccomplish the taskregardlessof themotordeficit, ithowever,maynotbedesirableforskillrequisition.Paststudieshaveshownthatlimitingthesecompensatorymovementseffectivelyimprovesreachingactivityinadulthemiparetics.Howeverinthosestudies,theinvestigatorsanalyzedtheeffectsoftrainingforaverybriefperiod.Thusinthisstudyweareaimingtodeterminetheeffectoftask-orientedtrainingwithtrunkrestraintonreachingactivityinadulthemiparetics,where20adulthemipareticsovertheageof40yearswererecruitedandwererandomlyallocatedtocontrol(n=10)andexperimental(n=10)groups.Participantsofbothgroupswereassignedareachingtaskfor60repetitionsinasinglesessionin3directionsfor10sessionswithin2weeksperiod.Trunkrestraintwasintroducedtotheexperimentalgroupwhileperformingthereachingtask.Preandpost–interventionscoresoftheReachingPerformanceScale(RPS)wereanalyzed.Participantsofboththegroupsshowsignificant(p<0.05)changeinRPSscores.IntergrouppostinterventionRPSscoresshowasignificant(p<0.05)differences.Additionally,whenthemeanvaluesbetween thegroupswerecompared, thepost interventionRPSscoresof theexperimentalgroupswerehigherthanthecontrolgroup,implyingbetterperformanceintheformer.

Keywords: Hemiparesis, Upper Extremity, Reaching Activity, Task Oriented Training, Trunk Restraint

Name and Address for CorrespondenceAnwesh PradhanAssociateProfessor,NopanyInstituteofHealthcareStudies,2CNandoMullickLane,Kolkata700006,India,Telephonenumber:+919932874589Email:[email protected]

INtRODUCtION

The ability to reach is critical for virtually allactivities of daily living (ADL) such as grooming,toileting, feeding and dressing.1 A necessary requisiteforcontrolledreachingisthecoordinationoftheactionof transporting the arm away from the body whileactivating appropriate muscles to stabilize trunk andscapula.Thetrunkisrecruitedbeforearmsuchthatthetrunkbeginsmovingbeforethehandmovementandcancontinuemovingevenafterthehandhasstopped.2

Previous studies in hemiparetic patients havedescribedexcessivetrunkorshouldergirdlemovementin pointing and in reach to grasp movements fortarget placed close to the body.3Wanger et al (2006)showed that deficits in strength appear to be themostinfluential sensorimotor impairment associated withlimiting reaching performance in subjects with acutehemiparesis.4 Additionally elbow shoulder inter jointcoordination is disrupted in hemiparetic patients. Incontrasttohealthyindividuals,reachinginhemipareticpatients is characterized by a lack of smoothness asevidencedbybothtemporalandspatialsegmentation.5

Therapist may approach the rehabilitationof reaching in several ways, eg. reflex basedneurofacilitationapproaches,thatisacquisitionoftrunkandshouldergirdlestabilitymustprecedetheretrainingofarmmovement.Unwantedmovementsandspasticityare inhibited and normal patterns are facilitated under

DOI Number: 10.5958/0973-5674.2018.00002.3


theassumptionthatregainingvoluntarycontroloverkeymovements will transfer to functional improvements.However empirical evidences for this assumption arelacking.6

A recent meta-analysis also showed that moreintensivetherapymayatleastimprovetherateofADLrecovery,particularlyifadirectfunctionalapproachisadopted.7

The rehabilitation of reaching has been basedon a task-oriented approach in which movement isbehaviorallydrivenandtheinteractionoftheindividualwiththeenvironmentisstressed.Itisseen,thatexcessivetrunkmovementinhemipareticswhilereaching,limitsthepotentialrecoveryofnormalarmmovementpatterns.Reducingcompensatorymechanismsbytrunkrestraintmay encourage the return of the movement patternstypicallyseeninhealthyindividuals.6

Peurala et al showed various constraint inducedmovementtherapy(CIT)doseswhichimprovedmobilityof the affected upper extremity.8 The Task relatedtraining (TRT) involved reaching to objects placedacrossthework–space.Progressiveresistiveexercises(PRE) involved whole- arm pulling against resistivetherapeutic tubing in planes and distances similarto that in TRT.5 Jeyaraman et al also demonstratedtrunk restraint as a effective treatment for decreasingcompensatorystrategies.9

Post stroke therapeutic interventions leading tofunctional improvement emphasize intensive task –specificpracticereportedtofacilitatetraining–inducedplasticity and active –induced neuroplasticitywhere itis necessary to determinewhether interventions resultin the reappearance of premorbid movement patterns(recovery)orinsubstitutionbynovelmovementpatterns(compensations).10

This study aims to show short duration trainingon reaching activity with trunk restraint for IndianPopulation.

MAtERIALs AND MEtHOD

After receiving clearance from the InstitutionalHumanResearchEthicsCommitteeforthisrandomizedcontroltrial,20subjectsfrombothgenders,overageof40 years were taken.11 Inclusion criteria for selectingsubjects were non traumatic single unilateral stroke(not less than1monthandnotmorethan6months),12

patients who have the ability to perform reach-to-grasp activity with the hemiparetic upper extremity(Brunstromrecoverystage3andabove)andthosewhounderstand simple commands in English. Those whohave severe cognitive impairment (MiniMental StateExam score < 18), contractures/ deformities on theaffected arm, shoulder- hand syndromewere excludedfromthisstudy.

Informed written consent was taken from all thesubjects.Thenallthesubjectswererandomlyallocatedinto two groups, Group A (Control group, n=20) andGroupB(Experimentalgroup,n=20).

AllthesubjectsinbothgroupswereassessedusingtheReachingPerformanceScale(RPS)forpreandpostinterventionscoring.Thesubjectswereseatedinachairwith their feet in full floor contact. The length of thefullyextendedarmfrommedialaspectof theaxilla tothe distal crease of the wrist medially was measured.Then a target (A conical object with base of 7 cmdiameterandheight17.5cm,madefromcardboardwitha rough surface)wasplacedon themid-sternal heightatsubject’sfullarmlength.Thesubjectswereaskedtoreachforward,graspandreturntheconetothemidchestregionat a comfortable self paced speedandasked torepeatthesameactionthrough20repetitions,taking2-3minutesrestafterthefirst10repetitions.Asinglesessionconsisted of 60 repetitions of the reach-to-grasp task,where20repetitionsdoneineachofthethreedirections;contralateral, ipsilateralandmidline.Theexperimentalgroupperformedthesameprotocolwithtrunkrestrainedtothechairwithatrunkrestraintbelt.Thedurationofthetrainingwasanoverallof10sessionsspreadovera2weekperiod,afterwhichRPSassessmentwasdonetogetthepostinterventionscoring.

REsULt/ FINDINGs

Statistical analysis using paired t-test showedsignificant (p< 0.05) change in reaching activity ofthe subjects in both the groups (n=10) (Table 1&2).Unpairedt-testshowedasignificant(p<0.05)differencebetweenthepostinterventionmeanscoresofthecontrolgroupandtheexperimentalgroup(Figure1).Comparingmeans before and after intervention showed thatparticipants frombothgroups improved their reachingactivityafterintervention.However,betterimprovementwasseenintheexperimentalgroup.


DIsCUssION

Task-oriented training is effective in improvingreaching activity of adult hemiparetics. Reachingactivity is an important component for independentliving. However, survivors of stroke often rely oncompensatory movement strategies to accomplishreaching tasks.9 Carr and Shepherd13 suggest thatcompensatorystrategiesaretheresultofusingavailablemovements given the post stroke state of centralnervous system, which leads to long term functionallimitations.Withoutintervention,strokesurvivorsoftenusetheuninvolvedlimbtoaccomplishfunctionalgoals,which results in learned disuse. In addition, failure touse the paretic limb can produce secondary changesin the effecter apparatus (muscle, connective tissueshortening)andleadtoastiff,immobileandsometimespainfulupperlimb.5Tominimizethesechangesandaswelltolimitcompensatorybehaviorinordertopromoterecovery,specificpracticerequiringthepatient’sactiveparticipation is suggested as being necessary.14 Thismay therefore be the reason behind the improvementinreachingactivityseenin thisgroupofpatientsaftertraining.

Quite a number of randomized control trials haveshown that task oriented training improves upperextremity functions in hemiparetic patients.15, 16 Themechanism behind this is the concept of specificityof training, which has been discussed in relation toable-bodied subjects and proposed as a means ofrehabilitating the movement disabled.14, 17, 18, 19 In thisconcept, it isemphasized that subjects improveon theactionswhichtheypractice.

The study also shows that task- oriented trainingwith trunk restraint is effective in improving reachingactivity in adult hemiparetics. The effects of trunkrestraint indicate that hemiparetic patients did not usetheir potential joint range for free arm movements.9 Hemipareticpatientscouldmakeisolatedelbowflexionand extension movements by using reciprocal muscleactivationpatternwithinavailablearticularranges.Theincrease in joint ranges with trunk restraint is partlydue to an adaption involving anticipation of changedexternalloadconditions.

Patients are forced to make movement out ofsynergywhichprobablyinvolvesafocusedandgreatereffortontheirpart.9Theadaptationofarmactivitywas

triggered by somatosensory input from the trunk orshouldercausedby the trunk restraint.Thestrategyofconstraining theunaffected arm to force thepatient tomakemoreuseof theaffectedarmwith theadditionalfeature that reduction of compensatory movementpatternsisalsotargeted.PhysicaltrunkrestraintcanbeconsideredsimilartoManualGuidanceinwhichspatialconstraints are used to promote use of more optimalmovementpatterns.20

Comparison of post training RPS scores of thecontrolgroupandtheexperimentalgroupsignifiesthattaskorientedtrainingwithtrunkrestraintisbetterthantaskorientedtrainingwithouttrunkrestraintonreachingactivityinadulthemiparetics.

The reason behind thismay be backed up by thestudy of Michaelson et al 2004,20 in which a singlesession of repetitive reach to grasp training to objectswithinarm’s reachduringphysical restrictionof trunkcompensatorymovementsledtogreatergainsinelbowextension,greaterdecreases in trunk involvement,andimproved temporal inter joint coordination comparedwithinstructedpracticealone.Ithasbeenrecognizedbyclinicians14,21thatoncecompensationhasbeenlearned,it isverydifficult tomodify. Indeed,prolongeduseofcompensatorytrunkmovementstoreachtargetsplacedwith in arms lengthmay result in the system learningnottousearmjointsforreachingandgrasping(learnednonuse) so that recovery of independent use of thesejoints would be discouraged. Physical trunk restraintcanbeconsideredsimilartomanualguidanceinwhichspatial constraints are used to promote use of moreoptimalmovement patterns justifying training inducedplasticity,andactivityinducedneuroplasticity.6,20InastudybyMichaelsonetal(2006)todeterminehowtrunkrestraint improves reaching ability in stroke patients ,kinematicanalysis revealed thatdecreasedmean trunkdisplacementby32.8mmatpost–testand14.2mmatfollow-up,whereastrainingwithoutTRincreasedtrunkdisplacement by 3.6 mm and 22.0 mm respectively.10 Thismay further explainwhymore improvementwasseenwithtrunkrestrainascomparedtotrainingwithouttrunkrestraint.

KwakkelGet al (2016) reviewed strongevidencethat constraint-induced movement therapy has greatereffectsonmotorfunctiononlywhenappliedintheearlierstagespoststroke,inwhichitisassumedthatrestitutionof neurological functions is still possible, but that in


the later phases constraint-inducedmovement therapysolelyinfluencesarm-handactivitiesbylearningtouseadaptation strategies (i.e., compensation) to improveupperlimbperformanceinActivitiesofdailyliving.22Inthisstudypatientswereselectednotlessthan1monthandnotmorethan6months,andsimilarlyalsoshowedbettermovement pattern development in task orientedtrainingwithtrunkrestraintonreachingactivity.

Results of this study have great implications forrehabilitation, demonstrating that stroke patients canimprove their performance on seated reaching taskswith a task oriented training program that takes intoaccountnormativebiomechanicsoftheupperextremitywhileminimizingunwantedcompensatorymovements.The findings directly challenge the assumptionthat improvement in function after stroke is due tospontaneous recovery only. In addition, the outcomeis consistent with the increasing evidence that strokepatientscanimprovetheirperformanceofspecifictasksifthosetasksareincludedintrainingandpracticed.

Trunk restraint may also be a useful techniqueto promotemaximal armmotor recovery in the acutestageof stroke,when thepotential forneuroplasticitymaybegreatest.Exerciseisknowntoinduceacascadeofmolecular and cellular processes that support brainplasticity. Brain-derived neurotrophic factor (BDNF)is an essential neurotrophin that is also intimatelyconnected with central and peripheral molecularprocesses of energymetabolism and homeostasis, andcouldplayacrucialroleintheseinducedmechanisms.An acute aerobic exercise unmistakably influencescirculatingBDNFconcentration, although theeffect istransient.23

Soitisevidentthatthebenefitsofthesimplereachtrainingwith physical trunk restraint employed in thisstudy provide a strong argument for applying thistraininginclinicalsettings.Theimplicationfortherapyis that restriction of trunk use should be used even inpatientswithchronichemiparetictoencouragemaximaluseofavailabledegreesoffreedom.

Figure 1: Comparison of post intervention RPs scores of Control and Experimental groups

table 1: Comparison between the Pre and Post Intervention performance in the Control group (GroupA)

Pre- scoreMean±sD

Post- scoreMean±sD

t sig. (2-tailed)

RPs score 23.1±4.01 29.1±2.42 -8.78 <0.05

Degreeoffreedom(df)=9

table 2: Comparison between the Pre and Post Intervention performance in the Control group (GroupA)

Pre- scoreMean±sD

Post- scoreMean±sD

t sig. (2-tailed)

RPs score 22.6±3.95 32.7±1.34 -10.65 <0.05

DegreeofFreedom(df)=9

CONCLUsION

Task oriented training is an effective means ofimproving reaching activity in adult hemiparetics.However, task oriented training together with trunkrestraintisabettermethodtoimprovereachingactivityinadulthemiparetics.

REFERENCEs

1. HouwinkA.Assessmentofupperlimbcapacityand

performanceinunilateralspasticparesis:Handinginnewperspective.Printedby:Ipskampdrukkers;Nijmegen,2012.

2. KaminskiTR,BookC,GentileAM.Thebetweentrunkandarmmotionduringpointingmovements.ExpBrainRes.1995;106:457-466.

3. CirsteaMC, LevinMF. Compensatory strategiesfor reaching in stroke. Brain. 2000; 123(5):940-953.

4. Wanger JM, Lang CE, Sahrmann SA et al.Relationships between sensorimotor impairmentsand reaching deficits in acute hemiparesis.NeurorehabilNeuralRepair2006;20(3):406-416.

5. Thielman GT, Dean CM, Gentile AM.Rehabilitation of Reaching After Stroke: Task-Related Training Versus Progressive ResistiveExercise.Arch PhysMedRehabil. 2004; 85(10):1613-18.

6. Michaelson SM, Luta A, Roby-Brami A et al.Effectoftrunkrestraintontherecoveryofreachingmovements inhemipareticpatients.Stroke.2001;32(8):1875-1883.

7. French B, Thomas LH, Leathley MJ et al.Repetitivetasktrainingforfunctionalabilityafterstroke.AmericanHeartAssociation.Stroke.2009;40(4):e98-e99

8. Peurala SH, Kantanen MP, Sjögren T et al.Effectiveness of constraint-induced movementtherapy on activity and participation afterstroke: a systematic review and meta-analysis ofrandomized controlled trials. Clin Rehabil 2012;26(3):2090223

9. Jayaraman S, Kathiresan G, Gopalsamy K.Normalizingthearmreachingpatternsafterstrokethrough Forced used therapy-A systemic review.NeuroscienceandMedicine.2010;1:20-29.

10. Michaelsen SM,DannebaumR, LevinMF. Task–specific training with Trunk restraint on armrecovery in stroke: Randomized control trial.Stroke.2006;37(1):186-192.

11. BanerjeeTK,MukherjeeCS,SarkhelA.StrokeintheurbanpopulationofCalcutta:anepidemiologicalstudy.Neuroepidemiology.2001;20:201–207.

12. Krakauer JW. Arm function after stroke: fromphysiology to recovery. Neurology, 2005; 2594):384-95.

13. Carr J and Shepherd R. Movement Science:FoundationsforPhysicalTherapyinRehabilitation(2ndEd),AspenPublishers,Gaithersberg,2000.

14. AdaL,CanningCG,Carr JHet al.Task specifictrainingof reachingandmanipulation. In:BennetKM,CastielloU, (eds) Insights into the reach tograsp movement. Amsterdam: Elsevier. 1994;105(1)239-264.

15. Dalal PM, Bhattacharya M. Stroke Epidemic inIndia:Hypertension–strokecontrolprogrammeisurgentlyneeded.JAPI.2007;55:589-591.

16. WinsteinCJ,RoseDK,TanSMetal.Arandomizedcontrolled comparison of upper-extremityrehabilitation strategies in acute stroke: A pilotstudyofimmediateandlong-termoutcomes.ArchPhysMedRehabil,2004,85(4),620-628.

17. CarrJ,ShepherdRB.Amotorrelearningprogramforstroke.2nded.Oxford,UK:WiiliamHeinemmeMedicalBooks,1987.

18. CarrJH,ShepherdRB.Amotorlearningmodelforstrokerehabilitation.Physiotherapy.1989;75(7):372-380.

19. Carr JH, Shepherd RB. Reflections onphysiotherapy and the emerging science ofmovement rehabilitation.Aust JPhysiother1994;40thJubilee:39-47.

20. MichaelsonSM,LevinMF.Short–termeffectsofpracticewithtrunkrestraintonreachingmovementsinpatientswithchronicstroke.Acontrolled trial.Stroke.2004;35(8):1914-1919.

21. BernsteinNA.ThecoordinationandRegulationofmovement.Oxford,UK:PergamonPress;1967.

22. Kwakkel G, Veerbeek JM, Wolf SL et al.Constraint-Induced Movement Therapy afterStroke, Lancet Neurol. 2015 February; 14(2):224–234.doi:10.1016/S1474-4422(14)70160-7

23. Knaepen K, Goekint M, Heyman EM et al,Neuroplasticity – Exercise-Induced Response ofPeripheral Brain-Derived Neurotrophic Factor ASystematic Review of Experimental Studies inHuman Subjects, SportsMed 2010; 40 (9): 765-801.


A study of High Fatigue and Low Fatigue Resistance training on Quadriceps Muscle strength and Hypertrophy in

Normal Individuals

sandhya Kashyapketan singal1, Manmit Gill2, Mumtajben Payla3, Nikita shah3

1I/C Lecturer, M.P.T. Sports, 2Senior Lecturer, M.P.T. in Musculoskeletal Conditions, 3M.P.T. Sports, Department of Physiotherapy, Government Spine Institute and Physiotherapy College, Civil Hospital Campus, Ahmedabad,

Gujarat, India

AbstRACt

background: Resistancetrainingisnowacceptedasanintegralandcrucialpartofanyathlete’strainingplan. Earlypre-seasonoroff-seasontrainingisreservedformaximumstrengthandhypertrophy.Theprescriptivevariablesarenumeroussuchasexerciseorder,restintervalsbetweensetsandexercises,frequency,velocityofmovement,numberofsetsandrepetitions,andloadorintensity.Allofthesevariablescanbemanipulatedtomeet specific training goals and address individual needs. Strengthening exercise of the quadricepsmuscleseemstobeimportantforthepreventionandrehabilitationofkneeinjury.Highresistancetrainingenhancesmuscular strength andhypertrophy; and some studies suggest an important role ofmetaboliteaccumulationinthisprocess. In thisstudy the two trainingprotocolsweredesigned todifferentiateasmuchaspossibleforfatigueandmetaboliteaccumulationbymanipulatingrestintervalsbetweensetsandexercise.

Aims and Objectives: To study effectiveness of high fatigue and low fatigue resistance training onquadricepsmusclestrengthandhypertrophyandtostudythecomparativeeffectofhighfatigueandlowfatigueresistancetrainingonquadricepsmusclestrengthandhypertrophy.

Methodology: Study included 30 college students with age between 18-24 years after getting writtenconsent.Trainingsessionswereconducted3daysperweekfor9weeks.Subjectsweredividedintotwogroups.GroupA(n=15)trainedwithhighfatigueresistancetrainingandGroupBtrainedwithlowfatigueresistancetrainingonquadricepstable.1RMwasusedasthecriterionmeasurementforstrengthandthighgirthat9”abovekneejointlineforhypertrophy.

Results:Resultsshowedasignificantimprovementinoutcomemeasuresofstrength(t=5.68,p<0.0001)andhypertrophy(t=5.82,p<0.0001)inboththegroups.Butwhencomparingtwogroups,moreimprovementinstrengthseeninhighfatigueresistancetraininggroup;thisgroupalsoshowedmoresignificantincreaseinthighgirthascomparedtolowfatigueresistancetraininggroup.

Conclusion:Highfatigueresistancetrainingforkneeextensionismoreeffectivethanlowfatigueresistancetrainingintermsofstrengthandhypertrophyofquadricepsmuscle.Trainingthequadricepsmusclesisanintegralpartofmostsportsstrengthprograms.Sohighfatigueresistancetrainingcanbeusedforgainingbetterresults

Keywords: Fatigue, Resistance training, Rest, Pause, Quadriceps muscle, Hypertrophy, Muscle strength.

INtRODUCtION

Resistance training is nowaccepted as an integraland crucial part of any athlete’s training plan 1. Earlypre-season or off-season training is reserved for

maximumstrengthandhypertrophy1.Forathletesnewto resistance training an extended period of timemaybe required for functional or anatomical training toprepare the body for amore strenuous program.1 Thedynamicstrengthofthequadricepsmuscleisimportant

DOI Number: 10.5958/0973-5674.2018.00003.5


forthestabilityandmovementofthehumanbodyandthus for sports activity2,3. Strengthening exercise ofthe quadriceps muscle seems to be important for theprevention and rehabilitation of knee injury4, 5, 6. Highresistance training enhances muscular strength andhypertrophy;andsomestudiessuggestanimportantroleofmetaboliteaccumulationinthisprocesswhileatsameotherstudysaidthatfatigueandmetaboliteaccumulationdonotappeartobecriticalstimuliforstrengthgain,andresistance training can be effectivewithout the severediscomfort and acute physical effort associated withfatiguingcontractions7.There is controversy regardingeffectiveness of high fatigue resistance training andlow fatigue resistance trainingonmuscle strength andhypertrophyandlackofresearchinthisera.So,purposeofthestudyistoseetheindividualeffectsofhighfatigueresistancetrainingandlowfatigueresistancetrainingonquadricepsmusclestrengthandhypertrophyandalsotocompare the effects of high fatigue resistance trainingandlowfatigueresistancetrainingonquadricepsmusclestrengthandhypertrophy.


For the study a random sample of 30 studentsvolunteer to participate were taken from our collegeafter getting informed written consent giving dueconsideration to inclusion and exclusion criteria.InclusioncriteriaforthisstudyisnormalmaleindividualswithBMIrangebetween18.5to24.9kg/m2 havingagebetween18to24years.Exclusioncriteriaincludesanyhiporkneepathology,anyhiporkneeinjurywithinlastoneyear,historyof resistance training in lower limbs,thosewhoreportedperformanceenhancingdrugs,pain,anymedicalillness,thosewhohavereportedanactiveparticipation in aerobic exercise program or doingaerobicexerciseregularly.Materialsusedinstudywereconsent form, quadriceps table, various free weightplates (lb), locks,measure tape, pillow, plinth,watch,weighing machine, height scale, and digital camera.Outcomemeasurestakenwere1RMkneeextensionformeasuringstrengthonquadricepstableandthighgirthmeasurement9”aboverightmedialkneejointlinewithmeasuretape.

Trainingsessionswereconducted3daysperweekand with at least 48 hours between sessions for nineweeks,andwasconductedundersupervision.Subjectswererandomlydividedintotwogroups.Theprocedurewasexplainedtoallsubjects.Subjectstrainedtherightquadricepsfemorismusclegrouponaquadricepstable.Knee is extended fromflexedpositioning in a smoothcontrolledmanner.Subjectswereaskedtomaintaintheirhabitual levelsofactivity throughout thestudyperiod.Themaximumloadthatcouldbeliftedjustonce(1RM)wasmeasured to thenearest 5 lb. and thighgirthwasmeasuredwithmeasuretapetothenearest0.1cmat9”abovetherightkneejointlineinlyingposition.Averageofthethreethighgirthmeasurementswastakenasfinalreading.

The 1RM and thigh girth were measured beforethe start of study and again after 9weeks of training.Testswere preceded bywarm up that included activemovementofkneefollowedbyflexibilityexercisesforknee musculatures for about 5 minutes. The trainingload for both protocols was specified as 75% of 1RM, and the total numbers of repetitions were samefor both protocols. The two training protocols weredesignedtodifferentiateasmuchaspossibleforfatigueandmetabolite accumulation. After the completion oftrainingsessioncooldownexercisesweregivenwhichincludeactivemovementofkneeandgentlestretchingexerciseforabout5minutes.


GroupAtrainedwithhighfatigueresistancetrainingandGroupBtrainedwithlowfatigueresistancetrainingon quadriceps table. In high fatigue (HF) resistancetraining, Group A performed extension of right kneejointfor4setsof10repetitionswith30secondsofrestbetween sets. Training loadwas 75% of 1 RM. Theywereinstructedtoperformthecontractionsineachsetcontinuously in a smooth controlledmanner, loweringtheweightfullyandliftingitthroughthefullrange.Thetrainingloadwastypicallyreducedby5lbonetotwotimesininitialtrainingsessionsintwosubjectsbecauseit was impossible for the subjects to complete all thecontractionsattheprescribedload(75%1RM)duetofatigue.

In Low fatigue (LF) resistance training, GroupB performed total 40 repetitions of right knee jointextensionwith30secondsrestbetweeneachrepetitionto minimize fatigue and metabolite accumulation.Training loadwas75%of1RM.Itwasneverneededtoreducethetrainingloadforanysubjectfollowingthisprotocol.Again,thesubjectswereinstructedtoperformeach repetition in a smooth controlled manner liftingtheweightthroughthewholerange.Thesubjectswereobserved for any change or any symptoms and askedto report if there is any discomfort. All the subjectscompleted the whole treatment program of 9 weeks.Totaldurationofstudywasoneyear.

FINDINGs

Total30 subjectswere randomlydivided into twogroups:GroupA(Highfatigueresistancetraining)and

GroupB(Lowfatigueresistancetraining).15subjectswere taken in each group. Table 1 displays the groupstatisticsofagedistributionamongthe30subjects.Nosignificantdifferencewasseenacrossthetwogroups.

tAbLE 1. AGE (IN YEARs) DIstRIbUtION OF tHE sUbJECts

GROUP n MEAN ±sD

GROUPA 15 21.20 1.47

GROUPB 15 21.07 1.53

Table 2 displays the group statistics of BMIdistribution among the 30 subjects. No significantdifferencewasseenacrossthetwogroups.

tAbLE 2. bMI (kg/m2) DIstRIbUtION OF tHE sUbJECts

GROUP n MEAN ±sD

`1GROUPA 15 21.63 1.57

GROUPB 15 22.62 1.21

Pairedt-TestwasappliedinGroupAandinGroupBforwith-ingroupanalysis.Unpairedt-Testwasappliedforbetween-groupcomparisonofGroupAandGroupB. In the group A results showed highly significantimprovementin1RMandthighgirthmeasurementafter9weeks ofHigh FatigueResistance Training of rightQuadricepsmuscleat5%levelofsignificance(Table3).

tAbLE 3 MEANs OF PRE EXERCIsE AND POst EXERCIsE 1 RM AND tHIGH GIRtH OF GROUP A

OUtCOME MEAsURE PRE MEAN±sD POst MEAN±sD t VALUE p VALUE

1RM(lb) 37.00±11.62 60.67±13.35 16.67 <0.0001

THIGHGIRTH(cm) 41.35±3.03 43.47±3.08 20.07 <0.0001

In thegroupBresultsshowedhighlysignificant improvement in1RMand thighgirthmeasurementafter9weeksofLowFatigueResistanceTrainingofrightQuadricepsmuscleat5%levelofsignificance(Table4).


tAbLE 4. MEANs OF PRE EXERCIsE AND POst EXERCIsE 1 RM AND tHIGH GIRtH OF GROUP b

OUtCOME MEA-sURE PRE MEAN±sD POst MEAN±sD t VALUE p VALUE

1RM(lb) 39.33±14.00 53.67±14.07 17.35 <0.0001THIGH

GIRTH(cm) 42.27±3.05 43.57±3.04 13.96 <0.0001

Studentt-test(unpairedt-test)wasappliedbetweengroupcomparisonforGroupAandGroupB.Oncomparinggroup A and Group B the results showed highly significant improvement in strength (t=5.68, p<0.0001) andhypertrophy(t=5.82,p<0.0001)(Table5).

tAbLE 5. ON COMPARING GROUP A AND GROUP b

OUtCOME MEAsURE GROUP A MEAN±sD

GROUP bMEAN±sD

t VALUE p VALUE

1 RM(lb) 23.67±5.50 14.33±3.20 5.68 <0.0001

tHIGH GIRtH(cm) 2.12±0.41 1.30±0.36 5.82 <0.0001

After9weeksoftraining,groupAshowedmoresignificantimprovementin1RMkneeextensiontestandthighgirthbasedupongirthmeasurementwithtapeincomparisontogroupB.

DIsCUssION

The present study was conducted to see theindividualeffectofhighfatigueresistancetrainingandlowfatigueresistancetrainingandalsotocomparetheeffectiveness of high fatigue resistance training versuslow fatigue resistance training on quadriceps musclestrengthandhypertrophyinnormalindividuals.Resultsshowedasignificantimprovementinoutcomemeasuresofstrengthandhypertrophyinboththegroups.Butwhencomparing two groups there was more improvementin strength seen in high fatigue training group; Highfatigue training group also showed more significantincrease in thigh girth as compared to low fatiguetraininggroup.Theprobablereasonforthisresultwaslocal accumulation ofmetabolic sub products such aslactate and hydrogen ions which stimulate exercise-inducedadrenalinesecretion9.Theincreaseinmetabolicstresswithincreasedlactateandadrenalinehasrecentlybeenshowntoplayanimportantroleintheregulationofanabolichormonesecretionsfromthehypothalamus-pituitarygland10,11.Metaboliteaccumulationwithinthemuscle causes concomitant growth hormone secretionand transient increaseofgrowthhormonecanproducean interaction with muscle cell receptors, aidingrecoveryandstimulationofhypertrophy10,11.Alongwiththe mechanical stimuli (time under tension, load) the

interactionofhormonal (testosterone,growthhormoneetc.)andmetabolic(e.g.lactate,glycogen,etc.)stimuliare important for development of maximal strength.These findings are in agreementwith observations byRooney K J et al. 1994 who investigated the role offatigueinstrengthtraining.Increaseinstrengthproducedbyatrainingprotocolinwhichsubjectsrestedbetweencontractionswerecomparedwiththoseproducedwhensubjectsdidnotrest.Bothtraininggroupsperformedthesamenumberofliftsatthesamerelativeintensity.Theyconcluded that improvement in strength of the elbowflexors following six weeks of dynamic resistancetrainingwassignificantlygreaterintheregimenwithoutrest, compared to a regimen with a 30 second restperiodbetweeneachrepetitionalthoughthemagnitudeof muscular hypertrophy was not evaluated . Thesefindings suggest thatprocesses associatedwith fatiguecontributetothestrengthtrainingstimulus12.

In the present study during the first week oftraining,thehighfatiguegroup(GroupA)experiencedseveremuscle soreness,which is indicative ofmuscledamage, but thiswas not the case for the low fatiguegroup.Muscledamagecancauseastrengthdecrementfordaysandevenweeks13,14and, in theory; thiscouldhave attenuated the strength gains and any advantage


of high fatigue training. However, Folland JP et al2002 had previously investigated the influence of amore acute bout of muscle damage during the initialstagesofastrengthtrainingprogrammeandfoundthatthisdidnotinfluencestrengthgainsformorethantwoweeks15.Our observations suggest that high fatigue isanessentialorprimarystimulusforgaininstrengthaswell in improving girth.Low fatigue strength trainingdesignedtominimisestressandmetaboliteaccumulationproduced significant increases in quadriceps musclestrength and hypertrophy but that were not of similarmagnitude to trainingdesigned tomaximise fatigueormetaboliteaccumulation.Thissuggests thatsignificantand comparable strength gains and hypertrophy canbe achieved with high fatigue training. This findingis supportive to two longer studies byRutherford andcolleagues, who found metabolite accumulation to beof significant benefit to strength gains16, 17, although asixmonth study by the same group, using a protocolidenticalwiththatofthepreviousinvestigations,foundno advantage to high metabolite accumulation18. So,lactic acid may not be the ‘bad by product’ althoughitmaycontributetofatigue;itcanbeusedasasourceof energy. Studies have shown that lactic acid maybe important for increase in muscle hypertrophy andstrength16,19.

CONCLUsION

Highfatigueresistancetrainingforkneeextensionismoreeffectivethanlowfatigueresistancetrainingintermsofstrengthandhypertrophyofquadricepsmuscle.Therefore,increasingthemetabolicstress(lactate)maybe an additional stimulatory mechanism for musclegrowth and strength.Training the quadriceps musclesisanintegralpartofmostsportsstrengthprograms.Sohighfatigueresistancetrainingcanbeusedforgainingbetter results.Futurestudiesshouldbedoneby takinglargersamplesizeandbytakingafemalepopulationtotheseetheeffects.

Conflict of Interest:NoneDeclared.

source of Funding:Nil.

Ethical Clearance:Informedwrittenconsentsweretakenfromallvolunteerparticipantsofthestudy.

REFERENCEs1. How to Design a Resistance Training Program

for Your Sport. Available from: www.

sportsfitnessadvisor.com

2. EkstrandJ,GillquistJ.Theavoidabilityofsoccerinjuries.IntJSportsMed,1983;4:124–8.

3. Thomeé R, Renström P, Karlsson J, Grimby G.PatellofemoralpainsyndromeinyoungwomenII.Musclefunctionsinpatientsandhealthycontrols.ScandJMedSciSports,1995;5:245–51.

4. Kannus P, Niittymaki S. Which factors predictoutcome in the nonoperative treatment ofpatellofemoral pain syndrome? A prospectivefollow-upstudy.MedSciSportsExerc,1994;26:289–96.

5. GrimbyG.Clinicalaspectsofstrengthandpowertraining. In:KomiPV,ed.Strengthandpower insport. Oxford: Blackwell Scientific Publications,1991;338–54.

6. Ingemann-Hansen T, Halkjaer-Kristensen J.Progressive resistance exercise training of thehypotrophicquadricepsmuscleinman.Theeffectsonmorphology, size and function as well as theinfluence of duration of effort. Scand J RehabilMed,1983;15:29–35.

7. Folland JP, Irish CS, Roberts JC, Tarr JE, JonesDA.Fatigueisnotanecessarystimulusforstrengthgainsduringresistancetraining.BrJSportsMed,2002;36:370-373.

8. Fernando Vitor Lima, Mauro Heleno Chagas,EricaFischerFernandesCorradi,GiseleFreiredaSilva,BrendaBebianodeSouzaandLuizAntônioMoreiraJúnior.Analysisoftwotrainingprogramswith different rest periods between series basedon guidelines for muscle hypertrophy in trainedindividuals.RevBrasMedEsporte,2006;Vol.12,Jul/Ago,Nº4:157e-160e.

9. Cryer PE. Regulation of glucose metabolism inman.JInternMedSuppl,1991;735:31-39.

10. TakaradaY,TakazawaH,SatoY,TakebayashiS,Tanaka Y, Ishii N. Effects of resistance exercisecombined with moderate vascular occlusion onmuscular function in humans. J Appl Physiol,2000;88:2097-2106.

11. Viru M, Jansson E, Viru E, and Sundberg CG.Effectofrestrictedbloodflowonexercise-inducedhormone changes in healthy men. Eur J ApplPhysiol,1998;77:517-522.

12. Rooney KJ, Herbert RD, Balnave RJ. Fatigue


contributes to the strength training stimulus.MedSciSportsExerc,1994;26:1160–64.

13. Gibala MJ, MacDougall JD, Tarnopolsky MA,Stauber WT, Elorriaga A. Changes in humanmuscle ultrastructure and force production afteracuteresistanceexercise.JApplPhysiol1995;78:702–8.

14. NewhamDJ, Jones DA, Clarkson PM. Repeatedhigh-force eccentric exercise: effects on musclepain and damage. J Appl Physiol 1987; 63: 1381–6.

15. Folland JP, Chong J, Copeman EM, Jones DA.Acutemuscle damage as a stimulus for training-induced gains in strength.Med Sci Sports Exerc2001Jul;33(7):1200-5.

16. Carey Smith R, Rutherford OM. The role ofmetabolitesinstrengthtrainingI.Acomparisonofeccentric and concentric contractions.Eur JApplPhysiol,1995;71:332–6.

17. SchottJ,McCullyK,RutherfordOM.Theroleofmetabolites in strength training II. Short versuslong isometric contractions. Eur J Appl Physiol,1995;71:337–41.

18. Welsh L, Rutherford OM. Effects of IsometricStrengthTrainingonQuadricepsMusclePropertiesinOver55YearOlds.EuropeanJournalofAppliedPhysiology and Occupational Physiology, 1996;vol.72,no3,pp.219-223.

19. ShinoharaM1,KouzakiM,YoshihisaT,FukunagaT. Efficacy of tourniquet ischemia for strengthtrainingwith low resistance. Eur JAppl Physiol,1998;77:189–91.

to Find Out the Correlation between Pain Disability and Quality of Life with Low back Pain in Housewives of

Age Group 40-50 Years

Ankita sharma1, saqueba shahi1, Rashida begum2, Nirupma singh3 1Intern, 2Assistant Professor, 3Physiotherapist, Jamia Hamdard, New Delhi, India

AbstRACt

background:ThelevelofQualityofLife(QOL)anddisabilityamongwomenwithlowbackpainisanimportanthealthissueatgloballevel.Objective:TofindoutthecorrelationbetweenpaindisabilityandQOL amongwomen.Materials And Methods:A community-based correlational studywas conductedamong200womenaged40-50yearswhohaveLowbackpainwereinterviewed,outofwhich39excludedbecausetheydidnotneedmeetourinclusioncriteria.SeverityofpainwasassessedusingVisualAnalogueScale, Oswestry Disability Low Back Pain questionnaire was used to measure the disability level andWHOQOL-BREFscalewasusedtoassessthequalityoflife.Results:Thefindingsofpresentstudyshowthat74.19%ofthesubjectshaveepisodesoflowbackpain.Thepresentstudyfindingsfoundthatthemostof thewomen(74.19%)with lowbackpainexperiencedmoderatedisability(83/161)51%,followedbyseveredisability(24/161)14%andminimaldisability(51/161)31.67%.Andcrippled(3/161)1.86%.Ithasanegativecorrelationwithavalueof(-0.11)thatmeansverylittleeffectonDisability.Theintensityofpaini.e.moderateorseverehasaffectedthephysicaldomainmosthavinganegativecorrelationwithavalueof -0.22 as compared to environment (-0.12), psychological (-0.08), social relation (-0.09).In this studywefoundthatwhenBMIincreasesorifapersonisoverweightthelevelofpainalsoincreasesshowingapositivecorrelationwithavalueof0.14

Conclusion:ItisconcludedthatmostofthehousewivessufferfromLowBackAche.Thephysicalqualityoflifeisinversely/negativelycorrelatedandBMIisdirectly/positivelycorrelatedwithintensityofpain.

Keywords- BMI,Disability,LBP,QOL,VAS.

Corresponding address: Ankita sharma (BOTIntern)JamiaHamdard,NewDelhi,[email protected],Mob.:9873328476

INtRODUCtION

Low back pain (LbP) is a commondisorderinvolving the muscles, nerves, and bones ofthe back.Pain can vary from a dull constant ache to asuddensharpfeeling. Lowbackpainmaybeclassifiedby duration as acute (pain lasting less than 6 weeks),sub-chronic(6 to12weeks),orchronic(morethan12weeks). Theconditionmaybefurtherclassifiedby the

underlyingcauseaseithermechanical,non-mechanical,orreferredpainthesymptomsoflowbackpainusuallyimprovewithin a fewweeks from the time they start,with40-90%ofpeoplecompletelybetterbysixweeks.

Awoman is the nucleus of the family, especiallyin India. The daily work schedule of women is veryarduous and demanding in nature. The non-neutralpostureofthetrunkfrequentlyadoptedbywomenisriskfordevelopingalowbackpain.[1]

Low back pain is a massive problem in modernpopulation,bothinsocialandeconomicterms.Itaffectslargenumbersofwomen,especiallythoseaged40-50.Going through a premenopausal period is associatedwithmanysymptoms,includinglowbackpain [2].

DOI Number: 10.5958/0973-5674.2018.00004.7


As their life expectancy increases, contemporarywomen live a thirdof their life inmenopause chronicpain in is more prevalent women than inmen, and itincreases with age. According to Whelan et al., even80%ofwomensufferfromvarioussymptoms(includingpain)inthepremenopausalperiod [2].

Internationalsurveysoflowbackpainreportedthat1monthprevalencewas19-43%andpointprevalencewas15-30%.The estimated worldwide lifetime prevalenceof lowbackpainvaries from50%-30%.Theestimatedworldwidelifetimeprevalenceof lowbackpainvariesfrom 50%to 84%.Studies in developed countries haveshown that the low back pain point prevalence was6.8% in North America,13.7%in Denmark,12% inSweden,14%intheUnitedKingdom,33%inBelgiumand28.4%inCanada.Similarly,somestudiesindevelopingcountrieshaverevealedmuchhigherincidenceof72.4%inNigeria,64%inChina,and56.2%inThailand.TheoccurrenceoflowbackpaininIndiahassufferedfromlowbackpainatsometimeduringtheirlifespan [1].

Low back pain also restricts mobility, interfereswith normal functioning and results in lifelong painandpermanent disability. In India,most of thepeopleare engaged in physically demanding jobswhichmayincrease the riskof lowbackpainanddisability.Lowbackpainalsoaffects thequalityof life [QOL]ofnotonlywomen themselves, but their families aswell .InIndia very few studies have been donewith regard tothis [1].

Withthisbackground,thepresentstudyaimed–Tofindthecorrelationbetweenpain,disabilityandqualityof lifewithLBP in housewives of age[40-50yrs].Wewanttothisstudybecausewomenusuallyhousewivesneglecttheirhealthanditaffectsothersfamilymemberstoobecausetheallofthemaredependedonher.

More than 85% of Indian women neglect theirhealthandconsultthedoctorwhentheyhavereachedattheirworststageofthedisease.ThisstudyisalsorarelydoneinSouthDelhi.

MEtHODOLOGY

• TYPE OF STUDY- Survey, Prospectivecommunitybasedcorrelationalstudy.

• ToolsUsed-

• VAS-Itisameasureoftheintensityofpain.

It is usually a 10 cm line with anchors of ‘no pain’and ‘worstpainpossible’withascoreofzeroand tenrespectively. The VAS is a simple, widely used selfreportmeasurethathasexcellentreliabilityandvalidity.17

• WHOQOL-BREF-Itcomprises26items,whichmeasurethefollowingbroaddomains;physicalhealth,psychologicalhealth,socialrelationships,environment.Itassessestheindividual’sperceptionsinthecontextoftheircultureandvaluesystem,andtheirpersonalgoalsandstandards.21

• OSWESTRY DISABILITY LOW BACKPAIN QUESTIONNAIRE- It is an index used bycliniciansandresearcherstoquantifydisabilityforlowbackpain.22

• SampleSize-217

• Excluded-56

• Sourceofdatacollection–Community

• Inclusioncriteria-HousewifewithLowBackPainAgegroup40-50years)

• Exclusioncriteria

Workingwomen

Housewiveswithanytrauma,infection,oranymajortraumatospinefracture.

Procedure

This study was a correlational. By using quotasampling method, 217 women aged 40-50 years whohave LOW BACK PAIN were interviewed, out ofwhom56wereexcludedbecausetheydidnotmeetourinclusioncriteria.The remaining161housewives tookpartinthestudy.

The language we choose is English and we alsomakepeopleunderstandthequestionsinHindisothatthequestionsmustnotbeignoredoransweredincorrectly.Weexcludedthehousewiveswhowereengagedinanysortofoccupationalactivityotherthanhouseholdwork,andalsothosewhowerepregnantordiagnosedwithanyneurological, cardiovascular or psychiatric conditions.Housewiveswith tumor, infection, or any othermajortrauma to the spine fracture was excluded from thestudy.Afterselectingthehousewivesforthesampling,


the interviewerconducteddoor todoorsurvey .Beforeproceedingtotheinclusion-exclusioncriteriaandwerewillingtoparticipateinthestudytheywerethenaskedtoprovidetheirdemographicaldetailsanypresentorpastmedicalhistory, surgeryhistory,gynecologicalhistoryandinformationforBMI.Afterexplainingtheneedandpurposeofthestudyawrittenconsentwasobtainedfromeachwomen.Allthethreescaleswereadministeredtoall of them. The language of the WHOQOL-BREFscaleisbothinEnglish&Hindi&OswestryLowBackPain Disability Questionnaire was in English so eachquestionwasexplainedbytheresearcherinHindi.Dataisrecordedonassessmentsheets.

DAtA ANALYsIs

AnalysisofthedatawasdonebyusingFormula:

Correlation Co-Efficient: Correlation(r) =[NΣXY - (ΣX) (ΣY) / Sqrt ([NΣX2- (ΣX)2][NΣY2-(ΣY)2])]N=NumberofvaluesorelementsX=FirstScoreY=SecondScoreΣXY=SumoftheproductoffirstandSecondScoresΣX=SumofFirstScoresΣY=SumofSecondScoresΣX2=SumofsquareFirstScoresΣY2=SumofsquareSecondScores

REsULts

Outof217subjects161hasLOWBACKPAINintheagegroupof40-50yrs.85%(n=136)ofwomenhadeducationuptosecondaryleveland15%(n=24)ofthemwere illiterate. None of the women is at menopausallevel.TheParity (no. of children)having subjects hasno correlation with each low back pain with a valueof 0.03. Regarding Body mass index (BMI), (6/161)3.7%ofsubjectsareunderweight, (69/161)42.85%ofsubjects are normal, (85/161) 52.79% of subjects areoverweight. As BMI increases the level of pain alsoincreases showing a positive correlation with a valueof0.14.Majorityofwomen(98/161)60.86%whohasmoderate pain followed by severe (61/161) 37.88%andmild(3/161)1.86%pain.Theintensityofpaini.e.moderate or severe has affected the physical domainhavinganegativecorrelationwithavalueof-0.22moreas compared to environment (-0.12), psychological(-0.08), social relation(-0.09). Subjects with Low backpain experienced moderate disability (83/161) 51%,followedbyseveredisability(24/161)14%andminimaldisability (51/161) 31.67%. And crippled (3/161)1.86%.It has a negative correlationwith a value of (-0.11)thatmeansverylittleeffectonDisability.

Wefoundthecorrelationbetween:

• VASAndParity

• BMIAndVAS

• VAS and physical ,psychological, socialrelation,environment&disability

Wefoundtherelationusing:

Formula:

Correlation Co-Efficient: Correlation(r) =[NΣXY - (ΣX) (ΣY) / Sqrt ([NΣX2- (ΣX)2][NΣY2-(ΣY)2])]N=NumberofvaluesorelementsX=FirstScoreY=SecondScoreΣXY=SumoftheproductoffirstandSecondScoresΣX=SumofFirstScoresΣY=SumofSecondScoresΣX2=SumofsquareFirstScoresΣY2=SumofsquareSecondScores

Youcalculatetheaboveformulainexcelutility

Formulaforexcel=Corel(X:XN,Y:YN)

sPECIFIC CORELAtION

PARItY vs. VAs 0.03

bMI vs VAs 0.14

VAs vs PHYsICAL -0.22

VAs vs PsYCHOLOGICAL -0.09

VAs vs sOCIAL RELAtION -0.08

VAs vs ENVIRONMENt -0.12

VAs vs DIsAbILItY -0.11

NOTE:

Correlation coefficient of –ve value indicates aperfectnegativecorrelation.AsvariableVASincreases,VariableofPhysical,Environment,&Disabilitydecreases.

Correlation coefficient of +ve indicates a perfectpositivecorrelation.AsBMIvariableincreases,variableofVASlevelwillincrease.

A correlation coefficient near 0 indicates nocorrelation: As in case of Parity vs. Psychological &SocialRelations.


GRAPH I

INTERPRETATION: It shows relation betweenBMI andVAS& indicates positive correlationwith avalueof0.14whichmeans thatwhenBMIofapersonincreasesi.e.thepersonisoverweightthelevelofpaini.e.(mild,moderate,orsevere)alsoincreases.

GRAPH II

INTERPRETATION:ItshowstherelationbetweenVAS and Disability. It indicates negative correlationwithavalueof-0.11whichmeansthelevelofpaini.e.moderate or severe leads tominimal disability amongsubjects.

GRAPH III

INTERPRETATION:Itshowstherelationbetweenthe VAS and Physical domain of Quality of life. Itindicatesaperfectnegativecorrelationwithavalueof-0.22whichshowsthatwhenpersonhasincreasedlevelofpaini.e.moderateorseverelevelsoultimatelytheir

physicalqualityoflifehampersordecreases

DIsCUssION

Women are also biologically prone to developlow back pain especially when they are at the ageof attaining menopause. In our study 97.51% is atpremenopausal and 2.48% attained menopause whichresult in hormonal changes responsible for globallaxity in the muscles and ligaments of the back, andultimatelyleadstodysfunctionsofspine.(11,12)Ourstudyreported that 75%of subjects have localizedbackpainand25%subjectshave radiatingpain to legsbyusingdigrmmating view of body also supported by AntjeSpijker-Huiges,FeikjeGroenhofet.alstudy.(20)

Thehousewiveswhoparticipatedinourstudyweremainlyattheage40-50years.Theyactivelyparticipatedinhouseholdactivitieswhicharecommonindailychoresandcouldbelistedasmaintainingtheirhome,sweepingfloor, washing clothes, lifting loads, taking care oflivelihood.Theseallactivitiesrequirerepeatedbending,twistingmovements, liftingandpullingmovementsofthe spine.(13)Koleyetal. (2008) reported thatmanualhandlingandimproperstyleofliftingobjectsharmthespineduetoabnormalstressandstrainimposedonspineduringactivities(14).

TheParity(no.ofchildren)havingsubjectshasnocorrelationwithlowbackpainwithavalueof0.03.Butwemusthavethisresultbecauseofsmallpopulation,butsomestudieslikeAlan.JSilman,SusanFerryANNetaldida study toestimate the influenceof thenumberoflivebornchildrenontheriskofLowbackpain.(16)Thepresentstudyfindingsfoundthatthemostofthewomen(74.19%) with low back pain experienced moderatedisability (83/161) 51%, followed by severe disability(24/161)14%andminimaldisability(51/161)31.67%.Andcrippled(3/161)1.86%.Ithasanegativecorrelationwithavalueof (-0.11) thatmeansvery littleeffectonDisability.ThesefindingsareconsistentwiththestudyconductedbyKoleySandSandhuNS(2009)(15)

The intensity of pain i.e. moderate or severe hasaffected the physical domain most having a negativecorrelation with a value of -0.22 as compared toenvironment (-0.12), psychological (-0.08), socialrelation (-0.09) whichwas supported by ThiasStefaneAmandaMunaridosSantoset.al.2013reportedphysicalquality of life is most impaired. (21)Out of lifestylefactorsobesitycanbeafactorassociatedwithLBP.In


this studywe found that (6/161) 3.7% of subjects areunderweight, (69/161) 42.85%of subjects are normal,(85/161) 52.79% of subjects are overweight. As BMIincreasesorifapersonisoverweightthelevelofpainalso increases showing a positive correlation with avalueof0.14.LowisachomSharmayneR.EBradyet.al.2016 supported this by saying LBP was associatedwith higher body mass index. (9)Regarding utilizationofhealthservicesforLBP,ithasbeenobservedthatalargenumberofsubjectswithLBPtooknoconsultation,followed by any kind of rehabilitation treatment.Majority of subjects preferred traditional methods ortookallopathicmedicationsortooknocare.Betterhealthcaremeasures to enhancehousewives educationaboutgood posture, ergonomic measures, health awarenessand activity pacing could help the housewives. Wegave health booklet to each subjects and make themunderstandsomebasicexercisessuchasbridging,backisometrics and straight leg rising and it also containthe basic ergonomics regarding LBP. It is in Englishlanguage and each sentences and exercises/techniqueswasexplainedinHindibytheresearcher.

CONCLUsION

It is concluded thatmostof thehousewives sufferfrom Low Back Pain. The physical quality of life isnegatively correlated andBMI is positively correlatedwithintensityofpain.

Ethical Clearance- Nil

source of Funding-Nil

Conflict of Interest - Nil

REFRENCEs

1. GunaSankarAhdhi,RevathiSubramanian,GaneshKumar Saya,Thiruvanthipuram VenkatesanYamuna; Prevalence of low back pain and itsrelation to quality of life and disability amongwomeninruralareaofPuducherry,India

2. Shyamal Koley and Navtej Kaur Sandhu; Anassociationofbodycompositioncomponentswiththemenopausal status of patients with low backpainintaran,taran,Punjab,India[2009]

3. Garima Gupta and Nupur Nandini;Prevalence oflowbackpaininnon-workingruralhousewivesofKanpur,India[2014]

4. Mateusz Kozinoga,Marian Majchrzycki,SylwiaPiotrowska;Lowback pain inwomen before andaftermenopause[2015]

5. Supreet Bindra,Sinha A.G.K and BenjaminA.I;Epidemiology of low back pain in Indianpopulation;Areview

6. SutharN,KaushikV.[3Dec2010] did a study onmusculoskeletalproblemsamongtribalwomenofUdaipur.

7. Tiwari etal [2003]-High BMI was found to beassociated with work related musculoskeletaldiscomfortandoccupationalpsychosocialstress.

8. Amod etal [2012]; present episode of LBP wasfound to be associated with previous history ofLBPintrunkdriversofNagpurcity.

9. LowisaChomSharmayneR.EBrady etal [2016]didastudyoftheassociationbetweenobesityandlowbackpainanddisability.

10. Loney PL. Stratford PW [1999 April] did astudy on the prevalence ofLBP in adultswith amethodological0differences.

11. BirabiBN,DienyePO,NdukwuGU.Prevalenceof lowbackpainamongpeasant farmers in ruralcommunity in South Nigeria. Rural RemoteHealth.2012;12:1920.

12. Hyder AA, Maman S, Nyoni JE, Khasiani SA,TeohN,PremjiZ,etal.Thepervasivetriadoffoodsecurity, gender inequity and women’s health:Exploratory research from sub Saharan Africa.AfterHealthSci.2005;5(4):328–34.

13. BioF,SadhraS, JacksonC,BurgeP.LowbackpaininundergroundgoldminersinGhana.GhanaMedJ.2007;41(1):21–5.

14. KoleyS,SinghG,SandhuR.SeverityofdisabilityinelderlypatientswithlowbackpaininAmritsar,Punjab.Anthropol.2008;10(4):265–8.

15. Koley S, Sandhu NK. An association of bodycompositionwiththemenopausalstatusofpatientswithlowbackpaininTarnTaran,Punjab.India.JLifeSci.2009;1(2):129–

16. Alan.Jsliman,SusanFerryANNetal;didastudyofestimatetheinfluenceofthenumberoflinebornchildrenontheriskoflowbackpain.

17. Ogon M K rismer M, Sollner W Kantner-Rumplmairetal;didastudyonchroniclowbackpainmeasurementwithVASindifferentsettings.


18. Mohapatraetal;[2011];LBPwasfoundtobemorecommon among females themmales in geriatricpatientsUttarPradesh.

19. Amod etal; [2012]; present episode of LBPwasfoundtobeassoiatedwithprevioushistoryofLBPintruckdriversofNagpurCity.

20. Antje Spijker-Huiges, Feikje Groenhof,etal;Theaim of this study was to calculate the incidenceandprevalenceofradiatinglowbackpain’

21. Thias Stefane Amanda Munaridos Santos etal;[2013]; did a study of chronic low back painintensity,disabilityandqualityoflife.

22. DarrelS.BrodkeMD,VadimGozMDetal[2017];dida study of clinical study ofOswesteryDisabilityIndex,apsychometricanalysiswith1,610patients

23. KarandDhara[2007]foundthatalargenumberoffarmerswithLBPcouldnotcompletetheirprimaryeducationandremainedbelowpovertyline.

A Comparison of the Immediate and Lasting Effects between Passive stretch and Muscle Energy technique on Hamstring

Muscle Extensibility

Mumtajben Payla1, Manmit Gill2, sandhya Kashyapketan singal3, Nikita shah4

1M.P.T. Sports, 2Senior Lecturer, 3I/C Lecturer, 4M.P.T. Sports, Department of Physiotherapy, Government Spine Institute and Physiotherapy College, Civil Hospital Campus, Ahmedabad, Gujarat, India

AbstRACt

background: Asurprisingnumberofproblemsarisefrominadequatehamstringsextensibilityand,givesthe frequencyofknee injuriesamongathletes,non-athletic individualsanddancers;so treatmentshouldbefocusedtoreducetightness.Oneofthemostimportantaspectsofperformanceenhancementotherthanskillistomaintainflexibilitysotherebyinjurycanbeprevented.Inordertoassisttheathleteintrainingforflexibilityeventandforgeneralpopulationtorelievethesymptomsduetoinadequatemuscleextensibility,stretchingtechniquesarecommonlyusedandtheconceptofmuscleenergytechnique(MET)evolvedoutofosteopathicproceduresdevelopedbypioneerpractitionerssuchasT.J.Ruddy,FredMitchellandPhilipGreenmanshouldbe incorporated.Thisarticlepresentsamoreeffectiveway to free thehamstringsandimprovetheperformance.

Aims & Objectives: TostudytheimmediateandlastingeffectsofMETandpassivestretchingonhamstringmuscleextensibilityandtocomparetheimmediateandlastingeffectsofMETandpassivestretchingonhamstringmuscleextensibility.

Materials and Method:Studyincluded40collegestudentswithagegroupbetween18-25years.Subjectswererandomlydividedinto2groupsaftergettingwrittenconsent.Singlesessionofinterventionwasgiventorightlowerextremityintheafternoon.Theactivekneeextension(AKE)andbacksaversitandreachtest(BSSR)wereusedasacriterionmeasurementforhamstringmuscleextensibility.BeforeinterventionmeasurementsweretakenthenGroupA(n-20)wasgivenMET,GroupB(n-20)wasgivenpassivestretching.BothMETandpassivestretchingwerematchedforrepetitions,durationandrestinterval.Immediateandlastingeffectsofinterventionsinbothgroupsweremeasuredagainbyabovementionedtestsimmediatelyandonehourafteranintervention.

Result:‘StudentstTest’(pairedt-test)wasappliedforwithingroupcomparison,bothgroupsindividuallyshowed highly significant improvement in range ofAKE and distance of BSSR test at immediate andafteronehourofintervention.Student’sttest(unpairedttest)wasappliedforbetweengroupshowednosignificantdifferenceinimprovementofAKEanddistancefrommiddlefingerofhandstogreattoeat5%levelofsignificance,althoughimprovementwasmoreinGroupAascomparedtoGroupB.

Conclusion:METissuperiortopassivestretchingintermsofhamstringextensibility.Hamstringextensibilityisobviouslyvaluableforathletesandalsoforgeneralpopulationtoavoiddeleteriouseffectsofhamstringtightness.ThereforethoseinvolvedinflexibilitytrainingcanconfidentlyincludeMETasadjuvanttotheirnormaltrainingprotocolthanusingpassivemusclestretching.

Keywords: Passive stretch, Muscle energy technique, Hamstring muscle extensibility.

INtRODUCtION

Hamstring muscle injuries are one of the mostcommon musculotendinous injuries in the lower

extremity1. They occur primarily during high speedor high intensity exercises and have a high rate ofrecurrence due to hamstring tightness2. Most medicalprofessionals, coaches and athletes consider aerobic

DOI Number: 10.5958/0973-5674.2018.00005.9


conditioning, strength training and flexibility, theintegral components in any conditioning program3. Lack of hamstring extensibility was the single mostimportant characteristics of hamstring injuries inathletes1. Decreased hamstring extensibility is a riskfactor for hamstring strain injury4, and symptoms ofmuscle damage following eccentric exercise. Passivestretching and isometric contract-relax stretching(muscleenergytechnique“MET”)arecommonlyusedinmanual therapyprofessions,suchasosteopathyandphysiotherapy,toimprovejointandmuscleextensibility.Passivestretchingconsistsofapassiveelongationofthedesiredmusclegroup,commonlywithdurationof10to30seconds5.METisanosteopathictreatmentprocedurethat involves the voluntary contraction of the musclein a precisely controlled direction, at varying levelsof intensity, against a distinctly executed counterforceappliedbytheoperator6.GreenmanstatedthatMETcanbeused to lengthena shortened,contracted,or spasticmuscle;tostrengthenaphysiologicallyweakenedmuscleorgroupofmuscles;andtomobilizeanarticulationwithrestricted mobility6. MET and passive stretching hasbeen demonstrated to improve extensibility and jointrangeofmotion(ROM),particularlywhenmeasuredbyactivekneeextension(AKE)testandbacksaversitandreach(BSSR)test,althoughthemechanismanddurationof effect remains controversial. Several studies haveshownvaryingresultsastothemosteffectivetechnique7. It is therefore important toexaminewhetherpassivestretching orMET produce either a greater or longerlastingeffectonphysiologicalrangeofmotion.Sotheobjective of this study is to investigate whether thesinglesessionofMETismoreeffective,andhasalongerlastingeffect,thanasinglesessionofpassivestretchingontheextensibilityofthehamstringmusclesmeasured.


Study included 40 college students volunteer toparticipatefortheintervention.Subjectswererandomlydividedin to twogroupsaftergettingwrittenconsentsgiving due consideration to inclusion and exclusioncriteria.InclusioncriteriaforthisstudyisnormalmaleandfemaleindividualswithBMIrangebetween18.5to24.9 kg/m2 having age between 18 to 25 years havingrightsidetighthamstring(Inabilitytoachievelastthan20 degree of knee extension actively with hip at 90°offlexion).Exclusioncriteria includeacuteorchroniclowback pain, acute or chronic hamstring injury, anyhip or knee pathology and sciatica.Materials used in

study were consent form, plinth, measure tape, crossbar, straps, wrist watch, weighing machine, heightscale, universal goniometer, stool and marker pen.Singlesessionofinterventionwasgiventorightlowerextremitytosubjectsofboththegroupsintheafternoon.Theactivekneeextensionandbacksaversitandreachtest were used as an outcome measure for hamstringmuscleextensibilitytakenbeforeandafterinterventioninbothgroups.

IngroupA(MET)thesubject’skneewasextendedwith90ºhipflexionactivelybyhimselforherselftothepositionwherethesubjectfirstreportedofanyhamstringdiscomfortandmoderateisometriccontraction(approx30%ofmaximal)ofthehamstringmusclewasgivenatthat barrier andmaintained for 7-10 seconds followedby 5 seconds relaxation. The kneewas then extendedwithflexedhip,takentoitsnewrestrictionbarrierandasmalldegreebeyond,passivelybytherapist,andheldinthispositionforatleast30seconds.Thiscompletesonerepetition.Totalfiverepetitionsweregivenwith20secondsrestbetweeneachrepetition.Duringsubsequentrepetitions,eachisometriccontractioncommencingfromapositionshortofthebarrierandisometriccontraction


holding time was increased from 7-10 seconds up to20seconds.IngroupBsubjectswerelyingsupineandasked to relax the legwhile the therapistextended thekneewithhipflexedtothepointoffirstonsetofpain.Thestretchwasheldfor30secondswheretheforceofstretch was increased as subject tolerance changed orthe muscle was felt to “give” during the stretch. Thetechniquewasrepeatedfivetimes.20secondsrestwasgivenbetweenrepetitions.

Subjectswereaskednottoparticipateinanyexertingphysicalactivityduring1hourinterval.AfteronehourAKEandBSSRtestwereperformedandmeasurementswere taken. The subjects were also observed for anychangeoranysymptomsandaskedtoreportifthereisanydiscomfort during treatments session.All subjectscompletedthewholetreatmentprogrammewithoutanydiscomfort.Totaldurationofthestudywas3months.

REsULt

Total 40 subjects, were randomly divided in to2 groups: Group A (MET group) Group B (Passivestretching group). The table 1 shows the GenderDistributionofthe40subjectsparticipatedinthestudy.Therewere9malesand11females inGroupAand8malesand12femalesinGroupB.

table 1: Gender distribution of the patients

GENDER GROUP A GROUP b

MALE 9(45%) 8(40%)

FEMALE 11(55%) 12(60%)

Table 2 displays the group statistics of agedistributionamong40subjects.Nosignificantdifferencewasseenacrossthetwogroups.

table 2: Age (in years) distribution of the subjects

GROUP n MEAN ±sD

GROUPA 20 23.15 1.53

GROUPB 20 23 1.3

All the statistical analysiswasdonewith thehelpofMicrosoftExcel2007version.Studentt-test(Pairedt -test) was applied for within group comparison ofgroup A and group B. In the group A and Group Bresults showed significant improvement inAKE rangeofmotion(ROM)onimmediateandonehour(Lasting)afteraninterventionat5%levelofsignificance(Table3andTable4).

table 3: Means of pre exercise and immediate AKE ROM (flexion angle) of Group A and Group b

GROUP PRE MEAN(º)±sDIMMEDIAtEMEAN(º) ±sD

t VALUE p VALUE

GROUPA40.1±8.9 34.7±7.9 12.8 p<0.001

GROUPB 39.9±7.9 35.7±8.3 9.9 p<0.001

table 4: Means of pre exercise and Lasting AKE ROM (flexion angle) of Group A and Group b

GROUP PRE MEAN(º)±sDLAstINGMEAN(º) ±sD

t VALUE p VALUE

GROUPA 40.1±8.9 36.2±210.3

p<0.001

GROUPB 39.9±7.9 37.1±8.6 6.5 p<0.001

IntheGroupAandBresultsshowedsignificantimprovementindistanceinBSSRtestonimmediateandonehour(lasting)afteraninterventionat5%levelofsignificance.(Table5andtable6).


table 5: Means of pre exercise and immediate effect distance of bssR test of Group A and Group b

GROUP PRE MEAN(cm)±sDIMMEDIAtEMEAN(cm) ±sD

t VALUE p VALUE

GROUPA 17.0±4.3 12.5±3.6 7.8 p<0.001

GROUPB 16.9±5.5 13.5±4.8 12.8 p<0.001

table 6: Means of pre exercise and lasting effect distance of bssR test of Group A and Group b

GROUP PRE MEAN(cm)±sDIMMEDIAtEMEAN(cm) ±sD

t VALUE p VALUE

GROUPA 17.0±4.3 13.7±3.6 6.5 p<0.001

GROUPB 16.9±5.6 14.4±4.8 11.8 p<0.001

Student’sttest(unpairedttest)wasappliedbetweengroupcomparisonforGroupAandGroupB.OncomparingimmediateandlastingeffectofinterventionbetweenGroupAandGroupBtheresultshowednosignificantdifferenceinimprovementofAKEROM(flexionangle)anddistance(frommiddlefingerofhandstogreattoeofrightfoot)ofBSSRtestat5%levelofsignificance,althoughimprovementwasmoreinGroupAascomparedtoGroupB.(Table7andtable8).

table 7: Means of differences of AKE ROM (flexion angle) of immediate effect and lasting effect for Group A and Group b

EFFECts GROUP A (MEAN±sD) GROUP b (MEAN±sD) t VALUE p VALUE

Immediate 5.4±1.9 4.4±2.0 1.6 p=0.11

Lasting 3.9±1.7 2.9±2.0 1.6 p=0.11

table 8: Means of differences of distance of bssR test of immediate effect and lasting effect for Group A and Group b

EFFECts GROUP A (MEAN±sD) GROUP b (MEAN±sD) t VALUE p VALUE

Immediate 4.5±2.6 3.4±1.21.6

p=0.10

Lasting 3.3±2.3 2.5±1.3 1.4 p=0.18

In this intervention, bothGroupA andB showedhighlysignificantimprovementinhamstringextensibilityat immediateandonehourafteran interventionbasedupon AKE ROM and distance of BSSR tests. Whilecomparing Group A and Group B improvement inhamstringextensibilityatimmediateandafteronehourismore in GroupA as compared to Group B thoughdifferencewasnotsignificant.

DIsCUssION

METandpassivestretchinghasbeendemonstratedto improvehamstringmuscleextensibilityand therebyincrease joint ROM, particularly when measured byAKEandBSSR,althoughthemechanismanddurationofeffectremainscontroversial.TheresultofthisstudyhasshownthatMETappearedtobemoreeffectivethan


passivestretchingforincreasinghamstringextensibilityimmediately post-treatment and still at one hour laterwhichcanbeexplainedbyno.ofpossiblemechanism.Instretchingtherewillbeincreaseinpassivetensionofthemusclewhichcreatesresistanceagainstsubsequentstretching and also due to stretchingpain, patientwillhave decreased tolerance to stretch8. The applicationof MET would appear to decrease an individual’sperception of muscle pain, and is greater than thatwhich occurs with passive stretching9. Stretching andisometric contraction in MET stimulate muscle andjoint mechanoreceptors and proprioceptors, and it ispossible that this may attenuate the sensation of painand thereby increase tolerance to stretch9. InMET theneurological effectsof the loadingof thegolgi tendonorgans of a skeletalmuscle bymeans of an isometriccontraction, produces a postisometric relaxation effectin that muscle10. Moreover, post isometric relaxation-biomechanicalevent:combinationofviscoelasticcreepandplasticchangesintheparallelandseriesconnectivetissueelementsofmuscleoccuraboveandbeyondthatobtainedbypassivestretching11. Inaddition,voluntarycontraction during a stretch increases tension on themuscle, activating the golgi tendon organs more thanthe stretch alone12. When the muscle performing theisometriccontraction is relaxed, it retains itsability tostretchbeyonditsinitialmaximumlength12,METtriestotakeimmediateadvantageofthisincreasedrangeofmotionbyimmediatelysubjectingthecontractedmuscletoapassivestretchandhelpstotrainthestretchreceptorsof the muscle spindle to immediately accommodatethis greater muscle length12. Ballantyne F et al 2003 concluded thatMuscleEnergyTechniqueproducedanimmediate increase in passive knee extension7. Thisobservedchangeinrangeofmotionispossiblyduetoanincreasedtolerancetostretchastherewasnoevidenceofviscoelasticchange.

CONCLUsION

Itcanbeconcludedfrompresentstudythatfollowingasingleapplication,METandpassivestretchinggroupsindividually showed highly significant improvementin hamstring extensibility immediately and still onehourafteran interventionbaseduponAKEandBSSRtests. While comparing both groups, improvement inhamstringextensibilityimmediatelyandonehourafteran intervention ismore inMETgroupascompared topassive stretching group although difference was notsignificant. So MET is superior to passive stretching

in terms of hamstring extensibility and perception ofstretching pain seems to be less inMET than passivestretching hencemore comfortable.Those involved inflexibilityprogramme likebeforegoing for any sportsto get immediate and sustained effect at least up to 1hour and in clinical situation to choosemoreeffectiveandmorecomfortableinterventionevenbyonlysinglesession,METcanbeusedasanadjuvanttotheirnormaltrainingprotocolratherthanusingpassivestretching.

Conflict of Interest:NoneDeclared.

source of Funding:Nil.

Ethical Clearance:Informedwrittenconsentsweretakenfromallvolunteerparticipantsofthestudy.

REFERENCEs

1. Warrel TW: Factor associated with hamstringinjuries.Anapproachto treatmentandpreventivemeasures.SportsMed1994;17:338-345.

2. Benjamin PJ, Lamp SP: Understanding SportsMassage.HumanKinetics,Champaign,IL,1996.

3. AmericanPhysicalTherapyAssociation:GuidetoPhysicalTherapistPractice,ed2.PhysTher2001;81(1):1–768.

4. BandyW,IrionJ,BrigglerM:Theeffectofstaticstretch and dynamic range ofmotion training ontheflexibilityof thehamstringmuscles. JOrthopSportsPhysTher1998;27(4):295–300.

5. WaseemM,ShibiliN,RamCS.EfficacyofMuscleEnergyTechniqueonhamstringmusclesflexibilityinnormalIndiancollegiatemales.CalicutMedicalJournal2009,7:e4.

6. GreenmanP,(WilliamsandWilkins).Principlesofmanualmedicine,2ndedn,Baltimore,1996.

7. Ballantyne F, Fryer G, McLaughlin P. Theeffect of muscle energy technique on hamstringextensibility: themechanismofalteredflexibility.Journal of Osteopathic Medicine. 2003; 6(2):59-63.

8. Taylor DC, Brooks DE, Ryan JB. Viscoelasticcharacteristicsofmuscle:passivestretchingversusmuscular contractions. Medicine & Science inSport&Exercise.1997;29(12):1619-24.

9. Fryer G. Muscle energy concepts - a need forchange. Journal of Osteopathic Medicine. 2000;3(2):54-59.


10. Chaitow,L:MuscleEnergyTechniques.ChurchillLivingstone,NewYork,1996.

11. Fryer G, Ruszkowski W. The influence ofcontraction duration in muscle energy techniqueapplied to the atlanto-axial joint. Journal ofOsteopathicMedicine2004;7(2):79-84.

12. Kieran O’ Sullivan, ElaineM, DavidS. Theeffect of warm-up, static stretching and dynamicstretching on hamstring flexibility in previouslyinjured subjects. MC Musculoskeletal Disorders2009;10;37.

Influence of Early Physiotherapy Intervention on Pain, Joint Range of Motion and Quality of Life in Unilateral Hip Joint

Replacement surgery

Anupriya sahu1, K senthil Kumar2, s Raghava Krishna3, K Madhavi4 1PG -Masters in Physiotherapy (orthopaedics), 2Asst. Professor, 3Lecturer, 4Professor,

College of Physiotherapy, SVIMS, Tirupathi, Andhra Pradesh

AbstRACt

background: Joint replacement surgery is procedure that has increasinglybeenperformed intending toimprovequalityoflifeforthepopulationlivingwithorthopaedicscondition.Inthejointsofthelowerlimb,thekneejointismostlyreplacedandnextisthehipjoint.Recentlythehipjointreplacementiscommonlyreplacingwithinternalprosthesisinelderlyindividuals,topreventthecomplication.Nowaday’sTHRIsthemostcommonsurgeryinthegeneralpopulation.AccordingtopreviousrehabilitationprogramofTHR,ambulationstarts6thor7thdayofsurgery,whichcouldnotabletopreventthepost-operativecomplicationssuchaspulmonaryembolism,urinary retention,bloodclotting,DVTafterTHR.For reducing thepost-operativecomplicationsandtoimprovethefunctionalactivityandQOL,wewillambulatethepatientson3rdpost-operativeday

Methodology: 32subjectswiththeunilateralTHRweretakingforthestudyanddividedintotwogroups.Group1wereambulatingwithin the3rddayof the surgeryandGroup2wereambulatingon7th dayofsurgery.PainwasmeasuredwithVAS,ROMismeasuredfromgoniometerandQOLismeasuredwiththeWOMACscore.

Results: Resultsoftheearlyambulationon3rddayisshowingthesignificantimprovement(p<0.05)ofpost-operativepainandQOLoftheunilateralTHRsubjects.

Conclusion: Onthebasisofabovestudyweconcludedthatearlyambulationwithin3rddayofsurgerywillmakedifferenceinQOLandfunctionalstabilityfollowingunilateralTHRsubjects.

Keywords: Total hip replacement, avascular necrosis, Quality of life.

Corresponding author : K senthil Kumar, MPT(ORTHO),MIAP,Asst.Professor,CollegeofPhysiotherapy,SVIMS,Tirupati,AndhraPradesh

INtRODUCtION

Thehipjointisaballandsocketverityofsynovialjoint;itiscomposedoftwolargebones,theinnominateboneofthepelvisandthefemur.

Hip motion is essential to many daily activities,including rising from a chair or toilet, picking upsomethingfromthefloor,walking,andclimbingstairs.Normal walking utilizes approximately 20”–30” offlexion, reaching a maximum at about initial contact.

Stair climbing utilizes more, approximately 45”–65”and slightly less for stair descent.Rising froma chairtypicallyrequiresmorethan100”ofhipflexion,usuallymoreamountofflexionusedwhenbendingtotieashoeorsquattingtopickupsomethingfromthefloor.4

The articular cartilage of the femoral head andof the acetabulum is among the thickest in the body.Reportedthicknessesrangefrom0.7to3.6mm,withthegreatestthicknessesusuallyfoundintheanterosuperioraspectoftheacetabulum.[4]Theacetabularandfemoralarticular cartilage surfaces exhibit small incongruitiesin shape, thickness, andstiffness,whichmay facilitatecartilage lubrication and chondrogenesis. They mayalsocontributetodegenerativechangesofthearticular

DOI Number: 10.5958/0973-5674.2018.00006.0


cartilage.4

As a synovial joint, the hip is supported by asynovialcapsulethatisattachedtothebonyrimoftheacetabulumproximallyandtotheintertrochantericcrestand line of the femur distally. The capsule of the hipjoint is composed primarily of fibres running parallelto its length, the longitudinal fibres. It also possessesa band of fibres oriented circumferentially around thecanter of the femoral neck. This bundle is known asthe zona orbicularis, or femoral arcuate ligament.Thecapsuleenclosesmostofthefemoralneckandtheentirefemoral head. The blood supply to synovial joints isgenerally provided by a network of blood vessels, oranastomoses,attheattachmentofthecapsuleandbone.Theprimarybloodsupplytothefemoralheadandneckarises from the medial and lateral circumflex femoralarteriesatthebaseofthefemoralneckthatthentravelproximallywithinsynovialfoldsofthecapsulereflectedontothefemoralneck.

Disruption of the hip joint capsule at the base ofthefemoralneckorinjurytotheneckitselfmaydisruptthebloodsupplyofthefemoralheadandendangertheintegrity of the head itself. A serious potential sequelof a femoralneck fracture is avascularnecrosisof thefemoralhead,whichcanresultwhenthefemoralheadisseparatedfromitsbloodsupplyinthefemoralneck.When the displacement of the femoral neck is severeor when the time between injury and intervention isseveral hours or more, the risk of avascular necrosisincreases. In such cases, the orthopaedic surgeonmaychoose to perform a partial or total joint replacement(arthroplasty)ratherthantrytorepairthefracturewithpinsorscrewsArthroplastyisparticularlyadvantageouswhenthefracturecannotbereducedreadilyorwhenitoccursinafrailpatient.Incontrast,intertrochantericandsubtrochanteric fracturespresentconsiderably less risktothevascularsupplybecausethecapsuleandfemoralneckand,consequently,thebloodsupplytothefemoralhead areusually spared.Therefore, these fractures aremoreamenabletotreatmentbyinternalfixation.12

There are different approaches for the total hipreplacement surgery that is anterior approach, lateralapproach, posterior approach, anterolateral approach,posterolateral approach and medial approach.Conventional THR surgery already provides excellentpain relief, functional improvement that minimallyinvasive. Total hip replacement will result in reduce

soft tissue trauma, reduce post-operative blood loss,decrease pain, shorter hospital stay, speeder recoveryandimprovedcosmeticapproach.

The most frequent complication after THR isthromboembolicdiseaseincludingdeepveinthrombosisandpulmonaryembolism.EarlyinthehistoryofTHRthe rate of total pulmonary embolismwas 15% to 22%.However at that timepatientwerekept atbed restforaslongas2to3weeksandkeptaslongas6weeksin the hospital. Early mobilization of the patient hasundoubtedlycontributed to the significant reduction intherateoffatalpulmonaryembolism.

Total hip replacement is the common operationtoday. Approximately 250000 replacements areperformed each year in India. The primary goal ofhipreplacementsurgeryis torelivepainwhichcanbeaccomplishedinmorethan95%ofpatients.TheresultofTHRcanlastapproximately15yearormore.Infactonestudyfoundthatmorethan90%ofTHRsurvivedaminimumof30year.InTHRboththesocket&theballarereplacedwithmetal&plasticpartcupcementedontotheboneorbyamentalshellimpactedintothepreparedacetabular space with a removable liner. The ball isreplacedbyametalballattachedtostemthatgoesinsidetheshaftofthefemur.3

In this present study physiotherapy managementgoalof theTHRpatient is1)Todecreasepain,2)TorestorehipandkneeROM,3)Toregainstrengthofhipmuscular. Physiotherapy management did with threestages:StageIincludeday1to3,StageIIincludesday4to9,StageIIIincludeday10to15.Afterthe15daysprotocol,patientdischargedfromthehospital&homeprogramtaughtpatients.

Patient can start ambulation within the 3rd dayof the surgery, which is beneficial for preventing thecomplicatedafter thesurgery&alsobeneficial for thelesshospitalstay&goodqualityoflife.

Themain objectives of this study are to evaluatetheeffectivenessofearlyphysiotherapyinterventiononpain(VAS)inunilateralTHRsubjects,toevaluatethe

EffectivenessofearlyphysiotherapyinterventiononactiveROMofhipinunilateralTHRsubjects,toevaluatetheeffectivenessofearlyphysiotherapyinterventiononfunctionalactivityinunilateralTHRsubjects,toevaluatetheeffectivenessofearlyphysiotherapyinterventionon


Intervention: Allsubjectsassessedpre-operativelyand post-operatively in the hospital. They receivedpost-operative rehabilitation program and dischargedwithhomeexercisesprogramfollowing8to15daysofhospitalstay.Allthesubjectsweredividedinto2groups.Group 1 ambulated on 3rd day of surgery and Group2 ambulated on 7th day of surgery. This rehabilitationprogram involves ROM exercise & isometricstrengtheningexercisesforthehipmusculatureaswellas encouraging walking with appropriate gait aids.Patientattendedpreoperativesessionsandpostoperative6 days/week for 12 days then encouraged to performhomeexercisedaily.Patientinstructed1)atthedayofsurgerytoavoidhipflexion90⁰,avoidinternalrotationoflowerextremity,avoidcrossingtheleg,avoidsittingonlowchair,performonlybedmobility.2)Onday1st to3rdallhipandkneemusclesisometrics,anklepump,abduction & adduction isometrics, Thomas stretchlonely for1-2day.3)From3 to7daysall isometrics&ambulationwithwalkersupportsstationarybicyclingexerciseswithahighseats.4)From2-6week’sactionhipflexion.5)From6-12weekshomeexercisesprogramstarted.Subjectswereevaluatedpreoperativelyandpost-operatively.WeassessedpainwithVASscore,rangeofmotionwithgoniometerandQOLwithWOMECscore.

stAtIstICAL ANALYsIs AND REsULts

Statistical analysis was done by the use of IBNSPSS statistics 22.0 software. Analysis was done bypairedsamplettesttofindouttheanalysisofpainandQOLpost-operatively.Allthe32subjectswerereceived6 weeks rehabilitation program. Pain and QOL wereanalysed.

QOLinunilateralTHRsubjects.

MAtERIALs AND MAtHOD

In our study we used inch tape to measure theleg length and 180” goniometer tomeasure the rangeof motion of hip. This is the experimental study todetermine thequalityof life.Simple randomsamplingisuseforpreventingthebiasinselectingwhichsubjectsunderwent forTHRsurgery.Subjects provided signedinformed consent and either approval was receivedfromBIRRD (Balaji institute of surgery, research andrehabilitation for disabled). Total 50 subjects wereselectedforthestudy,7subjectscomplainedmorepain,5 subjects excludedbecause of delayeddrain removal(4thday),4subjectswereafraidtowalkand2subjectshadhipdislocation,sototal32patientshavebeentakenfor rehabilitation, which was divided into two groups(n= 16). Subjects were age between 40-65 years ofage; both males and females were included for thestudy.32subjectshavebeentakenforthisexperimentalstudy.Subjectswhowere1stdiagnosedAVN;afterthefracture,anymetabolicdisorder,inflammatoryarthritisandOsteonecrosiswereincluded.Posttraumaticarthritis,Infection of hip, Significant neuromuscular disease,Malignancy,RevisiontotalhipreplacementsurgeryandHistoryofcontralateralTHRwereexcluded.

Algorithm showed consent study population:

tAbLE 1: Comparison of pain in Group 1 and Group 2 on 3rd pop day and 7th pop day

Pain N Mean SD Std.Error df t value p value

3rdday(Group1) 16 5.188 .6551 .1638

15 18.013 .0003rdday(Group2) 16 8.250 .6831 .1708

7thday(Group1) 16 2.313 .8732 .2183

15 6.343 .0007thday(Group2) 16 3.938 .7719 .1930


Forgroup1showsthereissignificantreductioninpainon3rdand7thpopdaythatis5.188±0.65and2.313±0.87.Forgroup2showsthereissignificantreductioninpainon3rdand7thpopdaythat is8.250±0.68and

3.938±0.77.On3rddaygroup2showsmorepainthangroup1thatis8.250±0.68andon7thdaygroup2showsmorepainthangroup1thatis3.938±0.77.

tAbLE 2: Comparison of QOL of Group 1 and Group 2

QOL n Mean sD std. Error df t value p value

Group1 16 32.875 0.8062 0.2016

15 35.825 .000Group2 16 41.813 0.9106 0.2276

Analysis shows significant improvement of QOL(Qualityoflife)ingroup1thangroup2thatis32.875±0.80and41.813±0.91.

Hencewefoundthat,weambulatedpatientwithin3rd day, so functional activity of the patient improvedwhichimprovedtheQOLofunilateralTHRsubjects.

DIsCUssION

Theprescribedexerciseprogramwaseffective fortheTHRpatients in this study.All outcomemeasuresimproved with the majority showing significantimprovement by the end. According to Jackson E etal (2004) an 8-week, hip-exercise intervention, duringwhich the control group received basic isometric andactive range of motion exercises; the experimentalgroupreceivedstrengthandposturalstabilityexercises.An exercise program emphasizing weight bearingand postural stability significantly improved musclestrength,postural stability, and self-perceived functioninpatients4 to12monthsafterTHA.HelenJ.Gilbeyetal(2001)saidthatrandomizedstudywastoapplyan8-weekcustomizedexerciseprogramtopatients(GroupE) scheduled for total hip arthroplasty, followed by apost-surgeryexerciseprogram,andshow theeffectonfunctional recovery compared with control subjects(GroupC)whoreceivednoadditionalexerciseapartfromroutinein-hospitalphysical therapy.Strength,rangeofmotion,andphysicalfunctiontestswerecompletedby57patientsatWeek8andWeek1beforesurgeryandatWeeks3,12,and24postoperatively.Nodifferencesbetweentheexerciseandcontrolgroupswereobservedatbaseline.

Present study is carried out using unilateral THRsubjects.Total number of subjects is 32; age group is40yearsto65yearswhichdividedinto2groups.Group1ambulatedwithin3rddayandGroup2ambulatedon

7th day of surgery. It showed that there is significantdifference between group 1 and group 2 on 3rd and7th pop day in pain and quality of life of the patientwho underwent unilateral THR surgery. In this studypreoperativeassessments (pain, limb lengthandQOL)of the patients have been done and post operativelyassessment (pain, limb length, ROM and QOL) andrehabilitation program have been started 1st post-oerativedayofsurgery.Exerciseshelpedtoreducepainby increasing the local blood circulation, which helptoremove thewestproductsandreducingpain,whichmeasured by VAS scale. In present study prescribedisometricexercisesofquadriceps,hamstrings,abductorsandadductorshelpedtoreducepainandincreaseROMofhipjoint.ActiveassistedROMexercisesforhipandkneeperformedinbothsupineandsittingposition.Gaittraining program started for group 1within 3rd day ofsurgeryandforgroup2on7thdayofsurgery.Whenweambulatedpatentson3rddayofsurgerythenitimprovedthefunctionalactivityandqualityoflifeofpatientsanditreducedhospitalstay.StatisticalanalysisshowedthereissignificantimprovementinQOLofgroup1.Alltheexerciseprogramshavebeenstartedwithin thedayofsurgery and have been progressed till the dischargedday.6weeksprotocolhasbeenfollowedforallpatients.Atthetimeoffollow-upallpatientshavebeenadvisedforhomebasedexerciseprogram.

CONCLUsION

Onthebasisofabovestudyweconcludedthatearlyambulation following surgery will make difference inQOLandfunctionalstabilityfollowingunilateralTHRsubjects. Therefore for the improvement of functionalactivity and QOL, early ambulation within 3rd post-operativedaywouldbethechoiceoftreatment,whichreducedthehospitalstay.


LIMItAtION:

• Studyisheterogeneous.

• Smallsamplesize.

• Studydurationwasshort.

Conflict of Interest–Nil

source of Funding-Self

REFERANCE

1. AlanGrahamApley,ninthedition,Apley’sSystemofOrthopaedicsandFracturespublishedin2010.

2. Gonzalez Saenz de Tejadaet al. “A prospectivestudy of the association of patient expectationswith changes in health-related quality of lifeoutcomes, following total joint replacement.”BMCMusculoskeletalDisorders2014,15:248

3. VivekSharmaMD,PatrickM.MorganMD,EdwardY.ChengMDADVANCEDTECHNIQUESFORREHABILITATION AFTER TOTAL HIP ANDKNEE ARTHROPLASTY,” Factors InfluencingEarlyRehabilitationAfterTHA.”ClinOrthopRelatRes(2009)467:1400–1411DOI10.1007/s11999-009-0750-9

4. Devid J.Magee, 4th edition, orthopaedicphysicalassessment.

5. Damien Bennett, David S Elliott ClinicalRehabilitation “Comparison of earlypostoperativefunctional levels following totalhipreplacement using minimally invasiveversusstandard incisions. A prospectiverandomizedblinded trial.” · September 2005 Impact Factor:2.24·DOI:10.1191/0269215505cr890oa·Source:PubMed.

6. Peters,CL.et al “Theeffectofanewmultimodalperioperativeanesthetic regimenonpostoperativepain, side effects, rehabilitation, and length ofhospitalstayaftertotaljointarthroplasty.”.(2006),J.Arthroplasty21,132-138.

7. SmJavadMortazavi, Patricia Hansen, Reads,“Hematoma Following Primary Total HipArthroplasty: A Grave Complication.” October2012with3,183

8. Larsenetal.2008“Acceleratedperioperativecareand rehabilitation intervention for hip and kneereplacementiseffective:Arandomizedclinicaltrialinvolving87patientswith3monthsoffollowup.”ActaOrthopaedica.(2):149–159.

9. HelenJ.Gilbey,PhD;TimothyR.Ackland,PhD;AllanW.Wang,MBBS; Alan R.Morton, EdD;“Exercise Improves Early Functional RecoveryAfter Total Hip Arthroplasty.” CLINICALORTHOPAEDICSANDRELATEDRESEARCHNumber408,pp.193–200,2001

10. GaleaMP,LevingerP,LythgoN,CimoliC,WellerR,TullyE,McMeeken J,WesthR.ArchPhys.”A Targeted Home- and Center-Based ExerciseProgramforPeopleAfterTotalHipReplacement:A Randomized Clinical Trial,” Med Rehabil2008;89:1442-7

11. Barone A, Giusti A, Pizzonia M, Razzano M,Oliveri M, Palummeri E, Pioli G. “FactorsAssociated With an Immediate Weight-Bearingand EarlyAmbulation Program forOlderAdultsAfter Hip Fracture Repair.” Arch Phys MedRehabil2009;90:1495-8.

12. Elizabeth M. Villalta, BPhys,a Casey L. Peiris,“Early Aquatic Physical Therapy ImprovesFunctionandDoesNot IncreaseRiskofWound-Related Adverse Events for Adults AfterOrthopedic Surgery: A Systematic Review andMeta-Analysis.” PhysArchives of PhysicalMedicineandRehabilitation2013;94:138-48

13. MaryP.Galea,PazitLevinger“ATargetedHome-and Center-Based Exercise Program for PeopleAfter Total Hip Replacement: A RandomizedClinicalTrial.”,August2008Volume89,Issue8,Pages1442–1447,

14. TobyO.Smith,CharlesJ.V.Mannb,AllanClark, Simon T. Donell, “Bed exercises followingtotal hip replacement:a randomised controlledtrial.” Orthopaedic Physiotherapy Research Unit,PhysiotherapyDepartment,Norfolk andNorwichUniversityHospital,ColneyLane,NorwichNR47UY,UKPhysiotherapy94(2008)286–291

15. Trudelle-Jackson E, Smith SS. “Effects of alate-phaseexerciseprogramaftertotalhiparthroplasty:arandomized controlled trial.” Arch Phys MedRehabil2004;85:1056-62,

Gender Difference in Physical Performance tests with in the Individual with Normal body Mass Index

K Kalaiselvi1, Mahendran P2, biswajit Debnath3

1Asst.Prof, 2Principal, 3Final year BPT Student, Acharya Institute of Health Sciences, College of Physiotherapy, Bangalore, Karnataka

AbstRACt

background: Health-relatedphysicalfitness(HRPF)isconsideredtobeanindirectmarkerofaperson’shealthandwellbeingreflectingtheinterplayandintegrationofmanypersons’systemsandbodyfunctions(musculoskeletal,cardiorespiratory,hemato-circulatory,psychoneurologicalandbodycomposition).UnderstandingtherelationshipbetweenBMIandHRPF,measuredbyvalidandreliabletests,willprovidekeyinformationtoaidthedesignofstrategiestoreducetheprevalenceofcardiometabolicriskfactorsamongchildrenandadolescents.

Purpose:Thepurposeofthestudyistocomparethegenderdifferenceinphysicalperformancetestswithintheindividualswithnormalbodymassindex.

Method: ThedataneededforstudyiscollectedfromAcharyacollegestudentsandtheresearchapproachadoptedisonetimestudy.Theresearchapproachincludescollectionofdatafrom80studentsonthebasisofinclusionandexclusioncriteria.

Results: Results show a significant difference in the physical performance test performed bymale andfemale students.Male students performedbetter than female students on the basis of timewith normalBMI.

Conclusion: ThepresentstudyshowsthatmalestooklesstimetoperformthephysicalfitnesstestwhencomparedtofemaleirrespectiveofnormalBMI.

Keywords: Health related physical fitness (HRPF), Body composition, physical fitness, physical performance, BMI.

Correspondence:Prof. Dr. Mahendran.P, Principal,AcharyaInstituteofHealthSciences,CollegeofPhysiotherapy,Bangalore,Karnataka.E-mail:[email protected]

INtRODUCtION

Body Mass Index (BMI) is a simple index ofweight-for-height that is commonly used to classifyunderweight, overweight and obesity in adults. It isdefinedastheweightinkilogramsdividedbythesquareoftheheightinmeters(kg/m2)1

Physicalactivityisdefinedasanybodilymovementproduced by skeletal muscles that result in energyexpenditure. Physical activity in daily life can be

categorized into occupational, sports, conditioning,household, or other activities. Physical fitness is a setofattributesthatareeitherhealth-orskill-related.Thedegree to which people have these attributes can bemeasuredwithspecifictest.2

Understanding the trendsofoverweightorobesityandunderweightinadolescentsisimportant,becauseitis associatedwith adverse effects onhealth and socialrepercussion in both adolescence and adulthood. Itis suggested that adolescence is a crucial period oflife, since dramatic physiological and psychologicalchanges take place at these ages as it may constitutethelastpossiblegrowthspurt3.Duringthisstageoflifethe development of physiological health risk factorsdependslargelyontheinitiationofhealth-compromising

DOI Number: 10.5958/0973-5674.2018.00007.2


behavior such as poor eating and inactivity 4. Studiesduring adolescencewould add support to the primaryassumptionsgivenforearlyinterventionstopreventriskfactorsofnon-communicablediseasesbeforebehavioralpatterns are fully established and resistant to change5. The consequences of the adverse health effects ofunderweightandobesityarelikelytobethedevelopmentof hypo kinetic diseases such as hypertension, cancerandType IIdiabetes aswell as reducedhealth-relatedphysicalfitness6.

Excessivefatness(determinedbybodymassindex(BMI) - a useful surrogate of percentage body fat) isfound to be negatively associated with performancetasks in which the body is projected through space,as in standing broad jump, and on tasks inwhich thebody must be lifted in space, as in bent arm hang 7. Consequently, hypokinetic diseases as well as poorphysicalfitnesshavethepotentialtoplaceconsiderablefuture burden on spiraling health costs and services 8. As such, early identification of adolescents at risk isessentialforpreventionofadulthoodobesity9.

Severalhealth conditions anddisordershavebeenattributedtobeingoverweightinchildrenandadolescents.For instance, overweight children and adolescents aremore likely to suffer from cardiovascular, metabolic,pulmonary, skeletalorpsychosocialdisorders.Even iftheseconditionsordisordersarenotmanifestedduringchildhood, being overweight in childhood increasesthe riskof illness in adulthood.Hence, it is critical toidentify risk factors for overweight in children andadolescentsandtoaddressoverweightduringchildhoodandadolescence.10

According to Bouchard et al. 11, both the familyenvironment and genetic predisposition influence thedevelopment of body fat content and distribution.Otherimportantfactorsincludelifestylefactorssuchasphysical activity (PA), nonsmoking, high-quality diet,sedentaryactivitiesandnormalweight.Lifestylefactorsarealsoimportant inthedescriptionof theobesogenicenvironmentthatisbasedonthefourpillarsfamily,sportandleisuretime,eatingbehaviorandsocialeducation12.

A flight of stair climbing also called a stairway,staircase,stairwellor juststair-does thesimple jobofdividing large vertical gaps into smaller vertical gapscalledsteps.Maximumcardiopulmonaryexercise testareincreasinglyusedtoassesstheaerobiccapacityofan

individuallikethestairclimbingtest.13

Hexagon agility test is a test of the abilityto move quickly while maintaining balance. This test is suitable for active athletes but not forindividuals where the test would be contraindicated.Reliability will depend upon how strict the test isconducted and the individual’s level of motivation toperformthetest.14

50feetWalkTestiswidelyusedandwell-definedmeasuringmethodtomeasurephysicalfunctioninmanydiseases.Theyarerecommendedforuseprospectivelyas outcomemeasures in research, and also in clinicalpracticetomaketreatmentdecisionsbasedontheresultsandtomonitorphysicalfunctionof individualpatientsovertime.15

MEtHODOLOGY

Population : 80studentsagedbetween18–25years

sample size :80students(40boysand40girls)

sampling method : convenientsampling

Research design: onetimestudy

study duration : onemonth

study setting : From Acharya Institute of HealthSciences

tools used in this stud : Chalkpiece

Inchtape,Stairs

Stationary(pen,paper,eraseretc.).

Stopwatch/Timer.

Weighingmachine

Staturemeter

Inclusion criteria : Agegroupbetweenand18-25years.

RegardlessofnormalBMI

Gender-both(boysandgirls)

Thosewhoarewillingtodo

Exclusion criteria: Athletes.

Anyfracturecases.

Cardiopulmonarydisease

Thosewhoarenotwillingtodo

Obesepersons

Outcome measures: Bodymassindex

Procedure

80subjectswereselectedonthebasisofinclusion


and exclusion criteria from Acharya College ofphysiotherapy.

Thestudypopulationconsistedofagegroup18to25years.Amongthe80subjects40weremalestudentsand40werefemalestudents.

Height (meter) and weight (kilogram) of eachindividualstudentwasnotedtocalculatetheBMI(18-25kg/m2).TheindividualswithnormalBMI(40malesand40females)wereselectedforthestudydependinguponinclusionandexclusioncriteriaandwereexplainedabout theprocedureof the study.After explaining thesubject about the physical performance test , writtenconsentwastakenfromsubject.Subjectsweredividedinto 4 groups viz. Group A, Group B, Group C andGroupD.Eachgroupconsistsof20students(10malesand 10 females). In the firstweek, datawas collectedfrom Group A, respectively second, third and fourthweekdatawas collected fromGroupB,GroupC andGroup D. Subjects were demonstrated the physicalperformance test to be performed and time taken toperformeachtestwasnotedinseconds.

PHYsICAL tEsts

1. 50 FEEt walk test

• Adistanceof50feethastobemarkedonastraightandplaneground.

• Askthesubjecttowalkasfastashe/shecanbutdonotrun.

• Timeisnotedbyusingastopwatch.

2. One flight stair climbing test

• Oneflightofstairs(10steps)wasselectedinsidethecollegecampus.

• Subjectswereinstructedtoclimbupthestairsandcomedownwithoutanystopinbetween.

• Clearinstructiontothesubjectweregivenregardingnottotouchthehandrailsortakeanysupport.

• Timeisnotedusingastopwatch.

• Stairmeasurement–1.Treed:26cm

2.Raiser:14.5cm

3. Hexagon test

• A hexagon is made on the plane surface with alengthof2feeteachside.

• The subject was instructed to stand inside thehexagon.

• Jumpoutandintillallthesixsideofthehexagonarecoveredinaclockwisefashion.

• Timeisnotedusingastopwatch

REsULts

Thestudyincluded80subjectswithboththesexes(male and female) to compare the physical fitness inyoungadultswithinnormalBMI.

No adverse effects were observed .All theparticipants completed the physical tests and showedsignificantdifference.

DAtA ANALYsIs

SPSSV.16.0Software

Excel has been used to generate bar diagram andtables

Pairedt-table

tAbLE 1: Analysis of 50 feet walk test

Pair 1 Mean n std. Deviation std. Error Mean

Male 7.3725 40 .75277 .11902

Female 7.8550 40 1.01121 .15989

Paired samples testPaired Differences

t df Sig.(2-tailed)Mean Std.Deviation Std.Error

Mean

95%ConfidenceIntervaloftheDifference

Lower Upper

Pair1MaleFemale

-.48250 1.17034 .18505 -.85679 -.10821 -2.607 39 .013


T-Testvalueis-2.607andpvalueis0.013whichislessthan0.05.

Thepislessthan0.05whichisstatisticallysignificantandindicatesbetterphysicalperformanceamongmaleswhencomparedtofemales.

table 2: Analysis of one flight stair climbing test

Paired samples statistics

Mean N Std.Deviation Std.ErrorMean

Pair1male 7.2200 40 .68433 .10820

female 8.1550 40 1.29812 .20525

Paired samples test

Paired Differences

t df Sig.(2-tailed)Mean Std.

DeviationStd.ErrorMean

95%ConfidenceIntervaloftheDifferenceLower Upper

Pair1MaleFemale

-1.03000 1.25498 .19843 -1.43136 -.62864 -5.191 39 .000


Thepislessthan0.05whichisstatisticallysignificantandindicatesbetterphysicalperformanceamongmaleswhencomparedtofemales

tAbLE 3: Analysis of hexagon test

Paired samples statistics

Mean n std. Deviation std. Error Mean

Pair1

MaleFemale

6.7150 40 .76109 .12034

7.7450 40 1.25493 .19842

Paired samples test

Paired Differences

t df Sig.(2-tailed)Mean Std.

Deviation Std.ErrorMean

95%ConfidenceIntervaloftheDifference

Lower Upper

Pair1malefemale

-1.03000 1.25498 .19843 -1.43136 -.62864 -5.191 39 .000


Thepislessthan0.05whichisstatisticallysignificantandindicatesbetterphysicalperformanceamongmaleswhencomparedtofemales.


50 feet walk test: One flight stair climbing test Hexagon test

DIsCUssION

Thepurposeofthestudyistocomparethegenderdifference in physical performance tests within theindividualswithnormalbodymassindex.

80studentswererandomlyselectedamongwhich40aremaleand40arefemale.EachindividualperformedthreephysicaltestsandtimewasnoteddowninsecondsalongwiththeirheightandweightinordertocalculatetheBMI.

F. Gashi , R. Ahmetxhekaj , E.Gara, B. Hoxie,Z. Durguti, I.Shalaj studied the gender difference ofphysical performance test and its relation to bodycomposition in adolescents andobserved thatphysicalperformancewashigher in boys than in girls.16 Inmystudyalsophysicalperformancetestisperformedbetterbyboyswhencomparedtogirls.

BeekhuizenKS,DavidMD,ColbarMJ,ChengMSstudied test re-test reliability and minimal detectablechange of the hexagon agility test concluded that theevidenceofreliabilityandeaseofadministrationmakesthe hexagon test a practical and effective method tomeasureagility17.InmystudyalsoIusedhexagontestasoneofthephysicalperformancetestasinthistestwithinthenormalBMImalestudentsweredoingbetterthanthefemalesstudentsanditishighlyreliable.

BayramUnver, SerpilKalkan, ErtugrulYuksel,TurhanKahraman andVasfiKaratosun studiedReliability of the 50-foot walk test and 30-sec chairstandtestintotalkneearthroplasty.Accordingtoresultsofthisstudy;both50FWTand30CSThaveexcellentreliability in patients with TKA18. In my study also Iused50feetwalktestasoneofthephysicalperformancetestwheremalestudentsweretakinglesstimecomparetofemalestudentswithinthenormalBMIasitishighlyreliableandeasytoadminister.

Alesssandro Brunelli, MD, Marco Monteverde,MajedALRefaistudiedStairclimbingtestinpredictionof postoperative complications after lung surgery.It was noticed that duration of postoperative periodhas an inverse proportion to a number of the climbedup footsteps and informative enough for prediction ofpostoperativecardiopulmonarycomplicationsafterlungsurgery19.InmystudyIalsousedstairclimbingtestasone of the physical performance test as I have taken10stepsasoneflightofstairsandmalestudentshaveperformed better than the female students within thenormal BMI. It is highly reliablemethod and easy toadminister.

The study is showing significant difference in thetimetakenbymalesandfemalestoperformthephysicalfitnesstest.Femalesaretakingmoretimetoperformthephysical test when compared to males irrespective ofnormalBMI.

CONCLUsION

Thepresentstudyshowsthatmalestookless timeto perform the physical fitness testwhen compared tofemaleirrespectiveofnormalBMI.

Limitations

• Samplesizetakenwassmall.

• Practicebeforethefinaltestwasnotdone.

• Withintheageof18to25manyareobese.

• Manystudentsaresportplayers.

Recommendation

• Furtherstudycanbedoneonlargersamples.

• Similarstudiescanbecarriedoutwithdifferentagegroup.

• A similar study can be done among theindividualssufferingfrompulmonarycomplications.


• Further study must establish the relationshipbetweentheindividualswithnormalandabnormalBMIonthebasisofphysicalfitnesstest.

Conflict of Interest: Nil

source of Funding: Self

Ethical Clearance: Taken from college ethicalcommittee

REFERENCEs

1. WHOexpertconsultation,appropriatebodymassindexforAsianpopulationanditsimplicationforpolicy and interventions strategies .The Lancet,2004;157to163.

2. CarlJCaspersen,PhD,MPH,KennethePowell,MD, MPH, Gregory M Christenson, Phd,PhysicalActivity,Exercise,andPhysicalFitness:Definitions and Distinctions for Health-RelatedResearch,March-April1985,Vol.10.

3. Manama Andriesmonyeki,Rik Neatens ,SarahJ .Moos and JosTwisk; the relationship betweenbodycompositionandphysicaltestin14yearsoldadolescent ,South Africa, The PAH study,2012may24.

4. DepartmentofHealth:SouthAfricademographichealthandhealthsurvey1998.1998,Departmentof Health, Medical Research Council, Pretoria,SouthAfrica

5. Donnelly JE, Smith B, Jacobsen MJ, Kirk MJ,DuboseK,HyderM,BaileyB,WashburnR:Theroleofexerciseforweightlossandmaintenance.BestPractResClinGastroenterol.2004,18:1009-1029.

6. Perry CL, Stone EJ, Parcel GS, Ellison RC,Nader PR, Webber LS, Luepker LV: School-basedcardiovascularhealthpromotion:theChildand Adolescent Trial for Cardiovascular Health(CATCH). J. SchoolHealth. 1990, 60: 406-413.10.1111/j.1746-1561.1990.tb05960.x.

7. Beunnen CL: Biological age in pediatric sportexercise research. Advances in Pediatric SportSciences.1989,HumanKinetics,Champaign,III,USA,III

8. Bovet P, Shamlaye C, Gabriel A, Riesen W,Paccaud F: Prevalence of cardiovascular riskfactorsinamiddle-incomecountryandestimatedcost of treatment strategy. BMC Public Health.2006,6:9-10.1186/1471-2458-6-9

9. Jerum A, Melnyk BM: Effectiveness ofinterventions to prevent obesity and obesity-relatedcomplicationsinchildrenandadolescents.PediatricNurs.2001,27(6):606-610.

10. AnnetteRauner,FilipmessandAlexanderWoll;the relationship between physical fitness andoverweightinadolescent,1feb2013.11

11. Bouchard C, Malina RM, Pérusse L: Geneticsof Fitness and Physical Performance. 1997,Champaign:HumanKinetics

12. WabitschM:ChildrenandadolescentswithobesityinGermany.Call for action.Bundesgesundhbl -Gesundheitsforsch-Gesundheitsschutz.2004,47(3):251-255.10.1007/s00103-003-0795-y.

13. Dobson F, Hinman RS, Roos EM, Abbott JH,Stratford P, Davis AM. OARSI recommendedperformance-based tests to assess physicalfunction in people diagnosed with hip or kneeosteoarthritis.Osteoarthritis Cartilage.2013; 21(8):1042–1052.

14. Jones CJ, Rikli RE, Beam WC. A 30-s chair-standtestasameasureoflowerbodystrengthincommunity-residing older adults.Res Q ExercSport.1999;70(2):113–119.

15. NoahAbdelKaderAbdelKaderHasan,HebatallahMohamed Kamal, Zeinab Ahmed HusseinRelationbetweenbodymassindexpercentileandmusclestrengthandendurancejournalhomeVol17,No4(2016)

16. F.Gashi,R.Ahmetxhekaj ,E.Gara ,B.Haxhiu,Z.Durguti,I.Shalaj.Estimatedbodycompositionand strength, and motor performance ofchronologically undernourished rural boys inSouthMexico;pp.119–132June,2014.

17. BeekhcuizenKS,DavidMD,KolberMJ,ChengMS.Testretestreliabilityandminimaldetectablechangeofthehexagonagilitytest.AmJRespirCritCareMed,159(1999),pp.1450-1456

18. BayramUnver, SerpilKalkan, ErtugrulYuksel,TurhanKahramanandVasfiKaratosunReliabilityofthe50-footwalktestand30-secchairstandtestintotalkneearthroplasty.Measuresofreliabilityinsportsmedicineandscience.SportsMed.2000; 30(1):1–15.

19. Alesssandro Brunelli,MD, Marco Monteverde,MajedALRefai.[July3,2012]Stairclimbingtestas a predictor of cardiopulmonary complicationafterpulmonarylobectomyintheelderly.

Effect of Asymptomatic Arm Neural Mobilization in Patients with Cervicobrachial Pain syndrome

Poonam Gupta1, Ganesh balthillaya2, Ramakrishnan Mani3, Ravi s Reddy4

1Assistant Professor, Manav Rachna International University, Sector 43, Faridabad, Haryana, India, 2Assistant Professor, School of Allied Health Sciences, Manipal University, Karnataka, India,

3Senior Lecturer, School of Physiotherapy, University of Otago, Dunedin, New Zealand, 4Assistant Professor, King Khalid University, Gurainger, Abha, Saudi Arabia

AbstRACt

Cervicobrachialpainsyndrome(CBPS)canbecharacterizedbyenhancedmechanosensitivityoftheneuraltissues that can be tested and treated using asymptomatic arm in patients with irritable symptom. Thestudyaimedat examining theeffectofasymptomaticarmneuralmobilizationonelbowextension,painintensityanddisabilityinpatientswithunilateralCBPS.Tenpatientswithmeanageof30.40±10.07mettheeligibilitycriteria.NPRSandDASHquestionnairewereadministeredatbaseline.ULNT1wasperformedonsymptomaticarmandelbowextensiontothepointoffirstpainwasnoted(P1).Holdingsymptomaticarmposition,ULNT1wasperformedonasymptomaticarmandchangeinsymptomaticarmelbowextensionwasmeasured(P1c).Sixsessionsofneuralmobilizationwereadministeredonasymptomaticarmforsixconsecutivedaysandchangeinsymptomaticarmelbowextensionwasmeasuredeveryday(P1m).NPRSandDASHquestionnairere-administeredattheendofsixthsession.Allthepatientsshowedasignificantimprovementinelbowextension(P1-P1cp<0.001andP1-P1mp<0.001)andasignificantdecreaseinpain(NPRSp=0.005)anddisability(DASHp=0.012).Thefindingsofthestudycanbeusedtoformthebasisoffuturestudies.

Keywords: Cervicobrachial pain syndrome, ULNT, Mechanosensitivity, Neural Mobilization

INtRODUCtION

Cervicobrachial pain syndrome (CBPS) is asignificantproblemaffectingmanyindividuals1.CBPSisdescribedasupperquarterpain,thoughunaccompaniedby neurological deficit, enhanced mechanosensitivityoftheupperlimbperipheralnervesmayhavearoleinitspathology2.Upperlimbneurodynamictests(ULNT)are used to identify the involvement of neural tissuein CBPS3,4. While performing these tests, varioussensitizing maneuvers near to or remote from theaffected area can be employed to alter the tension inthenerves4,5,6,7.Amultitudeofmanualphysicaltherapy

Correspondence to:Poonam Gupta, AssistantProfessor,ManavRachnaInternationalUniversity,Sector43,Faridabad,Haryana,IndiaTel-+919958995280;E-mail:[email protected]

treatment techniques have been studied in patientswith CBPS ranging from neural tissue mobilization1

,9,1011,12,13. A specific form of treatment technique hasbeen proposed by Elvey and Hall for patients withCBPS which focuses on passive mobilization of theneural tissues and surrounding structures using gentlecontrolledoscillatorymovements2.

According to the basic principles ofmobilization,one of the criteria on which the choice of treatmenttechniquedepends is symptom irritability14. Irritabilitycanbecommentedonbyvigorofactivity, severityofsymptomsandthetimetakenforthesymptomstoreturntothebaseline14,15.Symptomsinirritableconditionsareusually pain dominant and are of severe continuousquality;henceassessmentandtreatmentoftheaffectedareashouldbecarriedoutwithcaution16.Sinceremotecomponents can alter tension in the nerves4,5,6,7, inirritabledisordertheconceptofremoteareamovementis advisable to confirm the involvement of neural

DOI Number: 10.5958/0973-5674.2018.00008.4


tissue14.InunilateralCBPSwithirritablesymptoms,thechoiceof treatment techniquecanbe as remote as theasymptomaticorcontralaterallimbortowardsthelowerquarterandlegs.

RubenachstudiedthealterationinULNT1responsewhenULNT1wasperformedoncontralateralarmandfound reduction in the test response. He explainedthat this reduction of test response could be due themovement of spinal cord back towards the center ofthe canal thereby releasing the stress on the spinalnerve17.ShacklockproposedadifferentconceptwhichsaysthatthereductionofULNT1responseintheheldarmcanbeduetodownwarddescentofthespinalcordin the spinal canal6. Despite the widespread use ofmovementbasedapproachesforthetreatmentofneuralmechanosensitivityinCBPS,literaturelackstheuseofasymptomatic armneuralmobilization forCBPSwithirritablesymptoms.Therefore,thepurposeofthisstudyis to examine the effect of asymptomatic arm neuralmobilization on elbow extension, pain intensity anddisabilityinpatientswithunilateralcervicobrachialpainsyndrome.

MAtERIALs AND MEtHODOLOGY

The research design was single group pretestposttest experimental study design. Ethical approvalforthestudywastakenfromtheresearchcommitteeofManipal College of Allied Health Sciences, Manipal,Karnataka, India. Consecutive patients with unilateralcervical radicular pain referred to physiotherapydepartment of Kasturba Hospital, Manipal, betweenAugust 2008 and March 2009 were screened forinclusionandexclusioncriteria.Inclusioncriteriawere:unilateral CBPS patients of both genders with elbowextension restricted to minimum of 50o in ULNT1position.Exclusioncriteriawerecervicalradiculopathy,history of cervical myelopathy, fracture of spine andupper limb, deformities of upper limb affecting rangeofmotionofthejointsandothersoft tissueinjuriesofupperlimb.Aconveniencesampleoftenpatients,threemalesandsevenfemaleswithmeanageof37.33±9.29and 27.43±9.43 years respectively, met the eligibilitycriteria and gave their consent to participate in thestudy.Twoself-reportedmeasuresNumericPainRatingScale (NPRS)18 and Disability of Arm, Shoulder andHand (DASH) including work DASH (DASH_W)questionnaire19werecollectedatbaselineformeasuringpainanddisabilityofthesubjects.

Procedure:

Three qualified physiotherapists were involvedin the study: first therapist performed ULNT1 andmaintained the symptomaticupper limb in thedesiredposition,second therapistperformedtheasymptomaticarmneuralmobilizationandthethirdtherapistmeasuredtheelbowextensionrangeofthesymptomaticlimb.

Positioning of the patient (Figure1):

Each subject was positioned in supine lying withtheheadinneutralposition.ULNT1ofthesymptomaticarmwas performed by first therapist in the followingsequence: (1) shoulder girdle depression, maintainedat 60mmHg using Pressure Biofeedback (Stabilizer,Pressure Biofeedback Chattanooga Group, Inc) (2)abduction of glenohumeral joint to 110o (3) forearmsupination (4) wrist and finger extension (5) externalrotation of glenohumeral joint (6) elbow extension tothepointoffirstpainasreportedbythepatient.Amountofelbowextensionattainedwasmeasuredbythethirdtherapist using universal gonimeter (stationary arm ofthe instrument was held along the medial border ofhumerusandmovablearmwasalignedalongthemedialborderofulna,medialepicondylewasmarkedtoactasfulcrum)andrecordedasP1.

Figure1: Positioning of the patient

Asymptomatic arm ULNT1 (Figure1):

The test componentsof theULNT1performedonsymptomaticsideweremaintainedinthesameposition,whileULNT1wasperformedontheasymptomaticarmby the second therapist in the sequence stated above.Elbow of the asymptomatic arm was extended up tothepointoffirstpainasreportedbythepatientorfirstresistancefeltbythetherapist.AssoonasULNT1was


performed on asymptomatic arm, patient was askedto report whether the initial P1 on the symptomaticarmdisappeared.OnthedisappearanceofinitialP1ofsymptomaticarm,elbowofthesamearmwasextendedfurther till the first pain reported by the patient andchangeinelbowextensionwasrecorded(P1c).ProcedurewasnottobecontinuedifpatientsreportedincreaseinpainorP1didnotdisappear.Incidentallyallthepatientsexperienced disappearance of P1 on symptomatic armwhenasymptomaticarmULNT1wasperformed.

Neural mobilization of asymptomatic arm:

Before starting neural mobilization elbowof symptomatic arm was flexed to a point wheresubjects’ symptomswereata tolerable level.Asinglesession of Maitland’s grade IV mobilization usingelbow component of ULNT1 was performed on theasymptomatic arm by the second therapist. Three setsof10repetitionseachwascarriedoutwitharestperiodof10secondsbetweenthesets.Followingmobilization,elbow of asymptomatic arm was extended till firstpainandheldinsameposition.Thefirsttherapistthenextendedthesymptomaticarmelbowtillthefirstpainasreportedbythepatientandelbowextensionvaluenoted(P1m).Sixsessionsofsametreatmentwasgivenforsixconsecutivedaysand respectivevaluesofP1,P1c andP1mwerenoted.Attheendofthesixthsession,NPRSandDASHwerere-administered.

DAtA ANALYsIs

Areaundercurve(AUC)wascalculatedforelbowextensioninMicrosoftExcel2003usingformula20:

n-1AUC=½∑(t i + 1-ti)(y i+yi + 1)* i=0

*n=no.oftimeselbowextensionrangewasmeasured

t=timeinterval

y=elbowextensionrange

i=time(inthisstudy‘oneday’)

AUC is a two staged analysis method. Firstlysummaryoftheresponsesisobtainedbycalculatingareaunder the curve and then summary is analyzed usingsimple statisticalmethods21. In the current study, aftercalculatingAUCforallthevaluesofelbowextension,data obtained (AUCP1, AUCP1c and AUCP1m) wereanalyzed in SPSS (version 11.5) using paired t test.Comparisonwasdonebetween:

1. AUCP1andAUCP1c

2. AUCP1candAUCP1m

NPRS andDASHwere analyzed usingWilcoxonSignedRankTestinSPSS(version11.5).Asignificancelevelof≤0.05wassetforallanalyses18.

REsULts

Atotalof10subjectsmetinclusionandexclusioncriteria and participated in the study. Age, gender,occupation,symptomaticsideand irritabilityofall thesubjectsareshowninTable1.

table1: Demographic characteristics of participants

subjects Age Gender Occupation symptomatic side Irritability

1 21 F Student Right Mild


3 25 F Physiotherapist Right Moderate


5 23 F Physiotherapist Left Moderate

6 45 F BeediWorker Left Moderate

7 33 M Farmer Left Moderate

8 48 M Businessman Right Moderate

9 36 F Housewife Right Moderate

10 31 M Doctor Right Moderate


table3: NPRs and DAsH

Pre treatment Post treatment p

Median IQR Median IQR

NPRS 7.50 5.00-9.00 2.50 1.75-4.00 0.005

DASH 21.53 13.12-41.14 10.78 5.26-15.95 0.012

DASH_W 31.25 14.06-48.43 9.36 1.56-21.88 0.011

Thefigures 3, 4&5 depict the pre-treatment andpost-treatmentNPRSandDASHscoresofeachsubject.Magnitude of reduction in pain differed in differentsubjects. Patients with moderate irritability reportedbetterreductioninpainthanmildlyirritablecases.

Figure3: Pain changes pre and post treatment

Figure2wasconstructedtoillustratedailychangesofP1revealinganimprovementinelbowextensioninallthesubjectsbysixthday.

Figure2: Daily changes in P1

Pain and disability scores:

Two out of ten subjects were admitted, hencepost treatment DASH was not calculated for the twosubjects as they were not able to perform few tasksmentionedinDASH[AccordingtothecriteriaofDASHifmorethanthreeitemsarenotansweredDASHisnotreliable17].DASHscoresfromremainingeightsubjectswere analyzed. The median, IQR and p value of preand post treatment NPRS and DASH are outlined inTable3. Statistically significant decrease inNPRS andDASHwasseenposttreatment(NPRSp=0.005,DASHp=0.012,DASH_Wp=0.011)

Elbow extension range:

Area under curve was calculated to create a summary of P1, P1c and P1m values for all the subjects whoparticipatedinthestudy.PairedttestanalysisofthesevaluesrevealedthatthereisasignificantdifferenceinelbowextensionbeforeandafterintroductionofasymptomaticarmULNT1(p<0.001)aswellassignificantdifferenceisnotedafterasymptomaticarmneuralmobilization(p<0.001)(Table2).

table2: Comparison of AUC for elbow extension:

AUC Mean±sD

95% confidence interval

t pLower Upper

AUCP1-AUCP1c 41.75±8.25 35.85 47.65 16.00 <0.001

AUCP1c-AUCP1m 39.50±17.90 26.69 52.31 6.98 <0.001

Pain Scores

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10

Subjects

Pain Pre NPRS

Post NPRS


Work Option DASH

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10

Subjects

Dis

abili

ty

Pre DASH-WPost DASH-W

DASH

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8 9 10

Subjects

Dis

abili

ty

Pre DASHPost DASH

Figure4: DAsH changes pre and post treatment

Figure5: DAsH-W changes pre and post treatment

DIsCUssION

Although there are numerous studies that haveaddressed the treatment ofCBPS, few studies utilizedneuraltissuemobilizationtechniquesasaninterventionin the treatment of CBPS. Previous researchesinvestigated the effect of either mobilization ofstructuressurroundingtheneuraltissuesorsymptomaticarm neural mobilization1,13,22. This study attemptedto observe the effect of asymptomatic arm neuralmobilization in patients with unilateral CBPS andreported significant improvement in elbow extension,painanddisability.Thisisconsistentwiththefindingsofthepreviousstudiesthathavedemonstratedpositiveeffects of mobilization techniques addressing neuraltissueinCBPSpatients1,13,23.

Previous authors discussed that contralateralULNT1reducesthetestresponseintheipsilateralarmheldinULNT16,17.Inourstudyinspiteofpre-stressingthenervesofsymptomaticarm,allthesubjectsreporteddisappearanceofP1andshowedstatisticallysignificantimprovement in elbow extension after ULNT1

was performed on asymptomatic arm. Followingasymptomatic arm neural mobilization the result ofthis study showed significant improvement in elbowextension, pain and disability. This can be attributedto neurophysiological effects of mobilization24,25. Painalso has cognitive-behavioral aspect which meansthat reduction of pain leads to overall wellbeing ofan individual26. In the current study patients reporteddecrease in disability and increased efficiency whileperforming their daily work due to reduction in painlevels.

Itwasnotpossibletocontroltheuseofanalgesicsand electrical modalities due to ethical considerationsand we acknowledge lack of controlling this as alimitation of the study. Small sample size, stringentinclusion criteria (restricted elbow extension range ofmorethan500),lackofcontrolgroup,singletrialtofindP1andnofollowuparealsoacknowledgedaslimitationsofthestudy.Theclinicalimportancefromthefindingsof this study would suggest that in irritable cases ofCBPSasymptomaticarmcanbeastartingpointforthetreatment.Theresultsofthestudycannotbegeneralizedsince the sample size was less and no randomizationwasdone.Further research in the formof randomizedcontrol trialsshouldbedonetocompareipsilateralvs.contralateral neural mobilization with a larger samplesizeandpatientswithdifferentirritabilitylevels.

CONCLUsION

In this preliminary study all the patients havingunilateral CBPS demonstrated improvement in elbowextension and reduction in pain and disability withasymptomatic arm neural mobilization. Althoughdefiniteconclusioncannotbedrawn, thecurrent studycan form a basis for future studies. Further studies intheformofwell-designedrandomizedcontroltrialswithhigher sample size can be performed to evaluate theeffectivenessofthistreatmenttechniqueinCBPSwithirritablesymptoms.

source of Funding – Self

Conflict of Interest – Nil

REFERENCEs

1. Allison GT, Nagy BM, Hall T. A RandomizedControl Trial of Manual Therapy for Cervical-BrachialPainSyndrome–APilotStudy.ManualTherapy2002;7:95-102


2. Elvey RL, Hall T. Neural tissue evaluation andtreatment.In:DonatelliR(ed.)PhysicalTherapyof the Shoulder, 3rd ed. Churchill Livingstone,NewYork,1997:131-152

3. Elvey RL. Brachial plexus tension tests and thepathoanatomicaloriginofarmpain.In:GlasgowEF,TwomeyL,editors.Aspectsofmanipulativetherapy. Lincoln Institute of Health Sciences,Melbourne,1979:105-110

4. ButlerDS.Mobilizationof theNervousSystem.ChurchillLivingstone1991

5. Lewis J, Ramat R, Green A. Changes inMechanical Tension in the Median Nerve:Possible Implications of ULTT. Physiotherapy1998;84:254-61

6. Shacklock M. Clinical Neurodynamics: A NewSystem of Musculoskeletal Treatment. Elsevier2005

7. Walsh M. Upper Limb Neural Tension Testingand Mobilization: Fact, Fiction and a PracticalApproach.JHandTherapy2005,241-58

8. Butler D, Gifford L. The Concept of AdverseMechanicalTensionintheNervousSystem:Part1 – Testing for ‘Dural tension’. Physiotherapy1989;75:622-29

9. Butler D, Gifford L. The Concept of AdverseMechanicalTensionintheNervousSystem:Part2 – Examination and Treatment. Physiotherapy1989;75:629-36

10. ElveyRL.TreatmentofArmPainAssociatedwithAbnormal Brachial plexus Tension. AustralianJournalofPhysiotherapy1986;32:225-30

11. Coppieters MW, Stappaerts KH, Wouters LL,JanssensK.TheImmediateEffectsofaCervicallateralGlideTreatmentTechniqueinPatientswithNeurogenicCevicobrachialpain.JOrthopSportsPhysTher2003;33:369-78

12. Hall TM, Elvey RL. Management ofMechanosensitivity of the Nervous System inSpinalPainSyndrome.Grieve’sModernManualTherapy,3rded.,ChurchillLivingstone2004:413-31

13. Chhabra D, Raja K, Balthillaya G, Prabhu N.Effectiveness of neural tissue mobilization overcervical lateral glide in cervico-brachial painsyndrome - A randomized clinical trial. IndianJournal of Physiotherapy and OccupationalTherapy2008;2:47-52

14. MaitlandGD.Maitland’sVertebralManipulation,7thed.,Elsevier.2005

15. Barakatt ET, Romano PS, Riddle DL, BeckettLA. The Reliability of Maitland’s IrritabilityJudgments in Patients with Low Back Pain.JMMT2009;17:135-140

16. Butler DS. Adverse mechanical tension in thenervous system: A model for assessment andtreatment.TheAustralianJournalofPhysiotherapy1989;35:227-238

17. RubenachH.TheUpperLimbTensionTest–TheEffect of the Position and theMovement of theContralateral Arm. In: Proceedings of the 4th Biennial

18. CristianaK, JoshuaAC.VisualAnalogueScale,Numeric Pain Rating Scale and theMcgill PainQuestionnaire: An Overview of PsychometricProperties. Physical TherapyReviews 2005; 10:123–8

19. Beaton DE et al. Measuring the Whole or thePart?: Validity, Reliability and ResponsivenessoftheDisabilitiesoftheArm,ShoulderandHandOutcome Measure in Different Regions of theUpper Extremity. J Hand Therapy 2001;14:128-46

20. Portney L, Watkins M. Foundations of clinicalresearch: Applications to practice 2nd ed.Connecticut:AppletonandLange2000

21. Matthews JNS, Altman DG, Campbell MJ,Royston P. Analysis of serial measurements inmedicalresearch.BrMedJ1990;300:230-5

22. Cowell IM, Phillips DR. Effectiveness ofmanipulative physiotherapy for the treatment ofa neurogenic cervicobrachial pain syndrome: asinglecasestudy.ManualTherapy2002;7:31-38

23. Kaye S, Mason E. Clinical implications of theupper limb tension test. Physiotherapy 1989;75:750-752

24. Wright A. Hypoalgesia post-manipulativetherapy:Areviewofpotentialneurophysiologicalmechanism.ManualTherapy1995;1:11-6

25. Pickar JG. Neurophysiological effects of spinalmanipulation.TheSpineJournal2002;2:357–71

26. ButlerDS.TheSensitiveNervousSystem.Unley,SouthAustralia:NoiGroupPublications2000

27. HallTM,ElveyRL.NerveTrunkPain:PhysicalDiagnosis and Treatment. Manual Therapy1999;4:63-7

Correlation between balance and Functional Ability in Elderly: A Pilot study

samuel se1, shaji E P2, suresh b V3

1Professor and Principal,2 Postgraduate Student, 3Professor and Head of the Department, Department of Neurology, Laxmi Memorial College of Physiotherapy, AJ Tower, Balmatta, Mangalore, India

AbstRACt

background & Objectives: Higher-functioningolderadultsrefertoolderadultsaged65yearsandolderwhoareactive,ambulatory,andlivingindependentlyinthecommunity(eg,residentialhomes,independentlivingfacilities,andretirementfacilities).Agingprogressivelyimpairssight,vestibularinput,andsomato-sensoryinformation,whichresultsinareductionofenvironmentalperceptionandprecisionofmovements.Theobjectiveof the studywas tofind the relationshipbetweenbalanceandactivitiesofdaily living inelderlyindividuals.

Methods:Thestudy involved30subjects (community livingand those identified fromoldagehomes),aged65andabove.BalancewasassessedusingBergBalanceScale(BBS)andPhysicalindependenceindailyactivitieswasevaluatedusingtheBarthelIndex(BI).ThePearson’scorrelationcoefficientwasusedtoexaminetherelationshipbetweentheparametersevaluated.Significancewassetatthelevelof5%(p<0.05).

Results: Thepopulation’smeanagewas78.37±6.68years.ThemeanBBSscorewas51.87±4.21,whereasthemeanBIscorewas94.67±7.76.StatisticallysignificantrelationshipswerefoundbetweentheBBSandBI(r=0.678;p=0.000).

Conclusion: Theresultsshowedastrongpositivecorrelation(r=0.678)betweenbalanceandindependencelevel.Resultsfromalargersamplemaybenecessarytocorroboratethefindingsofthepresentstudy.

Keywords: balance, functional ability, elderly.

Corresponding author :-shaji E.P, PostgraduateStudent,LaxmiMemorialCollegeofPhysiotherapy,AJTower,Balmatta, Mangalore-575002,India.

INtRODUCtION

The growing population of the elderly (over 65years of age) has made the understanding of agingprocesstobecomeanecessity.Theincreaseinlifespanhas led to theprevalenceofchronicdiseaseswhich inturnhaveasubstantialimpactonthefunctionalabilityoftheelderlypeopleofthesociety.Functionalabilityisthecompetenceof an individual tohave thephysiologicalcapacity to perform normal everyday activities safely

and independently without under fatigue1. Due to thedecline of sensory and motor resources required forpostural stability the ability to maintain balance iscompromised.Agerelatedproprioceptiveandvestibularlossesassociatedwithrelianceonvisualinputsworsenthe situation. Musculoskeletal impairment along withsensorimotor deterioration contribute to poor posturalcontrol2,3. As the overall number of elderly peopleincrease,thereisacorrespondingriseinthenumberofolderpersonswithdisabilities.Suchdisabilitiesmaybesocial,physical,mentalorpsychological4.

Thepotentialoftheelderlyfordecidingandactingindependentlyintheirdailyactivitiesiscalledfunctionalability5. To be physically active , it is necessary tomaintainbalancefunction6.Reductionorlossofbalance

DOI Number: 10.5958/0973-5674.2018.00009.6


function leads to dependence of activities of dailyliving7,8,9. The reduction in the aerobic capacity andmuscle strength lead to decrease the functional abilitywhichultimatelycauselossofsocioeconomicbalance1. There isgreaterdependenceon the friendsand familyinordertoperformdailytaskssuchasstandingupandsittingdown,crossingtheroad10,11.

According to Jonsson, age-related deterioration ofbalanceorposturalcontrolhasanegativeimpactontheability to safely carry out day-to-day activities12. Theelderlysegmentofthesocietyismorelikelytosustainfractures, develop respiratory complications and otherassociated co-morbidities. Therefore it is necessary toknowtheetiologyofthefunctionaldecline.Sarcopenia-theagerelatedlossofmusclemass,thereducedabilityto interpret sensory information leading to impairedbalance, reduced proprioception all these factorscontribute to reducedmaintenance of balance13,14. Theaimofthepresentstudywastodeterminethecorrelationbetween balance and functional ability in elderlyindividuals.

MetHoD

This cross-sectional study was conducted in oldage homes and out patient clinics of selected tertiaryhospitals.StudyprotocolwasapprovedbyInstitutionalEthics Committee. The study was conducted over aperiod of 1 year. The study population was selectedby purposive sampling method which included 30Community-dwelling elderly individuals with ageof 65 and above, from both genders (18 men & 12women). Inclusion criteria were: subjects referredfor balance dysfunction, BMI ≤ 35, ability to walk20 feet(with or without assistive device), ability to

follow instructions and be independent in daily livingactivities.Theywere excluded if theyhadanyhistoryofneurologicaldisease(e.g.,Stroke,Parkinsondisease)withresidual impairment, unstableor limitingcardiacdisease(e.g.,angina),historyofmyocardialinfarction,coronaryarterybypassorothercardiacsurgerywithinthe previous 6 months, scored less than 24 in theMini-Mental State Examination (MMSE). The studyprocedure was explained and informed consent wastaken fromall thepatients.BergBalanceScale (BBS)and Barthel index (BI) scales were administered andresponsenoteddown.

stAtIstICAL ANALYsIs

Results were tabulated in Microsoft officeexcel and analysed by Statistical Package for SocialSciences (SPSS) version 17.Valueswere recorded asfrequency, percentage, mean and standard deviation.Pearson’scorrelationcoefficientwasusedtodeterminethe relationship between the evaluated parameters.Significancewassetatthelevelof5%(p<0.05).

REsULts

Outof the30elderly individuals studied,18weremenand12werewomenwithameanageof78.4±6.7years and mean BMI of 24.13±2.7. Every participanthad MMSE scores greater than 25(28.3±1.8). Theparticipants’ balance was evaluated using the BergBalance Scale (BBS), and functional independence indaily activitieswas evaluated using the Barthel Index(BI).ThemeanBBSscoreobtainedon thisstudywas51.9±4.2.ThemeanBIscoreobtainedonthisstudywas94.7±7.8.

table 1 : Characteristics of measurement

Descriptive statistics

n Minimum Maximum Mean std. Deviation

AGE 30 65 93 78.37 6.688

BMI 30 20 32 24.13 2.360

MMSE 30 25 30 28.33 1.788

BergBalanceScale 30 42 56 51.87 4.216

BarthelIndex 30 75 100 94.67 7.761

Correlationanalysisondatagatheredfromthecommunitydwellingelderlypeople,showedthat therewasastatisticallysignificantrelationshipbetweenBBSandBIscores(r=0.67;p=0.000),whichwasfoundtobeastrongpositivecorrelation.


table 2 : Correlation between bbs and bICorrelations

L’ test

berg balance scale

barthel Index

MMSE

r -0.117 0.180 0.058

p 0.539 0.341 0.761

N 30 30 30

Bergbalancescale

r 0.678

p 0.000

N 30

Figure 1 : Correlation between bbs and bI

DIsCUssION

The present studywas conducted as a pilot studytowards examining the relationship between balanceandfunctionalability. In thestudyonly thosesubjectswho are able to comprehend and communicate inEnglishwereincluded.Thestudywasconductedamongsubjectswhohadonlymildbalancedeficits(BBS≥41).This population with relatively good balance may bevulnerable to falls due to their limited perception orbalancedeficits.

TheBarthel index(BI)wasdeveloped in1965andlatermodifiedbyGrangerandco-workers,asascoringtechnique that measures the patient’s performance in10 activities of daily life: feeding, bathing, grooming,dressing, bowel motion, bladder motion, toilet use,transferstobedandchairandback,mobilityanduseofstairs20.Thescorecorrespondstothesumofallthepointsobtained, andcan range from0 to100points.Elderlypeoplewith scores from 0 to 20 are considered to betotallydependent; from21 to60, seriouslydependent;from 61 to 90,moderately dependent; from 91 to 99,slightlydependent;andof100,independent21.

The BBS is a 14-item scale that quantitativelyassessesbalanceandriskforfallsinoldercommunity-dwelling adults through direct observation of theirperformance. The scale requires 10 to 20 minutes tocompleteandmeasuresthepatient’sabilitytomaintainbalance—either statically orwhile performing variousfunctional movements—for a specified duration oftime.Theitemsarescoredfrom0to4,withascoreof0 representing an inability to complete the task and ascore of 4 representing independent item completion.Aglobal score is calculatedoutof56possiblepoints.Scores of 0 to 20 represent balance impairment, 21to 40 represent acceptable balance, and 41 to 56representgoodbalance.TheBBSmeasuresbothstaticanddynamic aspects of balance.The easewithwhichthe BBS can be administered makes it an attractivemeasure for clinicians; it involvesminimal equipment(chair,stopwatch,ruler,step)andspaceandrequiresnospecializedtraining19.

Dependence,byitself,doesnotconstituteanegativeevent.Atdifferentstagesoflife,individualsmayormaynotbedependent,oneitheratemporaryoradefinitivebasis. Dependence takes on greater importance whenthis appears because of events that occur during thefinalstageoflife,anddailyactivitiesareaffectedbythisdependence.

Results of the present study further indicated thatBI may be a good outcome measure to analyse thefunctional ability among community living elderlyindividuals.Ferruccietal.didastudyonstrokepatients,compared the Level of functional performance versusmotor impairment using Functional Measures withBarthel Index15. They reported that their study foundconsiderablestatisticalsignificancewhentheFMscalewascorrelatedwiththeBarthelIndex.

Some researchers have been demonstrating asignificant relationship between the measures ofbalance obtained bymeans of ordinal scales with theperformanceof functional tasks, such as the ability totransfer,walkandclimbstairs15,16,17.RobertadeOliveiraet al. did a study on post-strokemotor and functionalevaluations usingBergBalance Scale and theBarthelIndex, they could not find any relationship betweenbalance and functional ability, which contradicts thefindings from Berg et al., which reported an intensecorrelation between the scores obtained in both scalesforindividualswithstroke18,19.


Theagingprocess is related todecreasingbalanceand ability to perform daily activities, and thissituationmayleadtofalls,fearoffalling,dependence,institutionalizationanddeath.Specificallywithregardtodailyactivities,theneedforhelptoperformsimpledailytaskssuchaseating,bathingandwalkingisassociatedwithalargenumberofnegativehealthindicators,suchas hospitalization, treatment costs, quality of life and,finally,death22.BBS is a functionalwayofmeasuringan individual’s balance and can provide valuableinformationforcliniciansdesigningindividualexerciseprograms. Italso iseasy toadministerbecause itdoesnotrequiremuchtimeorequipment.However,itseemsimportantforclinicianstobecarefulwhenusingsingleassessmentsoftheBBStodrawconclusionsconcerningachangeinbalancefunctioninthestudiedpopulation.Ithasbeenindicatedthattheuseofthemeanofrepeatedmeasurements increases the reliability for tests ofwalkingability23.

Older adults’ confidence in their walking abilityduring everyday activities may be as important fortheir social participation as their actual ability.Thispresent study results also showed that, among theelderlyappraisedhere,therewasanassociationbetweenbalanceanddailyactivities,thusindicatingthatelderlyindividualswhohadbetterbalancekeptagoodlevelofindependence.ThevalidityoftheBBSwasinvestigatedbySteffenetal.amongelderlyadultswithdisability24. BBSscoresweremoderately tohighlycorrelatedwithscores in numerous functional measurements (BarthelIndex, FuglMeyer Testmotor and balance subscales,Timedupandgo,Performance-orientedassessmentofmobility balance subscale and the Emory FunctionalAmbulation Profile). The BBS scores also correlatedmoderatelywithdataobtained from theDynamicGaitIndex, gait speed, caregiver ratings of balance andcentre of pressuremeasures of body sway during stillandperturbedstanding.IthasbeensuggestedthataBBSscore of less than 45 is predictive ofmultiple falls inelderlyadults25.

LIMItAtION

Eventhoughtheresultofthepresentstudyindicateda strong correlation between balance and functionalability, the findings may be viewed with caution. ApossiblelimitationofthepresentstudymaybethatBImaynotbesensitiveinambulantelderlywithminimalfunctionallimitations.Hencefuturestudiesmayexplore

measures for the evaluation of functional ability thatmaybemoresuitableforthispopulation.

CONCLUsION

There was a strong positive correlation betweenbalance assessed by Berg Balance Scale (BBS) andfunctionalability(representedas Physicalindependenceindaily activities) - evaluatedusing theBarthel Index(BI)incommunitydwellingelderlyindividuals.

Abbreviations

BBS:-BergBalanceScale

BI:-BarthelIndex

Conflict of Interest - Nil


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13) Buford TW, MacNeil RG, Clough LG, DirainM, Sandesara B, Manini TM, Leeuwenburgh C(2013). Active muscle regeneration followingeccentric contraction-induced injury is similarbetween healthy you and older adults. J ApplPhysiol,Doi:10.1152/japplphysiol.01350.2012.

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15) Ferrucci L, Bandinelli S, Guralnik JM, et al.Recovery of functional status after stroke:a postrehabilitation follow-up study. Stroke1993;24:200-205.

16) BohannonRW.Determinantsoftransfercapacityin patients with hemiplegia. Physiother Can1988;40:236-239.

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patients referred for physical therapy. PerceptMotorSkills1995;80:379-385.

18) Oliveira R . Post-stroke motor and functionalevaluations. Arq Neuropsiquiatr 2006;64(3-B):731-735.

19) BergKO,Wood-Dauphine´eSL,WilliamsJI,MakiB.Measuringbalanceintheelderly:validationofaninstrument.CanJPublicHealth.1992;83(suppl2):S7–S11.

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Immediate Effects of Unilateral thoracic Postero- Anterior Pressure Versus transverse Pressure in Chronic

Mechanical Neck Pain: A Comparative study

Rishav shukla1, Pallavi sahay2, Rachana sharma3, bibhuti sarkar4, Abhishek biswas5

1Professional Trainee, 2Physiotherapist, 3Sr. Prof. Trainee, 4Physiotherapist,Department of Physiotherapy, 5Director, National Institute for Locomotor Disabilities (Divyangjan) Kolkata, West Bengal, India

AbstRACt

background: - Theprevalenceofneckpainhasgenerallybeenreportedtobe45–54%andapproximately50% forworkersof anykind.Related to this, approximately25%ofout-patient physical therapyvisitsconcernpresentationsofpainintheneckregion

Objective: - Themainobjectiveofthisstudywastocomparetwodifferentmanualtechniquesforthoracicspineinpatientswithchronicmechanicalneckpainandstudyitsimpactonpainandrangeofmotioninthecervicalspineinlateralflexionandrotationafterasingleintervention

Method: - PatientswithChronicMechanicalneckpainwereincludedaccordingtothecriteria.Theyweredividedintotwogroupsrandomly.OnegroupreceivedUnilateralthoracicpostero-anteriorpressure(GroupA)whiletheotherreceivedTransversethoracicpressure(GroupB)tothethoracicspine.Datawascollectedatbaselineandtenminutesafterasinglesessionwasgiven.

Results: - Boththegroupsreportedsignificantimprovementinpainandrange.InGroupAtheNPRSwentdown from6.2±1.28 to3.25±1.16whereas inB itwentdown from5.75±1.44 to2.45±1.39.The lateralflexion torightnd left ingroupAincreasedfrom25.78 to36.45and27.56 to37whereas ingroupBitincreasedfrom27.31to35.71and28.3to35.85respectively.TherotationrangeofmotiontotherightandleftingroupAincreasedfrom61.26to75.28and62.55to74.2whereasingroupBitincreasedfrom64.56to73.73and62.88to73.41respectively.TherewasmildtomoderatebetterimprovementingroupAandgroupBintermsofpainandrange.Therewasnosignificantdifferenceinrangeoflateralflexiontoleftbetweenboththegroups.

Conclusion: - Patients with ChronicMechanical Neck Pain showed reduction in pain with UnilateralThoracicPostero-anteriorPressure.Whichcanbeconsideredabetterformoftreatmentbasedontheresultsfoundinthepresentstudy.

Keywords: - Chronic Mechanical Neck Pain, Mobilisation, Manual Therapy, Thoracic Spine

Corresponding author:Rishav shukla, ProfessionalTrainee,DepartmentofPhysiotherapy,NationalInstituteforLocomotorDisabilities(Divyangjan)Kolkata,WestBengal,India

INtRODUCtION

Neckpainisoneofthecommonesthealthproblemsinthegeneralpopulation,particularlyamongpeopleofworkingage.Theprevalenceofneckpainhasgenerally

beenreportedtobe45–54%andapproximately50%forworkersofanykind.1,2

Neckpainisdefinedasofmechanicaloriginwhensymptomswillvarywithtimeandactivitiesandisoftenaccompanied by a limited range of movement (upto150) inthecervicalspine,mostlyinlateralflexionandrotation.

Mostneckpainofmechanicalorigin isassociatedwithpoorposture,anxietyanddepression,neckstrain,

DOI Number: 10.5958/0973-5674.2018.00010.2


occupational injuries, or sporting injuries, staticposturing and various other confounding physical,psychosocialandindividualfactors.11

Manual therapeutic techniques are used to relievepainandtoincreasethemobilityofjoints.

Cervical spine mobilisation includes severalrisk factors like exacerbation of symptoms, musclespasm, the most common one being vertebrobasilarinsufficiency.15 In a systematic review on the adverseeffects of spinal manipulation, adverse effects werefoundtobeconsistentwithcervicalspinemobilization.

Thecervicalandthoracicspines,whileanatomicallydistinct regions,arenotclinically independentofeachother.1 Studies have shown that dysfunctions in thethoracicspinemayresultinpainandalteredmovementpatternsinthecervicalspine.2

Astowhy,itiswidelythoughtthattheconceptualmodelofregionalinterdependenceisinvolved.16Clelandet al. suggested that multiple thoracic mobilizationGradeIIIcouldreducepainanddisability in theneck,ItwasclaimedthattheT6vertebrallevelwasthemostrigidintermsofnervoussystemmobility.17

Another neurophysiological effect that themobilization might have is the stimulation of thesympathetic trunk of the autonomic nervous system,lowering the pain-pressure threshold and vasodilationwhichincreasesbloodsupply to the tissueat faultandhenceenhanceshealingwhiledecreasingpain.18

Therecontinues tobe lackofevidencesupportingwhichmobilizationtechniqueoutofthetwocommonlyused, that is unilateral postero-anterior pressure to thethoracic spine and transverse pressure to the thoracicspine,willbemostsuitedclinically.

The purpose of this study was to explore whichtechnique of thoracic mobilization is best suited andproduces maximum benefit in patients with chronicmechanicalneckpain

MAtERIAL AND MEtHOD

40 patients were included in the study and thesample was collected from the National Institute forLocomotorDisabilities(Divyangjan),Kolkata.

Theinclusioncriteriawere

1.Age18–45years.17

2.Durationofpainatleast3monthsormorethanthat.27

3. Numeric pain rating scale score more than 3pointsand≤8onactivity.8

4.Dullachingpainincreasedbysustainedpostures,neck movements (lateral flexion and rotation) andpalpationofcervicalmusculature.27,28

The patients were excluded if Symptoms werepresent inferior to the suprascapular area, if therewasRed flags of Mobilization such as metastasis, burns,bony anomaly (Congenital or Acquired), etc.10,6 andPhysiotherapyTreatment for this condition in thepastthreemonths.

Demographic data was collected and the Patientswerefurtherevaluatedthoroughly.Patientswereaskedabout their pain intensity on NPRS during activity.Rangeofmotioninlateralflexionbilaterallyandrotationbilaterally was measured using a standard universalgoniometer inaccordancetoNorkinsCguidelinesanddocumented.

Thentheywereallottedtooneofthetwogroupsviasimplerandomsamplingandinterventionwasgiven.

GROUP A – UNILAtERAL tHORACIC MObILIsAtION GROUP

Patientswereaskedtolieinapronepositionontheexaminationtableandtheyweremarkedonbothsidesofthezygapophysealjoint.

The therapist stood beside the patient in stridestanding position and placed the thumbs on thezygoapophysealjointsbypalpatingthespinousprocessandmovingonefingerlaterallytotheaffectedside.10

The therapist then performed unilateral postero-anteriormobilizationat thezygapophyseal joint in theupperthoraciclevel(T1toT6)onboththeleftandright,1minuteoneachside.18

GROUP b – tRANsVERsE tHORACIC PREssURE GROUP

The physiotherapist stood at the patient’s rightside at the level of thevertebrae tobemobilized, andplacedthehandsonthepatient’sbacksothatthepads


of the thumbs were adjacent to the right side of thespinous processes while the fingers were spread overthepatient’sleftribs.Theleftthumbactedasthepointofcontactandwasfitteddownintothegroovebetweenthe spinous process and the paravertebralmuscles, sothatpartof thepadof theThumbwaspressedagainstthelateralaspectofthespinousprocessonitsright-handside.Itwasessentialtohaveasmuchofit,padincontactwiththespinousprocessaswaspossible.10

The pressure is applied to the spinous processthrough the thumbs by the movement of the trunk;alternatepressureandrelaxationisrepeatedcontinuouslyto produce an oscillating type of movement of theintervertebral Joint. The procedure was performed onboth sides,1minuteoneachside starting fromT1uptoT6.15

DAtA ANALYsIs

Thesamplesizewasobtainedbyusingthepreviousstudieswherethepoweranalysishasalreadybeendoneandwasfoundouttobe40fortheeffectsizes(d=0.5).TheConfidenceIntervalwaskeptatthestandardlevelof 95% and the data was analysed using IBM SPSSVersion23(SPSS,Inc,ChicagoIL,USA).

FINDINGs

ItwasfoundthatthedatabetweenthetwogroupsthatisgroupAandgroupBwhencompared,byindependentt-test the significance crossed 0.05 indicating that thenature of the data was homogenous as there was nostatisticallysignificantchangeinthebaseline.

Graph 1 – showing the pre-test post-test comparison of means on Numeric Pain Rating scale.

PRENPRS= Pre-test Numeric Pain Rating ScaleMeanScore

POSTNPRS=Post-testNumericPainRatingScale

MeanScore

Within group analysis was done using a pairedsamplettestforpreandposttestmeasurementsforthefive variables in SPSS for both the groups where thelevelofsignificanceα=0.05.PosthocanalysiswasdonebetweengroupsusingG*Powerversion3.1.7wheretheeffectsizebetweenthetwogroupswerecalculated.

Graph 2 - showing the pre-test post-test comparison of means

in lateral flexion and rotation movements of the cervical spine.

Legend to the Graph: -

PRELATFLNRT=Pre-testLateralFlexiontoRightMeanScore

POSTLATFLNRT= Post-test Lateral Flexion toRightMeanScore

PRELATFLNLT=Pre-testLateralFlexion toLeftMeanScore

POSTLATFLNLT= Post-test Lateral Flexion toLeftMeanScore

PREROTNRT= Pre-test Rotation to Right MeanScore

POSTROTNRT=Post-testRotationtoRightMeanScore

PREROTNLT= Pre-test Rotation to Left MeanScore

POSTROTNLT= Post-test Rotation to Left MeanScore

DIsCUssION

Although there are various treatment techniquesfortreatmentofchronicmechanicalneckpain,manualtherapyisawell-establishedalternativefortreatingsuchtypesofpain.


The neurophysiologic response of pain reductionthroughthoracicmobilizationmaybeexplainedintermsofseveralmechanisms.Onepossiblemechanismisthatthemobilization induces a reflex inhibition of pain ormusclerelaxationreflexbymodifyingthedischargeofproprioceptiveGroupIandIIafferents.Thismayalsoimprove spinemobility.26Asecondmechanism is thatthe spinalmobilizationactivatesdescending inhibitorymechanismsresultinginpainreductionindistantareasfromthemobilization.21,

The sympathetic trunks are two ganglionatednerve trunks that extend the whole length of thevertebral column. Therefore,when applying unilateralthoracic postero-anterior pressure the activation ofthe sympathetic trunk by direct pressure was morepronounced. This might be the reason why theimprovement in NPRS and range in lateral flexion inbothdirectionsandrotationtorightwasmildlybetterintheUnilateralthoracicpostero-anteriorpressurethanthetransverse thoracicpressuregroup.Thebiomechanicalalteration that these twotechniqueshavearerelativelythesamewhichistoimprovethemobilityofthefacetjointsofthevertralcolumnbutinthetransversepressuregroup, pressure was applied on the lateral aspect ofthe spinous process and there was no pressure of thesympathetic trunk.Hence the reduction in pain in theunilateralgroupwasmoreascomparedtothetransversegroupsince in the lattergroup, theautonomicnervoussystemcouldnotbeactivated.17

ThisisattributedtotheFryette’s3lawsthatisbasedontheinterdependenceofthespinalcolumn.21,23,25

The first law states that when the spine is in neutral, sidebending to one side will be accompanied by horizontal rotation to the opposite side. Inboththetechniques themobilization force that was introducedto the thoracic spineonlyhada rotationalcomponent.Therewasnolateralglidingofthesegmentswhiletheinterventionwasbeinggivenas itwasnotpossible inthis region of the spinal cord. There exists a causalrelationship in terms of biomechanics between thecervical and thoracic regions, therefore, pain andstiffness in the cervical spine will lead to decreasedrangeofmotioninthoracicspineaswell.21,30

The second law of Fryette’s states thatWhen the spine is in a flexed or extended position, side-bending to one side will be accompanied by rotation to the

same side. In a pathological scenario, if one vertebrais out of place (in flexion or extension), therewill beworsening of symptoms if movement in other planesareperformed.Sincetheregionofthespinewasalreadyplacedinflexionorextension(flexioninupperthoracicandlowercervicalregions,extensioninuppercervicalregions)therefore,movementinsideflexionorrotationworsenedthesymptoms.Thefaultinposturemightbeattributedtopainanddecreasedmobility,hencealtreingthenormalbiomechanicsofthespine.5,6,11,17

ThethirdlawofFryette’sstatesthatWhen motion is introduced in one plane it will reduce motion in the other two planes.Hence if therewasadysfunctionofrange inoneplane, all themovementsof the segmentwillbereduced.Thiswasalsotrueinourstudywheretherewasamobilisingforcebeinggiventobringaboutrotationofthespinalsegmentbuttherewasanoverallimprovement in all other ranges as well that is sideflexiontobothsides.Thismightagainbeattributedtothebio-mechanicalcorrectionthatcouldhavebeenbroughtonce themobilitywasmade better andmovements inrotationandsideflexionimprovedsignificantlyinboththegroupswhencomparedwiththebaseline.26,24

CONCLUsION

When a patient approaches with a chronicmechanical neck pain to a manual therapist, it wouldbe better to start with the unilateral thoracic postero-anterior technique descibed by Maitland first since itwouldproducebetterimprovementinpainandtherewillbebetterimprovementinrangeofmotioninthelateralflexiontobothsidesandrotationtoright.

Conflict of Interest: The authors certify thatthey have NO affiliations with or involvement in anyorganization or entity with any financial interest ornon-financialinterestinthesubjectmatterormaterialsdiscussedinthismanuscript.

Funding: Self

Ethical Clearance:InstitutionalEthicalClearancewas obtained before performing the study from theInstitutional Ethical Board of National Institute forLocomotorDisabilities(Divyangjan).

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PA:Saunders;1995.

2. Norlander S, Nordgren B. Clinical symptomsrelatedtomusculoskeletalneck-shoulderpainandmobility in the cervico-thoracic spine. Scand JRehabilMed.1998;30:243–52.

3. CôtéP,CassidyJD,CarrollL:TheSaskatchewanHealth andBackPainSurvay: theprevalenceofneckpainandrelateddisabilityinSaskatch-ewan.Spine,1998,23:1689–1698.

4. Gummesson C, Isacsson SO, Isacsson AH, etal.: The transition of reported pain in differentbody regions: a one-year follow-up study.BMCMusculo-skeletDisord,2006,7:17.

5. YoungJL,WalkerD,SnyderS,DalyK.Thoracicmanipulationversusmobilizationinpatientswithmechanicalneckpain:asystematicreview

6. MckenzieR,MechanicalDiagnosisandTreatment,CervicalandThoracicSpine,2ndEdition

7. Dr.Deepak Sharan: A Prevalence study of neckdisorders in Bangalore, Deccan Heralds, 2004-2005,Volume(3)2PageNo:23-35.www.deepaksharan.com/toicolumn.

8. FejerR,KyvikKO,HartvigsenJ.Theprevalenceofneckpainintheworldpopulation:asystematiccritical review of the literature. Eur Spine J2006;15:834–848.

9. Lee D. Biomechanics of the thorax: a clinicalmodel of in vivo function. J Man Manip Ther.1993;1:13–21.

10. Maitland GD, Hengeveld E, Banks K, et al.:Maitland’s Vertebral Manipulation. 6th ed.Oxford: Butterworth-Heinemann, 2001, pp 93–324.

11. BinderAI,2007,2007,NeckPain;JourofPain,pii1103.

12. Leininger BD, Exploring patient satisfaction:a secondary analysis of a randomized clinicaltrial of spinal manipulation, home exercise, andmedication for acute and subacute neck pain, JManipulativePhysiolTher.2014October;37(8):593–601.doi:10.1016/j.jmpt.2014.08.005

13. CarlessoLC,MacDermidJC,GrossAR,WaltonDM and Santaguida L. Treatment preferencesamongst physical therapists and chiropractorsfor the management of neck pain: results of aninternationalsurvey.

14. PuenteduraEJ,LandersMR,ClelandJA,MintkenPE, Huijbregts P, Fernandez-de-Las-Pen ÞasC. Thoracic spine thrust manipulation versuscervicalspine thrust manipulation in patientswithacuteneckpain:arandomizedclinicaltrial.JOrthopSportsPhysTher.2011;41:208–20.

15. McGregor C, Boyles R, Murahashi L, Sena T,Yarnall R. The immediate effects of thoracictransverse mobilization in patients with theprimary complaint of mechanical neck pain: apilot study: JournalofManualandManipulativeTherapy;2014;VOL.22NO.4:191-198.

16. ErnstE;Adverseeffectsofspinalmanipulation:asystematicreview:JournalOFTheRoyalSocietyOfMedicinevolume;100:july2007

17. ClelandJA,GlynnP,WhitmanJM,EberhartSL,MacDonald C, Childs JD. Short-term effects ofthrustversusnonthrustmobilization/manipulationdirected at the thoracic spine in patients withneckpain:arandomizedclinicaltrial.PhysTher.2007;87:431–40.

18. Chu J, Allen DD, Pawlowsky S, Smoot B.Peripheralresponsetocervicalor thoracicspinalmanual therapy: an evidence-based review withmetaanalysis.JournalofManualandManipulativeTherapy2014VOL.22NO.4

19. Cross Km, Kuenze C, Grindstaff T, Hertel J.Thoracicspinethrustmanipulationimprovespain,range of motion, and self-reported function inpatientswithmechanicalneckpain:Asystematicreview: journaloforthopaedic&sportsphysicaltherapy|volume41|number9|september2011|633

20. Gordonetal:Wakingcervicalpainandstiffness,headache, scapularor armpain:Gender andageeffectsAustralianJournalofPhysiotherapy2002

21. Suvarnnato T, Rungthip Puntumetakul, etal. The Effects of Thoracic ManipulationVersus Mobilization for Chronic Neck Pain: aRandomizedControlledTrialPilotStudy.J.Phys.Ther.Sci.25:865–871,2013.

22. Dunning Jr, Cleland Ja, WaldropMa, Arnot C,YoungI,TurnerM,SigurdssonG.UpperCervicalAnd Upper Thoracic Thrust ManipulationVersus Nonthrust Mobilization In PatientsWith Mechanical Neck Pain: A MulticenterRandomized Clinical Trial Therapy, level 1b. J


orthopsportsphysther2012;42(1):5-18,epub30september2011.Doi:10.2519/jospt.2012.3894

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26. Page P, Frank C, Lardner R. Asssessment andtreatmentofmuscleimbalance.1stEdition.

A Comparative study on Alteration of blood Pressure During Mechanical Intermittent and Continuous Cervical traction

Mudasir Rashid baba1, Muhammad Arafath km2, Niyaz Abdullah Ponneth2,

Ramlath Haseena2, Hafis Al Hassan2 1Assistant Professor, Yenepoya Physiotherapy College, Yenepoya University Mangalore, 2Intern,

Yenepoya Physiotherapy College, Yenepoya University Mangalore

AbstRACt

Objective: Todeterminethealterationinsystolicbloodpressureduringintermittentandcontinuouscervicaltractioninnormalhealthyindividuals.study Design:ComparativeStudy.Method:60healthyparticipantsaged between 18-25 years were included in the study. They were then randomized by lottery methodusing convenient sampling method into intermittent cervical traction groupA (n=30) and ContinuouscervicaltractiongroupB(n=30).Eachgroupthebloodpressurewasmeasuredbefore,duringandaftertheapplicationofcervicaltraction.TherepeatedANOVAtestwasusedtocomparethevariationsinsystolicbloodpressurewithingroupswhiletwosampleindependent‘t’testwasusedforbetweengroupdifferences.Levelofsignificancewassetatp<0.05.Results:TherewasnostatisticallysignificantdifferenceinmeanBPbetweengroupAandgroupB(p=0.137)Conclusion:Basedontheresults,conductingacomparativestudyusingthesametractionweightandwithasmallsamplesizemighthaveledtoweaknegativecorrelation.Hence,westronglyfeelthatfurtherresearchneedstobedoneconsideringgenderdifferencesindependentlyandalsowithalargersample.

Keywords: cervical traction, systolic blood pressure, repeated measurement.

INtRODUCtION

Cervicaltraction(CT)isappliedforneckorupperlimb pain caused by conditions such as, degenerativediscdisease(withorwithoutcervicalrootcompression),hypo mobile facet joints, and cervical musculardysfunction1.Acervicaltractionunitdeliversmechanicaltractionforcetothecervicalspine.Thetractioncanbegivensteadilyforacertainperiodoftime(continuous)or on and off cycle (intermittent), therefore, relievescompression on the nerve root by stretching the spineand widening the intervertebral foramina, decreasedspasm in paraspinal muscles, increased intervertebraldiscspace,improvedvertebralalignmentandimproved

disc hydration2. From an anatomical and mechanicalviewpoint,Cervicaltractioncanseparatezygapophysealjointswithintervertebralforaminaenlargement,increaseintervertebral space, tighten the posterior longitudinalligament to adjust the adjacent annulus fibrous andstretch muscles and ligaments3.However, it has beenreported thatadverseevents related to increasedbloodpressure,suchasheadache,dizziness,andnausea,coulddevelopaftercervicaltraction.Thetractionweightmaybeanimportantfactorinsuchsideeffects4.

Few studies reported changes in blood pressureduringcervicaltraction(CT)andsuggestedthatclinicalphysiciansandtherapistsnoticehemodynamicchangesduringitsuse.However,therelationshipbetweenside-effects and hemodynamic alternation is still unclear.Sincecardiovascularhomeostasisiscontrolledmainlybytheautonomicsystem5.Thereversiblechangesinbloodpressure may be related to various factors, includingdirect stretching to baroreceptors in the carotid sinusduring traction to elicit a baroreflex, direct stretchingto spinal muscles, tendons, and ligaments to cause a

Corresponding author: Mudasir Rashid baba, AssistantProfessor,YenepoyaPhysiotherapyCollege,YenepoyaUniversity,Mangalore–575018,Faxno:[email protected]

DOI Number: 10.5958/0973-5674.2018.00011.4


stress-related sympathetic reflex (physical stress); andpsychological irritability6. Few studies have addressedthe physiological effects of CT on the cardiovascularsystem4.

Manystudieshavefoundthesignificantincreaseinautonomicfunctionsandbloodpressureassociatedwithdifferentcervicaltractionweight.Studiesconductedonintermittent cervical traction shows that 15 percent ofbodyweighthassignificantincreaseinbloodpressure.Hence, the purpose of this study was to compare thealterationofsystolicbloodpressureduringmechanicalintermittent and continuous cervical traction by using15% of the body weight. The results can then beanalyzedtolayoutcomparisonbetweenthemechanicalintermittentandcontinuouscervicaltraction,andalsotovalidate the significance of the alteration. Applicationoftheseoutcomesmaybeextendedtoclinicaldecisionmaking process for giving tractions to patients withalteredbloodpressure.


This study was conducted among the healthyparticipantsagedbetween18to25yearswithasamplesizeof60.Prior toparticipation, theparticipantswereexplainedaboutthestudyandaninformedconsentwasobtainedfromthem.EthicalclearancewasobtainedfromUniversityethicscommittee.Participantswerescreenedbasedontheinclusionandexclusioncriteria.Inclusioncriteriawere:Healthyvolunteersofbothgendersagedfrom 18-25. Participants with normal neck ROM.Exclusioncriteriawere:Presenceofanymusculoskeletal,neurologicalandcardiovascularconditionoranyotherpathological condition contraindicating to cervicaltraction.Eligibleparticipantswerethenrandomizedbylottery method to either intermittent cervical tractionGroupA(n=30)andContinuouscervicaltractionGroupB(n=30).

MetHoD

For the participants in both the groups weightwasmeasured using aweighingmachine and 15% ofthe body weight of each participant was calculatedand noted. The first BP measurement was taken justprior togivingcontinuousor intermittent traction.TheParticipantswerelaidonthetractionbedwiththeneckflexedat20to30degrees,andsecuredwiththecervicaltractionbeltwiththeirforearmsplacedbytheirside.ThesystolicvalueofBPwasrecordedfromwhichthemean

of threemeasurementswerecalculatedandnoted.TheBPcuffwasplacedthroughouttheprocedureanditwasdeflatedwhennotinuse.

Group Areceivedmechanicalintermittenttractionusing15%ofthebodyweightwithhold/relaxsetat40secholdand20secrelax.ThesecondBPmeasurementwasstartedatthe10thminuteoftheintermittenttractionandthemeasurementwasrecordedduringholdtimeofintermittent traction. The third BP measurement wasconductedafter the15minutesof intermittent tractionwitheachmeasurementbeing repeated three times forcalculatingthemean.

Group b received mechanical continuoustraction with 15% of the body weight. The secondBP measurement was started at the 10th minute ofcontinuous traction. The third BP measurement wasconductedafter15minutesofcontinuoustraction.Eachmeasurementwasrepeatedthreetimesandthemeanwascalculated.

Inthisstudy,wecomparedthealterationofsystolicbloodpressureincontinuousversusintermittenttractionamonghealthyparticipants.


Statistical analysis was done using IBM SPSSstatisticsversion22.Descriptivestatisticswasreportedas mean (standard deviation) for continuous variablesand frequency (percentage) for categorical variations.Variation in systolic blood pressure was comparedwithineachgroupusingrepeatedmeasuresANOVAorFriedman’s test based on normality. Between groups,thesystolicBPcomparisonwasdoneusingtwosampleindependent T-Test Mann Whitney U Test basedon normality. A p<0.05 was considered statisticallysignificant.

REsULts

Results showed a weak negative correlation(R=-0.094) between Continuous traction groupand intermittent traction group and this differencewas found to be not statistically significant (ReferTable 1). A difference in average number betweenintermittent and continuous group at 3 end points.i.e., pre traction, during traction andpost tractionwasfound to be statistically significant using two sampleindependentT-test(p<0.05)(ReferTable2).Therewasno statistically significant difference in the base line


characteristics between two groups (p>0.05) using anindependent sampleT- test (Refer Table 3). There byprovingthefactthatintermittentandcontinuousgroupsarecomparable.AstatisticallysignificantdifferencewasfoundacrosstherepeatedmeasurementsusingarepeatedANOVA i.e. pre, during andpost traction average forthe intermittent group f valuewas found tobe16.591withapvalue<0.001.Fromthepairwisecomparison,wefindthat therewasasignificantdifferencebetweenpre tractionandduring tractionaverage(p<0.001)andalso a significant difference between during tractionand post traction average (p<0.001) (Refer Table 4).For the continuous group, f- value was found to be38.72withapvalue<0.001whichwasalsostatisticallysignificant. P value clearly implies that there was astatistically significant difference between the threerepeatedmeasurementswithinthegroupi.e.pre,duringandposttractionaverage(ReferTable5).Therewasnostatistically significantdifference inmeanBPbetweengroupAandgroupB(p=0.137)(ReferTable6).

DIsCUssION

Thisstudywasconductedtocomparethealterationof systolic blood pressure during continuous cervicaltraction and intermittent cervical traction in healthyindividuals. Sixty participants were included in thisstudyinanagegroupof18to24.Theywererandomlydivided into two groups. Intermittent traction group(GroupA)andcontinuoustractiongroup(GroupB).

Theintermittentgroupshowedanaverageincreaseof6.93mmhginsystolicbloodpressureduringtractioncomparedtopretraction.Immediatelyafterthetractionwasremoved,thebloodpressurereturnedalmosttothepretractionBPlevel,whereasincontinuousgroup,theblood pressure decreased by an average of 7.62mmhgduring tractioncompared topre tractionmeasurement.The post traction blood pressure came back to near-normal level as well. Many studies investigated thealterationinBPrelatedtodifferenttractionforcessuchas 5%, 15% and 25% out ofwhich 15% and 25% ofthetractionforcecausedsignificantalterationofbloodpressure.

A study done on Autonomic functions and bloodpressurechangeslinkedwithdifferentcervicaltractionweights found that there is a relationship betweencervical traction and autonomic functions. ResultsshowedthatsystolicanddiastolicBPwasincreasedbutheartrateandheartratevariabilityweredecreasedwhen

tractionwasgivenwith30%ofbodyweight7. AnotherstudyonClinicalresponseandautonomicmodulationasseeninheartratevariabilityinmechanicalintermittentcervical tractionfoundthat intermittentCTinasittingpositionusing10%bodyweighttractionforceismorecomfortable than using 20% body weight tractionforce. Using 20% body weight traction force causesmore subtle perturbation in the autonomic systemandis accompanied by a higher incidence of discomfort1. Comparison of Blood Pressure and Heart RateVariability in (Saunders Cervical Traction) at threedifferent forces in healthy volunteers found thatHeartrate variability (HRV), which is induced by changesin blood pressure, reduced with increasing cervicaltractionforce,andresultssuggestthattractionforcesof25%bodyweightshouldbeusedcarefullyforpatientswhereas15%ofbodyweightcanbesafelyused8.

In this study the traction weight 15% of thebody weight for both continuous traction group andintermittent traction group was used, there were nocomplaints of discomfort or side effects of cervicaltraction like dizziness, vertigo or nausea.Hence, 15%of traction force can be considered safe in healthyindividuals.Although the findings in this study are incontrastwithmanyotherstudiesintheliterature,Hence,westronglyfeelthatfurtherresearchneedstobedoneconsidering gender differences independently and alsowith a larger sample size and with painful cervicalconditions.

LIMItAtION

Conducting a comparative study using the sametractionweightandwithasmallsamplesizemighthaveled to weak negative correlation. Hence, we stronglyfeel that furtherresearchneeds tobedoneconsideringgenderdifferencesindependentlyandalsowithalargersamplesize.

table: 1: Pearson’s correlation was used to find whether there was a statistically significant correlation between (method A and b). Descriptive statistics

Descriptive statisticsCorrelation coefficient “r”/p value

Mean Std.Deviation N

-0.094/0.620INTER 113.36 7.85 30CONT 116.20 6.66 30


Therewasaweaknegativecorrelation(r=-0.094)betweenContinuoustractiongroupandintermittenttractiongroupandwasnotstatisticallysignificant.

table :2 t-test

Group n Mean std. Deviation

pretractionaverageIntermittentgroup 30 114.400 7.4027

Continuousgroup 30 118.133 7.5737

duringtractionaverageIntermittentgroup 30 119.333 6.7535


posttractionaverageIntermittentgroup 30 113.367 7.8586


AstatisticallysignificantdifferenceinaverageBPbetweenintermittentandcontinuousgroupsatpretractionandduringtraction(p<0.05)

table: 3: Independent samples test

t-test for Equality of Means

t P Mean Difference

95% Confidence Interval of the Difference

Lower Upper

AGE .306 .761 .1000 -.5539 .7539

GENDER 1.433 .157 .1667 -.0661 .3995

Therewasnostatisticallysignificantdifferenceinthebaselinecharacteristicsbetweentwogroups(p>0.05)

table: 4: Intermittent group

Mean std. Deviation n

pretractionaverage 114.400 7.4027 30

duringtractionaverage 119.333 6.7535 30

posttractionaverage 113.367 7.8586 30

F=68.591P<0.001

Pair wise Comparison of intermittent group

Measure:MEASURE_1

(I) factor1 (J) factor1 Mean Difference (I-J) P

95% Confidence Interval for Differenceb

Lower bound Upper bound

12 -4.933* <0.001 -5.836 -4.030

3 1.033 .356 -.599 2.665

2 3 5.967* <0.001 4.462 7.471

Basedonestimatedmarginalmeans(Themeandifferenceissignificantatthe.05level)


table : 5 Continuous traction

Mean std. Deviation n

pretractionaverage 118.133 7.5737 30

duringtractionaverage 112.400 7.6230 30

posttractionaverage 116.200 6.6613 30

F=38.872P=0.001

Pair wise Comparison of Continuous group

Measure:MEASURE_1

(I)factor1 (J)factor1 MeanDifference(I-J) Sig.b95%ConfidenceIntervalforDifferenceb

LowerBound UpperBound

12 5.733* <0.001 4.108 7.358

3 1.933* .038 .086 3.781

2 3 -3.800* <0.001 -5.357 -2.243

Basedonestimatedmarginalmeans(Themeandifferenceissignificantatthe.05level)

table 6: Independent sample t test

GROUP N Mean Std.Deviation t/pvalue

INTER 30 113.3667 7.85859 1.506/0.137CONT 30 116.2000 6.66126

TherewasnostatisticallysignificantdifferenceinmeanBPbetweengroupAandgroupB(p=0.137)

CONCLUsION

Thepresentstudyacknowledgesthat therewasnostatisticallysignificantdifferenceinmean(systolic)BPbetweengroupAandgroupB(p=0.137)

Conflict of Interest: There is no conflict ofinterest.


Ethical Clearance- Yenepoya University EthicsCommittee

REFERENCEs

1) PanPJ,TsaiPH,TsaiCC,ChouCL,LoMT,ChiuJH. Clinical response and autonomicmodulationas seen in heart rate variability in mechanicalintermittentcervicaltraction:apilotstudy.Journalofrehabilitationmedicine.2012Mar5;44(3):229-34.

2) Fritz JM, ThackerayA, BrennanGP, Childs JD.

Exercise only, exercisewithmechanical traction,or exercise with over-door traction for patientswith cervical radiculopathy, with or withoutconsideration of status on a previously describedsubgrouping rule: a randomized clinical trial.journaloforthopaedic&sportsphysical therapy.2014Feb;44(2):45-57.

3) WongAM,LEONGCP,CHENCM.Thetractionangleandcervicalintervertebralseparation.Spine.1992Feb1;17(2):136-8.

4) Akinbo SR, Noronha CC, Okanlawon AO,DanesiMA. Effects of different cervical tractionweightsonneckpainandmobility.TheNigerianpostgraduatemedicaljournal.2006Sep;13(3):230-5.

5) Joyner MJ, Charkoudian N, Wallin BG. Asympathetic view of the sympathetic nervoussystem and human blood pressure regulation.Experimental physiology. 2008 Jun 1;93(6):715-24.


6) Valtonen EJ, Kiuru E. Cervical traction as atherapeutic tool.Aclinicalanlaysisbasedon212patients.ScandJRehabilMed.1970;2(1):29-36.

7) ChangWD,LinHY,LaiPT.Comparisonofbloodpressure and heart rate variability in Saunders

cervical traction at three different forces. JournalofPhysicaltherapyscience.2012;24(6):509-14.

8) TsaiCT,ChangWD,KaoMJ,WangCJ,LaiPT.Changes inbloodpressureandrelatedautonomicfunctionduringcervicaltractioninhealthywomen.Orthopedics.2011Jul1;34(7):e295-301

Effect of strengthening of Inspiratory Muscles using Inspiratory Muscle trainer on Pulmonary Function among Patients with spinal Cord

Injury -A Quasi-experimental study

shanmuga Priya M1, Kalpana A P2 1Asst. Professor, 2Professor, MPT(Cardio-Pulmonary), KMCH College of Physiotherapy.

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background. Respiratorycomplicationsarethemajorcausesofmortalityandmorbidityinpatientswithspinalcordinjury.Thusthereisaneedtopreventtherespiratorycomplications.Inthesepatientsrespiratoryproblemsmay result froma lossofcontrolof theabdominalmuscles, intercostalsand in somecases, apartialortotallossofthediaphragmaticfunction.

Objective. Todeterminetheeffectofstrengtheningofinspiratorymusclesusinginspiratorymuscletraineronpulmonaryfunctionamongpatientswithspinalcordinjury.

study design. The study was a Quasi-Experimental study design. The sampling technique used wasPurposiveSamplingTechnique.ThestudywasconductedatCoimbatore,TamilNadu,India.Asampleof20malepatientswithtraumaticspinalcordinjurywithlevelrangingfromC5toT12wereselectedandassignedinto2groups.

Intervention. Group Iwas intervenedwith conventional chest physiotherapy.Group IIwas intervenedwith strengthening of inspiratory muscles using IMT Threshold device along with conventional chestphysiotherapy.Thestudywasconductedforaperiodof8weeks.Theoutcomemeasuresincluderateofperceived exertion assessed bymodifiedBorg’s scale,maximal inspiratory and expiratory pressurewasassessed by modified sphygmomanometer, peak expiratory flow rate was assessed by mini peak flowmeter.

Results. Statisticalanalysisweremadeusingstudent‘t’testandpaired‘t’testat5%levelofsignificance.Pretestvaluesshowedthatthereisnosignificantdifferencebetweentwogroups.ThereisimprovementinbothgroupsandtheexperimentalgroupshowedagreaterlevelofimprovementinMIP,MEPandPEFRthanthecontrolgroup.

Conclusion. From this study it is concluded that the inspiratorymuscle training is effective to improvepulmonaryfunctionamongpatientswithspinalcordinjury.

Keywords. Spinal cord injury, inspiratory muscle training, IMT Threshold device, maximal inspiratory pressure, maximal expiratory pressure

INtRODUCtION

A spinal cord injury (SCI) refers to any injuryto the spinal cord that is caused by traumainstead ofdisease.Dependingonwherethenerverootandspinalcordaredamaged,thesymptomscanvarywidely,frompaintoparalysistoincontinence.

Injury to the spinal cord, can cause severerespiratoryimpairmentdependingonthelevelatwhichthelesionoccurs.LesionsaboveC3arelifethreatening,causingparalysisofthediaphragm,intercostals,scaleniand abdominal muscles, thereby leading to a lackof ventilatory support and the need for mechanicalventilation.IftheinjuryoccursbelowC3,thediaphragm

DOI Number: 10.5958/0973-5674.2018.00012.6


remains totally or partially innervated. However,diaphragmatic function is impaired due to paralysisof other respiratory muscles, including the abdominalmuscles.

Spinal cord injury with the neurological levelthroughC3generallyresultsinaweakeneddiaphragm,paralysis of the external (parasternals) and internalintercostals, abdominal musculature resulting insignificantimpairmentofrespiratoryfunction.

Afterspinalcordinjury,therewillbeanalterationinthemechanicalpropertiesofthelungsandchestwallresult in paradoxical (out of phase) movement of thechestwall,andreducedlungandchestwallcompliance(flexibility). This, in turn, leads to reduced breathingefficiency,reducedmaximalstaticrespiratorypressures,andreduced lungvolumes. Impairmentof themusclesofinspirationreducesvitalcapacity(VC),preventsdeepbreath, and may lead to dyspnoea with exertion andcollapseofthelungs1.

Duetoimpairedcoughanddifficultyinmobilizingthe lung secretions, patients after spinal cord injuryare at increased risk of pneumonia. The pulmonarycomplications of SCI include increased risk ofpulmonary infection and death, and higher rates ofsymptoms of respiratory dysfunction. The inspiratorycapacity isdiminished in individualswithhigher levellesions, contributing tomicroatelectasis, dyspneawithexertion and in those with more severe impairments,respiratoryinsufficiency2.

Moreover,reducedlungvolumesandtheassociatedinadequatestretchofairwaysmoothmusclewithdeepbreathing may contribute to dyspnea, further limitingan individual from progressing in vocational andavocationalindependentactivities.

Thesepatientshaverestrictiveventilatorimpairmentand endurance time, as well as inability to cough,especiallyinasittingposition.Therefore,thesepatientsarehighlysusceptibletoinspiratorymusclefatigueandpulmonarycomplications.

The measurement of Maximal Respiratorypressure (MRP) bymanometers is a useful procedurein evaluating respiratory muscle strength3. Americanphysiologicalsociety,(2003) statedthattheInspiratorymuscle strength was measured at the mouth by anelectronicpressuremanometer.PImaxindirectlyreflect

the inspiratory muscle strength and sustained atleastfor 1 second while performing a maximal inspiratoryeffort.

Thestrengthandenduranceofrespiratorymusclesin individuals with acute and chronic SCI may befurther increased with specific resistive inspiratorymuscle training (IMT), suggesting this may help toprotect against respiratory infections, which in severeinstancescanevolve intorespiratoryfailure. Improvedinspiratory muscle strength and endurance couldpotentially improve cough and maximal exerciseventilation in addition with decreased dyspnea. Theinspiratorymuscles can be trained similar to the limbmuscles with inexpensive devices that increase theresistiveorthresholdinspiratoryloadontheinspiratorymuscles4.

Hence, this study was carried out to evaluate theeffect the strengthening of inspiratory muscles, usingtheinspiratorymuscletrainer(IMT)inindividualswithchronic spinal cord injury that prevent the pulmonarycomplicationsandrespiratoryfailure.

MetHoD

Design and participation selection

The study was a Quasi-Experimental study, withPurposive sampling technique. Twenty males withchronicspinalcordinjurywererecruitedforthestudy.Inclusion criteria for participation in the study were:Chronic cervical and thoracic level spinal cord injury(C5-T12), strength of the diaphragm- grade “fair”,Patients with good consciousness and cooperation,Patients who are medically stable. Unstable and noncooperative patients and patients with respiratorycomplicationswereexcludedfromthestudy.

Ethical considerations

Approval of the proposalwas obtained by ethicalcommittee of KMCH College of Physiotherapy,Coimbatore, Tamil Nadu, India. The study wasexplainedtothepatientsandtheircaretakers.Awritteninformedconsentwastaken.

Intervention

The 20 patients were divided into two, 10 ineach group. Pre-test was taken using modifiedsphygmomanometer to measure Maximal inspiratory


pressure andMaximal expiratory pressure,Mini peakflow meter to measure peak expiratory flow rate andModified Borg scale to measure rate of perceivedexertion. Group I with 10 subjects was providedwith conventional chest physiotherapy, that includeddiaphragmatic breathing exercise, air shift maneuver,assisted coughing and active cycle of breathingtechnique. Group II with 10 subjects received bothinspiratorymuscle training and the conventional chestphysiotherapy. For the patients undergoing inspiratorymuscle training 30% ofMaximal inspiratory pressurewassetastheresistanceaccordingtothepatient’sMIPvalue5. Nose clip was used to close the nasal orifice.Thepatientwasasked to inhaleagainst the resistance.Frequentrestperiodwasgiveninbetweenthesession.TheprogressionwasmadeaccordingtotheincreaseintheMIPvalue.Twosessionsperdayandeachsessionlasted15minutes.Thetrainingwasgivenfor4daysperweek,foraperiodof8weeks.Posttestwastakenafter8weeks.

DAtA ANALYsIs

Data analysis wasmade using independent‘t’ testandpaired‘t’testat5%levelofsignificance(p=0.05).

Rate of Perceived Exertion

When the values of Group I and II are analysedby Independent‘t’ test, the calculatedvalueofpre testwas0.84andposttestwas0.31.Thecalculated‘t’valuebetweenpretestandposttestofgroupIwas3.142andgroup IIwas3.493.Patients ingroup IIwho receivedIMTwith conventional chest physiotherapy showed agreaterimprovementthangroupIwhoreceivedonlytheconventionalchestphysiotherapy.But,theimprovementwasnotstatisticallysignificantastheRPEvaluesbecamezeroandtherewasnofurtherimprovementtobenoted.

Maximal Inspiratory Pressure

When the values of Group I and II are analysedby Independent‘t’ test, the calculatedvalueofpre testwas0.73andposttestwas2.55.Thecalculated‘t’valuebetweenpretestandposttestofgroupIwas6.125andgroupIIwas6.181.ItisprovedthatthereisastatisticallysignificantimprovementinGroupIIthanthegroupI.

Maximal Expiratory Pressure

WhenthevaluesofGroupIandIIareanalysedbyIndependent‘t’test,thecalculatedvalueofpretestwas

0.268andpost testwas2.772.Thecalculated‘t’valuebetweenpre test andpost testofgroup Iwas2.45andgroup IIwas6.082. It isproved that there isagreaterstatistically significant improvement in Group II thanthegroupI.

Peak Expiratory Flow Rate

WhenthevaluesofGroupIandIIareanalysedbyIndependent‘t’test,thecalculatedvalueofpretestwas0.586andpost testwas4.488.Thecalculated‘t’valuebetweenpretestandposttestofgroupIwas6.524andgroup II was 8.21. It is proved that there is a greaterstatistically significant improvement in Group II thanthegroupI.

GRAPHICAL REPREsENtAtION

FIGURE 1 - RAtE OF PERCEIVED EXERtION

FIGURE 2 - MAXIMAL INsPIRAtORY PREssURE

FIGURE 3 - MAXIMAL EXPIRAtORY PREssURE


FIGURE 4 - PEAK EXPIRAtORY FLOW RAtE

DIsCUssION

It is estimated that in theUnitedStates each yearthereareabout11,000newcasesofspinalcordinjury(SCI)andthattherearecurrentlyabout250,000personsalive with SCI. Because of improvements in medicalcareandsurvival, theprevalenceofpeoplelivingwithSCI has increased, and it is predicted that there willbe greater and greater numbers of older patients withSCI.Currently theaverageageat injury is37.6years,and about 80% of those affected are male.Becauseof the changes in pulmonary compliance, chest-walldistortion,andimpairmentinbothmusclesofinhalationand exhalation following spinal cord injury, thereoccursareductioninvitalcapacity(VC),inefficiencyinventilation,andmarkedlyimpairedcough.

Thisstudywasdonetofindtheeffectofstrengtheningof inspiratorymusclesusing inspiratorymuscle traineronpulmonaryfunctionamongpatientswithspinalcordinjuryforaperiodof8weeks.

William et.al (2000) stated that the pulmonaryfunction iscompromisedbymostof the lesionsof thespinalcord,eveninthosewithparaplegia,andisaffectedrelativetotheleveloflesion6.Jacksonet.alfoundthatthecomplicationsoveralloccurredsignificantlysoonerin the T1-12 group7. Hence, in this study both thecervicalandthoraciclevelofspinalcordinjurypatientsweretaken.

Haaset.aldescribedthatthereisamarkedreductionintheabilityoftetraplegicstoachievefulllunginflation,which predispose to the development of alveolarhypoventilation, as a result of paralysis of inspiratorymuscles.

Hence,GroupIwith10sampleswasprovidedwiththeconventionalchestphysiotherapy,includingSimpleRelaxed Diaphragmatic Breathing Exercise, Air Shift

Maneuver, Assisted Coughing, and Active Cycle ofBreathing.GroupIshowedasignificantimprovementinMIP,MEP,RPEandPEFR.

Group II with 10 samples were provided withInspiratoryMuscleTrainingalongwiththeconventionalchestphysiotherapy.Onepatientdiscontinuedthestudybecause of urinary tract infection and post test wastaken only to 9 patients. The result showed a greaterimprovementinmaximalinspiratorypressure,maximalexpiratorypressureandinpeakexpiratoryflowrateandrateofperceivedexertion.

Rutchicket.alconcludedthatthestrengtheningthemuscles of respiration is responsible for the improvedmaximalinspiratorypressure,whichresultedinincreasein both spirometric and lung volume parameters. Theamount of work performed by a muscle is reflectedin changes in the muscle itself. Several recognizablealterationsoccurinallmusclefibertypesduetotraining.There isan increase incapillarydensityof the trainedmuscles,aswellasinmitochondriawithinthecells,andthefiberssynthesizemoremyoglobin.Strengthtrainingof the respiratorymuscles has been studied in severaldifferent populations, including patients with COPD,asthma, muscular dystrophy and in both acute andchronicspinalcordinjury6,8,9,11.

The most successful findings have been attainedusing a resistive IMT device in the SCI population,in which several investigators have demonstratedsignificant and progressive increase in respiratorymuscle strength and endurance while improving lungvolumes2,3,7,10.

Inthisstudy,boththegroupsshowedareductionintherateofperceivedexertionbutthatwasnotstatisticallysignificant.Thiswasbecause,theposttestmeanvalueswere0.1and0andhencethefurtherimprovementwasunable to be noted.All the patients gave a subjectivefeedback that there is no dyspnea on exertion whencomparedbeforestartingthetreatmentprogram.

AsGroupIIshowedgreatersignificantimprovementwhencomparedtoGroupI,inspiratorymuscletrainingcan be effective in treating patients with spinal cordinjuryonpulmonaryfunction.

LIMItAtIONs AND sUGEssIONs

Inthisstudy,onlyasmallsamplesizewasincludedandlargenumberofsamplescanbeincludedinfurther


studies.Bothcervicalandthoraciclevelofspinalcordinjury patientswere included and studies can be doneconcentrating a single level. Both complete and theincompleteinjuryweretaken.Infuture,studiescanbedonepreferablyonincompleteinjuryforbetterresults.Modified sphygmomanometer was used in this studyanddigital pressuremanometer canbeused for betteraccuracy.Qualityof lifequestionnairescanbeusedtodocumentthelevelofimprovement.

CONCLUsION

The results showed a significant improvement inboththegroups.Thedatawascollectedandanalysedbyusingstudent‘t’testandpaired‘t’test.Oncomparison,the group II showed a greater improvement than GroupI.

Withthisstudy,itisconcludedthattheInspiratoryMuscle Training along with conventional chestphysiotherapywillhelptoimprovepulmonaryfunctioninpatientswithchronicspinalcordinjury.

Conflict of Interest: There was no personal orinstitutionalconflictofinterestforthisstudy

source of Funding:Self

Ethical Clearance:Fromtheinstitute

REFERENCEs

1. John Wiley. Respiratory muscle training forcervical spinal cord injury. Cochrane Databaseof Systematic Reviews. 2013,10.1002/14651858- CD008507.

2. Derrickson J,Ciesla N,Simpson N,Imle PC. Acomparison of two breathing exercise programsfor patients with quadriplegia. Phys Ther.1992Nov;72(11):763-9.

3. Gross D,Ladd HW,Riley EJ,MacklemPT,GrassinoA.Theeffectoftrainingonstrengthand endurance of the diaphragm in quadriplegia.AmJMed.1980Jan;68(1):27-35.

4. Mei-Yun Liaw, MD,Meng-Chih Lin, MD,Pao-Tsai Cheng, MD,May-Kuen Alice Wong,MD,Fuk-Tan Tang, MD. Resistive inspiratorymuscle training: Its effectiveness in patientswith acute complete cervical cord injury. S0003-9993(00)90106-0.

5. Hill K,Cecins NM,Eastwood PR,Jenkins SC.Inspiratory muscle training for patients withchronicobstructivepulmonarydisease:apracticalguideforclinicians.ArchPhysMedRehabil.2010Sep;91(9):1466-70.

6. Paltiel Weiner, M.D,Yair Azgad, M.S,RasemGanam,M.D.,MargalitWeiner,Ph.D.InspiratoryMuscle Training in Patients with BronchialAsthma.1992,10.1378/chest.102.5.1357.

7. HuldtgrenAC,Fugl-MeyerAR,JonassonE,BakeB. Ventilatory dysfunction and respiratoryrehabilitationinpost-traumaticquadriplegia.EurJRespirDis.1980Dec;61(6):347-56.

8. G Guyatt, J Keller, J Singer, S Halcrow, MNewhouse. Controlled trial of respiratorymuscletraining in chronic airflow limitation. Thorax1992;47:598-602.

9. Belman MJ,Thomas SG,Lewis MI. Resistivebreathing training in patients with chronicobstructive pulmonary disease. Chest.1986Nov;90(5):662-9.

10. TheodorWanke,M.D.,KarlToifl,M.D.,MonikaMerkle, M.D., Dieter Formanek, M.D., HeinzLahrmann, M.Sc.Ph., Hartmut Zwick, M.D.,F.C.C.P. InspiratoryMuscle Training in PatientsWith Duchenne Muscular Dystrophy. 10.1378/chest.105.2.475.

11. Biering- Sorensen F, et al., effect of respiratorytrainingwithamouth–nose–maskintetraplecics 10.1016/S0004-9514(14)60358-5.

12. Bissett BM, Leditschke IA, Paratz JD,et al. Protocol:inspiratorymuscletrainingforpromotingrecovery and outcomes in ventilated patients(IMPROVe): a randomised controlled trial.bmjopen-2012-000813.

13. Sutbeyaz, Serap T.; Koseoglu, Belma F.;Gokkaya, Nilufer K.O. The combined effects ofcontrolled breathing techniques and ventilatoryand upper extremity muscle exercise oncardiopulmonaryresponsesinpatientswithspinalcordinjury.InternationalJournalofRehabilitationResearch.2005,28:273-276.

14. Yasar F, Tasci C, Savci S, et al. PulmonaryRehabilitation Using Modified ThresholdInspiratory Muscle Trainer (IMT) in Patientswith Tetraplegia.Case Reports in Medicine.2012;2012:587901.


15. A.Helewa, C.H.Goldsmith, H.A.Smythe. Themodified sphygmomanometer—An instrumentto measure muscle strength: A validation study.0021-9681(81)90073-4.

16. Tyng-GueyWang,MD,Yen-HoWang,MD,Fu-Tan Tang,MD,Kwan-Hwa Lin, PhD, PT,I-NanLien,MD.Resistiveinspiratorymuscletraininginsleep-disorderedbreathingoftraumatictetraplegia.apmr.2002.30937.

17. Goosey-TolfreyV,Foden E,Perret C,DegensH. Effectsofinspiratorymuscletrainingonrespiratory

function and repetitive sprint performance inwheelchairbasketballplayers.bjsm.2008.049486.

18. Larson JL,Kim MJ,Sharp JT,Larson DA.Inspiratory muscle training with a pressurethresholdbreathingdeviceinpatientswithchronicobstructive pulmonary disease. 1988; 10.1164/ajrccm/138.3.689.

19. Janne Marques Silveira, Ada Clarice Gastaldi,CristinadeMatosBoaventura,HugoCelsoSouza.Inspiratorymuscletraininginquadriplegicpatients.2010,S1806-3713201000030000.

Invasive vs Non Invasive treatment in stenosing tenosynovitis

Amit Kumar1, Piyush Mittal2 12nd year Resident, Orthopaedics, 2Associate Professor, Department of Orthopaedics

AbstRACt

background: de Quervain’s tenosynovitis is an inflammation of abductor pollicis longus (APL) andextensorpollicisbrevis(EPB)muscletendonsheathsatthelevelofradialstyloidprocess.Itsconservativemanagement includes nonsteroidal anti-inflammatorydrugs, wrist and thumb immobilization, ultrasonictherapy(USTh.)andlowlevellasertherapy(LLLT).Invasivemethodsincludelocalinjectionofsteroidintendonsheath(inj.LHC)andsurgeryinvolvingreleaseoftendonsheath.

Materials and Method: SixtypatientsclinicallydiagnoseddeQuervainstenosynovitiswereincludedinthestudyandrandomlyassignedtotwogroups.Theaverageagewas36years(range:21-45years).OnegroupwasgivenLLLT+USTh.AndotherwasinjectionLHC.TheclinicalcriteriausedwereFinkelstein’stest,tendernessoverradialstyloid(Ritchie’stendernessscale),gripstrength,pain(visualanalogscale[VAS])andradiologicalcriteriawasultrasonographicassessmentofchangeinthicknessofAPLandEPBtendonsheath.Theyweremeasuredbefore commencement and at the endof seven sessions of therapy, as perstandardprocedure.

Results: Improvementwasseenwithinbothgroupsinthefollowingoutcomemeasuresassessed:Ritchie’stendernessscale,gripstrengthandVAS.Finkelstein’stestwassignificantlyimprovedininj.LHCgroup.Ultrasonographicmeasurementoftendonsheathdiameters,themediolateral(ML),andanteroposterior(AP)diameterswasnotfoundtobesignificantlydifferentinbetweenthegroupsaftertreatment.Oncomparingboththegroups,statisticallysignificantdifferencewasfound.However,lookingatthemeanvalues,thegripstrengthandVASshowedbetterimprovementintheinjLHCgroupascomparedtotheUS+lasertherapygroup.

Keywords: de Quervains tenosynovitis, low level lasers, ultrasonic therapy,inj LHC

INtRODUCtION

DequervainsdiseasenamedaftertheSwisssurgeonFritzdequervain,whoidentifiedfirstin1895[3].Itisaninflammationofthesheathortunnelthatsurroundstwotendonsthatcontrolsthumb.Itiscausedbyrepetitiveuseof the thumb in combinationwith radial deviation ofthewrist.(pinching,wringing,lifting,grasping,gardening,knitting).

Dequervains’tenosynovitis (inflammation ofabductor pollicis longus[APL] and extensor pollicisbrevis[EPB]muscletendonsheath)isarepetitivestraininjuryoracumulativetraumadisorder[1].

Patientusuallypresentscomplainingofradialwristpainwiththumbmovementandtendernessoverthefirstdorsalcompartment.Diagnosis isusuallyconcludedbyapositiveFinkelstein’s test ,aswellas thepresenseoftendernoduleoverradialstyloid.Finkelstien’stestwasfirstdescribedin1930andhasrecentlybeendescribedasbeingperformedinfourstages:firstwiththeapplicationof gravity assisted gentle active ulnar deviation at awrist,then the patient actively deviates thewrist in anulnar direction,then further passive ulnar deviationby the examiner and in the final stage the examiner

Corresponding author: Dr. Amit KumarAddress;B308roomno.phase2,NewPGHostel,CivilHospitalCampus,Asarwa,Ahmedabad,Gujarat.B.J.MedicalCollege,CivilHospital,Ahmedabad

DOI Number: 10.5958/0973-5674.2018.00013.8


passivelyflexesthethumbintothepalm.Thereliability,specificity,sensitivityhasnotbeingreported,butitwasclaimed that staged method of testing may be moreaccurate with higher sensitivity and specificity.Othertestsareindicativeofthisconditionincludingadecreasein pinch and thumb strength measurenments on thesymptomaticsite.

It is commonly managed nonoperatively by non–steroidal anti-inflammatory drugs,wrist and thumbimmobilization,ultrasonic therapy and low level laserthearapy(LLLT)[2-4]).

Ultrasound therapy is a therapeutic modalitywidelyusedformanagementofvarioussofttissueandmusculoskeletaldisorders.Althoughitsmechanismofactionisnotclearlyunderstood.[5-8].

Itsefficacyhasbeenquestionedinthepast[9].Mostofthe reviewsandmetaanalysisconductedonultrasoundtherapy are lacking in specific information regardingthedescriptionofrandomizationmethods,anultrasoundapparatus,mode of delivery,size of ultrasoundhead,treatmenttimeanddropouts[9-12].

Well-designed research studies are required tojustifytheuseofulstrasound,especiallyinvivo.

Lasershavebeenusedforphotobiomodulation[13].

The available literature gives conflicting resultsregarding the efficacy of themodality inmanagementof soft tissue disorders[14-17] and lack of descriptiveinformation,further makes analysis difficult. Althoughthere are some recent reports on the efficacy of theintra-sheath injectionof triamcinoloneacetonide (TC),whichisalong-actingandlyophobicsteroid,forpatientswith snapping fingers (34).There are no comprehensivereportsdescribingtheclinicaloutcomesofintra-sheathinjectioninthetreatmentofdeQuervain’sdisease.Wedescribe the intra-sheath injection of triamcinolonein the treatment of de Quervain’s disease and reporton its clinical outcomes and complications. Low levellaser therapy is effective in the management of theDequervains’tenosynovitis(2). As demonstrated ultrasonographically,however,studies on comperative efficacyof LowLevel laser therapy and ultrasound therapy inmanagement of soft tissue disorders are notmany[18].

This study assessed and compared the efficacy of injLHCandultrasoundtherapy+lowlevellasertherapyinDequervains’tenosynovitis.

MAtERIAL AND MEtHOD

Aims and Objectives

To compare the two different modality ofmanagement i.e invasive (inj LHC i.e triamcinoloneacetonide) and non invasive ultrasound therapy+ lowlevellasertherapyforDequervains’tenosynovitis.

study designs:

60consecutivepatients attending theorthopaedicsout patient department having clinically diagnosedDequervains’tenosynovitisonthebasisofpositiveFinkelstein’stest[23],wereincludedinthisprospectivestudy.

There were 54 females and 6 males patients.Theaverageagewas36.6years(range21-45years).

Inclusion criteria: femalesandmalesagesbetween21-45years

Exclusion criteria: cervical spondylosis with orwithout radiating pain,hypertension,diabetes mellitus,Carpel tunel syndrome,first CMC joint arthritis,Superficialradialneuritis,fractureofupperextremityoranyotherchronicconditionlikerheumatoidarthritis.

An informal consent for participation in the studywas taken.Thestudywasapprovedby the institutionalethicalcommittee.

Level of study:

Prospectivecomparativestudy[therapeutic];

A study inwhich patient group are separated nonrandomaly by exposure or treatment with exposureoccurringaftertheinitiationofstudy.

The patients included in the studywere randomlydivided in two groups,one group (n=30) receivedinj.LHC therapy and the other group(n=30) receivedultrasound+lowlevellasertherapy.

Theclinicaldiagnosiswasdonebytheorthopedician.Amixture of 1ml (10mg) of triamcinilone acetonideand1mlof2%lignocainehydrochloridewas injectedinfirst dorsal compartment of involvedwrist. Patientswere followed for 16 weeks on monthly basis. Theareaoftendernesswasconfirmedbeforeinjection.Theneedlewaspassedinthefirstextensorcompartmentofwrist,directingproximally towards thestyloidprocessof radius and parallel to the abductor polices longus


and extensor polices bravis tendons. Stretching ofthe synovial sheath by volume effect was observed.For early clinical response each patient examined twoweeks after the injection, and then followed monthlyfor 28 weeks .Injection was given by orthopedician .Application of ultrasound and laser therapywas donebythephysiotherapist.Finkelstein’stestwhichinvolvesgrasping the patients’s thumb andquicklymoving thehand ulnar ward was performed.Tenderness elicitedoverthetipoftheradialstyloidprocesswastakenasapositivetest.

Tendernessorpressureovertheradialstyloidwasgraded by Ritchie’s tenderness scale[25].The gradeswere grade-1 -tolerable pain,grade-2- patient wincesonpressureandgrade-3-patientwincesandwithdrawshand.

Gripstrength[24]wasmeasuredbyastandardmercurysphygmomanometer.Theelbowandarmweresupportedonatableandtheelbowflexedto900.Thecuffwasthenpressed in the cylindrical grasp.The elevation of themercury columnwas recorded3 times.The averageofthreereadingswastaken.

Anendolaser476withapencilprobe(wavelength830nm,power30-40mw,beamdiameter40mmat10mmfrom the probe,angle of divergence 2.50 . Exposuretime for2 min.Energy in joules37/cm2wasused fortreatment. The low level laser therapy was appliedtwice per session.Once the probe was held stationaryin contactwith skin at radial styloid and second timealongtendonsheath.Thelaserprobeandtheparttobetreatedwerecleanedwith70%alcohol to removeanyoilanddirtfromtheskinsurfaceforbetterpenetration.Protectivegoggleswerewornbypatientsandtherapist.3Mhz ultrasound generation was used for ultrasoundtherapy.An aqua sonic gel was used as a couplingmedium. For ultrasound therapy,the pulsed mode toexpose the area over radial styloid by 5ms and 5msoff. A space average intensity of 0.8w/cm2(depth oflesion0.5cmapproximately)foraperiodof3minwasdelivered.

The following outcome measure were usednamelyFinkelstein’stest,tendernessoverradialstyloid(Ritchie’s tenderness scale),grip strength ,pain asassessedbyvisualanaloguescale(VAS).

All the outcome measure were done beforecommencementandaftertheendoftherapy.

Clinically, the improvement was assessedsubjectively by the patient,using VAS(26) (0=nopain,10=severepain).

Theclinical tests were repeatedafteronedoseofinj.LHCandafter21daysforlaser+ultrasoundtherapy.Thepatientsweregivenultrasoundtherapy+lowlevellasertherapyfor21days.

Testing of optical outputwas performed regularlybeforeandtheendoftreatment.

Precautions regarding avoidance of forcefulmovementsofthethumbwereexplainedtothepatients.

DIsCUssION

30 cases of De Quervains tenosynovitis weretreatedbyinjLHCand30caseswithultrasound+lowlevellasertherapy.Thepurposeoftheourstudywastocompare the effectiveness between invasive procedureandthenoninvasiveultrasound+lowlevellasertherapyinDequervainstenosynovitis.

Dequervainstenosynovitisismorecommonlyseeninperimenopausalwomenandwomenofchildbearingageandhencetheagerangetakenthatis20–45years.Womenare seen tohavea significantlyhigher rateofoccuranceofDequervainstenosynovitisascomparedtomen.Therewereonly6malepatientsinthisstudy.

FaithfulandLambobserved that thenondominanthandisgenerallymoreaffected.

Mardiman S, Wessel J, Fisher B observed thatultrasound therapyandLow level laser therapy causeadecreaseinpain,decreaseinRitchie’stendernessscaleandVASscaleimprovementinallthepatientsandwasfoundtobestatisticallysignificant.

Finkelstein’s test is the classic diagnostic test forDe quervain’s disease. Finkelstein hypothesized thatentrapment of the extensor pollicis brevis (EPB) andabductor pollicis longus (APL) tendons into the firstextensor compartment was responsible for the painover the radial styloid.we had also used this test as aclinical parameter for diagnosing the De quervains’tenosynovitis.

Inourstudy,bothinjLHCgroupandLowlevellasertherapy+ultrasoundtherapyshowedanimprovementinDequervainstenosynovitis.TheinjLHCtherapygroupshowed marked better improvement as compared to


ultrasound+Low level laser therapy but withmorecomplicationslikelocalcellulitisoccurringin3patients,2 patients developed hypopigmentation at injectionsite,1patienthadtendonruptureandrequiredsurgicalintervention and 6 patients required repeated dose oflocalinjection.

REsULts

Of the sixty patients taken up for the study, theleft sidewas involved in34 (59%), and the right side(dominantextremity)wasinvolvedonlyin26patients.Bilateralinvolvementwasseenintwopatients.Howeveronly the more affected extremity was included in thestudy.

Finkelstein’s test conducted before and aftertreatmentwasstatisticallysignificantinboththegroups,thatis,InjLHCandultrasound+lowlevellasertherapy.

Grip strengthwas found significantly improved inthe inj LHC (P = 0.003) and low level laser therapygroup (P = 0.005). Grip strength for both the groups,beforeandafterthetreatmentvaluesweresignificantlydifferentfromeachotherandbetweenthegroups.

Visual analog scale when compared betweengroups, the change was found statistically significant

betweenthegroupsandwasfoundinsignificantwithinthegroup.

Looking at the mean values, the grip strengthand VAS showed marked better improvement in theinjectionLHCgroupascomparedtotheultrasound+lowlevellasertherapygroup.TheresultsimplythatinjLHCtherapy ismore effective than low level laser therapybuthasamorecomplicationsrateaswell.Inourstudy,65% of patients were symptom free two weeks afterintervention,80%afterfourweeksand95%werefreeof symptoms at sixweeks after intervention and 99%by theendof12weeks.Therewereno recurrencesat24 weeks. This shows that the effect of local steroidmay persist for 4 to 6weeks. It is believed that anti-inflammatoryeffectsofthisdrugpersistfortwotofourweeks.(4)Theadverseevents inour studywere seen in10outofthirty(33%)ofpatients.outofthese8patientsrecoveredfromtransientpainatinjectionsitewithin10days.InRemaining3patientswithskindepigmentation(2patients)andatrophyofsubcutaneousfat(1patients).The changes reversed in 20 weeks’ time. Steroidinjectionsmayhaveadversesideeffectse.g.painattheinjectionsiteandskinhypopigmentation.Theseeffectsaretransient.Itisrecommendedthatbeforestartingthetreatment the patients should be informed about thesesideeffects.(5,6)

table 1: Age, Distribution of sex and extremity involved

Demographic data Inj LHC(n=30)Ultrasound + Low level laser therapy (n=30)

Extremityinvolved(right/left) 14/16 10/20

Sex(female/male) 28/2 26/4

MeanSD MeanSD P(Mann-whitneyU-test) Significance

Age 34.46.20 36.47.5 0.521 Notsignificant

table 2: Grip strength

Grip strength Inj LHC(n=30) UsG+Low level laser (n=30)

P(Mann-whitney U-test) significance

MeanSD MeanSD

Beforetreatment 113.6049.58 111.1542.40 0.830 Notsignificant

Aftertreatment 196.3269.78 136.4049.45 0.384 Significant

P(sign-test) 0.006 0.002

Significance Significant Significant


table 3: VAs for pain

VAs scale Inj LHC(n=30) Ultrasound+Low level laser therapy (n=30)

P(Mann-whitney U-test) significance

MeanSD MeanSD

Beforetreatment 9.101.35 8.751.55 0.560 Notsignificant

Aftertreatment 4.413.00 4.203.44 0.324 Significant

P(sign-test) 0.001 0.0015

Significance Significant Significant

Conflict of Interest : Nil


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Comparison of Cardio Respiratory Responses and Level of Exertion Following two Common tests for Arm Exercise

Capacity in Patients with COPD

sumana baidya1, Michel W Coppieters2, subin solomen3, Pravin Aaron4

1Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Kavre, Nepal, 2Faculty of Human Movement Sciences, MOVE Research Institute Amsterdam, VU University Amsterdam,

Amsterdam, The Netherlands, 3EMS Memorial Cooperative Hospital and Research Centre, Perinthalmanna, Kerala, India, 4Faculty of Physiotherapy, Padmashree Institute of Physiotherapy, Rajiv Gandhi University of

Health Sciences, Bangalore, India

AbstRACt

Unsupportedarmexercisecapacityhasbeenmeasuredinvariousways.Commonlyusedunsupportedarmexercise tests includethe‘sixminutepegboardringtest’ (PBRT)and‘unsupportedupper limbexercisetest’(UULEX).Itisunknownwhetherthesetestselicitcomparablecardio-respiratoryresponsesandlevelof exertion inpatientswith chronicobstructivepulmonarydisease (COPD).The studyaimed toevaluatewhetherthetestsresultincomparableordifferentcardio-respiratoryresponsesandarmfatigueinpatientswithCOPD.Twenty-fivepatientswithCOPDrandomlyperformedthePBRTandUULEXwitharestof thirtyminutesbetweentwotests.Systolicbloodpressure(SBP),diastolicbloodpressure(DBP),heartrate(HR)andrespiratoryrate(RR)weremeasuredbeforeandaftereachtest.Immediatelyaftereachtest,participantsratedtheirperceivedrateofexertionforarmfatigueandsensationofdyspnoeausingmodifiedBorgscale.Statisticalanalysisincludedrepeated-measuresanalysisofvarianceandpost-hocDuncantests.Theincreasein cardiacvariableswasnotdifferentbetween the two tests (SBP:p=0.917;DBP:p=0.588andHR:p=0.764).DyspnoearatingsandlevelofexertionwerelargerfollowingUULEXcomparedtoPBRT(p=0.006andp=0.026,respectively).Thecardiac responses afterboth testswerecomparable,but respiratory responses (RRanddyspnoea) and arm fatiguewere triggeredmore easilywithUULEX.Although future studies on largersamplesarerecommended,findingsofthisstudyshouldbetakenintoconsiderationwhenselectingtestsforarmcapacityinpatientswithCOPD.PBRTandUULEXresultcomparablecardiacresponses,butdifferentrespiratoryresponsesandarmfatigue.

Keywords: Chronic obstructive pulmonary disease, upper limb fatigue, unsupported arm exercise test

INtRODUCtION

Patients with moderate to severe COPD oftendevelopdyspnoeawhenusingtheirarmsduringactivitiesofdailyliving(ADL)1.Theprogressivedeconditioningassociated with inactivity initiates a vicious cycle inwhichdyspnoeaoccursatprogressivelylowerphysicaldemands2.With time,patientsadopt irregular, shallow

and rapid breathing patterns while performing simplelow-intensitytasks3.

Common unsupported arm exercise tests include:maximum number of dowels arm lifts in 1 minute 4,incrementalunsupportedupperlimbexercise5,numberof rings moved vertically in 6 minutes 6, PBRT (Sixminute peg board ring test), UULEX (Unsupportedupperlimbexercisetest)orwithaupperarmexerciseelectromechanicaldevice7,8.

AstudydonebyJanaudis-Ferreiraet al , revealedthat arm ergometry may be best for measuring peakarmexercisecapacityandenduranceduringsupported

Corresponding author:sumana baidyaDepartmentofPhysiotherapy,KathmanduUniversitySchoolofMedicalSciences,DhulikhelHospital,Kavre,Nepal

DOI Number: 10.5958/0973-5674.2018.00014.X


exercises, while the UULEX, 6PBRT, and GST maybetter reflect ADLs and should be the tests of choicetomeasurepeakunsupportedarmexercisecapacityandarmfunction9.

UULEX is reproducible, inexpensive, andacceptabletopatientswithCOPDanddoesnotrequirea largeamountofspace.UULEXmimicsunsupportedmovementofupperlimbsrequiredinADLandissimpleto administer5. PBRT is a valid and reliable test tomeasurearmfunctionalcapacityinpatientswithCOPD.Itiscosteffectiveandsimpletoperform4.

Both tests measure arm function in patients withCOPD.Althoughtheresponsivenessandinterpretabilityof the UULEX or 6PBRT have not been specificallystudied, both tests demonstrate aspects of validity andreliability,requiresimpleequipment,andreflectADLsthat involve arm elevations 9.AsUULEX and 6PBRTboth are tests, which require unsupported upper limbactivity; it will be taxing on the cardio-respiratorysystem.There is a paucity of studies until nowwhichdetermines and compares cardio-respiratory responsesduring UULEX and PBRT. In addition, there are nostudieswhichdeterminewhichoftheabovetestsinducemorearmfatigue.

Theaimof the studywas todeterminewhich testinduces more arm fatigue and evokes more cardio-respiratoryresponsesamongpatientswithCOPD.

MetHoD

Participants

The study included 30male subjects with COPDvolunteered to participate in this study.However, twosubjects withdrew from the study as they could notperform thesecond testdue to fatigue,and threewereexcludedfromthestudyafterperformingthefirsttestastheydevelopedclinicallysignificantdyspneaduringthetest.Theremaining25subjectsperformedboththetestandtheyterminatedthetestduetofatigue.

Twenty-fivepatients with COPD, mean age (SD):59.6 (9.1) andFEV1 %ofpredictedvalue (SD):62.52(8.2)wererecruitedfromtwogovernmenthospitalsandoneprivateclinics.Patientswereclinicallystableattimeoftheirparticipationinthestudy.EachpatientunderwentaformalevaluationincludingPulmonaryFunctionTest(PFT)priortothestudy.PFTwasperformedasperthestandardsoutlinedbytheAmericanThoracicSociety10.

Thepatientsagedbetween45-75yearsofageanddiagnosedwithCOPD(withFEV145-75%ofpredictedvalue)wereselected.Thepatientswereexcludediftheyhad performed eitherUULEX or PBRT previously orperformed any upper limb exercise in preceding onemonth.Patientswithunstablecardiacconditions,upperlimb musculoskeletal disability preventing exercises,cor-pulmonale,respiratorymusclefatigue,hearingandvisualimpairments,acuteillnessandacuteexacerbationduringtheperiodofstudywereexcludedfromthestudy.The institution’s ethics committee approved the studyandallparticipantsprovidedinformedconsentpriortoparticipatinginthestudy.

Before the tests, heart rate (HR)11, blood pressure(BP)11, respiratory rate RR11, Borg scale for rate ofperceivedexertionforfatigueandbreathlessness12wasmeasured. Patients performed the PBRT and UULEXin random order with a rest of thirtyminutes betweenthe two tests. A 30-minute resting interval was givenbetween the PBRT and UULEX to avoid potentialfatigue.Testwasterminatedifpatientsreportedseverefatigueorbreathlessness.

ForPBRT, theparticipants sat in frontof aboardwith two lower (positioned at shoulder level) and twohigher pegs (at 20 cm above shoulders) and asked tomove as many rings as possible in 6 min. Ten rings(0.34 kg per ring)were put on each of the two lowerpegs. Patients were instructed to use both handssimultaneouslytomoveoneringatatimefromeachofthe lowerpegs toupperpegs, andviceversa.Patientswere permitted to stop and rest during the test if theyfeelseveredyspnoea,fatigue,orotherdiscomfort,andcontinuemovingthepegsassoonastheycan.

ForUULEX, participants sat in front of an eight-levelchartandraiseda0.2kgbarataconstantcadence(30beats/min).The test beginswith a 2-minutewarm-up, during which the patients extends their armssimultaneously,liftingbarfromaneutralpositiontothefirstlevel.Afterthewarm-up,theverticalamplitudeoftheliftincreasesby0.15meveryminuteasthepatientprogresses through the stages of the test. Once theparticipantreachedthehighest level, theweightof thebarwasincreasedby0.5kgeachminutetoamaximumof2kg.Thepatientcontinuedthetestaslongaspossibleuntilthesubjectfeelsbreathless5.

After both the tests, HR12, BP11 and RR11 were


measuredandthepatientratedthelocalmusclefatigueaccordingtoperceivedexertionfor local(arm)muscleusing themodifiedBorg 0-10 scale12. In addition, thepatientswereaskedtoratetheirsensationofdyspnoeausingtheBorg0-10scale12.

Data analysis

Repeatedmeasuresanalysisofvariancewasusedtoevaluatepre-testandpost-testoutcomevariables.Post-Hoc Duncan test was used to find out the significantdifference among variables. Pearson’s correlation testwasusedtofindoutrelationshipofvariables(HR,BPandRR).Spearmanrankordercorrelationtestwasdonetofindouttherelationshipofvariables(ModifiedBorgScale0-10fordyspnoeaandfatigue).StatisticalanalysiswasperformedbyusingStastistica64,version10.Alphavaluewassetas0.05.

REsULts

Themeanagewas59.6years(9.1)andmeanforcedexpiratoryvolumeinonesecond(FEV1)was62.5(8.2).TheoutcomevariablesaresummarizedinTable1.

Cardiacresponses:

Both the PBRT and UULEX resulted in asignificant increase in cardiac variables (HR:p≤0.001;SBP:p≤0.001;DBP:p≤0.001).Theincreaseincardiacvariableswasnotdifferentbetweenthetwotests(SBP:p=0.917, DBP: p=0.588andHR: p=0.764). Therewassignificant correlation between the two tests for allcardiac variables (SBP: r = 0.802, p≤ 0.01,DBP: r =0.701,p≤0.01;andHR:r=0.651,p≤0.01).(Figure1andFigure2)

Dyspnoearatingandrespiratoryrate:

There was a significant increase in respiratoryvariables (RR: p ≤0.001) and dyspnoea ratings (p≤0.001) after both tests. Compared with the changesobserved after PBRT, the magnitude of change wasgreater after UULEX, RR: p ≤0.002 and dyspnoearatings: p≤0.0006. There was a strong and significantcorrelation between the two tests for both respiratoryvariables(RR:r=0.772,p≤0.01,dyspnoearatings:r=0.794,p≤0.01).(Figure1andFigure2)

Perceivedrateofexertionratings:

AsignificantincreaseinPerceivedrateofexertionratings (p ≤0.001) was observed after each test. PRE

ratings for exertion showed greater changes afterUULEX thanPBRT (p≤0.026). Significant correlationwas found between the two tests for PRE ratings(r =0.599,p≤0.02)wasfound.(Figure1andFigure2)

DIsCUssION

There is no significant difference in increase inheartrateandbloodpressureafterUULEXandPBRT.BothUULEXandPBRTrequire thepatient toelevatethe arms in similar manner repetitively. But UULEXrequiresarmelevationtodifferentheightswhilePBRTrequiresarmelevationattwodifferentlevels.Thebloodpressureresponsesafter3differentarmpositionswerenotvaryinginpatientswithCOPD13.

UULEX test had showed significantly higherrespiratory responses, which may be due to thefactors such as increasing weights in UULEX, moreconcentrationrequiredbythepatients,wideramplitudeof shouldermovementsandwarmup time inUULEXascomparedtoPBRT.Somestudieshavedemonstratedthat the activities thatmaintain the arms elevated andunsupported produce a sensation of dyspnoea andthoraco-abdominal dyssynchrony14, an increase inoxygenconsumption(VO2)andminuteventilation(VE)

15 andanincrease incarbondi-oxideelimination(VCO2),respiratoryrate,andHR16.

Atrest,thediaphragmisdominantactiveinspiratorymuscle14. But during unsupported arm elevation,some of the upper torso muscles become involved inarm positioning and their participation in ventilationis decreased, there is a shift of ventilatory work todiaphragm. Also, arm elevation results in increaseddiaphragmaticworktomeetventilatorydemand15.

Velloso et alobserved that therewassignificantlyhigherrespiratoryresponseinactivitiessuchasliftingthepotsofvariousweightstoabovetheheadusingboththearmsincomparisontoactivitieslikeerasingblackboardandfixingthebulb17.Similarly,UULEXalsorequiresapersontoliftPVCpipesofincreasingweights,whichissimilartotheactivity,studiedbyVelloso et al.WhereasduringPBRT, the subject is only required to lift lightweightedringsforanumberoftimes.

Inthisstudy,thedyspnearatingsafterUULEXarealso significantly higher as compared to after PBRT.UULEX requires a great deal of physical effort bythe patients as the patient has to lift the PVC pipes


foranumberof timesatdifferent levelsat thebeatofmetronome. Velloso et al had found that any activitysuchasliftingpotswhichrequiresagreatdealofphysicaleffortbythepatientsandalsoinvolvethewideamplitudeofupperlimbmovementparticularlyshoulders,induceahigherperceptionofbreathlessness17.

TangriandWolffconcludedthatactivitiesrequiringahigherlevelofconcentrationleadpatientswithCOPDtoengageinshortperiodsofapneaduringtheseactivitiesand produces a sense of dyspnea2. As compared toPBRT,whichonlyrequiresthesubjecttoplacetheringsathisownpace,theUULEXtestiscumbersomeforthepatientandrequiresmoreconcentrationtoliftpipestobeatofmetronome.

The patients were given a warm up period of 2minutes before the UULEX test. But, in PBRT, theywere not given any warm up period. Only a practicemovementwasgiven.Thus,thepatientsmayhavebeenmore stressed before the commencement of UULEXas compared to PBRT. This may have led to higherrespiratory responses and perceived inpatients afterUULEX.

ThePerceivedrateofexertionratedbythepatientsafterPBRTandUULEXshowedsignificantdifferences.InUULEX,thepersonwasrequiredtoperformthetaskaccording to the beat of metronome, which allowed

no rest in between. But in PBRT test, the person canperformthetaskathisownpaceandisallowedtotakerestwithin the 6minute time period.Hence,UULEXinducedhigherPREforarmfatigue.

The limitation of the study was that participantswereonlymales.But,patientswithallseverityofCOPDwere included, so there is no reason to assume that itmighthaveaffectedtheresultofthestudy.

CONCLUsION

The cardiac responses after both tests werecomparable,butrespiratoryresponses(RRanddyspnae)and arm fatigue were triggered more easily withUULEX. The findings of this study should be takenintoconsiderationwhenselectingtestsforarmcapacityin patients with COPD. PBRT and UULEX result incomparablecardiacresponses,butdifferent respiratoryresponsesandarmfatigue.

table 1. baseline data, pre and post outcome variables

VariablesbaselineMean (sD)

Post PbRtMean (sD)

Post UULEXMean (sD)

SBP 137.8(4.6) 156.7(6.2) 156.8(6.5)

DBP 83.7(2.8) 86.5(3.7) 86.8(3.9)

HR 81.8(7.5) 98.1(6.3) 97.7(7.1)

RR 15.9(1.3) 21.2(2.0) 22.5(2.1)

PRE 0 6.3(1.2) 6.8(1.1)

Dyspnea 0 6.4(1.5) 7.2(1.2)

Figure 1: there was significant correlation between the two tests for all cardiac variables (sbP: r = 0.802, p≤ 0.01, DbP: r = 0.701, p≤ 0.01; and HR: r = 0.651, p≤ 0.01) (see fig 1 (A, b, C)), using Pearson’s correlation test. there was significant correlation between the two tests for both respiratory variables (RR: r = 0.772, p≤ 0.01, dyspnea ratings : r = 0.794, p≤ 0.01) and PRE ratings(r = 0.599, p≤ 0.02)(see fig 1 (D, E, F)).


Figure 2: Difference between baseline, pre-test and post- test outcome variables by using repeated measures analysis andPost-Hoc Duncan test.both the tests resulted in a significant increase in cardiac variables from baseline (HR:p≤0.001; sbP: p≤0.001; DbP: p≤0.001), but between UULEX and PbRt, the post- test variables were not significantly different,(sbP: p=0.917, DbP: p=0.588and HR: p=0.764)(see fig 2 (C,E,F)).there was a significant increase in respiratory variables (RR: p ≤0.001) and dyspnoea ratings (p≤ 0.001) after both tests and significant difference between post-test respiratory variables (RR: p ≤0.002 and dyspnea ratings: p≤0.0006)(see fig 2(A,b)).A significant increase in Perceived rate of exertion ratings (p ≤0.001) was observed after each test. PRE ratings for exertion showed significant changes after UULEX than PbRt (p≤0.026) (see fig 2(D)).


Conflict of Interest-Nil

REFERENCE

1. HollandAE,HillCJ,NehezE,NtoumenopoulosG.Doesunsupportedupperlimbexercisetrainingimprovesymptomsandqualityoflifeforpatientswith chronic obstructive pulmonary disease?Journal of cardiopulmonary rehabilitation.2004;24(6):422-7.

2. Tangri S, Woolf CR. The breathing patternin chronic obstructive lung disease during theperformance of some common daily activities.Chest.1973;63(1):126-7.

3. Celli BR, Rassulo J, Make BJ. Dyssynchronousbreathing during arm but not leg exercise inpatientswithchronicairflowobstruction.TheNewEnglandjournalofmedicine.1986;314(23):1485-90.

4. ZhanS,CernyFJ,GibbonsWJ,MadorMJ,Wu

YW.Developmentofanunsupportedarmexercisetestinpatientswithchronicobstructivepulmonarydisease.Journalofcardiopulmonaryrehabilitation.2006;26(3):180-7;discussion8-90.

5. Takahashi T, Jenkins SC, Strauss GR, WatsonCP, Lake FR. A new unsupported upper limbexercisetestforpatientswithchronicobstructivepulmonary disease. Journal of cardiopulmonaryrehabilitation.2003;23(6):430-7.

6. BreslinEH,AdamsE,LutzA,RoyC.Instrumentdevelopment in themeasurementof unsupportedarmexerciseendurance innormaladult subjects.Archivesofphysicalmedicineandrehabilitation.1993;74(6):649-52.

7. Breslin EH, Adams E, Lutz A, Roy C.Standardizationofadevicetomeasureunsupportedarm exercise endurance in chronic obstructivepulmonarydisease.Nursingresearch.1992;41(5):292-5.

8. Costi S, Crisafulli E, Antoni FD, Beneventi C,Fabbri LM, Clini EM. Effects of unsupported


upper extremity exercise training in patientswith COPD: a randomized clinical trial. Chest.2009;136(2):387-95.

9. Janaudis-Ferreira T, Beauchamp MK, GoldsteinRS, Brooks D. How should we measure armexercise capacity in patients with COPD? Asystematicreview.Chest.2012;141(1):111-20.

10. AmericanThoracicSociety.Lungfunctiontesting:selection of reference values and interpretativestrategies. American Thoracic Society. TheAmerican review of respiratory disease.1991;144(5):1202-18.

11. Wilkins RL, Dexter JR. Clinical assessment inrespiratorycare.4thed2010.

12. Borg GAV. Psychophysical bases of percievedexertion. Medicine and Science in Sports andExercise.1982;14(5):377-81.

13. BaarendsEM,ScholsAM,SlebosDJ,MostertR,JanssenPP,WoutersEF.MetabolicandventilatoryresponsepatterntoarmelevationinpatientswithCOPD and healthy age-matched subjects. The

European respiratory journal : official journalof theEuropeanSociety forClinicalRespiratoryPhysiology.1995;8(8):1345-51.

14. CelliB,CrinerG,Rassulo J.Ventilatorymusclerecruitment during unsupported arm exercise innormalsubjects.JApplPhysiol.1988;64(5):1936-41.

15. CouserJI,Jr.,MartinezFJ,CelliBR.Respiratoryresponse and ventilatory muscle recruitmentduring arm elevation in normal subjects. Chest.1992;101(2):336-40.

16. Criner GJ, Celli BR. Effect of unsupported armexercise on ventilatory muscle recruitment inpatients with severe chronic airflow obstruction.The American review of respiratory disease.1988;138(4):856-61.

17. VellosoM,StellaSG,CendonS,SilvaAC,JardimJR.Metabolicandventilatoryparametersof fouractivitiesofdaily livingaccomplishedwitharmsinCOPDpatients.Chest.2003;123(4):1047-53.

Prevalence of Anterior Knee Pain in Marathon Runners

Devashree s Mistry1, Leena Chilgar2, Ajay Kumar3

1Intern, 2Asst. Professor, 3Principal,DPO’S NETT College of Physiotherapy. Thane (W)

AbstRACt

background/purpose:Anterior knee pain (AKP) is a pain arising from the patellofemoral joint itselfspecifically called Patellofemoral Pain Syndrome (PFPS), it is a common problem among runners.5 Therefore,thenameimplies,runner’sknee.Runningwas,andcontinuestobe,thesportofchoiceformany,because of its convenience, health benefits& economical nature.5Over the last 10–15 years, there hasbeenadramaticincreaseinpopularityofrunningmarathons.4However,thepotentialforrunninginjurieshasincreased.Manybelievethatrunninginjuriesresultfromacombinationofextrinsicfactors(trainingerrors, old shoes, running surface) & intrinsic factors (poor flexibility, malalignment, previous injury,runningexperience).5Thusthemostaffectedjointisthekneejoint&themostcommonoveruseinjuryisthePatellofemoralPainSyndrome(PFPS).5MedicaldiagnosisofAKPhashistoricallyincludedmanydifferentconditions.PerhapsafunctionaldiagnosisasofferedbytheAKPQwouldbebetterthanamedicaldiagnosiswhentreatingpatientswithAKP.1Therefore,outcometoolssuchastheAKPQ,reportedvalidity(v=0.92)&reliability(r=0.92)1,2maybebettersuitedtodocumentsymptoms&chartprogressinpatientsduringtheirrehabilitation.1 Thepurposeofthisstudyis,toestimatetheprevalenceofAnteriorKneePain(AKP)inMarathonrunners.Andotherobjectiveswere,toreviewthemostaffectedcomponentofthequestionnaireandtoestimateagewiseprevalenceofAnteriorKneePain(AKP).

Method:Total100,male(n=48)andfemale(n=52)Marathonrunnerswithintheagegroupof15-30yearsold participated in this study, theywere surveyed forAnteriorKnee Pain& functional disability usingAnteriorKneePainQuestionnaire(AKPS)calledKujalascale.After thata totalscorewascalculatedofeachsubject.Acut-offof83ontheKujalascalewaschosentoidentifythoseindividualswithAnteriorKneePain(AKP).1

Result: 68% in the given population were positive forAKPQ and 32% were negative. Most affectedcomponentof thequestionnairewasPainonProlongedSittingaffecting51%.46%hadpainfulwalkingfor>2km.29%hadpainonrunningfor>2km,22%hadseverepain&14%wereunabletorun.AndtheleastaffectedcomponentwereAtrophyofThighmuscles&FlexionDeformitywhere82%hadnoflexiondeformity.Inaddition,injuriesoccurredwithahigherfrequencyinagegroupof23to25yearswith(meanage=23yearsold).

Conclusion:Thereis68%PrevalenceofAnteriorKneePain(AKP)inMarathonrunnersintheagegroupof15to30years.

Keywords: anterior knee pain, marathon runners, anterior knee pain questionnaire, kujala scale, prevalence.

Corresponding author:Dr. Leena Chilgar(PT)(Asst.Professor,DPO’SNETTCollegeofPhysiotherapy.THANE(W).

INtRODUCtION

Anterior knee pain (AKP) is a pain arising fromthe patellofemoral joint itself specifically calledPatellofemoral Pain Syndrome (PFPS). AKP or PFPShas been described as a common diagnosis among

DOI Number: 10.5958/0973-5674.2018.00015.1


young, active individuals.1 The termsAKP and PFPSareoftenusedsynonymouslytodescribethissyndrome,characterizedbykneepainrangingfromseveretomilddiscomfort seemingly originating from the contact oftheposteriorsurfaceofthepatellawiththefemur,thatincludespain in theanteriorpartof theknee.PFPS isa common problem among runners.5 Therefore, thename implies, runner’s knee. However, it may takeplaceinathletesthatareinvolvedinactivitiesrequiringfrequentkneebending,suchasjumping,bikingandevenwalking.

Running was, and continues to be, the sport ofchoice for many, because of its convenience, healthbenefits & economical nature.5 Over the last 10–15years, therehasbeenadramatic increaseinpopularityof running marathons.4 However, the potential forrunning injuries has increased. Many believe thatrunning injuries result fromacombinationofextrinsic(trainingerrors,oldshoes,runningsurface)&intrinsicfactors(poorflexibility,malalignment,previousinjury,running experience).5 Thus the most affected joint isthe knee joint & the most common overuse injury isthe PFPS.5Many etiological factors have been linkedto AKP. These factors can be broadly grouped underthefollowing:Muscular,Structural&TrainingFaults.Amongst these faults, researches have shown that thecombinationofthesefactorshavethehighestco-relationinpredictingthedevelopmentofAKP.

Diagnosis of AKP is usually determined bythe patient’s report of symptoms, rather than anycombinationofclinicalorfunctionaltests.1

Therefore,Signs&symptomsareasfollows,onsetof this condition is usually gradual. Most commonsymptomisdiffuseperipatellarpain(vaguepainaroundthekneecap)&localizedretropatellarpain(painfocusedbehindthekneecap).Affectedindividualstypicallyhavedifficulty describing the location of the pain, & mayplacetheirhandsoveranteriorpatellaordescribeacirclearound the patella (the “circle sign”). Pain is usuallyinitiatedwhenloadisputonkneeextensormechanism,e.g.ascendingordescendingstairsorslopes,squatting,kneeling, cycling, running or prolonged sitting withflexed knees. Latter feature is sometimes termed the“movie sign” or “theatre sign” because individualsmightexperiencepainwhile sitting towatchafilmorsimilaractivity.Painistypicallyachingwithoccasionalsharppains.Youmayalsoexperienceoccasionalknee

buckling, inwhich theknee suddenly&unexpectedlygivesway&doesnot supportyourbodyweight. It isalsocommontohaveacatching,orgrindingsensation&somecrackingsoundswhenyouarewalkingorwhenyouaremovingyourkneeespeciallybending.Presenceoftendernessintheinnerborderofthepatella.Insomecases, any sort of activity leads to development ofswelling.InchroniccasesofPFPS,thereispresenceofquadricepsmuscleatrophy.

MedicaldiagnosisofAKPhashistoricallyincludedmany different conditions. Perhaps a functionaldiagnosisasofferedbytheAKPQwouldbebetterthanamedicaldiagnosiswhentreatingpatientswithAKP.1 Severalauthorshave found little tonovalidity for thecommon clinical tools used to assess individualswithAKP.1 Furthermore, the diagnosis is usuallymade byruling out other conditions.1 Therefore, outcome toolssuch as the AKPQmay be better suited to documentsymptoms & chart progress in patients during theirrehabilitation.1

AKPQwasusedasthefunctionaloutcometool&itwaschosenbecausethereportedvalidity(v=0.92)&reliability(r=0.92)forthetestweredeemedadequate.1,2 However, it is easy to administer & subjects havereportedthatitwaseasytocomplete.1

Andasagreaterpercentageofthepopulationnowparticipates in running in Marathons. It is better tounderstandthecurrentscopeofthemostcommonkneeinjuriesthatisPFPSthatrunnersencounter.

MAtERIAL AND MEtHOD

1. stUDY DEsIGN

TYPEOFSTUDY:Observationalstudy.

MATERIAL USED FOR STUDY: AKPquestionnaire(Kujalascale).

DURATIONOFSTUDY:6Months.

LOCATION: Parks and jogging tracks ofmetropolitancity.

2. sAMPLING DEsIGN

SAMPLINGMETHOD:Convenientsampling.

SAMPLEPOPULATION:Marathonrunners.

SAMPLESIZE:100.


3. sELECtION CRItERIA

INCLUsION CRItERIA:

• Runnerswillingtoparticipateinthestudy.

• Individuals participating inMarathon runningonregularbasesforpast6months&more.

• Agegroupof15-30years.1,5

• Bothmalesandfemales.

• Running a minimum of 40 miles/week thatcomesto9km/day.4

EXCLUsION CRItERIA:

• Ligamentinjury.

• Meniscaltear.

• Bursitis.

• AnypastFractures.

• Anypastkneesurgery.

• Iliotibialbandfrictionsyndrome.

• Patellartendinitis/Jumpersknee.

• Osteoarthritisintheknee.

• Rheumatoidarthritis.

• PoplitealCyst(Baker’sCyst).

• Referredpainfromthehipjoint&fromlumbarspine.

PROCEDURE

Total of 100, males (n=48) & females (n=52)Marathonrunnerswithin theagegroupof15-30yearswere surveyed for Anterior Knee Pain usingAnteriorKnee PainQuestionnaire (AKPS) calledKujala scale.Before handling the questionnaire, each subject hadbeen given detailed information about the purposeof study. Consent was taken in the language bestunderstood by them. Various sections and optionalanswersgiveninthequestionnairewillbetranslatedinthelanguageunderstoodbysubjects,theyhavetomarkoneboxineachsectioninwhichthescoreisrated.TheythencompletedtheAKPQcalledKujalascale,basedontheircurrentsymptoms&functionalabilities.Afterthata total scorewas calculatedof each subject.A cut-offof83ontheKujalascalewaschosentoidentifythoseindividualswithAKP.1Number of subjectswhowereconsideredtobepositiveforAKPasdeterminedbytheKujalascalewerecounted.

FINDINGs

GRAPH-1 shows Prevalence of Anterior Knee Pain (AKP) in the given population.

REsULts: Pie diagram shows that 68% ofindividuals have Anterior Knee Pain & 32% ofindividualsdonothaveAnteriorKneePain.

GRAPH-2 shows number of individuals in the given population, affected by each component in the questionnaire.

REsULts:Abovedatastatesthatthemostaffectedcomponent of the questionnaire is Pain on ProlongedSittingandtheleastaffectedcomponentareAtrophyoftheThighmusclesandFlexionDeformity.


GRAPH-3 Age wise Prevalence of Anterior Knee Pain (AKP) from the total sample size into Affected and Non-Affected ones.

REsULts:Abovedatastatesthat,thereishighestPrevalenceofAKPintheagegroupof22-25years.

DIssCUsION

Graph1 showed68% in thegivenpopulationhadAKPamongMarathonrunners.Factorsthathavebeenlinked to AKP are Muscular, Structural & TrainingFaults. Running injuries results from a combinationof these extrinsic (training errors–training on hardsurfaces,oldshoesorprematurechangeoffootwear)&intrinsicfactors(poorflexibility,malalignment,patellardisorientation, previous injury, running experience).5 OneofthemaincausesofPFPSisthepatellarorientation&alignment.Whenthepatellahasadifferentorientation,itmayglidemoretoonesideofthefemur&thuscancauseoveruse/overload(overpressure)onthatpartofthefemurwhichcanresultinpain,discomfortorirritation.A study has shown that patientswith PFPS displayedweakerhipabductormusclesthatwereassociatedwithan increase inhipadductionduring running (muscularimbalance).Thisalters thepressuresunder thesurfaceof thepatella, causing aprematurewearingout of thecartilage&increasingtheriskofdegeneration&pain.

Graph 2 shows, the most affected componentof all was Q.8 Pain on Prolonged Sitting option d,which states, Pain forces them to extend their kneestemporarily, affecting 51% of the given populationshowcasing classical “movie theatre sign”. Sitting forprolongedperiodoftime,increasescompressiveforcesonthekneejoint,byextendingknees,itminimizestheforcesactingonkneejointprovidingrelief.10

2nd most affected component was Q.9 Pain, with37%hadslightpainoccasionally,31%statestheirpaingetsoccasionallysevere&21%hadpaininterferingtheir

sleep,abnormalpositionofthepatellaincreasesunduestresses on the cartilage & irritates the surroundingstructuresleadingtopain&discomfort.

61%werewithslightlimping,itisusuallyinitiatedwhen load is put on the knee extensor mechanismcausingforcesonkneejointtoincrease,itsuddenly&unexpectedlygivesway&doesnotsupportyourbodyweight.10

52% had painful weight bearing support, astudy says gliding of the patella in PFPS in standingposition had significantly increased lateral translation(maltracking),lateralpatellarspin&atendencytowardsincreased lateral tilt compared to healthy subjects,7 causinginstabilityofkneejoint.10

46%hadpainfulwalkingfor>2km,patellofemoraljoint reaction forces can become very high duringroutine daily activities. During the stance phase ofwalking,whenpeakkneeflexionisonlyapproximately20 degrees, the patellofemoral compressive force isapproximately25%-50%ofbodyweight.10Also,duetolackofpronationofrearfootonheelstrikeincreasingthestrainthatthekneeundergoesduetolackofabsorptionof the ground reaction force.7 Also athletes with pescavusorhigharchfoottypehaveasmallersurfaceareaofcontactthusincreasingthegroundreactionforce.

41% had abnormal painful kneecap patellarmovementsoccasionallyinsportsactivities&30%hadindailyactivities,duetothedamagedcartilagebeneaththekneecapcausingfriction&pain.

36% were suffering from slight pain whendescendingstairs&22%hadpainonbothascending&descending,asloadisputonkneeextensormechanismon stair climbing causing pain.Also, an imbalance intheactivationofthemuscleswherevastuslateraliswasearlier activated than vastus medialis obliquus whenpatientsclimbeddownstairs&upstairs.7

29% had pain on running for > 2 km, 22% hadseverepain&14%wereunable to rundue to lackofstrength, muscular imbalance of quadriceps correlateswith an increased impact on the knee during a runcausing biomechanical abnormality that may lead topatellar deviation& also provoke PFPS.With greaterknee flexion & greater quadriceps activity, as duringrunning, patellofemoral compressive forces have beenestimated,toreachbetween5-6timesbodyweight.10


Least affected component was Q.12 Atrophy ofthighmuscles,wherenoindividualshadatrophyofthighmusclesasitspresentonlyinsevere&chroniccasesofAKP,wheresevereweaknessofquadricepsispresent&isthecausativefactorforPFPS,&inthepopulationofthisstudytherewerenochroniccases.

2nd least affected component was Q.13 Flexiondeformity where 82% had no flexion deformity, but18%hadaslightflexiondeformity that isdue to tighthamstrings because of lack of stretching or passiveinsufficiency.7

69%hadnoswelling&18%hadswellingonsevereexertion, this signmay or may not be present due toinflammatoryreactions.10

36% had no difficulty in squatting whereas 29%had repeated squat painful, maltracking of the patellaplaysakeyrolefore.g.patientswithaPFPSsquatwithincreased lateralization & increased lateral tilt of thepatella& also a hypermobile patella had a significantcorrelationwiththeincidenceofpatellofemoralpain.7

31%hadnodifficultyinjumpingwhereas28%haddifficultyinjumping,painonjumpingismainlycauseddue patellar tendonitis (Jumpers knee) because theforcesactingonquadricepsextensormechanismwhichcauses the stress on patellar tendon. In PFPS there isdecreasedstrengthofhipabduction,externalrotation&extensionmuscles.Itisfoundthatdecreasedstrengthofmusclesgluteusmedius&gluteusmaximusisrelatedtoincreasedkneevalgusafterlandingadropjump.7

Graph3,showedAgewisePrevalenceofAKPintheagegroupof15-30years(Meanage=23years)stating,with increasingage there is increase in theprevalenceofAKPuptotheageof25years,maximumat24yearsold,aftertheageof25,therateofprevalenceofAKPgradually declines.As, runners of higher calibre havemore running experience&agreater ability to “listento the language of their body”, which are thought tocontributenegativelytotheincidenceofrunningrelatedinjuries.5Inaddition,certainpeoplemayhavedevelopedananatomicaladaptationtorunning&thusmaybeabletoavoidoveruseinjuriestoalargerextent.

Themostcommonoveruserunninginjury20yearsago was patellofemoral pain & this is still the casetoday.5

CONCLUsION

Thisstudyconcludedthatthereis68%PrevalenceofAnteriorKneePain(AKP)inMarathonrunnersintheagegroupof15to30years in100samples.Themostaffected component of the questionnaire was Pain onProlongedSittingandtheleastaffectedcomponentwereAtrophyof theThighmusclesandFlexionDeformity.Inaddition,injuriesoccurredwithahigherfrequencyinagegroupof22to25years.

Conflict of Interest: None.

source of Funding:Self.

Ethical Clearance: Obtained by DPO’S NETTcollegeofPhysiotherapy.

REFRENCEs

1. JamesR.Roush,&R.CurtisBay,etal.PrevalenceofAnteriorKneePainin18–35yearoldfemales.International Journal Sports Physical TherapyAugust2012,Volume7,Issue4,pg396-401.

2. Richard F. Ittenbach, Guixia Huang, Kim D.Barber Foss, Timothy E.Hewett,&GregoryD.Myer,etal.Reliability&ValidityoftheAnteriorKnee Pain Scale: Applications for Use as anEpidemiologic Screener. PLoS One July 2016,Volume11,Issue7.

3. M.Boling,D.Padua,S.Marshall,K.Guskiewicz,S.Pyne,&A.Beutler,etal.Genderdifferencesintheincidence&prevalenceofpatellofemoralpainsyndrome.ScandJMedSciSports.October2010.Volume20,Issue5,pg725–730.

4. MichaelFredericson&AnuruddhK.Misra,etal.Epidemiology&AetiologyofMarathonRunningInjuries.SportsMedicineApril2007,Volume37,Issue4–5,pg437–439.

5. J E Taunton, M B Ryan, D B Clement, D CMcKenzie, D R Lloyd-Smith, B D Zumbo. Aretrospectivecase-controlanalysisof2002runninginjuries.BritishJournalofSportsMedicine2002,Volume36,Issue2,pg95–101.

6. Kujala UM, Jaakkola LH, Koskinen SK,Taimela S, Hurme M, Nelimarkka O. Scoringof patellofemoral disorders. Arthroscopy. April1993,Volume9,Issue2,pg159–63.

7. Wolf Petersen, Andree Ellermann, AndreasGösele-Koppenburg,RaymondBest,IngoVolker


Rembitzki, Gerd-Peter Brüggemann & ChristianLiebau. Patellofemoral pain syndrome. KneeSurgerySportsTraumatologyArthroscopy.2014,Volume22,Issue10,pg2264–2274.

8. Robert Stahl, Anthony Luke, C. BenjaminMa, Roland Krug, Lynne Steinbach, SharmilaMajumdar, Thomas M. Link. Prevalence ofpathologic findings in asymptomatic knees ofmarathon runners before and after a competitionincomparisonwithphysicallyactivesubjects—a3.0Tmagneticresonanceimagingstudy.Skeletal

Radiology. July 2008, Volume 37, Issue 7, pp627–638.

9. Dr.AManoharan,Dr.PSelvaraj&Dr.VAnjanRamachandranath. Prevalence of anterior kneepain in 20-40 years old adults attending orthoOPD in a tertiary care hospital in Tamil Nadu.International Journal of Orthopaedics Sciences2016,Volume2,Issue4,pg244-247.

10. PamelaK.Levangie&CynthiaC.Norkin. JointStructure&Function:AComprehensiveAnalysis.4thEdition,Section4,Chapter11,pg420-430.

to Compare the Effectiveness of tendo-achilles and Plantar Fascia stretching with Ultrasound with Planta Fascia

stretching and Ultrasound in Plantar Fasciitis

shweta Kulkarni1, sunil K M2, Prashant Mukkannavar3

1Assistant Professor, 2Principal, 3Professor, SDM College of Physiotherapy, Karnataka, Dharwad, India

AbstRACt

Objectives:Thisstudywasdonetocomparetheeffectivenessofgroupreceivingcombinationofplantarfasciastretching,tendoAchillesstretchingandultrasoundwithgroupreceivingplantarfasciastretchingandultrasoundaloneinplantarfasciitis.

Design: AnExperimentalstudy.

Method: Thirtyparticipantswiththeclinicaldiagnosisofplantarfasciitiswererandomlyallocatedintwogroups.Group‘A’receivedplantarfasciastretching,tendoAchillesstretchingandultrasoundandGroup‘B’plantarfasciastretchingandultrasound.TheoutcomewasassessedintermsofVisualAnalogueScale,FootFunctionIndexandRangeofMotionofAnkle.

Results: WhenVAS,FFIandDorsiflexionROMmeanscoresforwithinthegroupsandbetweenthegroupswasanalyzed,therewasstatisticalsignificantdifferenceforwithinthegroupsandtherewasnostatisticalsignificantdifferencebetweenthegroups.

Conclusion: Therewas no significant difference in comparison of the effectiveness of group receivingcombination of plantar fascia stretching, tendoachilles stretching and ultrasound with group receivingplantarfasciastretchingandultrasoundaloneinplantarfasciitisonOutcomemeasures.

Keywords: Plantar fasciitis, Stretching, Ultrasound therapy.

Corresponding author: Dr. shweta Kulkarni AssistantProfessorE-mail:[email protected],Address:SDMCollegeofPhysiotherapy,Karnataka,Dharwad,India

INtRODUCtION

Plantar fasciitis is an inflammation of the plantarfascia and the perifascial structures. It is classifiedas a syndrome resulting from repeated trauma to theplantarfasciaatitsoriginonthemedialtubercleofthecalcaneus.1Plantar fasciitis is estimated to account for11to15%ofallfootsymptomsrequiringprofessionalcareamongadults.2,3Theincidencereportedlypeaksinpeoplebetweentheagesof40and60yearsingeneralpopulation and in younger people among runners.3Theconditionis thought tobemultifactorial inorigin

with factors such as increased age, decreased ankledorsiflexion due to tightness of the Achilles tendonand first metatarsophalangeal joint range of motion,obesityandexcessiveperiodsofweight-bearingactivitycommonly suggested to be involved. The literatureattributes plantar fasciitis to faulty biomechanics suchas excessive pronation. Structural deformities suchas forefoot Varus may result in excessive pronationduring gait. Over pronation contributes to excessivefootmobility,which can increase the level of stressesappliedtothemusculofascialandsofttissueelongationandincreasedtissuestress.2,3,4,5

Theclassicpresentationofplantar fasciitis ispainon the sole of foot at the inferior region of the heel.Patient reports thepain tobeparticularlybadwith thefirst step taken on rising in the morning or after anextendedrefrainfromweightbearingactivity.Afterfew

DOI Number: 10.5958/0973-5674.2018.00016.3


steps and through the courseof theday, theheelpaindiminishes, but returns if intense or prolongedweightbearingactivityisundertaken.Initialreportsofheelpainmaybediffuseormigratory;withtimeusuallyfocusesaround the area of the medial calcaneal tuberosity.Generally,painismostsignificantwhenweightbearingactivitiesareinvolved.6

A wide variety of management strategies havebeendeveloped to treat thedisorder.Theconservativetreatmentapproachesusedinplantarfasciitisareuseofheelpads,orthoses,steroidinjections,nightsplintsandextracorporealshockwavetherapy.

VariousphysiotherapytreatmentprotocolshavealsobeenadvocatedinthepastinwhichIontophoresis,Ice,Ultrasoundwere commonly used in the treatmentof plantar fasciitis.7 Ultrasound is a high frequencysoundwaveandmostlyused treatmentof choicewithanaffinityfortendonsandligaments(highlyorganized,withouthighwatercontent).8,9

Stretching and strengthening programs play animportant role in treatmentofplantar fasciitisandcancorrect functional risk factors such as tightness of thegastrosoleus complex and weakness of intrinsic footmuscles.Stretchingincludesgastrosoleusstretchingandplantarfasciastretching.9,10

Many studies concluded on stretching of plantarfasciaandstretchingoftendoAchillesaloneareeffectiveintreatingplantarfasciitis.8,10,11,15,18Althoughultrasoundisalsoprovedtobeeffectiveintreatingpaininplantarfasciitis.8,10,11,12,20,21Butnotmanystudieshavecomparedandassessedeffectivenessbycombinationofultrasound,tendoAchillesstretching andplantarfasciastretchingonoutcome measures. We conducted a study based oncombinationofallthreetreatmentproceduresinplantarfasciitispopulationtoknowtheireffectiveness.

HYPotHesIs

NULL HYPOtHEsIs (H0) – There will be nosignificantdifferenceincomparisonoftheeffectivenessof group receiving combination of plantar fasciastretching,tendoAchillesstretchingandultrasoundwithgroupreceivingplantarfasciastretchingandultrasoundaloneinplantarfasciitisonOutcomemeasures.

ALtERNAtE HYPOtHEsIs (H1) - Therewill be significant difference in comparison of theeffectiveness of group receiving combination of

plantar fascia stretching, tendoAchilles stretchingandultrasoundwithgroupreceivingplantarfasciastretchingand ultrasound alone in plantar fasciitis on Outcomemeasures.

MEtHODOLOGY

source of Data- All the subjects with plantarfasciitis, reported toOrthopedicDepartmentwhoweredirected to physiotherapyOPD,SDMmedical collegeandhospitalDharwad.

study Design- Experimentalstudy

sample size- 30subject

Duration of studty-oneyear

CRItERIA FOR sAMPLING

Inclusion Criteria:

1.SubjectsAgerangeisfrom18-60yrs.

2.Subjectswithclinicaldiagnosisofplantarfasciitisfor4weeksorlonger.

Exclusion Criteria:

1.Subjectswithclinicaldisorderswheretherapeuticultrasoundis

contraindicated.

2. Subjects with referred pain due to sciatica andotherneurologicaldisorders.

3.Subjectswhoreceivedcorticosteroidinjectionintheheelinpast3months.

4.Oldfractures,Deformitiesandinstabilitiesatfootandankle,Arthritisofankle,Metatarsalgia.

MAtERIALs

1)UltrasoundEquipment(electroson709).

2)UniversalGoniometer.

3)UltrasonicGel.

4)Towel.

MAIN OUtCOME MEAsUREs

1) Visualanalogscale(VAS).

2) Footfunctionindex(FFI)and


3) RangeofmotiononGoniometer.

PROCEDURE

EthicalapprovalforthetrialwasobtainedfromtheinstitutionalethicalCommittee.

A convenient sample of 30 subjects who werediagnosed for plantar fasciitis, were selected in thestudy. In each group 15 subjects were allocated byconcealed envelope method. Subjects who providedinformed consent were randomly allocated to one oftwogroups:Group A: aninterventiongroupreceivingplantar fascia stretching and tendoAchilles stretching,with ultrasound Group b: a control group receivingplantarfasciastretchingwithultrasound.

Both the groups received ultrasound. Ultrasoundwith output of 1W/cm2 for 5 minutes using a pulsedmode1:4ratiowithfrequencyof1MHZfor10sittingsfor10sessionsweregivenfortheboththegroups.9,20,21

Plantar fascia stretching was given by therapist,subjects insittingwith footplacedacross theoppositeknee.Thentherapistheldonehandattheheelandoneatmetatarsalregionandappliedastretch.19

TendoAchilles stretching was also carried out bythe therapist,subjects insupineposition.The therapistgrasped the patient’s heel and stretched the heel.TendoAchilles stretching was given only to Group‘A’.19

All subjectsweregiven therapy formaximum tensessions. Both the stretching exercises were given toboththegroupsfor10timespersessionandthestretchwassustainedfor30seconds.

Self-stretching exercises for plantar fascia andtendoAchillesweregiventotheboththegroupsduringtheirdischargetodoathome.19

Outcome measures VAS, FFI and ROM weremeasured pre-and post-interventions and data thusobtainedwasusedforstatisticalanalysis.

DAtA ANALYsIs

StatisticalanalysiswasdonebyusingSPSSversion16 software. The descriptive statistics were analyzedusing Mean and Standard deviation for the baselinecharacteristics. The Wilcoxon matched paired testby rank was used to analyze the difference in visualanalogue scale scoring from baseline to 10th day oftreatmentforboththegroups.Thedifferencesinvisualanalogue scale scoring between the two groups wereanalyzed by usingMann –WhitneyU test. Range ofmotion and foot function index values between andwithinthegroupswereanalyzedusingpairedttestandIndependentttest.

REsULts

ThemeanageofGroup‘A’was52.3(8.4)andthemeanageofGroup‘B’was47.6(13.7).ThetotalMeanagebetweenthegroupswas49(11.4).ThemeanageofMaleswas50.7(11.5)andFemaleswas48.1(11.6).

table 1: Comparison of pre and post treatment VAs scores in Group ‘A’ and Group ‘b’ by Wilcoxon matched paired test by ranks

Group treatment Mean sD Mean diff sD diff. % of change Z-value p-value

A Pre 8.0 0.7

Post 3.0 0.8 5.0 1.1 62.8 3.4 0.0007*

B Pre 8.2 0.8

Post 3.1 0.7 5.0 0.6 61.3 3.4 0.0007*

*Significantat5%levelofsignificance(p<0.05),SD:standarddeviation

When theVASscoreswerecompared forwithinandbetween thegroups, therewasa significantdifferencewithinthegroups(p=0.0007)and nosignificantdifferencebetweenthegroups.


table 2: Comparison of pre and post treatment Foot Function index scores in Group ‘A’ and Group ‘b’ by paired t-test

Group treatment Mean sD Mean diff sD diff. % of change

Paired t-value p-value

A Pre 365.8 48.4

Post 66.2 14.6 299.6 40.8 81.8 28.3 0.0000*

B Pre 374.5 51.3

Post 59.9 15.1 314.6 47.3 84.0 25.7 0.0000*

*Significantat5%levelofsignificance(p<0.05)

WhentheFootFunctionIndexscoreswerecomparedforwithinandbetweenthegroups,therewasasignificantdifferencewithinthegroups(p=0.0000)and nosignificantdifferencebetweenthegroups.

table 3: Comparison of pre and post treatment Dorsiflexion scores in Group ‘A’ and Group ‘b’ by paired t-test

Group treatment Mean sD Mean diff sD diff. % of change

Paired t-value p-value

A Pre 9.4000 1.5491

Post 16.1333 2.0999 -6.733 2.1865 -84.7328 -11.9272 0.0000*

B Pre 9.4000 1.5491

Post 15.466 2.6690 -6.066 2.8900 -80.7416 -8.130 0.0000*

*Significantat5%levelofsignificance(p<0.05)

Whenthedorsiflexionrangescoreswerecomparedfor within and between the groups, there was asignificantdifferencewithinthegroups(p=0.0000)and nosignificantdifferencebetweenthegroups.

DIsCUssION

The purpose of this study was to evaluate theeffectivenessofultrasound,plantarfasciastretchingandtendoAchillesstretchingincombinationascomparedtoultrasoundandplantarfasciastretchingaloneinsubjectswithplantarfasciitis.

Our results revealed that, therewas no significantdifference in comparisonof the effectivenessof groupreceiving combination of plantar fascia stretching,tendoAchilles stretching and ultrasound with groupreceivingplantarfasciastretchingandultrasoundaloneinplantarfasciitisonoutcomemeasures.

Whentheanalysiswasdonewithinthegroupsforpre and post treatment using VAS for assessment ofpain,themeandifferenceforGroup‘A’was5with62%andtheMeandifferenceforGroup‘B’wasalso5with

61%.Boththegroupsshowedastatisticalsignificancewithap=0.0007.

The significant decrease in pain in terms ofVASforboththegroupsmaybewiththeusageoftherapeuticultrasound in addition to other treatment. In a similarstudyperformedbyHanaHronkovain2000thegroupwhich received therapeutic ultrasound for plantarfasciitisshowedsignificantdifferenceintermsofpain.Painreliefoccursdue tonon-thermaleffectsofpulsedultrasoundintheformofstimulationofhistaminereleasefrommast cells and factors related frommacrophagesthataccelerates thenormalresolutionof inflammation.Therapeutic ultrasound has the potential to acceleratenormal resolution of inflammation provided that theinflammatory stimulus is removed. 9,20,21 Thereforewecanassumethatthisthemechanismbehindpainreliefinboththegroups.Whenbetweenthegroupsanalysiswasdone,therewasnostatisticalsignificance.Thismaybeduetothesimilarvaluesatbaselineandposttreatmentinboththegroups.

OurstudyanalyzedFootFunctionIndexasawholeand the three different subscales of FFI separatelybetween and within the groups. When the subscales


wereindividuallyanalyzedbetweenboththegroupsforpreandposttreatmenttherewasnosignificantchange.WhenthewholeofFootFunctionIndexscoreswastakeninto consideration there was a significant differencewithin the groups but no statistical significance wasfoundbetweenthegroups.

Previously also there were similar findings withtheauthorDiGiovanni.Hehadusedonly thefirst fewitemsofthepainsubscaleoftheFFIasprimaryoutcomemeasure.Hementionedinhisstudythatroutinelyintheclinicalpractice,subjectswithplantarfasciitisroutinelycomplained about the severe pain with the first fewstepsinthemorningandfocusonthepainwhenitisatitsworst.Atthestartofthestudytheauthorschosetoindependentlyanalyzeitems,sincethesewerethoughttobemostclinicallyrelevant to thesubject’scomplaints.Whenthescoreswerecombinedforalltheitemsalongwiththeinclusionoftheeffectsofwalkingbarefootandwalking with use of shoes, no significant differenceswere detected between the groups. Many subjectsreported that they never stood or walked barefootbecause of pain.15 Hencewe can attribute the activitylimitation and disabilityweremainly due to the pain.Aspainwasbetteractivitieswerebetteranddisabilitywas less. Therefore, overall FFI when analyzed wassignificantwithinthegroups.

Whenthedorsiflexionscoreswereanalyzedwithingroup showed significant difference. Improvement indorsiflexionrangemaybeattributedtostretchingeffectsas when a muscle is stretched there is elongation, atensioniscreatedinthemuscleandwhenthestretchisheld there isdisruptionof thecross-bridges leading toabruptlengtheningofmuscle.36

Sincethetreatmentwasgivenwithcombinationofultrasound and stretching has led to reduction in painin both the groups. According to DiGiovanni, plantarfascia stretching will help in recreating the windlassmechanism and to limit repetitive micro trauma andassociatedinflammation.15

Althoughthepreviousstudieshavedocumentedthatriskfactorsofplantarfasciitisincreaseasrangeofankledorsiflexionreduces.2,3,15,16Ourstudyshowedapositivecorrelation between reduced ankle dorsiflexion rangeandsymptomsofplantarfasciitis,butspecificstretchingof tendoAchilles to improve dorsiflexion range didnot show any effect on outcomemeasures.Hence the

improvementindorsiflexionrangemaybeattributedtoreducedinflammationofplantarfasciaorreducedpain.14,15,17

CONCLUsION

Based on the results of our study, there was nosignificantdifferenceincomparisonoftheeffectivenessof group receiving combination of plantar fasciastretching,tendoachillesstretchingandultrasoundwithgroupreceivingplantarfasciastretchingandultrasoundalone in plantar fasciitis on Outcome measures.Although the previous studies have documented thatriskfactorsofplantarfasciitisincreaseasrangeofankledorsiflexionreduces.2,3,15,16Ourstudyshowedapositivecorrelation between reduced ankle dorsiflexion rangeand symptoms of plantar fasciitis, however specificstretching of tendoAchilles to improve dorsiflexionrangedidnotshowanyeffectonoutcomemeasures.

LIMITATIONOFTHESTUDY

• Samplesize–small

• Study has no long term follow up and itwasconductedinshortduration.

FUTURESCOPEOFSTUDY

• Long term effect and follow up studies withlargesamplesizecanbeconducted.

• Studieswithcombinationofdifferenttreatmentscombinedwithourtreatmentapproachescanbedone.

• Differentdurationofstretchingandultrasoundcanbeusedandstudiedfurtherintreatmentofplantarfasciitis.


Conflict of Interest: Nil

REFERENCEs

1. LoriA.Bolgla;TerryR.Malone:Plantarfasciitisand theWindlass Mechanism: A Biomechanicallink to Clinical Practice, Journal of AthleticTraining2004;39(1):77-82.

2. Cornwall MW, McPoil TG. Plantar fasciitis:etiologyandtreatment.JOrthopSportsPhysTher1999;Dec29:756-760.

3. Rachelle Buchbinder: Plantar fasciitis: clinical


practice, The new England journal of medicine2004;May20;350:2159-66.

4. Craig C. Young; Darin S. Rutherford; Mark WNidefeldt:Treatmentofplantarfasciitis,AmericanFamilyPhysicianFeb12003;63(3):467-474.

5. KwongPK,KayD,VonerRT,WhiteMW.Plantarfasciitis. Mechanics and pathomechanics oftreatment.ClinicsinSportsMedicine1988;7:119-26.

6. DavidD.Dyck;LoriA.Boyajian:Plantarfasciitis,ClinicalJournalSportsMedicine;Sep2004;14(5);305-309.

7. RadfordAJ,LandorfBK,BuchbinderRachelle,CookCatherine.Effectivenessof low-Dye tapingfortheshort-termtreatmentofplantarheelpain:arandomizedtrial.BMCMusculoskeletalDisorders2006,7:64.

8. Thomas L J, Christensen C J, Kravitz R S,MendicinoWR.TheDiagnosisandTreatmentofHeelPain:AClinicalPracticeGuideline–Revision2010. The Journal of Foot & Ankle Surgery 49(2010)S1–S19.

9. TisdelCL,DonleyBG,SferraJJ.Diagnosingandtreatingplantar fasciitis: a conservative approachto plantar heel pain. ClevelandClinic Journal ofMedicine1999;66:231-5.

10. Hooper PD. Physical Modalities A Primer forChiropractic. Baltimore, USA: Williams &Wilkins,1996:86–91.

11. Kuhar Suman; Khatri Subash; Jeba. Chitra:Effectiveness of MFR in treatment of plantarfasciitis:ARCT,IndianJournalofPhysiotherapyandOccupationalTherapy2007;1(3):1-8.

12. Stephen L. Barrett; Robert O’Malley: Plantarfasciitis andother causesofheelpain;American

AcademyofFamilyPhysicians;April199915.

13. BudimanMakE,ConadKJ,andRoachKE:TheFootFunction Index:ameasureof footpainanddisability.Journalofclinicalepidemiology,1991;44(6):561-570.

14. Janice Owen, Derek Stephens, and James G.Wright:Reliability of hip range ofmotion usinggoniometryinpediatricfemurshaftfractures.CanJSurg,2007August;50(4):251–255.

15. DiGiovanni BF, Nawoczenski DA, Lintal ME,MooreEA,MurrayJC,WildingGE,BaumhauerJF.Tissue-specific plantar fascia-stretching exerciseenhances outcomes in patientswith chronic heelpain.Aprospective,randomizedstudy.JournalofBone&JointSurgery2003;85:1270-7.

16. MarioRoxas,ND:Plantar fasciitis:DiagnosisanTherapeutic considerations, alternative Medicinereview2005;10(2):83-93.

17. Daniel L. Riddle,Mathew Pulisic, Peter Pidcoe,Robert E. Johnson: Risk Factors for PlantarFasciitis:AMatchedCaseControlStudy.JBoneJointSurgAm,2003;85-A:872-877.

18. Rome Keith, Saxelby Jai. Critical Review,Assessment andmanagement of Plantar fasciitis.Britishjournalofpodiatry.2005;8(1):2-5.

19. KisnerCarolyn.TherapeuticExercise:Foundationsand Techniques. New Delhi: Jaypee brothers;2003.

20. Low John, ReedAnn. Electrotherapy Explained:Principles and Practice. New York: ButterworthHeinemann;2003.

21. Cameron Michelle, Physical Agents inRehabilitation. California: Saunders publishers;2000.

Foot Posture and Frontal Plane Knee Alignment in Obese Individuals with and without Osteoarthritis Knee

bharati Asgaonkar1, Ankita Prakash Matondkar2 1Associate Professor, 2M.P.Th Student, Physiotherapy School & Centre,

TN Medical College & BYL Nair Ch. Hospital, Mumbai Central, Mumbai

AbstRACt

background:Tofindthecorrelationoffootpostureandfrontalplanekneealignmentinobeseindividualswithandwithoutosteoarthritisknee.

Methodology: 218 obese individuals (109 individuals each with and without OA knee) were selectedaccordingtoinclusionandexclusioncriteria.FootpostureandfrontalplanekneealignmentwasassessedusingFootPostureIndex(FPI)andnon-radiographicmeasure(UmbilicalMethod)offrontalplanekneealignmentrespectively.

Result & Conclusion:PresenceofpronatedfeetinbothobeseindividualswithandwithoutOAkneewhilenopredominanceofasinglemalalignmentatkneeinobeseindividualswithandwithoutOAkneewasseen.AlsonocorrelationwasfoundbetweenfootpostureandfrontalplanekneealignmentinobeseindividualswithandwithoutOAknee.

Keywords: BMI ≥ 25 / Obesity, Foot Posture Index, Frontal Plane Knee Alignment, Osteoarthritis knee.

INtRODUCtION

Obesity is affecting men, women & children andprevalence rates are increasing all over the world.[1]

Obesity is potentially a modifiable risk factor, in theonsetandprogressionofmusculoskeletalconditionsofthe knee and foot.[2] Osteoarthritis (OA) is the secondmostcommonrheumatologicalproblemwithprevalencerates22%to39%inIndia.[3] Obesityisariskfactorforboth development and progression of osteoarthritisknee.[4,5] In comparison with underweight/normalweightindividualsOAwasupto7timeshigherinobeseindividuals.[6]Although,elevatedBMIincreasesriskofkneeOAprogression,effectofBMIislimitedtokneesin which moderate mal-alignment exists, because ofthe combined effect of load from mal-alignment andexcess loadfromincreasedweight.[7]There is increasein medial and lateral tibio-femoral loading varus andvalgus mal-alignment respectively. Risk of incidenttibio-femoral osteoarthritis is increasedwith varus butnotvalgusalignment.InindividualswithOAkneeriskofOAprogression is increasedwith varus and valgusalignment.[8] Duetotheanatomically,biomechanically,and functionally inter-relation of the knee and foot in

closed kinematic chain, any impairment or disease ofknee joint can affect foot posture andvice-versa.[9,10,11]

According to theestablishedbiomechanicalprinciples,varusalignmentatthekneeisaccompaniedbyexternalrotation and abduction of tibia which, in turn, leadsto supination at foot.[12] However, literature suggeststhat patients with medial osteoarthritis knee tend tohavepronatedfootinordertocompensateforthemal-alignmentatkneejoint.[13,14,15]

Figure 1: Relationship of obesity and foot and knee mal-alignment with knee osteoarthritis.

Theliteratureindicatesthatfootpostureandfrontalplane knee alignment is affected in obese individuals. Also it is knownthat obesity is a risk factor for both

DOI Number: 10.5958/0973-5674.2018.00017.5


thedevelopmentandprogressionofkneeosteoarthritis.Literature also gives that foot posture and kneealignment are affected in individuals with OA kneeandobeseindividualswithOAknee.Howeveritisnotclearwhetherthereisanycorrelationoffootpostureandfrontalplanekneealignment inobese individualswithandwithoutOAknee.

MAtERIAL & MEtHOD

Subjects were selected according to inclusioncriteria i.e.BMI≥ 25, age above 40 years, individualwith OA knee were selected using American Collegeof Rheumatology clinical classification criteria forosteoarthritisknee;andexclusioncriteriafollowedwasindividuals with significant trauma, surgery of lowerextremities or back, any severe orthopedic conditionother than OA knee, affecting knee or foot. Eachparticipant was informed prior about the purpose andnatureofthestudyandaninformedconsentwastakeninthelanguagetheyunderstood.BMI,FPIandfrontalplanekneealignmentwerethentaken.

I. body mass index:[16,17,18,19]

BMI=Weight(kg)/Height2(meter2)

table A: Indian cut-off for bMI was used to define obesity in this study.

BMI Classification< 18.5 Underweight18.5–22.9 normal weight23.0–24.9 Overweight≥ 25.0 Obese

II. Foot Posture Index:[20]

All the components of FPI using six itemversionFPI-6wereviewed.

Figure 1: Components of FPI-6.

Eachcomponentsoftestwasgradedas0forneutral,-2forclearsignsofsupinationand+2forclearsignsofpronation.ThereferencevaluesforFPIusedwere:

Normal=0to+5

Pronated=+6to+9,highlypronated10+

Supinated=-1to-4,highlysupinated-5to-12.

III. Non-radiographic measure (umbilical method) of frontal plane knee alignment: [21]

Subjects were instructed to take three marchingsteps in place and thenmaintain natural foot position.Subjectsweretheninstructedtoadduct their legsuntilcontact between the legs occurred (e.g. secondaryto soft tissue around the knee, lower leg, or medialmalleoli). Proximal landmark consists of umbilicus.Distallandmarkconsistsofapointequidistantbetweenthemedialandlateralmalleoliandthemiddlelandmarkconsistsofapointinthecenterofthekneeatthejointline. Both distal and middle landmarks were locatedwithaverniercaliper.Measureswereobtainedusinganextendablegoniometer(4.5to18inches).Valueswererecordedtothenearestdegree.

Figure 2: Non-radiographic measure (umbilical method) of frontal plane knee alignment

Useoftherawumbilicalmethodvalueswouldnotrepresentthe“true”radiographicangleandwouldmakeinterpretationofthevaluesproblematic.Toaccountforthis,followingregressionequationwasused:

Predicted radiographic value = 0.746(umbilicalmethod)–5.22.

Usingthismodel, theumbilicalmethodvaluewasdenotedas apositivenumber ifvarus, andnegative ifvalgusand“0”asneutral.


FINDINGs

ThedatawasanalyzedusingSPSS16.0. Datadidnotpassthetestfornormality;hencenonparametrictestswereused. 59.6%werefemaleswhile40.4%weremales(65femalesand44malesineachgroup).Themeanageofthepopulationwas53.09±7.79(95%CI)and52.05±7.02(95%CI)yearsrespectivelyforobeseindividualswithandwithoutosteoarthritiskneeandthemeanBMIofthepopulationwas28.49±2.45(95%CI)and27.75±2.02(95%CI)respectively.ThedatawashomogenouswithrespecttoageandBMIaspvaluewas>0.05usingunpairedt-test.

table 1: Frequency distribution of right foot posture of obese individuals with and without osteoarthritis knee.

Right FPIObese individuals with Osteoarthritis knee Obese individuals without Osteoarthritis

knee

Frequency Percent Frequency Percent

Highlypronated 35 32.1 41 37.6

Pronated 49 45.0 37 33.9

Normal 10 9.2 11 10.1

Supinated 8 7.3 10 9.2

Highlysupinated 7 6.4 10 9.2

Total 109 100.0 109 100.0

table 2: Frequency distribution of left foot posture of obese individuals with and without osteoarthritis knee.

Left FPIObese individuals with Osteoarthritis knee Obese individuals without Osteoarthritis

knee

Frequency Percent Frequency Percent

Highlypronated 34 31.2 40 36.7

Pronated 47 43.1 37 33.9

Normal 12 11.0 12 11.0

Supinated 9 8.3 11 10.1

Highlysupinated 7 6.4 9 8.3

Total 109 100.0 109 100.0

It shows that obese individuals with and withoutosteoarthritis knee both predominantly had pes planusi.e. flat or pronated feet. Thesefindings are similar tothestudiesdonebyButterworthP.etal;AurichioT.etal;FabrisS.etalwhofoundpresenceofpronatedfeetinobese individuals. Inobese individuals increasedaxialforces cause the arches of the foot to lower so as toaccommodateforexcessloadandweight.AlsoLevingeretal(2010),ReillyKetal(2006),ReillyKetal(2009)

stated presence of pronated feet in individuals withosteoarthritisknee.Osteoarthritiskneefrequentlyhavemedial compartment affection of the knee; pronatedfootcausesthecentreofpressuretoshiftlaterallythuspossiblyreducingloadonthemedialcompartment.[24,25] Thus, obesitymaybe themain contributing factor forpresenceofpronatedfeetinobeseindividualswithandwithoutosteoarthritisknee.


table 3: Frequency distribution of right frontal plane knee alignment of obese individuals with and without osteoarthritis knee.

RightKnee Alignment

Obese individuals with Osteoarthritis Obese individuals without OsteoarthritisFrequency Percent Frequency Percent

Varum 42 38.5 17 15.6Normal 18 16.5 46 42.2Valgum 49 45.0 46 42.2Total 109 100.0 109 100.0

table 4: Frequency distribution of left frontal plane knee alignment of obese individuals with and without osteoarthritis knee.

LeftKnee Alignment

Obese individuals with Osteoarthritis knee Obese individuals without Osteoarthritis kneeFrequency Percent Frequency Percent

Varum 37 33.9 21 19.3Normal 21 19.3 41 37.6Valgum 51 46.8 47 43.1Total 109 100.0 109 100.0

There was almost equal distribution of varusand valgus knee alignment in obese individualswith osteoarthritis knee and normal and valgus kneealignment in obese individuals without osteoarthritisknee.Gibsonetal,Sharmaetal(2000),hadfoundmorefrequencyofvaruskneealignment inobese individualwithosteoarthritisknee.Lavingeretal(2010),Lavingeret al (2013) had foundmore frequency of varus kneealignment in individualswithosteoarthritis.Bout et alhadfoundpresenceofvalguskneealignment inobesechildren. While Wise et al found presence of lateraltibiofemoral joint space narrowing and valgus kneealignmentinelderlywomen.

During bilateral stance weight bearing stressesare equally distributed between medial and lateralcompartmentsofkneejoint.Howeverduringunilateral

stance as while walking the weight bearing lineshifts medially thus causing increased compressiveforces on medial compartment. Due to any abnormalcompartmental loading the frontal plane alignment isaffectedthuscausingeithergenuvarumorgenuvalgum.[29-31]

Biomechanically it is seen that individuals withmedialcompartmentOAkneehavevaruskneealignmentwhile individuals with lateral compartment OA kneehave valgus knee alignment.[32] Literature gives thatmedial compartment is more affected in osteoarthritisknee. [24,25] In our study we found more frequency ofvalguskneealignment in individualswithandwithoutosteoarthritis. However we did not consider whichcompartmentofkneewasaffected.

table 5: shows that there was no significant difference found for foot posture and frontal plane knee alignment respectively in both obese individuals with and without OA knee as Mann-Whitney U test as p > 0.05 and no difference in mean ranks for foot posture and frontal plane knee alignment respectively.

Comparison of foot posture of obese individuals with and without OA knee

Comparison of frontal plane knee alignment of obese individuals with and without OA knee

RIGHt FOOt LEFt FOOt RIGHt LEFt

Mann-Whitney U 5.933E3 5.874E3 5.291E3 5.620E3

z -.017 -.152 -1.494 -.738

p- value .986 .880 .135 .461

Mean Rank 109.57 110.11 103.54 106.56

109.43 108.89 115.46 112.44


Thisisbecausetherewasmorefrequencyofpronatedfeetinboththegroups.Alsotherewasfrontalplanemal-alignmentpresentinboththegroupsirrespectiveofpresenceofosteoarthritisknee.

Spearmanco-relationcoefficientwasusedtocheckcorrelationoffootpostureandfrontalplanekneealignmentinobeseindividualswithandwithoutOAkneerespectively.Therewasnostatisticallysignificantcorrelationseenasp>0.05asseenintable 6.

table 6: spearman co-relation coefficient of obese individuals with and without osteoarthritis knee.

spearman’s rho Coefficient Correlation

Obese individuals with OA knee Obese individuals without OA knee

Right Left Right Left

0.030 0.22 -0.140 -0.086

p-value 0.759 0.822 0.148 0.372

Significant NO NO NO NO

Our study showedpreponderanceofpronated feetinbothobeseindividualswithandwithoutosteoarthritiskneeandnopredominanceofasinglemalalignmentatknee in obese individuals without osteoarthritis knee.Thiscouldbeareasonfornocorrelationoffootpostureand frontal plane knee alignment in obese individualswithandwithoutosteoarthritisknee.Hence,provingthenullhypothesis.

CONCLUsION

• Obese individuals with and withoutosteoarthritiskneebothhadpronatedfootposture.

• Obese individuals with osteoarthritis kneeshowed almost equal distribution of varus and valguskneealignment.

• Obese individuals without osteoarthritis kneeshowedalmostequaldistributionofnormalandvalguskneealignment.

• Frequency of valgus knee alignment wasslightlymoreinbothobeseindividualswithandwithoutosteoarthritisknee.

• There was no significant difference foundfor foot posture and frontal plane knee alignmentrespectivelyinbothobeseindividualswithandwithoutosteoarthritisknee.

• Therewasnostatisticallysignificantcorrelationbetweenfootpostureandfrontalplanekneealignmentin obese individuals with osteoarthritis knee withoutosteoarthritiskneerespectively.

LIMItAtIONs

• Compartmentofkneeaffectedinosteoarthritiskneewasnot considereddue to lackof availabilityofradiographs.

• Severity of osteoarthritis knee was not takenintoconsideration.

Conflict of Interest: None

source of Fundng:Self.

Ethical Clearance:TakenfromEthicsCommitteefor Academic Research Projects (ECARP), PGAcademic Committee, T.N. Medical College & BYLNairCh.Hospital.

ECARPReferenceNo:ECARP/2014/23.

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17. Healthizen.com, Bmi In Indians. [online]Available at: http://www.healthizen.com/health-special/world-obesity-day/bmi-in-indians.aspx.

18. Apps.who.int.WHO: Global Database on BodyMassIndex.[Online]Availablefrom:http://apps.who.int/bmi/index.jsp?introPage=intro_3.html;1995,updated2014.

19. JamesP,LeachR,KalamaraE,ShayeghiM.TheWorldwideObesityEpidemic.ObesityResearch.2001;9(S11):228S-233S.

20. Leeds.ac.uk.The Foot Posture Index. [Online]Availablefrom:http://www.leeds.ac.uk/medicine/FASTER/z/pdf/FPI-manual-formatted-August-2005v2.

21. GibsonK,SayersS,MinorM.Accuracyofanon-radiographic method of measuring varus/valgusalignment in knees with osteoarthritis.Missourimedicine.2008;106(2):132-135.

22. Butterworth P, Orf K, Gilleard W, UrquhartD, Menz H. The association between bodycomposition and foot structure and function: asystematicreview.ObesityReviews.2013.

23. Aurichio T, Rebelatto J, De Castro A, PaivaR. The relationship between the BMI and footpostureinelderlypeople.Archivesofgerontologyandgeriatrics.2011;52(2):89-92.

24. Levinger P, Menz H, Fotoohabadi M, FellerJ, Bartlett J, Bergman N, Others. Foot posturein people with medial compartment kneeosteoarthritis.JFootAnkleRes.2010;3:29.

25. LevingerP,MenzH,MorrowA,BartlettJ,FellerJ,BergmanN.Relationshipbetweenfootfunctionand medial knee joint loading in people withmedial compartment knee osteoarthritis. Journal


ofFootandAnkleResearch.2013;6(1):33.

26. GibsonK, Sayers S,MinorM.Measurement ofvarus/valgusalignmentinobeseindividualswithknee osteoarthritis.Arthritis Care \& Research.2010;62(5):690-696.

27. Bout-Tabaku S, Shults J, Zemel B, LeonardM, Berkowitz R, Stettler N et al. Obesity IsAssociatedwithGreaterValgusKneeAlignmentinPubertalChildren,andHigherBodyMassIndexIs Associated with Greater Variability in KneeAlignmentinGirls.TheJournalofRheumatology.2014;42(1):126-133.

28. WiseB,NiuJ,YangM,LaneN,HarveyW,FelsonDetal.Patternsofcompartment involvement intibiofemoralosteoarthritisinmenandwomenand

inwhites andAfricanAmericans.ArthritisCareRes.2012;64(6):847-852.

29. Norkin C, Levangie P, Chapter 11. The Knee.Jointstructureandfunction.4thed.Philadelphia,PA:F.A.DavisCo.;2006;396.

30. JohnsonF,LeitlS,WaughW.Thedistributionofloadacrosstheknee.Acomparisonofstaticanddynamicmeasurements.JBoneJointSurgBr62:346-349,1980.

31. AndriacchiTP.Dynamicsofkneemalalignment.OrthopClinNorthAm25:395-403,1994.

32. MaheshwariJ.Chapter39.MiscellanousReginalDiseases. Essential Orthopeadics. 3rd ed.(revised). New Delhi: Mehta Publishers; 2009;275,276.

Effect of scapula stabilizing Muscles strengthening to Improve throw-in Distance among College Level

Male soccer Players

Danishpaul P.D1, Veena Pais2

1Post Graduate, 2Associate Professor, Yenepoya Physiotherapy College, Yenepoya University, Mangalore

AbstRACt

Objective: Toinvestigatetherelationshipbetweenthestrengthofscapulastabilizingmusclesandthethrow-indistanceamongcollegelevelmalesoccerplayers.study Design: Randomizedcontroltrial. Methods: 32 collegelevelsoccerplayersagedbetween16and26years,whohadparticipatedinatleastonecollegeleveltournamentwereincludedinthestudy.Theparticipantswerethenrandomizedbylotterymethodtocontrolgroup (n=16) and interventional group (n=16).Control group underwent regular coaching program andinterventionalgrouphadspecificscapulastabilizingmusclestrengthtraininginadditiontoregularcoachingprogramfor6weeks.Theirpreandposttrainingstrengthandthrow-indistancemeasuresweredocumented.Datawas analyzed using paired‘t’ test and independent‘t’ test. Level of significancewas set at p<0.05.Results:Therewassignificantwithingroupimprovementinstrengthandthrow-indistanceinbothgroups.The intervention group showed greater improvement in both strength and throw-in distance comparedto thecontrolgroup.However, thebetweengroupcomparisondidnot showany statistical significance. Conclusion:Thisstudyshowedaclinicallysignificantimprovementinstrengthandthrow-indistancepostspecificscapulastabilizingmusclestrengthening.Thus,includingscapulastabilizingmusclestrengtheningin the regular coaching program could provide an added gain to the player and his performance in thesport.

Keywords: scapula stabilizers, soccer throw-in, resistance training

INtRODUCtION

Soccer is the most played team game which hasparticipationfromaround150countriesand250millionplayers.1. A throw-in comes into play when the ballcrossesoverthetouchline.2Alongerthrow-indistancecancreateabetteropportunitiestoscoreagoal,astheballcanreachthefartherplayernearertotheopponent’sgoal post more quickly.3 Longer throw-ins can beachievedbygeneratingmaximumforces in thekineticchain.4 Kinetic chain refers to continuous transfer ofenergy and momentum in a series of segments in arigid bodywhile a coordinatedmotion occurs.5, 6 This

Address for Correspondence:Veena PaisAssociateProfessor,YenepoyaPhysiotherapyCollege,YenepoyaUniversity,Mangalore–575018,Faxno:[email protected]

sequence of kinetic chain originates from the ankle,thenprogressestotheknee,hip,pelvis,trunk,shouldergirdle,elbow,hand,andfinallytotheball.7Dysfunctioninanyofthecomponentsofthiskineticchainwillleadtoreductionofthrow-inperformance.7Inliterature,thescapulo-thoracic joint isquotedasa“functional joint”rather thana true jointdue to the absenceof the jointcapsule and ligamentous network.8 In true sense, theupper limband thorax are structurally attachedby thesterno-clavicular joint and theacromio-clavicular jointthat forms a bridge between the overhead throw andthe muscular architecture by transferring the energyfrom the trunk to the upper extremity.7, 8 For efficientgleno-humeral movement, the scapula as well as themuscles controlling it must act as a stable base andmove the glenoid dynamically into various positions.9 Understandingof the forcecouplewithin the shouldercomplexisimportantasithasitsowncontributionsintheoverheadthrow-in.8Forathrow-in,theforcecoupleis generated during elevation of gleno-humeral joint

DOI Number: 10.5958/0973-5674.2018.00018.7


occurringbytheactionofdeltoid/rotatorcuffmusclesand the rotation at scapula-thoracic articulationby theaction of trapezius and serratus anterior.10 The Upperportionsoftrapeziusandserratusanteriormuscleworktogethertoproduceupwardrotationforceofthescapulaand forms the first part of the force couple. And thelower portions of trapezius and serratus anterior alsoassistintheupwardrotationandformthesecondpartoftheforcecouple.Thesemusclesarethemainsynergiststhatstabilizethescapulawhenthedeltoidexertsforceatgleno-humeraljoint8

During coachingmore importance is given to thestrengtheningofmusclesoflowerlimbs,abdomenandshoulderbutstrengtheningofscapulastabilizerisoftenneglectedinspiteofitsimportantrole.Variousstudiesonthrow-indistanceinsoccerhavebeendonetodeterminethebestprojectileangleof throw-in,strengthening therotatorcuffandtricepsmusclesandrunupthrow-inbutthe relationship of scapula stabilizingmuscle strengthand throw-in distance in soccer players still remainsunexplored. Hence, this study aimed to investigatethe relationship between strengthening of scapulastabilizing muscles and the throw-in distance amongmalesoccerplayers.


This study was conducted among 32 collegelevel male soccer players aged 17–26 years. Prior toparticipation,awritteninformedconsentwasobtained.Ethicalclearancewasobtainedfromuniversity’sethicscommittee. Participants were screened and includedif they were college level male soccer players, agedbetween17-26years,shouldhaveparticipatedinatleast1college level tournament. Participants with presenceof any musculoskeletal conditions, neurologicalconditions, cardiovascular conditions, undergoingintensebodybuildingworkoutsandanyotherconditionscontraindicating exercise participation were excluded.Participants were then screened using the ACSM’spre-participation screening questionnaire.11 Eligibleparticipants were then randomized by lottery methodinto interventional group and control group equally.Both groups received their regular soccer coaching3times a week for 6 weeks. The interventional groupreceived additional strength training for the scapularstabilizingmusclesnamelyserratusanterior, trapezius,rhomboids and levator scapulae. It included a trainingsessionof3setswith12,10,8repetitionsrespectively

withtrainingloadof70%of1RManda2-10%ofloadprogressionwasgiveniftheparticipantwasabletodo2-3repetitionsmorethanthedesiredsetrepetitionbasedontherecommendationsgivenbytheAmericancollegeofsportsmedicine.12Theexerciseswere

• Warm-up

• Serratusanteriorpunch9,13

• Seatedcablerows9

• Dumbbellshrugs9,14,15

• Pronelyingarmriseoverthehead16,17

• Cooldown

Theinterventionalgroupwastrainedthriceaweekfor 6 weeks.18 Each training session lasted around 40minutes and were supervised by one physiotherapistand an assistant. Pre and post evaluation of strengthof scapula stabilizers and throw-in distance of boththegroupsweredocumentedbeforeandafter6weeks.Strengthwasassessedby the following formula:1RM=100×W/[102.78-(2.78×R)]Where,RM:repetitionmaximum, W: weight, R: Repetition.19 The warmup session consisted of general as well as specificwarm up.20, 21 The pre and post throw-in distancewasmeasured by asking the participants to stand close tothe touchline by holding the ball (dusted with chalkpowder formarking) as in usual soccer throw-in, in astaggeredstance.Theywerethenaskedtodeliveralegalthrow-in in a forward direction as distant as possible.ThemaximumhorizontaldistancewasrecordedusingaFreemansstandardmeasuringtapepositionedatarightangle. The distance between the upper border of thetouchlineandthepointperpendiculartothelowerborderofthechalkmarkleftbythethrownballwasmeasured.22 The termination criteria adoptedwas: any participantsof the control group absent from regular coaching formorethan3daysfor2weeksandparticipantsfromtheexperimental group absent for more than 2 weeks oftraining session due to any reason including injury orillness.


StatisticalanalysiswasdoneusingSPSSversion22IBM.Shapirowilktestwasusedtocheckthenormalityofthedata.Paired‘t’testwasusedtocomparepreandpost measurements as the data followed normality.Independent t test was used to compare the data ofcontrol and experimental groups. P value < 0.05 was


consideredstatisticallysignificant.

REsULts

Withingroup improvement in strength and throw-indistancewas seen inbothgroups.However, thepre topoststrengthaswellasthethrow-indistancedifferenceintheinterventionalgroupoutweighsthedifferenceseenincontrolgroup(p<0.05)(ReferTable.1).Therewasastatisticallysignificantimprovementinstrengthgainintheinterventionalgroupcomparedtocontrolgroupwhenposttrainingcomparisonwasdone(p<0.05).However,therewasnostatisticallysignificantimprovementseeninthethrow-indistancebetweenthecontrolandtheinterventionalgroup.(ReferTable.2)

table 1: Pre-training to post-training differences within the groups

Pair no : Outcomes

Control group Interventional group

Mean sD P value Mean sD P value

1

pre-dumbellshrugs47.44 7.728

.001

50.63 7.535

.000post-dumbellshrugs

52.31 9.471 71.00 9.771

2

pre-seatedrow75.63 8.921

.00279.31 12.574

.000post-seatedrow 80.56 7.580 104.38 12.585

3

pre-pronelyingdumbbellraise 7.88 1.857

.038

9.00 2.191

.000post-pronelyingdumbbellraise 8.69 1.740 15.38 3.096

4

pre-serratuspunch 34.06 7.844

.000

33.50 8.140

.000post-serratuspunch38.19 6.565 48.44 8.571

5

Pre-averagethrowindistance(meters)

16.5373 2.05017

.015

16.47131.63756

.000Post-averagethrowindistance(meters) 16.9065

1.98258

18.03631.79365

table 2: Post-training difference between interventional and control groups

No : Outcome Group n MeanMeandifference

sD P value

1 post-dumbbellshrugsControl 16 52.31

-18.688

9.471.000*

Intervention16 71.00

9.771


2 post-seatedrowControl

16 80.56

-23.813

7.580

.000*Intervention

16 104.3812.585

3 post-pronelyingdumbbellraise

Control 16 8.69

-6.688

1.740

.000*

Intervention 1615.38

3.096

4 post-serratuspunchControl 16

38.19

-10.250

6.565

.001*Intervention 16 48.44

8.571

5 Post-averagethrowindistance(meters)

Control 16 16.9065

-1.12979

1.98258

.101Intervention 16 18.0363 1.79365

Cont... table 2: Post-training difference between interventional and control groups

DIsCUssION

Thisstudyaimed to investigate therelationshipofthestrengthofscapulastabilizingmusclesandthethrow-indistanceamongcollegelevelmalesoccerplayers.Thetargeted scapula stabilizer muscles strength improvedsignificantly using the four exercises. This gain instrengthmight have been due to the training load, setconfiguration,progressionofloads,frequencydesignedspecifically to increase the strength in accordance toguidelinesputforthbyRatames.Aetal in theirstudynamed “Progression models in resistance training forhealthyadults”.12

The improvement in post training strength foundin control group might be attributed to the type ofregularcoachingexercisesdone,whichincludedpush-ups, military press, pull-ups, bench press etc. whichindirectly requires and recruit the scapular stabilizermusclesasthesearecompoundexercises.Learl.J.andGrossM.Tdocumentedtheelectromyographicanalysisofscapularstabilizermusclesandpush-upprogressionsin which they stress the use of push-up progressionto facilitate activations of serratus anterior and uppertrapeziusmuscles.25AnotherEMGanalysisofscapularmusclesduringa scapular rehabilitationprogramdoneby Moscley J. B. et al. found effective activation oftrapezius,serratusanteriorwithmilitarypressandpush-ups.22

Alongwiththesignificantimprovementinstrength,improvementinpretopost throw-indistancewasalsoreflectedwithin the interventional group (Pre 16.4713meters&Post18.0363meters).Thecontrolgrouppre-postscoresalsoshowedsomeimprovementinthrow-indistance (Pre16.5373meters&Post16.9065meters).The improvement in the throw-in distance was morestatistically inclined towards the intervention group.When within group differences were evaluated. Thecontrol group also showed awithin group increase inthrow-in distance as there was significant increase instrength of the scapular stabilizer muscles. This is inaccordancewith a study conductedbyTillarR.V.D.who found a significant increase in throw-in velocityamong resistance training group .23 When strengthdifference between group was evaluated; statisticallysignificant improvementwasseenintheinterventionalgroup (p<0.05) compared to the control group in allthe 4 exercises. However, no significant difference inimprovementbetweengroupswasfoundinpostthrow-indistancewhencomparedbetweenthegroups(controlgroup mean 16.9065 & interventional group mean18.0363), thismight be due to the significant strengthgain exhibited by the control group as they were intheiroff-seasonperiod trainingandhad receivedmorestrength training sessions as a part of their routinetrainingprogram.


Although this present study aimed for maximumthrow-indistance,theimportanceoftheinfluenceofthereleasingangleandfastbackspinforsoccerthrow-inisinevitable.Thiscouldnotbeconsideredduetolackofadvanced resources.Linthorne.N.P. andEveretD. J.highlightstheimportanceofreleaseangleforattainingmaximumdistancefromthesoccerthrow-in,theyfoundthatusinglowreleaseanglesascloseas30degreesaswellasusingafastbackspinresultedingreaterreleasespeed and distance covered.3 The throw-in performedin standing and running have their own differencesthusCerrah.A.Oetal.documentedthathighervaluesof vertical ground reaction and longer throw-inswereobtained for a running throw-in when compared tostandingthrow-in.24

However,theresultofthestudystronglyrecommendsthestrengtheningofscapulastabilizingmusclesasapartof thecoachingprogram, thus,notonly improvingthethrow-in distance but providing an overall gain to theplayerandhissport.Thereisscarceliteratureavailableon this topicand thiswas thefirst studyof itskind toestablishadirect relationshipbetweenspecificscapulastabilizingmusclesstrengthening&itsinfluenceonthethrow-in distance for soccer players. Further researchisneededtogeneralizethefindingsofthisstudytothemalesoccerpopulation

CONCLUsION

The improved strength values of the scapulastabilizingmusclesfoundinthisstudyareastrongfactorthat describes standing throw-in performance amongmale soccer players. Soccer coaches can thus includethestrengtheningofscapulastabilizingmusclesaspartoftheirregularcoachingprogram.

Conflict of Interest:Nil.


Ethical Clearance- Yenepoya University EthicsCommittee

REFERENCEs

1) Eric weil. Football. available from; http://www.britannica.com/sports/football- soccer; 06-12-2015.

2) Fifa,lawsofthegame2008/2009,p.44,july2008.Available from;http://www.fifa.com/mm/document/affederation/federation/81/42/36/lotg_

en.pdf.

3) Linthorne NP, Everett DJ. Release angle forattainingmaximumdistance in the soccer throw-in.SportsBiomech.2006;5(2):243-260.

4) More J, Watts S, Tweed D, Miller B. Overarmthrowswiththenon-dominantarm:Kinematicsofaccuracy.J.Neurophysiol.1996;76(6):3693-3704.

5) Fleisig GS, Barrentine SW, Escamilla RF,AndrewsJR.Biomechanicsofoverhandthrowingwith implications for injuries.SportsMed.1996;21(6):421-437

6) ZachazewskiJE,MageeDJ,QuillenWS.AthleticInjuries andRehabilitation.Philadelphia,PA:W.B.SaundersCompany.1996

7) Bos KL, Gehrs KS, Hester ALC. Relationshipbetween a functional throwing performance testandstrengthofvariousscapularmuscles.GraduateResearch and Creative Practice. 1999: MastersTheses.Paper484.

8) Norkin CC, Levangie PK. Joint Structure &Function-A Comprehensive Analysis.5th ed.Philadelphia,PA:F.A.DavisCompany;2011.

9) Paine.R.M,Voight.M.Role of scapula. JOrthopSportsPhysTher;I993:18.

10) BaggSD,ForrestWJ.Electromyographicstudyofthe scapular rotatorsduringarmabduction in thescapularplane.AmJPhysMed.1986;65(3):111-124

11) American College of Sports Medicine. ACSM’sguidelines for exercise testing and prescription.LippincottWilliams&Wilkins;2013Mar4.

12) RatamessN,AlvarB,EvetochT,HoushT,KiblerW,KraemerW.Progressionmodelsinresistancetrainingforhealthyadults[ACSMpositionstand].MedSciSportsExerc.2009;41(3):687-708.

13) DeckerMJ,HintermeisterRA,FaberKJ,HawkinsRJ. Serratus Anterior Muscle Activity DuringSelected Rehabilitation Exercises. Am J SportsMed.1999;27:6.

14) Daneshmandi Hassan et al. Isometricscapulothoracic muscles strength in overheadathletes.Bhu.J.RNR.2015;Vol3:1,332-343.

15) JimmyPena.Thebookofshrugs.Placeunknown;24th august 2014. Available from: http://www.muscleandperformance.com/article/the-book-on-shrugs.


16) Ekstorm RA, Donatelli RA, Soderberg GL.SurfaceElectromyographicAnalysisofExercisesfortheTrapeziusandSerratusAnteriorMuscles.J.Orthop.SportsPhys.Ther.;2003:33(5).

17) Reuteman P. The Importance of ScapularStabilization in Shoulder Rehabilitation.CurrentConceptsofinSportsMedicine;2010.

18) Hibberd EE. Effect of a 6-week StrengtheningProgram on Shoulder and Scapular StabilizerStrength and Scapular Kinematics in Division ICollegiateSwimmers.JSportRehabil.2012;21(3):253-65.

19) Zarezadeh-MehriziA,AminaiM,Amiri-khorasaniM. Effects of Traditional and Cluster ResistanceTraining on Explosive Power in Soccer Players.IranJPublicHealth.2013;4(1):51-56

20) Ransone J. Essentials of Strength Training andConditioning. Journal of athletic training. 1996Oct;31(4):366.

21) American College of Sports Medicine. ACSM’s

guidelines for exercise testing and prescription.LippincottWilliams&Wilkins;2013Mar4.

22) MoseleyJRJB,JobeFW,PinkM,PerryJ,TiboneJ.EMGanalysisofthescapularmusclesduringashoulderrehabilitationprogram.AmJSportsMed.1992Mar;20(2):128-34.

23) van den Tillaar R, Marques MC. Effect of twodifferenttrainingprogramswiththesameworkloadonsocceroverheadthrowingvelocity.IntJSportsPhysiolPerform.2009Dec;4(4):474-84.

24) Cerrah AO, ŞimşekD, Ertan H. The EvaluationofGroundReactionForcesDuringTwoDifferentSoccer Throw-In Techniques: A PreliminaryStudy. Pamukkale Journal of Sport Sciences.2014;5(1):106-12

25) Lear LJ, Gross MT. An electromyographicalanalysisofthescapularstabilizingsynergistsduringapush-upprogression. JournalofOrthopaedic&SportsPhysicalTherapy.1998Sep;28(3):146-57.

stigmatizing Attitudes in Community towards People Living with HIV/AIDs: A Cross-sectional study

Rajiv D Limbasiya1, M M Prabhakar2, Rajendra Gadhavi3

1Lecturer, The Sarvajanik College of Physiotherapy, Surat, 2Additional Director, Medical Education and Research, Gandhinagar Medical Superintendent Civil Hospital, Ahmedabad, HOD, Orthopaedic Department, Civil Hospital,

Ahmedabad, 3Deputy Director, GSACS, Department of Health and Family Welfare, Govt. of Gujarat

AbstRACt

background:StigmarelatedtoAIDSwasoneoftherealpurposesbehinditsuncontainedobliterationofmillionsinIndia.IndividualswerehesitanttointerfacewithHIV/AIDSpeoplesinceitwasthoughttobeinfectious,executingmaladywhichhadnocure.

Purpose: TomeasurethelevelofcommunitystigmatowardspeoplelivingwithHIV/AIDS(PLWHA)andtofindouttheassociateddemographicfactorsforstigma.

Method: Acommunity-based,cross-sectionalanalyticstudywasconductedinSuratamong350participantsoveraperiodofthreemonths.Thesurveysincludedseveralaspectsofstigma,suchas:negativeattitudesandblametowardsPLWHAduetotheirdiagnosisandtheirperceivedHIV/AIDSriskbehaviour;perceivedriskofHIVinfectionduetocasualcontactwithPLWHA;socialdistancingfromPLWHAandgroupsathigherriskofHIV/AIDS.Thesequestionswerereadasuniformstatementswithresponsesintheformofa4-pointLikertscalerangingfromstronglyagreetostronglydisagree.ALogisticregressionanalysiswasdonebetweennostigmaandmildtomoderatestigmaforthedemographicvariables

Results: Meanstigmascorewas49.55withstandarddeviation12.16.Minimumstigmascorewas24andmaximum84 shows the rangeof60.Males andpersonswithonlyprimaryeducation levelhadmild tomoderatelevelofstigma(B=1.084&1.246);peoplewhoweredoingjob,studying,orinbusiness(B=-0.39,-0.326,-1.701respectively)hadlessstigmacomparedtothosewhowereunemployed,retiredorhousewives.

Conclusion: Therewere up to themoderate level of stigma towards PLWHA in the community.Maleandpeoplewithlesseducationhadmildtomoderatestigmacomparedtofemaleandpeoplewithhighereducation.Thosewhowerestudying,doingjobandweredoingbusinesshadlessstigma,thanunemployed,housewifeorretiredpopulation.

Keywords: Stigma, Community, People Living with HIV/AIDS.

Corresponding author: Rajiv D. Limbasiya, MPTAddress:TheSarvajanikCollegeofPhysiotherapy,Badatwadi,Chhada-ole,Rampura,Surat-03,Email:[email protected]:+91-9723016387

INtRODUCtION

TheepidemicsoftheAcquiredImmuneDeficiencySyndrome (AIDS) have become one of the mostcommon threats to human survival, development,

and prosperity in all parts of the world. The HumanImmunodeficiencyVirus(HIV)wassurvivedinhumanover threedecades,andthecasewasfoundinagroupof homosexual men in 1981 in U.S.A. has ruined alargenumberofindividualswherebythekidshavelosttheirfolks;familieshaveencounteredseriousmonetarychallenges; countries have lost their additions andventuresof numerousdecades; and societieshave losthugepotentialcontributions to thedifferent spheresoflifefromitsafflictedmembers(1).

TheHIV/AIDSpandemichasnotexclusivelybeenthe most noticeably awful disaster in contemporary

DOI Number: 10.5958/0973-5674.2018.00019.9


history, however, has additionally postured genuinestatistic, helpful,monetary and formative crisis. Rightfrom the earliest starting point, theHIV/AIDS plaguehasbeen joinedbyascourgeofdread,numbness,andforeswearing, prompting slander of and oppressionindividualswithHIV/AIDS(2).

HIV/AIDSstigmatizationposesamajor challengeto preventive public health efforts by contributing tounder-reporting of cases (3) (4) (5) (6). Early recognitionis subsequently key to keeping the spread of HIVsince it urges people to embracemore secure practice

(7) (8) (9)and results in more successful and proficienttherapeutic care by diminishing the infectivity ofpeoplewithHIV(10) (11), and in thisway the danger ofspreadingthevirus.Sometimesmanypeopleunderriskofinfection,thenalsotheyareavoidedforascreeningtestbecauseoffear that theresultwillbepositiveandthey will have to face the stigma because of HIV (3)(4) (12) (13). So stigma and discrimination towards AIDSbecome a global phenomenon and for that peopleliving with HIV are more prone to rejection, socialostracism, discrimination, and violence. Stigma onlyis one of the most common barriers to public action.AIDS-relatedshamealludes to thebiasandseparationcoordinated at individuals livingwithHIVandAIDS.It causes individuals livingwithHIVandAIDS toberejected from theirgroup, avoided,victimizedor evenget physically hurt. Researches confirm demonstratesthatsomeHIVandAIDSpatientsconfrontsomesortofshameanddiscrimination.StigmawhencoordinatedatindividualslivingwithHIV/AIDS(PLWHA),muddlesthebattleagainstHIVandAIDSsincewhenvilifiedthePLWHAexperienceissuestoadapttothediseaseatanindividuallevel.Inanexpansion,disgraceadditionallymeddleswithendeavourstobattletheAIDSpestilenceallinall(14).AninvestigationinBotswanaandZambiafound thatshameagainstHIV-constructive individualsanddreadofabusekeptindividualsfromtakingpartinwilful advising and testing and projects to counteractmothertokidtransmission(15).

Demoralization would make individuals reluctanttocompletethetest,inthismanner,morePLWHAareuninformedthat theyareexperiencingHIV/AIDS,andarealongtheselinesputtinghis/hersexualaccomplicesaswellas theneedle (16).Thereareafewexplanationsbehind the shame toward PLWHA among the overallpublic, one of them could be incorrect data about thetransmissionofHIV;creating irrationalbehaviourand

misperceptionsofpersonalrisks(16).

StigmarelatedtoAIDSwasoneoftherealpurposesbehinditsuncontainedobliterationofmillionsinIndia.Individualswere hesitant to interfacewithHIV/AIDSpeoplesinceitwas thought tobeinfectious,executingmaladywhichhadnocure.ThenatureofdiscriminationassociatedwithHIV/AIDSwascloselyrelatedtosexualstigmainIndia(17).Theprimaryobjectiveofthisstudyistolookatanddecidethelevelofthestigmaofpeopletowards PLWA with a view to proposing how suchdisgraceandsegregationcanberelieved.

MetHoD

Acommunity-based,cross-sectionalanalyticstudywasconducted inSuratamong350participantsoveraperiod of three months (August to September 2016).Participantswereselectedbynon-probabilitysampling.Inclusion criteria were participants’ willingness,between the ages of 20 to 60, eligible to answer allthe questions, and minimum education of primarylevel. Exclusion criteria were individuals with HIVpositive, health professionals, and mentally unstableindividuals.ThestudywasapprovedbytheinstitutionalethicalcommitteeandwrittenpermissionfromNACO(National AIDS Control Organization) was taken.Informed consent of all the respondents enrolled inthe studywas takenbefore starting the interview.Theinstrument that we use to evaluate stigma was HIVStigmascalewhichhas22items(18).Thesurveyincludedseveralaspectsofstigma,suchas:negativeattitudesandblametowardsPLWHAduetotheirdiagnosisandtheirperceived HIV/AIDS risk behaviour; perceived riskofHIV infection due to casual contactwithPLWHA;social distancing from PLWHA and groups at higherrisk of HIV/AIDS; and endorsement of restrictivepolicies for PLWHA These questions were read asuniformstatementswith responses in the formofa4-point Likert scale ranging from strongly agree (codedas4)tostronglydisagree(codedas1).Endorsementofstigmatizingviewsyieldedahigherscoreonthe4-pointscale.Iftherespondentrefusedtoprovideananswertoanyquestion, the interviewerscoded theresponseasarefusal.

DAtA ANALYsIs

Data were analyzed using SPSS version 20.0for windows at 95% confidence interval and p-value<0.05.The data were summarized in frequencies for


categoricalvariables,andlinearregressionanalysiswasdonetofindoutthevarianceofdemographicalvariablesonstigma.Alogisticregressionanalysiswasalsocarriedouttofindoutthecategoriesofdemographicalvariablesonstigma.

Results: Descriptive data analysis was conductedfirst in order to understand frequencies of the socio-demographic variables, HIV risk variables, and thestigmastatements

table 1: Demographic profile of study population (n = 300)

Demographic Variable Frequency Percent

Age(years)

20-3031-4041-5051-60

76747773

25.324.725.724.3

GenderMaleFemale

142158

47.352.7

Education

PrimarySecondaryHighersecondaryGraduateandabove

579547101

19.031.715.733.7

Occupation

StudyBusinessJobRetire/HW/Unemployed

316766136

10.322.322.045.3

Stigma

NoStigmaMildtoModerateStigmaSevereStigma

96204-

3268-

Outof350participants,300werecorrectlyfilledandreturnedgiving85.7%retrieval.Bothmaleandfemaleparticipantswere almost same.The highest age groupwaswithintherange41-50years(25.7%)whiletheleastagegroupwas51-60years (73%).Meanstigmascorewas49.55 (score range from22 to110)with standarddeviation 12.16. Minimum stigma score was 24 andmaximum84showstherangeof60.

table 2: Logistic Regression Analysis of demographic variables and stigma for HIV people

Demographic variable b sig. Exp(b)95% coefficient interval for exp (b)

Lower bound Upper bound

Mild to moderate stigma intercept 15.816 .000

Age

20-30 .426 .356 1.532 .620 3.787

30-40 .190 .641 1.209 .544 2.683

40-50 .337 .388 1.401 .651 3.017

50-60 0 . . . .

GenderMale 1.084 .004 2.955 1.415 6.171

Female 0 .

Education

Primary 1.246 .008 3.476 1.394 8.668

Secondary .668 .068 1.951 .952 4.000

Highersecondary .489 .264 1.630 .691 3.844

Graduateandabove 0 . . . .

Occupation

Study -.326 .586 .722 .244 2.329

Business -1.701 .000 .182 .075 .441

Job -.039 .927 .961 .414 2.235Unemployed/Retired/Housewife

0 . . . .

Cont... table 1: Demographic profile of study population (n = 300)


DIsCUssION

Study examines the patterns of stigmatizingattitudes towards PLWHA within a population-basedsample.We classify stigma into three classes like nostigma, mild to moderate stigma and severe stigma.Within these three class groups, the first (no stigma),comprised of about 32%of the population,while restofthepopulation(68%)havingmildtomoderatestigmatowards HIV individuals and not a single individualsshow severe stigma towards PLWHA. From all studyparticipants who knew an individual with HIV/AIDSreportedlessstigmatizingattitudesandlowerperceiveddiscrimination than thosewhodidnotknowsomeone,perhapsreflectiveofpersonalexperiencewithaccessingthe support and care that is available for PLWHA.Anastasia (19) in their study reported that knowingsomeonewithHIVorfeelingpersonallyat-riskforHIVwere significantly more likely to belong to the leaststigmatizinggroup.

Participantswhowereinbusinesshadsignificantlyless stigma towards HIV individuals when comparedto housewives, retire or unemployed. And those whowere studying or doing job also showed less stigma.Comparedtomalepopulationfemalepopulationshowsless stigma towards HIV/AIDS individuals. Higherthe level of education there was less stigma towardsPLWHA, compare to graduate and above level ofeducation; peoplewith the primary level of educationhad3.48times;thosewhostudiedsecondarylevelhad1.95 times, and higher secondary level of educationpeoplehaving1.63timesmorestigma.

Thequestionnaire focusedonpersonalbeliefs thattherespondentholds inrelation toPLWHAaswellastheirbeliefsregardingtheoriginsofstigmatizingattitudesanddiscriminationpracticeswithin their communities.CommunityrespondentsarelessfrequentlyexposedtoPLWHA, as todayHIV is concentrated in stigmatizedgroups.Thescalerelatestorespondentperceptionsaboutthe manifestations of stigmatizing attitudes existingwithin their community. Specifically, the questions inthescaleask theparticipant to react tostatements thatreflectanumberofdiscriminatorypractices thatoccurintheircommunity.Previousresearchhasdemonstratedthe inverse relationship between access to therapiesand HIV/ AIDS-related stigma (20). We didn’t foundstigma in population comparing with different agegroup. Gobopamang Letamo (21) in their study found

discriminatingattitudesamongadolescentsofbostanwa.ThestudysaysthatadolescentswholackunderstandingofmodesoftransmissionweremorelikelytostigmatizeanddiscriminateagainstpeoplelivingwithHIV/AIDS.Those who have misconceptions (those who believethat HIV/AIDS can be transmitted by sharing a mealwithPLWAorcanbecontractedthroughwitchcraftormosquito)weremorelikelytoexpressnegativeattitudestoward an HIV-positive teacher than those who hadcorrectknowledgeofHIVtransmission.

It appears again that lack of knowledge of howHIV/AIDScanbetransmittedisanimportantpredictorof discriminatory attitude among adolescents towardspeoplelivingwithHIV/AIDS.

Self-reported measures of stigma are subject toreportingbiassincesomesurveyquestionsare framedaroundhypotheticalscenariosandmayprovokesociallydesirableanswersfromrespondents.Inaddition,studiesareneededthatcontinuetoexamineHIV/AIDS-relatedstigma and discrimination across multiple culturalcontexts and todeterminewhether the factor structurepresented here is stable across other diverse researchsettingsinvariousstagesoftheHIVepidemic.

Limitation: studies are needed that continue toexamine HIV/AIDS-related stigma and discriminationacross multiple cultural contexts and to determinewhether the factor structure presented here is stableacrossotherdiverseresearchsettings invariousstagesoftheHIVepidemic.

CONCLUsION

According to the results of the study we canconcludethatmaleandpeoplewithlesseducationhadmildtomoderatestigmacomparedtofemaleandpeoplewith higher education. Business people had very lessstigma than unemployed, housewife or retired people.Similarlythosewhoweredoingjoborstudyingalsohadlessstigmanexttobusinesspeople.

Acknowledgment: This study was approved bythe institutional Ethical Committees and permitted byNACO.WewishtoexpressourheartfeltgratitudetoDr.A.ThangamaniRamalingamforhelpingusconstructingthisresearchstudy.

Disclosure: The authors report no conflicts ofinterestinthiswork.


source of Funding: This research received nospecificgrantfromanyfundingagency.Itsself-fundedresearch.

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1. Kakar SN, Kakar DN. CombatingAIDS in the21st century Issues and Challenges. SterlingPublishersPrivateLimited;2001.

2. OgdenJ,NybladeL.Commonat itscore:HIV-relatedstigmaacrosscontextsinternationalcentrefor researchonwomen. InternationalCenter forResearchonWomen;2004.

3. Chensney M, Smith A. Critical delays in HIVtestingandcare:Thepotentialroleofstigma.AmBehavSci.1999;42:p.1162–1174.

4. Harek G, Capitanio , Widaman. Stigma, socialrisk, and health policy: Public attitudes towardHIV surveillance policies and the socialconstructionofillness.HealthPsychol.2003;(22):p.533-540.

5. KleinS,KarchnerW,O’ConnelD.InterventionstopreventHIV-relatedstigmaanddiscrimination:findings and recommendations for public healthpractice.JPublicHealthManagPract.2002;8:p.44-54.

6. Malcolm , Aggleton , Bronfman , Galvao ,Mane , Verrall. HIV-related stigmatization anddiscrimination: Its forms and contexts. CriticalPublicHealth.1998;8:p.347-370.

7. Owen S. Testing for acute HIV infection;implications for treatment as prevention. CurrOpinHIVAIDS.2012;7:p.125-130.

8. Inciardi J, Surratt H, Kurtz S, Weaver J. TheeffectofserostatusonHIVriskbehaviourchangeamong women sex workers in Miami, Florida.AIDSCare.2005;17:p.s88-s101.

9. Holtgrave D, Pinkerton P. Can increasingawarenessofHIVseropositivityreduceinfectionsby50% in theUnitedStates? JAcquir ImmuneDeficSyndr.2007;44:p.360-363.

10. Bartlett J, DeMasi R, Quinn J, Moxham C,Rousseau F. Overview of the effectiveness oftriplecombinationtherapyinantiretroviral-naiveHIV-1infectedadults.AIDS2001.2001;15:p.1369–1377.

11. GulickR,MeibohmA,HavlirD,EronJ,MosleyA, Chodakewitz J, et al. Six-year follow-up

of HIV-1-infected adults in a clinical trial ofantiretroviraltherapywithindinavir,zidovudine,andlamivudine.AIDS.2003;17:p.2345–2349.

12. Aggleton P. Law, Ethics, and Human rights.HIV/AIDSrelated stigma and discrimination:A conceptual framework. Canadian HIV-AIDSPolicyLawReview.2002;7:p.115-116.

13. AggletonP,ParkerR.A conceptual frameworkand basis for action: HIV/AIDS stigma anddiscrimination. In UNAIDS World AIDSCampaign2002-2003;2002;GenevaSwitzerland.

14. AVERT Stigma, Discrimination and AttitudestoHIVandAIDS.Publishedon line. [Online].;2008. Available from: http://www.avert.org/aidsstigma.htm

15. NybladeL,FieldML.Women,Communities,andthePreventionofMothertochildTransmissionofHIV:Issueandfindingfromcommunityresearchin Botswana and Zambia. Washington, DC.ICRW.2000.

16. Government of India - Ministry of health andfamily welfare: State wise HIV prevalence(1998-2004). [Online]. cited 2016 Agust 25.Available from:http://www.acoonline.org/facts_hivestimates.htm.

17. Venkataramana CBA, Sarada PV. Extent andspeedofspreadofHIVinfectioninIndiathroughthe commercial sex workers: a perspective.Tropical Medicine and International Health.2001;6:p.1040-1061.

18. Becky L, Genberg , Kawichai S, Chingono A,SendahM, Suwat CKA, et al. Assessing HIV/AIDSStigmaandDiscriminationinDevelopingCountries.AIDSBehav.2008;12:p.772-780.

19. AnastasiaP,HoaNP,TishelmanC,MarroneG,ChucNTK,BrughaR,etal.Communitypatternsof stigma towards persons living with HIV: Apopulation-basedlatentclassanalysisfromruralVietnam.BMCPublicHealth.2011;11.

20. CastroA,FarmerP.UnderstandingandaddressingAIDS-related stigma: from anthropologicaltheory toclinicalpractice inHaiti.AmJPublicHealth.2005Jan;95(1).

21. Letamo , Gobopamang. HIV/AIDS RelatedStigma and Discrimination among AdolescentsinBotswana.AfricanPopulationStudies. 2004;19(2):p.191-204.

Level of stress among Doctor of Physical therapy students in Karachi, Pakistan

tooba Kafeel1, Rafia shoaib1, Fatima sohail1, Faisal Yamin2, Imran Ahmed2, Hafsa Paracha3

1House officer, 2Assistant Professor, 3Physiotherapy Student, Institute of Physical Medicine and Rehabilitation, Dow University of Health Sciences

AbstRACt

background: Stressissomethingthatdisruptsone’sbodilyorintellectualwellbeing.Mentalstresscomprisesofanxiety,hopelessnessandsignssuchas insomnia,pain inheadandback.Presentlymentalstress isaforemostrootofdisabilitywide-reaching,accountingfor1/3rdofdisabilityadjustedlifeyears(DALYs).ThepurposeofourstudywastoassessthelevelofstressamongstDPTstudentsinDowUniversityofHealthSciences,Karachi,Pakistan.

Methodology:Across-sectionalStudywasconductedamongundergraduateDPTstudentsstudyinginDowUniversityofHealthSciences,withthehelpofNon-probabilitypurposivesamplingtechnique.Estimatedsample sizewas 382.The study durationwas 3months.Datawas analyzed through SPSSVersion 23.PearsonChiSquareTestwasusedtodeterminethedegreeofimportbetweentwovariables.

P-Valuewaslessthan0.5

Results: Resultsofthestudiedshowedthat,outof382selectedstudents,40.1%studentswerefoundwithseverestress,38.2%studentshadModerateStress,19.6%studentshadmildstressandonly2.1%studentswerefoundwithoutanystress.

Conclusion:Thisstudydemonstratesasignificantincreaseintheproportionofstudentswithstress.Overallstudyshowedthatmajorityofthestudentshadseverestressduetoacademicandpersonalreasonswhichtheycouldn’tcopeup.

Keywords: Stress, Headache, Physical therapy students

INtRODUCtION

Stress is something that disrupts one’s bodily orintellectual wellbeing. Educational stress amongst theuniversitystudentsisagreatchallengefortheinstitutionscurrently[1]Stressisabodilyorpsychosomaticincidentdocumentedduringself-cognitionofaggravatingfactors,when interacting with one’s environment[2] Presentlymental stress is a significant communal health crisisand it is a foremost root of disability wide-reaching,accounting for 1/3rd of disability adjusted life years(DALYs).[3] Stress is ‘‘numerous usual responses ofthebody(psychological,emotional,andphysiological)intended for self-preservation’’ and as well as ‘‘acondition of psychological or emotional strain ordormancy’’.[5] Psychological stress, nervousness andbad temper are also experience by studentswhich are

too associated with stress.[12] Headache, back pain,painintorso,arms,legsorjointishighlypredominantin individuals with Post Traumatic Stress Disorder(PTSD).[15]

PhysicalTherapyisadifficultfieldandstudentsareexposed to numerous types of pressure as educationalstress,tryingtoachieveenhancedoutcomes,alterationsin environment, personal or family concern, lack ofconfidence about future, not sufficient spare time,handlingextremelyinspiringatmosphereofuniversity,examinations, increased work burden and financialconcerns.[19]

The bio-psycho-social approach is the mostextensiveinpresentingstressasasolitaryand/ormutualload.[24] The five commonly used coping strategies by

DOI Number: 10.5958/0973-5674.2018.00020.5


theundergraduatesallthroughtheeventsofstresswere:Positive Reframing, Planning, Acceptance, ActiveCopingandSelf-distraction.[8]

Favourable stress and unfavourable stress are twotypes of stress. Favourable stress is the type of stresswhich encourages and helps achieving knowledgeandwisdom and unfavourable stress is the onewhichprevents and suppresses achieving knowledge [4]

Anothertypeofstresswhichisnegativeisdistressthatcanharmfullyaffectphysicalandemotional lifeonanindividual [1].

Highoccurrenceofstresshasbeenreportedamongstmedical undergraduates i.e. from 25-90% [23]. A studyconducted amongstmedical students ofUSA reported23% students had clinical depressionwhile 57%wereunderpsychologicalstress.[10]63.8%inSaudiArabiaand90%inPakistanwasthereportedprevalenceofstress.[14]

Examinations, family and relationship issueswere themostcommonstressorsreportedbygirlsthanboys.[5]

Poor educational performance, dropout amountsgreater than before frommedical university, damagedrelationships, substance misuse and suicide might becaused by distress. Low self-esteem, low quality ofpatientcare,exhaustion,and,eventuallyanalterationinthevaluesofthemedicalcareermightalsobecausedbydistress [11]

Unsuccessful stress managing mechanism suchas avoiding problem, suspicious thinking, publicwithdrawal,andself-criticismhasharmfulconsequencesand might lead to despair, anxiety and reducedpsychologicalwell-being[22] Psychotherapyfacilitiesareessentialanditshouldbeaccessibletoundergraduatesinmedicaluniversitytocontrolthismorbidity[25]

Stresscanbebestcopedbyexercisingeveryday,meditationorotherrelaxationmethods,plannedintervalsand learning innovative coping strategies to producepredictability inour lives.Almost75%of themedicalundergraduatesweresatisfiedwiththeirspecificcopingmechanisms[5]

Therationaleofourstudywastodeterminethelevelof stress amongst Doctor of Physical Therapy (DPT)studentsstudyinginDowUniversityofHealthSciences,Karachi,Pakistan.

MEtHOD AND MAtERIALs

RESEARCHDESIGN

A cross-sectional (self-reported) questionnairesurveydesignwasusedfordatacollection.

SETTINGS

DPT studentsDowUniversity ofHealth Sciences(IPM&RandOJHA)

INCLUSIONCRITERION

• UndergraduateDPT students ofDUHS [(bothmaleandfemale)(1styear–5thyear)]

EXCLUSIONCRITERION

• DPTstudentsofuniversitiesotherthanDUHS

• Postgraduatephysiotherapists

• Technicianphysiotherapists

• BSPTandDiplomaholdersinphysiotherapy

DURATIONOFTHESTUDY

3 months after the approval of synopsis fromIPM&RScientificmeeting.

SIZEOFSAMPLE

382was thesamplesizecalculated throughWHOsoftware Open Epi Version 3.0 with 54% of thefrequencyhypothesized,with5%confidencelimit,1%ofdesigneffectand95%confidencelevel[22]

SAMPLINGTECHNIQUE

Non-probability Purposive Sampling Techniquewasused.

MEtHODOLOGY

SUBJECTS

All participants were given questionnaires afterexplanation of aim of study and taking consent. TheresearchwascarriedoutfromAugust2016toOctober2016.OurstudysettingwasIPMRandOJHASchoolofphysiotherapy.PermissionwastakenfromtheHeadofDepartments.

The Questionnaire had 2 parts, one containedthe demographic details of the participant and while


other one comprised of 32 potential stress producers,throughwhichyoucoulddeterminewhetheryouhaveexperienced low, moderate, or high stress in the pastyear.

MetHoD

In the beginning of our data collection we tookpermission from the HOD to approach the studentsandgetourformsfilled.Questionnairewasdistributedamongstthemaftertellingthemtheaimofourstudyandafter taking their consentWe divided the sample sizeequallyperclassandfurtherdividedthedataperclassintoOJHA and IPMR. Thenwe grouped the selectednumberofstudentsofIPMRintheclasswhogavetheirconsent(1classperday)andafterexplainingtothemthepurposeofourstudyandthequestionsincludedinthequestionnaire, questionnairewasdistributed.After ourdatawascompletedfromIPMR,wewenttoOJHA.WetookpermissionfromtheirHODaswellandthesameprocesswasrepeated.2ndyearwasontheirexaminationleave sowecouldn’tgetdata from there thereforewehadtowaitfortheirsemesterclassestostart.AftertheycamebackwehadtogotoOJHAonceagainandgetourformsfilledfromthem.


Data were stored and analyzed using IBM-SPSSversion 23.0, count and percentageswere reported forgender,agegroupandyearsofstudy,andlevelofstressamong doctor of physical therapy students of studiedsample, Pearson chi square test was used to see theassociation of stress with baseline factors, pie chartreported togive theprevalenceof stressandbarchartusedtogivegraphicalsummaryofresults.P-valuelessthan0.05wereconsideredsignificant.

REsULts/ FINDINGs

Inthepresentstudy382DPTstudentsparticipatedout of which 84.8% of the sample was female whilemales onlymade 15.2% of the total. 44% of studentswere below 20 years of age and 56%were above 20years. As per the division students participated in thestudywere;84studentsfrom1styear(22%),86studentsfrom2ndyear(22.5%),82studentsfrom3rdyear(21.5%),85studentsfrom4thyear(22.3%)and45studentsfrom5thyear(11.8%).(Table1)

Resultsofthestudiedshowedthat,40.1%studentsfoundwithseverestress,38.2%studentshadModerate

Stress,19.6%studentsdeclaredasmildstressandonly2.1%studentswerefoundwithoutanystress.(Table2)Thegraphicalpresentationofstresslevelisgivenusingpiechart.

Pearson Chi Square test was used to see theassociation of age, gender and years of study withlevel of stress, study showed that, only eight females,werefoundwithoutanystress,and89%femalesfoundwith moderate level of stress, 60.1% sample of agemore than twenty-years old found with severe stress,37.3%studentof2ndyear foundwithmildstress leveland26.8%studentof4thyearfoundwithseverestresslevel, results of chi square test showed that therewasnosignificantassociationofstresslevelswithagegroupand gender, but therewas significant associationwithyearofstudy,(Table3),barchartisreportedtogivethegraphicalrepresentationofstresslevelswithagegroup,genderandyearofstudy.

table 1: baseline Characteristics of studied sample (n=382)

Variables n %

GenderMale 58 15.2

Female 324 84.8

Age(years)<20Years 168 44

>20Years 214 56

YearofStudy

1stYear 84 22

2ndYear 86 22.5

3rdYear 82 21.5

4thYear 85 22.3

5thYear 45 11.8

table 2: Level of stress

LevelofStress N %

NoStress 8 2.1

MildStress 75 19.6

ModerateStress 146 38.2

SevereStress 153 40.1


table 3: Association of stress Levels with baseline Parameters using Pearson Chi square test

VariablesNo stress Mild stress Moderate stress severe stress

p-valuen % n % n % n %

GenderMale - - 12 16.0 16 11.0 30 19.6

0.12Female 8 100 63 84.0 130 89.0 123 80.4

Age(years)<=20Years 3 37.5 40 53.3 64 43.8 61 39.9

0.27>20Years 5 62.5 35 46.7 82 56.2 92 60.1

YearofStudy

1stYear - - 10 13.3 33 22.6 41 26.8

0.01*

2ndYear 3 37.5 28 37.3 31 21.2 24 15.7

3rdYear 3 37.5 16 21.3 31 21.2 32 20.9

4thYear - - 14 18.7 30 20.5 41 26.8

5thYear 2 25.0 7 9.3 21 14.4 15 9.8

*p<0.05wasconsideredsignificantusingPearsonChiSquaretest

DIsCUssION

Outofthewholesampleonly2.1%ofthestudentsreportednostresswhilethegreatestratioofthestudents40.1% reported severe stress with a little differencefrommoderatestressthatwas38.2%.19.6%ofstudentsshowedmildstresslevels.

Themain resultsof this studysuggest thatamongDoctorofPhysicalTherapystudentsatDowUniversityof Health Sciences only eight females, were foundwithout any stress, and89% femaleswere foundwithmoderatelevelofstress,60.1%sampleofagemorethantwenty-yearsoldfoundwithseverestress,37.3%studentof 2nd year found with mild stress level and 26.8%student of 4th year foundwith severe stress level.Ourstudy showed that therewasno significantassociationof stress level with gender. No significant associationbetweenstresslevelsandgenderinasampleofcollegestudents this result is correspondent with a report byCohenandcolleagues(Cohen, Kamarck &Mermelstein, 1983).

Theresultisnotparalleltothestudieswhichfoundthat both male and female students were likely toexperiencestress[14].Butfemalesperceivehighlevelsofstressasrelatedtomalessuggestedbymanystudies.Astheyperceiveadditionalburdenoverthemselves,they’renotmerelydifferentintheirperceptionofstressors,but

theirresponsestostressorsarealsochanged. [2]

Theresultsofourstudyshowedthat therewasnosignificant association of stress levels with age groupand gender, but therewas significant associationwithyearofstudyanditisanimportantfactorinperceivedstressinDPTstudents,

The results showed that37.3%studentof2ndyearfoundwithmildstressand26.8%studentof1stand4th yearfoundwithseverestress.StudiesdoneinAustralia,SaudiArabia,NorwayandEthiopiarecognisedthatfirstyearstudentsweremore likely tohavementaldistressthan second year and aboveAlthough, any significantassociation between year of study andmental distressdoes not show by other studies. This may be since,trouble inadjusting toUniversity trainingfacebyfirstyearstudents [3].Studiesshowthateachyearofmedicaltrainingisstressful,withthefourthyearnoworsethanothers[26].

Our study showed death of a relative as a majorstressorwhichwasnotreportedinanyotherstudiesonstress. Increasedworkload at schoolwas also amajorstressorwhichwaslikestudiesonstressbyYusoffetal.(2011)andSheikhetal.(2004).[4,5]Anothersignificantstressorwaschange in sleepinghabitswhichwasalsoreportedbyastudybyWaqasetal.(2015) [14].Changeinlifestyleforfinancialreasonwasalsoastressoramongst


many undergraduates which was contradictory to thestudybyWaqasetal.(2015)becausethatstudywasdoneinaprivateinstitutionwheremostoftheundergraduateswerefromahighersocio-economicclass [14].Changeinsocialhabitsand toomanymissedclassesalso lead todistressamongststudentsandwerenotmentionedinanyotherstudiesreportedonstress.

CONCLUsION

Accordingtothestudyaverylittleproportionofthestudents reported no stress while the greatest fractionof the students reported severe stress with a modestvariation from moderate stress that that the studentsreported.Mildstress levelswere reportedby less thanhalfofthesample.

Conflict of Interest:Nil.

source of Funding:Self.

Ethical Clearance: Taken from the committee ofDowUniversityofHealthSciences.

REFERENCEs

1. Memon AR, Khanzada SR, Khan K, Feroz J,Hussain HM et. Al. Percieved Stress AmongPhysical Therapy Students of Isra University.IJPHY.2016;3(1):35-8.

2. SabihF,SiddiquiFR,BaberMN.AssessmentofStress among Physiotherapy Students at RiphahCentre of Rehabilitation Sciences. JPMA. 2013March;63(3):346-9.

3. Dachew BA, Bisetegn TA, Gebremariam RB.Prevalence of Mental Distress and AssociatedFactors among Undergraduate Students ofUniversity of Gondar, Northwest Ethiopia: ACrossSectional InstitutionalBasedStudy.PLoSONE.2015March20;10(3):1-10.

4. Yusoff MSB, Hamid AHA, Rosli NR, ZakariaNA,RameliNAC,RahmanNSAetal.Prevalenceof stress, stressors and coping strategies amongsecondary school students in Kota Bharu,Kelantan,Malaysia.IJSR.2011;1(1):23-8.

5. Shaikh BT, Kahloon A, Kazmi M, Khalid H,Nawaz K, Khan NA et al. Students, Stress andCoping Strategies:ACase of PakistaniMedicalSchool.EH.2004November;17(3):346-53.

6. Kulsoom B, Afsar NA. Stress, anxiety, anddepression among medical students in amultiethnicsetting.NDT.2015;11:1713–22.

7. MarjaniA,GharaviAM,JahanshahiM,VahidiradA,AlizadehF.StressamongmedicalstudentsofGorgan(SouthEastofCaspianSea),Iran.KUMJ.2008;6(23):421-42.

8. Sreeramareddy CT, Shankar RP, Binu VS,Mukhopadhyay C, Ray B et al. PsychologicalMorbidity,SourcesofStressandCopingStrategiesamongUndergraduateMedicalStudentsofNepal.BMCMedicalEducation.2007August;7:26.

9. Sohail N. Stress and Academic Performanceamong Medical Students. JCPSP. 2013; 23(1):67-71.

10. SherinaMS,RampalL,KanesonN.PsychologicalStress among Undergraduate Medical Students.MedJMalaysia.2004June2;59:207-11.

11. Slonim J,KienhuisM,BenedettoMD,Reece J.The relationships among self-care, dispositionalmindfulness, and psychological distress inmedical students. Med Educ Online. 2015 June24;20:27924.

12. Qamar K, Khan NS Kiani MRB. FactorsAssociatedwithStressAmongMedicalStudents.JPMA.2015July;65(7):753-5.

13. Borjalilu S, Mohammadi A, Mojtahedzadeh R.SourcesandSeverityofPerceivedStressamongIranianMedicalStudents.IranRedCrescentMedJ.2015October;17(10):e17767.

14. Waqas A, Khan S, SharifW, Khalid U, Ali A.Association of Academic Stress with SleepingDifficulties in Medical Students of a PakistaniMedicalSchool:aCrossSectionalSurvey.PeerJ.2015March12;3:1-11.

15. Zhang Y, Zhang J, Zhu S, Du C, Zhang W.PrevalenceandPredictorsofSomaticSymptomsamong Child and Adolescents with ProbablePost-traumaticStressDisorder:ACross-SectionalStudy Conducted in 21 Primary and SecondarySchools after an Earthquake. PLoS ONE. 2015September1;10(9):1-14.

16. Momayyezi M, Fallahzadeh H, Momayyezi M.


ClinicaleducationstressorsinmedicaltraineesinShahidSadoughiUniversityofMedicalSciences,Yazd.JAdvMedEducProf.2016;4(1):8-12.

17. Cuttilan AN, Sayampanathan AA, Ho RCM.Mental health issues amongst medical studentsinAsia:asystematicreview[2000–2015].ATM.2016;4(4):72.

18. Abu-Ghazaleh SB, Sonbol HN, Rajab LD. AlongitudinalstudyofpsychologicalstressamongundergraduatedentalstudentsattheUniversityofJordan.BMCMedicalEducation.2016;16:90.

19. Jacob T, Einstein O. Stress Among BachelorPhysicalTherapyStudentsinIsraelduringClinicalPractice and Its Association with AcademicAchievements–ResultsofaLongitudinalStudy.IJAHSP.2016Jan12;14(1):

20. Abdulghani HM, AlKanhal AA, Mahmoud ES,Ponnaperuma GG, Alfaris EA. Stress and ItsEffects on Medical Students: A Cross-sectionalStudyataCollegeofMedicineinSaudiArabia.JHPN.2011October;29(5):516-22.

21. FarahangizS,MohebpourF,SalehiA.AssessmentofMentalHealthamongIranianMedicalStudents:

ACross-Sectional Study. IJHS. 2016; 10(1):49-55.

22. Eva EO, Islam MZ, Mosaddek ASM, RahmanMF,RozarioRJ,IftekharAFMHetal.Prevalenceofstress amongmedical students: a comparativestudybetweenpublicandprivatemedicalschoolsinBangladesh.BMCResNotes.2015;8:327.

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24. Rojas GLR, Grozo SC, Flores LD, Lijap LO,PerezDM,LozadaROetal.LevelofStressandCoping Strategy inMedical Students ComparedwithStudentsofOtherCareers.GMM.2015;151:415-21.

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Immediate Effect of Virtual Reality on balance, Gait and Posture in stroke Patients- An Experimental study

Anjali Parab1 Akshaya Patil1 1Student, KLEU Institute of Physiotherapy, Nehru Nagar, Belagavi

AbstRACt

background and purpose – Balance,gaitandpostureisaffectedinthestrokepatientsandalsohasadverseeffectontruncalstabilityalongwiththegait.Extensiveresearchhasbeendoneinthefieldofphysiotherapyinstrokerehabilitation;noevidenceisavailableforimmediateeffectofvirtualrealityonbalance,gaitandpostureinstrokepatients.

Objective – Toevaluatetheimmediateeffectofvirtualrealityonbalance,gaitandpostureinstrokepatientsusingTimedUpandGo(TUG),TinettiPerformance-OrientedMobilityAssessment(POMA)andPosturalAssessmentScaleforStrokePatients(PASS).

Methods and materials- Thepresentexperimentalstudywasconductedon13participantswhichincludedbothmaleandfemaleparticipantsbetween40to65yearswithchronicstroke.Theparticipantsweregivenvirtual reality for 45minutes. Pre-interventional and Post-interventional outcome measurements wereassessedusingTimedUpandGo(TUG),TinettiPerformance-OrientedMobilityAssessment(POMA)andPosturalassessmentScaleforStrokePatients(PASS).

Result- The difference between pretest and posttest ofTUG, POMA and PASSwas statistically foundsignificant.

Conclusion – The study concludes that there is immediate effect of virtual reality onbalance, gait andpostureinstrokepatients.Virtualrealitycanbeusedasadjuncttherapytotacklebalance,gaitandpostureissueinassociationwithconventionaltherapy.

Keywords: virtual reality, stroke patients, balance, gait and posture.

Corresponding author:Anjali ParabBPT,Student,KLEUInstituteofPhysiotherapy.NehruNagar,Belagavi. E-mail:[email protected]

INtRODUCtION

Stroke is the 2nd commonest cause of death1. WHO clinically defines stroke as ‘the rapiddevelopmentofclinicalsignsandsymptomsofafocalneurologicaldisturbancelastingmorethan24hours or leading todeathwith no apparent causeother than vascular origin2.Theglobal incidenceofstrokeis258/100,000/yearand1.5timeshigherinmenthaninwomen3.

Strokerelatedhemiparesisshowsasymmetryinstandingpostureandwalking,4-6duetomotorweakness,7 asymmetric muscle tone,8,9 and somatosensorydeficitsinlowerextremitieswhichleadstobalanceimpairment, postural sway9 , disordered gait andincreasedprobabilityoffalls.10Disuseofpareticlegcanbeaconsequenceforweightbearingasymmetryandimpairedbalancefunction.11VariousphysiotherapyapproachesincludingVirtualreality(VR)areavailablefor stroke rehabilitation. These are introduced to thepatientsfromhospitaladmission,basedonthestageofrecoveryinhemiplegics.

Virtual reality involves interactive stimulationdesignedtogiveusersanexperiencesimilartotherealworld through computer hardware and software12. It

DOI Number: 10.5958/0973-5674.2018.00021.7


providespatientswithconsistentpractice,biofeedbackand further encourages endurance practice. It hasnumerousbenefitsingait,balanceretraining,upperandlowerlimbrehabilitationetc.Inadvancementofvisual,auditory,tactileinputandmotivation,virtualrealityalso proves to be beneficial.13Moreover, programs inVR are more interesting and enjoyable than theconventional therapy task thereby encouraging thepatientstoincreasethefrequencyofactivity14withminimalassistancefromtherapist.

Virtualrealitygamesarefeasibleandbeneficialwhenintroducedtoelderlypatientswhoexperiencerecurrentfall.15Plentyofworkisdoneusingvirtualrealitytoassessbalanceandgaitinstrokepatients.Manystudiesshowedpositiveeffectonbalanceandgait among stroke patients who underwent longperiodsofinterventionusingvirtualreality.Studiesaredonewhichstatethatthereisimprovementinposturalsway,posturalstabilityandposturalcontrolbutnotmanystudiesaredoneonpostureassessmentusingvirtualreality.Afterextensiveliteraturesearch,wecouldnotfindanyconclusiveevidenceregardingan immediate effect of virtual reality onbalance,gaitandpostureinstrokepatients.Hence,thereisneedtoconductafurtherstudywhichwouldstateimmediateeffectofvirtualrealityonbalance,gaitandpostureinstrokepatients.


MethodsThe study was conducted over a periodof 6 months at a tertiary care hospital after takingrequiredethicalclearancefromtheinstitutionalethicalcommittee.Written informed consent was taken fromeachparticipant.Atotalof18participantswerescreenedand 13 participants were recruited on the basis of

inclusion and exclusion criteria. Inclusion criteria: Subjectsdiagnosedwith1steverattackofstroke,willingtoparticipateinthestudy,bothmalesandfemalesofagegroup41-65years, able to standwithout supportwithMinimentalstateexamination(MMSE)scoremorethan24outof30wereincluded.Exclusion criteria: Subjectswith other neurological conditions except stroke,individuals with vertigo, individuals with peripheralneuropathy, individuals with postural hypotensionand individuals with visual problems. A pre and postassessmentofbalance,gaitandposturewasdoneusingTimed Up and Go test (TUG), Performance OrientedMobilityAssessment(POMA)andPosturalAssessmentScaleforStrokePatients(PASS).

Procedure

Virtual reality therapy was given for 45minutesto all the subjectswhere subjectswere asked to standon the sensor platform. A walking task was given inwhichthesubjectshadtomarchonthesensorplatformwiththevirtualimageofthepersonmovinginastreetenvironment. The walking task was planned throughobstacleswhichhadtobeavoidedbyswayingandweightbearingeitherontheleftorrightleg.Thesubjectswereaskedtowalkonthevirtualrealityplatformviewingthevisualsinfrontofthem.

DAtA ANALYsIs

Nominaldatafrompatient’sdemographicdata i.e.age, gender were analyzed using t-test. Percentage ofdistributionofmalesandfemaleswithstrokewasdone.Comparison of pre intervention and post interventionscoresofTUG,POMAandPASSwerecomparedusingpaired t-test. Probability values less than 0.05 wereconsideredstatisticallysignificant.

REsULt

Theprevalenceofstrokewasmoreintheageof40-65yearswiththemeanage55.Thereweremorenumberofmales(76.92%)thanfemales(23.08%)inthepresentstudy.ResultsofTUGscore,POMAandPASSislistedinTable1.Therewasasignificantchangefromprevaluetopostvalueaftervirtualrealitytherapy.

table 1: Comparison of pre-test and post-test tUG scores, POMA scores, PAss scores.

Outcome Measure Pre test (Mean±sD) Post test (Mean±sD) P-valuetUG 36.96±26.92 28.65±19.42 0.0071*POMA 20.08±5.87 22.38±3.38 0.0250*PAss 28.62±5.58 30.38±5.36 0.0005*

*p<0.05


DIsCUssION

The present pilot study identified some beneficialeffectsofvirtualrealityonbalance,gaitandposture.Asexpected from previouswork on stroke rehabilitation,subjectsshowedimprovement.

PostinterventionassessmentdonebyPOMA,BBSand PASS scores showed significant improvement inneurologicalsymptomslikemuscleweakness,abnormalmuscle tone, sensory dysfunction, asymmetrical gaitpattern, slow gait speed, reduced balance ability andimpairedposturalcontrolwhichmayhave resulted inreducedriskoffallinstrokepatients.16

Normal functional tasks require input fromvisual,sensory, somato sensory systems for normal posturalcontrol.Virtualrealityexercisesincludedwere,avoidingobstacles,weightshiftingandstepping.Theseexercisesweremainlyincludedasitstimulatesthedynamicpartofposturalstability.Lossofposturalcontrolcancausedisturbancesinbalance,gaitandposture,thushamperingactivities of daily living.These exercises also improveweightsymmetrywiththeincreaseduseofpareticleg.This provides realistic visual and proprioceptive inputthus improving patient’s reaction time and posturalstabilityimprovingtheADL’softhepatient.17

These exercises are also essential componentsof locomotion. Gait and balance abilities of anindividual greatly depend upon the motor function ofthe ankle joint.Muscle tonehelps the structures tobein continuous and passive partial contraction whichhelpstomaintainbody’sposture.Inthelaterstagesofstroke,spasticitydevelops. Increased tone in theankleplantarflexorshindersstaticaswellasdynamicbalanaceandgait.Exerciseinvolvedinthepresentvirtualrealityprogrammeinvolvedtheanklejointwhichincreasedthecordination between agonist and antagonist muscles.Thus reducing the spasticity 18, and improving thefunction. Side stepping exercises thatwere performedhelped in activation the hip abduction. Thereby tryreducingthepelvicdropduringthesinglestancephaseofgaitcycle. 19

Physiologically, VR therapy helps to promoteneuralplasticity.Thereorganisationoccursbyactivationfromthesamesideofthebraintotheoppositesensorymotorcortextherebyimprovinglocomotioninchronicstrokesurvivors.Thismechanismcouldalsodenotethechangesinthegaitcycleimprovingthetime.19

In the present study virtual reality helped theparticipants to concentrate on games which improvedtheirbalanceandposturalabilitiesonaffectedextremity.ParticipantsfeltdifficultyinperformingtheVRtasksatthebeginningofbalancetrainingsessionsandfeltmoreconfidentattheendofthesession.Alsoafterthevirtualrealitytheparticipantswalkingspeedwasimproved.

Similar study was done in stroke patients andshowed significant improvement in balance. Dueto visual and auditory feedback and influence ofmotivationalaspectsonmotorperformanceprovidedbyvirtualrealitysystemtheseresultswereobtained.Thissensory informationprovidedbyvirtual reality systemallows the central nervous system for better controlposition and orientation of body segment to adapt theexternalenvironment.20

These positive improvements occurred in thesesubjects of already higher functioning stroke patientswho were ambulatory and also received alternativerehabilitation protocol. Therefore results cannot beattributedtovirtualrealityalone.21

ThelimitationsofthepresentstudyareStudywasconducted to assess the effect of virtual reality for itsimmediate effect which grossly restricts informationaboutthelongtermeffect.Totalnumberofsamplesizewasverysmall;hence itwillhavenegative impactongeneralizationof result.Thestudyassessed immediateeffect,hencetheeffectof longtermtherapynot taken.FutureresearchwithaLongtermeffectscanbeassessedinlargesamplesize.Similarstudycanbetakenupforassessing effect of long term therapy among strokepatients.

CONCLUsION

TheeffectofvirtualrealitywasfoundsignificantonparameterofTUGscore.POMAscorewasalsofoundsignificantly improved immediately after the therapy.The PASS score showed significant improvementamong the stroke patients. Static as well as dynamicbalanceandmobilityskillsfoundimprovedamongthepatients. There was improvement in balance and gaitparameters aswell as ability to standon paretic limb.Hence,Virtualrealitycanbeusedasadjuncttherapytotacklebalance,gaitandpostureissueinassociationwithconventionaltherapy.

source of Funding- Selffunding


Conflict of Interest- Nil

REFERENCEs

1. PandianJD,SudhanP.StrokeepidemiologyandstrokecareservicesinIndia.JStroke.2013Sep1;15(3):128-34.

2. Strong K, Mathers C, Bonita R. Preventingstroke:savinglivesaroundtheworld.TheLancetNeurology.2007Feb28;6(2):182-7.

3. Béjot Y, Daubail B, Giroud M. Epidemiologyofstrokeandtransient ischemicattacks:Currentknowledgeandperspectives.Revueneurologique.2016Jan31;172(1):59-68.

4. Eng JJ, ChuKS. Reliability and comparison ofweight-bearing ability during standing tasks forindividuals with chronic stroke. Archives ofphysical medicine and rehabilitation. 2002 Aug31;83(8):1138-44.

5. Rodriguez GM, Aruin AS. The effect of shoewedges and lifts on symmetry of stance andweight bearing in hemiparetic individuals.Archivesofphysicalmedicineandrehabilitation.2002Apr30;83(4):478-82.

6. WallJC,TurnbullGI.Gaitasymmetriesinresidualhemiplegia. Archives of physical medicine andrehabilitation.1986Aug;67(8):550-3.

7. Genthon N, Gissot AS, Froger J, Rougier P,Pérennou D. Posturography in Patients WithStroke.Stroke.2008Feb1;39(2):489-.

8. PERENNOU D, MARSDEN J, PLAYFORDE, DAY B. The vestibular control of balanceafter stroke.Commentary. Journalofneurology,neurosurgeryandpsychiatry.2005;76(5).

9. Pérennou D. Weight bearing asymmetry instanding hemiparetic patients. Journal ofNeurology, Neurosurgery & Psychiatry. 2005May1;76(5):621-.

10. ChengPT,LiawMY,WongMK,TangFT,LeeMY,LinPS.Thesit-to-standmovementinstrokepatientsanditscorrelationwithfalling.Archivesofphysicalmedicineandrehabilitation.1998Sep1;79(9):1043-6.

11. Aruin AS, Hanke T, Chaudhuri G, Harvey R,RaoN.Compelledweightbearinginpersonswithhemiparesis following stroke: the effectof a liftinsertandgoal-directedbalanceexercise.Journalofrehabilitationresearchanddevelopment.2000Jan1;37(1):65.

12. ChanCL,NgaiEK,LeungPK,WongS.Effectof the adapted virtual reality cognitive trainingprogramamongChineseolderadultswithchronicschizophrenia:apilotstudy.Internationaljournalofgeriatricpsychiatry.2010Jun1;25(6):643-9.

13. Bisson E, Contant B, Sveistrup H, Lajoie Y.Functional balance and dual-task reaction timesin older adults are improved by virtual realityand biofeedback training. Cyberpsychology &behavior.2007Feb1;10(1):16-23.

14. Laver KE, George S, Thomas S, Deutsch JE,CrottyM.Virtualrealityforstrokerehabilitation.TheCochraneLibrary.2015Feb12.

15. PigfordT,AndrewsAW.Feasibilityandbenefitof using the Nintendo Wii Fit for balancerehabilitation in an elderly patient experiencingrecurrentfalls.Journalofstudentphysicaltherapyresearch.2010;2(1):12-20.

16. AnS,JeeY,LeeD,SongS,LeeG.Predictivevalidity of the gait scale in the PerformanceOriented Mobility Assessment for strokesurvivors: a retrospective cohort study.PhysicalTherapy Rehabilitation Science. 2016 Mar30;5(1):1-8.

17. MaoY,ChenP,LiL,HuangD.Virtual realitytraining improves balance function. Neuralregenerationresearch.2014Sep1;9(17):1628.

18. YomC,ChoHY,LeeB.Effectsofvirtualreality-based ankle exercise on the dynamic balance,muscle tone,andgaitof strokepatients. Journalofphysicaltherapyscience.2015;27(3):845-9.

19. Kim JH, Jang SH, Kim CS, Jung JH, You JH.Use of virtual reality to enhance balance andambulation in chronic stroke: a double-blind,randomized controlled study. American JournalofPhysicalMedicine&Rehabilitation.2009Sep1;88(9):693-701.

20. CorbettaD,ImeriF,GattiR.Rehabilitationthatincorporatesvirtualrealityismoreeffectivethanstandard rehabilitation for improving walkingspeed, balance and mobility after stroke: asystematic review. Journal of physiotherapy.2015Jul31;61(3):117-24.

21. ParkYH,LeeCH,LeeBH.Clinicalusefulnessofthevirtualreality-basedposturalcontrol trainingonthegaitabilityinpatientswithstroke.Journalofexerciserehabilitation.2013Oct31;9(5):489-94

Effect of Cluster training Versus traditional training on Muscular strength among Recreationally Active Males- A

Comparative study

Akhil samson1, Padmakumar somashekharan Pillai2

1Post Graduate, 2Principal, Yenepoya Physiotherapy College, Yenepoya, Deemed University, Mangalore

AbstRACt

Objective: Tocomparetheeffectofclustertrainingandtraditionaltrainingonmuscularstrengthoutcomein recreationalmales.study Design:ComparativeStudy.Methods: 32maleparticipants agedbetween18-30yearswhowerealreadyexposedto6monthsofresistancetrainingwereincludedinthestudy.Theywerethenrandomizedbylotterymethodtoclustergroup(n=16)andtraditionalgroup(n=16).Eachgroupunderwent training for 7weeks and their pre and post training strengthmeasurewas documented.ThePaired‘t’testwasusedtoanalyzewithingroupdifferencewhileindependent‘t’testwasusedforbetweengroupdifferences.Levelofsignificancewassetatp<0.05.Results:Significant improvement instrength(p<0.05)wasfoundposttrainingcomparedtopretraininginboththegroups.HowevergreaterimprovementinstrengthwasseeninCTgroupwhencomparedtoTTgroup.Conclusion:Basedontheresults,Clustertrainingoutperformedtraditionaltraininginimprovingstrengthdevelopment.ClustertrainingmaybeanalternateforTraditionaltraininginstrengthdevelopmenttrainingprograms.

Keywords: cluster training, traditional training, Repetition maximum, intraset rest.

Address for Correspondence: - Padmakumar somashekharan Pillai, Principal,YenepoyaPhysiotherapyCollege,YenepoyaDeemedUniversity,Mangalore–[email protected],Faxno:0824-2203689

INtRODUCtION

“Resistance training is a formof physical activitythat is designed to improve muscular fitness byexercisingamuscleoramusclegroupagainstexternalresistance”.1Structured variation is the cornerstoneof an appropriately designed periodized strength andconditioningprogram.2

Evidence suggests that there are two main setstructures, the traditional (continuous repetition) andcluster set (intraset rest), that can be utilized in aresistance training program. Variation in a resistancetrainingprogramcanbedonebyvaryingtrainingload,numberofsetsandrepetitions,orderofexercise,exercisedensity(i.e.,numberofexercisesinasession,periodof

training,cyclingofexercises),trainingfocusorpriority,andbyprovidingrestintervalsbetweensets.2

Most commonly used set configuration istraditionalset.Thisinvolvesaseriesofrepetitionsthatare performed with the varying load in a continuousfashion. Traditional set structures are generally bettersuited for inducing hypertrophy, but theymay not bethebest for improvingmovementvelocity, strengthorpoweroutput.2Traditionalsetsconsistofthefollowingtypes, a) Straight sets, b) Pyramid sets, c) Reversepyramidsets.3Clusterset involvesvarying the intrasetrest (or inter-repetition rest) interval and/or trainingload.Typically,theclustersetstructureincludesa5-45secondsrest intervalbetweeneach individualorseriesofrepetitions,whichhasshownimprovementinpoweroutput,barbellvelocity,andbarbelldisplacementwhencomparedtotraditionalsetconfigurations.2,4Therearegenerallyfourbasicvariantsforclusterset training,a)Standard cluster set, b) Undulating cluster, c) Waveloading,d)Ascendingcluster.2,4

DOI Number: 10.5958/0973-5674.2018.00022.9


Traditionalresistancetrainingaffectsthequalityofrepetitionsduetofatiguecausedbytheaccumulationoflacticacid.Agreaterreductionofphosphocreatine(PCr)storeswill occur as a result of performing continuousrepetitionsduringasetwhichwillresultinanincreasedusageofmuscleglycogenandthus,agreaterincreaseinlacticacidconcentration.Thelacticacidproducedwilldecreasetheperformanceduringtraditionalsettrainingand also the force generating capacity which occursasaresultof thehydrogenionstimulatingareductionof the number of high force cross-bridge attachmentsin fast twitch fibers.4 Literature suggest that 15s ofrecovery effectively return force generating capacityto approximately 79.7%of the pre-fatigue capacity asaresultofthepartialreplenishmentoffuelsubstrates.4 Cluster trainingmight have has the ability to producehigherpoweroutputstoperformeachrepetitionowingto partial replenishment of Phosphocreatine duringthe intraset rest interval.4However, somestudieshavereported that traditional training has better strengthoutputs whereas some studies have supported clusterset training to be more effective for power outputs.5-8 Also, there exists conflicting results regarding whichof the two have a better effect on muscular strength.Also, very few studies have been done to find theeffectsoftraditionalversusclustertrainingspecificallyonstrengthoutput.Therefore, thepresent studyaimedto compare the effect of cluster versus traditional settrainingonmuscularstrength.


This study was conducted among males agedbetween18to25yearswithasamplesizeof32.Priorto participation, the participantswere explained aboutthe study and an informedconsentwasobtained fromthem. Ethical clearancewas obtained fromUniversityethicscommittee.Participantswere screenedbasedonthe inclusion and exclusion criteria. Inclusion criteriawere: Recreationally active male engaged in sports,agedbetween18-26years,Participantsexperiencedinresistancetrainingforatleast6months.Exclusioncriteriawere: Presence of any musculoskeletal, neurologicalandcardiovascularconditionoranyotherpathologicalcondition contraindicating exercise participation,Individuals already undergoing high-intensity strengthtraining.Includedparticipantswerescreenedusing theACSM’s pre-participation screening questionnaire.Eligible participants were then randomized by lotterymethodtoeitherTTgroup(16)orCTgroup(16).

MetHoD

Participants in both the groups trained thrice aweekfor7weekswitheachsessionlastingforupto1hourand theirpreandpostevaluationofstrengthwasdocumented by the formula:One repetitionmaximum(1 RM) = 100×W/ [102.78- (2.78× R)]Where, RM:repetition maximum, W: weight, R: Repetition.5 Trainingloadwassetatparticipant’s75%of1RMforboth the groups. Both the groupswere given 3 upperbodyexercises,viz.,Benchpress(Figure.3),Bentoverrow (Figure. 1), Shoulder press (Figure. 4) and threelowerbodyexercises,viz.,Backsquat(Figure.5),sumosquat(Figure.6),Calfraises(Figure.2)accordingtotheguidelinesprescribedinEssentialsofStrengthTrainingandConditioningmanual.9Beforeperformingtheaboveexercises the participants went through warm up andcool down sessions. The warm up session consistedofgeneralaswellasspecificwarmupeachlastingupto 5 minutes. The cool down period was 10 minutescomprising of static stretching of the muscles of theupperlimbandlowerlimbperformedafterthecessationoftheexercises.9ThetraditionaltraininggroupusedthePyramid set configuration.1st set of10 repetitions with75%of1RM,2ndsetof8repetitionswith75%of1RMadding additional weight than previously attemptedand 3rd set of 6 repetitions with 75% of 1RM addingadditionalweightthanattemptedinset2.10

Therestperiodbetweensetsintraditionalsetswas2minutes.Theclustertraininggroupusedthestandardcluster set protocol. A series of 24 repetitions wereperformedwith 3 repetitions in one cluster leading toanoverallof8clusters.4 The restperiodbetweeneachclusterwas15seconds.


StatisticalanalysiswasdoneusingSPSSversion22IBM.DatawasextractedandanalyzedbyShapiroWilktestofnormality.Pairedttestwasusedtoanalyzepre-trainingtopost-trainingdifferencewithinthegroups.Atwo sample independent t testwas applied to analyzepost-trainingdifferencebetween traditionalandclustergroups.P<0.05isconsideredtobesignificant

REsULts

Resultsshowedanincreaseinthepostmeanforallthepairswithinthetraditionalgroupandthisdifferencewas found to be statistically significant (p<0.001)


(Refer Table 1). Increase in the post mean was alsoseenwithin theclustergroup for all thepairs and thisdifference was found to be statistically significant(p<0.001) (Refer Table 2). Post-training differencebetweentraditionalandclustergroupshowedsignificantimprovementinstrengthintheclustergroupcomparedtotraditionalgroup(p<0.05)(ReferTable3).

DIsCUssION

Thisstudywasconductedwithanaimtocomparetheeffectofcluster trainingandtraditional trainingonmuscularstrengthoutcomeinrecreationalmales.Thirty-tworecreationalmaleswererecruitedinthestudywhocompletedtheexerciseprotocolfor7weeks.

Theclustergroupshowedsignificantimprovementin strength (Pvalue<0.05), post exercise.Thepre andpost trainingmean score (inKgs) of findingswere asfollows;benchpress77.38&99.75,shoulderpress57.50&83.00,bentoverrow76.50&102.69,sumosquat91.00and116.25,backsquat86.19&113.94andcalfraises97.75&125.63.Thiswasbecause15-30secondsofrestbetweentherepetitionshelpedre-synthesizingsomeofthedepletedphosphocreatine (PCr) in themusclecell,andthuscausedareductioninfatigue.DecreasesinbothATPandPCrareassociatedwithsignificantelevationsin lactate concentrations, which leads to substantialdecreasesintheamountofforcethatcanbegeneratedby the muscle. Haff et al found that Inclusion of 15seconds of recovery results in 79.7± 2.3% increase inmaximalforce–generatingcapacitythatcorrespondedtoofinitialcapacity.Increasedlactatelevelresultingfromshortrestintervalsisgenerallyassociatedwithnegativeeffects on muscle contraction leading to impairedATP production caused by changes in contractility,lactate accumulation ultimately altering function.11Thepresent study showed improvement in strength posttraining in the traditional group as well. The findingswere significant (P value<0.05) in all the 6 exercises.Thepreandpost trainingmeanscoreoffindingswereas follows;benchpress72.44&85.63, shoulderpress46.63&59.38,bentoverrow67.50&83.31,sumosquat73.19&89.06,backsquat74.00&90.69andcalfraises79.38&97.69.Thisimprovementmighthaveoccurredbecausethesetconfigurationwasdesignedspecificallyto target strengthwith the use of lower repetition andhigherweights.12Similarresultswereseeninthestudydone byMehriziAZ et alwho found that traditionaltraininghadanupperhandindevelopingstrengthwhen

comparedtoclustertraining.5

Moreover, the continuous repetitions might haveactivated the higher thresholdmotor units inactivatingthe lower thresholdmotorunits.Thiswasput forwardintheworkdonebyLawtonTetalwhocomparedtheeffectofcontinuousrepetitionandintrasetrestintervalonbenchpressstrengthandpower.Theyfoundthatnoregimen was superior in promoting power, however,benchpresstrainingwithcontinuousrepetitionsresultedin greater strength than with intra-set rest training.8

This increment in strength can also be attributed tothe build-up of metabolites that might have occurredduring the continuous repetitions that triggered thestrengthadaptation.ThiswasreflectedintheworkdonebyKarabulutMet alwho investigatedeffectsof low-intensityresistancetrainingwithvascularrestrictiononlegmuscle strength in oldermen. They found greaterincrementinstrengthwithlow-loadvascularrestrictiontraining.13However, this relationofmetabolites to thestrength adaptation is unclear and demands furtherresearch to reach into deep insights. The nature oftraditionalresistancetraininghadputthemusclesundergreatertimeundertensionwhichisinaccordancewiththe study done by Lawton T et al who found greatertime under tensionwith continuous repetition trainingthan intra set rest training.But this is in contrastwiththe study done by Gavin L et al who found greatertime under tension for muscles with cluster training.7

However,when the between group analysiswas donethe CT group exhibited greater significant strengthpost training (P value<0.05)when compared toTT inall the6exercises.TheposttrainingCTandTTmeanscores for the exerciseswere as follows; Bench press99.75 & 85.63, Shoulder press 83.00 & 59.38, Bentoverrow102.69&83.31,Sumosquat116.25&89.06,back squat 113.94 & 90.69 and calf raises 123.63 &97.69.Theintra-repetitionrestintheclustertraininghasshowntoreducethecentralandperipheralfatiguewhichmightbethereasonforbetterstrengthoutputexhibitedby the cluster training participants. Rio-Rodriguez,Iglesias-solerEandOlmoMFinvestigatedcentralandperipheral fatigue inducedbyTraditional set (TS) andintraset rest configurations (ISR),with anequalwork-to-rest ratio, and their relationshipwithcardiovascularchanges.TheyfoundthatISRinducedlowercentralandperipheralfatigueaswellaslowercardiovascularstressin comparison with TS configuration.14 Also, as theexerciseprotocolintheclustertrainingwasverynovel


totheparticipantsinthisstudy,itmighthavehadsomepsychologicalboostfortheparticipantstoworkoutwithmoreenthusiasmandreflectthisbigdifference.Althoughthefindingsinthisstudyareincontrastwithmanyotherworksintheliterature,clustertrainingcanbeutilizedbythebeginnerstobuildtheirstrength.

LIMItAtION

Therewasnofollowupdoneforthisstudy.Hencethelongtermeffectsofstrengthgainswithclustersettrainingisnotclear.

table 1: Pre-training to post-training difference within the traditional group.

Exercises Mean nstd. Deviation

t value/p value

Pair1 Pre-benchpress 72.44 16 12.431 6.933/<0.001

Post-benchpress 85.63 16 10.745Pair2 Pre-shoulderpress 46.63 16 10.372 5.447/<0.001Post-shoulderpress 59.38 16 9.273Pair3 Pre-bentoverrow 67.50 16 18.615 8.758/<0.001

Post-bentoverrow 83.31 16 17.910Pair4 Pre-sumosquat 73.19 16 21.772 7.657<0.001

Post-sumosquat 89.06 16 19.437Pair5 Pre-backsquat 74.00 16 18.694 8.535/<0.001

Post-backsquat 90.69 16 14.160Pair6 Pre-calfraise 79.38 16 17.723 8.442/<0.001

table 2: Pre-training to post-training difference within the cluster group.

Exercises Mean nstd. Deviation

t value/p value

Pair1

Pre-benchpress 77.38 16 9.301

10.791 /p<0.001Post-benchpress 99.75 16 14.599

Pair2

Pre-shoulderpress 57.50 16 9.987

11.731 /p<0.001Post-shoulderpress 83.00 16 14.024

Pair3

Pre-bentoverrow 76.50 16 14.922

9.472 /p<0.001Post-bentoverrow 102.69 16 17.951

Pair4

Pre-sumosquat 91.00 16 19.664

11.086/ p<0.001Post-sumosquat 116.25 16 19.018

Pair5

Pre-backsquat 86.19 16 20.782

7.986/ p<0.001Post-backsquat 113.94 16 19.478

Pair6

Pre-calfraise 97.75 16 11.807

11.887/p<0.001Post-calfraise 125.63 16 15.903


table 3: Post-training difference between traditional and cluster groups.

Exercises Group n Meanstd. Deviation

t value/p value

Post-benchpress

Cluster 16 99.75 14.599

3.117/0.004Traditional 16 85.63 10.745

Post-shoulderpress

Cluster 16 83.00 14.024

5.621<0.01Traditional 16 59.38 9.273

Post-bentoverrow

Cluster 16 102.69 17.951

3.056/0.005Traditional 16 83.31 17.910

Post-sumosquat

Cluster 16 116.25 19.018

3.999/<0.001Traditional 16 89.06 19.437

Post-backsquat

Cluster 16 113.94 19.478

3.862/0.001Traditional 16 90.69 14.160

Post-calfraise

Cluster 16 125.63 15.903

4.310/<0.001Traditional 16 97.69 20.480


CONCLUsION

Thepresentstudyacceptsthealternatehypothesis.Clustertraininghasanupperhandindevelopingstrengthinrecreationalmalescomparedtotraditionaltraining.

Conflict of Interest :Nil.

source of Funding:Self

Ethical Clearance: Yenepoya University EthicsCommittee

REFERENCEs

1. MichaelREsco.ResistanceTrainingforHealthandFitness. Available from: https://www.acsm.org/docs/brochures/resistance-training.pdf

2. Greg Haff. Cluster Sets - A Novel Method forIntroducingAdditionalVariationintoaResistanceTrainingProgram,NationalStrengthConditioningAssociation,2013

3. Bill Gelger. Building a pyramid; 2015 March26.Availablefrom:http://www.bodybuilding.com/fun/build-muscle-and-strength-with-pyramid-training.html

4. G. Gregory Haff et al. Cluster Training: ANovelMethodfor IntroducingTrainingProgramVariation.StrengthCondj;2008;30(1):67-76.

5. Zarezadeh-MehriziA,AminaiM,Amiri-khorasaniM.Effects ofTraditional andClusterResistanceTraining onExplosive Power in Soccer Players.IJHPA.2013;4(1):51-56.

6. Oliver JM et al. Greater gains in strength andpower with intra set rest intervals (ISR) inhypertrophictraining.JStrengthCondRes.2013;

27(11):3116-31.

7. GavinL.Moir,BruceW.Graham,ShalaE.Davis,John J.Guers,ChadA.Witmer.Effect of ClusterSet Configurations on Mechanical Variablesduring the Dead lift Exercise.JHK;2013: 39:15-23.

8. TLawton,JCronin,EDrinkwater,RLindsell ,DPyne.Theeffectofcontinuousrepetitiontrainingandintra-setresttrainingonbenchpressstrengthand power. J Sports Med Phys Fitness; 2004:44(4):361-67.

9. Thomas R. Baechle. Essentials of StrengthTraining and Conditioning. Third edition. HongKong:HumanKinetics;2009.

10. CamposGetal.Muscularadaptationsinresponseto three different resistance-training Regimens:specificityofrepetitionmaximumtrainingzones.EurJApplPhysiol.2002;88:50–60.

11. HaffGet al.ClusterTraining:ANovelMethodfor Introducing Training Program Variation.NSCA.2008;30(1):67-76.

12. Nick Tumminello. Size Vs. Strength: Are YouLiftingTooHeavy?2016February26Availableat: http://www.bodybuilding.com/fun/size-vs-strength-are-you-lifting-too-heavy.html[Accessedon8Feb.2017].

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14. Rio-Rodriguez D, Iglesias-Soler E, Olmo MF.SetConfigurationinResistanceExercise:MuscleFatigue and Cardiovascular Effects. PLoS ONE.2016;11(3):1-18.

Effectiveness of Kleinert’s Controlled Motion Protocol on tendon Gliding Following Zone 5 Flexor tendon Repair

Uday Raj J1, Praveen D2, Mukunda Reddy D3, srikanth R3

1Student (MPT Musculo Skeletal Sciences), Department of Physiotherapy, 2Faculty, Department of Physiotherapy, 3Professor, Department of Plastic and Reconstructive Surgery, Nizam’s Institute of Medical Sciences

(NIMS) (A Deemed University), Hyderabad.

AbstRACt

Introduction: Handisthemostactivepartofourbodyandusedextensivelyindaytodayactivities.Theflexoraspectofourhandisdividedinto5Zones.The5thZoneorZone5startsfromtheproximalpalmarcrease to the distal forearm. Flexor tendon injury at the Zone 5 includes loss of both finger andwristmovements.Post-operativerehabilitationisofutmostimportanceinrecoveringfunctionofthehand.

Purpose: TostudytheeffectofKleinert’sControlledMotion(KCM)ProtocolcomparedtotheConventionalAcceleratedMotion (CAM) Protocol followed in the hospital, in post operative Zone 5 flexor tendoninjuries.

Methods: The studywas conductedon30 subjects,whoseflexor tendonswere repaired at theZone5.Theywere randomlydivided into theKleinert’sControlledMotion (KCM)groupand theConventionalAcceleratedMotion(CAM)groupandwereassessedforactiverangeofmotionatthemetacarpophalangeal,proximalanddistalinterphalangealjointsbyFingerTiptoDistalPalmarCrease(FTDPC)measureandTotalActiveMotion(TAM)score;activerangeofmotion(AROM)atwristandpowergrip(PG).Thestudywasconductedfor12weeks.

Results:Both thegroupsshowedstatisticallysignificant improvement,but thesubjects in theKleinert’sgroupshowedbetterclinicalimprovement.

Conclusion: BetterimprovementinKleinert’sgroupmaybeattributedtothelowtensileloadputontheflexor tendonsduring thefirstweeksof rehabilitation leading tominimaladhesion formationandbetteroutcome.

Keywords: Kleinert’s controlled motion, Safe zone, Tendon Gliding and Power Grip.

bACKGROUND

Handisthemostactivepartofourbody.Whiletheeyeisonlyasensoryorganandthefootmainlyamotororgan, the hand plays a dual role. Injury to the handora lossof its functioncanhinderdailyactivitiesandthishasseverephysiological,psychologicalandsocialrepercussions.Topreservethemistheprimaryobjectiveofhandsurgeryandtorestorethem,ofrehabilitation1.

Injurytoflexortendonseitherbytraumaorsurgicalrepair result in adhesion formation. In 1960, Lindsayand Thomson showed immobilization was the key toadhesionformation,thoughgoodtissuehealingoccurs,restrictingtendonglidewithinanarrowtendonsheath2,3.

In1963,Potenzahypothesizedthatadhesionformationwas necessary for blood vessel in-growth into thetendon and healing occurs by fibroblastic response ofthesheathandsurroundingtissues(extrinsichealing)4,5. LaterMathewsandRichardsshowedthatflexortendonhealingcanoccurintheabsenceofadhesionformation,by nutrition supplied by diffusion from the synovialfluid (intrinsichealing).These twoconceptsof tendonhealing have guided strategies to improve the flexortendonrepairoutcomesovertheyears6-9.

Recent advances in surgical technique, centerson stronger repairs (more suture strands, more strongthe repair) that can tolerate active motion, to ensure

DOI Number: 10.5958/0973-5674.2018.00023.0


early gliding10-14. Research shows that tendons thatmove as they heal have a better final outcome15, butan early normal motion can result in tendon rupture.Therefore protectedmovements should be encouragedallowingsoundhealingwhilepermittingtendongliding.The strength of such tendons is better thanwhich areimmobilized16-20.

TherearemanystudiesdoneonZone2asthiszonehas more chances of adhesion formation than otherzones30. Movement at wrist usually affects movementatfingers.Thereforequalityoffunctionatwristdirectlyorindirectlyaffectsprehensionandpowerat thehand.ThusthereisaneedtoaddressZone5withanintensiverehabilitationprotocol.However there is less literatureavailable on the same. Kleinert’s Controlled Motion(KCM)ProtocolhasshownearlyrecoveryinZone230,but has not been addressedmuch in Zone 5 and thusthere is a need to provide evidence and compare thesamewithothertherapeuticregimens.

The purpose of this study was to determine theeffect of Kleinert’s Controlled Motion protocol when

compared to the Conventional Accelerated Motionprotocolfollowedatthehospitalinpost-operativeZone5flexortendonrepair.

MEtHODOLOGY

Forty six subjects from theDepartment of Plasticand Reconstructive Surgery (PS) of Nizam’s Instituteof Medical Sciences were screened according to theinclusionandexclusioncriteria,afterobtainingethicalclearance from IEC NIMS. Subjects with atleast onetendon repair between the ages 18 and 40 yearswereincludedandthosewithnerveinjuries,extensortendoninjuries, degenerative/rheumatoid arthritis, fractures,compression neuropathies, neurological diseasesinvolvingthehandwereexcluded.Thirtysubjectswhofitthecriteriawereselectedandrandomlydividedintotwogroupsof15eachbylotterymethodandinformedconsentwasobtainedfromboththegroupspriortotheintervention.Patientswereblindedforbeingineitherofthegroups.TheKleinert’sControlledMotionprotocolwas followed in the experimental (KCM)groupwhileConventionalAcceleratedMotionprotocolfollowedatthehospitalwasgiventothecontrol(CAM)group.

Week Kleinert’s Controlled Motion Group1 Conventional Accelerated Motion Group

Splint • Dorsalblocksplint(DBS)withwristin20°-30°,MCPin50°-70°,IPJsinextension

• Dorsalblocksplint(DBS)withwrist40°-50°,MCPin50°-70°,IPJsinextension

I–IIIHourlyexercisewithintheDorsalBlockSplint(DBS)

1. 50repetitionsofactivePIPJandDIPJextension2. 5-10repetitionsofisolatedpassivePIPJandDIPJflexion,followedbycompositepassiveflexiontoeachdigit.3. 2-5repetitionsofplaceandholdexercise.4. Shoulderandelbow(noforearm)exercisesinallplanes,edemareductionbyelevation,TENSforpainrelief.

1. PassivemovementstoallIPJs2. Shoulderandelbow(noforearm)exercisesinallplanes,edemareductionbyelevation,TENSforpainrelief.

EndofIIIrdweek Scarcare–massageofthescarduringtherapywithoutremovaloftheDBS.


IV

• Ifgoodtoexcellentmotion,itindicatesweakorminimalscarringofthetendonandtheDBSmustbewornforanother1-2weeks• Ifcontractureissettingin,DBScanberemoved.1. PatientisinstructedtousetheotherhandtoblockMCPinflexionduringactiveandgentleprotectedpassiveIPJextension.2. Gentlewristactivemovementexercises.3. FDS/FDPtendonglidingexercises.4. Continuescarcare

1. ActivemovementstoallMCPsandIPs2. Gentlewristactivemovementsandmovementisprogressedgradually3. Continuescarcare4. Electricstimulationisstartedat6thweekforimprovingFDS/FDPglide5. DBSiscontinuedtill6thweek

V

• ContinueDBSifexcellentmotionisseenordiscontinueincaseoflimitedmotion• Continueweek4exercises1. Gentlenon-resistiveblockingexercisetofacilitateFDS/FDPglide

VI

• DiscontinueDBS1. IsolatedFDS/FDPmusclegliding2. Gentlepassivestretchingtocontrolcontractures3. CompletewristAROMexercises4. ElectricstimulationforimprovingFDS/FDPglide5. Lightfunctionalactivities

VII • Exercisesasin6thweek1. Fullactivefingerandwristmovements2. Lightgripandwriststrengthening3. Lightfunctionalactivities

1. Fullactivefingerandwristmovements2. Lightgripandwriststrengthening3. Lightfunctionalactivities

VIII-XII • Progressivestrengtheningwithprogressiontoworkconditioning• Progresstonormalfunctionalactivities

• Progressivestrengtheningwithprogressiontoworkconditioning• Progresstonormalfunctionalactivities

• NOADDITIONALCHANGESWEREMADEINTHEPROTOCOL

Subjectswereassessed for active rangeofmotion(AROM)atinterphalangealjoints(IPJs)byFingerTiptoDistalPalmarCrease(FTDPC)measureusingaruler,Strickland’s Total Active Motion (TAM) score usingfingerGoniometer;AROM atwrist usingGoniometerandpowergripstrength(PG)usingJamar’shand-helddynamometer(JD)27,29.

ObsERVAtION AND REsULts

Duringthe12weeksofstudy,datacollectedwasasfollows:baselinevaluesat0weekforFTDPC,4thweek

forTAMandWristAROM(asAROMexerciseswerestartedat4thweek).Attheend,thebaselinevalueswerecomparedwiththe12thweekvalues.Powergripofthenormalandaffectedhandswereassessedandcomparedinthe12thweekonly,atthe2ndpositionofJD(astestingbefore12thweekcanloadthetendonscausingruptures).Notendonrupturesorsubjectdrop-outswererecorded.


table 1: Mean %ge and sD of each finger for FtDPC and tAM of Kleinert’s group and Conventional group.

FtDPCDifference between means 1st – 12th week mean%(sD)

tAM scoreDifference between means4th – 12th week mean%(sD)

KCM CAM KCM CAM

Index 6(0.6)* 5.5(0.5)* -67.8(9.2)* -52.8(17.1)*

Middle 5.7(0.9)* 4.5(0.5)* -66.2(10)* -52(17.9)*

Ring 4.8(0.9)* 3.9(0.6)* -57.7(13.8)* -48.5(15.2)*

Little 3.8(0.7)* 3.8(0.5)* -57(14.8)* -48.5(14.4)*

*-psignificantat<0.5

table 2: Mean %ge and sD of each finger for FtDPCand tAM of Kleinert’s group and Conventional group

Wrist AROMDifference between means 4th – 12th week mean%(sD)Experimental Control

Flexion 36(9.1)* 22.6(11.6)*

Extension 44(12.4)* 34.6(7.8)*

UlnarDeviation 21.6(8.1)* 17(4.9)*

RadialDeviation 10.6(3.7)* 7.6(3.1)*


table 3: Mean %ge and sD of Power grip of Kleinert’s group and Conventional group.

Power GripDifference between means At 12th week mean%(sD)

KCM CAM

13.8(3.5)* 6.9(2)*


DIsCUssION

Hand injuries are usually complicated withrestrictionofmovement.Achievingmaximumfunctionisatherapeuticchallenge.Theconceptofearlycontrolled

motionwas designed tominimize adhesion formationand maximize tendon gliding, reducing frequency oftendon ruptures8, 9, 21-23. An understanding of tendonglidingandrupturepavedtheconceptofSAFEZONEi.e.,‘the range of applied tendon loads should be large enough to induce tendon motion, yet small enough to avoid creation of a repair site gap or a tendon rupture’ 24.Recentstudiessuggestthattendonmotionratherthanloading,givesabeneficialoutcome.Thustendonshouldglide,butwithminimumforce.

Evidence shows that during the first few daysof surgery, resistance to tendon gliding is high and atendon’stensilestrengthdecreasesinitiallyaftersurgery,sothesurgicalrepairalonemustkeepthetendon’sendsapproximated25. Thus very early active IPJ flexion;provokes fresh bleed and in contrast, if immobilizedlonger, joint stiffness and friction between the tendonand its sheath increases, thereby raising glidingresistance and promoting adhesion formation26. Henceitisbettertowaitthreetofivedays,butnotaslongasaweek, for the postoperative thrombus tomature andfor theglidingenvironment to improvebeforestartingrehabilitation24.

InKCMgroup,passiveflexionandactiveextensionofIPJswasinitiallygiven,causingactivetendonglidingandlessstressonthetendonandinCAMgroup,passiveIPJmotionwas initiallygiven,causingpassive tendongliding,whichcaneitherstress the tendons(withoverpassivemotion)orleadtocontracture(withlesspassivemotion).SoinKCMgroupthereisadecreasedchanceof adhesion formation leading to better motion. Thusinitialweeksoftreatmentareimportantforabetterfinaloutcome.


FtDPC measure and tAM score:At theendofthe12thweektherewasasignificantdifference(p<0.05)seen between the groups, with KCM group showingbetter results. The results agree with the conclusionsdrawn from literature that by imparting low load onthe tendon, friction between the tendon and its sheathisreduced.Passiveflexionandactiveextension,causesatendontoglide,withoutputtingmuchloadonit.Thismovement is useful not only in reducing stiffness butalsoindecreasingtherisksofgaping24,26.

Wrist AROM:Attheendof12thweek,asignificantdifference (p<0.5) was seen between the groups butsuggesting better improvement in KCM group. Theseresults agree that, careful tissue handling reducesthe load for tendon gliding during the first weeks ofrehabilitationandtheproximallydirectedtendonforceappliedwithsimplepassivefingerflexionwiththewristflexed isminimal, therebyreducing the tendonglidingresistance24.SubjectsintheKCMgroupbenefitedbetterfinal active range of wrist motion as the wrists wereimmobilizedin200-300offlexionwhencomparedwithCAMgroupwheretheoperatedwristswereimmobilizedin40°-500flexionagreeingwithBengiOzet al27 that,toomuchwristflexionduringimmobilizationcanmakeitdifficulttoregainwristextension.

Power grip: There is a significant difference(p<0.05)inthemeansofthegripstrengthoftheaffectedhands between the groups with better improvementin KCM group. The results obtained in this studycoincidewith a systematic review inwhich therewas79% improvement in grip strength28. These findingsagree with Groth25 who considered that progressivestrengthening of the repaired tendons over time i.e.,raising of the upper limit of the ‘SAFEZONE’. Thisallowssafehealingofthetendon,whileimprovingthestrength of the tendon and avoids the risk of tendonruptureandgapping.

CONCLUsION

The present study was designed to determine theefficiency of the KCM protocol on tendon gliding inpost-operative Zone 5 flexor tendons when comparedwith the conventional protocol. A twelve weekinterventionwith theKCMprotocolhas improved thetensile strength of the repaired flexor tendons whencompared with the conventional protocol which wasattributedtotheprogressivestrengtheningoftheflexor

tendons, showing minimum adhesion formation andbetterhandfunction.

source of Funding: SELF

Conflict of Interest:NIL

REFERENCEs

1. Hunter, Mackin, Callahan. Rehabilitation of thehand:SurgeryandTherapy,1995VolI,Edition4.

2. Bunnell S: Repair of tendons in the fingers.Surgery, gynecology, and obstetrics. 1922, 35:88–9.

3. LindsayWK,ThomsonHG:Digitalflexortendons:an experimental study. Part I. The significanceof each component of the flexor mechanismhintendonhealing.BrJPlastSurg1960,12:289–316.

4. PotenzaAD:Critical evaluation of flexor tendonhealing and adhesion formation within artificialflexor sheaths. J Bone Joint Surg Am 1963, 45:1217–1233.

5. Potenza AD: Detailed evaluation of healingprocessesincanineflexordigitaltendons.MilMed1962,127:34–47.

6. MatthewsP,RichardsH:Factorsintheadherenceof flexor tendon after repair: an experimentalstudyintherabbit.JBoneJointSurgBr197658:230–236.

7. LundborgG,RankF,HeinauB: Intrinsic tendonhealing.Anewexperimentalmodel.ScandJPlastReconstrSurg1985,19:113–117.

8. Matthews P, Richards H: The repair reaction offlexortendonwithinthedigitalsheath.Hand1975,7:27–29.

9. Ferguson MW, O’Kane S: Scar-free healing:fromembryonicmechanisms to adult therapeuticintervention.PhilosTransRSocLondBBiolSci2004,359:839–850.

10. Savage R Risitano G. Flexor tendon repairusing “six strand” method of repair and earlymobilisation.JHandSurgBr.1989;14:396-399

11. Komanduri M et al. Tensile strength of flexortendonrepairsinadynamiccadavermodel.JHandSurgAm.1996;21:605-11.

12. SilfverskioldK,AnderssonC.Twonewmethodsof tendon repair:an invitroevaluationof tensilestrength and gap formation. J Hand Surg Am.


1993;18:58-65.

13. ShaiebMD,SingerDI.Tensilestrengthsofvarioussuture techniques. JHand surgBr. 1997;22:764-767.

14. Strickland JM, Cannon NM. Flexor tendonrepair – Indiana method. Indiana Hand centerNewsletter.1993;1:1-19.

15. Wojciak B, Crossan JF: The accumulation ofinflammatorycellsinsynovialsheathandepitenonduring adhesion formation in healing rat flexortendons.ClinExpImmunol1993,93:108–114.

16. Mason ML, Allen HS: The rate of healing oftendons: An experimental study of tensilestrength.AnnSurg 113:424-459, 1941; 113:424-59.

17. PotenzaAD,FlexortendonInjuries.OrthopClinNAm1970;1:355-373

18. Gelberman RH, Amiel D, Gonsalves M, et al:Theinfluenceofprotectedpassivemobilizationonthe healing flexor tendons:A biomechanical andmicroangiographicstudy.Hand13:120-128,1981.

19. GelbermanRH,NunleyJAIIOstermanAL,etal.Influences of the protected passive mobilizationinterval on flexor tendon healing: A prospectiverandomizedclinicalstudy.ClinOrthop1991;264:189-196.

20. Takai S, Woo SL, Horbie S, et al. The effectsof frequency and duration of controlled passivemobilization on tendon healing. J Orthop Res1991;9:705-713.

21. Strickland JW, Glogovac SV: Digital functionfollowing flexor tendon repair in zone II: Acomparison of immobilization and controlledpassivemotion techniques. JHandSurg [Am]5:537-543,1980.

22. ChowJA,ThomesLJ,DovelleS,etal:Controlledmotionrehabilitationafterflexortendonrepairandgrafting:Amulti-centrestudy.JBoneJointSurg

[Br]70:591-595,1988.

23. DuranRJ,HouserRG:Controlledpassivemotionfollowing flexor tendon repair in zones 2 and 3.In:AmericanAcademyofOrthopaedicSurgeonsSymposium on Tendon Surgery in the Hand. StLouis,MO,CVMosbyCo,1975,pp105-114.

24. Peter C. Amadio, MD: Friction of the GlidingSurface: Implications for Tendon Surgery andRehabilitation. J Hand Therap. 2005;18(2):112-119.

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Comparison between Immediate Effect Land based and Water based squatting Activity on Pain in

Osteoarthritis Knee Patients

Parag Kulkarni1, Arti tank2, Ajay Kumar3, satish Pimpale4, suchit shetty4

1Associate Professor, 2Intern, 3Principal, 4Assistant Professor, DPO’s NETT College of Physiotherapy

AbstRACt

Aim:Tocompareimmediateeffectofland-basedandwaterbasedsquattingactivityonpaininOAkneepatients.

Objectives: Toassess thepainusingVAS(visualanaloguescale)afterperforming landbasedsquattingactivityinOAkneepatients

• ToassessthepainusingVASafterperformingwaterbasedsquattingactivityinOAkneepatients.

• Tocomparebetweenimmediateeffectoflandbasedandwaterbasedsquattingactivity,onpaininOAkneepatients.

Results: Thestudyshowed thatsubjectsofosteoarthritiskneeshowedstatisticallysignificantdifference betweenimmediateeffectoflandbasedandwaterbasedsquattingactivity(p<0.05)

Keywords-OA,osteoarthrithis,squatting,knee pain,elderly

INtRODUCtION

OA is a nearly universal, slowly progressivedegenerativeconditionaffectingmenandwomenastheyage.OAofknee ismostcommon typeofdegenerativediseaseaffecting thousandsof Indiancitizens. It is thesecondmost common form of disability and althoughitaffectsbothmenandwomen,womenaremorelikelyto be symptomatic1. OA is a condition in which thecartilagethatactsasacushionbetweenbonesinjointsbegins towear out, causing pain and inflammation injoints,therebyrestrictingmovement2.

Hydrotherapyistheuseofwatertohealandeaseavarietyofailments.Hydrotherapyisthemostbeneficialsystemof restoringnormal functions in thebody. It isemployedtohelpbalancemetabolism3.Useofwaterinvariousformsandinvarioustemperaturescanproducedifferent effects on different system of the body. Theprincipleeffectsofwater includebuoyancy, resistance(viscosity), hydrostatic pressure and surface tension.Understandingthesebasic5

Principle helps us utilize them to their fullestpotentialon individualcases.Buoyancyandresistance

arethemostcommonlyknownprinciplesupwardthrustplaced on a body when the body part is submerged.When the body is submerge in a bath, a pool, or awhirlpool,itfeelsweightless6.

Thesquatisoneofthemostfrequentlyuseactivityin the day to day life. Benefits associated with squatperformancearenotlimitedtotheathleticpopulation8. Given that most ADL’S necessitate the simultaneouscoordinated interaction of numerous muscle groups.Squats can be performed at a variety of depths,generally measured by degree of flexion at the knee.Squatscanbeperformedusing justone’sbodyweightorwithanexternalload9,10.Effectofsquattingdependsupon the loads.Squatdepth shouldbe consistentwiththegoalsandabilitiesof the individual.Becausepeakpatellofemoral compressive forces occurs at or nearmaximumkneeflexion11,12.Squatdecentshouldalwaysbeexecuteinacontrolledfashion,witha2to3secondeccentric tempo considered a general guideline. Frontsquattendtoproducelesskneeextensortorquecomparetobacksquats14.

DOI Number: 10.5958/0973-5674.2018.00024.2


NEED OF stUDY

Osteoarthritisofkneeis thefourthmost importantcauseofdisabilityinwomenaccordingtoWorldHealthOrganization report on Global Burden of disease. InsubjectswithOAitseemsnecessarytoperformADLandaquatictherapyhasbeenshowntocapableofimprovingphysicalfunctionsinthesubjects.Howevernotmuchresearch has been done regarding the “comparisonbetween land-basedandwaterbasedsquattingactivityonpaininOAkneepatients“.Therearemanystudiesdone on “effectiveness of exercise performed in theaquatic pool and out of the pool in subjectswithOAknee”.

Hence, the present study has been undertaken tofindout the immediate impactofhydrotherapyonOAkneepatientsafterperformingsquatting.

AIMs AND ObJECtIVEs

AIM

To compare immediate effect of land-based andwater based squatting activity on pain in OA kneepatients.

ObJECtIVEs

• ToassessthepainusingVAS(visualanaloguescale)afterperforminglandbasedsquattingactivityinOAkneepatients

• ToassessthepainusingVASafterperformingwaterbasedsquattingactivityinOAkneepatients.

• Tocomparebetween immediateeffectof landbasedandwaterbasedsquattingactivity,onpaininOAkneepatients.

HYPOTHESIS

NULL HYPOtHEsIs:

There will be no significant difference betweenimmediateeffectoflandbasedandwaterbasedsquattingactivityonpaininOAkneepatients.

EXPERIMENtAL HYPOtHEsIs:

There will be significant difference betweenimmediateeffectoflandbasedandwaterbasedsquattingactivityonpaininOAkneepatients.

MAtERIALs AND MEtHODOLOGY

1. STUDYDESIGN

type of study:comparativestudy.

Population:Diagnosedcaseofkneeosteoarthritis.

Duration of study:6months

Location:metropolitancity.

2. SAMPLEDESIGN

type of sampling:convenientsampling.

sample size:60

Location:metropolitancity.

MAtERIALs

Visualanaloguescale

Paperandmarkers

Swimmingcostume

Swimmingpool

SELECTIONCRITERIA

INCLUsION CRItERIA:

1.DiagnosedcaseofkneeOsteoarthritis.

2.Patientswillingtoparticipate.

3.Patientswithagegroupof50to60years.

4.Patientwithbilateralkneeosteoarthritis.

EXCLUsION CRItERIA:

1.CNdisease,especiallyepilepsy.

2.Anyrecentlowerlimbfractures.

3.Severelungdiseasesuchase.g.COPD

4.PatientwithHydrophobia.

5.Largeskinwoundsorinflammatoryandulcerateddermatosisofthelegs.

6.Severefebrileinfectiousdisease

7.Inflammatoryarthropathyofkneejoint

8.Acute,hot,red,swollenkneejoint

PROCEDUREs

SubjectswithOA knee and are having knee painwhofulfilltheinclusioncriteriawillbeincludedinthestudy.Awritteninformedconsentwillbetakenfromallsubjects prior to participation. Purpose and procedurewillbeexplainedpriortoparticipationinthestudy.

The subject is asked to perform10 repetitions (asmuchashe/shecanperform)ofsquattingactivityoutside


thepool.He/shecantakethehelpofsupport(wallbar)ifrequired.Aftertheactivityhasbeenperformed,painwillbemeasuredusingVAS(visualanaloguescale).

Now, the patient is given rest for some time. Asthepainsubsides,ifpaindoesnotsubside,interventionwill be done for the same. Now activity will then beperformedinthewaistlevelaquaticpool.Herepatientcan take support of the pool bar for squatting, afterperformingactivity;painwillthenbenotedonVAS.

If pain will not subside then intervention will bedonetoreducethepain.

ThereadingofthepainwhichwasnotedusingVAS(visualanaloguescale),wouldbestatisticallyanalyzedtoconcludethestudy.

DAtA ANALYsIs

100 subjects of diagnosed case of bilateral kneeosteoarthritisweretakeninthestudyand10repetitionsof squatting were performed inside and outside theaquatic pool. Pain was measured using VAS insideand outside the aquatic pool and data was collected,statisticalanalysiswasperformedusingunpairedTtest.

A bar graph shows comparison ofpain (VASscore)inosteoarthritiskneepatientsbetweeninthepoolandoutofthepool.

REsULts

Graph 1: Comparison vas score between land and pool

REsULts

The study showed that subjects of osteoarthritis

kneeshowedstatisticallysignificantdifferencebetweenimmediateeffectoflandbasedandwaterbasedsquattingactivity(p<0.05)

DIssCUsION

Osteoarthritis, commonly known as wear-and-tear arthritis,isaconditioninwhichthenaturalcushioningbetween joints -- cartilage -- wears away. When thishappens,thebonesofthejointsrubmorecloselyagainstoneanotherwith lessof theshock-absorbingbenefitsofcartilage.Therubbingresultsinpain,swelling,stiffness,decreasedabilitytomoveand,sometimes,theformationof bone spurs. Previous studies says that exercisesperformedintheaquaticpoolintheOAkneepatientsreducespainasprincipleeffectsofwaterlikebuoyancy,surfacetension,viscosityactsonthejointandtherebyimproving range of motion of the joint. It has beenrecognizedthatexercisinginwatercanbeaneffectiveandusefulmodeoftherapeuticexercise,especiallyforthe individuals who have difficulties with the weight-bearing components while performing land exercises.It seems that itmay bemore suitable forwater basedexerciseprogramsthantheland-basedexercise.Anewstudy shows that both water-based (hydrotherapy) andtraditional gym exercise programs can increase musclestrengthandhelppeoplewith osteoarthritis ofthe knee orhipwalkfasterandlonger,whichmayreducetheriskoffallsanddisability.

There is a moderate quality level of evidencesupporting the notion that water-based exercise canimprove pain, function, self-efficacy, joint mobility,strength and balance outcomes for people withosteoarthritis knee. Hydrotherapy provides favorableenvironment and it can be beneficial for patientswithosteoarthritisknee.Hydrotherapywassuperiortoland-basedexerciseinrelievingpainbeforeandafterwalkingduringthelastfollow-up.

Water-basedexercisesareasuitableandeffectivealternativeforthemanagementofOAoftheknee.

Our study showed that water based squattingactivityshowsimmediateeffectonpainreliefthanlandbasedsquattingactivity.

CLINICAL IMPLICAtION

With the use of an aquatic therapy trainingof squatting activity can be started earlier in theOsteoarthritiskneepatients.


Aquatictherapycanbeusedforreductionofpain

SUGGESTIONS

Furtherstudycanbeundertakenusing,

ComparisonofVASscoresofmaleandfemale inthepoolandoutofthepool.PreandpostvaluesofVASscoresc

CONCLUsION

Our study concludes that water based squattingactivityshowsimmediateeffectonpainreliefthanlandbasedsquattingactivity.

Ethical Clearance-Takenfromcollegecommittee



REFERENCEs

1) Mc Cormack HM, Horne DJ, Sheather S.“Clinicalapplicationsofvisualanaloguescales”acriticalreview.HuskissonEC.

2) SrámekP,SimeckováM,JanskýL,SavlíkováJ,Vybíral S. “Human physiological responses toimmersion into water of different temperatures”European Journal of Applied Physiology ;Feb2000,Vol.81Issue5,p436.

3) EurJApplPhysiol.BoldtLH,FraszlW,RöckerL,Schefold JC,SteinachM,NoackT “Changesinthehaemostaticsystemafterthermoneutralandhyperthermicwaterimmersion.”NorthAmericanjournalofmedicalscience;2014May;6(5):199–209.

4) BenderT,KaragülleZ,BálintGP,GutenbrunnerC, Bálint PV, Sukenik S. “Hydrotherapy,balneotherapy, and spa treatment in painmanagementRheumatol Int.2005Apr;25(3):220-4.Epub2004Jul15.

5) Luciana ESilva, ValeriaValim, Ana PaulaCPessanha, Leda MOliveira, SamiraMyamoto,AnamariaJones, JamilNatour”HydrotherapyVersusConventionalLand-BasedExercisefortheManagementofPatientsWithOsteoarthritisofthe

Knee: A Randomized Clinical Trial” journal ofAmericanphysiotherapyassociation.

6) TextbookofRehabilitationByColbyKisner,6thedition,pg.no324.

7) Fry,ACsmith, JC,andSchilling,BK,”.ofkneepositiononhipankneetorquesduringthebarbellsquat.”Jstrengthcondres17:629-633,2003.

8) Dahlkvist,NJ,Mayo,p,andseedhom,BB.”Forcesduringsquattingandrisingfromasquat.EngmE11:69-76,1982

9) Isear,JA Jr.Erickson, JC,AN Worrell,TW.EMGanalysis of lower extremity muscle recruitmentpatternsduringkneemovement(loaded)MedSciSportsExerc29:532-539,1997.

10)McCaw,T andMelorse,DR’Stancewidth and barload effects on leg muscle activity during theparallelquat.MedScisportsexs31:428-436,1999.

11) McIlveen B, Robertson VJ. Randomisedcontrolledstudy of the outcome of hydrotherapyfor subjectswith lowback or back and leg pain.Physiotherapy1998;84:17-26

12) KamiokaH, Tsutani K, Okuizumi H et al. Effectivenessof aquatic exercise andbalneotherapy: a summary ofsystematic reviewsbased on randomized controlled trials ofwaterimmersiontherapies.JEpidemiol2010;20:2-12.

13) DeyleGD,HendersonNE,MatekelRL,RyderMG,Garber MB,Allison SC.Effectiveness of manualphysical therapy and exercise in osteoarthritisof the knee. A randomised controlled trial. AnnInternMed2000;132:173–81.7HurleyMV,ScottDL. Improvements in quadriceps sensorimotorfunction and disability of patients with kneeosteoarthritisfollowing a clinically practicableexerciseregime.BrJRheumatol1998;37:1181–7.

14) Childs JD, Sparto PJ, Fitzgerald GK, BizziniM, Irrgang JJ. Alterations in lower extremitymovement and muscle activation patterns inindividualswithkneeosteoarthritis.ClinBiomech(Bristol,Avon)2004;19:44–9.

Co-relation between VC & 6 Minute Walk test in Patients with Impaired Lung Functions

Ayesha shaikh1, Poonam Parulekar2

1MPT, 2Asst. Professor, Nanavati Super Speciality Hospital, Dept.of Physiotherapy & Rehabilitation, NMIMS (SOS), S.V. Road, Vile Parlewest, Mumbai

AbstRACt

Likeeverywhereelseintheworldandespeciallyinthedevelopingworld;Indiaischanging-notonlyintermsofitsdemographics,urbanization,economicprofile,pollutionbutalsointermsofitshealthburden,diseasepattern,dominant-disease-composition,morbidityandmortalitydeterminants.TheVCofthelungsis a critical component of good health. It is an indispensablemeasure for the diagnosis of pulmonarymechanicallimitationaswellasforadequationofpulmonaryre-expansiontherapyappliedtopatientsaftercardiacsurgery.Theevaluationofpulmonaryvolumesandcapacitiesisessentialtocharacterizepulmonarymechanicallimitationsinpostoperativecardiacsurgerypatientsandinobstructivedisorders.Measurementof exercise capacity is an integral element in assessmentofpatientswith cardiopulmonarydisease.The6MWTprovidesinformationregardingfunctionalcapacity,responsetotherapyandprognosisacrossarangeofchroniccardiopulmonaryconditions.ThisstudywasapprovedbytheResearchEthicsCommittee.Patients&writteninformedconsentwassigned.Subjectswereevaluated.Pulmonaryfunction(VC)wasassesedbyspirometry,atthePFTlab..6-MWTwasperformedonthe5thpostoperativedayCABG;1stpost-operativedayPTCA andOPDbasis forObstructivedisorder.The study showed that theVCand the6MWTwasalsoreducedinpostcardiacsurgeryandobstructivegroupofsubjects.ThereisNOstatisticalsignificantcorrelationbetweenVCand6MWTinpostcardiacsurgeryandobstructivegroupofsubjects.ThoughthepatternshowedmostofsubjectswithabetterVCcoveredmoredistancein6MWT.

Keywords:- VC, 6 MINUTE WALK TEST, LUNG FUNCTIONS, CABG, PTCA, COPD,

INtRODUCtION

Like everywhere else in the world and especiallyin the developingworld; India is changing - not onlyin terms of its demographics,urbanization, economicprofile,pollutionbutalsointermsofitshealthburden,disease pattern, dominant-disease-composition,morbidityandmortalitydeterminants.

TheVCof the lungs is a critical component ofgoodhealth.Itisdefinedasthemaximumamountofairthatcanbeexhaledafteramaximuminhalation,itisanindispensablemeasure for the diagnosis of pulmonarymechanical limitation as well as foradequationofpulmonaryre-expansiontherapyappliedtopatientsaftercardiacsurgery.ThenormalvalueoftheVCisfrom3to5L/min,however,theremaybevariationsregardingethnicity, age, gender, height and weight1-5.A studyshowedthemeanVCofIndianmaleis3.53L/minandthatofIndianwomenis2.37L/min3.

The evaluation of pulmonary volumes andcapacities is essential tocharacterizepulmonarymechanical limitation, especially in postoperativecardiac surgery patients6,7and in obstructivedisorders.Ithas been described thatVC lower than 25ml/Kgcan predisposeatelectasis,hypoxemiaand inefficientcough6,7.Aftercardiacsurgery, the impairmentofVChasamultifactorialmeaningand the restrictivepatterncan last formore than 116 days, predisposingatelectasisand postoperatorycomplications8,9. Similar changesareseeninobstructivelungdisorderslikeCOPD,Bronchiectasis,Bronchialasthma.dueto pathological processleadingtodeteriorationoftheVC.

Coronary heart disease is the most prevalentheart disease in India, contributingmore than 95%ofthe total CVD prevalence, and more than 85% of allCVDrelateddeaths in200410. IndiaalsocontributesasignificantandgrowingpercentageofCOPDmortalityestimated to be amongst the highest in theworld; i.e.

DOI Number: 10.5958/0973-5674.2018.00025.4


more than 64.7 estimated agestandardizeddeath rateper 100,000 amongst both sexes asmentioned in theWHO GlobalInfobaseUpdated on20th January2011(India 102.3 and China 131.5)19. This would translateintoapproximately556,000incaseofIndia(>20%)and1,354,000 cases inChina (about 50%) out of aworldtotalof2,748,000annually20.

Cardiac surgery causes a series of clinical andfunctionalcomplications,amongthem,thepostoperativecomplications are the most common, with incidenceranging from 6% to 88%, and directly contributes toincreasedmorbidityandmortality,durationofhospitalstay,useof resourcesand time to return toproductivelife11,12. This is due to changes induced by cardiacsurgery on pulmonary and cardiac mechanics whenusing generalanesthesia, mediansternotomy, thoracicmanipulation andcardiopulmonary bypass (CPB),causing depression ofcardiorespiratoryfunction andpostoperative pain13-15. These dysfunctions affect thebreathing pattern, reducing lung volume and capacity,contributing to the appearance ofatelectasisandchanges in the ventilation/ perfusionrelationship14,15,17,18. This presentation reduces thecardiorespiratorycapacity, which is also negatively influenced by physicalpostoperative inactivity, due to bed rest, which alsoproduces loss of muscle strength anddeconditioning,which is a risk factor for pulmonary complicationsandthromboembolism15-17. Similarly, changes duetopathophysiologicalprocesses leading to reduction inpulmonarymechanics, predisposing to various sign&symptomslikeDyspnoea,Cough,Expectorationsetc.

The positioning of the patient to rest in thedorsaldecubitus causesa reduction in volume andlung capacity and increased work of breathing andheartbeat.Thisisbecausethepositioningpromotestheaccumulationofcentralbloodvolumethatpromotestheformation of congestion, oedema and decreased lungcompliance,aswellasreducedcardiacoutputby30%,whichcanleadtoorthostaticintolerance16,18.

Measurement of exercise capacity is an integralelementinassessmentofpatientswithcardiopulmonarydisease. The 6-min walk test (6MWT) providesinformation regarding functional capacity, responseto therapy and prognosis across a range of chroniccardiopulmonary conditions. A distance less than 350m is associated with increased mortality in chronicobstructivepulmonarydisease,chronicheartfailureand

pulmonary arterial hypertension.Desaturationduring a6MWTisanimportantprognosticindicatorforpatientswith interstitial lung disease. A change in walkingdistance ofmore than 50m is clinically significant inmostdiseasestates21.

In light of the foregoing, the aim of this studywas to evaluate lung functions (VC) and distanceof the six-minute walk test (6-MWT) in patientsundergoing CABG,PTCA& those with Obstructivelungdisorders.Toassesstheinfluenceofbothvariablesonthelungfunctionandoverallfunctionalcapacityofthepatients.

No study has evaluated the relation ofVCtoother health parameters like Blood pressure, Heartrate,SPO2 and functional capacity(6 Minute walkdistance).Thus this study was designed to find anassociation(if any) between these above mentionedparameters.

MetHoD

Toassesthe lungVC&6minutewalk testinpostcardiac surgery and obstructive respiratorycondition.Alsoto findCo-relation between lungVC& 6minutewalk distance in post cardiac surgery and obstructiverespiratoryconditions

Studydesign–Experimental

Samplesize–215Patientsinexperimentalgroup

Typeofsampling–Conveniencesampling

Samplesource–Tertiaryhealthcentre

Materialsused-Spirometry(PFT),30mhallway,Stopwatch,Sphygmomanometer,Pulseoximeter.

Subjects-Post CABG, PostPTCA, ObstructivelungconditionS

INCLUSIONCRITERIA

1)Age:-20-60yrs.

2)PatientswithChronicobstructiveairwaydiseases:COPD,Bronchiectasis,Bronchialasthma.

3) Patients who had undergone cardiac surgery:Coronary artery bypass grafting (CABG),Percutaneoustransluminalcoronaryangioplasty(PTCA).


V.6-MWTwasperformedonthe5thpostoperativeday CABG; 1stpost-operative dayPTCA andOPDbasisforObstructivedisorders.Allthevitalparameterswere assessed at the beginning and at the end of thetest.Thepatientwasguided towalkasfaraspossiblewithout running, as recommended by the AmericanThoracic Society13in a course of 30 meters, markedevery3meters,withtheturningpointmarkedbyacone.Aftercompletingthesixminutes,thepatientwasaskedtoimmediatelystopandsitinachair.Thetotaldistancewalkedbythepatientwasrecorded.

REsULts

213patients were assessed.63 underwentCABG [Group I]40underwent PTCA [Group II] and103 had Obstructive lung conditions [Group III](COPD,Bronchiectasis, Bronchial asthma).They wereevaluatedforVCand6MWT&resultsshowedreductioninVC more pronounced in patients with obstructiveconditionswith an averageVCof 2L/min followed byCABG2.5L/minlastlyPTCAgroupshowed3L/min.Therewasreductionof6MWTdistanceinall3groupsMaximally reduced in CABG group 483m followedby PTCA 487m lastly Obstructive group 488m.Basedonspearmancorrelation test thepvalueforCABGIS0.3883;PTCAIs0.3433&obstructiveis0.9551.Henceconcludedthere isnoStatisticalCorrelationbetween6MWTdistanceandVCinallthe3groups.

EXCLUSIONCRITERIA

1)Trauma

2)Acuteexacerbation

3)Malignancy

4)Hyperpyrexia

5) Any musculoskeletal injuries or neurologicalinvolvement or any surgeries in lower limbs in past 6months

6) Patients with any associated psychiatricconditions.

PROCEDURE:-

I.ThisstudywasapprovedbytheResearchEthicsCommittee.

II.Patientswere informedabout theprocedures tobeperformedandwritteninformedconsenttoparticipateinthisstudywassigned.

III.Subjectsfrombothgenders(maleandfemale),aged between 20-60 yearswere evaluated in the timeperiodofJanuary2014toFebruary2015.

IIII.Pulmonaryfunctionwasassesedbyspirometry,using the portablespirometermanufactured by MicroMedicalmodelMicrolab3500(Rochester,England)bythePFTlab.ThevariablesofthetestusedinthestudyistheVC(VC).


DIsCUssION & CONCLUsION

213 patientswere evaluated forVC and 6MWD.There were 8droupoutsdue to lost tofollowup.Alldata was analysed on computer by means oftheGraphpadPrism(6.0) andMicrosoft Excel 2010Tocheck fornormalityKolmogorov-smirrnovtest wasapplied.As thedata was not following Normaldistribution,nonparametricSpearmancorrelationtestwasused.Stepwisemultipleanalysiswasusedtodeterminethebestpredictorforcorrelation.Apvalueoflessthan0.05wastakenassignificant.AsseeninVCwasreducedin all the patient groups as compared to normal(3-5L/min)1-5. Maximum reduction inVC(average 2L/min)was seen in patients with obstructivedisorders(COPD,Bronchial Asthma,Bronchiectasis).This can beattributed to the ongoing pathology of the diseaseprocesses77,83(FIgure3)In patients who underwentCABG showed an averageVCwas 2.5L/min.6MWTwas significantly reduced inpatient’swithCABG,followedbythosewhounderwentPTCA,lastlyinObstructivegroup.TheaveragedistancewalkedbyCABG patient’s was 483m, followed by PTCA was487mandmaximumwaswalkedbyobstructivegroupof patients 488m.Thereisamajor role of sedationduring the procedure, length of sedation, ventilationetc. This in turn may lead to weakness and fatigue.Other factors indirectly affecting the functional abilitymost commonly ispain.Onobserving the data closely;it showed that subjects with a higherVCcoveredrelatively more distance in the 6MWT though therewas no statistical significance.(FIgure4)In PTCAgroupVCismore(average3L/min)thenthoseinCABG

group(average 2.5L/min).Also the6 MWTin thePTCAgroupismore(averageof487m)ascomparedtothoseinCABGgroup(average483m).

Pathophysiology-Obstructiveconditions(Figure3)

Pathophysiology-VC(Figure4)


source of Funding-Self.

REFERNECEs

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4. “VC”. Family Practice Notebook. Retrieved 19February2015.

5. Rodrigues JC, Cardier JMA, Dussamra MHCF,NakaieCMA, Almeida MB, Silva Filho LVF,AddeFV.Provasdefunçãopulmonaremcriançaseadolescentes.JPneumol.2002;28:207–221.

6. Mallozi MC. Valores de referencia paraespirometriaemcriançaseadolescentes,calculados


apartir deumaamostrada cidadedeSãoPaulo.(Tese) São Paulo: Universidade Federal de SãoPaulo-EscolaPaulistadeMedicina.1995.

7. ForgiariniLAJr,RubleskiA,DouglasG,TieppoJ,VercelinoR,DalBoscoA,MonteiroMB,DiasAS.Evaluationofrespiratorymusclestrengthandpulmonaryfunctioninheartfailurepatients.ArqBrasCardiol.2007;89:36–41.[PubMed]

8. Newton-John H. Prevention of pulmonarycomplicationsinsevereGuillain-Barrésyndromeby early assisted ventilation. Med J Aust.1985;142:444–5.[PubMed]

9. YavagalDR,MayerSA.Respiratorycomplicationsofrapidlyprogressiveneuromuscularsyndromes:Guillain-Barré syndromeandmyastheniagravis.SeminRespirCritCareMed.2002;23:221–9.doi:10.1055/s-2002-33030.[PubMed][CrossRef]

10. Ropper AH. Critical care of Guillain-Barresyndrome. In Ropper AH, ed Neurological andneurosurgical intensive care. New York, RavenPress;1993.p.p371.

11. Rosamond W, Flegal K, Furie K, Go A,Greenlund K, Haase N, et al; American HeartAssociation Statistics Committee and StrokeStatisticsSubcommittee.Heartdiseaseandstrokestatistics-2008update:areportfromtheAmericanHeart

12. Association Statistics Committee andStroke Statistics Subcommittee. Circulation.2008;117(4):e25-146.

13. Faresin SM, Barros JA, Beppu OS, Peres CA,AtallahAN. Aplicabilidade da escala deTorrington e Henderson. Rev Assoc Med Bras.2000;46(2):159-65.

14. Borghi-SilvaA,Di Lorenzo PVA,OliveiraCR,Luzzi S. Comportamento da função pulmonar edaforçadamusculaturarespiratóriaempacientessubmetido à revascularização do miocárdioe a intervençãofisioterapêutica. Rev Bras TerIntensiva.2004;16(3):155-9.

15. Wynne R, Botti M. Postoperative pulmonarydysfunctioninadultsaftercardiacsurgerywith

16. cardiopulmonary bypass: clinical significanceand implications for practice. Am J Crit Care.2004;13(5):384-93

17. WeissmanC.Pulmonaryfunctionaftercardiacand

thoracicsurgery.AnesthAnalg.1999;88(6):1272-9.

18. KillewichLA.Strategiestominimizepostoperativedeconditioninginelderlysurgicalpatients.JAmCollSurg.2006;203(5):735-45.

19. Hirschhorn AD, Richards D, Mungovan SF,Morris NR, Adams L. Supervised moderateintensity exercise imporves distance walked athospital discharge following coronary arterybypass graft surgery: a randomised controlledtrial.HeartLungCirc.2008;17(2):129-38.

20. Kehlet H. Multimodal approach to controlpostoperativepathophysiologyandrehabilitation.BrJAnaesth.1997;78(5):606-17.

21. Dean E, Ross J. Discordance betweencardiopulmonary physiology and physicaltherapy. Toward a rational basis for practice.Chest.1992;101(6):1694-8.

22. WHO Global Infobase on 10th March 2012.(Updated as on 20/01/2011). Available online:https://apps.who.int/infobase/Index.aspx

23. Lopez AD, Shibuya K, Rao C, et al. Chronicobstructive pulmonary disease: current burdenandfutureprojections.EurRespirJ.2006;27:397-412[PubMed]

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25. EstimationoflungVCbeforeandaftercoronaryartery bypass grafting surgery: a comparisonof incentive spirometer and ventilometry JCardiothoracSurg.2011;6:70.Publishedonline2011May12.doi:10.1186/1749-8090-6-70

26. ATS Committee on Proficiency Standards forClinical Pulmonary Function Laboratories. ATSstatementguidelinesforthesix-minutewalktest.AmJRespirCritCareMed.2002;166(1):111-7.

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31. TaggartDP,El-FikyM,CarterR,etal.Respiratorydysfunctionafteruncomplicatedcardiopulmonarybypass.AnnThoracSurg1993;56:1123–1128.

32. Grondin CM, Campeau L, Lesperance J, etal. Comparison of late changes in internalmammary artery and saphenous vein grafts intwoconsecutive seriesofpatients10years afteroperation.Circulation1984;70(suppl1):208-12.

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36. Mak VHF, Bugler JR, Roberts CM, Spiro SG.Effectofarterialoxygendesaturationon6MWT,perceived effort, and perceived breathlessnessin patients with airflow limitation. Thorax1993;48:33-8.

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Intra and Inter-Rater Reliability of brief balance Evaluation system test in Patients with total Knee Arthroplasty

shah Mital b1, thangamani Ramalingam A2, bid Dibyendunarayan D3, Patel KeniK4, Patel Krishna s 4, Patel Kaushal A4

1Assistant Professor, 2Lecturer; 3Senior Lecturer; 4Physiotherapists, Sarvajanik College of Physiotherapy, Rampura, Surat, Gujarat, India

AbstRACt

background: FollowingTotalKneeArthroplasty(TKA)surgerythepatientsmayhavefunctionaldeficitslikereducedwalkingvelocityandstridelengthandduringthelevelwalking,balanceimpairmentcanleadtofallingriskinthem.Butcurrently,thebalanceevaluationsystemisnotaddressedinfulldepthwithamorereliabletoolinkneearthroplastypatients.

Purpose: ThepurposeofthisstudywastoevaluatethereliabilityofBriefBalanceEvaluationSystemTest(Brief-BESTest)scaleasanassessmenttoolforbalanceonindividualswithTKA.

Methods: Anobservationalstudydesignusedwith30individualsasparticipantswhohadundergoneTKAsurgery.Intra-classcorrelationcoefficients(ICC,modeltwo-wayrandom,typeabsoluteagreement)werecalculatedforexaminingthetest-retestreliability.

Results:TheIntra-raterreliability was 0.984(0.967-0.992); Inter-rater reliability was 0.987(0.973-0.994) and the Bland-Altman analysis of limits of agreement showed that the mean difference was -0.266±1.112fortheBrief-BESTestscale.

Conclusion: TheBrief-BESTestisareliableandtime-savingtooltoassessthebalanceinTKApatientsandismorereliablecomparedtoMini-BESTestandBESTest.

Keywords: Total knee arthroplasty, Stability, Balance test.

Correspondent author: shah Mital bAssistantProfessor;BPT;SarvajanikCollegeofPhysiotherapy,Rampura,Surat-395003,Gujarat,INDIA,E-mail:[email protected] Mobile:09227850012

INtRODUCtION

Total Knee arthroplasty (TKA) is a commonsurgical intervention to treat the patients with severeknee osteoarthritis. The incidence rate of TKA hasgrown over the last 20 years and will continue togrowdue tochangingpopulationdemographics(1).Theuses of knee arthroplasty surgery are to correct thedeformity, reducepain,and improvephysical functionand symptoms of osteoarthritis. However following

surgery the patients have functional deficits likereducedwalkingvelocityandstridelengthduringlevelwalking(2,3),alteredsensoryandmotorfunction,whichcan lead to impairment in balance function (4, 5) andalterationinmotorcoordination,musclestrengthand/orproprioceptive dysfunction(2, 6, 7). Balance impairmentcan lead to falling risk in patients with TKA(4, 5). Abalance test is used to assess different components ofbalanceandprovidesinformationregardingindividual’sfunctional recoveryand tomakepredictionsof falls(8). Falling is a serious public health problem amongelderly people becauseof its frequency, themorbidityassociated with falls and cost of the necessary healthcare(9,10).Approximately30%ofpeopleover65-yearsofagewholiveinthecommunityfalleachyear.Severalpotentially modifiable risk factors for falling such asmuscle weakness, impairment in balance and use ofmedicationhavebeenidentified(9,11,12).

DOI Number: 10.5958/0973-5674.2018.00026.6


Balance involves the interaction of both sensoryand motor systems (13). Previous research in balanceassessmentamongpatientswithTKAmainlyinvolvedadvanced technology and sophisticated equipment inlaboratory settings such as virtual or real obstaclesavoidance(14, 15), stabilogram analysis(16, 17), kinematicand electromyographic analysis(4, 18) and computerizeddynamicposturography(19),whichmightnotbeavailableand feasible in real clinical situations. Although BergBalance Scale (BBS) is a common tool for balanceassessment(20, 21) and can be considered as a referencestandard for assessing balance in patients with TKAclinically(22, 23). It mainly assesses static balance andhas been shown to have considerable ceiling effectsin various patients’ population(24, 25). Balance is animportantdynamictaskinwalkingbutisnotaddressedin the BBS (26). The BESTest was developed whichincludes 36 items that evaluate the performance of 6balance systems: biomechanical constraints, stabilitylimits/vertically, anticipatory postural adjustment,postural responses, sensoryorientation and stability ingait(27).Mostofthecurrentstandardizedclinicalbalanceassessment tools are directed at screening for balanceproblemsandpredictingfallrisk,particularlyinelderlypeople(28, 29). The BESTest takes about 45 minutes toadminister(30).Inaddition,equipmentsuchasaramp,afoamblock,ameterstick,atableanda2.27Kgweightis necessary for the BESTest andmay not be readilyavailable for clinicians. These concerns suggest thatBESTest, althoughmeasuring balance control systemsandpossessingreasonableaccuracyinpredictingfalls,may not be practical for regular use in all clinicalsettings(31).AcondensedversionofBESTestnamedthemini-BESTestwas derivedwith only 16 items,whichtakesonly15minutes tocomplete.However,2of thebalancesystem(biomechanicalconstraintsandstabilitylimits/verticality) are omitted in mini-BESTest(30). Toavoid the drawbacks of BESTest and mini-BESTest,the8-itemBrief-BESTestwasdevelopedwhichassessall6balancesystems. It requires less than10minutesto administer and could be more feasible for clinicaluse(32).

Section-1:Biomechanicalconstraints:Biomechanicalconstraintsforstandingbalanceincludehip/trunklateralstrength(item-1)inastandingpositiontoassessthebalancefunction(33).

Section-2: Stability limits: This system includesitemsforaninternalrepresentationofhowfarthebody

can move over its base of support before changingthe support or losing balance, as well as an internalperception of postural vertical (42, 43). Stability limitsinclude functional reach forward (item-2), whichmeasurestheabilitytoleanasfaraspossibleinstandingposition(36).

Section-3: Transitions –anticipatory posturaladjustment: This system includes tasks that requirean active movement of the body’s center of mass inanticipation of a postural transition from one bodypositiontoanother(37).Anticipatoryposturaladjustmentincludesstandingononeleg-leftandright(items-3and-4)toexaminebalancefunction(38).

Section-4: Reactive postural response: Reactivepostural responses include both in-place andcompensatory stepping responses to an externalperturbationinducedbytheexaminer’shandsusingtheunique “push and release” technique (39). The posturalresponse includes compensatory stepping-lateral, toboththesidesleftandright(items-5and-6)(40).

Section-5: Sensory orientation: This systemidentifies any increase in body sway during stanceassociatedwithalteringvisualorsurfacesomatosensoryinformation for control of standing balance. Sensoryorientationincludesstandingwitheyesclosed,onfoamsurface(item-7)(41).

Section-6:Stability inGait-Thissystemevaluatesbalanceduringgait (42).Stability ingait includes timed“up & go” test (item-8), which evaluates how fasta patient can sequence rising from a chair, walking,turningandsittingbackdownagain(43).

The purpose of this study was to evaluate thereliabilityofBrief-BESTestscaleasanassessmenttoolforbalanceonindividualswithTKA.

Figure-1: Model summarizing systems underlying postural control corresponding to sections of the bEstest (25)


MEtHODOLOGY

An observational study design used with 30individuals as participants who had undergone TKArecruited in the study based on the following criteria:Inclusion criteria: 1. Postoperatively one monthafter TKA done and able to fully participate in studyprocedure without fatigue 2. Able to stand and walkwithout any aids. Exclusion criteria: 1. Any othermusculoskeletal injuriesand2.Thecurrentuseofanymedicines, which can cause dizziness and fainting. 3.Anyneurologicalinvolvement.

Data collection included two assessors assessingall the 30 participants. All the subjects were testedunderthesamecondition.Beforethetest,demographicinformation was obtained from medical records andpersonal interview. First balance evaluationwas doneusingBrief-BESTestbybothassessorsseparately.Afteraperiodofoneweek,thesecondevaluationwasdonebythefirstassessor.


Intra-classcorrelationcoefficients(ICC,modeltwo-wayrandom,typeabsoluteagreement)werecalculatedforexaminingthetest-retestreliability.TheICCvaluesrangesfrom0to1;1=perfectreliability,0.90to0.99=

very high correlation; 0.70 to 0.89= high correlation;0.50to0.69=moderatecorrelation;0.26to0.49=lowcorrelationand0.00to0.25=little,ifany,reliability(44). The agreement was determined by the Bland-Altmanmethodinwhichtheindividualdifferenceswereplottedagainst the individual mean scores. The significancelevelwassetat5%(45).Thestandarderrorofmeasurement(SEM=Average SD x √1-ICC)was used to determinethemeasurement error. The SEMwas then convertedinto the Minimal Detectable Change (MDC), whichexpressestheminimalmagnitudeofchangethat likelyreflectstruechangeratherthanmeasurementerror.TheMDC95%wasestimatedfromtheSEMandcalculatedas1.96√2×SEM(46).

REsULts

The present study used 30 TKA patients. Fromthis sample, 21 subjects were females (70%) and 9subjectsweremales(30%).Themeanagewas62.77±13.20 years. Their mean height was 1.62±.075 meterandweight 69.60±6.27Kgs.Among them, 11(36.7%)undergone bi-compartmental and 19(63.3%) tri-compartmentalsurgery.

Table-1 shows the mean and standard deviationof Brief-BESTest score. The intra-rater, inter raterreliability and internal consistency of Brief-BESTest,areshowninTable-2&-3.

table-1: Mean and sD of brief-bEstest (N=30)

Minimum Maximum Mean sD

Rater 1 8 26 20.7 4.442

Rater 2 7 26 20.97 4.398

Rater 1 Retest 8 27 20.97 4.522

table-2: Intra-rater & Inter-rater Reliability

Reliability ICC 95% Confidence Interval

Intra-raterreliability 0.984 0.967-0.992

Inter –rater reliability 0.987 0.973-0.994


For Intra-rateror test-retest reliability, theBland-Altman analysis of limits of agreement showed thatthe mean difference was -0.266±1.112 for the Brief-BESTest.TheSEMfortheBrief-BESTestwas0.566.Inourstudy,calculationsrevealedanMDCof1.569pointsforBrief-BESTest.

Figure-1: bland-Altman Plot for measuring the limits of agreement of brief-bEstest scores

DIsCUssION

The present study is to determinewhetherBrief-BESTest has good reliability to assess balance inpatients with TKA. The study targeted both inter-raterand intra-rater reliabilityofbalancemeasures forparticipants in the study using a Brief-BESTest scale.In the intra-rater reliability of Brief-BESTest scale,ICC is 0.984 which is suggestive of high reliabilityandforinter-raterreliabilityofBrief-BESTesttheICCis 0.987 which is also suggestive of high inter-raterreliability. Similarly,Horak et al(25) conducted a studythat differentiates balance deficits by using Brief-

table-3: Component-wise Intra-Rater, Inter–Rater Reliability, and Internal Consistency

BriefBESTest Inter-rater reliabilityIntra–rater reliability

Internal consistency(Cronbach’ alpha)ICC 95%CI ICC 95%CI

BiomechanicalConstraint 0.918 0.829-0.961 0.939 0.874-0.971 0.937

StabilityLimits/Verticality 0.670 0.314-0.842 0.680 0.374-0.821 0.682

AnticipatoryPosturalAdjustments 0.940 0.876-0.971 0.888 0.767-0.947 0.939

PosturalResponses 0.965 0.928-0.983 0.996 0.991-0.998 0.996

SensoryOrientation 1.00 1.00-1.00 1.00 1.00-1.00 1

StabilityinGait 0.906 0.811-0.957 0.753 0.448-0.883 0.909

BESTest and he found that the Brief-BESTest is themostcomprehensiveclinicalbalancetoolavailablewithexcellent reliabilityandverygoodvalidity.TheBrief-BESTestdemonstratedreliabilitycomparabletothatofthe Mini-BESTest and potentially superior sensitivitywhile requiring half the items of the Mini-BESTestand representingall theoreticallybasedsectionsof theoriginalBESTest.The study suggested thatClinicianscanreasonablyrelyontheBrief-BESTestforpredictingfalls,particularlywhentimeandequipmentconstraintsareofconcern(47,48).

Moreover,astudybyAndyetal(49)toassessbalancefunctioninpatientswithTKAresultssuggestedthatallthe three BESTests demonstrated excellent inter-raterreliability,intra-raterreliability,andinternalconsistencyforevaluationofbalanceinpatientswithTKA.

Brief-BESTest isaveryreliable tool forassessingbalance problems in subjects with TKA. Most ofexistingclinicalbalancetestsaredirectedatpredictingfallriskorwhetherbalanceproblemsexists,ratherthanwhattypeofbalanceproblemsexists.

CONCLUsION

TheBrief-BESTestisareliabletooltoassessbalanceinpatientswithTKA.EvenBrief-BESTestdemonstratedreliability comparable to Mini-BESTest and BESTestanditisveryusefulforcliniciansforassessingbalancewithlesstimeconsumptioninassessment.

Ethical Approval: Permission taken fromSarvajanikCollegeofPhysiotherapy,Surat.

source of Funding:Self-financed.

Conflict of Interest:None.


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Efficacy of Retro-treadmill Walking Versus Forward-treadmill Walking on Hamstring Flexibility, strength and balance in

Young Collegiate students

shilpy Jetly1, Dhawani sharma2

1Associate Professor, 2Mpt 2nd year Student D.A.V Institute of Physiotherapy and Rehabilitation, Jalandhar

AbstRACt

Objective–Efficacyofretrotreadmillwalkingversusforwardtreadmillwalkinginhamstringflexibility,strengthandbalanceinyoungcollegiatestudent.

Methodology–Thedurationof the studywasoneandhalfyear.Minimumof60 subjectswere selectedbyrandomsamplingforthestudy.Theyweredividedrandomlyintothreegroups-GroupA,GroupBandGroupC.Eachgrouphadminimumof20subjects. InGroupA-subjectswere instructed todoforwardwalking.GroupB-subjectswereinstructedtodoretrowalkingandGroupC-waskeptascontrolgroup.5sessionsperweekweregivenfor2weeksrespectivelytoeachgroupandreassessmentwasdoneon5thand11thday.

Result- Theresultshowedthat therewasstatisticalsignificantdifferencebetweenboththeexperimentalgroups-GroupAandGroupB.itisclearthatforwardandbackwardwalkingimprovesflexibility,strengthandbalance.

Conclusion- Weconcludethatforwardwalkingandbackwardwalkingareeffectiveinimprovingflexibility,strengthandbalanceinhealthysubjects.Butbackwardwalkingprovestobemoreeffectiveinimprovingflexibility,strengthandbalanceascomparetoforwardwalkinghence,provingresearchhypothesis.

Keywords- Forward-treadmill walking, Retro-treadmill walking, hamstring flexibility, strength and balance

INtRODUCtION

Thetreadmillisasensiblechoiceasanalternativetoovergroundtrainingduetoitsavailability,aswellastheabilitytomaintainaspecificspeedandslope.Motorizedtreadmill has a flat running surfacewith amotor thatpropels a continuousmoving belt inwhich the runnerattempts to match the speed through stride lengthand stride rate.1The ability of an individual to movesmoothlydependsuponhisflexibility.Thehamstringsareanexampleofmusclegroupthathave tendencytoshorten.3 Ashorthamstringmuscleareassociatedwithvariousproblems,includingspecificdisordersoflumbarspine,generaldysfunctionsyndromesof lowbackandsports related injuries4.During forward walking kneejoint flexes, extends and then flexes in support phase,whereas knee initially extends, flexes and extends insupport phase, prior to flexing and extending during

swing.Howeversupportswingratioofbackwardwalkis similar to forward walking with 60% support and40% swing. Backward walking increases stride rate,decreases stride length and increases support time.Backwardwalkingoverall reduces rangeofmotionofknee thereby increase active functional range.7Duringbackwardwalking in the samemotorprogram is usedas during forward walking, but possibly running inreverse.29,35Ithasbeensuggestedthatbackwardwalkingappearstocreatemoremuscleactivityinproportiontoeffortthanforwardwalking.29,30Fortheperformanceofwalkingparameters thestepsofwalkingbackwardperminutewasmore than forward and relativelywalkingforwardneededlongingmovingtimeofperpace36,37.

Purpose of study:

The purpose of this study is to determine theefficacy of retro-treadmill walking versus forward-

DOI Number: 10.5958/0973-5674.2018.00027.8


treadmillwalkingonhamstringflexibility,balanceandstrengthinyoungcollegiatestudents.

Objectives:

• Toassess theeffectof retro-treadmillwalkingonhamstringflexibility,strengthandbalanceinyoungcollegiatestudents.

• To assess the effect of forward-treadmillwalkingonhamstringflexibility,strengthandbalanceinyoungcollegiatestudents.

• To compare the effect of retro-treadmillwalkingversusforward-treadmillwalkingonhamstringflexibility, strength and balance in young collegiatestudents.

MEtHODOLOGY

Experimental design (comparative in nature) wasused with random sampling. Outcome measures :Standing stork test for static balance,Star excursionbalance test for dynamic balance,AKED forflexibility,MVIC(maximum voluntary isometriccontraction) for strength 60 subjects were includedon the basis of inclusion criteria: both males andfemales,18-27yearsofage,normalsubjectswithtighthamstrings (extension lag 250or >250). Subjects wereexcludedonthebasisofexclusioncriteria:anyvisibledeformity of lower limb, ankylosing spondylitis, softtissue injury of lower limb, cardiopulmonary disease,anyneurologicalcondition,recentinjurytothehip,kneeorankle,rheumaticdisease.

Protocol

Awritten consentwas obtained from all subjects. 60 subjects were randomly divided into three groupsminimum of 20 subjects in each group. Pre data wasmeasured such as static and dynamic balance withstanding stork test and star excursion balance test,MVICofhamstringonEMGforstrengthandhamstringflexibilitybyAKED(Activekneeextensiondeficiency).Allthedatawasmeasuredinreferencetodominantleg.

Procedure on treadmill

BothgroupsAandBwereperformedtheforwardwalking and retro walking on a motorized treadmillat a speed of 3mph and uphill inclination of 10o for20 minutes for 5 sessions per week for two weeksrespective to their group. As a warm up subjects of

boththegroupwererequiredtoperformbackwardandforwardwalkingonatreadmillfortwominutesat0oofinclination.GroupCwascontrol.Datawerecollectedon1st(pre-intervention),after5th(pre-intervention)and11th (postintervention)respectively.

Procedure for static and dynamic balance

static balance

Standingstorktest:

Astopwatchwastheonlyequipmentnecessary.

• Thestudentsliftedtheirnon-dominantlegandplacethesoleofhisfootagainstthesideofthedominantleg’skneecap.

• The test administer gave command “GO”,startedthestopwatchandthestudentraisedtheheelofthefootoftheirdominantlegtostandontheirtoes.

• Thestudentwastoholdthispositionforaslongaspossible.1

Dynamic balance:

star excursion balance test

Intest,thelengthofthestancelegordominantlegwasmeasured from theanterior-superior iliac spine tothemostdistalpointoftheipsilateralmedialmalleolus,using a standard tape measure while participants laysupine on a plinth. The participant than performed 3testtrailsineachdirectionforeachoftheraters,sittingin a chair to rest for 5minutes between raters. The 3reachdirectionstestedwereanterior,posteromedialandposterolateral.2

Performance of the sEbt

Participant performed the SEBT by standing inthemiddleofatestinggridwithstripsoftapeplace45degreeangles,reachingdominantfootasfaraspossiblealongdifferentgridlines, thenreturningtothestartingposition.While standing bare foot or in the socks ona single limb and keeping the hands on the hips. Theparticipantswillmadeanefforttoreachasfaraspossiblewiththereachinglimbalongeachtapemeasure;touchlightlyonthetapemeasurewithmostdistalportionofthereachingfeet,withoutshiftingweighttoorcomingto reston the footof the reaching limband return thereachinglimbtothestartpositionattheapexofthegrid.


2

Hamstring flexibility

AKED (Active knee extension test)

The baseline extension was measured using adouble-armgoniometerwith0.97reliabilityvalue.Then,the subject performed the active knee extension testprocedureinsupineontheplinthandthehipofthelowerlimbbeingassessedwasflexedto90o.Thedistalpartoftheiranteriorsurfaceofthethighwasplacedincontactwithcrosslineofspeciallyconstructedofwoodenstool.Withhisankleinrelaxedposition,andensuringthathisthighmaintained contact with the crossed line on thewooden frame, the subject was instructed to activelyextendthekneetothepointwherehestartedfeelingastretch.The active knee extension deficiency (AKED)wasmeasuredusingthegoniometer0owasconsideredtobefullextensionoftheknee3

ELECtROMYOGRAPHY for hamstring strength

MeasurementofEMGactivity

Electrode placement: gross electrical activity ofhamstringmusclewasmeasuredusingadhesivesurfaceelectrodesandwereplacedmidwaybetweenglutealfoldand knee jointwhichwas determined using inch tapewith a 3cm interelectrode distance. Active electrodebeingplacedproximallyandpassiveplaceddistally.4,5

MethodformeasuringMVICofhamstring:

Thesubjectwaslaidpronewiththekneeflexedto90o. The researcher providedmanual resistance in thedirectionofkneeextensionwhilethesubjectflexedtheknee. Before contraction, a strap was placed aroundthepatient’ships tohipextensionandotheraccessorymotion.6

DAtA ANALYsIs AND REsULt

• Repeated measure ANOVA for within groupanalysis.

• For Between group analysis ONE WAYANOVAandposthocanalysisbyTukey’smethod.

table 1: Post hoc comparison of mean between groups for AKED-RIGHt

GROUPsDAY 11thMEAN ± sD

p value

GROUPAvsGROUPB

39.70±5.841

34.65±3.8845.05(S)

GROUPAvsGROUPC

39.70±5.841

44.70±8.1515(S)

GROUPBvsGROUPC

34.65±3.884

44.70±8.15110.05(S)

table 2: Post hoc comparison of mean between groups for AKED-LEFt

GROUPsDAY 11MEAN ± sD

p value

GROUPAvsGROUPB

39.60±4.430

33.50±4.5254.61(S)

GROUPAvsGROUPC

39.60±4.430

44.20±7.8714.6(S)

GROUPBvsGROUPC

33.50±4.525

44.20±7.87110.7(S)

table 3: Post hoc comparison of mean between groups for EMG-MVIC

GROUPSDAY11MEAN±SD

pvalue

GROUPAvsGROUPB

1665.18±450.731

2598.90±799.064933.72(S)

GROUPAvsGROUPC

1665.18±450.731

1032.61±265.843632.57(S)

GROUPBvsGROUPC

2598.90±799.064

1032.61±265.843566.29(S)


table 4: Post hoc comparison of mean between groups for sEbt (ANtERIOR)

GROUPS DAY11MEAN±SD

pvalue

GROUPAvsGROUPB

88.83±13.331

98.38±10.3459.56(S)

GROUPAvsGROUPC

88.83±13.331

75.26±12.97813.57(S)

GROUPBvsGROUPC

98.38±10.345

75.26±12.97823.12(S)

table 5: Post hoc comparison of mean between groups for sEbt (POstEROMEDIAL)

GROUPsDAY 11MEAN ± sD

p value

GROUPAvsGROUPB

75.55±11.558

86.51±10.89910.96(S)

GROUPAvsGROUPC

75.55±11.558

63.60±17.20214.71(S)

GROUPBvsGROUPC

86.51±10.899

63.60±17.20222.91(S)

table 6: Post hoc comparison of mean between groups for sEbt (POstEROLAtERAL)

GROUPSDAY11MEAN±SD

pvalue

GROUPAvsGROUPB

69.36±11.161

79.79±17.24010.43(S)

GROUPA

vs

GROUPC

69.36±11.161

58.34±17.24011.02(S)

GROUPB

vs

GROUPC

79.79±11.090

58.34±17.24021.45(S)

table 7: Post hoc comparison of mean between groups for sst

GROUPSDAY11MEAN±SD

pvalue

GROUPAvsGROUPB

6.47±2.570

9.44±2.4752.97(S)

GROUPAvsGROUPC

6.47±2.570

3.86±1.0962.61(S)

GROUPBvsGROUPC

9.44±2.475

3.86±1.0965.58(S)

DIsCUssION

The study demonstrated that both forward andbackwardwalking showed significant improvement inflexibility, strength and balance. However, Group Bshowed more significant improvement in variables ascomparetogroupAandGroupC.

Within group analysis: Group A and B showedstatistically significant improvement in variableswhereasGroupCdidn’tshowanystaticallysignificantimprovementinvariablesinhealthysubjects.

Flexibilityisanimportantphysiologicalcomponentof physical fitness and reduced flexibility can causeinefficiency in the work place. Increasing hamstringflexibility was reported to be an effective method forincreasing hamstringmuscle performance on selectiveisokineticconditions.1Theactivekneeextension(AKE)testwasusedtoevaluatethehamstringmusclelengthofthedominant lower limb.2These results could explainthegain inhamstring length5.Previous study revealedthat the treadmill training improves the balance andbuildmusclestrengthinlowerlimbswhichareinvolvedin the generation of more independent and maturewalking8. Treadmill training is believed to improvethe lower limbs muscle strength and balance as wellas stimulate neuronal connections that are involvedin generation of independent balanced walking.9 Thesignificant improvement in functional strength in BWisinaccordancewithvariousearlierstudieshavebeenobserved the increases in lower limb muscle strengthwith retro-walking 5.10. Previous studies indicate thatstrengths of quadriceps and hamstring muscles are


increasedafterBWexercises.12,ThestudyprovingthatbackwardwalkinggroupthatisGroupBshowedmoresignificantimprovementinmusclestrengththanGroupAwhichwastheforwardwalkinggroup.

Adaptive mechanisms necessary for coordinationpatterns, bodyorientation andbalance stability canbeimprovedbytreadmillwalking.15Walkingonatreadmillis more effective in activating the central gait patterngeneratorandenhancesmotor learningthanother typeof exercises.16Sensory integration can be improvedthrough specific training such as altering the standingsurface or its movement in order to enhance posturalstabilityinelderlypeople17.Afterforwardandbackwardwalking,forwardandbackwardinclinationoccurs15thatleadstoanteriorandposteriormusclestretching.Thisisfollowedbyco-contractionofmuscleswhichmaintainsbalance.18

The gain in dynamic balance in the present studycould be explained by the reason that there was anincreaseinstaticbalanceandthus,indynamicbalanceassessment by SEBT.Which requires stability aroundankle on stance limb can be the reason of increase inthe reach distance by the other limb.5Further, as therewasanincreaseinlengthofthehamstringmusclefoundbyWhitley, this could also be the possible reason forincreaseinthereachdistancewhichisasignofincreasein the dynamic balance. However, RW was itself adynamicactivityandstressmoredynamiccontroloverthe body during RW. The improvement in dynamicbalance could be explained as the increase in reachdistancebecauseofthereasonthatastherewasincreasein hamstring length, it could affect the reach distanceand thus increased in the reach directions had beenobserved.19

Conflict of Interest: There was no conflict ofinterest.

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