Indian Journal of

Physiotherapy and Occupational Therapy An International Journal

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

Volume 4 Number 1 January - March 2010

website: www.ijpot.com

Contentswww.ijpot.com

January - March 2010Volume 4, Number 1

Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No. 1 I

1 Dynamic balance and mobility in females with knee osteoarthritisAbha Sachdev, Savita Tamaria

4 Effect of strength training of muscles of lower limb of young children with cerebral palsyon gross motor functionAditya Kumar, Samim Kabeer, Ruby Aikat, Monika Juneja

8 Comparison of three different treatment protocols of low-energy radial extracorporeal shockwave therapy for management of chronic plantar fasciitisAfaf A.M. Shaheen

13 The effect of insole on ground reaction forces of two-legged vertical jumping for headingball in flexible flat foot male subjectsAli Asghar Arastoo

17 Adaptability in nature – Are lungs moldable?Amrith Pakkala

19 Effect of performing a cognitive task on gait performance in patients with hemiparesisfollowing stroke of greater than three months durationAngusamy R., Chandbibi. M.Y.

24 Awareness on diabetes mellitus and physical activity level among Malaysian publicAyiesah R., Nur Hidayah A. B., Nor Azura A.

29 Effect of high voltage healthron device on blood pressure and plasma glucose of normalsubjects – A technical reportOnigbinde Ayodele.T., Adedoyin Rufus. A.

32 Site specificity of sports injuries seen during the interschool competations held at belgauman observational studyMotimath B.S., Ganesh B.R., Murakibhavi V.G.

35 Mental imagery–A reviewChaya Garg

38 Incidence of brachial plexus injuries during cardiac surgeries - A review of literatureDarshpreet Kaur, Nidhi Billore

43 Family caregivers of Nigerian–African stroke survivors: Their knowledge and beliefs aboutstrokeTal-Hatu K. Hamzat, Oyedunni S. Arulogun, Salim A. Akindele

47 Efficacy of modified constraint-induced movement therapy in children with spastichemiparetic cerebral palsyMahotra Pardeep, Senthilkumar C. B., Shankar Mamta

54 Effectiveness of muscle energy technique on quadratus lumborum in acute low back pain-randomized controlled trialPrachi N. Patil, Basavaraj Chandu, Santosh Metgud, Subhash Khatri

59 Paraplegic can walk: A case report and review of literatureRajni Arora, Pradipta Tripathy, Santhosh Kumar

62 Stretching procedures for posterior shoulder tightness– randomized clinical trialRanjeet Sharma, Ganesh B.R., Vijay B. Kage, Subhash M. Khatri

68 Effects of local vs global stabilizer strengthening in chronic low back painPriyanka Goel, Zubia Veqar, Nishat Quddus

75 Comparative analysis of stretching vs mobilization on posterior shoulder tightness incricketersShaji M.S. John, Rohit Chachra

80 The efficacy of monochromatic infrared photo-thermal energy therapy in rehabilitation: Apilot study reportStanley Paul, Yuanlong Liu, Robert McAlister

Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No. 1

INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPY

EditorDr. Archna Sharma

Head, Dept. of Physiotherapy, G.M. Modi Hospital, Saket, New Delhi - 110 017E-mail : editor.ijpot@gmail.com

Executive EditorDr. R.K. Sharma, New Delhi

National Editorial Advisory BoardProf. U. Singh, New DelhiDr. Dayananda Kiran, IndoreDr. J.K. Maheshwari, New DelhiDr. Nivedita Kashyap, New DelhiDr. Suraj Kumar, New DelhiDr. Renu Sharma, New DelhiDr. Veena Krishnananda, MumbaiDr. Jag Mohan Singh, PatialaDr. Anjani Manchanda, New DelhiDr. M.K. Verma, New DelhiDr. J.B. Sharma, New DelhiDr. N. Padmapriya, ChennaiDr. G. Arun Maiya, ManipalProf. Jasobanta Sethi, BangaloreProf. Shovan Saha, ManipalProf. Narasimman S., MangaloreProf. Kamal N. Arya, New DelhiDr. Nitesh Bansal, NoidaDr. Aparna Sarkar, NoidaDr. Amit Chaudhary, FaridabadDr. Subhash Khatri, BelgaumDr. S.L. Yadav, New DelhiDr. Vaibhav Aggarwal, MeerutDr. Sohrab A. Khan, Jamia Hamdard, New Delhi

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Dr. M. Nellutla, RwandaProf. GoAh Cheng, Japan

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

“Indian journal of physiotherapy and occupational therapy” An essential indexed peer reviewed journal for allPhysiotherapists & Occupational therapists provides professionals with a forum to discuss today’s challenges - identifyingthe philosophical and conceptual foundations of the practics; sharing innovative evaluation and tretment techniques;learning about and assimilating new methodologies developing in related professions; and communicating informationabout new practic settings. The journal serves as a valuable tool for helping therapists deal effectively with the challengesof the field. It emphasizes articles and reports that are directly relevant to practice. The journal is now covered by INDEXCOPERNICUS, POLAND. The journal is indexed with many international databases.The journal is registered with Registrar on Newspapers for India vide registration DELENG/2007/20988

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II

Dynamic balance and mobility in females with knee osteoarthritisAbha Sachdev*, Savita Tamaria***Lecturer, **Clinical Demonstrator, Banarsidas Chandiwala Institute of Physiotherapy, New Delhi

Abstract

Objective

This study compared the dynamic balance and mobilityin Knee Osteoarthritis patients and their healthy counter-parts using simple clinical tests.

Methods

40 female subjects in the age group of 40- 70yrs weredivided into two groups: Group A (n=20) which includedbilateral knee OA patients and Group B (n= 20) whichincluded healthy asymptomatic subjects. Dynamic Balanceand mobility was measured using Step up test and Timedup and go test respectively.

Results

There was a statistically significant difference in Step UpTest scores (p < 0.01) and TUG scores (p < 0.01) betweenGroup A & Group B. This indicates that subjects with OAtook fewer steps in the 15s test period during Step Up Test,indicating poorer balance under dynamic testing condition.Also, they had significant lesser mobility as compared totheir healthy counterparts.

Conclusion

Patients with knee Osteoarthritis have poorer dynamicbalance and mobility as compared to their healthycounterparts. Additional research is needed to determinethe functional impact of such deficits in knee OA patients.

Introduction

Osteoarthritis is a chronic, localized disease affectingapproximately, one third of adults, with the diseaseprevalence increasing with advancing age. It mostly affectsweight bearing joints. Knee is the most common weightbearing joint affected by osteoarthritis1. It is more commonin females than in males. It is a major cause of impairmentand disability among the elderly. It is characterized by theprogressive erosion and loss of articular cartilage. Thesechanges are often associated with additional structuralchanges such as joint space narrowing and osteophyteformation. It also results in changes that affect not onlyintrcapsular tissues but also the periarticular tissues suchas ligaments, capsule, tendon and muscles2. Individualswith knee OA suffer from progressive loss of function,displaying increasing dependency in walking, stair climbingand other lower extremity task. Balance is an integralcomponent of such activities of daily living3.

Balance maintenance is a highly integrated multifactorialprocess. According to the systems approach, the ability tocontrol our body position in space emerges from a complexinteraction of musculoskeletal and neural system4. Itrequires a coordinated effort of the neuromuscular systemto obtain accurate sensory input (vision, vestibular andproprioception), organize motor programs and generateeffective motor output responses.

It has been well documented in the literature that agingprocess affects all the components of the postural control. Inthe sensory system, visual acuity, depth perception,proprioceptive sense loss has been demonstrated with age.In the central processing component, slowing of sensoryinformation processing and nerve conduction velocity maycontribute to latency of automatic postural responses. In theeffector system, factors such as range of motion, muscletorque, and power and postural alignment can all affect thecapacity of the person to effectively respond to thedisturbance of the balance5,6.

Since knee OA is common in elderly, it may result inchanges that accelerate the deterioration of these systemsand may culminate in greater impairment in balance in thispatient population, thus leading to increased risk of falls.

Falls and loss of balance most commonly occur duringdynamic activities (e.g. walking)7 than in static activities.Therefore balance assessment should emphasize ondynamic nature of ADLs as static tests are less able toidentify individual at risk of falls than the dynamic tests6,8.Many studies have evaluated the impact of knee OA onbalance, but only few have utilized simple, clinically practicalmeasures to assess balance in knee OA patients.

Therefore the purpose of this study was to comparedynamic balance and mobility in female knee OA patientsand their healthy counterparts using simple clinical tests.

Method

Subjects

40 female subjects in the age group of 40- 70yrs weredivided into two groups : Group A (n=20) which includedbilateral knee OA patients and Group B (n= 20) whichincluded healthy asymptomatic subjects. The subjects forthe study were selected from the outpatient department ofBanarsidas Chandiwala Institute of Physiotherapy.

Subjects were included in group A if they werediagnosed as having knee OA by the orthopedician on thebasis of ACR criteria,9 knee pain on most days of theprevious month (average pain > 3cm on 10cm on VAS),demonstrated osteophytes on x- ray and experienced painand difficulty when getting up from the sitting or climbingstairs. Subjects in group A were excluded if there was a

1Abha Sachdev / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

history of physiotherapy treatment, knee surgery, lower limbjoint replacement, intrarticular steroid injection, systematicarthritic condition or any sever medical condition.

Subjects in group B were excluded if there was a historyof recent injury around the knee joint, lower extremitypathology, presence of any disorder that could account forproblem in balance, an active illness that may interfere withparticipation in the study.

Instrumentation

The step up test and timed up and go test (TUG) wereused as measured of dynamic balance and mobilityrespectively. In the step up test,10 the subjects wereinstructed to maintain balance on one leg, while steppingthe contralateral limb on and off a 15cm step as quickly aspossible. The number of times the subject could place thefoot up onto the step and return it to the floor over a 15secinterval was recorded. If loss of balance occurred, the testwas ceased and the number of complete steps up until thispoint was recorded. Subjects in group A (osteoarthritisgroup) were made to stand on the most symptomatic limb.For group B (healthy subjects group) mean of the resultobtained while standing on each leg was noted.

TUG measures the time it takes for a subject to standup from an arm chair, walk a distance of 3 meter, turn, walkback to the chair and sit down11,12.

Procedure

The purpose of the study was explained to the subjects.Verbal description of all the procedure was given. Testingwas performed only after an informed consent was takenfrom the subject. The subjects who met the inclusion criteriawere grouped into group A (OA subject group) and group B(healthy subject group). The subjects were assessed anddemographic data such as height, weight, were measuredand noted. Then the subjects in both the groups wereassessed for SUT and TUG. The data thus collected wasrecorded.

Data analysis

The data was analyzed using SPSS – software.Statistical test used was t-test for finding the differencebetween the demographic data (age, height, weight),dynamic balance (Step Up Test scores) and mobility (TUGscores). A significant level of p< 0.05 was fixed.

Results

The result of the study showed no significant differencein the demographic data i.e. age, height, weight betweenthe Group A (X=56.1, S.D= ±6.97; X=157.7, S.D= ±5.72;X=68.9, S.D= ±8.49) and Group B (X=58.5, S.D= ±5.16;X=156.1, S.D= ±4.67; X=65.1, S.D= ±6.13).

It was also found that there was a statistically significantdifference in Step Up Test scores (p < 0.01) and TUGscores (p < 0.01) between Group A & Group B. Thisindicates that subjects with OA took fewer steps in the 15stest period during Step Up Test, indicating poorer balanceunder dynamic testing condition. Also, the subjects hadsignificantly lesser mobility as compared to their healthycounterparts.

Discussion

This study found that compared with healthy subjects,patients with knee OA have poor dynamic balance &decreased mobility. The possible reason for this could beattributed to the deficits of proprioception & muscle strengthwhich are associated with knee OA, thus impairing balance.Knee OA is associated with articular damage, which maystimulate articular mechanoreceptors evoking abnormalsensory information, which decreases voluntary activation.Afferent fibres from articular mechanoreceptors project ontoα-motorneurons the spinal cord & these α-motorneuronsactivate extrafusal muscle fibres. If articular damage evokesabnormal afferent information, which in turn decreases theexcitability of α-motorneourons, this would reduce voluntaryactivation of quadriceps.

Articular mechanoreceptors afferent fibres also projectonto γ-motorneurons in the spinal cord. γ-motorneuronsactivate the intrafusal muscle fibres that make up musclespindles. Thus γ-motorneuron excitability governs musclespindle sensitivity. If arthritic damage to articular mechano-receptors evokes sensory input that reducesγ-motorneurons excitability, this would decrease musclespindle sensitivity and consequently decrease proprio-ceptive acuity.

Therefore damage of articular mechanoreceptors mayimpair both motor control (that is, voluntary muscle

Fig. 1: Comparison of SUT scores between the Group A and Group B. Fig. 2: Comparison of TUG scores between the Group A and Group B.

02

46

810

1214

16

GROUPS

SU

T S

co

re

s

Group A

Group B

02

46

810

1214

16

GROUPS

TU

G S

co

re

s

Group A

Group B

Table 1: Comparison of Step Up Test (SUT) Score and Timed Up and GoTest (TUG) Score between Group A and Group B.

Variable Group A Group B t-valueMean S.D Mean S.D

SUT Score 8.9 1.68 13.85 1.84 8.87**TUG Score 14.09 2.38 10.94 1.88 4.64**

** Significant at 0.01 level.

2 Abha Sachdev / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

activation) and sensory appreciation (that is, joint positionsense) in patients with knee OA13.

As is well known control of balance is a complexprocess. It requires central integration of input from visual,vestibular and peripheral sensory systems, as well asprecise motor control to maintain equilibrium. Therefore,impairments in both, motor control and joint proprioceptionfound in knee OA patients are likely to cause impairments indynamic balance.

The findings of this study are supported by a study doneby Mohammadi et al, who also found that dynamic balanceis impaired in knee OA patients compared to their matchedcontrols14.

In addition pain associated with OA knee may also playa role in balance impairments. Pain may reflexively inhibitthe muscles around the knee, which could compromiseeffective and timely motor responses in postural control.Furthermore, pain may result in reduced loading of theaffected joint, potentially jeopardizing an individual’s abilityto maintain their centre of mass within the base of support.This is also supported by Hassan et al who also found painto be a significant predictor of sway in knee OA patients2.Impairment in balance, in addition to other factors such asquadriceps weakness associated with knee OA may lead toreduction in mobility found in these patients.

As there was no statistically significant difference foundbetween the groups with respect to the demographic data,it is inferred that the observed balance deficits are purelydue to presence of OA.

Thus on the basis of this study it is recommended thatwhen assessing knee OA patients, we should not confineto the assessment of musculoskeletal system alone. Weshould also assess the balance and mobility deficits in thesepatients, using simple clinical tests (such as TUG and StepUp Test). Further research is needed to determine thefunctional impact of such deficits in knee OA patients.

References

1. Kim L. Bennell, Rana S. Hinman, Ben R. Metcalf, Kay M.Crossley, Rachelle Buchbinder, Michael Smith, GeoffreyMcCol: Effect of age and activity on knee jointproprioception. American Journal of Physical Medicine &Rehabilitation. 1997; 76(3): 235-241.

2. B S Hassan, S Mockett, M Doherty: Static posturalsway, proprioception, and maximal voluntary quadricepscontraction in patients with knee osteoarthritis and

normal control subjects. Annals of Rheumatic Disease.2001; 60:6 12-618.

3. R S Hinman, K L Bennell, BR Metcalf, K M Crossley :Balance Impairments in individuals with kneeosteoarthritis: a comparison with matched controls usingclinical tests. Rheumatology. 2002; 41: 1388-1394.

4. Marjorie Hines Woollacott & Anne Shumway Cook:Changes in postural control across the life span-ASystems Approach. Physical Therapy, 1990, 70: 799-807.

5. Anthony A. Vandervoort : Ankle mobility and posturalstability. Physiotherapy Theory and Practice. 1999; 15:91-105.

6. Randall C Briggs, Marilyn R Gossman, Robert Birch,Judith E Drews and Shirley A Shaddeau BalancePerformance Among Noninstitutionalized ElderlyWomen. Physical Therapy. 1989; 69(9): 748-756.

7. Campbell AJ, Borrie MJ, Spears GF, Jackson SL, BrownJS, Fitzgerald JL. Circumstances and consequences offalls experienced by a community population 70 yearsand over during a prospective study. Age Ageing. 1990Mar;19(2):136-41

8. Shumway-Cook A, Brauer S, Woollacott M.Predictingthe probability for falls in community-dwelling olderadults using the Timed Up & Go Test. Physical Therapy.2000 Sep; 80(9):896-903.

9. Altman R, Asch E, Bloch D et al. Development of Criteriafor the classification and reporting of Osteoarthritis.Arthritis Rheumatology. 1986; 29: 1039-49.

10. Hill K.Bernhardt J.McGann AM, Maltese D. A new test ofdynamic standing balance for stroke patients. Reliability,validity and comparison with healthy elderly.Physiotherapy Canada 1996; 48: 257-62.

11. S. Mathias, U.S.L. Nayak & B.Isaacs: Balance in elderlypatients: the “get-up and go” test. Archives PhysicalMedicine and Rehabilitation: 1985; 67: 387-389.

12. Diane Podsiadlo & Sandra Richardson.: The time “upand go”: A test of basic functional mobility for frail elderlypersons. Journal of American Geriatrics Society: 1991;39(2): 142-148.

13. Hurley MV, Scott DL, Rees J, Newham DJ. Sensori-motor changes and functional performance in patientswith knee osteoarthritis. Ann Rheum Dis 1997; 56:641-8.

14. Farshid Mohammadi, Shohreh Taghizadeh et al.Proprioception, dynamic balance and maximalquadriceps strength in females with knee osteoarthritisand normal control subjects. International Journal ofRheumatic Diseases. 2008; 11: 39-44

3Abha Sachdev / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Effect of strength training of muscles of lower limb of youngchildren with cerebral palsy on gross motor functionAditya Kumar*, Samim Kabeer**, Ruby Aikat***, Monika Juneja*****MOT Student, Jamia Hamdard, New Delhi, **Lecturer, Deptt. of Occupational Therapy, Jamia Hamdard, New Delhi,***Occupational Therapist, Four Step, New Delhi, ****Associate Professor, Deptt. of Pediatrics, MAMC, New Delhi

Introduction

Cerebral palsy has movement deviation which isattributed to abnormal motor control, restricted range ofmotion & insufficient force production caused by selectivemuscle atrophy.

Methodology

Pre-test post-test control group design. Two groups offifteen children with diplegic CP of age 2.5 to 9.5 year havingGMFC score I to III were conveniently selected of which firstgroup were given strength training and conventional therapyand other group were given conventional therapy alone.They were given thrice weekly sessions for Six weeksperiod with a gap of one day between two consecutivesessions. They were given bilateral heel raises in which theparticipant stood on the edge of the table, Activities on lightweight portable steps (height 20cm), Bilateral half squatusing a large inflatable ball to guide the exercise, Isolatedquadriceps strengthening activities with graded weight,Isolated hip extensor strengthening activities, Data wererecorded on the GMFM scale to see the changes afterstrengthening activity.

Analysis

Data collected were analyzed through SPSS by usingstudent t-test shows level of significance at p<0.05 for preand post treatment within and between the groups.

Conclusion

Result showed an improvement in gross motor functionfollowing strength training protocol and also emphasizes theeffectiveness of the strength training program in childrenwho are developmentally at lower level in terms of mobility.

Key words

Strength training, Gross motor function, Conventionaloccupational therapy.

Introduction

Cerebral palsy is a collection of non-progressivedisorders characterized by an insult to the developing/immature brain that produces physical1, perceptual &cognitive disability. The movement deviation of the childrenwith cerebral palsy is attributed to abnormal motor control,restricted range of motion & insufficient force productioncaused by selective muscle atrophy. The recognition ofweakness as a component of cerebral palsy has been long

standing as evidenced by the name given to this disorder &its subtypes “cerebral palsy” means “weakness originatingfrom brain”2. A more accurate description of the usualmuscular symptoms might be weakness (paresis), andinability to make voluntary movement and suppressinvoluntary one. Because of impairment many people withcerebral palsy have difficulty with activities such as sitting,kneeling, kneel walking, walking independently, negotiatingsteps, running or navigating safely over uneven terrain. Thespastic form of cerebral palsy is most common and in thesepatient additional clinical sign may include muscleshortening, diminished voluntary control and muscleweakness. Muscle strength is one aspect of motor capacityand is limited to the amount of force generated, butcoordination of movement, balance and motivation of thechild is also an important contributor of the motor capacity3.More than 50 year ago Phelp contended that resistedexercise to develop strength or skills in weaken muscles oran impaired muscle groups were an integral part oftreatment in cerebral palsy since that time physicaleducators have also advocated strengthening6. Then foryears, conventional clinical wisdom in Occupational therapyargued against the use of strength testing and training inchildren with cerebral palsy and indeed in all persons withcentral nervous system disorder because they thoughtstrengthening muscles cause increase in spasticity level(Bobath). Only recently has strength testing and trainingexperienced resurgence in habilitation and rehabilitationprogramme for this population and for other spastic motordisorders.

Methodology

Research design: Pre-test post-test control group design,with analysis of difference type of study.Research setting: child development clinic; LNJP Hospital,New DelhiIndependent variables: Strength training, ConventionalOccupational therapyDependent variable: Gross motor function, Spasticity,Range of motion.Sample design: Two groups of fifteen diplegic CP subjectseach which were conveniently selected. One group gotstrength training and conventional therapy (experimentalgroup) and other the group got conventional therapy alone(control group)Inclusion Criteria: Age group 2.5 year to 9.5 year of bothsexes i.e. both Male & female, Gross motor functionclassification score ranges I to III (Walk without limitation –walk with assistive device), Subjects should be able tocommunicate verbally, Spasticity involving lower extremityin the range of 1-2 score according to Modified AshworthScale (at hip, knee and ankle), Those subjects who was

4 Aditya Kumar / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

5

able to understand command and perform accordingly (IQ=70)Exclusion criteria: One who had undergone orthopedicsurgery within a period of 1 year prior to start of this study,Children who had taken botox (Botulinum toxin-A) 1 yearprior to the start of the study, Children who had history ofspasticity altering surgery (e.g. Beclofen pump, Selectivedorsal rhizotomy etc.), Children who had a proposedsurgery during the period of this study, Having congenitalanomalies associated with cerebral palsy, Those who hadcontracture/deformity in the lower limb, Those who do notcompleted the total of 18 sessions, Those who had severeassociated problem such as seizure and respiratoryproblems.Intervention Period: Thrice weekly sessions for Six weeksperiod with a gap of one day between two consecutivesessions, i.e. total of eighteen sessions, of 45 minutes each.Instruments used were: Inflatable ball Steps (Height20cm), Back pack, Free weight,Scales: Gross Motor Functional Classification Scale(GMFCS), Gross motor function measure (GMFM), ModifiedAshworth scaleProtocols: Apart from conventional therapy they were givenStrengthening exercises: Bilateral heel raises in which theparticipant stood on the edge of the table, Activities on lightweight portable steps (height 20cm), Bilateral half squatusing a large inflatable ball to guide the exercise, Isolatedquadriceps strengthening activities with graded weight,Isolated hip extensor strengthening activities, All are gradedwith backpack for increasing the resistance of strengtheningexercise program.Procedure: 30 diagnosed cases of spastic diplegic cerebralpalsy were selected on the basis of inclusion and exclusioncriteria and were randomly assigned as experimental andcontrolled group after taking written informed consent fromthe parents of all subjects who were included in the study.General pediatric occupational therapy Performa was filledalong with standardized scales like Gross Motor Functionalmeasure and Modified Ashworth Scale. After theassessment according to the group distribution they werefollowed protocols. The subjects of Experimental group(strength training group) were given strength trainingprotocol along with the conventional therapy protocol duringtheir sessions.

In the strength training program a gradual increase intheir resistance was done by adding free weight to eitherdirectly to the lower limb or to their back pack. Then all thesubjects were reassessed after the completion of eighteensessions to know the outcome of study using same scales.

Data analysis

SPSS software was used to analyze the data. The meanand standard deviation of the experimental and controlgroup were calculated at 0 week and at the end of 6th week.Paired student t test were used to analyze the effect oftreatment protocol with-in the group. Independent sample ttest were applied to know the effect between the groups.

After data analysis level of significance in the pair of preand post treatment with-in experimental group analysisshows for GMFM is (t=5.024, p=0.000), and for CrawlingKneeling subcomponent of GMFM is (t=4.728, p=0.000),and for standing subcomponent is (t=4.340, p=0.001), and

for Walking Running Jumping subcomponent came as(t=5.003, p=0.000)

This level of significance is not only shown for thesubcomponents of GMFM rather it shows for most of thecomponents.

In control group also shows level of significance in thepairs pre and post treatment thus showed marked change inthe GMFM score and its components, crawling kneeling,standing, walking running jumping of GMFM at p<0.05.GMFCS & GMFM Correlations shows relation of severitylevel to outcome of gross motor function measure and itscomponents. It was found that significant changes wereseen in the crawling and walking component (t=2.237,p=0.027) of the gross motor function measure with higherseverity level i.e. GMFCS-III Although more changes wereseen in other components also in children with greaterseverity but not up to significant level. In between groupanalysis i.e. between experimental group and control groupshows significant change in the experimental group withmean of the difference of post and pre-treatment scores is16.63, with their standard deviation 12.82, and meandifference for the control group is 4.21 with std deviation is2.02 with t value (3.705), p value (0.001), shows level ofsignificance at p<0.05. The data also shows significantchange in standing (t=3.295, p=0.03) and walking, running,jumping (t=3.919, p=0.001) component of GMFM scale.

Discussion

Cerebral palsy is the most common cause of physicaldisability affecting children. It results in an upper motorneuron syndrome characterized by positive feature such asspasticity, co-contraction, and clonus. There are alsonegative features such as weakness, loss of selective motorcontrol and balance deficit that are probably relevant tolocomotors prognosis and function. This clinical trialprovides important new evidence that, strength trainingprogramme can be an effective and feasible strategy forincreasing gross motor function in young children with

GMFM (with-in group)

0

20

40

60

80

100

GMFM Pr GMFM Po

Sco

re (

mean

)

Exp.

Table I: Participant characteristics

Characteristics Exp. Gr. Contr. Gr.(n=15) (n=15)

Age (yr) 4.416 3.462Sex M/F 10/5 4/11Religion H/M 11/4 10/5Rural/Urban 6/9 5/10GMFCS levelLevel II 8 8Level III 7 7GMFM ScorePre-treatment 68.201 69.014Post-treatment 84.84 73.23

Values are mean: Exp. Gr.-Experimental Group; contr. Gr.- Control Group,n - Number of subjects; M-Male; F-Female; H-Hindu; M-Muslim

Aditya Kumar / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

cerebral palsy. Equipments used in this protocol were verysimple, inexpensive and easily obtainable and hence thepatients could follow up the therapy program at home also.Crawling, kneeling (p=0.000), standing (p=0.001) andwalking, running, jumping (p=0.000) in the experimentalgroup suggest that strength training has positive effect onthe gross motor function in the children with spastic diplegiccerebral palsy. The control group gross motor functionmeasure (p=0.000), crawling (p=0.001), standing (p=0.000),walking running jumping (p=0.000) suggest that there wasimprovement with the conventional therapy also. Howeverindependent sample t test between the group suggest thatthere was more improvement in the experimented (strengthtraining) group than control (conventional therapy) group,thus indicating the effectiveness of the strength trainingprotocol. Independent sample t test with Gross motorfunctional classification scale shows that improvement wasmore in the children who were in the gross motor functionalclassification level III than level II. This suggests that greaterthe severity more is the improvement with strength trainingin young children with cerebral palsy. No significant valueof t test and no score change seen after the treatment in themodified ashworth scale (MAS) suggest that there was nochange in the spasticity after the strength training program

Conclusion

The progression of gross motor function measure scorein strength training group is more than the conventionaloccupational therapy group. The improvement in grossmotor function in spastic diplegic cerebral palsy children hasalso significant value for the community integration of suchchildren. Strength training is more effective in children whoare developmentally at lower level in terms of mobility. Nochange in the modified asworth score suggests that thestrength training has no effect on spasticity. Suggestingstrength training is not contraindicated for spastic musclegroups of spastic diplegic cerebral palsied child.

References

1. D. L. Damiano, Nicholas F Taylor, and Karen J Dodd“Should we be testing and training muscle strength incerebral palsy?” Developmental medicine and childneurology 2002, 44: 68-72

2. Luci Fuscaldi Teixeira-salmela, Sandra Jean Olney,Sylvie Nadeau “Muscle strengthening and physicalconditioning to reduce impairment and disability inchronic stroke survivors” Arch Phys Med Rehabilitation1999, 80: 1211-1218

3. C Andersson, W Grooten, M Hellsten et al. “Adult withcerebral palsy: walking ability after progressive strengthtraining” Developmental medicine and child neurology2003, 45: 220-228

4. D. L. Damino, J. Quinlivan, B. F. Owen et al “Spasticityversus strength in cerebral palsy: relationship amonginvoluntary resistance, voluntary resistance, voluntarytorque, and motor function” European journal ofneurology 2001, 8(Suppl. 5): 40-49

5. Mary Elizabeth Wiley, Daine L Damiano “Lowerextremity strength profiles in spastic cerebral palsy”Developmental medicine and child neurology 1998, 40:100-107

6. Lotta Ahiborg, Christna Andersson, Per Julin “Wholebody vibration training compared with resistancetraining: Effect on spasticity, Muscle strength and motorperformance in adults with cerebral palsy” JournalRehabilitation medicine 2006, 38: 302-308

7. Eileen G Fowler, Teresa W Ho, Fredrick I Dorey, et al.“The effect of quadriceps femoris muscle strengtheningexercises on spasticity in children with cerebral palsy.”Physical therapy 2001, Vol. 81, No. 6: 1215-1223

8. Karen J. Dodd, Nicholas F Taylor, Diane L. Damiano “Asystemic review of the effectiveness of strength trainingprogramme for people with cerebral palsy” Arch PhysMed Rehabilitation 2002, 83, 1157-1164

9. Sandy A Ross, Jack R Engsberg “Relation betweenspasticity and strength in individuals with spastic diplegiccerebral palsy.” Developmental medicine and childneurology 2002, 44: 148-157

10. Samuel CK Lee, Ann M Tokay “Strength training usingneuromuscular electrical stimulation for children withcerebral palsy” from website clinical trial.gov (2006)

11. Damitrios Patikas, Sebastian I. Wolf, Katrin Mund et al.“Effect of a postoperative strength training programmeon the walking ability of children with cerebral palsy: Arandomized controlled trial” Arch Phys MedRehabilitation, May 2006, vol. 87, 619-626

12. Michelle Kelly, Johanna Darrah “Aquatic exercise forchildren with cerebral palsy” Developmental Medicineand Child Neurology 2005, 47, 838-842

13. Carolyn Patten, Heather E. Brown et al. “Weakness andstrength training in persons with post stroke hemiplegia:rationale, method, and efficacy. Journal of rehabilitationresearch & development 2004, 41; 293-312

14. Lee SCK, Mc Carthy, Smith BT “Neuromuscularelectrical stimulation and volitional strength training on inchildren with cerebral palsy” 9th Annual conference ofthe international FES Society September 2004

15. Jenni Allen, Karen J. Dodd, Nicholas F. Taylor et al.“Strength training can be enjoyable and beneficial foradults with cerebral palsy” Disability and Rehabilitation2004; vol. 26, No. 19, 1121-1127

16. Nicholas F Taylor, Karen J Dodd, & Helen Mc Burney etal “Factors influencing adherence to a home basedstrength training program for young people with cerebralpalsy.” Physiotherapy 2004, 90: 57-63

17. Nicholas F Taylor, Karen J Dodd, & Helen Larkin “Adultswith cerebral palsy benefit from participating in astrength training programme at a communitygymnasium. Disability and rehabilitation 2004; vol. 26,No.19, 1128-1134

18. Diane L. Damiano & Paul G. Jenkins “Strengthening inindividual with cerebral palsy” combined section meeting2003

19. Karen J Dodd, Nicholas F Taylor, Graham H Kerr “Arandomize clinical trial of strength training in youngpeople with cerebral palsy. Developmental medicine andchild neurology 2003, 45: 652-657

20. Helen Mc Burney, Nicholas F Taylor, Karen J Dodd et al“A qualitative analysis of the benefits of strength trainingfor young people with cerebral palsy. Developmentalmedicine and child neurology 2003, 45; 658-663

21. Tamar Heller, Gui-shuang Ying, James H Rimmer, BethA Marks “Determinant of exercise in adult with cerebralpalsy” Public Health Nursing 2002,19, 223-231

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22. Jack R Engsberg, Sandy A Ross, Kenneth S Olree et al.“Ankle spasticity and strength in children with spasticcerebral palsy. Developmental medicine and childneurology 2000, 42: 42-47

23. Ellen Wood, Peter Rosenbaum “The gross motorfunction classification system for cerebral palsy: a studyof reliability and stability over time” DevelopmentalMedicine and Child Neurology 2000, 42, 292-296

24. Diane L. Damiano. “Functional outcomes of strengthtraining in spastic cerebral palsy.” Archives of physicalmedicine and rehabilitation. Vol. 79, February 1998;119-125

25. Shelley A. Sharp, Brenda J. Brouwer “Isokinetic strengthtraining of the hemiparetic knee: Effect on function and

spasticity” Arch Phys Med Rehabilitation, 1997, 78,1231-1236

26. Diane L. Damiano, Christopher L. Vaughan, Mark F.Abel “Muscle response to heavy resistance exercise inchildren with spastic cerebral palsy” Developmentalmedicine and child neurology 1995, 37: 731-739

27. Dennis G. O’ Connell, Robert Barnhart “Improvement inwheelchair propulsion in pediatrics wheelchair usersthrough resistance training: A pilot study” Arch PhysMed Rehabilitation, 1995, 76: 368-372

28. Diane L Damiano, Luke E Kelly, Christopher L Vaughn“Effect of quadriceps femoris muscle strengthening oncrouch gait in children with spastic diplegia” PhysicalTherapy 1995, 75: 658-667

Aditya Kumar / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Comparison of three different treatment protocols of low-energyradial extracorporeal shock wave therapy for management ofchronic plantar fasciitisAfaf A.M. ShaheenBasic Sciences Department, Faculty of Physical Therapy, Cairo University, Egypt

Abstract

Objective

The aim of this study was to compare the effectivenessof three different treatment protocols of low-energy radialextracorporeal shock wave therapy for management ofchronic plantar fasciitis.

Subjects

The study was double-blind randomized study. Forty fiveadult subjects were randomly divided into three equalgroups (I, II & III).

Methods

The treatment group (I) received 2000 impulses with 2.5bars and frequency of 8Hz, group (II) received 3500impulses with 3-3.5 bars and frequency of 8Hz while group( III) received 1000 impulses with 1.5 bars and frequency of4.8 Hz. All groups received total 3 sessions given at weeklyinterval. Pain and function of foot were measured atbaseline, after 3 weeks of treatment and after 6 weeks offollow up after the end of the treatment by visual analogscale and ankle-hind foot scale respectively.

Results

The results revealed significant reduction of pain andimprovement in function of the foot in all treated groups (I,II & III) (P<.0.0001), significant difference in pain andfunction scores between group I & III as well as betweengroup II & III and negative correlation between pain andfunction of the foot (r=-.44) after 6 weeks follow up.

Conclusion

Radial extracorporeal shockwave therapy significantlyimproves pain and foot function. The delivery of low-energyradial extracorporeal shock wave therapy 3 sessions givenat weekly interval with 2000 impulses, 2.5 bars andfrequency of 8Hz is the most effective treatment protocol interms of relieving pain and restoring the functional activity ofpeople suffering from chronic plantar fasciitis.

Key wards

Plantar fasciitis, low energy radial extracorporeal shockwave therapy, treatment protocol.

IntroductionPlantar fasciitis is the most common cause of heel pain

and accounts for approximately 11% to 15% of all footsymptoms requiring professional care in the adult1. Thecourse of the disease is typically self-limiting, and about90% of patients are successfully treated with nonsurgicalmeasures2. Shortening of the plantar fascia leads to chronicbone traction in the heel and formation of heel spurs. Thepreferred treatment is physiotherapy, with the aim ofsuppressing pain and restoring the mechanical function ofthe plantar fascia for gait improvement3. Shockwaves havebeen used for 15 years as an alternative treatment formusculoskeletal disorders4. The treatment consists ofmechanical acoustic waves that are transmitted throughliquid and gaseous media5. Their biological effect comesfrom the mechanical action of ultrasonic vibrations ontissues6. Shockwaves can be focal or radial. Focalshockwaves have high tissue penetration power (10 cm)and impact force (0.08–0.28 mJ/mm²). They producemechanical and biological effects of greater intensity,including destruction of fibrosis and stimulation ofneovascularization in treated tissues4,5. Radial Extracor-poreal shockwaves (rESWT) are pneumatic waves that aregenerated by air compressors. They transmit radially, withlower penetration (3 cm), less impact (0.02-0.06 mJ/mm²)and limited biological effect7. They have been shown to beeffective for treating musculoskeletal disorders that aremore superficial, with clinical results that are similar to thoseof focal shockwaves8. The effect of radial shockwaves isless intense, but they have been shown to causedisintegration of fibroses and calcifications and increaseblood circulation at the treated location5.

By reviewing the published trials it becomes obvious thatthe different treatment parameters of ESWT are of utmostimportance for the outcome of treatment9. It becomesapparent that pooling data of different treatment protocols inmeta-analyses or systematic reviews is critical10.Therefore, in assessing the effectiveness of ESWT inplantar fasciitis, only specific treatment protocols should beevaluated, and results could not be generalized. There isstill much debate over several issues surrounding ESWTthat have not been adequately addressed by the literaturelike shockwave dosage and number of sessions requiredfor therapeutic effect. Up to now there is no standardtreatment protocol for the treatment of chronic plantarfasciitis and researches are needed to ascertain the mostbeneficial protocol for patient care11.

The aim of the present study was to compare theeffectiveness of three different treatment protocols ofrESWT for management of chronic plantar fasciitis

Subjects and methods

Design of the studyThe present study was (double-blind) randomized

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clinical trial. After taking the ethical approval from theresearch committee of security forces hospital the patientswho fulfilled the inclusion criteria and provided writteninformed consent were divided randomly into 3 equalgroups I, II and III to receive either treatment protocol1,2,3 oflow energy rESWT respectively according to a computer-generated random numbers list.

SubjectsForty five female patients were recruited from

rheumatology and orthopedic clinics in security forceshospital. Patients were included if they are 18 years or older,described heel pain felt maximally over the plantar aspectfor at least 3 months. All the previously get unsuccessfulconservative treatment. Patients were excluded if any of thefollowing were present: generalized inflammatory arthritis,including ankylosing spondlitis, rheumatoid arthritis, anywound or skin lesion, pregnancy, severe infection, bleedingdisorder, oral and/or topical non-steroidal anti-inflammatorymedication in previous 2 weeks, local corticosteroid injectionin the previous month, oral glucocorticosteriods within theprevious 6 weeks.

Intervention and blindingLow-energy rESWT was provided by Swiss DolorClast,

Electro Medical System (EMS), Switzerland; shockwaveapparatus with 2000, 3500, and 1000 impulses without localanesthesia (LA). Subjects were placed in comfortableposition either prone or in the side on the examination tablewith the affected foot placed in supported position. Prior toshockwave application, the area of pain was marked withan X on the skin to assist in focusing the delivery of theshock waves and the hand-piece was coupled to theidentified area by using specific ultrasound coupling gel(EMS Electro Medical Systems). The treatment group Ireceived treatment protocol (1) which consisted of 2000impulses with 2.5 bars and frequency of 8Hz, group IIreceived treatment protocol (2) which consisted of 3500impulses with 3-3.5 bars and frequency of 8Hz while groupIII received treatment protocol (3) which consisted of 1000impulses with 1.5 bars and frequency of 4.8.Hz. All groupsreceived total 3 treatments given at weekly interval. Boththe patients and a single outcome assessor were blinded tothe therapy received. Pain intensity was measured usingvisual analog scale (VAS) score while the function of thefoot was measured by American Orthopedic foot and AnkleSociety (AOFAS) Ankle-Hind Foot scale score (AHFS) (painand range of motion domains) a validated rating scale whichincorporates assessment of pain (40%), function (50%) and

alignment (10%). The measurements were performed at thebase line, after 3 weeks of treatment and after 6 weeksfollow up after the end of the treatment. After treatment andat each follow-up visit, blinding was assessed by askingsubjects to identify which treatment they believed theyreceived. All subjects were instructed to eliminate athleticactivities and pain medication post therapy until 6 weeksfollow up evaluation.

Data analysis

The collected data were statistically analyzed to showthe means and standard deviations of the scores of pain andfunction of the foot for each group at base line and after 3weeks of intervention. Then, a comparative study wasconducted between the mean differences of the pre-intervention and post-intervention measures for pain andfunction of the foot for each group by using the paired- t.Last, comparative studies was conducted between baselinemeasures, post-intervention measures as well as betweenfollow up measures of pain and function for the three testedgroups I, II and III using the analysis of variance (ANOVA).In case of significance, a Tukey-Kramer MultipleComparisons Test was conducted to detect pairs of groupssignificantly different. Correlation between pain and functionof the foot were determined using the person (r) coefficientin pairs of groups which were significantly different.Confidence interval 95% was assigned so P value < 0.05was considered. Data were analyzed using statisticalpackage for social sciences (SPSS) version 10.1.

Results

There were no difference between studied groups I, IIand III with regard to gender, age, or body mass index(BMI). The characteristics of subjects were shown in table(1), the mean age of all subjects was 42±9.28 years, andthe mean BMI 32.6± 5.76 indicated that the subjects areobese.

The paired t-test used to compare pain and functionscores at the base line and after 3 weeks of treatment foreach treated groups (I, II & III). The results revealedsignificant reduction of pain and improvement in footfunction in all treated groups after 3 weeks of treatment(P<0.0001) with high percentage of differences after 3weeks of treatment and 6 weeks of follow up in comparisonwith base line. Fig. 1 (a and b).

The one-way ANOVA (Table 2) showed a non-significantdifference among mean of pain scores at base line as well

Fig. 1 (a & b): Mean and standard deviation of pain and function of the foot for treatment groups.

a b

Paired t-test, pain

9.1 9.2 9.1

3.9 3.7 3.6

0

2

4

6

8

10

12

Group I Group II Group III

Studied groups

VA

S

At base line After 3 weeks

P<0.0001 ***

paired t-test, foot function

48.844.544.5

74.878.379.33

0

10

20

30

40

50

60

70

80

90

Group I Group II Group III

Studied groups

AH

FS

At base line After 3 weeks

P<0.0001 ***

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as after 3 weeks of treatment while there was significantdifference between pain measures after 6 weeks of followup. Post hock test (Tukey-Kramer Multiple Comparisons)showed significant differences between Group I & III(P<0.001) and between Group II & III (P<0.05).Regardingto the scores of foot function there was non-significantdifferences among base line measures while there weresignificant differences between post-intervention measuresas well as between follow up measures. Post hock test(Tukey-Kramer Multiple Comparisons) revealed significantdifference only between Group I & III after 3 weeks oftreatment (P<0.05) while after 6 weeks of follow up therewere highly significant difference between Group I & III aswell as between Group II & III (P<0.01).

Discussion

The plantar fascia is one of the most important staticstructures that support the medial longitudinal arch. Plantarfasciitis occurs as a result of repetitive microtrauma at theorigin of the medial tuberosity of the calcaneus; tractionforces during support lead to inflammatory processes thatresult in fibrosis and degeneration12. Heel spurs and nervetrapping (medial calcaneal, lateral plantar or fifth-fingerabductor) can be associated with the inflammatory process.Women are affected more often than men. Plantar fasciitisis associated with obesity and the climacterium3. In thepresent study, patients were obese female with mean BMI32.6± 5.76, and their mean age was 42±9.28 years.According to the results of the present study significantreduction of pain and improvement in function of the foot inall treated groups (I, II & III) were observed after 3 weeks oftreatment (P<.0.0001) with high percentage of reduction ofpain 88.97% and improvement in function of foot 111.71%in group I after 6 weeks of follow in comparison with thebase line. The results also showed significant difference inpain scores between group I & III (P <0.001) as well as

between group II & III (<0.05) after 6 weeks of follow up . Inregard to the function of the foot, after 3 weeks of treatmentthere was only significant difference between group I & III(P<0.05) while after 6 weeks of follow up there wassignificant difference between group I & III as well asbetween group II & III (P <0.01). At 6 weeks follow updecreased severity of pain was associated withimprovement in foot function (r=-.44). Furthermore, nodecrease in the ROM of the first metatarsal-phalangeal jointwas observed, this result was confirmed by D’Andréa Greveet al3 in contrast to the findings reported in the literature13.In addition; there were no observed decreases in ankle-flexion or extension.

Blinding of subjects and assessment of the efficacy ofthe blinding are necessary to control the placebo effect.Many previous trials of rESWT for plantar fasciitis did notinclude blinding or assessment of blinding3.

The rationale for the use of ESWT for orthopedicconditions is based on stimulation of soft tissue healing bylocal hyperemia, neovascularization, reduction ofcalcification, inhibition of pain receptors and/or denervationto achieve pain relief and persistent healing of chronicinflammatory processes14. In regard to plantar fasciitis,ESWT has become an alternative therapy that may, in someparticipants, alleviate symptoms and prevent the need formore invasive interventions15.

Martin et al 16 and Crawford and Thomson17 reviewednumerous studies of nonsurgical treatment for plantarfasciitis such as stretching, cryotherapy, heel cushions andshoe inserts, night splints, custom-made orthotics, anti-inflammatory drugs, corticosteroid injection, andimmobilization and showed success rates ranging from 44%to 90% 2,18. Nevertheless, not more than limited evidenceof efficacy could be demonstrated18. For patients withchronic heel pain resistant to nonsurgical treatment, surgicalinterventions are suggested. Surgery, however, can beassociated with prolonged healing19 and did not provesuperior to ESWT 20. Extracorporeal shock wave therapyfor plantar fasciitis has been investigated in multiple well-designed, randomized, and placebo-controlled trials,providing evidence of effectiveness and safety oftreatment9,20,21.

Shock wave therapy has several advantages and shouldbe considered an effective and safe tool in the treatment of

Table 1: Characteristics of the three treatment groups with confirmeddiagnosis of the unilateral plantar fasciitis.

Groups sex Age (yrs) BMI Duration ofFemale (Mean ± SD) (Mean ± SD) complain

Group I 15 44.2±11.8 33.2±6.2 >3 monthsGroup II 15 43.6±7.8 31.8±6.03 >3 monthsGroup III 15 41.1±8.7 32.8±5.3 >3 months

Table 2: One-way ANOVA among baseline measures, post-intervention measures as well as follow up measures for pain and function of the foot.

Source df SS MS F.ratio P.valuePain At baseline Among Groups 2 .178 0.08889 0.116 0.8910

Within Groups 42 32.267 0.7683Total 44 32.444

Pain After 3 weeks Among Groups 2 .844 .422Within Groups 42 33.467 .797 .530 0.5926Total 44 34.311

Pain Follow up Among Groups 2 8.044 4.022Within Groups 42 18.933 .451 8.923* 0.0006Total 44 26.978

Function of the foot Among Groups 2 184.933 92.467At baseline Within Groups 42 3555.867 84.663 1.092 0.3448

Total 44 3740.800Function of the foot Among Groups 2 205.73 102.87After 3 weeks Within Groups 42 990.27 23.578 4.363* 0.0190

Total 44 1196.0Function of the foot Among Groups 2 326.98 163.49Follow up Within Groups 42 828.67 19.730 8.286* 0.0009

Total 44 1155.6*Significant at 0.05. F: F value df: Degrees of freedom.SS: Sum of squares. MS: Mean of squares. P: Probability value.After 6 weeks of follow up negative correlation between pain and function of the foot (r=-.44) was observed.

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chronic plantar fasciitis. As an alternative to surgery, it is anoninvasive technology, which has considerably lesscomplication.

Assessment of the published data clearly showed thatthe outcome is strongly dependent on the administeredtreatment protocol, and conclusions concerning theeffectiveness of ESWT must not be generalized for differenttreatment setups therefore the effectiveness has to beassessed for the different devices and treatment protocols11,19,20,22. In addition researches are needed to ascertain themost beneficial protocol for patient care. Multiple studieshave been published describing the treatment of painful heelsyndrome by ESWT, but only a few publications weredesigned in a manner likely to ascertain the most beneficialprotocol for plantar fasciitis. With differences from thepresent study Sabeti et al23 compared between two differenttreatments with navigated extracorporeal shockwavetherapy for calcifying tendonitis. Group I underwent threesessions of constant low-energy treatment (0.08 mJ/mm2;1000 impulses) with out local anesthesia, Group II receivedtwo middle-energy treatments (0.2 mJ/mm2; 2000 impulses)with subacromial anesthesia. They concluded that clinically,both groups improved significantly (P<0.0001) in regard topain and shoulder function.

It is difficult to compare the result of the present studywith other studies, which use different patient populations,shock wave device, energy sources, and treatmentprotocols. However the results of the current study may besupported by number of studies published recently usedone of the three treatment protocols applied in presentstudy. Number of studies15,24 investigated the effect 3 weeklytreatment sessions with1000 impulses of rESWT.

On other hand Verratti 25 applied rESWT with 3500shocks at frequency of no more than 8 Hz and a pressureof 3 to 3.5 bars. Significant alleviation of pain andimprovement of function were noted after 3 weeks oftreatment and 6-week follow-ups in the treatment groupcompared with the placebo group.

In addition the randomized clinical studies performed byshaheen26 and Gerdesmeyer et al27 confirmed that rESWTapplied with 2000 shocks and rat of 8 impulses per secondsignificantly improve pain, function and quality of lifecompared with placebo in patients with chronic plantarfasciitis. The significant differences between the studiedgroups in the present study may be explained by a numberof factors including technical difference, shock waveintensity, work pressure and frequency of application. Alsothe variation between groups may be due to duration ofsymptoms, thickness of lesion, and total dose of rESWT.Helbig et al28 have suggested that patients with chronicsymptoms are more likely to have a positive effect fromrESWT, since in their study longer duration of symptomscorrelated with greater success of therapy. They postulatedthat this difference in response is related to fragmentation ofthe relatively avascular, sclerotic biomechanically abnormalreparative tissue which encourages more effective healingin those with chronic symptoms. Finally the use of differenttreatment variables might lead to different overall results.

Conclusion

The results of the current study concluded that rESWTsignificantly improves pain and foot function. The patients

obtained nearly equal results after 3 treatment sessions withthree different treatment protocols without localanaesthesia. The results also concluded that the delivery ofrESWT 3 sessions given at weekly interval with 2000impulses, 2.5 bars and frequency of 8Hz is the mosteffective treatment protocol in terms of relieving pain andrestoring the functional activity of people suffering fromchronic plantar fasciitis. The results are satisfactory andmay reduce the need for surgery in a high percentage ofpatients

Acknowledgment

I am extremely grateful to Dr.Khaled Sultan Alzahrani,chief of physiotherapy department for his supportthroughout the period of my research. I am also grateful toall the physiotherapy staff at Security forces Hospital and allpatients participated in this research.

References

1. Buchbinder R: Clinical Practice. Plantar Fasciitis. N EnglJ Med 2004; 350:2159-2166.

2. Atkins D, Crawford F, Edwards J, Lambert M: ASystematic Review of Treatments for the Painful Heel.Rheumatology (Oxford) 1999; 38:968-973.

3. D’Andréa-Greve JM, Grecco MV, Santos-Silva PR:Comparison of Radial Shockwaves and ConventionalPhysiotherapy for Treating Plantar Fasciitis. Clinics2009; 64:97-103.

4. Ogden JA, Alvarez RG, Levitt R, Marlow M: Shock WaveTherapy (Orthotripsy) in Musculoskeletal Disorders. ClinOrthop Relat Res 2001; 387:22-40.

5. Ogden JA, Alvarez RG, Levitt RL, Johnson JE, MarlowME: Electrohydraulic High Energy Shock-WaveTreatment for Chronic Plantar Fasciitis. J Bone JointSurg Am 2004;86:2216-28.

6. Haake M, Buch M, Schoellner C, Goebel F, Vogel M,Mueller I, et al: Extracorporeal Shock Wave Therapy forPlantar Fasciitis: Randomised Controlled MulticentreTrial. BMJ 2003; 327:75-90.

7. Haupt G, Diesch R, Straub T, Penninger E, Frolich T,Scholl J, et al: Radial Shock Wave Therapy in HeelSpurs. Der Nieder Gelassene Chirurg 2002;6:1-6.

8. Gerdesmeyer L, Weil L, Maier M, Lohrer H, Frey C,Feder K, et al: Treatment of Painful Heel. Swiss DolorClast: Summary of Clinics Study Results-DA/PMAApproval. 2007. Available from: http://www.dolo-rclast.com/page_clinicalstudies.php

9. Malay DS, Pressman MM, Assili A, et al: ExtracorporealShockwave Therapy versus Placebo for the Treatmentof Chronic Proximal Plantar Fasciitis: Results of aRandomized, Placebo-Controlled, Doubleblinded,Multicenter, Intervention Trial. J Foot Ankle Surg 2006;45:196-210.

10. Thomson CE, Crawford F, Murray GD: The Effecti-veness of Extracorporeal Shock Wave Therapy forPlantar Heel Pain: A Systematic Review and Meta-Analysis. BMC Musculoskelet Disord 2005; 6:19.

11. Chung B, Wiley P: Extracorporeal Shock Wave Therapy.A Review. Sports Med 2002;32(13):581-865

12. Roxas M. Plantar Fasciitis: Diagnosis and TherapeuticConsiderations. Alt Med Rev 2005;10:83-93.

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13. Riddle DL, Pulisic M, Sparrow K: Impact of DemographicAnd Impairment- Related Variables on DisabilityAssociated with Plantar Fasciitis. Foot Ankle Int 2004;25:311-317.

14. Wang CJ, Huang HY, Pai CH: Shock Wave-EnhancedNeovascularization at the Tendon-Bone Junction: AnExperiment in Dogs. J Foot Ankle Surg 2002; 41:16 –22.

15. Rompe JD, Schoellner C, Nafe B: Evaluation of Low-Energy Extracorporeal Shock-Wave Application forTreatment of Chronic Plantar Fasciitis. J Bone JointSurg Am 2002; 84-A: 335–341.

16. Martin RL, Irrgang JJ, Conti SF: Outcome Study ofSubjects with Insertional Plantar Fasciitis. Foot Ankle Int1998; 19:803-811.

17. Crawford F, Thomson C: Interventions for TreatingPlantar Heel Pain. Foot Ankle Int 1998; 19:803-811.

18. Ogden JA: Extracorporeal Shock Wave Therapy forPlantar Fasciitis: Randomised Controlled MulticentreTrial. Br J Sports Med 2004; 38:382.

19. Speed CA, Nichols D, Wies J, Humphreys H, RichardsC, Burnet S, Hazleman BL: Extracorporeal Shock WaveTherapy for Plantar Fasciitis: A Double-Blind,Randomized, Controlled Trial. J Orthop Res 2003;21:937-940.

20. Rompe JD, Decking J, Schoellner C, Nafe B: ShockWave Application for Chronic Plantar Fasciitis inRunning Athletes: A Prospective, Randomized, Placebo-Controlled Trial. Am J Sports Med 2003; 31:268-275.

21. Rompe JD, Meurer A, Nafe B, Hofmann A,Gerdesmeyer L: Repetitive Low-Energy Shock WaveApplication Without Local Anesthesia Is More EfficientThan Repetitive Low-Energy Shock Wave Applicationwith Local Anesthesia in The Treatment of ChronicPlantar Fasciitis. J Orthop Res 2005; 23:931-941.

22. Gollwitzer H, Diehl P, von Korff A, Rahlfs VW,

Gerdesmeyer L: Extracorporeal Shock Wave Therapyfor Chronic Painful Heel Syndrome: A Prospective,Double-Blind, Randomized Trial Assessing the Efficacyof a New Electromagnetic Shock Wave Device. J FootAnkle Surg 2007; 46:348-357.

23. Sebti M, Dorotka R, Goll A, Gruber M, Schatz KD: AComparison of Two Different Treatments with NavigatedExtracorporeal Shock-Wave Therapy for CalcifyingTendonitis- A Randomized Controlled Trail. Wein KlinWochenschr 2007; 119(3-4):124-128

24. Wang CJ, Chen HS, Huang TW: Shockwave Therapyfor Patients with Plantar Fasciitis: A One- Year Follow-Up Study. Foot Ankle Int 2002; 23(3):204-207

25. Verratti G: Extracorporeal Shockwave Therapy for theTreatment of Plantar Fasciitis: Comparative Study ofFocused ESWT versus Combined Focused and RadialESWT. Servicios Medicos Ortho-Shock,Venezuela. 2006

26. Shaheen AA: Low-Energy Radial Extracorporeal ShockWave Therapy for chronic Plantar Fasciitis: ARandomized Control Study. Presented at the 12thInternational conference for faculty of physical therapy;March 4-6, 2008, Ciaro

27. Gerdesmeyer L, Vester J, Maier M, Weil Jr L, Weil Sr L,Russlies M, Stienstra J, Scurran B, Fedder K, Diehl P,Lohrer H, Henne, M, Gollwitzer H: Radial ExtracorporealShock Wave Therapy Is Safe and Effective in theTreatment of Chronic Recalcitrant Plantar Fasciitis:Results of a Confirmatory Randomized Placebo-Controlled Multicenter Study. Am J Sports Med2008:1-10

28. Helbig K, Herbert C, Schostok T, Brown M, Thiele R:Correlations between the Duration of Pain and theSuccess of Shock Wave Therapy. Clin Ortop 2001; 387:68-71

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The effect of insole on ground reaction forces of two-leggedvertical jumping for heading ball in flexible flat foot male subjectsAli Asghar ArastooAssistant Professor, School of Rehabilitation Sciences, Ahwaz Jundishapour University of Medical Sciences, Ahwaz, Iran

Abstract

Objectives

To determine the effectiveness of insole for flexible flatfoot subjects with and without insole during stance phase oftwo-legged vertical jumping on a force plate for heading aball.

Design

Randomized assignment of participants for thisprospective study.

Setting

To measure salient points of three dimensional groundreaction forces and some temporal events of these points.A force plate flush mounted in the floor was used.

Participants

Fifteen FF foot subjects and fifteen normal foot subjectsof male sex voluntarily participated in this study. The mean,±SD of age, height, and weight of the normal foot subjectswere 23.13, ±2.72 years, 176.40, ±5.03cm, and 69.55,±8.31 kg; and those of the FF foot subjects were 22.73,±2.31years, 174.60, ±4.13 cm, and 69.87, ±9.2 kg,respectively.

Results

The use of insole could not have significant effect onparameters regarding saggital and mediolateral directionsin the normal and FF foot subjects. Moreover, findings ofGRF related to vertical direction for maximum force due totake off and stance duration revealed significant differencesbetween the normal foot and FF foot subjects without insole(p< 0.05 respectively) and insignificant differences betweenthe normal foot and FF foot subjects with insole adoption(p> 0.05 respectively).

Conclusions

The results of this study revealed that the use of insolein the FF foot subjects can be significantly effective inincrease of stance time duration and decrease of magnitudeof GRF of take off as the main constitution of verticaljumping.

Key words

Flexible flat foot, ground reaction forces, insole, kinetics,vertical jumping.

Abbreviations

FF, flexible flat; FP, force plate; GRF, ground reactionforce(s); 3D, three dimensional

Introduction

Vertical jump is directly related to explosive muscularpower of the legs1. The foot is designed basically forstrength, flexibility, and coordinated movements. The foothas two major functions: (1) to support the body in standingand progression; (2) to lever it forwards in walking, runningand jumping2. The main kinetic role of this body part is totransmit throughout the body the stress that creates thelocomotor activities of walking, running and jumping. Theligamentous and bony arrangements of the foot structureform several arches of the sole. These arches assist the footin absorbing the shock of weight bearing and supporting thebody weight during walking, running and jumping.

The main supporting ligament of the longitudinal arch isthe plantar calcaneonavicular ligament, which acts as a"spring" by returning the arch to its normal position after ithas been stretched. Along with ligaments, the plantar fasciasupports the foot against downward force3. The shock oftake off and landing due to jumping activity is transmitted tothe foot or feet. The one-legged and two-legged verticaljumps are used by athletes to propel themselves into air invarious athletic circumstances. In the two-legged jump bothlegs are in contact with the ground during the stance phasetime. The shock of GRF is exerted to the lower extremitiesdue to soccer type two-legged jumps for heading ball. Thelower extremities are prone to injury if there is any form ofstructural foot deficit such as FF foot. Supports of thelongitudinal arch (i.e. insoles) can provide arch support forthe FF foot. In this connection, Wong et al4 stated that themedial side of the plantar surface may be more prone toinjuries, and that foot orthosis adoption, improved soccerboot design could be considered. In addition, James et al5defined foot orthosis a type of shim placed between the footnear its neutral position, so it can function more effectively.The purpose of this study was to measure the magnitude of3D GRF of two-legged vertical jumps for heading ball in thetwo groups of normal and FF foot subjects with and withoutinsole adoption and to investigate salient points of GRF andsome related temporal events differences.

Design, setting and participants

Participants

Fifteen individuals with normal foot and fifteenindividuals with FF foot of male sex voluntarily participatedin this study after giving informed consent. All subjectsparticipated in this study were amateur soccer players. The

Ali Asghar Arastoo / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

insole adoption this difference was significant (p= 0.001). Inaddition, the comparison between peak F2 in normal footand FF foot with insole adoption revealed an insignificantdifference (p> 0.05). The intervention of insole on the stancephase duration of two-legged vertical jumping is effective inall the foot conditions, i.e. comparison of normal foot withFF foot without insole adoption (p= 0.01), and FF footwithout and with insole adoption (p= 0.001). Moreover thiscomparison between normal foot and FF foot with insoleadoption revealed an insignificant difference (p= 0.12).

Abbreviations: max F1, maximum force of initial foot-FPcontact; max F2, maximum force due to exchange of bodyweight between both limbs; decel F, maximum dynamicdouble limb retraction to ensure early weight bearingstability; accel F, maximum double limb loading responsefor forward take off; transit time, time to transition of forcesfrom deceleration to acceleration; peak F1, maximum forcedue to weight acceptance during loading response; troughF, minimal force between two peak forces; peak F2,maximum force due to take off for two- legged verticaljumping; trough time, time to trough F; and stance time,duration of two-legged stance on force plate to perform two-legged vertical jump.

Discussion

This study was designed to evaluate the effect ofintervention of insole on kinetics and temporal parametersof various foot conditions (i.e. FF foot without and withinsole), and compared with those of normal foot duringdouble foot stance phase of two-legged vertical jumping.Stance phase progression takes place from heel contact tothe toe off. An overall consideration of findings revealed thefact that insole has a determinant effect on the dynamicparameters of FF foot jumping stance phase to bring themtoward the normal foot values. The magnitude of theaverage GRF in the mediolateral direction is relatively low invarious conditions of normal foot, FF foot without and withinsole i.e. 5.56, 6.11 and 5.77 of %BW vertical loadrespectively (table 1, and fig. 3). This finding is in fullagreement with Neumann7 who indicated this figure lessthan 5%. In addition, the magnitude of the average GRF insaggital direction is also relatively low in various conditionsof normal foot, FF foot without and with insole i.e. 14.00,14.39 and 15.79 of %BW vertical load respectively. Thisfinding is in agreement with Neumann7 and Perry8 whoreported this figure less than 20 and 25 %BW vertical loadrespectively (table 1, and fig. 4). With respect to GRF inmediolateral and saggital directions the intervention ofinsole with foot condition (i.e. FF foot with and withoutinsole) and normal foot did not show a significant interactionof these parameters (p> 0.05 respectively). This is a multifactorial phenomenon, first: the magnitude of these forces islow, and second: the horizontal shear force of mediolateraland saggital directions during walking and running areproduced due to exchange of weight from one limb to otherand retraction to ensure early weight bearing stabilityrespectively.8 Furthermore, two-legged stance prior tovertical jumping in this study, leads to a minimal need forexchange of weight between lower limbs. Again, this maybe considered as a reason for data collection regarding lowmagnitude of horizontal shear forces in this study.

The vertical loading revealed that the magnitude of GRF

in this direction is proportional to the rate of loading on thetwo limbs to prepare for two-legged vertical jumping and isdeterminant of peak F1, peak F2 and trough between twopeaks (fig. 2c). This statement is in full agreement withPerry8 who indicated that the rate of loading the limb iscreated by gait velocity. Vertical force curves of two-leggedvertical jumping in this study show that generally, in all footconditions (normal foot, FF foot with and without insole) thelevel of peak F1 is considerably less than the peak F2 (referto table 1 and figure 2c). However, Neumann7, Perry8 andArastoo9 reported an approximately homogenous levels ofvertical load peak of 1.2, 1.1 and 1.1 BW respectively duringcustomary walking in the normal subjects; this amountincrease to 2.5 BW during running.8 Furthermore, the laterresults differ somehow with finding of this study for peak F2(take off phase), i.e. 2.9, 3.2 and 2.8 BW approximately fornormal foot, FF foot without insole and FF foot with insoleadoption respectively. The increase of the second peakforce (peak F2) and time duration in compare to the firstpeak force (peak F1) in this study is due to the fact that thefirst peak occurs shortly after heel contact in response toweight acceptance for the stability of body over the bothfeet. Early transition of forces from deceleration toacceleration in saggital direction and trough in verticaldirection force plots (refer to fig. 2 b and c and table 1 fortransition and trough times respectively) reveals the fact thatthe second peak force (peak F2) occurs in early stance inresponse to an effective take off production for two-leggedvertical jumping. This finding is different from that ofNeumann7 and Arastoo9 who reported occurrence ofsecond peak force in terminal stance during preferred gait inthe normal subjects. The potential energy released from therapid drop of the body center of gravity is converted in tokinetic energy10 and makes the trough between thesepeaks [refer to fig. 2 (c) and table 1 (trough time)], an actthat add the simultaneous effect of ankle plantar flexors,knee and trunk extensors to support flight acceleration ofbody weight to accomplish maximal two-legged verticaljumping for heading ball. In this regard Williams et al statedthat all the muscles of the trunk, arms and legs may beinvolved, as primovers, fixators or stabilizers to accomplishjumping2. The findings of this study, regarding vertical GRFshow that there are not major changes between various footconditions with respect to magnitudes of the peak F1 andtrough F (table 1). Interestingly, the magnitude of the peakF2 in the FF foot individuals without and with insole is 29.8%BW more and 12.5 % BW less than that of the normal footindividuals respectively. These figures show that the use ofinsole leads to a decrease of vertical GRF equal to 42.3%BW in the FF foot subjects. This phenomenon maycontribute to the anatomical modification of the foot in the FFfoot individuals in consequent to use of insole and the effectof insole to support their medial longitudinal arch, and sobrings this value towards that of the normal foot individuals.This is because foot orthotics are designed to provide anexternal correction of structural imbalance in the foot toreduce or eliminate compensatory motion by allowing thefoot to function as nearly as possible around the neutralposition11. While there is a significant difference betweenpeak F2 of the normal and FF foot subjects without insole(p= 0.01), this difference is insignificant after the use ofinsole (p=0.2). This result looks acceptable becauseaccording to Imhauser et al while FF foot deformity caused

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15

mean ±SD of age, height, and weight of the normal footsubjects were 23.13 ±2.72 years, 176.40 ±5.03 cm, and69.55 ±8.31 kg; and those of the FF foot subjects were22.73 ±2.31 years, 174.60 ±4.13 cm, and 69.87 ±9.2 kg,respectively. All the test subjects assigned randomlysatisfied the following overall criteria: bilateral FF foot,sustain general physical health, no experience of operation,no apparent physical deficit, and ability to perform two-legged vertical jumps safely to head a ball. All subjectsnormally wore the same type of trainer shoes.

Instrumentation

A Bertec force plate rectangular in shape, 40 × 60 cmflush mounted in the floor and a specialized software for thekinetic data collection (provec 5.0) was used to collectbiomechanical data of two-legged vertical jumping [(MIE)Medical Research Ltd- UK]. This system which is quoted asstandard line of six-component load transducers measuresthe three orthogonal components of the load (GRF), alongwith the moments about the orthogonal axes (i.e. Fx, Fy, Fz,Mx, My, and Mz). GRF data were collected at 500 Hz.

A Yagami mirror box flat foot tester model FF-1 (YagamiInternational Trading CO., Ltd– Japan) was used to identifythe evidence of flat foot in the test subjects and Fiess linetest was followed to determine the grade of flat foot.6

In order to perform heading ball action with maximal two-legged vertical jump, a pulley system was employed tosuspend the ball above FP in the maximal convenientvertical height, adjusted for each individual subject.

Foot wear and insole

One type of off shelf insole made of a soft, durable, nonmoldable, poly -urethane of 2 mm thickness at forefoot and2 cm at medial longitudinal arch with longitudinal andmetatarsal arch supports was used for all the FF footsubjects (Gomed modle– Germany). In order to eliminatethe effect of footwear on the kinetic parameter of jumping,the different sizes of the same type of trainer shoes wereprovided for all subjects (Addidas type). The normal footsubjects wore a suitable size of footwear, while the FF footindividuals wore a suitable size of combination of footwearfitted with insole if appropriate for testing protocol. All thesubjects were wearing thin cotton-nylon socks.

Testing protocol

Prior to data acquisition, each subject walked andpracticed two-legged vertical jumping for several minutes inthe laboratory to accustom to the trainer shoes (and insoleif appropriate) provided for vertical jumping test. Themaximal vertical height was measured by Sargent test; thiswas an index height to suspend football by a rope and pulley

system to identify the most convenient two-legged verticaljump height to head a ball. A start point was marked 1.5 maway from the force plate. This was to ensure a steady stateof locomotion toward the target ball for all subjects. Subjectswere given enough time to make several trials, to performtwo-legged vertical jumps on the force plate, before datacollections (fig 1).

Three proper successful two-legged vertical jump shotsfor heading ball were taken per subject.The test procedure for data collection consisted of thefollowing test groups:I) Normal subjects wearing same shoes.II) FF foot subjects wearing same shoes without insole.III) FF foot subjects wearing same shoes with insole.

Statistical data analysis

Data collection at 500 Hz frequency provides thepossibility of precise tracing of GRF and time from thecorresponding plots in 3D (i.e. mediolateral, saggital andvertical). Because it is impossible to compare the GRF plotsof jumping entirely by simple visual assessments, kineticsand temporal parameters of salient points were selected asthe basis of analysis and discussion. These salient pointsare labeled on the 3D GRF plots of mediolateral, saggital,and vertical directions, in fig. 2 a, b and c, respectively. Forthe ease of the parametric study of these points betweengroups, the corresponding GRF were normalized withrespect to the percentage body weight (%BW). The datawere analyzed statistically using SPSS 15 statistical routine.The mean of data regarding three jump shots werecalculated for salient points, as the basis of descriptivestatistics. For the analysis of the group average data, theindependent t–test was used to compare the data of thenormal foot subjects with those of the FF foot subjectsbefore and after utilization of insole. In addition, the pairedt–test was employed to compare the data of the FF footsubjects with and without insole (significance levels set at0.05 in all tests).

Results

The mean values of the salient points (kinetics andtemporal) and force plots of tow-legged vertical jumping inmediolateral, saggital and vertical directions for variouscondition are shown in table 1 and figs 3, 4, 5 andrespectively. The statistical analyses of that figuresregarding mediolateral and saggital directions showed thatthe foot condition (normal and FF foot) dose not havesignificant interaction with intervention of insole (p> 0.05).According to these findings there were insignificantdifference between GRF parameters related to the verticaldirection regarding peak F1 and trough F (p> 0.05).However, for peak F2 in FF foot individuals with and without

Table 1: Mean and standard deviation (SD) of normalized 3D GRF (% BW) and temporal events time (S) for various foot conditions.

Mediolateral SaggitalVerticalVariables max F1 max F2 decel F accel F transit time peak F1 trough F peak F2 trough time Stance time

conditions mean ± mean ± mean ± mean ± mean ± mean ± mean ± mean ± mean ± mean ±(SD) (SD) (SD) (SD) (SD) (SD) (SD) (SD) (SD) (SD)

Normal foot 12.81 12.75 18.40 46.34 0.049 170.63 121.67 288.27 0.055 0.332(4.96) (7.49) (8.12) (14.61) (0.016) (57.13) (60.82) (26.81) (0.018) (0.058)

Flat foot 13.89 15.73 20.73 48.99 0.051 165.73 126.88 318.07 0.057 0.289(without Insole) (7.99) (7.66) (6.06) (13.89) (0.024) (76.99) (52.70) (57.84) (0.023) (0.028)

Flat foot 9.47 16.20 19.43 50.76 0.059 168.04 118.93 275.78 0.063 0.366(with insole) (12.29) (11.81) (5.14) (12.06) (0.013) (59.59) (42.34) (49.48) (0.015) (0.060)

Ali Asghar Arastoo / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

a pattern of medial shift in plantar pressure distribution,insole orthoses stabilized both the hindfoot and the mediallongitudinal arch12. The significant increase of stance time inthe FF foot subjects in consequent to utilization of insole incompare to the FF foot subjects without insole (p= 0.04)[figure 6 and table 1] supports the idea of effectiveness ofinsole to decrease vertical load of peak F2. This suggeststhat insole adoption enables the FF foot individuals for alonger period of push off and loading response anddevelopment of a more effective take off for jumping withdecrease of magnitude of vertical GRF through body in thesecond peak. This phenomenon is in full agreement withPrapavessis and Mc Nair who studied effects of instructionin jumping techniques and experience jumping on GRF13.These workers concluded that high GRF may be aprecipitating factor associated with an injury, where the siteof tissue damage would benefit from decreased forces.

Conclusions

In this study, we compared the effectiveness of insoleadoption intervention in the flexible flat foot individuals,during two-legged vertical jumping for heading ball withrespect to salient points of 3D GRF plots and some relatedtemporal events. The result show that the use of insole hasno significant effect on kinetics of the mediolateral andsaggital directions, while it has a significant effect on thepeak F2 of the vertical direction which is related to aneffective take off for two-legged vertical jumping. In the otherwords the insole adoption, improved the FF foot individualsshoe design enabled them for development of a moreeffective take off for vertical jumping coupled with decreaseof magnitude of vertical GRF through body. Hence, savesFF foot athletes from impact of high level deforming forcesto their feet.

Acknowledgements

.......................

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References

1. Plowman SA, Smith DL. Exercise physiology for health:fitness and performance. 2rd ed. Wolters Kluwerbuisiness: Lippincott & Wilkins; 2008. p. 540.

2. Williams PL, Warich R, Dyson M, Bannister LH. Gray'sanatomy. 3rd ed. Churchill Livingstone; 1989. p. 657.

3. Arnheim DD, Prentice WE. Principle of athletic training.Mosby-year book Inc; 1993. p. 180-82, 454-55.

4. Wong PL, Chamari K, Maode W, Wisloff U, Hong Y.Higher pressure on the medial side in four soccer-related movements. British Journal of Sport Medcine2007; 41(2): 93-100.

5. James SL, Baten BT and Ostering LR. Injuries torunners. American Journal of Sports Medicine 1978; 6:40-50

6. Magee DJ. Orthopedic physical assessment. 4rd ed.Elsevier Sciences 2006; 807-808

7. Neumann D. A. Kinesiology of the musculoskeletalsystem- foundation for physical rehabilitation. MosbyInc; 2002. p. 551- 54.

8. Perry J. Gait analysis- normal and pathologic function.Slack Incorporated; 1992. p. 415-18.

9. Arastoo A A. Biomechanical and physiological charac-terization of locomotor impairment. PhD ThesisUniversity of Strathclyde, Glasgow, UK. 1992; 121-22

10. Kirtley C. Clinical gait analysis- theory and practice.Elsevier Churchill Livingstone 2006; 166

11. D΄Ambrosia RD. Orthotics devices in running injuries.Clinics in sports medicine 1985; 611-194

12. Imhauser CW, Abidi NA, Frankel DZ, Gavin K, andSiegier S. Biomechanical evaluation of the efficacy ofexternal stabilizers in the conservative treatment ofacquired flat foot deformity. Foot Ankle Int 2002; 23(8):727-37.

13. Prapavessis H, McNair PJ. Effects of instruction injumping technique and experience jumping on groundreaction forces. The Journal of Orthpedic & SportPhysical Therapy 1999; 29(6): 352-56.

16 Ali Asghar Arastoo / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

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Adaptability in nature – Are lungs moldable?Amrith PakkalaDept. of Physiology, PES Institute of Medical Sciences & Research, Kuppam, AP, India

Abstract

Background

Adaptability of the healthy pulmonary system indelivering oxygen to meet the demands of various degreesof exercise has been a topic of considerable debate. Oneview holds that the respiratory system is not normally themost limiting factor in the delivery of oxygen, others hold theabsence of structural adaptability to physical training causeof limitation of the pulmonary system.

Methods

Pulmonary Function Tests were done before & aftermaximal exercise testing to assess dynamic lung functionsin two groups viz., athletes & non-athletes.

Results

On studying the differences in dynamic lung functions intwo groups of non-athletes and athletes, there was nodifference in FVC& FEV1, before or after exercise testing ineither. The other flow rates MMEF, PEFR, MEF 25% to 75%were on the higher side in trained subjects which wasconsistently maintained after exercise testing. A higheradaptability of the respiratory system to the training stimulusin the form of a higher elastic recoil pressure of the lungsand a lower resistance of medium to small airways issuggested as the mechanism of adaptability in this study.

Key Words:- Adaptability, Healthy Pulmonary system,Exercise Testing, Airflow Limitation, Dynamic LungFunctions.

Introduction

There has been a considerable debate on theadaptability of the healthy pulmonary system in deliveringoxygen to meet the demands of various degrees ofexercise. Some authors believe that the respiratory Systemis not normally the most limiting factor in the delivery ofoxygen to the muscles during maximal muscle aerobicmetabolism¹.

Mechanical constraints on exercise hyperpnoea havebeen studied as a factor limiting performance in enduranceathletes’². Others have considered the absence of structuraladaptability to physical training as one of the “weaknesses”inherent in the healthy pulmonary system response toexercise³.

Dynamic lung functions are an important part offunctional diagnostics4, aiding selection and optimization oftraining and early diagnosis of sports pathology.

Assessment of exercise response of dynamic lung functionsin the healthy pulmonary system in the trained and theuntrained has a role in clearing gaps in the above areas.

Material and methods

The present study was conducted in the department ofphysiology, Karnataka Institute of Medical Sciences, Hublias a part of cardio-pulmonary efficiency studies on twogroups of non-athletes (n=30) and athletes (n=30)comparable in age & sex.

Informed consent was obtained and clinical examinationto rule out any underlying disease was done. Healthy youngadult males between 18-25 years who regularly undergotraining and participate in competitive middle distance (800metre, 1500 metre) running events for at least past 2 yearswere considered in the athlete group whereas the non-athlete group did not have any such regular exerciseprograme. Smoking, clinical evidence of anaemia, obesity,involvement of cardio-respiratory system was considered asexclusion criteria.

Detailed procedure of exercise treadmill test andcomputerized spirometry was explained to the subjects.

Dynamic lung functions were measured in both groupsbefore exercise was evaluated following standard procedureof spirometry using computerized spirometer Spl-95. Allsubjects were made to undergo maximal exercise testing toVO2 max levels on a motorized treadmill.

After exercise, the assessment of dynamic lungfunctions were repeated. All these set of recordings weredone on both the non-athlete as well as the athlete groups.

Statistical analysis was done using paired students t-testfor comparing parameters within the group before & afterexercise testing and unpaired t-test for comparing the twogroups of subjects.

A p-value of < 0.01 was considered as significant.

Discussion

Considerable information can be obtained by studyingthe exercise response of dynamic lung functions inuntrained and trained subjects.

Intra group comparison is helpful in noting the exerciseresponse and inter-group comparison in evaluatingadaptations of the respiratory system to training.

On comparing the anthropometric data of the two studygroups it is clear that the age & sex matched subjects haveno statistically significant difference in height, weight & BMItaking a p- value of <0.01 as significant.

VO2 max values were higher in athletes and wasstatistically significant (P< 0.001). This observation isexpected in view of the training stimulus and adaptability ofboth the pulmonary system and the cardio vascular system.

Amrith Pakkala / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

VO2 max is an objective index of the functional capacity ofthe body’s ability to generate power.

Forced vital capacity (FVC) is the volume expired withthe greatest force and speed from TLC and FEV1 thatexpired in the 1st second during the same manoeuvre. TheFEV1 was initially used as an indirect method of estimatingits predecessor as the principal pulmonary function test, themaximal breathing capacity5.

On comparing the response of exercise within the twostudy groups and in between them, there is no statisticallysignificant difference in FVC & FEV1 under any condition.

A normal FEV1/FVC ratio is observed always.Another way of looking at forced expiration is to measure

both expiratory flow and the volume expired. The maximumflow obtained can be measured from a flow –volume curveis the peak expiratory flow rate (PEFR). The peak flowoccurs at high lung volumes and is effort dependent. Flowat lower lung volumes is effort independent. Flow at lowerlung volumes depends on the elastic recoil pressure of thelungs and the resistance of the airways upstream or distal tothe point at which dynamic compression occurs.Measurements of flow at low lung volumes, mid expiratoryflow [MEF 25% to 75%] are often used as indices ofperipheral or small airways resistance5.

On examining Table 2 & Table 3 it is clear that exerciseper se does not cause a statistically significant change indynamic lung function parameters MMEF, PEFR, MEF 25%to 75% in either of the groups. This finding supports thehypothesis that the respiratory system is not normally themost limiting factor in the delivery of oxygen.

On comparing dynamic lung functions in terms of theabove flow rates of non-athletes & athletes before exercise[Table 4] it is seen that athletes have higher MMEF, PEFR,MEF 25% TO 75%. This suggests a higher adaptability ofthe respiratory system to the training stimulus.

These changes are consistently maintained aftermaximal exercise testing [Table 5] suggesting a higherelastic recoil pressure of the lungs and a lower resistance ofmedium to small airways in response to exercise as a resultof adaptive mechanisms in the pulmonary system.

Results

References

1. Guyton AC, Hall JE, editors–Text Book of MedicalPhysiology, 11th ed .Saunders, 2006 :1061-62.

2. Johnson BD, Saupe KW, Dempsey JA –Mechanicalconstraints on exercise hypernea in endurance athletes.J Appl Physiol 1992 Sep;73(3) : 874- 86

3. Dempsey JA, Johnson BD, Saupe KW-Adaptations andlimitations in the pulmonary system during exercise.Chest 1990 Mar; 97(3 Suppl):81s –87s

4. Andziulis A, Gocentas A, Jascaniniene N, Jaszczanin J,Juozulynas A, Radzijewska M –Respiratory functiondynamics in individuals with increased motor activityduring standard exercise testing. Fiziol ZH 2005;51(4):80-95.

5. Seaton A, Seaton D, Leitch AG, editors –Crofton andDouglas’s Respiratory Diseases, 5th ed. Oxford: OxfordUniversity press, 2000:43-45

Table 1: Comparison of anthropometric data & VO2 max of non-athletes &athletes with statistical analysis.

Parameter Non-Athletes Athletes T-value P- value RemarksAge (Yr) 21.50 ± 2.62 21.46 ± 2.84 0.05 < 0.10 NSHeight (cm) 169.70 ± 7.50 165.90 ± 7.24 1.94 < 0.10 NSWeight (kg) 62.66 ± 5.64 59.43 ± 6.26 2.06 <0.05 NSBMI (kg/m²] 22.02 ± 2.47 21.60 ± 1.75 0.74 < 0.10 NSVO2 max 2.3±0.16 3.1±0.27 13.0 < 0.001 HS(lit/min)

Table 2: Comparison of Dynamic Lung Functions of Non- Athletes beforeexercise testing (BE) & after exercise testing (AE) with statistical analysis.

NON-ATHLETES (n=30)

Parameter BE AE T-value P- value RemarksFVC (L) 3.58 ± 0.52 3.34 ± 0.56 1.84 < 0.10 NSFEV1 (L) 3.50 ± 0.50 3.25 ± 0.05 2.08 < 0.05 NSFEV1/FVC 0.95 0.96MMEF (L/S) 4.95 ± 1.31 4.96 ± 1.46 0.02 < 0.10 NSPEFR (L/S) 7.22 ±1.78 6.75 ±1.96 1.00 < 0.10 NSMEF 75(L/S) 6.41 ±1.94 5.85 ±1.74 1.22 < 0.10 NSMEF 50(L/S) 5.43 ± 1.44 5.40 ± 1.63 0.08 < 0.10 NSMEF 25(L/S) 3.45 ± 1.16 3.69 ± 1.47 0.75 < 0.10 NS

Table 3: Comparison of Dynamic Lung functions of Athletes before exercisetesting (BE) & after exercise testing (AE) with statistical analysis.

ATHLETES (n=30)

Parameter BE AE T-value P- value RemarksFVC (L) 3.31 ± 0.39 3.11 ± 0.30 2.50 < 0.05 NSFEV1 (L) 3.27 ± 0.30 3.09 ± 0.30 2.57 < 0.05 NSFEV1 /FVC 0.99 0.99MMEF (L/S) 6.00 ± 1.21 6.45 ± 1.07 1.66 < 0.1 NSPEFR (L/S) 8.75 ±1.09 8.58 ± 0.84 0.77 < 0.1 NSMEF 75(L/S) 8.27 ±1.28 8.13 ±1.13 0.46 < 0.1 NSMEF 50(L/S) 6.39 ± 1.20 6.83 ± 0.92 0.76 < 0.1 NSMEF 25(L/S) 4.34 ± 1.11 5.02 ± 1.05 2.51 < 0.05 NS

Table 4: Comparison of Dynamic Lung function of Non-Athletes & Athletesbefore exercise testing with statistical analysis.

ATHLETES (n=30)

Parameter Non-Athletes Athletes T-value P- value RemarksFVC (L) 3.58 ± 0.52 3.31 ± 0.39 2.45 < 0.05 NSFEV1 (L) 3.50 ± 0.50 3.27 ± 0.30 2.30 < 0.05 NSFEV1 /FVC 0.95 0.99MMEF (L/S) 4.95 ± 1.31 6.00 ± 1.12 11.66 < 0.001 HSPEFR (L/S) 7.22 ±1.78 8.75 ± 1.09 11.76 < 0.001 HSMEF 75(L/S) 6.41 ±1.94 8.27 ±1.28 4.53 < 0.001 HSMEF 50(L/S) 5.43 ± 1.44 6.39 ± 1.20 3.00 < 0.01 SMEF 25(L/S) 3.45 ± 1.16 4.34 ± 1.11 3.17 < 0.01 S

Table 5: Comparison of Dynamic Lung function of Non-Athletes & Athletesafter exercise testing with statistical analysis

Parameter Non-Athletes Athletes T-value P- value RemarksFVC (L) 3.34 ± 0.56 3.11 ± 0.30 2.09 < 0.05 NSFEV1 (L) 3.25 ± 0.50 3.09 ± 0.30 1.60 < 0.1 NSFEV1 /FVC 0.96 0.99MMEF (L/S) 4.96 ± 1.46 6.45 ± 1.07 4.80 < 0.001 HSPEFR (L/S) 6.75 ±1.96 8.58 ± 0.84 4.94 < 0.001 HSMEF 75(L/S) 5.85 ±1.74 8.13 ±1.13 6.33 < 0.001 HSMEF 50(L/S) 5.40 ± 1.63 6.83 ± 0.92 14.30 < 0.001 HSMEF 25(L/S) 3.69 ± 1.47 5.02 ± 1.05 4.29 < 0.001 HS

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Effect of performing a cognitive task on gait performance inpatients with hemiparesis following stroke of greater than threemonths durationAngusamy R.*, Chandbibi. M.Y.***Lecturer, M.P.Th (Neurology), Chandiwala Institute of Physiotherapy, New Delhi, India, **Lecturer, M.P.Th (Neurology),College of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia

Abstract

Background and purpose

Therapist rehabilitating patients mobility following strokeneed to take account of the evidence that cognitiveresources are drawn upon walking. Only few studiesreported the changes in gait performance in patients withstroke during dual-task walking. Therefore, this study isaimed to examine the effect of cognitive task performanceon the T-D parameters of gait in patients with stroke.

Sample

30 subjects with single CVA of greater than three monthsduration were included in the study.

Design

Pretest and Post-test design

Methods

Measurements were taken in two conditions: a) Walkingalone, b) walking with cognitive task- Subjects wereinstructed to enumerate names of animals or names offlowers while walking. Two measurements were taken onthe two different days.

Results

All subjects demonstrated statistically significant(p<0.05) decrement in gait T-D parameters while walkingwith cognitive task as compared to walking alone.

Conclusion

Performing a cognitive while walking resulted indecrement of gait T-D parameters in patients with stroke.

Key words

Dual-Task, cognition, Gait, Stroke

Difficulty in walking is a major feature of neurologicaldisease1 and loss of mobility is the activity of daily living onwhich the patient place most value2. Among all neurologicaldiseases, stroke is one of the leading cause of walkingdisability in the elderly and a significant source of disabilityin younger adults3. 75% of individuals who sustain strokeeach year report limitation in mobility that is usually relatedto walking4. While the majority of stroke survivors will regainsome ability to walk, 40% will require assistance with

walking and of those who are independent, 60% will belimited in community ambulation5.

Relearning to walk independently is a commonrehabilitation goal of stroke survivors6. Normal gait is multi-factorial in terms of its underlying cortical motormechanisms, which gives rise to the possibility thatcognitive processes are differentially related to gaitperformance7.

During many activities of daily living people need toperform more than one task at a time8. The capacity to do asecond task is highly advantageous during walking becauseit allows for communication between people, transportationof objects from one location to another, and monitoring ofthe environment so that threats to balance can be avoided8.

Dual- task performance is also known a “concurrentperformance”9. Dual tasking, that is, engaging in twoactivities at the same time is common in daily living9. Acommon method used to quantify the automaticity of motorskills is the dual-task paradigm10. Dual-task performanceinvolves the execution of a primary task, which is the majorfocus of attention, and a secondary task performed at thesame time. If the two tasks can be performed as wellsimultaneously as separately, then at least one task seemsto be automatic10. On the other hand, if one task (e.g.walking) is performed less well when it is combined with theother task (e.g. talking), then both tasks must be non-automatic. Performance decrement in the secondary taskas a result of the simultaneous performance of a primarytask is termed a dual-task interference effect10. Hence, theextent of the decrement in the secondary task whenperformed with the primary task compared to whenperformed alone provides a measure of the attentionaldemands (cognitive regulation) of the primary task10.

Dual-task paradigms typically are used for two differentpurposes11. One is to investigate the attentional demandsof a motor task and the other is to examine the effects ofconcurrent cognitive or motor tasks on motor performance.The later is sometimes referred to as a divided attention or“time-sharing” paradigm11.

When the dual-task paradigm is used to assessattentional demands, individuals usually are instructed tomaintain a given level of performance on the primary taskunder dual-task conditions11. Provided that primary taskperformance is maintained at baseline level under dual-taskconditions, any change in the performance of the secondarytask relative to baseline is taken as an indicator of theattentional demands of the primary task11. When thedemands of the concurrent tasks exceed the availableprocessing capacity, deterioration in performance of one orboth tasks is expected8,9,11. When dual-task methodology isused to investigate the effects of divided attention, subjectstypically are instructed to give equal priority to primary andsecondary task performance11,12.

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Cognitive processing plays an important role in motorperformance13. A series of cognitive processes areproposed to be involved in executing a motor skill, includingstimulus identification, response selection, and schemaretrieval from long-term memory13. Attention, described asthe capacity or resources for processing information, is onecognitive factor that is thought to affect motorperformance11. Researchers have used a dual-taskparadigm to investigate the attentional demands of motortasks and the effects of concurrent cognitive or motor taskson motor performance11,15.

Traditionally, stability in standing or walking has beenconsidered an automatic or reflex controlled task requiringmotor responses to sensory stimuli, but requiring minimalcognitive resources16. In contrast, more recent evidencesuggests that maintaining stability during either standing orwalking requires both cognitive and sensorimotorprocesses16. Dual task paradigms are used to examine theeffect of cognitively demanding tasks on primary activitiessuch as standing or walking16.

Studying the effects of concurrent task on motorperformances like walking may be important forphysiotherapists. These effects provide insights into thechanges in performances that may be expected when anindividual with stroke is required to do two things at once.Under these circumstances, attention is divided or sharedbetween the primary motor task and an additional cognitiveor motor task14. When motor skills become highly learnedor automatic, concurrent task are expected to produce littleinterference, and to have little effect on motorperformance15,14.

Dual task methodology has been used to examine theattentional demands of postural tasks. The inferencebetween postural and cognitive task in young healthy adultsis well documented87. Relatively limited number of studiesexamined6,24,8,14,16 the interplay between cognitive processesand gait involving simultaneous performance of cognitiveand motor tasks, in order to examine the relationshipbetween cognition and walking.

Movement involves not only motor skills, but is alsoreliant on sensory and cognitive system6 Therapistrehabilitating patients mobility following stroke need to takeaccount of the evidence that cognitive resources are drawnupon walking11. Few studies have reported changes in gaitperformances in people with stroke during dual-walkingtesting in a clinical environment6,24. Bowen et al6 noted asignificant decrease in gait speed and a significant increasein double-support time when a cognitive activity was addedto a walking test for people with stroke. Hoggard andCockburn24 reported a 1% decrement in stride duration anda simultaneous 4% decrement in cognitive taskperformances under dual-task condition for 50 peopleundergoing neurological rehabilitation that included 11people with stroke24.

By adding concurrent cognitive or motor task duringclinical examination and measuring changes in simpletemporal or distance variables, therapist may be able todetermine stroke patient’s abilities to perform motor task“automatically” or at least to divide attention between tasks.If therapists have information about how cognitive taskinfluences motor performances, they may be able to designmore effective interventions. This can be done by selectingmotor tasks, structuring the environment, and providing

instruction and feedback in a manner that is more consistentwith stroke patient’s abilities.

Only few studies examined the effect of concurrentperformance on Temporal Distance parameters of gait inpatients with chronic stroke. Therefore, this study is aimedto examine the effect of dual task performance on the T-Dparameter of the gait while performing a cognitive task andwalking with or without their own walking aid in patients withhemiparesis following stroke of greater than three monthsduration

Sample

Thirty patients, ranging in age from 35-65years, allhaving suffered a single completed stroke, between 4months to 2 years with residual hemiparesis with secondaryto vascular accident were included in the study. All subjectswere able to communicate and follow instructions. Allsubjects were able to walk independently with or without anassistive device. The subjects were recruited from the outpatient department of the Physiotherapy unit, G.B.panthospital, New Delhi. The inclusion criteria were-Hemiparesisas a result of a single CVA of greater than 3 monthsduration, able to walk independently with or without theirown walking aid and medically stable. The sample werescreened to ensure exclusion criteria of such factors as-ahistory of previous CVA and other neurological disease,MMSE <24/100, receptive aphasia, serious hemianopia andother conditions that affect mobility like arthritic disease andspinal deformity.

Design

Pretest and Post-test design.The following materials were used for data collection 26

inches wide and 5 meters long white paper, measuring tape,digital stop watch, bottled inks of two different colors,adhesive tape, and painting brush.

Procedure

Prospective participants were explained about thepurpose and nature of the study and an informed consentobtained from subjects willing to participate in the study.Preliminary data such as diagnosis, age, gender, andduration of onset of hemi paresis were obtained from patientinterviews and medical charts. A detailed neurologicalassessment of every subject was done. Prior to testing,each subject completed a Mini Mental State Examination toensure his or her general cognitive ability met the inclusioncriteria.

Two walking condition were used for data collection. a)Walking with or without their own walking aid. b) Walkingwith cognitive task and with or without their own walking aid.The test performances were selected in random manner.Cognitive task, involves verbal task i.e. enumerating outloud as many animal names as possible or names offlowers. For data collection, the subjects were made to walkalong a twelve-meter walkway with their own footwear. Themiddle five-meter of the walkway was covered with whitechart paper. The subject was seated on a chair at one endof the walkway. Two different color inks were applied to thepatient’s feet with the help of simple brush.

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The subjects were then instructed to stand at the oneend of the walkway and given the command to walk as fastas possible for taking the measurement. The subjects weregiven one practice trial along the walkway, before taking theexperimental measurement subsequently. Subjects weretold to look straight ahead while walking and had to continueto walk till the end of the twelve – meter walkway. Thestopwatch was used to record the time taken by the subjectto cross the ten meters along the walkway was noted. Thetime taken to walk first and last one meter of the walkwaywas eliminated because of the changes in velocity thatoccur when a person starts and stops walking. The numbersof steps taken by the person to walk ten meters werecounted by myself for calculating the cadence.

Ink prints (foot prints) of the three consecutive gait cycleswere taken from the middle portion of the walkway tocalculate the final values21,22. Footprints were used tomeasure stride length and step length21,22. After completionof the first walking condition the subjects were instructed towalk with the cognitive task that is they were instructed toenumerate out animals or flowers name while walking onthe walkway. One practice was given to the subject to getused to the task while walking. The measurement for thetwo walking condition were done on two different days. Allthe T-D parameters that is stride length, step length,cadence and walking speed were also measured for thesecond condition in a similar manner as the first walkingcondition.

Data analysis

Analysis was performed by using the SPSS version 12for windows software. Descriptive statistics was used toanalyze mean age, height, weight of the subjects. Studentst Test was used to compare the pre test and post test T-Dparameter values. In all cases significance was set atp<0.05.

Results

Table1 shows the demographic profile of the subjects.Table 5.2 shows the mean and standard deviation of theoutcome variables. Pre-test and post –test comparisonshows statistically significant difference in all the Temporal-Distance parameter of the gait in persons with hemiparesis

following stroke of greater than three months duration whilewalking with cognitive task as compared to walking alone.

Stride LengthThere was a significant decrement (p<0.05) in the post

test affected side stride length (ASTRL2 = walking withcognitive task), as compared to pre test condition(ASTRL1=walking alone).

ASTRL1 (Mean±SD) = 87.72±21.65ASTRL2 (Mean±SD) = 77.51 ± 18.34

There was a significant decrement (p<0.05) in the posttest normal side stride length (NSTRL2=. walking withcognitive task), as compared to pre test condition(NSTRL1=walking alone).

NSTRL1 (Mean±SD) = 88.63±22.21NSTRL2 (Mean±SD) = 79.68±19.39

Step LengthThere was a significant decrement (p<0.05) in the

affected side step length (ASTPL2=walking with cognitivetask), as compared to pre test condition (ASTPL1= walkingalone).

ASTPL1 (Mean±SD)= 43.13±9.52ASTPL2 (Mean±SD)= 37.92±8.75

There was a significant decrement (p<0.05) in thenormal side step length (NSTPL2=walking with cognitivetask) as compared to pre test condition (NSTPL1= walkingalone).

NSTPL1 (Mean±SD)= 46.46±10.99NSTPL2 (Mean±SD)= 40.59±9.35

CadenceThere was a significant decrement (p<0.05) in the post

test cadence2 (walking with cognitive task), as compared topre test cadence. (Walking alone).

Cadence1 (Mean±SD)= 81.27±19.37Cadence2 (Mean±SD)= 69.50±20.42

SpeedThere was a significant decrement (p<0.05) in the post

test speed 2 (walking with cognitive task), as compared to

Table 1: Demographic Profile of the Patients

Sex Age H. T W. T Dura. MMSEMale 52.10 165.00 65.73 9.5 81.10

(N=19) ±5.30 ±7.00 ±4.54 ±6.0 ±10.00Female 50.54 162.00 63.44 13±7 82.86(N=11) ±6.57 ±8.40 ±9.75 ±9.16

H.T.= Height, W.T= Weight, Dur.= Duration

Table 2: Comparison of Pre and Post Test Temporal-Distance Parameters

T D Parameters Pre test1 Post test2 t p ASTRL 87.72±21.65 77.51±18.34 6.53 0.00NSTRL 88.63±22.21 79.68±19.39 5.80 0.00ASTPL 43.13±9.52 37.92±8.75 5.47 0.00NSTPL 46.46±10.99 40.59±9.35 5.93 0.00CAD 81.27±19.37 69.50±20.42 4.48 0.00SPD 1.03± 0.40 0.83±0.34 7.05 0.00

ASTRL = Affected stride lengthNSTRL = Normal stride length ASTPL = Affected step lengthNSTPL = Normal step lengthCAD = CadenceSPD =Speed

Fig. 1: Comparison of Pre and Post Test Distance Parameters.

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Fig. 2: Pre Vs Post Test Comparison of Cadence.

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pre test condition (walking alone).Speed1 (Mean±SD)= 1.03±0.40Speed2 (Mean±SD)= 0.83 ± 0.34

Discussion

The aim of this study was to determine whether cognitivetask have an influence on temporal distance parameters ofgait in patients with hemiparesis following stroke of greaterthan three months duration. The pertaining outcomemeasures considered in this study for evaluating the effectof cognitive task on gait was stride and step length of bothaffected and unaffected sides, cadence and walking speed.

Our study results provide the evidence that performingthe cognitive task affects the gait temporal distanceparameters in patients with hemiparetic following stroke.Thus, these findings would not eliminate the cognitive-motor interference20 rooted to the dual task decrement20 ingeneralized significant deterioration in all temporal distanceparameters.

Effects of cognitive task on stroke gait

Walking is a complex voluntary rhythmic motor behavior.Its implicit nature suggests that reduced attention resourcesare required for its execution. However, recent workshighlights the involvement of attention resources, using adual task methodology6,20,8,23,25. According to dual-taskmethodology walking is an attention demanding task and isaffected by spoken verbal response as compared walkingalone.

Results of our study showed that patients withhemiparesis following stroke of greater than three monthsduration experienced marked deterioration in their temporaldistance parameters when they were required to performthe cognitive at the same time as walking. Deterioration oftemporal distance parameters with added cognitive task issupported previous studies of gait in stroke patients6,20,23.

The deterioration in the temporal-distance parametersof gait in our subject population can be explained by usingthe theories of dual task interference. A)The limited capacityor resource sharing model8,24 B)Cross talk model8 andC)Bottleneck model8,24

These are attentional models, with the term attentionalreferring the focus of mental activity on a task. Capacitiessharing models are based on the assumption that attentionresources are limited. Therefore, when people perform twotasks simultaneously, attention must be divided between thetasks20. Impairments of attention have been reported afterstroke and brain injury20.

The bottleneck and cross talk models assume that dualtask interference is affected by the type of tasks performedsimultaneously, rather than the amount of attention needed

to sustain the performance8,24. According to the bottleneckmodel tasks performed concurrently cause bottleneckinterference because they compete for the use of samepathway8,24. In contrast, cross talk model assumes that taskssimilarity reduces dual task interference, because the use ofsame pathway increases the efficiency of processing byusing less attentional resources capacity8.

The result of our study can be explained by using thetheory of attention related to a capacity model whereresources are shared9. In the resource framework, dual taskinterference could be attributed to either structural orcapacity limitation. Interference between structures canoccur when two tasks are sharing the same perceptual orexecutive pathways. In our study, we have used verbalfluency task as cognitive task to find out the dual taskinterference on gait temporal distance parameters.Activation of supplementary motor area in the frontal lobeis required for the verbal fluency task and serialsubtraction25. The supplementary motor area is also one ofthe brain regions associated with walking25.

So, when the patient performing the cognitive taskduring walking may utilize the same source that issupplementary motor area lead to resource-sharingbetween these two task and thereby deterioration in theTemporal-Distance parameters.

Future research

Future work is needed to investigate the possibility thatcertain clinical assessments may distinguish those mostsusceptible to interference from those who may benefit fromverbal guidence. Most importantly, before changing currentclinical practice, the effect of real life meaningful verbalinteraction on gait T-D parameters should be investigated.Further, effect of different cognitive tasks in different agegroups of stroke patients with different site of involvementshould be investigated.

Clinical implication

Rehabilitation of gait in hemiparesis is an importantdomine of physiotherapy care. The procedure used in thisstudy has several implications for physical therapist. Theprocedure can be used at critical points throughout therapyto assess whether a patient reduced attentional demandsassociated with effecting a movement being rehabilitated.So that, therapist can structure and modify the environmentand interventions to prevent patients from falling. Therapistscan be more cognizant of the demands they are placing onclients when they provide instructions, demonstrations, orsimply conversation that must be processed at the sametime as on-going motor performance. By adding concurrentcognitive or motor tasks during clinical examinations andmeasuring changes in simple temporal or distancevariables, therapists may be able to determine strokepatients abilities to perform motor tasks “automatically” or, atleast, to divide attention between tasks. If therapists haveinformation about how concurrent cognitive tasks influencemotor performance, they may be able to design moreeffective interventions by selecting motor tasks, structuringthe environment, and providing instructions and feedbackin a manner that is more consistent with a stroke patient’sabilities.

Fig. 3: Pre Vs Post Test Comparison of Speed.

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Conclusion

The results of our study supported our hypothesis that iscognitive task performance while walking will result indeterioration of T-D parameters of gait in patients withhemiparesis following stroke i.e, our hypothesis holds true.The results also suggest that physical therapist shouldconsider cognitive influences and attentional capacity of thestroke patients during therapy sessions.

References

1. Pearson O.R, Busse1 M.E, Quantification of walkingmobility in neurological disorders Q J Med (2004);97:463–475

2. Chiou II, Burnett CN. Values of activities of daily living.a survey of stroke patients and their home therapists.Phys Ther (1985); 65:901–6.

3. Sulloivan, Katherine J, Tara. Combined task-specifictraining and strengthening effects on locomotor recoverypost –stroke: a case study: J of Neuro Phys Ther (2006)30: 130-41

4. Duncun PW, Zorowitz R. et al. Management of adultstroke rehabilitation care: a clinical practice guideline.Stroke (2005); 36:100-143.

5. Jorgensen HS, Nakamyama H et al. Recovery ofwalking in stroke patients: the copenhagen stroke study.Arch Phys Med Rehabil (1995); 76:27-32.

6. Bowen A, Benman R. Dual task effects of talking whilewalking on velocity and balance following a stroke. Ageand Ageing (2001);30:319-323.

7. Holtzer R, Verghese J et al. Cognitive processes relatedto gait velocity: results from the einstein aging study(2006);20:215-223

8. O’Shea S, Morris ME et al. Dual-task interference duringgait in people with parkinson disease: effect of motorversus cognitive secondary tasks. Phys Ther. (2002);82:888–897.

9. Pellecchia LG. Dual-task Training reduces impact ofcognitive task on postural sway. J Motor behav (2005);37:239-246.

10. Regnaux JP, Roberston J. Human treadmill walkingneeds attention J Neuro Eng Rehab (2006): 3; 19.

11. Hsiang-JH, Vicki SM. Dual-task methodology:applications in studies of cognitive and motor

performance in adults and children Pediatr Phys Ther(2001); 13:133–140.

12. Maylor EA, Wing AM. Age differences in posturalstability are increased by additional cognitive demands.J Gerontol (1996); 51B:P143– P154.

13. Mudler T. A process-oriented model of human motorbehavior: toward a theory-based rehabilitation approach.Phys Ther. (1991);71: 157–16

14. Hsiang-Ju Huang, Vicki SM et al. Effects of differentconcurrent cognitive tasks on temporal-distancevariables in children. Pediat Phys Ther (2003); 15:105–113)

15. Smith MD, Chamberlin CJ. Effect of adding cognitivelydemanding tasks on soccer skill performance. perceptmot skills. (1992); 75:955–961

16. Hollman JH, Salamon BK et al. Age-related differencesin stride-to-stride variability during dual-task walking: JGeriat Phy Ther (2004); 27:83-87.

17. Olivier B, Aminian K et al. Dual-task related gait changesin the elderly: does the type of cognitive task matter? Jof Motro Behav (2005); 37: 259-264

18. Norkin CC, lavangie KP. Joint Structure and Function:A Comprehensive Analysis. Second Edtn, FA DavisCompany., (1998); 448-493.

19. Lajoie Y, Teasale N. Attentional demand for static anddynamic equilibrium. Exper Brain Reserch. (1993);97:139-142.

20. Haggard P, Cockburn J,. Interference between Gait andCognitive Task in a Neurological Population (2000); 69:479-486

21. Marion shores. Foot print analysis in gait documentation.Phy Ther (1980); 60;1163-1167.

22. Boeing DD. Evaluation of clinical methods of gaitanalysis. Phys Ther (1977); 57; 795-798.

23. Lord Es, Rochester L. The effects of environment andtask on gait parameters after stroke: a randomized ofmeasurement conditions. Arch Phy Med Rehab;(2006)87:967-97

24. Ulrich R, Susana RF. Motor limitation in dual-taskprocessing under ballistic movement conditions.Psycholol Science (2006)17 (9), 788–793.

25. Miyosh N, Kazui H et al. Association between cognitiveimpairement and gait disturbance in patients withidiopathic normal pressure hydrocephalus. DementGeria Cogn Disord (2005); 20;71-76.

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Awareness on diabetes mellitus and physical activity levelamong Malaysian publicAyiesah R.*, Nur Hidayah A. B.**, Nor Azura A.***Assc. Prof. Ayiesah Ramli (Lecturer), **Nur Hidayah Abu Bakar, **Nor Azura Azmi (Tutor), Physiotherapy Programme,Faculty of Allied Health Sciences, Universiti Kebangsaan Malaysia

Abstract

Background

Diabetes mellitus is on the rise in Malaysia and isbecoming a public concern, hence the awareness ofcondition is critical to avoid the increasing prevalence of thecondition.

Objective

This study determines the level of awareness onDiabetic Mellitus (DM) and the level of physical activityamong Malaysian public in Cheras, Kuala Lumpur.

Method

There were 107 subjects aged 40 years and aboveparticipated. Subjects were required to fill in thedemographic data, Diabetic Knowledge Questionnaire(DKQ) and International Physical Activity Questionnaire(IPAQ). Chi Square test was performed to identifyassociations between variables.

Result & discussion

Mean aged of subjects was 53.2+ 8.82 years and weremainly women (54.2%). Only 16.8% of the subjects wereaged 51 to 60 years (55.61+7.54) who had the highest levelof awareness on DM (p>0.05). Subjects with highesteducational level had the highest level of awareness on DM(66.7%), followed by those with secondary education(27.8%) and poor educational background (5.6%). Nosignificant differences were found between gender, race,family history of DM and medical problem with the level ofDM awareness (p>0.05). Subjects with the highestawareness level got their main source of information on DMawareness from electronic media (77.8%), printed mediaand health professional (66.7%). Majority of the subjectshad the lowest level of physical activity, n=46 (43%) withmean aged 53.72+8.73 years. Most of the subjects with thehighest level of DM awareness had only moderate physicalactivity level (26.3%). There was no significant differencebetween level of DM awareness with the physical activitylevel p>0.05.

Conclusion

The level of DM awareness was at the moderate levelamong the Malaysian public and was influenced by theirlevel of education.

Keywords

Diabetic Mellitus, Level of awareness, Level of physicalactivity, Diabetic Knowledge Questionnaire (DKQ) andInternational Physical Activity Questionnaire (IIPAQ).

Introduction

Diabetes mellitus (DM) is a common and costly diseasewhich is determined by high levels of blood glucose due todefect in insulin secretion. Insulin is one of the hormoneswhich regulates carbohydrate metabolism by controllingblood glucose levels1.

WHO (2000)2 had indicated that from the diabetesdatabase in 1999, about 4% adults are having diabetes in1995 and this figure is expected to increase proportionatelyup to 5.4% in 2025. Singapore contributes the highestprevalence of DM patients about 9% in 19983. According tothe Ministry of Health Singapore (1998),4 the NationalHealth Survey Configuration stated that DM is the sixthcaused of death and contributed to 2.2% of annual death.The average aged of patients diagnosed with DM are 47.3years old for Chinese, 45.7 years old for Malay and 45.8years old for Indian3. DM rank as the fifth highest diseasethat contributes to mortality regardless of race and ethnicgroups5.

This silent disease is very life threatening among thepublic due to lack of awareness and knowledge3. Thecommon complications of DM are heart disease, stroke,high blood pressure, blindness, renal dysfunction, impairedsensation, amputation, periodontal disease and pregnancycomplications1.

According to Nishida et al. (2000),6 energy consumptionwith physical activities is the main strategy in preventingincreasing population on type 2 DM. Low level of physicalactivities include walking, cycling, swimming, tai-chi, yoga,gardening and high level physical activities are sports,hiking, athletic and gymnasium exercises have proven toreduce risk of DM7. In a study that was carried out amongCanadians, the lack of leisure time, weather, increaseddistance of gymnasium location, fear of injury,hypoglycemia, fatigue, heart attack and heavy workschedules are the factors which limit one in doing physicalactivities8.

Educational status is one of the factors that can enhancepublic awareness regarding DM. The more educatedpopulation has more exposure and better understanding ingaining knowledge on diabetic awareness. Studies haveproven that public with tertiary education level who aregraduates from high schools or universities are 13.5 timesmore aware about DM disease compare to those with lowereducational background5. It is the purpose of this study todetermine whether the level of awareness on DM influences

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the level of physical activity among the Malaysian public atUKMMC Cheras, Kuala Lumpur.

Material and method

Study DesignA Cross sectional study was done to identify the level of

DM awareness among public at UKMMC Cheras, KualaLumpur from September 2007 to March 2008 usingconvenient sampling.

SubjectsOne hundred and seven respondents aged between 40

and 70 years participated in this study. They were patients,carer or visitors to the UKMMC, Cheras in Kuala Lumpur.The inclusion criteria includes subject aged 40 and above,whether diabetes or not while exclusion criteria are subjecthaving low mobility level such as bedridden, asthmaticduring exercise and below 40 years of age.

Assessments on Outcome Measurea. Diabetic Knowledge Questionnaire (DKQ)

This English version questionnaire has been developedby Villagomez in 1989 and consists of 25 items based onthe National Standards for Diabetes Patient EducationPrograms9. Domains from the questionnaires include:General Knowledge, Risk Factor, Symptom andComplication, Treatment and Care and Monitoring. Thescales of questionnaire are: 1 (correct answer) and 0(incorrect answer or not given or unsure). Following the totalscores are categorized as low awareness (0 – 8 scores),moderate awareness (9-16 scores) and high awareness(17-24 scores).b. International Physical Activity Questionnaire (IPAQ)

This questionnaire was developed by InternationalConsensus Group in 1997-1998 as an outcome measurefor studies done by 14 research centers in 12 countriesusing standard method and protocol10. The scores werecategorised into 3 levels of physical activities. Low level (1stcategory) is described as subject who is inactive. Moderatelevel (2nd category) – is describe as if subject has done anyof these criteria such as heavy activity at least for 20minutes every day for 3 days or more, or moderate activityor walking for at least 30 minutes every day in 5 days ormore, or any of combination activities such as walking,moderate or heavy activity using at least 600 metabolicequivalent (MET)-minute/week for 5 days or more. Highlevel (3rd category) is describe as for subjects who has metthese criteria of carrying heavy activity at least 3 days with1500 MET –minute/week, combination of activities such aswalking, moderate activity or heavy activity at least 3000MET-minute/week for 7 days or more.

Research ProcedureThe patients and clients who came to the Physiotherapy

Department were informed to fill in the self addressquestionnaires (DKQ and IPAQ) by the receptionist. A boxwas placed at the counter following which the answeredquestionnaires were placed by volunteered participated

subjects. The protocol of the study was approved by theethical committee at PPUKM and informed consentobtained from all patients and clients involved.

Statistic AnalysisThe SPSS version 12.0 software was used to analyse

data. Statistical test, Chi Square was used to analyse thedata with p<0.05 considered as significant association.

Results

One hundred and seven subjects at UKMMC, Cheraswere enrolled in the study and answered bothquestionnaires. Majority of subjects were females (54.2%,n=58) compared to males (45.8%, n=49) with mean age of53.2 + 8.82 years. Sixty five subjects (60.7%) were Malays,24 were Chinese (22.4%), 17 were Indians (15.9%) and only1 (0.9%) was others.

The level of awareness on DM was analysed using Chi-Square Test. The level of DM awareness score is seen inTable 1 that demonstrate 16.8% (n=18) subjects were agedbetween 51 to 60 years (55.61+7.54) with the highest levelof awareness on DM. About 68.22% (n=74) subjectsindicated moderate awareness were aged between 41 to 60years (52.53+8.86) and 14.95% (n=16) had the lowestawareness on DM among aged between 41 to 50 years(53.44+9.99). There were no significant associationbetween age group and level of DM awareness (p=0.23) asseen in Table 2.

From the DM awareness score in Table 2, both malesand females had scored 50% (n=9) for the highest DMawareness level. About 60% (n=9) males compared to 40%(n=6) females had the lowest DM awareness level. Thereare no significant associations between gender, race andDM awareness level of score with p > 0.05. Regarding theeducational level about 66.7% (n=12) subjects had thehighest awareness score are from tertiary education(universities or colleges), 27.8% (n=5) from secondaryschools and 5.6% (n=1) from primary schools and noneeducational background. Thus, the educational doesinfluence the awareness of DM among public with p<0.05.

From the study patients with no family history of DM hadhigh percentage of awareness level (55.6%, n=10)compared to subjects with family history of DM (44.4%,n=8). Among subjects with medical problem they seem todemonstrate poor awareness of DM level (73.3%, n=11)compared to subjects with no medical problem (26.7%,n=4). There were no significant differences (p>0.05) foundbetween family with history of medical and no medicalproblem in the level of DM awareness scores.

Reso urces of the information on DM awareness wereanalysed and reviewed. About 77.8% (n=14) subjects hadhighest awareness level from electronic media, followed by66.7% (n= 12) from printed media and health professionalresources. There were no significant differences (p>0.05)between resources with level of DM awareness score.

Table 3 showed that most of the subjects (43%, n=46)were at the lowest score of physical activity level with age41-50 years old (53.72±8.73). In contrast only 21.5% (n=23)subjects indicated the highest score of physical activity level(51.61± 10.65) and 35.57% (n=38) subjects were atmoderate level of physical activity (53.50±7.80). There wasno significant differences found between age and physicalactivity level with p > 0.05 as seen in Table 4.

Table 1: Score level of DM awareness on mean aged of the subjects

Score level of DM awareness N Mean + SD0-8 (Lowest) 15 53.80+10.23

9-16 (Moderate) 74 52.47+8.8217-24 (Highest) 18 55.61+7.54

Ayiesah R. / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Most of the females had highest physical activity level,(56.5%, n=13) compare to males (43.5%, n=10). Malaysubjects had the highest physical activity level (65.2%,n=15) compare to Indians (21.7%, n=5) and Chinese(13.0%, n=3). Most of Malay subjects had a moderatephysical activity level, while Chinese and Indian had thelowest level among themselves. There were no significantdifferences found between gender and race with physicalactivity level (p>0.05).

Most of the subjects from higher educational backgroundwere from universities or colleges and secondary schoolthat showed the lowest physical activity levels scoringbetween 23.9%, (n=11) and 47.8%, (n=22). About 56.5%(n=13) subjects with no medical problem had the highestlevel of physical activity while most of subjects 52.2% (n=24)with medical problem had the lowest physical activity.

There is no significant difference observed between levelof DM awareness with the physical activity level, p >0.05.Whereas most of the subjects with the highest level of DMawareness had only moderate physical activity level 26.3%(n=10).

Figure 1 illustrates the barriers to physical activity.Majority of the subjects 62.6% (n=67) indicated that the lackof time was the main barrier doing physical activity. About4.7% (n=5) assumed that they already active whichcontribute to the lowest percentage of barriers in physicalactivities. The barriers to physical activities that has beenidentified were medical problems, lack of physical activityknowledge, no friend to exercise with, assumption of alreadybeing active and others likes weather, feeling of tiredness

not interested and wanting to spend more time with familymembers.

Discussion

In this study the level of DM awareness amongst publicis moderate and mainly determined by the levels ofeducation. Educational level has been demonstrated toinfluence the level of DM awareness among subjects. Pooreducational background had the lowest level of DMawareness as supported with previous study11. The resultshowed there is no significant difference observed betweenlevel of DM awareness with age group, however in previousstudy had demonstrated that elderly people had less DMawareness between age group5.

It is important for public to get information regarding DMfrom various sources. From the study, sources from internetand magazine contribute significantly towards increaseawareness level among subjects when compared to othersources likes television, radio, health professional andnewspaper. Health professional seem to be less active ingiving information about DM through health talk and makeworst by the public having poor initiative in askinginformation from health professional3.

A television programme surveyed carried out on 30March 2008 through Utusan Malaysia Online, demonstratedthat only 3.4% of television programme showed healthissues while 70% indicated programme on entertainmentshow. This surveyed was carried out for all broadcast stationthat was popular in Malaysia (TV3, TV9, NTV7, RTM1,RTM2 and Astro Ria). As such health informationprogramme should take effort in providing more healthinformation as most of the public prefers to get informationfrom electronic media. Even though more health informationis easily accessible through internet, subjects showed lessinterests compared to Singapore and Western countries

26 Ayiesah R. / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Table 3: Score level of physical activity on mean aged of the subjects.

Score of Physical Activity Level N Mean + SDLowest 46 53.72+8.73

Moderate 38 53.50+7.80Highest 23 51.61+10.65

Table 2: Distribution of DM awareness within demographic data baseline

DM Awarenes (Questionnaire Score)Criteria Lowest Moderate Highest Total p values

n % n % n % n %Age Group

40 - 50 8 53.3 35 47.3 4 22.2 47 43.9 p = 0.063> 50 7 46.7 39 52.7 14 77.8 60 56.1

Gender Male 9 60.0 31 41.9 9 50.0 49 45.8 p = 0.632Female 6 40.0 43 58.1 9 50.0 58 54.2

Educational LevelUniversity/college 0 0.0 12 16.2 12 66.7 24 22.4 p=0.00*Secondary School 4 26.7 41 55.4 5 27.8 50 46.7Primary School &None EducationalBackground 11 73.3 20 28.4 1 5.6 33 30.8

Family History of DMYes 6 40.0 33 44.6 8 44.4 47 43.9 p = 0.812No 9 60.0 41 55.4 10 55.6 60 56.1

Medical ProblemYes 11 73.3 32 43.2 8 44.4 51 47.7 p = 0.124No 4 26.7 42 56.8 10 55.6 56 52.3

Resources Electronic MediaYes 8 53.3 40 54.1 14 77.8 62 57.9 p = 0.134No 7 46.7 34 45.9 4 22.2 45 42.1

Printed MediaYes 8 53.3 36 48.6 12 66.7 56 52.3 p = 0.399No 7 46.7 38 51.4 6 33.3 51 47.7

Health Professional Yes 8 53.3 49 66.2 12 66.7 69 64.5 p = 0.454No 7 46.7 25 33.8 6 33.3 38 35.5

* Significant p values

27

Table 4: Distribution of physical activity level within demographic criteria.

Level of physical activityCriteria Lowest Moderate Highest Total p Values

n % n % n % n %Age

40 - 50 21 45.7 14 36.8 12 52.2 47 43.9 p = 0.782>50 25 54.3 24 63.2 11 47.8 60 56.1

GenderMale 21 45.7 18 47.4 10 43.5 49 45.8 p = 0.907Female 25 54.3 20 52.6 13 56.5 58 54.2

RaceMalay 24 52.2 26 68.4 15 65.2 65 60.7 p = 0.352Chinese 13 28.3 8 21.1 3 13.0 24 22.4Indian 8 17.4 4 10.5 5 21.7 17 15.9Other 1 2.2 0 0.0 0 0.0 1 0.9

Educational LevelsUniversity/College 11 23.9 9 23.7 4 17.4 24 22.4 p = 0.500Secondary school 22 47.8 17 44.7 11 47.8 50 46.7Primary school &None educationalbackground 13 28.3 12 31.6 8 34.8 33 30.8Family History of DM

Yes 21 45.7 17 44.7 9 39.1 47 43.9 p = 0.635No 25 54.3 21 55.3 14 60.9 60 56.1

Medical ProblemYes 24 52.2 17 44.7 10 43.5 51 47.7 p = 0.449No 22 47.8 21 55.3 13 56.5 56 52.3

DM awareness levelLowest 8 17.4 6 15.8 1 4.3 15 14.0 p = 0.712Moderate 31 67.4 22 57.9 21 91.3 74 69.2Highest 7 15.2 10 26.3 1 4.3 18 16.8

Fig. 1: Barriers to Physical Activity62.6

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40

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where internet is the most popular and most accessiblemedia for sources of information3.

Surprisingly from this finding individual with family historyof DM has high level of awareness unlike the findings byCaliskan et al. (2006)5 which demonstrated otherwise.Patient with medical problem had also the lowest level ofDM awareness possibly due to poor information given byhealth professional12. Even in advanced countries about60% of American are still inactive and does not exercisedespite many sorts of health promotion carried out amongthe public13.

Level of DM awareness is not portrayed by their physicalactivity level even though most of the subjects are awarethat exercise can reduce the risk of DM and preventcomplication. Possible reason why middle age was morehighly physical inactive compared to elderly was that theywere too busy with their hectic work schedule while most ofthe elderly groups spend their time at home with family tolook after the grandchildren. The barriers to physicalactivities were similar to finding by King et al. (2000)14 suchas lack of time, less motivated and tired was the forthbarriers to be active.

Conclusion

Level of DM awareness among the public in Cheras,

Kuala Lumpur was moderate. Educational level was foundto be the determining factor that influences the lack ofawareness on DM with better awareness among the highlyeducated individuals. However it does not influence the levelof physical activity among individuals. From the study, themain barrier to physical activity was lack of time. It isrecommended that physiotherapist should play an importantrole in enhancing higher level of physical activity such as‘Exercise While Working’ programme to create awarenessamong public especially those who are having DM. Adviceon use of stairs case are encourage than using escalator orlift services during every day activities.

References

1. Centers for Disease Control and Prevention. Nationaldiabetes fact sheet: General information and nationalestimates on diabetes in the United States.http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf.2005; [Accessed 20 Julai 2007].

2. WHO. Diabetes Estimates 1995-2025. WHO DiabetesDatabase, 1999. Geneva: World Health Organization2000.

3. Wee HL, Ho HK, Li SC. Public Awareness of DiabetesMellitus in Singapore. Singapore Medical Journal2002;43(3):128-134.

4. Ministry of Health Singapore. National Health Survey.http://www.gov.sg/moh/nhs.html 1998; [Accessed 15August 2000].

5. Caliskan D, Ozdemir O, Ocaktan E, Idil A. Evaluation ofawareness of Diabetes Mellitus and associated factorsin four health center areas. Patient Education andCounseling 2006;62:142–147

6. Nishida Y, Higaki Y, Tokuyama K, et al. Effect of mildexercise training on glucose effectiveness in healthymen. Diabetes Care 2001; 24:1008-1013.

7. Hu FB, Sigal RJ, Rich EJW, et al., Walking compared

28 Ayiesah R. / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

with vigorous physical activity and risk of type 2 diabetesin women. JAMA 1999;282:1433-1439.

8. Delahanty LM, Molly BC, N. DM. PsychologicalPredictors of Physical Activity in the Diabetes PreventionProgram. Journal of the American Dietetic Association2006;106:698-705.

9. Alexandra AG, Evangelina TV, Sharon A. Brown,Kouzekanani. K, Hanis. CL. The Starr County DiabetesEducation Study; Development of the Spanish-languagediabetes knowledge questionnaire. American DiabetesAssociation Inc. Diabetes Care 2000;24:16-21.

10. Craig CL, Marshall AL, Sjöström M, Bauman AE, BoothML, Ainsworth BE, et al. International Physical ActivityQuestionnaire: 12 Country Reliability and Validity. MedSci Sports Exerc 2003; 8:1381-95.

11. WHO. Diabetes Estimates 1995-2025. WHO Diabetes

Database, 1999. Geneva: World Health Organization 2000.12. Murugesan N, Snehalatha C, Shobhana R, Roglic G,

Ramachandran A. Awareness about diabetes and itscomplications in the general and diabetic population in acity in southern India. DIAB 2007;3795:1-5

13. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA,Bouchard C, et al. Physical activity and public health : Arecommendation from the Centers for Disease Controland Prevention and the American College of SportsMedicine. The journal of The American MedicalAssociation. 1995; 273( 5): 402-407.

14. King AC, Castro C, Wilcox S, Eyler AA, Sallis JF,Brownson RC. Personal and Environmental FactorsAssociated With Physical Inactivity Among DifferentRacial-Ethnic Groups of U.S. Middle-Aged and Older-Aged Women. Health Psychology 2000;19(4):354-364.

Effect of high voltage healthron device on blood pressure andplasma glucose of normal subjects – A technical reportOnigbinde Ayodele.T., Adedoyin Rufus. A.Medical Rehabilitation Department, College of Health Sciences, Obafemi Awolowo University, Ile-Ife Osun State

Abstract

Electrotherapy continues to gain importance in medicalmanagement of diseases. There appears to be a shift infocus towards using Alternating current in the managementof both high blood pressure and diabetes especially in Asia.There appears to be dearth of clinical trials on efficacy ofHEALTHRON device in the control of high blood pressureand hyperglyceamia. Twenty-seven (27) normotensiveundergraduate students participated in the study. The bloodpressure and plasma glucose of the subjects weremeasured and each participant was subjected to highvoltage alternating current for 1 hour on the Healthrondevice. The procedure was carried out for three sessionsweekly for four weeks. Descriptive statistic and paired t-test(dependent) was used to compare the Pre and Post bloodpressure, heart rate and plasma glucose. The result of thepaired t-test showed that there was significant reduction inthe plasma glucose and blood pressure (systolic anddiastolic) after 4 weeks (P<0.000). This showed about 18%reduction in both the systolic and diastolic blood pressure.However, there was no significant reduction in the heart rateof the participants (P>0.09). This study was suggestive thatHealthron machine had positive physiological effects on thesubjects in this study.

Introduction

Electrotherapy is the use of electrical energy in thetreatment of impairments of health and a condition ofabnormal functioning1. The use of electricity in medicalmanagement of disease condition has gained popularity inthe recent times. The publication of the gate control theoryby Melzack and Wall in 1965 opened up for the proliferationof electric devices. In Asia, there appears to be a shifttowards using Alternating current in the management ofboth high blood pressure and diabetes.

Hypertension is one of the most common worldwidediseases afflicting human. Because of the associatedmorbidity and morality and the cost to society, hypertensionis an important public health challenge2. Over the pastseveral decades, extensive research, widespread patienteducation, and a concerted effort on the part of health careprofessionals have led to decreased mortality and morbidityrates from the multiple organ damage arising from years ofuntreated hypertension. All drug treatments have sideeffects, and while the evidence of benefit at higher bloodpressures is overwhelming drugs trials to lower moderately-elevated blood pressure have failed to reduce overall deathrates.

Diabetes mellitus and hypertension commonly overlapor co-exist in patients3. Diabetes mellitus refers to the groupof disease that lead to high blood glucose levels due to

defects in either insulin secretion or insulin action4. Diabetesand its treatments can cause many complications. Bloodglucose levels are controlled by a complex interaction ofmultiple chemicals and hormones in the body, including thehormone insulin made in the beta cells of the pancreas.

Naoki et al5 found that progressive hypertensive ratswhen subjected to Alternating-current, High-voltage, ElectricPotential (AC-HVEP) had significantly less blood pressurecompared to the control group. In addition, histo-pathological examination.showed greater restriction oflesions in the AC-HVEP than in the control group. Theysuggested that AC-HVEP exposure can suppressprogressive hypertension secondary to chronic renal failure.

HEALTHRON device is a high electric voltage (Alternatecurrent) device with limited clinical reports. Healthron wasformerly referred to as an Electrostatic curative, device (Moriand Miyazaki. 1990). The concept arose from Gremandocumentation that people that live under high-tensiontransmission appeared to be healthier that those in otherareas (Mori and Miyazaki, 1990). It is an electrotherapydevice that is claimed to have therapeutic affects on severalconditions such as hypertension and diabetes. The use ofhealthron is yet to be justified in the literature. Theevidences supporting its use are mostly personal. There arevery limited clinical trails on efficacy of HEALTHRON devicein the control of high blood pressure and the few reports areobservational reports. Similarly, most studies were carriedout among the Asians. Also, the number of subjects used inprevious studies appears to be inadequate and it is likelythat conclusion may not be drawn on the efficacy. Theefficacy of the device is yet to be conclusively ascertainedand the few studies on the use of high voltage electriccurrent were on hypertensive rats.

In spite of the wide-spread use of drugs and othermeans in controlling high blood pressure and diabetes,finding a lasting solution to control them still remain amyriad. As of today, there is no cure for hypertension anddiabetes. They are usually managed by a combination oftreatments. Most hypertensive and diabetic subjects still relyon medications. Even these drugs are with various sideeffects and even drug compliance is still very difficult amongusers. In view of this, there is need to further explorealternative treatment techniques. It appears there is dearthof adequate information on the use of high voltage electriccurrent in the control of high blood pressure and diabetes.

Materials and methodology

This study involved 27 normal participants who areundergraduate students of Medical rehabilitationdepartment of the Obafemi Awolowo University, Ile-Ife,Osun State, Nigeria. They all consented to participate in thestudy. The ages ranged between 18 and 30 years. The

29Onigbinde Ayodele.T. / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

subjects excluded from the study are those with:Cardiovascular disorders, Cerebrovascular disorder, Acuteinflammation, Tumors, Pregnant women, Cardiacpacemaker and any metallic implant, Impaired sensation,Cancer, Peripheral vascular disease and Seizure disorderThe study was conducted at the Medical rehabilitationdepartment of the Obafemi Awolowo University, Ile-Ife.

Instrumentations

Sphygmomanometer to (OMRON RX-Classic) was usedmeasure blood pressure and Glucometer (One Touch –Ultra easy model, LIFESCAN-Johnson & JohnsonCompany, 021-195) was used to quantify the blood sugarlevel (Fasting plasma glucose in mg/dl).

Procedure

Approval was sought from the Ethic and ResearchCommittee of the Obafemi Awolowo University TeachingHospitals. The age, weight, height and sex of each subjectwere taken and recorded. The blood pressure and plasmaglucose of the subjects were measured using theSphygmomanometer and glucometer respectively beforesitting on the Healthron device. The participants rested for30 minutes on a chair before sitting on the machine. Eachparticipant was subjected to high voltage alternating currentfor 1 hour on the Healthron device. The blood pressure andfasting plasma glucose were monitored immediately andafter 30 minutes of resting again on a chair. A drop of bloodsample was obtained through the use of a needle prick onthe thumb of each participant before sitting on the Healthronmachine and immediately after 1 hour elapsed. The drop ofblood was applied on a Glucometer (One Touch –Ultra easymodel, LIFESCAN-Johnson & Johnson Company, 021-195)to obtain Fasting blood sugar value.

The procedure was carried out for three sessions weeklyfor four weeks. A progressive assessment of the bloodpressure and fasting plasma glucose were measured andrecorded once a week. All the subjects fasted overnight.

Data analysis

A descriptive analysis was used to determine the mean,and standard deviation of the ages, height, weight, bloodpressure, heart rate and plasma glucose of the subjects. Aninferential statistic- paired t-test (dependent) was used tocompare the Pre and Post blood pressure, heart rate andplasma glucose.

Results

The result of the study showed that the mean age of theparticipants was 23± 8.9 years while the mean height andweight were 1.70± 0.11 meters and 62.56 ± 10.26 kgrespectively. Also, the initial fasting plasma glucose was103.5 ± 10.05 while the final plasma glucose was 99.56±13.20mg/dl after 4 weeks.

The initial systolic blood pressure was 133± 17.25mmHgwhile the final systolic blood pressure was109.11±14.00mmHg. Similarly, the initial diastolic bloodpressure was 83.33± 10.83 mmHg and the final was 68.00±11.00 mmHg. This showed about 18% reduction in both thesystolic and diastolic blood pressure. The study also foundthat initial heart rate was 71.89 ±12.62 beats/ minutes whilethe final heat rate after 4 weeks was 68.44±11.11beat/minutes. The result of the paired t-test showed thatthere was significant reduction in the plasma glucose andblood pressure (systolic and diastolic) after 4 weeks(P<0.000). However, there was no significant reduction inthe heart rate of the participants (P>0.09).

The result also showed that all the participants,27(100%) complained of fatigue and hunger that lasted untilthey were able to eat. Also 4 (14.8%) of the participants hadmoderate pimples on their faces while 8(29.6%) hadfuruncles in their axilliary folds.

Discussion

Regulation of normal blood pressure is a complexprocess and it is a function of cardiac output and peripheralvascular resistance. These variables are influenced bysodium intake, renal function, and mineral corticoids2. Theresult of the study showed that there was significantreduction in the blood pressure of participants after 4 weeksof utilizing high voltage healthron device. The difference inblood pressure was 18% and this appeared to be high whencompared to previous intervention such as exercise therapywhere there was about 5-10% reduction in blood pressure7.Evidence suggests that reduction of the blood pressure by5-6mmHg can decrease the risk of stroke by 40%, ofcoronary heart disease by 15%-20%, and reduces thelikelihood of dementia, heart failure, and mortality fromvascular disease8. Jurg et al9 reported that electricalstimulation of the carotid sinus activates the carotidbaroreflex resulting in a reduction in BP and HR inhypertensive subjects.

This study on HEATHRON device also corroborated thatof Naoki et al5 who found that progressive hypertensive ratswhen subjected to Alternating-current, High-voltage, ElectricPotential (AC-HVEP) had significantly less blood pressurecompared to the control group.

Plasma glucose is an important energy source inexercising humans, supplying between 20 and 50% of thetotal oxidative energy production and between 25 and 100%of the total carbohydrate oxidised during submaximalexercise10. There was a significant reduction in the fastingplasma glucose of the participants after 4 weeks. Mostparticipants reported fatigue and hunger after eachtreatment session with the healthron device. This may beattributed to increased metabolism after sitting on the high

Table 1: Anthropometric parameters of participants.

Mean Standard DeviationAge (Years) 23.89 3.86Height (m) 1.70 0.11Weight (kg) 62.56 10.26

Table 2: Result of paired t-test company fasting plasma glucose andcardiovascular Parameters

Mean SD P-level

Initial Plasma glucose 103.56 10.05Final Plasma glucose 99.56 13.20 0.000Initial SBP 133.00 17.25Final SBP 109.11 14.00 0.000Initial Diastolic 83.33 10.82Final Diastolic 68.00 10.99 0.000Initial Hear rate 71.89 12.62Final Heart rate 68.44 11.11 0.091

30 Onigbinde Ayodele.T. / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

voltage healthron device which subsequently lowers theglucose available for more energy production. Only very fewof the participants reported furuncles and pimples at the endof the 4 weeks study.

For a number of years it has been a more or less wellrecognized practice on the part of the medical profession toassume that electric currents of high potential andfrequency, have a helpful influence upon the bodymetabolism, particularly as a stimulant to the excretion ofbody wastes by the kidneys in those cases where faultymetabolism or faulty elimination is seemingly a dominantfeature of the symptoms-complex. Electrical forces appliedto the body bring about physiology changes for therapeuticpurposes1.

This study implied that electrical forces applied to thebody resulted to physiological changes within the body.Glucose comes from carbohydrate foods and it is the mainsource of energy used by the body. The lowered fastingglucose level obtained in this study is comparable to theeffect of exercise on glucose in some previous studies11.

Conclusion

This study concluded that there was significant reductionin the blood pressure and fasting plasma glucose ofparticipants in this study after 4 weeks of utilizing highvoltage Healthron device. The study is also suggestive thata lesser duration (dose) less than 1 hour should be utilizedin order to avoid undesired hypotension and hypoglyceamia.This study implied that electrical forces applied to the bodyresulted to physiological changes within the body. Furtherstudy is recommended.

Reference

1. IEEE (1997). Institute of Electrical and ElectronicEngineers. The IEEE standard dictionary of electricaland electronic terms, 6th edition, New York.

2. Sharma Sat and Claude Kortas (2009). Hypertension.Medscape,http://emedicine.medscape.com/article/241381-overview.

3. Epstein M and Sowers JR (1992)Diabetes mellitus andhypertension Hypertension, Vol 19, 403-418.

4. Rother, KI (2007). "Diabetes Treatment – Bridging theDivide". N Engl J Med 356 (15): 1499-1501.

5. Naoki Miura, Suzuki Shusaku, Hamada Yuji et al (2001).Effects of Exposure to Alternating-current, High-voltage,Electric Potential on Experimental Hypertension in Dahl-S Rats. Journal of the Japan Veterinary MedicalAssociation. Vol.54; No.6; Page.472-475(2001)

6. Muri and Miyazaki (1990). CLINICAL REPORTMANUAL ON Healthron machine.

7. Mayo Foundation for Medical Education and Research(2009), approach to lowering high blood pressure,E:\exer and blood.htm

8. Wikkipedia (2009). Diabetes Mellitus. http://en.wiki-pedia.org/wiki/Diabetes_mellitus

9. Jurg Schmidli; Hannu Savolainen; Friedrich Eckstein;Eric Irwin; Tim K. Peters; Roy Martin; Robert Kieval;Robert Cody; Thierry Carrel (2007) Acute Device-BasedBlood Pressure Reduction: Electrical Activation of theCarotid Baroreflex in Patients Undergoing ElectiveCarotid Surgery. http://www.medscape.com/viewarticle/557733

10. Coggan AR (1991) Plasma glucose metabolism duringexercise in humans. Sports Med. Feb;11(2):102-24.

11. "Effects of Exercise On Glucose Tolerance - BriefArticle". Nutrition Research Newsletter. FindArticles.com. 09 Jul, 2009. http://findarticles. com/p/articles/mi_m0887/is_1_18/ai_76283932/.

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Site specificity of sports injuries seen during the interschoolcompetations held at belgaum an observational studyMotimath B.S.1, Ganesh B.R.2, Murakibhavi V.G.31Lecturer, 2Assistant Professor, K.L.E.S. Institute of Physiotherapy, J. N. Medical College Campus, Belgaum 590 010,Karnataka, India, 3Professor and Head, Department of Orthopaedics, Jawaharlal Nehru Medical College, Nehru Nagar,Belgaum 590 010, Karnataka, India

Abstract

Background and objectives

The term sports injury refers to the kinds of injuries thatcommonly occur during sport or exercise. Sport andexercise can be very beneficial to health. The objective ofthe study was to know common sites of injury in childrenduring competitive sports events.

Methodology

The present observational study was carried during twointerschool competitions at Belgaum city, Karnataka statenamely football tournament and track and field events heldon July-2008. The study comprised of 1540 both male andfemale participants. As a part of procedure the site of theinjury and the gender of the individuals were noted. Thosesubjects who came to us for the purpose of first aid for thesystemic symptoms were grouped as others andpercentage for them was calculated separately. Theoutcome measures assessed were number of injuries seenat each joint. Data was analyzed manually to find out thepercentage of injuries at each joints and distribution ofinjuries.

Results

Total of 1540 participants had taken part in thesecompetitions. Out of these 36 (2.33%) sustained the injury.Among them 31 (86.2%) were boys and five (13.8%) weregirls with male to female ratio of 6.2:1. The total injuries per1000 participants were 24.

In this study majority that is eight (22.2%) had injuriesaround ankle and foot area. Seven (19.44%) had head,neck and facial injuries, six (16.6%) had injuries to the knee,four (11.11%) had injuries to the wrist and hand, three(8.33%) had injuries at shoulder and elbow, and five(13.8%) contributed to others.

Conclusion

The commonest site of injury during the competitiveevent is the ankle and foot region and the injuries are morecommon in boys than in girls at this age.

Key words

Sports injury; Site of injury;

Introduction

The term sports injury refers to the kinds of injuries that

commonly occur during sport or exercise. Sport andexercise can be very beneficial to health. They can reducethe risk of heart disease, stroke and obesity and help to beatdepression. Most people get sports injuries throughaccidents but professional and competitive athletes oftendevelop overuse injuries. An overuse injury is usually asprain, strain or fracture to part of the body that has beenused repetitively.

In recent years, medical and lay media have publicizedthe epidemic of obesity in Americans. Further, the last fourdecades have seen a disturbing increase in sedentarylifestyles in adults. Youth are also more sedentary, largelydue to the influence of television watching and hours ofindulgence in video games and online chats, activities thatneglect cardiovascular fitness and do not exercise majormuscle groups. Combating this trend is the push toencourage kids to participate in various sports. At this time,at least 25 million children engage in school-sponsoredsports. About 20 million children play in extracurricular,organized sports. The downside of a healthy focus on sportsis that injuries in children will occur1,2.

Each year, sports cause up to seven million injuries inAmericans3. One study found the most common cause ofpediatric injuries was sports/overexertion4. With the highestincidence of sports injuries, children ages five to fifteen have59.3 injuries per 1,000 compared to 25.9 injuries per 1,000in the general population3. The second highest group ischildren ages 15 to 24, with a rate of 56.4 per 1,000. Morethan one third of children suffer sports-related injuriesrequiring treatment from a doctor or nurse2.

Males experienced more than twice the injuries offemales in a United States based study3. However, aScottish study found that the difference was somewhatsharper, with the injury rate for boys ages five to sixteenbeing 2.5 times that of girls the same age5. The peak rate ofinjury occurred at age 12 in girls but age 14 in boys. Whitesincur 1.5 times more injuries than blacks3.

The relationship between age and sports injuries isinteresting. The injury rate for prepubertal children in sportssuch as football is much lower than that of postpubertalchildren. One might predict the opposite, but the reason forthe greater rate of injuries with increasing age iscorresponding increases in size, speed, and strength, allleading to greater impact3.

Sports injuries are common at the competitive eventsand many times injuries worsen because of the impropermanagement and negligence of the primary injury. If thereare studies that state the sites which are more prone forinjuries, they can guide the first- aid providers on theoccurrence of injuries so that they can be better preparedand even well equipped to manage the same on the fielditself. Moreover the same studies can guide to set up

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specialty centers so that the athletes can safely return totheir sport. Hence the study was planned to know the mostinjury-prone sites.

Objectives

The objective of present study was to know commonsites of injury in children during competitive sports events.

Method

Study Design: Observational study.Participants: Individuals aged less than 16 years andrepresenting different schools for the various events.

Procedure

After visiting various play grounds in Belgaum citycertain sports events were identified. For the study twointerschool competitions were selected out of which onewas the football tournament and the other was track andfield event. The data was collected with prior permissionfrom the organizers of the selected competitions. As a partof procedure the site of the injury and the gender of theindividuals were noted. Those subjects who came for thepurpose of first aid for the systemic symptoms likegiddiness, cramps or injury to the perineum and abdomenwere grouped as others and percentage for them wascalculated separately. After this the injured were given first-aid management. Total 1540 participants had taken part inthese competitions.

Outcome measures

Number of injuries seen at each joint.

Data analysis

Data was analyzed manually and with the calculator tofind out the percentage of injuries at each joints and thedistribution of injuries according to the gender.

Results

Total of 1540 participants had taken part in thesecompetitions. Out of these 36 (2.33%) sustained the injury.Among them 31 (86.2%) were boys and five (13.8%) weregirls with male to female ratio of 6.2:1. The total injuries per1000 participants were 24.

In this study majority that is eight (22.2%) had injuriesaround ankle and foot area. Seven (19.44%) had head,neck and facial injuries, six (16.6%) had injuries to the knee,four (11.11%) had injuries to the wrist and hand, three(8.33%) had injuries at shoulder and elbow, and five(13.8%) contributed to others.

Discussion

Studies in the past have calculated the injury rate per1000 participants and the highest incidence of sportsinjuries in children aged between five to 15 have 59.3injuries per 1,000, compared to 25.9 injuries per 1,000 inthe general population,3 but here in our study it is 24 per1000.

Previously there have been studies on sports injurieswhich have stated that as many as 61% of sports injuriesare soft tissue injuries5. The most common types of sportsinjuries are strains and sprains, comprising 31% to 34% ofall injuries3,6. Contusions comprise 30% of injuries, andfractures comprise 25%. In our study we have not classifiedthe injuries. There is been a study in the past which hastaken in to consideration the site specificity andepidemiology of only the stress fractures7 our study was notrestricted to any particular condition.

While concentrating on the cause few of the studieshave shown that Traumatic injuries are only a part of thespectrum of sports injuries in children. Another problem isthe overuse injury, typified by the upper extremity injurycaused by baseball1,8. Sports injuries are most often moreprecisely due to being struck by or striking an object,accounting for 34% of incidents, falls cause 28% of injuries,and overexertion causes 13% of the total injuries3.

Other studies have been similar to our study with theresults different from our study and stated that, the mostinjury-prone areas are the upper limbs, comprising as manyas 46% of injuries, followed by the lower limbs (36%), headand neck (15%), and trunk (three percent)5. In the UnitedStates. from 1997 to 1999, about 1.1 million injuries involvedthe head or neck areas, of which 17% were internal headinjuries. Sports are a major cause of traumatic brain injury.9Those who play football are most likely to injure the knee;the next most common injury sites in football are the ankle,wrist, and hand10. May be the difference that is beenwitnessed is because of the type of the sports being takenfor the study and the other reason for the same can be theplace where the study is been performed the study with thepreviously mentioned results has been carried out at theaccident and emergency department of the hospital.

Limitations and scope of the study

Type of injury have not been catagorised that is whetherbony or soft tissue or even traumatic or overuse, as thebasic objective of the study was only to find out the totalnumber of injuries at each joint. The causes for injuries seenon the field have not been mentioned as teams were notapproached before and the participants were seen directlyon the ground.

In future to establish the causes a study may be plannedby tracing the participants from the beginning of trainingperiod itself as training error is also one of the cause.

Conclusion

The commonest site of injury during the competitiveevent is the ankle and foot region and the injuries are morecommon in boys than in girls at this age.

References

1. Hutchinson MR, Ireland ML. Overuse and throwinginjuries in the skeletally immature athlete. Instr CourseLect 2003; 52: 25-36.

2. Adirim TA, Cheng TL. Overview of injuries in the youngathlete. Sports Med 2003; 33: 75-81.

3. Conn JM, Annest JL, Gilchrist J. Sports and recreationrelated injury episodes in the US population, 1997-1999.

33Motimath B.S. / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Inj Prev 2003; 9: 117-23.4. Hambridge SJ, Davidson AJ, Gonzales R, Steiner JF.

Epidemiology of pediatric injury-related primary careoffice visits in the United States. Pediatrics. 2002; 109:559-65.

5. Boyce SH, Quigley MA. An audit of sports injuries inchildren attending an Accident and EmergencyDepartment. Scott Med J 2003; 48: 88-90.

6. Damore DT, Metzl JD, Ramundo M, Pan S, VanAmerongen R. Patterns in childhood sports injury.Pediatr Emerg Care 2003; 19: 65-7.

7. Benell KL, Brukner PD. Epidemiology and Site

specificity stress fractures. Clin Sports Med 1997; 16(2):179-96.

8. Lord J, Winell JJ. Overuse injuries in pediatric athletes.Curr Opin Pediatr 2004; 16: 47-50.

9. MacKay M, Scanlan A, Olsen L, Reid D, Clark M, McKimK, et al. Looking for the evidence: a systematic review ofprevention strategies addressing sport and recreationalinjury among children and youth. J Sci Med Sport 2004;7: 58-73.

10. Adickes MS, Stuart MJ. Youth football injuries. SportsMed 2004; 34: 201-7.

34 Motimath B.S. / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Mental imagery–A reviewChaya GargHead, Banarsidas Chandiwala Institute of Physiotherapy, New Delhi

Mental imagery was defined by Denis1 in 1985 as "apsychological activity which evokes the physicalcharacteristics of an object either permanently ortemporarily absent from the perceptual field." The processcan apply to static or dynamic events, past, recent or yet tobe accomplished. Mental imagery, also called visualizationand mental rehearsal, is the experience that resemblesperceptual experience, but which occurs in the absence ofthe appropriate stimuli for the relevant perception.Whenever one imagines himself performing an action in theabsence of physical practice, he is said to be using imagery.Mental imagery involves the efferent activation of visualareas in prestriate occipital cortex and parietal and temporalcortex, with these areas representing the same kinds ofspecialized information in imagery as in perception. Variousmodes of Mental Imagery include: 1. Visual mode (most commonly used) 2. Auditory mode and3. Kinesthetic mode

Types

Imagery is classified into two types External Imagery: which is predominantly visual andcharacterized as a third-person perspective i.e. seeingoneself performingInternal (motor) Imagery: which is kinesthetic andexplained as a first-person perspective i.e. feeling oneselfperforming2

Research has demonstrated that the two types ofimagery were physiologically distinct by observing greatermuscle activity during internal imagery2,3,4. Furthermore ithas been determined that the internal version is moreeffective when used in connection with motor performance5.

Mechanisms

During mental practice, correlative activations occur atthe cortical level as well as in the musculature imagined asbeing used. For example, Breitling and colleagues7 reportedsimilar activity in the motor execution cortical areas whensubjects imagined finger movements in a relaxed state aswhen they actually performed the movements7. Studiesmeasuring electromyographic (EMG) activity, cortical motorevoked potentials, and cerebral blood flow also have shownthat the appropriate neuromotor pathways imagined asbeing used are actually being used and that metabolicactivity of neurons is increased during mental practice as ifthe activity is actually being performed8,9,10,11. Mentalpractice and physical practice also lead to plastic changesin the motor cortex area of the brain12. Other authors13 havedetermined that identical cerebellar control mechanisms areused in mental practice as are used in actual movement.

Jeanerrod and Frak6 found that neuron discharges in theparietal and premotor cortices ‘map’ a pattern of action evenwhen the given action is not being physically performed.Further, they asserted that motor imagery could be a potenttool in improving the function of the motor system.

Development plan (Sports)

Sport psychologist Rainer Martens suggested a threestage development plan to develop a systematic approachto using imagery

Stage I: Sensory Awareness First step towards use of imagery is to develop sensory

awareness. A fundamental point that must be made at thisjuncture is that visualisation and imagery are not one andthe same; imagery should involve far more thanvisualisation, including the feelings of movements, sounds,emotions and, in some cases, even smells.

A cricket batsman, for example, might attempt tobecome more aware of sensory process by recalling theimportant visual environmental features, as well as thesound of the bowler running-in and the noise the ball madethrough the air. He may recall the feel of swinging the batand making contact with the ball. The subsequent sounds ofbat on ball and the call of his partner to run may also beconsidered. The sense of control as the ball reached theboundary, a feeling of determination and the smell of freshlymown grass may help to stimulate all the senses. Thereforefirst stage is dedicated to appreciating things that theindividual may have come to take for granted.

Stage II: Develop VividnessThe next step is to develop vividness. It is true that some

people are able to recall or create very clear and vividimages, while others may struggle to get an image at all.With practice, though, most people are able to sharpen theirimages so that recognisable sensory experiences areevident. This is the stage to be creative and experiment byusing scenes and experiences that are very familiar to you.These exercises do not need to be sport-specific at first, asthe general idea is to promote overall clarity.

Stage III: ControlThe final stage of the development plan involves control.

If one is mentally rehearsing what he/she is going to do, itis important to have control over the images. This isbecause imagery can be destructive as well as helpful. If, forexample, a golfer is imagining the path of the ball on thegreen but continually sees herself missing the putt, this ishardly likely to help. The great thing about imagery is that,even if the golfer has missed putts in reality, imageryprovides an opportunity to correct errors.

35Chaya Garg / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

This stage is more sport specific and should incorporatethe desired outcome. One should feel the movement andsee a positive result, such as the golf ball following thecorrect path and entering the hole. If one does startimagining negative outcomes, one should try to recall aprevious success – or even watch another personsuccessfully complete the skill and try to replicate this inyour mind, with yourself in the role of successful performer.

Although the most obvious application of imagery is inthe learning and performing of sport skills, there are manyother ways to use the technique. For example, imagery canalso be used to practise strategies, manipulate levels ofarousal, manage stress, build confidence, deal with painand periods of injury and develop an appropriate focus.

Categories of imagery

For maximum effect, athletes should match the contentor type of imagery with the desired outcome. Athlete shouldthink carefully about the components of his imaginedexperiences and the aim of using imagery. Various aimsmay include facilitating learning and performance of skillsand strategies, or attempting to build confidence or tomotivate. The five main categories of imagery have beenidentified as follows:

1. Motivational-specific (MS): This involves seeing oneselfwinning an event, receiving a trophy or medal and beingcongratulated by other athletes. MS imagery may boostmotivation and effort during training and facilitate goal-setting, but is unlikely on its own to lead directly toperformance benefits.

2. Motivational general-mastery (MG-M): This is basedon seeing oneself coping in difficult circumstances andmastering challenging situations. It might includemaintaining a positive focus while behind, and then comingback to win. MG-M imagery is important in developingexpectations of success and self-confidence.

3. Motivational general-arousal (MG-A): This is imagerythat reflects feelings of relaxation, stress, anxiety or arousalin relation to sports competitions. MG-A imagery caninfluence heart rate – one index of arousal – and can beemployed as a ‘psych-up’ strategy.

4. Cognitive specific (CS): This involves seeing yourselfperform specific skills, such as a tennis serve, golf putt ortriple-toe-loop in figure skating. If learning and performanceare the desired outcomes, evidence suggests that CSimagery will be the most effective choice.

5. Cognitive general (CG): This involves images ofstrategy and game plans related to a competitive event.Examples could include employing a serve-and-volleystrategy in tennis or a quick-break play in basketball. Casestudies support the use of this type of imagery, althoughcontrolled experimental evidence is still needed.

Clearly there is potential for these types of imagery tooverlap if, for example, one imagines specific sports skills,such as a golf putt (CS), with the accompanying positiveoutcome and tournament-clinching result (MS). However, ifone chooses the wrong type of imagery, she may notachieve any benefits. For example, Cognitive specificimagery significantly improves sit-up performance, while

Motivational general-mastery imagery is ineffective.Conversely, Motivational general-mastery imagery is moreeffective than Cognitive specific imagery for boosting self-confidence. The trick is to decide what it is you want toachieve, then make the imagery content match your goals.

Effects & uses

Mental practice (also known as "imagery"), whencombined with physical practice, accelerates motor learningand improves subsequent physical performance15,16,17,18.Because of its positive effects on strength,19,20 endurance,21

and aim and precision,22,23 mental practice is frequently usedby professional and amateur athletes24,25. Mental practicehas also been suggested to be a viable tool for improvingmotor learning and performance in rehabilitative settings14,26.Some studies27,28 have demonstrated the effectiveness ofmental practice in therapeutic settings in improving motorperformance when it is combined with physical practice.Randomized controlled studies by Fansler et al27 and Lindenand colleagues,29 for example, demonstrated greaterimprovements on balance tasks (eg, one-legged standing)among elderly women who combined mental practice withphysical practice than those who participated only inphysical practice. Fairweather and Sidaway30 reported thata 3-week mental practice program, when combined withphysical practice, improved posture of individuals withabnormal curvature of the spine. In addition to usingrandomized controlled methods, all of these studies hadindependent evaluators and significant effects.

References

1. Denis, M.V. (1985) Visual imagery and the use of mentalpractice in the development of motor skills. CanadianJournal of Applied Sport Science 10, 45-165.

2. Epstein, M.L. (1980) The relationship of mental imageryand mental rehearsal to performance of a motor task.Journal of Sport Psychology 2, 211-220.

3. Jacobson, E. (1932) Electromyography of mentalactivities. American Journal of Psychology 44, 677-694.

4. Shaw, W. A. (1940) The distribution of muscular actionpotentials to imagined weight lifting. Archives ofPsychology, 247, 1-50.

5. Weinberg, R. S. (1982) The relationship between mentalpreparation strategies and motor performance: a reviewand critique. Quest 33, 195-213.

6. Jeannerod, M. and Frak, V. (2001) Mental imaging ofmotor activity in humans. Institute of Cognitive Sciences,Working Paper 99-8, 5-7.

7. Breitling D, Guenther W, Rondot P. Motor responsesmeasured by electrical activity mapping. BehavNeurosci.1986; 100:104–116.

8. Bakker FC, Boschker M, Chung J. Changes in muscularactivity while imagining weightlifting using stimulus orresponse propositions. J Sport Exerc Psych.1996;18:313–324.

9. Livesay JR, Samras MR. Covert neuromuscular activityof the dominant forearm during visualization of a motortask. Percept Mot Skills.1998; 86:371–374.

10. Roth M, Decety J, Raybaudi M, et al. Possibleinvolvement of the primary motor cortex in mentallysimulated movement: a functional magnetic resonance

36 Chaya Garg / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

imaging study. Neuroreport.1996; 17:1280–1284.11. Weiss T, Hansen E, Beyer E, et al. Activation during

mental practice in stroke patients. Int JPsychophys.1994; 17:91–100.

12. Pascual-Leone A, Dang N, Chen LG, et al. Modulationof muscle responses evoked by trans-cranial magneticstimulation during the acquisition of new fine motor skills.J Neurophysiol.1995; 74:1037–1045.

13. Ito M. Movement and thought: identical controlmechanisms by the cerebellum. Trends Neurosci.1993;16:453–454. Breitling D, Guenther W, Rondot P. Motorresponses measured by electrical activity mapping.Behav Neurosci.1986; 100:104–116.

14. Carr J, Shephard R. Neurological Rehabilitation:Optimizing Motor Performance. Oxford, England:Butterworth-Heinemann;1998.

15. Burhans RS, Richman CL, Burgey DB. Mental imagerytraining: effects on running speed performance. Int JSport Psych.1988; 19:26–31.

16. Yaguez L, Nagel D, Hoffman H, et al. A mental route tomotor learning: improving trajectoral kinematics throughimagery training. Behav Brain Res.1998; 90:95–106.

17. Bachman K. Using mental imagery to practice a specificpsychomotor skill. J Cont Ed Nurs.1990; 21:125–128.

18. Hird JS, Landers DM, Thomas JR, Horan JJ. Physicalpractice is superior to mental practice in enhancingcognitive and motor task performance. J Sport ExercPsych.1991; 13:281–293.

19. Shelton TO, Mahoney MK. The content and effectof"psyching-up" strategies in weightlifters. Cog TherRes.1978; 2:275–284.

20. Tynes LL, McFatter RM. The efficacy of"psyching"strategies on a weightlifting task. Cog Ther Res.1987;11:327–336.

21. Lee C. Psyching up for a muscular endurance task:effects of image content on performance and moodstate. J Sport Exerc Psych.1990; 12:66–73.

22. Murphy SM, Woolfolk R. The effects of cognitiveinterventions on competitive anxiety and performanceon a fine motor skill task. Int J Sport Psych.1987;18:152–166.

23. Wrisberg CA, Anshel MH. The effect of cognitivestrategies on the free throw shooting performance ofyoung athletes. Sport Psychologist.1989; 3:95–104.

24. Nicklaus J. Golf My Way. New York, NY: Simon &Schuster;1974

25. Wrisberg CA. An interview with Pat Head Summitt. SportPsychologist.1990; 4:180–191.

26. Warner L, McNeill ME. Mental imagery and its potentialfor physical therapy. Phys Ther.1988; 68:516–521.

27. Fansler CL, Poff CL, Shephard KF. Effects of mentalpractice on balance in elderly women. Phys Ther.1985;65:1332–1337.

28. Page SJ. Imagery improves motor function in chronicstroke patients with hemiplegia: a pilot study. OccupTher J Res. In press.

29. Linden CA, Uhley JE, Smith D, et al. The effects ofmental practice on walking balance in an elderlypopulation. Occup Ther J Res.1989; 9:155–169.

30. Fairweather MM, Sidaway B. Ideokinematic imagery asa postural development technique. Res Q ExercSport.1993; 64:385–392.

37Chaya Garg / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Incidence of brachial plexus injuries during cardiac surgeries - Areview of literatureDarshpreet Kaur1, Nidhi Billore2

1MPT, Ex. Lecturer Lovely Professional University, 2MPT, Lecturer R.V. Physiotherapy College, Bangalore

Introduction

Neuropathies involving the brachial plexus, phrenic,recurrent laryngeal, and saphenous nerves, as well as thesympathetic chain are complications of cardiac surgery.The reported frequency of nerve injuries varies from 1.5% to24% for the brachial plexus and 10% to 60% for the phrenicnerve1-5. Neuropathies of the recurrent laryngeal, lower limb(saphenous) nerves, and the sympathetic chain are lessfrequent.

There are three principal anatomical features that makethe brachial plexus susceptible to neuropathy:

First, its superficial location makes it susceptible to directdamage.

Second, the nerve roots of the brachial plexus are fixedboth proximally at their site of origin (the intervertebralforamina) and distally where they are tethered to theinvesting fascia, muscles, and other tissues. As a result,force applied between these points increases the likelihoodof producing a stretch neuropathy6,7.

Third, the space between the first rib and the clavicle islimited. Thus, fracture and/or displacement of the first ribcan directly damage the brachial plexus7.

Cell bodies in the dorsal root ganglion provide acontinuous supply of nutrients distally to the peripheralaxons.

Any injury that interferes with this supply can damagethe nerve. In 1973, Upton and McComas8 described the“double crush” hypothesis to explain nerve entrapmentsyndromes. This hypothesis states that two relatively minornerve lesions, which by themselves are incapable ofproducing significant nerve damage, can combine toproduce a significant lesion. For example, clinically silentulnar nerve entrapment in the cubital tunnel (presentpreoperatively) may be converted to an overt ulnarneuropathy by a minor stretch neuropathy to the lower trunkof the brachial plexus during sternal retraction. Thishypothesis may hold true for many brachial plexus injuriesafter cardiac surgery. However, despite the wideacceptance of this double crush hypothesis by the medicalcommunity, serious questions have been raised about thisconcept because no experimental studies have shownconclusively that double lesions across a nerve causemagnified damage9-12.

Risk Factors for Brachial Plexus Neuropathy

1. Sternal Retraction and Internal Mammary ArteryDissection

Sternal retraction is one of the key factors responsiblefor brachial plexus neuropathy. As discussed previously, theanatomical features of the brachial plexus render itsusceptible to stretch injury.

This stretching may be made worse by subsequentturning of the head to the contralateral side13. Direct traumaof the brachial plexus can occur by first rib fracturefragments or the associated fracture hematoma directlycompressing the nerves14,15.

Autopsy findings: posterior first rib fracture fragmentspenetrating the brachial plexus

Posterior fractures of the first rib can easily remainundiagnosed by routine radiography. The incidence of upperrib fractures after median sternotomy is uncertain. The radiographically reported frequency of first and second ribfractures varies from 4% to 16%16-18.

A: Normal course of the brachial plexus as it passes over the first rib.B: Opening the sternum widely causes superior rotation of the first rib thatpushes the clavicles into the retroclavicular space leading to stretching of thebrachial plexus.

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There are several commonly used sternal retractors.Most of the studies have been conducted with the Cooleyand the Ankeney retractors. Several studies have shownthat the more caudal placement of the retractors within thesternotomy is associated with a reduced incidence of firstrib fractures1,2,19. The optimal placement of the retractor iscontroversial.

Vander Salm et al.14 studied the placement of sternalretractors and first rib fractures in 20 noncardiac patientswho had autopsies performed through a mediansternotomy. They found that the frequency of first ribfractures was completely eliminated by placing the cephaladblade of the sternal retractor in the fourth intercostal space.In contrast, 11 patients had first rib fractures demonstratedby chest radiography when the cephalad blade was placedin the second intercostal space These authors suggestedthat, by placing the retractor in the cephalad position, theupper portion of the sternum is spread less and may resultin less pressure transmitted to the first rib with a resultantdecreased frequency of first rib fractures.Baisden et al.1 prospectively studied 36 consecutive cardiacsurgery patients undergoing median sternotomy. All patientshad preoperative and postoperative chest roentgenogramsas well as radionuclide bone scans 7 to 14 days aftersurgery. By removing the uppermost pair of blades from theAnkeney retractor, they were able to reduce the frequencyof first rib fractures from 50% to 16%.

2. PositioningStudies attempting to correlate arm positioning with

brachial plexus neuropathy have also produced inconsistentresults. However results showed that hands-up positioningwas associated with a lower frequency of SSEP amplitudedecreases, this did not reflect in a lower frequency of clinicalpostoperative brachial plexus neuropathies.

3. Central Venous Catheter PlacementThe internal jugular vein is closely related to the brachial

plexus. While cannulation of the internal jugular vein maylead to direct needle injury to the brachial plexus,cannulation of the internal jugular vein has not consistentlybeen shown to be associated with an increased frequencyof brachial plexus neuropathies. Additionally, most patientswho undergo internal jugular vein cannulation are not havingcardiac surgery. The frequency of brachial plexusneuropathies in this noncardiac surgery population is verysmall. Other investigators have not found the samecorrelation between internal jugular vein cannulation andbrachial plexus neuropathy2,27,28.

4. Patient and Operation CharacteristicsAdvanced age has been linked to brachial plexus

neuropathy4,15, but diabetes mellitus, sex, height, weight,history of smoking, and presence of carotid bruit do notappear to be significant risk factors26,30. The duration ofcardiopulmonary bypass (CPB), aortic cross-clamp times,total anesthesia times, hematocrit during CPB,or type ofoxygenator used have also not been associated withincreased frequency of brachial plexus neuropathies afterCABG surgery2,26,28,29.

Diagnosis of brachial plexus neuropathy

The majority of symptomatic brachial plexusneuropathies after cardiac surgery involve stretching of the

lower roots (C8-T1) related to use of sternal retractors andpresent postoperatively as ulnar neuropathy20,21,23. Otherpossible sites where the ulnar nerve can be damagedinclude the edge of the supinator muscle below the elbow,ulnar groove at the elbow, cubital tunnel, and the medialbase of the palm. Examination of the brachial plexusincludes a detailed history of upper extremity pain,parasthesia, assessment of sensation to pin prick, andexamination of motor function of muscle groups innervatedby the brachial plexus. Motor evaluation includes elevationof the scapula (C5), adduction (C5-7), abduction (C5-8),lateral and medial (C5-8) rotation of the arm, flexion andsupination of the forearm (C5-6), ulnar hand flexion (C7-8and T1), thumb flexion and opposition (C7-8) and T1),extension of the forearm and phalanges (C6-8), and radialextension of the hand and extension of the thumb (C7-8).Sensory and motor symptoms associated with ulnarneuropathy can differ remarkably depending on the site ofnerve damage25,31.

Ben-David and stahl33 concluded that

a. Although controversial, cardiac surgery is associatedmore with Brachial plexus neuropathy to the lower rootsas compared with upper and middle root associationwith noncardiac surgery.

b. Brachial plexus neuropathy after cardiac surgery resultsprimarily in sensory deficits as compared with relativelypainless motor deficits associated with noncardiacsurgery plexus neuropathies.

c. Brachial plexus neuropathy after cardiac surgery isgenerally associated with a more rapid recovery ascompared with noncardiac surgery34.Warner et al.32 identified male sex, low24 and high36 body

mass index, and longer duration of hospital stays asindependent predictors for the development of persistentpostoperative ulnar neuropathy in noncardiac patients.

Electrophysiologic studies can detect changes in nervefunction during the perioperative period, but these changesare very sensitive and often do not reliably predictpostoperative neuropathic symptoms.

Measurement of motor and sensory conductionvelocities, SSEP’s, and electromyography are some of thecommon modalities used.Maximum motor and sensoryconduction velocities (MMCV/MSCV) can be measuredacross the arm, elbow, and forearm. Major neuropathies areassociated with slowing of nerve conduction. Watson et al.34

prospectively studied bilateral ulnar nerve MMCV in 20patients preoperatively, immediately after cardiac surgery,and 4 to 6 weeks postoperatively. They considered slowingof MMCV more than 20% in the elbow relative to theforearm significant for ulnar neuropathy.However, ulnarneuropathy after surgery was uninfluenced by thepreoperative status of the ulnar nerve.

In contrast, Hickey et al.35 prospectively studiedintraoperative bilateral SSEP’s from median and ulnarnerves in 30 patients undergoing cardiac surgery. Theydemonstrated that central venous cannulation wasassociated with brief SSEP changes in 13% (4 of 30) ofpatients. Use of sternal retractors was associated withsignificant SSEP changes in 70% (21 of 30) patients. In 16of 21 patients, SSEP changes reverted to normalintraoperatively, and none demonstrated postoperativebrachial plexus neuropathies. The remaining 5 of the 21

39Darshpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

patients demonstrated postoperative neurological deficits.In all of these five patients, SSEP changes associated withsternal retraction persisted until the end of surgery.However, Seal et al.36 found no relationship betweentransient compared with persistent SSEP changes andsymptomatic postoperative brachial plexus neuropathy.

Prognosis of brachial plexus neuropathy

The overall prognosis of brachial plexus neuropathiesafter cardiac surgery is generally good. However, prolongedrecovery (up to one year), at times with residual symptoms,has been reported33. In a prospective study of 335 patients,Tomlinson et al.19 reported severe persistent brachial plexusneuropathy in only 1 of 16 (0.3%) patients considered tohave postoperative brachial plexus neuropathy. Theremaining 15 patients (4.8%) were symptom-free at the timeof discharge.

Hanson et al.26 studied 531 patients prospectively andthe clinical diagnosis of brachial plexus neuropathy wasmade in 5.0% (26 of 531) patients. Similarly only 1.0% (6 of531) of patients had persistent symptoms for more than fourmonths.

Vahl et al.22, in a prospective study of 1000 patients,showed that 0.8% (8 of 1000) patients had symptomspersisting for more than three months.

Prevention of brachial plexus neuropathy

It appears that, despite optimal surgical and anesthetictechniques, brachial plexus neuropathies can still occur.

Factors that may reduce the frequency of brachial plexusneuropathies include: a) Precise midline sternotomy to avoid subsequent

asymmetrical sternal traction,b) More caudal placement of the sternal retractor,c) Cautious use of asymmetrical sternal retractors, andd) Maintenance of neutral head position

Objectives

The objective of this study was to find out the incidenceof brachial plexus injuries post cardiac operations in arenowned cardiac hospital of India in Bangalore.

Methodology

Source of Data: In patients of the hospitalSubjects: 70 subjects undergone cardiac surgery from 55to 70 years of age satisfying the inclusion criteria wereincluded in the study.

Inclusion criteria

1. Subjects who’ve undergone cardiac surgery with mediansternotomy

2. Stable condition3. Age group 55 to 70 years4. Subjects having numbness or tingling sensation over

one or both the arms5. Subjects with pre-operative muscle power in upper limb

(all the groups) 5/5

Exclusion criteria

1. Subjects with recent history of fall or trauma to arm2. Subjects with history of frozen shoulder/shoulder

dislocation3. Subjects with extensive post surgical oedema in arm 4. Uncooperative patients5. Subjects with Horners syndrome6. Subjects with cervical rib/thoracic outlet syndrome7. Subjects with cervical spondylosis8. Subjects with neuralgic amyotrophy9. Subjects with history of PANCOAST’S tumour

Procedure

Patients undergoing the cardiac surgery between 5thmarch to 10th march 2008 were included for this study.Their pre-operative assessment was taken and manualmuscle power testing was done and recorded.

Post operatively after shifting from ITU to wards theirmuscle power was re-evaluated and findings were recorded.

All these 70 subjects were daily monitored for anyneurological signs or symptoms developing post surgically.

Results

Out of 70 subjects 4 subjects complained of post-operative tingling sensation and numbness in one arm &decreasing grip strength in the affected arm. They wereinstructed to do ball exercises and other active movementsof the arm, in order to get relief. But these exercises failedto provide any significant relief and after a period of 6 daysfollowing finding were noted in these patients:I. Weakness in left armII. Decreased sensation along C7,8 & T1 dermatomeIII. Power 3+/5 in lumbricals and interosseiIV. Egawas test positiveV. Froment’s /Jeanne’s sign was positive

Thus these positive findings indicate of ulnar nerveinvolvement in these patients.

Discussion

From the results obtained approximately 6% patientswho undergo cardiac surgery suffer from severe brachial

34

no numbness

or tingling

sensation post

operatively

32

mild post

operative

tingling

which

resolved

4Persistent

numbness

with gradual

muscle

weakness

70SUBJECTS

40 Darshpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

plexus injury and 46% from milder form, thereby leading tomuscle weakness, decreased grip strength and ultimatelypsychological distress to the patient.

Thus a physiotherapist attending such patients shouldmake sure that before the patient is discharged he/she isthoroughly evaluated, if required with electrophysiologicaltests, for any muscle weakness/numbness. In case of anysuch positive findings adequate physiotherapy should begiven to prevent such complications from gaining groundsand thus causing patient more distress and debilitatingfeeling.

Conclusion

Thus from the above study we can conclude that theincidence of brachial plexus injury in post cardiac surgerypatients can’t be under-estimated. In post operative cardiacrehabilitation a physiotherapist should pay due attention toany sign of neurological involvement and in case of anypositive findings the patient should be adequatelyrehabilitated to avoid development of any kind of disabilitylater on.

Further it is being recommended that similar studyshould be conducted on a larger population to give a nearexact estimate of patients suffering from brachial plexusinjury post surgery, which can not only form a guideline forphysiotherapists but also an indication for surgeons to adoptdifferent methods of surgeries as discussed in introductionpart, with adequate literature review.

References

1. Baisden CE, Geenwald LV, Sympas PN. Occult ribfractures and brachial plexus injury following mediansternotomy for openheart operations. Ann Thorac Surg1984;38:192– 4.

2. Vander Salm TJ. Brachial plexus injury after open-heartsurgery. Ann Thorac Surg 1984;38:660 –1.

3. Efthimiou J, Butler J, Woodham C, et al. Diaphragmparalysis following cardiac surgery: role of phrenic nervecold injury. Ann Thorac Surg 1991;52:1005– 8.

4. Abd AG, Braun N, Baskin MI, et al. Diaphragmaticdysfunction after open-heart surgery: treatment with arocking bed. Ann Intern Med 1989;111:881– 6.

5. O’Brien JW, Johnson SH, VanSteyn SJ, et al. Effects ofinternal mammary artery dissection on phrenic nerveperfusion and function. Ann Thorac Surg 1991;52:182– 8.

6. Gray H. Gray’s Anatomy. 15th ed. New York: Barnes &Nobles,1995.

7. Kirsh MM, Magee KR, Gago O, et al. Brachial plexusinjury following median sternotomy incision. Ann ThoracSurg 1971;4:315–9.

8. Upton RM, McComas AJ. The double crush in nerveentrapment syndromes. Lancet 1973;11:359–62.

9. Dellon AL, Mackinnon SE. Chronic nerve compressionmodel for the double crush hypothesis. Ann Plast Surg1991;26:259–64.

10. Mackinnon SE, Dellon AL. Experimental study of chronicnerve compression. Hand Clin 1986;2:639 –50.

11. Mackinnon SE, Dellon AL, Hudson AR, et al. Chronicnerve compression: an experimental model in the rat.Ann Plast Surg 1984;13:112–20.

12. O’Brien JP, Mackinnon SE, MacLean AR, et al. A model

of chronic nerve compression in the rat. Surg Forum1987;19:430–5.

13. Graham JG, Pye IF, McQueen INF. Brachial plexusinjury after median sternotomy. J Neurol NeursurgPsychiatr 1981;44:621–5.

14. Vander Salm TJ, Cereda JM, Cutler BS. Brachial plexusinjury after median sternotomy. J Thorac CardiovascSurg 1980;80:447–52.

15. Vander Salm TJ, Cutler BS, Okike ON. Brachial plexusinjury after median sternotomy. Part II. J Thorac Surg1982;83:914 –7.

16. Greenwald LV, Baisden CE, Symbas PN. Rib fracturesin coronary bypass patients: radionuclide detection.Radiology 1983;148:553– 4.

17. Curtis JA, Libshitz HI, Dalinka MK. Fracture of the firstrib as a complication of midline sternotomy. Radiology1975;115:63–5.

18. Carter AR, Sostman HD, Curtis AM, et al. Thoracicalternations after cardiac surgery. AJR 1983;141:475– 81.

19. Tomlinson DL, Hirsch IA, Kodali SV, Slogoff S.Protecting the brachial plexus during mediansternotomy. Thorac CardiovascSurg 1987;94:297–301.

20. Jellish WS, Blakeman B, Warf P, Slogoff S. Somato-sensory evoked potential monitoring used to comparethe effect of three asymmetric sternal retractors onbrachial plexus injury. Anesth Analg 1999;88:292–7.

21. Jellish WS, Martucci J, Blakeman B, Hudson E.Somatosensory evoked potential monitoring of brachialplexus to predict nerve injury during internal mammaryharvest: intraoperative comparisons of the Rultract andPittman sternal retractors. J CardiothoracVasc Anesth1994;8:398–403.

22. Vahl CF, Carl I, Muller-Vahl H, Eberhard S. Brachialplexus injury after cardiac surgery: the role of internalmammary artery preparation–a prospective study on1000 consecutive patients. J Thorac Surg 1991;102:724 –9.

23. Roy R, Stafford MA, Charlton JE. New injury andmusculoskeletal complaints cardiac surgery: influenceof internal mammary artery dissection and left armposition. Anesth Analg 1988;67:277–9.

24. Jackson L, Keats AS. Mechanism of brachial plexuspalsy following anesthesia. Anesthesiology 1965;26:190-4.

25. Jellish WS, Blakeman B, Warf P, Slogoff S. Hands-uppositioning during asymmetric sternal retraction forinternal mammary artery harvest: a possible method toreduce brachial plexus injury.Anesth Analg 1997;84:260 -5.

26. Hanson MR, Breuer AC, Furlan AJ, et al. Mechanismand frequency of brachial plexus injury in open-heartsurgery: a prospective analysis. Ann Thorac Surg1983;36:675–9.

27. Rieke H, Benecke ER, Devine E, et al. Brachial plexuslesions following cardiac surgery with mediansternotomy and cannulation of the internal jugular vein.J Cardiothorac Vasc Anesth1989;3:286 –9.

28. Stangl R, Altendorf-Hofmann A, von der Emde J.Brachial plexus lesions following median sternotomy incardiac surgery. Thorac Cardiovasc Surg 1991;39:360–4.

29. Sotaniemi KA. Brachial plexus lesion complicatingsternotomy. J Neurol Neurosurg Psychiatry. 1982;45:568.

30. Lederman RJ, Breuer AC, Hanson MR, et al. Peripheralnervous system complications of coronary artery graft

41Darshpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

surgery. Ann Neurol 1982;12:297–301.31. Brazis PW, Masdeu JC, Biller J. Localization in clinical

neurology. 3rd ed. New York: Little, Brown, andCompany, 1996.

32. Warner MA, Warner ME, Martin JT. Ulnar neuropathy.Incidence,outcome, and risk factors in sedated oranesthetized patients. Anesthesiology 1994;81:1332– 40

33. Ben-David B, Stahl S. Prognosis of intraoperativebrachial plexus injury: a review of 22 cases. Br JAnaesth 1997;79:440 –5.

34. Watson BV, Merchant RN, Brown WF. Early posto-perative neuropathies following coronary artery bypasssurgery. Muscle Nerve 1992;15:701–5.

35. Hickey C, Gugino LD, Aglio LS, et al. Intraoperativesomatosensory evoked potential monitoring predictsperipheral nerve injury during cardiac surgery.Anesthesiology 1993;78:29 –35.

36. Seal D, Balaton J, Coupland SG, et al. Somatosensoryevoked potential monitoring during cardiac surgery: anexamination of brachial plexus dysfunction. J Cardio-thorac Vasc Surg 1997;11:187–91.

42 Darshpreet Kaur / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

43Tal-Hatu K. Hamzat / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Family caregivers of Nigerian–African stroke survivors: theirknowledge and beliefs about strokeTal-Hatu K. Hamzat1, Oyedunni S. Arulogun2, Salim A. Akindele3

1Department of Health Promotion & Education College of Medicine (UCH), University of Ibadan, 3Department ofPhysiotherapy, College of Medicine (UCH), University of Ibadan, Nigeria

Abstract

Background

Family caregivers of Nigerian-Africans of South WesternNigeria who have suffered a stroke play a significant role inthe disease management including taking clinical and non-clinical decisions which may have both direct and indirecteffects on the patient’s recovery. This decision-makingprocess may be influenced by the knowledge and beliefs ofthese caregivers about the disease.

Aims and objectives

This cross-sectional study was carried out to assess theknowledge and beliefs of family caregivers of hospitalisedstroke survivors in six tertiary health facilities in South-Western Nigeria about stroke and its management.

Methods

Eighty-three caregivers comprising 50 males and 33females, aged between 17 and 66 years (32.86±10.92)were surveyed using a 39-item questionnaire. Data werecollected on their socio-demographic, known clinical historyof the patients, knowledge and beliefs of the respondentsabout stroke.

Results

Respondents were the children (54.2%), spouses(16.9%), and siblings (12.0%) of the post stroke patients.First place of seeking care after the onset of stroke werehospitals (81.9%) and traditional medical practitioners(16.9%). Out of the maximum obtainable score of 14 onknowledge of stroke, 49.4% got less than half score (zero to6 points), while 4.8% scored between 11 and 14 points. Theoverall group means score on belief was 3.4 out of themaximum 5.0.

Conclusions

The caregivers had average knowledge about strokeand their beliefs were considerably positive. In spite of this,some caregivers had misconceptions such as “stroke iscaused by witches and evil spirits”, “stroke can be sexuallytransmitted” and “only adults suffer from stroke”. These areimportant beliefs that should be taken into account whileplanning management intervention and enlightenmentprogramme to reduce the menace of stroke in thiscommunity.

Keywords

Nigerian-African; Caregivers; Stroke; Knowledge; Belief.

Introduction

Stroke is a leading cause of disability and avoidabledeath worldwide, with mortality and case fatality in somecountries of the Sub-Saharan Africa exceeding those in thedeveloped world1. It accounts for 50.4% of all neurologicadmissions in the Nigerian premier teaching hospital-University College Hospital, Ibadan2 and is reported to be asignificant cause of mortality in South West Nigeria3. Strokeis known to constitute a major health problem that hasimplication on public health. This is because apart fromclaiming hundreds of thousand of lives, it also disruptsfamilies and exerts significant impact on socio-economicactivities of the people in general. The burden of stroke toindividuals, families and societies is thus considerable4. Thehallmarks of this devastating illness, especially among theyoung victims, include marital breakup, unemployment,childcare responsibilities5 and dependence on own agedparents by the stroke survivors.

As a result of the stroke morbidity that sometimesincludes loss of consciousness in addition to the othersensori-motor dysfunctions; the individual who has suffereda stroke may not be able to take decisions on the type oftreatment attention he gets. This is especially if the patienthas communication disorder or language difficulty; whichmay translate into difficulty in understanding directions fortherapy6. Assistance and decisions on the course ofmanagement, particularly at the acute phase, may thereforebe at the discretion of others, namely: the emergencymedical aid team; the spouse; children; siblings and otherfamily members and in some cultures, members of thecommunity where the patient resides. In a typical Nigerian-African settlement like the Yoruba community of SouthWestern Nigeria, the immediate family members whoconstitute a sizeable percentage of informal caregivers takesuch vital decisions that include the type of treatmentattention received and the place where it is received, andother non-clinical decisions which may have both direct andindirect effects on the patient’s recovery, without consultingthe patient. This usually is not just because the individualwho has suffered a stroke is too ill to exert any significantinfluence, but because it is part of the cultural practice formembers of the extended family or community to playsignificant role in the care of the sick.

The decision-making process on care for a patient maybe influenced, among others, by factors such as theknowledge and beliefs of the caregivers towards the diseaseand its management. Since the action or inaction of thefamily caregivers with regard the treatment attention

received may eventually influence the prognosis of stroke,it is important to assess their knowledge and beliefs aboutthe disease. This study was carried out among immediatefamily members (family caregivers) of Nigerian-Africans whohave recently suffered a stroke and were hospitalised at thesix tertiary health facilities in South Western Nigeria. Theimmediate family members (family caregivers) referred to inthis study is the spouses, siblings, children andgrandchildren and the children in-law.

Methods

ParticipantsThe participants were freely consenting family

caregivers of patients who had recently suffered a strokeand were hospitalized in all the six teaching hospitals(tertiary facility) in the South-Western Nigeria over a 3-month period. The participants were recruited usingconsecutive sampling technique.

Study SiteAll the six tertiary health facilities in the South Western

Nigeria were used for the study. This category of healthfacility was selected based on the fact that they are thereferral centres for medical conditions such as stroke inSouth Western Nigeria.

ProcedureThe University of Ibadan/University College Hospital

(UI/UCH) Institutional Review Board approved the protocolfor this study. Approval was also obtained from themanagements of each hospital before embarking on thestudy. The study protocol was explained to the prospectiverespondents, and their informed consent was obtained priorto participation.

Instrument for data collectionA 39-item researcher administered questionnaire was

designed to gather information from the participants. Thecontent validity of the instrument was evaluated byknowledgeable practitioners in the field. The content validityof the final version was found to be 0.98. The questionnairewas divided into four sections:Section A: Consists of eight questions to gather data onsocio-demography of the caregivers.Section B (which has 2 parts): Bi consists of fivequestions to obtain information on what the respondent knew about the clinical history of thestroke survivors while Biisought information on the respondents’ knowledge about

stroke.Section C: Contains 11 questions to generate data on therespondents’ beliefs aboutstroke and its management.Section D: This section was open-ended allowing therespondents to freely express their other opinions andbeliefs about stroke aside those covered in the othersections of the questionnaire.

ScoringThe level of knowledge and beliefs about stroke was

determined by the number of statement/ question answeredcorrectly out of the total number of questions.

Section Bii of the questionnaire which assessed theknowledge of respondents was scored as follows: every

“NO” or “Undecided” to any correct statement was given ascore of zero while every “YES” to an incorrect statementwas given a score of zero as well. Every “YES” to a correctstatement was assigned a value of 1 while Every “NO” toany incorrect statement was also assigned a score of 1.

Section C of the questionnaire was scored as follows:Very Strongly Agree, Agree, Undecided, Disagree andStrongly Agree to any correct/true statement were scored5,4,3,2 and 1 respectively. Also, every strongly Agree,Disagree, Undecided, Agree and Strongly Agree to anyuntrue statement were scored 5, 4, 3, 2 and 1 respectively.

Data analysis

Descriptive statistic of mean, standard deviation, andfrequency percentage were used to summarize the dataobtained.

Results

Eighty-three individuals comprising 50 (60.2%) malesand 33 (39.8%) females, aged between 17 and 66 years(mean= 32.86±10.92) participated in this study. The meanduration of stroke was 6.12±2.47 weeks. Relationship ofrespondents to index stroke survivors showed that 45(54.2%) were their children, 14 (16.9%) and 10 (12.0%)were spouses and siblings respectively, and approximatelytwo-third of the subjects were Christians while 32.5% wereMuslims.

Majority 68 (81.9%) indicated that the first place theytook the patient to was the hospital while 14 (16.9%) firstsought the help of the traditional medicine practitioners.More than half (56.6%) and 6.0% of the caregivers wereaware of history of hypertension and diabetes respectivelyin their patients before the occurrence of stroke.

On the stroke knowledge items, 49.8% of therespondents got half of the questions testing their

Table 1: Some Demographics about the Respondents

n %Age Range

17 -26 32 38.627-36 20 24.137-46 24 28.947-56 3 3.657-66 4 4.8

Marital StatusSingle 49.4Married 49.4Divorced 1.2

Religious BeliefIslamChristianityAfrican Traditional Religion

Relationship to Stroke PatientsSpouse 16.9Children 54.2Sons-in-Law 3.6Daughters-in-Law 3.6Siblings 12Grandchildren 9.6

Level of EducationESE 6.0JSSE 13.3SSSE 24TE 56.6NE

Key: ESE=Elementary school education; JSSE=Junior secondary schooleducation; SSSE= Senior secondary education; TE=Tertiary education;NE=No formal education

44 Tal-Hatu K. Hamzat / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

knowledge correctly, while 5.0% got more than ¾ of theknowledge questions correctly. The maximum group meanscore for beliefs was 5.0 and the respondents scored morethan 2.5 points in the questions assessing their beliefs ofthe disease, except on the questions specifically askingthem if age is the only determinant of the stroke.

Discussion

Available data in Africa show that age-standardizedmortality, case fatality and prevalence of disabling stroke inAfrica are similar to or higher than, those measure in mosthigh income regions7. In order to reduce the incidence andmortality of stroke and enhance its prognosis, it would behelpful if the public is aware of the risk factors, theirpreventive strategies and the importance of early andappropriate medical intervention after the stroke might haveoccurred. The role of family caregivers in the totalmanagement of stroke is significant particularly in theNigerian-African communities especially because of thecultural practice and beliefs as well as model of pay-as-you-receive mode of health care that is still largely operational inthis part of the world. It is therefore important that thesecaregivers have sufficient knowledge about the disease andhave the right attitude towards its management. There ishowever dearth of information on the knowledge andattitude of family caregivers of stroke victims in this Africansub-population.

More than half of the family caregivers surveyed werechildren of the patients followed by their spouses and thesiblings, and then the children-in laws. This could be areflection of the family network system in the population.

The fact that the children accounted for majority of thecaregiver is not surprising as the social practice expectschildren to play a significant role in the care of their parents,especially when they are sick or in their old age.

Approximately one-fifth of the participants indicated thatthe first place they took their stroke patients to was thetraditional healers before taking them to the hospitals wherethis study took place. This trend is not odd because thetraditional healers tend lay strong claims to ability to cure alltypes of illnesses and diseases including stroke in thiscommunity and at supposedly cheaper cost. Some also tookthe patients first to the church apparently for spiritual healingand a significant proportion expressed the belief that acombination of prayer and medical treatment is the panaceato management of stroke. This could be a reflection of thesocietal beliefs of the respondents about the role of religionand spirituality in health or medical conditions. It is notuncommon among Nigerian-Africans to associate everyevent to a spiritual event that needs prayer intervention. Thistype of trend has been observed by Bham and Ross 8 whoreported that among the South African Indian Muslimcommunity, religion and faith in God play a pertinent role inbeliefs regarding cause of stroke.

The significant proportion of the caregivers (56.6%) whowere aware of history of hypertension in their index relativesbefore the incidence of stroke may suggest that thehypertension was probably not well taken care. Also only 5(6.0 of relatives were aware of history of diabetes in theirpatients. Half of the subjects can be said to have a goodknowledge about the risk factors and warning signs ofstroke in view of the results wherein 50.5% got half andmore of the knowledge score possible (7 and more out of14). This trend may suggest that the knowledge of the publicis good about stroke, a trend that may in part be attributedto the fact all the caregivers were literate and could haveobtained information through the media, personal readingand other sources. The trend observed in this studycontrasts with that reported by Gorelicks9 who submittedthat the public awareness about stroke and its warning signsare poor among the group studied.

Despite the appreciable level of knowledge of stroke bymany of the caregivers, it is imperative to note theresponses of those who were considered to have poorknowledge about the risk factors for stroke and whosebeliefs were shaped by incorrect knowledge ormisconceptions. The factors suggested by this group tocause stroke include frustration, poverty, sadism, excessivesugar and salt intake, food seasoning and haematinics,

Table 2: Respondents Perception on Risk Factors and Warning Sign ofStroke

n %Risk Factors

Habitual Snoring 6 7.2Alcohol Intake 31 37.3High Blood Pressure 71 85.5Oral Contraceptives 8 9.6Diabetes 26 31.3Stress 68 81.9Obesity 25 30.1Severe Headache 36 43.3Ageing 32 38.5Skin Disease 46 54.4

Sign of StrokeLoss of Memory 39 47.0Difficulty in Walking 55 66.3Sudden Confusion or Difficulty in Speaking 47 56.6Sudden Diarrhea 50 60.2

Table 3: Respondents’ Belief of Stroke

Statement Group Score Group Mean Score(Maximum=310) (Maximum=5)

Stroke is caused by witches, wizards, wicked people 156 2.5Stroke is a communicable disease 238 1.8Stroke can be sexually transmitted 232 3.7Only prayer can cure stroke 215 3.5Combination of prayers and medical intervention can cure stroke 291 4.7Traditional and medical treatments are the solution to stroke 165 2.7Stroke is preventable 244 3.9Physiotherapy is relevant in treating stroke 286 4.6Stroke can be a family disease 146 2.4Stroke is not preventable in the aged 165 2.7Only the aged suffer stroke 145 2.3

Key:Average mean score= 2.5Incorrect answer = Score of 2.4 and belowCorrect answer = Score of 2.5 and above

45Tal-Hatu K. Hamzat / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

while administration of intramuscular injection was indicatedby some as capable of causing or worsening the clinicalpresentations of stroke. Other misconceptions expressedinclude: only adults suffer from stroke”, “stroke is caused bywitches and evil spirits”, “stroke is a repercussion of one’swrongdoing to others”, “a consequence of curses” and“stroke can be sexually transmitted”. These are importantmisconceptions that may influence the judgment of caregivers in the choice of management of their patients whohave suffered stroke.

It is pertinent to observe that many of the caregivers inthis study indicated that physiotherapy play significant rolein the management of the patients. The high levelawareness of the respondents about physiotherapymanagement of stroke could be due to varying factorsincluding; the fact that some of the patients had beenreceiving physiotherapy and caregivers were probablyseeing the responses of the patients to this treatment,information they had obtained from other stroke survivorsor information given by the attending physician. Theimportance for relatives of hospitalised stroke patientshaving sufficient information, counseling and accessibilityhas been outlined by earlier researcher10.

Conclusions

The findings in this study show that on the average thefamily caregivers of the Nigerian-African individuals whohave suffered a stroke had good knowledge about stroke.Some however had the misconceptions about the diseasewhich may eventually influence the beliefs type of treatmentintervention given to the patient.

Limitations of the findings in this study include he factthat the caregivers were recruited from hospital settingswhich may make the sample to be somewhat selective andalso make some of them not to have expressed their truebeliefs about the stroke for fear of reprimand by theattending medical practitioners.

Implication of findings

It is instructive for all health practitioners involved instroke management to consider the opinions, beliefs andknowledge of the family caregivers of patients who havesuffered a stroke about the disease and also address themisconceptions that they may have about the disease. This

is of particular importance considering that irrespective ofwhether they have informed knowledge or not, the Nigerian-African family caregivers tend to play a significant role indecision making on the type of care received by the sick,which may affect the overall chance of recovery of thepatients. The beliefs and opinions expressed by some ofparticipants should also be taken into account whileplanning any educational programme to reduce the menaceof stroke in this community, through public enlightenmentcampaign.

References

1. Lemogoum D, Degaute JP, Boret P. Stroke prevention,treatment, and rehabilitation in Sub-Saharan Africa. AmJ Epidemiol. 2005; 29(5): 95-101

2. Talabi O.A. A 3-year review of neurologic admissions inUniversity College Hospital Ibadan Nigeria. West Afr JMed 2003; 22(2): 150-151.

3. Ogun SA, Ojini FI, Ogungbo B, Kolapo KO, Danesi MA.Stroke in south west Nigeria: a 10-year review. Stroke2005; 36(6): 1120-1

4. Young JB. The primary care stroke gap. Br J Gen Pract2001; 787-788.

5. Teasell, RW; Mc Rae, M.P and Finestone, H.M. Socialissues in the rehabilitation of younger stroke patients.Arch Phys Med Rehabil 2000; 81: 205-209.

6. Fritz SL, Light KE, Clifford SN, Patterson TS, BehrmanAL, Davis SB. Descriptive characteristics as potentialpredictors of outcomes following constraint-inducedmovement therapy for people after stroke. Phys Ther2006; 86:825-832.

7. Mensah GA. Epidemiology of stroke and high bloodpressure in Africa. Heart 2008; 94; 697-705.

8. Bham Z, Ross E. Traditional and western medicine:cultural beliefs and practices of South African IndianMuslims with regard to stroke. Ethn Dis. 2005; 15(4):548-554

9. Gorelick, P.B. Stroke prevention: windows opportunityand failed expectation? A discussion of modifiablecardiovascular risk factors and prevention proposal.Neuroepidemiology 1997; 16 (4): 163-73.

10. Van Der Smagt-Duijnstee, ME, Hamers JP, Abu-SaadHH, Zuidhof A. Relatives of hospitalized stroke patients:their needs for information, counselling and accessibility.J Adv Nurs 2001; 33(3), 307-315.

46 Tal-Hatu K. Hamzat / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Efficacy of modified constraint-induced movement therapy inchildren with spastic hemiparetic cerebral palsyMahotra Pardeep*, Senthilkumar C. B.**, Shankar Mamta****MPT Student, **Lecturer, ***Senior Lecturer, Department of Physiotherapy, Lovely Professional University, Punjab

Abstract

Modified constraint-induced movement therapy (mCIMT)implies restraint of the unaffected upper limb is applied andless than three hours per day of therapy is provided to theaffected limb. This is used to improve function ofhemiparetic upper extremity in cerebral palsy children; Thespecific objective of the study is to evaluate the effect ofmCIMT in upper extremity function of children with spastichemiparetic cerebral palsy. This study is a one group pretest post test design. 10 children with spastic hemipareticcerebral palsy were selected and assigned in one group.

Pre-test value of Quality of Upper Extremity SkillTest(QUEST) and Modified Ashworth Scale(MAS) wasmeasured on first day of the mCIMT program. mCIMT wasgiven two hours a day, five sessions a week, for three weeksper children. At the end of the mCIMT program, post-testQUEST and MAS was measured.

Major findings

Results shows that there is significant improvement inthe functional capacity as the calculated “t” value 7.173 forthe QUEST measure is in the table value at P=0.000

Results shows that there is significant improvement inthe muscle tone as the calculated “t” value 3.096 for theMAS measure is in the table value at P=0.013

Keywords

Cerebral Palsy, Hemiparetic, Spastic, Modified Const-raint Induced Movement Therapy.

Introduction

Little Club, named for the physician who first defined thecondition of cerebral palsy as “a persistent disorder ofmovement and posture appearing early in life and due to adevelopmental non-progressive disorder of the brain”1. Morerecently stated as a group of disorders of the developmentof movement and posture, causing activity limitation, thatare attributed to non-progressive disturbances that occurredin the developing foetal or infant brain which includes agroup of conditions and not a single clinical or pathologicalentity2,3.

By convention, a number of situations are excluded fromthe cerebral palsies: motor delay without specificneurological signs, including hypotonia in association withmental retardation, spinal cord damage; hydrocephalous;brain tumours; metabolic disease; well documentedsyndromes with a motor component; motor problems ofcerebral origin in spina–bifida; and disorders of fine motorcontrol3. The motor disorders of cerebral palsy are often

accompanied by disturbances of sensation, cognition,communication, perception, and/or behaviour, and/or by aseizure disorder4.

The prevalence of CP has risen to well above 2.0 per1000 live births in the last 40 years. Proportion of low birth-weight infants rose, proportion of diplegia decreased, whileproportion of hemiplegia increased in this time span. Themajority of people with CP have the spastic syndrome5.

In a retrospective study in Safdarganj hospital for CPcases, (91.4%) cases found were of spastic type. Hypotonic,ataxic and athetoid cerebral palsy were observed in 5.5, 1.5and 1.3% cases, respectively. With in the spastic group,quadriplegia comprised the maximum number of cases(34.9%) followed by hemiplegia (28.7%) and diplegia(21.9%)6.

Hemiparetic cerebral palsy is defined as a unilateralmotor disorder of early onset caused by static brainpathology. A degree of minor dysfunction on the oppositeside is usually accepted within this definition. Early handpreference and independent walking only mildly delayeddespite asymmetry of gait are the important signs. Usuallyupper limb is more severely involved, with major problemsin hand function3. This may also result into the ‘learned non-use’, that occurs, when individuals fail to use the affectedhand7.

The resulting motor failure results in suppression offuture attempts to use the more-affected limb. At the sametime, the individual learns to compensate by using only theuninvolved limb for most purposes. These efforts are at leastpartially effective, and the individual is consequentlyrewarded by this success. The result is that the individuallearns not to try to use the more-affected limb, the use ofwhich is then held in powerful inhibition8.

As the Children with hemiparetic cerebral palsy growand develop, they learn strategies and techniques tomanage daily tasks including play with one hand.Performance of tasks is discovered to be more efficient andeffective using the non-affected hand, even if there is onlymild impairment in the affected limb9.

Unlike adults with hemiplegia, who have had functionbefore the insult to the central nervous system, children withhemiplegia have usually never used their affected upperlimb normally10. Over time these children learn to disregardthe affected arm which has the potential to lead to furtherimpairment including increased muscle tone, poor motorcontrol, decreased active and passive range of motion ofthe joints of the limb, generalized weakness, and a delay inskeletal maturation9.

In children who sustain central nervous system injury inthe prenatal, perinatal, or early-postnatal periods, thesituation differs in some ways. For these children, differentclasses of behaviour fail to develop entirely. Thus, most of

47Mahotra Pardeep / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

these children do not have the experience of performingmotor activities that are later lost after a central nervoussystem injury, as in the case of adults after stroke. Onemight, therefore, more appropriately refer to "developmentaldisregard" in these children. However, the samemechanisms of punishment of ineffective, clumsy attemptsto use the more-affected extremity and reward for at leastpartially successful use of the less-affected extremity aloneare presumed to operate in young children as they do inindividuals with a mature motor repertoire. Developmentaldisregard might then be viewed as a special case of learnednonuse8.

Another important factor which may contribute to adevelopmental disregard of the affected upper limb in a childwith hemiplegic cerebral palsy is the presence of mirrormovements. These occur when repetitive voluntarymovements of one hand are accompanied by involuntarymirrored movements of the other hand mirror movementsmay, in fact, cause a decrease in the use of the affectedhand as they interfere with the skilled performance of thenon-affected hand These findings may suggest in favour ofunilateral approach to treatment in some children withhemiplegic cerebral palsy9.

Management of Cerebral Palsy includes medication,surgical, physical therapy and occupational therapyapproaches. Spasticity has appeared an attractivetherapeutic target in cerebral palsies. However suchtreatment can have no effect upon lack of selective motorcontrol or weakness that may dominate the picture.Selective posterior rhizotomy has been widely used inspastic diplegia but with concerns about long term benefits.Botulinum toxin A has been used in diplegia and hemiplegiawith useful benefits, but the scientific basis of this work hasbeen criticized. The use of intrathecal baclophen in spasticCP is lacking general applicability3.

Efficacy of any other treatment options, includingphysical therapy, occupational therapy, conductiveeducation, neurodevelopmental therapy, peripheralsplinting/casting, and pharmacotherapy (e.g. botulinumtoxin type A) is lacking11.

Cellular basis for the intervention planning exists in thebelief that the Plastic adaptation may occur at any stage inthe cell’s lifespan. One way of inducing neuroplasticadaptation is by manipulating the periphery to invoke achange in the target neurons’ environment. All these plasticadaptations can occur in the damaged nervous systems ofpatients with neurological disease. This adaptation is also afeature of the healthy nervous system and can be illustratedwhenever we learn a new skill12. So practicing movementsresults in improvement in performance and in plasticity ofthe motor cortex. It is already proved that learning inhumans occur through ‘Learning-Induced Cortical Plasticity’like mechanisms13.

Children possess far better brain reorganizationalcapabilities after lesions than adults. Such plasticity isassumed to be greater in younger children, because thecentral nervous system is still in the early stages of postnataldevelopment. The neural substrates for hand control,however, continue to develop over the first 2 decades of life,which suggests the presence of neuroplasticity in olderchildren as well14.

Constraint-Induced Movement therapy (CIMT), ForcedUse Therapy (FUT), Modified CIMT(mCIMT) is suggested

by Taub in 1995 as a promising new therapy for adults withhemiparesis consequent to stroke, which also offers apotentially efficacious approach to the treatment of juvenilehemiparesis9.

Patients in the CIMT group, compared to the delayedgroup, show significant clinical improvements in handfunction, increased maximum precision grip force, improvedforce and torque regulation, and reduced variability in rate offorce production during task performance15. CIMT involvespromoting use of the more-affected upper limb byrestraining the less-affected limb for a target of 90 percentof waking hours for 2 to 3 consecutive weeks (dependingon the severity of the deficit) with a padded mitt thatprevents use of the hand in ADLs. In its most common form,the patients receive a type of training called "shaping" for 6hrs per day9,16.

As the Treatment programs have sprung up all aroundthe world, implying or explicitly stating that CIMT is aneffective treatment for restoring motor function., mostrecently, studies comparing various modifications of CIMTare being published, again lending the impression that thebasic data demonstrating the effectiveness of any CIMTprotocol actually exist17.

Paediatric CIMT involves two stages firstly theConstraint of unaffected upper extremity with a sling,padded mitten or cast to prevent the use of the arm andsecondly the Shaping which is the repetitive use of theaffected extremity in which a behavioural objective(movement) is approached in small steps of progressivelyincreasing difficulty8,9,14,18.

CIMT involves promoting use of the more-affected upperlimb by restraining the less-affected limb for a target of 90percent of waking hours for 2 to 3 consecutive weeks(depending on the severity of the deficit) with a sling orpadded mitt that prevents use of the hand in ADLs. In itsmost common form, the patients receive a type of trainingcalled "shaping" for 6 hrs per day9,14,16 Multiple episodes ofPaediatric CIMT may be a useful intervention for a youngchild with hemiparesis associated with cerebral palsy.18However, this intensity of treatment may not be feasible inthe current managed care environment19. So the amount ofimprovement is not related to time spent wearing theconstraining7.

CIMT protocol which includes six to eight hours per dayof therapist-guided intervention cannot be adopted in themajority of clinical environments. It is also questionable thata protocol for young children (that is less than four years ofage) which involves six hours of therapist-guidedintervention is developmentally appropriate9. CIMT modifiedto be child-friendly, appears to be efficacious in improvingmovement efficiency of the involved upper extremity20.

Modified constraint-induced movement therapy (mCIMT)implies restraint of the unaffected upper limb is applied andless than three hours per day of therapy is provided to theaffected limb. The improvements in upper limb function wereachieved by using only gentle restraint and verbalinstruction9.

Modified constraint-induced movement therapy resultedin clinical improvement as proved by the Paediatric MotorActivity Log, Functional magnetic resonance imaging, shiftin the laterality index, Magnetoencephalography21. AfterCIMT there is an increase in activation in the (preservedcontralateral) cortical hand representation, and also a

48 Mahotra Pardeep / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

decrease in activation is observed in the (reorganizedipsilateral) cortical hand representation. Functionalimprovement of the paretic hand after CIMT is shown byfMRI and TMS22.

One potential mechanism for reorganization is thatadjacent cortical regions expand when pre-existing lateralexcitatory connections are unmasked by decreasedintracortical inhibition23. (Re-)organization after early brainlesions with ipsilateral corticospinal pathways includes, inaddition to the ipsilateral primary motor cortex, also theipsilateral basal ganglia – in contrast to the primary sensorycortex, which is typically preserved in the affectedhemisphere24,25.

Still only the few studies have been done till date to seethe efficacy of paediatric CIMT. Given the limited evidence,the use of CIMT, modified CIMT and Forced Use isconsidered experimental in children with hemipareticcerebral palsy.9 So the present study is focused on rigorousmethodology and valid and reliable outcome measures toprovide support of the effectiveness of mCIMT for childrenwith spastic hemiparetic cerebral palsy based upon theQuality of Upper Extremity Skills Test(QUEST) and theModified Ashworth Scale(MAS) as the outcome measures.

Modified Ashworth Scale has good interpreter reliability(intraclass correlation coefficient [ICC] >0.75) for elbowflexors and hamstrings. Intrarater scores are good (ICC>0.75) for hamstrings and moderate (ICC = 0.50 to 0.75) forother muscles26. Muscle tone at the shoulder, elbow & wristcan be measured using the MAS14.

Quality of Upper Extremity Skills Test can be used forthe assessment of fine motor function10. This is a reliableand valid outcome measure designed to evaluatemovement patterns and hand function in children withcerebral palsy within a play context in four domains:dissociated movement, grasp, protective extension, andweight bearing. Validation studies have been completedwith children with cerebral palsy, aged 18 months to 8 years.Observer reliability of the QUEST and its domains rangesfrom 0.51 to 0.96 with all coefficients except one greaterthan 0.70. Test-retest reliability of QUEST and its domainsranges from 0.75 to 0.95. Concurrent validity with thePeabody Developmental Motor Scales (PDMS) - fine motoris 0.8427.

1.1. Need for the study

Most of the studies show the children with cerebral palsywho underwent mCIMT program, experience improved levelof upper extremity motor function. Cerebral palsy is acommon neurodevelopmental disorder of childhood. Itaffects the upper extremity motor function which can leadto difficulty in practicing the perfect skills of daily life. mCIMTis one of the major approaches used to improve the upperextremity motor function of children with spastic hemipareticcerebral palsy. Most of the children with cerebral palsy willhave impairment in their motor function. This lacks thenormal function and muscle activity needed for childrenduring development.

1.2. Objective of study

To evaluate the efficacy of mCIMT in spastic hemipareticcerebral palsy children.

1.3. Hypothesis

Null Hypothesis: There is no significant efficacy of modifiedconstraint-induced movement therapy in children withspastic hemiparetic cerebral palsy.Alternate Hypothesis: There is significant efficacy ofmodified constraint-induced movement therapy in childrenwith spastic hemiparetic cerebral palsy.

1.4. Projected outcome

Upper extremity motor function will be assessed byQUEST; and Spasticity by MAS scale before and aftermCIMT in children with spastic hemiparetic cerebral palsy.

Based on literature review it is expected that mCIMT willimprove the ability to perform the upper extremity functions.Further this may lead to the improved physical activities,movement and postural responses in children with spastichemiparetic cerebral palsy.

Haore et al. (2007) searched the Cochrane CentralRegister of Controlled Trials, MEDLINE, CINAHL, EMBASE,PsychInfo and reference lists of all relevant articles toevaluate the effectiveness of CIMT, mCIMT or FUT in thetreatment of affected upper limb in children with hemiplegiccerebral palsy. Three studies met the inclusion criteria. OneRCT showed positive treatment effect favoring CIMT usingDissociated Movement subscale of QUEST. A CCTdemonstrated a significant treatment effect favoring mCIMTat two and six months using the AHA. Another trial showeda significant treatment effect at 6 weeks on the self carecomponent of WeeFIM using a FUT. This systematic reviewfound a significant treatment effect using mCIMT in a singletrial. A positive trend favoring CIMT and Forced Use wasalso demonstrated. Given the limited evidence, the use ofCIMT, modified CIMT and Forced Use should be consideredexperimental in children with hemiplegic cerebral palsy. Thisreview advocates further research using adequatelypowered RCTs, rigorous methodology and valid and reliableoutcome measures to provide higher level support of theeffectiveness of CIMT, mCIMT and FUT for children withhemiplegic cerebral palsy.

Materials and methods

Study design and methodology

3.1.Study Design: Quasi Experimental design (one groupPretest-Posttest study)3.2. Study Setting

Rehabilitation centre setting:OPD, Physiotherapy Centre, LPU Prayas School for

special children, Jalandhar Missionaries of Charity, ModelTown, Jalandhar Neurotherapy Centre, Jalandhar OT-OPD,DAVIPTR, Jalandhar Satguru PT Centre, Rama Mandi,Jalandhar3.3. Population and sampling population of study:Spastic Hemiparetic Cerebral Palsy children

Sampling Method: Convenient SamplingSample Size: 10 children with spastic hemiparetic

cerebral palsy3.4. Sampling criteria3.4.1. Inclusion Criteria1. Children with Hemiparetic Cerebral Palsy

49Mahotra Pardeep / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

2. Age between 2 to 8 years.3. MAS Spasticity score ranged from 1 to 33.4.2. Exclusion Criteria1. Profound bilateral hearing loss even after the use of

hearing aids.2. Any episode of seizure for past 6 months3. Severe visual disorder likely to interfere with the

treatment schedule4. Undergone a dorsal rhizotomy5. Received botulinum toxin in upper extremity during last

6 months.3.5. Variables

Independent Variables-Restriction time of unaffected extremity-Intervention time on affected extremityPositive Feedback on successful task completion.

Dependent Variables-Upper extremity efficiency score on QUEST.-Muscle tone (spasticity) score on MAS

3.6.Instrumentation and Tool for Data CollectionAssessment Tools1. Quality of Upper Extremity Skill Tests

The measure evaluates quality of upper extremityfunction in four domains: dissociated movements, grasps,weight bearing, protective extension in children who exhibitneuromotor dysfunction with spasticity and has beenvalidated with children 18 months to 8 years of age.2. Modified Ashworth Scale

This is a 6 point scale used to assess spasticity rangingas 0, 1, 1+, 2, 3 & 4 and has been validated in children withNeuro-motor disorders.

Instrument

3.7. Technique of data collection procedureIn this study, First information about the children was

taken by personal interviews with in various rehabilitationcentres and hospitals and then arranging a meeting with theparents or the caregivers.Informed Consent was taken fromthe parents/caregivers as well as the witness present on theoccasion.

Evaluation of the children are assessed by their generalHealth Record, History by caregivers and detailedPhysiotherapeutic Examination by the Investigator includingQUEST & MAS. Restriction of the unaffected upperextremity kept with the splint and the sling approximately 2hours a day, 5 days a week for 3 weeks

Activities given to the affected upper limb were chosenaccording to the interest of the child, age of the child,individual disability level and were graduated from easy todifficult in the capability level individualized to each child.

Shaping & Repetitive Task Practice was employed,duration and number of activities dependent on the attentionspan of the children.

Operant behavioral conditioning method was used byapplauding for each successful try but at the same time notdisregarding the unsuccessful try. Children were helpedeach time whenever they were unable to do or initiate anyactivity to place them at most stimulating condition to favouran activity. Sling was not removed for any child except forthe essential activities like toileting or hand washing duringthe intervention period.

Maximum try was done to achieve Chair / Table heightgraded according to the 90-90 position of the hips & kneesand feet lying flat on the ground. Front Table/Tray wasadjusted at the chest height to support the children’s armsand for easy hand activity by the children. For the childneeding more support, adaptive sitting was provided, withoften support from the caregiver or the therapist.Childrenreassessed after the intervention period with the QUEST &MAS.3.8. Technique of data analysis and interpretation

Data collected were analyzed using Paired ‘t’ test andANOVA to measure the changes between the pre and posttest values within the group.(a) Paired ‘t’ test(b) Analysis of Variance (ANOVA)

Table 1: Quest Scale ‘t’ value calculation (n = 10)

Mean = 8.203 S.D=3.61620 t value=7.173

Table 2: Anova Table for Quest

PRE ‘F’ POST ‘F’0.195 0.538

Fig.1: Pre-Intervention and Post-Intervention readings for QUEST

Fig. 2: Pre-Intervetion and Post-Intervention readings for individualcomponents of QUESTA – Dissociated Movements B - GraspC – Weight Bearing D – Protective Extension

58

60

62

64

66

68

70

72

PRE POST

QUEST score (PRE and POST Value)

PRE

POST

0

10

20

30

40

50

60

70

80

A B C D

QUEST components (PRE and POST Value)

PRE

POST

Resting hand splint fixed firmly to the ventral surface of the hand with theVelcro fastenings around the dorsum of the hand. Sling is sewn shut atperiphery and further reinforced with Velcro, then secured snugly to thechild's trunk with a strap to prevent use as an assist.

50 Mahotra Pardeep / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Data analysis and interpretation

Ten children received mCIMT was assessed withQUEST & MAS scale before and after 3 weeks of treatment.The data are presented in the table and mean, standarddeviation, t test and ANOVA were calculated. In this study4 female, 6 male children participated and age ranged from2 to 8 years.

Data interpretation

Paired ‘t’ test was used to analyze the significantdifference between the mean of the pre test values andmean of the post test values to determine the outcome ofthe mCIMT program given after a period of 3 weeks. Thestatistical analysis was done for the measures collected byQUEST & MAS scale.

Table 1 and 2

From the Table 1 and 2, Graph 1 and 2 it is inferred thatthere was gradual improvement in the functional outcomein the children after the mCIMT program. On analyzing thepre test and the post test values by paired ‘t’ test, there issignificant mean difference of 8.203 with Standard Deviationof 3.61620 and the t value of 7.173 at P=.000. ANOVAreadings of ‘F’ were PRE =0.195 and POST = 0.538 whichis non-significant

Table 3 and 4

From the Table 3 and 4, Graph 3 and 4 it is inferred thatthere was gradual improvement in the tone in the childrenafter the mCIMT program. On analyzing the pre test and thepost test values by paired ‘t’ test, there is significant meandifference of 0.7 with Standard Deviation of .71492 and thet value of 3.096 at P=.013. ANOVA readings of ‘F’ were;PRE = 10.383 and POST = 9.368 which are highlysignificant at the P = 0.000

Results and discussion

The study aims to evaluate the effect of mCIMT programon the children with cerebral palsy. Among the 10 selectedsubjects 4 are female and 6 are male children.

The selected outcome measures are QUEST & MASscores. Data are collected at the baseline and 3 weeks aftermCIMT program. The obtained data is analyzed by usingthe paired‘t’ test & ANOVA.

Results shows that there is significant improvement inthe functional capacity as the calculated t value7.173 for the

QUEST measure is in the table value at P=.000 The overall score of the QUEST measure scale also

shows similar trends of improvements. This indicates thechange in gross motor function of children after mCIMTprogram.

Results shows that there is significant normalization inthe muscle tone(spasticity) as the calculated t value 3.096for the MAS measure is in the table value at P=.013.

The overall score of the MAS measure scale also showssimilar trends of improvements. This indicates the change ingross motor function of children after mCIMT program.

A significant improvement in functional capacity ofcerebral palsy children is evident after 3 weeks of mCIMTprogram in this study.

Improvements in functional measures noticed in thisstudy may be due to the reason that mCIMT therapyprogram would have helped to reduce the diseasesymptoms and thereby improving the functional status inchildren with cerebral palsy.

Results from the study are consistent with other studiesin showing a significant improvement in upper limb functionafter mCIMT for 3 weeks in children.

Improvements in functional measures noticed in thisstudy may be due to the reason that mCIMT program wouldhave helped to unmask the non-used potential and therebyimproving the functional status in children with spastichemiparetic cerebral palsy.

Key difference between this study and the previousstudies is that the improvements in upper limb function wereachieved by using only gentle restraint and verbalinstruction.

5.1 Limitations

-Small number of participants.-2 drop outs out of total 12 children after 4 & 8 sessions

out of 15 respectively.-Study was carried for 5 months which may have given

a time frame difference in children.-Wider age criteria was taken-No follow up taken-No exact Family/Genetic/Medical history was available

Table 3: Mas Scale ‘t’ value calculation (n = 10)

Mean= 0.7 S.D.=.71492 t value=3.096

Table 4: Mas - Anova Table

PRE ‘F’ POST ‘F’10.383 9.368

Fig. 3: Pre-Intervention and Post-Intervention readings for MASFig. 4: Pre-Intervention and Post-Intervention MAS readings for individualmuscle groupsA – Shoulder Flexors B – Elbow Flexors C – Forearm Pronators D – Wrist FlexorsE – Finger Flexors

7.4

7.6

7.8

8

8.2

8.4

8.6

PRE POST

MAS score (PRE and POST Value)

PRE

POST

0

0.5

1

1.5

2

2.5

A B C D E

MAS Components (PRE and POST Value)

PRE

POST

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5.2 Recommendations

Based on the outcome of the statistical analysis, it issuggested that the future studies can be modified toaccommodate the following changes:

-Study can be made more reliable by having a largesample size.

-Using same treatment for other types of cerebral palsylike ‘monoplegia’.

-Single blinded study could be undertaken-Other motor function scales can be used.

Summary and conclusion

Based on the analysis of data it can be interpreted thatmCIMT produces significant improvement. In correlatingwith literature and statistical analysis, this study concludesthat mCIMT has produced significant improvement infunction & tone in children with Cerebral palsy.

Present study concludes that mCIMT protocol is aneffective therapeutic intervention in the less intensified formas well when compared to that of others having more than6 hrs intervention period which makes this form of therapymore clinically feasible; but still more reliability studies needto be done owing to the small sample size in the presentstudy.

It is evident that such an intervention is effective and ithelps in reducing disease symptoms and improves thegeneral functional well being among these children withspastic hemiparetic cerebral palsy.

Therefore, from the literature available and statisticalanalysis of the data, it accepted and stated as, “There issignificant Efficacy of Modified Constraint-InducedMovement Therapy in Children with Spastic HemipareticCerebral Palsy”.

References

1. Umphred DA, editor. Neurological Rehabilitation:cerebral palsy. 3rd ed. USA: Mosby; 1995.

2. Downie PA, editor. Cash’s Textbook of Neurology forPhysiotherapists: cerebral palsy – clinical. 4th ed. NewDelhi: Jaypee brothers; 1993.

3. Donaghy M, editor. Brain’s Diseases of the NervousSystem: paediatric neurology. 11th ed. NewYork: OxfordUniversity Press; 2001.

4. Bax M, Goldstein M, Rosenbaum P, Leviton A, PanethN, Jacobsson B. Proposed definition and classificationof cerebral palsy. Developmental Medicine & ChildNeurology 2005 April;47: 571–6.

5. Odding E, Roebroeck ME, Stam HJ. The epidemiologyof cerebral palsy: incidence, impairments and riskfactors. Disabil Rehabil 2006 Feb 28;28(4):183-91

6. Srivastava VK, Laisram N, Srivastava RK. Cerebralpalsy. Indian Pediatr 1992 Aug;29(8):993-6.

7. Eliasson AC, Sundholm LK, Shaw K, Wang C. Effects ofconstraint-induced movement therapy in young childrenwith hemiplegic cerebral palsy: an adapted model.Developmental Medicine & Child Neurology 2005;47:266–275.

8. Taub E, Ramey SL, Luca SD, Echols K. Efficacy ofConstraint-Induced Movement Therapy for ChildrenWith Cerebral Palsy With Asymmetric Motor Impairment.PEDIATRICS 2004 Feb;113 (2):305-12.

9. Hoare BJ, Wasiak J, Imms C, Carey L. Constraint-induced movement therapy in the treatment of the upperlimb in children with hemiplegic cerebral palsy(Review).Clin Rehabil 2007 Aug;21(8):675-85.

10. Naylor CE, Bower E. Modified constraint-inducedMovement therapy for young children with hemiplegiccerebral palsy: a pilot study. Developmental Medicine &Child Neurology 2005;47:365–369.

11. Boyd RN, Morris ME, Graham H. K. Management ofupper limb dysfunction in children with cerebral palsy: asystematic review. Eur J Neurol 2001;8(5):150 –166[CrossRef]

12. Hollis M, Cook PF, editors. Practical Exercise Therapy:neurophysiology of movement. 4th ed. U.K: BlackwellScience Ltd; 1999. p. 198-9.

13. Butefisch CM, Davis BC, Wise SP, Sawaki L, Kopylev L,Classen J, et al. Mechanisms of use-dependentplasticity in the human motor cortex, PNAS 2000 March28; 97(7)3661–5.

14. Gordon AM, Charles J, Wolf SL. Efficacy of Constraint-Induced Movement Therapy on Involved Upper-Extremity Use in Children With Hemiplegic CerebralPalsy Is Not Age-Dependent. PEDIATRICS 2006;117(3): 363-73.

15. Alberts JL, Butler AJ, Wolf SL. The effects of constraint-induced therapy on precision grip: a preliminary study.Neurorehabil Neural Repair 2004 Dec;18(4):250-8.

16. Lum PS, Taub E, Schwandt D, Postman M, Hardin P,Uswatte G. Automated Constraint-Induced TherapyExtension (AutoCITE) for movement deficits after stroke.JRRD 2004 May/June;41(3A):249-58.

17. Dromerick AW. Evidence-based rehabilitation: The casefor and against constraint-induced movement therapy.Journal of Rehabilitation Research and Development2003;40: 1.

18. Luca SCD, Echols K, Ramey SL, Taub E. PediatricConstraint-Induced Movement Therapy for a YoungChild With Cerebral Palsy: Two Episodes of Care.Physical Therapy 2003;Nov 83(11):1003-13.

19. Pierce SR, Daly K, Gallagher KG, Gershkoff AM,Schaumburg SW. Constraint-induced therapy for a childwith hemiplegic cerebral palsy: a case report. Arch PhysMed Rehabil 2002;83:1462-3.

20. Charles JR, Wolf SL, Schneider JA, Gordon AM.Efficacy of a child-friendly form of constraint-inducedmovement therapy in hemiplegic cerebral palsy: arandomized control trial. Dev Med Child Neuro 2006Aug;48(8):635-42.

21. Sutcliffe TL, Gaetz WC, Logan WJ, Cheyne DO,Fehlings DL. Cortical reorganization after modifiedconstraint-induced movement therapy in pediatrichemiplegic cerebral palsy. Journal of child neuro 2007-Nov;22(11):1281-7.

22. Mall V, Jünger H, Kuhnke N, Walther M, Linder M,Berweck S, et al. Two types of neuroplastic changesafter constraint induced movement therapy in congenitalhemiparesis: A fMRI and TMS study. European Societyof Magnetic Resonance in Neuropediatrics ,9thCongress, 2007 May 31 to June 2; Tübingen, Germany.p. 12.

23. Jacobs KM, Donoghue JP. Reshaping the cortical motormap by unmasking latent intracortical connections.Science 22 1991 Feb;251(4996):944-947.

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24. Jünger H, Wilke M, Lucht ML, Berweck S, Mall V, StaudtM et al. Reorganization of the motor system incongenital hemiparesis: fMRI activation of ipsilateralbasal ganglia. European Society of MagneticResonance in Neuropediatrics, 9th Congress, 2007 May31 to June 2; Tübingen, Germany. p. 12.

25. Everts R, Kiefer C, Lidzba K, Wilke M, Perrig W, SchrothG, et al. Reorganisation of cognitive functions afterstroke in childhood – preliminary data of a combinationof fMRI and DTI. European

26. Society of Magnetic Resonance in Neuropediatrics, 9thCongress, 2007 May 31 to June 2; Tübingen, Germany.p. 12.

27. Clopton N, Dutton J, Featherston T, Grigsby A, MobleyJ, Melvin J. Interrater and intrarater reliability of theModified Ashworth Scale in children with hypertonia.Pediatr Phys Ther 2005 Winter;17(4):268-74.

28. DeMatteo C, Law M, Russell D, Pollock N, RosenbaumP, Walter S. The reliability and validity of Quality ofUpper Extremity Skills Test. Physical and OccupationalTherapy in Pediatrics 1993;3(2):1-18.

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Effectiveness of muscle energy technique on quadratuslumborum in acute low back pain-randomized controlled trialPrachi N. Patil, Basavaraj Chandu, Santosh Metgud, Subhash KhatriK.L.E.S. Institute of Physiotherapy, J.N.Medical College Campus, Belgaum, Karnataka, India

Abstract

Purpose of studyLow back pain in developed countries is one of the most

common causes of disability, producing a large social andeconomic burden on society. MET is the form of manualtherapy effective for treating movement restrictions of boththe spine and extremities. It is an active technique used totreat patients with acute low back pain. The objectives ofthe present study were to compare the effectiveness of METon quadratus lumborum combined with IFT and IFT alone interms of reduction of pain, decrease in disability andincrease in range of motion.

Materials and methods

40 subjects (21 males and 19 females) diagnosed withacute low back pain were recruited from Department ofPhysiotherapy, K.L.E.S. Dr. Prabhakar Kore Hospital andMedical Research Centre, Belgaum. A written informedconsent was obtained from study subject and ethicalclearance was obtained. Subjects were randomly assignedto two groups of 20 each. The control group receivedinterferential therapy while interventional group receivedMET on quadratus lumborum combined with interferentialtherapy. Both groups received the selected treatment for 8days. The outcome measures were recorded pre and post-intervention using Visual Analogue Scale, ModifiedOswestry Disability Questionnaire and spinal range ofmotion.

Results

In the study both the groups showed statisticallysignificant difference (p<0.0001) in reduction of pain,decrease in disability and increase in spinal range of motion.MET on quadratus lumborum combined with IFTdemonstrated a statistically significant difference (p<0.001)showing decrease in disability and increase in spinal rangeof motion than IFT alone.

Conclusion

MET on quadratus lumborum combined withinterferential therapy is more effective in reduction indisability and increasing spinal range of motion thaninterferential therapy alone in patients with acute low backpain.

Key words

Muscle Energy Technique, Interferential Therapy, Lowback pain, Quadratus Lumborum

Introduction

Acute low back pain is treated by a variety of healthcareproviders utilizing an array of treatment approaches. Acutelow back pain occurs in people with a wide variety ofprofessionals, including those involving heavy labor,repetitive work activities, and extended sedentary postures.Half of the population will have experienced a significantincident of low back pain by age 301.

The lumbar spine is surrounded by a complex network ofmuscle with various fibre directions and depths2. Supportand stability to the low back arises from muscles.Surprisingly, the one muscle that is highly active duringflexion, extension and lateral bending tasks is the quadratuslumborum3. The quadratus lumborum muscle is one of themost commonly overlooked muscular and potential sourceof low back pain4.

Physical therapist attempts to manage patients withacute low back pain by utilizing a wide variety ofinterventions including like therapeutic modalities exercises,spinal manipulation and manual therapy1. Interferentialtherapy is a form of electrical stimulation produced using theprinciple of amplitude modulation whereby two mediumfrequency currents (in the kilohertz range), which are slightlyout of phase, are mixed (either within the tissues or within anelectrical stimulator) to produce a low frequency current (0-250 Hz). The resultant current produces less impedance inthe tissues and its intensity is perceived as being morecomfortable to patients than that produced by low frequencystimulators such as a transcutaneous electrical nervestimulation (TENS) machine.Interferential therapy has thehighest ownership and usage of all electrotherapeuticmethods by physiotherapists and is the most popular formof electrical stimulation for low back pain management,being predominantly used for its hypoalgesic effects,5

reaches deep muscles and nerves, stimulates voluntarymuscle, promotes an increase in peripheral blood flow andreduces pain6.

Common treatment for acute low back pain is the use ofmanual therapy. While under the broad umbrella of manualtherapy, Muscle Energy Technique (MET) does not fall intosubcategories of manipulation or mobilization.1

Muscle energy technique is active technique1 requiringthe participant to contribute the voluntary contraction of asubjects muscle in a precisely controlled direction, againsta counterforce provided by the operator7. The contraction isusually commenced from, or short of, a previously detectedbarrier of resistance, depending upon the relative acutenessof the situation. When MET is applied in acute conditionsthe tissue is passively moved to the new barrier without anyattempt to stretch and repetition of isometric contraction1. Itis claimed to be effective for a variety of purposes, includinglengthening a shortened or contracted muscle, streng-

54 Prachi N. Patil / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

thening muscles, as a lymphatic or venous pump to aid thedrainage of fluid or blood, increasing the range of motion ofa restricted joint8 reducing pain and disability9.

The mechanisms by which MET may produce increasedROM remain speculative. The efficacy of MET to relaxationof the affected muscles due to inhibition of motor activitythrough the Golgi tendon organs. Rhythmic repetitivemuscle contractions performed during MET may relievepassive congestion in the paraspinal muscles, as a result offluctuating blood and lymph pressure gradients propellingfluid throughout the body. Thus achieve a degree of easeand additional movement in the shortened tissues10.

MET has found an increased audience with clinicians,very little has been published in the peer-reviewed literatureon this intervention. Its widespread use makes it imperativethat we determine if this technique is a viable procedure forthe treatment of acute low back pain. The purpose of thepresent study was to determine whether patients diagnosedwith non specific acute low back pain with a concomitantdiagnosis of a lumbar side flexion restriction woulddemonstrate a reduction in pain assessed by visual analogscale and disability assessed by the Modified OswestryDisability Questionnaire (MODQ) and increase in range ofmotion, after being treated with MET treatment coupled withinterferential therapy compared to interferential therapyalone.

While both MET and interferential therapy is populartreatment for acute low back pain management, their effectshave not been directly investigated in a randomized controltrial. However, interferential therapy has been shown to beconsiderably more popular than transcutaneous electricalnerve stimulation for low back pain management; thus,research to find any difference in effectiveness of IFTrelative to MET is warranted. Combinations of treatmentmethods rather than the delivery of any mode of therapy inisolation represent the norm for a typical low back painphysiotherapy session.

Methods

Source of dataThe data for this study was collected from Physiotherapy

OPD of K.L.E.S Dr. Prabhakar Kore Hospital and medicalresearch centre, Belgaum, Karnataka state, India, duringthe study period from Nov 2007 to July 2008.

Study designThe study was randomized controlled trial for which

ethical clearance was obtained form the Institutional ethicalcommittee, J. N. Medical College, Belgaum beforecommencement of the study.

Subjects The study sample consisted of both male and female

participants (heterogeneous group) with clinical diagnosisof acute non-specific low back pain referred to thePhysiotherapy Outpatient Department K.L.E.S. Dr.Prabhakar Kore Hospital and Medical Research Centre,Belgaum for physiotherapy treatment.

Inclusion criteria1. Age between 18 – 50 years.

2. Both male and females participants with clinicaldiagnosis of acute low back pain.

3. Participants who will have duration of pain for 6 weeksor less.

4. Participants with non specific and postural low backpain.

5. Participants with lumbar pain and pain at theattachments of quadratus lumborum i.e. iliac crest andlower ribs.

6. Participants with restricted lateral flexion.7. Participants willing to participate in the study.

Exclusion criteria1. Participants who will have duration of pain more than 6

weeks. 2. Participants suffering from specific low back pain like

prolapse intervertebral discs with instability or anyradicular symptoms, lumbar spondylosis, lumbar canalstenosis, spondylolisthesis, sensory deficits, malig-nancies and tuberculosis.

3. Participants suffering from osteoporosis, psychiatricdisorders, pain relief patches / injections / slow releasinghormonal capsules, fracture or dislocation, haematomasor abscesses.

4. Any clinical condition that contraindicates the applicationof interferential therapy such as patients wearing cardiacpacemakers, thrombosis, recent hemorrhage,pregnancy, fever, tumors or with any metallic implants.

5. Any other local or systemic major illness.6. Participants with history of spinal surgery.

Procedure

All participants with acute low back pain, referred to thephysiotherapy out patient department were screened. Afterfinding their suitability as per the inclusion and exclusioncriteria, they were requested to participate in the study.Those willing to participate were briefed about the nature ofstudy and intervention. Only those willing to takeintervention were included in the study. Their demographicdata was collected along with their initial assessment of VASscore, range of motion of the lumbar spine and ModifiedOswestry Disability Questionnaire. The 40 participants wererandomly allocated to three groups of 20 each afterinformed consent had been obtained. The two groups werethe Control Group (A) and Interventional Group (B).

Prior to the commencement of procedure, weight (inkilograms) of the participants was recorded using a simplebathroom weighing machine. Height (in Meters) of theparticipants was recorded using a measuring tape, withheight marked on wall; ground to mark distance wasmeasured. The participant was asked to grade his pain onVAS scale 0 to 10 cms (0 indicating no pain and 10indicating maximum pain) with one mark per centimeterprior to the treatment. Lumbar range of motion wasmeasured by Finger to Floor method for side flexion andModified Scober’s method for flexion and extension using ameasuring tape before the commencement of theintervention. A Modified Oswestry Disability Questionnairewas given to the patient to fill up before the therapy wasbegun.

In control group (A) every participants were made to liedown (prone) on a plinth. They were treated with

55Prachi N. Patil / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

interferential therapy (IFT) using standardized parameters(carrier frequency - 3.85 kHz and pulse duration-130µs) withquadripolar application for treatment duration of 15 minutesfor successive eight days.

The interventional group (B) received additionalisometric contraction using post isometric relaxation of METthis is held for 5 seconds hold with 5 seconds of rest periodand repeated for 6 times per session on each side for eightsuccessive days. The procedure is performed as thetherapist stands behind side-lying patient, at waist level. Thepatient has upper most arm extended over the head to firmlygrasp the top end of the table and on inhalation, abducts theuppermost leg until the therapist palpates strong quadratuslumborum activity (elevation of around 30º usually). Thepatient holds the leg (and the breath) isometrically in thismanner, allowing gravity to provide resistance. After 5seconds contraction, the patient allows the leg to hangslightly behind him. This action is repeated alternately withraised leg in front and behind the trunk, in order to activatedifferent fibers. The therapist cradles the pelvis with bothhands (fingers interlocking over crest of pelvis) leans backto take out all slack and to ease the pelvis away from thelower ribs during an exhalation. This is performed bypassively moving to a new restricted barrier without stretchalong the direction of the long axis of abducted leg afterensuring patient has completely relaxed for 5 seconds.Perform movement to new barrier on an exhalation. Theprocedure repeated 6 times on each side.

VAS score and lumbar range of motion (Flexion,extension and side flexion) and Modified Oswestry DisabilityQuestionnaire was given to every participant to fill up preintervention on first day and post intervention on the eighthday of treatment session. The outcome was assessed onthe basis of post intervention scores.

Statistical analysis

Statistical analysis was done using the SPSS 0.4versions so as to verify the results obtained. Statisticalmeasures such as unpaired ‘t’ tests and paired ‘t’ tests wereused to analyze the data.

Unpaired ‘t’ test was utilized to measure the differencebetween the two groups and paired ‘t’ test was utilized tomeasure the difference within the two groups used tocompare the difference of VAS, MODQ percentage andspinal range of motion.

Results

Results of the study were analyzed in terms of pain reliefindicated by decrease in visual analogue scores, reductionin disability by MODQ percentage and increase in spinalrange of motion in terms of right and left side flexion,extension and flexion which was measured using finger tofloor method used for side flexion and Modified Schober’stest for flexion and extension.

The age of the participants in this study was in between19 to 46 years. The mean of the participants in control groupwas 27.5 ± 7.66 years and interventional group was 29.1 ±7.04 years. There were total 40 participants participated inthe study. Out of which 21 were males and 19 were females.There were 10 males and 10 females in control group and11 males and 9 females in interventional group. The BMI in

the two groups was 18.30 – 28.4. BMI estimated 75% of theparticipants were normal, 20% overweight and 5%underweight in the control group. BMI estimated 80% of theparticipants were normal and 20% were overweight in theinterventional groups. The mean duration of symptoms incontrol group were 11.6 ± 10.93 days and in interventionalgroup mean duration was 13 ± 11.35 days.

The average VAS score in the control group preinterventional was 7.6 ± 0.94 and post interventional was3.8 ± 0.94. The average VAS score in the interventionalgroup pre interventional was 7.6 ± 1.01 and postinterventional was 3.5 ± 0.92. (Graph 1) Within groupchanges in the visual analog scores revealed significantreduction in pain post interventional for both the groups (p< 0.0001). There was no significant difference in thereduction of pain when compared between the groups (p <0.001). Both the groups were equally effective in reducingpain post intervention.

The mean percentage of disability in the control grouppre interventional was 69.9 ± 11.47% and postinterventional was 41.8 ± 10.76%. The mean percentage ofdisability in the interventional group pre interventional was64.7 ± 12.25% and post interventional was 19 ±8.22%.(Graph 2) There was significant difference in thereduction of percentage of disability within the groups (p <0.0001) and when compared between the groups (p <0.001). Both the groups were equally effective in reducingthe percentage of disability post intervention.

In the study pre interventional right side flexionmeasurement was 54.2 ± 3.44 cms and 53.9 ± 2.47 cms incontrol and interventional group respectively, whereas postinterventional flexion measurement was 50.6 ± 3.63 cmsand 45.1 ± 2.15 cms in control and interventional grouprespectively. The pre interventional left side flexionmeasurement was 54.1 ± 3.57 cms and 53.9 ± 2.55 cms incontrol and interventional group respectively, whereas postinterventional flexion measurement was 50.4 ± 3.88 cmsand 45 ± 2.15 cms in control and interventional grouprespectively. The pre interventional spinal extensionmeasurement was 13.5 ± 0.51 cms and 13.5 ± 0.53 cms incontrol and interventional group respectively whereas postinterventional spinal extension measurement was 12.1 ±0.92 cms and 10.8 ± 0.78 cms in control and interventionalgroup respectively. The pre interventional flexionmeasurement was 17 ± 0.97 and 16.7 ± 0.75 cms in controland interventional group respectively, whereas postinterventional flexion measurement was 19.1 ± 1.35 and 21± 0.94 cms in control and interventional group respectively.Interventional group was found to be more effective inimproving the spinal range of motion as compared to thecontrol group (p < 0.001).(Table 1) Both the groups wereequally effective in increasing the spinal range of motionpost interventionally (p < 0.0001).(Table 2)

Discussion

The data from this study showed that pain, percentageof disability and range of motion significantly improved withinterferential therapy alone and muscle energy techniqueon quadratus lumborum along with interferential therapy.

However, muscle energy technique on quadratuslumborum along with interferential therapy was found betterin terms of reduction of disability and increase in range of

56 Prachi N. Patil / /Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

motion as compared to the interferential therapy alone.To date, no studies have examined the effects of IFT

alone and MET on quadratus lumborum along with IFT.MET has been advocated as a safer and commonly usedform of manual therapy for treatment of somatic dysfunctionand muscle pain. Most studies have examined its effects forincreasing flexibility and range of motion, although limitedresearch exists into the effects of MET on pain andtenderness.

A similar study performed by Wilson et al.1 aprospective, pilot clinical trial to determine the effectivenessof MET in patients with acute low back pain with lumbarflexion restriction. Both groups received MET 8 times forover four weeks, whereby application of MET in combinationwith neuromuscular re-education and resistance trainingdemonstrated a statistically significant difference showinggreater improvement in the Oswestry Disability Index scorethan MET in combination with re-education and resistancetraining. It was the only study done on symptomaticsubjects. In the present study three outcome measuresused were VAS, MODQ and range of motion of lumbarspine in participants with non specific acute low back withlumbar side flexion and extension restriction which wassignificant.

Schenk et al.11 performed a randomized controlled trialto determine the effectiveness of MET for increasing lumbarextension in asymptomatic individuals. Each session lastedless than 5 minutes with each subject receiving 4 repetitionsof the MET maneuver 2 times a week for 4 weeks. Whilethe authors did not mention the control groups treatment,they reported a statistically significant difference (p<.05) inthe increase of lumbar extension in experimental group.

In the present study 5 seconds of isometric contractionand 5 seconds of relaxation was used. A study failed todemonstrate a significant benefit in the use of a longer (20-second) isometric contraction when treating the uppercervical spine with MET10. The use of a 5- second isometriccontraction appeared to be more effective than longercontraction durations for increasing cervical range withMET. Two more studies9-12 used 5 seconds of isometriccontraction with 3 repetitions in asymptomatic subjectswhich showed significant increase in range of motion.

The evidence base to determine the clinicaleffectiveness of IFT is less adequate. The present studyshowed reduction in pain, decrease in disability andincrease in range of motion significantly with IFT alone when

compared within the group.A similar study by Hurley et al.13 compared the

effectiveness of manipulative therapy or IFT, whether usedin combination or in isolation on pain, functional disabilityand quality of life in acute low back pain. The resultssuggest positive short term effects in each interventiongroup and well maintained in 6 months and 12 months oftreatment but no significant difference was found.

Ronald Werners et al.14 study compared interferentialtherapy with traction/massage in the management ofpatients LBP. The study shows a progressive fall inOswestry Disability Index and VAS scores but did not showany difference at the end of treatment.

Pain relief in both the groups was statistically significanti.e. within the groups but when comparison was donebetween the groups results showed no statisticallysignificant values in reduction of pain. Results aftercomparison within the group revealed significant changesin pre and post intervention which indicated that both thegroups were equally effective in reducing the pain whichwas measured using the visual analogue scale. Pain is asubjective experience and therefore difficult to measure.Therefore, the reduced response to VAS may reflect thedifficulty of participants on understanding visual analogscale.

The result of the improvement in percentage of disabilityin terms of the Modified Oswestry Disability Questionnairescore was statistically significant in reduction of disability inboth the groups. Results after comparison of between thegroups revealed significant changes with muscle energytechnique on quadratus lumborum along with interferentialtherapy in reduction of disability.

Range of motion improvement in both the groups wasstatistically significant. Spinal range of motion side flexionwas measured using the finger to floor method and flexionand extension was measured using Modified Schober’smethod. The interventional group revealed significantchanges in ranage of motion with muscle energy techniqueon quadratus lumborum along with interferential therapyshowing statistically significant improvement in side flexion,extension and flexion than the control group. The studysupports the validity of using MET on quadratus lumborumto improve range of motion when restricted lumbar sideflexion and extension is present.

Table 1: Inter Group comparison of spinal range of motion.

ROM ‘t’ value df ‘p’ valueRight Side Flexion 5.882 38 0.000Left Side Flexion 5.437 38 0.000

Extension 4.909 38 0.000Flexion 5.161 38 0.000

Table 2: Intra Group comparison of spinal range of motion for Control Groupand Interventional Group.

Control Group Interventional Group

ROM ‘t’ value ‘p’ value ‘t’ value ‘p’ value

Right Side Flexion 16.185 <0.0001 16.268 <0.0001Left Side Flexion 18.308 <0.0001 13.582 <0.0001

Extension 10.873 <0.0001 12.111 <0.0001Flexion 11.831 <0.0001 21.670 <0.0001

Graph 1: Vas Score (in cms) Graph 2: Modq Percentage (%)

7.6 7.6

3.8 3.5

0

1

2

3

4

5

6

7

8

Control Group Interventional Group

Pre Interventional Post Interventional

69.964.7

41.8

19

0

10

20

30

40

50

60

70

80

Control Group Interventional Group

Pre Interventional Post Interventional

57Prachi N. Patil / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

In present study there was decrease in disability andincrease in range of motion significantly with MET onquadratus lumborum along with IFT when compared withIFT alone.

The present study demonstrates the positive effects ofIFT and MET on quadratus lumborum, two commonly usedtreatment with nonspecific acute LPB. This control trailprovides base treatment of similar LBP patients. Since, METis a form of manual therapy which can be mastered bytraining and practice its application at the community levelwould be of much benefit where adequate physiotherapyand rehabilitation facilities are not available.

Recommendations

1. Studies with larger sample size.2. The effect of multiple MET treatments on lumbar spine

over several weeks. It could determine whether multipletreatments enhance the observed changes in range ofmotion.

3. The effects of MET treatment in unilateral low back painand chronic low back pain.

4. The long term effect of MET by follow up.5. Validity testing of the neurophysiological models used

to explain the actual mechanism of MET treatment, suchas the effect of MET on segmentally contracted muscles,connective tissue changes and investigating the efficacyof MET on reducing passive congestion, may elucidatethe exact mechanism behind the therapeutic benefits ofMET.

Conclusion

Results from this study suggest that MET on quadratuslumborum combined with IFT was superior to IFT alone fordecreasing disability and improving the range of motion inpatients with acute low back pain. Further it can beconcluded that the efficacy of MET on quadratus lumborumcan be used as an adjunct to the conventionalphysiotherapy in the treatment of non specific acute lowback pain who demonstrate a side flexion and extensionrestriction.

References

1. Capt. Eric Wilson, Otto Payton, Lisa Donegan-Shof,Katherine Dec. Muscle energy technique in patients withacute low back pain: A pilot clinical trial. Journal ofOrthopaedic and Sports Physical Therapy 2003; 33(9):502-510.

2. E. A. Andersson, L I E Oddsson, H Grundstrom, JNilsson, A Thorestensson. EMG activities of the

quadratus lumborum and erector spinae muscles duringflexion- relaxation and other motor tasks. Clinicalbiomechanics 1996; 11(7): 392-400.

3. Liebenson D C. The quadratus lumborum and spinalstability. Journal of bodywork and movement therapies2000; 4(1):49-54.

4. Guy Hains. Locating and treating low back pain ofmyofascial orgin by ischemic compression. J CanChiropr Assoc 2002; 46(4): 257.

5. D. A. Hurley, S. M. Mc Donough, A. P Moore, M.Dempster, G. D. Baxter. A randomized clinical trial ofmanipulative therapy and interferential therapy for acutelow back pain. Spine 2004; 29(20): 2207-2216.

6. Tatiana F. Alemedia, Suely Roizenblatt, Ana AmeliaBenedito-Silva, Sergio Tufik. The effect of combinedtherapy (ultra sound and interferential current) on painand sleep in fibromyalgia. Pain 2003; 104: 665-672.

7. Fryer G, Ruszkowski W. The influence of techniqueapplied contraction duration in to the atlanto-axial jointmuscle energy. Journal of osteopathic medicine 2004;7(2): 79-84.

8. F. Ballantyne, G Fryer, PMcLaughlin. The effect ofmuscle energy technique on hamstring extensibility: themechanism of altered flexibility. Journal of OsteopathicMedicine, 2003; 6(2): 59-63.

9. Luke Hamilton, Caitlin Boswell, Gray Fryer. The effectsof high-velocity, low-amplitude manipulation and muscleenergy technique on suboccipital tenderness.International Journal of Osteopathic Medicine, 2007; 10:42-49.

10. Lenehan KL, Fryer G, McLaughlin P. The effect ofmuscle energy technique on gross trunk range of motion.Journal of Osteopathic Medicine 2003; 6(1): 13-18.

11. Ronald J. Schenk, Amy MacDiarmid, John RousselleEdD. The effects of muscle energy technique on lumbarrange of motion. Journal of Manual and ManipulativeTherapy 1997; 5(4): 179-183.

12. Denise K. Burns and Michael R. Wells. Gross range ofmotion in the cervical spine: The effects of osteopathicmuscle energy technique in asymptomatic subjects.Journal of Osteopathic Medicine 2006; 106(3):137.

13. D. A. Hurley, S. M. Mc Donough, A. P Moore, M.Dempster, G. D. Baxter. A randomized clinical trial ofmanipulative therapy and interferential therapy for acutelow back pain. Spine 2004; 29(20): 2207-2216.

14. Werners, Roland MD; Pynsent, Paul B. PhD; Bulstrode,Christopher J. K.Randomized Trial ComparingInterferential Therapy With Motorized Lumbar Tractionand Massage in the Management of Low Back Pain in aPrimary Care Setting. Spine 1999; 24(15): 1579.

58 Prachi N. Patil / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Paraplegic can walk: A case report and review of literature*Rajni Arora, **Pradipta Tripathy, ***Santhosh Kumar, ****Dheeraj K.V.*Associate Professor, College of Physiotherapy, CMC & H, Ludhiana, Punjab 1410 08, India, **Prof. & Head, NeurosurgeryDepartment, CMC & H, Ludhiana, Punjab 141 008, India, ***Asst. Professor, Department of Physical Medicine andRehabilitation, CMC & H, Ludhiana, Punjab 141 008, India, ****Professor, College of Physiotherapy, CMC & H, Ludhiana,Punjab 141 008, India

Abstract

Spinal cord injury (SCI) is a devastating condition. It notonly creates enormous physical and emotional cost to thevictims but also cause a financial burden to the society atlarge. The treatment of SCI focuses on preventing furtherinjury and enabling people to return to an active andproductive life within limits of their disability. Lack ofambulation lowers their self confidence as well as exposesto multiple complications. Benefits of standing andambulation of paralyzed individual are many. In recent timeswith the advances in rehabilitation assistive devices,ambulation of paraplegics is possible. We describe a caseof traumatic lumbar spine injury with paraplegia who hasbeen stabilized by surgical instrumentation andsubsequently made to walk with available resources likeknee ankle foot orthotic (KAFO) device and regularphysiotherapy.

Key words

Orthotic device, lumbar spine injury, paraplegia.

Introduction

The global incidence of SCI estimated primarily fromdeveloped countries ranges between 10.4 to 83 per millionpopulations per year when including only patients whosurvived before hospital admission1. In India, spinal injuriesare commonly due to road traffic accidents followed by fallfrom height2. 60 to 70% of these, are in their productive agebetween 14 and 45 years3. There are still 1.3 lacs survivorseach year following traumatic SCI who become wheelchairbound for rest of their lives which average more than 40years. Majority of SCI patients in India are rural based, livingbelow the poverty line, and unable to afford the cost oftreatment. Hence, the mortality rates in this group becomevery high due to complications arising out of immobility.

Cardiovascular, pulmonary, musculo-skeletal,integumentary, gastrointestinal, and renal function havebeen shown to be adversely affected by prolonged periodsof immobilization4.

The goal of treatment remains surgical stabilization andearly rehabilitation thus restoration and compensation of lostneuromuscular function by physiotherapy and functionalindependence. Training in activities of daily living byoccupational therapy, ambulatory and mobility training eitherin wheelchair or by using orthotic aids are the areas of majorconcern. Assisted standing systems target a sustainedstretch to promote hip and knee extension and ankledorsiflexion. Orthotic devices, however, enable some lowlevel thoracic paraplegics to stand and walk with the use ofwalking aids.

We described the case of lumbar spine fracture withcomplete paraplegia where we could make the patient walkwith orthotic device after the spine was surgically fixed. Theaim of this case report is to make aware the public and thetreating fraternity about the solid evidence supporting animpending paradigm shift from compensation for deficits torehabilitation as an agent for walking recovery.

Case report

A 26 year old male brought to CMC hospital on 13-08-08with history of road traffic accident around 8.15 A.M. He washit from back by a vehicle. No history of loss ofconsciousness, seizures, vomiting, ENT bleed. Historyrevealed loss of movement of both lower limbs since thetime of injury. Clinical examination revealed motor power0/5 both lower limbs, sensory loss to all modalities below L1on both sides. Superficial as well as deep tendon reflexeswere absent in both lower limbs. There was loss of Perianalsensation and decreased anal tone. An x-ray of lumbo-sacral (LS) spine was done which revealed burst fracturewith retropulsion and lateral translation of L1 vertebra overT12. The magnetic resonance imaging (MRI) of LS spineshowed hyper flexion rotation injury with near totaltransaction of spinal cord at T12-L1 level [Fig. 1].

On physiotherapy assessment, the upper limb powerwas found to be 4/5, sensory loss below L1 on both sides,myotome score was 52(26 on left side and 26 on right side)and dermatome score was 60 (28 light touch, 32 crudetouch), functional independence measure (FIM) score was1. (Score of "1" means "Total Assistance," in which theperson puts forth less than 25% of the effort necessary to doa task.). ASIA Scale was B (incomplete injury- Sensory butnot motor function is preserved below neurological level andincludes the sacral segments S4-S5). Preoperatively,physiotherapy was started with strengthening of shoulderflexors, extensors, abductors, elbow flexors, extensors andwrist flexors and extensors.

Operative procedure of posterior decompression (L1laminectomy) and stabilization by transpedicular rod & screwfixation between T12-L2 was done. Near total reduction ofburst fracture of L1 was achieved [Fig. 2]. On secondpostoperative day, upper limb strengthening and isometrics

59Rajni Arora / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

Fig. 1: MRI of spine showing hyper flexion rotation injury.

of spinal muscles was given. Patient was discharged fromneurosurgery unit on 7th post op day following sutureremoval.

Then he was re-admitted under rehabilitation unit for onemonth. Hyperextension brace was worn to preventpostoperative kyphosis. Upper limb strengthening protocolwas continued as before, progressive resistance withweights was increased every week until the strength ofupper limb muscles was 5/5. Wheelchair transfers weretaught to the patient. Mat activities programme was startedwhich includes rolling, prone on elbows, prone on hands,quadruped, kneeling and half kneeling.

The Knee Ankle Foot Orthosis provided a mechanicalsupport against gravity and locked the knees in extension sothey will not collapse. We provided the custom made KAFOto the patient and supported standing was started in theparallel bars by the end of one week. Slowly the patient wasmade to stand with one hand support and subsequentlywithout support. By end of two weeks he was made to standindependently without support. Once his standing balancewas trained, walking in the parallel bars was started. Firstthe paraplegic gait and then four point gait was taught to thepatient. At the time of discharge, reassessment was done.FIM score was- 6 (A score of "6" on the FIM scale means"Modified Independence," in which no helper is needed andthe person needs an assistive device. A score of "6" canalso be obtained when no help is needed but the persontakes more than a reasonable amount of time to do a taskor may complete the task in an unsafe manner.)

Discussion

Treatment of SCI has a most interesting past, an excitingpresent, and a very promising future. In the past treatmentfor spinal injuries included either complete bed rest orreduction by traction followed by immobilization.Subsequently the techniques of surgery itself improved,providing better reduction of deformity and stabilization overthe years. In the present, instrumentation techniques haveadvanced to assure rigid spinal stability, obtain precisereductions, maintain alignment, and thereby avoid the painand further disability caused by a deformed spine5. Inaddition, expert clinical, hands-on treatment also nowavailable to individuals with SCI both during acuterehabilitation and during ongoing outpatient care, especiallyin spinal centers, they can benefit from advances intechnology that have yielded better equipment. Powerwheelchairs can now perform weight-shifting functions bytilting and/or reclining. This has helped individuals with hightetraplegia expand their mobility with less stress on theshoulder joints6. Manual wheelchairs are now lighter,making them easier to propel and load into a vehicle. Duringthe past four decades, several orthotic devices have been

developed to allow some patients to stand and walk with theuse of walking aids. Lightweight orthotic devices for bothupper and lower extremities have made donning and doffingeasier and decreased energy cost for ambulatory persons7.The conventional KAFO consists of a shoe, ankle joint, kneejoint, medial and lateral metal or plastic uprights, calf band,knee pad, and thigh band. It provides a mechanical supportagainst gravity and locks the knees in extension so they willnot collapse.

The future of SCI management lies in regenerativetherapies like axonal growth inhibitor blockade, therapeuticvaccines, fetal stem-cell transplants, re-myelinativetherapies like Schwann cell transplants, oligodendroglial celltransplants8. Research scientists at the animal laboratorylevel have developed multiple strategies for studying andrepairing the injured spinal cord including both acute andchronic subjects. The effects of a SCI are far-reaching andthey impact the functioning of multiple body systemsincluding the cardiovascular, respiratory, musculoskeletal,urinary, and digestive systems.

Following a SCI, the majority of people experiencecomplications such as pressure sores, urinary tractinfections, osteoporosis, contractures, spasticity, andorthostatic hypotension (a drop in blood pressureimmediately upon moving to an upright posture, which canresult in dizziness and fainting).In SCI population, pressureulcer prevalence has been estimated to be between 17%and 33%.9 Individuals who do not stand are at an increasedrisk of developing tight hip and knee flexors as well as ankleplantar flexors.

Individuals, who have some residual motor function ofthe arms and trunk musculature, but varying motor functionof the lower extremities, may be able to engage in standingusing conventional Orthosis. The patient in this case wasmade to stand and walk with the help of Orthosis eventhough he had no power in the lower limb muscles. But withthe sufficient strength in upper limb muscles, abdominalsand good pelvic control, he achieved walking in ourrehabilitation centre.

Physiotherapy rehabilitation after SCI has been basedon the premise that the nervous system is hard-wired andirreparable. Upon this assumption, clinicians havecompensated for irremediable sensori-motor deficits usingbraces, assistive devices, and wheelchairs to achieveupright and seated mobility. Evidence from basic science,however, demonstrates that the central nervous systemafter injury is malleable and can learn, and this evidencehas challenged our current assumptions10. Because of theincreasing numbers of clients who have incomplete SCIs,the question for physiotherapists is less often whether anindividual with an SCI will walk again, but more a questionof how soon and how well11. A physiologically basedapproach for the rehabilitation of walking has developed,

Fig. 2: Post op X-ray of LS spine showing near total reduction with rod andtranspedicular screws in T12 & L2 body.

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Fig. 3: Showing the patient standing with KAFO.

translating evidence for activity-dependent neuro-plasticityafter spinal cord injury. Advanced by partnerships amongneuroscientists, clinicians, and researchers, criticalrehabilitation concepts are emerging for activity-basedtherapy to improve walking recovery, with promising clinicalfindings.

The purpose of describing this case report is to enrichpublic knowledge about the chances of standing andwalking of paraplegics following SCI with the help of orthoticdevices and regular physiotherapy. The cost & benefit ofearly ambulation with these devices surpass the mortalityand morbidity associated with prolonged immobilization.

References

1. Wyndaele M, Wyndaele JJ. Incidence, prevalence andepidemiology of spinal cord injury: What learns aworldwide literature survey? Spinal Cord, 2006; 44: 523-9.

2. Pandey VK, Nigam V, Goyal TD, Chhabra HS. Care ofpost-traumatic spinal cord injury patients in India: Ananalysis. Indian J Orthop, 2007; 41: 295-9.

3. Madan VS. Road Traffic Accidents: Emerging epidemic.Indian Journal of Neurotrauma (IJNT), 2006; 3: 1-3

4. Kunkel CF, Scremin AM, Eisenberg B, Garcia JF,Roberts S, Martinez S. The effect of “standing” onspasticity, contracture, and osteoporosis in paralyzed

males. Arch Phys Med Rehabil. 1993;74:73-8. 5. Donovan WH.; Operative and non-operative

management of spinal cord injury: a review. Paraplegia.1994;32:375–88.

6. Kirshblum S. New rehabilitation interventions in spinalcord injury. J Spinal Cord Med, 2004;27:342–50.

7. To CS, Kirsh RF, Kobetic R, Triolo RJ.; Simulation of afunctional neuromuscular stimulation poweredmechanical gait orthosis with coordinated joint locking.IEEE Trans Neural Syst Rehabil Eng, 2005;13:227–35.

8. Liverman CT., Bruce M. Altevogt, Janet EJ, Johnson RT.Institute of Medicine. Spinal Cord Injury: Progress,promise and priorities. National Academy Press;Washington, DC: 2005.

9. Carlson CE, King RB, Kirk PM, Temple R, HeinemannA. Incidence and correlates of pressure ulcerdevelopment after spinal cord injury. Journal ofRehabilitation Nursing Research, 1992;1:34-40.

10.Behrman AL, Bowden MG, Nair PM. Neuroplasticity afterspinal cord injury and training: An emerging paradigmshift in rehabilitation and walking recovery. Physicaltherapy, 2006; 86(10):1406-25.

11.Ladoucer M, Barbeau H, McFadyen BJ. Kinematicadaptations of spinal cord-injured subjects duringobstructed walking. Neurorehabil Neural Repair,2003;17:25-31.

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Stretching procedures for posterior shoulder tightness– randomizedclinical trialRanjeet Sharma, Ganesh B.R., Vijay B. Kage, Subhash M. KhatriK.L.E.S. Institute of Physiotherapy, J.N.Medical Collage Campus, Belgaum, Karnataka, India

Abstract

Purpose of study

Posterior shoulder tightness may be a contributing factorto subacromial impingement and recommend stretching asa prophylactic use for posterior shoulder tightness. Theobjectives of the present study were to compareeffectiveness of four stretching exercises, “towel stretch”,“cross-body stretch in sitting”,“cross body stretch in supine”and the “sleeper stretch”, in individuals with posteriorshoulder tightness.

Materials and methods

The present randomized clinical trial was conductedamong 80 an asymptomatic individual of both genders withposterior shoulder tightness from institute of physiotherapyand Anand cricket club, who were willing to take treatmentfor 4 weeks during the period of November 2007 to July2008. A written informed consent was obtained from studysubjects and ethical clearance was obtained. Theirdemographic data was collected and participants wererandomly allocated into four groups of 20 each. Preinterventional measurements were taken in terms internalrotation of shoulder and flexibility of posterior capsule ofshoulder. Shoulder stretchings were carried for a period offour weeks, following which post interventional measure-ments were taken.

Results

In this study, participants of interventional group showedhighly significant increase in internal rotation of shoulder(p=<0.001), flexibility of posterior capsule of shoulder(p=<0.001).

Conclusion

Sleeper stretch is more effective than cross bodystretching in supine, cross body stretching in sitting andtowel stretch in terms of flexibility and ROM that it is clinicallysignificant.

Key words

Internal rotation, Posterior capsule of shoulder,Stretching, tightness.

Introduction

Posterior capsule tightness of shoulder has beensuggested as a causative factor in shoulder impingement

syndrome (SIS) and labrum region. Patient with shoulderimpingement syndrome were limited in passive internalrotation range of motion (ROM) compared to healthysubjects and attributed this limitation to posterior capsuletightness1,2. The posterior capsular structures have beenshown to play a significant role in controlling normalarthrokinematics between the humeral head and theglenoid. Selective tightening of the posterior portion of theshoulder capsule causes anterior and superior translationof humeral head with the passive shoulder flexion3. Theabnormal humeral head motion can result in decrease insubacromial space during overhead activities. Thisapproximation of humeral head and acromion can lead tocompression of tissue in that region and may be associatedwith limited shoulder flexion, internal rotation (IR) andhorizontal adduction4. Even though the components of totalROM in the throwing shoulder may be altered, the total arcof motion that it is External Rotation and Internal Rotation isequal bilaterally5. Shoulderl adaptations commonly occur inbaseball pitchers due to repetitive throwing and extremelyhigh shoulder velocities. Some observed adaptationsinclude posterior shoulder tightness and glenohumeralinternal rotation deficit6.

Particularly in the throwing athlete, tightness of theposterior shoulder musculature and lack of GH IR affectsthe normal motion of the scapulothoracic articulation andleads to increased protraction of the scapula in cocking andfollow through phases7,8,9. This creates a “wind up” effect sothat the glenoid and scapula are pulled in a forward inferiordirection, thus resulting in excessive scapular protraction.This allows more anterior and inferior movement of theacrominon process, decreasing the subacromial arch, whichleads to decrease clearance of the rotator cuff and increaserisk for subacromial impingement10. Abnormal superior oranterior translations of the humeral head in the glenoid,abnormal scapular motions, imbalances of the rotator cuffmusculature, excessive capsular laxity, and or loss ofcapsular flexibility, have been implicated as etiologic factorsin both GH instability and impingement syndrome11. Manyoverhead athletes simply want to maximize theirperformance and have the most efficient and functionalshoulder possible, which makes a posterior shoulderstretching program important for the overhead athlete12,13.Baseball players repeatedly perform posterior shoulderstretches prior to activity for reasons of increasingflexibility14,15,16 preventing injuries, and improving muscularperformance17,18,19. The posterior shoulder inflexibility affectsefficient motion of the shoulder, studies have suggested thatpreseason baseball shoulder conditioning and rehabilitationshould concentrate on stretching the posterior shoulderstructures as well as obtaining a normal GH arc of motionand strength20.

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Stretching of the posterior shoulder is proposed as afundamental component of treatment for overhead athletesand any injury prevention program needs to be carefullydesigned to emphasize stretching of the posterior shoulderrather than stretching the entire upper limb to address thelimitation of IR.21Adequate flexibility of the posterior capsuleis important prior to beginning strengthening program22.

Several types of stretching procedures to stretchposterior shoulder tightness are:1. “Towel stretch” where the glenohumeral joint is

adducted, internally rotated and extended while thehand is located behind the individual’s back is pulled upby the opposite hand using towel23.

2. “Cross body stretch in sitting”where the shoulder is in90º of flexion and is pulled across the body in horizontaladduction with the opposite arm24.

3. “Cross body stretch in supine” where the shoulder is in90º of flexion and is pulled across the body in horizontaladduction with the opposite arm.

4. “Sleeper stretch” in which the subject lies on the side tobe stretched, elevating the humerus to 90º on thesupport surface and then passively internally rotating theshoulder with opposite arm25.As mentioned previously, to truly stretch the posterior

shoulder, the scapula must be retracted and stabilized.Scapular stabilization is an important technique used forisolating GH motion 26. Posterior shoulder stretches mustbe performed properly with scapular stabilization to assureaccurate stretching of the posterior shoulder and not thescapula thoracic articulation. Despite the recognizedimportance of scapular stabilization during stretching toisolate GH movement, no current research has investigatedscapular movement during a non-assisted posteriorshoulder stretch. The horizontal cross-arm stretch andsleeper stretches are designed to stabilize the scapulawithout assistance of another person.

Biomechanical studies suggest that posterior shouldertightness may be a contributing factor to subacromialimpingement and recommend stretching as a prophylacticuse for posterior shoulder tightness. However there is hardlyany study carried out to find out the effectiveness of thesestretching procedures in posterior shoulder tightness. Thepurpose of this study was to compare effectiveness ofstretching procedures for the posterior shoulder tightness.

Methodology

Source of data The source of data was Anand’s CricketAcademy and institute of physiotherapy. It was arandomized clinical trial for which ethical clearance wasgranted by the institutional ethical committee, J.N. MedicalCollege, Belgaum. Asymptomatic individuals of bothgenders with posterior shoulder tightness from institute ofphysiotherapy and Anand cricket club Belgaum who werewilling to take treatment for four weeks were recruited forthe study. Subjects were selected if they fulfilled the criteria:Individual with greater than 10-degree difference inasymmetry in shoulder internal rotation measured at 90-degree abduction. Age 18 to 30yr participants who werewilling to participate in the study. Exclusion criteria Anyprevious shoulder symptoms requiring medical care andsurgical care.

Procedure

The subjects with posterior shoulder tightness report tophysiotherapy department were included in the study.Subject included after the inclusion and exclusion criteriawere met along with signed informed consent. Theirdemographic data, ROM in terms of bubble inclinometerand flexibility of posterior shoulder capsule in term of rulermeasurement method were taken. Primary measure ofposterior shoulder tightness was passive internal rotation ofthe glenohumeral joint with the arm abduction upto 90degree. The bubble inclinometer was placed on the dorsalsurface of the forearm with the elbow flexion upto 90 degreeand prevents scapular substitution by watching the anterioraspect of the shoulder during the measurement1.

Measurement of Internal rotation of shoulder

Ruler measurement method for flexibility

Ruler measurement method was used prior to treatmentof first day with the subject in the side-lying position; the testarm was placed in 90-degree of abduction with the humerusin neutral rotation. The scapula of the test arm wasstabilized in the fully retracted position, and then humeruswas lowered the humerus into horizontal adduction. Thehumerus was lowered with the scapula stabilized inretraction until motion cease or humeral rotation occur.Standard carpenter’sruler to measure the distance (incentimeters) from the treatment table to the medialepicondyle. Increased distance from the treatment table tothe medial epicondyle indicates a less flexible posteriorcapsule27.

Participants were randomly divided into 20 subjectseach groups: Group A, Group B Group C and Group D.1. In Group A (towel stretch): “Towel stretch” where the

glenohumeral joint was adducted, internally rotated andextended while the hand was located behind theindividual’s back is pulled up by the therapist towel23.

2. In Group B (cross body stretch in sitting): “Cross bodystretch in sitting” where the shoulder was in 90º of flexionand was pulled across the body in horizontal adductionby the therapist24.

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3. In group C (Cross body stretch in supine) “Cross bodystretch in supine” where the shoulder was in 90º offlexion and was pulled across the body in horizontaladduction by the therapist.

Results

The results of this study were analyzed in terms ofincrease in the internal rotation range of motion of shoulderindicated by improving flexibility of posterior shouldercapsule and comparison was made between the 1st and30th day readings. Comparison was done between the fourgroups so as to evaluate intragroup effectiveness of the fourstretching procedure under consideration in the presentstudy.

Statistical analysis

Scheffe multiple comparison” test was utilized tomeasure the difference between the four groups in terms ofimproving flexibility of posterior shoulder capsule andincrease internal rotation range of motion of shoulder andpaired ‘t’ test was utilized to measure the difference withinthe four groups in terms of flexibility of posterior shouldercapsule and internal rotation ROM of shoulder.

Demographic profile

80 participants were studied, out of which 38 were malesand 42 were females, 20 each in four groups. towel stretchgroup consisted of 10 males and 10 females, cross bodysitting group consisted 9 males and 11 females, cross bodysupine consisted 9 males and 11 females and sleeperstretch group consisted 10 males and 10 females Age of theparticipants in this study was between 15 to 25 years. Themean age of the participants in towel stretch group was20.09 ± 1.12 years, mean age of the participants in crossbody stretch sitting group was 20.95 ± 0.99 years, meanage of participants in cross body supine group was 20.85±1.13 and mean age of participants in sleeper stretch groupwas 20.65 ± 0.93. There was no significant difference

Graph 1: Range of Motion

4. In group D (Sleeper stretch) “Sleeper stretch” in whichthe subject was made to lie on the side to be stretched,elevating the humerus to 90º on the support surface andthen passively internally rotated the shoulder by thetherapist25.

Stretching exercise was performed in all groups oncedaily for 5 repetitions holding each stretch for 30 seconds forfour weeks.6 End of four weeks ROM of internal rotationand Flexibility of posterior capsule of GH was assessedusing Bubble inclinometer and Ruler measurement method.

Table 1: Range of Motion

A B C D ‘F’ ‘P’Group Group Group Group value value

Before 73.15 72.25 73.15 73.30 0.137 0.938± 5.83 ± 5.79 ±5.83 ± 5.76

After 76.2 77.2 80.2 83.3 6.505 0.001± 5.38 ± 5.85 ± 6.07 ± 5.71

Difference 3.05 4.95 7.75 10 ± 0 153.355 <0.001± 1.19 ± 0.51 ± 1.77

Paired 11.402 43.406 19.581 ----t testDF 19 19 19 ----

‘P’ value <0.001 <0.001 <0.001 -----

Cross body stretch in supine

Sleeper stretch

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between the mean age of the participants in all groups.(f=0.313, p = 0.816)

Range of motion

In the sleeper stretch group the means of ROM on thefirst day was 73.30 ± 5.76, which was increased to anaverage of 83.3 ± 5.71 on the 30th day of the treatment.Mean difference between 1st and 30th day scores was 10.0± 0.(Table1; Graph1) All stretching procedure were foundto be effective in improving the internal rotation, but meanimprovement in sleeper group was more significantcompared to the towel stretch, cross body stretch sitting,cross body stretch supine group. (p = <0.001) (Table1;Graph 1 )

Flexibility

In the sleeper stretch group the means of flexibility onthe first day was 34.6 ± 2.70, which was reduced to anaverage of 30.3 ± 2.55 on the 30th day of the treatment.Mean difference between 1st and 30th day scores was 4.3± 1.17. (Table 2; Graph 2 ) All stretching procedures werefound to be effective in improving the flexibility of posteriorshoulder capsule but mean improvement in sleeper groupwas more significant compared to the towel stretch, crossbody stretch sitting, cross body stretch supine group. (p =<0.001) (Table 2, Graph2).

Discussion

An asymptomatic individuals to maximize theirperformance and reduce the risk of injury, it may bebeneficial to include posterior shoulder stretches into awarm-up program. This study demonstrates that the act of

stretching the posterior shoulder resulted in significantincreases in glenohumeral IR ROM and improvements inflexibility of posterior capsule of shoulder. Sleeper stretchcreated the greatest increase in GH IR ROM, however, allstretches resulted in significant increases in GH IR ROMafter stretching. ( p = <0.001) ( Table1, Graph1 ). This studydemonstrated an increase in GH IR of 4-10° followingstretching in a month. Previous literature has stated thatstretching immediately prior to an event, may be necessaryto ensure maximum ROM28.

The literature supports that a static stretch of 30 secondsat a frequency of 3 repeated stretches per single session issufficient to increase muscle length29. Whatman et alshowed that ROM increases can occur when performingstretches 4 times 20 seconds, for a total of 80 seconds ofstretching30. We showed similar ROM increases whenstretches were performed 5 times for 30 seconds, for a totalof 150 seconds of stretching. Our results are consistent withprevious literature that supports 5 times 30 seconds forincreasing ROM. Previous studies that have used otherprotocols such as 2 times 15 seconds have shown noincrease in ROM30.

This study demonstrated that the act of stretching theposterior shoulder resulted in increase in GH IR ROM. (p =<0.001) ( Table1 Graph1 ). The sleeper stretch is designedto stabilize the scapula while stretching the posterior rotatorcuff muscles and the posterior inferior capsule/GH ligamentin the shoulder31. The side lying PST assessment, asdescribed by Tyler et al, is a measurement of the distanceof the medial epicondyle of the humerus to the top of thetreatment table while the examiner stabilizes the scapula27.Although the side lying method has been shown to bereliable, it is difficult to make comparisons among patientsdue to different body structures and shoulder widths.Results of this study demonstrated significant improvementsin flexibility of posterior capsule of shoulder followingstretching. ( p =< 0.001) ( Table 2, Graph 2 ).

PST has also been associated and correlated with lossof GH IR ROM. Tyler et al found a significant correlationbetween IR ROM losses and increased PST in patients withshoulder impingement. Based on their data, they stated thatclinicians can expect 1cm of PST for every 4º of IR ROMlost. 27Scapular kinematic is important to minimize scapularmotion during stretching for better isolation of theglenohumeral joint. When the scapula is stabilized,stretching can occur at the glenohumeral joint resulting inincreased ROM.

The sleeper stretch, cross body stretch in supineprovided the most scapular stabilization and the cross bodystretch in sitting, towel stretch provided the least amount ofscapular stabilization. The mean difference of ROM sleeperstretch (10 ± 0) and difference of ROM in Cross body stretchin supine (7.75 ± 1.77) is more than cross body stretch insitting (4.95 ± 0.51) and towel stretch (3.05 ± 1.19).

The goal of the posterior shoulder stretches is to isolatethe GH joint and allow stretching to occur in the posteriorshoulder. The stretches chosen for this study were basedon the ability to be performed independently anywhere,without the help of a clinician to provide scapularstabilization. Previous literature describes various stretchingtechniques with the help of a clinician to manually providescapular stabilization32.

Clinical significance of study our data suggests that the

Table 2: Flexibility

A B C D F ‘P’Group Group Group Group value value

Before 33.9 34.05 34.70 34.6 0.522 .668± 2.38 ± 2.28 ±2.43 ± 2.70

After 33.05 33.3 32.7 30.3 6.871 <0.001± 2.35 ± 2.05 ± 2.43 ± 2.55

Difference -0.85 -0.75 -2 ± 0 -4.3 107.552 <0.001± 0.67 ± 0.44 ± 1.17

Paired 5.673 7.623 ---- 16.43t testDF 19 19 19 19

‘P’ value <0.001 <0.001 ----- <0.001

Graph 2: Flexibility

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sleeper stretch and the cross body stretch in supineeffectively increased GH IR ROM when performed 5 timesfor 30 seconds. With proper positioning for scapularstabilization, subjects can perform these stretchesindependently. Clinicians may instruct the athletes toperform these stretches as part of the on-the-field warm uproutine, or between innings for the maintenance of theirposterior shoulder flexibility. In addition, these stretches canbe performed independently off the field to enhance ROM,reduce muscle soreness, decrease the onset of injury, andthus enhancing their performance.

Limitation of the study was that all subjects wereassumed to be healthy based on absence of shoulder painor history of shoulder injury. No physical exam, x-rays ormagnetic resonance imaging (MRI) were performed to ruleout pathology. An additional limitation in this study was thatGH ROM and PST was not repeatedly measured after thestretch to know how long the effects of each stretch lasted.Only immediate effects were measured following stretching,thus, the duration of the stretch effects could not bedetermined. This study did not evaluate PNF stretching,assisted stretching, or dynamic warm up procedures. Onemore limitation, there was the use of asymptomatic studentsrather than throwing athletes or a symptomatic clinicalpopulation seeking medical care. A limitation of this work islack of any long term follow up.

Conclusion

Based on study findings sleeper stretch appears to bemore effective than cross body stretching in sitting and towelstretch subjects. While the improvement in internal rotationand flexibility from sleeper stretch was greater than thecross body stretch in supine and was clinically significant,the small sample size likely precluded statistical significancebetween all four groups.

References

1. Ludewig PM, Cook TM. Translations of the humerus inpersons with shoulder impingement symptoms. J OrthopSports Phys Ther.2002; 32(6): 248-259.

2. Burkhart SS, Morgan C. SLAP lesions in the overheadathlete. Ortho. Clinic North Am. 2001; 32:431–441.

3. Harryman DT, 2nd, Sidles JA, Clark JM, McQuade KJ,Gibb TD, Matsen FA, 3rd. Translation of the humeralhead on the glenoid with passive glenohumeral motion.J Bone Joint Surg Am.1990; 72(9):1334-1343

4. Warner JJ, Allen AA, Marks PH, Wong P. Arthroscopicrelease of postoperative capsular contracture of theshoulder. J Bone Joint Surg Am.1997;79:1151–1158.

5. Borsa PA, Wilk KE, Jacobson JA, et al. Correlation ofrange of motion and glenohumeral translation inprofessional baseball pitchers. Am J Sports Med.2005;33:1392–1399.

6. Schucker, Candice Pauline. Evaluation of three on thefield non assisted posterior shoulder stretches incollegiate baseball pitchers University of Pittsburgh,2007

7. Kibler WB, McMullen J. Scapular dyskinesis and itsrelation to shoulder pain. J Am Acad OrthopSurg.2003;11(2):142-151.

8. Kibler WB. The role of the scapula in athletic shoulder

function. Am J Sports Med.1998;26(2):325-337. 9. Meister K. Injuries to the shoulder in the throwing

athlete. Part one: Biomechanics/ pathophysiology/classification of injury. Am J Sports Med. 2000; 28(2):265-275B

10. Thigpen CA, Padua DA, Morgan N, Kreps C, Karas SG.Scapular kinematics during supraspinatus rehabilitationexercise: a comparison of full-can versus empty-cantechniques. Am J Sports Med.2006;34(4):644-652.

11. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J,Kennedy R. Patterns of flexibility, laxity, and strength innormal shoulders and shoulders with instability andimpingement. Am J Sports Med.1990;18(4):366-375

12. Lorenz D. The Importance of the Posterior Capsule ofthe Shoulder in Overhead Athletes. National Strengthand Conditioning Association.2005;27(4):60-62.

13. Litchfield R, Hawkins R, Dillman CJ, Atkins J, HagermanG. Rehabilitation for the overhead athlete. J OrthopSports Phys Ther.1993;18(2):433-441.

14. Smith CA. The warm-up procedure: to stretch or not tostretch. A brief review. J Orthop Sports Phys Ther. 1994;19(1): 12-17.

15. Williford HN, East JB, Smith FH, Burry LA. Evaluation ofwarm-up for improvement in flexibility. Am J SportsMed.1986;14(4):316-319.

16. Cramer JT, Housh TJ, Johnson GO, Miller JM, CoburnJW, Beck TW. Acute effects of static stretching on peaktorque in women. J Strength Cond Res.2004;18(2):236-241.

17. Halbertsma JP, van Bolhuis AI, Goeken LN. Sportstretching: Effect on passive muscle stiffness of shorthamstrings. Arch Phys Med Rehabil.1996;77(7):688-692.

18. Andersen JC. Stretching Before and After Exercise:Effect on Muscle Sorenes and Injury Risk. J AthlTrain.2005;40(3):218-220.

19. Evetovich TK, Nauman NJ, Conley DS, Todd JB. Effectof static stretching of the biceps brachii on torque,electromyography, and mechanomyography duringconcentric isokinetic muscle actions. J Strength CondRes.2003;17(3):484-488.

20. Bigliani LU, Codd TP, Connor PM, Levine WN, LittlefieldMA, Hershon SJ. Shoulder motion and laxity in theprofessional baseball player. Am J SportsMed.1997;25(5):609-613.

21. Boon AJ, Smith J. Manual scapular stabilization: Itseffect on shoulder rotational range of motion. Arch PhysMed Rehabil.2000;81(7):978-983.

22. Morrison DS, Frogameni AD, Woodworth P. Nonoperative treatment of subacromial impingementsyndrome. J Bone Joint Surg 1997; 79-A: 732-7.

23. McCLure PW, Bialker J, Neff N, William G, Karduna A.Shoulder function and three dimensional kinematic inpeople with shoulder impingement before and after 6weeks exercise program. Phys ther. 2004; 84:830-848.

24. Bandy WD Sander B. Therapeutic Exercise: Techniquefor intervention. Baltimore, MD: Lippincott Williams &Wilkins Sports Medicine and Arthroscopy Review:2001Volume 9(4); 325-336

25. Wilk KE, Meister K, Andrews JR. Current concepts inthe rehabilitation of the overhead-throwing athlete. Am JSports Med. 2002; 30: 136–151

26. Burkhart SS, Morgan CD, Kibler WB. The disabledthrowing shoulder: spectrum of pathology Part III: TheSICK scapula, scapular dyskinesis, the kinetic chain,

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and rehabilitation. Arthroscopy.2003;19(6):641-661. 27. Tyler TF, Roy T, Nicholas SJ, Gleim GW. Reliability and

validity of a new method of measuring posterior shouldertightness. J Orthop Sports Phys Ther. 1999;29:262–274.

28. Whatman C, Knappstein A, Hume P. Acute changes inpassive stiffness and range of motion post-stretching.Physical Therapy in Sport.2006;7:195-200.

29. de Weijer VC, Gorniak GC, Shamus E. The effect ofstatic stretch and warm-up exercise on hamstring lengthover the course of 24 hours. J Orthop Sports PhysTher.2003;33(12):727-733

30. Zito M, Driver D, Parker C, Bohannon R. Lasting effectsof one bout of two 15-second passive stretches on ankledorsiflexion range of motion. J Orthop Sports PhysTher.1997;26(4):214-221.

31. Nelson AG, Allen JD, Cornwell A. The relationshipBetween Glenohumeral Internal Rotation and Shoulderand Elbow Pain. PBATS Newsletter.2002;15(2).

32. Johansen RL, Callis M, Potts J, Shall LM. A modifiedinternal rotation stretching technique for overhand andthrowing athletes. J Orthop Sports Phys Ther. 1995;21(4):216-219.

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Effects of local vs global stabilizer strengthening in chronic lowback painPriyanka Goel*, Zubia Veqar**, Nishat Quddus****Former Visiting Faculty Jamia Millia Islamia, New Delhi, **Asst. Prof. Jamia Millia Islamia, New Delhi, ***Asst. Prof. JamiaHamdard, New Delhi

Abstract

Study design

A randomized control trial, pretest-posttest control groupdesign.

Objective

To determine the efficacy of local stabilizerstrengthening in the treatment of chronic low back pain.

Summary of Background Data. A recent focus in thephysiotherapy management of patients with back pain hasbeen on the specific training of muscles surrounding thespine, considered to provide dynamic stability and finecontrol to the lumbar spine. In no study the researchersevaluated the efficacy of this intervention in the populationof chronic low back pain.

Method

Forty-five subjects with this condition were assigned tothree groups with a 3 weeks intervention protocol. The firstgroup received the local stabilizer strengthening, secondgroup received the global stabilizer strengthening and thethird group comprised of combined strengthening of theupper two groups.

Results

After intervention, all the groups showed significantimprovement in the pain scales, disability index and theranges of movement of the lumbar spine. However, therewas slower and delayed improvement in local stabilizergroup as compared to the other two groups.

Summary

A treatment protocol consisting of combined streng-thening of local and global stabilizers appears moreeffective than commonly prescribed conservative treatmentprograms in patients with chronic low back pain.

Although low back pain is a self-limiting and benigndisease that tends to improve spontaneously overtime, amany varied therapeutic interventions are available for thetreatment of low back pain. However, the effectivenessassociated with most of the interventions has not yet beendemonstrated beyond doubt and consequently, thetherapeutic management of low back pain varies widely. Anepisode of acute low back pain resolves in only 2-4 weeksfor 90%of the patients. Yet in the year following the firstepisode of low back pain, the pain recurs in a staggering60-80%of the patients1. There appears to be a trend

towards chronic low hack pain with 40% of the subjectsreporting pain at 6 months and 33%still experiencing pain at1-2 years2. These recurrences incur major human andfinancial costs. Hence, successful prevention of recurrentlow back pain still remains a challenge. The physical therapyhas shown many promising advances in backcare in thepast few years. The most exciting advancements have beenin the field of stabilization of the lumhar spine. The concepthehind the strengthening of local system is to createstiffness in the spine before load is placed on it, thuscontrolling mid-range or neutral zone of the intervertebraljoints. Control of this mid-range helps decrease shear forcesand compression during movement and spinal loading.When working properly, the local intrinsic musculature firesbefore the actual motion of an extremity or trunk. Weaknessof these muscles decrease the person's ability to controljoint neutral position during movement or under load andhence can lead to spinal instability. As defined by Punjabi etal in 19923, spinal instability is defined as the significantdecrease in the ability of the stability system to maintain theintervertebral neutral zone within physiological limits, whichconsequently result in pain and disability Therefore, therecent focus in the Physiotherapy management of patientswith chronic low back pain has been on the specific trainingof muscles surrounding the lumbar spine whose primary roleis considered to be the provision of dynamic stahility andsegmental control of the spine. These are the deepabdominal and deep hack extensors muscles, namelyTransversus abdominis, Multifidus and Internal Obliquemuscles. Therefore, looking at the future of exerciserehabilitation in low back pain patients, the training of theintrinsic system is a major paradigm shift. Vast majority ofthe patients who experience low back pain needs anintrinsic retraining program first to ensure control of the jointneutral position. Although, this intrinsic system can be moretime consuming and difficult to teach to the patient at first,this system cannot be ignored any longer as the future inexercise rehabilitation. Lumbar motion segments are quitewell designed to carry and resist external forces. Despitethe stability provided by the osseous-ligamentous system,the spinal column devoid of musculature is incapable ofcarrying normal physiological loads (Punjabi et al, 1989)4.The muscular system around the spine can be divided intothree distinct categories which are Local stabilizers, Globalstabilizers and Global mobilizers7,8. Local stabilizers in thelumbar spine are defined as muscles that control the jointneutral position. They usually cross over only one spinalsegment and also attach directly to the lumbar spine.Activity of the local stability system is independent of thedirection of the movement and is invariably present duringall the movements of lower extremity (Hodges PW et al1997)5. Dysfunction of the local system results in motor

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control deficit associated with delayed timing, or recruitmentdeficiency. These muscles react to pain and pathology withinhibited firing patterns. This delay, or inhibition of thestability system decreased the patient's ability to control ajoint neutral position. This concept was demonstrated byHodges PW et ai, 1998.Global stabilizers comprise of largertorque producing muscles. They contract concentrically andeccentrically to produce or control range of motion. Theiractivity is direction dependent and they activate to controland transfer load. Contraction of these muscles can producerigidity, if the load is great enough, to protect from injury.These muscles react to pain and pathology in the form ofpainful spasm. This system comprises of AbdominalOblique muscles, Rectus abdominis muscle, Erector spinaemuscle, Gluteus maximus and Hamstrings. This systemconsists of muscles that are traditionally strengthened inpeople with low back pain. Evidences suggest that globalsystem may not be the optimal starting point for patientswith chronic low back pain. This is because only when thelocal stabilizers maintain the neutral joint position at eachlevel of the lumbar spine, the role of global stabilizers ofmaintaining the neutral position of the lumbar spine as awhole by virtue of their attachment to the rib cage andpelvis, come into plays . The purpose was to find the effectof loca! stabilizer strengthening on non-specific chronic lowback pain.

Methodology

This study was designed to find out the efficacy ofstrengthening of the local and the global muscular systemsaround the lumbar spine in patients with chronic low backpain. It primarily aimed to assess the effects of combinedstrengthening of the two groups when compared to that ofisolated strengthening of local and global muscles.

Patients

Patients were selected from the ones coming to theorthopaedic department of ESI, Okhla. Criteria for inclusionwere restricted to 45 subjects between the age of 30 to 50years with low back pain of insidious onset for more tan 3months. Patients were excluded if they had any neurologicalinvolvement, any recent trauma or surgery, any congenitalor acquired bony anomaly of he lumbar spine.

Study design

A randomized pre-post control group design with three

treatment groups. At entry level, patients were made to signan informed consent form and then underwent the testingprocedure. Every alternate patient was assigned into groupI, II and III respectively, depending upon their visit to thedepartment with each group being assigned 15 subjectseach.

Measures

Before measures were carried out, each patient’s heightand weight was assessed and a brief history was takenregarding age, mode of onset, duration and treatmenthistory. All measures used were valid and shown to haveacceptable reliability. 1. Pain score: 101 point numerical rating scale was used toassess the intensity of pain before the treatment and duringthe treatment.2. Disability index: The Oswestry disability questionnairewas used to give a score that indicated each patient’s levelof functional disability. It is used widely to monitor treatmentaffect with regard to changes in the functional mobility ofpatients with CLBP and is sufficiently sensitive to monitorthese changes.3. Lumbar spine range of motion: This was measuredusing an inch tape. Flexion: In standing, subjects will be asked to slide theirhands down the front of their legs until they experience thefirst point of pain or the first increase in pain. The distancefrom the end of the middle finger to the floor will bemeasured using an inch tape.Extension: Measured in the same way with subjects slidingtheir hands down the posterior aspects of their legs.Side flexion: Left and right side flexion will be measured inthe same way with the subjects sliding their hands down thelatera; aspects of their left and right legs, respectively.

Intervention

All the three groups underwent a 3 week treatmentprogram. The intervention involved patients being taughtexercises degined to strengthen the local stabilizers alongwith the conventional back extensor exercises as the homeexercise program. Local muscles were trained in the clinicunder the guidance of the trained physiotherapist.

The patients were made to perform 10 contractions with10 second holds. The number was increased to 12 and then15 in the second and third week respectively. Adjunctiveshortwave diathermy was given to each patient for 10minutes before the exercise session. Group I was givenlocal stabilizer strengthening with home exercise program,Group II was the control group getting only the homeexercise program, and Group III was given a combinedexercise regime along with the home exercise program.

Data management

All analysis was obtained using the softwareSTATA version 9.0. Demographic data of subjects

including sex, age, height and weight were descriptivelysummarized. To compare the effect of local stabilizerstrengthening on the patients with chronic low back painbetween the groups, one-way ANOVA was used, keepingsignificance value ,p=0.05. Within group improvements

Fig. 1.1: Positioning of the stabilizer.

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were analyzed by repeated measures ANOVA. Also, tocompare the differences between two groups at a time,posthoc analysis was being done. The same analysis wasthen used to compare the improvements within the groupsin order to assess the changes between the subsequentweeks of intervention.

Results

This chapter deals with the results of the study. Themean age of the participants in the study was 36.9±4.6years (refer table 6.1). the mean height and weight of theparticipants are59.1±10.9 and162.3±6.5 respectively. Theoutcome measures of the study were recorded on Day 0that is prior to the intervention as a pre-treatment record.The post-treatment recordings were taken on Day 7, Day15 and Day 21 of the intervention period, again beforestarting the treatment session.

Analysis of differences within each group after theintervention showed statistically significant improvements inthe pain levels as measured on the scale over three weeks,at p <0.05. However, there was no significant improvementin the pain scale in the first week of intervention in Group Iwith Day 7/ V7 , p = 0.06.Analysis of differences betweenthe three groups – I, II and III showed statistically non-significant differences in the results of Group I Vs Group II,Group I Vs Group III and Group II Vs Group III comparisonsin week one (v 7) and week two (v 15). However, on day 21there was statistically significant differences in the painscale in Group I Vs Group II (p = 0.03) and Group I VsGroup III (p = 0.004).

Analysis of differences within each group after theintervention showed statistically significant improvements inthe disability levels as measured on the scale over threeweeks. Analysis of differences between the three groups –I, II and III showed statistically non-significant differences inthe results of GroupI Vs Group II, GroupI Vs Group III andGroup II Vs Group III comparisons in week one (v 7) andweek two (v 15) and week three (v 21), except for thestatistically significant differences on Day 21 in group I Vs

group III with p = 0.01.Analysis of differences within each group after the

intervention showed statistically significant improvements inthe flexion range as measured using tape measurementsover three weeks, p < 0.05. In group I, improvement beingseen only in the last week on Day 21/ F 21, p = 0.02.Theoverall improvement was present from Day 0 to Day 21 inGroup II, p = 0.05.Group III showed statistically significantimprovement in the flexion range through the entire threeweeks intervention period. Analysis of differences betweenthe three groups – I, II and III showed statistically non-significant results.

Analysis of differences within each group after theintervention showed statistically significant improvements inthe extension range as measured using tape measurementsover three weeks, p < 0.05. Progressive improvement wasseen in all the three groups except in group I, where therewas no statistically significant improvement in the firstweek,day 7/ E 7 - p = 0.08. Analysis of differences betweenthe three groups – I, II and III showed statistically significantdifferences in the results on all the days of data collection,p = 0.001. Also, significant differences between groups I andIII were evident from second week, day 15/ E15 - p = 0.014However, there were statistically non-significant differencesbetween the groups II and III during the entire three weeksprotocol.

Analysis of differences within each group after theintervention showed statistically significant improvements inthe right side flexion range as measured using tapemeasurements over three weeks, p < 0.05. Progressiveimprovement was seen in all the three groups except ingroup I, where there was no statistically significantimprovement in the first and the second weeks, day 7/ RS7 - p = 0.39 and day 15/ RS 15 - p = 0.06. Similar patternwas seen in group II where day 7/ RS 7 - p = 0.16 and day15/RS 15 - p = 0.18. Statistically significant improvementswere seen in group III on all the subsequent days of datacollection. Analysis of differences between the three groups– I, II and III showed statistically non-significant differencesin the results.

Fig. 1: Comparison of pain scores

Fig. 2: Comparison of Disability Index

COMPARISON OF PAIN SCORES

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COMPARISON OF DISABILITY INDEX

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Grp-II GLOBAL (n=15) m+sd

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Fig. 3: Comparison of Flexion ROM

Fig. 4: Comparison of Extension ROM

COMPARISON OF FLEXION ROM

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COMPARISON OF EXTENSION ROM

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Analysis of differences within each group after theintervention showed statistically significant improvements inthe left side flexion range as measured using tapemeasurements over three weeks, p < 0.05. Progressiveimprovement was seen in all the three groups except ingroup I, where there was no statistically significantimprovement in the first and the second weeks, day 7/ RS7 - p = 0.86 and day 15/ RS 15 - p = 0.27. Statisticallysignificant improvements were seen in group II and III on allthe subsequent days of data collection. Analysis ofdifferences between the three groups – I, II and III showedstatistically non-significant differences in the resultsHowever, on day 15 there was statistically significantdifferences in the range of left side flexion in Group I VsGroup II (p = 0.04).

Discussion

This study was designed to find out the efficacy ofstrengthening of the local and the global muscular systemsaround the lumbar spine in patients with chronic low backpain. The main findings of the current study was that thethree treatment groups proved to be efficacious in theirability to reduce pain intensity and frequency and functionaldisability and on the other hand improve the range of motionof the lumbar spine which in turn improved the performanceof the tasks of daily living after therapy, though the timetaken for improvement by each group varied considerably.

As per the study findings, the mean age is comparativelyless as compared to the ones mentioned in the literature.According to the inclusion criteria of mechanical low backpain, it is well proven in the researches that it is common inindividuals less than 45 years of age. The reason for thiscould be the occupation, genetics or the personal behavior.Occupations that increase the risk for low back pain arethose that involve more of lifting, twisting bending andreaching. The subjects in this study were the young factoryworkers who were prone to low back pain due to their natureof work, thereby providing support to this shift in the agerange of chronic low back pain sufferers to the lesser age.According to the researches present in the literature, bothmales and females either have equal propensity to develop

low back pain or females are more prone to it. However, thecommon perception that women display a greaterwillingness to seek care for health issues, in an Australianstudy, Walker found females more likely to seek care for lowback pain. Unlike the above presented researches, thisstudy saw more male population being aware of the healthissues. This could be explained on the basis of the fact thatthe study was being conducted in a setup which providedservices to the insured factory workers. Since these workerswere the only earning members in their families, they weremore conscious of their back problems and hence moremotivated to seek help and get cured and they did not haveto pay for the treatment too, which is one of the importantreasons in this kind of setups

Comparison of pain scores

The measurement of subjective pain intensity continuesto be important to both researchers and clinicians. Althoughseveral scales are currently used to assess the intensityconstruct, it remains unclear which of these provides themost precise, replicable and predictively valid measures.According to work done by Mark P. Jensen et al, the 101point numerical rating scale appeared to be the mostpractical index as it fulfilled the major criterion, consideredin previous researches, of a valid scale.. In the within groupanalysis, there is statistically significant improvement in allthe three groups, irrespective of the interventions in each ofthe groups. However, the findings show that theimprovement in-groupI was comparatively lesser and sloweras compared to the control group and the group III. Also,the improvement in group I started only after the first weekof intervention as compared to the other two groups wherethe improvement started from the very next day of thestarting of the therapy. Positive changes within each groupcan be explained on the basis that low back pain may causemuscle spasm or refractory inhibition of the muscles of theinjured area and the subsequent functional disabilityprolonged pain may lead to avoidance behavior caused byfear of pain. In the long run this may lead to thedevelopment of the so-called Deconditioning syndrome6,which includes impairments in the back muscle force,

Fig. 5: Comparison of Left Side Flexion Fig. 6: Comparison of Right Side flexionCOMPARISON OF LEFT SIDE FLEXION RANGE

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Grp-II GLOBAL (n=15) m+sd

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COMPARISON OF RIGHT SIDE FLEXION RANGE

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Table 1: Outcome measures

OUTCOME MEASURES Pain Scores ODI Scale* Flexion Extension Right Side Flexion Left Side FlexionMean ± sd

Group I 45±15.2 12.6±6.3 20.7±9.2 53.4±2.9 42.8±5.3 42.2±4.2Group II 26.3±21.5 9.2±5.6 15.3±13.5 49.2±3 33.6±4.6 38.6±4.6Group III 21±18.2 6.4±3.2 18.7±5.7 48.5±2.4 39.4±4.4 40.1±4.3F value 6.96 5.19 1.14 13.2 3.24 2.54p value 0.003 0.09 0.32 0.001 0.04 0.009

*Oswestry low back pain Disability IndexSignificance level ≤ 0.05

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endurance, and spinal mobility. This impairment in themuscle function can be explained in the terms of structuralback extensor muscles and physiological changes that arereversible with intensive back muscle training. In general,exercises, of any kind, help in reducing pain by breaking thepain-spasm cycle, irrespective of the cause of it. Secondly,each protocol used had a substantial exercise componentfocusing on different muscle groups and hence, placingquite different demands on the type of adaptationsexpected. The finding that all the groups improved in relationto the baseline measures, irrespective of the time taken forimprovement, tend to suggest that the main effect wasinduced not through specific physiological adaptations butrather through some central effect, perhaps which involvesan adjustment in perception in relation to pain in all the threegroups. These findings therefore, support the Panjabi’s7

hypothesis that health of the lumbar spine is dependent notsolely on the basic morphology of the spine but also on thecorrect functioning of the neuromuscular system. Thereason for the slower improvement in group I as comparedto other two groups might be attributed to the ratio of type Ito the type II fibres in the local muscles being strengthenedin group I as compared to the ones being strengthened inthe other two groups. There appears to be greaterpercentage of type I fibres than type II in the multifidusmuscle, thereby suggesting its role as an important lumbarstabilizer8. According to the physiological basis, type IImuscle fibres take longer time to recover and get trained ascompared to type I fibres and hence, group I showed slowerresults9. Another reason for this could be the difficulty intraining of these muscles as compared to the global ones.This approach aims, in the early stages, to specifically trainthe isometric co-contraction of the lumbar multifidus and thedeep abdominals with minimal activation of the globalmuscle system. These co-contractions involve a high levelof specificity and patient compliance and low levels ofmaximum voluntary contractions. In all the patients of groupI, an isolated pattern of activation of the deep abdominalsand co-activation with lumbar multifidus was reported to bevery difficult to achieve, may be because of the dominantsubstitution of other trunk synergists. It was seen thatseveral patients took as long as full three weeks of specifictraining before an accurate pattern of co-activation wasachieved. Secondly, the use of the stabilizer, a pressurebiofeedback cushion, made the study readings morereliable, but at the same time, its training took a longer timeas compared to the other exercises in other two groups. Oncomparing the between group differences in the painscores, it was seen that strengthening of local and globalstabilizers together was more efficacious in decreasing thepain intensity that the isolated specific stabilizationexercises of local muscles and the exercises for the globalmuscles. The reason for significant differences in group Iwhen compared with other two groups might be the slowresponse of the local stability muscles to treatment, which isalready discussed above. On comparing the results of groupII and III, their relationship failed to achieve statisticalsignificance but it was clinically relevant with regard to thepain scores. The differences were visible graphically. Thisfinding can be justified by the fact that the only difference inthe intervention of group II is the additional strengthening ofthe local muscles in group III who have slow recovery

Comparison of the scores on the Oswestrylow back disability index

Waddell (1987) described disability as the mostimportant measure among low back pain disorders, ratherthan pain. Disability Questionnaires are the key to determinethe response to treatment as they provide information aboutwide range of functional tasks10,11. The index has beenshown to be useful in assessing and monitoring the changesin the function of patients with chronic low back pain. Thisquestionnaire is a valid and reliable predictor of disability.

Before discussing the results, one must be well versedwith the concept of disability in patients with chronic lowback pain. The current research of Gardiner-Morse et al12

tend to support Panjabi’s hypothesis, revealing that thereduction in the motion segment strength and stiffness byas little as 10% can compromise the stability of the lumbarspine. They concluded that factors such as physiologicalreduction in motion segment stiffness, as well as poorneuromuscular control of the spinal musculature anddecrease in muscle strength could all result in a state ofspinal instability and hence disability. Researchersinvestigating changes in the neuromuscular system in thepresence of low back pain and lumbar instability indicatethat it is the local muscle system that is particularlyvulnerable to dysfunction. Several studies have highlightedthe presence of specific dysfunction in the lumbarmultifidus13, and more recently the deep abdominalmuscles14 in the population of chronic low back pain. Suchchanges appear to result in altered patterns of synergisticcontrol or coordination between trunk muscles. Thesefindings support those clinicians who report the presence ofaltered patterns of motor control between trunk synergists,such that global system muscles have a tendency tosubstitute or dominate over the impaired function of localsystem in patients with chronic low back pain. Consistentwith these findings, Cholewicki and McGill15 reported thatlumbar stability is maintained in vivo by increasing theactivity of lumbar segmental muscles, and highlighted theimportance of motor control to coordinate musclerecruitment between larger trunk muscles and small intrinsiclocal muscle during functional activities to ensure thatstability is maintained and chronic low back pain anddisability are prevented. On comparing the within groupimprovement, group I showed slower improvements in thedisability index over the first week and then the spurt ofimprovement occurred in the following two weeks. Thisimprovement could be related to the better outcome resultsof lessened pain intensity. This improvement can also beattributed to the strengthening of the appropriate musclesaround the lumbar spine, both local and global, in theexperimental groups which could provide considerablestability to the lumbar spine and hence help in decreasingthe disability of the patients suffering from chronic lo backpain.The concept of different trunk muscles playing differentroles in the provision of dynamic stability to the spine wasproposed by Bergmark. He hypothesized the presence oftwo muscle systems in the maintenance of spinal stability;the local and the global muscle systems. The transversesabdominis and the posterior fibres of the internal obliquehave a direct potential stabilizing role on the lumbar spinethrough the thoracolumbar fascia16. Of the back extensors,the lumbar multifidus is considered to have greatest

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potential to provide dynamic control to the motion segment,particularly in the neutral zone17,18. The co-contraction of thedeep abdominal muscles with the lumbar multifidus has apotential to provide a dynamic corset for the lumbar spine,enhancing the segmental stability and decreasing thedisability during the functional tasks and the maintenanceof neutral spinal posture, irrespective of the position of thespine attained by global muscles. Analysis of differencesbetween the groups, partially supported the initialhypothesis that strengthening of local and global stabilizerstogether is more effective than specific stabilizationexercises However, these differences were clearly evidentgraphically. Lack of differences between groups II and IIIdemand some explanation. The main reason for this findingcould be attributed to the response of additional localstabilizer strengthening in group III in order to facilitatesegmental stability when compared with group II. Asevidenced in the literature and explained previously, thisgroup shows slower and delayed results and requires moretime to get strengthened. Hence, its presence in group IIIdid not bring much difference in the scores of the disabilityindex at the day 21 of the intervention. Therefore, the twoexercise protocols of groups II and III showed almost similarresults at the end of the study. This confirms,experimentally, the conclusion reached by Cairns et al19who compared conventional physiotherapy and specificspinal stabilization exercises with conventionalphysiotherapy. At the 6 months follow-up, both groupsimproved but there was no significant difference betweenthe groups for the outcome measurement of interest.However, it appeared that both forms of exercises werebeneficial in the management of low back pain.

Comparison of the range of motion of thelumbar spine

In attempting to assess objectively, impairments causedby low back pain, there is little universal agreement as towhich measure should be used. Range of motion,considered to be an objective and reproducible measure,currently is the only measure included in various popularpublished guidelines for assessing impairments. In thisstudy, small but significant improvements occurred inranges of motion of flexion, extension, right and the left sideflexion in all the groups. Comparatively, there were greaterimprovements in the movement range of extension ascompared to other movements, in all the three groups.Similar pattern of improvement was seen in the ranges ofright and left side flexion. However, there was comparativelyvery less improvements in the ranges of flexion of thelumbar spine. The improved extension can be attributed tothe relaxation of the para-vertebral muscle spasm andenhancement of the lumbar motion segment stability.However, the fact that the flexion range did not improvemuch can be explained on the basis of the muscles beinginvolved in the study. This study has focused on the localstabilizers i.e., lumbar multifidus, transverses abdominis andthe posterior fibres of the internal oblique muscle which actas extensors of the lumbar spine either directly or indirectlyvia the thoracolumbar fascia. Also, we are not focusing onany of the abdominal muscles which primarily act to improvethe flexion range of motion. Therefore, whatever flexionrange is gained during the exercise session may be due to

the carryover effect of the spinal extension exercises beingperformed in the study. The beneficial effects of exercisetherapy reported in the literature and in the previoussections of this study may be explained by improvednutrition of the intervertebral disc induced by motion. Inaddition, exercises release endorphins that modify theperception of pain in all the three groups. Although, soundevidence is lacking, there seems to be a consensus thatcurrently used management of patients with chronic lowback pain should be aimed at restoring normal function andrange of motion. Analysis of the differences between thegroup reveal that there is no significant differences betweengroup I and group II as well as between group I and groupIII. This difference can be very well explained on the basisof the evidences given in previous section. However, theabsence of any significant difference between the group IIand group III can be because of various possible reasons.As it is evident that the only difference between the twogroup is the additional local stabilizer strengthening in groupIII, which itself is a slow respondent very well explain thelack of differences. Secondly, as it is a known fact thatdecrease in the range of motion could be the result of painand spasm. Also, the joint instability could be the result ofmuscle weakness. These exercises thus aim at decreasingthe pain and spasm as well as improving the musclestrength. Hence, these effects of exercise are common toboth groups leading to insignificant differences between thetwo groups.

Based on the above discussion, we can see that groupsII and III had same result oriented treatment statistically. Butif we go by the graphs, we can very well visualize that groupIII is definitely better than group II. The reason for non-significant statistical difference was the longer time takenby the local stabilizers to get strengthened, which is alsovery well evident in group I where the improvement startedin week two. Therefore, clinically we have two options forthe treatment of patients with chronic low back pain, i.e.either group II or group III exercise protocol. Group II is abetter option if we have time constraint. But again, if we addlocal stabilizer strengthening in home exercise programbefore discharging the patient, results should be muchbetter as compared to only group II treatment protocol. Butthis has to be seen statistically later on which a lacunaremains in the present study because of the constraints inthe time.

Conclusion

The results of the study show that there is a significantdifference etween the painscores, disability index and theranges of movements of the lumbar spine of the localstabilizer strengthening group as compared to the groupcomprising of the combined strengthening of local andglobal stabilizer. All the outcome measures showed moreimprovement in the combined strengthening group ascompared to the groups comprising of isolatedstrengthening of the local and global stabilizers.

References

1. Anne F. Mannion, Markus Muntener, Simo Taime1a, JiriDvorak. 1999 Volvo Award winner in clinical studies.ARandomized Clinical Trials of three active therapies for

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chronic lowback pain. Spine, 1999; 24(23),2435 -2448.2. Jeremy S Lewis, Jane S Hewitt, Lisq Billington, Sally

Cole, Jenny Byng, Sandra Karayiannis. A RandomizedClinical Trial comparining two Physiotherapy Interven-tions for chronic lowback pain. Spine 2005; 30(7), 711-21.

3. Jennifer Klaber Moffett, David Torgerson, Sally Bell-Syer, David Jackson, Hugh Lleweyn - Phillips, AmandaFarrin, Julie Barber. Randomized controlled trial ofexercise for low back pain: clinical outcomes, costs, andpreferences. BMJ, 1999; 319,279–283.

4. Mauritis Vantulder, Antti Malmivaara, Rosmin Esmail,Bart Koes. Exercise Therapy for low back pain. Asystematic review within the framework of the cochranecollaboration back review group. Spine, 2000; 25, 2784-2796.

5. Olave Frode Aure, Jens Hoel Nilsen, Ottar Vasselijen.Manual Therapy and Exercise Therapy in patients withchronic low back pain. Randomized controlled trial with1 year follow up. Spine 2003 ; 28(6), 525 – 37.

6. Markku Kanhaaanpaa, Simo Tiamela, Osmo Hannien,Olavi Airaksinen, The efficacy of active rehabilitation inchronic low back pain. Spine 1999, 24 (10), 1034-1042.

7. Panjabi MM, the Stability system of the spine, Part I,Function, Dysfunction, adaptation and enhancement, J.Spinal Disorders 1992, 5, 383-389.

8. Sirca A, Kostevc V. The fiber type composition ofthoracic and lumbar paravertebral muscle in man. J.Anat, 1985, 141, 131-136.

9. Cynthia C. Norkins. Joint structure and unction, Acomprehensive analysis; 3rd edition, Pg 114.

10. Anne E. Holt, Nick J Shaw, Ajit Shetty, Charles GGreenough. The reliability of the lwo back outcomescore for Back pain. Spine 2002; 27 (2) 206-210.

11. Jeremy CT FAirbank, Judith Couper Mbaot, Jean BDavice, John P Brine. The Oswetry low back Paindisability Questionnaire Physiotherapy, August 1980, 6,(8), 271-273.

12. Gardiner- More M, Stokes I. Role of Muscle in lumbarspine stabilization in maximum extension effort, J.Orthop research, 1995, 13, 802-802.

13. Hides J, Richardson C, July G. Multifoods recovery isnot automatic following resolution of acute firs episode oflow back pain. Spine 1996; 21, 2763-2769.

14. Hodges P, Richardson C, Inefficient muscular stabili-zation of the lumbar spine associated with low back pain.A motor control evaluation of transverses abdomensspine 1996, 21; 640-650.

15. Cholewicki J, Mcgill S. Mechanical stabilization of the in-rivo lumbar spine. Implication for injury and chronic lowback pain. Clinical Biomech 1996, 11 1-15.

16. Tesh KM, Dunn JS, Evan JH. The abdominal musclesand vertebral stability.sSpine 1987; 12,501

17. Kaigle A, Holm S. Experimental instability in the lumbarspine. Spine 1987, 12, 501-508.

18. Wilde H, Wolf S. Stability increase of the lumbar spinewith different muscle groups. Spine 1995, 20, 192-198.

19. Cairns MC, Foster NF, Wright cc-A pragmaticrandomized controlled trail of specific stabilizationexercises and conventional physiotherapy in themanagement of recurrent lumbar spine pain anddysfunction 6 month follow up. 4th interdisciplinaryWorld congress on low back and pelvic pain; 2001November 8-10; Montreal, Canada. InterdisciplinaryWorld Congress on low back and pelvic pain 2001.

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Comparative analysis of stretching vs mobilization on posteriorshoulder tightness in cricketersShaji M.S. John*, Rohit Chachra***Asst. Professor, Dept. of Therapies & Health Science, **Researcher, Sports Physiotherapy, Dept. of Therapies and HealthScience, Faridabad Institute of Technology, Sect-43, Aravali Hills, Faridabad, India

Abstract

Purpose

To compare effect of stretching and mobilization onposterior shoulder tightness in cricketers.

Methods

45 asymptomatic male subjects (16-24yrs) whopresented with posterior shoulder tightness participated.Subjects were randomly allocated to 3 groups of 15 each:Group A- Stretching, Group B- Posterior glide mobilization& Group C- combination of both. Digital inclinometer andGoniometer was used for measurements. Tightness wasassessed by measuring internal rotation (weekly) andhorizontal adduction distance (pre-post). Stretching andMobilization was given accordingly. Duration of study: 3weeks.

Results

ANOVA and Post Hoc Scheffe analysis revealed Group-C has maximum improvement in internal rotation- 20.6º(32.2 %), horizontal adduction- 10.73º (15.8%) followed byGroup-A then B respectively.

Conclusion

Combination of stretching and mobilization is mosteffective in rehabilitation of PST. They can also be usedindividually.

Key words

PST, GIRD, Stretching, Mobilization

Introduction

Cricket is a popular team sport played throughout theworld. The three unique aspects of the game are bowling,batting, and fielding which are frequently associated withinjury1. Fielders have the most upper limb injuries 26%,possibly because of the forces involved in throwing longdistances1. A study conducted at a cricket academy showed62% of cricketers who had limited internal rotation sufferedfrom a preexisting injury, 37% injured their shoulders duringthe study and 50% of those with the history of previousinjury, had decreased glenohumeral internal rotation rangeof motion3.

During the career of a high performance throwingathlete, shoulder injury is common. Usual shoulder probleminvolves instability, impingement syndrome and ultimately

rotator cuff disease2.Physical examination of overhead throwing athletes

consistently demonstrates adaptive changes in glenohu-meral internal and external range of motion of the dominantshoulder when compared with non dominant - shoulder5.Non-symptomatic pitchers have been reported to witnessan increase of up to 30o glenohumeral external rotation inboth frontal and scapular plane when compared with theirnon-dominant shoulders. Glenohumeral internal rotationdeficit of 15 to 20o has been associated with non-symptomatic pitchers, while symptomatic pitchers havereported deficit as high as 45o. These changes have beenattributed to number of factors including posterior inferiorcapsular restriction, muscular inflexibility of the externalrotators, and osseous adaptation of the humeral head orglenoid6.

Throwing motion and its related biomechanics aredivided in to five stages: phase of Windup, Cocking,Acceleration, Deceleration, and Follow-through. It has beenobserved that postero-inferior contracture most likely occursin response to the stress loads associated with the follow-through motion in throwing6. Harryman et al, 1990, haveshown that selective tightening of the posterior portion ofthe shoulder capsule causes anterior and superiortranslation of the humeral head with passive shoulderflexion. The abnormal humeral head motion can result in adecrease in the subacromial space during overheadactivities. This approximation of the humeral head andacromion can lead to compression of tissues in that regionand may be associated with limited shoulder flexion, internalrotation, and horizontal adduction9.

Research has documented that tight capsular andmuscular tissue of the shoulder affect normal shoulderrange of motion3. Posterior capsular contracture is acommon cause of shoulder pain in which the patientpresents with restricted internal rotation and reproduction ofpain. Burkhart et al, 2003, claimed that posterior shouldertightness is the ultimate culprit in the development ofshoulder injuries such as superior labrum anterior posteriorlesions, internal impingement, anterior joint capsule failure,and rotator cuff tears4.

The length tension curves obtained from normal musclesshow that maximum tension is developed when the musclelength is approximately 90% of its maximum length.Conversely, when the muscle is fully shortened, the tensiondeveloped is minimal6. Several studies conducted onstretching techniques found stretching to be effective inincreasing flexibility of posterior shoulder structures.6-8Cross arm and sleeper stretch is among the most frequentlyused stretching methods. The objective of passive staticstretch therapy is elongation of shortened muscle fibers andconnective tissues that limit range of motion.

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Dysfunction that progressively limits the movement canalso be treated with joint mobilization to increase availablerange of motion or retard progressive mechanical restriction.Evidence suggests that joint mobilization procedures canlessen the associated glenohumeral rotational deficitscharacteristic of this condition9-13.

There is a dearth of studies about the effectiveness ofmobilization techniques in young cricketers having posteriorshoulder tightness. As per my observation this is first everstudy being conducted on the cricket players for reducingposterior shoulder tightness with posterior glide mobilizationtechnique.

So the purpose of the study is to investigate whetherstretching and posterior glide mobilization individually or incombination is an effective way in restoring lost internalrotation range of motion of shoulder joint and improvingglenohumeral joint adduction distance

Materials and methods

Participants

45 asymptomatic male bowlers who met the inclusioncriteria with the help of permuted block randomization wereassigned in to three groups.

Subjects were selected from the Nahar Singh CricketStadium Faridabad. All the subjects were assessed forinclusion and exclusion criteria of the study. The inclusioncriteria for the subjects included the following: Asymptomaticright-handed male bowlers with no shoulder pain from thepast six months within age group of 16-24 years. Bowlerspracticing regularly from at least one year and attendingpractice sessions at least 4 times in a week in stadium.Difference of more than 10 degrees in internal rotation incomparison to the contra lateral extremity. Glenohumeraljoint horizontal adduction difference in comparison to thecontra lateral extremity

Exclusion criteria for the subjects included: Presence ofsigns of acute inflammation. History of any pathology orsurgery related to the shoulder joint. Previous manipulationunder anesthesia and history of corticosteroid injection tothe shoulder joint.

Instrumentation

Digital inclinometer and goniometer wasused

Procedure

Preliminary measurements, taken prior to beginning thestudy, included the measurement of body parameters usingstandardized techniques.

By measuring internal rotation range of motion andglenohumeral joint adduction distance posterior shouldertightness was assessed. For internal rotation range ofmotion Subject was placed supine on a treatment table withthe hips and knees each in approximately 90o of flexion. Thetest arm was elevated to 90 degree of abduction. The testerthen passively moved the humerus into internal rotation.The humerus was rotated until scapular motion wasinitiated, at which time the second tester used thegoniometer to take the measurement. The test was then

repeated for external rotation. For both internal and externalrotation measurements, the fulcrum of the goniometer wasplaced over the olecranon process, the stationary arm wasaligned perpendicular to the floor, and the moving arm wasaligned between the olecranon process and the styloidprocess of the ulna.

Measuring glenohumeral joint horizontal adductiondistance as described by Kevin et al, 2006, was done toassess glenohumeral joint horizontal adduction distance;subjects were positioned supine with both shoulders flushagainst a standard examination table. The tester stood atthe head of the examination table towards the head of thesubject and positioned the test shoulder and elbow in 90degree of both abduction and flexion. The tester stabilizedthe lateral border of the scapula by providing a posteriorlydirected force (towards the examination table) to limitscapular protraction, rotation, and abduction motions. Thetester’s opposite hand then held the proximal portion of thesubject’s forearm, slightly distal to the elbow, and passivelymoved the humerus into horizontal adduction. At the endrange of horizontal adduction, a second tester recorded theamount of motion present. To measure glenohumeral jointhorizontal adduction, the digital inclinometer was alignedwith the ventral midline of the humerus.Group A- which included 15 subjects underwent stretching.Group B- included 15 subjects, they received mobilization. Group C- underwent combination of both stretching andmobilization

The three groups were comparable with respect to age,height and weight.

During the research period the subject’s were allowedto continue their training program, competitive play and anyexisting regular exercise programs.

All Participants were asked to do general body warm upin the form of jogging for 6 minutes and specific freeexercises for the shoulder. Before any stretching ormobilization, passive movements were given.Group A: Subjects in these groups were stretched to a pointof mild discomfort once daily for five repetitions holding eachstretch for 30 seconds with 30 second rest periods inbetween each stretch. Intervention was given six times in aweek.

In the sleeper stretch, Fig-1 the athlete adopts a side

Fig. 1: Sleeper Stretch

77Shaji M.S. John / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

lying position with the humerus flexed 90o. The elbow is alsoflexed 90o. One hand is placed on the proximal humerus toassist the body weight in stabilizing the scapula. The otherhand is placed on the posterior aspect of the distal ulna. Adownward motion at the distal ulna medially rotates thehumerus. At the completion of medial rotation, the torso isrotated toward the humerus to enhance the stretch.

For the cross arm stretch, Fig-2 the athlete waspositioned close to the edge to expose the lateral border ofthe scapula. The scapula is stabilized with the hip and theshoulder is moved in to horizontal adduction.

Group B and C: Subjects in both groups were mobilized3 times in a week for 10 repetitions per session maintainingend position for one minute and total treatment session forsustained stretch was for 15 minutes with 30 seconds restinterval in between.

Initially subjects were given posterior glide, Fig-3 if whensufficient range was achieved then progression of posteriorglide was used. Subject was made to lie supine with the armin resting position investigator used to stand with back topatient, between the patient’s trunk and arm; arm wassupported with therapist trunk; with lateral hand distalhumerus was grasped. By placing the lateral border of tophand just distal to the anterior margin of the joint, withfingers pointing superiorly mobilizing force was given.Humeral head was glided posteriorly by moving entire arm,as knees were bend.

In Posterior Glide Progression subjects were positionedsupine with the arm flexed to 90 degree, internally rotated,and with elbow flexed. Therapist used to place paddingunder the scapula for stabilization. One hand was placedacross the proximal surface of the humerus to apply a grade1 distraction. With other hand over subject’s elbow, humeral

head was glided posteriorly by pushing down at elbowthrough the long axis of humerus.

Statistical analysis

The data was managed on an excel sheet and wasanalyzed using SPSS software with a difference of p<0.05considered statistically significant. Statistical tests usedwere:1. Paired t-test for pre and post intervention internal

rotation range of motion for each group.2. Paired t-test for pre and post intervention horizontal

adduction distance for each group.3. ANOVA to compare the improvement in internal rotation

range of motion at different intervals (pre exercise, post1 week, post 2 week, post 3 week) with in and betweenthe groups.

4. ANOVA to compare the improvement in horizontaladduction distance at different intervals (pre exercise-post exercise) between the 3 groups (Stretching,Mobilization, Stretching and Mobilization).

5. To analyze significant changes, post-hoc comparison ofvariables was performed to evaluate differences amongspecific means between the 3 groups (Stretching,Mobilization, Stretching and Mobilization).

Results

The descriptive data for age, height and mass for boththe groups was matched and no statistical difference wasfound. A paired t-test was used to compare the internalrotation range of motion between pre and post interventionin the same group.

The t-value analyzed for range of motion values in all the3 groups between pre intervention and post interventionshowed significant difference at p<0.05 level indicating thatthere was marked improvement in the internal rotation rangeof motion.

Analysis of variance was used to analyze the differencefor internal rotation range of motion at different intervals (Preexercise, Post 1 week, Post 2 week, Post 3 week) within thestretching group, mobilization group and stretching+mobilization groups. The F values for the three groupswere 28.795(p < 0.05), 20.70(p < 0.05) and 36.026(p<0.05)respectively. The values suggest that there were significantchanges within the group for internal rotation.

With the help of post hoc Scheffe analysis whichcompared the three exercises regimes at different interval,total study of 3 weeks (Post 3 week – Pre exercises) showsthat Group C is significantly better than Group A and GroupB whereas there is no significant difference between GroupA and Group B though Group A has given better results thanGroup B.

A paired t-test was used to compare the horizontaladduction distance between pre and post intervention in thesame group.

The t-value analyzed for horizontal adduction distancevalues in all the 3 groups between pre intervention and postintervention showed significant difference at p<0.05 levelindicating that there was marked decrease in the horizontaladduction distance.

Horizontal adduction distance decreases significantly inall three groups C > A > B respectively which can be seen

Fig. 2: Cross Arm Stretch

Fig. 3: Posterior Glide Mobilization

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through the Mean ± SD values that show initial values asGroup A-67.60 + 2.50 Group B -67.73 + 4.94 Group C -67.53 + 5.79. There was significant improvement in allgroups. Group C - 56.80 + 5.01 showed most significantimprovements than group A -59.33 + 4.16 and least in groupB -61.53 + 2.58. When mean differences and standarddeviation for horizontal adduction distance at (Post – Pre)intervals of exercises for stretching, mobilization andstretching + mobilization were analyzed the values forstretching group at different intervals comes out to be 8.26+ 3.78, for mobilization group values was 6.2 + 4.14 themean difference for stretching + mobilization group was10.73 + 3.61 respectively.

With the help of post hoc Scheffe analysis whichcompared the three exercises regimes at different interval,total study of 3 weeks (Post 3 week – Pre exercises) showssignificant difference when Group B and Group C werecompared whereas there is no significant change betweenGroup A and Group B and Group A and C though Group Chas given better results than Group A.

Discussion

In this study it was found that Group C showedsignificant improvement in internal rotation range of motion(28.4%) and in horizontal adduction distance by (15.8%).Since posterior shoulder tightness is associated withanterosuperior translation of the humerus, and soft tissuetightness, in this group both the components wereaddressed. Studies have reported improvements inposterior shoulder tightness by using prolonged stretching,4

with mobilization techniques,12 combined local anesthetics,intra-articular steroids, and manipulation,11 and mobilizationwith an interscalene brachial plexus block10.

As posterior translation of the head of the humerus canbe affected by length and tension of the posterior capsule inmedial rotation, asymmetric tightening of the capsule duringhumeral rotation results in translation of the humeral headopposite to the direction of capsular tightening, when theposterior capsule becomes tight and pushes the humeralhead anteriorly, it may result in anterior translation throughthe capsular restraint mechanism. This excessive anteriortranslation was addressed with the help of posteriormobilization technique as an attempt was made to force thehumeral head at optimal position consequently stretchingposterior capsule. In studies where posterior glide wasused, marked increase in internal rotation as well asexternal rotation range of motion was noted10-12.

The stretching technique chosen for the present studyfocused on stretching the posterior shoulder structures,which consists of posterior rotator cuff muscles, theposterior deltoid and the postero-inferior aspect ofglenohumeral joint capsule. These muscles are responsiblefor glenohumeral external rotation range of motion,however, they limit glenohumeral internal rotation range ofmotion when contracted. Our results found an increase inglenohumeral internal range of motion after stretchingbecause of stretching the posterior shoulder which createdposterior shoulder tightness. In a similar kind of study whereMcClure et al, 2007 compared cross body and sleeperstretch found significant improvement in the internal rotationrange of motion and glenohumeral horizontal adductiondistance as both these stretches focus on posterior inferioraspect of the glenohumeral joint and internal rotation deficitis found to be associated with postero-inferior aspect ofglenohumeral joint capsule14.

Limitations of the study: Proper follow up would havegiven better understanding of the results. Throwing velocitycould not be measured due to lack of proper equipment.

Applications

Results of the study are in consistent with the finding thatcricketers also show decreased internal rotation at shoulderjoint. So both for prevention and as apart of rehabilitationrestoration of normal joint range of motion is required forwhich combination of both stretching and mobilization hasbeen found to be most effective and mobilization andstretching can also be used individually. Limited studieshave focused on upper extremity force output and ballvelocity following static stretching. This information isimportant to determine the timing of these stretches prior toan event. Once the duration of the stretch effects, forceoutput, and ball velocity are determined, more effectivestretching and mobilization protocols can be established.

Conclusion

The findings of the current study suggest that all theinterventions show significant improvement in posteriorshoulder tightness but stretching and mobilization whenused in conjunction over a period of three weeks lead to asignificantly increase in the internal rotation range of motionand improved the horizontal adduction distance in cricketplayers. Stretching programs when incorporated individuallyhave shown significant improvement in past but the effect ofmobilization on posterior shoulder tightness was lacking.Hence the findings of this study suggest that mobilization

Comparison of mean values for HAD at Pre and Post intervals

between Group A, Group B and Group C

55

59

63

67

71

Pre Post

Intervals

Mean

valu

es Group A - Stretching

Group B - Mobilization

Group C - Stretching +

Mobilization

Comparison of mean values for Internal rotation at different

intervals between Group A, Group B and Group C

60

65

70

75

80

85

90

Pre Post 1 week Post 2 week Post 3 week

Intervals

Me

an

va

lue

s

Group A - Stretching

Group B - Mobilization

Group C - Stretching +

Mobilization

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can also be added in rehabilitation programs of thecricketers having posterior shoulder tightness. Stretchingincorporated along with mobilization is the most efficaciousway to reduce the deficits associated with posterior shouldertightness.

References

1. Bartlett, Roger M. The science and medicine of cricket:an overview and update. Journal of Sports Sciences2003; 21(9): 733-752.

2. Johansen R Lance, Mitch Callis, James Potts, LawrenceShall M. A Modified Internal Rotation StretchingTechnique for Overhand and Throwing Athletes. JOrthop Sports Phys Ther 1995; 21(4): 216-219

3. Tyler F Timothy, Timothy Roy, Stephen Nicholas J,Gilbert W Gleim. Reliability and Validity of a New Methodof Measuring Posterior Shoulder Tightness. J of OrthopSports Phys Ther l999; 29 (5): 262-274.

4. Burkhart SS, Morgan CD, Kibler WB. The disabledthrowing shoulder: Spectrum of pathology I:Pathoanatomy and biomechanics. Arthroscopy 2003;19: 404-420.

5. Myers Joseph B, Kevin Laudner G, Pasquale Maria R,Bradley James P, Lephart Scott M. GlenohumeralRange of motion deficits and posterior shouldertightness in throwers with pathologic internalimpingement. Am J of sports med 2006; 34 (3): 385-391.

6. Donatelli Robert A. Physical Therapy of the shoulder.Fourth Edition 1997; Philadelphia: Churchill Livingstone;11-50

7. Rick Hjelm, Chris Draper, Sarah Spencer. Anterior-

Inferior capsular length insufficiency in the painfulshoulder. J Orthop Sports Phys Ther 1996; 23(3):216-222.

8. Kibler WB, Chandler TJ. Range of motion in junior tennisplayers participating in an injury risk modificationprogram. J. Sci Med Sport 2003; 6(1): 51-62.

9. Kessler Randolph M, Darelene Hertling. Management ofcommon musculoskeletal disorders: Physical therapyPrinciples and methods. Third edition 1996; RavenLippincott; 112- 132

10. Roubal P J, Dennis Dobritt, Jeffrey Placzek D.Glenohumeral gliding manipulation following inter-scalene brachial plexus block in patients with adhesivecapsulitis. J Orthop Sports Phys Ther 1996; 24: 66-77

11. Placzek JD, Roubal PJ, Freeman DC, Kulig K, Nasser S,Pagett BT. Long-term effectiveness of translationalmanipulation for adhesive capsulitis. Clin Orthop RelatRes. 1998; 356:181-91.

12. Vermeulen M Henricus, Piet M Rozing, Wim RObermann, Saskia le Cessie, Thea PM, Vliet Vlieland.Comparison of high grade and low-grade mobilizationtechniques of adhesive capsulitis of the shoulder:Randomized clinical Trial. Phys Ther 2006; 86(3): 355-368.

13. Kisner Carolyn, Lynn Allen Colby. Therapeutic Exercise:Foundation and Techniques. Third edition 1996; India.Jaypee.143-233.

14. Mcclure Philip, Jenna Baliacuis, David Heiland, MariaEllen Broersma, Cheryl k. Thorndke, April Wood. ARandomized Controlled Comparison of StretchingProcedures for Posterior Shoulder Tightness. J OrthopSports Phys Ther 2007; 37 (3) 108-114.

80 Stanley Paul / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

The efficacy of monochromatic infrared photo-thermal energytherapy in rehabilitation: A pilot study reportStanley Paul*, Yuanlong Liu**, Robert McAlister****Associate Professor, School of Allied Health Sciences, Department of Occupational Therapy, Medical College of Georgia,Augusta, GA 30912, United States of America, **Professor, College of Education, Department of Health, Physical Education& Recreation, Western Michigan University, Kalamazoo, MI 49008. United States of America, ***Assistant Professor,Department of Occupational Therapy, Spalding University, Louisville, KY 40203. United States of America

Abstract

The therapeutic effects of Monochromatic InfraredPhoto-Thermal Energy (MIRE) were studied on 20 patientswith Diabetic Peripheral Neuropathy (DPN). The Semmes-Weinstein Monofilament 5.07 (SWM 5.07), Wong-BakerFaces Numerical Pain Scale, and Tinetti PerformanceOriented Mobility Assessment (POMA) were used in datacollection. The results showed a significant improvement insensation, balance, and a reduction in pain on both lowerextremities. The results of this pilot study suggests thatMIRE therapy may have contributed to a reduction in pain,improvement in sensation, and an increase in balancefunction in participants with DPN. The implications forrehabilitation therapies are that such improvements maycarry over to increased independence in every dayfunctional tasks, functional mobility, and quality of life.

Key words

Monochromatic Infrared Photo-Thermal Energy (MIRE),Diabetic Peripheral Neuropathy (DPN), Wong-Baker PainScale, Semmes-Weinstein Monofilament (SWM), TinettiPerformance Oriented Mobility Assessment (POMA).

Introduction and background

Anodyne therapy or Infrared light therapy has been usedfor over two decades to increase circulation and reduce painin a broad range of patient populations. Anodyne treatmentis not limited to a particular group of patients but can beused for several conditions that include: arthritis, bursitis,fibromyalgia, slow healing wounds, strains and sprains,diabetic neuropathy and ulcers, tendonitis, carpal tunnelsyndrome and plantar fasciitis. After receiving the Food andDrug Administration (FDA) approval in 1994, anodynetherapy is being used increasingly in many hospitals,universities, clinics, home health agencies, rehabilitationcenters, long term care facilities, physician offices, andmilitary hospitals.

During an Anodyne therapy session, pads are applieddirectly to the skin and light energy (Monochromatic InfraredPhoto-Thermal Energy or MIRE) is emitted by the diodesimbedded in the pads. Monochromatic means that the lightemitted is within one specific wavelength, namely 890nanometers. This wavelength was chosen because of thedepth of penetration and high absorption because photoenergy to be effective must be absorbed by the targettissue. Since the photo energy (light) is infrared, it cannotbe seen. The average energy emitted from the diodes is 9milliwatts per square centimeter. The density of the photoenergy emitted per pad is 43.2 Joule /square centimeter1.Anodyne therapy consists of 10 to 12 sessions lasting 30

minutes each. However, a patient may feel the result fromanodyne treatment in as little as one treatment session2,3.During this treatment time, energy is penetrating the tissuethat increases circulation up to 400 percent. It is thisincrease in circulation that results in relief of pain and rapidwound healing. The light emitted is absorbed by hemoglobinin the blood which increases the nitric oxide level and theblood vessels in that area dilate. The increased blood flowto the area provides more oxygen and nutrients, leading toincreased level of circulation that improves nerve function.Anodyne treatment effect also contributed to a decrease infalls and improvement in balance2.

Peripheral neuropathy, a disorder of the nervoussystem, is a long-term complication of diabetes that usuallycauses numbness, weakness and pain, primarily affectingthe arms and legs. One potential option for helping thesepatients is anodyne therapy. Being a non-invasivetreatment, anodyne therapy has garnered praise in clinicalstudies and anecdotal kudos from podiatrists and theirpatients. For example, wounds or diabetic ulcers leftuntreated can lead to amputations. Once seriouscomplications manifest, an approach to treatment mayinvolve surgical placement of stents and the use ofprescription drugs. Anodyne offers a new alternative. It is atherapy that can be used to intervene at the early stages ofdisease in order to prevent the more serious complications.

Anodyne therapy also referred as Light therapy/Monochromatic Infrared Energy, has many reported uses(Fig 1). It is not contraindicated in most cases except whena patients is pregnant (or likely to be pregnant), and inpatients with cancerous lesions or active malignancy4. Theoriginal Anodyne Therapy Company stated that the increasein blood circulation (as measured by the Laser Doppler) canhelp reduce pain and inflammation and improve patientquality of life1. Anodyne Therapy, when used adjunctivelywith a personalized rehabilitation therapy (physical and/oroccupational therapy) treatment sessions, may help relievepain that has not responded to other medical interventions”1.The goal of this pilot study was to assess the efficacy ofanodyne therapy and its potential benefits with the specificpatient population of Diabetic Peripheral Neuropathy (DPN)thus adding to the empirical data in the use of physical agentmodalities (PAM) within various rehabilitation fields.

When the MIRE therapy system is used, light skincontact is all that is required for successful release of thephoto energy5. During a typical MIRE therapy session, padsare applied directly to the skin of the patient’s affected areaor as close to the affected area as possible, via Velcrostraps, and light energy is emitted by diodes in the pads (Fig2). Each pad consists of sixty diodes, and electricity issupplied to the pads to make the diodes luminous. Whilethe diodes are luminous, infrared light penetrates the skin,causing the release of nitric oxide by the body and ultimately

81Stanley Paul / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

increased circulation1. Treatments which customarily lastthirty minutes each, are normally given three times a weekfor four to six weeks. The appropriate energy level for eachpatient varies depending on the individual patient diagnosis.Patients may experience some warmth within the treatmentarea although extreme heat should not be experienced4.

A study involving 2,239 participants with DiabeticPeripheral Neuropathy (DPN) examined whether treatmentwith MIRE was associated with increased foot sensitivity tothe Semmes-Weinstein Monofilament (SWM) and areduction in neuropathic pain. More than half of the patientswho were initially diagnosed with loss of protectivesensation obtained a temporary return of sensation, andfurthermore, ninety-eight percent of patients reported havinga significant reduction in pain weeks after MIRE treatmentswere completed6. A randomized, double blind study byLeonard, Farooqi and Meyers7 determined that treatmentswith MIRE improved balance and sensation in the feet ofsubjects with DPN, along with a reduction in pain reportedby the subjects. Another study looked at the effects of MIREon tendonitis, capsulitis, and myofascial pain. It assessedpatient’s pain response to MIRE treatments on a scale oftotal relief, excellent relief, fair relief, poor relief, and norelief. Of the two hundred patients with tendonitis, 88%reported total to excellent relief, 11% had fair to poor relief,and 1% percent had no relief in one to twelve treatments8.

A study by Volkert, Hassan, Hassan, Smock, Connon,McFee, Ferguson, and Burke,9 evaluated the effect ofmonochromatic infrared photo energy (MIRE) combinedwith physical therapy in reducing pain, improving sensation,and increasing balance in patients with peripheralneuropathy. Two hundred seventy two patients with theaverage of 69 years were included in the study. Neuropathicpain, diminished foot sensation, and balance impairmentsat baseline were present in 93% of patients. After anaverage of 18 treatments, neuropathic pain decreased by38%, lower extremity sensory impairment improved by 77%,and balance deficits decreased by 73%. The authorssuggested that MIRE™ plus manual physical therapy mayhave contributed to the improvement in pain, balance, andsensation symptoms in patients with peripheral neuropathy,at least temporarily.

In spite of these reports, the number of rehabilitationtherapies incorporating MIRE into their Physical AgentModalities (PAM) is relatively small. MIRE therapy can bevery beneficial in rehabilitation settings to address functionalmobility, activities of daily living, work, leisure and overallquality of life. The authors believe that such limited use ofMIRE in rehabilitation fields can be attributed to the needfor continued research on it’s effectiveness with variouspatient populations and conditions.

Peripheral neuropathy, a disorder of the nervoussystem, is a long-term complication of diabetes that usuallycauses numbness, weakness and pain, primarily affectingthe arms and legs. The most common peripheralneuropathy in advanced nations is diabetic neuropathy,which is reported to account for more hospitalizations thanall other diabetic complications combined3,10,11. There are80,000 amputations in the United States each year, oneevery two minutes, and 87% are due to neuropathy and thecost, aside from human suffering, is known to be in thebillions of dollars each year. Diabetic peripheral neuropathywith loss of sensation is the major cause of diabetic foot

ulcers and amputation as well as one of the major factorswhy diabetic ulcers fail to heal12,13.

A clinical study reported that it is possible to restoreprotective sensation to a significant degree in diabeticpatients (Type 1 and Type 2 diabetes) with peripheralneuropathy including those with loss of protective sensation(LOPS)14. This outcome was achieved using twelve 30-minute Anodyne Therapy System (ATS) treatments on ninepatients with DPN. The average age of the patientsevaluated was 71 years. Eight of the nine patients weremale and one patient was female who all exhibited diabeticneuropathy with loss of protective sensation with theaverage number of sites insensate to the SWM 5.07 being3.3/4.0. Insensitivity to the SWM 5.07 at not less than twoareas out of four trials (2.0/4.0) on either foot is sufficient todiagnose loss of protective sensation under Medicare PolicyMemorandum CAG-00059. The results were impressivesince there has been no known treatment option to restoreprotective sensation in DPN, which is recognized as thehighest risk factor for foot ulcerations and lower extremityamputations among people with diabetes14. The resultsdemonstrated that therapeutic intervention with the ATSwas clinically effective in the treatment of DPN. At theconclusion of therapeutic intervention with ATS, all patientsobtained improvement in sensation, and seventeen of theeighteen feet examined obtained protective sensation. Onaverage 3.7/4.0 areas were able to sense the SWM 5.07after treatment with ATS14. One example of MIRE treatmentcausing blood flow increase to the plantar surface of the footwas illustrated in an article by Burke4 that displayed picturesof thirty minute treatments of MIRE using laser Dopplerimaging. The images showed that MIRE treatmentincreased blood flow by four hundred percent over baselinedue to elevated skin temperature.

Goldman15 went on to evaluate the long-term effects ofATS treatment among the same subjects studied byKockman et al14. Follow up examinations took place as earlyas twelve weeks and as late as twenty-four weeks after thelast ATS treatment. The average number of weeks to followup was 18.5. At follow up, eight of nine patients experienceda decline in sensation and one patient maintained thesensory improvement obtained with therapy. Although anaverage of 2.3/4.0 sites exhibited a decrease in sensitivity tothe SWM 5.07 compared to immediate post ATS treatmentlevels, only two of these patients had returned to the originallevel of sensory impairment documented prior to theinitiation of therapeutic intervention with ATS15,16. Thiscurrently available noninvasive medical technology offersthe opportunity to positively affect the lives of people whosuffer from DPN and are at high risk for foot ulcers and lowerextremity amputations.

In a retrospective cohort study by Powell, Carnegie, andBurke17, 252 diabetic patients (mean age 76 years) withdocumented, monochromatic near-infrared phototherapymediated, symptomatic improvements of DPN symptomswere studied and successive implications for rehabilitationtherapies were suggested. The study objective was todetermine whether improvements in sensory impairmentsas a result of DPN, would reduce the number of falls andthe fear of falling and improve activities of daily living (ADL)in a Medicare-aged population. Results showed that theincidence of falls and fear of falling decreased within onemonth after the sensory improvements and remained low

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even after one year. Likewise, improvements in ADLs wereevident soon after the completion of MIRE therapy andcontinued well after one year. Overall, improvements inperipheral neuropathy related symptoms in a clinician'soffice and subsequent use of MIRE at home was associatedwith a 78% reduction in falls, a 79% decrease in balance-related fear of falling and a 72% increase in ADL function.According to the authors, these results suggested thatsymptomatic improvements of DPN will have a substantiallyfavorable, long-term socioeconomic impact on patients inthe Medicare system, and improve the quality of life forelderly patients with diabetes and peripheral neuropathy17.

Even with such positive results, it is necessary to notethat restoration of sensation in DPN from MIRE treatmentalong with rehabilitation therapies can heighten overallincrease in functional mobility and ADL performance withdiabetic patients. MIRE therapy can be beneficial inrehabilitation therapy settings to address functional mobility,activities of daily living, work, leisure and overall quality oflife.

Patients with complaints of pain and no additionalpathologies, however, are sometimes overlooked and pain,though, is very significant – can be a credible subjectiveinfluence on patient performance in therapy. Withimprovements in pain symptoms, patients are much morelikely to show therapy performance results once deemedunreachable. Burke4 encourages MIRE use on wound careand pain issues saying, MIRE can substantially increasesmicrocirculation in the tissue under and around the diodearray and increases venous flow thus reducing cellularedema in the wound site, increasing tissue blood flow andoxygenation. Endogenous growth factor and white bloodcells are delivered to healing tissue and the increasedcapillary blood flow promotes a positive wound healingenvironment4.

Wound pain is the factor with the greatest negative effecton quality of life. Without reasonable treatment alternativesto pain other than through medications, addictions reign asprevalent as the pain itself. A comprehensive painmanagement program must include measures to prevent orminimize acute pain associated with debridement anddressing changes in addition to measures to managechronic or persistent pain, whether, nociceptive,neuropathic, or mixed18. MIRE therapy, being non-invasiveachieves the goals of a desired pain management program.It also improves perfusion to the peripheral nerves helpingto reverse neuropathy by the release of nitric oxide.Generally, the goals in managing wound pain are to reducethe pain to a level at or below the patient’s established goaland to prevent the development of chronic pain syndromes.Pain management often is an overlapping category for useof MIRE therapy in conjunction with DPN or loss ofprotective sensation, tendonitis, capsulitis, andlymphatics16,18.

With MIRE therapy, differing patients see many of thesame benefits, thus showing the widespread use of suchphototherapy. Many of the potential uses of MIRE therapyhave not been extensively researched. Since the keycomponent to the success of MIRE is the release of nitricoxide from the hemoglobin and other proteins in surroundingtissue and that nitric oxide is a known signaling moleculethat relaxes smooth muscle found in arteries, veins, andlymph vessels, the possibilities of MIRE therapy in

rehabilitation therapy fields may be many. When themusculature of the vessel muscles relax, they dilate,allowing increased circulation. In a study by Carnegie5, nitricoxide was found to promote collagen synthesis, collagenfibril alignment, and angiogenesis. These are essential forwound healing. Additionally, nitric oxide is also aneurotransmitter and a mediator of osteoblastic boneformation. When MIRE therapy is used, photo energy dilatesthe vessels, increasing circulation, reducing pain, anddecreasing swelling, inflammation, and muscle tightness.According to Carnegie5, patients also reported an increasein range of motion, lymphatic drainage, and venous dilation.Diabetic patients with peripheral neuropathy typicallyexperienced an increase in sensation to pressure andtemperature changes. Such advancements lend toimprovements in quality of life including increasedperformance in activities of daily living and mobility.

With such a direct correlation to use in rehabilitationtherapies, research must continue to validate MIRE’s useand its implementation to practice. The studies reviewedspeak of temporary return of sensation and other beneficialeffects of MIRE treatment. If MIRE therapy is to beconsidered a useful treatment for neuropathy and loss ofsensation, its reliability has to be proven time and timeagain.

Method

The participants of this study included 20 male andfemale subjects with Diabetic Peripheral Neuropathy (DPN)between the ages of 40-80. They were recruited from aregional medical center in the state of Georgia, UnitedStates. Patients who are pregnant, those with cancerouslesions or active malignancy were excluded from the study4.The objectives of the pilot study were to determine theefficacy of MIRE in patients with DPN within a rehabilitationtherapy setting. The instruments used for data collectionincluded Semmes-Weinstein Monofilament (SWM)19, TinettiPerformance Oriented Mobility Assessment (POMA) (20),and Wong-Baker Faces Numerical Pain Scale21. Before andafter the intervention, the above instruments were employedto investigate whether MIRE has significantly improvedsensation, balance, and a reduction in pain on both lowerextremities.

Semmes-Weinstein Monofilament (SWM) is a sensorytesting device that was used as a standardized assessmentto measure the increased sensitivity to stimulus or lighttouch19. The monofilaments are flexible, bendable nylonabout two inches in length with varying thickness. Theadministration of the (SWM) assessment started at the 5.07thickness level. The filament was placed at key points alongthe lower extremities from proximal to distal direction. TheSWM was administered and assessed at these points in thefollowing order: 1.tibial tuberosity; 2. three points down thetibia; 3. medial and lateral malleoli; 4. navicular bone oftarsals; 5. the dorsal side of the 1st toe; 6. the calcanealtendon; 7. the heels of the feet; 8. the base of the 1st toe; 9.the plantar side of the 1st toe; 10. in-between the base of the2nd and 3rd toe; 11. in-between the base of the 4th and 5thtoe; and 12. the plantar side of the 4th toe (See Figure 3).With the patients eyes closed, the monofilament was held atthese points with slight pressure to bend the monofilamentslightly for a minimum of 3 seconds in order to ensure inter-

83Stanley Paul / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

rater reliability during administration. The patient was askedto say when they felt the pressure and the results wererecorded.

Tinetti Performance Oriented Mobility Assessment(POMA): Tinetti assessment tool is a standardizedevaluation used to measure the client’s risk for falls throughobserving the client’s gait and balance. Balance wasassessed during standing, sitting, arising, turning, disruptionof balance, and with eyes closed. In gait, the left and rightfeet are evaluated for step length and clearance and arethen compared to each other for symmetry and continuity. Ascore is then determined for gait (16 points) and balance(12 points) and a total score (28 points) is derived from bothsections20.

Wong-Baker Faces Numerical Pain Scale: Wong-BakerFACES Pain Scale Assessment uses the numbers onethrough ten, corresponding with the recognized faces, forthe client to tell the therapist what degree of pain is beingexperienced. One means no pain and ten means the worstpain a patient can tolerate. Many healthcare professionalsand facilities use this scale to assess pain21.

Procedure

A referral was obtained from the participant’s primarycare physician. The participants were interviewed formedical and personal information such as employment,roles, interest, ADL status, level of pain, and personal goals.If found suitable for the study, proper informed consent wasobtained and pre-treatment data was collected on the threeassessment tools in order to obtain their baselineperformance to be compared with the post-treatment data.Following pre- assessment, treatment began as directed bythe MIRE administration protocol. According to the protocol,the participants were placed in a sitting position with feetand legs propped up for comfort and easy access to thearea to be treated. A plastic lining or bag was placed overthe MIRE pads. The plastic was used for participants’protection from heat as well as hygiene purposes so thatthe unit can be used safely with all participants. The MIREunit has six sets of pads of which two sets contain two padsthat were be placed on the medial and lateral aspect of thelower leg just above the involved area. The remaining foursets of pads are single pads that were placed on the dorsaland plantar sides of the foot. Both extremities were treatedsimultaneously if both extremities were affected. The MIREunit was set to eight bars for the treatments. The durationand number of treatments were for thirty minutes two tothree times a week for a total of twelve treatments. Duringthe thirty minutes, the participant relaxed in the chair withminimal movement and read, watched television, did

puzzles, slept, or simply sat in that resting position. Theparticipants were re-evaluated following the completion ofthe 12 treatment sessions.

Data analysis

Descriptive statistics were performed to measuredifference in pain, sensation, and balance between the preand post intervention phases. Correlated t-tests were usedto examine the effects of MIRE intervention on the Tinetti(POMA) and SWM. The Tinetti scale measured balance andSWM measured sensation. The pain score on the left andright lower extremities were measured by the Wong-BakerFaces Numerical Pain Scale and the data was analyzedusing the 2x2 [Leg (R&L) by Time (pre/post)] RepeatedMeasures (RM) ANOVA.

Results, Discussion and Implications

Table 1 shows balance, sensation and pain magnitudesbefore and after the intervention. The results of thecorrelated t-test showed a significant improvement inbalance scores following the MIRE treatment (t=14.20,p<.01). The average magnitude of balance scores changedfrom a Mean of 16.65 to 23.45 following the intervention.The improvement in sensation (507 R MV) was alsosignificant (t=10.35, p<.01). The mean sensory scoreimproved from 1.81 pre-intervention to 10.50 following theMIRE treatment. The RM ANOVA results showed that thepain symptoms significantly reduced on both legs(FL=116.63, FR=110.10, p<.01) and there was nosignificant interaction effect which indicated that both legshad similar pattern of the pain improvement.

The implications of this pilot study suggests that MIREtherapy may have contributed to the reduction in pain,improvement in sensation, and balance in these participantswith diabetic peripheral neuropathy. Such a symptomimprovement can positively influence their ADL function,mobility and quality of life. Continued research reports maybe warranted to add to the efficacy literature about the MIREtherapy and its use as a physical agent modality (PAM) invarious rehabilitation settings.

This pilot study results and earlier studies show thatMIRE therapy may be beneficial for patients with DPN andother conditions presenting with pain, sensory loss andbalance problems. Diabetic peripheral neuropathy with lossof sensation is the major cause of diabetic foot ulcers andamputation and until recent years, there has been noeffective treatment for the loss of sensation associated withneuropathy. Rather, those of us who care for people withdiabetes are left to rely on a combination of periodic visits,

Table 1: Magnitudes Pre and Post Intervention

507Pr 507Po Tin Pr Tin Po PPr-R PPo-R PPr-L PPo-LMean 1.81 10.50 16.65 23.45 7.55 2.35 7.10 2.25

SD 2.01 3.52 3.20 2.33 2.78 2.08 2.86 2.02Min 0.01 3.00 9.00 17.00 0.01 0.01 0.01 0.01Max 5.00 16.00 24.00 26.00 10.00 7.00 10.00 7.00

507Pr = Sensation measured pre-intervention 507Po = Sensation measured post-interventionTin Pr = Tinetti measure of balance pre-interventionTin Po = Tinetti measure of balance post-interventionPPr-R = Pain R Lower extremity measured pre-intervention PPo-R = Pain R Lower extremity measured post-intervention PPr-L = Pain L Lower extremity measured pre-intervention PPo-L = Pain L Lower extremity measured post-intervention

84 Stanley Paul / Indian Journal of Physiotherapy and Occupational Therapy. January - March 2010, Vol. 4, No.1

protective shoes, surgical treatment and, most importantly,the patient’s self-management to prevent the occurrence offoot ulcers that can lead to amputations. Loss of protectivesensation reduces the warning signal of pain and makes itmuch more difficult to obtain the patient compliancenecessary to reduce risk of complication in neuropathicpatients. Effective treatment of DPN, particularly if it resultsin restoration of protective sensation, would offer abreakthrough intervention to prevent diabetic ulcers andamputations. Additionally, treatment of this condition mayoffer substantial improvement in the quality of life for thesepatients. MIRE can be a useful step in the process ofregaining function, when used as a PAM modality.Continued research and evidence based knowledge aboutthe application of MIRE is needed in order to help thesepatients achieve maximum benefits from their therapy.

References

1. Anodyne therapy systems. 2009; Retrieved June 11,2009, from http://www.anodynetherapy.com/index.htm.

2. Hicks L. A New Breakthrough Treatment: AnodyneTherapy. Diabetes Health. 2004; 13:60.

3. Nather A, Sim YE, Chew LLJ, Neo SH. Anodyne therapyfor recalcitrant diabetic foot ulcers: a report of fourcases. Journal of Orthopedic Surgery. 2007;15(3):361-5.

4. Burke TJ. Five Questions-and answers-about MIREtreatment. Advances in Skin and Wound Care. 2003;16:369-371.

5. Carnegie DE. The use of monochromatic infraredenergy therapy in podiatry. Podiatry Management. 2002;11:129-34.

6. Harkless LB, DeLellis S, Carnegie DH, Burke TJ.Improved foot sensitivity and pain reduction in patientswith peripheral neuropathy after treatment withmonochromatic infrared photo energy—MIRE. Journalof Diabetes and Its Complications. 2006; 20:81-7.

7. Leonard DR, Farooqi MH, Meyers S. Restoration ofsensation, reduced pain, and improved balance insubjects with diabetic peripheral neuropathy. DiabetesCare. 2004; 27:168-72.

8. Thomasson TL. Effects of skin-contact monochromaticinfrared irradiation on tendonitis, capsulitis, andmyofascial pain. Journal of Orthopedic Medical Surgery.1996; 16:242-7.

9. Volkert W, Hassan A, Hassan MA, Smock VL, ConnonJP, McFee B, Ferguson SK, Burke TJ. Effectiveness ofMonochromatic Infrared Photo Energy and PhysicalTherapy for Peripheral Neuropathy: Changes inSensation, Pain, and Balance– A Preliminary, Multi-Center Study. Physical & Occupational Therapy inGeriatrics. 2005; 24(2): 1-17.

10. Powell MW, Carnegie DE, Burke TJ. Reversal ofdiabetic peripheral neuropathy and new woundincidence: The role of MIRE. Advances in Skin andWound Care. 2004; 17:295-300.

11. Vinik. K. Neuropathy: New concepts in evaluation andtreatment. South Medical Journal. 2002; 95: 21-23.

12. Barrett SL. Restoring sensation in diabetic patients.Podiatry Today. 2002; 15:38-44).

13. Levin M. Management of the diabetic foot: Preventingamputation. South Medical Journal. 2002; 95:10-20.

14. Kochman AB, Carnegie D.H, Burke TJ. Symptomaticreversal of peripheral neuropathy in patients withdiabetes. Journal of American Podiatry MedicalAssociation. 2002; 92:125-130.

15. Goldman SM. Long term restoration of sensation ofdiabetic patients with peripheral neuropathy. Conferenceproceedings of the 2002 American College of Foot andAnkle Surgeons conference, Boca Raton, FL, USA;2002.

16. Kochman AB. Monochromatic Infrared Photo Energyand Physical Therapy for Peripheral Neuropathy:Influence on Sensation, Balance, and Falls. Journal ofGeriatric Physical Therapy. 2003; 27:18-21.

17. Powell MW, Carnegie DE, Burke TJ. Reversal ofdiabetic peripheral neuropathy with phototherapy(MIRE) decreases falls and the fear of falling andimproves activities of daily living in seniors. Age and

Fig. 1: MIRE System

Fig. 2: MIRE set up

Fig. 3: Administration points for Semmes-Weinstein Monofilament 5.07

85

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