Indian Journal of Physical Therapy

www.indianjournalofphysicaltherapy.com

Editor
Dr. Dinesh M. Sorani,
M.P.T. (Physical & Functional Diagnosis),
Senior lecturer,
Government Physiotherapy College, Jamnagar
Email:
[email protected]
Phone: +91-9426786167
Associate Editor
Dr. Paras Joshi
M.P.T. (Neurological Conditions)
H.O.D. Physiotherapy Department,
Civil Hospital, Rajkot.
Advisory Board
Dr. Nita Vyas (Ph. D.)
Principal,
S.B.B. College of Physiotherapy,
Ahmedabad

Dr. Anjali Bhise

M.P.T. (Cardio-Pulmonary Conditions)
Principal,
Government Physiotherapy College,
Ahmedabad

Dr. Yagna Shukla

M.P.T. (Orthopedic Conditions),
Senior Lecturer,
Government Physiotherapy College,
Ahmedabad

Dr. Sarla Bhatt

Principal,
Shri. K. K. Sheth Physiotherapy College,
Rajkot
 Indian Journal of Physical Therapy
www.indianjournalofphysicaltherapy.com

Editor’s Desk

Dear Physiotherapists,

It gives me great pleasure to write from editor's desk of Indian Journal of Physical
Therapy on the very first issue of volume.
Now-a-days era of evidence based practice has emerged. Whatever we give to the patient
in form of treatment whether it is electrotherapy or exercise therapy, we must have evidence that
that particular treatment is effective for the condition patient is suffering from.
From this journal our aim is to provide the researcher's view based on the evidences to all
possible Physiotherapy professionals. For each issue, we are bound to give study materials by
which one can give best to his/her patient. We also take care that in each issue, we provide
different subject related evidence based knowledge.
A lot of research work is going on at present in our country in the field of Physiotherapy
including various research institutes, Physiotherapy colleges and as a part of various post
graduate and Ph D thesis programs. However, a platform for compilation and publication of this
hard work of everyone is yet somewhat limited. Indian Journal of Physical Therapy is a small
effort to provide platform for this hard work to bring into notice of all interested Physiotherapists
and clinicians and to create a database that will be of great help to all the professionals.
On behalf of all staff members of IJPT, I request all Directors, Deans, Principals,
Academic Staffs, Clinical Practitioners, Interns and Students to send us articles for publications
and write us for any suggestions, queries or inquiries on our website.
Waiting eagerly for your positive response for this journal.

Thank You.

Dr Dinesh M Sorani
Editor
Indian Journal of Physical Therapy
 Indian Journal of Physical Therapy
January-June 2013, Volume. 1, Issue. 1

1 Arthrogryposis Multiplex Congenita (AMC): A case report 1

Ashish Kakkad

2 Effect of Pulmonary Rehabilitation on Quality of Life of T.B. Patients 3

Monali P. Nawal, Priya Igatpurikar

3 Effect of pain and fatigue on functioning in subjects with post polio syndrome 6
Srishti Sharma, Megha Sheth, Nita Vyas

4 A study to evaluate activation of the lower trapezius muscle during varied forms of Kendall exercises 11
Vaibhavi V. Ved

5 A comparison between single task versus dual task condition balance training in older adults with balance 14
impairment
Meenakshi Verma, Stuti Sehgal

6 The effect of lower limb progressive resistance exercise on balance in subacute and chronic stroke patients 20
Tulsi L. Govani

7 Energy expenditure during wheelchair propulsion in different levels of paraplegics 24

Ankur Parekh

8 Immediate effectiveness of diathermy, positional release therapy and taping on acute wry neck in a post- 28
partum woman: single case report
S. M. Khatri, S. S. Sant

9 A comparitive study to analyze the risk factors in elderly with and without fear of fall 31
Arasavalli Karuna Kumari, C. M. Radhika

10 Immediate effectiveness of positional release therapy in acute ankle sprain 36

Priyanka Diwadkar, S. M. Khatri
 Arthrogryposis Multiplex Congenita (AMC): A Case Report

Ashish Kakkad
Asst Professor, Shri K K Sheth Physiotherapy College, Rajkot

Introduction right side. Amount of wasting found was 0.5 cm and 1 cm

respectively in thigh and leg. Limb length shortening was found
Arthrogryposis multiplex congenita (AMC) is a rare on right side as compared to left side. Amount of shortening
congenital disorder that is characterized by multiple joint found was 6 cm and 2 cm in above knee and below knee
contractures and can include muscle weakness and fibrosis. It is measurement.5
a non-progressive disease. The disease derives its name from
Greek; literally meaning curved or hooked joints.
In some cases, few joints may be affected and may
have a nearly full range of motion. In the most common type of
arthrogryposis, called amyoplasia, hands, wrists, elbows,
shoulders, hips, feet and knees are affected. In the most severe
types, nearly every joint is involved, including the jaw and back.
Frequently, the contractures are accompanied by muscle
weakness, which further limits movement. AMC is typically
symmetrical and involves all four extremities with some
variation seen. 1, 2, 3

Case report Figure 1 Patient before surgeries

Here reported case is of 7 years old male child born

with blood group A +ve and suffering from AMC. At the time
of birth patient had bilateral Congenital Dislocation of Knee
(CDK) and bilateral Congenital Talipes Equino Varus (CTEV).
Child was not able to stand or walk due to deformities. Patient
has been operated for the same seven times with serial plaster
casts in his 7 years of life.
At the age of 5 years on examination patient had CTEV
and bilateral CDK with 400 Fixed Flexion Deformity (FFD) of
Right knee, recurvatum with 200 valgus of Left knee and
bilateral radial head dislocation with restricted supination.
Patient was operated for Left quadriceps-plasty, reduction of
knee joint, bilateral Tendo Achilles (TA) Tenotomy, Plantar
fasciotomy and Tibialis Posterior release. After surgery patient Figure 2 Patient after surgery (Supine)
was advised for strict limb elevation and active toes movements
followed by physiotherapy.
At the age of 6 years on examination patient had
recurred CTEV and ended up in fixed deformity including
varus, adduction, cavus and equines and patient was operated
for bilateral dorsal wedge resection of foot & k-wire fixation,
TA tenotomy & posterior capsulotomy of ankle and subtalar
joints bilaterally. Four months after surgery, on clinical
examination residual knee FFD of 100 of right knee and resistant
left foot deformity for correction to neutral position.
At the time of presentation to physiotherapy clinic after
last surgery for physiotherapy patient had reduced muscle power
on both lower limbs. By manual muscle test described by Daniel
muscle power was reduced in all muscles of lower limbs, but in
majority of muscles power was found > 3 out of 5.4 On girth Figure 3 Patient after surgery
measurement, wasting of was found on left side as compared to
(Walking with rollator)
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

Physiotherapy treatment was directed towards and physiotherapy treatment, child can be made independent as
maintenance of range of motion in all joints of bilateral lower much as possible. Before surgery, patient should be assessed for
limbs, strengthening of weak muscles of bilateral lower limbs as manual muscle testing to decide the possible outcomes of
well as gait training with bilateral ankle foot orthosis and knee surgery as muscle power reduces after surgery. After surgery, if
extension brace and with rollator. Bilateral upper limbs were physiotherapy treatment given properly, child can live with
only given home exercises and patient had become habitual with better quality of life later on.
the use of both upper limbs even with restricted supination
range of motion. Along with this physical treatment, Funding
psychological counseling of patient’s father about regular
follow-up to orthopedic surgeon and consistency in visit of The above study is not funded by any institute or
physiotherapy department without fail was done. person.

Discussion Conflicts of Interest

The patient selected for the study was not able to walk There was no personal conflict of interest.
before surgery as the above mentioned muscles were very short
and not allowing movement in full range of motion. Due to
short muscles since birth there was also development of above
Consent of Patient:
mentioned deformities. If child would have been untreated, he
might not have been able to stand on his own. Preoperative The author was not able to acquire consent letter for
physiotherapy, surgeries with serial plaster casts and this study.
postoperative physiotherapy made the child walking with the
help of assistive devices like splints and mobility aids like References
rollator. There are very few researches available for role of
physiotherapy in arthrogryposis multiple congenita and other 1. Arthrogryposis [cited 2013, 25 February]; Available from:
related congenital abnormalities. So more numbers of researches http://en.wikipedia.org
are needed to be done with long term duration. This can also 2. Alfonso I., Papazian O., Paez J.O., Grossman J.A.I (2000).
help for creating awareness about changing common belief that "Arthrogryposis Multiplex Congenita". International
for this type of child, only maintenance of condition and Pediatrics 15 (4): 197–204.
preventing complication is not sufficient. This type of patient 3. Donohue M, Bleakney DA. Arthrogryposis Multiplex
can be given improved quality of life even though the condition Congenita. In: Campbell SK ed. Physical Therapy for
itself is not curable. Children. Philadelphia, PA: WB Saunders; 1995:261-277
4. Daniels and Worthingham's Muscle Testing: Techniques of
Conclusion Manual Examination, 8e; 2007
5. David J. Magee. Orthopedic Physical Assessment, 5e; 2007
Arthrogryposis multiple congenita is rare congenital
disorder. It is not curable but by multiple corrective surgeries

2
 Effect of Pulmonary Rehabilitation on Quality of Life of T.B. Patients

Monali P Nawal1, Priya Igatpurikar2

1. Intern Student, N.D.M.V.P.S. College of Physiotherapy Adgaon. Nashik
2. Asst Professor, N.D.M.V.P.S. College of Physiotherapy Adgaon. Nashik

Abstract
Objective -to see the effectiveness of pulmonary rehabilitation on quality of life of TB patients.
Study design - Cohort study.
Sample size - 40 patients.
Methodology- 40 patients were selected irrespective of the gender with sputum negative TB infection were selected for the study and divided into 2
groups: Group A - 20 patients who received pulmonary rehabilitation Group B - 20 patients who received breathing rehabilitation. Outcome was
measured by 6 min walk test (6 MWT) and Saint George respiratory questionnaire (SGRQ). Data were analyzed by paired and unpaired“t” test.
Conclusion:- According to statistical analysis, pulmonary rehabilitation group shows improvement in quality of life of TB patients.

Introduction economical development and because of stigma of TB, person

cannot get socialized easily.
Tuberculosis (TB) is an infectious disease caused by In India Tuberculosis is major cause of death. To
‘Mycobacterium Tuberculosis ‘and rarely by the other organism control TB the national tuberculosis program of India (NTP)
of the Tuberculosis complex. was initiated in 1962. A full-fledged program was started in
Tuberculosis is most commonly transmitted by 1997 which is known as Revised National Tuberculosis Control
inhalation of infected droplet nuclei which are discharged in the Program (RNTCP). This program works on DOTS i.e. Directly
air when patients with untreated sputum positive TB coughs or Observed Treatment, short course. In this program health
sneezes. If the bacillus succeeds in infecting a person and only worker watches as patient swallow all medication. This helps in
5-10% of such infection develops active disease. In the ensuring cure. Along with DOTS other treatment methods are
remaining 90-95%, initial infection goes unnoticed. Tuberculin also helpful as supportive therapy to restore the functional
sensitivity appears within a few weeks of infection and initial capacity. Pulmonary rehabilitation techniques shows good result
lesions commonly heal leaving no residual changes except on pulmonary condition to restore the lung capacity.
occasional pulmonary or tranche bronchial lymph node Pulmonary rehabilitation is non-pharmacological
calcification (primary complex). Infection occurs exclusively treatment in pulmonary condition. Application of pulmonary
through respiratory route. rehabilitation improves physical condition and restores quality
Post primary TB (Active) arises from the latent foci of life & social integration.
which dormant since initial infection. Post primary TB in 85% This study aims to see the effectiveness of the pulmonary
affects lungs and then through blood stream, lymph it may rehabilitation on quality of life of TB patients.
spread towards lymph nodes, pleura, bones and joints, genitor-
urinary tract, the nervous system, intestine etc. So pulmonary Materials and Methodology
TB should receive topmost priority for treatment.
In pulmonary TB, fibroblastic reactions causes fibrosis 60 patients were enrolled in treatment program
and chest wall retraction compromising pulmonary expansion. initially, then according to inclusion and exclusion criteria 40
This leads to long disability, restrictive lung movement and patients were selected and written consent was taken from them.
many daily living activities are hampered because of that. Out of 40 pulmonary T.B. patients, 20 were randomly
One third of the global population so estimated to be allocated for pulmonary rehabilitation (PR) & 20 were given
infected with TB bacillus. It is estimated that 1.8 million people conventional breathing exercises (BE) along with airway
die from TB each year. TB remains a major public health clearance technique.
problem in India. Annual risk of Tuberculosis infection (ARTI) PR program was explained to them. Basic CVS, RS
study done for the four zones of the country from 2008 to 2010. and musculoskeletal examination was done. SGRQ and 6 min
India accounts for one fifth of global incidence of TB. walk test was evaluated and target HR was decided on the basis
In India every day more than 5000 developed TB and of heart rate maximum by Karvonen’s formula.
more than 1000 people die from it. According to WHO Both groups received protocol treatments for 6 weeks.
(Estimate made in 2006) more than 170 million people work Pulmonary rehabilitation group received protocol given by
days are lost. Nearly 3,00,000 school children dropout from the King’s college, (Lambeth & Southwark pulmonary
schools More than 1,00,000 women rejected by their families. rehabilitation program). The protocol included warm up
Tuberculosis causes physical, economical and social exercise session followed by aerobic as well as strengthening
dependency on family. It is a biggest barrier to socio- exercises followed by cool down exercises including stretching
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

exercises. Breathing exercises group was daily treated with This result shows significant improvement in both groups. The
conventional breathing exercises like diaphragmatic and RPE values decreases after treatment because regular exercise
segmental breathing, thoracic expansion exercises, incentive helps to increase the endurance and reduce the breathlessness.
spirometry and chest clearance techniques. In case of SGRQ, in pulmonary group before treatment
Then again 6 min walk test and SGRQ questionnaire value is 82.95 and after treatment value is 35.73 and in
was evaluated after 6 weeks. breathing group before treatment value is 82.39 and after
Pre and post rehabilitation data were analyzed using treatment value is 52.24. t value for pulmonary group is 9.99
paired and unpaired Student’s t test. and for breathing group 4.93.Both group shows significant
improvement. The reason behind improving quality of life is
Results decrease in breathlessness and increase in functional capacity.
Overall endurance is also increased.
Table 1: Average parameters of 6 minute walk test RPE, When after treatment results were compared by
distance covered during 6 minute walk test and quality of life unpaired t test following results were seen. When distance
(SRGQ) score in both groups before and after intervention covered was compared between both the groups, pulmonary
group shows more improvement (t = 3.35). When RPE was
PR BE
compared then also pulmonary group shows more improvement.
Before After p Before After p (t = 2.37). When SGRQ were compared then also pulmonary
RPE 5.56 2.7 < 0.05 5.35 3.65 < 0.05 group shows more improvement. (t = 2.28).
DISTANCE COVERED 178 202.25 < 0.05 170 181.5 < 0.05 Thus, it is concluded that both groups shows
QUALITY OF LIFE 82.95 35.73 < 0.05 82.39 52.24 < 0.05 improvement in the quality of life but pulmonary rehabilitation
group shows more significant improvement as pulmonary
Table 2: Comparison of parameters between groups rehabilitation program shows effect on every system of the body
and helps to restore functional capacity.
Mean difference
Limitation
PR BE p
RPE 2.95 1.7 < 0.05 The sample size is too small to arrive at a concrete
DISTANCE COVERED 24.25 10 < 0.05 conclusion and the study is recommended on more subjects.
< 0.05 Questionnaire had to be translated in local language to explain
QUALITY OF LIFE 47.18 30.13
to the subject.

Conclusion
Discussion
Pulmonary rehabilitation is effective treatment method
The aim of this study is “To see the effectiveness of which helps to improve quality of life in TB patients.
pulmonary rehabilitation on quality of life of TB patients”. For
this study 40 patients were selected with DOT treatment and References
divided into two groups. Group A received pulmonary
rehabilitation and group B received breathing exercises.
1. Saint George respiratory questionnaire manual by Paul
Distance covered, RPE and questionnaire were taken into
Jones and yvonne Forde.
consideration. Before pulmonary rehabilitation (PR) and after
2. Physical rehabilitaion-susan sullivan.
PR as well as before breathing exercises (BE) and after BE
3. Exercise therapeutics by Carolyn kisner.
values were compared by paired t test. Both groups showed
4. Barley EA,jones PW, a comparison of global questions
improvement in quality of life. Mean differences of both groups
versus health status questionnaire as measures of
were then compared by unpaired t test.
severity of TB.
Distance covered in pulmonary rehab group before
5. World health organisation;global TB control.WHO
treatment was 178m and after treatment was 202.25 m. t value
report 2001.geneva switzerland.
for this group is 7.07. In breathing group, distance covered
6. Sharma,mukhopadhyay,arora,verma,pande,khilnani
before treatment was 170 m and after treatment was 181.5m. t
gc.computed tomography in milliary TB.aust radiol
value for this group is 3.37.both the group shows improvement.
1996;40:113-8
The reason behind this is because of exercise lung capacity
7. Kings college hospital, lambeth and southwark
increase and it helps to increases the endurance.
pulmonary rehabilitation programme.
RPE values in pulmonary rehab group, before treatment was
8. Pulmonary rehab:joint ACCP/AACVPR evidence
5.35 and after treatment was 3.65. And in breathing group
based guideline. American college of chest
before treatment it was 5.56 and after treatment was 2.7. t value
physician. chest 1997;112(5)1363-96.
for pulmonary group is 6.89 and for breathing group it was 4.25.

4
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

9. National institute for clinical excellence(NICE) COPD: 11. Pasipanodya jg,miller tl,vecino m, munguia g, bae s,
guideline for management of COPD in adult in primary drewyer g.using SGRQ to ascertain health quality in
and secondary care.thorax2004;59 person with treated pulmonary TB. CHEST
10. Ando m , mori a, esaki h, shiraki t. the effect of 2007:132:1591-8
pulmonary rehabilitation in post
TB.chest2003:123;1988-95.

5
 Effect of pain and fatigue on functioning in subjects with post polio syndrome

Srishti Sharma1, Megha Sheth2 , Neeta Vyas3,

1 Mpt-Rehabilitation, SBB College of Physiotherapy, VS Hospital, Ahmedabad.
2 Lecturer , SBB College of Physiotherapy, VS Hospital, Ahmedabad.
3 Principal, SBB College of Physiotherapy, VS Hospital, Ahmedabad.

Abstract
Introduction - In the past few years, many polio survivors have experienced late-onset neuromuscular symptoms and decreased functional abilities.
Post-polio syndrome (PPS) refers to a clinical disorder affecting polio survivors with sequel years after the initial polio attack. These patients report new
musculoskeletal symptoms like fatigue, pain, new and unusual muscular deficits, on healthy as well as deficient muscles initially affected by the
Poliovirus. Although pain and fatigue have been identified as common problems in these individuals, less research has examined the role that these
symptoms might play in their physical or psychological function. In this study, effect of pain and fatigue on function in subjects with PPS was seen.
Methodology - A co-relational study was conducted on a convenient sample of 50 subjects with the diagnosis of PPS according to Halstead criteria
(1985), above 18 years of age, in the community of Gujarat. Subjects unwilling, with cognitive impairment were excluded.
Procedure - Subjects with PPS were approached and those willing to participate were assessed for pain, fatigue and function. Pain and Fatigue intensity
were examined using Numeric Rating Scale (P-NRS and F-NRS respectively). Physical and psychological functioning were examined using PROMIS
(Patient Reported Outcomes Measurement Information System) and PHQ-9 (Patient Health Questionnaire-9) questionnaires.
Results - Pearson’s test for co-relation was applied. A negative linear co-relation was found between Pain intensity and functioning; indicating that pain
affects physical function in subjects with PPS and a positive linear co-relation between pain and psychological function was found; indicating higher
levels of depression in those with higher levels of pain. Correlation between fatigue and functioning was insignificant; indicating that fatigue did not
affect function.
Conclusion - Pain affects the physical and psychological function of subjects with PPS, highlighting the need for effective and accessible pain relieving
treatment options.
Keywords: Post polio syndrome, Pain, Fatigue, Functioning, PROMIS, and PHQ-9

new weakness in muscles previously affected or unaffected, new

Introduction muscle atrophy, functional loss, cold intolerance.
5. No other medical explanation found.
In the past few years, many polio survivors have Halstead revised these criteria in 1991 and added
experienced late-onset neuromuscular symptoms and decreased gradual or abrupt onset of new neurogenic weakness as a
functional abilities.1 After many years of stable functioning, necessary criterion for PPS, with or without other co-existing
these patients report new musculoskeletal symptoms like symptoms.4 Dalakas redefined and narrowed the use of PPS in
fatigue, pain, new and unusual muscular deficits, in healthy 1995 with an additional criterion of neurological examination on
muscles as well as deficient muscles initially affected by the EMG and/or MRI.5
poliovirus. These symptoms have been termed Post The prevalence of PPS has been reported to be between
Poliomyelitis Syndrome (PPS).2 20% and 85% of people who have had poliomyelitis.6 This
PPS is an exclusion diagnosis. There is no diagnostic disparity is most probably caused by the use of different clinical
test for PPS, and the diagnosis is based on a proper clinical diagnostic criteria. In this context, it is important to remember
workup where all other possible explanations for the new that people who have sequelae of poliomyelitis but who do not
symptoms are ruled out. The existence of PPS has been fulfill diagnostic criteria for PPS might still have substantial loss
questioned, but the late effect of poliomyelitis, or PPS, is of motor function and be in need of therapeutic interventions.
generally accepted as a defined clinical entity. The term post- Pain and fatigue are common in individuals with PPS
polio syndrome was introduced by Halstead in 1985 to cover and have been recognized as the key symptoms. PPS subjects
medical, orthopedic and psychological problems possibly or are more prone to fatigue and have more physical mobility
indirectly related to the long-term disability occurring many problems than non-PPS subjects.7 The main functional problems
years after the acute episode. The criteria for PPS3 were as in these subjects are related to physical activities such as
following: walking, climbing stairs, and mobility-related activities of daily
1. Confirmed history of polio. life. Measures of pain and fatigue have been shown to be
2. Partial or fairly complete neurological and functional associated with various measures of dysfunction in PPS
recovery after the acute episode. populations. Hildegunn et al found that self-reported muscle
3. Period of at least 15 years with neurological and functional strength, disability, and pain intensity were all associated
stability significantly with measures of fatigue and activity level in a
4. Two or more of the following health problems occurring after sample of 32 patients with PPS.8 Ostlund et al found pain
the stable period: extensive fatigue, muscle and/or joint pain, intensity to be significantly associated with lower levels of
physical and psychological functioning in a sample of 143
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

individuals with PPS. In another survey study, measures of using a 4-point scale, where 0 is “not at all,” and 3 is “nearly
fatigue demonstrated significant associations with both physical every day.” The PHQ-9 total score can range from 0 to 27, and a
and psychological dysfunction.9 higher score represents higher levels of depressive symptoms.
Interest in PPS has increased over the past two to three The PHQ-9 has been widely used to assess depression severity
decades worldwide, with research varying in focus from and has a great deal of support for its validity in populations
molecular to clinical aspects, and health-related quality of life. with physical disabilities. Level of significance was kept at 5%.
India had traditionally been considered one of the toughest
places in the world to eradicate polio. Considering the large Results
number of polio survivors in our country and looking at the
prevalence of pain and fatigue in polio survivors, it becomes Statistical analysis was done using SPSS 16.0.
important to identify the problems faced by PPS subjects as a Variables were evaluated to ensure that they were normally
rehabilitative perspective. The purpose of the current study was distributed using one sample Kolmogorov- Smirnov test.
to better understand the importance of pain and fatigue in Pearson’s test of co-relation was applied, co-efficient r was
relation to functioning. The study was aimed To find the determined and the p value was noted. Descriptive statistics of
correlation between pain and fatigue intensity; using Numeric age, pain, fatigue, physical and psychological functioning are
Rating Scale with Physical and Psychological Functioning using listed in Table 2.
PROMIS and PHQ-9 Questionnaires respectively.

Methodology Table 2: Descriptive Statistics

A convenient sample of 50 subjects, both males and Variable Mean +SD

females above 18 years of age, with PPS according to Halstead Age 32.58+7.65
Criteria (1985) was selected from the community of Gujarat. P-NRS 6.82 +1.48
The study design was co-relational. Those with cognitive F-NRS 6.54 +1.34
impairment or unwilling to participate were excluded. All PROMIS 19.99 +2.13
subjects provided informed consent for participation in the PHQ-9 24.10 +2.39
study. Subjects were assessed for Pain intensity, Fatigue Pain intensity had a strong linear co-relation with
intensity using Numeric Rating Scale (P-NRS and F-NRS physical functioning (r=-0.794; p =0.01) which was statistically
respectively). Physical and psychological functioning were significant, indicating that the physical functioning of subjects
examined using PROMIS and PHQ-9 questionnaires. Subjects with PPS was affected if they had pain. Pain had a moderate
were asked for their age at onset of polio and about the usage of linear co-relation with psychological functioning (r= 0.564;
assistive devices in daily life. p=0.01), indicating that pain had an effect on the psychological
NRSs are frequently used to assess symptom severity, functioning of subjects with PPS. Fatigue intensity had a weak
including the severity of both pain and fatigue, and research
supports their validity for this purpose.10 Participants were asked
to rate the severity of these symptoms over the past week on
scales from 0 to 10 (0 being none; 10 being very severe).

Table 1: PHQ-9 Interpretation

Total score Depression severity
1-4 Minimal
5-9 Mild
10-14 Moderate
15-19 Moderately severe
20-27 Severe

PROMIS11 Physical Functioning item bank assesses an

individual's ability to perform a range of physical activities.
Average performance in ability to engage in various tasks over
the past week is measured on 5-point scales that range from
“without any difficulty” to “unable to do”. Higher the Raw score
of PROMIS, better the physical function. PHQ-911 is a 9-item
measure which asks respondents to rate the frequency that they
experienced 9 symptoms of depression in the past 2 weeks by

7
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

linear co-relation with physical functioning (r= -0.135, p = consistent with our study in that the fatigue intensity (6.54
0.351) and psychological functioning (r= 0.072; p=0.620) which +1.34) was moderate.
was statistically insignificant. In a similar study by Trojan DA et al (2009), different
Figures 1-4 show the graphs of co-relation between the variables were found to be associated with general, physical,
outcome measures. Components most affected on the physical and mental fatigue.14 Correlates of general fatigue included
function scale were “being unable to bend down and pick up disease-related and psychosocial factors whereas correlates of
clothing from floor”, “being unable to push a heavy door”, physical fatigue were disease-related and behavioral factors, and
“unable to do eight hours of physical labor” and “unable to correlate for mental fatigue was a psychosocial factor. The
reach and get down an object from above the head”. On components most affected on physical and psychological
psychological function scale, the components most affected function scales in our study are similar to the findings of this
were “feeling tired or having less energy”, “Moving or speaking study.
so slowly that other people could have noticed- or the opposite, Stoelb BL et al studied the frequency, intensity and
being so fidgety or restless that you have been moving around a impact of pain in persons with PPS.15 Pain interfered most with
lot more than usual”. sleep and with activities requiring a high level of
musculoskeletal involvement. Respondents also reported pain
Discussion problems that were more severe than those of the general
population and than those of a sample of people with multiple
The findings from this study suggest a statistically sclerosis. Participants with pain in our study reported a
significant co-relation between the severity of pain and lower moderate level of pain intensity (P-NRS= 6.82+1.48) which was
levels of physical functioning and higher levels of depression in higher than the above mentioned study.
individuals with PPS whereas severity of fatigue did not have a Earlier, Nollet F et al did a study to compare perceived
statistically significant co-relation. Also, the severity of pain health problems and disability in former polio subjects with PPS
showed a stronger co-relation with physical functioning than and non-PPS subjects, and to evaluate perceived health
with psychological functioning. These findings have important problems, disability, physical performance, and muscle
implications in understanding the role of pain on functioning in strength.16 Health problems mainly concerned with physical
PPS subjects. mobility, energy and pain on NHP were higher in PPS subjects
Jenson MP et al (2008) studied the independent effect as compared to non-PPS subjects and most disabilities in PPS
of pain and fatigue on function in subjects with PPS and subjects were concerned with physical and social functioning.
concluded that pain and fatigue both made independent Figure 5: Flow chart of overuse and disuse leading to pain and
contributions to the prediction of functioning.11 They found that hence, reduced function.
relationship between pain and fatigue and both physical and
psychological functioning was similar across all age cohorts
suggesting that complaints of pain or fatigue in patients with
PPS who are older or elderly should not be attributed merely to
the process of aging. In contrast, the present study did not show
a co-relation with psychological function. The reason could be
the recruitment of younger participants in the present study.
Hidegunn L et al (2007) studied the perceived
disability, fatigue, pain and measured isometric muscle strength
in patients with post-polio symptoms.8 They found significant
correlation of self-reported general muscle strength, pain
intensity and pain distribution with patients' perceived fatigue
and function at the activity level. This is much in line with the
results of our study.
Consistent with previous findings, participants in the
In a cross sectional case control study, On AY et al
present study reported pain problems that were significantly
(2006) assessed the impact of post-polio related fatigue on
affecting their functioning. Figure 5 explains the flow chart of
Quality of Life (QoL).13 The presence and severity of fatigue
overuse and disuse leading to pain.
was measured using Fatigue Severity Scale (FSS), QoL by
A co-relation between pain and reduced function is
Nottingham Health Profile (NHP) and the impact of fatigue on
believed to be either a measure of overuse or disuse that falls
QoL using Fatigue Impact Scale (FIS). Fatigue (FSS score> 4)
into a vicious cycle. Motor unit dysfunction leads to atrophy and
was significantly higher (p value <0.05) in the PPS group
cramping muscle pain, both of which lead to a combination of
(76.9%) than both the non-PPS (30%) and the control group
overuse and disuse in muscles. When musculoskeletal overuse
(23.3%). Also, NHP scores were significantly higher in the PPS
occurs, pain develops. Rest and immobilization can relieve this
group than in the control group (p value <0.05) with the
pain, but this leads to decreased use of certain muscles, with
dimensions of physical mobility, energy, pain and emotional
development of disuse atrophy and further weakness. After this,
reaction particularly affected. These findings are much

8
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

relatively normal use of the muscle leads to pain and further postpoliomyelitis syndrome: a 6-year prospective follow-up
disuse. Musculoskeletal dysfunction resulting in pain occurs as a study. Arch Phys Med Rehabil 2003; 84: 1048-56.
consequence. And this pain restricts an individual’s level of 2. Halstead LS, Rossi CD. Post-polio syndrome: clinical
physical function and as a result to some extent, psychological experience with 132 consecutive outpatients. Birth Defects
function as well. Fatigue did not have a significant effect on Original Article Ser 1987; 23: 13-26.
function, indicating that affection in function was mainly due to 3. Halstead LS, Rossi CD. New problems in old polio
pain and not fatigue. Possible reasons for which could be self patients: results of a survey of 539 polio survivors.
pacing of daily activities, inacceptance or denial of having Orthopedics 1985; 8: 845–850
fatigue 4. Halstead LS. Assessment and differential diagnosis for
post-polio syndrome. Orthopedics 1991; 14: 1209–1217
Limitations 5. Dalakas MC. The post-polio syndrome as an evolved
clinical entity. Definition and clinical description. Annals of
The sample size was small. Various studies done on the New York Academy of Sciences 1995; 753: 68–80.
PPS suggest younger subjects experience more pain and fatigue 6. Nollet F, Beelen A, Prins MH, et al. Disability and
than the older subjects because of the nature of PPS17. Hence, functional assessment in former polio patients with and
study is likely to be biased based on the age included (32.78 + without postpolio syndrome. Arch Phys Med Rehabil 1999;
7.65). 80:136-43.
7. Farbu E, Gilhus NE, Barnes MP, et al. EFNS guideline on
diagnosis and management of post-polio syndrome: report
Future Recommendations of an EFNS task force. Eur J Neurol 2006; 13: 795–801.
8. Hildegunn L, Jones K, Grenstad T, Dreyer V, Farbu E,
The use of assistive devices plays an important role in Rekand T. Perceived disability, fatigue, pain and measured
health related problems. Hence, an elaborated study with effects
isometric muscle strength in patients with post-polio
of these biomechanical devices on pain and fatigue should be
symptoms. Physiother Res Int. 2007;12:39–49
done. Future prevalence study can focus on the frequency of
9. Ostlund G, Wahlin A, Sunnerhagen KS, Borg K. Vitality
pain, and also examine rates of pain in normals compared to
among Swedish patients with post-polio: a physiological
presenting rates of pain specific to PPS. A study to assess phenomenon. J Rehabil Med. 2008;40:709–714
potential predictors of these outcomes may be valuable. The
10. Farrara JT, James P. Young, Moreaux LL, Werth JL, Pool
current study also highlights the need of helpful and accessible
RM. Clinical importance of changes in chronic pain
treatment options for pain relief.
intensity measured on an 11 point numeric rating pain scale.
International Association for the Study of Pain. 2001. Pgs
Conclusion :149-158.
11. Jenson MP, Kevin N Alschuler, Amanda Smith, Aimee M.
This study suggests that pain and fatigue are common Verall Mark C Goetz, Ivan R Molton. Pain and fatigue in
problems in subjects with PPS and pain intensity significantly persons with post-polio syndrome: Independent effect on
affects the physical and psychological function highlighting the functioning. Archives of Phys Med and Rehab Volume 92,
need for effective and accessible treatment options. Issue 11 , Pages 1796-1801, November 2011
12. Lygren H, Jones K, Grenstad T, Dreyer V, Farbu E, Rekand
Clinical Application T. Perceived disability, fatigue, pain and measured
isometric muscle strength in patients with post-polio
Acute polio is no longer a constant threat to people in symptoms. Physiother Res Int 2007; 12:39-49.
the polio-free areas of the world but there are still thousands of 13. On AY, Oncu J, Atamaz F, Durmaz B. Impact of post-
polio survivors who are at risk of developing late manifestations polio-related fatigue on quality of life. J Rehabil Med.
of the disease. These findings highlight the importance of 2006;38:329–332
carefully screening all patients with PPS for the presence of pain 14. Trojan DA, Arnold DL, Stan Shapiro, Amit Bar, Ann
and fatigue, so that a variety of interventional strategies to Robinson, Jean-Pierre Le Cruguel, Sridar Narayanan,
reduce their problems are implemented promptly. Tartaglia MC, Zografos Caramanos, Costa DD, Fatigue in
Post-poliomyelitis Syndrome: Association With Disease-
Related, Behavioral, and Psychosocial Factors. American
Academy of Physical Medicine and Rehabilitation, Vol. 1,
442-449, May 2009
References 15. Stoelb BL, Carter GT, Abresch RT, Purekal S, McDonald
CM. Pain in persons with postpolio syndrome: frequency,
1. Nollet F, Beelen A, Twisk JW, Lankhorst GJ, de Visser M. intensity, and impact. Arch Phys Med Rehabil. 2008; 89:
Perceived health and physical functioning in 1933–1940.

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 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

16. Nollet F, Beelen A, Prins MH, et al. Disability and 17. Silver JK, Gawne AC. Postpolio syndrome. Hanley and
functional assessment in former polio patients with and Belfus publications. 2004. Chapter 5: Joint and muscle
without postpolio syndrome. Arch Phys Med Rehabil. pain. Pgs: 61-71.
1999;80:136–143

10
 A study to evaluate activation of the lower trapezius muscle during varied forms of
Kendall exercises

Vaibhavi Vijaykumar Ved

Final Year MPT (Musculoskeletal and Sports) Shri K.K.Sheth Physiotherapy College, Rajkot

Abstract
Background - The trapezius muscle, a dynamic structure plays a crucial role in maintaining proper shoulder mechanics and is often considered a source
of weakness and dysfunction in patients.
Objectives - To evaluate the activation pattern of lower trapezius muscle during varied forms of kendall exercises, so that it can help clinicians to design
an efficient shoulder rehabilitation program.
Design - A Cross Sectional Observational Study
Method - The muscle activation pattern of lower trapezius muscle of 50 individuals, aged 20 to 30 years was measured using surface EMG for maximum
voluntary isometric contraction against manual resistance during which EMG activity of lower trapezius muscle was assessed in shoulder at 75o, 90o,
125o, and 160o of abduction with arm externally rotated and manual resistance was applied at the distal forearm.A repeated measure ANOVA was then
performed.
Results - Means of lower trapezius showed highest muscle fiber activation at 160o abduction. Then ANOVA was applied and calculated using Graphpad
Version 3.10, Obtained values: p = 0.5139, F = 0.7675.
Conclusion - There was no significant difference in activation of lower trapezius muscle at any angle of arm abduction.
Keywords - Electromyography; Kendall exercises; Arm Abduction, Shoulder Rehabilitation

strengthening; thereby it is very important to know which

Introduction position will have the maximum activation of the muscle.
Moseley et.al. (1992) indicated that rows, horizontal abduction,
The shoulder moves in a complicated manner during scaption, and shoulder flexion being the optimal exercises for
elevation, involving all of the joints at the shoulder complex, to lower trapezius. Ekstrom studied 10 different exercises at high
facilitate optimal placement of the hand for function.1 During intensity (85-90% of one repetition maximum) and identified
elevation, glenohumeral motion occurs around the stable base of overhead arm raise in standing and shoulder external rotation at
the scapula, with that stability provided by the scapulothoracic 900 of abduction were optimal exercises for lower trapezius.4
muscles. In addition these muscles also dynamically position the Interestingly, one exercise examined was a 900 horizontal
scapula for efficient glenohumeral motion (Paine and Voight, abduction exercise based on Kendall’s position. Activation was
1993). not highest among the exercises, but was substantial. The
The trapezius muscle plays a crucial role in intensity of exercise makes any generalization to the
maintaining proper shoulder mechanics and is often considered rehabilitation population difficult and examining a single
a source of weakness and dysfunction in patients. The trapezius Kendall position limits the knowledge of its effectiveness.
muscle is a dynamic structure, which is called upon to play The purpose of this study was to investigate the muscle
multiple roles in maintaining glenohumeral joint stability and activation patterns of the lower trapezius during four specific
functional outcomes.2 As the humerus is abducted, the three therapeutic exercises using positions described by Florence
portions of the trapezius (upper, middle, and lower) act along Kendall (Kendall et.al. 1980).5 By identifying the most effective
with the serratus anterior to concentrically control upward positioning criteria in targeting the lower trapezius muscle,
rotation of scapula.3 A dysfunction or weakness in this muscle clinicians will be better able to design a more efficient and
may lead to muscle imbalance, decreased muscle endurance and centered rehabilitation program. The purpose of the study was to
altered scapulohumeral rhythm, which in turn might lead to evaluate the activation pattern of lower trapezius muscle during
shoulder impingement, muscle fatigue, instability of the four specific therapeutic exercises using positions described by
glenohumeral joint and postural changes (Fuglevand et.al., Florence Kendall.
1993; Lehman et.al., 2004).
Past research has used electromyography (EMG) to Methodology
investigate the muscle activation patterns and muscle fatigue of
the shoulder musculature in functional activities. Lower Cross senctional observational study was performed on 50
trapezius muscle is often targeted in shoulder rehabilitation due healthy individuals at Shri K. K. Sheth Physiotherapy College.
to its contribution in maintaining proper shoulder kinematics The subjects were selected by simple random sampling.
and stabilization.1 Studies have shown that therapeutic exercises Inclusion criteria were (1) Normal Individuals ( BMI 18 to 24.9
aimed at strengthening of separate portions of the trapezius can kg/m2) (2) Between ages of 20 to 30 years (3) Both Gender –
ultimately improve scapulohumeral rhythm. Several authors Males and Females. Subjects were excluded (1) Those who had
recommend different positions for the lower trapezius muscle participated in consistent resistive weight training within the
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

past 6 months. (2) Those with History of previous Neck, Back, Graph 1: lower trapezius activation at various angles
or Shoulder Pain and/or Trauma. (3) Those with any associated
Musculoskeletal or Neurological disorder affecting the Study. 700
589.64
624.27

Prior to the commencement of the study, consent had 600 527.37

554.27

been taken from all the subjects. Muscle activation pattern of 500

lower trapezius muscle was measured using surface EMG

MVIC (microvolts)
400 323.37 333.35
281.36 275.65
SD
during Maximum Voluntary Isometric Contraction (MVIC) at 300
MEAN
four different angles of arm abduction. Subject lie prone with 200

arm abducted and externally rotated such that thumb is pointing 100

towards ceiling. Each subjects was shown and practiced the four 0

testing positions, i.e. 75o, 90o, 125o, and 160o of shoulder

75 degrees 90 degrees 125 degrees 160 degrees
ANGLE OF ARM ABDUCTION KENDALL'S POSITION
(degrees)
abduction wherein they were suppose to perform Maximum
Voluntary Isometric Contraction.
Active Electrode was placed perpendicular to vertebral Results
column at the level of inferior angle of scapula, 3-4 cm (2
fingers breath) lateral to the spinous process of 7th dorsal Out of 50 subjects tested, 18 were males and 32 were
vertebrae. Reference Electrode was placed 3cm distal to it.6 females. ANOVA was applied and calculations done using
With the subject prone on the plinth, goniometer was Graphpad Version 3.10, Obtained values of p = 0.5139 and F =
used to move the arm into one of the four positions of arm 0.7675 is considered non significant and thus the variation
abduction; 0o was defined as the subject having the arm obtained among column means is by chance.
completely adducted against the thigh. The glenohumeral joint
was used as base for the goniometer. Electromyography activity Discussion
of MVIC of lower trapezius muscle was assessed at each of the
four positions against the manual resistance being applied at the The results of the study showed that lower trapezius
distal forearm and the subject was asked to raise their arm muscle demonstrated no significant level of difference of
against it. Three trials at each position were taken with the activation at any of angle of arm abduction. These findings are
MVIC for 5 seconds and 5 seconds rest between each repetition. congruent with that advocated by Paula et al., that patterns of
increasing and decreasing activity were nearly equally present in
individuals, consequently resulting in no significant increase in
the group mean value between 90o and 140o.
While lower trapezius demonstrated the greatest
activation at 1600, this position was not significantly greater
than the other three positions; 750, 900 and 1250 of arm
abduction. Activation at 1250 was lower than all other angles for
the lower trapezius muscle. This findings are contrary to Elissa
Kinney et.al., (2007) who suggested greatest amount of lower
trapezius activation is during 900 and 1250 of arm abduction.
However Kendall (1980) advocated 160o angle of arm abduction
will target the lower trapezius muscle maximally, since the
overhead arm position will target lower fibers optimally.
Ekstrom (2003) showed that lower trapezius showed maximal
Figure 1 Method of recording MVIC of lower trapezius muscle activation at 125o as the muscle fibers have been estimated to
at varied Kendalls positions run at that angle. Moseley et. al., conducted a fine wire EMG
study of trapezius muscle and found optimal position for lower
trapezius activation was horizontal arm abduction (90o).
Data Analysis Data from this investigation provides baseline
Mean of the highest measure obtained at each position information regarding muscle activation of the lower trapezius
was taken and then standard deviation was calculated. A single during horizontal abduction. The variability in patterns of EMG
factor repeated ANOVA was performed for each aspect of activity reported in this study may explain the apparent
trapezius studied. contradiction in reports of lower trapezius activity among
preceding investigations. Previous authors report increasing
activity of the lower trapezius at increased humeral elevation
angles,7 decreasing activity after 900,8 or activity changes being
dependent on the plane of elevation.9 In the present study,
patterns of increasing and decreasing activity were nearly
equally present in individuals, consequently resulting in no

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 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

significance. Thus the probable reason being that as the angle of References
elevation increases the contribution from the serratus anterior
and upper trapezius muscle increases, thus there is combine role 1. Sudarshan Dayanidhi, Margo Orlin, Scott Kozin, Susan
of these muscles in the upward rotation of scapula as the arm Duff, Andrew Karduna. Scapular kinematics during
elevation increases, causing no significant increase in the lower humeral elevation in adults and children. Clinical
trapezius muscle firing with arm elevation.10 Biomechanics 2005; 20:600–606.
These findings can be generalized to strengthening in 2. Ellisa Kinney, Jodi Wusthoff, Amy Zyck, Brian Hatzel,
the clinical setting. When clinicians are formulating Dan Vaughn, Tim Strickler, Stephen Glass. Activation of
rehabilitation programs for patients with shoulder, neck and the Trapezius Muscle during Varied Forms of Kendall
back problems. It may provide some insight into the exercises – Physical Therapy in Sports. 2008 February;
rehabilitation of patients with shoulder pathology in clinical 9(1):3-8
setting, causing clinicians to question the effectiveness of 3. Lehman, G.J., Buchan, D.D., Lundy, A. Meyers, N., &
exercises that have been considered the standards of practice for Nalborczyk A. Variations in muscle activation levels during
quite some time by many. traditional Latissimus Dorsi weight training exercises: An
The limitations of the study were small sample size, experimental study. Dynamic Medicine. 2004; 3:4-15.
temperature could not be controlled and only one muscle lower 4. Ekstorm, R A., Donatelli, R.A., & Soderberg, G.L..,
trapezius was analyzed. The study can be in future conducted by Surface Electromyographic Analysis of Exercises for the
involving the simultaneous EMG recording of Maximum Trapezius and Serratus Anterior Muscles. Journal of Sport
Voluntary Isometric Contraction of all three, upper trapezius, & Physical Therapy. 2003; 33:247-258.
lower trapezius, and serratus anterior muscle in Kendall’s 5. Kendall, F.P., McCreary, E.K., & Provance, P.G. Manual
positions. Testing and Function (4th Edition) Philadelphia, PA: WB
Saunders.
Conclusion 6. U.K. Mishra, J Kalita. Clinincal Neurophysiology.
Publication- 1st Edition New Delhi, Elsevier, Reed Elsevier
The investigation suggests that for shoulder rehabilitation India Private Limited, 2005
program, lower trapezius muscle strengthening at any angle of 7. Bagg S.O, Forrest WJ: Electromyographic study of the
shoulder abduction (750, 900, 1250, or 1600) would lead to scapular rotators during arm abduction in the scapular
equal amount of lower trapezius muscle activation. plane. Am J Phys Med Rehabilitation 1986; 65(3):124
8. Saha A.K., Das N.N., Chakravarty B.G. Studies on
Clinical implication electromyographic changes of muscles acting on the
shoulder joint complex. Calcutta Med. 1956; 53(1):409-4
As there is no significant difference in activation 13.
pattern of Lower Trapezius between any of the angle of arm 9. lnman V.T., Saunders J.B., Abbott L.C., Observations on
abduction, thus any of the four positions can be used for an the function of the shoulder joint. Journal of Bone Surgery.
efficient rehabilitation program. 1944; 26(A):1-30.
10. Paula M. Ludewig, Three-dimensional Scapular Orientation
and Muscle Activity At Selected Positions of Humeral
Elevation. Journal of Sports and Physical Therapy. 1996.

13
 A comparison between single task versus dual task condition balance training in older
adults with balance impairment

Meenakshi Verma1, Stuti Sehgal2

1 Research student, ISIC Institute of Health and Rehabilitation Sciences, New Delhi
2 Research guide, M.P.T Neurology, Lecturer, ISIC Institute of Health and Rehabilitation Sciences, New Delhi

Abstract
Background and Purpose - Traditionally, rehabilitation programs emphasize training under single-task conditions to improve balance and reduce for
falls. The purpose of the study was to compare the efficiency of three different balance training strategies in an effort to understand the mechanisms
underlying training-related changes in dual task balance performance of older adults with balance impairment.
Methods - 45 older adults with balance impairment were recruited and randomly assigned to three groups. Group one received single task balance
training, group two received dual task training balance training under fixed priority, group three received dual task balance training under variable
priority. Subjects received one hour individualized training sessions, five times in a week for two weeks. Berg balance scale, time up and go test and
dynamic gait index were the outcome measure and their scores for all groups were taken prior and after the training.
Results - One way analysis of variance was used to analyse the difference among the balance improvement in Group one, two and three. And the results
revealed that post intervention scores were highly significant (p 0.05) in group two and group three performed better than group one.
Conclusion - In conclusion, dual task training is effective in improving balance under dual task context in older adults with balance impairment, and
single task training may not generalize to balance performance under dual task conditions.
Keywords - Balance, Fall, Berg balance scale, Time up and go test, Dynamic index gait, Dual task.
condition to increase the challenge to balance during
performance under which the subject practices for example –
Introduction changing the availability of sensory cues (reduce visual cues by
Falling is one of the most serious problems associated asking the participants to close your eyes), or support surface
with ageing.1 Falls are the most frequent cause of injury- related conditions (example- Walking on a flat surface versus an
morbidity and mortality among the elderly. The risk of falling inclined surface. 23-24
exceeds 20% per year among persons aged 65 and older and Dual task method, which requires participants to
living in the community and reaches 35% per year among those perform multiple tasks simultaneously, has been used to
75 and older.2,3 investigate the effect of cognitive tasks on postural control and
Falls are costly and have potentially devastating vice-versa. It has been shown that the ability to maintain
physical, psychological and social consequences. Several postural stability is reduced when performing two or more tasks
studies have been performed among both home living and concurrently & these deficits are increased in elderly people
institutionalized populations to define risk factors associated with balance impairment.25-28
with falls.11-15 Some studies compared the effectiveness of
These risk factors have included both- intrinsic or whole/dual-task training under various set of instructions (fixed
personal factors (example- Balance impairment, neurological priority versus variable priority). In fixed priority condition,
disorders, postural hypotension, and medication use)1,8,10,16-18 participants were asked to place the same amount of attention on
and extrinsic or environmental factors (example- Ill fitting both tasks at all times, whereas in variable priority condition,
footwear, poor lighting, slippery surface and inappropriate attention was switched between tasks.
furniture.1,8-10,18-20 Kramer et al31 compared dual task training under two
There are multifactorial intervention have been instructional sets; fixed priority and variable priority
introduced which included eliminate environmental hazards, instructional sets. In their study included a monitoring task in
improve home support, provide opportunities for socialization conjunction with an alphabet-arithmetic task. Results showed
and encouragement, modify medication, provide balance that the variable priority group improved (increased accuracy
training, involve family and provide follow up.9,21,22 and decreased response time) significantly more than fixed
Keeping this in mind, this study is designed with the priority group and dual task processing skills learned during
purpose of identifying the most appropriate balance training variable priority training transferred to novel tasks. In this study,
program under single and dual task condition in older adults the effect of instructional set on dual task balance training in
with balance impairment because no research have examined elders is not known. In light of research indicating that inability
the effects of training balance under single task versus dual task to perform concurrent tasks is a contributing factor to instability
(fixed priority versus variable priority) conditions in older and falls in many older adults, it has been suggested that
adults. training under both single and dual –task condition is necessary
Single task training involves practicing functional task to optimize functional independence and reduce falls in elderly
requiring balance (example Standing, walking, transfer) in people. So my purpose of study is to compare the effects of
isolation. In previous researches, the therapist may vary the training balance under single task versus dual task (fixed
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

priority versus variable priority) in older adults with balance 1 while simultaneously performing auditory and visual
impairment. discrimination tasks as well as cognitive tasks such as
Three balance scales are used to assess the outcomes of substraction and subjects were directed to maintain attention on
both interventions. They are Time Up and Go Test, Berg both postural and secondary tasks at all times.
Balance Scale and Dynamic Gait Index. These scales have good Group 3 received Dual task condition training under
reliability and validity. These scales have been selected for variable priority which included half training was done with a
study because focus on postural task performance, and half had a focus on
1. They are very simple to administer secondary task performance such as semi tandem with eyes
2. They are quick and practical. closed and arm alteration was postural task and spell word
3. They are easy to be conducted in Indian clinical setting backward is secondary task and attention was switched between
4. The contents of these scales closely mimic the day to the task.
day activities and are easy for the patients to Subjects were then assessed on three balance scales-
understand. Berg Balance Scale, Time Up and Go Test, Dynamic Gait Index

Methods Statistics
The data was managed on excel spread sheet and was
Selection and description of participants analyzed using SPSS (Statistical Package for social sciences for
windows) software, version 12. A One way analysis of variance
A sample of convenience of 45 older adults with was used to analyze the difference among the balance
balance impairment took part in this study. Subjects were improvement in Group 1, 2, 3. Post hoc analysis of significant F
gathered through a Free Physiotherapy Camp organized at
ratio (p≤ 0.05) was conducted using Duncan mean test. Student
Sarvodaya Hospital and community center at Ghaziabad and
t- test (paired) used to analyze the difference between the
ISIC, Hospital, New Delhi. Subjects who fulfilled the inclusion
balance improvements within the group. A significance level of
criteria and were ready to attend exercise program regularly
p ≤ 0.05 was fixed.
were selected.
To participate subjects had to meet the inclusion
criteria: (i) Subjects with age of 65 of years or above. (ii) Results
Subjects with history of one fall within the previous year.(iii)
Independent ambulators with ability to walk 9 meter without The group 1 receiving single task condition balance
any assistance.(iv)Subjects who were independent in their training program consisting of 12 males and 3 female with a
activities of daily living. (v) Subjects who scored greater than 24 mean age of 68.47 years. Group 2 receiving dual task condition
on mini mental status examination score.39 with fixed priority balance training program consisting of 12
Exclusion Criteria for the subjects were: (i) History of males and 3 females with a mean age of 68.20years. Group 3
any other severe neurological, musculoskeletal and receiving dual task condition balance training with variable
cardiovascular condition that affected balance. (ii) Any history priority balance training program consisting of 12 males and 3
of dizziness, depression. (iii) Any uncorrected severe hearing & females with a mean age of 68.07 years. All three groups were
visual impairment which will affect the balance in elderly. (iv) matched in terms of age, height, weight (table 1.1. and figure
Receipt of physical therapy or enrollment in any other formal 1.1). One way analysis of variance was used to compare the
exercise program at the same time. performance of subjects of group 1, 2, 3 on Berg balance scale,
Time up and go test, Dynamic gait index.
Technical information
Graph 1.1. Comparison of age among the group 1, 2, 3
A pre-post experimental design was used. The subjects Group 1 = Single task condition balance training
were invited to participate in the study and were divided Group 2 = Dual task condition balance training
accordingly into three groups. A detailed explanation of the Group 3 = Dual task condition balance training
procedure was given to the patients after which they signed Comparison of age among the group 1, group 2 and
informed consent. Then the subjects were assessed on 3 balance group 3
72
scales included in our study: Berg balance scale, time up and go
71
test, dynamic gait index. Balance training sessions followed 70
Gentile’s taxonomy of movement tasks, a theoretical framework 69
Age (years)

for retraining motor control. 68

67
Group 1 received Single task condition training which 66
included balance activities such as standing with reduced base 65

of support, tandem standing, standing with eyes closed. 64

63
Group 2 received Dual task condition training under Group 1 Group 2 Group 3

fixed priority which included same set of balance tasks as group Age 68.47 68.2 68.07

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 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

Table 1.1. Demographic Data: Comparison among Group 1, Group 2, Group3 (One way ANOVA)

Gp 1 (n = 15) Gp 2 (n = 15) Gp 3 (n =15)

Variables Mean (SD) Mean (SD) Mean (SD) F value p value
NS
Age ( year ) 68.47 (2.66) 68.20 (2.21) 68.07 (2.12) 0.113 0.893
NS
Height ( cm ) 165.93 (11.61) 164.93 (10.35) 164.33 (10.37) 0.084 0.9195
NS
Weight ( kg ) 61.66 (6.04) 60.93 6.06) 60.80 (5.88) 0.0907 0.9134
Gender Male = 12 Male = 12 Male = 12
Female = 3 Female = 3 Female = 3
NS = Not significant at p≤ 0.05 level
n = number of subjects
Gp = Group
Group 1 = Single task condition balance training
Group 2 = Dual task condition with fixed priority balance training
Group 3 = Dual task condition with variable priority balance training
Pre-intervention scores of Berg balance scale (Graph 1.2) Graph 1.2. Comparison of pre and post intervention of berg
All the groups did not showed significant difference balance scale scores among group 1, 2, 3
(F= 0.8543, p≤ 0.05) indicating that all three groups were BBS0 = Pre-intervention scores of Berg balance scale
matched in terms of Berg balance scale. Group 1 (mean= 49.55, BBS1 = Post-intervention score of Berg balance scale
SD=1.88), Group 2 (mean= 50.33, SD= 1.75), Group 3 (mean=
50.20,SD= 1.74).
Comparison of pre and post intervention BBS scores
Pre-intervention scores of Time up and go test for balance between group 1, group 2 and group 3
58
(Graph 1.3)
56
All the groups did not showed significant difference
Berg Balance Scale Scores
54
(F= 0.5513, p≤ 0.05) indicating that all three groups were 52
matched in terms of Time Up and Go Test. Group1 (mean= 50
11.14, SD= 1.24), Group2 (mean= 11.33, SD= 1.03), Group3 48
(mean= 11.57, SD=1.06). 46

Pre- intervention scores of Dynamic gait index for balance 44

(Graph 1.4) 42
Group 1 Group 2 Group 3
All the groups did not showed significant difference BBS0 49.55 50.33 50.2
BBS1 54.33 55.66 55.8
(F= 0.7434, p≤0.05) indicating that all three groups were
matched in terms of Dynamic Gait Test. Group 1 (mean= 20.40,
SD= 1.05), Group 2 (mean= 20.40, SD= 1.18), Group 3 (mean=
Graph 1.3. Comparison of pre and post intervention of time up
20.00, SD= 0.84)
and go test scores among group 1, 2, 3.
Post- intervention scores of Berg balance scale (figure 1.2)
TUGT0 = Pre-intervention scores of Time Up and Go Test
Results revealed significant difference in group 1
TUGT1 = Post-intervention score of Time Up and Go test
versus group 2 and group 1 versus group 3 with F value=
9.1953, p≤ 0.05. Group 1 (mean=54.33, SD=1.63), Group 2
Comparison of pre and post intervention TUGT scores
(mean= 55.66, SD= 0.48), Group 3 (mean= 55.80, SD= 0.56) between group 1, group 2 and group 3
Post- intervention scores of Timed up and go test (figure1.3) 14
Timed Up and Go Test Scores (sec)

Results revealed significant difference in group 1 12

versus group 2 and group 1 versus group 3 with F= 6.68451, 10

p≤0.05. Group 1 (mean =9.70, SD= 0.80), Group 2 (mean = 8

8.80, SD= 0.84), Group 3 (mean = 8.72, SD= 0.75) 6

Post- intervention scores of Dynamic gait scale (table 1.3 and 4

figure 1.4) 2

Results revealed no significant difference in among all 0

Group 1 Group 2 Group 3
three groups with F= 1.4135, p ≤0.05. Group 1 (mean=23.53, TUGT0 11.14 11.33 11.57
SD =0.74), Group 2 (mean = 23.80, SD= 0.41), Group 3 (mean TGUT1 9.7 8.8 8.72

= 23.86, SD=0.51).

16
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

Graph 1.4. Comparison of pre and post intervention scores of dual task training groups with either fixed priority or variable
dynamic gait index among group 1, group 2 , group 3 priority instructions could learn to coordinate the two tasks.
DGI = Dynamic Gait Index However, after training, the processing demand required to
DGI0 = Pre-intervention scores of Dynamic gait index perform the tasks was less when their attention was shifted
DGI1 = Post –intervention scores of Dyanmic gait index between the two tasks, as was required in dual task training with
variable priority instructions group. This could explain why the
Comparison of pre and post intervention DGI participants in our dual task training with variable instructions
scores between group 1, group 2 and group 3 group were able to learn faster. Although in our results we could
not found a significant difference between fixed priority and
30
variable priority instruction but the subjects who received
Dynamic Gait Index Scores

25
variable priority have done less number of miss steps and less
20

15
errors in verbal response during the intervention period as
10
compare to fixed priority instructional sets.32-34
5 After two weeks intervention program, subjects in all
0 training groups significantly improved performance on Berg
Group 1 Group 2 Group 3
balance score and Time up and go. But results did not show the
DGI0 20.4 20.4 20
DGI1
significant improvement on Dynamic gait index. Although
23.53 23.8 23.86
Dynamic gait index have shown improvement with in all three
groups. No research studies have examined that support the
Discussion dynamic gait index is improved in dual task condition balance
training. Might be the rate of learning and retention phase was
The results of study have revealed that subjects in not appropriate. Thus, the outcomes suggest that dual task
group 1 (single task condition balance training), group 2 (dual condition balance training is more effective than single task and
task condition balance training with fixed priority), group 3 the importance of instructional set during balance training.
(dual task condition balance training with variable priority)
benefited from balance training intervention with a significant Conclusion
improvement in post- intervention balance scores on Berg
balance scale, Time up and go, but results did not show the The result of the present study clearly states that dual
significant improvement on Dynamic gait index. Although task training is effective in improving balance under dual task
Dynamic gait index have shown improvement with in all three context in older adults with balance impairment, and single task
groups. training may not generalize to balance performance under dual
Secondarily, post intervention scores were highly task conditions. The instructional set was an important in dual
significant in among the groups but group 2 and group 3 task performance. The variable priority instructional set offered
performed better than group 1. So dual task condition balance advantages over the fixed priority instructional set in terms of
training program was found to be more effective in improving the rate of learning and ability to maintain the skill level
balance in older adults with balance impairment. achieved during training. Although in our results we could not
One factor that might have contributed to improved found a significant difference between fixed priority and
scores in group 2 and group 3 could be based on task variable priority instruction but the subjects who received
coordination and management theory proposed by Kramer et al. variable priority have done less number of miss steps and less
According to this theory practicing two tasks together (not a errors in verbal response during the intervention period as
single task practice) allows participants to develop task compare to fixed priority instructional sets.
coordination skills. Thus, a possible explanation of this outcome Thus, the alternate hypothesis stated in the beginning
is that the efficient integration and coordination between the two of the study, that is, Dual task condition balance training acts as
tasks acquired during dual task training is crucial for improving better technique from single task balance training in older adults
dual task performance. Alternatively, according to Task with balance impairment, have been proved.
Automatization hypothesis, practicing only one task at a time
(single task training) allows participants to automatize the Clinical Implication
performance of individual tasks. As a result, the processing
demand required to perform the tasks is decreased, leading to This study found that it was feasible to implement
more rapid development of skills.33-36 individual dual task training, combining traditional
Another factor that might have contribute to improved intervention with a variety of cognitive tasks, in community-
scores in group 2 and group 3 was that they had instructional set dwelling older adults with balance impairment. We also found
in dual task training. Research by Kramer et al suggests that that older adults could in fact adhere to instructional sets
who receive dual task training with variable priority instructions regarding attentional forces. They successfully allocated their
have advantage over those who receive training with fixed attention to task in which they were instructed. Thus, results
priority instructions. These researchers found that participants in

17
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

may generalize to similar older adults with balance impairment, 16. Tobis J.S., Reinsch S., Swanson J.M., Byrd M and Scharf
excepting those with a significant neurological or T. (1985). Visual perception dominance of fallers among
musculoskeletal diagnosis. community-dwelling older adults. Journal Of American
Geriatric Society, 33, 330-333.
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1. Brian E. Maki, Pamela J. Holiday, Anne K. Topper (1991). 18. Tinetti M.E., Speechley M., Ginter S.F.(1988). Risk factors
Fear of falling and Postural control performance in the for falls among elderly persons living in the community.
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(1991). Risk factors For injurious falls: A prospective (1977). Falls In the elderly realated to postural imbalance.
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4. Richard C. Nelson and Murlidhar A. Amin (1990). among the elderly. New England Journal Of Medicine, 320,
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Murphy, T., Tobin, aimed at reducing postural instability. Physiotherapy
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and Garry , P.J (1997). Fear of falling restriction of 24. Alexander NB, Galecki AT, Grenier ML et al (2001). Task-
miobility in elderly fallers. Age and Ageing, 26, 189-193. specific resistance training to improve the ability of
8. Mathias S., Nayak and Isaacs, B. (1986). Balance in eldery activities of daily living-impaired older adults to rise from a
patients: The “Get- up and Go” Test. Archives of physical bed and from a chair. Journal of American Geriatric
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9. Campbell AJ, Borrie MJ, Spears GF, et al. (1990) 25. Lord SR, Castell S. Physical activity program for older
Circumstances and consequences of falls experienced by a persons: effect on balance, strength, neuromuscular control,
community populations 70 years and over during a and reaction time. Archives of Physical Medicine
prospectives study. Age and ageing, 19, 136-141. Rehabilitation, 75, 648-652.
10. Tinetti ME., Baker D.I., McAvay G., et al.(1994) A 26. Brown L.A., Shumway-Cook A. (1999). Attentional
multifactorial intervention to reduce the risk of falling demands and postural recovery: the effects of aging.
among elderly people living in the community. New Journal of Gerontology, 54, M165-171.
England Journal Medicine, 331, 821-827. 27. Kerr B., Condon S.M., McDonald L.A.(1985). Cognitive
11. Sattin RW. (1992) Falls among older persons: a persons: a spatial processing and the regulation of posture Journal
public health perspective. Annual Review Public Health, Experimental Psychology Human Perceptual Performance,
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12. Tinetti M.E., Williams T.F., and Mayewski R. (1986). Fall 28. Brauser S.G., Woollacott M, Shumway-Cook A. (2002).
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disabilities. The American Journal Of Medicine, 80, 429- postural stability in balance-impaired elderly persons.
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13. Granek E., Baker S.P., Abbey H., Robinson E., Myers A.H. 29. Shumway-Cook A., Woollacott M., Kerns K.A. (1997). The
Samkoff, J.S. and Klein, L.E. (1987). Medications and effects of two types of cognitive tasks on postural stability
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14. Whipple R.H., Wolfson L.I. and Amerman P.M.(1987). The 30. Connell B.R., Wolf S.L., Atlanta FICSIT Group. (1997).
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home residents: An isokinetic study. Journal Of American with falls at home among healthy elderly individuals.
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individuals: a preliminary study. Journal of American older adults with balance impairment. Physical therapy, 86,
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Training of balance under single and dual task condition in

19
 The effect of lower limb progressive resistance exercise on balance in subacute and
chronic stroke patients

Govani Tulsi Laxmidas

M.P.T (Neuro), Private practitioner, Rajkot

Abstract
Background and Objective - Balance problems are thought to be common after stroke and they have been implicated in poor recovery of activity of daily
living and mobility and an increase risk of falls. A positive correlation exists between balance impairments and decreased lower-limb strength. So the
aim of the study was to find out effect of lower limb progressive resisted training on balance.
Methodology - An experimental longitudinal study was conducted with 30 subacute and chronic stroke patients. The experimental group (N=15) were
given progressive resistance training with 70% 0f 1 RM, 3sets of 8-10 repetition, 6 days/week for 4 weeks. Exercises were given to HF, HE, HAB, HAD,
KF, KE and ADF. Progression was checked every week and accordingly increase in resistance was given. The control group (N=15) were given
conventional physiotherapy for same duration. Pre and post evaluation of strength and balance was taken by 1 RM and BBS respectively.
Result - The paired –t test for intra group comparison of pre and post treatment 1RM shows significant improvement in strength in both groups. The
unpaired- t test inter group comparison of post treatment 1RM shows significant improvement in experimental group compare to control group HF
(t=5.42, p<0.001) HE (t=8.46, p<0.001) HAB (t=5.40, p<0.001) HAD (t=6.14, p<0.001) KF (t=7.03, p<0.001) KE (t=5.08, p<0.001) ADF (t=6.74,
p<0,001). The Wilcoxon Signed Rank test for intra group comparison of pre and post treatment BBS score shows significant improvement in balance in
both groups (z=3.414, p<0.001 for experimental group, z=3.495, p<0.00 for control group). The Mann Whitney U test for inter group comparison of
post BBS score shows significant improvement in balance in experimental group as compared to control group ( z=2.725, p<0.006).
Conclusion - There was significant improvement in muscle strength of lower extremity and balance after progressive resistance training in experimental
group as compared to control group.
Key words - Stroke, BBS, 1RM, Progressive resistance exercise

balance impairments consistently have shown that people with

Introduction stroke have greater postural sway than age-matched volunteers
who are healthy. They also have altered weight distribution
The traditional definition of stroke, devised by the patterns; so that less weight is taken through the weak leg, and
World Health organization in the 1970s, is a "neurological they have smaller excursions when moving their weight around
deficit of cerebrovascular cause that persists beyond 24 hours or the base of support, especially in the direction of the weaker leg
is interrupted by death within 24 hours”. Stroke or Cerebral appear to take longer to reach the same level of functional gain.7
Vascular Accident (CVA) was the 3rd largest cause of death In the literature, post stroke weakness has been
after heart disease and cancer worldwide1 and the most described not only as impaired force magnitude but also as a
important single cause of severe disability in people.2 more broadly defined phenomenon, including slowness to
Hemiplegia is registered in 70–85% of first case stroke, produce force, a rapid onset of fatigue, an excessive sense of
and reduced muscle strength is considered a major cause of effort, and difficulty with producing force effectively within the
motor disability.3 Balance problems are thought to be common context of a taskictions.8
after stroke, and they have been implicated in the poor recovery A positive correlation exists between balance
of activities of daily living and mobility and an increased risk of impairments and decreased lower-limb strength.4,6 In
falls. More than 80% of subjects who had first-time stroke, have hemiparetic patients, weakness and impaired muscle control of
limited sitting balance, standing balance and stepping balance in the affected lower limb, decreased range of motion, and pain
acute phase.4 Balance is a pre-requirement for all functional can lead to changes in the base of support (BOS) control.6
activities and an essential part of sitting, sit to stand, and Abnormal motor control, with a decrease in rate and frequency
walking activities, depends on integrity of the CNS. of motor neuron activation and poor timing and co-ordination of
The functionally significant components of balance are muscle contraction (i.e. loss of muscle strength and co-
maintenance of a posture, postural adjustments in anticipation of ordination) which cause problems of force and timing lead to an
and during a self initiated movement, and postural adjustments inability to maintain a relatively stable posture against gravity.
made in response to an external disturbance. Balance emerges According to Carr & Shepherd it is lower extremity
from a complex interaction of the sensory and musculoskeletal muscles that control the movements of trunk over the base of
system integrated and modified within the central nervous support.9 The strength of multiple muscle groups of the paretic
system (CNS) in response to changing internal and external lower limbs has been shown to correlate with independence in
environment conditions.5 the stand-pivot-sit transfer. The decreased trunk movements
Decreased muscle strength, range of movement, seen as a person post-stroke reaches out in sitting, reflects a
abnormal muscle tone, motor coordination, sensory reluctance to move the body mass too far towards the periphery
organization, cognition, and multisensory integration can of the base of support because of insecurity that results from
contribute to balance disturbances at different levels.6 Studies of difficulty stabilizing the lower extremity.9 So it is important to
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

improve muscle strength in stroke patients on affected side to p<0.006) HAB (t=3.84, p<0.002) HAD (t=4.51, p<0.001) KF
maintain good balance. So the aim of the study was to find out (t=4.93, p<0.001) KE (t=2.77, p< 0.01) ADF (t=2.25, p<0.02)
effect of lower limb resisted training on balance. Table 2 shows the value of unpaired t-test for strength
on comparing pre and post training between the Group A and
Methodology Group B. The result shows that there was significant
improvement in muscle strength post training in Group A
The study design was experimental. 30 subjects with compare to Group B. HF (t=5.42, p<0.001) HE (t=8.46,
subacute and chronic stroke were selected from various p<0.001) HAB (t=5.40, p<0.001) HAD (t=6.14, p<0.001) KF
physiotherapy centers in Rajkot. The patients were divided into (t=7.03, p<0.001) KE (t=5.08, p<0.001) ADF (t=6.74, p<0,001)
group A (experimental) and B (control) by random sampling.
Inclusion criteria was (1)Single episode of unilateral stroke, (2) Table 1: Comparison of pre and post treatment measurement of
Less than one year post stroke (sub-acute to chronic stage), (3) 1RM mean and results of paired t – test (In Group A and B)
Both male and female, (4) Age group 40-65 and (5) GROUP A GROUP B
MUSCLE
Brunnstrom`s recovery grade more than 3. Patients were GROUP Mean (SD) (gms) p Mean (SD) gms p
excluded if they had (1) More than one instance of Pre HF 2300 (1221.82) 1300 (649.17)
< 0.001 < 0.001
cerebrovascular event, (2) Visual and auditory deficits, (3) Post HF 3286.66 (1704.14) 1466.66 (673.65)
Aphasia, (4) Inability to follow simple commands, (5) Pre HE 933.33 (593.61)
< 0.001
580 (439.48)
< 0.006
Uncontrolled hypertension or (6) Any other orthopedic, Post HE 1666.66 (748.01) 633.33 (468.53)
neurological or cardiovascular problems affecting muscle Pre HAB 1800 (996.42) 766.66 (409.99)
< 0.001 < 0.002
Post HAB 2500 (1309.3) 866.66 (361.87)
strength or balance.
Pre HAD 1700 (1014.18) 886.66 (561.71)
1RM of major muscle groups of lower limb (hip Post HAD 2466.66 (1288.22)
< 0.001
973.33 (592.17)
< 0.001
flexors, extensors, adductors, abductors knee flexors, extensors Pre KF 1125.46 (1125.46) 913.33 (669.61)
and ankle dorsi-flexors) and BBS of all patients were taken. < 0.001 < 0.001
Post KF 2513.33 (1277.19) 1033.33 (679.98)
Group A were given progressive resistance exercise with Pre KE 1586.66 (977.5) 1020 (583.34)
< 0.001 < 0.01
conventional treatment. Group B were given only conventional Post KE 2433.33 (1374.07) 1073.33 (572.54)
treatment. Pre ADF 466.66 (381.1) < 0.001 180 (101.41) < 0.02
GROUP A: The progressive resisted exercise was Post ADF 886.66 (582.93) 206.66 (103.27)
given with 70% of 1RM. Resistance was given with free
weights. 3 sets of 8-10 repetition at 70% of 1 RM. Exercise Table 2: Comparison of post treatment measurement of 1RM
were given 6 days/week for 4week.10 Exercise were given to mean and results of unpaired t – test (Between Group A and B)
hip flexors, extensors, abductors, adductors knee flexors and MUSCLE GROUP MEAN (SD) gms p
extensors, and ankle dorsi-flexors. Progression was checked Pre HF 986.66 (581.7)
< 0.001
every week with 1 RM and according to increase in weight, Post HF 166.66 (61.72)
progression in 70% of 1RM was given. Pre HE 766.66 (319.97)
< 0.001
Post HE 53.33 (63.99)
GROUP B: Conventional treatment was included Pre HAB 700 (414.03)
stretching for hamsring and calf muscles and wrist flexors, < 0.001
Post HAB 106.66 (96.11)
normalizing tone activity, mat exercises, sit to stand activity, Pre HAD 766.66 (416.9)
< 0.001
Proprioceptive neuromuscular facilitation for lower limb and Post HAD 93.33 (79.88)
trunk, task specific activities for upper limb. Exercises were Pre KF 646.66 (269.56)
< 0.001
Post KF 126.66 (96.11)
given 6 days/week for 4 weeks.
Pre KE 846.66 (599.84)
Post exercise 1RM and BBS were assessed for both the < 0.001
Post KE 53.33 (74.32)
group. Pre ADF 420 (221.03)
< 0.001
Post ADF 26.66 (45.77)
Results
Table 3: Comparison of means of BBS score measured pre and
Table 1 shows the value of Paired t-test for 1 RM on post treatment for Group A & B and Wilcoxon Signed Rank test
comparing pre and post training in the Group A and B. The for inter group comparison
result shows that there was significant improvement in muscle Mean (SD) z p
strength post strength training. HF (t=6.56, p<0.001) HE Group A Pre treatment 31.2 (5.1) 3.414 < 0.001
(t=8.87, p<0.001) HAB (t=6.45, p<0.001) HAD (t=7.12, Post treatment 41.06 (5.3)
p<0.001) KF (t=9.29, p<0.001) KE (t=5.46, p<0.001) ADF Group B Pre treatment 42.6 (5.67) 3.495 < 0.001
Post treatment 32.53 (5.73)
(t=7.35, p<0.001) in group A. In the Group B the result shows
that there was significant improvement in muscle strength post
conventional training. HF (t=10.45, p<0.001) HE (t=3.22,

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 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

Table 4: Comparison of means of BBS score measured post Graph 4: Comparison of means of BBS score measured pre and
treatment between Group A and B and results of Mann-Whitney post treatment in Group A & B
U test for inter group comparison
MEAN SD z p BBS score
Group A 42.6 5.73
2.725 0.006 41.06
Group B 32.53 5.26 45
40 36.53
35 31.2 32.06
30
Graph 1: Comparison of means of 1RM measured pre and post 25
Group A
20
strength training for different muscle group in the Group A 15 Group B
10
5
0
Group A strength (1RM)
3286.66

Pre treatment Post treatment

2513.33

3500
2466.66

2433.33
2500
2300

3000
1666.66

1586.66
1800

2500
Discussion
1700

1125.46

2000
933.33

886.66

PRE
1500
466.66

1000 POST
500
The result of the present study are in line with findings
0 in literature and support the conclusion that by application of
HF HE HAB HAD KF KE ADF progressive resistive exercises lower limb muscle strength and
balance are improved. Many researchers like Patricia Kluding et
Graph 2: Comparison means of 1RM measured pre and post al., (2009)11, Stephen J page et al, (2008)12, Weiss et al.,
strength training for different muscle group in the Group B (2000) 13, Richard W. Bohannon et al., (1991)14 have
documented that lower limb strength was associated with gain in
balance (BBS). Dean CM et al., (2000)14 demonstrated
Group B strength (1RM) significant improvement in walking speed and endurance, force
1466.66

production through affected leg during sit-to stand and the

1300

1600
number of repetition of the step test by application of muscle
1073.33
1033.33

1400
973.33

1020
913.33
886.66
866.66

1200 strengthening exercise in affected lower limb.

766.66
633.33

1000
The possible mechanism for improvement in balance
580

800 PRE
explained by supporting studies was, strength training can result
206.66

600
POST
180

400
200 in increased motor unit activity, there by potentially increasing
0
strength after stroke. Progressive resistance training includes
HF HE HAB HAD KF KE ADF
higher level of neuromuscular activation than functional
activity.15 It also produce physiological changes in the muscle
Graph 3: Comparison of means of 1RM measured post strength (hypertrophy) and mechanical effect such as increased joint
training for different muscle group between the Group A and stability16.
Group B Changes in the pattern of motor unit recruitment and
increase in the neural drive may be inclusive factors after
strength training. Thus, based on the principles of
Inter group strength (1RM) neuroplasticity, strength or resistance training plays an
important role in improving motor unit recruitment, because the
986.66

1200
846.66
766.66

766.66

1000 capacity to produce muscular force is primarily a neural

646.66
700

800 phenomenon with task specific regulation of neural activity. All

420

600 Group A previous study found the improvement in functional balance, sit-
166.66

126.66
106.66

400
to-stand activity, stair climbing and walking speed. All these
93.33

Group B
53.33

53.33

26.66

200
0
activities represent good static as well as dynamic balance. So
HF HE HAB HAD KF KE ADF
ultimately it represents increase in balance.16
These results contrast with those of Indr Kligyte ea al.,
(2003)9, Mead et al., (2007)17, Yang et al., (2006)18, Shart et al.,
(1997).19 They found lower limb muscle strength has a poor
influence on dynamic balance problem17 and no significant
improvement was seen in dynamic balance after endurance
resistance training program.17,18
Weak correlation between the Functional Reach test
and lower extremity muscle strength was obtained in above

22
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

study because no measure were taken to control the subject`s dynamic balance in people post-stroke.” Medicina. 2003;
strategy of reaching forward. One other reason was that the 39(2): (122-128).
assessment of the strength of isolated muscle group was taken 10. Richard W. Bohannon, Susan Walsh. “Association of
instead of assessing synergistic muscle group.17 But in present paretic lower extremity muscle strength and standing
study balance measure used was BBS, which includes static as balance with stair-climbing ability in patients with stroke.”
well as dynamic balance component. And all major muscle Journal of Stroke and Cerebrovascular Diseases. 1991; 1(3):
group strength was taken in to consideration. Progressive load (129-133).
applied to patient after checking strength improvement every 11. Page SJ, Levine P, Teepen J, Hartman EC.
week in present study, was not given in above studies. “Resistance-based, reciprocal upper and lower limb
locomotor training in chronic stroke: a randomized,
References controlled crossover study.” Clinical Rehabilitation. 2008;
22(7): (610-617).
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“Relationship between lower extremity muscle strength and

23
 Energy expenditure during wheelchair propulsion in different levels of paraplegics

Ankur Parekh
Lecturer, R.K. College Of Physiotherapy, R.K. University.

Abstract
Background - Wheelchair is considered as an efficient means of locomotion with optimal independence for a non – ambulatory person with
dysfunctioning lower limbs. A linear relationship between oxygen consumption (VO 2 ) and heart rate at submaximal levels has been repeatedly proven in
able-bodied subjects, handicapped children, and paraplegics during arm cranking at different power levels. Therefore heart rate is used an indicator of
energy expenditure. This study is aimed to evaluate the energy expenditure during standard wheelchair propulsion in different levels of paraplegics using
Physiological Cost Index (PCI).
Materials & Methodology - Male paraplegics (n=50,) age = 31.52 ± 5.20 (Mean ± Standard Deviation) years between T7 to T12 spinal level using
wheelchair were included in the study. Patients were given 5 minutes time at the starting line in order to attain a steady resting heart rate which was
measured by palpation of radial pulse. Subjects were instructed to propel the wheelchair at their normal propulsion speed on a standard level corridor
(walkway of 25 meters) for a minimum duration of 5 minutes to attain a steady physiological heart rate. At the end of 5 minutes, they were instructed to
stop and steady propulsion heart rate was measured. Energy expenditure (PCI) was calculated by: PCI (beats/meter) = Steady propulsion heart rate –
Resting heart rate (beats per minute / propulsion speed (meter/minute)
Results - Descriptive statistics using mean and standard deviation and Pearson correlation was used. There was a strong correlation between PCI and
duration since wheelchair used.
Conclusion - There is strong correlation between PCI and duration since wheelchair used, but there is no correlation between PCI and different level of
thoracic injury, American Spinal Injury Association (ASIA) score and speed of propulsion.

Energy expenditure is an important parameter in the

Introduction assessment of orthotic treatment or during wheelchair
prescription in paraplegics. Estimation of energy cost of
Spinal cord injury (SCI) is an insult to the spinal cord ambulation provides functional efficiency of the user, loco
resulting in change, either temporary or permanent, in its normal motor efficiency of the wheelchair and potential benefits of the
motor, sensory or autonomic function.1 propulsion system.9
Spinal cord injury (SCI) is catastrophic condition that, In able body subjects, heart rate and oxygen uptake
depending on its severity may cause dramatic changes in have linear relation upto submaximal workloads. This has
person’s life.2 The degree & type of forces that are exerted on enabled the clinician and the researcher to monitor the energy
the spine at the time of injury determine the location & severity cost of a variety of physical activities by monitoring the heart
of the damage that occurs.3 The incidence of multiple traumas in rate alone. In high thoracic paraplegics monitoring heart rate
the client with a traumatic spinal cord injury is 55.2%.4 was considered to be unreliable because of suspicion of injury to
Spinal cord injuries are the named according to the the sympathetic contribution of the cardiac plexus, Bar-on and
level of neurological injury and are classified as complete or Nene found that, in paraplegics below the lesion level of T3
incomplete. The neurological level of injury is defined as the spinal level injury, heart rate shows linear relation to oxygen
most caudal level of the spinal cord that exhibits intact sensory uptake.8
and motor functioning.5 A person is said to have a complete Both speed and heart rate have been used as indicator
spinal cord injury if there is total and permanent functional of efficiency and energy cost of locomotion but their combined
disruption of the cord. No sensory or motor function is present use was first reported by Mac Gregor in 1979, who highlighted
in areas innervated below the neurological level of injury. A the problems of factor other than work load which may cause
lesion is classified as incomplete if any sensation or voluntary heart rate variability. He introduced a new method of finding the
motor function exists more than 3 segments below the energy expenditure and it was termed as Physiological Cost
neurological level of injury.5 index (PCI). PCI (beats/meter) = Steady propulsion heart rate –
The wheelchair should enable individuals with Resting heart rate (beats per minute / propulsion speed
paraplegic to perform the activities of daily living (ADL) that (meter/minute)
are important for them, with minimal to no assistance and with
the least amount of energy expenditure. Types of activities Aim and Objectives
include transfers, personal needs (e.g. bathing and toileting),
AIM: To determine the energy expenditure during wheelchair
working, preparing meals, cleaning and shopping.6
propulsion in different level of paraplegics.
Energy is defined as the “capacity of a physical system
OBJECTIVES: (1) To correlate the physiological cost index
to perform work”. Energy exists in several forms such as heat,
during wheel chair propulsion and different levels of thoracic
kinetic or mechanical energy, light, potential energy, electrical,
injury. (2) To correlate the physiological cost index during
or other forms. The SI unit of energy is the joule (J) or Newton-
meter (Nm).7
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

wheel chair propulsion and the duration since wheel chair use in
different levels of thoracic injury.

Methodology
STUDY DESIGN: Cross-sectional observational study
STUDY SETTING: Government Physiotherapy College, Civil
Hospital, Ahmedabad.
STUDY DURATION: The study was performed only in a single
session.
SAMPLE SIZE: Fifty
7 subjects with T7 spinal cord injury. Figure 1: Paraplegic patient sitting on wheel chair
9 subjects with T8 spinal cord injury.
9 subjects with T9 spinal cord injury. Patients were given 5 minutes time at the starting line
7 subjects with T10 spinal cord injury. to sit quietly in order to attain a steady resting heart rate which
8 subjects with T11 spinal cord injury. was measured by palpation of radial pulse. Subjects were
10 subjects with T12 spinal cord injury. instructed to propel the wheel chair at their normal speed on a
STUDY POPULATION: Subjects diagnosed with spinal cord standard leveled corridor (which had a walkway of 25 meters)
injury for a minimum duration of 5 minutes to attain a steady
SAMPLING DESIGN: Simple random sampling physiological heart rate. At the end of 5 minutes, they were
AGE GROUP: 20 – 40 years, mean age 31.52±5.20 years instructed to stop and immediately the steady propulsion heart
INCLUSION CRITERIAS: rate was measured by the palpation of radial pulse. The distance
1 Patients who were willing to participate. travelled by the patient was measured by calculating the number
2 Only male subjects were selected. of rounds covered by the patient multiplied by 25 meters (walk
3 Spinal cord injury patients between T7–T12 levels. way distance) and the extra distance was measured using an
4 Medically stable patients. inch tape. Wheel chair propulsion energy expenditure using PCI
5 Height of patient varying from 5 feet 4 inches to 6 feet 2 was calculated.
inches.
6 Patients who were already trained for wheelchair Results
propulsion for at least 3 weeks.
EXCLUSION CRITERIAS: Table 1: Mean age and DSWU in patients with spinal cord
1 Any cardio–respiratory abnormality. injury (T7–T12)
2 Any musculoskeletal abnormal abnormality preventing
appropriate seating or propulsion of wheel chair. MEAN (SD)
3 Any neurological problems (e.g. tumors, cerebro-vascular 31.52(5.2)
AGE
accident)
4 Pain in upper limb. DSWU 24.54(13.42)
5 Patients with bed sore. Table 2: Mean values of ASIA, RHR (Beats/Minute), PEHR
PROCEDURE: A written consent form was taken from patients (Beats/Minute) and Distance (Meter).
who fulfilled the inclusion and exclusion criteria. The procedure
was explained to them. A thorough neurological examination
MEAN (SD)
was done. ASIA scale was used to differentiate between the
complete or incomplete spinal cord injuries and also to know the ASIA 134.1(17.53)
level of impairment. RHR (beats/minute) 87.9(15.9)
A standard wheelchair was used on which the patient 113.3(19.55)
was seated with a cloth belt tied at the level of anterior superior PEHR (beats/min)
iliac spine to prevent him from sliding from seat. Another cloth DISTANCE (meter) 130.6(47.59)
belt was tied horizontally just above the foot rest to prevent the
legs from slipping from the rest during wheel chair propulsion.

25
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

1.2 1.05 2.0

0.94 0.94 0.96
1 0.85 0.87
PCI (BEATS/MTER)

0.8 D7 1.5
D8
0.6
D9 PCI (BEATS/METER) 1.0
0.4
D10
0.2
D11
0.5
0
D12
D7 D8 D9 D10 D11 D12 0.0
0 20 40 60 80
LEVEL OF INJURY
DSWU(WEEK)

Graph 1: Mean values of PCI (Beats/Meter) in different levels Graph 3: Correlation between duration since wheelchair used
of spinal cord injury (DSWU) and PCI

Table 3: Correlation between different levels of paraplegics and Table 5: Correlation between PCI and ASIA score in different
PCI. (Pearson Product moment correlation coefficient) levels of thoracic injury (T7 – T12). (Pearson Product – moment
correlation coefficient)
Variables Mean Pearson P
(SD) correlation
coefficient R Mean Pearson correlation P
PCI 0.94(0.23) (SD) coefficient R
(beats/meter) 0.1410 0.3338 PCI 0.94
Thoracic 9.5(1.8) (Beats/meter) (0.23) 0.0772 0.5976
level injury ASIA score 134.1
(17.53)
2.0
PCI (BEATS/METER)

2.0
1.5
PCI (BEATS/METER)

1.5
1.0
1.0
0.5
0.5
0.0
6 8 10 12 14
0.0
LEVEL OF INJURY 100 150 200 250
ASIA SCORE
Graph 2: Correlation between different levels of paraplegics and
PCI Graph 4: Correlation between PCI and ASIA score in different
levels of thoracic injury (T7 – T12)
Table 4: Correlation between duration since wheelchair
used (DSWU) and PCI. (Pearson Product – moment correlation Table 6: Correlation between PCI and speed of propulsion in
coefficient) different level of thoracic injury (T7 – T12). (Pearson Product –
moment correlation coefficient)
Mean Pearson P
(SD) correlation Mean Pearson P
coefficient R (SD) correlation
PCI 0.94 coefficient R
(beats/meter) (0.23) - 0.7971 <0.0001 PCI (beats/meter) 0.94
DSWU 27 (0.23) - 0.2516 0.0812
(week) (14.26) Speed of propulsion 26.12
(meter/min) (9.52)

26
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

Limitations of the study

2.0
1 Small sample size.
PCI (BEATS/METER)

1.5 2 Propulsion technique was not controlled.

3 Body Mass Index was not noted.
1.0
Suggestions for Future Study
0.5 1 Patients with similar duration of wheelchair training should
be included for homogeneity.
0.0 2 Patients should be instructed to propel the wheelchair in
0 20 40 60 80 100 higher velocity to analyze the effect of trunk muscle
SPEED (METER/MIN) activity on energy expenditure (PCI).

Graph 5: Correlation between PCI and speed of propulsion in

Conclusions
different level of thoracic injury (T7 – T12). (Pearson Product –
moment correlation coefficient)
There is strong correlation between the duration since
wheelchair and the energy expenditure where longer the
Discussion duration lesser the energy expenditure but there is no correlation
between different levels of spinal cord injury level and the
This study consisted of only male paraplegics to avoid energy expenditure during wheelchair propulsion, no correlation
any gender influences in energy expenditure. All the subjects between ASIA scores and PCI in different levels of thoracic
were below the level of T6 as patients above this lesion have no injury, no correlation between the speed of propulsion and PCI
control over their sympathetic system which leads to loss of in different levels of injury.
control in heart rate and blood pressure which may affect the
heart rate index.8
Reference
The average speed of propulsion was 26.11
meter/minute. There was a significant negative correlation
1. Segun T Dawodu. Spinal Cord injury – Definition,
between speed of propulsion and PCI suggesting that increasing
Epidemiology, Pathophysiology.Dec.22,2008
in speed had resulted in less energy expenditure.
2. Umpherd D. Neurologocal rehabilitation 5th ed.St.Louis,
There was no significant correlation between different
Missouri:Mosby Elsevier Publication; 2007
levels of spinal cord injury and PCI. This may be because the
3. Hanak M.scott A:spinal cord injury :an illustrated guide for
muscles used during propulsion may not have highly differed
health care professionals,New York ‘1983,springer.
between various levels of spinal cord injury. Mulroy SJ et al
4. Stover SL,Delisa IA,whiteneck GG : spinal cord injury :
studied the muscular activity and found that the shoulder girdle
clinical outcomes from the model systems. Gathersburg
muscles contribute to a greater extent for the propulsion of
,MD ,1995 ,Aspen publication.
wheelchair. They identified functional synergy : push ( anterior
5. Martha Freeman Somers .spinal cord injury functional
deltoid , pectoralis major, supraspinatus , infraspinatus ,
rehabilitation .1st edition Appleton and Lange ;1992.
subscapularis , serratus anterior , biceps ) and recovery ( middle
6. Alicia M. Koontz, Donald M. Spaeth, Mark R. Schmeler
and posterior deltoid , supraspinatus , subscapularis , middle
and Rory A. Cooper, prescription of wheelchair and seating
trapezius , triceps). 10 In our study all the patients had these
system, physical medicine and rehabilitation,3rd edition
shoulder girdle muscles preserved.
18;381-395.
Similarly there was no correlation between the ASIA
7. Andrew Zimmerman Jones, About.com Guide,2011
and PCI due to lack of homogeneity among the subjects in the
8. A V Nene ,S J Jennings ,Physiological cost index of
same level of thoracic injury. Also the ASIA scores reports only
paraplegic locomotion using the ORLAU parawalker
about the sensory scores and not about the motor scores at the
.paraplegia.1992;246-252.
thoracic level. So the correlation could not be established.
9. Goutham Mukherjee, Amalendu Samata .Evaluation of
There was a very strong correlation between duration
ambulatory performance of the arm propelled three wheeled
since wheelchair used to PCI. Longer the duration since use of
chair using heart rate as the control index. Disability and
wheelchair lesser was the energy expenditure. This may be
rehabilitation .2000;10:464-470.
because of the improved cardiovascular efficiency with longer
10. Mulroy SJ ,Farrokhi S, Newsam CJ Perry J. Effect of spinal
usage, increased muscular power in the propelling muscles and
cord injury level on the activity of shoulder muscles during
due only about the effect of motor learning as less muscle
wheelchair propulsion : an electromyographic study. Arch
activity is required with improved learning. This suggests that
Phys Med Rehabil. 2004 Jun ;85 (6):925-34.
with longer usage, wheelchair propulsion may become a more
energy efficient form of ambulation in paraplegics.

27
Immediate effectiveness of diathermy, positional release therapy and taping on acute wry
neck in a post-partum woman: single case report

Khatri SM1, Sant SS2

1 BPhT, M.P.T. (Ortho), PhD (Sports Medicine), Principal, College of Physiotherapy, Pravara Institute of Medical Sciences, Loni (Bk),
2 M.P.Th. IInd. College of Physiotherapy. PIMS. Loni (Bk).

ABSTRACT
Objectives - To find out the immediate effectiveness of diathermy, taping and positional release in the treatment of acute wry neck in a post-partum
woman.
Design - Single case study design.
Setting - Tertiary care center.
Participants - A single individual with acute wry neck participated in this study.
Interventions - Interventions used in this study included continuous short wave diathermy, positional release therapy and taping.
Main outcome measures: Pain relief in terms of visual analogue scale and active cervical side flexion to opposite side in centimeters.
Results - Pain was reduced by 6.8cm on VAS scale and active cervical side flexion was increased by 3.2cm immediately after the interventions.
Conclusions - Diathermy, taping and positional release therapy can be used for immediate relief of acute wry neck pain and restricted movements.
Keywords - neck pain; physiotherapy; taping; positional release technique; continuous short wave diathermy; positional release.

Background and Purpose Case Description

Neck pain is a common condition, with an annual The patient (Mrs. DK) was a 27 year old software engineer. She
incidence estimated at about 15%1. Patients with neck pain was referred for acute wry neck by gynecologist after discussing
frequently are treated without surgery by primary care and the case with orthopedician. The case was attended by
physical therapy providers1. It has been estimated that as many Physiotherapist and enrolled on daily treatment basis.
as 70% of individuals report experiencing neck pain at some Patient history: Mrs. DK complained neck pain for three days.
point in their lifetimes, and at 5 year follow-up, 78% of men and She delivered a female baby and when recovered out of general
85% of women report full recovery.2,3 The economic burden anesthesia, she noted that there was severe neck pain on her
associated with neck pain is immense, and nearly one-third of right side. She rated her pain as 8.6 on a 0–10 centimeter visual
people who experience first-time onset of neck pain will analogue scale and described it as severe at the time of
continue to report healthcare utilization for their neck pain at a examination. She noted that almost all the neck movement were
5-year follow-up.4 Acute neck pain is usually the result of injury painful especially more pain was perceived on active right
or accident, most often road vehicle accidents associated with rotation and left side flexion of cervical spine. She recalled no
whiplash. Some prognostic studies have suggested that chronic specific injury to her neck or history of similar problem in the
neck pain is related to repetitive working conditions5. However, past. Further, she reported that there were no temporal variations
there is also an association between depression, chronic neck but sleeping with neck support could alleviate her symptoms.
pain and low back pain. Patients with neck pain often presents
with acute wry neck, neck pain with scapular pain and neck pain Physical Examination
with root pain depending on their underlying pathology. Despite
the prevalence of neck pain, there is a lack of evidence at Physical examination was performed on the third day of
present regarding whether to include or exclude the use of symptoms. On physical examination it was found this patient
thermotherapy, therapeutic massage, EMG biofeedback, had forward head posture, elevated right shoulder, spasm of
mechanical traction, therapeutic ultrasound, TENS, electrical upper trapezius and scalenii muscles, tender C 5 and C 6 spinous
stimulation, and combined rehabilitation interventions in the process of cervical vertebrae, painful & limited active and
daily practice of physical rehabilitation of patients with acute passive neck movements 200 left side flexion and 150 right
and chronic neck pain.6 In spite of the neck pain being so rotation. Cervical compression test was positive and x-ray was
common, there are hardly any study that has evaluated the normal.
combined immediate effectiveness of interventions like
Diathermy, Taping and Positional release therapy in relieving Treatment Methods
acute neck pain and improving disability in patients with non
specific neck pain. Hence, in this study an attempt is made to The patient was treated with continuous short wave
determine the immediate effectiveness of these interventions in diathermy for 10 minutes in supine position with pad electrodes
relatively unusual case of acute wry neck in a post partum placed on either side of neck with a pillow support.7, 8 For
woman.
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

positional release9 the pressure was applied at tender point Conflicts of Interest
located at the middle portion of the right upper trapezius by
pinching the muscle between the thumb and the fingers. The As per knowledge and study of authors, the presented
patient’s head was side-flexed laterally toward the tender point case study report is having no personal or institutional conflicts
side. The therapist grasped the patient’s forearm and abducted of interest.
the shoulder to approximately 900 and added slight flexion or
extension to fine tune. This position was held for 90 second and
Consent of Patient:
the procedure was repeated three times. After positional release
therapy, taping was applied with elastoplast in X shaped manner
The author was not able to acquire consent letter for
over both nape and upper thoracic region so as to keep both the
this study hence, all the personal details and information was
scapulae in retracted position that minimized her discomfort.
omitted from present case study paper.
She was treated for additional three days and her case follow up
was done six months. The primary outcome measure was a
horizontal 10 cm VAS for pain (graded from zero, representing References
no pain, to 10, the worst imaginable pain).10, 11
1. Cote P, Cassidy JD, Carroll LJ, et al. The annual incidence
Results and course of neck pain in the general population: a
population-based cohort study. Pain. 2004; 112:267–273.
2. Palmer KT, Walsh K, Bendall H, et al. Back pain in Britain:
Immediately after the completion of treatment
comparison of two prevalence surveys at an interval of 10
procedure, patient was re-evaluated for pain relief. It was found
years. BMJ. 2000:320; 1577-1578.
that her visual analogue scale score got reduced to 3.1 and her
3. Pernold g, Mortimer M, Wictorin C, et al. Neck/shoulder
active range of motion of side flexion at left side was 400 and
disorders in a general population: natural course and
right rot was 550. She expressed it as dramatic relief of her
influence of physical exercise-a 5-year follow-up. Spine,
symptoms.
2005.30:E363-E368.
4. Enthoven P, Skargren E, Oberg B. Clinical course in
Discussion patients seeking primary care for back or neck pain: a
prospective 5-year follow-up of outcome and healthcare
The results of this study showed that a single session of consumption with subgroup analysis. Spine, 2004:29:2458-
diathermy, postural release therapy and taping is useful in the 2465.
treatment of acute wry neck. This could be due to muscle 5. Philadelphia Panel Evidence-Based Clinical Practice
relaxation, relief of pain, placebo effect, removal of stretch from Guidelines on Selected Rehabilitation Interventions for
spasmodic muscles, reduction in nocisecptive stimuli and Neck Pain Physical Therapy. Volume 81. Number 10.
improved circulation. However, exact cause and effect October 2001 [1701-1717]
relationship could not be studied. 6. Bot SDM, van der Waal JM, Terwee CB, et al. Incidence
Since there is hardly any study with similar study and prevalence of complaints of the neck and upper
design and interventions, the results could not be interpreted extremity in general practice. Ann Rheum Dis. 2005;
with preceding literature. The obvious limitation of this study is 64:118–123.
generalization to other individuals or situations is difficult. Also, 7. GUIDELINES FOR LIMITING RADIOFREQUENCY
single subject participation in this study limits the conclusion of EXPOSURE Environmental Health Directorate Health
study for specific person. Protection Branch Published by Authority of the Minister of
National Health and Welfare http://www.hc-
Conclusion sc.gc.ca/ewhsemt/pubs/radiation/83ehd-dhm98/control-
operat-limit-eng.php [cited on 18-05-2010]
The results of this study suggest that short wave 8. Michlovitz, Susan L. Thermal Agents in Rehabilitation.
diathermy, positional release therapy and taping may be an Philadelphia: F.A. Davis Company, 1996
effective management strategy for a patient with acute wry neck 9. Makofsky HW: Spinal manual therapy: An introduction to
in a post partum woman. Further studies are needed to soft tissue mobilization, therapeutic and home exercises.
determine the clinical utility of this treatment approach in a Thorofare, NJ: SLACK Incorporated: 2003:73.
larger population. 10. Scott J, Huskisson E. Graphic representation of pain. Pain
1976; 2:175–84.
Funding 11. Price DD, Bush FM, Long S, Harkins SW. A comparison of
pain measurement characteristics of mechanical visual
The above study is not funded by any institute or analogue and simple numerical rating scales. Pain 1994;
person and is completely based upon authors at their own 56:217–26.
interests.

29
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

12. Cote P, Cassidy JD, Carroll LJ, et al. The annual incidence extremity in general practice. Ann Rheum Dis. 2005;
and course of neck pain in the general population: a 64:118–123.
population-based cohort study. Pain. 2004; 112:267–273. 18. GUIDELINES FOR LIMITING RADIOFREQUENCY
13. Palmer KT, Walsh K, Bendall H, et al. Back pain in Britain: EXPOSURE Environmental Health Directorate Health
comparison of two prevalence surveys at an interval of 10 Protection Branch Published by Authority of the Minister of
years. BMJ. 2000:320; 1577-1578. National Health and Welfare http://www.hc-
14. Pernold g, Mortimer M, Wictorin C, et al. Neck/shoulder sc.gc.ca/ewhsemt/pubs/radiation/83ehd-dhm98/control-
disorders in a general population: natural course and operat-limit-eng.php [cited on 18-05-2010]
influence of physical exercise-a 5-year follow-up. Spine, 19. Michlovitz, Susan L. Thermal Agents in Rehabilitation.
2005.30:E363-E368. Philadelphia: F.A. Davis Company, 1996
15. Enthoven P, Skargren E, Oberg B. Clinical course in 20. Makofsky HW: Spinal manual therapy: An introduction to
patients seeking primary care for back or neck pain: a soft tissue mobilization, therapeutic and home exercises.
prospective 5-year follow-up of outcome and healthcare Thorofare, NJ: SLACK Incorporated: 2003:73.
consumption with subgroup analysis. Spine, 2004:29:2458- 21. Scott J, Huskisson E. Graphic representation of pain. Pain
2465. 1976; 2:175–84.
16. Philadelphia Panel Evidence-Based Clinical Practice 22. Price DD, Bush FM, Long S, Harkins SW. A comparison of
Guidelines on Selected Rehabilitation Interventions for pain measurement characteristics of mechanical visual
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October 2001 [1701-1717] 56:217–26.
17. Bot SDM, van der Waal JM, Terwee CB, et al. Incidence
and prevalence of complaints of the neck and upper

30
 A comparative study to analyze the risk factors in elderly with and without fear of fall

Arasavalli Karuna Kumari1,C.M.Radhika2

1 Department of Physiotherapy, Sri Ramachandra University, India.
2 Department of physiotherapy, Sri Ramachandra University, India.

Abstract
Older people make up a large and increasing percentage of the population. As people grow older they are increasingly at risk of falling and consequent
injuries. . The prevention of falls is of major importance because they engender considerable mortality, morbidity. The exact cause of falling, though
unclear, some authors agree on the multi factorial etiology like fear of fall, dizziness, loss of muscle power and proprioception, visual impairment,
problems in gait and balance. This study analyzes the risk factors, their contribution for fall in elderly who experience fear of falling and in those who do
not experience fear of falling. In the present study seventy normal elderly individuals of age 60 years and above, who were physically independent were
recruited and among them , individuals who experience fear of fall were grouped together and those who did not experience fear of fall were in the other
group and the above mentioned risk factors were assessed and concluded that all the risk factors were present in both the groups but with greater
proportion in the individuals who experience fear of fall, with greater deficits in proprioception, vestibular function and depression leading to fall.
Key words:Aging, elderly, fear of fall, fall, risk factors.
Seventy physically independent elderly individuals of
Introduction age sixty years and above were recruited. The subjects were
screened for eligibility to participate in the study, and are
Aging is a dynamic, progressive, and physiological counseled regarding the study and asked to sign the informed
process accompanied by morphological, functional, biochemical consent.
and psychological changes, which cause a reduction in the
Inclusion criteria
functional reserve of organs and systems.1The rate and
magnitude of change in each system, may differ from person to 1. Subjects (both males and females) aged between 60 years
person, but total body decline is an inevitable part of life for and above, who had experienced at least some fear of fall
everyone. and without fear of fall.
Falls and fall-related injuries among older people are 2. Medically stable.
major issues for health and social care providers in India and 3. Ambulatory.
indeed the world, because of the rapid increase in life 4. Able to understand simple commands.
expectancy observed during the twentieth century.2 Falls among
older adults are recurrent and may occur due to many factors3,4 Exclusion criteria
therefore examining an individual at risk of falling by
considering only the physical risk factors is in a sense to neglect
1. Acute medical illness.
other important aspects that cause falls, such as the fear of
2. Orthopedic disorders.
falling. Falls and fear of falling are interrelated problems; each
3. Preexisting Neurological disorders.
is a risk factor for the other.5,6 Both of these can substantially
4. Cognitive dysfunction
reduce quality of life and independence and almost 33% of the
older population experience functional decline after a fall.7 Instrumentation:
Risk factors associated with fear of fall are dizziness,8,9
depression,10,11 visual impairment,12 decline in muscle Mini mental state examination.
strength,13 decline in lower extremity proprioception, problems Fall Efficacy Scale,
with gait and balance.5,11 Depression Anxiety Stress Scale,
The present study analyzes the risk factors and their Electronic goniometer,
contribution for fall in the elderly individuals who experience Hand held dynamometer,
fear of falling and in those who do not experience fear of falling Romberg Test.
and also it identifies which group of population has more
number of risk factors. Procedure
The subjects were initially screened by Mini Mental
Methodology State Examination. The total score of the examination ranged
from 0-30. Subjects with scores greater than 24 were considered
Study design: Observational analysis. for the study.
The subject’s level of confidence was measured using
Ethics: This study has been approved by Ethics Tinetti’s Fall Efficacy Scale for a specific activity of daily
committee for student’s proposals (CSP/11/AUG/18/55), Sri living. This Scale consists of 10 components with a total score
Ramachandra University. of 100. Subjects who had a score of greater than 70 were
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

considered to have Fear of falling and with a score of lesser than Results
70 were considered to have no Fear of fall.
The subject’s depression, anxiety, stress was quantified The data has been analyzed by the SPSS 15th version
by Depression Anxiety Stress Scale 21. This scale consists of 21 software. The variables tested were vision, vestibular function,
items. Each item is scored on a 4-point scale (starts from ‘0’= proprioceptive deficit, muscle torque, depression, and anxiety
did not apply to me at all, and ends with ‘3’ = Applied to me and stress scores.
very much or most of the time). Scores from each subscale are The data was found to be normally distributed and
summed and multiplied by two. Subscale score range from 0 to independent ‘t’ test was used to analyze these variables. The
42. Higher scores indicate greater levels of distress. mean and standard deviation for each variable was calculated
The subject’s isometric force of lower limb and chi-square test was used and found that there was linear
musculature especially knee flexors, extensors, ankle association between fear of fall, proprioception, vestibular
dorsiflexors was measured by Hand-held dynamometer. This dysfunction, depression and to some extent to muscle torque.
digital dynamometer displays force measurements to the nearest
0.1 kg to a maximum of 100kg. Table 1: group statistics
Group N Mean (SD) T P
The isometric force of knee extensors was tested with
AGE Without Fear of Fall 60 63.03 (1.868) -1.048 .299
the subjects sitting upright, hip and knee flexed 90deg, hands With Fear of Fall 10 63.70 (1.829)
resting in lap. Dynamometer placement is just proximal to FES Without Fear of Fall 60 11.17 (2.817)
malleoli. For knee flexors subjects were positioned in prone With Fear of Fall 10 88.00 (2.582)
lying, dynamometer placement is just proximal to ankle joint MMSE Without Fear of Fall 60 30.00 (0.00) a
(posterior). For ankle dorsiflexors, subjects were positioned With Fear of Fall 10 30.00 (0.00) a
vision score Without Fear of Fall 60 1.00 (0.00) a
supine with knee maintained in full extension, leg supported With Fear of Fall 10 1.00 (0.00) a
with foot off the table. Dynamometer placement is just proximal vestibular Without Fear of Fall 60 1.00 (0.00)
to metatarsophalangeal joints. score With Fear of Fall 10 1.80 (0.422)
Subjects then performed the action actively until they proprioceptio Without Fear of Fall 60 1.48 (0.504)
were able to perform correctly. Isometric “make” tests were n score With Fear of Fall 10 1.80 (0.422)
muscle Without Fear of Fall 60 1.00 (0.00) a
used as the subjects were asked to build their force gradually to torque score With Fear of Fall 10 1.00 (0.00) a
a maximum voluntary effort over a self-determined 2-second Dep_score Without Fear of Fall 60 9.93 (4.599)
period. They then maintained maximum effort for 5additional With Fear of Fall 10 14.20 (6.763)
seconds. The dynamometer was programmed so that each trial Anx_Score Without Fear of Fall 60 6.27 (1.894)
lasted 7 seconds, during which the tester held the dynamometer With Fear of Fall 10 6.40 (2.066)
stationary against the limb segment. Peak force values were Sress_Score Without Fear of Fall 60 11.83 (4.603)
With Fear of Fall 10 12.80 (4.131)
recorded from the digital readout on the dynamometer. a. t cannot be computed because the standard deviations of both groups are 0.
The proprioception of knee and ankle joint is measured
by joint reposition method using electronic Goniometer. The Table 2: chi-square tests for depression
subjects were instructed to slowly straighten their knee or ankle Value Df Asymp. Sig.
and told to stop at a random angle. This ‘test angle’ is measured (2-sided)
by goniometer. Then the subject was asked to reproduce the test Pearson Chi-Square 9.678a 2 .008
angle in the contra lateral limb and is measured. The procedure Likelihood Ratio 10.540 2 .005
was performed for 10 test angles chosen randomly throughout
Linear-by-Linear Association 9.532 1 .002
knee flexion, extension, ankle dorsiflexion and plantar flexion.
N of Valid Cases 70
The mean error between 10 test and reproduced angles was
calculated. a. 2 cells (33.3%) have expected count less than 5. The
minimum expected count is .86.
Visual dysfunction is screened by using pocket – size
Snellen chart, A score of 20/200 may signal that vision is Table 3: Chi-Square Tests for anxiety:
contributing to the patient’s instability and vestibular
Value Df Asymp. Sig. (2-sided) Exact Sig. (2-sided)
dysfunction is screened by Romberg test, in which subject is
asked to stand with the heels together, first with eyes open, then Pearson Chi-Square .239a 1 .625
with eyes closed and any excessive postural sway is noted. Continuity Correctionb .021 1 .883
The subjects were categorized into 2 groups according Likelihood Ratio .241 1 .624
to their level of confidence in activities of daily living. Both Fisher's Exact Test .739
groups were administered the above mentioned instruments, Linear-by-Linear
.235 1 .628
questionnaires. Values tabulated and results analyzed. Association
N of Valid Casesb 70
a. 1 cells (25.0%) have expected count less than 5. The minimum expected count
is 4.71.
b. Computed only for a 2x2 table

32
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

Table 4 : Chi-Square Tests for stress Discussion

Asymp. Sig. Exact Sig. Exact Sig. (1-
Value Df (2-sided) (2-sided) sided) Aging is a fundamental process that affects all of our
.154
a
1 .695
systems and tissues. Population aging is a worldwide trend.
Pearson Chi-Square
b
Studies involving community dwelling older adults (76.3±6.6
Continuity Correction .002 1 .961
years) show that approximately 20 to 60% of this population
Likelihood Ratio .155 1 .694 have already experienced the fear of falling, with a higher
Fisher's Exact Test .745 .484 frequency in women, particularly those who have a sedentary
.151 1 .697
lifestyle.14
Linear-by-Linear Association
In the past, studies have analyzed either one or two
b 70
N of Valid Cases above said risk factors among individuals who experienced fear
a. 1 cells (25.0%) have expected count less than 5. The minimum expected count is 4.57. of fall. Unfortunately, there has been no study which analyzed
b. Computed only for a 2x2 table risk factors among elderly individuals who experienced fear of
fall and in those who did not experience fear of fall and hence
Table 5: group statistics of muscle torque the need was felt for such a study. In the present study risk
factors like vision, vestibular function, Muscle torque,
Group Group Mean (SD) T P
proprioception, depression, anxiety, and stress were analyzed in
Rt knee 0 12.10 (1.03) 5.745 0.000
1 10.22 (.12)
both the groups.
extension The fear of falling has negative consequences for older
Lt knee 0 12.29(1.00) 6.271 0.000
1 10.27 (.11) adults’ physical and functional well-being, degree of
extension
0 11.93 (1.00) 5.557 0.000
independence, ability to perform activities of daily living
Rt knee flexion (ADLs) and restriction on physical activity, which explains the
1 10.16 (.093)
Lt knee flexion 0 12.08 (.99) 5.992 0.000 high prevalence of sedentary lifestyle in this age group. A
1 10.19 (.10) sedentary lifestyle leads to reduced mobility and balance and,
Rt ankle 0 9.07 (.58) 1.911 0.060 consequently, higher risk of falls and heightened fear that they
1 8.72 (.049)
dorsiflexion might occur. 15,16,17
Rt ankle 0 9.23 (.57) 2.903 0.005
1 8.69 (.14)
Fear of falling has been compared to a vicious circle
planterflexion that includes the risk of falls, deficit of balance (muscle strength
and proprioception) and mobility, fear and functional decline
Table 6: Chi-Square Test for Vestibular component resulting in more fear.17 Due to the relevance of this issue
Value Df Asymp. Sig. Exact Sig. Exact Sig. among older adults, the aim of the present study was to analyze
(2-sided) (2-sided) (1-sided) the risk factors in elderly individuals who experienced fear of
Pearson Chi-Square 54.194a 1 .000 falling and those who did not experience fear of falling.
Continuity Correction b
46.578 1 .000 Muscle weakness and reduced physical fitness,
Likelihood Ratio 39.746 1 .000 .
particularly to the lower body, are one of the most common
intrinsic risk factor, increasing risk of fall by four to five
Fisher's Exact Test .000 .000
times.18 A reduction in muscle strength is common with ageing,
Linear-by-Linear Association 53.419 1 .000
this reduced function is due to the loss in strength results from
N of Valid Casesb 70 an age-related decrease in muscle mass.
a. 1 cells (25.0%) have expected count less than 5. The minimum expected count is In the present study, in comparison with both the
1.14.
b. Computed only for a 2x2 table
groups, muscle torque in individuals who had experienced fear
of falling was slightly reduced but it was not statistically
significant.
Depression, anxiety also appeared to be a risk factor in
Table 7: Chi-Square Tests for proprioception
four studies.19,20 Anxiety and/or fear of falling need to be
Value Df Asymp. Sig. (2-sided) considered for everyone experiencing a fall —an important
a .002
consideration given that fear of falling does not necessarily need
Pearson Chi-Square 12.345 2
to result from an actual fall. It may be appropriate to consider in
Likelihood Ratio 9.205 2 .010 older people with new onset anxiety or depression and changes
Linear-by-Linear Association 8.663 1 .003 in activity. 5,21
Falls, fear of falling and subjective dizziness were
N of Valid Cases 70 strongly associated with anxiety and depression. Individuals
a. 3 cells (50.0%) have expected count less than 5. The minimum expected count is 1.00. who experience fear of falling had high anxiety and depression
scores. This may be an indication of the psychological impact of
falls. .Fear of falling and depression were significantly
associated with falling.22

33
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

Knee proprioception deficits are exacerbated in the References

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35
 Immediate effectiveness of positional release therapy in acute ankle sprain

Priyanka Diwadkar1, Khatri SM2

1
Postgraduate Student, College of Physiotherapy, Pravara Institute of Medical Sciences, Loni
2
Principal and Professor, College of Physiotherapy, Pravara Institute of Medical Sciences, Loni

Abstract
Ankle sprain is often seen and treated by sports and orthopedic physiotherapists working in different setups. The real challenge in treating ankle sprain
is immediate relief of pain so that the individual can continue the physical activity in the chosen filed within the limits of the injury. Few studies have
reported the immediate effectiveness of positional release therapy an orthopedic manual therapy technique in various musculoskeletal conditions.
However, there is limited evidence for the same in acute ankle sprain. Hence, this pilot study was undertaken to find out the immediate effectiveness of
positional release therapy in alleviation of pain associated with acute ankle sprain, pressure pain threshold and active ankle inversion. Eight
participants with acute ankle sprain were treated with positional release therapy and their pre and post pain intensity, pressure pain threshold and active
range of ankle inversion was measured. Results showed significant differences (p<0.01) in these outcome measures immediately after the three sessions
of this intervention in acute ankle sprain.
Keywords: Positional release therapy, acute ankle sprain, physiotherapy

Introduction RICER protocol i.e. rest, ice, compression, elevation and

referral which is advocated for pain and swelling. No HARM
Ankle injuries are one of the most commonly occurring treatment protocol should be applied- no heat, no alcohol, no
musculoskeletal injuries and it is estimated that 75% of all ankle running and no massage. All theses will lead to increased
injuries are ankle sprains with 85% of those ankle sprains bleeding and swelling in injured area. Studies have proved that
caused by inversion trauma.1, 2 It is estimated that per 10,000 use of non-steroidal anti-inflammatory drug improves healing
people, one ankle sprain will occur per day .Ankle sprain and speeds recovery. Functional treatment (early mobilization
injuries are most common in sports, activities of daily living and with external support) involves semi-rigid or rigid brace, taping
occur usually in young physically active individuals.3 Ankle and elastic bandage which facilitates early weight bearing.
sprain has been shown to be 20 times more common in the There are various physiotherapy treatment approaches for
dominance leg and to have a high (73.5%) prevalence of treating acute ankle sprain which includes electro physical
recurrence.4 agents, orthopaedic manual therapy, proprioception training,
Most common causes of sprained ankle is fall, a strengthening exercises and soft tissue therapies.13-17
sudden twist or blow that leads to mechanical forces exceeding Positional release therapy (PRT) or positional release
the tensile limits of ankle joint capsule and supportive technique or strain counter strain technique was 1st developed by
ligaments.5 There are several predisposing (intrinsic and Dr.Lawerence Jones in 1955. PRT is an osteopathic indirect
extrinsic) factors that lead to ankle sprain which like history of manual therapy for tissue resistance, which places the affected
previous ankle sprain, increased body mass index, limb part of the body into position of greatest perceived comfort
dominance, increased foot width, weak or lax ankle joint (ease) through passive motion using the tender point to relieve
ligament, weak muscles especially peroneal muscle and hind the associated dysfunction. Holding the position of comfort
foot varus deformity, walking or running on uneven surfaces, (ease) as 90 seconds evokes therapeutically significant
inappropriate shoes, tight heel cord and lack of warm up or physiological response in tissue i .e neurological and circulatory
stretching before exercise.6, 7, 8 which alleviate pain, enhanced mobility and resolution of actual
The most common mechanism of injury in ankle sprain dysfunction.18-21
is combination of inversion and adduction of plantarflexed foot Positional release therapy (PRT) is one such technique
which often leads to a predictable sequence of lateral which has been studied earlier by various authors. The aim of
ligamentous complex tear which includes anterior talo-fibular this study was to evaluate the immediate effects of PRT on acute
ligament (ATFL) that is torn first, followed by the calcaneo- ankle sprain. The treatment effect in pain, pain pressure
fibular ligament (CFL), and lastly the posterior talo-fibular threshold and active inversion range of motion was measured
ligament (PTFL). 9, 10 In this type of injury lateral ligaments are before and immediately after technique was performed.
stretched followed by pain, tenderness, swelling, limited range
of ankle motion, functional and mechanical instability.11 Materials and methods
Specifically the ATFL is reported to be weakest ligament and
hence is most commonly injured.12 Participants and study design
Primary aim of treatment in acute ankle sprain is to
manage pain, control inflammation and protect joint. Treatment A pilot quasi-experimental design was conducted in
varies according to grades and duration of injury. The Department of orthopaedic Physiotherapy, Pravara Rural
immediate treatment of any soft tissue injury consists of the Hospital (tertiary hospital).The study received approval from
Institutional Ethical Committee (IEC) of Pravara Institute of
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

Medical Sciences, Loni, India. The purpose of the study was slight either internal or external rotation was used to fine tune
explained to the participants with acute ankle sprain and written position. Once tender point sensitivity was reduced by 70%,
informed consent was obtained for their active participation. position of comfort was held for 90 seconds. After 90 seconds
Participants who consented were screened for inclusion and pressure was released, the participant’s foot was placed back to
exclusion criteria. Between period of April and May 2012 the normal position and again reassessment of participant’s
participants were recruited for inclusion in our study in the severity of pain was done. This was repeated thrice so as to give
college of physiotherapy, PIMS, Loni, India. They were referred the intervention for a total period of 270 seconds.18, 20,21,32
to the orthopedic physiotherapy OPD with clinical diagnosis of
acute ankle sprain. Both male and females whose age between Statistical analysis
15-35 years, who were diagnosed with acute ankle inversion
The results were analyzed with GraphPad Instat
grade I ankle sprain, symptom less than 6 week, with unilateral
software 3.03. Data was presented as mean, standard deviation
inversion ankle sprain and tenderness at anterior talofibular
(SD). Differences in baseline outcome measures prior to the
ligament isolation were included in study.22-25 Exclusion criteria
interventions and immediately after the interventions were
were those, previous history of ankle sprain, presence of severe
tested using paired t test.
pheripheral vascular disease in lower limb, lower extremity
surgery and hard tissue injury.24, 26.
Results
Measurements
The baseline characteristics of all eight participants are
Participants were evaluated and assessed on visual shown in Table I.
analogue scale (VAS), pressure pain threshold (PPT) and active
ankle inversion range of motion initially and immediately Table 1
treatment session.
Visual Analogue Scale (VAS): Visual analogue scale was used to Total no. of participants 8
Age (years) 22.87±2.41
measure the intensity of pain before and after the intervention. Height (cms) 159±5.14
The pain was recorded with 10 cm horizontal visual analogue Weight (kg) 58±8.26
scale (VAS), the participants were asked to mark their intensity BMI (kg/m2) 21.96±2.06
of pain on a 10 cm long line in the data collection sheet with no
pain and most severe pain on either end of the scale. The
reliability of VAS has been reported to be 0.88.27 Descriptive statistics show participant’s VAS (Table II
Pressure pain threshold (PPT): Quantitative measures of pain and Figure1), PPT (Table III and Figure 2) and active ankle
were measure via pressure pain threshold. Pressure algometry inversion ROM (Table IV and Figure 3) which illustrates the
was used to measure PPT. The head of the algometer (hard improvement in all variables after immediate post intervention.
rubber tip, surface area 1 cm2) was applied at right angle to The pre- interventional average VAS score was 7.05±1.19 and
ATFL and pressure was increased steadily at rate of after immediate intervention the average VAS score of these
approximately 1 kg/cm2. The range of values of the pressure participants was 4.22±0.91. The average difference in pre and
algometer is 0 to 30 kg, with 0.3-kg divisions. The participants post intensity of pain in terms of VAS score was
were instructed to say stop as soon as the sensation of pressure 2.82±0.90.Significant difference was found between pre and
became discomfort or turned into pain. PPT measurements post mean score of VAS and p value (p<0.01) was highly
were taken 3 times with 30 seconds rest interval between each significant.(Table II and Figure 2).
measurement. The mean of these 3 trials was used for data
analysis28, 29. The reliability of PPT has been reported to be 0.9
to 0.95.30
Active inversion ROM: Active ankle inversion range was Table 2 Comparison of VAS mean score between pre and
measured by using universal goniometer. The reliability of immediate post treatment Figure 1 VAS Score pre and post test
universal goniometer has been reported to be 0.91.31
Mean
Pre Post ‘p’ ‘t’
Procedure treatment treatment
difference
value value
Result
±SD
Eight participants (5 females and 3 males) were treated <0.00 Highly
7.05±1.19 4.22±0.91 2.82±0.90 8.797
1 Significant
with PRT. For this purpose supine with complete relaxation was
preferred as starting position and therapist stood by the foot end
of treatment plinth. The tender point was palpated at ATFL and
continuous pressure was applied by thumb until maximum pain
was experienced by participant. While monitoring the tender
point with thumb, the participant’s foot was then dorsiflexed
and everted till tender point sensitivity was reduced by 70% and

37
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

Figure 1 VAS Score pre and post test

5 4.22 Figure 3 Active inversion pre and post ROM

4
2.82
3 29
Pre test 28
2 28
Post test
1 27
25.87 Pre test
0 26
VAS Post test
25
24
Table III and Figure 2 showed results of PPT of ROM
participants. At beginning of treatment the overall mean PPT
scores was 3.03±0.03 and after immediate treatment it increased
to 3.91±0.33.The average difference in pre and post PPT mean
score was 0.878±0.31. Significant improvement was noted in Discussion
terms of PPT among participants. The mean values of pre and
post treatment in PPT were highly significant (p<0.01). The results of the present study showed that positional
release therapy (PRT) may be an immediate effective technique
Table 3 Comparison of PPT mean score between pre and for patients with acute ankle sprain. It showed significant
immediate post treatment decrease in pain, increase in PPT and improvement in active
ankle inversion range in patients with acute ankle sprain.
Pre Post Mean ‘p’ ‘t’
treatment treatment difference ±SD value value
Result According to ‘Lawrence Jone’ (1981) a combination of the
Highly position of ease for 90 seconds (comfort) while simultaneously
3.03±0.03 3.91±0.33 0.878±0.31 <0.001 7.77
Significant applying pressure on tender point showed dramatic
improvement in severe and painful conditions as well as it
Figure 2 PPT score pre and post
evoke a therapeutically significant physiological responses i.e.
reduction in tension, nociceptive sensitivity, minimizes the
5 stimulation of the affected proprioceptors and circulatory
3.91 enhancement which helps to resolve musculoskeletal
4
3.03 dysfunction18, 33. Bailey and Dick (1992) proposed a
3 nociceptive hypothesis that tissue damage can be reduced by
Pre test PRT mechanism. Relaxation of the damaged tissue may be
2
Post test achieved by placing patient in position of ease and consequent
1 improvement in vascular and interstitial movement in distressed
0 tissue (i.e blood and lymph). This can have an indirect effect on
PPT removal of inflammatory chemical mediators18, 19. Travell and
Simons stated that the pain is produced due to the localized
The pre- interventional average active ankle inversion ischemia and lack of oxygen in stressed soft tissue. Jacobson
range was 25.87±1.95 and after immediate intervention the and colleague (1989) suggested that in PRT unopposed arterial
average active inversion range of these participants was filling occur in tissue during 90 second hold in position of ease.
28.0±2.13. The average difference in pre and post range of ankle It helps to wash away the toxic products thus providing relief of
inversion was 2.12±0.64. There was statistically significant pain and restoring range of motion18.
difference in average active range of ankle inversion and p value The result of present study showed that there was
(p<0.01) was highly significant. (Table IV and Figure 3). increased PPT immediately after PRT which might be due to
capacity of PRT to relief tissue tenderness. Previous literature
Table IV. Comparison of active ankle inversion ROM mean postulated that PRT decreased irritability of tissue tenderness by
between pre and immediate post treatment position of comfort, altering nociceptive activity as well as
maintaining inhibitory pressure on tender point which induced a
Post Post Mean ‘p’ ‘t ‘
treatment treatment difference ±SD value value
Result degree of local and reflex inhibition of neural activity18. This is
Highly in accordance with the study of Baldry who (1993) stated that
25.87±1.95 28±2.13 2.12±0.64 <0.001 9.379
Significant after application of pressure analgesic endorphin was released in
local soft tissue which was important mediator in pain relief34.

38
 INDIAN JOURNAL OF PHYSICAL THERAPY. JANUARY-JUNE 2013, VOL. 1, ISSUE. 1

It has already been observed that individual with ankle 4. Naris C. Sport injuries diagnosis and management. 2nd
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DOI:10.1093/bmb/ldq028]
used for immediate pain relief, increasing pressure pain
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