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ISSN P - 0973-5666 ISSN E - 0973-5674 Volume 6

Number 1

January - March 2012

Indian Journal of Physiotherapy and Occupational Therapy

An International Journal

website: www.ijpot.com

INDIAN JOURNAL OF PHYSIOTHERAPY AND OCCUPATIONAL THERAPY Editor Archna Sharma (PT) Head, Dept. of Physiotherapy, G.M. Modi Hospital, Saket, New Delhi 110 017 E-mail: [email protected] Executive Editor Dr. R.K. Sharma Dean, Saraswathi Institute of Medical Sciences, Ghaziabad (UP) Formerly at All-India Institute of Medical Sciences, New Delhi

International Editorial Advisory Board

National Editorial Advisory Board

Dr. Amita Salwan, USA Dr. Smiti, Canada Dr. T.A. Hun, USA Heidrun Becker, Germany Rosi Haarer Becker, Germany, Prof. Dra. Maria de Fatima Guerreiro Godoy, Brazil Dr. Venetha J. Mailoo, U.K. Dr. Tahera Shafee, Saudi Arabia Dr. Emad Tawfik Ahmed, Saudi Arabia Dr. Yannis Dionyssiotis, Greece Dr. T.K. Hamzat, Nigeria Prof. Kusum Kapila, Kuwait Prof. B.K. Bhootra, South Africa Dr. S.J. Winser, Malaysia Dr. M.T. Ahmed, Egypt Prof. Z.W. Sliwinski, Poland Dr. G. Winter, Austria Dr. M. Nellutla, Rwanda Prof. GoAh Cheng, Japan Dr. Sema Oglak, Turkey Dr. M. Naveed Babur, Pakistan

Prof. U. Singh, New Delhi Dr. Dayananda Kiran, Indore Dr. J.K. Maheshwari, New Delhi Suraj Kumar, New Delhi Renu Sharma, New Delhi Veena Krishnananda, Mumbai Dr. Jag Mohan Singh, Patiala N. Padmapriya, Chennai G. Arun Maiya, Manipal Prof. Jasobanta Sethi, Bangalore Prof. Shovan Saha, Manipal Prof. Narasimman S., Mangalore Kamal N. Arya, New Delhi Nitesh Bansal, Noida Aparna Sarkar, Noida Amit Chaudhary, Faridabad Subhash Khatri, Belgaum Dr. S.L. Yadav, New Delhi Sohrab A. Khan, Jamia Hamdard, New Delhi Dheeraj Lamba, Haldwani Dr. Deepak Kumar, New Delhi Kalpana Zutshi, New Delhi

Print-ISSN: 0973-5666 Electronic - ISSN: 0973-5674, Frequency: Quarterly (4 issues per volume). “Indian journal of physiotherapy and occupational therapy” An essential indexed double blind peer reviewed journal for all Physiotherapists & Occupational therapists provides professionals with a forum to discuss today’s challenges - identifying the philosophical and conceptual foundations of the practics; sharing innovative evaluation and tretment techniques; learning about and assimilating new methodologies developing in related professions; and communicating information about new practic settings. The journal serves as a valuable tool for helping therapists deal effectively with the challenges of the field. It emphasizes articles and reports that are directly relevant to practice. The journal is now covered by INDEX COPERNICUS, POLAND. The journal is indexed with many international databases, like PEDro (Australia), EMBASE (Scopus) & EBSCO (USA) database. The journal is registered with Registrar on Newspapers for India vide registration DELENG/2007/20988. The Journal is part of UGC, DST and CSIR consortia.

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Contents Volume 6, Number 1

January - March 2012

1

Symphysis Pubis Dysfunction During Pregnancy- A multimodality physiotherapeutic approach Arati Ramannavar, Shobhana Patted

5

Computerised Dynography in Hemiparesis: Case study Satralkar AN, Khatri SM, Anap DB, Shalini Sumbh

8

A study of limitations of the Pulmonary System in Adaptability to Exercise in Luteal Phase of Menstrual Cycle Amrith Pakkala, N. Veeranna

11

A Comparative Study on Effectiveness of Ultrasound Therapy and Low Level Laser Therapy in the Management of Second Stage Pressure Sores Anil Rachappa Muragod, Sreekumaran P, Danesh K U

15

Efficacy of Microcurrent Electrical Stimulation on Pain, Proprioception Accuracy and Functional Disability in Subacromial Impingement : RCT Azza M. Atya

19

A Study to Correlate Postural Thoracic Kyphosis and Abdominal Muscle Strength and Endurance Bharati Asgaonkar, Rati P. Ghumare

22

Effect of Deep Cervical Flexor Strengthening on Vertical Mandibular Opening on Subjects with Forward Head Posture Dheeraj Lamba, Satish Pant, Girish Chandra, Asha Joshi2, Divya Dalakoti

26

Comparison among Different Head Neck Positions for the Effects on Wrist Flexor Torque Production Dheeraj Lamba, Sapna Kharayat, Jaya Mehta, Ajay Joshi, Manish Kandpal

29

Effect of Hand Span on Different Grip Spacing During Grip Measurement in Normal Young Individual Dheeraj Lamba, Priyanka Maheshwari, Deepti Pandey, Swastika Verma, Asha Joshi2

32

Effect of Reciprocating Gait Orthosis on Standing Balance in Children with Spastic Diaplegic Cerebral Palsy Reda S Sarhan, Enas Elsayed, Fatma A Hegazy, Abeer Elwishy

36

Effects of Static and Dynamic Stretching on Agility Performance in Tennis Players Hardik Trambadia, Mehul Jadav

40

Study on Physiological Outcomes after Phase 1 Cardiac Rehabilitation in Mitral Valve Replacement IndividualsAn observational study K. Asha Jyothi, K. Madhavi, K. Charan, P. Thabita

44

Effect of Human Immunodeficiency Virus Infection on Nerve Conduction Velocity Study in Neurologically Asymptomatic Patients Kakkad Ashish

48

Role of Shoes and Surfaces on Foot Strike Hemolysis During Running: A review Kamal Janakiraman, Shweta Shenoy, Jaspal Singh Sandhu

51

Reliability and Validity of Bengali Language Short Form IIQ-7 and SF-36 for Utilization in Postpartum Bangladeshi Women Lori Walton, Dawn Brown, Reshma Parvin Nuri, Muhammad Mizanur Rahman

56

Prevalence of Cervicogenic Headache in the General Population Mitul Thakur, Mritunjay Kumar

59

Retrospective Study on Limitations of Activities of Daily Living in Geriatric Women Steffi Mascarenhas, Sujata Yardi

66

Efectivenes of Conservative Hand Therapy Treatment in Rheuumatoid Arthritis Meenakshi Sharma, Sandeep Singh Saini

70

Effect of Ischemic Compression and Picking Up in Treating Tender Point of Upper Trapezius Muscle Mridu Agrawal, Sumit Kalra Effectiveness of Plyometric Training in the Improvement of Sports Specific Skills of Basketball Players Deepti Sharma, Narinder Kaur Multani

77 83

Effect of Meditation and Autogenic Training on Autonomic Nervous System in Normal Adolescent Females Chandan Rashi, Raghumahanti Raghuveer, Narkeesh

88

Effect of Mental Imagery on Upper Extremity Function in Stroke Patients Nayeem Z, Majumi M, Fuzail A

91

Effect of Peripheral Muscle Strength Training on Exercise Capacity in Subjects with Chronic Obstructive Pulmonary Disease P. Thabitha, K. Madhavi, K. Charan, K. Asha Jyothi

Indian Journal of Physiotherapy and Occupational Therapy. Jan-Mar., 2012, Vol.6, No.1

96

Comparative Analysis of Cyriax Approach Versus Mobilization with Movement Approach in the Treatment of Patients with Lateral Epicondylitis Pooja Ghosh Dasm

103

Mini Mental State Examination for Cognitive Screening in Indian Child Population: An association with intelligence quotient Jyoti Marwah, Pooja Sharma, Nitesh Bansal

107

Relationship of Foot Characteristics on Balance with Ageing Narinder Kaur Multani, Pragya

112

Reliability of 20 Meter Shuttle Test and Rockport one Mile Walk Test for Measuring Vo2 Max Prahlad Priyadrshi, Rahul Singh Parihar

116

Cortical Visual Impairment : A review Renu Chauhan

119

A Comparative Study of Single Versus Dual Cognitive Tasks on Spatio-temporal Gait Variables in Children Richa Sharma, Pritpal Singh, Senthilkumar CB

123

Effectiveness of Slump Stretching in Comparison to Conventional Physiotherapy in Treatment of Subacute Nonradicular Low Back Pain Rimpy Jain, Unaise Ahmed Hameed, Ruchika Tuteja

127

Effectiveness of Median Nerve Slider’s Neurodynamics for Managing Pain and Disability in Cervicobrachial Pain Syndrome Rohini Gupta, Shallu Sharma

133

Role of Mettler’s Release as an Adjunct in the Management of Post-Immobilization Knee Stiffness- A pilot study Roopa RD, Ranganath G, Ravi SR

136

Comparative Study of Sensory Threshold between Neurologically Asymptomatic Diabetics and Normals P Sathya, Sruti Modi

139

Effect of Whole Body Vibration Training on Bone Mineral Density in Cerebral Palsy Children Shamekh Mohamed El-Shamy, Mohamed Salah Eldien Mohamed

142

Difficulties Faced by the Wheel Chair Users in Accessing Automated Teller Machine (ATM) : A case study Abhay Kumar, Soman Sharad K, Anwer Shahnawaz

145

Effect of Patellar Taping on Dynamic Balance During Star Excursion Balance Test in Patients with Patellofemoral Pain Syndrome Nitya Goel, Shipra Bhatia

149

Physiotherapist’s Emotional Quotient and Patient Satisfaction Khatri SM

152

Prevalance of Low Back Pain in Geriatric Population in and Around Ludhiana Supriya Sharma

156

Comparison of Functional Reach Values between Young and Geriatric Female Population – Role of ankle and subtalar joint Syamala Buragadda, Ganeswara Rao Melam, B. Praveen Kumar

160

Factors Related to Complex Regional Pain Syndrome-1 in Stroke Tanwir Ahmad, Ona P. Desai, Kamal Narayan Arya, Ramesh Arya

166

Correlation of Hand Grip Strength Measured Using Mercury Sphygmomanometer and Martin Vigorimeter Tushar J. Palekar

170

Subscapularis a Hidden Culprit in Shoulder Pain: A case report Patil TP, Khatri SM & Shalini Sumbh

172

Does Training on Swiss Ball Improve Trunk Performance after Stroke?- A single blinded, quasi experimental study design. Akshastha Nayak, Vijaya Kumar.K, Karthick Babu.S

176

Awareness of Physiotherapy among Higher Secondary Students and Perseverance among Physiotherapy Students and Professionals in Meerut - A survey Yashaswi Agarwal, Manish Agarwal, Nalina Gupta

178

Multi-joint Coupling Strategies to Enhance Functional Recovery in Knee Osteoarthritis- A case report Vijay Batra, Vijai P. Sharma, Meenakshi Batra, Vineet Sharma

183

Efficacy of Plyometric Trainig in Basketball Players - A critical Review Samantha .F, Vibha.B, B.R.Ganesh, Kage.V

187

Effects of Short Term Pulmonary Rehabilitation with or without Respiratory Muscle Stretch Gymnastics on Quality of Life in Patients with Chronic Obstructive Pulmonary Disease Pinki Bhasin, S. Ananda Subramanian

191

A Study to Correlate the Predictability of Waist Circumference and Body Mass Index on Respiratory Function in Obese Children Sangeeta Lahiri

196

A Comparative Study Between the Efficacies of Post Isometric Relaxation Versus Post Isometric Relaxation with TENS on Upper Trapezius Myofascial Pain Syndrome Senthilkumar Thiyagarajan, J. Andrews Milton

200

A Study on the Efficacy of Muscle Energy Technique as Compared to Conventional Therapsy in Chronic Low Back Pain Due to Sacroiliac Joint Dysfunction Supreet Bindra, Mithilesh Kumar, Pankaj Preet Singh, Jagmohan Singh

Indian Journal of Physiotherapy and Occupational Therapy. Jan-Mar., 2012, Vol.6, No.1

Symphysis Pubis Dysfunction During Pregnancy- A multimodality physiotherapeutic approach Arati Ramannavar1, Shobhana Patted2 1

Assistant Professor, KLE University’s Institute of Physiotherapy, Belgaum, 2Professor, Dept. of OBG, KLE University, Belgaum

Abstract Background and Objectives Symphysis Pubis Dysfunction (SPD) is a common complication of pregnancy and childbirth, characterized by stiffness or excessive movement of the symphysis pubis associated with pain centered on the joint at the front of the pelvis, possibly because of a misalignment of the pelvis resulting in pain and functional limitation. The present study was aimed to evaluate the effect of a multimodality physiotherapeutic approach in pregnancy induced SPD.

Material and Methods Twenty seven pregnant women with clinical diagnosis of SPD were recruited after obtaining an informed consent and clearance from the institutional ethical committee. Physiotherapy intervention included cryotherapy, transcutaneous electric nerve stimulation, elevator exercises for pelvic floor strengthening, postural correction and stabilization of symphysis pubis by trochanteric belt along with modification of activities of daily living (ADL) for 5 days. Outcome measures were documented using visual analog scale (VAS) on 1st day pre intervention, 3rd and 5th day post intervention and Modified Oswestry Disability Questionnaire (MODQ) on 1st day pre intervention and 5th day post intervention respectively.

Results The data was analyzed using Wilcoxon signed ranked test and z test. There was significant decrease in VAS scores on day 1, day 3 and day 5 (p=.000). MODQ scores significantly decreased on 5th day post intervention (p=0.000).

Conclusion A multimodality physiotherapeutic approach has shown to decrease pain and improve functional outcome in pregnancy induced SPD.

Key Words Pregnancy, SPD, Multimodality physiotherapy, VAS, MODQ.

dysfunction in the joints that make up the pelvis. This results in pain in the pelvic area, predominately over the symphysis pubis. The incidence of SPD varies from 1:36 to 1:300 in the British population. SPD has its occurrence as early as 12 weeks of gestation2. Physicians and surgeons often dismiss this pain as either ‘inconsequential’, ‘unfixable’, or ‘just one of those pregnancy discomforts that have to be endured. The normal physiology of pregnancy and childbirth leads to an escalation of the levels of relaxin and progesterone, which facilitate the relaxation and consequent widening of the birth passage. This predisposes to symphyseal diastasis and subsequent dysfunction during pregnancy and most commonly occurring secondary to childbirth3,4. The average symphysis pubis gap during the last two months of pregnancy is 7.7 mm with a range of 3–20 mm; 24% of women have a gap greater than 9 mm5. Symphysis pubis dysfunction occurs where the joint becomes sufficiently relaxed to allow instability in the pelvic girdle5,6. In severe cases of SPD the symphysis pubis may partially or completely rupture. When the gap increases to more than 10 mm this is known as diastasis of the symphysis pubis (DSP)7,8,9,10. Pregnant women with symphysis pubis dysfunction and objective evidence of biomechanical dysfunction may improve symptomatically with rest by the use of a nonelastic trochanteric belt and modification of daily activities. Manual techniques and education regarding posture & back care, and modification of daily activities all help to ensure optimal postural alignment, which minimizes joint stress in pregnant women11. Education, postural training, exercises that include pelvic floor muscle strengthening are potential methods of reducing discomfort in pregnancy induced SPD. It can also prevent functional changes from progressing to dysfunctional changes. As pain during pregnancy is mainly caused by biomechanical changes/ mechanical dysfunction, it is always beneficial to treat it by correcting the pathomechanics rather than treating the symptoms. There is no evidence in the medical literature to support any particular treatment for SPD during pregnancy. The mainstay of currently accepted treatments is the use of elbow crutches, pelvic support devices and prescribed pain relief in postpartum period. To the best of our knowledge and literature search, a multimodality physiotherapeutic approach for symphysis pubis dysfunction during pregnancy is sparse and lacks evidence. Hence present study was aimed to evaluate the effect of a multimodality physiotherapeutic approach in pregnancy induced SPD in terms of pain and functional outcome.

Methods and Material Study Design

Introduction During pregnancy maternal anatomic changes present mechanical challenges to the musculoskeletal system1. Most common musculo-skeletal problem addressed during pregnancy is vertical back pain (lumbar region), horizontal back pain (sacroiliac joints) and pubic symphysis pain that appear to be increasing. The reported incidence of pelvic pain is 9:300 pregnancies [MacLennnan 1997]. SPD, also known as anterior pelvic pain is a under diagnosed condition of pregnancy characterized by stiffness or

The present study was designed as an experimental trial aimed to find the effectiveness of a multimodality physiotherapeutic approach in pregnancy induced symphysis pubis dysfunction.

Source of Data Data was collected at K.L.E’s Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum, Karnataka, India for a period of two years from October 2007 to October 2009.

Arati Ramannavar / Indian Journal of Physiotherapy and Occupational Therapy. Jan-Mar., 2012, Vol.6, No.1

1

Recruitment and Informed Consent Prior to the commencement of the study, approval was obtained from the institutional ethical committee of K.L.E University’s Research Ethical Board and K.L.E’s Dr. Prabhakar Kore Hospital and Medical Research Center, Belgaum, Karnataka. All Pregnant women, 18 years old and above with complaints of symphysis pubis pain, referred from OBG department to physiotherapy OPD was recruited for the study. After fulfilling the inclusion criteria a written informed consent was obtained from all the participants prior to the commencement of the study.

Sampling Design and Method 27 pregnant women with complaints of symphysis pubis were recruited using non-probability sampling and convenience method of sampling.

Inclusion Criteria i)

ii) iii) iv)

The presence of pubic pain, which was defined as pain experienced between the inferior border of the pubic symphysis that started during pregnancy. Pain that increased by position and locomotion. Restriction of normal daily activities because of symphysis pubic pain. Willingness of a woman to participate in the study or having a clear treatment preference.

Exclusion Criteria i) ii) iii)

Women treated with exercises and medication for pelvic pain during present pregnancy for last 4 weeks. Women with organic pathology (such as nerve root pathology, rheumatoid disorders, tuberculous spine). Women with obstetric complication such as known antepartum hemorrhage, haemodynamically unstable patients, incompetent cervix/cerclage, multiple gestations, persistent second or third trimester bleeding, pregnancy induced hypertension.(Absolute contraindications to exercise during pregnancy- American College of Obstetrics & Gynecology, 2002)12.

Intervention Multimodality treatment included cryotherapy, TENS, postural correction & education, pelvic floor strengthening and pelvic support belt was carried out for 5 days16,17. Cryotherapy was applied over the symphysis pubis in the form of cryopack for 10 mins. Elevator exercises for pelvic floor muscle strengthening was done in crook lying position and instruction was given to envision pulling the muscles of the vaginal area up and in towards your baby without feeling your buttocks, thighs, or abdominal tightening18. The subjects were asked to hold the contraction for 10 secs and let go which was repeated for 10 times every second hourly. Supine posture was modified with crook lying with knee supported over pillows. Side lying was modified with a thigh separator. Transcutaneous electrical nerve stimulation (low TENS) was applied over pubic area with one electrode over symphysis pubis and another over suprapubic area with 5 cms above the symphysis pubis for 15 mins19,20. Trochanteric belt was tailor made according to individual sizes and were instructed to wear during functional activities like standing, walking, getting in and out of the car, sitting, step climbing and other activities of daily living21. Five sittings of therapy with once a day treatment were given on OPD basis. Pain was scored using VAS on 1st day prior to intervention and 5th day post intervention. MODQ was scored on 1st day preintervention and 5th day post-intervention respectively.

Statistical Analysis Data was computed and analyzed using SPSS software. Mean and standard deviations were calculated for age, gestational age, VAS on 1st day, 3rd day and 5th day and MODQ on 1st day and 5th day respectively. The data was analyzed using non-parametric tests. Wilcoxon signed ranked test and z-test were used to measure the statistical differences between preintervention and post-intervention data.

Results

Procedure A detailed history focusing on the onset of pain and functional status during pregnancy, variation of symptoms with physical activities (rolling in bed, climbing stairs, Sitting and rising from a seated position such as getting in and out of cars, bed, Lifting, twisting, bending forward and walking), radiation into the legs, back pain versus leg pain, neurological signs, spinal deformity, obstetric complications were recorded using a data collection instrument (DCI), a history of low back and pelvic girdle pain prior to this pregnancy and other differential diagnoses were made.

Examination Clinical examination was performed, which included inspection of the subject while standing, then while bending forward, followed by palpation about the spine, paraspinal area, and sacrum & movements of lumbar spine (flexion, extension, side flexion, rotations). Pain was assessed and scored using Visual analog scale before commencement of the study. Special clinical tests for symphysis pubis dysfunction were done to confirm the diagnosis of SPD13,14. 2

Leg abduction test which provokes pain in symphysis pubis with leg abduction and the range is limited within 300 Symphyseal pain was tested by direct pressure over the pubic symphysis15. Fortin finger test was considered positive if the subject could localize pain with one finger over symphysis pubis and consistently points to this area.

The mean age of the participants was 27.08+/- 3.56 and mean gestational age was 26.44+/- 5.04. The clinical characteristics of the subjects are summarized in (Table-1). VAS day 3 scores showed significant reduction in pain compared to VAS day 1 with p=0.000.VAS day 5 scores were significantly reduced compared to VAS day 3 (Table-2/ Fig-1). MODQ scores reduced significantly at day 5 compared to day 1with p=0.000 (Table-2/ Fig-2). Table1: Mean age and mean gestational age of 27 subjects Age

Gestational Age

Mean

27.08

26.44

SDV

3.56

5.04

Discussion The results of the present study showed that there is significant pain reduction with a tailor made physiotherapy intervention for symphysis pubis dysfunction manifested during

Arati Ramannavar / Indian Journal of Physiotherapy and Occupational Therapy. Jan-Mar., 2012, Vol.6, No.1

Table 2 : VAS and MODQ

Z p-value

VAS3 - VAS1

VAS5 - VAS1

VAS5 - VAS3

MODQ5 - MODQ1

-4.545(a)

-4.543(a)

-4.542(a)

-4.543(a)

.000

.000

.000

.000

pregnancy. Functional outcome also improved like rolling in bed, standing, walking and performing daily activities with minimal pain as noted by the modified oswestry disability questionnaire. Though the symptoms and clinical presentation of SPD are gross and may be incapacitating, conservative physiotherapy approaches are found to be effective in antenatal period as reported by Seth S et al in a single case study. UAC Okafor and TF Sokunbi in 2009 reported in a case study that subsequent management of postpartum diastasis symphysis pubis with conservative physiotherapy, using pain modulating treatment combined with bed rest for 4 weeks, resulted in very significant improvement in pain, mobility, and gait which could not be attained when the patient had been placed on bed rest for 5 weeks without physiotherapy intervention which showed that bed rest would not be the option for relief of SPD pain20. The present study aimed for a sequence in therapy by using cryotherapy followed by TENS22, pelvic floor strengthening exercises and posture and activity modification throughout the day with the trochanteric belt in situ (Fig-3,4). The use of cryotherapy produced effect on the sensory nerves and reduced inflammation of symphysis pubis joint thus decreasing pain. TENS has been used by pregnant women for many years without any reported side effects for either the mother or baby. In fact, it has been suggested that TENS enhances placental blood flow23. In a meta-analysis of six randomized, placebo-controlled trials, transcutaneous nerve stimulation was found to relieve the symptoms of back pain. Pelvic floor strengthening exercises/ elevator exercises helps to hold the symphysis pubis joint Fig. 1: (VAS Mean Score)

Fig. 3

Fig. 4

together providing active stability. The trochanteric belt stabilizes the joint in place that move due to laxity with the movement of the legs and various activities of daily living providing passive stability24 (fig-1, 2). Studies have found supportive binders to be ineffective in case of misaligned pubic symphysis25,26,27. However, in the present study none of the subjects showed discomfort with the support belt and no clicking was diagnosed in the initial assessment suggesting of misaligned pelvis. The participants were asked to use the trochanteric belt only during activities and not in supine resting position or during sleep. Two cases of spontaneous rupture of the symphysis pubis (SP) during delivery were reported by Dhar S and Anderton JM in 1992 2. The separations were associated with considerable pain, swelling, and tenderness over the symphysis pubis and were treated conservatively with bed rest, mostly in the lateral decubitus position, within pelvic binders. The patients were essentially asymptomatic and walked normally. Conservative treatment followed by early mobilization was concluded to be adequate treatment for symphysis pubis separations. In the present study subjects were functional with minimal pain by therapy and support belt which was not achieved even with complete bed rest for one week prior to intervention. It could therefore be implied that early physiotherapy intervention can help women with SPD to reduce pain and be functional instead of being bed ridden throughout pregnancy and also to resolve the after effect of the condition and for hormonal resolution effect in post partum period.

Conclusion

Fig. 2 : (MODQ Mean Score)

A multimodality physiotherapeutic approach in pregnancy induced symphysis pubis dysfunction has shown to be effective in terms of pain reduction and improving functional outcomes. However, the therapy sessions were short and follow up was lacking. Additional studies are needed to follow up the effect of therapy until delivery of the fetus.

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Arati Ramannavar / Indian Journal of Physiotherapy and Occupational Therapy. Jan-Mar., 2012, Vol.6, No.1

Computerised Dynography in Hemiparesis: Case study Satralkar AN, Khatri SM, Anap DB, Shalini Sumbh College of Physiotherapy, Pravara Institute of Medical Sciences (PIMS), Loni, Maharashtra State, India - 413736

Abstract The purpose of this study was to assess the gait asymmetries in terms of temporal and force gait parameters using Computer Dynography (CDG) system in a hemiparetic person. A 72 year male patient diagnosed as right sided cerebrovascular accident was referred to physiotherapy department with complaints of weakness in left upper & lower limbs and difficulty in walking in terms of impaired foot clearance since one and half year. His computerised gait dynography was done with Computer DynoGraphy (CDG)® system (Infotronic, Netherlands, http://www.infotronic.nl). It was found that there was asymmetry in his cyclogram, gait line, histogram, force gait line, force graphic, step times which included gait cycle, frequency, symmetry ratio, single support time, double support time, single swing, stance time and step time. Hence, it was concluded that CDG may be considered as one of the useful clinical tool for the assessment of gait asymmetries in hemiparetic patient so as to plan therapeutic interventions.

determining gait velocity and asymmetry of stroke patients.11 Hence the present study was aimed to find out the asymmetries in gait parameters in a stroke patient.

Case Description The patient (Mr.V.G.) was a 72 year old bank manager. He was referred for stroke rehabilitation by Neurologist. The case was attended by Physiotherapist and enrolled on daily treatment basis.

Patient History Mr. V.G. complained of difficulty in moving his left upper and lower extremity since one and half year. He was diagnosed as right side cerebro vascular accident (CVA) with left side weakness. He was known cigarette smoker for past thirty years. He had been suffering from hypertension since last thirteen years and since then he was on antihypertensive drugs.

Key Words

Physical Examination

Computer dynography, cyclogram, force graphics, histogram & hemiparesis.

Physical examination was performed by the investigators and it was found this patient had typical hemiplegic posture, STREAM (Stroke Rehabilitation Assessment of Movement) score was 32/40 for voluntary control and 21/30 for basic mobility, Berg balance score was 36/56, dynamic gait index 20/24, intact sensation and his blood pressure was 140/90. Magnetic Resonance Imaging (MRI) brain reports revealed large right Middle Cerebral Artery (MCA) territory infarct and generalised cerebral atrophy.

Introduction Stroke is considered to be a leading cause of disability throughout the world.1 The reported annual incidence of stroke in India is around 130 per one lakh population with an equal gender ratio. Further, it has been estimated that about 20 percent of patients with heart ailments are susceptible to stroke.2 After an initial period of high mortality, survival from stroke is generally good, with 50% of stroke patients alive for 7 years post stroke.3, 4 Although, neurological impairments may resolve spontaneously or decrease following rehabilitation, persisting disabilities leading to partial or total dependence in activity of daily life (ADL) can still be present in 30 to 60 % of stroke survivors. More than 85% of stroke survivors can eventually walk with or without assistance.1, 5 Common features of walking after stroke include decreased gait velocity and asymmetrical gait pattern.6-7 It is suggested that in stroke patients, almost 40% of the required muscle work is performed by the muscles of the affected side during walking.8 Hip flexors, knee extensors and ankle plantar flexors symbolize the chief contributors of this required muscle work. It is believed that in stroke patients, these lower limb muscles of the affected side lose their capabilities to generate the normal levels of muscular forces.9 Recent studies on quantitative gait analyses of hemiparetic patients using computer dynography (CDG) have indicated that temporal and distance parameters are clinically useful indicators for assessment of their gait performance and monitoring of functional recovery.10 To enable stroke patients to achieve these goals, therapists designing a gait-retraining program should first identify the primary underlying impairments that account for the reduced gait velocity and asymmetry of these patients. However, there is hardly any study about quantitative analysis of gait parameters and the impairments that are the most important factors in

Computerised Dynography Evaluation The computerised dynographic evaluation of Mr. V. G. was performed with CDG® system manufactured by Infotronic, Netherlands, http://www.infotronic.nl. This system consists of sensor shoes, connecting cables, internal memory unit and computer with ultra tech software. The CDG system (figure 1) provides quantitative data about histogram, cyclogram, gait line, force gait line, step times and force graphics. Prior to the dynographic evaluation, patient was informed about the procedure and an informed written consent was obtained. Then internal memory unit was connected to the computer and settings of force value under each sensor was sampled at a rate of 50Hz, for two minutes walking period and stored in the software. Patient wore loose short trouser to avoid any discomfort. Then sensor shoes (Figure 2) were worn by the patient, which were connected using connecting cable to internal memory unit attached to the back of patient with waist belt (Figure 3). A trial test was performed to make sure that the patient was at an ease with instrument and the procedure. Then 20 minute rest interval was given as a washout period prior to the final assessment. After this, actual gait evaluation was done in which he was asked to walk over a walkway of 10 meters to and fro at comfortable speed for two minutes. After this, sensor shoes and internal memory unit was removed and

Satralkar AN / Indian Journal of Physiotherapy and Occupational Therapy. Jan-Mar., 2012, Vol.6, No.1

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data was transferred from internal memory unit to the computer for data analysis. Patient completed the distance of 30 feet in 2 minutes. Four base support stick was use by the patient during walking. Fig. 1 : CDG system

Fig. 2 : A sensor shoe

Results CDG revealed abnormal changes in cyclogram, histogram, gait line, force gait line, step time and force graphics gait pattern suggesting pathological gait asymmetry. Cyclogram (figure 4) represents the kinematics during total gait cycle. Cyclogram Fig. 4 : Cyclogram

revealed a shift in centre of gravity and concentration of force lines on unaffected side suggesting maximum weight bearing on unaffected side during the whole gait cycle. Histogram (figure 5) represents the amount of force borne by each of eight shoe

Fig. 5: Histogram

Fig. 3 : Patient & CDG

sensors during the gait cycle. Histogram of this patient showed an excessive increase in weight bearing on unaffected foot from heel to toe with heel bearing 66% weight. The interesting fact noted here was increased weight bearing on medial border of unaffected foot suggesting flat foot. Gait line (figure 6) and force gait line (figure 7) is concentration of forces starting from heel to Fig. 6: Gait line

Fig. 7: Force gait line

Fig. 8: Step times

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Satralkar AN / Indian Journal of Physiotherapy and Occupational Therapy. Jan-Mar., 2012, Vol.6, No.1

Fig. 9 : Force graphics

toe. In this patient, it was altered on affected side and started from mid foot instead of heel and continued to forefoot suggestive of abnormal weight bearing pattern on affected side. Step times(figure 8) represent all temporal parameters in terms gait cycle, frequency, single support time, double support time, single swing, stance time and step time. In this case, gait cycle was 3.96 seconds, frequency/minute was 30, left single support time was 0.370 seconds, right single support time was 0.658 seconds, left double support time was 1.606 and right double support time was 1.329, left single swing time was 0.658seconds, right single swing time was 0.370 seconds, left stance time was 3.305 seconds, right stance time was 3.596, left step time was 1.976 seconds, right step time was 1.987 seconds and symmetry ratio was 0.99. Force graphics (figure 9) represents the sum of forces on sensors during gait cycle. In the present patient, it showed a 750 N on left side and 850 N on right side. In summary, there was 61% reduction in single support time, eight times increased in double support time on affected side and decreased frequency by 23.8%.

Discussion Results of this study showed abnormal changes in cyclogram, histogram, gait line, force gait line, step time and force graphics gait pattern suggesting pathological gait asymmetry. This could be due to various pathological factors, such as abnormalities in motor control, motor impairment, presences of compensatory strategies and spasticity. The results are partly in accordance to the study performed by Wong et al12 who investigated the feasibility of using a foot contact pattern to predict neurologic recovery and the effect of ambulation training in hemiplegic stroke patients with conventional gait analysis system (6 cameras) and the portable Computer DynoGraphy (CDG) system and found negative correlation between the Brunnstrom stages and the foot contact patterns.Clinical implications of CDG for stroke patients may include detection of abnormality, treatment planning and prognosis. Obvious limitation of this study includes difficulty in generalising its outcome and hence future randomised controlled trials can be done to investigate further pathophysiology pertaining to the gait deviations in stroke patients.

Ethical Approval Institutional ethical permission was obtained on 15th November 2010. Funding; No funding was expected from any agency.

References 1.

2.

3. 4.

5.

6. 7.

8.

9. 10.

11.

Conclusion 12. CDG is one of the useful clinical tools for the assessment of gait asymmetries in terms of force and temporal parameters variations in stroke.

Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS: Recovery of walking function in stroke patients: The Copenhagen Study. Arch Phys Med Rehabil 1995: 76:27-32. http://www.headlinesindia.com/health-and-science-news/ lifestyle-disease/brain-stroke-third-largest-killer-in-indiabut-awareness-very-low-26548.html (accessed on 3rd November 2010) WM Garraway, JP Whisnant, and I Drury: The changing pattern of survival following stroke, Stroke, 1983: 14: 5, 699-703. DT Wade, R Langton-Hewer, VA Wood, CE Skilbeck, and HM Ismail: The hemiplegic arm after stroke: Measurement and recovery. J. Neurol. Neurosurg. Psychiatry. 1983: 46:6: 521-524, Wade DT, Wood VA, Heller A, Maggs J, Langton Hewer R: Walking after stroke. Measurement and recovery over the first 3 months. Scand J Rehabil Med 1987:19: 25-30. Dewar ME, Judge G: Temporal asymmetry as a gait quality indicator. Med Biol Eng Comput, 1980:18:689-93. Ozgirgin N, Bolukbasi N, Beyazova M, Orkun S. Kinematic gait analysis in hemiplegic patients. Scand J Rehabil Med, 1993;25: 51-5. Olney SJ, Griffin MP, Monga TN, McBride ID. Work and power in gait of stroke patients. Arch Phys Med Rehab 1991; 72: 309-314. Bourbonnais D, Vanden S. Weakness in patients with hemiparesis. Amer jour occup ther 1989; 43: 313-319. RW Nakamura, T Handa, Sayuri & Isamu Morohashi: Walking Cycle after Stroke Narugo Tohoku J. exp. Med. 1988: 154: 241-244. An-Lun Hsu, MS, PT, Pei-Fang Tang, PhD, PT, Mei-Hwa Jan, MS, PT: Analysis of Impairments Influencing Gait Velocity and Asymmetry of Hemiplegic Patients After Mild to Moderate Stroke. Arch Phys Med Rehabil: 2003:84:1185-93. Wong AM, Pei Y-C, Hong W-H, Chung C-Y, Lau Y-C, Chen CP: Foot contact pattern analysis in hemiplegic stroke patients: an implication for neurologic status determination. Arch Phys Med Rehabil: 2004;85:1625-30.

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A study of limitations of the Pulmonary System in Adaptability to Exercise in Luteal Phase of Menstrual Cycle Amrith Pakkala1, N.Veeranna2 1

Associate Professor, Dept. of Physiology, PES Institute of Medical Sciences & Research, Kuppam, AP, India, Ex-Professor, Dept. of Physiology, Karnataka Institute of Medical Sciences, Hubli

2

system in the trained and the untrained has a role in clearing gaps in the above areas.

Abstract The role of progesterone on PFT was well known in the normal course of the menstrual cycle. Significant increase in both progesterone (37%) and estradiol (13.5%), whereas no change in plasma FSH & LH was observed in exercising women in previous studies. Therefore this study was intended to see the limitations of the pulmonary system in adaptability to exercise in luteal phase of menstrual cycle. It was observed that exercise per se does not cause a statistically significant change in dynamic lung function parameters MMEF, PEFR, MEF 25% to 75% in either of the groups. This finding supports the hypothesis that the respiratory system is not normally the most limiting factor in the delivery of oxygen even under the predominant influence of progesterone in luteal phase which is further accentuated by exercise.

Key Words Luteal phase, Progesterone in Exercise, PFT, Adaptability

Introduction The influence of hormones on the healthy pulmonary system in delivering oxygen to meet the demands of various degrees of exercise has been a matter of differences in perception. There are conflicting reports that the respiratory System is not normally the most limiting factor in the delivery of oxygen to the muscles during maximal muscle aerobic metabolism whereas others do not subscribe to this¹.Within this context it is appropriate to study the effect of luteal phase of menstrual cycle on ventilatory functions after exercise. Mechanical constraints on exercise hyperpnoea have been studied as a factor limiting performance in endurance athletes’ ². Others have considered the absence of structural adaptability to physical training as one of the “weaknesses” inherent in the healthy pulmonary system response to exercise ³ Ventilatory functions are an important part of functional diagnostics 4, aiding selection and optimization of training and early diagnosis of sports pathology. Assessment of exercise response of dynamic lung functions in the healthy pulmonary

Material and Methods The present study was conducted as a part of cardiopulmonary efficiency studies on two groups of non-athletes (n=10) and athletes (n=10) comparable in age & sex. Informed consent was obtained and clinical examination to rule out any underlying disease was done. Healthy young adult females between 19-25 years who regularly undergo training and participate in competitive middle distance running events for at least past 3 years were considered in the athlete group whereas the non-athlete group did not have any such regular exercise program. Smoking, clinical evidence of anemia, obesity, involvement of cardio-respiratory system was considered as exclusion criteria. Basal body temperature method was used to confirm luteal phase of menstrual cycle. Detailed procedure of exercise treadmill test and computerized spirometry was explained to the subjects. Dynamic lung functions were measured in both groups before exercise was evaluated following standard procedure of spirometry using computerized spirometer Spl-95. All subjects were made to undergo maximal exercise testing to VO2 max levels on a motorized treadmill. After exercise, the assessment of dynamic lung functions was repeated. All these set of recordings were done on both the non-athlete as well as the athlete groups. Statistical analysis was done using paired students t-test for comparing parameters within the group before & after exercise testing and unpaired t-test for comparing the two groups of subjects. A p-value of < 0.01 was considered as significant.

Discussion Pulmonary function testing has a central place due to advances in pulmonary physiology and medical instrumentation. With the development of computerized spirometry, there is the need to rework a lot of values obtained in earlier studies done

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

T-value

P- value

Remarks

21.50 ± 2.62

21.46 ± 2.84

0.05

< 0.10

NS

Height (cm)

159.70 ± 7.50

155.90 ± 7.24

1.94

< 0.10

NS

Weight (kg)

52.66 ± 5.64

55.43 ± 6.26

2.06

0.05). Comparison of the pre- and post-treatment values revealed a highly significant pain reduction in active group (p=0.001) with no significant change in the placebo group (p=0.156). Post-treatment measurement comparison showed a significant difference between groups (p = 0.051) in favour of active microcurrent group Table 2

Propriocepion Comparisons of the pre- and post-treatment values showed no significant difference was found either in active group

Azza M. Atya / Indian Journal of Physiotherapy and Occupational Therapy. Jan-Mar., 2012, Vol.6, No.1

Table 1: Demographic Data of 40 Patients with subacromial impingement Characteristics

Group I (n=20) mean ±SD

Group II (n=20) mean ±SD

P- value

Age (year)

48.8 ±6.0

49.1 ±3.3

0.871

Weight (kg)

86.05 ±9.98

81.35±8.50

0.117

Height (cm)

160.8 ±7.52

163.4 ±2.79

0.168

5.67±3.13

6.55±2.21

0.315

Duration of symptoms (month) *SD: standard deviation, P: probability

Table 2 : Statistical analysis of pain and functional disability scores within each group and between groups Variables

Group IMean±SD

Group IImean±SD

U

P- Value

7.65 ±0.87

7.25±1.05

144.5

0.134

6±1.07

6.8±1.08

111.5

0.015*

Z- value

-3.32

-1.41

P- value

0.001*

0.156

66 ± 6.41

67.05± 5.27

190.5

0.79

60.65 ± 7.7

67.6± 6.88

101.5

0.007*

Z- value

-2.94

-.633

P- Value

0.003*

0.52

Pre Pain intensity (VAS) Post

Pre Disability (SDQ) Post

U: Mann–Whitney U statistic. Z : Wilcoxon Signed Ranks Test *significant SDQ: shoulder disability questionnaire VAS: visual analogue scale Table 3 : Statistical analysis of propriocepion accuracy within each group and between groups Variables

Group IMean±SD

Group IImean±SD

t-value

P- Value

11.11 ±0.65

10.81±0.95

1.16

0.255

10.47±1.34

10.39±1.13

0.20

0.84

t-value

1.94

1.238

P- Value

0.067

0.231

Pre Proprioception accuracy Post

(P =0.067) or in the placebo group (p=0.238). The analysis between the groups showed no significant difference in the pretreatment values (P = 0.255), and in post-treatment values (p=0.84). Table 3

Functional Disability Comparison of the pre-post values of the disability score revealed a significant improvement in disability score in the active microcurrent group (p = 0.003), with no significant change in the control group (p= 0.52), post treatment comparison results indicate a significant difference in disability score between groups in fovour of active group (p=0.007) Table 2.

Discussion This study was designed to evaluate the potential effects of microcurrent electric stimulation in treating patients with subacromial impingement. The most significant finding of the current study was that MENS has the ability to reduce pain, improve functional disability but with no effect on proprioception accuracy. Clinical application of microcurrent for pain management has been investigated in many studies 17-19. Although the mechanism of pain reduction not clearly understood, it is known that MENS produces electroanalgesia by facilitating production of beta endorphin [20]. Becker's theory and Nordenstom theory

stated that whenever pathology of tissue occurs there will be an increase in the resistance in the area that will be highly positively charged. Thus, the nutrients in this area will be lost. MENS decreases the tissue resistance and therefore nutrients are supplied to these tissues enhancing its repair21, 22. The improvement in function activities recorded in MENS group could be explained by the previously reported physiological effects of MENS that related to enhancement of the intrinsic healing of the tendon include promoting ATP production which is crucial to restore cellular function, increasing amino acid uptake, increase capillary perfusion and capillary proliferation [23,24] . The precise mechanism of action of microcurrent is unclear. However, it is suspected that a significant cause of chronic tendon pathology may be related to diminution of tenocyte activity, resulting in a failure to adapt to overload. Thus stimulation of active secretion of tenocytes and subsequent increase in collagen production through microcurrent application promoting to regain the proper tendon function14. Another possible mechanize was that the muscle microtruma is a subsequent event of subacromial impingement. It may lead to transient changes in calcium concentration (essential for muscle excitation contraction coupling). Sustained Ca+ increases may result in activation of calcium- sensitive proteases and phospholipases. This activation is deleterious to cell membrane and sarcoplasmic reticulum integrity, causing a change in transmembrane permeability. As the microcurrent is a very low frequency current within the range of physiological body current, it provides the advantages of intracellular Ca+

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homeostasis , increasing sensory comfort with no muscular contraction, electrical discomfort, or significant side effects [25]. Although these were interesting findings, no similar studies are available to compare these results. However the findings of the current study support previous publication cited that microcurrent therapy has the potential to control inflammation and augment soft tissue healing in chronic achilles tendinopathy [14] . Regarding the proprioception accuracy, it was hypothesized that proper signaling of joint position sense is mediated through proprioceptive feedback mechanism provided by tension that develop in normal capsule and ligaments of the glenohumeral joint. Mechanical deformation of these soft tissue structures may disrupt this neuromuscular mechanism [26]. So more prolonged course of treatment may be required to significantly improve the proprioception accuracy of these patients by obtaining greater and longer lasting benefits of pain reduction and restoration of shoulder joint activities.

Conclusion

10.

11.

12. 13.

14.

15.

Microcurrent electrical stimulation is non-invasive therapeutic modality that could be an effective in reducing pain and improving functional disability in patients with subacromial impingement. Further study needed to investigate the long term effect with different parameters of MENS on shoulder proprioception accuracy.

16.

17.

References 1.

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18

Roquelaure Y, Ha C, Leclerc A, Touranchet A, Sauteron M, Melchior M, Imbernon E, Goldberg M: Epidemiologic surveillance of upper-extremity musculoskeletal disorders in the working population. Arthritis Rheum 2006, 55(5):765778. Van der Windt D A, Koes BW, De Jong B A, Bouter L M: Shoulder disorders in general practice: Incidence, patient characteristics, and management. Ann Rheum Dis. 1995, 54(12):959-964. Vecchio P, Kavanagh R, Hazleman B L, King R H. Shoulder pain in a community-based rheumatology clinic. Br. J.Rheumatol.1995; 34, 440–442 Koester M, George M, Kuhn J. Shoulder impingement syndrome Am. J. Med 2005; 118, 452–455. Mac Donald P B, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg. 2000; 9: 299-301. Warner J J, Lephart S, Fu F H. Role of proprioception in pathoetiology of shoulder instability. Clin Orthop 1996;330: 35-9. Machner A, Merk H, Becker R, Rohkohl K, Wissel H , et al. Kinesthetic sense of the shoulder in patients with Impingement syndrome -. Acta Orthop Scand. 2003; 74 (1): 85–88. Sauers E. Effectiveness of Rehabilitation for Patients with Subacromial Impingement Syndrome. J Athl training.2005;40(3):221–223. Senbursa G, Baltac G, Atay A .Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a

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prospective, randomized clinical trial. Knee Surg Sports .2007 ; 15:915–921. Ludewig P M, Borstad J D. Effects of a home exercise program on shoulder pain and functional status in construction workers. Occup Environ Med. 2003; 60: 841– 849. Borstad J D. Resting position variables at the shoulder: Evidence to support a posture-im¬pairment association. J Orthop Sports Phys Ther. 2006; 86 :549–557. Picker R I. Low-volt pulsed microamp stimulation: part 1. Clin Man.1989;9 :28-33. lambert M I,Marcus P, Burgess T, Noakes TD. Electromembrane microcurrent therapy reduces signs and symptoms of muscle damage.Med Sci Sports Exerc. 2002; 34:602-607. Chapman-Jones D, Hill D. Novel microcurrent treatment is more effective than conventional therapy for chronic Achilles tendinopathy: randomized comparative trial. Physiotherapy. 2002 ; 88:471–480. Mercola JM. Kirsch DL. The basis of microcurrent electrical therapy in conventional medical practice, J of Advancement in Medicine.1995; 8(8):225-25-31. Van der Windt DA, van der Heijden GJ, de Winter AF, Koes BW,Deville W, Bouter LM. The responsiveness of the shoulder disability questionnaire. Ann Rheum Dis.1998; 57:82–87. Cho M, Park R ,Park H, Cho Y, Chang G. Effect of microcurrent inducing shoes of fatigue and pain in middle aged people with plantar fasciitis. J.Phys.Ther.Sci.2007;19:165-170. El-Husseini T, El-Kawy S, Shalaby H, El-Sebai M. Microcurrent skin patches for postoperative pain control in total knee arthroplasty: a pilot study. Int Orthop. 2007; 31:229-233. Mc Makin C. Microcurrent treatment of myofascial pain in the head , neck and face. Top Clin Chiro .1998; 5(1):2935. Kim HN, Park RJ: The effects on the level of endorphin and pain threshold according to each TENS and MENS application. The journal of Korewn socity of physical therapy.1997:9:103-115. Becker RO, Selbon G. Body Electric. New York: William Marrow; 1999. Nordenstrom B . Biological Closed Electric Circuits: Clinical, experimental, and theoretical evidence for additional circulatory system. Sweden: Medical Publication. 1983; 347-52. Cheng N, Van Hoof H, Bockx E, Hoogmartens MJ, Mulier JC, et al. The effects of electric currents on ATP generation, protein synthesis and membrane transport of rat skin. Clin Orthop Relat Res.1982; (171):264–72. Bourguignon, G and Bourguignon, L .Electrical stimulation of protein and DNA synthesis on human fibroblasts, Federation of American Societies for Experimental Biology.1987; 5:398-402. Kin M, Kwon D, Lee H. Therapeutic effect of microcurrent therapy in infants with congenital muscular torticollis. Phys Med and Rehabil. 2009; 1:736-739. Machner A, Merk H, Becker R, Rohkohl K, Wissel H, Pap G. Kinesthetic sense of the shoulder in patients with impingement syndrome. Acta Orthop Scand 2003; 74 (1): 85–88.

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A Study to Correlate Postural Thoracic Kyphosis and Abdominal Muscle Strength and Endurance Bharati Asgaonkar1, Rati P. Ghumare2 1

Associate Professor, 2M.P.Th. Musculoskeletal, Department of Physiotherapy, TN Medical College, Mumbai

Abstract Objective To find the correlation between kyphotic index and abdominal muscle strength and endurance using manual muscle testing and pressure biofeedback methods, in kyphotic individuals and individuals with ideal posture.

Methodology Study design: Non interventional analytical, Study location: Physiotherapy OPD of tertiary care hospital, Study duration: 1year, Subjects sampled: Sample size – 60, Age group: 20 to 50 Yrs. Subjects were screened using plumb line assessment method in lateral view and divided into Group A: - 30 individuals with postural thoracic kyphosis, Group B: - 30 individuals with ideal plumb line alignment.

Assessment Parameters -

Posture: a) Plumb line assessment b) Kyphotic index using Flexi curve Manual muscle testing: - Lacote’s method (Grades 1 to 5) Prone pressure biofeedback for strength and endurance Posterior pelvic tilt using pressure cuff, for strength and endurance Number of curl ups in one minute.

Results Data was statistically analyzed using Pearson’s correlation coefficient. The results showed no statistically significant correlation between strength of abdominal muscles and kyphotic index (r = 0.05 to 0.27) and endurance of abdominal muscles and kyphotic index (r = 0.03 to 0.26) in either of the groups.

Conclusion With increase in postural thoracic kyphosis, there is no significant difference in the strength and endurance of rectus abdominis, obliques internus and externus, transversus abdominis muscles

Key Words Postural thoracic kyphosis, Kyphotic index, Abdominal muscles

Introduction Maintenance of upright posture by humans is unique among mammals and primates. Adopting an upright posture and acquiring freedom to use upper limbs independently of lower limbs, has increased the

dynamic demands on the vertebral column. As a consequence, changing to an upright posture has resulted not only in specific human functional abilities, but also unique functional disabilities which have implications in our day to day activities1, 2. When there is a postural fault, there is no abnormality in muscle strength or flexibility, but if the faulty posture continues and becomes habitual, strength and flexibility imbalances gradually develop25. Sustained faulty posture disturbs the length tension relationship of muscles responsible for maintaining optimal posture13. This altered length tension relationship leads to either stretch weakness of tight weakness. Abdominal muscles originate from the rib cage and insert on to the pelvis and play an important role in maintenance of upright posture3, 5, 8. Habitual faulty or sustained postures disturb the length tension relationship of the muscles responsible for maintaining an optimum posture27. These changes occur due to structural changes in the muscles13.

Need of Study Considerable research and documentation has been done on the prevalence of back extensor weakness in thoracic kyphosis. But little study has been done to find the correlation between thoracic kyphosis and abdominal muscle strength. During prolonged stooped postures at work, particularly in slouched sitting the distance between the rib cage and the pelvis reduces and the abdominal muscles are put into a biomechanically altered position thus leading to altered length tension relationship of these muscles2, 14, 23, 36. This study has been attempted to find whether abdominal muscle strength and endurance alters with postural thoracic kyphosis. Also, early detection of abdominal muscle weakness, if any, would help in preventing further problems of backache.

Methodology Study was conducted in Physiotherapy OPD of a tertiary care hospital, with approval from ethics committee and after a written consent of the participants. Individuals between the age group of 20 to 50 were screened for posture in lateral view using a plumb line assessment method. Centre of shoulder was marked and any deviation of point of shoulder ahead of plumb line was considered as increase in thoracic kyphosis. Hyperextension test was performed to differentiate between postural and structural thoracic kyphosis. 30 individuals with ideal plumb line alignment were included in group A and 30 with postural thoracic kyphosis were included in group B. Individuals with any pathology of spine, including PID, scoliosis, Koch’s spine, fracture and those involved in vigorous physical training were excluded from the study. For flexi curve assessment, C7 spinous process was marked on subjects back and the lumbo-sacral interspace was also marked. Subjects were instructed to ‘stand in your usual relaxed posture’ flexi curve was molded on the bare back and the curve was carefully traced on a graph paper33,34. Thoracic width (TW) and length (TL) was measured and kyphotic index (KI) was calculated as TW/ TL*1006,7,22.

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Subjects were then assessed for abdominal muscle strength using Lacotes method of assessment for individual muscles. (Upper rectus abdominis, lower rectus abdominis, internal obliques, external obliques, transversus abdominis). For a more objective assessment of muscle strength, pressure biofeedback technique was used.

Posterior Pelvic Tilt (PPT) Subject was positioned in crook lying position on a firm plinth. The pressure cuff cell of the aneroid sphygmomanometer was placed under the lumbar lordosis with the lower end at the PSIS level. The cell was then inflated till it filled the space of lumbar lordosis. The subject was then asked to perform a posterior pelvic tilt till the back was flat on the plinth. The increase in pressure cuff reading was noted.18 Three such readings were taken and the best reading was considered as final Subjects were carefully observed to avoid any trick movements like neck lifting or shoulder protraction.

Prone Pressure Biofeedback Subject was made to lie prone with arms by the side. The pressure cuff cell was placed under the abdomen in such a way that its lower end was at the level of ASIS. The pressure in the cell was inflated to 70 mmHg and the cuff was allowed to stabilize. Then subjects were instructed to breathe in and out and then without breathing in, to draw in the abdomen so that it lifts off the pressure on the cell, keeping the lumbar spine steady. Once the contraction was achieved, subject was instructed to breathe normally while maintaining the abdomen tucked in. A pressure drop of 6 – 10 mmHg was considered normal. Three such readings were taken and the highest reading was considered as final9, 28, 29. Similarly for endurance testing, the number of seconds the subject could hold the PPT and PPB positions was noted. A curl up test was performed for endurance. Subject was asked to perform curl ups in crook lying position with arms behind the head. The number of curl ups the subject could perform in one minute was noted35.

Muscles operate with greatest active force when close to an ideal length (often their resting length).4 When stretched or shortened beyond this (whether due to the action of the muscle itself or by an outside force), the maximum active force generated decreases. This decrease is minimal for small deviations, but the force drops off rapidly as the length deviates further from the ideal. As a result, in most biological systems, the range of muscle contraction will remain on the peak of the length-tension curve, in order to maximize contraction force19. Prolonged length changes in muscles as the result of postural abnormalities has been hypothesized but there is lack of evidence on the same. Although current studies neither prove nor disprove the existence of clinically measurable change in muscle as a result of prolonged length changes, the possibility of the same cannot be ignored27. According to Kisner and Colby, muscles with altered length due to habitually wrong posture, test stronger only in their habitual length, whereas they test weaker when they are tested in their normal physiological length. However, the altered length at which this weakness ensues needs to be determined.

Conclusion From our study it was concluded that, with increase in postural thoracic kyphosis, there is no significant difference in the strength and endurance of rectus abdominis, obliques internus and externus, transversus abdominis muscles.

Limitations of the study 1) 2) 3)

Declaration of Interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References 1.

2.

3.

Results

4.

The data was statistically analyzed using Pearson’s correlation coefficient. The results showed no statistically significant correlation between strength of abdominal muscles and kyphotic index (r = 0.05 to 0.27) and endurance of abdominal muscles and kyphotic index (r = 0.03 to 0.26) in either of the groups.

5. 6.

7.

Discussion 8. Our study found no statistically significant correlation between KI and abdominal muscle strength and endurance. This may imply that, probably the increase in thoracic kyphosis and hence the KI was not so significant as to cause significant change in the strength and endurance of the abdominal muscles. 20

The sample size was small Integrated EMG to assess abdominal strength could have been done Gender bias was not taken into consideration

9.

10.

Andrew Briggs. Thoracic Kyphosis affects trunk muscle forces. PHYS THER Vol. 87, No. 5, May 2007, pp. 595607 Angelica Reevea Effect of posture on thickness of transversus abdominisin pain free subjects., , and Andrew Dilleyb, revised 1 February 2009; Bergmark A. Stability of the lumbar spine: a study in mechanical engineering. Acta Carolyn Kisner, Lynn Allen Colby. Therapeutic Exercise Foundations and Techniques, Fifth edition. The Spine and Posture. Pg. 394 Carrie M. Hall, Brody. Ed.2 2005 Therapeutic Exercise: Moving Towards Function Carlos vol.11 no.3 May/June 2007 Reliability and validity of thoracic kyphosis measurements using the flexicurve method . Carleen Lindsey. Flexi curve spinal measurement: courtesy Protocol for clinical assessment of kyphosis and lordosis. Christopher Norris Ed. 2 2008 Pg 89 Back Stability: Integrated Science and therapy. Cheri Drysdale; Jennifer Earl; Jay Hertel, Surface EMG of Abdominal Muscles During Pelvic Tilt & Abdominal Hollowing, Journal of Athletic Training 2004; 39(1):32-36). Cynthia Norkins, Pamella Levangie, Joint Structure and Function: A Comprehensive analysis, Ed.4

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Cresswell, AG, Grundstorm, H, Thorstensson, A: Observations on Intra-abdominal pressure & patterns of Abdominal intramuscular activity in man. Acta Physiol Scand 144:409 1992) D Ryan, L P Fried Johns J Am Geriatr Soc. 1997 Dec; 45 (12):1479-86 The impact of kyphosis on daily functioning. Gossman, M,Sahrmann, S, Rose, S:Review of length associated changes in muscles Phys Ther 62: 1977, 1982 Gerr. F Marcus, M, et al: A Prospective study of computer users. I. study design and incidence of msk symptoms and disorders. Am J Ind Med 41: 221-235, 2002 Hinman MR. Comparison of thoracic kyphosis and postural stiffness in younger and older women. Spine J. 2004; 4(4): 413-7] Iddings DM, Smith LK, Spencer,Phys Ther. 1970 Oct;50(10):1456-66.) (Muscle testing. 2. Reliability in clinical use, WA. Phys Ther Rev. 1961 Apr;41:249-56.) Kendall and McCreary, EK, Provance, PG: Muscle Testing and Function, Ed. 4. Williams and Wilkins, Baltimore, 1993 Kendall and Mc.., Bellare B, Sona Sharma, Journal of Indian Association of Physiotherapists.) Kessler Ed.4 Pg. 799 Common Musculoskeletal Problems, Lacote, Clinical Evaluation of Musvle Function, Ed.2, 1987. Martini, Anatomy & Physiology, Ch. 10 Muscle tissue: 1999-2000 by Prentice Hall, Inc. Milne JS, Lauder IJ. The relationship of kyphosis to the shape of vertebral bodies. Ann hum biol. 1976; 3:173-9. ] Indian journal of occupational and environmental medicine April 2007, Volume 11, issue 1. Oatis. Part 3: kinesiology of head and spine; structure and function of bones and joints of thoracic spine, Ch. 29, Pg 498. Pg 532-537 Panjabi MM, Takata K, Goel V, et al.:Thoracic human vertebrae: quantitative three dimensional anatomy. Spine 1991; 16: 888-901. Paul Hodges, Carolyn Richardson, paul hodges, Julie Hides. Therapeutic exercise for Lumbopelvic stabilization:

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a functional model of the biomechanics and motor control, Ed.2, Ch.2 pg 13 - 28 Rowena Topenberg The inter relation of spinal curves, pelvic tilt and muscle length in adolescent females, The Australian Journal of Physiotherapy. Vol 32, No. 1, 1986. Richardson, CA, et al: Techniques for Active Lumbar Stabilization for Spinal Protection: A Pilot Study. Aust. J. Physiotherapy 38: 105, 1992) 17 Richardson Carolyn, Jull 1999, Therapeutic Ex for Spinal Segmental Stabilization in Low Back Pain, Churchill Livingstone). Carolyn Kisner, Colby Therapeutic Exercise: Foundations and Techniques, Ed.5, Ch 16, Pg. 455 Stability of lumbar spine; a study in mechanical engineering. Acta Orthop Scand. 1989; 230:20-24] Indian journal of occupational and environmental medicine-April 2007, Volume 11, issue 1. Further standardization of manual muscle test for clinical study: applied in chronic renal disease, Silver M, McElroy A, Morrow L, Heafner BK. Reliability and validity of thoracic kyphosis measurements using flexicurve. 2008 Revista Brasileira de Fisioterapia May/June 2007, vol.11, no.3, p.199-204. ISSN 1413-3555. To establish interrater reliability of flexicurve when used by novice testers to measure thoracic kyphosis and lumbar lordosis in a community- based Print 1878-6324 online, ISSUE- vol 17 number1/2003/2004,pages – 33-36 To compare intensity of upper Vs lower rectus activity provoked by two different abdominal exercises and to contrast the intensity of contraction elicited by each exercise on each portion of rectus 2009 Elsevier B.V. The effect of different standing and sitting postures on trunk muscle activity in a pain-free population. Spine, 2002. 27(11): p. 1238-44. Urquhart, DM, Hodges, PW, et al: Abdominal muscle recruitment during a range of voluntary exercises. Manual Ther 10(2): 144-153, 2005

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Effect of Deep Cervical Flexor Strengthening on Vertical Mandibular Opening on Subjects with Forward Head Posture Dheeraj Lamba1, Satish Pant2, Girish Chandra2, Asha Joshi2, Divya Dalakoti2 1

Incharge, 2Interns, Dept. of Physiotherapy, IAHSET Medical College Haldwani, Uttarakhand

Introduction

Methodology

The temporomandibular disorders (TMD) include a variety of condition associated with pain and dysfunction of the masticatory muscles. An estimate 20% of population is affected by this disorder. A wide variety of physical techniques including joint mobilization, exercise prescription, electrotherapy, education, biofeedback and relaxation, and postural correction, have been used in the management of temporomandibular joint (TMJ) disorders. Vertical mandibular opening is measured by Interincisal distance between edges of right upper and lower central incisors as measurement with a millimeter ruler. The normal opening of adults is between 35 to 50 mm i.e. 3.5 to 5 cm. but the functional opening is 25 to 35 mm i.e. 2.5 to 3.5 cm or at least two knuckles between teeth. The resting position of mandibular plays important role to produce movement of vertical mandibular opening. In resting position of mandibular, the lip is in light contact or slightly apart, the opposing teeth are separated, all the jaw muscles are at rest function and the mandible is passively suspended against gravity. Normally, no occlusal contact exit between the maxillary and mandibular teeth when the muscles are relaxed. The distance has been measured to be 2-4 mm (freeway space or interocclusal distance). When the resting vertical dimension is altered, as clinically observed with faulty posture, it encroaches the freeway space, the mandibular condyle may intrude upward and backward in glenoid fossa, the teeth may be in contact eliminating the rest position and creating tension on the muscle of mastication and stress on teeth and supporting structures. The tongue is suspended like sling by its myofacial and ligamental attachments from the styloid process of the temporal bone and the anterior portion of the mandible. It has been demonstrated that cervical muscle influences masticatory muscle activity. The influence of posture and stress on musculoskeletal pain and dysfunction is a prime etiologic factor that is commonly overlook. Normal mandibular rest position may be altered by respiratory, posture, masticatory and temporomandibular intracapsular disorders. The forward head posture is commonly associated with a temporomandibular joint dysfunction and the temporomandibular joint dysfunction is commonly associated with a forward head posture.

Aims and Objective

30 subjects with forward head posture (FHP) participated in this study, but 3 were lost in follow-up till end. Only 27 subjects (14 female and 13 male) completed the exercise protocol of one month. The subjects were recruited from Sushila Tiwari Memorial Hospital, Haldwani. The subjects were of mean age 23.15 + 2.50 years, mean height 161.85 + 8.60 cm and mean weight 55.96 + 9.31 kgs.

Inclusion Criteria 1. 2. 3.

1. 2. 3. 4. 5. 6.

7. 8. 9. 10. 11. 12. 13.

The deep cervical flexor strengthening is effective in improving forward head posture and also has an effect on vertical mandibular opening.

Any history of trauma of cervical region. History of cervical spine pathology. History of dizziness and vertigo. Postural abnormalities like scoliosis. Torticollis. Known medical problems like Rheumatic arthritis, Ankylosing spondylitis and Tuberculosis of spine, bones or joints. Painful temporomandibular joint (TMJ). Any popping sound or locking of temporomandibular joint. Difficulty with functional activities of temporomandibular joint, like chewing, talking, yawning. Recent teeth excision. Current teeth pain or teeth infection. History of tobacco chewing. Mouth splinting.

Study Design- Experimental Study Instrumentation

2. 3. 4. 5.

Hypothesis

Age- 18-30 years. Both male and female subjects. All subjects having forward head posture (craniovertebral angle less then 49 degrees.).

Exclusion Criteria

1.

Observe the effect of deep cervical flexor strengthening on vertical mandibular opening on subjects with forward head posture. This study is to determine if the correction of forward head posture may help to improve the temporomandibular function.

22

Sample

6. 7. 8. 9.

Digital camera- A digital Nikon camera (Cool pix L10) with 5 mega pixel and 3x zoom lenses was used. Tripod camera stand- A Simpex tripod camera stand was used. Measuring tape. Adhesive skin markers- Red color adhesive marker was used to denote the anatomical landmarks. Image-tool software- UTHSCSA image-tool software for windows version- 3.00 was used. Plumb line Millimeter ruler- A 15 cm ruler was used. Disposable gloves. Disinfected liquid- Isopropyl alcohol U.S.P. liquid was used

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10.

11.

to remove skin secretions from the site of anatomical landmarks fixation and to clean the millimeter ruler, before and after taking mandibular opening of each subject. Pressure biofeedback- A pressure biofeedback unit (manufactured by Chattanooga group, Inc, Hixson, TN) was used for exercise performance. Stop watch- A runner 2000 digital stop watch was used.

Protocol Based on inclusion and exclusion criteria, the subject were recruited for the study. Each subject was informed about the purpose of the study and proper instructions were given about procedure. All subjects went through the consent form, prior to participation. Anatomical landmarks were marked at C7 and tragus of the ear. Digital photograph was taken for measuring the craniovertebral angle. After this subject were checked for vertical mandibular opening.

Procedure All the subject were ask to sit comfortably on back supported armless chair with both feet flat on floor, hips and knees positioned at 900 angle and buttock positioned against the back of chair. The subjects were asked to rest their hands on their lap and to keep their shoulder against the back of the chair. Adequate exposure of neck up to shoulder level to clearly define anatomical landmarks was done. The most prominent spinous process at the base of cervical spine was palpated. After it was identified, the cervical spine was passively flexed and extended to verify which one moved first. C6 vertebra should be more mobile, whereas C7 should demonstrate less motion. Skin over the anatomical landmarks was wiped with cotton soaked in sprit to remove skin secretions for proper fixation of adhesive markers. Anatomical landmarks were marked with marker pen; thereafter adhesive markers were fixed over the anatomical landmarks. Then taken the measurement of the height between ground and C7 in sitting position of each subject was done with help of measuring tape. That same reading was taken to adjust camera height over the tripod. The camera was placed so that the center of the lens was 0.8 meter from the subject in orthogonal to sagittal plane of the subject. Distance between chair and tripod was fixed at 0.8 meter and not altered in any conditions. The craniovertebral angle was measure by angle between mid point of the adhesive marker at tragus of right ear and mid point of the reflective marker at C7. This angle described the position of head relative to C7 when viewed from right side of head relative to C7. Then the photographs were transferred to laptop for measuring the craniovertebral angle by using imagetool software. After that all subjects were asked to sit comfortably on back supported armless chair with feet flat on floor, hips and knees positioned at 90 degree angle and hands on their lap. The subjects were asked to focus on a point directly in front of them and to open their mouth as widely as possible without feeling any strain. The vertical mandibular opening was measured between the incisal edges of the right upper and lower central incisors teeth by using a millimeter ruler. The same procedure was repeated for three times and mean value of the readings obtained. A pair of sterile hand gloves was worn throughout the procedure. The subjects were not asked to eat or chew gum for at least one hour before the measurement. The exercise procedure with pressure biofeedback (craniocervical flexor exercise) was explained to the subject. Low load endurance exercises were used to increase the tonic holding capacity of deep neck flexors muscles. In this, subject was positioned in supine lying. Then pressure biofeedback was placed between the plinth and the posterior aspect of the cervical

spine just below the craniocervical junction. The subject’s head and neck was positioned to ensure a neutral cervical spine and craniocervical position. The pressure sensor was inflated to 20 mm of Hg so that the space can be filled between the back of the neck and the plinth. As already instructed, subject placed the tongue on the roof of the mouth, lip together but teeth just apart, then asked the subject to posterior retraction of chin to push neck directly back on the sensor. Each subject was given sufficient time to practice the same exercise with pressure biofeedback unit. The dial was kept in front of the subject so that he can monitor any deflection of the pointer during holding phase which was 10 second. The feedback which was given by the pressure sensor showed the subject’s ability to hold the position in a controlled manner. Two sets of 10 repetitions were done, with 2 minute rest in between. This exercise was given to all the subjects for 5 days in a week for one month. A home exercise program was instructed to all subjects for rest of 2 days of the week. For home exercise program the subjects was asked to placed a 4 inches towel roll under the neck at place of pressure biofeedback unit and performer the same procedure of craniocervical flexion exercise. After 1 month the outcome measures were assessed again for craniovertebral angle and vertical mandibular opening by same procedure which was already described.

Data Analysis Data was analyzed with the SPSS statistical package (version-12). Descriptive statistics (age, height, weight) were calculated in terms of number of subjects, minimum and maximum values, mean and standard deviation. Student’s paired t-test was used to test change in quantitative data preintervention and postintervention i.e. craniovertebral angle and vertical mandibular opening. Pearson product moment correlation analysis was used to study correlation between craniovertebral angle and vertical mandibular opening for all the subjects.

Results Sample comprised of 27 of subjects recruited in one group. The age of subjects ranged from 19 to 28 years, mean age was 23.15 + 2.50 years. The height ranged from 151 to 178 cm, mean height was 161.85 + 8.60 cm. The weight ranged from 40 to 85 kg, mean weight was 55.96 + 9.31 kg. (Table-5.1) Table 5.1 : Variables

Values (Mean + SD)

Minimum

Maximum

Age (years)

23.15 + 2.50

19

28

Height (cm)

161.85 + 8.60

151

178

Weight (kg)

55.96 + 9.31

40

85

The mean value of pre intervention craniovertebral angle (C.V.A.) of the subjects was 45.13 + 11.05 and the mean value of post intervention craniovertebral angle of the subjects was 54.16 + 10.79. The mean value of pre intervention vertical mandibular opening (V.M.O.) of the subjects was 3.49 + 0.24 and the mean value of post intervention vertical mandibular opening of the subjects was 2.99 + 0.23. (table-5.2) Table 5.2 : Mean value of pre intervention and post intervention C.V.A. and V.M.O. Preintervention

Postintervention

C.V.A.

45.13 + 11.05

54.16 + 10.79

V.M.O.

3.4 + 0.24

2.99 + 0.23

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Compared with baseline data the mean change in craniovertebral angle, after the 30 days of exercise protocol was -9.03 + 2.47. Subjects with forward head posture demonstrated a significant progressive increase in craniovertebral angle post intervention. (t= -18.95, p