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ISSN P - 0973-5666
ISSN E - 0973-5674
Indian Journal of
Volume 5
Number 1
January - March 2011
Physiotherapy and Occupational Therapy
An International Journal
website: www.ijpot.com
INDIAN JOURNAL OF PHYSIOTHERAPY AND

OCCUPATIONAL THERAPY
Editor
Dr. Archna Sharma
Head, Dept. of Physiotherapy, G.M. Modi Hospital, Saket, New Delhi 110 017
E-mail: editor.ijpot@gmail.com
Executive Editor
Dr. R.K. Sharma, New Delhi
Dean (R&D), Saraswathi Institute of Medical Sciences, Ghaziabad (UP)
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Dr. Sohrab A. Khan, Jamia Hamdard, New Delhi
Print-ISSN: 0973-5666 Electronic - ISSN: 0973-5674, Frequency: Quarterly (4 issues per volume).
Indian journal of physiotherapy and occupational therapy An essential indexed double blind peer reviewed journal
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www.ijpot.com
Contents
Volume 5, Number 1
1
5
9
14
18
21
24
27
33
36
40
43
47
52
56
60
63
66
70
73
77
80
Jan.-March. 2011
Footwear effects on balance and gait in elderly women of Indian population between the ages 55
and 75 years
Aditi Bhatia, Sumit Kalra
The effect of short term dynamic and isometric resistance training in knee osteoarthritis
Ajit Singh, Shekhar
Multimodal therapy in cervicogenic headache- a randomized controlled trial
Akanksha Sharma, Unaise Abdul Hameed, Shalini Grover
Combined effectiveness of Maitlands mobilization and patellar taping in patellofemoral
osteoarthritis: A randomised clinical trial
Alok Kumar, Ganesh B. R.
Maximal oxygen consumption as a function of anthropometric profiling in a group of trained
Indian athletes
Amrith Pakkala, Ankita Dutta, N.Veeranna, S.B.Kulkarni
Titanic splint
B.Anandha Priya, Snehal Pradip Desai
Normative data of Jebsen Taylor Hand Function Test [modified version] on indian population
B.Anandha Priya, Snehal Pradip Desai
Effect of 2-week and 4-week wobble board exercise programme for improving the muscle
onset latency and perceived stability in basketball players with recurrent ankle sprain
A.S. Dinesha , Arun Prasad.B
A comparative study of the therapeutic effect of pelvic floor exercises and perineometer among
women with urinary stress incontinence
Ms. K. Vairajothi, T.V. Chitra, Professor, R.Baranitharan, V.Mahalakshmi
A study of effects of gluteal taping on TD-parameters following chronic stroke patients
Bhatri Pratim Dowarah
Role of physiotherapy in palliative care
Binoy Mathew K V.
Comparing effectiveness of antero-posterior and postero-anterior glides on shoulder range of
motion in adhesive capsulitis - a pilot study
Harsimran K, Ranganath G, Ravi SR
Effect of 12 weeks weight bearing and non weight bearing aerobic exercises on overweight and
obese individuals
J. Deepa, Monalisa Pattnaik, P.P Mohanty, Venkadesan. R
Effect of functional strength training on functional motor performance in young children with
cerebral palsy
Dharam Pani Pandey, Vimal Tyagi
Effect of post isometric relaxation on pain intensity, functional disability and cervical range of
motion in myofacial pain of upper trapezius
Dheeraj Lamba, Satish Pant
The effect of foot orthoses on energy consumption in runners with flat foot
F.Farmani, M.Sadeghi, H.Saeedi, M.Kamali
A study of prevalence of Developmental Coordination Disorder (dcd) at kattankulathur, chennai
Mr.ganapathy Sankar U, Ms. S.saritha
Dynamic standing balance in individuals with osteoarthritis knee- a comparison with matched
controls
R.HariHaran
Effect of play therapy in children with attention deficit hyperactivity disorder - a single blinded
randomized controlled study
Jagatheesan Alagesan, Sardesai A. Shradha, Sankar B. Mani
A study of effectiveness of wheelchair skill training program (wstp) in teaching wheelie to
occupational therapy students
Kamal Narayan Arya
Perception and functional wellbeing of patients receiving physiotherapy services in a
multispecialty hospital prospective observational trial
T. Lavinia Marwein1, Baskaran Chandrasekaran, Bidhan Chandra Sharma
Effect of concurrent quantitative feedback training on intra-rater and inter-rater reliability of
grade iii mobilization over fourth lumbar spinous process
Nidhi Gautam, Shallu Sharma
Indian Journal of Physiotherapy and Occupational Therapy. Jan. - March. 2011, VOL 5 NO 1
85
90
95
100
103
107
112
116
119
122
125
128
133
137
140
142
147
150
154
Efficacy of deep transverse friction massage in treatment of chronic ankle sprain

Pooja K Arora, Sujata Yardi, Kunal Pathak
Comparative analysis of 12 minute walk test and modified shuttle walk test in normal subjects
Richa Rai, Sujata Yardi
Cervical spinal mobilization versus TENS in the management of cervical radiculopathy: A
comparative, experimental and randomized controlled trial
Ronald Prabhakar, G. J. Ramteke
Home based constraint-induced therapy for children with hemiplegic cerebral palsy: A pilot
study
Saleh AL-Oraibi, Hashem Abu Tariah
Taping and OKC exercises versus taping and CKC exercises in treating patients with patellofemoral
pain syndrome
Yehia N. Abd Elhafz , Mohammed S. Abd El Salam , Samiha M. Abd Elkader
Cardiovascular responses to McKenzie lumbar spine exercises in hypertensive individuals
Prabhu. R, Nambiar V.K, Ravindra .S, Kommineni. P
Care allowance for people in need of care in Turkey: An ethical and social evaluation
Sema OLAK , Erdem ZKARA
Comparative study of anaerobic capacity in sprinters and foot ball players
D.s.sakthivelavan, S.sumathilatha
Effect of varying abdominal pressures on pulmonary function in seated tetraplegic patients: A
case report
Shweta Gore, Sivakumar T.
Stabilization exercises in postnatal low back pain
Tarek A. Ammar, Katy Mitchell, Amir Saleh
Efficacy of neural mobilization in sciatica
Sharma Vijay., Sarkari E. and Multani N.K
Prevalence of various health problems in traditional goldsmith
Anup Pednekar, Anu Arora, Sujata Yardi
Effect of 12-weeks posterior tibial nerve stimulation in treatment of overactive bladder
Anwar Abdelgayed Ebid
Comparison of manual physical therapy and conventional physical therapy programs in
osteoarthritis of knee
Dheeraj Lamba, Satish Chandra Pant
Efficacy of home based pulmonary rehabilitation program on pulmonary functions and quality of
life in asthmatic children
Ganesan Kathiresan , Andrew J Newens
The relative efficacy of mobilization with movement versus Cyriax physiotherapy in the treatment
of lateral epicondylitis
Pooja Bhardwaj, Amit Dhawan
Use of electrical stimulator to detect neurosensory changes - a case report
Prachur Kumar, C.S Ram, Suhas.S.Godhi
Relationship between depression and duration from the onset of injury in traumatic spinal
cord injured patients
Renu Singh, Ms. Ruby Aikat
Efficacy of Mulligan Concept (NAGs) on Pain at available end range in Cervical Spine: A Randomised
Controlled Trial
Kumar D, Sandhu J S, Broota A
Indian Journal of Physiotherapy and Occupational Therapy. Jan. - March. 2011, VOL 5 NO 1
Footwear effects on balance and gait in elderly women of Indian

population between the ages 55 and 75 years
Aditi Bhatia*, Sumit Kalra**
*Student, **Lecturer, Banarsidas Chandiwala Institute of Physiotherapy, New Delhi.
Abstract
Purpose
To determine effects of different footwear and barefoot condition
on measurement tools like FRT, TUG and TMW in elderly women
of Indian population.
Subjects
Sixty women, aged 55 to 75 years.
Methods
Each subject performed the Functional Reach Test (FRT), Timed
Up and Go (TUG) and Ten Metre Walk (TMW) while wearing
walking shoes, heel shoes, and barefooted. One-way repeatedmeasures analysis of variance (ANOVAs) and a Tukey Honestly
Significant Difference test were used to compare the outcomes
for the 3 footwear conditions.
Results
Subjects performed better in the FRT when barefooted or
wearing walking shoes compared with when they wore heel
shoes. For TUG and TMW, the women were slowest wearing
heel shoes, with no significant differences in walk shoes and
barefoot.
Conclusion
For administration of measurement tools like FRT, TUG and
TMW in clinical settings and for research purposes, footwear
should be consistently standardised from one patient or subject
to another or from one facility to another. Moreover, balance
and gait in elderly women can be improved through correct
footwear recommendation.
Introduction
Physical function refers to the normal performance of an
individual in managing ADLs and represents an important aspect
of the individuals overall health. Physical function impairs if
balance and gait are altered. Many falls experienced by older
people result from age-related deterioration of the balance and
neuromuscular systems(1). Most falls occur during motor tasks(2)
and footwear has been identified as an environmental risk factor
for both indoor and outdoor falls(3). By altering somatosensory
feedback to the foot and ankle and modifying frictional conditions
at the shoe-sole/floor interface, footwear influences postural
stability and the subsequent risk of slips, trips, and falls, thereby
impairing balance and gait.
Wearing different footwear or being barefooted influences
balance and gait. When walking barfooted, proprioception and
plantar sensitivity provide optimal input to the postural control
system. However, wearing a shoe,provide more grip than the
plantar sole of the foot, protecting the foot from mechanical insult
and irregularities in walking surfaces, thereby reducing the risk
of slipping(4).
Moreover, in heeled shoes, heel elevation is associated

with an increased risk of falling in older people by elevating and
shifting the wearers center of mass (COM) forward, high-heel
shoes affect balance control and lead to postural and kinematic
adaptations(5). In a plantar-flexed ankle position adopted when
wearing elevated heel shoes, calcaneal eversion is reduced,
which is often noted in high-heeled gait, and foot rollover in the
shoe is absent(6), these later adaptations might prevent the foot
from pronating, affecting the foots natural shock-absorption
mechanism(4) and thus leading to falls.
Heeled shoes cause abnormal forces across patellofemoral
and medial compartments of knee which are typical anatomical
sites of degenerative joint changes(7). First metatarsophalangeal
joint reaction forces were twice as large in high heels compared
to barefoot walking(8).
With increasing risk of slips, trips and falls due to footwear,
evaluation of physical impairments and functional limitations has
become an essential part of research related to clinical practise
for proper diagnosis as to give proper and accurate management
and early rehabilitation. Evaluation of balance and gait can be
done by available multiple instruments such as Sharpened
Rhomberg, One Leg Stance Test, Functional Reach, Timed Up
And Go, Berg Balance Scale, Gait Speeds etc(9). Among the
physical performance measures that fulfill these requirements
are the Functional Reach Test (FRT), the Timed Up and Go
Test (TUG), and measures of self-selected gait speed such as
the 10-Meter Walk Test (TMW). All 3 of these scales are
continuous measures and, therefore, theoretically more
responsive to change than categorical scales(10).
The FRT captures the ability to control movement of the
center of gravity over a fixed base of support, in the standing
position with excellent test-retest reliability(11). Concurrent validity
as a marker of physical frailty in community-dwelling elderly
people (12), predictive validity in identifying risk of falls in
community-dwelling male veterans(13) and sensitivity to change
in balance in inpatient male veterans undergoing physical
rehabilitation(14) have been reported for the FRT. Older adults
have shorter distances of functional reach when compared with
young adults(15). The average reach length of females is 13.5%
smaller than that for the corresponding males(16).
The TUG is typically used to evaluate basic mobility in
elderly people. Podsiadlo and Richardson (17) reported an
excellent intrarater reliability and interrater reliability for a
subgroup of 22 people. Women performed significantly poorer
on TUG(18). TUG shows a trend towards age related declines as
measured for both male and female subjects(19).
The TMW is a measure of self-selected walking speed(20)
which, according to Cress et al(21) is the best predictor of selfperceived function and overall physical performance. The
comfortable walking speed of older adults was an average of
71% to 97% slower than that of young adults(22). Gait velocity
was higher for women than for men(23).
Standardization of test procedures is often critical for reliable
generalization of results from one patient to another. The type
of footwear worn by the patient or subject is not consistently
standardized in the administration of the FRT, TUG, and TMW.In
previous studies in which the FRT was used as an outcome
measure, the authors rarely mentioned footwear when describing
the measurement procedures (24) . Footwear also is not
standardized for the TUG or TMW and reported as regular
Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol.5, No.1
footwear and as normal walking shoes(25) respectively.

Several investigators have reported other effects of
footwear. Few studies included older women like a study done
by Solveig et al(32), reported that walking shoes, heel shoes and
no shoes affect the gait pattern of older women of American
population. However, no study encompassed the effect of
footwear on FRT, TUG, and TMW scores amongst elderly women
of Indian population.
The purpose of our study was to determine the effects of
footwear on FRT, TUG, and TMW scores in elderly women of
Indian population. The focus of our study was limited to elderly
women because they are at higher risk for disablement than are
men(26). In addition, women wear high-heeled dress shoes that
may have a great impact on balance and gait performance.
We hypothesized that elderly women of Indian population
show low FRT scores, larger TUG scores and slower self
selected gait speeds with heel shoes, with no significant
differences in walk shoes versus barefoot condition.
Method
Subjects-60 healthy female subjects were taken.
Inclusion criteria(1) Between age group of 55 to 75 years,
(2) Owned at least one pair of walking shoes and at least one
pair of dress shoes (with heel height of atleast 1 inch)
(3) Wore these shoes at least occasionally
(4) Had at least 90 degrees of shoulder flexion
(5) No history of any balance problem
(6) Able to stand unsupported for 30 seconds or more,
(7) Could walk independently at least 20 m and turn 180
degrees,
(8) Did not wear a lower-extremity brace or orthosis,
(9) Should be able to stand barefoot on the floor.
Exclusion criteria(1) Ability to understand standardised test instructions,
(2) Any psychological disorder,
(3) Any neurological disorder,
(4) Any recent or acute fracture of lower limb,
(5) Any recent lower limb surgery,
(6) Any inflammatory condition, joint infection of lower limb
joints,
(7) Any diabetic or lower limb neuropathy,
(8) Tendoachilles not stretchable to 90 degrees,
(9) Any shoulder pathologies or deformities,
(10) Any spinal pathology,
(11) Wore any lower extremity brace or orthosis,
(12) Foot deformities, foot abnormalities like painful corns and
ulcers.
Instrumentation1. Walking shoes
2. Dress shoes of atleast 1 inch heel
3. Yardstick
4. Measuring tape
5. Digital stop watch
6. Chair with arm rest, cushioned back and seat. The chair
should have seat height 44cm, seat depth 44cm and arm
height 63cm.
Data analysis
A one-way repeated-measures ANOVA was used for each
test to compare the outcomes on the FRT, TUG, and TMW for
the 3 different footwear conditions. A post hoc comparisons
among footwear conditions were performed using the Tukey
Honestly Significant Difference (Tukey HSD) test with a
significance level of P<.05. The 95% confidence interval (95%
CI) also was calculated for each point estimate.
Results
Table 1: Comparison of FRT in different footwear conditions
(barefoot) walk shoes and heel shoes)
FUNCTIONAL REACH TEST (FRT) in cm
BAREFOOT WALK
HEEL
SHOES
SHOES
MEAN
8.267
8.162
6.612
STANDARD 2.672
2.682
2.371
DEVIATION
Table 2: Comparison of TUG in different footwear conditions
TIMED UP AND GO TEST (TUG) in seconds
BAREFOOT
WALK
HEEL
SHOES
SHOES
MEAN
12.375
12.208
14.477
STANDARD 3.709
3.696
3.856
DEVIATION
Table 3: Comparison of TMW in different footwear conditions
TEN METRE WALK (TMW) in metre/second
BAREFOOT WALK
HEEL
SHOES
SHOES
MEAN
0.544
0.554
0.465
STANDARD 0.129
0.133
0.098
DEVIATION
Graph-1 Comparison of FRT in different footwear conditions
(barefoot, walk shoes and heel shoes)
Graph-2 Comparison of TUG in different footwear conditions

Procedure
All the subjects who were willing and fulfilling inclusion
criteria were taken for the study and explained about the testing
procedure. They were asked to sign an informed consent. The
subjects were asked to perform FRT, TUG and TMW under three
footwear conditions (barefoot, walk shoes and heel shoes) for
two trials. To avoid undue fatigue subject rested 3minutes
between footwear conditions and 1minute between different
functional measurements.
Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Graph-3 Comparison of TMW in different footwear onditions

The ANOVAs revealed an overall footwear condition effect

for FRT scores of subjects (F=7.908; df=2; P<.001), for TUG
scores (F=6.807; df=2; P<.001), and for TMW scores (F=9.739;
df=2; P<.001).
Tukey HSD post hoc pair-wise comparisons revealed that
the subjects performed better on the FRT when they were
barefoot or wore walking shoes compared with when they wore
heel shoes(HSD.05=5.060 and HSD.05=4.655 respectively) with
no significant difference between the barefoot and walking shoe
conditions(HSD.05=.405).
Subjects when performing TUG performed better in barefoot
and walking shoes compared with when they wore heel shoes
(HSD.05=4.33 and HSD.05=4.68 respectively) with no significant
difference between the barefoot and walking shoe conditions
(HSD.05=.344).
In TMW test, subjects performed better in barefoot and
walking shoes compared with when they wore heel shoes
(HSD.05=4.996 and HSD.05=5.628 respectively) with no significant
difference between the barefoot and walking shoe conditions
(HSD.05=.632).
Discussion
The results of the study indicates that in elderly women,
type of footwear is an important factor while measuring and
analysing findings of common clinical tests like FRT,TUG and
TMW.
The results of this study indicates that FRT scores are better
in walk shoes or no shoes in comparison to heel shoes.
The results of FRT scores are quite consistent with findings
of Lord and Bashford(27) who studied the effects of footwear on
balance in 30 women aged 60 to 89 years using a swaymeter.
These women performed better in flat shoes or barefoot than
when they wore high heeled shoes.
The lack of differences in FRT scores between barefoot
and walking shoes condition is consistent with study by Briggs
et al(28). They found no effect of wearing shoes versus not wearing
shoes on performance in sharpened Rhomberg and OLST
among older women with no known pathology.
Footwear effects on TUG and TMW showed worse
performances with heel shoes with no significant differnces
between barefoot and walk shoes walking. These performances
in heel shoes condition agrees with observations of Snow RE et
al(29) whose studies demonstrated slower gait in high heeled
shoes compared with low heeled shoes. The decreased scores
of TUG and TMW in heels is supported by work of de Lateur(30)
which states that increased heel heights corresponds to
decreased gait speeds and step length.
According to Menant et al(31), elevated heel shoes lack
comfort, stability and lead to a conservative walking pattern
characterised by increasing step width and double support time.
The study also indicates that there is no significant
difference in walk shoes versus barefoot condition of TUG and
TMW scores, contradicting the study of Solveig et al(32) which
states that walk shoes give lower TUG scores and faster selected
gait speed than with no shoes.

Though barefoot walking increases precise foot position
awareness, but elderly women cannot be advised to walk without
shoes because barefoot walking can cause cuts, abrasions,
bruises, punctures, wounds from foreign objects. Moreover
hookworm larvae can easily burrow through a bare human foot.
In addition individuals with diabetes mellitus which affect
sensation with in feet are at a greater risk of injury when walking
without shoes so they can only be advised to walk with shoes
with no or minimal heel.
It is also important to note that during the testing, subjects
wore their own shoes, because testing in new shoes may
influence postural responses to footwear. Moreover in clinical
settings, subjects are generally assessed in their own shoes.
This study also indicates that during assessments and
followups of elderly women of balance and gait abilities,
comparative analysis should be drawn in similar footwear
condition with its proper documentation.
Results of current study suggest that correct footwear
recommendation can help to improve balance and gait abilities
in elderly women. But further research is needed to identify
important shoe characters that can help to improve balance and
gait abilities in elderly women.
Conclusion
Based on the findings of this study, it can be concluded
that scores of FRT, TUG and TMW are affected by type of
footwear condition in elderly women. It is also important to keep
the footwear constant and properly documented when using FRT,
TUG and TMW in clinical settings and research purposes. In
addition, improvement of gait and balance in elderly women can
be undertaken by proper footwear intervention and it is
suggested that elderly females should be advised to wear
minimal heel shoes as it can prevent further risk of falls as they
can walk barefoot.
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25. Schenkman M, Cutson TM, Kuchibhatla M, et al. Reliability
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Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
The effect of short term dynamic and isometric resistance training

in knee osteoarthritis
Ajit Singh*, Shekhar**
*Assistant Professor, Department of Orthopaedics, Rohilkhand Medical College, Bareilly, **Assistant Professor, Department of
Physiotherapy, Jaipur College of Physiotherapy, Jaipur
Keywords
of all adults at or over age 65 years exhibit radiographic evidence

of OA2. When symptoms of the disease affect the knee, as in
10% of all adults, it results in a limited ability to complete activities
of daily living (ADLs)3. Many studies have indicated that the
primary lesion of OA is in the articular cartilage4. Quadriceps
strength, knee pain, and age are more important determinants
of functional impairment in elderly subjects than the severity of
knee osteoarthritis as assessed radiographically5. Among these,
quadriceps weakness may be the most amenable to treatment
for the prevention of knee OA.
Treatment options in OA knee may be classified as
nonpharmacologic, pharmacologic, or surgical. Given their
relatively low toxicity and cost, nonpharmacological strategies
(such as physical therapy, including exercise) are recommended
as the first-line treatment for the knee OA6. The primary goals of
physical therapy are to reduce pain and decrease disability7.
Physical therapy encompasses a variety of treatment modalities
for knee OA, including manual joint mobilization, exercise
prescriptions, hydrotherapy, massage, knee tapping, knee
braces, and shoe insole. Numerous studies have documented
the symptomatic benefits of isometric exercise for individuals
with knee OA.6,8,9,10 Functional ability requires movement of the
joint over a functional range. Isometric resistance training
improves muscle strength only at joint angle at which the training
takes place11,12, this specificity of training principle may limit how
much isometric training can affect performance of functional task
that requires joint movement beyond the joint angle prescribed
in the isometric training. A possible advantage of isometric
training may be that it does not stress the joint over a functional
range of motion. Reduced joint movement may result in less
pain during and after the resistance training.
In contrast, dynamic resistance training in non-OA subjects
improves the strength of the trained muscle over the entire range
of motion(ROM). It has been reported that dynamic resistance
training correlates with improve knee strength, increased
neuromuscular performance on selected functional tasks.
Although, dynamic resistance training improves strengths and
functioning over the training ROM, the joint is being loaded while
it is moved, which may result in pain in OA patients.
Since strength training affects the outcome of OA knee,
thus this study aims to assess the effect of short term multiple
angle isometric resistance training and dynamic resistance
training on pain and function among adults with OA knee.
Disability; dynamic resistance training; isometric exercises;

knee osteoarthritis.
Method
Abstract
Background and purpose
Since strength training affects the outcome of OA knee,
thus this study aims to assess the effect of short term (3 weeks)
multiple angle isometric resistance training and dynamic
resistance training on pain and function among adults with OA
knee.
Study design
A pre-post experimental design.
Subjects
A total of sixty subjects were selected on the basis of
inclusion and exclusion criteria; Group 1 (n=30) was
administered with multiple angle isometric resistance training
and Group 2 (n=30) was administered with dynamic resistance
training.
Methods
The muscle strength was measured using strain gauge,
pain of the subjects was evaluated on Visual analog Scale,
function of knee was measured on reduced WOMAC scale.
Results
The result indicates that both the interventions were equally
effective in reducing pain, improving isometric strength of
quadriceps, and improving functional status.
Conclusion
Dynamic or isometric resistance training improves
functional ability and reduces knee joint pain of patients with
knee OA.
Introduction
Osteoarthritis (OA) is common, progressive health problem
among adults. It is the most prevalent disease in our society,
with a world wide distribution and is the second most common
cause of disability among older adults1. It is estimated that 80%
Corresponding author:
Dr Ajit Singh, Assistant Professor , Department of Orthopaedics,
Rohilkhand Medical college, Pilibhit bypass Road, Bareilly. PIN243006.E-mail: ajitsingh2409@gmail.com
Phone number: (0581)2526011
Mobile number: 09319930079, 9458407500
The study was conducted using pretest post test

experimental design at Ortho & Physiotherapy OPD, Rohilkhand
Medical College, Bareilly on 60 subjects who were randomly
divided into two equal groups. A total of sixty, both male(n=33)
and female(n=27) patients were included in the study. The
criteria for inclusion were: pain in and around knee; radiological
evidence of primary osteoarthritis with grade II, III on KellgraneLarance scale13; age between 50 -75 years; unilateral or bilateral
involvement, in case of bilateral more symptomatic knee was
included. Subjects were excluded if they had any deformity of
knee, hip, or back, limitation in knee range of motion, history of
bony or soft tissue injury to knee joint, backache with radiating
pain to leg, any central or peripheral nervous system
involvement, received steroid or intra articular injection within
Ajit Singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
previous six months, systemic inflammatory disease e. g. gout,

rheumatoid arthritis, ankylosing spondylitis, had metallic implant,
uncooperative patients or mentally unstable. Patient taking
non-steroidal anti- inflammatory drugs had been on stable dose
over the last two weeks.
Procedure
After screening for inclusion and exclusion criteria the
subjects were randomly assigned into two groups with 30
subjects in each group and informed consent was obtained from
the subjects. Randomization was done by permuted block
randomization.
Intervention
All the subjects received hot pack at the affected knee joint
and resistance training exercises according to their respective
groups. The intervention was given for three weeks (3 days/
week). Hot packs were given after the exercise session with
patient in supine lying.
Group A: hot packs with multiple angle isometric resistance
training at 30 , 60 and 90 degree of knee flexion.
Group B: hot packs with dynamic resistance training.
The outcome measurements in this study were isometric knee
extensor strength at 30 , 60 and 90 degree of flexion, reduced
WOMAC14 score and VAS15 score.
Measurement of isometric strength
The isometric strength of quadriceps femoris was measured
by using a strain gauge at baseline (before intervention) and
recorded as ISO01, ISO02, ISO03 and at the end of intervention
recorded as ISO31, ISO32, ISO33 for isometric strength at 30
,60, 90 degree of knee flexion respectively. During the testing
subjects were made to sit on quadriceps table with knee joint at
30 , 60 and 90 degree of flexion .thigh was stabilized with belts;
the shin pad was adjusted at 5.1 cms (2 inches) superior to the
medial malleolus. The fulcrum of the lever arm was aligned with
the most distal part of lateral epicondyles of the femur. The strain
gauge was attached to the distal end of the quadriceps table
arm.
Subjects were given verbal encouragement in order to
motivate to attain maximum effort during the 5 seconds
contraction. Each test included 3 consecutive trials with 30
seconds rest in between the trials. The mean of 3 readings was
used for the purpose of analysis.
Measurement of functional score
The functional score was assessed by using reduced
WOMAC scale. The reading were taken at baseline (before
intervention) and after the end of three weeks and marked as
WOMAC0 and WOMAC3 respectively.
Measurement of pain intensity
Pain was assessed using a horizontal analog scale. The
reading were taken at the baseline and at the end of intervention

and marked as VAS0 and VAS3 respectively.
Data analysis
A pre-post experimental (parallel group) study was used
for the study. Data was analyzed using the SPSS 15 software.
Paired t-test was used for comparison of strength with the groups.
Independent t-test was used to compare the strength between
the groups, the values of both of the two groups i.e. group A and
Group B were compared at baseline and post intervention. The
test was applied at 95% confidence interval. The results were
taken to be significant if p<0.05.
Results
Within group analysis in Group A and B revealed that there
was a statistically significant difference (p<0.05) in isometric
strength of quadriceps at 30, 60, and 90 degrees of knee flexion
after 3 weeks of training, when compared to the baseline values.
The mean improvements in isometric strength in Group A at 30o
was 3.341.06; at 60o was 4.121.52 and at 90o was 3.551.06.
Within Group B the mean improvements in isometric strength at
30o was 3.751.47; at 60o was 4.511.32 and at 90o was
3.711.29. (Table. 1)
Both Group A and B showed a statistically significant
difference (p<0.05) in VAS Score after 3 weeks of training when
compared with baseline values. The mean improvements in VAS
Score was 4.31.6 in Group A and 4.361.56 in Group B.(Table.
2).
Within group analysis in both groups revealed that there
was a statistically significant difference (p<0.05) in WOMAC
Score after 3 weeks of training when compared with baseline
values. The mean improvement in WOMAC Score was11.44.15
in Group A and 12.334.08 in Group B .(Table. 3)
Discussion
This study provides important information about the efficacy
of Dynamic resistance training and Multiple angle isometric
resistance training on quadriceps strengthening in OA patients.
Both the two groups showed a significant reduction in pain,
improvement in isometric strength of quadriceps, and
improvement in functional index scale from their base line values.
But when compared between the groups, there was no significant
difference observed. Thus, the old idea that isometric exercise
is the only correct exercise for people with arthritis is challenged
by this study.
Table 1 : Isometric strength of quadriceps at 30, 60, and 90 degrees of knee flexion after 3 weeks of training.
Knee Flexion
Pre TestMeanSD
Post TestMeanSD
t value
5.011.71
8.342.31
-12.19
Group A
At 300
6.252.07
10.372.89
-10.45
At 600
5.661.98
9.212.39
-12.93
At 900
4.701.26
8.461.53
-9.87
Group B
At 300
6.121.47
10.631.76
-10.12
At 600
5.501.44
9.221.59
-11.07
At 900
Table 2 : Within group analysis of VAS Scores

Pre TestMeanSD
Post TestMeanSD
Group A
6.841.17
2.571.11
Group B
6.831.38
2.471.39
t
10.32
10.89
p
<.05
<.05
Table 3 : Within group analysis of WOMAC

Pre TestMeanSD
Post TestMeanSD
Group A
20.733.75
9.332.76
Group B
22.673.79
10.333.73
t
10.68
11.7
p
<.05
<.05
p value
<.05
<.05
<.05
<.05
<.05
<.05
Ajit Singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
The results of the resistance training tested in the current

study appear to have a greater percentage impact on improving
actual functional measures and reducing pain than previous
exercise interventions. The Fitness Arthritis and Seniors Trial16
reported a modest 8%to 10% improvement in pain and
functioning scores as a result of 18 months of aerobic or
resistance exercise among their sample of knee OA patients.
This modest, although signicant, effect of a long-term exercise
program, which included resistance training, was also reported
by Rogind et al17. Even the previously cited reviews10,18 of the
literature indicated that exercise seems to have a small to
moderate effect on joint pain and functional outcome measures
with a more moderate effect on self-perceived measures of
functioning. Our ndings suggest that resistance training
interventions reduced pain and increased functional ability
similarly or to a greater extent than the previously studied
interventions and that too in a lesser duration. This may be
possibly due to the fact that, the present interventions were
primarily resistance training and may have required a higher
intensity of training than the previous studies. The results of this
study support the efficacy of resistance training program in
management of OA patients, which is in agreement with various
other studies which support that activities involving strengthening
of quadriceps are helpful in the management of OA knee
patients19.
Several investigators20,21have reported declines in the
sensorimotor function of the quadriceps (proprioception) among
knee OA patients. This decline may be a primary factor
contributing to the development and progression of knee OA22.
If proprioception is impaired, the timing of the eccentric
contraction of the quadriceps during weight-bearing activities
will be clumsy, thus resulting in higher impact and impulsive
loads being transmitted through the joint23. These higher loads
being transmitted through the knee joint will lead to microtrauma
to the articular cartilage and/or the subchondral bone, which
are characteristics of knee OA24. A hypothesized outcome of
resistance training of the leg is an increased sensitivity in the
sensorimotor structures of the quadriceps including the muscle
spindles and Golgi tendons25. Resistance training has been
shown to increase the alpha motor discharge or tone of the
muscles trained. This alpha motor neuron activity is reciprocally
influenced by muscle spindles and Golgi complex within the
muscles. Thus, regular resistance training may lower the impact
and impulsive loads through the knee joint not by only increasing
the strength of the muscle surrounding the knee joint but also
by increasing sensitivity and coordination of the proprioceptors
within the quadriceps muscle26.
Pain is a major factor to the disability in the patients with
osteoarthritis knee. Hence, reduction in pain can explain a
concomitant improvement in the functional status of the patients.
Disability in OA is due not only to the arthritis but also to the
inactivity associated with the disease and with aging. It has
been postulated that resistance training increases the hyaluron
levels in the OA knee patients. With repeated muscle contraction
there occurs a synovial cell stimulation which is responsible for
activating hyaluron synthesis. This viscous hyaluron is much
suited to joint lubrication and thus help in alleviating pain. Thus
it can be the factor that could have lead to a reduction in pain
after resistance training.
3.
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Ajit Singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Multimodal therapy in cervicogenic headache- a randomized

controlled trial
Akanksha Sharma*, Unaise Abdul Hameed*, Shalini Grover**
*MPT Student, Faridabad Institue of Technology, Faridabad. *Assistant Professor, DTHS, MREI, **Assistant Professor, DTHS,
MREI.
Multimodal therapy is significantly more effective than

exercise therapy as well as control intervention in patients with
cervicogenic headache.
terms such as cervical, occipital and cervicogenic to specific

terms such as third nerve occipital headache1 .The prevalence
of cervicogenic headache in the general population is estimated
to be 0.4% 2.5%, but is as high as 20% in patients with chronic
headache. The mean age of patients with this condition is 42.9
years and it is four times more prevalent in women2.
The World Cervicogenic Headache Society3 has defined
cervicogenic headache as referred pain perceived in any part
of the head and caused by a primary nociceptive source in the
musculoskeletal tissues that are innervated by the cervical
nerves.
Cervicogenic headache arises primarily from
musculoskeletal dysfunction in the upper three cervical
segments4. The pathway by which pain originating in the neck
can be referred to the head is the trigeminocervical nucleus,
which descends in the spinal cord to the level of C3/4, and is in
anatomical and functional continuity with the dorsal gray columns
of these spinal segments. Hence, input via sensory afferents
principally from any of the upper three cervical nerve roots may
mistakenly be perceived as pain in the head, a concept known
as convergence5.
The location of symptoms is usually unilateral and does
not change sides; they begin in the neck and spread to the head.
Pain can range from a dull, deep ache to a heavy pressure of
moderate or severe 6, 1. Cervicogenic headaches may be present
upon waking or can begin or worsen in intensity as the day
goes on, especially with sustained neck postures or movements.
While this type of headache can begin at any age, it often
increases in frequency and intensity over a period of years and
may or may not accompany a history of neck trauma or cervical
joint degenerative disease6.
The most effective form of treatment for cervical headache
has not been established, but a variety of invasive and
noninvasive treatments have been reported. Many authors have
reported the effectiveness of manual therapy in reducing or
alleviating headache but little attention has been afforded to the
muscle system, although muscle impairments are listed as a
characteristic of cervicogenic headache7 and specific deficits in
what can be identified as muscle control of the region have been
identified8.9. Moreover very few studies have incorporated the
combined use of manual as well as exercise therapy in form of
multimodal therapy10, 11, 6 although there is evidence to suggest
that multimodal therapy is superior for neck disorders 12.
It should be noted that, out of these aforementioned studies,
study by Beeton K., Jull G.11 and Shannon M. Peterson 6 is a
single case study with one subject so the results cannot be
generalized to the entire cervicogenic headache population. The
work of Jull et al.10 provides the highest level of evidence
regarding the impact of the combined program or multimodal
therapy, but there is lack of more of such kind of evidence to
make definitive recommendations about the effectiveness of
multimodal therapy to the cervicogenic headache population.
So the present study aims to fulfill the gap in literature
regarding the use of multimodal therapy including cervical spine
mobilization as well as exercise therapy interventions in patients
with cervicogenic headache.
Introduction
Methods
Headaches which are believed to originate from structures

in the neck have been given various names, ranging from broad
The study was a randomized controlled trial. Under

convenience sampling, subjects were recruited from the
Abstract
Study design
The study was a randomized controlled trial. This study
was reviewed and approved by the research review committee
at Faridabad Institute of Technology. (Faridabad)
Aims and objectives

To determine the effectiveness of multimodal therapy that
is a combination therapy including cervical mobilization and
exercise therapy in patients with cervicogenic headache.
Summary of background data

There is lack of quality of Randomized Controlled Trials
analyzing the combined use of cervical mobilization as well as
exercise therapy intervention although there is evidence
suggesting that multimodal treatment therapy is superior for neck
disorders Moreover much of the research on cervicogenic
headache has concentrated on the use of spinal manipulation
techniques alone as well as in combination with other modalities
but the use of vertebral mobilization techniques along with
exercise therapy in the form of multimodal therapy have certainly
been ignored.
Methods
In this study 27 subjects who met the inclusion criteria were
randomized into three groups- multimodal therapy, exercise
therapy and control group. The primary Outcome measures were
Headache Frequency, Intensity and Duration. Secondary
outcome measures were Neck Disability Index Score and
Performance Index of Deep Neck Flexors.
Results
The results of the study demonstrates that patients with
cervicogenic headache receiving multimodal therapy
experienced a significantly greater improvement in Headache
Frequency, Intensity, Duration, Neck Disability and Performance
Index of Deep Neck Flexors when compared to exercise therapy
group as well as control group. Also exercise therapy alone also
resulted in significant improvement across all outcomes; however
the level of significance is less than multimodal therapy group.
Moreover the control group did not demonstrate significant
improvement across all outcomes at all level of comparison with
respect to time.
Conclusion
Akanksha Sharma / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
physiotherapy department of Bhagwan Mahavir Hospital (Delhi).

The subjects were screened using a screening form relevant to
the inclusion and exclusion criteria. Those who fulfilled the
symptomatic criteria underwent a physical examination of
cervical spine, which included manual palpation of upper cervical
joints relevant to the inclusion criteria. Qualifying subjects were
then randomly allocated to one of the three groups- group A
(Multimodal therapy group), group B (Exercise therapy group)
and group C (Control group) by simple random sampling. 9
subjects in each group completed the treatment.
Inclusion criteria -: 1) Age -20-50 years. 2) Unilateral or
unilateral dominant side headache associated with the neck pain
which may project to the forehead, orbital region, temples, vertex,
or ears. 3) Headache frequency of at least 1 per week over a
period of 2 months to 5 years. 4) Pain precipitated or aggravated
by specific neck movements or sustained neck posture. 5)
Resistance to or limitation of active and passive (accessory or
physiological) neck movements in the upper cervical spine
occiput, and/or palpable tenderness. 7) All subjects fulfilled the
first four criteria and had at least one component of fifth criterion.
8) Sufficient English language skills to complete the
questionnaire.
Exclusion criteria-:1) Subjects with bilateral headaches. 2)
Subjects with features suggestive of migraine. 3) Subjects with
conditions or diseases which are contraindicated for mobilization
treatment: Pagets disease, rheumatoid arthritis, ankylosing
spondylitis, spondylolistheses, cervical fractures, osteoporosis,
osteomyelitis, malignancy, pregnancy, and spinal cord
syndromes. 4) Subjects with radicular signs and symptoms into
the upper limbs or exhibited a positive vertebral artery test during
the screening evaluation. 5) Subjects with hypermobility of
cervical spine.
Interventions
Group A (Multimodal therapy group ) received cervical spine
mobilization , exercise therapy intervention including low load
exercise regimen and active ROM exercises of cervical spine
and postural correction intervention , Group B (exercise therapy
group) group received low load exercise regimen , active ROM
exercises of cervical spine and postural correction intervention
and Group C (Control group) received postural correction
intervention only.
(1) Cervical spine mobilization- Treatment consisted of
mobilization techniques to the limited and painful segment
found on passive accessory and physiological testing. The
subjects were given cervical spine mobilization (posteroanterior central vertebral pressure) as described by
Maitland13.
Fig.1: Postero-anterior central vertebral pressure
jerky craniocervical flexion movement.

Training commenced at the target level that the subject
could achieve with a correct movement of craniocervical flexion.
They were then trained to be able to sustain progressively
increasing ranges of craniocervical flexion using feedback from
the pressure sensor, which was placed behind the neck. For
each target level, the contraction duration is increased to 10
seconds, and the subject was trained to perform 10 repetitions.
At that stage, the exercise was progressed to train at the next
target level.
Fig. 2: Training the craniocervical action with the use of
feedback pressure biofeedback
(3)Active range of motion exercise included cervical spine

flexion, extension, side flexion and rotation. The subjects were
advised to perform 10 repetitions of each exercise twice a day.
(4) Postural correction intervention included training to sit
in an upright neutral posture while gently retracting and adducting
their scapula. Training of neck flexors and scapular muscles
was also incorporated in postural correction intervention
performed with 10 repetitions twice daily. Exercises which were
included are upper cervical flexion in supine as well as sitting,
cervical rotation in sitting ,lower trapezius exercise in prone and
facing wall, arm slide and scapula adduction.
Treatment was given three times per week for four weeks,
for a minimum of eight and maximum of twelve sessions.
Outcome measures-:
The primary outcome measures were -:(a) Change in
headache frequency was recorded as the number of headache
days in the past week, (b) Change in headache intensity was
rated on a Visual analogue scale (VAS) ,(c) Headache duration
was the average number of hours that headaches lasted in the
past week.
The secondary outcome measures were-: (a) Disability (as
measured by Neck disability index\NDI). (b) Performance index
of deep neck flexors was calculated using craniocervical flexion
test.
Statistical analysis
Readings of the variables taken at the baseline and at the
end of first , second , third and fourth week were analyzed for
intragroup differences using repeated measure ANOVA and
paired samples t-test with Bonferroni correction. Intergroup
differences were analyzed using one way ANOVA.
For intergroup differences result was considered significant
if p value d 0.05 and for intragroup differences result was
considered significant if p-valued0.01.
(2)Low load exercise regimen-This program used low-load
endurance exercises to train muscle control of cervicoscapular
region14. The subject were guided by the feedback from the
pressure sensor to sequentially reach 5 pressure targets in 2
mm Hg increments from a baseline of 20 mm Hg to the final
level of 30 mm Hg. Subjects were instructed to gently nod their
head as though they were saying yes. The physical therapist
then identified the target level that the subject could hold steadily
for 10 seconds without resorting to retraction, and without a quick,
10
Results
Analysis of headache frequency between group A and B at
baseline, at the end of 1,2, 3 and 4 week suggested that there
was no significant difference between the group. Analysis of
headache frequency between group B and C suggested that
there was no significant difference between the group. Analysis
of headache frequency between group C and A at baseline
suggested that there was no significant difference between the
Akanksha Sharma / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
group at the baseline and at the end of 1st, 2nd week but significant
difference was found at the 3rd ( p=0.05) and 4thweek (p=0.011)
Analysis of VAS scores between group A and B at baseline
, at the end of 1st,2nd, 3rd and 4th week suggested that there was
no significant difference between the group at the baseline but
significant difference was found at the end of 1st(p=0) 2nd (p=0),3rd
(p=0) and 4th(p=0) week. Analysis of VAS scores between group
B and C suggested that there was no significant difference
between the group at the baseline and at the end of 1st week at
2nd ,3rd and 4th week. Analysis of VAS scores between group C
and group A suggested that there was no significant difference
between the group at the baseline but significant difference
was found at the end of 1st(p=0), 2nd(p=0), 3rd (p=0)and 4th
(p=0)week.
Analysis of headache duration between group A and B at
baseline , at the end of 1,2, 3 and 4 week suggested that there
was no significant difference between the group at the baseline
,but significant difference was found at the end of 1st(p=0.019),
2nd( p=0.007) , 3rd (p=0.001) and 4th(p=0.001) week. Analysis of
headache duration between group B and C suggested that there
was no significant difference between the group at the baseline
and at the end of 1st, 2nd,3rd and 4th Analysis of headache duration
between group C and group A suggested that there was no
significant difference between the group at the baseline , at the
end of 1st, 2nd week but significant difference was found at the
end of3rd(p=0.001) and 4th(p=0.001) week .
Analysis of NDI scores between group A and B at baseline
, at the end of 1,2, 3 and 4 week suggested that there was no
significant difference between the group at the baseline, but
significant difference was found at the end of 1st(p=0) 2nd
(p=0),3rd(p=0) and 4th (p=0)week. Analysis of NDI scores
between group B and C suggested that there was no significant
difference between the group at the baseline and at the end of
1st week at 2nd, 3rd and 4th week. Analysis of NDI scores between
group C and group A suggested that there was no significant
difference between the group at the baseline but significant
difference was found at the end of 1st (P=0), 2nd (p=0), 3rd(p=0)
and 4th (p=0)week.
Fig. 4: Comparison of mean values of headache intensity from

baseline to 4th week.
Fig. 5: Comparison of mean values of headache duration from

baseline to 4thweek.
Fig. 6: Comparison of mean values of NDI scores from baseline

to 4th week.
Analysis of performance index of deep neck flexors between

group A and B at baseline, at the end of 1,2, 3 and 4 week
suggested that there was no significant difference between the
Fig. 3: Comparison of mean values of headache frequency
from baseline to 4th week.
Fig. 7: Comparison of mean values of performance of deep

neck flexors from baseline to 4th week
Fig. 8: Percentage of improvement in all outcome measures

across all three groups.
group at the baseline but significant difference was found at 1st
(p=0), 2nd (p=0) ,3rd (p=0)and 4th (p=0)week. Analysis of
performance index of deep neck flexors between group B and
C suggested that there was no significant difference between
the group at the baseline but significant difference was found at
1st (p=0.003), 2nd (p=0), 3rd (p=0) and 4th(p=0) week. Analysis of
performance index of deep neck flexors between group C and
Group A suggested that there was no significant difference
between the group at the baseline, but significant difference
was found at the end of 1st (p=0) ,2nd (p=0),3rd (p=0)and 4th (p=0)
week.
11
Table 1: Percentage of improvement in all outcome measures across all three groups.
Outcome measure
Percentage of improvement
A (Multimodal therapy)
B (Exercise therapy)
Headache frequency
56.89%
29..66%
Headache intensity
83.89%
18.24%
Headache duration
60%
26.48%
Neck disability index score
92.92%
20.62%
Performance index of
401.27%
311.67%
deep neck flexors
Discussion
experienced a significantly greater improvement in headache
frequency, intensity, duration, neck disability and performance
index of deep neck flexors when compared to exercise therapy
group as well as control group. The results of the present study
are in accordance with the studies by Beeton and Jull G11, Jull
et al0 and Shannon M. Peterson6.
It is important to understand the underlying mechanisms of
treatment effect, although they were not addressed directly in
the study. Mobilization has been suggested to affect pain
processing at the spinal cord level via a phenomenon known as
the gate control theory, which was first described by Melzack
and Wall15 in 1965. Moreover there is research to suggest that
afferent input induced by manual therapy procedures may
stimulate neural inhibitory systems at various levels in the spinal
cord and may also activate descending inhibitory pathways for
example lateral periaqueductal grey area of midbrain16.
Also worth mentioning is the fact that multimodal therapy
addressed both articular as well as muscular dysfunction which
are characteristics of cervicogenic headache8 thereby resulting
in significantly more improvement in multimodal therapy group
than exercise therapy or control group.
Results of the present study also demonstrated that
exercise therapy alone also resulted in significant improvement
across all outcomes; however the level of significance is less
than multimodal therapy group. The significant improvement in
the exercise therapy group can be attributed to low load exercise
regimen which was used to train muscle control of cervicoscpular
region. Also the results are in accordance with the single case
study by Beeton and Jull11, in which the headache log revealed
that the complete resolution of headache at 6 weeks coincided
with the time frame when DCF training was initiated.
So exercise therapy could be used as an alternative therapy
in patients with cervicogenic headache manifesting certain other
conditions which contraindicate the use of cervical spine
mobilization.(Example- pregnancy, rheumatoid arthritis,
osteoporosis , malignancy etc.).
In the present study although control group did not
demonstrate significant improvement across all outcomes at
all level of comparison with respect to time but significant
improvement was still seen in headache frequency , VAS score
, headache duration , neck disability index scores as well as
performance index of deep neck flexors. This improvement can
be attributed to the postural correction intervention being
imparted to the group and also to the recovery associated with
passage of time.
An important issue to address is the role of placebo.
Placebo effect refers to an improvement in the patients condition,
which is not directly attributable to the treatment. It is not yet
known why this occurs but without a control group for comparison
it is hard to know if a placebo effect is taking place. The
improvement may occur because the patient had a belief in
the treatment and /or confidence in the practitioner. The
improvement may also have occurred as a natural course of
the condition regardless of the intervention. This is an important
consideration as only the work of Jull et al.10 utilized control
group for comparison. The present study too utilized a control
12
C (Control)
15.69%
8.0 %
18.76%
12.36%
46.67%
group to know if placebo effect is taking place or not.

The treatment protocol used in the present study included
cervical mobilization and not the manipulation because there is
ample literature to suggest that there are substantial risks
associated with cervical manipulation such as stroke or death.
The present study describes the multimodal approach for
the management of cervicogenic headache by physical therapist
.It is essential that the underlying impairment of decreased
mobility, strength, endurance and postural control to be
addressed while dealing with the subjective complaints of the
patient. A comprehensive treatment approach in the form of
multimodal therapy addresses all these impairments by
emphasizing on restoration of normal joint mobility, strengthening
of postural muscles and postural retraining.
Result may be difficult to generalize to other population in
which the patient differ from the sample. Also because a few
eligible subjects refused to participate in the study, so population
eventually composed of volunteers. Although it does not affect
the validity of the finding it may limit generalizibility to other
population and setting.
Other limiting factors were inability to keep the subject or
therapist unaware intervention being delivered i.e. lack of
blinding, small sample size as well as absence of follow up.
Conclusion
The Conclusion of the study is that the multimodal therapy
that is a combination of cervical spine mobilization and exercise
therapy is significantly more effective than exercise therapy alone
and no treatment in patients with cervicogenic headache.
experienced a significantly greater improvement in headache
frequency, intensity, duration, neck disability and performance
index of deep neck flexors when compared to exercise therapy
group as well as control group.
References
1.
2.
3.
4.
5.
6.
Sydney Kim Schoensee, Gail lensen, Garvice Nicholson,

Marilyn Gossman, Charles Katholi: The Effect of
Mobilization on Cervical Headaches. JOSPT. 21 (4):184196, 1995.
David M. Biondi, DO .Cervicogenic Headache: A Review
of Diagnostic and Treatment Strategies, JAOA, 105 (4) ;
16-22, April 2005 .
World Cervicogenic Headache Society. Cervicogenic
Headache Definition. Available at: http: //www. Cervicogenic
.com/definit2.html. Accessed: 1998.
Bogduk N. Headache and the neck. In: Goadsby P,
Silberstein S, editors. Headache. Melbourne, Australia:
Butterworth-Heinemann; 1997.
Toby Hall, MSc, Post-Grad Dip Manip Ther, Kathy Briffa,
PhD, and Diana Hopper, PhDClinical Evaluation of
Cervicogenic Headache: A Clinical PerspectiveJ Man Manip
Ther. 2008; 16(2): 7380.
Shannon M. Petersen, Articular and Muscular Impairments
in Cervicogenic Headache: A Case Report, J. Orthop Sport
Phys Ther.2003; 33:2130.
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7.
International Headache Society Classification Committee.

Classification and diagnostic criteria for headache
disorders, cranial neuralgias, and facial pain. Cephalalgia
1988; 8:996.
8. Jull G, Barrett C, Magee R, et al. Further characterization
of muscle dysfunction in cervical headache. Cephalalgia
1999; 19:17985.
9. Watson DH, Trott PH. Cervical headache: An investigation
of natural head posture and upper cervical flexor muscle
performance. Cephalalgia 1993; 13: 27284.
10. Gwendolen Jull, Patricia Trott, Helen Potter et al A
Randomized Controlled Trial of Exercise and Manipulative
Therapy for Cervicogenic Headache, SPINE Volume 27,
Number 17, pp 18351843,2002.
11. Beeton, K., & Jull, G. Effectiveness of manipulative
physiotherapy in the management of cervicogenic
12.
13.
14.
15.
16.
headache: a single case study. Physiotherapy, 80(7), 417423, 1994.

Aker PD, Gross AR, Goldsmith CH, et al. Conservative
management of mechanical neck pain: Systematic overview
and meta-analysis. BMJ 1996; 313:12916.
Geoffary Douglas Maitland. Maitland vertebral manipulation
7th edition 2005 p-229-301.
Jull G. Management of cervical headache .Manual therapy
1997;2(4);182-90.
Melzac R, Wall PD. Pain mechanisms: a new theory.
Science. 1965; 150:971-979.
M. Sterling, G. Jull et al Cervical mobilization: concurrent
effects on pain sympathetic nervous system activity and
motor activity Manual Therapy, volume-6, May 2001, page
72-81.
13
Combined effectiveness of Maitlands mobilization and patellar

taping in patellofemoral osteoarthritis: A randomised clinical trial
Alok Kumar*, Ganesh B. R.**
*Physiotherapist,**Assistant Professor, KLEU Institute of Physiotherapy Belgaum, Karnataka
Abstract
Purpose of the study
To find out the effectiveness of medial and lateral taping
with Maitlands mobilization in patellofemoral joint osteoarthritis
.
Materials & methods

60 subjects having clinical diagnosis of osteoarthritis of
patellofemoral joint were randomly allocated to two study groups.
Group A received Short wave diathermy (20mins/day), Maitland
mobilization, Isometric exercises, Medial taping using adhesive
tape and group B received lateral taping and other treatment
same as group A for 6 times / week for 2 weeks. The outcome
was assessed in terms of VAS, and Western Ontario and
McMaster University Osteoarthritis Index on first and last day of
intervention.
Results
The demographic data was well matched in both the groups.
Pain intensity in terms of VAS and Western Ontario and
McMaster University Osteoarthritis Index decreased significantly
in both the groups after the treatment. Comparing the two groups
better effect was seen in group B (p=0.0001)for VAS and
(p=0.0001) for WOMAC.
Conclusion
The present study demonstrates evidence to support the
use of physical therapy regimen in the form of medial and lateral
taping along with conservative physical therapy treatment in
relieving pain, well being in subjects with subacute and chronic
patello femoral osteoarthritis. The study also demonstrated that
lateral Taping Technique were more effective in decreasing pain
and disability.
Keywords
Patellofemoral osteoarthritis, Taping, Maitland Mobilisation,
SWD, Exercises.
Hypotheses
Introduction
The knee joint is one of the most common sites of
involvement because of its weight bearing requirement, high
mobility and lack of intrinsic stability. Patellofemoral joint
osteoarthritis is one of the most common musculoskeletal
disorder1.
It is reported to affect 15-30% active adult population 2125% of the adolescents and greater then 25% among the athletic
group. Incidence reported to be higher in females. It is
consistently reported with the activities such as ascending and
descending stairs, squatting1. Patellofemoral pain in elderly
patient is usually due to degenerative arthritis of the knee joint.
Symptoms presented in the patellofemoral arthritis are pain
around and anterior to patella, crepitus, giving away of the knee
14
and episode of patellofemoral instability along with stiffness and

swelling 2 . Extensor mechanism provides stability to
patellofemoral joint during physical activity. Tracking is the
change in the position of patella relative to femur during knee
flexion and extension3. Patellofemoral pain syndrome is related
to abnormalities of extension mechanism. Many authors have
proposed the primary cause of patellofemoral pain syndrome is
lateral tracking of patella3. Clinically Patellofemoral osteoarthritis
demonstrated squatting, stair ascending and descending, cycling
and sitting with knee flexed or prolonged period of time 4.
Degenerative changes are usually more prominent in the medial
compartment of the knee, leading to varus (bow leg) deformities5.
Physiotherapy treatment options have been recommended
to relieve pain which includes short wave diathermy, Maitlands
mobilisation, isometric exercise and taping etc. Among which
short wave diathermy plays an important role in pain relief,
decrease tissue viscosity and with this muscular and tendinous
contractures. Additionally, the deep heating effect of continuous
short wave diathermy induces an anti-inflammatory response,
stimulate connective tissue repair, reduce joint stiffness, muscle
spasm and pain6.
Maitlands mobilization is another physiotherapy technique,
which involves to reduce pain and stiffness by using various
grades of mobilization7.
Exercise is another approach in the treatment of
Patellofemoral arthritis, which is targeted to improve the
quadriceps muscle strength. Isometric contraction of quadriceps
muscle helps to increase the strength and prevents the
maltracking of patella8.
Many studies have shown patellar taping is helpful to
decrease pain and improve patellar tracking. Knee taping is one
of the strategy recommended by American College of
Rheumatology, based on the theory of patellar maltracking.
McConnell has divised a system of treatment for patellofemoral
arthritis by taping the patella in medial and lateral direction9.
A study was done on patellofemoral pain syndrome using
three different methods of taping techniques (Medial, Lateral &
Neutral) and found that all three methods of taping produced a
significantly greater degree a pain relief. Further they concluded
that lateral taping is effective in immediate reduction of pain10.
Hence the present study is being undertaken with the
intention to compare the combined effectiveness of Maitlands
mobilisation and patellar taping in patellofemoral osteoarthritis.
Null Hypothesis {Ho}: There will be no beneficial effect to the

subjects treated with Maitlands mobilization and medial or lateral
patella taping.
Alternative Hypothesis {Ha}: There will be beneficial effect to
the subjects treated with Maitlands mobilization and medial or
lateral taping.
Objectives of the Study
1. To assess the effectiveness of medial taping technique with
Maitlands mobilization in patellofemoral joint osteoarthritis
2. To assess the effectiveness of lateral taping technique with
Maitlands mobilization in patellofemoral joint osteoarthritis
3. To compare the effectiveness of medial and lateral taping
with Maitlands mobilization in patellofemoral joint
osteoarthritis
Alok Kumar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
Materials and methods
border and push the patella medially.(Photo No.1)
Source of Data: KLES Dr. Prabhakar Kore hospital and MRC

and BM Kankanwadi Ayurveda Hospital and MRC Belgaum.
[Photograph No.1]
Method of collection of data

Study Design: Randomised Clinical Trial.
Sample Size: 60 Participants.
Duration of Data Collection: 9 Months
Participants: Both men and women with pain in anteroior knee
joint and radiologically diagnosed as patellofemoral arthritis &
who are referred to the physiotherapy OPD, KLES Dr. Prabhakar
Kore hospital and MRC and BM Kankanwadi Ayurveda Hospital
Belgaum.
Sampling Methods: Simple random sampling method will be
used for this study. 60 participants will be randomly allocated
into two groups as follows.
Group A: Short wave diathermy + Maitland mobilization +
Isometric exercises + Medial taping.30 participants.
Group B: Short wave diathermy + Maitland mobilization +
Isometric exercises + Lateral taping: 30 participants.
Lateral glide: Pads of the thumb are placed on the medial border
and push the patella laterally.(Photo No. 2)
[Photograph No.2]
Materials used
Record or data collection sheet,Consent form, Wooden
Plinth, Towel, WOMAC, Tape.
Equipment used
Short wave diathermy,[Electrowave 400 Technomed] Made
in India
Inclusion criteria
1.
2.
3.
4.
Participants with radiological diagnosed as patellofemoral

osteoarthritis.
Both Men and women > 40 years ofage.
Average knee pain e 3 cm on visual analogue scale.
Those who are willing to participate in the study.
Superior glide: Place the heel of the hand against inferior

margin of the patella and directs the forearm superiorly.(Photo
No. 3)
[Photograph No.3]
Exclusion criteria
1.
Concomitant pai n from other knee structures, hip or lumbar

spine.
2. Traumatic injury to the knee joint with in 6 months of study.
3. Severe medical condition precluding safe testing or a past
allergic tape reaction.
4. Metallic implants in the lower limbs.
5. Impaired thermal sensation.
Procedure
All participants with patellofemoral arthritis who report to
the physiotherapy department will be screened. After finding
their suitability as per the inclusion and exclusion criteria they
will be requested to participate in the study. A written consent
will be obtained from the participants. Their demographic data,
weight, height and initial assessment of VAS score and WOMAC
will be recorded. After this 60 participants were randomly
allocated to 2 groups of 30 each.
Group A: short wave diathermy, Maitlands mobilisation,
isometric exercises and medial patellar taping.
1. Subject will be in sitting/supine position and short wave
diathermy pads will be applied in contraplanar method for
20 minutes per day.19
2. Maitland Mobilization: Oscillatory movements are given to
the patella in different directions as required. Patient in
supine position and therapist stands by the right side.
Medial glide: Pads of the thumb are placed on the lateral
Inferior glide: Place the heel of the hand against superior

margin of the patella and directs the forearm inferiorly.(Photo
No.4)
[Photograph No.4]
All the four Maitlands patellar glides will be given to both

the groups (A & B).
Alok Kumar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
15
3.
Isometric exercises: Static quadriceps exercises will be

given in long sitting/supine position with a towel placed
underneath the popliteal fossa and will instruct the patient
to press the rolled towel. Contraction will be maintained for
6 seconds and repeated for 10 times with 10 seconds rest
between each repetition.15
4. Medial taping- The patella is displaced medially using
manual pressure and then maintained in own position by
tape across the middle of the patella using light to moderate
pressure.
Group B: short wave diathermy, Maitlands mobilisation,
isometric exercise and lateral patellar taping.
1. Lateral taping- Same technique is used but the patella is
glided in the lateral direction. Tape will be retained for 24
hrs.
2. Rest of the procedure are same as Group A.
Review of litrature
An ultrasonographic study was done to see the effects of
repetitive shortwave diathermy in patients with knee osteoarthritis
and indicates that shortwave
diathermy in patients with knee osteoarthritis can
significantly reduce both synovial thickness and knee pain11.
The current findings and the statistical difference confirms
that a combination of Maitland mobilization with isometric knee
exercise is more effective than isometric knee exercise in
decreasing pain, dysfunction, stiffness and improving the
functional capacity in patients with Patellofemoral arthritis7.
Comparative study of different patella taping techniques,
like medial, neutral and lateral tape showed that medial tape is
more effective in reducing pain in patient with Patellofemoral
pain syndrome irrespective of how taping was applied12.
A study was done on patellofemoral osteoarthritis using
three different methods of taping techniques ( Medial, Lateral &
Neutral) and found that all three taping technique produced a
significantly greater degree a pain relief. Further they concluded
that lateral taping is effective in immediate reduction of pain13.
A study was done to determine the efficacy of physical
therapy and exercises for osteoarthritis of the knee and authors
concluded that patients with osteoarthritis who are treated with
a regimen that combines manual physical therapy with isometric
exercise have improved function and less reported pain and
stiffness than patients who are not treated with a physical therapy
program. This type of treatment may decrease the need for knee
surgery14.
Data analysis
The independent variables were SWD, Maitlands
mobilization, isometric exercises, medial, lateral taping and
dependent variables were Pain (VAS) and WOMAC. Analysis
was performed by statistical means, standard deviation and
Paired and Unpaired t test is used for comparison within the
groups and between the groups.
Results
In the present study, within group analysis showed that pain
relief and WOMAC was statistically significant in the two the
groups (p<0.0001). where as considering in between group
analysis reviled that Group B (p= 0.0001) was highly significant
as compared to Group A.
Discussion
The present clinical trial was conducted to compare the
effectiveness of medial and lateral patellar taping combined
with Maitlands Mobilization with a common treatment of
shortwave diathermy and exercises to the two groups.
16
The results from the statistical analysis of the present study

supported alternative hypothesis which stated that there will be
beneficial effect to the participants treated with medial and lateral
patellar taping with Maitlands mobilization. The mean values of
data from present study indicates that the group B treated with
combination of lateral patella taping with Maitlands mobilization
showed better pain relief on visual analogue scale and the
physical function capacity.
Mei Hwa Jan et al attempted a study to quantify the
thickness of synovial sac and pain index before and after
application of short wave diathermy for patients with knee
osteoarthritis. The result of study showed that the application of
short wave diathermy in patients with knee osteoarthritis can
significantly reduce both synovial thickness and knee
pain6.Hence in present study it can be postulated that pain
reduction could be because of short wave diathermy application.
A study showed that patellar taping using a medial glide,
neutral glide, and lateral glide technique produced a significant
average reduction in pain in patients with patellofemoral pain
syndrome. Both neutral glide and lateral glide produced
significantly greater degrees of pain relief than the medial glide
taping technique13.
A clinical analysis study of alignment, pain parameters,
common symptoms and functional activity level showed that
there were no radiographic signs of malalignment of the patella.
This strongly supports the previous studies that the success of
patellar taping is not based upon realignment of the patella13.
The present study demonstrated that the application of
Maitlands Mobilization had shown significant change in pain
and physical functional outcome. However, these findings are
consistent with studies conducted in other joints of the body
that have shown similar effects with the Maitlands Mobilisation
techniques. Wright in 1995 has postulated that the mechanisms
responsible for manual therapy treatment results in decrease in
pain on VAS. The results also showed changes in joint, muscle,
pain and motor control systems15.
On the contrary, Maitlands mobilisation technique was
found effective in decrease in pain and stiffness. Manipulative
therapy lays stress on treatments to regain both angular and
linear movements. Different grades of mobilization, according
to Maitlands concept, will produce selective activation of different
mechanoreceptors. Clinically, resistance due to pain and
stiffness melts under mobilization or manipulation16.
WOMAC a self reported measure designed to determine
patients response to three different functional criteria namely
the pain, stiffness and physical function. This could be attributed
to frequent complaints of patellofemoral joint stiffness in individual
with patellofemoral pain syndrome as individuals with chronic
patellofemoral pain syndrome often misinterpret chronic pain
as stiffness17.
Patellofemoral osteoarthritis presents a serious health care
problem and produces a huge burden on society. Simple, safe,
physical treatment procedures such as lateral taping combined
with other simple non invasive interventions such as Maitlands
joint mobilization could be of great value. This provides a low
cost, easy means of treatment in subjects with Patellofemoral
osteoarthritis.
Conclusion
In conclusion, the present randomized clinical trial provided
evidence to support the use of physical therapy regimen in the
form of Lateral Patellar Taping and Maitlands Mobilisation in
relieving pain, stiffness and, functional well being in subjects
with patellofemoral osteoarthritis. In addition, results supported
that combination therapy is of great value which can be useful
in improving quality of life as patellofemoral osteoarthritis is a
heterogeneous condition.
References
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6. By Mei - Hwa Jan, Huei-Ming Chai, Chung-Li Wang, YeongFwu Lin and Li-Ying Tsai. Effects of repetitive shortwave
diathermy for reducing synovitis in patients with knee
osteoarthritis: an ultrasonographic study. Physical therapy
journal, 2006; vol 86(2): 236-244.
7. G.D.Maitland. Peripheral manipulation,3rd edition; 2003:25055.Butter worth-Heinemann.
8. Key M crossley,Bill vicenzino. Targeted physiotherapy for
patellofemoral joint arthritis. BMC Musculoskeletal
Disorders 2008, 9:122doi:10.1186/1471-2474-9-122.
9. G Kelly Fitzgerald and Carol Oatis. Role of Physical Therapy
in management of knee osteoarthritis. Current Opinion in
Rheumatology, 2004; 16:143-147.
10. Tony Wilson, Nicholas carter, Gareth Thomas. A multicenter,
single- masked study of medial, neutral and lateral patellar
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17.
taping in individuals with patellofemoral pain syndrome.

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volume 33(8):437-443.
By Mei - Hwa Jan, Huei-Ming Chai, Chung-Li Wang, YeongFwu Lin and Li-Ying Tsai. Effects of repetitive shortwave
diathermy for reducing synovitis in patients with knee
osteoarthritis: an ultrasonographic study. Physical therapy
journal, 2006; vol 86(2): 236-244.
Ng, G.Y. Cheng, J. M. The effects of patellar taping on pain
and neuromuscular performance with Patellofemoral pain
syndrome. Clinical rehabilitation, 2002 ;16:821-27.
Tony Wilson, Nicholas carter, Gareth Thomas. A multicenter,
single- masked study of medial, neutral and lateral patellar
taping in individuals with patellofemoral pain syndrome.
Journal of orthopaedics sports physical therapy; 2003;
volume 33(8):437-443.
Deyle G D et al. Effectiveness of manual physical therapy
and exercise in osteoarthritis of the knee. A randomized
control trial. Ann Intern Med, American Academy of Family
Physician 2000; 132: 173-81.
Wright A. Hypoalgesia post manipulative therapy: A review
of the potential neurophysiological mechanism. Manual
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Wyke, B. D: Articular Neurology and Manipulative therapy,
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Karrie L, Hamstra WC, Swanik B, Ennis TY, Swanik KA.
Joint Stiffness and pain in individuals with patellofemoral
pain syndrome; 2005; 35: 495- 501.
17
Maximal oxygen consumption as a function of anthropometric

profiling in a group of trained Indian athletes
Amrith Pakkala*, Ankita Dutta**, N.Veeranna***, S.B.Kulkarni****
*Associate Professor, Dept. of Physiology, PES Institute of Medical Sciences & Research, Kuppam, AP, **Resident, PES Institute of
Medical Sciences & Research, Kuppam, ***Ex-Professor, Dept. of Physiology, Karnataka Institute of Medical Sciences& Research,
Hubli, ****Ex-Principal & Head, Dept. of Physiology, Karnataka Institute of Medical Sciences& Research, Hubli
Abstract
Physiologists have been interested in studying

cardiopulmonary responses to physical exercise and measuring
work capacity of healthy individuals as indices of physical fitness
of population groups. The locomotive apparatus and service
organs constitute the main part of the total body mass in higher
animals including humans.
This study aims to correlate the distribution of VO2 max in
the study group with various anthropometric parameters like age,
height & weight. This gives an idea about the natural distribution
within the athlete group. Although it is well known that maximal
oxygen consumption depends on age and other anthropometric
parameters like height, weight and body surface area data on
Indian subjects and a profiling on these lines in such studies on
cardio-pulmonary efficiency are lacking.
Keywords
anthropometric distribution, VO2 max, athletes
Introduction
Higher animals are basically designed for mobility.
Consequently, their locomotive apparatus and service organs
constitute the main part of the total body mass. An engineering
approach to view the body would be as a working machine1.
The human bodys potential performance capability has always
fascinated exercise scientists. The shape and dimensions of
the human skeleton and musculature are such that the human
body cannot compete with a gazelle in speed or an elephant in
sturdiness, but in diversity man is indeed outstanding.2
This study aims to correlate the distribution of VO2 max in
the study group with various anthropometric parameters like age,
height & weight. Although it is well known that maximal oxygen
consumption depends on age and other anthropometric
parameters like height, weight and body surface area data on
Indian subjects and a profiling on these lines in such studies on
cardio-pulmonary efficiency are lacking. This gives an idea about
the natural distribution within the athlete group.
Historical aspects
Exercise physiology arose mainly in early Greece and Asia
minor although related topics concerned even earlier
civilizations.3
The greatest influence on Western Civilization came from

Greek Physicians Herodicus (5 th century B.C);
Hippocrates (460-377 BC) and Galen (131-201 AD)
The first formal exercise physiology laboratory was

established in the U.S. in 1891 at Harvard university. George
wells Fitz, played a major role in its establishment4,5
Austin Flint Jr. in 1877 published a textbook of physiology

where many topics related to exercise were discussed.
Per-Olof Astrand from Karolinska Institute Medical School

in Stockholm, Sweden in 1954 prepared data on the
physical working capacity of both sexes aged 4 to 33 years.
This important study along with collaborative studies with
his wife Irma Ryhming propelled Astrand to the forefront of
experimental exercise physiology.
18
Sir Joseph Barcroft (1872-1947) pioneered fundamental

work concerning the functions of hemoglobin.
Christian Bohr (1855-1911) Studied solutioning of gases
in various fluids including Hb solutions.
Otto Meyerhof (1884-1951) studied energy changes during
cellular respiration.
Martti J. Karnoven (1991) devised the method to predict
optimal exercise heart rate.
Physical work capacity

Competitive sports events represent the classical test of
physical fitness or performance capacity. The following factors
serve as a frame of reference:
Physical Performance
Energy output
o Aerobic processes
o Anaerobic processes
Neuromuscular function
o Strength
o Technique
Psychological factors
o Motivation
o Tactics
All the factors listed above can be modified by training,
better techniques and superior equipment2.
Physiologists have been interested in studying
cardiopulmonary responses to physical exercise and measuring
work capacity of healthy individuals as indices of physical fitness
of population groups6.
Cardio-pulmonary Efficiency
It is well known that athletes who excel in endurance sports
generally have a large capacity for aerobic energy transfer.
Maximal oxygen uptake (VO2 max)

The requirement of oxygen by the various tissues of the
body is met by the combined cardiovascular and pulmonary
systems, which function as a unit termed the oxygen transport
system of the body.
If a person is subjected to progressively increasing
workloads, there is a linear relationship between work load and
oxygen uptake until maximal oxygen uptake is reached7.
Maximal oxygen uptake is defined as the highest oxygen
uptake the individual can attain during physical work, breathing
air at sea level2.
Tests of Maximal Aerobic power

VO2 max is the first choice in measuring to assess a
persons cardio-respiratory fitness8. It is a fundamental measure
of physiologic functional capacity for exercise3, 9, 10.
Criteria for maximal oxygen consumption2 :
There are 2 main criteria showing that VO2 max has been
measured:
1. There is no further increase in oxygen uptake despite further
increase in work load.
Amrith Pakkala / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
2.
The blood lactate concentration is above 70 to 80 mg/100ml

of blood.
Material and methods

The present study was conducted in the department of
physiology, Karnataka Institute of Medical Sciences, Hubli as a
part of cardio-pulmonary efficiency studies on a group of male
athletes (n=30).
Informed consent was obtained and clinical examination
to rule out any underlying disease was done. Healthy young
adult males between 18-25 years who regularly undergo training
and participate in competitive middle distance (800 metre, 1500
metre) running events for at least past 2 years were considered
in the athlete group. Smoking, clinical evidence of anaemia,
obesity, involvement of cardio-respiratory system was considered
as exclusion criteria.
Detailed procedure of exercise treadmill test was explained
to the subjects.
Methods of directly assessing aerobic power

There are three general methods of appraising maximal
oxygen consumption.
(i) treadmill (running and walking)
(ii) cycling (bicycle ergometer) and
(iii) stepping (step bench).
Treadmill methods11:
The following are several reliable test procedures:
Mitchell, Sproule, Chapman method 12.
Saltin Astrand method13
Ohio state method8.
The manner in which the work load can be increased in
these tests is either discontinuous or continuous. Expired air is
collected in a Douglas bag and analyzed for oxygen content.
1.
2.
3.
Methods of indirectly assessing aerobic

power
Tests for direct assessment of VO2max are limited in that
the test is difficult, exhausting and often hazardous to perform
regardless of the type of ergometer used. For this reason, several
methods for predicting VO2 max from sub maximal exercise data
have been developed.
1. Astrand astrand nomogram14.
This was originally constructed from data gathered on
young (18 to 30 years), healthy, physical education students,
and it is based on the idea that heart rate during sub maximal
exercise increases approximately linearly with oxygen uptake
and the nomogram was said to be more accurate if heart rates
between 125 and 170 beats per minute were used to make
predictions of max VO2. For subjects older than 25 years, age
correction factors must be used
2. The fox equation 15
This is a simple method for predicting VO2 max in males. It
is based on a linear equation relating the directly measured VO2
max to the sub maximal heart rate (HR sub) response.
The equation is :
Predicted VO2max (lit/min) = 6.3 - (0.0193 x HR sub)
The standard error of the method for prediction of VO2
max from sub maximal exercise test is about 10 percent in
relatively well trained individuals of the same age and when
employed as a screening test a consistent difference between
measured and predicted maximal oxygen uptake of a few 100ml/
min is of no importance.
Predictions from non-exercise data16.
A unique approach to VO2max prediction for quick screening

of large groups of individuals involves collecting specific nonexercise data from a questionnaire.
Data input to predict VO2max
1. Sex (Female = 0; Male = 1)
2. BMI
3. Physical activity rating (PA-R). A point value between 0 and
10 representing overall physical activity level for the
previous 6 months.
4. Perceived functional ability (PFA). Sum of the point values
between 0 and 13 for questions about current level of
perceived functional ability to maintain a continuous pace
to cover a distance of 3 miles without becoming breathless
or overly fatigued.
Equation
VO2 max (ml/kg/min) =
44.895 + (7.042 X sex) (0.823 X BMI) + (0.738 X PFA) +
(0.688 X PA-R).
Results
A) Age Group distribution of Athletes.
Age (years)
Athletes
No.
Percentage
18-19
11
36.67
20-21
4
13.33
22-23
5
16.67
24-25
10
33.33
Total
30
B) Height distribution of athletes.

Height (cm)
No.
155-165
19
166-175
6
176-185
5
Total
30
C) Weight distribution of athletes

Weight (kg)
No.
46-56
9
57-66
15
67-76
6
Total
30
D) Participation profile of athletes

Participation status
No.
National / All India
7
Inter university
State / Zonal
14
District / University
9
Total
30
Athletes
Percentage
63.33
20.00
16.67
Athletes
Percentage
30
50
20
Percentage
23.33
46.67
30
E) Cross table of Distribution of VO2 max (lit/min) with Age (Yr)

(Athletes)
Age (Yrs) of subjects
VO2 Max )
(lit/min
18-19
20-21
22-23
24-25
2.8 3.0
7
1
3
7
3..01-3.20
2
1
1
3.21-3.40
2
1
1
3.41-3.60
2
3.61-3.80
1
1
Total = 11+4+5+10=30
Amrith Pakkala / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
19
F) Cross table of distribution of VO2 max (lit/min) with body

weight(kg) (Athletes)
Weight (Kg) of subjects
VO2 max
(lit/min)
46-56
57-66
67-76
2.80-3.00
8
7
3
3.01-3.20
1
3
3.21-3.40
4
3.41-3.60
1
1
3.61-3.80
2
Total = 9 + 15 + 6 = 30
5)
6)
7)
8)
9)
G) Cross Table of distribution of VO2 max (lit/min) with body height
(cm) Athletes
Height (cm) of subjects
VO2 Max
lit/min
155-165
166-175
176-185
2.8-3.0
13
3
2
3.01-3.20
2
1
1
3.21-3.40
4
3.41-3.60
2
3.61-3.80
2
Total = 19+6+5 = 30
10)
11)
12)
13)
References
14)
1)
2)
3)
4)
20
Fox E et al, The Physiological Basis for Exercise and

Sport, 1993, 5th Edition, 660 67pp.
Astrand P.O. and Rodahl. K., Textbook of Work Physiology
1970, First Edition, 279, 305 15, 354 59 pp.
Mc Ardle W.D. et al, Exercise Physiology 2001, 5th edition,
231 248 pp.
Gerber E.W., Innovators and institutions in physical
education, 1971, Philadelphia: Lea & Febiger.
15)
16)
Kroll W, Perspectives in physical education 1971, New

York: Academic Press.
Jain A.K. et al, Cardio respiratory responses to steady state
in sedentary men 20 30 years old. Ind J. Chest Dis &
Allied Sc 1983; 25: 172 185.
Mitchell J.H. and Blomqvist G., Maximal oxygen uptake.
N. Engl J Med 1971; 284: 1018 1022
Fox E, Differences in metabolic alterations with sprint
versus endurance interval training. Metabolic Adaptation
to prolonged physical Exercise, Basel, Switzerland:
Birkhauser Verlag 1975; 119 126 pp.
Mc Ardle W.D. et al, Reliability and inter relationships
between maximal oxygen intake, physical work capacity,
and step test scores in college women. Med Sci Sport
1972; 4: 182.
Taylor H.L. et al, Maximal oxygen intake as an objective
measure of the cardio respiratory performance. J. Appl
Physiol 1955; 8: 73 80.
Wilmore J.H., The assessment of and variation in aerobic
power in world class athletes as related to specific sports.
Am J Sports Med 1984; 12(2) : 120 126.
Mitchell J et al, The physiological meaning of the maximal
oxygen intake test. J. Clin Invest 1957; 37: 538 547.
Saltin B and Astrand P.O., Maximal oxygen uptake in
athletes. J. Appl Physiol 1967; 23: 353 358.
Astrand P and Rhyming I, A nomogram for calculation of
aerobic capacity (physical fitness) from pulse rate during
sub maximal work. J.Appl Physiol 1954; 7: 218 22
Fox E, A simple, accurate technique for predicting maximal
aerobic power. J. Appl Physiol 1973 ; 35 (6) : 914 916
George J.D. et al, Non exercise VO2 max estimation for
physically active college students. Med Sci Sports Exerc
1997; 29: 415.
Amrith Pakkala / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
Titanic splint
B.Anandha Priya*, Snehal Pradip Desai**
*Occupational Therapist, No.72, Anna Street, Babu Nagar, Pattabiram, Chennai-72, Tamil Nadu, India, **Lecturer, Occupational
Therapy, O.T School &Centre, Seth G. S. Medical College & K. E. M. Hospital, Parel, Mumbai, Maharashtra India
Abstract
Objective
To study the design and effectiveness of the Titanic Splint
to position and maintain the shoulders as well as elbows in
antideformity position in bilateral axillary and elbow burns.
Method
Twenty two female clients with acute bilateral axillary and
elbow burns were included in the study. An initial evaluation of
passive range of motion was done at the time of prescription of
the splint. The Titanic splint was given to all the clients and they
were followed up for a period of 6 months.
Result
Application of the Titanic splint for bilateral axillary and elbow
burns is a safe, comfortable, easy way of splintage resulting in
better compliance and maintenance of range.
Introduction
Burns of the upper extremity result in severe deformities
leading to functional and aesthetic problems. The extent of the
deformity is directly related to the severity of the initial injury.
The development of contractures is common sequelae after burn
injuries. If a body part is left immobile for a prolonged period
after injury the skin and the fascia across the part gets contracted
along with capsular contraction and shortening of tendons and
muscle groups. This rapid process can be prevented by a
program of Active & Passive Range of Motion, anti-deformity
positioning and splinting. Splints are used to maintain
antideformity position for joints that are directly or indirectly
affected by burn injury.
Burns of the upper extremity involving the shoulder, axilla
and volar aspect of the elbow may lead to severe contractures
with restrictions of shoulder and elbow movements. The skin
and fascia gets contracted along with contractures of the muscles
Pectoralis Major, Deltoid and Subscapularis.When the lateral
part of the trunk and medial part of the arm have burn wounds,
it may heal together leading to loss of axillary space. Axillary
burns often result in limited abduction of arm and present a major
hindrance in rehabilitation. Chronic pain leads the client to adduct
the arm in a position closer to the body than normal, and this
allows the contracture to develop more easily. An inability to
abduct the shoulder is a disability that greatly hampers everyday
activities.
Whenever there are burns in the volar aspect of the elbow,
the skin and fascia of the cubital fossa gets contracted with or
without contracture of the anterior capsule and Biceps, Brachialis
and Brachioradialis muscles. To prevent the above mentioned
problems, in case of burns in the axilla and elbow, the limb should
be positioned with the Shoulder in 90 degrees abduction and
elbow in extension. When burns involve both the extremities, all
four joints i.e., bilateral shoulders and bilateral elbows need to
be splinted. Generally, bilateral abduction splints and bilateral
elbow guards are prescribed in the above condition. Wearing
all four splints together becomes cumbersome for the client. At

the same time, donning and doffing of the splints also becomes
very difficult.
Aim of the study

The aim of the present paper was to study the design and
effectiveness of an innovative splint named TITANIC SPLINT that
helps to position and maintain both the shoulders as well as
elbows in antideformity position and which can be used instead
of the conventional splints.
This splint should be given in the early stages of acute
burns before the client starts to lose range of motion at the
affected joints.
Review of literature
Many studies had been conducted on the splinting
techniques for the management of axillary burns. Each study
has its own merits and demerits. The following are list of
previously conducted studies:
*Abhyankar (1) designed a positioning device named
Salute Splint for positioning the shoulder after contracture
release of the axilla. The main drawback of the splint is that it
causes unwanted flexion contracture of the shoulder and also
of the elbow if the volar aspect of the elbow is involved.
*Chown GA (2) designed a modified high-density foam
aeroplane splint to increase comfort and compliance by the
clients and family members, and decreased fabrication time by
health professionals. Even though the splint has many
advantages, the clients might feel uncomfortable wearing the
splint if they sustain burns in the lateral aspect of the trunk.
Moreover as per the authors comments, if increased wear time
is desired when the client is upright or ambulating, then a
traditional thermoplastic splint may need to be incorporated in
to the splinting regime.
*Manigandan. C, Gupta. K, Venugopal. K, Ninan.S, Cherian.
R. E,
Bedford. E, Padankatti. S, M&Paul. K(3,4,5) designed a
multipurpose, self -adjustable aeroplane splint, which provides
prolonged stretch to contracted tissues and acts as a serial cast
in increasing the shoulder range. This adjustable aesthetic splint
can hold the arm in as much as 150 160 degrees of abduction
and can be worn inside the clients regular garment. The demerit
of the splint is that it was not designed for treating acute burns.
*Obaidullah, Ullah & Aslam (6) conducted a descriptive
study on 40 clients who had chronic extensive axillary
contracture. All the clients were treated with simple release and
skin grafting followed by Figure of 8 Sling. The Figure of 8
Sling is widely available and is used for clients with fracture of
the clavicle. According to the researchers, pre-operatively the
shoulder abduction range was 0-80 degrees and postoperatively
at 1 year of follow-up the ranges improved to 0-140-180 degrees.
The main demerit of the splint is that, it cannot be used by the
clients in their acute stage of burns.
Methodology
The present study was conducted in Occupational TherapyPlastic Surgery Department. The Titanic Splint was given to 22
B. Anandha Priya M.O.Th / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
21
female clients with 60-90 degrees of acute burns. Clients who

had bilateral axillary and elbow burns were included in the study.
All the clients had a minimum qualification of 10th standard and
most of them were housewives except 2 clients who were
involved in clerical job.
All the clients were undergoing regular Occupational
Therapy treatment in the Department. Therapy was focused on
improving joint range of motion and preventing the formation of
tightness and contractures. Evaluation of passive range of
motion was done at the time of prescription of the splint and
after every 2 months duration. The clients were followed up for
a period of 6 months.
Materials required for the fabrication of the

splint
1.
2.
3.
4.
5.
6.
Broad thick aluminum strip

High Density Thermoplastic-Poly Vinyl Chloride
Cotton niwar
Rivets
Glue
Ethaflex
BC&DE= 5 inch distance from the clients body.

CD=Distance between the two shoulders
EF=Distance between 2 inch distal to the left
shoulder joint to mid of left elbow guard.

A-F=Total length of the aluminum strip
2.
A broad thick aluminum strip is cut based on the A-F

measurement (Fig: 3)
Fig-3: Measurement of the Aluminum Strip
3.
4.
5.
6.
7.
The measurements of AB, BC, CD, DE&EF are marked on

the aluminum strip.
A 90 degree bend is made at the point B.
Second 90 degree bend is made at the point C (as shown
in fig: 4).
The third 90 degree bend is made inwardly at the point D.
The fourth 90 degree bend is made from the point E (as
shown in fig; 4).
Fig-4:
Fabrication of the titanic splint

The following are the steps that are involved in the
fabrication of the Titanic splint:
8.
Fabrication of the elbow guard

1.
2.
3.
4.
The longitudinal distance between the half of the arm and

half of the forearm is taken.
The circumference of the mid of the arm and mid of the
forearm is taken and half of the measurement is noted.
The measurement is marked on the high density
polyethylene sheet (Poly Vinyl Chloride-PVC).
The poly Vinyl Chloride (PVC) sheet is cut according to the
measurement. (Fig: 1)
Once all the measurements are marked and all the angles
are made, the aluminum strip will be in the design as shown
in the figure (4).
Making of the titanic splint

This is the last step and involves attachment of the elbow
guard to the aluminum strip
1. Holes are drilled both in the elbow guard and the aluminum
strip as shown in figure (5)
Fig-5: Making of the Titanic Splint
Fig-1:
2.
5.
The cut PVC is molded according to the contour of the

clients extremity and the edges of the elbow guard are
softened so that it does not hurt the client (Fig: 2).
3.
Fig-2:
4.
The elbow guards are attached to the aluminum strip by

riveting.
The portion of the elbow guard which comes in contact
with the clients body surface is padded using Ethaflex.
(Note- If the clients dressing is bulky, there
is
no
necessary for padding, since the dressing it self protects
the skin from compression of the elbow guard)
Velcros are stitched to the cotton niwar (2 inches in breadth)
and the niwar is stuck to the elbow guards as shown in the
figure (6) for harnessing the splint. In final step, the client is
Fig-6:
To Measure for the aluminum strip

1.
22
The client is made to lie in supine position and the elbow

guards are placed on the clients extremity in position and
the following measurements are taken:
AB=the distance between the mid of the right elbow
guard to 2 inch distal to
the right shoulder joint
Table 1: Outcome with the usage of the splint

Total number of clients
Number of clients who maintained
their shoulder & elbow ranges
Number of clients who lost their shoulder
& elbow ranges
22
19
3
B. Anandh Priya M.O.Th / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
Bent Aluminum strip positioned over the Elbow guard
made to wear the splint, and checked for proper fit and
comfort.
Wearing schedule
Clients were required to wear the splint throughout the day
and night with intermittent mobilization during the daytime. The
family members were educated about the method of donning
and doffing of the splint. The splint should be worn for a period
of 6 months.
Final fabricated Titanic Splint
Conclusion
To conclude the application of Titanic splint for bilateral
axillary and elbow burns is a safe, comfortable, easy and more
compliant way of splintage. This study used a small convenience
sample from one facility. Further studies have to be done on a
larger scale to analyze the results obtained using the splint.
References
1.
Results and discussion

Compliance regarding the splint wearing schedule was
verified by verbally questioning the clients and their family
members. At the end of 6 months, the clients were evaluated
for their shoulder and elbow ranges.
Among the 22 clients selected for the study, 19 clients
maintained their shoulder and elbow ranges. Only 3 clients lost
their shoulder and elbow ranges since they had poor compliance
of wearing the splint.
Titanic splint its merits over the rest

The following are the advantages of the Titanic Splint over
the conventional splints:
1. Single splint replaces the use of four splints (2shoulder
abduction splints and 2 elbow guards)
2. Simple design
3. Lightweight and cost effective
4. Comfortable-The area covered by the Titanic splint is very
less. This helps in easy dressing of the burnt area of the
lateral aspect of the trunk.
5. Easy to construct-The time taken for the construction of
the splint is less (approximately 1-1 1/2 hours)
6. Durable- High Density Thermoplastics are comparatively
stronger than Low Density Thermoplastics
7. Easy donning and doffing
8. With modification, it can be used to improve the horizontal
abduction range.
9. If elbows are not involved in burns the same splint can be
modified to keep the elbows free.
Disadvantages
1.
2.
Maintains but does not improve the ranges (same as

conventional splint)
Cannot be prescribed for clients with unilateral burns.
2.
3.
4.
5.
6.
7.
8.
Abhyankar S.V. The salute splint for axillary contractures:

British Journal of Plastic Surgery, 2001, 54(3), 213-5.
Chown G.A. The high- density foam aeroplane splint: a
modified approach to the treatment of axillary burns. Burns,
2006,32 (7), 916-9.
Manigandan. C, Gupta A.K, Venugopal. K, Ninan.S &
Cherian R.E A multipurpose, self-adjustable aeroplane
splint for the splinting of axillary burns.Burns. 2003, 29,2769.
Manigandan C, Bedford.E, Ninan.S, Gupta.A.K, Padankatti
S.M &Paul.K). Adjustable aesthetic aeroplane splint for
axillary burn contractures. Burns, 2005 31(4), 502-4.
Manigandan C, Gupta.A.K, Ninan.S & Padankatti.S.M.Re
emphasizing the efficacy of the multipurpose, self
adjustable, aeroplane splint for the splinting of axillary
burns.Burns.2005,31, 500-1.
Obaidullah, Ullah. H & Aslam. M . Figure - of - 8 sling for
prevention of recurrent axillary contracture after release and
skin grafting. Burns, 2005. 31(7), 283-289.
Roger L. Simpson & Michael C. Gartner. Management of
burns of the upper extremity. In Hunter Rehabilitation of
the hand and upper extremity. Mackin, Callahan, Skirven,
Schneider, Osterman, (5th edi.), vol-1, Mosby. 2002.
Marlys J.Staley & Reginald L.Richard.Burns. In. Physical
Rehabilitation: Assessment and Treatment. Susan
B.OSullivan.(4th edi. ), Jaypee Brothers. 2001.
Acknowledgement
We would like to thank Dr. Amrish Baliarsingh Prof. & Head
(former), Plastic Surgery Dept., K. E. M. Hospital, Mumbai for
granting permission for conducting the study.
We would like to extend our sincere thanks to Dr. Vinita
Puri, Associate Prof.(former) Plastic Surgery Dept, K.E.M.
Hospital, Mumbai for her timely help.
Last but not the least we would like to thank our clients for
their cooperation.
B. Anandha Priya M.O.Th / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
23
Normative data of Jebsen Taylor Hand Function Test [modified

version] on Indian Population
B. Anandha Priya*, Snehal Pradip Desai**
*Occupational Therapist, ESIC Hospital, K.K.Nagar, Chennai 600078, Tamil Nadu, **Lecturer, OT School & Centre, Seth G.S.
Medical College, K.E.M Hospital, Parel, Mumbai 400 012
The functions of the hand are multiple, though the most

important are the sensory function of touch and the function of
prehension. The hand has numerous other functions that play
essential roles in our lives - functions of expression through
gestures, visceral functions in carrying food to the mouth,
emotional and sexual functions in caressing, and aggressive
function in the form of closed fist for defense, functions relating
to body care and thermoregulatory function.
The ability of a person to use his hands effectively in
everyday activity is dependent upon anatomic integrity, mobility,
muscle strength, sensation and coordination. For this reason,
hand function should be tested by tasks representative of
everyday functional activities.
Jebsen taylor hand function test

The Jebsen Taylor Test of Hand Function is a commonly
used standardized test for assessing a persons functional hand
use. It evaluates unilateral hand skills and provides an objective
assessment of hand function involved in activities of daily living.
The test includes a series of seven subtests that provide a broad
sampling of hand functions. All the subtests are performed with
the non-dominant hand first followed by the dominant hand.
The seven subtests are

i.
Writing ( Printing a 24 letter sentence of third grade reading

difficulty )
ii. Turning over 3" X 5 cards ( Simulated page turning )
iii. Picking up small common objects (pennies, paper clips,
bottle caps) and placing them in a container.
iv. Simulated feeding
v. Stacking checkers (Test for eye-hand coordination)
vi. Moving large empty cans (Number 303 cans)
vii. Moving large weighted cans (0.45 kg or one pound cans)
Aim of the study

The aim of the study was to find out the norms of Jebsen
Taylor Hand Function Test (Modified version) on Indian
population.
Normative data are available for males and females
between the age group of 20-60 years, for both the dominant
hand and the non- dominant hand (1)
Hackel and colleagues (2) provide normative values of
Jebsen Taylor Hand Function Test for people aged 60-90 years.
Many studies had been conducted to assess the improvement
in hand function using the Jebsen Taylor Test for clients with
mild to moderate stroke, arthritis, acquired neurological disorders
and outcome of tendon transfer in tetraplegia secondary to spinal
cord injury, The test has been used with children from 8 years of
age (3, 4).
Methodology
Subjects
The test was administered on 300 samples, 30 males and
30 females (normal subjects) in each of the following age groups
; 20 -29 years, 30-39 years, 40 - 49 years, 50 - 59 years and 60
24
94 years.
The samples were from various geographical locations, with
various educational qualifications and various occupations
(Farmer, Driver, Student, Housewife, Clerical workers etc.), but
without any neurological or musculoskeletal problems.
The test was also administered on 30 patients with stable
hand disability post burn contracture hand, Volkmans
ischaemic contracture, crush injured hand etc. The mean age
was 33 16.5 years.
Instrumentation
The following materials were used in the Jebsen kit:
1. Writing (Modified writing)
Black ball pen
Ruled sheets
1 clip board with stand
1 clip board (or) writing board.

2. Simulated page turning
Ivory cards [one side plain and one side marked as

cross].
3. Lifting small common objects
1 empty can
2 paper clips
2 regular sized bottle caps
2 one rupee coins.

4. Simulated feeding
5 kidney shaped beans
1 empty can
5. Stacking checkers
4 brown colored wooden checkers.

6. Lifting large light objects.
5 empty cans.
7. Lifting large heavy objects.
5 heavy cans.
Other materials required
1 wooden board
1 stop watch
1 C clamp
Procedure scoring
Verbal consent was taken from all the subjects who were
included in the study. The sequence of performing the subtests
was explained.
Each subject was seated on a chair of 33" height in front
of a desk of 29" height and 35.5"breadth in a well lighted room.
Subtests were administered using verbal instructions.
The tests were performed with the non-dominant hand first
followed by the dominant hand. The subtests are scored by
recording the number of seconds required to complete each
task using a stopwatch. Increased time to complete the subtests
is related to decrease in functional use of hand.
The wooden board was secured to the desk with a C
clamp, when performing the following subtests simulated
feeding, stacking checkers, lifting larger light objects and lifting
larger heavy objects.
1. Modified Writing
The subject is asked to copy the designs that are printed

on a paper and fastened to a bookstand .Before administering
the test; the subject is asked to wear glasses, if needed.
2. Simulated Page Turning
The subject is asked to turn the cards over one at a time,
as quickly as possible. The cards may be turned in any way as
the subject wishes. Timing is from the word GO until the last
card is turned over.
3. Lifting Small Common Objects
In this subtest, the subject is asked to pick up the objects
one at a time and place them in the can. Timing is from the
wordGOuntil the sound of the last object striking the inside of
the can is heard.
4. Simulated Feeding
The subject is asked to pick up the kidney bean with the
fingers and drop it inside the empty can. Timing is from the word
GO until the last bean is heard hitting the bottom of the can.
5. Stacking Checkers
In this test, the subject is asked to stack the checkers on
the board .Timing is from the word GO until the fourth checker
makes contact with the third checker.
6. Lifting Large Light Objects
This subtest involves placing the empty can on the board.
Timing is from the word GO until the fifth can has been released.
7. Lifting Large Heavy Objects
In this test, the subject is required to place the heavy cans
on the board. Timing is from the word GO until the fifth can
has been released.
Data analysis and results

Data were collected in terms of the total time taken to
complete each subtests with both the hands. Mean and standard
deviation were calculated.
Table -1 shows the mean time taken and standard
deviations for normal subjects for the dominant hand.
Table-2 shows the mean time taken and the standard
deviations for normal subjects for the non- dominant hand.
To evaluate the reliability of test results in a given individual,
30 patients with stable hand disabilities were tested on 2
occasions. The time interval between the initial evaluation and
final evaluation was 2 weeks. The data were analyzed by
obtaining the Pearson-Product Moment Correlation Coefficient.
Most of the components in the dominant hand had significantly
high correlation(r=1). Subtest modified writing had moderate

correlation(r=0.7).Subtests picking up small common objects and
simulated feeding had low correlation(r=0.5, o.4)
In the non- dominant hand, subtests simulated feeding,
lifting large light objects and lifting large heavy objects had
significant correlation(r-1). The remaining subtests had very low
correlation(r=0.1, 0.5).
Practice Effect- Using the test retest reliability data on 30
patients, a t- test of the difference between the means of the
two occasions was obtained for each hand and test. All failed to
achieve significance at 0.05 level of significance.
Discussion
The subtests of the original test were modified according
to Indian population. The following modifications were done in
the test.
The subtest writing: consisted of copying a sentence of 24
letters and which is of third grade reading difficulty. To administer
the Jebsen Test even on uneducated population writing the
sentence was modified as copying the designs.
The subtest simulated feeding has been modified as picking
up the kidney bean with the fingers and dropping it in the empty
can; as eating with hand is in general practice among Indian
population.
Instead of pennies, Indian coins were used in the subtest,
picking up of common objects.
It will be noted from the tables 1& 2 that the mean time
taken to complete each subtest was less than 10 seconds except
for writing and page turning. . Analysis of the data of the normal
samples revealed significant age and sex differences, the trend
being that the oldest age group performed all subtests slower
than the younger age groups. This supports the concept that
there will be a decline in the normal hand function as age
increases. Interrater reliability was checked on normal samples
and there was no significant difference between the mean
scores.
Education was not a hindrance in performing the test.
Uneducated people were also able to copy the designs like the
educated people. Occupation also had an effect on the
performance of the test. Persons having jobs involving finer
coordination (Glass cutter, watch repairer etc.) had better
performance in the following subtests lifting common objects,
stacking checkers and simulated feeding.
Since the non-dominant hand is not used so frequently as
Table 1: Mean time and standard deviations for normal subjects- Dominant hand.
Factor
Males
Age range, years
20 to 59
60 to 94
Total no: of Subjects
120
30
1
Modified writing
30.21.4
52.715.2
2
Page turning
7.94.1
10.32.9
3
Picking up small common objects
6.92.5
8.52.2
4
Simulated feeding
5.30.9
6.91.4
5
Stacking checkers
3.30.7
4.51.3
6
Lifting large light objects
3.40.7
4.40.7
7
Lifting large heavy objects
3.70.9
4.60.8
Females
20 to 59
120
37.326
7.12.6
6.31.4
5.20.8
3.20.7
3.50.7
3.80.7
Table 2: Mean time and standard deviations for normal Subjects - Non dominant hand.
Factor
Males
Age range, years
20 to 59
60 to 94
Total no: of Subjects
120
30
1
Modified writing
55.920.8
84.826.1
2
Page turning
9.43.3
11.73.2
3
Picking up small common objects
7.72.7
9.92.2
4
Simulated feeding
5.91.1
6.81.5
5
Stacking checkers
3.70.8
51.4
6
Lifting large light objects
3.70.7
4.70.7
7
Lifting large heavy objects
4.10.9
50.9
Females
20 to 59
60 to 94
120
30
65.437
96.719.4
8.43
11.52
71.7
10.61.7
5.60.9
7.10.4
3.70.8
4.70.6
3.60.7
4.80.6
40.9
50.6
60 to 94
30
58.98.2
10.61.7
9.91.6
6.60.3
4.20.3
4.60.6
4.80.6
25
Table 3: Test Retest Reliability using 30 patients with Stable

Hand Disability Correlation Coefficient
Test
Dominant Non dominant
hand
hand
1 Modified writing
0.7
0.5
2 Page turning
1
0.1
3 Picking up small
0.5
0.1
common objects
4 Simulated feeding
0.4
1
5 Stacking checkers
1
0.1
6 Lifting large light objects
1
1
7 Lifting large heavy objects
1
1
compared to the dominant hand, the time taken for completion
of all the subtests was longer. This was more evident in the
subtest writing.
Certain facts were observed in the patients while performing
the test. Gross motor functions were less affected when
compared to the fine motor functions, in most of the patients
who sustained Median nerve injury, Ulnar nerve injury, combined
Ulnar and Median nerve injury, clawing of hand due to any reason
etc.
Patients who had strong long flexor contracture could easily
perform subtests which involved finer coordination as compared
to subtests which involved gross motor coordination.
Stability of the proximal parts and strength of the proximal
muscles are also important in efficient functioning of hand. This
was evident while testing a patient with proximal weakness.
Conclusion
The Jebsen Test of Hand Function is reliable, easily
performed and involves tasks that are functionally related. The
test is easy to administer within a short period of time and the
materials used are also readily available. In the present study,
the test is modified according to the Indian situation. The data
obtained can be used to assess the hand functions required for
activities of daily living.
26
References
1.
2.
3.
4.
Robert et.al. An objective and standardized Test of Hand

function .Archives of Physical Medicine and Rehabilitation,
June,-1969, 50(6), 311-319.
Mary E Hackel ,George A Wolfe, Sharon M Bang, Judith S
Canfield: Changes in Hand Function in the Aging adult as
Determined by the Jebsen Test of Hand function , Physical
Therapy , May 1992 , Vol. 72 , No. 5(373-377).
Fess, E.E.(2002).Documentation :Essential Elements of an
Upper Extremity Assessment Battery. In Hunter- Mackin
Callahan, Rehabilitation of the Hand and upper extremity,
Volume- 1, (page No. - 278), Fifth Edition.Philadelphia:
Mosby.
Virgil Mathiowetz and Julie Bass Haugen.Evaluation of
Motor Behaviour: Traditional and Contemporary views. In
Trombly C A., Occupational Therapy for physical
dysfunction, Fourth Edition (Page No.174-175
).Philadelphia: Williams Wilkins.
Acknowledgement
We would like to extend our sincere thanks to Dr. R. E.
Rana, Former Head of Plastic Surgery Department and Dr. Indira
R. Kenkre, Former Head of Occupational Therapy Department,
Seth G.S. Medical College &K.E.M Hospital for their guidance
and help
We are thankful to Dr. Shashi Oberoi, Head of Occupational
Therapy Department, D.Y .Patil Medical College, Navi Mumbai
for her timely help.
We are thankful to staffs and colleagues of Occupational
Therapy Department, Seth G.S. Medical College for
encouragement and support.
Last but not the least; we would like to thank all the
participants for their cooperation.
Effect of 2-week and 4-week wobble board exercise programme

for improving the muscle onset latency and perceived stability in
basketball players with recurrent ankle sprain
AS Dinesha*, Arun Prasad B **
*Physiotherapy Instructor Medical training Center and Command Hospital Air Force, Bangalore, **Department of Musculoskeletal
and Sports Physiotherapy, Padmashree Institute of Physiotherapy, Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.
Abstract
This study was carried out to find the effects of 4-week
and 2-week wobble board training in improving of muscle onset
latency and perceived stability in basketball players diagnosed
with recurrent ankle sprain, as there is decreased muscle onset
latency of peroneus longus and tibialis anterior muscle and
perceived instability following ankle sprains.
Design
Different subject experimental Pre to Post test design.
Setting
Clinical setting.
Participants
Twenty seven male and three female recurrent lateral ankle
sprain individuals.
Outcome measure
Surface EMG of PL (peroneus longus) and TL(tibialis
anterior),this was measured during sudden 200 inversion using
trap door mechanism, AJFAT(ankle joint functional assessment
tool) questionnaire was used to rate each participants
perception of their ankle stability.
Results
The outcome difference of PL latency between Group A (2
weeks) (15.73+_6.01) and Group B(4weeks) (30.20+_6.44)
shows a strongly significant difference and effect size is VL (very
large) i.e.2.26 (p<0.001**).
The outcome difference of TA latency between Group A
(21.13+_11.47) and Group B (30.53+_8.48) shows a moderately
significant difference and effect size is L (large) i.e.0.91
(p<0.016*).
The outcome difference of AJFAT between Group A
(9.20+_3.29) and Group B (15.80+_3.45) shows a strongly
significant difference and effect size is VL (very large) i.e.1.88
(p<0.001**).
Conclusion
Results demonstrated that the 4-weeks wobble board
exercise programme significantly decreased muscle onset
latency of the TA and PL in response to a sudden 20 ankle
inversion as compared to 2 weeks wobble board exercise
programme.
Hence this study concluded that 4 weeks wobble board
CORRESPONDING AUTHOR :
Prof. Arun Prasad.B
Padmashree Institute of Physiotherapy, #23, Gurukrupa Layout,
80 feet road, Nagarabhvi, Bangalore-560072
bapganesha@gmail.com (+91 9886172495)
exercise was better than 2 weeks wobble board exercise training

for improving muscle onset latency and perceived stability in
ankle sprains.
Keywords
Ankle sprain; Proprioception; Electromyography.
Background
Ankle sprains are amongst the most common injuries within
the athletic population with an incidence rate as high as 80%.1
Injury to the most commonly affected lateral ligament complex
is a result of a combination of excessive plantar flexion and
inversion.2 Furthermore, and of significant concern, is the
reoccurrence of ankle sprains reported that as many as 73% of
athletes had recurrent ankle sprains and 59% of these had
significant residual symptoms (e.g. pain, weakness, crepitus,
instability, swelling, stiffness) that affected their performance.3
These symptoms may be a consequence of residual mechanical
instability, functional instability, or a combination of both.
Mechanical instability involves muscle weakness and joint laxity;
however, many people have no mechanical deficit but experience
recurrent ankle sprains because they have functionally unstable
ankles (FUAs).4 Functional instability of the ankle defined by as
a feeling of giving way in the ankle and redefined as a subjective
complaint of weakness often in the absence of mechanical
instability.5 The pathogenesis of FUAs is complex but is reported
to involve sensorimotor, mechanical, and muscular deficiencies.6
Loss of proprioception, resulting in lack of balance and joint
position sense, is considered to be particularly important.7
Proprioception involves stimulus detection, processing, and
the initiation of a reactive output via the neuromuscular system.7
Konradsen & Ravn, 1997 reported a delay in the onset time of
the peroneal muscles to a sudden ankle inversion in individuals
with a FUA, which may explain why sprain reoccurrence is so
frequent.8 Other studies found no difference in onset latency of
peroneal muscles between individuals with and without FUAs.9
After initial acute treatment a rehabilitation regimen is pivotal
in speeding return to activity and preventing chronic instability.
In recent military series it was found that lack of rehabilitation of
ankle sprains delayed return to duty for several months.
Prolonged immobilization after ankle sprains is a common error;
functional stress stimulates the incorporation of stronger
replacement collagen. Functional rehabilitation begins on the
day of injury and continues until pain-free gait and activity are
attained. The four components of rehabilitation are range of
motion rehabilitation, muscle strengthening exercise,
proprioceptive training and activity specific training. 15
strengthening of weakened muscles is essential for rapid
recovery and important in preventing injury.16 Exercise should
focus on the conditioning of peroneal muscles, because of
insufficient strength in this muscle group has been associated
with ankle instability and recurrent injury. Resistance exercise
should be performed with an emphasis on eccentric
contraction.17 As a patient achieves full weight bearing without
pain; proprioceptive training is initiated for recovery of balance
and postural control. The simplest device for proprioceptive
training is wobble board, a small discoid platform attached to a
hemisphere base.13 Use of these devices in concert with a series
27
of progressive drills can effectively return patients to a high

functional level.18,19 A multi station proprioceptive exercise
programme can be recommended for prevention and
rehabilitation of recurrent ankle inversion injuries. 20 Use of
proprioceptive balance board program is effective for prevention
of ankle sprains recurrences.21 The wobble board is commonly
used in the rehabilitation of FUAs; it is designed to assist the
reeducation of the proprioceptive system by improving
mechanoreceptor function and restoring the normal
neuromuscular feedback loop.22 The effectiveness of wobble
board training in the improvement of markers of proprioception
in individuals with no history of ankle instability has been well
documented.23
Previous research has also shown that wobble board
training improves single leg stance ability and postural sway in
participants with a FUAs.22 Electromyography (EMG) has been
used in the assessment of proprioception as it allows the timing
and degree of muscle activity to be determined during a
functional task. Soderberg, Cook, Rider, & Stephenitch, (1991)
investigated the activity of the TA, PL, and gastrocnemius in
participants with FUAs during exercise on a wobble board,
although they did not investigate the effect of any rehabilitation
program per se.24
Our aim was to describe the effect of 4-weeks wobble board
exercise training on recurrent ankle sprain. To find out the effect
of 2-weeks wobble board exercise training on recurrent ankle
sprain. In addition compare the effects of 4-weeks and 2-weeks
wobble board exercise on recurrent ankle sprain.
Study Design
A experimental pre to post test design with 30 players were
randomized in to one of the two groups, 15 players in Group A
(Type of exercise- Wobble board exercise 2 weeks) and 15
players in Group B (Type of exercise-wobble board exercise 4
weeks) was undertaken to find out the effect of 4-weeks and 2
weeks wobble board exercise training on recurrent ankle sprain.

3.1 Source of data
Sports Authority of India (SAI), Bangalore.
Sports Authority of Karnataka (SAK),
Kanteerva stadium, Bangalore.
Padmashree Clinic of Physiotherapy,
Nagarabhavi, Bangalore.
3.2 Subjects
Subjects for the study were selected and assigned to
one of the two groups by simple random sampling.
All cases diagnosed as recurrent ankle sprain of
basketball players by the medical officer and referred
to physiotherapy department for the treatment.
3.3 Materials used
Wobble board, Surface EMG, Customized platform,
Goniometer, Ankle Joint Functional Assessment Tool
(AJFAT) questionnaire
3.4 Sample size:
30 subjects of both the genders.
Wobble board exercise for 2 weeks.7
Group B=15 players
Wobble board exercise for 4 weeks.
3.5 Inclusion criteria for both groups
Participants between 20-30 years of age, both genders,
Participants should have a subjective complaint of a weak ankle
and a history of at least 2 ankle sprains of lateral complex over
past 1year Participants should have a negative anterior drawer
test.
3.6 Exclusion criteria for both groups
28
History of TA rupture, fracture, dislocation in foot and ankle

complex, Abnormal biomechanics[i.e. calcaneus varus of 20
and valgus of 10,a medial tibiofemoal angle of 180-195,genum
recurvatum less than 10,and a medial hip rotation of 30-60
and lateral hip rotation of 45-60 at 90flexion].45
Intervention done
Participants individual consent was taken and outcome
measures used were AJFAT and muscle onset latency of TA
and PL with EMG. The subjects were asked to complete the
ankle joint functional assessment tool questionnaire (AJFAT),
which is used to rate each participants perception of their ankle
stability.22 Biomechanical alignment and mechanical stability of
patients ankles were assessed using a goniometer .46 The belly
of the tibialis anterior (TA) and peroneus longus (PL) was located
using resisted ankle dorsi flexion with foot inversion and plantar
flexion with eversion respectively. The area of maximal muscle
bulk will be palpated, shaved, and cleaned with an alcohol wipe
to reduce skin-electrode impedance.Two 3.3 cm2.3 cm Ag/
AgCl electrodes were placed either side of the belly of the muscle
with a distance of 5 mm between their edges, and parallel to the
orientation of the underlying muscle fibers. Electrode positions
is measured in relation to anatomical landmarks and
photographed to ensure that the same positions were used
during subsequent testing sessions. 47sEMG activity is recorded
at a frequency of 1000 Hz over a 3-s period that included the
opening of the trap door. Each participant will be performed the
test three times and group A were asked to return to the clinic
after 2 weeks of wobble board exercise and group B were asked
to return to the clinic after 4 weeks of wobble board exercise for
repeat testing of outcome measures.
Group A=15 players,

Type of exercise- Wobble board exercise for 2 wks 2.
Stand with feet parallel on the board, rock the board forward
and back
2. Stand with feet parallel on the board rock the board from
side to side
3. Stand with feet wide apart on the board rock the front of the
board from side to side in a circulating movement
4. Repeat exercises 1-3 but with your knees slightly bent and
your hands on your buttocks Continue exercises 14 for
30 s, rest for 10 s and repeat
5. Stand on the previously injured leg and keep the board
level for 10 s, repeat six times, rest for 10 s and repeat
If in stage 5, balance can be maintained without losing
stability of the board, then complete with the eyes closed
1.
Group B=15 players

1.
2.
3.
Type of exercise- Wobble board exercise for 4 wks.

Stand with feet parallel on the board, rock the board forward
and back
Stand with feet parallel on the board rock the board from
side to side
Stand with feet wide apart on the board rock the front of the
board from side to side in a circulating movement
(a) Stand with feet parallel (b) Rock the board forward and
backward
(c) Rock the board from side to side (d) Exercises 1-3 but with
your knees slightly bent
(e) Side to side in a circulating movement (f) Stand on Previously

injured leg.
group.48, 49
Statistical software: The Statistical software namely SPSS
15.0, Stata 8.0, MedCalc 9.0.1 and Systat 11.0 were used for
the analysis of the data and Microsoft word and Excel have
AJFAT
Pre
intervention
Post
intervention
% Change
P value
Group A
26.532.80
(22-31)
35.733.69
(30-42)
34.67%
<0.001**
Group B
27.272.37
(24-34)
43.071.98
(40-47)
57.93%
<0.001**
P value
0.446
<0.001**
-
been used to generate graphs, tables etc
Results
(g) Balance maintained complete with the eyes closed
Effect of 4-week and 2-week wobble board exercise

programme for improving the muscle onset latency and
perceived stability in basket ball players with recurrent ankle
sprain was analyzed after evaluating for the following
parameters.
1. Muscle onset latency of peroneus longus and tibialis
anterior was measured by mili seconds using ENMG.
2. Functional outcome was measured using Ankle Joint
Functional Assessment tool Questionnaire.
parameters
4.
Repeat exercises 1-3 but with your knees slightly bent and
your hands on your buttocks Continue exercises 14 for
30 s, rest for 10 s and repeat
PL
TA
AJFAT
Group
A
15.73
6.01
21.13
11.47
9.20
3.29
Group
B
30.20
6.44
30.53
8.48
15.80
3.45
P value
Effect size
<0.001**
2.26 (VL)
0.016*
0.91 (L)
<0.001**
1.88 (VL)
Comparison of PL (mili sec) of two groups

Results are presented in Mean SD (Min-Max)
PL (mili-sec)
Pre
intervention
Post
intervention
% Change
P value
Group A
84.536.68
(68-97)
68.806.39
(58-84)
18.61%
<0.001**
Group B
90.535.99
(81-99)
60.334.27
(52-67)
33.36%
<0.001**
P value
0.014*
<0.001**
-
5.
Stand on the previously injured leg and keep the board

level for 10 s, repeat six times, rest for 10 s and repeat
If in stage 5 balance can be maintained without losing
stability of the board, then complete with the eyes closed
WOBBLE BOARD EXERCISE
Emg recording
Trapdoor in (a) closed position and (b) the open position
in 200 of ankle inversion
Comparison of TA (mili sec) of two groups

Comparison of AJFAT of two groups
Comparison of outcome in two groups of players
(Difference of Pre and Post)
Figure 9: Comparison of PL (mili sec) of two groups Pre and
post exercise periods findings of PL (mili sec) shown in Fig-9.
Figure 10: Comparison of TA (mili sec) of two groups Pre and
post exercise periods findings of TA (mili sec) shown in Fig-10
Figure 11: Comparison of AJFAT of two groups Pre and post
intervention findings of AJFAT score shown in Fig-11.
Fig. 9:
Analysis of data
Descriptive statistical analysis has been carried out in the
present study. Chi-square and Fisher Exact test has been used
to test the significant proportion of study characteristics between
two groups. Studentt test (Two tailed, Independent) has been
employed to test the significance of study parameters between
the two groups of subjects. Student t test (Dependent) has been
used to find the significance of study parameters within each
29
TA (mili-sec)
Pre
intervention
Post
intervention
% Change
P value
Group A
85.607.87
(70-98)
64.476.31
(54-76)
24.68%
<0.001**
Group B
89.937.48
(74-99)
59.405.76
(52-70)
33.95%
<0.001**
P value
0.133
Fig. 12(c):
0.029*
-
The comparison of pre and post outcome difference in two

groups of players shown in Fig-12(a), 12(b) &12(c).
Fig. 10:
Discussion
Fig 11:
The results of this study showed that the time for activation
(i.e. the onset latency) of the TA and PL in response to rapid
Fig. 12 (a):
ankle inversion was significantly reduced by 4 weeks of wobble

board exercise as compared to 2 weeks wobble board exercise.
Participants perception of their ankle stability also improved over
the course of the exercise programme.
Significant differences existed in reaction time of PL muscle
in pre exercise score between the Group A and Group B
(p=0.014*) it may be because of number of times of recurrent
injury.
Neither muscle onset latency or perceived stability were
statistically different between the two groups at the start of the
investigation, which indicates that the changes observed were
likely to be due to duration of wobble board training alone.
Whilst this investigation found the wobble board programme
to cause a significant decrease in the latency of both the TA and
PL, however, reveals that the 4-weeks exercise groups PL
latency reduced by 33.36% and TA is reduced by 33.95%.
The exercise programme demanded that the participants
learn to react to a variety of movements on the wobble board.
The large reductions in onset latency observed in the 4weeks exercise group (TA=33.95%.PL=33.36%) initially suggest
that such movements resulted in an improvement in the
mechanoreceptor function, which restores the neuromuscular
loop (Rozzi et al., 1999).
However, it has been reported that neither otolith
(Waddington & Shepherd, 1996) nor proprioceptive (Konradsen,
Voigt, & Hojsgaard, 1997) generated responses could protect
the ankle until 130 ms or 176 ms, respectively, after stimulus
detection.
As the trapdoor mechanism similar to the one used in this
study rotates through 20 in approximately 80 ms it is likely that
these responses would be too late to produce sufficient eversion
torque to prevent injury from sudden inversion (Konradsen et
al., 1997).
Further research is required to investigate when during the
rehabilitation period wether wobble board induced improvements
in muscle latency and perceived stability begin to plateau.
Conclusion
Fig. 12(b):
The findings of this study advocate the use of 4-weeks

wobble board exercise programme as part of the rehabilitation
for individuals with FUAs who experience recurrent ankle sprains.
Results demonstrated that the 4-weeks wobble board
exercise programme significantly decreased muscle onset
latency of the TA and PL in response to a sudden 20 ankle
inversion as compared to 2 weeks wobble board exercise
programme.
Hence this study concluded that there is significant
difference between 2 weeks and 4 weeks wobble board exercise
programme.
Whilst these improvements may still not be enough to
produce sufficient torque to prevent injury from sudden inversion,
it is likely that they would reduce the risk of recurrent injury by
increasing joint stiffness.
Acknowledgements
would like to acknowledge Prof.Arun Prasad.B for his kind
30
encouragement and support. I would also like to thank each

patient who participated in the study.
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A comparative study of the therapeutic effect of pelvic floor

exercises and perineometer among women with urinary stress
incontinence
K. Vairajothi*, T.V. Chitra**, R. Baranitharan***, V. Mahalakshmi****
*Post Graduate Student, PSG College of Physiotherapy, **Dept. of OG, PSG Hospitals, ***Professor & Vice Principal, PSG College
of Physiotherapy, ****Associate Professor, PSG College of Physiotherapy, Coimbatore, Tamil Nadu
Background
Stress urinary incontinence is responsible for approximately
50% of the symptoms of urinary incontinence in women between
25 and 49 years of age. Though surgery has been widely
accepted as the treatment choice for this condition, there has
recently been an increased interest in the conservative
management. There is a need to study effect of biofeedback
assisted pelvic floor muscle exercise in women with urinary stress
incontinence with a limited number of treatment sessions.
Objective
To improve pelvic floor muscle strength.

To compare the effect of Perineometer with pelvic floor
exercise training versus pelvic floor exercise alone in
women with urinary stress incontinence.
To reduce the severity of urinary stress incontinence.
Methodology
Quasi experimental design Pre test post test with a
comparison group was used. 20 women with stress urinary
incontinence (Group A Perineometer with pelvic floor exercise
and Group B pelvic floor exercise alone) using convenient
sampling method were selected. Pre and post test data including
the digital evaluation of pelvic floor muscle strength,
perineometer pressure readings & severity index were taken
and were statistically evaluated.
Result
There was a significant difference in pelvic floor muscle
strength (t value for digital evaluation and Perineometer were
6.14 and 5.12 respectively; p< 0.001). There was a significant
improvement in the severity of incontinence within the groups,
with mean difference of 2.5 and 1.5 for Group A and B
respectively. There was no statistically significant improvement
of Severity index score between the groups (t value was 1.726
; p>0.05).
Conclusion
Perineometer training along with pelvic floor exercises has
significant effect in improving the pelvic floor muscle strength
than pelvic floor exercises alone in women with urinary stress
incontinence thereby promoting continence.
Keywords
Perineometer, Incontinence, Pelvic floor exercises
Introduction
Stress Urinary Incontinence is the most common form of
urinary incontinence in women. The International continence
society (ICS) defines stress urinary incontinence as the complaint
of involuntary leakage on effort or exertion or on sneezing or

coughing. The perineometer appears to be a highly reliable
method of measuring pelvic floor muscle strength and endurance
(Nahid Rahmani et al.,2009)1. Supervised pelvic floor muscle
exercises presented better results in objective and subjective
evaluations than did unsupervised exercises (Miriam Raquel et
al., 2007)2. Stress urinary incontinence is responsible for
approximately 50% of the symptoms of urinary incontinence in
women between 25 and 49 years of age. Though surgery has
been widely accepted as the treatment choice for this condition,
there has recently been an increased interest in the conservative
management (Mariana T Rett et al, 2007)3. There is a need to
study effect of biofeedback assisted pelvic floor muscle exercise
in women with stress urinary incontinence with a limited number
of treatment sessions. The present study was done with an aim
to improve the pelvic floor muscle strength and to compare the
effect of perineometer with pelvic floor exercise training versus
pelvic floor exercise alone in women with urinary stress
incontinence and to reduce the severity of urine leakage with a
limited number of treatment sessions.
Methodology
Normally delivered primigravidae, multigravidae and
postmenopausal women with stress urinary incontinence who
visited the out patient Department of Obstetrics and Gynecology,
Department of Physiotherapy, PSG Hospitals from July to
November 2009 were the population included for this study.
Quasi experimental design pretest posttest with a comparison
group and a convenient sampling technique were adopted in
this study. Women with stress urinary incontinence of Slight to
Moderate severity (severity index) between the age group of 25
and 60 years (including post hysterectomy women) experiencing
urine leak for > 3 months with pelvic floor muscle grade between
2 and 4 (clinical scale for grading digital evaluation of muscle
strength) were included. Women with other type of incontinence,
recent pelvic surgeries, intrauterine devices and any other pelvic
floor dysfunction were excluded for this study. Ethical clearance
was obtained from the Human Ethics Committee of PSG Institute
of Medical Science and Research Institute and informed consent
were received from the participating women. Out of the 20
women selected, 10 women (Group A) underwent Perineometer
training along with pelvic floor exercises and 10 women (Group
B) were taught pelvic floor exercises alone. The total duration of
treatment was 6 weeks for both the groups.
Treatment protocol
Base line assessment of pelvic floor muscle strength by
digital evaluation and using perineometer were taken for both
the group on the day of assessment. Severity of incontinence
was assessed using severity index. Women in Group A were
given training for pelvic floor muscles using Perineometer on
the day of assessment and were taught pelvic floor exercises (3
sessions of exercise with 5 minutes for the first week and
gradually increasing the duration to 20 minutes at 4th week. On
the 5th and 6th week the exercises are performed for 30 minutes
2 or 3 sessions / day). Pelvic floor exercises were taught to the
women in Group B on the same protocol. Follow up assessments
of pelvic floor muscle strength were taken every 2nd week till six
33
weeks of treatment for both the groups. Severity index scores

were taken on the day of assessment and sixth week. The
baseline data and the data obtained on the final day of treatment
were used for statistical analysis.
Results
The mean difference of Group A was 1.8 (SD = 0.42) and
the t value was 13.5; p<0.001 and in Group B the mean difference
was 1.1 (SD = 0.31) with t value was 11.2; p<0.001 showing
the improvement of pelvic floor muscle strength within the groups
(Table 1 & Graph I).
The independentt test was performed between Group A
and Group B to analyze the significance of the pelvic floor

exercise with perineometer training. The t value was 6.14;
p<0.001 and 5.2; p<0.001 for digital evaluation and Perineometer
feedback indicating a significant effect of pelvic floor exercise
with perineometer pressure feedback training and pelvic floor
exercises than pelvic floor exercise alone in improving pelvic
floor muscle strength in women with stress urinary incontinence.
The calculated t value for the severity index was 1.726 ; p>0.05,
and hence there is no statistically significant improvement in
the severity of incontinence between the groups (Table 3). There
was a significant improvement in the severity of incontinence
within the groups, with mean difference of 2.5 and 1.5 for Group
A and B respectively (Graph III).
Table 1: Paired t test values, the Mean, Mean Difference And Standard Deviation of Pelvic floor muscle Strength
Evaluation of Group A and B
GROUPS
Mean
Mean Difference
Standard Deviation
t value
GROUP A
Pre test
2.1
1.8
0.42
13.5
Post test
3.9
GROUP B
Pre test
2.1
1.1
0.31
11.2
Post test
3.2
Using Digital
P value
P<0.001
P<0.001
Table 2: Pairedt test values, the Mean, Mean difference and Standard deviation of Perineometer pressure readings in Group A and
Group B.
GROUPS
Mean
Mean Difference
Standard Deviation
t value
P value
GROUP A
Pre test
7
33.6
13.32
7.97
P<0.001
Post test
40.6
GROUP B
Pre test
7
10.8
4.43
7.70
P<0.001
Post test
17.8
Table 3: Independent t values, Mean Difference and Standard deviation of Pelvic floor Muscle strength and Severity index
Outcomemeasures
Mean difference
Standard deviation
t value
P value
Clinical Scale for Grading Digital
0.7
0.26
6.14
P<0.001
Evaluation of Muscle strength
Perineometer pressure
22.8
9.93
5.2
P<0.001
feedback readings
Severity index score
0.6
0.79
1.726
P>0.05
Graph I: Mean difference for Pelvic floor muscle strength in

Group A and Group B
Table 2: Pairedt test values, the Mean, Mean difference and

Standard deviation of Perineometer pressure readings in Group
A and Group B.
Graph II: Mean Difference for Perineometer pressure Readings

in Group A and Group B
Discussion
Treatment of stress urinary incontinence with pelvic floor
exercises associated to biofeedback caused significant changes
in the parameters analyzed, with maintenance of good results 3
months after treatment. (Maria V et al 2006)3. Biofeedback
method revealed better PFM strength results with respect to
digital palpation. (Aksac et al., 2003)6. Biofeedback therapy
resulted in a better subjective outcome and higher contraction
pressures of the pelvic floor muscles (Pages IH et al., 2001)7.
There is good agreement between digital assessment of
pelvic floor contraction strength and vaginal perineometry (P.J.
Isherwood et al., 2005)4. This study also used both digital
evaluation and Perineometer for assessing the pelvic floor
34
Ms. K. Vairajothi / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
muscle strength. It was found that there was a good improvement

in pelvic floor muscle strength following Perineometer training
with pelvic floor exercises than pelvic floor exercises alone.
Pelvic floor exercise is an accepted conservative treatment
modality used for mild to moderate cases that have not yet
completed their families. Pelvic floor exercise with biofeedback
is a very important treatment modality, requiring a highly
motivated patient and a physiotherapist specialized in pelvic
floor exercise (Gordon et al., 1999)8. Adding biofeedback to pelvic
floor muscle exercises might be more effective than pelvic floor
muscle exercises alone six treatments. (Berghams et al., 1996)9.
This study analyzed the influence of pelvic floor exercises and
biofeedback on objective parameters. Moreover, the
perineometer biofeedback patients showed them to be more
satisfied may be because of the supervision and weekly
assessment.
The subjective parameter chosen for analysis in this study
was the severity index score. Though the severity of incontinence
was found to be reduced within the groups, there was no
significance difference between the groups. The complementary
effect of biofeedback on pelvic floor rehabilitation program is
still a controversial subject. In 1998, Berghaman et al., found
that there was strong evidence that biofeedback associated with
pelvic floor exercises did not increase the efficacy of the
treatment. On the other hand, the meta analysis performed by
Weatneral led to the conclusion that biofeedback was an effective
aid in strengthening pelvic floor muscles for it presented
increasing cure rates. Nevertheless, these studies differ greatly
regarding interventions conducted, research population,
assessment measures and equipment used, making them
difficult to be compared.
The limitations of this study were relatively small group size,
short duration and only the pelvic floor muscle strength and
Severity index were taken into the consideration in this study.
The plan of the study did not take into account to compare the
duration of exercises, bladder dairy and quality of life. Further
research could be done by comparing the other biofeedback
device with Perineometer. The pelvic floor muscle strength
among the pre and post menopausal women with stress urinary
incontinence can also be compared.
Conclusion
Perineometer with pelvic floor exercise is an effective
intervention in improving the pelvic floor muscle strength thereby
reducing the severity of incontinence. Considering the overall
treatment outcome, this study concludes that the perineometer
training was more effective than the pelvic floor exercise alone
in the management of urinary stress incontinence.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Acknowledgement
The authors would like to thank the women who participated
in this study for their cooperation.
19.
20.
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35
A study of effects of gluteal taping on TD-parameters following

chronic stroke patients
Bhatri Pratim Dowarah
*Assistant Professor, Department of Physiotherapy, J.R.N.R.V. University, Dabok, Udaipur, Rajasthan 313022
Need of the study

The aim of the study is to determine whether gluteal taping
on the affected side improves walking for chronic stroke patients.
Objectives of the study

To study the effects of gluteal taping to patients with chronic
stroke having abnormal (hemiplegic) gait.
Hypothesis
Experimental hypothesis:
There will be significant improvement in walking pattern in
chronic stroke patients treated by control exercise program with
gluteal taping.
Null hypothesis:
There shall not be significant improvement in walking
pattern in chronic stroke patients treated by control exercise
program with gluteal taping.
Systematic research has shown that organized
multidisciplinary care and rehabilitation of the stroke enhance
patients survival independence, as well as reducing the length
of in patient stay. It remains unclear, however, why specialized
stroke units are more effective than usual care. A no of
components have been identified as contributing to the
efficacious care delivered in such units. These include the
comprehensive assessments of the medical problems,
impairments and disabilities; active physiological management;
early mobilization and avoidance of bed rest; skilled nursing
care; early setting of rehabilitation plants involving careers; and
early assessment and planning for discharge needs. Several of
these factors are closely related to physical therapy which is
often perceived as one of the key disciplines in organized stroke
care. The main foci of physical therapy after stroke are to restore
motor control in gait and gait related activities and to improve
upper limb functions, as well as to learn to cope with existing
deficits in activities of daily living and to enhance participation in
general. Besides using physical exercises, physical therapists
often apply assistive devices for gait, and employ other
equipments such as treadmills and electronic devices to support
their treatment. In addition, advice and instructions are provided
to the patients, family and other members of the stroke team
regarding prevention of complication such as falls and shoulder
pain. Today, the importance of evidence based medicine as a
guide for the clinical decision making process is increasingly
being recognized by physical therapists.
Gait is defined as the manner of moving the body from one
place to another by alternatively and repetitively changing the
location of the feet, with the condition that atleast one foot is in
contact with the walking surface.11
Normal walking is characterized by a smooth succession
of steps with first one leg and then the other. The time taken for
36
each step is similar, as is the distance covered with each step

during forward progression.the gait cycle consists of two steps,
as body weight is accepted and transferred over first one foot
and than the other during forward progression. A gait cycle thus
includes a stance and swing phase and two periods of double
support at the beginning and end of the stance as the weight is
transferred from one leg to the other.59
The gait cycle is defined as the time interval between two
successive occurrences of one of the repetitive events of walking,
convinent to use the instant at which one foot contacts with the
ground ( initial contact ) until the same foot contacts the ground
again. In each gait cycle, the stance phase usually last about
60% of the cycle, the swing phase about 40% and each period
of double support about 10%. However, these varies wiyh the
speed of walking,the swing phase becoming proportionately
longer and the atsnce and the double support phases shorter
as the speed increases.22
Each phase of gait (stance and swing phase) has been
devided into the following:
Stance phase (heel strike, foot flat, mid stance, heel off
and toe off) and
Swing phase (acceleration, mid swing and deceleration).
The Los Amigos research and
education institute, including of Rancho Los Amigos Medical
Centre has developed a different terminology in which the
subdivisions have been redefined and named as; stance(initial
contact, loading response, midstance, terminal stance and pring
swing) and swing (initial swing, midswing and terminal swing)1.
In each gait cycle, there are spatial (distance) and temporal
(time) parameters, which are basic parameters of motion, and
measurement of these variables, provide a basic description of
gait.
Temporal parameters include stance time, single limb and
double support time, swing time, stride and step time, cadence
and speed.
Spatial parameters are stride length, step length, width of
walking phase and degree of toe out. These variables provide
essential quantitative information about a persons gait and
should be included in any gait description.
The mechanism underlying gluteal taping is not known.
McConnell has hypothesized that this particular gluteal taping
technique may alter the orientation of the gluteus maximus
muscles fibres. According to this hypothesis, the taping elevates
and stretches the belly of the muscle, increasing the overlap
between the actin and myosin filaments and therefore the
potential cross-bridge interactions.7
The length tension curve is shifted to the left, with the
gluteus maximus able to contract more forcefully, producing
an increasing in hip extension after taping.23
Gluteal taping improves the propioceptive activity through
pull of the tape on the skin.24
The Kinesio taping method used to improve the upper
extremity function in the adult with hemiplegia. The Kinesio
taping method in conjunction with other therapeutic
interventions may facilitate or inhibit muscle function, support
joint structure, reduce pain, and provide proprioceptive
feedback to achieve and maintain preferred body alignment.
Restoring trunk and scapula alignment after the stroke is critical
in an effective treatment program for the upper extremity in
hemiplegia.25
Bhatri Pratim Dowarah / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Humans can walk up to 4 m/s, but natural transition

between walking and running is roughly 2.2 m/s .26
Influence of walking speed on gait parameters to and out
their normal ranges. The results can be used as a reference
for comparison with other pathological cases.27
Several works extract parameters of body and gait, such
as, stride length, cadence, height, joint angles to use in the
classification tasks. They analyze the identity information
contained in the lower-body joint-angle trajectories using the
data measured with 3D motion capture system.28,29,30,31
Speed effects in gait recognition have not been
emphasized much. There are not many works that exploit the
relationship of gait features with respect to walking speeds in
their techniques to help deal with walking speed variations of
people. They present a method that focuses on distinguishing
normal walking movement from other non-walking movements
using low-level stride-based features. They present a modelbased technique that estimates stride length and cadence as
gait features and use the linear relationship between stride
length and cadence in their recognition step.29,32
Extensor muscle over activity is one of the components of
gait disorders in stroke patients. Extensor muscle over activity
or spasticity is a real cause in gait disturbances.8
Studied between spastic and non-spastic limb, as well in
between stance and swing phases of the gait cycle, reported
that planterflexion spasticity is a factor contributing to the poor
locomotors performance.9
Reported an average stride length of 0.6 +/- 0.25 m/sec
and cycle duration of 2.3 +/- 0.8 m/sec. these limitations in
stride length and walking speed may be associated with
advancing the paretic limb efficiently in swing and in shifting
weight to the paretic limb in stance. Lack of hip extension during
terminal stance may result in a shorter stride length and
decreased gait velocity reported in hemiplegic subjects.10
Studied on 42 patients with unilateral 1st stroke who were
able to walk 10 meters and reported that the goal of
rehabilitation is to increase gait velocity and normalize the gait
pattern, treatment should focus on decreasing the double limb
stance and unaffected single limb support phases of the gait
cycle.15
Measured temporal gait asymmetries in 25 patients with
residual stroke, Reported that both the extent and patterns of
temporal gait asymmetries with respect of the phases of the
gait cycle were found to very. The basic rehabilitative implication
of these findings is that it is not possible to design a single gait
re-education program for all residual stroke patients; the
exercises prescribed must addressed the unique differences
of each patients.16
Studies have been asserted that speed alone is an
effective indicator of the degree of gait abnormalities.17
All this study provides evidence that gluteal taping is
worthy of further investigation as a strategy for improving
walking patterns of chronic stroke patients .The participants in
the study had history of chronic stroke from months to years
with walking problems , with application of the gluteal taping a
modest increase in the walking pattern along with the
improvement in the unaffected leg. Further study is required to
determine how it improves the walking pattern of chronic stroke
patients.
Materials and methodology

Design of study:
It is an experimental study design, a sample of 30 patients
in both the groups were included in the experimental study with
a pre-test and post-test study design.
The samples of patients were selected as the basis of
convenient sampling. The sample confirmed with the diagnosis
of stroke, by the consulting Neurologist, took part in the study.
It was experimental study, pre-test and post-test different
subjects design, a total of 30 patients were taken. Patients will

be treated with control exercise program along with gluteal taping
and were treated within 3 months.
Sample design:
A total no. of 30 patients between the age group of 40-60
years with chronic stroke i.e. 3 months was recruited by
convenient sampling. Patients were taken from L.L.R.Medical
College, Meerut, Annapurna Charitable Trust, Meerut and
College OPD.
The entire patient were diagnosed & referred by
Neurologist. The eligibility criteria were checked & informed
consent were taken from patients.
Inclusion Criteria:
Cerebral artery involvement, both ischemic and

hemorrhagic.
Hemiplegic gait.
Age group 40-60 years
Chronic stroke patients (2-5 years).
Can walk without use of any aid
Decreased hip extension due to problems in gluteal

muscles
Exclusion Criteria
Pre existing deformity and other complications
Hip flexor and planter flexor contracture ( as evidenced by

Thomas test )
Allergy to adhesive sports tape
If they could not comprehend and follow simple verbal

instructions
Visual and hearing problems and cognitive deficits
Severe psychological disorders
Recurrent stroke
Methodology
Materials, Tools and Apparatus
Neurological evaluation chart
10 meter paper track
Marker or water color or ink (vatika oil-washable)
Inch tape
Sport tape
Anti-skin infection tape or hypoallergenic tape ( micro-pore)
Reinforcement tape ( leucoplast ), Johnson
Pen, paper etc.

Assessment tools:
Sport tape (Johnson & Johnson) :

Hypoallergenic tape was 1st applied without tension
to protect the skin .Sport tape was then applied with tension
over the protective tape. 3 pieces of tape were applied while the
buttock was supported by the therapist.
10 meter paper track :

The paper track is mainly used for the
measurement of the parameters, in which 2.5 meters should be
left in the start and at the end. The patients were walked over
the mid section of a 10 meter track. The subjects walk over the
track 3 times at their self selected speed.
Protocol:
A total number of 30 patients were taken which were
randomly selected from the mentioned placed in Meerut, both
male and female. Group A: Subjects are randomly assigned.
Subjects were treated with normal control exercise program with
exercises like PNF, mat exercises, passive movements,
stretching and stimulation etc. Group B: Subjects were randomly
assigned. Subjects were treated with normal control exercise
program along with gluteal taping .Taping were applied to
affected side with patient standing.
All the patients had attended physiotherapy session daily
for 3 months. During this time they were advised not to take any
other treatment or medications.
Bhatri Pratim Dowarah / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
37
Procedure
Informed consent was taken from each subject. Subjects
were then screened from inclusion / exclusion criteria. Subjects
were made to understand about the study and purpose of the
study in their own language. Patients were then made to undergo
the exercise protocol along with gluteal taping.
Gluteal Taping: Taping was applied to the affected side with
the subject standing by the therapist. Hypo allergic tape was
first applied without tension to protect the skin. Sport tape was
than applied with tension over the protective tape. Three pieces
of tape were applied while the buttock was supported by the
researcher. Tape was applied:
1. From the medial aspect of the gluteal fold, pulled laterally
and superiorly towards the greater trochanter. And From
the medial aspect of the gluteal fold to the top of the buttock
above the gluteus maximus muscle belly, lifting the buttock.
2. From the superior end of the second piece of the tape to
the greater trochanter.
The tape was applied only to the buttock and not to the
posterior thigh. Two dimensional adhesive markers of 1.5 cm
were placed over the mid axillary line of the iliac crest, the greater
trochanter, and the lateral femoral condyle of the affected side
and each subjects were fimed, both in a relax standing posture,
to produce a neutral reference.
Subjects walked over the mid section of a 10 meter paper
track with color or ink in the sole of the foot, so that foot left
marks on the walkway track three times at their self speed.18
Than the step length, stride length and step width is to be
measured along with in terms of cadence and step time.19
Data analysis
All analysis were obtained using SPSS Windows version
11.0. Demographic data of patient including sex, age, disease
duration, stride time, step length, step width, cadence and step
time were descriptively summarized. The dependent variable
for statistical analysis were, pain and disability. An -level of
0.05 was used to determine statistical significance. Statistical
techniques used for analysis were student t-test or Man Whitney,
whichever is applicable, to compare each point of time in the
two groups. Both- within group and between group analysis was
done to analyze the dependent variables. One way multivariate
analysis of variance (MANOVA) with repeated measure was
performed to analyze the differences in the subjects with gluteal
taping. Follow up analysis of variance were conducted if the
MANOVA test demonstrated statistical significance.
Results
In this 30 subjects were randomly selected, and then were
allocated in group A and B. There were 19 males and 11 females
with a mean age of 56.93 + 3.12 ranging from 46-60 in group A
and a mean age of 56.53 + 3.79 with a minimum age of 48-60 in
goup B. A baseline reading was taken using Time-distance
parameters in the patients with chronic stroke.
Within group analysis

However there is no significant difference between pre and
post physiotherapy treatment among the subjects in Group A
but the mean value shows that intervention has better effects in
Group B.
To look for the difference between the baseline readings
taken on the first day of the study with the post test readings of
Time-distance parameter by applying gluteal taping on the 90th
day an independent t-test was performed which showed a
significant difference in both group A as well as in group B (
table 1 to table 5 ). It was found that there is a improvement in
the Time-distance parameter on application of gluteal taping in
38
the patients with chronic stroke which was found significant

(p<=0.000). A similar results in group B was seen which was
significant (p<=0.000).
Discussion
In this study of moderate hemiplegics we tried to assess
the improvement in the hip extension using the gluteal taping
along with exercises program. It is well established fact that the
hemiplegics have gross abnormalities of gait produced due to
their inability to overcome the spasticity in the antigravity
muscles, resulting in non-reduction of limb length during gait.
This relative lengthening of limb is compensated by
circumducting the lower limb. To avoid this abnormality, the
patient is specifically trained flexing activities. This problem is
compounded by the fact that most of the hemiplegics are elderly
having other neurological compensation including co-ordination
difficulties.
It is mandatory to have hip, knee and ankle interaction
during gait especially during gait. The use of gluteal taping
improves hip extension during gait cycle, this started as early
as possible to avoid possible learned movement dysfunctions.
The Time-distance parameter as a primary parameter in
the evaluation of outcome as it involves the objective way of
measuring the effects of using gluteal taping on a real time basis.
This test also encompasses the person co-ordination activities
by increasing the hip extension.
The taping improves muscle activation through cutaneous
stimulation (Garnett and Stephens 1981) or improves
proprioceptive acuity through the pull of the tape on the skin
(Robbins at el 1995). The mechanism underling the gluteal
taping not known, McConnell(2002) has hypothesized at that
this particular taping technique may alter the orientation of
gluteus maximus muscle fibres. According to this hypothesis,
the taping elevates and stretches the belly of the muscle,
increasing the overlap between the actin and myocin filament
can there fore the potential crossbridge interactions.
This study provides evidence that gluteal taping is worthy
of further investigation as a strategy for improving hip extension.
The participants in this study had of history of stroke ranging
from year with well entrenched gait patterns. With the application
of gluteal taping the patients increase their hip extension.
Future studies
In future studies in this particular area it is recommended
that homogeneity of the patients should be done on a more
specific and discrete fashion. Follow up and recording of
sustained of the improvements will give more validity into the
use of gluteal taping. The segregation of the patients according
to the arterial involvement and gender will make outcome
measure more reliable. The reliable of the study can also be corelated with functional index to understand the translation of
this improvement to functional outcome.
Limitations
The study is done on an immediate basis i.e. the timedistance was measured immediately on the use of gluteal taping
and no follow up was done. The lack of follow up has the
drawback that the sustained of this improvement and further
progression value is not revealed. The hemiplegics were of both
the sides (right and left). It is known that right sided hemiplegics
usually have some perceptual disorder also which is not
considered in the study, but nevertheless can affect the outcome.
Though patients had homogeneity of suffering from
moderate hemiplegia according to Orpington Prongnostic Scale,
their pre-morbid status was not recorded and also the fact that
the spaticity was not graded asworth scale.
The patients were not ideally similar because though they
Bhatri Pratim Dowarah / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
suffered chronic hemiplegia, they were having different arterial

in involvement, hence might have difference in their outcome.
Conclusion
It has been recorded from the study that use of gluteal taping
produces significant improvement in the time-distance
parameters with chronic stroke patients. It can be seen that use
of gluteal taping in patient with hemiplegia is beneficial. This
can be used to enhance the functional outcome of these patients.
Hence alternate hypothesis is accepted at p = 0.00 and the null
hypothesis is rejected.
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in man, Journal of Physiotherapy ,311:463-473
24. Robbins S, Waked E and Reppel R (1995) , Ankle
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Bhatri Pratim Dowarah / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
39
Role of physiotherapy in palliative care

Binoy Mathew K V.
Physiotherapist, Life Care Clinic, Kochi
Introduction
Physiotherapist in palliative care
In palliative care settings, physical therapists strive to

promote quality of life. Minimal research exists; however, to guide
therapists working with patients with terminal illness.1Physical
therapy for patients receiving palliative care is directed at
achieving symptom control, maximizing remaining functional
abilities, providing caregiver education, and contributing to
interdisciplinary team communication. 1
There is a paucity of physical therapy literature to educate,
guide, and support therapists involved in caring for patients who
are dying. 1The World Health Organization estimates that 15
million people will develop cancer in 2015, up from approximately
9 million people in 1985. Based on this information, the number
of older adult patients with cancer who require services, including
physical therapy, will continue to grow. 1
The value of physiotherapy in palliative care has been

increasingly recognized over the past few decades, with a shift
in emphasis from a predominantly medical/nursing model of care,
which focused primarily on symptom control, to a more interdisciplinary, rehabilitative approach.6 In patients with advancing
disease, where functional limitations are unavoidable, the
physiotherapist is the expert in helping both patients and carers
cope with these changes, whilst maximizing their potential to
achieve realistic goals and thereby achieve optimal quality of
life. 6
Physiotherapy in the palliative setting should aim to enhance
the patients quality of life. This may be achieved by improving
function, or where this is not possible, by improving the patients
and carers ability to cope with the patients deterioration. A
fundamental goal of palliative care is the relief of pain and other
symptoms.7
Safe, effective physiotherapy intervention involves:
Medical screening prior to referral to physiotherapy;
Thorough assessment and regular reassessment of the

patients physical status with an acute awareness of their
psychological, social, and spiritual well-being;
An awareness of the multidimensional nature of symptoms

such as pain, dyspnoea, and fatigue and an holistic
approach to their assessment and management;
Appropriate goal-setting according to the patients identified

problems and priorities;
Modification of goals as the patients condition changes;
A problem-solving approach to management;
Clear and sensitive communication with the patient, carers,

and the inter-disciplinary team;
Effective communication between hospital, hospice, and

community settings;
The fostering of hope and prevention of feelings of

abandonment. 6
Physiotherapy approaches and techniques included are
Palliative care
Palliative care is the active total care of patients whose
disease is unresponsive to curative treatment. Palliative care
aims to relieve suffering and improve the quality of life for patients
with advanced illnesses and their families through specific
knowledge and skills, including communication with patients and
family members; management of pain and other symptoms;
psychosocial, spiritual, and bereavement support; and
coordination of an array of medical and social services. 1
The 6 fundamental principles of palliative care are:
1. Affirm life and regard dying as a normal process.
2. Neither hasten nor postpone death.
3. Provide relief from pain and other distressing symptoms.
4. Integrate the psychological and spiritual aspects of patient
care.
5. Offer a support system to help patients live as actively as
possible until death.
6. Offer a support system to help family members cope during
the patients illness and their bereavement. 1
It is based on an interdisciplinary approach that is offered
simultaneously with other appropriate medical treatments and
involves close attention to the emotional, spiritual, and practical
needs and goals of patients and of the people who are close to
them.2Palliative care providers respect and attend to the
individual needs of each patient from a perspective of total pain,
defined as physical pain, emotional pain, psychological pain
spiritual pain. 1
Palliative care should be offered simultaneously with all
other medical treatment. 2Integration of palliative care as a
component of comprehensive intensive care is now seen as
more appropriate for all critically ill patients, including those
pursuing aggressive treatments to prolong life.3It can bring
considerable improvements in function and quality of life for
seriously ill people and their families and can reduce
psychological and spiritual distress.4 It is an approach that can
give a patient the opportunity to find purpose, self-worth, and
control at a time when they are experiencing a loss of
independence. 4
Disability in patients with advanced cancer often results
from bed rest, deconditioning, and neurologic and
musculoskeletal complications of cancer or cancer treatment.5
40
Education and Instructions

Physical therapy should focus on patient education
regarding comfortable and safe positions in which to rest or sit.
5
Comfortable or relaxed positioning with pillows for relief of
cancer pain,especially pain caused by bone metastasis and
abdominal discomfort.8 The physiotherapist may employ general
relaxation techniques to control anxiety that often augments other
symptoms, including pain.
Patients with vertebral metastasis are taught not to rotate
the back.
Education in care giving techniques, such as transfer
training and positioning for comfort, of any person construed by
the patient as a family member may decrease a familys
perceived stress of providing care and a patients concern about
being a burden.1Instruction by physical therapists in hands-on
techniques reassures families that they will not hurt patients
and that it is important to touch, thus fostering social relationships
and continuity in ways of relating that may have been disrupted
by age and terminal illness. 1
Therapists could provide opportunities to discuss the
patients values and beliefs.Physical therapists who are able to
Binoy Mathew K V. / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
listen to patients and discover the particular strategies the

patients are using may more effectively support these strategies
and integrate them into the format, focus, and goal setting used
in physical therapy interactions and interventions. 1 Therapists
who possess knowledge of their patients self-defining roles,
routine pursuits, and valued relationships may be better equipped
to tailor treatment to the individual. 1
By providing patients with opportunities to voice concerns,
grief, and reflections related to what they are going through and
by attentively listening to all that is said and intimated, clinicians
may gain an understanding of their patients death-related
anxieties. An intact knowledge of the physiological processes
of death and variability in psychological reactions will enable
physical therapists to share with patients and families answers
to general questions related to physiological signs and symptoms
of active dying and the typical sequence of events. Openly
communicating about the dying process, the normality of
fluctuating emotional levels and anticipatory grief may reduce
patients fear of the unknown and reinforce coping abilities. 1
Therapeutic exercise
Therapeutic exercise aimed at improvement in muscle
strength, range of motion and balance. Weak muscles are found
and strengthened.Active, active assisted, passive and stretching
exercises relieve and prevent joint contracture, muscle spasm
and deep vein thrombosis of the lower limbs. Proper sitting
balance is an important function, because it increases
individuality and activity and decreases complications of the bed
ridden. 8 Exercise can counteract the effects of inactivity and
improve psychologic status. There is also some evidence that
immune function may be improved by moderate exercise.
Intensity of exercise should be at the lower end of the range. 5
Pain related to a specific activity or the impact of pain on the
performance of daily activities must be considered when
prescribing exercise. 5 Exercise is an effective holistic intervention
as the patient may experience physical benefits such as
improved endurance, muscle strength and power, flexibility, and
balance in addition to psychological benefits such as
improvements in body image, confidence, social interaction, and
depression.6
Activities of Daily Living (ADL) exercises comprised bed
exercises such as changing and maintaining positions, transfer
from bed to wheelchair and from wheelchair to toilet, as well as
wheelchair exercises and ambulatory exercises. These exercises
are designed to enable patients to function with even a minimal
level of independence at the late terminal stage. 8
Endurance training aimed at physical fitness helps to
increase pulmonary and cardiovascular function. Chest
physiotherapy included diagraphmatic breathing exercises,
relaxation exercises and postural drainage. 8
Physical modalities
The use of physical modalities such as massage, heat,
and cold can be implemented at bedside and aid in the pain
management of patients. Their use may decrease the need for
pain medications. Heat can be applied as hot packs, moist heat,
and heat lamps. Heating soft tissues prior to a range of motion
exercises and activity can decrease pain and muscle spasm
and decrease joint stiffness. Heat should not be applied to skin
areas that are insensitive, have been exposed to radiation, or
are atrophic or acutely inflamed. Ice is usually applied as ice
packs, ice compression wraps, or ice massage. Cold packs
should be sealed, flexible enough to conform to body contours,
and applied to produce a comfortable and safe intensity of cold.
Cold therapy as heat is contraindicated for areas of atrophic
skin or skin that has been exposed to radiation therapy. Cold
therapy is also contraindicated for patients with Raynaud
phenomenon or on ischemic limbs. 5
Transcutaneous Electrical Nerve Stimulation (TENS) is the

most frequently used form of electro-therapy in the palliative
setting, generally used in the treatment of neuropathic, bone,
and chronic pain. Physiotherapists working in palliative care are
now increasingly using acupuncture to treat pain in palliative
patients.9
Assistive Devices
The prescription of assistive devices, such as canes,
walkers, and crutches, and the teaching of compensatory
techniques for mobility can aid in ambulation. 5 Environmental
modification and simple equipment such as tub benches, raised
toilets, and handlebars can have a significant impact in patients
overall function and aid in preserving independence in activities
of daily living. 5 Supportive measures such as the provision of
collars, slings, splints can also reduce pain whilst optimizing
function and mobility. 5
Basically though the principles and approaches of
physiotherapy are the same, in palliative care precise
observations, frequent evaluations, sound clinical reasoning and
compassionate attitude is more important. Routine assessment
has been shown to identify overlooked and unreported
symptoms, facilitate treatment, and enhance patient and family
satisfaction Improved treatment of symptoms has been
associated with the enhancement of patient and family
satisfaction, functional status, quality of life, and other clinical
outcomes.
Palliative care and rehabilitation share common goals and
therapeutic approaches. Both disciplines have a multidisciplinary
model of care, which aims to improve patients levels of function
and comfort The rehabilitation of terminally ill patients has
received little attention, and there is scarce data to support its
efficacy.5 Rehabilitation is the process of helping a person to
reach the fullest physical, psychological, social, vocational, and
educational potential consistent with his or her physiologic or
anatomic impairment, environmental limitations, desires, and
life plans. 5 During the rehabilitation of terminally ill patients,
maintaining a balance between optimal function and comfort
becomes a key issue. Rehabilitation is unlikely to restore a
premorbid level of function to these patients but may provide a
reasonable degree of independence and quality of life. 5
Rehabilitation goals for patients with advanced cancer must be
realistic and take into consideration the stage of the disease;
the patients medical status, cognition, and prognosis; and the
site of planned discharge. 5 Rehabilitation becomes an essential
component of palliative care rather than an additional luxury.10 It
is an approach to care that focuses on setting goals, re-enabling
patients, and in helping them to adapt to their changed
circumstances so that they may live fulfilling lives
Rehabilitation in palliative care differs from rehabilitation in
general medicine. In palliative care, a rehabilitation programme
must be seen in the context of an illness that is uncertain and
will cause deterioration. Consequently, both patients and
professionals need to understand the implications of a poor
prognosis. 10
Palliative care clearly has an important role in patients with
non-cancer conditions who are in the advanced stages of their
illness and imminently dying. 10
The rehabilitative approach in palliative care is appropriate
in all health care settings. Physician, Nurses Physiotherapists,
occupational therapists, speech therapists, dietitians, social
services, counselors are the main members of the palliative care
team. 10
Physiotherapy is an important part of the rehabilitation
service. The inclusion of physiotherapists in palliative care teams
in hospitals, hospices, and in the community is therefore of vital
importance in helping to minimize patients discomfort and
maximize functional potential. 6
Factors related to functional improvement following a PT
Binoy Mathew K V. / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
41
course were a higher albumin level and a diagnosis of dementia.

Prospective trials of PT in palliative care patients are needed to
better define response rate and predictors of response.9
Patients must be supported with strategies to cope with a
life-threatening illness and, where possible, to come to terms
with impeding death. In these circumstances, goals that foster
insight and understanding may be more important than those
that facilitate physical independence. For some individuals, the
focus may be their comfort, ease, and solace10.
Palliative care clearly has an important role in patients with
non-cancer conditions who are in the advanced stages of their
illness and imminently dying. The most common serious chronic
diseases that are relevant to a non-cancer rehabilitation practice
are chronic pulmonary disease, end-stage cardiac disease, and
neurological disease. Chronic renal failure and end-stage liver
disease (ESLD) are also important to consider. Need for
rehabilitation in respiratory, cardiac, neurology patients, etc., is
unquestionable. 10
Conclusion
The physiotherapist has a vital role to play in maintaining
an optimal level of physical functioning in the palliative patient.
This must be achieved via a process of realistic goal-setting
with the patient, being aware of the patients psychosocial needs,
constant reassessment of the patient, and appropriate goalmodification. This translates to maximizing the patients
independence, and maintaining their hope in the face of
progressive disability.
42
References
1.
Mackey KM,Sparling JW. Experiences of older women with

cancer receiving hospice care: significance for physical
therapy. Phys Ther. 2000;80:459468.
2. R. Sean Morrison, M.D., and Diane E. Meier, Palliative Care,
N Engl J Med. 2004; 350
3. Nelson, Judith E.Danis, Marion. End-of-life care in the
intensive care unit: Where are we now? Critical Care
Medicine. 2001. 29(2) 2-9
4. Petty, T.L. Pulmonary rehabilitation in chronic respiratory
insufficiency: 1. Pulmonary rehabilitation in perspective:
historical roots, present status, and future projections.
Thorax. 1993; 48, 855-862
5. Juan Santiago-Palma, Richard Payne. Palliative Care and
Rehabilitation. Cancer. 2001; 92: 104952.
6. Luke Doyle, Jenny McClure, Sarah Fisher.The contribution
of physiotherapy to palliative medicine.Editors: Doyle,
Derek; Hanks, Geoffrey; Cherny, Nathan I.; Calman,
Kenneth.In Oxford Textbook of Palliative Medicine, 3rd
Edition,Oxford University Press
7. OGorman, B. and Elfred, A. Physiotherapy. In Cancer Pain
Management: A Comprehensive Approach (ed. K.H.
Simpson and K. Budd), 2000. Oxford University Press;pp.
63-73.
8. Yoshioka H.Rehabilitation for the terminal cancer
patient.Am J Phys Med Rehabil 1994;73:1999-206
9. Marcos Montagnini, Mohammed Lodhi, Wendi Born.
Journal of Palliative Medicine.2003, 6(1): 11-17
10. Petty, T.L. Pulmonary rehabilitation in chronic respiratory
insufficiency: 1. Pulmonary rehabilitation in perspective:
historical roots, present status, and future projections.
Thorax 1993 48, 855-862
Binoy Mathew K V. / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Comparing effectiveness of antero-posterior and postero-anterior

glides on shoulder range of motion in adhesive capsulitis - a pilot
study
Harsimran K*, Ranganath G**, Ravi SR**
*Department of Physiotherapy, Manipal University Karnataka, India. **Assistant Professor, Department of Physiotherapy, Manipal
University, Karnataka, India.
Abstract
Objective
To compare the effectiveness of antero-posterior (AP) and
postero-anterior (PA) glide mobilization on external rotation range
of motion (ROM) in patients with adhesive capsulitis.
Methodology
Patients referred to the department of physiotherapy with the
diagnosis of primary adhesive capsulitis were included in the
study. Subjects were from both gender groups between 35 to
70 years of age, with capsular pattern of shoulder. Total of 15
participants were included in the study by convenience sampling
and were randomized to 2 treatment groups (antero-posterior
i.e. AP and postero-anterior i.e. PA) by block randomization. AP
group consisted of 8 subjects & PA group consisted of 7 subjects.
Out of 15 subjects 10 completed the study & 5 were lost to
follow up. Kaltenborn grade III mobilizations were provided to
both the groups, with direction of mobilizations directed anteriorly
in one group & posteriorly in the other group.Improvement in
shoulder external rotation range of motion at 45 of abduction
was the primary outcome measure, with secondary outcome
measures as Visual Analogue Scale (VAS) pain scores.
Results
Descriptive analysis of 15 subjects using median and
interquartile values revealed that there was improvement in the
primary & secondary outcome measures in both the groups (AP
& PA). There was no clinically significant difference between
the 2 groups.
Observation
Both the glides antero-posterior (AP) and postero-anterior (PA)
showed to be effective on external rotation range of motion in
patients with adhesive capsulitis.
Keywords
Adhesive capsulitis, mobilization, concex-concave rule
Introduction
Adhesive capsulitis or frozen shoulder is one of the
common pathologies leading to shoulder pain & dysfunction.1
Its prevalence in general population is reported to be 2%, with
an 11% prevalence in individuals with diabetes. 2 Dense
adhesions & capsular restrictions in the dependent fold of the
capsule is characteristic of this condition.3 Adhesive capsulitis
Corresponding Address:
Harsimran Kaur
Department of Physiotherapy, Manipal college of Allied Health
Sciences, Manipal University, Manipal, Karnataka, India.
Email: simran.khurana.k@gmail.com
is more common in women between fourth and sixth decade of

their life.4
The onset of this condition is usually gradual and idiopathic,
but it may also be acute and associated with history of minor
injury to the shoulder.5 Adhesive capsulitis has been divided
into 2 types.3 Primary adhesive capsulitis, which refers to the
idiopathic form of a painful and stiff shoulder & secondary
adhesive capsulitis, indicated as a loss of motion resulting from
many predisposing factors such as trauma, diabetes, stroke,
upper extremity fractures or surgeries with immobilization.
Adhesive capsulitis is one of the most common, self limiting
disorders of the musculoskeletal system with a duration varying
from one to three years.6 Long term range of motion limitations
lasting from 2 to 10 years may be suffered by 20-50% patients
with adhesive capsulitis. According to Cyriax, tightness in a joint
capsule results in a pattern of proportional motion restriction,
called capsular pattern in which the range of motion of external
rotation is more limited than abduction, which in turn is more
limited than internal rotation.7
In Frozen shoulder, there is global loss of both passive and
active range of motion of the glenohumeral joint with external
rotation usually being the most restricted physiologic movement,
following the capsular pattern.8,9 This condition can be managed
by physical therapy 3, medical therapy 5, corticosteroid
intraarticular injections5, hydroplasty2, manipulation of the joint
under anaesthesia1 & surgical interventions.10 Physical therapy
can include stretching, heating modalities, strengthening
exercises and mobilizations. 5 Common joint mobilization
techniques incorporated for improvement in range of motion
deficits are inferior, postero-anterior (PA ) & antero-posterior
(AP) glides. According to Convex-Concave rule, the head of the
humerus glides anteriorly during external rotation.1 However in
adhesive capsulitis different areas of capsular adhesions maybe
seen, such as superior, anterior, inferior & posterior, causing
the humeral head to glide in a direction opposite to the capsular
tightness, called the Capsular Constraint Mechanism.11
Arthrokinematics of the joints are considerd according to
the convex-concave rule.12,13 However deviations from this rule
have been reported in the literature.14,15 According to Howell et
al with elevation and maximal lateral rotation of the arm, the
center of the humeral head was positioned 4 mm posterior to
the center of the glenoid cavity, which is in contrast to the ConvexConcave rule.13,14 Similarly Harryman et al reported that with
extension & lateral rotation, the humeral head translated
posteriorly, which according to him was due to asymmetrical
tightening of the capsule during humeral rotation resulting in
translation of the humeral head in the direction opposite to the
tightened capsule called Capsular Constraint Mechanism.13,15
Mid range mobilization (MRM), end range mobilization
(ERM), & mobilization with movement (MWM) techniques have
been advocated by Maitland, 16 Kaltenborn,17 Mulligan. 18
respectively. Kaltenborns concept of joint mobilization includes
three grades of mobilization.17Grade I are small amplitude
distraction applied with no stress on the capsule, grade II are
distraction/ glide applied to tighten the tissues around the capsule
& grade III are large amplitude distraction/glide to stretch joint
capsule & surrounding periarticular structures.
Traditionally postero-anterior (PA) glides of the humeral
head have been used to improve external rotation range of
motion, which is the direction of choice based on the Convex -
Harsimran K / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
43
Concave rule.17 However; Roubal et al & Johnson et al on the

contrary found that antero-posterior (AP) glide is effective in
improving external rotation range of motion in patients with
adhesive capsulitis, which is in accordance with Capsular
Constraint Mechanism.9,19
In order to assess the function of patients with shoulder
problems objectively, measurement of shoulder range of motion
with universal goniometer is advocated. Intratester and
Intertester reliability of measuring passive range of motion for
lateral rotation of the shoulder complex was found to be similar
i.e 0.96 and 0.97 respectively.20
Methods
A pre-test post-test study was conducted, involving the
patients referred to Physiotherapy department with the diagnosis
of adhesive capsulitis. Subjects included in the study were males
& females between 35 & 70 years of age, in their subacute or
chronic stage with capsular pattern of shoulder i.e. external
rotation range of motion more limited than abduction, which in
turn is more limited than internal rotation.Subjects with capsular
tightness were differentiated from muscular tightness i.e.
subjects with external rotation range restricted that worsened
with abduction of shoulder were included in the study. Patients
with diabetes, neurological disorders, previous history of trauma
or surgery of the affected shoulder were excluded from the study
. Total of 15 patients were included in the study by convenience
sampling. Procedure was explained in detail & written informed
consent was obtained from them. Subjects were then
randomized in 2 treatment groups by block randomization, group
AP (antero-posterior) & PA (postero-anterior). During
Randomization 3 blocks were used, with each block consisting
of 6 units (3 AP & 3 PA). Two blocks out of 3 were utilized
completely & from the 3rd block only 3 units were used. After
allocation, group AP consisted of 8 & group PA consisted of 7
Figure 1: Antero-posterior mobilization
subjects.
Investigators
Two investigators (qualified physical therapists) were
involved in the study. Primary investigator performed the
mobilization technique and second investigator was blinded to
the group allocation of the participants and measured range of
motion before and after every treatment session.
Outcome measures & instruments
Primary outcome measure selected was external rotation
ROM at 45, with secondary measures as Visual Analogue Scale
(VAS) pain scores. Universal Goniometer was used for
measurement of shoulder ROMs and 10 cm Visual Analogue
Scale was used for recording pain scores.
Procedure
Treatment technique selected was Kaltenborn grade III
mobilizations. Prior to intervention, demographic data i.e. age
(in years), height (in cm), weight (in kg), dominant side, affected
side & duration of symptoms (in months) were recorded. Baseline
clinical characteristics that were recorded prior to first treatment
session included VAS pain scores, shoulder abduction ROM,
internal rotation & external rotation ROM at 45 of shoulder
abduction.
The shoulder range of motion was measured by the
universal goniometer with the patient in supine on the treatment
table. The baseline data & subsequent measurements after every
treatment session were recorded by the second investigator of
the study. Subjects were followed up for 5 consecutive treatment
sessions, with 1 session provided per day. Prior to mobilization,
moist heat was applied to the target shoulder for a time period
of 15 minutes. Patients were positioned appropriately on the
treatment table in supine position for AP glide mobilization
(Figure 1) & in prone position for PA glide mobilization (Figure
2). Affected limb was taken to available abduction range of motion
and grade III Kaltenborn mobilizations were provided for 30
Figure 2: Postero-anterior mobilization
Table 1: Comparison of demographic data by group (Median & interquartile range)

Group Gender
Age(in years)
Height(in cms)
Weight(in kgs)
AP
PA
AP =
PA =
M=
F=
M=5F=3
52(50-57.8)
M=4F=3
56(49-62)
antero-posterior group
postero-anterior group
Males
Females
164.5(159-175.2)
161.5(149-176.7)
67(55.2-77.8)
62(57-75)
Table 2: Comparison of clinical characteristics at baseline by group (Median & interquartile range)
GP
VAS
ABD
IR45
AP
5.5(4.25-7)
90(90-107.5)
60(41.25-80)
PA
5(5-6)
90(85-120)
40(30-80)
GP = Groups
VAS = Visual Analogue Scale
ABD = Shoulder abduction
IR45 = Internal rotation ROM at 45 abduction
ER45 = External rotation ROM at 45 abduction
44
Duration ofSymptoms
(in months)
3(3-3.75)
1.5(1-7)
ER45
33.5(30-42.5)
20(16-55)
Harsimran K / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Figure 4: Comparison of ROMs by group (Median & interquartile

range)
ROM (DEGREES)
VAS SCORE DIFF
Figure 3: Comparison of VAS scores by group (Median &

interquartile range)
Group :
Group :
X-axis: Groups, AP = antero-posterior group, PA = posteroanterior group

Y-axis: Difference in VAS scores pre & post treatment
ABD= abduction ROM, IR45= internal rotation at 45 abduction,

ER45= external rotation at 45 abduction
seconds duration. This technique was repeated for 5 times in 1

treatment session. Physiologic movements of the affected
extremity were provided for 1 minute after every 30 seconds of
mobilization procedure. Post mobilization, moist heat was
applied again for 15 minutes, followed by Codmans exercises
and finger ladder exercises.3 Subjects were then advised to
continue the same exercises at home.
Baseline clinical characteristics , showed similarity in VAS pain

scores, abduction ROM & internal rotation ROM at available
end range of abduction. But variations were observed in external
& internal rotation ROM at 45 abduction and external rotation
at available end range of abduction.
Five subjects out of fifteen were lost to follow up. Three
were from AP group and two from PA group. Two subjects from
AP group underwent Manipulation under anaesthesia and other
three subjects could not be followed due to personal constraints.
Data of these five subjects was analyzed for intention to treat
analysis. None of the patients included in the study reported of
any kind of trauma or surgery minor or major of the affected
shoulder. All the 15 subjects were right side dominant & nine
out of them had their non-dominant side as the affected side.
Onset of symptoms was reported to be of gradual in nature in
most of the subjects. At baseline both the groups showed
similarity with regards to VAS pain scores & reduction in pain
scores was observed in both the groups over a period of five
treatment sessions. This reduction in pain was seen to be almost
similar in both the groups and was considered to be clinically
significant.
In case of shoulder ROMs, improvement was observed in
all the shoulder ranges in both the groups, with the exception of
internal rotation ROM at 45 of abduction, where no change in
ROM was observed over five treatment sessions. This result
could be attributed to the fact that internal rotation at 45
abduction in most of the subjects was nearly full prior to the
treatment & did not change in subsequent treatment sessions.
Improvement observed in ROMs seems to be more in AP group
as compared to PA group, for abduction, external rotation at 45
& internal rotation at end range of abduction, whereas PA group
seems to better for external rotation at end range of abduction.
However, the improvements observed are not clinically
significant. These changes observed could be due to small
sample size or standard measurement errors.
Results of our study seem to be different from the study by
Johnson et al, where improvement in external rotation was found
in AP group, as no clinically significant improvement was
observed in external rotation ROM at 45 and end range of
available abduction in our study. However the two studies are
not comparable as no statistical test of significance was
performed in our study due to small sample size. Improvements
seen in the primary outcome (i.e. external rotation at 45
abduction) in both the groups could be attributable to either of
the two mechanisms;Concave-convex rule which might be
responsible for improvement in PA group or capsular constraint
mechanism which might be responsible for improvement in AP
group. There were some limitations of the present study like
external rotation ROM was not measured at the same available
end range abduction , where the initial value was measured
and Daily pre-treatment VAS & external rotation ROM values
Data analysis
As being a pilot study, statistical tests of significance were
not used. Data analysis was done using SPSS Version 16.0.
Analysis was done by descriptive statistics. Median &
Interquartile values were observed for all 15 participants. The
primary outcome of the treatment was based on the change in
median values of external rotation range of motion (at 45 & at
end range of available abduction) from 1st treatment session till
the 5th session and secondary outcomes were based on change
in VAS pain score from 1st treatment session till the 5th session.
There was a loss to follow up of 5 participants out of 15,
Median values of the lost data were included in the analysis for
intention to treat analysis.
Results
Total of 15 subjects gave written informed consent and
participated in the present study. Out of them 10 participants
completed all 5 treatment sessions and 5 were lost to follow up.
From this lost data 3 were from AP group and 2 from PA group.
Comparison of the median values of the demographic data (age,
height, weight, duration of symptoms) of both the groups was
done. (Table 1). Groups were also compared at baseline for
VAS pain scores and shoulder range of motion (abduction,
external rotation at 45 & end range of available abduction,
internal rotation at 45 & end range of available abduction). (Table
2). Median values of VAS and external rotation range of motion
(at 45 & end of availiable abduction) were compared for change
from 1st treatmant session to the 5th session. (Figure 3 & Figure
4 respectively)
Discussion
The results of present study show that both the mobilizations
(i.e. AP & PA) are effective in improving external rotation ROM
in patients with adhesive capsulitis. Demographic data of both
the groups was seen to be similar, with the exception of duration
of symptoms (DOS), where median value of DOS in AP group
was 3 months and in PA group was one and half. There were 5
males & 3 females in AP group and 4 males & 3 females in PA
group. Hence both the gender had almost equal representation.
Harsimran K / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
45
9.
were not recorded.
Conclusion
Both the glides antero-posterior (AP) and postero-anterior
(PA) showed to be effective on external rotation ROM in patients
with adhesive capsulitis. Study with larger sample size and
keeping all the limitations in mind is recommended.
10.
11.
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2.
3.
4.
5.
6.
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Harsimran K / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Effect of 12 weeks weight bearing and non weight bearing aerobic

exercises on overweight and obese individuals
J. Deepa1, Monalisa Pattnaik2, P.P Mohanty3, Venkadesan. R4
Post Graduate Student1, Lecturer2, Head of the Department3, Swami Vivekananda National Institute of Rehabilitation Training and
Research (SVNIRTAR), Cuttack, Orissa, Lecturer4, Lovely Professional University, Jalandhar, India
Abstract
Objective
To find out the effect of 12 weeks weight bearing and non weight
bearing aerobic exercises on overweight and obese individuals
Methods
Thirty subjects were selected and divided into three groups; 10
in each, namely group I, group II and group III. Subjects in group
I received weight bearing aerobic exercise, subjects in the group
II received non weight bearing aerobic exercise and subjects in
the group III received no treatment. Treatment outcomes were
assessed on the basis of abdominal circumference, skin Fold
Thickness, body mass, resting heart rate and resting systolic
BP.
Results & Conclusion

There is no difference between weight bearing aerobic exercise
and non weight bearing aerobic exercise performed at similar
intensity, duration and frequency with regard to abdominal
circumference, skin fold thickness, body mass, resting heart rate
and resting systolic blood pressure. This suggests that non
weight bearing aerobic exercise and weight bearing aerobic
exercise are equally beneficial as a weight reduction program
Keywords
Obesity, Aerobic exercise, Weight bearing, Non weight bearing
Introduction
Obesity is defined simply as a condition of abnormal or
excessive fat accumulation in adipose tissue, to that extent that
health may be impaired1. Obesity is a world wide epidemic6,
with more than one billion adults overweight, at least 300 million
of them being clinically obese and is a major contributor of global
burden of chronic diseases and disability 2. Health care
professionals should be concerned about overweight and obesity
because of the well established relations between excess body
weight and such medical conditions as Hypertension, Coronary
heart disease, Type II diabetes mellitus, Stroke, Osteoarthritis
and other chronic disorders, that reduce the quality of life2,3,4,5,6.
In 1997, World Health Organization published a landmark
document recognizing obesity as a world wide disease1. The
WHO recently stated that the growth in the number of severely
overweight adults is expected to be double that of underweight
during 1995 2025 (WHO 1998). An Indian study recently
revealed that almost 20% adults who were not overweight or
obese still had central obesity, putting them at a greater risk of
developing associated disease (Gopalan 1998)7. Obesity in
adulthood is associated with an increased risk of disability
throughout life and a reduction in the length of time spent free
of disability, but no substantial change in the length of time spent
with disability1,7. Strong evidence links obesity to increased
morbidity and mortality6,8,9. Excess body weight is a result of an
imbalance between energy intake and energy expenditure

resulting in the storage of the excess energy, primarily as fat10.
The important fact that is to be considered is that in case of
obese persons the deposition of the fat takes place in the exterior
(subcutaneous tissue), around the internal organ, and the
intermuscular space, which makes the obese person further
inactive8. On the other hand, sustained elevation of energy output
to levels greater than those of energy input creates an energy
imbalance that reverses this process10. Based on scientific
evidence, there are a number of intervention strategies that can
be used to induce and maintain significant weight loss11. In the
human system, energy expenditure has three primary outlets:
(i). Resting metabolic rate. (ii) The thermic effect of food. (iii).
Physical activity, of the three outlets, physical activity is the one
most readily manipulated. An increase in physical exercise thus
appears to be a logical method for achieving the negative energy
balance necessary for weight loss10, 32. In human beings, adipose
tissue constitutes the major form of energy storage. It follows
logically that in situations of negative energy balance, fat stores
will be called upon to make up the energy deficit, thus reducing
the total amount of body fat and producing a loss in weight10.
Although caloric value remains the cornerstone of obesity
reduction, physical activity in the form of structural exercise
contributes to the creation of an energy deficit by increasing
total energy expenditure & that the exercise induced weight loss
is associated with greater reduction in total body fat, a
preservation of lean tissue mass & an increase in cardiorespiratory fitness, in comparison with equivalent diet induced
weight loss12. Aerobic exercise for the obese population should
concentrate on the frequency of sessions. Low intensity exercise
is often considered the most appropriate method of increasing
energy expenditure for weight loss purposes because the
proportion of lipid organized under these conditions is higher
than that oxidized during vigorous exercise10, 12. Robert Ross et
al in the year 2000 conducted a randomized controlled trial which
aimed at determining the effects of equivalent diet or exercise
induced weight loss & exercise without weight loss on
subcutaneous fat, visceral fat, skeletal muscle mass & insulin
sensitivity in obese men. The study was conducted with 52
obese men for 3 months. He concluded that weight loss induced
by increased daily physical activity without caloric restriction
substantially reduces obesity and exercise without weight loss
reduces abdominal fat and prevents further weight gain13. There
are people who are referred for weight reduction programme
but still cannot carry out common weight reduction programmes
which involves weight bearing activities like walking, running,
jumping, stair climbing etc. eg. Osteoarthritis and ligament injury
patients whose conditions may be worsened when they carry
out such activities. So there is a necessity to design weight
reduction program for such disabled people.
A current comment on energy expenditure is different
modes of exercise written for the American college of sports
medicine by Len Kravitz Ph. D & Chantal A. Vella M.S has
explained that at the same level of intensity, most persons will
expend more calories performing a weight bearing activity14. But
still the individual effects of weight bearing and non weight
bearing exercise on obesity & compared effects of the weight
bearing and non weight bearing exercise remains to be
investigated. Therefore this study is aimed to determine the
effectiveness of weight bearing and non weight bearing aerobic
J. Deepa / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
47
exercise in overweight and obese individuals.
Methods
Subjects: A total of 30 subjects with obesity were selected
in SVNIRTAR, between Nov 2005 to Dec 2006 by random
sampling method. They volunteered to take part in the study
and met the following inclusion criteria: (i) Male/female. (ii)
Age: 20-45 yrs. (iii) BMI: 25-35. (iv) Subjects who meet the
physical activity readiness questionnaire.Exclusion criteria
were (i). Uncontrolled Hypertension. (ii) Pregnancy. (iii) Use of
any medication that affect the body composition, lipids or glucose
metabolism. (iv) Activity restriction due to disease, unstable
cardiac or pulmonary disease, significant arthritis. (v) Diabetes
Mellitus. All participants gave their written informed consent
before participation in the study. Before initiation of the study,
institutional review board approval was obtained.
Procedure
The subjects were divided into three groups; 10 in each,
namely group I, group II and group III. After the assignment into
groups, a day before the exercise program started, all the
subjects were subjected to baseline measurements. The resting
heart rate, resting blood pressure, abdominal circumference,
skin fold thickness and body mass were tested in order, by the
investigator. The therapy was started the day after the
measurement was taken. Subjects in group I received weight
bearing aerobic exercise, subjects in the group II received non
weight bearing aerobic exercise and subjects in the group III
received no treatment. All the subjects were informed not to
change their eating habits and not to take any medications to
reduce weight, and subjects in the control group (group III) were
also asked not to participate in any extra physical activities more
than they do normally. The subjects in group I & II received
aerobic exercise 5days in a week for 12 weeks, at an intensity
of 40% to 50% of THR calculated using Karvonens formula. It
was confirmed that none of the subjects in the study received
any other form of exercise. The data were collected after 12
weeks and was statistically analysed.
Data analysis
The dependent variables were analysed using 3 X 2
ANOVA, with repeated measures of the second factor. There
was one between factor with three levels (Group weight bearing
aerobic exercise, non weight bearing aerobic exercise and
control group), and one within factor with two levels (Time
pre, post). All pair wise, post-hoc comparisons were done using
a 0.05 level of significance.
Results
ABDOMINAL CIRCUMFERENCE: There was a main effect for
time F 1,27,0.05 = 26.817, p = 0.000 and there was also a main
effect for time X group interaction, F 2,27,0.05 =11.397, p = 0.000.
However there was no main effect for group F 2,27,0.05 = 0.516, p
= 0.603. Tukeys HSD analysis showed that both the weight
bearing and non weight bearing aerobic exercise group improved
significantly compared to the control group. However, there was
no significant difference between the exercise groups.
SKIN FOLD THICKNESS: There was a main effect for time, F
= 81.343, p = 0.000 and there was no main effect for
group, F 2,27,0.05 = 2.164, p = 0.134. However the main effect
was qualified by time X group interaction, F 2,27,0.05 = 32.828, p =
0.000. Tukeys HSD analysis showed that both the weight
1,27,0.05
48
BODY MASS: There was a main effect for time, F 1,27,0.05 = 16 ,

p = 0.000and there was also a main effect for time X group
interaction, F 2,27,0.05 = 15.063, p = 0.000. However there was no
main effect for group F 2,27,0.05 = 0.050, p = 0.952. Tukeys HSD
analysis showed that both the weight bearing and non weight
bearing aerobic exercise group improved significantly compared
to the control group. However, there was no significant difference
between the exercise groups.
RESTING HEART RATE: There was a main effect for time F
= 95.184, p = 0.000 and there was a main effect for time
1,27,0.05
X group interaction F 2,27,0.05 = 32.423, p = 0.000. However the
main effect for the group was also qualified, F 2,27,0.05 = 5.238, p
= 0.012. Tukeys HSD analysis showed that both the weight
RESTING SYSTOLIC BLOOD PRESSURE: There was a main
effect for time, F 1,27,0.05 = 86.901, p = 0.000 and there was no
main effect for group, F 2,27,0.05 = 0.564, p = 0.575. However this
main effect was qualified by time X group interaction, F 2,27,0.05 =
21.725, p = 0.000. Tukeys HSD analysis showed that both the
weight bearing and non weight bearing aerobic exercise group
improved significantly compared to the control group. However,
there was no significant difference between the exercise groups.
Discussion
The overall results of the study showed reduction in
abdominal circumference, skin fold thickness, body mass, resting
heart rate and resting systolic blood pressure in both weight
bearing aerobic exercise group and non weight bearing aerobic
exercise group compared to the control group. However there
was no statistically significant difference between the
experimental groups with regard to the above variables. This
study suggests that the results obtained with non weight bearing
exercise were as beneficial as those obtained with the weight
bearing aerobic exercise in overweight and obese individuals.
ABDOMINAL CIRCUMFERENCE: The findings of the study
showed significant reduction in abdominal circumference
measured at the level of umbilicus in both the exercise groups
compared with the control group. However there was no
significant difference between the exercise groups. This is
supported by the following studies. In 2001 Daniel W. Schmidt
in his study of long versus short bout exercise on fitness and
weight loss in female college students found significant reduction
in abdominal girth measurement (at the level of umbilicus).
Sojung Lee et al (2005) found significant reduction in waist
circumference (at the level of the last rib) in a 13 week aerobic
exercise intervention program that consisted of either walking
or light jogging on a treadmill for 60 minutes, 5 times per week
at a moderate intensity (60% of peak oxygen uptake). Jakicic
et al in 1999 conducted a randomized trial in sedentary
overweight women evaluating the effects of intermittent with
traditional continuous exercise on weight loss, adherence and
fitness in which there was significant reduction in the waist
circumference following 18 month program which included
exercise and behavioural weight control program. Hideki
shimamoto in 1998 compared the effectiveness of low impact
aerobic dance for 60 minutes for a total duration of 3 months,
consisting of diet and exercise prescription found significant
reduction in the waist circumference.The reduction in abdominal
circumference in this study can be attributed to reduction in
abdominal fat, which is not reduced selectively from the
exercised areas, but rather from total body fat reserves and is
usually from the areas of greatest fat concentration. It is believed
that an increase in a muscles activity facilitates a relatively
greater fat mobilization from the storage areas. Excess fat in
J. Deepa / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
APPENDIX
MASTER CHART
S. No Group Sex
Age
Abdominal
circumference
Pre
Post
Test
Test
1
2
3
4
5
6
7
8
9
10
1
1
1
1
1
1
1
1
1
1
M
M
F
F
F
F
F
F
F
M
39.00
39.00
33.00
32.00
20.00
28.00
21.00
20.00
20.00
28.00
95.50
92.00
94.00
91.00
109.00
90.20
86.00
90.00
92.00
86.00
93.60
91.00
84.00
91.00
99.00
88.50
83.50
80.00
85.50
85.00
11
12
13
5
16
17
18
19
20
2
2
2
2
2
2
2
2
2
M
M
M
F
F
F
F
M
M
20.00
26.00
38.00
20.00
42.00
20.00
20.00
28.00
38.00
96.00
97.00
94.00
104.50
94.00
76.00
82.00
89.00
95.00
91.00
93.00
88.50
100.30
87.00
73.00
78.00
87.00
93.00
21
22
23
24
25
26
27
28
29
30
3
3
3
3
3
3
3
3
3
3
F
F
F
F
M
M
M
M
M
M
38.00
32.00
23.00
22.00
41.00
26.00
26.00
36.00
29.00
28.00
93.50
90.00
88.00
90.00
94.50
96.00
84.00
92.00
100.00
96.00
96.00
90.00
89.00
90.00
94.50
98.00
86.00
92.00
100.00
96.00
Skin Fold
Thickness
Pret
Post
Test
Test
Group-I
154.32 125.99
130.31 100.31
140.31 118.33
148.65 111.30
152.99 128.32
135.65 104.64
142.99 118.66
148.65 132.66
146.62 123.63
147.89 110.90
Group-II
68.65 140.32
97.32 90.64
111.32 103.32
206.98 181.98
186.99 133.98
124.32 99.99
126.64 84.32
146.32 133.65
121.66 101.32
Group-III
189.66 193.33
151.98 152.00
147.98 160.00
147.99 147.33
150.66 154.32
153.31 156.00
101.98 108.32
114.65 116.65
160.98 171.33
150.99 152.66
the abdominal area is more active metabolically than fat located

in the other areas 33. The lack of significant difference in
abdominal circumference reduction between the weight bearing
and non weight bearing aerobic exercise group may be attributed
that both the exercises had similar effects.
SKIN FOLD THICKNESS: This study demonstrated significant
reduction in skin fold thickness in both the experimental groups
compared with the control group. However there was no
significant difference between the experimental groups. These
findings are supported by the following studies. Slentz et al
(2005) in a randomized controlled trial found significant
decreases in visceral, subcutaneous and total abdominal fat,
without changes in caloric intake. Robert Ross et al (2005)
reported significant reductions in subcutaneous adipose tissue
and visceral adipose tissue. Robert Ross and Janssen
colleagues (2004) conducted a 14 week intervention program
reported greater reduction in total fat and abdominal
subcutaneous fat in the exercise group. Susan B Racette et al
(1995) reported significant reduction in fat mass in the aerobic
exercise group. Brocham CAG et al (2005) examined the effect
of 8 weeks of stair climbing on blood lipids reported significant
reduction in low density lipoprotein cholesterol. The reduction
in skin fold thickness may be attributed to the mobilization of
lipids from adipose tissue which plays a key role in the regulation
of free fatty acid use as a energy substrate for skeletal muscle
metabolism during endurance exercise, especially prolonged
exercise of low to moderate intensity. The rate of mobilization
of free fatty acid from adipose tissue is largely dependent on
the rate of lipolysis. Rate of adipose tissue lipolysis increases
with exercise duration. Adipose tissue lipolysis is under hormonal
Body mass
Pre
Test
Post
Test
Resting
Heart Rate
Pre
Post
Test
Test
Resting
Systolic BP
Pre
Post
Test
Test
73.00
67.00
69.00
67.00
75.00
77.00
65.00
68.00
73.00
70.00
72.00
67.00
67.50
67.00
73.00
77.00
64.00
66.50
70.50
69.50
82.00
85.00
93.00
90.00
90.00
87.00
85.00
90.00
92.00
88.00
77.00
81.00
87.00
78.00
85.00
80.00
78.00
84.00
82.00
88.00
126.00
110.00
120.00
110.00
120.00
116.00
110.00
110.00
110.00
120.00
120.00
106.00
118.00
102.00
116.00
110.00
100.00
104.00
104.00
118.00
66.00
90.00
77.00
86.00
65.00
55.00
57.00
65.00
71.00
66.00
89.00
76.00
85.00
63.00
55.00
55.00
63.00
70.00
78.00
84.00
89.00
88.00
90.00
89.00
89.00
85.00
87.00
72.00
78.00
83.00
82.00
87.00
82.00
84.00
80.00
81.00
120.00
110.00
120.00
110.00
120.00
110.00
110.00
120.00
120.00
116.00
100.00
116.00
106.00
118.00
100.00
104.00
114.00
116.00
66.00
52.00
59.00
65.00
72.00
79.00
72.00
67.00
91.00
84.50
67.00
52.00
60.00
65.00
73.00
80.00
73.00
67.00
91.00
84.50
89.00
88.00
89.00
90.00
83.00
86.00
87.00
88.00
92.00
88.00
89.00
90.00
89.00
90.00
83.00
89.00
88.00
88.00
92.00
88.00
118.00
110.00
110.00
110.00
126.00
120.00
110.00
120.00
120.00
110.00
118.00
110.00
110.00
110.00
126.00
120.00
110.00
120.00
120.00
110.00
regulation. The essential changes promoting increased lipolysis

during whole-body exercise are increased sympathoadrenal adrenergic stimulation and decreased circulating insulin levels.
Upon their mobilization from adipose tissue, free fatty acid
circulate in plasma. The exercise induced increase in plasma
FFA availability is important because it is a contributing factor
for the regulation of FFA use by muscle. During low to moderate
exercise intensity in humans, the gradual increase in plasma
FFA concentration is associated with an increase in the FFA
turnover and oxidation35. The main effect with time in both the
weight bearing and non weight bearing aerobic exercise group
may be attributed to the above fact. The lack of significant
difference between the weight bearing and non weight bearing
exercise group reveals that both the exercise has contributed
similar effects.
BODY MASS: The result of this study showed significant
reduction in body mass in both the non weight bearing and weight
bearing aerobic exercise group compared with the control group.
However there was no significant difference between the
experimental groups. The findings are in accordance with the
following studies. In 2001 Daniel W. Schmidt et al evaluated the
effects of long versus short bout exercise on fitness and weight
loss in females in 12 week duration at an intensity of 75% of
heart rate reserve using treadmill found significant reduction in
body mass. Robert Ross and Janssen Colleagues (2004)
conducted a 14 week intervention program with brisk walking
and light jogging in treadmill and reported reduction in body
weight in exercise weight loss group. Slentz et al (2005)
conducted a randomized controlled study of exercise intensity
and amount for duration of 8 months, reported significant
49
reduction in body weight with the exercise group. The significant

reduction in body mass in both the weight bearing and non weight
bearing aerobic exercise groups with time might be ascribed to
unbalancing the energy balance equation by increasing caloric
output through endurance-type exercise 33 . The lack of
significance difference between the weight bearing and non
weight bearing aerobic exercise group suggests that both the
exercises has attributed similar effects on body mass. The result
of this study differ from the study of Sojung Lee et al (2005) who
examined the effects of exercise without weight loss on obesity
reduction in obese individuals and did not find any significant
reduction in body weight following 13 week of aerobic exercise
as the subjects consumed the calories required to compensate
for the energy expended during the exercise session.
CARDIOVASCULAR ENDURANCE (RESTING HEART RATE
AND RESTING SYSTOLIC BLOOD PRESSURE) : The current
study demonstrated significant improvement in the
cardiovascular endurance (Resting heart rate and resting systolic
blood pressure) in both the weight bearing and non weight
bearing aerobic exercise group compared to the control group.
However there was no significant difference between the
experimental groups. The findings are in accordance with the
following studies. Daniel Schmidt et al (2001) aimed to determine
if three 10 minute bouts of exercise per day (3 X 10) and two 15
minute bouts per day (2 X 15) were as effective as one 30 minute
bout per day (1 X 30) for improving VO2max and weight loss
and found significant improvement in the VO2max and reduction
in the resting heart rate in the exercise groups, but not in the
control group. Marcia L. Stefanick (2000) examined the effects
of diet and exercise in men and menopausal women with low
levels of HDL cholesterol and high levels of LDL cholesterol
and found significant improvement in the maximal oxygen
uptake. Johan M. Jakicic et al (1999) examined the effects of
intermittent exercise and use of home exercise equipment and
found significant improvement in the cardio respiratory fitness
(resting heart rate, resting blood pressure). Anderson et al (1999)
examined effects of lifestyle activity vs. structured aerobic
exercise in obese women found significant improvement in
maximum oxygen capacity, reduction in resting heart rate and
resting blood pressure. The reduction in the resting heart rate in
the weight bearing and non weight bearing aerobic exercise
group over the control group in the present study can be
attributed to the central adaptations. Stimulation of the
sympathetic cardioaccelerator nerves releases epinephrine and
norepinephrine, which accelerate the depolarization of the sinus
node. Acetylcholine, the hormone of the parasympathetic
nervous system, retards the rate of sinus discharge and slows
the heart rate. The effect is largely mediated through the action
of the vagus nerve whose cell-bodies originate in the cardioinhibitory centre in the medulla. Vagal stimulation has essentially
no effect on myocardial contractility. Exercise training creates
an imbalance between tonic activity of the sympathetic
accelerator and parasympathetic depressor neurons in favour
of greater vagal dominance. This is mediated primarily by an
increase in parasympathetic activity perhaps a decrease in
sympathetic discharge. In addition, training may also decrease
the intrinsic rate of firing of SA node. The lack of significant
difference between the exercise groups attributes that both the
exercises have similar effects. The mechanism for the exerciselowering effect on blood pressure in weight bearing and non
weight bearing aerobic exercise may be due to the reduction of
the catecholamines with training. This response would contribute
to a decrease in peripheral resistance to blood flow and a
subsequent reduction in blood pressure. Exercise training may
also facilitate the elimination of sodium by the kidneys to
subsequently reduce fluid volume and blood pressure33, 36. The
main effect with time in both the weight bearing and non weight
bearing aerobic exercise group may be attributed to the above
50
fact. The lack of significant difference between the exercise

groups attributes that both the exercises have similar effects.
The lack of significant difference between the weight bearing
and non weight bearing aerobic exercise groups in all the
variables may be due to the fact that both the weight bearing
and non weight bearing aerobic exercises were performed at
same intensity, duration and frequency.
Conclusion
There is no difference between weight bearing aerobic
exercise and non weight bearing aerobic exercise performed at
similar intensity, duration and frequency with regard to abdominal
circumference, skin fold thickness, body mass, resting heart rate
and resting systolic blood pressure. This suggests that non
weight bearing aerobic exercise and weight bearing aerobic
exercise are equally beneficial as a weight reduction program.
The above findings suggests that non weight bearing aerobic
exercise can be prescribed as a weight reduction program for
the individuals who should not carry out weight bearing activities
as a prophylaxis measure and cannot perform weight bearing
activities owing to pain and other disabilities.
Limitations
(i) Small sample size
(ii) Carry over effect of the exercise group was not observed.
(iii) Other aspects like visceral fat, lipid levels, cholesterol levels,
energy expenditure index and aerobic capacity which are
closely related to obesity program was not observed.
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and visceral adipose tissue in men. J. Appl. Physiol. 1996;
81;6;2445 2455.
30. Susan B. Rachette et al. Effects of aerobic exercise and
dietary carbohydrate on energy expenditure and body
composition during weight reduction in obese women. Am.
J. Clin Nutrn. 1995; 61; 486 94.
31. Barbara J. de Lateur. Application of exercise to fat
reduction. Physical Medicine and Rehabilitation Clinics of
North America. 1994; vol. 5; No. 2; 309 316.
32. Darren E. R. Warburton et al. Health benefits fo physical
activity: The evidence. Review. CMAJ. March 2006; 174;
6; 801 9.
33. William. D. McArdle, Frank. I. Katch and victor L. Katch.
Exercise Physiology. Fifth edition. Lippincott Williams and
Wilkins.
34. Frank J. Cerny. Harold W. Burton. Exercise physiology for
health care professionals. 2001. Human Kinetics.
35. Larraine D. Turcotte. Role of fats in exercise. Types and
quality. Clinics in sports medicine. July 1999; vol.18; No.
3; 485 498.
36. ACSMs resources for clinical exercise physiology.
Lippincott Williams and Wilkins 2002.
37. Peter G. Kopelman. Clinical problems caused by obesity.
Chapter 13. March 2002. Endotext.com obesity,
Behaviour modification for obesity.
51
Effect of functional strength training on functional motor

performance in young children with cerebral palsy
Dharam Pani Pandey*, Vimal Tyagi**
*Head Department of Physiotherapy & Rehabilitation Sciences, Jaipur Golden Hospital, Rohini Delhi-110085, **Lecturer Physiotherapy,
Imperial University, Lucknow, UP
Abstract
Keywords
Objective
Functional strength training, Cerebral Palsy, Functional Motor

Performance.
The main objective of this study was to determine the effects

of task-specific strength training of lower limb on functional motor
performance in children with spastic cerebral palsy, and to assess
the feasibility of closed kinetic chain exercise on functional
motor abilities in children with cerebral palsy.
Design of study
A single blinded randomized controlled intervention study
consisted of two groups and three measurements, pre
intervention, post intervention and follow up.
Participants
18 children with spastic diplegia among them 11 were male
and 7 were female. All the subjects were received physiotherapy
previously and none were allowed to attend physiotherapy other
than intervention protocol.
Main outcome Measures

Functional strength was assessed by Lateral step up test,
functional motor performance was assessed by minimum height
chair test, motor assessment scale( sit to stand item), 10 meter
walk test, 2- minute walk test.
Results
The lateral step up test of both, the left leg (p=0.002),
(F=22.57) and the right leg (p=0.001), (F=44.8) demonstrated
the significant improvement where as control group did not
showed any such significant improvement, left leg (p=0.502),
(F=0.476) and right leg (p=0.332), (F=1). Motor assessment
scale sit-to stand item showed significant (p=0.041), (F=4.92)
change pre to post training as compared to control group.
Minimum height chair test score demonstrated significant
improvement in intervention group (p=0.001) post training. In
control group there was no such significant (p=0.88),) F=0.02)
changes noted. All the gain in intervention group was maintained
at follow up without any significant decline.
Conclusion
The result of present randomized clinical study support the
view that a four week functional strength training programme
consisting of weight bearing exercises functional strength of
muscle of lower extremity and also improves functional motor
performance such as walking, running, stair climbing, sit to stand
in young children with spastic diplegic cerebral palsy, the finding
are in agreement with other previous studies which have shown
that functional strength training in cerebral palsy is associated
with improvement in motor functions. Results of this study
provides the ground for future research with a larger sample
size and longer follow up and with more severe form of cerebral
palsy.
52
Cerebral palsy is term for a range of non-progressive

syndrome of posture and motor impairment that results from
insult to developing central nervous system.1
Cerebral palsy is most common developmental disorder of
children first described by William little in 1861.2 being the most
common physical disability in childhood which results from a
non progressive injury to the developing central nervous system.
Cerebral palsy has many neurological disorders of which motor
impairment is most remarkable.
These impairments include3
1) increased muscle tone
2) impaired muscle control
3) Decreased muscle strength.
The primary culprit of motor performance has been
debatable for long time.3 Muscle strength is a reflection of motor
control and evidence now strongly supports that increased
muscle strength results in better performance.3,4,5,6. It is evident
that muscle weakness has impact on motor performance and
that an increase in muscle strength could improve motor
performance. 6,10
Several studies in children provide evidence in support of
this training and exercise approach. Investigations of effect of
exercises for lower limb muscles demonstrated the increase in
strength and function in children with cerebral palsy, 10, 11 with no
increase in spasticity. 14, 17, 21 These positive results are in
agreement with several studies of adults following stroke also.
Many of previous study method were based on open chain
(non-weight bearing) training. 6,9,10, 12,15,18,19 The gain in strength
may enhance functional motor performance if strengthening
exercises are involves more practice of functionally related
closed kinetic chain (weight bearing) exercise.15
Our main objective of present study was
1) To determine the effects of task-specific strength training
of lower limb on functional motor performance in children
with spastic cerebral palsy.
2) To determine the feasibility of closed kinetic chain exercise
on functional motor abilities in children with cerebral palsy.

Subjects: Invited subjects in the study were 18 children
with spastic diplegia among them 11 were male and 7 were
female. All the subjects were received physiotherapy previously
and none were allowed to attend physiotherapy other than
intervention protocol.
Inclusion criteria
1.
2.
3.
4.
Spastic cerebral palsy children aged between 5-10 years.

Able to walk with or without aids.
Able to extend knee from 90 degree to 45 degree or more
in sitting position with full passive range of motion in supine.
No known mental impairment (understand simple command
given by therapist.)
Dharam Pani Pandey / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
5.
Able to flex knee to 90 degree in prone position without

simultaneous hip flexion.
6. Spasticity grade to or less than 2 on modified ashworth
scale( Hip adductor/abdductor, knee flexor, ankle planter
flexor)
Subjects with known cognitive impairment, orthopedic/
medical condition that prevent from exercising, cerebellar
symptom, known visual, speech, hearing disorders, systemic
medical problem which prevent from exercising, lower limb
surgery within 12 months, on anticonvulsant. antispastic
medication and those non-ambulatory were excluded from study.
A convenience sample of twenty six children aged from 5
to10 years were invited to participate in the study among them
23 were male and 7 were female all the subjects had the
diagnosis of spastic diplegia . After assessment only 18 children
were qualified the inclusion criteria. All the children and parents
were Informed about the purpose of study and gave written and
verbal consent to participate in the study, All eligible subjects
were randomly assigned to intervention (n-9) group and control
group (n-9)
All eligible subjects were randomly assigned to intervention
group and control group, through use of random number
generator with sealed envelopes.
The study employed a randomized single blind controlled
trial design consisting of two group and three measurement ,
training was conducted in one-hour sessions twice a week for
four weeks
where as control group did not showed any such significant

improvement, left leg (p=0.502), (F=0.476) and right leg
(p=0.332),(F=1). Motor assessment scale sit-to stand item
showed significant (p=0.041),(F=4.92) change pre to post
training as compared to control group. Minimum height chair
test score demonstrated significant improvement in intervention
group (p=0.001) post training. In control group there was no
such significant (p=0.88),(F=0.02) changes noted. There was
also significant improvement in intervention group in walking
speed (p=.0015), children walked faster with improved stride
length (p=0.024), took less time to complete 10 meter walk test
(p=0.0013) and also they walked more distance at 2-minute walk
test (p=0.034).where in control group changes did not reached
significant level. All the gain in intervention group was maintained
at follow up without any significant decline.
Discussion
The unstabelised motion against resistance, not only
improved balance and coordination but also helps nervous
system and muscle to learn to operate more efficiently, increases
the integrity of joints, connective tissue and improves the
performance of the central nervous system. Impairments
Graph 1: showing comparison between interventions and control
group score of lateral step up test of left leg.(Mean value)
Outcome measures
Lower extremity functional strength was tested with the
Lateral Step-up Test, using 22 cm height stable step13,20 the
number of step-ups performed in 15 seconds was recorded using
a stop watch . Functional motor performance: Minimum height
chair-Test was done using draughtsman adjustable height chair
without arm rest, lowest value of tree successive repetitions was
recorded. Motor Assessment (sit-to-stand item) test was carried
out using motor assessment scale (developed by Carr and
Shepherd 1987). The stride length, cadence and speed were
then calculated from the score of 10 meter walk test. 2-minute
walk test was used to assessed the walking speed.
Graph 2: showing comparison between intervention and control

group score of lateral step up test of right leg.(Mean value)
Intervention
Each session started with warm-up stretches of major
muscle groups (hip flexors, adductors, knee flexors, extensors
planter flexors). Children then move to practice functional training
and exercises designed to strengthen lower limb muscles,
improve segmental control of the lower limbs, and improve
balance which included bilateral heel raises, sit to stand, standing
balance exercises, step up, vestibular ball supported half squat.
The therapist supervised the training, giving individual training
with assistance from parents each session.
Data analysis
To examine the effect of training on functional motor
performance and lower extremity functional strength .A repeated
measures of ANOVA were performed using data analysis
software Biostat 2007 Professional.

group score of sit to stand test.(Mean value)
Results
Functional strength test and functional performance score
both demonstrated the significant improvement following training
and maintenance of the gains at follow up in intervention group,
whereas control group did not showed such significant changes.
Functional Strength test: The lateral step up test of both,
the left leg (p=0.002),(F=22.57) and the right leg
(p=0.001),(F=44.8) demonstrated the significant improvement
Dharam Pani Pandey / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
53

group score of minimum height chair test.(Mean value)

group score of 2 minute walk test.(Mean value)

group score of 10 m walk test.(Mean value)

group score of walking speed.(Mean value)
Table 1:
Intervention Group
TEST
LSUT Lt (Reps)
LSUT Rt (Reps)
Pre training
(A)
M
SD
3.11
0.72
3.2
0.8
Post training
(B)
M
SD
5.9
1.5
6.3
1.12
Follow up
M
SD
5.55
1.24
6.44
1.01
A-B Effect
F
22.51
44.8
p
*0.0002
*0.0001
B-C Effect
F
0.0339
0.0488
p
0.8562
0.828
Table 2: The table reports the means and standard deviations at pre training, post training and follow up. F score and p values of pre
training to post training (A-B) effect and post training to follow up (B-C) effect comparisons
Control Group
TEST
Pre training
Post training
Follow up
A-B Effect
B-C Effect
(A)
(B)
M
SD
M
SD
M
SD
F
p
F
p
LSUT Lt (Reps)
3.22
0.83
3
0.6
2.8
0.463
0.476
0.5025
1
0.332
LSUT Rt (Reps)
2.9
0.6
2.67
0.53
2.56
0.74
1
0.332
0.1081
0.746
training to post training (A-B) effect and post training to follow up (B-C) effect comparisons.
Result of fst - intervention group
TEST
Pre training
Post training
Follow up
A-B Effect
B-C Effect
(A)
(B)
M
SD
M
SD
M
SD
F
p
F
P
LSUT Lt (Reps)
3.11
0.72
5.9
1.5
5.55
1.24
22.51
*0.0002
0.0339
0.8562
LSUT Rt (Reps)
3.2
0.8
6.3
1.12
6.44
1.01
44.8
*0.0001
0.0488
0.828
MST-STS Score
2.22
1.56
3.3
0.9
3.3
0.7
3.4783
0.0806
0.3459
0.5646
Min.chair height(cm)
21
7.1
17
1.8
16.7
1.39
46.623
*0.001
3459
0.5646
Walking speed (m/s)
0.54
0.08
0.7
0.1
0.71
0.13 14.6269
*0.0015
0.0431
0.8382
Stride length (m)
0.63
0.16
0.63
0.1
0.63
0.059
6.1762
0.0244 0.02221
0.6438
Cadence (steps/min)
111
10
127
11
132
17.8
6.7121
0.0197
0.5541
0.4674
10-m walk test (m)
19.7
3.12
15.1
1.72
14.4
2.34 15.0517
*0.0013
0.5067
0.4868
2-m walk test (s)
66.4
9.58
87.1
13.1
85.8
16.4 13.6386
*0.002
0.0348
0.8544
54
Dharam Pani Pandey / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
training to post training (A-B) effect and post training to follow up (B-C) effect comparisons. (Result of functional test Control group)
TEST
Pre training
Post training
Follow up
A-B Effect
B-C Effect
(A)
(B)
M
SD
M
SD
M
SD
F
p
F
p
LSUT Lt (Reps)
3.22
0.83
3
0.6
2.8
0.463
0.476
0.5025
1
0.332
LSUT Rt (Reps)
2.9
0.6
2.67
0.53
2.56
0.74
1
0.332
0.1081
0.746
MAS-STS Score
1075
0.71
2
1
2
1
0.6667
0.4262
0
1
Min.chair height(cm)
23
1.7
23
1.6
22.67
1.3
0.0209
0.8867
0.0237 0.8797
Walking speed (m/s)
0.59
0.09
0.6
0.1
0.62
0.08
0.0008
0.9784
0.4124 0.5298
Stride length (m)
0.58
0.14
0.6
0.1
0.67
0.1
0.0084
0.9282
0.3255 0.8591
Cadence (steps/min)
125
27
127
26
126
24.7
0.0179
0.8953
0.0008 0.9779
10-m walk test (m)
20.4
3.15
16.7
2.92
17.3
2.82
0.1113
0.743
0.0025 0.9404
2-m walk test (s)
74
11.7
74
10.4
75.2
9.82
0.0056
0.9415
0.2944 0.5949
affecting muscle strength and motor control are major causes
of motor performance deficit in children with cerebral palsy. 6,7,10,11
Non weight bearing exercises may have limited
transferability as compared to weight bearing exercises as weight
bearing training involves different and more complex pattern of
muscle activation, the gain in strength may transfer better in to
improvements of functional motor performance if strengthening
exercises involves the practice of more functionally related
closed kinetic chain exercises.16,18
The present study examined the repetitive practice of weight
bearing (closed kinetic chain) exercises with similar
characteristics to those normally found in many functional
activities that involves lower extremity in support, balance.
Exercises included in this study have the potential to train
the motor performance such as coordination, balance, strength,
endurance and physical conditioning. The practice these task
related exercises are expected to refine the efficient motor
patterns.
7.
Conclusion
13.
The present study examined the repetitive practice of weight

bearing (closed kinetic chain) exercises with similar
characteristics to those normally found in many functional
activities that involves lower extremity in support, balance, and
results suggests that a four week functional strength training
programme should be considered in clinical practice while
dealing with pediatric population.
Limitations: This study has limitation in smaller sample size
and only one follow up post training. Never the less the finding
are in agreement with other previous studies which have shown
that functional strength training in cerebral palsy is associated
with improvement in motor functions.
References
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Cerebral Palsy: An overview Wajid Ali et.al Curr Pediatr
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K.Tammic el.al. Neuromuscular function in children with
spastic cerebral palsy Brain and development
2007,29(9):553-558
K.J Dodd et al.A randomized clinical trial of strength training
in young people with cerebral palsy. Dev Med & Child Neu
2003, 45: 652657
C.Andersson et al. Adults with cerebral palsy: walking ability
after progressive strength training ,Dev Med & Child Neu
2003, 45: 220228
Damiano D et.al Effect of quadriceps femoris muscle
strengthening on crouch gait in children with spastic
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Giuliani CA. Dorsal rhizotomy for children with cerebral

palsy: support for concepts of motor control. Phys Ther
1991; 71: 24859.
Engsberg JR, et al. Hip spasticity and strength in children
with spastic diplegia cerebral palsy. J Appl Biomech 2000;
16: 22133.
MacPhail HE, Kramer JF. Effect of isokinetic strength
training on functional ability and walking efficiency in
adolescents with cerebral palsy. Dev Med Child Neurol
1995; 37: 76375.
Damiano DL, et.al Muscle response to heavy resistance
exercise in children with spastic cerebral palsy. Dev Med
Child Neurol 1995; 37: 73139.
Jack R Engsberg et.al. Ankle spasticity and strength in
children with spastic diplegic cerebral palsy DevMedicine
& Child Neurology 2000, 42: 4247
Damiano DL, Kelly LE, Vaughan CL. Effects of quadriceps
femoris muscle strengthening on crouch gait in children
with spastic diplegia. Phys Ther 1995; 75: 65871.
Worrell TW, Borchert B, Erner K. Effect of a lateral step-up
exercise protocol on quadriceps and lower extremity
performance. J Orthop Sports Phys Ther 1993; 18: 646
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Fowler EG, Ho TW, Nwigwe AI et al. The effects of
quadriceps femoris muscle strengthening exercises on
spasticity in children with cerebral palsy. Phys Ther 2001;
81: 121523.
Diane L Damiano et.al. Should we be testing and training
muscle strength in cerebral palsy? Developmental Medicine
& Child Neurology 2002, 44: 6872
SW Blundell, RB Shepherd, CM Dean, RD Adams,
Functional strength training in cerebral palsy: a pilot study
of a group circuit training class for children aged 48 years
Clinical Rehabilitation 2003; 1 7: 4857
Fowler EG, Kolobe THA, Damiano DL, et al Developmental
Medicine & Child Neurology 2004, 46: 580589 Promotion
of physical fitness and prevention of secondary conditions
for children with cerebral palsy: Section on Pediatrics
Research Summit Proceedings. Phys Ther. 2007;87:1495
1510.
Shepherd RB. Physiotherapy in pediatrics, third edition.
Oxford: Butterworth-Heinemann, 1995.
Damiano DL.et.al. Activity, activity, activity: rethinking our
physical therapy approach to cerebral palsy. Phys.Ther.
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Ross M. Testretest reliability of the Lateral Step-up Test in
young adult healthy subjects. J Orthop Sports Phys.Ther
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Dharam Pani Pandey / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
55
Effect of post isometric relaxation on pain intensity, functional

disability and cervical range of motion in myofacial pain of upper
trapezius
Dheeraj Lamba*, Satish Pant**
*Incharge, Physiotherapy IAHSET, Medical College Haldwani, **(B.P.T. Final Year) IAHSET, Haldwani.
Introduction
Instruments
MPS is the most common overlooked cause of chronic

disability. Chronic pain leads to depression, physical
deconditioning due to sleep disturbances, lack of exercise and
other psychological and behavioral disturbances. A recent
epidemiological study of young women (age 20-40 years)
revealed that MFP occurs in about 30% of this population, with
6% having symptoms severe enough to require treatment. Fore
muscles trapezius, levator scapulae, infraspinatus and scalenus
accounted for 84.7% of the trigger points. Out of these four
trapezius account for 34.7% and levator scapulae constitute
19.7% of trigger points .Upper trapezius is the most common
muscle for development of Myofascial trigger point.
Myofascial pain is the pain that drives from Myofascial
trigger points which are small highly sensitive areas in muscles.
Trigger points are characterized by hypersensitive palpable, taut
bands of muscles that are painful on palpation and reproduce
patients symptoms and cause referred pain. Myofascial pain
syndrome has been termed Myofascial pain, myofibrositis,
myogelosis, myalgia and Myofascial pain dysfunction when it is
associated with temporomandibular joint dysfunction. There are
a lot of perpetuating factors for it like postural, mechanical,
environmental stresses emotional stresses and external
compression.
1.
2.
3.
4.
Purpose
1.
2.
To find out the effectiveness of post isometric relaxation

technique on pain intensity, functional, disability, cervical
range of motion in patients with myofascial pain of upper
trapezius.
To find out effectiveness of five treatment sessions.
Methodology
Sample
30 subjects (19 females, 11 males) with myofascial pain of
upper trapezius participated in this study. The subjects were
recruited from the Sushila Tiwari Hospital, Haldwani. Subjects
were of mean age 28.2 years and all subjects were diagnosed
by orthopedics surgeons of Sushila Tiwari Hospital. The subjects
were selected on the basis of inclusion and exclusion criteria
and were recruited to the group randomly.
Inclusion Criteria
1.Both male and females.
2.Age groups 18-35 years.
3.Active trigger point of
upper trapezius.
Exclusion Criteria
1.History of trauma to the neck.
2.Sprain/ strains in cervical
spine
3.Malignancies
4.Congenital anomalies
5.Upper quarter surgery
6.Neurological deficit
7.Generalized inflammatory
diseases
8.No known cardiac conditions
Design
This is an experimental design.
56
Moist hot pack

Measuring tape
VAS
N.D.I.
Protocol
Based on inclusion and exclusion criteria, subjects were
included in the study. Convenient sampling with random
allocation to the two groups. Group A (control group) standard
therapy i.e. hot pack, ischemic compression, auto stretch and
ergonomic advices were given. Group B (experimental group)
received standard therapy and post isometric relaxation.
Procedure
Group a (control group)
All Patients in this group received hot pack for 15 min
followed by ischemic compression for upper trapezius muscle.
They were advised to perform auto stretches for upper trapezius
at home. The stretches were performed in 3 sets, 3 times a day
for a total duration of 5 days. Before starting the treatment
therapist palpated patients upper trapezius muscle for the trigger
point with the help of pincher grip and flat palpation. Then local
twitch response and jump sign were recorded in the assessment
form. In subject having more than one active trigger point, the
most hypersensitive point was selected and marked by using
the permanent marker. Before starting the treatment on zero
day, patients were made to fill VAS, N.D.I.
Hot Pack
Subject was made to lie down in prone lying position with a
pillow under his legs for relaxation and his head resting on his
palm. Then hot pack wrapped in 4layers of towel was applied
on upper trapezius of the side to be treated for 15 minutes. It
was followed by ischemic compression.
Ischemic compression
After hot pack treatment, therapist placed his thumb on the
trigger point. Thumb was pressed against the trigger point till
nail bed blenching took place and then pressure was further
increased up to subjects tolerance. Subject was instructed to
raise hand when he could not beat pain anymore. It was held
for 30 second. After compression, band- aid was applied on the
trigger point to avoid confusion on next therapy session.
Auto stretch
Following this treatment subject was taught auto- stretches
for upper trapezius as home program. Subject was made to fix
his right arm (if right side trigger point) by hooking the seat of
chair on which he was sitting and then was asked to vend the
neck away from the side on which shoulder was fixed. While
maintaining this position he was instructed to move his neck
forward and finally to rotate their neck to side of pain. If he felt
enough stretch in this position only then the stretch was
considered to be effective. Otherwise he was made to increase
the stretch by keeping his left hand on the head and stretch was
imposed by the hanging weight of the arm. The stretch was
sustained for 30 second followed by relaxation for 30 seconds.
Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Subject was instructed to do stretching 3 times per sitting and 3

times a day.
Ergonomic advice
1. Sit on a chair with armrest not on without armrest.
2. Avoid static posture for prolonged period.
3. Do not sit too long in a position when watching T.V., or at a
mover theater. At interval move your head from side to side
and rotate your shoulder.
4. Do not try to lift heavy piece of furniture by yourself or to
carry anything on your head.
5. Sleeping posture- For patients who preferred side lying were
instructed to tuck the corner of pillow around between the
lower most shoulder and chin. For subjects who preferred
supine lying were instructed to use only on pillow under
the head. Patients were instructed to avoid prone lying.
6. Reading- always read with neck properly supported and
arm resting on arms of chair and try to keep book at the
level of eyes and avoid prolong bending of neck.
7. Womens were advised to avoid carrying bags on one
shoulder. A wide strap is helpful when it is want across the
body.
8. Females were instructed to use handbags with short slings
and were instructed to hang them on the acromion.
9. Women were advised to avoid tight strap bra and were
advised to use elastic strap bra.
10. Driving while driving they were instructed to hold steering
wheel with one hand at
bottom and with the forearm supinated and rested on thigh.
Group B (Experimental group)
All subject in this group received above described standard
therapy i.e. hot pack for 15 minutes followed by ischemic
compression as given for group A. In addition to this post
isometric relaxation (Lewit) was given for upper trapezius. Before
starting the treatment on first day, patients were made to fill
VAS, N.D.I. and their range of motion was measured by using
tape method.
After getting ischemic compression, subject was made to
lie down on plinth in supine lying. A pillow was given under his
knees to relax hamstring muscles. Then therapists one hand
was placed on the ipsilateral shoulder (affected side shoulder)
and cupped the mastoid area of the same side of the head with
other hand. Then neck and head were moved away (side bend)
maximum from the affected shoulder till the restriction was met.
Subject was instructed to move the ear towards the shoulder of
the affected side and the same shoulder towards the ear, against
the resistance of the therapists hands with minimum force (only
20%of there total force). For this he was firstly asked to was
their maximum force and with reference to this he was instructed
to was only20% of their force. No movement was allowed to
occur at neck so that it resulted in the isometric contraction of
upper trapezius. During this procedure he was instructed to see
towards the side away from which head was bent and hold their
breath. He was made to hold this position for 10 seconds subject
was instructed to exhale completely and relax. During this
relaxation phase head and neck were taken further away from
ipsilateral shoulder and ipsilateral shoulder was pushed
downward until next restriction is met. Stretch was stopped at
the slightest resistance. From this new position the procedure
was repeated. care was taken that the range of motion gained
was not lost during isometric contraction. This procedure was
repeated 3 times. After this, subject was taught auto stretching
procedure like group A and were given ergonomic advices.
He was made to demonstrated for the first time and then
he was instructed to repeat 3 times per set and 3 times per day
for 5 days.
Data analysis
It was done by using SPSS software version 11.0. All the
variables of age, VAS,NDI, right lateral flexion, left lateral flexion,
right lateral rotation and left lateral rotation were analyses by
using paired t test within group A and group B.
Variable of VAS, NDI, right lateral flexion, lateral flexion,
right lateral rotation and left lateral rotation were analyzed by
using independent t test between group A and group B.
Data analysis of rate of improvement between group A and
group B was done for variable of VAS, NDI, tight lateral flexion
left lateral flexion, tight lateral rotation and left lateral rotation by
using independent t test.
Statistical significance was set at (p<0.05) level.
Results
Analysis of age of Group A and Group B was done but on
comparison no significant difference gas been observed. (table
5.1)
Analysis of VAS, NDI ,and cervical range of motion (Right
and left lateral flexion and lateral rotation) was done between
group A and group B on 0 day 5th day. The results showed no
significant difference in VAS,NDI and Cervical range of motion (
right and left lateral flexion and lateral rotation) on 0 day. But
there was a significant difference in NDI on 5th day. (Table5.2)
On analyzing the data within group A and group B results
showed significant difference in VAS, NDI cervical range of
motion (right and left lateral flexion and lateral rotation) on 5th
day. (table5.3)
Table 5.1: Demographic Data
Variable Group AMeant. Group BMeant
+ S.D
+ S.D
27.3 + 2.7
Age
28.2 + 2.5
t
value
0.973
p
value
0.339
Table 5.2: Comparison of VAS, NDI, Cervical Range of motion between. Group A and Group B on 0 day to 5th day.
Variable
Days
Group A
Group B
t value
p value
Mean+S.D.
Mean+S.D.
6.27+ 1.2
0.619
0.541
VAS
0
6 + 1.1
3.2+ 1.3
1.824
0.079
5
4 +1.1
NDI
0
49.9 +12.4
51.02+14.8
0.215
0.831
26.3+ 13
2.210
0.035
5
35.6+ 9.6
5.09 +1.1
0.018
0.086
Right lateral flexion
0
5.1+ 0.9
6.41+ 1.2
1.528
0.138
5
5.83+ 0.90
5.1+1.0
0.202
0.84
Left lateral flexion
0
5.65+0.9
5.35+1.0
1.914
0.066
5
5.65+0.9
Right lateral rotation
0
7.64+1.3
7.84+1.8
0.452
0.655
8.6+1.0
0.815
0.423
5
8.27+1.4
7.82+1.2
0.351
0.728
Left lateral rotation
0
7.66+1.3
8.71+1.1
1.078
0.290
5
8.23+13
VSA: - Visual Analog Scale
NDI: - Neck Disability Index
Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
57
Table 5.4 explains the comparison of rate o improvement

in pain intensity, neck disability and cervical range of motion
(right and left lateral flexion and rotation) from 0 day to 5th day.
The results show significant improvement in both the group.
But on comparison, Group B is giving more significant results.
Discussion
The result showed that both the treatment method i.e.

ischemic compression and post isometric relaxation are effective
in reducing pain, functional disability and improving cervical
range of motion. But the rate of improvement in group B which
received both therapies is more.
The significant results of ischemic compression treatment
explained the effectiveness of this treatment due to ischemia
Table 5.3: Comparison of the VAS, NDI, Cervical range of motion within. Group A and Group B on 0 to 5th day.
t value
Variable
Group
0day
5th day
Mean+S.D.
Mean+S.D.
4+1.1
14.491
VAS
Group A
6+1.0
3.20+1.2
4.869
Group B
6.2+1.2
35.6+9.6
11.23
NDI
Group A
49.9+12.4
Group B
51.0+14.8
26.3+13.0
8.04
5.8+0.9
14.83
Group A
5.1+0.9
6.4+1.1
23.12
Group B
5.1+1.1
5.6+0.9
15.31
Group A
5.0+0.9
5.3+1.1
20.94
Group B
5.1+1.0
8.2+1.4
4.09
Group A
7.6+1.3
Group B
7.8+1.0
8.6+1.0
7.37
8.23+1.3
11.76
Group A
7.6+1.2
8.7+1.1
8.708
Group B
7.8+1.2
NDI: - Neck Disability Index
p value
.000
.00
.000
.000
.000
.000
.000
.000
00.1
.000
.000
.000
Table 5.4: Comparison of the rate of improvement in VAS, NDI,Cervical range if motion between Group A and Group B from 0 day
to 5th day
Variable
Group A
Group B
t value
p value
3.06+.79
4.2
.000
VAS
2+.53
24.62+11.85
3.1
.004
NDI
14.28+4.9
1.32+.22
7.7
.000
.733+1.9
1.2+.22
8.6
.000
.62+.15
.80+.42
28
.368
.63+.59
.88+.39
28
.007
.56+.18
NDI: - Neck Disability Index.
Fig 5.1: Graphical representation of VAS in graph A and Group
B on 0 day and 5th day.
Fig 5.2: Graphical representation of Neck disability index in

Group A and Group B on 0 day to 5th day.
Fig 5.3: Graphical representation of right lateral flexion in Graph

A and Graph B on 0 day to 5th day
Fig 5.4: Graphical representation of left lateral flexion in Group

A and Group B on 0 day to 5th day
58
Fig 5.5: Graphical representation of right lateral rotation in Graph

A and Graph B on 0 day to 5th day
Fig 5.6: Graphical representation of left lateral rotation in Group

A and Group B on 0 day 5th day
followed by hyperemia of the muscle. The skin first balanced

and then shows reactive hyperemia. The changes in perfusion
of the skin likely corresponds to the circulatory changes in the
muscle beneath, which was subjected to the same pressure.
This may inactivate the trigger points as ischemia is removed
from flushing the blood into the vessels Similarly Chuen RuHeu et. L. reported that hot pack followed by ischemia
compression for 30 sec is most effective in decreasing pain. It
was suggested that it may result from reactive hyperemia in the
Myofascial trigger points, counter- irritation effects or spinal reflex
mechanism for the relief of muscle spasm. Another theory for its
effectiveness is the Melzack and Wall Pain Gate theory, on
giving ischemic compression mechanoreceptors ate stimulated,
initiating an interference with pain messages teaching the brain.
This 5 days study did not produced any significant results
but the rate of improvement was more in-group B who received
post isometric relaxation in combination with ischemic
compression. According to literature upper trapezius gas three
fibers anterior, middle and posterior and the stretching maneuver
for each fiber is different. With the neck side bent and not rotated
only anterior fibers are being treated. So, this might be the cause
for significant results. The study might have shown significant
results if isolated treatment to each fiber would have given. But
rate of improvement was more in-group which received post
isometric relaxation in combination with ischemic compression.
But the time period over which accumulation or rate of
improvement took place was small (5 days). So it might be
another cause for non significant result at the end.
The significant increase in rate of improvement in group B
can be due to post isometric relaxation. It is in consistence with
different studies.
improvement took place was small thus it could not produce

any significant difference at end. Secondly, the results might
have come significant if all the fibers of upper trapezius wound
have been treated.
Conclusion
Result of present study reported no significant difference
in the effects of post isometric relaxation with ischemic
compression when compared to ischemic compression on pain
intensity, cervical range of motion (lateral flexion and lateral
rotation.) But this study does not conclude by stating that post
isometric relaxation is an ineffective intervention as significant
difference in rate of improvement was found in group which
received post isometric relaxation with ischemic compression.
Since the duration over which accumulation of rate of
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post-isometric relaxation Archives of Physical Medicine
& Rehabilitation 65, 45-57, 1984
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myofascial pain. The Mount Sinai Journal of Medicine 58 ,
235-249, 1991
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Williams and Wilkins, 1990.
59
The effect of foot orthoses on energy consumption in runners

with flat foot
F.Farmani1, M.Sadeghi2, H.Saeedi3, M.Kamali3
1
MSc in Orthotics and Prosthetics, Iran University of Medical Sciences, Tehran, Iran. 2PhD student of physical therapy, Tehran
University of Medical Sciences. 3Academic staff of Faculty of Rehabilitation Sciences, Mohseni Square, Tehran University of Medical
Sciences, Iran.
Abstract
Foot orthosis uses as conservative treatment in subjects
with flatfoot. This study aimed at assessing the effects of Foot
orthosis on Energy consumption in 20 runner subjects with Flat
foot. In this study treadmill and Quark b2 oxygen consumption
device were used. In the first stage patients did not wear Foot
orthoses.Then in the second stage for each patient prepared a
pair of suitable foot orthosis and they wore orthoses. The
maximum running Heart rate, vo2 max and vo2 of the patients
with Flat foot were measured and calculated with and without
Foot orthoses. statistical analysis indicated significantly less HR,
VO2, VO2 max in before and after use of foot orthoses on runners
with flat foot. (P-Value <0.05). Foot orthoses result in realignment
of lower extremity Joints in patient with flat foot, thus lengthTension Relationship of muscles improves. this prevent of fatigue
on this muscles, when he run in long- distance. Finally, when
suitable Foot orthoses was applied energy consumption during
running decreased.
Key words
Energy consumption, Foot orthoses , Flat Foot
Introduction
Foot is changed more than other parts of body. One of the
most important and changeable structural characteristics of foot
is height of medial longitudinal arch on bearing the weight (1).
Flat foot is a trouble in which the height of medial longitudinal
arch is lost or reduced. Flat foot can be flexible or rigid. The
people who suffered from flat foot have a lot of biomechanical
inefficiencies in foot and ankle and they also become involved
in unusual walking. (2). Flat foot can cause biomechanical
irregularities in running of athlete and this leads to pain of Achilles
tendon, pain of shank, pain of heel, hamstring strain, quadriceps
strain, knee pain, backache and premature fatigue (3,4). In the
people who suffered from flat foot, muscular activity of lower
limb is changed because of biomechanical changes. Mostly,
these people express premature fatigue while walking and this
problem is due to high activities of their muscles (5). In treating
the flat foot, using usual shoes which have supporters of medial
arch or medical shoes is common (6). The main function of
orthosis in flat foot which is flexible is improving the direction of
foot bones and returning them back to normal direction. Runners
use foot orthoses in order to avoid injuries, rehabilitation of
injuries, enhancing the comfort and improving the efficiency (7).
Most of these bony-muscular injuries are accompanied with
kinematic alterations of muscular activity due to structural and
abnormal direction of foot. One of the advantages of using
orthosis is related to reducing muscular activity which is required
for stability or axial control of lower limb rotations and guiding
foot alignment. Primary studies showed considerable changes
in activity of foot muscles with using insoles. To describe these
changes, it is noted that orthosis reduces muscular activity with
controlling abnormal movement of joint (5).
It is assumed that biomechanical imbalances is expressed
60
more in runners who suffered from flat foot because of enhancing

the forces which are sustained by body and this will cause
muscular fatigue and increasing the energy consumption in
runners (5)Amount of energy consumption is very important for
runners because of individual and collective competitions, speed
and endurance running races and it can be considered by
medicine society. So in this way, compensating flat foot which
has been done by insoles would be very important. The aim of
this research is to investigate and compare the effect of foot
orthoses on energy consumption in runners who suffered from
flat foot.

This research was done pseudo empirically with the type
of simple improbable on 20 athletic men who affected by flexible
flatness on two sides of foot. These persons are selected among
runners who have referred Enqelab Sports Complex of Tehran
that didnt have any cardiovascular and pulmonary diseases or
operation surgery in lower limbs, deformity in lower limbs and
psychological diseases. Average age of these persons is 23
and average BMI (body mass index) of them is 21.99 kg/m2 and
the place of performing the research was physical education
assessment center which is located on National Academy of
Olympic. First, testable person completed questionnaire
contained required information after filling consent form for
participating in the study. Then foot of patient was assessed in
order to determine and diagnose flat foot based on arch ratio
which is obtained by dividing posterior surface of foot middle
point up to land level on the length of area which is extended
from behind the heel to the internal middle of first
metatarsophalangeal joint. For this, testable person asked stand
up barefooted with equal distribution of weight on two feet. In
these conditions, height of posterior surface of foot to land level
is measured in parallel with foot,s middle point. Moreover, the
figure of foot was drawn on a paper which was placed under the
foot. Then the length of that foot area which was extended from
behind the heel to medial middle of the first metatarsophalangeal
joint was measured and finally, height of foot is divided on target
length (8 ).
If the presence of flat foot is diagnosed, patient should be
placed in the mode with not bearing the weight in order to finalize
about the presence of flexible flat foot. In the event that flexible
flat foot is observed, patient has been provided for molding.
Then the patient should be lied down on his stomach and molding
plaster with type of negative mold was prepared from the feet of
patient and then a pair of insoles made of leather and supportive
foam of longitudinal arch was made. Testable person received
the insole and placed it in his shoes and he came to the test
place after two weeks of using the insoles. A pair of sneakers
was given to each participant in a way that all snickers were the
same. Test has been done in two stages. Firstly, the person
wears sneakers with insoles while he was standing up on an
ergometer device and he fastened oral mask of oxygen
consumption measurement device with commercial name of
Quark b2 with its vest to face and body of himself. In fact, Quark
b2 device was used near an ergometer so that in this test, all
F. Farmani / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
information related to respiratory and cardiovascular system was

calculated and was given to us by device; this information are
maximum heart rate in a minute, total volume of consumed
oxygen with the unit of ml/minute and maximum of oxygen
consumption by the person with unit of ml/minute for one
kilogram of his weight.
Tests have been performed by the protocol of Producer
Company of device (COSMED). Onset of persons movement
is considered 6 km in an hour in a way that speed of device is
increased one kilometer in an hour for each minute. In this way,
order of running speed for each person is gradually increased.
Display screen of device showed a graph which indicated
consumed oxygen of the person. Speed of device was increasing
until the volume of oxygen consumption reached to maximum
volume therefore the increasing graph of oxygen consumption
reached to a linear form and actually, maximum volume of
oxygen consumption was identified.
After 24 hours, testable person would be come to test place
for the second stage of test. Again, the first stage conditions
were performed. Choice of being first or second in the stage of
using insole in th0e test was done randomly. All obtained
information of device was recorded in the questionnaire of each
person. Analysis of the results in this research has been done
by SPSS in 11th version. Since k.s test showed the overlap of
variables with theoretical normal distribution, t test has been
used for comparing the results before and after the intervention.
Results
The results of this test showed that volume of consumed
oxygen has a significant difference before and after using insole
(P-value: 0.035) in a way that after using insole, volume of
consumed oxygen has been decreased for each person (Table1).
Maximum rate of consumed oxygen showed a significant
difference before and after using of insole (P-value: 0.029) in a
way that after using insole, maximum volume of consumed
oxygen was decreased for each person (Table 1). Maximum
heart rate showed a significant difference before and after using
of insole (P-value: 0.031) in a way that maximum heart rate has
been decreased after using insole (Table 1).
Discussion
The results of this research showed that using Foot orthosis
in runners who suffered from flat foot can decrease the volume
of consumed oxygen, maximum consumed oxygen and
maximum heart rate in running. Change in stability of ankle and
over pronation can lead to change in muscle activity which finally
caused muscular fatigue and the injuries due to extremely high
activity. Reason of these injuries and fatigues are several factors
but over pronation imposed a force on muscles which leads to
inju(5). Increasing muscles activity is necessarily accompanied
with increase in oxygen consumption and carbohydrate as main
metabolic factor of muscles (9).
One of the consequences of flat foot is premature fatigue
in runners (4) and it could be said that this problem has a direct
relation with change in muscular activity and subsequently,
increase in oxygen consumption of them (10). Change in foot
stability with abnormal pronation can be along with change in
muscular activity (5 ). One of considerable advantages of Foot
orthoses is that they cause to decrease required muscular activity
in order to stabilize in sole and to control axial rotation of lower
limb and guiding the foot alignment. Additionally, decrease in
muscles activities which is controller of maximum pronation of
ankle in first half of stance phase of gai, are of main results in
using medical insoles.( 5)
Base of this research was that if Foot orthosis can properly
guide and support the movement of ankle joint, then activity of
muscles will be decreased. Trend of the research is such a way
that participants were investigated in two stages with and without
using insoles and in the stage of using insole, reduction in the
activity of muscles was showed. In these studies, it is expressed
that increase of level and speed in the activity of muscular fibers
caused premature fatigue (11).
In fact, it is assumed that with prescribing and wearing an
appropriate insole in the shoes of runners who affected by flat
foot, abnormal alignment of their ankles can be improved and
as a result, level of muscular activity which play an important
role in controlling this improper direction can be modified and in
this way, total level of energy consumption and also maximum
oxygen consumption for each kilogram of body weight and using
total oxygen of body can be decreased. As mentioned earlier,
one of the consequences of flat foot is premature fatigue and
the reason of this is that person passes aerobic respiration range
with lower activity.
In related works such as the study which has been done by
Hennacy RH. in 1973, consumed oxygen is investigated in the
persons who suffered from flat foot before and after using insoles.
The results were in a way that all participants had a primary
increase in oxygen consumption which showed negative effect
of orthosis. Nevertheless, oxygen consumption has been
showed after 3 months (12). The reason of obtained results in
that research is that the authors investigated immediate effect
of insole on oxygen consumption and there was no change
because the persons didnt get used to insoles. It was reported
that after a time period of using insoles, a significant decrease
was observed in oxygen consumption which are consistent with
obtained results of the present study.
In another research which has been done by Bergg and
Sady in 1985, volume of consumed oxygen in healthy students
with using orthosis is investigated with comparing without using
orthosis. The persons were run on a treadmill equipped with
measurement mask of oxygen consumption in two stages with
using shoes and insole and with using shoes solely. The
researchers havent observed any considerable variable in the
volume of oxygen consumption in these persons with and without
using medical insoles (13). As mentioned before, medical insoles
were given to healthy runners in this research and the result of
research showed any change in volume of oxygen consumption
before and after using orthosis. But in the present research,
Table 1: Comparison among the volume of consumed oxygen, maximum consumed oxygen and maximum heart rate before and
after using the insole in runners.
P-value
SD(standard deviation)
Mean
Description
0.035
467.83436
4504.6
VO2 before using Foot orthosis (Ml/minute)
478.31295
4488.3
VO2 after using Foot orthosis (Ml/minute)
0.029
6.53850
63.6040
VO2 Max before using Foot orthosis (Ml/minute
for each kilogram of body weight)
6.62031
63.3715
VO2 Max after using Foot orthosis (Ml/minute
for each kilogram of body weight)
0.031
6.15673
168.7
Max Heart Rate before using Foot orthosis
based on number of heart rate
6.29118
168
Max Heart Rate after using Foot orthosis based
on number of heart rate
F. Farmani / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
61
participants have two-side and flexible flat foot. According to

biomechanical direction of their lower limbs especially in ankle
and knee joints, insole was effective on muscular activity and
so on oxygen consumption with improving this direction.
Also in a similar research which has been done by Otman
et al. in 1988, the effect of supporter orthosis in the sole arch is
investigated on energy consumption in the patients who suffered
from flat foot. He measured Heart Rate and volume of oxygen
consumption in patients in the time of resting and walking on a
treadmill device. His research has been done in two stages; in
the first stage: the measurement was done without using insole
and in the second stage: a pair of insoles was given to patient.
In that research, in the first stage, while resting, there is no
significant difference in Heart Rate and oxygen consumption
with and without using insole but in the second stage, walking;
there are significant differences in volume of oxygen
consumption and Heat Rate in two situations of with and without
using insoles. The results of the research showed that an
appropriate insole can decrease volume of oxygen consumption
while walking. As mentioned before, in the present study, in using
insole, volume of oxygen consumption and Heart Rate were
decreased (14) Twenty persons were assessed in two studies
who suffered from flat foot and the same results were obtained.
References
Conclusion
9.
In runners who affected by flat foot, biomechanical

imbalance leads to muscular fatigue and increase in energy
consumption in these persons. So compensating the flat foot
with using medical insoles can improve biomechanical direction
of lower limbs, improve the muscular performance and
consequently, reduce in energy consumption and this issue is
very important for runners in speed and endurance running races
in sport fields. Using insoles caused to returning normal walking
back and lower energy consumption in persons who suffered
from flat foot and this subject can be considered by physicians
and experts and sports teams.
Acknowledgement
2.
3.
4.
5.
6.
7.
8.
10.
11.
12.
13.
14.
The work was supported by National Olympic Academy of

Iran.We would like to thank Mrs Behshid Farahmand and Dr
morteza bahrami nejad for assisting with performing this study.
62
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Bergg K. Sady S. Oxygen cost of running at sub maximal
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F. Farmani / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
A study of prevalence of Developmental Coordination Disorder

(DCD) at Kattankulathur, Chennai
Ganapathy Sankar U*, S. Saritha**
*M.O.T. (Paediatrics), Research Scholar, Vice Principal, SRM College of Occupational Therapy, SRM University, Chennai. **B.O.T.,
Occupational Therapist, SRM College of Occupational Therapy, Chennai.
Abstract
Objective
To find out the prevalence rate of Developmental Coordination
Disorder (DCD) at Kattankulathur among 5 10 years of age
group.
Method
Two hundred and ninety one subjects (Mean age = 7.5 years ,
S.D = 1.39) participated in this study. The Developmental
Coordination Disorder Questionnaire (DCDQ) was distributed
to parents and filled Questionnaires were collected. Data was
analyzed by descriptive statistics.
Results
Four children were screened as Developmental Coordination
Disorder. It shows that the prevalence rate was 1.37%. DCD
was more prevalent in boys than girls.
Conclusion
The study concluded that there is prevailing (Prevalence
rate=1.37%) of Developmental Coordination Disorder among
the age group of 5-10 years at Kattankulathur. The prevalence
of the disorder suggests a need for program to educate parents,
caretakers, teachers and professionals about DCD.
Keywords
Prevalence, Developmental Coordination Disorder,DCDQ
Introduction
Developmental Coordination Disorder (DCD) is a motor skill
disorder that often becomes evident in school-aged children.
Children with DCD lack the motor co-ordination necessary to
perform tasks considered appropriate for their age, given normal
intellectual ability and the absence of other neurological disorders
1
.For the last 100 years, poor motor coordination in children has
been recognized as a developmental problem. As early as 1937,
these children were classified as clumsy2. Since then, other
terms such as motorically awkward, motor impaired, and
physically awkward have been used to describe these children,
and the terms developmental apraxia and perceptual motor
difficulties have been used to characterize this developmental
problem 3,4. These terms does not distinguish the specific
difficulties experienced by the children in any meaningful way
As a result, an international consensus meeting was held in
1994 to debate the usage of different terms and to streamline
research in this field; Researchers and clinicians from around
the world agreed to accept the diagnostic term Developmental
Coordination Disorder (DCD) as an umbrella term to describe
these children5.
Children with DCD demonstrate significant difficulty with
self care tasks (eg. dressing, using utensils, toileting); academic
tasks (eg. copying, organizing seat work, gym class ); leisure
activities (eg. sports, playground activities); or a combination of

the above6. Difficulties in any one of these areas can be
negatively affect the childs social integration and developing
sense of self concept 7.This can be lead to repeated experiences
of failure for the child causing a significant negative impact on
their self esteem, socialization, behavior and academic
performance 8.Children with DCD may therefore be socially
excluded 9 because they engage in passive, solitary activities
and they rate themselves as particularly low in social acceptance
10
.The prevalence of DCD are estimated to represent 5% to 6 %
of the school aged population11. Although some estimates of
the prevalence of DCD ranges from 5 to 15 %. Of the primary
school population12, the widely accepted rate is 5 to 6 % or
approximately 1 in 20 children13. Given these rates there is likely
to be at at least one child with DCD in every class room.
Prevalence of DCD in children has been reported as high as
19%.However two studies undertaken in the U.K reported a
prevalence of 5 to 8.5 % respectively 14. The prevalence of
DCD in India has not been reported. Since the prevalence of
this disorder is unknown at Kattankulathur,Chennai. It is
appropriate to conduct a study, as this will ascertain the
prevalence of DCD at Kattankulathur, therefore the major thrust
of this study was to find out the prevalence of DCD at
Kattankulathur,Chennai.
Material and methodology

Sample
This study employed the survey design, cross sectional
study. Two ninety one children (n =291) were participated in this
study. The samples were selected by means of convenience
sampling Procedure at Kattankulathur area. The sample
included boys and girls between the ages of 5 -10 years (Mean
age = 7.5 years + = 1.39)
Instrument
Developmental coordination disorder
questionnaire (DCDQ)
The Developmental Coordination Questionnaire (DCDQ)
is a parent report measure developed to assist in the identification
of Developmental Coordination Disorder (DCD) in children.
Parents are asked to compare their childs motor performance
to that of his/her peers using a 5 point Likert scale. It provides a
standard method to measure a childs coordination in everyday
functional activities. The DCDQ consists of 15 items, which group
into three distinct factors. The first factor contains a number of
items related to motor control while the child was moving, or
while an object was in motion, and is labelled Control during
Movement. The second factor contains Fine Motor and
Handwriting items and the third factor relates to General
Coordination. The DCDQ usually takes parents about 10-15
minutes to complete.
The alpha coefficient for the total test was .88. The alpha
of each item, if that item was deleted, measured greater than
.87 (range of .87 to .88). The total score of the DCDQ was
Mr. ganapathy Sankar U / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
63
significantly correlated with each of the items of the test, another

measure of internal consistency. These item total correlations
ranged from r = .40 to r = .76, with all significant at the probability
level of .0001.The total score of the DCDQ was significantly
correlated with the four complete scores of the BOTMP ( r = .46
to .54 , p<.0001). The DCDQ was also significantly correlated
with the total Impairment score of the movement ABC ( r =
.59,p<.0001).
Data collection procedure

The Purpose of the study was explained to panchayat union
leader. Door to door survey was conducted at Kattankulathur
area,Chennai and consent forms were obtained from concerned
parents. The Developmental Coordination Disorder
Questionnaire (DCDQ) was distributed to parents and
investigator explains the DCDQ in details and clarify the parents
doubts. The filled Questionnaires were collected. The data was
analyzed using descriptive statistics.
Results
This study investigated the prevalence Developmental
Coordination Disorder (DCD) at kattankulathur. Two hundred
and ninty one children (291) were studied.126 were Boys and
165 were girls. The age range was 5 to 10 years with mean age
of 7.5 years. Descriptive statistics was used to analyse the data.
The result showed that 4 out of the 291 children had scores that
met the criteria for a diagnosis of Developmental Coordination
Disorder (DCD), giving a prevalence rate of 1.37% (Table I).
Table 1: The Prevalence of Developmental Coordination
Disorder (DCD) at Kattankulathur
Age interval
Total sample
Prevalence rate %
5.0-5.11
49
0
6.0-6.11
55
0
7.0-7.11
65
0.68
8.0-8.11
58
0.34
9.0-9.11
64
0.35
Total
291
1.37
This confirms the existence of Developmental Coordination
Disorder (DCD) among 5-10 years at Kattankulathur. From the
respondents the percentage of children who were screened as
having the symptoms of Developmental Coordination Disorder
(DCD) was computed using simple percentages. The percentage
of children studied that suffer from this disorder is presented
(Table II) as follows; Girls - 1.37% (4 girls were screened as
DCD) and Boys 0 (No one screened as DCD in boys.)
Table 2: The Prevalence of Developmental Coordination
Disorder (DCD) in both gender
Gender
Total sample
Prevalence rate %
Boys
126
0
Girls
165
1.37
that four children (1.37%) were screened positive for DCD.

Prevalence of DCD in children has been reported as high as
19%. But prospective data of prevalence of DCD in India is not
available. The prevalence rate was comparatively low compare
to previous studies. Culture difference influences the DCD
prevalence rates. Increasing level of physical activity may assist
in reducing prevalence rate of DCD in children 15 (Tsiotra, Flouris,
Koutedakis, Faught, Nevill, Lane, and Skenteris 2006). This
study was done in village which might be influence the results.
The comparison of prevalence of DCD in both genders
shows that 4 subjects were identified with DCD in boys and not
in girls. The results indicate that DCD was more prevalent in
boys than girls. This may be due to behavior of boys with motor
incoordination may be more difficult to manage at home and in
the classroom. This result was supported by 16 Smyth,
1992.Certain limitations of the research need to be taken into
account when relating to the findings. One is the possibility of
potential bias since the results are based only on parents reports,
which, by their very nature, are subjective and may be influenced
by factors such as denial, over anxiety or wishful thinking. The
questionnaire was translated in Tamil, the most of the parents
are illiterate and some of the parents hesitate to clarify their
doubts in questionnaire. This may influence the results of the
study. The data in this study are based on a screening survey
instrument. The intensive follow up diagnostic assessments or
confirmatory test of those identified as positive for the
Developmental Coordination disorder was not done.
Conclusion
The study concluded that there is prevailing (PR=1.37) of
Developmental Coordination Disorder among the age group of
5-10 years at Kattankulathur. The prevalence of DCD was high
in Boys than girls. The prevalence of the disorder suggests a
need for program to educate parents, caretakers, teachers and
professionals about DCD.
Acknowledgements
I pay my sincere thanks to the chairman of SRM group of
institutions and SRM University. I express my sincere thanks to
all the participants who have been the real pillars of this study.
Last but not least, I thank all of them whose names have
inadvertently fails my memory and who in their own unique way
have made this project a reality.
References
1.
2.
3.
4.
Discussion
5.
Developmental Coordination Disorder (DCD) is common
disorder which affects well being of children and their families.
There are strong associations with learning disabilities and
psychiatric illness in adolescence. The family physician and
pediatrician frequently do not recognize the DCD or dismiss it
as transient and unimportant. The present study was carried
out to identify prevalence rate of DCD at Kattankulathur.
In this study 291 parents were participated. Result shows
64
6.
Barnhart, R.C., Davenport, M.J., Epps and Nordquist, V.M.

Developmental Coordination Disorder. Physical Therapy,
2003; 83, (8) : 639 - 651.
Coleman, R., Piek J.P., Livesey D.J.. A longitudinal study
of motor ability kinesthetic acuity in young children at risk
of developmental coordination disorder. Human Movement
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Miyahara, M., Register, C. Perception of three terms to
describe physical awkwardness in children. Res Dev
Disabil, , 2001; 21: 367- 376.
Miyahara, M., Mobs, I. Developmental dyspraxia and
developmental coordination disorder. Neuropsychol Rev,
1995; 5: 245268.
Polatjko, H., Fox, M., and Missiuna, C. An international
consensus on children with Developmental Coordination
Disorder. Canadian Journal of Occupational Therapy, 1995;
62: 3 6.
Miller, L.T., Missiuna, C.A., Macnab, J.J., Malloy Miller,
T., and Polatjko, H.J. Clinical Description of children with
Developmental Coordination Disorder. Canadian Journal
of Occupational Therapy, 2001;68: 5 15.
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Skinner, R.A., and Piek, J.P. Psychosocial Implications of

Poor Motor Coordination in Children and Adolescents.
Human Movement Science, 2001; 20: 73 94.
8. Parnmenter , T.R., & Knox, M.. The post school
experiences of young people with a disability . international
Journal of rehabilitation research, 1991; 14: 281 291.
9. Hallum, A. Disability and the transition to adult hood : Issues
for the disabled child,The family and pediatrician. Current
Problems in Pediatrics, 1995; 12 50.
10. King, G.A., Shitz, I.Z., Steel, K., Gilpin, M., & Cathers, T.
Self concept of adolescents with physical disabilities.
American Journal of Ocupational Therapy, 1993; 4: 132
140.
11. Sugden, D., and Keogh, J.F. Problems in movement skill
development. Columbia, SC: University of South Carolina
Press; 1990.
12. Wilson, P.H.Practitioner review: Approaches to assessment
and treatment of children with DCD: An evaluative review.
13.
14.
15.
16.
Journal of Child Psychology and Psychiatry, 2005;46: 806

823.
American Psychiatric Association . Diagnostic Statistical
Manual of Mental Disorders (DSM) 4th ed, Washington;
2001.
Michelle & Miller. Develpomental Coordination Disorder :
A review of evidence and models of practice employed by
allied health professionals in Scotland. Dyspraxia
Foundation; 2008.
Tistoria, G.D., Flouris, A.d., Koutedakis, Y., Faught, B.E.,
Nevill, A.M., Lane, A.M., and Skenteris, N. A comparison of
Developmental Coordination Disorder Prevalence Rates
in Canadian and Greek children. Journal of Adolescent
Health, 2006; 39: 125 127.
Smyth, T. R.Impaired motor skill (clumsiness) in otherwise
normal children : a review. Child Care, Health and
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Mr. ganapathy Sankar U / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
65
Dynamic standing balance in individuals with osteoarthritis kneea comparison with matched controls
R.HariHaran
Senior Lecturer, M.M College of Physiotherapy & Rehabilitation, M.M University, Mullana, Ambala, Haryana
Abstract
Objectives
(i)
(ii)
To compare the dynamic standing balance in individuals

with osteoarthritis Knee and in age, gender, body mass
matched controls using simple functional tests
To find the agreement between two functional dynamic
standing balance tests
Study design
Non-experimental design
Case- control (cross-sectional), Agreement between two clinical
measures
Participants
Thirty-four patients with Osteoarthritis Knee and Thirty-four age,
gender, BMI matched Controls participated in the study
Interventions
Not applicable
Outcome measures
Dynamic Standing balance is assessed through Step Test and
Functional Reach Test
Data analysis
Paired T test & Spearman P Coefficient were used to analyze
the data
Results
Poor dynamic standing balance is evident in OA group
(P<0.0001) than the controls when assessed through step test
and functional reach test. Step test and functional reach test
agreed with each other in assessing dynamic standing balance.
Conclusion
Dynamic standing balance is impaired in individuals with OA
Knee when compared with age, gender and BMI matched
controls. There is good agreement between the step test and
functional reach test in assessing dynamic standing balance in
OA Knee.
Keywords
Dynamic standing balance, Osteoarthritis Knee (OA knee), step
test, functional reach test, Body mass index (BMI)
Introduction
Osteoarthritis knee (OA) is one of the most prevalent
66
musculoskeletal complaint worldwide. It is a major cause of

impairment and disability among the elderly. Individuals with OA
knee suffer progressive loss of function, displaying increasing
dependency in walking, stair climbing and other lower extremity
tasks. (1,2)
Balance is a complex function involving numerous neuro
muscular mechanisms.
Control of balance is dependent upon sensory input from
the vestibular, visual and somatosensory (proprioception)
systems. Central processing of this information results in
coordinated neuromuscular responses that ensure the center
of mass remains with in the base of support (BOS) in situations
when balance is disturbed. Effective control of balance thus relies
not only on accurate sensory input but also on timely response
of strong muscles. Balance is an integral component of activities
of daily living. Balance impairment is associated with an
increased risk of falls and poorer mobility in the elderly
population. (2)
Age related impairments in balance and postural stability
are well documented. (3,4,6) Ageing is associated with a decline
in the integrity of neurophysiological systems that contribute to
the control of balance. The presence of OA knee may result in
changes that accelerate the deterioration of these systems or
compound the effects of ageing. Individuals with OA knee display
reductions in quadriceps strength and activation as well as
impairments in knee joint proprioception. (8,9,10,11,12) These
deficits, in combination with the ageing process, may culminate
in greater impairments in balance in this patient population,
compared with healthy counter parts.
Falls and loss of balance most commonly occur during
movement-related tasks such as walking and less frequently
during static activities. (5,6,7) It is therefore important that the
evaluation of balance incorporates testing procedures that reflect
the dynamic nature of locomotor tasks. Simple, inexpensive and
easy to administer clinical tests are required to allow the clinician
to assess balance readily and quickly in patients with OA Knee.
Limited research has evaluated the impact of OA Knee on
balance. Few studies, all utilizing force platform to identify
balance deficits in this patient population have revealed deficits
in balance compared with asymptomatic subjects. Simple,
Clinically practical measures to assess dynamic standing
balance in individuals with OA Knee were not used in any of the
studies. The effect of OA Knee on functional dynamic tests of
balance remains unknown.
Methodology
Participants
Thirty-four participants (19 male, 15 female) with
osteoarthritis knee (primary, both unilateral and bilateral) and
equal number of controls (19 male, 15 female) aged between
45 to 55 years were included in the study. Both groups i.e.,
osteoarthritic group and the control group were similar in age,
weight and BMI (table-1). Orthopaedician and or physiatrist
diagnosed OA knee
Participants in OA group were excluded if they had any
knee surgery, past history of lower limb joint replacement,
systematic arthritic condition, severe medical condition
R. HariHaran / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
precluding safe testing, vertigo. Control participants were

excluded if they reported any lower limb pathology, joint disorder,
injury to (or) pain in either knee in the past year, displayed
abnormality on physical examination of knees, vertigo and other
musculo skeletal disorders.
Materials used:
15 cm foot stool
tape measure
stop watch
Weighing machine
The two tests step test and functional reach test were used
to assess the dynamic standing balance in both groups.
Step test:
The step test is functional, dynamic test of standing balance
with known reliability and validity. (17,18,19) Participants were
instructed to maintain balance on one leg, while stepping the
contralateral limb on and off a 15 cm step as quickly as possible
by utilizing footstool. The number of times the participant places
the foot up on to the step and return it to the floor over 15 second
interval was recorded by using stopwatch. Participants performed
the test with bare feet, and no hand support was permitted. For
OA knee participants, the test was performed while standing on
the osteo arthritic limb. For those with bilateral symptoms, the
most symptomatic limb was deemed the osteo arthritic limb for
the purpose of study. In all participants, the test was performed
once only, with two to three practice steps permitted before the
test. If loss of balance occurred, the test was ceased and the
number of steps up completed until this point was recorded.
Forward reach test (or) functional reach test:
Functional reach test, developed by Duncan et al is a test
of dynamic standing balance. (21,22,26) Functional reach test
is defined as the maximal distance one can reach forward beyond
arms length while maintaining fixed base of support (BOS) in
standing position. The participants, relaxely stands next to the
wall (without touching) with the shoulders flexed to 90 degree

and elbows extended. Both hands are fisted. The initial markings
were made on the wall at shoulder level and fist level. The patient
is then instructed to lean as for forward as possible without losing
balance (or) taking a step. Again the marking was made at the
fist level in forward reach position. The difference between the
markings in the two positions were noted and documented for
both groups.
Independent group t test for means was used compare the
characteristics (Age, Height, Weight, BMI) of OA group and
Control group
Paired T Test was used to compare the difference between
the control group and osteoarthritic group. P values< 0.05 (5%)
were regarded statistically significant.
In order to determine the relationship between the step test
and the functional reach test spearman P coefficient was used.
The data were analyzed using statistical package for social
sciences (SPSS)
Result
There is no significant difference in age, height, weight,
BMI between the OA group and Control group (Table: 1)
Compared with controls, participants in the OA group took
approximately eight fewer steps (table 2) in 15 seconds test
period while standing on their osteoarthritic leg. The p value is
less than 0.001 indicating poorer balance under dynamic testing
condition.
Ho: Let there be no significant difference between the
observations of control group and OA group in step test
According to the table values
Table 1: Presenting characteristics of OA and control participants

Characteristics
OA group (N=34)
Control group (N= 34)
Mean
S.D
Mean
S.D
Age (Years)
49
3.44
48.79
3.13
Height (meters)
1.58
0.08
1.57
0.07
Weight (Kgs)
60.55
9.78
58.94
8.3
BMI
24.26
3.70
25.47
3.31
Pain (NPRS)
6.85
Duration of
8
symptoms (months)
NPRS- Numerical Pain Rating Scale
NS- Not Significant
SD- Standard deviation
Table 2: Mean Values of step test with standard deviation for both groups
Step Test
Groups
Mean(number of steps
Number of
in 15 seconds)
Subjects
OA Group
12.91
34
Control Group
21.79
34
Significance (Confidence
Level- 95%)
NS
NS
NS
NS
Standard
deviation
3.47
3.64
Table 3: Mean Values of functional reach test with standard deviation for both groups
Forward reach Test
Groups
Mean (cms)
Number of Subjects
Standard deviation
OA Group
17.44
34
3.19
Control Group
23.78
34
4.00
Standard
error mean
0.59
0.62
Standard error mean

0.55
0.69
Table 4: t values of step test and forward reach test (Comparison of means between control group and OA group)
Paired differences
Mean
Standard deviation
Standard error mean
t values
df
Step test
8.88
5.61
0.96
-9.237
33
Forward reach test
6.34
4.68
0.80
-7.891
33
R. HariHaran / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
67
Fig 1: Mean results of the step test for OA and control group
participants
The mean results of the functional reach test is presented in fig

(2).
t 0.05, 33 = 2.00
t = 9.237 (according to the calculation; table 4)
t > t 0.05, 33
Ho is rejected at 5% level. Hence there is significant
difference between the control group and OA group in the step
test.
The mean results of the functional reach test is presented
in fig (2)
Compared with the controls, participants in the OA group
was 6 cms (table 2) low in functional reach test.
Ho: Let there be no significant difference between the
observations of control group and OA group in functional reach
test.
According to the table values,
t 0.05, 33 = 2.00
t = 7.891 (According to the calculation; table 4)
t > t 0.05,33
Ho is rejected at 5% level. Hence there is significant
difference between the control groups and OA groups in
functional reach test.
Agreement between balance measures
The two tests step test and functional reach test were
correlated. Spearman P coefficient is 0.79 between step test
and forward reach test.
t-test for the significance of the correlation coefficient =
10.4795 > (95% C.I for slope 0.5291 to 0.8038)
Two-tailed probability = 0.0000
Total number of subjects was sixty-eight. There is good
agreement between two tests. The means of step test and
functional reach test are positively correlated. When the values
of step test increases (or) decreases the values of functional
reach test increases (or) decreases respectively.
their center of mass within the base of support. Further research

is required to determine the impact of OA knee on the systems
responsible for postural control before mechanisms behind
balance deficits can be understood.
Four other studies evaluated balance in people with OA
knee. (9,14,15,16) Three of the studies have utilized force
platforms and one utilized postural swaymeter. Hassan et al
and wegner et al demonstrated increased postural sway in
subjects with OA knee when standing on a firm surface, with
eyes opened and closed, in both AP and lateral directions. In
contrast Hurley and colleagues were unable to detect a deficit
in body sway in individuals with OA knee despite the OA Group
being more unsteady as a whole compared with controls. Hinman
et al found there is increased postural sway in subjects with OA
knee on postural sway meter when compared with the controls.
The close matching of control participants in this study
compared with the published investigations, supports the
hypothesis that observed balance deficits are due to the
presence of OA knee, and not to inherent differences between
groups with regard to age, gender (or) BMI.
Simple, inexpensive tests of balance are necessary for use
in clinical setting. The step test and functional reach test is very
quick to perform, requires minimal apparatus and does not need
analysis (or) manipulation of results. Since our study reveals
that there is good agreement between functional reach test and
step test, either functional reach test or step test can be used to
assess balance. Limitations to the interpretation of results of
this study exist. The results of this study shows statistically
significant balance impairments with the OA group, the functional
impact of such deficits remains unknown. Further research is
warranted to determine the magnitude of balance deficit (as
assessed by functional reach, step test) is required before
function is impaired.
The findings of this study have important clinical implications
for the understanding and management of patients with OA knee.
Balance deficits in this population can be identified easily and
quickly in the clinical setting by the use of step test and functional
reach test, however the clinical and functional implications of
such deficits are unknown. Treatment strategies directed at
improving balance in these people may be warranted and require
future investigation.
Discussion
Using simple clinical measures, the result of the study
demonstrate that individual with OA knee display impairment in
postural control, mostly under the dynamic resting condition.
This reflects a reduced ability to maintain standing balance while
performing a potentially destabilizing activity.
Deficits in lower limb proprioception and muscle strength
arte associated with OA knee and thus may be postulated as a
cause of impaired balance. (3,4,8-12) However studies of
balance in this population are yet to establish a relationship
between these parameters, rendering this hypothesis open to
question. Pain associated with the OA knee may play a role in
balance impairments. (1,3) The presence of pain may reflexively
inhibit the muscles around the knee, which could compromise
effective and timely motor responses in postural control.
Furthermore pain, may result in reduced loading of the affected
joint, potentially jeopardizing an individuals ability to maintain
Conclusion
Dynamic standing balance in individuals with osteoarthritis
knee is impaired when compared with age, gender and BMI
matched controls. There is good agreement between the step
test and forward reach test. Either the step test or the forward
reach test can be used to assess the dynamic standing balance
in individuals with Osteoarthritic knee.
R. HariHaran / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
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Dis 2001; 60:612-618
17. R.S.Hinman et al. Balance impairments in individuals with
symptomatic knee osteo arthritis: a comparison with
matched controls using clinical tests. Rheumatology 2002;
41:1388-1394.
18. Hill K et al. A new test of dynamic standing balance for
stroke patients: Reliability, validity and comparison with
healthy elderly. Physiother can 1996; 48:257-262
19. K.L Benell et al. Efficacy of physiotherapy management of
knee joint osteoarthritis a randomized double blind, placebo
controlled trial. Ann Rheum Dis 2005;64:906-912
20. Sarch F Tyson et al. Reliability and validity of functional
balance test post stroke. Clinical rehabilitation 2004;
18:916-923.
21. Koralewicz LM, Engh GA. Comparison of proprioception in
arthritic and age- matched normal knees. J bone joint surg
Am 2003 Nov; 82-A (11): 1582-1588.
22. Duncan PW et al. Functional reach: a new clinical measure
of balance. J. gerontol 1990 Nov; 45 (6):M 192-197.
23. Duncan PW et al. Functional reach: a predictive validity in
a sample of elderly male veterans. J. gerontol 1992 May;
47(3): M 93-98
24. Karinkanta S et al. Factors predicting dynamic balance and
quality of life in home dwelling elderly women. Gerontology
2005 Mar- Apr; 51(2): 116-121
25. Smith PS et al. Berg Balance scale and functional reach:
determining the best clinical tool for individuals post acute
stroke. Clin Rehabil 2004 Nov: 18(7): 811-818
26. Karin Ringsberg et al. Is there a relationship between
balance, gait performance and muscular strength in 75 year
old women? Age and Ageing 1999:28:289-293.
27. Susan B.OSullivan, Thomas J.Schmitz. Physical
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edition); 196.
R. HariHaran / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
Effect of play therapy in children with attention deficit hyperactivity

disorder - a single blinded randomized controlled study
Jagatheesan Alagesan1, Sardesai A. Shradha2, Sankar B. Mani3
1
Associate Professor, K J Pandya College of Physiotherapy, Sumandeep University, Vadodara, 2Pediatric Physiotherapist, Ashadeep
Special School, Vasco Da Gama, Goa, 3Professor, K J Pandya College of Physiotherapy, Sumandeep University, Vadodara
Abstract
Objective
The current study is proposed for incorporating play therapy
in the treatment of children with attention deficit hyperactivity
disorder with the Objective being to determine the beneficial
effects of play therapy on Attention in attention deficit
hyperactivity disorder.
Method
50 children diagnosed with Attention deficit hyperactivity
disorder between the age group of 5 to 12 years satisfying the
selection criteria were included in the study. A routine pediatric
assessment was done and attention was assessed using
Conners Abbreviated Teacher Rating Scale. Children were then
divided in to 2 groups. Group-A was experimental group receiving
play therapy along with medications. Group-B was control group
receiving only medications. Play therapy was given for one hour
daily for one month and post intervention values were assessed.
Result
The statistical analysis of the data supports the beneficial
effect of play therapy on attention component of children
diagnosed with Attention Deficit Hyperactivity Disorder. The
objective improvement in the majority of the subjects was
statistically significant with p value <0.001, i.e. decrease in the
score on Conners Abbreviated Teacher Rating Scale.
Conclusion
From the study it has been observed that play therapy
intervention is effective and beneficial in Attention Deficit
Hyperactivity Disorder rehabilitation.
Keywords
Attention Deficit Hyperactivity Disorder, Play therapy,
Conners Abbreviated Teacher Rating Scale.
Introduction
Attention Deficit Hyperactivity Disorder has many faces and
remains one of the most talked about and controversial subjects
in education, hanging in the balance of heated debates over
medication, diagnostic methods and treatment approaches are
children, adolescents and adults who must manage the condition
and lead productive lives on daily bases.01
The childhood cognitive and behavioural difficulties
Address for correspondence:
Dr. A. Jagatheesan, MPT, M.Sc, M.Phil, MIAP,
Associate Professor, Kashiba Jayashanker Pandya College of
Physiotherapy, Sumandeep Vidyapeeth, Piparia, Waghodia,
Vadodara, India-391760. Mobile: +91 9725837903; Email:
jagatheesanmpt@yahoo.com
70
categorized as problems of inattention, impulsivity and

hyperactivity have presented a clinical challenge over the past
50 years.02 Attention Deficit Hyperactivity Disorder refers to a
family of related chronic neurobiological disorders that interfere
with an individuals capacity to regulate activity level
(hyperactivity), inhibit behavior (impulsivity) and attend to tasks
(inattention) in developmentally appropriate ways.03
According to Diagnostic and Statistical Manual of Mental
disorder (DSM-IV, APA, 1994) the essential feature of ADHD is
.....a persistent of inattention and/or hyperactivity, impulsivity
which is more frequent and severe than is typically observed in
individuals at a comparable level of development. Symptoms of
ADHD must be present before the age seven years and must
interfere with developmentally appropriate social, academic or
occupational functioning in at least two settings (for example at
home and at school).04
The world wide prevalence of attention deficit hyperactivity
disorder is in the range of 7 to 17 % of school aged children.04 In
India prevalence of the disorder in the age group of 5 to12 years
in pediatric clinic was 15.5%, the inattention sub type was
predominant. The mean age of boys and girls was 8.49 and
6.82 years respectively also male: female was 6.4:1. Majority of
patients were from middle socio-economic status belonging to
Hindu families.05
The management of Attention Deficit Hyperactivity Disorder
must be multidisciplinary, multimodal and maintained over a long
period. By far the most effective short term interventions for
Attention Deficit Hyperactivity Disorder are combination of
Medical, Behavioral and Environmental techniques.02 Theories
suggesting the mechanism of increasing attention are that the
brain reorganizes itself allowing the undamaged areas to take
over the responsibilities of the damaged areas. Another theory
suggests that recovery of function occurs when the brain uses
its remaining functional capacities to achieve behavioral goals
by different routes.06 In the recent years a growing number of
noted health professionals have observed that play is important
to human happiness and well being as love and work.
Play therapy may be directive that is the therapist may
assume responsibility for guidance and interpretation or may
be non directive where the therapist may leave responsibility
and direction to the child. In non directive play therapy the child
is given the opportunity to play out his accumulated feelings of
tension, frustration, insecurity, aggression, fear, bewilderment
and confusion.
Objective of the study

Objective of this study is to determine the beneficial effects
of play therapy on attention in Attention Deficit Hyperactivity
Disorder.
Methodology
Research Design
Single Blinded Randomized Controlled Trail
Source of Data & Setting
Subjects with ADHD from a Special School in Bangalore,
Karnataka
Sample Size
50 subjects of both genders fulfilling selection criteria were
Jagatheesan Alagesan / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
selected from the population and randomly (lottery method

without replacement) divided into 2 groups.
GROUP A: Experimental group received play therapy along with
medications [25 subjects]
GROUP B: Control group received only medications [25 subjects]
Selection Criteria
Subjects diagnosed as Attention Deficit Hyperactivity

Disorder by neuropsychiatrist based on DSM-IV and
undergoing drug therapy
5 -12 years of age
Both male and female children
No other medical or psychiatric disorder

Therapy Duration
Play therapy was given for one hour daily for one month.
Outcome Measure & Tester
Conners Abbreviated Teacher Rating Scale (ATRS) 07,08 was
used as outcome measure and the special educator of the study
setting was the blinded tester for the study.
Procedure
Selected subjects were included in the study after getting
informed consent from parents. The study was approved by
institutional ethical committee. Subjects in both groups were
receiving their routine medications; experimental group in
addition was given with following play therapy. Steps that were
followed during play therapy are,
A connection was made with the subject by shine

acceptance, embracing, joining him/her with his/her
interests, giving him/her control, not manipulating him/her
physically, staying at his/her eye level and not being in the
teacher mode.
Getting delighted in the connection that had been

established so a difference was made. The feeling of joy
and fun was expressed to the child.
A game was started by use of fairly basic toys and games

in number of different ways. The process of treating was
as much fun as getting into the play therapy room. Games
in which the subject was interested were made more
interactive. The ongoing activity was not changed, but
interspersed with another variety. Thus making the child
stay in the activity by having energy, excitement and
enthusiasm.
Getting the subject excited and motivated for an activity.
By making a request the following task was made to do by

the subject.
Tasks that required prolonged attention such as solving a

jigsaw puzzle.
Playing with building blocks was performed by the subject.
Tasks were performed in the presence of distraction.
Child played computer exercise that aimed at increasing

attention.
Data analysis and results

The Statistical software SPSS 11.5 for windows was used
for the analysis of the data. The results were tabulated in terms
of Mean, Standard Deviation, Effect size, Z- Value, and P- Value
by using Wilcoxon Signed Rank test.
Table 1: Age and Sex Distribution of subjects in both groups
Age
Experimental group
Control group
Males Females Total Males Females Total
5-8
13
7
20
11
5
16
9-12
3
2
5
6
3
9
Total
16
9
25
17
8
25
Table-1 shows the age and sex distribution of 50 subjects
participated. In the study 36 (72 %) subjects belonged to 5- 8
years age group and 14 (28%) belonged to 9-12 years age group.
In the experimental group 16 (64%) were male children and 9
(36 %) were female children and in the Control Group 17 subjects

that is 68 % were male children and 8 subjects (32 %) were
females. The Experimental and the control groups were assigned
randomly so the homogeneity of the groups was not checked.
Graph-1&2 shows the age and sex distribution of experimental
and control group respectively.
Graph 1: Age and Sex Distribution of Experimental Group
Graph 2: Age and Sex Distribution of Control Group
The table-2 and graph-3 shows the comparison of before

intervention and after intervention values within the Experimental
and Control Group by Wilcoxon Signed Rank Test. In the study
it is observed that the MeanSD of the experimental group during
Pre therapy is 11.804.06 and during Post therapy is 8.245.04
with an effect size of 0.78. Hence there is a difference from Pre
therapy to Post therapy and is statistically significant with p value
being <0.001.
In control group the Pre therapy MeanSD is 8.804.00
and during Post therapy is 8.884.81 with a negligible effect
size of 0.02. Hence there is no statistically significant
improvement from Pre therapy to Post therapy with p value being
>0.903.
The Pre treatment and Post treatment values between
groups were not compared since there is no statistically
significant improvement in the Post treatment values of the
control group.
This statistical analysis of the data supports the beneficial
effect of Play therapy on attention component of children
diagnosed with Attention Deficit Hyperactivity Disorder. The
objective improvement in the majority of the subjects was
statistically significant i.e. decrease in the score on Conners
Abbreviated Teacher Rating Scale. So play therapy intervention
is effective on children with Attention Deficit Hyperactivity
Disorder.
Discussion
The study showed inattention component was significantly
decreased in experimental group which had received play
therapy intervention along with medications and there was no
improvement in the control group which had received only
medications.
In the support of this study, Susan Hansen, Karen Meissler
and Ovens in the study of group Play therapy model for children
Jagatheesan Alagesan / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
71
Table 2: Comparison within the Experimental and Control Group by Wilcoxon Signed Rank Test
Group
Pre treatment
Post treatment
Effect size
z-value
MeanSD
MeanSD
Experimental
11.804.06
8.245.04
0.78
3.365
Graph 3: Comparison of Pre & Post treatment values of

Experimental & Control Group
p-value
<0.001
Conclusion
Play therapy intervention along with medications is effective
in enhancing attention in children diagnosed with Attention Deficit
Hyperactivity Disorder. Play therapy intervention can be included
as an essential measure in the rehabilitation of children with
Attention Deficit Hyperactivity Disorder.
Bibliography
with ADHD symptomology had concluded that a significant

increase in self esteem was seen which ultimately allows for
heightened level of functioning and overall increased ability to
engage in social acceptable behaviour.09
Also Marcus D in his study emphasized that Play therapy
helps the child not only at home but also helps in the school
environment.10
But Jerker Ronnberg in his review concluded that executive,
central functions (e.g. attention) are negatively affected. Thus it
is ventured that this type of theoretical analysis of consequences
are prerequisites and are important for the future development
of physiotherapy in research and practice.11
The current study has opened doors for physiotherapy to
explore the role of a pediatric physiotherapist while treating
children with Attention Deficit Hyperactivity Disorder. We can
say Play therapy intervention is a boon for children suffering
with Attention Deficit Hyperactivity Disorder. Thus on the bases
of the result Play therapy with medication is very effective in this
particular disorder.
Limitations
72
Treatment was given for a short duration and long term

carry over effects were not calculated.
The study was conducted on a small population from one
special school.
The experimental and control groups were assigned
randomly from population and they were heterogeneous
before treatment in terms of inattention component.
Only Conners Abbreviated Teacher Rating Scale was used
as an outcome measure other test batteries could act as
adjuncts for more conclusive results.
Effect of Play therapy was found with medications, the effect
of only play therapy without any other treatment was not
found.
01. Kelly Henderson, Identifying and treating Attention Deficit

Hyperactivity Disorder: A resource for School and home;
2003:1.
02. Sam Goldstein and Cecil R. Reynolds. Handbook of
Neurodevelopment and genetic disorder in children;
1999:154-184.
03. Matthew Cordes and T.F.Mchaughlin. Attention Deficit
Hyperactivity Disorder and Rating scales with a brief review
of the Conners teacher rating scale. International journal
of special education, 2004; vol19: No.2.
04. Michael Martin et al. Report on attention Deficit Hyperactivity
Disorder (ADHD).Connecticut ADHD task Force; 2005, 3rd
Edition: 10.
05. Mukhopadhyay M, Misra T, Niyogi P. Attention deficit
hyperactivity disorder. Indian J Pediatrics; 2003Oct, 70(10):
789-92.
06. Rachel S Tappan. Rehabilitation for balance and ambulation
in a patient with attention impairment due to intracranial
hemorrhage. Physical therapy; 2002 May, volume 82 No.5:
473-484.
07. C. Keith Conners, Gill Sitarenion, James D.A.Parker and
Jeffery N.Epstein. Revision and Restandardization of the
Conners teacher rating scale (CTRS-R): factor structure,
reliability and criterion validity.Journal of abnormal child
psychology; 1998 Aug, vol 26 No.4: 279-291.
08. Farre-Riba A, Narbona J. Conners rating scales in the
assessment of attention deficit disorder with hyperactivity
(ADHD). A new validation and factor analysis in Spanish
children. Journal of abnormal child psychology; 1997 Feb,
25(138): 20.
09. Susan Hansen, Karen Meissler and Richard ovens. Kids
Together: A group play
Therapy model for children with
ADHD symptomalogy. Journal of child and
Adolescent
Group Therapy; Dec 2000, Volume 10, no. 4:191-211.
10. Marcus D. Play therapy with young children. Indian journal
pediatric; 1992 Jan-Feb, 59(1): 53-60.
11. Jerker Ronnberg. Cognitive and comminicative perspective
on physiotherapy: A review. Advances in physiotherapy;
1999, vol1 No.1:37-44.
A study of effectiveness of wheelchair skill training program

(WSTP) in teaching wheelie to occupational therapy students
Kamal Narayan Arya
Senior Occupational Therapist, Pt.DDU Institute for the Physically Handicapped, 4 Vishnu Digamber Marg, New Delhi - 2
Abstract
Introduction
The wheelie is a useful skill that enables the wheelchair user
to overcome a number of environmental obstacles. The inability
of most wheelchair users to perform wheelies is due to lack of
formalized training. The Wheelchair Skills Training Program
(WSTP) is a structured protocol which is used to test and train
wheelchair users and/or their caregivers and clinicians.
Usually in Occupational Therapy curriculum such training

is not given in formalized manner to the students. As a result
Occupational Therapist lacks skills and ability to become expert
trainer for their clients.
The Wheelchair Skills Training Program (WSTP) is a
structured protocol that incorporates several principles of motor
learning. Evidence has shown that learning wheelchair skills in
a formal setting is better than learning through trial and error,
and that improvement in wheelchair skills can be retained. The
WSTP has been shown to be a practical, safe, and effective
way to improve wheelchair skills performance and knowledge.5,
6, 7, & 8
Objective
To test the hypothesis that formalized training based on WSTP
guidelines given to Occupational therapy students would improve
their skills of doing Wheelie.
The primary purpose of this study was to test the hypothesis

that formalized training based on WSTP guidelines given to
Occupational therapy students would improve their skills of doing
Wheelie.
Methodology
Research Design Pretest Post-test single group design
15 Students of Occupational therapy(BOT III /BOT IV) were
taken.
Setting College/Lab setting
Materials/equipment Wheelchair, wooden blocks/bricks,
Spotters strap, stop
watch, measuring tape, WSTP
Outcome Measures Height of Castors rise, Time in seconds
for maintaining wheelie position, Safety perception on Visual
Analog Scale
Procedure - Subjects were trained for wheelie by using WSTP
guidelines. They were assessed by using the outcome measures
Results
There was significant difference (p<0.05) between pre and
post training measure
Conclusion
Formalized training based on WSTP guidelines given to
Occupational given to Occupational Therapy students improved
their skills of doing wheelie.
Introduction
Wheelchair is the most important therapeutic devices in
rehabilitation.1 The fundamental purpose of a wheelchair is to
promote mobility, inclusion and enhanced quality of life of the
user. It is a mobility device to promote inclusion and participation
(WHO definition)2
The wheelie is a useful skill that enables the wheelchair
users to alter their position in space and to overcome a number
of environmental obstacles (e.g., rough ground curbs) that may
otherwise limit mobility. To perform a wheelie, the wheelchair user
must lift the casters off the ground to the point where the combined
center of mass (COM) of the users and wheelchair can be
balanced over the rear axles.3, 4 It is surprising that the wheelie
has received little attention in the scientific literature and that only
a minority of wheelchair users ever learn to perform them4.
Kirby RL, Mifflen NJ, Thibault DL, Smith C, Best KL,

Thompson KJ, MacLeod DA (2004) studied Wheelchair Skills
Training Program (WSTP) version 2.4 effectiveness in improving
the wheelchair-handling skills of untrained caregivers. Twentyfour caregivers of manual wheelchair users were taken.
Caregiver participants underwent the WSTP, adapted for
caregivers. The greatest improvements were at the advanced
skill level. The WSTP was found to be a safe, practical, and
effective method of improving the wheelchair-handling skills of
untrained caregivers.7
MacPhee AH, Kirby RL, Coolen AL, Smith C, MacLeod DA,
Dupuis DJ (2004) conducted a study to test the hypothesis that
a brief, formalized period of additional wheelchair skills training
was safe and results in significantly greater improvements in
wheelchair skills performance than a standard rehabilitation
program. Thirty-five wheelchair users participated in the
Wheelchair Skills Training Program (WSTP). The WSTP group
showed significantly greater improvements than the control
group. programs. 5
Coolen AL, Kirby RL, Landry J, MacPhee AH, Dupuis D,
Smith C, Best KL, Mackenzie DE, MacLeod DA (2004) tested
the hypothesis that a brief formalized period of wheelchair skills
training, added to the standard curriculum, results in significantly
greater overall improvements in wheelchair skills than a standard
undergraduate occupational therapy (OT) curriculum alone. The
22 second-year students, randomly allocated to the Wheelchair
Skills Training Program (WSTP) group, on the 50 skills that make
up the WSTP. The WSTP was found to be an effective way to
improve the wheelchair-skills performance of OT students. This
has implications for the education of all rehabilitation clinicians.6
Best KL, Kirby RL, Smith C, MacLeod DA (2005) tested the
hypotheses that wheelchair skills training of community-based
manual wheelchair users was efficacious, safe, and practical.
Twenty community-based manual wheelchair users were taken.
Participants were randomly allocated to the Wheelchair Skills
Training Program (WSTP) or control groups. The WSTP group
had clinically significant pre and post training improvements in
the success rates of 25 of the 57 individual WST skills, compared
with only 5 skills for the control group.8
Kamal Narayan Arya / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
73
Methodology
Research Design Pretest Post-test single group design
Sample size 15 (6 male & 9 female)
Sample characteristics Subjects were students of
Occupational therapy who have been taught Wheelchair as
per their curriculum. Students were selected from two different
colleges.
Setting College/Lab setting
Materials/equipment Wheelchair, wooden blocks/bricks,
Spotters strap, stop watch, measuring tape, WSTP
Duration of study 5 months (May 2007 to October 2007)
Time of training for each subject 1 month, 12 to 15 sessions
of 10-15 minutes each, total of 3 hours, in a group of 3-4 students
(but individual practice session was also encouraged)
Procedure
1.
2.
3.
Construction of spotter strap 9 & 10

Fig 1: Spotter strap
4.
5.
6.
A simple webbing strap that can be attached to the

wheelchair at one end and held by a spotter at the other
was constructed. It reduced the likelihood of injury due to
rear-tipping accidents at the time of training without making
the spotter to bend forward to catch a tipping wheelchair.
Outcome measures
7.
8.
Height of Castors rise (vertical) in inches, measured for

maximum safe and successful performance, subject was
instructed for minimal wheelchair displacement.
Fig 2: Measurement of vertical height rise
Qualitative Video analysis of Wheelie related functional

activity
9.
Familiarization with wheelchair skills and parts All the

subjects were assessed for their knowledge of wheelchair
parts and their basic skills for wheelchair propulsion such
as rolling forward, turning etc. Subjects had been taught
about wheelchair parts and basic skills wherever required.
Testing of Wheelie with safety measures Ability to do
wheelie was tested for every subject by taking proper safety
measure
About Concept of Wheelie & its application Following
concepts had been explained to all subjects in group/
individually - It is very useful for crossing thresholds, curbs,
uneven terrain steps, obstacles. They are of two types Static
& Dynamic, static is useful for crossing levels, steps etc
while dynamic wheelie is helpful in descending inclined
without which risk of rolling over is always there. In static
wheelie effort is done to do wheelie so as to cross a
particular height after that position of wheelie is released
to further propel the wheelchair. While in dynamic wheelie
user propels the wheelchair in wheelie position.
Biomechanics of wheelie Following biomechanics concepts
of wheelie had been explained to subjects either in group
or individually - Wheelie, balancing of wheelchair on rear
wheels is achieved when COG of wheelchair & user
combined lies vertically over the rear axle. Initiated by
accelerating and transferring weight rearward, inertial effect
resist the acceleration, causes a turning moment about the
axle Balance wheelie position by propelling rear wheel in
front and back so that base of support comes under
combined COG of user and wheelchair
Video demonstration clips of wheelie and its application in
various activities Video clips of various steps related to
wheelie skill training and its application in daily activities
were shown to all subjects in group/individually10
Use of bricks/blocks Four bricks/wooden blocks were used
to block the both rear wheels of wheelchair to create a
position of wheelie passively by the trainer. This position
was tried to be balanced till the subject achieve few seconds
of hold by shifting his Centre of Gravity (COG) through trunk
movements.
Use of spotters strap Spotters strap was used through out
the training as and when required.
Use of Motor learning principles Basic principles of motor
learning were applied during learning the skills such as
video/practical demonstration, drill practice, varied
environment, mass/distributed practice, feedback (visual
through mirror & auditory by trainer).
Post training assessment Post assessment was done by
using the same outcome measures as for pre training
Data analysis & results

Sample characteristics 15 subjects, 6 males & 9 females
with mean age of 20.57 years and standard deviation (SD) of
+1.55.
74
Time in seconds for maintaining wheelie position, both for

Static & Dynamic stop watch was used to measure the
maximum time for which subject could maintain wheelchair
after training
Safety perception on Visual Analog Scale (ten points)
4
Subjects were asked to perceive their feeling of safety while
doing wheelie pre and post training on visual analogue scale
of 10.
Data was analyzed for following variables
Height of castor wheel rise (vertical)
Safety perception on Visual Analog Scale (ten points)
Time in seconds for maintenance of wheelie position

static& dynamic
Total time of training (in minutes)

Main findings of the data analysis are summarized in table &
graph (1 to 5)
Kamal Narayan Arya / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Table 1: Post training height rise (inches) of castors

Mean
12.78
+ 2.59
SD
Test value
t = - 8.128
p
< 0.0005 (significant)
Table 4: Relation between training time (in seconds) & height

of castors rise (inches)
Test value
r = 0.79
p
Graph 4:
Graph 1:
Table 2: Post training VAS score for perceived safety

Mean
7.46
+ 1.34
SD
Test value
t = - 1.962
p
Table 5: Relation between training time (in seconds) &

maintenance of dynamic wheelie (in seconds)
Test value
r = 0.927
p
Graph 5:
Graph 2:
Table 3: Post training maintenance of static wheelie (in seconds)

Mean
185.33
+ 80.36
SD
Test value
t = - 1.857
p
Graph 3:
Discussion
Wheelie, an important wheelchair skill to perform various
daily activities always seems to be difficult to do and far more
difficult to teach to clients. The following study used WSTP
guidelines to teach wheelie to Occupational therapy student
which showed positive results of learning. None of the subjects
had ability to do wheelie before training though they have
undergone their usual curriculum of theory and practical classes.
Post training, significant results were found for doing wheelie in

terms of height of castor rise (vertical), time for maintaining
wheelie position (Static) & safety perception. No adverse
incidents were recorded. Similar results were found in a study
done by Coolen AL et al (2004) 6.
Mean vertical rise of castors was 12.78 inches, p <
0.0005(significant), which was also clinically significant and had
functional implication for crossing levels of appropriate height,
descending ramps etc.
Kirby and et al (2001) proposed 14 wheelie specific skills
such as wheelie rest, stationary, move forward, turn, incline
descent etc.4 In the present study implication of learning wheelie
could not be checked quantitatively for all specific skills.
Qualitative video analysis was done on few subjects pre & post
training to see the change and its implication.
All the subjects had 0 (zero) score for perceived safety on
Visual analogue scale (VAS) of 10 points pre training. Post
training mean VAS was 7.46, p< 0.05(significant).
Post training mean time in seconds for maintenance of
static wheelie was 185.33 seconds, p < 0.05(significant). This
time of static wheelie is enough to perform wheelie related
activity. A L Coolen & et al (2004) reported mean time of 30
minutes (180 seconds) for teaching stationary wheelie to
occupational therapy students.6
Though post training mean time for maintenance of dynamic
wheelie was 149 seconds, not found statistically significant but
had functional significance and more time could be achieved by
practice. There were some subjects who could do either of the
static or dynamic wheelie for infinite seconds or till they get tired.
Personal factors such as motivation to learn, fear to fall could
be probable explanation for this.
Kamal Narayan Arya / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
75
Qualitative educational usefulness was felt among all the

subjects for such type of practical training
There was strong positive correlation found between
training time and rise of castors wheel, r = 0.79, p < 0.0005.
With practice more rise could be achieved but up to a certain
level where COG just lies above the axle of rear wheels. The
more rise could be achieved by using strategies such as trunk
forward flexion, propelling wheelchair in forward and backward
direction. Safe and successful maximum rise also depends on
type of wheelchair. Wheelchair with more anterior axle in relation
to backrest improves ones ability to perform ability but at the
cost of stability. Most of the imported wheelchair has more
anterior axle as compared to Indian one.
There was no statistical relation found between training
time and perceived safety on VAS but clinically it was found that
with practice all the subjects felt more confident and safe. The
statistical insignificance could be attributed to small sample size
and large standard deviation. This could also be the probable
reason for statistical insignificance relation between training time
and maintenance of static wheelie. Though very strong positive
correlation was found between training time and maintenance
of dynamic wheelie(r = 0.927, p < 0.0005). Also clinically subject
could perform better static wheelie with more practice session.
Limitations
- Long term retention of skill could not be checked
- Functional implication of wheelie skill in daily activity was not
tested
- Randomized Controlled Trial could not be conducted
- Sample size was small
- Teaching was performed in lab setting only
Recommendations
Use of video analysis for feed back of learning to the

subjects
Students from more different colleges
Use of high technological aids such as Smart wheelchair,

motion analyzer etc.
More in depth study to study the variables such as visual

feedback, use of spotters strap, specific motor learning &
biomechanical principles, training sessions & time, group
vs individual training etc. on learning wheelie.
Effect of such skill on improvement in activity, participation

and over all quality of life.
Therapy clinicians which would improve their practice skill

leading to better service for their clients. Such formalized
structured training program should be incorporated in
Occupational Therapy curriculum.
Conclusion
Formalized training based on WSTP guidelines given to

Occupational therapy students made them skillful in doing
wheelie. This has implications for the education of Occupational
76
References
1.
Kirby RL Principle of W/c design & prescriptionin : Lazar

RB editor, Principle of Neurorehabilitation, Mc graw hillnew
York 465-81
2. ISPO consensus conference on wheelchairs for developing
countries: Conclusions and recommendations., Prosthet
Orthot Int. 2007 Jun;31(2):217-23
3. JP Bonaparte et al, Learning to perform Wheelchair
Wheelies: comparison of 2 strategies, Archives of PMR,
May 2004, V 85, 785-793.
4. RL Kirby et al, New Wheelie Aid for Wheelchairs: Controlled
Trial of Safety and Efficacy Archives of PMR, March 2001,
V 82, 380-390.
5. Mac Phee AH et al, Wheelchair skills training program: A
randomized clinical trial of wheelchair users undergoing
initial rehabilitation; Arch Phys Med Rehabil. 2004
Jan;85(1):41-50
6. Coolen et al, Wheelchair skills training program for
clinicians: A randomized clinical trial with Occ therapy
students; Arch Phys Med Rehabil. 2004 Jul;85(7):1160-7
7. Kirby RL et al, The manual wheelchair-handling skills of
caregivers and the effect of training, Arch Phys Med Rehabil.
2004 Dec;85(12):2011-9
8. Best KL, Wheel skills training for community-based manual
wheelchair users: a RCT, Arch Phys Med Rehabil. 2005
Dec;86(12):2316-23
9. Kirby RL et al, Spotter strap for the prevention of wheelchair
tipping Arch Phys Med Rehabil. 1999 Oct;80(10):1354-6.
10. www.wheelchairskillsprogram.ca
Acknowledgement
I would like to thankDr. Dharmendra Kumar, Director PDU IPH, New Delhi
Dr. Anoop Agarwal, HOD (OT), PDU IPH, New Delhi
Dr Manish Samnani, Demonstrator (OT), PDU IPH, New
Delhi
Dr. Kirby, Faculty of Medicine, Dalhousie University, Canada
Dr. Roory Cooper, University of Pittsburg, USA
BOT IV(2007) students of PDDU Institute for the Physically
Handicapped & BOT III students(2007) of Jamia Hamdard
for their support and cooperation as subjects.
Perception and functional wellbeing of patients receiving

physiotherapy services in a multispecialty hospital prospective
observational trial
T. Lavinia Marwein1, Baskaran Chandrasekaran2, Bidhan Chandra Sharma3
1
Physiotherapy Intern, College of Physiotherapy and Medical Sciences, Guwahati, 2 Lecturer in Physiotherapy, Sikkim Manipal
College of Physiotherapy, SMU, Sikkim, 3 Assistant Professor in Physiotherapy, Sikkim Manipal College of Physiotherapy, SMU,
Sikkim
Introduction
Physiotherapy plays a vital role in the recovery of physical,
emotional illness of the various functionally impaired and re integration into their family and community. Physiotherapy may
add life to years of the patients and increases their physical,
emotional and social wellbeing1.
The physical, social and psychological wellbeing after
rehabilitation is well established in well planned, statistically
strong earlier studies2-6. The wellbeing, an abstract thinking is
mainly relied on the patient perception which is highly subjective
and non reproducible. Hence these studies are questioned for
their validity and reliability2-7.
Very few reliable and valid scales have been developed to
measure patient satisfaction of patients receiving out-patient
physiotherapy3, 5, and 7. Recent patient satisfaction questionnaire
developed by American Physical therapy Association (APTA)
claims high validity and reliability in their application5 but it has
not been used in India so far and the patients quality of life after
physiotherapy remains unknown.
The treatment was based on the assessment by the clinical

physiotherapists who are blinded to the current study. The
physiotherapists recruited to the study were assessed for sound
clinical knowledge, judgment and prioritizing the treatment
techniques. We found that inter - rater reliability in the
assessment techniques was high since stratified on the basis
of qualification and experience.
Functional assessment questionnaire

The questionnaire consists of 18 components was given in
which the patient have to circle according to the functional
restriction and impairments. However, a higher score
corresponds to greater activity response and the lowest score
corresponds to lower activity status or greater impairment.
Objectives of study
The individual components of functional assessment

questionnaire between pre and post physiotherapy intervention
is compared by paired sample t test. The rest of the data is
described by descriptive analysis.
1.
Results
2.
To find the efficiency of physiotherapy services in outpatient

set-up.
To qualitatively evaluate and document the satisfaction and
the quality of life in physiotherapy out patients.
Methodology
Study Design: Prospective observational trial .
Study Setting: Central Referral Hospital, Gangtok.
Sample Size: 50 patients required to find minimum effect size
of 50% improvement in the functional scores and at power of
80% and level of significance of 90%.
Patients: The study was approved by Sikkim Manipal Institute
Ethics Committee. The patients enrolled for outpatient
physiotherapy without the due consideration to their ailments
and are willing to participate are explained about the study. The
subjects whose compliance was questioned are excluded from
the study. It was assumed to have 100% compliance to the
physiotherapy treatment. They are recruited after the informed
consent. They were asked to fill the functional assessment
questionnaire prior to the physiotherapy treatment. The patients
are then assigned to the clinical physiotherapists of similar
demographics, professional qualification and experiences
blinded to the research question and procedure.
Procedure
Assessment
The routine assessment was taken based upon the
individual differences in the problems, pain pattern and
intellectual context, reasoning skills and the rationale of diagnosis
of the physiotherapists performing the assessment.
Physiotherapy treatment
Totally 50 patients screened and analyzed. Only 37 patients

completed the overall physiotherapy treatment sittings. The data
are presented in the table: 1.
Satisfaction: the average satisfaction score from the APTA
questionnaire is 85.3 which are depicted in percentage in the
fig: 2.
The Functional Assessments:
The t test showed that all the functional components reached
significant level except driving and is presented in table. 2.
(To be significant, observed t value should be greater that of
calculated t value 2.042 for 36 degrees of freedom with CI of
95% and = 95%)
Discussion
1. Satisfaction:
We have observed that the 85% of the patients have
satisfied with the present physiotherapy services. The current
therapists rationalistic knowledge, inter therapist relationship in
assessment and the management, patient friendly environment
and accessibility and availability of the physiotherapeutic
equipments might be the reason for the satisfaction.
We agree to the previous literature claims 2-7 that
physiotherapy services might give an excellent satisfaction if
the services were easily accessible, excellent based on the
availability of modalities and therapists, therapists knowledge
and treatment planning, timing of the treatment, improvement
in lifestyles and patient friendly.
No previous reports have reported a satisfaction statistics
of this high magnitude. This satisfaction may be due to chance
because of the low sample size.
2. Functional capacities evaluation:
We have proved that almost all the aspects of the functional
T. Lavinia Marwein / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
77
evaluation scale were reported to reach significance levels after

their comparison among pre and post physiotherapy (graph. 3
and table 2). This definitely implicates that Physiotherapy brought
improvements in their quality of life by improving functional
abilities.
We had an assumption that any precise physiotherapy
assessment and treatment pertained to the condition might
decrease the above impairments and restore wellbeing. We have
observed from our study that all the common functional
impairment components improved with higher levels of
significance in ADL activities like bathing, functional activities
like carrying and lifting and recreational activities like sports.

We agree to the earlier literature8, 9 proving that the planned
and structured physiotherapeutic assessment and treatment
bring about improvement in their ADL activities (Basic,
instrumental and recreational activities).
Conclusion
Physiotherapy improves quality of life of the patients
receiving outpatient rehabilitation services inspite of the ailments
and the therapists. More than 2/3rd of the total patients receiving
Table 1: Table explain the individual components of functional assessment questionnaire and satisfaction of the patients
Table 2: paired t test analysis of the pre intervention and post intervention functional capacities of the individuals
Components of the functional assessment questionnaire
95% CI
t
Sig. (2
Mean
SD
SEM
Lower
Upper
-tailed)
Pre PT sleep disturbances - Post PT sleep disturbances
1.08108 1.03758 .17058 .73513 1.42703
6.338
.000
Pre PT up and down stair climbing Post PT stair climbing
.97297 .95703 .15734 .65388 1.29206
6.184
.000
Pre PT cooking,eating - Post PT cooking, eating food
1.05405 1.26811 .20848 .63124 1.47686
5.056
.000
Pre PT walking - Post PT walking
.64865 1.08567 .17848 .28667 1.01063
3.634
.001
Pre PT grooming (bath, comb, shave) - Post PT
1.24324 1.49825 .24631 .74370 1.74278
5.047
.000
Pre PT transfer - Post PT getting up and down(chair,bed)
1.10811 1.14949 .18897 .72485 1.49137
5.864
.000
Pre PT dressing - Post PT normal dressing
.97297 .86559 .14230 .68437 1.26158
6.837
.000
Pre PT tie shoes, button shirt - Post PT tie shoes, button shirt .81081 1.32995 .21864 .36738 1.25424
3.708
.001
Pre PTlifting, carrying - Post PTlifting, carrying
1.40541 1.03975 .17093 1.05874 1.75208
8.222
.000
Pre PT sitting - Post PT sitting
.81081 1.41102 .23197 .34035 1.28127
3.495
.001
Pre PT standing - Post PT standing normal period
1.75676 4.65717 .76563 .20398 3.30953
2.295
.028
Pre PT reaching - Post PT reaching
1.67568 3.63665 .59786 .46316 2.88820
2.803
.008
Pre PT leisure, recreational - Post PT leisure, recreational
1.18919 1.30890 .21518 .75278 1.62560
5.526
.000
Pre inter squat to pickup - Post intersquat to pickup items
1.18919 1.30890 .21518 .75278 1.62560
5.526
.000
Pre inter running, jogging - Post inter running, jogging
.94595 1.50824 .24795 .44308 1.44882
3.815
.001
Pre intervention driving - Post intervention driving
.37838 1.38145 .22711 -.08222 .83898
1.666
.104
Pre PT job requirements - Post PT job requirements
.91892 1.08981 .17916 .55556 1.28228
5.129
.000
Pre intervention VAS - Post intervention VAS
3.78378 1.98795 .32682 3.12097 4.44660 11.578
.000
78
T. Lavinia Marwein / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Fig. 2: Mean satisfaction of the patients attending Physiotherapy

department of SMIMS
Graph 3: Bar diagram, showing a pre and post intervention

difference in functional activities
physiotherapy satisfy with the available physiotherapy services

in the outpatient rehabilitation
5.
References
6.
1.
2.
3.
4.
Crosbie J, Naylor J, Harmer A, Russell T. Predictors of

functional ambulation and patient perception following total
knee replacement and short-term rehabilitation. Disabil
Rehabil. 2009 Oct 28.
Deutscher D, Horn SD, Dickstein R, Hart DL, Smout RJ,
Gutvirtz M, Ariel I. Associations between treatment
processes, patient characteristics, and outcomes in
outpatient physical therapy practice. Arch Phys Med
Rehabil. 2009 Aug;90(8):1349-63.
Marc S Goldstein, Steven D Elliott and Andrew A Guccione.
The Development of an Instrument to Measure Satisfaction
with Physical Therapy. Phys Ther Vol. 80, No. 9, September
2000, pp. 853-863
P.F Beattie, M. B. Pinto, and M. K Nelson and R. Nelson;
Patient Satisfaction With Outpatient Physical Therapy:
Instrument Validation; Physical Therapy, June 1, 2002;
82(6): 557 - 565.
7.
8.
9.
Longitudinal Continuity of Care Is Associated With High

Patient Satisfaction with Physical Therapy; Physical
Therapy, October 1, 2005; 85(10): 1046 - 1052.
P.F Beattie ,R.M Nelson and A.Lis; Spanish-Language
Version of the MedRisk Instrument for Measuring Patient
Satisfaction
With
Physical
Therapy
Care
(MRPS):Preliminary Validation. Physical Therapy,
June 1, 2007; 87(6): 793
Roush SE, Sonstroem RJ.Development of the physical
therapy outpatient satisfaction survey (PTOPS). Phys Ther.
1999 Feb;79(2):159-70.
Adamsen L, Quist M, Andersen C, Mller T, Herrstedt J,
Kronborg D, Baadsgaard MT, Vistisen K, Midtgaard J,
Christiansen B, Stage M, Kronborg MT, Rrth M. Effect of
a multimodal high intensity exercise intervention in cancer
patients undergoing chemotherapy: randomised controlled
trial. BMJ. 2009
R P. Van Peppen, G Kwakkel, S Wood-Dauphinee, H J.
Hendriks, P. J Van der Wees, andJDekker. The impact of
physical therapy on functional outcomes after stroke: whats
the evidence? Clinical Rehabilitation, August 1, 2004; 18(8):
833 862.
T. Lavinia Marwein / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
79
Effect of concurrent quantitative feedback training on intra-rater

and inter-rater reliability of grade III mobilization over fourth
lumbar spinous process
Nidhi Gautam*, Shallu Sharma**
*Research Student, ISIC Institute of Rehabilitation Sciences, New Delhi, **Research Guide, M.P.T. Manual Therapy, Lectrurer, ISIC
Institute of Rehabilitation Sciences, New Delhi
Abstract
Postero-anterior mobilization of spine have been found to have
quite beneficial effects in various musculoskeletal conditions,
yet, the reliability of various parameters of grade, dosage (force,
amplitude, acceleration, deceleration, etc) have not been
concluded so far. Feedback training has positive impact on motor
skill acquisition. The purpose of the present study was to
investigate whether intra-rater & inter-rater reliability of grade III
mobilization over L4 spinous process can be improved
secondary to feedback training using pressure algometer ?
Subjects & method

200 asymptomatic, healthy subjects participated in the study.
Two equally qualified & skilled raters were recruited & were
provided with four week of feedback training in applying grade
III mobilization over L4 spinous process over 200 healthy
subjects, by the same mentor. Posts training intra-rater & interrater reliability of grade III mobilization force over L4 spinous
process in 193 healthy asymptomatic subjects were calculated.
Results
Excellent intra-rater & high inter-rater reliability values (ICC =
.9434* & .8019* respectively, pd 0.01) of grade III mobilization
over L4 spinous process were obtained.
Discussion & conclusion

Mobilization procedures are motor skills which require practice
to be learnt properly. Feedback training has established positive
role in facilitating motor skill acquisitition. Improved values of
intra-rater & inter-rater reliability of grade III mobilization over
L4 spinous process secondary to feedback training using
pressure algometer, obtained in the present study can be
explained in consensus with the positive impact of feedback
training on acquisitition of motor skills.
Key words
feedback training, algometer, reliability, motor skill acquisition
Introduction
Manual therapy is the mainstay of modern physiotherapy
which includes a wide range of interventions such as joint
mobilization, manipulation, traction, soft tissue techniques, etc.
It requires expertise in skillfully applying these different manual
techniques, thus, maximizing their effectiveness. 1,2,3,4
Mobilization refers to gentle, repetitive, rhythmic movements
forming the mainstay of manual therapy assessment & treatment
techniques. The outcomes of spinal manual therapy have most
commonly been described in terms of biomechanical response
to application of treatment technique. Majority of these studies
on applied manual forces relates to
the posterior to anterior (PA) spinal mobilization technique
that was described by Maitland et al in book that is Maitlands
vertebral manipulation (seventh edition) 5 - four grades of
mobilization were defined with Grade I & II to be primarily used
80
for treating pain while grade III & IV to be used for

stretching.6,7,8,9,10
Reliability forms an important basic question addressing
the fact that a test (a tool of measurement or scale) should
measure exactly the same quality or attribute each time it is
used. Intra-rater reliability is the similarity in the measurements
of a quality or an attribute taken by a same individual on specific
intervals of time whereas inter-rater reliability is the similarity in
the measurements of same attribute or quality taken by two or
more individuals taken on specific intervals of time.
A large amount of literature investigating these various
parameters of applied forces along with the concept of reliability,
in relation to various therapists & patients related factors, already
exists. Most of these studies were teemed with various flaws &
limitations like testing over mechanical simulating models other
than living subjects, inappropriate inclusion criteria of raters,
lack of proper pre-training and feedback for acquired skill, and
absence of trials, etc, thus, making results of these different
studies incomparable & incoherent.
A study on manual forces applied during cervical
mobilization by Suzanne et al in 2007 provided preliminary
evidence that cervical mobilization forces vary considerably
between therapists, but intra-therapist repeatability was high.11
Suzanne et al in 2009 re-established the variability between
therapists, but, intra-therapist reliability was good (intraclass
correlation coefficient [2,1] for different force parameters, 0.840.93). Mean peak forces increase from grades I to IV, ranging
from 22 to 92 N for resultant forces.12 Mc Harms et al found
inconsistency between experienced therapists in applying lumbar
mobilization.13
On the other hand, J Keating et al in their study on effect of
training on physical therapists ability to apply specified forces of
palpation, concluded that training improves accuracy in force
application during various manual techniques. 14 Similarly,
Michael et al in 1990 established significant improvement in
accuracy & consistency in the application of the mobilization
force with the use of feedback training during learning session
of vertebral joint mobilization skill.15 B J Downney et al in 1999
indicated training in spinal therapy enhances the palpatory skills
of physiotherapists in palpating nominated lumbar spinal levels.16
In the present study, pressure algometer which has been
commonly used in clinical settings, was used as a feedback
tool to facilitate teaching & learning of graded mobilization during
pre-training sessions.
Various sophisticated devices like force plates, specially
designed instrumented plinths, or more complicated devices
have been used to quantify various parameters of forces applied
during manual therapy techniques. Most of these instruments
are very sophisticated, expansive with complex functioning
mechanism which is more useful for research purpose in
laboratory settings rather than clinical purposes. There is need
of a simple, easy to use, economical, easily accessible, but,
accurate and reliable device which can be used in laboratory as
well as clinical settings easily for quantification of force
parameters during various manual therapy techniques.
Pressure algometer is one such simple device fulfilling these
requirements with good intra-rater & inter-rater reliability for force
application in various pathological conditions.17
In the light of these various inconclusive, equivocal studies
leading to lack of proper documentation of vital parameters of
Nidhi Gautam / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
mobilization forces, there is a need of well organized, systematic

study keeping various limitations in mind, thus, addressing the
very important basic question of reliability of mobilization forces
applied by different therapists. A study aiming at finding some
practically effective method to find whether these mobilization
techniques application can be improved or not, is needed.
Thus, the present study, using a conventional spring loaded
pressure algometer to provide feedback training during learning
session of graded mobilization, is an effort towards overcoming
various flaws & limitations of these previous studies to reach a
more reliable & meaningful conclusion in the field of manual
therapy.
Methods
Subjects: A total sample of 230 healthy asymptomatic
subjects collected by displaying of advertisement on various
notice boards of ISIC hospital & academic section of ISIC
Institute of Rehabilitation Sciences. Out of 230 volunteer subjects
who satisfied inclusion criteria were selected. A detailed
explanation about the procedure and purpose of the study was
provided to the subjects. Informed consent was duly signed by
all the subjects after they agreed on participating in the study.
Simultaneously two physical therapists with similar age, clinical
experience and theoretical background, were randomly recruited
as raters for the study from a group of therapists specializing in
the field of musculoskeletal physiotherapy.
A mechanical Force dial TM FDK/FDN model algometer
by Wagners was used for the study. These models are calibrated
in the factory prior to the delivery to the customer, so no further
calibration was required prior to commencement of the study.
The instrument has 10 kg/cm2 marked scale with a 1 cm2 rubber
foot plate with an accuracy of two grades ( 2) through 5 lbf/
2500gf [ (1) one grade over 5 lbf/2500gf)]. A standard error of
three grades was present in the model used in the present study
which was considered subsequently during the whole data
analysis.
A four week training session aiming at adequate
understanding and learning of grade III mobilization technique
over radial styloid process followed by over L4 spinous process
manually & later by using pressure algometer over L4 spinous
process provided by a skilled mentor preceded the data collection
period. The mentor recruited for the purpose was an experienced
clinical physiotherapist having five years of experience with
specialization in neuro-musculoskeletal physiotherapy.
First, both the raters were only provided with theoretical
knowledge of grade III mobilization to be applied over L4 spinous
process which was pre-marked by an independent rater. Proper
thumb grip was attained. Following this, raters were trained for
applying grade III mobilization force using thumb grip over the
superior surface of algometer dial placed vertically on a hard
table with the styloid facing downward. The same placement of
algometer and grasp was used over L4 spinous process marked
by an independent rater as described before. All these volunteers
were dealt in this way within three days with no concurrent
quantitative feedback given to raters. Readings of force applied
by two raters on same day and rater 1 on three consecutive
days, were recorded by the third rater independently. The raters
were asked to perform three to five oscillation over L4 spinous
process and mean of last two readings was taken on day 1 and
two consecutive days for data analysis to find pre-training force
magnitude and intra-rater and inter-rater reliability.
After the first leg of study, the second leg commenced
with progression of the study towards four week training session
in which each rater was trained to acquire the feel of grade III
mobilization force by direct application using thumb grip over
soft skin of forearm, followed by bony prominence of radial styloid
process and finally over spinous processs of fourth lumbar
vertebra. Mentor affirmed the correctness of technique of grade
III force application. They were progressed further to application
of grade III mobilization force using pressure algometer over L4

spinous process. The L4 spinous process was marked by third
independent rater using iliac crests and posterior superior iliac
spines as reference landmarks. Rater perform grade III
mobilization and concurrently feedback regarding force
magnitude was provided by the mentor for facilitating their
learning of correct technique of graded III mobilization. During
this training period, range of force applied by the mentor recorded
with pressure algometer was used as a reference for learning
amount of force to be applied in grade III mobilization over L4
spinous
Once both raters became confident of acquired skill &
consistency of their technique was re-evaluated by the mentor,
these raters were upgraded to perform the same procedure
over study sample of 193 healthy subjects over the period of
five months. Now, these force readings were noted for data
analysis to calculate intra-rater and inter-rater reliability of grade
III mobilization over L4 spinous process.
A total of 193 subjects could be re-contacted. The third leg
of the study started with brief introduction of study explained to
every subject using forearm as demonstrating media. Subjects
were positioned in prone lying on a firm plinth with a small pillow
under hips to allow slight flexion of hip joints thus, making lumbar
lordosis neutral, allowing easy palpation of L4 spinous process.
Rest spine was made to lie in neutral relaxed position without
any lateral bending or rotation with the arms relaxed by the side
of the trunk and head rotated comfortably to one side as per
subject comfort. Now, palpation & marking of L4 spinous process
was done by third independent rater using highest points of iliac
crest as well as PSISs (Posterior superior iliac spines) as
reference points chosen randomly for reconfirmation.
Subject was instructed to exhale normally at force
application by the raters. First grade III mobilization was applied
using thumb grip directly on L4 spinous process & subjects were
asked to remember the amount of force as far as possible
through the perception felt at the end of procedure, immediately
thumb grip application was switched on to algometer force
application. Grade III mobilization force was applied 3-5 times
with an interval of 30 seconds between each trial, using pressure
algometer over L4 spinous process & three readings which were
also in consensus with subject perception of force applied, were
used for data collection.
Rater 2 performed similar method of force application on
each subject for testing inter-rater reliability after five minutes
of force application by rater 1, during which subject was not
allowed to change his/ her position. Rater 1 used same method
for two more consecutive days over same 193 subjects for intrarater reliability testing. All the readings were recorded by the
third rater who had no knowledge about the purpose and
objective of the study. The average of last two of these three
readings was taken as the amount of force applied by each
rater during different trials for calculating post-training intra-rater
and inter-rater reliability of grade III mobilization over L4 spinous
process. These values were further taken for data analysis to
calculate intra-rater and inter-rater reliability of grade III
mobilization over L4 spinous process using suitable statistical
tools.
Results
Results of the current study showed post training
improvement in intra-rater and inter-rater reliability of grade III
mobilization forces from ICC values of .8344* (intra-rater); .7044*
(inter-rater) to ICC values of .9434*(intra-rater); .8091* (interrater) respectively.
Discussion
Over the past two decades (1985-2009), with growing
understanding of various parameters of mobilization forces,
Nidhi Gautam / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
81
Table 1: Demographic details of the subjects (pre-training period)

N=200 (F=102,M=98)
VARIABLES
MIN.
MAX.
MEANSD
AGE
20.00
44.00
30.018.44
WEIGHT
45.00
79.00
64.198.10
HEIGHT
1.07
1.80
1.669.04
BMI
18.5
25.00
23.071.80
Ra1
2.30
6.65
4.400.81
Rb1
2.50
6.85
4.740.77
Ra2
2.85
6.45
4.460.70
Ra3
2.85
6.45
4.560.74
Abbreviations:
BMI- Body Mass Index
Ra1 force readings (in Kgf) of rater 1 on first day
Rb1 force readings (in Kgf) of rater 2 on first day
Ra2 - force readings (in Kgf) of rater 1 on second day
Ra3 - force readings (in Kgf) of rater 1 on third day
Table 3: Demographic details of the subjects (post-training

period)
N=193 (F=102,M=91)
VARIABLES MIN.
MAX.
MEANSD
AGE
20.00
44.00
29.866.41
WEIGHT
45.00
79.00
63.968.10
HEIGHT
1.07
1.80
1.669.08
BMI
18.5
25.00
23.031.81
Ra1
2.65
6.75
4.370.78
Rb1
2.75
6.85
4.720.80
Ra2
2.85
6.45
4.490.75
Figure 5: Post-training force variation of rater1 on three

consecutive days
Figure 1: Pre-training force variation of rater1 on three

consecutive days without feedback training
Table 2: Pre-training Intra-rater and inter-rater reliability values

obtained in 200 healthy subjects
VARIABLES
AVERAGE
ICC
FORCE
APPLIED (kgf)
INTRA
Ra1
4.40
RATER
Ra2
4.46
.8344*
Ra3
4.56
INTER
Ra1
4.40
RATER
Rb1
4.74
.7044*
Results showing high intra-rater and moderate inter-rater
reliability of grade III mobilization during pre- training session
Table 4: Post-training Intra-rater and inter-rater reliability values

obtained in 193 healthy subjects
VARIABLE
AVERAGE
ICC
FORCE
VALUE
APPLIED (kgf)
INTRA
Ra1
4.37
RATER
Ra2
4.49
.9434*
Ra3
4.57
INTER
Ra1
4.37
.8019*
RATER
Rb1
4.72
Results showing excellent intra-rater reliability & high inter-rater
reliability between two raters post-training
Figure 6: Post-training force variation between two raters
Figure 2: Pre-training force variation between two raters without

feedback training
various modifications have occurred suggesting improvised

reliability & reproducibility [poor to fair ranging from k=-.20 to
.26; p=0.001].11,12,14,15,18, 19, 20,21,22,23,24,25,26,27 Since, these studies
were based on dimensions of parameters like stiffness; it is an
ongoing process. The current study focuses on investigating
force related parameters & theoretical construct of grade III force
testing.
In the present study, asymptomatic healthy subjects have
been selected to assess grade of mobilization as symptomatic
82
subjects have been found to have varying amount of interexaminer reliability in palpation and examination of intersegmental mobility suggesting an unexplained variability
between candidates.20,22,24,25,26,29,30,31,32,,33 In the present study, L4
vertebra was targeted as this level simulates normal spinal
kinematics to application of postero-anterior force. Moreover,
L4 vertebra has better comparative values for intra-rater and
inter-rater reliability for palpation than other lumbar vertebral
levels (L2, L3, L5) 21,34. Therefore, use of L4 in the current study
strengthens the internal validity of the study, as L4 is assumed
to follow normal kinematic principles to poster-anterior force
application.35
Subjects falling in the normal range of BMI (18.5-25) has
been selected in the present study, to address another source
of variation i.e. obesity, thus limiting the variations in force
parameter due to excess fat tissue deposition (subcutaneous

and inter-vertebral space). G.D.Maitland has suggested two
types of grips- the thumb grip & the pisiform grip. He suggested
the loss of feel as source of bias in perceived magnitude &
reduction in stimulus discriminability. Since, both type of grip
have equal stimulus discriminability, the therapist can use either
of these grips, but, should ensure use of same grip each time
for test & retest.36 ,thus, justifying use of thumb grip in the present
study.
The results of the present study supports the experimental
hypothesis. Living human subjects have been used in the present
study, suggesting better expected values of perceived stiffness
than on simulating mechanical models employed in earlier
studies.17,31,37
As the study by NJ Petty et al in 2002 suggested that
patterns of stiffness observed in movement diagrams of spinal
or peripheral joints are not analogous to normal tissue loaddisplacement curve, depicting the first point of resistance felt by
examiner (R1) at the beginning of the range, as early as the
beginning of the range (at point A), the choice of resistancedefined treatment grades of movement would, as a
consequence, be limited to grade III (III-,III,III+) and grade IV
(IV-,IV,IV+) only.38,39,40 Therefore, grade III mobilization with much
lesser variability as suggested in line with these previous studies,
was taken as part of the present study.
Mobilization procedures are motor skills that require practice
and correction in order to be learnt and repeated. Practice of a
motor act is necessary for it to transpire into the skill.41 In the
present study, two equally qualified and skilled physiotherapists
were recruited as raters who were provided with a four weeks of
training aiming at acquisition of motor skill of grade III mobilization
prior to the start of the study.
It has been shown that concurrent qualitative and
quantitative feedback in the form of real-time ultrasound imaging
and pressure feedback training improves the learning of correct
technique of abdominal drawing-in maneuver.28
Table 3 shows high values of inter-rater & intra-rater
reliability( .8019* & .9434* respectively) of grade III mobilization
post motor skill acquisitition using pressure algometer as
compare to moderate inter-rater reliability( ICC= .7044*) values
obtained during initial pre-training phases without use of
concurrent quantitative feedback ( algometer), in consensus with
various behavioral studies emphasizing beneficial effect of
feedback training. 28
These results from the current study are in accordance with
prior studies using sophisticated instruments showing high
reliability values.14,15,16,31 They suggests the advantage of relying
not only on perception of resistance/ force which was taught in
accordance of theoretical concepts, but also referring quantitative
measurement of amount of forces applied in the present study
In the study under investigation, the focus was on studying the
effect of concurrent quantitative feedback training on improving
reproducibility & repeatability of grade III mobilization forces over
L4 spinous process, having taken care of substantial patient as
well as therapist related variables, we conclude that results are
applicable to normal clinical settings.
well as research purposes in turn, it could help in improvising

inter-therapist communication and skills.
Clinical significance
11.
Improved reliability & accuracy of force application in grade

III mobilization over L4 spinous process was supported by the
high inter-rater reliability values obtained in the present study,
highlighting the beneficial use of concurrent quantitative
feedback training using pressure algometer while training grade
III mobilization over L4 spinous process.In light of the comparable
results of the current study to previous literature, it is
recommended to be used in clinical and educational set ups.
Encouragement for its use can contribute to homogeneity and
objectification of the teaching methods of manual mobilization.It
would improve method of data collection for patient records as
Future researches
Studies to adjudge force with respect to graded application
in a holistic view (that is force acceleration, deceleration,
amplitude, etc) using advanced instrumentation are required.
Effect of feedback training and its long term retention using
algometer can be tested on diverse group of population &
therapists.
Potential limitations of the study

A random choice from a group of suited raters would have
better addressed the therapist related variables. Above
mentioned condition, though was not feasible for the present
study, is considered as a potential limitation.
Conclusion
After addressing deficiencies of relevant previous studies
from the review of literature, the present study concludes that
concurrent quantitative feedback training using pressure
algometer plays a significant role in improving reproducibility
and repeatability of grade III mobilization over L4 spinous
process. Hence, feedback training and use of force magnitude
as a form of concurrent quantitative feedback is recommended
for use in educational and clinical settings.
Acknowledgement
I wish to thank my guide Ms. Shallu Sharma. Also I would
like to thank my HOD (Ms. Chitra Kataria) & all faculty members
of ISIC Institute of Rehabilitation Sciences. Lastly my thanks to
all the participants of my study & my family & friends without
whom this study would not have been successfully completed.
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Efficacy of deep transverse friction massage in treatment of

chronic ankle sprain
Pooja K Arora*, Sujata Yardi**, Kunal Pathak***
*Lecturer, Dept. of Physiotherapy, Pad, Dr. D.Y Patil University, Nerul, Navi Mumbai, **Professor & Head, Dept. of Physiotherapy,
Pad. Dr.D.Y Patil University, Nerul, Navi Mumbai, ***Intern, Dept. of Physiotherapy, DY Patil University, Nerul Navi Mumbai
Abstract
Introduction
Intervention: Ultrasound
Group was treated with Ultrasound and Strengthening
exercises. The
Deep Friction Massage
Ankle sprains of lateral ligaments are extremely common injuries

in athletic and physically active population and recurrence
remains a common problem accounting for as high as 80% with
ankle instability. Neuromuscular and proprioceptive deficits are
thought to be related to chronic ankle instability, including
functional and mechanical insufficiencies. Physical therapy is a
treatment modality for patients who have suffered moderate to
severe ankle sprains, especially persons who have chronic
instability and recurring symptoms. Deep Transverse Friction
Massage (DTFM) is a special type of connective tissue massage
used after an injury or mechanical overuse in muscles, tendons
and ligaments is evaluated as a method of treatment in Ankle
sprains.
Group was treated with Deep Friction Massage and

Strengthening exercises. Allocation to Intervention was by block
randomization of 6 done by chit method.
Methodology
Results
Aims & objectives
Of 30 patients, 19 were females (63.33%) suggesting female

preponderance. The mean age of the patient was
24.63years.Twenty One patients had right side ankle
involvement. Two groups were comparable for age, gender and
side of sprain. On comparing the results of two therapies there
was no statistically significant difference noted in relief
parameters suggesting that the two studies were giving
equivalent short term relief to patients of chronic ankle sprains.
Overall analysis of Ankle disability score recorded pre-treatment
and post treatment in both modalities showed statistically
significant improvements in Ankle disability scores.
To evaluate and compare the short term therapeutic effects of

Pulsed Ultrasound and Deep Friction Massage with
Strengthening in Treatment of Recurrent Ankle Sprain
Study design
Hospital based, single blind, Randomized Controlled
Equivalence Trial
Study population
The study population were patients clinically and radio logically
diagnosed by Consultant Orthopaedic surgeon in Orthopaedic
OPD as recurrent ankle sprain and referred to physiotherapy
for treatment. The
Inclusion Criteria
Patients >15 years age, of both genders with ankle sprain
with previous history of minimum two episodes of ankle sprain
in the same foot and who had suffered from last ankle sprain
within two months.
Exclusion Criteria
Acute inflammation and swelling(less than 48 hours),Ankle
fractures and unstable ankles, Neurological disorders like
neuropathy, Musculoskeletal condition of the lower limbs like
limb shortening, foot deformities (Congenital or acquired)
A total of 30 patients who were fulfilling the inclusion criteria
were enrolled in this study.
Study factors
Address for Communication:
Dr Pooja Arora
Lecturer, Dept of Physiotherapy, Pad. Dr.D.Y Patil University,
Nerul, Navi Mumbai. Mobile.: 9869672223
Outcome factors
A blinded observer recorded pain scores on rest and on
movements before treatment, than on 3rd, 7th, and 10th day after
completion of therapy using visual analog scale (VAS). Range
of movement at ankle namely Dorsi flexion, Plantar flexion,
Eversion, Inversion at ankle joint was measured by Goniometer
and. Foot and ankle disability scale score was recorded pretreatment and post treatment.
Conclusion
DTFM is an efficacious tool for short term treatment of chronic
ankle sprains. Its efficacy is equivalent to standard ultrasound
therapy.
Keywords
Chronic Ankle Sprain, Ultrasound therapy, Deep Transverse
Friction Massage, Ankle Disability Scores
Introduction
Ankle sprains especially of lateral ligaments are extremely
common injuries in athletic and physically active population.
Despite vast amount of research in management of ankle
sprains, recurrence remains a common problem accounting for
as high as 80%.1 The possible causes of recurrence could be
healing of ligament in lengthened position, persistent peroneal
weakness, 2 hereditary hyper mobility of joints, loss of
proprioception of the foot, 3 impairment of reflex stabilization of
foot, 4 dysfunction of peroneal nerve and impingement by distal
fascicle of antero-inferior tibio-fibular ligament. The incidence
of developing chronic ankle instability is 20-40% of those who
had previously sustained an acute ankle sprain.5 Neuromuscular
and proprioceptive deficits are thought to be related to chronic
Pooja K Arora / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
85
ankle instability, including functional and mechanical

insufficiencies.6 The functional limitations and disability are most
important to the patient and is essential that clinicians quantify
dysfunction at this level. The Foot and Ankle Disability Index
(FADI) was designed to assess functional limitations related to
foot and ankle conditions7 and is used as a tool of assessment
in present study.
Physical therapy is a treatment modality for patients who
have suffered moderate to severe ankle sprains,
especially persons who have chronic instability and recurring
symptoms.8 The goals of Physiotherapy treatment are to regain
the full range of motion (ROM), improve strength and stability of
the ankle joint.9, 10
Amongst treatment modalities in physiotherapy, Pulsed
ultrasound therapy is traditionally used to facilitate soft tissue
healing. It acts on cell membrane destabilization which is thought
to enhance the inflammatory response from the inflammatory
phase to the proliferative phase. Deep Transverse Friction
Massage (DTFM) is a special type of connective tissue massage
used after an injury or mechanical overuse in muscles, tendons
and ligaments. The technique is often used in conjunction with
mobilization techniques. Proper case selection and effective
execution of massage at exact site give good results.11 There is
paucity of data on effectiveness of DTFM in recurrent ankle
sprains and no scientific study is documented in the literature
on the use of DTFM in the treatment of recurrent ankle sprains.
Hence present study looks at effectiveness of DTFM in recurrent
ankle sprains and its comparison to standard pulsed Ultrasound
therapy.
Allocation to Intervention
Patients were divided into two treatment groups i.e. Ultrasound
Group & Deep Friction Massage Group by block randomization
of 6 done by chit method.
Intervention
Ultrasound Group was treated with Ultrasound and
Strengthening exercises. 1 MHz ultrasound machine was used
to deliver the treatment for 10 min using a pulsed mode at an
intensity of 1W/cm2. The Deep Friction Massage Group were
treated with Deep Friction Massage and Strengthening
exercises. The patient was placed in a comfortable position.
After locating the ligament through proper palpation, deep friction
massage was given transversely across the affected fibres for
10 minutes in such a way that the therapist finger and the
patients skin moved as one.
Strengthening was given with the help of a Theraband for all the
groups of muscles around the ankle in both the groups.
Outcome factors
A blinded observer unaware of treatment status was asked to
record the following outcomes:
1. Record pain scores on rest and on movements before
treatment, than on 3rd, 7th, and 10th day after completion of
therapy using visual analog scale (VAS).
2. Range of movement at ankle namely Dorsi flexion, Plantar
flexion, Eversion, Inversion at ankle joint was measured by
Goniometer before starting treatment and than after
completion of treatment on 10th day.
3. Foot and ankle disability scale score was recorded pretreatment and post treatment.
Methodology
Aims & objectives

To evaluate the short term therapeutic effects of Pulsed
Ultrasound and Deep Friction Massage with Strengthening in
Treatment of Recurrent Ankle Sprain and to compare the
effectiveness of both the modalities.
Study design
Hospital based, single blind, Randomized Controlled
Equivalence Trial
Study setup
The study was carried out at Department of Physiotherapy, Pad.
Dr.D.Y.Patil Medical College and Hospital, Nerul, Navi Mumbai.
Study population
The study population were patients clinically and radiologically
diagnosed by Consultant Orthopaedic surgeon in Orthopaedic
OPD as recurrent ankle sprain and referred to physiotherapy
for treatment.
Analytical Statistics:
A Comparison of basic features of two groups was done i.e.
age, sex and side of sprain to confirm that the two groups were
comparable and random allocation was adequate.
The mean Pre test scores of Pain were compared with scores
of day 3, 7, and 10 in both groups. Similarly Pre-test scores of
range of motion and ankle disability were compared with score
of day 10 using unpaired Student t test.
In order to find out equivalence of two therapeutic regimes all
pre treatment and post treatment scores and range of movement
were analyzed using paired t test.
Subjects
Inclusion Criteria
Patients of more than 15 years age, of both genders
Patients having ankle sprain with previous history of minimum
two episodes of ankle sprain in the same foot and who had
suffered from last ankle sprain within two months.
Exclusion Criteria
Acute inflammation and swelling(less than 48 hours)
Clinically and radio logically diagnosed Ankle fractures and
unstable ankles.
Neurological disorders like neuropathy.
Musculoskeletal condition of the lower limbs like limb shortening,
foot deformities (Congenital or acquired)
Sample size
A total of 30 patients who were fulfilling the inclusion criteria
were enrolled in this study.
Study factors
Basic demographic and clinical data was recorded
Foot and Ankle Disability Scale were administered to record the
pre training data.
86
Results
Of 30 patients, 19 were females (63.33%) suggesting
female preponderance. The mean age of the patient was
24.63years.Twenty One patients had right side ankle
involvement. On comparing two treatment modalities groups
were comparable for age, gender and side of sprain.
In Ultrasound group the pain scores of both pain at rest
and pain on motion showed statistically significant reduction from
3rd day onwards and scores continued to improve till 10th day.
(Table I and II) Similar improvements in range of movement
were also observed (Table III) These results imply that
Ultrasound treatment cause pain relief and improved range of
motion. DFM group results also showed statistically significant
score improvements and range of movement improvement by
10th day starting from 3rd day. (Table IV, V, VI)
On comparing the results of two therapies there was no
statistically significant difference noted in relief parameters
suggesting that the two studies were giving equivalent short
term relief to patients of chronic ankle sprains.
Overall analysis of Ankle disability score recorded pretreatment and post treatment in both modalities showed
statistically significant improvements in Ankle disability
scores.(Table X) On comparing the two treatment modality the
improvement in score was not significantly different suggesting
equivalence of both treatment modalities.(Table XI)
Pooja K Arora / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Table I: Showing Pain Scores at rest in Ultrasound group

Pain score
n
Mean
Before Treatment
15
3.23
15
0.4
3rd day after Treatment
15
0.26
7th day after Treatment
Std. Dev.
0.99
0.51
0.457
Table II: Showing Pain relief Scores with movements in Ultrasound group
Pain Score on movement
n
Mean Pain Score Std. Dev.
PreTreatment
15
5.766
0.98
15
3.266
1.162
15
1.466
1.407
15
0.66
0.259
Table III: Showing improvement in range of movements in Ultrasound group
Movement
n
Mean range
Std. Dev.
Pre Treatment Dorsi flexion
15
5.33
1.29
Post treatment Dorsi flexion
14
1.36
Pre Treatment Planter flexion
15
16.4
0.73
Post Treatment Planter flexion
46
1.3
Pre Treatment Inversion
15
5
3.7
Post treatment Inversion
11
12.1
Pre treatment Eversion
15
0.93
1.7
Post Treatment Eversion
12.66
2.58
Table IV: Showing Pain relief score at rest and after Deep friction massage
Pain score
n
Mean score
Pre Treatment
15
3.4
15
0
15
0.26
15
0
95% CI
2.68 3.78
0.119 0.68
0.013 0.052
p Value
0.00 HS
0.00 HS
95% CI
0.97 5.2
2.62 3.91
0.68 2.24
-0.076 -0.2
p value
0.00 HS
0.00 HS
0.00 HS
95% CI
4.6 6
13.24 14.75
2.82 14.83
5.07 43.19
2.93 7.06
4.2 17.15
-0.01 1.88
11.23 14.09
p Value
0.00 HS
0.00 HS
0.000 HS
0.000 HS
Std. Dev.
1.19
0
0.2
0
95% CI
2.73 4.0
0
0.79 0.175
0
p Value
0.00 HS
0.00 HS
0.00 HS
Table V: Showing Pain relief Scores with movements in Deep friction massage
Pain Score on movement
n
Mean Pain Score
Std. Dev.
PreTreatment
15
6.2
0.94
15
2.4
1.3
15
1.26
1.03
15
0.13
0.35
95% CI
5.64 6.68
1.74 3.18
0.69 1.83
-0.06 0.32
p value
0.00 HS
0.00 HS
0.00 HS
Table VI: Showing improvement in range of movements after Deep friction massage
Movement
n
Mean range
Std. Dev.
Pre Treatment Dorsi flexion
15
5.8
2.07
Post Treatment Dorsi flexion
13.66
2.2
Pre Teatment Planter flexion
15
17.86
5.02
Post Teatment Planter flexion
48.66
2.96
Pre Treatment Inversion
15
5.53
3.9
Post Treatment Inversion
32.66
2.6
Pre Treatment Eversion
15
5.93
3.12
Post Treatment Eversion
13.13
2.9
95% CI
4.64 6.95
12.4 14.9
15 206
47 50
3.37 7.7
31.7 34
4.2 7.66
11.5 14.74
p Value
0.000 HS
Table VII: Comparison of Pain Relief in 2 modalities of treatment

Pain Score at rest
Mean Ultrasound
Mean Deep
friction therapy
Pre Treatment at rest
3.23
3.4
0.4
0
3rd day
0.26
0.26
7th day
0.26
0
10th day
0.000 HS
0.000 HS
0.000 HS
St. Dev.
95% CI
p value
1.08
0.64
0.34
29 3.72
0.13 0.66
0.27 0.5
0.004 0.26
0.68 NS
0.05 S
0.30 NS
0.03 NS
95% CI
p value
5.6 6.32
2.31 3.3
0.91 1.8
0.013 0.21
0.26 NS
0.08 NS
0.66 NS
0.55 NS
Table VIII: Comparison of Pain relief on movement in two modalities of treatment

Pain Score
Mean Ultrasound
Mean Deep
St. Dev.
friction therapy
Pre Treatment
5.76
6.16
0.964
3.26
2.46
1.27
3rd day
1.46
1.26
1.21
7th day
0.066
0.133
0.30
10th day
87
Table IX: Comparison of changes in range of movements in two modalities of treatment

Range of movement
Mean I
Mean II
Std. Dev.
Dorsi flexion pre Treatment
5.33
5.8
1.715
Dorsi flexion post Treatment
14
13.66
1.85
Planter flexion pre Treatment
16.4
17.86
4.07
Planter flexion post Treatment
46
48.66
4.3
Inversion pre Treatment
5
5.53
3.75
Inversion post Treatment
11
32.66
13.98
Eversion pre treatment
0.93
5.93
3.54
Eversion post treatment
12.66
13.13
2.72
Table X: Showing improvement in ankle disability scores
Modality of Treatment
N
Ultrasound
15
15
Pre-test scores
28.2
30.13
95% CI
4.9 6.2
13.13 14.52
15.6 18.65
45.7 48.93
3.86 6.67
16.61 27
2.1 4.75
11.88 13.9
Post-test Scores
63.26
70.866
Table XI: Showing comparison in Ankle Disability Scores between 2 modalities of Treatment
Scores
N
Ultrasound
Pre-treatment
15
28.2
30.13
Post-treatment
15
63.26
70.866
Discussion
DTFM is a special type of connective tissue massage
applied by fingers directly to the lesion and transverse to the
direction of fibres.12 It is used for injury or mechanical overuse
of muscles, tendons and ligaments. It was used as an alternative
to steroid infiltration, but had slower effects with physically more
fundamental resolutions resulting in more permanent cure and
less recurrence. This was the rational for selection of DTFM as
a modality of treatment. It is important to note that massage
should be performed at exact site of lesion in the right direction
by a trained therapist to obtain best results, which is usually
noted in 6-10 sessions. Lack of scientific evidence on DTFM on
recurrent ankle sprains was another rational for selecting this
modality for research. Ankle sprain was selected for
management because of high incidence of recurrence inspite
of best therapy. Here DTFM could give relief of pain and help in
effective connective tissue repair by stimulating phagocytosis
and regenerating connective tissue and also prevent adhesion
formation and ruptures unwanted adhesions.
The Improvements in pain scores and ROM observed
DTFM group could be due to post massage analgesic effect,
modulation of non-nociceptive impulses at spinal cord level (Gate
control theory) and inhibition of mechanoreceptors by rhythmical
movements over the affected area, just closing the gate for
afferents. Friction also leads to increase destruction of pain
provoking metabolites (Leviss substances) whose presence in
high concentration provokes ischemia and pain. Another reason
for pain relief after prolonged deep friction to a localized area
could be lasting peripheral nerve disturbance with local
anaesthetic effects.13,14 The ROM improvement could be due to
reduction in pain.
The present study was for short term effect only for 10 days
and looked at mainly pain relief and improvement in range of
motion. So the long-term effect of DTFM and Ultrasound on
connective tissue repair was not evaluated. On comparing the
2 modalities of treatment namely Ultrasound and DTFM, DTFM
was equally efficacious in reducing the pain and restoring the
movements when compared with standard Ultrasound therapy.
It should be kept in mind that the results of DTFM are based on
proper case selection and is therapist dependent. Similar results
were seen in Cochrane review 2002 which showed efficacy of
DTFM in treating patients with ITBFS and ECRT15. No specific
study showing utility of DTFM in chronic ankle sprain was found
88
p value
0.466
0.6317
0.3329
0.089
0.704
0.00 HS
0.00 HS
0.646
p Value
0.00(HS)
0.00(HS)
P value
0.4(NS)
0.002(HS)
in literature. Hence present study is first to take up such

evaluation. However a study using pulsed electromagnetic field
therapy and interferential treatment showed significant
improvement in pain relief in ankle sprains.16
The weakness of present study could be non calculation of
sample size considering this to be an equivalence trial which
might require larger samples. But considering this to be an
expedition study a larger trial could be taken up at a later date.
Another drawback was that the study looked at only pain relief
and ROM evaluated only till 10th day, thus missing an opportunity
to look at the long term effects on healing and prevention of
recurrence which is an important complication of ankle sprains.
Conclusion
DTFM is an efficacious tool for short term treatment of
chronic ankle sprains. Its efficacy is equivalent to standard
ultrasound therapy. Important point to remember is that DTFM
is operator dependant procedure and results could vary from
therapist to therapist. More randomized trials are necessary to
collect enough evidence to establish DTFM as standard
treatment modality for chronic ankle sprains and long-term followup studies are required for assessing its role in maintaining the
ankle stability and preventing recurrence.
References
1.
2.
3.
4.
5.
6.
Hertel J. Functional instability following lateral ankle

sprain. Sports Med. May 2000;29(5):361-71. [Medline].
Bosien WR, Staples OS, Russell SW. Residual disability
following acute ankle sprains. J Bone Joint Surg
Am. Dec 1955;37-A(6):1237-43. [Medline]. [Full Text].
Freeman MA, Dean MR, Hanham IW. The etiology and
prevention of functional instability of the foot. J Bone Joint
Surg Br. Nov 1965;47(4):678-85. [Medline]. [Full Text]
Freeman MAR, Wyke BD. An experimental study of articular
neurology. J Bone Joint Surg. 1967;49B:185.
Valderrabano V, Wiewiorski M, Frigg A, Hintermann B,
Leumann
A. [Chronic
ankle
instability]
[German]. Unfallchirurg. Aug 2007;110(8):691-9; quiz
700. [Medline].
Hubbard TJ, Kramer LC, Denegar CR, Hertel
J. Contributing factors to chronic ankle instability. Foot Ankle
Int. Mar 2007;28(3):343-54. [Medline].
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7.
Brown C, Padua D, Marshall SW, et al. Individuals with

mechanical ankle instability exhibit different motion patterns
than those with functional ankle instability and ankle sprain
copers. Clin Biomech (Bristol, Avon). Jul 2008;23(6):82231. [Medline].
8. Hubbard TJ, Denegar CR. Does cryotherapy improve
outcomes with soft tissue injury?. J Athl
Train. Sep 2004;39(3):278-9. [Medline]. [Full Text].
9. Laufer Y, Rotem-Lehrer N, Ronen Z, et al. Effect of attention
focus on acquisition and retention of postural control
following
ankle
sprain. Arch
Phys
Med
Rehabil. Jan 2007;88(1):105-8. [Medline]
10. Van der Windt DAWM, Van der Heijden GJMG, Van den
Berg SGM, Ter Riet G, De Winter AF, Bouter LM.
Therapeutic ultrasound for acute ankle sprains. (Cochrane
Review). In: The Cochrane Library, Issue 1, 2006. Oxford:
Update Software.
11. This text is an Abstract of the chapter Deep Transverse
Friction from the book A System of Orthopaedic Medicine.
This book is available on Amazon.com.
12. Carreck A. The effect of massage on pain perception

threshold, Manipulative Physiotherapist. 1994, 26:10-16
13. Kaada B,Torsteino O Increased plasma beta-endorphins
in
connective
tissue
massage.Gen.Pharmacol.1989;20(4):487-9
14. Goats GC. Massage Therap effects. Am
Psychol.1998;53(12):1270-81
15. Brosseau L, Casimiro L, Milne S, Robinson V, Shea B,
Tugwell P, Wells G. Deep transverse friction massage for
treating tendonitis Cochrane Database Syst Rev.
2002;(4):CD003528.
16. Sharma Bhakti ,Yadav Vikram Singh,Sandhu Jaspal Singh.
A comparative study on the efficacy of pulsed
electromagnetic field therapy and interferential therapy in
the management of ankle sprains. Indian Journal of
Physiotherapy and Occupational Therapy.2007(1):4:
89
Comparative analysis of 12 minute walk test and modified shuttle

walk test in normal subjects
Richa Rai*, Sujata Yardi
*M.P.Th Cardiovascular, Mumbai, **Prof and Head, Department of Physiotherapy, Padmashree Dr D.Y. Patil University Navi Mumbai.
Objective measures of functional limitations and impaired

exercise are essential for assessment and clinical management
of patients with cardiopulmonary limitations. The traditional
incremental maximal treadmill testing and cycle ergo meter
requires sophisticated instruments and is expensive and may
not be relevant to usual exercise patterns and thus proves
difficult.
Certain performance and predictive tests, which do not
require such expensive sophisticated instruments, are therefore
devised to know and predict VO2 max, to assess functional
limitations, to assess outcome of interventions such as exercise
programs and to examine effects of recovery strategy on exercise
programs. Subsequently, sub maximal tests like 12 Minute Walk
Test (MWT) and 6MWT were devised which measure responses
to standardized physical activities that are typically encountered
in everyday life, like walking. In 1976 Mc Gavin et al [10]
introduced 12 MWT to evaluate the disability in patients with
chronic obstructive pulmonary disease. In 1982, Butland and
co-workers [11] had compared the validity of different walk tests
as exercise test protocols in predicting maximal ventilatory
functions to determine if a shorter length test could be used.
They found 2-,6- and 12 MWT to be comparable. But in these
fields walking tests the subject are asked to walk as fast as
possible and the test is not graded with respect to speed.
This prompted the development of a standardized and
externally paced field walking test-MSWT Modified shuttle walk
test, incorporating an incremental and progressive structure, to
assess functional capacity of an individual.
Leger and Lambert devised the original shuttle walk test
[6] for athletes. However later in 1992, Sally J. Singh et al
modified the protocol for chronic obstructive pulmonary diseases
group of population and compared the modified protocol to 6MWT and proved MSWT to be an effective means in comparison
to 6-MWT [6]. MSWT has also been validated on individual other
than lung diseases as compared to 10 MWT, in patients with
cardiac pacemakers by Payne GE et al [9].
However in 1994 Singh N.P et al [13] compared 6MWT,
4MWT and 2MWT to 12 MWT and observed that 12 MWT is
superior because changes in VO2 /kg in 12 MWT correlated better
with changes in the maximal exercise tests than in other walking
tests of shorter duration.
No attempt was made as yet to compare 12MWT with
MSWT, as to know how an individual would respond when
subjected to both the tests in terms of physiological variables.
So the aim of this study is To assess and compare
cardiopulmonary responses of the 12 MWT and modified shuttle
walk test in asymptomatic adults of different age groups.
Material and method used were
90
Sphygmomanometer and stethoscope

Polar digital heart rate leads
Tape measure
RPE Scale
2 stools
Watch
Pre recorded audiotape
Cassette Player
Counter
Consent Form and Case Report Form (CRF)
A uniform tile terrain, 10 meters in length with 2 stools placed

10 meters apart and 0.5 meters from the ends to prevent abrupt
changes in direction. Thus 20 meters marked on the terrain.
Exercise test procedure

75 subjects of age group 20-59 years volunteered for the
study out of which 44 were males and rest 31 were females.They
were screened for entry into this study on the basis of normal
physical examination i.e. no recent major history of any medical/
surgical condition, pregnancy or any neuromotor or locomotor
disorder. Obese, alcoholics and smokers were all excluded.
Volunteered subjects were asked to get clearance from a
physician.Patients with absolute contraindications like
Resting ECG abnormalities
Recent MI
Unstable Angina
Ventricular Arrhythmias
Heart Blocks and pacemakers
CCF with Cor Pulmonale
Aortic Stenosis or any other rheumatic heart disorders
Acute infections
Pulmonary embolism were all excluded.
Others with relative contraindications like
DBP > 115,SBP >200
Pregnancy
Electrolyte abnormalities
PVCs
Ventricular aneurysm
Uncontrolled Metabolic Disorders (diabetes)
Chronic Infectious disease (hepatitis, AIDS ) etc
Silent ECG abnormalities ruled out on GXT were also
excluded.
Before starting each test, all volunteered subjects were
asked to sign a consent form ,complete a medical history
questionnaire- PAR-Q and describe personal details to be noted
on Case Report Form(CRF) .After this the CRF for the individual
was numbered and his MHR and THR calculated by Karvonens
formulae as follows:
MHR=220-Age
THR= [60-70%(MHR-RHR)]+RHR
Where RHR= Basal Resting Heart Rate
MHR= Maximal Heart Rate
THR = Target Heart Rate
Testing sessions were scheduled at 1-week interval and
the subjects were asked to keep their living and activity habits
constant for the course of the study. Avoid strenuous activity 24
hours prior to testing and heavy meals 2- hours prior testing.Visit
one comprised of one practice trial of each test spaced at atleast
45 minutes interval.For visit 2, a randomized balanced design
(with random no. table) was used with one Shuttle walking test
followed approximately one week later by a 12MWT or vice
versa.Basal Parameters of the subjects were noted on CRF and
a warm up session of calisthenics and stretching given. Subjects
were continuously monitored for H.R. with polar leads For 12
MWT, individuals walked bare footed on the 20 meters terrain,
with standard instructions to all to cover as much ground as
possible on foot in 12 minutes by walking as fast as possible so
that at the end of the test he should feel that he could not have
covered more ground in the same amount of time.
Richa Rai / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
The instructor stood in the mid of the 20 meters course

and boosted him at every 30 seconds, giving the subjects a
feedback on time progression and encouraging him to keep on
walking as fast as possible (standard for each person)[2] H.R.
was monitored and noted at every 2 minutes.
The subjects who stopped because of pain, fatigue,
breathlessness or any other limiting factor and could not
complete the 12MWT were excluded from the study. For the
ones who completed the following outcomes were measured.
Subjective level of exertion was qualified using Borg 6-20
scale [16]
Peak Heart Rate (H.R.)
B.P (by auscultation method)
Respiratory Rate (R.R)
Total number of rounds i.e. distance covered in meters
Reason for stopping
Finally subject was made to sit for a cool down and recovery
pattern was taken at 3 minutes and later at every minute till the
parameters were near basal and recovery time was noted.
For MSWT, at the same place and almost the same time a
week later the subjects basal parameters were noted and after
a warm up the test started with the standard instructions of how
much time an individual should take to cover the 10 meters
distance, of one round, at each level.
By the end of the counts of seconds on the audio, the
individual should be walking around the stool and should start
only when the next count starts. i.e. if he covered the distance
earlier than required he had to wait for the next beginning count
to start a new round. The accuracy of the timed signal was
ensured by the inclusion on the tape of a calibration period of 1
minute. (The cassette available)Individuals were thus instructed
walk or may be run, if required, at a steady pace, aiming to turn
around when you hear the instruction. You should continue to
walk until you feel that you are unable to maintain the required
speed, without becoming unduly breathless or fatigue and or
when instructed to stop.The instructor stood along side the 20
meters course and no encouragement was given. Only advice
given each minute was to increase the walking speed slightly.
All subjects found it easy to pace themselves and no
difficulty was encountered in administrating the test.The modified

shuttle walk test (MSWT) starts at 0.50meters/second speed
for level 1, each level lasts for a minute and speed is increased
each minute by 0.17meters/second for 12 minutes to a final
speed of 2.37 meters/second (Appendix-A)
The individual continued until a) He or she was breathless
or showed any signs and symptoms of exertion beyond which
he or she was unable to carry on the test.b)He or she was 0.50
meters away from the stool, kept at each end of the course,
when the count for that particular level was over.
The same outcome measures were noted as in 12MWT
and the distance was noted as the number of shuttles was
known. Subject was then allowed to sit comfortably and the
recovery pattern was noted.
Profile of peak heart rate

Table 2.1
AGE(20-39 years) H.R
Table 2.2
AGE(40-59 years) H.R
Age predicted MHR = PMHR

Peak H.R on 12MWT (PHR)
Peak H.R on 12MSWT (PHR)
% Adequacy of PHR on 12MWT to PMHR
% Adequacy of PHR on MSWT to PMHR
Peak H.R
(Mean + SD)
191.8 + 5.9
139.8 + 7.6
169.7 + 10.4
72.8 + 4.0 %
88.2 + 4.4 %
Profile of heart rate with the target heart rate (thr)

Table 3.1 AGE (20-39)
H.R
THR (Mean + SD)
PHR on 12MWT
139.8 + 7.6
PHR on MSWT
169.7 + 10.4
Target Heart Rate Zone
148.7 + 3.5
(from Karvonens formulae)
159.1 + 4.1
The above data shows that peak heart rate obtained on 12 MWT
falls approximately near the lower limit of THR and that of MSWT
is higher than the upper limit of THR zone.
Profile of systolic b.p.
Table 4:
AGE (years )
12 MWT
20-39
40-59
S.B.P (Mean + SD)

MSWT
163.42 + 13.2
143.05 + 15.05
169.45 + 11.33
150.45+ 13.48
P< 0.05 significant
Results
Table 1: Profile of heart rate
AGE (years)
H.R. (mean+ SD)
12 MWT
MSWT
20-39
139.84 + 7.7
169.71+ 10.63
40-59
129.37 + 10.15
151.86 + 8.5
P < 0.05 significant
HEART RATE
Comparison of heart rate between 12mwt & mswt Grap. 1:
The above data reveals mean peak heart rates obtained in

MSWT was significantly higher when compared to 12MWT in
both age groups. Also within the test, heart rate showed a
significantly lower response in subjects of 40-59 years of age
as compared to 20-39 years of age.
Peak H.R
(Mean + SD)
Age predicted MHR = PMHR
172.35 + 5
Peak H.R on 12MWT (PHR)
129.6 + 10.2
Peak H.R on MSWT (PHR)
151.8 + 8.4
% Adequacy of PHR on 12MWT to PMHR
74.3 + 5.8 %
% Adequacy of PHR on MSWT to PMHR
88+ 3.6 %
The above tables reveal that % adequacy of PHR on MSWT to
age predicted MHR is 88 % and that of 12MWT is 73 % in 20-39
years of age and 74 % in 40-59 years of age.
Table 3.2 AGE (40-59)
H.R
THR (Mean + SD)
PHR on 12 MWT
129.6 + 10.2
PHR on MSWT
151.8 + 8.4
Target heart rate zone
136.5 + 3.6
(from Karvonens formulae)
145.7 + 3.7
The above table shows that peak heart rate of 12 MWT falls
approximately near the lower limit of THR zone and that of MSWT
is higher than the upper limit of THR zone.
Profile of respiratory rate
Table 5:
AGE (years)
R.R (Mean + SD)
12MWT
20-39
28.55 + 4.89
40-59
30.21 + 2.61
Richa Rai / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
MSWT
36.68 + 5.28
38.45 + 2.42
P< 0.05 significant
91
Graph 5: Comparison of r.r. Between 12mwt & mswt
R.R
SBP
Graph 4: Comparison of s.b.p. Between 12mwt & mswt
The above data reveals that mean systolic B.P. showed

significant increase after both the tests, among which the S.B.P.
in MSWT was significantly more than 12MWT for both the age
groups.
Respiratory rate shows a statistically significant higher value in

MSWT as compared to 12MWT for both age groups. However
within the protocol higher age group showed a significantly higher
respiratory rate as compared to the lower age group
Profile of rate of perceived exertion (rpe)

Table 6:
AGE (years)
RPE (Mean + SD)
12MWT
MSWT
20-39
10.26 + 2.34
Profile of distance covered (meters)

Table 7
AGE (years )
Distance (Mean + SD )
12MWT
MSWT
974.21 + 90
20-39
1305.78 + 106.45
726 + 181.6
40-59
1090 + 70.4
P < 0.05 significant
13.86 + 1.8
Graph 7: Graph 4: Comparison of rpe between 12mwt &

mswt
RPE
METERS
Graph 6: Comparison of rpe between 12mwt & mswt
The above data reveals that when the rate of perceived exertion
(RPE) was compared across the groups, MSWT showed
statistically significant higher values in both the age group as
compared to 12 MWT.
The distance traveled in 12 MWT was significantly greater for

both age groups as compared to MSWT.
Exercise duration vs heart rate for 20-39years and 4059years (graph 1.1,1.2)
Pink -MSWT and Blue -12MWT
Graph 1.1
Graph 1.2
Discussion
Laboratory assessment of functional capacity of an
individual is not widely available and may be expensive and
intimidating to the patient. As questions regarding the need for
further diagnostic studies, therapeutic decisions and prognosis
can often be resolved by knowing the functional capacity, the
willingness for exercise testing is catching demand.
Therefore, field walking tests are often used in absence of
sophisticated instruments. They comprise a self paced test in
92
which the subject walks as fast as possible in 12 minutes [1]. To

maintain the pace of the subject however becomes the limitation
of the test, which can be overcomed by regular motivation and
encouragement as validated by Guyatt et al [2].
Review of literature [6] of our study shows that MSWT is of
12 minutes duration therefore 12 MWT was an ideal test with
which the former could be compared. Normal adults of two age
group 20-39 years and 40-59 years were included in the test. A
practice trial was administered for both the test to make the
results valid [15].As we have seen; both the 12 MWT and MSWT
are simple and require no sophisticated instruments. Moreover,

act of walking used in the test is familiar to all. Both the tests are
of 12 minute duration and are being used for stress testing and
to evaluate cardio-pulmonary system.
However, MSWT is an externally paced test in which the
subject walks to the audio signal dictated to him. As the test
continues, he slowly increases his speed by 0.17 meters/second,
every minute, as guided by the audio signal, whereas in 12 MWT
the subject has to walk as fast as possible from the very
beginning.
On viewing these differences in both the tests, it seemed
essential to know as to how these would reflect in the cardiopulmonary responses of an individual. Therefore, the study was
initiated to compare the physiological responses, in both the
tests, as the same individual was subjected to them.
Consequently, the results show that the average peak heart
rates obtained in both the age groups, were significantly higher
in MSWT as compared to 12MWT.(table 1, graph 1)
Also seen in graph 1.1, 1.2 the peak heart rate response
which was achieved at 12 minutes duration in 12 MWT was
reached in a graduated manner and at duration much earlier in
MSWT.
On comparing the average heart rate for both the tests to
age predicted MHR (PMHR) of the two age groups, we found
that percentage adequacy of the peak H.R. response obtained
in MSWT to predicted MHR is 88% whereas even though the
subject performed for longer duration in 12 MWT as seen in
graph 1.1, 1.2 they reached to only 74% of their predicted MHR
(table 2.1,2.2)
Moreover the mean peak H.R. obtained in MSWT is higher
than the upper limit of THR zone whereas that of 12 MWT falls
approximately near the lower limit of THR zone (table 3.1, 3.2)A
close look at the graph 1.1, 1.2 shows that in MSWT, in the
initial stages, the H.R. is even lower than that achieved in 12
MWT. This could be attributed to the persons maximal effort
right from the start in 12MWT as compared to the initial very
slow defined speed of walking in case of MSWT. Moreover,
these defined speeds ensure that work load increases in a
manner that provides an incremental stress and a graded
cardiovascular pulmonary response, as seen for heart rate
achieved in MSWT in the graph 1.1, 1.2.However, the steeper
increase in heart rate observed in the end stages of MSWT
may increase the sensitivity of the test but it also means that the
subject should be able to cope up with the stress induced.
The other physiological variables like systolic B.P,
respiratory rate and rate of perceived exertion (RPE) were also
significantly higher for both the age groups at the end of MSWT
as compared to 12MWT. (Table 4, 5, 6 and graph 4, 5, 6). This
demonstrates a greater and graded stress imposed on
cardiopulmonary system as compared to 12 MWT.
The average distance covered in MSWT for the age groups
20-39 years is 794.21-1154.21 meters as compared to 10921518 meters in 12 MWT. Similarly for age group 40-59 years,
average group distance for MSWT was 362-1089 meters as
compared to 949-1130 meters on MSWT. (Table 7- Graph 7).
The distance covered in MSWT, for both the age groups were
significantly lower in shorter duration in comparison to 12 MWT
but maximal physiological variables were achieved.
Thus, MSWT reveals cardiopulmonary limitations to
exercise and the initial slow and subsequently increasing speeds
used in the modified protocol in comparison to that of Leger and
Lambert [6] makes it an objective measure for exercise testing
for a wider variety of subject population.
However, the steeper increase in exercise intensity in the
later stages is a disadvantage for the elderly cardiopulmonary
compromised subjects but its a potential measure for evaluating
young active group of population.
For the subject population, for whom it is very easy to
perform on 12 MWT, this 12MWT might not be effective enough
to stress the cardiopulmonary system and evaluate the reserve
capacity.
As the graph 1.1, 1.2 shows the longer duration and an
almost steady heart rate response on 12 MWT as compared to
MSWT, it could be used as a exercise test for endurance training
and to evaluate the functional capacity of normal sedentary
and elderly deconditioned individuals with cardiopulmonary
compromised state.[14]
For this group, walking being an activity of daily living (ADL),
12MWT evaluates the persons ability to walk continuously for
over a period of time and thus to know the factors which limit his
functional capacity and endurance. MSWT can be used as a
progression or as an additional test to check the reserve capacity
in such cases.
External pacing in MSWT allows valid inter subject and
intra subject comparison and can yield a precise end point and
a specific outcome measure that can easily be applied to
exercise rehabilitation for different groups of people, by
calibrating an individuals physiological responses to the test;
also a suitable walking speed can be judged for a training
program. This being an objective measure may enable more
effective comparison of different approaches to patient
management and treatment than has previously been possible
with other field exercise tests.
Thus, quantitative methods of assigning exercise like
MSWT may improve exercise prescription specificity and
precision in comparison to 12MWT. However, clinical decision
regarding the prescription of a proper performance test should
be made according to the age, health status and the initial level
of fitness of the population to be studied.
Conclusion
12MWT and MSWT both are easily administrable, simple,
non-invasive and cost effective exercise testing protocols.MSWT
stresses cardiopulmonary system more in terms of H.R, B.P.,
R.R and RPE than 12MWT.However, to evaluate an individual,
clinical decision should help to individualize the test according
to the subjects age, health status, initial fitness and objective of
the testing.
(Appendix)
MODIFIED SHUTTLE WALK TEST
LEVEL
SPEED IN
NO OF NO OF
shuttles 2/shuttle
M/s
Km/h
mph
1
0.50
1.72
1.12
3
20
2
0.67
2.40
1.50
4
15
3
0.84
3.00
1.88
5
12
4
1.06
3.61
2.26
6
10
5
1.18
4.22
2.64
7
8.5
6
1.35
4.83
3.02
8
7.5
7
1.52
5.44
3.40
9
6.6
8
1.69
6.04
3.78
10
6
9
1.86
6.65
4.16
11
5.45
10
2.03
7.26
4.54
12
5
11
2.20
7.87
4.92
13
4.6
12
2.37
8.48
5.30
14
4.2
References
1.
2.
3.
Swinburn
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Cervical spinal mobilization versus TENS in the management of

cervical radiculopathy: A comparative, experimental and
randomized controlled trial
Ronald Prabhakar*, G. J. Ramteke**
*B.P.T., M.P.Th., **Professor & Principal (B.Ph.T, M.Ph.T.), Datta Meghe Institute of Medical Sciences, Ravi Nair Physiotherapy
College, Sawangi (M), Wardha, Maharashta
Abstract
Purpose of study
The need of study was to find out whether a movement based
approach along with exercises is beneficial than a nonmovement based electrotherapeutic approach along with
exercises for relieving upper limb radiculopathy arising due to
cervical spondylosis
Materials & methodology

75 subjects were randomly allocated into three groups i.e. Group
A: (Hot fomentation, Cervical contralateral lateral flexion
mobilization and Isometric neck exercises), Group B: (Hot
fomentation, Transcutaneous electrical nerve stimulation and
Isometric neck exercises), Group C: (Control group: Hot
fomentation and Isometric neck exercises).The duration of
intervention was 3 weeks and treatment was given on The
outcome measures were VAS pain score, Elbow extension range
of motion measured in upper limb tension test-1 position,
Northwick Park neck pain questionnaire, Neuropathic pain scale,
Short form of Mc Gill pain questionnaire. Pre and post
intervention values of outcome measures were recorded and
also after a follow-up of 6 weeks.
Results
The participants treated within groups showed a statistically
significant decrease in pain, increase in elbow extension ROM,
and an improvement in the functional outcome scores as per
NPQ score, NPPS and SF- MPQ score with p<0.001. But there
was no statistically significant difference in pain scores when
compared between the experimental groups (p= 0.075), increase
in amount of elbow extension ROM (p=0.024) was significant,
and a significant improvement in functional outcome level as
per NPQ (p=0.034) and a non-significant improvement in NPPS
and SF-MPQ score (p>0.05), after 3 weeks of intervention.
Conclusion
condition of the cervical spine that most likely is caused by agerelated changes in the intervertebral disks 3 . Cervical
radiculopathy has an incidence rate of 83 per 100,000 population
and a prevalence of 3.3 cases per 1000 people 4. The
radiculopathy is a result of mechanical pressure on the nerve
root exerted by disk protrusion or spondylotic spurring or a
combination associated with an inflammatory component5.
Testing of nerve reaction indicates the sensory nerve root
as a prominent site of pain production in a dermatomic
distribution6. Pain of aching nature is felt proximally and a
parasthesia or sensation of numbness is felt distally, pain more
distal in radiation is dermatomal in distribution, whereas pain
proximal to the interscapular area is more likely from posterior
primary division radicular pain7. The recognition of the origin of
the referred pain is important for both the indication and
contraindication of specific physiotherapy treatment techniques8.
Clinical practice guidelines recommend the use of manual
therapy along with exercise therapy for managing mechanical
neck disorders9. Cervical mobilization reduces pain and disability
and, more specifically, with studies illustrating the benefits of a
movement-based treatment approach of patients with peripheral
Neurogenic pain10. Both manual therapy interventions combined
with home exercises are effective in improving pain intensity,
pain quality scores and functional disability levels11. Cervical
lateral flexion mobilization is used in patients whose symptoms
of cervical origin are unilaterally distributed, either cranially or in
the neck, scapula or arm 12. The main aim of this technique is to
produce lateral flexion so as to direct the mechanism toward
opening of the intervertebral foramen12. Release of pressure in
this situation may help venous return, improve resolution of
inflammatory process, reduce tissue fluid pressure and improve
intraneural circulation13.
In a survey of physicians about attitudes on treatment of
musculoskeletal disease, active exercise, traction, TENS, and
ultrasound were perceived to be the best methods for the
treatment of neck pain14.. In the past decade, a number of studies
have indicated that strengthening of the neck muscles in patients
with chronic neck pain results in reduced pain and decrease in
disability 15. Nordemar and Thorner reported that TENS
significantly increased neck mobility compared with wearing a
neck collar in patients with neck pain16
Cervical mobilization when compared to Transcutaneous

electrical nerve stimulation is equally effective in relieving pain,
reducing the radicular pain in upper limb and improving the
functional outcome.
Key words
1.
Neck pain, Cervical radiculopathy, Cervical lateral flexion

mobilization, TENS, Isometric neck Exercises, ULTT-1.
2.
3.
Introduction
Study setting
Neck disorders affect 13% of adults at any one time and up

to 30% of men and 50% of women in the course of a lifetime1,2.
Some studies have stressed the importance of physical factors
like faulty posture, monotonous work and unsuitable working
positions1. Cervical spondylosis is a common degenerative
Datta Meghe Institute of Medical sciences Ravi Nair

Physiotherapy College, Musculoskeletal physiotherapy OPD.
Materials used
Single channel TENS Kit. (Galtron electromedical
equipments, 20E620, 100 Hz)
Universal Half circle plastic goniometer.
Hot moist pack.
Inclusion criteria
1.
Subjects between 20 to 50 years of age.
Ronald prabhakar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
95
2.
3.
4.
Subjects having neck pain and tingling numbness

unilaterally in upper limb for more than one week.
Diagnosed cases of Cervical spondylosis.
Participants who gave informed consent to participate in
the study.
Fig 2: Taking up the head and arm position
Exclusion criteria
1.
2.
3.
4.
5.
6.
7.
8.
permitting any lateral flexion of the subjects head or allowing

any movements of the heel of hand away from the subjects ear,
the therapist moved around alongside the subjects contralateral
shoulder to face diagonally across his head.
Presence of VBI syndrome

History of fracture cervical vertebrae
Cervical hypermobility
Bone disease: tumors or infection.
Diabetic neuropathy
Acute intervertebral disc prolapse
Osteoporosis
Rheumatoid arthritis/ inflammatory arthropathies
Methodology
Subject Recruitment: 75 subjects which were diagnosed cases
of Cervical Spondylosis with history of subacute unilateral upper
limb radiating pain of cervical origin in the age group of 20 - 50
years of age were referred from Department of Orthopedics to
Musculoskeletal physiotherapy OPD. The subjects were then
randomly assigned to three study groups. Then subjects consent
was taken for their willingness to participate. All the rights of the
participants were protected.
Assessment: The subjects were assessed using the
assessment proforma. The testing for reduced intervertebral
foraminal opening dysfunction or reduced closing dysfunction
were then performed for conforming the mechanical diagnosis
of the disorder.
Application of Hydrocollator packs: The part to be treated
was properly exposed covering rest of the body. The subject
was asked to lie prone on the treatment plinth in prone position
with one pillow under the chest. The hot pack was then applied
to the posterior aspect of neck.
Stage 3: The final stage involved crouching to hug the

subjects head while adopting the required degree of lateral
flexion by displacing his neck to affected side with the
contralateral hand and laterally flexing the head on the opposite
side The movement was localized to particular intervertebral
level by the pressure of the palmar surface of the index finger,
just distal to MCP joint on the relevant level of articular pillar.
Fig3: Adopting the initial stage of mobilization
Group A: Cervical contralateral lateral flexion mobilization

(Dynamic Opener):
Depending upon the dermatomal involvement and the
relevant upper limb neural tissue provocation test, the level/
Fig1: Application of hot moist pack to neck.
The oscillatory movement was then produced by body

motion. The body movements generated a force which was
transmitted to subjects neck by a much localized pressure
against the articular pillar which displaced the neck away causing
the intervertebral foramen to open up on to the affected side.
Amplitude: Grade II: Large-amplitude movement without
moving into resistance / Grade III: Large-amplitude movement
upto the limit of the range.
Frequency of oscillations: 1 repetition / 5 seconds.
No of repetitions: 10-15 oscillations.
Group B: Application of Transcutaneous electrical nerve
stimulation
levels of mobilization was/were determined14. Irrespective of

the type of dysfunction diagnosed while performing the specific
tests mentioned above, dynamic opener technique applied for
the opening of intervertebral foramen was used.
Stage 1: Subject lied on his back with his head and neck
beyond the end of couch supported by the therapist.
Stage 2: Initially the therapist stood at the head end of couch
and took up the head and arm position i.e. the head of the subject
supported by the therapist arm. The position was then altered
so that the ipsilateral forearm lied behind the subjects ear almost
under the occiput and the contralateral hand was brought
forwards so that the palm covered the whole of ear. Without
96
Preparation of apparatus: All the apparatus and equipment

needed were assembled and suitably positioned.
Preparation of the subject: Area to be treated was properly
exposed covering rest of body.
Application: Silicone rubber electrodes were fixed to the
skin with adhesive tape. The dermatomal placement method
was used: One electrode was placed at the corresponding spinal
nerve root level and other at the distal end of dermatome.
Type of TENS:
Conventional
Pulse duration:
50 s
Frequency:
100 Hz.
Mode of application: Continuous
Duration of treatment: 30 minutes
Isometric neck exercises: (Figure.)
Fig5: Application of TENS to subject.
Isometric neck exercises began with isometric contractions

for neck flexors, lateral flexors, rotators, and extensors. These
contractions were maintained for a period of 6-8 seconds.
Subjects were asked to perform 5 repetitions in each direction.
Group C (Control group):
Subjects allocated to this group received hot fomentation applied
to posterior aspect of neck region for 20-25 minutes. After the
application of hot pack, they were taught the Isometric neck
exercises and were asked to perform it under supervision. The
procedures were the same as mentioned above.
Intervention:
10 treatment sessions were given to the subjects, on alternate
days for a period of 3 weeks. They were called after period of 6
weeks for follow-up.
Outcome measurement tools

Procedure: Assessment on the outcome parameters was
performed as follows.
1. Visual Analogue Scale: Pain was rated by the subject
placing a mark in one location on the line.
2. Elbow extension range of motion measured in the upper
limb tension test 1 position: The recording of the range of
motion was done by a therapist using a half circle plastic
goniometer, who was blinded from the nature and expected
outcomes of the study.
3. Northwick Park Neck pain questionnaire (NPNQ): There
are 4 points given to each question for e.g. no pain =0 and
worst pain=4. The subject is asked to select only one option
in each question according to the present status
4. Neuropathic pain scale (NPPS): The scale measures
several different aspects of pain Each pain descriptor was
been given 10 points for e.g. 0= No pain and 10= the most
intense pain sensation imaginable. The subjects were
asked to put an X through the number which best described
the type of pain.
5. Short form of Mc Gill pain questionnaire (SF-MPQ): The
main component of the SF-MPQ consists of 15 descriptors
(11 sensory; 4 affective) which are rated on an intensity
scale as 0 = none, 1 = mild, 2 = moderate or 3 = severe.
The subjects were asked to rate their symptoms.
Demographic profile- The mean age of subjects in

group A was 36.339.4 years, in group B was 37.259.8 years
and in group C was 39.338.6 years. There were 52% females
and 48% males. As a result all groups were found to be
homogenous regarding age; body mass index and duration of
symptoms.
Within group analysis- Meansd reduction in VAS score
in Group A was after intervention of 3 weeks was 4.490.76
which was statistically significant (p=0.000) and a similar result
at 6th week follow-up. Improvement in the Elbow extension range
of motion after intervention was 14.65.94 which was
statistically significant (p=0.000). Improvement in the Northwick
Neck pain questionnaire score was 9.151.96 and this result
was statistically significant (p=0.000). Mean improvement in
NPPS scores after the intervention was 19.435.14 which was
found to be statistically significant (p=0.003). Reduction in the
SF-MPQ score was 14.405.44 which was statistically significant
(p=0.000).
Meansd reduction in VAS score in Group B after
intervention of 3 weeks was 3.53 0.76 which was statistically
significant (p=0.000). Improvement in the Elbow extension range
of motion after intervention was 10.174.36 which was
statistically significant (p=0.011). Improvement in the score was
7.651.81and this result was statistically significant (p=0.006).
Mean improvement in neuropathic pain scale scores after the
intervention was 19.24.14 which was found to be statistically
significant (p=0.007). Reduction in the Short-form McGill pain
questionnaire score was 112.16 which was statistically
significant (p=0.006).
The meansd reduction in VAS score in Group C (control
group) was 2.16 0.8 which was statistically significant (p=0.042).
The improvements in the scores of other parameters in i.e.
NPNQ, NPPS and SF-MPQ were non-significant (p>0.05).
Between group analysis- All the outcome parameters of
the Groups A, B & C were compared at various intervals i.e.
Pre-intervention, Post-intervention (3weeks) and Follow up (6th
week) using One-way analysis of variance (ANOVA) and Post
HOC Tukey-HSD test.
1. Visual analogue scale score:
Graph 1:
There was insignificant difference between the VAS scores

of Group A&B (F= 18.49, p=0.075) and a significant difference
between group A&C and group B&C (p<0.005)
2. Elbow extension ROM limitation measured in ULTT1
position:
Graph 2:
Results
Statistical analysis was done by the statistical package of
social science (SPSS) version 14.0. The results are expressed
by means and SD, confidence interval & p value for significance.
Chi-squared tests were used for nominal data comparison. Also
statistically three groups were compared by ANOVA & Post hoc
test. Within group comparison was done by using paired t-test.
97
There was non significant difference in the

ranges of
Group A&B (F=12.01, p=0.024). But between Group B&C in
which there was a significant difference (p=0.005), and also
between Group A&C (p=0.000) showed a significant difference.
3. Northwick Park neck pain questionnaire score:
Graph 3:
When the scores of Group A&B were compared there was

statistically significant difference (F=39.28, p=0.015) between
them. When scores of Group A&C was compared there was a
significant difference (p=0.000) and also a similar result when
groups B&C were compared (p=0.001).
4. Neuropathic pain scale scores:
Graph 4:
When the Group A&B were analyzed there was nonsignificant difference between the scores (F=15.93, p=0.953)
and significant difference between the groups A&C and Groups
B&C (p<0.05).
5. Short form-McGill pain questionnaire score:
Graph 5:
A comparison of all the 3 groups demonstrated a significant

difference in the functional outcome score subsequent to the
treatment (F=28.23, p= 0.000). When the scores of Group A&B
were compared there was statistically significant difference
(p=0.001) between them. When scores of Group A&C and
groups B&C were compared there was a significant difference
(p=0.000)
Discussion
The analysis of the treatment effects revealed that
98
significant differences could be observed between the effects

of cervical mobilization and TENS when compared using a
control group. The results of the study have demonstrated that
the manipulative physiotherapy treatment for cervical spine and
exercise protocol is capable of producing beneficial effects on
pain, functional disability in subjects with lower cervical
radiculopathy associated with cervical spondylosis.
In a comparative group study done by Nordemar R and
Thorner C16, neck collar, neck collar plus transcutaneous
electrical nerve stimulation and neck collar plus mobilization were
compared in the treatment of sub-acute cervical pain. The
mobilization group exhibited greater improvements in short form
McGill (SF-MPQ) score at 1 week, but no significant differences
were noted at 8 weeks and 3 months. Our results of between
group analyses revealed that there was a significant difference
in the score of the two experimental groups were compared
(p=0.001). In the study done by Michel W. Coppieters et al17,
analyzing the treatment effects between the 2 groups i.e. one
group of subjects receiving cervical mobilization and the other
receiving therapeutic ultrasound for the management of
cervicobrachial pain, significant differences could be observed
in the increase in the elbow extension range of motion (P=.0306).
Our results of between group analyses revealed that there was
a significant difference in the elbow extension range of motion
between ranges of the two experimental groups (p=0.024).
In a study done by Cowelland IM18, whereby they had
obtained 55% improvement in the Northwick neck pain
questionnaire score of the subject receiving cervical mobilization.
This result is similar to the result of our study, where in the
subjects receiving cervical spinal mobilization had a significant
improvement (62%; p=0.000) in the NPPQ score.
Also in the study group, where the subjects received TENS
there was a significant improvement (53%; p=0.000). A similar
result was found in a randomized clinical trial done by Thomas
TW chiu et.al 19 in which they investigated the effect of
transcutaneous electrical nerve stimulation(TENS) and neck
exercise in chronic neck pain patients where there was a
significant reduction(p=0.034) in the Northwick park neck pain
questionnaire score of subjects receiving TENS. The mechanism
of the analgesia produced by transcutaneous electrical nerve
stimulation is explained by the gate control theory of pain
modulation proposed by Melzack and Wall20.
Rationale of the treatment by cervical spinal mobilization
technique: According to classical work on neurodymamics by
Michael Shacklock(2005)13, treatment for different nerve roots
problems often gravitate towards similar technique, that initially
focus on reduction of pressure on the nerve root. Release of
pressure in this situation may help venous return, improve
resolution of inflammatory process, reduce tissue fluid pressure
and improve intraneural circulation. In the case of cervical
radiculopathy, the key concern is to take pressure off the nerve
root and improve its blood flow and oxygenation. Thus Cervical
lateral flexion mobilization was used in patients whose symptoms
of cervical origin are unilaterally distributed, either cranially or in
the neck, scapula or arm20. In such cases, when this mobilization
was being used for the first time it was done with the patients
head laterally flexed away from the painful side. The direction of
movement, particularly of a mobilization technique, is guided
by the purpose of the technique21. Thus the aim was to open
intervertebral space of the affected side.
It is also hypothesized that with enhanced intersegmental
motion, the introduction of home exercises also enabled the
subject to have a physiological and remedial influence on the
pathological neural tissue. In a study done by AIlison GT et.al22,
the subjects receiving passive technique for mobilizing neural
tissue structures and the cervical spine, showed greater
improvements in pain intensity, pain quality scores and functional
disability levels at 2 weeks. In the present study, where in the
subjects receiving cervical spine mobilization had a significant
improvement (57%; p=0.000) in the score.
Conclusion
The randomized control trial showed that Cervical
mobilization when compared to Transcutaneous electrical nerve
stimulation was more effective in relieving pain, reducing the
radicular pain in upper limb and improving the functional outcome
for a short term duration of 3 weeks. However in long term
duration the results remained equivocal as subjects in both
experimental groups had similar scores in the functional
questionnaires.
10.
Limitations of Study
12.
1.
2.
Relatively smaller sample size.

The motor weakness present/absent in the muscles of the
upper limb associated with cervical radiculopathy was not
taken into consideration while comparing the effectiveness
of cervical mobilization and TENS in the managing cervical
radiculopathy.
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99
Home based constraint-induced therapy for children with

hemiplegic cerebral palsy: A pilot study
Saleh AL-Oraibi*, Hashem Abu Tariah**
*Assistant Professor, Physical Therapy Department, Faculty of Allied health Sciences, Hashemite University, Jordan, **Assistant
Professor, Department of Occupational Therapy, Hashemite University, Jordan
Abstract
Background
Constraint induced movement therapy (CIMT) has been
documented to improve motor function in children with
hemiplegic cerebral palsy. Most of CIMT previous studies were
carried out by therapists at laboratory or clinical-based
environment.
Purpose
The purpose of this pilot study was to evaluate the possibility
of using CIMT in children with hemiplegic cerebral palsy by their
mothers at their homes.
Methods
Three children with hemiplegic cerebral palsy participated
in CIMT training and completed the evaluation. Childrens
functional upper-extremity activities were assessed at home
using the Pediatric Motor Activity Log (PMAL) (parent ratings)
at baseline, after, and at 4 weeks post-treatment. The CIMT
involved promoting increased use of the more-affected arm and
hand by intensive training of the more-impaired upper extremity
for six hours/ day for 21 consecutive days coupled with bivalve
long arm casting of the childs less-affected upper extremity.
Results
Constraint-induced movement therapy as implemented in
this study was acceptable to mothers and their children but with
some difficulties. Over the intervention period, participants
experienced improvements in the performance of important daily
activities as determined by parents rating.
When an individual experiences a dysfunction in an UE, he/she

tends to depend more on the unaffected UE and neglecting the
use of the affected one. This observation is called learned- non
use and it is the base of the CIMT approach (Taub, et al., 1993).
The CIMT includes constraining the movement of the
unaffected hand and at the same time encouraging the use of
the affected hand by presenting different UE functional skills for
the patient to perform (Taub, et al., 1993; Taub & Uswatte , 2003).
Following promising outcomes in adult stroke patients, CIMT
has been introduced for children with hemiplegic cerebral palsy.
However, limited studies have evaluated the use of CIMT in
children with hemiplegic cerebral palsy to improve their hand
functions and all these studies have indicated positive outcomes
(Charles, Lavinder, & Gordon, 2001; Willis et al., 2002; Karman
et al., 2003; DeLuca, Echols, Ramey, & Taub, 2003; Taub,
Ramey, DeLuca, & Echols, 2004).
There are some concerns related to the CIMT training
programs, such as it is mainly conducted in clinical/laboratorybased environments which questioning the possibility of
transferring the approach into usual rehabilitation program.
Additionally, CIMT requires concentrated period of therapists
time with limited studies looking at the applicability of CIMT in
natural environments where children spent most of their normal
lives with their families. Moreover, family involvement in
implementing CIMT has not been evaluated. For all these
reasons and other methodological reasons (Grotta, et al., 2004),
CIMT is not yet become part of routine children rehabilitation
program and the approach still under investigation. To strengthen
the evidence of the CIMT approach and validate the applicability
of CIMT in children who have had hemiplegia across various
cultures and environments, additional studies are needed to
understand better whether the CIMT would be carried out in
childrens homes by their mothers. The aim of this study was to
evaluate the possibility of using CIMT in children with hemiplegic
cerebral palsy in their homes.
Method
Conclusions
Modified constraint-induced therapy which is family-focused
is sufficiently promising to justify additional studies with larger
sample size in the form of a randomized control trails using
different types of splints.
Key words
Physical therapy, Occupational therapy, Constraint Induced
Movement Therapy, Children with Hemiplegic Cerebral Palsy,
Home based therapy
Introduction
Constraint Induced Movement Therapy (CIMT), a new
rehabilitative therapeutic approach to improve affected hand
function was emerged and it has been used with stroke patients
with upper extremity (UE) dysfunction (Taub et al., 1993; Taub
& Wolf ,1997). The CIMT studies in adult stroke patients showed
promising outcomes for reducing impairment and improving
functional use of the affected UE (Weinstein, Miller , et al., 2001;
Pierce, Daly , Gallagher , Gershkoff , & Schaumburg , 2002).
100
Subjects
Participants were recruited with the help of therapists who
work at the Cerebral Palsy Foundation (CPF) in Amman-Jordan.
For practical reasons children and their mothers were selected
purposively. Four children were recruited initially; one child was
dropped out at an early stage resulting in three children who
completed the CIMT program. The reason for the drop out was
related to the childs rejecting the cast and it was difficult for the
family to cope with the situation.
The children included in the study had a diagnosis of
congenital spastic hemiplegic cerebral palsy made by a
consultant neuro- pediatrician. Parents were able and willing to
commit to the time required for the daily procedure and the followup care after the program completed (see Table 1).
Intervention
The Hashemite University of Jordan Research Review
Board approved the study protocol, and parents signed informedconsent statement. Prior to therapeutic intervention, families had
Saleh AL-Oraibi / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Table 1: Demographic data of cerebral palsy children with hemiplegia (n= 3)

Child
Age (months)
Gender
Gestational
Parents level
week
of education
1
18
Female
Preterm
College
26
Male
Full term
College
24
Male
Preterm
HighSchool
received proper training to enhance their abilities to carry out

the treatment sessions at home. The training was conducted by
two therapists (a physiotherapist and occupational therapist). A
three-days parents training program included: orientation about
the CIMT approach, the important of mothers commitment to
the success of training activities and detailed information about
training activities to be carried out at homes during the
intervention and the follow-up period. The follow-up period lasted
for four weeks post intervention. Mothers were allowed to ask
questions and express their concerns during the training
sessions. Examples from previous CIMT studies were discussed.
Mothers were also provided with detailed instructions about
casting procedures and cast handling at home.
A lightweight, fiberglass cast was applied to the less affected
UE from shoulder to fingertips (DeLuca et al., 2003). The cast
was applied to the UE in 90 degrees of elbow flexion and in a
neutral position of wrist and fingers. The cast was bivalved so
that it could be removed once a week to wash the arm, permit
active range of motion and to check skin integrity. The cast was
worn for 24 hours a day for the three-week intervention period.
In order to avoid any risk of skin breakdown or discomfort, the
cast was fabricated by hand therapists. Mothers were given
instructions about how to manage the cast and to report any
problem.
The daily hand training program was provided by childrens
mother with a once a week visit by therapist and follow up phone
calls three times a week. The six-hour daily training took place
in the childs home for 21 days. All three mothers were house
wives and have no commitment outside their homes. Training
agenda was based on sensorimotor activities, encouragement
of gross motor movements training and behavioral techniques.
All these activities were shown to mothers and mothers were
provided with written training guideline. Training was based on
motivating the child to use the impaired hand to play, selecting
activities of an appropriate level of difficulty to develop new skills
and to provide opportunities for repetition.
Outcome measurement tool

The Pediatric Motor Activity Log (PMAL) and parents open
interview were used. The PMAL test was used to assess
childrens upper limbs performance before and after intervention
period and it was based on the Motor Activity Log (MAL) measure
used for adults (DeLuca et al., 2003). The PMAL is a 22-item
parental interview used to measure the childs upper-extremity
functioning in different activities at home. Upper-limb use is
scored on two ordinal scales, How Often and How Well. The
How Often scale ranges from 0 (never uses the affected arm
for task completion) to 5 (uses affected arm on almost all
occasions for task completion); the How Well scale ranges
Age at
Therapy
diagnosis of CP services at enrollment
(hr/week)
4 months
hour/week
of
physiotherapy (regular)
6 months
hour/week
of
physiotherapy plus
hour/week
of
occupational therapy
(regular)
5 months
hour /week of
physiotherapy (regular)
from 0 (unable to use affected arm for task completion) to 5

(uses affected arm in a way that is normal for childs age). Scoring
for both scales involved averaging across the 22 items, with a
higher score indicating a better performance. The mothers
perceptions of quantity and quality of their children upper
extremity function were recorded by one of the therapists once
a week totaling three assessments of PMAL throughout the
intervention period. The assessment of PMAL was repeated at
follow up period once a week. The validity and reliability of the
measure still not yet established.
An open interview was performed with childrens mothers
to evaluate their experiences with the CIMT. Interviews were
conducted by the researchers after the intervention period was
completed. Families were also provided with diaries to record
childs daily upper arms functional activities.
Data analysis
Data were managed and analyzed using the Statistical
Package for Social Sciences (SPSS) version 16 (SPSS Inc.,
Chicago, IL., USA). Because of the small number of data points,
only descriptive statistics were used. The PMAL scores for the
three children were calculated at the baseline, post-intervention,
and at four weeks post-intervention. Authors of the study
separately reviewed mothers interviews. Qualitative data from
the mothers interviews was coded into initial categories. Initial
categories compared, contrasted, and refined to come out with
major categories of the study (Bogdan and Biklen, 1992).
Consensus was reached by the two authors about the
categories.
Results
Table 2 presents scores of PMAL means and change scores
for the three children at baseline, post treatment and at the end
of four weeks follow up. The analysis revealed pronounced
trends of improvements in the PMAL amount of use and quality
of use scales for all three children.
All of the three mothers completed the CIMT intervention
with their children as expected in the study design. Compliance
of the families with CIMT intervention was varies. Families
reported satisfaction with carrying CIMT intervention at home.
There were no transportation arrangement, transportation cost,
clinic waiting time, arrangement of baby sitter or somebody to
do house work during their absence from home as reported by
mothers. Additionally, mothers reported that being at homes
reduced their worries about other siblings and allow them to do
their daily home-management activities.
The mothers reported that their children used the full bivalve
long arm cast in their home environment during the three weeks
period. Mothers reported that children were not happy with
Table 2: PMAL means and change scores for 3 children at baseline, post treatment and at 4 weeks follow up
Time of assessment
Mean
Changes
How often(0-5)Pre-treatmentPost treatment4 weeks follow up
0.71.51.3
+0.8+0.6
How well (0-5)Pre-treatmentPost treatment4 weeks follow up
0.31.91.7
+1.6+1.4
Saleh AL-Oraibi / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
101
casting procedures, especially when the cast saw was used

to bivalve the cast. The mothers also reported that in the first
three days of donning the cast children had experienced some
sleep disruption.
In terms of the increased treatment intensity, mothers find
it difficult to manage time for the treatment at the beginning,
especially in the first week of intervention period. During the
first week, mothers also reported that children were crying during
training sessions and felt slowness of using their both hands,
slow movement in the lower limbs and muscle soreness but
these consequences improved in the next two weeks of the
intervention period.
According to their reports all mothers were pleased with
the observable improvement in their childrens functional use of
the affect arm and hand. Mothers reported various functional
improvements including bimanual activities, using the affected
hands during play activities, less need for assistance, and
improved reaching activities especially during the last two weeks
of the intervention and on the follow up period. All mothers
were pleased with the results and with the overall treatment
approach. During interviews, mothers suggested readymade
cast with lighter materials, less training intensity, and more
frequent visits by therapists might enhance their future
participation.
Discussion
The purpose of this study was to evaluate the possibility of
using CIMT in children with hemiplegic cerebral palsy in their
homes. Results from this study are consistent with other studies
in showing improvement in upper limb function after CIMT in
young children with hemiplegic cerebral palsy (Willis et al., 2002;
Eliasson, et al., 2005). Unlike other studies, the CIMT
improvements in this study were completed by childrens
mothers. Mothers reported various functional improvements
including bimanual activities, using the affected hands during
play activities, less need of assistance, reaching activities
especially during the last two weeks of the intervention and at
the four week follow-up period. Similar to other CIMT studies,
the improvement of these functional activities may be due to
the intensity of training and the type of training (Taub & Uswatte,
2003). However, other factors such as the mothers commitment
to attend the three days workshop, to carry out the training by
themselves with weekly regular visits and follow up phone calls
by therapists might contribute positively to the improvement of
upper limb function.
In this study, despite difficulties to adapt long arm cast in
the first week of the intervention, all three children used the arm
cast as expected. Similarly, these difficulties have been recorded
in previous children CIMT studies (Charles, Lavinder, & Gordon,
2001). Other consequences such as muscle soreness, lower
limb slow movement especially in the first week of intervention
reported in this study were also reported in other studies (Glover,
Mateer, & Yoell, 2002; Crocker, et al., 1997). The possible
explanation for these consequences following casting might be
due to restraint type, restraint duration and intensity of training.
In regards to restraint type, other studies using similar restraint
type recorded similar difficulties (DeLuca, et al., 2003). Side
effects of prolonged restraint duration in this study were in
agreement with other studies (Willis et al., 2002; Yasukawa,
1990). The possible explanation for these side effects that the
CIMT used in adults may be not appropriate to children as it
may affect their interaction with the environment around them.
It has been suggested that the CIMT used in adults should be
modified when used with children (Crocker et al., 1997).
In this study mothers were committed to complete the
training intensity at home beside their other house hold task.
These mothers were housewives and the training was integrated
in childrens routine daily activities, but one could argue that
this type of intervention may not be appropriate for mothers who
have commitment outside their homes.
102
Limitations of the study

This home-based study found positive effects of pediatric
CIMT for hemiplegic cerebral palsy. However, the findings of
this study must be interpreted with caution for the following
reasons: purposive sampling was used, where mothers who
were able to attend the workshop training and had commitment
to complete the program at home were selected. A further study
involving a sample of participants selected randomly might lead
to different findings. The sample size in the current study was
also small (Three children only) raising concerns about the
generalizability of the study. Other limitation was that the PMAL
measurements used in the study lacked reliability and validity,
which brings the results into question.
References
Bogdan, R., & Biklen, S. (1992). Qualitative Research for
Education: An Introduction to Theory And Methods (2nd
edn). Needham Heights, MA: Allyn and Bacon
Charles, J., Lavinder, G., & Gordon, AM. (2001). Effects of
constraint-induced therapy on hand function in children with
hemiplegic cerebral palsy. Pediatr Phys Ther , 13, 6876.
Crocker, MD., MacKay-Lyons, M., & McDonnell, E. (1997).
Forced use of the upper extremity in cerebral palsy: a
single-case design. American Journal of Occupational
Therapy, 51(10), 824-833
DeLuca, SC., Echols, K., Ramey, SL., & Taub, E. ( 2003).
Pediatric constraint-induced movement therapy for a young
child with cerebral palsy: two episodes of care. Phys Ther
, 83,10031013.
Glover, J. E., Mateer, C. A., Yoell, C., & Speed, S.(2002). The
effectiveness of constraint induced movement therapy in
two young children with hemiplegia. Pediatr Rehabil , 5
(3), 125-31.
Grotta, J., Noser, E., Ro, T., Boake, C., Levin, H., Aronowski,
J., & Schallert,T.(2004). Constraint-Induced Movement
Therapy. Stroke, 35 [suppl I], 2699-2701.
Karman, N., Maryles, J., Baker, RW., Simpser, E., & BergerGross P.(2003). Constraint-induced movement therapy for
hemiplegic children with acquired brain injuries. J Head
Trauma Rehabil, 18, 259-267.
Pierce, SR., Daly, K., Gallagher, KG., Gershkoff, AM., &
Schaumburg, SW. (2002).Constraint-induced therapy for
a child with hemiplegic cerebral palsy a case report. Arch
Phys Med Rehabil , 83,1462-1463.
Taub, E., & Uswatte, G. (2003). Constraint-induced movement
therapy: bridging from the primate laboratory to the stroke
rehabilitation laboratory. J Rehabil Med , 41 (suppl), 34
40.
Taub, E., Miller, N.E., Novack, T.A., Cook, E.W. , Fleming, W.C.,
Nepomuceno, C.S., Connell, J.S., & Crago, J.E. (1993).
Technique to improve chronic motor deficit after stroke. Arch
Phys Med Rehabil, 74, 347354.
Taub, E., & Wolf, SL. (1997).Constraint induction techniques to
facilitate upper extremity use in stroke patients. Top Rehab
Top Stroke Rehab, 3, 38-61.
Weinstein, CJ., Miller, JP., Blanton, S., Taub, E., Uswatte, G.,
Morris, D., et al (2003). Methods for a multisite randomized
trial to investigate the effect of constraint-induced movement
therapy in improving upper extremity function among adults
recovering from a cerebrovascular stroke. Neurorehab
Neural Repair , 17, 137-152.
Willis, JK., Morello, A., Davie, A., et al (2002). Forced use
treatment of childhood hemiparesis. Pediatrics,110 ,9496.
Yasukawa, A.(1990). Upper extremity casting: adjunct treatment
for a child with cerebral palsy hemiplegia. American Journal
of Occupational Therapy, 44 (9), 840-84
Saleh AL-Oraibi / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Taping and OKC exercises versus taping and CKC exercises in

treating patients with patellofemoral pain syndrome
Yehia N. Abd Elhafz 1, Mohammed S. Abd El Salam 2, Samiha M. Abd Elkader3
1
Department of Musculoskeletal Physical Therapy, Faculty of Physical Therapy, Cairo University, Giza, Egypt, 2Department of Physical
Therapy, College of Applied Medical Sciences, King Saud University, Riyadh, KSA, 3Department of Physical Therapy, College of
Applied Medical Sciences, University of Dammam, Eastern Province, Dammam, KSA.
Abstract
This study aimed to compare the combined effect (s) of
taping and open kinetic chain (OKC) versus taping and closed
kinetic chain (CKC) exercises in patients with patellofemoral pain
syndrome (PFPS). Thirty patients with PFPS were randomly
assigned to group A (tape, OKC), or group B (tape, CKC). Tape
was applied, for both groups A and B using medial glide. Patients
in both groups practiced exercises three times weekly for four
weeks. A 10 cm visual analogue scale (VAS) was used for
assessment pain. Q- angle, and congruence angle were used
for assessment of patellar maltracking. Both OKC and CKC
exercises combined with taping were significant in reducing pain
and improving patellar alignment. However, neither intervention
was significantly more efficient in reducing pain and improving
patellar alignment compared to the other. Combined patellar
taping and either OKC or CKC exercises were considered
equally effective in treating PFPS.
Key words
Open kinetic chain (OKC), closed kinetic chain (CKC),
patellar taping, patellofemoral pain syndrome (PFPS).
Patellofemoral pain syndrome (PFPS) is a common problem
in third and fourth decades of life, characterized by retropatellar
pain or peripatellar pain when ascending or descending stairs,
squatting or sitting with flexed knees 1.
Weakness of vastus medialis obliquus (VMO) was
suggested to cause abnormal patellar tracking in PFPS2. It was
proposed that PFPS results from muscle imbalance between
VMO and vastus lateralis (VL) 3. Patellar mal-alignment may be
related to tightness of soft tissues around patella 4, 5.
Increased Q-angle is a biomechanical factor observed in
PFPS. Q-angle creates a lateral force vector on patella and
exposes it to lateral displacement during activation of Quadriceps
6
. Tendency for lateral displacement of patella are believed to
increase as Q-angle increases. This will contribute to increased
patellar contact pressure 7. An increase in Q angle (more than
150) may increase patella lateral pull, causing patella to glide on
the lateral ridge of femoral groove and produce pain 8, 9.
Among commonly used plain radiographic measures of
patellar mal tracking is patellar congruence angle (CA), which
measures relationship of patella to intercondylar sulcus . If apex
of patellar articular ridge is lateral to the zero line, CA is positive.
If it is medial, CA is negative 10.
One main objective of rehabilitation is to strengthen VMO
to counterbalance VL action during activities 8. It is debatable
whether it is better to apply OKC or CKC exercises for quadriceps
strengthening in such conditions. However, there is strong
evidence that both modes are equally effective11, 12.
Taping is utilized in managing PFPS to improve pain and
function. Some authors suggested that mechanical advantage
of quadriceps is maximized because of increased leverage by
patella via a medial shift as it returns to trochlear groove of the
femur 13, 14, 15, 16. Others hypothesized that patellar taping reduce
neural inhibition of quadriceps and modulate pain via large
afferent fiber input 14, 15, 17.
Under influence of patellar taping, altered afferent input in
and around patellofemoral joint may improve proprioceptive
functions in patients with PFPS 2, 13, 18. Studies showed significant
improvement of VMO initiation timing under taping condition 19,

.
Since application of OKC and CKC exercises under taping
conditions takes place under modified mechanical and
neuromuscular conditions compared to non- taping condition,
we expected effects of both exercises modes might differ. Since
comparison of combined effects of taping and OKC versus taping
and CKC has not been done yet, so, purpose of this study was
to compare those combined effects on pain and patellar
alignment in patients with PFPS. It was hypothesized that there
would be no significant difference in pain and patellar alignment
following application of taping/ OKC or taping/ CKC in patients
with PFPS.
20
Methods
Thirty patients (19 males and 11 females), age 35.83(+ 5.36)
years with PFPS were randomly selected, from patients files of
physiotherapy clinic. They were randomly assigned to group A
(n=15) received patellar taping and OKC exercises, and group
B (n=15) received patellar taping and CKC (Fig. 1).
Patients were included if they presented with diffuse,
unilateral anterior knee pain for at least 8 weeks, exacerbated
by activity and isometric quadriceps contraction 21, 22. Patients
were excluded if they had a history of lower limb surgery,
deformities, or patellar fractures or dislocations 23.
Before the study began each subject signed a written
consent form after they got full explanation of evaluation and
intervention procedures that conforms to Helsinki Declaration.
Evaluation procedures
A physical therapist carried out; pain assessment using a10cm visual analog scale (VAS) 16, and Q- angle measures clinically
by identifying center of patella, tibial tuberosity, and ASIS. Then,
assessor connected center of patella with ASIS, and center of
patella to tibial tuberosity, and measured angle between them
using universal goniometer 8.
A radiologist carried out radiological evaluation to assess
CA measured by X-ray
(Toshiba radiographic machine, Toshiba co, Japan, and Xray film, Fuji film type 20 x 25cm), applying Merchant view 17.
Both assessors and Patients were blinded; unaware about
number of groups, randomization technique, or interventions
for each group.
Treatment procedures
Patients in both groups received 3 sessions per week for 4
weeks. Patients in group A received OKC exercises; Patients in
group B received OKC exercises; and medial taping was applied
for both groups.
Taping technique
Therapist applied medial patellar taping before exercises.
Patients were instructed to maintain tape in-between sessions.
Therapist applied a 15-cm cover-roll tape directly onto the skin,
then a 12-cm Leukotape P (BSN-JOBST, Inc) 24.
Yehia N. Abd Elhafz / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
103
Fig. 1:
34-
Squat-to-stand and stand-to-squat tasks

Forward step up exercise on stairs.
SPSS version 12.0 was used for data analysis. Significance
level (P < 0.05)
Results
Pain assessment within groups analysis showed significant
improvement in pain in groups A and B. (Table 1 and Fig 2).
Fig. 2: Within groups comparison between mean VAS at pretest
versus posttest evaluations
Comparing within groups means at pretest- posttest

evaluations showed a significant reduction of Q- angle in groups
A and B. Within group mean values for groups A and B should
significant reduction in CA post-test (Fig. 3).
Fig. 3: Within groups comparison between mean Q-angle and
CA at pretest versus posttest evaluations.
Exercises
Prior to onset of experiment several recommended OKC
and CKC exercises were revised in previous studies 25, 26,27,28 to
select exercises applied in this study.
Patients in group A applied OKC exercises including;
1- Flexion SLR from supine.
2- Isometric exercise of the quadriceps from supine.
3- Short arc knee extension from sitting position, 30o flexion
to full extension.
Patients in group B applied CKC exercises including25
1- leg press machine
2Mini squats
In-between groups analysis showed non-significant

differences between groups A and B at both pretest and posttest
evaluations for pain, Q-angle and CA values (Table 2 and Figs.
4&5).
Table 1: Comparison of mean VAS, Q-angle, and CA within groups A and B at pretest versus posttest evaluations.
Evaluations
Mean
SD
95% Confidence Interval
t value
of the Difference
Lower
Upper
Group A
Pre
6.51
1.52
1.45
1.85
17.60
(VAS)
Post
4.87
1.43
Group B Pre
6.97
1.28
1.17
1.78
10.43
0.00
(VAS)
Post
5.50
0.85
Group A
pre
15.20
0.94
1.18
1.89
9.28
(Q-angle)
Post
13.67
1.05
Group B
Pre
15.53
0.83
1.53
2.47
9.17
(Q-angle)Post
13.53
1.06
GroupA Pre
3.13
1.85
1.20
2.39
6.44
0.00
(CA)
Post
1.33
0.98
Group B
Pre
3.367
1.53
1.16
2.84
5.12
(CA)
Post
1.367
1.08
P<0.05
104
Sig.
0.00
0.00
0.00
0.00
Yehia N. Abd Elhafz/ Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Table 2: Comparison of mean VAS , Q-angle, and (CA), In-between groups A and B at pretest versus posttest evaluations.
Groups
Mean
SD
95% Confidence Interval
t-value
Sig.
of theDifference
Lower
Upper
VAS Pre
Group AGroup B
6.516.97
1.521.28
-1.51
0.59
-0.89
0.38
VAS Post
Group AGroup B
4.875.50
1.440.85
-1.51
0.24
-1.48
0.15
Q-angle Pre
Group AGroup B
15.2015.53
0.940.83
-0.99
0.33
-1.03
0.31
Q-angle Post
Group AGroup B
13.6713.53
1.051.06
-0.66
0.92
0.35
0.73
CA Pre
Group AGroup B
3.133.37
1.851.53
-1.50
1.04
-.38
0.71
CA Post
Group AGroup B
1.331.37
0.981.08
-0.80
0.74
-0.09
0.93
Fig. 4: In- between groups comparison between mean VAS at
pretest and posttest evaluations.
Fig. 5: In- between groups comparison between mean Q- Angle

and CA at pretest and post test evaluations.
Discussion
be better in managing patients with PFPS. Results achieved

suggested that there was no significant difference between
outcomes in either interventions. Unfortunately, to our best
knowledge, no previous existing literature that would help in
explaining this finding. It seemed that whatever effects suggested
to occur with patellar taping with medial glide, it did not modulated
and/ or enhanced the effects of either OKC or CKC exercises
on pain and patellar alignment. However, the effect of combined
taping and OKC compared to combined taping and CKC
exercises should be further studied to identify the effects of either
combinations in improving function, VMO strength, and VMO/
VL timing compared to one another.
Analysis of data showed within groups reduction of pain,

besides reduced Q-angle and CA angles in both intervention
groups A and B.
There is general agreement among all reviewed
literature that taping and exercises program, produces reduction
of pain at pretest- post-test comparisons 15, 16, 19, 29, 30, 31, 32 .
However, capacity of patellar taping to provide correction of
patellar alignment had been debatable. Christou19 demonstrated
that patellar taping reduce pain and enhance activity of VMO
during CKC movement, however, author reported that this
outcome was equivocal when taping was applied with medial
glide or in neutral position which reflected no taping effect on
patellar position. In the contrary, the current study patellar mal
tracking was measured as indicated by Q- angle and CA. Both
showed improved patellar positioning with both interventions.
We suggest differences in those outcomes was due to lack of
patellar alignment measures in Christous study. Whittingham
et al31, suggested improved pain and function in patients with
PFPS when therapeutic taping is combined with exercises
compared to placebo taping and exercises, and exercises alone
conditions. These findings indirectly supported our findings
concerning efficiency of combination of tape and exercises. We
would not claim direct relativity of these findings to ours as current
study did not included placebo tape or exercise only groups.
Reduced Q- angle and CA was reported in literature for
combined taping and exercises. However, reduced CA with
patellar taping has been reported by Worrell et al. 33. It was not
comparable to this study as measurement of CA was done during
taping using MRI, and no exercises were involved. Other authors
17, 34
reported non- significant difference in patellar alignment
with taping. Bockrath et al.17 had subjects who applied tape
regularly well before assessment that might caused some bias
to occur, while Gigante et al. 34 applied assessment of CA in CT
scan rather than plain radiographs applied in this study, and no
exercises intervention has been applied. However, it can be
suggested that the combined effect of taping and exercises, of
either modes, had enhanced onset of VMO activation, increased
VMO activity, and VMO/VL ratio, as supported by several authors
thus, reducing lateral patellar shift, and adjusting patellar
alignment 19, 20, 26.
Post experimental In-between groups analysis had been
our target. So that we would conclude which combination would
Conclusion
Application of patellar taping combined with either OKC or
CKC exercises showed to be beneficial in reducing pain and
patellar mal tracking in patients with PFPS. Despite this, no
significant differences were detected in combining taping with
either OKC or CKC exercises in pain values, Q- angles, and CA
values in patients with PFPS.
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Yehia N. Abd Elhafz/ Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Cardiovascular responses to McKenzie lumbar spine exercises

in hypertensive individuals
Prabhu R1, Nambiar V.K2, Ravindra S3, Kommineni P4
1
Dept. of Physiotherapy, KLE Hospital, Belgaum, 2, 3, 4Dept. of Physiotherapy, M.S.R.M.T.H, Bangalore
Abstract
Extension exercises.
Interpretation and Conclusion

Background
Low back pain (LBP) is one of the most common health
problems
in
the society. Repetitive lumbar spine exercises which are
recommended by McKenzie such as flexion and extension
exercises in lying (FIL and EIL) and flexion and extension
exercises in standing (FIS and EIS), have been used in the
assessment and management of low back pain since 20 years.
Studies are done in normal individuals to see the cardiovascular
changes after repetitive McKenzie exercises. So, there is a need
to study the effect of these exercises on cardiovascular system
in hypertensives, who are at risk to develop cardiovascular
complications. Therefore, this study was undertaken to examine
cardiovascular effects of McKenzie exercises in hypertensive
individuals.
Objectives
1.
To measure the pattern of HR, SBP and RPP during flexion

McKenzie
lumbar spine exercises in hypertensive individuals.
2. To measure the pattern of HR, SBP and RPP during
extension
McKenzie lumbar spine exercises in hypertensive
individuals.
3. To compare the changes in HR, SBP and RPP between
flexion and extension
individuals.
Methods
A convenience sample of 60 hypertensive individuals
between the age group 30 to 60 years was recruited from the
M. S. Ramaiah teaching hospital, Bangalore. The subjects were
administered flexion in lying (FIL), extension in lying (EIL), flexion
in standing (FIS) and extension in standing (EIS) with a wash
out period of 30 minutes between each exercise. Cross over
trial was followed. Subjects performed 10 repetitions of assigned
exercises. Blood pressure, Heart rate and rate pressure product
were recorded before and after each set of repetition.
Results
Paired t test was used to compare the amount of change in
heart rate,
systolic blood pressure and rate pressure product between
resting and
FIL, EIL, FIS and EIS exercises. For comparison of FIL
with EIL and FIS with EIS, Paired t-test was used .Data analysis
have shown that there is a significant change in blood pressure,
heart rate and rate pressure product after 10 repetition of FIL,
EIL, FIS and EIS exercises when compared with resting.
Comparing FIL with EIL exercise and FIS with EIS showed a
significant change in BP, HR and RPP. The effect size of flexion
exercise showed more change in SBP, HR and RPP than
In hypertensive individuals, McKenzie flexion exercises put

a greater stress on the cardiovascular system than the extension
exercises. Therefore, in such individuals, flexion exercises
should be given under close monitoring.
Keywords
Cardiovascular responses, blood pressure, McKenzie
lumbar spine exercises, low back pain, Rate pressure product.
Introduction
problems in the society and causes considerable disability, work
absenteeism and use of health services.1 LBP is commonly
seen in people aged between the ages of 35 and 64yrs 2.
In 1981, Robin McKenzie proposed a classification system
for LBP and a classification based treatment for the same labeled
as mechanical diagnosis and therapy, or simply the McKenzie
method 3 . These exercises are used to classify patients, having
1 of the 3 syndromes (postural, dysfunction and derangement
syndromes) and to guide the treatment 4.
McKenzie exercises include repeated flexion and extension
movements performed in different body positions.5 Based on
McKenzie approach, the patient performing 10 to 15 repetitions
every 2hrs in home program implies that end range exercise
will be attained 80 to 100 times a day. The number of repetitions
and type of exercise can affect the overall physiological demand
of exercise 6 .
The McKenzie exercises involve muscle co-contraction to
stabilize the trunk and some exercises involve arm exercises,
both of which are associated with disproportionate cardiovascular
demand to a given load compared with leg work 7 , 8.
Non invasive measure of cardiovascular responses can
be obtained with HR, systolic BP and rate pressure product
(RPP). RPP is a product of HR and systolic BP. The RPP is
considered an excellent index of myocardial oxygen demand
and therefore work of heart 9 . The increase in HR and SBP per
unit increase in work is greater during upper extremity exercise
than during lower extremity exercises 10,11 .
Some risk factors for back pain are similar to those
associated with cardiovascular disease (eg, lack of physical
conditioning, obesity, smoking ) 12. This evidence suggest that
clinicians working with patients who have low back pain need to
consider that there can be an increased risk of an adverse
cardiovascular response.13 14
Spinal flexion exercise in lying position, involves work of
large muscle mass of upper and lower extremities, abdominal
muscles and trunk muscles (acting as stabilizer). Therefore the
demand of oxygen to supply this contracting muscles is
increased and this leads to increase in HR, BP and therefore
RPP 15
In McKenzie extension exercise such as push up involves
static contraction of upper extremity muscle which increases
work load on heart after 10-15 repetitions.
So understanding the cardiovascular responses to
Prabhu. R / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
107
McKenzie exercises on hypertensive individuals, can be useful

for clinicians in prescribing these exercises for treatment
purpose. Little evidence is available on the cardiovascular
changes occurring in hypertensives during McKenzie lumbar
spine exercises. Therefore there is a need to study the effect of
McKenzie exercises (i.e. lumbar spinal flexion and extension in
standing and lying, repeated at 10 times), on cardiovascular
changes in hypertensives, as a precautionary measure, before
prescribing them the same.
Null Hypothesis McKenzie lumbar spine exercises will not
bring about a change in HR, SBP and RPP in hypertensive
individuals.
Alternate Hypothesis McKenzie lumbar spine exercises
will bring about a change in HR, SBP and RPP in hypertensive
individuals.
Aims and objectives

1.
To measure the pattern of HR, SBP and RPP during flexion

McKenzie lumbar
spine exercises in hypertensive individuals.
2. To measure the pattern of HR, SBP and RPP during
extension McKenzie lumbar
spine exercises in hypertensive individuals.
3. To compare the changes in HR, SBP and RPP between
flexion and extension
individuals.
McKenzie R A, in 1981 proposed a classification system
and a classification based treatment for LBP called as McKenzie
method 16 Donelson et al reported that, 4 sets of 10 repetitions
of McKenzie lumbar spine flexion and extension exercises with
30 to 60 seconds rest in between each set of exercise were
used for treatment of LBP 17.
Leino-Arjas P et al. found that the increased LBP score
was predicted by a high BMI, serum total cholesterol, triglyceride,
SBP and DBP levels and smoking status at baseline. An overall
score of CVD risk factors showed a graded association with
increased LBP 18.
Nicholas U. Ahn et al. concluded that smoking, hypertension
and coronary artery disease (CAD) are all associated with
development of LBP. These same factors as well as
hypercholesterolemia, are associated with development of
degenerative lumbar spondylosis and spondylolisthesis19.
It is known that in a healthy individual HR and SBP
increases during exercises. Increase in HR is a first physiological
response of cardiovascular system to exercise, which is under
control of sympathetic system. Myocardial oxygen consumption
has an other independent determinant, which is called rate
pressure product (RPP). It has been well documented that RPP
is a valid and reliable index to measure the myocardial oxygen
consumption 20.
Greer M et al. reported HR and BP responses to several
methods of strength training programs. The isometric, isotonic
and isokinetic exercises are included in this study which showed
that there was a significant increase in SBP, HR and RPP in all
exercises 21.
Liu Danhua et al. established that the repeated McKenzie
exercises causes more cardiovascular stress, so there is need
to monitor HR and BP in cardiovascular dysfunction patients
who are at risk 22. All the above studies in the literature review
have been done on cardiovascular changes in normal individuals
during McKenzie lumbar spine exercises, but little evidence
exists supporting the cardiovascular changes during McKenzie
exercises in hypertensive individuals.
The present study was undertaken to determine the
108
difference in the amount of changes in HR, SBP and RPP during

McKenzie lumbar spine exercises in hypertensive individuals.

Source of data
Hypertensive individuals between the age group of 30 to
60 years visiting General Medicine OPD at M. S. Ramaiah
Teaching Hospitals, Bangalore, Karnataka, from March to August
2007. The type of study was cross sectional and convenience
sampling method was used. Sixty hypertensive individuals were
recruited for the study.
Inclusion criteria: Controlled hypertensive (who are on
medications) of either sex in age group between 30-60 years
Exclusion criteria: History of low back ache, any spinal
trauma. any history of pulmonary conditions and patients with
neurological deficit
Materials: Philips A 1 Monitor for HR and BP, Couch.
Procedure: An ethical clearance was obtained from ethical
committee of M. S. Ramaiah Medical College, Bangalore,
Karnataka. Hypertensive individuals from M. S. Ramaiah
Teaching Hospital were taken up for the study through
convenience sampling. The subjects were administered flexion
in lying (FIL), extension in lying (EIL), flexion in standing (FIS),
and extension in standing (EIS) with a wash out period of 30
minutes between each exercise 23,24. Cross over trial was
followed. The experimental protocol was based on established
clinical standards for performing repetitive exercises of the
lumbar spine as advocated by McKenzie.
Subjects were made to relax for 5 minutes in the reference
position (supine lying) prior to the test procedure, following which
HR and BP was measured. To begin with, FIL exercise was
performed by all the subjects, in supine lying with hip and knee
fully flexed and taking it towards the chest by clasping the hand
around knees to apply maximum overpressure to the lumbar
spine. After 30 min of washout period patient were made to do
EIL exercise in prone lying with full extension of both the hands
near the shoulder (as traditional press-up exercise), to overcome
the weight of the upper trunk against gravity. After 30 min of
washout period, subjects performed FIS exercise with feet apart
(30cms) and bending forward, sliding the hands down the front
of the legs in order to have some support. Again after the washout
period of 30 min, they performed EIS exercise with feet apart
and hands placed in small of back across the beltline and then
lean backwards as far as possible using hands as fulcrum. The
subjects were made to perform 10 repetitions of each of the
assigned exercise and then instructed to assume the resting
position. Subjects were instructed not to hold breath. After 10
repetitions, they returned to the reference position. HR and BP
were recorded and RPP was calculated.
Statistical analysis: Statistical analysis has been done
using the statistical software namely SPSS 11.0 and Systat 8.0
and Microsoft word and Excel have been used to generate tables
etc.
Results
A cross-sectional study consisting of 60 hypertensive
individuals including 34 males and 26 females between the age
group of 30 to 60 years was taken for this study.
Discussion
This study has been undertaken to study the effects of
Prabhu. R / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Table 1: Comparison of SBP, HR and RPP between resting

and FIL exercise
Mean
SD
t-value
P-value
SBP Resting
138.00
7.67
18.383
<0.001
FIL
156.92
7.43
HR
Resting
77.97
6.43
23.203
<0.001
FIL
89.02
7.11
RPP Resting 10778.70 1206.92 25.870
<0.001
FIL
14001.30 1652.71
The above Table 1 shows that there was a significant change in
SBP, HR and RPP after flexion in lying (FIL) exercise when
compared with resting (p<0.001

and FIS exercise
Mean
SD
t-value
P-value
SBP Resting
136.35
7.164
14.593
<0.001
FIS
150.68
8.550
HR
Resting
76.92
6.285
24.999
<0.001
FIS
85.77
6.500
RPP Resting 10499.38 1138.578
23.281
<0.001
FIS
12990.77 1372.090
SBP, HR and RPP after flexion in standing (FIS) exercise when
compared with resting ( p<0.001)

and EIL exercise
Mean
SD
t-value
P-value
SBP Resting
137.27
7.38
22.935
<0.001
EIL
152.33
7.02
HR
Resting
76.87
5.99
23.021
<0.001
EIL
86.38
6.58
RPP Resting 10567.30 1159.65
27.130
<0.001
EIL
13185.70 1446.04
SBP, HR and RPP after extension in lying (EIL) exercise when
compared with resting (p<0.001).

and EIS exercise
Mean
SD
t-value
P-value
SBP Resting
137.12
6.62
19.529
<0.001
EIS
146.32
5.91
HR
Resting
77.13
6.13
18.316
<0.001
EIS
83.27
6.58
RPP Resting 10587.90 1101.72
28.312
<0.001
EIS
12189.73 1102.57
SBP, HR and RPP after extension in standing (EIS) exercise
when compared with resting (p<0.001).
Table 5: Comparison of SBP, HR and RPP between FIL and EIL exercises.
FIL
EIL
Mean diff.
Effect size
t-value
P-value
Mean
SD
Mean
SD
SBP
156.92
7.43
152.33
7.02
4.58
0.63
4.968
<0.001
HR
89.02
7.11
86.38
6.58
2.63
0.38
6.127
<0.001
RPP
14001.30 1652.71 13185.70
1446.04
815.60
0.53
6.901
<0.001
The above Table 5 shows that there was a significant increase in SBP, HR and RPP i.e. P<0.001 when compared between FIL and
EIL exercises. The effect size of SBP, HR and RPP shows that FIL exercise causes more haemodynamic changes i.e. SBP, HR and
RPP than EIL exercise.
Table 6: Comparison of SBP, HR and RPP between FIS and EIS exercises.
FIS
EIS
Mean diff.
Effect size
t-value
P-value
Mean
SD
Mean
SD
SBP
150.68
8.55
146.32
5.90
4.37
0.59
5.330
<0.001
HR
85.77
6.50
83.27
6.58
2.50
0.38
7.198
<0.001
RPP
12990.77 1372.09 12189.73
1102.57
801.03
0.64
10.547
<0.001
The above Table 6 shows that there was a significant increase in SBP, HR and RPP i.e. P<0.001 when compared between FIS and
EIS exercises. The effect size of SBP, HR and RPP shows that FIS exercise causes more haemodynamic changes i.e. SBP, HR and
RPP than EIS exercise.
McKenzie exercises on the cardiovascular response in the
hypertensive individuals.
The results as seen in Table 1 shows that in FIL, SBP, HR
and RPP was increased significantly from resting. McKenzie
FIL exercise involves supine lying with hip and knee actively
going into flexion, this involves the work of large muscle mass
of lower extremities, the abdominal muscles and the trunk
muscles (acting as a stabilizer). Because of the raised position
of diaphragm and increased intra abdominal pressure there is
an increase in vascular resistance bringing about an increase
in HR and BP thereby increasing RPP. The demand for oxygen
to supply the contracting muscles is increased. Consequently,
cardiac output (CO) and stroke volume (SV) are increased. There
is increase in venous return and central blood volume which
increases the demand on heart in lying because of the cephalic
shift of the fluid in lying position 6.
The results as seen in Table 2 shows that in FIS show
SBP, HR and RPP was increased significantly from resting. This
may be because the upright bending position exercise causes
kinking of large vessels situated in abdominal cavity namely
abdominal aorta and inferior vena cava which in turn increases
the load on heart. FIS exercise, involves large range of motion
which presumably increases the muscle work .This in turn
increases the SBP and HR, thereby increasing RPP. FIS requires
that while returning to the upright position involves the concentric
contraction of the back muscles. This brings about greater
increase in the SBP and HR.
McKenzie EIL exercise as seen in Table 3 shows that there
is significant increase in SBP, HR and RPP. EIL exercise involves
prone lying with the weight of the upper trunk has to be overcome,
against gravity which is a closed chain exercise. This static
exercise causes the smaller arm muscle mass and vasculature
to offer greater resistance to blood flow than the larger leg muscle
mass which in turn increases SBP, HR and RPP. Palatini et al
described the mechanism of increase in BP and HR during static
exercises. During static exercises, the pressure within the muscle
increases and causes the small blood vessels (i.e arterioles and
capillaries) of these muscles to collapse 25. This reduces the
supply of oxygen rich blood to these working muscles. The
hypoxia (i.e. lack of oxygen) results in increase in SBP and DBP
during the contraction.
The results from Table 4 show that there is significant
increase in SBP, HR and RPP with EIS as compared to resting.
EIS causes eccentric contraction of abdominal muscles but while
returning to the upright position, there is concentric contraction
of the same which may be responsible for changes in
109
cardiovascular responses.
Analysing Table 5 it was found that, there was a significant
increase in SBP, HR and RPP in FIL exercise when compared
with EIL exercise as seen by effect size. FIL exercise involves
larger range of motion and more muscle work than EIL which
indicates that FIL exercise is haemodynamically more stressful
than EIL exercise.
The results as seen in Table 6 shows that there was a
significant increase in SBP, HR and RPP in FIS exercise when
compared with EIS exercise as seen by effect size. FIS exercise
involves larger range of motion and more muscle work than EIS
exercise. Biomechanically, it is known that the spinal extension
range is less than the spinal flexion. In addition at the end of
extension the limitation of chest movement prevents further
alteration in cardiovascular changes. In EIS exercise there is
expansion of thoracic cage which puts less stress on larger
vessels of heart reducing its workload.
The result of this study supports the idea that the McKenzie
exercises typically performed within 1min represent a risk of
cardiovascular stress in the hypertensive individuals 25. Thus,
absolute increase in RPP may constitute marked haemodynamic
strain in hypertensive individuals.
On comparison of haemodynamic parameters in resting
with FIL, EIL, FIS and EIS McKenzie exercises (Table 1, 2, 3, 4)
it was found that there was a significant increase in SBP, HR
and RPP. All these four McKenzie exercises showed a significant
change in SBP, HR and RPP (P<0.001). The comparison of FIL
with EIL exercises showed a greater SBP, HR and RPP in FIL
as seen in effect size (Table 5). Similarly, FIS showed greater
SBP, HR and RPP than EIS as seen in effect size (Table 6).
Thus we conclude that exercises in FIL and FIS are more
strenuous than EIL and EIS.
The study signifies that the physical therapists should
consider monitoring of the cardiovascular status of hypertensive
individuals with spinal problems for which McKenzie exercises
are indicated. The standard McKenzie evaluation form should
include assessment of baseline HR and BP. Patients should be
warned not to exceed the prescribed number of repetitions and
sets for each exercise when prescribed as a home exercise
program, especially hypertensive patients.
Since the FIL and FIS puts more stress on the
cardiovascular system, it is advisable to give extension exercises
prior to the McKenzie flexion exercises, especially in
hypertensives.
Therefore, the routine monitoring of BP and HR is a
fundamental component of all physical therapist examinations
in hypertensive individuals. Monitoring is also an important
precautionary measure during McKenzie lumbar spine
assessment and management.
Limitation
A larger sample size needs to be studied to be
representative of the population.
Conclusion
In hypertensive individuals, McKenzie flexion exercises put
a greater stress on the cardiovascular system than the extension
exercises. Therefore, in such individuals, flexion exercises
should be given under close monitoring.
Summary
problems and it is more common in the age group of 35 to 65
years. LBP affects approximately 80% of individuals, is the
second most reason of activity limitation in individuals under 45
years of age.
McKenzie are used for assessment and management of
110
LBP. McKenzie exercises include repeated flexion and

extension exercises in lying and standing position which may
cause cardiovascular stress in hypertensive individuals. Little
evidence is available on cardiovascular responses to repetitive
McKenzie exercises in hypertensive individuals. Therefore,
this study was undertaken to examine cardiovascular effects of
McKenzie exercises in hypertensive individuals.
A convenience sample of 60 hypertensive individuals
between the age group 30 to 60 years was recruited from the of
M. S. Ramaiah teaching hospital, Bangalore. Subjects who
fulfilled the inclusion criteria were included into this study. The
subjects were administered flexion in lying (FIL) , extension in
lying (EIL), flexion in standing (FIS) and extension in standing
(EIS) with a wash out period of 30 minutes between each
exercise. Cross over trial was followed. Subjects performed 10
repetitions of assigned exercises. Blood pressure, Heart rate
and rate pressure product were recorded before and after each
set of repetitions.
Results of this study showed a significant change in SBP,
HR and RPP when compared FIL, EIL, FIS and EIS with resting.
FIL and FIS McKenzie exercises cause greater haemodynamic
stress when compared with EIL and EIS respectively.
In this study it was concluded that, in hypertensive
individuals, McKenzie flexion exercises put a greater stress on
the cardiovascular system than the extension exercises.
Therefore, in such individuals, flexion exercises should be given
under close monitoring.
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111
Care allowance for people in need of care in Turkey: An ethical

and social evaluation
Sema OLAK *, Erdem ZKARA**
* PhD, Dokuz Eyll University Health Vocational of Training School 35300 nciralt-Izmir, Turkey, **Assoc. Prof. M.D, Dokuz Eyll
University Medical Faculty, Department of Forensic Medicine 35300 Izmir, Turkey
ABSTRACT
With economical and social developments, population
structures of countries have changed and the rate of people in
need of care and demands for care services have increased.
People may need help of their relatives to activities of daily
living in order to survive at one stage of life. Both the foresight
that the burden of care is too severe to cope with and the fact
that all states have social responsibilities underlined the
importance of regulations to support families although
traditionally people are responsible for caring their ill relatives.
In recent years, attempts to support people in need of care have
increased in Turkey. The Disability Law was enacted in 2005
and it was modified in 2006. The statutes regulating selection of
disabled people in need of care were also issued in 2007. The
Disability Law and the statutes, for the first time, made it possible
for people taken care of by formal and informal caregivers to
receive care allowance.
Care allowance for formal and informal care at home has
underlined ethical principles. It provides formal and informal
caregivers with financial support. However, it is still debatable
whether caregivers should be paid by governments.
In this article, the scope and effects of the Disability Law
and the relevant statutes will be evaluated and ethical and
medico-legal problems likely to appear in practice will be
discussed.
Keywords
Home care, people in need of care, care allowance and
ethics.
Introduction and aim

In this article, recently enacted laws concerning being in
need of care and home care in Turkey will be evaluated and
social effects and medico-legal and ethical aspects of home
care will be compared with those from other countries.
Being in need of care

People may need help of their relatives to perform activities
of daily living (ADLs) necessary to lead a normal life at one
stage of life (Seyyar., 2005). Traditionally, if one of the family
members is ill, the rest of the family is responsible for the care
of the ill member. However, the burden of care may become so
severe that family members may not cope with it. Both this
excessive burden of care and social responsibilities of states
have resulted in new laws concerning support for families of
people in need of care (Commonwealth of Australia., 2003).
Increased elderly and disabled population, changes in the
family structure and increased care expenditures have forced
countries to seek effective solutions to care for the elderly and
Correspondence:
Sema Olak
Dokuz Eyll University Health Vocational of Training School,
35300 nciralt-zmir-TURKEY
E-mail: sema.oglak@deu.edu.tr
112
disabled people throughout the world. In many developing and

developed countries, home care services are financed by care
insurance systems and predominantly by government funds.
The governments have shared the burden of care and started
to create care insurance systems which support families of
elderly and disabled people (Brodsky et al., 2000). In this setting,
elderly and disabled people have been provided care at home
by either family members or professional and semi-professional
caregivers. The care insurance systems require that difficulties
which prevent people in need of care from leading a normal life
in their own places should be eliminated (Olak., 2007a). Care
insurance systems provide long-term care and short-term
preventive medicine, medical and social care and rehabilitation
as well as professional health care either at home or in institutions
and financial support in cases of irreversible conditions (Seyyar,
2005; Olak, 2006). Home care has been increasingly preferred
in recent years in that it decreases health care costs, allows
delivery of health care at home and offers an appropriate
environment for maintenance of patient self-esteem.
Care allowance and ethics

Home care is offered by three types of organization: profit
organizations, public institutions and non-profit organizations.
This naturally causes differences in duration, monitoring and
quality of home care. Home care should have a high quality in
that a high quality home care increases quality of life and patient
satisfaction and is an indication of respect for patient rights
(Francis & Netten, 2004). Ethical principles are of great
importance particularly in home care. It is quite difficult to monitor
home care services compared to other health care and social
services and care standards and ethical principles can be
violated by caregivers. Respect for preferences of people in need
of care and neglect, abuse and bad behaviour likely to arise in
home care are the issues which attract attention at present
(Garcia, 2006; Letizia&Casagrande., 2004).
So that patient rights are not violated, individuals receiving
care and treatment at home should participate in the decision
making processes for all interventions they undergo and should
have the right to decline interventions. In other words, patient
autonomy should be respected. Care given by caregivers
unaware of patient rights may have undesirable effects. There
are ethical concerns about home care given by family caregivers
in that it may not be qualified enough, can be difficult to monitor
and may cause such risks as abuse and mistreatment
(Kondratowitz et al., 2002; Picard et al., 2003; Brodsky et al.,
2000; Gross., 1994; Penhale., 2006; zkara.,2003 ).
Care allowance is money paid monthly either directly to
caregivers or to individuals in need of care depending on the
degree of care needs. The primary goal is to decrease financial
burden on people taking care of their ill relatives. Care allowance
is preferable in that it offers the right to choose the person/
institution which will provide care and flexibility in care plans
(Stryckman & Nahmiash.,1994). In addition, it is agreed that
care allowance encourages families to provide care for elderly
and disabled people, provides compensation for financial losses
resulting from work leaves of carers and is indicative of an
appreciation of family caregivers efforts although the amounts
of payment are not so high (Horfmarcher & Riedel., 2001).
However, it is argued that care allowance for the care of
Sema Odlak / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
elderly and disabled people may increase the number of

caregivers without relevant qualifications who work
independently and that care services may not be sufficiently
monitored. In addition, individuals may have difficulties in
selecting caregivers and care providing institutions, caregivers
may abuse care allowance and elderly and disabled people can
be abused financially, exposed to violence and neglected ( Picard
et al., 2003).
It is difficult to determine criteria for quality standards of
home care, a complicated and multi-faceted process, since it is
difficult to monitor home care services, individuals offered home
care cannot easily assess or criticise the value and quality of
the care and care providing institutions offer a wide variety of
care services. In addition, there is concern that uneducated staff
and lack of standards for home care may result in neglect and
mistreatment (Merlis., 2000). In some situations, not only
concrete criteria but also moral values play an important role in
home care quality. Irrespective of education, lack of mercy and
compassion may cause neglect and maltreatment. In fact,
American Bar Association reported that home care services may
cause quality problems such as physical damages, insufficient
time for patients due to caregivers reluctance or incompetence,
mistreatment, insufficient or inappropriate performance and
behavioural problems such as insensitivity, disrespect, threats,
psychological abuse and financial abuse (The Quality of Home
Care., 2006). The fact that individuals who receive home care
are usually old, disabled and alone and do not have strength to
defend themselves makes the quality of home care important.
In fact, if home care is not performed in accordance with
predetermined standards, abuse of individuals in need of care
is inevitable (Penhale., 2006).
The quality of life is directly related to the quality of home
care among individuals who need home care. Therefore,
determination of quality standards for home care is the primary
responsibility of states. Netten et al. noted that there were six
aspects of home care quality: reliability, flexibility, continuity,
communication, behaviour and attitude of caregivers and
knowledge and skills of caregivers (Netten et al., 2003; Francis&
Netten., 2004;).
The WHO made the following recommendations to improve
the quality of home care (Gibson et al., 2003):
a) Regulatory systems should be created and regulations for
fulfilment of minimum standards should be adopted.
b) Knowledge and skills of caregivers should be improved and
accordingly educational standards should be determined.
c) Standard processes and substructure characteristics of
education should be clearly described.
d) Measurements concerning educational outcomes should
be evaluated regularly.
e) The obtained results should be used to improve the quality
of home care.
It is important to monitor home care in order to assure the
quality of care. Abuse and neglect are social and forensic
problems (Wang et al., 2006; Penhale., 2006). Based on the
statistics, abuse of elderly and disabled people is widespread
(Wang et al., 2006).
There is public awareness in these problems in many
countries. For example, many studies from Ireland have revealed
that caregivers suffer from heavy workload and psychological
stress. Another issue which strikes attention is abuse of
individuals in need of care. It has been reported that individuals
cared by family members are exposed to verbal and physical
violence (Mc Cann &Evans., 2002). Ventura found in 1980 that
115 caregivers who offered home care had negative attitude
towards the elderly and did not have sufficient knowledge about
old age (The Quality of Home Care, 2005 ).
The WHO reported that 4-6% of the elderly were exposed
to abuse in Europe. The highest rate of psychological abuse
was reported to be 54.1% in the USA followed by 21% in China
and 5% in Britain and Holland (Tazuko et al., 2005).
A study from Japan revealed that home care related

excessive stress caused mistreatment and neglect, which cause
elder abuse (Tazuko et al., 2005).
It has been reported that women and individuals aged over
80 years are more frequently exposed to abuse and neglected.
In Japan, it has been shown that women who look after their
spouses parents and disabled family members more frequently
exhibited abuse and bad behaviour (Tazuko et al., 2005; The
Administration for Children and Families and the Administration
on Aging; 1998).
The elderly with Alzheimers disease are more frequently
exposed to abuse than the general elderly population. In fact,
one study revealed that 33% of the caregivers who took care of
family members with Alzheimers disease abused and neglected
the ill family members (Coyne et al., 1993).
Disabled people taken care of by family members such as
mother, father, spouse, children and spouses wives are most
frequently abused and neglected. Excessive workload related
stress, lack of support from other family members, insufficient
time for personal things, insufficient knowledge and skills and
conflict with the individuals who need care are factors which
increase neglect, mistreatment and abuse (Tazuko et al., 2005).
In Turkey, the Disability Management Directorate affiliating
with the Prime Minister (ZDA) has created programs to solve
social problems of disabled people. These programs have
increased sensitivity to and public awareness in abuse of
disabled people. In fact, governments should give priority to
prevention of abuse as much as solving social problems
(Babakanlk zrller daresi Bakanl OZDA.,2006). In
Turkey, the disability law numbered 5378 enacted on 1 July 2005
requires that disabled people are taken care of at home by
caregivers authorized by Sosyal Hizmetler ve ocuk Esirgeme
Kurumu (SHEK) (Social Services and Child Protection Agency)
and by health staff working at public institutions (zrller ve
Baz Kanun ve Kanun Hkmnde Kararnamelerde Deiiklik
Yaplmas Hakknda Kanun., 2005). The law, for the first time,
provided poor disabled people with care free of charge either at
home or in an institution (Olak., 2007b).
However, the law 5378, which stipulates that disabled
people without health insurance should be provided with care,
and the relevant statutes have created some inequalities in
practice. Therefore, the law was changed on 10 February 2007.
The new law, numbered 5579, requires that if disabled people
and their family members have a total monthly income of less
than two thirds of the minimum wage, those disabled people
should be provided with care in public and profit organizations
or at home when they need it (Sosyal Hizmetler ve ocuk
Esirgeme Kurumu Kanununda Deiiklik Yaplmas Hakknda
Kanun, 2007).
According to regulations numbered 26430 and dated 23
October 2007 on determination of disabled people in need of
care and the principles of care services:
a- A two-month minimum net salary is paid when a disabled
person is cared in an institution for 24 hours.
b- A one-month minimum net salary is paid when a disabled
person is offered care in an institution for 8 hours during
day time.
c- When a disabled person is offered home care by the staff
of a care institution for 4 hours a day, a one-month minimum
net salary is paid to the institution.
d- When a disabled person is taken care of by his relatives, a
one-month minimum net salary is paid to the relative taking
care of the disabled person.
Despite its deficiencies, the law which requires that people
who provide home care for their disabled relatives for 24 hours
should be paid a one-month minimum salary in Turkey seems
promising. This has improved care for the disabled people.
However, there are concerns about neglect and abuse likely to
be caused by care allowance to people for caring their disabled
family relatives. In fact, care strategies and goals which
Sema Odlak / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
113
guarantee the quality of the given care and quality performance

criteria have not been described yet and it is not obligatory for
family members to attend trainings and to get a certificate in
order to offer high quality care (Olak., 2007c).
High standards and monitoring which will prevent financial,
verbal, psychological and physical violence towards vulnerable
disabled people taken care of by their family members or
caregivers who work for private care institutions should be
formed. According to the results of many studies and news, the
belief that there are strong ties between family members and
that neglect and abuse are less frequently encountered in our
country has been weakened. For example, in a study on 3500
elderly people from seven different regions of the country by
Ulusal Sosyal ve Uygulamal Gerontoloji Dernei (Turkish
Gerontology Society), it has been noted that the number of the
elderly exposed to various forms of physical and psychological
violence in family settings was striking and that out of 10 elderly
people, 9 were exposed to psychological violence and 3 were
exposed to physical violence (Ulusal Sosyal ve Uygulamal
Gerontoloji Dernei., 2006).
In view of the literature, it can be suggested that both
ZDA and SHEK shoulder great responsibilities for home
care which is in its infancy in Turkey. The things which should
be prioritized are as follows:
a. Care quality standards should be determined.
b. Individuals at a high risk of abuse and neglect should be
followed closely.
c. Caregiver education should be supervised and caregivers
should be observed for neglect.
d. Caregivers should be provided with emotional support.
e. Caregivers should be offered training for communication
and problem solving skills.
f.
Training for moral values and compassion should be offered
and sensitivity to the care of elderly and disabled should
be increased.
g. Caregivers workload should be decreased. Attempts to
provide formal care should be increased.
Conclusion
Despite its deficiencies and limitations, the recently enacted
law which requires the government should pay for the care of
the disabled is an important and promising development and
an indication of social welfare function of the state. Provision of
care for disabled people and care allowance to caregivers taking
care of their disabled relatives seem to be promising; however,
quality care assurance systems, performance indicators, home
care standards and grading systems for monitoring home care
should be formed. In addition, it is imperative that home care
services given in partly isolated places should be monitored and
that caregivers should be provided with appropriate education
and trained for communication and problem solving skills in order
to avoid malpractices likely to result from the home care
environment and personal characteristics of caregivers and to
prevent elderly abuse.
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Sema Odlak / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
115
Comparative study of anaerobic capacity in sprinters and foot

ball players
D.S. Sakthivelavan*, S. Sumathilatha**
*Associate Professor, Department of Physiology, Hi-tech Medical College, Bhubaneshwar, Orissa, ** Assistant Professor, Department
of Anatomy, Sri Ramachandra University, Chennai.
Abstract
Purpose of the study
This study was aimed at comparing the anaerobic capacity
in sprinters and foot ball players.
Methodology
30 elite male sprinters who received extensive resistance
training and 30 male football players who received both
resistance and endurance training for a period of more than 1
year were chosen for the study. Physical parameters were
measured and exercise stress testing was done on a cycle
ergometer with a portable gas analyzing system. Maximal power
output and carbon dioxide production at peak exercise were
measured as parameters to study anaerobic capacity.
minutes of play2. The resultant motor unit characteristics and

the muscle fiber groups of these athletes were also found to be
different1. Measurement of anaerobic energy transfer in these
muscles required the evaluation of the immediate and short term
energy systems (the ATP-Creatine Phosphate, and the Lactic
acid system). They were done by assessing the maximal power
output. Power in this context may be defined as the rate of doing
work. Sports that require brief all out activities, requiring
instantaneous tremendous force rely on energy from these short
term systems. Greater the power, greater is the ability to derive
anaerobic energy. When anaerobic glycolysis predominates,
large amount of lactic acid accumulate in the blood. The level of
blood lactate is the most common indicator for the short term
energy system1. As the lactic acid generated during muscle
metabolism is buffered to release CO2, the measurement of CO2
which exits through the lungs is used as an indicator of blood
lactate levels1.
Methodology
Result
Selection and preparation of Participants
Significant (P<0.05) difference existed in values of Maximal

power output and carbon dioxide production at peak exercise
for sprinters and football players.
Conclusion
The higher anaerobic capacity displayed by the sprinters
when compared with football players could be due to variations
in adaptations that happen in them due to different types of
training.
Keywords
Resistance training, Maximal Power output, CO2 production at
peak exercise, Sprinters, Football players.
Introduction
This study was conducted to analyze the variations in
anaerobic energy capacities in Indian male sprinters (short
distance runners -100 m, 200 m, and 400 m) and foot ball players
as there were not many Indian studies in this field. The sprinters
predominantly underwent resistance training in the form of weight
lifting. With this method exercises are designed to strengthen
specific muscles by causing them to overcome a fixed resistance,
usually in the form of a dumbbell or weight plates on a pulley
or cam-type machine1. On the other hand the foot ball players
received both resistance and endurance training which involved
continuous steady paced prolonged exercise in moderate
intensities for long distances. This is because the average
professional footballer is in motion almost constantly for 90
Corresponding Author:
D. S. Sakthivelavan, MD.,(Physiology),
No 8 A, Jai Balji Nagar, Nesapakkam, Chennai 78.
e-mail iconsakthi@yahoo.com
116
Sixty elite male athletes were selected from Prime Sports

Academy - Chennai. Thirty of these were sprinters undergoing
resistance training and the other thirty were football players
undergoing resistance and endurance training (apart from sport
specific exercises which included muscles stretching, posture
control, passing, ball control, kicking, heading, dribbling etc.)
for more than one year at college grounds of Madras medical
college. All the subjects were between 19-25 years and
procedures followed were in accordance with the ethical
standards set by the institution and as per the Joint Statement
of the American Thoracic Society (ATS) and the American
College of Chest Physicians (ACCP) on Cardiopulmonary
Exercise Testing4. Every individual was informed about the
objective of the study and his consent was obtained. Respiratory
or cardiovascular disabilities and medications contraindicating
their participation in the exercise stress test were ruled out. A
detailed clinical examination was also done to any exclude
systemic pathology. All participants did not involve in any kind
of exercise for the 6 hours before the test. The subjects were
instructed about the importance of the test and proper technique
was demonstrated. Precautions like loosening of tight clothing,
usage of nose clips and keeping the pneumotach clip in the
upright (12 o clock) position were adequately taken care of.
Determination of Anaerobic Capacity
The athletes physical parameters were recorded and
exercise stress testing was done on a cycle ergometer in the
CPX EXPRESS system, which is a portable breath-by-breath
gas analyzing system. It measures the power out put, analyses
the gas concentration and determines the VCO 2 at peak
exercise. The gas analyzer module of the CPX express system
contains O2 and the CO2 breath-by-breath analyzers3. The O2
sensor consists of a zirconium cell and CO2 sensor is a dual
path infra red (IR) analyzer. The system was then calibrated
and made ready for use4.
Selecting Bike protocol
An incremental protocol where the wattage changed in
discrete steps was selected for the bike (cycle ergometer). The
D.S.Sakthivelavan / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
time increment was specified as 30 seconds and a work

increment of 15 watts, allowing a work rate increase by a single
15 watt step every 30 seconds4.
The subjects were completely familiarized with the test
procedures before experimental data collection. Before
administration of each test, the seat handle bars and toe clips
of the cycle ergometer were adjusted to the needs of each
subject. Resting data for CO2 production per unit time (VCO2)
was collected for 3 minutes of rest, followed by 3 minutes of
unloaded pedaling, followed by the incremental phase of
exercise (with a single 15 watt step every 30 seconds) during
which the subject maintained the bike revolutions anywhere
between 40-60 revolutions/min. The power output required by
the athlete to overcome the resistance offered was displayed
by the cycle ergometer. The VCO2 was displayed on the LCD
screen of the CPX system. As the wattage increased the subject
found it more and more difficult to maintain revolutions between
40-60 revolutions/min. Subjects were required to remain seated
throughout the test and verbally encouraged to pedal maximally.
Exercise was continued to his supra maximal limit, a stage after
which he would not be able to exercise. This was considered as
the subjects point of peak exercise. The values of maximal
power output and VCO2 production at peak exercise were
recorded.
Fig 1: A subject undergoing exercise stress test on CPX system
Then the subjects were allowed to recover from exercise

by continuing to pedal the bike without any resistance and the
recovery data was colleted for 5-10 min4.
The mean and standard deviation of maximal power out
put and VCO2 production at peak exercise for both the groups
were first calculated and the data was subjected to Student-t
test with a significance level of 0.05.
Results
The mean of maximal power output (in watts) for sprinters
was found to be 242.66 35.18 and this was significantly higher
(P<0.05) when compared with the football players where it was
found to be 220.38 30.12. The mean of VCO2 production at
peak exercise (in ml/min) for sprinters was found to be 4082
376 and this was significantly higher (P<0.05) when compared
with the football players where it was found to be 3878 332.
Thus greater the power, greater the force generated by the

muscles put into contraction. Power is measured in watts. The
power out put in our study was greater in sprinters when
compared with football players. This is due to the various
adaptations that occur in the sprinters.
Adaptations could include hypertrophy of existing fast twitch
fibers and even conversion of type I to type II fibers for exerting
more force. These fast twitch fibers have high capacity for
electromechanical transmission of action potentials, a high level
of myosin ATP-ase, a rapid level of calcium release and uptake
by a highly developed sarcoplasmic reticulum., and a high rate
of cross-bridge turn over, all of which are related to this fibers
ability to generate energy rapidly for quick, powerful actions.
The fast twitch fibers intrinsic speed of shortening and tension
development is five times faster than slow twitch fibers. The
fast twitch fibers rely on their well developed short-term glycolytic
systems for energy transfer. This explains how these fibers
successfully recruited in the sprinters and are better equipped
to overcome the rapid change in resistance to pedaling that
was occurring at the end of every 30 second interval during the
exercise stress test1.
Carbon dioxide production measured at the mouth after
anaerobic threshold was used for ventilatory detection of lactic
acid production (lactic acid produced in the muscle is buffered
to CO2). The levels of lactate are most common indicator of
short term energy system and the CO2 levels achieved by
sprinters were significantly greater when compared to footballers.
This is because when an all out effort is needed in the final
stages of the graded exercise stress test, the energy required
to produce motion significantly exceeds the energy generated
by oxidation of hydrogen in the respiratory chain. Consequently,
the anaerobic glycolysis predominates and the lactic acid
production serves as a sink for excess hydrogen end product.
Continued release of anaerobic energy in glycolysis depends
on the availability of NAD + for oxidation of 3phosphoglyceraldehyde. Otherwise, the rapid rate of glycolysis
would grind to a halt. NAD+ is generated as pairs of excess
hydrogen combine with pyruvate catalyzed by lactate
dehydrogenase. This forms lactic acid1.
The lower levels of power and VCO2 at peak exercise by
football players could be explained by the fact that they undergo
endurance training to develop their aerobic system along with
resistance training. This could have converted their muscles
partly into slow twitch fibers which produce less anaerobic power
and lower levels of lactate1. A comparison of maximal power
output achieved by athletes competing at the national and
international level from India5,6 and foreign countries7,8,9 with that
of the current study revealed that the levels achieved by athletes
in current study were much lower.
Conclusion
Higher anaerobic capacity was displayed by the sprinters
when compared with football players and this could be due to
variations in adaptations that happen in them due to different
types of training.
References
1.
2.
3.
Discussion
Power is defined as the rate of doing work and work is said
to be done when force acts against resistance to produce motion.
4.
William D. McArdle, Frank I. Katch, Victor L. Katch, editors.

Exercise physiology energy, nutrition, and human
performance. 6th ed. Baltimore (ML): Lippincott Williams &
Wilkins; 2007. p. 521, 299, 383, 233-8, 539-47, 477-88.
Expert Foot ball [online]. [cited 2009 Oct 21]; Available from:
URL http://www.expertfootball.com/training/
Beaver WL, Wasserman K, Whipp BJ. On-line computer
analysis and breath-by-breath graphical display of exercise
function tests. J Appl Physiol. 1973;34:128134.
Joint Statement of the American Thoracic Society (ATS)
and the American College of Chest Physicians (ACCP)
D.S.Sakthivelavan / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
117
5.
6.
118
Cardiopulmonary Exercise Testing as adopted by the ATS

Board of Directors, March 1, 2002 and by the ACCP Health
Science Policy Committee, November 1, 2001. Am J Respir
Crit Care Med 2003;167:211277.
J. L. Bhanot and L. S. Sidhu. Maximal anaerobic power in
national level Indian players. Br J Sports Med. 1981
December;15(4):265268.
Col SC Singh. Maj R Chengappa,Lt Col A Banerjee.
Evaluation of Muscle Strength Among Different Sports
Disciplines: Relevance for Improving Sports Performance.
MJAFI. 2002 October;58(4):311-4.
7.
8.
9.
Davis JA, Brewer J, Atkin D. Pre-season physiological

characteristics of English first and second division soccer
players. J Sports Sci. 1992 December;10(6):541-7.
Popadic Gacesa JZ, Barak OF, Grujic NG. Maximal
anaerobic power test in athletes of different sport disciplines.
J Strength Cond Res. 2009 May;23(3):751-5.
Ward-Smith AJ, Radford PF. Investigation of the kinetics of
anaerobic metabolism by analysis of the performance of
elite sprinters. J Biomech. 2000 Aug;33(8):997-1004.
D.S.Sakthivelavan / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Effect of varying abdominal pressures on pulmonary function in

seated tetraplegic patients: A case report
Shweta Gore*, Sivakumar T.*
*Lecturer, Department of Physiotherapy Sancheti Institute College of Physiotherapy Pune, Maharashtra 411005, India
Abstract
Background
Purpose: This study was done to evaluate the effect of
varying pressures of abdominal binders on pulmonary function
in seated tetraplegic patients.
Methods
Three subjects with lower cervical spinal cord injury were
included in this case report. Forced Vital Capacity (FVC) and
Peak Expiratory Flow Rate (PEF) were recorded first without
the binder (baseline) and then with the binder by gradually
increasing the abdominal pressure till the measured FVC value
fell below baseline level. Values were then plotted on a graph to
see the trend.
Discussion
It was observed that as compared to baseline, there was
linear increase in the FVC and PEF values in all the three
subjects with increase in the abdominal pressure with binders.
The change in FVC was more linear when compared to PEF
with in the subjects
Keywords
Abdominal binder, abdominal pressure, Pulmonary
Functions, Tetraplegia
protection and bronchial hygiene are also compromised due to

poor cough/forced expiratory maneuvers resulting from
abdominal weakness/paralysis 5 . Although patients with
tetraplegia use accessory muscles (clavicular portion of the
pectoralis major) to deflate the rib cage during cough and forced
expiration5, 6,7,8 their ability to raise intra thoracic pressure is
markedly reduced due to paralysis/weakness of the abdominal
and expiratory rib cage muscles5, 8,9.
Use of abdominal binder to improve pulmonary function
and cough efforts has been studied extensively. Abdominal
binder supports the anterior abdominal wall and assists breathing
and cough by increasing intra abdominal pressure in seated
tetraplegic patients 1,3.
However, the effect of varying abdominal pressure imposed
by the abdominal binder is not reported. The amount of pressure
applied by the binder on the anterior abdominal wall would differ
depending on how tight or loose the binder is fastened. Too
tight binder might even restrict the respiratory pump hampering
respiratory function.
This study was carried out to evaluate the effect of varying
abdominal pressure due to binders on pulmonary function in
seated tetraplegic patients.
Case description
Three tetraplegic patients from university hospital, Manipal,
were selected for the study. Written informed consent was taken
from the participants. All the patients were spontaneously
breathing with out any assistance and with no pulmonary
complications at the time of examination. Demographic
characteristics of all three patients are presented in table 1.

Spinal cord lesions cause motor and sensory alterations,
leading not only to physical dependency but also to social,
psychological and professional dependency1. Traumatic lesions
of spinal cord produce paralysis of the skeletal muscles supplied
by the nerve from and below the level of the lesion1. The degree
of respiratory failure/insufficiency associated with spinal cord
injuries depends upon the level of injury and it is directly related
to the paralysis / weakness of the muscles of respiratory pump2.
High cervical lesions cause paralysis of the diaphragm,
intercostals and abdominal muscles, which might necessitate
mechanical ventilation for survival. Lower cervical and upper
thoracic lesions can lead to various degree of respiratory
insufficiency loss of pulmonary volume and capacity due to poor
respiratory mechanics. However in these patients spontaneous
ventilation is possible and the respiratory functions will be
subnormal2.
Various literatures have reported the changes in pulmonary
function following spinal cord injuries. A decrease in expiratory
reserve volume, vital capacity, total lung capacity, maximal
inspiratory pressure, maximal expiratory pressure and an
increase in residual volume were reported following SCI1.
The abdominal wall in tetraplegic patients is twice as
compliant as in normal subjects due to paralysis of abdominals3,
4
. In erect postures the abdominal contents fall forwards
unopposed by the abdominal muscles and results in flattening
of diaphragm, which is mechanically disadvantageous3. Airway
Table 1: Demographic characteristics of three patients

Patient 1
Patient 2
Patient 3
Gender
Male
Male
Female
Age in years
29
38
36
Height in cm
174
160
150
Weight in Kg
48
65
48
Abdominal girth in cm 67.5
82.5
80
Level of lesion
C6
C5
C5
Cause
RTA
RTA
Domestic
Duration in months
25
11
7
Procedure
Prior to the study a pilot study was done on age and sex
matched individuals to find the maximal abdominal pressure
within the comfort fit of abdominal binder. The comfort range
was up to 80 mm Hg. And this was set as higher limit for study
population. Any respiratory medication, which might affect the
respiratory function, was avoided six hours prior to the procedure.
The patients were made to sit upright with the back
supported fully ( Fig 3). The technique of spirometry was
explained, demonstrated and familiarized to the patients.
Baseline values of FVC and PEF were recorded without the
abdominal binder using Schillers PFT machine (Fig 1). FVC
Shweta Gore / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
119
and PEF techniques were done following the standard AARC

guidelines for PFT. The Abdominal binder, (model 0604, MGRM
medical limited) with 9" elastic band, foam fused fabric panels
and Velcro closure was then applied to patients. A manometer
cuff was placed between the binder and abdomen to record the
pressure (Fig. 2). It was assumed that change in the cuff pressure
would be directly proportional to the rise in the abdominal
pressure due to fastening of abdominal binder. Initially the binder
was fastened to the pressure level of 20 mm Hg. The FVC and
PEF values in this position were recorded. The pressure in the
cuff was then increased at gradations of 10 mm Hg till 80 mm
Hg or till the FVC values fell below baseline value and FVC and
PEF measures were taken. The total procedure was spread over
two days. The time intervals between the each measurement
were not controlled due to time constraints and patient
compliance.
Outcome
The data obtained is presented in table2.
Table 2 depicts the changes in FVC and PEF values with
increase in abdominal pressure. FVC was observed to increase
with increase in the pressure until 60 mmHg after which there
Fig1: Schillers PFT machine
Fig 2: Technique of application of binder
was a decline. Similarly PEF values also showed increase till

40 mm Hg followed by decline. The trend of measures with
increasing pressures followed same pattern for all three patients.
The data were also represented in graphs.
Graph 1 depicts the trend of FVC with increasing abdominal
pressure and graph 2 depicts the trend of PEF.
Discussion
This study yields the changes in FVC and PEF values with
the application of abdominal binders at different pressures. As
compared to without the binder, there is an increase in the FVC
and PEF values in all the three cases with the application of the
binder. With binder application, there was an improvement of
7.82% and 12.68% in FVC and PEF respectively. These values
improved with subsequent increments of pressure. The FVC
increased to 34.78% as compared to baseline at 60 mm Hg.
PEF at 40 mmHg was 28.35%as compared to without the binder.
The graph shows the trend of pulmonary function measures
with increasing abdominal pressure with binders in all three
tetraplegic patients. The FVC sows a linear rise till 60 mm Hg
after which the values started falling. PEF shows a linear rise till
40mm Hg after which there was a fall in the values.
However, there are certain limitations to this study. A gradual
raise in the PEF till 60 mm Hg follows the sudden dip in PEF
after 40 mm Hg. This could be possibly due to the fact that the
technique was effort dependent and the values were subjected
to change with patients effort. Also, the rest period was not
maintained constant during the procedure because of time
constraints and patient compliance. So, patient fatigue could
have been a contributing factor to the sudden dip in PEF.
The length of time since injury was different for each patient.
This study attempted to evaluate the changes in pulmonary
function values with one time application of abdominal binder.
Continual use of the abdominal binder may vary the results and
trend of pulmonary function with increasing abdominal pressure.
Observations of this study lay the foundation for control trials to
substantiate the results. This study does show an improvement
in the pulmonary function with increasing pressures. This should
be validated with further randomized trials.
Fig 3: Measurement in sitting
Table 2: showing median values of FVC and PEF for case 1, 2 and 3.
Baseline
20 mm
30 mm
40 mm
Hg
Hg
Hg
FVC (L)
1.15
1.24
1.36
1.44
% change from Baseline
7.82
18.26
25.21
PEFR (L/m)
2.68
3.02
3.12
3.44
% change from Baseline
12.68
16.41
28.35
120
50 mm
Hg
1.46
26.95
3.08
14.92
60 mm
Hg
1.55
34.78
3.10
15.67
70mm
Hg
1.25
8.69
2.53
-5.59
80 mm
Hg
1.30
13.04
2.29
-14.55
Shweta Gore / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Graph 1: Trend of FVC with increasing abdominal pressure
Graph 2: Trend of PEF with increasing abdominal pressure.
References
6.
1.
2.
3.
4.
5.
C M Boaventura, A C Gastaldi, J M Silveira, P R Santos, R

C Guimaraes, L C De Lima. Effect of an abdominal binder
on the efficacy of respiratory muscles in seated and supine
tetraplegic patients. Physiotherapy 2003; 89:290 295.
John C McMichan, Luc Michael, Philip R.Westbrook.
Pulmonary dysfunction following traumatic quadriplegia.
JAMA 1980; 243: 528 531.
J M Goldman, L S Rose, S J Williams, J R Silver, D M
Denison. Effect of abdominal binders on breathing in
tetraplegic patients. Thorax 1986; 41: 940 945.
J M Goldman, L S Rose, M D L Morgan, D Denison.
Measurement of abdominal wall compliance in normal
subjects and tetraplegic patients. Thorax 1986; 41: 513
518
Estenne M, Pinet C, De Troyer A. Abdominal muscle
strength in patients with tetraplegia. American J Respir Crit
Care Med 2000; 161:707 712.
7.
8.
9.
Estenne M, Van Muylem, , Gorini M, Kinnear W. Effects of

abdominal strapping on forced expiration in tetraplegic
patients. Am J Respir Crit Care Med 1998; 157: 95 98
Marc Estenne, Andre De Troyer. Evidence of dynamic
airway compression during cough in tetraplegic patients.
American Journal of Respiratory and Critical care medicine
1994;150:1081 -1085
Cees P. van der Schans, Alberta Piers, Gerdina A Mulder.
Efficacy of coughing in tetraplegic patients. Spine 2000;
25: 2200 - 2203
Andre De Troyer, Marc Estenne, Andre Heilporn.
Mechanism of active expiration in tetraplegic patients. New
Eng Journal of Medicine 1986; 314: 740 744.
Acknowledgement
We thank the Department of physiotherapy, Manipal, for
having given the opportunity to conduct the study. We thank Dr.
Kavitha Raja (MPT, Ph.D.). for her expert opinion and constant
support throughout the study.
Shweta Gore / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
121
Stabilization exercises in postnatal low back pain

Tarek A. Ammar*, Katy Mitchell**, Amir Saleh***
*Lecturer, Faculty of Physical Therapy, Cairo University, Cairo, Egypt, **Assistant Professor, School of Physical Therapy, Texas
Womans University, Houston, Texas, ***Assistant Professor, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
Abstract
Postnatal low back pain is a frequent complication of
pregnancy. The purpose of this study was to evaluate the effect
of McGill-based stabilization exercise program in reducing pain
and disability in patients with postnatal low back pain. Thirtyfour female subjects with postnatal low back pain participated in
this study. Numerical rating scale and Oswestry disability
questionnaire were used to measure pain and disability,
respectively. The first group (n=17, mean age= 29.5, SD=5.2)
received a traditional intervention only (heat therapy, stretching,
and strengthening exercises). The second group (n=17, mean
age=26.4, SD=5.3) received McGill-based stabilization
exercises. The second group showed statistically significant
differences in pain reduction (F1,31= 10.189, P<0.025) and
disability reduction (F1,31= 15.351, P<0.025). A program based
on McGill stabilization of the trunk was found to reduce pain
and disability in women with postnatal low back pain.
Key words
low back pain, stabilization exercise, postnatal, females
Introduction
Low back pain (LBP) is a common pregnancy complication
affecting nearly 80% of women.1 Postnatal LBP may be a
continuation of antenatal LBP, faulty postures or may be
precipitated by excessive straining during the expulsive phase
of delivery.2, 3 Many factors contribute to back pain during and
after pregnancy, including the effects of the hormone Relaxin
which causes relaxation of the support structure of the spine
and pelvis. This may lead to overstretching of the ligamentous
support and instability of the pelvis.2,3 Not only does the hormone
Relaxin affects the pelvic structures, but can affect other joints
in the body. LBP usually resolves in the first few weeks after
delivery, but it may continue for several months or years. Postural
imbalances (increased sway in the low back, increased forward
head and rounded shoulder) are important causative factor in
low back pain during and after pregnancy. 4 These changes
may get worsened by abdominal and back muscle weakness.
In a Swedish survey, postnatal pain persisted for an average of
18 months after delivery in a third of the women who experienced
LBP during pregnancy.5
Physical therapy methods used to treat LBP include
flexibility and strengthening exercises, postural training,
modifying activities of daily living, massage, joint mobilization,
manipulation traction, biofeedback, cryotherapy, deep and
superficial thermal modalities.6-8 Various therapeutic exercises
have been developed to reduce pain and disability, restore
function, and prevent recurrence in patients with LBP.9
Lumbar stabilization exercises have been used for patients
with LBP.10-16 Richardson and Jull designed specific stabilization
Tarek Ammar, PT, PhD
Address: 3333 Cummins street, apt. 1403, Houston, Texas
77027, Phone: 832-896-0554
E-mail: tarekpt@windowslive.com
122
exercises that focus on reeducating the motor control system to

activate the transversus abdominis and multifidus in patients
with LBP.17 In contrast, McGill designed stabilization exercises
that achieve activation of some key abdominal and back muscles
(rectus abdominis, quadratus lumborum, transversus abdominis,
multifidus, and erector spinae) with minimal spinal loading to
ensure spinal stability in patients with LBP.18 Thus, stabilization
exercises aim at recruiting and strengthening various abdominal
and back muscles safely, in a manner not to provoke the low
back pain with excessive loading.
This is the first study of stabilization exercises of McGill
that has been done in postnatal subjects with LBP. The purpose
of this study was to determine the effect of McGill stabilization
exercises on reducing pain and disability in postnatal subjects
with LBP.
Methods
Design: A randomized controlled trial was performed with
subjects randomly assigned to one of two treatment groups: (1)
a group that received a traditional program only (heat therapy,
stretching, and strengthening exercises) or (2) a group that
received stabilization exercises. The physical therapist that
performed the outcome assessments and data analysis before
and after treatment was unaware of group allocation. However,
a second physical therapist, who administered the exercise
programs, was aware of group allocation.
Subjects: Thirty-four subjects were recruited from Cairo
University Hospital in Cairo, Egypt. They were outpatients
seeking treatment for LBP. Women of any race were allowed to
participate in the study if they were at least 18 years old with a
current complaint of postnatal LBP. Exclusion criteria included
a history of previous lumbar surgery, spinal stenosis,
spondylolisthesis, neurological dysfunction, radiculopathy,
systemic disease, carcinoma, injection therapy, or a reluctance
to participate in the study.
All subjects signed a consent form permitting the use of
their data for research purposes. Confidentiality was assured
by the use of a coding system. The consent form also included
a clear explanation of the benefits and expected possible risks
of the study. The rights of human subjects were protected at all
times.
After informed consent was obtained, all subjects were
interviewed and examined by a research physical therapist who
was unaware of the intervention assignments, to ensure that
the inclusion and exclusion criteria were fulfilled. Subjects were
randomly assigned to one of the two intervention programs via
a computer generated random number list. Both groups received
three sessions per week for four weeks. Each session lasted
for 45 minutes. The treating physical therapists asked subjects
(regardless of group assignment) to fill out weekly self report
logs to monitor home adherence.
Outcome measures: The numerical rating scale was used
to measure pain intensity. The NRS is a valid and reliable scale
in which 0 equals no pain and 10 equals worst possible pain.19
An Oswestry Disability Questionnaire (ODQ), a disease-specific
patient-completed questionnaire, was utilized as a reliable and
valid method to measure functional disability. 20,21 The
questionnaire includes 10 sections and each section contains
six statements. Each section is scored on a 0-to-5 scale, with
Tarek A. Ammar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
higher values representing greater disability.20,21

Intervention: Subjects in those with LBP in the first group
received infra-red heat (15 minutes), stretching and
strengthening exercises for the trunk and lower limbs.
Trunk stretching and strengthening exercises for the control
group included the following exercises:
trunk flexion: single and double knee to chest from supine
trunk extension: raising the upper trunk off the floor while
keeping forearm in contact with the plinth.
trunk rotation: lowering knees toward each side of the body

in supine
Hip extension strengthening: bridging exercises
Trunk lateral flexion: side bending of the trunk in standing

position with and without opposite arm lifting.
Piriformis, hip abductor and extensor stretching

For a home program, subjects also performed three to five
exercises based on their needs. For instance, subjects who had
weak hip abductors and tight piriformis and hamstrings did three
to five exercises to recruit the hip abductors and stretch the
hamstrings and the piriformis at home. Subjects performed two
sets of 10 repetitions for each exercise, with a 30-second to
one-minute rest between each set rest between each set.during
eaive ng scale in Subjects were instructed to perform their
home exercises for approximately 10 minutes, twice a day.
Subjects in the second group received a McGill-based
stabilization exercise programs. The therapist helped the patient
find the comfortable neutral spinal posture or the position of
least pain prior to initiating the stabilization program and asked
the subject to maintain this position (as able) during the
performance of stabilization exercise. To determine the neutral
posture, the subject put one hand on the abdomen and the other
on the lumbar region and then tilted the pelvis, which flexed and
extended the lumbar spine, until achieving the least pain position.
The stabilization program consisted of the following:
cat-camel motion exercise: consisted of six-to-eight cycles

of spinal flexion and extension in a quadruped position.
curl-up exercises: the subject flexed one knee while keeping

the other straight. The therapist placed a rolled towel under
the lumbar region to maintain the neutral spine posture.
The subject performed the curling up by raising just the
head and shoulders a short distance off the floor.
side-support exercises: lying on the side supported on her

elbow and hip, knees bent to 90, free hand placed on the
opposite shoulder. The subject then lifted her trunk until
the body is supported on the elbow and the knee. If the
subject was not able to perform the side support exercise,
the subject would assume the side lying position and initiate
an isometric contraction of the quadratus lumborum by
trying to lift both lower limbs up towards the ceiling.
single arm and/or leg lifting in the supine lying and

quadruped positions For a home program, subjects in the
second group performed three to five stabilization exercises.
They did two sets of 10 repetitions for each exercise with a
30-second to one minute rest between each set. Duration
of each home program session lasted for 10 minutes twice
a day. The average rate for home adherence was 70% in
the first group compared with 80% in the second group.
This was based on weekly subject logs.
Subjects of both groups received a series of progressive
exercises building up to a maximum of 10 to 12 exercises by
the final visit. The subjects were asked to complete one set of
10 reps for each exercise, with a 30 second to one minute rest
before each set during each exercise session. Each session
lasted for 45 minutes.
Data analysis
Separate univariate analyses of covariance, with the pretest
scores as the covariates, were performed to determine whether
there was a difference between the two groups on the posttest
scores of pain as measured by a NRS and disability as measured

by an ODQ. A Bonferroni approach was used to maintain the
alpha level at P< 0.05. The analysis of covariance adjusts the
dependent variable to eliminate the influence of the pretest on
the post test. The analysis of covariance asks the question, if
you hold constant the pretest scores is there a significant
differences between the posttest scores for the two groups? 22
Results
Thirty nine subjects with postnatal LBP participated in this
study. However, two subjects in each group dropped out of the
study due to time constraints. One subject in the first group
dropped out of the study due to travel. Age of patients ranged
between 21 and 38 years old. Women of any race 4 to 28 weeks
postpartum with a history of LBP were eligible for the study.
Group 1 comprised 17 subjects, average age 26.4 (SD 5.3)
years, height 157.7 (SD 22.6) cm, and weight 74.4 (SD 11.1)
kg. In group 1, pretest and posttest pain scores were 7.1 (SD
1.5) and 5.1 (SD 1.4). For disability, pretest and posttest scores
were 15.4 (SD 2.8) and 10.7 (SD 2.4). In group 2, pretest and
posttest pain scores were 7.6 (SD 1.3) and 4.9 (SD 1.5). For
disability, pretest and posttest scores were 7.6 (SD 1.3) and 4.9
(SD 1.5).
For pain intensity, the analysis of covariance revealed a
significant difference between the two groups (F1,37=6.97,
P=0.01, table 1) in favor of the second group. For disability, the
analysis of covariance revealed a significant difference between
the two groups (F1,31=7.4, P=0.01, table 2), with group 2 having
a lower disability posttest mean.
Discussion
This study found that there were statistically significant
differences in reduction of pain and disability between both
groups, in favor of the second group. There have been several
studies investigating the effects of stabilization exercises of
Richardson and Jull (1995) in different patient populations with
LBP. 6-33 There have been contradictory results of these studies.
For example, Hides et al. (1996), Borx et al. (2003), and Cairns
et al. (2006) found that stabilization exercises did not reduce
pain or disability in patients with LBP.23-25 On the other hand,
OSullivan et al. (1997), Sung et al. (2003), Stuge et al. (2004),
Koumantakis et al. (2005), Rackwitz et al. (2007), Hides et al.
(2008), Kofotolis et al (2008), Kumar et al. (2009), and Franca
et al. (2010) reported that stabilization exercises reduced pain
or disability in patients with LBP.26-34
There has been no research about the effect of
McGill=based stabilization exercises for postnatal women with
LBP. However, Stuge et al. (2004) studied the effect of
stabilization exercises of Richardson and Jull for postnatal
women with LBP.27 In their trial, 81 women with pelvic girdle
pain were randomized to 20 weeks of treatment with physical
therapy focused on stabilization exercises, or to an individualized
physical therapy program without stabilization exercises. The
group that received stabilization exercises had decreased pain
intensity and disability and improved quality of life compared
with the control group post- treatment and at one year
postpartum. The authors reported that functional disability was
reduced by more than 50% in the group that received stabilization
exercises.
The major limitation of the present study is the lack of
measuring long-term outcomes that are needed to further
substantiate the present study findings. It is not known if the
frequency of the studied interventions (three times per week for
four weeks) is appropriate to produce demonstrable results. This
study did not assess muscle recruitment during the performance
of either exercise program. Therefore, it is difficult to know if the
two exercise regimens were different enough. Patients in the
regular exercise group may have recruited the trunk muscles to
Tarek A. Ammar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
123
hold the neutral spinal position during performance of the

traditional exercises. Therefore, patients in both groups may
have been engaging the same muscles, making the two exercise
groups similar. There was also lack of observation of the home
exercise program.
There is a need to measure long-term outcomes to further
validate the results of the present study. Also, electromyography
should be used to assess muscle recruitment during exercise
performance. The present study findings suggest that
stabilization exercises as compared to a more general program
of heat and stretching/strengthening may reduce pain and
disability in postnatal patients with LBP.
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Kofotolis ND, Vlachopoulos SP, Kellis E. Sequentially
allocated clinical trial of rhythmic stabilization exercises and
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Carneiro KA, Rittenberg JD. The role of exercise and
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Tarek A. Ammar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Efficacy of neural mobilization in sciatica

Sharma Vijay1, Sarkari E2, Multani N.K3
1
Consultant Physiotherapist, Sharma Physiotherapy,Centre, Ambala Cantonment, 2Ex-Lecturer, M.M.I.P.R, Mullana (Ambala), 3Prof.
and Head Department of Physiotherapy and Sports Science, PU, Patiala
Abstract
The study was conducted on 30 patients, between age
group of 40-65 years who were diagnosed cases of radiating
low back pain. Subjects were randomly allocated to either group
A or B. The patients of group A ( n = 15 ) were treated with
neural mobilization along with conventional treatment, whereas
group B ( n = 15) was administered only conventional treatment.
ROM and pain were assessed using goniometer and Visual
Analog Scale(VAS). Neural mobilization along with conventional
treatment was found out to be more effective in relieving low
back pain (t = 7.643) as well as improving the range of SLR (t =
5.848) than conventional treatment alone.
Key words
Neural Mobilization, Low Back Pain, ROM, VAS
Introduction
Sciatica is a symptom not a diagnosis. It is a non-specific
term commonly used to describe symptoms of pain radiating
downward from the buttock over the posterior or lateral side of
the lower limb. It is usually assumed to be caused by
compression of nerve. Due to the dynamics of human spine,
lumbar disc syndrome and accompanying complaints of sciatica
are long standing afflictions of our species (Karampelus et al,
2004). It was not until 1943, with land mark publication of Mixter
and Barr that the herniated lumbar disc was shown to be a major
cause of sciatica(Karampelus et al, 2004). At some time, up to
40 percent of people experience sciatic pain, which occurs when
sciatic nerve is trapped or inflamed (Harvey Simon, 2003).
Prevalence of sciatic symptoms did not differ between males
and females( Kelsey and Ostfeld, 1975). It was 5.1% for men
and 3.7% for women aged 30 years or over(Heliovaara et al,
1987 and AHCPR, 1994). It is occupation related also (Magora,
1973,Videman Battie, 1999). Traditional exercise therapy
program for sciatica primarily focuses on pain relief. Butler(1991)
recommends that neural neural mobilization be viewed as
another form of manual therapy similar to joint mobilization. In
order to pay heed to it manual methods should be used in order
to restore the mechanical function of impaired neural tissue (intraand extra neural impairment) in the lumbar-pelvic-lower limb
complex. The focus of this study is to see the effectiveness of
neural mobilization on individuals with sciatica and to judge its
superiority over the conventional treatment.

Once the subjects registered themselves in the Out Patient
Department with the complaint of radiating low back pain, they
were assessed according to format. Andersson GB & Deyo RA
(1996). Differential diagnosis with other back conditions
mimicking sciatica was established. If the subjects were found
to have sciatica, all inclusion and exclusion criteria were checked.
The subjects were included in the study if all the inclusion criteria
were met and no exclusion criteria were found. 30 subjects were
selected between the age group 40 to 65 years of which 14
were males and 16 were female, of these 20 had symptoms on
right side and 10 had on left side. The subjects were told all
about intervention and procedural details to follow in study and

thereafter consent was obtained.
Range of motion was measured using goniometer. A Visual
Analog Scale was used for assessing the pain. Patients were
conveniently allocated either to group A or to group B
Group A (n=15) Experimental Group
Sciatic Nerve Mobilization
Traction
TENS
MHP
Group B (n=15) Control Group
Traction
TENS
MHP
Before starting the intervention all the patients were checked
for range of motion of SLR at the hip and pain with the help of
standard goniometer and visual analogue scale respectively.
The control group (Group B) participated in a standard
rehabilitation program or conventional physical therapy treatment
(Vroomen PC et al, 2000) for the disease which included MHP
for 10 min, Traction for 10 min(intermittent) with 1/3 of body
weight with the patient in supine and hip and knee flexed to
900.This was followed by High TENS for 10 min. The
experimental group (Group A) participated in a standard
rehabilitation program supplemented with neural mobilization
program for sciatic nerve.
Neural mobilization was given for approximately 10 minutes
per session including 30 sec hold and 1 min rest. The straight
leg raise is done for inducing longitudinal tension as the sciatic
nerve runs posterior to hip and knee joints, first described by
Leseague in 1864.The leg is lifted upward, as a solid lever, while
maintaining extension at the knee. To induce dural motion
through the sciatic nerve, the leg must be raised past 35 degrees
in order to take up slack in the nerve. Since the sciatic nerve is
completely stretched at 70 degrees, pain beyond that point is
usually of hip, sacroiliac, or lumbar spine origin David J Magee
(1997). The unilateral straight leg raise causes traction on the
sciatic nerve, lumbosacral nerve roots, and dura mater. Adverse
neural tension produces symptoms from the low back area
extending into the sciatic nerve distribution of the affected lower
limb.
To introduce additional traction (i.e., sensitization) into the
proximal aspect of the sciatic nerve, hip adduction is added to
the straight leg raise. The average total treatment time was
approximately 30-40minutes per session and the whole
treatment was given for 9 sessions. Pain free ROM at hip and
VAS was recorded at the end of every 3rd 6th and 9th sessions.
The patients were instructed not to do any type of exercise at
home or take any medications.
Data was analyzed using the SPSS version 14 for Microsoft
Windows. Independent T-Test was performed to compare the
ROM and pain on VAS scale between groups A&B at 0, 3, 6, 9
sessions. Paired t test was also performed to compare
improvement on 0-3, 3-6, 6-9 and 0-9 sessions within the two
groups. The significance (Probability-P) was selected as 0.05.
Results
Fifteen subjects were taken in each group A and B with the
mean age of 56.1 4.95, and 58.3 4.37 respectively (Table 1).
Sharma Vijay / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
125
Table 1: Subject information

Serial No.
Group
N
1
2
A
B
15
15
Age,yrs(MEAN
+ S.D.)
56.1 + 4.95
58.3 + 4.37
At zero session the mean of ROM of group A was 39.67

and that of group B was 42.33.When comparison of mean ROM
was done between Group A and Group B at zero session the t
value was found to be0 .794 which was insignificant. Thus there
was no disparity in ROM at the starting of the treatment session
between the two groups. ( Table 2).
At the end of 3rd session mean of ROM of group A was
53.00 and that of group B was50.00, the difference in mean
was insignificant. At the end of 6th session mean of ROM of
group A was 71.00 and that of group B was59.33 the t value
was 3.38 and was significant. At the end of 9th session mean of
ROM of group A was 86.33 and that of group B was 67.33 the t
value was 5.85 and was significant ( Table 2).
Similarly the reduction in pain was noted through VAS score
and was evaluated using independent t test. At zero session
the mean of VAS of group A was 7.4 and that of group B was
7.13 and the t value was found to be 0 .587which was
insignificant(Table 3).
P<0.05 = Significant
At the end of 3rd session the mean SD of VAS of group A
was 5.271.22 and that of group B was 6.21.42 and the t value
was found to be 1.926which was insignificant. At the end of 6th
session the mean SD of VAS of group A was 3.470.99 and
that of group B was 5.531.13 and the t value was found to be
5.34 which was significant. At the end of 6th session the mean
SD of VAS of group A was 1.670.98 and that of group B was
4.601.121 and the t value was found to be 7.64 which was
significant. Thus ROM and VAS showed significant results only
by the end of 6th and 9th sessions, whereas the results at the
end of 3rd session were insignificant (Table 3).
Paired T test is done to compare the improvement between
0-3, 3-6, 6-9 and 0-9 session. The mean difference of ROM of
group A between 0 to 3rd session was 13.334.87 whereas that
of group B was 7.674.17 and their t values were 4.82 and 4.32
respectively. Thus group A showing more significant
improvement than group B from 0 to 3 rd session. Similarly
between 3 and 6th session the mean difference of group A was

18.002.50 whereas that of group B was 9.334.58 and the t
values were 5.28 and 4.47 respectively. Between 6th to 9th
sessions the mean difference of group A was 15.334.42 and
that of group B was 8.04.14 .The t values were 5.01 and 4.39
respectively. Between 0 and 9th session the mean difference of
group A was 46.674.49 and of group B was 25.008.45.The t
values were 5.33 and 4.89 respectively ( Table 4).
Comparison of improvement in VAS score was calculated
similarly using the paired t test. The mean difference of VAS for
group A between 0 to 3rd session was 2.130.35 and that of
group B was 0.930.70, their t values were 5.25 and 3.75
respectively. Thus group A showing more significant
improvement than group B. Similarly between 3 and 6th sessions
the mean difference of group A was 1.80.56 whereas that of
group B was 0.670.82 and the t values were 4.96 and 0.76
respectively. Between 6th and 9th sessions the mean difference
of group A was 1.80.41 whereas that of group B was 0.671.23
and the t values were 5.14 and 1.98 respectively. Between 0
and 9th session the mean difference of group A was 5.7330.88
and of group B was 2.271.58.The t values were 5.27 and 3.9
respectively (Table 5).
Discussion
The result of this study shows that neural mobilization
technique is effective in increasing range of motion at hip and
decreasing paint thus reducing the symptoms of sciatica. The
mean value of group A where neural mobilization was given
shows more significant increase as compared to group B. When
the comparison of means of ROM and VAS was done between
group A and B by the end of 3rd session there was no significant
increase in the ROM (t= 0.863) and decrease in the VAS (t=
1.926) scores. Thus we can conclude that the effectiveness of
our neural mobilization was only by the end of 6th session for
ROM (t=3.379), as well as pain (t= 5.339). By the end of 9th
session again there was a significant increase in ROM (t= 5.84)
and decrease in VAS score (t= 7.634). Thus neural mobilization
technique given to group A proved more effective than the
conventional treatment for sciatica administered to group B.
Effectivity of neural mobilization is thought to be due to
neural flossing, effect, that is ,its ability to restore normal mobility
and length relationship, and consequently, blood flow and axonal
Table 2: Comparison of mean of rom between group a and group b

S.No.
Group
N
S0
1
A
15
39.677.90
2
B
15
42.3310.33
3
t value
.79
ROM MEAN SD
S3
S6
53.006.49
71.007.37
50.0011.80
59.3311.16
.863
3.38
Table No 3: Comparison of mean of vas score between group a and group b

S.NO
Group
N
VAS MEAN SD
S0
S3
S6
S9
1
A
15
7.401.24
5.271.22
3.470.99
2
B
15
7.131.25
6.201.42
5.531.13
3
t value
.59
1.926
5.34
Table No 4: Comparision of mean difference of rom within group
a and b
S.NO Session Group
MEAN SD
t VALUE
1
0-3
A
13.334.87
4.82
B
7.674.17
4.32
2
3-6
A
18.002.50
5.28
B
9.334.58
4.47
3
6-9
A
15.334.42
5.01
B
8.04.14
4.39
4
0-9
A
46.674.49
5.33
B
25.008.45
4.89
126
S9
86.336.67
67.3310.67
5.85
1.670.98
4.601.12
7.64
Table No 5: Comparision of mean difference of vas within group

a and b
S.NO Session
Group
MEAN SD
t VALUE
1
0-3
A
2.130.35
5.25
B
0.930.70
3.75
2
3-6
A
1.800.56
4.96
B
0.670.82
0.76
3
6-9
A
1.800.41
5.14
B
0.671.23
1.98
4
0-9
A
5.730.88
5.27
B
2.271.58
3.9
Sharma Vijay / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
transport dynamics in compromised neural tissue. Neural

mobilization is very effective in breaking up the adhesions and
bringing about mobility. The results of this study also depict the
same. The conventional treatment effectively reduces pain and
increases ROM at the joint but is unable to eliminate the root
cause of the problem. According to Carey TS et al(1995) , it
helps in providing symptomatic relief only.
5.
6.
7.
Limitations
Lesser number of subjects

No group had similar patients with same degree of
involvement
Age variation from 40-50 years
Patients built was variable
Proper strengthening program was not followed after neural
mobilization sessions due to lack of time
8.
9.
10.
Clinical implication
11.
This study provides some evidence for use of Neural

Mobilisation as an adjunct to conventional exercise therapy
regime in Sciatica. This study suggests that Neural Mobilisation
is effective in the treatment of Sciatica.
This study provides preliminary evidence that neural
mobilisation is effective in the treatment of Sciatica.
12.
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Sharma Vijay / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
127
Prevalence of various health problems in traditional goldsmith

Anup Pednekar*, Anu Arora**, Sujata Yardi***
*Intern, **Asst. Lecturer, ***Prof. & H.O.D. Pad. Dr. D. Y. Patil College of Physiotherapy, Sector-7, Nerul, Navi Mumbai
Abstract
Keywords
goldsmiths, occupational hazards, health problems
Background
Goldsmiths are commonly renowned for possessing the
intricate art, skill & capability to mould the precious metal into
an aesthetic masterpiece.
However, these traditional goldsmiths are exposed to
various occupational health hazards ranging from
musculoskeletal to respiratory to ocular and skin problems.
Additionally very less is known & done about these issues. It
has also been seen that these goldsmiths are not adequately
aware of the safety measures which could be undertaken to
prevent these adverse occurrences.
Introduction
DESIGN: Cross Sectional Survey Study

STUDY POPULATION: 58
INCLUSION CRITERIA: Traditional Goldsmiths working since
at least 3yrs & for more than 5 days a week.
EXCLUSION CRITERIA: Working less than 3yrs and pain due
to trauma out of workplace.
STUDY FACTORS: A questionnaire was made based on the
review of literature & a pilot study that was conducted. The
questionnaire was then administered to goldsmiths belonging
to different regions of Maharashtra. Data was collected by direct
method and represented through bar and pie diagram.
Goldsmiths are commonly renowned for possessing the

intricate art, skill & capability to mould the precious metal into
an aesthetic masterpiece.
Making jewelry from gold is essentially an art. An art, that
basically intends to satisfy the human aesthetic sense. These
men work hard to cater this sense, by putting their heart in the
creations.
But as said by a British Play writer in the 15th century, A
mask of Gold hides all deformities
Goldsmiths are exposed to various occupational health
hazards. They generally have to assume a posture for prolonged
periods along with repeated activity of upper limb with intricate
precision. This makes them prone to various musculoskeletal
problems.
The workers are also exposed to toxic chemicals & acids
like sulfuric, nitric acid NO & NO2, which might be detrimental
to their health.
The working area is often not well ventilated. Commonly,
the workers suffer from minor accidents like burns, cuts &
penetrating injuries at workplace. Negligence, improper handling
and storage of chemicals and gasoline sometimes may lead to
fire which is difficult to contain, due to the nature of combustible
materials in workplace which again poses a major health hazard.
It has been seen that these professionals are not adequately
aware of safety measures against the issues mentioned above.
Recognizing these factors prompted me to take up this study
to find out the prevalence of common health problems in
traditional goldsmiths.
A questionnaire was made based on a pilot study
encompassing domains like
Results
Musculoskeletal, respiratory, eye and skin
Our study shows that; The most common problems reported

by the goldsmiths were musculoskeletal problems 91.37%.
Respiratory complaints were reported by 43.1%. Eye irritation
was reported by 77.58% subjects. Skin irritation was reported
by 13.79% subjects. Headache during work was reported
72.41% subjects.
The commonest position assumed was Cross-leg sitting
with back unsupported (82.75%). None used a Nose mask.
Majority of goldsmiths used a LPG burner which prevents
exposure to smoke during work than a traditional kerosene
burner.
Other questions involved aspects like headache, posture

assumed, workplace environment, working hrs, type of lamp
used etc. The questionnaire was formulated to find out commonly
encountered health problems in goldsmiths & about the working
conditions.
Objectives
1.
2.
3.
To find prevalence of common health problems in traditional

goldsmiths.
To study their workplace environment.
To make appropriate recommendations.
Method
Objectives
1.
2.
Conclusions
To find out prevalence of common musculoskeletal,

respiratory, eye, skin & headache problems in traditional
goldsmiths.
To study their workplace environment.
Material and methodology
Musculoskeletal pain, commonest being back, neck and

knee were reported among goldsmiths.. Eye and respiratory
problems were also reported probably owing to exposure to
harmful gases like NOx (NO+NO2) produced while gold
purification and also lack of protective gears like nose masks.
Skin irritation in the form of allergies, itching and rashe were
also reported probably due to exposure to acids and alkalis.
1.
2.
3.
4.
Research Approach: Retrospective

Study Tool: Questionnaire
Study Design: Cross Sectional
Inclusion Criteria: Traditional Goldsmiths working for at
least 3yrs & more than 5 days a week.
Anup Pednekar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
5.
6.
7.
8.
9.
Exclusion Criteria: Working less than 3yrs and pain due

to trauma out of workplace.
Study Setting: Rural Set up
Sample Size: 58 subjects
Duration of Study: December 2008 to March 2009
Methodology: A questionnaire was made based on the
review of literature & a pilot study that was conducted. The
questionnaire was then administered to goldsmiths
belonging to different regions of Maharashtra.
GRAPH 5: Respiratory problems
Data presentation
GRAPH 1: Common Health Problems faced by traditional
goldsmiths:
GRAPH 6: Eye problems
GRAPH 2: Musculoskeletal pain
GRAPH 7: Skin problems

GRAPH 3: Musculoskeletal injury
GRAPH 4: Joint pains
GRAPH 8: Headache
Anup Pednekar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
GRAPH 9: Burns
GRAPH 10: breaks taken during work
GRAPH 11: Posture during work
Discussion
Musculoskeletal problems
The most affected domain the traditional goldsmiths, was
musculoskeletal.
This could be attributed to the nature of physical work which
requires sustained posture with repetitive activity of upper
extremity like hammering, polishing, carving etc making them
prone to musculoskeletal pain and minor soft tissue injuries.
Low back pain can be associated with prolonged sitting as
required in this profession. The avg. time for which the subjects
worked at one stretch was 3.7 Hrs, while total working hrs on an
Avg. was 7.72 Hrs.
Sitting by itself does not increase the risk of LBP (Low Back
Pain). However, sitting for more than half a workday, in
combination with WBV and/or awkward postures, does increase
the likelihood of having LBP and/or sciatica, and it is the
combination of those risk factors, which leads to the greatest
increase in LBP .[4]
Awkward posture was also independently associated with
the presence of LBP and/or sciatica. [4]
130
It has been postulated that sustained awkward seating

posture (cordoned or kyphosed, overly arched, or slouched) can
result in higher intra-discal pressure and may be injurious to
spinal postural health. Therefore, awkward postures while sitting
have been described as possible risk factors for the presence
of LBP [4]
The commonest position assumed during work was Cross
Leg Sitting.
In cross leg sitting position which is unsupported sitting
places more load on the lumbar spine than standing because it
creates a backward tilt, a flattening of the low back, and a
corresponding forward shift in the Centre Of Gravity.
This places loads on the discs and the posterior structures
of the vertebral segment. Sitting long in the flexed position may
increase the resting length of the erector spinae muscles and
overstretch the posterior ligamentous structures. [7]
Neck pain can be associated with the neck posture
assumed during work.
Forward head posture during work, which involves an
excessive anterior position of the head in relation to the
theoretical plumb line perpendicular to the bodys center of
gravity, and can be considered similar to a protracted position
of the cervical spine in which the lower cervical vertebrae are
flexed in a forward glide and the upper cervical vertebrae are
extended.
This causes a shortening of the posterior cervical and suboccipital muscles, lengthening and weakness of the anterior neck
muscles, weakness of the scapula retractor muscles and
increased stress on the ligaments. The imbalances created by
this position decrease muscular efficiency, and extra muscular
action is needed to hold the head and neck in a stable position.
[3]
The association between forward head posture and neck
pain has not been clearly defined, but a mechanism for the
development of neck pain from habitual postures has been
demonstrated. Studies of the effect of sustained forces have
indicated that a single posture should not be sustained for longer
than 1 hr. McGill and Brown have shown that 20 min in a position
of sustained loading can induce creep in soft tissues, with
recovery taking longer than 40 min. [3]
Sustained forces produce time-dependent deformation and
adaptations in soft tissue. Short-duration stretching produces
temporary deformation of soft tissues, but 1 h of stretching might
be sufficient for long-term soft-tissue adaptations. Therefore, a
long-term habitual posture can result in abnormal loading of
ligaments and muscles that might ultimately contribute to a
reduction in the cervical ROM and to the development of neck
pain. [3]
Knee and hip pains were also the next most commonly
reported complaints.
The probable reason would be age related degeneration
in these joints which may be aggravated by positions of extreme
knee flexion that are assumed in cross leg sitting where
maximum joint compression occurs in knee joint. Also 22/25
who complained of knee pain had assumed cross leg sitting
position.
The subjects who complained of upper extremity pain
appeared to be at risk for musculoskeletal pain probably because
of following reason: [2]
Speed and intensity of muscle effort
Persistent Strain
Overuse
Change in equipment
Poor Ergonomic Design of Furniture & Equipments
Insufficient Rest Breaks.
Respiratory problems
Respiratory problems were also frequently reported by the
traditional goldsmiths.
Among the subjects 8 reported poor ventilation at workplace

(22.41%)
None used a nose mask during work.
9 out of 58 used Kerosene burners while others used LPG

burner.
This underlines the fact that poor ventilation alone cannot
be a factor for respiratory ailments. The probable reason for the
respiratory complaints lies in the processes used to purify gold.
The process can be briefly explained as follows:
At the first stage pure gold was obtained by melting impure
gold and mixing it with twice the amount of silver. Later, nitric
acid was added and the mixture was heated up again. Gradually,
pure gold settles down in the pan while other impurities get
dissolved. The procedure is repeated twice or thrice to obtain
gold. Later, copper is added to recover silver and iron to take
out copper.
The recovered pure gold is later mixed with silver, cadmium
or copper, this time according to goldsmiths own requirements.
Gold, silver and copper, all have high melting points: 1,063
Celsius, 961 Celsius and 1,083 Celsius, respectively.
The melting and mixing process with the help of nitric acid
is carried out on coal fuel many times while sulphuric acid is
needed at the polishing stage.
The manufacturing item gets black after going through
different stages. It regains brightness when dipped in sulphuric
acid and heated up. The acid is used again at the final stage to
enhance the shine.
NOx (a mixture of NO2 and NO gas) is a red brown toxic
gas. When inhaled through the respiratory tract and absorbed
through the skin, it causes various skin diseases and respiratory
problems.
Based on in vitro studies, Beckett et al. postulated that the
environmental concentration of HNO2 is formed within the
respiratory system predominantly by hydrogen abstraction, with
subsequent conversion of HNO2 at physiologic pH, to H+ and
NO2.
Victorin proposed that HNO2 formed in this way may
contribute to the bronchoconstricting effects of NO2 seen in
normal subjects and asthmatics. [6]
Victorin also observed eye irritation just before, during, and
immediately after exposure of asthmatic patients to NOx .
Moreover NO2 levels as low as 0.5 ppm increase susceptibility
to bacterial infection of lungs. [6]
Studies of nitrogen dioxide (NO2) inhalation, in both animals
and humans, have demonstrated that this agent can cause
epithelial cell damage and inflammation of the airway epithelium
[5]
Occupational Asthma is defined as a condition which occurs
after a variable period of symptomless exposure to sensitizing
agent at work. Other definitions have included agents that
produce bronchoconstriction by mechanism other than immune
sensitization. It has become increasingly clear that non-immune
mechanisms are important particularly for highly reactive
chemicals of low molecular wt. [1]
This may probably help us to explain the symptoms like
shortness of breath, frequent cough & rhinitis.
These problems may be further aggravated by factors like
poor ventilation at the workplace & reluctance to use the nose
mask while working which was evident from the questionnaire
where none of the subjects used a nose mask during work.
Eye and skin problems

Eye problems were in the form of eye irritation, reddening
& watering. However, only 1 out 58 reported poor lighting
conditions at workplace.
Thus the probable causes for eye problems could be;
Exposure to chemicals, gases & fumes at workplace as

mentioned above.
Poor ventilation may aggravate the above problem.
Prolonged working hours & nature of intricate work putting

strain on eyes.
Age related changes in eyes.

Skin problems were in the form of rashes or irritation while
handling chemicals at workplace.
The skin problems can be attributed to:
Chemicals used at workplace.
Improper handling of chemicals
Headache
Headache was also commonly reported by by the traditional
goldsmiths during or after work.
The probable causes for headache can be
Pain referred from Neck
Congested workplace with poor ventilation
Hot environment
Exposure to various chemicals listed before.
Environmental and job related stress.
Burns
These injuries occur during usage of burners either LPG
or Kerosene while melting gold for purification purposes and
other procedures.
Awareness of health problems

The subjects that took breaks voluntarily were 35 while
those took because of pain or discomforts were 23.
This indicates that around 60 % of the subjects were
probably aware of the harmful effects of prolonged posture which
commonly present as musculoskeletal pain.
However none of the subjects used a Nose-Mask while
working to avoid respiratory problems reporting as its usage
being a discomfort while work.
Conclusions
Based on the findings of the study the occurrence of various
health problems were probably due to the lack of appropriate
knowledge about the hazards and also precautions for the same.
These problems are moreover largely preventable. Thus based
on this information certain recommendations can be made.
Recommendations:
The nature of health problems faced by these traditional
goldsmiths is avertable to a large extent by proper
ergonomic advice and some precautionary measures
undertaken during work.
Proper Ergonomic Advice can help reduce the
incidence of Back pain.
While sitting
Use a chair preferably while working.

Adjust the height of furniture according the persons height
so that he does not need to bend forward while working.
Arm Rest should be provided
If the chair does not provide proper back support, tuck a
small pillow or rolled up towel between the chair and your
lower back to maintain the lower back curve.
Activity recommended
An individual should briefly stretch, stand up, move around

or do a different task.
Anup Pednekar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
131
Exercise Breaks: Perform Stretching and Gentle exercises

to help relieve muscle fatigue every 1-2 hours.
For pain in upper limb
During Work
Take frequent breaks during work.
Stop the work if you experience any pain to avoid further
injury.
void positions of extreme joint bending(flexion or extension)
Use adaptive devices that reduce pressure on the skin
during work.
Skin problems
1.
2.
Avoid direct contact of chemicals with skin.

Maintain good personal & environmental hygiene.
Repeated cleaning & frequent washing should be practiced.
Personal protective clothing should be used whenever Use
of barrier creams like;
Simple vanishing cream type containing zinc oxide which
fills the skin pores & prevents entry of irritants.
Water repellent creams which form an insoluble film that
gives protection against substances like acids, alkalis,
kerosene etc.
Posture correction exercises
References
Simple posture correction exercises can be done which

include chin tucks and shoulder retraction.
Bibliography
1.
Respiratory problems
Use of personal protective gears like properly fitting Nose

Mask.
Ensuring proper ventilation at the workplace.
Prompt treatment of various respiratory symptoms.
Periodic medical examination to detect cases early.
Eye problems
2.
3.
4.
5.
Adequate lighting at workplace.

Use of special eye & face protective gears.
Good general ventilation to avert contact with dust & fumes.
Proper First Aid Training should be provided to deal with
medical emergencies like chemical & acid splashes.
Eye cup goggles with plastic or glass lenses or plastic eye
shields are used for protection against chemicals.
6.
7.
8.
132
A Practical Approach to Occupational and Environmental

Medicine-2nd Edition, Robert J. McCunney
Ergonomics-The Physiotherapist in Workplace by Margaret
Bullock
The relation between active cervical ROM and changes in
head and neck posture after continuous VDT work-Industrial
Health 2009,47,188-183, Won-Gyu Yoo & Duk-Hyun AN
Association between Sitting and Prolonged LBP- Eur Spine
J. 2007 February; 16(2): 283298.
Effect of nitrogen dioxide on synthesis of inflammatory
cytokines expressed by human bronchial epithelial cells in
vitro- American Journal Of Respiratory Cell & Molecular
Biology: Vol/Issue: 9:3
Effects of NOx on Somatic Chromosomes of GoldsmithsEnvironmental Health Perspectives Volume 106, Number
10, October 1998, - Joginder S. Yadav and Neena Seth
Biomechanical Basis of Human Movement, 2nd EditionJoseph Hamill & Kathleen M. Knutzen
Occupational Health Hazards and Remedies- First edition
2002-R Mohapatra
Effect of 12-weeks posterior tibial nerve stimulation in treatment

of overactive bladder
Anwar Abdelgayed Ebid
Lecturer Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Egypt.
Abstract
The aim of this study is to investigate the effect of posterior
tibial nerve electrical stimulation (PTN) on urodynamic
parameters and in treatment of overactive bladder. Sixty patients
their ages ranged from 20-70 years were participated in this
study. They were randomly allocated into two groups. Group
(A) received 12 weeks posterior tibial nerve electrical stimulation
and group (B) received pelvic floor exercises for 12 weeks. The
result revealed that, Bladder stability in group (A) showed a highly
statistical significant improvement while for group (B) is not
significant , by comparing both groups post-treatment, there was
a statistical significant difference between groups with high
percentage of improvement of the bladder stability in group (A)
more than group (B). Maximum flow rate was significantly
improved post-treatment for group (A) as well as for group (B)
and by comparing both groups post treatment there was a
statistical significant improvement in (A) group more than in
group (B) . The results demonstrated that, there is objective
effect of PTNS on urodynamic parameters; also PTNS is effective
to suppress detrusor overactivity.
incontinence, neuromodulation may therefore be the treatment

of choice as an alternative to drug therapy it can offer
improvement in patient quality of life (4).
Electrical stimulation therapy can be considered a passive
physiotherapy; there is a twofold action of electrical stimulation
when applied to the pelvic floor: contraction of pelvic floor
muscles and relaxation with inhibition of bladder overactivity (5).
Transcutaneous stimulation progressed to percutaneous
stimulation and is known as posterior tibial nerve stimulation
(PTNS) was initially known as Stoller afferent nerve
stimulation.Posterior tibial nerve stimulation look to be an easy
and less expensive way to reach satisfactory results (3).
Urodynamic detrusor overactivity (UDO) is currently defined
by the International Continence Society (ICS) as a condition in
which the bladder is shown to contract either spontaneously or
with provocation to contraction during filling while the subject is
attempting to inhibit micturition, Urodynamic investigations are
a functional assessment of the lower urinary tract, the purpose
being to try to reproduce the symptoms and obtain an objective
explanation for the dysfunction.

Key words
Posterior Tibial Nerve, Electrical stimulation, Overactive
Bladder, Urgency.
Introduction
Urinary incontinence and overactive bladder are common
conditions in adult population, with impact on physical,
psychological and social well-being, and represent an important
burden to the economy of health services (1).
Overactive bladder symptoms include (urgency, frequency,
nocturia and urge incontinence) are frequent complaints of
patients attending urology and gynecology clinics. In many
patients, the cause is idiopathic with no obvious underlying
neurological abnormality. Patients with overactive bladder also
suffer from sleep disturbance, psychological distress from
embarrassment due to incontinence and disruption to social and
work life. Quality of life scores (QOL) are consistently reduced
in this group of patients (2).
PTNS is a minimally invasive neuromodulation system
designed to deliver retrograde electrical stimulation to the sacral
nerve plexus through percutaneous electrical stimulation of the
posterior tibial nerve. The posterior tibial nerve contains mixed
sensory and motor nerve fibers that originate from L4 through
S3, which modulate the innervation to the bladder, urinary
sphincter, and pelvic floor. The specific mechanism of action of
neuromodulation is unclear,theories include improved blood flow
and change in neurochemical balance along the neurons.
neuromodulation may have a direct effect on the detrusor or a
central effect on the micturition centers of the brain (3) .
Neuromodulation had been reported to be effective for the
treatment of stress and urgency urinary incontinence. The cure
and improvement rates of pelvic floor neuroodulation in urinary
incontinence are 3050% and 6090% respectively, pelvic floor
exercise with adjunctive neuromodulation is the mainstay of
conservative management for the treatment of stress
incontinence. For urgency and mixed stress plus urgency
Sixty patients with overactive bladder (urge incontinence)

participated in this study, they were randomly selected from the
department of urodynamics of The National Institute of Urology
and Nephrology between years 2008-2010. Their ages were
ranged from 20 to 70 years old (mean age 52.96 15.18), from
both sexes. Weight ranged between 60-93 kg with a mean of
74.4 9.41 kg in group (A), while it ranged between 60-90 kg
with a mean of 76.36 7.7 kg in group (B).Height ranged
between 156-179 cm with a mean of 166.68 5.9 cm in group
(A), while it ranged between 155-176 cm with a mean of 166.2
6.15 cm in group (B).Comparing age, weight, and height
revealed no statistically significant differences (P>0.05) between
the two groups.
Patient Criteria: Inclusion Criteria: Patient age was > 19
years old; patient had e 6 month history of documented
overactive bladder, patient had failed other conventional therapy,
patient free from mechanical urethral obstruction, patient
demonstrate an understanding of neuromodulation therapy, its
benefits, and its potential risks, patient had an intact peripheral
neurosensory system, If the patient is/was on pharmacologic
treatment for urgency/frequency syndrome, a 10-day washout
period prior to treatment must be completed.
Exclusion Criteria: Pregnant patient or intends to become
pregnant during the course of the study. (Patients becoming
pregnant during the course of the study will immediately be
terminated from the study.), patient had an active urinary tract
infection, patient had a bladder stone, patient had ankle injury
or surgery which results inability to stimulate the tibial nerve or
discomfort in using the foot cradle, patient has a hyperreflexic
neurogenic bladder or urodynamically proven instability
secondary to a known neurourologic cause (i.e. stroke,
Parkinsons, Multiple Sclerosis), patient had uncontrolled
diabetes, patient had diagnosed peripheral neuropathy such as
diabetes with peripheral nerve involvement,
Complete physical examination and a complete history was
taken for all patients, including previous urological symptoms
Anwar Abdelgayed Ebid / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
133
as frequency, urgency, nocturnal, or incontinence. The physical

examination included was neurological assessment of perianal
sensation, anal sphincter tone, and a brief screening for any
neurological factors as, Parkinsons disease, multiples sclerosis,
stroke or previous operations (mainly pelvic surgeries). Detailed
analysis of the present overactive bladder symptoms had been
carried. Medical history including drugs in actual use especially
diuretics, and anti-diabetic drugs had been considered. Urologic
examination carried by the staff of urology department of the
National Institute of Urology and Nephrology, to exclude any
genitourinary infection that might cause urinary incontinence.
Laboratory investigations, mainly fasting and postprandial blood
glucose, complete urine analysis had been carried out to exclude
diabetes mellitus, urinary tract infection as well as renal infection.
Urodynamic studies had been carried by the staff of urodynamic
unit, to confirm the diagnosis of overactive bladder and urgency.
The patients were randomly divided into two equal groups.
Group (A) include thirty patients suffer from overactive bladder
(urge incontinence) ,they received posterior tibial nerve electrical
stimulation of faradic type, biphasic continuous rectangular, with
frequency of 0-10 Hz, pulse width 200 HZ, 15 minutes daily,
three days/week, with maximum tolerable intensity, for 12 weeks,
plus the routine pelvic floor exercise. Group (B) include thirty
patients who received the routine physical therapy program of
pelvic floor muscle through pelvic floor exercises 15 min three
times a week for 12 weeks.
Electrical stimulation delivered to the posterior tibial nerve
via a combination of electrode and generator components,
including a small 34-gauge needle electrode, surface electrode,
lead wires and hand held electrical generator. The low-voltage
stimulator had adjustable pulse intensity according to patient
tolerance, a fixed pulse width of 200 microseconds and a
frequency of 10Hz. The device produces an adjustable electrical
impulse that travels to the sacral nerve plexus via the tibial nerve.
Urodynamic investigation system had been used to perform
the urodynamic investigations as voiding cystometry .It is
comprised of a trolley-mounted unit with integral printer and
monitor, a mobile patient unit with built in H2O and CO2 pumps,
a stand-mounted uroflow transducer and a stand-mounted puller
mechanism. Measurement was done by the staff of the
urodynamic. All patients had been subjected to multichannel
cystometry before starting the study and at the end of the study
(after 12 weeks).
The Measurement was done by Urodynamic Evaluation
System This procedure was performed by using the DANTIC
UD5000/500 urodynamic investigation system. The urodynamic
studies are valid and reliable, by testing the multichannel
cystometry.
The variables measured. (1st) First desire to voide which
reveals bladder sensation, (2nd) Bladder stability (number of
uninhibited detrusor contractility), and (3rd) Maximum flow rate.
Comparative Analysis of Testing First Desire to void

between Groups.Un-paired t-test of 1st desire to void at pre
treatment for group (A) and group (B) revealed no statistical
significant differences (p>0.05) of mean value of 1st desire to
void among both groups at entry of the study.
Comparative Analysis of 1st desire to void at end of
the study (Post-treatment): Un-paired t-test of 1st desire to
void after application of treatment (Post) for both groups (A)
and group (B), revealed no statistical significant differences
(p>0.05) of mean value of 1st desire to void among both groups
after application of treatment.
(2nd) Results of stability
1-Results of stability for group (A): The statistical analysis
of the mean differences of stability by Wilcoxon matched pairs
signed ranks test at pre-treatment and after application of
treatment (Post) of electrical stimulation group revealed that,
there was a highly statistical significant difference (P<0.05) in
stability, after application of treatment (Post) of PTN electrical
stimulation group when compared with the corresponding mean
value before initiation of treatment (Pre).with a percentage of
improvement of 48.69% after application of treatment (Post) of
electrical stimulation group.
2-Results of stability for group (B): the statistical analysis
of the mean differences of stability by Wilcoxon matched pairs
signed ranks test at pre-treatment and after application of
treatment (Post) of exercise group revealed the following results:
There was no statistical significant difference (P>0.05) in stability,
after application of treatment (Post) of exercise group when
compared with the corresponding mean value before initiation
of treatment (Pre).with a percentage of improvement of 4.25%
after application of treatment (Post) of exercise group.
3-Comparative Analysis of testing stability between
Groups of the Study:
Comparative Analysis of stability at entry of the study (Pretreatment):
Mann-Whitney test of stability at pre treatment for PTN
Electrical stimulation group (Group A) and Exercise group (Group
B) revealed no statistical significant differences (p>0.05) of mean
value of stability among both groups at entry of the study.
Comparative Analysis of stability at end of the study
(Post-treatment):
As observed in table (1) and figure (1), Mann-Whitney test
of stability after application of treatment (Post) for PTN electrical
stimulation group (Group A) and Exercise group (Group B)
revealed statistical significant differences (p<0.05) of mean value
of stability among both groups after application of treatment.
Table (1): Comparative analysis of the mean value of
stability among Electrical stimulation group (Group A) and
Exercise group (Group B) after application of treatment (Post).
Results
(3rd) Results of Maximum flow rate:
The result of this study includes (1st) Results of 1st desire

to void in both groups and between Groups, (2nd) Results of
Stability in both groups and between groups and (3rd) Results of
Maximum flow rate in both groups and between groups: The
collected data presented as before (pre) and after 12 weeks of
treatment application (post), that to determine role of PTNS in
patients with overactive bladder (urgency).
1-Results of maximum flow rate for group (A):

As observed in table (2). There was statistical significant
difference (P<0.05) in maximum flow rate, after application of
treatment (Post) of electrical stimulation group when compared
with the corresponding mean value before initiation of treatment
(Pre).With a percentage of improvement of 25.2% after
application of treatment (Post) of electrical stimulation group.
Table (2): The statistical analysis of mean differences of
maximum flow rate before initiation of treatment (Pre) and after
application of treatment (Post) of Electrical stimulation group
(Group A).
(1st) Results of 1st desire to void. There was no statistical

significant difference (P>0.05) in 1st desire to void for both
groups (A) and (B) , after 12 weeks (Post) when compared with
the corresponding mean value before initiation of treatment (Pre),
with a percentage of improvement of 8.64% and 0.88% for group
(A) and (B) respectively.
134
2-Results of maximum flow rate for group (B):

There was statistical significant difference (P<0.05) in
maximum flow rate, after application of treatment (Post) of
exercise group when compared with the corresponding mean
Table 1: Comparative analysis of the mean value of stability

among Electrical stimulation group (Group A) and Exercise group
(Group B) after application of treatment (Post).
Statistics
Stability after application of treatment
Electrical stimulation
Exercise
group (A)
group (B)
Mean
1.933
1.633
Standard Deviation
0.254
0.49
Mann-Whitney
315
U-value
Probability value
0.0411
Significance
Significant
Table 2: The statistical analysis of mean differences of maximum

flow rate before initiation of treatment (Pre) and after application
of treatment (Post) of Electrical stimulation group (Group A).
Statistics
Maximum flow rate
Pre
Post
Mean
12.51
15.663
Standard Deviation
6.263
3.861
Mean Difference
3.153
Paired t-value
3.277
Probability value
0.0027
Significance
Significant
Percent of Change
25.2 %
Table (3): Comparative analysis of the mean value of maximum

flow rate among Electrical stimulation group (Group A) and
Exercise
group (Group B) after application of
treatment (Post).
Statistics
Maximum flow rate after application
of treatment
Electrical stimulation
Exercise
group (A)
group (B)
Mean
15.663
12.807
Standard Deviation
3.861
4.693
Un-Paired t-value
2.575
Probability value
0.0126
Significance
Significant
Discussion
value before initiation of treatment (Pre). With a percentage of

improvement of 12.37% after application of treatment (Post) of
Exercise group.
3-Comparative Analysis of Testing Maximum flow rate
between Groups of the Study:
Comparative Analysis of maximum flow rate at entry of the
study (Pre-treatment):
Un-paired t-test of maximum flow rate at pre treatment for
B) revealed no statistical significant differences (p>0.05) of mean
value of maximum flow rate among both groups at entry of the
study.
Comparative Analysis of maximum flow rate at end of the
study (Post-treatment):
As observed in table (3) and figure (2), un-paired t-test of
maximum flow rate after application of treatment (Post) for
B) revealed statistical significant differences (p<0.05) of mean
value of maximum flow rate among both groups after application
of treatment.
Table (3): Comparative analysis of the mean value of
maximum flow rate among Electrical stimulation group (Group
A) and Exercise group (Group B) after application of treatment
(Post).
Percutaneous tibial nerve stimulation is reliable and

effective for nonneurogenic, refractory lower urinary tract
dysfunction. Electrical stimulation of the posterior tibial nerve
with needle electrodes demonstrates an effect to suppress
detrusor contraction in patients with overactive bladder. Posterior
tibial nerve electrical stimulation was chosen as the
physiotherapeutic method because it is an interesting alternative
for the treatment of overactive bladder, which is effective and
without side effects, despite the fact that pharmacological
treatment is currently the first option for the treatment of patients
with clinical symptoms of overactive bladder, but adherence to
treatment is low. Posterior tibial nerve electrical stimulation is
considered to be a simpler, less invasive and easy to apply form
of peripheral sacral stimulation that is well tolerated by patients
and more affordable (6).
PTNS offers a nondestructive alternative for patients with
urge incontinence, the aim of this treatment modality is to achieve
detrusor inhibition by electrical stimulation of somatic nerve fibers
by means of PTNS. (3).
In a prospective observational study, the efficacy of a tibial
nerve stimulation device in patients with overactive bladder
unresponsive to pharmacotherapy, the result of initial success
rate was 54%, with improvements seen in voiding diary
parameters, urodynamic parameters and quality of life scores
(7)
.
Additional studies assessed patients treated with PTNS and
concluded that PTNS is an effective, minimally invasive
procedure to treat urge incontinence and idiopathic voiding
dysfunction ( 8).
There is little difference in outcomes in incontinent patients
randomly assigned to PTNS weekly (group 1) versus 3 times
per week (group 2), the result showed 63% and 45% were
completely cured after treatment for group 1 and 2 respectively
(9)
. In our study we use 1-10 Hz pulse rate which did not lead to
fatigue contraction of the leg muscles.
PTNS in patients with over active bladder symptoms
(urgency ,frequency) had a good results and urodynamics
parameters were improved after treatment and proved
Anwar Abdelgayed Ebid / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
135
statistically significant decrease in leakage episodes ,frequency

and nocturea (10) .
Objective results based on frequency volume charts, voided
volume, number of leakage episodes, incontinence severity,
number of pads used and quality of life was reported after
application of PTNS ( 11).
PTNS had proved to be effective and well tolerated in adults
and produced modification in urodynamic pattern in patients with
nonneurogenic bladder dysfunction (12).There was an objective
effect of PTNS on urodynamic parameters (significant
improvement in maximum cyctometric capacity and involuntary
detrusor contraction and this improved bladder over activity is
an encouraging argument to PTNS as a non invasive treatment
in clinical practice (13) .
Peripheral nerve stimulation produce a statistical significant
improvement in lower urinary tract symptoms specially day time
and night time voiding frequency and volume, leakage episodes
(10)
.
PTNS is a minimally invasive technique that is effective to
suppress detrusor over activity, also it improve bladder
cyctometric capacity.PTNS has a subjective efficacy of 6364%
and an objective efficacy of 4654% in a non-neurogenic patient
with overactive bladder (3).
Our results inconsistent or unsupported by the study
conducted on patients with interstitial cystitis which revealed
that PTNS had no significant clinical effect and it may give some
response but less than through sacral root itself (14).
PTNS had no effect or failed to suppress detrusor
contraction on neurological detrusal over activity patients but
the bladder volume during the first contraction and cyctometric
bladder capacity was increase (15).
2.
Conclusion
10.
This study has demonstrated that PTNS, which is a

minimally invasive technique, is effective to suppress detrusor
overactivity. Also, demonstrated objective effect of PTNS on
especially bladder stability, and maximum flow rate, improved
urodynamic parameters with PTNS, which is observed in this
study, is an encouraging finding that further supports its use as
an effective treatment modality in the clinical practice of detrusor
overactivity. No serious adverse events or side effects were
observed during or after treatments, so posterior tibial nerve
electrical stimulation is a new trend in the treatment of overactive
bladder and urgency.
3.
4.
5.
6.
7.
8.
9.
11.
12.
13.
Acknowledgement
I would like sincerely to thank Dr.AboZeid A. Mansour,
Consultant urologist in Elmatarya institute for urology for his
technical assistance, and many grateful to Dr.Marwa M.Abd El
Motelb PT, D. for their generous assistance in sample collection.
References
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14.
15.
Susan Calvert M. Percutaneous Tibial Nerve Stimulation

for the Treatment of the Overactive Bladder. UROLOGY
NEWS 2008; Vol (12).
Van Rey J.P.F.A.and Heesakkers. Applications of
Neurostimulation Urinary Storage and Voiding for
Dysfunction in Neurological Patients. Urol Int 2008; 81: 373
378.
Yamanishi T., Sakakibara R., Uchiyama T., and Yasuda K.
Comparative Study of The Effects of Magnetic Versus
Electrical Stimulation on Inhibition of Detrusor Overactivity.
Urol 2000; 56: 777-781.
Moore KN, and Dorey G. Conservative Treatment of Urinary
Incontinence in Men. Physiotherapy 1999; 83:77-87.
Patricia O. Bellette, Paulo C. Rodrigues-Palma, Viviane
Hermann, Cssio Riccetto, MiguelBigozzi,Juan M. Olivares
.Posterior tibial nerve stimulation in the management of
overactive bladder: A prospective and controlled study
ACTAS UROLGICAS ESPAOLAS 2009; 33(1): 58-63.
Nuhoglu, B., Fidan, V., Ayyildiz, A., Ersoy, E., Germiyanoglu,
C. Stoller afferent nerve stimulation in woman with therapy
resistant over active bladder; a 1-year follow up. Int
Urogynecol J Pelvic Floor Dysfunct 2006 May; 17(3):2047.
Vandoninck, V., van Balken, MR., Finazzi Agro, E.,
Heesakkers, JP., Debruyne, FM., Kiemeney,
LA.,Bemelmans, BL. Posterior tibial nerve stimulation in
the treatment of voiding dysfunction: urodynamic
data.Neurourol Urodyn 2004; 23(3):246-51.
Van der Pal F, van Balken MR, Heesakkers JP, et al
.Percutaneous tibial nerve stimulation in the treatment of
refractory overactive bladder syndrome: is maintenance
treatment necessary? BJU Int 2006; 97(3):547-50.
Van-Blaken M.R., Vergunst H., and Bemelanans B.L. The
Use of Electrical Device for The Treatment of Bladder
Dysfunction: A Review of Methods Journal of Urology 2004;
(172): 846-851.
Van Melick H,Gisolf KW,Eckhardt MD,vanVenrooij
GE,Boon TA .one24- hour frequency volume chart in
women with objective urinary motor urge incontinence is
sufficient . Urology 2001; 58:188-92.
Bower WF, Moor, KH. and Adams, RD. Apilot study of the
home application of transcutaneous neuromodulation in
children with urgency or urge incontinence .J Urol 2001;
166:2420.
Amarenco G., Sheikh I, Raibaut P., Kerdraon J. Urodynamic
Effect of Acute Trasncutaneous Posterior Tibial Nerve
Stimulation in Overactive Bladder.J Urol 2003; 169 :22102215.
Zhao J, and Nordling J. Posterior tibial nerve stimulation in
patients with intractable interstitial cystitis. BJU Int 2004;
94:101104.
Fjorback ML, Van Rey FS,van derpal F et al .acute
urodynamic effect of posterior tibial nerve stimulation on
neurogenic detrusal over activity in patients with MS.Eur
Uro 2006;51:464-470.
Sofia Correia, Paulo Dinis, Nuno Lunet.Urinary

Incontinence and Overactive Bladder A Review.ArquiMed
2009; 23(1):13-21.
Comparison of manual physical therapy and conventional

physical therapy programs in osteoarthritis of knee
Dheeraj Lamba*, Satish Chandra Pant**
*Incharge/Lecturer, Physiotherapy, Uttarakhand Forest Hospital, Trust & Medical College, Haldwani, **B.P.T. Final Year Student
Introduction
1.
Knee Osteoarthritis is a prevalent condition that contributes

significantly to functional limitations & disability in older people.
It is the most important cause of the pain & disability in the world.
Defined by American College of Rheumatology (ACR) as a
heterogeneous group of conditions which lead to joint symptoms
& signs associated with defective integrity of the underlying bone
& joint margins. 80% patients develop medial compartment
osteoarthritis & develop a varus or bowlegged deformity. Pain
is the most dominant symptom. The osteoarthiritic patient may
also present with limitation of joint motion, muscle atrophy &
weakness, joint instability & progressive functional limitation.
Exercise & applied physiotherapy consisting of heat, instructions
in joint use, maintenance of joint range of motion is quite useful
in osteoarthritis knee.Fitness walking, aerobic exercises &
strength training also result in functional improvement in patients
with OA knee. Manual therapy procedures are also used as
part of comprehensive rehabilitation programs to help patients
regain joint mobility & function.
Aims and objectives

To compare between manual physical therapy program and
conventional physical therapy program in treating osteoarthritis
knee.
3.
4.
5.
Knee pain & Crepitus with active motion and morning

stiffness in age group: 45-65 years.
Knee pain on most days of previous month (average pain,
more than 5cm on a 10cm VAS).
Minimum available range of 0-100 degrees knee flexion.
Experience pain or difficulty in getting up from sitting or
coming down on stairs.
Difficulty in household activities due to pain and swelling.
Exclusion criteria
1.
2.
3.
4.
5.
Symptoms or signs of synovitis.

Acute or chronic ligamentous insufficiency.
Any history of recent injury to knee joint.
Any history of knee surgery (previous 3 months).
Any history of Physiotherapeutic treatment for the knee
(Previous 12 months).
6. Systemic Arthritic conditions.
Fifty patients completed the study, while 4 of Manual
Physical Therapy group & 6 out of conventional physical therapy
group withdraw from the study due to various reasons.
Preliminary measurements were taken at baseline prior to
beginning of the study, which included Range of motion, Pain
on VAS scale & Distance covered in 6 minutes. Treatment
Program was limited to 3 weeks duration with 5 sessions a week.
PROCEDURE
Hypothesis
Experimental Hypothesis : Manual physical therapy
program is better than conventional physical therapy program
in treating knee osteoarthiritic patients.
Null Hypothesis : Manual physical therapy program is not
significantly better than conventional physical therapy program
in treating knee osteoarthiritic patients.
73 subject screened
A sample of 60 patients selected
Explanation of procedure
Methodology
Informed consent
Sampling method: Convenient sampling

Sample size: 73 subjects were screened for the study. A
sample of convenience of 60 subjects (both male and female)
with age range of 45 to 65 years who met the inclusion criteria
was taken
Sample design : Experimental design
Sample source : OPD Sushila Tiwari Memorial Hospital
Trust & Medical College, Haldwani.
Variables
Independent variable
Manual Physical Therapy
Conventional Physical Therapy

Dependent variable
Range of Motion
Pain on VAS
Distance covered in 6 Minutes
Inclusion criteria
Pre Intervention Reading
Manual Physical Therapy
Concentional Physcal Therapy
Post Intervention reading
Post Intervention Reading
Group 1
Initially Short wave diathermy were given.

Then Manual Physical Therapy program was given which
is as follows:
Manual Mobilization of Extension
Manual Mobilization of Flexion
Patellar Glides
Later on manual passive stretching for Calf, Hamstring &
Quadriceps is administered
Followed by supervised exercise program including
strengthening & mobility exercises.
137
Group 2
Subjects were initially given Short wave diathermy for 20

minutes by covering whole aspect of knee and wrapping it
with a towel with medio -lateral placement of pads.
This will be followed by supervised exercise program
including strengthening & mobility exercises.
Data analysis
Statistics were performed using an Excel spreadsheet &
Statistical Package for Social Sciences (SPSS) software was
used for data analysis.
Student t test was used to compare
1. Unpaired t test for between group comparisons.
2. Paired t-test for within group comparisons.
A significance level of p<0.05 was set
Results
*Significant (pd 0.05)
There is significant improvement in range of motion at the

end of week 3 from day 0 in both groups (pd0.05)
There is an insignificant difference between Group 1 and

Group 2 at Day 0 with t value=0.68, p>0.05.
But there is a significant difference between Group 1 and

Group 2 at Week 3 with t value=1.67, p<0.05.
Discussion
The results of the study showed a statistically significant
decrease in pain scores & improvement in six minute walk test
Graph 1:
distances and range of motion over 3 week period. Subjects in

the manual physical therapy group appeared to be more satisfied
than subjects in conventional physical therapy group. The
difference between the two groups is likely attributable to the
additional effects of manual physical therapy program consisting
of passive physiological and accessory movements and muscle
stretching that conventional group was not performing.
Deyle et al supported our results when they found no
significant change in pain scores and six-minute walk test
measurements in patients with knee OA who received a clinically
applied placebo treatment in comparison to those receiving
manual therapy in osteoarthritis knee. The possible mechanism
for better results are that the passive physiological joint motion
stimulates biologic activity by moving the synovial fluid, which
brings nutrients to the avascular articular cartilage of the joint. It
also helps in maintenance of extensibility and tensile strength
of the articular and periarticular tissues & thus helps in
maintenance of joint motion and general health
The manual therapy passive movement techniques were
also found to increase excursion in both intra-articular and
periarticular tissues when restricted mobility was judged to be
related to the reproduction of symptoms or functional limitation.
G D Maitland states that gentle passive physiologic and
accessory movements techniques stimulate neurophysiologic
and mechanical effects thus can be used to treat painful joints,
muscle spasm & joint hypomobility.
G. D. Maitland, Hoeksma et al, G D Deyle et al, Pamela A.
Kovar et al, N E Henderson et al through various studies also
support the results of the study.
Future research
Further studies can be carried out with a large sample size
with some radiographic support of OA knee.
Future studies should also focus on correcting the
disarrangement due to osteoarthritis by use of manual therapy
combined with exercises.
Future studies should also focus on various factors affecting
the outcome like articular factors, kinesiological factors and
psychological factors.
Clinical relevance
This study establishes that manual therapy combined with
exercises helps to relieve pain and improve function in OA knee
patients.
This study will help the therapists to use a combined
approach involving both manual therapy and a supervised
exercise program to improve function in better way. .
Table 1: Comparison of Basic characteristics (Age & Weight) between Manual & Conventional Physical Therapy Groups
Subjects
Manual Physical
Conventional Physical
t-value
characteristics
Therapy Group
Therapy Group
Mean S.D.
Mean S.D.
Age
50.6154 6.38yrs
50.9167 5.97yrs
.17NS
Weight
62.9615 7.84Kg
62.6667 7.18Kg
.14NS
Height
162.655.08cm
162.345.14cm
.14NS
Key words
Yrs-year
Kg-kilogram
cm- centimeters
Table 2: Comparison of Pre-intervention scores of Range of Motion with post-intervention scores for Group 1 and Group 2
Days
Range of Motion
t-value
p-value
MEAN
S.D
Group
Day 0
117.26
4.49
20.84*
0.00
1(N=26)
Week 3
123.64
4.54
Group
Day 0
116.04
3.4
10.83*
0.00
2(N=24)
Week 3
119.72
3.4
138
Table : Comparison of Pre-intervention scores of Pain on VAS with post-intervention scores for Group 1 and Group 2
Days
VAS
t-value
p-value
MEAN
S.D
Group
Day 0
6.78
.96
9.42*
0.00
1(N=26)
Week 3
4.77
.86
Group 2
Day 0
6.46
.96
13.30*
(N=24)
Week 3
5.74
.91
0.0
* : Significant (pd 0.05)
Ta ble : Comparison of Pre-intervention scores of 6 min walk test with post-intervention scores for Group 1 and Group 2
Days
Distance Covered in 6 minutes
t-value
p-value
MEAN
S.D
Group
Day 0
235.73
15.2
13.39*
0.00
1(N=26)
Week 3
252.32
12.94
Group
Day 0
239.42
12.63
5.46*
0.00
2(N=24)
Week 3
245.54
11.08
* : Significant (pd0.05)
There is significant improvement in distance covered in six minutes at the end of week 3 from day 0 in both groups (pd0.05)
Graph 2:
Graph 3
Conclusion
2.
The result of this study shows that manual physical therapy

is found to be more effective.
The dependent variables Range of Motion, pain score on
VAS and Distance covered in 6 minutes improved for both the
groups, but the results were better in Manual Physical Therapy
Group.
The study therefore concludes by accepting the
Experimental hypothesis, Manual physical therapy program is
better than conventional physical therapy program in treating
knee osteoarthiritic patients.
3.
6.
Refernces
7.
1.
Altman R.D., Asch E, Block G, Bale G, Borenstein K & Brandt

K (1986) Development of Criteria for classification of
Osteoarthritis. Arthritis & Rheumatism; 29: 1039-1049
4.
5.
John M Walker, Antonie Helewa. Physical Therapy in

Arthritis: W.B. Saunders Company, 1996
S Brotzmann & K E Wilk. Clinical Orthopaedic
Rehabilitation, 2nd ed., Mosby, 2003.
J Bruce Moseley, Kimbertly OMalley, Nancy J. Peterson,
Terri J. Menke, David H. Kuykendall; Vol.37, (2002). A
Controlled trial of arthroscopic surgery for osteoarthritis of
the knee. The NEW ENGLAND JOURNAL OF MEDICINE;
Vol 347: 81-88.
Maitland GD. Vertebral Manipulation, 5th ed., London;
Butterworths, 1986
Maitland GD. Peripheral Manipulation, 3rd ed., Boston;
Butterworth Heinmann, 1991.
American College of Rheumatology (2000).
Recommendations for the medical management of
osteoarthritis of the hip and knee. Arthritis & Rheumatism,
Vol 43, No. 9, September 1905-1915.
139
Efficacy of home based pulmonary rehabilitation program on

pulmonary functions and quality of life in asthmatic children
Ganesan Kathiresan 1, Andrew J Newens
Lecturer, Masterskill University College, Selangor, Malaysia, 2 Senior Lecturer, Institute of Rehabilitation, Faculty of Health, University
of Hull, UK
Abstract
Objective: To Investigate The Efficacy Of Home Based Pulmonary Rehabilitation Program On Pulmonary Functions And
Quality Of Life In Asthmatic ChildrenMethology: 28 (twenty eight)
children with mild persistent or moderate asthma were included
into a double blind, randomised study. 16(Sixteen ) children (9
girls , 7 boys) with the mean age of 10.8 2.3 were assigned to
receive pulmonary rehabilitation program with their parents for
30 days (group I). Control group included 12 children (6 girls, 6
boys ) with the mean age of 10.2 2.4 (group II). Symptom and
medication scores quality of life index and pulmonary function
tests were evaluated in rehabilitation and control group in the
beginning of the study and after the one month period.Results:
the groups did not differ on all parameters before the study (p >
0.05). Statistically significant decrease were found in symptom
and medication scores in rehabilitation group (p < 0.05) and
quality of life index was increased significantly in the same group
(p < 0.05). Pulmonary function measures also significantly
improved including vital capacity, forced vital capacity, FEV1,
PEF and FEF25-75 in the rehabilitation group (p < 0.05). The best
improvement were seen in FEF25-75 (10.09% increase) and PEF
(7.81% increase) values. In control group no statistically
significant differences were found in all parameters.Conclusion:
This study was shown that pulmonary rehabilitation at home
could improve quality of life and pulmonary functions. So
pulmonary rehabilitation should be placed as a component of
management in childhood asthma.
Keywords
Pulmonary rehabilitation, asthma, Pulmonary Functions And
Quality Of Life
Introduction
A number of patients with chronic obstructive pulmonary
diseases and asthma is on the rise over all the world. Education,
environmental control and drug therapy are the corner stones
in the management of asthma. Nowadays pulmonary
rehabilitation is a recognised discipline for stabilisation and
improvement of asthma and chronic obstructive pulmonary
diseases. Pulmonary rehabilitation program (PRP) could improve
the quality of life, pulmonary functions, exercise tolerance, reduce
the symptoms and anxiety of patients and decrease frequency
and duration of hospitalisation (1-6).
The aim of this study is to investigate the efficacy of Home
baesd pulmonary rehabilitation program in children with asthma.
Methodology
Ganesan Kathiresan
LECTURER
Masterskill University College Of Health Sciences,
G8, Jalan Kemacahaya 11, Taman Kemacahaya, Batu 9, Cheras
43200, Selangor, Malaysia. EMAIL: gans_therapist@yahoo.co.in
PHONE: 0060176033025
140
Twenty eight children with mild persistent or moderate

asthma were included into a double blind, randomised study.
Sixteen children (9 girls, 7 boys) with the mean age of 10.8
2.3 were assigned to receive pulmonary rehabilitation program
with their parents for 30 days (group I). Control group included
12 children (6 girls, 6 boys ) with the mean age of 10.2 2.4
(group II). Children in both groups were comparable according
to the stage of asthma and they had been using same drugs at
least for six months.
Pulmonary rehabilitation program consisted of relaxation
exercises, endurance exercises, breathing exercises and
rhythmic mobilisation exercises. Patients and their parents had
visited Physical Medicine and Rehabilitation Department at the
first visit and they were thought to perform this program at home
for 30 days. Symptom scores, medication scores (7), quality of
life index (8) and pulmonary function tests were evaluated in
rehabilitation and control group in the beginning of the study
and after the one month period.
The results in both group were given as mean scores and
standard deviation. The findings indicated that non parametric
methods were appropriate so Wilcoxon matched pairs test was
used for difference between results at baseline and after the
study. Mann-Whitney U test was used for comparing the groups.
A p value of < 0.05 was regarded as statistically significant.
RESULTS
Symptom and medication scores and quality of life index
of group I and group II were listed in table I. The groups did not
differ on all parameters before the study (p > 0.05). Statistically
significant decrease were found in symptom and medication
scores in rehabilitation group (p < 0.05 ) and quality of life index
was increased significantly in the same group (p < 0.05) (table
I). Pulmonary function measures also significantly improved
including vital capacity, forced vital capacity, forced expiratory
volume in the first second of expiration, peak expiratory flow
rate (PEF) and FEF25-75 in the rehabilitation group (p < 0.05). the
best improvement were seen in FEF25-75 (10.09 % increase) and
PEF (7.81% increase) values (table II).
In control group no statistically significant differences were
found in symptom and medication scores, in quality of life index,
even in pulmonary function tests (p > 0.05).
Table 1: Symptom and medication score and quality of life index

of group I (rehabilitation group) and control group
First visit
Second visit p
Rehabilitation
group (Group I)
Symptom score
0.63 0.71
0.19 0.40
0.01
(median: 0.5)
(median: 0)
Medication score
4.40 1.70
3.50 0.80
0.007
Quality of life Index 6.02 0.5
6.40 0.40
0.009
Control Group
Symptom score
0.67 0.57
0.49 1.40
0.16
(median: 0)
Medication score
4.09 0.79
4.06 0.93
0.32
Quality of life Index 6.15 0.29
6.27 0.49
0.16
Ganesan Kathiresan / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Table 2: Pulmonary functions (% prediced values for age and

height) of group I (rehabilitation group) and control group
First visit
Second visit
p
Rehabilitation group
VC
76.62 8.64
83.12 12.38 0.05
FVC
78.00 8.83
84.75 10.76 0.02
74.23 11.67 80.62 12.27 0.009
FEV1
PEF
65.62 8.50
73.43 7.32 0.001
75.73 11.12 85.31 14.45 0.006
FEF25-75
Control group
VC
78.66 10.39 80.25 6.25 0.75
FVC
79.67 8.64
81.41 7.07 0.36
73.75 7.12
75.91 5.43 0.15
FEV1
PEF
6.33 7.22
68.91 9.16 0.21
74.54 11.96 76.66 10.37 0.37
FEF25-75
Discussion
Pulmonary rehabilitation program had both physiological
and psychological beneficial effects on patients with chronic
obstructive pulmonary diseases. Pulmonary rehabilitation
relaxes the chest muscles, improves ventilation, decreases work
of breathing and decreases the anxiety of patients and their
parents.
In this study it was shown that pulmonary rehabilitation could
improve the quality of life and pulmonary functions. Similar to
our results Cambach et al had reported that quality of life and
exercise capacity improved after the rehabilitation program (2).
Field et al also had demonstrated that children with asthma had
improved pulmonary function after the daily relaxation and
massage therapy (4). They found best improvement in FEF25-75
values like our finding which reflects the small airway obstruction.
These results mean PRP could lead improvement in airway
obstruction and control of asthma.
In another study that were carried out by Cox et al it was
shown that pulmonary rehabilitation had beneficial effects on
endurance, psychological variables, quality of life, skills,
coordination, smoking habits, airway obstruction and dyspnea
(6). However bronchial hyperresponsiveness, need of pulmonary
drugs and complaint of cough did not change. They followed
patients for two years and long term effects of PRP were
evaluated. Our study is a preliminary study and long term effects
of PRP is well not known.
The cost effectiveness of PRP is another point that could
discuss. In our group PRP was performed at home by parents
and it makes less cost. If we had enough data about the results
of PRP performed by physiotherapists we could make a
comparison for these both methods. Effects on psychological
variables and compliance could not be evaluated in this study.
In conclusion because of the beneficial effects on quality
of life and pulmonary functions pulmonary rehabilitation should
be placed as a component of management in childhood asthma.
Further studies are needed to investigate the long term effects
and cost effectiveness of PRP.
Authors Statement
With the submission of this manuscript I would like to
undertake that the above mentioned manuscript is original and
has not been published elsewhere, accepted for publication
elsewhere or under editorial review for publication elsewhere;
and that my Institutes representative is fully aware of this
submission.
Competing interests
There are no sources of funding used to assist in the
preparation of this manuscript.
There are no potential conflicts of interest the authors may
have that are relevant to the contents of this manuscript
Open access
This article is distributed under the terms of the Creative
Commons Attribution Noncommercial License which permits any
noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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Ganesan Kathiresan/ Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
141
The relative efficacy of mobilization with movement versus Cyriax

physiotherapy in the treatment of lateral epicondylitis
Pooja Bhardwaj*, Amit Dhawan**
*Sr. Lecturer, D.A.V. Institute of Physiotherapy & Rehabilitation, Jalandhar, Punjab, India. **Sr. Lecturer, Department of Physiotherapy,
Lovely School of Applied Medical Sciences, Lovely Professional University, Phagwara, Punjab, India
Means and standard deviations were used as descriptive

statistics. It was revealed that MWM reduces pain and increases
grip strength to a greater extent than Cyriax Physiotherapy.
as cited by Mulligan (1995) is that a minor positional fault of

joint may occur following an injury or strain, resulting in
movement restriction or pain. Lewit (1985) has shown that
reduced joint mobility can often be a result of a mechanical
block from inert structures within a joint. Joint movement can
be reduced as a result of reflex muscle splinting. It is suggested
that treatment directed at the joint will have an effect on muscle
activity and vice-versa. Paungmali A (2003) concluded that MWM
for lateral epicondyalgia is capable of producing concurrent
hypoalgesic effects during and following its application as well
as altering CNS functions, Vicenzino demonstrated beneficial
effects of applying MWM technique on pain and dysfunction
that is classically associated with tennis elbow. They concluded
improvement in grip strength, function and reduction in pain
level.7 Articular Neurology is one of the fundamental sciences
of manipulative therapy. Manipulation activates type 2 (fast
adapting, with dynamic response to increased or decreased joint
movement) and type 3 (high threshold) mechanoreceptors
respectively. Pain abates after manipulation due to the reflex
inhibition of the muscle spasm. Spinal Manipulation on the
cervical spine resulted in significant deviation in plasma
endorphins (natural pain killers) levels.8
Cyriax claimed substantial success in treating tennis elbow
using deep transverse friction (DTF) in combination with Mills
manipulation, which is performed immediately after DTF. For it
to be considered a Cyriax intervention, the two components must
be used together in the order maintained. 9
Within the field of manual therapy for lateral epicondyalgia,
there are several randomized controlled trials (RCTs) that are
specifically evaluated for Cyriax Manipulation, transverse friction
massage, and mobilization with movement (MWM) in lateral
epicondyalgia. Both techniques have reported efficiency in
improving pain and grip strength.
Discussion and conclusion
Methods
The study finds evidence to support the use of both MWM

and Cyriax in lateral epicondylitis over ultrasound; however
Cyriax is inferior to MWM, although in post treatment they were
very similar in effect. The results after one month follow up were
clearly in favour of MWM as supported by the analysis.
The Institutional Review Boards at M.M.Medical College &

Hospital, Ambala, & Indira Gandhi Medical College & hospital,
Shimla, India had granted approval for the study.
Backround
Proposed mechanism for pain in tennis elbow as cited by
Mulligan (1995) is that a minor positional fault of joint may occur
following an injury or strain, resulting in movement restriction or
pain. Paungmali A (2003) concluded that Mobilization with
Movement (MWM) for lateral epicondyalgia is capable of
producing concurrent hypoalgesic effects and altering CNS
function.
Purpose
To investigate the effects of MWM and Cyriax physiotherapy
and to compare these techniques in reducing pain and improving
grip strength in patients with lateral epicondyalgia.
Methods/design
Sixty subjects with a history and examination results
consistent with lateral epicondyalgia participated in the study.
The subjects were randomly assigned to a group that received
MWM + Ultrasound (Group I), Cyriax Physiotherapy + ultrasound
(Group II) and Ultrasound (Group III). Follow-up was done after
one month. The primary outcome measures were NPRS, Grip
Strength and Patient Rated Forearm Evaluation Questionnaire
(PRFEQ). Analysis was performed using post HOC test, one
way ANOVA, Paired and Unpaired t tests.
Results
Keywords
Hypoalgesia, Grip Strength, MWM, Mills Manipulation,
Ultrasound.
Introduction
It is a work related or sports related pain disorder with
macroscopic and microscopic tears in the Extensor Carpi
Radialis Brevis 1 , usually caused by excessive quick,
monotonous, repetitive eccentric contractions and gripping
activities of the wrist.2, 3 Recent studies showed sensory fibres
containing substance P & CGRP (calcitonine gene related
peptide) in the origin of ECRB. 4,5 The presence of these
neuropeptides which is limited to a subgroup of small vessels,
implies the possibility of neurogenic inflammation as a cause of
perceived pain.6 Proposed mechanism for pain in tennis elbow
142
Study sample
60 patients with signs and symptoms of lateral
epicondyalgia were involved in the study. Over a period of one
year, patients were recruited from:
The Outpatient Department of Orthopaedics and
Physiotherapy of M.M. Medical College & Hospital, Mullana,
Ambala & Indira Gandhi Medical College & Hospital, Shimla.
The study will include the patients who meet the following
inclusion criteria:
Patients with age between 45-54 years were included in

the study.
Both male and female patients were recruited.
Pain that increased on palpation of the lateral epicondyle.
Pain during gripping.
Pain on resisted wrist extension.
Pain on resisted middle finger extension.
Pain of at least 6 weeks of duration.

The following exclusion criterion was used for this study:
Age less than 45 and more than 54 years.
Pooja Bhardwaj / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Bilateral elbow symptoms.

Cervical radiculopathy.
Any other elbow joint pathology.
Peripheral nerve involvement.
Previous surgery of the elbow.
History of dislocation
History of fracture of humerus, radius and ulna.
Systemic or neurological disease (stroke and head injury).
Shoulder, wrist and hand pathology.
History of rheumatoid disease.
Health conditions that would have precluded treatment (eg,
osteoporosis, malignancy, haemophila, diabetes)
Recent steroid injection
Using medications such as analgesic drugs.
Design of the study

Randomised controlled design
60 subjects were divided randomly into 3 groups. 20
subjects were included in each group and treated as follows:
Group I Ultrasound therapy+ MWM
Group II Ultrasound therapy+ Cyriax physiotherapy.
Group III Ultrasound therapy (Control Group)

All participants provided written consent prior to
participation.
The instrumentation for data collection included:
Numeric Pain Rating Scale (NPRS) 14
Patient Rated Forearm Evaluation Questionnaire (PRFEQ)
12,
Grip Strength 13
Equipments used
group I and group II received ultrasound therapy for 10 minutes.

The trial comprised a two week intervention period for group
I and four week intervention period for group II and III and one
month follow up for each group.
Participants were assessed:
Before treatment (baseline)
Group I after two weeks of treatment (final assessment)
Group II and III after four weeks of treatment (final

assessment)
At 1 months after final assessment (follow up)
Mobilization with movement (mwm)group i

11
The patient was made to lie supine on the couch. Therapist

stood by the involved side. Treatment was to make the patient
exercise his forearm repeatedly in any way that was (on testing)
painful, but, exercise when done with a sustained mobilisation
was painless. Patient elbow was in full extension and forearm
in pronation. Belt was worn around the therapists waist and
was parallel to the ground. Lateral glide of the forearm relative
to the humerus was produced by the mobilisation belt, was pain
free and now rendered strong resisted wrist extension pain free
which was applied by the therapists hand. Mulligan described
this technique as being effective as supported by early case
study research.
The glide was painlessly applied and sustained for
approximately 6 seconds while the participant performed the
pain free resisted wrist extension. Gliding pressure was
maintained until participant brought the wrist back to neutral. 3
sets of 10 pain free MWMs were performed against strongest
pain free wrist extension resistance. Patients were warned that
no pain should be perceived during the procedure.
Dynamometer`
Stopwatch
Mulligans Belt
Ultrasound modality (Phyaction)
Cyriax physiotherapygroup ii
It includes Deep Transverse Friction (DTF) in combination
with Mills Manipulation, which was performed immediately after
DTF. For it to be considered, a Cyriax Intervention, the two
components were used together in the order mentioned. The
protocol was followed 3 times a week for 4 weeks.
Deep transverse friction 10

Patient was made to sit on the chair comfortably and exact
site of lesion was palpated. DTF was performed only at the exact
side of lesion with depth of friction tolerable to the patient. It was
applied transversely to the specific tissues involved. The
therapists fingers and patients skin moved as a single unit. It
must be applied for 10 minutes.
Procedures
Patients were screened according to the inclusion and
exclusion criteria. 60 patients who met the criteria were included
in the study. They were allocated into three groups by simple
random sampling. Procedures were explained to the patients
and duly signed written consent was taken. All the patients of
Mills manipulation 10
It was performed immediately after the DTF, provided the
patient had full range of passive elbow extension. Patient was
positioned on chair with backrest and therapist stood behind
the patient. Patients arm was supported under the crook of elbow
with shoulder joint abducted to 90 and medially rotated with
forearm pronation. Patients wrist was fully flexed and forearm
Pooja Bhardwaj / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
143
pronated by the therapist. Hand supporting the crook of elbow

was moved on to the posterior surface of the elbow joint and
while maintaining full wrist flexion and pronation, patients elbow
was extended until all the slack has been taken up in the tendon.
Therapist then stepped sideways to stand behind the patients
head, taking care to prevent the patient from leaning away either
forwards or sideways, which would reduce the tension on the
tendon. Minimal amplitude, high velocity thrust was then applied
by simultaneously side flexing therapists body away from the
arm and pushed smartly downwards with the hand over the
patients elbow.
Groups
GP 1
GP 2
GP 3
Groups
GP 1
GP 2
GP 3
Mean post
pain
2.751.3
3.51.27
5.61.14
Mean post
PRFEQ
21.779.05
17.886.75
33.246.03
Mean post
Grip Strength
12.254.3
114.5
7.702.86
Follow up
Pain
1.551.3
3.651.5
5.85.81
Follow up
PRFEQ
18.449.74
18.526.73
35.044.43
Follow up
Grip Strength
18.204.9
11.554.26
7.203.1
Post hoc analysis for pain scores
The subjects in both groups I and II would receive

Ultrasound treatment before undergoing MWM and Cyriax
Physiotherapy.
Ultrasound therapy group iii
24
The subjects were given pulsed ultrasound with an on to

off ratio of one to four and a frequency of 1MHz. The spaceaveraged intensity was set to 1w/cm2 and treatment time to 10
minutes during the course of treatment. 12 treatments were given
(three per week) over four weeks, except for MWM group which
received ultrasound as per the number of MWM sessions.
Data analysis
Means and standard deviations were used as descriptive
statistics. A within-subject and between subject design was used
to evaluate the effect of 2 independent variables: treatment
conditions (mobilisation with movement and cyriax
physiotherapy) and a no treatment group/control group
(ultrasound). Pain, PRFEQ and Grip Strength as dependent
variables of mobilisation with movement and cyriax
physiotherapy. Significant interactions and main effects were
further explained with post HOC (multiple comparisons,
bonferroni) test of simple effects. SPSS software (version 13.0,
SSPS. Inc, Chicago, Illinois, USA) was used in statistical
analysis, and level of significance was set at p< .05.
Results
No statistically significant difference existed between the
groups in terms of age and gender. Before the application of
treatment, the mean and standard deviations of pre pain, pre
PRFEQ, pre Grip Strength scores for 3 groups were as follows:
Groups
GP 1
GP 2
GP 3
Mean pre
pain
7.05.83
6.5.946
6.3.979
Mean pre
PRFEQ
39.786.68
36.305.12
36.604.42
Mean pre
Grip Strength
4.253.5
6.153.8
6.453.4
After 1 month of treatment, the mean and standard

deviations of post pain, post PRFEQ and post grip strength were
as follows:
Following 3 weeks after treatment, Pain, PRFEQ scores
are again taken. The mean scores of follow up were as follows.
144
According to Bonferroni, multiple comparisons, it was

revealed that there is no significant difference between GP 1 &
2 and GP 2 & 3 in terms of pre pain scores, except in case of
GP 1 & GP 3.
There exists no significant difference when GP 1 was
compared with GP 2 but with GP 3 there was a significant
difference in terms of post pain scores.
A significant difference exists when GP 2 was compared
with GP 3 in terms of post pain and follow up scores.
Paired sample test analysis for pain scores

There was a significant difference between pre pain and
post pain measurements and pre pain and follow up pain
measurements in all 3 groups.
Post hoc analysis for prfeq scores:

The results revealed that there was no significant difference
between GP 1, 2 & 3 in terms of pre PRFEQ scores.
There exists no significant difference when GP 1 was
compared with GP 2 but with GP 3 a significant difference exists
in terms of post PRFEQ scores.
No significant difference exists between GP 1 and GP 2 in
terms of follow up PRFEQ scores.
GP 2 and GP 3 showed a significant difference between
them in terms of follow up PRFEQ scores.
Paired sample test analysis for prfeq scores:

There is a significant difference between pre PRFEQ and
post PRFEQ measurements and pre PRFEQ and follow up
PRFEQ scores in all 3 groups.
Post hoc analysis for grip strength scores

The results revealed that there exists no significant
difference between the 3 groups in terms of pre grip strength
scores.
In terms of post grip strength, no significant difference
existed between GP 1 and GP 2 (p value = .977) but a significant
difference was there between GP 1 and GP 3 (p value =.002).
GP 2 and GP 3 have a significant difference between them (p
value = .034)
Paired sample test analysis for grip strength

scores:
There was a significant difference between pre grip strength
- post grip strength and pre grip strength follow up grip strength
scores in all the 3 groups, except in group 3 (.143).
The measured values for assessment of effectiveness are
standardised as per percentage of improvement, calculated by:
% improvement = data before treatment data after
treatment/data before treatment

Mobilisation with Movement (MWM) reduced the pain by
61.28% after treatment sessions but when 3 weeks follow up
was done, the reduction in pain level was found to 78.42. It
showed 46% increase in the PRFEQ and this gain in PRFEQ
was increased to 54% after 3 weeks of treatment.
Cyriax Physiotherapy reduced the pain by 46.69% but after
3 weeks of follow up the reduction level in pain was found to be
44.03%. Cyriax physiotherapy reported 51.7% increase in
PRFEQ and this gain was seen to reduce to 49.7 after 3 weeks
of treatment.
Ultrasound reduced the pain by 10.22% but reduction in
pain level after 3 weeks follow up was only 5.93%. The PRFEQ
was increased by 9.21% and after 3 weeks of follow up it was
just 4.14%.
Graph I: Comparison of pain scores (NPRS)
Graph II: Comparison of PRFEQ scores
Graph III: Comparison of Grip Strength scores
Discussion
The study finds evidence to support the use of both MWM
and Cyriax in lateral epicondylitis over ultrasound as used in
control group during the post treatment session; however Cyriax
is inferior to MWM, although in post treatment they were very
similar in effect. Cyriax had already claimed substantial success
in treating tennis elbow using Deep Transverse Friction (DTF)
in combination with Mills Manipulation, which is performed
immediately after DTF.
DTF produced a numbing effect.15,16 It quickly results in
analgesic effect over the treated area and is not at all painful for
patient if correctly applied.17

It has been hypothesised that DTF has local pain
diminishing effect and results in better alignment of connective
tissue fibrils, therefore increasing the strength and mobility.18
According to Cyriax, DTF also leads to destruction of pain
provoking metabolites like Lewis substances, which produces
ischemia and pain. 10 minutes of DTF give lasting peripheral
disturbance of nerve tissue with local anaesthetic effect.18 Diffuse
noxious inhibitory controls is another pain suppression
mechanism that releases endogenous opiates which are
inhibitory neurotransmitters diminishing the intensity of pain
transmitted to higher centres.57 DTF produces breaking down
of the cross links or adhesions that have been formed, softening
the scar tissue and mobilising the cross links between the mutual
collagen fibres. 17, 18, 20, and 22
Cyriax stated that Mills Manipulation should be performed
immediately after DTF to elongate the scar tissue by rupturing
the adhesions within the teno-osseous junction making the area
mobile and pain free.23
MWM and Cyriax both were initially superior to the control
group with no significant difference amongst themselves but
this effect was lost in the follow up period of one month, in which
the follow up results showed reversal in all three outcome
measures for Cyriax interventions. Furthermore, Ultrasound
(control group) gave poor outcome both in post treatment and
follow up showing that it is not effective treatment strategy as
are MWM or Cyriax.
Results of ultrasound as indicated by the analysis of control
group, failed to show any improvement in any of the outcome
measures on the basis of therapeutic effects of ultrasound in
tennis elbow.
At one month follow up MWM is superior to Cyriax
intervention on global improvement in all 3 measures. Cyriax is
superior to ultrasound (control group) for all outcome measures.
Long term results of the study were not evaluated but Smidt et
al concluded that given appropriate advice, tennis elbow is a
self-limiting condition at 52 weeks in most cases.25
The reported efficiency of MWM over Cyriax & ultrasound
and maintenance of its beneficial effects even after
discontinuation of treatment are substantiated by many theories
and studies. Both Exelby and Wilson postulated a
neurophysiological rationale for the success of this approach.26
Mulligan favours a biomechanical thesis citing a theoretical
positional fault.27
Paungmali A et al concluded that MWM treatment exerted
a physiological effect similar to that reported by spinal
manipulations and also that it is capable of concurrent
hypoalgesic effects during and following its applications, as well
as altering somatic nervous system function.28
All the above mentioned theories and studies are very much
in accordance with the results of the present study proving the
beneficial effects of MWM over Cyriax and control group in post
treatment and follow up periods.
There are certain limitations of the study. 1.
Discrepancy in the number of treatment sessions between the
protocols; the MWM protocol was administered for four treatment
sessions over a two week period, whereas Cyriax and ultrasound
were administered for three sessions per week for four weeks.
But the discrepancy taken into account, the results should have
been in favour of Cyriax or control group for their longer treatment
sessions, which was not so.
2. The long term effects of all the 3 groups were not
evaluated to encounter whether any difference would still prevail
amongst the groups as is cited by Smidt et al after 52 weeks of
treatment.
3. Use of ultrasound in all the 3 groups which would
further reduce the generalisibility of results purely to either of
the two experimental conditions i.e. MWM or Cyriax.
Furthermore, another purpose of using ultrasound was to soften
the fibrosed tissue before applying either form of mobilisation.
Pooja Bhardwaj / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
145
Therefore, it was administered for 4 sessions in mulligan group

and 12 sessions in cyriax group as per their recommended
protocols. This led to the discrepancy among the number of
ultrasound sessions in both mulligan and cyriax group. This
discrepancy taken into account, the results should have been in
favour of either cyriax or control group, which was not so. Hence,
unequal ultrasound sessions did not lead to any significant
differences in results, and the results were still better with lesser
number of ultrasound sessions in MWM group.
4. Last, but not the least, the amount of force
recommended for MWM is not stated in mulligans text. Mc Lean
et al (2002)29 did a study to demonstrate the amount of force
used, using hand held dynamometer and showed that 66% or
100% resulted in significant gains but these parameters were
not included and force is purely guided by the comfort level of
patient, which did not produce pain while performing the
movement.
This study compared the effects of MWM and Cyriax on
tennis elbow patients and found significant differences among
the results at the end of one month of follow up period. The
effects at the end of 52 weeks of treatment were not seen, to
analyse whether any significant differences will exist at the period
of time or not as indicated by Smidt vet al, therefore the future
research is warranted. The sample size could be enlarged in
future research for better generalisibility of results. The
discrepancy in the number of treatment sessions among the
MWM and Cyriax group should be overcome to see the exact
improvement in outcome measures with similar number of
treatment sessions.
Quantification of the force was not done while administering
the MWM and the amount of force was purely guided by the
comfort level of the patient. Therefore future studies should
consider the recommended force levels while administering the
technique to eliminate the individual force differences.
8.
9.
10.
11.
12.
13.
4.
14.
15.
16.
17.
18.
19.
20.
Conclusion
MWM and Cyriax, both were effective in reducing pain and
improving grip strength after the treatment sessions. But benefits
of MWM in tennis elbow patients as compared with Cyriax in
follow up period are substantial, therefore proving MWM to be
the better treatment strategy than Cyriax.
21.
22.
23.
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Use of electrical stimulator to detect neurosensory changes - a

case report
Prachur Kumar*, C.S Ram**, Suhas S. Godhi***
*M.D.S, Senior Lecturer, Department of Oral and Maxillofacial Surgery, K.M.Shah Dental College & Hospital, Vadodara, **M.S.P.T,
Director, Department of Physiotherapy, I.T.S, Ghaziabad, ***M.D.S, Professor, I.T.S C.D.S.R., Ghaziabad
Abstract
The zygomatic bone provides prominence to the cheek
which leads to its increased chances of fracture and the
infraorbital nerve is often involved in the trauma to the zygomatic
complex resulting in the sensory disturbance of the area
innervated by it. The aim of the study was to evaluate the
persistent sensory disturbances of the infraorbital nerve after
recovery from isolated zygomatic complex fracture. The patients
was evaluated for sensory disturbances in infraorbital nerve by
performing two tests that included Pin prick test and Electrical
detection threshold test. The results suggested that
neurosensory disturbance in infraorbital nerve was present in
the patients with zygomatic complex fracture. At one month postoperatively some sensory deficit was present on the affected
side. After six months the patient showed near to normal
improvement comparable to normal side.
Keywords
Neurosensory , Electrical Stimulator, Electrical detection
threshold
Introduction
Pain, temperature, touch, pressure, and proprioception
(sense of body position) are transmitted centrally from the perioral structures via the inferior alveolar, lingual, infraorbital and
mental nerves. Each of these sensations is carried out by
different types of sensory receptors and nerve fibers, each
showing different susceptibility to injury and recovery. After an
injury, each of these sensory modalities must be tested and their
recovery must be monitored. Maxillofacial neurosensory
deficiencies may be caused by various surgical procedures such
as third molar surgery, trauma, osteotomies, preprosthetic
procedures, excision of large tumors or cysts, surgery of
temporomandibular joint.1
Electrical detection threshold

Fig 1: Lateral side of nose
The sensory disturbances of the infraorbital nerve are

frequently present in zygomatic complex fractures.2 The nerve
can be damaged by a secondary mechanism through a blunt,
crush type of injury or by a bony compression of the nerve at the
fracture site as it leaves the infraorbital foramen.3
Case report
A female patient 35 yrs of age reported to Department of
Oral and maxillofacial surgery with a chief complaint of swelling
on her face on the right side along with numbness and was
unable to open her mouth. Patient had a road traffic accident
which occurred while she was traveling on a bike along with her
husband and had a fall from the bike .She had a fall which caused
her face to hit the ground on the right side. Her medical history
was unremarkable. Tenderness was present at the right side at
the infraorbital rim .On examination a definite step was present
at the infraorbital rim along with pain and swelling on the affected
side. Paresthesia was present on the right side (lower eye lid,
lateral side of the nose, upper lip and cheek). Radiographic
examination revealed zygomatic complex fracture right side. To
evaluate the neurosensory defecit Electical detection threshold
test along with Pin prick test was performed. We performed
electrical detection threshold test at all the four sites (lower eye
lid, lateral side of the nose, upper lip and cheek) (Fig.1).
Continuous trains of Interrupted Galvanic stimuli were delivered
through a pen electrode (active) from an electrical stimulator
device (Vectrostim) (Fig.2). Passive electrode was placed behind
the neck. Stimulus frequency was 100 Hz. Polarity of the
electrodes was randomized. Stimulating current was increased
at a fixed rate until the subject indicated detection. The detection
threshold value at each location was noted. Results were
expressed in ratios between the injured side and the control
side. Pin prick test was performed with the help 0.2-mm diameter
blunted acupuncture needle (Fig.3) which was pushed against
the patients skin until the needle slightly bends (the skin will be
dimpled but not penetrated)(Fig. 4). The graded sensation of
patient was recorded in 100 mm visual analogue scale. Results
were recorded as the difference in the VAS values between the
control and injured sides.
Material used
Fig. 2: Electrical stimulator device (Vectro Stim) used for
electrical detection threshold.
Prachur Kumar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
147
Fig. 3: 0.2-mm diameter blunted acupuncture needle used for

pin prick test
For the treatment of the fracture zygoma was done by

performing Open reduction with internal fixation using 2 mm
stainless steel plate along with screws.
Patient was again evaluated again with both these tests
after one month and showed hyposthesia on the affected side.
On evaluation of the patient after 6 months the patient showed
near to normal sensation on the affected side when compared
with the unaffected side.
Discussion
The infraorbital nerve is often involved in trauma to the
zygomatic complex at the site of the infraorbital fissure,
infraorbital canal, or foramen. The neurological symptoms arise
from the fact that the fracture line runs through or in the
immediate vicinity of the infraorbital canal and foramen, affecting
the infraorbital nerve.4 This results in sensory disturbances
including all kinds of dysaesthesia and neuralgic pain skin of
the lower eyelid, cheek, lateral side of the nose, and upper lip
and to the labial mucosa, gingival and teeth.3
Previous studies have shown that the frequency of
persistent sensory disturbance was independent of the method
of reduction and fixation. However, a little more favorable results
were obtained in those cases in which infraorbital nerve was
explored and relieved at the infraorbital foramen. Some were
able to prevent persisting morbidity of the infraorbital nerve
regardless of the treatment procedures.
In the present study the recovery of the infraorbital nerve
function was evaluated with two different procedures which
included electrical detection threshold and pin prick method.
Patient was treated by open reduction and miniplate fixation
and almost complete recovery of infraorbital nerve was observed
after 6 months.
However it is extremely difficult to compare across studies
that have employed diverse methodologies to assess nerve
function. Two-point discrimination, pressure thresholds , pinprick
test , gross assessment with sharp and blunt instruments and
thermography, and gross temperature assessments have all
been adapted to the study of nerve recovery following
trauma.5,6,7,8,9..
Physiological studies have confirmed the Lewis theory,
stating that when a nerve is compressed, the fibers are affected
differently: the bigger the fiber, the more likely to be affected by
trauma. Fibers are therefore affected in the order of their size.10
Electrical detection threshold and Pin Prick are relatively
less used in the assessment of nerve recovery. The advantage
of multimodal testing is the ability to differentiate between largely
mechanosensitive neurons (A fibers) by employing electrical
stimuli and Pin prick for selectively activated nociceptors (A
and C fibers).9 Electrical threshold and pinprick responses are
useful tools.
Most cases of Infraorbital nerve dysfunction following
zygomatic fractures will recover by 6 months. The incidence of
residual sensory dysfunction varies with the testing modality.
148
Fig 4: Photograph of Pinprick test being performed on the cheek
Conclusion
Nerve recovery can be accurately tested using electrical
detection threshold method.
Legends
Preoperative
Electrical threshold detection test findings
Site
Control side
Affected side
Lower eye lid
5 amp
5 amp
Lateral side of nose
3 amp
4 amp
Upper lip
3 amp
3 amp
Cheek
3amp
6amp
Pre operative pinprick test findings as VAS score

Site
Control side
Affected side
Lower eye lid
2
1
2
4
Upper lip
2
3
Cheek
2
6
Findings of Electrical threshold detection

After one month
Site
Control side
Affected side
Lower eye lid
4 amp
5 amp
3 amp
3 amp
Upper lip
4 amp
3 amp
Cheek
3 amp
4 amp
Pinprick test findings as VAS score after 1 month

Site
Control side
Affected side
Lower eye lid
2
3
2
3
Upper lip
3
5
Cheek
2
4
After six month

Findings of Electrical threshold detection
Site
Control side
Affected side
Lower eye lid
4 amp
4 amp
3 amp
3 amp
Upper lip
3 amp
2 amp
Cheek
4 amp
4 amp
Prachur Kumar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
Relationship between depression and duration from the onset of

injury in traumatic spinal cord injured patients
Renu Singh*, Ruby Aikat**
*Research Student, ISIC Institute of Health and Rehabilitation Sciences, Vasant Kunj, New Delhi, **MOT (Neurology), Lecturer,
ISIC Institute of Health and Rehabilitation Sciences, Vasant Kunj, New Delhi

Research finding regarding relationship between
depression and duration from the onset of injury in traumatic
spinal cord injured patients.
Study design
Correlational survey design.
Subjects
96 subjects were recruited from Indian Spinal Injuries
Center, Vasant Kunj, New Delhi.
Method
Purposive sampling of 96 SCI subjects was done according
to inclusion criteria and exclusion criteria. Written informed
consent had been taken from the subjects, in English or
Hindi languages. The quadriplegia patients, who could not
sign the consent form, thumb-impression had taken. After
taking the in formed consent, the subjects were divided into
3 groups depending upon the duration of SCI, i.e. 0-1
month (group-1), >1-6 months (group-2), and >6-12 months
(group-3) post injury. In each group there were both
quadriplegic, and paraplegic patients. Depression was
assessed by CES-D scale.
Results
Weak correlation between CES-D and duration from
onset of injury was found for the total sample, r-value
0.039. The comparison of CES-D among the three groups
was taken. The mean value of group-3 was higher than the
mean value of other two groups. Also, the f-value was 0.67
but was not significant at level 0.05. Comparison of CESD scores with the level of injury i.e. quadriplegics and
paraplegics for the total sample was done. Paired t-value
was 5.57** which was highly significant at p < 0.01 level.
Comparing on the basis of age groups (20-35 years and
36-50 years age-ranges), the younger age group had higher
mean value than the older group.
Conclusion
The level of depression was found to be higher in
group-3, that is >6-12 months from injury, as compared to
the other two groups 0-1 month, >1-6 month.
Depression was found to be highly significant in
quadriplegics in all groups (0-1 month, >1-6 months, >6-12
months) as compared to the paraplegics .
Also, the results showed that the depression was more
in younger age group (i.e. 20-35 years) as compared to the
older age group 36-50 years.
Spinal cord injury is defined as damage or trauma to
the spinal cord that in turn results in a loss or impaired
function resulting in reduced mobility or feeling. 1
It is a low incidence, high cost disability requiring
150
tremendous changes in an individuals life-style. The effects

of SCI have an impact not only on the lives of the client
and family but also on society as a whole. Clients need a
well-coordinated, specialized rehabilitation program consisting
of a team of physicians and health care professionals to
provide the tool necessary to depression and hopelessness,
an indirect indicator of suicide risk in the SCI population.
According to a study done by Y. Kishi. The mood
disorders appear to be related to the heterogeneous
etiological factors, including previous psychiatric history and
severity of impairment in activities of daily living. It could
also be seen that starting three months after SCI, about
half of the depressions resolved. Nonrecovery from
depression may be related to lack of adequate social
support. 3
But the depressive disorders developed within a month
of the injury as well as post injury depressive disorders
were more common in patients with complete spinal cord
lesions and were divided equally between paraplegics and
quadriplegics. 4
Depression is a condition that causes feeling of sadness
and hopelessness. It may be short term or long term. It
affects the persons health, interpersonal relations, work,
and ability to enjoy life. Depending upon its severity, most
people, when properly assisted, will experience significant
improvement within a few weeks and complete improvement
within 6 to 12 months. Improvements in the symptoms of
depression quickly lead to improvement in other areas,
including personal relations, motivation, health and quality
of life. 5
The CES-D scale is one of the most common screening
tests for helping an individual to determine his or her
depression quotient. The quick self-test measures depressive
feelings and behaviours during the past week. 6, 7
The CES-D scale is designed to measure depressive
symptoms in the general population. The 20-item selfadministered scale measures the major components of
depressive symptomatology, including depressive mood,
feeling of guilt and worthlessness, psychomotor retardation,
loss of appetite and sleep disturbances. 8
From the Medical Record Department (MRD) of ISIC
Hospital by the permission of Medical Superintendent (MS).
Written informed consent had been taken from the subjects,
in English or Hindi languages. The Quadriplegia patients,
who could not sign the consent form, thumb-impression
had been taken. After taking the in formed consent, the
subjects were divided into 3 groups depending upon the
duration of SCI, i.e. 0-1 month (group-1), >1-6 months
(group-2), and >6-12 months (group-3) post injury. In each
group there were both quadriplegia, and paraplegia. The
Demographic details had been taken. Then the Depression
was assessed by CES-D scale.
CES-D with duration
There is weak correlation between CES-D and duration
from onset of injury for considering all for the whole
sample (Table-1). r-value 0.039, p-value 0.01.
develop a satisfying and productive post injury lifestyle. 1
In the light of these disabilities, the mental state of
patients also has been considered and many researchers
Renu Singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
have documented the elevated levels of depression and

suicide in the spinal cord injured populations, with the
majority of suicide attempts occurring within 12 months of
injury onset. Various social supports have been linked with
the depression and suicidal intent, and its mandatory to
determine the impact of the quality and quantity of the
social support on levels of
Methods
A purposive sample of 96 SCI subjects took part in the
study those were being assessed at the Rehabilitation
Department of ISIC, Vasant Kunj, New Delhi.
Variables
Independent variable - Duration from onset of SCI.
Level of injury.
Age range.
Dependent variables - CES-D scale.
Inclusion criteria
1. Traumatic SCI.
2. Age group - 20-50 years.
3. Both males and females.
4. Duration of SCI up to 12 months from onset of SCI.
Exclusion criteria
1. Any other higher mental function disorder.
Withdrawal criteria
1. Frustration and irritability on the part of the patients.
2. Subject wishes to withdraw his participation any time
during the course of the study.
Instrumentation
1. Centre for epidemiologic studies depression
scale ( CES-D scale ) in English.
2. Centre for epidemiologic studies depression
scale ( CES-D scale ) in Hindi.
Procedure
Translation of CES-D scale in to Hindi: After taking
permission from the author, the developer of quick self-test
measures depressive feelings and behaviours during the
past week. 6, 7
The CES-D scale is designed to measure depressive
symptoms in the general population. The 20-item selfadministered scale measures the major components of
depressive symptomatology, including depressive mood,
feeling of guilt and worthlessness, psychomotor retardation,
loss of appetite and sleep disturbances. 8
From the Medical Record Department (MRD) of ISIC
Hospital by the permission of Medical Superintendent (MS).
Written informed consent had been taken from the subjects,
in English or Hindi languages. The Quadriplegia patients,
who could not sign the consent form, thumb-impression
had been taken. After taking the in formed consent, the
subjects were divided into 3 groups depending upon the
duration of SCI, i.e. 0-1 month (group-1), >1-6 months
(group-2), and >6-12 months (group-3) post injury. In each
group there were both quadriplegia, and paraplegia. The
Demographic details had been taken. Then the
Depression was assessed by CES-D scale.
Data analysis
The data was managed on an Excel spreadsheet and

was analyzed using SPSS software. Statistical tests used
were t-test, DUNCANS Mean Test and Pearson correlation
coefficient to analyse the data.
CES-D with duration
There is weak correlation between CES-D and duration
from onset of injury for considering all for the whole
sample (Table-1). r-value 0.039, p-value 0.01.
CES-D scale, for getting the CES-D scale translated
into Hindi, the translation procedure was done by the Back
Translation Method. 9 Then the Hindi version was piloted on
Table 1: Correlation of duration with CES-D in the whole
sample i.e. (N=96).
DURATION CESD
DURATION Pearson Correlation 1
.039
Sig. (2-tailed)
.708
N
96
96
CESD
Pearson Correlation .039
1
Sig. (2-tailed)
.708
N
96
96
Significant at level 0.01.
10 SCI Hindi speaking patients.
Sample selection procedure
Purposive sampling of 96 SCI subjects was done
according to inclusion criteria and exclusion criteria. Out of
the total 96 patients, 90 patients had been taken from ISIC
Rehabilitation Center. Also, the addresses of the discharged
SCI patients who fulfilled the inclusion criteria had been
taken The comparison of CES-D among the three groups
was taken through the DUNCANS Mean Test and the
respective means and standard deviation for each groups
are as ( Table-2). Out of these three set of datas, the mean
value of group-3 is higher than the mean value of other
two groups. Also, the f-value is 0.67 which was not significant
at level 0.05.
CES-D with level
Comparison of CES-D scores with the level of injury
i.e. quadriplegics and paraplegics. In the whole sample,
comparing the CES-D between quadriplegics and paraplegics
(Table-3), the quadriplegics had a higher mean value.
Paired t-value was 5.57** which was highly significant at
p < 0.01 level.
Comparison of CES-D between diagnosis-1
(quadriplegia) and diagnosis-2 (paraplegia) of group-1 (Table4). By this, it is quite obvious to see that diagnosis-1 has
higher mean value than diagnosis-2. Also, paired t-value is
2.25* is significant at p < 0.05 level
In the similar manner, the comparison of CES-D
between diagnosis-1 and diagnosis-2 of group-2 (Table-5),
out of which, diagnosis-1 has higher mean value. Paired tvalue is 4.22** which is highly significant at p < 0.01 level.
In similar ways, the comparison of CES-D between
diagnosis-1 and diagnosis-2 of group-3. It is also seen that
diagnosis-1 has higher mean value (Table-6). Paired t-value
is 3.24** which is again highly significant at p < 0.01 level.
CES-D with age range
Now comparing on the basis of age groups
(2035 years and 36-50 years age-ranges)
(Table-7). The
group-1 has higher mean value than group-2 and the tvalue is 0.06 which is not significant.
Table 2: Comparison of CES-D among those group (Gp-1 duration < 1 month, Gp-2 duration, 1-6 months, Gp-3 duration 612 months) DUNCANS Mean Test.
Variables
GP-1 (N=30)
GP-2 (N=33)
GP-3(N=33)
G1 V/S G2
G1 V/S G3
G2 V/S G3 F-Value
Mean
SD +_
Mean
SD +_
Mean
SD +_
CES-D
19.27
7.96
18.21
8.50
20.64
9.03
0.67
Not significant at p < 0.05 level.
Renu singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
151
Table 3: Comparison of CES-D between diagnosis-1

(quadriplegia) and diagnosis-2 (paraplegia) whole sample
i.e. (N=96).
Diagnosis
N
Mean
SD +_
T-Value
Diag-1
48
23.58
8.50
5.57**
Diag-2
48
15.16
6.68
Table 4: Comparison of CES-D between diagnosis-1
(quadriplegia) and diagnosis-2 (paraplegia) of group 1 (< 1
month).
Diagnosis
N
Mean
SD +_
T-Value
Diag-1
15
22.33
7.33
2.25*
Diag-2
15
16.20
7.56
*Significant at p < 0.05 level.
Table 5: Comparison of CES-D between diagnosis-1 and
diagnosis-2 of group 2 (1-6 months).
Diagnosis
N
Mean
SD +_
T-Value
Diag-1
17
23.11
8.52
4.22**
Diag-2
16
13.00
4.50
**Significant at p < 0.01 level.
Table 6: Comparison of CES-D between diagnosis-1 and
diagnosis-2 of group 3 (6-12 months).
Diagnosis
N
Mean
SD +_
T-Value
Diag-1
16
25.25
8.41
3.24**
Diag-2
17
16.29
7.43
**Significant at p < 0.01 level.
Table : 7 Comparison of CES-D between 20-35 years and
36-50 years.
Variables
Gp-1 (N=57)
Gp-2 (N=39)
t-value
Mean
Std
Mean
Std
0.06
Dev
Dev
CES-D
19.52
8.81
19.41
8.29
Not significant at p d 0.05 level.
Discussion
CES-D with duration
In the present study, the duration was correlated with
the CES-D. A weak correlation between
CES-D and duration from injury, for 96 subjects, was
found ( Table 1 ). The possible reason could be the various
factors that affect the level of depression. Some factors
tend to increase and some level to decrease the level of
depression. For example, according to A. Beedie 2 and Y.
Kishi, 3 soon after injury the depression is usually more, as
patient receives increase as there is some impression
depression might become less as patient may become
hopeful of improvement gradually as patient realise that
improvement has reached a plateau and he is still not
independent in all his activity of daily living and other
elements he is likely to get depressed again. This could be
one of the reason why a high correlation has not been
found in my sample of subjects.
Also when the CES-D scale was compared among all
the three groups i.e. 0-1 month (group-1), >1-6 months
(group-2), >6-12 months (group-3) (Table 6 ), the result was
not significant. The possible reason could be that, as
supported by the past studies, depression is a symptom
which is seen in most of the SCI patients, irrespective of
their duration from the injury. 2,3,4
CES-D with level of injury
Now, when comparing the levels of depression according
to the level of injury i.e. diagnosis-1 (Quadriplegic) and
152
diagnosis-2 (Paraplegic)
(Table 3), the depression was
found to be more in the quadriplegics and results were
highly significant. Possible reason could be that the level of
disability and dependence on others for activities of daily
living is much more in quadriplegics as compared to
paraplegics (Table 3), contributing to higher degrees of
feelings of sadness and depression. 10
CES-D with age range
When comparison of level of depression was done
in the 2 age range i.e. 20-35 years and 36-50 years
(Table 7), the results showed that depression was more in
younger age group i.e. 20-35 years as compared to 36-50
years. Possible reason could be that the younger age
group usually had people who had not settled in their lives
yet: during this age people have aspiration and unfulfilled
ambitions in life. As a consequence of SCI, that gets
shattered, leading to a high degree of depression as
compared, to age group 36-50 years.
Significance of the study

The result of this study show that when we plan the
occupational therapy program for a SCI patients we need
to keep in mind the duration from injury and correspondingly
the likely level of depression in the patients.
Also, since the study shows that quadriplegics suffer
from depression more than paraplegics. This aspect also
has to be kept in mind when giving therapy to such
patients.
Also, while dealing with SCI patients belonging to
younger age group, we need to emphasise more upon
counselling and managing the levels of
depression, as compared to when dealing with the
older age group.
Conclusion
Conclusion of this study is that the level of depression
was found to be higher in group-3, that is >6-12 months
from injury, as compared to Depression was found to be
highly significant in quadriplegics subjects in all groups (01 month, >1-6 months, >6-12 months) as compared to the
paraplegics subjects.
Also, the results showed that the depression was more
in younger age group (i.e. 20-35 years) as compared to the
36-50 years age group.
Limitations
The relationship of depression was found out with only
one variable that is duration from injury. Relationship with
other variables such as age etc was not out.
Future recommendations
A large sample can be taken such that gender based
comparison can be performed.
Acknowledgements
Appreciation is expressed to Ms. Ruby Aikat, M.O.Th.,
Lecture of Occupational Therapy (Neurology), ISIC Institute of
Health and Rehabilitation Sciences, for her unwavering
encouragement, valuable advice and expertise. More words
do not suffice to express my feeling and gratitude to all
Spinal Cord Injury Patients, without whose participation the
study would have not been completed.
References
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Call for Papers/Article Submission

Indian Journal of Physiotherapy and Occupational Therapy has commenced publication since 2006. IJPOT will he published
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Purpose & Scope: IJPOT is a multidisciplinary refereed journal devoted to disseminating rigorous research on all aspects
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The journal encourages research from theoretical perspectives, research reports of evidence based practice as well as
praxis research work that focuses on the interface between theory and practice and how each can support the other. In
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Renu singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
153
Efficacy of Mulligan Concept (NAGs) on Pain at available end

range in Cervical Spine: A Randomised Controlled Trial
Kumar D1, Sandhu J S1, Broota A2,
1
Guru Nanak Dev University, Amritsar, 2University of Delhi, Delhi.
Abstract
Purpose
The aim of the study is to evaluate the effects of NAGs on
pain at available end range in cervical spine pain and stiffness.
Method
Ethical approval was taken from Guru Nanak Dev University.
It is a repeated measure design, with double blind controlled
trials. VAS score in available end rage and the range of motion
were the dependent measures.
Participants
100 patients, attending OPD, suffering from mechanical
neck pain, meeting the predefined criteria were included in the
sample. The sampling was incidental; subjects were randomly
assigned to 3 experimental and 1 control group. All groups
received hot packs for 12 minutes along with set of active
exercises from day 1 to day 12. In experimental group 1, 2, and
3, NAGs as mobilisation technique was added at different points
of study. All patients were assessed before and after the
treatment on day 1, 2, 6, 7, 12 and 42 as follow up.
Analysis
Simple analysis of covariance (ANCOVA) with post-hoc ttest with adjusted means and graphical presentations.
Results
A significant improvement in ROM and decrease in pain at
available end ranges was noticed in all experimental groups
immediately after NAGs and was maintained on 42nd Day. Group
1 showed better recovery than group 2 and 3.
Conclusions
The results indicate that the NAGs is a useful manual
therapy technique for achieving faster result as measured in
terms of ROM and pain at available end ranges.
Keywords
NAGs, Pain, Range of motion and Cervical Spine.
Introduction
Neck pain is one of the commonest musculoskeletal
disorders more common in women and its prevalence gradually
increases with age1,2,. They also stated that certain cervical
movements like turning and bending result in unbearable pain,
crunching sounds and a feel of neck stiffness. Along with neck
Address for correspondence:
Deepak Kumar
179, Basement, Jagriti Enclave
Karkardooma, Delhi-110092, India
Tel: +919810265641; deepakcapri@hotmail.com
154
pain, other disabling features of neck disorders are decrease in

range of motion3,4 and altered position sense5. Ct6 reported
that in comparison to low back pain, neck pain has been poorly
researched. In a population-based study by Evans7, in Canada
and Finland, 70% of adults had suffered from neck pain at some
stage of their life. They also concluded that 5-10% of such
population complained of severe disability and around 14%
developed chronic pain. Whereas, in a 3 months epidemiological
study it was reported that 31% of the population suffered from
neck pain in the U.S.8 Though little is known about its aetiology
and its related disability, workplace physical exposures like
sedentary work position, repetitive work, precision work,
awkward work postures, physical work environment, and
computer workstation setup and psychosocial exposures like
quantitative job demands and social support at work are the
risk factors for neck pain in workers 9,10. Neck pain has a
multifactorial aetiology and its development is dependent on
the presence of more than one risk factor9. Disability associated
with neck pain varies from less to highly severe and its incidence
in the general population is very common 11 and results in a
considerable economic burden12, 13. MaCaulay14 reported that
neck pain has personal (pain and stiffness), social (disability)
and health system costs. It has been estimated that pain and
stiffness is responsible for over 500 million dollars in lost wages
each year, and people with pain and stiffness lose an average
of two and one-half work days each month7,15. Hence, personal
sufferings and lost work productivity have been some of the
reasons that require effective management of this condition.
A large number of conservative treatment options are
reported in the literature for treating mechanical neck pain. There
has been a mixed response available regarding their efficacy.
Therapies involving manual therapy and exercise were found
to be more effective than alternative strategies for patients with
neck pain16. Increasing inclination towards manual therapy was
seen in a U.S. survey in which 54% of total patients sought
treatment from manual therapist17. Mulligans approach is
frequently used in clinical practice for reducing pain and
improving functional abilities of neck pain sufferers18. Passive
oscillatory movements called natural apophyseal glides (NAGs)
and sustained glides with active movements are the mainstay
of Mulligans spinal treatment concept 19. NAGs are
predominantly useful in restoring painful loss of active cervical
motion20. Further, NAGs are much less likely to provoke latent
pain than other spinal techniques.
The literature on the efficacy of Mulligan techniques is
scanty and descriptive case report publications 20,21 generally
dominate whatever researches are available. Exelby22 presented
a paper on application of mulligan concept on spinal conditions
in which she reported the clinical examples to illustrate the
concepts application to the spine, how it has evolved and been
integrated into constantly changing physiotherapy practice.
Personal sufferings and lost work productivity have been
some of the reasons that require effective management of
cervical spine pain. The limited evidence of the effectiveness of
Mulligan techniques in the cervical spine, lack of literature on its
efficacy in improving the cervical spine problems and
recuperating the patients daily activities encouraged the author
to further explore the problem. The objective of the present
research, therefore, is to provide an integrated source of
evidence-based information, which can be used to bridge the
Kumar D. / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
gap between research and best practice.
Aims and objectives
To evaluate the efficacy of Mulligan concept in improving

ROM in lower cervical pain and stiffness.
To evaluate the efficacy of Mulligan concept in decreasing
pain at available end ranges in lower cervical pain and
stiffness.
To establish a scientific evidence to use Mulligan Concept
for the benefit of the patient.
Methodology
Double blind, randomized, controlled clinical trials with 4
different treatments. It is a single factor analysis of covariance
(ANCOVA) design23. A total of 100 subjects were assigned
randomly to the 4 groups, 3 experimental and 1 control, on the
basis of predefined inclusion and exclusion criteria.
Inclusion Criteria
Both male and female subjects of 30 years and above.

Patients with either local spinal pain or joint stiffness or
combination of both between C3-C7 with no radiating pain
in the upper limbs.
Neck pain that was located at least partly in the area defined
by Merskey24, i.e. anywhere within the region between
superior tip of 3rd cervical spinous process and an imaginary
line drawn through the tip of the 1st thoracic spinous process
and laterally by sagittal planes tangential to the lateral
border of neck.
The pain was of perceptible intensity to the individual to
permit a clinically demonstrable effect.
Only subjects who gave informed consent in writing were

included.
Exclusion Criteria
Subjects were excluded if found to have any of the following

disease or had them in last 6 months: Cancer, Tuberculosis,
Osteoporosis, aortic aneurysm, Neurological deficit due to
Prolapsed inter vertebral disc, Vertebrobasilar insufficiency,
local infection of cervical spine, lymphadenopathy, recent
trauma to cervical spine, cervical myelopathy, upper motor
neuron disorder, metabolic bone / joint disorder, hyper
mobility, on anticoagulant therapy, on steroids, on
chemotherapy, on radiotherapy, and psychological
disorders like depression, mania or any other major
psychosomatic problem. All these conditions are
contraindicated to any manual therapy.
If they had undergone neck surgery in the previous twelve

months.
Four groups (1, 2, 3, and 4) were formed through random
assignment. Further, the 4 treatments were assigned randomly
to the groups. Patients were assessed on day 1, 2, 6,7,12, and
42 (as follow-up) and both pre- and post-treatment data were
recorded. Range of motion (ROM) of cervical spine and pain
intensity in all six cervical ranges, at available end range was
recorded. In present research, dual inclinometer technique was
used for measuring cervical spine ROM as American Medical
Association25,26 has accepted the inclinometer as a feasible and
potentially accurate method of measuring spine mobility figure:
1(a), (b), (c), and (d) demonstrate the placement of inclinometer
to record various ranges. VAS is the standard tool for rating the
pain either by patient himself or by the health care workers,
thus, used as a tool for measuring pain levels. The patients
were asked to track the pain along a straight line by circling the
number that best describes the question being asked. As a
Fig. 1: Position of the bubble inclinometers measuring

A: Flexion
B: Extension
C: Side flexion
D: Rotation.
Kumar D. / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
155
Fig. 2: NAGs. Position of the patient & therapists hand

placement.
improvement in terms of VAS in side flexion and a highly

significant difference is seen. The value of F (between O1 and
O14) of different groups associated with ANCOVA, of VAS in side
flexion to left and to right are found to be [F (3,95) =4.02; p <
.01] and [F (3,95) =5.33; p < .01], respectively. While studying
the collected data of VAS in rotations, a significant difference is
observed between the group treated with NAGs and group
treated with sham intervention. The value of F associated with
ANCOVA in VAS in rotation to left is [F (3, 95) =6.59; p < .01]
while the value of F in VAS in rotation to right is [F (3,95) =6.15;
p < .01]. Figure 3 shows the adjusted means of VAS at available
end ranges in all ranges of cervical spine.
Fig. 3: Adjusted means of VAS in all available end ranges in
the cervical spine, O1 (pre-Treatment) and O14 (Average of six
posttreatments) of different groups
treatment, all 4 groups received hot pack for 12 minutes along

with a set of active range of motion exercises and isometric
strengthening exercises for the cervical spine. NAGs are
oscillatory accessory movements in anteriocranial direction,
gliding one spinal facet upon facet beneath it, and are performed
passively on a patient21. Wilson20 mentioned that NAGs are
carried out in mid to end range and are used to treat movement
problems originating from C2-T3. Applied centrally or unilaterally
with the cervical spine in neutral or positioned in the direction of
movement limitation. Direction of the glide is upwards and
forwards, towards the patients eyes. Patient was seated
comfortably on a chair before the treatment to be delivered as
shown in figure 2. Group 1 (experimental 1) received Mulligans
Mobilization in forms of NAGs from day 1 to day 12. Group 2
(experimental 2) also received Mulligans Mobilization in form
of NAGs but only from day 1 to day 6. From seventh day onwards
this group was treated with sham intervention. Group 3
(experimental 3) did not receive any form of NAGs from day 1 to
day 6 and only a placebo was given. On 7th day onwards NAGs
was added to this group and continued till day 12. Group 4
(control) did not receive any form of NAGs on any day and only
the placebo was continued from day 1 to day 12. Frequency of
the glide was 1-2/sec and duration was 30 sec. in each set and
there were 3 sets in a session. Total treatment was for 12 days.
Patient was asked to do home exercises in the form of active
exercises and isometrics strengthening exercises. Patients were
regularly re-assessed on day 1 [post treatment, observation 2
(O2)], day 2 [post treatment, observation 4 (O4)], day 6 [post
treatment, observation 6 (O6)], day 7 [post treatment, observation
8 (O8)], day12 [post treatment, observation 12 (O12)], and day
42 [follow up, observation 13 (O13)], and the data were recorded.
Observation 14 (O14) is the average of the above mentioned six
post treatment and follow-up observations (O2 to O13).
In post-hoc comparison of both VAS in flexion and VAS in

extension (showing average of six observation between O2 to
O13) and the multiple comparisons among the means (t), it was
observed that the overall recovery between 1 vs. 4, 2 vs. 3, 2
vs. 4 is highly significant (p < .01) and 1 vs. 3 is significant at
(p<.05). This indicates that overall recovery of the group 1
receiving NAGs is significantly better than group 3 which started
receiving NAGs from 7th day onwards and group 4 receiving
placebo throughout, similarly group 2 is overall significantly better
than group 3 and group 4.
While studying the Range of motion it is observed that there
is a significant difference between the groups treated with NAGs
and sham intervention. The value of F (between O1 and O14) of
different groups associated with ANCOVA of range of motion in
flexion and extension is found to be highly significant. The value
of F in ROM (Flexion) and ROM (Extension) is [F (3, 95) =4.50;
p < .01] and [F (3, 95) =15.41; p < .01], respectively. ROM in
side flexion to left also showed similar results. The difference
Fig. 4: Adjusted means of all range of motions in the cervical
spine, O 1 (pre-Treatment) and O14 (Average of six posttreatments) of different groups.
Result
When studying the VAS scores at available end ranges of
all ranges of motion, it is observed that value of F (between O1
and O14) of different groups associated with ANCOVA are highly
significant. The values of VAS (Flexion) and VAS (Extension)
are found to be [F (3, 95) = 5.45; p < .01] and [F (3, 95) =6.83; p
< .01], respectively. This indicates that there is a highly significant
difference between the groups treated with NAGs and sham
intervention. All the experimental groups showed better
156
between the groups was found to be highly significant as the

value of F associated with ANCOVA in ROM in left side flexion
was [F (3,95) =6.16; p < .01]. However, the value of F associated
with ANCOVA in ROM in side flexion to right is not significant at
the conventional .05 level of confidence, but it is found to be
significant at .1 level of confidence [F (3,95) = 1.57; p < .1].
ROM in rotation to left and to right showed highly significant
differences. The value F associated with ANCOVA in ROM (Lt.
Side rotation) and ROM (Rt. Side rotation) is [F (3,95) =8.51; p
< .01] and [F (3,95) =6.30; p < .01], respectively. The significant
difference in ROM in all cervical ranges is evident from figure 4.
Discussion
It was found that NAGs is effective in improving the range
as well as decreasing the level of pain at newly achieved end
range. Post treatment observation revealed that ROM increases
after NAGs and VAS score at new range is also lower than VAS
score at pre-treatment range. After treating with NAGs, cervical
ranges are better and less painful. Decline in VAS scores can
be due to neurophysiological effect of NAGs. Excitation of
mechanoreceptors inside joint capsule initiates the stimulation
of higher centres, which in turn inhibits incoming nociceptive
information. This spinal gate control mechanism eradicated
pain27. Stimulation of other centres such as dorsal periaqueductal
grey matter (DPAG) region produces a profound and selective
analgesia28, and it has been implicated that spinal mobilization
therapy may exert its initial effects by activating this region.
VAS scores at available end ranges are reduced, which
can be explained by the positional fault theory18, mechanical
neck pain is usually associated with zygapophyseal joint maltracking and failure of the posterior column joints to glide properly
may result in an altered instantaneous axis of rotation and
increased anterior column stress 29,30,31. Mulligan 19 stated
physiology of NAGs can be explained as appropriate accessory
movement correcting the mechanical block within a joint and
make the joint return to it physiological position. The accessory
movement takes the joint through what would be the normal
physiological movement of the joint. The pre-injury joint tracking
is re-established reasserting the joint memory or prior
conditioning of the healthy joint. These techniques are unique
because they consist of the application of accessory glide to a
joint, after which the patient performs a previously painful
movement of that joint19. Reduction in pain seen may also
possibly be attributed to the fact that the accessory glide
component of cervical NAGs could ameliorate pain by either
separating the facet surfaces or releasing the entrapped
meniscoid, or by allowing the entrapped meniscoid to return to
its intra articular position, or perhaps by stretching adhesions. It
may be this intimate relationship that can best explain why NAGs,
which would appear to principally affect apophyseal joint function,
are often dramatically effective32. Significant improvement in
ROM may be attributed to the mechanical effect of NAGs.
Mechanical effects could involve a permanent or temporary
change in length of connective tissues structure such as joint
capsule of the zygapophyseal joints, ligaments and muscle.
Threlkeld33 suggests that the forces used in mobilization are not
great enough to result in micro failure of tissues and more likely
to cause temporary length changes due to creep which is
reversible over time. Motion involves a combination of vertebral
tilt and translations at the zygapophyseal joints 34,35. Vascular,
fat-filled synovial folds project between articular surface as
meniscoid inclusion, and are prone to bruising or rupture in
injuries forming joint hemarthroses36. After passive inter-vertebral
accessory movements the frequency of entrapment of synovial
folds readily decreases. After NAGs with no soft-tissue
entrapment, better physiological translation at facet joint and
increased range of motion pain is less in the patients. Rotations
are coupled with lateral bending further enhancing the chances
of lateral root compression through osteophytes. NAGs
decreases the chances of lateral root compression as stated by

Mulligan19 (1999) technique restores the normal movement
option to the joint, which may have both mechanical and
neurological components. Whereas, Wilson20 summarized that
the core of Mulligans work in symptom free joint mobilization
added to muscular activity. Better plane of movement and added
muscular activity increase the range of motion and decrease
the pain at available end range.
Conclusion
The results of this study highlight the effectiveness of NAGs
in improving Range of motion and decreasing pain at available
end range simultaneously in the patients suffering from cervical
pain and stiffness. NAGs is effective in improving the range as
well as decreasing the level of pain at newly achieved end range.
Group 1 and group 2 treated with NAGs show better and quicker
recovery than group 3 and control group. Better physiological
movements have led to decline in pain at available end ranges,
thus making the movement smoother and easier. This will serve
as evidence in establishing effectiveness of employing the
technique as a treatment of cervical pain and stiffness.
Limitations
With a sample size of 100 subjects, the number of elderly
participant being less in the sample, it may not be possible to
generalize the results of the study to larger population. Further,
the study was conducted at one place and with local population;
replicating the study with different populations could obviate this
deficiency. Besides treating cervical pain with NAGs, heating
modality and exercises were also introduced to take care of
ethical issues involved. Employing VAS score as a dependent
variable for measuring pain was a limitation to an extent, as it is
a subjective way of assessment. This being the first investigation
to study the efficacy of NAGs in treating cervical pain and
stiffness, the outcome of results has not been substantiated and
supported by other studies.
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ISSN P - 0973-5666

January - March 2011

Physiotherapy and Occupational Therapy

INDIAN JOURNAL OF PHYSIOTHERAPY AND

International Editorial Advisory Board

National Editorial Advisory Board

Efficacy of deep transverse friction massage in treatment of chronic ankle sprain

Footwear effects on balance and gait in elderly women of Indian

Moreover, in heeled shoes, heel elevation is associated

footwear and as normal walking shoes(25) respectively.

Graph-2 Comparison of TUG in different footwear conditions

Graph-3 Comparison of TMW in different footwear onditions

The ANOVAs revealed an overall footwear condition effect

gait speed than with no shoes.

Lord SR, Sherrington C, Menz HB. Falls in older people:

11. Duncan PW, Weiner DK, Chandler J, Studenski SA.

The effect of short term dynamic and isometric resistance training

of all adults at or over age 65 years exhibit radiographic evidence

Disability; dynamic resistance training; isometric exercises;

The study was conducted using pretest post test

previous six months, systemic inflammatory disease e. g. gout,

reading were taken at the baseline and at the end of intervention

Table 2 : Within group analysis of VAS Scores

Table 3 : Within group analysis of WOMAC

The results of the resistance training tested in the current

Felson DT, Naimark A, Anderson J, KazisL, Castelli

Rejeski WJ, Craven T, Ettinger WH Jr, McFarlane M,

21. Barrett DS, Cobb AG, Bentley G. Joint proprioception in

25. Hutton RS, Atwater SW. Acute and chronic adaptations of

Multimodal therapy in cervicogenic headache- a randomized

Multimodal therapy is significantly more effective than

terms such as cervical, occipital and cervicogenic to specific

Headaches which are believed to originate from structures

The study was a randomized controlled trial. Under

Aims and objectives

Summary of background data

physiotherapy department of Bhagwan Mahavir Hospital (Delhi).

jerky craniocervical flexion movement.

(3)Active range of motion exercise included cervical spine

Fig. 4: Comparison of mean values of headache intensity from

Fig. 5: Comparison of mean values of headache duration from

Fig. 6: Comparison of mean values of NDI scores from baseline

Analysis of performance index of deep neck flexors between

Fig. 7: Comparison of mean values of performance of deep

Fig. 8: Percentage of improvement in all outcome measures

group to know if placebo effect is taking place or not.

Sydney Kim Schoensee, Gail lensen, Garvice Nicholson,

International Headache Society Classification Committee.

headache: a single case study. Physiotherapy, 80(7), 417423, 1994.

Combined effectiveness of Maitlands mobilization and patellar

Materials & methods

and episode of patellofemoral instability along with stiffness and

Null Hypothesis {Ho}: There will be no beneficial effect to the

Materials and methods

border and push the patella medially.(Photo No.1)

Source of Data: KLES Dr. Prabhakar Kore hospital and MRC

Method of collection of data

Participants with radiological diagnosed as patellofemoral

Superior glide: Place the heel of the hand against inferior

Concomitant pai n from other knee structures, hip or lumbar

Inferior glide: Place the heel of the hand against superior

All the four Maitlands patellar glides will be given to both